HX64076261 R A967 H 1 8 A treatise on hospit RECAP n Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseonhospitOOhamm n«ALTM A treatise: ON HOSPITAL AND ASYLUM CONSTRUCTION; WITH SPECIAL REFERENCE TO PAVILION WARDS. BY GEORGE F. HAMMOND, ARCHITECT. VOL. I. SPECIAL PRELIMINARY EDITION. CLEVELAND, OHIO, 1891. Note — As some of the plans and illustrations contained in this \vork are not original wilh the writer, the general copyright is taken in trust for the un- known originators or owners of thcni. luiU credit is given where known, and should in all cases of reprinting be re- spected. % copy RIGHT BV GEORGR F. HAMMOND, 1 891. CONTENTS. CHAPTER I. Types of Hospitals, ...... i CHAPTER II. Shapes of Pavilion Wards, . . » ,6 CHAPTER III. Relative Position of Pavilions, . . . .16 CHAPTER IV. Skeleton Plans of Hospitals, . . , '24 CHAPTER V. Classes of Hospitals, . . . , .45 CHAPTER VI. U. S. Military Hospitals, . . . . .66 CHAPTER VII. Permanenc}' of Hospitals, , . . .So CHAPTER VIII. Operating Rooms, . . . . o .86 CHAPTER IX. . . Renewal of Air in Wards, . . . -96 CHAPTER X. Relative Capacity of Rectangular an 1 Circular Wards, . 124 CHAPTER XI. Heating, . . . . . . -133 CHAPTER XII. Ventilation, . . . . . .149 CHAPTER XIII. The Use of the Fan, . . . . .167 ILLUSTRATIONS CLASSIFIED. TYPES OF HOSPITALS. Plate i. Fig. i. Block Plan . . . .3 Fig. 2. Corridor Plan, . . .3 Fig. 3. Pavilion Plan, . . .3 THE AULT^L\N MEMORIAL HOSPITAL, CANTON, O. Plate 3. First Floor Plan, . . . .7 " 4, Perspective. . . . . .9 CIVIL HOSPITAL, ANTWERP. Plate 7. Plan of One Pavilion, (See also Plate 12, Page 25 for Arrangement) . . -15 Plate 8. Elevation of One Pavilion . . -17 CHILDRENS' TEMPORARY WARD, LAKESIDE HOS- PITAL, CLEVELAND, O. Plate i i . Fig. i. Plan, . . . -23 Fig. 2. Elevation, . . . 23 SKELETON PLANS OF HOSPITALS. Plate 12. Civil Hospital, Antwerp, . . -25 Lariboisere Hospital, Paris, . . 27 Lincoln Army Hospital, (temporary) Washington, . . . -29 Hicks' Army Hospital, (temporary) Baltimore, 31 Hammond, Sedgwick, and other Temporar}^ Arm}' Hospitals, . . -33 Cit}^ Hospital, Boston, . . -35 Johns Hopkins Hospital, Baltimore, . . 39 San Andrea Hospital, Genoa, . . 43 ONE STORY SURGICAL WARD, CITY HOSPITAL, BOSTON. Plate 18. Fig. i. Elevation, . , . -37 Fig. 2. Plan, . . . -37 Fig. J. Section, . . . -37 13 1 ( 14 Plate 15- ( 1 16. Pl.\te 17- ' ' 19. " 21. PivATE 26. (( 27 Platk 22. ( ( 23- l< 24. ' ' 25- ( ( 28. ( ( 29. 1 1 30. PtATE 31- 1 ( 32. ' ' 33- ' ' 34- U. Plate 36. '^ 37- ( ( 38- 1 ( 39- ( ( 40. 41- Plate 42 " 43- YORK HOSPITAL, FIFTEENTH STREET. Perspective, . . . . -55 Second, Third and Fourth Floors, . . 57 OUT-PATIENT DEPARTMENTS. Perspective — City Hospital, Boston, . . 47 First Floor Plan — City Hospital, Boston, . 49 Second Floor Plan — City Hospital, Boston, . 51 , Third Floor Plan— City Hospital, Boston . 53 Perspective — ^Johns Hopkins Hospital, Baltimore, . . . -59 First Floor Plan — Johns Hopkins Hospital, Baltimore, . . . .61 Section — ^Johns Hopkins Hospital, Baltimore, 63 AN EMERGENCY HOSPITAL. Perspective, . . . . . 65 Basement Plan, . . -67 First Floor Plan, - - - - 69 Second Floor Plan, . . . -71 S- MILITARY OR POST HOSPITALS. Plan for eight or twelve bed Hospital. First Floor . . . . -75 Plan for [twenty-four bed Hospital. P'irst Floor, . . . . -77 Plan for twenty-four bed Hospital. Second Floor, . . . . -79 Plan for thirty-six bed Hospital, First Floor 81 Elevation of twenty-four and thirty-six bed Hospital, . . . . -83 Modification of twenty-four bed Hospital, . 85 OPERATING ROOMS. Perspective of McLane Operating Room, Roose- velt Hospital, N. Y. . . .87 Plan of McLane Operating Room, Roosevelt Hospital, N. Y. . . .89 O PK R ATI N G ROOM S— Con tin u e d . Pltak 44.. Perspective of Bradlee Operating Room, Massachusetts General Hospital, Boston, gi 45. Plan of Bradlee Operating Room, Massachu- setts General Hospital, Boston, . . 93 " 46. Interior of Bradlee Operating Room, Massa- chusetts General Hospital, Boston, , 95 inp:xpensive operating and emergency ANNEX. Platk 77. Floor Plan, . . . . .161 " 7S. Elevation of Frouc, . . . . 163 " 79. Elevations of each End, . . .165 COMPARISONS OF CIRCULAR AND RECTANGULAR WARDS. Platk 47. Wards of equal perimeter, 135 feet, . . 97 " 62. Wards of equal perimeter, 198 feet, . . 127 " 63. Wards of equal perimeter, 135 feet, . 129 CANCER HOSPITAL, NEW YORK. Platk 4S. Perspective, . . . . -99 " 49. Second Floor Plan, .... loi WARREN WARD, MASSACHUSETTS GENERAL HOSPITAL, BOSTON. Platk 50. Perspective, ..... 103 " 51. Floor Plan, . . . . . 105 OCTAGONAL Wx\RD, JOHNS HOPKINS HOSPITAL, BALTIMORE. Platk 52. Perspective, ..... 107 53. First Floor Plan, .... 109 RECTANGULAR W^ARD, JOHNS HOPKINS HOSPITAL, BALTIMORE. Platk 54. Perspective, . . . .111 " 55. Floor Plan of Head House, . -113 " 56. Floor Plan of Ward, . . . 115 " 57. Section through Ward, . . • u? ROYAL INFIRMARY, IJVERPOOL. Pirate 58. Bird's Eye View, . . • • ^^9 59. Plan of Circular Ward, . . .121 60. Plan of Rectangular Ward, . . .123 HOSPITAL FOR A CITY LOT. PivATEi 64. First Floor Plan, . . . -131 " 65. Perspective, . • • , • -135 SUGGESTION FOR CIRCULAR WARD PAVILION. Pi,ATK 66. Basement Plan, . • . -137 " 67. First Floor Plan, . . • -139 68. Section, . . • • .141 " 69. Elevation, . . • • -143 CAMBRIDGE HOSPITAL, CAMBRIDGE, MASS. PI.ATE 70. First Floor Plan, . . • • HS " 71. Perspective, . . . • • i47 AMPHITHEATRE, JOHNS HOPKINS HOSPITAL. BALTIMORE. Plate 72. Plan, . . . • • -151 ** 73. Section, ..... 153 MARY HITCHCOCK MEMORIAL HOSPITAL, HANOVER, N. H. i Plan of Ward and Head House, . . 155 Section of Ward and Head House, . • i57 Elevation of Ward and Head House, . 159 MISCELLANEOUS PLATES. An Improper Arrangement, . • • 5 Example of Toilet Plan, . . .11 Nierensee's Octagonal Plan, . . -13 Miller Memorial Hospital, Greenwich, Eng. 19 Soldiers' and Sailors' Orphans' Home Hospital, Xenia, O., . • • .21 MISCELIvANKOUS PLATES— Continued. Plate 20. Perspective of Johns Hopkins Hospital, Baltimore, ... 41 " 35. A Temporary Structure for Contagious Diseases, 73 " 61. Anemometer for Measuring Air, . -125 " 80. /•>";'. / — Herbert Hospital Toilet Pavilions, Woolwich, . . . .169 Fi'o. 2 — General Infirmary Toilet Pavilions, Leeds, ..... 169 Fig. J — Royal Infirmary Toilet Pavilions, Edinlnirgh, . . . 169 Plate 81. F/'o-. i — Woolwich and Norwich Hospital Toilet Pavilions, Norwich, . • 171 Fig. 2 — Western Infirmary Toilet Pavilions, Glasgow, . . . 171 Fig. s — Royal Infirmary Toilet Pavilion, Liverpool, . . . -17- Fig. / — Suggestion for a Toilet Pavilion, . 171 PREFACE. A friend, to whom a selection from this book was sent before "going to press," wrote, "I do not know whether you submit the quotation from your forthcoming book with intent of having it criticised or not, but I fear that reviews of the book will con- tain criticisms of what you say." Having prepared it from an interest in the subject and because of the pleasure derived from jotting down one's thoughts on paper, rather than with a premeditated idea of publication, the prospects of its being honored by a "review" had not been considered by the writer. The answer may be quoted from the Autocrat of the Breakfast Table. "I wonder if anybody ever finds fault with anything I say at this table when it is re- peated? I hope they do, I am sure. I should be very certain that I had said nothing of much sig- nificance, if they did not." As it is not written with the expectation of mak- ing every physician his own architect, the plates are merely outlines intended to visibly demonstrate the letter press; therefore. flues, air spaces and other necessary details are not, as a rule, indicated. The book's "raison d' etre" is the fact that while some pli}-siciaiis luivc acquainted themselves M-ith the sub- ject, more have — very properly — couceutrated their thoughts on matters pertaining more directly to their private practice, and who, when they are called on for advice on the subject (as they are liable to be at an}' time) naturally turn for reference to the earlier works on the subject. From them they are liable to infer that the fan for heating or ventilating is "a weak invention of the enemy"; that a fire place, instead of being a val- uable adjunct on account of its ventilating qualities, is the onh' proper means of heating a ward ; that because old fashioned plumbing is offensive no modern work can be sanitarily correct, and must be banished to a semi-detached pavilion, which while desirable as affording an additional securit}^, the writer does not consider essential if reasonable attention is paid to the cleanliness of exterior surfaces. He further believes that wdiile the pavilion hospital should invariably be built wdien the site will admit, other methods of planning may be sana- tive, if earefully stndied^ior "half a loaf (well pre- paredj is better than no bread." He further believes that a successful plan is more important than an imposing exterior, though the latter should not be sacrificed if it can be helped. While Hospitals and Asylums are so closely allied that the dividing line is scarcely discernible. it seemed advisable to separate these subjects in this work, altliougli iiiucli relating to one is equally applicable to the other. This division is all the more difficult to deter- mine because the trend of professional parlance is to apply the term ''Hospitals" to all institutions for the treatment of the insane. But while the writer is in accord witli this practice, lie has adhered to the older and more significant term "x\sylums" to Avliich is devoted the second section of this work. A plea is made for specialism in both hospital and asylum construction, with the belief that soon special hospitals for the treatment of Gynaecological and Lying-in cases and special asylums for the treatment and segregation of Bpileptics and also Insane Criminals, will be recognised as advisable. The writer makes no pretensions to any medical knowledge beyond that acquired in the study of hospital construction, and the few medical terms have been used because they best convey his mean- ing. Reports or information concerning newly erected or proposed hospitals or asylums will be gratefully acknowledged by him. Having thus expressed the object of this work, it is sent forth with the hope that it may add its mite to the knowledge of these buildings ; the sub- scriber being solely responsible for the status of the original theories advanced herein. Cleveland, Ohio, GEORGK F. HAMMOND, May, i8gi. architect. NOTE. The writer desires to express his obligations to the follow- ing physicians for letters of information, or conrtesies extended at the numerous hospitals visited by him. H. H. Powell, M. D., Cleveland. R. B. Dixon, M. D., Boston. G. H. U. Rowe, AI. D., Supt. and Res. Physician, City Hos- pital, Boston. Edward Cowles, M. D., Med. Supt., McLean Asylum, Somer- ville. John \V. Pratt, M. D., Res. Physcian, Mass. Gen. Hospital, Boston. George P. Ludlam, M. D. , Supt. New York Hospital, New York. Jas. R. Lathrop, M. D., Supt. Roosevelt Hospital, New York. Willard D. Becker, M. D., House Surgeon, Cancer Hospital, New York. Henry M. Hurd, M. D., Supt. Johns Hopkins Hospital, Baltimore. P. M. Wise, M. D., Med. Supt. St. I^awrence State Hospital, Ogdensburg. William A. Hammond, M. D., Washington. John B. Hamilton, U. S. Marine Hospital Service, Washington. Georges Angenot, M. D., Civil Hospital, Antwerp. Herbert Jones, B. A., M. B., M. R. C. S., Miller Memorial, Greenwich, Eng. And to the following architects for letters of information and drawings of the following buildings : Charles C Haight, New York, Cancer Hospital. Rand and Taylor, Boston, Mary Hitchcock Hospital. W. Wheeler Smith, New York, McLane Operating Room. Alfred Waterhouse, Eondon, Royal Infirmar}-, Eiverpool. And to other unknown architects whos2 buildings are represented lierein. NOTE SPECIAL PRELIMINARY EDITION. This volume is one of a small preliminary edition whicli the writer has had printed for convenience in making references in the succeeding volumes. For this reason and because it has been pre- pared during the interim and subject to the inter- posing duties of Architectural engagements, no careful revision of grammatical and typographical errors has yet been made. The scope of the entire work will be substan- tially as follows : Vol. I. Hospitals. General Introductory. Vol. II. Asylums. General Introductory. Vol. III. Construction and Sanitary Devices. Vol. IV. Special Departments and Stationary Fixtures. The letter-press and some of the illustrations of the first three volumes are ready and will be pub- lished with such additional volumes as the writer's time and means will permit. GEORGE F. HAMMOND, Cleveland^ O., architect. Septeviber^ 1891. CHAPTER I. TYPES OF HOSPITAI^S. Hospitals may be divided into tliree general types according to tlieir outline or plan, viz : First, Block planned; Second, Corridor planned; Third, Pavilion planned. Until a comparatively recent date hospitals were planned on either the Block or Corridor system, the former being the most common. Now it is obsolete so far as planning new buildings is concerned, and it is to be hoped that it will not be many years before the use of the Block hospital is abandoned. It consisted of any irregular shaped building of large size, say rectangular, subdivided by interior walls into connecting wards : this made it frequent- ly necessary to pass through one ward to get to another, although, of course, some had entrances on halls. It also prevented the wards from having light on both sides, while beds were placed against the interior partitions that were perforated b}- occasional door openings. These admitted the air from one ward to another, by reason of the draft, to be breathed by the patients of both wards in common. 2 HOSPITAL, AND ASYLUM CONSTRUCTION. The two latter S3'Stenis must uot be con- founded : ■ althougli both ma}^ have corridors, the corridor S3'steni per sc consists of a building having a corridor along one side or in the center, with wards opening from it, the corridor partition forming one side of the w^ard. The ^vards w^ere therefore lighted on one side onty, beds were arranged on both, and there was no noticeable difference in the interior appearence of the wards of the block and corridor plans, althougli the marked difference in separating them by a corridor is easily perceptible. In the pavilion plan, the corridor still connects with the wards, but they are separated from each other so that light is admitted to them on two and usually three sides, their ends connect wdth the corridor, and windows are placed in the corridor walls betw^een the w^ards. These are the t3'pical characteristics of the three classes of hospitals, although modifications of each have been erected that were great improve- ments on their prototypes. Plate I, page 3 shows the three systems. Fig. I, Block plan; Fig. 2, Corridor plan; Fig. 3, Pavilion plan. The writer has prepared a modification of the Block plan in plate 2, page 5, which resembles in some respects the Pavilion plan. It is possible that it might be of some slight value as an opthalmic Fig. 3- Pag:^ 3. Plate i. 4 HOSPITAL AND ASVLl'M COMSTRUCTION. ward, or for couvalesceut cases of measles or scarlet fever, where strong light is objectionable, as there wonld be no glare from opposite windows ; bnt the temptation to place beds against the blank wall as shown, and to change the ward to genera I wsq^ makes it objectionable and renders the plan dangerons. It is shown here as an example of what slionld Jiof be done nnless beds are confined to the spaces between, or next to windows. A modification of the corridor plan, resembling the pavilion plan in some respects, is shown in plate 3, page 7, and is now being erected from the writer's plans. It is his expectation, that eventually semi-detached pavilion wards will be erected in con- nection with it, as shown by dotted lines. It will be noticed that the larger wards have light on three sides, and the single rooms on each side of the corridor are intended for mild cases : the building is two stories in height, one floor being devoted to males, the other to females. Surgical cases will occup}^ one side and medical cases the other. The pavilion plan has been modified in two wa3-s of man}" stages each : first, as regards the shape of pavilions, second, as regards their relative position. The shape of the pavilion has resulted i:i the circular ward as the latest form of construction. While considered experimental until recentl}", its growth h.as been gradual, but steady. H G 1 ) F ^_^,^^ n n n| 1 1 N.-! 1 'J B-% — t lO D B ImmI f 30 35 Plate 2, Page ;. An Improper Arrangement. A, Ward; B, Lobby; C, Connecting Corridor: D, Lavatory; G, Bath Room; H, Nurse. CHAPTER II. SHAPES OF PAVILION WARDS. The shape of pavilion — and of conrse in pavil- ion hospitals this means the ward, — varies greatly, and each form has its advocates. Of course the pavilion itself with its semi-isolation, its fresh air and sunshine, is of greater importance than its shape ; though this too is worthy of serious consid- eration. All pavilions may be divided into the following classes. First, oblong, in which the length is usually about three times the width ; second, square; third, octagonal; fourth, circular. While many examples of wards of each shape may be found in block or corridor planned hospitals dating earlier than all pavilion construction, it was by these stages, wheii applied to pavilions^ that the circular form which is the latest, was reached. The development of the circular pavilion hospi- tal was slow, and its success was assured only after repeated failures of many other forms, — although the failures were usually on account of their arrange- ment or relative location rather than because of their shape. r v. / pL, E - i ioL J ,.-.-.!. -,i-.). £ S K I I i ° En (^ w c C M .2 _o o ■!-> ei +-» > O- rt E •-^ 'C *^ o c rt r" -f o o r " ^o h- c rt u C CAl sj c 't; .' rt __ .^ v^/ •-r" C/5 o '^^ , E v: ^ rt r<~. (U C M s _0J s £ f^ c rt o >^y c: 1 Oh o c "s .— tJO ij ti: < >, rt c o rt PL, 'rt o PP ^ s en 15 CT! ^ -•- -•' rt s ^- o ^ o ^H V . -N ^ ^ ^ ^ tn rt > ^<_ \ _« • ' L... ...L;:. 8 HOSPITAL AND ASYLUM CONSTRUCTION. Among the first buildings attempted with rectanguhir pavilions, was the often referred to Lari- boisiere hospital, built in Paris in 1S54 ; it was mostly three stories in height, but the stairs were so arranged that there was direct communication by them from one floor to another so that no isolation of v.'ard air could be obtained. The new Hotel Dieu in Paris, completed in 1876, is another example of the man3'-storied pavilion hospital, but it has been severel}^ criticised by French authorities on Hospital work. It was during the Franco-Prussian war, just previous to the completion of this building, that the Toilet S3'stem of hospital construction was inaug- urated. It consisted of a one story pavilion with windows on both sides, with the corners rounded, and with a cylindrical or elongated dome ceiling in the ward. The roof had a decided pitch, being usually covered with shingles or slate. Along one side it was customary to build a balcony or piazza. The toilet apparatus was built in a semi-detached pavilion. The entire building was set on a series of posts or piers so as to admit of a free circulation of air under as well as around it. It was usually heated b}^ a stove or stoves set in the centre of the ward, or by fire places. This Toilet system of construction is well adapted for military or field uses, and for temporary rather than for permanent buildings in this country 'firmi II rgnf k^ ,' lO HOSPITAL AND ASVLU.M CONSTRUCTION. where tlie climate is so variable and severe : it was the progenitor of most modern pavilion hospitals of this class. Plate 5, page 11. It was also about this time, or shortly previous, that a plan for an octagonal ward was produced by the late John R. Niernsee, an architect of Baltimore. The ceiling of this pavilion ward was arranged to pitch in straight lines towards the centre, and fire- places were located in the centre for ventilation as well as heating. It contained beds for 24 patients and had a diameter of a little over 60 feet. The advantage of a -ward of this shape can be readily seen, as it admits sunlight from all points of the compass during the entire day if it is properly located. It has in connection with it certain administra- tion rooms, and they are designed to be connected by a continuous enclosed corridor leading to the other similar pavilions. While some portions of this plan are open to criticism, it at that time represented a step some- what in advance of those mentioned before. The diameter of the ward (60 feet or more), seems to be excessive ; as a rule from 30 to 45 feet are sufficient, and it would seem injudicious to construct these wards of a greater diameter, than 50 feet. Where a larger number of beds must be accommodated in one ward than can be accomodated in a ward of this 12 HOSPITAL AND ASVLUM CONSTRUCTION. diameter, it would be preferable to erect an obloug shaped ward : because altliougli the beds are placed at the walls, the centre of the ward should be well lighted, and twent3'-iive feet is quite as far as it will well illuminate in wards of usual height. Another reason is that there would be dif&culty in obtaining an equal distribution of fresh air, and in preventing areas of stagnation in the ward. Plate 6, page 13. We will now consider a ward that is in many characteristics different from any other, viz: a circular ward with a domed or sloping ceiling. An example of it may be found in the Civil Hospital of Antwerp, plate 12, page 25, which shows to advantage the skeleton plan of the entire building, and plate 7, page 15, which shows an enlarged drawing of the arrangement of one of the wards or pavilions. It represented the newest form of pavilion construction. It attracted much attention because it was the first building planned in this manner to be used for hospital purposes. Each ward has a diameter of 61 ^ feet and an average height of 17 feet. The space which is divided off in the centre for the nurse is not intended as a sleeping apartment. It is fitted up with shelves on which are put bottles for medicines, dishes and other articles needed in the ward. The beds are arranged for 26 patients. It is claimed that any domed ceiling produces air currents which materially aid natural ventilation, — particu- A, Ward. B, Fireplace. C, Scullery. D, Lobby. E, Water Closets F, Sink. G, Linen. H, Closet. I, Dumb Waiter. Nurse. K, Lobby. L, Bowles, General Bath, Vapor and Shower Bath. Patients' Wardrobe. Hall. Connecting Corridor. ', Ventilating *o 60 I Plate 6, Page 13. Niernsee's Octagonal Ward. 14 HOSPITAL AND ASYLUM CONSTRUCTION. larly if the dome is not too flat. This was noticed in church buildings used temporarily as hospitals many years ago, but the discovery does not seem to have been utilized until recently. It is undoubtedly true that these currents of air exist in rooms with ceilings of this form, but to what extent they possess superior sanitary con- ditions, cannot very well be decided on account of the lack of unity in size, heating and ventilating arrangements of wards of this shape, which would render it difiiciilt to form a true comparison. But if the ventilation is obtained by mechanical means, it would seem that a flat ceiling would be sanitarily correct because the ventilation is assured and con- Unuous^ and does not require the aid of a sloping form to lead to the apertures in the ceiling, in order to facilitate the escape of foul air and gases thereby. Immediately following the Antwerp hospital was commenced the construction of the Miller Memorial hospital near Greenwich, England : it too, was constructed with circular wards containing ten beds and with a diameter of thirty-five feet. On some accounts it attracted more attention than the Antwerp Civil Hospital, and in a letter from the resident physician in 1887, the writer was informed that the success attending this ward, its conveniences and its facilities for light and air, were of so superior a nature that the erection of another was contemplat- ed in the near future. Plate 9, page 19. A, Ward; B, Ward Utensils; c, Heatinj^ Columns; C, Ventilat- ing Column ; D, Con- necting Lobby ; E. F. Separation Wards; G, Hall; H, Stair-well; I, Stairs; J, Poultice room containing chute to basement; K, Sep aration Ward ; L, Elevator; M, Stairs to s]jace above w^ard and roof; N, Diet Kit- chen ; (), Bath; P, Lavatory; (), Bowls; R, IJrinalsl; S, Water Closets; T, Scullery; U, Corridor roof con- necting with other wards. Plate 7, Page 15. Circular Ward, Civil Hospital, Antwerp. See also Plate 12, Page 25. CHAPTER III. REI.ATIVE POSITION OF PAVILIONS. As regards the relative position of pavilions, the most popular is the arrangement in which their medial lines are parallel with each other. The rea- sons for this are, that in even the largest institutions, sufficient land to place them any other way and secure the requisite accomodations is frequently unobtainable, and because they all bear the same relative position to the points of the compass and receive the sun alike. This arrangement may be advantageous for oblong pavilions receiving the sun principally on one or two sides, but is not of so much importance in locating octagonal or circular pavilions which may receive light and sunshine equally well from any direction. In all hospitals there have been attempts to completely isolate surgical and medical wards. With the best pavilion plans, there has been, according to the number of stories, a distance of 50 to 100 feet between the pavilions when placed par- allel with each other. This is undoubtedly suf&cient, because contao'ious diseases should not be received o X w 7^ n > < u M— < oo o w Td H rri <; '-^ PL, W l8 IIOSPITAI. AND ASYLUM CONSTRUCTION. in common with other cases. Regarding the dis- tance between them, it may be governed entirely by the height from the first floor to the top of cornice, and most writers have decided (when they have mentioned it at all) that twice the height of the pavilion is snflicient (meaning from the gronnd). It should be borne in mind that this is to allow direct sunlight to shine into the sides of the lower wards as early and as late as possible, as well as to secure satisfactory isolation. Attention is called to the following cut showing the advantage of a low pitched roof, and the writer has adopted for his guidance a rule which is given here for what it ma}'- be worth. lo 5 o lo 20 30. I mmI ,i,i | I I -I ^^t^^ j\Iake the inclination of the roof 26° 34' (quarter pitch), and continue the line of it until it intercepts the line representing the lower floor level. This will give the minimum distance between parallel pavilions, and prevent the attics being improperly used for temporary wards. Of course a steeper pitched roof should not change the angle Second Floor Plan, Miller Memorial Hospital, Greenwich, Eng. 10 Itl i 1 1 (O q:o 30 Plate 9, Page 19. 20 HOSPITAL AXD ASYLUM CONSTRUCTION. Avhich would then be made b}^ drawing a line from the ridge of the roof to intercept the floor line as before. But the value of octagonal or circular wards seems to the writer to be enhanced b}^ the curved or half circle position, with radiating and circumfer- ential platforms, not enclosed by walls. This ensures isolation, places the pavilions equally distant, and prevents the wdnd from getting a straight range over and through the entire line of pavilions, as would be the case if the}^ were placed parallel with each other. Plate lo, page 21, fig. i, shows a skeleton plan of a children's hospital, now erecting from the writer's plans, in which this arrangement is to be carried out. The figures on the pavilions indicate the uses to which they may be put. i. Measles ; 2, Scarlet fever; 3, Diphtheria ;4, Medical ward; 5, Opthalmic and Aural ; 6, Surgical ward ; C, Administration. As the buildings are being erected from time to time, modifications of these divisions may be made and the writer considers the administration build- ing — as planned — too small, tJioiigh as extensive as t lie funds will admit ; he has recommended its en- largement as in modified plan on plate 10, fig. 2. The first octagonal pavilion on this plan erected by the writer, is the one built in connection with the Lakeside Hospital in Cleveland, and is a temporary A, Pavilions; B, Plat- forms; CHall; D, Boys' Waiting Room; E, Girls' Waiting Room; F, China Closet; G,Officers'Dining Room ; H, Dispen sary; I, Sitting ""^ Room; J, Reception Room; K,Ofifice; L, Piaz- za; M, Vestibule; N, Plat- forms to Isolating Wards; O, Operating Room; P, Etherizing Room; Q, Re- covery Room; R, Toilet Pavilions; S, Lobby; T, Special Cases. Plate io, Page 21. Ohio Soldiers and Sailors Orphans' Home Hospital, Xenia, O. 22 liuSl'ITAI. AND ASVLUM CONSTRUCTION. Structure, costing less tlmu ^3.000, including all plumbing and steam fitting. It is provided witli a solarium, and the ward contains beds or cribs for twelve patients (cliildren) ; it is heated by steam, assisted — for ventilating purposes — by four fire places, and four registers in tlie ceiling, above wliicli is a large air space under tlie roof. An illustration of it also is shown on plate 11, page 23. Provision is also made for a special room, and a nurse's room in connection with it and the ward ; the special room is not intended for contagious diseases, but for an interesting case or one which demands isolation. Toilet arrangements are not arranged in a separate pavilion, although there is a lobby between them and the ward ; a small closet is provided for physi- cians' use, and a closet, which has a window in it, opens out of the ward. Although it is not especially intended for linen, it can be used for that purpose. The whole structure is connected to a permanent building belonging to the U. S. Government operat- ed by the Lakeside Hospital Corporation until the end of a nearl}^ expired lease, when it will probably be removed. Therefor the cost was kept at a mini- mum and the excellent results of the heating and natural ventilation are all the more gratifying for that reason. An account of the results of a test by the writer, showing the ventilation in this ward, is given in the chapter on the renewal of air. A, Ward; B, Warm Air Registers; C, Ceil- ing Registers; D, Fire- places; E, Solarium; F, Radiators; G, Special Room; H, N u r s e's Room; I, Closet; J, Physician's Closet; K, Toilet; L, Hall. Plate ii, Page 23. Temporary Ward, Lakeside TTo>pital, Cleveland. CHAPTER IV. SKELETON PLANS. Almost tlie first tiling to be decided after de- termining tlie sliape and cliaracter of tlie pavilions, is of course, tlie arrangement of tlie outline or skeleton of tlie hospital. Many forms liave been used, and it may be interesting to note some of tlie tj^pical outlines wbicb bave been given tbem. No attention bas been paid to tbe precedence of tbe skeleton plans in tbis work, eitber as regards tbe date of erection or permanency of tbe buildings. A furtber description of some of tbese hospitals may be found in anotber cbapter. On some of tbe plates wbere more tban a mere outline is sbown, tbe black portions denote two or more stories of lieigbt : scored portions represent one story enclosed : outlined portions represent open or enclosed galleries, corridors and platforms. As some of tbe buildings do not now exist, baving been temporary structures, all of the departments are not lettered, as tbe general outliue ratber tban detailed information i:i the object. Plate 12, Page 25. Skeleton Plan, Antwerp Civil Hospital. See also plates 7 and S, pages 15 and 17. 26 HOSPITAL AND ASYLUM CONSTRUCTION. The Antwerp Civil Hospital, of v.-liicli an enlarged plan lias been given on prccceding pages, is shown on page 25, plate 12. The letters on the plan indicate departments as follows. A, Administration bnilding containing of&ces and ad- ministrative departments. B, Operating Pavilion. C, Alorgne. D, Chapel. E, Kitchen, sewing room, store rooms etc. and Pharmacy and Chemical Labora- tor3\ F, Dormitories of the Sisters of Charity who act as nnrses in this institution. G, Russian, Turkish, and Roman — as Avell as ordinary — bathing pavilion. H, Laundry and Engine rooms and appurtenances, with Boiler room underneath. I, Pavilions for pa3dng patients. J, Circular wards with rectangular "head houses," and toilet pavilions. The total number of circular wards is 16, (two in each pavilion) in addition to which there are 4 rectangular wards for children in one of the central buildings. The LariboisierE Hospital of Paris, as re- presented on page 27, plate 13, has served as a proto- type for many hospitals in different parts of the world, though it is claimed that it is defective in that the ward pavilions are not sufficiently distant from each other, and that the stairs prevent a satis- factory isolation of ward air. The buildings are mostly three stories in height, connected by a gallery and one story sections, and enclosing a large Plate 13, Page 27. Skeleton Plan, Lariboisiere Hospital, Paris. 28 HOSPITAL AND ASYLUM CONSRTUCTION. cpen court 150 feet by- nearly 400-feet. At the rear there are also two smaller courts. The letters on the plan indicate departments as follows. A, Administrative departments. B, Kitchens etc. on ground floor, Officers' apartments on first and Attendants' rooms on second floors. C, Phar- macy and Laboratories on ground floor and other stories like B. D, One storied Reading Room for males. E, Same for females. F, F, F, Pavilions of three stories for female patients. G, G, G, Same for males. H, Chapel and vestry, containing the tomb of Mme. Lariboisiere. I, I, I, I, I, I, One storied wards or day-rooms. J, Pavilion of three stories for the Sisters of Charity, who act as nurses. K, Laundry and appurtenances on ground floor, Linen rooms on first and employees' rooms on second floor. L, L, Baths for each sex. M, M, Operating rooms. N, N, Morgue and dissecting rooms, Am- bulance department etc. etc. O, O, O, Open courts and gardens. The Lincoln Hospital, was one of the tempor- ary structures erected by the U. S. Goverment during the Civil war, and was located in Washington. A skeleton drawing of it is shonw on page 27, plate 13, fig. I. It was shaped like the letter V and consisted of a series of wards connected by covered, but not enclosed, platforms forming an angle of about 50"^. The chief criticism to be made of the <) c Plate 14, Page 29. Skeleton Plan, Lincoln Hospital, Washington. Erected for temporary use during the Civil War. 30 HOSPITAL, AMD ASYI.UM CONSTRUCTION. arrangement is tliat the wards were not far apart, but the mortality does not appear to have been greater than in similar hospitals of different form. The same length of arms spread to an angle of 90 ° as shown by dotted lines would have added over 50 per. cent, to the distance between the wards, without increasing the cost of construction. Bach ward was constructed of rough boards, whitewashed; roofs covered with tarred paper, and the walls plastered to a height of 8 feet from the floor. There were 20 wards, each 24 feet wide, 187 feet long, 16 feet to the eaves and 20 feet to the ridge, containing 31 beds on each side of the ward, and therefor allowing about 1,300 cubic feet of air space to each bed. Food was conveyed to the wards by means of a railroad 2,156 feet long on the platforms. The capacity was 2,575 patients, including those occupying adjoining bar- racks and 100 hospital tents which had raised wooden floors, where many of the worst cases were treated. The total number of patients treated in this hospital during its operation was nearly 24,944, of whom 1,221 died. The letters on the plan indicate departments as follows. A, Administration. B, B, The two lines of wards. C, C, Tents. D, Kitchen. B, B, Dining Rooms (total seating capacity 860). F, Commissary Department. G, Laundry. H, Sisters' Dormitor- ies. I, Stewards' Quarters. J, Sutler. K, Chapel. M N Plate 15, Page 31. Skeleton Plan, Hicks General Hospital, Baltimore. Erected for temporary use daring the Civil War. 32 HOSPITAL, AND ASYLUM COXSRTUCTION. L, Stable. ^I, Dead-house. X, Guard-house. O, Barracks. P, P, Officers Quarters. The Hicks General Hospitai. at Baltimore page 31, plate 15, was built iu a half circle, with eighteeu, one stor}-, radiating wards ; the buildings were constructed of frame but of a rather more sub- stantial character than those preceding it, although it also was of a temporary nature : in many respects its arraneement was much more desirable than the Lincoln Hospital, as there was more distance between the wards, and the interior court was not occupied b}^ buildings. The connection between wards and the admin- istration building and dining room was by means of a covered platform. The different departments are indicated on the skeleton plan as follows ; — A, Administration building. The first story contained offices for the surgeon and other execu- tive officers, and a library and printing office : on the second floor were sleeping apartments for them. B, Linen room. C, Dispensary and operating room. D, D, Wards radiating from the covered platform. B, Dining room : the chapel and nurses' dormitories, which were above it, Avere reached by outside stairs. The dining room was capable of seating 1,200 patients. F, Kitchen, laundry, engine and boiler room. G, Special dormitory for detailed men. H, Knapsack room, where the property of patients was Plate r6, Page ^^. Skeleton Plan, Sedgwick, Hammond and other similar Hospitals. Erected for temporary use during the Civil War. 34 HOSPITAI^ AND ASVI,UM CONSTRUCTION. kept. I, Commissary store-department. J, Quarter- master's store-departmeut. K, Tank supplying water to tlie buildings. L, Dormitory for guard. M, Stable. N, Wagon liouse. O, Sutler. P, Steward's quarters. Q, Worksliop. R, Isolation ward for contagious cases. In addition to this department tbere were at different points on the ground (outside of the circu- lar portion,) accommodations for the officers ; also the guard room and entrance lodge. The buildings were lighted by gas and supplied from city water works ; the tank was used for the purpose of a water supply in case of fire. Bach ward, at its further extremity, was supplied with a lavatory, bath room and water closet. The building was not open- ed for patients until about the middle of 1865, or the close of the war. The Hammond Hospital was one, of a series of similar buildings erected for temporary hospital uses during the war, and was in mau}^ respects superior to either of the forms we have just examined, in that the distance between the pavilions was greater than in the foregoing examples. Page 33, plate 16. It consisted of a covered platform forming a complete circle with four platforms radiating from the centre of the circle, with wards radiating from the circular platform. There were fifteen one story pavilion wards 24 feet wide by 145 feet long, and an EST Plate 17, Page 35. Skeleton Plan, City Hospital, Boston. 36 HOSPITAI, AND ASYLUM CONSTRUCTION. administration building 40 feet wide and 145 feet long. The wards were very similar to those of the two first examples of temporary structures, being constructed of boards with shingled roofs. They were, like the preceding examples, raised above the ground to allow a free circulation of air under them. The wards had a capacity of 40 beds each, and an air space of about 1,200 cubic feet for each bed. There were two small rooms at each end, three of which were used for nurses and the fourth for a bath room and toilet purposes. Referring to the skeleton plan the departments are sliowu by letters as follows ; — A, Administration building, two stories high, containing the o£fi.ce and dispensary on the first floor, and rooms for the officers above it. B, B, B, Wards. C, Kitchen and engine room, boiler room, store room etc. D, D, Dining rooms. E, Guard house, and store rooms for knapsacks, etc. F, Cis- tern containing 150,000 gallons. The accommo- dation for patients in the fifteen wards was 600. The Boston City Hospital consisted when erected, of five semi-detached buildings exclusive of the working service department. An outline of it, in 1891, is shown on page 35, plate 17. Since its enlargement in 1876, several one story pavilions have been erected, one of which (I) is shown on page 37, plate 18, being the one in which occurred the 'o 5 lU (J b» > kj .2 tJ o CT! o ^ a m if "5 •-1 qj >H C/2 bo ^ ffi a - (-1 38 HOSPITAI. AND ASYLUM CONSTRUCTION. interesting experiments of Dr. Edward Cowles on the subject of ventilation. This hospital, as first erected, was one of the examples (more often found in old than in recent buildings,) of architectural effect out-ranking the accommodations for patients. Therefore wards were arranged in the attics and basement, although the latter have since been given up, and the former are not used to au}^ extent in warm weather. While not as pretentious as many of the more recent structures, it is certainly admirably arranged in one respect, viz., the complete separation of surgical and medical cases. It will be noticed that all surgical cases — either male or female — are on the left of the administration building, while the medical cases are on the right: this arrangement extends even to the Out Patient departments. The surgical and medical attendants are totally separated from each other, when on duty, so that there is no danger of any infection being spread from a medical to a siirgical case, or vice versa^ as might happen if one staff of officers were obliged to attend all cases indiscriminately. The chief criticism to be made of this hospital is that the Aledical, Scarlet Fever and Diphtheria wards, (J, K, L,) are rather too near each other. It might be inadvisable to erect more surgical pavil- ions without removing the kitchen, bakery, refriger- Plate 19, Page 39. Skeleton Plan, The Johns Hopkins Hospital, Baltimore. 40 HOSPITAL, AND ASYLUM CONSTRUCTION. ator and greenhouse to the rear of the lot, which would admit of a open court 125 feet wide between the ends of the one story medical and surgical pavilions. A new greenhouse might be erected in the centre. Communication between the kitchen and each pavilion could be made by an under-ground passage, as well as b}^ the covered platforms, and food would be quickly conveyed in tram-cars as at present. An extensive use of tents is made during the summer season, for serious cases, with gratifying results. Referring to the skeleton plan, the different departments are indicated as follows. A, Adminis- tration Building. B, Surgical Building and Opera- ting Theatre. C, Medical Building. D, Surgical Pavilion, 3 wards. E, Medical Pavilion, 3 Avards. F, Surgical Out Patient department. G, Medical Out Patient department (see also chapter on this subject). H, H, Horse Sheds. I, Surgical Ward, (see also page 37, plate 18). J, Medical Ward. K, Scarlet Fever Ward. L, Diphtheria Ward. M, Male Isolating Ward. Female Isolating Ward above it. N, Greenhouse. O, Kitchen and Bakery. P, Laun- dry. O, Garbage. R, Morgue. S, Boiler House. T, Carpenter Shop. U, Tents. Thk Johns Hopkins Hospitai. of Baltimore is considered the ne phis ultra of the modern hospitals of the United States to-day, but its great cost as ^^li'ii 1 o a, o 42 HOSPITAIv AND ASYLUM CONSTRUCTION. compared witli its capacity will prevent for years to come, if ever, a repetition of all its successful features. The plan was decided upon by tHe trustees after consultation witli a number of well known physicians wlio liad made a study of hospital arrangements, and the work was completed under the most vigilant supervision. The buildings are of brick with stone trim- mings, and while every care was taken to secure the best sanitary results, the external appearance was not neglected. The skeleton plan on page 39, plate 19, shows the buildings as erected, and in faint lines, the plan as projected. The various departments are indicated as fol- lows. A, Gate Lodge. B, Administration. C, Male paying patients. D, Female paying patients. B, Bathing Pavilion. F, Kitchen, Bakery and Boilers. G, Nurses' Home. H, Apothecary, (hospital dis- pensar}') with officers' dining room and servants' rooms above. I, Octagon Ward. J, J, J, Common Wards. K, Isolation Ward. L, Laundr}-. M, Pathological Building. N, Stable. O, Dispensar}^, ''out patient dej^artment). P, Amphitheatre. The basement or ground floor of nearl}^ all of these buildings is on a level with the ground, and is practically unused. The floor of the connecting and enclosed corridor, indicated by heavy lines, is also on the same level, with a flat roof which is on a 44 HOSPITAL A.\D ASYLUM CO^'STRUCTION. level with the first floor of the wards, and is used as a terrace connection between them. It will be noticed that this hospital plan, as projected, differs from those preceeding it, in that all the wards would, if thus built, face in the same direction. Probably the most costly hospital in the world, considering its capacity (300 beds), is the San Andrea hospital of Genoa, Ital}'. Its cost was over $2,400,000, and it was built through the generosity of the late Duke of Galliera. The skeleton plan of it is shown on page 43, plate 21. The six pavilions contain twelve wards of 20 beds each, while a large infirmary ward and separate rooms accommodate the balance of patients. CHAPTER V. CLASSES OF HOSPITALS. Special Hospitals. Many small hospitals in large cities cover a wider field of treatment than is desirable, but the tendency seems to be towards the establishment of special hospitals for the segregation of certain classes of cases. This is one of the natural results of specialism in medical practice, and its advantages are manifold. The specialist is enabled to secure to his patients the attention of nurses educated to the requirements of his special work. There is little danger of in- fection from cases of a different character. The hospital may be located in a cit}^, on a comparative!}' small lot, easily obtainable, instead of necessitating acres at a greater distance from the center of population. As all hospitals are usually private enterprises, the dislike, so common among the better class of people, of "going to a hospital" is lessened : there they are protected from the well-meant but often irritating visits of friends, and the ph3'sician can 46 HOSPITAI^ AND ASYLUM CONSTRUCTION. give tlieni better atteutioii thau if the}'- are scattered about tHe cit}^ iu their liomes. Sucli hospitals would probably be limited to three or four classes, viz : one for Cancer patients ; one for Gynaecological cases ; one for 'Xying In" cases ; and perhaps one for Opthalmic and Aural cases. As population increases these would increase in size, until what might have had its commencement in a city dwelling house, would be occupying build- ings especially erected for its use. The first two classes of patients mentioned above, while not dangerous to others in a general hospital, are them- selves particularly sensitive to infection ; for this reason special hospitals (or at least the most careful isolation), is advised for them. If knowledge of disease has been increased by the labors of specialists, why should not the treat- ment of disease be improved by special hospitals ? Notwithstanding the advent of anti-septic sur- gery, the decrease of mortality percentage, and the greater infrequency of septicaemia than heretofore, what an advantage it will be when the erection of hospitals for special work of the above character will be the I'lde rather than the exception. General Hospitals. While it is desirable that the special cases referred to above should be treated in separate buildings, there is no question i^-^Ms%^nmmitAj&'-M "\ 48 HOSPITAL AND ASVLl'Ar CONSTRUCTION. but that, if necessary, they can be successfully treat- ed in general hospitals provided they are detached, or semi-detached, from the main group of buildings. The other medical and surgical cases can be safely treated in one group of buildings, under one administrative department. A detached auxiliary group should contain wards and private rooms for the treatment of Measles, Scarlet Fever and Diphtheria. One-story pavilions should be provided for them. The general hospital will remain an essential feature of medical practice for all time, and anti-septic surgery and the constant modification of the treatment of disease, under the researches of specialists mostly, render the treatment of medical and surgical cases in one building much safer than was the case not many years since, though separate wings should be provided for each. Of course care should be taken to render the separation of wards as complete as possible, and the extent to which this can be done depends largely upon the amount of land obtainable. Hospitals on City Lots. But it is not always possible to build extended pavilion hospitals of only one or two stories, and when this cannot be done it is necessary to arrange a more condensed plan ; for rather than to have no hospital at all, one planned X B o o ■»-> o n Pi a hn a fl rt y. ti W a 13 Ti c < rt bO Q - »\ a; a H o ^ o o ho ■ -N rl bO a rt t— < t^ :3 4-> o rt u > >- CU Ph 'a ^ o r ^ bC )h c o . -s • r^ n a c q:: o 9. Tl CJ CJ v^ c ^ o c^ n w ft tAi
  • Xfl ^< OJ d .22 rt hJ S o o ^5 r be CA) C O O O o o U o CA3 52 HOSPITAL AND ASYLUM CONSTRUCTION. It also remained an acknowledged fact, that while such comparative immunity from Hospitalism \\2iS possible, the fewer-storied buildings were bene- ficial to all patients : owing to the decreased expense of constructing low buildings and the increased amount of sunlight gained in a given space thereby, they still, and for j^ears to come, will be built and shoitldh^ built when sufi&cient ground is obtainable. One of the advantages of the fan for mechanical ventilation and heating, lies in the fact that in hospitals of many stories the fresh warm air may be inspirated by one fan located in a sanitarily safe place, and vitiated air expirated in another, and if the ventilating fan does its work constantly the tendency to cause a vacuum will prevent the air from one ward mixing with that of another by means of the windows, which might be the case if natural ventilation only were relied upon. "Out Patients" Department, In large hos- pitals on the pavilion plan, where the grounds are extensive, this department should be an out depart- ment, entirely isolated excepting, possibly, an un- derground passage from the other buildings. In a hospital on a city lot, this, of course, may be imprac- ticable, but it should in that event be all the more carefully ventilated. It is one of the advantages of the fan ventilating apparatus, that divisions of a hospital requiring more rapid ventilation, or more o U c a Z o X vt; c H 54 HOSPITAIv AND ASYL,UM CONSTRUCTION. frequent renewal of air than others, ma}^ be arranged with a larger ventilating shaft. This can be readily accomplished. The reception room of these patients, if space is limited, may be nsed in common b}^ males and females ; otherwise it would be advisable to have separate divisions for them. Leading from this room should be a series (according to the probable number to be treated) of examination rooms, which need not be more than eight by ten feet square if the space is limited. Toilet facilities should be provided for this department, to insure its complete isolation. Pages 59, 6i, 63; Plates 28, 29, 30, show the department for Out Patients at the Johns Hopkins Hospital in Baltimore. The Boston City Hospital has recently completed a new building for "out patients," which will ^e used for the examination of medical cases exclusively. It is shown on pages 47, 49, 51, 53; plates 22, 23, 24, 25. The objection to French or Mansard roofs for hospitals does not apply so particularly to this building, because the story in the roof is occu- pied by rooms for male nurses, and patients would probably never be placed in any of these rooms. This department is so complete and the arrange- ments of it are so perfect, that it is given as one of the best which has yet been erected. It is of brick 50 HOSPITAL, AND ASYLUM CONSTRUCTIOIN. with stone trimmings, and is loo feet in length and an average width of abont 40 feet. The ventilation and heating is by the natural method, and the warm air is supplied to all the rooms b}^ indirect radiation at the outside walls ; the central longitudinal wall is divided into flues and serves for ventilation. The air in these flues is warmed (and thereby given an upward current) by steam pipes which are connect- ed with the radiators in the Mansard story. The former "out patient" department is to be used in the future as a surgical *'out patient" department. This new building will also serve as an entrance office for the hospital. Emergency Hospitals. One of the chief hospital needs of almost all cities is for emer- gency hospitals to which purely surgical cases demanding immediate attention can be quickly transported. How often has the distance to the hospital caused the death of some unfortunate through the slipping of the hastily applied compress, or the continuance and intensification of the collapse attending the accident. In an emergency hospital devoted entirely to "accident cases," there would not be the unspoken fear on the part of surgeons that their efforts were being counteracted by dangerous medical cases in adjoining or neighboring wards. t^ -"-^ =C _.J^ 58 HOSPITAL AND ASYLUM CONSTRUCTION. An emergency hospital can be readily adapted to almost any lot and need not contain a large number of beds, though certain divisions are neces- sary for isolation of special cases, and for the sake of brevity reference is made to the proposed arrange- ments on pages 65, 67, 69, 71 ; plates 31, 32, 33, 34. Of course all hospitals should contain an accident ^vard, so that when an emergency hospital is not near at hand the patient may receive prompt attention. Such a ward, however, should be built in a pavilion if possible. In fact, the writer cannot help stating that all wards should be built in pavilions if possible. It would be desirable, also, to have in connection with it a convalescent Avard, in which might be put mild cases, as well as several private rooms for patients who are able to pa3^ Te:\iporary Structures or Huts. Walls of metal may be assumed to be useful only for small structures or huts for the isolation of the worst forms of contagious diseases, and even then their value is largely problematical. The cheerless ap- pearance of such walls, usually of iron, unless plastered inside, with the added discomforts of the noise of the wind as it blows over the corrugated surfaces, must have a very depressing effect on the patient, and operate against that hopefulness and determination to get well that forms so powerful an 6o HOSPITAIv AND ASYLU.M CONSTRUCTION. adjunct, witli fresh air and sunsliine, to tlie labors of the nurses and phj-sicians. Such structures are usually nearly square, con- sisting of a single room with a nurse's room connect- ing, and should seldom be arranged for more than two beds, preferabl}' one, to secure the best results. They are usuall}'- built on piers or cedar posts, with lattice work between them, and hinged sash, onl}^ one of which is shown in the perspective. The sash should be kept open except in the coldest weather. A light skeleton of wood is used for walls and roof, over which the iron is securely fastened. The heating should be by means of a fire place in each room with a ventilating flue between the backs of the grates. Such a structure, but covered with clapboards or shingles, is shown on page 73, plate 35. The designation of the letters is, A, One of the sashes over the lattice ; B, Transom of window to open in ; C, Ward ; D, Nurse's Room ; E, E, Fireplaces ; F, Ventilating flue ; G, Porch. Connected with the ventilating flue between the grates are pipes below the floor connecting with Tctised registers under the beds (H,) and also wall ventilators (I, J,) which connect into the ventilating flue between the ceiling and the roof. The 16 X 16 ward contains, if constructed with a "half pitch" roof on 10 feet studs, 3,840 cubic feet or 1,920 cubic feet per. bed. pq 'Bl. O X o 62 HOSPITAI, AND ASYLTIM CONSTRUCTION Windows should be placed on three sides of the nurse's room and on four sides of the ward. The doors should be glazed. A porch should be pro- vided |for the benefit of convalescents. The chief objection to such huts is that the iron is practi- cally indestructible, and might, even after the most thorough fumigation, prove fatal to future oc- cupants. It would seem preferable to erect such struct- ures entirely of wood, and their isolated position would admit of their being torn down and burned after use for any length of time. A number of cheap houses were erected for the sufferers from the recent flood at Johnstown, P'^., '^t a cost of $260 each. These were two stories in height. Previously a number of one story huts were put up at a cost, it was reported, of $125, for 10 X 20 feet in size, and $190, for 16 x 24 feet in size, o. b. c. Chicago, where they were made. They were of course "portable" houses, viz : constructed in sections that would admit of taking down and removal, being fastened together by bolts, and are suggested here as a quick means of tempor- ary relief from epidemics or contagions diseases in crow^ded asylums, "homes" and similiar State In- stitutions that frequently have no separate hospital pavilions provided. ^ o •« rt C/3 CA3 ^ brj ^ v c rt o rt U c ■42 4_, -*-» CJ rt pa t) u > ffi ^' ^ ^-^ -^ Oh ro ffi U vO en a W J2 el U OJ rt P^ 1—. a CO oS a CD CO Ph < s 64 IIOSI'ITAL AND ASVIA'.M CONSTRUCTION They could be erected rapidl}- after delivery of the sections on the ground, and the sizes above mentioned are usuall}^ carried in stock. ^i:/ cu O K lO >-. VO o c bl a> O fan Ph > a, P-i CHAPTER VI. U. S. MILITARY HOSPITALS. In 1888 considerable improvement was made in the arrangement of Alilitary or Post Hospitals, and outlines were published b}^ the War Department as guides in planning such buildings whether erected for permanent or temporary structures. The following description is taken from the o-eneral directions accompanying the outline plans : " It is not expected that they will be literally followed. Circumstances of location, ground levels, nature of soil, climate, etc., will require variations from them to produce the best results at a reason- able cost; but when such variations are made, either in plan or material, the reasons for so doing and the estimated cost must be clearly stated in forwarding the detailed jDlans and specifications for the approval of this office. For example, these plans provide for cellars underneath the building to receive the heat- ing apparatus. In some cases, owing to level of soil water, or to nature of foundations, dry suitable cel- lars cannot be constructed at a reasonable cost. In such case the walls of the bacement may be made >. 'Z 1) 68 HOSPITAL AND ASYLUM CONSTRUCTION. higher and the basement windows lengthened. If the hospital is to be placed on sloping ground, the one end of it may be so high that the basement will be entirel}^ above ground, in Avhich case it may be worth while to lengthen the basement windows and floor, the room thus made to be used as a lecture and drill room for stretcher service, etc. In all cases the ground floor must be raised at least 1 8 inches from the ground, and in warm cli- mates and malarious regions it should be at least three feet above the ground, on piers or open arches, and to insure cleanliness the space between piers or arches should be fitted with lattice-work sufficiently close to exclude dogs and fowls. These hospitals are designed for temperate cli- mates. Por cold climates on the northern frontier, and at all posts wheie the mean temperature of the Avmtei IS liable to fall below 20^ F., the ward ceil- ing should be reduced to 12 feet in height, the ceil- ings 111 rooms 111 main building to be corresponding- ly leduced in height to 1 1 feet on first stoiy and 10 icet on second story. In such cases the ward win- dows will be double and 7 feet high b}^ 3 feet wide, me windows 111 main building to be 6 feet high by 3 teet in width.'' These hospitals are to be heated with steam. Plate 36, page 75 sliows the arrangement for a Regulation hospital of eight or twelve beds, to be constructed of brick and heated by steam. « o A 1 *=^ E ■-I 1 t4 Be - Ul 1 -^ £ 12; Q -^ „- ^ fci J 2 > 1— I 70 HOSPITAL AND ASYLUM CONSTRUCTIOX. The plan as drawn shows a hospital for 8 beds. For 12 beds the ^vard is simply lengthened in pro- portion, giving one additional window on each side, the administration building being unchanged. A, AVard 24' 4" x 30' i". B, Smoking Room, 9 2" X 10' o". C, Toilet Room, 10' o" x 13' o". D, Steward's Room, 14' 11" x 17 2". B, ]\Iess Room, 14 11" X 15 5". F, Office, 14' 11' X 17' 2". G, Kitchen, 13' o" x 14' 11". H, Pantr}^ 5' 3" x 10' o". I, Entrance. J, \'estibule, 5' o" x 13' 3". K, Hall, 6' o" wide. L, Piazza or covered Veranda, 6' 6" wide. The ward is one stor}^ high. The administration building is two stories high, and the second story contains four rooms for attend- ants over and of the same size as the four rooms on the first floor, with a store room over the pantr}'. Plate 37, page yj, shows the arrangement of the first floor of a Regulation hospital for 24 beds, to be constructed of brick and heated by steam. This hospital consists of a central administra- tion Iniildmg, flanked with two wards as wings, with a detached building m the rear containing kitchen, diiimg room, isolation w ard and attendant's quarters. Each ward is 14 feei high , though lor ver}^ cold climates the height may be i educed to 12 leet as above stated. In the 24 bed hospital there is but one set of watei closets and bath rooms for the o < PL| CO o S o o CC £3 O u -c •- O u-l > ro V tii H "^ < p 5 74 HOSPITAL AND ASYLUM CONSTRUCTION. D, Transverse Hall, 7' 6" wide. E, Longitudinal Hall, 6' o" ^vide. F, Dispensar}-, 15' o" x 16' o''. G, Office, 15' o" X 16' o". H, Piazza or covered Veranda, 10' o" Avide. I, Kitchen, 14' o" x 18' 4". J, Pantr}'. K, Dining Room, iS' 4" x 23' o". L, Entrance. ]\I, Porcli. Tlie second floor of this hospital is exactly the same as the second floor of the 24 bed hospital, so no drawing of it is shown here. Of course the one story roofs are longer, and it is suggested b}'' the War Department that the pitched roof attic may be arranged b}^ mansard construction to contain rooms similar to those of the second stor}', as shown by the elevation in plate 40, page S3. While these plans are undoubtedl}^ superior to man}'- that have been suggested heretofore, there seems some room for improvement in the following directions : — I St. The toilet arrangements might be much imjDroved b}^ placing them in semi-detached wings, for as the buildings are to be heated by steam the question of climate need not enter into the consider- tion. Whether tliese hospitals are used for surgi- cal or medical cases, or both, it is highly desirable that complete isolation of plumbing, however well it may be done, be procured. 2nd. The wards are not sufficiently isolated ; the air of the wards having more or less close con- nection with that of the administration building. 10 5 5 10 '^1^ ip IS'- 30 =)? ■ Y 45 so 'SS SO Plate 36, Page 75. U. S. Military or Post Hospital for eight beds. 76 HOSPITAL AXD ASYLUM CONSTRUCTION. 3rd. The isolation ward, although accessible only by an outside stair case, is located exactly over the kitchen, where all the food for patients and attendants is prepared, and in summer time, when the windows are open, there must be more or less connection between the air of the two rooms, and air from the isolation ward must in a more or less diluted state enter the kitchen by the windows. No surer way of spreading disease germs could be well invented. Besides the placing of a patient over a hot kitchen cannot be productive of good to him, no matter how careful the nursing or skilful the medical treatment may be. As a modification of these plans, that shown in plate 41, page 85, for a 24 bed hospital, is suggested by the writer as perhaps containing less objection- able features. As a basis for comparison of cost, it may be stated that in plate 37, there are 570 lineal feet of brick wall. In this, 546 feet. In plate 37 there are 445 lineal feet of piazza (measuring in the centre). In this 345 feet (F). Doors and windows remain nearly the same. The administration department in this building has four corner rooms on both first and second floor. The toilet rooms are in- a semi-detached wing. The piazza on one side of wards may be used for lounging chairs or cots in pleasant weather. ^' o c w M-( rt \D ^— ^— < rt u- ;-> Q- o ^ m o O X ■-4 tn .^ 78 HQSPITAI^ AND ASYLUM CONSTRUCTION. The piazza arouTid the admiuistratiou building ina}^ be reserved for promenading. The sun-rooms at end of wards ma}^ be omitted if desired. The wards are light, having piazzas on one side onlv. The smell of cooking is kept in the administration building and is fully as isolated, so far as patients are concerned^ as in plate 37. The isolation ward does not exist. If one is needed (and there should be one) it should be a frame hut and really isolated. In au}^ event, the government cannot ?£ford to set the example of placing an isolation ward over the kitchen. The letters in plate 41 indicate departments as follows : — A, A, Wards ; B, B, Sun Rooms ; C, Toi- let Pavilion ; D, Disconnecting Lobb}^ ; B, Hall F, F, Piazza ; G, Dispensar}^ ; PI, Waiting Room I, Office ; J, Kitchen ; K, Pantry and China Closet ly, Dining Room. Proper ventilation can easily be obtained in the Sun Rooms to admit of their being also used as Smoking Rooms without affecting the air of the ward. Other plans for Hospital stewards' quarters, as recommended by the War Department are interest- ing, although in the specifications for a building to cost not to exceed $1,200, the clause ''The requisite provision to be made for the support of the rear chimney upon the stud partitions below " is un- fortunate. ^ ^1 .- - ^ :/3 CHAPTER VII. PERMANENCY OF HOSPITALS. Much lias been written upon the permanency of hospitals, or pavilions connected with them, and probably on this there is a greater difference of opinion than on any other subject. There is no question but that poor materials, in a badly con- structed hospital, are productive of evil sanitary results and that a renewal of them should occasion- all}^ be made. There is, also, no question but that the c[uality of much of the better class of Avork done at the present day is far superior to what was produced in some of the older buildings now being, or about to be, abandoned. It would seem that the existence of hospitalism at the present day is generally produced by bacteria (floating in the air or water supply,) and to no subject has so much recent study been given by the medical profession. There can be no question but that in time, and perhaps at no far-distant time, the knowledge of bacteriology will be increased to such an extent that hospitalism, septicaemia and erysip- elas will never be known in hospitals. When this ■ * ■ 1 « a |i — 1 f i • ■ la . lJ m t CZI - ICD CZ] ■ ■LI (^ • L.Imi M . 1 PI C5 1 • r m J " ' I W 1 fe J ■ ' POTT IT] ■ ■ 1 1 1 IR^a w ' • m, 1 1 JM im czjI |l 1 [ZDM ■^^■L—^^^si 1 kH CO o M-l c w i— " rt c c3 ■^ ^"^ P , ' ' CO n ^ O o C^ •"^ >::: 1-^ c/: O X L. < ^ ri^ U O S2 HOSPITAIy AND ASYLUM CONSTRUCTION. State of affairs exists (not because the air is purer, but because tlie means of resisting or preventing tbe results of it on patients is discovered), there will no longer be any need of temporary hospitals, and the writer is of the opinion that the success attend- ing the administration of many modern hospitals within the last five 3'ears, would seem to warrant that permanent buildings are more desirable than any temporar}' structures can be. It is also true that the architect is not expected to perform miracles so often in the construction of permanent as of temporary buildings. Few hos- pital Boards realize how much things cost, and ex- pect all the conveniences in a $2,500 frame pavilion that they would in a $10,000 or $20,000 brick one. It should be, but is not generall}'- known that wood invariably shrinks after being cut. The use of lum- ber in our cities and the depletion of our forests is going on at an enormous rate, and it is almost im- possible at certain times of the year to obtain dry lumber. Hospital Boards, even when composed of phj^sicians, are usuall}^ desirous of speedily pro- viding that protection which they feel is needed by patients, and consequently a temporary building is frequently "run up," and occupied in as short a space of time as possible. The results cannot be different from those in dwelling houses constructed of frame or wood. In CO O I- O -a 84 HOSPlTAl^ AND ASVLL'M CONSTRUCTION. the course of three to six months cracks appear at the angles of rooms, and there is a settlement of the floors Avliere joists are supported b}^ frame work. This can be prevented only b}^ "crowning" all joists, and raising them where they rest on the frame partitions, but while they will then shrink to a level, tJicy zi'ill sliri)ik\ and cracks must be the inevitable result. This is not so liable to happen in permanent as in temporar}^ buildings, but the necessity of hav- ing the mechanics return after the building had been occupied, (sometimes at serious inconvenience, or hurt, to the patients) is avoided by slower con- struction. Such things are not done with such speed in other countries : we are a fast nation, and live — and die — in a hurry. The writer believes that as frequently "haste makes waste" in the rapid con- struction of hospitals, as in anj^thing else. "Comparisons are Odious." This is especial- ly true of the cost of hospitals, where the examina- tion made by a visitor, who is is a member of another hospital board, and^vho is "looking up" the subject, will frequentl}^ cause him to take home incomplete or erroneous impressions as to the cost of the build- ing. In man}" places it is the custom to state the cost of a building exclusive of heating, ventilation and half a dozen other things of minor importance, but all constituting a comparatively large sum. Plate 41, Page 85. A suggestion for U. S. Military or Post Hospital for 24 beds- First floor plan. CHAPTER \'III. OPERATING ROOM. Most hospitals are provided with an ainplii- tlieatre or au operating room. This is necessary in order that the coming generations of physicians ma}' derive experience from witnessing operations on living snbjects. It is the cnstom, however, to ar- range them on such a large scale that accommoda- tions are provided for a much larger number than could witness an}- operation and receive any ma- terial benefit from it. The superficial knowledge gained thereby is an illustration of the old proverb — "A little learning is a dangerous thing;" and therefore, before laying out an amphitheatre, it is the duty of the architect to find out the probable number of students whose presence would be allowed at one time, and to keep the size of the room, (allow- ing, of course, ample cubic space for ventilation), as small as possible. Amphitheatres are necessary, of course, for clinical lectures when a medical school is situated in the immediate vicinity of the hospital. But for many operations, (particularl}^ in abdominal surgery), a large number of observers is not only tn O X o o - p< " s H O o o - c 83 HOSPITAL AND ASYLUM CONSTRUCTION. undesirable but daiigerous. With three to seven persons actually engaged in the operation, or assist- ing at it, an unobstructed view is seldom obtainable b}^ many observers. Undoubtedly the finest operating room 3'et visited b}^ the writer is the one in connection with the Roosevelt Hospital, in New York, erected by Dr. Jas. W. McLane and known as the Mclvane Operating Room. The exterior is shown on page Sy, plate 42, and he arrangement on page 89, plate 43. The letters indicate divisions as follows : — A, Hxamination Room in main building ; B, Hall; C, Wardrobes ; D, Stack ; H, Preparation and Etherizing Room ; F, Students' entrance from gar- den ; G, Operating Room; H, Ventilator in ceiling ; I, Sky-light (shown on plate 42) in ceiling; J, Brass Rail ; K, Room for washing utensils used in opera- ting room ; L, Surgeon's Wardrobes ; M, Lavatory ; N, N, Fifteen Registers in walls near^ floor. Out- side of the rail are benches for students. The floor is marble mosaic ; the walls are of white marble to a height of about 8 feet ; the wood work and remain- der of walls is painted a cream white color ; the exposed plumbing pipes are of polished brass, and unlike most exposed Avork is kept constantly cleaned. Plate 43, Page S9. Plan of the McLane Operating Room, Roosevelt Hospital, N. Y. 90 HOSPITAL AXD ASYLUM CONSTRUCTION. Indeed, the chief siiperiorit}^ of this room is the cleanliness of it, and the care bestowed on the glass and metal furiiitnre, the instrnments sub- merged in the anti-septic preparations and the abundant supply of fresh warmed air indicated by the writer's anemometer. If a gallery is desired, no better example can be found than in the operating room of the "Bradlee Ward" of the Massachusetts General Hospital in Boston, Reference is made to the illustrations of it on pages 91, 93, 95, plates 44, 45, 46. The walls are lined with marble to the underside of the gallery, and the floor is of asphalte. A number of small rooms are arranged for the care of instruments and utensils, and rooms for the preparation, or recovery from ether^ of patients are provided. The gallery is not arranged as an amphitheatre, consequently a large number of observers cannot be present at an operation — which is well — but ow- ing to their elevated position a better view can be obtained than by any amphitheatral arrangement. All operating rooms should be located in sepa- rate pavilions, if possible. Nothing is more danger- ous than to have the air of the operating room communicating with the administration building or the air from the wards. The light should be north, as nearly as possible, and cross light from a number of sides is not desirable. The height of the room 92 HOSPITAL AXD ASYLUM CONSTRUCTION. should be sufficient to admit of a skA'-light, M'itliout increasing the temperature in summer to any ap- preciable extent ; in fact, an artist's studio with the corners rounded is the kind of room desired, and the sky-light and side-light should be continuous not separated b\' a section of the roof. The operating room should have iu connection with it a preparation room, especiall}' in emergenc}^ hospitals, which should be in close proximity to the ambulance entrance, and used for the reception of patients, and where they would be examined to ascertain whether their condition would warrant immediate operating or not. From the preparation room, the patients are removed to small rooms, where, if the case is hopeless, the}^ may die without disturbing other patients, or where the}^ may rest a short time preparatory to being operated upon. They are then removed to the etherizing room, then to the operating room, and after the operation to the recovery room ; this latter department being es- peciall}^ desirable because mau}^ patients in ''coming out of ether" are so noisy that others are easily dis- turbed by them. The floor of the operating room should be of asphalte, slate or marble in preference to other ma- terials, because these are non-absorbent. The walls should be formed, if the funds will admit, of large slabs of marble, not necessarily white, or slate ; 1) in O o 5; n; C* Ef^ « X 7. w ., J ^> ^ , ,
  • n ;_ ^ rt p-l til O! m ID G . ^ ^— ( W tn o S^ a; D V o W u rt ;^ rt a. :/2 > r u G Z til CL, - o Fi U o •^ o c ^ ^ G bO tuo ■!-> 4.J rt K a; C p ^ •""1 c o o rt «J ^ K k^ § ^ o -< 3 s a o c o o o U P^ P< 94 HOSPITAL AXD ASYLUM CONSTRUCTION. where this cannot be done the hardest kind jf plas- tering should be provided. In case it should be deemed impossible to provide such special plastering throughout a hospital, the operating room should be the one place in preference to all others, where it should be used. Too great care cannot be given to the heating and ventilating of this room, and the windows should be arranged so that in case it were desired, they could be opened in warm weather, when an op- eration is not in progress. Where funds will admit, all that portion of the walls and partitions not covered by marble, should be of brick or surfaced with hard plaster ; if brick is used, light tinted or white glazed brick are prefer- able to any others. No drainage outlets should be arranged in con- nection with or under the operating table or floor of the room, and it should be remembered that unless the ventilation is continuous, whether the room is occupied or not, there will be a stagnation of air which may produce evil results. The supply of fresh air should be as great as can be admitted with- out causing a draught, in order to give a proper amount for each person to breathe, and to accomplish this best, a number of small inlets is desirable, as is the case in the jMcLaiie operating room. CHAPTER IX. RENEWAL OF AIR IN WARDS. The frequent repetition of words in this chap- ter is intended to prevent any misunderstanding. In connection with the subject of ventilation it nia}^ be well to state that in some countries or cities rules have been adopted for the number of cubic feet of air space to be allotted to each bed, or the number of square feet of floor surface each shall occup}'. Provided the air is properly warmed on or before its admission to the room, and provided a suffic- ient amount is exhausted or removed by ventilation, there can be no danger of providing too much air or floor space to the patient. It should be borne in mind that for surgical cases that are serious, such as the treatment of very bad suppurating wounds and g3maecological cases 3,000 or even 4,000 cubic feet of air space per patient may be desirable, although for ordinary medical cases 1,000 to 2,000 cubic feet of air space is suffic- ient. Therefore the size of wards depends entirely on the number of patients to be accommodated in 1 2 6 7 8 9 10 Plate 47, Page 97. Comparison of Circular and Rectangular Wards of equal perimeter. 93 IIOSPITAI. AXD ASVIA'M CONSTRUCTION. them, mid the class of disease with which the}" are afflicted The basis of all calculations on the renewal of air in wards must be the patient. If a small amount of air space be allotted him, a more frequent renewal of the air becomes necessar}^ in proportion to the amount of space supplied. The ratio is dependent largely on the floor space and distance between beds. Thus, beds six feet "on centres" in a ward thirty feet wide and twenty feet high should receive a more fre- quent renewal of air than if the height were reduced to sixteen feet and the beds placed seven and one-half feet on centres, although in both cases the amount of air space per bed would remain the same, viz. i,8oo cubic feet. The reason for this is that as air moves in a horizontal as well as a vertical direction, and, as some claim, in the direction of the longitudinal axis of a ward, the air breathed by one patient would be re- breathed by his neighbor to a greater extent as the distance between beds decreases. As one of the objects of hospital construction is to secure fresh air for each patient, close spacing of beds is objectionable. It may be pertinent here to call attention to the fact that in circular wards, as the heads and feet of the patients lie in concentric circles, there is more space between the heads of the beds than between their feet. As a line of given O »- 1-1 CO 0) lOO HOSPITAL AND ASYLUM CONSTRUCTION. length \vill enclose more space in the form of a circle, than if it forms a rectangle, it will be readily seen that a niaxininm amonnt of horizontal and cnbic space is obtained in wards of this shape. For example, plate 47, page 97, a ward interior 375^ feet long, 30 feet wide, and 16 feet high would accommodate five beds on each side spaced 75^ feet on centres, and contain iS,ooo cubic feet of air giving 1,800 feet to each bed. The line enclosing this space would be 135 feet long. A circular ward, plate 47, page 97, 43 feet in diameter would have a circumference of 135 feet, an area of 1,452 square feet, and if the height be 16 feet, the cubic air space would be 23,232 cubic feet (in comparison with 18,000) : and if ten beds are put in there would be 2,323 cubic feet of air space for each (in comparison with 1,800.) But the circular ward could contain 13 beds, giving each 1,787 cubic feet : — onl}^ thirteen feet less than in the rectangular ward of the same wall length containing only ten beds. As regards the spacing of them, the plate shows the circular ward arranged for ten beds in "full" lines and thirteen beds in dotted lines : this gives for thirteen beds a spacing of about ten feet on centres at the head, and seven at the foot, and for ten beds a spacing of about thirteen feet at the head, and nine at the foot. (The consideration of the relative e ^ s o 3 s o o o v^ pi; f^ P< >^ ill tiD C «3 c > r. •13 > cS Jx rt "*"* 'iu ^ W Q C/D aQ (In S ^ 6^ a7 6>f^ u5 fi u n o . o o M i^ "O tn ■*-' t. nj — ] > ^ ^ C^ ^ o ^ ^ >^ - c _^ >, Tl o <1) -O x: OJ Lj o o Ul at o O rt cq CQ U I02 HOSPITAL AND ASYLUM COXSTKUCTION. capacity of rectangular and circular wards is dis- cussed in chapter X.) Thus it will be seen that the wall space beings equal, increased head spacing' is obtained in circular wards. The same is true of octangular wards to a slighth' less degree. As the consumption of air by the lungs is by means of the nose and mouth, it must be desirable to have the patients lie as far apart as possible. This aids, b}- proper ventilation, the isolation of patients, and decreases the chances of drafts from in-coming fresh air between beds. In the New York Hospital, on Fifteenth Street, arrangements have been. made whereb}' each bed has an adjustable ventilator under it; a small projection being built above the floor with the register open- ing in the side, which serves to a certain extent to secure an independent ventilation for each bed, and for this reason helps to isolate each patient. The amount of cubic air space per capita recom- mended b}- writers on Hospital construction varies from i,ooo to 3,600 cubic feet per bed, the latter amount being advised for dangerous cases, while in the Workhouse Infirmaries of England a minimum of 850 cubic feet is allowed. It ma}' be considered that any allowance below 1,000 cubic feet is insufiicient for severe cases of any nature. When new buildings are being con- stantly designed with a view to improving upon past m SSSliiii^Pf^ o X O a > o f. H in *-• ^-^ r) f_ < P-l J3 c rt >-l o U3 ci lO cd O w S tn c- ^ bo < ■n c h4 ii ^ CL, ni c^ 0^ I04 HOSPITAL AND ASV1.U:\I CONSTRUCTION. examples there can be no excuse for encroacliiiij^- on so small an allowance. The following is a list of some existing con- ditions in Hospitals of comparativel}- recent con- struction. Pages. Name of Hospital. SnArE OF WaKI). No. I5i;d.s Ctnic Ft. Aut SrACB PiiR Bed. ;,7. City, Boston, Mass. Rectangular 28 1929 19. Miller Memorial. London, Circular 10 1200 56, 57. New York, N. Y. loth St., Rectangular •21 1800 9.t, 101. New York, N. Y. Cancer. Circular 11 1-143 103, 105. Mass. General. Bostou. Warren (near- ly .square) 20 2268 107, 109. Johns Hopkins. Baltimore, Octagonal 21 1701 Ill, 113, 115, 117. Johns Hopkins. Baltimore, Rectangular 24 1769 77. New r. S. Military. Rectangular 12 im , Hi', 1-21. Koyal Infirmary Ijverpool. Circular 18 2052 123. Royal Infirmary Liverpool. Rectangular 18 1867 Of course a percentage of the fresh air entering the ward is not utilized, i. e. breathed by the pat- ients, and passes from the inlets more or less direct- ly to the ventilating outlets. The writer suggests that the balance which is breathed be called the ef- fective respiratory energy of the ward. As carbonic anhydride forms the largest ingredient in the impuri- ties of the atmosphere it alone is usuall}^ considered as their index in calculations. The amount varies from possibly one part per io,ooo in the country, to perhaps five parts per io,ooo in manufacturing cities where extensive combustion increases the pro- portion of carbonic anhydride in the atmosphere. The average has been assumed by some authorities at four parts in io,ooo, and air containing a no great- ud O ^ o W M rt ^ a O c U D rt 'v kH ^H o Xfi c <+-! C) S o . r^ aj s in n O M I06 HOSPITAL AND ASYLUM CONSTRUCTION, er than this proportion ma}' be considered reasona- bh" pure. The amount of carbonic anhydride produced b\' an adult in an hour has been proved b}- careful ex- periments to be .6 cubic feet, hence if a room con- tains 6,000 cubic feet he will pollute the air in it in a ratio of .6 to 6,000 i. e. i to 10,000. If the air is to be kept at this standard of purity it is necessary to suppl}' 6,000 feet of fresh air per hour for him to breathe. The normal proportion of impurity existing in the air, viz. four parts per 10,000, should be added to this, which would give the total pollution of the air per hour ; from which deductions the writer has prepared the table near the end of this chapter^ to which the reader's attention is called. The limit of allowable total pollution as set down b}' the same authorities is 10 parts of carbonic anh3'dride to 10,000 parts of air and by the table it will be seen that 1,000 cubic feet of air must be sup- plied per hour to keep the purity at even this low standard. While this ma}^ do for people in health, it is entirely inadequate for sick people, especially when a number are breathing air in common. If fresh air is more healthful than impure air, the purer it is the more healthful it must be, there- fore the more frequently air is renewed in a ward, Plate 52, Page 107. Perspective of Octagonal Ward, Johns Hopkins Hospital, Baltimore. lOS HOSPITAL AND ASYLUM CONSTRUCTION. provided the patient is uot iu a draft, the more bene- ficial the result. In the examples above referred to of a rectan- gular ward often beds and a circular ward of thirteen beds, the allotment of undivided air space per patient is i,Soo cubic feet (about), and if we desire to supply him with 3,000 cubic feet of fresh air in an hour it will be necessary to renew his allotment i -3 times. According to the table there would then exist the constant pollution of 6 parts carbonic acid to 10,000 parts of air. But it has been mentioned be- fore that a percentage of the air supplied is not breathed by the patient ; so to produce a net result of 3,000 cubic feet per hour it will be necessary to supply a gross amount equal to the amount desired plus the amount lost. Few tests to discover the percentage of air not breathed have been recorded, and they are of lit- tle value, because the conditions under which they were made might not, — probably would not, corres- pond with those of new wards under construction. The onl}' wa}- to be on the safe side is to provide a sufficient surplus of air to make up the deficiency, or to produce the desired result by increasing the speed of the fans, if mechanical ventilation is used. The experiments of Dr. Edward Cowles, in the Accident Ward of the Boston City Hospital, as pub- lished by him in a pamphlet in 1879, were very care- U r- OJ rt n Ju ci P "rt 1) C! ^ L. J= J rt c CJ ea (U .ti ^^ in n C^ O V S n U O G S O C4 O Cl. O U a ^ ffi bx) a 2; CO rt Q i^ 't1 O •J^ ffi >— . u a J ■a > tr> > ^ 7i , , rii ^ G rt ^ a OJ G O bo > o o O .^ o O c c o c n 1- 3 ou o tA2 o 13 ^ L^ ^ K O J • -N U s o o S T3 > o o ^ c :^ H ^ 110 HOSPITAL AND ASYLUM CONSTRUCTION. fully made on a thorough and scientific basis ; and it was found that the amount of air utilized i. e. "breathed" was about 78 per cent, of the amount supplied b}' the fresh air ducts. The ventilation was by natural means at the ceiling, though steam coils were placed in the ventilators to aid the exit of foul air. If we accept this percentage (jS) as the average effective respiratory energy of a ward, it will be seen that the amount utilized is not much more than three quarters of the amount received, and therefore to conservatively produce a net result of 3,000 cubic feet we must admit 4,000 cubic feet for each patient per hour. While conditions may vary, it would seem that it is safe to allow for this percentage of loss. Until the ward is built and the Hospital is in operation, local conditions governing the effective respiratory energy must be largely a matter of conjecture : so it is imperative to provide for a considerable excess of power in the heating and ventilating plant, in order that the demands caused by our variable cli- mate may at all times be supplied. It should be remembered that the additional air admitted is to make up the amount lost which is not breathed^ so that the percentage of carbonic anhy- dride is not increased. HU.Sl'lTAl, AND ASVIA'.M CONSTKrCTION". f . If the writer's deductions are adopted as a pre- liminary calculation the following- table may be used. fc g. U E n ^ P. P" :^ -r. 'S tion arts 0000 =' S C 3 o *"* ^ '^ "cc <0 r- ^ ii 3 c -^ ci »r- "3 H^ Ti di -= >, b 5 "o ross cubic ir supplie our for ea ent. Estimal amount waste ret cubic ir supplie our to ea ent. Dilution b iration (P; alunie in 1 A-erage Po 1 fresh air y volume i otal Polli 'arts by \ I 10.000). C a X 'Z ?r, r. ^ -Z ^ ^ > < .- .r: H Ct .= 4000 1000 3000 2. 4 6 3600 900 2700 2.22 4 6.22 3333 S33 2500 2.4 4 6.4 2933 733 2200 2.72 4 6.72 2666 666 2000 3- 4 7 2400 600 1800 3-33 4 7-33 2000 500 1500 4- 4 8 1866 466 1400 4.28 4 8.28 1600 400 1200 5- 4 9 1466 366 1 100 545 4 9-45 U33 333 1000 6. 4 10 It should be borne in mind that in our example we are working on a basis of 1800 cubic feet of air space, and that if more is allotted the patient it will not be changed so often, and z'l'ce I'crsa ; al- though the net amount of 3000 cubic feet of supply should remain unchanged. Therefore the fact that there is no constant ratio between the amount of air space and air supply should not be forgotten. For instance, 3000 cubic feet of fresh air per hour dcliverered to a sub-marine diver in his suit and the same amount delivered in a room to you, reader, would simply subject him to a greater "draft" • ' «j --» il tfl o rt ^ O (U » £3 -i J!r 'r^ *^ o L S _S o >^'&° at D3 1-1^ -^ t^ "rt Hal Bat rido ri« - »-^ o Q o K rt r- > .H K g o _id Ul ^ ^ a V ro o 2 « S ^ c o - •"* t/3 O ■!-• 0 J2 ., ~ a -•-> •^ «-■ a rt .y O o gK ^ o > ^ 0) o i ^ o o ni; is-^ zr 73 rt w) « -^ 3 o Men- — 1 <^ ca fcO Q O C V, ^ c ^ d tj o 5 B, Vcntil oal Lift; etj L, W atients' C CJ s P^ [Ju U CU 114 HOSPITAL AND ASYLUM CONSTRUCTION. than 3'ou, owing to a more freqnent renewal of the air in the small space he has to breathe in compared with that which yon enjo3^ Becanse he is confined in a small .space does not enable him to maintain life with a proportionately less snpply of air. In arranging for a gross snpply of 4000 cnbic feet per honr care shonld be taken that the patient is not subjected to injurious drafts. Returning to our example we have in our wards 10 and 13 beds respectively — assuming that all are oc- cupied we intend to admit and remove 40,000 (gross) cubic feet of air per hour in the former and 52,000 in the latter. To do this properly without drafts it is necessary that the openings for ingress be suffici- ently numerous. In the rectangular ward (doors being at ends) air could be conveniently admitted at four points on each side of the ward, between beds. In the circular ward (13 beds) it could be admitted at eleven places between beds and leave two places for door openings. To admit 40,000 cubic feet per hour through eight openings would give each 5000 cubic feet, or 83.33 cubic feet per minute and about 1.39 cubic feet per second. To admit 52,000 cubic feet per hour through eleven openings would give each 4727 cubic feet, or 78.78 cubic feet per minute and about 1.31 cubic feet per second. Therefore the velocity with which the air would move through a register of one foot (net) area would o 3 Q (1> bO fl a o ■(-> a o m a V > u M ffi 1^ o C < 15 rrt FM P^ Xi o rn M3 K to lO fi c '^J ^ lA o < >— » r! ^ <4-l Hj > T) 03 M ^ C o S B o, Tl U li no HOSriTAI^ AXU ASVl.l'M CONSTKICTION. be 1.39 lineal feet per second in the rectaugular ward, and 1.31 lineal feet in the circnlar ward. If the net area of the opening is increased to two feet the velocity is decreased to one half, and we obtain a rule that the velocity decreases inversely as the area increases and vice versa. The above results for velocity are conservative and Avithin the limits set by Parke in his JNIanual of H3'gicne which gives 5 feet per second as the limit of velocit}' advisable. It is desirable to provide a number of points of ingress to insure even distribution and to prevent intervening areas of stagnation. If the fan is used for supplying air it should be remembered that the area of the spaces between the bars of the register must equal the area of the pipe supplying the air unless the pipes are much larger than necessary. Valves, if M-rought iron pipe, or dampers if galvanized iron or tin pipes are used, should be provided, so that by testing at the various openings a uniformity of velocity ma}- be obtained, when the valve or damper should be set. Where the indirect method of admitting warmed air is used a larger amount of area may be advan- tageously given. It should not be forgotten that registers, either for ventilating or heating, should never be placed in the floor (unless they are some distance from the beds) as they will surely become Plate 57, Page 117. Section of Common Ward, Johns Hopkins Hospital, Baltimore. U, Warm Air Registers; V, Foul x\ir Shaft in Base- ment; W, Central Ventilating Shaft; X, Foul Air Shaft in Attic; Y, Heating Coil. Il8 HOSPITAL AND ASYLUM CONSTRUCTION. breeding places for germs. All registers, near or between beds, should be vertical, either built iuto the wall or iu the sides of projections built above the floor. The remarks regarding air spacr and air supply apply to exhausting the air by a fan as well as supplying it, and care must be taken that the combined areas of exits are equal to those of inlets. This will admit of the same sized fans being used for both heating and ventilating and running them at the same speed. Results of Test, by writer, of Ventilation in the McLane Operating Room, Roosevelt Hospital, New York, March 13, 1S91. See plales 42, 43 ; Pages S~, Sg. Cubic space, about 9,100 feet. Inlets for warmed air (N) are fifteen in num- ber, each register measuring 3^" x 17", or a total gross area of 960 square inches. Allowing a de- duction of 25 per cent, for the area (in this case) of the bars of the registers, we have a total net area of 720 square inches, or exactly 5 square feet. The corrected test of the anemometer at each group of registers gave an average incoming velocity of 223 feet per minute, or 1,115 cubic feet of fresh warmed air supplied to the room per minute, or 66,900 per hour. As a fan is used for mechanically delivering a constant supply of \varm air by the plenum method, it is evident that the exit of air per hour through the ceiling ventilator must about equal the amount I20 HOSPITAL AND ASYLUM COXSTRUCTIOX. supplied, although, owing" to the height, no accurate reading of the ceiling was obtained. Tlie above is sufficient, hc)\\e\-er, to show tliat excellent results are obtained in this operating room, and it nia}- be of interest to state, with reference to future remarks on mechauical ventilation, that the fan is stopped only ten minutes each day for oiling. Results of Tests, hx wKurKR, of Ventilation in the Children's Ward at Lakicsidic Hospital, Feb. 21, 1S91. See Plate II ; Page 23. The fresh warm air is admitted at 4 registers (B), placed in the floor to save expense in the con- struction which was kept at minimum. The vitiated air is removed by four fire-places (D), in the center of the \vard. The four ceiling registers (C), are not depended upon to any extent, although fresh cold air may be admitted through them in winter, and heated air emitted in summer, thus preventing areas of stag- nation. All registers may be operated from the floor of the ward. The warm air is passed over steam coils, placed below each floor register, each of which has an independent supply of fresh cold air also controlled from the ward. The ward contains about 12,530 cubic feet of air, and 12 cribs for children are provided, thus allowing each 1,044 cubic feet: it should be borne in mind o o a c3 P-l -^ U Pi 122 HOSPITAL AND ASYLUM COXSTRUCTIOX. that children and old people give off less carbonic anhydride tlian others. {Parkcs.^ The size of each fresh -warm air register is 14" X 21", or a total gross area 11 76 square inches and an estimated available net area of 74S square inches. The anemometer showed (testing each) an average corrected incoming velocity of 15S lineal feet per minute or a total supply of S59 cubic feet per min- ute for the ward. The total exit area of the four fire-places (at the "throat" of each) is 450 square inches, and the anemometer showed an average corrected outgoing velocit}' of 15S lineal feet per minute, or a total dis- charge of 967 cubic feet per minute for the ward. Owing to the height of the ceiling registers no accurate registration was obtained except that a slight inflow of air was perceptible, — probabh' suffi- cient to make up the difference between the warm air supply and discharge. From the above test it will be seen that the measurable renewal of air in the ward was 967 feet per minute, or 58,020 feet per hour, or an hourly suppl}' of 4,835 feet for each crib, with a constant air space of 1,044 cubic feet each. The anemometer used b}" the writer is shown on plate 61, page 125, and is very sensitive. en .ii fa o o o 0^ 1) cn l-l O ,_ o ~ o -t-* w" o o '.J o Q > a 7i ^ (U S o o o s K L. 'V tS ij^ w ^ tr. m' 15 OJ >^ O c ^ X U < ^ o ;-. )^ Q U a r-; 2 1 • - t/: I-' ^ p T3 S Ki rt s ^ rt — bo C ^ a n <:i o o 4-> "^ ^ w OS ^ ' Cri m ^ Q. • ' ci rt o m in •^ o s: o _^ >^ c T3 >-> c u c o ^. , > o rt '^ ^* rt '^ > *v 1— 1 r. '^^J O " U ^^ O >-— ■■^ c ~~ ;-! , > 'A^ o n (L» O bO H 126 HOSPITAL AND ASYLUM CONSTRUCTION. be a poiut \vliere the diameter, area and cu1)ic capac- ity of a circular ward M-ould be largel}- in excess of all possible requirements, and then it is certain that a Avaste of money takes place in the construct- ion. That this must be so is evident from a glance at the two diagrams on plate 62, page 127, where the large amount of interior floor space in the circular ward could certainly be better utilized in a ward of rectangular shape. That this waste space (for it cannot properly be used for any purpose whatsoever,) does not exist in small circular wards may also be seen by referring to plate [63, page 129. The reason for this is that as hospital beds are spaced about eight feet apart on centres, be the ward large or small, the individual floor space for each bed in a circular ward must be a sector, the vertex of which would be at the centre of the Avard. In wards of large diameters these sectors must be narrower than in smaller wards (because their chords are nearly alike,) and the distribution of floor area becomes worse as the sector becomes narrower. The size of the rectangular ward on plate 62, page 127, is 24 feet x 75 feet, perimeter 198 feet, area i,Soo feet, height 16 feet, containing 28,800 cubic feet, or 1,600 cubic feet for each of the 18 beds. The diameter of the circular ward on the same page is 63 feet, circumference 198 feet, area 3,117 feet, Plate 62, Page 127. Relative Capacity of Circular and Rectangular Wards of equal perimeter. I2S HOSPITAL AND ASVI.U:\r CONSTKrCTIOX. height 1 6 feet, eoiitaiuini;' 49,872 culjic feet, or about 2,375 ^'^^^^ic ^'-''-'t for eaeh oi' the 21 beds. The beds in eaeh of these wards are drawn eiofht feet on centres : therefore it is evident that quite a large circle could be removed from the centre of the circular ward and lea\-e a space l)etween the concentric circles, wliich would give eaeli bed 100 square feet, or the same area as in the rectangular ward. The area of the circular ward is 3,117 square feet, and the dotted circle has a diameter of nearly 36 feet and contains 1,017 square feet, leaving a space between the circles of 2,100 square feet for 21 beds, or 100 square feet each. This space cannot be used for stairs, for a direct communication would be made with the ward above ; it cannot be utilized for a central fire place and ventilating stack, for it is too laro-e, and several on its circumference would obstruct the ward. It is much larger than is necess- ar}' for keeping bottles, dishes and other articles used in the ward, as is the case at the Antwerp Civil Hospital (see pages 12 and 15), and it would be criminal to make use of it for a day room or sleep- ine room for a nurse. Therefore it will be seen that a large circular ward wastes much valuable ground. Let us now refer to plate 63, page 129, and we have a rectangular ward 24 feet x 43^ feet, perimi- Plate 63, Page 129. Relative Capacity of Circular and Rectangular Wards of equal perimeter. 130 HOSPITAL AND ASVI.L"."\I CuNSTKUCTloX. tcr 135 fe'et, area 1,044 ^^^^, height 16 feet, contain- ing 16,704 cubic feet, or about 1,670 cubic feet for each of the 10 beds. The diameter of tlie circuhir ward, on the same page, is 43 feet, circumference 135 feet, area 1,452 feet, height 16 feet, containing 23,232 cubic feet, or about 1,787 cubic feet for each of the 13 beds. Proceeding, as before, to remove a central circle so as to leave the same area for each bed. as in the rectangular ward (in this case 104.4 f^^t), we find the diameter of the inner circle is only 11 feet with an area of 95 feet. This small space can be used, and to advantage, by building a brick stack with four fireplaces and four ventilating flues, which would take up, sa}^, 65 square feet, leaving only about 30 square feet of surface wasted. But, in this case, I's it wasted? By referring to both plates it will be noticed how much nearer the so-called waste space is to the bed in tlie small ward, and the greater divergence of the radiating lines bounding it. It will also be seen that with the same perimeter (135 feet) the cir- cular ward contains three- more beds spaced the same — at the centres — than the rectangular ward under the same conditions. Thus it will be seen that a large circular ward compared with a large rectangular ward, wastes 10 5 lo io 30 40 50 60 A, Medical Ward, men B, Surgical Ward, men C, Solarium. D, Toilet Pavilion. E, Hall. F, Etherizing Room. G, Ambulance Lobby. H, Operating Room. I, Recovery Room. J, Dispensary. K, Surgeons' Room. L, Vestibule M, Office. N, Matron. O, Special Ward. P, Toilet Passage. Q, Bath Room<. R, Water Closets. S, Stairs. T, Nurse. U, Elevator. V, Linen. W, Reception Room. X, Ventilating and Smoke Stack. Officers' and Attendants' Rooms, Kitchen, etc., in third stor} Boilers, Laundry, etc. in front basement. 13- HOSPITAL AND ASVI.UM CONST KTCTION. rooiu, but that (as stated on page lo) circular wards, of from ;^o to 45 feet diameter, are desirable, and contain greater capacit}^, under luore advantageous conditions, than small rectangular wards. The writer has endeavored to consider the sub- ject in its true light, on a proper basis of compari- son to offset the results of tlie misguided criticism of <■?// circular wards as advanced in a recent Knglisli publication. CHAPTER XI. HEATING. Various systems of heating hospitals have been devised ; some of them are successful on account of simplicity of construction ; others are successful in operation when the direction of the wind is favor- able, and others seldom work well under any con- ditions. It may be stated that, as a rule, the simpler the method of admitting heat to wards, the more equable will be the result obtained. It should be understood that to successfully heat a ward it is necessary to remove an amount of air equal to the quantity of fresh air admitted, because where this is not the case, there must be more or less stagnation or lack of circulation in various parts of the ward. Heating may be divided into several main classes. First^ by reflection from an incandescent sur- face. Second^ by direct radiation, so-called, or by means of radiators, for steam or hot water, set in the ward. Third, b}^ indirect radiation or the admittance of air through such radiators, before passing it into the ward. 1 34 IIOSI'ITAI. an:) ASVI.l'M COXSTKUCTIOX. FourfJi^ b}' forcing- fresh air, b}- means of a fan, through a large coil of pijDcs for steam or hot water, and thence conducting the air b}' means of pipes to various portions of the Avard and admitting it through registers in the floor or walls. Of all these methods of heating the first is the most primitive and unscientific, althourh there is no question but that the open fireplace is the best nat- ural I'ciitilator for removing heavier gases which accumulate uear the floor. But a ward fire-place should not be depended upon for giving out heat ; in fact, fire-places in hospitals might be constructed without the usual projecting back for throwing out heat by reflection so as to prevent overheating the ward at certain points ; but a brisk fire should be burning at all times where such heat is not object- ionable, for the sole purpose of creating a strong upward draft and removing foul air from the ward. The heating of the ward should be obtained b}^ one of the three latter ways described ; of them the least desirable is the use of the direct radiator or coil standing in the ward. While this is permissible in an administration building, and affords a ver}^ ample means of heating Avhere the officers, luho are zvell^ pass much of their time, it would not be a satis- factory means of warming the air breathed b}' patients. As there is no direct supply of fresh air from the outside to these radiators, except b}^ the 136 IIOSIMTAL AND ASVLl-^l CDNSTKUCTION. windows, and such places where air may leak through walls or pass through doors, there is some probahilit}^ of the air becoming stagnant and dead. Tlie frequent packing of valves, and the frequent t)pcning of cocks to release the confined air in the radiator and to produce a circulation of steam, cre- ates an almost constant hissing sound, very disa- greeable even to well persons and more so to patients of a nervous temperament. The third method of admitting air by means of openings connected with each separate coil, is on many accounts the best ; by it no one point is de- pended upon for suppl3'ing all the fresh air for the building, and each ward or room may be controlled by the nurse or patient from the ward, so that the air ma}' be admitted to any extent desired. This should be accomplished by extending the valves through the floor of the ward, and by means of a damper for the admission of cold air from the out- side. The damper should not be arranged. to work with chains, unless it is unavoidable, on account of the rattling which they cause and the liability to become broken or slip from the pulle3'S over which the}^ pass. ]\Iuch has been said about the location of the fresh air inlets; some writers claiming that the air should be taken from near the roof. It should be remembered, however, that in cities the '-ronductors which convey the rain water from the c w a -*-> ci- u .n^ o == Oh ^ ,« c _o bC rt a -> > ^' a ^ ^ ■3 ^ U ^ 5- < ^ y^ flH °x- ^ U :-. O •'- cS m H -^ 2 ^ rt t. — C/2 < bp ^ ■- O ^ u ':^ c a ._ > '£ . - <" f^ 1}S HOSPITAL AND ASYLUM CONSTRUCTION. gutters are usually connected \\itli the sewers, and that there is Irequently a stream ot sewer gas exu- ding from th.-ir openings at the gutters, which might contaminate the fresh air admitted to the patients, were it obtained from near these points. Therefore the writer is of the opinion that it is far preferable to admit the fresh air quite' close to the ground, taking care that ashes and accumulations of dirt are not allowed near these openings and that if possible, grass be grown for a considerable dis- tance around them. It is far preferable to take the chances of dust being admitted to the ward and in- haled b}^ the patient than the probability of admit- ting air which has been poisoned b}' the germs and baccilli which sewer gas may contain. In connect- ion with this it would also be well to state that as it has been, and still is, the custom in the erection of buildings to put in area cesspools of iron, which are connected with a drain, for the removal of rain which may fall into the areas, the}- should be omit- ted in all hospital buildings, because if fresh air is admitted from near the ground, these area cesspools after a continuance of dr\^ weather (which would evaporate the water from the trap,) would admit sewer gas as described above. Another reason why this method of admitting air at various points to the individual coils is preferable to au}^ other, is be- cause with the fan ventilation a given quantit}^ of foul air is removed from the ward and the t2ndenc3^ i.: to eS > eS d rt ~ .- Ui br, .^ bxj p ^a; ' >j~ rt O c: rt o o ^ X O rt o pq O o Cn fi^ r'5 '" 9) Ui ,'- ;-i < 3 ^ , 2: ^ ^ (U t--. o «3 -^ r ) U H pj ^ < n-i co" ^ 140 IIOSPITAI, AX!) ASYLUM COXSTKUCTION. :aiise a vacuum ; llicu frcsli air will admit itself to readjust the equilibrium aud there cau be little op- portunit}'- for a draft because of the uuuierous divisious through which the fresh air is aduiitted, althougdi the exhaust fau might be removiug uuiuy thousand cubic feet of air per minute. The fourth method, while advocated by some as being preferable to all other methods, nui}- be used in tw^o wa3'S, first, b}^ forcing in warm fresh air aud admitting it through registers to wards, and at the same time removing the foul air by means of the ventilating fan; or by admitting the warm air in the same wa}- and depending upon the pressure of it in the ward to force out foul air through the ventilating shaft. This latter method should never be adopted for the simple reason that the foul air will be forced out of the openings through which it has the easiest •and most direct communicatidn with the ventilating stack, leaving, frequentl}', the lower openings for ventilating inoperative and causing the accumula- ting of stagnant air and carbonic anhydride over the lower levels of the ward. The disadvantage of blowing in fresh air and exhausting foul air by means of two fans is open to criticism — the criti- cism that luJicre a direct method will ivork satisfact- orilv a luechanical devise should not be employed ; it is where a direct method will not give the desired result that the fan is most valuable. This method to •- ■!-> >-• in S d « o 3h U bO C \^ ri o .S 2 ^ •'5 Q o x: c en Z3 o (U (U £3 C CL, ~ L' P en < L:^'^ bJD c s b£P^ .i: Pi c/5 -z: o 'B > Ol o fcO 142 HOSPITAL AND ASYJ.UM CONSTRUCTION. of heating by forcing in warm air with a fan phices the entire hospital at the nierc}^ of any nialicions person who might be disposed to poison the enter- ing air which wonld be admitted b}- means of the varions ramifications of pipes to all the different rooms. Again, if an}^ disease germs or odors from an}' nianufactnring establishment or the smell of cooking, were strong in the vicinit}^ of the fresh air sonrce, it wonld also be disseminated in a mild form thronohont all the wards. It is also a fact that this method of forcing warm air into the wards, when awarded to the ''lowest bidder," is an incentive to him to place a mnch smaller nnmber of inlets than shonld be made, thereby increasing the ve- locity; while this is pardonable in factories it shonld never be allowed in tii2 heating of hospitals, where drafts of warm air are as injnrious as cold. Bnt where fnnds will permit, and a constant certain snpply of fresh air can be obtainei at one point, the nse of a heating fan and a ventilating fan prevents the direction of the wind from forming a varying factor in the warm air snpply. Having then decided that we would prefer warm fresh air admitted natur- ally at numerous points, it remains to Ijc decided whether steam heat or hot water heat shall be used. There is a decided advantage in favor of hot water, on some accounts, the most important of which is the low temperature whicli th^e water may be main- o 'C c/5 144 IIOSI'ITAL AND ASVIA'.M CGN\STKrCTU).\. tallied, at in temperate weather, tliereb}' giving a more temperate heat, while in eokl weather the heat of the water may l^e raised so tliat the temperature of the ward ma}' l)e maintained alike at all times. This cannot be so well done with steam, or rather it wonld be better to say this is not so easily done with steam becanse committes desire that the worlv cost as little as possible, and unless it is "so nomi- nated in the bond " the steam fitter will not sub- divide his coils to admit of operating one or all sec- tions according to the temperature of the outside air. When this is done steam can be governed as easil}' as hot water. The most important part in either of these methods of heating is to see that the coils are kept clean. The writer has seen in almost all instances, where these methods have been nsed, great accu- mulations of dirt and filth drawn in from the out- side air and covering the coils wdiicli warm the air before passing it to the ward. As these coils are usuall}^ enclosed in galvanized iron, or tin lined wooden boxes, they are "out of sight and out of mind;" therefore, while great care is taken* in keep- ing floors and bedding clean, in order that the pa- tients ma}^ have fresh air to breathe, the fresh (?) air which is being admitted is passing over a vast area of filth, and bearing with it a floating popula- tion and dust. OS tuo . S IT", rt «^ '^ O o ffi g T3 P-i s PL, 146 HOSPITAL, AND ASVl.UM CONSTRUCTION. There is uo metliod of heating which can be taken care of by simply cleaning out the boiler tubes occasionall}^ and it should be the duty of the engi- neer having the nicclKiiiical apparatus in charge to periodically ha\c all these coils thoroughly cleaned; much of this hltli could be prevented from entering coils and M'ards by thin cotton screens to be renewed from time to time, Avliich should be placed in the openings ^vhere fresh air is admitted. The location of the registers for admitting fresh air to the wards should be between the beds and near the heads of the beds; i:i tliis way a gentle draft is produced so close to the wall that no stag- natiod of air can be produced at this point. In a small pamphlet entitled a ''Contribution to the Stud}^ of Ventilation," b}^ Edward Cowles, I\I. D., he p'ives observations which were made in the one story surgical ward, of which a plan is given in plate 18, page 37, of this work, and it was found that the "Force of the extracting power exercised by tlie ventilating chamber is not immediately felt ])V the air currents below, until within a few feet of the outlets in the ceiling. Above the height of twelve to fourteen feet, the inflowing currents of air seem to have quite lost their initial velocity, and the movement is, as a rule, thence directly upward till deflected towards the central openings by the ceil- to a U o O < ffi a; ^ bC r^ ."2 u id J3 H 3 < rt U 0^ I4S HOSPITAL, AND ASYLUM CONSTRUCTION. "There ccrtainl}- appears to be no advantage gained l)v liaviiig the upper six feet of air space, wliich \v()uld not be more than offset by that gained from the more frequent change of the whole atmos- phere of the room that the same volume of air sup- pi v would give with the lessened air space. It would seem, therefore, that in this case the ceiling might as well be lowered to a height of at most four- teen feet, thus permitting the foul air to escape soon- er from the room, instead of occup3'ing the waste space now existing above that level, at the risk of falling again and remixing with the air below." The height of the ward in which these observa- tions were made, from the floor to the center of the curved ceiling, is twent}^ feet, or an average of about eighteen and one-half feet ; each bed has a clear sj^ace of about eight}^ and one-half square feet , and an air space of about one thousand, four hundred and eight3--nine feet. CHAPTER XII. VENTILATION. In commencing the construction of a hospital, it is invariably the case that every one connected with it announces that the plumbing and sanitary appliances will be of a superior order, "containing all the latest improvements," and that special atten- tion will be paid to heating and ventilation. The Trustees after "looking up" the matter, in- dividually meet to examine the plans, only to find that each has decided ideas of his own on the sub- ject, and that of all the "systems" none full}^ agree. Then, with all due regard for every one's opinion, and after modifying his ideas to suit those of the most influential members, some sanitary engineer gets the "job." The result is, a system of pipes, coils, receivers, dampers, etc., which are bewildering to look at, but which seldom heat well, and it might also be said never ventilate. After the hospital has been turned over to the manager, he and the physician in charge (whose pet theory has probably been upset) unite in condemn- 150 HOSriTAI, AND ASVI.UM COXSTKIICTION. iiig' the arrangenieiits, and after a series of expen- sive experiments, a combination that never has been seen betore, and that no cnie wislies to see again, is arranged, tliat will prodnce a cnrrcnt of air in one direction one da\-, in the opposite direction the second and remain inoperative the third. But the hospital is new and patients go there because it has been so highl}' sj^oken of; the wards are bright and snnnv; most of the patients get well, and the ''s3'steni" of ventilation falls into a state of "inocnotis destietude''. That such a state of affairs exists, is due largely no doubt, to the popular delusion that a flue in a wall with a register at the bottom and an opening above the roof is going to cause a continuous draught of air up it and out at the top. There are times, no doubt, when this is the case to a limited extent. AVhen the air in the ward is much warmer than the outside air the difference in temperature will cause an upward current, but which will be decreas.d In' friction and more or less counter- acted bv opposing currents of cold air at the top. But the draught will not usually be permanent, and cold air ma}' frequently be blown into the ward. In the summer, when the temperature inside the ward ma}' be only a few degrees cooler than the air outside, there is nsuallv no current discoverable. 15- HOSriTAI. AND ASYl.L'M CONSTRUCTION. The only way that such a flue, or series of flues can vcntihite is to apph' to them a strong continuous artificial heat, either by steam coil, stove, gas jet, or the juxtaposition of a heated smoke flue. The latter is tlie surest method, although it is not usual that such an arrangement can be econorai- call}' made in a series of detached or semi-detached pavilion wards. In arranging three or four fire places back to back in one stack of mason work, in the centre of a ward, as shown in Plates 6, 9, 35, 51 and 59, it is entirely practicable to leave a space for the admis- sion of fresh air to the ward. The air would be admitted to the ward through openings four or five feet above the floor, and the supply of fresh air should be brought from the out- side of the building to the stack in a galvanized iron pipe below the Avard floor. The smoke flues w'ould also cause an upward current in ventilating flues commencing nearer the ceiling of the ward and separated from the smoke flues only b}^ their brick walls. This arrangement will work tolerably well when there are fires in the grates^ but cannot be de- pended upon at other times. It is also open to the objection that onh' a limited amount of warmed fresh air can be admitted owing to the limited heat- A, Main Floor; B, Basement Flooi; C. Ventila- ting Chimney; D, Acclerating Steam Coils; E, Gal- lery Floor; P, Covered Corridor. •0 6 o 6 o lo io I iimImmI I I 30 *0 so 60 70 I'll! Plate 73, Page 153. Section of Amphitheatre Johns Hopkins Hospital. Baltimore. 154 HOSPITAi, A:^D asylum COXSTKICTIOX. iiig surface of the backs of the fire places, and if used should he re-eii forced l)y other arrangements. This is the only way that heat can be economi- call}' applied, without mechanical force, for the ptir- pose of ventilating in pavilions, because the units of heat that would be otherwise wasted, pass up the smoke flues and induce an upward draught in the adjacent ventilating flues. The cost of providing heat at the foot of vent- latino- flues arranged around the sides of the walls for the purpose of inducing an upward current would be more expensive than the cost of running a fan to produce b}^ suction a current in a large ventilating shaft into which all the smaller ventila- ting ducts from the various pavilions could connect. Probably no means of ventilating has been con- demned so extensiveh% and with such unanimity of opinion, as the fan. Frequently because it was not understood — more frequentl}^ because the cost of running it has, until recentl}-, been an unknown quantity. It is onl}^ recently that electricity, as a mercan- tile commodity, has been offered to the public, like gas and water, for a stated price per month. With the advent of electricity the most serious objections to the use of the fan as a means of ventilation have been removed. Heretofore, it has been necessary, ^ i/i rt c c OJ o Ph o c a o X 156 HOSPITAL AND ASVLl'M CONSTRUCTION. to obtain efficient service to keep up the steam the year around and maintain a more or less expensive eno-ine for runniiu'- the fan. o o This necessitated a skilled engineer and fire- man, and occasioned large bills for repairs. Now any local electric lighting plant can furnish power by means of its wires to an electric motor which will revolve the fan with little attention. The sizes of these motors vary from one-half H. P. up ; it being seldom that one of greater than two and one-half H. P. capacity is needed. Such a motor will revolve a fan 42" in diameter at a speed of 250 revolutions per minute, and move 7,079 cubic feet of air per minute. This speed may be increased, and the air moved will be increased in proportion. The care of the fan and motor can be easily undertaken by any one possessing ordinary intelligence as it can be made "self oiling," and the amount of time needed to keep it in order should not exceed one hour per week. Of course, in hos- pitals M'arranting such an expenditure, or in insti- tutions of any size where the funds for construction will admit, an entire electric plant may be put in for furnishing this power and light. P)Ut if the institution is a small one and the power is bought at a stated price per horse power per month, it can be utilized, besides running the fan, for turning the washing machines in the laundry J- o — X ^ ^ rt X :- r^ > o c O o Pi , Tl OS c ■J^ rt a. W) pLn Ph O o a rt ffi „ rt Oh t« O X ^.^ CJ 0^ )-l lO O S O -ff Q-i ^'-' CUBIC AIR spacp: Recommended by writers on hospital construction 1"J^ No excuse for encroaching upon it Itlg CYLINDRICAL Or elongated dome ceilings ° D DAMPERS . Should not be arranged to work with chains ioo DANGER Of air communication between operating rooms and wards yU DECREASE Of mortality percentage under antispeptic surgery 4b DECREASED Expense of constructing low buildings ^^ DRAFTS; Not liable with wide spacing of beds ^^^ DRAINAGE Outlets improper in operating rooms 94 DUKE DE GALLIERA 44 DOUBLED WINDOWS For cold climates "O DIFFICULTY Of obtaining an equal distribution of fresh air in large circular wards \^ Of obtaining dry lumber °2 DIPHTHERIA, . . Measles and scarlet fever should be treated in one-story pavilions... 48 DIRECT 'M^T«01J of heating ,-.,,..133, 134 DISCHARGE Of foul air never from basement openings 164 DISTANCE Between pavilions 1" E EASE Of erection of portable houses o* EFFECTIVE RESPIRATORY ENERGY Of the ward. Carbonic anhydride the largest ingredient of atmos- pheric impurity 1*^* ELECTRICITY As a means for running ventilating fans l^ As a mercantile commodity l'^'* ELECTRIC MOTORS For revolving fans 1'''" EiMERGEXCV lloSlMTAl ;.;65. (TT, 09. 71, 56, 58 Should be devoietl lo accident cases 56 Needed in most cities 56 ENGINEER;— Should clean coils periodically 146 An cxiu-it engineer should be consulted for ventilation 16(5 EC^K'ILIHRIIM Re-adjusteil by fresh air supply HP ERYSIPELAS »■■ ■ Caused by bacteria 80 ETHERIZIXC. ROOM Near operating room ;..... 92' EXCESS OF FLOOR AREA Necessitates a useless expenditure of money 126 EXCESS OF POWER . . • . • In heating and ventilating desirable 110 F FAN For ventilating compareil to cost of ventilating by heat lo4 FIREPLACES May be built in center of circular warils 130 Should be depended on for ventilating rather than for heating 134 FLOORS RAISED Above ground 66 FLOOR REOISTERS Under beds 102 FLOOR SPACE;— Too much floor space cannot be provided 96 FLIES IN WALLS;— ^'entilation without heat doubtful 150 FORESTS ;— Depletion ol our forests 82 FOUL AIR;— DesirabiHty of heating before passing out 164 FRESH AIR;— Numerous small fresh air inlets desirable in operating rooms 94 Point of supply 136 Regisers should be between beds 146 FRICTKJN In ventilating pipes. Due allowance should be made for 100 c GALLERY In operating rooms 90 GALVANIZED IRON PIPES For ventilating ducts preferable to tin 160 GENERAL HOSPITALS 48 Essential to the future of medical practice for all time 48 Should have detached auxiliary groups of buildings 48 GLAZED BRICK Desirable for operating rooms 94 HAMMOND And Sedgwick hospitals 34 HEATING AND VENTILATION Of operating rooms 94 HEATING ;— Four methods 133 Not successful unless proper ventilation is given 13- Separate coils desirable 13H Simplicity advisable 1'5'i Should be by means of fire-places On Of huts by fire-places 6U HICKS HOSPITAL, Baltimore 32 HOSPITALISM Caused by bacteria 80 Prevented by antispeptic methods 50 HOSPITAL FIRES ;— Precaution against in arranging ventilating system 162 HOT WATER HEATING Ease of operating 144 HEIGHT OF BUILDINGS ;— One Story pavilions for contageous diseases 48 Fevs^ stories desirable 52 HUTS 58 Should be built on piers or posts GO Of frame 60 Should be used only for the worst forms of contageous diseases 58 Should have nurse's room with light on three sides 62 I IGNORANCE Regarding fan for ventilating , 154 IMPROPER ARRANGEMENT Of hospital wards 4 INCOMPLETE Information 84 Or erroneous impressions 84 INCREASED HEAD SPACING In circular wards 102 INDIRECT METHOD Ot heating 133, 134 INJUDICIOUS To construct circular wards of a greater diameter than 50 ft 10 ISOLATION Difficult with close spacing of beds 98 ISOLATION WARDS Over kitchen improper 76 Should be in temporary structure 78 VI. J JOHNS HOPKINS HOSPITAL. Baltimore 40 Its great cost, as compared with its capacity 42 Plan decided upon after consulting with well known physicians 42 Octagonal Ward, cubic feet airspace 104 Rectangular Ward, cubic feet air space 104 L LARGE CIRCULAR WARDS Necessitate useless expenditures of money 126 LARGE OBLONG SHAPED WARD Preferable to a large ciicular ward 12 LAUNDRY MACHINERY Running by electricity 156 LEYEL CEILING Sanitarily correct, if ventilation is obtained by mechanical means... 14 LIMIT Of allowable total pollution 10 Of valuable area of circular wards 12 LINCOLN HOSPITAL, Washington 28 LISTER, Professor of Edinburgh 50 LOW BUILDINGS Beneficial to all patients 52 Should be built if sufficient ground is obtainable 52 LOCATION OF FAN Near Engineer desirable l62 M MANUAL OF HYGIENE. Parkes — Limit of air velocity 116 MARBLE Desirable for floors of operating rooms 92 Used in operating rooms 90 MAXIMUM AMOUNT OF SPACE In ci rcular wards 100 MEASLES, Scarlet fever and diphtheria should be treated in one-story pavilions. 48 MECHANICAL VENTILATION: — Advantageous for high buildings 52 Arrangement should be simple 158 MEDICAL AND SURGICAL CASES Should be treated in separate wings 48 MILLER MEMORIAL HOSPITAL Near Greenwich , . Eng 14 Cubic feet air space 104 MISGUIDED CRITICISM Of all circular wards 132 VII. MODIFICATION Of Ideas caused by antispeptic surgery 54 Of pavilion plans '• (Jf U. S. Military Hospital 80 7o MOST CAREFUL ISOLATION Advised for cancer and gynaecological cases 40 N NATURAL VENTILATION Counteracted by cilrrent of cold air 150 Of slight value in summer 150 NET RESULTS Of air supply 108 NEW YORK CANCER HOSPITAL, Cubic feet air space 104 NEW YORK HOSPITAL On Fifteenth St 55, 57, 102 Cubic leet air space 104 Independent ventilation 102 NEW U. S. MILITARY HOSPITAL, Cubic feet air space 104 NIERNSEE, JOHN R. Octagonal ward 10 NIGHTINGALE, FLORENCE .-. 167 NON-ABSORBENT SUBSTANCES Desirable for floors of operating room !'2 NORMAL Proportion of impurity m air 106 o OBSERVERS In Abdominal Surgery 86, 88 OCTAGONAL WARDS :— Increased head spacing obtained in them 102 Advantages of 10 OPEN SPACE For circulation of air under military hospitals 68 OPERATING ROOMS 86 OPERATING ROOM, Roosevelt Hospital, New York 87, 89, 88 OPERATING ROOMS Frequently too large 86 OPERATING ROOM Walls should be formed of marble or slate, or non-absorbent sub- stances 92 OPERATING ROOMS Should be located in separate pavilions 90 OUT PATIENTS' DEPARTMENT At City Hospital, Boston 47,49,51,53, 54 At Johns Hopkins Hospital, Baltimore 54, 59, 61, B3 Should be entirely isolated 52 Should be particularly well ventilated 52 VIII. p PARALLEL PAVILIONS Receive the sun alike 16 I'ARKES— Limit of velocity of air 116 PATIENT The basis of all calculations for the renewal of air 9S PAVILION;— A type of hospital planning 1 Accident ward in pavilion 58 Shajies of pavilion (! Development of circular pavilions (i, 14 Shapes of pavilion G PECULIAR CURRENTS OF AIR First noted in church buildings 14 PERCENTAGE OF AIR Not breathed 108 Not utilized . 104 PERMANENT BUILDINGS Properly constructed are more desirable than temporary buildings.. 80 PERM AN EN CV Of hospitals 80 PLENUM:— Method of forcing fresh air by a fan llirougli a coil 134 POPULAR DELUSION Regarding flues in walls 150 PORTABLE HOUSES Used for temporary wards 62 PREPARATION ROOMS In close proximity to ambulance entrance 92 PYAEMIA ;— Disappearance of in a Parisian Hospital 167 R RECOVERY FROM ETHER Rooms desirable 92 REGISTERS Not to be placed in the floor 116 REGULATION ARMY HOSPITAL, 8 beds 75, 68 24 beds 77, 70 36 beds 81, 72 RELATIVE Capacity of rectangular and circular wards 124 Location of pavilion not important 16 Position of pavilions with medial lines parallel most common 16 REMARKS On many-storied hospitals by Prof. Lister 50 RENEWAL OF AIR In wards 96 Desirable 106 IX. Patient must be the basis of all calculations -^B ROYAL INFIRMARY, LIVERPOOL, Rectangular Ward, cubic feet air space |'^4 Circular Ward, cubic feet air space l'^4 s SAN ANDREA HOSPITAL, Genoa, Italy ** SCARLET FEVER, .,. .. Measles and diphtheria should be treated in one-story pavilions 4« SCREENS Of cotton should be removed from time to time 146 SURGICAL PAVILION, City Hospital, Boston ^" SENSITIVENESS To infection of gynecological patients 4b SEPTICAEMIA Caused by bacteria ^^ SEWER GAS Frequently escapes at gutters 1^° SEWING MACHINES ta i=;a Running by electricity 1-^°' 1^° SHRINKAGE In hastily constructed hospitals °^ SIMILARITY Of appearance between block and corridor wards ^ SKELETON Or outline of hospital '^'* SKYLIGHT And sidelight necessary in operating rooms > y^ SLATE . Desirable for floors of operating rooms »^ SMOKE FLUE Valuable in inducing ventilation l'^^ SPACE FOR NURSE Should never be divided off in the center of the ward 12 SPACING OF PATIENTS In circular wards ^° SPECIAL HOSPITALS 45 Advantages for gynecological cases 4b Little danger of infection from cases of a different character 4o Are the natural result of specialism in medical practice 45 STAIRS ;— Communication of air by them improper o STAGES By which the circular ward was reached o SUNLIGHT ;— Increased amount of sunlight gained by low buildings o'Z SUPERIORITY Of hospital construction of the present day 80 SURGICAL AND MEDICAL WARDS X. Should 1)0 coiiiplotely isolated 16 SlRriAS OF AIR M vist be jiio vidcd 108 T TABLE Of proper air supply 11- ( )f existing conditions of a\r space 1U4 TEMTARATLRK Easy of governing with hot water 144 TEMPORARY STRUCTURES Not so desirable as permanent buildings 82 Or huts of iron inadvisable ; — wpod preferable 62 TEMPORARY WARD, Lakeside Hospital, Cleveland 22 TENDENCY Towards special hospitals 45 TEST BY WRITER At Lakeside Hospital, Cleveland 120 At Roosevelt Hospital, New York 118 THEORY That domed ceilings produce air currents 12 THREE TYPES Of hospitals 1 TIN Pipes for supplying heat preferable to galvanized iron 160 TOLLET SYSTEM 8 Adapted for military hospitals 8 TREATMENT Of medical and surgical cases in one building much safer than formerly 48 u UPTAKE;— Usual temperature of 166 USE OF THE FAN 167 U.S. MILITARY HOSPITALS 66 V YALUE Of octagonal or circular wards enhanced by radiating platforms 20 YALYES :— Frequent packing necessary in direct radiation 1.36 Should be operated from the ward 136 YELOCITY Counteracted by currents of cold air loO VENTILATING Between backs of fire places 152 Ducts should never be formed of wood 160 Fan — Location of L58 Downward ventilation safer than ventilating through the roof 162 R egisters under the beds 102 Ducts formed of non-absorbent substances 1 60 XI. Invariable announcement. 149 At Roosevelt Hospital, New York 118 At Lakeside Hospital, Cleveland 120 VERTICAL REGISTERS Should be used 118 w WARDS ;— Height of 148 WARREN WARD, Massachusetts General Hospital, Boston, 103, 105 Cubic feet airspace 104 WASHING MACHINES Run by electricity 156 WINDOW VENTILATION Alone not sufficient 168 WRITER'S RULE For deciding distance between pavilions 18 DUE DATE COLUMBIA UNIVERSITY 0027673618