HX00015415 COLUMBIA UNIVERSITY LIBRARIES 0043076190 ^^9^€>3 s/-?#\ ~^y s /& -7 A^- THE MODERN HOSPITAL ITS INSPIRATION : ITS ARCHITECTURE ITS EQUIPMENT: ITS OPERATION JOHN ALLAN HORNSBY, M. D. SECRETARY HOSPITAL SECTION, AMEKICAN MEDICAL ASSOCIATION AMERICAN HOSPITAL ASSOCIATION, AMEKICAN ASSOCIATION FO ADVANCEMENT OF SCIENCE, AND ASSOCIATION OP MILITARY 51 GEONS OF THE UNITED STATES; FIRST LIEUTENANT, MEDICAL RESERVE CORPS, U. S. ARMY AND RICHARD E. SCHMIDT, Architect FELLOW AMERICAN INSTITUTE OP ARCHITECTS WITH 207 ILLUSTKAT/OXS III MH 1 I'MI \ WHI UN'IIIIN W. B. SAUNDERS COMPANY '9'3 /3~v Copyright, 1013, by W. B. Saunders Company « A ^ ^ 3 HI? PRINTED IN AMERICA PREFACE Tn resigning the rranuscripl of this book to the publishers, the autho so in full appreciation of its many shortcomings and of its unfinished character. In mitigation of the o Tense, they beg to recall to the public mind the sparsity of hospital literature, am' the many rapid changes thai are taking place in the science of hospital administration, thai would render the literature of today valueless for tomorrow. If the wisdom of the main- splendid hospital administrators has no1 been called into requisition more frequently in its pages, it is because there is practically no literature from the pens of these men to draw upon for inspiration. If one of the authors has many times employed illustrations from the institu- tion over which he has the honor to preside, it has not been in any vainglorious spirit, but solely for the reason that he has been more familiar with the workings of that institution than with many that may perhaps be doing things far bet- ter, and many of its methods of operation arc expressions of his own conviction-. This book has the tremendous weakness of being a record almost wholly of the experiences of two men, and the authors have seriouslj r pondered the question of how far a discriminating public will be willing to follow the experiences of an individual through a book the size of this. In justification, it may be urged that the history of mankind is a composite of individual life stories, and it is only an infinitesimal number of these millions of members of human society who have here ventured to record their own experiences, not in the hope of permanent fame or glory, but merely with the hope that there may be contained within its pages some new thought, or some old thoughl clothed in new garb, that may help some perplexed and tired worker, and if this shall come to pass, the hook will not have been written in vain. It will be noted that in many parts of the book reference i- made to articles manufactured by individuals and firms, and the names and addresses of these firms are given. The authors and the publishers are quite aware of the oppor- tunity that this arrangement offers for criticism, and perhaps for charges ii\ inter- ested people that it lias been done by way of advertising, and perhaps for a price. In answer to this, the authors have onlj to -ay that not one single dollar has been paid by any one, excepting the authors, for any purpose in connection with this book, but the authors and publishers feel that if a recommendation of any arti- cle is worthy of serious attention on the part of the reader, then the reader lias also aright to all the information at the author-' disposal, and this information must include the name and address of the person or linn fro m whom the article may be purchased. No attempt has been made in this book to achieve a literary success. It is merely what its name implies — a hook about the modern hospital, the inspira- tions that bring it into being, its architecture, its equipment, and it- adminis- tration. John Allen Hornsby, Km ii VSD E. S( HM1DT, Chicago, Ii.i.., Ha ch, 1913. 7 Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/modernhospitalitOOhorn CONTENTS Introduction 17 The General Hospital 17 The Charity Hospital 18 Mixed Hospitals 19 The Private Hospital 19 The Character of the Hospital 20 Financing t he Hospital 20 Running Expenses Hospital Architecture : 33 The Site :; 1 Planning the Hospital 36 The Area Per Pat ient 40 Arrangement of Administrative Units 40 The Admission Rooms m The Locker and Sterilizing Rooms 43 The Kitchen 13 The Medical Unit 15 The Surgical Unit 47 The Operating Suite 17 Details of Structure 51 Foundat ions 51 Walls and Facings 52 Floor Construction 55 Roofing 58 Floor Surfacings 60 Base Coves 67 Stairs in the Hospital 69 Partitions 71 Furring 73 Window Frames . I Woodwork 76 Plastering and Wall Finishes 7^ Interior Painting 7^ Screens 79 Weather Strips 79 Hardware 79 Blanket Warmer v " Permanent Installat ion BO Boiler and Power Supply sl > Heat ing Pipe Covering Lighting s ~ Signaling Systems Doctors' Call Systems Sewerage and Plumbing Water Piping ' Plumbing Fixtures Ventilation Ref rigerat ion „ Vacuum Cleaning Elevators 108 Divisions of a < ieneral Hospital Administrative Departments Kitchens Dining-rooms ' ' ' 10 CONTENTS Hospital Architecture (Continued) page Serving-rooms / 114 Dining-rooms j 116 Diet Kitchens I 116 Bakery ! 116 Sun Parlors I 117 Apartments for Patients /. 117 Private Rooms J 117 Private Wards 1 119 Public or Charity Wards \ 119 Infectious Department 120 Children's Hospital ., 121 A New Children's Hospital 132 Maternity Hospital ) 139 Architecture of the Small Hospital | 140 Estimated Costs in Detail 155 Equipment of the Hospital 157 Fixed Furnishings 157 Vacuum Cleaners 157 Blanket Warmers 159 Sterilizers for Institution Use 160 Mattress Sterilizers 163 Utensil Sterilizers 165 Typhoid Stool and Urine Sterilizers 167 Linen Sterilizers 168 Dressing Sterilizers 169 Water Sterilizers 173 Instrument Sterilizers 174 Combination Set 175 Furniture in the Hospital 176 Beds 176 Springs 178 Mattresses 178 Children's Beds 179 Interns' and Nurses' Beds 183 Nurse's Couch 183 Bed Rests 183 Bed Raisers 184 Bed Rollers 185 Tables in the Institution 187 Ornamental Tables 187 Bedside Tables 187 Side Tables 187 Children's Tables 188 Serving Tables 190 Head Nurse's Desk 190 Chairs in the Institution 190 Rockers 191 Morris Chairs 191 Ward Chairs - 191 Wheel Chairs. 192 Commode Chairs 194 Chairs for the Insane 195 Rugs 197 Screens 197 Bed Screens in Wards 197 Private Room Screens 198 Door Screens 198 Portable Bath 199 Decorations in Institutions 200 Draperies 200 Pictures 201 Frescoes 201 Books 202 Receptacles for Clothing 202 Equipment of the Operating-rooms 204 The Furnished Room 204 Operating-table 206 The Shelf Rack 209 CONTENTS 1 1 Equipment of tiik Hospital (Continued) paof. Instrument Tray Stand 211 Drum Stands. 211 Sponge Rack 212 Irrigator Carl 212 Instrument Table 213 Ann Immersion Stand 213 Solution Rack 213 Goose-neck Reflector 214 The Sinks 214 Soap Containers 215 Instrument Cabinet 215 Purely Technical Apparatus 216 Anesthetizing Apparatus 217 Cautery Apparatus 218 Bone Drill 219 Cystoscopic Battery 222 Special Apparatus for Special Departments 223 Dressing-rooms 224 I Jressing Carts 225 ( lynecologic Table 225 The Kitchen Equipment 226 Ranges 226 The Kitchen Table 226 Disli Warmers 227 Steam Table 228 Dish Washers 228 The Sinks 231 Soup-stock Boiler 231 Vegetable Peelers 232 Meat Cutters 232 Bread Slicers 233 Vegetable Cookers 234 Coffee and Tea Urns 236 The Diet Kitchen 237 Butcher Shop 23S Store-rooms 240 Pastry Pant ry 241 Serving-room Equipment 242 Individual Hot Trays 242 Food Containers 244 Food Cars 245 Equipment of the Small Private Hospital 247 Operation of the Hospital 248 The Board of Directors 248 How Created 249 Authority 250 Committees 250 Board Meet ings 251 Women's Auxiliary Boards 25 1 Superintendent of the Hospital 253 Relation to the Board 255 Relation to Attending Physicians 257 Relation to House Staff 260 Relation to Nurses Relation to Business Management- 261 Relation to Patients and Public 262 The Medical Staff 263 The Service Staff 265 Consulting Staff 272 The Adjunct Staff 273 Relations to Superintendent and Hoard 273 Relations to House Staff 274 Relations to Nursing Corps 275 The Open-door Policy 276 Relation of the Hospital to the Medical School 280 House Medical Staff 284 Duties of the Modern Intern 284 Duties of Junior Interns 285 12 CONTENTS Operation of the Hospital (Continued) page In the Surgical Service 287 In the Obstetric Service 288 In Other Departments 288 Duties of Senior Interns 289 Methods of Choosing Interns 290 Rotation or Permanent Service 293 Limited Rotation 294 Relations to the Superintendent 295 Relations to Visiting Physicians 296 Relations to the Nurses 297 Relations to Patients 298 Relations to Each Other 299 By-products of Internship 300 Rules for Interns 301 The Modern Trained Nurse 304 History of Nursing 304 The English Nurse 306 Preliminary Training 309 Age and Temperament 309 Health of Probationer 311 Training-school in the Small Hospital 312 In the Large General Hospital 314 Distribution of Nurses 315 The Flying Squadron 316 Training-school Heads 316 Discipline in the School 316 Teaching Probationers 318 The Theoretic Training 319 Necessity for Rigid Technic 321 Length of the Course ! 323 Hours of Duty 323 Home Life of Pupils 324 Undergraduate Specials 325 The Graduate Special 327 Rules for Graduates 32S Graduates in Private Service 329 Nursing and the Public 330 The Curriculum 332 Male Nurses 335 Rules for Technical Department 337 Surgical Rules 337 For Children's Department 340 For Maternity Department 343 The Surgical Operating-rooms 351 Preparation of Material 351 Sponges and Gauze 351 Making Up Sponge Drum 352 Hysterectomy Gauze 352 The Long Pack 352 Laparotomy Binder Package 352 Contents of the Drum 352 Bandages 353 Solutions : 353 Schleich Solution 353 Harrington Solution 353 Gelatin Solution 353 Thiersch Solution 353 Bichlorid Solution 353 Boric Solution 354 Iodin and Lysol Solutions 354 Ringer and Locke Solutions 354 Carbolic Acid Solution 354 Beta-eucain Solution 354 Sterilization of Solutions 354 Temperature of Solutions 354 Silkworm, Horsehair, and Silk 354 Wax 354 Care of Rubber Goods 355 Drainage 355 CONTENTS L3 Operation of the Hospital (Continued) paoe Soaps 355 Make Up of Trays 355 Preparation of the Room ::.~^ Kquipmcnl of Shelf Stand 358 The ( >ther Furniture 359 Preparation of Patient 359 Positions on Table 359 Preparatory Asepsis Win Rules for Nurses 360 Preparation of Catgut 361 Rubber Cloves 365 The Test 366 Sterilization 367 " Firsts" and ".Seconds" 367 The Surgical Anesthetic 368 Chloroform 369 El her 369 Nitrous Oxid-oxygcn 370 Et her and Gas Combined 370 Choice of Anesthetic 371 Cost of Ancsthet ics 372 Rules for Administration 373 Minor Technic in the Wards 376 Spinal Puncture 376 Venesect ion 377 Direct Transfusion 377 Subcutaneous Transfusion 377 Paracentesis i!77 Wet Dressing Box 378 Preparation of Bodies for the Morgue 378 Department of Pathology 379 Who Shall Do the Work? 379 Where the Work is Done 381 The Ward Laboratories 382 The Central Laboratories 382 Instruments and Apparatus 382 Microscopes 382 Incubators 383 Laboratory Sterilizers 383 Microtomes ' 383 The Ovens 384 Laboratory Floors 384 The Hoods 384 Laboratory Sinks 384 Test-tube Board : 385 Tables and Benches 386 Laboratory Paint 386 Slide Cases 386 Laboratory Lighting 387 The Dark'Room 387 Post mortem Room 387 Postmortem Table 388 The Animal Rooms 388 Frozen Section Work 389 The Museum 390 The Refrigerators 390 Pathology for Small Hospitals 390 Department of Hydrotherapy 392 History of the Science 392 The Douche 394 The Nauheim 394 Dry and Vapor Heat 394 Passive Exercises :>!>.". Massage Equipment 396 Control Table 197 Needle and Shower 399 The Hospital Pharmacy 4(X) Equipment of Drug Store HH) 14 CONTENTS Operation of the Hospital (Continued) page The Bottles and Labels 402 Ward Cabinets 402 Methods of Dispensing 404 Hospital Dietetics 405 Science of Special Feeding 406 Chemistry of Foods 406 Caloric Values in Diets 406 The Diet Kitchen 407 Charting Special Diets 408 Common Diet Lists 409 Diets in Small Hospitals 411 Milk in the Hospital .412 Sources of Supply 412 Treatment of Milk 413 Certified Milk 414 Milk for Children 415 Sterilized Milks 415 Milk Formulas 415 The Milk Laboratory 419 The Work Table 420 The Peptonizer 421 The Commercial Milk 422 Checking Systems 423 Isolation and Disinfection 425 Diseases of Childhood 426 The Examining Rooms 426 Care of the Exposed 427 Complete Isolation 428 Raising the Quarantine 429 The Isolatable Diseases 430 Tuberculosis and Pneumonia 430 Typhoid Fever 431 Erysipelas 432 Cerebrospinal Meningitis 433 Gonorrhea 433 Syphilis 434 Pyocyaneus 435 Pyogenic Infections 435 Other Pyogenic Organisms 435 Processes of Disinfection 436 Heat 436 Fluids 436 Chemical Agents 437 Gases 438 Model Isolation Unit 440 The ,-r-Ray Department 446 Equipment 447 Portable Apparatus 448 Stereoscopic Apparatus 449 Protective Devices 450 Plans of the X-Ray Suite 452 Patients' Records and Record Keeping 453 History Taking 454 Laboratory Routine 457 Physical Examination 462 Daily Record 463 Nursing Chart 463 Permit for Operation 464 History of Operation 465 Filing and Indexing 467 Who Shall Have Access to Records? 471 X-Ray Record 473 Who Shall Have Access to X-Ray Plates? 475 Social Service and Outpatient Work 477 Organized Charities 477 The Dispensary 479 Outpatient Hospital Service 481 Parole of Children 482 COXTI - 1") Operation of the Hospital {Continued) paoe Business Management is i The I tffice w I Admission of Patients 485 The Room Board 188 Disposition of Effects 189 Hospital Visitors 190 To Private Patients i"i In Large Wards I'M \ isitors in Maternity 182 Visitors io Children a Section I'll Social Visits of Physicians 195 Devices for Handling Visitors 196 The Hospital Telephone 198 Physicians' Register 499 The Condition Hook Intern Call Systems 502 The Key Board 502 Repairs in the Hospital 503 Disposition of the Dead 504 Effecl s of t he Dead 505 Papers to Certify 506 ( obtaining Autopsies 507 Ambulance Service 508 The Horse Vehicle 508 The Auto Ambulance 509 Comparative Costs 509 Hospital Accounting 511 Income 511 Expenditures 514 ( leneral Accounts 518 Investment Accounts 518 Insurance 521 Analysis of Expenditures Book 522 Balance Sheet 524 Pel ty Cash Book 527 House Count 52S Superintendent's Report 531 Financial and Stat istical Statement 533 Purchase of Supplies 535 Requisit ions 536 The Storekeeper 537 Medical and Surgical vSupplies 539 Gauze and Cotton 539 Linens and Cottons 541 Blankets 542 Coats, Gowns, Uniforms 543 Enamel Ware 545 Irrigators and Glassware 546 Miscellaneous Rubber Goods 547 Sheets and Blankets .".17 Other Rubber Supplies 548 Consumable Supplies 550 Meat and Fish 550 Eggs 554 Butter 556 Fresh Fruits 558 Root Vegetables 560 Canned Vegetables 562 Canned Fruits 565 Olives 566 Coffee 566 Cooking and Kitchen Ware 568 Granil e Ware 568 Enamel Ware 569 Tinned Steel 569 Copper Ware 569 Aluminum 569 Cutlery and Table Ware 570 China and Glassware 572 16 CONTENTS Operation of the Hospital (Continued) • page Soaps 573 Janitors' Supplies 577 Housekeeping Department 580 The Housekeeper 580 Feeding the Hospital 582 Kitchen Operations 582 Divisions of Table Service 585 Menus for the Help 586 Menus for Patients 586 Feeding the Small Hospital 589 Cost of Private versus Charity Patients 591 Employment of the Help 592 The Trained Help 593 The Common Help 594 Cleaning the Hospital 596 Institution Laundry 598 Laundry Problems 599 Capacity of the Laundry 601 Laundry Machinery 603 Laundry Space 607 Laundry Rules 608 Laundry Costs 611 Handling the Linens 612 Steam, Water, and Power 615 The Installation 616 The Linen Rooms 621 Laundry Chutes 624 Destruction of Waste 626 Sanitary Garbage Destroyer 627 Combination Garbage Plant 629 The Institution Bakery 631 Cost of Home-made Bread 631 Equipment of Home Bakery 631 Cost of Bakers' Bread 632 Index 633 INTRODUCTION Problems incident to the creation and operation of institutions intended for the care of the sick are practically the same whether the object be a sanitarium, an asylum for the mentally diseased, a home for the helpless, old or young, or a general or special hospital. Communities, like individuals, inevitably reach a parting of the ways in the course of their lives and adventures, and one of two things must happen: either they warp, shrivel up and stagnate in development and eventually become social defectives, to live on the bounty of others; or they grow to strong, virile maturity that brings with it those responsibilities that have for their object the care and guardianship of the unfortunate and helpless. When such an epoch comes in the life of a community, the stimulus is usually a present and a pressing necessity. 'flic inspiration behind the demand will be the same no matter what class of insti- tution is required — the growing community and the increasing number of people intended to be benefited, the distance to the nearest institution of the same nature that has been utilized in the past, the present ability of the community to bear the new burden independent of outsiders — all these questions present themselves when such new philanthropic enterprises are contemplated. Usually, the first necessity will be for a general hospital to care for and cure the vasl majority of diseases; and so great and varied and many sided is this question that in its investigation we will naturally come upon many side questions, which would likewise arise in the event that some special institution was under discus- sion, and, therefore, it may be profitable for us to diverge occasionally and follow some of these by-paths of thought to their logical end. THE GENERAL HOSPITAL General hospitals divide themselves automatically into three classes: first, those that are wholly charitable in their good office; second, those that are partly given over to charity and partly to pay patients; third, those that accept only pay patients. In nearly every part of the world hospitals that do charity work only are sup- ported by the organized public— that is, either by the state or the municipality; in such institutions the very poorest class, composed of people who are permanent charges upon society, are cared for, and in these the primary demand, at least in the past, has been in the direction of economy in operation. That such a policy is a mistaken one. and not in conformity with modern civilization and phi- lanthrophy, needs no argument. Hospitals that do a considerable amount of charity, and at the same time pro- vide accommodation for a certain proportion of private pay patients, occupj a vastly different plane in society from those thai do only charity work. Their contemplation brings us to a more inviting field. These establishments must have their initiative and make up their deficit-- from one or several sources; sometimes 2 17 18 INTRODUCTION the institution will be created and supported in large part by a peculiarly fortunate member of the community who has the necessary wealth at his disposal, coupled with a philanthropic mind. Frequently a religious order, a church organization, may inaugurate the movement for such a hospital, and rally to its support for the success of the enterprise a sufficient number of adherents of the faith to guarantee the creation and support of the institution. Oftentimes the movement is a racial one, and the first thought in the conduct of such a hospital will be the care of the particular transplanted race that has inaugurated the movement and made pos- sible its achievement. Again, the inspiration may be independent of any special faction or class or creed, and where public subscriptions behind a stimulus of good citizenship will build the hospital and afterward supply a large measure of its support. Occasionally an institution founded by one of these classes in the community will diverge, owing to changed conditions, and become the particular philanthrophy of an entirely different class; as, for example, a hospital instituted and supported for a length of time by public subscriptions may be the recipient of a large individual gift in the shape of an endowment or bequest, oftentimes carrying with it certain conditions which may change the whole character of the institution. Now let us consider a hospital inaugurated with some ulterior purpose in view and intended to be self-supporting from charges against pay patients. Very often this class of institution will have its birth in the business acumen of one or a coterie of physicians who have in mind a better care for their patients than can be given in some already existing institution, in which part of the support may come from free gifts on the part of the public. Many times such an establishment re- sults from the concerted action of well-to-do people of the community, where there is already in existence a charity hospital having no accommodation for those who can afford to pay for their care. THE CHARITY HOSPITAL There are some advantages and many disadvantages, taking a broad view- point, in all three classes of institutions which we have named. Regarding charity hospitals there is too commonly an impression in the public mind that, since the patients to be benefited are public charges, contributing no part toward their support, almost anything is good enough for them; a place to be housed — without much regard to the kind of housing; indifferent medical attention; more indifferent nursing; the cheapest food; the most rudimentary and often obsolete methods of treatment — these seem too often to meet the requirements of even en- lightened, self-satisfied communities. These disadvantages in the public charity hospital are overcome almost wholly, when they are overcome at all, by an aroused public conscience — as, for instance, within the past few years in some American communities, where charity boards, state officials, and municipal commissions have been arraigned before the bar of public opinion, and even in the courts of law, for wanton neglect of their obligations toward the helpless charges committed to their care. So great indeed seems to be the change in the public mind within recent years, that it is certain the day is not far distant when the public hospital will become an object of pride to society, where the poor will have the same advan- tages in the treatment and cure of disease as private patients in more exclusive insti- tutions; indeed, it may be frankly stated that there are even now, thanks to this aroused public conscience, some institutions in several of the states of the Ameri- can union to which even well-to-do people seek admission, because of the high order THE PRIVATE HOSPITAL L9 of administration and of their humane and modern methods. The insane asylums stand out boldly as examples of this new era of our civilization, owing somewhat, perhaps, to the peculiarly helpless condition of the wards of the public and the sympathy aroused in their behalf. MIXED HOSPITALS The quasi-public hospitals, which provide a part of their service for charity and another for those who can afford to pay, have also their advantages and disad- vantages. Naturally, the private patients will come to these institutions by election, and, therefore, the service received must be of a sufficiently high order to attract them; thus, this part of the question will take care of itself, in a general way. The charity patient will not always fare so well. Here, too, in late years the public conscience has been aroused and in rather a unique way: The time is past when administrators of such an institution can go to the pub- lic and command support on the score of duty and good citizenship. Charity givers and philanthropists of large means are usually men and women, who, hav- ing succeeded in their business life by reason of mental superiority and discrimi- nating methods, are apt to ask embarrassing questions on being approached for donations; statistical reports of stewardship, setting out in detail the disposition of funds employed in the past will lie required. It will not do any longer to appeal to the wealthy for donations on the score that the institution lias been run during the past year at a low per-capita cost, because the discriminating philanthropist will pry beneath these figures to ascertain what has been done in a humanitarian way as measured by the medical skill and possibilities of the time. Modern thought along these lines has been a vast advantage in these mixed hospitals, compelling administrators to give to the free patient a higher order of service and a better scientific care than formerly. THE PRIVATE HOSPITAL The private hospital of the day, in which all of the patients are expected to pay in full for the care they receive, is one of the most interesting public problems of the time. It is dependent for its prosperity on the number of patients attracted, and this brings about a healthy competition in service and care. Usually, the physician is responsible for the patient's entry into the institution. If the doctor is financially interested in the establishment, he is certain to be even more interested from a financial standpoint in the proper care of his patient, and, however much he may desire to support the institution where his investment lies, he will rarely be willing to do so at the expense of his own standing with his patient and his patient's family; and even if we are willing to endow the doctor with the most sordid and selfish motives, we must yet give him credit for a certain business judgment, which will coerce him into a demand for the very besl scientific care of his patient. In a very large way we can look to this class of hospitals for new standards, for the latest scientific methods in the treatment of disease, for the highest order of technical skill. If, moreover, all these are found in one hospital, and tor a favored class, it will not be very long before the public will demand their introduction in the care of less fortunate patients, and in this wise the community will gain for its public charges the same standards in force in behalf of the more fortunate of it^ members. 20 INTRODUCTION THE CHARACTER OF THE HOSPITAL We have now considered some of the underlying thoughts which will move a community to build or propose to build a hospital, and which will probably lead to the particular kind of hospital demanded. But there are other considerations, local in character, which must be reckoned with. It may be a mining community, in which the vast majority of the people are in moderate circumstances with fixed incomes, small, but constant; a milling neighborhood, where the conditions would be practically the same; again, it maybe the site of railroad shops or shipyards; here the kind of hospital will be decided upon by the employers of the labor, the corporations. Local conditions leading to certain classes of diseases will frequently determine the character, as, for example, where lung troubles and the catarrhal affections are most frequent; or, in the south, where the micro-organisms of malaria have their abiding place; or a region of mountain fevers, or in those low, humid areas where the gastro-intestinal diseases are common. If it be some port of entry where foreign- ers come and go, and where the communicable infections are likely to prevail, isolation is a prerequisite. In a railroad town where the hospital is to be built for the accommodation of railroad men, perhaps to be built and supported by the railroad corporation itself, the question is rather an easy one, and perhaps of the simplest form. Surgical wards for injured men, medical wards for sick railroad employees, and it may be a genito-urinary department, will meet almost all the requirements. If it is a milling town, where the men work among iron or steel filings, or in an atmosphere filled with wool and cotton particles or charged with noxious gases, there must be special departments for the eye, ear, nose, and throat. When the hospital is to be located where the employed men reside, the further question naturally presents itself, is it intended to take care of the families of the workmen, and if so, is it to be done free of charge or for a modest sum? It will then be necessary to include wards for the women, not only for those sick with ordinary afflictions, but with special women's diseases. As it is coming nowadays to be a necessity for women to retire to a hospital for their maternity, an obstetric department will be needed. Not only the ordinary diseases of children must be considered, but malnutrition, which brings in its wake provision for their diet, either in the shape of wet-nurses, milch-goats, healthy cows, kept and milked in a sanitary way, or some form of prepared milk food. For the communicable diseases of childhood isolation wards must be supplied. FINANCING THE HOSPITAL Having considered somewhat the character and the size of the hospital most needed, out next thought, and certainly the most important one, has to do with the raising of money to build the institution and to provide for its permanent sup- port. We must revert again to our previous classification of general hospitals. The charity hospital, pure and simple, will necessarily be financed by the political body inaugurating it — that is, the legislative assembly will appropriate the money to build it, with at least an implied obligation to appropriate annually thereafter the necessary funds for its support. We need only say a few words in this behalf. Until very recently public hospitals have been miserably provided for, and it is within common knowledge that the administrator even now held highest in the esteem of the appointive power is he who has been able to operate his institution FINANCING THE HOSPITAL 21 for the least money, without much regard to the character of the service given to the patients. The administrator, having received definite orders from his masters, the public, has merely obeyed these commands and operated his institution in the manner required. It has not been his fault if the orders have been mediaeval and if the policies transmitted are unhumane, unenlightened, unscientific, and even in- human. If legislators have demanded such an administration, they again have merely taken their orders from the public which has elected them to office and continues them in office only so long as they do the public bidding. If public hospitals are to be administered in step with the scientific tone of the time, and if the wards of the public are to have the scientific skill in the cure of their diseases to which they are entitled by reason of the modern status of medicine and surgery, the orders must come direct from the public conscience, as expressed in a determi- nation for larger appropriations for these institutions. There is rarely a protest if the salaries of politicians are increased, or if new offices are created or new public buildings proposed. But one who may have the curiosity to consult the legislative annals in any given state, over a long period of time, will find that to-day, notwith- standing the increased cost of everything in the way of living, the amounts of money appropriated for public institutions are about the same as many years ago, and administrators are expected to operate their institutions within those limited means. A proposal from a governor or mayor or legislator for an increase in appro- priations for a public institution is usually met with the cry of graft, the inference being that political henchmen are to be fed at the public crib. And so the pro- posal dies away, and so it will continue to die away until the public recognizes that the hospital of to-day cannot be operated upon the same standards and with the same simplicity that obtained twenty years or even ten years ago. And when that time comes, public hospitals will not be the disgrace they are to-day. Let. us turn now to a more attractive and inviting field of speculation, the financing of another class of general hospitals, the one inaugurated by private enterprise, by philanthropy and private charity combined. There a proportion of the patients is treated free and another proportion, large or small, is supplied with accommodations for which they must pay. We ought, perhaps, to set out upon this discussion with the flat declaration that no institution that proposes to take care of any considerable percentage of its patients free can be self-support- ing. In other words, the pay patients of an institution should not be compelled to do more than pay for their own care. They should not be coerced into helping pay the expenses of others. That money should come by voluntary contribution, which is not the case when a private patient is charged for the service he receives more than it costs. When we think of a part pay and part free hospital, we must settle definitely the number of free patients to be provided for and then figure upon financing the institution for that many free patients, leaving the private work in the hospital to merely take care of itself. In the first place, the institution must be planned along the lines of our pre- vious discussion; and then the money must be raised with which to build it, since no part of the building fund is at hand from any private patients to be received. Later on we shall discuss the major items of expense in building the hospital; at this time we are concerned only with its subsequent support and with methods for raising the money required to build it. Of these there are a number. Naturally. the easiest and most satisfactory is by direct gift from some wealthy member of the community, or from some wealthy philanthropist whose interests are there. Such a donation may be direct, during his lifetime and under conditions which he himself may dictate, and in two parts, one for the building of the institution and 22 INTRODUCTION one for its subsequent support; or it may come in his will by bequest. In this case the restrictions usually intended by the giver will give direction to the subsequent character and conduct of the institution. The next best method of raising funds for the building and support of the hos- pital or similar institution will be by way of some organized body of citizens, pre- ferably a body having a corporate and, therefore, permanent, existence, a church organization, or one or another of the religious orders having some binding issue, such as the religious thought, as its moving purpose. Such initiative has many advantages and some disadvantages. The cohesive power is great in a church or religious organization and is not likely to be lost in the passage of time, and, there- fore, support pledged to-day to a hospital in the community will not be lost unless for excellent reasons. And usually an organization with such a serious purpose has certain ideals and certain standards which will be infused into any creature to which it gives birth. There is no greater human motive than the religious impulse, and the adherents of a faith will rally round a standard set by their leaders, and there- fore a hospital instituted under such auspices is likely to be permanently sup- ported, and to that extent such support has its advantage. Unfortunately, we occasionally find such religious thought not quite abreast of the day from the medical and surgical standpoint, and it is possible for a hospital operated by a religious society or the leaders of a religious sect to fall somewhat short of the scientific requirements of the time; but usually this tendency is combated and overcome by a secondary leadership or a demand which may emanate from the medical staff or the lay members of the sect, and which will serve to keep the institution up to present-day standards. Another form of support for an institution of this character will be rather racial than sectarian. Next to the religious motive there is hardly an impulse that moves the heart so completely as that of love of country. In some communities there are large numbers of transplanted foreigners from a land beyond the seas, and, far from home, they oftentimes are somewhat clannish, as expressed in a desire of some members to help the less fortunate. There are German hospitals and French hospitals and Scandinavian hospitals. Usually such support will be almost community wide, and the support of the hospital will be in proportion to the strength of the race in the community, and in any event is likely to be earnest, per- manent, and as generous as the institution deserves. Then there is the way of independent subscriptions taken from individuals in- discriminately. This is the least desirable and the most hazardous support an institution can have. The fortunes of the givers may change; there is no rallying ground and no common standards upon which such an institution can be operated, because of the diversity of opinion and the diversity of interests of the givers; so that it may well come to pass that a large giver to such an institution may be- come dissatisfied with the policies and standards upon which it is conducted, and failing to change these to suit himself his subscriptions may be withdrawn. For the support of Catholic institutions, the clergy, the various orders of monks, and the sisterhoods can appeal to contributors from the religious side. These religious orders have their ideals and their institutions will be conducted in step with these ideals, so that there is something very definite upon which the institution can be founded, and whatever the weaknesses may be in such hospitals there will be no contending factions, only one set of morals, one set of ideals, and the institution will be maintained along one single rigid line of conduct. Not always are these holy people broad-minded. They have few opportunities to see life in its broadest side. But their economies will be great and their humanities FINANCING THE HOSPITAL _':i greater, and if the question of financial support must come to a test, as between these orders and any other form of support, the Catholic hospital will be operated and maintained more economically than any other, not only because of the single- Handedness of the moving spirits, but also because many of these religious people give their service for the glory of God and without salaries. These Catholic hospitals are an illustration of the support of the hospital from the religious side. Another illuminating example of support based upon the religious impulse is the maintenance of a great number of organized charities in the country by the Jewish people, the most characteristic of which, perhaps, are those of the Associated Jewish ( 'harities of Chicago. This organization is composed of some four thousand of the Jewish people of the city who have arrived at that stage of financial inde- pendence that will permit them the privilege of contributing money for purposes other than their own living. They give §5 a year or 85000, according to their ability. This money is placed in a common fund for the support of a large number of charities. These charities have been initiated at different times through large gifts of individuals, perhaps, and, after having been operated in a small way by such individual support, they have been thereupon taken over by the Associated Jewish Charities and have been supported out of this common fund. In this way the Jewish people of Chicago are maintaining a hospital of four hundred beds, con- ducted along modern lines; a home for orphans, a home for the friendless, a home for the aged, a bureau to provide for the temporary relief of those who need it, a per- sonal service institution to compel negligent heads of families to support those dependent upon them, that takes care of helpless and unfortunate girls, and the like; a dispensary in the center of the poor section of the city that ministers to some sixty thousand patients per year; a milk station in the heart of the poor section, which provides pure milk for the sick and for the babies of the poor, either entirely free or at actual cost. This central organization maintains a general watchfulness over all its insti- tutions — insists upon economy and efficiency in their administration. Each institution is conducted by its own board of directors, and these are answerable at the end of each year to the central organization for their stewardship. At the end of each month the deficits of all the institutions are made up by check from the central body, so that in an existence of forty years or more not a single one of the Jewish institutions of Chicago has ever owed a dollar for more than thirty days. This method of financing makes for economy in the purchase of supplies and for business principles in the administrative forces of the institutions, and while the central Jewish body is most liberal toward the boards of directors of its subsidiary organizations, it is equally exacting in the matter of correct financial methods in the institutions working under it. There is a lesson for all in the results that this great Jewish body in Chicago has attained. At the present time the subscription list aggregates (465,000 per annum, and it is a comparatively easy matter for the leaders of the Associated Charities to increase this amount at any time that added funds may be needed, because all these charities are so conducted that every subscriber has come to take a personal interest and a personal pride in their achievements and the amount of good they do. The broad lesson to be learned is this, that there are enough char- itably disposed people in nearly every community to provide for the needs of that community. It is only essential to inspire confidence in the earnestness and intensity of effort in the conduct of the institutions to secure adequate support for whatever institutions are required. 24 INTRODUCTION Of course, there are drawbacks and hazards in this form of support, and there are dangers threatening this kind of organized charity. In the first place there are many people who have very decided views as to the direction they want their charity to assume. One person may be attracted toward a children's charity; another may wish his or her money to be expended in the care of a maternity hospital, while still another will prefer, for sentimental reasons, to give for the benefit of orphans, or for unfortunate girls, or for some other very special purpose. To these classes a great, all-embracing charity will not particularly appeal, and it may not satisfy them at all. To this extent such an association will fail to attract some support that would be well worth having. Then, also, there is danger of overloading such an association. One or a few very active and philanthropic persons may inaugurate some special charity, run it at their own expense for a time, then undertake to load it on the association. The charity itself may be a most worthy one, but may prove the proverbial- straw to overload the association; and in any event it will open the way to similar demands and make a precedent not easily brought to a check when necessary. But to the author's mind there is another factor in this association form of charity that ought to be reckoned with at the very outset. Naturally, the organizers of such an association will want to look a long way ahead for breakers, and to discern the clear sailing waters of permanency and safety. They will most likely want to provide against a rainy day, if the metaphor may be changed, by influencing the gifts of large funds by way of bequests and legacy. Shall such gifts be made to the individual charities or to the association? Are association officers warranted in asking the subsidiary charities to pool their gifts into the common fund without any conditions of reversion, or may each charity accept whatever is offered, the interest to be used for the institution's benefit, and the principal to be controlled by its own board? And will such pooling serve eventually to rob the individual charities of their sentiment, and take away that personal thing so necessary if a board of directors is to do the greatest amount of good to a chosen class? It looks to the author like such an association could well become so big eventually that it could afford to devote its funds toward the prevention of poverty, or at least pauperism, by inaugurating works that would tend to take the beneficiaries out of the pauper class and place them in the class of self-supporters. In such a case the charity would have ended and a business regime would have begun. Again, the association officers or trustees might grow cold toward certain charities very dear to the hearts of those who had given money for their permanent support. If the association were established in a policy which did not permit it to accept other than annual subscriptions, and if the individual charities were put on their mettle to acquire permanent endowments to make them as nearly self-supporting as possible, there would be much nearer a survival of the fittest in the stretch of years, and it would seem to be a better arrangement all round. Additional Support of Quasi-public Institutions. — We have now discussed, at least, the more desirable forms of primary support for these community institu- tions. There are oftentimes very material resources from one direction or another that will serve to make up any deficiency with which they may be threatened or that they may actually face. Perhaps one of the surest of these is a form of state aid of recent birth, especially in some of the eastern states. This support takes the form of a per capita allowance to the various recognized hospitals and asylums for all patients cared for, who would otherwise be direct charges on the public and who would have to be cared for in state or county or municipal insti- tutions. Like most new efforts, this plan has not yet assumed the best attainable FINANCING THE HOSPITAL 25 form and lias met with abuses, as, for instance, in one of the stales, institutions that arc fortunate in their political affiliations arc granted lump sums in the state's annual appropriations, irrespective of the actual number of patients cared for in them. Undoubtedly the per capita allowance system of auxiliary support will, in the near future, become count ry-wide and will settle down in its details to a rational and equitable basis. This system is in vogue in a few of the cities of this country, and it seems to operate about in the same way as state aid. In Canada there is a disposition to enlarge upon this idea, and to encourage the building of quasi-public institutions by private charity. In a few places, notably Winnipeg, the city authorities have entered into contract with the hospital for the care of pauper patients to an agreed extent and at definite rates extending over fixed periods of time, thus insuring the institution against a burden greater than it can bear. In some sections of the country the so-called "Saturday and Sunday collec- tions" make up a very consequential fund to be divided among certain institu- tions. Too often these collections are committed to the discretion of persons who favor certain institutions, and thus the funds are not always divided upon as just a basis as could be desired, but that, too, will be cured in time. The so-called "Tag Day" innovation is in the same class, but this has already won for itself the general opprobrium of the public because it has been allowed to fall to the level of the now obsolete strawberry festival, where one had to run the gauntlet of women who knew no limit to their insistence and who excused themselves for indecent solicitation on the score that it was "in a good cause." And, then, there are the individual gifts to institutions — outright donations by the living and bequests in the wills of the dead. While such gifts are uncertain and never to be counted on, there are certain peculiar features attached to them to which allusion ought to be made. In years gone by it was the custom for the people able to give to make their occasional donations, large or small, to the insti- tutions appended to their churches or their favorite societies, and donors were not, as a rule, very exacting in their demands as to how their money was to be employed. This indifference is very rapidly giving way, perhaps as a part of our more accurate commercial sense, to a demand for detailed reports of stewardship. This means that in the future donations of this individual sort, in order to be received, must be deserved. It will not do any longer to present to a prospective giver a pamphlet of an institution containing a few glittering generalities and much self-praise. If the annual report of the institution sets out that the per capita cost of caring for patients during the past year was $2, the prospective giver will want to know what became of that S2; it will be no answer to say that this S2 was 50 cents less than the amount expended per capita in some other institution. Details are wanted: Have the patients been properly housed in sanitary, well-ventilated, and clean rooms and wards? Have they had the benefits of modern medical and surgical appliances in the treatment of their diseases? Was there an adequate dietetic competently carried out under the orders of medical men well versed in the laws of metabolism, nutrition, waste? Did tin- surgical patients have the advantages of modern asepsis in the operating- and dressing-rooms and in the details that go to make these rooms efficient? Did they have the benefits of modern .r-ray appliances and electrical apparatus? What about their pathology as aitl to the diagnosis of disease — the urinology, bacteriology, surgical pathology, serum and vaccine therapy? No institution should be per- mitted to exist in this modern day of science unless its administrators have at least shown an appreciation of these scientific necessities of the time. 26 INTRODUCTION' Such demands as these, if insisted upon, may seem exacting and even cruel, but would it not be better to have fewer institutions, and larger and better ones, that can make a wiser use of philanthropic funds for the adequate scientific care and cure of sick people, than to have many and irregular and inefficient hospitals and asylums? Many years ago — and not so very many years ago, either — good hospital care would be satisfied with a clean bed in a clean ward, practical but untrained nursing, a good doctor to prescribe plenty of medicine. This descrip- tion will not satisfy for an up-to-date modern hospital. Additional Support from Special Charges. — It is unfortunate, but true, that in most quasi-public hospitals and similar institutions the administrators rely for a considerable proportion of their support on special charges against patients in the institution. The insistence that there ought not to be any special charges of any kind against any class of patients in any institution will be strongly criticized. And yet let us see if this position is not well taken: When we accept a patient in a hos- pital or sanitarium or asylum or in any institution where a cure is to be attempted, the patient comes to the institution with at least an implied guarantee that he will get the best the institution has to give. If he is a pay patient, we have accepted his money on those cerms, no matter how much or how little he pays. If he is a free patient, we have accepted funds from some source, and in accepting those funds have guaranteed, at least by inference, to give patients the best attention of which modern science and modern humanity are capable. If we withhold from him the service of the laboratory of pathology to aid his doctor in the diag- nosis of his disease, because he cannot pay for such service, we have been guilty of gross deception to that patient or to the donors of the funds supposed to have been given for his care. If we decline to take an x-ray picture of a broken bone because the patient cannot pay for it, we have refused him one of the most necessary aids to his cure. If we have failed to give him the benefits of the modern laws of dietetics, as expressed in his food, we have deprived him of one of the fundamental factors in modern therapy. These thoughts may be construed as Utopian, since even to-day in nearly every quasi-public institution in this country extra charges are made for these services. But they will not remain Utopian, and a time is coming, and shortly, when the acceptance of a patient will carry with it an obligation to furnish, on the terms of admission, every known and approved scientific aid for the diagnosis and treatment of the disease or injury. But while such charges for special service dominate the administration of almost every institution, we shall perhaps have to recognize them and bow to them until a better day comes; and, therefore, we shall have to analyze these extra charges, and will take occasion to do so from time to time as we proceed, under the correct headings ; for instance, we will discuss the cost of feeding free patients as against the cost of feeding pay patients; we shall take account of the cost of pro- ducing x-ray pictures and their uses and limitations, and we shall discuss the cost of various forms of pathologic work as they come up in order under the general headings of pathology in hospitals. Classified Hospital Expenditures. — The natural sequence of thought, if we are to contemplate the establishment of a public or semipublic institution in a com- munity, is to work from the demand toward the accomplishment; that is, we have the demand for a specific institution, and we have now to look somewhat to satisfying it, the kind and scope of the institution required, and we have taken the measure of the avenues of support upon which we may count. But we have not yet taken into account the amount of support required, nor the FINANCING THE HOSPITAL 27 various channels against which the supporting funds must be charged. Lei us do so briefly. In the first place we shall have to build the structure. In our sections on Architecture the details of cost will be given, but there are some very rough figures that may be profitably used just now to give us at least some idea of the amount of money we shall have to use immediately. Broadly speaking, hospital architects have about agreed that the modern hospi- tal building, without any ornamentation whatever and without any such fittings as plumbing and ventilation, and including only the walls, partitions, floors, doors, foundations, and roof, all of them built of the average material under average con- ditions, is about twenty-five cents per cubic foot of space occupied by the building. The additional cost, or what we may loosely term extras, will be for ornamentation, varying greatly in amount, depending on the elaborateness or simplicity of the structure; the power plant, the plumbing, including steam, gas, and electric fix- tures, and whatever of artificial ventilation it is determined to employ. Let us take for instance a building 100 feet long, 40 feet wide, and six stories of 12 feet each as the dimensions of the building, that will give us an area of 288,000 cubic feet and an additional 40,000 which we must add for a ten-foot basement, or a total of 328,000 cubic feet. At twenty-five cents per cubic foot, the cost of such a structure, wholly bare of fittings or furnishings or ornamentation, will be $82,000. The fittings for such a building, according to figures allowed by the average hospital architect, and providing for the very best of plumbing, carried in runways in the walls according to the latest approved plan of plumbing installa- tion, will cost $30,000. This will include, however, the necessary installation of steam pipes to carry live steam for sterilization in the operating, dressing, serving, and sterilization rooms, and this will also include the necessary electric installa- tion for light and power and a sufficient amount of gas-piping to duplicate the lighting plant. Artificial ventilation is as yet so uncertain and unsatisfactory that it may well be considered wholly experimental, and while it may be a question of indi- vidual judgment as to whether such a plant should be installed in the present state of the art, there is no question that provision in the walls should be made for it against that day when some satisfactory ventilation scheme shall be offered by inventors. There are a number of kinds of runways installed to carry fresh and tempered air into various parts of the hospital, that which seems to meet with present favor being galvanized iron runways in the walls, varying in size accord- ing to the area to be aired and tempered. We will discuss this question of arti- ficial ventilation very much more in detail, and perhaps more dogmatically, under that heading in the sections on Architecture, including an estimate of the cost of such installation. The only other permanent fitting in the hospital, the cost of which ought to be included in the architectural estimates, is the vacuum-cleaning system, and this also we have gone into more in detail under the sections on Equipment. When we have taken all these items of expenditure into account, we may be able to pretty accurately determine the cost of the building we are to erect, exclu- sive, of course, of the item of ground for the institution, which will vary so greatly both in quantity of land and price as to prohibit any further discussion, and also exclusive of whatever extraordinary ornamentation may be designed. It will be noted that no attempt has been made in this section to estimate the cost of the construction of the building on a basis of the number of beds to be installed. Some expert writers on these costs will insist that the only proper com- 28 INTRODUCTION putation of cost is per bed, and the figures given will run from $1200 to $2500 per bed. It may be seriously doubted whether such figures are really helpful. The question will come as to the proportion of space in the institution designed to be actually occupied by patients, and the other space that we might call ad- ministrative in character, such as offices, reception rooms, kitchens, dining rooms, serving rooms, storage space, and the like. The equipment of the new building for operating purposes contemplates so nearly the whole question of hospital or institution management that we shall have to dismiss this part of the subject from our thought at this time, referring the reader to the section on Equipment of the General Hospital as an aid to the furnishing of whatever kind of institution he is interested in ; and we come now to that peculiarly elastic subject of "running expenses." RUNNING EXPENSES In the term "running expenses" we must include every item of cost of opera- ting the institution, including the interest on building funds. Necessarily any figures touching upon operating expenses must be extremely elastic, and in a work such as this is designed to be these figures must safely cover the expenses incident to running an elaborately planned institution, that is, one in which it is designed to give patients the very highest order of scientific service of every character. The figures herein set down must not be harshly criticized if they are greatly in excess of those shown in the annual reports of average insti- tutions in this country. It is not intended to advocate in this work average insti- tutions or institutions conducted upon the average scale. This work has in con- templation throughout the best sort of institutions known to modern science. For instance, some city and county hospital, poorhouse, and asylum administra- tors point with pride to their low cost of feeding patients; one large general hos- pital, conducted by one of the first cities in this country, might be cited as an ex- ample; its annual reports cite the fact that it is operated for less than $1 per day per patient. And yet, turning a few pages of this annual report, one finds that there are thirty-six nurses to care for a few short of six hundred patients, and that the pathologic work is performed by one intern, who also has other duties; and, still further, that the raw food for patients, employees, nurses, and interns averages nineteen cents per day per capita. Instead of a record of laudable achievement, may not such a report be regarded as disgraceful and a scandal upon twentieth century civilization? There are no figures to be offered for such conduct of an institution, and no figures to be offered to those who would follow such a lead. It is pleasanter and will be more profitable to describe a rational regime, in accordance with the laws of living as they are to-day and along the lines of the sci- entific possibilities of the time. The intimation above that the pro rata cost will be about the same whether the institution be a hospital of fifty or five hundred beds will have been noted by the reader. This will bear a momentary pause for contemplation. The state- ment was not made without due reflection. It is true that in a large institution purchase prices will be lower; the hospital that can buy half a million yards of gauze at a time will undoubtedly obtain these goods at a lower price than the one per- mitted to buy only fifty thousand yards; and food purchased in large quantities will be likewise lower; and it might be that heads of departments could manage a large number of people quite as well as a small number, as, for instance, a head janitor could superintend the operations of fifty floor men, wall washers, window Ki NNING EXPENSES 29 cleaners, and the like quite as well as he could direct the operations of eight <>r ten people; and if the salary of this head janitor be divided pro rata between five hun- dred patients, the per capita would be extremely small. And this same logic will run throughout the hospital. Bui I here are offsets and counterbalances to these items of saving in a large institution, which may well he construed to go quite to the extent of complete cancellation. For instance, if there are only ten men workers in the institution, they will not need a head janitor to direct their work; it can be done by the matron or housekeeper of a small institution, or by the superintendent of the training- school. If there he a considerable saving in the price of gauze purchased in the larger lot as against the smaller, the waste in the use of gauze in a large institution will almost, if nut quite, offset the difference in price as against the economics and care and watchfulness that can be practised in the smaller hospital, and the same may lie said also of the purchase of food supplies; where small quantities are purchased for a small number of people, while the price may be greater, the waste will he infinitely less in the small hospital, due to the possibilities of the same watchfulness and care in the supervision by some responsible head. And so things will go clear through the institution; economies in purchase practicable in the larger one will be oftentimes more than counterbalanced by the economies in the use of consumable things in the smaller institution. Take, for instance, as one more illustration, the difference in salary between the two superintendents in these two institutions under discussion. The small institution will pay its superintend- ent SI 200 per year. He may be an untrained layman or even a fairly good physician; if a layman, he may be well versed in the accounting department of such an institution and may be able to keep his books in good order, but he is more than likely to fall far short in his ability to purchase supplies; and if he should happen to be an expert in both of these directions it is highly probable that his talents do not go so far as to equip him for carefulness in the husbanding and purchase of medical and surgical supplies. If the superintendent be a medical man he may participate in that proverbial lack of business directness so common to the mem- bers of the medical profession, and so the institution loses to whatever extent it shall fall short in business administration of its affairs. The superintendent of the large hospital of to-day draws a salary varying anywhere from S5000 to $10,000 a year, and it is highly probable that the $10,000 man is the cheapest investment his institution indulges in; and without any question he will not only make his salary a non-essential in the saving that he will be able to practice, bu1 will probably be able to save many times his salary each year, so that again the difference in the expenditure between the large and the small hospital is apparent rather than one that could be set down as dominating the situation. Roughly speaking, the modern American hospital expends about $2.50 per day per patient. There are many institutions that are run more economically than this, and that are operated fairly well at an expense of about S2.00, where certain special economics are practised and where not very much scientific work is clone, but it may be said the average will run about $2.50, and these expendi- tures can be distributed or classified approximately according to the subjoined tabic, although exact figures can never be had in such classification: for the obvious reason that one institution may be specially fortunate in one direction or in the acquisition of one class of supplies; or one institution may exert its activities in one or another expensive direction or cater to a class of patients that will demand some specially liberal expenditure. 30 INTRODUCTION PROVISIONS: Cents. PerCent. Raw food — per patient, not per person $ .766 30.7 Surgery and Dispensary : Drugs and drug sundries ] Appliances Instruments | Wines and liquors and alcohol } .206 x-Ray supplies Laboratory and sundries Gauze, cotton, gas, etc Domestic: Crockery Silver and glassware Kitchen utensils Cleaning supplies Hardware and brushes Fuel and light J. .263 10.9 Repairs and expenses Laundry supplies Miscellaneous hospital supplies Bedding and linen Furniture and fixtures, etc j Establishment Charges: Insurance 1 m _ _ Taxes, etc I ° 17 ■' Power Plant: Fuel , ) Oil and waste \ .20 8.0 Ice plant, etc J Rent 014 .6 Salaries and Wages 913 36.6 Miscellaneous : Printing and stationery ^| Postage Advertising \ .053 2.1 Telephone and telegraph I Sundries J Management: Incidentals — Auditing, etc .064 2.6 $2,496 100 Let not the prospective hospital builder or board be frightened at the pres- entation of figures of expenditure. These are not hard-and-fast figures, and many economies can be practised to lower them here and there under conditions that exist in every hospital. For some institutions the raw food figures might per- haps be higher, although that is not likely, and in some places they will be materially lower. The question of hospital help will be subject to variation. In a good many places convalescent patients can be pressed into service to perform quite a con- siderable amount of the unskilled labor of the institution. In asylums, poor- houses, orphanages, and even in some general hospitals where convalescents are kept until well advanced in convalescence, there will be practically free help available to grow farm products, if the land is at hand; to raise poultry, if there is an expert director for that department of industry; and to care for and milk the institution's own herd of cows, if it be practicable for the institution to keep a herd. Let us now pause for a moment on the ground we have just covered, in order to fix in the mental vision some essential points in institution organization, construe- RUNNING EXPENSES 31 tion, and operation. If we have dwelt upon the problem of a new institution in a new community, it has been wholly for the purpose of discussing the question from its inception to its realization. The problem will hardly come in a new shape to most of us. We have already made the start; we have a hospital or sanitorium or orphanage already in operation; it has grown too heavy a financial load, or it seems not altogether in tone with the greatest local need, or in some of its parts the machinery seems not to work well. In what we have said heretofore in this chapter we have tried to present some basic thoughts, which, while they may not fit the special case, will, at least, raise some doubts about present methods and so move toward new view-points ; and, finally, in the mental struggle we may arrive at a successful settlement of our individual problem, whatever it may be. We have started out with the conception of a new institution in the mind of perhaps a single individual; we have seen the idea grow until it became a commu- nity-wide problem; we have attempted to give it direction and force, to supply the details as to the kind, character, and size of institution needed; to offer a few sug- gestions as to the creation of a strong and enduring organization behind it; to point out some of the means by which the modern institution may be financed and some of its avenues of expenditure. The pathway we have trod in the story is worn hard by the travel of many tired feet; the ashes of old camp-fires are everywhere along the way, where those who have been lost in the mazes have stopped to rest and build up new strength for the further journey over the rocks and through the woods of perplexity. Our roadway has led into no new and unexplored country, but perhaps some of us by traveling day after day and year after year have found a short cut here and there where the going is smoother and the road is pleasanter. If this section shall have added a single new thought, or led to one new idea, or given a single ray of light to one fellow-traveler whose burden is heavy, it will not have been written in vain. PART I HOSPITAL ARCHITECTURE FOREWORD The following work was written to place the various kinds of building mate- rials, devices, and arrangements before people interested in the building and man- agement of hospitals, so that prospective builders may intelligently select the article best suited to their needs, the local conditions, and the available funds. The writer has studied materials in use in hospitals for upward of fifteen years, and the statements are made with such authority. It is not a treatise on the architectural art or the science of construction, but a simple exposition of the ordinary, also latest, practice of building in this country for hospital purposes. The planning of a hospital is probably more difficult than the planning of any other kind of a building under the best of conditions, that is, with unlimited land and unlimited funds; but when the site and the funds are restricted the problem becomes further complicated and depends so much on the surroundings, the method of management, and its intended use that it is practically impossible to lay down rules which can be followed and which will fit every case. Few architects understand that there is a great difference in the management of hospitals, and that which is considered excellent in one institution may be held execrable in another. In consequence, many institutions are built without a proper understanding between the architect and the management. The scheme devised by the architect may operate like a well-made machine in the hands of one person, and may break down completely in the hands of another trained in an institution having a totally different method of operation. This argument is not advanced to defend all of the architectural mistakes, but many of the so-called mistakes are thereby explained. In too many instances the management looks to the architect as a person of unlimited knowledge of all the details of hospital management, and pays but little attention to his sketches and plans when they are submitted in the formative stage, and he, in turn, hearing no criticism, believes that his sketches and drawings have had the study and approval of the management or building committee, so that no one is aware of the short- comings in the building until it has progressed so far that the damage is irre- coverable. Almost every architect is only too glad to have an intelligent criticism of his preliminary work, for a piece of work that is satisfactory to its users and patients will redound to the credit of all connected with it. Tt might be wished that super- intendents, matrons, superintendents of nurses, and directors appreciated that a failure in the proper working out of a plan can easily be avoided if they would gather their views into a sensible co-ordinated statement, and discuss these with 3 33 3-4 HOSPITAL ARCHITECTURE the architect before the plans have advanced to a point where it would mean loss to the architect if he had to begin over again, and discuss the various points with him, each patiently listening to the other's criticism or reasons why any arrange- ment under discussion will not permit of proper or economic administration, or may not be good planning, and thereby arrive at a mutually satisfactory arrangement. Naturally, the architect, expert and learned though he may be in the technic and practice of his own profession, cannot be expected to be familiar with the details of the work of the hospital superintendent, housekeeper, superintendent of nurses, and the various departments heads; therefore, he must rely in a large meas- ure upon those who are familiar with hospital administration for suggestions con- cerning the utilitarian purposes of the building to be erected. There is another difficulty just here, too, in that very few hospital workers seem to be able to interpret even the simplest rough sketches, floor plans, eleva- tions, and details. The result is that they are inclined to attach a blanket approval to whatever is submitted to them, and then, after the specifications are drawn and even after contracts are let, they come in with an eleventh-hour protest against plans that already have received the unanimous and supposedly intelligent approval of everybody concerned. All this means that the architect is entitled to an intel- ligent and painstaking study of his plans by those who are considered worthy of having responsibility placed in their hands. THE SITE The situation of a hospital is of prime importance, and the existing and pos- sible future surroundings must be carefully considered. Often a hospital obtains possession of a piece of property by gift or bequest at the inception of the enterprise, or an existing hospital is in possession of a piece of property when the time for an important increase in the size of the institution arrives. The piece of property in question may be totally unsuited for hospital purposes and should be abandoned, and, although such abandonment may be heroic and an apparent sacrifice, the loss in many cases will be only temporary. Unsuitable sites hamper the growth of the institution, the constant increases or changes required to keep step with the progress of medicine, or an impending change in the neighborhood from a residential quarter to a business or manufactur- ing quarter, or the modifying of the hospital clientele to a locality situated at a greater distance from the hospital may make such a site undesirable for the pur- pose. Generally, the difference in cost between a new site and the selling price of the unsuitable site is small and a very small percentage of the total investment. The more the location and surroundings of a hospital approach those desirable for a high-class residence, so much more will the site be desirable. Ample air, distance from neighboring buildings, distance from the dust of the streets, and noises caused by steam railroads, street traffic, electric railways, and manufactur- ing plants are all of them exceedingly important to hospital patients. If a hospi- tal is close to dusty streets the dust will enter the building, of course, through open windows, but also through crevices around tight windows. The ventilating appa- ratus will become clogged and very costly in point of constant attention to keep the air-washing devices in the perfect operation necessary to prevent the dust from entering the ducts. Inasmuch as most hospitals must be maintained within the limits of large cities, close to their activities, they must be built on restricted ground areas. In such cases the fresh air and ventilating devices must be more highly organized THK BITE 35 and, naturally, more expensive to install and operate. On account of the rela- tively high price of land, city hospitals must frequently be built on the masse or block plan. The difficulty with this is to arrange the building in such a manner that every room will receive direct sun-rays during some time of the day. This is practically an impossibility, and it is, therefore, desirable to plan so thai the wards and rooms of the sick will receive as much sunlight as possible. The auxil- iary rooms, such as pantries, chart rooms, and linen rooms, are then placed on the north side of the building. Many of the hospitals in which the best work has been done in this country are built on such plans; but where a semiblock or semipavil- ion plan is possible it is usually more desirable. The appearance of such a plan is that of a number of barrow strips, sometimes joined solidly and sometimes by cut-offs or necks. On such a plan all of the wards can usually be arranged to receive direct sun-rays during some hours of the day, and only so much of the northerly side of the building is arranged into patients' living space as may be absolutely necessary, or for such as eye wards, where sunlight is not so necessary. Sunlight is now an acknowledged retardant, if not an actual destroyer, of micro-organisms, and it is highly desirable that sunlight shall enter almost every part of an institution. The complete pavilion style of buildings can be applied but very seldom, usu- ally only for public institutions. It is more expensive to build and operate, and, naturally, more elevators and more attendants are required. The kitchen ser- vice and all other service is at a greater distance from the patients, and, especially in inclement climates, covered passageways must be built, and usually these must be two stories in height — the lower one for pipes, conduits, and kitchen service; the upper one for patients, visitors, medical attendants, and nurses. Such passageways are of a high first cost; their maintenance, heating, and light- ing also must be taken into account. Where a large number of patients must be housed, such as in public hospitals of large cities, counties, and states, such an arrangement is necessary and advisable. In choosing a site a pleasant prospect from the wards is desirable and certainly a benefit, so that for a general hospital, an elevation, if the ground is rolling or hilly, is more desirable than lower ground, for naturally the institution will be more windswept, and an airy situation is highly beneficial. An elevation has the further advantage of good natural drainage. The basements and cellars can be drained by gravity flow of sewage. If the surrounding ground is sandy or gravelly, and the drainage is of adequate size and at a sufficient distance below the lowest floor level, absolutely dry cellars can be built, and a certain extent of cellar is useful, especially in connection with the kitchen, because vegetables and some other stores can be bought in quantities to advantage and kept in good condition until required. If the ground is sandy or gravelly and several feet above the drains, it will be permissible to build a main floor directly on the ground without an intervening cellar or basement. This can be done at a considerable saving in a large institution. Several hospitals of this kind with a first floor but S inches above the surrounding grade have been in existence for a number of years, anil are sanitary and otherwise successful. Inasmuch as the bottom of foundations must be at least 4 feet below the surface of the surrounding ground in localities having the average temperature of this country, not much is gained by using a portion of this depth as a cellar or basement wall, and, further, the expense of excavating the entire site of the building and removing the excavated material is so great per unit that it hardly pays to create ~o much cellar or basement space to lie used only for storage and the passage of pipes. The existence of a space for too much storage is 36 HOSPITAL ARCHITECTURE often a detriment, for if the space did not exist, useless plunder would be destroyed or sold and not allowed to accumulate to gather dust and become dangerous as a fire hazard or in affecting the purity of the air. Large and useless cellar spaces, unless carefully built and maintained, are also likely to become foul and noisome. In the institutions mentioned previously, where the first floor was less than a foot above the surrounding ground, every square foot is usefully applied to the many auxiliary activities of the hospital, and the space which is generally created at a considerable cost and used only for storage and waste space is converted into valuable space by the additional cost of finishing, and actually one story is gained. PLANNING THE HOSPITAL A plan should be laid out with reasonably straight lines to permit easy obser- vation, good illumination, ventilation, a good circulation from section to section, and a proper interrelation between its parts. It should be a good architectural composition not simply to be one, but because a good composition will afford all such desirable qualities, whereas a heterogeneous jumble of rooms, curved, broken, and contracting and expanding corridors will defeat and prevent the desirable qualities, making administration and cleaning difficult, almost impossible. More- over, it must be understood that straight lines and rectilinears are stock materials, and any deviation from these adds immeasurably to the expense of a building. Wide corridors are attractive in appearance, facilitate communication, and assure good ventilation, for they provide a large volume of air when windows must be kept closed. They sometimes impress the laymen as unnecessarily costly, but they are not, for they are the least expensive part of the structure; one foot or more added to the width adds only to the cost of floor and roof construction, and not of walls, partitions, equipment, or any of the units, such as doors or windows. When reinforced concrete floors are continuous from outer wall to outer wall, over the two corridor walls or girders, fairly wide corridors actually effect an economy in the amount of steel and concrete in the floors or the rooms each side of the corridors. Very large hospitals, such as governmental institutions, will usually be built with separate buildings connected only by tunnels and possibly covered walks on the roofs of same, the separate buildings obtaining power and light from a cen- tral station, but the majority of hospitals to be built will probably house less than 250 patients, and will be built in cities where they should be fairly close to the homes of patients, and will, therefore, be built where land values are compara- tively high, which will result in restricted dimensions, and this does not permit of spreading the buildings over acres of ground. The most suitable plans for such areas are the semi-isolated pavilion type of the block plan, which can be combined in a variety of arrangements and some of which are shown in the illustrations. Where there is sufficient land area to make it possible to build single build- ings, that is, completely isolated pavilions, this should be done, connected by one-story enclosed corridors for service piping, and used during inclement weather, with covered open passages on the roof. If the roof is sufficiently low and over- hanging, there can be no objection to their use in any kind of weather. Wide comiecting corridors provide pleasant open-air porches and are very convenient to the connecting pavilions, and if the pavilions are two stories high and the passages the same, these must be quite ■wide and imposing to avoid an ungainly appearance. Probably 20 feet is not too wide and does not add much to the cost, for this is only in the excavation, floor and roof construction, the cost of PLANNING THE HOSPITAL 31 the side \v:ills remaining the same. In such cases, it would, however, he hesl to arrange for the fitting of casement sash, so that they may be used as parlors in stormy weather. A small complete hospital contains all of the parts which a unit .,1' a large hospital should also have, and, inasmuch as proper administration requires the division of a large hospital into parts or units, any one of these should he the -ann- as the ward Moor of a small hospital. In a small as well as in a large hospital one floor of any unit may be arranged for an administration, or service, or nurses' teaching, or operating department. Many large and elaborately illustrated works have been published on Conti- nental European hospitals, but these are of little value to the American builder, for the foreign builders do not appear to consider it necessary to have the con- veniences and accessories to the wards considered so essential in this country, nor do they have many private rooms. In the European plans often one bath to a III km appears to be considered sufficient, whereas in this country very many patients demand separate rooms and private baths. Whatever private rooms they have are usually on the corridors of the wards, where the patients are subjected to the noise of communication and curiosity of other patients, whereas American practice endeavors to locate the private rooms away from corridor traffic, to make them as quiet and give them as much privacy as possible. American designers are planning hospitals with more single, two, three, or four lied wards, and with fewer large wards. This may increase the cost of nursing and other service, but it assists in isolation and classification, and, considering that many more people capable of paying at least part rates are making use of hospi- tals, the additional cost is thereby balanced. A building for convalescents is very helpful to patients, and will often be re- munerative to the hospital; such a building need not be as highly detailed or as fully equipped as the hospital building proper, for the convalescents can help them- selves to a great extent, can go some distance to their meals, so that a much cheaper grade of building will suffice. A unit in proportion to the size of the proposed hospital should be designed and one of these incorporated in the whole plan for each department, such as male medical, female medical, male surgical, female surgical, maternity, private rooms, etc., each one as far as possible self-contained so as to keep the nurse close to her patients, and make it unnecessary to leave the unit while on duty; the surgical units should have a surgical dressing-room, the maternity department, a nursery, labor rooms, and accessories, and each of the others their special requirements. The units must be in easy communication with the kitchen, the general labora- tory, the operating department, anil other common divisions. A unit should have the following rooms: 1. The ward or private room. 2. Toilet room. 3. Nurses' toilet room. 4. Serving room or diet, kitchen. 5. A quiet room for one bed. 6. Bath-room. 7. Utility or sink room. 8. Cabinet for linen. 1). Cabinet for medicine. 10. Station for nurses. 38 hospital architecture Plan of Unit If the units can be made large enough, one or more of the following will be of advantage : 11. A solarium. 12. A reception alcove or room. Where two or more units are close together, Nos. 3, 4, 5, 11, and 12 may some- times be arranged so that they can be used in common. The same space occupied by a ward can be divided into a number of single- bed or private wards, or into half-pay wards. One of these units may be one- story or any number of stories in height to increase the capacity. The small plans (Figs. 1 and 2) show a development of one of these units in the simplest form, with wards, a single private room, a quiet room for emergency, PLANNING TIIK HOSI'ITAJ, 39 and the few absolutely necessary administrative offices; toilet, bath, slop, sink- room, nurses' retiring-room, supply room, and a sun porch in the semicircle at the end. The following plana illustrate combinations of two, three, four, and more units and the manner in which they are customarily assembled to obtain different capac- Fig. o. — Various combinations of units assembled in various ways to suit varying capacities and conditions. ities, and huge institutions are merely modifications of these arrangements, to meet particular conditions, special sites, or individual taste. Under the chapter on the Architecture of the Small Hospital, we have gone somewhat into detail con- cerning economies in space, cost, and convenience, but the units themselves are the same. 40 HOSPITAL ARCHITECTURE Figure 3 shows a number of such combinations, assembled in the various shapes, because of the lay of the ground, shape of the lot, or the taste of the building board. THE AREA PER PATIENT The minimum area and cubic contents per bed permitted in Chicago at the close of 1912 are 80 square feet and 800 cubic feet. No distinction is made between adults, children, or infants. Such factors are probably based on usage which appears to have been safe, or they were selected to accommodate and not disturb existing institutions. A new law with factors for adults, children, and infants will be submitted to the legislature of the State of Illinois in the coming session. A similar law will prob- ably be enacted for the State of Ohio. The factors are as follows: Minimum square feet of floor space per person: Adults. Children". Babies. Private rooms 90 75 55 Wards SO 65 45 Minimum cubic feet of air-space per person: Adults. Children. Babies. Private rooms 900 675 500 Wards S00 600 400 These minimum factors are low and permit considerable individual discretion. The placing of the bed and the floor area for one-bed wards is described in a later section. In larger wards the spacing of the beds depends generally upon the architectural spacing of the windows, and, therefore, in a measure, governs the floor area occupied and the story height. A few dimensions will explain the various factors. Inasmuch as the most important dimensions of the areas is the distance from center to center of bed, area alone, without a minimum distance from bed to bed, does not result in a sound provision. Eight feet from center to center of bed is fairly liberal, but for infectious cases this dimension should be greater. Where beds are placed on both sides of a ward, the distance between the ends of the beds should not be too close for efficient ward work. Eight feet appears to be the minimum for this dimension, with two beds, each 6 feet 6 inches long, and the space of 1 foot 6 inches at the head of each bed will result in a ward 24 feet wide, and this dimension should be increased if clinics with large numbers of students are held in the ward. A ward 24 feet wide, with beds 8 feet on centers, provides 96 square feet per bed. If the stories are 12 feet high the cubic contents will be 1152 cubic feet per bed. Possibly this story height may be decreased in the open country under careful management of windows and transoms. ARRANGEMENT OF ADMINISTRATIVE UNITS THE ADMISSION ROOMS Before we can discuss the form of the admission rooms in an institution, we must understand first just what work is to be done there. It matters little whether it be a hospital for the insane, a special institution, a small hospital in a sparsely settled community, or a large general hospital in a metropolis, the work in the ad- mission rooms is the same, and that ought to be limited to the examination of ARRANGEMENT OF ADMINISTRATIVE UNITS 41 patients, preliminary to their acceptance or rejection; out-patienl and dispensary operations and the business of the public should be performed at some other entrance, and if there can lie entrances for each of these classes of business 30 much the better. Indeed, if visitors to patients can be classified according to their social status, the ward patients' visitors baving one entrance and private patients' visitors another, the visiting system will lie much simplified, because in most hospitals ward patients cannot have visitors as frequently or as long as those in private rooms for obvious reasons; and yet it is difficult for the public to under- stand this, and embarrassing situations are likely to arise if two persons enter at the same time, and one is permitted to visit the sick relative and the other is re- fused. Naturally, admission-rooms in a charity or free hospital will be more largely patronized than where the clientelle is made up exclusively of private patients, because, in this latter case, the patients will have been examined by the doctor at home, and the patient's status in the hospital will have been directed by the attending physician, and will not be subject to revision by admission interns. So that, in contemplating a large elaborate admission department, we must under- stand that we are dealing especially with institutions that receive a considerable number of free patients, or at least those whose status must be subjected to in- quiry before they can be admitted or rejected. Figure 4 gives an outline of a suite of admission rooms for a general hospital, and this arrangement may lie elaborated almost indefinitely or contracted to meet the needs of a small institution. There are two classes of patients that pass through the admission-rooms, the ambulatory cases that come afoot, or in some vehicle other than an ambulance, and the ambulance cases that come on a stretcher. The curved clotted line in the illustration shows a peaked roof for the entrance to the department along the carriage drive. This driveway should be enclosed at all hours, because patients entering a hospital must be badly frightened at best, and if there are loungers and curiosity seekers about they will be frightened all the more. Let us follow the patient who comes afoot, applying for admission to the hospital. He passes through the large double-door entrance, turns to the right into the common waiting rooms, which contain seats on three sides. When his turn comes to be examined, he passes into the next, or examining room, where there is a large window and all the paraphernalia for making preliminary observa- tions. If he is accepted, he is taken in charge by an attendant, male or female, as the case may be, and passes along the inner corridor into the bath-room, where his clothes are removed, tied into a bundle, labeled, and thrown into the chute. After the bath he is given hospital clothing from the closet at the end of the cor- ridor, and passed across the main corridor to the elevator, which takes him to his destination upstairs. In the event that the admission department is large enough to justify two examination-rooms, the second room shown in the cut may be used and the patient passed in the same way. The ambulance patient is brought on the stretcher into the ambulance dress- ing-room on the left side of the main corridor. Any necessary preliminary dress- ing can be done, such as blood stopping, and, if ihe case is urgent, the patient may be placed at once in the elevator and taken to bed upstairs. Sometimes it is necessary for the patient to rest following a dressing or examination, and for that purpose he may be placed on a couch in the quiet room just off the reception room. At times it is impossible to give the patient a bath and change the cloth- 42 HOSPITAL ARCHITECTURE ing, as a preliminary to his reception, and he must be taken upstairs at once. But, again, there are many patients who come to a hospital in an ambulance in such a filthy condition that it is out of the question to admit them to the clean hospital wards until some sort of effort has been made to free them at least from the vermin with which they are infested, and for that purpose there is a bath- room, just off the quiet room, where these patients can be bathed and reclothed with hospital garments; and, as with the other class of patients, the clothing . rvte.u u AN C. E A. D N*l I -5.5 t O N DE.PA.R.T M E N T- Fig. 4. can be done up in bundles, labeled carefully, and thrown into the chute. The last room on this side of the corridor is reserved for stretchers, stores, and dressings In smaller institutions, or where the admission department is of small im- portance, there need be only one reception-room, and that can be used for both classes of patients, with the one examining-room off it, which may be used also for a quiet room. Under such conditions there can be one bath, one clothes closet, and one chute, through which to drop the patient's clothing to the sterilizing room, and thence to the lockers in the basement. ARRANGEMENT OK ADMINISTRATIVE UNITS 43 ARRANGEMENT OF THE LOCKER AND STERILIZING ROOMS Figure 5 shows a locker and sterilizing room for patients' clothing thai can be changed, constricted, or elaborated to meet any size of institution. It will he noted that there is an elevator coming down into this suite which can lie used to convey mattresses. There is a chute also for the handling of patients' cloth- ing from the admission rooms above. The sterilizer is placed conveniently for the placing of either mattresses or clothing at one end, to be taken out the other. The mattresses, after sterilization, are taken back upstairs by way of the elevator, v/);////////////;^,',. ' ^ ^ JOR.TINO Fig. 5. which is not ideal, but practicable, and the clothing can be placed in the lockers marked in the illustration. The sorting table, with bins across a corridor in the long room, may be arranged under certain conditions for the handling of the laundry, and especially of that part of it that should be sterilized before going to the laundry proper. THE KITCHEN The food supply of an institution reaches the very vitals of the administration. More will depend on the economy and system of the arrangement in this depart- ment than in any or all of the other departments combined, because upon that arrangement and system will depend economics in the care, preparation, and serv- ing of food, and upon these factors will depend in turn the costliness or the econ- omy of the institution management. No matter whether it is a large or small in- stitution, no matter whether the help are high-priced paid individuals, or largely recruited from convalescent patients, the system, or want of system, will be ever present for or against possible economies and a high order of food service. If it is a small institution of very limited means, the more reason why the very best should be got out of every dollar expended for table supplies. If it is a large and wealthy institution, the food will be served better for the application of proper system, and patients will get more for whatever money is expended, so that the kitchen 44 HOSPITAL ARCHITECTURE arrangements and the kitchen auxiliaries cannot be overestimated in import- ance. Of course, the first question is the location of the kitchen and the location of the auxiliaries, meaning the pantry, refrigerators, meat shop, pantry for prepar- ing vegetables and food of various sorts, closets, scullery, and utensil shelves. i ^i^^j^T-^f^jiiiii W//////////M I 1 A.FCFC.A.NG-E.N'I Fig. 6. It seems to be the fad just now to build the kitchen at the top of the house. Twenty years ago it would have been well to have the kitchen up where odors could not penetrate to the balance of the house. We had practically no venti- ARRANGEMENT OF ADMINISTRATIVE UNITS I") Intion in those days, and knew almosl nothing about taking care of vapors and odors. We do know something, at least, aboul taking care of these things aow, and the same imperative reason does not exist for having the kitchens just under the roof. An immense amount of carriage is required to and from the kitchen. Many trips of many people are required daily and hourly to and fro, especially by people from the outside, and mosl of us object to tradespeople and all the non- descripts who come to the kitchen for various purposes, going through the rest of the institution, even on an elevator; they stop off and pry where they have qo business. If the institution is a large one, literally tons of material must be taken up and down, and, unless one has paid some attention to the immense amount of s- 1 ul!" t hat reaches the kitchen in the course of a day, one will not be able to compre- hend just what this traffic means. Moreover, the top of the house is perhaps the most desirable part of the house for institution purposes, and the basement is the least desirable, so there is a question of space involved also. Laws of sanitation, and in many places the law of the locality, prohibits people living in the basement, even the help, and if the kitchen is on the top floor the stores must be there also, so that the basemen! is practically vacant. If the kitchen is on the top floor, the help must have their meals on the top floor, and more valuable space is taken up, whereas if one uses the basement space for these purposes there is economy of space; it may be safely concluded, therefore, that the basement is the proper place for the kitchen and its auxiliaries, always provided that it is arranged properly, well lighted, ventilated properly, and is connected conveniently for the transportation of food to various parts of the house. Figure 6 is a diagram of the author's conception of an ideally arranged kitchen with its auxiliaries. This diagram contemplates a basement kitchen, with the highest possible ceiling, 20 feet as a minimum, 30 feet by preference. There is an areaway 10 feet wide on each side of the kitchen; the windows go almost to the ceiling, and the window glass is in three independent sash, each capable of being raised or lowered independent of the others, for purposes of light, air, and additional ventilation as required. ARRANGEMENT OF THE MEDICAL UNIT The medical ward with its appurtenances furnishes all the ideals of what we ordinarily term a hospital unit. It is composed of a ward and a quiet room for patients, and the things that lend themselves to the service of these patients — linen-room, serving-room for the handling of food for the ward, a convalescent dining-room for those who can be at table, slop-sink room, with the necessary sterilizers and sinks, a combination bath and toilet-room, or two separate rooms for these two separate purposes, and one or more quiet rooms in which to care for recently operated patients, or those who are noisy or nervous, or for those who are dying. If the ward is to be kept nice and clean, and free from mops and pails, then there should be a porter's room or janitor's closet. Figure 7 shows what the author thinks is an ideal arrangement for such a suite as this planned upon a somewhat elaborate scale. Changes may be needed in this arrangement to meel certain conditions; for instance, the isolation-rooms might have to be away from the main corridor of the building, because of the noise that might emanate from them and extend to other parts elsewhere. The linen and slop-sink room should certainly be very near the ward. Perhaps the slop-sink room might be allowed to change places with the bath and toilet rooms, so that these latter could be a little bit nearer the patients. The medicine cabinet- for such a suite as this can be set into the walls of the corridor, just outside the ward, or at some point in the walls of the ward itself. 46 HOSPITAL ARCHITECTURE The serving-room for taking care of the food is properly located at some dis- tance from those offensive rooms — the bath, toilet, and slop-sink rooms — and the convalescent dining-room is properly located at a point furthermost from the ward, because it is unnecessary that it should be any nearer. lZZ . ■ r . MEDICAL NiVAK-D A K R.ANG-E ! Fig. 7. The combination of double swinging doors at the entrance to the suite are for the ingress and egress of patients, either to or from the suite, into and out of the building. In this arrangement the elevator is also situated at the end of a small vestibule, which takes away a great amount of the noise normally coming from an elevator. ARRANGEMENT OF ADMINISTRATIVE UNITS 47 THE SURGICAL WARD UNIT The surgical ward unit may be arranged precisely as the foregoing, excepting that there should be a dressing-room for surgical patients. This might be made in the same space by constricting somewhat some of the other rooms, or one of the isolation rooms might be taken for the purpose. A good deal of the dressings j n such a surgical ward could he done at the bedside, by the use of a dressing call loaded with dressing accessories. ARRANGEMENT OF THE OPERATING SUITE Before we discuss the ideal operating-room, or suite, we must understand in a general way what is to be done there. Of course there must be a surgical operating-room, or several rooms, as the case may be, and as we shall need sterile water, and as the instruments must be sterilized immediately before, and sometimes during, the operation, it will be necessary to have the sterilizing room nearby. Supplies are constantly called for. and therefore there must be a supply room in the vicinity. The instru- ments must be taken eare of properly after they have been used and washed, and there must be a case for them; and, if the institution is large enough, there should be a room kept under certain physical conditions as to dryness. There is washing of every sort, soap and solutions to be made, utensils to be boiled, and all these things make it necessary that there should be a wash-room with basins, sterilizers, and gas plates. Anesthetics must be given, and it is becoming more and more the custom to give the anesthetic in another, rather than the operating- room, because of the mental effect on the patient; therefore, one or more anesthetic rooms must be provided, which may be used also for the preparation of the patient. There ought to be quarters for the surgeons, and in this room there should be a sufficient number of lockers to serve the number of men who operate, and since modern surgery demands cleanliness of person on the part of the surgeons, it is desirable to have in the surgeons' dressing-room a shower bath, an ordinary bath- tub, a toilet, and a hand wash-basin. In some hospitals there are many medical visitors who come to see surgery; it is the custom for these men to take their coats and vests off and to don an opera- ting coat or gown, each institution being a law unto itself as to the character of the visitor's gown. It is not desirable to have these casual visitors frequent the regular surgeons' dressing-room, therefore there should be a visitor's dressing-room with lockers, a table with writing material, perhaps a lounge, and some institutions have a telephone for the use of visiting physicians. The nurses are perhaps the most important factor of all in the operating-rooms, and, although most surgeons seem to overlook the fact in their demands on the nurses in the operating service, these girls are just ordinary human beings, and quite as likely to become exhausted and fagged out as the surgeons themselves, and oftentimes one of them will get sick while at work, so that by all means the nurses ought to have a room for themselves in connection with the operating suite, which should be equipped, just as the surgeons' dressing room is equipped, with lockers, a shower and bath, toilet and basin, and there should be a lounge in the nurses' room, so that a tired girl may rest sometimes. Last, hut not least, there is an immense amount of cleaning and janitor service to lie performed in connection with the surgical suite, and there ought to be a small room in which to keep the janitor's supplies, mops, buckets, [adders, and brooms. 48 HOSPITAL ARCHITECTURE And if there could be still another room, that might be kept under lock and key for the safety of the larger apparatus occasionally called for in the operating-rooms, it would be an economy, because in many places these things set around, to be fingered and handled by casual visitors, and oftentimes they are put out of order and are not ready for use when called for — such apparatus as the large cautery, the jury mast and attachments for putting on body casts, the surgeons' bone-drill, the battery for cystoscopic work, and perhaps some of the cases of the larger in- struments. There are many institutions that will not have all these rooms, but it is equally certain that every institution competent to handle modern surgery will have to meet all the requirements of such an operating suite as has been outlined. In other words, no matter how small a hospital, there must be instruments, and there will have to be a case for them, and they will have to be kept in a dry place or they will rust and soon become useless. There must be supplies in even the smallest hospital, and sterile hot and cold water, and the instruments will have to be steril- ized, and one of the worst possible things is to boil instruments in the operating- room, so that there ought to be some place in which to do this sterilization. The anesthetic must be given, even in the smallest hospital, and if it is not to be given in the operating-room itself, there must be a small room in which to give it. The surgeons and nurses must dress and undress, and there certainly must be a place for them to perform these offices. In many institutions, large as well as small, all sorts of makeshifts will be resorted to to meet the requirements that have been outlined. Sometimes the wash-room, sterilizing-room, and supply room are in one; sometimes there is only a closet for the surgeons to put on their operating- room paraphernalia, and the nurses are compelled to use the supply room for this purpose, and a corner in the same room will perhaps serve for the janitor's sup- plies. In such an institution the anesthetizing-room will be dispensed with, and patients will be put to sleep on the operating table, in spite of the fact that some- times they are almost frightened to death at the sight of white-robed, white-masked surgeons and nurses flitting about. Figure 8 shows rather an elaborate operating suite that seems to meet most requirements. The plan provides for three operating-rooms and their auxiliaries. This whole scheme may be constricted to provide for one operating-room only. The three operating-rooms are side by side, each having its northern window lights, of any design that may be selected. There is a side window in each of the two end rooms for additional light and air. All of these rooms open by double swinging doors, containing stops and checks, upon a common corridor of rotunda form, to allow of the easy handling of carts. In some operating suites the steriliz- ing-room is placed between the operating-rooms, with shelf window between it and each operating-room, for the handling of supplies and water; this arrangement is unsatisfactory, because the sterilizing-room is of necessity a very hot place in the summer time, and nearly all sterilizers emit at least some steam into the room, no matter what preventative devices are used. Both the heat and steam are ob- jectionable in operating-rooms; therefore, it seems better to have the sterilizing room across the corridor from the operating suite, as indicated in the drawing. The sterilizing-room, containing water, instruments, dressing, and salt-solution sterilizers, can be kept cool by an exhaust fan above the window, which will serve to draw the hot air out of doors. It would seem a much more advantageous ar- rangement if there were a common dressing sterilizer-room somewhere else, in the basement perhaps, with a sufficient number of sterilizers to make up supplies in drums for all parts of the house, and have these supplies distributed daily. The ARRANGEMENT OF ADMINISTRATIVE UNITS 49 same may be said of the salt-solution sterilizer, excepting, perhaps, that in some institutions these normal salines are kept ready for use at a temperature that will make them immediately available, and where that is done perhaps it will be better to have the salt-solution sterilizer in connection with the operating-room suite. L ■ , .- , ^ i ^ pw— Jr ^"T 4 . 1 OpeR_A.*TING DEPAl Fig. 8. The next room of this suite on the same side of the general corridor, leading from other parts of the hospital, will be the supply room. The shelving, closets, and lockers of the supply room will be obvious in their arrangement. Just off this supply room is a long narrow slit in the wall, the blanket wanner. This is an ordinary laundry drier, with steam coils ill the rear. The carriage is 50 HOSPITAL ARCHITECTURE run in and out on tracks just as in the laundry. This little drier has an immense usefulness in the operating-room suite. It practically does away with the necessity to warm beds by the use of hot-water bottles in preparation for patients expected from. the operating-room. Where this drier is used, it is the custom to hang the horse full of all-wool blankets, and as many as may be needed are tucked about the patient when he is taken from the table to the stretcher, and he can be put into bed when he arrives at his room, with these hot blankets still around him. Patients get to bed in a very much better condition, and freer from the shock of the opera- tion in this way, and the peripheral circulation is very much hastened when the patient is wrapped up in hot blankets immediately at the conclusion of the opera- tion, and the burning of patients by hot-water bottles, so common in hospitals, is practically ended. The vitality of the patient under an anesthetic, and espe- cially at the end of a long operation, is very low, and a ho1>water bottle, contain- ing water at 120 degrees, will oftentimes make a very serious burn. This little hot-blanket room practically does away with all this danger. By the time the blankets are cold the patient and the bed are warm, and the blankets can then be removed, sterilized, and returned. Next to the supply room is the wash-room, with its hand-basin, sinks, gas plate, utensil sterilizer, and a row of shelves; here the soaps are made, sponges boiled, and instruments cleaned. Still further along, on this same side, is the instrument-room. There is no door between the wash-room and the instrument-room, because it is necessary to keep the instruments very dry, which will not be possible if steam from the wash- room is allowed to penetrate. This instrument-room should be plainly furnished; the instrument case itself and a long table will be all the furniture required, with the possible exception of a white enameled stool or two for the nurses to use while arranging and putting away the instruments. The last room on this side of the corridor is for the janitor's stores; this room, if occasion requires, can be used also for keeping the larger apparatus, where, the janitor and operating-room orderly are one. The average house man, who would be called upon to mop the floors in the operating-room suite, would slap a wet mop against a piece of valuable appa- ratus and rust it beyond all usefulness in a short time, and the first intimation of the fact would be when the instrument was called upon for use. Let us now go back to the other side of this main corridor, where the first two rooms are arranged for anesthetizing the patient. These rooms ought to contain, in the shape of furniture, an operating-room table, a cabinet to hold the anesthet- ics and masks, and the scrubbing-up material, such as soaps, ether, alcohol, iodin, and brushes. There ought to be a small anesthetic table and stool, and an ordinary table at the side of the room for emergency purposes. There ought to be a basin with hot and cold faucets, a brush and comb box above the basin and at the side of the mirror, because oftentimes patients will come to the hospital to take "a whiff" of gas for some slight operation, and they will want to spruce up again and go home. The gas-anesthetizing apparatus will, of course, be in these rooms, and the carbonic-acid freezing set for the quick removal of warts, moles, and nevi, with the frost pencil. The next room is the nurses' dressing-room, with shower, toilet, basin, and couch. The next room is the surgeons' dressing-room, equipped precisely like that of the nurses', and, last of all, the locker-room for visiting physicians. Some surgeons choose to have, in connection with the operating suite, a series of recovery rooms. The advantage of this arrangement may be doubted. When DETAILS OF STRUCTURE 51 the operation is concluded the patient is asleep, the wound is fresh, and not yet sore, and he would not feel pain in any event; therefore, it would seem to be good practice to rush the patient, covered in hot blankets, back to the bed where he is to remain, as quickly as possible. If the patient is allowed to remain in a recovery room on the car for two or three hours, or even twelve hours, he is sick and sore, perhaps nauseated, and it will be very much more painful and more difficult to move him then than it would be in the first place. Moreover, many times patients need a great deal of attention from the nurses immediately following the opera- tion — there may be nausea and vomiting. They may need a "hypo," either of morphin or strychnin. They may need irrigation — abdominal, subcutaneous, or intravenous — and, under any of these circumstances, it would seem very prefer- able to have the patient back in his own bed, where he is going to remain, as soon after the operation as possible. DETAILS OF STRUCTURE FOUNDATIONS The type of foundation which is to be employed is an engineering question, depending on the height of the building and the nature of the soil. Generally, hospitals are not high, and, inasmuch as their floor-carrying requirement is very low, the ordinary spread foundations are the most suitable and economic, and in localities where the contractors are conversant with reinforced concrete con- struction the foundations should be built of this material, provided that the cost of the material compares favorably with the cost of other materials for foundation uses in the same locality. Reinforced foundations save on the excavation and on the amount of material. Rooms which are to be used for service cannot have the footings which are obligatory when common rubble stone is used. In some localities rubble stone is so cheap that it should be employed, but the builder must weigh carefully the additional cost of excavating, and it should be laid in mortar composed of Portland cement and a coarse sand without the admixture of lime. Inasmuch as lime is hygroscopic, a wall laid with lime mortar and below ground will be moist almost continuously and certainly intermittently. Gravel and crushed stone or crushed slag are equally good for mass concrete such as is usually used in foundation walls. It is not generally known that ordinary cement concrete is not a dependable material for the building of waterproof basements or cellars. To obtain such it is necessary to employ special mixtures and unusual care, which results in a completed work of unusual cost. The simplest arrangement to obtain a dry basement is to have the elevation of the basement floor several feet above the drains, and to drain the subsoil under the basement floors and the ground surrounding the building by agricultural drain tile laid below the level of the basement floor, so that, if the house-drains and the street-drains are of sufficient capacity to take off the greatest known precipita- tion for a given time, it will hardly be necessary to make any other provision to obtain a dry basement, for water will follow the line of least resistance, and will follow the outer surface of the cellar wall to the nearest drain tile, unless the wall is so badly built that there are actual channels for the water through the wall. The customary plastering of the exterior of the wall with cement-mortar will pre- vent much seepage if the plastering is done reasonably well. Where a site is below the line of drainage, or where the sewers are so small that their carrying capacity 52 HOSPITAL ARCHITECTURE is overtaxed, it will be necessary to make special provisions, either by making the floors and walls actually waterproof, as though the cellar or basement were the hull of a vessel floating in the water, or by providing piping for the interception of seep- age at every possible point of entrance, and providing channels which will be the line of least resistance and lead the water to basins which can be drained by auto- matic ejectors. In very small cellars an automatic water-lift will be sufficient, and these are of low price, but in large establishments, or where considerable ground water must be removed, power ejectors are necessary. The water can be removed by the use of a steam ejector, but this is an expensive method, not auto- matic, and limited. Automatic electric bilge-pumps and compressed-air ejectors have been in use for many years and are satisfactory ; they can be obtained in units of many sizes and prices, and are usually installed in duplicate, to have one in reserve in the event that one of them fails to operate. The waterproofing of walls and cellar floors can be done with a mixture of special compounds and Portland cement, and troweling these mortars on the surfaces. There are a number of very good mixtures on the market. The dis- advantage of such a method is that the slightest settlement may open a hair crack in the floor or wall and permit the ingress of water. The building of specially prepared felts, asphalt, or bitumen into floors, and joining these into the walls and continuing the same as an envelope on the outside of the walls to the ground surface, is the most certain method of building a permanently water-tight vessel, and it has been most generally used in works of importance, such as tunnels and subways. This is also an expensive operation, on account of the special materials, care, and workmanship, and is not employed except in special cases. WALLS AND FACINGS The means at the disposal of the institution will usually dictate the facing of the exterior wall, and, granted that the hospital must have incombustible walls, such as concrete or masonry, and that frame walls are not to be considered, the relative cost of the different materials is about in the following order in the vicinity of Chicago: Hollow tile unplastered, common brick, which can be laid in red mortar, paving brick, cement blocks, common brick plastered with cement, or common brick plastered in pebble-dash cement; hollow tile plastered in pebble dash; a high grade of pressed brick, then limestones, sandstones, and granite. An ex- terior of paving brick, trimmed with granite for the base courses and entrance steps, and stone or terra-cotta trimmings, will be durable and suitable for a hospi- tal, and it will probably serve the public best if the further money which may be at the disposal of the institution is used for an extension of the work of the insti- tution, and a more elaborate use of costly materials on the exterior of an institu- tion may be considered a waste. Practically all stones and concrete except granite absorb considerable water, which discolors them, and is also very likely to cause deterioration by the action of frost; consequently a base of granite directly on the ground is very desirable to keep the base of the wall dry and in good appearance. Notwithstanding that there may be a waterproofing course through the walls at the level of the ground, the splashing of the storm water on the ground or on walks and rebounding to the walls will frequently water-soak the base of the walls, and, whether of brick, terra-cotta, concrete, or stone, this will have its effect in time; consequently an impervious material, such as granite, is most desirable. DKTAILS OF STRUCTURE .>} Generally brick is the mosl economic incombustible material. In localities where the price of brick or of skilled mason labor is high, walls of hollow concrete blocks or of monolithic concrete may be an economy. The exterior treatment of such walls is, however, rather difficult and somewhat expensive. If the material is to hi' of good appearance as it comes from the forms, these must be made very carefully, and are, therefore, expensive. The concrete must be mixed with care- fully gauged materials, and placed against the forms with extraordinary care, and even then ragged spots often appear on account of the leakage of water through the forms, and an invisible repair is well-nigh impossible. It is sometimes feasible to remove the forms of vertical portions very soon after the material has been placed, and wash the fine material from the surface by the use of stiff brushes and clean water. When this is done the finished surface will have the appearance of a rubbed natural stone, and is a highly satisfactory method for small pieces of work. Another method is to wash the concrete, after the forms have been re- moved, with a dilute acid, which will dissolve the fine cement on the surface and also produce a pebbled appearance. Granite Mix. — Washing the surface of concrete when still new, or washing it with strong acid, removes the cement and exposes the aggregate, which should be composed of material broken into comparatively small pieces which have small voids in between them. The low-priced materials, such as coarse sand, fine gravel, or crushed stone, generally do not have a desirable color when so exposed. In- asmuch as the mixtures of fine stuff are not advisable or economic for the full thickness of the walls, these mixtures must be placed against the forms in thin layers and in courses, as the height of the whole of the wall is increased. The facing of fine stuff is backed with the coarse mixture and these sequences until the completion of the work. The facing of fine stuff does not require much material, and can, therefore, be made of materials which will have a more pleasing color than sand or crushed stone for a small additional percentage of the cost of the whole concrete work. The mixture of 5 bags of granite screened through a No. 5 sieve, 2 bags of Blanc white cement, and i bag of ground mica has made a concrete which resembles dressed granite of the same kind as used in the mixture so closely that a layman could hardly detect the imitation. Mixtures of crushed red and crushed black granite with mica and white cement and many other combinations are possible. The design of concrete work is sometimes such that it is impossible to remove the forms early enough to wash the surface with water or acid, and it is then im- possible to remove the surface cement in this manner, but the texture and color can be exposed by bush hammering the surfaces in the same manner as natural stone is bush hammered. This will result in a very satisfactory surface finish. Journeyman mechanics capable of executing such work are as yet very rare. A few of the larger construction companies have trained a limited number of nun to execute such work, but as yet such labor is not an ordinary commodity on which Contractors will bid on small profits and narrow margins for contingencies. The difficulty of preparing concrete blocks of uniform or equal absorption, and the unartistic appearance of these blocks, which are often too large in scale for the wall surface, or of poor proportion, makes them unsatisfactory material for the facing of buildings. Unequal absorption causes a spotty appearance niter :i rain-storm, and also causes some of the pieces to absorb dust and SOOt. The unsatisfactory appearance of concrete block buildings is largely caused by unwise economy, which prompts the use of as few molds as possible; consequently the design does not follow the law of proportion. In order to design the blocks accord- 54 HOSPITAL ARCHITECTURE ing to proper laws of proportion a large number of dies or forms are necessary, and the cost will then approach, and possibly exceed, that of a monolithic concrete construction, except in the case of low buildings, in which the walls do not carry much weight in proportion to their thickness. The appearance of concrete-block houses can be made interesting and possibly beautiful by modeling and courses, or by obtaining an individual texture, a texture which will not be an imitation of natural stone or of stamped steel ornament, which, unfortunately, forms the basis for most of the ornamental dies now on the market. Fig. 9. — Walls of hollow tile plastered in pebble dash. The ornament on concrete blocks is limited by the same difficulty which sur- rounds the manufacture of satisfactory stamped steel ornament, which is that the stamping does not permit sharp outlines or undercutting of the ornament, both of which are necessary to obtain an artistic play of light and shade. It is neces- sary to use a comparatively dry mixture of sand, cement, and water to produce the blocks rapidly; such a mixture is porous, and is the cause of the spotty and water- soaked appearance of a cement block house after a rain-storm. DETAILS OF STRICTURE .-,.-, Hollow Clay Tile. — Hollow clay tiles are made of varying thicknesses, usu- ally 12 by 12 inches, and 3, 4, 6, 8, 10, and 12 inches in thickness. Those thicker than S inches are usually termed "wall blocks." Well-burned clay tile does not disintegrate in moist or damp places. They arc suitable for use for buildings of any kind where the unit stresses are not too great. Special blocks for high unit stresses can be obtained, so that this form of construction, supporting fireproof floors, can be used for buildings having as many as five stories, and is shown in Fig. 9, photographed from material made by the Laclede Christy Co., of St. Louis, Mo. The exterior walls in colder climates — that is, in localities north of a line ap- proximately on the 30th degree isotherm for January — should have a hollow space to retard the loss of heat and to prevent the discharge of moisture through the walls into the building. Such spaces are formed by furring the inside of the building with hollow clay tile or hollow' gypsum boards, also by the use of metal furring, all of which is described in another paragraph. The webs of the hollow building blocks appear to transmit heat to such an ex- tent that moisture is condensed on the inside or outside of walls built of such blocks opposite the webs when the conditions are favorable to condensation, unless the inner surface of the blocks is sealed or protected by bituminous or asphaltic com- pound. Hollow bricks are sometimes used for the inner course of brick walls, but the same objection holds in their use. FLOOR CONSTRUCTION The invention of reinforced concrete and reinforced tile construction has produced a fireproof construction which increases the cost of a hospital only from 10 to 20 per cent, above the cost of one in which wood-construction floors are to be used, depending on the kind of floor surfacing selected. TTTWryr »!«?•- CcwcttTc CouurAN E " I J Fig. 10. — Solid concrete, skeleton construction. High steep roofs of fireproof construction are expensive, requiring special forms which are used only once, more material than a floor, and an expensive covering, such as slate or tile. Where a roof of such a form is considered an esthetic neces- sity, and money is not on hand to build it of enduring construction, it should have steel framing and 2- or 3-inch thick planking, approximating mill construction, with an unobstructed attic cement-finished floor below it, sloping to outlets in the outer walls, thereby affording protection from storm water to the lower stories in the event of a partial destruction of the roof by tire. The most popular forms of fire-resisting construction are the following, viz.: (a) licinforccil Concrete. Flat Slabs (fig. 10).- Its cheapest application is for Comparatively short spans, probably 15 feet is the economic limit, the thickness 56 HOSPITAL ARCHITECTURE will vary from 4 to 6 inches; transmits sound easily if covered with a hard floor; plaster adhesion to smooth cement surface is not certain; only small electric and gas pipes can be embedded within the concrete; plumbing and steam pipes not only weaken the floor on account of their size, but must lie free to expand and contract, consequently pipes hanging from such construction must be concealed by sus- pended or false ceilings in certain rooms, inasmuch as laying plumbing pipes on the construction and raising a bath-room floor not only increases the cost, but the steps which are then necessary at a bath-room door are very objectionable. Kg. 11. — Johnson type, tile and concrete, bearing walls. (b) Reinforced Concrete Ribs and Slabs (Fig. 11). — When the spans are too great for an economic use of flat slabs, ribs or beams of greater depth are introduced, spaced at intervals to obtain thin slabs and beams of proper proportion; this form of floor is subject to the same objections as noted under type (a), but to the further objection that the ribs cannot always be spaced symmetric to the walls of a room and also obstruct light; if a metal lath-and-plaster ceiling is suspended below such construction its cost is increased considerably above that of some of the flat ceil- ing constructions described below. Fig. 12. — Concrete, rib, and tile, skeleton construction. (c) Tile and Reinforced Concrete. — The kind shown in Fig. 12 contains a woven wire fabric in the lower layer of concrete in short spans and rods in longer spans; it also requires a strong concrete layer on its upper surface, firmly united to the tile; it is a fairly economic construction; it affords considerable resistance to the transmission of sound and presents a flat ceiling. The objections to this form of construction are that the surface to be plas- tered is concrete, and that certain stresses must be transmitted through the tile to obtain a safe floor. This is obtained by the mortar bond and is not certain to occur everywhere. DKTAILS OF STKIITI l{K 57 (d) Reinforced concrete rib and tile construction (Fig. 13) shows that this form of construction consists of two parts: the reinforced concrete joist and the hollow tile between; this is only a filling, and may he cut out or formed into chan- nels for the reception of pipes and conduits. It requires very simple forms for erec- tion, affords a flat ceiling resistance to the transmission of sound, a good surface for plastering, and space for the reception of piping of the size ordinarily required. If an unusually large space is required it can be formed as shown in the illustration. Steel und Tilt . — Steel beams and girders, connected together into a floor sys- tem, or combined with columns into a skeleton steel construction, are too well known to require description. In the best form of this construction (Fig. 14) the spaces between the beams are filled with hollow clay tile, or sometimes concrete is used, but unless the ar- rangement of the building is unusually simple and the price of steel abnor- mally low none of these forms of construction can approach the other four types described above in point of cheapness, and can never do so if there are men trained and experienced in reinforced concrete construction in the field. Types (a) and (b) are very useful for rooms and first floors which are not over sleeping or living apartments, but the types should be the same throughout a building, to permit of the frequent use of one set of forms. Fig. 13. — Tile arch construction. A finished cement surface can be obtained with types (a) and (6) at a slight additional cost; therefore suitable for laundries and storerooms. The four types are drawn to be suitable for linoleum or magnesia-cement floors, or the kind of wood flooring which is secured to the cement by asphalt and bitumen, described in a later paragraph. Where ordinary wood flooring is described it is necessary to lay wood-nailing strips in a meager concrete, such as cinder concrete, on any of these types. Skeleton concrete construction or wall-supported floors may be combined with any of these types, but their choice is an engineering question in which height of building, thickness of walls, and cost of walls are important factors too intricate and involved for the scope of this work. The much-advertised systems of construction afford some one an opportunity to obtain a much higher price for reinforcing steel, because of a valueless change of shape than for the ordinary stock shapes of the steel trade, or some one is ob- taining engineering services and working drawings from a "System Company," thereby stifling competition and permitting the "System Company" to recover the cost of the engineering services in an excessive unit price of the steel or an 58 HOSPITAL ARCHITECTURE unnecessary quantity; the cost of advertising and engineering must be paid for somewhere, and will increase the cost of the building, because it will be paid by the owners in one form or another. To permit contractors who are in the same position as tradesmen to write speci- fications and make any portion of the plans is pernicious and often immoral. Such conduct of constructive work permits irregularities and should not be tolerated. The architect should be paid a fair commision, but he must be what the title im- plies, competent to analyze the situation, form proper conclusions, and design the whole of the work, so that bona fide competitive proposals will be submitted by the best and most reliable contractors in the field. Fig. 14. — Steel and tile construction. The architect who has had the most experience and the best training will obtain the most for the money expended, and notwithstanding his commission may be more than that asked by others, he will return it many times in a more suitable design. The old saying that the highest-priced man usually is the best is as true in building as in many other human activities. ROOFING The slope or pitch of the roof depends on the design and the available funds. Steep pitched roofs which are visible and ornamental must be covered with slate, tile, or copper laid with ornamental seams. Such roofs are so well known that DETAILS OF STRUCTURE 59 they require no description. Stamped tin, galvanized iron, or copper shingles are offered in imitation of molded roofing tile, hut, inasmuch as they are an imi- tation and represent something which they are not, they are an esthetic abomina- tion. They arc no cheaper than a well-made metal roof, and, inasmuch as they must lie painted, they present, no advantage over the older form, and have the disadvantage of enclosing surfaces which may be attacked by moisture and can- not be reached by the paint brush. The ordinary felt and composition roofing requires no description, and if laid by an established and reliable roofer, who is paid a fair price, such roofs have a long life. Their weakest point is in the junction between the roof and the walls. Heretofore this has been made tight by inserting a strip of wood into the wall, and securing the felt to the same by a wooden cleating strip, covering the whole with tar and pitch. The air being thereby excluded from the wood, this is subject to dry rot, and, inasmuch as the gravel cannot stand on the vertical surfaces, the volatile oil in the tar, pitch, and roofing felt is soon distilled by direct sun-rays, so that the roofing becomes brittle and nails lose their hold. This objection has been largely overcome by a new form of clay tile block having a groove, into which the felt is wedged, and termed a "raggle block." When, in combination with this block, the angle between the roof and wall is rounded off, a permanent device has been substituted for the vulnerable point. Few of the many kinds of prepared roofing now on the market are as good as a good felt composition and gravel roof. Their reason for existence is largely the lack of skilled labor in small towns or remote localities, where there is not sufficient work to employ composition roofers con- stantly. The special roofs containing high-grade felt or burlap in combination with asphaltic compounds are excellent, and the companies manufacturing such material will send their experts to lay such roofs almost any distance if they are of sufficient size. A roof to be used as a promenade or roof garden must have a special surface; level wooden floors with open joints blocked up on the roof are often used, but these are not only a fire hazard, but objectionable on account of loss of small articles through the open joints, rotting of the wood, and odors from the enclosed space. Monolithic Portland cement roofs, reinforced to guard against cracking from expansion, contraction, or unequal settlement, and having a waterproofing com- pound in the top dressing, may be used without any other roofing beneath if the dimension of the roof between the walls is not large, but as the size increases the danger of cracking increases, and if such slabs form the full thickness of the roof condensation will gather on the ceiling below in cold weather, which will drip to an annoying extent. Roofs must be insulated to retard the rapid loss of heat, either by the use of a hollow tile construction or the forming of an attic space, the temperature of which would be a mean between the room and the outdoor tempera- ture, or by a filling of dry cinders on the structural portion of the roof. It is usually more economic to build a horizontal roof construction and obtain the pitch necessary to drain storm-water by a filling, provided the roof is a composi- tion roof having a pitch of about i inch vertical per foot horizontal measurement. \\ hen filling of this kind is vised the upper surface should be compacted by rolling, and covered with a 1-inch thickness of strong Portland cement mortar to provide a firm foundation for a felt and composition roof. If the roof is not to serve as a garden, the felt should be covered with screened gravel as for any other composition roof, but if it is to serve as a garden, it should have six thicknesses of felt everywhere of G-ply, then mopped with hot asphalt compound and covered with a layer of Hat red tile made for this purpose in Akron, Ohio, and measuring G by inches, 1 60 HOSPITAL ARCHITECTURE inch in thickness, and scored with deep grooves on the underside, which assist the adhesion of these tiles to the roof. Such tile are laid with a sliding movement, forcing the compound into and over the joints; the excess of material is cut off after a few days. Such roofs have an attractive appearance and usually require no re- pairs for twenty to twenty-five years. Small cement tile or cement work like sidewalk work may also be used in the same manner, but, inasmuch as the Akron tile are impervious, it is more certain of leading all storm- water to the gutters and conductors. The comparative cost of different kinds of roofing are as follows, and based on the square of 100 feet (10 by 10): Variegated green and purple slate S13.00 Black slate 15.00 Five-ply felt and composition roofing 5.00 Portland cement slabs on 6-ply felt for roof gardens 21.00 Flat red terra-cotta tile on 6-ply felt for roof gardens 24.00 Tile roofs, interlocking red tile 19.00 Interlocking green dull glazed tile 27.00 Interlocking green high glazed tile 29.00 Red Spanish dull tile 22.00 Green Spanish high glazed tile 34.00 Red shingle tile 23.00 Dull glazed shingle tile 30.00 High glazed shingle tile 32.00 FLOOR SURFAONGS The requisites for a satisfactory floor for hospital purposes are many. The floor should be impervious, it should be monolithic or jointless, elastic, noiseless, non-slippery, of pleasing appearance, easily cleansed, and economic of mainte- nance. It is almost impossible to find a floor which will have all of these quali- ties. Wood. — The cheapest serviceable floor is a matched hard maple floor, yf-inch thick, and having a face from 2 to 2\ inches wide, tongued and grooved on the edges as well as on the ends, also bored for nailing. Such flooring, including labor of laying, nails, scraping, shellacking, and varnishing two coats will cost about 10 cents per square foot, and to this the cost of nailing strips and cinder concrete filling between such strips must be added. The strips used are of hem- lock, 2 inches thick and 4 inches wide, beveled on both edges, so that the con- crete filling will hold the strips and prevent these from rising. The cost of the strips and concrete filling is about 5 cents per square foot, and this cost of 15 cents must be added to the cost of subconstruction if ordinary wood flooring is used. Slash-sawed southern yellow pine splinters and is unfit for flooring, and such wood must be quarter-sawed to make a satisfactory floor. Its cost is then about the same as the maple flooring described, but not as serviceable. It has the further disadvantage of not retaining a varnished finish as well as other hard woods, and apparently the great quantities of resin do not combine permanently with shellac and varnish. Oak flooring of the same dimensions, and manufactured in the same manner as maple flooring, is well known, and there are the same objections to its use; the cost is about 2 cents per square foot more than the maple for plain oak floors, and there will be a larger proportion of short pieces, from 2 to 4 feet in length. High-grade oak flooring, such as quarter-sawed white oak, costs from 5 to 6 cents per square foot more than maple flooring, but plain sawed is fully as ser- viceable as quarter-sawed. DETAILS OF STRUCTURE fil Wood is slashed, or plain sawn, when the log is cut into boards by parallel saw cuts; quarter-sawed wood is obtained by sawing a log into four equal-sized pieces by two saw cuts at right angles to each other, and each of these quarters cut into smaller pieces by cuts parallel to radii. The general objection to wood floors is the cost and difficulty of maintenance, also the large number of joint openings, which increase in size as the wood ages, and form innumerable recesses which cannot be cleaned and which may harbor objectionable germs. It is also difficult to join wood floors to coved bases and the bases to the walls. Only varnishes of the very best quality will wear satisfactorily, and then only for a comparatively short time, and to maintain such floors in proper appearance requires a continuous expense for labor and for costly varnish. The varnish is quickly destroyed by use of hot water, soap, and brush, and nothing destroys the finish of the floor more quickly than an industrious scrub woman. It is well known that tepid water, with a light soapsud and a rag, will remove dust and dirt from a varnished surface without attacking it. This is rather slow work, and it appears to be impossible to have the help available for such kind of work pay any attention to this requirement. Maple floors can be finished in a fairly satisfactory manner by giving them coats of boiled linseed oil mixed with turpentine and japan. The first coat will soak into the wood, and in drying quickly fills the pores, so that a second coat will dry on the surface similar in appearance to varnish, but not as durable. Oak floors should be filled with a mineral filler in hospital use to close the numerous pores, shellacked one coat and varnished two coats. A very serviceable and com- paratively inexpensive finish can be obtained on oak by rubbing the wood, after filling, with boiled linseed oil and pumice stone. This will leave a velvety, dead finish, which can be constantly maintained by the house service, and can be walked on immediately after completion. The oak and maple flooring will stain from water if wet before it is treated with oil or varnish. This is especially the case with oak, so that if the varnish is scrubbed off the oak will turn a blue black, and its original color cannot be regained except by scraping away the wood to a considerable depth. A form of wood flooring which is used considerably in European hospitals, and also in some American institutions, consists of pieces of oak about 18 inches in length, tongued on one side and one edge, and grooved on the other side and edge, so that these pieces can be laid together in herring-bone pattern. These strips are molded in various forms of dovetailing on the underside, according to the respective makers or patentees. Such material is laid in hot asphalt or bitumen, which is spread upon the floor in a thin layer, and each piece is successively pushed into place, forcing some of the bitumen into the joints and filling these to the sur- face; the excess is cut off, and the floors then planed and scraped by hand or polished with an electric floor surfacer. Such floors do not have the objectionable open joints, but the difficulty of maintaining a satisfactory appearance is fully as great as it is with other wooden floors, but it is likely that this difficulty will soon be overcome by the use of oiling machines, designed similar to carpet sweepers and electric rotary polishers. The floors laid in this manner cost about 25 cents per square foot, and if a building is of reinforced concrete construction, an additional 4 or 5 cents per square foot must be spent to prepare a smooth surface on the structural concrete. If the building is of hollow tile fireproof construction, from 9 cents upward for a thickness of about 3 inches must In- expended to prepare a surface suitable for laying such a herring-bone floor. The junction with the walls 62 HOSPITAL ARCHITECTURE is fully as difficult with this kind of flooring as with other wooden flooring, and it will probably be necessary to employ a coved base of magnesia cement, which will be described later. Linoleum has been found to be fairly satisfactory when used in the ordinary thicknesses and laid in the ordinary manner, but when this material is used in the heavy grade known as "battleship" linoleum, and cemented to the foundation, it is a very superior floor, filling almost every one of the requisites of a perfect hospital floor. The foundations should be trowel-finished Portland cement, made about \ inch, or the thickness of the linoleum below the edge of the baseboard. This form of flooring has been in use in some of the large hospitals of Germany for several years, and will probably crowd out every other form. In that country the material is laid on the floor loosely and allowed to expand, contract, and accom- modate itself to the new condition, and is then cemented solidly to the foundation with a glue or cement, and is weighted down with innumerable iron weights and bags of cement while the cement is set- ting. After the work is completed the floor is perfectly true, without wrinkles, and does not give out the objectionable hollow sound heard when walking on linoleum which is only tacked down. Such lino- leum costs approximately 15 cents per square foot cemented in place, and also requires a trowel-dressed Portland cement foundation, so that, if the construction is reinforced concrete, an additional charge of 5 cents per square foot over and above the cost of the structure must be paid, and if the building is of hollow tile construction, an additional cost of 9 cents and upward per square foot must be added. Inas- much as the so-called sanitary cove at the intersection of the floor with the walls is desirable, an artificial marble or magnesia- cement baseboard and cove should be used (Fig. 15). Attempts have been made to cover a cement cove with the floor linoleum, curving this to the cement upward to a steel corner bead, forming the division between the plastered wall and the floor linoleum. This could be done fairly well adjoining the straight walls, but it is unsatisfactory in both re-entrant and salient angles. It will be seen that the salient angles must be filled with a small patch of linoleum, or a cement such as magnesia-cement, but the result is not as perfect a piece of work as a combination of linoleum floor and artificial marble or magnesia-cement baseboards, as shown in Fig. 16. There is a plastic linoleum recently come on the market which promises a good deal as a substitute for "battleship." The floors of the new New York Post Graduate Fig. 15, -Section through tile base and linoleum floor. DKTAILS OF STIU'CTl'ItK 63 School Hospital arc made almost exclusively of it, and the effect is very attractive. It is simply a composition identical with " battleship " linoleum, the only difference being that the mixture is made up like any concrete at the time and place where it is to be used. It requires exceedingly careful troweling if it is to look well. It can be made up practically in any solid color. In the same hospital the labora- tory work-table and bench-tops are of the same material. It has hardly been in use long enough anywhere to tell whether it is to be a permanent form of flooring. McKim, Mead, and White, the New York architects, think well of it. Portland cement does not make a satisfactory floor except when special mate- rials and special workmanship are applied. When the troweling has been perfect, and continued to the extent that the surface is glazed, the softer particles will soon wear away at doorways and other much traveled places, so that the harder grains of sand will project and show a surface similar to sandpaper, and these por- tions will soon have a different texture and color from the floor at walls and under LlNOL-EIUM F=l_OOfZ.. r T6M PORTAKy OBDU N O. Fig. 16. — Steel corner plate between plaster of wall and composition base. tables and beds and other pieces of furniture. Portland cement is not hard enough uniformly to resist hospital wear. Such floors can be given a finishing of special cement floor fillers of solid colors — Pompeiian red, sage green, deep buff, and gray — and if the cement has been troweled with great care, to bring it to a true smooth surface, these colorings will produce a floor of good appearance, but, inasmuch as the finish is practically on the surface, it, will not last much longer than the var- nished and painted surfaces of wood, and must be renewed from time to time. Such floors are quite serviceable for rooms which do not receive much usage, as trunk-rooms, patients' locker-rooms, morgues, and small chapels, used only for funeral services. White Portland cement can be obtained, and if white sand is used a nice appearing floor can be obtained at a comparatively low cost, but all monolithic floors of Portland cement and Terrazzo have the disadvantage of crack- ing in unexpected places and in unexpected directions. This is probably due to the different ratios of contraction between the floor and the substructure or to a varia- 64 HOSPITAL ARCHITECTURE tion in the settlement of the building. Portland cement is not elastic like asphalt or wood floors; it is more like glass, and when pressure is exerted it will break. Inasmuch as Terrazzo floors are only Portland cement floors with chips of marble used as the aggregate of the surface, such floors crack in a similar manner to cement floors. Cement floors can be laid in squares, and Terrazzo floors should be divided into small fields by the use of strips of marble, so that if there is a tendency to crack it will occur in these joints or along these strips, since they offer the least resistance. All floors of the tile form have the advantage over the Terrazzo of dividing the shrinkage or cracking along the many joints in an irregular maimer, so that cracks are seldom noticeable in floors made of tiles. Terrazzo mosaic floors cost approximately 25 cents per square foot, and the cove bases can be laid monolithically with such floors. The plinths for casings, steps, and all kinds of projections, and the variation in the wall or floor surfaces can be easily made with the floor and the junctions coved together at a comparatively low expense. These floors can be ground to fairly smooth surfaces by rubbing with sandstone blocks, and portions which it is desired to polish can be polished with electric polishing machines. It is rather difficult to run the bases true against the wall in place, and the better contractors prefer to make the cove bases and plinth blocks in molds in their shops and there grind the edges straight on rubbing beds, rub and polish the cove by machinery, and set these against the wall on the floor before laying the Terrazzo floor. The mosaic floors cost considerably more than other floors described, and are usually used only in the portions of hospitals which are intended to be more orna- mental, such as the vestibules, entrances, and chapels. There are marble mosaic floors and ceramic mosaic floors, and these cost from 55 cents a square foot upward. The marble mosaic floors are more expensive and more beautiful in coloring, the colors being softer and blending together better than the opaque pottery colors used in the ceramic material. The cracks mentioned in connection with Ter- razzo are also frequently noticeable in marble or ceramic mosaic floors, and are due to unequal settling of the building and different ratios of contraction between the floor and the substructure. Coved bases of marble, glazed tile, artificial marble, or magnesia-cement can be used in connection with such floors. Chemical solutions and scrubbing in operating- and dressing-rooms in time destroy these floors by action on the Portland cement in their composition. A kind of flooring related to Terrazzo and marble mosaic is called tutti colori — or many colors. It is made by scattering the colored marble chips used in making marble mosaic flooring indiscriminately into a cement field so that the pieces fit together irregularly; this is rubbed with rubbing stones similar to Terrazzo, and any of the forms of base described can be used. Tutti colori costs about 35 cents a square foot, and has the same faults as Terrazzo. Artificial marble tiles are very durable, satisfactory, and economic floors, suitable for kitchens, pantries, toilet- rooms, and the like. These tiles are made about 1 inch in thickness, either square, hexagonal, or oblong, in hydraulic machinery. They have a wearing surface of colored marble chips and a backing of Portland cement and screened stone. These tiles are about 9 inches square, and allowed to set under favorable conditions so the cement becomes dense and hard. They are then ground on a rubbing bed in the shop and set in the building similar to any other form of tile. They can be made in any coloring and any design. Some of these are pleasing for use in an en- trance hall. Such floors-cost about 42 cents per square foot, and the bases, 5 inches high, about 60 cents per lineal foot, and have the advantage of not showing cracks, of being truer and denser than Terrazzo. Coved bases, plinths, and stairs are made DETAILS OF STRUCTURE 65 in tlic same manner in the shop, and the walls and partitions should be prepared to receive them in the same manner as described fur magnesia-cemenl floors: a design for stairs made of polished artificial marble of this kind is illustrated in the section describing stairs. Such flooring, used as a border in corridors with coved base and plinths of the same material, and a runner strip 5 or 6 feel wide down the center of the corridor, made by laying a smooth cement floor about | inch lower than the surface of the artificial marble tiles, and filling the runner Strip with "battleship" linoleum cemented into place, will make almost an ideal corridor floor. Anything harder than linoleum, cork carpet, rubber, or cork is too noisy for a corridor. The well-known encaustic tile floors cost about 45 cents per square foot, but are little used at the present time, and do not appear to be in favor, according to the passing fashion of the day. These tiles are made in pleasing colors, but they break quite easily and sometimes separate from the foundation, so that walking over a defective tile floor produces a rattling sound. This is probably due more to improper laying than any fault in the material. If the tiles are well soaked, anil genuine Portland cement used, such tiles ought to have a foundation so firm that they cannot break under ordinary usage or become loose, but there is no tile cove made which has not the objection of being in small pieces, so that an artificial marble or magnesia-cement base should be used in connection with such tile. Ceramic tiles are very dense, flinty pottery, and absolutely impervious. The surface is slightly gritty, so that they are not slippery, and wdren used in the larger sizes such a floor is one of the best for operating-rooms. These tiles can be ob- tained in 2-, 3-, 4-, and 5-inch hexagons, also in squares of the same dimensions. The one fault of this kind of flooring is that the tiles must be set in a pervious mor- tar joint, which forms a network over the entire floor and which cannot resist scrubbing. In time these joints will be considerably lower than the surface of the tile, become dark, and sometimes black. Either artificial marble coves and plinths or genuine marble or magnesia-cement should be used in connection with such floor. One-inch thick white glass can be obtained and has been used for operating- room floors. This material is ground on the rubbing bed, similar to plate glass, to a true, slightly gritty surface, and is beautiful in appearance. The coves and plinth blocks can be made of the same material and these can be polished if de- sired. The material costs approximately S2 per square foot. It is not advisable to lay pieces larger than 18 by 30 inches on the floor, for it becomes too difficult to bed large pieces so perfectly that there will not be places without bedding. It is obvious that a piece which is not perfectly bedded will crack very easily. Slate, at about 70 cents per square loot, white Italian marble, at 80 cents per square foot, gray Tennessee marble, at 90 cents per square foot, make good service- able floors, and the sizes of the pieces are subject to the same limit as heavy glass. The slate is very dense and impervious, but its dark appearance is not suitable for an operating department. The Italian marble is not sufficiently impervious. The light gray or pink Tennessee marble is very dense and a very serviceable floor. Its color is such that it does not show the tracking of footsteps readily, and may lie objectionable in a hospital for this reason. Rubber floors cannot lie obtained for lcs> than Si per square foot, except where very large quantities are used, and this kind of flooring requires a special cement foundation similar to that described for linoleum, so that its cosl is almost pro- hibitive in a hospital of moderate cost. The rubber comes in tiles usually of an 66 HOSPITAL ARCHITECTURE interlocking pattern, in a variety of opaque colors, and can be laid in pleasing patterns, but rubber coves are not good, and it will be necessary to use one of the forms of cove described with the tile floors. Compressed cork is one of the newest materials on the market, has a very pleasing, warm color, similar to English oak or tobacco brown. It is elastic and noiseless, and the makers claim that it will not wear out. It must be laid on a cement special foundation, composed of sawdust and Portland cement, which costs about 8 or 9 cents per square foot, depending on the thickness. The cork floor- ing can be obtained in different sized squares 3 by 3 inches and 9 by 9 inches and in different shades, so that it can be laid in a variety of patterns. The manu- facturers also offer a cork base cove and plinth blocks, and show how it can be used for the treads of stairs, and, inasmuch as it is not slippery, it makes an excellent stair tread. The material in large quantities costs about 85 cents per square foot. Its chief disadvantage is that it is probably not sufficiently impervious to septic matter and micro-organisms, as most other floorings. Magnesia Composition Floors. — These floors are known under various trade names, such as Asbestolith, Karbolith, Monolith, Flexolith, Magnasite, and Dolo- ment. They are composed principally of pure ground magnesia and other ingre- dients, which are trade secrets. Some makers use hardwood sawdust, others short fiber asbestos or quartz sand, and possibly many other materials. The flooring, when well laid and properly maintained, has almost every one of the requisite qualities of a good floor. It is applied in the plastic state, so that it is jointless. The baseboard and cove can be made monolithic with the floor. The material can be applied around bases of all pieces of furniture, columns, and into plinths for door trim. If the mixture is not too rich or too hard in itself the flooring has some elasticity, is not as noisy as wood, tile or mosaic, is less slippery than these, can be colored and be pleasing in appearance, and, inasmuch as there are no joints or crevices, can be easily cleaned. The completed flooring should be treated with an oil in order to preserve the depth of coloring and finish. The oil also protects the material from water. The material is not suitable for places where water is used freely, or where water is allowed to drop on it, as in the douche room of the hydrotherapeutic department; it can be easily cleaned by wiping with a cloth moistened in tepid water and a light soapsud, but should not be scrubbed with a brush, for the stiff bristles will loosen particles of the surface in time and change the floor from a smooth to a pitted surface. The material is probably not suited for operating- and dressing-rooms on account of the use of chemical solutions and the necessary frequent scrubbing. The efficiency and durability of a magnesia composition floor depends not only on the quality of the material used, but on the most careful proportioning of these materials and perfect troweling. The work must be laid by mechanics skilled in this class of work, and these are difficult to find. Workers of Portland cement believe themselves capable of executing such floor work, but they require consid- erable practice before becoming skilled. If the troweling is not carefully done and properly executed, the floor will have a very wavy appearance and a surface of unequal texture. The material appears to be so easily used and applied that many inexperienced persons are offering to-day this class of work, with the con- sequent result that there have been many more failures than successes. Some of these floors have shrunken to such an extent that they were obliged to crack, loosen themselves from the foundations into irregular-shaped pieces, and con- sequently rattle and rock when walked upon. Others have been so soft that the floors disappear in patches, exposing the concrete foundation. When such work dicta i ls of stricture G7 is required it should be given only to established concerns, having had years of experience and successful work for satisfied customers, to which prospective customers can be referred, and, in the case of firms meeting such requirements, it would be well to exact a carefully written guarantee for not less than eighteen months. Magnesia composition floors are practically well adapted for use in buildings of reinforced concrete construction, inasmuch as the floor construction proper serves as a foundation for the composition without special finishing and troweling of the concrete surface, such as must be supplied when linoleum or cemented wood flooring is used. The cost of magnesia composition floors approximates 25 cents per square foot, and coved 8-inch high baseboards approximately the same amount per lineal foot. Measurements should be taken from wall to wall for the floor- ing and the baseboards added as a separate item. The material can be laid in patterns and borders by the use of brass dividing strips, filling the various spaces with different colored or tinted composition. BASE COVES The several kinds of flooring described have each a base eove most suited for the purpose. It is recognized that any surface having a horizontal projection will catch more dust than vertical surfaces. Also that re-entrant angles require con- siderable labor to remove dust from them, so that the omission of re-entrant angles Fig. 17. — An internal angle showing a coved wooden base flush with floor and plaster. Xotiee the corner block which must conform to the radius of the plastered corner coves, and is made by the upper floors through a stairway. Stairs of wood are used only in comparatively small buildings, and it is more difficult to keep up their appearance than if is that of floors. ( lonsequently, stairs are usually built of incombustible material which may lie molded in the mo-i desirable shapes and requires little or no expense for up-keep. Cast-iron and 70 HOSPITAL ARCHITECTURE wrought-iron stairs or a combination of these are comparatively low in price, but the treads become slippery quickly and they are exceedingly noisy. Such treads can be covered with linoleum glued to the treads and finished with a brass nosing, but the junction with the strings and risers form dirt-catching recesses. The combination of iron supports with slate, marble, or magnesia cement treads are better, but they also have deeply recessed angles in the corners. ■ Polished artificial marble made in the same manner as described for floor surfacing is one of the best and most economic stair materials. If used in combination with solid masonry walls such stairs can be self-supporting without the use of iron, except such is used for the balustrade. Figure 20 illustrates such a stairway. If solid Fig. 20. — Scale drawing and details of reinforced concrete stairs with safety tread nosings and magnesia cement treads, risers and strings joined by coves in the angles. masonry walls cannot be built, such a stair may be supported on steel supports or a reinforced concrete slab, which will require a plastered finish on the soffit, which is good, but not as attractive as a polished artificial marble surface. This material is easily prepared to receive specially made antislip nosings. Such nosings are usually made of a combination of lead and steel, or brass, or carborundum; all of these are both sightly and effective. On account of the cost these safety nosings are generally used in strips only about 3^ inches wide, countersunk into the stair tread. Stairs formed of reinforced concrete, plastered on the soffit, covered with magnesia cement on the treads, risers, and strings, and provided with a metal safety tread are economic, of very good appearance, solid, practically noiseless, and easy to clean, for all angles and corners can be coved. DETAILS OF STRUCTURE 71 The landing railings and stair railings should ho higher than in the dwelling- houses and other buildings. The rule for dwellings is to make the top of the railing 28 inches above the step at the nosing, but in a hospital the railing should be 6 or 8 inches high, and at floor landings and other landings railings should beat least 4 feet high. In a children's hospital and in asylums it would be best to have stair- ways with solid masonry piers between the flights from the bottom to the top or balustrades about (5 feet in height with wooden hand-rails on metal supports at a convenient height. PARTITIONS Inasmuch as it is expected that only hospitals of fireproof construction shall be erected, combustible partitions will not be described. The ordinary forms of incombustible partitions are: first, gypsum blocks, 3, 4, and 5 inches in thick- ness and upward; second, hollow fire-clay tiles, 3 inches in thickness and upward; so-called solid plaster partitions, 1| inches and upward in thickness; metal stud and metal lath-and-plaster partitions; gypsum stud and gypsum board partitions. Gypsum block partitions are sometimes known as mackolite. The blocks are usu- ally made 1 foot wide and 4 feet long, of varying thicknesses, with several round longitudinal perforations reinforced with lath or rods, and made of gypsum. These partitions are good insulators against sound and heat, and cost, with plastering on both sides, approximately 17 cents per square foot. The hollow clay tile parti- tions are made 1 foot square, with perforations or rectangular cross-sections through them and the wall of tile about f- to f-inch thick. These tiles are burned in kilns similar to brick and terra-cotta, and a 3-inch partition plastered on both sides costs approximately 19 cents per square foot. Thoroughly burned clay tiles do not disintegrate in moist or damp places, and are suitable for use in situations where gypsum blocks are less satisfactory, viz.: laundries, steam-rooms, sterilizing-rooms, boiler-rooms, and in basements. Where plastering is not required, and whitewashing will be a sufficient finish, clay tiles are more suitable than the other partition described, and they can be obtained unscored, i. e., smooth, for this purpose at a cost of about 9 cents per square foot erected. Solid plaster partitions are made by using f- or 1-inch steel channel bars, stuck into holes in the floor and ceiling, and there secured by screws or staples. These are placed about 12 inches center to center, and a wire cloth, expanded metal, or other metal lath is secured to these studs by soft iron wire (Fig. 21). The metal lath is then given a thin coat of mortar. This upon setting has stiffened the partition considerably, and additional coats are then applied on each side and brought to a thickness of almost li inches for the thinnest kinds. When this is done the parti- tion is so stiff that the journeyman can use the necessary pressure to produce fairly true surfaces. These are then given thin coats or a finishing coat of lime, putty, or plaster of Paris. Such partitions cost about 17 cents per square foot. Inasmuch as electric outlets must have steel boxes, it is difficult to enclose these in solid plaster partitions of only 1 J inches in thickness, and it is necessary to make them 2 inches in thickness to conceal the box, and then it is further necessary to use a special mat-board for the switch or a flush electric socket. These parti- tions have a lower sound-insulating value than any of the other partitions described, but they have been used in a number of hospitals and have given fair satisfaction. There are partitions in which metal studs, made of specially formed sheet metal, are employed, and these studs have spike-like projections over which the metal lath can be stretched and secured by a blow with a hammer. Such partitions 72 HOSPITAL ARCHITECTURE have metal lath on both sides, which must be plastered with three coats of plaster, and, consequently, cost fully as much as a gypsum block or hollow clay tile parti- tion, but they have the advantage of a continuous air space, and, therefore, a higher sound-insulating value. These partitions cost approximately 21| cents per square foot plastered complete. There are other partitions on the market, but not in very common use. One of these consists of strips of gypsum which are set upright similar to wooden stud- ding, and to which 1-inch thick boards of gypsum blocks and jute are secured on both sides by plaster of Paris. In some localities these can probably be ob- Fig. 21. — An elevation of a solid cement plaster closet stall partition. Notice the iron door- post, steel top and bottom rails, vertical steel channels, wire bath or expanded metal wired to the channels and to plaster surfaces. The plaster surfaces are to be coved into the walls at the back of the stalls. tained for less money than the gypsum blocks, and, inasmuch as they have air spaces, their sound-insulating value is fair. Partitions are sometimes made of well-burned steam boiler cinders and plaster of Paris in the form of blocks, similar to gypsum block. This material can be made by mechanics on the site, and, if carefully made and properly dried out, makes a good and economic partition. Partitions are sometimes made by stretching wires vertically, horizontally, and diagonally in two directions, approximately 1 foot apart ; board forms about 3 feet high on each side of these wires are set so that a space of 2 to 2k inches will intervene between the board forms, and these forms are then poured full of mortar composed of plaster of Paris, sand, and cinders. As soon as the mass has set sufficiently to remain in place the forms are raised, and DETAILS OF STRICTURE !'.*, the same procedure :is before is continued until the partition is built close to the ceiling. It is obvious that a small strip near the ceiling must be filled in by a trowel from one side. In a building which need not be strictly fireproof it is permissible to use 2 by 4 inch wooden studding, placed 12 inches on centers and lathed on both sides with wire lath, each plastered with three coats of mortar. Such parti- tions cost a little more than the solid plaster partitions, but are somewhat more sound-proof. If particularly sound-proof partitions are required for special cases, it is advisable to build these double and with unbroken air spaces. The insulation may be increased by applying 1-inch cork boards against one of the partitions. The cork board can be in the space between the two or it can be inside of the inner partition, for it can be plastered with Portland cement fully as readily as any masonry surface. It is obvious that to obtain a sound-proof room the room must have no rigid connection with any other part of the building, and any rigid connection from one portion of a hollow partition across the air space will carry some sound; likewise, sound will be carried through the floor underneath the partition or through the ceiling over the partition, so that this desirable quality can only be obtained in degrees proportionate to the increased expense. Some builders have advocated the use of rubber blocks under special sleepers and the joining of the two separate and distinct door frames, one in the inner partition and one in the outer partition, by flexible rubber strips. This can unquestionably be done and a sound-proof room can be obtained, but the expense of doing so will seldom be entertained by any hospital committee. FURRING Material built close to a wall or clown from a ceiling to form an air space, to conceal constructive features or pipes, or to give semblance to constructive forms, as the imitation of a pilaster or a vault, is termed "furring"; as explained in the paragraphs on exterior walls, it is a necessary device in northern climates to pre- vent the forming of condensation and to diminish the loss of heat through the outer walls of a building. Some of the waterproofing liquids on the market, composed of bitumen and water-glass, will seal the pores on the inside of the wall quite effectively, so thai plastering can be applied directly on the brick, concrete, or other forms of masonry, and the makers claim almost as high an insulating value as any of the furrings described, but it is still questionable if this is a fact, and the cost of applying such waterproofing and insulating compounds is almost as much as the cost of furring the walls. The air space is also invaluable, insomuch that it provides a space in which pipes of all kinds can be placed and concealed, without making the laborious pro- cess of forming or cutting channels in the brick tile or concrete walls compulsory. Such cutting is not only expensive, but. often shatters and weakens a wall or pier. Furring is usually executed with the same kind of material used for the partitions. Gypsum furring boards are made from 1 to 2 inches in thickness, and have ribs formed on their backs to obtain a thin air space. Clay tile furring is obtained by splitting 3-inch pieces into two equal parts along grooves formed in the blocks intended for this purpose, and made by the block-making machine before burning, resulting in a 1-ineh air space. \\ ire mesh, metal lath, and expanded metal is held away from the exterior walls by bands of crimped steel, which can be obtained in varying widths, \ to I inches wide being the mosl suitable. 74 HOSPITAL ARCHITECTURE Where water-closet soil-pipes or other large pipes require large spaces, 3-inch blocks, set the requisite distance away from the structural walls, should be em- ployed. The cost of furring is about three-quarters that of the partition and plastering. WINDOW FRAMES The windows are of such a great importance for ventilating that they must receive special consideration. The standard window in the market is the one hav- ing two sliding sash, technically known as the double-hung check-rail sash with EXTEEIOE.' -INTEEIOE. 'EUE wv-ri O N s • Fig. 22. — Window details. box frame. This kind of window has the advantage of accessibility for cleaning, and where a safety rope is used the cleaner can stand on the outside of the window sill and wash the window while it is closed, but the window has several disad- DETAILS OK STRUCTURE 40 vantages. One is that it does uo1 open the entire opening of the window, but only half in hot weather, and in cold weather it permits direct drafts. The so-called plank frame window, with hinged or casement sash swinging inward, is also objectionable on account of the direct drafts and the difficulty of applying an adjuster by which the sash can be set and held at any angle. These objections also apply against the same kind of a frame with sash swinging outward, but such sash can be equipped with satisfactory operators, can be opened and closed without removing the insect screens, which must be on the inside when the sash swings out- ward. Double transom sash in the upper part of a window will ventilate a room -DSLTAU-sS-^ °F THE. "HOLDFA5T" CASE.nE.AJT WIAJDOW ADJUSTER. Fig. 23. — " Holdfast " easement window adjuster. rapidly without objectionable drafts. Such transoms can be used in combina- tion with double-hung sash for the lower part of the window, but this is not advis- able, except where the window frames and the stories are unusually high. Where th«y are to be used iii frames and stories of ordinary height the lower portion of the window should be equipped with outward-swinging casement sash (Fig. 22), operated by casement adjusters, such as the Casement Hardware Co.'s "Hold- fast" (Fig. 23), or the Yale and Towne Mfg. Co.'s Wilkins' "Operator" (Fig. 24). The inside of the frame should be rebated for hinged screens for summer use and inwardly swinging casement sash for winter use. With such windows the cut ire window opening can be used in summer time. 76 HOSPITAL ARCHITECTURE The outer transom should be hung on its upper edge and swing outward from the bottom. The inner one should be hinged at the bottom and swing inward from the top, and the two connected by a friction center device, which can be obtained from several makers of hardware, and which will not interfere with the placing of an insect-screen in the middle of the space between the two transoms. The con- necting device will open and close the outer sash when the inner one is similarly operated. The outer sash, fitting like an awning, will protect the open window from rain, and can be left open unless the rain-storm is accompanied by a very strong wind. The inner transom will deflect air currents upward, so that the fresh air POSITION Of HANDLE UAU3CHED, rr Fig. 24. — Details of the "Wilkins" casement window adjuster. will be diffused and not enter in drafty currents. The frame and sash are illus- trated in Figs. 22-24. To obtain a weather-proof joint between the edges of pairs of hinged sash where they meet, the architect must resort to peculiar detailing of the woodwork, which permits the opening of either the right- or left-hand sash in advance of the other, whichever way it may be detailed; this can be avoided by placing a vertical fixed piece of wood, termed a "mullion," between the two sash. WOODWORK Dense, close-grained, hard woods are the most desirable for hospital purposes. The coarse-grained woods, such as oak, ash, and mahogany, must be filled with a mineral filler to obtain a smooth surface before they are otherwise treated. DETAILS OF STRUCTURE 77 Birch is the lowest priced hard wood on the market when accepted without Selection. This is not suitable for light or natural finish on account of variations in coloring. The greater portion has an even, pleasing color, but there are enough pieces of white sap or a dark-blue sap to destroy the harmony, and it is consequently necessary to stain such wood, when it a1 once becomes darker than is generally accepted as suitable for a hospital, and it becomes necessary, therefore, to specify a selected birch, which costs a little more. This, when finished natural, is very satisfactory, (iuni wood is rather too dark for hospital use, is of comparatively Milt texture, but may be considered in some instances. Yellow pine is hard, dense, ami one of the best, of the cheap woods; it darkens, however, with age to an extent ami to a tone not generally pleasing. It can be stained in any variety of stains except the lighter ones, so that, whereas it may be usable in the service portions of the hospital, it is hardly suitable for the wards and the rooms used by patients. Mahogany may be used, but, on account of its expense, only in a few special private rooms; but even in these genuine white enamel work on birch would be more attractive to the average patient. White enamel work, having the appearance of the favorite egg-shell surface, can be produced by the brush without rubbing if one of the higher grades of enamel is used, and this effect can be obtained by a comparatively small number of coats; in some instances as low as three. Inasmuch as the wood used should be hard enough to resist some wear and abrasion, the cheapest kind of birch may be used, and with three or four coats of good enamel paint such woodwork does not cost any more than a good oak or ash. In order to avoid recesses and other places which are cleaned only by the expenditure of considerable labor, it has been the fashion for the past fifteen years to use only flush doors, that is, doors without panels, in the latest hospital construc- tion, but these doors are so severe in appearance that they have a gloomy effect on patients, so that some of the newer hospitals have reverted to the use of single- panel doors; it is not necessary to do this, however, for the flush doors are veneered on built-up soft wood cores, and with veneering it is a simple matter to inlay a border line or lines marking imaginary panels. These border lines can be made up of narrow strips of dark or black wood, so that the heavy, severe effect is removed at once. This is done by a number of manufacturers and at a comparatively small expense above the cost of a flush door. Those who have complained of the severity of the flush panel doors object to the omission of woodwork; in their opinion the depressing effect of the cell-like severity is much greater than the possible deleterious effect of the few additional angles introduced by trimming the door and window openings with wooden facings. The wooden casings should be molded sensibly and with not too many quirks and angles. Many attempts have been made to avoid the use of projecting wooden door and window casings, but this has not been successful for several reasons, viz.: The frames cannot be set after the plastering is completed, except by the use of temporary frames or other woodwork to furnish a guide for the plasterer. After the temporary woodwork has been removed and the permanent frame set the joint between the wood and plastering must be filled or pointed, but the twisting or shrinking of the wood or the slamming of doors break the putty joint, and it is then even more unsightly and unsanitary than the angle between the plastering and wooden casings which it is endeavored to avoid. Steel Frames and Casings. — Plastering is attended with the use of so much water that it is not practicable to set finished door frames prior to the plastering, 78 HOSPITAL ARCHITECTURE consequently it is necessary to make flush frames of a material not effected by water. Drawn steel, combined frames and casings, appear to be the first suc- cessful casings of this kind. They are slightly molded, but without sharp angles. The edge adjoining the plastering is raised slightly, so that if the joint between steel and plaster is opened by the slamming of doors it will not be so noticeable as it would if both surfaces were wide and flush. The cost of metal doors and furniture has been greatly reduced very recently, and it is possible that simple metal trims, fitting the plaster closely and coving away from its surface, will soon be on the market. If this is realized, the objec- tion to casings will fall away, for there will be no internal angles, and the coved and rounded surfaces can be cleaned by one movement of the moistened cloth. The hospital architects of Germany have recognized the severe appearance of hospital wards on account of the omission of woodwork, and have overcome this successfully by designing simple painted wall treatments, using lines and stencil dots or stencil ornaments designed in good taste, outlining the door and window openings, and possibly paneling the walls by the application of painted lines. Such work, in the hands of the ordinary house-painter, would be worse than the severity of untrimmed openings, but in charge of a competent designer can be made pleasing and can be obtained at a low cost. It must not be forgotten, how- ever, that metal door and window frames have the disadvantage of not yielding to repairs in the event of a door or window warping, as will sometimes happen. PLASTERING AND WALL FINISHES The cement wall plasters now on the market are preferable to lime and sand, on account of the more reliable mixing of the ingredients and on account of being harder after setting. For walls and living-rooms a lime, putty, finishing surface is usually hard enough, but the prepared wall surfaces, such as the U. S. Gypsum Co.'s Universal Finishing Material, is somewhat harder and denser. The same company's gray finishing material, if thoroughly troweled with a steel trowel, will result in a very hard, dense surface having a slight polish. Keene cement, used as a finishing surface, is very hard, smooth, and dense. The No. 40 finishing material or Keene cement should be used in toilet-rooms, bath-rooms, operating- rooms, dressing-rooms, serving pantries, kitchens, and wherever steam is used in sterilizers or steam tables. In cellar and basement rooms any kind of plaster mixed with lime should be avoided, and only Portland cement and sand should be used. Plasterers object to this, for it is difficult to apply and hard to work, inasmuch as it is not as fatty as lime mortar, and the average journeyman mechanic will insist on adding cement to lime mortar, but the result will not be efficient, for lime is hygroscopic and will dry out and absorb moisture alternately, showing efflorescence on the surface and saponifying the oil in paints. INTERIOR PAINTING The modern high-grade enamel paints, made of Damar varnish and pulverized quartz or spar, are best suited for hospital work, and should unquestionably be used throughout the operating departments, dressing-rooms, bath-rooms, toilet- rooms, excreta closets, and wherever steam or water is used considerably, and, if the means will permit, such material should be used throughout the hospital. Where this expense cannot be met the walls should be sized with oil size, and painted with not less than three coats of white lead and linseed oil. Enamel DETAILS OF STRICTURE 79 paint and oil paints can be tinted to any desirable shade, and it is quite obvious iha i the lighter shades should be used, but, inasmuch as this largely is a matter of individual taste, a recommendation by the author will serve no purpose. DETAILS OF EQUIPMENT AND MECHANICAL ARRANGEMENT Screens Insect screens are now made by so many specialists in this class of work that i hey should not be purchased of the ordinary mill or carpenter, for the screen makers have machinery for producing stronger joints than the ordinary halving or tenon and mortise, also for special rebates and interlocking mouldings to secure the wire mesh and facilitate its replacing. There are also several manufacturers of metal-frame screens. In the first of these to be marketed the wire mesh could not be replaced except at the factory, hut this is not. now the case with some of them. A durable wire mesh is important; bronze wire is the best; tinned wire, also termed "pearl wire," and galvanized japanned wire are named in the order of their durability. Inasmuch as the life of metal frames is probably longer than that of wooden frames only bronze wire should be used with such frames. Screens should be the full size of the window opening, so that windows having double-hung sash may be opened at both the top and the bottom. Sliding screens equipped with springs to hold them at any position, either at the top or bottom of a window, can be obtained, but these do not permit the open- ing of both the top and bottom, and are not convenient for moving to different positions by the nurses when the windows are large. Miscellaneous Weather Strips. — There are many kinds of metal weather strips on the market which should not be confounded with the old-fashioned wood and rubber strips, which soon lost their efficiency by the hardening of the rubber. The cost of these is not high, and they undoubtedly make for comfort, and also for economy in the consumption of fuel, and reduce the amount of necessary cleaning. Such strips do not cost over 8 cents per lineal foot, so that the stripping on a window of average size costs about $2.50. Hardware. — The variety of hardware now manufactured is so large that it is not necessary to describe all. The points of greatest importance for hospitals are simplicity and durability. A ward is seldom locked, but the knob latch is in con- stant use. This should, therefore, be well made, of generous size, with good springs and an additional "easy spring." Smooth glass or porcelain knobs should be used, for these can be cleaned easily and reveal the presence of dirt and dust. Doors to offices and supply rooms which must be frequently locked and un- locked should have .cylinder locks; entrance doors, sink-rooms, pantries, and doors to many other rooms should have door checks and springs to make them work noiselessly and automatically. Practically all doors should have door checks to prevent their slamming, but, inasmuch as the cosl of the only satisfactory checks is about S3.50 and upward, this safeguard against noise is usually omitted. Many inexpensive devices, such as rubber stops, have been tried, but usually fail on account of lack of adjustment. A small cylinder secured to the head of the door and a plunger on the door itself may be obtained at a reasonable price, but 80 HOSPITAL ARCHITECTURE the door can only be closed slowly when one of these is attached and the doors are frequently left open when they should be closed. Glass, porcelain, and enameled iron push and kick plates are easily broken, and, therefore, plain or nickeled brass is generally used. Blanket Warmer. — A blanket warmer, such as illustrated on page 159, for an operating department will be sufficiently insulated if the floors, partitions, and covers are of ordinary hollow clay tile or gypsum block plastered on both sides. The doors and door frames should be of iron neatly fitted together, and the floor should have a guide track to guide the carrier, which is the same as a standard clothing carrier of a laundry dryer. The dryer recess should not exceed 7 or 8 feet in height, and should have a flue to draw off moist air. Any of the laundry-dryer makers can make a truck for carrying the blankets, which will operate satisfac- torily. Any good metal door and frame, about 2 feet wide and 7 feet high, as obtain- able in the open market can be used. The heating coil can be the usual pipe coil. The blanket warmer can be built by local mechanics if laundry-dryer makers are out of reach. The coil should be connected to the line of steam piping, which supplies the steam tables and sterilizers with steam under 30 to 60 pounds pressure, because the heat- ing apparatus of the building may not be in operation in mild weather. An electric light on the ceiling of the warmer, with an indicating switch on the wall outside of the door, is a convenience. PERMANENT INSTALLATION BOILER AND POWER SUPPLY The steam supply for hospitals includes primarily that necessary for the heating system, for sterilizing, cooking purposes, water heating, for laundry equip- ment requirements, and for the elevators and other motors, such as the fans. As all of these uses, except the heating, need steam of high temperature (and con- sequent high pressure), the use of the low-pressure cast-iron type of boilers, as commonly installed for heating plants, is here precluded, unless a small high- pressure auxiliary boiler, such as a vertical boiler, is installed solely for this purpose with no connection to the heating apparatus. This requires two fires in winter, but has the advantage of requiring only a small fire in summer. The high-pressure type of steel boiler in some of its usual forms is, accordingly, almost universally installed. In small institutions the fire-box brick enclosed type is often used. This type has heat passages around outside of the shell and be- tween it and the enclosing brick work, thus utilizing the outer shell as added heating surface. Marine type boilers are also used in somewhat larger sizes. They are self-contained, installed without brick work, and are of high efficiency. Their somewhat higher first cost is an offsetting feature which may decide against their use. The most commonly used boilers, however, are the horizontal cylin- dric shell, return flue boilers, set in brick work, with furnaces and grates designed either within the brick work of the setting or as "Dutch ovens" in front, as deter- mined by size, capacity, coal available, space limitations, and the like. The first two types of boiler have their furnace spaces enclosed within the steel water-containing portions of the boiler, and are generally found objection- able on account of their smoke production. It is practically impossible with many PERMANENT INSTALLATION 81 kinds of coal to so fire thorn throughout the range of their capacity and under the usual operative conditions that smokeless combustion will result. The more important cities are recognizing this, and many restrict their use to the smaller sizes and under very moderate operative requirements. The return flue boilers in brick settings may, on the other hand, have their furnaces properly designed to suit practically any of the commercial grades and kinds of fuel, and this type of boiler is to be recommended for use up to the limit- ing size and capacity. They are ordinarily built in commercial sizes up to 150 II. P., and are to be considered when the plant does not require more than. say. three of this size. To these should be added one spare boiler beyond the maximum requirements of the entire hospital service load, for so imperative are the needs for steam in a hospital that a reserve boiler should always be available in case ot accident, and principally for use during the necessary shut clown of any one of the other units for cleaning. Where the power or steam requirements are greater than above, the water tube boiler in some of the standard high-grade types should be used. These are ordinarily built in sizes ranging upward from 175 to 200 H. P. Water tube boilers have a considerable advantage over any of the other types in respect to safety, cost of maintenance, and length of life. They are so constructed that failure or deteri- oration of one part, such as a tube, necessitates only the renewal of that part, and leaks or other failures commonly develop in these boilers only as minor defects, readily remedied. Automatic stokers of a type suitable to the coal and the operating conditions should replace hand-firing in the case of larger units and in smaller institutions whenever, by their use, labor can be saved. This is usually the case when more than three or four boilers compose the installation. In all power plants coal-storage space must be considered, and in the larger ones the use of coal bunkers or overhead tanks or bins are advantageous. espe- cially where automatic stokers are employed. Coal conveyors and elevators and apparatus for ash handling are also items to be provided for in the larger boiler plants. The boiler-room location should receive early consideration and a liberal space be provided. Any handicap in this department is a continued tax upon the hospital operating cost. The introduction of engines and electric generating units is a problem that hinges upon the cost of electric current as obtainable from outside sources, such as city or public electric-supply companies. The local labor costs are another important item, and in case of hospitals, say, with ion beds or larger, the solution most frequently is found to be that a private power plant can furnish steam and electricity for light and power more economic- ally than would result from the purchase of electric current from outside concerns. It must he borne in mind that steam must lie furnished to the hospital at all times, and that throughout a large portion of the year the steam requirements For heating may be in excess of that for power, so that live .-team must be used in addi- tion to the exhausl steam from engines. Only a fraction of the heat in the steam entering the engine cylinders can be extracted for power production and the remainder i> available for heating purposes. The supply of the exhaust steam i> often adequate for heating purposes, except during extremely cold weather. It should be home in mind that the illuminating service and heating service are not simultaneous (hiring each twenty-four hours. The demand for heat is greatest during the morning hours: much the greater part of electric lighting is crowded into the late afternoon and evening. This lack of coincidence is an obstacle 82 HOSPITAL ARCHITECTURE to the economic application of steam to heating and the production of electric energy. The added cost, then, for electric current throughout the heating season is a very small item, consisting of some added labor and some investment charges to cover the generating units; thus the average yearly power, light, and steam bills are, on this account, lowered considerably. In the case of all hospitals, however, this important question should be care- fully considered well in advance of the planning, and, like all of the engineering equipment problems, of which this is probably the most important in a financial sense, it should be answered only after it has received study and has been esti- mated in detail and reported on by some experienced engineering authority. Frequently the question arises, will it not be expedient to buy light and power from a commercial company? This question cannot be settled alone in dollars and cents. It must be borne in mind that the hospital needs not only light and power for the motors, but exhaust steam for heating, boiler heat for sterilizing its considerable quantities of water necessary in all modern institutions where asepsis is practised, such as the wash and dressing waters in the operating department, and the high-pressure steam for sterilizing and for cooking vegetables and the like and making the coffee and tea. High-pressure steam can be carried over very short distances, if it is to be efficient, and the drop in efficiency of exhaust steam is so great in the pipes that the losses in going a considerable distance render the practice prohibitive. Pipes well covered and carried through tunnels where a dry and warm temperature can be maintained will deliver efficient steam at a commer- cial price 300 or 400 feet, but beyond this the losses are so great that an institution should attack such a proposal very reluctantly. Then, again, a hospital must have its service at unusual hours that cannot be controlled, and a commercial plant will find it extremely expensive to deliver high- pressure steam even a short distance at midnight, or even to be always ready to do so. Another question concerns the engineering staff. There is always plumbing to be repaired or altered, radiators and regulators to be fixed, and work for an elec- trician to be done. The hiring of this work in small jobs and in frequent visits of those mechanics is extremely expensive, while one's own engineering force can do it all as a part of the day's work. There are also innumerable odd jobs that good plumbers, steamfitters, and electricians can do not strictly within those trades if a small shop is available, such as mending kitchen utensils and machinery, the var- ious sterilizers, and a great part of the operating apparatus, such as metal beds, tables, wheel chairs, and so on. Many of these men, too, are most ingenious and initiative — they can make splints, mend clocks, construct artificial supports, bed- rests of special pattern, and help the doctors in the design and construction of spe- cial apparatus, and so on almost ad infinitum. All these things cost too much money to warrant liberality in respect to them, and yet, if they can be done with a force working for wages at other work, there will be a constant stimulus for the doctors to do new things and thus progress. So there are many questions to be answered before a hospital management can decide whether or not to build and operate a power plant. General Service Steam Piping. — Besides the steam required by the heating system and the laundry there are many uses for steam throughout the hospital, and to supply these, in general, a steam service system of piping should be brought from the boiler-room and extended throughout the hospital to the various loca- tions where this service is required. PERMANENT INSTALLATION 83 Among the various steam-using utilities will be kitchen equipment, including dish washers, steam tables, hot plates, coffee urns, steam food boilers, jacketed cooking kettles, bakers' proving closets, and pastry kettles. In the diet kitchens, steam tables, dish heaters, hot plates, the autoclave, steam tallies, and the like require steam. The service rooms throughout the building will need steam tables, dish sterilizers, and utility sterilizers. Utility rooms will have similar steam requirements. Surgical dressing-rooms will need steam for instrument sterilizers and water sterilizing apparatus. The blanket warmers should also receive steam from these service lines. The service piping system, in general, should be designed along the usual lines of high-pressure steam piping service. It may have to carry a working pressure of between nO and 80 pounds, and it should be tested to at least 120 pounds. This necessitates high-grade heavy valves and fittings and good workmanship through- out. In general, the piping system should extend as directly as possible to the various locations where used, and should be exposed and accessible for inspection wherever possible. The lay-out requirements will include a main from the boiler-room, this branch- ing to risers throughout the building, and these, in turn, having small branches running directly to the fixture locations. From the fixtures return branches are carried to return risers and these assembled in a return main, extending back to the boiler-room, where, properly trapped, it discharges the condensed steam into a hot-water collecting tank, or to a boiler feed water heater. Valves should be provided at all fixtures. As the above description would indicate, it is essential that all of the various steam-using items of equipment be selected early ami their location within the hospital then determined, so that the most direct and economic method of pip- ing and equipment can be determined in the planning of the building. The detailed designing of this pipe work needs expert consideration, and it will ordinarily be designed, purchased, and installed as a part of the heating power and other piping work. HEATING The comfort of patients, and the carrying on of the various activities of a hos- pital, depend so largely, throughout a considerable portion of the year, upon the proper heating of the rooms that the hospital heating system must necessarily be most complete and effective. The requirements of the several hospital departments are so specialized that a detailed design should be executed by experts especially experienced in hospital engineering. Among the requirements for a satisfactory hospital-heating system must be considered cleanliness and ease of maintaining cleanliness, noiselessness at all times, prompt and ready regulation, and this, preferably, through a considerable range of temperature', freedom from leakage, odors, or deleterious effects upon the air of the rooms, with simplicity of operation and substantial design throughout. The special air-supply requirements of various classes of rooms project the influence of ventilation upon the heating requirements, and tin- design of the Ventilating and heating equipments should go hand in hand and should receive equal consideration. 84 HOSPITAL ARCHITECTURE As to the various types of heating apparatus, stoves and hot-air furnaces have proved inadequate and unsuitable to high-grade or exacting requirements, and are now seldom considered in hospitals of any permanency or importance. Ho1>water heating systems are easily managed and hold a uniform heat for some considerable length of time without attention, and they are accordingly ser- viceable in smaller institutions. Where the matter of attendance at night is an important factor the slow cool- ing of the system is an advantage, although this is offset largely by the fact that it responds with equal slowness to a demand for more heat. This system is at a disadvantage, in that it requires quite a considerable increase in the size of the piping and all of the radiators over that required by steam heat, hence it is also more expensive to install. Steam heat is more extensively used in hospital practice. Of the several steam-heating systems the simplest is the plain or gravity system. The single- pipe method of piping is, in general, the least expensive, and may adwsedly be adopted in smaller institutions, where the distances of pipe runs are short, and accordingly permit satisfactory uniformity of operation throughout the building. With this system there is the objectionable feature of air valves on radiators, which allow the escape to the rooms of objectionable air from the radiators when- ever steam is turned on. An auxiliary air discharge line system, connecting all the air valves to an outlet in the boiler-room, though an added expense, is desirable in any installation of this type. Larger buildings require a more effective piping system and added devices to insure proper uniformity of heating throughout their extent. Steam-heating systems in these cases should have the two-pipe system for supplying steam and returning the condensed steam from radiators to the boilers. The so-called vacuum systems of steam heating include specially designed vacuum valves or traps between the radiators and the return piping and a vacuum pump in the machinery room operated to draw a vacuum in the return piping system, thus inducing prompt removal of air and more rapid and complete fill- ing of the radiators with steam. In consequence, the operation of the heating system at a lower steam pressure is possible with these systems. Vacuum systems are of special value where the heating system takes steam from the power plant, utilizing engine exhaust. As the steam can be delivered to the heating system at practically atmospheric pressure a resultant saving in the capacity and economy of the engines thus obtains. A recent development of temperature-control valves for radiators deserves especial attention in connection with hospital installations. These are designated by the various makers by different trade names, such as vapor systems, modula- ting systems, vacuo-vapor, thermograde systems, and the like. They are substantially similar in principle, and furnish essentially some type of hand-control lever valve on the radiators with indicating disks marked in frac- tional parts and designed for setting at f , §, f, or the full capacity of the radiator. These systems need a proper and ample piping system, efficient regulating valves on the main steam-supply, so operating that they assure a positively uniform steam- pressure at all radiators and with a return piping system carrying back the con- densed steam and any entrained air. These systems operate most effectively to permit the use, at will, of either the entire radiator or approximately such frac- tional parts of it as is desired by simply turning the valve to the desired indicated position. PERMANENT INSTALLATION 85 The systems give by far the best control of radiators that has yet appeared and their use will result in a very considerable saving of coal-supply. Manu- facturers claim and will guarantee a saving of between 15 and 25 per cent, of the season's coal bill. This is largely due to the fact that, with the usual systems, the temperature control in rooms almost universally is attempted by closing and opening windows, with the resultant loss of heat from the building. These systems require radiators of the hot-water type, but intermediate in size between those required for steam heating and for hot water. The cost of these installations is, in the larger buildings, somewhat less than that of hot-water heat- ing systems. Large institutions, especially those including a number of buildings separated over some considerable area, will ordinarily have their own power and electric generating plants. These may well consider the installation of a system of forced circulation of hot water, which, while equipped in the various buildings and rooms, practically the same as in the ordinary hot-water heating system, has a circula- ting pump connected to the main supply pipe in the power plant or supply point, so that the water is circulated rapidly, positively, and uniformly throughout the whole institution. One advantage of a forced circulation of hot water is that the water can be cir- culated at a positive uniform speed under all conditions, while the temperature of the water can be varied to suit the varying demands for heat in accord with the outdoor temperature changes. The temperature of the whole institution is then readily regulated in the engine-room as the variation of the temperature of the hot-water supply can be controlled by a single steam valve. The control of temperature in the rooms is readily regulated by adjusting the individual radi- ator valves. Inasmuch as the varying hot-water temperature demands are best made by varying the steam-supply temperatures, the main advantage of this type of heat- ing systems is that it permits the power-plant engines to be run much more eco- nomically as condensing engines, exhausting their steam under a varying vacuum (and thus at a corresponding variation of temperature), which will follow the heating requirements very closely. This utilization of the low-temperature steam will permit, through the use of condensing engines, a probable saving of coal costs over non-condensing engines of between 15 and 25 per cent, throughout the beating season. The cost of this system should not be much in excess of that of the usual hot- water heating system. The added cost, however, is more than offset by the gain in economy of operation. Referring to details of construction, the item of radiators in hospitals is im- portant, regardless of the system selected. Those of the simplest and plainest design should be the only ones chosen, as the so-called ornamentation serves to collect dirt and increases the cost of keeping them clean, or results in their always being foul. The type of ornamentation is, moreover, frequently obtrusively ugly. The proper location of radiators should always receive study, ami the services of an experienced designer is here required. Extra high legs on radiators are most advantageous, as they permit the more rapid cleaning of the floor. Better still is the use of legless radiators, supported free from the floor by bracketed attachments to the side walls. These are largely contemplated now in the better class of hospital designs. The use of radiators, having especially large and free -paces between tin cast- iron sections, is most advantageous for facilitating ready cleaning, and. although 8b HOSPITAL ARCHITECTURE such radiators occupy more space and are slightly higher in cost, their use in hospitals is recommended. In operating- and similar rooms they should always be insisted upon. The desire to keep operating-rooms as free as possible from all apparatus, fittings, and other items other than surgical apparatus has resulted in a number of special methods of heating such rooms. Notably among these have been some operating-rooms recently constructed, with their interior walls made up almost entirely of opalescent glass, and between these inner walls and the parti- tion walls steam coils and radiators have been installed, so that the entire wall surface of the rooms is so heated as to keep the room at the required tempera- ture. This system needs especial attention in design to preclude the necessity for attention or repairs and some extra building space has to be provided for it; but the operation is so entirely satisfactory that the added expense is more than justified. In the halls, corridors, lecture rooms, and general public sections of hospital buildings, where uniformity of temperature is more desirable, the added expense of a system of thermostatic control for radiators is usually justifiable in connection with the heating system. These consist, in general, of a system of thermostats mounted on the room walls, and so connected electrically or by an air-pressure piping system to specially designed radiator valves that a change of two or three degrees in the temperature of the room will cause them to automatically regulate the radiator valves to hold the temperature constant. The details of heating system, piping, valves, and equipment, including the method of running piping and the like, should, of course, be left in the hands of experienced engineers, with whom the architects will co-operate to provide space and facilities. It should be stated, however, that in no other service is excellence of design or high quality of equipment so essential as in hospital work, as the operating requirements are most exacting and low cost for attention and repairs is most desirable. While it is, in general, advisable throughout the hospital construction to keep all rooms as free as possible from fixtures, apparatus, and fittings not actually necessary, the question of whether the heating-system pipes, such as risers and returns, should be left exposed or hidden in the walls is one of the problems of hospital architecture. Concealed piping is difficult to reach, and occasionally a leak will appear that may mean a break anywhere within several floors, and a great amount of wall may have to be torn out. But modern plumbing, with cast pipe and threaded joints, has made such forward strides that such leaks are very rare, especially in concrete construction. On the other hand exposed piping is hideous to look at, intolerable in the rooms and wards of a hospital, impossible to keep clean, and necessitates loose connections at the ceiling openings, which may easily be the avenues by which infections may be spread upward or downward. Assuming good construction in both cases, the cost and upkeep will be pretty nearly the same. PIPE COVERING Discretion in selecting piping covering or insulation for the various piping systems will result in considerable saving of cost of installation, combined with the most economical operative and maintenance expenditures. The highest grade of insulation for high-pressure steam and refrigerating piping is essential. Cold- water pipes need insulation only to prevent condensation of moisture upon them. PERMANENT INSTALLATION 87 Hot-water piping should have a good grade of insulation. Steam-heating sys- tem piping, where passing through heated rooms, needs, in general, only enough insulation to protect the room occupants in case of accidental contact, but if these arc embedded in outer walls they should have high-grade insulation. As with other details of the engineering equipment, trained technical advice is advisable in making an economic selection of insulation. LIGHTING Beside the usual problems of efficient interior building lighting called for by offices, assembly rooms, corridors, halls, and service rooms, a hospital presents many problems peculiar to its own class of service. Most modern hospitals are so located that electric current is available either from outside sources or from local power plants, and, on account of its decided advantages over other systems, electricity has practically superseded all other forms of illumination in hospitals. Throughout the service rooms and those given over to the use of the public, the illumination is governed to a certain extent by the architectural treatment, but more usually by the location of furniture and fixtures. The tendency in modern practice is to provide the best possible light dis- tribution without overintensity. Standard fixtures are available in a variety of types, which allows of ready selection to suit any condition or requirement. Patients' rooms, and wards in general, require a soft, subdued light, and the so-called indirect systems are gaining in favor. These systems use inverted light- ing fixtures, which throw the light directly to the ceiling, whence by reflection it is diffused throughout the room. Either with this system in use, or with the use of ordinary ceiling fixtures, side-wall bracket lights are essential for use when doctors or nurses are working about the patients. Wall plug outlets for attachment of cords, with portable lamps for doctors' use, are of great assistance, and are commonly included in the equipment. These outlets are also available for use with the many serviceable electric specialties now on the market. Foremost among these are electric-warming pads, which seek to displace the usual hot-water bottles. There still exists unfilled a demand for a practical adjustable wall-bracket light shade which will permit, at will, a variation of intensity or direction of light ; in consequence, unsightly temporary shades, constructed impromptu from news- papers, magazine backs, and the like are seen frequently in use. A desirable fixture arrangement, especially in rooms used by convalescent patients, is a pendant switch on a cord, arranged to be available at the patient's hand, and by which the bracket light above the bed can be turned on or off at will. This makes a very complete and convenient fixture when a wall switch for nurses' use is included at the bracket. The lighting of operating-rooms is, no doubt, the most difficult of hospital- lighting problems, and many methods are in use and many more have been ex- perimented with. Obviously the light should correspond in direction, source, in- tensity, and color as nearly a- possible to daylight illumination entering through the large north windows. Figure 25 shows a combination of daylight and night illumination. Modern incandescent lamp filaments are more anil more nearly approaching daylight color. The location of light source has many practical limitations. Fixtures extending into the room continually gather dust, and, when lighted and 88 HOSPITAL ARCHITECTURE thus heated, they induce air currents which tend to circulate the dust around the room. Groups of lights in fixtures hung from the ceiling are, on these accounts, more or less of a menace and are difficult to keep clean. The cleaning may be facilitated by having the fixtures made adjustable and counterbalanced. Port- able banks of lights fitted upon stands with heavy iron bases have been much used, but lamp cords are then under foot and the fixtures usually in the way. Groups of lights under a large reflector on swinging brackets (Fig. 28) are also in use. These do away with some of the objections to floor-stand fixtures, but are open to the same objections as to dust collection as are ceiling fixtures. It is rather difficult to so locate this type of fixture as to avoid objectionable shadows. Large groups of lamps placed close to the operating table are also objectionable, on account of the heat which they generate. Elevation Hi -Section- Fig. 25. — Combined operating-room window and skylight. Some operating-rooms, especially abroad, have had installed systems of strong arc lights equipped with lenses and reflectors, and placed outside of the operating- room walls at such locations as to direct and concentrate their rays about the opera- ting table. These are rather expensive systems, but if the lamps are well placed are effectual, though surgeons using them complain of the heat they generate and also of the intensity; at the same time the limited area of the light focus. A very effective method of illumination in operating-rooms, which has been recently installed in some hospitals, makes fixtures or lighting devices within the room unnecessary. (See Figs. 26, 27.) It is made up, in general, as a con- tinuous box or trough installed in the side walls and ceiling of the room and en- circling the north light window frame. This trough is provided with a glass front set tightly in a frame work flush with the plaster. It is found that an ample number of lights can be installed in this fixture to give proper intensity of illu- mination, and the glass being made prismatic or ribbed good diffusion results. PERMANENT INSTALLATION 89 A recently developed form of incandescent light, shaped as a straight tube about a foot long and supplied with a straight filament, can be so placed in these troughs as to make the light source a continuous line in the troughs and thus give perfect uniformity of illumination. The above type of lighting fixtures, forming as it does a part of the wall surface, is tight and free from dust circulation and as readily kept clean as are the walls themselves. The Moore light, a type of illumination now being developed, promises much in the way of a uniformly diffused light source of good quality. This light is made up within the rooms to lie illuminated as a continuous glass tube, and consequently may be located wherever desired. The light source is a luminous vapor existing throughout the extent of the tube, this being controlled electrically and mechanic- I NT C&IOE. VI EW Fig. 26. — Interior view, operating-room windows showing linolitc- lighting around windows ally by the very ingeniously contrived automatic devices forming a part of the lamp. This lamp in the above form has not as yet been developed commercially to any extent, although the makers are now furnishing a small portable lamp unit, consisting of parallel illuminating tubes framed with a suitable reflector to form a lighting surface about 2 feet square. Some of these have recently been set Up in hospital operating-rooms, and especially on account of the fact that the quality of the light furnished approximates sunlight very closely considerable success is claimed for them. Lighting Fixtures. — Lighting fixtures should be selected for simplicity. The tubing anil other metal of wall brackets should lie heavy to withstand usage. If the "indirect" types of fixtures are chosen, particular attention should be given to their reflecting surfaces, for some of them deteriorate so rapidly that the illumination suffers. Such fixtures require light-colored ceilings, preferably enamel paint, in order to reflect the light as much as possible. 90 HOSPITAL ARCHITECTURE In any case much light is absorbed by the reflectors and the ceilings, and, unless the most efficient lamps (with Tungsten filaments) are used, an excessive amount of current will be consumed to give the required illumination throughout the rooms. There are two forms of light regulation for private wards and rooms that have recently become popular. One is called the "high low" and the other the "dim- Fig. 27. — Section of operating-room windows showing linolite lighting around windows. mer." In the former there is resistance in the lamp filament, and in the latter the resistance is in the socket. In both there is a tiny chain attachment that when manipulated turns the light up or down, just as an oil lamp may be turned up or down. The difference between the two forms is one of cost. The "dimmer" PERMANENT INSTALLATION 91 socket costs about 75 cents, Imt is as permanent as any other socket. The "high low" lamp costs 25 cents, but the lamp is short-lived, perhaps one-quarter the life 28. — An admirable lighting for operating-room. of an ordinary lamp, and must then be renewed. One or other of these lamps is almost necessary in the hospital sick-room. SIGNALLING SYSTEMS Beside the usual public and private telephone systems with which modern hospitals are equipped, the special needs of hospital service call for reliable signal- ling systems for a number of purposes. An electric system of signals for calling nurses to the patient's bedside is now considered essential. The simplest and gen- erally the least expensive type of these is the annunciator system. This is quite similar to those usually installed in hotels. An annunciator located at the curses' desk or station in the corridor has drops or signal disks, numbered or lettered to designate the various rooms or patients' bed locations in wards. A pear-shaped bush button attached to a flexible insulated wire or cord is furnished at each bed anil wired electrically from the bedside location to the annunciator, where the patient's call is announced whenever the button is pushed. To attract the attention of nurses from a distance an electric bell or buzzer is located at the annunciator, or an electric light is installed and so wired as to be lighted whenever a call is shown on the annunciator. Resetting the annunciator when answering the call extinguishes the light until another call is sent in. A marked improvement is an extension of this system, accomplished by adding electric resetting circuits, so wired that to reset or cancel the call from the annun- 92 HOSPITAL ARCHITECTURE ciator the nurse must go to the room and push a button located at the bedside outlet from which the call originated. This guarantees that in every case the signal is responded to in person, and that if a signal is canceled from an annunciator this has been done by some one at the patient's bedside. The importance of this feature of the service is at once apparent. The only trouble is that in case the nurse fails to answer promptly the patient may undertake to call again by another push on the button, and so put out the annunciator light. To obviate this the shut- off light may be placed near the door, inside the patient's room, when the nurse can use it immediately on entering and so cancel the call, but where the patient cannot reach it. A supervisory annunciator can be readily added to this system. This is a large annunciator, located at the superintendent's or other official's desk, and having signal drops duplicating those on the entire equipment of the signal annun- ciators throughout the hospital and working in unison with them. This places before the official continuously a visual record of unanswered calls, and should tend to very considerably increase the efficiency of this most important item of the nursing service. More extensive elaborations of the above signalling systems have been devel- oped. In place of the usual type of annunciators these have the signal cases con- taining electric lamps to indicate the calls instead of numbered drops or disks. These lights are visible and readily discernible at greater distances and tend toward bettering the service. These signal cases may have a large or pilot light located above them or at any required location, and so wired as to be lighted and give indications that a signal is recorded or a call unanswered at the station. Lights placed above the doors of the patients' rooms or wards may be installed to serve as additional signals to safe- guard each call and facilitate prompt attention. Electric resetting devices in the various rooms are similarly used with the various light signal systems. The latest refinement in the matter of record keeping has recently been brought out in the form of a supervisory chart-drawing electric recorder. This has a con- tinuously moving clock-driven record sheet upon which pens, operating in unison with their corresponding patient's call signal lights, leave a line measurable as minutes on the chart, and which indicates the exact time of calling and of answer- ing every patient's call throughout the day. These charts can be taken each day from the recorder, and the bound sheets form a written record always available. With increasing elaboration of the signal systems there increases, in general, the complication of construction. Care, judgment, and experience are essential in selecting the type best adapted to the hospital service requirements. The grade of construction and material should be of the best, thus insuring length of life and certainty of operation of the system. Important to be kept in mind as essential is the selection of the most reliable and constant source of electric current, whether from dry, wet, or storage batteries, or by transformers or from the lighting current. In general, it is better if all the bell signalling and other service current can be supplied from one central source of energy. Current from the hospital lighting system, if perfectly adaptable, is preferable to storage batteries, and these, in turn, in cost of upkeep and uniformity of electric output are more serviceable than wet or dry batteries. Care must be taken that none of the lighting current can reach the patients' push cord, and, to avoid this possibility, it may be preferable to use storage cells that can be charged from the lighting circuit whenever necessary. In small installations the simplicity of dry batteries as a current source renders this type acceptable. PERMANENT INSTALLATION 93 Among other details of the nurses' signal service bedside wall outlets should receive attention. These should he located so as not to be disturbed or injured when moving the beds. The cords at the lied should he heavy and of best quality. The pear push button should be smooth, readily cleaned, and as aseptic as pos- sible. Beside the doctors' call system, to be referred to later, other miscellaneous signalling service systems about the hospital include elevator call-bells, with pushes mi each floor and annunciators in the cars; dumb-waiter calls, with pushes at each floor connected to an annunciator at the service floor, and with the gang of answer- ing push buttons on the service floor connected each with a corresponding answer- ing hell at I lie various floors. A speaking tube at the dumb-waiter location is an added facility now usually considered essential. DOCTORS' CALL SYSTEM For the prompt and silent signalling of house physicians, staff physicians, and interns a very effective system is that of having banks of incandescent lights installed in prominent locations on the various floors of the hospital, as in corri- dors. These lights may be set either exposed in a vertical row on the side wall and be distinctively colored, or they may be boxed in by an appropriate fixture or case with ground glass sides, having numbers or letters corresponding to each lamp to designate the various persons to be called. These lights are electrically connected with a set of push buttons grouped at a central point (usually at the telephone switchboard operator's desk), and in such a manner that, in the event a doctor is wanted, the pushing of his respective button puts in service his light signal in all of the corridors or signal locations throughout the hospital. Me can at once get in communication with the telephone operator from the nearest telephone. • These systems are usually operated directly from the electric current of the house-lighting system, and are usually installed as a part of it and of a similar standard of construction. SEWERAGE AND PLUMBING Drain pipes, inside or under the basement floor, should be of iron to the connec- tions witli ordinary drains outside of the walls. The best material for outside drains is salt-glazed clay pipe. In localities where iron piping or labor to lay such is too expensive clay tile, surrounded in good cement concrete, is a good substitute for iron drains. For these a bed of concrete about 3 inches in thickness should be laid first, projecting about 3 inches each side of the drain, and the space each side filled with concrete to prevent irregular settlement and opening of joints. Drains for chemical laboratories should lie salt-glazed pipe. The vertical, soil, and waste pipes should also be of iron. For these and the iron drains either extra heavy asphalted inside and outside cast-iron pipe and Bttings with caulked and leaded joints must be used, or asphalted steel pipes, such .■I- steam pipes with screw joints and special fittings threaded and recessed, so that the passage through t he lit tings will be smooth and have the same diameter as the pipes. Where the city drains are too small to carry off the waste and roof water, or so located thai water will back out of the fixtures on the lowest floor during storms, the drainage system should be divided into two parts, one part conducting the \\ : i — 1 1 ■ from the upper floors and roof to the city drains without an opening closer than ID 94 HOSPITAL ARCHITECTURE to 12 feet above the city drain, and the other part leading all waste into a sump equipped with an automatic ejector. These are operated by electricity, com- pressed air, or steam, and, if the waste consists only of water, a duplex equip- ment may be obtained for $500 or $600; but if the waste is also from closets, the lowest cost for a duplex equipment is about $1200, and from these prices upward, depending upon the amount of waste. The best known of these ejectors are the Priestman, Shone, and Yeomans, all of which are good. The drains from the upper stories should be suspended from the basement ceiling, unless the use of the room makes this prohibitive, and brass cleaning screws should be provided at frequent intervals to facilitate the removal of insoluble articles. The exact arrangement of waste and soil pipes, the ventilating of the system by secondary pipes, is so complicated that its description is beyond the scope of this work, and should be entrusted only to competent contractors and based on a thorough specification. Where city drains are not available it will be necessary to install a sewage disposal plant for the breaking up of sewage and rendering it inocuous, inoffensive, and odorless. Modern sewage-purification plants first liquefy the organic solids in the sew- age in tanks in order to prepare it for aerating beds, sometimes called "filter beds." The tanks alone are not sufficient. The changes which sewer liquor undergoes in a septic tank are of less importance than the subsequent aeration. The tanks must be of the right form and capacity to treat the amount and char- acter of sewage discharged into them. The tanks appear to intensify ordinary fermentation or putrefaction, settling a small portion of the solids to the bottom of the tank and breaking up the remainder. This is done by anerobic bacteria. When the liquid reaches the aerating beds it is fully purified by the anerobic bacteria, which cover the filtering material with a film and where the poisonous elements are changed to harmless elements. Such aerating filter beds are usu- ally constructed beneath the surfaces of the soil, for this appears to encourage bacterial activity and it entirely removes the possibility of freezing. Bacterial activity is largely dependent on natural warmth, hence a frozen bed does little purifying while it appears to operate. The space occupied by the filter bed may be used for yard or garden the same as though the plant were not there. Some cities require an open aerating bed, and for such an exclusive space is required. The bed, like the tank, must be given a certain capacity to do a certain work, but the bed may be placed at some distance away from the tank as conditions on the premises demand. In time the filtering medium becomes coated with a jelly-like film, and in this film, or coating, live the myriad hosts of bacteria. The poisonous liquids are rapidly converted and a harmless liquid, produced and collected, runs away as water. The final step in sewage purification and disposal is in getting rid of the water. This may be disposed of by discharging into farm drains, streams, or lakes, or by absorbing the water in the soil, by means of underground ducts laid beneath the surface of the soil. Such systems may be built close to institutions without danger of contamination of the drinking-water supply, of noisome odors, or any other discomfort, but the plant must be designed by experts to be of the proper design PERMANENT INSTALLATION 95 :in install pumps and tanks, so that there will be a cold-water tank system of pip- ing for the upper stories, cold-water city pressure for the lower stories, a hot- water system under tank pressures. In institutions having a system of refrigera- tion a system of drinking-water piping should be installed, and it is very important that this is covered with the most efficient form of covering at every point. There may also be a system of sterilized-water piping, both hot and cold, with sterilizers and tanks in the power house or in a sterilizing-room situated above the highest outlets. The hot-water piping should be paralleled by a system of return pipes, so that hot water will flow from any faucet immediately after it is opened; the return pip- ing permits of a constant circulation of the water entering the bottom of the heat- ing lank and leaving the top and will greatly save hot water, which means coal. A separate system of pipes for fire protection should also be installed, and so situated that water can be thrown into every enclosed space. Unless the city requirements demand a large hose, the hose should not be more than li inches in diameter, for larger hose cannot be handled to advantage except by trained fire- men. It is not possible to place all plumbing pipes in shafts or conduits where they are always accessible at a reasonable expenditure, except where the plumbing fix- tures are directly one above another and comparatively limited in number. Such shafts are expensive and require considerable space, but, since the elimination of Bead for supply and waste pipes, the danger of bursting pipes has been greatly reduced, and, whereas it may cost from $50 to §100 to repair floors and parti- tions where they have been broken to repair a broken pipe, it would probably cost thousands of dollars to build shafts and raceways. Waste and soil pipes should be tested by filling them with water to the top, and water-supply pipes by subject- ing them to a water pressure much greater than the normal city pressure before they are enclosed in partitions and plastering. Plumbing Fixtures Enameled iron fixtures were a great improvement on plain iron sinks, planished copper bath-tubs, and marble wash-bowls, but the gloss of enameled iron is SOOD destroyed by scouring soaps and stained by disinfectants anil solutions used in hospitals, so that a more durable material, such as porcelain or chinaware, should be used for every fixture, with the exception of the scullery and some of the kitchen sinks. The idea] material is vitreous chinaware, which is dense, hard, glass-like, noii- absorbent, the same throughout, and fused on the surface to make the glaze. 96 HOSPITAL ARCHITECTURE At present it is not made into large pieces, such as bath-tubs and large sinks. There appears to be a difficulty in the burning, consequently the older form of so-called solid porcelain must be used for bath-tubs and other large pieces. The glaze on such fixtures is made by firing a glazing material on the mass. This glaze is quite easily damaged, and then exposes the much softer interior mass, which is absorbent and which blackens and stains. Fixtures of such material do not retain their original white color for many years, and on these, as on enameled iron, gritty scouring material should not be used. Solid porcelain is divided into A, B, and C grades by the makers. The A grade is almost perfect, free from flaws, and is desirable for the operating department. The only defects which place a fixture in the B grade are small spots and black lines, called "checks." This grade is very good for every fixture, and sometimes, if an order is sufficiently Fig. 29. — Double kitchen sink. large to require a special burning at the potteries, a number of C-grade fixtures can be used. The design of plumbing fixtures is constantly being improved, consequently recommendations of certain fixtures have little permanency, and it is much better that the purchaser visit the show-rooms of makers or apply to them for their latest catalogues. The fashion of setting the fixtures away from the walls was made necessary by the form of porcelain fixtures which were first made. They offered no pro- tection to the walls, and these were either continuously splashed and washed, there- by destroying their finish, or protected by a marble or glass covering. The latest forms of porcelain fixtures are designed to be built into the walls, and in the case of bath-tubs into the floors, thereby reducing the number of spaces which are difficult to clean and inspect. Sinks and wash-bowls are made with high backs, which are in one piece with the sink or bowl, thereby avoiding dirt-gathering joints. These are set prior to the PERMANENT INSTALLATION 97 plastering and built into the walls, greatly reducing the labor necessary for clean- liness and affording few spaces for the gathering of dirt. The form of the fixture for the operating department is not agreed upon by all surgeons, buf a deep sink, about '_'(i by to inches, appears to be the most favored, equipped with a nickel- plated stopper actuated by a handle moving either right or left and with a high combination goose-neck supply pipe, the valves of which are controlled by knee- stiri'ups, or foot-pedals, and which are automatically closed by springs when the knee is withdrawn. This automatic closing is important to save water, espe- cially hot or sterile water, which means fuel. The amount of nickel-plated metal work should be reduced as much as possible by concealing piping in the walls, behind porcelain backs, covering the handles with porcelain, and making the parts which are below the fixture top of brass or iron, which can be painted with thin enamel paint, which requires much less labor Fig. 30.— Kitchen sink. to apply once or twice a year than it docs to polish the metal at the frequent intervals necessary to keep nickel bright. Inasmuch as constant polishing soon removes plating, white metal or German silver metal work should be used instead of nickel-plated brass wherever the conditions will permit, for it is of the same material throughout without plating. Figures 29-33 show some of the major plumbing fixtures designed especially for hospital service. Figure 2!) shows a double kitchen sink that may have a drain board on either or boih sides. It is a convenient affair, easily cleaned, with a minimum of nickel to I < < p clean, with the back set into the wall, and is made of porcelain. There may be a metal stopper at the bottom or not as preferred. Figure :>() is merely a kitchen sink, to which a drain board may be attached ii desired. This sink may also be used for an operating department, and when 98 HOSPITAL ARCHITECTURE so used may be equipped with knee-action faucet. In case this sink is used in the operating department, the plumbing may also contain a faucet leading from the 5^jy.i.J»8Wli»JWWw Fig. 31. — Bath-tub on concrete pedestal for children's department. Fig. 32.— Bath-tub set on floor. hot- and cold-water sterilizers in another part of the suite to a faucet, as shown in the upper part of the illustration. PERMANENT INSTALLATION 99 Figure 31 shows a bath-tub in the children's department set upon a concrete pedestal. Note the entire simplicity of arrangement, without cracks or corners for dirt, and with all smooth surfaces for easy cleaning. Note also the small amount of nickel at the faucets above the tub. This tube is placed so that the nurse can bathe small children without having to stoop over much. Figure 32 is practically a duplicate of the previous illustration, excepting that the tub is set into the floor. This is for bathing larger children, but this tub on a larger scale is used also for tubbing typhoids and ordinary bathing. Every- Fig. 33. — : Bath-tub set into wall on two sides. thing is smooth about this tub. It is free from the wall, excepting at the head. where it is set into the wall, so that there are no catch places for dust or dirt. The metal parts are reduced to a minimum, as in the previous case. Figure 33 shows another form of bath-tub, with the practical repetition of the main factors of the other tubs. In this case the tub is set into the wall on two sides. These five cuts are reproductions of fixtures in the new Sarah Morris Hospital for Children, which is a part of the Michael Reese Hospital. The fixtures are made by the L. Wolff Manufacturing Co., of Chicago, and they are specially designed for the purpose intended. Heretofore specially designed tubs, either as tn shape, size, or material, cosl enormously, but the manufacturers are reaching a period in their processes where they can make to order almost any set of fixtures Without any considerable increase in cost, which is a great satisfaction to the builders of institutions. Hot-water faucets should be of the compression type, for these contain a leather washer which is not destroyed by heat. The Fuller type of lancet- con- tain- a rubber ball, which is hardened and destroyed by the very hot water usu- ally supplied from steam-heated tank-. 100 HOSPITAL ARCHITECTURE The size of the supply pipes and the size of the openings from the supply fix- tures of bath-tubs should be much larger than furnished in the stock fixtures for dwellings, in order to insure a rapid filling of the tub. Nickel-plated brass pipe or white metal pipe should be of iron-pipe size and gauge. If this is not stipulated, a very thin pipe, not heavy enough for cutting a good thread, may be furnished, and will soon prove a source of weakness. Wall outlet water-closets bracketed from the wall, and which have no portion touching the floor, present the advantage of an unobstructed view for inspec- tion and insure a clean floor and no hidden spaces. Such closets, equipped with push-button flush valves, appear to be more desirable than the old type of tank closet, whether high or low, but the durability of the valve depends somewhat upon the freedom of the water from silt or sand, |S) for these cut the working parts and soon cause them to leak, except in the case of oil-operated valves. Figure 33a shows a new style of closet bowl in which none of the parts reach the floor. This is made by the L. Wolff Manufacturing Co., of Chicago. Kitchen and scullery sinks are sub- jected to such hard usage that only the most durable material is suitable. Porce- lain sinks may be used only for drawing of water, or possibly the washing of berries and small vegetables, but large porcelain sinks, like laundry tubs, are very useful for the washing of potatoes and coarse vegetables. Slate and soapstone sinks have internal angles which are not easily kept clean, are friable, soon broken by heavy kitchen utensils, and a dark color which may con- ceal foreign substances. Salt-glazed ware and yellow ware cost almost as much as class C porcelain and is also chipped by heavy utensils. Heavy cast iron is the most durable for such use. Well-made cypress wood sinks are excellent, but they must have brass rims. The large and deep sizes necessary for this work are not generally kept in stock, but sinks which measure 24 by 30 by 18 inches in depth, all inside measurements, are not expensive, and should be obtained on account of the durability and the facility which the large size affords for rapid and economic work. Manufacturers of plumbing fixtures make the height of sink tops 30 inches from the floor, the same height as an ordinary table. This height is not convenient, for little work can be done by sitting at the sink, and it is back breaking for stand- ing work, and it should, therefore, be required that special legs be furnished to raise the top of the sink to a height about 35 inches from the floor. Fig. 33a. — Wall-hanging closet. VENTILATION The subject of ventilation in hospitals is perhaps one of the broadest, most important, and most widely discussed, and yet one upon which there is the least unanimity by doctors, hospital managers, engineers, and architects. PERMANENT INSTALLATION 101 It is understood and agreed by all thai nowhere is pure air more essential than in ami about hospitals, but the methods recommended fur obtaining pure air conditions arc about as diverse as the present state of the art of ventilating will permit. The physical and chemic properties of pure air and vitiated air have lieen studied in a highly scientific manner by many scientists, such as 1 >0Uglas < Sal- tan and A. Wynter Hlyth, who explain the mechanism of air contaminations, the loss of gaseous diffusion, and the changes which take place in respiration; and it is not necessary to explain to-day that ventilation, as known, does not destroy the deleterious gases, but dilutes the air, and in successful installations the air dilution is sufficient to purify the atmosphere and make it harmless for re- breathing. The ventilation induced by fireplaces and flues direct from rooms to the air are helpful in a very limited degree, but seldom under conditions more exacting than those of small residences and the like. Similarly, drafts induced by gas jets or steam coils placed directly in flues, while simple in operation, are effective to but a limited degree when in small units, and when installed to any extent may usually he more economically replaced by fans. Ventilating openings in outer walls connected with flue type radiators in rooms and air passages beneath floors or in connection with indirect radiators are now seldom used in hospital practice, largely on account of the fact that it is practically impossible to insure proper cleanliness in their use, especially when adjacent to dusty roads or streets. Small hospitals are designed with little or no provision for ventilation, depend- ence being placed upon window, transom, and door arrangement for air circulation. This, in many cases, is considered adequate, but, as hospitals of larger size are considered, the complication of the structure itself introduces rooms and depart- ments that cannot be readily ventilated. This necessitates special methods for introducing air changes. Prominently, for first consideration, is the kitchen, which usually requires fans to extract the excess of heated air. These fans are most frequently attached to a ventilating flue continued from the hood over the ranges. In large kitchens these are frequently supplemented by other fans, either the simple disk or propeller fan placed in openings through an outer wall, or, preferably, the more positive and efficient, centrifugal fan, with ducts and registers, to more effectively direct air currents. In many cases the fans are simply used to withdraw air from the kitchens, its entry being permitted through windows and other openings; however, in many large kitchens the fan system includes fans with ducts for introducing air to the kill hen. These fans must necessarily be equipped with steam-heating coils for cold weather use. In the larger hospitals, toilet rooms, utility rooms, service rooms, and the like can seldom be adequately ventilated by natural draft, and ordinarily, owing to their grouping, can be connected advantageously by ducts extending up through the building to centrifugal fans in the attic or housed above the roof. The with- drawal of air from these rooms may help ventilate adjacent corridors and halls by being drawn into the ventilated rooms4 through register faces in the walls or doors leading to the corridors. Often the doors are shortened so as to leave a nar- row opening beneath them sufficient for the air-supply requirements. The doors to these rooms art' usually provided with springs to keep them closed, and the ventilating system acts most effectively to prevent odors from entering halls and corridors. 102 HOSPITAL ARCHITECTURE The laundry department of the larger hospitals can seldom be so located that at least one or two disk fans may not be advantageously added for withdrawing the heated and moist air. In this department, as in all others, the centrifugal type of fan should be employed where it becomes necessary to use duct work, either to control the source of air supply or to conduct it to any distance for outlet. The importance of ventilation in assembly rooms, lecture rooms, and the like is now so fully recognized that the larger cities prescribe a legal minimum limitation of air supply allowable for the needs of audiences as based on the seat- ing capacity of the rooms. Here again, as size increases, the possibility of natural or window ventilation frequently will not satisfy the requirements, and artificial ventilation must be resorted to. This usually calls for air introduction by means of fans and through duct work. Such a system must be laid out to avoid objec- tionable drafts. Heating coils are necessarily a part of this equipment. Laboratories and similar rooms usually need ventilation to carry off fumes and gases. In these locations small electric fans, placed above the hoods and connecting to outlet ducts or flues, usually suffice. These fans should be especially selected and constructed to withstand deleterious action of the chemic fumes. Among hospitals of larger extent the design must necessarily bring other rooms and departments into the class where natural ventilation is inadequate, and, as in common with most power-driven apparatus, the larger ventilating units are usu- ally more efficient and satisfactory, so the ventilating needs of the institution are then usually considered as a whole, and it is endeavored to assemble the various requirements for outgoing and incoming air on as few fans as possible by com- bination and extension of the duct work. There is no considerable question raised by either medical or other authorities about the advisability of mechanically carrying foul air away from hospital build- ings, especially in the parts of buildings above referred to. With the bringing of outside air mechanically into the building, however, there arise more complications, and there are numerous incidental difficulties and ob- jectionable features to this class of service. Most hospitals must be located in the cities, and frequently in congested districts, where the air is far from clean, and the large amount of air which is always drawn into a building by mechanical ventilation is accompanied by the introduction of large quantities of dust. The economy of the labor for cleaning the building and the saving to decorations and contents by excluding the dust and the air are considerable. The air which constantly passes through a building is freed of a large percent- age of its dust by the change of direction and size of passageways, which deflect and affect the air currents in the same manner in which baffle-plates precipitate chemicals in manufacturing processes. It is, therefore, important that the air intakes are efficiently guarded by air washers, lest the whole building become a sort of gigantic air-filter, and it is fully as necessary to maintain a vigilant obser- vation of the working of the screens and air washers lest they become inefficient, as it is necessary to constantly observe and cleanse water-supply filters in order to be assured that the water supply is reasonably free from impurities. For cleansing the air, first, various types of screens, and, more recently, air- washing devices, which are virtually artificial rainfall producers, have been devel- oped in connection with the fan outfits. These last have attained a high degree of efficiency, and the control of humidity has been developed in connection with them to such an extent that the quality of air can be ordinarily kept equal to, or, where required, can be modified to be, in general, more satisfactory than the exist- PERMANENT INSTALLATION 103 ant outdoor air conditions. During the hoi months the air may he cooled to an appreciable extent in its passage through the cold-water spray. These systems cannot, however, be fully 100 per cent, efficient, and, further, in spite of watchful attendance, they may at times be shut down. Eventually, then, some considerable dust and dirt will find its way into the various air passages and ducts, and thence become disagreeably evident at times. Accordingly, the only proper duct work for inlet air passages in a hospital is such that, by il- size and smooth hard interior finish, will admit of thorough scrubbing and disinfection in common with the rest of the hospital walls and fittings as frequently as inspec- tion shows the need. This facility for cleansing should extend to all the detail construction of the apparatus and passages in contact with the washed air. No doubt this method of construction, if adopted, will do away with prac- tically all the reasonable objections to mechanical introduction of air to hospital rooms. An exception would be the operating-rooms, where the air-supply registers should be provided with some form of efficient, antiseptic air-filter. Air drafts are a troublesome feature in ventilated rooms. The ideal air con- dition for some persons being still air, any degree of air movement will be more or less strenuously objected to by them. These objections can usually be properly done away with by furnishing the registers with clampers which may be readily adjusted to suit individual needs. It must be realized that any extensive ventilating system, or one in any way complete as a whole, is quite a considerable installation, and is not only expensive to install, but entails continual operative cost. Like all hospital equipment, it is actively in use, and represents a continuous outlay to produce a continuous definite result ; therefore, careful study should be given early in the planning of the hospital to the consideration of just what equipment in the individual case is necessary, what is advisable, what advantages, what ends are to be attained, and at what disadvantage and cost. The investment and operative costs must be carefully weighed. All of these, in common with all the engineering equipment problems, require expert considera- tion and the advice of those broadly experienced in the specialized problem at hand. Many modern hotels are equipped with elaborate air-washing and tempering devices, especially in their assembly halls and restaurants. But this is extremely costly apparatus, both in first cost and maintenance, and no attempt has been made on any considerable scale to extend such an equipment to private rooms of guests, with the exception perhaps of an isolated "royal suite" in some fashionable hotel. There is no such equipment at work satisfactorily in any hospital anywhere, and, until the art of mechanical ventilation is farther developed, we might safely stop when we have provided the kitchens, serving rooms, and utility rooms with this feature. In building large and costly hospitals it might be well to install metal or porcelain ducts of large size and a pattern that can be reached for cleaning, so that, when the problem of air washing has been solved, the machinery can be installed with small cost and without disturbing the walls. REFRIGERATION As the proper preservation and condition of foods and the purity of water supply are of the utmost importance in hospital service, so the refrigerating requirements are most exacting. The advantages of refrigeration in hospitals include the cool- ing of main kitchen and diet kitchen food-supply boxes, refrigeration in service rooms located throughout the hospital, cold-storage refrigerators for stocks of foods 104 HOSPITAL ARCHITECTURE and supplies, the preparation of such foods as ices, ice-cream, and delicacies for the sick. In modern hospitals the service and similar rooms are quite commonly served by dumb-waiters, and located as nearly as possible above each other throughout the building. This facilitates the installation of refrigeration piping to the boxes in these rooms, as pipe shafts can readily be laid out for this purpose in the parti- tion walls between them. The well-known advantages of artificial or mechanically produced refrigera- tion over coiling by means of ice make this the method to be preferred in any case. If the hospital is small, and natural ice always obtainable at low cost, there may be a saving which, for financial reasons, would make the use of natural ice a necessity. A decision in choosing between the two methods should only be made after a care- ful consideration, and after having obtained expert engineering advice, based upon an estimate of the investment and operating costs under the local conditions as to cost of ice, power, supplies, labor, and equipment. The type and size of refrigerating equipment and the details of the machinery proper and accessories should be similarly decided. The advantages of mechanically produced refrigeration are primarily the ability to keep the various refrigerated, boxes or spaces at any desired low temperatures and to control these closely, while, at the same time, maintaining the boxes in a far more highly sanitary condition, due to the ability to hold them at a proper degree of dryness. Refrigerated drinking water is readily available with mechanical refrigeration. The cooled water, when piped in a closed circuit and thus kept pure and clean, can, when refrigerated, be circulated throughout the hospital at any required temperature. This facility has not been available with the use of natural ice. The freezing of the hospital's requirements of pure ice is an added feature now largely adopted by most hospitals of considerable size. The mechanical refrigerating equipment requires space for machinery, tanks, and pumps. Adequate space should be allotted in a central location on the lower floor, preferably in or near the power plant or boiler-room, and with electric current (or steam) water-supply and drainage readily available. Of the several types of refrigerating machinery that most commonly in use is the compression system. This has a gas compressor, driven by either motor or steam engine as the conditions of operative economy may decide. Small units usually are motor-driven and larger ones have engines, which permit a greater economic range of speed and capacity throughout varying weather conditions and requirements. Amm onia and carbonic anhydrid, commonly known as carbonic-acid gas, are the refrigerating mediums most commonly employed. The ammonia compres- sion machines are most largely in use, as they have been more generally on the market for a number of years, and are built in a large variety as to style and size and by a large number of manufacturers. This is probably on account of the fact that this machinery is operated under a considerably lower pressure than are carbonic-acid compressors, and thus does not call for as highly specialized design- ing or factory construction. The carbonic-acid machines, though not built in the largest sizes, have entered the field more largely of late, especially where a fear is expressed of disturbing odors due to gas leaks, the carbonic-acid gas being odorless, while the pungent odor of ammonia is well known. In a properly designed and tested plant this fear need not be a disturbing one, and it is practically offset by the fact that such leaks as PERMANENT INSTALLATION' LOS may occur axe commonly small ones, which, in the case of ammonia, are promptly discovered and made tight, while the carbonic-acid leak may continue unnoticed long enough to cause an extensive loss of gas and even of operative efficiency or capacity before discovery. Where plenty of exhaust steam is available the absorption system of refrigera- tion claims some increased economy of operation, but this system, in the sizes ordi- narily required by hospitals, has not been largely adopted, possibly as the process is rather more involved than the mechanical compression system, and not as readily kept up to the best operative efficiency by the class of labor usually available on the hospital force. As to comparative operative cost, though the ammonia compression system is considered theoretically somewhat more economic than the carbonic-acid gas, practically in the size of units and under the operative conditions existing in hospital requirements, the makers of both types give about equal guarantees as to the cost of power for operation. Theoretically, both the ammonia and carbonic-acid gas are used over and over indefinitely, and there is supposed to be no material expense attached to renewal of gases. In the case of ammonia this is approximately true, because a leak is immediately detected by the odor and is stopped. There is no such safeguard with carbonic gas, since there is no odor. As a matter of fact, in the Michael Reese Hospital, w'here this latter system is in operation, the expense of gas renewals is a constant one, amounting to approximately §300 per year, and it is significant that the ice-machine makers have developed a practical monopoly in the sale of carbonic-acid gas. This is a feature of this system worth taking into account. Refrigerating boxes are cooled by two methods, termed "direct expansion" and "brine circulation." In the first, the compressed and liquefied ammonia or carbonic anhydrid is piped directly to the refrigerator boxes, and there passes into the cooling coils through "expansion" valves with fine orifices through which the fluid is vaporized, and expanding to a gas in the cooling coils becomes very cold, thus chilling them. One feature tending to render direct expansion in small coils impracticable is the frequent stoppage of the fine valve orifices by rust, scale, and other solids. Where brine circulation is adopted the ammonia or carbonic-acid expansion piping is entirely confined in a brine cooler or tank in the refrigerating machinery room, and the brine made of common salt or, in some cases, where very low tem- peratures are required, of calcium chloric!, is then cooled and thence circulated throughout the hospital to the various refrigerator boxes in a closed piping circuit. The valves located at the boxes can be set to suit the amount of refrigeration needed by each, and thereafter the brine temperature, being controlled in the machinery room, the required temperature of all the boxes can be thus properly maintained without more than the occasional inspection necessary for the removal of frost, which forms gradually on the refrigerating pipes in the boxes, thus insula- ting and rendering them inefficient. In many cases where mechanical refrigeration is installed consideration should be given to the saving in labor, which is effected by having the machinery of ade- quate capacity to supply the refrigerating requirements easily when operated only through the daytime, and arranged to have only the small brine circulation pump in operation through the night. This is one feature in favor of brine circulation instead of direct expansion system where refrigerating gas is circulated direct through the building. To eliminate a considerable loss in economy, all the cold piping of the refrigera- 106 HOSPITAL ARCHITECTURE ting system should be protected by a heat-insulating covering of the highest obtain- able quality (Fig. 34). Standard coverings are furnished of compressed cork and of wood or hair felt. In selecting insulation it must be kept in mind that a con- siderable difference in first cost will be very rapidly outweighed by the continued loss of refrigeration due to the selection of a lower quality of insulation. ASPHALT Fig. 34.- -Insulating partition between refrigerator and main room. Usually the cork is placed above the tile. The cut is not correct in this particular. The specifications should establish a guaranteed result of refrigeration and a five-year guarantee against deterioration of the covering. Pipe-covering manu- facturers who specialize in refrigerating insulation will agree to such guarantees. VACUUM CLEANING Removal of dust and dirt and their attendant bacteria in a manner at once thorough and with a minimum of labor and noise has long been an important problem in hospital management, and mechanical vacuum cleaning or sweeping devices have been adopted by hospitals as rapidly as their development has brought them into the realm of hospital usefulness. While portable vacuum cleaners or sweeping machines have been developed for use in residences and small buildings, the more exacting requirements of hospi- tals make it advisable in all cases to install stationary equipment with machines located in the basement or machinery room and connected to a complete vacuum- piping system extended throughout the building. Inlets, with openings conve- niently located throughout the building, allow of attachment of cleaning and sweeping tools by means of flexible rubber or steel hose. An objection to the portable vacuum cleaners is that they discharge the air into the rooms which are being cleaned, much of the finer dust being stirred up with the air. In designing a layout for a stationary vacuum cleaner considerable care should be given to the location of hose-connecting outlets, as long sections of hose cut down the effectiveness of operation quite rapidly. The opening should be so placed that every part of every room may be reached by as short a hose as practicable. Hose is generally furnished in 25- and 50-foot lengths, and longer lines than 50 feet, or possibly 75 feet, are hardly to be recommended. The tools are usually furnished in sets of from eight to a dozen kinds, the different ones being designed for cleaning various surfaces, such as rugs, bare PERMANENT INSTALLATION 107 floors, walls and ceilings, tapestry, furniture, and clothing, thus individual require- ments can be readily met by proper selection. The number of sets of tools and hose outfits is determined, of course, by the size of the hospital. It is best to have only as many sets as will be required to (•(instantly employ the operators throughout the day by an orderly procedure from room to room in accordance with some regular schedule. The hose-connecting pipe openings should have tight valves to prevent loss through leaks. A pipe system should be laid as directly as possible and be properly designed as to size, with absolutely smooth interior and with cleanout openings at points sufficient to allow ready inspection in case of stoppage. Vacuum machines are ordinarily designated by size, as one-sweeper, two- sweeper capacity, etc. The required size is determined by the number of sets of tools to be kept in use simultaneously. The power used corresponds to the work done by the pump, and accordingly the equipment, like the tools, should be selected small enough in size to run nearly continuously with small power rather than intermittently with greater power requirements. The vacuum-cleaning system operates to effect the withdrawal of the dirt and dust through the aperture in the hand tool along with a strong current of air drawn into and through the hose of the piping system, and thence through dust-separating and cleansing chambers or tanks, by means of a power operated vacuum-pro- ducing pump. The piping system, as before described, is extended from the various outlet locations to the machinery room, where the separating receptacles and the pump with its motor are located. The piping system can be installed under proper supervision by plumber or Bteamfitting contractors. Hose, fittings, and the dust-separating equipment and air-pumping machinery are sold and installed ordinarily by the manufacturers. As vacuum cleaning is rapidly being adopted in many classes of buildings, the speedy development of the field has brought many types of vacuum machines on the market, these necessarily varying in excellence of design and type. The dust-collecting receptacles are usually metal tanks or boxes, ample in size to properly slow down the air currents, and equipped with baffles, screens, and trays to receive the dirt. For further elimination of dust from the discharged air some have water Bprays in tanks in series with the dry separator, in which case water supplies and drainage to sewer must be connected. When the dry separator only is used the dry-air discharge pipe is ordinarily led away to the outdoor air or to some flue or chimney. In hospital practice it is advisable, where possible, to lead this air in under grates of boilers or into garbage destructors, so that the discharged air may be thoroughly sterilized and rendered harmless and the dirt consumed. Among the types of vacuum-producing pumps there are prominently the reciprocating vacuum pump, the positive rotary pump, and the fan-type pump. Owing to the simplicity of construction and smoothness of operation the two latter types are much more prominently in use. After deciding upon the capacity, the selection of the type of vacuum machinery required should be governed by a comparison of the sturdiness of construction, wearing qualities, smoothness of operation, noiselessness, the economy ot power consumption for a guaranteed vacuum produced, and, further, as to general thor- oughness and completeness of design. The motor should be of a standard high-grade design, preferably mounted with 108 HOSPITAL ARCHITECTURE the vacuum pump on a heavy common metal base plate, and connected to it either directly or by a heavy belt or well-designed noiseless chain drive. Automatic control switches, which either shut down or unload the machinery whenever the sweeping tools are not in use, are desirable, and now usually included with the standard equipments. In small installations, control switches may be advantageously located at each hose connection. The wiring for such motors and switches should be of high grade, installed in iron conduit by competent electricians. Hospital administrators need not expect to cut down their cleaning by other means when they install vacuum cleaners. The same amount of hand cleaning will have to be done. Moreover, it must be admitted that in the present state of the vacuum-cleaning art there is very much work that these cleaners will not do. They will clean rugs and carpets, tapestry curtains, upholstered furniture, if such unscientific stuff be a part of the hospital equipment, and they will take much dirt out of the mattresses on the beds and on the nurses' couches. They are not satis- factory for removing the dirt from bare floors, especially wood floors with cracks in them, nor are they satisfactory as wall cleaners, because the best tools made leave streaks after them that do not come off except by washing; and, if we must wash after them, why not wash without them? Their usefulness in cleaning radia- tors is very limited, since none of the tools made get very far between the coils, and the commercial vacuum will not draw from a sufficient distance to get out very much excepting the surface dust. The furniture cannot be cleaned by the vacuum cleaner, whatever the manufacturers say, because the tools scratch the varnish or finish and soon ruin it. In short, the vacuum cleaner is a most attractive device theoretically, and has more good "talking points" than almost any other hospital convenience, especially that upon which manufacturers have to dwell — namely, that it removes the dirt from the room instead of stirring it up to settle elsewhere. That would be true, if it did all the things claimed for it, but it does not do so. ELEVATORS Modern hospitals, several stories in height, are so largely dependent upon elevator service that the elevators will at once be recognized as a most important item of equipment, which should receive early consideration in the planning of the building. The efficiency of the hospital service can be largely influenced by proper elevator location. The number of elevators to be installed for a hospital of given size is influenced by the relative location of various departments, the class of hospital, the service offered, and by special features, such as lecture rooms, clinic rooms, and the like, if located on upper floors, and the influence of these various features should be carefully estimated. The larger part of the elevator service is passenger service. In large hospitals one freight elevator is usually installed, or, in lieu of this, one of the passenger elevators, properly located, has doors in the car adapted to freight service, to which it may at times be given over. In selecting the type of elevator the aim should be to obtain that which gives the greatest range of speed combined with absolute smoothness of running and certainty of control. In general, the hydraulically operated types of elevator most nearly fulfil these conditions. These are, in general, somewhat more expen- sive in first cost than electrically driven elevators, but, if well designed, less expen- PERMANENT [NSTALLATION 109 rive in upkeep. Moderate speeds are satisfactory in hospital elevator service, ami electric-elevator control lias been developed to a point whore it is now reason- ably satisfactory for this service. The elevator car or cab, if ample in size to readily accommodate a wheeled stretcher and attendant doctors and nurses, is sufficient for the regular passenger service. The laying out of the approaches and the elevator doors should have in view the ready transfer of patients on wheel stretchers or in wheel chairs. One elevator in large hospitals may, if properly located, be advantageously set aside for the use of hospital servants and those connected with the rough labor about the building. This location, in all probability, would make advisable its use also for freight purposes. In smaller hospitals the push-button type of elevator control, if installed, allows of operation by the passengers and does not need the service of a regular attendant. This is equipped with automatic starting and stopping devices, con- trolled entirely by push buttons at the elevator doorways and in the cab. The elevator can lie called to any floor by pushing the button located outside the door- way, and the passenger in the car can direct the elevator to any desired floor by pushing a correspondingly numbered button within the car. The equipment is safeguarded automatically to the extent that cars cannot be started or stopped while doors are open, nor can doors be opened while the car is in motion, nor in any case except at the landing where the car stands. ( (nly those who have been in a hospital as patients appreciate the necessity for eliminating noises of every kind, many of which persons in good health will not notice, but which are extremely annoying to patients, and especially at night. The operation of an elevator is attended by noises, some of which cannot be avoided, as control devices must make and break electric connections by a snappy movement; so that the machine should be thoroughly enclosed wherever located. It is probably least noticeable in a basement room. If, however, it must be overhead it should not stand directly over a ward, but in a tower directly over the shaft, Elevator Doors. — On account of fire hazard elevator doors should be made of metal. Light metal doors are noisy. They should be made of heavy sections of steel, and hung on perfectly turned ball-bearing wheels. Heavy solid tracks for noiseless operation of the elevators are essential, and especial attention to attain this end should be given the door construction. Heavy doors increase the difficulty of operation. There are well-designed door buffers on the market, also automatic-air or power-driven door opening, closing, and locking devices; these, although an added expense, are, in hospital service, most desirable on account of the safety which they insure. They can. in general, he constructed so as to be practically noiseless. The compressed-air devices cost about 8100 per opening; the Norton elevator door check about *'-'■">. The first opens and closes the door automatically; the second closes the door automatically and must he opened manually. Special attention should be given to requiring a good set of tracks and wheels for the rolling doors. These are made to range in cost from a few dollars to about ■■"-I") a set. In the latter the moving parts are carefully machined and rolled on a Continuous row of large perfectly turned steel balls, so that heavy doors may be moved smoothly and easily. The tracks of cheap hangers are made either of stamped sheet steel or thin bar iron which has not been straightened or trued, and, although the faces of the wheels may lie turned on a lathe, they jump along the track, and thereby cause noise which is added to the hollow sound given out by the tracks. 110 HOSPITAL ARCHITECTURE Inasmuch as the elevator should be large enough to carry a wheel chair, and in some cases a bed, the full opening of the door should be 3| feet wide. This cannot always be opened in a single door rolling in one direction, and because of this the doors can be made in two parts, parting in the middle of the opening and each half rolling to either side. The width of the hatchway is sometimes not sufficient to allow the installation of wide elevator doors, unless a two-thirds operating device is used. This moves two parts of equal width to one side simultaneously, and recjuires a space or pocket only one-half the width of the door, with 4 inches added for the operating device. The underside of the door-sill, which usually projects into an elevator shaft, should have a slanting sheet of steel secured to it and to the wall below, so that the accidental projection of a stretcher cart or of a person's foot beyond the edge of the car will not result in a serious accident. If the guard is placed at a sufficiently steep angle the car or foot will be pushed away. If there are two openings in an elevator cab, the one used the least must be pro- tected by a door sliding on the cab or by a folding door. Solid sheet steel doors, known as art metal doors, with polished wire glass panels are preferable to open iron grill doors on account of partially preventing the travel of noise from story to story. The best arrangement to exclude the noise of elevator travel and doors from the wards is to arrange a sound lock or hallway between the principal corridor and the elevator shaft, with doors at the corridor. The lock must be large enough to contain a stretcher car and several persons and to permit of opening the hinged doors in the corridor opening. Elevator Signal Push Buttons. — Signal push buttons at the elevator doors should preferably be designed for two separate buttons, one marked "T_"P" and one marked "DOWX." These, when wired to annunciators equipped to give similar indication, greatly facilitate prompt elevator service. Safety Devices for Elevator. — Door-operating devices are now so constructed that they serve to interlock the elevator car and the doors at each floor in such a manner that the car cannot be started from the floor unless all the doors are locked, and no door can be opened except when the car is stopped and standing opposite it. These devices safeguard the elevator positively from the most common cause of elevator accidents, and no doubt serve to save many lives. A practical mechanical attachment for this purpose has recently been put on the market and installed in some hospitals. This is designed to be attached to most of the types of elevators now in use and at a moderate cost. Devices of this sort are of vital necessity in public buildings of the hospital type, where the class of passengers and operatives make carelessness probable. Dumb-waiters. — Dumb-waiters or small service lifts are considered essential in hospital construction. These are installed to run between main kitchens, diet kitchens, and service rooms upstairs, and may, in small hospitals, be hand-operated, but in large hospitals power-driven dumb-waiters are a necessity. Electric-driven dumb-waiters are now equipped with push-button control, so that they may be automatically called to or from a floor by means of push buttons located at the door openings on all floors. Safety is assured by doors being auto- matically locked while the car is moving and the car being automatically held at a given floor until all doors are shut. Other Elevators. — Hand-operated freight lifts of "sidewalk type" are frequently of use in handling supplies to and from hospital basement storerooms and the like. DIVISIONS OF A GENERAL HOSPITAL 111 Small hand-operated or electric lifts are in some cases useful in connection with laundries when located on upper floors, but, as a rule, the modern demand for mechanically operated things almost multiplies the usefulness of anything that contemplates hand operation. Besides, these small openings are dirt catchers, hard to clean, and have been many times suspected of conveying infections from one floor to another. They had better be left out and things carried up and down otherwise. DIVISIONS OF A GENERAL HOSPITAL ADMINISTRATION APARTMENTS The administration apartments of a hospital should be planned to permit the patient or relative to travel in a direct line from the entrance to the point of destination without returning on his or her path. Adjoining the main entrance there should be an open office in full view of the main entrance for an information bureau or orderly's desk. Behind this bureau of information the general offices, as bookkeeper's, superintendent's, and assistant-superintendent's offices, should be located, so that if a visitor has business with any of these employees, he may be directed to them and observed until he has passed into the respective offices, or, if a visitor enters the hospital and wishes to call on a patient and has to inquire in regard to his location and the permissibility of seeing him, such a visitor can then be directed to a flight of stairs or an elevator within view of the information clerk or orderly, the intention being that every visitor should be under the observation of a hospital employee or attendant while in the building, and that the entrance to the elevator should be under the observation of the information desk, the entrances of the elevators at the various floors close to the floor nurse, and so on. A visitors' parlor should be close to the main entrance, and in a large hospital there should be two or three, one for charity patients and their friends and the other for pay patients. These parlors should connect directly with toilet-rooms. It is also desirable to have a visitors' dining-room, in order to control the serving of meals to relatives and friends of patients. Such a room will be an accommodation to such persons as well as a check for a hospital. The size of the institution will govern the rooms for attendants. Every institution should have at least a bed- room and sitting-room for the superintendent, and, where space permits, he should have a dining-room of his own and unquestionably a complete bath-room. As the size of the institution dictates, there should be a private room with private bath for the superintendent of nurses, the matron, each intern, and the druggist. The interns ought to have their own rooms with private bath, and lounging room and library in common. Inasmuch as any one or more of these may be required at any time of the night they ought to be housed within the build- ing. For tlu- same reason, it is not necessary that the cooks, laundresses, chamber- maids, scrub women, and other help of like nature be housed on the grounds. The advisability of having the nurses housed in a separate building at some distance from the hospital needs no argument. If nurses are housed in the hospital building proper it should be done only temporarily, as, for instance, when isolated with a patient. The ultimate design should be to house them in a separate build- ing. This may be directly or closely connected with the hospital, bu1 it is pref- erable to have the building separate several hundred feet, in order to give the nurses the benefit of changed environment, a short walk through outer air, freedom from noise, and general atmosphere of the sick. Within the hospital there should be ample toilet facilities, separate toilet-rooms for the nurses, close to their sta- 112 HOSPITAL ARCHITECTURE tions; separate toilet-rooms for visitors of both sexes on the ground floor; toilet- room for office help, for the kitchen service, the engineers, and other male help; also close to the laundry for the laundresses. The nurses and other hospital attend- ants should not be obliged to use toilet apparatus used by patients. A floor station for the nurse in charge should be provided on each floor close to the elevator and in sight of it, also centrally and conspicuously located, so that the nurse in charge will be in a position to observe the corridors of the floor and the elevator openings, so she may see visitors and attending physicians when they land on the floor. A recess or alcove on a corridor or a corner can be cut off by a light partition, principally of light metal framework and glass. The space need be only large enough for a table or desk and two or three chairs, with a glass deal Fig. 35. — Floor station for nurse in charge of floor. plate and opening through the glass portion of the partition for the handling of papers and small articles. The space should contain the control annunciator or the regular annunciator if the institution is comparatively small. A photograph of such a partition is shown in Fig. 35. Kitchens, Diet Kitchens, Dining-rooms, Serving-rooms, Etc. The location of the kitchen should be such that the food will be delivered from the cooking apparatus to the patient in the shortest time, through the shortest distance, and with the least handling. It is not always easy to obtain all of these qualifications, and it is usually necessary to sacrifice one or more of them. Where rapidly traveling automatic dumb-waiters are used the vertical dis- DIVISIONS OF A GENERAL HOSPITAL 113 tnnce may he ignored. In large public institutions, where the cost per patient need mil be closely calculated and extra help can he obtained at the hands of con- valescent patients, the horizontal distance is not a governing factor, for effi- ciently heated carts can be obtained. In the new hospital at Berlin, Germany, the buildings are scattered over a large area, and the food is distributed by a narrow -gauge electric railway, on which a small electric locomotive, sufficiently large to carry the motorman, is used to draw metal food cars heated by electricity. It is also to be remembered that the food must be distributed unobtrusively, and food carts must not be rolled along corridors used by visitors. The main kitchen should be connected with the food dumb-waiters or elevators by separate corridors, so that the food carts can be moved to the dumb-waiters or elevators, the food placed on these and discharged from them in the several serving-rooms. The farther away the dumb-waiters are from the kitchen the less likelihood will there be of drafts carrying odors to the upper parts of the house. Inasmuch as the kitchen will probably be placed either in the basement or on the uppermost floor of the hospital building, a separate corridor, such as described above, is not difficult to plan and obtain. Notwithstanding that a kitchen can be ventilated by mechanical means, it is advisable to have a high story, from 15 to 18 feet is not too high, if the kitchen has a greatest dimension of 40 or 50 feet, and if the kitchen is larger it should be proportionately higher. The high story insures not only good ventilation, pro- vided that the windows extend close to the ceiling, but it also insures a flood of daylight and a consequent purity and cleanliness of the food. The kitchen is best if above ground, but, if it is necessary to place the kitchen in a basement, not more than 40 per cent, of its height should be below the level of the surrounding ground, and the walls should be exposed to light and air by the construction of areas of ample width and at least as deep as the level of the base- ment floor. If a kitchen is built as described above and thoroughly ventilated by mechani- cal means, there is no danger of having the cooking odors permeate the building, and there appears to be no necessity for using valuable created space on top of a building for kitchen and kitchen service, and having a kitchen on top of a build- ing will remove it from the vegetable cellars, It is true that fully as efficient rooms can be built above ground to serve as vegetable cellars, but only at a great expense, and by using space more valuable for other purposes and leaving cellar space unused which has no other value. Where kitchens are on the top floor it is necessary to elevate, not only all sup- plies, ice and coal, but also the help, and a separate elevator will be necessary for this purpose, the cost of which is discussed in another section. The cost of lowering food on the dumb-waiters is equal to the cost of raising it, and seems no sound argument for placing a kitchen in space as valuable as an upper floor. The air-passage ways from the kitchens to the remainder of the build- ing can be cut off by numerous doors, especially if these are low, in high studded rooms. The following rooms should be grouped around the kitchen, so that they are easy of access to the kitchen pantry: A vegetable storeroom, a vegetable preparation room, large enough also to accommodate an ice-cream machine and a mechanical vegetable peeler; a large refrigerator, divided into several separate compartments for meat, fish, milk, butter, and eggs, ami for berries, fruit, ami vegetables; a small butcher shop, with meat- block adjacent to the meat-box of the refrigerator; a scullery, with special deep c 114 HOSPITAL ARCHITECTURE sinks for the cleaning of large kitchen utensils; a large corridor or other place to store the food carts; a dish-washing room and dish room, also with special deep sinks and possibly a dish-washing machine, this room to have dealing counters in large openings in the wall surrounding it, so that clean tableware can be placed within convenient reach of the attendants, and also so that the soiled tableware can be placed within easy reach of the washers. The tableware would only be that used for charity patients and the house help, which will be served close to the kitchen, such as the kitchen help, laundresses, and the help performing the coarser labor. The dining-rooms and pantries for nurses, interns, and others will be described later. The general storeroom should be close to the kitchen. The room should be sufficiently large to store large quantities of staple groceries and other house supplies in quantity, such as soaps, pails, brushes, toilet paper, and should have a small private office for the storekeeper, with a railing or counter between the room and the entrance. The stores, as required from time to time by the steward or cook, are obtained from this room on requisitions, as described in the sections on Administration, from day to day as required. In direct connection with the kitchen there should be a small storeroom, in which smaller quantities of kitchen supplies can be kept. In a large institution, where the kitchen and other ordinary help is not housed in the institution, it is necessary to provide dressing-rooms with lockers. The room for the men would contain only lockers, wash-basins, and the toilet-room; the one for the women, however, should be larger, and it is advisable to provide a few laundry tubs, a laundry dryer, and electric, gas, or other facilities for ironing, for, inasmuch as such women usually perform their own laundry work, they can do so between meal hours, and if a space is provided for them they will not use kitchens and other unsuitable places for laundry work. Soup, vegetable, and stock kettles should not be connected directly with a drain for sanitary reasons, and also to avoid the stoppage of the drains, and it is a good plan to set such apparatus in a row and enclose the floor space beneath them by a curbing, sloping the floor slightly toward one or more cesspools with remov- able strainers. If the flooring and curbing is made of Terrazzo or other impervi- ous material which water will not affect, the different apparatus described can be cleaned and flushed, and the water can fall into the curb-wall space through the valved drain pipes and escape to the house drains. This arrangement affords an easy and rapid method of cleansing such apparatus. The water from these curbed spaces should be intercepted by catch basins, because the water enters the public sewers. SERVING-ROOMS The serving-rooms should be centrally located, and in a private institution 50 patients per serving-room is probably a maximum number, for the serving-room must be large enough to accommodate considerable furniture and a number of people. Each bed should have a tray, and the serving-room should have a tray rack on which the trays with tableware, napkin, and silverware can be placed when not in use. Inasmuch as a tray occupies a space approximately 24 inches long, and should have a clear space of about 7 inches in height, and as the lowest trays should not be closer than 18 inches to the floor, and the highest cannot be more than about 5 feet from the floor, there is space for only six trays in a floor space of approximately 18 by 24 feet, so that the area required for a given number of trays can be easily calculated. DIVISIONS OF A GENERAL HOSPITAL 115 A serving-room should have a small refrigerator for milk, cream, eggs, fruit, possibly a few other items, and a space for a ehipped-ice receptacle, so that this will always be convenient for the nurses; a combination gas and steam table; a sink for washing dishes; a cupboard for extra tableware; the dumb-waiter should open directly into the serving-room. A serving-room 11 feet wide by 15 feet long is probably a minimum dimension, and it is not unusual to have a serving-room 16 by 24 feet for 40 or 50 patients. Refrigerators and cupboards should have slant- ing tops for constant observation as to cleanliness. Refrigerators, tables, and cupboards should stand on coved bases, the space beneath filled solid with a meager concrete to avoid all spaces which might harbor vermin. FiR. 36. — Sorvinp-rod Ash is the most suitable wood to use for drain boards and ot her woodwork which is subject to water, for it does not stain. The tops of serving tables and kitchen tallies are best anil most solid if made of strips of maple, about f-inch thick and 2\ inches wide bolted together. Laminated tops of this kind will not split or war]). The tray racks in serving-rooms can be made in several different methods of construction; hardwood is the cheapest, but most difficult to maintain properly varnished and cleansed at the same time. A tray rack can be made of steel pipe, painted with white enamel paint, 10 feet long, and, therefore, large enough to accommodate the necessary number of trays at a cost of about $20. A rack of this kind ran be made by any skilled gas- or steainfitter. 116 HOSPITAL ARCHITECTURE Another method is to use steel channels punched with key-hole shaped holes — such channels as are used in show windows. Metal brackets having studs which will engage in the holes are also obtainable, so that a tray rack of this kind can be set up quickly by a house carpenter, and the brackets can be increased in number from time to time or entirely removed. Figure 36 shows a serving-room archi- tecturally equipped, but without table or tray racks. DINING-ROOMS The various classes of attendants and help should be separated and have their individual dining-rooms, and the location of these should be as pleasant as pos- sible to preserve the self-respect of the hospital help. The nurses should have a large dining-room, to seat all those who can eat at the same time; an ample pantry, similar to the serving-room, as described for patients. The interns and drug- gists' dining-room should be served from a similar serving-room. The elevator men, orderlies, and engineers' assistants should have a separate dining-room, and if the institution has male heads of scientific departments, such as resident patholo- gists, another dining-room should be supplied, perhaps in common with the better class of office assistants, accountants, artists, x-ray operators, and other heads of departments DIET KITCHENS The diet kitchen should be a complete kitchen, with all of the equipment of a general kitchen, with the exception of the larger mechanical-cooking apparatus; should have the gas range or ranges, steam table, refrigerator, large kitchen tables, deal tables in the partitions, telephone and dumb-waiter connections with the respective floors. Inasmuch as the food cooked in the diet kitchen is for "special diet" and perhaps private-room patients, and since the trays for these classes must be made up, if not entirely prepared, in the diet kitchen individually, it will be necessary to have a larger room, constructed to accommodate a great number of individual trays. A kitchen cabinet is necessary for the storing of small quanti- ties of food supplies and condiments, and many of the ready-made cabinets on the market can easily be made to suit the purpose. The diet kitchen should be of sufficient size to accommodate a small class of nurses for instruction. A cupboard for note-books and pencils should be provided, also a blackboard for purposes of instruction and general directions and orders. The best blackboards are made of sand-finished green slate with finished and beveled edges. The slate should be secured to the walls by round-headed blue screws, and should have a moulded wooden shelf for the chalk and eraser. Many institutions do not bake their own bread, and this appears to be an eco- nomic question to be decided by local conditions and the administration of the institution. A bakery should be well ventilated and illuminated by windows. It need not be very large, for the modern ovens occupy a space of about 10 by 10 feet. If the bakery is not on the ground floor a strong floor must be provided, for the brick-set ovens weigh several thousand pounds. The room should have running water and two adjacent rooms, one for the storage of flour and the other for the storing of the finished product; both of these should be fairly cool, and they do not require radiation, and it is best not to have steam pipes pass through them, but, if this is a necessity, these should be efficiently covered. DIVISIONS OF A GENERAL hospital 117 SUN PARLORS Sun parlors can be placed on southerly exposures, but, inasmuch as they cannot be targe in such exposures without covering windows of the most desirable rooms, it is probably best to place sun parlors on the roofs of buildings. In this case an elevator should rise directly to the level of the sun parlor. There should also be B toilet-room on the same floor level. As much as possible of the sun parlor should be made of glass and of light steel framing. Possibly it would be best to have the central portion of the roof of opaque roofing, for the heat in a sun parlor is akin to the heat in a greenhouse, and is, therefore, not pleasant to some patients. These probably feel much better in a reflected light, whereas others will be satis- fied in sit in the direct rays of the sun. Unless the roofs of sun parlors are opaque, the sun glare will always be too great in the summer time for the comfort of most patients. Many sun parlors are practically out of commission in summer on account of the great heat. The windows must be screened, and at the same time they should be made to open as wide as possible. It is also advisable to provide shades so that the light will not be too glaring, and so that during the hot weather of summer the patients can sit practically outdoors and still in the shade. If the exhaust pipes of ventilating systems are close to a sun parlor, the piping should be extended several feet above the roof of the sun parlor, and likewise the ventilating pipes of the drainage system should be extended at least 2 feet above the tops of windows in the sun parlor. If the roof surface will permit a number of doors leading to a platform on the roof, provided this is sheltered by a wall on the north or by walls on two or three sides, such a place can be used to advantage for patients. The edges should lie protected by high railings, and no place should lie left unprotected, so that it will not be possible for a delirious patient to escape from the unclosed space. APARTMENTS FOR PATIENTS Location of Private Rooms. — It is most desirable to have the private rooms in a separate pavilion, but this involves the difficulty of longer distances to the operating department and other departments of the hospital for either the private patients or the ward patients, and is a matter which depends principally on the size of the hospital. If the institution is a very large public hospital, of such size thai the pavilion system is chosen, it would then be quite natural to provide one or more pavilions for private rooms. In a small one-building hospital, or in a large city hospital of only one building, it would probably be most desirable and best to place private rooms on a floor by themselves, and, if the stairs and elevators are enclosed and good discipline maintained, there can be no objection to having large wards and private wards in the same building. Having all of the private rooms close together allows great flexibility in a general hospital, inasmuch as many private rooms can be used for any kind of patient. If the private rooms are placed adjacent to and in direct connection with the various larger units, such as male surgical, male medical, female surgical, female medical, and gynecologic wards, their use would be rigidly limited to patients of that particular department, and fluctuations in the number of cases of one kind or another could not be accommodated if the number exceeded the number of private rooms for the particular kind of sickness without mixing the cases ni an unsatisfactory manner. This can be done in a small hospital, but would be very inconvenient to the staff and the management in a large institution. 118 HOSPITAL ARCHITECTURE A small number of private rooms closely connected with the wards will be useful in a large institution for patients who can pay a nominal fee, or who are so ill as to require practical isolation. Details of Private Rooms. — Private rooms may vary in size in proportion to the proposed price, but the minimum size should not be less than 11 by 15 feet, and the management of many hospitals insist on having every private room suffi- ciently large to accommodate two beds if necessary, and this will require that the dimensions are not less than 12 by 16 feet. It is well to arrange the door and window adjacent to one of the longer walls, so that the head of the bed will not be in a draft. The doors should be 3 feet 4 inches in width to permit the moving of the standard 3-feet hospital bed from one room to another. The general illumi- nation of the room should be obtained by an inverted reflector, such as the x-ray system, and this fixture should be placed in the center of the ceiling, low down and controlled by a switch at the bed. There should also be a bracket outlet over the head of the bed controlled by an extension cord switch which the patient can control. Every private room should have at least a wash-bowl, with running hot and cold water; also, if possible, a water-closet. At a height of 2 feet 6 inches from the floor, and adjacent to the bed, there should be an outlet box for the portable table lamp, and another for portable examina- tion light on a cord, the table lamp and the examination light to be brought by the nurse as the patient or physician requires. The receptacle for a portable telephone should be placed in the wall at the same time and adjacent to the two electric-cur- rent receptacles, and also arranged and finished in a similar manner; the tele- phone to be of the portable type with a cord and plug, to be brought into the room and connected only when permitted by the nurse. The medical profession is beginning to object, however, to portable telephones, on the ground that they may carry infections from a patient suffering from one disease to a patient already sick with something else. There should also be a receptacle similar to those described, and at the same elevation from the floor, for the signal system, with a cord and push in the control of the patient. Care must be exercised in obtaining keys or sockets M'hich cannot be accidentally interchanged with the electric-lighting socket, and for this reason it would probably be best to attach the signal cord permanently to the wall plate. In many places no provision has been made to hang the signal cord when not in use. It, therefore, would be well to obtain a push with a ring secured to same and a small brass hook on the wall or on the lighting bracket over the bed. The question of having a private clothes closet, or not having one, has been much discussed, and some hospital boards believe them sanitary and that no good private room should be without a closet; again, other hospital boards refuse to have them, and maintain that a patient should come to a hospital with only one change of clothing, and that these should be kept in metal lockers in a general locker- room and returned to the patient when required. The closet adds a number of additional corners and surfaces which increase the labor of cleansing, but there should be no danger if maintained in a sanitary condi- tion. Inasmuch as but little clothing need be stored in them, it is best to build a false ceiling immediately above the door, cutting off a number of feet of useless space and space which is difficult to clean and an unnecessary first cost and an unnecessary cost of maintenance. The stud height of all private rooms and also the wards must be well considered. A high stud is naturally desirable for a large room, such as a ward, whereas the same height appears disproportionate and objectionable for a private room. Fif- DIVISION'S OF A GENERAL HOSPITAL 119 teen feet for a ward height is not too great, but it will not do for a room 11 feet wide and 15 feet long, .so that a compromise must be made and a balance struck by the architect, based on sound judgment, to ascertain the height of stud which will be the most suitable and also the least objectionable for all the different kinds of rooms. Inasmuch as the floor area and cubic contents of the room is fixed by law in many localities these two factors must be considered. No less than 80 square feet should be allowed for each bed, so that a room of 10 by 16 feet may be used for two beds, but as the cubic contents per patient should not be less than 1200 cubic feet, such a room would then require a stud of 15 feet, but, as this height of stud for so small a room is undesirable, it would be better to increase the floor area, but, inasmuch as increasing the floor area involves greater expense than increasing the stud height, this matter must be carefully considered. A high studded room may appear more airy than one of a lower stud height, but the difference in temperature in the air of the various heights in the higher room probably interposes greater difficulties in easy ventilation. The appear- ance of a high small room is very unsatisfactory, and especially when viewed from the bed. The electric-light plug outlets, telephone outlet, and signal cord should be on the side of the bed nearest the door, so that the nurse will not be obliged to walk around the end of the bed. The head of the beds should be placed about 1 foot from the wall, so as to place the patient's head in a zone having sufficient circulation of air. The air close to the wall is frequently stagnant. A lounge is often desirable, and is then best placed opposite the foot of the bed, allowing a passageway of 2\ feet, also 2§ feet for the lounge, 65 feet for the bed, and 1 foot at the head of the bed requires a width of Yl\ feet. Fine large rooms in the best obtainable proportion with openings spaced har- moniously, so that the effect will be that of a refined private dwelling or hotel, will bring a large return. The entire furnishing of such rooms should be of richer materials, of good proportion, good design, but the detailing should be a com- promise between hospital details and dwelling-house details. Some of the effect should be obtained by flat decorations; that is, painted work. A room 25 feet square will bring a proportionate return, and these rooms should be arranged so that one or more can be occupied as a suite. Suites of sitting-room, bed-room, bath- room, and clothes closet should be planned; also suites of the same number of rooms with an additional bed-room for parent, wife, or husband of the patient. Such rooms should have every modern convenience. The window-sills of private rooms should not be so high that the view of a patient recumbent on a bed is restricted too much, but the height of the sill must lie compatible with safety. Private Wards. — Rooms for two or more patients, each paying less than the cost of a private room, are termed "private wards." These frequently have two, three, four, five, or six, but seldom a greater number, of beds. In arrangement tiny do not differ from the public wards. The patient can obtain a little more privacy, ami sometimes selected patients may be grouped according to their social status, the diseases from which they suffer, or their behavior. Public or Charity Wards. — The number of beds governing the phrase "a large ward" is indefinite. The Hotel Dieu in Paris contained a ward of several hundred beds, and wards with a large number of beds were no1 Uncommon in the middle of the last century, but the tendency has been to decrease the number, so thai a ward 120 HOSPITAL ARCHITECTURE of 25 beds is considered a large ward to-day, and, in view of the psychologic effect on the patient, it is probably well that not too many beds are placed in one ward. Each ward should have direct access to its toilet-room and bath-room. A wash- stand for the use of the attending physician in the middle of the ward is a desirable adjunct to the room. Its benefit to the patients is obvious, when one considers that the physician may examine from a dozen to twenty-five different kinds of cases. The form of illumination for the general wards, in which the illuminating bodies are concealed and where the intensity of the light can be controlled, is almost a necessity in a ward, in order to save the patients from looking at intense points of light. This result can be obtained by using inverted reflectors and Tungsten lamps, reflecting the light on a light-colored ceiling. Strong illumination can be obtained by this method and also a dimmed illumination for the sleeping hours. Where the inverted reflectors are not in use a rheostat or stage dimmer can be installed, and the voltage produced to so low a point that the filaments in the lamps will only glow and afford the nurse sufficient illumination to pass around the room. For special illumination a plug outlet should be provided at each bed, as described for the private rooms, so that the nurse accompanying the staff physician can carry an examination light with a cord and plug, or, in special cases, a portable lamp can be placed on the bedside table. The signal system, cords, and pushes should also be provided for each bed as for the private rooms. If it is necessary to economize, the light sockets can be spaced so that one will serve two beds. The windows should be spaced in such a manner that the head of each bed will be at a pier, and it is better to have a window each side of each bed than it is to have two beds on one pier. It is also desirable to have the beds placed so that as few as possible of the patients will be obliged to look toward the windows when lying in normal positions. The floors of wards should not be of ordinary matched wood. Linoleum is probably the best material. A fireplace in the ward is a cheerful addition, and further it will assist in the ventilation. The equipment and special features of all these administrative units of the hospital are discussed more in detail under the sections on Equipment. INFECTIOUS DEPARTMENT The building for infectious cases should contain several suites, each a unit in itself, divided into a room for the patient or patients, a private quiet room, a room for the nurse, and a toilet-room and bath for the patient and another for the nurse; small entry and small kitchen or service-room. Each of these units should be completely separated from the other and have an independent entrance from the outer air. The nature of the ground where the building is erected may make it necessary to begin the foundations at some distance below the surface of the ground, so that it will be more economic to use the space created by the foundations below the first floor than it would be to build entirely above the ground. The cases are taken into the separate units by the routes marked "entrances," and attending medical men enter the first one by the same route and leave by the door marked "exit" and pass to the basement, leaving their infected garments in the sterilizing-room, pass through the bath-room, then to the dressing-room, where they will find sterilized clothing, from which room they can enter the lounging- room and remain there and leave the institution with safety to others, but if there DIVISIONS OF A GENERAL HOSPITAL 121 are different kinds of ease.- in the different units the medical men will follow this routine for each kind of disease. When the patient has recovered and is ready to leave the building, the patient and nurse must follow the same route to the basement and enter the separated bath departments, where they will find clean clothing, after which they can also leave the institution with safety. The windows to the entry and to the kitchen of each suite should be arranged so that packages and vessels can easily he passed in and out. Food can be brought to the kitchen from the main hospital kitchen; the dishes and vessels can be sterilized in the kitchen and placed on the outside of the window-sill, which should be specially wide and suitable for the purpose. The wards should have a set of adjustable pipe posts, rods, and canvas curtains, so that the patients can be screened from each other if this is found desirable. A large hospital for contagious diseases may have its corridors arranged with doors opposite each room or at least frequent intervals, which can be closed and sealed, so as to increase the number of beds for one disease and decrease those of another, to accommodate the fluctuating number of cases of the diseases, on the same principle which has frequently been applied in apartment houses to provide elasticity in the number of bedrooms available for apartments. Inasmuch as this portion of a hospital is not used much, and may stand for months and years without being used, it should be built as economically as will be compatible with safety and durability. Thin solid plaster partitions, enameled iron plumbing, anil painted Portland cement floors will suffice. The technic and equipment of an isolation department are discussed under the section on Isolation and Disinfection. CHILDRENS' HOSPITAL For several reasons explained on the following pages a children's hospital should not be directly connected with a hospital for adults. The isolation of the patients in a children's hospital must be more complete, and is a necessity on account of the communicable nature of childrens' diseases from one to another and on account of their peculiar liability to secondary infections. Their resistance to such infections is lowered by wasting disease. Perfect isolation is easily obtainable in a large institution built on the cottage plan, and can also be maintained in a pavilion plan, but it is more difficult to accomplish this in a small hospital in which all of the patients must be housed in one building. This is likewise the case in the usual city hospital built on the block plan. Small hospitals and city hospitals should be designed and equipped SO that t h- ■> can be divided into separate units by closing doors which are normally con- cealed in recesses across corridors and by sealing the joints. Many of the rooms should have French windows opening to exterior porches, so that the isolated portions of the building can be served by way of stair- open to the ail-. The institution must be divided up into as many well-separated units as pos- sible, to provide lor partial isolation of different classes of diseases. Surgical (clean and pus), medical, skin, gastro-intestinal diseases, and the specialties, eye, ear, nose, and throat, etc. There must be ample provision for the isolation of patients in small wards and single rooms. The unit measurements of the architectural features should also differ in a hospital for children from those in a hospital for adults, ami it is a mistake to attempt 122 HOSPITAL ARCHITECTURE to maintain the same unit measurements of floor, window, and air space. Inas- much as the childrens' beds are the smaller, the window spacing should be in pro- portion, the window-sills ought to be lower, and the stories need not be as high, for their breathing capacity does not require as much initial air space. The stairs should have a lower rise and many other details require special treatment. Authorities differ as to the patients' ages. They are usually from birth to about twelve years. There are those who claim that the second year should be the divid- ing line. It is conservative to say that the infants of one year and under should occupy separate rooms, and in large institutions, where it is possible, they should have separate buildings, for they require separate isolation in some of their sick- nesses, and the temperature of the rooms should be much higher for them than for older children; also the diet is different and a separate kitchen is desirable. The medical staff must decide if there shall be separate departments for medi- cal and surgical patients, or if these shall be mingled in the same wards. It is probably better to separate these services if the size of the institution permits. There should be separate wards for infants, others for children of two to five or six years, and still others for those from six to twelve years, and these latter must be divided according to sex. Wards for children should be smaller than those for adults, probably not over 10 beds. Advantages of the small wards are: there can be better separation of service, age, sex, and of cases according to severity and type of disease; also, epi- demics are checked quicker, and are not likely to extend so far when only a small number of patients have been exposed. There is a constant possibility that measles, mumps, whooping-cough, scarlet fever, and other diseases may break out and infect all of the exposed children, which is the strongest argument in favor of small wards, and the important point to consider in arranging a hospital for children different from a hospital for adults. The wards for children up to two or three years of age should be arranged to permit isolation more rigid than is necessary for older children. In the case where the childrens' department is part of a general hospital the age limit may be placed at seven years, but, where it is a separate institution, children up to twelve or fourteen years of age are generally admitted. There must be quiet rooms for nervous cases and for critically sick children, so that their parents can be with them. The question of how many children to have in one room is of great import- ance, and experience has demonstrated that the incidence of an epidemic usually does not bear relation to the size and position of the room. In place of a small room the box system has been inaugurated, by which is meant the division of the ward by means of complete and incomplete glass partitions into small rooms, each room containing one bed. Some of these boxes are of iron and glass extending from floor to ceiling, each box a complete room; in others, the partitions do not close the room toward the center of the ward. Again, in some of them the partitions reach from the floor almost to the ceiling, and in still others they reach neither the ceiling nor the floor. Authorities agree that the only advantage in the closed partition is to make the nurse more careful, and if it were possible to make her so without this reminder, the partitions would not be required, for each bed should have a number and a corresponding locker. Everything used for the infant, including bed, table, tray, cup, dishes, hair-brush, comb, powder-box, even toys, should have the same number. These "boxes" are more appropriately discussed in the sections on Isolation and Disinfection. It is certainly proper to maintain as great an amount of sepa- divisions OF A GENERAL HOSPITAL 123 ration between the sick as possible, but it has been found that nurses are very prone to rely wholly on such "constructive" isolation for safety, and so let down the bars of carefulness and strict cleanliness. In planning a children's hospital, air space and sunlight for the children are the most important points. The rooms should be well ventilated and sunny and yet the latter can be overdone. A children's hospital should have a number of separate entrances — namely, a principal entrance for physicians, and possibly parents and friends of pay patients, directors, and auxiliary societies. This entrance should not be used for receiving prospective patients; and, for administration reasons, it is best to have the entrance section connected to the hospital proper by only one door, connecting with the stair and elevator hall, under the control of the person in charge, for it is more necessary with children than with adults that they be protected and have no contact with any one but the physicians, interns, and nurses, and occasionally with parents and friends, and this should be only on occasions when the physician determines that there is no danger. The entrances should be so arranged that visiting can be absolutely controlled and prevented if necessary. The main entrance should have a waiting space proportionate in size to the hospital itself, one reception-room with women's toilet-room, another for men, and a room with lockers for the attending physicians with an adjoining toilet-room. There should be a separate entrance leading to the kitchen and storerooms for the trades people. The most important entrance, however, is the one for the reception of prospec- tive patients. The vestibule should open into a commodious waiting-room, where the applicants need not be huddled together or in too close contact. A study of Fig. 37 will quickly explain the arrangement described below: A hallway from the waiting-room should lead to at least two examination rooms, one of these arranged so that it may be used as a surgical dressing or exami- nation room, and both of them connected to disrobing booths, so that the attend- ing physicians' time can be economized. Sinks with running water should be in each one. Two rooms will be enough for a hospital of 25 patients. A laboratory should be adjacent to the examination rooms, which need not be more than 6 or 7 feet in width and 12 to 15 feet in length. Inasmuch as an applicant may be Buffering with diphtheria or other contagious disease, and cannot be received in the hospital, one or two small rooms immediately adjacent to the entrance should be maintained, in which such a patient with mother or relative can be comfortably isolated until arrangements can be made to take the patient to a hospital for con- tagious diseases or back to its home. These rooms need not exceed 7 by 9 feet, but should have a window, and each one should connect with a separate small toilet-room, containing a water-closet and wash-stand with running water. Some- times several hours will pass before the patient ran be taken away, so that it is necessary to have such an arrangement ready for instant use. The finish and fittings of such rooms should be very simple, so that they can be easily disinfected alter use. After it is decided to accept a child it should be taken from the examination room directly to the entry bath, from which the child's clothing can be dropped into the disinfecting or sterilizing-room in the basement through a trap-door in the Boor, and not through a long chute with walls which may become infected. The entry bath-room has a linen closet, so that the child can be clothed with hospi- tal clothing and taken from there t<> the observation department, which should be isolated from all other parts of the building. The patient's clothing should be 124 HOSPITAL ARCHITECTURE DIVISIONS OF A GENEUAL HOSPITAL 125 passed directly to a stcrilizing-room, where the clothing can be disinfected, bundled, tagged, and stored. In sonic in>titutions the child's clothing is returned to the \\ ailing parent, so that the labor of tagging and storing and possibly loss is avoided. Alter a child is accepted it should be placed in an observation department, iso- lated from all other rooms in the building. To make the isolation effective each child should have a separate complete small room, where it can remain isolated for a proper period to determine if it may be safely placed among the children in the hospital proper. Each such room should contain running hot and cold water. Figure 08 shows a series of these observation rooms with glass partitions between, so that a nurse may see through the whole suite at once. k m series of observation rooms with glass partitions between. The observation department will require all of the auxiliary rooms necessary t<> make it a complete unit, such as a serving-room, milk kitchen, linen closet, cart closet, a slop-sink room, also a nurses' sleeping-room with bath. General baths are not necessary in this suite, as the children are bathed in bed, and portable commodes are sufficient instead of ordinary toilet-rooms. 'l'ln' observation department should have one or more complete suites or unit-. where a patient and a nurse can both be completely isolated if it should become ry, such suites to include a patients' room, a nurses' room, and a nurses' bath-room with tub. closet, and wash-stand. If necessary, one main room for both patient and nurse will do. but the other factor- are necessities. In connection with the general wards of the hospital, balconies are of the greatest importance, but their value is measured more by the ease of access than by their size and exposure (Figs. 39, 40). They should be conveniently situated, 126 HOSPITAL ARCHITECTURE so that the bed may be wheeled there at any time. Such balconies should be esti- mated of greater value than play rooms and day rooms. Figure 41 shows a con- Fig. 39. — A balcony. Fig. 40. — Reinforced concrete balconies obtained by continuing the floor slabs over and beyond the exterior walls. A very economic form of construction of durable and fireproof porches. venient form of window letting on to these balconies from the ward. The serving- room, toilet- and bath-room, day wards, and porches should be in direct connection with the wards, so that they may be under the observation of the ward nurse, and DIVISIONS OF A GENERAL HOSPITAL 127 Section- E LE.VATION- Fig. 41.— Double hung windows opening on balcony. Panel below sill slides up same as sash. Scale detail of double hunt; window lending to porch with a balanced bottom panel which can be easily raised and leave the passageway from room to porch unobstructed for rolling chairs or beds. 128 HOSPITAL ARCHITECTURE for this the upper part of as many as possible of the partitions should be of glass. The partitions between the day rooms and ward, also between porches and ward, should have only a very light framework of wood or metal and as much glass as possible. The convenience of the nurses is a point of the greatest importance, and the building should be so planned that a certain number of nurses may care well for the largest number of sick, observe the convalescents at play, and where they will be required to take the fewest steps. Metal linen closets and medicine cases (Fig. 42), also running water, should be placed in each ward, bathing and toilet facilities nearby; also a small refrigera- Fig. 42. — Metal closets for linen and medicine cases. tor and hot plate in adjacent alcoves or rooms separated from the ward by clear plate-glass partitions, so that the nurse may remain in the ward or observe the patients as much as possible. If the convalescent children can play on balconies, or in sun parlors or play rooms, good administration will require a watcher in each of these rooms, or arrangements that will enable her to see all at once. A large, bright ward and a good balcony offer all that is necessary for the few children who are apt to be up and out of bed at one time. The meals can be well arranged for in the ward itself. There should be in each department or on each floor a kitchen, laboratory, DIVISIONS OF A GK. MORAL HOSPITAL 129 linen closet, nurses' toilet-room, janitor's closet, storeroom for wheel chairs, slop- sink closets, and a surgical dressing-room adjacent to the surgical wards. Every ward should have running water, so that the attendants may wasti their hands after leaving each patient. A bath-room adjoining a ward with a window between, so that the nurse can bathe one child and observe the ward at the same time, is a good arrangement, probably better than having the tub in a corner of the ward or in an alcove, but this is often done, and is preferred by some. A small room or alcove arranged for stor- ing milk and oilier food for the night and warming it when needed, also directly connected with a ward in the same manner as described for the bath, is required and desirable for nurslings' wards. Details. — Walls in bath, toilet, sink rooms, and floor pantries or kitchens should he tiled aliout o feet high, and if the means permit the walls of wards, day rooms, and balconies should be tiled about 3| feet high. The tiling should extend into the window reveals and the sills should be of some impervious material, not too high, mi as to permit the children to see things out of the window, but. it is probably besl to slope the window-sills so that the children cannot stand or sit on them. Radiators should be enclosed in boxes of wire mesh to protect the children from con- tact with the heated surfaces. No. 18 wire woven into a square mesh of five per 2 inches and galvanized is quite suitable. Radiators standing against the walls should have hoods to deflect the air-currents from the walls; this tends to a better circu- lation and protects the wall from becoming blackened. Double casement windows and double transoms have the advantage of permitting the passage of the greatest amount of air and may serve as doors to balconies, and when double sash are used the glass does not become obscure by vapor. The child should have a view out of doors, and where the beds cannot be placed so that it faces the windows large mirrors are sometimes provided on the opposite walls so that it may have some view. Door-sills are not necessary, but in some European institutions the whole floor of the room toward which the door sw'ings is about ^ inch lower than the floor of the adjoining room, so that the lower edge of the door swings against a ^-inch brass edge. This arrangement is also used where doors open on balconies. The portion where the hand usually strikes should be guarded by glass or celluloid. For every bed there must be a wall cupboard over the bed, with glass door to let down and form shelf. This is to take the place of individual tables, which are costly, unsightly, and in the way. (See Fig. 43.) There must lie a small clinical laboratory on each floor. There must be a linen room on each floor and auxiliary linen closets (preferably metal and glass) in each ward. All medicine cabinets must be self-locking and located in the wards — this and previous features to enable nurses to remain in the wards and not have to go outside to get things; there must be bath arrangements in every baby ward for the same reasons. The dining-room off of each complete unit is useful, but tiiis can be combined With the porches, and il is belter not to create this space for such usage except in the most elaborate construction. Fig. 43. — Wall cabinet. 130 HOSPITAL ARCHITECTURE There should be three operating-rooms, one for clean and one for pus cases, and one for minor work, such as adenoids and tonsils, and this last very simple and easily and quickly cleaned, and need not be very well lighted as most such work is done under artificial light. There should be a serving-room adjacent to each complete unit, fitted with gas, steam table, etc., and so arranged that fluid foods and children's between-meal nourishment can be correctly and expeditiously prepared. Fig. 44. — Babies' bath cabinet. There should be an x-ray and fluoroscopic room, also fitted with electric apparatus for treatment. If the childrens' hospital is an adjunct of a larger institution it should have a room fitted for cooking for special purposes in case of necessity to isolate the whole building. Similarly there should be at least a small hand laundry in the basement, with a few tubs and a dryer. Spaces should be provided for the storage of wheel chairs, bed elevators, and rollers, an incubator room with electrothermo regulator and outside ventilation, a play room or gymnasium for a Zander outfit and for exercising for larger children. DIVISIONS OF A GK.NKRAL HOSPITAL 131 The ordinary form of bath-tub is not suitable for babies. A shallow sink-like tray on a pedestal, which does not require a nurse to stoop, is probably the most suitable; a combination cock with hose and spray nozzle is better than a full tub-bath. Such a device is shown in Fig. 44. It is the design of Dr. Arthur B. Ancker, Superintendent of the St. Paul City and County Hospital. The tank above is connected with the hot- and cold-water supply. The tank is filled and the temperature of the water accu- rately measured before the bathing be- gins. It is a delicate matter to place the thermometer so that the actual temperature of the water in the tank shall be taken; a thermometer fixed in a tube outside the tank will not do, be- cause the water then may be stagnant and register either much lower or much higher than that in the tank. Rather the thermometer should be set directly into the tank at an angle, and located as nearly as possible to the point where the water is withdrawn for the baths. Both hot and cold water should be let in at the same time and allowed to stand for several minutes before being used, so that it will be thoroughly mixed. An ex- cellent recording thermometer for this purpose is made by Schaefer and Buden- berg Manufacturing Co., of New York (Fig. 45). It permits of the reading record being placed at a considerable distance. A refinement of the bathing plates is now under construction. It consists of a white metal water container, 2 inches thick and long and wide enough to cover the porcelain bath plate, one for each side of the cabinet. There is a funnel-tube at the upper and inner corner out of the way, for filling with warm water from the tank. There are two metal yokes with buttons to fasten the two beds together so they will not move while in use. When not in use the beds can be emptied, dried, and hung up. Linen cabinets should be numerous and recessed into the walls or partitions in wards and bath-rooms or very close to them. Railings on stairs and balconies should be of vertical bars with no cross-rods, so that a child cannot find a foot-rest for climbing; probably 5 feet high will be suffi- cient on balconies, but on stairs they should be even higher. A large wall clock with a lar<;e conspicuous second-hand is very valuable, since the pulse can be counted at any part of the room without contaminating a watch by the infected lingers. A milk station is necessary, and should contain a separator, a pasteurizer, Fig. 45. — Recording thermometer. 132 HOSPITAL ARCHITECTURE peptonize: - , refrigerator, a testing table, and an agitator. The power to drive the machinery should be electricity, the room in as cool a location as possible, convenient for the receipt and return of milk cans, and also to the dumb-waiters reaching to the several floors. This milk station is described in greater detai under the sec- tion on Milk in the Hospital. A stationary laundry tub in each sink-room is very useful. An outdoor play ground for mild weather and a sunny general play room, with gymnastic apparatus or a Zander's outfit for larger children, will be of advantage. The infants' floor or department should have an incubator room, or possibly a more preferable arrangement is to have small box-like rooms for the same pur- pose, from 6 to 7 feet square and 7 or 8 feet in height, with constant temperature, thermostats, air inlets, and outlets; air propelled by small electric fans and heated by electric heaters. It is best to make the walls of these rooms of double-plate glass, set and puttied into iron frames, with cork insulation in floors, ceilings, and walls. The infants' department should also have rooms for wet nurses, with sleeping apartment of their own with separate bath-rooms. Provision should also be made for a number of nursery maids. A few of these will be needed to assist the nurses in the wards to oversee the children on the balconies or at play, or to take them out in perambulators. Nursery maids for service in families are sometimes trained in childrens' hospitals, so that the number of rooms set aside for their use must be governed accordingly. They should also have a separate sleeping apartment with their sitting-room and bath-room. The wards should be separated into free wards, semiprivate wards for part- paid patients, and also provisions for private-room cases separated from the remainder of the hospital. There should also be quiet rooms for critically sick chil- dren, so that their parents can be with them. If the nurses, doctors, orderlies, elevator men, common house men, maids, and wet nurses do not sleep in the building some provision must be made to accommo- date a number of them in times of isolation, so that some places must be so ar- ranged that they may be used for bed- and dining-rooms for such persons. Inasmuch as children play directly on the floors, it is highly desirable that these be warm and have some elasticity, so that the requirements for a good floor for a general hospital are intensified in a children's hospital. "Battleship" linoleum seems best to meet all the requirements. The painting is important. It should be of a very good material which will resist scrubbing, as it is important that the walls and woodwork be washed fre- quently. The question of wall decorations is an open one, and many believe that the pic- tures please the decorators and donors rather than the children, and that the latter care very little for them, but if they are provided they should be simple, applied directly on the plaster. Tile pictures have the objection of unpleasantly reflecting light. The monotony of dead-white walls may be broken by an occa- sional strip of color or small stenciled ornament. If possible there should be no projecting edges on the walls; flush surfaces should be used elsewhere. A New Children's Hospital The Sarah Morris Hospital for Children, just now completed under the direc- tion of the Michael Reese Hospital, Chicago, is believed by the author to contain the last word in childrens' hospital construction, and for that reason the author DIVISION'S OF A UKNKUAL HOSPITAL 133 believes the plans of this hospital, with some explanatory notes, giving the reasons for certain phases of construction, would be of interest as a contemporary piece of hospital constructive work, and for that reason they are produced here. Figure 46 outlines the half-basement floor, that has an areaway on two sides of a width of 5 feet, giving full-sized windows for this floor. The space is broken into rather large areas for miscellaneous purposes. We will begin with the entrance, by way of a tunnel from the main Michael Reese Hospital building, and we first come upon a large kitchen, and adjoining a service-room that is connected by the dumb-waiter with the serving-rooms on the floors above. This kitchen may be at any time employed for its legitimate purposes, but it is contemplated now to feed the childrens' hospital from the main Fig. 46. — Sarah Morris Hospital, ground floor. kitchen of the Michael Reese. This kitchen, serving-room, and the storeroom adjoining make up a service unit. The next unit is that devoted In the residence of wet nurses. There are three of these rooms that may be used for two we1 nurses each and two babies, as the occasion requires, and there are bath and toilet between. The next area on our way back to the point of beginning is the milk station, which is divided into three rooms. No. :•> being the pasteurizing room. No. 4 the work room, and a third room, not marked on the plans, but beginning where the word "milk" occurs, and taking up 10 feet of space by the full width of the room and devoted to cleaning purposes, that is, the slop-sinks, utensil sterilizer, and so on. The churn, separator, and peptonize!' are putside of this small room 0] 134 HOSPITAL ARCHITECTURE from a motor that turns a main shaft running the full width of the room. This complete milk station is shown in the section on Milk in the Hospital. The next room, No. 5 of the plan, is the sewing and linen room, in which there are shelves and cupboards for keeping the reserve stock of linens for the establish- ment. It will be noted there are two dumb-waiters connected with this room: one of them leads only to the one floor immediately above, which we will see presently is the observation department of the hospital, and consequently likely to contain communicable diseases. A second dumb-waiter leads to the second, third, and fourth floors, and has no outlet at the first floor. It is thought that in this way the spread of infections from the first floor will be minimized. Fig. 47. — Sarah Morris Hospital, first floor. The next areas of importance form a unit — that is No. 10, a locker room for the childrens' clothing; a soiled-clothes room, No. 11, and a laundry, No. 12. It will be noted that the laundry chute, which we have treated elsewhere, comes down between the laundry and soiled-clothes room, and soiled clothing may be dropped from the floor above, either into the laundry, to be there washed or disin- fected, or into the soiled-clothes room, to be treated in the mattress sterilizer, or disinfector, as it is called in the plans. The plan of this disinfector is such that one end opens into the soiled-clothes room, into which the soiled clothing or infected mattresses or other material are put, and the other end opens into a clean room, or locker room, in which the childrens' lockers are kept. The small trap door, indi- cated in the plans, in the soiled-clothes room leads only from the bath-room of the admission department, one floor above. DIVISIONS OF A GENERAL HOSPITAL 135 This floor contains almost all of the administrative departments of the building. Over on the corner, No. 34, is a gymnasium or play room lor the children, about 30 feet square. It has cement floor, high walls, with skylight ami ventila- tors all above. Admission Department. — The first or main floor of the building contains prac- tically three units — an admission suite, an observation department, and the execu- tive department, including the entrance, offices, and reception rooms. Beginning with the vestibule, which is the entrance of the admission depart- ment, we enter the main waiting-room, in which there are two toilets and basin-, a drinking fountain, and seats for parents and children while waiting. There are three examination rooms, Nos. 112, 114, and 117. It will be noted there are small dressing closets off each of these examination rooms — merely for the purpose of saving the doctor's time; when he finishes examining a child it may be taken into one of these closets and dressed by the mother, during which time he may be exam- ining another child. When it is finally determined that the child is acceptable, it is taken into room No. Ill, marked entry bath, which is fitted with a high bath-tub in the center of the room and cabinets containing hospital clothing; there is also an opening into the laundry chute, and another into a clothes chute, so that the child's bundle of clothing may be dropped into the soiled-clothes room below to be disinfected before being put away. It may be stated just here that the disinfector below stairs contains one large horse with eight bars, and it is intended to use metal clothes pins to fasten all the clothing of one child to each bar, that w r ould make it possible to disinfect the cloth- ing of eight children at one time, and also to disinfect two or three mattresses at the same time if desired. Across the hall from the waiting-room are two isolation rooms, each containing basin, toilet, and bath. If it is determined after examination that the applicant has a communicable disease, and for that reason cannot be accepted as a patient, the child and mother are placed in one of these rooms, and kept there completely isolated from all other parts of the hospital until definite arrangements can be made for its care — in this case until the health department of the city can call for the child in its own ambulance. These rooms contain Terrazzo tile flooring and Keene cement walls and ceiling covered with zinc-enameled paint, in order that they may be disinfected with live steam, if necessary, with a 5 per cent, carbolic spray or with formaldehyd spray. There is a small laboratory room, No. 123, for the purpose of examining smears and doing emergency w r ork connected with the admission department. After the child has been accepted and garbed in hospital clothing it is taken along the passage marked 124 and 125 over to the corridor marked 132. which is the observation department of the institution. Under the section on Childrens' Hospitals a photograph is shown of a vista down through the six observation rooms of this department, with glass partitions between. Each of these rooms is fitted with hot and cold basin. In the figures D. W. are shown the linen chutes or dumb- waiters, one opening into the corridor on this floor, the other going past without stopping. At the extreme end of the corridor, room No. 101, is a surgical dress- ing-room, intended to be used for children hurt at the time of admission, and not only dressings but minor surgery may be done there. It is fitted with enameled metal cabinets along one side of the room, and on the other side are the sterilizers and sink; a dressing table or small operating table occupies the middle of the floor. 136 HOSPITAL ARCHITECTURE Across the hall from this are two rooms, Nos. 130 and 131, marked "Isolation." In the event that a child occupying one of the observation rooms develops some- thing suspicious so as to make it necessary to remove it from the apartment, and yet it is not desired to take the child into an isolation hospital, it is placed with a nurse in one of these isolation rooms — the door off the corridor is immediately closed and may be sealed. The first small room, as we enter from the corridor, is a service-room, containing sink and drain board, with hot and cold water, a gas plate, and small refrigerator; in the other small room are bath, basin, and toilet for the nurse, since a child in such a situation will be bathed and served in bed. The outside openings to these two suites are porches, each enclosed with high wire fence, and the gates are provided with locks. It is through this outside entrance that food and necessaries of all sorts are brought to the compartment by the orderly, and set upon the porch where the nurse may get them. Fig. 48. — Sarah Morris Hospital, second floor. The serving-room for this floor, marked No. 128, connects with a dumb-waiter from below, and contains a refrigerator, steam table, gas plate, and plenty of tray racks. The next room, No. 129, is the slop-sink room for the department, and con- tains a metal cabinet 7 feet high and 7 feet wide as a receptacle for bed-pans and urinals, and in which to lock enema cans, hot-water bottles, ice-caps, rubber tubing of various sorts, and the general supplies of that character. This room also con- tains a slop sink, the utensil sterilizer, and will contain a typhoid stool sterilizer as soon as a proper one can be found or designed. The Second Floor. — This floor has three hospital units and certain administra- tive areas, as shown in the plans. It will be necessary only to call attention to the arrangement of the wards and the auxiliary rooms. One of these large wards at DIVISIONS OF A GKNKRAL HOSPITAL 137 the end of the building is for male children, older than the infant age, and the other for females. There is a quiet room off each one, in which a specially sick child, or one who is nervous, or a child who is dying, may be placed. In the sec- tion on Childrens' Hospitals the sun porch and the things relating to them are shown in photograph form. The furnishing of the ward is extremely simple — a bed, and over the head of each lied a small ward cabinet, a drawing of which is also shown under the section on Childrens' Hospitals. Attention is called again to the laundry chute, w : hich opens on this floor into the corridor, so that the soiled clothes from the whole floor may be placed in it at a pretty nearly central point. Fig. 49. — Sarah Moms Hospital, third floor. It will be noted that there are two dressing-rooms on this floor, rooms Nos. 204 and 205 — one for the treatment of diseases of the ear, nose, and throat, and the other for miscellaneous surgical dressings. Infants' Floor.— The third floor contains three complete units for infants. These ward units are practically the same — a sun porch and two wards, separated by the bath. The bath for this latter is given in detail elsewhere. The room otherwise contains a refrigerator, gas plate, and a cabinet fur such clothing as diapers, and which is furnished with a small steam coil at the bottom, which may be turned on when necessary to keep the children's clothing warm. There are two small rooms on this floor which will deserve an instant's atten- tion, "Box" No. 1 and "Box" No. '_'. These are merely small rooms in which to keep children that ought not to be placed in the ward or with other children. 138 HOSPITAL ARCHITECTURE Another room which deserves attention is the couveuse, or incubator room. This room is 16| feet long by 10 feet wide, with a plate-glass partition cutting off a vestibule 6 by 10, in which the nurse may stay out of the greater heat of the incu- bator room proper. The incubator room itself is a cube 10 feet each way, lined with cork, felt, and asbestos, besides the other normal coverings. There is a double window, with separate double transom, and exhaust fan and an intake fan. It is necessary, in connection with the incubation of premature infants, to have not only the proper temperature, but the proper humidity and the proper ventilation, and these things must be carefully considered before such a room can be considered better than the now almost obsolete baby incubators that are 24 by 18 by 12 inches in size. Fig. 50. — Sarah Morris Hospital, fourth floor. The Private and Operating-room Units. — The fourth floor has two complete units — one made up of a series of private rooms, and the other the operating department. Each of the private rooms has a sun porch, or small balcony, open- ing off the window, which is the outer opening, double-casement style. Each private room has its own toilet and basin, and there is a bath between each pair of rooms, with double doors, so that the bath may be used either in common for the two rooms or by either one exclusively. The operating suite contains a surgeon's dressing-room, No. 416; a nurse's work room, No. 417; an anesthetizing room, No. 420, at the end of the corridor; a ster- ilizer room, and a general utility or janitor's room. There are three operating rooms — two facing to the north — one for clean and DIVISIONS OF A GENERAL HOSPITAL 139 the other for pus cases, and a nose and throat operating-room facing to the south, and not very well lighted, because most of the work done in this room is done under artificial light. It will be noted that this suite is entirely cut off from the rest of the hospital, except by way of the elevator and double doors at the end of the corridor, leading to the common stairway, and these may be locked if occasion requires. The elevator has a special opening for this department. Attention may be called to the stair hall in this, as well as the other floors, be- cause the landings are to be used for sort of reception rooms. The floors in these stair halls are made of art marble, in figures; there is a telephone in each, and they are to be furnished as reception and waiting rooms. Reverting to the operating department for a moment, it will be seen there are two spaces in the corridor for wall cabinets. These are instrument cabinets, and, like all the cabinets, closets, and receptacles throughout the building, they are made of metal set into the partition flush with the wall. General Arrangement. — All the corridors, and all wards and private rooms, have a floor, covering of " battleship " linoleum, j-inch thick, and set flush with the floor edge of the base cove everywhere, and this base cove reaches out on to the floor for a distance of 6 inches from the vertical wall. The administration rooms have a floor covering of hexagonal terrazzo flags, 12 inches in diameter; the corridors and all parts of the operating suite have a floor covering of white vitrified tile G inches in diameter. The wall coverings of the building are as follows: All corridors, stairways, and the rooms in basement, excepting the milk station and service rooms, are of light buff or deep cream color, with ceiling and 9-inch frieze of a still lighter color. The first, or main floor, which is naturally not so light as the upper floors, is painted in a light steel gray, with 2-inch stencil of a darker color, 10 inches from the ceiling; ceiling and 10-inch frieze being a grayish white. The second floor is tinted sea green, with ceiling and frieze of a much lighter tint, and 2-inch stencil between of a darker green. The infants', or third floor, is in baby blue, with ceiling and frieze of a lighter color. The private rooms on the fourth floor are painted in pairs, but the colors being those that prevail on the floors. The operating suite throughout, as well as all bath-rooms, slop-sink rooms, and serving-rooms, are all in zinc-white enamel paint. The general construction of the building is a light-gray brick, with granite and terra-cotta facings, reinforced concrete foundations and floors, mackolite partitions. The window frames are of wood, and all door frames and glass-partition frames are of steel. MATERNITY HOSPITAL The arrangements and details of a maternity hospital and its equipment should not differ from those of a general hospital, excepting that the finish of the wards and private rooms may have slightly more grace in the matter of form and decoration and less severity. A parlor on every floor, open loggias, porches, and sun parlors are very desir- able. The special designations are as follows: Waiting wards and rooms. Examination, preparation, labor, birth, and rest rooms. 140 HOSPITAL ARCHITECTURE Comfortably furnished rooms for the doctor and nurse, also for the husband or mother of the patient. Pleasant nurseries, with one or more infants' baths. Incubator room, such as described in the Childrens' Hospital, also wet-nurses' rooms. It is only before and during labor that the patient needs much nursing. If she has entered the hospital before labor, it is because she is sick with some compli- cation of pregnancy, and she will need attention. During labor every facility for aseptic surgery will be required, but afterward she is a well woman, just passed through a period of suffering, and before that a long siege of anxiety and nervous tension. Therefore, she needs cheerful surroundings, flowers, sunshine, bright colors, and the company of at least a few intimate friends to share her pleasure at the happy advent of the little stranger. ARCHITECTURE OF THE SMALL HOSPITAL The principles of hospital architecture apply equally in the small and the large institution. The radical difference between the two is simply that one con- tains a very few units and the other a great number of units. In the large hos- pital there are questions of transportation of food and hospital supplies that do not apply in the small institution. There are questions of light, and perhaps problems of ventilation and heating, that render the scheme of architecture more complicated. We have taken up these questions of light, ventilation, transporta- tion of supplies, and other economies of administration as they apply in any insti- tution, and it will not be difficult for us to apply them, no matter what the size or the purpose or the location, and about the only thing that we need consider here is the economy of arrangement for small units, and a small number of each, considering the fact that oftentimes we will have to use a single unit for a greater number of purposes. For instance, a small hospital of, say, four units, may have to care for all the specialties in medicine and surgery, and facilities will have to be furnished for treatment of all sorts of cases, whereas in the hospital of great size a single unit can be used for a single purpose, which greatly simplifies the architecture. The hospital unit, as such, has not changed greatly in the past few years, in fact, Florence Nightingale, in her "Hospital Construction," published in 1863, giA^es us some hospital units that were proper for her day. Figure 4 is produced here from Florence Nightingale's book, merely as an indication that we have not progressed very far in hospital arrangement, notwithstanding the fact that the whole science of medicine has undergone vast changes. As against these old-time plans, we are producing also plans for small hospitals that have been recently perfected and executed. It will readily be seen that in these plans for small hospitals the proportion of space for administrative pur- poses must be largely increased, as compared with bed space for patients, and if we consider administrative economies, bed for bed, the small hospital does not compare favorably with the large one, and yet we know quite well that a small hospital can be administered more economically, in point of help per patient, than the large institution. No doubt this is very largely due to the fact that we must have greater hall space; distances are greater, more walking to and fro is to be done. But more important still is the fact that in the large hospitals more work is done per patient, scientific apparatus is employed, arrangements for feeding patients are more elaborate, and what would seem abundantly up to date, and LRCH1 n: TC. p u A. » 1. Wards. 2. Office. 3. Parlor. 4. Interns' room. 5. Linen closet. 6. Elevator. 7. Men's department cor- ridor. S. Duty room or floor pantry. 9. Utility i-loset. 10. Women's department corridor. 11. Vault. 12. Public bath and toilet room. • OAStMfNT v 1. Kitchen. 2. Pantry. 3. Helps' dining room. 4. Nurses' dining room. 5. Laundry. 6. Engineer. 7. Boiler room. s. Coal room. 9. Drug room. id. Morgue. 11. Storage. 12. Sewing. 13. Refrigerators. 14. Ambulance entrance. 15. Basement corridor. lii. Elevator antispaee. 17. Elevator. Fig. 56. 146 HOSPITAL ARCHITECTURE The lowest proposals amounted to 26 cents per cubic foot, or $26,260, divided as follows: General work: viz., walls, floors, roofs, plastering, woodwork, painting, and glass 19.25 cents. Plumbing 3. " Heating 1.30 " Wiring 75 " Other Items ■ 1.70 " • Total 26 cents. Plan No. II (Fig. 56) The width of this building is 33 feet, the length 111 feet, and contains the following beds: First floor : 4 three-bed wards 12 1 two-bed ward 2 Interns 2 Second floor : 8 one-bed wards 8 Third floor : Nurses and help 12 Basement : Fireman 1^ Total number of beds 37 Each of two first-floor wards will accommodate an additional bed, making a total of 39 beds. The cost of this building, if erected according to the same specifications as building No. I, should not exceed $38,500. The addition of the elevator increases the cubic-foot cost above that of plan No. I. If the three floors and all partitions are built of fireproof construction, and slate roof on wood roof construction, the cost should not exceed $45,000, or about 33| cents per cubic foot. Plan No. Ill (Figs. 57-60) This plan differs from plans Nos. I and II by having the operating department on the first floor; the number of beds are as follows: First floor: Superintendent 1 Second floor: 2 eight-bed wards 16 2 private wards 2 Third floor : Either patients, nurses, or help 18 Basement : Janitor 1 Total number of beds 38 1. Helps' rooms. 2. Nurses' or patients' rooms. 3. Nurses' or patients' toilet and bath. 4. Corridor. 5. Elevators. 6. Helps' bath-room. 7. Helps' toilet-room. Fig. .57— Plan III— Third floor plan. AECHITECTOEE OF THE SMALL HOSPITAL 147 Fig. 58. — Plan III — Second floor plan. 1. Private room. 2. Private room. 3. Ward. 4. Corridor. 5. Elevator. 6. Toilet-room. 7. Bath-room. S. Bath-room. 9. Toilet. 10. Nurses' toilet-room. 11. Utility or sink-room. 12. Sewing room. 13. Ward. 14. Airing loggia. 15. Dumb-waiter. 16. Porches. 1. Vestibule. 2. Office. 3. Waiting room. 4. Corridor. 5. Elevator. 6. 6, 6. Private rooms. 7. Toilet and bath. 8. Private bath. 9. Utility or sink room. 10. Stairs to basement. 11. Operating corridor. 12. Operating-room. 13. Sewing room. 14. Sterilizing room. 15. Anesthetizing room. 16. Porches. Fig. 59.— Plan III— First floor plan. 1. Kitchen. 2. Sewing room. 3. Morgue. 4. Corridor. 5. Elevator. 6. Area and basement entrance. 7. Nurses' dining room. 8. Helps' dining room. 9. Storeroom. 10. Man's room. 11. Laundry. 12. Coal vault. 13. Furnace room. 1 1 Storeroom. 15. Ash-bin. Fig. 60.— Plan III— Basement plan. The ground dimensions are 45 by 95 feet, and, if buill according to the speci- fication outlined for Plan No. 1, its cost should not exceed 146,000, and, with floors of fireproof construction, fireproof partitions, wood construction roof, and slate covering, $52,000. 148 HOSPITAL ARCHITECTURE Plan No. IV (Figs. 61-64) The length of this building is 130 by 41 feet wide, and contains the follow- ing beds: First floor: Second floor: Third floor: Janitor and fireman 2 1 ward 7 Wards for 1 bed 3 Superintendent and interns 3 1 ward 7 Wards for 1 bed 8 1 ward 7 Wards for 1 bed 5 Total number of beds 42 Fig. 61. — Basement plan: 2, Corridor; 3, elevator hall; 4, elevator; 17, stair hall; IS, serving- room; 27, kitchen coal; 28, kitchen stores; 29, kitchen; 30, refrigerators; 31, kitchen stores; 32, helps' dining-room; 33, nurses' dining-room; 34, janitor and fireman; 35, janitor and fireman's bath-room; 36, helps' toilet-room; 37, laundry; 38, coal storage; 39, boiler room; 40, ward; 41, diet kitchen. wm n £„ , r ,, Mh ,., r„ ., r Fig. 62. — First floor plan: 1, Vestibule; 2, corridor; 3, elevator hall; 4, elevator; 5, office; 6, telephone booth; 7, vault; 8, broom closet; 9, private wards; 10, private toilet-rooms; 11, private bath-room; 13, interns; 14, superintendent; 15, superintendent's bath; 16, interns' and public bath-room; 17, stair hall; 18, floor pantry; 19, utility and sink room; 20, general bath-room] 21, water-closets; 22, ward; 23, quiet room; 24, reception room; 25, 26, porches; 27, linen cabinet; 2S, medicine cabinet. AKCHITECTUKE OF THE SMALL HOSPITAL 149 Fig. 63. — Second floor plan: 2, Corridor; 3, elevator hall; 4, elevator; 8, broom closet; 9, private wards; 10, private toilet-rooms; 11, private bath-room; 17, stair hall; IS, floor pantry! 19, utility and sink room; 20, general bath-room; 21, water-closet; 22, ward; 25, 26, porches; 27, linen cabinet ; 2S, medicine cabinet. ■ 1 ]T □ 25 1=1 '< I l= I □ J 1=1 L= ^sU 4 Dif | 1 3 P\ tn =3E MM — ,^-m vTN .: Fig. 64. — Third floor plan: 2, Corridor; 3, elevator hall; 4, elevator; S, broom closet; 9, private wards; IS, floor pantry; 19, utility and sink room; 20, general bath-room; 21, water-closet; 22, ward; 25, 26, porches; 27, linen cabinet; 2S, medicine cabinet; 29, operating-room stores; 30, anesthetizing room; 31, sterilizing-room ; 32, operating-room; 33, surgeons' scrub room; 34, general toilet and bath-room; 35, doctors' toilet-room; 36, operating department corridor. This plan is designed as a three-story building with a flat roof, and will cost approximately 855,000 if built according to the specification outlined for Plan No. I, and $63,500 if the floor, roof, and partitions are made of fireproof con- struction. Plan No. V (Figs. 65-69) This plan illustrates a building in the course of construction in 1012, in a city of about 40,000 inhabitants, on a thirty-acre tract of ground, rolling, partly wooded, and which rises gently from the principal approach to the main entrance, and falls away toward the rear about the full height of the basement, so that the kitchen floor and ambulance entrance, both in the rear of the basement, are level with the ground on their side of the building, and the main entrance only two steps above the driveway grade at the front. Eventually, the nurses are to be housed in a separate building, and the super- intendent will be provided with a dwelling-house, both situated on the hospital grounds; temporarily, they will be accommodated within the building, but later some of these accommodations will be altered for the use of patients. The building is designed to have masonry walls with stone and terra-cotta 150 HOSPITAL ARCHITECTURE trimmings, floors, partitions, and roof of fireproof construction, copper sheet metal work and slate roof. The floors throughout will be of marble, vitrified tile, cera- mic mosaic and Portland cement, the latter for "battleship" linoleum above the basement. The woodwork will be of hard wood, finished in natural finish in the service portion and for white enamel in the wards, private rooms, and operating depart- ment. The cost stated below includes all of the general work, such as mason work, steel, fireproofing, finished cement, ornamental iron, cut stone, terra cotta, sheet metal, slating, composition roofing, plastering, carpenter work and cabinets, cases, painting, decorations of walls, glass, marble, terrazzo, tile, ceramic mosaic floors, weather strips, screens, and hardware, as well as two boilers, steam heating, ventilating equipment, quartz water filters, electric passenger elevator, vacuum- cleaning machine, vacuum-steam circulatory system, plumbing, gasfitting, garb- Fig. 65. — General view of building and grounds. age destructor, ash elevator, electric wiring, signalling systems, telephone sys- tem, lighting fixtures, laundry machinery, blanket warmer, mattress disinfector, fire hose, refrigerators, and sterilizing equipment. The main entrance, lobby, waiting-room, and office will have imported marble floors; architectural treatment of walls and enriched ceilings. Toilet, bath, sink, service-rooms on each floor, and the whole of the kitchen department will have shop-made terrazzo tile floors and 9-inch high shop-made polished terrazzo door trim plinths, base boards and coves set flush with the plaster. The whole of the operating department and the dressing-rooms will have 6 by 6 inch white flint tile floors and 9-inch terrazzo bases and door trim plinths. Wards, corridors, and all other bedrooms, similar plinths and baseboards, Portland cement floors, which are to be covered with "battleship" linoleum cemented solidly to the cement. ARCHITECTURE OF THE SMALL HOSPITAL 151 ^ The central portion with the two sun-porch wings, the power and laundry building, were placed under contract for $165,000. They contain 515,000 cubic feet, at an average price of 32 cents per cubic foot, which includes completing the building ready for use, with the exception of portable furniture, linoleum tioor 152 HOSPITAL ARCHITECTURE covering, house furnishings, instruments, driveways, and improvement of the grounds. Temporarily, the sun porches will be used as 10-bed wards, and the contract sum includes bath and toilet rooms, also emergency stairways in brick towers at each end of the two sun porches; these sun porches are also of fireproof construction. AlirillTKCTlKK OF TIIK SMALL HOSPITAL 153 o 6 A g B Rfl.tfAP^iB^flOTPPl O: 154 HOSPITAL ARCHITECTURE ARCHITECTURE OF THE SMALL HOSPITAL 155 The beds in the portion under contract are disposed as follows: First floor: Interns 2 6 one-bed wards 6 2 ten-bed wards 20 Second floor: 2 two-bed wards 4 15 one-bed wards 15 2 ten-bed wards 20 Third floor: 10 two-bed wards 20 Fourth floor: Dormitories 10 Total number of beds 97 The two-story cross-shaped wings which are to be erected in the future will increase the capacity by 108, or a total of 205 beds. The two cross-shaped buildings will require no additional machinery and spe- cial equipment, so that their cubic-foot cost will not exceed 26J cents, which will reduce the average cost of the completed building to 29 cents per cubic foot. THE COST PER CUBIC FOOT OF SOME OF THE PARTS The cost of plumbing per cubic foot of a hospital building, where enameled iron fixtures are used, in a large institution will average 2\ cents; in a small one, 3 cents. In large institutions, 3 cents will be sufficient for porcelain and vitreous china fixtures. These costs are governed by the quantities, so that the cubic-foot cost of plumbing in one hospital built by the writer has been as high as 5 cents. Low pressure vacuum steam-heating system, including steam for laundry, cooking, and sterilizing, also high pressure boilers, have not fluctuated much above or below 2\ cents. The many other items required to build and complete a hospital vary so great ly in quantity, quality, or sendee requirements, especially in the case of mechanical devices, that the cubic-foot cost is seldom the same in two buildings, and very misleading in estimating the cost of a proposed building. The total cubic-foot cost of the described building is as follows: Masonry. Reinforced concrete — structural tile work. Plain cement. Steel and iron work. Ornamental and light iron work. Cut stone. Terra cotta. Fireproofing. Sheet metal work and slating. Composition roofing. Plastering. Carpenter work — interior finish. Cabinets, cases, fixtures, etc. Painting. Interior decorative 1 painting and plain wall treatment. Glass and glazing. Magnesia composition stair covering. Marble work. Vitrified tile floors. 156 HOSPITAL ARCHITECTURE Terrazzo tile floors, plinths, and baseboards. Weather strips. Screens. Hardware. Per Cubic Foot. Cost of all above items S116,000 or 22J cents. Plumbing, drains, and septic tank 16,000 or 3| ' Boilers, heating, and ventilating 11,000 or approx. 2j cents. Electric wiring, signalling systems, and telephones, less than 1 cent. The remaining items make up the total of 32 cents. A duplicate electric generating plant would cost S5500 A six-ton refrigerating and ice-making plant 3500 A refrigerated drinking-water system 1250 The stone columns, carving, and terra-cotta embellishments amount to 1 cent per cubic foot. As stated, the European publications are of little value in the building of American hospitals. Some of the best material on hospital planning has been published in the architectural periodicals, such as: Mr. Bertrand E. Taylor's article in the "Brick Builder," 1903 and 1904. The "Hospital Unit," by Geo. H. M. Rowe, M. D., "Brick Builder," August, 1904. Illustrations in the "American Architect": "Brick Builder." "Architectural Review." "Architecture." "International Hospital Record." "The Planning of Hospitals," Ernest Flagg, "Brick Builder," May and June, 1903. "The Orientation of Hospital Buildings," William Atkinson, "Brick Builder," July, 1903. The "Brick Builder," Xo. 9, vol. xix.. Notes on "Planning Hospitals," Dr. S. S. Goldwater. Also on the use of an "Elastic Ward in the Construction of Hospitals for Contagious Diseases." "Planning of Children's Hospitals," Dr. Charles Butler, No. 8, vol. ix, "Brick Builder." A complete list of these for the past twelve years can be found in the "Quarterly Bulletin of the American Institute of Architects," compiled by Glenn Brown, Secretary, the "Octagon," Washington, D. C, containing an index of literature from the publication of architectural societies and periodicals on architecture in which hospitals have a classification. The following are valuable contributions to the literature of hospitals: "A Preliminary Report Concerning the Construction of Hospitals for Children," Chas. P. Emerson, M. D., Baltimore, Md. "Three Special Clinical Hospitals of the University of Breslau, German}'," Edmund Wheel- wright. "Small Hospitals and Suggestions for Hospital Architecture," A. Worcester and Wm. Atkin- son, John Wilev & Sons, 1S94. "Healthy Hospitals," Sir Douglass Galton, Oxford, "The Clarendon Press," 1S93. "Rudolph Yirchow Krankenhaus," vol. vi., Neubauten der Stadt, Berlin, Ernest Wasmuth, Berlin, 1907. "Handbuch der Architektur," Stuttgart, 1903. "Zeitschrift fur Krankenanstalten" (periodical), Leipzig, F. Leineweber. PART II EQUIPMENT OF THE HOSPITAL As the equipment of the hospital includes everything that goes inside the insti- tution after the architect has turned it over to the administration, it will be neces- sary to adopt a system by which we can discuss items of equipment under general headings. FIXED FURNISHINGS Let us begin with the discussion of those things which, while hardly a part of the architecture of the building, are yet permanent fixtures in it. Under the section headings of Architecture we have already discussed the plumbing, refrigeration apparatus, steamfitting, electric lighting, and fixtures. We have not discussed, for instance, the vacuum-cleaning apparatus, dishwashing machinery, sterilizers for ordinary purposes, laundry chutes, linen-counting rooms, blanket warmers, towel driers, mattress sterilizers, and the apparatus for disinfecting and cleaning patients' clothing. We will discuss these under their several headings as briefly and concisely as possible. Vacuum Cleaners. — At the outset of a discussion of vacuum cleaning, as applied to institution work, it will be profitable to summarize the many forms of cleaning that must be done. Dust must be removed daily from the floors of the institution ; this includes scraps of paper, stray threads, and odds and ends of all sorts that will accumulate during the day, both wet and dry. Rugs and carpets must be gone over lightly daily, and at intervals they must be thoroughly cleaned. The furniture of the room must be dusted; this includes tables, chairs, dressers, and whatever upholstered furniture there may be. The window-sills and the cracks about the windows must be cleaned of their dust daily. Walls and ceilings must be cleaned at least periodically. Mattresses and couches must be cleaned occasionally, and the interstices of the radiators must be cleaned. What part of this work will the vacuum cleaner accomplish in the present state of that art? Let us first see what the vacuum cleaner is, and how it works; briefly, it is an air-tight chamber, at one side of which an electrically operated fan is mounted. When the fan revolves the air in the chamber is withdrawn, leaving the sem- blance of a vacuum. The pipes. or hose culminating in the halls and on the floors lead to the chamber, and the creation of a vacuum in the chamber causes a suction at the pipe terminals. A specially devised "tool" of one shape or another is attached at the pipe terminal, and, by reason of its shape or construction, picks up the dirt or debris over which it passes, and carries it to the vacuum chamber downstairs. The integrity of the "tool" depends on a more or less tightly closed mouth or lips about the article to be drawn in. Just before reaching the vacuum chamber the dirt must pass over a screen of gauze or loosely woven cloth, and it is caught and held in the screen, to be carted away later on. 157 158 EQUIPMENT OF THE HOSPITAL There are all sorts of refinements of this grossly described mechanism in the many vacuum cleaners on the market, and the various makers claim virtues for their machines in many directions. It must be seen at a glance that any differences between them must be due, first, to strength of suction in the air chamber; or, second, to differences in the shape of the "tools" employed, that will permit a wider range of usefulness in pulling power. The vacuum cleaner will remove only the dirt that is perfectly dry and freely movable; it will not remove mud or wet dirt; this means that the dust on the floor can be drawn into the vacuum if the proper tool is employed. The carpets can be well cleaned by the vacuum, including the dirt on the floor underneath them. Mattresses and the couches can be very nicely cleaned if the proper tool is employed. The furniture cannot be cleaned at all by any vacuum system in existence to-day, and is quite certain to be scratched by the metal tools. Some of the dust in the window seats and about the crevices in the walls can be removed by the vacuum. A very small part of the dust adherent to the walls and ceilings about the pictures and about the picture moldings can be removed, but the greatest possible care must be taken, since the vacuum tool will serve only to rub in whatever soot may be present, and the wall will be streaked and look all the worse for its use. In some of the systems of vacuum cleaning there is a double pipe employed, by which air cannot only be drawn out of the room, but forced into the room ; especially in the smaller portable machines there is an arrangement for employing both vacuum and air-pressure, one to blow the dust from the radiator interstices, and the other to suck it into the vacuum as it flies through the air. Almost all the loose dirt in the room can be removed by a minimum of labor on the part of a very few people in the institution working a vacuum apparatus, but the loose dirt is only a small part of the cleaning to be done, and it is necessary to go over everything that the vacuum cleaner has already gone over if we are to have a clean room. Of course, there will be less dirt to remove by hand, and, in proportion to the frequency with which we go over the room with the vacuum cleaner, will we have less dirt to contend with everywhere; for instance, it will do very little good to dust a room with a feather duster if we merely drive the dust from one place to another, but it would do a good deal of good if we drove the dust with a feather duster from the furniture and fix- tures and walls onto the rugs and floors, and then cleaned it from those places with a vacuum tool. If one inquires of the great mercantile houses whether or not the vacuum cleaner is a satisfactory device in their own business houses, one will get as many answers as there are kinds of business. For instance, the furniture house will say that the vacuum cleaner is of practically no use because it will not dust furniture, but the department store manager finds that it fills a real place in the house. He will tell you that piles of goods on shelves can be pretty well cleaned by the suction of the vacuum cleaner, and that this can be done without raising more dust to settle on the goods elsewhere. He will tell you, moreover, that vacuum cleaning can be done in the daytime, even when customers are in the house, without any noise or dust, and, if the store is a very large one, there will be a great lighting bill saved, because, when the janitors get to work in department stores at night, the place must be well lighted for several hours, and the lighting of a big store costs a good deal of money. In one department store the manager had made the statement that the vacuum cleaner saves them about $1000 per month in the preservation of goods, in the saving of lighting bills, and in cutting down the number of janitors employed. A great deal of saving can be accomplished also in the large hotels, especially where they have carpets all over the floors, not only in the rooms, but in the corri- FIXED FURNISHINGS 159 dors, banquet halls, reception rooms, and parlors. In one such house there are 75,000 yards of carpet to be cleaned, and if the vacuum cleaner did nothing else it would be invaluable here for carpet cleaning. The same would not be true in a hospital, or in any institution in which the sick or ailing are cared for. There are no carpets on the floors; if there are rugs at all they are small, and easily taken out to some central point to be cleaned. There are no tapestried curtains, few if any pictures on the walls, and little or no upholstered furniture, so that the vacuum cleaning would be confined to the floors and walls and rugs. The rugs could be taken outside somewhere, perhaps to the roof, and that much of the dirt would be thus removed from the room. So that, after all of the pros and cons are considered, we may sum up the situ- ation by saving that an institution may be kept very much cleaner by the use of the vacuum system, but practically the same amount of cleaning will have to be done by hand in any event, and the janitor service of the institution will cost prac- tically the same as it did before the vacuum was installed, but the house will be kept a good deal cleaner, though at an additional cost — cost of installation of the machine, cost of the power to run it, and cost of extra help to operate it. These arguments, pretty generally known, have been sufficient to deter the aver- age hospital or institution administrator from installing a vacuum-cleaning system in the past, because the expense of such installation has been great, costing any- where from SI 000 to S3000 or $4000, according to the size and architecture of the building to be installed. Recently there has been placed on the market a portable vacuum cleaner, the best of the kind perhaps being made by the Duntley Manufacturing Co., a Chicago corporation, and this machine has proved quite satisfactory in homes and apart- ment houses, and small hotels and some hospitals and similar institutions have either installed them or considered doing so. The principal defect, and one that must settle the matter for the hospital administrator at least, is the prohibitive amount of noise made by the portable motor in operating. In the home or in the hotel this noise is made in the daytime, when occupants are away, and consequently cuts very little figure. In the hospital or institution the noise is intolerable, and cannot be thought of. Very recently this same company is installing a modification of the portable vacuum cleaner that is simply the portable machine on a very much larger scale, located at some point in the basement, from which noises cannot travel readily, and connected to the floors upstairs by pipe lines capable of being installed at a very moderate expense and run up elevator shafts. This machine costs only $300 or $400, and is large enough to permit two outlets to be w r orked at a time; a line of pipe can be sent up as high as six stories, at a cost of something less than $50, and it can be tapped on each floor. Such an installation is comparatively econom- ic, and even if it did no more than clean the rugs and pull the dirt from the mat- tresses, it would pay to employ one or two men at this work; at least one such in- stallation is working satisfactorily. Blanket Warmers. — Of all the semifixed furnishings of an institution there will hardly be an item that will give more satisfaction than the ordinary laundry drier, built in the wall, for the purpose of warming blankets, or for the occasional drying of wet linens, towels, or dressings. This apparatus is nothing more nor less than a chamber in the wall, about 14 inches wide, S feet high, and about 8 feet deep. There is an ordinary steam-coil at the back that must not be attached to the heat- ing apparatus of the house, because blankets should be kept hot winter and sum- mer, and it will, therefore, be necessary to have the coil attached to the power- 160 EQUIPMENT OF THE HOSPITAL house itself, or to the steam-service pressure line that serves the steam tables and sterilizers, or if there is a system of these blanket warmers, the piping will be an Fig. 70. — Blanket warmer. easy matter. The warmers should be in the operating suite and off the wards and dressing rooms. They may be built of tile, plastered and white enameled inside (Fig. 70). STERILIZERS FOR INSTITUTION USE In discussions of the administrative operations of the general hospital it will be necessary to take up the questions of prevention, disinfection, and isolation as administrative problems, and the methods by which to achieve the best results. At this time we are discussing merely the equipment of the institution, and will, therefore, entertain only the question of the destruction of the pathogenic micro- organisms and the mechanism devised for that purpose. Every institution, whether it be a general hospital or an asylum, school, acad- demy or hotel, or a ship that sails the seas, must be equipped for the destruction of one or several forms of pathogenic micro-organisms, parasites, or vermin. To- day, in the light of what we know about these forms of microscopic life, we have settled down to one of three destroying agents — heat, gases, or chemic solutions. STERILIZERS FOR INSTITUTION' USE 1G1 Chemic solutions and the gases have special applications, and need not now be thought of. To use either of them in a general way no special apparatus is required. The other form of disinfection — namely, heat — requires special equipment, made to accommodate the material to be sterilized. It is not the purpose in this con- nection to discuss the physics of heat or the physical changes that occur when heat destroys micro-organisms. These discussions have a place in works on physics and in books on engineering. Suffice it for us to recognize certain physical facts that are the result of long experience in the engineering profession; nor are we here to design sterilizers, but to place ourselves in possession of sufficient information concerning their principles and mechanism to enable us to buy the proper sterilizer for the purpose intended. There are, grossly speaking, four forms of heat sterilization: one contemplates the use of dry heat only; a second employs hot water; a third, moist heat in motion, that is, streaming steam ; and a fourth contemplates the employment of steam under pressure in connection with a mechanism to create a vacuum at certain points of the process, with a view to enable the steam to penetrate to all parts of the con- taining device, and thus destroy all micro-organic life resident there. There are two fundamental objections to the employment of mere dry heat, no matter at what temperature it may be supplied: the principal objection is that dry heat penetrates such material as woolen and cotton goods and packed hair, such as mattresses, very slowly, and, if it is carried at a temperature sufficient to destroy life when it arrives at the spot, it is also of sufficiently high temperature to destroy most fabrics, especially woolens. Therefore we have practically given over any attempt to sterilize by the use of dry heat alone, and use it instead merely as a drying process, in what we shall hereafter describe as the vacuum system of sterilization. Boiling water has physical disadvantages that limit its use to very special purposes, such as the sterilization of the rougher utensils of the sick room, as bed-pans and urinals. There are two forms in which steam is employed in sterilization, whether it be as streaming steam or in the vacuum devices, namely, saturated steam and super- heated steam. Contrary to the usual understanding, saturated steam need not necessarily be just at the temperature of boiling water, that is, the temperature at which water is changed into steam. It may be of any temperature, but by the term "saturated steam" we mean the initial temperature, and consequently the initial pressure at which steam leaves the water container as it is volatilized. Super- heated steam is steam that has left its water reservoir as saturated steam, but whose pressure has secondarily been tremendously increased by further applica- tion of heat. There is no doubt that saturated steam at a given temperature, and hence a given pressure, has a greater power of penetration than superheated steam at the same pressure. In the case of saturated steam, however, there is a greater tendency toward condensation than in superheated steam, and consequently the last process of sterilization in the use of steam — that is, of drying — is rendered more difficult and requires more time; hence the total time employed to sterilize goods and make them again ready for use will be greater if saturated steam is employed than it" the steam is superheated. But the fact that superheated steam has a less pene- trating power, because of its drier physical condition, is almost or completely offset by the fact that its higher potential temperature is capable of greater and quicker destruction when once it does penetrate, and by the further fact that fabrics can be dried in the container more readily because they are not so wet at any stage of the process. 162 EQUIPMENT OF THE HOSPITAL Some makers of sterilizing apparatus are fond of making diagrams showing the container with a great volume of steam under pressure, occupying all the space excepting an infinitesimal point at the center of the apparatus, and a good deal is made of the fact that this central point, however small it may be, is capable of pro- tecting a sufficient number of micro-organisms to start an entirely new infection of the material in the container almost immediately the heat is removed. Those manufacturers whose apparatus calls for a constant moving volume of steam from one end of the cylinder to another insist that there can be no point, however infini- tesimal, that will escape the penetrating of the moving steam, providing there is an opening at some dependent portion of the container to allow all the latent air to escape, and hence to allow all the space in the container to be occupied by the steam. Those of us who have followed the logic of the makers of the various forms of sterilizing device have merely arrived at a stage of indetermination, and have achieved possibly less knowledge from our reading than if we had merely used our common sense. But those of us who have prosecuted our investigations to the point of actual experiments, using the ordinary materials that we have to sterilize artificially infected with some special form of pathogenic micro-organism, have come to almost a unanimous conclusion that, given a container that will allow of the invasion of a volume of steam, saturated or superheated, if it be under a pres- sure of, say, 15 to 18 pounds — that is, at a temperature of 250° to 275° F. — and if this steam can be circulated in the container for a sufficient length of time, we can achieve actual practical sterilization in almost any apparatus now offered on the market for sale. A clear warning must be sounded, in effect, that no apparatus, under any con- ditions whatsoever, should be accepted on the assumption that it will do what is claimed for it until actual experiments have been made, and those of us who are very particular about our sterilization, especially in the sterilization of opera- ting-room material, are in the habit of periodically and frequently making plants of pathogenic micro-organic cultures, and placing them at the core of a package of material which we know to be difficult of sterilization, and, if those hardy micro- organisms can be wholly destroyed under specially difficult conditions, then we accept that sterilizer and the work we are doing with it as a sufficient steriliza- tion. It is not likely that we shall have anthrax and tetanus or their spores to deal with ordinarily, but no sterilization can be considered efficient unless it is a spore destroyer, for it is those hardy micro-organisms that will occasionally upset all our fine calculations. It is not sufficient that we make these plants and esti- mate the effect of our sterilization once, at the time of purchase of the apparatus, because a hinge on the sterilizer may loosen, or the seat may dry out, or a leak may occur almost anywhere, in which case the sterilization will not be complete, and our first warning of the fact may be some grave postoperative infection. THE VARIOUS STERILIZERS Beginning with the largest sterilizer that we will be called upon to use, we have that huge piece of mechanism usually confined to the basement of the insti- tution, and which we call the mattress sterilizer or disinfector, used not only for the sterilization of mattresses, but for patients' clothing, blankets, rugs, and the like. Then we have the utensil sterilizer, used to sterilize ward utensils, bed-pans, basins, and urinals. There is also the linen sterilizer, a mechanism devised espe- cially for the disinfection or sterilization of the bed-clothing and bedding of infected STERILIZERS FOR INSTITUTION USE L63 patients before they can be sent to the laundry. There is likewise the excreta sterilizer, a mechanism devised to destroy infected stools, urines, and sputa of patients suffering from typhoid fever, tuberculosis, and the exanthemata. Then we have the dressing, instrument, and water sterilizers in the operating depart- ment of the hospital. In the diet kitchen we have the autoclave for the steaming and disintegration of foods that go to make up certain special diets, and a similar device lias a place in the laboratory of pathology for the purpose of destroying micro-organisms for vaccines and for similar purposes. All these devices arc in- tended to achieve a single result, that is, the destruction of pathogenic micro- organisms, and they arc made in different forms to accommodate the materials intended to be sterilized in them. Let us first take the mattress sterilizer. Mattress Sterilizer. — This mechanism has reached a stage of great usefulness in institution administration. Its primary requirements are that it shall be large enough to contain several mattresses at a time, and yet it must be small enough to be economic in the point of steam usage. It must be strong enough to withstand the necessary steam pressure to bring the temperature up high enough to destroy even the hardiest of the pathogenic micro-organisms. It must be so arranged that infected mattresses, bedding, and patients' clothing can be put into it and sterilized, and then removed without danger of reinfection. This means that the mattress sterilizer must have an entrance door at one end and an exit door at the other, and the entrance door must open into one compartment wholly separated from the compartment into which the exit door opens; the mechanism, more- over, must be simple, so that the ordinary houseman can manipulate its valves without danger of injury either to himself or others or to the apparatus. Some of these large sterilizers are made with a door smaller than the inside diameter of the vault itself, but it is extremely difficult to get a thick, heavy mat- tress into it, although, after it is inside, there is plenty of room and to spare; this means that entirely too many cubic feet of steam, under the necessary pressure, will have to be employed to sterilize the material that the doors allow to enter. This is especially true with the cylindric devices; but, even if the door is made the same size as the cylinder itself, the shape of the vault in the cylindric types is not adapted to hold as many mattresses as the cubic area will take care of, and there will be a good deal of unoccupied space. Most institutions have a uniform size of bed throughout, and there will be a uniform size of mattresses. When this is the case it will be easy to select the mattress sterilizer of the right dimensions. For instance, the average hospital will hardly have any mattresses that will be more than 42 inches wide, 8 inches thick, and 78 inches long, so that a sterilizer with inside measurements of 84 inches long, 48 inches high, and 48 inches wide (which is a standard size) will accommodate four mattresses comfortably standing on edge. In the best institutions now all the clothing of free patients and of those not very clean is sterilized before being bundled for the lockers. If the bundles are put in the sterilizer they are very certain to come out damp, no matter how much care is taken in the drying part of the process, and, when they are called for, on the discharge of the patient, they will be found ruined. If, on the other hand, they are sterilized separately, and thoroughly dried before being bundled, they will keep nicely for an indefinite time. The cylindric sterilizer lias no conveniences for hanging clothes inside. The 48 by 48 by 84 inches rectangular sterilizer, on the other hand, has a rack made partly for a "clothes-horse" ; if the pieces of clothing are fastened with metal clothes-pins, each bar of the rack will hang all the clothing of one patient, and, as there are eight of these liars, two in each division, the 164 EQUIPMENT OF THE HOSPITAL clothing of eight patients can be sterilized at one time. The rectangular apparatus has usually a formaldehyd-ammonia disinfecting device for clothing that cannot be subjected to wet heat, such as felt hats and shoes, and these articles can be sterilized altogether and without heat. There are two types of the rectangular mattress sterilizer — one made by the American Sterilizer Co., of Erie, Pa., and the other by the Kensington Engine Co., of New Jersey. There is no doubt about the integrity of the American apparatus as to matei'ial and workmanship, and it has given satisfaction wherever used. The Kensington disinfector has perhaps a more convenient and more quickly fastened door mechanism, in the form of a series of toggle bolts, that spin around by a motion of one finger until they are set home. In the American, the door is fastened by a wheel movement similar to that in the dressing sterilizer; it takes longer to fasten Fig. 71. — "American" rectangular 36-inch wide, 54-inch high, 84-inch long, internal dimen- sions, steam-pressure disinfector, complete with its regular equipment, including the American vacuum type formaldehyd-ammonia generators with independent steam generator, by which arti- cles of leather, rubber, and other materials that would be injured by steam, can be disinfected by formaldehyd gas let into chamber under a high degree of vacuum without any heat whatsoever in the jacket of disinfector. the door in the American apparatus. To more than offset the inconvenience, the door carriage of the American is a more substantial and smoother working device. The door seat is a matter of a good deal of moment. Aside from the packing, the seat is tongue and groove in form, that is, there is a deep groove all around the sterilizer mouth, and opposite this grove in the door is a tongue that sets deep into it. At the bottom of this groove is the packing, which is a secret process material composed of asphaltum and asbestos. Figure 71 is a photograph of the American Sterilizer Co.'s rectangular mattress and clothing sterilizer. This apparatus may be used without fear of disaster to any who may employ it; it is particularly recommended by Dr. James Duncan Gatewood, instructor in naval hygiene of the United States Naval School at Wash- ington and medical inspector in the United States Navy. Dr. Gatewood went into STERILIZERS FOR INSTITUTION USE 1G5 this question of disinfection and sterilization most completely in connection with installation of sterilizers for battleships. Utensil Sterilizers. — Every well-equipped institution should contain a num- ber of utensil sterilizers located wherever utensils are cleaned. There is nothing very particular that need be said about the utensil sterilizer excepting the foot Fig. 72, — "White Line" utensil sterilizer. mechanism, which, in most types, is usually nut of order. The oil-tank escapement mechanism in some of the types is especially untrustworthy, and, after all, the free floor lift with a notched locking device is best. In some of the newer patterns there is a gaskcted seat, winch, when operated with a locking lid, makes a steam- tight container, capable of holding a1 leasl 5 or (i pounds of steam, enough to materially shorten the time of sterilization. Perhaps the hydraulic lift will be 166 EQUIPMENT OF THE HOSPITAL best after it has been perfected, but it increases the cost out of proportion to its value. Figure 72 shows the "White Line" utensil sterilizer, made by the Scanlan Morris Co., of Madison, Wisconsin. This sterilizer is made of heavy copper, the outside of the body and the lid nickel-plated; it is coated inside with block tin, and has the simple foot-lift for raising the cover, and at the same time raising up the metal Fig. 73. — "American" (patented) hydraulicly operated utensil sterilizer, also method of operating; tray, cover, and contents being elevated by city water pressure _ acting under hydraulic plungers. Tray, cover, and contents are lowered by pressing the opposite pedal, thus opening water escape valve. tray containing the utensils. There is a heavy counter-weight attached to the cover hinge that holds the cover up after it is raised by the foot-lift. There are other sterilizers of almost the same pattern, but with a different lifting device and differ- ent control, that seem not to be so convenient of operation, as, for instance, that particular mechanism in which the cover and tray are raised by the turn of a valve. This necessitates using the hand, not always a desirable thing to do. STKHILIZKKS I'OK I XSTITITII )\ USE 167 Figure 73 shows the American Sterilizer Co.'s utensil sterilizer. This is also a most excellent mechanism. The cover and tray are raised and lowered by foot pedal, and there is an added simplicity in this device by reason of the few valves to be employed, but the Scanlan Morris mechanism has the greater advantage of the tight water-seal connection between the cover and the container. Typhoid Stool and Urine Sterilizer. — Figure 74 shows a diagram of a stool sterilizer made by the American Sterilizer Co., the best device of the kind at this time, when all the types are unsatisfactory. It is almost automatic in its operation, the pan being merely set into the machine, caught by a moving arm, upset and emptied, then washed, then sterilized automatically, the process including the total Fig. 74. — "American" stool sterilizer. destruction of the micro-organisms in the contents of the pans by the steam that is released into the chamber. This device has not yet reached a very high state of perfection, but heretofore we have had to treat the contents of pans and urinals to a disinfecting solution of carbolic acid or bichlorid for several hours, ami, in addition, sterilize the vehicles themselves in the ordinary utensil sterilizer, so that the composite sterilizer is an actual advance. There are other forms of typhoid stool sterilizers that arc quite as unsatisfac- tory as the one described above. One of these is in use in the Massachusetts General Hospital, another was designed for the Lakeside Hospital, Cleveland. The Hospital Supply Company, of New York, makes one, ami one is now under construction by the Scanlan Morris Co., of Madison, Wisconsin. 168 EQUIPMENT OF THE HOSPITAL All, excepting the last named, consist of a cast-iron chamber equipped for a jet of low-pressure steam and hot water. Dr. Washburn, of the Massachusetts General Hospital, has redesigned his hopper, by giving it a double jacket down to the shut-off valve. The process con- sists in letting in steam and hot water up to a certain point. Dr. Hurd, of Johns Hopkins Hospital, in attempting to use this hopper found it impossible to keep it from overflowing and making a mess on the floors. He finally dispensed with its services. They are still using it in the Massachusetts General Hospital, although they find it necessary to use in addition a copper tank in which to boil the bed-pan and urinal after emptying the contents into the hopper. Altogether this makes a most cumbersome affair, and requires great attention to details for its suc- cessful carrying out. It is made by E. B. Badger & Co., Boston (Fig. 75). The Scanlan Morris Co. has now in course of construction a high-pres- sure zinc-jacketed, cast-steel hopper, porcelain lined and porcelain covered. Its working mechanism consists of a high-pressure steam jet, with pressure valve and automatic hot-water shut off. There is a steam pipe leading from the hopper to an exit, either at the roof or into a sewer catch. Into this steam escape pipe is placed a high-pressure cock with automatic shut off, and also a trap for condensation, controlled by a small pet cock at the bottom. Linen Sterilizers. — Manufacturers of sterilizing apparatus have clone their best for a long time to design a mechanism that would act to- ward loose linen and cotton gar- ments and bedclothing as a dress- ing sterilizer does toward operating paraphernalia; that is, disinfect it and subsequently dry it, so that it can be handled conveniently into the laundry. They have not been very successful. They have tried three methods: one by dry heat, which has uniformly destroyed the fabrics; one by the simple boiling of the goods in water; and the third, by the use of live steam let loose inside the container. There has been no trouble in disinfecting, but no mechanism offered has as yet succeeded in drying the goods for the laundry. Obviously, any system of disinfection without agitation of the goods, such as we obtain in the laundry washers, will not take the dirt out of the goods, and the two processes are absolutely necessary, either together or separately. Both the large laundry manufacturers — that is the Troy and the American — make what they call a disinfector, and they claim for it more than they are able to deliver, but perhaps enough to meet the requirements until we can obtain some special mechanism that may be installed or employed in the wards or service rooms of the hospital. The laundry disinfector is merely a washing machine of small type, made of Exhaust outlet on opposite side from steam in- Fig. 75. — Badger typhoid stool sterilizer. STERILIZERS FOR INSTITUTION USE 169 metal with gasket scat to the lid and a locking device, supposed to control the machine up to about as high a point as the ordinary dressing sterilizer. As a matter of fact it does not do so. The obstacles to be overcome in designing a serviceable linen sterilizer are such that there promises to be no relief, except in the form of a vacuum double- jacketed device of some such type as the dressing sterilizer. Most hospitals arc still disinfecting their typhoid linens, and other goods that have been in touch with communicable disease, in vats or tanks of disinfecting solution of carbolic acid or biehlorid, and leaving them there the prescribed time — that is, over night — because it seems to be agreed by pathologists that the micro- organisms of the diseases of childhood, and diphtheria, typhoid fever, and tuber- culosis are then completely destroyed in a 3 per cent, carbolic-acid solution or a 1 : 1000 biehlorid solution. In some hospitals the ordinar}' utensil sterilizer is employed for sterilizing infected fabrics, the process being a boiling of five or ten minutes, and the goods are then conveyed to the laundry in a wet state. This is a saving of time over the all-night cheniic solution process, and, in either event, the goods go to the laundry wet, but the special preference for the boiling process is that we have not to contend with the carbolic acid smell which it is impossible to remove, and biehlorid is rather an expensive disinfector for use in that way. Operating-room Sterilizers. — Before any sterilizer is set to work in any insti- tution exhaustive tests should be made to determine the definite lethal point of the hardiest varieties of spore-forming pathogenic micro-organisms, and these tests should be repeated at intervals frequent enough so that the surgeons of the institution can be guaranteed the complete sterility of the articles they use in their operations. All the mechanics of steam have not been mastered by physicists, and it so happens that, for some inexplicable reason, a sterilizer that operates perfectly to-day may deteriorate in its usefulness, although the physical reasons may not be apparent; at least that has been the costly experience of some very careful administrators. Little might be said here of the pro or con of the argument as to vacuum steril- ization. The whole purpose of seeking a vacuum in any sterilizer is to be secure the steam is at proper pressure, consequently at proper heat and at proper moisture, and in every part of the container, and so that it shall invade every atom of its contents. Dressing Sterilizer. — What has been said at the beginning of this section about the purpose of steam sterilization is perhaps more nearly applicable in the case of the dressing sterilizer of the operating department than to any other form of that article. Here, again, it is the case of a vacuum, or no vacuum device, and without doubt almost any of the sterilizers on the market are quite capable of doing the work efficiently under certain well-established conditions, and these conditions can be ascertained only by experiment; it may be stated that there is no type now on the market that can be taken on honor, to be used for any particular purpose, with- out carefully planned and executed experimentation. 1'or instance, the Bramhall device, in which the door works from the inside and sets upon a scat resisting an outward pressure, is the least likely of all to get out of order, because of the very simplicity of the door mechanism. In this form of sterilizer (Fig. 76) the greater the- pressure within the snugger the door will set upon its seat; and it has the ad- ditional advantage of being free from danger to the nurse or attendant who should happen to unlock the door before the steam is all out ; it would be difficult to unseat a Bramhall door while there is enough pressure inside to seriously burn an attend- 170 EQUIPMENT OF THE HOSPITAL ant, and in this form also there is no question of the wearing out of the hinges or hinge bars of the door, nor is there a question of the wear and tear on the fingers of a locking device such as the other sterilizers contain. The great objection to the Bramhall sterilizer is that the opening is consider- ably smaller than the cylinder itself, as, for instance, a 24-inch cylinder will ordi- narily have a door of 16 inches, so that when the material is pushed in on the car- riage there will be an unnecessarily large space to be occupied by steam pressure, and it may well be conceived that the expense of operating this mechanism on the score of steam alone will amount to considerable in the course of a year. On the other hand, it seems physically impos- sible to have a door seated like the Bramhall door set into an opening the full size of the cylinder, so that we must accept one or the other horn of the dilemma. Certainly the Bramhall sterilizer is the simplest form of de- vice, and it may be doubted whether one of that make will ever wear out. Where the dressing sterilizer is in- tended to be used as an autoclave, either in the laboratory of pathology or in the diet kitchen, and where the demand is not great, the question of steam is not an overpowering one, and in both these places the Bramhall sterilizer has given perfect satisfaction in institutions where the device has been in constant use. It is true that in neither the laboratory or the diet kitchen is the mechanism so constantly called upon as in the operating- and dressing-rooms. In the laboratory, for instance, the autoclave will hardly be used for more than two or three hours a day, and in the diet kitchen it will perhaps be used a considerably shorter time than this, and not every day. The diet kitchen autoclave is used to disintegrate meat, to free it from its extracts by means of pressure devices, and to break up the myosin and melt out the stearin. The operating-room sterilizer is ordinarily in use about twelve hours a day, and may be called on to do from fifteen to twenty-four complete sterilizations in the course of that many hours. This means that it must be well built, that its vulner- able parts must be of the highest order of efficiency — such, for instance, as the finger of the interlocking device on the doors and the hinge and hinge rods. In most of the dressing sterilizers in which the doors open outward repairs must be done so frequently that the apparatus is out of use a good part of the time; these doors are heavy, and they are opened and closed frequently, and thus the hinges and hinge rods are subjected to a great deal of wear and tear, to say nothing of their share of the pressure from within. This wear and tear on the doors has the effect Fig. 76. — Bramhall autoclave. STERILIZERS M>K INSTITUTION I SE 171 of loosening the seat in most of the sterilizers, which tends to decrease the efficiency by releasing a certain amount of the steam. In the Michael Reese Hospital a careful test has been made recently of the ad- vantages and disadvantages between the American dressing sterilizer and one of the older types, and it was found that, in addition to the advantages of the safetj device and the greater durability of the hinge and bearing parts, the American apparatus has a great advantage in the time employed in bringing it up to the . I Fig. 77. — "American" dressing sterilizer, including independent steam generator with automatic control valve and the " American " (patented' three-way control valve, by means of which steam is admitted to chamber, withdrawn from chamber, and vacuum created in chamber at the will of operator. proper steam pressure. The American sterilizer (Fig. 77), used was 21 inches deep and 22 inches in diameter, inside measurement, and it was found that 250° F. of heat (that is 15 pounds of pressure) could be reached in three minutes, which is about ten times as rapid of operation as the other machine, a very considerable point in a busy operating department. This is due to the independent steam gen- erator. Additional security is offered in the door of this sterilizer by a stop notch in the wheel screw, which releases the door so it gapes a quarter of an inch, sufficient 172 EQUIPMENT OF THE HOSPITAL to allow any unregistered steam to escape sideways, and holding it there for an instant before opening completely (Fig. 78) ; this saves careless nurses from being burned. In its operation this sterilizer acts like the other so-called vacuum devices, having a steam jacket, an outer and an inner shell, with an opening at the depend- ent points of the bottom, by which air is forced out of the cylinder as the steam enters under pressure, and mobilized from time to time, so that it will have an opportunity to invade whatever pockets there are. All the present makes of dressing sterilizers, excepting the Bramhall Dean, are based upon principles laid down in the old Sprague sterilizer of more than twenty years ago, and no improvement whatever has been made since that time, except in the matter of material and finish. The Hospital Supply Co., of New York, is the A\ n lp\_| \ \ \ first manufacturing concern to attempt the design I ^ J MLj \ J f an en ti r ely new principle in dressing sterilizers >U U InlN-Jl / > — that is, a new design for this country. In Europe, especially in Germany, the cabinet or wall sterilizer has been in use for some years; not a wholly satisfactory use it is true, but along lines that the Hospital Supply Co. seem to think they can make perfectly efficient by certain changes de- vised in the Michael Reese Hospital for this mechan- ism. This new cabinet sterilizer is only 18 inches deep, set into the wall or recess, and properly in- sulated by asbestos composition. The door is copper-lined, with a layer of asbestos composition between the outer and inner plates, so that the radiation of heat is reduced to a minimum. Any number of drums or metal dressing boxes can be placed in the shelves and kept there after steriliza- tion, as in an ordinary cabinet, or sealed and set in the drum racks. This cabinet has the advantage of the present dressing sterilizer, and yet occu- pies no much-needed space about the operating-rooms, and has practically no heat radiation. There is a packing of magnesium blocks for non-radiation surround- ing the cabinet except on the front or door side. While we are on the subject of dressing sterilizers, it will not be inappropriate to say a word on the desirability of sterilizing operating clothing, bandages, packs, and sponges in a container that can be subsequently sealed and kept sterile until used. These sterile drums are 12 inches in diameter and 9 or 12 inches high. The lid is fastened with staple and hasp, and can be locked for perfect security. Around both top and bottom of the sterilizer is a broad rim 1 inch in width, with |-inch holes at intervals of 2 inches, and there are corresponding holes underneath in the body of the drum, which are opened or closed by sliding the bands. Another type contains elliptical holes at intervals all over the sides, with wire-mesh cover- ing, and inner slide device for covering the holes after sterilization. The objection to this form is that the great amount of surface covered in the double jacket per- mits the whole mechanism to get out of working order if a small dent is made at any point. After the drums have been packed the holes are opened, and they are closed immediately after the drums are taken from the sterilizer. Fig. 78. — Cross-section of "American" dressing sterilizer. Door construction, including packing joint, ball-and-socket arm connection, and improved stop. STERILIZERS FOR INSTITUTION USE 173 Under the head of Operating-room Material, in another part of the hook, will be found a list of the packages usually contained in these drums, and, if used properly, the whole device is most satisfactory. There can he a sufficient number of drums to meet any emergencies in the operating-rooms, and the drums can be so packed that they will answer for the usual classic operations. Water Sterilizers. — Most hospitals have a water-sterilizing attachment to the general power plant, and all the water t hat runs to the operating- and dressing- rooms is sterilized, and, in most of these plants, the sterilized water has been previously triple filtered, to take out the mechanical dirt. In connection with one such institution, where the power plant was located at the end of 350 feet of water pipe before it reached the operating-room, repeated tests of the sterilization were made, and, notwithstanding the fact that medical men believe water pipes are liable to bacterial growths, every test showed the water to be sterile. Nevertheless, most surgeons seriously object to the use of such water fur t lie irrigation of wounds and for wringing sponges, as well as for the making up of their solutions, so that additional precautions must be taken, and this must be done by the use of water sterilizers in the operating-rooms. All the commercial water sterilizers offered on the market to-day are capable of giving practically a perfect sterilization to meet the most exacting requirements for operating- and dressing-rooms. These sterilizers are made up of three parts — a quartz filter, through which the water to be used is passed as it enters the chamber, a jacket containing the live-steam pipes, and the container itself. Up to this point all the sterilizers are practically the same. There is one point, however, well worthy of consideration, and that is the question of the ease with which the water sterilizer can be cleaned. Nearly all these sterilizers are built with the tank ami its bottom in one piece, with a top removable by means of bolts. This seems to be an error of construction, since it is practically impossible to keep out every particle of mechanical dirt, even after careful filtration, and this dirt will gravitate to the bottom. In the course of time quite a layer of dirt will lie on the bottom of the sterilizer, and there ought to be a means of reaching the bottom for cleaning purposes. In only one of the sterilizers made is this point covered, and that is in the mechanism offered for sale by the American Sterilizer Co. In this mechanism, as shown in Fig. 79, the sterilizer itself is shown as a one-piece device, except- ing for the bottom, which is bolted, making the sterilizer easily accessible for cleaning purposes. The bolts are hidden on the inside of the rim; the top being a part of the shell, it is smooth and easily kept clean on the outside, and. as the whole shell lifts up with a moment's work, the mechanism is easily cleaned of sediment. The other makers claim that their apparatus is quite as easily cleaned by tak- ing the bolts out of the top lid and lifting out the coils. But the sediment is still at the bottom, and the whole mechanism must be dismantled to get at it. Recently a new plumbing arrangement has been designed for obtaining hot or cold sterile water from the sterilizers, delivered to the sinks in the operating-rooms by means of piping and faucets. This mechanism contemplates placing the hot- and cold-water sterilizers at the ceiling in the sterilizing room, piping over to the one or more sinks in the operating-room proper, so that hot or cold water can he drawn at the sink just the same as other water. Additional faucets, self-closing in type, must be placed over the sink in addition to those for ordinary washing water. Heretofore sterile water has been carried usually in pitchers, and, more often still, the ordinary water that has come from the power plant, or from the city mains, has been used for the irrigation of wounds, dipping of sponges, and 174 EQUIPMENT OF THE HOSPITAL so on. Most surgeons are no longer satisfied with this slip-shod method, and demand not only sterile water, but demand that it be sterilized in the operating- room suite. Instrument Sterilizers. — There is almost no point to be made concerning instru- ment sterilizers for operating-rooms; any metal box, mounted Upon legs to give a convenient height, is practical for all purposes of instrument sterilization. The Fig. 79. — "American" design of water sterilizers with all operating valves (each fitted with name-plate indicating function) and self-contained piping. These reservoirs are also fitted with our new design of quick closing water-gage valves; separating joint for cleaning at bottom, thus giving direct access to the interior and doing away with the unsightly dust-catching joint at top. instruments are set in a tray and covered with a towel, and the sterilizer is partly filled with hot water and live steam is turned in. This is the simplest form of sterilization, because there are no hiding places for micro-organisms, and uniform wet heat can reach every part of the instruments at all times. The only point about instrument sterilizers is that they must be operated by a foot pedal, since nearly always the nurse who handles the instruments is a clean nurse, and oftentimes STERILIZERS FOR INSTITUTION USE 175 she is gloved for clean work. A mechanism that will raise the tray to the top is desirable, because a nurse working in a hurry will sometimes burn herself lifting a tray out. Fig. 80. — "American" special combination sterilizing outfit, consisting of dressing, water and utensil, and instrument sterilizers, together with six water-tight storage lockers, designed expressly for U. S. Navy Department, and installed on battleships "Arkansas" and "Wyom- ing." Combination Set. — Figure 80 shows a compact set, made up of all the neces- sary units — dressing utensil, water, and instrument. This is a most convenient set for small hospitals. It can be had to run by electricity where high-pressure steam is not available, or by a small gas boiler. The set costs about $400. FURNITURE IN THE HOSPITAL Beds and bed fittings, tables of various sorts, chairs, receptacles for clothing, and rugs for the floors — all these are furniture common to all parts of any insti- tution, and it may be just as well to take them up in their regular order in this place. BEDS The bed is the most important article of furniture in any sick room, and its composition and dressings are certainly among the most important items in insti- tution administration. Of course, none but metal beds are to be considered. It is to be doubted whether the particular metal makes very much difference, except as a matter of strength. Simplicity is of prime importance, because plain material can be cleaned more readily and will be cleaned oftener than decorated, fretted stuff, and white enamel is the best material to clean, because it shows dirt more readily, and will therefore be cleaned more thoroughly; but, up to the present time, there is no enamel that will not scratch off under ordinary usage, and nothing looks quite so untidy as a badly scratched white bed. White enamel again makes the cheapest of beds, because the manufacturers can use the cheapest forms of iron when they know they are to be covered by a white paint. For the wards of an institution there is no form of bed now made that will take the place of white enamel, but we must resign ourselves to the fact that constant re-enameling must be done. If users would pay the price for a properly made article, bed makers would be compelled to build their baking ovens large enough to take in bed parts, and take them at a sufficiently high temperature to fuse the enamel into the metal, and there would be no cracking or scratching. For private rooms brass would be without question the best metal for beds, but for the one fact that at the present time no polish or material of any kind is made that can be used to keep the brass from tarnishing, and, after a year or two of wear, with the spilling of acids and medicines, brass beads are not pretty. The design of the hospital bed is a question to which very much attention has been given by recent inventors and designers, and there is on every hand an ap- parent desire to complicate this piece of furniture by the addition of all sorts of alleged conveniences. They are made now so that the feet can be raised and the head lowered, or vice versa; so that both head and feet can be raised and the buttocks rested in a hollow between the two; some are made to allow patients to sit up in comfort, and some are even made so that they can be tilted sideways, and patients are thus allowed to turn over without any effort on their part. All these efforts are worthy as to their intention, but result in complications of mechanism that get out of order constantly, are veritable dust catchers, and almost require an engineer to operate them. The better way is to have the bed in the simplest possible form, and pieces of furniture in convenient closets about the ward or floor that may be used for achiev- ing the same purposes intended in these beds. There are so few patients that need the auxiliaries that it seems hardly worth while to furnish a hospital with a lot of 11 KX III RE l\ THE HOSPITAL 177 lumbering stuff that has many disadvantages and such semi-occasional usefulness. For instance, there are side rests made of wire, and bound with heavy metal, that arc convenient and easily placed either over or under the mattress. There are hack rests that are the essence of simplicity in construction, and there are foot props that will serve every purpose to prevent patients from working to the foot of the bed. The height of the bed is of the utmost importance, not so much in the interest of the patient perhaps as to facilitate easy handling by the nurse, a matter that is of vital importance if patients are to obtain adequate care. The low bed is a, back- breaker. The low bed is one that is 22 inches to the top angle iron frame of the mattress. The high bed, approximately 28 inches high to the top of the mattress, will never lie found disagreeable to the patient while lying in lied, and will allow the nurse to perform all the necessary duties to the patient without stooping over much. The high bed is, of course, an inconvenience for getting in and out, but patients Fig. SI. — High bed with nurse's couch half drawn out. are not getting out and in bed vcy often, and the act of assisting them in and out will happen infrequently, while die duties of a nurse to a patient lying down are so constant that there seems tj be hardly an argument against the high lied. The high bed is especially advantageous in private rooms, because the nurse's couch can be kept under it when not in use, and oftentimes these couches are most grateful to patients who wish to change for a rest from one bed to another, or to allow their own bed to air. Figure 81 shows a high bed with nurse's couch half drawn out. Width of Beds. — The width of the bed, especially for the adult, is a matter of a good deal of importance. The patient needs a wide bed, and the nurse is better off if the bed is narrow, but as the patient is of somewhat more importance, and has to use the bed more constantly than the nurse, perhaps we would better con- sult the patient's comfort rather than that of the nurse in this particular instance; hence, the wider the bed the better off we are. Perhaps a happy medium, taking 178 EQUIPMENT OF THE HOSPITAL into consideration the patient's comfort, the space allowable, and the ease with which the patient may be handled by the nurse, would be 42 inches. Springs. — The spring of the bed is a matter of very great moment, so far as the patient's comfort is concerned, durability, and economy. Commercially, the bed-spring business is not in very good shape. Figure 82 shows one that is perhaps, for all purposes, the best. It consists of chain and cross-chain lengths, with wire side line from end to end of the bed, and with spirals at each end of every chain. The only part to wear out with this spring is the spiral, especially those toward the center of the bed, and these are sometimes made of double strength, so that the full weight of the patient is compensated by the extra strength of the spring. This spring is not at all likely to give down in the middle, it does not fix itself in a hollow, and gives readily with the movement of the patient from side to side or from head to foot. It is not a costly spring. It can be used in private rooms, pri- vate and public w 7 ards, in the adults' or childrens' departments, with equal comfort Fig. 82. — Form of bed springs. and advantage. The old form of spiral spring is out of date, and is not admissible for the purposes of a public institution. It hat the habit of wearing down in the middle, by the stretching of the spirals. There is a disposition on the part of some institution managers to do away entirely with springs, and to use slats lengthwise and crossways, made of metal bands. When this is done there must of course be a very large, thick mattress, and it may be doubted whether any material will retain its springiness sufficiently to compensate for a spring of a different sort so that the patient will be comfortable. There is a disposition in other quarters to go back to the old box-spring of twenty or thirty years ago. This is entirely out of the question, because the box-spring can never be cleaned, and becomes a breeding ground and hiding place for germs of all sorts, microscopic as well as macroscopic. Mattresses. — The mattress is perhaps quite as important as the spring, and, so far as the comfort of the patient is concerned, much more important than any of the articles in the furnishing of a room. FURNITURE IN THE HOSPITAL 179 Some of thorn arc cotton, some felt, some a mixture of these two, and others of h:iir of various qualities and of various kinds. It is questionable whether such a mattress as the Ostermoor is the best for a private home, and for well people to sleep on, but the manufacturers of these fell mattresses have not striven very hard to place them in institutions, for the obvious reason that they do not lend themselves to institution requirements. Beside the item of comfort to the patient that of cleanliness is a most important factor, and it is not easy to get blood and the fluid secretions out of a felt mattress. The same would be true of cotton, only in a greater degree, and both of these materials should be ruled out for hospital beds, not only because they are difficult to clean, but because they do not lend themselves well to fumigation and sterilization, on account of the compactness of their texture; and, notwithstanding the slightly greater first cost, there is no material for the hospital mattress that will take the place of curled hair. It is expensive, and will cost for the average mattress S8 to $10, but, because of its porosity, it can be easily fumigated, and under the severest tests the hardiest of the pathogenic micro-or- ganisms can be destroyed if embedded in the middle of a thick curled-hair mattress, under the intense fumigation or sterilization that will be employed in the insti- tution. If the tick is soaked with blood it can be renewed, and the hair washed and sterilized at a total expense of $1 or SI. 50. Then, again, curled hair is a versatile mattress in its usefulness; it can be made into pads of any size and thickness and for any purpose, either for adults or infants. Pillows can also be made out of it for leg or arm rests. It does not wear out, and is practically a permanent invest- ment. If desirable, it can be turned out in bulk into the fumigating room and fumigated, or disinfected at any temperature required, even to the point of live steam. The cheaper grades of hair are not economic because the individual hairs break, and eventually the mattress packs like felt without the latter 's springiness; the hair is too short in these cheap grades. Childrens' Beds. — There are so many points to be considered in the design and use of a child's bed, and so many conditions to meet as to the place in which the bed is to be used, the age of the child for whom it is intended, whether it is a well child or a sick child, that there seems not to have been designed any bed that would meet all the required conditions. First, we must think of the very small infant, only recently born perhaps, whose mother is not yet strong enough to lift the child over a high rail. Then, for this same young baby the bed must be made with bars so close together that the head, or even a limb, cannot get through so as to be hurt in case the child tosses about. Then, there is the older child, just learning to stand while holding on to something, and that will certainly pitch over t lie top of a rail unless it is higher than the rails of most beds. If we are to have a rail around a child's bed, the catches must be so strong and easily adjustable that there will be no danger of the child pushing the rail over, in the event that the nurse or mother should happen not to latch it securely. There is also the still larger child that rolls about and tosses in bed. These conditions concern the age of the child. Now, let us take the private home, in which there cannot always be a nursery maid, and where the mother must depend upon some sort of security after it has reached the crawling age, and where it cannot get hurt. We oftentimes see two or three chairs laid down on the floor, and a pen made of them to keep the child from crawling into danger, but nearly always there are openings through the parts of the chair that the baby will crawl through, and perhaps gel into the tire or fall downstairs; or perhaps the baby may pull one of these chair- over on itself and be 180 EQUIPMENT OF THE HOSPITAL severely hurt; then there are nearly always rough parts of the chair exposed, so that the baby may fall and be severely injured. But the baby that is old enough to get into this sort of michief will be old enough also to climb over the rail of almost any of the ordinary makes of bed and fall to the floor, so that it seems we need a bed with a rail high enough so that the baby can play in it, and allow the mother to be in another room or downstairs, without any fear of something happening. We must always think, too, of a rail for the child's bed that can be almost auto- matically so securely fastened that there will be no danger of a careless nurse or a careless mother leaving it in such shape that the child will push it down. Then, there is the hospital bed; and this bed, too, must meet a number of re- quirements, all those that have been suggested above, and others made necessary Fig. 83. — Child's bed designed by the author — cage lowered. by the large number of children that a single nurse must sometimes care for, that is, the security must be even greater than in a case of a single child in its own home. The child's bed in the hospital must be of a sufficient size and of proper make so that either a very young baby or a child of considerable size can be accommodated in it. There is the question of space in the ward that must be taken into con- sideration. The children s' ward in the hospital is usually made up of rows of beds, with the heads against the wall, and in this modern day it is a prerequisite that every child shall have its own equipment, linens, dishes, dressings, thermometer, and the like, and these may be kept on a small table at the bedside. So we have a large number of varying conditions that confront us when we attempt the selec- tion or design of a child's bed. Take, for instance, the hospital child's bed in which the rail is fastened to each end at the top with a bolt that goes into the KrHXITlKK IN THK HOSPITAL 181 upright, when the bolts arc drawn out the rail falls outward and downward. This makes it necessary that we shall have an unoccupied space on each side of the bed equal to the height of the rail, so that the rail will not be impeded when it is swung outward and downward; even if we have a sufficient unoccupied space to allow of the rail being swung downward on either side, we will sometimes have tin- attend- ing physician and the intern walking up to the bed on one side for the purpose of examining the child, and the nurse will be on the other side, and it will lie a very awkward matter for the nurse to lower the rail on the doctor's side without neces- sitating the doctor's getting out of the way, and time will be required for the nurse to go round on her side and lower her own rail so she can undress the child. The bed with the outward swinging rail, one on each side, is one of three forms of child's bed that can be purchased on the market. Fig. 84.— Cr by the author — cage raised. The second style is one in which the side rails travel straight tip and down on an independent rod, with a hook catch at the top of each end that catches on a pro- jecting notch. The objection to this style of bed is that it requires almost no force to spring the rod at one end or the other, so that the rail will bind as it passes up and down; and it is the experience of hospital people that this rod is nearly always so out of order that the rail does not work freely. Another objection to this bed is that tin 1 catches oftentimes stick and fail to clasp the projecting notch firmly enough to insure that the rail will not fall. Many accidents have happened to children on account of this rail slipping from its fastening and catching the leg or arm or head of the child. There is another style of bed not so well known as the two above; this is a fixed 182 EQUIPMENT OF THE HOSPITAL cage fastened to four posts, and the two longitudinal side rails of the bed project considerably beyond the head and beyond the foot. The ends of these two rails are movable pieces fastened with a spring, and on the inside of the two upright posts are notches in which these extensions can be made to catch. The bed is worked by one nurse at each end. The two extensions are pulled toward each other out of the notches, and the bed containing the child is raised or lowered to the desired point, and the extensions are then released so that the bed catches at that height. The objection to this bed is that it must be pulled away from the wall in order to be worked, and that it requires two nurses to work it. It was designed by Dr. Holt for the New York Babies' Hospital. There is a new form of child's bed, designed by the author, and intended to overcome all of the objections of all the other beds. Figures 83 and 84 show two views of this bed. It consists of four posts, 30 inches high. These posts are held in Fig. 85. — Nurse's couch. place by an angle-bar running entirely around the top, and a second one running around the lower part, about 6 inches above the floor. The spring of the bed is stretched across the top bar. The posts are slotted on the inside. The rail of the bed, 26 inches high, extends clear around, and each corner contains a guide runner that works up and down in the slot of the post. This arrangement allows the cage to play up and down the posts. Across the bed in the middle, and just under the spring, is a spring roller, to act precisely as an ordinary window-shade roller. A steel cable runs from each post, to wind around this spring roller, and is fastened to the guide runner on the inside of the post over a small pulley. This arrangement forms a spring counterweight for the cage, so that one may, with a single finger, raise or lower the cage to any desired height. The spring is so adjusted that the cage will remain where it is placed, whether it be clear down, giving one the impression that the bed is merely an examining table, or at its full FURNITURE IN THE HOSPITAL 183 height of 21') inches above the mattress. The balance of the mechanism consists in a screw lock worked from either side, and which, when given half a turn, locks the cage at its desired height. This lied, though rather complicated in the description, is extremely simple, and no more intricate in its mechanism than the ordinary curtain shade. It can be made quite as cheaply, if not even cheaper than the other child's beds, and it is believed that it will fill a definite place wherever there is a child. Interns' and Nurses' Beds. — Living accommodations for nurses and interns are usually limited, and there is nothing more comforting to the young people after their work is over than to be able to lounge in their rooms. Usually their quarters are not large enough to afford space for couches, so that the beds must be made to serve for lounging as well as for sleeping purposes, so that it is well to remember two or three things: first, the beds should be low for the comfort of lounging; next, they ought to have strong springs, very much stronger than will be necessary where sick people are to occupy the beds, because these young people oftentimes do some gymnastics on their beds. Perhaps the nurse's couch shown in Fig. 85 will be best for their rooms. This couch is of iron, strongly and simply made, with a serviceable spring. It is com- fortable to sleep on, easily kept clean, and occupies less room than any other bed. BED RESTS There are a number of pieces of mechanism designed to give the patient a change of position in bed. The most important of these is the back rest. This is a simple mechanism, as shown in Fig. 86, but a very much-used device in all institutions Fip. 86. — Simplest form of bed rest. where there are sick people. It can be raised or lowered by the simple notched arm, as shown in the cut, so that a patient may almost lie down or sit almost straight up. The body of the device is of wire netting, si) that, if desired, the patient's back can be exposed to the air, with sheet or light blanket protection, and thus the effects of the hot bed can be ameliorated for the time. It may be doubted whether there is a choice in the several makes of this device. They all serve practically the 184 EQUIPMENT OF THE HOSPITAL same purpose in practically the same way, and as the only opportunity for break- age is in rough handling when being moved from place to place they last a long time. There is another form of device employed to place the patient on the side. It extends practically from the shoulder to the lower hips, and the patient's body rests in the mechanism as though in a swing. It is often grateful to very helpless patients and to those with bed sores, and, while not nearly so commonly used as the back rest, one or two should be kept in every institution. Both of these pieces of mechanism will work entirely independent of any neces- sity to have a specially devised bed, cumbersome and complicated, the spring of which can be made to assume any one of half a dozen positions, either to ease the patient or to meet the requirements of the attending physician or surgeon. There are, of course, also arm rests and leg rests made with wire-mesh work. These are rather special appliances, and are a matter of taste and special occasion, rather than a part of the ordinary equipment of an institution. Fig. 87. — Greensfelder's bed-splint. Fig. 88. — Greensfelder's bed-splint. Buck's extension is a strictly surgical apparatus, designed by a surgeon to meet special indications in fractures, and need not be more than mentioned, and the same is true of the many modifications of the Buck mechanism. The Hodgen splint for leg fractures, and for injuries to dependant parts of the leg or thigh, is a very old and a very useful splint, unfortunately not very well known to modern surgery. There is a new bed splint for children that seems to justify more than passing mention. Two views of it are shown in Figs. 87 and 88. It was designed by Dr. L. A. Greensfelder for the children's service in the Michael Reese Hospital. Obviously, it is intended for treatment of hip fractures in children, and permits the patient much freedom of movement, either in bed or in a wheel chair. BED RAISERS The bed is not a very light article of furniture, and the leverage that must be applied to raise the bed is considerable, especially with the ordinary commercial bed raisers, that must be partly slipped under the bed in half-horizontal position, and then stood upright upon fastenings provided for the purpose. Kl'UMTl'HK IN THE HOSPITAL 185 Another form of this mechanism is represented by Fig. 89. This is set close to tin' head or Tool of the bed, whichever it is designed to raise, and two people are required, one cm either side, to raise the bed up to the notches. Usually the people who raise the bed raise it too high and let it drop into place, so that, in the ease of either of these devices, there must be a considerable amount of strength to withstand the wear and tear of constant usage. Of course there will be careful people who use them and careless people, and let us give the nurses and orderlies the benefit, of the doubt, and say that there will be one hundred careful people who raise the beds to one careless one. But the one careless one will break a hook off, and the mechanism is rendered useless, because, as a rule, separate parts are not made for this mechanism, the design of all those offered on the market being prac- tically the same, and most of them are made to fit any form of bed. In purchasing this device we look for two things — strength and price. What seems to be the most practical and efficient bed raiser now offered on the market is made by the Bernstein Co., of Philadelphia. It is simply a large caster, with extension that fits up into the hollow tubing of the bed-post. There is a pin that goes through the tubing and the extension. One nurse raises it up while a second nurse removes the pins and resets them in the new place. Unfortunately, the bed has to be made with a view to this particular form of raiser. BED ROLLERS Bed rollers are made to wheel the bed from place to place about, the ward, or from one pari of the hospital to another. They are used instead of the bed castors proper, because they are fitted with large wheels, rubber or pneumatic tires, ami move noiselessly, without jolting the patient and without marking the lloor. The rollers are made to fit the ordinary ward beds, and the process of applying them is 186 EQUIPMENT OF THE HOSPITAL to slide the wheels part way under the bed until the bottom rod of the bed catches into the fastenings made for the purpose, and they are then lifted to a vertical posi- tion. There is a clamp at the top, on each side of the roller, as shown in Fig. 90, that holds the top round of the bed, and the roller becomes, in effect, a part of the furniture. Care must be taken in this roller to see that it is designed to fit all the beds in the institution. The top clamps are not made to go high enough to fit some beds, and the bottom clamps often do not reach out far enough to catch the cross-bars of other makes. These rollers are usually made of castings, and one often sees a large number of them broken, especially the hook upon which the bed rests, so that special care must be taken to see that these rest pieces are strong enough. A good many of these makes of bed rollers are fitted with a heavy piece of rubber band on Fig. 90.— Bed rollers. the wheels, instead of cushion tires, and when they are new they run very smoothly and noiselessly and do not jar the patient; it does not take them long, however, to dry out, become loose, and they eventually crack and fall off. The mechanism is important and useful enough to justify a better tire than this, and a form of bicycle tire, with grooved rim to the wheel, is not very much more costly than a flat rubber band. Much better than either of these, however, is the pneumatic tire, practically like the automobile tire. The cut shows a flat tire, which is by no means desirable. Some designs of beds do not lend themselves readily to the ordinary bed roller and bed raiser. Some beds, for instance, are made with a cross-bar between the two head posts, 6 inches or a foot from the floor, and this bar is expected to hold the weight of the bed, even at the extreme Fowler position; this is not a safe way, FUUXITURP. IN' THF. HOSPITAL 187 however; in brass beds this bar is simply a piece of very thin brass tailing, fastened to the posts by small screws, and it is unsafe to trust the weight of the patient, plus the weight of the bed, to these bars so flimsily fastened. In this sort of bed an en- tirely different arrangement of a bed raiser and bed roller must be substituted. In some institutions the raiser or roller is made radically different for this reason — the posts of the bed are hollow, and the casters are set into a socket in the bottom of the post. Then when a bed roller or bed raiser is to be used the caster is taken out, and the raiser or roller is pushed into the hollow tube. There is an individual raiser for each post, and there is a stop notch, or several of them, to gauge the height at which the bed is to be held. This is a modification of the Bernstein castor. TABLES IN THE INSTITUTION Ornamental Tables. — There must be tables all over the institution — in recep- tion rooms, study halls, libraries, private rooms, and wards, and they ought to be ornamental in design, yet very ^^^^^^^^^^^^^^^^^^^ simple for purposes of cleanliness. | Some of them must be of wood, and if they are substantial they will last longer and look better than metal, and give an air of luxury wherever they are. It is the style now to leave ornamental tables free of cover- ing, except perhaps a piece of drapery across the middle, or an ornamental skin thrown with artful carelessness across a part of the table top. Such tables as this can also go into the rooms of the nurses and interns and the well people of the hospital gen- erally; the character of the table, then, depending a good deal on the expenditure possible. Bedside Table. — Figure 91 shows a bedside table that seems to answer all the requirements. It is easily ad- justable as to height, and the table part can be set at any angle. It may be made of any of the woods or of enamel. The top may be made any size required. It may be made with a rim around the edges, so that china or glassware will not slip off, or it may be made with the top entirely plain, so that patients may use it conveni- ently for writing or playing cards. Side Tables. — Each room and each ward should be furnished with a side table, one for each patient occupying the room. If it is a private room, something like an air of luxury must be allowed; therefore, these small side tables should be of ornamental wood, harmonizing with the other furnishings of the apartment. They need not be large, perhaps IS by 20 inches is the best size, with a drawer in Fi K . 91.— Bedside tabic. 188 EQUIPMENT OF THE HOSPITAL one side, and with a shelf 8 inches above the floor on which to place books and mag- azines. Patients in private rooms like to cover their tables with friendly fancy goods brought from home. In the private and public wards it is not possible to observe the same amount of individuality. More patients use the tables, and, for those who are careless of their furniture, it would seem preferable to have white enamel tables, as well as for their durability and ease of cleaning as to preserve the general tidy and cleanly appearance of the wards, because in most institutions the beds and screens, and sometimes the dressers and chiffoniers, are made of white enamel. In these ward tables the material of the top is of some consequence, and this can be either enam- eled, sheet metal, or porcelain, that seems to be coming into fashion for hospital Fig. 92. — Table for children's ward. furniture. Glass is not advisable, not only because it breaks easily, but because things slip about much more readily on glass than even on white enameled stuff. Childrens' Bedside Tables. — If there must be tables in the childrens' wards they should be very simple, but should have at least two drawers and a lower shelf to contain a drinking glass, mug for milk or other drinks, and whatever nicknacks a child may be allowed to eat from time to time, such as oranges or crack- ers (Fig. 92). In the first drawer are the dishes, knife, fork, and spoons, cup and saucer, large and small plate, gruel bowl, and perhaps one or two vegetable dishes. In the lower drawer will be the towels and linens for the bed, and for female children of whatever age there should be vulval pads, made of some material cheap enough to be destroyed after one using. They are making now a very handy thermometer case, nickel-plated, with small chain attached, so that the case may be hung to the Fl'KNmKIO I.\ THE HOSPITAL 189 bed-post, ami these cases should be labeled, one for the mouth and one for the rec- tum. The objection to them is that the patients play with and break them. Fig. 93. — Head nurse's table. Fig. 94. — Metal table for nurse's station and history sheet holders. Of course the linens on these individual tables must l>e changed daily, and they should not be allowed to remain in the ward for any length of time, as there is eon- 190 EQUIPMENT OP THE HOSPITAL stant danger of micro-organic infections. This table is employed in the contagious pavilion of the Cook County (Chicago) hospital. Serving Tables. — The only other tables that seem to be of sufficient importance to demand special consideration are the serving tables in various parts of the house, on which food is kept and from which it is served either to patients, patrons, or employees, and the only detail of this table that is likely to cause annoyance is the material for the top. It is almost certain that linoleum and oil-cloth must be re- jected, because they are cut too frequently in the slicing of bread. If it is a figured linoleum it is certain to be scrubbed with sapolio, which will wear it out quickly. The covering of zinc is expensive, and not very pretty or clean looking, and it is difficult to clean a zinc top so that it will not look greasy. If the table has a smooth top of fine-grained wood, and there is very much wear and hard use, it maybe treated with laboratory stain, the formula for which will be found under the heading of Equipment for the Laboratory. Grease, acids, alkalis, and the like will not effect this stained top, and, although black in color, it will always look clean. Head Nurse's Desk. — In some institutions the head nurse's quarters are in the ward itself, and sometimes in a small room off the ward or corridor; the chief article of furniture for the head nurse is to be a table, and on the character of this will depend the system, or want of system, with which the head nurse does her work. Figure 93 shows a head nurse's table that seems to meet the requirements. It is 30 to 36 inches long, 18 inches deep, and with a top 30 inches high. It has three draw- ers, with a. shelf above the top drawer and just under the table top, in which the record books may be kept. The three drawers may be broken into compartments if desirable, so that the nurse can keep things well separated. This table is of white enameled metal ware with glass top. It might have a white enameled top and be quite as useful and ornamental. It should by all means be fitted with rubber tips on the feet. On top of the table or over it, toggle bolted to the wall, the records may be kept in an article of furniture indicated in Fig. 94. CHAIRS IN THE INSTITUTION There is probably more irresponsibility in a hospital than in almost any other occupied building. In a hotel certain servants are detailed to clean certain rooms, and certain dining-rooms and parlors, and if furniture is broken the culprit can be easily found. In a hospital, however, there may be a dozen or twenty different people doing things in a single room or ward in the course of a day — orderlies, nurses, maids, floor men, and interns, besides the patient and his friends — and it is almost impossible to fix responsibility for the breakage of furniture, and there is more wear and tear on the chairs than any other of the furnishings. People insist on sitting on the arms or back, or tilted back with two feet off the floor, and it is probably impossible to build a chair that will not break if a heavy man tilts back in it and twists it about; the prime consideration, therefore, in the chairs of an insti- tution is strength, and this must be had without very much reference to the pri- mary expenditure. A good chair may cost $6, and last six years, whereas a poor chair will probably cost $4, or in that proportion, and break before the year is over. So that in the ordinary chairs distributed about the various parts of a public or semipublic institution we must have strength, and we must have rubber tips on the four feet and a rubber tip on the back of the top rail, so that the chairs, if leaned against the wall, will not scratch the paint. There should be one exception in the matter of tips for the feet, and that is in the dining-rooms; the noise incident to the rising of a dining-room full of nurses is almost unbearable, but rubber tips FURNITURE IN THE HOSPITAL 191 will not allow the chairs to slide backward and forward and the effect is most awk- ward. A felt tip instead of rubber is far preferable in the dining-room, and if the floor is hard wood, oiled or waxed, metal tips may be used; they make some noise, not nearly so much, however, as the unshod feet of the chairs. Rockers. — Roeking-ehairsmust beconsidered a luxury in any institution.but they are extremely comfortable, and in many places necessary. A convalescent patient will easily tire if compelled to sit bolt upright or at any particular incline, and he will want to change his position from time to time. He can do this, of course, by a give-and-take mechanism, such as we have in the Morris chair, but it is very much easier to lean forward just a little on the rocker or backward. There is a mistaken idea that the back of a rocking-chair for a convalescent patient should lean far back. This is not according to the best comfort of the patient. A very few degrees back- ward from the severely vertical position is very much better, and, if the patient wants to lean far backward, he can rest his feet on a stool or hassock or another chair, and obtain almost a reclining position if desired. The rocking-chair should have broad arms, low enough so that the elbows of the patient can rest easily with- out pushing the shoulders upward. If the arms are broad enough to hold a writing pad, the patient will be able to adjust his arms so that they will rest easily and not be strained. Metal is not the best material out of which to make rockers. In the first place it is cold to the touch, and if the joints give even ever so little the play allowed will soon develop into a loose joint, and the next step will be a break. In other words, the metal chair is too rigid, and will break before it will give ever so slightly. The best material is good, strong, well-seasoned oak, or preferably, if it can be had, hickory. The rocker need not be very long and sweeping. Very few patients will want to or should rock hard, but a very little vibratory movement in the act of rocking to and fro will oftentimes be of great comfort to a nervous patient and serve to quiet him. This is perhaps more true of women than men, and very much truer of Southern people than of Northern people, because in the South nearly everyone uses a rocker. The rocker for nursing mothers and wet nurses, and to be used by the nurses in the maternity hospital, should be very low and narrow and without arms. It can be cane-seated or cushioned, preferably the former, for sanitary reasons, and painted or enameled to conform to the other furniture in the nursery. Morris Chairs. — The only objection to the Morris-chair principle is the uphol- stery, and, as usually made, it is not very sanitary for that reason, and can hardly be made so. If the cover is of leather, it cannot be fumigated, and can never be sterilized, and sometimes this will be required. The best way is to have the seat in one simple piece and the back in another, and to have these upholstered pieces covered with some plain, strong material, such as denim. In any case, the up- holstered seat and back of the Morris chair ought to be enveloped in a washable linen fabric. There is a new Morris chair with a mechanism that permits the back to be brought forward or lowered into complete reclining position by means of a thumb push at the side of the seat of the chair, just under the arm. This mechanism is easy to work, is very simple, and hence does not get out of order, and the lock mechanism of it is perfect enough to prevent slipping. It is shown in Fig. 95. Ward Chairs. — In a great many institutions there is a desire, amounting almost to an obsession, to have everything in the ward pure white, and this has led manu- facturers to attempt to make an easy chair of white enamel for the ward patients. Figure 9o shows one of these ward, so-called, easy chairs. It is reproduced lure as a 192 EQUIPMENT OF THE HOSPITAL warning rather than for any recommendation. Generally this chair is made large so that it can be lined with pillows, and is so high when a pillow is in the seat that the average patient will not be able to touch the floor with his feet; and, with this pillow idea still in his head, the manufacturer has made the chair so deep from front to back that, even with one or two pillows at his back, the patient will still cut his legs behind the knees on the front edge of the seat. The mechanism to raise or lower the back is made very rigid, and consequently hard to work, and the patient will not be able to work it alone. If this chair was very much smaller and lower, and much more nearly on the pattern of the average rocker, it might tie of service in the ward, chiefly because it would be sanitary; and if it was made to conform to the bends of the body it would Fig. 95. — Morris chair with push-button mechanism. give a good deal of comfort, but there is no enameled chair made of metal that meets these requirements. For military camps, field hospitals, and tuberculosis shack colonies a most comfortable invalid chair can be made out of a barrel cut half-way down on one side, and a piece of heavy canvas tacked across ; or with a common saw buck, with a back made of two uprights and a cross-piece nailed to one side; two arms can be made by nailing common boards across the forks and canvas tacked from the top of the back to the round coupling; a foot stool completes as comfortable a loung- ing chair as money will buy. Wheel Chairs. — In one institution that has distributed about the house some- thing more than fifty wheel chairs of supposedly the best and strongest make, there is an average of six chairs daily in the repair shop, and it has become the custom in this institution for the repair man to make his morning rounds for broken chairs. FIRNITTRF. IN THE IWSI'ITAL 193 All these chairs are comparatively new, and all of them are of the most expensive make of wheel chair. These facts are cited merely to show that the wheel-chair industry is not on a very efficient basis. Figure 97 shows perhaps the best all-round wheel chair for institution pur- poses now on the market. It is made by the Gendron Co., of Toledo, Ohio. There are a number of weak spots in this chair; the extension thai slips under the seat of the chair to hold the leg-piece in position usually breaks easily; the hand rail at- tached to the wheel breaks easily or, rather, comes loose from the wheel; the foot- Fit;. 96. — Morris chair of white enamel. piece on the leg extension is weak. These weaknesses do not develop in ordinary use; in fact, with ordinary care, any of the wheel chairs will last indefinitely, and for the private use of the individual in his own home will do nicely and last a long time, but in institution work they do nol gel ordinary care. Oftentimes the nurse is not strong enough to effectively help the patient into the chair or out, and hence she raises the back wheel of the chair so that the foot- piece touches the ground, and then she has the patient stand upon this foot-piece and she bears down on the back part of the chair, throwing both her weight and that of the patient on the mechan- ism. If this method of handling the patient is common to the nurse, it is very 194 EQUIPMENT OF THE _ HOSPITAL much commoner in the case of the orderly, who is notoriously careless anyway, and even still more common in the case of the patient's friends, who, not satis- fied with balancing the patient against the leg mechanism, oftentimes sit upon that mechanism themselves while both the patient's legs are perhaps resting on one side, or they sit on the arm of the chair and catch their heels in the hand rail. However, there seems to be no cure for these inherent weaknesses in even the best wheel chair made, and we shall have to get along with what we have until some enterprising manufacturer can accomplish the apparently impossible feat of making an indestructible wheel chair, or perhaps there might be a hint to some erstwhile bicycle maker, whose legitimate business has gone automobileward, and he may make for us a tubing or metal wheel chair at a price that institutions can afford to pay. Fig. 97.— Wheel chair. If there are steps to be negotiated by the wheel chairs in the institution in getting in and out of doors, the chair with the single small rear wheel will not serve the purpose, because the chair cannot be balanced on the single wheel after the fashion employed with baby carriages, and two rear wheels will be necessary. Commode Chair. — A very essential piece of furniture, and one that must be kept at convenient intervals all over any institution where there are sick people, is shown in Fig. 98. This is at best not a very ornamental piece of furniture, but the one in the cut is perhaps the least suggestive of its vulgar use. The legs of this chair should be shorter than those usually furnished by the manufacturers. There is a receptacle under the seat for the chamber vessel, and if the vessel does not fit tight up against the hole, it should be made to do so with a block of wood, other- wise urine will find its way out of the vessel, and sometimes onto the floor. If 11 1,'MI'l RE I\ THE HOSPIT ih 195 the seat of the chair is low enough there can he a properly shaped cushion of some sort for seal and back, to be used when the chair is acting merely as an ordinary piece of furniture and its necessary but homely office need not he suspected. Figure 99 shows another and improved form of commode adaptable as a piece of private-room furniture; it maybe used as a jardiniere or stool. It is of white porcelain, double-hinged, so that the one pair of hinges operate the outer lid as well as the inner. It has knob feet for sliding over either bare floors or carpet. This is made by the Scanlan Morris Co., of Madison, Wisconsin. These same people also make another very useful article, shown in Fig. 101, and which they call the white line cabaret commode. There are hangers inside for bed-pan, slop-bowl, male and female urinals. It opens on three sides and is consequently easily cleaned. Fig. 9S. — Commode chair. Chairs for Insane Persons. — It often becomes necessary, especially in hospitals for the care of the insane, to get patients out of bed against their inclinations. They have perhaps been shackled, and compelled to remain for a long period of time in a more or less cramped position. For the best good of these unfortunate people they ought to be sat up frequently, but, unless they can afford the luxury of a constant attendant, it will be necessary to find some sort of chair in which they can be controlled as to arms and legs and body. There is a chair made for the pur- pose that has very broad and heavy feet, so that the patient who happens to be shackled cannot toss about and throw the chair over and injure himself. This chair is provided with rings in the back part of both sides, and there is a strap that can be snapped into the rings, and it will hold firmly across the upper parts of the patient's thighs in the bend of the body. There are other rings part way up the 196 EQUIPMENT O" THE HOSPITAL Fig. 99. — White Line sanitary commode. Fig. 100. — White Line sanitary commode. Fig. 101. — White Line cabaret. FURNITURE IN THE HOSPITAL 197 back of the chair, out of the patient's reach, and a strap with snap buckle fastens across the chest of the patient, about the height of the diaphragm. There are leg and foot extensions cither in one piece or two, and there are strap arrangements at the back of each extension about the height of the knee, so that straps can be fast- ened about the lower leg. If possible it is always advisable to leave the patient's hands and arms free, at least below the elbows. Sometimes this cannot be, as they get the straps off the rest of the body, hence there are rings in the under part of the arms of the chair, and there are elbow pieces made of padded leather into which the elbow fits snugly, with a padded strap in the bend of the elbow, and these elbow shackles are snapped to the rings through holes in the chair-arm. If the patienl cannot be allowed even wrist movement for comfort, the horizontal piece of the elbow shackel extends to the end and fastens about the wrist with a strap. A chair like this can be easily made out of metal to meet the particular require- ments of any case that promises to extend over a long period of time, or it can be bought of most of the hospital-supply manufacturers. RUGS Well people in the hospital — nurses, interns, and administrative officers — have the right to be as comfortable as possible, therefore they will most always have pictures on their walls, draperies in the windows, and rugs on the floors; these rugs can sometimes be made large enough to practically fit the room, and they can be cleaned with a vacuum cleaner, or rolled up and cleaned out of doors when necessary. Rugs in private rooms are concessions to luxury and are unsanitary at best; they should be vacuum-cleaned every day, and sterilized throughly when- ever a patient leaves the apartment as a part of the general cleaning; therefore, they cannot be very large, say 3 by 6 feet; such rugs can be taken up when the bed has to be moved, and they are small enough so that one or two bed-posts will not have to stand on them, which is objectionable. Private Ward Rugs. — The private wards of a hospital can be made much more comfortable looking and cozy if they have one large or several small rugs on the floor, and, since it is highly necessary to maintain the utmost cleanliness and sani- tation in these wards, a hard, bright-colored porous rug will answer the purpose better than a Wilton or Brussels, and there is such a rug made of Southern grasses, very economic in price, very easily cleaned or scrubbed, and capable of fumigation or steaming. It is sometimes known as the Crex, but about the same thing is sold under different names in most furniture and carpet houses. These rugs cost about 87 for a by 12 feet, or $1 for a 3 by 6 feet. They do not wear very well on a much-used floor or in the larger sizes. It will not be possible to include rugs among the furnishings of a public ward; first, because these wards are very much larger, and next, because ii is impossible to control the class of patients occupying them and the friends who visit them. SCREENS Bed Screens in Wards. — The screen to shield patients during the bed-bathing or dressing or examination is a rather important item. There are many such screens sold on the market, and none of them is acceptable; usually they are frail. It they are of metal they are too heavy to be moved readily, especially when the materia] is of heavy cloth or canvas, and where they have castors the castors are usually out of order. If they are made of wood and are light, the slightest push 198 EQUIPMENT OF THE HOSPITAL knocks them over, and the paint soon is worked off by cleaning, and they are not very sanitary. Generally speaking, these screens have hinges that are difficult to clean, and they are either left uncleaned or require very much time of the nurses to keep them in order. Figure 102 shows one kind of screen that answers a certain demand; it cannot be used for private rooms, as it is too large and heavy. Some institutions are equipped with screens about each bed; a cable is stretched on standards about 5 feet high, one at each post; there is a width of light canvas or heavy sheeting for each side and each end; the screens can be pulled back when not in use and fastened to the standards. This kind of screen adds greatly to the laundry if they are kept clean, and if not kept clean they are a menace to patients Fig. 102. — Bed screen for use in wards. on the score of sepsis. At any rate, they should not be used except when abso- lutely necessary, because they interfere very much with the circulation of air. There is another screen, made of two metal standards, 3, 4, or 6 feet apart, each one supported on widespread legs. The cloth is stretched across; one side of the bed can be shut off by such a screen, and its greatest disadvantage is that the legs are always in the way and it is constantly getting kicked over. Private Room Screens. — The three part, straight-sided, ordinary house screen, made of wood to match the furniture, with screen material of some pretty-figured wash stuff, probably answers all the requirements of private rooms. Door Screens. — Every door to a private room or private ward of a hospital — indeed, every door of every room intended for the privacy of individuals — should have some sort of protective device that can be made to take the place of a door, that will at once give the occupant of the room the air and light from the outside FURNITURE IN THE HOSPITAL 199 and protect him from the gaze of passers by. Figure 103 shows such a screen, one which may be well accepted as suitable for any place where such a device is needed. The frame is made of wood to correspond with the door. Simple detachable brass rods are placed across the upper and lower margins of each opening, so that hem- stitched linen or dimity or cheese-cloth fabrics, with a double hem, can be stretched across the openings. These fabrics may be changed whenever desired. These screens wherever used give such complete privacy to occupants of rooms, and allow such free circulation of light and air, that it seems almost impossible to do without . 103.— Door screen. them after they have been once used. They at once protect the privacy of the patient and admit the friendly sounds of life and bustle on the outside, so grateful to convalescents. THE PORTABLE BATH There is no unanimity of opinion that the portable bath is a necessary or even useful piece of institution mechanism. In some hospitals, notably the Johns Hop- kins, it is used regularly and in a routine way in the wards. In some of the insane hospitals it is employed for the long-continued, or even the continuous, bath for unruly, violent, or nervous patients; some dermatologists employ it for continuous 200 EQUIPMENT OF THE HOSPITAL bath in pemphigus, and a few surgeons like it for continuous bath for bad burns. There are objections to the portable bath. Generally, quite exact temperatures are ordered for patients where a portable bath is required, and generally, also, the bath is expected to cover long periods of time. It usually happens that there is no running water in the immediate neigh- borhood that can be conveniently used, and it almost always happens that the outlet of the bath-tub cannot be made to reach a check or sewer opening; therefore, the temperature must be raised or lowered by means of the bucket or vessel, and, unless extreme care is taken, the patient is often badly burned with hot water or chilled with cold. In order to reach its highest perfection in any of the cases referred to there should be hot and cold water for continuous intake, and a sewer outlet, leading directly from the bath outlet, in order that the water may be continuously changed and a correct temperature kept. Most of these portable wheel baths have a suspension bed inside, upon which the patients may be lowered or raised at will, and there are a few cases of one sort or another where they serve a most excellent purpose, but in the vast majority of cases where a portable bath would serve the purpose a permanent tub would do quite as well. It is not certain that the tubbing of typhoids and other high-fever cases cannot ordinarily best be done in the stationary baths about the wards, and in a number of excellent institutions that have the wheel baths, the Burr baths, Kelly pads, and rubber sheets for the bathing of patients in their own beds the stationary bath in the regular bath-room is usually employed; this for a number of reasons. First, the tubbing of patients is usually a sloppy, noisy, fussy procedure, and, having to be repeated at frequent intervals, it interferes very much with the comfort and quiet of other patients if it is done in the ward. Then it slops the floors very much and often the beds are wet, and the whole procedure is a sort of makeshift that is not the case where a patient is gently lifted to a stretcher or cart and taken to the permanent bath-room. Moreover, the continuous bath for pemphigus is losing favor with most dermatologists, and surgeons generally have gone back to the dry powder or to the open-air treatment of burns. In one institution, where the port- able bath is strongly advocated and frequently used, there is the apparently in- congruous condition of a separate room fitted up for it, with taps for hot and cold water to run in at the head, and with an outlet situated conveniently at the foot, so that new water can be continuously run in at one end while the used water runs out at the other. It would be interesting to learn just wherein the portable feature is advantageous under such circumstances, since the patient must be brought to this room quite the same as though the tub were an ordinary one fixed in the floor; the raising and lowering device has no special advantage, as the water can be accom- modated to the patient quite as easily as the patient can be raised or lowered to fit the height of the water. DECORATION IN INSTITUTIONS The furnishing of private rooms of a hospital, or similar institution requiring a particularly high order of sanitation, is not a very simple matter, and the simpler the furnishing the more difficult does the problem become, because of the necessity to preserve appearances. This is not quite so true regarding the furnishing of private wards, because the straining for effect and the necessity for "coziness" are not so great. For instance, the question of rugs and draperies, curtains, couches, and other furniture is a matter of a good deal of importance. A bare room looks FURNITURE IN THE HOSPITAL 201 uninviting, while draperies and table covers take away from the room much of that coldness and unhospitality felt by most sick people. Yet these articles of furni- ture are dirt catchers and vermin containers, and if the rugs and draperies are not cleaned frequently, the appearance of the room is worse than one furnished in ihe greatest simplicity, besides being positively dangerous. It costs a good deal to launder linen curtains and dresser covers and couch covers, yet this must be done very frequently if the room is to make a presentable appearance. Medical literature is interspersed freely with arguments for and against pictures on the walls of the sick room, the presence of books, and the circulation of magazines, and there is now almost a concensus of opinion that books may not be circulated or kept in sick rooms — that they cannot be fumigated efficiently — and most mem- bers of the profession object strenuously to pictures on the walls. It may be questioned whether a good deal of this protest against adequate furniture in a sick room is not straining at the small things; it is quite certain that the mental rest- fulness of a well-furnished room will oftentimes add greatly to the comfort and well being of the patient, and more than compensate for any harm that can come, especially if due diligence is employed to keep things clean and sanitary, but per- haps there is a happy medium that will permit of proper rugs on floors and lace draperies in the windows, with perhaps decorations of cheneille or similar stuff with linen covers in figures on the dressers or tables. This arrangement must always be presaged, however, by the understanding that these rooms are to be well kept, that the linens are to be changed at least often enough to prevent their use by more than one patient, and there is nothing more cold or disagreeable and discomforting than a bare floor, and in these days, wdien vacuum cleaners can be had that do good work with rugs, and when every room is supposed to be well fumigated with an effective germ destroyer, there would seem to be no adequate reason why a patient's comfort and luxury may not be considered. As for pictures on the walls that is a matter for each individual institution, and, if any are used, they should depict cheerful subjects, likely to take the mind of the occupant away from pain and the depressing influences of illness — prints of good originals, scenery, interesting ruins, and historical events. It should be a part of the cure in many cases to have a patient's mind diverted, and there is not very much in bare walls to hold one's attention away from himself. In children's hospitals heavy stensils may lie used in colors, either as a dado or frieze. There are whole stories of these now — " Mother Goose," " iEsop's Fables," etc. Of course, if the institution is to allow dust to accumulate behind these pictures, and allow the pictures themselves to be defaced and soiled, that is a proposition rather of censure for the institution than of the practice of having pictures. An institution that does not thoroughly clean every part of every room as soon as vacated by a patient and before another is admitted is neglecting one of the very first principles of institution management, and when we talk of hospital practice, or institution administration, we are assuming that things are done properly. Therefore, it should not be out of place to furnish cozy surroundings and some of the elements of luxury to patients in private rooms of an institution, whether it be a sanitarium, insane asylum, or general hospital. Similar conditions do not exist in wards, either small or large. Even where there are two patients in a room it. will be found impossible for many. months at a time to adequately fumigate and clean the room, because there will always be at least one patient present. In wards accommodating several patients, such fumigation and proper cleaning can only be done under the greatest emergency, such as the appearance of a contagious disease, when all the patients must be taken out and 202 EQUIPMENT OF THE HOSPITAL the room fumigated and cleaned thoroughly, and this will be found oftentimes to require a week or more, because the floors must be scrubbed and filled and refinished, the walls must be painted, and all of the wiring gone over, the pipes and radiators thoroughly cleaned, so that in these wards it would be impossible to have draperies in the windows or covers of heavy goods on the tables and dressers. It is not quite so certain that, even in large wards, a few carefully framed, cheer- ful pictures would not be appropriate, and if there is a proper fumigation room in the institution these can be removed to it occasionally and every visage of infection destroyed. BOOKS As for books for patients, there is no doubt they may carry within their pages micro-organisms that cannot be destroyed by any ordinary fumigation. Numer- ous tests have been made under laboratory conditions by the great libraries to determine the facts on this subject, and it has been found that even so easily destroyed a germ as the pyocyaneus, planted within the leaves of a volume, will resist the most extensive formaldehyd fumigation. So that while books and maga- zines would be in many cases most excellent diversion for patients, the dangers arising from their promiscuous distribution are so great that the practice should not be entertained. Books may be brought in by the friends of patients, and, if there is an adequate control of their circulation, there would seem to be no good reason why they might not be passed from one to another clean case, or from one case to another in which there is no micro-organic influence at work; but the circulating-library business of an institution is a dangerous one, and ought not to be encouraged. RECEPTACLES FOR CLOTHING Private rooms usually have ample. closet room for patients' clothing, and are furnished with chiffoniers and dressers sufficient for all the needs of the occupant of the room. There are other parts of the hospital, however, in which there must be accommodation for the keeping of clothing, hats, shoes, and the hanging of garments. Figures 104 and 105 show a most convenient form of locker. Usually it is made two sections in one piece, each section 15 inches square on the inside and about 5 feet high, with beveled top. It may be had with one, two, three, or four compartments or stories, according to the use to which it is to be put. The single compartment locker has a far greater usefulness in many parts of the house than that in which there are divided compartments, because it permits the hanging of dresses, trousers, and coats without folding. There is a shelf a few inches from the floor on which the shoes may be kept, and a second shelf a few inches below the top for hats and small articles, while the rest of the locker is fitted with hangers. This locker is a most useful piece of furniture for private wards, for the surgeons' dressing-rooms, and in the operating suites for the nurses' locker room and for the use of visiting physicians. It is fitted with a good lock, with upper and lower lock bar that prevents the prying open of the door either from above or below. It takes up very little room, and, being made in two sections, is flexible enough to be used in private wards. A sufficient number of these lockers can be placed against the wall at almost any part of the room not occupied by the bed, and its use is a source of great satisfaction, not only to the occupants of the wards, but to the nurses and orderlies and workers generally, FURNITURE IX THK HOSPITAL ju:; because it is not an infrequent occurrence that patients will take each other's things unless they arc kept under lock and key. Fig. 104. — Locker for elothin Fig. 105. — Locker for clothing. This is rather an inexpensive article of furniture, costing about $5 for each section. If it is not necessary to hang up outer garments and night clothes, the lockers may be in two sections, or even three or four, and then can be used like a chiffonier. EQUIPMENT OF THE OPERATING-ROOM There is a disposition among surgeons, interns, and nurses to litter up opera- ting-rooms with apparatus. Perhaps such a statement as this ought to be qualified by stating that where this tendency does exist a good many surgeons operate. In other words, in the modern hospital that practices the open-door policy, allowing almost any surgeon to schedule an operation, each surgeon will want a lot of things of his own, special instruments and special technic. In order to accommodate each r ' Fig. 106. — Operating-room too full of furniture. one of these men in their own way, the operating-room interns and nurses keep adding things to the operating-room equipment until they have right at their elbow almost everything that anyone can want for any operation under any cir- cumstances. In order to accommodate all these etceteras of operating procedure it is necessary to have a lot of shelf stands and tables, until the operating-rooms become so clogged with paraphernalia that no one can move about. The ideal operating-room can be obtained, of course, when there is only one man who works there. The furnishing of such a room can be of the plainest sort, and ought to be; the operating table, the instrument tray that sets above the 204 KtiUIl'MKNT OK THE OI'KRATING-ROOM _'n:, patient, a tabic and stool for the anesthetist, and perhaps a shelf stand over in the far corner of the room are about the only pieces of furniture needed. Everything else can be in an adjoining room, pre- sided over by one careful nurse, who can pass out additional instruments, packages of combination, sponges or packing, and who can take away the used sponges. It goes without saying that this annex room must be a sacred place, not open to the intrusion of anyone, and the presiding nurse must be one who can be implicitly relied on, both as to efficiency and conscientious- ness. Such an arrangement as this presupposes a single surgeon, with a minimum number of assistants and a simple technic. The two extremes of operating- . room furniture are shown in Figs. 106 and 107. In Dr. William J. Mayo's room a "sister" is the only assistant, and she works opposite the operator all the time, year in and year out. There is a nurse placed over against a far wall where the instruments are, and whose duty it is to see that the operator gets what he calls for and to keep out of the way. An intern is present in the room, having brought the patient up- stairs; he will also return the patient to bed; his only other duties are to read ; an extract from the record when called upon and to thread a needle occasion- ally. He renders no other assistance. This system, however unsatisfactory it may be from the standpoint of the intern and nurse in the matter of training, is certainly simple. The operator has a perfectly trained assist- ant, and does his work expeditiously and without any unnecessary fuss at the hands of beginners. In the Michael Reese Hospital (Fig. 106) there are always five assist- ants and generally six an anesthetist, a senior assistant, and three nurses, an instrument nurse, sponge nurse, ami "supe" to take away, count, and hang up used sponges, pass needed articles to the instrument nurse, etc. Generally there is a second senior medical assistant to hold retractors, especially in deep abdominal 206 EQUIPMENT OF THE HOSPITAL work. Different institutions have different ways of doing these things, all the way from the simplicity of Dr. Wm. J. Mayo to the intricate technic of the Michael Reese Hospital. It is the personal judgment of the author that there is a happy medium between these two extremes, and that a small amount of operating-room furniture can be used advantageously; but it should be kept out against the walls and away from the center of the room. Of course there is a fair proba- bility that Dr. Wm. J. Mayo goes farther in the way of simplicity in furniture, in order to accommodate his custom of wheeling the operating table about the room at various interesting stages of the proce- dure, to show the field to the clinic oc- cupying two sides of the room. Operating Tables. — It is a peculiarity of the surgical profession that, as soon as one of its members has got far enough along to be on speaking terms with a def- inite technic, the first thing he does is to develop original ideas on the subject of operating tables, until there are about as many designs as there are surgeons. Fortunately, most of the new ideas are de- veloped around tables already in the rooms, and consist of pieces that fit into sockets made for something else — shoulder pieces leg pieces, head pieces, and pieces to ac- commodate almost every inch of the body for some special operation; and fortu- nately, again, storage rooms for junk are usually at hand to swallow up in their dusty caverns most of these ingenious de- vices "until they are needed." The only clearly discernible fact about operating tables is that no two operators can be appeased by any one table, and the wise hospital administrator who needs a table will fix the maximum price he is willing to pay for it, and give the operator who is to use it carte-blanche within those figures to go and buy what he wants. If several surgeons are to use it, he has one of two horns of the dilemma to choose from — either give over the selection to the surgeon who seems to know what he wants, and makes the greatest row if he doesn't get it, or ignore all of them and buy the table himself. He can then stay out of the operating-rooms until some new and greater calamity comes to divert everybody's attention. If this latter course is chosen, a few principles in operating tables ought to be kept in mind. In the first place simplicity is a jewel, and complications breed woe at critical times. The table that "works like a charm" in the show rooms generally fails to work at all when some instantaneous move must be made, per- haps to save a patient who has suddenly gone to the bad. Any one of half a dozen tables readily admit of a satisfactory Trendelenburg, Cunningham, and the vari- ous lithotomy positions. s*c hi Fig. 108. — McArthur's head rest. EQUIPMENT OF THE OPERATING-ROOM 207 There are some points about the Hartley table, made by the Hospital Supply Co., after the design of Dr. William Hartley, of New York, that make it perhaps the most satisfactory of all, taking everything into consideration, that it admits of the Trendelenburg, lithotomy, and Cunningham positions in all their variations. Only in one or two slight particulars does it fall short; one of these is that the shoulder braces for the position of perineal prostatectomy are too low down, as they allow the patient to slip forward, so that the surgeon must work over the edge of the table, which prevents free access to the field of operation. This can be remedied, Fig. 109. — Hartley operating table in Trendelenburg position. however, by a little different design of the shoulder brace, giving it an arm that will throw the brace about 4 inches lower toward the foot of the table. This arm can be made, with sliding set-screw attachment, to meet the requirements in any size of patient. Another detail in which the Hartley table seems to not quite meet all the demands in brain surgery is in the fixed head rest. These head rests have an extension arm, and they do not provide against vibration in chiseling operations which they are intended to do. Dr. L. L. McArthur, Dean of the Michael Reese surgical staff, has added to the table for brain operations a simple, strong head rest, composed of a heavy upright piece of tubing set upon three legs: a strung 208 EQUIPMENT OF THE HOSPITAL cup is fixed at the top of this stand to rest the head in. This form of head rest can be raised or lowered, either by set-screw attachment at the junction of the legs or by archimedian screw or worm gear; the head cups are made in several forms, to fit the head in any position. The Hospital Supply Co. makes this head piece, a cut of which is shown in Fig. 108. The hot-water containers in some operating tables seem not to be desired by most surgeons, and, where the hot-water containers are present, they are rarely used, except in cases of small, very delicate children; and for work with children, the complexities of the Hartley table are in no demand whatever, so that for Fig. 110. — Hartley table in position for kidney work. childrens' surgery the simplest form of table is one in which the whole table is a warm-water container, and the only movement required one that will raise the body and lower the feet, or vice versa. Whether the operating table shall have a white enameled, or glass or gun metal or bronze top, is rather a question of taste. Perhaps the top made of cast steel with baked white enamel — that new form of table top that seems now to be fashionable — may be finally agreed upon as the most easily cleaned as well as the most durable top. Glass is more easily broken, but it is more easily kept in good condition, and it certainly gives a comely appearance to the table. Gun metal, EQUIPMENT OK THK Ol'KKATIXG-ROOM 209 steel, and brass are eventually marred by contact with acids and blood, but any of these tops will give satisfaction, and the question of which one shall be used is hardly worthy of serious discussion. Whatever table is used there ought to be large ball-bearing rubber-tired wheels, with a locking device that will hold them absolutely when the table is in use. It is extremely desirable to have good wheels, because in most modern hospitals patients are anesthetized on the operating tabic itself, so that it will be unnecessary to drag them about from the stretcher to the table. It is quite as necessary, how- ever, to have an attachment that will lock the wheels, so that the table will not move about under the surgeon's manipulations. A X Fig. Ill— Shelf rack. Figure 109 shows a Hartley table in the Trendelenburg position. A glance at the shoulder braces will indicate the defect pointed out above. The same table is also shown in position for kidney work (Fig. 110). Shelf Rack. — The next most important piece of furniture in the operating-room is the shelf rack, shown in Fig. 111. This rack is made of two pieces of gas pipe, white enameled. 5 feet apart, connected by shelving of heavy plate glass. The feet are shod with rubber lips. This shelf usually contains the various powders, catgut in its various forms, some 210 EQUIPMENT OF THE HOSPITAL I I f! Fig. 112. — Instrument tray stand. Fig. 113. — Drum stand. few solutions in small quantities, and jars containing gloves, iodoform gauze wrapped in oiled paper, plaster-of-Paris bandages, adhesive rolls, and odds and ends of opera- tive procedure. EQUIPMENT OF THE OPERATING-ROOM 211 Instrument Tray Stand. — The instrument tray stand is indicated in Fig. 112. This is merely a stand on wheels, made of four tubular, white enameled legs, joined by enameled brass angle iron at the top; and another section of the same, 14 inches lower down, with angles made so that the instrument trays set into their respect- ive places securely. The whole table is 36 inches high, 43i- inches long, and 11 f inches wide. The instrument tray that belongs to this stand is made of perforated metal of any kind, preferably aluminum, because of its non-corrosiveness. The objection to the instrument tray is. in- ability to find a handle that will not heat, or that will cool quickly; but this objection is common in all the makes, and is overcome by the use of metal handles, made in the shape of retractors. The tray handles are picked up with them. Fig. 114.— Sponge rack. Fig. 115. — Irrigator cart. Drum Stands.- -Most modem hospitals use their sponges, packing, and various dressings directly out of laparotomy drums in which they have beeu sterilized. The stand for these drums operated by foot-pedal is shown in Fig. 113. This stand was designed for the New York City Hospital, and is a most convenient and accessary piece of operating-room furniture. The table shown in connection with the stand is not necessary, and serves to render the whole piece of furniture 212 EQUIPMENT OF THE HOSPITAL cumbersome and awkward to handle. A much smaller, table upon which to handle the dressings will answer every purpose, and, being independent of the drum stand, can be moved readily, and the whole equipment will be much more convenient for that reason. The drums themselves are circular in shape, 10§ inches high, 14 inches in diameter, and operate by means of a triangle fastened into the top, which hangs in the arm extension of the foot-pedal. The fastening device is a staple and hasp that may be locked by a padlock. The circular band of metal around the top and another around the bottom, per- forated to fit similar perforations in the drum itself, serve to open and close the drum as it enters and is taken from the sterilizer. Fig. 116. — Arm immersion stand. The electric drum, made similar to the ordinary drum, but 13| inches high in- stead of 10^ inches, containing electric-heating coils on the inside, and designed for St. Luke's Hospital, New York, seems to be a superfluous piece of apparatus. The coils soon burn out, and the utensil is rendered useless. Sponge Rack. — Figure 114 shows the best style of sponge rack for operating- room use. It consists of a standard mounted on four feet, 60 inches high, with three horizontal bars, 40 inches long, 14 inches apart, containing hooks 2 inches apart. There must be ten hooks on each side. This sponge rack is designed by the Michael Reese Hospital, especially with reference to the make-up of the drums, described on page 352 in the section on Operation. Irrigator Cart. — Figure 115 shows an operating-room irrigator cart designed for the Michael Reese Hospita.l A worm gear in the telescope upright raises and EQ1 IPMENT OF THE OPERATING-ROOM 213 lowers the irrigator jars, and the mechanism is on wheels, so thai it can be moved readily. It is perhaps the best irrigator arrangement for general use in the hospital, as well as for the operating-rooms. Instrument Table. — The instrument table for the surgeons' use is merely an extension of the principle of the ordinary bedside table. Instead of special fittings this table may rest in a socket designed for that purpose as a part of the table. There are no advantages in any particular make. B Fig. 117. — Solution rack. Arm Immersion Stand.— The arm immersion stand for operating-room use is shown in Fig. 116, in connection with the solution basins. This combination of basins and stand is to lie preferred to the two separated, since the immersion stand in this case takes up no more room and serves every good purpose. It is made of any metal that will permit a permanenl burning in of white enamel. In most of them the enamel soon chips and the metal rusts, a most undesirable thing where asepsis and cleanliness are prerequisites. Solution Rack.— A somewhat cumbersome and quite costly piece of mechanism, 214 EQUIPMENT OF THE HOSPITAL yet one that will oftentimes serve a very good purpose, is the solution rack, shown in Fig. 117. The purpose of this rack is to contain various solutions in large quantities. It was designed for battleship use in the United States Navy, and is so arranged that the sections can be turned upside down, or the upper tier of bottles can be changed to the lower tier by release of a spring and with simple hand move- ment. It is not worth the price asked for it for land hospital uses. Fig. 118. — Solution rack. Goose-neck Reflector.— Figure 119 shows a goose-neck flexible reflector light for operating-room use, designed by Dr. Greensf elder for the Michael Reese Hospi- tal. The advantage of this particular style of reflector is mobility and the flexi- bility of its light to any point for a survey of the field. It is made by the Hos- pital Supply Co. Operating-room Sinks.— There is very little to be said about the operating- room sinks, excepting that they shall have abundant shelf room beside the basins, to contain the jars of sterile brushes, nail files, Schleicht or marble-dust soap, and green soap. The faucet connections may be either knee, elbow, or foot move- ment, but, in either event, must be so connected that the flow of water, both hot EQUIPMENT OP THE OPERATING-ROOM 215 and eokl, must immediately stop with the removal of the elbow or foot. In a good many hospitals, where there is a knee action, the movement of the knee starts the How, hut docs not stop it. In nearly every hospital the wasli water in the operating-room is sterile, which means that it has cost fuel to make it ready, and fuel eoMs money. Where the movement is of this character il i- the hal.it of surgeons to start the water and let it run, and sometimes it is left running dur- ing the whole of an operation, which will always mean a drain on the coal pile. Sur- geons, as a rule, object to mechanism in which the water stops running with the removal of pressure. The reason they give is that it requires too much attention to attain the right temperature of water; this, however, is merely an inconvenience to them and requires a little more of their atten- tion, , while the constant flow type of the faucet means a constant drain on the coal pile, and this, repeated throughout the house, runs into money rapidly. Whether the action of the faucet shall be by movement of the elbow, the knee, or the foot is rather a question of taste and convenience; the foot action answers every purpose, with the pedal low enough to rest on the floor, and thus give a fulcrum to the foot when the pedal is pressed upon. There are knee action, spring faucets with some of the newer plumbing, but they do not act smoothly, and surgeons object to them because too delicate adjustment is required to obtain the right temperature of water. Soap Containers. — There is a universal demand for a green-soap container, fixed to the wall above the basin, operated by foot or knee action, that will release the green-soap solution in a practical, convenient way. There seems to be no such device on the market. There are a number of these soap containers offered for sale, but they soon get out of order, and after the soap has been in them for a few hours they clog and fail to operate. Such a piece of apparatus of a workable sort, practical in its operation and that would not get out of order, would fill a much-needed place in operating- and dressing-rooms. Instrument Cabinet.- A very necessary piece of furniture, not for the operating- room itself, but that musl be nearby, is the instrumenl cabinet. Figure 120 shows such a cabinet of practical design, easily cleaned, and well lighted. The beveled top and back are of sheet metal, white enameled, and the door frames and front are of angle-iron white enameled. The shelves and doors and ends are of plate glass. giving at all times a full view of the instrument- in the cabinet, and making it cer- Fig. 119. — Goose-neck reflector. 216 EQUIPMENT OF THE HOSPITAL tain that dirt and dust can be readily seen, and hence the cabinet will be kept clean. It does not seem desirable to have these instrument cabinets very large. The one in the cut is 72 inches wide over all and 84 inches from the peak of the beveled top to the floor. It would seem preferable to have more than one cabinet rather than a larger one in one piece because of the difficulty in moving, and also because there will rarely be a location where a greater space than this can be well lighted. It will, of course, be necessary to have an excellent lock on all instrument cabinets, preferably one in which the turning of the key will release top and bottom plunge rods, so that the cabinet door cannot be pried open easily. The instrument Fig. 120. — Instrument cabinet. cabinet should be kept at a distance from the operating-room itself and from the sterilizing room, so that the instruments will not come in contact with the moisture and steam incident to sterilization and the use of hot sterilizer instruments in the operating-rooms. Every cabinet should contain a hygrometer, or moisture gauge, and these gauges should be inspected frequently and heeded, in order that the instruments may be kept dry and free from rust. Purely Technical Apparatus. — There are certain pieces of apparatus that do not properly come under the head of furnishings, and are not necessarily a part of the equipment of the operating-room, apparatus that might be classed as instru- EQUIPMENT OF THE OPERATING-ROOM 217 ments perhaps, but some of these things are so common in the operating-room of to-day that, by stretching a point, we may call them a part of the mechanical equipment. Some of these things are: The gas anesthetizing apparatus, bone drill, cautery machine, and electric battery designed for lighting cystoscopic lamps. Anesthetizing Apparatus. — The anesthetizing apparatus, for the giving of ni- trous oxid gas over long periods of time in certain classes of operative cases, is a very important mechanism. Figure 121 shows this apparatus, designed by the Michael Reese Hospital, in use in that institution for the past four years. Another Tip,. 121. — Apparatus for administering nitrous oxid gas. design for the same purpose, and quite as efficient in its operation, has been made by the Teter Manufacturing Co., of Cleveland, Ohio. The Michael Reese appara- tus has never been placed on the market, hut is made on order by the Chicago Sur- gical and Electrical ( !o., < Chicago. The mechanism consists of a stand with double arms at the top. ( )n one side are the two oxygen tanks, and on the other the nitrous oxiil tanks. On each side, and between the tanks and the upright of the stand, is a gas-bag, one to contain nitrous oxid gas and the other oxygen. Valves are placed at various points, by means of which the gas or oxygen is released into the bag. There are several varieties of the bag used; that made by the Teter Manufacturing Co., of pure gum with t wine-net covering, is the besl . as it is elastic, and either the 218 EQUIPMENT OF THE HOSPITAL oxygen or nitrous oxid can be kept under pressure, so that it can be paid to the patient as required. There is a 5-foot tube of woven silk with rubber lining lead- ing from the tank to the face-mask. This tube is kept expanded by wire coils inside. The face-mask used is a patented article, sold by the S. S. White Dental Manufacturing Co., the chief feature of which is a rubber air-cushion rim that fits tightly about the face of the patient, so that all outside air can be excluded. By all odds the chief factor in gas anesthetization is the operator, and the giving of continuous gas is so much of a modern art that the subject will be treated in detail in a special section in this book, under the heading " The Anesthetic," from the administrative standpoint. The Cautery Apparatus. — There are many types of cautery outfits on the market; most of them have only a small output of current, sufficient for heating small cautery knives; others have a large output of current, only suitable for the heaviest electrodes. 7HoloT -Generate. Fig. 122. — Cautery apparatus. The diagram shown herewith (Fig. 122) illustrates a cautery apparatus that has a wide range of output, making it possible to heat anything from the most deli- cate cautery knife to the heaviest electrode. It consists of a small, but powerful, motor generator, which changes the direct current into alternating, which in turn is converted through an induction transformer into a cautery current. Perfect control of the output is afforded by means of two wire rheostats. The speed- controlling rheostat regulates the volume of the alternating current before it reaches the transformer. When no current is taken from the transformer the motor runs freely, and does not consume a wasteful amount of electricity. This method of control also assures a full efficiency of the motor. The cautery-controlling rheostat controls the current supplied to the cautery electrode from the transformer, and has a range of current wide enough to heat the smallest cautery knife as well as the heaviest electrode, without danger to the one or fear of inefficiency in the other. EQUIPMENT OF THE OPERATING-HOOM 519 A common annoyance with heavy cautery electrodes is the frequenl breaking of the porcelain tips carrying the platinum wire. This has been eliminated l>y u.-ing a specially made lava tip instead of porcelain, as lava is extremely tough and practically indestructible. Lava also retains heat much longer than porcelain, which adds to the efficiency of the electrode. In coming in contact with blood or any other liquid, the porcelain tip often cracks in several pieces while the lava tip remains intact. The base of the cautery apparatus may be slate or marble, as they cost about the same and are equally efficient. Either will break if allowed to fall, and. a- the apparatus must be mounted on a portable carriage for use anywhere in the insti- Fig. 123. — Author's bone drill. tution, it is necessary to choose carefully the vehicle on which to set it. There should be large, easy running wheels, set under standards spread well apart, so thai the outfit will not tip over easily. This apparatus operates off an ordinary lamp outlet, using a common drop- cord socket. Bone Drill. — For many years — that is, ever since brain surgery became a scien- tific practice — surgeons have demanded an apparatus that would give them more than the trephine, an apparatus that would permit the making of large bone Baps, through which major operations, such as removal of tumors ami exploratory exam- inations, may be done. There are three forms of mechanism offered on the market for this purpose: 220 EQUIPMENT OF THE HOSPITAL One is the hand apparatus, on the principle of the brace and bit; the other is an adaptation, with modified tools, of the dental drill ; the third is the direct employ- ment of the small motor with the tool fastened in its armature. The end desired in a bone drill is not only to cut through the bone, but to do so rapidly, in any direction and in such a way that the dura mater will not be wounded. Some excellent surgeons prefer one of the instruments suggested and some another. Largely, however, it has been a matter of dexterity and skill on the part of the sur- geon himself, and he has divided the honors with his instrument. Speaking broadly, none of the three mechanisms does the work well. The brace and bit mechanism is awkward, works slowly, and is likely to plunge down upon the dura, even in the most delicate handling. f ti TTT^ TTT m Fig. 124.— Tools for use with author's bone drill. The second mechanism is that designed by Dr. Hartley, of New York. It is heavy, too difficult to control, and more likely even than the hand mechanism to plunge down upon the dura, because the operator must hold the eight- or ten-pound motor up against his chest or abdomen, and has no substantial leverage by which to delicately control his pressure. The dental drill is very much too small an affair, either to drive a trephine or any tool of considerable size. The author has designed a bone drill, shown in Fig. 123, that some of the surgeons have been good enough to say meets the requirements of brain surgery. It has been necessary, however, to design also a number of tools different from those heretofore in use, a group of which are shown in Fig. 124. This apparatus consists of a half-horse, shunl-wound, direct-current motor that drives belt-wise the rotating drill that has its movement in the covered cable, as EQUIPMENT OF THE OPERATING-ROOM 221 shown in the cut. The 6-foot cable shown in the hand of the operator is made of bundles of steel wire wrapped. The covering is a flexible steel tubing used by the electric people for interior conduit work, enclosed in a leather case treated with an oil-asbestos preparation that permits its sterilization. The tool holder a\ the end of the drill is a clamp operated by the finger, in which a turn or two releases or tightens the tool, and then- is a shoulder at the end of each tool that fits into the end of the clamp. There is no new principle in any of this mechanism. It is the application of a large number of old principles to achieve the desired result; and the only particular Fig. 125. — Examination chair. in which this apparatus differs from others is the increase in driving power of the drill, the flexibility and workableness of the moving mechanism, the difference in some of the tools, and the fact that the shunt winding of the armature allows the operation of the full power of the motor on cither slow or fast speed. One of the surgeons who uses this drill makes three trephine openings, forming a triangle, slips a flexible steel duck-bill director into one and along toward another, between the dura and the bone, and works the saw above the director. The Victor Electric Co., Chicago, has recently put on the market a very excel- lent machine that wants very little improvement, namely, a good hand-hold in the 222 EQUIPMENT OF THE HOSPITAL tool mechanism. They also do not make a good or serviceable variety of tools. The machine is made to set on a table, which is not the best arrangement, since very often there is no convenient place to set a table. The author's hand-hold is far better than theirs, and his small tower on wheels is more adaptable to the space of an operating-room. Their tool-clamp method is better than his. Cystoscopic Battery. — The small lights in the cystoscope and proctoscope are made to work at four volts direct current. Ordinarily, operators take their current for these lights from the regular lighting circuit in the institution, using a rheostat to lower the voltage. Those who have used these instruments know how frequently their lamps burn out while they are making an examination, necessitating the remo- val of the instrument constantly, a lot of pain, the insertion of new lamps, and a second introduction of the scope, with additional great pain and loss of time. The Eclipse head lamp in use. burning out of these lamps is due to irregularities in the voltage of the lighting circuit itself. The scheme, then, is to provide a current of electricity that will light these small lamps up to their maximum voltage, and that will, under no cir- cumstances, permit of a high enough voltage to burn them out. The author has made for this purpose a small battery, composed of 6-1 ampere, one volt dry cells. The cells are placed in a box connected in series, and a simple button switch is placed on the top of the box, with the two connections at the side. With this mechanism one may turn the switch from one to six cells (that is, from one to six volts, and the battery is not capable of a higher voltage, so that the lamp will under no circumstances burn out. This little device can be made by the electrician on the corner, and it has given great satisfaction to the genito-urinary surgeons who have used it. EQUIPMENT OF THE OPERATING-ROOM 223 Special Apparatus for Special Departments.— In the eye car, nose, and throat operating-room, or in the case of the small hospital, the special apparatus that will be required for eye, ear, nose, and throat operations are an extension light, a head lamp, and a special chair. This apparatus need not be expensive. Figure 125 illustrates a convenient, inexpensive, and competent examination chair, and one that will do very nicely for the simpler operations that require only local anesthesia. This is merely a strong chair, with support for the back of the head. There are many more elaborate chairs than this, some that hold the head by a clamp action in precisely one position. Such an apparatus is not only costly. but it falls far short of the purpose intended, in that the effort on the part of the Fifj. V27. — Dressing cabinet. patient to get away from the instrument and the inflexibility of the bead supporl make it all the more difficult for the operator to keep, the head where he wants it. It is the experience of nose and throat men that the patient whose head rests easily, and without a clamp, will hold still much better than one whose head is fixed immovably. Figure 12G shows the eclipse head lamp, which has perhaps fewer disadvantages and more advantages than mosi others. The reflector is bell shaped; the lamp it-elf is small, by comparison; the combination allowing the light to lie thrown into a rather narrow field in front of the operator, whether it be the field of operation in a deep laparotomy or mastoid, or whether it be the examination field in the throat, 224 EQUIPMENT OF THE HOSPITAL nose, or ear. This lamp is commonly used by nose and throat surgeons in the performance of tonsillectomy and the removal of adenoids. A particular advan- tageous feature is the mechanism of the head piece, which is formed of a pad of asbestos felt. Unfortunately, the cover to this felt asbestoid is made of a cheap black-colored cambric, which runs when the operator perspires. This may be avoided by lightly sewing on to the head piece a band of oiled silk. This lamp may be had of almost any of the surgical supply houses, and costs about $5. Dressing-rooms. — The dressing-room is a place where much work is done, but where little apparatus need be used. A regular operating table of almost any Fig. 128. — Dressing carts. design, or a gynecologic chair, may be used for the patient. Whichever is em- ployed, the coverings must be so arranged that the waters of irrigation will run immediately into a basin or bucket on the floor. This can be done with rubber cloth, a Kelly pad, or a Burr bath apparatus. The. most important article of furniture in the dressing-room is the dressing cabinet, illustrated in Fig. 127. The drawers of this cabinet will hold practically all the details of any dressing, and the shelves will hold the solutions, powders, syringes, and whatever j ars may be required . The only advantage of this particular form of cabinet is in the large number of drawers it contains and the ease of access to those drawers. EQUIPMENT OE THE OPERATING-ROOM 225 The basins, percolators, and general furniture are practically duplicates of those used in the operating-rooms. Dressing Carts. — One of the handiest pieces of dressing-room apparatus, al- though it is not used in the dressing-room itself, is the dressing cart, illustrated in Fig. 128. This is merely the three-wheeled percolator cart \\ ith worm gear, made by the Hospital Supply Co. especially for the Michael Reese Hospital, and chd in- rated by the author by the addition of shelves, as indicated in the illustration. The percolators may be filled with the necessary solutions; the turret at the top may be filled with powders and whatever solutions or drugs are usually employed in the dressings; one of the shelves may contain a basin to be used for catching the waters of irrigation, and the other shelves may contain instruments, bandages. Fig. 129.— Gynecologic table. adhesive plaster, gauze, and dressing drum. The particular advantage of this cart over others that are offered for sale is in its ease of handling, because of the short- ness of the cart, the single front wheel, and the movable tongue. The cart may he wheeled into the ward or into a private room for the dressing of a patient that cannot be taken to the dressing-room proper. Gynecologic Table. — In the gynecologic dressing-room the only feature that need , be mentioned is the dressing-table itself, illustrated in Fig. 129. This dressing- table is simple in its construction and design, comparatively inexpensive, with enameled metal top and moving mechanism to place the patient in any of the classic dressing positions. The step on the side, as shown in the illustration, differs somewhat from most tables, in which the step is at the foot of the table, and this seems to be a desirable arrangement in the estimation of a good many gynecologists. 15 EQUIPMENT OF THE KITCHEN Ranges. — The size of the institution and the consequent size of the kitchen will make very little difference in the arrangement of the kitchen for convenience. What will be convenient in one will be convenient in another, and what will tend toward sanitation and cleanliness in the one will tend toward the same virtues in the other. By all means the ranges, whatever their size and construction, should be in the middle of the floor. The make of kitchen ranges is not a matter of supreme importance. Most of those on the market answer the purpose intended. The good features of any range contemplate the concentration of heat on all sides of the oven, with an abundant supply of heat distributed to the top of the range. The question of fuel may just as well be briefly discussed here, because the con- struction of the ranges will depend a good deal on the kind of fuel to be used. In this matter there is hardly a choice. Hard coal, when it can be had, is the only fuel for kitchen purposes. Gas, whether it be artificial or natural, is far too expensive; soft coal is too dirty, and its heat power is too low. Some illuminating figures might be given showing the relative economy of gas and hard coal. In round figures, gas, even when it is to be had at most economic prices, will cost at least four times as much as hard coal in any central part of this country and give less satisfaction. The exception in the use of hard coal is in the matter of broilers; it is doubtful whether coal will give that even distribution of heat for broiling purposes neces- sary to proper preparation of the food, and gas seems to meet these requirements far better. Almost any of the broilers and toasters on the market will meet their several requirements. Of course, the broiling and toasting must be done below the fire, and there will be a considerable economy in fuel if the flame burns against a heavy steel asbestos-backed plate, the heat radiating, not from the gas itself, but from the heated plate above. When this mechanical construction is employed the evenness of the heat can be much better controlled than where the heat of the flame itself is to be depended on. If there is to be very little broiling or toasting, and that little at long intervals, the heat of the heavy plate will require too much time and too much gas, but in most institutions there will be sufficient work to justify the heating of the heavy steel plate for each meal. There ought to be shelves in the superstructure of all ranges for pans, spoons, forks, and kitchen tools generally that are constantly employed at the stove. If the cook can reach for these things without having to leave the front of the range there will be considerable economy in time. There should not be any arrangement for the warming of plates or dishes in connection with the ranges except in a very small institution, where a separate dish warmer would hardly pay; they will always be subjected to grease and the natural soiling processes of the range atmosphere. The Kitchen Table. — The next most important thing in the kitchen is the table, which should extend at least the length of the range and broilers, and it cannot be made too substantial; it must certainly be made of 2-inch stuff for the top, and the best are made of 2 by 4 inch edge grain Georgia pine for the top. These two by fours are planed on both sides, and enough of them are laid side by side on edge to make the whole top of the table. If properly made there are no cracks, and these pieces can be bolted so tightly together that they make practically a solid top 4 226 EQUIPMENT OF THE KITCHEN 227 inches thick. Of course there will be drawers for keeping all sorts of range, carving, and serving utensils. The drawers should not continue to the floor; there should he sufficient space underneath to permit mopping and cleaning; besides this, cooks like to stand close to the table when they are working, as the strain on the back will be less, and if there is no place under the bench for their feet they cannot stand close. Dish Warmers. — In serving meals, naturally the cook and his assistants will stand between the table and the range. On the other side of the table will be the Fig. 130. — Dish warmer. serving maids or men, and just back of these servers is a place for the dish-warming apparatus, and this piece of mechanism is rather an important one. It need not be complicated in any way, but it should be of considerable size, large enough at least to hold all of the dishes necessary to be used for any one meal in all those por- tions of the house for which the food is to be served in the dishes. A good part of the institution will be served from the serving rooms on the floors, and the food will be transported in food boxes, to be described later. This dish-warming apparatus consists of two upright metal pieces, preferably of J-inch sheet steel or iron, strengthened with upright eye beams. Shelves are 228 EQUIPMENT OF THE HOSPITAL placed between the uprights, made also of sheet metal, supported on eye beams, with central upright supporters made of eye beams if necessary. Each one of these shelves is turned down at the front and back edge for an inch, and just under each shelf will be a sufficient number of steam coils to serve the purpose; the width of the mechanism will be 12 or 14 inches. Figure 130 will give the principal points in this dish-warming mechanism. It is a very simple affair and very serviceable. The back and front can be closed with an ordinary duck curtain, and nearly all the heat will be retained when this curtain is drawn. It will be only necessary to turn on the steam fifteen or twenty minutes before the dishes are to be used. Steam Table. — Another piece of mechanism in the equipment of the kitchen that must be chosen with care is the steam table. This article will be used mostly for cooking cereals over night and during the day, and keeping roasts and vegetables warm. Almost all of the steam tables on the market now are efficient and adequate to do any work called for, and there is hardly a choice, excepting perhaps in the material, finish, and the arrangement of the compartments. The steam baths and warming apparatus are practically the same in all of the makes, so that in buy- ing a steam table there are practically two considerations only: first, to get a table large enough to do not only the present work, but in anticipation of future growth of the institution, and to get a table apportioned in regard to its compartments, so that it will meet the requirements intended. Manufacturers are not always the best judges as to how many vegetable, meat, and cereal compartments a steam table should have, and the purchaser must use his own judgment. The second considera- tion in purchasing a steam table is the price, and that will depend a good deal on the material used and the workmanlike manner in which the table is put together. We must remember that a steam table is intended to last a great many years — a generation — if properly made and properly used, so it would be false economy to select, for instance, galvanized iron or any material capable of corrosion, when a few more dollars would buy the best heavy copper. Dish Washers. — If the dishes used by the nurses and interns and hospital help are sufficiently numerous, and can be readily assembled at one point, it may well be economy to install dish-washing machinery. In hotels this can readily be done because the dining-rooms are placed together and all the dishes placed approxi- mately at one place; there is, undoubtedly, a good deal of economy to be practised in having dish-washing machinery when the dishes can be assembled in large quan- tities. With dish-washing machinery about as many people are required to do the work as where it is done by hand, but there is an immense saving in the time occu- pied in the work, and the people who are charged with the dish-washing work can then go to some other occupation. In a dish washer there are two or three fundamental principles to be observed. One of these is that the dishes must be so fastened in the machinery that they will not move about and break, and at the same time they must be so placed that the insides as well as the outsides can be thoroughly washed. Economy of space for the machine is important because oftentimes there is not a great deal of room in the scullery for the machine; the mechanism must be simple, so that ordinary dish washers can manipulate it without danger either to themselves or to the machinery, and last, but by no means least, the mechanism must be of such character that water and slop and steam will not be allowed to get all over everything in the room, and there must be economy in water and, more especially, in soap. There are several dish-washing machines on the market, the best of which, at least until very recently, is the Insinger machine, made by the Insinger Co., of Philadelphia (Fig. 131). This washer answers all of the requirements; it has two EQUIPMENT OF THE KITCHEN _'_".! tanks, each of which is operated by a propeller, driven by a motor placed at one end of flic machine. The dishes are fastened in the crate so thai they are immovable, and they do not touch one another; they remain stationary during the whole proc- ess, and the motion comes entirely from the water, which is propeller-driven in the tank. The dishes are first placed in one tank, which is filled with water at about 60° or 70° F., and the water is agitated by the propeller until the dishes are practically clean; there is an automatic arm working from above that lifts tin- crate out of the cold water into the next tank, in which the water is kept at the boil- ing-point; again the process of violent agitation takes place, and whatever residue of grease remains on the dishes is carried away and they are thoroughly cleaned. Fig. 131. — Insinger dish-washing machine. The boiling-point of the water is sufficient to sterilize the dishes, and it makes them so hot that when they arc again lifted out by the automatic hoist they dry themselves thoroughly. This machine is made in several sizes, one with a capacity of 12,000 pieces per hour, another with a capacity of 5000 or 6000 per hour, and there are smaller ones. It would seem that any place that is not large enough to require at least a 5000 or 6000 capacity machine would hardly be large enough to justify the installation of such a plant. With this particular machine the breakage is extremely small — in fact, a negligible quantity — and there are other machines that break a great many dishes, This machine costs more than most of the others, perhaps 10 or 15 per cent, more, 230 EQUIPMENT OF THE HOSPITAL but the saving in dishes would more than justify the additional expenditure. Figure 130 shows this machine with the motor mechanism, one of the crates, the two tanks, and the automatic hoist. The Blakeslee machine is of similar type, but the tanks that hold the water are round or barrel shaped, and the water enters at the top, from the sides, causing a whirlpool of water to pass down through the contents, tossing the china about in the tank, rubbing the glaze off, and breaking some. It is not very successful in washing cups. The Hamilton Lowe machine is another model of a similar type, with the excep- tion that it has the square tank, and the water goes through the same' operation as in the Blakeslee. It requires a good deal of help, and the baskets that the china is placed in have to be raised and lowered several times during the operation. Furthermore, the china comes in contact with wire baskets and metal, which rubs the china and spoils the glaze, an expensive operation for a hotel or restaurant or hospital that uses high-class table ware. The Garis-Cochrane machine was placed on the market with a view to washing dishes with speed and economy. In this machine the china is placed in wooden racks. These are then placed in the machine, several racks on top of each other. In the operation of the machine the soapy water is forced through a pipe with a small pump. This pipe is worked on a spiral, and the water circulates through the tank in the shape of a cross. At the end of each arm of the cross there is a T with a cap on the end, which releases itself, allowing the water to pass out between the T and the cap, making a circular spray. The force of the water is slight, passing as it does to and fro across the tank, washing as it flows. During the operation the machine is kept closed to prevent the water from splashing on the floor. Then the pump is shut down, and fresh water is turned on from the faucet, to go through the same pipe and through the same operation as the soap water has done, in order to rinse the dishes. This has been found impractical, as there is not force enough in the water to rinse the dishes properly. Furthermore, the whole operation is a slow one and expensive for that reason. The Victor machine, which has lately been put on the market by L. A. Haustet- ter, of Chicago, an old hotel steward, is perhaps the simplest of all dish-washing machinery. It is strong, and built to withstand the wear and tear of heavy, con- stant work. There are two water levels in the tank, one for the rinsing, which contains clean water, and the other the soap-suds for washing and removing the grease. The level of the rinsing water is kept at a higher level, by an automatic feed device, than the soap water, and there is maintained a constant flow from the rinsing to the soap tank, as over a dam, thus carrying the skum and grease from the clean to the soap side. But this flow continues across the soap tank, forcing the grease and skum on and out to some grease-catching device, to be destroyed or kept for rendering. There are two centrifugal pumps run by a motor, one pump for the soap water and one for the rinsing water. The water is pumped from the bottom of each tank into a spraying device above, and the water is used over and over, with the soap and skum constantly going over the dams out of the sphere of action. Each one of these spray plates contains 2000 i-inch holes. The china is placed in wooden baskets, having no metal, that do not move while in operation. As one rack is filled it is placed in the machine at the soap-water end, then another rack is filled and placed in the machine, pushing the rack previously put in ahead. This operation is con- tinuous. Two persons are engaged, one to assemble and place the dishes in the rack and EQUIPMENT OF THE KITCHEN 231 the rack into the machine, and another to take away and distribute those that are clean. Since the rinsing water is very hot the dishes dry themselves quickly. It is claimed for this machine that it is not only more rapid in action, but that the water and soap required are less than in other machines. Figures 132 and 133 show the mechanism of this apparatus. It costs a little more than any of the other dish-washing devices. Sinks. — The kitchen sinks are of a good deal of importance. Manufacturers have tried long and hard to find a material that would wear well. There are a good many people who believe that wooden sinks are the best; there are others who like porcelain; and even a larger number who prefer concrete; slate is the choice Victor dish-washing machine. of others. These slate slabs should be not less than 1-* inches thick; they can be fitted tightly by rabbitting the bottom with the sides and ends, but slate will not do at all unless it is bound with brass or nickeled brass; slate is not a very hard sub- stance, and, unless it is bound, it soon wears on the edges and chips. There is a softness about slate that will cause fewer broken dishes than with either concrete or porcelain. Sinks made of 2-inch cypress wood, and bound on the edges with brass or even steel, are inexpensive and very durable; if the segments of wood .ire doweled in and fastened with long bolts they do not warp; moreover, the wood is so soft and springy that dishes sometimes escape destruction when they fall. Soup-stock Boiler. — One of the most important articles of kitchen equipment is the soup-stock boiler. Several manufacturers are making this article of an 232 EQUIPMENT OF THE HOSPITAL outer and inner case of cast steel with steam coils between, and with a steam release valve that will allow the live steam to permeate the contents. Both these casings are made very heavy, and the steam coils are generally inadequate to provide a sufficient quantity of heat to start the boiling in a reasonable time. A very efficient pattern of this mechanism is that made by the Wrought Iron Range Co., of St. Louis. The inside of the mechanism is a half-globe of polished steel in one piece, with no joints or connections of any sort, and the provision for steam in the jacket is sufficient to start soup-stock boiling in a few minutes after the steam is turned on. Vegetable Peelers, Meat Cutters, and Bread Slicers. — There are certain labor- saving mechanical devices in the kitchen that will be of interest only in large insti- tutions. One of these is the vegetable peeler. We have had something to say else- where about the economics of vegetable peeling. We will now deal only with the \ f Fig. 133. — Victor dish-washing machine; side view, interior. devices for doing the work. Potatoes, carrots, and turnips are peeled in the fol- lowing manner: a quantity, according to the size of the device and the number of people to be fed, is placed in a hopper, which has a lining grater that rotates rapidly, either by motor or from line shaft. A stream of water pours onto the vegetables while they are rotated in the hopper. The work is not evenly done. Sometimes a vegetable will be stuck, so that it doesn't rotate and will be ground away. As a rule, however, the grinding is pretty uniform, though the eyes of the potatoes are not taken out. There are several manufacturers of this device, and each claims for his mechanism all sorts of virtues as to time and economy in operation. Most of these claims are not borne out by the facts, and it may be very safely doubted whether there is much saving, either in time or money, in the present makes of vegetable peelers. The only part of the mechanism that permits of the choice EQUIPMENT OF THE KITCHKN 233 between the various makes of machine is the grating device. The Franklin Company use a thin metal prater that has to be renewed about once a month, and each renewal costs $6. This machine is, to all intents and purposes, worthless. Other manu- facturers use a carborundum grater, that is, fine particles of carborundum fused into a cylinder of cast steel. Carborundum is extremely hard, and the grater is, therefore, very durable. Perhaps the best manufacture of this device is shown in Fig. 134, made by the N. R. Streeter Co., of Rochester, N. Y. The same company makes a meat sheer, shown in Fig. 135. It has an adjusting device for fixing different cuts of meat. This machine is used more especially for cutting dried beef and bacon. It is rather an expensive machine, but very satisfactory, and it may be safely doubted whether it is not an actual economy, Fig. 134. — Power peeler with motor stand and guard. because thin sliced bacon and chipped beef are not only nicer, but since we all eat so much with our eyes it may be safely said that about so many slices of meat will be eaten, whether they are thin or thick, and the thinner they are the farther they will go. The working parts of this device are rather easily cleaned, and it need not give any special trouble. There is almost nothing to be said about a bread slicer. There are any number of makes on the market, some of them elaborate, made of castings with self-feeding devices, and expensive. Others are made of wood, like a fanner's ordinary feed chopper, and the one that should be used will depend a good ileal on the amount of work to be done. The principle thing to consider is the safety of the device. Maids seem to forget about their ringers when they are in a hurry slicing bread, and, 234 EQUIPMENT OF THE HOSPITAL unless the device is "fool-proof," there will be a good many accidents. Figure 136 shows one of these rather elaborately made devices. Fig. 135. — Meat slicer. Fig. 136.— Bread slicer. Vegetable Cooker. — Preliminary to a discussion of mechanism in which to cook vegetables, let us think briefly of the requirements in vegetable cooking and of the KQIII'MI'.NT OF TIIK KITCHF.X 235 chemic changes that occur when vegetables arc cooked. We cook vegetables in one of two ways, either in boiling water or by means of steam, and, usually speaking, we cook vegetables until they are soft. When we cook them in wati r we do so at a temperature of 212° F., that is, the boiling-point of water, and one of the peculiar physical characteristics of water when it is boiling is to take out of meat or vegetables that are cooking in it certain of their extracts and soluble constit- uents. If we boil meat long enough in water we remove nearly all of its extracts and nutrient properties — its fats, myocins, ami even its taste — so that at the end of four or five hours of boiling one will hardly be able to distinguish between mutton and beef, and we use the water in which this meat is boiled as a soup stock, and ex- pect it to contain practically all the juices formerly held in the meat. Now, when we boil vegetables in water we perform practically the same office. For in- stance, with potatoes we not only coagulate the starches, but we remove most of the protein of the potato if it is cooked long enough, and a well-boiled potato, especially if the jacket has been removed, has almost nothing left but starch. The peeling serves to hold these nutrient proteins for a much longer time, but eventually the peel comes off too, and with it the protein zone on the outside. The same may be considered true of beans, peas, corn, asparagus, and even the leaf vegetables, such as spinach, cabbage, and cauliflower. The ideal way to cook vegetables is in the so- called tireless cooker, but this, of course, cannot be done for a large institution. The most de- licious navy beans can be prepared in the Dutch oven, in which the vegetable is practically sealed during the whole process of cooking, and not only the juices, but the taste, is retained. Such a device is not practicable for the large quantities of food used in an institution, but there must be a substitute. Nearly all vegetables, especially when fresh, contain a sufficient amount of water in which to cook themselves, and they need practically only the direct application of heat to prepare them for the table. The best form of heat is steam, a few degrees higher than the boiling-point of water, and, if this is applied carefully, almost no part of the vegetable, not even the taste and odor, need be lost, and all of its chemic virtues as a nutrient retained. Figure 137 shows rather a new device for cooking vegetables by means of high- temperature steam, applicable to institutions of any sort. It is made by the Boin Steel Range Co., Cleveland, The illustration shows three separate independ- ent cookers; each section measures IS inches wide, 22' inches deep, and inches high inside, and each section is provided with a perforated galvanized-iron steam basket. Instead of the basket there is also a removable perforated shelf to fit any of the sections, to cook, for instance, whole potatoes. These sections are made wholly independent of each other, and. instead of three sections in a device. there may be two, or one, or five, as the institution may require. The sections Fig. 137. vegetable 236 EQUIPMENT OP THE HOSPITAL are made of cast iron, seamless, and each is fitted with a steam-tight door. There are check valves on both vent and drain connections, to prevent the mixing of odors or flavors, and it is a matter of experience to determine just how much steam shall be let in, and to what extent the vent pipe shall be opened, to insure a perfect cooking of the vegetable without loss of its taste and odor or any of its chemic nutrient properties. In an era that is now rapidly approaching it will be necessary for the dietitian to set on the patient's tray a certain quantity of nutriment that has been previously definitely figured out on a basis of the raw material employed, and when that day comes the dietitian will have to take into consideration all the delicate chemic changes that take place when heat is applied to the article to be cooked. In our present state of ignorance as to the finer chemic changes that occur during the processes of cooking we are wasting much, and depriving the patient of some of the most highly nutritive products that the food article contains. Let us prosecute this thought just one step with a view to illustrate the point. We know, of course, that the human assimilative mechanism can master the animal proteins in meat, and we know that the human digestive process can assimilate such vegetable proteins as occur in the legumes, beans, peas, and lentils, but we know also that wheat bran contains a large quantity of vegetable protein that is utterly useless to the human economy. When the chemist is asked why this is true, he will say that the protein of wheat bran is enveloped in a cellulose insoluble in any of the human gastric juices, and he will tell us that the cow, horse, hog, rabbit, and other of the lower animals can assimilate the proteins of wheat bran because of certain bacterial action that occurs at some point along the alimentary tract, as, for instance, the large cecum in the rabbit, during the activities of which the cellulose envelope is broken down and the protein released for assimilation. The main purpose in cooking food is to make it more agreeable to the taste, because the cooking process releases many of the chemic constituents; cooking also softens most vegetables and makes them easier to eat; but it is not necessary or desirable to destroy their form, one of the appetizing features of food, nor is it desirable to separate the parts of a vegetable. We must take these things into con- sideration in cooking, and, therefore, whatever devices we use, they must serve the ulterior purposes, and a slow cooking without water is the best. Coffee and Tea Urns. — Coffee and tea urns are a makeshift at best, and, as they are built for restaurants, hotels, and institutions, they are merely a concession, and the best substitute in consideration of the great amount of coffee and tea to be prepared. The ideal way to prepare these beverages is in small individual brewers. For private patients at least tea ought always to be brewed in individual pots; and, in the case of coffee for private patients, a sufficient quantity should be made in a small percolator or coffee-pot, to serve a small number of patients who are to have their meals at the same time, on the same floor, or in the same pavilion, so that the beverage can be served hot and fresh; in no other way is it possible to serve coffee that will be satisfactory to people of refinement and wealth, who are accustomed to properly served things in their own homes. For private ward and ward patients, and for the well people in the hospital, who are in considerable numbers, it will always be necessary to make both coffee and tea in the large commercial urns installed for the purpose. There is hardly a choice in the mechanisms offered on the market as coffee and tea urns. They are practically all alike, differing only in workmanship, finish, and strength. The main point about making either coffee or tea in these large EQUIPMENT OF THE KITCHEN' 237 urns is to make it properly and to servo it fresh. Manufacturers generally send printed instructions for the use of the urns they sell, and the details of these instruc- tions are generally questions of taste and individual idiosyncrasy. There is very much more in the quality of the coffee and tea to be used, and in the brewing, than there is in the mechanism employed. We shall have a good deal to say in regard to the qualities and methods of purchase of coffees and tens when we come to the section on Kitchen Service under the administrative operations of the institution. An urn for hot water installed between one for tea and one for coffee, with ample protective valves to make them all proof against explosion, will be necessary equip- ment. There will be much said by manufacturers about the linings and jackets, but there is hardly a choice between the different makes, as they are all built in about the same way and out of the same materials. THE DIET KITCHEN Under the section on Operations of the Hospital we shall dwell particularly on the efficiency and completeness of arrangements for transporting food to patients, and we shall likewise discuss the serving of special diets throughout the institution, and the responsibilities attendant on carrying out the doctors' orders in regard to the delivery of the special diets to the patients for whom they are devised, and upon the efficiency of the methods employed will depend the reliability with which an institution can undertake to give special diet. All these things go back funda- mentally to the diet kitchen, its arrangement, and its management. The equipment of the diet kitchen itself is a simple matter. First, it should be close by the general kitchen, because, whatever the plans may be as to the division of work between the two, there will be some dishes, generally the staples, that must be prepared in the general kitchen and taken thence to the diet kitchen for distribution in the form of made-up trays. The other important element that goes to make up a first-class diet kitchen is plenty of room, because many trays will have to be made up for distribution, no matter how many serving rooms there are in different parts of the house, so that in the diet kitchen there must be plenty of shelf room on which to set trays, and these shelves must be low enough to be convenient, high enough to be easily reached without stooping, and with room enough between them so that the nurses will have freedom of action. Without all these factors the trays will be slovenly and unap- petizingly made up. There must, of course, be a refrigerator, preferably one with several compart- ments, which need not be large. If ice is used in the refrigerator it may be in the rear, taken in through a rear door or elevator and packed up against the shelving. If the refrigeration is part of a brine plant, the coils may be at the rear and the shelves left free. One of the compartments will be devoted to cream, milk, butter, and cheese; it will not matter if the eggs are also kept there; another may be used for the salads, celery, and the like; a third may be used for the days' meats, and a fourth may be used for keeping cool such prepared dishes as jellies and custards. The supplies used in the diet kitchen will, of course, be kept in the respective refrigerators elsewhere, except from day to day. It goes without saying that there must be a steam table in the diet kitchen, and this should be large enough to contain not only the cereals to be steamed over night, but it will be necessary to provide steam-table space for whatever staple meats or vegetables or soups are cooked in the general kitchen and brought over for distri- bution. 238 EQUIPMENT OF THE HOSPITAL There must be at least one range in the diet kitchen, which need not be very large, even though the institution itself be a large one, because most of the roasting is done in the general kitchen, and it will be necessary to devote most of the cooking space on the diet kitchen range to broiling purposes for steaks, chops, and birds, and there must be a toaster also. It is highly essential that there should be plenty of water, hot and cold, in the kitchen, and the sinks should all be supplied with stoppers at the bottom, so that plenty of water can be had for the washing of spinach, lettuce, and celery, and it will be found convenient to have movable perforated shelving part way across the sinks to contain vegetables while cold water is running over them ; the shelving can be made out of white metal or copper, neither of which will corrode easily, or even slatted wood. Another essential of the diet kitchen is a large framed felt-covered board on one of the walls, on which there are plenty of labeled hooks to segregate and classify the diet slips; and it will serve a most excellent purpose if this menu board is divided off into segments, one for each of the pupil nurses working in the kitchen, so that the dietitian may divide the work among her assistants, just as a copy cutter does the work of a composing room; and if this classification and division and the handling of this board are done systematically, it will mean much in favor of correct methods and reliability in the preparation and serving of special diets. The walls of the diet kitchen, where space will allow, may be decorated with charts, showing the cuts of meats on various animals and their location. By far the best of these charts are prepared by the Pratt Institute, of Brooklyn, and they may be had at a price that barely covers the cost of production. It is essential that there be a dish warmer in the diet kitchen similar to that we have described for the larger kitchen, and there should also be a large, roomy closet with bins for the keeping of flours and meal, metal receptacles for cloves and spices, and various condiments, and there should be plenty of shelving in this closet for the odds and ends constantly in use. In addition to this closet there should also be one large cupboard, with rack space for pots and pans and the ordinary kitchen utensils. Nothing looks so disorderly and conduces so much to slovenliness as a workshop of any kind in which there is no regular receptacle for things not in use. In the section on Architecture the conveniences aimed at in the location of the dumb-waiters is treated with sufficient amplitude, so that we need not dwell on this subject at this place. THE BUTCHER SHOP The butcher shop is one of the important auxiliaries of the general kitchen, and its equipment is neither a difficult nor complicated one; but having it rightly placed means a tremendous amount in the saving of time and the cleanliness involved in the preparation of the meats. As the kitchen diagram, page 44, will show, the meat refrigerator should be immediately off the butcher shop, and this refrigerator should be long and wide enough to permit the hanging of carcasses on both sides, with a walkway down the center. If the refrigerator is cooled by coil refrigeration, this will be an easy architectural plan ; if the refrigerator is cooled by ice carried in, there should be easy access from the outside by a slide or chute, so that the ice may be easily stored in the compartments arranged for it. Even if the institution be a very small one, there should be room enough in the refrigerator to hold a car- cass of beef, one or two of mutton, one of veal, and perhaps a hog, with additional room for fowls and birds, and there should also be shelf-room for the keeping of left-over cooked meats. These may be just as well kept in the meat house, as there EQUIPMENT OF THK KITCHEN 239 is no sanitary reason why they should not lie, and it will save having a separate refrigerator for them. Fish, however, should never be kept in the refrigerator in which the meat is hung. The atmosphere of fish is tainted with the odor, and meats kept in the vicinity, even at a very low temperature, will oftentimes carry a disa- greeable odor, as well as taste, so that there should be an independent, isolated refrig- erator or ice-box for the fish. Every butcher shop should contain a chopping-block, and the made-up ones are best, because of the difficulty of obtaining good hard-wood chopping blocks without cracks, and four tables, one to contain the beef, mutton, veal, and pork, brought out to be cut up, one for cleaning and dressing fowls, and a third for dressing fish. There should likewise be two sink basins, one for fowls and one for fish. The butcher shop and refrigerator should be well lighted, and both thoroughly drained, so that a hose can be turned in for cleaning them. The floor of the butcher shop should be of concrete or, preferably, some one of the granitoid pavements, which are much smoother and more easily kept clean. Fig. 13S.— Refrigerator. In connection with the butcher shop there should be a scale, registering to at least 10(10 pounds. A cheap scale is not an economy, but may cost a good deal in the course of a year by false weighing, and, if one has a scale known to register correctly, he may feel perfect freedom in checking up the weights of the meat deliv- ery to see that the institution is not short-weighted. If the scale is a poor one, likely to get out of order, the butcher, or storekeeper, or receiving clerk will loose confidence in its reliability, and will presently cease to protest when his weights differ from those of the invoice brought to him, and a curious thing about meat invoices is that they seem never to err advantageously to the institution. The butcher shop should be large enough to allow at least three or four people to work in it at one time; one may be cleaning fowls, another fish, and the butcher himself may be at his meats. It naturally follows that the ventilation of the butcher shop ought to be good, and it should have plenty of daylight, so that the work people can be comfortable; there is nothing more likely to conduce to shift- 240 EQUIPMENT OF THE HOSPITAL lessness on the part of the employees of an institution than an ill-lighted and ill- ventilated working place, and there is nothing so likely to conduce to cleanliness as plenty of light everywhere. In the plan for kitchen suite, the fruit and vegetable refrigerators are shown to open only into the butcher shop. There is a definite purpose in this arrangement: where these rooms open independently into the kitchen the help soon get into the habit of stopping as they pass by to purloin an orange or apple, or even a tomato or bunch of radishes, and the loss amounts to a good deal in the course of the year. The butcher or any one person can be clothed with the responsibility of guardian- ship and held to account, while the goings and comings of many people spell ir- responsibility and waste. If there is no genera*! system of refrigeration, ice, if properly placed, does very well, as, for instance, as shown in Fig. 138. Here the ice is brought from above and through a special doorway, and placed at the roof of the refrigerator. THE STOREROOMS The equipment of storerooms for any institution, large or small, is a very simple matter, but the location of these rooms is extremely important, considered from the standpoint of economy in time. It must be understood that the storekeeper is the receiving clerk of the institution, and it will be found best to have him receive and receipt for everything brought to the institution, whether it be a paper of pins or a load of groceries or the coal supply, so that the location of the storerooms is an important matter, if viewed from the standpoint of convenience for the recep- tion of goods, and the storerooms of various sorts ought to be so arranged that they can be reached from the vehicles in which they arrive. There ought to be a centrally located retail store, the distributing point for the several departments, where small quantities can be expeditiously obtained. This room ought to be very convenient to the kitchen and diet kitchen and to the elevator, so that people from the floors who want goods can get there and back with the least possible waste of time; it must, of course, be equipped with a great amount of shelving, and there ought to be cupboards which can be locked independ- ently of the store itself, for the keeping, for instance, of liquors and wines and other goods likely to attract the cupidity or appetite of the help. These people must constantly visit the storeroom, and if the custodian is out for a moment they will help themselves, if possible. Then there must be drawers for nuts and loose articles of that sort. There should be glass-covered cupboards for the keeping of surplus stocks of valuable cloths. There must be shelving for small quantities of glass- ware. There must be a great amount of small shelving for the finer canned goods, like French peas and asparagus, or baking powders, spices in original packages, and the like, and there must be a long table in the middle of the room for the cutting of cloth and the setting of packages of all sorts and for the display of samples. In addition to this central or retail grocery store, there must be several separate com- partments, perfectly detached for the keeping of various stocks, one for case goods; and, if possible, the china and glassware can be kept in this room. There must be another room, not necessarily a large one, for soaps and scouring powders and janitor's supplies; these goods must not be kept where there are food supplies, espe- cially crackers, cereals, breakfast foods, tea, and coffee, because all of these things absorb odors from the atmosphere easily, and a few boxes of bar soap can soon communicate a soapy taste to large quantities of food supplies. Then it may be necessary to have a cold room, which may or may not be connected with the refrig- EQUIPMENT OF THE KITCHEN _' I 1 eration of the house for the keeping of surplus fruits. As a rule, fruits are aol bought in very large quantities in the summer time, because they do not keep will even in such cold storage as institutions afford, and they are received every day. so that their preservation is a mat ter of unimportant consideration. But in the winter time considerable quantities of apples, oranges, lemons, grape-fruit and the like will be purchased, and there ought to be a room well separated from everything else, built on the plan of an ice-box with filled walls and filled door, and an opening to the outside air. This opening should be in the shape of a small window, prefer- ably with double frame, so that there will be an air space between the two panes of glass. The temperature of the room can then be very w-ell regulated. If it is at all possible, the stores should be kept in rooms where there are no steam pipes. Basement rooms in a modern building run a very even temperature, winter and summer, and if they are free from artificial heating apparatus, have good ventila- tion, and a fair amount of light, the usual institution stores will keep very well; if hot pipes must run through them, heavy asbestos-pipe covering can be used, or even two wood coverings, with a small air space between the two layers. THE PASTRY PANTRY The pastry pantry should be a well-lighted, well-ventilated room of good size, with plenty of bins for flour and meals, plenty of shelves for fruits and flavors and condiments, and there should be a large center work bench, made preferably 6 inches higher than the ordinary table of 30 inches, because it will be found much easier to work upon a 3-foot table than on a lower one, and the pastry makers are much more likely to be careful in their methods if they are not compelled to stoop over into a back-breaking position. This large table ought to have plenty of cup- boards to contain molds, rolling pins, and the ordinary pastry-making utensils. Cook books, special recipes, and the like may be kept on the shelves, or in some special little shelf closet designed for that purpose. Usually the pastry cook will prize these recipes very highly, and, as a rule, will be interested in locking her door when she leaves the pantry if she has them about her work room. The pastry pantry should, of course, have a sink and basin, and should have hot and cold water. 16 EQUIPMENT OF THE SERVING ROOMS The equipment of the serving rooms is a matter of very great importance, be- cause, no matter how direct are our means of transportation from the kitchens to the patient, there must always be in large institutions some half-way station between the kitchen operatives and the nursing department, which must eventually serve the food to the sick in wards and private rooms. In large institutions the serving rooms will be connected directly with a dumb- waiter, such a one perhaps as is described under the section on Architecture, using electric signalling and safety devices. The most important article of furniture in the serving rooms is the steam table. This should be built, not only to retain the heat in articles of food that arrive at the floors in some bulk form for redistribution by the nurses, but it should be arranged for keeping the dishes warm. A refrigerator is necessary, either an ordinary ice-box or one that is brine cooled, such as we described in the section on Architecture. There must be a gas or electric plate for heating things and an adaptable garbage receptacle. There must be plenty of shelving room on which the trays may be set as they are being made up, and if there can be a large table in the middle of the floor with one or two shelves above, it will be a great convenience for the nurses. There must be cupboards with substantial locks for locking up the silverware and food receptacles of various sorts. Of course, there will be running hot and cold water, and a large sink with drain for dish drying, and if the bottom of the sink has an adjustable stopper, so that it may be partly filled with water during the dish-washing process, it will be a con- venience. This sink should be furnished with a strainer at the exit, so that articles of food may be caught. There is a good deal of choice in the selection of trays for the conveyance of patients' food. Most hospitals use papier mache trays, about 14 by 18 inches in size. They are light and very durable. Some manufacturers are now making a white enamel tray in two or three dimensions, but they must either be made so heavy for purposes of rigidity that they are out of the question, or, if made light enough to be serviceable, they bend, and eventually the enamel comes off, and they are not very inviting. Nickeled metal trays are also used, but these are rather expensive and heavy. There is made a plate containing a hot-water container underneath that is fairly serviceable, but it can be made to contain only one article of food, and the food dries up quickly, notwithstanding a rather tight-fitting lid that goes with it. It is an expensive plate, and its use is limited. The author has designed for use in the Michael Reese Hospital an individual hot-water tray, show T n in Fig. 139. The mechanism is obvious. The tank is made to contain about a gallon of hot water. The top of the water chamber is of stamped metal, with insets for the small vegetable dishes, and a larger center piece to contain soup. The soup bowl is made of aluminum, as, indeed, the whole tray can be made of that metal. After the hot dishes are set into their proper places a light cover is placed on to prevent the fumes of the contents from wetting the tray itself. The tray acts as a final cover also, and is made to contain the plate, also a cup and saucer, 212 EQUIPMENT OF THE SERVING ROOMS 243 cutlery, sugar, and creamers, and whatever cold dishes, salads, or desserts may be desired. This tray is heavier than the ordinary tray, because of the addition of Fig. 139. — Individual hot-water tray. Fig. 140. — Individual hot-water tray. hot water, but it is carried down at the nurse's side, where weight is not quite so great a consideration. Fig. 141. — Food containers. Sometimes a patient is not ready for the meal, and it will have to wait for a considerable period of time, and in the ordinary trays will be cold and uninviting. 244 EQUIPMENT OF THE HOSPITAL This tray will keep the meal hot for as long as an hour, and the warm vapors are confined, so that the food does not dry out rapidly. Food Containers. — The subject of containers for the bulk foods, to be distrib- uted to various parts of the house, has been left until we had finished the descrip- tion of the general and diet kitchens, because these food containers must go from both places under certain conditions, which will be more fully described under the head of "Kitchen Management" in the section on Operation. Figure 141 shows a general form of food container that meets most requirements. These containers are made up, as the illustration shows, of a large pan 12 inches wide, 16 inches long, and 6 or 7 inches deep, with tight-fitting lid. This pan must be strong and, preferably, reinforced with metal bands. Inside of these containers are the food pans themselves. One of these may be large enough to fit very loosely into one-half Fig. 142. — Food car. the entire container; another may fit one-quarter of the whole, and there may be two others to occupy the other quarter. If desired, the container may be made large enough so that, instead of holding four food pans, it will hold six or even eight, and when wanted for use all of the food pans may be of the smaller size, or all of the pans may be of the largest size; in other words, interchangeable. The inside pans should all be larger at the top than at the bottom, and should be just large enough to fit very loosely into the container, so that when the food pans are in place a considerable quantity of hot water may be poured in. Then the lid can be put on, and the food is ready to be taken to the floors, where it is set on the steam tables in the serving rooms about the house, and can be kept hot for any reasonable length of time without fear that it will either dry up or be soaked with water. The metal out of which these food boxes are made is a matter of a good deal of importance. They do not last very well at best, and if they are made EQIII'MENT OF THE SERVING ROOMS 245 out of the ordinary shoot metal they rust rapidly, and the expense and time in- volved in the mending of them counts up rapidly, so that they should be well made at first and of a metal that does not rust; copper is preferable, and, if the item of expense involved in polishing the copper vessels is to be considered, the copper may be tinned. After a while this tin coating will wear off, but it may be replaced easily and cheaply. It is useless to make these containers out of so-called tin, which is only a sheet of steel dipped in tin, a coating so thin that it lasts almost no time. The Food Cars. — In institutions of large size, where food must be distributed over considerable areas to different parts of the building, it is necessary either to have several dumb-waiters starting from different parts of the basement and run- Fig. 143. — Food car. ning to different parts of the upper house, or, if there is only one dumb-waiter, to have food cars for each floor to wheel the food from the dumb-waiter to the several parts of the floor intended to lie served: a number of dumb-waiters located in different points, in which most of the transportation of the food can be accomplished in the basement by a corps of help devoted to that service, under a concerted supervision, is best where the architecture will permit. In either case it will be necessary to employ food ears of some sort. Some of these offered for sale are noisy and rumble unnecessarily; some of I hem are so light that they wear out or break easily under the rough usage that they are bound to have; again, some of them are so heavy that when loaded they are difficult to handle; there are others that do not lend themselves to short turns, because the 246 EQUIPMENT OF THE HOSPITAL wheels are too high to work under the body; there are others, apparently all right, that are made with flat wheels covered with tightly drawn belting, or in some cases covered with a woven cloth containing some rubber ingredient that makes them run smoothly and noiselessly, but this covering soon stretches and falls off and is difficult to replace satisfactorily, as the manufacturers rarely keep the material in stock. There are cars whose wheel has a grooved felloe, like automobile or bicycle wheels; this is the car to use, and, as all four wheels are the same size, about 12 inches, and can be replaced if they break or wear out, and the bicycle tires can always be renewed. The wheels are set up on a gearing, the axle of the hind wheels fixed and the front wheels set truck fashion, so that they work each independent of the other under the car and on ball bearings. The architecture of the car is a matter of individual choice. If the framework, shelving, and supports are of wood, the paint wears off, and the car presents an uncomely appearance; if the structure is metal, enameled or painted, the paint or enamel wears off, but the metal car can at least be kept clean. Figure 142 shows a car that will meet most requirements. It gives no trouble, is noiseless, and, while light, is very strong, owing to the I-beams used for reinforcement. Another form of car (Fig. 143) contains doors, so that the car can be closed up for transportation of food out of doors or over long distances. The wheel arrange- ment is the same in the two cars. One has grate shelves and the other solid sheet metal. This is made by the Scanlan Morris Co., of Madison, Wis. There are other cars that are heated, some by electricity from an ordinary lamp socket applied to a plate in the bottom, and others contain reservoirs of hot water. Individual condi- tions must guide the choice. EQUIPMENT OF THE SMALL PRIVATE HOSPITAL There are many very excellent physicians, surgeons, general practitioners, and specialists who live in communities too small or too scattered to afford a good general hospital, and a great many of these men are finding their environ- ment unsatisfactory and their facilities to do modern work insufficient. They are banding themselves together, therefore, in many places and are equipping large private homes or modest houses of one sort and another to do at least the commoner things in medicine, surgery, and the specialties. The question comes up, therefore, What are the necessities for such an equip- ment — not what would be desirable, but what must be put in with which to just barely get along? This question is placed before hospital administrators almost daily, and, with an apology for a recommendation of anything less than proper modern equipment, we shall undertake to answer that question. The first necessity, indeed, the only actual necessity, is an efficient sterilizing plant. This can be made up very compactly and set upon a rack made of gas- piping, white enameled. It can contain a hot- and cold-water sterilizer of 8 or 10 gallons capacity each, a utensil sterilizer about 16 inches square, and one or two instrument sterilizers 9 x 16 x 6 inches. They are made now so that an electric current can be used where such a convenience is available, and they are also made with a self-contained generator or small steam boiler. Any of the sterilizer houses will furnish such a plant for approximately S300. A few rubber sheets, a Kelly pad, or similar device, for dressing patients in bed; a few hot-water bottles, urinals, bed-pans, enema sets, made up of can, tube, and point; a nutritive set or tube, made up of can, tube, points, and funnel; a few sputum cups; a few drinking funnels, basins, pus-basins, and anesthetizing set; either ether masts or oxygen gas outfit — these are practically all the require- ments of a private small hospital. Plain three-quarter width white-enameled beds, curled hair mattresses, one hair pillow and two feather pillows for each bed, one or two pairs of blankets, two spreads, and half a dozen sheets and pillow slips will equip the beds; ordinary trays will do for serving meals to patients unless the money is available for bedside tables; an ordinary small table, a dresser, and a rocker compose the furniture for private rooms. There should be a commode or two in the house, and a wheel chair or two, if possible. The surgical appliances need not be listed. They will be made up to suit the inclination of the individual surgeons who operate. In the section on Equip- ment of the Operating Suite there will be found a very detailed description of the material for any operating-room, large or small, and the manner of its preparation. Articles for the comfort of private patients may be bought or improvised, such as back- and head-rests, Morris chairs, and the like. Carpets nailed to the floor should be tabooed; if the floors are bad, they should be covered with linoleum and small rugs used here and there, and these latter should be made up of home-made stuff, or so-called "rag rugs," that can be boiled and cleaned; they are very cheap. •247 PART III OPERATION OF THE HOSPITAL THE BOARD OF DIRECTORS If we are to contemplate intelligently the personnel of the board of directors of a public or semipublic institution, and to frame an opinion as to the qualities, social and business, that should be looked for in a member of the board, we must first understand something of the duties of the board. The board of directors is the hub around which must revolve all the activities of the institution. It is not only the creative, constructive body, but it is the operative body and the executive inspiration of the institution. Its members must be not only alert, active, intelligent members of the community, but they should be people who cover a large field socially, intellectually, and financially. One of the duties of the board is to buy land and construct a building, and there should be a few members who are familiar with real estate and building enter- prises, and the other members of the board ought to be well enough balanced individuals to recognize their inability to cope with these particular problems and to allow of their handling by those who are most competent. Another duty of the board is to appoint executive officers, and there should be at least two or three members who are accustomed to handle people, and to judge of their value and to get work out of them. Another duty of the board is to finance the institution, and there should be two or three members whose business is finance, and who know figures, and who can appreciate balances and make comparisons of value in figures, whether it be goods purchased or work clone. Another duty of the board is to secure money with which to operate the institution, and every board of directors should contain in its membership several people who have the utmost confidence of the community, and who can go to individuals and command not only respect, but material support. Another, and perhaps the most important duty of a board of directors, is to give personal attention to the conduct of the institution for which it is to be held responsible. The crying need in directorates of institutions in this country, operated without profit, is for men and women who will take a personal interest. This does not mean that a board of directors should divide itself up into committees to look after the janitors and housework, or to run the training-school, or to tell the members of the medical staff how to treat their patients; too many boards of directors contain just such members, members who have plenty of time on their hands, but very little else to give to the institution ; who have little influ- ence in the community, who have less judgment, and who eventually earn the whole- some contempt of those who have to do the real work in the institution — that is, the salaried employees. The question of whether a board of directors should be made up partly of men and partly of women will depend very much upon individual conditions: first, the 248 THE BOARD OF DIRECTORS 249 character of the institution; second, the available material out of which to choose the directors. There is no question that every institution, now operated exclusively by men, would lie better administered if it had the leavening influence of one or more of the right sort of women ; the great trouble is and has been to get the right sort of women. More times than not, when a women is chosen for membership on a board of directors, it is because she or her family has given some money for the construction or support of the institution, and too many times such a woman will feel under an obligation to spend her time watching the expenditure of the money she is supposed to represent. Such an influence will not make for very much good in an institution. On the contrary, it will be hurtful in the extreme. Another woman perhaps may be chosen for her individual activity, her industry in securing gifts for the institution — perhaps of linen or articles of clothing — and such a woman will too often insist upon managing the whole linen department, and upon giving orders to everybody concerned in the distribution and use of the articles which she has had a hand in collecting, and such an influence is not a wholesome one in any institution. In other words, the best conducted institution of whatever kind will be that in which the members of the board of directors are large and broad men or women, or both, who will insist upon the selection of the right sort of executives; who will, in a practical way, watch the conduct of the institution, to see that its paid officers make the most of their opportunities and facilities; who will be potent in securing material resources, and who will guard its efficiency and modernity; and yet, a board of directors that can and will encourage all of its officers to do their utmost for the common good, that will encourage all the factors in the institution to work in harmony, and with a common helpfulness. Board members of these institutions are usually prominent members of society; they have many friends who are likewise friends of the institution; they have constant opportunity to test the esteem in which the institution is held; to hear complaints of service, of policy, and even of the medical care patients are receiving. There is no more serious duty of board membership than to give the institution the benefit of such complaints, and of the oftentimes valuable advice accompany- ing them. The superintendent, if he be worthy of the position he holds, should welcome and profit by such vigilant interest on the part of his board members, and take advantage of every complaint and of every item of advice — not always to follow it perhaps, but to weigh it and give it consideration. The superintendent has no such close touch with the outside world as have his board members, and very often interested people refrain from confiding to him what is on their minds, sometimes because they think he is responsible for the thing complained of, and sometimes because they arc not on sufficiently confidential terms with him; in any event, he has a right to all the information his board members can supply, to the end that he may better conditions and give a higher order of administra- tion. How Created. — The manner of the creation of a board of directors will depend largely upon conditions in individual cases. Naturally, the board of directors will be chosen to represent the people who support the institution by their philan- thropy and charity, and that will, at the same time, be representative of the bene- ficiaries of the institution. As a rule, the institution will be chartered under the law of some state as a "no profit" enterprise. Its charter will give it certain privi- leges extended to those who put up the money for its support, the privilege of elect- ing a board of directors, and of saying in its constitution how the successors to these members shall be chosen. Generally speaking, boards of directors arc chosen for 250 OPERATION OF THE HOSPITAL varying periods. At the creation of the enterprise, for instance, a number of directors will be chosen for one year, a similar number for two years, and others for three or perhaps four years, so that after the first year a certain number of members will fall out, or be obliged to stand for re-election at the hands of the mem- bers or stockholders, so to speak, of the corporation. In some institutions the whole board is chosen annually, a practice that has the disadvantages of changing policies and practices following every annual meeting. There is no consistency or constancy in the operation of such an institution. No one can take the same serious interest in its welfare as where the institution is com- posed of a board whose policies are definitely fixed, and whose members have definite ideals of a fixed destiny, and whose membership changes so little from year to year that these policies cannot be changed following any single annual election. Oftentimes the people on the outside are not well informed about the affairs of an institution, and they will sometimes set up for election some member of the community wholly opposed to the policies of the board of directors, and whose campaign for election perhaps is a cry for investigation and upheaval and reversal. It has been known that such a member after election, and after proper study of the institution's policies, welfare, and needs, has changed about utterly, and has become one of the staunchest supporters of the policies of the board. This fact means two things : first, that the public should be always taken into the confidence of the board of directors of a semipublic institution; it should be kept well advised of everything that goes on there ; second, it means that every institution interested in the welfare of the community at large, without hope of profit to any individual, should not only have settled policies and definite ideals, but the board should be so constructed that these ideals and policies cannot be subverted or changed over night in obedience to a popular and perhaps unjust cry. Authority. — The authority of the board of directors should — indeed, must — be absolute, and naturally the board will be always answerable to those who elect it. But the authority of the board of directors cannot be wisely exercised through individual members on their individual initiative; in other words, the authority of the board cannot be delegated to committees or sub-committees. These are not intended, and should not be used for any such purpose. The president of the board of directors should not only be the spokesman in matters expressing the board's wishes, but he should be the authority of the institution, except when the board is in session, and the president, therefore, must be answerable to the board at all times for his actions and subject to the board's commands. The only officers of a board of directors of a public institution who should have an executive voice are the president, and in his absence the vice-president, and the treasurer — the one to represent the board when it is not in session, and to give orders concerning the material welfare of the institution itself, and the other to guide and guard the institution's finances. Committees. — The board of directors should be divided into a number of com- mittees in order to facilitate the work that the board has to do, and these commit- tees should be chosen carefully, with special reference to the qualifications of the members for the work the committee has to do. Generally speaking, committees will work through the superintendent of the institution; at least, they should do so, and it should be their duty to help him, with their wisdom and judgment, to a solu- tion of the many problems that must confront him, as it should be his duty and his pleasure to avail himself of their aid and support and experience at every turn. But the jurisdiction of committees should not become executive; in other words, they should have no power to direct or command the-superintendent or any other THE BOARD OF DIRECTORS 251 officer of the institution, and their functions should cease with the power of recom- mendation, or, at most, their duty will end by calling the matter at hand to the attention of the president, and by reporting it to the whole board at its next meet- ing. If it came to pass in any institution that the committees, or the chairman of a committee, or an individual member of a board, had the power to give orders to the superintendent or to the officials of the institution, the work of the institu- tion would at once enter upon a chaotic regime, without head, without guidance or control, and such a superintendent would become at once the play of contending currents, ineffective and vacillating, for fear of offending some dominant factor in the board, and, finally, he would be a conspicuous failure, with perhaps inherent ability to become a distinct success under other conditions. Meetings of the Board. — A board of directors has no right to dispense with its regular meetings, and one of the chief factors in bringing about dry rot and stag- nation in an institution is the failure on the part of the board of directors to meet regularly, to meet frequently, and to have its full membership present at its meet- ings ; one of the most vital forces in a virile, business-like, pushing administration is an active board of directors. Nothing tends so much to make one lackadaisical, and to cause one to lose inter- est in an enterprise, as absence from the meetings at which its affairs are discussed. Nothing tends so much to an active interest on the part of the salaried people of an institution as an active and personal interest on the part of the directors. Meetings can be held too often, because the most desirable members for a board of directors are usually busy people, who find it impossible to attend very frequently, so that meetings should not be held so close together that the members cannot find time to attend, and times of meeting ought to be so chosen that the members can attend. In a good many institutions it has been found that Sunday morning, or at least some hour on Sunday, is the best possible time for the meetings of the board of directors of such institutions as we are now discussing. If the sacredness of the Sabbath be offered as a reason why these meetings should not be held on that day, it might be asked, is there any higher or holier duty than participation in the successful management of an institution devoted to the welfare — physical, mental, or moral — of the people of the community, and especially the dependent members? Womens' Auxiliary Boards. — In some very wisely conducted hospitals, whether the board of directors is made up entirely of men or is a mixed board of men and women, they have added to the governing authority certain auxiliary boards of women, contributors to the funds, wives of trustees, or members of the medical stall', or members of the religious body under whose auspices the hospital is con- ducted, and these boards operate in a measure as committees, and have at least theoretic charge of certain physical parts of the hospital management. There is a committee, for instance, in charge of the linens and laundry work, a committee in charge of hospital furnishings, a committee to collaborate with the nursing enterprises of the hospital, another visiting committee, and so on along the whole line of physical activities of the hospital. As a rule, these womens' committees have not the direct charge of their several departments. They cannot, of course, give definite orders, and their function is more or less of an advisory character. These womens' boards are most excellent adjuncts to the active management of any institution. As a rule, their members are entirely reasonable, ami they recognize that there cannot be several directing bodies, and that their office must be an advisory one. And if these womens' auxiliaries are conducted tactfully, 252 OPERATION OF THE HOSPITAL both on behalf of their own officers and members and in behalf of the hospital active administration, only good can come out of their activities. In the first place, these women are made thoroughly informed of the hospital's possibilities and limitations, and they are very likely to become so enthusiastic over their work that they will go out among the public at any time and secure contributions of either money or material, and in a good many hospitals they make up no inconsiderable part of the hospital furnishings, linens, and the like, by their own unaided activities in the way of collections. Perhaps the best function of all, and the most valuable one from the standpoint of the hospital, is that the members of these womens' auxiliary boards are out on the firing-line, so to speak, to keep peace between the hospital and the public. There was never a hospital created about whose management there was not fault finding from some section of the community. Sometimes such complaints are unjustified, even where the things complained of are true. For instance, there may be a com- plaint about torn or stained linen, and these women will know definitely, and can explain to the public that while the linens may be torn and stained yet this is due entirely to the financial limitations of the institution, that will not permit them to indulge in better grades of linen or new linen when it is needed. Perhaps there is trouble with the food, and the public is talking about it. Now we all know that patients and patients' friends are very apt to find fault with the food in a hospital. The patients find fault with it because they are sick, and have no appetite in any event, and perhaps they are on a diet, by the doctor's . orders, that is repulsive to them, and this is charged up to the institution itself and its management; then we know that in an institution it is impossible to provide food and to serve it exactly as we have it in our own homes, and there is a complaint on that account from the nurses and interns and executive officers. There is also, to be sure, a certain same- ness and monotony in the food service of a large institution, and all these things go to the public in the form of complaints, and there is no influence in the community half so strong to stem the tide of fault finding with an institution like a good, strong auxiliary board of women that know the facts, whether they are justified or not. If they are justified, these women are quite capable of making all sorts of a row to change the conditions, and if the complaints are not justified, leave it to them to see that the actual facts are placed before the public in a proper manner, to the relief of the institution. It has been claimed sometimes that these auxiliary boards of women are meddle- some and officious, and that they are likely to keep things in a ferment and turmoil in the institution. Of course this may be true in individual cases, and probably sometimes will be so, but an exception to the rule is not a sufficient condemnation of a practice, and it is certainly true that these boards of women are perhaps the greatest of all factors in the success of the institution, and if here and there, in an individual case, the women are meddlesome, it seems to many of us who have had a broad experience in this field that a leavening process is achieved by the sanity and reason and common sense of a majority of the members. Personally, the author has found some of his greatest inspirations in the advice and counsel of the level- headed women members of the committee devoted to the institution. THE SUPERINTENDENT OF THE HOSPITAL The superintendent of the hospital is the executive officer of the board of directors — the general manager of the corporation. Standards of hospital admin- istration have been practically revolutionized within the past five or ten years, and the standards of hospital managers have changed within the same time. The man or woman who was a competent hospital director a few years ago may be to- day so far behind the times that the whole institution is out of date. In the old days, if the hospital manager was economical in his purchase and distribution of supplies, if he kept his house clean, kept the bugs out of the beds, and gave his patients fairly decent food to eat, he was considered an exemplary and illuminating example of a hospital superintendent. To-day the whole aspect is changed. He must not only do these things or know how to direct them, but he is expected to keep abreast of medical and surgical progress, to know what new apparatus of a medical or surgical kind should be bought and used. He must know the laws of asepsis, and at least enough about the character of the com- municable diseases to guard not only against their appearance in the institution, but to prevent their spread, by proper isolation and disinfection; and, as these offices are performed under definite and rigid rules and scientific conditions, he must be in touch with medical science in order to perform them. If he does not know the laws of hydrotherapy and the various forms of physical therapy he must, at least, know sufficient about them to select competent workers in those depart- ments and to judge of their qualifications. If he is not a trained dietitian, he must at least be sufficiently well informed on the physiology of digestion, the chemic constituents of food, and the functions of the digestive organs of the body to direct a proper dietary, not only in the main kitchen, but in the special diet department. If the modern superintendent is not an expert in the purchase, testing, analysis, and formulations of infant foods in the milk laboratory, he must at least be suffi- ciently well informed to see that this work is done properly and under scientific conditions and to appreciate its value. If the modern superintendent is not a surgeon or internist, or pediatrician or gynecologist or obstetrician, he must at least be sufficiently well informed on all of these subjects to engage in intelligent conference with the members of his medi- cal staff, to help them create rules for the operation of their departments, to equip them with proper apparatus for their work, and to intelligently purchase for them proper current supplies. How long would the business manager of a mercantile corporation be per- mitted to occupy his position who did not know how the details of the business were performed, who was not fully conversant with the processes of manufacture of the article in which his corporation dealt, who did not know the intricacies of the business from both its buying and selling side? In these business corporations the proprietors or owners or officers give personal attention to the business, and are generally active in the direction of their affairs; how much more important is it, therefore, that the superintendent of the hospital, who must be the highest active officer, should be one who knows every detail of the institution's activities? The chief business of the hospital is the care and cure of the sick, and every other 253 254 OPERATION OF THE HOSPITAL function merely involves a detail of this work. And yet there are those who hold that the best hospital administrator is he who can buy supplies best, or he who can keep the cleanest house, or he who can keep the accounts of the institution best. In view of these thoughts, it must be self-evident that the hospital administrator must be a many-sided, intelligent, versatile man or woman. He or she must know a great many things on a great many subjects. It goes without saying, however, that the hospital superintendent will hardly ever be a specialist, except in his own work; indeed, the very fact of specializing would be a prominent factor in his un- doing as a competent hospital administrator. There are many hospitals in which the superintendent is a member of the medical staff and does part of the professional work. Especially is this true of special hospitals, such as railroad institutions and maternity hospitals, and it is equally true of some of the large public eleemosynary institutions. But it is quite equally true that in almost every case, at least in the larger hospitals, where a superintendent is found peculiarly unfit for the position he holds, he is less of an administrator of the institution than a specialist in some department of the institution work. In other words, scientific specialization in a hospital superin- tendent is diametrically opposed to an even, intelligent administration of all the departments. Most of us have heard hospital trustees excuse themselves for having at the head of their institution an incompetent man or woman, by the statement that the institution is small and that they could not afford a higher salaried official. Natu- rally, the question will be asked whether an inefficient and incompetent superin- tendent is not an expensive official at any price, and in sequence it naturally follows that if a thoroughly competent superintendent can increase the efficiency of his institution by modern, up-to-date, scientific methods, and improve its economy by careful buying of supplies, by a thorough knowledge of the commodities with which the institution has to deal, then such an efficient officer is cheap at almost any price. The difference between a $1000 superintendent and a $3000 superintend- ent for even a small institution can be wiped out by an economy or an efficiency in perhaps two or three directions, and if then the more expensive official can be utilized in all the departments of the institution, what a great saving there will be in administration, and what greater efficiency must come from such a policy. If this great difference is to be found in small institutions, that must weigh their dollars and their pounds carefully to see that the one offsets the other, how much greater will be the difference in the administration of large, costly, expensively conducted institutions! The superintendent of a large hospital who draws $3000 per year can easily waste another $3000 by indifferent purchase of supplies, by wastefulness in the use of his commodities; and when we add to this inefficiency on the part of the low-salaried official in the scientific work of the institution we have a comparison that will hardly admit of argument. Most hospital boards of directors are coming to take this view, and it is the rule rather than the excep- tion that hospital superintendents are drawing larger salaries than ever before, and that more is expected of them. The direct consequence of this is that whereas in the old days members of the medical staff were constantly harassing the super- intendent of their institution for new things, new apparatus, new methods, nowadays it is the other way about, that the hospital superintendent under the new order of things is suggesting new methods, new apparatus, and is giving new inspiration to the medical staff wholly within the realm of administration. If the hospital superintendent is to really superintend the activities of the THE SUPERINTENDENT OF THE HOSPITAL 255 institution over which he presides, and if those activities are to continue along the present lines of progress and scientific achievement, it seems to be almost a self- evident necessity that he or she must be a person with medical training, not neces- sarily that he should do any part of the scientific work, but that he should know how it ought to be done, and how to equip the institution with the facilities for doing it. Moreover, if the hospital administrator is to be the actual head of the insti- tution these days, when the open-door policy is becoming general, and if there is to be any sort of supervision of the scientific work of invited physicians, then it would seem even more necessary that the hospital administrator be a person of medical training. Let us take, for instance, a general hospital that has an organ- ized medical staff in the several departments, but, under the policy fixed by the board of directors, invites outside physicians to participate in the activities of the institution: let us suppose that a surgeon in the community, or at least a physician who considers himself a surgeon, asks for the privileges of the surgical-operating department, and has a private patient on whom to operate. The institution has perhaps published the fact that any reputable physician in the community may bring his patients there. It would seem, in such a case, almost impossible to deprive a reputable physician of the privileges of the hospital, and the courtesies of the institution are extended to him and he performs the surgical operation required. At the end of the procedure it is ascertained that the physician not only made an inexcusable blunder in the diagnosis of his case, and perhaps operated unnecessarily, but that he did the operation in such an unworkmanlike manner that his patient became infected and eventually died. In such a case, it goes without saying, the operator ought to be forbidden thereafter to do a surgical operation in that institu- tion, but the surgical members of the staff have a peculiar delicacy in the matter. If they ask that the operator be excluded, it may be suggested that their course is actuated by personal reasons; that they fear the competition of the newcomer. If they approve of his continuing to operate, they can clearly be accused of condon- ing^in offense that means the lives of human beings; so that, no matter what posi- tion"the existing surgical staff may take, the situation of the members will be a most embarrassing and unpleasant one. But suppose, for instance, the institution has at its head a competent medical administrator, one who is not in active practice, and who has at his command for counsel a corps of medical men quite capable of advising him as to the actual occurrences during the course of the operation we have outlined. No one can accuse the superintendent of interested motives or personal prejudice; if he invites the offending operator into his office and states merely the facts of the case, and then, kindly and courteously, but firmly, informs the operator that because of his unskilful methods he is asked to discontinue opera- tive work in the hospital, no fault in such a case can be found, at least no personal motives can be adjudged. In any event, a hospital presided over by such an admin- istrator will not likely become involved in disreputable professional practices, and it would seem that such a superintendent had not gone too far in protecting his institution and his medical staff, as well as the public at large, from the imposition of unskilful professional work. He will be criticized, of course, but hardly justly. Relations to the Board of Directors. — The superintendent of the institution being the executive officer of the board of directors, it is his duty to carry out to the best of his ability the wishes and policies and the rules and regulations of those to whom he must look for his orders. If it is the duty of the superintendent to carry out the orders of his board, it is certain that he cannot divest himself of the additional duty to give to his hoard and to the institution his best abilities in the way of advice and counsel. He is sup- 256 OPERATION OF THE HOSPITAL posed to be an expert in the management of such an institution, and as such he is expected to know how things should be done, and he should be expected to give the benefit of his knowledge to those by whom he is appointed, by whom he is paid, and to whom he is responsible. If the relationship between the superintendent and the board of directors is to be a pleasant one to all parties, as well as a profitable one to the institution, it goes without saying that there should be the greatest possible frankness and confidence between the board and its superintendent. The members of the board owe it to the superintendent and to the institution to deal fairly with him, to keep back nothing that can help him in his office as administrator. If they find that, according to their judgment, he is falling short of what such an officer ought to be it is their duty to tell him so. If they find that their superin- tendent is drifting away from the moorings which they have built and to which they wish the institution still to cling, they ought to point out to him the weakness of his position in detail and to insist upon a change. On the other hand, if the superintendent of an institution is to be happy and comfortable, and is to be efficient and give to the institution the benefit of all the ability he possesses, he is entitled to the confidence of his board of directors and to an appreciation of that confidence when occasion offers. If the superintendent finds, at any time, that he is apparently out of touch with his board, or with a faction of the board, it ought to be his privilege to say so frankly, so that there may come a better understanding, and so that any apparent difficulties may be ad- justed. The question often comes up whether a hospital superintendent ought to attend the meetings of the board of directors. Perhaps that question cannot be answered for individual cases, and it would seem that while a superintendent is new, and while his status with his board of directors is rather unsettled, and while, perhaps, the members wish to feel free to discuss him and his acts without his being present, the superintendent might very well absent himself from meetings of his board, and the invitation for him to be present should certainly come through the board to him, and not vice versa. It would seem that, if a board of directors is to have the great- est possible benefit of the knowledge and judgment of its superintendent, he ought to be present during the discussion of things apropos of hospital administration, so that he may offer a suggestion here and a bit of information there, and certainly, under such conditions, there will come a wiser and safer settlement of problems if the superintendent is taken into the confidence of his board of directors than where the board must act on its own initiative, and without that intimate information that the superintendent of the hospital, always attending to the duties of the insti- tution, could give. It has been frequently stated by members of a board that they would like to have their superintendent present, but that sometimes they will want to discuss matters with which he is not concerned, or in which he is personally involved, and that, if he is expected to be present continuously, they will not have the privilege of perfect freedom. It would seem that this is a mistaken view. Every sensible hospital administrator must know that at times he is under discussion — his methods, his personality, and his conduct — and it is equally sure that such a man must under- stand that the board will want to be unembarrassed by his presence while such things are under discussion, so that, if there is that utmost frankness that there ought to be between the board and its executive officer, it should be an easy matter for the president of the board, or any member, to merely hint that the absence of the superintendent is desired; or a member of the board ought to feel free to sug- gest that he would like to bring up a matter that is rather personal to the super- THE SUPERINTENDENT OF THE HOSPITAL 257 intendent, and that he would like to have it discussed by the board, and that, there- fore, he would like to request that the superintendent absent himself. If this com- mon ground were definitely understood between the board and the superintendent, it ought to make things very much easier from every view-point. Of course there is the other view, too: the superintendent ought to have the privilege of excusing himself for attendance on any meeting of his board if his duties call him elsewhere, or if it is inconvenient for him to be present, and if there is perfect confidence between the board and its executive officer, such an explanation ought to suffice to free him from any possible thought in the minds of the board that he has some ulterior motive. Relation of the Superintendent to Attending Men. — If the superintendent of the hospital is the executive officer of the board, and, if the board of directors is responsible for the conduct of the institution in every part, then it naturally follows that the superintendent must be the director of the hospital's affairs in the absence of the board. If there are established rules for the conduct of the medical men in the institution, of course it will be the duty of the superintendent to see that those rules are enforced, as an expression of the policy fixed by the board of directors; in some institutions there are such rules worked out pretty much in detail, and the superintendent of such an institution will have rather easy sailing in keeping the members of the medical profession within the limits of the rules. But such insti- tutions are not the ones that progress the most or diverge into the broadest work. They are rather narrow in their activities, and there is not very much encourage- ment in iron-clad rules, either for the members of the medical staff or for the superintendent of the hospital, to branch out into new fields of activity and to es- tablish new standards when they constantly feel the confinement of despotic rules. Most institutions, however, do not have printed rides for the conduct of visiting medical men; medical men resent iron-clad rules. There is an air of subservience in being held within the narrow limits of rules, and where there are no specific rules, but general policies, there is present a constant incentive to the visiting medical men to work out progressive ideas. And it is in such an atmosphere as this that a superintendent will find his best inspirations. He is not the servant of the medical staff or the medical men, nor is he their master. His position is one of responsi- bility for the care of patients in the institution, no matter who the doctor may hap- pen to be. In other words he is a consultant, so to speak, in every case in the hospital, and his specific duty is to provide the necessary facilities for the doctor in the treatment of the patient — not alone to provide what the doctor wants, but to suggest, if he can, new ideas that are within the reach of the institution and of the presence of which the doctor is perhaps not informed. The greatest incubus to an ambitious hospital superintendent is subserviency, either to a personality, a faction, or a factor in the administration of the hospital. In the first place he ought to feel that his judgment in any given case is final. There are many institutions in which there is a definite understanding that the board of directors will support its superintendent in any decision he may make; sometimes his decision will not accord with the views of the board of directors, and some- times he will be wrong without any question, but every principle of discipline would be violated if, after the superintendent had made a decision in a case affecting one or more members of the medical profession, the board of directors were to reverse his decision, so that the wise board will always support its superintendent, right or wrong. If the superintendent should be repeatedly wrong in his decisions, and should make those decisions so binding that his board would have cither to decide for him or against him in an uncompromising manner, his position would become 17 258 OPERATION OF THE HOSPITAL very soon untenable, and he would be guilty of so gross a violation of good diplo- macy and tact that the board would have to make him understand that he would either have to decide questions tentatively and put the final decision up to the board, or he would have to be replaced by some one of more tact and judgment. If it became known that a member of the medical staff, or, indeed, if it became known that any factor in the hospital administration could overturn a decision of the superintendent by an appeal to the board of directors, the superintendent's mastery of the affairs of the hospital would be at an end and his usefulness gone. The wise superintendent, who has the confidence of his board of directors, will naturally also have the confidence of the members of the medical profession and of the public and of the patients, because his inherent qualities, that have given him the confidence of his board, will have brought confidence in other fields, and such a man will naturally maintain that confidence by calm deliberation in his judgment, by fair decisions, and, above all, by a square deal to everybody. If there is to be harmony between the various factors in the operations of an institution, the superintendent must be the pivot around which that harmonious operation must revolve; and the very key-note in the creation of such harmony will be an established feeling on every hand that there is no favoritism, and that every one at all times is secure in obtaining exact justice. If the medical men feel that one of their number can get about what he wants, and if there are other medical men who feel that there is an element of favoritism in the conduct of the affairs of the hospital at the hands of the superintendent, harmony will be at an N end; friction is sure to follow. There will come every-day problems in the medical care of patients, and in the medical and surgical operations of the hospital gen- erally, and nearly always these problems will involve the personal interests of those whom they affect. If the medical men themselves, by way of their staff organiza- tion or by way of the personal strength and influence of certain members with members of the board of directors, are compelled to settle their own problems, there will grow up a species of hospital politics, one of the most insidious cancers in an institution, and an evil that will do more harm than almost any other. But sup- pose, for instance, that there is a superintendent on the ground who has a knowl- edge of medical ethics, who appreciates the relationship between medical men toward each other and between the medical men and the public, and who can be counted on to make a wise, diplomatic, and judicious disposition of perplexing problems that arise! To-day such a decision may hurt one man, to-morrow it may favor him. At the time the decision is made the person against whom it lies will naturally feel disgruntled, but if the decision has been of such character that he can feel, on sober second thought, after the personal interest phase has disappeared, that the decision has been for the best good of the institution, and consequently for the best good of all, it will not be long before such a superintendent has the entire confidence of everybody, to the end that his decisions will become effective without protest, and then, and then only, can there be considered a harmonious administration of an institution. Sometimes in the smaller hospitals, where there is an inadequate or incompetent medical service in one or other of the departments, it may become necessary under certain conditions for the superintendent to take a professional part in the care of patients, and such a superintendent's duties will be onerous in the extreme and his difficulties great. His attitude will be that of a competing practitioner, in a sense, attempting to give equal justice to himself and to the members of the staff, his natural competitors. Those of us who have had large experience in institu- tional work will search the past in vain for an example of an institution where the THK SUPERINTENDENT OF THE HOSPITAL 259 superintendent is, at the same time, a part of the medical staff and superintendent of the institution, and whose administration has been harmonious and successful. The superintendent of any hospital ought to keep in touch with the advances in the medical profession. He ought to know the new discoveries and about the invasion of new fields, and he ought to be well grounded in the fundamental principles of the science, so that in any case that may arise he will be able to dis- cover the difference in a medical attendant between the wheat of practical things and the chaff of an enthusiasm that is not balanced by sound, practical sense. Almost daily members of the medical profession are appealing to the progressive superintendent of the hospital for new apparatus, or new methods of procedure, or new activities along some scientific line. If the superintendent says "no" on general principles, and continues to say "no," to these constant demands of the profession, his attitude will throw cold water upon many deserving propositions and many deserving features of hospital conduct. On the other hand, if he says "yes" to every proposition, he will shipwreck his administration on the rocks of extravagance. So that, again, he must fall back upon a common-sense and administrative wisdom, coupled with a sound knowledge of what is going on in the medical profession. There are certain phases of hospital administration in which superintendents must be guided by the greater wisdom, or, rather, the more specialized wisdom of members of the medical profession; and the wise superintendent will divide his responsibilities many times, not with a single confidential adviser or an intimate personal friend in the medical corps, but, as each problem arises, he will divide his responsibilities with the particular member of the medical corps that would seem, from his position, to be the safest guide in that particular direction. It is perhaps a question of isolation in the children's. department, and there will be one particular man, perhaps the chief of the pediatric section, whose experience and judgment will be the best in such a case, and the wise superintendent will counsel with such a man and follow his advice. Perhaps it is a case of erysipelas in a surgical patient. The attending surgeon in the case may not be the best judge as to what should be done, because his interest in his own patient may obscure somewhat his judgment as to what would be best for the institution as a whole, but there will be some un- prej udiced member of the surgical staff who can think clearly, because disinterestedly, in that particular case. At any rate, before taking any radical action, the. super- intendent can have the advantage of such advice before proceeding to a course that may work harm in some direction. And so we might carry problems through all the departments of the institution, and find a different adviser for the settlement of each. And if it becomes generally known among the medical men that the super- intendent has a habit of seeking the advice of disinterested members from their own number in the settlement of current problems, such knowledge will add to the confidence in the wisdom of the administration of the institution. On the other hand, if it becomes known that the superintendent of the hospital is seeking counsel and taking the advice of one member of the corps, or of one coterie, on all problems that arise, this again will give rise to hospital politics of a most hurtful character. which will have for its end the discrediting of the activities of the superintendent, and the best that can be looked for under such conditions will be an unharmonious conduct of affairs. It takes courage to administer the affairs of a hospital, and to maintain control, on the part of the superintendent. Where men's interests are involved their activ- ities will lie great, and oftentimes they will employ every art i lice and every influence that can be brought to bear to succeed in their purposes, and. if the hospital super- intendent shows the least weakness under such pressure, his influence will be de- 260 OPERATION OF THE HOSPITAL stroyed; so that he ought to be especially careful in making his decisions, in order that under pressure, and iD the face of any opposition, he will be able to maintain his position against a member or the whole medical corps. Relation of the Superintendent to Interns. — The superintendent of the insti- tution must have absolute control over the interns, and there can be no half-heart- edness about such authority, nor can written rules and fixed practices be waived for an instant. These young men are at a period of their lives where they rebel the greatest against constituted authority, and where their judgment is not good enough to be entrusted with discretion. In a hospital where intern services rotate, and where an intern that is serving one attending physician to-day changes, and is under another jurisdiction in three months from now, it naturally follows that it will not be best for the medical men to be entrusted with authority over the interns. Moreover, the medical men are away from the hospital a good deal of the time, and these young men must be entrusted with a great deal of responsibility in the care of patients, and there must be some ever-present absolute authority. Rules cannot be worked out too much in detail for these young men. It must be definitely stated what they shall do, and when and how; even the details in their home-life in the institution must be specific, and, after all is said, they will be suc- cessful or failures, depending on whether they are compelled to obey definite rules. There never was an intern corps the members of which did not break every rule that they could break with impunity. In other words, if they were not punished for a violation of the rules the rules soon become a dead letter. In many institu- tions the administration has started out on the assumption that the interns are young physicians and men of honor, and, if placed on their honor, they would live up to the highest expectations that could be fixed for them. Those who have had much experience with interns will know that this attitude is an artificial one and that it is not successful. The young men may be gentlemen of the highest moral character, their home training may have been correct and their ideals high, but as a corps, living in an institution, and given for the first time a certain limited authority, glorified by the title of doctor of medicine, and the intern has yet to be born who does not lose his head, become self-opinionated, arrogant, and sometimes even dangerous. So that in every successful hospital where interns are employed the rules for them are iron-clad, and are lived up to, and if this is to be the status of affairs it must come through the superintendent of the institution. We have had elsewhere a copy of rules for the government of interns, and if the superintendent of the institution shall have seen to it that these young men obey these rules, he will not only get the best service possible out of them, but he will be doing more for them, and for their future careers as medical men, than by any sentimental course of conduct that places them upon an idyllic plane, and that clothes them with a personality and a personnel that they do not yet possess, and will possess only after a vast amount more of experience in buffetings of the world. Relation of the Superintendent to Nurses. — Whatever opinion the superinten- dent of a hospital may hold as to the modern training of nurses, or whatever his attitude may be toward the adequacy of modern nursing methods, he has at least a definite duty to the patients in the hospital that are under his care, and that is to see that they are properly nursed, to see that the orders of physicians and house physicians are carried out in a competent, prompt, and efficient manner. When this is done he may invade the realm of speculation as to modern nursing methods, the training that is at the present time prescribed for pupil nurses, and those other academic problems of training-schools. This right of speculation is his as an inter- ested observer of contemporary things, but he will be doing less than his whole THK SUPERINTENDENT OF THE HOSPITAL 2G1 duty unless he insists upon a training that will nurse his patients efficiently. Such training is not being given to nurses at the present time in any school in this country. If they are efficient and skilful with their fingers, understand medical and surgical technic, and are otherwise capable, it is a personal fitness other than one resulting from contemporary training. The attitude of the public toward trained nurses at this time is too well known for this statement to be controverted. With this arraignment of a somewhat academic character, let us proceed to the actual administration of the average institution where pupil nurses are employed. Complaints of poor nurses, and of irresponsible conduct, and of still more irrespon- sible statements of nurses to their patients, of injudicious utterances — all these come to the superintendent's office, and his administration is held accountable for these short-comings whether he would evade this responsibility or not. If a pupil nurse makes a mistake that costs a patient's life the reflection is on the hospital, and the community will hold the hospital and its administration responsible for the wrong, and in the public arraignment of such wrong-doing the training-school and the nurse will not be mentioned. So that it is not only the duty, but well within the province of the superintendent to insist on efficient nursing. It would be a violation of good discipline for the superintendent of any hospital to attempt to deal 'with the nurses individually. He must make himself effective through the superintendent of the training-school or not at all. All orders should go through the superintendent of the training-school, who should feel that she is responsible for the conduct of her nurses. It goes without saying that the superintendent who happens to see a nurse doing a wrong thing should correct her on the spot, and that he should then follow up this correction by a report to the head of the training-school. Whether such a regime of nursing is successful or not will depend very much upon the relationship between the superintendent of the hospital and the head of the training-school. It is unfortunate that in many institutions the training-school has arrogated to itself so important a function, that it has come to dominate the administration and to supplant good nursing by a regime of institution politics, in the presence of which good administration and good nursing are both impossible. Relation to the Business Management. — The superintendent will naturally have charge of the business management of the institution. The board of directors that institutes dual authority in a business manager and a medical director of an institution invites disaster. The business manager of such an institution will naturally look to his own success, which means economy in expenditure. The medical director, on the other hand, will look to the success of his department in a scientific way. He will want to provide good food; he will want to provide adequate surgical supplies, instruments, and apparatus, and whatever medicines, serums, vaccines, and therapeutic agents may be called for in the modern treatment of diseases. If the business manager, who is not a person of medical knowledge, and who is not specially interested in the scientific welfare of the institution, has it in his power to veto a purchase there will be little or no progress in the institution. Methods will look toward economy rather than efficiency. Scientific work will be minimized. In other words, the institution will stand still, and there can be DO harmony between two officers whose duties are so antagonistic, and especially if either or both of them happens not to be broad-minded, progressive men. On the other hand, if the superintendent of the institution is charged at once with all the hospital's activities, and held responsible alike for its scientific progress and its financial economies, it will be in his interest to temper his ambitions of a scientific character with his financial limitations. 262 OPERATION OF THE HOSPITAL In a large institution, where the duties of the superintendent are onerous and exacting, there will naturally be an accounting department, and, in a general way, this branch will be charged with the collection of accounts, and with the watching of the expenditures, with the checking of bills and the like, so that the superintend- ent's duties can be minimized and confined to a general supervision of fiscal affairs, and this is one department in which the superintendent can be greatly aided by that particular member, or that particular committee of the board of directors, charged with the finances of the institution. In other words the superintendent of the hospital must work with the finance committee, and if this is done harmoniously an immense amount of work and worry will be taken from his individual shoulders. There must be some one who shall have discretionary power in current financial matters, some one who can purchase goods for immediate use, and some one who shall have power to make emergency arrangements with a pay patient in the insti- tution for holding a bill in abeyance, or for making certain deductions in an account, or a certain refund, and naturally this power will fall to the superintendent, subject always, of course, to the supervision and control of the board of directors. It goes without saying that, if the superintendent is to be charged with the proper administration of the affairs of the institution, he must have power to employ and discharge the help, and this power should be absolute and final for the common help, and he should always have power to suspend any one working in the institution until such time as the board of directors may investigate and make final decision upon the matter. Relations to Patients and the Public. — The relations of the superintendent of the hospital to patients and the public may be considered as one problem. It is a delicate relationship. His function in the hospital is to give a high order of care to patients, and in doing this he will give the greatest possible amount of satis- faction to the relatives, who may be considered to represent the public. It is the duty of the superintendent to investigate all complaints of patients or their rela- tives as to abuses in the institution, and to correct these when found. It is the superintendent's duty to meet the relatives of patients and individuals who may be interested in their welfare, and to discuss their anxieties with them, and to help them by his advice in every way possible, and the most delicate of all his duties will be sometimes to adjust the attitude of patients and their friends toward their medical adviser. Oftentimes a complaint will be made to the superintendent of the institution that the patient is not getting proper medical treatment, and there will sometimes be coupled with this complaint a demand for another doctor, or for consultation, and in such contingencies the success or failure of the super- intendent to be of assistance to his patient, or his patient's family, will depend very much upon his relation to the members of the medical corps. If he is on such terms with these medical gentlemen that he can go to them in a confidential capacity, and represent the patient, or the patient's friends, in voicing a complaint, he can be of aid both to the physician and the patient. He can sometimes bring about a new stimulus to the physician in the treatment of the patient, and sometimes his consultation with the physician will enable him to assure the patient that he is getting the very highest order of professional service, and, in any event, he can be of infinite service to all concerned. THE MEDICAL STAFF The medical staff is the most important factor in any hospital. Upon it will depend the success or failure of the institution. We may operate every other de- partment of the institution along the most highly developed business lines; we may buy supplies with the greatest possible acumen and judgment; we may employ excellent people and work them to the best possible advantage. Every feature of the operation of the institution, its technic, its specialties, its care of patients, may be of the highest order, but, unless the medical staff is right, the institution will be wrong, because the members of the medical staff are responsible for the care and cure of patients, and, unless their orders are right, patients will not be treated right, and so the institution will be a failure. Unfortunately there are few instances and few institutions in which the medical staff can be chosen upon a practical basis, and too often policy and politics, social and professional necessity, and, above all, financial necessity, will dictate the creation of the medical staff. Oftentimes it is the medical men in the community who are the inspiration for the creation of the hospital, and quite as often that inspiration is born of personal ambition, a desire on the part of the medical men to build up an institution that will serve their personal interests. Fortunately, men strong enough in the community to bring such ambitions to a successful issue, by securing sufficient co-operation of the citizens generally, will usually be big enough, and broad enough, and unselfish enough to want the institution successfully conducted, even though their own personal interests must sometimes be set in the background. It is difficult enough to operate successfully a hospital born of personal ambition, even under the most auspicious conditions. It is impossible to conduct an insti- tution successfully, and that larger success is meant that stands for the greatest good to the greatest number, when the man behind the philanthropy or enterprise would prefer failure of the undertaking, as^'whole, to failure of his own personal aims. _ _ be said. The board of trustees, having decided upon the number of men for each de- 266 OPERATION OF THE HOSPITAL partment in the hospital, proceeds by election, or in any way it may see fit to out- line, to fill the various positions. Usually a nominating committee of the board fills in the name of each staff member. When the list has been reviewed by the board, the latter will then proceed to a formal election of the men decided upon. In filling a vacancy in an already established hospital the method may be the same, excepting that it is a proper courtesy to the medical staff for the board to notify the staff that it has such appointment under consideration, and to ask whether the appointment will meet with the approval of the staff. Medical men are very loathe to interfere in such a case, and, if they do so, it is likely to be because there is some very well-founded doubt as to the fitness of the proposed new member. Nor is there any ethical reason why a board should abide by the wishes of the staff concerning the appointment. In presenting the name, the board ought to ask the staff to confine its consideration to the fitness of the candidate for the position, and the staff should not be allowed to go into and act upon the personal relations of members or a single member to the proposed appointee. Medical men are not free from those personal and professional jealousies that afflict the rest of mankind, and it not infrequently happens that a board, dissatisfied with a department, may wish to strengthen it by the infusion of new blood. The old members may resent the inference that they are no longer satisfying to the board, and in that spirit may persuade the other staff members to side with them and to withhold their recommendation. When a name for appointment is sent to the staff and meets with disapproval, it would seem that the board is entitled to know the reasons; and that, if in the judgment of the board, it is due to some unworthy motive, the man ought to be appointed over the head of the staff. Some medical staffs actually shrivel up from dry rot, for no other reason than that they have been able, from year to year, to go along as they pleased, and without any other incentives than their own convenience and the value of the hospital to them as a personal asset. And it will often happen that the only way to wake the staff up will be to infuse new blood. Appointment by Competition. — The new way, appointment by competition, is a much mooted method, one open to a good deal of criticism, which, however, if successful, will result in, by all odds, the best working staff for the institution. It will hardly be the one chosen for a private or semiprivate institution, and would seem best fitted for the great charity hospitals in the large cities. The most illustrious example of this method occurred in the case of the Cook County Hospital at Chicago, not long enough ago to determine its success or failure. Staff service had not been a success. There had been much looseness in method, absence of technic, inattention to duty on the part of the staff members, indiffer- ence as to attendance, and a general atmosphere of professional irresponsibility. Interns had been permitted to do much of the work, even major surgery, and many scandals had arisen. The Board of Cook County Commissioners finally determined, after the ques- tion had been discussed at length, not only among themselves and with the ablest medical men in the community, but in the public press and among citizens generally, to attempt to create a staff by competitive examination. It would not do to require an eminent surgeon, who had been following his branch of the profession for perhaps twenty years, to pass an examination in chem- istry, or clinical medicine, or in diseases of the eye, nor would it do to require a medi- cal man to pass an examination in minute anatomy; so it was agreed that there should be a different examination for applicants in the different departments; for instance, the applicants for positions as staff surgeons were examined in surgery, THE MEDICAL STAFF 267 anatomy, pathology, and physiology, all of these branches coming directly into play in their every-day practice and in their particular branch of the profession. Nor would it do to place these experienced men, of long practice and practical work in the profession, upon the same plane as young men who were just leaving school, because the younger men would have the literature over a wide range at their fingers' ends, but would have had no experience at all in the practical operations of their branch of science. Therefore, it was decided to allow 40 per cent, out of 100 for what was called "experience," including the number of years of hospital experience the applicant had had, his connection with teaching institutions, the original work that he had turned out, and the number of years he had been in practice. Sixty per cent, was then allowed for the technical answers in the written examination. This method was not satisfactory to the profession at large. The older and more experienced surgeons who had reached prominence in the community hesi- tated to measure their attainments, either in theory or practice, with their fellows in a contest that might be subject to a good many of the vagaries of luck. The young men protested against this form of appointment because of the tremendous handicap of 40 per cent, given to the older men; but, in spite of the extreme pres- sure against the method, it was finally carried out. The result was the acquisi- tion of a medical staff of active, earnest, practical, experienced men, ambitious enough to have entered the contest, and ambitious enough to want to achieve some- thing once they were appointed; and the staff so chosen seems to be one of the most successful that has ever been charged with the professional work of a great hospital. One of the questions incident to this contest concerned the personnel of the examining board. It was settled by the appointment of a board composed of some of the older and most eminent men in the profession, whose lives were full of honors, and whose private practices required so much of their attention that they had neither the time nor inclination to devote additional time to public work, to which they had already given so many years of their lives. In the hospitals affiliated with or operated in conjunction with a medical school the process of staff building is, of course, different. There the heads of depart- ments in the school will be automatically the service staff members of the hospital; and we might pause here just long enough to suggest that, instead of its being detri- mental to patients to be used as clinical material, they will thereby always be the greatest gainers by such use. In the first place, the cases are better worked up and the correct diagnosis more eagerly sought. The medical attendants give more careful attention to patients, because it would be rather embarrassing for a professor to have some bright student or intern "spot" something he had failed to find. So the patient profits to that extent. Number of Men on Service. — The number of medical men to be distributed through the hospital to do the work will depend on several conditions, the chief of which will be the number of patients in the several services. It is almost an acknowledged assumption that medical men, who are prominent enough to deserve appointment as visiting staff members of a large general hospital, are too busy in their private work to devote more than say two or three hours per day to the institution charity work, and it is the more generous of the men, and certainly the more ambitious of them, who will continue from year to year to give that much time. So that we can safely calculate upon two or three hours per day as the limit of service to be expected from the average member of the staff. Some departments of the hospital will require a good deal more time than others. It is said that a 268 OPERATION OF THE HOSPITAL patient on the medical service cannot be properly gone over for physical examina- tion in less time than an hour. If there is a good intern service in the hospital, one in which the histories are efficiently handled, in which the physical examinations by the senior house staff members are made in a scientific manner, and in which the laboratory work is properly done, the length of time the visiting physician will have to spend will be very materially reduced, and he ought to obtain a very ex- cellent idea of the average case in fifteen or twenty minutes. There will be obscure cases in which he will have to go over the patient time and time again, but even in these cases he may be so puzzled as to request the advice of some member of an- other department in the hospital, and thus his own time will be shortened by that much. It will be only the new cases in the hospital that will require as much as fifteen or twenty minutes of the attending physician's time. A good many of his cases, if he has an efficient intern service, he will not have to see at all some days, and some of them will require only a sufficient amount of time for him to read the house physician's daily record, and the nurse's notes of temperature, pulse, respira- tion, feedings, bowel movements, and the like, in all a matter of five minutes. In this way we have a very fair idea of the number of average cases the average phys- ician can take care of in a hospital in the average amount of time that will be ac- corded the work. We have been contemplating in this connection the medical services of the hospital. The surgical department will not differ materially as to time occupied, and amount of work to be done, if the proportion of patients is about the same. Most surgeons do not operate every day on service cases, but twice or three times a week, and the average surgeon will spend say three or four hours in the operating-rooms, which will average up about two hours a day for the week. If he has efficient in- terns, he will rarely need to see his convalescent cases in the wards more than two or three times; if everything goes well, and if the dressing-room service is prompt and efficient, he should not lose much time in looking at the wounds of the cases it is necessary for him to see. His technic will soon have become a second nature in the hospital, and his methods will be followed as a routine practice. So that he will spend about as much time in the hospital as the medical man. The attending physicians in the children's department will spend about rela- tively the same amount of time with their patients, assuming the number of patients to be about the same as in the departments which we have already discussed. The specialties are a vastly different matter. If the hospital is in a metropolis where the school rules are strict about tonsils and adenoids, the nose and throat men may have a good deal of work to do, their cases usually coming to the hospital with a diagnosis already made, and they will not be placed in the attitude of con- sultants, so they can immediately proceed with their work, and do it promptly. The neurologist will not have so many cases, in fact, in the average hospital will hardly be called in to see more than one, or at most two, cases per day, and these in a consulting capacity, and will have to go over his patients very thoroughly every time. Whether or not his service shall be a very heavy one will depend not only on the number of patients in the hospital, and the general character, class, sex, nativity and environment of the patients as bearing upon their neuropathic peculiarities; the extent of his service will also depend very largely upon the free- dom with which he is consulted by the medical men. This brings into the fore- ground the attitude of the heads of those respective departments toward each other. In the diseases of the skin and of the eye the work will often be advisory, and, unless there are very special conditions in the hospital, those services will not be very large, and the visiting men will hardly be called to more than one or two THE MEDICAL STAFF 209 patients at each visit. Oftentimes they do not visit the hospital regularly at all, because of the infrequency of their calls. In special eye and skin hospitals, of course, the case will be wholly different, and the men will be heads of recognized services; and it will be the same in general hospitals that have special eye and skin depart- ments. The men will have about as much work to do as the other major branches. These foregoing thoughts will lead us, in a large measure, to a conclusion as to the number of medical men required to do the work in the hospital. The question of actual work to be done, however, is not the only one involved in contemplating the number of men to be appointed in the different services. Permanent or Occasional Service. — A question of very prime importance to staff members of hospitals everywhere is the continuity of their service. A good many ambitious, energetic, high-class men are connected with more than one institution, it being their purpose to be on service at one or the other institution all the year round. One of the livest topics of discussion and disagreement between boards of trustees and medical staffs of large general hospitals concerns the continued service of the members of the staff throughout the year, and from year to year. Medical men greatly object to being on service for two, three, or six months of the year, and then retire from the service for the balance of the year. They lose touch with the institution if they are on service only a part of the time, unless their private patients in the hospital are many. They forget the special technic of the hospital ; they forget the rules of the institution, and they even forget the people, unless they are constantly brought in contact with them. Besides that, they nearly all try to keep up to date in the literature, and they like to have material with which to obtain experience with new methods, new lines of treatment, new surgical opera- tions, so that nearly every medical man of ambition is willing to make a good deal of a sacrifice in the extra time he must give to the institution to take care of the full service all the year round, in order to keep in training, as it were. From the standpoint of the hospital there are advantages and some disad- vantages in this continuity of service of the medical staff. The patient in whose welfare the hospital is deeply interested obtains better treatment, a greater amount of consideration, if a physician who has studied his case from the beginning can be allowed to treat him until the end. To that extent the hospital benefits. The technic of the institution, the methods to be employed by the interns and nurses, will have a greater permanence, and the discipline will be good or lax, in propor- tion as the service of the medical attendance is permanent or frequently changed. Again, a great deal of apparatus and many instruments are employed in the institution, each physician having certain notions of his own as to their use. If there are few men on continuous service in the institution, the changes in appara- tus, the demands for new apparatus and new instruments, will not be great, and, in proportion as the number of men on service during the year increases, so will the demands for new things, and if the hospital is liberal, and if the rotation of service is frequent, it can well come to pass that the institution will find itself burdened with the expense of these new things, and top-heaviness in the use of a great variety of instruments to perform the same service. The board of directors being a financial body, charged with the physical admin- istration of the institution, and constantly looking for funds with which to conduct it, and being in a measure dependent on a large number of people through whom to secure these funds, will be interested in having the greatest possible number of physicians devoted to the fortunes of the institution, anil hence will lean toward the employment of a large medical staff. Sometimes the board, anxious to secure the co-operation, financial, social, and professional, of a large number of men, will 270 OPERATION OF THE HOSPITAL look about for reasons, additional to the real ones, which may be used as argument in favor of their wishes, and occasionally the members of the medical staff will supply these good arguments, not from any wish to do so, nor from any want of interest, but from lack of competition. If one or two medical men are kept on continual service in the medical department year in and year out, and throughout the year, it is only human that after a while they will become rather careless, slovenly in their work, prone to throw a good many things on the interns, and, "so master so man," the interns and nurses on their part will be likely to become negligent and careless. When such a time comes the institution will have set upon a period of stagnation, and there is only one course to be pursued for a radical cure, that is, the appointment of additional members of the staff, and the division of the service by periods of time with the men who are already there. This course will set up a brisk competition. Each set of visiting men, as they come into service, will be put on their mettle. They will be obliged to do their best, with a snappiness and efficiency that will show up well in comparison with their fellows, and, in the end, such a course will bring a very much better grade of work to the patients and a higher order of scientific care. If the appointments to the staff are so arranged that all of the men can be on service all the time, it must be kept in mind that no emergency must arise that will not bring the promptest attendance of some staff member. The skin diseases in the hospital, for instance, may be rare, and the attend- ance of the member of that service may be very infrequently required, but occasion- ally that member will be out of the city or incapacitated, for some reason, when he is most urgently needed. To avoid such a contingency there ought to be for each service at least enough men so that one or the other can always be on call. It is an embarrassing thing for a hospital to have to send out for some man not a member of the staff, who has perhaps been refused membership, because the attending physician cannot be reached. Divisions of Service. — A divided authority can never achieve the best order of service in any direction. In any branch of human endeavor a general is left free to direct the activities of his army. The captain of a ship is given despotic power. This principle ought to prevail in the medical service of the modern hospital. It will not be always in the interest of all the members of the staff, but it will certainly be in the interest of the hospital, and the chief factor we must consider — the patient. This idea has been growing on the hospital world for several years, and some of the best institutions of the country are already pretty well forward with details of arrangement, looking to an undivided authority in all their medical services. The Massachusetts General Hospital began with the surgical service, and at date of publication of this work had extended the idea to its other primary services, including medicine. The University of Minnesota is rather unique in this respect. Possessed with practically unlimited money to carry out high ideals, this university and its hospital have developed a detail of arrangement that borders on the ideal. There is one single authority in medicine, another in surgery, and so on through the branches. Each one of these heads has under him two, or in some cases three, associates, and these associates have each two or three assistants, and these, in their turn, are assisted by the senior students in the university in the working up of the cases in the hospital. As Dr. Washburn of the Massachusetts General Hospital said most aptly in a bronchure, which he published at the time the surgical services of that institu- tion were rearranged under this plan: THK MEDICAL STAFF 271 "The position of chief-of-service, whether medical or surgical, thus becomes one of the greatest importance. It is a position to be filled by a man of singular capa- bilities, not necessarily an older man, a great surgeon, an eminent physician or brilliant investigator, but a man who combines the rare qualities of tact, generosity, judgment, breadth, executive ability, and the capacity of discerning and bringing out the best in other men. He should be a man desirous not to develop his service for himself or his own reputation, but to stimulate the highest possible develop- ment of the individuals who compose it. He should be an instigator and director of investigation and progress. Such men are hard to find. Upon their judicious selection will depend the success of the present project." This single authority in the direction of scientific services of the hospital has an infinite number of advantages, and its only disadvantage worth considering is the personal equation — the displacement of those men who are not chosen as the chief — but it seems hardly fair to ask an institution to set aside an admirable arrangement in behalf of its management and its patients to serve the interests of individuals. Relations Between the Departments. — There is another phase in the divisions of service in a general hospital that ought to be discussed at least briefly. The field of medicine is so vast in this advanced day that many specialties have arisen, and in a general hospital these specialties are assuming an aggressive status, and their devotees are demanding service in the charity wards for themselves. How- ever much we may favor specialties, the fact should never be overlooked that all these specialties ultimately must submerge themselves into one of four or five fundamental departments. For instance, if we take surgery in the broad sense, we cannot afford to recognize as on the same plane with it such special branches as genito-urinary surgery, brain surgery, orthopedic surgery, the nose and throat, the eyes, dental surgery, and so on ad infinitum. In the field of internal medicine we would find ourselves in a maze of complexities if we were to recognize as co- ordinate departments such specialties as the throat and chest, the stomach, the skin. There has arisen even the specialist in tuberculosis. The classic quarrel between the internal medicine man and the neurologist concerning the cause, pathology, and treatment of hundreds of diseases is something even the medical faculty itself avoids. If then, in a general hospital, we designate as departments medicine, surgery, pediatrics, and obstetrics, we will come nearer hitting the mark than by any longer division. Perhaps gynecology might be added to this list, not because it is a funda- mental department, but because the surgery of women has attained so large a growth, occupies so special a field, and requires such special operative training that it must be recognized as having a distinct entity. In some hospitals the practice is, and it would seem properly so, to have every case admitted to one or the other of these primary departments and assigned to the men on service there. If, for instance, it is a surgical case that may subsequently require a surgical operation on the nose or throat, then the general surgeon will transfer the case to that specialty, or, if it is a case of inherited deformity, the case will naturally be transferred to the orthopedist; if a case assigned to the medical service develops upon examination a neurologic aspect, then the medical service man will naturally transfer it to the specialist in that department. But those who have tried to differentiate these cases in the admission room will understand that the attempt is almost fore- doomed to failure. There must be one fundamental, underlying principle in the management of the medical staff in any hospital if there is to In- harmony anil co-operation, ami that 272 OPERATION OF THE HOSPITAL is, that administration must be accomplished under definite and fixed policies, and that the members of the medical staff must live and act under those precepts, and that no member of the medical staff shall have power to give any orders whatever, excepting those that directly appertain to the care of his individual patient. The moment one medical man can give an order concerning the transfer or removal of a patient from one service or one part of the house to another affecting the patient of another physician, there will come friction and disagreement between the individual staff members, and a lack of harmony to mar the smooth operation of the institution. The best method of securing co-operative work of a high order is to have the members of the services enact rules for the government of their several departments. For instance, if there are four members of the surgical staff, it would be in order to have them formulate what they consider to be proper rules for the surgical work of the hospital, including the technic of the operating-rooms, technic of the minor operations, such as venesection, injection of abdominal, subcutaneous, and venous salines, and even still more minor operative procedures, like catheteriza- tion, the introduction of the stomach-tube, and the giving of high rectals. All these things are subject to a technic, and the house physicians and nurses should be taught this technic uniformly and without any alternative. No physician, staff member or otherwise, should be allowed to disturb it. When such a code of rules has been formulated by the members of a service staff, it should be the duty of the administrator of the hospital to go over them with the medical men, pass on them from his own standpoint of administration, and veto any part of them likely to bring disaster or inefficiency or friction anywhere. Some of these rules will be in reality fundamental policies, in so far as they affect the conduct of the staff members themselves, and will be covered in that peculiarly elastic thing known as the medical code of ethics, or in that other and more common form of ethics called courtesy, or, sometimes, the Golden Rule. These rules may be so wide-reaching over all the departments that we can better apply them under other headings, such as rules of technic, rules for interns, rules for nurses, and the like. There are three departments where special rules of this character will not fit the hospital in general — surgery, pediatrics, and obstetrics — and under proper head- ings elsewhere we have incorporated these, and out of these any one may build a set of rules for almost any part of the institution and to cover any special conditions. The Consulting Staff. — In most large general hospitals and in many small ones there are a few medical men who have passed the age of their best activity, who have served the institution or the community well in their professional capacity, and on whom it is desirous to confer the highest honors which the institution has to offer. If these men are kept on the service staff they stand in the way of progress in the institution. After a certain age men do not readily adopt new ways, and do not take readily to advances in medicine and surgery. Any institution, therefore, in which the scientific work is dominated by these men must fall behind. It is a wise thing in such cases to create what may be called a "consulting staff," on which the older men are given places as posts of honor. It is the case of "old men for wisdom and young men for war." These positions are not merely emeritus in the sense used by medical schools or educational institutions; they are oftentimes of the very highest order of good to the hospital, and many times profitable to the incumbents, because these men are set upon a pedestal, so to speak, and often called by the younger men in consultation in the service cases in the hospital. Thus others likewise learn to lean on their judgment, and oftentimes men who have never had a large consultation practice before find themselves more advantageously situated in this regard than they had ever hoped to be. The institution, it goes THK MEDICAL STAFF 273 without saying, benefits by the change because it enlists at once the energies and activities of younger men. Automatic Retirement for Age. — In some ably conducted hospitals there is a rule by which members of the active or service staff are retired automatically at a prescribed age, precisely in the manner practised in the United States Army and Navy. It is never very gracious to emphasize the old age of those we respect, and when, coupled with an implication that the revered person is past his usefulness, it reaches the acme of cruelty. How much better, therefore, to formulate a rule for general application, to work automatically without personal reference. The end is the same; the harshness of the act is somewhat tempered when we allow one whom the institution has delighted to honor to step gently aside instead of forcing him out. Every one else knows that a man is old before he himself realizes it, and too often he will persist in the performance of a fancied duty, even when all the rest of us know that his service is without value and oftentimes actually harmful. The Adjunct Staff. — Now, having selected the heads of the several departments, and removed as gracefully as possible the dead timber, are we to allow the busy senior men to do all the work, and determine all the scientific activities in their several departments? It would seem not. First, they are too busy, and have too little time at the disposal of the institution; next, they have in many cases outworn the ambitions of their youth, no longer need the peculiar form of recognition which comes from contributions to the literature of their profession, from their attendance on medical societies, from the institution of new practices, and the invasion and exploitation of new fields. In order, then, to secure the greatest possible amount of scientific work that requires time and ingenuity there must be certain young men attached to the staff — coadjutors, adjuncts, or auxiliary men — who have their careers before them, and need only the opportunity, and possibly a certain amount of direction at the hands of the older men, to obtain results which will redound not only to their own success, but that of the institution as well. Of such there should be a sufficient number so that they can work up and exhaust the ma- terial in the shape of patients in the institution. If their labors are directed in right channels, and along lines that will be competitive and stimulating, and espe- cially if their efforts are aided and supplemented by the directors of the laboratory, pathologists, bacteriologists, and physiologic chemists, they will turn out "Arbeits" which will meet almost immediate recognition of every interest concerned. Relations of the Medical Staff to the Superintendent and the Board of Directors It should always be understood that the superintendent of the institution is the executive officer of the board of directors. He is not a member of the medical staff, and his functions follow precisely along the lines of the activities of the board of directors. Their privileges are his, their duties are his, and in the absence of the board he is their representative. Leaving out of the question the terms of employment, the medical staff is an operating department of the institution, and its members must always be con- sidered employees under the board of directors, no matter what the terms of contract, the limitations of the agreement, or the personnel of the medical men employed. The argument is that the board of directors, charged with the duty of taking care of patients in an institution, has made arrangements with certain medical men to perform certain duties for a certain consideration, and, where a definite term of appointment is named in the creation of the medical staff, this term of employment 18 274 OPERATION OF THE HOSPITAL may be considered a time contract made by the board of directors with an employee. To be sure, there is usually no money consideration in this contract, and, generally speaking, the terms of employment are about as follows: The board of directors, party of the first part, employs Dr. Blank, party of the second part, to treat the patients in the institution, and to do whatever work is necessary to that end, the consideration being that the doctor has been given an appointment that has brought with it high prestige, much honor, a position in his profession that will bring him a larger share of public patronage than he could other- wise have obtained, and a much wider range of experience than he could have had if he had not been connected with the institution. We have in this sort of an agree- ment the actual employment of the doctor and the consideration he is to receive. Carrying this commercial figure a step farther, we have in the superintendent of the institution the general manager of the corporation, through whom all policies of the board of directors are executed and through whom all orders issue, so that natu- rally it transpires that the members of the medical staff must transact their business with him, and more or less under his jurisdiction and direction. The medical staff ought to be able to look to the superintendent for the prompt and efficient transaction of whatever business may be required, and, if he is fully awake to his exact status, he should be of an immense amount of help to the medi- cal staff and never a hindrance in their work. It may be seriously doubted if there should be written or printed rules for the government of the medical staff in an institution. If there are reasonable, rigid rules for the house staff, for the nurses, precise regulations covering the status of patients in the institution, and a fairly detailed printed technic for the operation of the various departments, instigated by the medical men in those departments, the question of rules governing the conduct of the visiting staff will be a negligible one. It will be found easy and pleasant, by reversing the position of members of the medical staff, and by making them a part of the administrative force of the insti- tution, each member with his own responsibility, to see that all rules of the insti- tution are being carried out. In this way the members of the medical staff are made the rule-making power, and a part of the rule-enforcing machinery, rather than the objects of that machinery. For instance, let us say there is a rule providing that the junior intern is to write the history of his cases within twelve hours after the admission of the patient; it will not be obeyed unless the attending physician on that service demands its enforcement as a part of the administration. Relation of the Medical Staff to the House Staff The policy of making the medical staff a part of the administrative force of the institution brings us to the relationship between the visiting, or attending staff, and the house staff of the institution. Stated bluntly, it is that of master workman and apprentice. The visiting staff does not appoint the house staff, does not prescribe the rules for the government of the house staff, and the two bodies are present wholly as fellow employees under the board of directors. Generally, the members of the house staff are not paid in money for their ser- vice; the board of directors rather undertaking to give these young men a certain experience in their profession in consideration of their labors in the care of patients; and, tacitly, it is understood that acting for the board of directors in this special undertaking the members of the medical staff are committed to the duty of instruct- ing these young men in the performance of their professional duties. THE MEDICAL STAFF 275 The attending physician must, therefore, see that these young men carry out orders promptly, efficiently, and conscientiously; and, in the event of their failing to obey their superiors in this way, the attending physician must report their dereliction to the executive officer of the institution, in order that the proper dis- cipline lie maintained. Let it be understood that these young men are almost as unfamiliar with their duties of citizenship as they are with the practice of their profession. They have not yet learned a correct bearing toward patients, toward nurses, and toward the public, and the staff member has not performed his whole duty by his apprentice unless the lessons that he teaches go beyond mere medical service, and enter upon the domain of ethics in all its branches. Egotism and self-importance are the legacies of youth, and these breed impatience of counsel, a disposition to override authority, heedlessness of advice, and some- times bad temper and impatient personal conduct. It would seem to be one of the self-appointed tasks of the attending physician in an institution to help these young men overcome these inherent weaknesses. Just how this task shall be performed must he left to the individual member of the medical staff and of the house staff — sometimes by good advice, calm counsel, sometimes by proper, dignified rebuke, which we may be pardoned for calling a "dressing down," but every "dressing down" should carry its permanent lesson. Medical schools of the day, be they efficient or inefficient, stop short of teach- ing students the details of their profession, such as the bedside care of patients, whether it be the physical handling of the patient, scientific physical diagnosis, clinical pathology, or what not, and only too commonly the visiting staff expects these young men to come from a school desk into an immediately efficient hospital service. They have in their minds merely some vaguely understood theories of medical science, fragmentary bits of theoretic knowledge, and their very presence in the hospital as interns is an acknowledgment of their inexperience and their desire to learn; therefore, members of the visiting staff ought to be patient and painstaking as teachers. It is a fact, however, that many of the schools, and some of the very best, are turning out young men and women who are not only not at all fitted for their pro- fession, but who can never be made so. It is the duty of the medical staff members to detect this unfitness in its incipiency, and to insist upon the withdrawal of the incompetent from the position of responsibility in the institution, even if they are not able to effect his withdrawal from the profession itself. Relations of the Medical Staff to the Nursinc; Corps. What has been said above can almost be duplicated in this place. Unfortunately, a v;ist majority of the young women who apply for admission to training-school.-, are undereducated, both in book learning and in worldly experience. Most of these young women come from the rural districts; they have been reared almost within touch of the mother's apron strings; they have never rubbed elbows with the world or mixed with people; therefore are not only ignorant, in the broader sense, but are likewise without rules of personal conduct. In other words, they are little more than children. Nurses come into the training-school from country homes, with their canvas bags in their hands, who could not give an intelligent answer to the simplesl question because of their embarrassment; some of them are afraid of the elevator; some are afraid to sleep alone in their rooms. Imagine, then, this sort of girl set to work upon a writhing, bloody patient, and wonder, if you need, why she does 276 OPERATION OF THE HOSPITAL not make good! We are all familiar with the old story of the nurse who was placed at the patient's bedside and told to watch for hemorrhage, and who watched for hemorrhage until the patient had bled to death, without knowing enough to call for help. We have seen this same girl, and watched her week after week, month after month, year after year, and have seen her unfold and develop, and have seen her become veritably a nursing machine under the guidance of efficient, careful teach- ers; we have seen this same sort of girl devoted to the point of utter unselfishness; we have seen her step to her duty amid loathesome infections without the slightest regard for self, and we have been overjoyed at the development of character and efficiency in these unlettered, unlearned, ignorant country girls, and have wondered if, after all, they were not the stuff of which to make trained nurses. And we have seen that other girl, educated at finishing schools, reared in the lap of luxury, kissed always by a kind fortune, bathed in the sunshine of prosperity; have seen her forsake her automobile, her beaux, her pretty clothes and her jewelry, and don the nurse's garb, and succeed in every call of her duty; and we have won- dered whether this was not the stuff of which trained nurses are made. So it seems the girl from the humble home in the country, and the girl from the palace in town, can be molded and developed to do her duty as a trained nurse, to give efficient, prompt, conscientious care to the sick, and we have conceived, after all these experiences, a firm conviction that the trained nurse is the girl of her training, and that as her training has been so will she be as a trained nurse. And thus we come to the relationship of the medical staff to the trained nurse, and the part the medical man must play in that training. Patience, care, the tell- ing over and over and over again of the way to do things, the showing of the way, practical illustration, bedside help — these would seem to promise more in the field of education of nurses than a rigid discipline, fault-finding censure for mistakes, holding of the reins against innocent pleasures and pastimes. If, moreover, the attending physicians in the institution will help train the pupil nurses in this way, their reward will come when these same nurses are graduated and sent into the homes to take care of their private cases; for there they will show their effi- ciency and devotion, or they will show the want of training, for which the physician is in no small measure responsible. The Open-door Policy Most hospitals of the present time receive not only the private patients of the members of their regular medical staffs, but also those of outside physicians who have no connection with the institution. The exceptions to this rule are the large charity hospitals in which no private patients are cared for, such special hos- pitals as are operated by corporations in the interest of their employees, and a few private institutions owned by one or more physicians. There are hardly any pri- vate or semipublic hospitals which do not accept the patients of outside physicians. These hospitals are known as open-door hospitals. Many features of the open-door policy are subject to serious criticism, and again it has many advantages. Most physicians living in communities populous enough to afford more than one hospital are usually connected more or less intimately with one or the other, and will naturally prefer to send their private patients there; but most sick people, classed as private patients, also have some hospital connection or are attached for one reason or another to some particular institution. Usually when a private patient desires to go to some hospital to which the physician is not attached his wishes will be respected, and he will be taken where he wishes to go. It may not THE MEDICAL STAFF 277 bo always wise for the patient to choose a hospital with which the physician is not acquainted, because every medical man can get a better service, at least one with which he is more familiar, in the hospital where most of his work is done. It is not a very difficult matter for the management of one institution to classify professionally the physicians in the community who are attached to some other hospital, to ascertain their abilities, shortcomings, and peculiarities; but there are some medical men who do not belong to any hospital, and who w r ander about from one institution to another, sometimes from an unsatisfied desire to secure a better hospital service for their patients, sometimes because their peculiarities or their mediocrity has rendered them personae non gratae wherever they have gone, and they have not been made welcome and content. This open-door hospital policy has been rather a free and easy one until within recent years, but it has now risen, or is rapidly rising, to the dignity of a very dis- tinct ethics, and the more responsible and progressive institutions are facing the necessity of enacting some very radical restrictions. In most hospitals the technical training of interns and nurses, and, indeed, the whole hospital entourage, has come to be one of the most important features of the institution practice, and, if there is to be a regular technical routine practice as laid down by the responsible medical heads of the several departments, no out- sider may come and lightly set these well-established practices aside. Whoever comes into a hospital to which he is not attached must inevitably do his work under a technic with which he is not familiar. For this reason, most of the prominent surgeons, and more especially obstetricians, whose work is done usually under exact- ing conditions, refuse to operate in institutions other than their own. The time seems to be very rapidly approaching when every physician will have to be definitely connected with some one institution and do all his work there; and, at a day not far distant, no institution of standing and responsibility will allow a member of its medical staff to be connected with any other institution. This will mean a tre- mendous step in hospital progress, and will speak immeasurably for the advantage, not only of the physician and the hospital, but for the patient's best good. Some very important ethical points must be met fairly and settled equitably. In the first place, it has come to be a very common feeling of members of the medi- cal profession that they cannot take a private patient to a hospital not their own without fear of his being taken away from them by some factor in the hospital administration, and turned over bodily to a member of the medical staff of the insti- tution. The interns and nurses are usually implicated in this habit of "case stealing" in some hospitals. It should be a well-recognized rule of every hospital, large or small, that no physician may ever have his patient alienated by any act on the part of the hospital administration or any one who works there. Dr. Jones sends his patient to a hospital with which he has no connection, and in which he is not acquainted, and he proposes to perform a surgical operation upon the patient; a few days' time will be necessary, perhaps, for the patient to 1 le properly prepared; presently a nurse or intern will drop some light remark within the patient's hearing that Dr. Smith's patient, a Mrs. So-and-So, is going home to-day; she was operated upon last week for precisely the same disease that Dr. Jones' patient has; indeed, it is truly remarkable how many of these cases Dr. Smith has operated upon successfully and not one of them had died. "How about Dr. Jones?" the patient in bed will ask; "isn't he a got id surgeon?" "Oh, I wouldn't for the world say anything against Dr. Jones," the nurse will reply. "He is probably an excellent surgeon, but of course we do not know him, and we do know that Dr. Smith has had hundreds of these cases," and the nurse 278 OPERATION OF THE HOSPITAL will probably mention any number of cases that have been recently in the hospital, and have been operated upon for this same disease by Dr. Smith, and that have recovered in almost no time and have gone home permanently cured. The patient will probably not say very much more on the subject, but as she lies in bed in the dark of the night, thinking about the hazards of the operation she is about to undergo, it is almost a moral certainty that by morning she has concluded that if Dr. Smith has been so eminently successful in this particular line of work, and that if Dr. Jones is not known at all for his work in this direction, it stands to reason that she ought to have Dr. Smith do the operation upon her, and Dr. Jones will lose the case and Dr. Smith will do the operation. Again, members of medical staffs of most institutions are rather inimic to outside physicians. They are not very gracious about welcoming them, and some- times go so far as to render their work difficult and their positions uncomfortable. Oftentimes this attitude of the medical staff takes on the dignity of an actual hospi- tal atmosphere against outsiders, so much so that the interns and nurses, unless closely watched, will give as little service and as poor a service to the outsider as they dare. Sometimes there is a show of reason for this feeling of hostility on the part of the interns and nurses; most of these young people are trained by the members of the medical staff, and naturally are taught that the technic and the routine procedures of their teachers are really text-book practices, and that no other technic is proper or legitimate. The encouragement of this feeling is not altogether wrong, because interns — and more especially nurses — are more or less creatures of habit and training, and, unless instructed that there is only one right way to do a thing, are pretty apt to think that almost any way will do; hence the necessity of a distinct technic. It follows, therefore, that when some outside physician comes in and proposes a line of procedure wholly at variance with what these young people have been taught, they naturally are not very much impressed with the ability and learning of the outsider, no matter how he may measure up in the profession at large. Then, very often, these young people, especially in the larger, more progressive institutions in the centers of population, are pretty good judges of what constitutes proper technic and proper procedure. The interns in these institutions are from the best schools, and usually the best men from those schools. Where this is the case, the position of the outside medical man of mediocrity is a very difficult one. In the medical departments of the hospital, and in those other sections of the institution where promptness and instant action are not quite so important, it does not matter quite so much if a mediocre or poorly informed medical man has a pri- vate case for treatment, because it will not take the administration very many days to learn whether the doctor is giving his patient adequate attention. But in the departments of surgery and obstetrics, and such specialties as the eye, the ear, nose, and throat, where a single act or an instant's delay may mean success or failure, the case is vastly different. It would seem to be the duty of the hospital administra- tor to know his man well, or for some member of the staff to know him, before an outside physician is allow r ed to engage the operating-rooms or to bring an operative patient into the institution. It makes very little difference to the outside layman whether or not the doctor is a member of the staff so long as he is permitted to operate in the institution; and the public generally will measure the class of work done in the institution, not by that of its strongest staff member, but by that of the weakest outsider allowed to operate there. It is a difficult matter to open just a crack of the door of the hospital to the out- side physician, or to open it to the physician and keep it closed to the surgeon or obstetrician; but the time seems to be very rapidly approaching when this will have THK MEDICAL STAFF 279 to be done. Most hospital administrators will recall instances within their own insti- tutions where patients have selected the doctor wholly by reason of the fact that he was reputed to be a regular operator in that hospital, and were not aware that he was merely there as an outsider when he chose to bring a private patient. They have judged the doctor by the institution, and.no institution can afford even pas- sively to submit and to allow such judgment to prevail; assuming all this time, of course, that the medical staff of the institution is composed of the best men in the community. In the establishment of the open-door policy in an institution some very definite rules should be laid down for the conduct of outside men who bring their patients there ; rules relating largely to the duties of the administrator of the hospital under such conditions. If, for instance, a physician brings a medical case to the hospital, and persists in a flagrantly wrong diagnosis and a bad course of treatment, according to the standards of the institution, as judged by the laboratory men and house physicians, it would seem to be the immediate duty of the superintendent of the hospital to call the attention of the physician to the view-point of the institution in regard to the conduct of his case, and to insist upon a consultation with some physician in whom the institution has confidence. The superintendent would naturally allow the physician a wide choice of consultants, without even a hint that the consultant should be a member of his own medical staff, because that would look as though there were an attempt to take the case from the physician who had brought it there in the interest of a member of the hospital medical staff. This duty is a most delicate one. In the first place, who is competent to say that the case has been mismanaged? The superintendent himself has not seen it, and, even if he has, he is not in active practice, and is, therefore, not competent, at least theoretically, to pass upon the merits of a case open to discussion in the matter of diagnosis. No member of the regular staff has seen it, and if he has, he has been guilty of the grossest violation of the very fundamental principle of pro- fessional ethics in visiting and examining the patient of another physician without his consent, and in no case could the superintendent use information obtained in that way. Is it a house physician or an intern who has brought the case to the attention of the office? Who has set these young men up as critics of their elders? They are only beginners themselves. Sometimes reliable information can come by way of the laboratory of pathology, where the technical findings in the case will be so contradictory of the clinical diagnosis as to justify complaint on the part of the hospital administration. Sometimes the matter may be delicately brought up in some such way as occurred not long since in a large hospital, to which a patient had been admitted to the service of an outside physician with a diagnosis of appendicitis. The operating-room had been ordered for an emergency operation. The patient was admitted at two o'clock and the hour for operation set at four. When the intern approached the bedside for the routine history, he was so im- pressed with the condition of the patient that he at once reported the case to his senior, and together they made a clear diagnosis of pneumonia, with manifesta- tions pointing somewhat toward appendicitis. When the physician arrived, just before time for the operation, he was asked to see the superintendent before going upstairs, and the following very brief dialogue took place: "Doctor, I am obliged to inform you that your patient seems to have devel- oped a pneumonia since you saw her, ami I have taken the liberty to cancel your operation; of course, I knew you would not want to operate on a patient in that condition." 280 OPERATION OF THE HOSPITAL "I am surprised at the turn," replied the physician, "but, if that is the case, of course I would not want to operate." As a matter of fact, the patient had a well-developed second stage of pneu- monia at the time, ran a typical course, and got well. The physician's feelings were respected, his patient protected, and the incident closed in the friendliest way. If the patient is brought by an outside physician to one of the operating depart- ments of the hospital there should be well-defined limitations and definite rules laid down for the conduct of members of the medical profession, whether they be of the medical staff or not, so that there will be a feeling that all physicians are being treated alike. If it is the surgical department, the rules of technic and asepsis should be pointed out to the newcomer, and he should be courteously informed that there is no departure from these rules. This would include the method of cleaning up for an operation, the wearing of gloves, and the asepsis generally, but he should of course be allowed the widest latitude in the professional treatment of his patient. If the operator is not well known as a surgeon, he should have the services of the best house surgeons or senior interns to assist him, and if they are capable men, and if there is an efficient nursing corps, the inexperienced operator will not be likely to go very far wrong before his assistants ascertain his incapability, and give him a sufficient amount of help, courteously offered, to bring the operation to a successful issue. After the first operation the hospital administrator will have no difficulty in securing information as to whether or not the operator ought to be invited to con- tinue surgery in the institution, and if not, the visitor should be politely informed that his discontinuance would be appreciated. It is in the obstetric department of the institution where the most harm can be done in the least possible time by an inexperienced man. In surgery the operator sets out to perform a definite operation under classical rules, well understood by the house staff, and any departure from these narrow limitations as to how an operation should be performed will be recognized almost immediately, and the attention of the operator called to the fact. In the obstetric department, however, the case is. vastly different; there is no infallible rule when forceps should be applied that will fit all cases; there is no definite instant at which labor should be immediately induced that can be universally applied; those procedures must depend so much on the condition of the child, and the condition of the mother, and an infinite number of conditions in detail, that the conduct of the obstetrician must be based upon a broad knowledge applied to the particular case in hand. Poor judgment, or ignor- ance, or a want of technical skill, may destroy mother or child, or both, before the operator can be interfered with. And, in the case of a postpartum hemorrhage, there will be no time to discuss the line of conduct and the wisdom of a particular procedure. The operator will have to act instantly, and sometimes radically, and if he acts wrongly the institution will suffer for his wrongdoing. So. that in this one department, at least, if the institution is to become famous for the skill and dex- terity and success of its obstetric service, it would seem almost necessary to limit the courtesies of the institution to those who have well-established reputations for their ability in that field. Relations of the Hospital to the Medical School The relationship between affiliated hospitals and medical schools has been very far from satisfactory in the past, largely due to the differences in view-point between hospital administrators and the faculties and trustees of the medical schools. THE MEDICAL STAFF 281 Faculty members in medical schools have been, and still are, very prone to feel that the teaching end of the combination is about the only part really worth while, and that the hospital is an after consideration and should be merely an adjunct, and consequently under the absolute direction of the school authorities. Unfortunately, this attitude has been strengthened and given countenance by the fact that the hospitals, as a class, have not been up to date, and have not kept in step with the march of medical science; and the college professors have felt that they should be in authority to an extent, at least, that would give them con- trol of hospital material for scientific and teaching purposes, to the end that they could enforce what they regarded as proper hospital practice. Very many of the college professors, too, have been either educated abroad or have taken postgraduate courses in the great centers of Europe, where patients have no other aspect than as "clinical material," without very much regard for the life or health of that material. In this country this view-point as to the patient is repugnant, and the sympathies and sentiments of the people will not permit the brutalizing instinct to prevail with public charges as its object. The humanitarian view is dominant in this country, and even in the great eleemosynary institutions, supported wholly by charity, there is a unanimous demand on the part of the public that the inmates shall be treated with something like recognition of the Golden Rule, and it goes without saying that private hospitals, and those supported in a measure by subscriptions, demand good care of the patient first and the abstract benefits to science as an after consideration. There is no reason why the two factors in this classical controversy cannot be reconciled under terms by which both will be vastly benefited. In the first place, the schools have a right to demand of the hospital the scientific treatment of dis- ease and equipment commensurate with that purpose, so that their students may be taught modern medical methods at the bedsides in the wards of the institution. The medical profession, as expressed in the school faculties, has a right to a review of its scientific work for the benefit of humanity, meaning by this the right of autop- sies when there is any scientific point at issue. Almost, if not every state in the American Union, prohibits an autopsy without the express consent of the friends of the dead; and there is a very pervading notion in the public mind, which expresses itself also in boards of trustees of hospitals, that hospital administrators should go to the extreme in forbidding the autopsy as a sweeping routine. The law about autopsies should be changed. We are past the Dark Ages, when the mutilation of the dead was considered a sacrilege. The fact is, there is no religion dominant in this country to-day that has one word or one rule, or one principle in its creed, that forbids the autopsy, and there is no telling what untold harm is being done to humanity every day by the burial of professional mistakes, that, if properly re- viewed, might clear up and make curable many diseases that are now obscure and incurable. The medical faculties are right, therefore, in demanding a better co- operation and a greater amount of complaisancy on the part of the hospital in regard to postmortem material. Then, again, in these days of higher medical education and more practical teach- ing, very much of the school work is done in the wards of the hospital, and how can this teaching be done unless the hospitals themselves are doing in a routine way the class of work that the teachers are trying to impress upon their students? In other words, the professor of medicine has been lecturing for months, say, to his pupils upon the value and significance of urine examinations, blood-counts, blood-press- ure, and the microscopic and chemic analysis of secretions and excretions; then he takes his class into the wards of the hospital, only to find thai the records of 282 OPERATION OF THE HOSPITAL the institution express only the physical examination as it was conducted fifty years ago — that is, examination by the eye and ear of the physician — his splendid lectures upon the scientific aids to diagnosis must be wholly lost upon the student in such an instance as this, and the professor has a right to something better. There is no good reason why there should be a controversy between the hospital administration and the teacher in the school. It should be well understood by both that no patient need be subjected to a clinic examination or clinic treatment without his consent, whether he be a private or charity patient. Charity patients on the wards of the hospital may have been failures in their financial operations of life, but most of them usually have a good deal of canniness or common sense, and it is a well-known mental attitude of these people that they want the highest grade of professional care, and, as a rule, they are pleased when the "professor" takes them before the class and goes over them carefully; and when he points out something to the members of the class that seems to be of unusual interest, the patient has a feeling that the professor is getting near the diagnosis, and that this must be speed- ily followed by a cure. It is common knowledge in hospitals everywhere that patients want to be shown before the classes, and that they go back to their wards and talk about their experiences to their fellow-patients with much pride and satisfaction. There is a vast difference between showing the patient before the class and subjecting that patient to a painful or wearying examination, and the humane professor will be quite as anxious not to tire or hurt the patient as the hospital administrator or its trustees. It should be the highest ambition of the trustees of the hospital to have their patients given the best possible scientific attention, and it is common knowl- edge in professional circles that teachers in the schools spend more time and more patience in their examinations when they know their work is to be reviewed before the class than they could possibly afford for mere private purposes; and, in the long run, the patients in the hospitals, where there is teaching and where the teachers are always on their mettle, will get better care than is the case in private hospitals, where the diagnosis lies solely in the mind of the attending physician without the stimulus of outside inspection. It is said sometimes that the professors in the schools who hold clinics in the hospitals give orders for patients that are too expensive to be carried out, and that inroads are thereby made on hospital finances by men who have no personal interest in the conduct of the institution and its economies. This point is hardly worthy of notice. There are no professional men' in the great schools of the country who are not reasonable enough to understand the limitations in the finances of the hospitals, and who will not regulate their orders accordingly. Taking the other horn of the dilemma — hospitals that cannot afford to carry out the doctors' orders — that is, the orders of doctors interested solely in the welfare of the patient and his recovery — ought to close their doors, or else limit the number of patients within their means. We may go a step further, and say that the hospi- tal that cannot afford the necessary apparatus and the necessary equipment to give all of the modern scientific aids to the physician, to the end that he may make his diagnosis and treat his patient properly, ought also to go out of existence, and give over its humanitarian work to those who have the confidence of the giving public sufficiently to enable them to attract the necessary funds for their purpose. There are some affiliated hospitals and schools that are operated under one management and supported out of a common fund ; there seems no reason why this fact should make any difference. The hospital administrator, if he be a medical THE MEDICAL STAFF 283 man. and it is unlikely that any other will be placed in charge of an institution 30 intelligently conducted as the school hospital is certain to be, will know quite ae well as the faculty member whether a given ease is in condition to be shown in a clinic, and his should he the final decision where the patients of the institution an' concerned. There are certain faculty members in most schools, who either use little judgment in this regard or quite systematically sacrifice the interests of the patients to their own enthusiasm; but such men are not the dominant spirit in any of the great schools, and they can and should be controlled and their activities should be suppressed. Then, again, questions are constantly arising as to just what service, what appa- ratus, and what equipment shall be furnished by the school and what by the hospi- tal; this seems also unnecessary if both sides are disposed to be fair-minded. Of course, if either the school or hospital has plenty of money and the other is strug- gling to get along, the rich one will naturally have to do more than its fair share; but, if both are alike in this particular, why would it not be an equitable adjust- ment for the hospital to furnish everything that it would have to furnish for a high order of scientific care of patients if there were no school, and for the school to do all the work of treating the patients and furnish such apparatus as applies to the actual teaching of students, and which is of no particular value in the treatment of patients. For instance, blood-counters, hemoglobinometers, blood-pressure ap- paratus, electric apparatus, such as x-ray machines and batteries, and a laboratory in which to examine urines; blood and pathologic tissues are needed for actual diagnosis and treatment in connection with the patients, and the hospital should furnish them. If more microscopes and a greater number of these other things are needed, so that a greater number of students may have the use of them, the school should furnish them. A great many hospital administrators and boards of trustees are under the impression that the hospital gives more than it gets out of such a partnership; but it must be remembered that school teachers are usually the best men in the community, and that they give the best of their time and their talents to the patients, not wholly with an eye single to the patients, perhaps, but they do it, and so the patients get a service vastly superior to what they would otherwise receive, and the efficiency of the hospital and the good it does are increased by that much. Even the same men, without the teaching stimulus, would not spend half the time or take half the pains with their work. HOUSE MEDICAL STAFF Duties of the Modern Intern Internship in the modern hospital has changed very radically within the past few years. It is not so long ago that the hospital intern was part nurse, part doctor, and very much of a menial. He was required to do dressings, and wait on himself, to move patients in bed, to give enemas, tub typhoids, give hypodermic injections, do all the catheterizing of patients, and see that the doctor's orders were carried out; in some hospitals, in order to fill in his time, he was expected to clean instruments and apparatus, and do a good deal of work that is now confined to the hospital orderly. No doubt in many hospitals this general routine of intern duty still prevails to a certain degree, especially in small hospitals, and in this class of institutions that same intern will be charged with the serious care of patients. In the modern hospital this has changed to a great extent, and the character and equipment of the intern has changed. Under the old regime, the intern had often come direct from the plow, with little or no education, and had "read" medicine for two short terms of four or five months each, and he was expected to be equipped to practice his profession, but in those days there was practically no hospital pathology, almost no urine examination, no blood work whatever, and no scientific work of any kind, except that practised by the attending physician, with his trained ear and finger and eye, in the physical examination of his patient at the bedside. To-day the duties of the intern are almost exclusively scientific in progressive institutions. He is charged with the taking of the histories of his cases, with making at least a preliminary physical examination, and he is expected to make, or know how to make, urine examinations, blood examinations, to make blood-counts of all sorts, to measure the hemoglobin, to take the blood-pressure, and to interpret all of these findings in the light of the scientific literature of his profession. He is expected to be a master of the microscope, and to make diagnosis from tissue taken from the operating-table. Not only this, the intern in the modern hospital is expected to work out, under the direction of the attending physician, some definite, original investigation into the etiology and pathology of disease with material gathered at the bedside of his patients. But the preliminary equipment of the young physician intended for this sort of work has grown quite in step with his duties. Nearly all first-class medical schools to-day require a high order of preliminary education. A few of them accept only college graduates, and hardly any of the schools worth mentioning admit a student who has not had at least some college training. In most of the universities there are special courses for men who expect to study medicine, and they are taught physiology, organic and inorganic chemistry, biology, botany, and microscopy in preparation for the strictly medical training. In a few more years no man who has not had this training will be eligible for admission into any first-class med- ical school. HOUSE MEDICAL STAFF 285 Then, these young men have at least four years of grinding work in the various branches of medicine, a great deal of time being spent at the bedside and in the laboratories of good hospitals, so that when they are graduated they have a fine foundation upon which to build a highly specialized career in their chosen profes- sion. The men who are thus well equipped almost all find places in the large pro- gressive hospitals, at the present time, where there are medical staffs of high attain- ment and modern learning, and pathologic departments presided over by thor- oughly trained scientific men. It goes without saying that these men in such institutions achieve the highest possible order of success, not only during their intern days, but afterward. Anything short of these standards of internship, both as to preliminary equip- ment and service, must be makeshifts in institutions that, because of their poverty or small size, or both, cannot afford to command the highest order of talent. Just here, in passing, it might be suggested that the small hospital could well afford to pay for the services of at least one young man who has had a complete training in some high-class hospital, and who would enter with a progressive and scientific spirit into the work about him, to the end that the institution would progress, at least in a small measure, commensurate with the possibilities of the time. Usually interns serve two years in the hospital, one year as junior and one year as senior. There are variations in this regard, especially where there are perma- nent services in the institution, but in the majority of the hospitals of this country this is the term of service of internship, and the specific duties of these young men can be pretty well defined along logical lines. In some hospitals, especially the larger ones, there are regular house physicians in the several departments, men who have graduated from their internship, and who are given third or even fourth year work to fit them as specialists. This is an excellent system for several reasons : in the first place, it gives the attending physicians a higher order of expert assistance, and to that extent is in the direct interest of the patients; next, it gives an excellent special training in some chosen branch to a young man whose counterpart of several years ago had to go to Europe for that finishing course. Duties of Junior Intern. — Let us take the junior intern immediately upon his admission to the hospital, and follow him through his various routine duties, as those duties seem to fall to him naturally. The place at which his service will begin is the laboratory of pathology, where he should have'a training of at least two or three months in urinalysis, blood exami- nation, and clinical pathology under the immediate direction of the very best talent obtainable. Naturally, if the full corps of junior interns is taken into the hospital at one time, it will be impossible for all of them to get their laboratory training be- fore they are sent to the wards. This is a misfortune, the only cure for which is to give the men a part of their laboratory training before they are officially entered as interns. In many schools the men graduate some months before the time arrives for them to enter the hospital to which they are appointed, and, when this is the case, they can be given a good deal of preliminary training before their formal advent in the institution. Different hospitals will have different methods of arriving at an arrangement by which all the men can go into the wards with a practical labora- tory training. The main thing is that they should have this training in some way at the very earliest possible moment in their hospital careers. If the junior intern can have three months' laboratory service, one-third of this period may be spent on urine work, and he should be trained thoroughly in the 286 OPERATION OF THE HOSPITAL chemistry and bacteriology of normal urines and the departures from the normal in the course of disease, and he should be compelled to study hard in the litera- ture concerning the significance of urine pathology. His second month may be devoted to blood work, the first phase of which will be blood-counts, white and red, and the differentials. He should have a severe practical drill in the physiology and pathology of the blood, using the material of the hospital wards. He should be taught the technic of blood bacteriology and the significance of the blood-pressure, the hemoglobin, the Widal and Wassermann tests, the various tuberculin tests, and their reactions and value. During this period he should be given a sufficient amount of milk investigation to make him familiar with the technic of milk exam- inations — physiologic, bacteriologic, and chemic. This work in milk need not go into speculative fields, but there are certain definite agreed constituents of milk, physiologic as well as bacteriologic, and these things the first year intern ought to know. The third month of the intern's stay in the laboratory may be most profitably spent in clinical pathology — the examination of tissue from the operating-table and the identification of morbid growths. This month's work may also take him back into the field of blood pathology, and his training at this period should also include a study of blood-serum and the various branches of serum therapy, the vaccines, and antitoxins. Naturally, these latter studies would more properly come during the second month, in connection with his blood work, but they might be also classified as a finishing course in blood study, and he will probably have more time to do this work and be better equipped to understand it than if it had come earlier in his training. Nearly every hospital nowadays does certain of its pathologic work and micro- scope analysis in small auxiliary laboratories, located at some point convenient to the various wards, and a good deal of the laboratory work can be done there by the junior intern. There are two or three reasons why these small department laboratories are advantageous, the chief of which is the personal equation. Nearly every attending physician and surgeon has pretty definite notions of his own con- cerning the laboratory work that he wants done on individual patients, and he will want to see the results of this work without having to folloAV the specimen to the main laboratory of the institution; therefore, he gives his orders to the junior intern, who carries them out personally in the auxiliary laboratory, where the specimen can be saved for him and shown to him by the man who has done the work. Thus there can be a definite study of the individual case, correlating the laboratory finding with the clinical picture, which is an immensely important thing in diagnosis. There is also a great saving of time where these auxiliary laboratories are operated. Let us say there is a case of nephritis, or any of the lesions in which there are variable quantities of albumin and sugar in the urine; the intern who is examining the urine of a given patient every day, or at stated intervals, will soon come to have the daily recurring picture in his mind, and, at a glance, will be able to tell whether the albumin or sugar is increasing or decreasing without very much of a quantitative examination, and, while it requires onty a moment to obtain a sugar or albumin reaction, it requires many minutes to make a complete urine examination. If the specimen goes to the general laboratory of the hospital there is no individualism in the specimen, and the man who does the work has no notion of the peculiarities of the case. Therefore, he is compelled to make a complete exam- ination and send up a complete report, whereas the intern on the case, working in his little cubby-hole, can make a better finding at infinitely less pains from the view-point of the physician in the case. There is another saving : it too often hap- HOUSE MEDICAL STAFF 287 pens that the attending physician orders a daily urinalysis or an hourly blood-count, and the nurse, in her zeal to obey instructions, sends the specimen to the laboratory for weeks and even months after it has ceased to be useful unless she is stopped; then, again, a good many visiting physicians ask for urine and blood examination just as a routine practice, and the intern, making the rounds with his senior, will rarely interfere unless he is having the work to do himself, in which case he will often be able to call the attention of the attending physician to the fact that he is very busy, and get the order called off. So that from every conceivable stand- point the auxiliary laboratory is an advantage in economy and efficiency. The next most important duty of the junior intern, after he arrives on the wards of the hospital, is history taking. This is an immensely important part of the exam- ination of the patient, leading up to diagnosis; so important, indeed, that nearly every hospital staff member has at some time in his career created for himself some special system of history writing, and there are almost as many systems in exist- ence as there are physicians in practice. We go into this question of history writing so completely in our section on the Records of Patients that we will pass over it for the present. These two duties, that of doing the laboratory work and that of writing the histories, are the only ones definitely assigned to the junior intern in the hospital, merely because he is a junior intern. In addition to these duties, he should share with his senior the privilege of accompanying attending physicians upon the rounds of the hospital, taking orders, getting his first lessons in physical diagnosis, and in the treatment of patients. He should be allowed, likewise, a share in attending the visiting physician on the rounds of the private cases, so that he may learn some- thing of the ethics of his profession, how to handle sick patients of the higher classes, how to meet their relatives, and to act diplomatically and tactfully in dealing with them, and he should be expected to always be on the wards of the hospital during the regular visiting hours of the institution, not only for the purpose of guarding the patients from undue annoyance by their own or other visitors, but for the purpose of answering pertinent questions of anxious relatives; no matter that the patients are poor and illiterate — they are human and suffering, and they have relatives who are anxious about them, and who are entitled to courteous answers to their inquiries as to the probable duration of the patient's illness, his likelihood to recover, and to smooth out any unnecessary misgivings concerning the case. Where the medical department of the hospital is a very heavy service, the junior intern will always have to divide with his senior the duty of watching the detailed care of patients at the hands of the nurses and orderlies. If he does not catheterize, he should see that that service is properly performed. He should see that typhoid and pneumonia cases are properly tubbed for reduction of temperature, and he should be almost constantly about the wards to watch after the personal comfort of his patients, and to exercise perhaps a greater amount of discretion in carrying out the attending physician's orders than would be allowed a nurse or an orderly. Surgical Department. — In a good many hospitals the junior interns in the surgical section give the anesthetics. There are many surgical operations whose chief danger lies in the general anesthetic, and it would seem that this procedure is important enough and sufficiently scientific to engage the lust attention of well- trained men. In some institutions there are regularly employed and highly trained medical or non-medical women, whose only duty is to give the anesthetics; and, where there is peculiar fitness on the part of the individual, this is all right, but as a rule or practice it can hardly be countenanced. Anesthetics affect individuals differently, not only because the individuals themselves differ in their physiologic 288 OPERATION OF THE HOSPITAL make-up, but because of the nature of the disease from which they are suffering, as, for instance, heart cases and nephritics, patients who have bad lungs, and the like, and oftentimes in the course of an anesthetic there comes over the patient almost an instant change, which the medically trained person will recognize at once as the effect of the anesthetic on a peculiarly susceptible patient, and with this change will come the necessity for immediate action to bring relief. It would seem that the frequency of these emergencies would plead in favor of a skilful anesthetist who has had a careful medical training. If these premises are logical, it naturally follows that the junior intern is not a good anesthetist, and that this important work ought to be laid upon more responsible shoulders; but in most operative sur- gical procedures of the present day the surgeon can advantageously use two assist- ants: one, the senior, who will stand opposite him and give him trained technical assistance, and the other, who will hold retractors, move extremities, and do other work of not quite so technical a character, and it would seem that the junior intern ought to be allowed to do this work in preparation for his subsequent more respon- sible duties. In this department, also, the junior intern may have an opportunity to assist in putting on plaster casts and various surgical splints, including the various suspension splints. He will have learned also, in the course of his laboratory ex- perience, to make lumbar puncture, do venesections, and the various transfusions; as a rule, too, the junior does at least part of the dressings. Sometimes the senior will take the clean dressings and the junior the infected or open cases. Obstetric Department. — In the obstetric department it is the rule in most insti- tutions to allow the junior intern to participate in the delivery of patients during the presence of the attending obstetrician, and to be generally helpful in the delivery room. He should' be charged with looking after the infant immediately upon its delivery, the washing of the eyes with prophylactic solution, the care of the cord, the examination and measurement of the placenta for the detection of retained particles; then, immediately after the infant is tagged and taken from the delivery room, it should be his duty to take its measurements and weights. In institutions where outside physicians are allowed the courtesies of the maternity department, it should be the duty of the junior intern to see that the outside physician is inducted into the mysteries of the department technic, to see that he reads the few rules for attending men in regard to the wearing of gloves, the scrub- bing up processes, and the other essential points in a well-regulated maternity de- partment. In some institutions a good many of these duties are left to the nurses, and there can be no valid argument against this, excepting, perhaps, that an intern may more diplomatically lead an attending physician into proper channels than the nurse, but the junior intern should at least know how to do these things, and how to regulate the department in the absence of his senior or the staff obstetrician. Other Departments. — The specific duties of the junior intern for the department of medicine, surgery, and obstetrics will naturally follow in the other departments of the hospital, as, for instance, the junior in the pediatric service will in all medical cases follow the routine of the practice in the medical department, and in the sur- gical cases he will follow the practice in the surgical department. In such special- ties as gynecology, the eye, ear, nose, and throat, and in the section on genito-urinary surgery the duties of the junior will be obvious. In the children's department, where the institution has an isolation building, there will usually be a special intern, who will be thoroughly trained in the pro- phylaxis against carrying infections from one class of diseases to another. If this isolation service is a very small one, and the discipline of the interns is rigid, the junior intern will not infrequently be allowed to take care of the infectious diseases, HOUSE MEDICAL STAFF 289 under mosl rigid directions as to the carrot' bis hands, clothing, and person generally; but oftencr, and perhaps more properly, the care of the communicable infections will be restricted to the more responsible and hence more careful members of the attending staff. Duties of Senior Interns. — The senior interns are supposed to have had junior service in all the departments of the hospital in which they are working as seniors, and, upon arrival at their seniority, are supposed to be equipped to represent the attending physician during his absence. They will, of course, have junior interns under them, and, if they are to be held responsible for the care of patients, they must be clothed with authority over their juniors, so that they can apply some sort of system in getting the work done. They will not, of course, have disciplinary power over the junior interns, and can only report their derelictions to the super- intendent of the hospital, who will naturally back up their requirements to any reasonable extent. It should be the duty of the senior intern to see that the junior writes the history in all cases admitted, promptly and efficiently, and the senior will also see that the junior does whatever laboratory work may be required for the presentation of the case in a proper manner on the next visit of the attending physician. The senior intern is charged with the duty of making the physical examina- tions of all ward eases, preliminary to presentation to the visiting physician. Sometimes the attending physicians prefer to make this physical examination themselves; there are two advantages in having the senior intern do this work: First, so that he may order the necessary laboratory work on the patient, in the light of the clinical picture, which can be reported to the visiting physician upon his first introduction to the case; second, the making of the physical examination by the senior is most excellent intern practice, as he can be checked up on his diag- nosis by the visiting physician in whose service he is working. It naturally will be the duty of the senior intern to perform such minor tech- nical operations as venesections, subcutaneous and intravenous normal salt irriga- tions, spinal punctures, and the injection of whatever vaccines and serums may be prescribed, always subject to direction by the attending physician, of course. The senior intern in the surgical service and the various surgical specialties will naturally act as first assistant to the operating surgeon, at least in all ward cases. Sometimes the surgeons have a private assistant of their own whom they require to assist them at operations upon their private patients, and these private assistants are a bone of much contention in a good many institutions. Naturally the surgeon has a perfect right to demand a high order of service in his surgical operations, and oftentimes a very exacting surgeon, who happens not to approve the class of assistance given him by the particular senior intern who serves him, will wish to call in his own private assistant, even on free or ward cases, and it is a serious question how far a hospital administrator may go in his insistence that the house senior intern shall be first assistant to the operator. It would seem equitable that the operating surgeon should accept the assistance of his senior intern, other things being equal, in all operations on free patients, and in the cases of all those who pay a very small sum for their keep in the hospital and who do not pay a fee to the surgeon; but at the same time the surgeon is responsible for his work, and he will probably he quite as insistent about expert help on the ward cases as on private ones; and who shall insist that he use an intern he regards as incompetent, especially since it is common knowledge that suits for malprac- tice are oftenest brought by this class of patients? By the very nature of things, the senior intern, who assists his chief in surgical 290 OPERATION OF THE HOSPITAL operations, must do the clean dressings, and should keep himself clean to that end, because at any moment he may be called upon to go into a clean wound with his chief, and the junior intern may well be charged with the duty of doing the dress- ings in pus cases. Since the senior intern assists his chief in surgical operations, it falls, of course, that the same intern should write up for the record the gross pathology of all surgical operations performed at which he is present as first assistant. The above division of departments, as between the junior and senior intern, will hold as a general rule in the average hospital. Most visiting physicians and surgeons will want the continued service of one man to take orders on individual private cases during the whole case, and sometimes the duties of the junior and se- nior will be so divided up that a junior intern will be compelled to make rounds with the chief of the department, and it will be necessary for him often to continue constantly on certain very special cases in the house, such, for instance, as those in which the attending physician may apprehend some serious and sudden emergency. It will make very little difference in such cases whether the intern is a junior or senior, but may make a vast difference whether he has been given such explicit orders as will enable him to meet such an emergency. Methods of Choosing Interns. — It is impossible to fix hard-and-fast rules for the choosing of interns. In every method there are difficulties and disadvantages, and a method that would be ideal for one institution would not do at all for another. There are some hospitals that will always have difficulty in securing a sufficient number of competent young men to do the work in the institution, first, because these small hospitals are usually not very well equipped to do a high order of scien- tific work; they have no high-class paid pathologist to train these young men in one of the most essential features of their education, and, therefore, the best men will choose larger and more roundly equipped hospitals where they can get a better training; then, again, in the smaller hospitals the material in the shape of patients will be more or less limited; and, third, usually these smaller hospitals cannot afford the proper paid help to do the menial work, and they are sometimes short of nurses, and the interns will, therefore, often be called upon to do work which they regard as that of a nurse, or even of a menial, and they do not take to this sort of work, especially in view of the fact that in the larger institutions their duties are so differ- ent. However, there are some very fundamental thoughts that ought to underlie the choosing of interns even in small, not very well-supported institutions. One of the very worst things that can happen to a hospital is to be compelled to accept for an intern the son or protege of some influential man in the insti- tution, a member of the board of directors, a powerful member of the medical staff, or a consequential contributor. The disadvantage of this sort of an intern is not confined to the small hospital, but is present wherever such an intern is accepted. The first one may be a high-class, ideal young man in every way, and he may per- form his duties so equitably that this method of choosing interns will become a fixed custom in the institution, and continuously a number of men whose influence has secured their positions for them may all be most acceptable young physicians, but there will almost inevitably come a time when the custom will be abused, and some unworthy young man will get in by reason of his social or professional influ- ence, and one man of this class can undiscipline and disorganize a whole institu- tion. Oftentimes his conduct will be in utter defiance of rules and of the discipline, and he will often attempt to overrule orders by the superintendent. If direct appointments of interns must be made by the board of directors or by the medical staff, without any examination of the qualifications of the applicants, HOUSE MEDICAL STAFF 291 it is very far better to inaugurate some system of choice that will prohibit the fasten- ing upon the institution of some unworthy protege of some strong supporter. One method of such choice is to leave the matter to the dean of the nearest or most favorably situated medical school, or the registrar of the school, who can present the opportunity afforded by the hospital to the senior students, and very often some excellent young men can be secured in this way, especially if it does not neces- sitate their coming up for a competitive examination. There are a number of small hospitals that secure a rather high order of interns in this way. A good many small special hospitals, such as sanitariums and invalid homes of various sorts, pay a small amount for their interns, and get them from the large institutions after they have served a year or two. A good many of these young men are poor, and need to make a little money before starting out upon their careers of medical practice; and very often, for $25 or $50 per month, excellent young men can be had by this sort of fellowship. Some of these institutions employ one good ex-intern of a large hospital, and then appoint the balance of the corps in some other way and without paying them; they may be fresh out of school, chosen perhaps in the manner first named, that is, by appointment on recommendation of the dean or registrar of a medical school. The direct method of appointment of interns, without recourse to any examina- tion whatever, is quite as mimic to the best interest of the large hospitals as the smaller ones, and for the same reasons, so that to-day in nearly all of the large insti- tutions of the country the choice of interns is by some method looking to compe- tition. Sometimes the competition is in the shape of a written examination only; sometimes it is oral only; sometimes a combination of the two, and in a few instances, another phase is added by way of a personal inquiry into the habits and morals of the candidates, and they are marked on these virtues and personal vices in the same way as in the written and oral examinations. A good many hospitals are directly affiliated with medical schools, and, where this is the case, the choice of interns must be made from the students of the school, oftentimes without any further in- quiry than the markings of the students during their undergraduate examinations; that is, the highest men in each class are given the intern positions in the hospital attached to the school. But, as an abstract proposition, the competition method of choosing interns is pretty well established, and the experience of years has led to a definite routine in the choice of these young men — almost to a technic, it would seem. The first step in this competitive procedure is to post a notice of examination for internship in the institution on the bulletin boards of the medical schools whose students are invited to participate, and this notice calls for the personally written application of those young men about to graduate who desire to take the exami- nations, and who are asked to file with their applications such letters of commenda- tion as they can secure, preferably from the officers of the school and from the lead- ing men of their home towns — ministers, physicians, and the like. The adminis- trators of the hospital have their first opportunity, in these written applications, to cull out any undesirable candidates, if such are found, early in the procedure. The next step is to request the presence of the applicants in person at the institution at some appointed hour, ostensibly for the purpose of registering for the examinations, but in reality for the purpose of a review before some com- mittee, preferably one composed of an equal number of the members of the board of directors and of the medical staff; but care should be taken, when medical men are chosen for membership on this committee, to see that the same men are not later chosen to conduct the examinations. The young men can be ushered before 292 OPERATION OF THE HOSPITAL this joint committee one at a time, their names and addresses and home towns can be taken, the personality of the applicant in each case can be considered by this joint committee, and, upon the exit of each one, some appointed member of the committee can set down the relative marking of the candidate. If he is of excellent personality, and apparently in every way a desirable man for an intern, he can be marked AA, or 100. Sometimes this ordeal will eliminate one or more undesirable men who might pass excellent written and oral examinations, but whose personality, for one reason or another, would seem to render them wholly undesirable as interns, and in such cases it would seem to be the privilege of the committee or its executive officer, the superintendent of the hospital, to privately advise such applicant not to take the examinations. The next step in the procedure is the beginning of the examinations, written and oral. If the examinations are to be entirely fair, and beyond question of fairness, the following preparation is in general use : There are a sufficient number of envelopes enclosing a card, so that there will be one for each applicant. These envelopes and the enclosed card are numbered from one up, the same number on the envelope and card. These envelopes, with the card enclosed, are passed around as the applicants sit at their desks, ready to write. The men are required to take the card from the envelope, write their names on it on the same side as the number, place it in the envelope again, and seal the latter. Each man is notified that he will bear the number that has been given him throughout the examinations, written and oral, and that he will be expected to place his number on every sheet that he writes, and that when the oral examina- tion takes place he will introduce himself to the examiners by number and not by name. The sealed envelopes are then placed in a receptacle, usually a metal box, se- curely locked, placed in the vault of the institution, and the keys will be handed to some responsible person, to the end that the box may not be opened again for any purpose whatever until it is finally opened in the presence of the applicants them- selves, or some committee agreeable to them, or in the presence of the board of directors or medical staff of the hospital, for the purpose of ascertaining the names that go with the fortunate numbers. It is usual that the written examinations in each branch of medicine are con- ducted by the staff members in that branch ; for instance, there are four members of the surgical staff, and the examination in surgery will take place from nine until ten, and there are four questions, each with one or more parts. Each surgeon will write a question, seal it in an envelope for security, and let it be opened the moment that the examination is about to begin, when all the questions will be written on the blackboard. Sometimes the department staffs will appoint one of their number to conduct the written examination in the subject, and generally he is aided by one or more members of the house staff of the hospital or by the superintendent of the institution. Sometimes the members of the staff merely hand in their ques- tions, and the superintendent of the institution, to save the time of the attending physicians, will conduct the examination, aided by some of his interns. Usually the examinations, both written and oral, will include medicine, surgery, obstetrics, gynecology, pediatrics, and pathology, the latter including bacteriology and urin- alysis, and the other branches will naturally include the specialties that are related to them. At the close of the written examination the papers will be examined by the men who have prepared the questions, each member of the staff marking only the answers to the question that he has handed in. It is oftentimes very difficult to HOUSE MEDICAL STAFF 2 ( J3 get the members of the staff to take the necessary time to mark the papers, in which case that ciuty is relegated to some of the younger men, ex-interns or adjunct mem- bers of the staff, and these younger men confer, before beginning their work, with the men who have asked the questions, so that there will be uniformity in the markings, and so that the markers can follow the ideas of the staff members as to the relative value of the different sections of the question and the relatively important phases of it. But all papers should be marked by the same person or persons to insure fairness. The oral examinations are usually held by two or three members of the staff in the various branches sitting together, and this would seem necessary, because if one member of the surgical staff, for instance, examined groups of the men, and others examined the balance, the examiners might differ very materially in their estimate of the answers, and so inevitably be unfair in their markings; but, where there are two or three men for each branch, the candidates can enter the room one at a time and answer the questions put to them by the examiners, and, after the appli- cant has left the room, each man can give the marking he thinks proper; if there are three examiners, the three marks can be added and divided by three, which will give a fair average of the applicant's percentage in the oral examination in that branch. At the end of the written and oral examinations a committee appointed for that purpose can take the percentages in the written and in the oral examinations and in the personal inquiry that was made by the first joint committee, and the sum of these markings divided by the number of subjects will give the proper averages. Rotation or Permanent Service. — There is no doubt that the ideal intern ser- vice, from the standpoint of the patient and of the institution and the attending physician, is one in which the men are continued in one place for the longest possible time, largely because they become efficient to an extent that is impossible where frequent changes are made, and many hospitals practice this continued or perma- nent service of the intern staff. Continued service in one department of a general hospital is attractive to the bright, well-equipped young medical man. It serves to bring him to a specialty in his profession by a short road, but it may be fairly doubted whether he will be able to go very far in his specialty, handicapped by the limitations of such a train- ing. It matters little whether the medical man is a general practitioner in a country town, or whether he is a specialist in some particular branch in a large city, the measure of his success in a final analysis will depend upon his ability to make diag- nosis of disease. The intern who leaves school after a theoretic training, and is immediately given service in the surgical section of a large hospital, for instance, may become a most expert and skilful mechanic, but such a service will not make him a good diagnostician. He must have served under a skilful chief in the medi- cal service before he can make a diagnosis in cases of abdominal pathology for instance; and, if it be an adult female, he must have served in the gynecologic and obstetric service if the patient is to get the largest measure of profit from his knowledge and experience. It is one thing to do a surgical operation laid down in the text-books on classical lines, but it is a vastly different thing to make a diagnosis and to determine a course of treatment in the same case, and the man with one- sided training, such as continued service in one department of the hospital would give, can never hope to hold his own with the trained men of the present day. In the smaller hospitals the interns will naturally rotate, or, at least, they will be compelled to cover a good deal of ground, and to take in. perhaps, at the same time, several classes of patients. In such an institution the training will depend 294 OPERATION OF THE HOSPITAL a good deal on their superiors and the scientific work they are compelled to do. In the large municipal institutions, where there is vast material in every department of medicine and surgery, it would seem that the intern should be given a careful, methodical training in all departments, so that, if he should then desire to proceed along some special line, he will have had abundant general training to lead up to that. In a few institutions in this country an attempt is being made just now to give a large body of interns a general training in all of the departments, and to give a few carefully selected men special training as a sort of postgraduate course. Up to within the past very few years it was conceded that no man could be a well-rounded out specialist in any branch of medicine without a European post- graduate training. Recently, however, even Europeans concede that there is some merit in American training, and a few of the large institutions are prepared to demonstrate that fact by giving a finishing course for special work to especially equipped young men to fit them for practice in one or another of the branches of medicine. Two or three of the departments in a general hospital would seem to suffer much more than others from a frequent change in the service of interns; the one most vitally affected is, of course, the maternity service, and the one that suffers only slightly less is the children's department. Very great harm can be done in almost a moment in the maternity department by inexperienced or inefficient men, and it is impossible to hope that the intern service can be so regulated that there will always be present for every occasion an experienced visiting obstetrician. A young man, who has had only two or three months' obstetric training, is hardly equipped to intelligently examine patients with a view to ascertain abnormalities and to lay out a program for the delivery. In the children's department the particular need is for a man who can deter- mine the difference between the adult and the child, not only the physical signs of disease between the two, but for purposes of surgical diagnosis and operative pro- cedure. Naturally, also, it will require a great deal of experience for these young men to make early diagnosis of the communicable infectious diseases, such as the exanthemata. Limited Rotation. — Perhaps there is a happy medium somewhere between the continuous intern service and short rotation. For instance, the young man who thinks he would like to practice obstetrics as a career must know a good deal about gynecology, and ought to have a service in that department; the obstetrician must, of course, know children and their diseases, and he ought to have a service in that department. The young man who is enthusiastic enough about his own future to select the profession of surgery at the outset of his career will not only want to do surgery in the hospital, but he must have a thorough training in medicine, for pur- poses of diagnosis and differential diagnosis. He ought to have work in the nose, throat, and ear department, in the genito-urinary wards, and in the orthopedic, section of the children's department. The young man who inclines toward internal medicine must, of all things, have a thorough training in the laboratory of path- ology, bacteriology, and urinalysis, and it will not be quite so important for him to see very much surgery or the special surgical branches. Naturally, the young man who thus chooses a specialty for himself ought to be given a service in that specialty in the hospital, immediately after he has had a good preliminary training in the laboratory of pathology. He will acquire in his first training a fair idea of what a special branch contemplates, and he will go into auxiliary service in other departments with a good deal more enthusiasm than if he HOUSE MEDICAL STAFF 295 were put into these first without having been led up to them. For instance, the young prospective surgeon would hardly he able to appreciate the surgical necessi- ties in the field of diagnosis until he had had actual work in surgery, but he could never acquire ability as a diagnostician without service in the medical wards, and his first service in surgery would convince him of this. Ethics of Internship Relation of Interns to the Superintendent of the Hospital. — If one will look about the country to find the well-conducted hospitals, he will soon realize that the best are those that have an executive officer of first-rate ability, and one of the most important functions of the executive is to take good care of patients. He cannot do this without the best of intern service, and he cannot have such service without the fullest measure of authority over the interns, personally, with power to discipline them when necessary. Therefore, the interns in the hospital ought to be directly under and answerable to the superintendent. The rules for these young men should all contemplate responsibility to the head of the hospital. These young men will have duties that involve the patients, the attending physicians, the training-school, and the public, but there can be no divided authority that will be conclusive or final, so that, in all of their dealings, these young men should under- stand definitely that they are answerable to the superintendent of the hospital and, as a finality, to no one else. On the other hand, the superintendent of the hospital should give the greatest possible consideration to these young professional men. He should uphold their dignity in every possible way, compel obedience to their proper professional orders, and, when a plain duty necessitates his decision that they have been wrong in a given case, it is highly essential that the decision be rendered in such a way that the position of the intern wiLl not be made untenable by the fact that a nurse or a junior medical man has reversed his orders. In his relations to the interns, it will be the duty of the superintendent of the hospital to see that their living arrangements are pleasant, that their quarters are comfortable and well furnished, that they have facilities for recreation, quiet places in which they may study, that their food is wholesome, well cooked and well served, even if plain. These young men have usually come from well-to-do homes in which the creature comforts are present, and if they are the right sort of young men their abilities will insure for them in the future the personal comforts, and even luxuries, of life. So that in this formative stage of their careers they should be made as happy and comfortable as possible. There seems to be the best possible atmosphere to encourage work, and interest in the work of the institution, where the superintendent of the hospital is on such terms with these young men that they can go to him in their troubles, confide to him their difficulties, and confess to him any wrongdoing or negligence of which they may have been guilty, and the dis- cipline of the institution will hardly ever suffer when such a relationship exists When interns are found fault with by visiting physicians, their superiors, the super- intendent of the hospital will hardly do his whole duty in such a case without an unprejudiced examination into the facts, and the interns ought to feel that their side of the case will be given a fair hearing, and that they will not be disciplined unless they have deserved it. Sometimes the visiting physician will, for some reason, take a peculiar dislike to an intern, and sometimes unjustly find fault with his work; sometimes, too, attending physicians are tired and irritable and unrea- sonable — as all human beings are on occasion — but that is no reason why an intern should suffer or be humiliated. 296 OPERATION OF THE HOSPITAL Relation of Interns to Visiting Physicians. — Visiting physicians are charged with the treatment and care of patients, and their orders should be conscientiously and as literally carried out as each case will permit, and, if the interns are directly answerable to the physicians whom they are serving in the institution in all pro- fessional matters, the largest possible measure of good to the patient will be the result. Rules for interns must explicitly state that they are to keep in constant touch with the men whose patients they are watching; that any radical or alarming change must be immediately reported to the attending physician, and any question bear- ing upon the condition of the patient must be reported to the attending man at the first opportunity, whether that question concerns the actual physical condition, medication, or dressing of the patient, or whether it be a social question concern- ing the patient's relation to his family or friends or to the hospital. When a patient dies during the absence of the attending physician, the intern should immediately communicate the fact to his senior, for the purpose of getting orders as to the signing of the death certificate, or whether a certificate shall be signed, and whether the physician desires to sign it himself or requires that his intern shall do. so. The interns in the hospital should make every endeavor to prepare the cases for visiting physicians, and to anticipate their wishes in regard to laboratory or blood work that ought to be done. The intern should see that the histories are properly written, and that the greatest possible amount of information is at hand for the first visit of the attending physician, in order to minimize the labor of that busy man. The relationship between the intern and his senior, the visiting physician, should not be wholly one-sided. There are obligations on both sides. The young man is serving his internship for the purpose of learning the greatest possible amount about the practice of his profession, and it is the duty of the attending physician to help him in every way. The most successful visiting physicians in getting work out of the members of the house staff are those who are courteous and considerate toward the young men. This does not mean obsequiousness; it means merely that these young men stand in the relationship of a junior and assistant, a professional apprentice to the older and more experienced visiting physician, and they ought to have the benefit of every aid that he can give them. Unfortunately, some visiting physicians demand the respect of the members of the house staff; instead, they should command it. They should deserve it by their conduct toward their patients, toward the nurses, toward the hospital officials, and toward the young men themselves. In the experience of the oldest and maturest hospital superintendents there comes rarely an incident of insubordination to authority on the part of interns that there is not some justice on both sides, and too often the justice is far more on the side of the hospital intern than upon that of his senior. Perhaps one reason for this is that visiting physicians are busy, tired men. The interns are sometimes ignorant, the visiting physicians impatient and intol- erant of ignorance, and it has been very often known to happen that interns have lost their respect for a senior wholly because of the latter's inattention to his duty, his neglect of his patients, and his failure to perform a high order of professional service, and these young men are quick to grasp such failure. The relations between the visiting physicians and the members of the house staff, and the obligations of each toward the other, need in no way affect the relations of each toward the superintendent of the hospital. When a visiting physician finds carelessness or neglect, or a failure to perform a manifest duty on the part of the intern, there is no good reason why he should not censure his junior with becoming mil Si: MEDICAL STAFF 207 dignity, which need never, and which should never, go to the extreme of abuse or offensiveness of maimer or language. If the offense mi the pari of the young man is severe enough to justify that course, it should lie the duty of the attending phy- sician to bring the incident to the attention of the superintendent of the hospital, who, after all, must lie responsible for the conduct of these young men, and in whose discretion should he left whatever action is necessary in the case. Too often visit- ing physicians, fearing some retaliatory act on the pad of the intern, will complain to the superintendent of the hospital, but will make the proviso that nothing -hall be done in this particular case because the informer desires not to incur his junior's enmity. This course of conduct is hardly fair. Perhaps the intern has not been at fault at all, perhaps the visiting physician misunderstands the attitude of the intern in the case, and perhaps from sheer embarrassment the intern has failed to set his position correctly before his senior; it would seem, therefore, the duty of the superintendent of the institution to insist upon an immediate reckoning of the case, without fear that the feelings either of the attending physician or the intern may be hurt. Such an outspoken course promises a clearing of the atmos- phere, and oftentimes a return to the friendliest feelings between the two gentle- men, who, after all, must work together if there is to be a high order of service and what may be called team work. Relation of House Medical Staff to the Nurses. — A discussion of the relation- ships that exist between the young medical men of the institution and the nurses is an approach toward very delicate ground. It may not be hoped that any atti- tude assumed on this question will be free from censure, or accepted as final, by any considerable number of people involved in this relationship. Perhaps, then, the most important feature of this relationship involves the broadness or the narrow- ness of those who are responsible for the actions and conduct of the young people of both sexes. Generally speaking, the young medical men of an institution will just about measure up to the opinion of their seniors. If the attitude of the board of directors and the visiting staff, the superintendent of the institution, and the head of the training-school is one calling for the highest honor and the most gentle- manly bearing of these young men toward the young women with whom they must daily come in contact, it might be taken almost for granted that the young men will live up to this good opinion, and this rather complacent attitude as to their moral tone. If, on the other hand, those over them assume that these young gentlemen arc reprobates and dishonorable, and that they must be watched carefully to see that they do not commit all the indiscretions and crimes possible, it is more than likely that the attitude of the young men will be one in which trials of wit and daring will be the chief feature. They are put upon their mettle, they arc distrusted, they have a bad name, and are more than likely to try to deserve it. In many institutions there is a hard-and-fast rule that interns ami nurses are not allowed to speak to each other except while on duty, and then only concerning work in hand. There are other institutions in which nurses and interns arc dis- missed from the institution for having any sort of social relationship, such as an evening walk together, or a chat in some quiet part of the grounds of a summer evening. On the other hand, there are institutions in which parties are given to the young people, and during which they are allowed to dance with each other and have a good social evening of it. Not long since in a certain large institution such an arrangement as this began. The nurses were given a party each month, and the interns were always expected. Before the first party was undertaken there was a heart-to-heart talk with the nurses and with the interns, in which the epoch of 298 OPERATION OF THE HOSPITAL ' parties and evening entertainments was promised, only on the condition that the entertainments would continue just so long as the young people appreciated them to an extent that would not allow them to interfere in any way with their respective duties in the institution; that if it became necessary for the young people to chat about "last night" during their work in the institution the next morning, and to live the evening's entertainment all over again when their duties were elsewhere, then the parties would cease and never again be commenced. The evening entertain- ments in this institution have never been interrupted since that time, and there never has transpired a single incident in the conduct or actions of either interns or nurses that could give rise to a feeling on the part of their superiors in the hos- pital that these entertainments were unwise. In this same institution the nurses and interns are allowed to walk out together when not on duty. They may sit together in the grounds and on the steps and en- joy short periods of comradeship, and if an eavesdropper could hear the conversation during these resting spells, he would oftener than not find that it drifted toward the duties of the day, a recitation of the trials and triumphs in the sick ward. If once in a long while Cupid should chance to perch himself upon the back of a bench be- tween one of these young couples, the eavesdropper would find that the Cupid was an honest youngster, free from guile, and that he was shooting an honest dart, and if the eavesdropper remained until he had seen love's arrow pierce the hearts of the young wooers, he would hear their conversation bent upon the future, with perhaps a recitation of the hopes and the fears of an honest union as the two should walk together down life's busy way. So that it would seem the relationship between the young people and their seniors, and the conduct of these young people toward each other, can be regulated almost at will by the seniors, without in any way limiting the freedom of intercourse of the young people. Relation of the House Medical Staff Toward Patients. — It has been truthfully said that the worst place for a young medical man to begin his career is in one of the large charity institutions of the country where the poor are called "paupers," and where the sick are regarded as mere "cases" and as so much "material." In these great institutions the paid officials and retainers serve over long periods of time, and they become calloused and indifferent to suffering. They come hourly in contact with the lowest order of human beings, men who are vicious, ignorant, and unappreciative, and women who are worse, and it is into such an atmosphere that these young people are thrown without the experiences of life behind them. Is it any wonder that they accept the attitude of those about them, and assume the same manner toward the patients? And, if such is the atmosphere that pervades the large charitable institutions of this country, there is a far worse atmosphere in the great hospitals of Europe, where there are practically no nurses with training as such, and where, in almost every case of obscure or interesting pathology, there is a latent, if not expressed, hope in the minds of the professional men that they will eventually have the pleasure of confirming their diagnosis in- the postmortem room. Such an atmosphere is not one calculated to train the young physician in human- itarianism, in courtesy, in delicacy of feeling toward those who are suffering and in distress. On the contrary, the best atmosphere within which these young gentle- men may begin their professional lives with the greatest possible hope of return is the hospital in which the higher requirements of studentship are exacted, in which the patient is regarded as a human being, in which humanitarianism is a confirmed habit of thought, and in which the free patients are regarded as upon HOUSE MEDICAL STAFF 299 exactly the same level as those who pay the highest fees for their service. Amid such surroundings as these the young medical man may hope to have his sympathies aroused rather than deadened. He may hope to realize a state of mind that will make his profession a mission of mercy. There are some physicians who regard it as a sacred privilege, almost, to be with their patients when the end comes, so that they may console and sympathize with the family, and perform those little, trivial, but important, services which, if they do not render death less terrible, at least make it more bearable to those who survive. These thoughts are the structure upon which successful internship should be built; a young man in the hallowing influences of a humane, sympathetic environ- ment need not feel that his conduct toward his patients in after-life will be anything but proper; his bearing could not well be coarse or brutal, and one of the greatest satisfactions that can come to the high-minded physician is a feeling that his people venerate and lean upon him in their hours of suffering. In the institution it should be the duty of the interns to remain on their wards at all regular visiting hours. They ought to be there for the purpose of giving information to the friends of patients, and thus, too, they will learn how to conduct themselves with the friends of patients. The responsible relatives have a right to know the condition of a father, mother, or sister, and, if the story the intern must tell is a sad one, he will soon learn how to tell it so that the heavy blow will not fall too suddenly when it is too heavy to bear, and thus, again, he will get one of the most profitable lessons for his career when he leaves the institution. It is in the attitude of the intern toward the private patients of a visiting physician that the greatest delicacy will be required. The intern is not the physician — he merely represents the physician as an assistant, and his bearing in the presence of his senior should be one of the utmost loyalty and one of perfect confidence. Perhaps he may have misgivings as to the diagnosis that his senior has made, the course of the disease, and the treatment, and it would seem that he has a right to express this doubt to his senior, but certainly not to the patient or the patient's friends. Perhaps this pendulum may swing too far the other way with some young men ; there may be a tendency to become more than properly intimate with the patients of the visiting physician; they may arrogate too much to themselves in the treat- ment and care of the patient, and thus raise a doubt in the mind of the patient or his friends as to whether, after all, the intern is not the better doctor of the two. This has been known to occur. Interns should be quick, courteous, sympathetic, and, above all, businesslike in their dealings with the private patients of their seniors. They should visit the sick room as often as duty calls them. They should stay while it is their duty to be there, and they should immediately leave when that duty is accomplished. It is no part of the duty of an intern to visit a patient in the hospital socially, to sit with the patient's friends and relatives; such conduct is disloyal to the attending physician, and no honorable intern will be guilty of it. In the course of his dealings with visiting physicians in the institution the intern will have occasion sometimes to so gravely question the ability of his senior in a given case, and so seriously doubt the correctness of his views regarding the patient, that it will be his duty to confide his doubts and misgivings to his closest superior, the superintendent of the institution, who, in some such way as may best suit the purpose, will ascertain for himself the correctness or incorrectness of the young man's judgment, and take proper action to safeguard the patient's best interests; but these misgivings should never be confided to another visiting physician under any circumstances whatever, and the wise intern will never discuss the conduct 300 OPERATION OF THE HOSPITAL of one physician with another. These men are on competing ground in the hospital, their interests clash, their ideals are sometimes sordid, their motives sometimes self- ish, and one may never know when a casual remark of an intern, suggesting a weakness or failure on the part of the physician, may not be used to his detriment by another. Relation of Interns toward Each Other. — An esprit du corps in an intern staff is a guarantee and forerunner of successful work; the want of it stands for failure. These young men have not always the best judgment, as they have not had broad experiences of life, and too often they may feel that their success must be purchased at the expense of some one else in the brotherhood. The contrary is true. Where there is a fine spirit of comradeship and mutual helpfulness better work will be done, a broader education will be attained, and a worthier maturity for the young men will be the result. The intern who adds one atom to the sum of common knowledge helps his fellows not alone by the one idea that he has offered, but the mere fact of his keenness has put his fellows upon their mettle and thus sown the seed of ambition and emulation, and a full harvest of achievement will result. ■ On the other hand, if there is a selfish secretiveness, each man hiding and hold- ing what he gets, no one helping any one else, there will breed a narrowness, a want of progressiveness, and the whole corps will suffer. Not alone will a broad spirit of helpfulness in the corps redound to the credit of the men in after years in a greater knowledge of the science of medicine, but for their temporary purposes; their comforts will be greater, they will have more pleasure in their work, they can relieve each other for recreation, do each other's work on occasion, to the end that the whole corps may have a freedom of action that will allow them to keep outside engagements freely, because, having unselfishly helped an intern friend, they will be free to call upon him for service in kind. By-products of Internship. — It is not enough that young men shall be trained in the practical essentials of their profession in the hospital; that they shall be broad- ened and ripened in the humanities and started upon the way of world knowledge. It is equally incumbent on the hospital to drill and train them in the art of study, and teach them how to meet their fellows of the profession on the rostrums and in the pages of the periodicals. Medical men are not measured wholly by what they know, but by what they can tell of what they know. Therefore interns should be taught to search the literature, to prepare papers on live subjects, and to read those papers and be prepared to defend them in gatherings of physicians. An excellent way to do this, and one in use in at least a few of the large hos- pitals, is to organize the intern corps into an institution clinical society. This society should meet at least once or twice a month on regular and fixed dates, and should be conducted by some medical man of experience connected with the hospital, prefer- ably the director of the laboratory of pathology. This permanent president should apportion out the dates, make the programs, aid in the preparation of the papers, and generally act as mentor of the corps. Usually the visiting staff men in the different services will be able to suggest pieces of original work for their interns, based on a case or a series on the wards, and the attending physician will always be glad to direct the search of the literature and the subsequent preparation of the paper. There will be some one always at hand on the medical staff who will edit the paper for style and composition. The director of the seminar or society should personally see that the writer has covered his subject in a way that will make the paper a credit to him and to the institution. The medical journals will always be glad to publish such papers if they are really worth while, and by the time he has finished his internship each member of the corps will have introduced himself HOUSE MEDICAL STAFF 301 in the literature of his profession, and his reprints will be his best introduction to the medical men in the community where he settles down to practice. These intern meetings can be made so popular that members of the attending and consulting staffs will attend them and take part in the discussions. To add to the interest, each meeting may be started with a demonstration of cases from the wards, the interns presenting them. The attending men of the services will always be glad to lead the discussion of their own cases, and in this way the interns are thrown into the maelstrom of active debate with their seniors, and they will learn to talk extemporaneously and on their feet. In Europe it is the practice for the assistant or intern to sign the paper for publi- cation, and to credit the work to the service of Professor So-and-So of blank clinic. If this is done, the head of the service is at once enlisted in behalf of the paper, and he will want it to go out in a creditable condition. The societies benefit the hos- pital, the patients, the attending staff, but, above all, the interns. Rules for Interns All the foregoing discussion upon the subject of interns focuses upon a few fundamental rules of conduct. A set of these rules is appended as seeming to meet the necessities for almost anv occasion in intern service: RULES FOR THE HOUSE STAFF 1. The number of house physicians shall be fixed by the board of directors, and may be changed from time to time as the exigencies of the service may require. 2. The term of service for members of the house staff shall be two years, but the board of directors may terminate the service of any member at any time, either because of any delin- quency on the part of said member or in the interest of the service of the hospital. 3. Members of the house staff shall be chosen each year by competitive examination, the details of such examination and the eligibility of candidates to be fixed arbitrarily by the board of directors. 4. Before entering upon their duties, each member of the staff shall subscribe to the fol- lowing obligation: "This is to certify that I accept the position of member of the house medical staff of the Hospital, that I have carefully read the rules and regulations of said hospital, and that I will carefully abide by them and by any other rules and regulations properly authorized during my term of service." 5. Members of the house staff shall be divided into juniors and seniors, serving one year in each capacity, unless otherwise assigned by the board of directors or the superintendent of the hospital. 6. At the close of their service, if the same has been satisfactory to the board of directors, each member of the staff shall be awarded a diploma, signed by all the officers of the board of directors, by the members of the staff committee of the board, and by all the members of the conference committee of the medical staff. 7. Duties of Juniors. — During their junior year members of the house staff shall be under the immediate direction of the senior in the particular service in which they are engaged, and shall further specifically perform the following duties: (a) Take and record minutely and carefully the history of each patient as soon after his or her admission to the hospital as the exigencies of the case will permit, but, in any case, within twelve hours after admission; (6) personally see that all data, including the necessary laboratory findings, are obtained for the information of the attending man in the case at the earliest moment possible; (c) make daily additions to the history of each case, recording any new developments, as indicated by the attending man or the senior in the service, and describing in detail any operation that may have been performed, with the full names, and, where possible, the addresses, of every person who was present at said operation (excepting the nurses); (-, as possible, to furnish undergraduate specials to private patients rather than call graduates from private duty on the outside. In most of the large institutions graduate special nurses feel themselves inde- pendent of the training-school discipline, refuse to be bound by it, oftentimes resent any interference, and hold themselves responsible to the physician alone. It is to be feared that sometimes this attitude of the graduate nurse has its birth in, and is fostered by, the disinclination to be responsible for her acts to the doctor on the case. This whole attitude of the graduate nurse is to be greatly deplored, and seems to be hastening the day when the well-regulated hospital will refuse t<> em- ploy outside nurses, or to allow them the courtesies of the institution in their professional capacity, because of their growing arrogance in almost every city and every institution. Considering the undergraduate or pupil in the capacity of a special nurse, however, we are confronted by a responsibility toward the pupil that it seems we do not weigh quite heavily enough. The good soldier obeys orders, and the well- disciplined pupil nurse goes where she is sent, and performs her duty there to the best of her ability, and remains, like a picket on duty, until relieved. Sometimes the case is an extremely arduous one, that requires the nurse to lose an immense amount of sleep, and to be on her feet and rustling every minute of the time. The good nurse does not complain; consequently, unless the heads of the training- school watch very carefully the service of the undergraduate special, they will find their pupil is being overworked, and doing day and night duty to an extent that will undermine her health. Instances have been known where a pupil nurse was put on a case and kept there on twenty-four-hour shifts until she was utterly broken down and sent off sick. Immediately thereupon two graduate specials have been required to do the same work the unpaid, overworked pupil nurse had done until she was incapacitated; it ought to be borne in mind, therefore, that very great care must be taken in the selection of patients in whose cases an under- graduate special may be employed, to see that the work is either arranged in double shift and two pupil nurses employed, or to see that ample arrangements for relief are made. The Graduate Special. — We have almost covered the question of the em- ployment of graduate nurses within the institution, but, since we are now upon the subject of nursing, and, therefore, on the subject of the training-school, it would seem in place to discuss at least briefly the question of the duties of graduate nurses. We have argued somewhat against the principle of the employment of graduate nurses in the hospital, and the reasons have been given. Sometimes, however, it will become necessary, either because of scarcity of nurses in the training-school or because of insistence on the part of patients or their friends or the physician, to bring in a graduate nurse. In most institutions where this is done, and it is done al- most everywhere, the graduate nurse comes in and takes charge of her patient with a chip on her shoulder, so to speak, resenting interference at every point, and reserving the right to ride over rough shod the rules of the institution appertaining to everybody. If the institution discipline and administrative Functions of the hospital alone were disturbed by this attitude it might not be quite unbearable, but these are the least of the difficulties. Most graduate nurses forget a good deal of their training after they have left the hospital a short time, and no longer are mis- tresses of the technic of the institution and its ways of doing things: therefore they become unfamiliar with apparatus and instruments, and they are disposed to call for new things, and they even attempt to disturb the technic of the institution and to revolutionize wherever they may; and sometimes, where they are not per- 328 OPERATION OF THE HOSPITAL mitted to do so, they will succeed in arraying the patient, the patient's friends, and even the physician against the methods and procedure of the institution, and we next hear the complaint that there is too much red tape employed, and that, therefore, the patient suffers for want of proper and prompt attention. Without doubt, most of these graduate nurses are loyal to the institution because they are graduates of it and because their friends work there, and because the institution helps them to get private cases, so that we may safely assume that it is merely want of tact that makes them unruly and apparently disloyal. There is a cure for this, and that is to have a code of rules for graduate nurses on duty in the institution that must be inviolably lived up to and infractions punished by dismissal; and, since hospital berths are most attractive to most graduate nurses, if they are given distinctly to understand, and if there have been a few illustrations to emphasize the fact that they will be dismissed from the institution if they do not obey its rules, there will presently come a pretty well understood relation between the institution and the graduate nurses. Sometimes the heads of the training-school, who are responsible for the execu- tion of these rules, will excuse want of obedience by the statement that they cannot afford to drive away the graduate nurses who condescend to perform service there. A little reflection, however, and a little inquiry into the attractiveness of institu- tion service from the standpoint of the graduate nurses will reassure us on this point, and in some places, where a strong stand has been made, and where these young women have been compelled to obey rules, even they themselves presently admit the advantage of the rules and the betterment of the service because of them. Perhaps first among these rules is a provision that the graduate nurse shall work under the general supervision of the head nurse of the department. This is the most difficult of all rules to enforce, and it is the one above all others that needs enforcing, primarily for the good of the patient and in the interest of the execution of proper orders. It may be noted that very few institutions work under definite printed rules for graduate nurses, and it may not be out of place, therefore, if we subjoin some that are in use in at least a few of the institutions of this country: Rules for Graduate Nurses Immediately upon entering the hospital, the graduate nurse who has been called for a case will report to the superintendent of the training-school for orders concerning the patient. Graduate nurses will wear their full uniforms when on duty in the hospital. Graduate nurses will wear rubber heels in the hospital, and will not be permitted to go on duty without them. Graduate nurses, when leaving the room of the patient at night, will be dressed sufficiently to appear in public. The graduate nurse will be required to carry meals from the serving room to her patient, and to return the used tray promptly after the meal is over. She will be required to wash whatever dishes or utensils she has occasion to use, excepting for the regular meals, and to return them to their proper places on the shelves. Private rooms are swept and dusted once daily, and rugs are cleaned as often as necessary; the nurse will be expected to otherwise keep her patient's room in a clean and orderly condition. It is an important part of the duty of the graduate nurse to make her patient comfortable mentally as well as physically, and to see that patient, relatives, and friends are pleased with the institution and its service. The graduate nurse is understood to have entered the service of nursing in the hospital with a full knowledge of its rules in all departments, and of the technic of all nursing procedure, and to have accepted the responsibility of conforming to them. She will nurse her patient according to the methods of the institution in all details. The graduate nurse will take orders for her patient from the medical attendant in the case or from the intern on the service; if, for any reason, the orders cannot be carried out precisely as given, she will immediately communicate with the intern, or, failing to reach him, with the attending physician, to have the orders changed. If she cannot reach one of the responsible THE MODERN TRAINED NURSE 329 physicians she will lay the difficulty before the nurse in charge of the floor or ward or the super- intendent, and thus place responsibility whore it belongs, whether on the physicians or cm 1 1 n - nursing representatives of the hospital, Graduate nurses on duty in the hospital are expressly forbidden to eat in their patients' rooms, or to order any food whatever except inn for their patients' own use. Graduate nurses will not be permitted to visit in any part of the hospital excepting where their duty lies, excepting with the explicit consent of the superintendent, of the training-school in each instance. Graduate nurses will be expected to report all breakages and damage to hospital property immediately on their occurrence, and to pay for same unless payment is expressly waived by the superintendent of the hospital in each case. Failure or refusal to pay for same on demand will subject the offender to immediate dismissal from the institution, and she will not again be per- mitted to nurse in the hospital until the amount, has been paid. The hospital declines to collect fees for graduate nurses, and will under no condition assume any responsibility for same. The institution business office will at any time be pleased to give the special nurse any information in its possession concerning the financial responsibility of her patient, but declines to be held responsible for the correctness of said information. The hospital, as an accommodation, provides board for graduate special nurses on duty there, charging the actual cost of same against her patient, but the institution will, under no con- ditions, undertake to furnish special diet for nurses on duty. Repeated or flagrant violation of these rules will subject the offender to dismissal and to refusal of further employment in the institution. Graduate Nurses in Private Practice. — We enter upon very briefly here the contemplation of a situation which may be characterized as very little short of dis- graceful. We are all of us busy training pupil nurses to be efficient, intelligent, obe- dient caretakers of the sick, with the intention that as soon as they are fitted for this work they shall be clothed with proper authority as certified in their diplomas. We have a right to assume when a nurse leaves the institution with her diploma in her hand that she is going to make herself useful to sick people, and we uphold her in certain demands that, on the whole, bespeak for her a position of dignity and importance, one well up in the social scale, and one in which she will not be bur- dened with overwork. In return, we ask of her the performance of certain duties in an acceptable maimer, and those duties have to do with the sick person, with the family and friends of the sick, with the physician who is responsible for the care of the sick, and with the public at large. The term disgraceful, as applied to the situa- tion in this country, is justified by the unquestioned fact that graduate nurses, as a class, are not living up to the expectations either of the public, the physician, the patient, or the schools that sent them out. Let us see briefly wherein lies the failure : in the first place, the home to which the graduate nurse is called is in a turmoil; some one is ill, the family is anxious and in trouble, things generally are at sixes and sevens, the servants have no mistress; the housekeeping duties are neglected, the meals probably irregular; the servants are asked to serve one or two members of the family at a time, and, therefore, the meals are strung out almost through the day. The servants, being rather an ignorant and consequently narrow-minded lot, become impatient and dissatisfied, and they talk about leaving, even if they do not go so far as to actually quit tin- service of a family that lias already trouble enough. Now, the graduate nurse comes on the scene. Would it not seem that a part of her duty, after she gives her immediate attention to the sick person, is to help make things comfortable and pleasant in the home itself, to make as little trouble as possible, to go about her duties without friction with the servants, to make few demands of a personal nature. and to content herself witli what is in sight? Will any of us dare to say f hat t his is the common attitude of the graduate nurse? It is not the experience of most of us. If we ask ten people who have had graduate nurses in their families during the past year, nine of them will agree that the nurse required more waiting upon and more personal service than the sick person; that 330 OPERATION OF THE HOSPITAL she made demands that were oftentimes practically impossible to gratify; that her first thought was for herself and her personal comfort, for her meals, and for her sleep- ing accommodations, for her laundry, and so on, down a long list of outrageous demands. Fortunately, there is another side to this picture, and all of us have personal knowledge of a number of graduate nurses and their methods, who bring to their duties an unselfish devotion, a tact and thoughtfulness worthy a better reception. There are some women and men, too, who employ graduate nurses, and who at once set them in a class with the cook and the laundress; who exact of them the most me- nial service of a personal nature; who work them day and night, not only in the care of the sick for whom they were employed, but in a personal service for well members of the family. To illustrate what a graduate nurse in a house of trouble should be: she steps soft-footed into the house of sickness, she takes with her a cheery smile, a modulated voice, and an animated demeanor. She goes about the house getting what she needs for her patient. If she cannot find precisely what is wanted, she will often- times make something else do. She will make friends with the servants, and, after an hour, sometimes will have them on her staff working disinterestedly with her toward a common end. Oftentimes, and by easy stages, she will unobtrusively take over the duties of the housekeeping, sometimes even to the extent of ordering the meals. She will provide little comforts and pleasant surprises for the grief-stricken mother, perhaps, and so by her good offices render her presence in the home a dis- tinct blessing, rather than tolerated as a necessary evil. Without any question, this disagreeable attitude of the average graduate nurse in private practice, when it exists, is the fault of bad training. In the curriculum of nearly every training-school there may be found a course of lectures on the "ethics of nursing," and it will be found of intense interest to those of us who are actively interested in nursing problems, if we were to listen to one of these lectures or read one of them that attained the dignity of publication. When we know what these lectures contemplate, as a rule, we will have very little difficulty in judging the cause of poor nursing, poor judgment, and want of tact in the modern graduate nurse. There is a cure for this, and that cure must be administered in the training- school, and it must take the form of definite teaching of the domestic virtues, of tact in the attitude of the nurse toward her patient and the people who surround the patient. A lecture on ethics will not do it; it must be a constant drilling; it must be a drilling on the wards of the institution, in the private rooms of patients there, in the conduct of the pupil nurse toward her comrades and co-workers in the hospital. The Nursing Profession and the Public. — The earnest, thinking friends of the nursing profession look with a good deal of apprehension upon the tendency of present-day methods in the profession that seemingly have for their object the es- tablishment of principles on the lines of labor unions. In all other professions — that is, medicine, law, engineering, and art — it has long become an established principle that there can be no fixed prices for professional services independent of the conditions in each case; and those of us who are anxious to see the profession of nursing established on a high plane feel the same way about that profession. Just how far we may go in this direction it is difficult to say, but those of us who share the fear that the nursing profession may be brought down rather than lifted up by the inculcation of union labor principles, are looking toward the nursing commissions of the several states, that have been recently established under new laws, for a solution of this much discussed question. THE MODERN' TRAINED NURSE 331 Nearly every state in the Union now has a nursing law, and they are pretty uniform, taken altogether. They differ, of course, in details, but they follow the same . general principles. In some states the commission, usually appointed by the governor, is made up wholly of nurses. In other states, such, for instance, as Pennsylvania, the nursing commission is made up of physicians and nurses. And, yet again, in a few states there is a small admixture of influence outside both these professions by the appointment of some public-spirited citizen, who has taken a particular interest in nursing as a profession. In some of the states these com- missions have risen to a high plane, and have fine aspirations for the profession. In other states there is a definite trend toward the principles of union labor. Without any question, time will smooth out many of the rough places, and it is to be hoped that wise counsel in the leadership of the profession of nursing will set that profession beyond the sordid things that have their whole expression in a fixed rate of pay per day for the trained nurse, irrespective of her qualifications or previous education and her power for initiative. The state nursing commissions have hardly gone far enough with their work as yet to be fairly judged as to what the future will bring, and some of them that seem to have been going in a dangerous direction will undoubtedly see their mistakes and correct them. For instance, in some of the states the nursing commissions have prescribed a curriculum for the training-schools that goes very far beyond the capacity of women who are obtainable to enter these training schools. Of course this practice must eventuate in badly trained nurses, just as any one in any calling will be badly trained who is asked to prosecute his or her training far beyond the mental capac- ity of the individual. This, too, will be smoothed out in time. And even the qualifications for entrance to the training-schools will be set upon a different plane, or the curriculum established by the state commissions will be modified to meet the practical necessities of the case. In this modern day the trained nurse is a necessity, not a luxury. Fortunately, the people are finding it desirable to go to the hospitals when they require technical care, and this will come to be the case more and more every year, until presently it will be considered a matter of course that the man, woman, or child who is sick, from whatever cause or with whatever ailment, shall go to the hospital, but until that comes the sick must be nursed at home under certain conditions, and there must be nurses to take care of them. A goodly part of this work is done now by visiting nurses employed by associations of various sorts, and the visiting nurse is another expression directly from the public that the average individual at home cannot afford to pay the price of a trained nurse, and, therefore, the community is being asked to pay for the trained nurse. A very large percentage of the cases of illness that remain at home to be cared for need very little or no technical attention, and in a great majority of these cases the people cannot afford to pay a trained nurse. The question is. What is to lie done about it? Are they to have trained attention withheld from them because they cannot afford to pay the schedule price? This is quite satisfactorily settled in the medical profession, because it is uniformly recognized that physicians must base their professional charges upon the ability of the patient to pay and nut upon the value of the service, without any other condition than the doctor's ordinary charges. We all know very well that the ablest men in the medical profession, both those in general practice and those restricting themselves to the special branches of medicine, do an immense amount of work at vastly reduced prices, in addition, of course, to what they do entirely free. This principle of "tempering the wind to the shorn lamb" is so thoroughly understood in the medical profession that we 332 OPEKATION OF THE HOSPITAL need not dwell on it, and it is understood quite as well, too, that the doctor has a right to charge more than his ordinary fee to the patient who can abundantly afford more, and the patients themselves recognize this condition of affairs, and, as a rule, acquiesce in it. Is it not possible to place the nursing profession on some such plane as this? Of course, there is the difference that the nurse must give her whole time to one patient, and that she cannot be earning money elsewhere while she is on that case. Then, shall we permit her to charge more on the next case where the people can afford to pay more, or shall we detail, to take care of the patient, the nurse of mediocre attainments, one, perhaps, not at all popular with the doctors in her sphere, but who is recognized as a conscientious, painstaking nurse? We know there is as much difference between the ability of nurses as between doctors or lawyers, and it is never expected that the doctor of mediocre attain- ments and limited education shall earn as much money or receive as high honors as the man of extraordinary ability; and does not all this bring us back again to the question, Whether we shall not have grades of trained nurses whose diplomas from their schools and whose licenses from their states shall prescribe precisely the character of work they may or may not do? THE CURRICULUM Schedule for First or Junior Year First year pupils are divided into divisions according to the number in the class, and with- out reference to the probationary period, each division taking the same work at different hours and under the same teachers; it would seem expedient to put the brighter or better educated girls together, and those less favored together. Dietetics (this work is given in the diet kitchen in actual work of cooking for patients, and in lectures by the dietitian) : 1. Foods — marketing and care of foods. 2. Classification of foods chemically. 3. Character of food constituents, proteins, fats, carbohydrates, etc. 4-6. Physiology of the digestion — describe the alimentary canal, juices along its course, and functions of each, beginning with the mouth. 7, 8. Chemic and physiologic values of specific food articles. 9, 10. Metabolism — what becomes of the food and how it is distributed to the tissues as nutriment. 11, 12. Waste — what is wasted and what becomes of it. _ Note. — These lectures may be contracted into fewer or more lectures, according to the time at disposal and the abilities of the classes. Household Economics: 1-3. Relative value and uses of household materials and their care. 4, 5. Furnishing a house; furnishing a room; furnishing a sick room. 6. Ventilation in the home, in the hospital, in the sick room. 7. Plumbing and drainage — the care of sinks, basins, toilets. 8. The disposal and destruction of infectious excreta. 9, 10. Linens — purchase and test of cloths; care of linen and cotton goods. Making up hos- pital pieces. 11, 12. The laundry — how to wash and clean wool and cotton goods, blankets, flannels, curtain cloth, and the rougher wash goods. Note. — Part of this period should be spent in the linen and supply rooms at mending, sorting, distributing, and making up supplies. Surgical and Medical Supplies: 1-5. Use and care of material — bedside utensils, bed furnishings, rubber goods, enameled ware, etc. Cleaning and sterilization. 6-10. Surgical dressings and material — bandages. Surgery: Surgical dressings. 1-5. Surgical dressings. 6-10. Bandaging. THE MODERN TRAINED NURSE 333 ,•1 natomy and Physiology (12 lectures with manikin or plates, on the chief organs of the body, with physiology of each): 1. Brain and spinal cord and nervous system. 2. Thorax and diaphragm. 3. Heart. 4. Lungs. 5. Abdomen and peritoneum. 6. Stomach. 7. Intestines, small and large. 8. Liver. 9. Spleen and pancreas. 10. Kidneys and adnexa. 11, 12. Bladder and lower urinary tract — genitals. Materia Mcdica (10 lectures and demonstrations — the principle families of medicine, the commoner forms of administration, physical and physiologic character of each, and dosage). Note. — Details of this subject must be loft to the teacher, unless some primary text-book is followed. Pathology and Bacteriology (15 lectures in the laboratory, illustrating and demonstrating the pathogenic and non-pathogenic micro-organisms; the fundamentals of asepsis and antisepsis). Note. — All the groups will have demonstrations in bedside nursing, the use and handling of bed-pans, urinals, head and back rests, lifting and moving patients; use and care of rubber goods, water-bags, ice-bags, rubber tubes, catheters, stomach-tubes, etc., the giving of enemas, high and low, irrigations, care and use of percolators, dressing cars, etc. Second Year Dietetics (practical repetition of first year's work, with more detail in making up of special diets for certain classes of patients, diabetics, etc. This work will be in the diet kitchen and in lectures, the number of which will depend on the time allowance. Caloric and chemic calculations of foods will be taught at this time). Medicine: 1. The keeping of records, taking temperatures, pulse, respiration, and why. 2, 3. Importance of little things in records: vomiting, nausea, chills, body movements, like tossing head, etc., rolling eyes, gritting teeth, lapses into delirium, spasms, general or local; character of bowel movements and peculiarities of same with significance. 4-6. The eruptive fevers, their differential diagnosis and fundamentals in treatment. 7, 8. The acute fevers, pneumonia, typhoid — principals underlying their care. 9, 10. Arteriosclerosis — chronic interstitial nephritis and complications — Bright's disease. 11. Diseases of the digestive organs, gastric disorders, diarrhea, dysentery, constipation. 12. Diseases of other abdominal organs — liver, spleen, kidneys, pancreas, the enteroptoses. 13, 14. Tuberculosis — pulmonary — elsewhere. Anatomy: 1. The bony frame — its physical properties and uses — its physiologic properties. 2. The bones of the skeleton — their divisions — the long bones — the flat bones — the round bones. 3. The bony cavities — what each contains — Nature's protective devices. 4. The brain and cord — functions — major divisions. 5. Throat — pharynx — larynx. 6, 7. Thorax — heart, lungs, pleura, diaphragm — relations and gross functions. 8, 9. The abdomen — stomach and intestines; liver, spleen, kidneys and ureters, pancreas, ovaries — their relations and location. 10, 11. The pelvis — bladder, uterus, rectum, and genitals. 12. The muscles of the body — flexors, extensors, physical properties — direction of their ac- tion in relation to origin and insertion. Physiology: 1. The circulation of the blood and its functions. 2. The functions of the brain and cord. 3. The functions of the heart. 4. The functions of the lungs. 5. The functions of the stomach and intestines. 6. The functions of the liver, spleen, pancreas, kidneys, and skin. 7. The generative apparatus — male. S. The generative apparatus — female. 9. The sympathetic and general nervous system. 10. Organs of special sense — eye. 11. The car. 12. The Dose. 334 OPERATION OF THE HOSPITAL Surgery: 1. Fractures and dislocations — treatment. 2. Wounds of soft tissue: incisions; contusions, lacerations, burns and frost bites; treat- ment; processes of repair. 3-5. The classical surgical operations. 6. Orthopedic surgery: aims and fundamentals. 7. Corrective or plastic surgery. 8-10. Surgical preparations: asepsis and antisepsis. Pathology and Bacteriology: 1. Urinalysis. 2. Inflammation: elementary pathology of. 3. Tumors: varieties and peculiarities of each. 4. The micro-organisms: classes and peculiarities. 5. The non-pathogenic bacteria. 6. The pathogenic bacteria: streptococcus, erysipelas, three forms, staphylococcus, pneu- mococcus, tubercle bacillus; the spore-formers. 7. The processes and methods of infection. 8-11. The vaccines and serums — their processes of operation and methods of employment; immunity. 12. Use of blood-counters. 13. Use of hemoglobinometer. 14. Use of blood-pressure apparatus. Third Year Dietetics (diet kitchen work, especially as to special diets and feeding values, 10 lectures). 11. Milk: chemistry and physiology of milk. 12. Pasteurization and sterilization of milk. 13. Formula; and compounds. 14. Feeding values of various milk combinations. Obstetrics: 1. Pregnancy: process of ovulation and fecundation. 2. Signs of normal and abnormal pregnancy. 3. Complications of pregnancy: abortion, miscarriage, and eclampsia. The vomiting of pregnancy. 4. Labor — the phenomena of: stages, presentations. 5. Accidents of labor. 6. Abnormalities of pregnancy: anatomic malformations. 7. Abnormal labor. Forceps and their indications; placenta prsevia; prolapse of cord; Cesarean section. 8-10. Care of the newborn child: emergencies. 11, 12. Care of the postpartum mother: genitalia, breasts, bowels, food. Infants and Young Children: 1, 2. Anatomic and physiologic peculiarities of the infant. 3, 4. Inherited abnormalities: bony malformations; club-foot, rickets; skull deformities; cross-eyes, skin lesions; birthmarks. 5, 6. Care of the newborn and premature infant. 7, 8. Infant feeding: breast and artificial. 9. Faults of digestion and improper feeding. 10, 11. Malnutrition: gastro-intestinal disorders; summer complaint. 12. Ordinary diseases of childhood. 13. Exanthemata: diphtheria, whooping-cough. 14. Hygiene and care of the healthy child. Nervous, Mental, and Special Diseases: 1. Care of the insane. 2. Care of "rest cures." 3. Nervous complications of medical cases. 4. Care of skin cases. 5. Care of diseases of the eye, ear, nose, and throat 6. Hygiene and preventive care of tuberculosis. THE MODERN TRAINED NURSE 335 MALE NURSES Those of us who practised medicine, or directed the affairs of hospitals, under the old regime, when the trained woman nurse was unknown, and when the male nurse was a composite of drunkenness and genius, wonder whether the change that has wholly eliminated the trained male nurse is for the best. There is no doubt that there is something stronger, more virile, more substantial, and certainly less finnicky in the male nurse than in the female. That tender touch that we are ac- customed to sentimentalize about, that human sympathy that we are accustomed to associate with femininity, finds almost no resting place in the institution young woman nurse of to-day. Many times she is quite as heartless as the most heart- less of the opposite sex. Oftentimes she is not more conscientious. Almost always she is subject to whims. She must be accorded more consideration, at the expense sometimes of the patient. On the other hand, the male nurse has usually some overpowering failing, some inherent weakness, that forbids his success in any permanent line of human endeavor. In other words, the male nurse has been nearly always "a failure." Many times he has become a periodical drunkard. Sometimes he has been a bright young busi- ness man or mechanic or clerk, whose intemperate habits have brought him to the hospital, and, after repeated trials and repeated failures, he has found that his only safety lies in shutting himself out from the world, and subjecting himself to the discipline of the hospital or the eleemosynary institution. The most competent and reliable male nurse will oftentimes go along for weeks or months, attending conscientiously to his duties, taking most efficient care of patients, until in some unlucky moment he finds the whisky bottle in the medicine cabinet, and takes "just a drop to steady his nerves." The rest of the story is easily imagined. It has become a maxim that a trained male nurse would not be a nurse if he were fit for any other occupation, and that is probably true. So that time and events, changed conditions everywhere, have practically eliminated the male nurse, except for certain special services and in special places. In the large general hospital even the term "male nurse" is rarely heard. He is an "orderly" now, and usually has all the weaknesses of the old male nurse, with rarely few of his good points, and the orderly, as we have come to know him, is a roving, restless incompetent, too often dishonest in a petty way, and rarely efficient enough to give the nurses very much intelligent help. Of course, there are exceptions; there are a few male nurses in every city whose time is always employed at remunerative wages, some who make as much as |30 or $40 per week and are always busy; and there are a few orderlies in large hospitals that are competent men, sober, industrious and honest, who live in the institution, who save their money, who are accommodating in their work, kind to patients: but the work of even these few is gradually lowering in its grade. The male nurse used to catheterize, give enemas, do dressings, and, in rare instances, do minor surgery. Nowadays the woman nurse gives the enema, and since catheterization is included within the realm of aseptic minor surgery, either the doctor or his assist- ant performs that office for the male, while the woman nurse does it for the female patient. So that the orderly's work is almost reduced to a janitor's service. He mops the dressing-rooms and sometimes the wards and halls. He may occasionally give an enema to male patients. He helps lift patients, lie puts them on the cart for transportation to the operating-room ami back again. He is called to control delir- ious patients occasionally, by reason of his strength. He helps with the service of the meals, he carries the stores and the supplies to and fro, and otherwise make- 336 OPERATION OF THE HOSPITAL himself generally useful, and his compensation is usually $20 or $40 per month, with room and board in the institution. As attendants on patients in insane hospitals and public eleemosynary institu- tions, there is very little to choose between men and the ordinarily employed women. The occupation in such institutions is brutalizing, and as the public is parsimonious and stingy about caring for its wards, and as charity commissioners are usually negligent where they are not ignorant, and as superintendents are too often political proteges of politicians, so, "like master like man," the attendant male and female are calloused, lazy, often dishonest, and rarely possessed of humanitarian qualities. This is not a pleasant section to write. The ideality of the situation as com- pared with the reality is discomforting and discouraging. There is no reason why there should not be competent sober, industrious male nurses. The price of their service is usually regulated by the value of that service, and the value of the male nurse has receded, and has reached so low an ebb, along with his deficiency and his frailties, that in many institutions even the orderly has been dispossessed, and there are now only nurses and janitors, and this condition will increase, and male attendants in institutions will become rarer as the trained woman nurse becomes more efficient and more courageous in her activities. RULES FOR TECHNICAL DEPARTMENTS Rules for administrative procedure are scattered through these pages with regard to their specific employment and in the various proper places rather than under any very precise order as rules. The following rules for three special de- partments, it is thought, are so important that they had best be assembled at this place. RULES FOR THE SURGICAL DEPARTMENT Following are a few general rules intended to apply in the surgical rooms of the average general hospital, operating under the ordinary conditions in this country. These rules can be amended or elaborated or cut to meet special condi- tions. General Rules Visitors. — Physicians only shall be allowed to visit the operating suite while operations are in progress, and under no circumstances will a non-medical person, whether relative or friend of a patient or otherwise, be allowed to be present at a surgical operation without the specific consent of the superintendent of the hospital in each case. Physicians are welcome in the operating department under the following condi- tions: They must don visitor's coat or slip gown before going into the arena or into the private operating-rooms. In the amphitheater visitors will confine themselves to the seats intended for the regular audience, and must not enter the arena except on specific invitation of the operator. Visitors must respect the "private" sign on operating-room doors, and will enter only upon the specific invitation of the operator, or after permission from the head nurse of the department. In attendance upon operations in the private rooms visitors must keep outside the zone set apart for nurses and assistants, and will come closer only upon invita- tion, of the operator, and will immediately step back again after they have seen what the operator wished to point out. In the "clean" rooms when a visitor has been invited into the atmospheric field of operation, he must be clothed in head-cloth and mouth-cloth, the latter covering nose, mouth, and beard. Visitors must not assist in any way in the operating-rooms, unless specifically invited to do so by the operator, and must not touch trays, tables, or any o\ the paraphernalia for any purpose. Visitors will enter the preparatory or anesthetizing rooms only upon invitation of the surgeon in charge of the case. Schedules of operations are posted in the surgeons' dressing-room and in the visitors' locker room; the schedule book upon the head nurse's desk is private property, and visitors, whether staff members or not, are not expected to peruse it. •>2 W7 338 OPERATION OF THE HOSPITAL A room for visitors and a room for operators is provided; those who are not actually at work are requested not to loiter in the corridors of the suite, and will, under no circumstances, notice patients in transit. Loud talking and unnecessary noise are prohibited. Visitors to the city who desire to be called for any particular operations or for any surgeon's schedule must leave their telephone number with the head nurse, and arrange at the other end of the phone for the taking of the message when the number is called. Out-of-town men may be notified by telegraph or long-distance telephone twenty-four hours in advance when possible, at their expense. Operators.— Surgeons who participate in the work of the hospital must adhere to the institution technic in so far as asepsis and the service of interns and nurses and preparation of patient are concerned ; it is only in this way that an adequate asepsis and assistance can be maintained. Operators are expected to accept the dictum of the head nurse in the schedul- ing of operations. The operating schedule-book will be in the custody and under the control of the head nurse of the department, who will be held responsible for the proper scheduling and conduct of operations. No operation will be set down for a time that would naturally make it lap over on another operation previously scheduled, and the head nurse must be the final judge as to this time. Fifteen minutes' delay will be considered sufficient to meet all the require- ments of the profession, and any operator who is more than fifteen minutes late for an operation will be considered to have forfeited his time, and must then wait until the regular schedule shall have been completed. His patient will be returned to bed. Operators are expected to choose their instruments for any operation at least half an hour before the time set for the operation; otherwise the institution's regular tray for that operation will be picked and sterilized, and the operator will be expected to get along with those. This rule is made necessary to avoid un- necessary delays in sterilizing additional instruments. Operators who require over-night preparation of patients, or who require special instruments or apparatus or dressings, must give orders in ample time, as delays cannot be allowed to make up for this delinquency. . Operators are expected to select and announce the anesthetic they wish to employ in ample time for preparation, and where "continuous gas" is to be used for private patients the operator is expected to inform his patient, or to have his intern do so, that there is a special charge for this anesthetic. Operators are privileged to invite any physician to see them operate, but non- medical persons will not be allowed in the operating-rooms except by special per- mission of the superintendent of the hospital in each case. The private assistant of any operator may assist him in any private case, but the institution reserves the right to have its own surgical interns scrubbed up and present for any emergency. No non-medical person will be allowed to assist in the operating-rooms in any capacity whatsoever, excepting the regular nurses of the institution. Any procedure in connection with a surgical operation that partakes of the nature of administrative technic, and varies in any way from the regular technic of the institution, must be announced to the head nurse before the operation begins, and must have her approval; any appeal on this point must be made to the super- intendent of the hospital. RULES FOR TECHNICAL DEPARTMENTS 339 The Anesthetic. — No anesthetic will be commenced, under any circumstances, until the operator appears in the operating suite. No outsider will be permitted to administer an anesthetic in the institution; the hospital maintains a corps of expert operators in this department, who are familiar with the rules of the institution and with the apparatus available for service. Members of the house medical staff are not permitted to administer anesthetics until they have been passed as competent by the regular staff men on service. In exceptional cases, where the operator has reason to anticipate difficulty with the anesthetic because of the patient's condition, one of the regular staff anesthetists on service must be called in, after due notice through the operator's intern, and in such case the operator may use his judgment whether the patient should pay a fee to the special anesthetist, but there is no obligation on the part of the patient to pay such fee except when previous arrangement to that effect has been made by the operating surgeon with his patient. The regular staff anesthetists may be called upon to give an anesthetic in any case, after reasonable notice, and they are forbidden to send a bill to any patient for such service, except with the written approval of the operating surgeon as an endorsement on the bill, and, when such fee is permitted, it shall not be more than $10 in any case, unless specific arrangement to that effect shall have been approved by the superintendent of the hospital. The Patient. — No patient, whether private or a patient in a free ward, shall be taken to the operating-room until the following conditions have been complied with : (1) Written consent for the operation, signed by the patient, if an adult, and in mental condition to give such consent, on the regular "permit for operation" form of the institution; if the patient is under legal age, eighteen years in females and twenty-one in males, or, if the patient is unconscious or delirious or in such mental condition as to be unable to realize the gravity of the operation, the permit must be signed by the responsible person nearest of kin available ; if there is no such person present or available, the facts must be stated to the superintendent of the hospital, who may use his discretion in issuing a special permit, on the face of which all the facts must be stated. This permit must be taken to the operating-room as a part of the regular record of the case. This permit must be had whether the anes- thetic is to be general or local. (2) No patient shall be taken to the operating-room without a complete urine examination, and the laboratory report must accompny the patient as a part of the record. In the event that a specimen of urine cannot be obtained for analysis, the superintendent of the hospital must be notified of the facts, and he may, in his discretion, issue a waiver permitting the operation, but the reasons therefor must be stated in the superintendent's handwriting on the permanent record of the case. (3) No patient shall be taken to the operating-rooms until arrangements are completed, assuring* the commencement of the operation within fifteen minutes after the patient's arrival there. If, for any reason, a longer wait is necessary the patient must be taken back to bed. This rule is to guarantee prompt attention to patients, so that they may not be kept under hurtful suspense unduly. At the end of an operation no patient shall be taken back to bed without the attendance of a responsible medical man. preferably an intern of the institution. No patient shall be left alone, for even the shortest interval, in the operating- room suite. A physician or nurse must always be present in the room. Immediately following the operation, it -hall lie the duty of the first assistant 340 OPERATION OF THE HOSPITAL to the operator to see that the patient is removed from the table to the stretcher and properly prepared for the journey back to bed. He must likewise be convinced that the patient is in good condition before transfer to the stretcher is attempted. THE CHILDREN'S DEPARTMENT General Rules Visitors. — Visiting time in the children's department shall be as follows: Large (free) wards, 2 to 4 p. m., Wednesday and Sunday. Small (private) wards, 1 to 8 p. m. daily, in the discretion of attending physicians. Private rooms, without other limitations than the orders of attending physician. In Isolation. — No visitors at any time, upon any pretext whatsoever (excepting in cases of impending death, and then under detailed supervision of the superin- tendent of the hospital). Only the parents or guardian will be permitted to visit patients, excepting on the specific order of the superintendent of the hospital in each case. Children will not be permitted to visit in the children's department. Visitors of whatever class, whether parents, visiting physicians, or casual guests of the hospital, shall be clothed in the regulation visitor's gown of the insti- tution before entering the rooms where there are sick children. Visitors, whether parents or others, will not be allowed to handle the sick children, or to wait upon them, or to give them anything to eat or play with without the express permission of the head nurse in charge in each particular instance. Note. — These rules relative to visitors do not apply to members of the young ladies' society detailed to entertain the children, and whose conduct is prescribed in special rules. Admission of Patients. — No patient shall be admitted by the physician detailed in the admission rooms until a throat smear has been made and found negative in all cases, and a vaginal smear has been made and found negative in all female children. When either of these findings shall have been found positive, the super- intendent of the hospital shall be immediately notified for discretionary action in the case. Whether the smears prove positive or negative, it shall be the duty of the admitting physician to take cultures from throat and vagina, and send them to the incubator in the general laboratory of the institution for final treatment and report. After admission, cultures from throat and vagina shall be taken each day for three days by the junior house physician, carefully examined, and the findings added as a part of the permanent record, and twice a week thereafter. As soon as a patient has been admitted by the physician it shall be the duty of the admission nurse to remove all clothing in the presence of one of the house phy- sicians in that service, whose duty it shall be to examine the body of the patient for bruises, eruptions, marks of all kinds, malformations and irregularities, and to make note of them on the history sheet as part of the routine physical examination. The nurse shall immediately thereafter, unless forbidden to do so on account of the critical condition of the patient, give it the regular bath prescribed, weigh the patient naked, clothe it in the hospital bed clothing, and put it to bed in the prescribed location. After one hour the nurse shall take the temperature, pulse, and respiration, and record them as a part of the admission entry in the nursing chart. RULES FOE TECHNICAL DEPARTMENTS 341 Before the parents of the child shall have left the hospital it shall be the duty of the junior house physician to interrogate them on the history of the ease, as prescribed under the rules for history taking, and to record their story in detail on the record. As soon as possible, and, in any event, within twelve hours after the admission of the patient, the junior house physician shall make and record a complete urine examination, and shall, in addition, examine the blood or such other excreta — fluids, tissue — as in his judgment are likely to prove of value in the physical examination to he made later by the attending physician. As soon as the routine admission service has been performed it shall be the duty of the junior house physician to notify his senior of the admission of the patient, and it shall be the duty of the senior to see the patient at once. If.it is a private case, he shall at once call the attending physician by 'phone, notify him of the ad- mission of the patient and the present condition, and ask for orders. If it is a ser- vice (free) case, he shall at once make a complete physical examination, record his finding on the permanent record, according to the rule for making physical examina- tions, and, in his discretion, shall give the necessary orders, or call up the service attending physician, relate the facts, and ask for advice. Every patient, upon admission, shall be assigned to a bed in one of the observa- tion rooms of the department, and shall not, under any conditions whatever, be removed to a ward in which there are other children until so ordered by the attend- ing physician in the service. Care of Children. — Immediately upon admission, it shall be the duty of the ad- mitting nurse to examine the patient carefully for head and body vermin. The general bath will be adjudged sufficient treatment for body lice; when found on the head, she will apply the institution's technic prescribed, and the treatment will be continued until the patient's head is free from them. But under no circumstances will it be permitted to cut a female patient's hair, except with the express consent of the parents or an order from the superintendent of the hospital. A full bath, either tub or sponge, must be given every patient daily except on counter order of the physician. Children's hair must be kept combed, and, in the case of females with long hair, it must be braided and neatly tied with ribbon or tape. Finger- and toe-nails must be kept trimmed and neatly manicured at all times. Tooth-brushes are provided by the institution for older children, who must be taught their proper use whenever their health permits, and the mouths and teeth of all children must be kept clean. In the case of infants the nurse is forbidden to clean the mouths with her finger, but must use a soft mop made of wooden handle and absorbent cotton swab. The handle must be notched, so that the swab when tied on will not slip off. In the absence of special orders by the physician, a saturated boric acid solution may be used for mouth-wash. Each child must have its own comb and brush while in the hospital, and the comb and brush that have served one child shall not be used again until they have been completely sterilized by soaking in a solution of 1 : 4000 bichlorid for at least six hours and then rinsed in clean sol'1 water. Brushes and combs must not be boiled. The genitals and buttocks of each infant must be given careful attention l>\ washing in warmed water after each bowel movement and must be kepi well pow- dered with talcum. The id a ns and foreskin of male children must be watched care- fully and kept clean, and every female infant shall have a vulval pail in COnstanl use, and this must be changed whenever we1 or soiled. Any discharge in cither --ex must be communicated to the physician in charge. 342 OPERATION OF THE HOSPITAL Each child large enough to use bed-pan and urinal must have separate utensils of both sorts, and these must not be used for any other child. After each use they must be scalded and passed through the prescribed disinfecting utensil sterilizer. Each child, large and small, shall have separate wash-basin, wash-cloth, cup, spoons, and dishes, and these shall be identified by number of bed. Each child shall have its own thermometer, rectal for infants, and both rectal and mouth for older children, kept in proper receptacle at the bedside, and after each use it shall be washed and carbolized or disinfected in the institution's routine way. When a patient is discharged all utensils and thermometers shall be passed through the special sterilizing process for the required time before being used again. Infants' diapers must be kept, when containing bowel movement, in the special receptacle provided for them in the slop-sink room until the next visit of the attend- ing physician; they must then be cleaned of feces, and placed to soak in 5 per cent, carbolic solution for twelve hours, then rinsed, and sent to the laundry for washing. All linens in the children's department, bed clothing of patients, sheets, slips, and pads, must be soaked in 5 per cent, carbolic solution for twelve hours before being sent to the hospital laundry. Nursing and bottle infants must invariably be fed by prescription of the physi- cian as to time, amount, temperature, and kind of food, and at least once daily each nursling must be weighed naked before and after feeding to test the integrity of the method. No nursling must be left alone while feeding from the bottle; the nurse must remain and hold the bottle during the whole process, or, when the auto- matic bottle-holder is used, a nurse may watch and aid all the children in the ward while nursing. Infants nursing wet nurse must be especially watched for weight, to see that the foster mother gives her charge an honest feeding. Infants' mouths must not be washed after nursing except on the order of the physician. Rules for Handling Wet Nurses. — In the modern hospital for children there will come many babies suffering from gastro-intestinal disorders, who, the doctors insist, cannot live unless they are fed mothers' milk, and for these cases many institutions are now finding it necessary to employ wet nurses. Almost invariably these women are from the lowest classes of society; they are usually ignorant, and their standards are often very little higher than those of the lowest animals. Most of them are unmarried, and some of them even make a business of wet nursing, and to that end become pregnant and give birth to a new child as often as occasion seems to require. Of course, there is an occasional wet nurse who, from misfortune, has been obliged to seek employment of this charac- ter to tide over the time until her baby, with whom she has been left dependent, arrives at an age that will permit her to make a living in some other avenue; but the great mass of wet nurses must be handled within rigid rules, without much reference to sentiment of any sort, if they are to be of service to the institution in the feeding of sick babies. As a rule, the children of these wet nurses are healthy, and a con- siderable part of their food can be made up of formula milks without any harm to them, and, in any event, it is always necessary to know exactly what each woman can supply for the use of other children and her own, and to this end there are some very definite rules that can be laid down, and which must be insisted upon if the nurse's service in the institution is to be of any value. RULES FOR TECHNICAL DEPARTMENTS 343 First: The wet nurse is never permitted to have her child with her except at feeding time, and then for not more than fifteen or twenty minutes after the breasl has been emptied as well as may be for the feedings of the children whom she is nourishing. Sick babies are not permitted to nurse from the wet nurses' breasts; the milk must be drawn by the wet nurse herself into a graduated bottle, a sufficient quantity in each bottle for the nursing of one baby, and the milk so drawn must be fed to the sick baby while it is yet warm; milk must be drawn in the presence of a nurse. Second: Wet nurses must not be allowed to go to a general table for their meals, but must have their meals brought to them where they may partake of their food under the eye of a nurse wdio understands what their diet is to be. Wet nurses have precarious appetites, as a rule, and they are more likely than not to have a craving for something that will either diminish the amount of their milk or impart some condition that will make it disagree with the sick babies. Wet nurses should be fed on the plainest food, and the more protein in character the better it will be ; rare meats, legume vegetables, whole wheat and cornbreads, milk, eggs, butter, and a sufficient amount of bulk foods to fill the stomach and thus make them satisfied ; potatoes and bread are the chief of these latter. Third: Wet nurses should be kept rigidly within regular hours in the insti- tution. They should not be permitted to go out after night, because they will do indiscreet things, eat foods calculated to interfere with their efficiency as wet nurses, drink alcoholic stimulants, and so upset themselves generally that the milk supply will be diminished. On the other hand, the wet nurses should be made comfortable, and should be given a sufficient amount of work in the institution to keep them busy. They are disposed to resent restraint, and, unless their time is fully occupied, they will be sure to fret, and thus diminish their milk supply. Fourth: The wet nurses should be obliged to observe the laws of health and cleanliness ; they should be obliged to bathe regularly, and it should be the duty of the head nurse of the department to see that their bowels are kept in proper condi- tion and that their genitals are clean and healthy. Fifth : Wet nurses should never be employed until the Wassermann test has been made, and until a competent physician has given them a thorough examination, to determine the presence or absence of specific disease. They should never be per- mitted to go on duty with running ears, sore eyes, sore throat, bad teeth, or any discharge from a mucous membrane or any skin eruption. Sixth: The wet nurse should be given a certain number of babies to feed, and, as long as her milk agrees with '.them, should be kept to the same babies without any admixture of the milk of any other nurse. A change of wet nurses has been known to destroy whatever gain had been made by a sick baby, and to cost the life of the child. Seventh: The wet nurse that cannot produce at least 32 ounces of milk per twenty-four hours, in addition to what is required for her own baby, is not worth keeping, and there are many of them who produce twice that much or even three times. RULES GOVERNING MATERNITY DEPARTMENT These rules are created by the obstetrical staff of the Michael Reese Hospital, and are approved by the board of directors. They will, therefore, govern the con- duct of all who have to do with the department, whether it he start' members, visit- ing obstetricians in charge of patients, interns, nurses, patients, or the public. 344 OPERATION OF THE HOSPITAL General Rules No one will be permitted to perform any service in the maternity depart- ment of any character whatsoever who has bad or decaying teeth, any discharge from any mucous membrane, or any open sore upon any part of the body, or who has been within the sphere of any communicable disease within the past twenty-four hours. No babe whose mother is a patient in the maternity department shall be taken out of the bounds of the department for any reason whatsoever without the consent of the attending physician in the case and the approval of the superintendent of the hospital; and no baby that has been removed under such consent can be returned to the department without the specific consent of the superintendent of the hos- pital; provided, however, that this rule shall not apply in cases where the mother occupies a room in another part of the hospital, in which case the babe must be carried, thoroughly wrapped up, directly to and from the nursery, without exposure at any point en route, and such child shall not be allowed in the room with its mother during the presence there of any other child under fifteen years of age. Visitors. — The regular visiting hours are as follows: Large wards, Sunday and Wednesday, 2 to 4 p. at. Small wards, daily from 1 to 8 p. at. Private rooms, daily from 1 to 8 p. at. Visitors in the large wards will be absolutely restricted to husband and parents of the patient. In other parts of the department indiscriminate visiting is to be discouraged, and should be confined to the immediate family of the patient. Children under fifteen years of age will not be permitted to visit in the depart- ment under any circumstances whatever. No physician will be permitted to visit the patient of another physician in the department, except on specific invitation of the attending physician; provided, however, that this rule does not release the staff director of the department from observing the necessary supervision over all patients to maintain cleanliness and asepsis. Visitors in the department, excepting those who call exclusively upon patients in private rooms, must wear the hospital sterilized gowns provided for the purpose; gowns from other parts of the hospital will not be allowed. Visitors must not sleep in the maternity department under any circumstance. Relatives of critically ill patients may be provided for in other parts of the hospital. Interns and nurses on duty in other parts of the hospital will not be permitted to visit the maternity department except by special permission of the head nurse and under rigid precautions. Admission of Patients. — No patient shall be allowed to enter the precincts of the department, except in extreme urgency, until the house physician on duty in the department shall have examined her (not vaginally) to make sure she is free from infection. Immediately upon the entry of a patient in the hospital the proper house physician must be notified. When a patient is admitted, clothes and all personal belongings must be labeled and registered, valuables given to the head nurse in charge of service, who shall take them to the office and receive receipt for same; in the event of neglect or loss to account for same, the head nurse will be held financially responsible. Clothing must be listed and sent to the storekeeper, who will receipt for same after checking, and who will be held responsible for all pieces receipted for. The head nurse will be held responsible for lost articles not listed. RULES FOR TECHNICAL DEPARTMENTS 345 Discharge of Patients. — No private patient shall be sent home or allowed to leave until explicitly discharged by the attending physician. No bleeding patient, and no patient presenting any abnormalitity of any kind, shall be discharged except upon the explicit order of the physician in charge. Patients must be discharged and prepared to leave the hospital so that they shall be at home before dark in the evening, that is, 7 o'clock in the summer and 4 o'clock in the winter. No patient shall be allowed to leave the hospital unless patient and baby are comfortably clothed, considering the season. No patient shall be allowed to leave the hospital without an escort competent to see her and her baby safely home under every circumstance. No patient shall be allowed to leave the hospital without a definite destination, and without abundant assurance that she and her baby will be properly cared for. Consent for Operation. — No instrumental delivery, or delivery by surgical inter- ference, will be permitted under any circumstances without competent consent in writing of the patient; if the patient be incapable of giving intelligent written con- sent, same must be obtained from husband or other responsible relative, and, in the absence of any of these, the attending physician must avail himself of the counsel of the nearest available physician in active practice, both of whom shall sign a state- ment of the facts in the case. If there is no such available consultant, the facts must be communicated to the superintendent of the hospital, who will sign a special permit, setting forth the facts in the case for any legal review that may follow. Isolation of Mother and Baby. — Whenever any infection shall occur in mother or child the superintendent of the hospital must be notified, and patient and babe shall be at once completely isolated to the satisfaction of the medical staff. If this cannot be done satisfactorily, other accommodation must be found, and patient and babe removed at once. The medical staff of the department shall be the judge of what is an isolatable infection and what is satisfactory isolation. No private patient shall be transferred from the maternity department to make room for another patient without the consent of the attending physician, and the manner and place of removal shall be satisfactory to the patient and her attending physician. Circumcisions. — The operation of circumcision shall be performed in the matern- ity department precisely in the manner and under the asceptic technic of the sur- gical department of the hospital. All operators shall scrub their hands with brush and marble-dust soap for twenty minutes, cleaning finger-nails thoroughly. They shall wear the regulation operating- room gown and rubber gloves. Their instruments, thread, and dressings must be sterilized by the nurses in the department in the usual way. Bleeding vessels must be carefully tied, and the parts must be stitched and the operation performed in every way according to accepted aseptic surgical procedure. If the operation is performed as part of a religious rite, the operator must agree in writing beforehand, and the agreement made a part of the record of the patient . that he will perform the operation strictly in accordance with the above rule. There may be three persons present at any circumcision beside the hospital assistants, of whom the operator shall be one; the others may be selected by the family of the child. No circumcision shall be performed on any child who is not perfectly healthy. No person shall perform the operation of circumcision without the written con- sent of mother or father, and said written permit shall state who is to perform the 346 OPERATION OF THE HOSPITAL operation, and the written permit must be made a part of the permanent record of the case. No person not connected with the hospital shall be allowed to perform the opera- tion of circumcision until he shall have signed an agreement to abide by the rules of the hospital as to asepsis and methods of cleanliness and technic. No intern shall perform the operation of circumcision without the express con- sent of the staff obstetrician on duty in the department at the time, and never without the written consent of one parent. Authority in the Maternity Department. — The obstetric staff of the Michael Reese Hospital will be responsible for the medical and scientific conduct of the department, and will have full authority to that end. The physician in charge of each case will give whatever orders he may desire relating to his own patient, and they will be carried out by interns and nurses, unless they are in violation of these rules, in which case the person to whom the order is given will notify him of the rule, and, if the physician persists, the head nurse of the department will be notified, and, if the physician still persists, the superin- tendent of the hospital will be at once notified of the facts. Interns on duty in the department are supposed to know the wishes of visiting physicians in relation to their patients, and their orders will be carried out, subject only to countermand by the head nurse of the department until the attending phy- sician can be reached for a final . decision. The Head Nurse. — The head nurse of the department shall be in direct charge of all the work. She shall be held responsible for the technic, excepting that of attending physicians and interns, and her orders in every case, and under all cir- cumstances, shall prevail, subject to approval (1) by the medical staff in relation to medical and scientific matters, (2) the attending physician in regard to any indi- vidual case, and (3) the superintendent of the training-school in all matters in rela- tion to the nursing of patients and the nursing technic of the department. The head nurse shall be in charge of all supplies of every description, and shall be held responsible for their economic and proper distribution and use. The head nurse shall be responsible for the cleanliness and asepsis of the depart- ment and all its belongings, and, to that end, will be in authority over all the order- lies, floormen, and maids, as well as nurses who are detailed for duty there. The head nurse must conduct drills of technic and in the conduct of typical cases at intervals when the department is not busy. In the event of a difference of opinion between the head nurse and a visiting physician or an intern, she shall at once notify the superintendent of the training- school, or, in her absence, the superintendent of the hospital, for a decision of the question. The head nurse shall report all abnormalities of patients and unusual conditions to the house physician at once, and to the attending physician on his next visit. In addition to her other duties, the head nurse shall keep a book in which she shall record all mooted questions that may arise appertaining to the conduct of the department, to the end that the rules may be amended from time to time. Rules for Attending Physicians. — Physicians working in the maternity depart- ment, whether members of the medical staff of the Michael Reese Hospital or other- wise, must conduct their cases, in so far as operative technic is concerned, in strict conformity with these rules. Attending physicians are expected to visit their patients daily. For the protection of the department, and to safeguard its asepsis and clean- liness, the staff member on service is directed to inspect all parts of the premises at RULES FOR TECHNICAL DEPARTMENTS 347 frequent intervals, and to maintain sufficient watchfulness over the work of attend- ing physicians and over their patients to guarantee this result in the conduct of the department. The staff physicians are expected to co-operate with the hospital in the taking and keeping of the prescribed records, and to frequently inspect such records to see that they are being adequately kept. Attending physicians are urged to call consultations freely in difficult cases, not only to protect their own interests in a medicolegal sense, but to divide responsi- bility. Service members of the staff are urged to call freely upon the advice and counsel of their confreres, not only for the above reasons, but in order to share their experience in regard to interesting cases. Physicians are urged to read carefully all rules of the department, to the end that they may not be embarrassed by the refusal of the interns and nurses to obey their orders. Rules for Interns. — The division of labor between seniors and juniors will be made as in other parts of the hospital, excepting that no junior shall conduct a case of labor unaided until pronounced competent by his senior. In case of abnormality, the junior must immediately notify his senior and take orders in relation thereto. The senior intern must immediately report any ab- normality to the obstetrician on service, if it is a service case, and to the attending physician in a private case. If the regular attendant cannot be located, another staff member must be called, and, if none can be found, the superintendent of the hospital must be notified of the facts. In a private case, if the attending physician cannot be located in an emergency, the superintendent of the hospital must be notified. • The intern on duty, and who has begun a case of labor, must remain within easy call of the nurses until the case is over, or until he has expressly resigned the case to another intern and has notified the nurses to that effect. In the event that an intern does so resign a case in favor of another, he must write the conditions of the patient as they exist at the time he leaves the case, and said written directions must be made a part of the permanent record of the case. An intern who has begun as a participant in an abnormal case will under no conditions whatsoever leave until the case is concluded. Interns are not allowed to reprimand nurses. Any incompetence or neglect of duty must be reported to the head nurse. Interns on duty in the maternity department are forbidden to visit the morgue, to be present at any autopsy, whether human or animal, and are expressly for- bidden to participate in any pus operation or dressing except under conditions that may be prescribed by the medical staff of the department. Books used by interns during student days, such as anatomies, books on path- ology, and physiology, shall not be brought into the maternity department. The intern on duty must make rounds twice daily in all cases, and as much oftener as may be necessary. Rules for Maternity Nurses.— All pupil nurses on duty in the maternity department will be under the direct jurisdiction of the head nurse of the department. In the absence of the head nurse a senior pupil nurse must lie left in charge, whose orders will be as implicitly obeyed by other nurses as though given by the head nurse direct, and whose authority in the department will follow that of the head nurse. Whenever a pupil nurse in charge of the department meets an emer- gency she will call first the intern on duty, then the superintendent of the training- 348 OPERATION OF THE HOSPITAL school. In an extreme case she will call the attending physician directly to save time. The nurses conducting a labor must be gloved and gowned. Graduate Nurses. — Graduate nurses on duty in the maternity department must consider themselves subject to the same rules as those governing the pupil nurses. They will take orders from the head nurse of the department, and will report to her any unusual or abnormal condition in either mother or child in their care. In an emergency, the graduate nurse in charge of a patient may report directly to the physician in charge of the case if she is unable to secure the presence of an intern promptly. After calling the physician she must report the emergency to the head nurse. On being summoned to the maternity department to take charge of a case the graduate nurse must first report to the superintendent of the training-school, and then to the head nurse of the department. The graduate nurse will not take charge of her patient's delivery except on express request or invitation of the head nurse. Graduate nurses will consult the head nurse of the department before going off duty or accepting relief. Technic of the Department. — Before Labor. — Vaginal examination on waiting women must be made once only except in emergency, and then with same pre- cautions as in labor. Measurements of pelvis, inspections of abdomen and breasts, must be accurately made immediately upon the admission of a patient, and the finding recorded in detail. Urinalysis must be made on all waiting women at least three times a week, and oftener if necessary. History in detail, with all external measurements, should be secured in all private cases, when consent of patient can be had, and the same accurately recorded. Soapsuds enema must be given, and, if the patient is in labor, she will use jar, and if not, use toilet. After bowel movement, give the patient a full bath unless membranes are ruptured or her condition is too serious, in which case, and comple- tion of labor not imminent, give bath with seat in the tub. If the patient is in labor and the membranes are ruptured she must be imme- diately put to bed, unless otherwise ordered. Never catheterize unless ordered. Never use glass catheter on patient in labor; catheterize under running water if possible. Have patient urinate in clean jar as soon as admitted; note quantity, color, and odor. Save entire amount for laboratory examination. Scrub patient's hands and the arms up to the elbows, clean and trim finger-nails and also toe-nails if possible. Never touch genitals, instruments, or linens unless hands are sterile. The Labor. — Prepare two sets of three basins each. First set: (1) Basin 50 per cent, alcohol; (2) basin 1 : 4000 bichlorid; (3) basin \ per cent, lysol. Second set for hands and rubber gloves: (1) Basin 1:500 bichlorid; (2) basin sterile water; (3) basin \ per cent, lysol and cotton. Always have float in bichlorid basin. The genitals should be carefully shaved. Both hands must be gloved at every examination. No delivery can be per- mitted in the department without gloves; this rule applies as well to staff members as to visiting physicians in attendance on private patients. Ill I. IS Mil; ']')•:( IIMCAL DKI'AKTMENTS 34!) Every stage of every abnormal labor must be recorded accurately, and made a pari of the permanent record of the ease. Never leave a patient while in labor. She must be constantly attended, to guard against hemorrhage, eclampsia, ruptured uterus, etc. Record pains every hour, as to frequency, duration, and character. Record every examination during;, as well as before, labor, by whom made and finding. Vaginal discharge during labor must be accurately recorded as to color, quantity, and character. There should be as few examinations as possible, and always under extreme pre- cautions. Record fetal heart sounds every hour as to frequency, character, and location. The head should be delivered with patient on her side. The third stage of labor should not be interfered with for thirty minutes unless for some very valid reason, such as hemorrhage, impending death, etc. If patient is bearing down when she ought not to, place her on her side; to hold her hack interlock fingers of both hands, cover genitals with hands in rubber gloves. Cover genitals of patient in labor with sterile pads. Touch these pads only at edges and with sterile hands. Keep genitals clean with § per cent, lysol. All linen and clothing of every sort coming in contact with patient in labor must be sterilized. After Delivery. — Mother and babe must be immediately and carefully tagged by numbered sewing tape on wrist of each. The babe and placenta must be examined and measured at once, and findings accurately described as a part of the permanent record of the case. Alter birth of child patient should be assisted to turn on back from side, with her knees closed, and the nurse's hands on fundus uteri. Fundus should be held, not manipulated, however, for thirty minutes. Then, and not until then, accoucheur should deliver placenta. Fundus should be held for another thirty minutes before putting abdominal binder on. If bleeding is in the least profuse, nurse should report same to head nurse at once, certainly before applying binder; to do so, however, she must not let go her hold on the fundus. One dram of ergot is given to all patients immediately after delivery of child, and 5 minims should be given to all prirniparse every six hours for three days postpartum. Care of the Mother. — Nurses ought first, in taking care of the mother, attend to breasts, then give enema if directed, then clean parts again and apply hinder. An enema ought not to be given to a delivered woman, however, unless specially ordered by the physician. The breasts should he placed in the breast-binder after the first nursing, which should occur about eight hours after the birth of the child. Nipples should he cleaned before nursing with boric solution. Hands of nurse or patient should never touch nipples, nor should they be touched by clothing. They should he kept covered with sterile cloth. Temperature, pulse, and respiration of the mother should he taken and recorded three times a day, and oftcner if necessary. Diet of patient should be light soft diet for two days. After that generous diet, avoiding alcoholics and fruit. Patients should not rise until ninth day; then out of bed if condition permits. Each patient should have her own nipple shields and boric solution pan. 350 OPEEATION OF THE HOSPITAL Always keep patient's knees together when turning in bed. Empty bowels on third day. Full bath should not be allowed until after three weeks. Until then use bed- bath, sponge, etc. Vulval pads must always be changed before the outside has become moist. Every patient must be examined before leaving the hospital, and findings ac- curately described as a part of the permanent record. No patient with the least departure from normal must be allowed to leave until the attending physician has been notified of the facts and has approved the discharge. In such case, the facts with the physicians' decision must be stated on the record. Care of the Baby. — Eyes. — Immediately after birth of babe, holding babe on lap with eyes looking upward, drop one drop of 2 per cent, solution of silver nitrate into each eye, then following with a flushing of normal saline, always using sterile cloths. Cleanse eyes daily with 2 per cent, boric acid solution, wiping toward nose. Cord. — Dress cord daily with 10 per cent, salicylic acid in starch, using sterile lint and flannel bandage. Always cover babe's face when powdering cord. Keep cord dry. Temperature. — To be taken per rectum at birth and twice daily thereafter, a. m. and not earlier than 4 p. m. Weight. — Weigh immediately after birth and once daily thereafter before bath and morning feeding; care should be taken to see that same weight of clothing is used with each weighing. Bath. — The first bath is to be of sterile lard. Afterward a daily sponge bath until cord is off and umbilicus dry; then a daily tub bath, 98° F., disinfecting tub with 5 per cent, phenol before each bath. Nurse to scrub hands with green soap and disinfect with bichlorid, 1 : 5000, before each bath. Once daily after morning baths boil all tubs and basins used in nursery. If babe is circumcised give daily sponge-bath until* healed. After lard bath finish dressing babe and place on side between blankets. Keep head covered and lowered for from twelve to twenty-four hours. Then place in its own bed, numbered same as tape on wrist of mother and babe. Always place babe in its own bed. Never put hot-water bags next to any part of a babe. Mouth. — Look into mouth morning and evening. Never wash mouth unless ordered to do so. Bowels. — Note time of first stool and urination. Babe should have at least two stools daily. Circumcision dressing to be changed once daily or oftener if necessary. Feeding. — Put babe to breast eight hours after birth and once again during first twenty-four hours — afterward nursing every three hours during day, not waking at night unless ordered. Give sterile water, 1 to 2 ounces, twice every twenty-four hours. THE SURGICAL OPERATING-ROOMS If there is to be competent surgery in an institution, and if the best interests of patients are to be conserved, there must be definite rules for the conduct of the department, no matter whether the operators be exclusively staff members or mem- bers of the profession at large in the community. Nearly every surgeon, and, indeed, nearly every medical practitioner, in what- ever branch, thinks his own case at hand is a very special one and entitled to the right of way over all others. These men are right, and it is according to the highest ideals of the profession that they should feel so. But a still larger duty devolves on the institution management, that has for its end the best possible conditions surrounding every case coming for surgical care, and such conditions cannot be achieved by granting special concessions to one or a few men at the expense of all the others. Hence, the very first necessity in the proper conduct of a surgical de- partment is to place every operator on the same plane, so that each one shall have every facility of the institution for the care of all his patients, rich and poor alike, and all the time. Ordinarily it will not be an easy thing to hold a rigid rein over busy men, many of whom will aggressively make demands for special service and extra time and more nurses and assistants than the institution affords, and oftentimes for more than there is any real need ; and it may be suggested that the only way to take the burden of such rigorous rules off the operating-room heads and off the shoulders of the super- intendent of the institution is to place the responsibility on the surgeons themselves by having the staff adopt the rules by formal action, and this action can be clinched by the approval of the board of directors or trustees. Men wall oftentimes approve a course of conduct in the abstract at a time when there is no case in point, when they will not be so reasonable in the absence of such formal rule when they and their patients are the particular objects of the rule in some special emergency. Under the head of Hospital Rules, to be found preceding, we will include rules for the surgical operating-rooms. Just now, let us take up the preparation of material and the general conduct of the department, PREPARATION OF MATERIAL Gauze, Bandages, Drum Material Sponges and Plain Gauze. — There are two kinds of sponges — gauze strips and laparotomy sponges. Gauze strips are made 8 inches wide anil 1 yard long, the width of the material. These arc used for mopping until the peritoneum is opened, when laparotomy sponges are used. The gauze strips are to be tied in packages of U> (ten), to be counted by two nurses, and name of each nurse on a slip of paper and left in pack- age. The bundles of 10 are tied in unbleached muslin squares, 16 by 16, and marked "Ten (10) gauze sponges." They are then washed and boiled with Labar- raque and soap for one hour, followed with sterilization for forty minutes. 351 352 OPERATION OF THE HOSPITAL Laparotomy Sponges. — Laparotomy sponges are made in three sizes: 11 inches square (5); 8 inches square (4); 4 by 7 inches (1-stitch sponge). These sponges are made eight thicknesses. The edges are whipped, and the sponge is then quilted across. On one corner of every sponge there is a tape 12 inches long, used for hanging on sponge rack. These sponges are always used wet, with warm normal salt solution, 110° or 112° F. Making up Sponge Drum. — Sponge drums contain 20 bundles gauze strips (10 sponges in each bundle), 8 bundles laparotomy sponges (10 sponges in each bundle), and two long packs. Hysterectomy Gauze. — Cut gauze, 20 inches by 1| yards. Fold until gauze is 2| inches wide. Attach black silk, No. 18, to inner end of roll. This gauze is done up in blue paper, marked "hysterectomy gauze," and sterilized for forty minutes for three successive days, 10-20-10. Long Pack. — The long pack is 5 yards long by the width of gauze, folded 4-ply. Laparotomy Binder Package. — The laparotomy binder package is made up as follows : (1) Three gauze strips, 7 inches wide and 1 yard long, are folded three times, making three pads of 8 thicknesses each, about 4 by 7 inches. (2) Three pads, made up of pieces of gauze 12 inches wide and 1 yard long, folded into four thicknesses, making a pad 8 by 12. (3) Combination made up of two pieces of gauze, 14 inches wide and 10 inches long, on each side of heavy cotton wadding. These are all rolled in the laparotomy binder, with the small ones inside and the larger ones outside. They are enclosed by the wadded pad, and over all is the binder, so that when the package is opened they can be reached in the proper order. Sterilize 10-20-10. Contents of the Laparotomy Drum. — Ten towels; 4 large sheets; 1 small sheet; 1 stomach sheet; 1 pillow case; 10 towels; 4 gowns; 1 sheet; 2 towels. These are put in top downward, so that when the drum is opened the first articles will be two towels for wiping nurses' hands; next, one sheet for covering table, allow- ing the gowns and towels to be laid out for the surgeon and his assistants; then the sheets for covering patient, who is brought into the room prepared and anes- thetized. At the bottom are ten towels for protection of the field of operation. Sterilization for Laparotomy Drum. — Vacuum, 10; steam, 20; vacuum, 10. Formula Gauze. — There are three kinds of formula gauze: Iodoform, wide and narrow; viaform, wide and narrow; xeroform, wide and narrow. The wide gauze is cut 1| yards by 9 inches, 8 strips to 3 yards. The narrow gauze is cut If yards by 4 inches, 18 strips to 3 yards. Wide and narrow iodoform, iodoform Mikulicz drain, and iodoform selvedged are prepared with the following: Iodoform 27 gm Glycerin 60 c.c. 75 gm Alcohol 210 c.c. 168 gm Sterile water 90 c.c. 90 gm Gauze 130 gm This makes a little over 5.5 per cent., allowing for inequalities in gauze, etc. Wide and narrow viaform are prepared with the following: Viaform 27 gm Glycerin 60 c.c. 75 gm Alcohol 210 c.c. 168 gm Sterile water 90 c.c. 90 gm Gauze 130 gm THE SURGICAL OPERATING-ROOMS '■>■'<■'• Wide ;md narrow xeroform are prepared with the following: Xeroform 27 gm. ( ilycerin 60 c.c. 75 rim. Alcohol 210 c.c. 168 gm. Sterile water 90 C.C. 90 gm. ( iauze 130 gm. Bandages. — Spica Bandages. — The muslin for spica bandages is cut 10 yards long by 4 inches wide, then kept in a roll. It is not sterilized. Plaster-of-Paris Bandages. — Plaster-of-Paris bandages are cut: Two inches by ii yards; 3 inches by (> yards; 4 inches by 6 yards. ( Jut wadding is rolled on before the plaster of Paris is put on in any of the fol- lowing sizes: 2-inch by two lengths; 3-inch by two lengths; 4-inch by two lengths. SOLUTIONS LabarraqtM : 12 ounces chloric! of lime and 6 pints cold water. 16 ounces soda and 2 pints boiling water. After stirring each solution thoroughly allow them to settle. Strain and pour together. Then strain through filter-paper. Keep in glass-stoppered bottles. Schleich: Formula No. i. Cocain HC1 2 Morphin 02 Sodium chlorid .2 Aqua dest 100.0 Formula No. 2. Cocain HC1 1 Morphin 02 Sodium ehlor .2 Aqua dest 100.0 Formula A r o. 3. Cocain HC1 1 Morphin 005 Sodium chlorid .2 Aqua dest 100.0 Harrington: Commercial alcohol 640 c.c. Hydrochloric acid 60 c.c. Water 300 c.c. Corrosive sublimate 0.S gr. Hi latin (2 per cent.): Knox gelatin 20 gm. Normal salt solution 1000 gm. Dissolve gelatin in 140 c.c. salt sol. Add sod. hydrox. sol., few drops, until it turns red litmus blue. Add remainder of salt sol. and heat to boiling. I'll, 1 rscli: Boric acid 210 gm. Salicylic acid 40 gm. Tr. ferri chlorid q. s. Dist. water to make 4000 gm. Dissolve the acids in the water and add of tr. ferri chlor. to make purple color. Bichlorid: Bichlorid 1 : 6000 is the strength in general use in operating-rooms. 2 '._, ounces of the 1:500 solution to 1 quarl sterile water makes a 1:6000. 10 ounces of the L : 500 solution to l gallon water makes 1 : 6000. 30 ounces of the 1 : 501) solution for one of the plungers, which holds i! gallons. 23 354 OPERATION OF THE HOSPITAL Boric Acid Saturated (5 per cent.): Boric acid crystals to gallon of water. Iodin: Lysol: Use 15 c.c. to sufficient water to make 1000. For \]/2 per cent, use !}•£ ounces to quart of water. Ringer's: Potassium chlorid 2.4 "| . , ....... Calcium chlorid 7.2 4 °- C ; *°A a W Aqua dest 120.0 ' normal salme - ^"Uc.c. 3.0 J non Locke's: Sodium chlorid 0.9 Sodium bicarbonate 0.02 Calcium chlorid 0.024 Potassium chlorid 0.03 Four c.c. to 1000 c.c. of normal saline. Carbolic Acid (5 per cent.): Carbolic, 86.4; 232 c.c. to 4000 c.c. of water. Bela-eucain: Beta-eucain 0.1 Sodium chlorid 0.8 Aqua dest 100.0 Sterilization of Solutions: Cocain, any per cent. Beta-eucain. Schleich solutions. Ringer's solutions. Locke's solutions, etc. Put cotton stoppers in bottles. Place in basin of warm water (with corks). Boil over flame for thirty minutes. Replace sterile corks and label. Temperature of Solutions: Basins (ordinary irrigating) 108° F. Intraperitoneal salt solution 108° F. Intra-uterine douches 115°-120° F. Silk and Silkworm, Horsehair, Melted Wax, Etc. Horsehair. — Boil for ten minutes. Keep in sterile absolute alcohol. Preparation of Silkworm. — Color with saturated solution pyoktanin; rinse well; boil ten minutes; keep in alcohol 95 per cent. Black and White Silk. — Boil for ten minutes. Dry thoroughly. Put up in small envelopes. First wrap in paper. Sterilize 5-10-5 three successive days. Black Waxed Silk. — Boil in carbolic 5 per cent, to remove dye for ten minutes. Dry and rinse thoroughly. Wind on cards. Dip in (sterile) melted beeswax and carbolic 10 per cent. Wrap in waxed paper. Seal in clasp envelopes. Sterilize same as white silk. Melted Wax for Silk. — Carbolic 10 per cent.; pure beeswax. All Silk Sterilized. — Vacuum, 5; steam, 10; vacuum, 5. Boil for three suc- cessive days. Horsley's Wax. — Salicylic acid, 1; olive oil, 1; beeswax, 7. Boil one hour. Strap jar with adhesive. the 8uhgical operating-rooms '■'•'>'> Rubber Goods — Care of Rubber Tissue and Oiled Muslin. — Soak in bichlorid, 1: 500 for thirty minutes. Dry in sterile towel. Place in sterile cloth. Sterilization of Catheters. — Urethral and Prostatic. — Place in formalin 40 per cent, for one hour. Seal with adhesive. Rinse in sterile running water. Drainage (Various) Bullet Drains.— Light-weight rubber dam about 4 by 7, covered with wide iodo- form gauze, and a piece of small drainage-tubing just tacked to the center of the rubber dam. Jacket Drain. — A piece of j-inch rubber tubing cut spirally, and two pieces of iodoform selvedged, inserted in the center of the tube. It is then wTapped with iodoform selvedged and covered with rubber tissue. Cigarette Drain. — A piece of j-inch tubing, perforated, wrapped with iodoform selvedged, and covered with rubber tissue. Soap Marble-dust Soap. — Cut rosin soap, 750 grains; warm water, 1500 grains. Melt and boil for one and one-half hours. Add wax and stearin paste of each 150. Lastly, add marble dust, 7000 (15 pounds). Sterilize when boiling. Green Soap. — A fair grade of green soap is made mostly of cotton seed and corn oil, softened by as much linseed oil as the prices proposed can stand, and the soap is made slightly alkaline in reaction, and when bought is not greater than 38 to 40 per cent, moisture, because otherwise we are paying an unnecessary amount for water. The green soap for operating purposes is made by boiling the soap with a sufficient quantity of water added to give the desired thickness. If it is to be used in beer-mugs or big-mouth bottles, and is used rather carefully by the surgeons, it can be made thick, and a thick soap has advantages. If it is to feed from one or another of the patent wash-basin soap feeders it wall have to be made very thin, in order not to clog the outlet of the mechanism. It is highly disadvantageous to use a soap that is green in color, which some dealers sell on the reputation that the color is from the natural olives. There is no green soap colored by olives that can be purchased at anything like a price that brings it within the reach of any institution. The green color in all these soaps is a grass stain. The Making Up of Trays Amputation Instruments '2 saws (large anil small). Gouges. 2 saws (chain and Gigli). Chisels. Amputation knives. Mallet. 2 bone-cutting knives. 1 three-tailed retractor. 2 lion-jaw forceps. 1 periostotome. 1 bone-holding forceps. 1 sequestrum forceps. S/„ , ml for Cm ii it/I Work Gait's conical trephines. 2 bone-CUtting forceps. 2 hand drills and points. 1 periostotome. Bone-gouging Devibiss forceps. Saws (chain and Gigli). 1 chisel and gouge. 1 sequestrum forceps. 1 mallet. 356 OPERATION OF THE HOSPITAL Emergency Tray 1 grooved director. 1 tenaculum. 2 probes — 1 large, 1 small. 1 needle forceps. 6 curved snaps. 6 pair straight snaps. Needle-holder. 1 intestinal forceps (rubber tip). 12 rat-tooth snaps. 1 curved forceps, large. 1 suture dish. 2 aneurysm needles. 2 curets. 2 single volsella. 2 double volsella. 3 8-inch clamps. 4 dull retractors. 2 flat retractors. 2 sharp retractors. 1 Kocher director. 2 pair tissue forceps, plain. 2 pair tissue forceps with teeth. 2 pair tissue forceps without teeth. Add for hernia — bladder sound. Add for kidney cases — pedicle clamp. Add for gall-bladder — trocars and stone curets; 1 Murphy button; 1-inch forceps; have ready potain aspirator. Add for stomach and intestinal cases — intestinal and stomach-clamps, protected with rubber tubing. Curettage Tray 1 stone forceps. 4 polypus forceps. 1 curved dressing forceps. 1 uterine sound. 1 medium bladder sound. 3 8-inch clamps. 3 double volsella. 3 single volsella. 1 small Sims' speculum. 1 large Sims' speculum. 7 flat retractors. 1 intra-uterine douche point. 1 large dilator (Goodell). 1 small dilator (Sims). 1 set dilators (Hegars). 3 applicators. Curets, all kinds and sizes. Have ready tr. iodin; tr. iodin in carbolic acid; zinc chlorid, 50 per cent. Perineorrhaphy- Curettage instruments, and 2 tissue forceps with teeth. 2 tissue forceps without teeth. 1 long tissue forceps. 6 curved artery snaps. 6 straight artery snaps. -Trachelorrhaphy — Colporrhaphy 6 rat-tooth artery snaps. 1 needle forceps. 1 tenaculum. 1 probe. 2 lateral retractors. 4 5-inch snaps. Gynecologic Laparotomy All curettage instruments, and 9 8-inch clamps. 3 angle clamps. 3 straight 5-inch clamps. 1 uterine sound. 2 bladder sounds. 1 straight dressing forceps. 1 curved dressing forceps. 2 tenacula. 1 needle-holder. Artery snaps — straight, 6; curved, 6; Kocher, 12. 2 tissue forceps with teeth. 2 tissue forceps without teeth. or Vaginal Hysterectomy 1 probe. 1 grooved director. 1 polypus forceps. 3 trocars. 1 intestinal forceps. Long slender forceps for a ventral fixation. 3 pedicle clamps. 2 large double volsella. 1 Kocher director. Scissors — 1 dressing; 1 perineorrhaphy; 1 curved; 2 angle. 1 long tissue iorceps with teeth. 1 long tissue forceps without teeth. 2 lateral retractors. Rectal Vaginal Fistula Small emergency tray, with curettage instruments, and 2 small tissue forceps. 6 rat-tooth artery snaps. 2 straight artery snaps. 2 curved artery snaps. 2 pair tissue forceps with teeth. 2 pair tissue forceps without teeth. 1 hemorrhoid clamp. Hemorrhoids 2 8-inch clamps. Needle forceps. Small Sims' speculum. Have cautery ready. 6 straight artery snaps. THE SURGICAL OPERATING-ROOMS 357 Tracht olomy Inslrurm nts 2 flat retractors. l si itch scissors. 2 sharp retractors, 3 prongs. 2 pair tissue forceps without teeth, '_' sharp retractors, 2 prongs. 2 pair tissue forceps with teeth. -1 sharp retractors, 1 prong. 1 Eustachian catheter. 3 knives. 2 dilators. 1 aneurysm needle. 2 sponges. 1 grooved director. Tracheotomy tubes, all sizes. 1 probe. 2 curved artery forceps. 1 curved scissors. 2 straight artery forceps, 1 angle scissors. Tape, catgut, silk, needles, gauze for packing, medicine-glass, iodoform gauze, gauze. Tent Insertion Tray 1 8-inch clamp with safety-pin. 2 retractors. 1 applicator. Sterilized tents (all sizes). 1 uterine sound. Cut cotton. 1 double volsclla. Alcohol lamp and matches. 1 single volsclla. Lysol solution, ' per cent. 1 stone forceps. Sterile gloves. 1 Sims' speculum. Eye Operations The surgeon selects his own instruments. Have ready — (1) 2 per cent, boric in basin (warm). (7) Eye needles. (2) 4 per cent, cocain (sterile). (8) Plain catgut, No. and No. 1 black silk. (3) Adrenalin. (9) Sterile vaselin. (4) Atropin sulphate, 1 per cent (sterile). (10) Sterile cotton and bandages. i.'i) Eye-pads. (11) Fine sharp knife. (ti) Medicine-glasses and droppers. Nasal Operation Tray The operator selects his own instruments in each special case. Have ready — (1) 2 medicine-glasses and droppers. (5) Posterior tampons. (2) Cocain (the percentage the surgeon (6) Bernway's sponges. requires). (7) Powder-blower. (31 Adrenalin. (8) Iodoform and xeroform gauze. (4) Sterile olive oil — large glass. Adenoids and Tonsils 7 sponge-holders. 1 tonsil volsclla. 2 mouth-gags. 2 tonsil volsella. 1 tongue depressor (large). 1 tonsil hook. 1 tonsil gouge. 1 large glass. Adenoid forceps. Adenoid sponges. 2 Gottstein curets. Cut gauze. 2 tonsil knives. Stitch Tray 1 pair stitch scissors. 1 long artery snap. 1 pair curved scissors. 1 probe. 2 pair tissue forceps (1 with teeth, 1 I grooved director. without). 1 sharp retractor. 2 pair artery snaps ll straight, 1 curved). 1 dull retractor. 1 scalpel. Venesection Tint/ 2 pair artery snaps. 1 probe-pointed grooved director. 2 pair tissue forceps. 1 hook. 1 pair stitch scissors. 1 probe-pointed aspirating needle. 1 pair small curved scissors. '_' aneurysm needles. 2 small knives. In test-tubes add — 2 aspirating needles. White- silk and needles. Horse hair and needles. Catgut No. and needles. Silk-worm and needles. PipetS. 358 OPERATION OF THE HOSPITAL Also add to tray — Sterile towels. 2 medicine-glasses. Sterile brushes. Camels' hair-brushes. Sterile cotton. Bandages, all sizes. Dressing Tray 1 curved artery snap. 1 small retractor. 2 straight artery snaps (1 with teeth, 1 sharp retractor. 1 without teeth). 1 curet. 1 plain tissue forceps. 1 curved scissors. 1 tissue forceps with teeth. 1 stitch scissors. 1 grooved director. 1 dressing scissors. 2 probes. Outfit for Cystoscopic Examination 2 soft-rubber catheters, Nos. 14 and 16. 1 large irrigating syringe. 2 sterile medicine-glasses. 1 large sub Q syringe. 2 bottles of glycerin. Sterile cotton. 2 kidney basins. 4 sterile bottles marked "R" (right). 1 medium urethral syringe. 4 sterile bottles marked "L" (left). PREPARATION OF THE OPERATING-ROOM There are three large pitchers for sterile water and one quart pitcher for measur- ing bichlorid, also a small pitcher for making normal salt solution out of the satu- rated solution. A bundle of basins is then brought in, containing eight large basins and one small one. The large basins are 15 inches across the top and 6 inches deep. Large basins are used for hand solutions. Small basins are put on sponge nurse's table, to be filled with salt solution for dipping sponges. There is an arm plunger 20 inches deep, 6 inches across the bottom, and 8 inches across the top, for operators and nurses to complete sterilization of arms and hands. Sometimes this plunger is attached to a revolving stand containing also solution basins. There are two percolators, to be filled with any irrigating solutions designated by the operator. Two or three large buckets, one for underneath the operating-table and others at convenient points, for throwing used linen or material. Shelf Stand and Other Furniture The first shelf on the stand contains the following : Lysol. Alcohol in bichlor. Phenol, 86.4 per cent. Glass catheters. Olive oil. Glycerin. Viaform. Iodoform. Iodoform selvedged. Pulled iodoform. Plain and pulled white gauze. Alcohol. Ether. Second Shelf. — Tr. iodin. Collodion. Sal. salt sol. Special bottles. Silkworm- gut. Gloves all sizes. Third Shelf. — Hypodermic tray. Camels' hair-brushes. Safety-pins. Sealing gauze. Vaselin. Iodo. vasel. Suture tray. Dusting-powders, all kinds. Forceps. Politzer bag. Thiersch sol. Bichlor. sol. Boric. S. S. Fourth Shelf. — Transfusing needles and tubing. Green soap. Medicine-glasses. Glass syringe. Rubber tubing. Brushes. Enema points. Connecting points. Irrigating points. Angle tubes. Two hypodermics are put on the hypodermic tray and filled, one with strychnin and one with brandy, before each operation in case of emergency. There must be a sponge-rack made to conform to the method of sponge counting, whatever that method may be. THE SURGICAL OPERATING-ROOMS 350 The instrument tray stand. The drum stands with full laparotomy drums. The anesthetic stool. The anesthetic table containing: Roll of gauze (4 inches) sewed with black thread; mouth-gag; tongue-forceps; small basin; ether or chloroform in the original cans, sealed; ether mask; safety-pins and towel; gas mask and gas machine if gas- oxygen is given; oxygen can with mouth-piece if gas is not given. A 2-liter flask of salt solution, Locke or Ringer, as preferred by the surgeon, is kept sterile at a temperature of 120° F., ready for immediate use. One small funnel 3 inches in diameter at the top, which is used in case salt solution irrigation is to be poured directly into the abdomen. Transfusion tray is kept in the operating-room. Mouth-cloths, head-cloths, and rubber aprons for operator and his assistants, including nurses who must come into the atmospheric field of operation. PREPARATION OF THE PATIENT Have ready — For Vaginal Scrubbing. — Eight-inch clamp; retractor; scrub basin; gloves (scrub, 1 large); gauze, 2 pieces (1 small); bottle of sterile soap; irrigating tubing. For Abdominal Scrubbing. — Scrub basin minus instruments and tubing; toothpick swabs; alcohol and ether sponges; bichlorid towel; gloves; gauze. The area of operation is shaved and scrubbed with green soap and sterile water and cleansed with alcohol and ether. Some surgeons follow with a wet bichlorid towel; others paint the area with tincture of iodin and cover with a dry sterile towel. This latter part of the preparation is a matter of preference on the part of the operator. Some surgeons prepare all patients the night before by scrubbing with green soap and water and with ether and alcohol washing, followed by bichlorid wet- dressing, left on until time of operation, when the usual preparatory room technic is employed. All patients' feet are tied to the table with broad bandages with padded leather ankle cuffs, except in rectal or vaginal operations, one foot to each side of the table. Patient's hands are tied with arms straight to sides, with wrist straps that are tied to each other under the back, the straps just sufficiently tight to hold the arms close to the sides to prevent them from falling off the table, but so that neither hands nor arms are under the patient. For breast and neck operations hands are held by assistants and are not tied. In all rectal and vaginal operations the legs are held by assistants. In most up-to-date hospitals straps are obsolete, excepting in the preparatory room, before the anesthetic is started, when stirrups and straps may be used to save assistants. Only for laparotomies are the hands tied above the head. Never tie a patient's hands until the anesthetic is started, and the nurse should never leave patient while anesthetic is being given. Position on Table Laparotomy or Dorsal. — That in which the patient lies on the back. Knee-elbow. — One in which the patient lies upon the knees and elbows, with the head upon the hands. Knee-chest or Genu pectoral. — That in which the patient rests upon the knees and chest, with the arms crossed above the head. 360 OPERATION OF THE HOSPITAL Lithotomy. — One in which the patient lies on the back with the legs and thighs flexed and the knees wide apart. Sims. — One in which the patient lies on the left side with the right thigh and knee drawn up and the left arm placed along the back. Cunningham. — Position for kidney work. Trendelenburg. — For gynecologic patients. The patient lies on back with head and foot of table dropped. Preparatory Asepsis Scrubbing Up. — Hands are scrubbed with sterile brush and soap for five min- utes, then nail-file and scissors are used; Schleich or sandsoap is then used with gauze for ten minutes, scrubbing arms above elbows. This is followed by hand solutions, alcohol, 60 per cent., bichlorid, 1:6000 (this in plunger), then followed by sterile water. The whole procedure takes at least twenty minutes. Surgeons put on clean undershirt, operating-room trousers, rubber apron, head- cloth, and mouth-piece, with sterile operating-room gown over all. The gloves are helped on by the nurses. Instrument nurse has on sterile gown, sterile gloves, mouth-piece, and head- piece; likewise the sponge nurse. The supe nurse is not supposed to be clean. Operator and his assistants are sterile, but anesthetist is not. RULES FOR NURSES Instrument tray, after being made for specified operation, is put in to boil for half an hour before the operation. When a drum or binder package has been opened for an operation, the mate- rial must never be used again until recounted and resterilized as originally done. No ligatures, sutures, tendon, or other material that has once been exposed in an operation shall be used again until sterilized all over. All tubing and sutures are treated in 95 per cent, carbolic acid for ten min- utes. Never force an instrument together. If it does not go together easily there is something wrong. Oil the joints of all the instruments with alboline each time they are used before sterilizing. Dry all needles (transfusing), trocars, and snares with compressed air (Politzer bag). In case an instrument falls on the floor, always boil for ten minutes before using — never sterilize in carbolic and alcohol. Count sixty before removing an instrument or suture from carbolic into alco- hol. Disconnect instruments before putting into carbolic. The Operation. — At the time of operation the sponge nurse counts every bundle of sponges as she opens them. Used sponges are picked up by the supe nurse and hung on the rack for that purpose, which contains 10 hooks on each side for convenience in counting. Before the peritoneum is closed the sponge nurse and instrument nurse count the sponges and instruments, and report to the surgeon whether all are there. Sponges from clean operations are saved, washed, boiled for one hour, dried, and folded. From pus cases they are burned. THK SURGICAL Ul'IOKATlM i-l« )( >.MS 301 THE PREPARATION OF CATGUT With the uses of catgut the hospital administrator has nothing to do; thai is the province of the surgeon; but the suture material has been so efficiently devel- oped in the past decade that it now is standardized and classified, and it has attained such constant units of tensile strength, and such precisely regulated time of absorp- tion, that the busy surgeon has been able to practically waive his former duty of superintending the details of its preparation, and may to a large extent content himself with knowing definitely the care bestowed upon this important factor in his success, or, better still, the source of the product. Most modern hospitals in which a considerable amount of surgery is done have given over the home preparation of catgut, and buy their supply from recognized experts in that business. There are many reasons for this : on the score of reliability there can hardly be a doubt that a scientifically inspired commercial house, whose chief asset is public confidence, will use every expedient to maintain and even im- prove its product in accord with scientific principles; whereas, the home-prepared article must constantly be subjected to the hazards of handling by uninformed nurses, who are frequently changed from post to post, further complicated by the neces- sarily unsystematic procedures and conditions in the preparation rooms concerning a matter outside the routine of hospital practice; nor will it be possible ever to guar- antee precisely the same conditions for any two days or any two batches of gut in the hospital; so even if the utmost care and conscientiousness be admitted, without the advent of a single unguarded movement, there will be a difference now and again in the time of absorption of the gut, a matter of the most vital concern to the sur- geon who has predicated his whole operation upon the sequel of events in the healing of the tissues and the absorption of the suture material and its consequent non- irritating effects. If it be on the score of economy — the inexpensiveness of the home-prepared article, as compared with the apparently high-priced purchased product — the ad- vantage is apparent rather than real. As a matter of fact, surgeons know hospital conditions pretty well, and the unpreparedness of the institution in the matter of carefully measured processes required in the preparation of gut, and they are becoming more and more reluctant to hazard their success upon the unskilful work of hospital people in the performance of a duty that must be, after all, only a very small part of the day's employment, and they will not take their important patients where they must use such material. In the free wards of the institution, and in the surgical rooms of the charity hospital, there is another factor at work, even if the welfare of the patient and his safe recovery be not the first consideration — and that is, delayed convalescence in the event of catgut infection or irritations due to improperly prepared gut, which amounts almost to the same thing, because irritation stimulates an exosmosis of serum about a wound, and this in turn forms an almost perfect culture-medium for those micro-organisms always present more or less in the tissues, and which, under proper conditions, eventuate in pus formation. It costs money to keep a patient in the hospital, and, whatever may be the attitude of the institution on the point of keeping a pay patient as long as possible, it will not take very long for a free patient to consume in food and dressings whatever difference I here may have been between the purchased and the home-prepared article. Moreover, it frequently happens that a whole batch of catgut is either spoiled in the process of preparation iii the hospital, or else is found to be unsterile upon culture tests and must be dis- carded, which would also tend to indicate the danger of the whole system, or fre- 362 OPERATION OF THE HOSPITAL quently the tensile strength is found to be so poor at the operating-table that strand after strand breaks, which has the disadvantage of trying the surgeon's nerves, in addition to the loss of the material. So that, by either horn of the dilemma, the home preparation of catgut is not as inexpensive a proposition financially as it appears prima facie, and a careful analy- sis calls for the conclusion that "home-made" catgut does not represent surgical economy. Now let us discuss the physics of catgut preparation as it is conducted by ex- perts : The first question naturally is, how can catgut be rendered perfectly sterile without affecting its integrity for the uses to which it is to be put? The methods by which catgut can be prepared are divided into two general classes — first is the heat method, and second, the chemical process. Of the chemicals used in catgut preparation iodin seems at the present time to be the most popular ; biniodid and bichlorid of mercury are also used to some extent. The chief objection to the chemical method of catgut preparation is that the chemicals produce an antiseptic material, and the obvious drawback lies in the fact that in burying the catgut the surgeon introduces a certain amount of the chemical ; or, in other words, the tissues must take care, not only of the catgut itself, but also of the antiseptic. It seems only reasonable to assume that whatever antiseptic is powerful enough to destroy bacteria will also be powerful enough to destroy leuko- cytes, the great repair agents upon which the surgeon must rely. The second serious objection to chemic methods of preparing catgut is the fact that the chemicals do not seem to completely penetrate the strand; this may readily be demonstrated by taking, for instance, a piece of iodin catgut and stripping it, which will show that the inside is yellow instead of the reddish-brown color apparent on the surface of the strand; the natural color of the iodin tincture is reddish brown, and, since the inside of a piece of iodin catgut is found to be yellow, it seems apparent that the sterilizing agent has not come in contact with every part of the strand in any considerable strength. Consequently, although the chemical used may have sterilized the outside, the "core" is in the same bacteriologic condition that it was before the immersion of the gut in the antiseptic. This fact has been demonstrated in the Michael Reese Laboratory in the fol- lowing manner: two strands of iodin gut were taken from a batch, some of the strands of which had given rise to slight infections — one of the strands, picked under carefully sterile conditions, was embedded in culture medium; the other strand, handled also under careful technic, was cut into j-inch sections and embedded in another test-tube of the same medium. After fourteen days no growths had occurred in the case of the full-length strand, but healthy growths were present in the tube containing the sectioned gut. This procedure was re- peated five times to avoid technical errors, but the results were the same each time. It was deduced that the gelatinous coat of the whole strand had prevented the escape of the micro-organisms, but the cut ends of the sectioned gut had permitted the escape and subsequent activities of the bacteria. There is scarcely a doubt that persistence to the point of solution of the undivided strand would have led to bacterial growths there also. Still another objection to iodin catgut is that the iodin has a rotting effect upon the animal tissue, and the longer the gut is left in it or the greater the strength of the tincture, the more marked is the rotting action of the iodin. It may be well to mention here that catgut, purposely left in iodin for a long time, was found to have THE SURGICAL OPERATING-ROOMS 3G3 lost its tensile strength, and, therefore, could not be used for surgical purposes, and even then the "core" of the strand stripped a clear yellowish color. With bichlorid of mercury, one must bear in mind that the action of this on albumin or gelatin is to form an insoluble albuminate of mercury; the nature of catgut being gelatinous, the action of the bichlorid would be to form an impene- trable albuminate; in other words, the action of the antiseptic would be to defeat the very object intended. Home-made catgut is prepared in some hospitals by the so-called Claudius method, which calls for the immersion of the gut in a 1 per cent, tincture of iodin in alcohol, in which the material is supposed to be stored for eight days. Several modifications of this method have been suggested — some vary the time, generally 1 ly reducing the number of days (to minimize the rotting effect of the solution), while others vary the strength of the tincture. Some prefer an aqueous solution of iodin instead of the alcoholic tincture recommended by ( 'laudius. Water seems to be the only liquid which has the property of penetrating a strand of catgut through and through, but, unfortunately, water cannot be used to sterilize catgut, on account of its liquefying action upon the animal tissues. Alcohol, chloroform, and ether are other liquids that seem not to completely pene- trate catgut. There is, how r ever, one method of catgut preparation which calls for the boiling of catgut in water for a short length of time; to comply with it, the catgut must be previously hardened by means of formalin, to guard against the softening action of boiling water — but, even then, the No. 1 can be boiled only from seven to nine minutes, and the smaller sizes for even a shorter time than this. In view of the fact that bacteriologists maintain the minimum thermal death-point of tetanus spores to be twenty minutes of wet heat at 212° F., it is at once apparent that by this method it is physically impossible to destroy all bacterial organisms. In other words, the surgeon who has his catgut prepared by this method allows his instru- ments to receive more sterilization than his catgut, which is not consistent, because with catgut the inside as well as the outside must be rendered sterile, whereas, with the instrument, it is merely a matter of surface sterilization, and, above all, the cat- gut is to buried in the tissues, which is not the case with the instruments. Inci- dentally, another serious drawback to this method is the mummifying of the animal tissue by the action of the formalin, tending to produce a brittle material. Since, then, neither the chemic nor the wet-heat method is ideal as well as practicable, let us now consider the only other procedure which remains open — that is, the use of dry heat. Since organisms that may be destroyed at a certain temperature in wet heal are not destroyed at the same temperature in dry heat, it is obvious that the temperature must be raised and maintained for a greater length of time than would be the case with wet heat; and again, authorities have found that several applica- tions of dry heat (fractional sterilization) are more destructive to bacteria than only one prolonged application. Dry heat, moreover, not only goes to the core of the strand, but an aseptic, non-irritant material is produced, for there is no chemical to injure the tissues. It is claimed that, while the staphylococcus is destroyed in wet heat at 180° F. in a few minutes, it requires sixty minutes in dry heat at the same temperature (Lehniann). With the tetanus spore the established thermal death- point is considered 302° F. for an hour in dry heat (Rosenau, Park, and others); it has also been found that this organism will resist 284° F. for as long as three hours (Sternberg). Of course, the possibility of anthrax in catgut is well known as it i- a sheep 364 OPERATION OF THE HOSPITAL disease, and it is possible for spores to be present in the intestines. Tetanus being a soil disease, the sheep is quite likely to act as a host to the spore of this bacillus. It is by no means a common thing to find either of these spores in raw catgut even before any sterilization is attempted, which is a fortunate thing for those who use indifferently prepared catgut. The surgical world should be grateful that tetanus or anthrax infections are rare with any kind of catgut, but there is a danger, and the conscientious surgeon and hospital administrator must take steps to eliminate the possibility. Commercial raw catgut is surprisingly clean, even before sterilization, and so long as the catgut preparer deals with clean catgut — so far as pathogenic bacteria are concerned — immersions in alcohol, ether, chloroform, or iodin will produce ex- cellent results; but this clean catgut really would not need any sterilization at all, or, to put it more clearly, if we could select the pathogenically clean raw catgut and use it as it is, the chances for infection would be very small. The worst result that might follow its use would be an irritation, perhaps, from the non-pathogenic bacteria present in it, and such irritation the surgeon might attribute to some cause other than the catgut. The f ollowing methods of sterilization by dry heat are used to some extent : The strand of catgut is placed in a paraffin-paper envelope, placed in an oven and subjected for three hours to a temperature of about 250° F., after which the material is ready for use. There are objections to this method: first, the material has not been subjected to a temperature considered by authorities to be the thermal death-point of tetanus and anthrax spores. Sternberg has found that tetanus spores resist 284° F. for three hours, as mentioned above, while this method calls for only 250° F. for the same length of time; second, by this method the material receives only one application of heat, whereas it seems to be acknowledged that three fractional applications of heat are necessary, and it is significant that most hospitals sterilize their dressings by means of three fractional applications. Another method in use in some hospitals consists in boiling catgut in alcohol, the length of time and temperature varying with the individual operating-room nurse's "technic"; some nurses boil catgut in alcohol without pressure for an hour; the boiling-point of alcohol is 170° F. Occasionally the time is raised to as much as two hours or even three hours. A great many, however, subject the alcohol to pressure in a steam sterilizer, and run the temperature as high as 225° and even 250° F.; when the alcohol is subjected to pressure in this way, the length of time is generally not more than an hour, or even, in some institutions, less. In considering the efficiency of this method it is necessary to draw a line be- tween wet liquids and dry liquids, because this is of the utmost importance bacte- riologically. Water is a wet liquid — any liquid containing water is a wet liquid; liquids containing no water are dry. Commercial absolute alcohol (95 per cent.) does not contain a sufficient quantity of moisture to gelatinize catgut boiled in it, and it is a dry liquid. It is physically impossible to boil catgut in water or anything containing as much as 15 per cent, or more of water, because the water in a very short time softens and gelatinizes the animal tissue; therefore, it is absolutely neces- sary to boil catgut in a liquid containing no water, otherwise the gut will be soft- ened and, therefore, rendered useless. Now, then, with alcohol we have a dry heat of 170° F. (the boiling-point of alco- hol) compared with 302° F., or, if boiled under pressure, the maximum temperature obtainable with alcohol is 250° F.; 170° F. does not compare very favorably with 180° F., the thermal death-point of staphylococcus (Lehmann), and certainly neither 170° nor 250° F. with dry heat are sufficient to destroy tetanus spores in the THE si RGICAL OPERATING-ROOMS 3<>5 time usually allowed by hospitals thai prepare their own catgut. It is evident, therefore, that the alcohol methods are not safe from the bactcriologic standpoint, measured by recognized bacteriologic authorities. There are a number of concerns that have the confidence of the medical pro- fession in the preparation of catgut. One of these is Van Horn and Sawtell, a firm that has many adherents, and whose catgut products are regarded as standard by a large section of the profession. The Michael Reese Hospital employs the catgut of this firm exclusively, and we are, therefore, taking the liberty of accepting its methods of catgut sterilization as illustrative of the expert preparation of efficient catgut. After the necessary pre-preparation of the gut the strand is rolled up and placed in a previously sterilized tube, one end of which is sealed and the other left open; in this way reinfection of the gut, due to its being touched by human hands, is impossible after the process commences. In the oven it receives an application of dry heat for a period of four and one-half hours, the temperature gradually reaching a maximum of 240° F., and cumol, one of the benzine series (used because it allows of a high temperature and does not soften the catgut) , is placed in the tubes with the catgut and also surrounding the tubes. From 240° F. the temperature is gradually raised to not less than 310° F., at which minimum it is kept for two hours. On the following day the cumol is poured off, and another application of 240° F. for an hour is made; this application not only forms the third fraction of the process, but evaporates the cumol from the surface of the strand. Then the preserving fluid is placed in the tube with the strand under aseptic precautions, after which the tube is sealed. On the following, or fourth day, to guard against any possible air contamination which may have taken place during the filling of the tube with the preserving fluid in spite of the precautions, the sealed tube is placed in the steam-pressure sterilizer and subjected under pressure to 270°; F. for one hour, and this is repeated on the fifth day, thus making five fractional sterilizations, three of which take place before the sealing of the tube and the concluding two after the sealing. Kangaroo tendons are taken from the tail of the kangaroo, anel, after the necessary cleansing preparation, are sterilized in precisely the same way as catgut. Chromicized catgut is made by treating catgut with chromic acid for varying periods in proportion to the time it is intended to resist absorption in the tissues. It is obtainable in resistances of ten, twenty, thirty, and forty clays, referring to the length of time the catgut can be depended upon as a suture— in muscle tissue before absorption begins. After the catgut has been treated in chromic acid for the proper length of time the acid is eliminated, and the sterilization proceeds by the fractional method described above. RUBBER GLOVES Gloves are so essentially appurtenances of the operating- and dressing-rooms that we shall be justified in considering them apart from the other rubber goods of the institution. There is no concensus of opinion as to just how far rubber gloves should be used in institutions. There are many hospitals that do not offer their surgeons, obstet- ricians, and gynecologists rubber gloves, and some institutions require operators to furnish their own gloves when they wish to wear them, and there is rather a dispo- sition everywhere to make operators furnish their own gloves, not because institu- tions regard gloves as a luxury, but rather because operators an' prone to go just 366 OPERATION OF THE HOSPITAL one step farther than most administrative officers feel justified in following; that is, if the institution begins to furnish gloves and to mend those that are pricked with a needle or very slightly torn, the operators are likely to offer the objection that infectious matter may catch at the point of the mend, and, therefore, they ask for new gloves for every operative procedure. Also, nowadays many operators go to the extent of demanding clean, new gloves for every one of a series of clean operations and for each dressing. Other operators require not only their first assist- ants, but all the nurses engaged in the operating-room to wear new, sterile gloves. It seems a good deal of this glove technic borders closely upon faddism; a sterile glove should be a sterile glove, whether it is brand new or has a mend in it; if the glove is not sterile, the mend will not be sterile, and if it is sterile, then the mend is sure to be also sterile, and usually the point of a mend in a glove is stronger than any other part, so far as its likelihood to break is concerned. It is an illuminating fact that surgeons who must buy their own gloves do not carry their demands very far into faddism, and can usually get along with far fewer gloves than those to whom the institution supplies them. Then there is the question of the lightness or heaviness, smoothness or rough- ness of gloves, the length of the gauntlet, the reinforcement and taper of the fingers. Choice in all these particulars is individual to the operator; some operators, for in- stance, require pebbled gloves of the thinnest kind for laparotomies, whereas they will require a smooth glove for superficial operations, and vice versa. Some operators require that all finger-tips be reinforced and shaped to the nail, whereas others insist on the very thinnest sort of finger-tips; most operators who do deep surgery require gauntlet gloves; some surgeons require in all their work a very heavy loose fitting glove, such as that commonly used in postmortem work, where the deftness of finger is not of prime consideration. It is not at all certain that any institution, however rich and liberal, should be asked to furnish all these various sorts of gloves for its attending operators. In a certain institution, where there are perhaps fifty or more operators at various times in a large or small way, it is the rule to furnish each operator with whatever kind of gloves he requires, and for that purpose an infinite variety of gloves, as to form, size, texture, and make, are kept on hand, and there is an immense waste in this procedure, because rubber gloves oxidize and vulcanize very easily, and cannot be kept intact and in serviceable form longer than a few weeks at most, and when they undergo this degeneration they are, of course, worthless, as they tear on the slightest attempt to put them on. In this institution the glove bill alone amounts to $2000 to $2500 per year. The Test of Gloves. — It goes without saying that gloves must be fresh and comparatively new, and of the purest rubber, if they are to be useable and capable of sterilization. There are many salesmen who sell gloves to hospitals,- or attempt to do so, but most of these people are mere hucksters, and there are only three or four firms that make gloves worthy the name and whose goods are to be relied upon, and then only providing they themselves offer them first hand and under the name of "firsts." The Canton Rubber Co., Faultless Rubber Co., and Miller Rubber Co. are practically the only makers of rubber gloves that are worth buying. There are only two tests for gloves that amount to anything — one of them is to blow the glove up until it is as thin as tissue paper, and then go over it critically with the eye and finger to detect weak spots either in the finger-ends or elsewhere. There are sometimes blebs or blisters in the glove, but the usual defects are in or between the fingers. After the glove is well blown up it should bear a considerable amount of pressure as the hand goes over it trying out the various parts. If the glove THE SURGICAL OPERATING-ROOMS 307 has undergone deterioration, due to oxygen in the atmosphere, such as will invariably occur in the shop-worn gloves, where will appear sometimes distinct cracks, especi- ally at the finger-ends, but more generally this deterioration will be manifest in lighter colored specks in the glove, and these light spots arc always weak; these spots show clearest when the glove is relaxed and not blown up. The other test for gloves is hot water blown into the glove under pressure with a syringe; this will invariably reveal even the most infinitesimal needle prick. The heat from the inside will dry any water that may be on the outside, and if some pressure — as for instance, from a bulb syringe — has been used in filling the glove a wet spot will appear wherever there is the smallest hole; and, by the way, this is the best of all methods of detecting flaws in gloves after they have been first used and before they are resterilized. In a good many institutions the nurses test their clean gloves by blowing them up, covering them with powder, and holding every part in turn to the cheek, but it goes without saying that this method is defect- ive and open to many errors. Sterilization of Gloves. — In some institutions gloves are sterilized by boiling alone. Of course this method is plainly defective in two directions: first, boiling water has a temperature of only 212° F., which will not destroy a number of patho- genic micro-organisms, especially the spore formers; and, secondly, because boiling water destroys the rubber very rapidly. Some institutions again sterilize in live steam under a pressure of 15 pounds, and a good many of the sterilizer manufactur- ers advocate this method; it is certainly the best way if the life of the glove alone is under consideration, as gloves can be resterilized as many as six or eight times if vapor sterilization is employed, but it is not effective even at a pressure of 15 pounds to the square inch, or 250° F. for thirty minutes, because gloves heated in this way, and then planted in one or other of the culture-media, have shown vigorous growths of micro-organisms. In the Michael Reese Hospital the following method is employed: The gloves are first washed clean in hot water; they are then wrapped in cloths and put in the sterilizer, and kept under live steam at 250° F. for thirty minutes. The vapor is then withdrawn, and a dry heat of the same temperature is introduced for thirty minutes longer. This last half-hour is hard on the glove, but no culture has ever been formed following it, and will not be, unless there is some defect in the technic of getting the glove from the sterilizer to the culture-medium. "First" and "Second" Gloves. — There seems to be a good deal of high finance in the sale of rubber gloves by the manufacturers. Most makers sell their "firsts" or "prime" gloves at prices varying from $5.50 per dozen pairs for the smaller smooth gloves, to $7.50 for the larger size smooth and rough gloves, with an extra price for gauntlets and for fads of individual operators, but the market for these gloves is somewhat limited, and it is the custom of manufacturers to sell their sur- plus as "seconds." These "seconds" are admittedly defective, but sometimes t hese defects cannot be pointed out even by the manufacturers themselves. Sometimes these gloves not only show no defects, but stand all the tests as to freshness and first-class quality, and should be sold as "surplus" instead of "seconds"; at least the plea of "defective" gives the manufacturers warrant to let the gloves go at a lower price than "firsts" are held at. However, glove buyers should make them- selves so thoroughly acquainted with all the tricks in the glove business as to be able to buy their gloves independently of whatever the manufacturers may say or offer. If "seconds" that are really as good as "firsts" can be purchased a saving of 50 per cent, can be made. Sometimes a manufacturer, in offering "seconds" that appear to be "firsts," will hint that perhaps the "seconds" will not bear resterilization as 368 OPERATION OF THE HOSPITAL many times as the "firsts," but this statement does not work out in practice, as it is the experience of a good many of us that a good glove, whatever it may be called as to quality, will wear about as well, will stand pricks as poorly, and will sterilize as frequently as any other good glove. THE SURGICAL ANESTHETIC The subject of anesthetics for the operating department must be considered from the standpoint of the surgeon and from that of the hospital administrator. However, since both have the same ultimate purpose in view, we shall endeavor to analyze and correlate the two sides of the problem. The first and most vital question to be answered is this: Into whose hands shall the actual administration of the anesthetic be entrusted? Hitherto the custom in many hospitals has been to detail the house physicians as anesthetists, allowing them to become proficient in that best of schools, experience, under the guidance of skilled tutors. In some private hospitals each operator has his own paid anesthetist ; in a few there is a salaried expert anesthetist for all cases, and in others an expert available for special cases. There is a tendency, manifest with many surgeons, to employ specially trained young women to administer their anesthetics, but, since it is not proposed that these operators shall have had a competent medical education, their employment as a solution of the problem is hardly worth considering, because, while a person trained by thumb-rule may administer in the classical, average operation, the great majority of patients will fall outside the class of ordinary, and the conduct of the anesthetic must meet the requirements of the individual and not the class. No two cases of pneumonia can be treated precisely alike, even though both may run a normal course, nor can any two sick people ever be treated exactly alike. There are radical differences between individuals — no two will have the same receptiveness to certain drugs, and in the same way, and perhaps for the same physiologic reasons, no two persons will take any anesthetic exactly alike. There are some medical men, even able surgeons, who think all the requirements have been met if the patient is kept relaxed and noiselessly asleep during the operation and is put back to bed alive. This philosophic attitude will hardly do to-day, when the surgeon is under- taking surgical operations that call for the severest tests upon the reserve forces of sick people, when a feather-weight of difference may mean life or death. What a huge percentage of patients operated upon die nowadays from postoperative complications — pneumonias, uremias, shock, and infections — that just a little more resistance might have enabled them to weather! Then how important is it to bring the patient through the operation in the best possible shape, and with the greatest possible amount of reserve force for the long days and nights of hazardous convalescence! It will not do any longer to order any particular anesthetic for any given case before the patient goes to the operating-room. Preparations must be made for an instant change from gas to ether and the reverse. The anesthetist must realize, from second to second, any adverse effect of the drug upon the patient, even to the finest shade, and must be ready to shift his mask before another breath is drawn. How negligent, even criminal, it is to subject a patient to the mercies of a person unversed in the sign and symptom language of unconsciousness. It is for these reasons that anesthetics must be given by trained, experienced medical persons, into whose hands even then will come enough untoward results to make it imperative that only the most competent should be employed. THE SURGICAL OPERATING-ROOMS 309 In the Michael Reese Hospital there is an anesthetic staff of three physicians, former interns, two of whom are on service simultaneously, and whose duty it is to teach all new interns the Michael Reese methods of administration, remaining with each new man until they can certify him as experienced or shift him as impossible. They are also present for any particularly difficult case, ward or private. In cases of special hazard, or at the request of the operator, the expert attending anesthetist, himself must give the anesthetic, receiving remuneration therefor. This arrangement places the responsibility on the shoulders of experienced men, and results in a much better average of anesthetics, and breeds a sense of security during the operation, a feeling most operators will appreciate. The purpose of the anesthetic is to keep the patient in a state of unconscious- ness, with relaxation, during the surgical operation, and to bring him out of the operation with the least possible damage, both as concerns the effect of the anes- thetic itself and the surgical insult to the system. To achieve this double pur- pose many of the best minds in the surgical world and great numbers of able laboratory men have spent vast energy and deep investigation. We shall omit discussion of those methods which are still on trial, and content ourselves rather with a view of those anesthetics that are recognized and approved by the medical profession. There are only three of these anesthetics — ether, nitrous oxid with oxygen, and chloroform. Chloroform. — Chloroform is quickly disposed of. In this country and in the best clinics abroad, notably Von Eiselsberg in Vienna and Bumm in Berlin, it has been discarded almost entirely. Its use should be restricted to those few cases in which ether is contra-indicated, and even here it is in large part being supplanted by nitrous oxid-oxygen. Some few men still persist in its use, but there is no doubt that its extremely narrow margin of safety renders it dangerous in the hands of the average anesthetist, and, although statistics are most unreliable, all are agreed in assigning the highest mortality to chloroform. Moreover, the recent work of Henderson, to be referred to later, helps to explain its dangerous properties. When used at all, it must, of course, be given dropwise on the open mask, always remaining below a vapor concentration of 2 per cent. A chloroform anesthetic may be switched to ether with comparative impunity, but the reverse procedure, unless interrupted by several moments of air breathing, may result in disaster. Finally, the immunity to chloroform, supposedly possessed by women in labor, remains debatable, and here, also, chloroform is beginning to be displaced. Ether. — Ether has been the anesthetic of choice up to the present time, and rightly so, when its striking advantages are taken into consideration; chief among these is its wide margin of safety in the hands of the average house physician alter complete relaxation is achieved. It affords complete relaxation, with safety, in a group of cases in which nitrous oxid-oxygen occasionally fails — i. c, perineal and pelvic surgery and surgery about the diaphragm. Itself a stimulant of the respira- tory and vasopressor centers, it is least often followed by shock when properly ad- ministered. It is safest in arteriosclerotic and in organic heart lesion-. When preceded by nitrous oxid, ether loses its chief terror to the patient the relatively long period of discomfort before unconsciousness is attained. It is unsuited in all cases of respiratory and renal disease. The method of administra- tion of choice is the open mask drop method, preceded in the modern hospitals in all cases, except children, by nitrous oxid to obtain unconsciousness quickly and without discomfort. 370 OPERATION OF THE HOSPITAL In alcoholics a concentrated vapor is attained by adding folded towels, which are removed as soon as may be. Nitrous Oxid-oxygen. — Nitrous oxid-oxygen has rapidly won favor in some of the best hospitals. It has undoubted advantages over ether as a general anesthetic, the most vital of these being its transitory effect on the organism. Nausea and vomiting are practically eliminated, being reduced to 2 per cent, of cases, and careful investigations have revealed no changes in the blood and none in the urine. It is much more desirable in all respiratory and renal diseases, eliminating almost entirely the dangers of uremia, acute bronchitis, and similar sequelae. The mortality with this anesthetic is lowest of all the general anesthesias — always bearing in mind these facts: that it is contra-indicated in organic heart disease and arteriosclerosis, since it causes an increased blood-pressure, and an overdose of nitrous oxid results in tonic and clonic muscular contractions, which may send the blood-pressure to a disastrous point, and it is the most difficult of all general anesthetics to administer because of the extremely narrow margin of safety between consciousness, complete unconsciousness, and an overdose, with symptoms of nitrous-oxid poisoning. Finally, the expense, which will be detailed later, is a very important item in the hospital administration. Combined Ether-nitrous-oxid-oxygen. — The combined method, already men- tioned, may be carried to a point of high efficiency, and some of the best anesthetists are accustomed to nurse dangerous risks along, starting with nitrous oxid-oxygen, switching to ether if the patient does poorly or refuses to relax properly, and then going back to gas again as soon as relaxation is attained; occasionally this switch- ing will be made two or three times in the course of an operation, and a patient believed to be all but inoperable will be worried through some desperate operation in this way with little or no anesthetic risk and insult. Gas anesthesia is not generally well understood, and it may safely be said that many of the mishaps that have occurred with the use of gas were due to inexpe- rience on the part of the anesthetist. In the Michael Reese Hospital continuous nitrous oxid-oxygen is used in about 50 per cent, of all the anesthesias, and it is used in any procedure, from a mere whiff for examination in the anesthetizing room to a case that will last for two or three hours, as witness the record of the continuous use of gas-oxygen for three hours and forty-five minutes, with recovery, in a case of universally adherent multilocular ovarian cyst, where the various points of the tumor had to be dissected out of the abdominal cavity, and its use continuously for an hour or more is of daily occurrence. There are two recognized forms of apparatus for the use of gas-oxygen. One is the design of Dr. Teter, of Cleveland; an excellent apparatus, if somewhat com- plicated; and the other is the one designed in the Michael Reese Hospital, a much simpler device. This apparatus is illustrated in the sections on Equipment of the Operating-rooms. Within the past year a new design of gas-oxygen apparatus has been placed on the market; the cylinders are mounted on wheels, and the oxygen tank holds 750 gallons, while the gas tank holds 1250 gallons. The chief advantage of this larger equipment is that no change of cylinders need occur in the course of the operation and there is no freezing of the gas to delay or annoy the anesthetist; its chief disadvantage is a somewhat more complicated arrangement of valves, which, unless carefully watched, will cause a waste of gas by leakage. In the Michael Reese Hospital the old apparatus is set upon the platform of the new carriage, and we have then the advantage of the larger cylinders. Although in the physical laboratory, under controllable conditions of pressure THE SURGICAL OPERATING-ROOMS 371 and temperature, these two gases can be mixed on a percentage basis, in the opera- ting-room no such attempt can be made, the quantity of oxygen being continually altered to suit the condition of the patient. The mask is the ordinary mask sup- plied by the S. S. White Dental Manufacturing Co. under patents, and the Teter Co.'s gas bags are the best that are made. They are of pure rubber and protected by a net that prevents, at least to a certain degree, undue expansion. The usual procedure in gas administration is to administer the nitrous oxid pure at the start, and carry it to a point where the patient begins to show asphyxiation, as expressed in the beginning cyanosis of the face. Then a small flow of oxygen is added, which serves to clear the patient's face and skin and yet hold him unconscious and relaxed. This administration of gas and oxygen cannot be made by any set rule or on any percentage basis, the patient's condition being the only guide. There is a very simple form of apparatus, made by most of the gas manufactur- ing concerns, that consists of a standard with a tank of gas on either side and a gas bag suspended from another point. A modification of this same apparatus consists in using a tank of gas on one side and oxygen on the other, the gases both going through the same bag. The principle of this bag is wrong, of course, as the bag must be emptied of gas before an unmixed oxygen can be had for the patient's revival if things do not go right, and the patient might die long before the bag hail been emptied and the oxygen brought into use. The Johns Hopkins Hospital has designed an apparatus employing the principle of rebreathing, by which the nitrous oxid is inhaled and exhaled and reinhaled a number of times. That institution claims great merit for the apparatus, but others who have tried it very carefully, and with every intent to succeed with its use, have been unable to do so. It is knowm that exhaled breath contains, besides carbon dioxid, definite if small quantities of toxic volatile substances, and it seems to those who have tried this rebreathing method that there is a profounder poisoning follow- ing it than with the direct use of fresh gas all the time, and the patients seem to have taken this profound poisoning back to their beds, and to have been some time recovering, whereas with fresh gas and without its re-use, but with the employment of carefully administered oxygen, the patient, even after a long operation of an hour or two, wakes up almost refreshed, and within a few respirations after the gas is discontinued and pure oxygen substituted the patient usually gets back to bed without any nausea and without any apparent exhaustion, and there seem to be no ill after-effects. There is at present, however, thanks to the illuminating theories on acapnia and shock, as advanced by Professor Henderson, of Yale, considerable experimenting being done in the use of carbon dioxid during anesthesia, and especially in the nitrous oxid-oxygen method. In the Michael Reese Hospital this newest adjunct, intended to serve as a weapon against shock, is employed in two ways — first, as pure carbon dioxid compressed and available at will, and, secondly, in combination with oxygen as an 8 per cent, admixture of carbon dioxid, these combined gases being used in the oxygen tanks instead of pure oxygen. This whole principle is yet in the experimental stage. Choice of Anesthetic— With most patients the surgeon himself will choose liis anesthetic, in view of the patient's condition, as expressed in the physical examina- tion of heart ami lungs and the pathology of the ease, and in the urine as indicative of the kidney condition. In the operating-rooms of the better hospitals the choice of the anesthetic seems to be a routine one. based on these findings, and the choice is usually made by the hospital interns along lines of policy established by the institution's surgical staff. 372 OPERATION OF THE HOSPITAL The Cost of Anesthetics. — In the administration of ether the personal equation is a very important factor. Some anesthetists can use an open mask, and yet keep a patient nicely asleep on an amount of ether that would make no impression on him at the hands of another anesthetist, whose method would result in the evapo- ration outward of a very much larger proportion of the anesthetic. There is much to be said about the cost of ether. The Squibb's ether contains a small percentage, about 2 per cent., of alcohol, and its evaporation from the mask is very much less than it would be if the drug were pure. The Malinckrodt ether has about the same quantity of alcohol, and experi- ments conducted in the laboratory of the Michael Reese Hospital indicate that under identical temperature conditions the two varieties, when exposed in identical calibrated glass receptacles with identical evaporating surfaces, have the same rate of evaporation; moreover, the quantity administered per hour per patient, when averaged over long periods, is about the same. The cost of the Malinckrodt ether is much less than that of Squibb's product. Most of the large institutions of the country use, indifferently, either Squibb's or Malinckrodt's ether, and with about, the same results apparently, excepting in the matter of cost, which is in favor of the Malinckrodt. The cost of gas-oxygen for anesthetic purposes is a very considerable item, either in the running expenses of the operating department or from the standpoint of the patient, if there is a charge made for the gas. Nitrous oxid costs from $1.25 to $2 for a 100-gallon tank, according to the amount purchased by the institution, and oxygen in the same compression tanks costs about the same for 40 gallons. A single tank of nitrous oxid of 100 gallons will last an average of about 25 minutes— that is, it will require two to two and one-half tanks to do an operation extend- ing over one hour. Some patients require much less than this, while other patients, especially alcoholics, and those that have been accustomed to narcotic drugs, will require very much more, and the amount used will also depend a good deal on whether the gas must be used without any considerable mixture of oxygen, or whether a good deal of oxygen has to be used from time to time during the operation to avoid cyanosis. Taken on the average, from 200 to 250 gallons of gas and 40 to 50 gallons of oxygen per hour will be used. If the nitrous oxid is used rapidly during the anesthesia the tanks are likely to freeze at the valve, and must then be shut off until they thaw out again, and, where careless people handle the gas, a good deal of it is lost, because they neglect to use the balance of it after the valve thaws out, which occurs in a few minutes. Although we have discussed, under the section on Records of Patients, the necessity of making urinalyses and of obtaining a permit for the operation, we may be pardoned for very briefly mentioning these two items of procedure again, especi- ally the routine practice of never giving a general anesthetic to a patient without the report of the urinalysis being present in the operating-room for purposes of observation. It cannot be too strongly insisted upon. Where this is not practised many a patient has been put to sleep with ether whose urine examination showed a kidney condition that would absolutely prohibit that form of anesthesia, and, as a rule, the urinalysis will have a very large weight in the choice of the anesthetic to be used and the after-conduct of the anesthesia itself. the surgical operating-rooms 373 Rules for the Administration of Anesthetics General Remarks. While the operating surgeon cannot waive his responsibility for the proper conduct of the anesthetic, it sin mid lie the duty of the hospital administration to establish and carry out a routine, acceptable to the surgical staff, that will ensure a high order of service and reduce the danger of accident to the lowest possible point. We have discussed elsewhere the preliminary permit for the operation and the establishment of the patient's condition, as expressed in the urinalysis and blood-pressure, and of the duty of the operator or his medical associates to select the anesthetic to be given in all debatable cases. However, if rigid rules are enforced, based upon a broad experience, even these duties become negligible in a properly conducted hospital. We have discussed elsewhere also the personnel of the anesthetic service; let us add only the suggestion, that oftentimes a very simple surgical procedure may take on extremely grave complications, chargeable directly to the anesthetic, and the most critical operations may go smoothly and terminate happily if the anes- thetic is administered in a masterful and workmanlike manner. The Anesthetist. All human beings have their "off" days, and the giving of an anesthetic is a trying ordeal at best; consequently, no person should officiate unless he is men- tally placid and calm and physically sound. He should be personally clean, and not have come from the postmortem room, from a pus dressing, or from attendance on communicable disease, and especi- ally erysipelas. He should be free from ear, nose, throat, or eye infections. He should be perfectly familiar with the operating-table and all its movements and possibilities. He should have available for immediate use and understand thoroughly the emergency set for subcutaneous or intravenous administration of salt solution (Locke's formula). Preparation of the Apparatus. All anesthetic apparatus should be ready before the time set for operation. No anesthetic may be started until there is an ordinary mouth-gag, a Heister gag, tongue forceps, throat swabs, gauze, towels, fan, and pus basin at hand. An ether can should be opened and a double-grooved cork with cotton wick should be prepared. Only the drop method on an open mask is to be employed, except on the special order of the operating surgeon. N 2 Oj apparatus must be tested beforehand. The face mask must be clean and the valves working freely. All four cylinders must contain some gas or oxy- gen. New cylinders with tried valves must be available. The method of cleaning the masks consists in boiling for the ether masks, and in soap and water cleansing, followed by ten minutes' immersion in 5 per cent, carbolic solution, for the gas masks with rinsing in sterile water. The hypodermic tray should contain a syringe loaded with strychnin, gr. .,'„ (0.0021, and another with Til xxv (1.7) of camphor in oil, and the following prepara- tions ready for immediate hypodermic use: Caffein. Adrenalin. Digalen. Nitroglycerin. Camphor in ether. Morphin. 374 OPERATION OF THE HOSPITAL Preparation of the Patient The blood-pressure must be known in all cases scheduled for operation. Urin- alysis must be recorded, and operating permit signed by the patient if an adult, by the legal guardian if a minor or mentally incompetent, or by the hospital author- ities if an emergency case be in profound shock or unconscious from hemorrhage before bringing the patient to the preparatory room. Before starting the anesthetic, be sure: (1) That the patient's mouth is empty, i. e., artificial teeth removed. (2) That there is no constriction about the neck. (3) That the position is the desired one on the appropriate table — the patient should be as far toward the foot of the table as possible. (4) That arms and legs are properly secured and no straining or cramping of limbs. (5) That the head pillow is out, or is removed shortly after starting the anesthetic. Administration A. Choice of anesthetic. The routine anesthetic for adults is N 2 0, followed by ether; for children straight ether. Variations from this will be under instructions from the operator or the staff anesthetist. Ether is contra-indicated in: (1) Infections of the respiratory tract. (2) Nephritis. (3) Brain surgery. N,0-0 2 (continuous gas anesthesia and preliminary gas anesthesia) is contra- indicated in cases with the following : (1) Blood-pressure above 165 mm. (2) Myocarditis and serious valvular lesions. (3) High-grade arteriosclerosis. B. Guides to depth of anesthesia and condition of the patient: (1) Respiration; somewhat quickened, deep and regular. Judge by the sound and by watching chest or abdomen. Noisy, stertorous breath- ing usually means the tongue has fallen backward. (2) The pulse; note the rate, volume, and rhythm: it should be full and somewhat quickened. (3) Color: This may be slightly cyanosed in continuous gas, but in no other anesthesia. (4) Muscular relaxation and reflexes. (5) The pupils: These should be small and sharply reacting; when testing, hold the lid closed an instant, then open toward the light. Never touch the cornea. Morphin renders the pupil test useless. C. Details of administration: Never be left alone with a patient after starting the anesthetic. Take the patient to the operating-room as soon as possible after unconscious- ness (not complete surgical anesthesia) supervenes and reach surgical anesthesia in the operating-room. The anesthetist must concentrate his attention on the anesthetic. The opera- tor wishes to rely on the anesthetist, but cannot be expected to do so if he finds him inspecting the field of operation instead of watching the patient. THE SURGICAL OPERATING-ROOMS 375 Note the time of starting and finishing the anesthesia; keep a written pulse record every ten minutes on tablets provided for that purpose. (This need not interfere with constant attention to the pulse.) Do not use tongue forceps nor ordinary mouth nor Heister gag unless it seems imperative. Extension of the head and protrusion of the lower jaw held under the symphysis suffices nearly always to open the respiratory tract. Avoid throat swabbing, which rarely reaches the mucus that is causing the noisy breathing and usually excites further mucus production. Avoid prolonged pressure at the angles of the jaw — it always causes soreness for several days, and occasionally a traumatic parotitis. In holding the jaw under the symphysis keep hands and fingers off the trachea and vessels of the neck. Protect the eyes, and if ether does reach the conjunctiva instil a drop of castor oil at once. Always remove the anesthetic during beginning dilation of the rectal sphincter. During vomiting never interfere with tongue nor jaw. Turn the head and shoulders sideways, wipe out ejecta to avoid aspiration, and then crowd the anes- thetic. The anesthetic may be crowded: (1) Just before and during the stage of excitement. (2) Just before vomiting, as evidenced by swallowing motions of the throat and shallow, rapid breathing. (3) Just after vomiting. (4) At the operator's request, and if the patient's condition is good. (5) When hypersensitive areas are being handled, as the diaphragm, the Douglas, and the perineum. Avoid supersaturation of the mask — the excess ether is wasted, and may drip into the patient's mouth and throat and thus cause further mucus pro- duction. D. Economy and statistics. Two hundred and fifty grams ether cans contain 350 c.c. Measure by volume the quantity used at each operation; the first 350 c.c. should last from one and one-fourth to one and one-half hours, except for alcoholics and patients accustomed to narcotics and stimulants. N 2 cylinders contain 100 gallons. For continuous anesthesia the average is 200 to 250 gallons N 2 per hour. Do not remove N 2 nor 2 cylinders from the apparatus until empty. It is not necessary to start each operation with full cylinders. Some one must use up those partly empty. E. Danger signals: In ether anesthesia: (1) Respirations shallow, gasping, or obstructed. (2) Pulse-rate rising, volume decreasing (more than the length of operation or loss of blood warrants). (3) Mucus accumulating in throat. (4) Cyanosis beginning. (5) Pupils dilating and reacting sluggishly or not at all. In NjO-Oj anesthesia: (1) Cyanosis. (2) Muscular twitching — seen first about the eyelids and extremities. (3) Eyeballs turning upward — pupils dilating. (4) Pulse-rate decreasing. (5) Respirations slowing — stertorous. 376 OPERATION OF THE HOSPITAL F. Efforts at resuscitation: If the patient stops breathing: (1) Remove the anesthetic. (2) Artificial respirations, 15 to 20 per minute, combined with famiing or the use of oxygen. The upward arm motion or expansion of the chest must be simultaneous with outward traction on the tongue. (3) Make sure of an open and unobstructed respiratory tract. (4) Rhythmic tongue traction associated with artificial respirations. (5) Lower the head and chest to stimulate the medullary centers. (In early chloroform cardiac paralysis, with engorgement of the heart and thoracic vessels, raise the head and chest for half a minute to help empty by gravity the overburdened heart and vessels, and then place body flat.) (6) Heart massage — 120 per minute. In the absence of a pulse, successful heart massage makes a palpable pulse in the carotid arteries. (7) Drugs, hypodermic — strychnin, gr. ^c, repeated; camphor in oil, one or two barrels (fflxxv each); digalen,Ttlx, repeated; caffein, gr. j. (8) Stretch anal sphincter. G. Responsibility: Do not assume unnecessary responsibility when acting alone. If in doubt stop the anesthetic, and give air or oxygen until your doubt is removed. A struggling patient is better than a death from anesthesia. If the general condition of the patient is disquieting, announce the fact or facts on which your judgment is based to the operator. Note. — These rules are in use in the Michael Reese Hospital, and were prepared by Dr. Joseph L. Baer, of the anesthetic staff of the institution. MINOR SURGICAL TECHNIC AND APPARATUS There are a few minor surgical operations that are usually done with the patient lying in bed. The operations are often left to the house medical staff and the nurse. It may be helpful, therefore, to emphasize some of the fundamentals of technic and list the apparatus and material required of the nurses. Spinal Puncture. — Instruments. — Needle, 2\ inches long; syringe for injection of serum (Quincke trochar and cannula) ; sterile tubes. Site of puncture is between the fourth and fifth or third and fourth lumbar vertebra, and an easy method of finding this is by going in parallel with the crest of the ilium. In children the needle is inserted directly in the midline, and in adults the needle is generally inserted about \ inch the other side of the midline and pointed slightly inward and upward. The patient's skin, the operator's hands, and the field of operation must be sterilized as for a surgical operation. Position of Patient. — The patient is preferably lying in bed on one side, with head flexed on the chest, knees flexed on the thigh, and the thigh flexed as close to the body as possible, making the back as convex as possible, so as to separate the ver- tebra. Some prefer doing lumbar puncture with the patient sitting up, but in a reclining position. After the procedure the field of operation is best dressed by a piece of sterile cotton or gauze covered with a strip of adhesive plaster. The needle is inserted as directed, and when it enters the spinal canal the fluid will immediately flow. It is never necessary to exert suction on the needle to with- draw fluid. A "dry tap" generally means that the needle has not entered the canal, but it may indicate an absence of fluid due to inflammatory involvement of the cerebrospinal meninges, which has closed the foramen of Magendie. THE SURGICAL OPERATING-ROOMS 377 Venesection. — Instrument*. — Two pair artery snaps; 2 pair tissue forceps; 1 pair stitch scissors; 1 pair small curved scissors; 2 small knives; 1 probe-pointed grooved director; 1 hook; 1 probe-pointed aspirating needle; 2 aneurysm needles. In test-tubes, add— 2 aspirating needles; horsehair and needles; silkworm and needles; white silk and needles: catgut No. and needles; pipets. Also add to tray — sterile towels; sterile brushes; sterile cotton; 2 medicine- glasses; camel's hair-brushes; bandages, all sizes. The patient is lying in bed, with arm extended on the side of the bed. When time permits it is best to dissect down on the vein. The first procedure is to compress the arm above the elbow until the veins in the elbow stand out promi- nently. The skin incision can best be made by pulling the skin slightly aside from the vein and cutting to the level of the vein in one stroke. This avoids the danger of cutting the vein in the preliminary skin incision. The vein is then dissected free from the surrounding tissue and a ligature placed ready to tie. A sharp scis- sors is used to make a "V" incision with the apex pointing distaUy. When suffi- cient blood has been obtained the ligature is tied distal to the incision and the skin sewed up with two or three silk stitches. By some it is preferred to lay the stitches in the skin before making the incision in the vein and simply stop the ven- ous flow by pressure. In case of emergency a knife-cut through the skin and across the surface of the vein will perform the duty. Direct Transfusion. — For direct transfusion of salt solution or of drugs into the circulation the technic of exposing the vein, as above outlined, is employed. How- ever, when the vein is exposed and dissected free two ligatures are laid, about 1 inch or more apart. The lower distal one is tied before the incision is made, there- by stopping the flow of blood. A small cannula is inserted through or cut into the vein and tied with the proximal ligature. In the meantime, the cannula must be connected with the solution for injection and all air-bubbles allowed to run out before the cannula is inserted in the vein. The constriction on the arm is then removed, and the fluid, always kept at body temperature, is allowed to run slowly into the circulation — fifteen minutes for 100 c.c. is the time generally used. After sufficient fluid is allowed the cannula is withdrawn, the proximal ligature tied, and the skin sewed and dressed as above described. Subcutaneous Transfusion. — For infusion of salt solution, or of Locke or Ringer solution, an outfit containing the necessary apparatus should always be on hand. The sites generally selected for infusion are under the breast or the exter- nal aspect of the thigh. The needle is generally about 2 to 2h inches long and of not very large caliber. The field of operation is sterilized as for a surgical opera- tion, and the needle, connected with the fluid which is suspended at the proper height, is inserted rather deeply in the subcutaneous tissue. The fluid is allowed to flow slowly, and light massage is made over the area after the fluid enters the tissue. Paracentesis.— Paracentesis thoracis may be divided into two parts: one explor- atory, when the nature of the fluid is unknown, and. second, for the aspiration of a known non-purulent fluid. In cither case, the site of the puncture depends on physical signs of localization of the fluid. After sterilization of the field the needle, attached to a good working syringe, is applied along the upper borders of the rib and gently pushed straight toward the pleura. When the pleura is reached there is a perceptible change in the resistance to the needle, which is then shoved a little further in in order to pierce the pleura. Suction is then made by means of the -> ringe and the nature of the fluid ascertained, [f it is desired t>> evacuate a large amount of fluid the needle is then connected with an aspiration outfit, by which negative 378 OPERATION OF THE HOSPITAL pressure can be produced in the large receiving bottle. Negative pressure may be made either by a suction pump attached to the other end of a bottle which has valves, or in the absence of such an apparatus, a convenient vacuum can be obtained by burning alcohol in a bottle and immediately stoppering it. In paracentesis abdominus a trochar and cannula is used instead of a needle, and the skin is generally nicked with a knife before insertion of the trochar. The incision of choice is about midway between the symphysis and umbilicus, after the operator has made certain that the urinary bladder is empty. The patient is best sitting in bed, propped up on pillows if necessary. In paracentesis abdomi- nus there is some danger of shock, and it is always wise in all punctures to have stim- ulants ready for immediate use. Wet Dressing Box. — Green soap; sterile gauze; sterile cotton; sterile towels; scrub-brushes (sterile); sterile camel's hair-brushes; toothpick swabs; bandages of various sizes; alcohol; ether; tincture of iodin; collodion; oiled muslin; rubber tissue; safety-pins; lap binder. Preparation of Bodies for the Morgue. — Contents of Morgue Box. — Five pounds oakum; non-absorbent cotton; straight pins; stick; morgue sheet; safety-pins; bandages, 2- or 3-inch. The Adult Body. — The body must be bathed all over with soap and water, the finger- and toe-nails cleaned, the hair combed and braided, and the ends tied tightly. The rectum is packed with oakum, and, if the body be that of a female, the vagina will be packed, and a large pad or diaper will be adjusted to cover rectum and vagina. The throat and nostrils must be packed with oakum and the eyes band- aged, with a wad of cotton underneath the bandage to press on the lids sufficiently to keep them closed. If there is a wound following an operation the dressings must be removed and clean dressings put on, with a sufficient amount of packing to prevent oozing. The dressings may be fastened with adhesive plaster instead of a regular binder. The ankles are tied together, and also the legs below the knees. The arms are folded over the chest, and the wrists are tied lightly together with a broad bandage, so that the skin underneath will not be discolored when the band- age is removed previous to burial. There need be no clothing on the body other than the morgue sheet, which must be invariably pinned in front throughout its whole length, the superfluous material being tucked in as a pad, especially over the face. The sheet must be pinned on in such a manner that the face can be quickly exposed. The death report, fully made out, with name and all necessary data, must be pinned over the face to the morgue sheet. All jewelry must be removed from the body, unless otherwise specifically directed, and turned over to the head nurse. The body must be removed to the morgue immediately after the preparations are completed unless there are specific orders to the contrary. The head nurse of the floor must as expeditiously as possible thereafter send the patient's clothing and all other belongings to the office, and take a receipt in detail therefor. The Child. — Children beyond the infant age will be treated as adults. The infant must be washed, and a diaper of gauze and cotton put on. The body must then be wrapped in a thin pad of cotton and gauze, and over this the morgue sheet, as in the case of adults. Premature infants and still-boms must be treated exactly as other infants, and must under no circumstances be sent to the laboratory of pathology except on specific order of the superintendent of the hospital. DEPARTMENT OF PATHOLOGY In this era of pathology, bacteriology, serum, and vaccine therapy the depart- ment devoted to this work in the modern hospital may be said to have four func- tions: First, as an aid to diagnosis; second, as a part of the treatment of disease; third, educational as contributing to the literature of medicine; and, fourth, experi- mental medicine in the employment of animals for testing and proving theories that have for their ultimate object the cure of disease. It might have been said only a few years ago that the chief function of the department of pathology was as an aid to diagnosis; that is not true to-day, and its office in the treatment of the disease after its nature has been definitely estab- lished is quite as important, as, for instance, iii vaccine and serum therapy. Almost the whole literature of modern medicine is made up of the records of patients on the wards of the hospital, and a very valuable part of these records is that which contains the work of the department of pathology. In the light of to-day's progress in medicine and its various branches there could be no literature worthy the name that did not contemplate urinology, bacteriology, surgical, and postmortem pathology. The final function, and perhaps eventually the most important of all, concerns research into the cause and character of disease with a view to its cure, and this research function of hospital pathology is a question of the ambitions of individuals on medical staffs, of the caliber of men, of equipment, and of material in the form of patients with which to operate. Hospital pathology as a well-rounded branch of administration, with definite clinical aims and clear-cut technic, is rather new, and clinicians themselves are just learning its resources and limitations. Its functions are not only to aid the men in the diagnosis and treatment of their cases, but to inspire them with a spirit of investigation, and to open up to them speculative fields for clinical study with its aid. We need not look for very much inspiration in the laboratory from the older medical men, because they are not quite sure themselves, and they do not always know just how far the laboratory can go to help them, therefore the directors of the laboratory must keep in touch with staff members in the medical profession, and must act as a sort of binding link between the laboratory and the bedside. It will not be necessary or profitable for us to go into the question of the extent to which a laboratory department can be carried in the hospital, but rather we might discuss very briefly some fundamental principles of laboratory operation as applied to hospital practice in conjunction with bedside work. Who Shall Do the Work? — The most vital problem concerned in the organiza- tion and operation of a department of hospital pathology concerns the personnel — who shall do the work of the institution? The problem is not a very difficult one, and settles itself in the large, richly endowed institutions that can afford an elabo- rate organization; and, as a rule, in such institutions, which are almost always connected with a medical school, the routine work will be done by senior students under the direction of teachers in the school. The urines can be done by senior students who have passed a period of apprenticeship, and who are always under the eye of a trained analyst. Certain of the baeteriologic work, including the 380 OPERATION OF THE HOSPITAL staining, can also be done by senior students, but very much of this class of labora- tory work is valuable from its educational side only, and very much more largely concerns the workers than the patients involved. Where the chief function of the laboratory concerns the patient, and where that department is maintained as an aid to attending physicians in practice in the institution, medical students are not quite reliable if left too much to themselves. The institution that has for its prime and only function the care of patients has no medical school connection, and only in very rare instances will such an institution be properly endowed to maintain a large pathologic force. Not so very long ago it was the custom to charge patients for laboratory examinations, and it is the custom still in some places, but the custom is becoming obsolete, and it is coming to be a common view that the doctor is entitled to all the aid the institution can give him for the diagnosis and treatment of his case, and urine work, bacteriology, and pathology are coming to be regarded quite as essentially a part of the routine of the hospital as the dietary or good nursing. This innovation of providing labor- atory work without a special charge against patients is throwing the burden of a large expense on the institutions which most of them cannot afford. But the whole question is one of education on the part of the physicians who bring their patients for treatment to the hospital, and physicians are now becoming so well educated in the laboratory side of their profession that they know what good laboratory work means, and they are quite able to separate the honor work and efficient service from all too common guess-work practice. After all, patients go to the hospital in which their medical advisor has confidence, and the day is not far distant when the semiprivate hospital will be equipped to fix a flat rate room charge for all its pay patients, with the understanding that the single charge includes everything the patient will need, including laboratory work. The room charge in such a case will be higher, of course, but the patient's bill will be smaller in the end, and the doctor and his patient will get very much more for their money. This brief diversion was made necessary to emphasize the point that hospital laboratory work cannot be done in a competent and efficient manner by students undirected or by any one not specially trained. Necessarily there must be trained experts in any department of pathology that will be entitled to respect. If the institution is a small one, one man with an all- round training will perhaps give a mediocre satisfaction in the organization of the department and in the checking up of the routine work undertaken by the institu- tion in urines, bacteriology, and surgical pathology. Where the work is more varied and larger in quantity, there ought to be, beside the director, one other trained man, preferably one skilled in bacteriology and work upon the blood, who can also do the Wassermann, Widal, and such other scientific tests. Good interns can usually be intrusted to carry out the technic of spinal puncture, the injection of antimeningitis serum, the antitoxins, and the various vaccines on the wards. A conscientious woman, who has had a medical train- ing, oftentimes gives the highest order of satisfaction in doing the Wassermann tests, vaccines, etc., but the same person, however well trained she may be and however well informed, will hardly be satisfactory in carrying out the Avork on the floors of the hospital, for the same reason that women are not, as a rule, good surgeons. In a good many institutions the interns do most of the laboratory work. Work done by these young men without expert direction is usually a fraud on the physi- cian, who is looking to the institution for conscientious help, and a fraud on the patient, because it is not expert work. DEPARTMENT OF PATHOLOGY 381 There is a way, however, to employ the services of these young men most adequately and efficiently. There is no medical school in the country, with pos- sibly two or three exceptions, that gives a sufficient practical training to its slu- dents to enable them to do the hospital laboratory work after they are graduated without the direction of an expert. In some institutions, however, and this seems to be a rather coming practice, the interns immediately upon their admission to the hospital are sent to the laboratory, and there given practical work for a few weeks in urines and blood work. If the young men have had a good theoretic train- ing beforehand, with the amount of practical application of their training given to them by the better medical schools of the day, they will be prepared very quickly to do the laboratory work on the wards of the hospital as indicated in another part of this section, and especially will this be true if the attending physi- cians in the institution are sufficiently well informed about laboratory practice and laboratory technic to at least prevent indifferent or hasty work. A pretty safe method, with an adequate check on the results, is to have the junior intern, following his preliminary training in the laboratory, do all the work relating to his patients excepting the bacteriology and surgical pathology. By this method the junior intern will have his senior to check him up, and then both of them will have not only the attending physician, but the expert laboratory directors. Most of the better hospitals of the time include, as a part of their staff organi- zations, certain of the younger practitioners, ex-interns, perhaps, who prosecute special work on the wards along the lines of a general scheme of investigation. These men not only bring fame to the institution in which they work by the pub- lication of their researches, not only are of vast benefit to patients by the advanced scientific work they do in diagnosis, and during the progress of disease in the way of guidance in diet, medication, and general or special treatment, but they stimu- late similar activity on the part of the intern corps; where these associate staff members are encouraged it will be found that the whole trend of the institution is toward high ideals, extending to the every-day care of patients, better history- taking, more careful physical examinations, more accurate laboratory investiga- tions as a part of the general practice, and a high order of service in every direc- tion. Where the Work is Done. — In some institutions all laboratory work is done at one central point. Elsewhere a part of the work is done in small laboratories, scattered about the wards or floors of the institution. In the first plan of work all specimens of whatever nature, and from what- ever part of the institution, are brought to the laboratory properly labelled, and accompanied by a request from the physician for the kind and extent of the work he requires. A blank form of this sort is shown in the section on Records of Patients. There are some advantages to this method of operating the service, the chief of which is the reliability of the work done, because it will all be done under the direction and personal supervision of the trained men paid for that purpose. In the second method there is a central laboratory for the more important work, and the small auxiliary laboratories located about the institution, conve- nient to the larger wards, where the simpler work can be done by interns on the various services. This is an excellent plan, and has many advantages and one or two disadvantages. There is a great deal in the personal touch of the attending physician with his patient, and, whether it lie a clinical finding or a laboratory discovery, the physi- cian will usually want to see the result of whatever technic is applied, and he can 382 OPERATION OF THE HOSPITAL only do this where the work is done on the floors where he can see the slide or specimen without going a long distance to the central laboratory. Moreover, there is a good deal in the personal equation as applied to the men doing the work. When a specimen is sent to the central laboratory it is merely a specimen in the abstract, and has no identity, no significance, and no special interest concerning any particular patient or disease, in which case there is greater likelihood that the worker will rush the examinations in a routine way as a part of an uninteresting day's labor. It may be a case of nephritis that has been running in the institution for weeks, and the albumin content of the urine will be the only thing that the physician requires, and he not only wants to know the quantity, but he will want to have some sense of proportions and comparisons from day to day. Perhaps one man in the laboratory will make the examination to-day and another man to-morrow, and the personal equation in such case is entirely lost, and it resolves itself into a purely technical affair, and the work is rushed through ; whereas, if the examination is made on the ward by the intern on the case, for the benefit of the attending physician, the examination can take on a personal relation, and a com- parison can be made from day to day which will not only be illuminating, but an immense saving of time, because of the fact that only an albumin test need be made, which takes a moment; whereas, if it were clone in the central laboratory a complete urinalysis would have to be made every time, which is a vastly different matter, and occupies a good deal of time. Equipment of Ward Laboratories. — These small auxiliary laboratories need not be imposingly placed or elaborately equipped. If the institution is not very new and specially provided with such rooms or spaces a table in a corner of the ward will answer the purpose, or, preferably, a nook in some room or alcove out- side, because the smell of boiling urine is not a pleasant one for patients. The simple reagents for sugar and albumin, a small hand or water or electric centrifuge, a microscope and slides, a blood-counter, a hemoglobin, and a blood-pressure apparatus will be all sufficient. A garbage can with tight cover will be found convenient as an inducement toward neatness. Hot- and cold-water faucets are desirable, but not absolutely necessary. THE CENTRAL LABORATORY It makes no difference how many rooms are employed for the central labora- tory, the' equipment will be practically the same. The urines, the bacteriology, the surgical pathology, and the postmortem processes must be done, and space must be employed within which to do them. For convenience of operation, and so that the people engaged in the different phases of the work can have their own things and be undisturbed while they are working, a series of rooms, however small, should be available, and we can now proceed to the equipment for this work, taking, first, certain of the fixtures that will be common to the whole suite. The Instruments and Apparatus. — The Microscopes. — Perhaps the most important instrument of the laboratory is the microscope, and, as it is to be used for several purposes, one instrument will not be enough; and, even if the most expensive instruments are available for the central laboratory plant, there will have to be other instruments, vastly cheaper, if some of the laboratory work is to be done on the wards of the hospital. The Zeiss instrument seems to meet with the greatest satisfaction for central laboratory purposes, and then, in the order of preference, might be named the Leitz, Spencer, and the Bausch and Lomb. The Zeiss is an expensive instrument, and for nearly all purposes will not be superior to the Leitz microscope, and the cheaper DEPARTMENT OF PATHOLOGY 383 makes of any of these firms will serve all the purposes of the smaller laboratories. A very good instrument for the interns to use can be purchased for about $75. Unfortunately, hospitals not connected with an educational institution must pay import duties on foreign-made microscopes, since the law does not permit hospitals to import free of duty; the laws, too, are very strict, and the government watchful to see that instruments bought by an educational institution that may import them free, are not used by an institution not allowed to import free. The law is wrong, of course, and if any institution ought to be allowed to import needful apparatus free it is the hospital. The Incubator. — The incubator is the most important piece of apparatus in the bacteriologic room, used principally in growing cultures. There are two types of incubators purchasable on the market, one in which the heat is furnished by means of the electric current and the other by gas. Experience has shown that the gas regulators, owing to the variation in the pressure of the gas and the amount of dirt the gas sometimes contains, are frequently difficult of accurate regulation, and, of course, a constant temperature at the desired point is the prime requisite in a laboratory incubator. Quite recently an electric-heated incubator has come into the market and promises much more than the gas type. One of the difficulties in the way of maintaining a constant temperature in these incubators is that most of them have a water jacket composed of copper, and copper is an excellent heat conductor, so that variations outside the mechanism act quickly upon its interior. Experiments are now being made with an incubator heated with electricity that is composed of an outer jacket of wood with copper lining and asbestos or magnesia wool between, and theoretically, as well as in practical service, this promises to solve the temperature-regulation difficulties. Laboratory Sterilizers. — In some laboratories there is a special steam chamber for the purpose of sterilizing culture-media and destroying cultures of pathogenic bacteria. A better method of destruction of these micro-organisms and a better mechanism for various sterilizing purposes is the common autoclave, and the one that seems to be most satisfactory is that made by the Bramhall-Deane Co. This autoclave is very simple in construction, is easily operated, has no complicated sys- tem of bolts and wheels, and can be used either with high-pressure steam from the engine-room, or by means of a small boiler with gas flame located under the mechan- ism. We have dilated more on the good points of the Bramhall-Deane sterilizer for laboratory purposes in the general section on Sterilizers. Another sterilizer of great use in the laboratory is one in which the sterilization can be accomplished by means of steam not under pressure, and a serviceable type of this sterilizer is that known as the Arnold. This type has the door opening from the front rather than from the top. This instrument is almost imperative for the preparation of certain of the culture-media. The Microtomes. — Every laboratory should be equipped with three microtomes: a paraffin microtome, a celloidin microtome, and a freezing microtome, with the necessary attachments for each. For the freezing microtome carbon dioxid gas is the preferable method of freezing tissues, and the gas is best dispensed from the ordinary tank of commerce. This tank can be fastened to the wall lying on its side, or even placed under the table on its side, and the microtome can be con- veniently attached to the table itself. This microtome is usually equipped with small copper tubing, leading from the tank to the instrument with the proper attachments, and this copper-tubing method of attachment seems to be preferable to the direct connection of the microtome to the tank, because of a very much greater convenience in arrangement. 384 OPERATION OF THE HOSPITAL For all work a large, heavy machine is required for accuracy, and there seems to be hardly a choice between any of the standard makes offered for sale. Recently a comparatively new type of machine has been placed on the market, which can be used for either paraffin or celloidin work; this is the "wedge base" microtome. The Paraffin Oven. — The paraffin oven for embedding tissues is essential in the pathologic room, and the particular type of oven that seems to be in favor with the pathologists is that shaped like a box and opening from the front, and in which the paraffin cups are placed inside the box. Floors of the Laboratory. — The floors of laboratories should not be of wood, because they stain easily and are eaten away by acids; nor should they be of monolithic compounds, or stone or tile, because of the far greater glass breakage in a room with a stone floor. The best flooring for a laboratory is linoleum, and more especially the heavy "battle-ship" linoleum, of a single color, a quiet brown or gray. If these linoleums are oiled occasionally with a very little boiled linseed oil, and the oil rubbed in carefully, they do not admit of the eating processes of acids and re- agents to any great degree, and will keep in good order and be presentable for a long time. If it is a new building to be equipped, the concrete subfloor is made with a cove base extending several inches out on the floor from the wall, and then a drop in the concrete amounting to the thickness of the linoleum, which is cut to exactly the right size, and set into this frame with the 5 regular cement sold for the purpose. The Laboratory Hoods. — An important thing to consider in the construction of the hood is the flue leading from it. If the building is high and the flue extends to the roof it may not be necessary to have an exhaust fan at the exit, especially where large burners can be placed at the lower opening. In small buildings, and especially where the flue either does not go to the roof of the building, or where the roof of the building is below the roofs of adjoining structures, it will probably be necessary to have such an exhaust fan to draw out the fumes of gases, acids, and the like. In most of the hoods in the new laboratories there are double openings — the main one at the top of the hood to carry off the lighter gases, and the other, near the bottom, carries off the heavier gases. It is well in such a hood to have a large- caliber lead piping, with holes in the side, and with an outlet leading to the upper opening in the hood for the purpose of oxidation. The framework of hoods may be prepared either of woods treated with a fire- proof paint or of steel coated with some paint that will not be affected by acids, gases, or fumes. It is the feeling of a majority of chemists that wooden hoods are preferable, because, in spite of the paint, steel work rusts, and it is impossible to maintain the hood so that it will be presentable. The bottom of the hood is usually composed of a slab of albaline, and under the floor there may be shelves for keeping various utensils, and for appearance the shelves may be enclosed with small doors. Leading to the hood are pipes for cold water and gas, and a small opening should be left in the floor of the hood for the exit of waste water. Fig. 144 shows an excel- lent form of hood that can be connected with any flue. Laboratory Sinks. — There is now made a porcelain sink, about 2 by 3 feet in the bowl, with a flat bottom, on which acids and stains make but slight impression, and this particular form of sink can well be used in all places employed in labora- tory work. In order that the breakage of glassware may be reduced to a minimum there is a wooden slab made to fit the bottom of the sink, with an end-piece at each end rabbited in so that the board cannot warp. Small auger-holes are bored at intervals in the board, or the slab may be a slatted affair made of crossed pieces, DEPARTMENT OF PATHOLOGY :;n:, leaving open squares '-inch in diameter. This bottom can he painted with a waterproof paint, or with a preparation such as we shall hereafter discuss as a cover- ing for laboratory tables and wooden furniture. Glassware falling on this wooden bottom will not break so easily, and the saving in specimen bottles alone will be considerable. The Test-tube Board. — There is a board for the back of and just over the sink that will be found extremely useful. It is merely a dressed board, perhaps 2 feet Elevati ON- JDECTION -A-B- ~-F , L_/\l\l Fig. 144. — Laboratory room hoods. square, with rabbitted ends to prevent warping, with a lot of wooden pegs driven in so that when the board is fastened over the sink the pegs will point upward at a slight angle as they leave the wood. They should be large pegs, and driven in so that about 2' or 3 inches of the length protrudes. After specimen bottles and test- tubes are washed they can be stuck on these pegs, and they dry OUl quickly and effectively, because the sag of the bottle permits all of the water t<> tun away. This board should also be painted with a stain-proof paint, and will then not be affected by water or the operations of the sink. 25 386 OPERATION OF THE HOSPITAL Tables and Work-benches. — Modern laboratories are no longer lumbered up with high work-tables in the middle of the room, interfering with the freedom of movement on the part of the workers, who must move quickly from one part of the room to another. The tables and work-benches are now nearly always fastened to the wall. They are narrow, as a rule, extending out not more than 2 feet, or even 20 inches from the wall, and they should be of convenient height, so that the worker may sit in an ordinary chair, say, about 30 inches high. There should be wall cases almost everywhere in the laboratory to contain bottles, small and large; otherwise the laboratory tables will always be littered up with an infinite number of bottles nearly all of which will be out of place and impossible to find when wanted. The doors and frames of these cases may be painted any agreeable color. Paint for Tables and Furniture. — It has always been a great problem in labora- tories to find a table or work-bench top that would not be constantly stained with acids and reagents. Marble and stone are impossible, because whatever falls on them, no matter how short a distance, will be broken. Wood, as it is ordinarily treated, or as it is ordinarily painted and varnished, is impossible because of the acids, reagents, and stains that fall upon it. Of late years there has been devised a preparation that seems to meet all the requirements, and the formula is herewith given with the method of its application: Five Solutions (a) Potassium chlorate 10 gm. Copper sulphate 10 gm. Water 1000 c.e. Apply two coats of the hot solution. Allow first to dry before applying the second. Allow to dry and wash with water. (6) Anilin hydrochlorid 12 gm. Water 1000 c.c. Apply one coat. Allow to dry. (c) Potassium bichlorate, 10 per cent, in water. Apply one coat. Allow to dry. (d) Hydrochloric acid, 5 per cent, in water. Apply one coat. Allow to dry and wash with water. (e) Linseed oil. Iron in with hot iron. These five processes are applied, one after another, as soon as dry, a day or two between each coat, and several days should elapse after the oil is applied to allow the furniture to dry thoroughly. Slide Cases. — Probably the most satisfactory method of filing pathologic slides is consecutively, and placing them in long boxes, which are then subdivided in such a manner that the slides will rest on their ends. If in doing this, certain slides, every fiftieth, for instance, have a number projecting free above the level of the other slides, it would be easy, by thumbing the exposed ends, to find ony one wanted. If slides do not accumulate too rapidly a very nice method of doing this is to use the ordinary card-filing case, subdivided as above described. In keeping such records it is necessary, in order that quick access may be had to any par- ticular case, that three records be kept, one in a large book containing consecutive numbers, opposite each of which is to be found the patient's name and hospital number, doctor's name, nature of material and date. This book serves to keep track of the serial numbers. In addition to this book there should be a cross-card DEPARTMENT OF PATHOLOGY 387 index — one index should show the name of the patient, arranged alphabetically, and the other the organ. By this method, if it is desired at any time to obtain the pathologic findings of any case, or the particular disease of any organ, it will only lie necessary to turn to that organ in order to find not only the number of tin- case and the diagnosis attached, but also the name of the patient, and in this way the case histories can lie found. In many instances the index will be used only to find the diagnosis in the ease of a certain patient, and here it is only necessary that we have the name. It is believed that by this arrangement an accurate record can be kept of all specimens coming to the laboratory. Lights for Night Work. — The ordinary gaslight and electric light are wholly unfitted for the purposes of the microscope, and a convenient light for this work is a small white-frosted electric-light bulb, which can be attached to a block of wood and placed in any required position on the work-table, or a Welsbach may be used. These lights must be movable of course. The Dark Room. — An essential part of a good pathologic department is a dark room, necessary, of course, if there is microphotography, and extremely useful for the polariscope. The ordinary dark room of the photographic studio will answer every purpose, and the room need not be a large one. The Postmortem Room. — There seems to be a disposition on the part of archi- tects and hospital administrators to place the postmortem room and the refrigera- tors for the dead in almost any out-of-the-way place not needed for other purposes, and wholly regardless of the lighting and ventilation. That this is a great mistake will become obvious to any one who will take the trouble to visit a number of hospitals. Where there is a well-lighted, well-ventilated, comfortable room in which to work, the postmortem room is one of the interesting places of the insti- tution, and it will be found that when there are no postmortems to be done, the interns, and more especially the younger attending physicians and surgeons, will frequent the room, prosecuting their studies there, anatomically, either on the bodies of the dead or the bodies of lower animals. If the room is dark, ill-venti- lated, and uninviting, no work will lie in progress and it will be a neglected place. Besides good light and good ventilation there should be a good refrigerator, large enough to hold not only the bodies of those who die until they can be removed, but with a compartment to contain anatomic parts. The postmortem room refrig- erator is of some moment, the crates for the box being the most important part. In a great many postmortem refrigerators there is a plain slatted slab on which to lay the body, and it is difficult to get the body in and out on this slab, and gener- ally two boxes are needed or two stools, and it is a back-breaking process. A very convenient mechanism is a double-slide arrangement, on the principle of double-door elevators, where one door goes part way out and in and the sec- ond door goes the other part of the way. The mechanism is on a double se1 of wheels, and the sides of the slab operate in a groove, and act as a lever to hold the body in suspension, even after it is three parts of the way out of the box. The sides of the slab ought to lie of heavy stuff, either metal or strong wood, pref- erably 2 by G inch pieces of oak, the full length of the refrigerator, and the crate is built up between these side pieces. Most postmortem refrigerators are now cooled by nitrous oxid or ammonia pipes as a pari of the general refrigeration scheme of the hospital. Ice can be used above the boxes where there is no refrigeration system. The floor of the postmortem room should beof cement, sloping from all sides to a central trapped drain, which may be placed under the table. The walls 388 OPERATION OF THE HOSPITAL should be of some material that will permit of washing with a hose, and to this end the room ought to be as free as possible from everything excepting the appa- ratus to be used in postmortem work. If there be a small amphitheatre, so that an audience can attend autopsies, there should be at least a 6-foot solid wall between the arena and the audience seats, so that at least the arena can be kept clean and sweet. There must be a sink with a large bowl, stoppered at the bottom, for hot and cold water. It may be necessary oftentimes to wash large organs, and the sink ought, therefore, to be made so it will hold water. In some operating-rooms there is a cold water outlet with hose attachment over the operating-table; experi- ence does not develop a great amount of usefulness for water above the table, and the use of water at that point is disagreeable and oftentimes splashes over the clothing and faces of the people at work. A bucket of water and a large sponge serve the purpose, or, better still, an open-mouth small hose at the side of the table, worked with a self-closing faucet. The Postmortem Table. — Just how the postmortem table should be arranged is a mooted question, and various types have been recommended. A very good scheme is the one used at the Massachusetts General Hospital in Boston. This table is arranged in the form of a box about a foot deep, and either composed of, or covered with, sheet iron. Across the top of this box is stretched iron netting, with rather close meshwork to prevent instruments and tissues falling through into the box below. At the bottom, in the central part, is a large outlet for fluids and water. The water pipe extends through the bottom almost to the top, and is here connected with rubber tubing, which, in turn, is connected with a copper receptacle measuring about 18 inches in length, about 12 in width, and about 12 in depth. The rubber tubing is connected with the bottom of this receptacle, which can be moved to any portion of the table desired. As the water is allowed to flow continuously into this vessel during the postmortem, it will be seen that one great advantage of this type of table is that, regardless of where the vessel may be placed, the overflow will run through the iron meshwork and not over the surface of the table and on the floor, as occurs in so many old-fashioned marble- top tables. The marble-top table as usually made for this purpose is of doubtful advantage, owing to the sloppy appearance which it generally presents, and to the fact that, when a body is on the table, the central opening, which is supposed to allow the escape of fluids, is usually blocked by the body itself, thus defeating the purpose for which it is intended. The placing of a fan at the side of the outlet, such as is done in the Massa- chusetts General Hospital, to suck away the odors which are usually present is a very good scheme, but in many places hardly practicable. The Animal Room. — Every hospital should keep at least a few animals for pathologic purposes, and the larger institutions will, of course, keep many animals of the smaller varieties, like rabbits, guinea-pigs, rats, and mice. Even where no research work is done, and where no educational activities are contemplated, guinea- pigs will often be required in the diagnosis of tuberculosis, for instance, and this work at least is necessary for diagnostic purposes. If proper quarters are provided for these small animals they ought not to be very expensive or give very much trouble — guinea-pigs, especially, increase rapidly and thrive under any sort of decent conditions. The other annuals — rabbits, rats, and mice — do not do so well except under the most favorable conditions. Rabbits are subject to an infinite number of skin diseases and catarrhal affections and epidemics of one sort and another, and, when the stock has to be replenished DEPARTMENT OF PATHOLOGY M.N!) from the outside, oftentimes an epidemic will strike the burrow and destroy them all. Rats and mice eat their young if they are not fed properly, and they, too, are subject to diseases of many sorts. It appears that almost always the darkest, dampest, and dingiest room in the house is selected as the quarters for the animals, and then the hospital manage- ment wonders that it has had luck with its stock animals. All these little animals ought to be kept above the ground and in well-lighted quarters, and their habita- tions ought to lie kept clean. Rabbits, at least, ought to have a runway, and if they have a burrow out in the yard, and are allowed to increase without the advent of new stock from the outside, and are properly fed on cabbage-leaves, new grass, carrots, potatoes, and turnips, they will thrive nicely and keep in good condition. It does not make so very much difference about the size of the stock cages, but there ought not to be too many animals in a cage. A dozen or twenty guinea-pigs will thrive and breed rapidly in a cage 5 or 6 feet long and 3 feet wide, made out of small mesh-wire. A half-dozen rabbits can be kept in such a cage, but they will not breed satisfactorily unless they can get into the ground and have more room and some seclusion. The inoculation cages for both rabbits and pigs are usually 24 inches long, 17^ inches wide, and 15| inches high. The animals, after inoculation, need very little room, and the cages can be kept close together. The room in which the animals are kept ought to be so arranged that a hose can be turned on it, and it should be possible to seal it perfectly so that it can be given a formaldehyd fumigation whenever necessary. Frozen Sections. — Every modern institution that pretends to do surgical work undertakes, or should undertake, to aid the surgeon in the establishment of his diagnosis while the patient is on the table, and so quickly after the tissue is taken that the operator may have the advantage of his finding in the final disposition of his surgical procedure. For instance, there is a breast tumor to be removed. It is axiomatic with surgeons that every tumor of the female breast is guilty of malig- nancy until it is proved innocent, and if immediately after the tumor is removed a frozen section can be made of the tissue at several points of the tumor, and a reli- able diagnosis of innocence can be made, the surgeon will be enabled to close up his wound and limit the operation to the actual removal of the tumor. If the path- ologist finds, however, that there is cancerous tissue or suspicious looking tissue in the specimen given to him, the surgeon will want to invade the armpit, remove any glands he may find there, and remove the breast. Many times where these frozen section facilities are not available, the sur- geon will either be compelled to assume the gravest character of the disease and so prosecute his operation to perhaps dangerous lengths, or he will have to close the wound, with the possibility that he may have to do a second stage as soon a- the laboratory has made its report in a day or two or at some subsequent time. It is true that frozen-section pathology is not nearly so valuable and trustworthy as an examination of tissue done by the longer processes possible in the Central labora- tory of the institution, but, for the immediate purposes of the surgeon, the frozen- section method is imperative. A very small equipment is required for this frozen-section work, and a very small space, enough for a table 2 by 3 feet and a stool for the pathologist, somewhere convenient to the operating suite; under the table he will have his tank of carbonic acid or freezing gas; on the table he will have his microtome, a large dish of water for the handling of sections, a microscope, a box of slides and 390 OPERATION* OF THE HOSPITAL cover-glasses, with the few bottles of stains that he may need. The technic of this frozen-section work is clearly within the realm of the pathologist and has no place here. The Museum. — Wherever surgery is done, or any attempt is made to do inter- esting scientific work, either upon patients or in an educational way, there ought to be a pathologic museum, and, however humble and simple such a room appears, there are a few principles that must be considered, the chief of which is the lighting scheme. Bright or direct fight causes the colors in prepared specimens to fade rapidly, and, therefore, the light ought not to be too great, and it should be indi- rect; even a very dark room may be used for museum purposes, with electric or gas light, to be turned on and off when necessary; or the windows, if the room is well lighted, should be of dark-colored glass or covered with some dark material, such as heavy curtain cloth ; or the shelves themselves may be covered with drop curtains, which will answer the same purpose. The size of the room will be, of course, a question that will depend on the amount of work to be done and the character of specimens to be saved. In a good many hospitals everything is saved, and, where this is the custom, the collection is usually very systematic and the specimens are tabulated and indexed and cross-indexed, and sometimes there is even a triple index, under the head of (a) the name of the patient and number, (b) the organ from which the specimen is taken, and (c) the disease illustrated in the specimen. If the arrangement of specimens is properly done a comparatively small room, with ample wall shelving, will hold an immense number of specimens, and then a double row of shelving may at some future time be erected in the center of the room, leav- ing a walk-way all around. In some hospitals test-tubes are used for museum specimens, such as the appendix specimens, and these test-tubes are sealed with a cork and paraffin, and certain classes of specimens are placed together in boxes or cans and indexed so they can be immediately found. The Refrigerators. — In some part of the laboratory suite there must be a refrigerator, preferably in the bacteriologic room. The size of this refrigerator is not nearly so important as its reliability in temperature. If the institution is large and serum work is attempted there might be a second refrigerator for the se- rums, and if there are two refrigerators the problem of temperature will be a good deal simplified. Most culture-media with contents last longer at a temperature of about 38° F. and up to 40° F. Serums must not be kept above about 45° F. and they often freeze just under 40° F., after which they are worthless. The refrigerator can be connected to the refrigeration plant of the institution, if there is one, and the ordinary regulation of the whole plant will serve all the pur- poses of that refrigerator, but very careful laboratory men find great difficulty in maintaining an even enough temperature and one that can be accurately controlled; they sometimes prefer an old-fashioned ice-box, in which a block of ice will keep to a temperature just low enough without clanger of freezing. PATHOLOGY IN THE SMALL HOSPITAL It will not do any longer for even the smallest and most unpretentious hospital to take the ground that it cannot afford to do pathologic work. Pathology, bac- teriology, urinology, vaccine, and serum therapy are very much more a part of the modern practice of medicine than the drugstore, and the hospital that cannot afford to give its patients these diagnostic and therapeutic advantages cannot afford to exist, and will be a menace rather than a help in the community. But it will not be necessary for a small institution of 25, 50, or even 100 beds DEPARTMENT OF PATHOLOGY 391 to maintain an elaborate pathologic equipment. Perhaps one good man, trained to his work, will be sufficient, with an assistant in the person of an intern or even an intelligent pupil nurse, or, better still, a permanently employed young woman, fairly intelligent in mind, conscientious in method, and skilful with her fingers. Almost the whole expense of such an organization will be the salary of the expert and the renewal of breakages. The original equipment for a sufficient plant under such an organization can be provided for $800 or §1000. One large room will serve the purpose, or a large room and a small one, and the equipment will be pretty well satisfied if it includes an ordinary ice-box, an incubator, a single steam sterilizer, such as the Bramhall-Deane, which costs about §125; a good microscope at, say, S100; one microtome, at $75; one incubator, at $50; a centrifuge, at $50, because a cheaper one will not throw down bacteria; and then a few pieces of smaller apparatus, such as scales, water-bath, water-vacuum filter, all of which are inexpensive, and the necessary glassware and reagents. Such an equipment will not be ample to do a great deal of work, and will neces- sarily be limited as to the broadness of the work, because no man will be found who can give an adequate service on anything like a workable scale in the urines, blood examinations, the technical tests, and at the same time make blood-counts, hemoglobins, blood-pressures, and do the vaccine and serum work on the patients in the institution. However, where the institution is small, there will probably not be more than one or two attending physicians or surgeons who would appreciate the significance of even the modest work outlined here, and it could well be that such a pathologist would have to lead and inspire the attending physicians in the institution rather than be overworked by them. THE DEPARTMENT OF HYDROTHERAPY In this modem day, when the dosing of patients is on the decline, and dietary and physical therapy are on the increase, every institution employed in the care of the sick, and that pretends to scientific attainment, must be equipped with at least a modicum of apparatus for hydrotherapeutic treatment. While it is not the purpose in this book to discuss disease from any medical stand- point, it might be profitable as a prelude to the equipment of a department of hydro- therapy to very briefly consider the avenues along which water in some form is in- tended to be beneficial in the cure of disease. It may be stated broadly, at the outset, that water is employed for one of three primary purposes: First, as a means for the introduction of certain medicines, more especially the mineral salts. Second, as a physical agent, by which the skin and periphery of the body are irritated or stimulated to a point where the blood-vessels dilate as an invitation to large quantities of blood to leave the centers, that is, the internal organs, and thus allow those organs to resume a function that has been greatly impeded by what we call congestion. Third, purely for its mental impression on patients, especially those suffering from some form of nervous disease. There is still a fourth employment of water, namely, that principle used in the tubbing of typhoids, pneumonias, heat prostrations, and the like, where high temperatures must be lowered speedily; but hydrotherapy is hardly to be thought of in this connection, and no special apparatus need be supplied beyond a common bath-tub or wet sheets. The biblical pool of Bethesda was an illustration of medicinal waters, admin- istered to the outer surface of the body, and all clown the ages there have been "springs" and "baths" whose virtues are supposed to reside in certain mineral salts in solution in the waters. These curative waters are scattered everywhere about the earth, and some of them have earned great fame, some perhaps justly, and others because whatever virtues they may have had have been supplemented by carefully devised courses of treatment, diet, and exercise in adroit and skilful professional hands. The school of hydrotherapy began in Germany, and was known as a water cure or "the baths," because patients were sent to towns or to villages in which there were springs of some supposed virtue. Patients drank the waters and were bathed in them. People flocked to Germany from all over the world to take the baths, and they did so because there were many cures effected, and there is no doubt that many of these cures were due to other factors besides the waters and the baths; the family physician ordered his patient to take certain baths at a certain place, and sent him to some particular specialist there; the very fact of this order aroused the patient to a realization that he was a sick man, and the result was that he was in a mental frame of mind when he arrived at his destination to place himself un- reservedly in the hands of his physician and to obey orders. These orders usually contemplated diet as well as baths and drinks. A great many of these people 392 THE DEPARTMENT OF HYDROTHERAPY 393 were in those days, just as they are to-day, troubled with functional disturbances, due either to indiscretion in living, diet, or dissipation, or to the strenuous business lives they were living. Such a patient, placed on a restricted diet, given regular exercises, and drenched pretty well with water — no matter what kind — was almost bound to be benefited. The German waters in this way have become famous for their curative prop- erties, and Germany has built up an immense industry, especially in such cities as Nauheim, Carlsbad, and Baden-Baden. The prosperity of the German watering-places called forth a great number of imitators, and people in all parts of the world began to exploit springs of various sorts, and it made very little difference what was the nature of the water or its temperature, so that it was in some one thing out of the ordinary. In this country there grew up in the neighborhood of several of these springs prosperous communi- ties, the permanent population in which had a common purpose in the exploitation of their springs, to the end that a thriving trade could be worked up with strangers at the hands of the population and of learned men in the medical profession. From time to time efforts have been made to manufacture some of these "waters," and to employ them at the patient's home rather than send him across the earth to secure their benefits; or the actual waters have been bottled and shipped for use, but the other elements of treatment have been usually lacking or carried out half- heartedly, and, therefore, the same amount of good has not come about in most instances. But in all these localities there are great numbers of doctors, and patients are given not only the waters, but more or less careful auxiliary treatment, and usu- ally the success of the place depends even to-day on the adroitness and profes- sional skill with which the medical practitioners treat their patients professionally in other ways besides the waters. Upon the heels of the "springs" and "baths" finally came the era of artificial- ity, in which nature was aped by mechanical invention, and in this way the modern hydrotherapeutic departments in institutional work came into effect. Ordinary river waters were treated and made to masquerade as mineral spring waters; any temperatures could be achieved; calisthenics and athletics could be employed; diet could be regulated as in the watering-places elsewhere. In this way and by easy stages hydrotherapy has come down to us at the present time. In all these years vast experience has been acquired, and it seems that we are just now on the eve of a definite parting of the ways. Charlatanism and mental therapy, working hand in hand, are choosing a ceremonious magnifi- cence of equipment, much mysterious, sleight-of-hand work and more so-called "suggestion." On the other hand, has come to us something of real value in the hands of modern, up-to-date, and honest practitioners of internal medicine, and with these men hydrotherapy means something very real. It is certain that very many disturbances of the brain anil nervous system have their origin in an active congestion in the brain and its membranes, and a tre- mendous number of diseases of every part of the body are due to disturbances of tile circulation, whereby the heart, called upon to do more than its normal work, becomes fatigued. The first effort of nature to help compensate the circulation results in an increase in the size of the heart muscle. This heart dilatation. QJ per- trophy, and a subsequent dilatation changes the relation of the vessels to the valves that control them, and we get what we call heart leaks or broken compensation. In this condition the- heart works hard, but does little, because a considerable part of the blood leaks backward and is not driven through the vessels and into the 394 OPERATION OF THE HOSPITAL arteriovenous stream as it ought to be. All the patient's functional organs become clogged because too much blood remains in them, as in a reservoir, and interferes with their functional activities, and this condition is expressed by a pale, waxy hue of the face and cold, clammy skin and extremities of the patient. Under these conditions medical heart stimulants have about the same effect as whipping a tired horse. What we want to accomplish in these cases is to move the blood in the easi- est possible way, and with the least work of the heart, away from the great central organs of the body and out into the muscles and skin and extremities. And we do this with water under conditions that will so shock the nerve ends that the arteries and capillaries will be dilated and thus invite the blood stream, rather than by remaining contracted repel the stream and dam it back into the centers. The Douche. — Experience has shown that the best way to bring this result about is to employ alternate hot and cold douches, the changes being made so rapidly that the temperature of the body cannot possibly be raised by the hot douche or lowered to the point of chilling by the cold douche. Anything in the shape of a douche, spray, or shower will bring about this result, provided the tempera- ture of the water used either changes rapidly or varies greatly from the temperature of the body. The Nauheim. — Another way to achieve this same purpose is by the applica- tion of either chemic or physical irritants to the skin. One of these methods we have in the so-called Nauheim bath, in which gas-bubbles of carbon dioxid are released on the patient's body while he is in a bath at about or just a little below the normal body temperature. There are certain chemic bricks which when dropped in the water will break up into certain constituent elements, releasing carbon di- oxid gas, and this gas rises as bubbles from the bottom of the tub, attaches itself to the patient's body, and, because it is lighter than water, works its way upward on the skin, irritating as it goes, until it finally bursts into the atmosphere at the surface. Perhaps a cleaner, if not more economic, method of achieveng the same purpose is to employ tanks of carbon dioxid gas, and a nickeled coil can be made to circulate the bottom of the bath-tub, with small pinholes at f-inch in- tervals along its length to release the gas particles. The tank is connected to this coil, and the gas is released at the bottom of the tub after the tub is filled with water at the proper temperature and the patient is placed in it. At the end of ten or fifteen minutes of this sort of bath the patient comes out with the body and the skin and surface muscles full of blood drawn away from the great central organs, and with corresponding relief to the breathing apparatus and the heart's work, because an immense quantity of blood has been coaxed, as it were, away from the centers out into the newly dilated peripheral vessels. Another way of bringing about the same result is by rubbing the patient with sea salt or any other kind of salt, or with any more or less irritating substance, im- mediately after or at intervals during a bath in common water. This method has the disadvantage of applying the irritant to only a small part of the body at one time, unless the rubbing is very vigorous and takes in large areas of the surface, and there is hardly a question that the virtues of mineral baths and salt baths of various sorts are dependent on this very quality of irritating the skin and thus dilating the peripheral vessels, and to this extent, and perhaps to this extent alone, the mineral waters of certain springs are efficacious. Dry or Vapor Heat. — There is another way, besides those mentioned, of increas- ing the peripheral circulation of the blood, and in that way emptying the great central organs of their superfluous supply, and that is by the direct application to the skin of vapor or dry heat. This is dene in the so-called cabinets, or sweat THK DEPARTMENT OF HYDROTHERAPY 395 baths, or "bakes," and there is little doubt that the physiology of this sort of heat action is twofold: first, it has an irritant action, that of heat itself, and thus serves to dilate these small vessels; and the second action is the sweat process of withdraw- ing water from the body, and is a physiologic form of depletion which it will not be necessary for us to go into in more detail; the main point is that the process brings about an increased circulation of the blood away from the great central organs that have been so clogged that they have been unable to perform their functional duties. A good many medical men have begun to use the "bake" in a local way also in cases of neuritis or rheumatism, caused, perhaps, actively by the presence of uric acid or other toxic matter, which, acting as a direct irritant of the nerve ends in the particular locality affected, may give rise to the pain or neuritis or rheumatism. The "bake" in these cases performs the same office, but in another way, that is, it increases the circulation of the blood in the part affected, and that increased blood activity serves to carry away the poisonous matter in the blood stream some- what in the same way that a great rain storm flushes the sewers and cleans out the city. Passive Resistance Exercises. — Great numbers of the people who go to Europe to the baths are men and women well along in years, who have lived sedentary lives or who have dissipated a great deal, either-at the table or in the matter of alcoholic stimulants. They have had functional disturbances of the various organs of the body for many years, but, because of their youth and strength and recuperative powers, they have been enabled for a long time to recover from these periodic or occasional attacks, brought on generally by some special overindulgence, either of work or dissipation. But finally age comes along as a side issue of the seizure, and they are unable to "come back," as the athletes have it. If they are financially able to do so they are ordered by their physicians to travel and go to the baths of Germany or elsewhere, and there they place themselves under the rigid discipline of a doctor, and are ordinarily helped along by diet, depletion in some such way as we have outlined, and flushing with the waters. Eventually there comes a time when these artificial agents no longer serve the purpose. The heart refuses to pick up its work well, the blood is hardly set in normal motion in some one of the ways we have suggested before it again settles into the centers, and the heart, like a great pump with too small a suction-valve, pounds away, accomplishing little. We must resort now to another, a subtler, a gentler, and a less shock-producing method of coaxing the blood away from the centers, and this we do by a process the best known form of which is Dr. Schott's passive resistance exercises. There are a great many movements in these exercises, involving, first and last, nearly every muscle of the body. It will not be profitable for us to go into detail as to these movements. They are treated in exhaustive chapters in all the medical works on the heart and circulation and metabolism. Suffice it to say that the muscles of the body are moved at different times and in varying degrees of activity against an almost imperceptible resistance on the part of the patient, and this gentle work of the muscles calls the blood away from the central organs to com- pensate for the waste of muscular tissue by work, the difference between this and the former methods of evening up the circulation being that this particular process has for its object a more lasting result. These movements are made to take up a great deal of time, beginning with perhaps five- or ten-minute periods and increas- ing from day to day until a half-hour can be devoted to the work, and eventually a considerable amount of exercise can be gained without overworking the heart, as would be the case if it were active exercise performed by the patient himself. Many patients, old men and old women, come for treatment with heart beating 396 OPEEATION OF THE HOSPITAL at 125 per mintue, in a flabbly, sluggish sort of way, and at the end of the day's treatment with these passive resistance exercises the heart will have subsided to 90 or even 80, and its beat will have taken on a better tone and will have become more productive of results. At first this improvement will last for only a short time, but after a while the improvement will continue for many hours, and event- ually the heart will have settled down regularly to the profitable employment of getting the blood stream through all parts of the body. Massage. — Massage is a somewhat different thing, but it is proper that massage should be done in connection with a department of hydrotherapy because its ulte- rior purpose is along the same general line. Massage of a muscle, no matter which muscle, is the working of that muscle involuntarily, so far as the patient is con- cerned. It is passive motion again, and the kneading process employed in massage calls the blood supply to the part, stimulates metabolism, and not only improves the quality of the muscle and increases its usefulness, but it likewise withdraws from the centers the additional amount of blood necessary in the performance of the muscle work, and thus helps in a small way to relieve the clogging of the centers. But massage has another purpose. Generally speaking, in those who are proper subjects for general massage there is a great deal of unemployed fat in the tissues. No voluntary movements of the patient will serve to increase the blood supply in that fatty tissue, and hence, after a while, we have a condition in the fatty tis- sues of the body that might be likened to a swamp where water stands and where nothing happens, either in the water or in the soil. The whole area becomes waste and worthless and unproductive. But the waste isn't carried away because there is no running water — or no flowing blood. To relieve this condition we must bring in some artificial stimulation to increase the blood supply, to carry away the waste- products, and to release the constituents of the fats out into the blood stream that has been brought there, and so get rid of the whole marsh. Therefore, we pinch and knead and punch the area. We "insult" the locality, as the physician says, and blood rushes in as nature's way of coming to the rescue, and in this way we flush out these fatty areas and carry the waste away. Having now considered some of the uses of water in the treatment of disease and the ulterior motives behind its employment, we have to consider the apparatus necessary in the equipment of such a station in an institution. For the small institution with small funds and perhaps little room much may be done with very little apparatus, and that of inexpensive design, such as a large tub for plain or medicated baths, and in which an excellent Nauheim may be given by the use of the chemic carbonic acid gas bricks, and which may be used also to give sea or other salt rubs or so-called "glows." A shower, with plumbing so arranged that it may be quickly changeable from hot to cold and vice versa. A sweat cabinet can be home made: merely a tight box with a hole in the top for the head, and with a few steam coils inside, arranged behind a grating so the patient cannot touch them; a long thermometer protruding from the inside, so that it may be easily read by the attendant. If an "arm-bake" and "leg-bake" are de- sired, these can be made with sliding panels in the sides for the arms, and with panel section in the front for one or both legs, on the principle of the old-fashioned prison stocks. A strong, narrow table 3 feet instead of 30 inches high for purposes of massage. This simple equipment can all be installed in one large room, and, if parti- tions made with canvas hung on nickeled tubing are used, a single operator may care for two or more patients at a time — one in the cabinet, one in the tub, and a third Till'. DEPARTMENT OF II VDItOTIIKHAPY 397 hands on the massage table. Fig. 115 shows this arrange- by canvas few chairs under tl perator': iiicnt very well. There ought to be a second room with rest couches, separated also 1 >ar1 i I i< >ns. A few 1< ickers for patients' clothing and the bath-robes and a will complete an unpretentious but very ser- viceable equipment. For the large general hospital, the insane asylum, or the pretentious sanatorium, where a more elaborate equipment is desired, there should be at least three rooms, the most im- portant of which is the douche room, because here must he installed the douches, needle sprays, showers, and the salt baths. Fig. 146 shows an assemblage of these devices. The difficult essentials for success in this room are (1) a properly constructed control table, (2) a lead basin at least a foot deep over the whole floor, with drain and slatted floor, and (3) properly constructed walls that will with- stand steam vapor and hot and cold water. Control Table. — It will be rather super- fluous to go into a description of a control table, because the makes of the different manufacturers are practically alike. The tables are usually made of marble, with nickeled finishings. There is a mixing cham- ber on each side in the interior, and these lead to the various sorts of outlets — that is, the douches, needle spray, shower, and the various sorts of baths. Some of the tables have an ice-water connection, besides the usual hot and cold, hut most of us find this ice water wholly superfluous, excepting perhaps in the hot climate of the South, and even there there is usually a great enough difference between the hot and cold water to obtain all the shock necessary to the system. The temperature of the water is regulated through the mixing chambers by sliding valves operating on regu- lating levers in the face of the apparatus. There is a douche spout coming from each mixing chamber — that is, one on each side of the apparatus— and it is from these we obtain the alternating hot and cold douche. There are two thermometers, one on each side of the apparatus, and each one connected with its mixing chamber, for indicating the tem- perature of the water as it passes through the chamber. In some of the newer tables there are also two electric t herinomelers. the temperature device resting in (he mixing chambers, and the electric controls operating a bell, through an ordinary dry cell battery: this electric mechanism is used as a thermostat and as 398 OPERATION OF THE HOSPITAL an alarm, to indicate the maximum and minimum heat and cold points for the protection of the patient. The details of the control table are so nearly alike in all the makes of apparatus that the differences of mechanism between the various varieties need not greatly concern the hospital administrator who proposes to purchase an apparatus, and his chief anxiety must be directed to obtaining a mechanism of installation that can be absolutely depended on in the matter of temperatures. All the makers of this control table claim exceptional devices for controlling the temperatures to the smallest fraction of a degree, but it is the experience of most of us that none of them live up to the claims made for them, and there seems to be only one method by which the temperatures of the water in the two sides of the con- trol table can be maintained over any considerable length of time, and that is by arrangement of the plumbing outside the table itself. Where the control table is fed from a common circulating system it is impossible to control the temperatures. Fig. 146. — The water-room of the department. For instance, we may desire a temperature on one side of the table of 105° F., and we manipulate the temperature lever until we fix that temperature definitely by the introduction of hot and cold water into the mixing chamber on that side; but presently the faucets at some remote point in the circulation of the cold water are turned on, which has the effect of immediately dropping the pressure all along the line, including the mixing chamber, and, therefore, the relative pressure of the hot and cold water are changed. More hot water rushes in because the cold water pressure is reduced, and the temperature runs up so rapidly in some cases as to burn the patient before the alarm is given, and the contrary may also occur, that is, the hot water may be drawn upon and the pressure reduced, allowing a greater amount of cold water to rush in and the temperature is lowered rapidly. In a great many instances the alternating hot and cold douche, in fact, any of the various forms of control table therapy, are used in connection with nervous patients, and such a patient is not likely to be improved if the water in the bath is THE DEPARTMENT OF HYDROTHERAPY 399 allowed to jump almost instantly from body heat (98.6° F.) up to 120° or 130° F., or from body heat down to 55° or 65° F., and oftentimes great harm is done by fright to the individual and a shock to the system, and any good that could possibly be accomplished by the use of the apparatus is destroyed. So important is this tem- perature regulation that we should go clear back to the power-house for our supply, from which the pressure will always be the same. It will be all the better for the regulating effect if the hot- and cold-water pipes can come directly off the power- plant reservoir, and are entirely independent of any circulation pipes whatsoever. Needle Spray and Shower. — This device is not only a very popular, but a most efficient method of employing water in the treatment of disease. There are four columns of tubing, rising square-like, each equally distant from the other, with the pipes bent to converge at 6 or 7 feet from the floor. Beginning knee high, and at intervals of 6 or 8 inches, there are 3|-inch rose sprays leading from each point for the needle spray and there is a shower at the top. The rose sprays are set in ball-bearing joints, permitting a free movement to fix the direction of the small streams. While all the manufacturers of control tables are making sincere and serious and progressively successful efforts to improve their devices, it seems that the J. L. Mott Co., of New York, has, up to the present time, given the matter more atten- tion than others, and has produced a mechanism of better workmanship and of more perfectly working parts than others, and capable of a more certain control. We show in Fig. 145 a very well designed hydrotherapeutic suite that may be elaborated or contracted to conform to any special conditions desired. THE HOSPITAL PHARMACY Equipment of the Drug Store. — The question of drugs naturally is not nearly so important as it was a few years ago; indeed, there are many physicians and surgeons, especially the latter, who confine their medical prescriptions almost exclusively to an occasional placebo or to a quieting potion following some severe surgical procedure. In the medical department many of the foremost practitioners, having turned their attention to metabolism and to the modern view-point of the nature, etiology, and cure of disease, rely almost wholly upon the dietary for their results, with such aids as they may receive from a careful direction of the habits, rest, and exercise of the patient, and some form of mental suggestion. In the maternity department medicines are very little used, with the exception of an occa- sional aperient or some outward application in the case of the mother, and, so far as the baby is concerned, if the institution could be entirely free from medicine of every sort the newborn baby would probably fare better. In the children's department diet has come to take the place almost exclu- sively of the medication of a former day. Milk and milk formulae, cereals, and soft diets generally are the treatment that are relied on almost exclusively by the modern pediatrician. Again, the great drug houses and chemical manufactories are compounding tablets, pills, and quasi-proprietary medicines of such accurate value that the former necessity to make up these prescriptions in the pharmacy of the institution no longer exists. And yet every hospital and similar institution must have a drug supply and a place in which to dispense the drugs, and a few pertinent questions arise concern- ing the equipment and conduct of this necessary feature. Where in the institution shall the drug store be? Shall the medicines be dis- pensed directly to the patients from the main drug store or from auxiliary medicine cabinets on the floors? What fixtures shall be used in the drug store — what kind of medicine containers? What kind of labels shall be used in the drug store and in the medicine cabinets on the floors? What shall be the extent of the drug supply? Must large quantities of medicines be bought and kept, or small? If medicines are kept in cabinets on the floors and adjacent to the wards, must these auxiliary sup- plies be large or small in variety? These are some of the questions that present themselves. Without much reference to the order in which these questions have come up, let us discuss them briefly. In the first place, the generosity of the drug supply will depend on a number of things, as, for instance, the character of the institu- tion, the kind and variety of its work. If there are a great number of departments, or especially if there are a great number of medical men attending the institution, it will be necessary to carry a considerable chug stock, because it is almost impossible to get medical men to agree on the -dosage and forms of medicine they are to use. This question is vastly simplified if the institution is a public one, where there is a good deal of sameness in the character of the diseases treated. Sometimes in such a case a few formulae can be employed, and the whole medication of the insti- tution confined ■within the bounds of a dozen prescriptions, put up in large quanti- ties, and dispensed by numbers on the bottles. It is not the staple medicines that 400 THE HOSPITAL PHARMACY 401 cost the money in the institution drug store of to-day; it is the vast variety of pro- prietary medicines that must be bought for individual cases to please the doctor who has a private patient on his hands. Oftentimes we must pay seventy-five ciiits or a dollar, sometimes four or five times that amount, for a sealed package out of which one or a very few doses are used. And this question of whether a large or small stock of drugs must be kept is dependent very much on the loca- tion of the institution. If it is in a large city or near a wholesale drug house, where an emergency medicine can be had quickly, the variety of the stock necessary to be kept will be very greatly simplified. There is the ethical question also that must lie settled before we can undertake to determine the extent of the stock to be kept, ami it is whether or not the attending physicians in the institution shall be allowed to have entire freedom in their prescription writing. A physician can almost break up an institution, if he has considerable practice there, and allows his fancy to run riot in the way of medicines. On the other hand, who shall say whether the ingredients in a given prescription are simply a fad on the part of the doctor or are actually necessary to the well being of the patient? Just here there seems to be the greatest possible need that the medical staff shall work in harmony with the necessities of institution economies, and where this harmony exists there will hardly come a question as to whether or not the doctor may have the medicines he prescribes. Then the next question is, What quantities of a staple medicine, such as glycerin, quinin, carbolic acid, castor oil, linseed oil, flaxseed meal, and the like, are to be kept? There are two phases of this question. The first concerns the keeping qual- ity of the medicines. If, for instance, it is glycerin, that can be very well kept if propery contained; one may lay in a large supply occasionally. There are other medicines, however, that must be purchased in very small quantities, as needed, such, for instance, as hydrocyanic acid, apomorphin, and all its salts and prepara- tions, and nitrate of silver, crystals or molded. There will often come an occasion such as this — a physician will prescribe half a dram of a certain medicine that must be bought in a sealed package costing, say, $5 a pound, and it will be necessary to purchase the whole package or to pay 25 cents for a dram. The question comes up which is the more economic. Undoubtedly, if the medicine is one which is very rarely employed, or likely to spoil in keeping, it will be more economic to pay 25 cents for the amount actually required than to buy a whole unbroken package, which may never be used again or kept beyond its keeping power before it is called for. ( M'tentimes the druggist of the institution will be warned by his wholesale house that a certain article is going to presently advance, as, for instance, when the law- went into effect in this country prohibiting the adulteration of glycerin, immedi- ately the price of glycerin almost doubled. Many institution pharmacists take ai [vantage of the certainty of the advance in price and lay in a large supply. There will frequently be like periods in regard to other drugs, and the institution will have an opportunity to lay in a large supply at sometimes one-half the price they would have to pay a little later. If it is a drug that will keep well, of course it will pay to lay in the larger amount. These main thoughts will probably suffice as to the drug supply itself. Let us now consider the fixtures in the drug store. Glass and metal and marble make beautiful fixtures for a drug store, and if they be supplemented with a white tiled floor we have a most attractive room. But, in the interest of the greatest useful- ness, we must forego the question of ornamentation that would be secured in these pretty fixtures. A drug store is a place of bottles, and bottles break easily when 402 OPERATION OF THE HOSPITAL coming in violent contact with metal or marble or other glass, and it may be questioned whether the clean look of this metal and marble furnished drug store is actual or apparent. There is no doubt that many acids stain marbles and corrode metals, and it will not be very long before the drug store that started out so beau- tiful will be a place of spots and stains, and, where glass shelving and marble tables are employed, the metal screws and rivets and other fastenings will loosen eventually, especially those parts that come in jarring distance of the work counter, where the mortar and pestle are used and where unguents are rubbed up. On the other hand, well-seasoned, substantial wood fixtures, well painted and varnished, will keep in good order for a long time, and they can then be repainted and revarnished to make them as good as new, and there are very few medicines and even acids that damage wood as much as they do metal and marble, so that wooden fixtures in a drug store, and even the tops of the work tables and counters, will last longer and look better if made of birch or maple. And the same will be true of the floor- ing; tile is very pretty when new, but is easily stained by certain drugs, and the expensiveness of a concrete floor is not told in its first cost, but rather in the tre- mendous breakage, due to falling bottles, glass stoppers, glass utensils, and the like. The next question that will present itself is the labels for the bottles, not only for the drug store, but for the medicine cabinets on the floors. This looks to be rather a trivial matter, but frequently the cost of labeling the bottles in an insti- tution runs up into many hundreds of dollars if the work is done in a permanent and attractive manner. Ground stoppered glass bottles, with etched or glass labels, and properly labeled ointment pots cost on an average about 40 cents each, or, for the hundred articles that go into each floor cabinet, about $60. In some hospitals gum labels with paraffin covering are used, or even the plain gummed labels, without any protective covering at all. For laboratories, or when only one or two careful, scientific men are to handle them, this may be sufficient, untidy as it is, but where bottles must be handled by undergraduate nurses who change frequently, and when a mistake in the reading of a blurred label may spell the death of a patient, it will not do at all. The next question that will arise concerns the dispensing of medicines to the patients; that is, the character and location of auxiliary medicine cabinets about the institution. Some few years ago a hospital architect somewhere designed a medi- cine cabinet that was most attractive. It was made of metal, set into the wall at a convenient location near the ward, or in some instances in the ward, and was made up of two compartments, with a marble slab 30 inches from the floor as the bot- tom of the cabinet; and the upper part was divided into two sections, one large, to contain the great bulk of the commoner medicines, and a small compartment with a separate door. The shelves in the cabinet were nearly a foot deep, and a great many medicines could be carried in the cabinet by setting the bottles several rows deep. The attractive feature of the whole arrangement was the lighting scheme. The small cabinet inside the larger one was supposed to contain alkaloids and poisons generally, and a red light, supposed to be the danger signal, was turned on automatically when the door was opened. A white light was turned on auto- matically when the double doors of the main cabinet were opened. The marble slab at the bottom of the cabinet had a basin and faucet about the middle of it, with hot and cold water. The whole arrangement looked most attract- ive, and was one of the most deceptive things imaginable. The presence of the red light indicated, in the first place, that there was need of warning somebody presumably ignorant of the character of the drugs kept in the case, and the genius THE HOSPITAL PHARMACY 103 who designed the apparatus probably expected patients to go there and help them- selves to medicines. The depth of the cabinet, providing for several bottles dec]). made the whole thing unusable, because, as a rule, nurses who want medicines cannot take the time to remove half a dozen bottles before they get the one they want, and, as a rule, the nurses will not even take the time to see if the medicines arc in the cabinet; they will order new ones from the main drug supply, so that it can well happen that there will be three or four different bottles of a certain medi- Fig. 147. — Medicine case. cine in the cabinet at the same time. The glass shelves of the cabinet reached out to the miter edge of the marble slab, placed there for the purpose of being Used as a work table to hold the medicine trays, and the fact that these shelves project over so far makes the marble slab unavailable for use. Fig. 1 17 shows a different sort of medicine cabinet. This cabinet was designed for the Michael llee-e Hos- pital. The illustration is good enough to show all the details of the cabinet, and it will, therefore, need no description. The only lighl in the cabinet, and the oiil\ 404 OPERATION OF THE HOSPITAL light needed, is a white light set into the top. The shelves are 4 inches deep, and will hold only one bottle in depth. The sink and basin are off to one side of the marble work slab, and the slab is 16 inches deep, leaving plenty of space to set the medicine trays. The space under the work slab is made up of shelves on one side and a cupboard on the other. This cabinet has been adopted in a large number of hospitals, and it is giving perfect satisfaction. We may go out of our way here just long enough to suggest that these medicine cabinets should never be in the wards, except in children's hospitals or wards, in which case it is necessary for the nurse to be always in sight of the patients; then the cabinet should be kept locked or closed with an automatic fastener. Many of us can remember the time when each patient's medicine was kept on a small table at his bedside, and he was expected to take his medicine without bothering the nurse about it. This will not do any longer, because patients are wholly irre- sponsible regarding their own necessities; therefore, in every well-regulated insti- tution there are medicine nurses, and patients are never permitted to handle either their own or other patients' medicines; indeed, many patients have committeed suicide by the ease with which they could get poisonous medicines, and many patients have lost their lives through the irresponsibility of other patients who undertook to dose out the medicine to them. If it is a very small hospital, or a very small floor or ward, it will not take very long for the nurse to get round periodically to give patients their medicines, and, if it is a large area to be covered and a large number of patients to be served, there ought to be a nurse charged with the respon- sibility and detailed for the purpose of giving medicines. There is a good deal to be said on the question of the location of medicine cabinets, the responsibility resting upon the hospital in the matter of giving medicines to patients, and the care and technic with which medicines should be given. Modern medicine has brought into use many serums, antitoxins, and vaccines, and these things need to be kept at certain low but regular temperatures if they are to be relied upon, and this makes it necessary to have an accurately controlled refrigerator in or very near the drug room. If the temperature is permitted to run too low these biologic preparations will be destroyed, and if it is allowed to go too high they will be destroyed even more quickly; about 40° F. is usually considered the best temperature, but it must not be allowed to vary. In large institutions these goods may be kept in the refrigerators of the laboratory of pathology, but they are better kept with the drug supply, so they will not be likely to be mistaken for other things in the laboratory refrigerator not intended for patients. HOSPITAL DIETETICS There are, or should be, three chemists' shops in every hospital. One is the drug store, in which prescriptions for medicine are compounded; the second is the milk laboratory, in which prescriptions for milk arc compounded, especially for sick children; and the third is the diet kitchen. Of these three, undoubtedly the department of dietetics is the most important, because medicines are becoming less a factor in the care of the sick, and, in any event, their preparation is a thoroughly settled profession; and, in a final analysis the sick children could be fed on mothers' milk, or pure fresh cows' milk, or the milk of some other animal, like the goat. But the dietary for the adult has become of vast importance in the treatment of disease, and many of the great medical men of the day are almost confining themselves in the treatment of disease to physical and dietetic therapy. It is no concern of the hospital administrator what diet is prescribed, but it does concern him that the doctor shall have for his patient precisely what he orders in the way of a diet. In nearly all institutions there are prescribed diets, as, for instance, a non- nitrogenous diet, a diabetic diet, a salt-free diet, and so on, and these printed diet lists are usually hung in conspicuous places in the kitchens and serving rooms, and every patient in the institution will be fed according to one or the other of them. The unfortunate thing about our attempts to administer an efficient dietary in an institution is that the principles of biology and physiology and the science of dietetics are themselves in an evolutionary stage, and the doctors do not agree; and, still more unfortunately, some of the doctors when they prescribe, for in- stance, a non-nitrogenous diet, expect the patient to be fed on food that con- tains no nitrogen; manifestly, this is impossible, because all food materials con- tain nitrogen or the making of nitrogen. These same doctors who prescribe a diabetic diet expect their patients to have a diet entirely free from sugar; this, again, is impossible, because all diets contain sugar or some sugar-former to a cer- tain extent. The diet lists of all hospitals, therefore, are merely relative, and arc confined to such articles of food as contain a minimum of the interdicted constituent, whatever ttiat may be. Furthermore, the manner of preparation of foods plays an important part in the availability of their nutritive constituents — that is to say. in the cooking of meats the temperature may be brought to so high a point that the proteins will be coagulated past the possibility of breaking up, and will thus be lost as an available nutriment; the carbohydrates may not lie sufficiently cooked to soften the intercellular tissue, so that the digestive agents can reach the actual value within to make that available. Again, new choline compounds are some- times formed in the processes of cooking, and these may be important factors to aid or retard digestion. So it will not do to prescribe foods taking their chemic ratios for granted, as we do in medicines from the pharmacy; we must look veiy much further ahead, to determine not only what the particular food is, but all its chemic and physiologic value. It is a peculiar fact that, while medical science has progressed tremendously in the fields of metabolism, and has reversed many beliefs of a former day. we still employ those sacred diet lists that were revered twenty years ago. No1 only that, 406 OPERATION OF THE HOSPITAL while the laboratory of to-day has placed on record a distinct recognition of vast differences between individuals in the matter of food assimilability, we, in the clinics, go along prescribing three or four diets, as though all individuals were alike, and there were only three or four diseases in the world. In a fortunately long- forgotten day every hospital had its half-dozen gallon bottles of formulae on the shelves of the pharmacy, and it was a rare case and a brave doctor that needed to go outside of that precious coterie of nostrums. That isn't quite true to-day; prescriptions are written and compounded for individuals, not classes, and to meet the actual conditions of the particular case, and not to meet the requirements of a type. CALORIC VALUES IN DIET Nearly all doctors who practice in our institutions know, in a general way, that a full diet for a well person at hard work means about 3000 calories daily when chem- ically analyzed; that a well person not at work can live on considerably fewer calo- ries, and these caloric values are figured out with a pretty general uniformity for sick people of various ages and suffering from various diseases, and if we could feed our patients indiscriminately in calories, according to the doctor's orders, the question of hospital dietetics would be reduced to its simplest form. But digestion is to a great extent a process of oxidation; one person may be capable of oxidizing and assimilating food material much more completely than another; most certainly this ability is affected by manner of living, age, occupation, physical condition, habits, and constitutional peculiarities. Again, even a well person will not require the same number of calories at different seasons of the year, or in performing differ- ent kinds of labor, or in different environment; so that, no hard-and-fast rule can be laid down for measuring foods in calories, even in conditions of health, how much less so in varying conditions of disease? Moreover, caloric values take no account of interdicted chemic constituents of food, except in a very limited degree, and if a physician undertook to feed his diabetic patient in calories the hospital diet kitchen might make up a large percentage of the prescribed allowance in a sugar- bearing food. If, on the other hand, we take the remaining horn of the dilemma, and undertake to select a diet for any case or for a class of cases by the thumb-rule method of printed diet lists, we must ignore entirely the part that individuality plays, and depart quite as far from a scientific basis as though we had taken the route of the calories. If, therefore, we, as hospital caterers to the medical profession, undertake to invade the realms of physiology and chemistry in the conduct of our dietary, we find ourselves under the necessity of reckoning with each physician in the insti- tution in a different way, and of becoming involved in a difficult maze of chemistry and physiology and figures with each individual patient; it is manifestly impossible to do this; it is also quite unnecessary. It is the doctor's business to prescribe medicine for his patient, and quite as much so to prescribe a diet. The hospital will be delivering all that can possibly be expected of it if it carries out faithfully and intelligently the doctor's orders. It is well enough to have diet lists, because there are a great many physicians who will not take the trouble or time to prescribe a scientific diet, and there are many who do not know what a scientific diet is. We shall have occasion to use the thumb- rule diet lists with many practitioners, but there are a few scientific men in every community who do know what they want in the way of diet, and whose results in the feeding of the sick entirely j ustify us in making every effort to carry out their orders. HOSI'ITAL DIETETICS 407 This brings us to the middle, and undoubtedly the straight and narrow way thai leads to the future of scientific diet, the individual prescription for the individual case, and thus we come hack to our starting-point, that most important of .-ill chemists' shops, the diet kitchen. The main question is. How shall we create a system that will prove efficient in serving a special diet to every patient in the hospital who needs it, and pre- cisely according to the doctors' orders, continued over any period of time that it may be required? The answer deals entirely with the personnel of the diet kitchen. THE ORGANIZATION OF THE DIET KITCHEN It makes no difference whatever whether all the food is cooked in the large hospital kitchen, or whether the staple articles are cooked there and the special articles prepared in the diet kitchen, or whether all of the food shall be bought for, Michael Reese Hospital Special Diet Record Admission No Policial Location Intone Date of Admission Special or Floor Nurse Diagnosis Special Diet Nurse Special Diet for 191 BREAKFAST ART.CLE „„s™, <*»„„ ass cSrsa -•«"• Hydrate «■ "" ~* c-lon. ■— *■ TOTAL, DINNER Fig. 148. sent to, and cooked in the diet kitchen. These things are all of economic value only. The technic of the serving department is the essential thing. In the very few institutions in this country that really aspire to a scientific dietary the various classes of diets are distributed among the persons employed to prepare the trays, and these persons are held to a strict accountability for what goes on them. This presupposes, of course, thai tin- hospital discipline is rigid enough to maintain invio- late a tray that has linn prepared in the diet kitchen until it reaches the patient for whom it is intended. For instance, all diabetic trays will be assigned to one nurse at work in the diet kitchen. When a doctor prescribes a diet in detail for his patient, she will merely till the prescription and prepare the tray down to the lasl teaspoon, to say nothing of every item of food. In cases of patients whose phy- sicians merely prescribe a diabetic diet, she will prepare the meal composed entirely of articles taken from the diabetic list at hand. Each tray, when completed, con- tains the name of the patient and his bed number or room number, and the tray will 408 OPERATION OF THE HOSPITAL not again be added to or subtracted from in the slightest particular until it reaches the patient. This naturally presupposes a prompt service in the transportation of trays from the kitchen to the patient, else, however satisfactory the tray may be from a scientific standpoint, it will reach the patient cold and in bad order, will be unappetizing, and the patient will not eat the food. Nor is it sufficient that we get the prescribed meal to the patient in an attractive condition, every article carefully weighed down to the gram or even grain; our part is not completed until the tray is returned to the nurse who set it, and who is now to weigh back every particle of the "left-overs," and enter the total actually consumed in the nursing or diet record of the day. However important or unimportant the old diet list may be, the con- veniently arranged diet slip, that will permit a quick and comprehensive setting ^**.j fc .M!5S. HOSPITAL Kami. _ mm! _r*»» SPECIAL... P. !A?J1TE.5 CHART ■DECEMBER 1910 5 6 7 8 9 10 11 \z 13 14 IS 16 17 18 19 FOOD Meat 250 Eggs 200 Vegetables 300 27oo 237-4 Butter ISO Bread 75 Potatoes OatGruel 600 Protein 7*7 54. 36 Fat 166.6 8.) 276 Orb'h'tf 49.7 102.6 16f> Nitrogen 11.9 8.6 6.0 CAL0RIE5 22A-6 717 3393 URINE Amount 2^0 2730 2360 Spec.Grav. 1040 1030 7022. Sugar % ZX 27 .82. Sugar Gms. 53 737 I