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 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924012504076 
 
SMALL HOSPITALS. 
 
 ESTABLISHMENT AND MAINTENANCE 
 
 BY 
 
 U I I 
 
 A. WORCESTER, A.M., M.D. 
 
 : V I J; 1 1 'i > 
 
 1 » f U I: V 
 
 AND 
 
 SUGGESTIONS FOR HOSPITAL 
 ARCHITECTURE. 
 
 WITH 
 
 PLANS FOR A SMALL HOSPITAL. 
 
 BY 
 
 WILLIAM ATKINSON, Architect. 
 
 NEW YORK : 
 
 JOHN WILEY & SONS, 
 
 53 East Tenth Street. 
 1894. 
 
 9 
 
vi i J firA'H'.t' 
 VfiAJ.i ) > ! 
 
 A'- 7*7741 
 
 Copyright, 1894, 
 
 BY 
 
 A. WORCESTER. 
 
PREFACE. 
 
 Many times within the last few years it has been 
 my privilege to address audiences in neighboring 
 communities where the hospital movement was under 
 consideration, and to meet visiting committees who 
 had come to study the methods and plans of the one 
 hospital which I have had the pleasure of seeing grow 
 from nothing into its present condition of usefulness. 
 At such meetings the impossibility of even briefly tell- 
 ing the whole story has always been an embarrass- 
 ment. And now in this attempt to tell it I have the 
 pleasure of hoping to help others to the fruition of 
 their endeavors. 
 
 This hope has been greatly enhanced by the addition 
 of Mr. Atkinson's admirable description of the model 
 hospital from the architectural standpoint. 
 
 A. W. 
 Waltham, Mass., June, 1894. 
 
CONTENTS. 
 
 Part I. 
 
 CHAPTER I. 
 
 PAGE 
 
 The New Hospital Movement. Its Origin. Advantages 
 
 of Small Hospitals to the Community . . . . i 
 
 CHAPTER II. 
 
 How to Interest the Public. Preliminary Meetings. Selec- 
 tion of Committees 12 
 
 CHAPTER III. 
 
 Hospital Organization. The Corporation. The Board of 
 Managers. By-laws. The Executive Committee . 21 
 
 CHAPTER IV. 
 
 The Medical Question. Homoeopathy and Allopathy. 
 Possible Solution of the Difficulty. The Selection of 
 the Staff. Charges for Professional Services to Hospital 
 Patients 29 
 
 CHAPTER V. 
 
 The Nursing Service. Establishing a Training School. 
 Selection of a Superintendent. Probationers and 
 Student Nurses 41 
 
VI CONTENTS. 
 
 CHAPTER VI. 
 
 PAGE 
 
 The Temporary Hospital. Transformation of Dwelling- 
 house. Temporary New Wards. Cottage Ward for 
 Contagious Diseases. Furnishings. The Ambulance 53 
 
 CHAPTER VII. 
 The Admission of Patients. Necessary Regulations . 65 
 
 CHAPTER VIII. 
 
 The Permanent Hospital Buildings. How to Plan and how 
 to Build them 71 
 
 CHAPTER IX. 
 
 Hospital Finances. Hospital Aid Associations. Hospital 
 Sunday and Saturday Collections. Endowments. 
 Free Beds. Public Appropriations .... 79 
 
 Part II. 
 
 HOSPITAL ARCHITECTURE, 91 
 
SMALL HOSPITALS. 
 
 CHAPTER I. 
 
 THE NEW HOSPITAL MOVEMENT. — ITS ORIGIN.— 
 ADVANTAGES OF SMALL HOSPITALS TO THE 
 COMMUNITY. 
 
 WITHIN the last few years small hospitals have been 
 built in many of our larger towns and smaller cities, 
 and where this is not already accomplished steps 
 thereto have been taken. Indeed, so rapidly is the 
 movement progressing that it seems as if even the 
 smaller towns would soon be planning each to have its 
 own hospital. It is a striking instance of our advanc- 
 ing civilization. Before the war there were hospitals 
 only in the largest cities. During the war and the few 
 following years these institutions, in spite of the exist- 
 ence of the great temporary hospitals, were frightfully 
 y overcrowded. It would seem natural, therefore, to find 
 in those years the beginning of the popularity of the 
 hospital movement. But it was not then. Although 
 the army surgeons and hospital stewards carried back 
 into their peaceful lives a knowledge of the worth of 
 hospitals for the results of violence, they as yet saw 
 no advantage in them to an ordinary community. 
 
2 SMALL HOSPITALS. 
 
 These men knew how to build and equip and carry on a 
 hospital, but they did not know nor did any one know 
 how to prevent the occurrence of hospital fever, or, in 
 more exact words, the various forms of blood-poison- 
 ing. It is terrible now to recall the ravages even in 
 late years of septicaemia, not only in hospitals, but in 
 the homes of the rich as well as of the poor — terrible, 
 because it was preventable. Words cannot be found 
 in which to express the gratitude humanity owes to 
 the discoverers of the vegetable origin of these diseases 
 and of the methods of destroying these bacteria. It is 
 here, in the discovery of the prevention of blood- 
 poisoning, that we rightly find the beginning of the 
 new hospital movement. No longer could it be said 
 that any patient would be safer in his own home, even 
 if on a mountain-top, than in the hospital. Indeed, so 
 perfect has become the germ-defying regime of the 
 modern hospital, that it can be truly said a patient is 
 there less exposed to the danger of blood-poisoning 
 than he would be in any private home. 
 
 The old disadvantage thus swept away, nothing was 
 left to weigh against the manifold advantages which 
 can be furnished to a community by a hospital. None 
 were so quick to recognize this as the old army sur- 
 geons and hospital stewards. You will find them on 
 every hospital staff and governing board, and on the 
 committees of supply you will find women whose 
 hands have rolled bandages and scraped lint in the 
 dark days thirty years ago. 
 
 Not in one direction alone are we ever to seek for 
 the cause of a general advance. Hospitals are every- 
 where springing up, not merely because their advan- 
 tages were made so apparent in war times, nor only 
 
THE NEW HOSPITAL MOVEMENT. 3 
 
 because the germs that formerly killed have them- 
 selves met their destroyer. An even greater cause is 
 to be found in the development of the art of nursing. 
 
 Trained nurses can now be had in almost any com- 
 munity ; and yet there was not one in this country at 
 the breaking out of the last war. Nor were there any 
 really trained nurses for some years after the war. 
 Dreadful as was the nursing in private homes, in hos- 
 pitals it was simply atrocious. In the Bellevue Hos- 
 pital of New York, for instance, the nursing was 
 formerly entrusted to women who in the police courts 
 chose a term of service as hospital nurses when the 
 alternative of a term of imprisonment was given them. 
 No wonder that these nurses would occasionally be 
 found drunk by the deathbeds of their neglected 
 patients, whose stimulants they had stolen. Now in 
 the same hospital the nursing is done by intelligent, 
 cultured women, who almost give their services for 
 the education there obtained. And the profession of 
 nursing having supplanted the vile trade of last resort, 
 rightly shares with the profession of medicine the 
 highest honor and glory. Graduates of the various 
 training schools are now at hand to take charge of the 
 new hospitals and to carry on not only the hospital 
 work, but also the work of training other nurses, who 
 in their turn will extend the same blessings into ever 
 widening fields. 
 
 Surely it is to this development of the profession of 
 nursing that the rapidity of the new hospital move- 
 ment is most largely due. Among other causes is the 
 great advance of recent years in surgery. Owing pri- 
 marily to the discovery of germicides, and of the means 
 of preventing the access of germs to wounds, surgeons 
 
4 SMALL HOSPITALS. 
 
 have been enabled to operate without danger to the 
 patient's life in regions of the body formerly inaccessi- 
 ble because of the peril involved. An abscess, for in- 
 stance, may arise in any part of the body. In former 
 times if the abscess was located near the surface or in 
 one of the limbs the patient's life was not seriously 
 threatened : if, however, the abscess was inside the 
 body proper, — in the skull, the chest, or the abdominal 
 cavity, — then it was considered out of the surgeon's 
 reach, and the victim was doomed. Now the skull, the 
 chest, or the abdomen can be safely opened, and the 
 destroying pus evacuated. But such operations can 
 be more safely performed in a hospital, in a room es- 
 pecially adapted for such work. In the single matter 
 of suitable light, for instance, it is easily explained that 
 the surgeon must have light from overhead. No side 
 light from an ordinary window is sufficient to illumine 
 the depths of the incision into the body. And this is 
 only one of the many advantages to both surgeon and 
 patient afforded by the modern hospital, but chief 
 among them all is the already mentioned greater secur- 
 ity from blood-poisoning. It would take too long to 
 explain this greater security, and the countless details 
 upon which it depends. Suffice it that the ablest men 
 in the world of science are continually at work upon 
 the subject of disease germs and the means of their 
 eradication. And each hospital strives to adopt in 
 practice the rapid improvements these scientists make 
 known. But these processes of eradicating disease 
 germs are often slow processes, requiring great expen- 
 diture of time, money, and attention. It would be as 
 impracticable to provide in the ordinary house for the 
 possible necessity of a surgical operation as it would 
 
THE NEW HOSPITAL MOVEMENT. 5 
 
 be to provide a fully equipped machine shop. In 
 short, owing to the rapidly increasing knowledge in the 
 domain of surgery, the difference between a private 
 house and a hospital suitably provided for the safest 
 treatment of patients is a difference of increasing con- 
 sequence, and even now of almost insurmountable im- 
 portance. 
 
 Owing to the general intelligence and to the increas- 
 ing interest in such matters, it is not surprising that 
 the hospital movement claims the attention of every 
 progressive community. Almost the first question 
 that confronts those interested in the movement is that 
 of the size of a community which absolutely requires 
 a hospital, and then the size of the hospital required. 
 The question is a complicated one. The advantages 
 of the smaller hospitals have not yet obtained general 
 recognition. The large hospitals have still the pres- 
 tige of years of splendid service ; they have also the 
 curses of self-satisfaction, of red tape in profusion, of 
 sluggishness in adopting improvements. In them the 
 individuality of the patient is lost sight of, the friends 
 and family can visit him only briefly and at stated 
 hours. The regulations, of necessity, must be very 
 strict. True, on the staff of the large hospitals are the 
 ablest physicians and surgeons of the city and of the 
 State. But in reality the direct immediate care of the 
 patients is in the hands of the " house officers," who are 
 either still students of medicine or at best graduates 
 having no acquired skill in the art of healing. 
 
 In the smaller hospitals, on the other hand, there is 
 no prestige, no red tape, no self-satisfaction ; instead, 
 there is an immediate, eager readiness to adopt every 
 improved method. Owing to the smaller size there is 
 
6 SMALL HOSPITALS. 
 
 possible a more home-like arrangement : the patient's 
 individuality is not lost ; his friends can more easily 
 visit him ; and he is under the care of his own physician 
 or surgeon, who, of course, is not so famous as they 
 of the larger hospital staffs, but who nevertheless will 
 devote his whole attention to his patient, and who 
 would not, even if he could, surrender the care of him 
 to unskilled hands. 
 
 Some patients would not be distressed by the whole- 
 sale regime of the famous large hospital ; others would 
 prefer being treated nearer home, within calling dis- 
 tance of their friends, by their own doctors. But aside 
 from this question of preference, it sometimes happens 
 that one's distance from a hospital is a question in- 
 volving life and death. Where one can at one's leisure 
 canvass the pros and cons of different hospitals, that is 
 one thing ; it is quite another in the emergencies where 
 an artery is bleeding in the crushed leg, or where an 
 internal abscess has suddenly developed. Then comes 
 the question, Can one be safely moved to the neighbor- 
 ing little hospital ? No longer can the famous large- 
 city hospital be considered. 
 
 The gist of the matter is that both large and small 
 have their uses, and both are needed ; but inasmuch as 
 the advantages of small hospitals are less widely known, 
 and moreover for the reason that the writer's experi- 
 ence is wholly concerned with the same, the following 
 pages will be found to be devoted to the inception and 
 management of small hospitals in small communities. 
 
 As regards the question of how large a town may 
 be, without the absence of a hospital being a reflection 
 upon the enterprise and charity of the community, of 
 course much depends upon the location of the town — 
 
THE NEW HOSPITAL MOVEMENT. J 
 
 much, also, upon the character of its inhabitants. Thus, 
 as is readily seen, a town far removed from any city or 
 larger town, and itself the centre of still smaller neigh- 
 boring villages, is in far greater need of a hospital than 
 is an even larger but suburban town within easy reach 
 of the large-city hospitals. Then again, a manufact- 
 uring town with a shifting population, where many are 
 especially exposed to accidents, and where few have 
 homes of their own, stands in greater need of a small 
 hospital, where sick strangers can be cared for, and 
 where mangled patients can be taken, than does a rural, 
 peaceful community of equal population, where acci- 
 dents are few, and where every one has his own home. 
 
 In the country one expects to be far removed from 
 hospitals, as well as from schools and fire-engines and 
 police and many other conveniences and safeguards of 
 town life. But in any centre of civilization one natu- 
 rally looks for all its adjuncts. Schools and markets, 
 however, being in ever present need are rightly looked 
 to first ; and only the more thoughtful and experienced 
 residents will look anxiously towards the foundation 
 of a hospital, which after all is only for occasional 
 service. It is well, therefore, at the outset to consider 
 the various uses for which a small hospital serves. 
 
 Some of these uses have been already mentioned. 
 But besides the advantages in cases of important sur- 
 gical operations, which, in the absence of hospital 
 accommodations, are not often attempted, there are 
 other almost equally important advantages to be 
 thought of. 
 
 The health of the community depends largely upon 
 the proper isolation of the sick ; and the more we 
 know about the nature of diseases the more true does 
 
8 SMALL HOSPITALS. 
 
 this become. Some diseases have always been con- 
 sidered contagious and infectious. The list of dis- 
 eases known to be so is constantly growing ; and the 
 continued presence of these preventable diseases is a 
 just cause of reproach in any community. True, it 
 may be from faulty water-supply, or from bad drain- 
 age, or from other sanitary defects that the zymotic or 
 germ diseases derive their support ; but the real root of 
 the evil will always be found in the improper care of 
 patients suffering from these diseases. For the proper 
 care of the sick implies not only a regard for the pa- 
 tients themselves, but also full precautions against the 
 spread of the disease. It is generally recognized that 
 hospitals are necessary for the, proper care of patients 
 suffering with smallpox, or Asiatic cholera, or leprosy. 
 It is not generally recognized that hospital care is 
 also necessary for the proper treatment of many other 
 equally contagious and infectious diseases. 
 
 If the scarlet fever, or typhoid fever, or diphtheria 
 patient lives in a large house ; if others of the family 
 can be sent away for safety ; if trained nurses can be 
 afforded ; in short, if the patient's house can be trans- 
 formed into a temporary hospital, then there would be 
 no particular advantage to the patient or to the safety 
 of others in moving him to a hospital. But where any 
 of these conditions is wanting, the danger to the com- 
 munity is very real. Some cities have so fully realized 
 this danger, and by hospital provisions have so fully 
 guarded against it, that they no longer suffer from 
 epidemics. Occasional cases of these dreadful diseases 
 will doubtless occur for many years to come, but in an 
 intelligent community there should never occur any 
 epidemic. Nor would there, if in every such com- 
 
THE NEW HOSPITAL MOVEMENT. 9 
 
 munity there was suitable hospital provision for the 
 prompt and complete isolation of cases as they occur, 
 and provision for the temporary isolation of persons 
 who have been exposed to the contagion, and finally 
 provision for the thorough disinfection of all infected 
 clothing and furniture. These are not visionary state- 
 ments, but verities based upon actual facts. And yet, 
 so little attention is paid to sanitary matters, that less 
 money is usually granted to hospitals and boards of 
 health for this special purpose of fighting contagious 
 diseases than is granted for the fireworks for public 
 holidays. The direct and the indirect money loss 
 caused by sickness and death is so vastly above the 
 loss caused by fire that it would seem a plain business 
 necessity to provide means of fighting contagious dis- 
 ease as well as fire apparatus. And it is as hopeless 
 to prevent the spread of scarlet fever, for instance, 
 without suitable hospital wards for the isolation of 
 patients, and suitable disinfecting stations, as without 
 fire-engines to confine to its place of origin a fire once 
 started in the thickly settled tenement portions of the 
 town. 
 
 If anything can be more forlorn than homesickness, 
 it is sickness away from home. And if any sacred 
 duty equals that of providing for one's own, it is that 
 of providing for the sick stranger within our gates. 
 In these days of easy journeying we have not only the 
 helpless tramp fallen by the wayside to care for, and 
 the servants and the laborers whose only homes, very 
 likely are across the seas, but we have also to think of 
 the larger and larger class of visitors and travelling 
 salesmen and agents, who when well are abundantly 
 able to care for themselves, but when overtaken by 
 
10 SMALL HOSPITALS. 
 
 sickness or accident in hotels and boarding-houses, or 
 worse yet, in lodgings, where there is no provision for 
 their food, to say nothing of care, or in the stable- 
 lofts and garrets of their employers, who, however 
 willing they may be, simply cannot properly care for 
 their sick servants. Then the first question is, where is 
 the nearest hospital ? 
 
 In olden times there was no floating population. 
 Servants came from neighboring homes, to which, in 
 case of illness, they could easily be returned. The 
 occasional stranger, if sick, was cared for by the 
 whole community, serving in turn as " night-watchers." 
 Then, in the same way if any one family became 
 especially stricken, the burden was shared. But even 
 then how often did the sickness of one entail the sick- 
 ness and perhaps death of others of the overburdened 
 family ! Times have greatly changed. It is not that 
 hearts have grown cold. Those who formerly so freely 
 spent their strength in nursing their neighbors, now in 
 obedience to the advancing conditions of our civiliza- 
 tion, spend their strength and their money in building 
 and in managing hospitals, where all this old-time ser- 
 vice to the sick and suffering can be, and is done with 
 far better effect. 
 
 Done far better, — that is, so far as the patients are 
 concerned. But how about the counter effect upon 
 the hearts of the well-to-do ? Are we to lose from the 
 earth that noblest type of woman, whose spirit was 
 never tired by night after night of watching by some 
 poor suffering neighbor's bedside ; who carried no card- 
 case, but who directed her calls where God prompted 
 her loving heart to go? Surely some substitute for 
 this old-time service to the neighbor must be found, 
 
THE NEW HOSPITAL MOVEMENT. II 
 
 or well-meaning men and women will again be asking, 
 Who is my neighbor ? 
 
 And not the least of the uses of a hospital, founded 
 and supported by a small community, is to be found 
 in the knitting together of the hearts of the men and 
 women and children in a noble service, under the in- 
 spiration of the very essence of Christianity. 
 
 L'Hotel Dieu, God's Inn, the hospital used to be 
 called, and is so best called to-day. The word hos- 
 pital itself carries in it the whole spirit of hospitality ; 
 and a most suitable dedicatory inscription over every 
 hospital door would be : 
 
 " Eo «£o& anir to tje stranfler foretiet." 
 
CHAPTER II. 
 
 HOW TO INTEREST THE PUBLIC— PRELIMINARY 
 MEETINGS.— SELECTION OF COMMITTEES. 
 
 The inauguration of any public improvement de- 
 pends at first upon the enthusiasm of a very few, and 
 afterwards upon the awakened enthusiasm of the 
 many. There is nowadays on the one hand a growing 
 tendency to leave to the government all undertakings 
 designed for the public good, and on the other hand 
 another tendency to take from public management 
 and give over to the churches' control educational 
 and charitable institutions. So far as the good of the 
 churches is concerned it cannot be doubted that that 
 is strengthened and revivified by the undertakings of 
 any active Christian work. But as regards the greatest 
 good to the community which may come from found- 
 ing and supporting hospital work, there is no doubt 
 that neither by any one religious denomination nor by 
 the public government, but by the co-operation of all 
 these agencies, and also of individuals, is the best way. 
 
 And the problem confronting the few whose at- 
 tention is first given to the hospital question, whose 
 enthusiasm has been first aroused, is how to enlist 
 the support of every existing agency for good works 
 and of every individual in the place. It is indeed 
 a problem. Different societies and circles and dif- 
 
HOW TO INTEREST THE PUBLIC. 1 3 
 
 ferent persons must be approached in different ways. 
 One reason for one, another for another, must be 
 advanced until all the reasons requiring the institution, 
 all the advantages that will follow, are clearly under- 
 stood by all. So much tact and discretion are required 
 in the would-be promoters that many times it seems as 
 if the whole future of the movement depends upon the 
 chance of who happens first to talk of it. But that 
 is really never true. And those who try their best in 
 this as in every good work must not be discouraged 
 if their own ways fail. Let them rather modify their 
 ways and trust fully to the ultimate success of every 
 good motion. There is no such thing as crop failure 
 for good seed, however long in coming may be the 
 harvest-time. 
 
 The one great principle for the guidance of those 
 who seek to establish a hospital is to utilize every 
 existing possible agency, and the second principle is 
 to guard jealously the equal representation of every 
 agency employed. Naturally the churches are thought 
 of first. Now, if the work of arousing general interest 
 in the hospital movement is rightly done, each relig- 
 ious denomination and each parish will forever feel 
 an equal share in it. This desirable result cannot be 
 obtained by letting the Baptists, for instance, take 
 up a collection in aid of the enterprise before ever the 
 Methodists or the Unitarians have heard of the pro- 
 posal. Nor will it do to ask the aid of the Roman 
 Catholics, as an afterthought, after all the offices in 
 the preliminary organization have been filled with 
 Protestants. Each parish must be fairly treated. 
 
 Suppose that the original promoters number three — 
 only they must never let their identity as promoters 
 
14 SMALL HOSPITALS. 
 
 be known. If the movement is to be a popular move- 
 ment it must not be handicapped by the appearance 
 of its being Mrs. Jones' or Mr. Brown's blessing thrust 
 upon the community. But, further supposing that 
 these three promoters are really in living earnest, let 
 them on the very same day, if possible, call upon each 
 clergyman and upon several of his most influential 
 parishioners to talk with them about the plan. Not to 
 tell them that everything is already on the high road, 
 but to ask their opinions about the usefulness of the 
 movement, about the probabilities of enlisting all the 
 churches and, incidentally, the non-church-goers. The 
 main thing to be found out in these interviews is 
 the person's name in each religious society most sure 
 to be willing to serve in the preliminary organization 
 of the hospital and most sure to represent well his or 
 her society. 
 
 Then these representatives are to be assembled. If 
 any fail to appear, every effort must be made to secure 
 some one in his place. 
 
 The only question before this first meeting is that of 
 v the desirability and necessity of the proposed hospital. 
 It would of course seem both natural and fitting at 
 this stage to have the opinions of the members of the 
 medical profession. Unfortunately there is too much 
 truth in the trite opinion that doctors seldom agree. A 
 special chapter shall be devoted to that question and 
 to the means of persuading them to pull together. 
 But now, at this early and most critical stage of hospital 
 development, no risks must be run. If there is only 
 one physician in the place, then by all means invite 
 him to the meeting, and listen, to him and then be 
 
HO W TO INTEREST THE PUBLIC. I 5 
 
 guided by what he says, if he happens fully to approve 
 of the movement. 
 
 It is not a bad plan to arrange for the visit of some 
 one well acquainted with some neighboring hospital in 
 a community of equal size, who can tell the meeting 
 of the difficulties in the way and of the advantages 
 secured by surmounting them. No one at this meet- 
 ing is to be allowed to throw the cold water of doubt 
 as to how the money needed for the purpose is to be 
 raised. Time enough for that question will be allowed 
 later on. The sole question is whether there is need 
 of a hospital. If there is, if any of the advantages 
 enjoyed by other communities having hospitals, or if 
 any of the recognized disadvantages in not having 
 one so appeals to the judgment of this conference as 
 to impose upon it the moral necessity of at least trying 
 to get one for their own community, then let this 
 judgment be duly recorded. And let this conference 
 immediately organize itself into a temporary board of 
 management of the enterprise. Otherwise let it be 
 dissolved to await the enterprise of succeeding genera- 
 tions. We meantime will go on by the optimistic road 
 with those who believe where there's a will there's 
 a way. 
 
 The immediate business before the new hospital 
 promoters is to search out every possible helpful 
 agency, and to ask from each some promise of its 
 support for at least one year. Can each church be 
 persuaded to take up a collection for the hospital 
 on one Sunday of the year? Hospital Sunday is 
 popular where it is once begun. Many give then 
 whose hearts and pockets are touched at no other 
 time. 
 
l6 SMALL HOSPITALS. 
 
 And then, will the different clubs and social circles 
 take an interest in the work ? Will the King's Daugh- 
 ters sew for the hospital? Will the Young Men's 
 Christian Association give the needed carriage-hire 
 for moving the sick, as the associations elsewhere so 
 kindly do ? Will the Cross-road Corner's Club promise 
 to give to the hospital the proceeds of their next play 
 or minstrel show ? In short, will every one take hold 
 and help on the movement for a new hospital ? These 
 are some of the countless questions to be asked by the 
 managers of the movement. And these and other 
 questions must be most discreetly asked. It will 
 never do to have Jenkins ask the Smiths who own the 
 factory if they will support a free bed for the possible 
 use of their operatives. Oh no ! Let Jenkins under- 
 take the Knights of Cereus. Let Tompkins ask the 
 Smiths — why, he is hand in glove with them. They 
 will back him every time. 
 
 So it is the world over. And it is astonishing how 
 easy it always seems to do anything when you know 
 how to do it. The rub comes when no one does know 
 just how to do it. But discouragements come just to 
 try our hearts — to prove if we are in earnest. And it 
 is no easy task to found a hospital — nor, indeed, to 
 found or support anything else that is worth support- 
 ing or founding. 
 
 In this particular work of canvassing the town to 
 enlist the support of every organization and of all the 
 citizens, comes the great opportunity for making 
 widely known the expected advantages that will en- 
 sue. If the aid of the local papers can be secured, so 
 much the better. But, after all, it is by talking, talk- 
 ing, talking, that general interest in an innovation is 
 
NOW TO INTEREST THE PUBLIC. 1 7 
 
 obtained. Too much must not be expected from the 
 first encounter with the conservative elements. Some 
 are so constituted that they never can accept a new 
 idea on first hearing. To them time must be given. 
 In the end these very individuals may become the 
 most enthusiastic friends of the movement. 
 
 When this preliminary canvass has been thoroughly 
 made, a public meeting should be called, not in any 
 church nor in any one society's abode, but in the most 
 public place. And the call should be so generally 
 given that every man, woman, and child shall feel it to 
 be a personal invitation to be present. The managers 
 of the movement will have to work hard to make this 
 meeting a success. Not only is it necessary to arrange 
 beforehand who shall speak, but also almost what shall 
 be said. There will be provision, of course, for the 
 impromptu speeches of any who wish to speak ; but it 
 never works well to trust to such in a public meeting 
 where it is hoped to accomplish anything. And at 
 this meeting it is desirable to secure a vote to estab- 
 lish a hospital, and also the appointment of a com- 
 mittee to carry this vote into effect. 
 
 The clergymen and the lawyers always speak easily, 
 and then comes the question how to draw out the 
 physicians. This is just the time to do it. Each 
 should be personally asked to attend and to express his 
 views ; and there is no harm in asking one if he will 
 not speak of the advantage of a hospital in the matter 
 of protecting the community from the spread of con- 
 tagious diseases, nor of asking another if he will not 
 explain to the meeting the advantage in cases of acci- 
 dent and of the graver surgical operations. 
 
 The presiding officer of the meeting will be able, if 
 
1 8 SMALL HOSPITALS. 
 
 he has enough tact, to draw from the different speak- 
 ers in turn what remains to be said in order fully to 
 cover the ground. But it is only fair to help him by 
 giving him, with the list of those who will speak, at 
 least the head-lines of what each has been especially 
 asked to say. 
 
 It is comparatively an easy matter to plan for the 
 vote of the meeting to go ahead with the scheme ; it 
 is more difficult to arrange for the public authorization 
 of the men and women who are to go ahead. If the 
 board already at work has been well chosen, if every 
 class and society is well represented, perhaps the meet- 
 ing will entrust the public interests to them. The 
 final work of the provisional board is perhaps the 
 hardest of all, for they must carefully select from their 
 own number and from all others the ones who are 
 best fitted and best able to carry on the work. And 
 it does not follow that those most able to interest 
 others in the new movement will be best able to or- 
 ganize and superintend the work. Perhaps in the 
 canvass just made others will have been discovered 
 who are manifestly better able to execute the scheme, 
 and whose interest in it is equally hearty. However 
 that may be, it is a time for no false modesty, for it is 
 a work in which noble souls may rightly volunteer ; 
 nor is it a time for any exhibition of mere personal 
 gratification at being made somewhat conspicuous. 
 The utmost frankness in the preliminary meeting is 
 necessary in order surely to secure the best possible 
 list of nominations for the public meeting to act upon. 
 And it is still of the utmost importance that this list 
 shall be of truly representative persons. Each person 
 to be nominated should be directly asked to serve in 
 
HOW TO INTEREST THE PUBLIC. 19 
 
 case of election ; for nothing is more disheartening, as 
 a public meeting is on the point of dissolving, than to 
 have one after another rise to withdraw his name. 
 Such doings are contagious. 
 
 It matters not the least what name is given either to 
 the preliminary managers of the movement, or to those 
 elected at the public meeting. Commissioners, trus- 
 tees, committeemen, or simply managers — whatever 
 they may be called, they have a great work before 
 them. They must form a legal organization. They 
 must collect money. Eventually they will be the ones 
 to build the hospital and to manage its work. Legal, 
 business-like methods must be employed. Some of 
 the board should be good financiers ; some should be 
 good housekeepers; some should know about build- 
 ing matters ; and, most important of all, some should 
 know what hospitals are and what hospital work means. 
 The medical question is thus brought to the front. 
 And although that is to be discussed later, it is neces- 
 sary now to point out the desirability of having on the 
 board of managers one or two physicians. So much 
 of the work must otherwise be done in the dark, not 
 only in carrying on the hospital, but even more in 
 planning it. Inasmuch as the hospital is a special 
 field for medical and surgical work, and as the man- 
 agers will have to decide upon the regulations of that 
 work, there is of course abundant opportunity for jeal- 
 ousy in the appointment of one out of two, or of two 
 out of ten medical practitioners. But it will be found 
 in the end to be far better to have made a selection, 
 the best that can be made, than to have attempted to 
 please all parties by appointing on the board two who 
 will quarrel at every opportunity. Nor need there 
 
20 SMALL HOSPITALS. 
 
 ever be any trouble from the jealousy or rivalry of 
 those not on the board, if only it is forever plain that 
 no professional advantages accrue to the physicians 
 from their office as managers. At all odds let the best 
 men as well as the best women in the community be 
 nominated and elected to carry out these good inten- 
 tions. We may now pass on to the work directly be- 
 'fore them. 
 
CHAPTER III. 
 
 HOSPITAL ORGANIZATION.— THE CORPORATION.— 
 THE BOARD OF MANAGERS.— BY-LAWS.— THE 
 EXECUTIVE COMMITTEE. 
 
 A HOSPITAL is not simply a building. Indeed, it 
 would be quite possible for a city to have a fine, 
 well-appointed building, dedicated as a hospital, and 
 yet for that city to be unable to provide hospital care 
 for a wounded wayfarer. And again, it might happen 
 in another city, where there was as yet no fine hospital 
 building, or where perhaps what was the hospital had 
 just been burned down, that hospital care could be 
 given to one or to many needing it. 
 
 A hospital is essentially an organization of men and 
 women ready to do hospital work. True, it is almost 
 impossible to conceive of such without some sort of a 
 shelter for the sick and wounded for whom they stand 
 ready to work. But a tent, or a new unused barn, or a 
 vacant house, can always be found in less than a day's 
 search and the accommodations required never fail in 
 coming if the hospital itself, the organization, is alive. 
 
 The first work, therefore, before the committee to 
 whom the public has just entrusted the new hospital 
 movement is that of organization. And the chief 
 thing to be thought of is to legally qualify this organi- 
 
22 SMALL HOSPITALS. 
 
 zation for the acquisition of property bequeathed or 
 given in trust for hospital purposes. The necessary 
 steps differ in different States. Legal advice is thus in 
 immediate demand. If, unfortunately, there is no law- 
 yer on the board, it is not improbable that some lawyer 
 in the town will be very willing to give his best services 
 to the good cause by starting the board aright in this 
 most important process of organizing. There will then 
 be a corporation, with by-laws and with duly elected 
 officers. Inasmuch as the sole purpose of this organi- 
 zation is to be able legally to acquire and to hold prop- 
 erty, and as it is necessary that all its meetings should 
 be called according to law, and its proceedings likewise 
 recorded, it really simplifies matters to confine the cor- 
 poration merely to this function of holding property. 
 And this can be done by entrusting the whole hospital 
 management to a committee, which may be elected 
 annually. 
 
 The corporation itself may include any number of 
 citizens. Indeed, it is very well to elect as members 
 all who show their interest in the work and are willing 
 to attend the meetings. The members of the corpora- 
 tion are simply corporators, and the real managers of 
 the hospital must be elected by them. To them the 
 managers must make their annual report of the con- 
 dition and needs of the hospital and of its past year's 
 work. But beyond selecting the managers, the cor- 
 poration has nothing more to do with their work, which 
 must be untrammelled. 
 
 The duties of the corporation being thus simple, it 
 is an easy matter to arrange its by-laws. Here, for in- 
 stance, is an example that may perhaps serve as a 
 model : 
 
HOSPITAL ORGANIZATION. 23 
 
 THE BV-LAWS OF THE CORPORATION OF THE UTOPIA 
 HOSPITAL. 
 
 I. The name of this Corporation is The Utopia Hospital. 
 
 II. (a) Any person may become a member of the corporation who 
 shall be elected by a three-fourths vote at the annual meeting, or at 
 any meeting called for the purpose of electing new members, and who 
 shall signify in writing his or her acceptance of election. 
 
 (i) Membership of the Corporation shall be forfeited by absence 
 from the meetings of the Corporation for three consecutive years. 
 
 III. The officers of the Corporation shall be a President, a Vice- 
 President, a Clerk, a Treasurer, and a board of twelve Managers, who 
 shall be elected by ballot, as follows : 
 
 The President, Vice-President, Clerk, and Treasurer shall be elected 
 at the annual meeting ; the Managers shall be elected also at the 
 annual meeting — at first, four for a term of three years, four for a 
 term of two years, and four for one year, and thereafter four for a. 
 term of three years, and as vacancies occur. 
 
 IV. The duties of the officers shall be as follows : 
 
 (a) The President, and, in his absence, the Vice-President, shall pre- 
 side at all meetings of the Corporation. 
 
 (6) The Clerk shall call stated meetings of the Corporation, and 
 extra meetings at the request of any three members, by mailing to 
 each member a notice of the meeting four days previously ; he shall 
 duly record all the doings of the Corporation. 
 
 (c]_ The Treasurer shall receive and hold all moneys acquired by the 
 Corporation ; he shall pay out as ordered by vote of the Corporation 
 or of the Board of Managers, and at the annual meeting he shall pre- 
 sent a full financial report. 
 
 (d) The President and the Clerk shall also serve as auditors of the 
 Treasurer's annual report. 
 
 (e) The Board of Managers shall have full control of the work of 
 the Hospital, and shall make an annual report thereof to the Corpora- 
 tion. 
 
 V. The annual meeting shall be held on the first Monday in Jan- 
 uary. A majority of the members shall constitute a quorum. 
 
 VI. These Bylaws may be altered or amended at any meeting ; 
 notice of such alterations and amendments having been given at a 
 previous meeting, and also in the Clerk's call of the meeting. 
 
24 SMALL HOSPITALS. 
 
 After these by-laws or any others have been adopted, 
 it is proper for all members of the committee appointed 
 at the public hospital meeting to sign the same. The 
 organization has then become a reality, and the cor- 
 poration is ready to elect its officers. This done, the 
 corporation is free to undertake any work by commit- 
 tees appointed for special purposes, or by acting to- 
 gether. Thus, for instance, if it is desirable to hunt 
 for the best location of the hoped for hospital, or to 
 interview the town officials to find out if public lands 
 or public funds may be had, special committees may 
 well act for the corporation. But if, on the other 
 hand, a complete canvass of the community for funds 
 is voted to be first in order, then the corporation may 
 well act as a whole, each member taking his share of 
 territory to cover. 
 
 One of the services that can be well rendered by 
 the members of the corporation, after a hospital is 
 established, is that of making regular visits of inspec- 
 tion, and of reporting to the managers any criticisms 
 or suggestions for improvement. It would be a good 
 plan for the president of the corporation, at the annual 
 meeting, to appoint a list of visitors to the hospital, 
 two for each month in the year. 
 
 Meanwhile, if the managers idly wait for a building, 
 or for a goodly bank-account in the treasurer's hands, 
 before getting all ready to begin hospital work, they 
 will make a great mistake. 
 
 Kindly disposed testators will not be so likely to 
 leave generous slices of their estates to a corporation 
 whose officers are unprepared to use even what they 
 have. Nor is it a simple task before them, this getting 
 ready for work. Their first business is to adopt by- 
 
HOSPITAL ORGANIZATION. 25 
 
 laws. The corporation entrusts to them the whole 
 control of the hospital's work. It is for them to 
 decide upon all questions of general policy, to engage 
 the officers who are to have direct charge of the 
 execution of their orders, and to adopt such rules 
 and regulations as will ensure the orderly progress of 
 the work. 
 
 Before adopting their by-laws it would thus seem 
 necessary that the managers should have definitely 
 decided just how to carry on their work. This would 
 certainly require of them the possession both of vivid 
 imaginations and of a remarkable unanimity, were it 
 not for the help at hand in the published experience 
 of other similar institutions. It is easy to secure the 
 annual reports of all the small hospitals in the State, 
 or in the country for that matter ; and not much study 
 of the by-laws of other' hospitals is needed in order to 
 throw great light upon the whole question. 
 
 It will be quickly seen that the underlying principle 
 of all such organization is that of the division of labor. 
 An army differs from a mob simply in the fact that in 
 the army each man knows exactly what is expected 
 of him. He knows his place so well that he can find 
 it and keep in it the darkest of nights. Each officer 
 knows the extent of his responsibility. So it is on 
 shipboard ; each has his duty and does it. So must 
 it be in a hospital. Discipline is as necessary there as 
 in a fort or aboard a man-of-war ; and it is equally 
 necessary in a hospital to have one person in supreme 
 command. 
 
 In large hospitals this commander is the superin- 
 tendent. In small hospitals the matron usually holds 
 the reins. Now it is her duty to manage the hospital 
 
26 SMALL HOSPITALS. 
 
 according to the managers' orders. The by-laws of 
 the managers must therefore either contain their 
 orders for the management of the hospital, or these 
 orders must be published separately under the title of 
 " Rules and Regulations of the Utopia Hospital." 
 
 The latter seems to be the simpler way. And then 
 the by-laws of the managers need only cover their 
 own work. The board must have a president and 
 secretary, whose duties shall be such as usually pertain 
 to their offices. And then, in obedience to this foun- 
 dation principle of all effective organization, the board 
 should resolve itself into separate committees, which 
 shall each attend to one particular part of the manage- 
 ment. Thus there should be one committee on strictly 
 medical matters, another committee on housekeeping, 
 another on accounts and reports, and another on the 
 nursing-service, and perhaps other committees on other 
 branches of the work. Three is a good number to 
 have on a small working committee. 
 
 In this way each manager will have some particular 
 duty in planning the orders that will be given out by 
 the whole board and in superintending the execution 
 of these orders. But different interests are very liable 
 to conflict with each other, and unless some provision 
 is made for the harmonious working of these com- 
 mittees there might result no end of confusion. Each 
 committee should have its chairman, who can act for 
 the committee at that committee's pleasure. And 
 these chairmen of the various committees ought to 
 meet frequently, as an executive committee of the 
 managers, charged with the duty of acting for the 
 board when not in session. 
 
 Such are the main features needed in the by-laws, 
 
HOSPITAL ORGANIZATION. 27 
 
 and the following draft will make these features 
 plainer : 
 
 THE BY-LAWS OF THE MANAGERS OF THE UTOPIA 
 HOSPITAL. 
 
 I. The officers of this Board shall be a President and Secretary, 
 who shall be elected at the first meeting after the annual meeting of 
 the Corporation, and whose duties shall be such as usually pertain 
 to their offices. 
 
 II. The Managers shall meet on the first Wednesday in each month, 
 and at other times at the request of any two members. 
 
 III. Standing committees, of three members each, on Accounts and 
 Reports, on Medical Matters, on Housekeeping, and on Nursing- 
 service shall be elected by ballot at the first regular meeting after the 
 annual meeting of the Corporation, the member receiving the highest 
 number of votes being thus elected to the chairmanship of those com- 
 mittees. In case of two or more members receiving the same number 
 of votes, another ballot shall be taken to decide the chairmanship. 
 
 IV. The chairmen of the standing committees, together with the 
 President of the Managers (who shall here serve as chairman), shall 
 constitute the Executive Committee of the Board of Managers. 
 
 V. The Executive Committee shall act for the Managers in the 
 intervals of the Managers' meetings, and shall fully report to them at 
 each meeting. 
 
 VI. These By-laws may be altered or amended at any regular meet- 
 ing, or at any meeting called for the purpose, by a three-fourths vote 
 of all the Managers. 
 
 Having adopted their by-laws, and having elected 
 their officers and committees, the managers are ready 
 for real work. If a railroad accident occurs that night 
 and the question comes flashing over the wires to 
 Utopia asking if the new hospital is ready to receive 
 a dozen mangled patients, the answer can be made 
 in the affirmative. The executive committee can be 
 assembled, each member will have some definite part 
 of the task already assigned him, and an improvised 
 
28 SMALL HOSPITALS. 
 
 hospital will be ready on the arrival of the train bear- 
 ing the wounded. 
 
 We will hope, however, that no such exigency will 
 happen, but, instead, that ample time will be had to 
 draw up carefully the rules and regulations by which 
 the hospital is to be governed, to purchase and prepare 
 all sorts of hospital material for the comfort and relief 
 of the suffering, and otherwise to carry into good 
 effect all the good intentions of the Utopia Hospital 
 managers. 
 
CHAPTER IV. 
 
 THE MEDICAL QUESTION.— HOMCEOPATHY AND 
 ALLOPATHY.— A POSSIBLE SOLUTION OF THE 
 DIFFICULTY.— THE SELECTION OF THE STAFF. 
 —CHARGES FOR PROFESSIONAL SERVICES TO 
 HOSPITAL PATIENTS. 
 
 The medical question is the bugbear of hospital 
 management. As the reader will have noticed, it has 
 been possible to dodge it thus far only by promising 
 to devote a separate chapter to its consideration. 
 
 So many opposing interests are involved, and so 
 much of the opposition is beyond the comprehension 
 of laymen who have never given special attention to 
 the question, that it is no wonder the managers of new 
 hospitals so often stumble over it. 
 
 It is in itself a very difficult question ; but there is 
 hope for its final and satisfactory solution in any com- 
 munity where the question itself is fairly stated and 
 the essential difficulty generally understood. Thus it 
 is no exception to the rule that any problem, if truth- 
 fully stated, is already more than half solved. 
 
 The medical question that confronts hospital man- 
 agers is, however, not a simple one. It is really a com- 
 bination of questions, which must be sifted down, till 
 each can be separately considered, before any solution 
 is possible. Some of the separate questions that con- 
 
 29 
 
30 SMALL HOSPITALS. 
 
 tribute to the general difficulty are very apparent, and 
 indeed unduly prominent, while others are not easily 
 unmasked. 
 
 The chief difficulty concerns the so-called different 
 schools. In common parlance and in common belief 
 there are at present in this country two schools of 
 medical practice — one the old school or allopathic, 
 and the other the homoeopathic or new school. There 
 are also other schools, — the eclectic or Thompsonian, 
 for instance, — and there have more lately arisen schools 
 of Faith-cure, Mind-cure, and of Christian Science 
 healing. But hospitals are not likely to be vexed by 
 any question concerning these smaller schools. The 
 real difficulty comes in what may be called the homoe- 
 opathic question. 
 
 The first surprise in store for investigators into this 
 question is the wrathy repudiation by all physicians 
 of the term "allopath." The homceopathists cherish a 
 theory of cure which is expressed by the word " homoe- 
 opathy." So they, naturally enough, are willing to be 
 called by that name. But physicians who do not 
 happen to believe in any theory of cure naturally 
 object to the name "allopath," which implies a belief, 
 or a theory of practice, never countenanced if indeed 
 it ever existed. The early homceopathists called all 
 others allopathists. That was and is considered a 
 reproach by all who know what the word means. And 
 that is why the designation is so indignantly repudiated 
 by the ordinary physician. 
 
 When it comes to the terms " old school " and "new 
 school," there again is found an unwillingness on the 
 part of every physician to be called of the old school. 
 The whole science of medicine, while as old as Galen, 
 
THE MEDICAL QUESTION. 3 1 
 
 is still so rapidly improving that no member of the 
 profession likes to be thought possessed of only time- 
 honored methods. 
 
 Thus as the question is studied the difficulty in- 
 creases of finding acceptable terms in which to de- 
 scribe the very evident differences that divide the 
 medical profession. Well may the managers ask, in 
 despair, of the men who will not be called allopaths or 
 old-school doctors, " What will you allow yourselves to 
 be called ? " Unfortunately the answer will not be 
 very satisfactory, the reason being that the great 
 majority of physicians disclaim any particular system, 
 of practice. They feel themselves free to use any 
 remedy or to adopt any methods or measures that 
 promise relief to their patients ; and so they want to be 
 free from any prefix to their simple title of doctor of 
 medicine, given them by their universities. They want 
 to be called simply physicians or surgeons, just as 
 lawyers are called attorneys or counsellors at law. 
 But this wish of most doctors not to have any extra 
 designation, it must be allowed, is very inconvenient. 
 And the public is so wedded to the use of the names 
 "old school," and "allopath," and "regular," and the 
 names are now used in such entire ignorance of the 
 doctors' antipathy to them, that it is only on such occa- 
 sions as that of a hospital's advent that vehement pro- 
 tests are evoked. No wonder the new managers are 
 astonished at the outburst. 
 
 And still, in spite of the inconvenience in not hav- 
 ing a handy name for the medical practitioners in the 
 community who are not homceopathists, it is perhaps 
 not too much to ask of the managers that they shall 
 respect the wishes of the common doctors in this 
 
32 SMALL HOSPITALS. 
 
 matter, and speak of them simply as physicians and 
 surgeons. This much is sure : by accepting the incon- 
 venience and gratifying them in this matter, much will 
 have been accomplished towards a satisfactory solution 
 of the main question. 
 
 Strange as it may at first appear, it is nevertheless 
 true that most of the bitterness attached to the ques- 
 tion will be found among the laity and not among 
 the doctors. Indeed, the different kinds of doctors 
 'generally pull fairly well together. They visit in the 
 same families; they are always willing to help each 
 other in emergencies ; and often they are very good 
 friends. In some localities they consult together, but 
 this is not generally the case. 
 
 Now, in almost every community large enough to 
 have a hospital, there are many homceopathists. Even 
 if there is not a physician of that school, there are 
 many families who believe in homoeopathic practice, 
 and at any time a homoeopathic practitioner may 
 settle there. In large cities the homceopathists have 
 their own hospitals. But in smaller communities that 
 is, of course, impracticable ; and it is only fair that, in 
 the small hospital founded and supported by the pub- 
 lic, the homceopathists should have equal rights and 
 privileges. 
 
 Many different plans have been adopted to accom- 
 plish this desirable condition. In some hospitals there 
 are two distinct staffs. Patients desiring homoeopathic 
 treatment are referred to the homoeopathic staff, and 
 patients who have no choice are alternately likewise 
 referred. But this is a particularly objectionable plan, 
 for it perpetuates and emphasizes the differences and 
 dissensions which all desire to have lessened and 
 
THE MEDICAL QUESTION. 33 
 
 ended. There is in this plan, too, an essential ab- 
 surdity, which rightly brings upon all concerned the 
 ridicule, if not the contempt, of their fellow-practi- 
 tioners. The absurdity is in asking patients to state 
 the kind of practice they will have — patients who, very 
 likely, not only have no choice, but who are in blissful 
 ignorance of the existence of schools and methods and 
 systems of medical practice. The chief objection to 
 this plan, however, is that by accepting it every physi- 
 cian and surgeon admits the existence of two schools, 
 and moreover assents to the fact of his belonging to 
 one or other of them. As has been already said, the 
 homceopathist very properly can do this ; but the phy T 
 sician who does not hold to any particular theory and 
 system of practice cannot do it except at the expense 
 of principle. And in fact, so far as the writer is in- 
 formed, those who have accepted this arrangement 
 justify their acceptance only by the cheapening excuse 
 of expediency. It is true that where this plan has been 
 adopted the management has tried to make it as 
 acceptable as possible by describing the different staffs 
 as members of this or of that medical society. This 
 thinly hides the underlying objections ; and in fact at 
 such hospitals the question put to the incoming pa- 
 tient, who perhaps can neither read nor write his name, 
 is, " Do you wish for homoeopathic or allopathic treat- 
 ment ? " And although to casual view such hospitals 
 seem to flourish, yet the best practitioners will not be 
 found there ; nor will the work be exemplary. To sum 
 up the advantages and disadvantages of this double- 
 staff plan in a single sentence, it may be said that it 
 apparently is a fair plan for all, but it does not meet 
 the conscientious approval of physicians and surgeons 
 
34 SMALL HOSPITALS. 
 
 who hold to no one theory of practice ; it does not 
 secure for hospital service the best fitted therefor ; 
 and, inasmuch as it is essentially a compromise, which 
 hides the real question at issue, it cannot really suc- 
 ceed. 
 
 Fortunately there are other plans for us to consider. 
 One is to avoid in the by-laws and in the rules and 
 regulations of the management all reference to the ex- 
 istence of different methods of practice, and to allow 
 to every patient the right to choose his own physician. 
 If the patient has no choice, then he is put under the 
 charge of the number of the staff happening at that 
 time to be on duty. 
 
 Now, if homoeopathic practitioners were elected to 
 positions upon this staff, this plan would be an ideal 
 one. And presumably any homoeopathic practitioner, 
 if elected as a homceopathist, would be willing to 
 serve the hospital in this capacity. But this difficulty 
 at once presents itself : most practitioners who obsti- 
 nately refuse to be especially designated will not serve 
 on a staff or on a medical board where any are elected 
 as representatives of a particular school. 
 
 This seems at first sight only an instance of pig- 
 headedness ; but on further examination it will appear 
 not unreasonable, and furthermore that we are near- 
 ing the very root of the difficulty. 
 
 Why is it, then, that the doctors who are on such 
 friendly terms with their homoeopathic brethren in 
 every-day life will not serve with them on a hospital 
 staff ? They go to the same private family, one to one 
 patient, the other to the other. In emergencies they 
 will give each other aid. Why cannot they, in the 
 
THE MEDICAL QUESTION. 35 
 
 same way, serve the hospital ? The homceopathist is 
 willing ; the other is not. 
 
 The reason of his refusal is that he cannot accept a 
 position on a board or staff where the existence of one 
 school of medicine is recognized, without thereby- 
 abetting the already extensive popular error that he 
 himself belongs to a school, and is bound to one par- 
 ticular theory or system of medical practice. This is 
 the whole truth of the matter. His refusal is not based 
 upon prejudice, nor upon jealousy, nor upon simple 
 obstinacy, but upon conscientious principles, which 
 he is ever hoping may become more generally under- 
 stood. 
 
 Granting for the time that his principles are flimsy 
 and doomed to eventual sacrifice, is it not possible for 
 the Utopia Hospital to respect the positions and the 
 desires of both parties to this question. Would not 
 the following plan accomplish this : 
 
 First, let every patient choose his own physician, 
 and the hospital in behalf of that patient ask the favor 
 of that physician's services. 
 
 Second, let the hospital ask the physicians in the 
 community to inform the hospital during what por- 
 tions of the year they will be ready to respond to such 
 calls, and also to give their regular attendance. Then 
 let the managers elect from the volunteers a staff to 
 serve by turns for a year ; and in this election let the 
 fitness of the practitioners as physicians and surgeons 
 be the sole guidance to the managers. And let there 
 be no mention of schools. 
 
 Third, in order to ensure perfect fairness to the 
 homceopathists and to the patients who may desire that 
 form of treatment, let the managers arrange for the 
 
36 SMALL HOSPITALS. 
 
 constant appointment of a homoeopathic practitioner, 
 or of a set of them as homoeopathic specialists to the 
 hospital. 
 
 If the Utopia Hospital managers will adopt this plan 
 they will find it to possess these merits : Patients of 
 the hospital will have the greatest possible freedom in 
 choosing their professional attendants, the poorest 
 beggar being in this respect as rich as the Crcesus of 
 the city. The principles and wishes of the so called 
 old-school regulars will be respected, and their hearty 
 cooperation will be assumed. And, finally, the homoe- 
 opathic physicians will have the double privilege : first, 
 of serving on the regular staff undesignated except by 
 the honor of success in an open election at the hands 
 of their fellow-citizens ; and, second, of serving as ho- 
 moeopathic specialists, and of being so designated. 
 
 This homoeopathic question, although so promi- 
 nent, is by no means the most important division of 
 our subject. That is rather the problem of securing 
 the best medical and surgical talent, regardless of all 
 else. In hospitals where patients have no choice in 
 the matter of their medical attendants, the positions 
 on the staff carry far greater prestige ; but still, in 
 however small a hospital, an appointment to the staff 
 is an honor. And, although where free choice of at- 
 tendants is allowed the patients, much less devolves 
 upon the staff surgeons, yet the responsibility upon 
 the management is no less to furnish the best possible 
 surgical attention to the poor, mangled brakeman who 
 is brought to the hospital unconscious, and unable to 
 choose his surgeon even if he knew any in the place. 
 
 This responsibility must not be shirked. The man- 
 agers must not yield to the temptation to elect Dr. 
 
THE MEDICAL QUESTION. 37 
 
 Smith because of his supposed influence with the large 
 donors to the hospital, if they are satisfied that some 
 other surgeon of less influence among the wealthy is 
 really better fitted for the position. Nor may the 
 managers decide in favor of one on the grounds of 
 personal friendship. If they do so mistake their duty 
 they make themselves in part responsible for the suf- 
 ferings and deaths in the hospital which might have 
 been prevented by a better surgeon. 
 
 But, it may be urged by a timorous manager, How 
 can a lay board judge as to the merits of the different 
 surgeons available ? At the start this is not an easy 
 matter. After the hospital work has begun it is easy 
 to find out who give most attention to their patients, 
 who comply most scrupulously with all of the hospital 
 regulations, and who really stand first in the estimation 
 of their professional brethren. And even before this 
 test of experience, in the conferences which the man- 
 agers will have had with all of the members of the med- 
 ical profession they will become enabled to judge fairly 
 well who the ablest are, and who will be most likely to 
 give the hospital their very best service. 
 
 As a general rule the younger members of the pro- 
 fession are able to do most for the hospital. They are 
 likely to be more acquainted with modern hospital 
 methods, and to have more time to devote to hospital 
 work ; they have their reputations still to make — they 
 must do well. 
 
 . It need not, however, be supposed that all the vexa- 
 tions of the medical question are ended with the elec- 
 tion of the staff. Countless matters will be coming up 
 which would sorely vex the managers did that board 
 not have a committee on medical matters to which all 
 
38 SMALL HOSPITALS. 
 
 such questions may be referred. Only the large ques- 
 tions of policy need to be discussed in the full meet- 
 ings ; the details can be well left to the medical com- 
 mittee. 
 
 One of the questions that will come before the full 
 board is that of professional fees for services rendered 
 to patients in the hospital. It is a question that has 
 been discussed for ages. In some hospitals no fees are 
 allowed to be charged under any circumstances. In 
 others it is the customary and expected thing for the 
 professional attendants to charge and to be paid for 
 their services. Still again in other hospitals the sur- 
 geons are allowed to charge their fees, except during 
 their own particular months of service, when they are 
 expected to serve gratuitously. 
 
 There are many sides to the question. On one 
 view it would seem that the surgeons and physicians 
 are paid for their work, indirectly, by the prestige of 
 their connection with the hospital. To those who 
 look at it in this way it no doubt seems that all medical 
 fees are in a measure extortions. But, from another 
 point of view, doctors are seen to do a deal of gratu- 
 itous work. And in the hospital itself, for the charity 
 patients, they cheerfully do their best, without thought 
 of money recompense. Why should they attend 
 gratuitously patients in the hospital, who are able to 
 pay for all they receive, and who would of course pay 
 for medical attendance at their own homes ? 
 
 The tradesmen charge for supplying food to the 
 hospital patients, whether paying or free patients ; the 
 druggists charge for their medicines. Why, then, 
 should not the doctor, who charges nothing for at- 
 tending the poor, charge those who can pay him ? 
 
THE MEDICAL QUESTION. 39 
 
 Take, for instance, the case of a fairly wealthy man 
 who breaks his leg and is taken to the hospital ; or 
 one similarly well off, in whom there develops the 
 need of some surgical operation, and who goes to the 
 hospital. Each there, in paying the hospital charges, 
 will pay out far less than equal attention would have 
 cost him at home. Why should either be relieved of 
 paying the proper charges for his surgical attendance? 
 
 So far as the recipients of the hospital's charity are 
 concerned, there is of course no question. For them 
 all professional attendance is entirely gratuitous. And 
 then there is another class of patients just able to pay 
 the regular hospital charges, but not able to pay more. 
 One reason why they go to the hospital is to be 
 relieved of every avoidable expense. The needs of this 
 class can be met by the provision of gratuitous attend- 
 ance by members of the staff serving in rotation. 
 
 Another class of patients, who also cannot pay more 
 than the hospital charges, and who nevertheless espe- 
 cially want the services of some particular surgeon, 
 can be provided for by allowing such the privilege of 
 requesting any they please, and making with him their 
 own terms. 
 
 Then those who can pay for their professional 
 attendance, and who from the hospital as from their 
 own homes, or from a hotel, send for their family 
 doctor, or for some other physician or surgeon, may 
 be fairly expected to pay the usual charges for what 
 they thus receive. 
 
 The one drawback to this great freedom of choice 
 allowed to all patients is the variety and number of 
 doctors that will be in attendance at the same time. 
 This bothers the nurses, and leads to more or less 
 
40 SMALL HOSPITALS. 
 
 confusion. But, after all, it is the best way yet devised 
 for meeting fairly all the needs and interests which it 
 is incumbent upon a small hospital to serve. 
 
 For the protection of the hospital, and for the good 
 order of the work, it is necessary to require of every 
 physician and surgeon attending patients in the hos- 
 pital to write out each day, in books provided for the 
 purpose, both his reports of the cases and his orders 
 for the coming day. It is also necessary to require 
 daily visits from all having patients in the hospital 
 under their charge. 
 
CHAPTER V. 
 
 THE NURSING SERVICE.— ESTABLISHING A TRAIN- 
 ING-SCHOOL.— SELECTION OF A SUPERINTEND- 
 ENT.— PROBATIONERS AND STUDENT NURSES. 
 
 Much as the success of a hospital depends upon its 
 medical and surgical staff, even more does it depend 
 upon its nursing service. No matter how well the 
 orders are given, all depends upon their good execu- 
 tion. 
 
 There are three ways of providing the nursing ser- 
 vice in a small hospital. The first way is by hiring 
 nurses who have been trained elsewhere. The chief 
 disadvantage of this plan is its expensiveness. Trained 
 nurses can earn such high wages in private nursing 
 that they cannot afford, except at high rates, to take 
 permanent positions where they will have no special 
 opportunities for rising in their profession. And in a 
 small hospital there are no such opportunities. Much 
 of the nursing service is necessarily monotonous. It is 
 no wonder that nurses who have already received 
 their training do not like to do the work that might 
 just as well be done in great part by untrained nurses. 
 
 The advantage of this first plan, if the hospital can 
 afford it, is that the management is entirely relieved 
 of all vexations as to the nursing service. The work 
 
 41 
 
42 SMALL HOSPITALS. 
 
 will be well done. All that is needed is a capable 
 matron, who can keep the reins well in hand. A set 
 of trained nurses is a strong team. 
 
 The second plan is a modification of the first. By 
 hiring besides the matron, who herself is a trained 
 nurse, as many other trained nurses as are needed to 
 fill the positions of head-nurses, and then by hiring 
 young women of the upper-servant class, who can be 
 taught to do the main part of the work under the con- 
 stant superintendence of the head-nurses, the patients 
 can be very well cared for. Such girls can be hired 
 at a little above servants' wages ; and, although more 
 nurses will be needed, yet the total cost will be less 
 than by the first plan. Where untrained help can be 
 readily obtained, this plan works well. The girls soon 
 learn to do the ordinary work very well, and in emer- 
 gencies there are several trained nurses to call upon. 
 The chief disadvantage is that the nursing-work is 
 done simply for weekly wages, and by girls who have 
 no inducement to give better and better service. 
 After all, such nurses are servants, and the hospital 
 loses the services of the ambitious, capable young 
 women who clamor for admission to those hospitals 
 that have regular training-schools. 
 
 The third, and by far the best, plan is for every 
 hospital, however small, to have its nursing service 
 done by the student nurses of a training-school. Such 
 service costs far less than the other kinds. Moreover, 
 in this way is secured the service of the finest women 
 in the land ; for training-schools now receive as 
 students only well-educated, refined, young women, 
 who by nature are already well fitted to enter this 
 noble profession. 
 
THE NURSING SERVICE. 43 
 
 But how, it may be asked, is the new hospital to 
 secure such advantages, when there is as yet no train- 
 ing-school within perhaps hundreds of miles ? If there 
 is no other way, let the hospital start a training-school. 
 Indeed, this is the usual process. Sometimes, however, 
 training-schools are first started, and hospitals after- 
 wards as adjuncts. But this is not the best way. Nor 
 is it advisable for the hospital to take upon itself the 
 management of a training-school, unless there is no 
 other way. It is far better for some of the managers, 
 with any others who may likewise be especially inter- 
 ested in the subject of training nurses, to undertake 
 this work independently. Then the training-school 
 can furnish nurses to the hospital. And this can be 
 done at low rates, in return for the advantage 
 thereby gained for the school in the opportunity for 
 instruction. 
 
 Were hospital wards the only places where nurses 
 can be trained, there would not be any great gain in 
 delegating the business to any outside institution. 
 And many, who have had experience only with the 
 large hospital training schools, still believe that this is 
 the fact. But it is not so. And even the best of the 
 large hospital training-schools are now beginning to 
 recognize this, and, for the purpose of increasing the 
 efficiency of their graduate nurses, are now planning 
 for portions of their studentship outside the hospital 
 walls. 
 
 The great advantages, both to the medical profes- 
 sion and to those in need of nursing service, furnished 
 by training-schools which send out their student nurses 
 to private service, need not be more than mentioned 
 
44 SMALL HOSPITALS. 
 
 here. I have elsewhere fully discussed the subject.* 
 But it is necessary here to show how feasible it is for 
 such an auxiliary association to furnish at extremely 
 low rates the nursing service of a small hospital. For 
 on account of the dependence of hospital work upon 
 efficient nursing service, such provision becomes almost 
 the first duty of the hospital managers. 
 
 The ease with which trained nurses can now be 
 secured, who are fully competent to superintend a 
 hospital, and also to carry on a training-school wherein 
 others can be likewise trained, has already been men- 
 tioned as one of the causes of the new hospital move- 
 ment. Such a woman, being able to superintend both 
 the small hospital and the training-school, allows a 
 saving of hospital money, because her salary can prop- 
 erly be divided between the two institutions that she 
 serves. Thus a considerable economy is effected. 
 
 From the very nature of its work, which must al- 
 ways be largely charitable, a hospital depends for its 
 support upon either private endowments and subscrip- 
 tions, or else upon the public purse. But a properly 
 managed training-school, on the other hand, should be 
 fully self-supporting ; and that, too, while furnishing 
 nursing service at low rates to its sister institution, the 
 hospital, and also, at no cost whatever, the charity 
 nursing needed in the community. All that is needed 
 in order to establish this desirable condition of things 
 is a small income for the use of the training-school 
 during its first year, until it is fairly inaugurated. 
 
 This makes plain some of the reasons why it is bet- 
 ter to have the two institutions separate. The train- 
 
 * Training-Schools for Nurses in Small Cities. Geo. E. Ellis: 
 Boston. 
 
THE NURSING SERVICE. 45 
 
 ing-school can easily earn its own way ; and general 
 knowledge of that fact, unless the training-school is 
 plainly a separate institution, seriously hampers all 
 efforts to secure contributions for the hospital. Then, 
 again, as every such institution obtains, and probably 
 in part fairly deserves, more or less criticism and oppo- 
 sition in the field of its operations, it is only a wise 
 precaution not to let that apply also to the hospital. 
 The training-school, being independent of public sup- 
 port, is far better able to bear single-handed all cen- 
 sure and dissatisfaction than the hospital is able to 
 bear even a part of it. 
 
 There is nothing miraculous in the financial success 
 of a training-school for nurses. In other kinds of 
 training-schools no profit is expected from the work 
 produced. But in this the students are taught while 
 in actual service, for which the school charges and 
 receives due money compensation ; meanwhile, the 
 student nurses are paid for their labor by the instruc- 
 tion given them. Nor are the instructors paid from 
 the school's treasury. They are paid by the advan- 
 tages they have in any desired amount of nursing ser- 
 vice for their families and friends and charity patients, 
 and by the great conveniences they thus obtain in 
 theirjwork. 
 
 There are of course some necessary expenses in car- 
 rying on such a school. There is the salary of the 
 superintendent, which, as has just been said, may well 
 be divided with the hospital — at least at first, when 
 both institutions are in their early stages. And then 
 a small monthly money allowance must be given to the 
 student nurses for incidental expenses ; and they must 
 also be boarded by the school when not out at private 
 
46 SMALL HOSPITALS. 
 
 service or assigned to hospital work. It is necessary, 
 therefore, to have some home for them, which serves 
 also as headquarters, where they report each afternoon 
 for instruction and for their orders. Then there are 
 other minor expenses — for the laundry, for books and 
 stationery ; for telephone communication with the hos- 
 pital, the doctors, and the families desiring nurses; 
 and for countless other incidentals. But all these ex- 
 penses can be met by the income earned by the stu- 
 dent nurses in service where the patients are able and 
 willing to pay for it. 
 
 As would be naturally inferred, it is far easier to 
 start a training-school for nurses than it is to start 
 a hospital. And it is equally plain that no greater 
 help can be given to the new hospital movement than 
 can be given by inaugurating a training-school. The 
 latter naturally leads to the former. So ready is the 
 training-school, when in running order, to do real 
 hospital work that, unless the hospital managers bestir 
 themselves to carry their plans into effect, the training- 
 school will soon be having a hospital of its own. 
 
 For, in nursing the sick poor, it will immediately be 
 very plain that much better work could be done, 
 and at great saving of expense, by removing the 
 patients from their wretched surroundings to some 
 central and more sanitary quarters. If this is done 
 a temporary hospital is the result. But then the 
 training-school, instead of being concerned only with 
 the nursing of these patients, which is quite enough, 
 would have to assume also the expenses and the 
 general management of the affair ; whereas, it is just 
 for this work that the hospital organization has been 
 created. 
 
THE NURSING SERVICE. 47 
 
 No better illustration could be given of the mutual 
 dependence of the two institutions. And this is as- 
 suredly the fitting time to urge those who are especially 
 interested in the subject of the training-school for 
 nurses to begin their labors. All interested in the 
 new hospital will wish them God-speed. 
 
 There are many advantages and no disadvantages 
 in having some of the hospital managers also directors 
 of the training-school. The interests of both are thus 
 served ; and their interests are largely identical. 
 
 The committee of the hospital managers on nursing- 
 service surely ought to be ready to take active part 
 in the organization of the training-school. So ought 
 all the members of the hospital staff. Perhaps some 
 other physicians in the community may be found who 
 will also be eager to join in the work, and who, during 
 their own previous residence in other hospitals, have 
 taken part in the training of the nurses there. And 
 then outside of the board of managers, among the 
 corporators, or even outside of all who have shown 
 any interest in the hospital movement, may also be 
 found women who will gladly aid in the work. 
 
 The few who are especially interested should care- 
 fully select, from all available persons, perhaps a dozen 
 who may be expected to give most valuable aid. It is 
 not necessary to canvass the town, nor to hold any 
 public meetings in starting this work ; for it is not to 
 be dependent upon public support. It is, however, 
 necessary at the outset to obtain a few hundred 
 dollars, and also a guaranty of as much more, to fall 
 back upon, in case of need during the first year. And 
 this ought to be no difficult matter ; for it can be 
 truthfully stated, in soliciting this money, that every 
 
48 SMALL HOSPITALS. 
 
 penny received will eventually be used in furnishing 
 nursing service to those who need it and could never 
 pay for it. 
 
 In many cities there are district-visiting nurse so- 
 cieties, which annually secure large contributions for 
 this work of charity nursing. And therefore those 
 who can give may very properly be asked for the little 
 money, and for the small guaranty, that is needed to 
 institute the training-school, which will at once and for 
 all time undertake this most needed charity. 
 
 In asking for even this it is only fair, as far as 
 possible, not to interfere with the canvass which very 
 likely is being made simultaneously for the hospital. 
 Some do not like to be asked for money, even for 
 charity, twice in the same day. On the other hand, 
 those who give most freely of their time and of their 
 money are the very ones who, when giving, thank 
 those who present to them the opportunities. 
 
 Having obtained the necessary funds and guaranty, 
 the promoters of the training-school may immediately 
 organize. It does not matter much what by-laws they 
 adopt. They need a name ; and for officers a president, 
 clerk, and treasurer; and there is need also of a small 
 executive committee to act for the whole board, when 
 it is not in session, and in matters too unimportant to 
 demand assembling it. The officers of the board may 
 well constitute this committee. 
 
 Then they must all study up the subject. . Books, 
 more interesting than novels, may now be had which 
 tell about nurse-heroines and about famous schools; 
 and others, only less interesting, which tell of the 
 details of management in these institutions. Some 
 of the directors of the new school possibly can spare 
 
THE NURSING SERVICE. 49 
 
 the time to visit the schools already in operation, and, 
 if not, to collect by correspondence all that can be 
 had of the reports, the rules and regulations, and the 
 printed " blanks " used by these schools in their work. 
 
 The first real business for the directors is to secure 
 the right woman for superintendent. And as the 
 hospital is at least equally interested in this matter, 
 a conference committee must take it in charge. And, 
 as this is only the first of a never-ending series of 
 questions, where both the hospital and the training- 
 school will be equally interested, it will be well to 
 arrange for the permanence of this joint committee. 
 
 By applying to other training-schools, any number 
 of candidates for the position of superintendent can be 
 secured. Every school appreciates the compliment 
 of being thus asked to nominate a candidate. Each, 
 naturally enough, enjoys in anticipation the extension 
 of its own methods, by the natural increase of nurses 
 who will inevitably bear more or less resemblance to 
 the ancestral stock. 
 
 In the embarrassment of opportunities thus show- 
 ered upon the committee entrusted with the selection 
 of one upon whose ability and natural fitness for the 
 work so much will depend, it is not unwise to be 
 guided by the characteristics of the ancestral stock. 
 In general, it may be truly said that a nurse whose 
 only training has been in a large hospital will not be 
 so able as one from a smaller school to manage a small 
 institution. Some knowledge of wholesale trade may, 
 however, enhance the worth of a retail clerk. And if 
 a nurse can be found who is thoroughly acquainted 
 with the work of both large and small hospitals, so 
 much the better. But for the training-school work it 
 
SO SMALL HOSPITALS. 
 
 is absolutely necessary that, either in her studentship 
 or afterwards in a special course there, she should 
 have acquired a perfect understanding of the methods 
 of training in the schools where much of the training 
 is given outside the hospital walls. 
 
 Having secured a suitable superintendent, the direc- 
 tors can rest awhile upon their oars. She will be able 
 to present to them a scheme for the new school, which, 
 if necessary, they can help her to modify, in order to 
 make it better fit the locality of Utopia. 
 
 There will doubtless be some friction at first, due to 
 misunderstanding of the respective responsibilities of 
 the directors and of the superintendent. The work is 
 new. The superintendent will have her own very posi- 
 tive ideas as to how it shall be carried on. And, 
 while willing enough to carry out the policy adopted 
 by the directors and plainly expressed to her, she will 
 not relish any interference with the details of her 
 management. She may rightly ask for written in- 
 structions, in order that there may never be any ques- 
 tion as to the orders which she is expected to execute. 
 She is responsible for the work of her nurses ; there- 
 fore, she should be the one to select them, and to dis- 
 charge them, if need be. • In this, as in all her work, 
 she acts subject to the approval of the board of direc- 
 tors ; but in every way her authority as captain must 
 be maintained. 
 
 After a general scheme for the school has been 
 adopted, applications for admission may be considered. 
 Although the superintendent should be held responsi- 
 ble for the selection of her nurses, after she has had a 
 chance to try them, it may be necessary at first, for the 
 directors to take some steps to secure likely " proba- 
 
THE NURSING SERVICE. 5 I 
 
 tioners." Again, by communicating with other schools 
 already famous, names can be secured of applicants 
 there who, rather than wait their turn of admission, 
 would like to enter a new school. 
 
 In selecting probationers the one great question is 
 whether to give preference to applicants who live near 
 by. On the whole, it is better, at least at first, to take 
 others. At any rate, it is not well to let the item of 
 local residence weigh in their favor. For while nurses, 
 after they have received their training, are likely to suc- 
 ceed exceptionally well in their own communities, yet, 
 while in process of training, it is better for them to be 
 well away from their friends and acquaintances. But 
 questions of race, of religious denomination, of locality 
 of present and former homes, count as nothing in 
 comparison with the questions of their health and 
 strength and natural fitness for the work. There need 
 be no doubt that plenty will apply, and no matter what 
 delay, let no second best be taken even as probationers. 
 
 Very soon the school will be in operation. The 
 doctors will be giving their daily lessons, and taking 
 the student nurses out to help them in their work, 
 perhaps to leave them as night-watchers. And in cases 
 where skilled nursing is not required, or cannot be 
 afforded, the student nurses will be doing their best. 
 At such places they will be cheered on by the doctors, 
 who will prolong their visits to tell them just what to 
 do and how to do it. The superintendent will also 
 make them a morning call, to criticise their work, and 
 to show them how to bring about that comfortable 
 tidiness that only skill and training can effect. 
 
 Each afternoon the student nurses will come back 
 to the home to hear the lecture, and to get, with their 
 
52 SMALL HOSPITALS. 
 
 cup of refreshing tea, renewed inspiration for the 
 weary watches before them. Soon they will be bring- 
 ing back to the amazed directors all sorts of compli- 
 ments for the training-school. 
 
 And the directors may soon confidently offer to the 
 hospital managers all the nursing service desired. 
 
CHAPTER VI. 
 
 THE TEMPORARY HOSPITAL.— TRANSFORMATION 
 OF DWELLING-HOUSE. — TEMPORARY NEW- 
 WARDS.— COTTAGE WARD FOR CONTAGIOUS 
 DISEASES.— FURNISHINGS.— THE AMBULANCE. 
 
 Every workman must have his workshop. Without 
 it, by carrying his tools to different houses, he can get 
 along for a time ; but unless he has his own shop, 
 with its bench and other fittings, he will not be able to 
 do his best work. 
 
 So is it with a hospital organization that is ready for 
 work, and yet has no place to do it in. By taking 
 advantage of the help the training-school for nurses 
 stands ready to give, and by sending one or other of 
 the staff surgeons out to needing patients ; by sending 
 out also food and clothing and medicines, the hospital 
 organization can do something towards fulfilling its 
 mission. But its real work is begun only when it has 
 opened the doors of some home of its own for the 
 entrance of the afflicted. Any home will do for this 
 real beginning. A tent will do in summer, or in the 
 far South during any season. A common dwelling- 
 house often suffices for a hospital's first years. 
 
 The building of a permanent hospital ought to be 
 very slowly undertaken, and never hurried at the ex- 
 pense of the best possible workmanship. In this coun- 
 try building almost always is too hurried. Few here, 
 
 53 
 
54 SMALL HOSPITALS. 
 
 even of the costly hospitals, can fairly be expected to 
 outlast some in Europe which already are centuries 
 old. And yet not only the permanence but the 
 quality of the hospital, in the vital matter of its free- 
 dom from contamination, is jeopardized by too hurried 
 building. 
 
 And, again, it is a matter requiring long thought 
 and study to get the best possible plans for a hospital. 
 Especially is this so when those who are to decide 
 upon the merits of various plans know little as yet 
 about other hospitals, or, indeed, about the work of 
 the hospital which they must house. So much must 
 be said about the permanent hospital, that the subject 
 may well be postponed for a subsequent chapter. 
 
 But it will not do for the hospital organization, be- 
 fore beginning its real work, to wait for a permanent 
 home. For, should this be done, several misfortunes 
 would result. The hospital buildings would not be 
 exactly fitted for the work, as nobody could know 
 beforehand just what the work would require. And 
 then inevitably the work of building would be hurt by 
 being hurried in response to the outcry for the hospi- 
 tal work to begin. And still, worst of all, the delay in 
 beginning hospital work would allow a fading out of 
 the popular eagerness for it, and willingness to sup- 
 port it. 
 
 On the other hand, if some temporary hospital 
 buildings are utilized, the public interest will have 
 some object upon which it can be concentrated and 
 where it can be fostered : the managers will have not 
 only plenty of time for building well the permanent 
 hospital, but they will also have time for becoming 
 acquainted with their work — they can grow with it. 
 
THE TEMPORARY HOSPITAL. 5$ 
 
 Some objection may be felt to beginning the work 
 in anything short of a fine building. Such objections 
 are not well grounded. As reasonable would it be for 
 a religious society to wait for its permanent church 
 edifice before beginning to hold its services : unless 
 the church's work be begun in a log house, or, even 
 before that, under the shelter of the forest's natural 
 arches, would not that church forfeit its right to exist ? 
 Can any other fate be fit for a hospital organization 
 that idly waits for the slow growth of walls of brick 
 and stone ? 
 
 In time of need, the home of any well-to-do patient, 
 at twenty-four hours' notice, can be turned into a 
 fairly good hospital. If it be an old-fashioned house, 
 with open fireplaces, and yet having some of the mod- 
 ern improvements, such as a furnace and good plumb- 
 ing arrangements, it will be quite easy to make a 
 comfortable hospital of it. And if such a house can 
 be obtained some months before it is needed for a 
 hospital, it can at a moderate expense be made very 
 suitable. Or if an ordinary dwelling-house, suitably 
 located, with plenty of vacant land around it, can be 
 secured, then on this vacant land temporary hospital 
 wards can be quickly built, and at small expense. By 
 connecting these wards with the house by means of 
 corridors a hospital is obtained of most modern and 
 approved plan. 
 
 When the permanent hospital is ready these tempo- 
 rary wards can be sold as sheds, or even as kindling- 
 wood ; and the cost of them distributed over several 
 years will be less than the rent of other accommoda- 
 tions. The original house would be just as good as 
 before. 
 
56 SMALL HOSPITALS. 
 
 The expense of carrying out either of these plans 
 depends of course upon the locality, upon the prices 
 of houses and land, and of building material. Unfortu- 
 nately little help can be gained by studying other 
 hospital reports, so different are all these conditions in 
 different parts of the country. 
 
 The objects to be gained, however, are the same the 
 world over. In the first place, then, let us consider 
 what is most desirable in the situation of a hospital. 
 It is not time yet to choose the best location. Let 
 the building committee find that for the permanent 
 hospital. For these temporary quarters it is necessary 
 to find a building as well as a site. The choice, more- 
 over, is limited by the necessity of having the hospital 
 not too far from the centre of the town. It must be 
 in an accessible place, and yet sufficiently retired to be 
 out of the noise and dust of the busiest places. 
 
 For the convenience and advantage of both institu- 
 tions the hospital and the home of the training-school 
 for nurses must be very near neighbors. There will 
 thus be saved to the hospital the necessity of providing 
 living rooms and chambers for the nurses employed 
 there, and also all the trouble of boarding them. To 
 a small hospital just starting this is a great saving. 
 And as the requirements in the matter of situation are 
 practically the same for both institutions, there ought 
 to be no difficulty in effecting this proximity. 
 
 If possible, the situation must be above the general 
 level in order to insure good air and good drainage. 
 Finally, the water-supply must be the very best that 
 can be had in that portion of the country. 
 
 So much for the matter of location. And now let us 
 consider first what must be done to transform a common 
 
THE TEMPORARY HOSPITAL. $7 
 
 house into a hospital. Afterwards we can take up the 
 rather more attractive subject of building temporary 
 hospital wards to be connected with an ordinary house. 
 
 For economy's sake no alterations not absolutely 
 necessary must be made which would leave the house 
 in more unsalable condition when the hospital moves 
 to its permanent abode. Some of the alterations ad- 
 visable may indeed increase the worth of the building. 
 
 The cellar is first to be looked to. If the house is 
 an old one the cellar will be found too low. But it is 
 not much of a job to raise a frame house a few feet on 
 jack-screws and to build under it a higher underpinning. 
 True the chimneys are heavy ; but even so the screws 
 will lift them, and their foundation piers can be easily 
 pieced ; and as a result, instead of a low, dark cellar, a 
 light, airy basement is obtained. If now the floor is 
 concreted with cement this basement can serve for a 
 laundry, for storage-room, and also for whatever heat- 
 ing apparatus is adopted. The walls and the ceiling 
 of the cellar should be well whitewashed. 
 
 After the cellar probably the attic will need most 
 attention. That also is apt to be low and dark and 
 unserviceable. But by cutting through the roof for 
 large dormer-windows, by laying a new floor on the 
 old rough boards, and then by painting or lime-wash- 
 ing the walls and roof, a fine dormitory can be had, 
 which increases greatly the capacity of the house. 
 
 Not much needs to be done to the rooms on the first 
 and second floors. If any old fireplaces have been 
 bricked up it is easy to knock down the false-work. 
 If any paper still hangs on the walls, that is to be 
 scraped off, and the ceilings and walls are to be painted 
 so that they can be easily washed. Soft wood floors 
 
58 SMALL HOSPITALS. 
 
 must also be painted, after careful filling of all cracks 
 with putty, or even first calking with oakum. 
 
 The comfort of patients will be greatly heightened 
 if broad piazzas are available. And, besides steps 
 leading down to the grass, there should also be an 
 incline for rolling-chairs. Nothing is so helpful in 
 restoring the spirits of a convalescent as to roll him 
 out of doors on a wheeled chair, or even on his bed. 
 And then, if he can be so taken out on the grass, 
 under the trees, that tonic is of wonderful effect. 
 
 The most important, and probably the most expen- 
 sive, improvements that must be made in the old 
 house come under the head of heating and plumbing. 
 For the heating a first-rate furnace will answer. Care 
 must be taken that the cold-air supply for it comes 
 through a perfectly tight shaft, so that no cellar-air 
 shall enter the wards, as we must now call the refitted 
 rooms. And the furnace ought to be of the ki«d that 
 allows separate currents, not merely from the common 
 heating-chamber of the furnace, but all the way from 
 the cold-air supply. Only in this way can the even 
 heating of the house be secured in different winds. 
 And the furnace should be of such capacity that it 
 will never be necessary to close the ventilators in order 
 to keep the house warm. 
 
 Where there are open fireplaces these will serve 
 as ventilators. If a little fire in each would be too 
 much, then a common lamp burning in it will create 
 an upward ventilating current. Where there are no 
 fireplaces or no unused chimney- flues which can 
 be cut into, special ventilating-pipes must be put in. 
 This is as necessary as the introduction of hot-air 
 pipes from the furnace ; for hot air or fresh cold air 
 
THE TEMPORARY HOSPITAL. 59 
 
 cannot be made to enter a room unless some way is 
 provided for the escape of the air already in. Great 
 ingenuity may be required to provide this ventilating 
 system. If the ventilating-pipes can be grouped and 
 led into one large shaft, then by heating the air in this 
 shaft with a gas or kerosene stove sure ventilating 
 currents can be secured. In close weather, when there 
 is no furnace fire, this especially heated ventilating 
 apparatus becomes a necessity. For in no other 
 way can fresh air be induced into the fever-laden 
 wards. 
 
 If any rooms must necessarily be heated separately, 
 Franklin stoves are good substitutes for fireplaces. 
 Where there is not even a chimney flue available, the 
 " St. Louis Ventilating Fresh-air Heater " * is a most 
 satisfactory apparatus. 
 
 A plentiful supply of good water is an absolute 
 necessity in a hospital. If, unfortunately, there is at 
 hand no public supply, then wells and windmill-pumps, 
 or at any rate a large tank in the attic, and powerful 
 hand force-pumps, must be provided. Unless the 
 necessary plumbing can easily be introduced into the 
 house it may be cheaper as well as better to build 
 an adjoining tower for all the water-works. This 
 would almost surely be less expensive than to tear the 
 house to pieces, as plumbers seem to delight in doing, 
 where bathrooms and water-closets and wash-sinks 
 have to be provided only for one floor. And even 
 where there are two floors, the men's wards below and 
 the women's above, to be provided, still, if there is any 
 easy way of connecting this water-works tower with 
 
 * Made and sold by E. F. Crosby, Brookline, Mass. 
 
60 SMALL HOSPITALS. 
 
 the house, it may be the least expensive way, and 
 always it is the best way. If this tower plan is adopted 
 the laundry can be incorporated in it, thus relieving 
 the cellar, and avoiding the expense and trouble of 
 properly ventilating a basement laundry. 
 
 The patients' bathtubs ought to be on wheels, that 
 the tubs may be carried full to the bedsides, and then 
 wheeled back to their places for emptying. 
 
 Where no suitable house can be found for trans- 
 formation into a hospital, and, instead, a small ordinary 
 dwelling with plenty of unoccupied land is secured, 
 then the task of providing a temporary hospital is 
 plainer and pleasanter. 
 
 To begin with the house itself, that needs almost 
 no alteration. If in fairly good repair, it will do at once 
 for the general kitchen, for the office and living-rooms 
 of the matron and head nurse, for the store-rooms 
 of hospital supplies ; in short, for the administration 
 building. And, besides, there will perhaps be rooms 
 in it for private patients or for convalescents. 
 
 Two wards, one for male the other for female pa- 
 tients, can be built, one on each side of the adminis- 
 tration or " centre " building, and connected therewith 
 by corridors. 
 
 Each ward, being of one story and not intended for 
 a permanent building, can be lightly framed. There is 
 no need of a cellar. And to prevent the floor from 
 cold, a lathed and rough-plastered ceiling should be 
 laid below the floor-beams. This must, of course, be 
 carried out flush with the outer walls. The inside 
 finish should be of ordinary plastering carried up to 
 the ridge. 
 
 These wards may be of any desired size, but, whether 
 
THE TEMPORARY HOSPITAL. 6 1 
 
 for few or many patients, each should be so divided as 
 to have separate rooms in one half and an open ward 
 in the other. The nurse in charge must have a room 
 there for her medicines and supplies. And often pa- 
 tients are too sick or too troublesome for the open 
 ward. Then, too, when the end is nigh a separate 
 room is of utmost importance. 
 
 A chimney and open fireplace for a ward is a great 
 luxury. An open stove with its smoke-pipe carried up 
 through the roof is equally good and far less expensive. 
 But for the uniform heating of such a ward there is no 
 better way than the hot-water system, used in green- 
 houses and fast coming into use in our best buildings. 
 By using this system both wards, and the centre house 
 as well, can be heated from one fire. The apparatus 
 can be put in the house cellar, and the pipes, properly 
 protected, carried thence out to the wards, around 
 their walls, just under the windows, and then back 
 under the floors to the central apparatus. 
 
 The chief objection to this system of heating is that 
 it does not provide any fresh supply of air. It is 
 therefore necessary to arrange for a separate system 
 of ventilation. Apertures can be made in the walls, 
 just opposite the heating-pipes, with registers in them 
 for allowing the entrance of fresh air, which will be- 
 come more or less warmed by passing the hot-water 
 pipes. 
 
 The familiar window ventilating-screens can also be 
 employed. And for the egress of air from the wards 
 special ventilators should be made in the gables and 
 also in the roof. 
 
 To complete this temporary hospital it is now only 
 necessary to arrange for the water-works. All the 
 
62 SMALL HOSPITALS. 
 
 sinks, laundry-tubs, bathrooms, and water-closets may 
 best be put in a separate building, easily accessible 
 by short corridors both from each ward and from the 
 centre building. 
 
 Either of these plans for a temporary hospital would 
 lead to a happy result ; neither requires a great ex- 
 penditure of money nor a long delay ; and, by adopt- 
 ing either, the hospital work may soon be well begun. 
 But if for any reason neither of these plans can be 
 adopted, even so let there be no faint-heartedness in 
 providing the best accommodations that can be af- 
 forded. Once having taken hold of the plough-handles, 
 go on. 
 
 In order to make the temporary hospital ready for 
 all kinds of work, some extra provision must be made 
 for the treatment of cases of contagious diseases. For 
 such cases an isolated ward is necessary. It need not 
 be far off, but it must be entirely separate from the 
 other buildings, and it must itself be a miniature hos- 
 pital ; for in it the nurses must stay, as well as the 
 patients, and all the housekeeping work has to be 
 done there. 
 
 A small cottage will serve the purpose fairly well. 
 It will only occasionally have to be used for cases of 
 contagious disease, for such diseases, happily, are not 
 always attacking the community. And when not so 
 used, it will be better for the cottage to let some of 
 the nurses or servants, or even the convalescent pa- 
 tients, live there. Then at an hour's notice, if needed 
 for a scarlet-fever patient, it could be made ready, and 
 this more surely than if it stood entirely vacant for 
 most of the time. 
 
 There is no doubt that it is now possible to disinfect 
 
THE TEMPORARY HOSPITAL. 63 
 
 thoroughly a room or a house after its occupancy by 
 patients suffering from any of the contagious diseases. 
 It is possible also to disinfect clothing and furniture ; 
 but not always without damage to the disinfected 
 articles. For this disinfection dry heat or steam heat 
 is the best agent. And no contagious-disease hospital 
 would be complete without some apparatus for disin- 
 fecting contaminated material. A brick chamber, say 
 in the cellar of the cottage, might be made, with a 
 small steam-boiler near by, so arranged as to keep the 
 chamber either full of live steam, or at an equally high 
 dry heat, for hours if need be. Such a " sterilizing 
 oven " would be of great use to the other parts of the 
 hospital, in renovating mattresses and in disinfecting 
 other articles of furniture. 
 
 The proper furnishing of a hospital is not a difficult 
 task. There are no carpets, no hangings, no fancy 
 articles of any kind, to be bought. Everything must 
 be plain and substantial. 
 
 The bedsteads are the only articles of peculiar de- 
 sign. These should be of very strong iron construc- 
 tion, and higher than the ordinary cot. 
 
 The mattress should be of best curled hair. Noth- 
 ing can be too good in the way of bed for those who 
 have to stay on it both day and night. Each bed has 
 to have a rubber protecting sheet. 
 
 The blankets and sheets, the pillows and counter- 
 panes, must all be of best quality ; for nothing of poor 
 quality will stand the wear of the necessary washing. 
 
 Plain bureaus and wardrobes and open wash-stands, 
 a few plain chairs, and some small, simple tables com- 
 plete the list of needed furniture. Everything must 
 be of such design that it can be kept clean, wiped over 
 
64 SMALL HOSPITALS. 
 
 in every part with a dampened cloth, at the least pos- 
 sible expenditure of time and strength. 
 
 The table and kitchen furnishings, as well as the 
 furniture for the office and officers' living-rooms, can 
 of course be of any style. But the china to be used 
 on the patients' trays ought to correspond with fickle 
 appetites. A nurse cannot serve tempting tidbits in 
 heavy, thick ware. 
 
 The accumulation of strictly hospital material need 
 not bother the managers. That can be safely left to 
 the matron, who, if she knows her business, will know 
 where and in what forms to buy it most advantage- 
 ously. But in order to be businesslike from the start, 
 no bills for furnishings or for hospital material ought 
 to be paid out of the hospital treasury which have not 
 been approved by the managers as well as by the matron. 
 
 In furnishing a hospital it is customary to make 
 special appeals to individuals or to societies for the 
 furniture of special rooms, or for some special articles. 
 In this way beautiful memorials have been founded. 
 All such gifts should, however, be made only upon 
 consultation with the housekeeping committee, in 
 order to insure the necessary uniformity. 
 
 One of the costly and yet very desirable possessions 
 for a hospital is an ambulance. Even where there is 
 no hospital, such a vehicle, constructed for the easiest 
 carriage of the sick and injured, is occasionally a great 
 comfort and blessing. Where there is a hospital, an 
 ambulance becomes almost a necessity. And the need 
 of it offers to those who might give it a fine oppor. 
 tunity for generous giving. 
 
 The ambulance should be kept at some central stable, 
 where its services can be quickly had when needed. 
 
CHAPTER VII. 
 
 THE ADMISSION OF PATIENTS.— NECESSARY. 
 REGULATIONS. 
 
 WHILE the temporary hospital is being made ready 
 the managers will have ample opportunity for deter- 
 mining the general policy of the hospital, and for 
 drafting the rules and regulations by which its work 
 shall be governed. 
 
 Those who have expected that it will be possible for 
 the hospital to fulfil every need will have to suffer 
 some disappointment. Thus in a general hospital it 
 is not advisable to take in patients suffering with 
 chronic diseases. The beds ought rather to be re- 
 served for patients who at least have a chance of being 
 cured, or for patients who otherwise would die or suffer 
 longer and more keenly ; and yet it is very hard to 
 rule out the helpless old man whose last sickness is 
 upon him. 
 
 In large cities there are homes for the aged and 
 helpless, and special hospitals for consumptives and 
 for those afflicted with cancer, and asylums for those, 
 most unfortunate of all, who have lost their minds. But 
 in a small city, while there is equal variety of suffering, 
 there are not enough patients in the different classes 
 to make separate provision for them possible. A 
 small hospital should therefore be more general in the 
 
 6 5 
 
66 SMALL HOSPITALS. 
 
 character of its work than a large hospital can be, 
 without interfering with its main mission. But even 
 so, for the sake of all concerned, it will not do to fill 
 the beds with consumptives, and then not have room 
 for the victims of accident, for the sufferers from acute 
 diseases, and for those whose lives depend upon hav- 
 ing hospital care after some needed surgical operation. 
 And then, besides, if the hospital is nearly full of 
 patients who can never leave it alive, there is in that 
 very fact an inevitable depression ; and soon there 
 will be a general fear of being carried there. 
 
 Some forms of disease are also so annoying or so 
 offensive to those in the immediate neighborhood of 
 the patient that even well people can hardly endure 
 the strain. Patients so afflicted might be helped in the 
 hospital, but other patients there would suffer. 
 
 Again, on the other hand, in many cases of chronic 
 disease it is often possible by proper treatment to 
 bring the patients into much more comfortable condi- 
 tion, and indeed to prolong their lives. This is espe- 
 cially true in cases of consumption. And this disease 
 in most localities is more prevalent, as well as more 
 fatal, than all other infectious diseases put together. 
 It would be an inestimable service to the community 
 if every consumptive could be given a season of hos- 
 pital treatment, and there taught how to take care of 
 himself properly, and at least how to prevent the infec- 
 tion of others. Were this done, not a few would be 
 cured ; many would be greatly relieved, and their lives 
 and usefulness prolonged : all would be made more 
 comfortable. 
 
 If consumptives, or patients suffering from other 
 chronic disease, are admitted for only a definite period ; 
 
THE ADMISSION OF PATIENTS. 67 
 
 and if care is taken to discharge them, when they have 
 improved as much as they probably will there, or when 
 it is evident that they are failing, — then the hospital can 
 do much good, and yet not suffer, as inevitably it 
 would suffer, were chronic cases admitted to stay as 
 long as they might live. 
 
 It is thus manifest that the usefulness of the hospital 
 greatly depends upon the class of patients admitted. 
 And in framing the regulations this question becomes 
 the first for consideration. 
 
 Large hospitals have a resident medical officer who 
 can decide upon the admission of patients. But even 
 there some regulations must express the policy of the 
 hospital in this matter. In the small hospital there is 
 no resident medical officer. Nor is it fair to leave 
 much responsibility of this kind to the matron. In 
 emergencies she may admit a patient ; but it is as out- 
 side her rightful province to diagnosticate diseases as to 
 decide questions of the general policy of the hospital. 
 
 One of the medical staff, or one of the physicians 
 belonging to the board of managers, may well serve as 
 the admitting officer. In this way the matron can be 
 relieved of much responsibility. Only when the ur- 
 gency is great, and where there can be no doubt of the 
 propriety of admitting a patient, need she admit except 
 with a permission in writing from the admitting officer. 
 
 So far we have considered this question of the ad- 
 missibility of patients only in its medical aspects. That 
 is of most importance. But the question is also to be 
 considered from the financial point of view. 
 
 The charity of the hospital must always be strictly 
 reserved for those in absolute need of it. Even if only 
 so used, it will be hard enough to collect the money 
 
68 SMALL HOSPITALS. 
 
 needed. Patients who can pay the cost of their sup- 
 port should certainly be required so to do ; and those 
 who can pay only a part should also be required to 
 pay what they can. There is great opportunity here 
 for mistaken kindness on the part of the authorities. 
 For to very few in this world is sickness not a direct 
 money hardship ; and it seems heartless to take from 
 the sick man his few saved-up dollars. But it is not 
 the hospital's mission to ease the financial burdens of 
 people. Let other charities do that. The hospital's 
 mission is to relieve and comfort the sick and suffering, 
 to help all curative processes, and to do this alike for 
 the rich and poor. And in order to be able to do this 
 for the poor money must be solicited. This is trust 
 money : it is given for an especial purpose, and that 
 purpose must ever be held in view. 
 
 Nor is it sufficient observance of the obligations of 
 the trust to admit to the hospital as a free patient 
 one whose family or employer is morally bound, and 
 also perfectly able, to pay the cost of his care. In de- 
 ciding in such cases the managers must not follow their 
 own personally generous impulses : they must remem- 
 ber that the hospital funds have been entrusted to 
 them for the support of the friendless poor, of the ab- 
 solutely impoverished. 
 
 And when it is remembered that the patients who 
 pay to the hospital full cost pay really much less than 
 they would have to pay for lodging and board and 
 nursing of any kind outside ; and further, that much 
 more is given them than twice as much money would 
 buy for them anywhere, except in a hospital, — then it 
 does not seem such a hardship to require of all who 
 can pay that they should do so. But it is a most dis- 
 
THE ADMISSION OF PATIENTS. 69 
 
 tasteful business, this hunting into patients' ability to 
 pay, and it is the part of the managers' business most 
 often neglected. Nevertheless it is a grand opportunity 
 for real useful service. As its importance is recognized 
 perhaps some one of the managers will volunteer to 
 help the hospital by bringing to the treasurer or to the 
 executive committee all possible information concern- 
 ing the financial ability of applicants for free beds in 
 the hospital, or for rebates from the cost charges. 
 Such rebates and admissions to free beds should be 
 granted only by the executive committee, and only 
 upon fullest information. 
 
 Now comes the task of summing up in one rule 
 these restrictions, and others that may be locally advisa- 
 ble, regarding the admission of patients. The follow- 
 ing attempt may serve as an example : 
 
 Regulation I. — Admission of Patients. 
 
 1. Patients applying for admission to the Utopia Hospital must 
 present to the matron a recommendation from the admitting physi- 
 cian, Dr. So-and-so [residence and office hours here to be given], and 
 also satisfactory evidence of their ability and willingness to pay the 
 hospital charges of ten dollars per week. 
 
 2. Patients desiring admission to free beds, or rebates of the regu- 
 lar charges, after obtaining the recommendation of the admitting phy- 
 sician, must apply for the same to Mrs. Blank [residence here to be 
 given]. In making this application applicants must give all particu- 
 lars of their needs, for the information of the executive committee. 
 Every patient is expected to pay as much as can possibly be afforded 
 towards the cost of his care. 
 
 3. Patients suffering from mental diseases or from alcoholism will 
 not be admitted. Patients suffering from chronic diseases will be 
 admitted only for temporary treatment. In cases of accident or other 
 emergency, patients may be admitted at the discretion of the matron. 
 
 In the chapters upon the medical question and upon 
 nursing-service the different policies possible, and also 
 
70 SMALL HOSPITALS. 
 
 the best to adopt, were fully discussed. In order to 
 bring these policies plainly into view, we will now try 
 to incorporate them in regulation shape. 
 
 Regulation II.— Surgical and Medical Attendance. 
 
 i. Patients desiring the service of any particular surgeon or physi- 
 cian are at liberty to engage the same, just as they would in their own 
 homes. But in case the patient is the recipient of hospital charity, it 
 must be understood that no professional charge is to be made or paid. 
 
 2. Patients having no choice as to their professional attendance will 
 be attended gratuitously by the members of the hospital staff, serving 
 in rotation. 
 
 3. Patients desiring homoeopathic treatment, upon so informing 
 the matron, will be furnished with the same. 
 
 4. Changes in professional attendance will not be allowed, except 
 with the sanction of the medical committee of the managers. Re- 
 quests therefor may be made through the matron. 
 
 Regulation III. — The Nursing-service. 
 
 1. The nursing-service is entrusted to the Utopia Training-school 
 for Nurses. 
 
 2. All nurses, as well as all other employes of the hospital, are 
 under the direction of the matron. The implicit, immediate, and 
 cheerful obedience of all is especially enjoined. Any failure therein 
 will lead to the dismissal of the offender from the hospital's service. 
 
 These three regulations ought to cover fairly well 
 the general policy of the hospital. As for the rules by 
 which the actual work is done, these should be left for 
 the matron to evolve. The rules, as well as the regu- 
 lations, should be printed, and always given to those 
 concerned. 
 
CHAPTER VIII. 
 
 THE PERMANENT HOSPITAL BUILDINGS.— HOW 
 TO PLAN AND HOW TO BUILD THEM. 
 
 After spending considerable money and much time 
 and attention upon a temporary hospital, it is perhaps 
 asking too much of the ordinary mortal to think seri- 
 ously of the subject of a permanent hospital. And 
 yet no harm can result, and possibly great good may 
 come, by beginning early to study plans and methods 
 of building. In growing towns it is important, too, to 
 secure the best possible location, before land becomes 
 too expensive for allowing to the hospital a generous 
 area of surrounding lawn. 
 
 Then it must be remembered that the temporary 
 hospital is only a makeshift, and that better work can 
 be done in buildings designed and built for the pur- 
 pose. Nor need it be so very long before the perma- 
 nent hospital may be begun. Some rich men may be 
 even now ready to give largely to it, or some wills may 
 be drawn in the hospital's favor, and large bequests may 
 come unheralded. This latter event is more likely to 
 happen if the hospital people push on their good work 
 to completion. And in order to do this intelligently it 
 is necessary to know what others have done elsewhere. 
 
 The reports published by hospitals lately built gen- 
 erally give sketch plans of their buildings, and also 
 
 71 
 
72 SMALL HOSPITALS. 
 
 some description. The only satisfactory way of study- 
 ing the subject of hospital building is to visit all the 
 new hospitals within easy reach. 
 
 Every one interested in the hospital movement 
 should make it a point, whenever in another city or 
 hospital town, to visit and to study the methods em- 
 ployed there, and also the construction of the build- 
 ings. Notes should be freely taken, and kept within 
 easy reach. In this way a large collective fund of 
 information can be gathered, which will help greatly 
 towards making the new hospital the best in the world 
 — as indeed the newest hospital ought always to be. 
 
 Twenty years or so ago the idea was prevalent that 
 hospital wards should always be of such cheap con- 
 struction that they could be replaced every few years 
 with fresh buildings of like temporary structure. This 
 idea in the light of present knowledge is a frightful 
 one. For, supposing a ward must necessarily become 
 contaminated, this is as likely to happen in the first 
 month as it is after several years of use. Or, in other 
 words, such a ward after its first use might always be 
 a source of danger. And then, besides the unavoida- 
 ble extravagance of this way of doing, there would of 
 necessity be a sacrifice of every structural convenience 
 that could be dispensed with. Indeed, as has been 
 mentioned, the sanitariness of the wards would be 
 jeopardized by the cheapness of the construction. 
 And this is enough said ; for the whole intent of hos- 
 pital construction is to secure the highest possible 
 sanitary quality, together with such conveniences of 
 arrangement as will allow the greatest economy in ad- 
 ministration. 
 
 In one sense this is the architect's business. But 
 
THE PERMANENT HOSPITAL BUILDINGS. 71 
 
 architects do not usually know much about hospitals, 
 for they do not have to build many ; and it is unlikely 
 that an architect can be found for the Utopia Hospital 
 who has ever before built one. And however this 
 may be, the hospital organization before engaging an 
 architect ought to have very definite ideas of what 
 sort of buildings are wanted. 
 
 All preliminary consideration of the problem, as well 
 as the immediate supervision of the plans, and finally 
 of the building process, can best be done by a com- 
 mittee appointed for the purpose by the corporation. 
 
 The problem of determining the general plan best 
 adapted to the particular conditions in any given case 
 is in reality the very problem that most demands ex- 
 pert study and advice, and can be considered intelli- 
 gently only by those who have made themselves famil- 
 iar with the various requirements of a model hospital. 
 Let us then consider these different requirements. 
 
 It is fitting to think first of the operating-room and 
 its accessories. Grewsome as the subject seems to 
 those who would never know of the world's woes, yet 
 to those who know how much suffering is relieved and 
 how many lives are saved by modern surgery the sub- 
 ject of providing suitable facilities for it is intensely in- 
 teresting. No other part of the hospital is of so great 
 importance. Severely simple and plain these rooms 
 must be; but the lighting, heating, ventilating, and 
 plumbing arrangements must be perfect. 
 
 Besides the operating-room itself, even in a small 
 hospital, there should be an adjoining dressing-room 
 and wash-room for the surgeons ; a room for drugs and 
 supplies ; an etherizing-room ; and an accident ward 
 for the reception and preliminary treatment of such 
 
74 SMALL HOSPITALS. 
 
 patients. Thus five or six rooms are needed for what 
 may be called the surgical suite. 
 
 This set of rooms, while in one sense making the im- 
 portant centre of the hospital, should be well away 
 from the wards, and also so separate from the main 
 building as not to allow, on one hand, the transmission 
 of the ether fumes or of the patient's outcries, or, on 
 the other hand, the entrance into the operating-room 
 of the dust and noise of the administration-rooms and 
 hallways. A very good way of obtaining this desirable 
 isolation would be to group these rooms in a one-story 
 wing leading out of the central building. 
 
 The operating-room itself must be thus built, for that 
 room must have skylights, as well as one of its sides 
 practically of glass. Adjoining the operating-room a 
 large wash-room is needed, and then, beyond that, a 
 dressing-room for the surgeons. 
 
 The room for drugs and for surgical supplies, if 
 large enough to allow glass cases on the sides for the 
 storage of these articles, can also well serve as the 
 preparation-room, where all surgical material can be 
 sterilized. For this work bench-tables and sinks may 
 be placed in the centre of the room. This room, and 
 also the accident ward, must be well lighted. The 
 etherizing and the consulting rooms need no special 
 provisions ; nor, indeed, need they be immediately ad- 
 joining the others of this suite. 
 
 Passing now to the wards, it will be easier to make 
 plain what arrangements are desirable. Each ward 
 should lead off from the administration building by a 
 corridor, which, as it nears the ward, should be espe- 
 cially its own. If there are to be many wards, one 
 may be made up of small single rooms opening out 
 
the Permanent hospital Buildings. 7% 
 
 of a centre hallway ; and other wards may be open 
 throughout their extent, except for the nurses' office, 
 one or two separate isolating-rooms, and the supply- 
 room, at one end. But if there are to be only two or 
 three ward wings, then it will be most convenient to 
 have in each more of the space allotted to separate 
 rooms, for these purposes. For patients often need 
 separate accommodation, as when too sick to bear the 
 necessary noise or temperature or light of the general 
 ward, and when for many reasons their presence in the 
 ward would disturb and distress other occupants. ■ 
 
 The best place for the housekeeping work of a small 
 hospital, for the kitchen, and perhaps also for the laun- 
 dry, is in the top story of the administration building. 
 There is thus secured the greatest freedom from the 
 odors and steam, and also the greatest convenience in 
 distributing the food to the wards by means of a light- 
 weighted lift from the tea-kitchens below. 
 
 It is not within the province of this chapter to dis- 
 cuss the details of the arrangement or of the construc- 
 tion of the different parts of the hospital. But it may 
 serve the general purpose to point out some of the 
 requirements in these respects that naturally provoke 
 most astonishment upon first consideration. Thus in 
 the matter of permanence, which has already received 
 some attention, it must be remembered that the hos- 
 pital building and all its fixtures will receive vastly 
 more wear from legitimate usage than will any private 
 dwelling. The work of the hospital is to be continu- 
 ous, both by night and by day, for years and for gen- 
 erations after its builders shall be gathered to their 
 fathers. No material can therefore be too durable for 
 employment in its construction. Especially does this 
 
7& SMALL HOSPITALS. 
 
 fact apply to those parts which if their integrity is im- 
 paired would jeopardize the sanitary quality of the 
 hospital. Thus the plumbing must necessarily be the 
 best obtainable regardless of cost. And, again, be- 
 cause of this certainty of long use, and with respect to 
 true economy, there must be full as many sinks and 
 bowls and other plumbing conveniences as can be used. 
 Saving in this would be a lasting wastefulness of labor. 
 And what would be lavish provision in a private resi- 
 dence would be entirely insufficient provision for a 
 hospital. In no other department, with possible ex- 
 ception of the heating and ventilating systems, is there 
 such imperative need of expert advice as to plans and 
 supervision of the workmanship. 
 
 Returning now to the general plan for the arrange- 
 ment of the different parts of the hospital, it may be 
 laid down as an axiom that the best arrangement is 
 that of a central or administration building, with semi- 
 detached wings for wards and for the surgical suite. 
 This general plan, or pavilion-plan as it is called, allows 
 great diversity of arrangement in order best to adapt 
 the buildings to local conditions. 
 
 The building committee must become accustomed to 
 looking far into the future. They must always keep 
 in mind that what they will build is only a nucleus of a 
 far larger institution, and therefore must be so arranged 
 as to allow for this extension with greatest advantage. 
 Fortunately this requirement also is admirably met 
 by the pavilion-plan. 
 
 So far as the outside of the buildings is concerned, 
 while there is no danger in having that ornamented 
 according to taste, yet it is not to be forgotten that 
 there is beauty in severe simplicity, and that the great- 
 
THE PERMANENT HOSPITAL BUILDINGS. TJ 
 
 est success in architecture, even from the aesthetic 
 standpoint, depends upon the perfect adaptability of 
 the buildings to their especial purposes. 
 
 In deciding upon the size of a permanent hospital 
 the probable growth of the town is the factor needing 
 most consideration. That, of course, is not accurately 
 determinable. But it can be well guessed at. And 
 the hospital ought to be planned for at least fifty years' 
 service without change of its general plan. This can 
 be effected by making the central building large enough 
 to serve all the wards which it is expected will be 
 needed for fifty years to come ; and by so arranging 
 the wards that others can be added without interfering 
 with those first built. The size of the temporary hos- 
 pital, and the numbers of patients during successive 
 years, will give the best information' as to the size 
 needed for the permanent hospital, which, because of 
 its greater advantages, will of course have to be even 
 at the beginning larger than the temporary hospital. 
 In some communities hospitals need to be relatively 
 larger than in others. No general rule of much value 
 can be given. Probably one hospital bed for every 
 five hundred is a better rule than one bed for every 
 thousand inhabitants. 
 
 The size as well as the construction of the hospital 
 depends in the first instance upon the amount of money 
 available for building. It will never do, however, to 
 let this consideration govern the planning. The busi- 
 ness of the building committee is to procure the best 
 possible plans for what is needed. The soliciting 
 committees can then work for some definite object. 
 If there appears no possibility of securing enough to 
 
78 SMALL HOSPITALS. 
 
 build by these plans, then it is soon enough to modify 
 them. 
 
 The search for money to build with is a task separate 
 from all other soliciting. If a community contributes 
 enough money to fit up a temporary hospital and to 
 carry that along, it is useless to ask for enough more 
 to build a permanent building. .The city government 
 might do it by taxing the people, but that is a poor way 
 for the city and for the hospital as well. It seems to 
 be almost the only way in this country of securing such 
 a boon to enlist the interest of the wealthy and to 
 obtain the needed funds from a comparatively few 
 donors. The beautiful idea, of making these small 
 hospitals or parts of them memorials for those " loved 
 long since and lost awhile " is sure to gain more and 
 more in favor. Living memorials in continuous use 
 are so incomparably above all useless piles of stone. 
 
CHAPTER IX. 
 
 THE HOSPITAL FINANCES.— HOSPITAL AID ASSO- 
 CIATIONS.— HOSPITAL SUNDAY AND HOSPITAL 
 SATURDAY COLLECTIONS. — ENDOWMENTS. — 
 FREE BEDS.— PUBLIC APPROPRIATIONS. 
 
 FOR enthusiasts who are acquainted with the good 
 work of hospitals in relieving the sufferings of human- 
 ity it is often a dreary, perplexing question why it is so 
 hard to raise the money necessary for the work. There 
 can be no doubt the money would always be forth- 
 coming were the need of it and the right use of it 
 widely known. This, then, is the first task before the 
 finance committee — to show forth both the need of 
 money and the economical use of it in the hospital. 
 For this purpose the businesslike balance-sheets of the 
 treasurer are useful only to the very few who can read 
 them. Most people need more simple statements. 
 They can understand the cost per week of groceries, 
 of milk, and of ice ; they know, too, how essential 
 these expenses are. And some will contribute towards 
 one of the special expenses of the hospital when they 
 could not be induced to help swell the general expense 
 fund. Indeed, the treasurer's statement that he has 
 left for running expenses only a few hundred dollars 
 carries no sort of appeal to those who never have 
 many dollars ahead. But those same people will often 
 
 79 
 
80 SMALL HOSPITALS. 
 
 willingly give a dollar or two to supply some thoroughly 
 understood want. 
 
 The expenses of the hospital should therefore be 
 analyzed by the finance committee, and presented to 
 the public through the local papers or by leaflet state- 
 ments in the most simple and intelligible way. If the 
 children realize that a few pennies from each in the 
 school will allow some sick child to be fed and tenderly 
 nursed in the hospital for a few days or weeks, the 
 little scholars will save their pennies, and then, in 
 giving them in charity's sweet name, they will have 
 learned a real lesson. 
 
 And in the same way their parents, who perhaps 
 have never formed the habit of giving, may be led to 
 share their children's joy if it is presented to them what 
 blessings their few dollars will afford to the helpless 
 sick. 
 
 In like manner the work done by the hospital ought 
 to be made generally known, not only in the tables of 
 the annual report, which few read and still fewer under- 
 stand, but also in more readable form. The particular 
 story of the care given to some sick stranger will inter- 
 est people who would care nothing about the compos- 
 ite story of twenty such cases. And these particular 
 stories can be given out frequently. This is an advan- 
 tage ; for the public cares little about things seldom 
 heard of. 
 
 It is not enough to give such information only by 
 the printer's types. Valuable as the printed reports 
 may be, such means should be supplemented by direct 
 speech. All interested in the hospital's success should 
 take every opportunity to enlist the interest of others. 
 And those who can tell the story in an interesting way 
 
THE HOSPITAL FINANCES. 8 1 
 
 to companies of people should always be ready to tell 
 it. Such personal appeals are often the most effective 
 of all. 
 
 In giving all possible information to the public, both 
 as to the need of continuous gifts of money and also 
 as to the work that is done with the money as given, 
 the managers of the hospital really are doing all that 
 can fairly be expected of them. They are immediately 
 concerned in the right expenditure of these trust funds. 
 And it is only right that they should receive help in 
 the raising of the money. 
 
 Another distinct organization for this especial pur- 
 pose is very desirable. In many hospital towns there 
 is this Hospital Aid Association, and it is an admirable 
 institution. Such an association may naturally grow 
 out of the company that first holds a fair or festival 
 for the hospital's benefit ; or from some circle of 
 generous women who meet to do the sewing needed. 
 It soon is plain that it is easier to hold over than it is 
 to form new organizations each season as needed. 
 
 As the work done for the hospital by such an asso- 
 ciation increases, it becomes advisable to effect a suit- 
 able organization. At first it is better that the meet- 
 ings should be entirely informal. Ladies then like to 
 attend the meetings ; and interest in the association's 
 work grows apace. Many of the hospital managers 
 will take part, and often some of the surgeons or the 
 matron can attend the meetings and tell what is going 
 on. Often, too, the association can be invited to the 
 hospital to see what the work there really is. In such 
 ways a deep, abiding interest in hospital work can be 
 created and fostered. 
 
 One great boon of having such an auxiliary associa- 
 
82 SMALL HOSPITALS. 
 
 tion is that it can decide what sort of means shall be 
 employed each year for providing the hospital's support. 
 Fairs and festivals, benefit concerts and balls, are all 
 very well in due season ; but if such affairs come too 
 often people soon tire of the sound of the word charity. 
 And yet when some club offers an entertainment to 
 be given under the auspices of the hospital, it is a very 
 ungracious thing to have to decline the offer. The 
 predicament is escaped most neatly by referring the 
 offer to the Hospital Aid Association, which can 
 arrange such matters with due regard to the pleasure 
 of the public. 
 
 There are several well-recognized ways of raising the 
 money for hospital support, which we will now con- 
 sider one by one. First, the Hospital Sunday collec- 
 tions. The church as a whole is the largest body to 
 which appeal can be made for any good work. And it 
 certainly seems very fitting that one Sunday of the 
 year should be devoted by the church to a recognition 
 of the Christian work of hospitals, and to exertions in 
 its behalf. This fitness is generally recognized, and 
 the churches are very willing to cooperate. But con- 
 siderable arranging is necessary to bring about the in- 
 stitution of the custom. The churches must each be 
 asked long in advance, as in many churches arrange- 
 ments as to the disposition of the Sunday collections 
 are made for a year ahead. Different churches prefer 
 different seasons for such a collection. And it is no 
 small task to bring about a general agreement. After 
 that is effected, and a certain Sunday is designated, 
 every effort should be made to make this a permanent 
 custom, otherwise the work of arranging has to be 
 repeated each year. Nor is it sufficient to obtain the 
 
THE HOSPITAL FINANCES. 83 
 
 consent of every church to the arrangement ; for 
 what is not made some one's particular business is apt 
 to be neglected. Clergymen and church officials are 
 constantly changing, and what one promises another 
 forgets to do. And if the custom is to prevail some 
 committee must attend to these details. This com- 
 mittee can best be appointed by the Hospital Aid As- 
 sociation. Their business will be to make sure that 
 every clergyman is interested in the hospital and un- 
 derstands its work. If one has not seen it, let some of 
 the committee take him there and explain its work. 
 Then this information, and the statements of expenses 
 and of needs for the coming year, should be given on 
 printed or written slips to each clergyman several 
 weeks before Hospital Sunday. During the week 
 before that day public appeals should be made, with 
 the request that those who cannot conveniently con- 
 tribute in the churches should send their subscriptions 
 directly to the hospital authorities, or through the 
 hands of their pastors or church treasurers. As soon 
 afterwards as possible the treasurer of the hospital 
 ought to make a public announcement of the contribu- 
 tions received from each source. And this statement 
 ought to be republished a few weeks before the next 
 Hospital Sunday. 
 
 In order effectively to reach the non-churchgoers, 
 several plans may be suggested. One plan, which 
 works very successfully in the large cities of England, 
 is that of Hospital Saturday collections. The Satur- 
 day chosen for this work should be several months 
 distant from the Hospital Sunday, in order not to in- 
 terfere with the full success of either day's collections. 
 The same preliminary work must be done of calling 
 
84 SMALL HOSPITALS. 
 
 general attention to the needs of the hospital, and to 
 the particular day appointed for the collections. A 
 special committee for managing the matter is also 
 needed. Well-known persons — and the more promi- 
 nent they are the better for the success of the scheme — 
 have to be secured to take charge of the collection- 
 boxes, which may be stationed in the most accessible 
 places for different wards or districts. Thus stations 
 should be established at factory doors, in the post-office, 
 at the railway-stations, or wherever many persons will 
 pass during the few hours appointed for the collecting. 
 And as soon as the treasurer receives the collections 
 the returns should be made public. 
 
 Still another plan for reaching all is that of the 
 soliciting canvass. By this plan a large number of 
 volunteer solicitors, among whom the town is divided 
 up into sections, — one section for each solicitor, — un- 
 dertake to ask a subscription from every individual in 
 the community. In order to make this canvass effec- 
 tive, the solicitors ought to be assembled for full instruc- 
 tions. Every solicitor must have at tongue's end the 
 reasons for asking for money, and in fact a general 
 knowledge of what the hospital is doing. For many 
 inquiries will be made of them, and all sorts of criti- 
 cisms of the hospital will be poured into the solicitors' 
 ears instead of money into their boxes. If, however, 
 the solicitors are well informed, in this way a general 
 knowledge of the hospital is publicly diffused, in itself 
 a most desirable result. 
 
 Success by this method depends upon the number 
 of volunteer canvassers and upon their hearty work. 
 At the start, and when the public interest is especially 
 aroused, many will volunteer for this work and do it 
 
THE HOSPITAL FINANCES. 85 
 
 well. But in the natural course of things it will prob- 
 ably always become necessary to supplement this vol- 
 unteer work by that of paid canvassers. Many who 
 would like to work, in this way really cannot afford to 
 give the requisite time, but if paid fairly for it they 
 can help both themselves and the hospital. Such can- 
 vassers are under better control than unpaid ones. 
 They can be given the districts to work in where volun- 
 teers fail. 
 
 By combining with this plan of a general canvass the 
 advantages of the " envelope " or pledge system, prob- 
 ably the most satisfactory results will be obtained. 
 
 Each solicitor will ask not only for one subscription, 
 but will also ask for a pledge of another like subscrip- 
 tion at some appointed future date. On obtaining 
 this promise the solicitor will leave with the one thus 
 promising an envelope with the amount pledged, and 
 also the date on which the pledge is due plainly printed 
 on it. The solicitor then returns to the committee in 
 charge the money collected, and also the names and 
 addresses of those who have taken envelopes of the 
 different denominations. And when the next appointed 
 day arrives, the same solicitor or another calls on those 
 who have taken envelopes for the amounts pledged. 
 
 Instead of envelopes thus distributed in accordance 
 with the pledges, the names of all willing to contribute 
 yearly or quarterly or monthly may be recorded in 
 books specially designed for the purpose. With these 
 books the canvassers can make the stated collections. 
 
 Where this plan of collecting is adopted besides the 
 large amount gained there is the advantage of having 
 a basis for estimating what the yearly income of the 
 hospital will be. In every mercantile enterprise, and 
 
86 SMALL HOSPITALS. 
 
 in every household, reasonable prudence requires the 
 limiting of expenses within the estimated income. In 
 hospital management such prudence would smooth the 
 pathway of the finance committee, but unfortunately 
 it is seldom possible. And any system of collecting 
 subscriptions, by which closer estimates of the probable 
 income can be made, will highly commend itself to the 
 managers. 
 
 We have now considered two sources of a hospital's 
 income — the revenue from patients able to pay, wholly 
 or in part, the cost of their stay, and the annual con- 
 tributions of the public. Each of these sources yields 
 a varying income. And it is almost necessary that the 
 hospital shall have some portion of its income a cer- 
 tainty. To this end it is very desirable that an endow- 
 ment fund be established either in the form of a general 
 fund or in the form of special endowments for the 
 support of free beds. The latter form appeals more 
 strongly to those who wish to create memorials ; and 
 also to those who are liable to want to send their 
 employes as patients to the hospital. 
 
 But, after all, the matter of free beds in a hospital is 
 more or less of a fiction. For no particular beds are 
 thus designated, and the hospital rules regulate the 
 admissions in all cases. It is, however, a common 
 practice in hospitals to accept as free patients all who 
 are sent by those who have given free-bed endowments 
 or annual subscriptions affording equal income. And 
 where a free bed is established for the benefit of a 
 certain class, as for instance the operatives in some 
 particular factory, the managers are enabled to be 
 especially liberal in the acceptance of such as free 
 patients. 
 
THE HOSPITAL FINANCES. 87 
 
 Special privileges may with propriety be given to 
 donors of free beds ; for it is the hospital's business 
 to furnish what is especially wanted by those who 
 support it. 
 
 The only other source of certain revenue is that of a 
 possible annual grant from the city government, or, 
 better still, a contract with the city whereby a certain 
 allowance shall be paid to the hospital for every patient 
 cared for who otherwise would surely be a public 
 charge. Such an arrangement is of great advantage 
 both to the city and to the hospital. The city is 
 thereby relieved of carrying on an almshouse hospital, 
 which is an unfailing source of extravagance to the 
 city and of misery to the sick poor ; and at the same 
 time the hospital is assured of a part of the expense of 
 caring for those who can pay nothing. 
 
 Whatever money arrangements are made with the 
 city, the hospital should never allow any dictation as 
 to its own management. As a proper compliment to 
 the powers that be, it is all very well to have the mayor 
 of the city or some one of the town's officers a member 
 ex officio of the hospital corporation. But only those 
 who have an earnest, deep interest in hospital work 
 should ever be intrusted with its management. 
 
Part II. 
 SUGGESTIONS 
 
 FOR 
 
 HOSPITAL ARCHITECTURE, 
 
 WITH 
 
 PLANS FOR A SMALL HOSPITAL. 
 
 BY 
 
 WILLIAM ATKINSON, Architect. 
 
HOSPITAL ARCHITECTURE. 
 
 It is the province of hospital architecture to provide 
 for the collective treatment of sick and wounded per- 
 sons, and to promote, as far as planning and construc- 
 tion of buildings can do so, their comfort and restora- 
 tion to health. The excellence of a hospital does not 
 consist in the proportions of its facade, or the profiles 
 of its mouldings ; it is to be sought for in the records 
 of mortality and cure within its walls. From the pre- 
 liminary studies to the last details of construction, the 
 sanitary aspect of the problem should be uppermost in 
 the mind of the designer. 
 
 The following suggestions, while applicable to hos- 
 pitals of any description, are more especially intended 
 for those built on the "pavilion plan," of detached 
 buildings of a single story, either entirely separated 
 from one another, or connected by means of open or 
 partially enclosed corridors. 
 
 From the architect's point of view the planning of a 
 hospital resolves itself into three parts : (i) the general 
 arrangement of the buildings on the site ; (2) the 
 planning of the individual members of the group ; and 
 (3) the design of details, including methods and ma- 
 terials of construction, and the heating, ventilating, 
 and plumbing systems. 
 
 91 
 
92 SMALL HOSPITALS. 
 
 In the arrangement of the buildings on the site we 
 should endeavor — 
 
 (i) To secure a large amount of sunlight for each 
 one; 
 
 (2) To impede as little as possible the circulation of 
 air in and around the buildings ; 
 
 (3) To provide for the future enlargement of the 
 hospital ; and 
 
 (4) To promote convenience and economy of admin- 
 istration. 
 
 To study properly the question of sunlight, a " sun 
 plan " of the buildings must be drawn, and their posi- 
 tions considered with reference to the shadows they 
 cast upon each other and upon the ground. An 
 astronomical table, showing the path of the sun, from 
 sunrise to sunset at the different seasons of the year, is 
 desirable for this work. The length of a shadow cast 
 by an object being in proportion to the height of the 
 object, it follows that low buildings, with flat roofs, 
 are to be preferred to high buildings and roofs of steep 
 pitch, entirely apart from other considerations. Flat 
 roofs also allow of overhead lighting of the rooms 
 below. Skylights or monitors may be placed anywhere 
 upon their surface, and the sunlight thus let into rooms 
 which otherwise might get none.* 
 
 The buildings should be placed so as to offer as little 
 obstruction as possible to a free movement of air in 
 and around them. Projections from the general sur- 
 face of a wall, forming sheltered angles, in which air 
 may stagnate ; quadrangles enclosed on all sides, or 
 
 * The term "flat roof" is used here in its usual sense, and means 
 a roof of exceedingly gentle pitch, generally about half an inch to 
 the foot. 
 
HOSPITAL ARCHITECTURE. 93 
 
 blind courts, with no outlet for the pocketed air, are 
 bad features in any hospital design. 
 
 The buildings occupied by the sick should be located 
 away from all possible sources of noise, and the win- 
 dows of the wards should command an agreeable 
 prospect, and not be subject to the observation of curi- 
 ous neighbors. 
 
 The general ground plan of the hospital will of 
 necessity be largely governed by local conditions — such 
 as the nature of the surface, the character of neighbor- 
 ing buildings, the possibilities of acquiring adjoining 
 properties for future growth, and the like. Such con- 
 ditions often necessitate a departure from an ideal 
 arrangement. 
 
 In designing the individual buildings the aim should 
 be to satisfy the requirements with the simplest floor- 
 plan obtainable, and to avoid a multiplicity of angles. 
 Every unnecessary corner adds so much extra labor to 
 the task of keeping the building clean. 
 
 There should be abundant light in every part. Pas- 
 sages and hallways should be straight, and capable of 
 being opened at both ends, to allow of quick ventilation. 
 
 For the ward pavilions, buildings of a single story are 
 preferable, and each pavilion should contain but one 
 principal sick-ward, with its adjuncts. In this way 
 only can a complete isolation of the different classes 
 of patients be obtained. 
 
 Where limitations of site make the use of two-story 
 pavilions desirable, the upper and lower wards should 
 be, as far as possible, isolated from each other. No 
 channel of communication, by dumb-waiter shafts, 
 ventilating-flues, or the like should be allowed between 
 them. The stairways to the upper ward should be built 
 
94 SMALL HOSPITALS. 
 
 outside the walls of the building or in a staircase well 
 opening to the outer air. The floors between should 
 be made absolutely sound-proof, and ample means of 
 escape, in case of fire, must be provided for the upper 
 ward. 
 
 The ward windows should have square tops and 
 extend clear up to the ceiling. The arched form of 
 window is unsuitable for hospital construction, as it 
 curtails the light at the point where it is most valuable. 
 The sills should be low enough for the patients to see 
 out of the windows from their beds, and the floor-level 
 should be sufficiently above the outside grade to pre- 
 vent people outside from looking in. The blinds or 
 window-screens should be arranged in two parts, to 
 pull up from the bottom and down from the top. By 
 this arrangement the distribution of light within the 
 ward may be more exactly controlled. 
 
 In the design of details one of the chief considera- 
 tions is the avoidance of lodging-places for dust and 
 dirt. Air is constantly passing through a building, 
 more or less according to the efficiency of the ventila- 
 tion, and in its passage leaves behind a certain per- 
 centage of its dust. A building acts as a sort of 
 gigantic air-filter, and tends to accumulate dust, year 
 by year, exactly as a water-filter becomes clogged with 
 particles. Dust is also brought in from outside on 
 the clothing of the inmates, and is also produced to a 
 certain extent within the building itself. 
 
 The greater part of this dust settles on horizontal 
 surfaces, but vertical surfaces also collect a certain 
 amount. Even such a smooth material as window- 
 glass becomes clouded in time with impalpable dust 
 particles. 
 
HOSPITAL ARCHITECTURE. 95 
 
 The aim of the designer should be to reduce the 
 amount of dust-collecting surface, and to render such 
 surface accessible, so that the dust may be periodically 
 removed. Concealed spaces, through which there may 
 be a circulation of air, should be avoided as far as pos- 
 sible, as they act as dust collectors. The amount of 
 dust in a building may be very much reduced by filter- 
 ing the air before it enters from outside. In a dusty 
 neighborhood some such provision is imperative. 
 
 In order to reduce as much as possible the number 
 of resting-places for dirt, it is a common practice in 
 hospital construction to provide for rounded corners 
 at the junction of two wall surfaces, or of wall with 
 floor and ceiling, thus avoiding a right angle. Where 
 this can be done in some stable material, such as 
 plaster, cement, or iron, it is an excellent plan, and 
 makes the labor of cleaning much less. If constructed 
 of wood great care must be taken in the execution, 
 lest cracks and crevices, caused by the shrinking of the 
 material, frustrate the aim of the designer. 
 
 In the selection of materials of construction those 
 of a porous, absorbent, or perishable nature should be 
 avoided. Wood, on account of its absorbent proper- 
 ties, and its expansion and contraction under varying 
 hygrometric conditions, should be used as sparingly 
 as possible. 
 
 The walls should be designed with a view to their 
 function as a protection against the weather rather 
 than proportioned for strength alone. If of brick or 
 stone the material should be selected for its non-heat- 
 conducting properties chiefly. Both the inside and 
 outside faces of the wall should be rendered as far as 
 possible impervious to moisture. 
 
g6 SMALL HOSPITALS. 
 
 The body of the wall may well be made of several 
 thicknesses of hollow brick (which is a good non-con- 
 ductor of heat), and the outside faced with a dense 
 hard brick, of minimum absorptive power. The wall 
 may then be plastered on the inside with a hard, 
 cementitious plaster, smoothly finished, and applied 
 directly to the masonry, without furrings of any 
 kind. 
 
 The, interior partition walls may be of brick, terra 
 cotta, or metal lathing, plastered on both sides. 
 
 Ventilating-ducts and flues, where they are built 
 into the walls, should be constructed of some smooth 
 material, such as fire-clay flue-liners, and the align- 
 ment should be as straight as possible. Such flues, as 
 ordinarily constructed in brick walls, with rough inte- 
 rior surfaces, accumulate quantities of dust, which from 
 its inaccessibility is not easily removed. 
 
 The framing of floors and roofs may be of rolled 
 iron or steel beams, with fire-clay arches, and the ceil- 
 ings plastered without furrings. 
 
 If the roofs are flat, they must be made of sufficient 
 thickness and of such material as to be a sufficient pro- 
 tection against the heat of summer and the cold of 
 winter. There are many excellent coverings for flat 
 roofs in the market. 
 
 For the corridors, toilet-rooms, and offices, the 
 flooring may be of asphalt, marble "terrazzo,"or other 
 impervious material. Such a floor, however, would 
 be unsuitable for the rooms occupied by the sick, un- 
 less artificially warmed. For these the flooring may be 
 of wood, of the best quality, and laid in the best man- 
 ner, in default of any better material. 
 
 If such permanent fire-resisting forms of construction 
 
HOSPITAL ARCHITECTURE. $] 
 
 are out of the question on account of their greater 
 cost, and it is decided to build of wood, the solid open 
 " mill construction " should be used, as being far 
 superior to the ordinary combustible methods of wood 
 construction. In this case the framework of the 
 building may be of well-seasoned hard pine columns 
 and beams, with outside walls of 3" pine planking, 
 grooved and splined, covered with clapboards, shingles, 
 or Portland cement, and plastered on the inside on 
 metal lathing, which will do away largely with cracking 
 of the plaster. Such a wall is a far better protection 
 against the weather than a thin brick wall constructed 
 in the ordinary cheap manner. 
 
 The interior partitions may be, as above, of metal 
 lathing, plastered on both sides, and the floors and 
 roof of 3" planking, with the ceilings plastered on 
 metal lathing. Provision should be made for deaden- 
 ing the floors to the passage of sound. This may 
 be done by inserting several thicknesses of thick 
 sheathing-felt between the planking and the upper 
 flooring. 
 
 Such a construction is " slow-burning," there are no 
 concealed spaces, and the defects of wood as a material 
 are minimized. 
 
 Especial care must be taken in designing the fram- 
 ing to dispose the material in such a manner as to 
 prevent cracking of the plaster surfaces by unequal 
 shrinking of the wood. 
 
 The heating and ventilating systems are so mutually 
 related that they must be considered together. In our 
 northern climate dependence must be placed on some 
 method of artificial ventilation during the greater part 
 of the year. There are also many days, even in sum- 
 
98 SMALL HOSPITALS. 
 
 mer, when natural ventilation by doors and windows is 
 insufficient. If the ventilation is to approach perfec- 
 tion there must be means of moistening, cooling, and 
 filtering the air. It is also especially important that 
 the temperature of the air supplied to different rooms 
 should be under easy control from the rooms them- 
 selves. Furthermore, every portion of the heating 
 and ventilating systems, especially the air-ducts and 
 flues, must be easily accessible for cleaning. 
 
 There is a great variety of systems of heating and 
 ventilation. The one which seems to best meet the 
 requirements of a hospital is the so-called "plenum 
 system," in which the movement of the air is effected 
 by a fan or blower driven by mechanical power. 
 
 In this system the outside air is taken in at one or 
 more definite points, filtered, cooled, moistened, or 
 heated, according to the requirements of the day, and 
 then forced, through a ramifying system of conduits 
 and flues, to the various points where it is wanted. The 
 air may receive a further addition of heat in its course 
 to the different rooms, varying in each case according 
 to the particular need. 
 
 The supply of air, from its entrance to the building 
 to the points of distribution, is under perfect control. 
 By varying the speed of the fan the amount of air sup- 
 plied maybe increased or decreased, and by varying the 
 amount of heating-surface or by the use of mixing- 
 valves the temperature may be controlled without 
 changing the amount of air supplied. 
 
 Outlet shafts for the foul air must be built for every 
 room, whatever system of ventilation is employed. 
 But with the power-fan in operation every such shaft 
 will draw well, whereas with other systems they 
 
HOSPITAL ARCHITECTURE. 99 
 
 must often be artificially heated to make them 
 work. 
 
 Such shafts or conduits should take the shortest and 
 most direct course to the outer air, and not be carried 
 any great distance within the building itself, so that 
 the foul air may be got outside of the building as 
 quickly as possible. 
 
 It is a good plan to provide open fireplaces, both 
 for the cheer they give and also as a resource in case of 
 temporary failure of the regular system of heating. 
 
 For the plumbing nothing but the very best is suit- 
 able for a hospital. The fixtures should be simple and 
 substantial. All plumbing devices of a complicated 
 nature should be viewed with suspicion. Plumbing 
 fixtures in connection with sick-wards should be iso- 
 lated, so that odors may be cut off. 
 
 The above are but a few of the considerations which 
 should govern hospital building. The reader who 
 desires to pursue the subject further may consult the 
 following books : 
 
 Notes on Hospitals (Third Edition). Florence Nightingale. 
 London, 1863. 
 
 Hospitals: their History, Organization, Management, and Con- 
 struction. W. Gill Wylie, M.D. New York, 1877. 
 (This excellent book is unfortunately out of print.) 
 
 Hand-book for Hospitals, No. 32. State Charities Aid Asso- 
 ciation. New York, 1883. 
 
 Hospitals and Asylums of the World. Henry C. Burdett. 
 London, 1891. 
 
 Healthy Hospitals. Sir Douglas Galton. London, 1893. 
 
 Hospitals, Dispensaries and Nursing. Baltimore, Johns Hop- 
 kins Press, 1894. 
 
IOO SMALL HOSPITALS. 
 
 Description and Plans of a Small Hospital. 
 
 The accompanying plans are an attempt to put into 
 a concrete form the " permanent hospital building," the 
 special needs and requirements of which have been 
 enumerated in Chapter VIII. It is assumed that an 
 ideal site has been secured, with ample room for future 
 extension. The plan (see Plate I) shows a lot of about 
 six acres in extent, bounded by a street on one side 
 only. It will be observed that each building is in plan 
 a simple rectangle without wings, L's, or re-entrant 
 angles. The buildings are grouped in alternate succes- 
 sion on opposite sides of a corridor, which is the avenue 
 of communication between them. This arrangement 
 leaves the ends of the buildings free and insures an 
 end-to-end ventilation of the wards. The axis of the 
 corridor lies northwest and southeast. All of the build- 
 ings, except the Administration Building, are but one 
 story high, with a basement, and all have flat roofs, the 
 under side of which forms the ceiling of the room 
 below. The roofs are rendered non-heat-conducting 
 by a covering of pine planking four inches in thick- 
 ness. 
 
 The Administration Building, which occupies the 
 centre of the group, is two stories high. This plan 
 supposes a hospital laundry and a nurses' home in 
 separate buildings outside, and is the ideal arrange- 
 ment ; but if land is too valuable the Administration 
 Building may be built three stories high, with a laundry 
 on the top floor (the least objectionable location), and 
 rooms for the nurses on the second floor. By this 
 arrangement the Nurses' Home and the Laundry build- 
 
Crtfitagfous'Ward* 
 
 - Boiler • Honse,' Morpie 'and 'HoreeTihefe' 
 
 fe p^^^^CT^^^^?^^ 
 
 •Ground' 
 
 "Scale -of' 
 
PLATE I. 
 
 'laundry 'Building^ 
 
 •Ward' 
 
 'Ward' 
 
 Plan- 
 
HOSPITAL ARCHITECTURE. JOI 
 
 ings could be dispensed with. It is much better, how- 
 ever, to provide for these separately, as shown upon 
 the plan. 
 
 The corridor is to be left open in warm weather. In 
 winter it is to be closed in with glass sufficiently to 
 afford protection to the nurses on their way back and 
 forth. 
 
 The Administration Building, which, from its greater 
 height, casts more shadow than the ward pavilions, is 
 placed so that its shade falls during the greater part of 
 the day clear of the other buildings. 
 
 The capacity of the hospital may be increased by 
 continuing the corridor in either direction and adding 
 extra wards. Two such wards are shown in shaded 
 lines upon the plan. (See Plate I.) 
 
 The buildings occupied by the sick are furthest 
 removed from the street ; and the least agreeable build- 
 ings of the group from their associations, the Contagious 
 Ward and the Morgue, are placed where they are least 
 likely to be seen by the patients. The Morgue is 
 furthermore concealed by being combined in a group 
 with the Boiler-house and Horse-sheds. A separate 
 entrance from the street, with high wall and gate, is 
 provided at this point, hidden from the other buildings, 
 for the entrance of coal-teams and for the hearse. 
 
 The horse-sheds are commanded from the windows 
 of the Administration Building, so that the doctors 
 may be relieved of all anxiety concerning their horses. 
 
 The ward pavilions are composed of two portions, 
 the Main Ward, and its service-rooms. The body of 
 the building, containing the Main Ward and the Sun- 
 room, rises above the rest of the building about four 
 feet. The break thus made in the roof allows of a 
 
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HOSPITAL ARCHITECTURE. 103 
 
 window high up at the inner end of the main ward, thus 
 giving an end-to-end ventilation. (See Plates II and 
 III.) 
 
 The Main Ward accommodates 14 beds. In the 
 centre is a chimney with two open fireplaces. At the 
 southern end is a Sun-room with glazed sides, and 
 beyond this a platform with an Incline, so that patients 
 may be wheeled down onto the turf. 
 
 The dimensions of the common wards are as follows : 
 
 Height of ward 14 feet. 
 
 Width " " 30 " 
 
 Length " " 56 " 
 
 Lineal bed space 8 " 
 
 Floor space for bed 120 sq. feet. 
 
 In connection with the main ward are two isolation 
 rooms, u' 9" X 11' 9", each with an open fireplace. 
 Opposite is a room for the nurse, with a window com- 
 m manding the ward. The plumbing fixtures consist of 
 "a sink, a slop-hopper, a hand-basin, two water-closets, 
 and two bath-tubs, one of which is portable. They 
 are cut off from the rest of the building by solid parti- 
 tion walls which extend down through the basement, 
 and are reached by way of an outside semicircular 
 Lobby built out from the north wall of the pavilion. 
 This Lobby has three large windows, which are always 
 to be left open a few inches, even in winter, to secure a 
 constant passage of air across. The plumbing fixtures, 
 though under the same roof, are thus as effectually 
 isolated from the ward as if built in a separate tower 
 or annex. The room in which the plumbing is con- 
 tained is lighted from above by a large skylight through 
 which the sunlight comes. The floor and walls are 
 
104 SMALL HOSPITALS. 
 
 impervious, so that the whole apartment may be 
 washed down with a hose. There is a large room for 
 the storage of patients' clothes, with a door opening 
 onto the outside corridor. In front of each pavilion 
 the width of the Main Corridor is increased to twelve 
 feet. There is a stairway giving access to the subway 
 below. The two ward pavilions are duplicates of each 
 other. 
 
 The general floor level of all the buildings is about 
 six feet above grade. This secures the privacy of all 
 the rooms, and gives a light and airy basement. 
 
 To the southeast of the Administration Building is 
 the Private Ward, a pavilion containing five patients' 
 rooms. These are n' 9" X 13' 9", with an open fire- 
 place in each. Each of these rooms also has the sun. 
 The isolation of the plumbing is effected in the same 
 way as in the common wards above described. (See 
 Plate IV.) 
 
 The Contagious Ward (see Plate V) stands at some 
 distance from the other buildings. It consists virtually 
 of two separate hospitals under one roof. A solid 
 partition wall divides the building in the middle. The 
 wings containing the patients are one story in height ; 
 the central portion of the building, containing the 
 rooms of administration, is two stories in height. The 
 building accommodates eight patients in separate 
 rooms. The plumbing is isolated by an outside plat- 
 form, and the second floor (see Plate VI) is reached by 
 outside stairways. 
 
 On the opposite side of the Administration Building 
 from the Private Ward is the Surgical Building (see 
 Plate VII). This contains the most important room in 
 the hospital, the operating-room. A Corridor eight 
 
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PLATE IV. 
 
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 •Main •Corridor* 
 
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 Private Ward' 5 
 
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 — i— 
 
 20 
 
 — t— 
 
 30 
 
 — I 
 
 Scale of Feet 
 
 106 
 
HOSPITAL ARCHITECTURE. 107 
 
 feet wide runs through the building from end to end. 
 Patients enter the building from the Main Corridor and 
 are taken directly into the Etherizing-room. When 
 everything is ready they are taken across the corridor 
 into the Operating-room. This room is absolutely 
 bare. Everything necessary for an operation is brought 
 in on glass tables and taken out again as soon as the 
 operation is over. The floor and walls are impervious, 
 and the floor drains to the centre. There is a window 
 on the northwest wall and extending without a break 
 as a skylight half-way back into the ceiling. Just 
 across the Corridor, directly opposite, are two rooms, 
 a dressing-room for the surgeons and an instrument- 
 room. 
 
 For the reception and treatment of accident cases a 
 separate room is provided, which is a duplicate of the 
 Operating-room, but with the addition of sinks, hand- 
 basins, and instrument-cases. There is another ether- 
 izing-room opposite. At the other end of the building 
 is the Sterilizing-room, also provided with sinks and 
 hand-basins. There are two Recovery-rooms, with sunny 
 exposure, for patients after operation. At the north 
 end is a covered Porch, for the reception of patients 
 from the ambulance. 
 
 The Administration Building {see Plate VIII) is two 
 stories high above the basement. Visitors enter a large 
 Hall, which also serves as a waiting-room. This hall is 
 entered from a Vestibule from which on one side opens 
 the Office and on the other side a room for the janitor 
 wjth circular stair to the basement. Opening off the 
 hall is the doctors' Library, and beyond this a room for 
 the head nurse. 
 
 The Dining-room is of ample size, and has a China 
 

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PLATE VII. 
 
 Surgical Building' 
 
 1 1 1 1 1 1 
 
 10 
 
 20 
 
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 30 
 
 — I 
 
 Scale of Feet 
 
HOSPITAL ARCHITECTURE. Ill 
 
 Closet with sink for washing dishes. The Linen Room 
 has the sun nearly all day long. Beyond this is the 
 Nurses' Parlor. Opposite is the Tea Kitchen, which is 
 the depot from which the food is served to the various 
 wards and also to the Dining-room. There is a dumb- 
 waiter service to the floor above. From the Office there 
 is a private passageway to the Rear Hall, giving quick 
 communication to the wards. Off this is a toilet-room 
 for the nurses. 
 
 On the second floor is the Kitchen. (See Plate IX.) 
 Communication is had with the basement by a large Lift 
 on which supplies are brought up. In connection with 
 the Kitchen is a Scullery communicating with the Tea 
 Kitchen below by a dumb-waiter. All the tableware 
 for the sick-wards (excepting the contagious ward) is 
 kept here, and here the patients' meals are prepared 
 and sent down to the tea kitchen to be distributed. 
 
 On this floor is the Matron's Room, with bath-room 
 adjoining, and a Spare Bedroom for visitors. Opposite 
 are two large bedrooms for servants and a separate 
 room for the cook. A large bath-room for their use 
 is provided. 
 
 The Hall is abundantly lighted from a skylight over- 
 head, and the staircase is continued up to the roof. 
 
 The basement of the Administration Building con- 
 tains a cold-storage room for provisions, bins for the 
 kitchen coal and for the wood or coal for the open 
 fires, and a toilet-room for the janitor. 
 
 The steam-boilers for the heating apparatus may 
 also be placed in this basement, but it is better, if it 
 can be afforded, to locate them in a separate building 
 outside, as shown on the plan. (See Plate I.) 
 
 Under the Main Corridor is a subway, about six 
 
PLATE VIII. 
 
 Administration Building 
 
 'First-Floor-Plan' 
 
 IO <!' i 
 
 Scale of Feet 
 
PLATE IX. 
 
 Administration Building 
 
 Second-FIoor-Plan* 
 
 * 
 
 •Scale of Feet 
 
 113 
 
114 SMALL HOSPITALS. 
 
 feet high, in which are placed the hot-air conduits, hot 
 and cold water pipes, gas-pipes, and electric wires. No 
 portion of the waste-pipe plumbing system should be 
 allowed in this subway, since it contains the conduits 
 through which passes all the fresh air for the hospital. 
 
 The buildings are planned to be heated and venti- 
 lated by the plenum system of forced ventilation, 
 which has been described above. A battery of boilers 
 (which may be increased as the hospital grows in size) 
 is located in the Boiler-house (see Plate I). Here all the 
 steam required to carry on the work of the hospital is 
 generated. An underground tunnel, through which 
 the steam-pipes are carried, communicates with the 
 basement of the Administration Building. 
 
 In the Fan-room beneath the semicircular veranda 
 in front of this building is located the heating and ven- 
 tilating apparatus which supplies fresh air to the whole 
 hospital (see Plate V). The air-supply is taken in 
 through large windows in the periphery of this veran- 
 da and forced through conduits hung in the subway 
 beneath the Main Corridor to the various buildings. 
 
 In carrying out the plans above described a begin- 
 ning could be made by constructing the Administration 
 Building, Boiler-house, Surgical Building, and two of 
 the Ward Pavilions. The other buildings could follow 
 with the growth of the hospital. 
 
 The plan as described provides for 45 beds — two 
 ward pavilions of 16 beds each, a private ward of 5 
 beds, and a contagious ward of 8 beds ; and by adding 
 the two extra pavilions shown in dotted lines the 
 total becomes 77 beds. 
 
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 3 1924 012 504 076