'0 CoUege of Pi)j»gictang anti ^urgeong i^N Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/healthyhospitalsOOgalt HEALTHY HOSPITALS Sm DOUGLAS G ALTON Bonbon HENRY FROWDE Oxford University Press Warehouse Amen Corner, E.G. H. K. LEWIS 136 GowER Street, W.C. MACMILLAN & CO., 66 FIFTH AVENUE HEALTHY HOSPITALS OBSERVATIONS ON SOME POINTS CONNECTED WITH HOSPITAL CONSTRUCTION SIR DOUGLAS GALTON Late Royal Engineers, K.C.B., Hon. D.C.L., LL.D., F.R.S., Assoc. Inst. C.E., M.I.Mech.E. F.S.A., F.G.S., E.L.S., E.C.S., RR.G.S., &-c. Forfnerty, Secretary Railway Department Board of Trade Assistant Inspector-General of Forttficatio7is Assistant Under Secretary of State for War Director of Public Works and Btiildings WITH ILLUSTRATIONS AT THE cLaRENDON PRESS SOLD BY HENRY FROWDE OXFORD UNIVERSITY PRESS WAREHOUSE, AMEN CORNER, LONDON AND BV H. K. LEWIS, 136 GOWER STREET, LONDON, W.C. 1893 PRINTED AT THE CLARENDON PRESS HY HORACE HART, PRINTER TO THE UNIVERSITY o —mi o to CD LO PREFACE The object which I have had in pubHshing these notes on Hospital Construction is to place on record those principles which ought invariably to be followed in every good hospital, and to point out those condi- tions of construction which according to recent practice represent the minimum standard required to be fol- lowed in building a new hospital. These notes do not embody the detailed require- ments of hospitals for special diseases, which may entail in some cases separation of patients, in others special curative adjuncts. They are limited to explaining the general principles upon which healthy construction must be based. Fortunately the tendency of the modern hospital architect is not to be content to accept the dicta of his predecessor, but to endeavour always to improve upon former practice ; and a great development in new methods of hospital construction has been the result. This tendency has however the drawback, that it has not invariably added to the hygienic perfection of the structure ; indeed in some recent palatial buildings it has been very detrimental, and it has in every case added to the expense of hospital construction. It seems therefore desirable to bring the fundamental principles which should govern hospital construction vi Preface. prominently before the hospital architect as well as before those who are concerned with proposals for new hospitals. If simplicity of design is the main object which the architect keeps in view in following out these principles, the cost per bed of new hospitals would certainly be much smaller than has been the case in many of those which have been recently constructed. This question possesses especial importance at the present time, because the prosecution of sanitary measures and the development of sanitary progress, consequent upon the institution of County Councils over the country, render it probable that a large number of new hospitals for infectious cases and others may ere long have to be constructed. In pursuing this object it has been necessary to consult a large number of authorities, both English and foreign. Among these authorities may be specially mentioned Dr. Mouat and Saxon Snell, Toilet, Leroux, Surgeon-General Billings, Burdett, and Herr V. Kohler, Pistor, Bohm, and many others. As it would have been inconvenient to refer in the text to every book from which information has been sought, it has been thought preferable to append a list of many of the principal works w^hich have been referred to in the compilation of these notes. DOUGLAS GALTON. 12 Chester Street, Grosvenor Place, London. August, 1893. CONTENTS PAGE CHAPTER I. Preliminary 1 CHAPTER II. Defining a Hospital ........ 9 CHAPTER III. Site 21 CHAPTER IV. Conditions which vitiate the Air in an Occupied Room . 37 CHAPTER V. Quantity of Air necessary to mitigate these Conditions 47 CHAPTER VI. Purification of Air 62 CHAPTER VII. Movement of Air ''^ CHAPTER VIII. Warming ^^^ CHAPTER IX. Warming (^continued) 11'* CHAPTER X. Warming {continued) • .121 viii Contents. PAGE CHAPTER XL Lighting 138 CHAPTER XIL Some of the Methods in which the before-mentioned Principles have been applied in Hospitals . . .145 CHAPTER XIIL The Ward Unit — The Wards 174 CHAPTER XIV. The Ward Unit [continued) — Ventilating Inlets and Out- lets, Windows, Doors, Walls, and Floors . . .197 CHAPTER XV. The Ward Unit {continued) — Ward Offices , . .213 CHAPTER XVI. Aggregation of Ward Units 224 CHAPTER XVII. Administrative Buildings ....... 239 CHAPTER XVIII. Observations on some Points connected with Hospitals for Incurables, Children's Hospitals, Convalescent Homes, and Infectious Hospitals 254 CHAPTER XIX. Lying-in Institutions . . . . . . , .265 CHAPTER XX. Remarks on Temporary Structures, and Conclusion . .275 Index 283 LIST OF SOME OF THE BOOKS CONSULTED IN THE COMPILATION OF HEALTHY HOSPITALS Angus Smith Baldwin Billings BiNNIE Blyth BOHM . BOTTGER Box . Briggs BURDETT Carnelley Carnelley and Mackie Carnelley, Haldane, and Carnelley and Wilson . Clifford-Smith Corfield .... curgenven Curschmann UND Deneke Dawson .... De Chaumont . DONKIN Duncan Erichsen, J. Eric Farr . Frankland Galton, Sir D. Air and Rain. Steam Heating for Buildings. Ventilation and Heating. Mean or Average Rainfall. Manual of Public Health. Instruction fiir die Behandlung des Ventilationsapparatus. Das Kochsche Institut fiir Infectionskrankheiten in Berlin. A Practical Treatise on Heat. On Rotary Fans. On the Relation of Moisture in Air. Steam Heating, Ventilating, Halls, Schools, &c. Cottage Hospitals. Hospitals and Asylums of the World. Hospitals and the State. Hospital Annual. Cost and Efficiency of Heating and Ventilation in Schools. The Determination of Organic Matter in Air. (Roy. Soc.) Anderson. CO^ Organic Matter and Micro-organisms in Air. Micro-organisms in Air. (Roy. Soc.) Hospital Management. Sewage. The Disinfection of Scarlet-fever and other Infectious Diseases. Hamburg Hospital. Gas Power for Electric Lighting. On Ventilation and Cubic Space. Theory of Ventilation. (Roy. Soc.) Hospitals — Encyclopedia Britannica. Measurement of the Velocity of Air in Pipes. Spread of Phthisis and Tubercular Disease. On Hospital Federation for Clinical Purposes. Vital Statistics. Influence of Gases on Micro-organisms. (Roy. Soc.) Healthy Dwellings. Notes on Hospital Construction. Report on the Herbert Hospital, Woolwich. Report on the Drainage of Cannes. Lectures to Royal Engineers at Chatham. Some of the Sanitary Aspects of House Construction. X Books Consulted in Compilation. Anstalten und Einrichtungen des offentlichen Gesundheitswesens in Preussen. Systemes de Chauffage et de Ventilation a I'Hopital La Riboissiere. Das zweite Garnison-Lazareth fiir Berlin. Public Health. The Plumber. Design for New General Hospital, Birmingham. Warming and Ventilation. Etude sur las Hopitaux. The Works' Managers' Handbook. Johnston, Miss, and Prof. Carnelley. Effect of Floor-deafening on the Sanitary con- dition of Dwelling-houses. (Roy. Soc.) Ueber natiirliche Ventilation. Annales d'Hygiene et de Medecine Legale. Les Matemites. Hopitaux Marins. Dusty Air in the neighbourhood of Illuminated Bodies. Sanitary drainage and Plumbing. Circular Wards. Typhoid Fever and Tropical Life. Medical Service in Modern War. Welche Aufgaben erfullt das Krankenhaus der kleinen Stadte und wie ist es einzurichten ? Manual pratique du Chauffage et de la Ventilation. On the Ventilation of Public Buildings. Ventilation, Proc. Inst. C. E., vol. xliv. Hospital Construction and Management. Notes on Lying-in Institutions. Notes on Nursing. Hygiene publique. Hygiene. Heating and Ventilating the Glasgow University. Notice on Dr. Van Heecke's System of Warming and Ventilation. Journal d'Hygiene. Studien uber Krankenhauser. A System of Ventilation. La Construction des Casernes. Dictionary of Medicine and Nursing. Practical Sanitation. Hot-water Apparatus. Dictionnaire de Medecine et Chirurgie. Charitable and Parochial Institutions. Manual of Heating and Ventilation. Ventilation and Warming of Buildings. Journal Statist. Soc, vol. xl. Murphy. Hygiene and Public Health. Warming and Ventilation of Public Buildings. Public Health Problems. Hospital Mortality. Dictionnaire d'Hygiene Publique. Les Nouvelles Maternites. GOSSLER und PiSTOR Grassi . . . . Gropius und Schmieden Guy . Hellyer Henman Hood . HUSSON Hutton Lang . La YET . Lefort Leroux Lodge and Clark Maguire . Marshall . Marston, Surgeon-Gen Mencke Morin Morrison . Mouat and Saxon Snell Nightingale, Miss Palmberg . Parkes Phipson Pietra Santa . Plage Potts Putzeys, Drs. F. et Em. QUAIN Reid .... Rosser and Russell Sarrazin . Saxon Snell . Schumann . Smead Steele ... Stevenson and Shirley sutcliffe . Sykes ... Tait-Lawson . Tardieu . Thevenot . Books Consulted in Compilation. XI Trelat Trotter TUSON Waddington Wallace . Waring Watson Werner et Schutte Whitelegge WiLLOUGHBY Wolpert . TiEDEMANN . . . Die medicinischen Lehrinstitute der Universitat Halle. TOLLET .... Les (Edifices hospitallers depuis leur origine jusqu'a nos jours. La Reforrae du Casernement. Les Hopitaux. The Distribution and Measurement of Illumination. Efficacy of Sulphur in Epidemics of Cholera. Burnley and Southport Hospitals. (Designs.) Sanitary Engineering in India. Sewage Disposal for Isolated Houses and Large Institutions. Disposal of Refuse. De Tame'nagement intcrieur d'un Lazaret Portatif. Hygiene and Public Health. Health Officer's Pocket Book. Ventilazion und Heizung. Reports and other Detached Papers :— Cubic Space of Metropolitan Workhouses, 1867. Sanitary State of the Army in India, Report and Appendix, 1863. Report of British National Society for Aid to Sick and Wounded, Franco-German War, 1870-1871. Reports of Medical Officer of Privy Council, 1864, et seq. ,, „ „ „ Messrs. Bristowe and Holmes. ,, „ „ „ ,, Thorne and Power. Small-pox and Fever Hospitals' Report, 1882. Report on the Sanitary Condition of the Army, 1858. Sanitary Reports, Army Medical Department, 1869-91. Barrack and Hospital Commission Reports, 1858-1862. British Medical Journal, Builder and Lancet. Official Report, Smoke Abatement Committee, 1882. Report of Ninth International Medical Congress in Washington, 1887. Sanitary Engineer, New York. International Congress of Hygiene, 1891. Ueber zweckmassige Einrichtungen von Kliniken. Army Sanitary Commission, Condition of Barracks and Hospitals. Allgemeine Grundsatze fiir den Neubau von Gamisonlazarethen. Construction and Maintenance of School Infirmaries and Sanatoria. Sonder-Abdruck aus der Deutschen Vierteljahresschrift fiir offentliche Gesund- heitspflege. Heating and Ventilating Apparatus, Union League Club, New York. Ventilation of the Small-pox Hospital Ship ' Castalia.' Salford: Description of Ladywell Sanatorium. HEALTHY HOSPITALS. CHAPTER I. PRELIMINARY. Hospitals for the reception of sick and injured date from very early times. The Buddhist religion, which overspread India 400 years before the Christian era, gave rise to numerous conventual establishments, containing many thousand monks; these were in some cases practically Universities. In them Science, Medicine, Philosophy, and Law were taught, as well as Theology. Great Public hospitals were established in every city which afforded facilities for continuous study. Discoveries of celebrated drugs and remedies as well as the power of treating difficult surgical operations with boldness and skill resulted from this experience. Military hospitals appear to have been first established for the Roman armies in the time of Trajan. At Delos we read of a Lying-in hospital. St. Jerome mentions a hospital built by the Roman matron Fabiola 360 years after Christ, and the Emperor Valens is said to have richly endowed a hospital at Cassarea about 370 years after Christ. In the ninth century there were twenty-four hospitals in Rome. These hospitals seem to have been B 2 Healthy Hospitals. [ch, under the Deacons supervised by the Bishops. In Paris the Hotel Dieu dates from the Merovingian Kings, and in 660 it received from Archambaud, Count of Paris, the gift of his Palace and Chapel, and was further enlarged by the architect Adam, under King Philip Augustus II, in 1198. In 1 153 there were established hospitals at Chartres and Angers in the form of a cross. At Ourscamp about the same time a hall was built to accommodate 100 sick and injured persons, which was 144 feet long, 64 feet wide, and '^'>^ feet high, affording 92 superficial feet per bed. Margaret of Burgundy established a hospital at Tonnere, nursed by Sisters of Mercy, where the beds were placed along the sides of the Hall each in its own compartment surrounded with curtains. The appearance of the plague in France in 1360 caused a great addition to the hospitals. Those for isolation purposes were generally situated outside the towns, and were subsequently used as lodgings by strangers who came to the towns after the gates were closed at night. In this country St. Bartholomew's Hospital was founded in 1 1 25. The principal existing hospitals in England date however from periods between 1700 and the middle of the present century ; but many hospitals of the last and of the be- ginning of this century have been entirely rebuilt during the last twenty or twenty-five years ; it may be further observed that a great development has taken place during recent years in Cottage hospitals for Villages and in Isolation hospitals for infectious diseases. It is not, however, intended here to give a history of the progress of hospital construction since early times. That will be found in M. Toilet's beautiful book, Mr. Burdett's comprehensive work, and in other publications. We desire only to show in a succinct manner what are the principles of hospital construction which have been developed in late years by the careful consideration that has been given to 1.] Preliminary. 3 the causes of disease, their prevention and cure. But before proceeding to discuss this question we may recall a few of the considerations which have led to the present form of hospitals. The shape and disposition of wards which have been arrived at in recent years were worked out after experience had shown the importance of these forms, rather than as a consequence of a preconceived theory. The fact is that our present system of hospital construction mainly owes its rise, in this country at least, to the experience derived from the wars of the last and present century, where large numbers of sick and wounded were collected together in extemporised hospitals. Dr. Brocklesby had shown as early as 1758, and Sir John Pringle and other military surgeons later on, that hospital huts and tents, in which the patients were exposed to unfavourable conditions from cold and wet, produced more numerous and rapid re- coveries from wounds during these wars, and from the diseases incidental to camps, than the permanent hospital buildings then in use. But it was mainly in consequence of the experience of the Crimean War, the American War of Secession, and the Franco-German War of 1870-71, that physicians and sur- geons generally became impressed with the importance of so arranging the buildings for sick and wounded that they should be constantly under the favourable influence of fresh air and cleanliness. There is abundant evidence that the agglomeration of sick and wounded men into the permanent buildings used as hos- pitals during these wars was very destructive of life, while it was seen that wounded recovered best when scattered among cottages, attended almost entirely by the people, notwith- standing that they were often indifferently fed ; and it was found far better to place wounded men, as a rule, in detached buildings, or even under a canvas roof, or any similar shelter B a 4 Healthy Hospitals. [ch. sloping from a barrack or church wall, than to take them inside the building even in cold weather. In some of the reports on the reconstruction of the Hotel Dieu in Paris made before the breaking out of the Revolution, the objection to massing together large numbers of patients in one building was strongly urged, and instances were given in official reports of the evil influences of the sick upon each other. Cases were quoted in which persons whose beds were placed not far from wards which contained patients ill with putrid fever, did not get cured at all, or were cured with great difficulty. No doubt many of the early hospitals were of the pavilion form of construction, so far as placing windows on opposite sides is concerned, but a very large number of beds were placed in several rows in one long room or gallery, and under one roof. In this country the earliest specimen of a hospital on a pavilion system, with a limited number of patients in each pavilion building, appears to have been built for sailors, at Stonehouse, near Plymouth, by an architect named Rovehead, between the years 1756-64. In this building the ends of the pavilions were united by a covered corridor to protect persons passing from one pavilion to the other. This hospital was based on the principle of limiting the number under one roof, and was a practical protest against the plan then largely prevalent, chiefly on the Continent, of agglomerating a large number of sick or injured in one large hall. But it did not embody the cross ventilation of our present pavilion construction. This form was not, however, followed generally in this country, and the corridor system with rooms, each containing a limited number of sick, opening out of a common corridor, arranged apparently with the object of facilitating the inter- change of vitiated air, appears for a long time to have been preferred — a system which culminated in Netley in 1856. I.] Preliminary. 5 This was not the case in France. In that country the excellent work of M. Toilet shows that the pavilion principle, as now understood, was suggested as far back as 1750, with wards limited to about thirty-four beds in each. In the American War of Secession long wooden huts^ erected for receiving the sick and wounded, were resorted to instead of existing brick buildings. The Lower General Hospital of Philadelphia consisted of a series of one-storied huts disposed round an interior area, in which the offices and abodes of the administration were situated. The site was a high and airy plateau, on which fifty huts afforded accommodation for 500 patients. These huts were arranged like spokes of a wheel around a central corridor, and open freely to the air, but closed and warmed in winter by stoves ; this corridor afforded, at all seasons, a pleasant lounge for the convalescent patients. A tramroad ran round the corridor, on which waggons brought the food and supplies to the end of each hut-ward without delay. A telegraph connected the huts and the kitchen with the director's office and other parts of the administration. A branch from the railroad permitted the railway cars, in which the patients had been laid near the battle-field, to dis- charge their freight at the door of the hospital ; thus the patients suffered only one change, from the railway to their beds. It was upon this model that the German temporary hos- pitals were organised during the Franco-German war. In this war the want of suitable hospitals led to the erection of a large number of buildings of wood, as well as to the use of tents. Neuwied, Frankfort, Mannheim, Heidelberg, Darm- stadt, and Aachen afforded some very good examples of extemporised hut hospitals. In all these the arrangement aimed at was to give the 6 Healthy Hospitals. [ch. patient as much fresh air as possible. The sides were in many cases capable of being entirely opened, and were kept open till late in the autumn. Along the ridge a very large space was devoted to the admission of air. Where the sides were continuous, and there were windows, a large opening for fresh air was reserved along the eaves, and frequently also along the floor. The floor was always raised from two to four feet off the ground. Some surgeons, in addition to the arrangements for securing fresh air in the huts, caused many of their patients to be carried in their beds by day into the adjoining meadow, and would willingly have kept the wounded in the open air through the winter, but the nurses could not stand the cold. These hospitals, although crowded with wounded, pre- sented scarcely any cases of pyaemia or hospital disease so long as they were permeated by fresh air. But curiously enough, as soon as the winter set in with severity, the ad- vantages of fresh air were ignored, the sides and even the windows were nailed up, leaving only one or two moveable ventilators at the top of the building, and a nurse employed in one of them said, — ' The air was so utterly foul and corrupt, that a feeling of nausea came over me each time I entered them'; and during the winter hospital diseases made their appearance. There is no question but that the experience of the ad- vantages of fresh air in hospital wards, gained during these wars, has led the medical profession to approve of the present pavilion system of hospital construction. There does not appear to be any very definite view as to the extent of hospital accommodation which is necessary to be provided in proportion to the population. According to Mr. Burdett and other authorities, there should be one bed to every i,ooo inhabitants for general diseases and surgical cases. The whole hospital accommodation of London, ex- clusive of Infectious hospitals, may be said to aflbrd about I.] Preliminary. 7 one bed to every 800 inhabitants. In some counties the pro- portion is only one bed to 2000 inhabitants, and in others, if we include the workhouse infirmary, it approaches within measurable distance of Mr. Burdett's standard. Of course this provision refers to an average ; and in a village of say 500 or 1,000 inhabitants, if a cottage hospital were provided, three or four beds at least would be necessary. It is quite certain that many persons, even of the fairly well-to-do class, would have much better chances of recovery from either sickness or injury in a well-administered hospital than in their own homes. This is especially the case with the less well-to-do. For infectious or contagious diseases, where early separation of the sick from the healthy is of paramount importance, a hospital is a necessity. In the case of small-pox and scarlet fever, unless provision for isolation is sufficient to permit of the earliest cases being weeded out at once, the prime object of an Infectious hospital is not attained. In the case of Infectious hospitals the ratio given by Mr. Netten Radcliffe as desirable was about twenty beds for a popu- lation of 35,000. In twenty-seven important towns, having a total population of nearly 4,500,000, there are twenty infectious beds to each 29,000 persons. This seems too small in the event of epidemics. As a matter of fact London at the present time has nearly 4600 beds in the hospitals of the Metropolitan Asylums Board. This, on Mr. Netten Radcliffe's calculation, should be sufficient for a population of 5,700,000, which is more than the population of the Metropolitan area. But the hospitals of the Metropolitan Asylums Board are overcrowded when an accession of scarlet fever occurs, accompanied by that of any other disease, as for instance in the autumn of 1892, when there was at the same time much diphtheria, and provision was also required to be made in anticipation of cholera. From this experience it may be inferred that a larger proportion of beds, either by temporary provision or otherwise, is necessary to meet such an emergency. It would, 8 Healthy Hospitals. however, be costly to provide, and to keep up permanently, sufficient accommodation to meet the occasional contingency of epidemics. The reasonable course would seem to be, that the per- manent provision should suffice for an average number of two or three simultaneous infections, and that this should be sup- plemented by temporary arrangements in case of need. Late authorities have proposed that infectious accommodation should be provided in the proportion of ten beds per 10,000 of population, with arrangements framed to admit of three dif- ferent infections in both sexes. The case of cholera involves other considerations. It is worthy of note that the removal of the patients to hospital does not find favour with those who have had experience in the treatment of this disease. The act of removal is attended by fatigue, which during an attack of cholera appears to re- duce the probabilities of recovery. In such cases it might be preferable to leave the patient in his own home, and to make provision elsewhere for the healthy occupants of the house. It may, however, be observed that both cholera and enteric fever might, with proper precautions, be treated in General hospitals, in isolation wards, a course which would not be advisable in the case of scarlet fever and small-pox. CHAPTER II. DEFINING A HOSPITAL. A Hospital is not only a place for the reception and cure of the sick poor ; it has, so far as the community is concerned, another very important function. It is the technical school in which the medical student must learn his profession, and it is an experimental workshop in which the matured physician or surgeon carries on scientific research. As a place for the reception and cure of the sick or injured, who do not possess facilities for being nursed at home, the hospital should be so arranged as to possess conditions more favourable for recovery than such persons could otherwise command in their own homes. The care of the sick and injured, which in the time of the Egyptians, Greeks and Romans, seems to have been connected with the religion of the people, has in these later days, especially in this country, been mainly the attribute of the charitable. Our principal institutions, where they do not possess en- dowments, such as are possessed by St. Bartholomew's, St. Thomas's, and Guy's Hospitals, have necessarily to depend for their maintenance upon the contributions of the public. Our Infectious hospitals and Poor Law infirmaries, on the other hand, are built and maintained out of the rates. These institutions in London have not hitherto been adapted to the very important objects which a hospital fulfils in edu- cating the medical student. It must be remembered that in other professions the lo Healthy Hospitals. [ch. student can pursue his studies largely in his library, but for the medical student the patients are the books out of which he has to read at the bedside, and hence it is of essential importance to the community that every hospital should be available for study. It is, however, true that recently, in consequence of the absorption of all infectious cases into the Metropolitan Asylums Board and the impossibility therefore of students having the opportunity of studying these diseases outside, some small provision has been made for students in these hospitals. In towns of moderate size an individual interest is taken in the hospital or infirmary, and the county population sur- rounding the town, which is in a position to derive advantage from the hospital, willingly contributes to its maintenance. But London has in a great measure outgrown this feeling of individual interest. The supporters of many of the hospitals now necessarily often reside far from them. The poor in their immediate vicinity have not the means or inclination to give substantial support. The new Workhouse infirmaries and the Asylums Board hospitals are gradually impressing on the poorer classes the feeling that they ought to be treated for illness at the expense of the community. The necessities of the hospitals grow daily with the grow- ing population, but the funds do not proportionately increase. Hence important questions arise as to their future main- tenance. Some influential persons have advocated that the subscrip- tions for hospitals should all be collected by a central federated committee, by whom they should be distributed to the several hospitals. Such a system would probably soon dry up all that remains of individual effort, and the only solution of the question then would be for all the cost of the hospitals to be borne on the rates, and for the parochial authorities to partly recoup themselves by charging a reason- able sum to every patient who could afford it. II.] Defining a Hospital. \ i In Paris, when in the Revolution of 1789 the charitable and other endowments shared the same fate as our monas- teries under Henry VIII, the State had ultimately to make some provision for the sick poor. And at the present day all the hospitals are under the direction and control of an Administrative Council, subject to the Prefect of Paris and ultimately to the Minister of the Interior, while the necessary funds are supplemented annually by votes in the budget, a legal power being given to assess patients admitted to a pro- portion of the cost of maintenance apportioned to their means. In Sweden the hospitals are managed by separate govern- ing bodies, as in London, but submitted to a State control so far as necessary to insure a certain unity of system and administration, and especially as regards finance and account- ability. A scale of charges is also established, and all pay something except the really poor. The first class pay a substantial sum, as now in our paying hospitals ; the second pay less, but still a remunerative sum. Without entering further into these questions it may be admitted that it certainly would seem desirable that those patients who can afford it should contribute to their treat- ment when in hospital. This principle is endeavoured to be enforced in our In- fectious hospitals in London. They are built and maintained out of the rates ; the cost of each patient is charged to the parish whence he comes, and the parochial authorities call on those patients, who can afford it, to repay them their contri- bution. The argument for payment in these Infectious hospitals is not, however, so strong as in other hospitals, because they are established as a protection to the commu- nity rather than for the advantage of the affected individual ; and enforced payment tends to discourage resort to them. Whether, however, the Hospital is supported by voluntary effort, or whether it is supported by the rates, the necessity for economy in management is apparent, and it follows as an 12 Healthy Hospitals. [ch. important feature of hospital construction that the building should be so arranged as to enable a small staff of medical men, nurses, and assistants to minister to the wants of a large number of sick. This can only be done by bringing many sick together in one establishment, and, except in special cases, placing several sick in one room. The attention which has been given of late years to the management of sick and injured persons, in connection with the investigations which have taken place into the causation of disease, have led to a considerable development of the practical application of hygienic principles to hospital con- struction. These general principles of construction may be assumed to be similar under all circumstances. That is to say, in every hospital it is necessary that the building be so arranged that it shall stand on a pure soil ; that it shall be supplied with pure water; that it shall be permeated with pure air ; and that its cleanliness shall be ensured by abundance of light. There must, however, be a division between certain classes of patients. For instance, it may be desirable to keep in separate classes — (i) Contagious and infectious diseases, possibly including phthisis. (a) Ordinary sick. (3) Injured or wounded. (4) Aged sick poor. {^) Lunatics and imbecile. (6) Pregnant women, who are not suffering from disease in the ordinary sense. (7) Convalescents'. And there are further subdivisions which are necessary as regards infectious and contagious diseases. It is noteworthy that the Infectious or Contagious hospital was at one time a necessary adjunct to every small community. II.] Defining a Hospital. 1 3 With the diminution in the number of the violent outbreaks of such diseases, consequent upon the improved habits of cleanhness in the population, these lazar or pest houses fell into disuse, and it is only now that we are awakening to the necessity of again making such establishments an appendage of every Sanitary Authority, and, unlike the case of general hospitals, charging the cost of their construction and mainten- ance to the rates. In these hospitals small-pox should be separated from scarlet fever and diphtheria. Some forms of ophthalmic disease require separation. Subdivisions may also be neces- sary in the case of the sick admitted to General hospitals. For instance — the temperature to be maintained for those suffering from bronchitis and pulmonary complaints may differ from that for other cases of sickness, and so forth. Hence the class or character of disease to be treated may require a special application of these general principles ; and this has led to the adoption of separate hospitals, suited to various classes of patients, and various categories of disease. Existing hospitals may be said to fall under the following general heads : — A. Those connected with treatment and cure of disease, each of which may be assumed to require special arrange- ments. (1) General Hospitals, with a medical and surgical side, with which must be grouped the small Cottage hospitals, which have attained a certain extension, in recent years, both in this country and elsewhere. (2) Children's hospitals with a similar division of medical and surgical cases. (3) Infection hospitals. (4) Lying-in hospitals. (5) Convalescent hospitals. (6) Seaside hospitals for treatment of lymphatic and scrofula patients. 14 Healthy Hospitals. [ch. (7) Special hospitals for surgical treatment — as ophthal- mic, orthopcedic, dental, and otherwise. In connection with these it may be desirable to mention dispensaries, either provident or otherwise, and assistance to be rendered where patients are treated at home. Workhouse infirmaries have also received extended de- velopment in late years, but these are mainly for paupers and charged to the rates ; whilst Military and Naval hospitals are a necessary appendage to every garrison and naval port ; and Field hospitals the necessary accompaniment of every army. B. Those hospitals which are more in the nature of permanent refuges : — (i) For Incurables. (2) Imbecile Asylums. (3) Lunatic Asylums. It is beyond the province of this book to discuss the detailed construction of all these various institutions, but there are certain general considerations which affect all hospitals, and it is to these principles that it is now proposed to direct attention. The first object of a hospital, as has been already mentioned, apart from its function as a teaching institution, is to enable the sick to recover in the shortest possible time. In a treatise on hospital nursing, Miss Nightingale observes that — ' Sickness or disease is Nature's way of getting rid of the effects of conditions which have interfered with health. It is Nature's attempt to cure ; we must help her.' In addition, therefore, to being supplied with the most complete curative appliances, the hospital should furnish all those conditions which are wanted to enable Nature to set up her restorative processes, and to put the patient in a condition to recover. These conditions are summed up by Sir John Simon, the former Medical Officer of Health to the Privy Council, in the following apt words : — ' A healthy hospital is one which 11.] Defining a Hospital. 15 does not by any fault of its own aggravate ever so little the recovery of persons who are properly its inmates. The faults by which a hospital fails to attain to the best results for its medical and surgical treatment may be of two kinds — either it is an inherent fault as of site and construction, or else it is a fault of keeping, as dirtiness or overcrowding, or neglect of ventilation.' There are in existence many hospital buildings which, although they are not well calculated by their form to allow of the free permeation of fresh air, and to which light does not readily penetrate to all parts, yet show a record of favourable recoveries, owing to the larger floor space which is allotted to patients in the wards, to the judicious use which is constantly made of such means of aeration as exist, and to the scrupulous cleanliness which is maintained in every part of the building. Cleanliness and fresh air do not so much give life as they are life itself to the patient. Cleanliness — clean air, clean water, clean surroundings — and a fresh atmosphere everywhere are the true safeguards against ' infection ' ; segregation by ample floor and cubic space, ample ramparts of fresh atmo- sphere, rather than segregation by walls and divisions. You cannot lock-in or lock-out the infectious poison. You can air it out, diffuse it, and clean it away. In order to facilitate the maintenance of healthy conditions in a hospital the form of the building should be such as to ensure the provision and proper application of (i) Fresh air, with the necessary warmth and coolness. (2) Ample light '* icluding the penetration of sunshine to every part, (3) Purification o. floors and walls. (4) Means of personal cleanliness. (5) Adequate bed and bedding maintained absolutely clean, and adequately prepared food and drink. (6) Attendance. 1 6 Healthy Hospitals. [ch. The constructional arrangements which bear on these various matters may be conveniently summed up under the following heads : — (i) The soil on which the hospital stands should be clean, that is to say, the soil should neither emit, nor should it be exposed to any injurious emanations. (2) The surrounding air should be pure, and there should be no appreciable difference in purity between the air inside and that outside the building. (3) The pure air supplied to the wards, corridors, and offices should be capable of being warmed to any required extent. (4) The water supplied for use should be pure, and after use it should be removed with its impurities to a distance from the hospital. (5) Perfect cleanliness should prevail within and around the building. In respect of the importance of cleanliness, the following extract from the report of Sir John Simon deserves notice : — ' That which makes the healthiest house, makes likewise the healthiest hospital ; the same fastidious and universal cleanli- ness, the same never-ceasing vigilance against the thousand forms in which dirt may disguise itself in air, and soil and water, in walls and floors and ceilings, in dress and bedding and furniture, in pots and pans and pails, in sinks and drains and dustbins. It is but the same principle of management, but with immeasurably greater vigilance and skill ; for the establishment which has to be kept in such exquisite per- fection of cleanliness is an establishn. it which never rests from fouling itself ; nor are there any ducts of its foulness — not even the least odorous of such .roducts — which ought not to be regarded as poisonous.' The number of the inmates in a hospital — the number col- lected under one roof^the shape of the hospital buildings, and their distribution in regard to each other, and the II.] Defining a Hospital. 17 methods of administration, all materially affect the preserva- tion of the purity of the air. The best index to the relative efficiency with which this purity is maintained in different hospitals would probably be an equation in which the mor- tality and the length of time required for recovery of patients would form the chief factors. But the facts of medical science are complex in their nature and liable to be influenced by an infinite number of collateral and minor considerations. Attempts therefore to compare large hospitals with small, to show the superiority of one form of construction over another, based on results derived from their mortality as at present ascertained, or on the average length of time cases are under treatment, are as yet too deficient in scientific accuracy to afford reliable data for the solution of this problem. As has been already mentioned, we meet with hospitals converted from ordinary houses, where a scrupulous attention to cleanliness and the maintenance of a large floor space in the wards have produced satisfactory results. Other statistics have been adduced to- show that the small cottage hospitals have produced fewer deaths and more rapid recoveries than larger town hospitals ; but those statistics did not suffici- ently bring into comparison the nature of the cases treated in each hospital, the form of the wards, the degree of clean- liness and of excellence of maintenance and nursing in each hospital. As a general rule, however, it is quite certain that those hospitals in which the external architectural design had been the first care of the architect and the free circulation of air a secondary consideration, have produced results in deaths and in difficulty of cure far exceeding those which take place in hospitals where the architect has endeavoured, in the first instance, to arrange a plan which will secure free permeation of fresh air and an absence of dark corners as the normal condition of the building. C 1 8 Healthy Hospitals. [ch. With these prehminary remarks we will proceed to consider the conditions which should regulate — (i) The site of the proposed hospital. (2) The form of the rooms in which the sick are to be placed and nursed, so as to ensure purity of air and convenience of nursing ; because these rooms form the principal units of hospital construction. (3) The distribution of these units, and of the other neces- sary accessories, which when combined constitute the hospital. As a preliminary to these questions it will be convenient to mention what are the several parts of which a hospital may be said to be composed, bearing in mind that simplicity of design should be one of the aims of the hospital architect, and that any useless multiplication of administrative offices can only lead to complication of administration, confusion of the departments, and needless expense. The several parts of a hospital may be classed as follows : — I. Those connected with the admission and treatment of the sick. (i) Rooms for reception and examination and for dis- charge of patients. (2) The wards and their appurtenances. (3) Baths for treatment, including medicated, Turkish, vapour, electric, &c. (4) Operation room and its adjuncts. (5) Dispensary and drug store. (6) Splint store and workshop. (7) Mortuary and its adjuncts. (8) Out-patients' waiting room and the various rooms for their examination and treatment ; where an out- patients' department exists. II. Connected with boarding and clothing of patients, (i) Kitchen with its adjuncts. (2) Stores of food, fuel, linen, patients' clothes. II.] Defining a Hospital. 19 (3) Laundry. (4) Disinfection. (5) Destruction of refuse. (6) Servants' accommodation, male and female bedrooms, dining rooms, sitting rooms, &c. III. Connected with nursing accommodation. (i) Nurses' rooms or Nurses' home with bedrooms, dining room, sitting room, library and lecture room. (2) Probationers' rooms in connection with training school. IV". Connected with Medical Education, (i) Post-mortem room. (2) Preparation room and laboratory. (3) Museum and library. (4) Lecture room. (5) Students' waiting rooms and Cloak rooms. V. Connected with General Supervision. (i) Accommodation for meetings of Governing body, and for Secretary, Accountant, the keeping of Registers, &c. (2) Rooms for Medical Staff, resident and non-resident. (3) Apartments of Matron, or Superintendent of female staff connected with service of hospital. (4) Arrangements for controlling ingress to and egress from Hospital. The wards are the units which govern the general shape of a hospital, and the shape of the wards is therefore the first point to be settled. The form and size of the wards depend upon the air- space required for each individual patient placed in the ward, and upon the way in which this air-space is distributed round him. This air-space is governed by the questions involved in the renewal of air, and these are affected by the methods adopted for the introduction of fresh air and the arrangements for warming the wards. C a 20 Healthy Hospitals. These questions are so vital to the form of the wards that it will be desirable to consider them before discussing the shape of the wards. They may be described under the following heads : — (i) Conditions which vitiate the air in an occupied room. (2) Quantity of air necessary to mitigate these conditions. (3) Movement of air — (a) by natural means, (/3) by artificial appliances. (4) Conditions which regulate the warming of air. But in the first place we must consider the conditions which regulate the choice of the site on which the hospital should stand. CHAPTER III. SITE. The site to be selected for a hospital depends upon various considerations, and cannot be determined merely by its physical condition. On the one hand, in order that the curative art may be carried on under the most favourable circumstances and with- out disturbing causes, it is necessary that the hospital building, in which the patients are lodged, should be furnished with the most complete appliances, and that it should be placed in the most favourable hygienic conditions. If these latter conditions are to be fully ensured, the hospital should be in the open country, and if health considerations alone are to prevail, no hospital would probably be located in a town. But, on the other hand, a hospital must be so placed that it will be conveniently available for the reception of the sick poor, and in the case of accidents, and of many diseases such as enteric fever, scarlet fever, pneumonia, cholera, &c., it is of im- portance that the distance which the patient has to be con- veyed shall be as short as possible. The hospital should also be easily accessible to the physicians and surgeons, both to enable them to prosecute the study of their profession, and to give clinical instruction to the Medical Students. The leading physicians and surgeons of a town necessarily reside near the more crowded localities. These conditions would require that hospitals should be placed in centres of population. Consequently, one of the 2 2 Healthy Hospitals. [ch. principal considerations in determining the position of a site for a General hospital is proximity. Other classes of hospitals, including Cottage hospitals, for comparatively scattered rural populations. Asylums, or hos- pitals where the treatment is for special diseases, are not similarly fettered. In the case of Isolation hospitals for small-pox and fevers, whilst it is desirable that the patients should not be transported to great distances by road, yet it is of importance that, where it can be avoided, they should not be treated in centres of population ; besides which these institutions are always objected to, mainly on grounds of sentiment, as disagreeable neighbours. Hence, when the size of a town admits of it, they are placed in the open country. But in London, the great distances to be traversed render this impossible, in the case of those infectious diseases which would especially suffer from a long land-journey. Convalescent hospitals are placed in the open country, or by the sea-side. In England there are such hospitals, both for adults and for children, at Margate, Hastings, and other sea-side places ; whilst in France and Italy there are numerous Marine hospitals, where children of lymphatic nature, or those suffering from scrofula, rickets, or tuberculosis, are treated. Indeed, the municipality of Paris has for many years had a hospital of i,ioo beds at Berck-sur-Mer, in the Pas de Calais. The asylums for imbeciles or lunatics are similarly placed in the open country. The consideration of proximity must, however, be controlled to a great extent by physical conditions, and therefore in selecting a site for a hospital it is essential, where the con- ditions admit of it, to test the healthiness of a proposed site, by enquiry into the rate of mortality in the district ; as well as the prevalence of sickness, and the nature of the diseases. Whenever this information can be satisfactorily obtained, it III. J Site. 23 would afford a ready and effectual means of ascertaining the suitableness of a site for the sick. On the assumption that the choice of a site is unfettered, except by hygienic require- ments, the qualities of a site most favourable to a hospital may be described to be a situation in the open country; upon a clean, porous, and dry soil, with free circulation of air round it, but sheltered from the north and east ; raised above the plain, with the ground falling from the hospital in all direc- tions, so as to facilitate drainage. The elevation of a site above the surrounding country is very important. Observations taken in Switzerland have shown that a milder and more equable climate prevailed at a few hundred feet above the valleys than at the bottom, where the vegetation of the hillsides would not thrive. In the British Isles, during a frost of long duration in 1H79, at certain stations on hills, which were 200 and 300 feet above the adjacent valleys, the minimum cold registered during the winter was 17° Fahr., when in the valleys the absolute cold registered as low a minimum as i-i° and 2°. The general conclusion shown by these and many other observations is, that at a height about equal to that of the upper rooms in a high house a more equable and drier climate prevails than at lower levels ; drier than at the seaside, and with a daily range not much greater, and much less cold on the coldest and foggy nights than down below. Hence, in ordinary circumstances, delicate persons should not sleep on a ground floor ; and living near the top of a high house, or on the ridge of a hill, might be of great benefit in many cases of lung and throat diseases, and in cases where night air has a bad effect. But the selection of an elevated site requires care. For though elevated positions are generally healthy, yet in cases where they are exposed to winds blowing over marshes or malarial ground, their very elevation may be a source of danger. 24 Healthy Hospitals. [ch. On the other hand, in the case of buildings placed at a slight elevation above a marsh, the evil effect of the marsh has sometimes been obviated by the interposition of a belt of high trees which have shielded the buildings from the influ- ence of the wind blowing over it. The site selected for a hospital should not receive the drainage of any higher ground. The supply of water must be ample and good. It is an error to build a hospital on a steep slope. No doubt, by forming a plateau for the structure, and adopting a system of catch-water drainage, the water from the higher ground may be more or less cut off from the building ; but the higher ground, especially if it be near to the building and steep, and if it rise to a considerable height above the hospital, will stagnate the air just as a wall stagnates it. Shelter from cold, or from unhealthy winds, be it by means of a range of hills, or walls, or houses, or trees, should always be at a suffi- cient distance to prevent stagnation of air and damp, otherwise the shelter from an evil recurring only at intervals may be purchased by sacrifice of healthiness at all times. The level of water in the subsoil regulates the amount of ground air. Ground air has a most important influence on the healthi- ness of a site. It is desirable to have clear ideas upon this subject. The air does not cease where the ground begins ; but air permeates the ground and occupies every space not filled by solid matter or by water. The particles of soil may be com- pared to a pile of shot with the interspaces, where the circumferences of the shot do not touch, filled with air, or which would be filled with water if the ground on which the shot are standing were submerged. Thus, if you build on a dry, gravelly soil, where the inter- stices between the stones are naturally somewhat large, you practically build over a large stratum of air. This air moves III.] Site. 25 in and out of the soil in proportion to barometric pressure, and with reference to the wind. If there is much water in the soil, the air carries with it watery vapours, and is cold, and we say such a site is damp. There is a considerable quantity of carbonic acid in the ground, and there are even considerable variations in the amount of carbonic acid present in the soil of localities in close proximity to one another ; the amount has been found to be doubled in a distance of 50 yards with apparently similar soil, probably depending on the organic matter which has been present or has percolated into the soil at different places. The processes going on in the soil at these spots must have differed materially ; and if such processes affect health, persons inhabiting a building over one of these sites would be exposed to different hygienic conditions from persons living over the other. The fact of this continual free passage of air in and out of the ground makes it important that not only should the ground we live on be free from water, but more especially that it should also be free from impurities. We might just as well (indeed probably far better) live over a pigsty, than over a site in which refuse has been buried, or in which sewer water or other impurities have penetrated, or over a soil filled with decaying organic matter. Ground air has been found to contain 50 per cent, more carbonic acid than the ground water. The level of water in the soil necessarily affects the air contained therein : when the level of the water rises, the air is forced out ; when it falls, air is drawn in ; but in con- nection with this it may be observed that whilst a permanently low water level (say 15 feet) in the soil may be healthy, and a permanently high water level (say under 5 feet) may be less healthy, a fluctuating water level is very unhealthy, especially when the fluctuations are rapid. The unhealthiness mainly shows itself when the level of the 26 Healthy Hospitals. [ch. ground water falls. This probably occurs from the decay of organic matter left by the receding Vv^ater, and from this cause apparently fever chiefly occurs in flooded districts when the floods have receded. Hence it is desirable to keep the permanent level of water in the soil, where habitations are placed, as low as possible. But where the water cannot be maintained permanently at a low level, then keep it at an even level. Of course these conditions are modified by considerations of geological formation. On clay or on impervious formations water either remains to stagnate on the surface, or if the levels allow, it passes off the surface rapidly. Porous soils, on the other hand, allow of the penetration through them of pollution in connection with water to very considerable distances. For instance, it may be mentioned that a dis- infectant put into the sewers has been known to be traced — after no long interval — in wells situated at comparatively considerable distances from the sewers. It is obvious that the sewers must have been faulty. Water sinks into a sandy gravelly soil and thence it drains away when not retained by an impervious subsoil. The impurities would not be carried into the clay soil, but the sandy or gravelly soil acts as a filter to retain the impurities which surface water may bring into it, and fever has been observed to stop on passing from a sand district to a clay district. Indeed, long-continued saturation of porous sandy or gravelly soil in towns by sewage or other foul refuse appears to be the cause of much of the typhoid fever which cannot be traced to definite causes. Sir Charles Cameron has pointed out that in Dublin the chances of getting typhoid are 50 per cent, greater on the gravel than on the clay, and attributes this to the fact that the soil of Dublin has been polluted by a system of storing human excreta for centuries, and the enormous accumulation of organic matter thus formed is under certain conditions in a state to give out into the atmosphere the poison which III.] Site. 27 favours disease. Similar conditions are probably the cause of much of the enteric fever in India, and it has long been known that whilst in the great cities of America, malaria was disappearing with the advance of population, it is being replaced by typhoid fever, because the ground has been allowed to be saturated for years with organic matter from the animal kingdom. Parkes tells us that cholera is un- frequent on granite, metamorphic and trap rocks, but a careful collation of facts shows that so far as cholera, or indeed other zymotic diseases are concerned, the site and the geological formation have comparatively little to do with it. These diseases occur when there is a population living in a filthy condition, where impurities are retained around, on, in or under the dwellings — or are allowed to percolate into the ground surrounding the dwellings, or into the wells rendering the water impure. The prevalence of fever in new houses built on the outskirts of towns frequently arises from the fact, that the gravel and sand which constituted the original soil had been removed, the hole thus formed let as a shoot for rubbish, and the restored surface converted into a building site ; consequently the gradual decay of the refuse evolves emanations which pass up into the houses, even through concrete. In connection with this it may be instanced that a site which has been occupied as a market garden, or which has been highly manured, would not be safe for a building site for a hospital unless the surface soil were removed to a depth in some cases of from one to two feet, or burned. The importance of a clean soil is apparent when it is remembered that vapour is constantly escaping day and night from the soil, especially under grass, and bringing up ground impurities with it. This vapour often becomes visible as fog in an evening over low-lying meadows, for the same reason that fog appears over a river or pond, when after a hot day the air cools down at sunset leaving the water warm. 28 Healthy Hospitals, [ch. It follows that the ground surface on which hospital wards stand should be covered, both under the buildings and between the buildings, by a coating of impervious material, as for instance asphalte, or in default of asphalte, cement concrete. The temperature of the soil depends on its geological forma- tion. Thus if the power of sand to absorb heat be taken at 100, the power of clay to absorb heat would be represented by 66. Moreover, sand radiates heat more slowly than clay. Therefore a sandy soil is always warmer than a clay soil. Herbage lessens the absorbing power of the soil, and in hot climates the oppressive heat of a sandy soil may be tempered if the surface be covered with grass. The disturbance of soil impregnated with organic matter has been a source of danger in tropical and semi-tropical climates. Whilst brushwood is a source of danger in hot climates, the removal of brushwood by stirring up decaying organic matter has caused fever. Digging out foundations, or any disturbance of the soil, is almost sure to be followed by an outbreak of malarious disease ; the tendency to which diminishes or altogether disappears in time as the surface of the soil hardens, or undergoes other changes from exposure to air. The presence of superfluous and stagnant subsoil water in the vicinity of a healthy site is dangerous. A distinct relation has been shown to prevail between phthisis and the level of ground water ; that is to say, the lowering of the water level has led to a direct reduction in mortality from phthisis. But the level of ground water is a condition which it is eminently within the power of the engineer to remove by drainage of the soil. In India, wherever water is applied in excess for irrigation so as to become stagnated in the subsoil, there we have ague and spleen disease. But such localities have been improved by draining away III.] Site, 29 the superfluou55 stagnant subsoil water. To prevent such evils, drainage should be combined with irrigation works from the beginning. These remarks are based upon the assumption, that, in the selection of a site, healthiness is the only consideration ; hence it will be convenient to summarise here the conclusions to which the above considerations point. (i) A clay soil is disadvantageous from its cold character, but it prevents the percolation of foul matter. (2) Ground at the foot of a slope, or in deep valleys, which receives drainage from higher levels, predisposes its occupants to epidemic diseases. (3) High positions exposed to winds blowing over newly excavated ground, or over low marshy ground, even when miles away, are in certain climates unsafe on account of fevers. But the immediate vicinity of a marsh, or other local cause of disease, which is separated by a belt of trees from the occupied site, may be safer than an elevated and distant position to leeward. (4) Elevated sites situated on the margin or at the heads of steep ravines, up which malaria may be carried by air currents flowing upwards from the low country, are apt to become unhealthy at particular seasons. Such ravines, more- over, from want of care, are often made receptacles for decay- ing matter and filth, and become dangerous nuisances. (5) Ground covered with rank vegetation, especially in tropical climates, is unhealthy, and the presence of such vegetation marks the presence of subsoil water. (6) In warm climates, muddy sea beaches, or river banks, or muddy ground subject to periodical flooding, and marsh lands covered alternately by salt and fresh water, are peculiarly hazardous to health. (7) A porous subsoil, not encumbered with vegetation and protected from impurities, with a good fall for drainage, not receiving or retaining the water from any higher ground, 30 Healthy Hospitals. [ch. and the prevailing winds blowing over no marshy or unwhole- some ground, will, as a general rule, afford the greatest amount of protection from disease of which the climate admits. It follows, from these considerations, that a site selected for occupation should be thoroughly under-drained, except pos- sibly where the ground is so elevated and porous as to ensure that water never remains in it ; and that if there is higher ground adjacent, the water from the higher ground shall be carefully cut off by underground catch-water drains, and led away from the vicinity of the site. The object to be attained in laying out the ground is the rapid and effectual removal of all water from the buildings themselves, and from the ground in their vicinity, so that there shall be no stagnation in or near the site. Hence a hard compact surface should be secured in the vicinity of buildings. It prevents soakage, facilitates sweeping and surface cleanli- ness, and diminishes the soil emanations from below. It may be stated as a general proposition that the area in any country over which fogs appear soonest after nightfall should be avoided. It has already been mentioned that there are many other considerations besides those dependent upon hygiene alone which influence the choice of a site for a hospital. Amongst these, the necessity of placing the hospital in a convenient locality, accessible both to patients and medical men, is a very real difficulty, and this often compels the erection of a hospital in the midst of a population or in unfavourable surroundings. In the open country when the site is surrounded only by fields, it is of little consequence what is the area of the land enclosed in the hospital grounds, except for the purpose of preventing encroachment. But in towns the impurity of the air of a hospital will diminish in proportion to its distance from thickly inhabited places, and under these circumstances III.] Site. 31 an enlarged area ought to be provided to counterbalance the unhealthiness of a site. In a town, however, the surrounding population often makes it either impossible or very expensive to obtain a large site. So far this consideration has reference to the maintenance of the purity of the air to be breathed by the sick. But a certain space for a hospital placed in a town is also necessary for isolating the hospital, for the sake of the popu- lation living round the hospital. Every sick person is a focus from which emanations of more or less injurious kind are being thrown off, and the accumulation of numerous cases of sickness in one locality adds to the pollution in a rapidly increasing ratio. Whatever may be the influences which cause the vitiation of the air in and around a hospital, whether they be due to putrefaction or fermentation and to the development of germs, or living organisms, or to consequences entailed by such organisms which have not yet been accurately ascer- tained, it is abundantly proved that the crowding together of individuals on a limited space is favourable to the develop- ment of such causes, whilst a large surrounding air-space reduces or limits the danger arising from them. Consequently it may be taken as certain that a larger free space around a building in which sick or injured are located is necessary, that is to say in the case of a hospital, than would be required in the case of a collection, in a given area, of persons in good health. In the case of some infectious diseases this has been especially apparent. No doubt well-managed fever hospitals which stand on an adequate area have not been found to involve any appreciable risk to the neighbourhood ; yet even with these hospitals the Local Government Board prescribe, for London fever hospitals, that no building to which the sick would have access should be placed within 40 feet of the boundary wall. But in the neighbourhood of small-pox 32 Healthy Hospitals. [ch* hospitals there would appear to be a graduated intensity of infection, and it has been shown that the incidence of small- pox upon houses within a mile radius of a small-pox hospital, apart from any infection due to the conveyance of patients to the hospital, was as follows : — The total number of cases under review was 2,527. For every 100 houses in the circle of a quarter of a mile from the hospital there were i7'35 cases. In the ring between a quarter and half a mile, 9'25. In the ring between half and three-quarters of a mile, 6* 16. In the ring between three-quarters and one mile there were 2'57 cases in every 100 houses. On this account it has been considered that small-pox hospitals are not properly admissible in a populous locality ; fortunately small-pox patients may under ordinary circum- stances be conveyed some miles by land in well-arranged ambulances without much risk, so that in a town it is only necessary to provide for a limited number of acute cases, and these can be safely treated even among a dense population, provided arrangements be made to burn all the air which passes out of the ward in which they are placed. Some years ago the Surgical Society of Paris appointed a committee to consider what should be the minimum area of site to be allowed for each sick person in ordinary hospitals. The Committee recommended that this minimum area should be 50 square metres, or say 60 square yards per patient. It must be remembered that the resident population of a hospital is much more numerous than that indicated by the number of beds, as it includes nurses, servants, staff, and resident medical officers. It will probably be found not far out of the way to assume that the total resident population in a hospital amounts on the average to one- half as many again as the patients. The proportion of space per patient mentioned above means for a hospital of 100 beds nearly i\ acres; 200 beds, nearly %\ acres ; 500 beds, rather over 6 acres. m.] Site, 33 These areas, however, are only admissible in cases where the obtaining of a larger site is a matter of exceptional difficulty, and there are few town hospitals in this country which occupy areas as small or smaller than these. For instance, the Leeds Hospital, which stands in the centre of the town, when originally constructed, occupied about 3^ acres or 56 yards per bed for 328 patients, instead of something over 4 acres, according to the standard above mentioned, but in this case the site is surrounded by streets, which brought up the area of open space between surrounding houses to very much more than the standard of 60 yards per bed before mentioned. The Marylebone Infirmary affords little over half the above- mentioned standard area, viz. under 3a yards per patient ; but at the present time there is ground quite open to the country on one side. The old hospitals of King's College, Middlesex, and Charing Cross, cannot be cited as desirable examples of a site. Uni- versity College Hospital has had the advantage of the grounds of the College opposite to it. St. George's Hospital occupies about seven-eighths of an acre. On this area it has to accommodate -^^6 patients all under one roof, or at the rate of 12 square yards per patient, instead of the allowance of 60 square yards per patient recom- mended by the Paris Surgical Society; these, with the nurses and others living in the building, bring up the resident number to a population of 580 per acre, which is a larger popula- tion per acre than the most thickly inhabited quarter of London. In addition to which there is a medical school and a large out-patients' department crowded on to the site. The site has, however, the benefit of a fine open space on three sides, but this advantage is very much diminished by the way in which the buildings have been agglomerated, so as to prevent the permeation of fresh air to the centre, as well as by D 34 Healthy Hospitals. [ch. numerous projections which impede the flow of sunshine and fresh air to the wards. As a contrast to this hospital we may instance the Johns Hopkins Hospital which stands on an elevated site at Balti- more. It accommodates 361 patients on 14 acres, with a superficial area per bed of about 186 square yards, and every building is separate ; there is ample permeation of air and sunlight round all the buildings. We may also mention the New York Hospital, which was built in 1877. It stands on nearly an acre of ground in the centre of New York, and accommodates 180 patients, affording nearly 30 square yards per bed. It is built with five floors of wards. This hospital is, however, arranged to admit light and air to every part of the building, in addition to which the wards are supplied with carefully devised arrangements for artificial ventilation. St. Thomas' Hospital was built to accommodate 573 patients, and the area of the site affords above 70 yards per bed, in addition to which the site faces the River Thames, which supplies a constant aeration. The New Liverpool Hospital affords about 90 yards per patient, but there are public streets on three sides, and the grounds of the medical school on the fourth side, which give additional aeration. The Burnley Hospital was arranged to allow no yards with 88 beds, and if extended to 132 beds 73 yards, but this hospital had an open space on one side. The Bradford Hospital, in the centre of the town, with i.'if'X beds, affords about 100 yards per bed, and the site is surrounded by buildings. The Glasgow Western Infirmary, besides being built on an open site, affords 154 yards per bed, and the Edinburgh Royal Infirmary, also in an open situation, affords 93 yards per bed. Of the more recent foreign hospitals, the Antwerp Hospital affords about 118 yards, and the Berlin Military Hospital III.] Site. 35 above 135 yards per bed, and the Berlin Civil Hospital 190 yards per bed. The St. Eloi Hospital at Montpelier occupies 22 acres, and accommodates 600 patients, or at the rate of nearly 180 yards per bed. The hospital at Menil Montant (Paris) contains 726 patients and occupies a little over 13 acres, affording about 89 square yards per bed, but it stands in an open and airy situation above Mont Martre. The conclusion to be drawn is to obtain as much open space round a general hospital as its position will admit of. The Infectious Fever Hospitals of London afford the fol- lowing areas per patient : — The Eastern Hospital atHomerton, 98-5 yards ; the North-Western Hospital at Haverstock Hill, 128 yards; the Western at Fulham, 100 yards; the South- western Hospital, 117 yards; and the South-Eastern Hos- pital in the Old Kent Road, 115 yards. In these hospitals the rule is not to place a sick ward nearer than 40 feet from the enclosure wall. In fact the minimum space laid down by the Surgical Society of Paris has only been acted on in very exceptional circumstances, and should be strictly limited to the case of small hospitals. Good hygienic conditions are comparatively easy to obtain even in towns in hospitals of from 150 to 250 beds, but very difficult to obtain, especially in large towns, if these numbers are exceeded. In proportion as the cases of disease are agglomerated together, so is the degree of vitiation increased ; hence a hospital with few patients may be placed upon a smaller area, per patient, than a large hospital ; in other words, the area of space occupied by a hospital, per patient, should be increased in proportion to the number of patients. With a hospital of from 100 to 200 beds, 60 square yards per patient might suffice under very exceptional conditions, D 2 36 Healthy Hospitals. but with 300 to 400 beds the area should be at least 90 yards per patient, and with 500 beds and upwards, 120 to 140 square yards per patient would be required. But it may be safely laid down that, on a town site surrounded by houses, it is not desirable to afford in any hospital less than from 90 to 100 yards per patient to be accommodated ; or practically a town site should not contain more than 50 beds per acre, and for fever and infectious hospitals a larger area should be pro- vided, and the number per acre should be limited to o^^^ 40, or at most 45 beds per acre. Hence it would be preferable that in the centre of cities hospitals should be erected for urgent cases only; and in any case, hospitals in the centre of towns and surrounded by dwellings should not be constructed for more than from 300 to 300 patients each, which would be sufficient for clinical purposes. Where large hospitals are built they should be installed on open sites in the country, because there the land required would be comparatively cheap, and the absence of surrounding houses renders the question of area a secondary consideration. As regards the acquisition of sites for hospitals, it is no doubt reasonable that when a new hospital is projected the site on which it is to be placed should be a matter of private arrangement. But in the case of well-established hospitals, which are in efficient action for the public good, and con- ducted without any desire of gain, it would certainly appear reasonable, where their managers are anxious to enlarge their premises with a view of increasing the amount of accommoda- tion, or of ameliorating the condition of their patients, that the power should be afforded them, under proper restrictions, of purchasing compulsorily adjacent land for such purposes. The Metropolitan Asylums Board possesses such power under a recent Act of Parliament, and there seems to be no reason why this should not be extended to other responsible hospital authorities in the Metropolis and in other large cities. CHAPTER IV. CONDITIONS WHICH VITIATE THE AIR IN AN OCCUPIED ROOM. It will be convenient in the first place to explain briefly what are the reasons on the ground of health why a certain air-space is wanted, and though in other books this subject has been treated at length, it may be convenient here to summarise the reasons for change of air. Let us first consider how far do we obtain pure air out-of- doors. Really pure air is composed as follows, viz. Oxygen 209-5 Nitrogen 7^9' 3 Other Gases -2 Parts of Air 1000 The oxygen is necessary to life, but if it were breathed pure, it would burn us away. The nitrogen is an inert gas which dilutes the oxygen and prevents it from being injurious in the process of breathing. In air out of doors in the open- country, there are from 3 to 4 parts of carbonic acid gas (CO2) in 10,000 parts of air, indeed it is sometimes as low as 2 parts ; this amount will sometimes be increased by vegetation, as in a wood, or by the emanations of animals, as, for instance, in proximity to a flock of sheep. In towns a much larger quantity will sometimes be found. Dr. Angus Smith showed an average of 3-8 in the streets in London, as compared with 3-0 in the parks, and he found that as much as 6-8 per 10,000 parts of air were present 38 Healthy Hospitals. [ch. in confined streets in a fog in Manchester. Dr. Russell has found as much as 9, ti, and even 14 parts of CO2 in 10,000 volumes of air in a dense fog in London. But on the whole it has been considered that 4 parts per 10,000 of CO^ in outside air may be assumed to be the standard amount. Moreover there is always dust in air, i. e. solid particles. Dr. Langley has observed the presence of dust in air on the tops of the highest mountains. The rain washes the dust out of the air ; Dr. Aitken found near his laboratory in Glasgow, that whilst during rain, a cubic centimetre of air out-of-doors contained 32,000 of these solid particles largely inorganic, in dry weather it held 130,000 particles, and in his room the air in some parts yielded nearly 6,000,000 particles. Professors Carnelley, Haldane, and Bedson have shown that the air of a room, in which much movement of persons or of articles takes place, exhibits much more dust than that of a room which is left for a long time in absolute quiescence. This dust consists partly of inorganic matter, and partly of minute organisms. The number of organisms^ e. g. bacteria and spores found by Dr. Miguel in air from the streets in Paris, averaged 3,480 per cubic metre in summer. In the vicinity of the Mont Souris Observatory they averaged only 480, whereas none were found on the top of a high mountain in the Alps. In winter the numbers found were much less than in summer. In the open country in summer the dust in the air consists largely of pollen. This dust affords nuclei upon which the aqueous vapour in the air can settle, and this forms haze and fogs, and when the particles are over-loaded with moisture they fall down as rain. Near the sea, where the inorganic dust contains saline particles, or in towns where it contains ammonia, its affinity for moisture is greater, and fogs are more prevalent ; and where smoke from our coal fires is added, the tarry matter renders the fogs more persistent, and the sulphurous acid makes them more unpleasant. IV.] Conditions which Vitiate the Air, etc. 39 When a person is in an open space out-of-doors, the air is perpetually flowing past him. It has been estimated that the air of the atmosphere moves at a rate of rarely less than from 5 to 7 miles per hour ; the former is equivalent to 7 feet per second, but the average movement is from 20 to 24 feet per second. Now 24 feet per second means 17 miles per hour; but let us consider what the effect will be of a move- ment of only 7 miles an hour, or 10 feet per second. Imagine a frame about the height and width of a human body in the open air: that is to say, about 6 feet high by i^ foot wide, occupying an area of 9 feet. If this be multiplied by 10 feet per second for the velocity of air, it will give as the quantity of air which will pass over an individual in one second 90 cubic feet, in one minute 54°° cubic feet, and in one hour 324,000 cubic feet. Even out-of-doors the effect of congregating large numbers of persons together may prevent the free access of fresh air to those in the middle of a crowd. As an instance of this, it has happened that on a still day, persons in the middle of a crowd have fainted for want of air. But in an occupied room the respiration of individuals, their perspiration, the burning of candles, emanations from food and all such matters, vitiate the air of rooms at a certain rate. Every human being, in order to live, must be constantly breathing ; in the act of breathing he takes in oxygen, and throws out from his lungs carbonic acid (CO,) ; but he also throws off a large amount of watery vapour, organic matter and ammonia. This organic matter consists of epithelium, and molecular and cellular matter. In addition to this matter from the lungs, portions of epithelium are constantly being given off from the skin. In hospitals there are sometimes pus cells in the air, which are given off from suppurating surfaces, A large amount of watery vapour is also given off from the skin. 40 Healthy Hospitals. [ch. The amount of watery vapour varies ; but taking the amount given off by an individual in ordinary health from the skin and lungs together, it is enough to saturate about 90 cubic feet of air per hour, at a temperature of 6'^ Fahr. This watery vapour is full of the organic matter which is thrown off from the body. With persons suffering from disease, especially infectious fevers, or from wounds or sores, these emanations, as well as those from the lungs in the case of phthisis, are greater in quantity, and it is generally assumed more poisonous in quality, than from persons in health. Hence it may be assumed that vitiation occurring in the air of occupied rooms may arise — (1) From products of normal respiration and perspiration; (2) From products of disease, want of cleanliness, or other abnormal conditions of the persons present in the rooms ; (3) From impurities arising from the floor, walls, &c. of the room itself. As a rule the proportion of carbonic acid present in the air is taken as a sufficient index of vitiation. But air which, judged by the carbonic acid standard, is sufficiently pure, might be exceedingly impure when judged by the number of micro-organisms present in it, and vice versa. The carbonic acid and micro-organisms have different sources. The amount of the former depends on the number of persons or lights burning in the rooms as compared with the means of ven- tilation — that of the latter being determined chiefly by the conditions of the room itself and its occupants as regards cleanliness, &c. The immediate dangers from breathing air highly vitiated by respiration appear to arise mainly from the excess of carbonic acid and deficiency of oxygen. But the actual quantity of air impaired each minute by any one individual in a state of comparative rest is really IV.] Conditions which Vitiate the Air, etc. 41 small. About i of a cubic foot of air is vitiated by breathing (inhaled and exhaled) in the one minute's time, and even this is not entirely spent for use over again. To this must be added the quantity of air vitiated by transpiration, from the person, of moisture laden with organic matter. Ventilation would probably be perfect, if there could be removed, without admixture of other air, the volume of air exhaled in breathing, together with a layer of air next the person, and the two volumes were taken to be one cubic foot of air per person per minute, while at the same time there should be furnished the same quantity, to answer the double purpose of supplying fresh air for inhalation, and a new ' atmosphere ' next the person. But as we cannot in practice thus catch emanations from each person, they mix with the surrounding pure air, and our only remedy is to dilute this mixture with an adequate volume of outside air, so as to bring the whole to some accepted standard of impurity. The measure of impurity of air in an occupied room has been till recently always taken from the excess of CO2 in the occupied room over that out-of-doors, and from Professor Haldane's recent experiments, this would appear to be a safe standard to rely upon. The estimates of sanitarians as to the amount of air re- quired are generally based upon the observations of De Chaumont, Parkes, and others, as to the amount needed to keep an occupied room free from perceptible odour to a person entering it from the outer air, and on the percentage of car- bonic acid which is found in the air of rooms in which this animal odour is barely perceptible. When, as a product of respiration, the proportion of carbonic acid in a room is increased from the normal ratio of between 3 and 4 parts in 10,000 to between 6 and 7 parts in 10,000, a faint, musty odour is usually perceptible. Assuming that the air of an inhabited room should be just so impure as to 42 Healthy Hospitals. fCH. possess this odour, the following table by Parkes shows the amount of air necessary to dilute to this standard : — Amount of cubic space (breathing space) for one man in cubic feet. Ratio per 1,000 of carbonic acid ftom respiration at the end of one hour if there has been no change of air. Cubic feet of air necessary to dilute to standard of -2, or including the initial carbonic acid, of -6 per 1,000 vols, during the first hour. Cubic feet of air necessary to dilute to the given standard every hour after the first. lOO 6-00 2,900 3,000 200 3.00 2,800 3,000 300 2.00 2,700 3,000 400 1.50 2,600 3,000 500 1.20 2,500 3,000 600 1. 00 2,400 3,000 700 0.85 2,300 3,000 800 0.75 2,200 3,000 900 0.66 2,100 3,000 1000 0.60 2,000 3,000 The above table refers to rooms occupied for a number of hours consecutively. Dr. de Chaumont's experiments were made in barracks and in hospitals, and a result comes out from them confirmatory of the opinion that, in the case of sick men, more air is required to keep the air-space pure to the senses than is necessary in the case of men in health. Thus, in barracks, the mean amount of respiratory carbonic acid, when the air was pure to the senses, was -196 per 1,000 volumes, but in hospitals it was only -157 ; or, in other words, whilst in the hospitals the air would have smelt somewhat impure when the CO2 was -196, in the barracks with that amount it was fresh. Surgeon-General Billings, of the U. S. Army, gives a com- paratively simple method of testing for CO2 in breathed air in the appended foot-note ^. ^ For ordinary purposes a conve- of carbonic acid is the following, nient method of testing the amount for which there will be needed six IV.] Conditions which Vitiate the Air, etc. 43 Various methods have been used for measuring the organic matter in air. Dr. Angus Smith devised two methods. According to the first of these methods, a definite quantity of the air to be examined is slowly bubbled through a dilute solution of potassium permanganate of known strength, until it is fully or considerably bleached, and the amount of unde- composed permanganate determined by oxalic acid. In the second method a known volume of air is bubbled through distilled water, and the latter examined for free and albuminoid ammonia by Wanklyn and Chapman's process for water analysis. These methods are, however, inapplicable in circumstances and in places where such determinations are most desirable, chiefly on the score of time and of the extent and compli- cation of the apparatus required. Moreover, very considerable variations in the organic matter are sometimes liable to occur within the period of determination required by Dr. Angus Smith's method. well-stoppered bottles, containing 10,000. If no turbidity appears, respectively 450, 350, 300,250, 200, treat the next sized bottle, viz. of and 100 cubic centimetres, a glass 200 cubic centimetres, in like man- tube or pipette graduated, to con- ner. Turbidity in this would indi- tain exactly 15 cubic centimetres to cate 12 parts in 10,000. If this a given mark, and a bottle of per- remains clear, but turbidity is pro- fectly clear and transparent fresh duced in the 250 cubic centimetre lime-water. The bottles must be bottle, it makes about 10 in 10,000. perfectly clean and dry. Having The 300 cubic centimetre bottle made sure that they are filled with indicates 8 parts, the 350, 7 parts, the atmosphere which is to be ex- and the 450 less than 6 parts. To amined, which can best be done by judge of the turbidity, mark a small pumping into them a quantity of piece of paper on the inside with this air by means of one of the a cross in lead pencil, and gum to small handball syringes, which may the side of the bottle on the lower be procured in any drug store, and part. When the water becomes tur- taking care that none of your own bid the cross will become invisible breath is pumped in, add to the when looked at through the water, smallest bottle by means of the Thiswill enable one to judge roughly pipette 15 cubic centimetres of the of the amount of carbonic acid in lime-water, put in the cork, and the air. For more accurate analysis, shake the bottle. If turbidity ap- the method of Pettenkofer, as de- pears, the amount of the carbonic scribed by Parkes, should be em- acid will be at least 16 parts in ployed. 44 Healthy Hospitals, [ch. A modification of Dr. Angus Smith's plan has been adopted by Dr. Carnelley, that is to measure the volume of oxygen required to oxidise the organic matter in a definite number of volumes of air by the reduction of potassium permanganate \ This method, however, does not give absolute, but only relative results. The general conclusions, however, which Dr. Carnelley obtained from a number of experiments are deserving of notice here : — (i) As regards outside air, the quantity of organic matter varies considerably, within certain limits, from day to day, and from hour to hour on the same day. Variations from day to day are subject to the conditions of the weather. It has been found somewhat less immediately after or during rain or snow. The highest results of all were obtained on foggy nights, e.g. 15-7, 17-0 volumes of oxygen were required to oxidise 1,000,000 volumes of air. High results were also obtained during a slight drizzling rain, accompanied by mist. (a) A close connexion is observed between the amount of organic matter present in air and the combustion of coal. The organic matter is lowest in the middle of the night, rather higher in the morning, and considerably higher in the middle of the day, and higher still towards evening, after which it decreases. On comparing the averages of a large number of cases it appears that a high carbonic acid is accompanied by a high organic matter, and vice versa. But whilst the carbonic acid seldom passes beyond the limits of 2 to 6 volumes per 10,000, the organic matter varies ^ There are some objections to matters in the air, besides the or- this method ; for instance — ' it does ganic matter, such as sulphuretted not directly estimate the organic hydrogen, nitrous acid, sulphurous matter, but only measures the acid, &c. Moreover the organic amount of oxygen required to oxi- matter in air is of various kinds, dise either the whole, or more pro- and consequently the permanganate bably only a portion of it ; and the will most probably be selective in permanganate acts upon various its action.' IV.] Conditions which Vitiate the Air, etc. 45 from a quantity too small to estimate to as much as will require for oxidation about 16 volumes of oxygen per 1,000,000 volumes of air. The organic matter in air is most probably partly solid and partly gaseous ; the solid — obeying a different law to that of diffusion — slowly settles down, whilst the gaseous part, unlike carbonic acid, is most likely an unstable compound or com- pounds, and readily undergoes oxidation. An atmosphere which has been entirely at rest for some time is found to contain less organic matter than it did previously. This is not necessarily entirely due to the settling down of the solid organic dust, but is probably due in part to oxidation. It may, however, be assumed that the quantity of CO2 in breathed air will within limits, on the average, afford under ordinary circumstances a fair test of the quantity of organic matter present. An index of the degree of impurity in the air in occupied rooms has been sought in the presence of those minute organisms which have been recently brought into prominent notice by the increased attention given to the study of bacteriology. But our knowledge of this science and of the nature of organisms is too recent to allow us to lay down any fixed rules for judging of what are the dangerous characteristics of air in wards measured by this standard. In addition to this, there is a further difficulty with such a test. The dust and the number of organisms present in the air of any room may be enormously increased at any moment by movement of persons or materials in the room. The shaking of a counterpane, the movement of a nurse or of a patient, might seriously change the conditions exhibited by this method of test. Moreover, any test for impurity in the air of a sick ward should be such as can be made without undue delay, and the time required for the cultivation of the organisms present in the air would prevent this method of 46 Healthy Hospitals. testing air from being available, except for special objects and enquiries. In considering the vitiation of the air in its relation to ventilation^ it has to be remembered that the emanations from the bodies of patients do not diffuse themselves so rapidly or uniformly as, under ordinary circumstances, is the case with carbonic acid. They hang about as the smoke of tobacco may be said to do, in corners and places where there are obstructions to the movement of the air. For instance, in some experiments made upon the air of a well-ventilated ward, it was found that whilst there were 5*8 volumes of CO^ per 10,000 volumes of air near the patients, and 8-5 volumes in the centre of the ward, the volumes of oxygen required to bleach the organic matter in 1,000,000 volumes of air was fifteen times as much, near the patient's bed, as it was in the centre of the ward. This may probably be accounted for by the fact that any movement, as^ for instance, of the bedclothes of a patient, would largely add to the organic dust in the vicinity. CHAPTER V. QUANTITY OF AIR NECESSARY TO MITIGATE THESE CONDITIONS. If the condition of the air throughout the ward were uniform, ventilation would be comparatively simple, and whatever were the amount of the floor-space or cubic space, the whole air would attain a permanent degree of purity, or rather impurity, theoretically dependent upon the rate at which emanations are produced and the rate at which fresh air is admitted, and the question of space between the patients would be of less importance. That is to say the same supply of air will equally ventilate any space^ or which is the same thing, the same supply of air is required for a small space as for a large space. Hence the question of what should be the minimum cubic space depends upon the following considerations : — (i) An adequate floor-space. (2) A change of atmosphere frequent enough for health, but not so frequent as to cause draughts. (3) Sui^cient space to reduce to a comparatively small amount the danger from temporarily impeded ventilation. (1) Adequate floor-space. The floor-space is the im- portant element of the cubic space ; whilst it is undesirable that any ward should be less than 12 feet high, it has been generally assumed that, in hospitals, the height above 12 feet may be left out of consideration in calculating cubic space ;^ 48 Healthy Hospitals. [ch. but this cannot be accepted as an axiom because, with a very long or wide ward, the height forms an important element (1) in the movement of the currents of air, (2) in the pene- tration of daylight ; and whilst we may accept a height of 12 feet for a barrack room or ward of 20 to 22 feet wide, the due movement of the air in wards of 26, 28 and 30 feet require heights of 13 feet, 14 and 15 feet, and with greater widths 16 feet. Exclusive of the question of the due aeration of the space occupied by the patient, the floor space must suffice for — {a) Adequate space between sides of beds, to admit of all necessary operations of nursing. {h) Adequate width at foot of bed for furniture, and easy movement about the ward. {c) Adequate space for students, when there is a Medical School. The distance between beds at a low computation should not be less than from 4 feet 6 inches to 5 feet ; this, with a three-foot bed, would afford a lineal bed-space of from 7 feet 6 inches to 8 feet : assuming the foot of the bed to be 7 feet from the wall, each bed-space should extend 6 feet at least beyond the bed ; thus each bed would occupy a space of 8 feet X 13 feet, or 104 square feet of area, which would afford 1,300 cubic feet, with a ward 12 feet 6 inches high; 1,350 cubic feet with a ward 13 feet high ; and 1,450 cubic feet with a ward 14 feet high. Of course this floor-space would be a minimum and must be increased if there is a Medical School, or in the case of an excess of emanations from the patients, wherever the ventilation does not adequately remove such emanations. But it must be remembered that any increase to the floor or cubic space beyond what is actually required causes unneces- sary outlay in first construction, and entails a continuing excess in the charges for warming and service. And it may be assumed as an axiom that, without unduly depreciating the beneficial effect of abundant air-space, the frequency with v.] Quantity of Air Necessary, etc. 49 which, and the manner in which, the air is changed, is a far more important point to be attended to in providing a purer atmosphere, than floor space or cubic space. (2) A change of atmosphere frequent enough for health, but not so frequent as to cause draught. And — (3) Sufficient space to diminish danger from impeded ventilation. Let us first consider the effect of arrested ventilation. Let us suppose two occupied spaces, one of 500, and the other of J 000 cubic feet, ventilated so that the ratio of carbonic acid is -06 per cent., and that from some cause or other the ventilation is arrested in both, the condition will then be as follows : — Ratio of Impurity, calculated fro7n Prof. DottkirCs formula. 1000 ft. CO2. Soo ft. CO2. After I hour . -12 per cent. . .18 per cent >, 2 hours . • -18 „ . -30 „ „ » 3 >) • -24 » . .42 „ „ » 4 )) • • -30 » . -54 „ » „ 6 )) . .42 „ . -78 „ „ „ 7 >j • -48 „ • -9° „ „ There is difference of opinion as to the amount of carbonic acid that can be borne, but when conjoined with fetid organic matter, as in the products of respiration, it is pretty generally agreed that -3 per cent, can hardly be supported, and that at •5 per cent, the atmosphere is unendurable. From the foregoing table it will be seen that -3 per cent, is reached in the case of 500 feet in two hours, but in the case of 1,000 feet in four hours, whilst '5 per cent, would be reached in the former case in about three and a half hours, in the latter not until seven hours had elapsed. The change of atmosphere frequent enough for health depends upon the observance of certain conditions of temper- ature and humidity, as well as upon the amount of impurity from CO2 in occupied rooms. £ 50 Healthy Hospitals. [ch. On this account the atmospheric conditions of the country in which the hospital is to be placed have to be studied. The comfortable warmth of air indoors is given by various authorities, as follows : — Peclet, 'Traite de la Chaleur,' gives 59° Fahr. Morin, ■ Etudes sur la Ventilation,' for nurseries, schools, &c. 59° Fahr., hospitals 61° to 64° Fahr. Tredgold, ' Principles of Warming and Ventilating,' &c., 56° to 62^ Fahr. Reed, ' Illustrations of the Theory and Practice of Ventilation,' 65° Fahr. De Chaumont, 62° to 65° Fahr. for hospitals. These apply to this country, and to France ; whilst in the United States Surgeon-General Billings lays it down that the tem- perature of 68° to 70° Fahr. is necessary. Comfort, if not existence, depends upon a constant loss of heat from the person. The internal natural warmth of the body is about 98-6° Fahr., and this is independent of the heat of the external air, and is maintained by the food we eat and the oxygen we breathe ; the personal comfort which arises from the temperature and humid condition of the air proceeds from the cooling effects which must go on with constancy and regularity, and yet not so fast as to produce the sensation of cold. The origin of the natural heat is well established. There is inhaled by each adult in comparatively still life, each three to four seconds, from 30 to 40 cubic inches of air, under such atmospheric conditions as may exist at the place. Thus there may be extreme differences of temperature ranging from —40° to + 140° Fahr., as well as extremely variable proportions of humidity, from the point of saturation on the one hand to that of nearly an anhydrous air on the other. A portion of the oxygen of the inhaled air is con- sumed in the system ; and the exhalation which follows each inhalation, emits about 4 per cent, of carbonic acid, and i\ per cent, of vapour of water. Two or three grains of carbon are consumed in the system each minute, giving out 3I to 5| units of heat ; the unit of heat being the equivalent of a v.] Quantity of Air Necessary, etc. 5 1 pound of water heated 1° Fahr. It is the dispersion of this heat which establishes the sensation of comfort. The deprivation of heat from the person is more due to evaporation from the lungs or throat, and from the skin, than from heat lost by conduction to the surrounding air or dis- persed by radiation to adjacent objects. Thus the inhalation of cold vapour from fog may cause much discomfort from the rapid absorption of heat which it induces. And the hygrometric state of the air has so much effect in inducing or retarding evaporation, as to make ^6° Fahr. in the west and south of England, in Ireland and in Normandy, sensibly as warm as 80° in Canada or Minnesota at the same season. As regards Tempei'atiire, it may be assumed for hospitals that the dry-bulb thermometer ought to read 63° Fahr. to 6^ Fahr., and should not if possible go much below 60° Fahr. The wet-bulb ought to read 58° Fahr. to 61° Fahr. In any case the difference between the two thermometers should not be less than 4° Fahr. or more than 8° Fahr. In the open air in healthy weather it is often 8° or 9°. The difference is of course increased in hot and dry climates. Vapour ought not to exceed 4-7 grains per cubic foot at a tem- perature of 6'^, or 5-0 grains at a temperature of 6^ Fahr. The limit of humidity which can be permitted in hospitals in this country is ']^ per cent, of total saturation or under. When the outer air is saturated, as in wet weather, the reduction of the humidity in a room will depend on the increase of temperature of the air admitted. The capacity of the air for moisture increases enormously with the temperature, and that which would saturate air at 50° Fahr. would give about 70 per cent, at 60° Fahr. Thus, at 50° Fahr. a cubic foot of air is saturated by 4-1 grains ; but at 60° Fahr. it requires 5-8 grains, so that 4-1 grains would give us only 71 per cent. The table on the next page shows the proportion of moisture required to saturate air at different temperatures : — E il ■52 Healthy Hospitals. [CH. < O < 'S >^ 3 CJ O ^ rt U-i > O m Tt (U fi j:^ cti u OS 6* 3 u. O dj a, x) rt r- > .Jh W a, S (U ^ a °T3 rt u S u rt g c t. ^^ ro >-i i-H u^ OS O 1-1 00 MD Weight of Dry Air mixed with one pound of Vapour in pounds. lO ^ t^ ON '^ i-O OO LO g ^ GO t^ liH ro OS ^ O N ro M •rf OS N l_i ^ ON srs M OO LO '^f N o N (— t ^- -S-a d) 5s'M:hl _ N OS OS ON O M r^ LO ON t^ r^ 00 SO '^ SO el Weig Vap mixec one p of A pou o ro 00 so ro u-l ''t Q n O hH h-t cs rj- M '^• q q q q q q CJ of„H§ " ON Tf t^ ^ ^ r^ t-^ SO o ^ t^ () M 00 c^ sr:) OS N d m lY^ N "^ OS N OO '^ 00 .2 so o r^ u^ m 01 OO OO so t^'S 2 2 CO 00 t^ t^ r-N t^ so LO fT IS" O o q q q q q q q ^ s ^ ° ri o 0-3 3 .. ft. ON Tl- r^ 1— ( ^_< r^ r^ so o R> l^ o N 00 N so CJN t^ o CO OO t-^ t^ t^ t^ SO '^ o If- O q q q q q q q • for Air IX tu r an ur i sof ury t~^ n ro vr% so OS vo M o t^ ^ fO so ro N 00 ON o lastic f the heM of Ai Vapo inche Merc GO t^ "-1 CO i-i oo 00 ON o ON ^^ OS ON ON CO t^ 1— f o M cs M N N N « M W o* s ti •3 S'-g S w Tl- w CO so M so O M u- 4j rt t; ti c • bo o j>,it: g 5 o f^ Os i-i O ^ ON t^ SO LO O O O -r hS ft. a, o " LO O M M M N fO ro Q Tl" SO CO O Tj- On O O O O "-I 1-1 v.] Quantity of Air Necessary, etc. 53 The diagram (Fig, i on page 54) shows the increase in the capacity of the air for carrying off moisture, as the temperature of the air rises. The curved lines represent 10, 20, &c. to 100 percent, humidity; 100 per cent, being the dew point. The horizontal line of figures from 10 to 200, at the top of the diagram, indicate the grains of moisture per cubic foot of air, while the temperature of the air is given in degrees Fahr, at the left side. If therefore the outer air is at a temperature of 50°^ and if the temperature inside the room be maintained at a comfortable standard, say 6'^ to 6^, the incoming moisture due to the condition of the outer air would never cause an excess of humidity. In the case of an external atmosphere saturated at or above the temperature in the room, such as occurs occasionally in hot climates, it would be necessary to let in an unlimited quantity of air through every possible aperture. The volume of air which should be provided in a room to maintain the atmosphere at a proper degree of humidity, depends upon the sources of vapour inside the room. Every man gives off from lungs and skin each hour enough to raise the humidity from 70 per cent, to complete saturation in 500 cubic feet at 60° Fahr., and to raise it to 82 per cent, in 1500 cubic feet. Now to reduce this amount to ']'^ per cent, would take 3,000 cubic feet of air saturated at 50° Fahr,, or 2,000 at 98 per cent. But the vapour given off by the body is not the only source of humidity. Humidity may arise from the combustion of lights. For instance, a gaslight affording i candle power of light, that is to say giving an amount of light equal to a sperm candle burning 1 20 grains per hour, will emit -025 lbs. of watery vapour, A sperm candle would for the same amount of light give out -02 lbs. of watery vapour, and an oil lamp •018 lbs. Thus we shall not be far wrong in considering the effect on the air of each gas or candle light burned in the room as equivalent to that of a human body. 54 Healthy Hospitals. [CH. M E }!at4U9j(iivj sa9jSsQ v.] Quantity of Air Necessary, etc. 55 The humidity will moreover be affected by the vapour of liquids used in the room. Upon this theoretical assumption it would appear that with an initial air-space of 1000 cubic feet occupied by one indi- vidual it would be necessary to supply 3000 cubic feet, per hour, to maintain the room in a proper condition of humidity. As regards other impurities, if 0-2 per 1000 of CO2 is accepted as the limit of respiratory impurity in a well- ventilated air-space, in addition to the 0-4 per 1000 in normal air, we can calculate the amount of air necessary for the purpose. For this, it is more convenient to state the ratio of COg per cubic foot, so that o-3 per 1000 would be 0-0002 per cubic foot, and calling this M, the amount of CO2 given out by a single individual C, and the delivery of air required ;ir, we have : _C_ ^~ J/' Now, when C = o-6, and M = 0-0002, we have the following : 0.6 0-0003 ^ Or, it requires 3000 cubic feet per hour to preserve the air-space in the required state of limited impurity. Upon these assump- tions the theoretical calculations, based first upon humidity and secondly on carbonic acid, bring us to similar conclusions in each case. In connexion with this it is desirable to mention that experiments made in barracks showed that a much less amount of air, per head, delivered through ventilators kept the air of the room in a satisfactory con- dition as tested by the sense of smell ; and this was attributed, partly, to the badly fitting doors and windows, and partly to porosity of walls. The barrack-room walls were generally of brick, lime-whited without plaster. The volume of air which will flow through ordinary brick walls and plaster is very great. 56 Healthy Hospitals. [CH. The experiments of Shultze and Marker, and of C. Lang of Munich, showed that with a brick wall of ordinary thick- ness, and a difference of temperature of o^^ between that of the room and the outside air, very nearly lo cubic feet of air passed through each square foot of wall surface, but the mortar in the walls was nearly equal to one-sixth of the cubic content of the wall. A wall of mud and plaster allowed a passage of ] 8 cubic feet of air, per hour, per square foot of wall, with a difference of temperature of 20° inside the room as compared with that outside. These amounts would show that in the case of a closed barrack room or hospital ward at night, with a high inside temperature as compared with the temperature outside, 300 or 400 cubic feet, per occupant, per hour, might easily pass in through brick and plaster walls. But the porosity of a material is more fully shown by its power to absorb water. The following is the percentage of its own weight of water which each of the materials mentioned below has been found to absorb : — Bricks. per cent. Stones. aer cent. Malm cutters . 22 Good granite •5 Malm bright stock . . 22 Bad specimen granite 3 Brown paviors . • 17 Sandstone — Hard paviors . 9.5 ■ Craigleith 8 Common grey stock . . 10.5 Mansfield 10.4 Hard „ „ . • 7-5 Hassock (very bad quality) 20 Staffordshire — Limestone — Common blue . 6.5 Portland 13-5 Brown glazed brick . . 8.6 Ancaster 16.6 Bath 17 Chilmark 8.6 Kent rag 1-75 Ransome artificial stone 12 v.] Quantity of Air Necessary, etc. 57 From this it appears that walls of any of these materials, being always more or less porous, must admit of a continuous spontaneous change of air when dry. An experiment made in New York, by Mr. Putman, as detailed in the note^, showed that with every means taken to prevent porosity or cracks, the inflow through walls amounted to nearly 5,400 cubic feet per hour, in a room containing only a little over 3,000 cubic feet of air space, when the outside air was about 2fi° Fahr,, and that inside varied from 72° to above 90° Fahr. These facts may help to explain some matters connected with the healthiness of improvised hospitals. But with the modern system of ward walls lined with either highly glazed ^ Experiments on porosity of walls to air in an ordinary living room, by Mr. Putman of New York. The room was about 5 metres square and 3-6 metres high, having 5 windows, 2 doors, and a fire-place, with plastered walls and ceiling, and a soft pine floor. A flue 10 metres long, from a base- ment furnace, furnished the rooms with hot air. The windows and doors were first made as tight as possible with rubber moldings. The fire-place was then closed by draw- ing the damper and pasting paper over the cracks. The brick back and jambs were oiled to render them impervious. All the woodwork was thoroughly oiled and shellacked. A good fire was lighted in the furnace, and the register opened into the room, all doors and windows being closed and locked, and the key- holes stopped up. The hot air entered almost as rapidly with the doors closed as when they stood open, and it continued to enter at the rate of 2-5 cubic metres per minute without diminution as long as the experiment was continued. The thermometer stood at 2° C. outside. The entering hot air ranged from 40° to 55° C. The day was March 3, 1880. The pressure of the hot air from the register was suffi- cient only to raise a single piece of cardboard from the register. On the 5th March a coat of oil paint was applied to the walls and ceil- ings. This diminished the escape of air only about 5 per cent. On the 19th March four coats of oil paint had been put on the walls and ceilings, and three coats on the floor, to render them absolutely im- pervious to air. The escape of air was diminished only about 10 per cent. On the 25th March all the window sashes were carefully ex- amined, and all visible cracks at the joints, at the pulleys, cord fastenings, &c., carefully caulked and puttied. The result of all this was a dimi- nution at the utmost of but 20 per cent, in the entrance of air through a register. Each experiment was continued during more than an hour. The air entered as freely at the end as at the beginning of the hour. 58 Healthy Hospitals. [ch. bricks with cement joints, or with polished Parian cement, very Httle change of air can take place through the walls. In a warm climate the natural changes of temperature, and consequent alteration of the conditions which govern the movement of air, differ widely from those in temperate and cold climates, but there other conditions step in, and open \vindows and other apertures for air may be largely resorted to. Of course the admission of a definite quantity of air into a room means the removal of an equal quantity from the room. Consequently, 3,000 cubic feet being the quantity to be removed, we must now consider how often we can change the air of a room without producing a draught. This must depend upon varying conditions of temperature. Dr. de Chaumont's experiments led him to the conclusion that it would be difficult to effect a change of the air of a room oftener than six times in an hour under ordinary circum- stances. These experiments were made in barrack rooms affording 600 cubic feet of space. And the experiments of Pettenkofer led to a similar con- clusion. But even, with that amount of cubic space, this change would be difficult to effect without draught, unless the tem- perature of the incoming air was above that of the room occupied, because it must be borne in mind that this change is to go on at all times, whether windows be open or shut, although we cannot do away with the desirability or indeed the necessity of opening windows when circumstances permit. The problem is much simplified if, by giving a cubic space of 1,000 cubic feet, we limit the change of air to three times an hour, and with an increased cubic space of over 1,000 cubic feet we should require even a less frequent change. It will be recollected that Professor Faraday showed by experiments, that a velocity of two feet per second would not be perceptible, and with properly arranged inlets, no draught need be felt with a change of air of three times per hour. v.] Quantity of Air Necessary, etc. 59 The position of air inlets both in relation to their level and inclination will be alluded to in connexion with movement of air. But it will be convenient here to add a few words on the measurement of the quantity of air passing through inlets or outlets for purposes of ventilation. The only way in which actual measurements can be taken is by causing the air to pass along a channel the size and area of which is known, and then to measure the velocity with which the air passes through this channel. The multiple of the area into the velocity in a given time gives the volume which passes through in that time. It is, however, somewhat difficult to obtain correct results, because so many eddies accompany the flow of air in a tube, which are further aggravated by the introduction of measuring apparatus. The velocity of the air may be measured in various ways. It may be measured by puffs of vapour of turpentine, or by balloons filled with hydrogen and weighted to be of the exact specific gravity of air^ the time occupied by the puff of vapour or balloon in passing along a measured length being accurately ascertained. For low velocities, it is worth noting that a sheet of light tracing paper, moved through the air at 2 feet per second, takes up an angle of 45°, and affords a ready means of measuring that velocity ; and, for smaller velocities, the angle assumed by the flame of a candle affords a fairly accurate index according to the following table : — Velocity of flow of air. Feet per second. Angle of inclination of flame of candle with horizon. 1.6 1.0 0.75 0.50 .40 60° 64° 6o Healthy Hospitals. [ch. In other cases, where the flow of the air is more rapid, an anemometer may be resorted to. An ordinary form of ane- mometer is that of vanes fixed to a spindle, the revolutions of which are recorded by a counter. The vanes are turned by the direct action of the current of air, and the number of revolutions which are recorded by the counter gives the velocity. The vanes will only begin to move after the current of air has attained a certain strength, depending upon their weight and form, and this method of measure- ment is therefore not applicable to very low velocities. Of course the value of the revolutions has to be ascertained in the first place by direct experiment ; that is, by forcing a known bulk of air through a channel of a given size, and ascertaining the number of revolutions made by the vanes at different velocities, and thus obtaining the equation for the particular instrument. Another method of ascertaining the value of the revolutions is to move the instrument itself through stagnant air at given velocities. On account of friction the number of revolutions corresponding to a given volume of air when the current of air is moving slowly, does not necessarily correspond with the number of revolutions re- quired to measure the same volume of air when the current of air is rapid. The currents prevailing in the room, where the measurement takes place, have also an appreciable effect on the movement of the vanes. The most convenient apparatus for the purpose of measuring the relation between the motion of the vanes and the rate of the flow of air, is a graduated vessel constructed on the principle of the ordinary gas-holder, from which a known quantity of air can be drawn in, or expelled at will, through a channel of a size to correspond with the size of the anemometer, and so that the whole of the air will pass over the vanes, proper precautions being taken to protect the channel from eddies. Fletcher's Anemometer is another very convenient form for v.] Quantity of Air Necessary, etc. 6i measuring the speed of air in heated flues. The instrument consists of two parts : the first part of two metal tubes of about y^jy inch internal diameter, open throughout, and of any length ; the second part, of a manometer, or pressure-guage. Of these tubes, the end of one is straight and plain, while that of the other is bent to a right angle. When in use these tubes are placed parallel to each other, and so that their ends are exposed to the current of air to be measured. They lie at right angles to the current, which thus crosses the open end of the one and blows into the bent end of the other. By this means a partial vacuum is established in the straight tube, whilst the pressure of the current forces the air into the bent tube ; a differential manometer, attached to the outer ends of the tubes, shows the excess of pressure in the bent one over that in the straight one. The manometer used is a simple U-tube of glass set vertically, containing ether, fitted with vernier scales, by which the difference of level of the surfaces of the ether in the two limbs can be measured to rwoth of an inch. This difference of level between the columns of ether becomes a measure of the speed of the current passing the ends of the anemometer tubes ^. The connexion between the tubes in the chimney and the glass U-tube may be conveniently made by means of india-rubber tubing. 1 The law which governs the of liquid driven up the tube mea- speed is expressed generally by the sured in inches, and v is the velocity formula v = ^/ p x 28"55. The cor- measured in feet per second of air rections to be made for small varia- at a temperature of / degrees Fahr., tions of barometric pressure and under a pressure of h inches of temperature are unimportant. The mercury. corrections when required are em- Tables of the velocities corre- bodied in the following formula : — sponding with the readings are sup- plied with the anemometer, and V— sj p— — • X 28*55, ^^^° ^ table of correction for tem- 29.92 459 + ^ perature. See ' Healthy Dwellings,' where/ is the height of the column p. 69. CHAPTER VI. PURIFICATION OF AIR. The necessity for placing hospitals in the middle of towns has introduced the double question : — (i) Of purifying the air which is passed into the wards, for the protection of the patients. (2) Of purifying the air which is removed from wards, placed in the centre of towns, in which a contagious or infectious disease such as small-pox is treated, for the pro- tection of the surrounding population. (i) Purification of air passed into the wards. In large towns the fog-laden air in the winter is always injurious to patients, and it may often be said that the larger the quantity of air introduced into a ward the greater will be the fog in the ward. In cases of bronchitis and of diseases of the respiratory organs the presence of fog is especially injurious, as is shown by a rise of mortality from these diseases in the periods of dense fog in London. Air filters of dry cloth and cotton- wool filters become easily clogged, and when clogged no longer prevent the passage of dirt. Moreover, they do not prevent the passage of fog. The system adopted in the Houses of Parliament, viz. to pass the air through a spray of water and then to filter it through dry cotton wool, does not prevent fog from penetrating into the building. A method of purification by washing the air has been adopted at the Victoria Infirmary, Glasgow, under the design Purification of Air. 63 of Mr. William Key, which appears to fulfil the necessary conditions, when efficiently worked, of purification of air from smoke and fog. This plan has been in operation since the opening of the first portion of the Infirmary, April 1890. The Infirmary at that time contained 400,000 cubic feet of air-space, and it is stated that the apparatus was designed to renew this from five to nine times in an hour. The cold fresh air is drawn through the air-cleansing arrangement, by the agency of Blackman fans, which are placed between the chamber, in which the air is cleansed and then tempered by heat, and the flues through which it passes up to the wards. 'f>',.->^^f-:,. Loose pverhanginq '■Vi-'^', Flannel. ■' CocoAnut Ma.Hinq Screen. Fig. 2. Section of Water Trough. The suction of the fans draws the fresh air down a capacious air inlet 16 feet x 4 feet, lined with white enamel bricks and open to the sky. The mouth of this inlet is placed at least 10 feet above the level of the ground, to obviate the drawing into it the dust that prevails nearer the surface. This air from the outside is admitted to a chamber, which is divided in half by a close hanging screen. This screen is fixed to a beam near the ceiling by means of its upper side, and connected with a longitudinal trough extending along its whole length which is filled with water. The arrangement of the trough is shown in the sketch. The screen is 16 feet long and 12 feet high, thus affording nearly 200 feet of surface. 64 Healthy Hospitals. [ch. The screen consists of several thousand cords of cocoa-nut fibre or other suitable material stretched from the upper beam to another near to the floor of the air-chamber. The cords are placed so close that they touch each other ; copper wires are laced through the vertical cords in horizontal rows, which being drawn tight, give the screen a flat surface, so that when finished, the screen has the appearance of coarse cloth stretched across the apartment ; the rough fibrous nature of the material breaks up the entering air into very minute streams, which pass through equally all over its surface. The screen may be formed double in order to give an extra cleansing or scrubbing surface when desired. There is a constant trickling overflow of water down this screen from the trough, assisted by the capillary attraction through the loose piece of flannel or canvas which hangs over the edge of the trough, which keeps the screen wet. The wet surface catches the dust and soot particles in the air as it filters through, and when once these have adhered to the wetted cords, no current of air at whatever velocity can ever remove them, but they are carried down to float off at the drain by the flushes of falling water. For this purpose an automatic flushing tank is fixed in a position whereby 20 gallons of water is instantaneously discharged over the surface of the screen either once, twice, or three times an hour, as may be necessary, to flush and remove any accumulation of wetted dust, soot, or germs which may not be removed from the screen by the trickling water over its surface. This goes on automatically day and night. The wetted surfaces of the air filtering screen is a decided improvement over any dry cloth or cotton-wool screens, be- cause these must be frequently renewed as they become foul, and the dry process after a time will allow dust particles to pass through. The wet screen automatically flushed prevents this. The area of the screen should be such as to allow the air VI.] Purification of Air. 65 to pass through at a rapidity of not more than from 2 to 4 feet per second ; a lower velocity would be better, because if air is forced rapidly through a screen it cannot fail to carry dust with it ; this is very apparent in using dry cotton- wool filters. After passing the wet screen the air is warmed by coming in contact with steam-heated coils erected on a wooden plat- form. There are eight distinct coils in the air-chambers on this platform ; the steam to each coil is admitted by means of a gun-metal wheel valve ; the attendant may turn on one or more of the coils, or admit only a thin stream of steam to each, and thus increase or modify the temperature of each coil at pleasure. The coils are clustered in a space 16 feet long by 9 feet high, and formed of the best hydraulic tubes \ in. bore. During winter it frequently occurs that the mornings are bitterly cold, with keen frost, and provision is made for warming the air accordingly; but by eleven or twelve o'clock the sun shines forth and the air becomes warm and pleasant, to be followed in an hour or two by the air again becoming intensely cold. To meet this emergency, doors are erected between the incoming washed air and the heating coils ; there are six of these doors, of which one or more can be opened or closed at will. When all are closed, the heating coils are cut off, and the incoming air prevented from coming into contact with them ; or one or more only are closed, according to the temperature desired ; and while this is so, there is also provided a corresponding number of bye-pass doors, which are opened under the coil platform, so as to bye- pass the air which is prevented from passing through the heating coils by the upper doors being shut ; in this way the attendant can keep the temperature uniform, and make alterations as rapidly as they take place in the external air. In opening one or more bye-pass doors, and closing those in front of the coils, the cold air which passes through mixes with the warmed air from the coils as it passes through F 66 Healthy Hospitals. [ch. the air-propeller, and is forced inwards at the desired tempera- ture. Thus the temperature of the air can be changed with- out waiting for the coils to cool down, after shutting off the steam, or withdrawing the furnace fire as is generally the case when hot-water pipes are in use to warm the incoming air ; this system of tempering does not reduce the volume of air moving inwards. It is practically a modification of the system of steam coils used for regulating the temperature in the Houses of Parlia- ment. One of the chief advantages of the washing screen has proved to be the facility with which it removes every vestige of fog. During the winter of 1890-91 and 1891-92 there were many days of fog of great density in Glasgow^ yet within this building, so soon as this screen was passed, the air is stated to have been beautifully clear and bright. {%) Purifying air which is removed from wards in the case of infectious disease. This question was raised by the Royal Commission on Small-pox and Fever Hospitals, which reported in 1882. They stated that 'We find in each epidemic period an excessive incidence of small-pox in the neighbourhood of the hospital as compared with that at a distance. * Comparing epidemic with epidemic, we find that the aggregate incidence varies with the amount of hospital operations. ' Analyzing the incidence, we find that the proportion of houses invaded by small-pox decreases as they are more distant from the hospital, with a regularity strongly suggestive of a natural law. ' And examining the incidence from fortnight to fortnight, we find that the number of cases of small-pox arising in the neighbourhood varies generally with the number of acute cases under treatment in the hospital. 'In a special and carefully studied outbreak of disease, we VI.] Purification of Air. 67 find a large number — an unusually large number, it is said — of independent cases which cannot, after the most minute inquiry, be connected with the personal communications of the hospital, or with any other source of infection by contact, and particularly that the houses on the lines of human inter- course have not suffered more than other parts of the same neighbourhood. ' We feel that so long as it is not proved that " personal communication " is adequate to the explanation of the whole spread of small-pox, and so long as distant " atmospheric dissemination " is not shown to be in the highest degree improbable, so long it is essential that in the construction and management of small-pox hospitals, both sources of danger should be, with the utmost care, guarded against. ' It is of paramount importance that the areas of the small- pox wards, as well as their administration, should be rigorously separated from those of the fever hospitals ; and further, that their construction should be such as to reduce within the smallest limits the chance of spreading infection. We fully believe that contrivances for this purpose might be devised.' In the Appendix to that Report, Dr. Burdon-Sanderson recommended a plan by which the air of small-pox wards should be passed through a heated disinfecting chamber. But to this particular plan Surgeon-General Billings pointed out certain practical objections. In 1888 a Committee of the Metropolitan Asylums Board drew up a plan for the effectual purification of all infected air from small-pox wards for a limited number of patients, to be applied to a ward attached to the Western Fever Hospital at Fulham. In consequence, however, of the freedom from small-pox in London resulting from the effectual isolation of individual cases by their removal to the hospital ships in the Lower Thames, the subject has remained in abeyance. As, however, this is the only serious plan which has been drawn up by a competent engineer, to effect the purification of the F 2 68 Healthy Hospitals. [ch. infected air of a hospital ward before it is passed into the atmosphere, it will be useful to explain it here. The method by which the proposal was to be carried out was placed in the hands of Mr. E. A. Cowper, C.E., of Great George Street, S.W., to design. There was a vacant and incomplete ward. No. 6, which the Committee suggested should be connected with a furnace placed in the yard, to draw from the ward all air that passes into it; the air to be then subjected to a scorching heat in the furnace, by passing some of it through the fire, and the rest immediately over the fire into the flame and products of com- bustion arising from the fire. The Committee further suggested that the waste heat should be utilized in cold weather to warm the ward itself, by means of a boiler and hot-water pipes. These suggestions were carried into effect as follows : — In order to ensure the absolute abstraction of all vitiated air from the ward, all air that entered the ward was to be drawn from it, passed through or immediately over the fire by means of a tall chimney, say loo feet high, to cause a strong draught from the ward, through flues to the fires ; and in order to have these means entirely under control, the admission of external air into the ward was arranged to be connected with the hot- water pipes for warming it in winter, and was passed through a number of valves regulated by wooden slides. On occasions when there might be a high wind on one side of the building, the slides on that side would be somewhat closed, so that no excess of air could enter. The windows would all be close and air-tight. Thus the draught of the chimney would at all times tend to cause air to enter the ward, and would never allow any air to pass out of the ward except through the flue to the fire and thence up the chimney. It was proposed to divide the building into two wards, one for six men and the other for six women ; they would be entirely separate, with a room for a portable bath, and water-closets VI.] Purification of Air, 69 JO Healthy Hospitals. [CH. VAVVVVVVVN»X^ S^SSESS to "/ .^ passssass^ % I ^ iX^'V^VVV^g 1 1,11 !!!• ■'ii L5-H --i I ;''l2ii;'a_ }'L-a--g}-. # / r ■vvJ y^ ^-' -'' ?;nn ;<< V V ^.- -'' PflO f ^ y Kv" ',- ,'" pnn -^ ^>^l ^ rt iirtf V 1 I.SO %' H /< V> ct ^ . --' 100 ^ H^v ■in ^ '-' ^ ^' 700 6£0 600 550 £00 4-50 400 360 300 250 SOO 150 ICO £0 Difference ofx^ 20° 30° 40° so° 6o° 70° ao" 30° ido° 110^ 120° ii3o°Ko°i50°i6o° no'iao'iadzoo'TeTn-perahire. TenvpertibuTe oJAir 60° Fig. 18. Units of heat from cast-iron and wrought-iron pipes. the bulk i\ for a difference of loo degrees ; in other words, the 480 cubic feet will be increased to 583 when heated 100 degrees, and the 4,800 will be increased to 4,930 or -^-^ of its bulk for a rise of temperature of 10''. The annexed Figure 18, resulting from Mr. Anderson's experiments, is published in the Journal of the Institution of Civil Engineers for 1877, and shows the total units of heat given out by cast-iron and wrought-iron pipes, per square foot K a 132 Healthy Hospitals. [ch. of surface, per hour, for various differences of temperature, applicable either to hot-water or steam-pipes. Suppose, for example, it is required to know how much heat will be given out by 4-inch pipes at 190° in a room, the temperature of which is 60°, the difference of temperature being 130° : look along the line of abscissae for 130°, and the ordinate then gives 23a units for 4-inch pipes, and '3,^6 units for 2-inch wrought-iron pipes per square foot per hour. These data and those in the foot-note on p. 1 26 are merely mentioned to give a general idea of the effect of pipes. But for purposes of calculation the reader is referred to Box on Heat, to Hood, Baldwin on Steam-heating, and Hutton's 'Works Manager's Handbook,' and other authorities whose names will be found in the list appended to this volume ^ HI. Warming by heat acting in the wards either (a) by close stoves or {b) by hot-water and steam-pipes. Preliminary remarks. — Although these methods are in many respects materially different, they yet present certain conditions which may be conveniently considered together. ^ A rough approximate rule for Manager's Handbook,' gives the pipes heated with exhaust steam following rule : — has been given by Mr. Boulton, Heating Rooms by Steam at who has largely used exhaust steam 212° Fahr. as follows : — i superficial foot of A I -horse-power boiler is suffi- steam-pipe for each 6 superficial cient for 48,000 cubic feet of space, feet of glass in the windows ; I To heat a room to 60° F. the length superficial foot of steam-pipe for of steam-pipe may be found by the every 6 cubic feet of air removed following rule — To find the length for ventilating purposes per minute; in feet of steam-pipe, multiply the I superficial foot of steam-pipe for volume of air in cubic feet, to be every 120 superficial feet of wall, warmed per minute, by the dififer- roof,orceiling, allowing about 15 per ence of temperature in the room cent, on the amount thus obtained and the external temperature, and for contingencies. He states that, divide the product by 304 for 4-inch roughly speaking, the exhaust steam pipe, or by 228 for 3-inch pipe, by due to one-horse power can be 152 for 2-inch pipes, and by 76 made to warm 30,000 cubic feet of for i-inch pipe, space. In neither case is due allowance Mr. Hutton, in 'The Works made for ventilation. X.] Warming. 133 Stoves or pipes warm the air in contact with them, and give out a proportion of radiant heat, which passes to the walls and furniture of a room, dependent upon the degree of heat to which they are warmed. Thus with ordinary low-pressure hot-water pipes, the temperature of which rarely exceeds from 120'' to 130^, the larger proportion of the heat acts to warm the air of the room, and the air warms the walls and furniture. But when stoves or pipes are heated to a high temper- ature, the heat is partly communicated to the adjacent air, and partly acts as radiant heat to warm the surface adjacent. This will be best explained by imagining a stove-pipe heated at the end nearest the stove to a dull red heat of 1230° Fahrenheit, and of sufficient length to allow the heat to be diminished to 150° at the further end. It would then be found that at the stove-end of the flue- pipe, 92 per cent, of the whole heat emitted by the pipe is given out by radiation to the walls, and only 8 per cent, to the air ; but at the exit end the heat is nearly equally divided, the walls receiving ^^ and the air 45 per cent. Taking the whole length of such a pipe, the walls would receive 74 per cent, and the air 26 per cent, of the heat emitted. With flue-pipes heated to lower temperatures the air might receive much more than half the heat. When, therefore, the object is to heat the walls of the room, rather than the air, the temperature of the pipes should be high. For instance, with the Perkins' system of small pipes and closed circulation, the temperature of the pipes may vary from 150° to 250° or even 300°. With these latter more than half the heat would be radiated to the walls. With low-pressure steam-pipes the heat will vary from about 230° to 180°, and with high-pressure steam-pipes as 134 Healthy Hospitals. [ch. much as 300° to 400° may be obtained, and with both these much heat is radiated to the walls. Thus the character of the heat which we desire to obtain must decide the form of heating, and the temperature to be maintained in stoves or pipes. With warm walls and floors and furniture the air must be comparatively cool for comfort, or we should not be able to part with our heat at a sufficient rate ; on the other hand, if the walls are cold we must have a hotter temperature in the air, to prevent the heat of our bodies being parted with too rapidly, but comfort is greater when warmth in the walls and floors is combined with cool air to breathe, as for instance, air at a temperature of 54° to 56°. In considering the economy of these various methods of heating, it may be observed that with hot-water or steam- pipes a proportion of the heat generated by the fuel is applied to effect mechanical motion in the water or steam, and does not therefore appear as heat in the room ; on the other hand, the non-conducting covering of the pipes should prevent the loss of any heat by the radiation from the pipes which might occur between the source of heat and the ward or place where it is utilized. With a close stove in the room all the heat generated by the fuel, except a small proportion lost up the chimney, passes into the room. («) Close stoves placed in the Wards. As a rule the close stove does not assist ventilation. If of iron, it may allow carbonic oxide to pass into the ward ; if of tile, its temperature would be too low to afford radiant heat to the walls. The most economical and probably the most perfect form in which stove-heating can be applied is the old German stove, or at any rate some modification of it. But it is limited in its application, and unless very large the fire-clay cannot X.] Warming. 135 give out sufficient heat to warm a large body of incoming air. Its economy depends upon its not being combined with the admission of fresh air through internal flues in the stove ; when the heat is so extracted the expenditure in fuel is necessarily increased. Moreover, a stove of fire-clay with a tile-surface is a more hygienic way of applying heat to air than an iron stove in which the fire is in contact with the iron, mainly because of the risk of gases from combustion passing through the iron. A stove with a fire-clay lining which shields the iron covering from the direct action of the fire, but allows the iron to warm the air, affords a safe way of applying heat to air. The simple iron-stove, if heated to a very high temperature, might supply a large proportion of heat to the walls of the ward, but such a high temperature might injure the air ; on the other hand, low-temperature iron and other stoves only heat the air, which in its turn warms the walls. All these methods of heating have the inconvenience of requiring the fuel to be brought into the ward, as is the case with the open fire ; but they have not the advantage which the open fire has of supplying radiant heat, and of largely pro- moting the extraction of air from the ward. A gas-stove is not a satisfactory form of heating for a hospital ward ; the fumes are comparatively low in tempera- ture, hence the draught they produce in the chimney is small, and they are therefore liable to pass back into the ward. (b) Hot-water or steam-pipes fixed in the locality to he heated. These may be used, as already mentioned, either in con- nexion with the open fire, or again, where warmed air is also supplied ; or they may be applied as the only source of heat. The selection of the method of heating the pipes will depend upon the local circumstances. In the case of a large hospital, where steam-boilers are 136 Healtfiy Hospitals. [ch. required for providing power for lifts, laundry work, &c., and where an engineer or artificer would be at hand, steam-pipes would probably be found the more convenient and economical method. In the case of smaller local hospitals, it might be preferable to use hot-water under pressure or otherwise, which would not require skilled attention. The low-pressure hot-water pipes, which do not convey heat to adjacent cold surfaces, have the tendency to cause the deposit of dust, therefore those pipes, such as high-pressure hot-water or steam-pipes, which are at a temperature which enables them to radiate heat to and warm the adjacent objects, would seem preferable, on the ground of cleanliness, to low-pressure hot-water pipes. But the low-pressure hot- water pipe which does not contribute much heat to warming the walls, might therefore be preferably used in connexion with the open fireplace, whose action is to warm the walls. In a hospital ward it is preferable that the heat should be uniformly diffused along the walls ; therefore it is better to lay the pipes along the walls without radiators, which collect the heat at certain points. It would also be advisable, as a means of equalizing the temperature of the walls, to carry a portion of the pipe-surface near the floor-level, and a portion round the upper part of the walls above the level of the windows, so as to distribute the heat more uniformly. All heating-pipes in a ward should be laid above the floor level, exposed to view, with sufficient space between them and the floor or wall to enable dust or dirt to be easily removed. A uniform distribution of heat over the whole floor of the ward, without the inconvenience of pipes exposed to view, has been effected by placing steam-pipes under a floor made of marmor terrazzo, and so warming the whole floor. Supplementary heating in this case might be applied by an open fire, or as has been provided in the instance under X.] Warming. 137 consideration by steam radiators, standing like stoves in the centre of the ward, through which fresh air is passed and warmed before it enters into the ward. In no case should a ward be warmed by pipes in the floor so laid as to admit of any communication between the ward and the channel in which the pipes are laid. For in that case the channel would only become a receptacle for dirt. It is also an axiom that pipes for heating purposes should be entirely separate from pipes for the supply of hot water. CHAPTER XI. LIGHTING. Day Light. — Light and particularly sunlight maintains the purity of the atmosphere and exerts an important influence on vitality. It is essential for the organic development of plants and animals : and on the other hand, sunlight, and especially the actinic rays of the spectrum, has been shown to kill some classes of spores and bacilli and to check the development of certain forms of micro-organisms in connexion with disease. The absence of light seems to be one of the contributing causes of the low health and deformities often prevailing amongst the children of the poorer classes in towns, which is diminished if not removed by their exposure to light and fresh air in the country. But independently of this, light is required in hospitals as an antagonist to dirt. Dark corners mean dirt, because dirt must be seen to be removed. The absolute cleanliness which is essential throughout a hospital can only be obtained where a flood of light is directed to every part of the building, as much under staircases^ in closets, and in cup- boards, as in the wards themselves. So far as work or reading is concerned, it may be assumed, according to Dr. Forster^, 'that the most perfect ease in reading, or in fine work, is felt in the open air on a summer ^ See Willoughby's ' Hygiene and Public Health.' Lighting. 139 day when the sky is overcast. Under these circumstances the light is ample, but it is perfectly diffused, there is neither glare nor shadow, and the light may be said to come from all sides, but from no one in particular.' But it is an axiom that direct sunlight should penetrate into a room occupied by the sick. Hence the conditions required for light necessarily affect the shape of the hospital wards. An East and West aspect for a hospital ward, which has windows on opposite sides, allows of this permeation of sun- light at some period of every day on which the sun shines. Independently, however, of the question of direct sunshine the light should as far as possible come from the sky, and no part of a room can be deemed sufficiently lighted from which a certain amount of sky cannot be seen. This affects both the question of the level of the upper part of windows as well as the proximity of buildings. Dr. Forster of Breslau laid down as a rule that the arc of sky visible from any part of a room should not be less than 5°. This seems somewhat small for a hospital ward, but if the height of the ward is made equal to half its width, if the windows are carried up to within about a foot from the ceiling, and if the adjacent buildings are placed at a distance equal to twice their height measured from the level of the ward floor, this proportion of sky illumination would be more than obtained, and, indeed, with windows of adequate size placed on both sides of a ward the light would be abundant. Artificial light. — Every form of matter, when sufficiently heated, has the power of emitting rays of light, and thus becomes self-luminous. This condition is termed incandescence. All artificial sources of light depend upon the development of light during incandescence. In every ordinary flame we recognize two things, light and heat. But they are very 140 Healthy Hospitals. [ch. different ; the one depends upon the amount of incandescent matter diffused throughout the flame, the other upon the amount of matter oxidized or burnt in a given time. A flame, that of a candle for example, structurally consists of two hollow cones, the inner of gases and matter going up to be burned, the outer of burning matter and of incandescent particles diffused through it. For the purposes of lighting our streets and houses we have hitherto chiefly made use of a combustible gaseous combination of carbon and hydrogen which forms the chief constituent of ordinary coal gas. When this hydro-carbon burns, that is to say, when its elements unite with the oxygen of the air, it undergoes partial decomposition, the hydrogen unites with the oxygen, and forms water, and heat is evolved. The carbon is separated in the solid state, and floats in a finely divided and incandescent state in the interior of the burning vapour, and this constitutes the flame. The presence of the particles of carbon may be easily shown by holding a non-combustible body in the flame, when the carbon, in fine powder, will be deposited upon it, forming a layer of soot, or what we generally term lamp- black. The combustion of the particles of carbon takes place at the border of the flame, where they are first brought into contact with the oxygen of the air, when these substances unite and form carbonic acid ; but if the supply of oxygen to them be insufficient in quantity, they partly go to form carbonic oxide, which is a highly deleterious gas. Moreover, a portion escapes into the air of the room as solid particles, the result of which is that the flame is said to smoke. The brightness of the flame is owing to these solid incan- descent particles. The burning gas itself possesses only a feeble illuminating power. The Bunsen burner gives a smokeless and non-luminous flame. In the Bunsen burner ordinary gas is conducted into the tube of the burner, but at the same place air enters, and XI.] Lighting. 141 mixes itself with the gas in the interior of the tube ; and thus oxygen is admitted, not only to the border of the flame, but throughout its whole mass, and the carbon is accordingly burnt into carbonic acid before it can separate in the solid form, so that the flame is composed of incandescent gases alone, and gives a very feeble light, and deposits no soot on bodies held in it. If a solid body be introduced into this feebly luminous flame, such, for instance, as a piece of platinum wire, the incandescent metal glows with a brilliant light ; and this fact has been utilized to produce the Welsbach and other similar forms of incandescent light. The flames of candles and lamps, whether the substance burnt be tallow or wax, rape or petroleum, do not differ essentially from those of an ordinary gas-burner. The same hydro-carbon gas, which is the essential constituent of common gas, is the source of light in them. The hot wick, which draws up by capillary attraction the fluid material about to be burnt, plays the part of a small gas factory, the produce of which is used on the spot^ the only difference being that coal-gas is always purified before it is consumed, whereas the extemporaneous gas of a candle or lamp is consumed without being purified at all ; on the other hand, the tallow, wax, and oil contain the carbon and hydrogen in a purer and more concentrated form than the coal from which ordinary coal-gas is made. The flames of candles and of lamps all owe their luminosity to the incandescence of particles of carbon floating in them ; and the reason why one description of candle or lamp is more smoky than another is because the supply of air in the smoky one is not sufficient to produce adequate combustion. From this it is obvious that in order to obtain the highest illuminating power of a flame in which hydro-carbonaceous compounds are undergoing combustion the regulation of the 142 Healthy Hospitals. [ch. supply of air is essential. This more perfect combustion is also essential to the maintenance of the purity of the air of the room. In a hygienic aspect, it is also essential that the compounds used to produce light should be as pure as possible ; and during the last twenty years vast improvements have taken place in the methods of purifying gas, so that now the London gas is almost entirely free from sulphur and its compounds. The effect caused on the air of a room by combustion is (ist) to diminish the oxygen, and (2nd) to increase the car- bonic acid and to produce water and ammonia. If the combustion is imperfect, the effect is also to create carbonic oxide and soot, as well as to disperse into the room any impurities which the material used for illumination contains, besides the carbon and hydrogen which are necessary for purposes of illumination. The standard which has been adopted for light is that of a No. 6 sperm candle burning 120 grains per hour. Illumination consists of two factors, candle-power and distance. The candle-foot, that is, the illumination produced by one standard candle at a distance of i foot, may be taken as the unit of illumination. The candle-foot is a very convenient and ' comfortable ' illumination. It is, for most people, the best illumination for reading, and is to be found on most well-lighted dining- tables. More than 1 candle-feet is seldom attained in artificial illumination. One candle at i foot is equivalent to 4 candles at 2 feet, and 9 candles at 3 feet. The illumination produced by a i6-candle lamp, at a distance of 8 feet, is only 0-25 candle-foot. The following table affords a general comparison of the effects of the combustion of different materials employed for purposes of illumination upon the air of a room in XL] Lighting, 14: producing one candle power ; but the form of the wick and burner would modify the actual figures. Quantity Consumed. Carbonic acid produced. Water Vapour. Units of Heat. Tallow . . . Sperm , . . Oil Grains. 120 91 Cubic feet. •51 .41 ■11 lb. •023 ■020 .018 97 79 72 Gas — Cubic feet 5.6 .40 .025 121 Oil gives out light with the least injurious effect on the air of a room. For the same amount of light, gas throws out the largest amount of impurity and also produces the largest amount of heat ; the conditions are, however, altered by the use of regenerative burners. Independently of this, the hygienic conditions in the burning of gas differ somewhat from those in the case of candles. The gas comes from a street main, in which the pressure is constantly varying, partly in consequence of the continual variation which takes place in the number of lights in use. With increased pressure much unconsumed gas may be forced through the burners, and this is of itself highly injurious to breathe, especially for the sick. Indeed the leakage of unconsumed gas through burners when not in use is a reason not to place a gas-burner in a bedroom. Gas, in hospitals especially, is not safe without the use of some form of regulator. The efficiency of regu- lators is much affected by differences of pressure, hence it is preferable that each floor of a building should have a separate regulator. The fumes from gas may under favourable conditions be utilized to assist ventilation, by being led into exhaust ventilating flues, but unless there is some motive power in 144 Healthy Hospitals. the flue independent of the heat from the gas, the fumes are liable to return into the room. Gas contributes warmth to a room in addition to light, and for this reason is much appreciated by the less well-to-do classes of the community. The electric incandescent light, formed by a thread of carbon, rendered incandescent by means of an electric current, and contained in a closed vessel out of any contact with the atmosphere, can in no way vitiate the air of a room, and is in fact the most hygienic form of light which can be imagined. On the other hand, the arc electric light, which is not con- tained in a closed vessel, may be injurious to health in an occupied space because of the nitric acid developed. At the same time it must be borne in mind that the arc light, combined with artificial heat from hot-water pipes, will develop the growth of plants, produce flowers, and ripen fruit. May not, therefore, the same qualities in its light furnish curative influences on sick persons ? The electric light cannot be modified or turned low as a gas light can. With the incandescent electric light an 8-candle power light is probably the most convenient size to adopt in a ward. The lights should be distributed so as not to con- centrate glare at any one point ; the globes should be pre- ferably frosted, and each light should be arranged to be shaded when desired. Every bed, or each pair of beds, should be furnished with an attachment into which the wires of a moveable light can be inserted, so that full illumination at any patient's bed may be afforded to the nurse or doctor when desired. CHAPTER XII. SOME OF THE METHODS IN WHICH THE BEFORE-MENTIONED PRINCIPLES HAVE BEEN APPLIED IN HOSPITALS. Having thus explained the general principles which govern the movement and the warming of air, we now proceed to make a few remarks upon some of the methods by which these principles have been applied in practice. It will be convenient to adopt the same classification as before, viz. I. Simple natural ventilation by windows and fireplaces, or by stoves in the wards, assisted by additional inlets and out- lets, the effect of which is dependent on natural movement of the air. 3. Mechanical extraction of the air from the ward, supple- mented by the provision of fresh warmed air to take its place. (a) By aspiration. (d) By propulsion. I. Ventilation by windows and fireplaces, or by stoves in the wards, assisted by additional inlets and outlets. This is the general system in use in temperate climates, such as England, apparently because the climate is so variable. Whilst we' may occasionally in winter have weather as cold as in Germany or the United States, it does not last, but a milder temperature generally prevails, which the warming must be continually varied to suit. The convenience of this system lies in the fact that each L 146 Healthy Hospitals. [ch. ward is self-contained as to its ventilation. The simplest form of this plan is, when in small and old-fashioned hospitals the fireplaces depend for inlets on the windows only, by- means of a broad bottom bar on the lower sash of the window, so that the window when raised affords a vertical inlet along the middle bar and avoids making an opening at the bottom of the window, which would cause a draught on the patients ; or else one of the window-panes may be converted either into a Moore's ventilator or into a hopper ventilator. Another arrangement is for the window to be divided into three parts, of which the upper part is made to fall in and form a hopper ventilator, whilst the two lower divisions are made either like an ordinary double-hung sash window, or like a French casement window, in which latter case almost the whole window opening can be utilized for admitting fresh air. Inlets are also made independent of the windows. For instance, Sherringham ventilators are placed near the ceiling or midway between ceiling and floor, or vertical tubes with openings at 5 o^' ^ feet above the floor may be used, but these latter are objectionable, as affording convenient recep- tacles for the collection of dirt ; openings just above the floor-level are sometimes adopted, which afford a useful means of occasionally sweeping out foul air from under beds, but these are unfit for continuous use because air thus ad- mitted gives a sensation of cold to the feet both of nurses and patients. The number of days in the year on which windows can be kept open in this climate is considerable. With windows open on opposite sides of a room, and with a moderate movement of the atmosphere outside blowing across the building, air would enter the open window at one side, and would be extracted at the other side. The volume of air which would pass through the building by XII.] Methods Applied in Hospitals. 147 means of each pair of opposite windows, as well as that which passes through the walls, would amount to at least from 500,000 to 700,000 cubic feet per hour. With a hospital ward which is arranged for one window to every four beds, this would afford some 120,000 to 180,000 cubic feet per hour per patient ; and this would be a change of air difficult to arrange by any method of purely artificial ventilation. On days on which the windows cannot be kept fully open, and when a fire is lighted, the chimney-flue forms a powerful extraction-shaft to assist the movement of air. The fireplace is preferably placed in the centre of a ward, as it distributes thence its rays more equably. If placed in a side wall, and if there are two fireplaces in the ward, it would be preferable for the movement of the air currents which the fireplaces generate, that both should be on the same side ; but, on the other hand, for distributing the rays of heat to the walls they would be preferably on opposite sides. In a circular ward three fireplaces placed round a central chimney would probably afford radiant heat to the whole wall-surface. The change of air by means of open fireplaces depends upon the current in the chimney-flue ; this is strong when there is a good fire. In military hospitals an additional means of extraction is provided by vertical shafts carried from the room to above the roof. When these shafts are combined with fireplaces in winter ventilation they should invariably be carried from the floor-level to above the roof But it is convenient to have them arranged with a valve, so that if desired in summer they may be used to remove the air from the ceiling-level, as shown in Figure 23 (page i57)j because, in summer when the fire is not lighted and windows are much opened, extraction might advantageously take place at the L a 148 Healthy Hospitals. [ch. upper part of the ward. All such shafts should preferably be straight and vertical, i.e. without bends, which create much friction. They should be of such a size that a moderate upward current may produce an adequate removal of air ; and the movement of outside air will rarely afford a less movement in the shaft than 3 or 4 feet per second. If one were allotted to every two beds, a shaft 9 inches square at the low velocity of 3 feet per second (corresponding to a movement of the outside air of about 3 miles per hour), would remove a volume of air amounting to 2,000 cubic feet per hour. This, with the additional effect of the open fire in a ward of 20 beds, would be to cause the removal of at least 3,000 cubic feet per patient per hour. And with ade- quate inlets for air, accompanied by properly arranged shafts, a continuous and generally adequate ventilation would pre- vail, which might, however, require occasional supplementing by opening windows. It may be here observed that the plan which is frequently adopted by architects of placing the fireplace in the centre of the ward and carrying up the flue directly through the ceiling, and thence utilizing it to warm a flue or chamber for assisting the extraction of air from the ward ceiling, is not recommended. Firstly, it applies the extracting power of the heated flue much less efficiently than if the inlet for extraction were on the floor-level, because with equal temperatures in the flue the draught in a heated flue largely depends on the height of the warmed flue. Secondly, a consideration of the method mentioned in a former chapter, by which a fire causes air currents to circulate in a room, shows that any part of the chimney- breast above the fire is the worst place from which to effect the removal of air from a room. With the extraction of the air at the floor-level, the admission of air, exclusive of windows, should not be placed XII.] Methods Applied in Hospitals. 149 lower than at least halfway between floor and ceiling, and the inflowing air should be directed upwards. But the inlets should be arranged to admit air also at the floor-level, for summer ventilation, or for occasionally sweeping air out of the ward. With the large volume of air moved out, and of air ad- mitted to replace it at the outside temperature, it is necessary to provide in hospital wards for some amount of warming besides the open fire. In some hospitals this is effected by warming a portion of the incoming air, by means of a ventilating grate. But in a large ward this will not suffice in cold weather. The use of low-pressure hot-water pipes is found to be a satisfactory adjunct to an open fire up to a certain point, because the radiant heat from the open fire warms walls and furniture. But the fire does not shine on all parts of the ward, and consequently, to assist in warming the walls, a convenient arrangement is to have either high-pressure hot-water pipes or low-pressure steam-pipes carried round the outer walls of the ward. Thus in Burnley Hospital, which is heated by steam, there are three rows of steam-pipes carried round the ward, each of a different size, so that the heating power can be varied either by using each pipe separately or any combina- tion of the three pipes. By this means the temperature of the wards can be easily regulated at will from inside the ward, and although in this hospital fireplaces round a central flue entered into the original design of the hospital, they have not been used. A better distribution of heat would be for two-thirds of the heating surface, i. e. two of the pipes, to be carried just above the floor-level, and one-third, or one of the steam- pipes, to be carried round the upper half of the ward, just above the windows or the upper inlets for air. ISO Healthy Hospitals. [CH. ?> w % f ¥^ tifl XII.] Methods Applied in Hospitals. 151 The radiant heat from the high temperature of the pipes would thus distribute warmth over the walls and would prevent the feeling of draught from the incoming cold air. These pipes should be under the control of the ward sister, so that the regulation of the temperature of the ward would be self-contained. In other cases the steam-pipes instead of being exposed in the wards have been applied to warm the floors of wards. Warmed floors were used by the Romans : the plan is described by Vitruvius and may be seen in the ruins of Roman villas and baths. Warmed floors were applied in a small hospital in Switzer- land by a French architect, Jager, and have been recently adopted in the Hamburg Hospital, built by the architect W. F. Dencke in 1889. The arrangement is based on the principle of keeping the feet warm and the head cool. It would not conveniently be applied to other than buildings of one story, and it is incompatible with a wooden floor. The warmed floor is constructed as follows : — Upon a layer of cement concrete, about 6 to 9 inches thick, to cut ofi" all communication with the earth, are formed ten longitudinal channels, separated from each other by walls in which are openings at intervals to allow of a community of air between the channels. This is shown in the basement plan, Fig. 19, and the sections, Figs. 21 and 33. These channels are about 3 feet high and 3 feet wide ; they have a carefully cemented and tiled bottom and are covered with rectangular slabs of cement about \\ inch thick, which are supported for greater strength on iron supports. These slabs are afterwards carefully jointed with cement and covered with a thin layer of cement concrete upon which is laid the floor of the ward. This is made of Marmor Terrazzo (i. e. pieces of marble let into cement mortar). In these channels, about 3 inches from their upper covering, one or more steam-pipes are carried along each channel Healthy Hospitals. [CH. r=0 ° u 2 S 6 3 O rt M £ -2o§ t^ O cS XII.] Methods Applied in Hospitals. 153 supported on iron brackets let into the walls ; the pipes are on the low-pressure system of steam-heating, and are so inclined as to allow of the water of condensation to pass through a return pipe back to the boiler. These channels have no connexion with the outer air or with the air of the wards ; access is obtained to them through iron doors opened only when required for repairs. The general plan of the ward itself with its appurtenances is shown in Fig. 20. Instead of fireplaces or stoves there are two radiators in the ward heated by steam from the boiler ; these radiators are unconnected with the underground channels or pipes. Fresh air is brought to them from the outside in ducts which pass under the heating channels but do not communicate with them. The removal of air is effected by means of a ridge outlet along the whole top of the ward which is regulated by valves. The bath-room floor is warmed similarly, but its arrange- ments are independent of those for the ward floor. The single wards and the w. c. are warmed by steam pipes, but the floors of these are not warmed. The steam boiler is under one of the single wards in a basement, and is managed without communication with the wafd floor. The warmed floor prevents any effluvia remaining in corners or under beds, as all air in contact with the floor is kept in movement by the warmth. And this system of floor- warming has the advantage that it permits of the use of a perfectly impervious clean floor, which is free from the difficulties of wooden floors ; these advantages can with diflficulty be ob- tained in any other way. Such a floor should however be kept scrupulously clean ; otherwise effluvia would pass up- wards from it into the air of the ward. Indeed the con- sideration occurs whether it might not be well to combine 154 Healthy Hospitals. [CH. o ■- ■-2 6 T3 >; XII.] Methods Applied in Hospitals. 155 a warmed floor with removal of air from the floor-level between the patients' beds. With the open fireplace warmed air from a central calorigen is sometimes used for the air supply of the wards. As an instance of one of the earliest methods by which fresh warmed air was systematically applied in this country to hospital ventilation, the plan adopted by Mr. Sylvester for the original Derby Infirmary, built about 1810, may be mentioned. The method adopted was to combine propulsion with extraction, both by natural means, upon the principle of the windsail of a ship's hold. The extraction was effected by flues carried up in the walls from the floor-level ; the passage of air through these flues depended partly upon the difference between the inside and outside temperature, and partly upon the movement of the atmosphere ; these flues from all the rooms were concentrated into a turncap above the roof, which was kept always turned away from the wind by means of vanes. The flues had openings for winter use at the floor- level, which were closed in summer, and openings for summer use at the level of the ceiling, which were closed in winter. The propulsive force to assist the inflow of air was ob- tained by a turncap placed upon a tower at some distance from the building in an exposed situation, with the opening always kept turned by vanes towards the wind. The air was thus forced down the tower by the movement of the wind ; and it passed through an underground passage, some 200 feet long, to a cockle in the basement of the hospital, where it was warmed and passed into the wards at a level between the height of the patient's head and the ceiling. It may be mentioned that although the surface of this cockle was heated to 280° Fahrenheit, it was stated that it was not found to injure the air, apparently because of the large volume of fresh air which passed rapidly over its surface. The open fire was retained to assist extraction. ^56 Healthy Hospitals. [CH. There were many ingenious and complicated arrangements in the old Derby Infirmary; but their control passed into the hands of a subsequent generation which did not under- HamOurg Hospital Cross Sett/on of Ward shewing Fresh air^ ^Channel fl rrmirTTT Fres h air ^ Channel Y^wmw^} Hamburg H capital Cress Seetron of Wara EL_ <"■» iq Metres 20 J I y I I I ' i I ' ' I I ' I I I Fig. 2 2. stand them and led to disaster. The moral to be drawn is that simplicity in the long run is the great element of safety in a hospital. This system was identical in principle with that of General Morin, only it used the movement of the atmosphere for XII.] Methods Applied in Hospitals. 157 extraction instead of artificial heat. A plan similar to that of General Morin and Mr. Sylvester is in use in the United States, namely that of Mr. Smead, which uses artificial heat instead of the wind force as the motive power in the flue for ex- traction of air, and an improved form of cockle already described for warming the inflowing air. The Smead system has also been applied in combination with a Blackman Fan, instead of heat, for obtaining motive power for the air. The change of air in hospital wards by natural means was also made use of by Dr. Bohm (of Vienna). He combined ventilation with the German stove in the Rudolf Stift on the same principle of extraction as the flues in military hospitals. He trusted for his ventilation to the windows and to the difference of the inside and outside tempera- ture, as well as to the outside move- ment of the atmosphere. He pro- vided for the admission of air by tubes which were carried from an opening into the open air at the floor-level to the upper part of the ward ; there was an opening to the ward at the floor-level as well as one at the upper part of the ward ; it being arranged that one should be closed when the other was open. Fig. 23 shows Dr. Bohm's arrangement for inlet flues. Fig. 23. Inlet flue for fresh air arranged to admit air either at floor-level or at ceiling-level as desired. Rudolf Stift (Dr. Bohm). 158 Healthy Hospitals. [CH. The air entered the flue from the outside at the level of the ward floor ; and by means of valves, of which one was at the floor-level and the other just below the ceiling-level, the air was either allowed to pass directly into the ward near the floor, or it was di- rected upwards so as to pass in near the ceiling. In summer, when the stove was not used, the lower opening for the ad- mission of air at the floor-level was kept open. In winter, when the stove was in use, the lower opening was closed and the upper open- ing kept open. For the extrac- tion of air, Dr. Bohm carried a flue from the floor-level to above the roof; this flue had openings into the room at the floor-level as well as under the ceiling. Fig. 24 shows the arrangement by which the lower valve at the floor-level could open and the upper valve near the ceiling close, and vice versa. In summer, when there was no fire, he opened the upper Fig. 24. Extraction-flue arranged to extract air either frX r^ S ^^ r O C/'lB 3 3 3 a K-C ^ c ni pj CO Crq ^ i«' Ov fl n- D. nr << !-» re of the Johns Hopkins Hospital ; each of which, except as regards cooking and general administration, may be said to form a complete hospital in itself. The ventilating pipes under the floor are shown by the M 2 164 Healthy Hospitals. [CH. short dots. The ventilating pipes in the attic are shown by the long dots. Fig. 27 shows a section of the building explaining how the air is led into the main ventilating shaft. From what has already been said in previous chapters on warming, it is clear that warmed air supplied to a ward from — Johns Hopkins ! Hospit al — "^FEEJ Part Longitudinal Section Fig. 27. a central supply should be passed into the ward through flues in the walls, so as to allow the walls to derive some heat from the warmed air before it enters the ward. When the flue is in the outside wall the side of the air-flue facing the outer side of the wall would allow heat to pass away unused into the outer air. This loss would be best diminished by making the flue semicircular and exposing XII.] Methods Applied in Hospitals. 165 the larger portion of the side of the flue to the ward, and protecting the side of the flue nearest to the outer face of the wall by a closed air-cavity which would enormously diminish the loss of heat. The striking feature of recent hospital construction is the introduction of simplicity of form. In the United States, in Germany, and also in France, the best examples of modern hospital construction have treated each large ward, with its subsidiary small wards and other appur- tenances, as a separate hospital unit on one floor, and in most cases detached. This renders a combined system of ventilation and warming for the whole establishment more difficult and less economical ; but each ward unit is simple to construct and is self-contained. The Johns Hopkins Hospital is an instance in point, but there, although the separation of ward units is a principal feature of the design, simplicity of arrangement in the ward unit itself seems to have been somewhat overlooked. In some hospitals the extraction of air by shafts has been supplemented by propulsion in the introduction of fresh air. Thus the Barnes Hospital at Washington is an instance of propulsion for fresh air, combined with extraction by heated upcast aspiration-shafts. This is applied in the winter only, the summer ventilation being by open windows. Fresh air is supplied by a shaft 8 feet in diameter and 38 feet high, placed 74 feet west of the building. This shaft is connected with a brick air-duct, which passes beneath the basement through its entire length. At the point of junction of the vertical shaft with this fresh- air duct, is located the fan. This fan drives the air along the main duct into branch channels, leading to the coil-chamber, from whence the fresh-air flues are carried into the wards. The removal of foul air by aspiration is effected by two chimneys in the administration building, which are warmed by iron flues from the boiler and other furnaces ; and to promote 1 66 Healthy Hospitals. [ch. aspiration when the boiler is not at work a separate fire is arranged. The foul-air ducts from the wards are led into the chimney-shafts. The aspiration system, although very simple and efficient, has not obtained any extensive adoption in hospitals in this country, partly from the fact that the arrangements for its due action are necessarily much interfered with by the opening of windows, which of themselves produce an inflow and out- flow of air from ten to twenty times as great as any artificial extraction can pretend to give. {b) By Propulsion. Methods of propulsion of air for hospital wards are based on one common principle, namely, that the air is to be moved from a central position, from which it has to be conveyed in air-trunks, subdivided into branches, and finally admitted into the rooms at such points as may be determined on. These methods generally provide for the egress of foul air from rooms so ventilated by means of foul-air shafts. Two examples in use forty years ago, of the method of ventilation by propulsion, are those of Thomas and Laurent at the Hospital Lariboissiere at Paris, and the plan of Dr. Van Heecke in the Hospitals Beaujon and Necker at Paris. These plans may be briefly described as follows : — That of Thomas and Laurent consisted of two 15-horse power high-pressure engines, with fan-blowers attached, to be used alternately in case of accident to one. The air from the blower was conducted along the arched basement of the hospital, in which the machinery was placed, by means of a large plate-iron pipe, from which branches were given off to the different buildings, these branches being again sub-divided to convey air to the wards. As the air-flues passed under the floors, sufficient space was left between the floor and the ceiling of the room below for an air-trunk T4 inches deep. The fresh air was admitted to the wards through pedestals 4 and 5 feet high, in the middle of the xir.] Methods Applied in Hospitals. 167 floors, and the foul air escaped by openings close to the floor, one between every two beds, which openings communicated with flues in the walls, carried up to the roof of the building. The loss of force in driving air by means of a fan through a series of narrow and frequently bent tubes involves a serious outlay. Dr. Van Heecke's plan had the merit of greater economy. The form of his fan was better proportioned to its work, and by an ingenious provision the pitch of the screw used by Dr. Van Heecke was made to adapt itself to the velocity of the engine, an arrangement by which the air- current was maintained at one uniform strength ; and at the Hospital Beaujon the air was propelled by a small steam- engine in the basement directly up through the centre of the wards, by a tube passing through the floors of each superimposed story, and left to find its way out. In some other foreign hospitals propulsion is also resorted to. In the Antwerp Hospital in summer the windows only are used, but the diameter of the ward, 61 feet 6 inches, is very large for ensuring thorough ventilation, and there is further a serious central obstruction to the movement of air. In winter fresh air is propelled into the wards by means of fans situated in the laundry building ; this air is warmed by being passed over coils of hot-water pipes contained in a chamber situated in the basement under the central portion of each tier of wards, and the air so heated is propelled into the wards at the upper parts of the central columns. In the Menilmontant Hospital the warming and ventila- tion is effected by propulsion. Fans drive the air through subways from a central point ; these subways run beneath the various corridors of the buildings to the basements of the pavilions, in each of which there are placed coils of steam- pipes, enclosed in casings through which the air passes ; it becomes heated by impinging against the steam-pipes, and is carried up vertically through flues in the walls, and dis- charged into the wards through ornamented pedestals which 1 68 Healthy Hospitals. [ch. are placed on either side of the entrance doors. There are also additional inlets formed by the projecting jambs of the fireplaces. These are ordinary fireplaces with large open grates. The removal of the foul air from the rooms is through outlet openings at both the level of the ceilings and the floors, which communicate with vertical shafts that ascend in the outer walls into channels running longitudinally along the centre of the roof to a chamber that is heated by hot air, for the purpose of further inducing an upward current; and it is discharged through the sides of \S\q fikhe surmounting the roof of the building. In the New York Hospital propulsion is used both for supplying fresh and removing foul air. The hospital is built in the centre of the city. It is five stories high and contains 163 beds. In the wards there is one window to each bed, each external pier of the building being a flue, which is lined with hollow bricks, to prevent, as far as possible, loss of heat by radiation. Through the centre of these flues run cast-iron pipes, intended to be fitted so as to be air-tight, through which fresh air is forced into the building by a fan. The spaces outside these fresh-air iron pipes are the foul-air flues. These terminate above in pipes leading to an exhaust fan, placed at the top of the centre building. The heating is by steam, the coils being arranged at the bottom of the fresh-air pipes in such a way that the cool air from the propelling fan can be sent by a valve either through or around the heating coil. The fresh air is admitted to the wards through slits in the window-sills, forming a jet directed upward. The openings for the exit of foul air from the wards are in part placed in the walls of the piers and in part beneath the beds. The principle of placing fresh-air pipes inside of the foul- XII.] Methods Applied in Hospitals. 169 air ducts is objectionable, and on a par with placing water- pipes in sewers, for although the fresh air-pipes are of iron, and may have been tightly fitted, it is only a question of time when some communication will be established between the inner and outer surfaces of these pipes, either by rusting or by alternate expansions and contractions, and then the foul air may be carried back into the wards. The iron pipes are not moreover easily accessible, enclosed as they are in the brick walls, and there is no ready means of determining their condition. There are peculiar difficulties to be overcome in attempting to secure a satisfactory distribution of air in a lofty hospital of many stories. While the resources of modern engineering are, no doubt, competent to secure satisfactory ventilation in a hospital of even ten stories high, if necessary, this can only be done at a comparatively great cost, and it is therefore now generally admitted that it is best to put hospitals where they can have plenty of room without being compelled to go upward in order to obtain fresh air. A method of ventilation by propulsion is in use, as already mentioned, in the Victoria Hospital, Glasgow, where it is combined with purification or washing of the air. It has been applied by Mr. Key and is the most recent application of the principle of propulsion to a hospital in this country. It is unnecessary to repeat the arrangement adopted by Mr. Key for the purification and warming of the air ; it will suffice to take up the description after the air has passed the air-tempering appliances. Two air propellers of the Blackman type collect the air and propel it forward through the main air-ducts leading to the administrative block and to the wards. The fans have been in use for 'x\ years, for 23 to 24 hours daily, and are worked by two electric motors supplied by power from the laundry engine. These fans, which can be worked separately (or conjointly if desired), drive lyo ' Healthy Hospitals. [ch. the air into the main ducts, which are about 5 feet high by 3 feet 6 inches wide. These ducts pass under the centre of the wards, and from them horizontal ones are carried to the outside wall. On each side, from these horizontal ducts, shafts of about 4 feet by 6 inches are carried by the side of, or in, the outside wall vertically up to the inlets provided in the wards. Secondary heating-coils are placed at the base of the several shafts leading to the inlets in the wards, which can be used or not, as desired, by the persons in charge of the ward, and by this means the temperature of the air of each different ward can be varied at will to suit the orders of the medical man or the requirements of the ward sister. The air forced into the wards is under a pressure of ^V to Y^o of an inch of water column. The size of the main ducts under the wards should be such as to allow a person to pass along them ; and the preferable arrangement would be that these main ducts should be carried close to the outer wall on either side, in order that each ward inlet might be supplied by a subsidiary duct leading vertically up from the main duct ; by this means the condition of cleanliness of every part would be capable of being examined at any time. If therefore the inlets are in the outside wall, it would be advisable to have a duct on each side of the ward next the wall. There is, however, no valid reason why the inlets should not be raised by means of half-columns placed along the centre line of the wards, with the outlets on the floor level in the walls. The flues which lead to the inlets are either formed in the side walls or placed within the structure close against the side walls. The inlets are arranged to deliver the air vertically upwards at about 5 feet to 5 feet 6 inches from the floor. The air is warmed or cooled as may be desired. It passes away xii.] Methods Applied in Hospitals. 171 by ducts within the structure of the walls, opening into the ward just above the floor-level. These ducts are led up to the roof, where they are all collected into a square turret with louvred sides standing well above the roof; the louvres consist of hanging valves made of cloth, six inches deep. These valves open outwards the full width of the frames, and are thus at all times available for the air to escape. Even in tempestuous weather, or during a gale, the outward flow is never interrupted, for while the valves are closed on the side of the cupola exposed to the influence and pressure of the wind, and prevent the wind from entering, those on the lee side are under no such pressure, the air passing out uninterruptedly. The theory of propulsion when supplemented by shafts is based upon the assumption that the air will come in at defined inlets, and will similarly have its exit at defined apertures, and upon this assumption the opening of windows would entirely derange the condition of the supply. Therefore Mr. Key urges that the use of windows for the admission of fresh air is incompatible with the system of ventilation by propulsion ; and that in fact with this system windows must be kept closed and reserved only for light. If there were an open fire the pressure of air in the ward would increase its draught. But its retention would not be logically consistent with this system of ventilation. The system of propulsion for hospital ventilation has not found general favour with hospital architects or managers in this country. There is one very patent and valid reason, which is that in this climate windows can be kept open : and when windows are open the volume of fresh air which passes through a ward will be at least 30 times greater than either the theoretical 3,000 cubic feet per hour, or even the 5,000 or 6,000 cubic feet, which some of these systems profess to furnish, without entailing the large expenditure of fuel necessary for moving a large volume of air. For even at 172 Healthy Hospitals. [ch. 3,000 cubic feet per bed a ward of 20 beds will require some 600 tons of air to be pumped into it in 24 hours. Indeed experience would seem to justify the hesitation which has been felt with respect to artificial ventilation. The following quotation from the Report of the Barracks and Hospital Improvement Commission explains this partly : — ' In one hospital we examined, which was ventilated by one of the most perfect apparatus we have anywhere seen, and which professed to supply between 4,000 and 5,000 cubic feet of air per bed per hour, we found the atmosphere of the wards stagnant and foul to a degree we have hardly ever met with elsewhere. We at once pointed out this circumstance. An inquiry was immediately instituted, when it appeared that one of the valves of the supply pipe had been tampered with, for no other reason, that we could perceive, except to save fuel by diminishing the quantity of warm air supplied to the sick. The ventilation in this case was worse than a delusion.' The writer has visited on several different occasions three of the important hospitals in Europe and the United States of America in which the ventilation depended on propulsion, and on every occasion the propulsion happened to be out of use for the time ; in some cases evidently with the object of saving the expense of fuel. Methods of artificial ventilation are more or less dependent upon careful training in the assistants, they may answer well when first put into operation, but the arrangements, in their simplest form, present some complications and require some special knowledge for their efficient working. Hence the changes in personel which necessarily take place in the course of time may introduce want of appreciation or of care in the management : moreover, the continuous cost of working presses upon the resources of voluntary hospitals. The more the question is examined, the more advisable does it appear to adhere to simplicity in all details of hospital construction. xn.] Methods Applied in Hospitals. 173 As regards the opening of windows, it may be observed that the author visited a hospital recently in which the ventilation was by propulsion. The amount of fresh air which was entering the wards was stated to be at the time at a rate of over 5,000 cubic feet, per patient per hour, and yet there was a distinct feeling of relief and freshness on passing from the ward to the open air. This is not surprising if we consider how small is the volume of fresh air entering the ward compared with the volume of air which would enter by the window. Moreover^ the nurses in that hospital were said to prefer fireplaces and open windows in the Nurses' Home, to the system of ventilation and warming in the hospital. The reason of this seems abundantly supplied by the facts just mentioned. Whilst, however, it would seem to be in the highest degree imprudent to trust in any hospital entirely to ventilation by propulsion, there are conditions connected with the air of large towns, in winter especially, which apparently can only be removed by a system of propulsion, combined with purification of the air from dust and fog by a system of air washing. These conditions are so eminently unfavourable to patients suffering from bronchial diseases, phthisis, or other respiratory trouble, that it would seem expedient, if not essential, to provide at least one or two wards with such a means of purifying the air in general hospitals and workhouse infirmaries in large towns. CHAPTER XIII. THE WARD UNIT. The Wards. The distribution of buildings on a site depends on the form of the buildings. The ward with its necessary- adjuncts is the central unit of hospital construction; the form of the ward will govern the features of a hospital. The first principle upon which the pavilion system is based is to limit the number of patients placed under one roof. The second is to afford to those patients abundance of fresh air by means of cross ventilation. The third is to ensure that sunshine shall penetrate as large a portion of the building as possible — both inside and outside. The number of patients under one roof. The ward and its appurtenances under one roof practically constitute a small hospital of itself; and the multiplication of these, several small hospitals under one administration. Dr. Rumsey said, '(i) That the disease in hospitals and other large institutions, especially the mortality following operations (and universally that after childbirth), are greatly increased by the mere aggregation of patients and, ceteris paribus, in proportion to the density of that aggregation, apart from all other circumstances which might affect success or endanger life; (2) that the death-rate calculated, as it should be, on the number of patients, and not on the number of beds, increases with the size of the establishment and the number of its inmates ; and (3) that wherever this assemblage of the sick and hurt occurs in the centre of a crowded popula- tion, the rate of mortality attains its maximum.' The Ward Unit. 175 00 •^ ON <^ 41. V to « > — 1 cr P 1? Hi 0) v; p H H P t/i o'_ cr p* p 2; ffi % Crq B ^ g "^ p B tr' Pi p p P ►^3 Cfl ■-( s Cfl •^ G 5' •5' CD, P_ 3 p en" p I-H to >-( ►i en 5' cr c 1-1 n' 5. 3" P 1 E. §pp t-H h-4 H-l 1-1 to w to 4^ OJ pB-o, - - « ►-. 10 00 -1^ 4^ 00 i3 P 3 P 2: p cr h3 ^ re k-t HH » p ". N M OJ to ixi ON \0 l-H On a' S- a" 4i- 00 00 ON Oi ON to On 3 S" p B- c 5. 3 »-( ^ C/3 c bO to OJ M 4^ CO -t' 4i^ p re ■a p P 0" 3 re 3 3 hj •-t -f^ -^ OJ tJ 00 ON 00 4^ ^J p c a. c . . 3 hJ t-H H-t t_t r^ iP H M OJ 00 00 ON ON t-H ^J " S'S CO w U) -1^ vO 4^ On OJ r*i S£. 3 5; re - g :z;a 00^ m n' P a" Med uble air P^ ^■fT o' ^ ■Td P •73 P Si I P p <; p <: — .-.. a 05 HI- p Block ilion ration 3 ^ o 3 p 3 crq P cr o rt) 3 c 3 cr 2 c 3 ft) o 3 (T) O O 3* O 176 Healthy Hospitals. [ch. Whilst this may be accepted as a general truth, no doubt the efficiency or otherwise of ventilation and aeration will govern the question to some extent. The accepted doctrine of late years has been that the number of from 100 to 120 patients under one roof should not be exceeded. But this is certainly larger than is de- sirable in surgical and fever cases. The one-story ward units do not contain more than 32 as a maximum. And if two floors of wards are superimposed the number would not exceed 64 under one roof, even in the case of a double pavilion, that is to say, if the staircase be so arranged that it will cut off the two pavilions from each other, so far as ventilation is concerned. The form of ward has to be first considered, under the condition whether the ward is to be on one floor or to occupy two or more floors. Dr. Mouat says, ' The majority of cases, particularly of fevers, lung diseases, &c., demand a purity of atmosphere on their own account, which is difficult, if not impossible, to obtain in a multiplication of stories.' It is very difficult to prevent the air from the lower wards from permeating corridors and staircases, and from passing up or down through windows so as to affect to some extent the air of the wards above or below. In the United States, in Germany, and in M. Toilet's plans in France, single stories are preferred, for surgical wards especially ; and unless under the exceptional condition of a town site, two stories are not exceeded for simple medical cases. In the Infectious Hospitals of the Metropolitan Asy- lums Board and in many country infectious hospitals the single-story pavilion is preferred for fever wards. Wounded men when agglomerated in a building cause a larger amount of contamination to the air than probably any other cases, except possibly virulent small-pox, fevers, or lying-in women ; for all such cases it is admitted that wards without buildings over them, that is to say one-story XIII.] The Ward Unit. 177 buildings, are best, and it may be almost assumed as an axiom that wards on one floor would be always preferable if circumstances permitted. This accentuates the conclusion that, having regard to the condition of town sites, all hospitals ought to be situated away from centres of population. But this is a practical impossibility for reasons already given. On these grounds, in considering the construction of hos- pitals, the question must come in as to the nature of the sick to be treated. Accidents, wounds, virulent infectious disease, lying-in women, should always be treated if possible in one-floor buildings, which should contain the smallest number of patients compatible with economy of nursing. There are many cases, such as those suffering from de- generative diseases, that do not require either so large a floor space or cubic space as acute febrile cases or injuries, and it would seem reasonable that hospitals should be so divided as to afford a smaller floor and cubic space with superimposed wards for the milder and less urgent medical cases ; whilst the larger floor and cubic space would be allotted to severe surgical and other serious cases. The zone of aeration round any hospital should not be less than twice the height of the surrounding buildings, so as to allow sunshine to fall as fully as possible on the walls and surrounding grounds. Where more than one superimposed ward has been con- sidered unavoidable, in consequence of a confined site, the necessity of the arrangement should be discounted by special precautions. Before considering the form of the ground-plan of a ward unit it will be convenient to discuss the section of the ward. It is only in one-story buildings that any material difference in the shape of the section can prevail. A ward which has no building over it possesses many facilities for aeration without resorting to artificial appliances. N 178 Healthy Hospitals. [ch. But the full advantage of the one-story building for aeration will not be secured unless each ward with its ward appurte- nances is detached ; for that is the only way in which fresh air and sunshine can reach all sides of the building, and simplicity form the leading feature. We have already shown that for large buildings the removal of warm and vitiated air can be advantageously made from near the floor level, but in a one-story building the facility for renewal of air by ridge ventilation materially alters the conditions. The most usual section for a simple one-story ward is either a flat ceiling covered by a roof sloping to the ridge with a ventilating flue, carried from the ceiling to above the ridge, or the comparatively flat ceiling may itself form the roof, as is the case at the Hamburg Hospital, with ventilating flues passing through it. (See Figs. 21, 22, pages 154, 156.) Or^ again, the ceiling instead of being flat may slope parallel to the roof up to the ridge, where ventilation may be provided. This arrangement may be supplemented by dormers and windows in the sides and in the gables, if the latter are free. If ridge ventilation is resorted to, it is clear that the more convenient form is that in which there are fewest angles and where the ceiling is made to slope upwards towards the ridge. Ridge ventilation is very effective. In the Dresden Public Hospital the ventilation in wards of 30 beds was ascertained to amount to nearly 5,000 cubic feet per bed per hour, effected simply by a roof lantern which occupies rather more than two- thirds of the length of the ward, assisted by four aspiration- shafts, two in each of the end walls ; the inflowing air being supplied by being drawn in over two caloriferes underneath the ward. M. Toilet's plan for the section ^'>, b show a ward of the Burnley Hospital built by Mr. Waddington, in plan and section, with the day or as it is termed sun room over the ward, into which patients can be taken by means of a bed-lift. The circular form of ward is very cheerful, because the windows catch the sunshine at a larger number of angles than is the case with the rectangular form. IQO Healthy Hospitals. [CH. XIII.] The Ward Unit. 191 The circular form is also convenient for artificial ventilation, in that the air can be extracted at a central flue and admitted equally all round the circumference. The larger area over which the admission of air is spread favours its coming in gradually, whilst a higher velocity may be given to the central outflow. The advantage of the circular ward lies in the absence of angles. This advantage can be obtained to some extent in the rectangular ward by rounding all angles and avoiding all cornices, as shown in M. Toilet's St. Denis Ward, Fig. 29, and by placing a window at the corner of the ward, between the end beds and the wall. The height of the ward for purposes of daylight must depend upon the width. Its height is also dependent to some extent upon its length, because the breadth, the height, and the length all influence the efficient circulation of air ; it is of course assumed that the windows are carried up high both to admit daylight and prevent stagnation of air in the upper part of the ward. For a small single or double ward a height of 1 2 feet might suffice, but in wide wards due proportion for the circulation of air requires that this height be increased, and the table given in a former page shows that hospital architects have recognised this necessity. On the other hand, any height beyond that actually required means unnecessary cost in construction and more space to be warmed. The floor space, the lineal wall space per bed, and the width of ward being decided on, the number of beds in the ward regulates the length, or in circular wards the diameter. Whilst the medical man prescribes for the sick, he depends for the execution of his orders upon the nurse. The nurse applies the remedies, gives food, and regulates the atmo- sphere, as an hourly continuous duty. The disciplinary and economical dispositions in a hospital require that each nurse should have the patients allotted to her placed in one ward, under her immediate eye; and the 192 Healthy Hospitals. [ch. head-nurse should be supreme in the ward which she nurses. Moreover, as economy of labour in administering the hospital is a main object to be sought in hospital construction, the hospital should be so laid out as to enable the largest possible number of patients to be nursed by a given number of nurses. The number of patients to be placed in a ward will there- fore depend upon the number which can be efficiently nursed, and the form of the ward must be calculated to facilitate nursing as well as to ensure free circulation and change of air. Miss Nightingale says that ' a head-nurse or sister can efficiently supervise, a night nurse can carefully watch, 32 beds in one ward ; whereas with 32 beds in four wards this is impossible,' (Report on Cubic Space in Workhouses.) Miss Nightingale further shows (in her ' Notes on Hospitals,' 1 863) that if the annual cost of nursing be capitalized, and if a hospital for a given number of sick be divided into wards of nine patients each, the cost of nursing in perpetuity would be £\i'^ per bed : whereas, if the hospital were divided into wards of 25 beds each, the cost would be ;^ 231 per bed, and with wards of 32 beds, the cost would be ;^22o per bed. It has followed from these considerations, that from 20 to 32 beds have been taken as the unit for ward construction to include the number under one sister or head-nurse. In hospitals where cases of more than ordinary severity are likely to be received, it would be necessary to diminish the size of the wards on grounds of health, and thus to make some sacrifice of economy of nursing for the sake of the patients. The apportionment of beds between Medical, Surgical, and other cases depends on local conditions. In the Metropolitan Asylums Board Hospitals, excluding small-pox, the per- centage of diseases provided for is about 72 for scarlet fever, 10 for diphtheria, and 9 each for enteric and other diseases. The following table shows the number of beds provided in large and in small wards in various hospitals : — XIII.] The Ward Unit. 19: Name of Hospital. Accom- modation. General Wards. Small or Separation Wards. Percentage of beds in Wards ofoneand two beds each to total accom- modation. No. of Wards. No. of Patients in each. No. of Wards. No. of Patients in each. Hamburg .... 1340' 30 II 30 J 14) II II 119 ■! 10.5 S. Marylebone In- firmary. 744 24 28 36 2 9.6 Tenon (Menilmon- tant) 726 20 2 8 22) 12 16 10 42 4) ^\ 2 r I ) 8.5 Herbert Hospital . . 650 IS 5 I 20) 8 I 1-2 S. Eloi (Montpelier) 600 12 6 6 4 28 i lof 8; 44 W 19-6 S. Thomas' .... 573 15 3 7 28) 20 > 8) 17 3 W 6.4 Berlin Military Hos- pital. 504 14 16 27 24 23 H 9.1 Antwerp 380 16 20 60 I 157 Johns Hopkins . . 361* 10 24 I 27 64 ■! 32.6 Leeds Infirmary . . 328 4 6 32 ) 28 \ 2 5 :i Norfolk and Norwich 218 6 2 24 \ 17 ) I 17 3 ii 16.9 S.Denis 166 7 4 11 6 10 ;l 13.2 ^ Includes accon and violent ^ Includes about imodatic latients. 28 payir n for 72 paying p ig patients, chiefl atients a y in one- nd 29 de Ded ware lirious is. 194 Healthy Hospitals. [ch. The actual ward figure for each hospital must depend on the nature and to some extent on the size of the hospital. But to every large ward there should be attached small wards. These form part of the ward unit under the charge of the ward sister. Patients suffering from injuries to, or disturbances of, the nervous system suffer much from light, heat, noise, or presence of other patients in a ward. Other cases require isolation for treatment or for observation. The number of these small wards, and the question as to whether they are to accommodate one or two or more patients, is necessarily a matter which the medical advisers on the local wants of the hospital must define in the original plan. It somewhat depends upon the provision made for paying patients. But there seems to be a growing feeling that the number of small wards is insufficient in most modern hospitals. Thus the provision of one and two-bed wards in St. Thomas's Hospital amounted to 6-4 per cent, of the total ; but in the Hamburg Hospital there has been provided 10-5 per cent, of one-bed and two-bed wards ; in the Antwerp Hospital about 15-7 per cent. ; in the Montpelier Hospital nearly 20 per cent. ; and in the Johns Hopkins Hospital nearly '>,'>, per cent. From the conditions under which these smaller wards would be occupied the floor space and cubic space per bed should at least be full; and it would appear that the floor space allotted to separate wards rarely falls below 120 square feet, and occasionally amounts to 160 square feet per bed, with cubic space varying from 1,450 to 2,000 feet. A one or a two- bed ward may be warmed and ventilated by means of a ventilating open fireplace and the window, if the upper part of the window is arranged to fall in and make a hopper ventilator ; but with more beds, a shaft to remove foul air and additional inlets for fresh air would probably be required, as well as additional heating arrangements. These should be XIII.] The Ward Unit. 195 adapted to such specialities of treatment as might be necessary, and their position with respect to the main ward, nurses' rooms and ward appurtenances, should be such as to facilitate con- venience of nursing. Day Rooms and Sun Rooms. It has become the practice in some of the more recent hospitals to make a day room an integral part of the prin- cipal ward. This is the case in the Royal Infirmary, Liver- pool. It is shown in the sketch of the Hamburg Hospital ward. It is adopted in another form in the Johns Hopkins Hospital. In the Montpelier Hospital day and dining rooms are provided in the basement floor under the wards. The Bourges Hospital, also on Mons. Toilet's plan, provides a small day room to each ward. Some of the new circular hospitals in this country provide as one of their principal features a sun room, placed on the top of the circular ward, protected by glazed sides and warmed by steam-pipes, with a circular open promenade round it. The access to this is sometimes made through a staircase central to the ward. This obstructs ventilation, is necessarily dark, and furnishes dark corners, in which, sometimes patients' clothes and sometimes rubbish, is accumulated, and it does not allow of patients in their beds being brought into the sun rooms. A more recent arrangement is shown in Fig. 33, 2)?)^^ 33^- This leaves the circular ward free from impediment, except from a column in the centre which forms the chimneys and ex- traction flues, and access is afforded to the sun room by a staircase outside the ward, adjoining which is a lift for beds, so that a patient can be rolled out of his ward and conveyed up by the lift into the sun room. The sun room when properly utilized forms a very useful and pleasant addition to a ward. In some cases these rooms are divided into a reading room and a smoking room. O 2 196 Healthy Hospitals. In the Breslau Surgical Clinical Hospital, in addition to a day room placed at the end of the ward, the object of a sun room is to some extent obtained by an open air verandah along the south side of the ward, into which patients' beds can be moved. Breslau Surgi cal KfJnik - — Scal e — S ^ 7 8 9 10 II 12 13 M- IS le n i§_f^_zo Metres a. Day Room. b. W.C, &c. c. Isolation Ward. d. Bath Room. e. Linen Store. f. Ward for recent operations. g. Operating Theatre. h. Undressing Room. i. Instruments. o. Open Verandah. /. Attendant. r. Laboratory. Fig- 34- It is not assumed that many of the patients would be able to leave their beds to occupy the day room. The area of day rooms in the Berlin Friederichshain Hos- pital would appear to be nearly 33 feet per bed in the ward it accommodates. The Johns Hopkins Hospital would afford nearly 13 super- ficial feet to each of the patients occupying the large ward. In the Hamburg Hospital it is a little over 15 superficial feet per bed in the wards. In the Bourges Hospital the day room only affords 5 superficial feet per bed. In the Tenon Hospital, Menilmontant, the floor-space for the day room is nearly 10 superficial feet per bed. CHAPTER XIV. THE WARD UNIT {continued). Ventilating Inlets and Outlets^ Windows^ Doors, Walls, Floors. Ventilating Inlets and Outlets for Air. — No inlet or outlet ought to be placed in the floor. Hot-water pipes ought never to be placed in channels in the floor with open gratings ; such a position only affords receptacles for dirt ; when placed in the middle of the ward, patients spit down them. In the Johns Hopkins Hospital some of the extraction out- lets are placed under the beds, but this does not entirely remove the objection to their becoming receptacles for dirt. Any such opening should be above the floor-level, and therefore they are best in the side walls, with a sloping back, so that anything thrown into them falls back into the ward. Whilst outlets for extraction shafts may preferably be placed near the floor-level, inlets for the warmed fresh air should not throw cool air, or air whose rapidity of movement makes it feel cool, on to the feet. They are therefore best placed somewhere above 5 feet or 6 feet from the floor-level. The velocity of inflowing air should never exceed 2 feet per second. Air should preferably flow in at a velocity of i foot or I foot 6 inches per second. The velocity of outflow in outlet flues as they leave the openings into the wards should, simi- larly, not exceed 1 feet per second on entering the mouth of the outlet, which should be large enough to limit the velocity to that speed; but it may travel along the outlet flues at a rate of from 3 to 4 feet per second or more. 198 Healthy Hospitals. [ch. Windows. — Second only to air, is light and sunshine essential for growth and health ; and it is one of Nature's most powerful assistants in enabling the body to throw off those conditions which we call disease. Not only daylight, but sunlight ; indeed, fresh air must be sun-warmed, sun- penetrated air. The sunshine of a December day has been recently shown to kill the spores of the anthrax bacillus. In her article on 'Nursing' in Quain's Dictionary, Miss Nightingale observes that ' light should be meant to include colour, pleasant and pretty sights for the patient's eyes to rest on — variety of objects, flowers, pictures. People say the effect is on the mind. So it is ; but the enlightened physician tells us it is on the body too. The sun is a sculptor as well as a painter. The Greeks were right as to their Apollo.' The form of the windows must be considered first, in their aspect of affording light as a necessary means of promoting health ; secondly, of affording ventilation ; thirdly, of facili- tating nursing and of enabling the patients to read in bed. Light can always be modified for individual patients. In order to give cheerfulness to the wards, and to renew the air easily, the windows should extend from within % feet or 2 feet 6 inches from the floor, so that the patients can see out, to within 1 foot, or if possible 6 inches, from the ceiling. Given a certain area of window, this would preferably be distributed in a tall and narrow window than in a wide and short window. No room can be cheerful in which there is much space between the top of the windows and the ceiling, or between the bottom of the windows and the floor ; or in which a portion of sky is not seen from every part of the room. The vertical arc of sky thus visible should not be less, in the aggregate, than 5° in any part of the room. In special cases the lower part of the window could be shaded, but if a window is constructed too high from the ground, it causes a permanent want of cheerfulness. XIV.] The Ward Unit. 199 In the pavilion plan of construction the windows are, as has been already explained, placed on each side of the ward, with not more than two beds between adjacent windows, so that plenty of light may be thrown on each bed, for facility of nursing. Where the corridor system prevails and the windows are on one side only, the dimensions of the windows should be at least one-third more^ in proportion to the contents of the ward, than in the pavilion system with opposite windows. To promote cheerfulness, and for ensuring cleanliness in the angles of a rectangular ward, it is desirable to place a window at the angle next the wall. These windows need not be of the same width as those which regulate the bed spaces. The distance between the windows must be regulated by the lineal bed space. Window openings themselves may generally be assumed at 4 feet 6 inches wide, with one window to two beds, or narrower with one window to each bed. The sides of the window openings may be splayed about 6 inches on each side into the ward. In wards of military hospitals, affording about 1,250 cubic feet per bed, and with one window to two beds, the bed space between the end wall and the first window was made 4 feet 6 inches, and the spaces between the adjacent windows 9 feet. This afforded a lineal bed space of 6 feet 9 inches. But with a larger lineal bed space, the distance between the windows and the width of windows might be somewhat increased. An end window to a long ward is a great element of cheerfulness, and materially assists in the renewal of the air. It is essential to cleanliness that every part of the ward should be light. But the actual amount of window space must depend much on situation ; in a town the amount sufficient for a free country aspect would be gloomy. The window space will appear cheerful with light-coloured walls, whereas it may appear gloomy if the walls are dark- coloured. 200 Healthy Hospitals, [CH. The area of window space for light must therefore vary with climate, and also with position of a hospital, whether in a town or otherwise. The architect Lorenz of Berlin appears to lay down 32 superficial feet of window space to each bed if the windows are on one side, as is the case with wards on the corridor system, and 1 6 superficial feet per bed with wards on the pavilion system. But this rule would omit considerations of cubic space. In this country the area of window space with respect to floor space has been generally looked upon as the index to refer to ; but the cheerfulness of a room will mainly depend upon the area in proportion to the cubic contents. One superficial foot of window space to from 50 to 70 cubic feet of space, according to position and climate, will afford a light and cheerful room. Where there is a verandah more window surface would be necessary in this climate. The following table shows the proportion which has been adopted in different hospitals, calculated on this basis. It will be observed that there is no general concurrence in window space judged by this rule. Glazed Surface. In Towns. S. George's Union Infirmary Leeds Hospital Hotel Dieu* Tenon (Menilmontant) * . . Halle Herbert Moabit Johns Hopkins Montpelier . . " . . . . Hamburg One Square Foot of Window Space to Square Feet to Cubic Feet of Floor Space, of Cubic Space. 4.6 4.9 6.7 6. 8.2 5-1 6.2 4.8 47 5-3 60 80 175 102 123 69 1^ 7^ 112 * First Floor. XIV.] The Ward Unit, 201 The loss of light through the windows varies with the quality of glass. Polished British plate glass, 4 in. thick, intercepts ,13 per cent of the light. 36 oz. sheet glass .... ■)■) 22 » » Cast plate glass, 4 in. thick ■>■) 30 j> j> Rolled plate glass, 4 corrugations in an inch j> 53 » )> Clear glass is thus of great importance, and the thicker it is, consistent with clearness, the better, because thin glass allows of a more rapid loss of heat, and it is essential, especially in this climate, to economize heat in wards, with so much outer wall as the provision of windows on both sides requires. The loss of heat through windows amounts to that lost by radiation added to the loss of heat by contact with air. It may be assumed with thin glass that the temperature of the outer surface of the glass is a mean between the tempera- ture inside the room and that of the outer air. With thick glass the conducting power of the material may be taken into account, as in the case of a wall. From these considerations it is desirable to make the windows of thick plate glass. Double windows of ordinary glass would very largely reduce the loss of heat and facilitate ventilation ; but they would greatly diminish the light passing through. The loss of heat with double windows is much less than that with single windows, and they have the advantage not only of transmitting less heat, but, from the temperature of the inside glass being greater, less radiant heat is absorbed from the occupants of the room. Peclet found that the loss of heat in double windows increased somewhat with the distance apart of the inner and outer glass, owing probably to the greater facility for currents of air in the wider space between the glass. 202 Healthy Hospitals. [ch. Thus, with an intermediate space between the windows of •8 of an inch, the loss of heat of the single window to that of the double window was in the proportion of i : -47 ; with a distance apart of i inches, the proportion was as i : -55 ; with a distance apart of 2-8 inches, which is nearly what exists in practice, with double windows the proportion would probably be as i : -6. On these grounds the windows of all hospitals should be double. This may be effected either by double sashes or by a French sash inside and a double-hung sash outside ; but according to Peclet a better result for saving heat may be effected by double glazing the lower sashes. In this case the window bars must be prepared on their inner side to receive the inner plate of glass ; this should be laid on a narrow flannel band and secured by means of a wood fillet screwed into the side of the window bar. The flannel will be the most effectual way of keeping the inner surfaces clean. Dirt penetrates to the space between the two sheets of glass, by means of the constant inflow and outflow of air going on as the result of changes of tempera- ture, and the flannel acts as a filter to retain the dirt which the outer air would otherwise carry into and deposit in the interspace. The method of fixing the fillet should be one that will afford easy means of removal for cleansing. The double glazing has however the disadvantage of always obstructing light, whereas, in the case of the window with a double sash, one sash can be left open at times, or altogether removed in summer. The best form of sash for ventilation in this climate is the ordinary sash, opening at top and bottom ; but windows made in three or four sections, each of which falls inwards from an axis at the bottom of the section, have been extensively used in hospitals, and possess many advantages ; although it is certain that the air of the wards cannot be so thoroughly XIV.] The Ward Unit. 203 changed by means of these windows as by means of the ordinary sash. It would therefore appear desirable to make hospital windows in either two or three divisions, the lower divisions occupying between § or | of the height of the window, the upper portion between | or | ; the upper portion being hung on hinges at its lower part, so as to fall inwards. Glazed triangular sides project into the room into which it falls, so as to create a sort of hopper when open, which admits fresh air upwards and prevents side draughts on the patient. The lower half of the window may be preferably a double-hung sash, which with the aid of a deep bottom bar enables an opening to be maintained at the centre bar, without any opening at the bottom bar which might create draught upon the patient. If desired, a French casement window may be adopted ; this latter affords the fullest area of opening. Although double windows would greatly economize heat, yet there would be complications in making the upper in- falling flap double. A combined double and single window will enable the most essential part of the window, viz. the lower part, to be made double, and would prevent radiation from the patients. Figure '>,^, p. 304 shows a window in the Surgical Ward of the Gottingen Hospital, of which the lower half {a, a) is double, opening inwards as double casement windows ; the middle part {b, b) is a casement opened by cords, above and independent of the former ; and the upper part {c) falls in to create a hopper ventilator. In the Surgical Hospital, Bonn, the upper single portion of the window is made to open by falling inwards, and the lower casement, occupying two-thirds of the height of the window, is made double. The woodwork of windows, as well as all woodwork in a ward, should be of hard wood painted and varnished, so as 204 Healthy Hospitals. [CfT. to admit of easy washing and cleansing. The cleanest and most durable material is varnished light-coloured wainscot oak or teak. C/inical Surgical Hospital Gotting&n a. Double Window casement. b. Single Window casement. c. Single Window falling in on bottom hinge. d. Interspace between Windows. Fig- 35- Doors. — Ward doors should be arranged in number and position so as to facilitate nursing and prevent panic in case of fire. They must be large enough to allow of the passage through of sick on moveable stretchers. Double doors are not very convenient, because the opening XIV.] The Ward Unit. 205 of the whole door is somewhat troublesome, unless they are made on Mr. Appold's plan, in which the leaves are con- nected by a lever at the top and the two leaves open simultaneously in opposite directions. In large wards, operation-rooms, &c., double doors are often necessary, and should afford an opening of about 5 feet. Single doors should afford an opening of from 3 feet 8 inches to 4 feet ; which would allow of the passage of stretchers, trays on wheels, &c. It is generally convenient that the principal ward-doors should open both ways, and be self-closing. To prevent panic in case of fire, a second door opening outwards should be placed at the end of the ward opposite the principal entrance. Doors into bath-rooms should be large enough to allow of the passage of a moveable bath ; probably 3 feet 9 inches would suffice. The doors for lavatories should be of the same width, but doors for w.c.'s might well not exceed 3 feet 4 inches. The material for ward-doors is preferably hard wood, such as oak, varnished, which can be easily washed. The construction of all doors in and near wards should be such as to present as few projections, interstices, or other places for the accumulation of dust as possible. The upper part of the entrance doors to wards and all swing doors might advantageously be glazed. Walls. — All walls should be protected from damp rising in them by a dampcourse of slate, asphalte, an efficient form of glazed brick, or some impervious composition. The top of the wall should similarly be protected so that rain shall not sink in at the top ; and eaves or cornices should project sufficiently and be so formed as to prevent a drip from the roof on the face of the wall. The walls should be such as will allow of a smooth surface. A wooden hospital has the advantage of being erected rapidly; but the numerous joints 2o6 Healthy Hospitals. [ch. and chinks, which are favourable to the permeation of air, become after long use adverse to cleanliness. A wall of brick or of some material which can be used without pre- senting chinks on the surface, is therefore preferable in hospitals of any degree of permanence With a view to economize heat in winter, and to keep the rooms cool in summer, the walls should be hollow, care being taken that the hollow air-space is closed in top and bottom to prevent circulation of the enclosed air. All hospital wards should be ceiled, and the roof con- structed of a good non-conducting material. If of slates or tiles, they should invariably be laid on boards and felt. Our gradually extending knowledge into the causes of disease shows that in houses and hospitals where diseases have appeared to linger, or to break out afresh after long periods of being shut up, there has generally been ample opportunity for dirt to lodge in the cracks of the floor or the interstices of the walls, or for nitrogenous organic matter to be absorbed into plaster, where warmth and moisture may favour its decomposition. And there has been no more striking exemplification of the value of clean- liness than that afforded by Sir Joseph Lister's system of treating wounds; a system based on the most absolute cleanliness. It has followed that this absolute cleanliness is a necessary feature of a well-managed hospital. Now this means that the walls shall afford no lodgement for dust, that there shall be no cracks in woodwork, or between the woodwork of windows and doors and the walls, and that walls and floors shall not be absorbent nor afford corners where dirt can lodge or interstices into which dirt can penetrate. As regards corners, it is possible to scrape with a penknife from the floor in the corner of an ordinary room an amount of dirt which is surprising. In a hospital this dust may consist of epithelium, threads of lint, and other objectionable matter. This may be XIV.] The Ward Unit. 207 avoided by replacing the angles made by the walls with each other and with the ceilings and floors with curves or quadrants, the concave surfaces of which face the wards ; in fact, by carrying out to their fullest extent the principles advocated by M. Toilet. As regards interstices or cracks, the best lining for a hospital ward would be an innpervious polished surface, which, on being washed with soap and water and dried, would be made quite clean. Plaster, wood, paint, and varnish all absorb the organic impurities given off by the body, and any plastered or papered room, after long occupation, ac- quires a peculiar smell. Ammonia is always found on surfaces of occupied rooms. In a discussion in the French Academy of Medicine, a case was mentioned in which an analysis had been made of the plaster of a hospital wall, and 46 per cent, of organic matter was found in the plaster. No doubt the expensive process which is sometimes termed enamelling the walls, which consists of painting and varnishing with repeated coats, somewhat in the manner adopted for painting the panels of carriages, would probably prove impervious for some time, but it would be expensive, and very liable to be scratched and damaged. Parian cement polished has been much used for wall surfaces, but it is costly, and it is difficult to get it of an even colour, it becomes discoloured apparently from internal change, and is therefore disappointing ; it can only be applied on brick or stone walls, and not on woodwork or partitions, because, being very inelastic, it is liable to crack. The want of elasticity in Parian cement is unfavourable to its use in ceilings. Cracks in a hospital ward are inadmissible, as they get filled with impurities and harbour insects. For this reason it is advisable that all division walls in hospitals in connexion with the sick be built of brick. Glazed bricks have however been largely adopted as a lining for wards of late years; but from their numerous joints these 2o8 Healthy Hospitals. [ch. can only be safely used provided the joints are most carefully made in cement and painted. A very good specimen of glazed brick is to be found in the Burnley Hospital, where the bricks were specially ordered to be made as true and straight in the edge as possible : they were laid in very fine mortar: the joints were scraped out and pointed with Keene's cement, and this was painted with two coats of white enamel — albarine, or Aspinall's enamel — a mixture of zinc white and varnish. As these joints after five years show no sign of imperfection, it may be assumed that with care the glazed brick will afford a safe wall-surface for wards. In default of a satisfactory impervious wall covering, cem"^ent well trowelled to a flat surface and oil-painted makes a good wall, which can be washed with soap and water, and scraped and repainted from time to time. A safe arrangement is plaster lime-whited or painted, provided it be periodically scraped so as to remove the tainted surface, and be then again lime-whited or painted. When plaster is used, it is essential, for the reasons before mentioned, that at the expiration of a very few years the whole outer coat of plaster should be removed from the walls and ceilings, and new plaster substituted. Of course these arrangements require the wards to be periodically vacated, which is of itself a great recommendation to the use of plaster. The material used for colouring walls connected with the sick should be one capable of being washed. It should present a cheerful light colour, but of a tint restful to the eyes. The walls and ceilings should be quite plain, and free from all projections, angles, cornices or ornaments which could catch or accumulate dust. As already mentioned, angles at the junction of walls and ceilings and elsewhere should be rounded, or rather coved. Floors. — It is essential that wards for the sick should be raised above the ground level, with a free air-space under. XIV.] The Ward Unit. 209 This view is endorsed in the most recent hygienically built hospitals, as for instance the Johns Hopkins, the Montpelier Hospital, and the Hamburg Hospital. Broadly speaking, the higher the floor is above the ground- level the better. In the first place, aqueous vapour is always rising more or less from the ground. A layer of cement or of concrete will not entirely prevent the ground air from rising from the part under the building : an interposed layer of asphalte may do so ; but it is" liable to cracks, in which case it would not prevent the ground air from rising. Moreover, the ground air will in any case rise from the space round the building ; and for that reason it is essential to cover the spaces between pavilions with asphalte or tar pavement. In this country this argument has not been fully recognized, although it is even more important in consequence of the dampness of the climate and soil. Indeed, some of the medical men in the hospitals of the Metropolitan Asylums Board have stated that those wards which have tar-paved surfaces between the pavilions are more favourable to the recovery of patients than those where the surface is garden or grass. When the ward is raised above the ground-level, the spaces thus left under the wards should be light, accessible, and kept clean and free from any substance which could create un- healthy emanations ; for instance, they should not be used as coal-stores, or stores for perishable things. As regards the material for the floor of a ward, if any one will examine the floor of any hospital when there are only small spaces at the joints between the floor boards, he will find these joints filled with filthy matter. If the floors are washed, this is carried down into the cinders and other sub- stances used for deadening sound. If the boards are taken up, it will be found that this dirt has penetrated and lodged beneath the floor, and that it affords a birthplace for putre- faction; and possibly for germs of diseases. As bearing on P 2IO Healthy Hospitals. [ch. this, Dr. Emmerich of Leipzic investigated the effect on the air of the room of the material used for deadening sound between floors. He found the substances under the floors of dwelling-rooms highly contaminated with nitrogenous organic matters, and their decomposed products. Professor Carnally and Miss Johnston in 1889 made cor- roborating experiments on the material of floors at Dundee, and concluded that the deafening material for floors is a source of contamination of the air of dwellings, in that it furnishes a good and suitable medium for the growth of micro-organisms and gives off" fetid gases from putrefaction, provided the necessary factors — moisture, warmth, and nitro- genous organic matter — are present. On these grounds there should be no sawdust, cinders, or other organic matter subject to decay under the floor. When one ward is placed over another it is essential that the floor should be non-conducting of sound. But the above-men- tioned experiments show the great care that must be taken to watch the character of the material used for this purpose. The floors should also be so formed as to prevent emanations from patients in the lower ward from passing into the upper wards. Similarly, where there are skirting-boards round the ward, some interstices will be found to exist, affording a receptacle for dirt. It is partly because this foul matter may be carried down under the floor by water, and also because of the damp intro- duced into the ward, that medical men generally forbid the practice of washing the floors. Many matters are spilt on a hospital floor which should not be allowed to sink in, therefore the surface of the floor should be as non-absorbent as possible. Floors of stone, cement, or asphalte, although favourable for cleaning, are too cold for sick persons, and would be equally bad for nurses who have to occupy the wards by day and by night ; hence XIV.] The Ward Unit. 21 1 for the sake of warmth to the feet, floors must in this country- be either of some material like marble terrazzo warmed under- neath as in the case of the Hamburg Hospital, or else of wood. All wooden floor-boards must be of well-seasoned wood carefully planed, grooved, and tongued. If of deal or pine they require especial care. With the best workmanship and materials, interstices between the boards will appear, and their width will vary with changing meteorological conditions ; debris of all sorts will be gradually sifted through and accumulate putrefying organic filth between the floor and ceiling. One plan for delaying this result is to caulk the interstices between the floor-boards, like a ship's deck, to about half their depth, then to fill up the other half to floor-level with marine glue; thus connecting the boards by means of an elastic waterproof surface. This floor should be saturated with drying linseed oil, well rubbed in, stained not too dark so as not to hide dirt, beeswaxed with turpentine, and polished. If the floor-boards are alternately wetted and dried in the process of washing, their consequent expansion and contraction may form openings between them and the marine glue. In an old hospital, cracks can be filled in with clean sand, and the upper part of the joint made good by putty and then painted. Oak, teak, or any other close hard wood, with close joints, with iron tongues, oiled and beeswaxed, rubbed to a polish, makes a very good floor, and absorbs very little moisture. A floor of teak or oak with joints as close as the best parqueterie, affording no inlet for the lodgement of dirt, and the floor saturated and the interstices filled with paraffin or even bees- wax, makes a very good floor. An economical floor can be obtained by first laying rough deal boards and covering them across with thin, narrow, closely-laid oak boards beeswaxed and polished. The double boards assist in preventing the penetration of dirt. A very good hospital floor is one in use in Germany, which is of pine wood, oiled, lacquered, and polished, so as to P 3 212 Healthy Hospitals. resemble French polish. It is damp-rubbed and dry-rubbed every morning, which removes the dust. The only objection to it is want of durability. The processes above mentioned render the floor non- absorbent, and do away with the necessity of scouring. A French floor, oiled, beeswaxed, and polished, stands the most wear and tear, but it must be cleaned by a frotteur, which is more laborious than scrubbing, and does not remove the dust. The proper process for cleaning such floors is to wipe them every morning with a damp cloth and polish them with a floor-brush, or else to clean them by a broom with a cloth tied over the head, the beeswax or paraffin being renewed from time to time as necessary. This wet and dry rubbing process of cleaning is far less laborious than either frottage or scrubbing, and completely removes the dust and freshens the ward in the morning. Practically, with care, a well-laid oak floor, with a good beeswaxed surface, can always be kept clean by wiping over with a damp cloth and rubbing. An old-fashioned, simple method of sweeping a ward floor is to use tea-leaves sprinkled with carbolic acid ; these collect and retain the dust very efficiently. All ward floors should be scraped and repolished periodi- cally. CHAPTER XV. THE WARD UNIT {co7itinned). Ward Offices. The ward offices are of two kinds : — [a) Those which are necessary for attendance on the sick and for facilitating the nursing and administration of the wards, as the room for the medical man, the nurses' room, and ward scullery. {b) Those which are required for the direct use of the sick, so as to prevent any unnecessary processes of the patients taking place in the ward ; as, for instance, the ablution-room, the bath-room, the water-closets, urinals, and sinks for emptying foul slops. There should, in addition to the bath-room here mentioned, be a general bathing-establish- ment attached to every hospital, with hot, cold, vapour, sulphur, medicated, electric, shower, and douche baths, which are gradually assuming a prominent position in curative treatment. Hot and cold water should be laid on to all ward offices in which the use of either is constantly required, to effect economy of labour in the current working of the hospital. For convenience and economy of administration, when the wards are on two or more floors, lifts should be provided to carry up coals, trays, bedding, and patients. Miss Nightingale ('Notes on Hospitals') estimates that a convenient arrangement of lifts and the laying on of hot and cold water economizes in attendance as much as one attendant to thirty sick. 214 Healthy Hospitals. [ch. {a) Ward Offices connected with Nursing and Admitiistration. Surgeon s Room. — Wherever there is a medical school in hospitals it is advisable to have a surgeon's or physician's room, forming a part of the ward offices attached to the ward unit. This is the more necessary with detached pavilions ; but, on the other hand, one for every ward unit would add materially to the cost. The object is to have a place for necessary examination and in surgical cases for minor opera- tions. It should be light, airy, and if for the last- mentioned purpose, afford a floor space of not less than from 150 to 180 superficial feet. Nurse's Room. — In some hospitals the nurse lives close to her ward ; in that case she should have a bed-room and a sitting-room. This plan is not desirable, as it is of importance for health that the nurse should always sleep and take her meals quite away from the ward air ; and at night the night- nurse would take her place. The nurse's sitting-room should be sufficiently large to contain a bed. It should be light, airy, and well venti- lated, as a cheerful room is a material assistance to a nurse. It is necessary to discipline that it .should be close to the ward door, and that it should have a window looking into the ward, so as to command it completely. If the nurse has two wards to supervise, her room should be placed between the two, with a window opening into each ; in any case it must be so placed as to afford supervision over the small wards forming part of the ward unit. Ward Scullery. — There should be a scullery attached to each ward, adjacent to or opposite the nurse's room, so as to be under her eye. The scullery should be supplied with complete, efficient, simple apparatus, for its various purposes ; there should be a small range for ward cooking, so that the nurse can warm the drinks and prepare fomentations, and a sink for washing up but XV.] The Ward Unit. 215 not for slops, &c. The sink for washinf^ up and for cleaning utensils should be of a light colour to show when it is not clean, and of a non-absorbent material capable of being easily cleaned. It should have hot and cold water laid on, with taps affording a full supply, and a waste-pipe large enough to discharge rapidly, and trapped close under the sink. Care should be taken that the waste-pipes deliver into the open air over a trapped gully, so that there should be no direct communication between the waste-pipe and the drain, otherwise foul air is certain to find its way into the hospital. Shelves or racks should be provided for ward crockery, but it is undesirable to have many cupboards or closed recesses, as they become in time receptacles for dirt and rubbish. There should be no dark corners under the sink or anywhere in the scullery, and it should have ample window-space. The scullery should be large enough for the assistant nurses to sit in, and to have their meals comfortably, if required. There should be provided in connexion with the scullery, a separate place for keeping the necessary provisions such as milk, fitted with a refrigerator, but cut off from the ward air ; a miniature dairy receptacle outside a window, and with perforated sides, is a convenient arrangement for this purpose. Also a hot closet for airing clean towels and sheets. For foul linen it is undesirable to have any receptacle near the wards, or indeed in the hospital building. It should all be placed in galvanized iron receptacles, or trucks on wheels, and conveyed as soon as possible to the laundry. Ward-sweepings and refuse should similarly be placed in moveable receptacles, and taken out of the building with as little delay as possible ; structural provision is not advocated for the retention of these in or near the hospital. Brooms, brushes, pails, &^c. — There must be a closet for these cleaning appliances, but it must be very light and airy to prevent its becoming a receptacle for rubbish. 2i6 Healthy Hospitals, [ch. Store for patients' clothes. — Patients' clothes are removed on their entering the hospital ; the linen, cotton, or woollen clothes are washed, and the cloth clothes disinfected by heat or otherwise. When they have been so treated it is generally convenient, as a matter of administration, to restore them to the care of the ward nurse. In this case it is necessary to attach a store to each ward unit. This store should be very well lighted, kept scrupu- lously clean, and supplied with racks, and numbered divisions, to allow of each patient's clothes being kept separately. A store for patients' clothes without direct window light is objectionable. The clothes should be taken out, unfolded, re-folded, and put away again at least once a fortnight to prevent moths. In an infectious hospital this arrangement will not suffice. The patient will wear hospital clothing while in hospital. His own clothes, after washing and disinfection, will go to a general store, adjacent to the discharge rooms. These rooms consist of waiting room and undressing rooms, opening in to bath rooms ; these latter open into dressing rooms connected with the discharge room on the other side. The patient leaves his hospital clothes in the undressing room, goes into the bath, and then passes on to the dressing room, where he puts on his own clothes, and is then discharged. (Jj) Ward Offices required for the direct tise of the Sick. The custom has been to place this, the second class of ward offices, at the opposite end of the ward to that occupied by the nurses' rooms, scullery, &c. This entails additional expense in the pipes for the supply of hot and cold water, and sometimes in that of the drains for the removal of refuse water. There is, however, no reason why they should be so placed with the present improved arrangements for the removal of foul water, and the construction of drains outside the buildings. XV,] The Ward Unit. 2 i 7 Moreover, expense would be diminished if these appur- tenances were placed nearer to those of the first class. Ablution Room, Water-Closets^ &^c. — These ward offices of the second class ought to be as near as possible to the ward. but cut ofif from it by a lobby, with windows on each side, and with separate ventilation and warming, so as to prevent the possibility of foul air passing from the ward offices into the wards. When placed at the end of the ward, furthest from the entrance and nurses' room, they are best distributed at each side, so as to enable the ward to have an end window. In the Breslau Surgical Hospital and some other German hospitals, as well as in the Johns Hopkins Hospital, these ward offices are placed at the same end of the ward as the scullery, nurses' room, &c. ; but the arrangements in these hospitals leave something to be desired. M. Toilet's plan at Montpelier also places them centrally, and seems to cut them off more effectually than in the cases just mentioned. The principle which M. Toilet would appear to advocate most strongly is in the St. Denis Hospital; there he allows no air connexion between the w.c.'s and slop-sink, &c. and the ward and other ward offices ; he effectually cuts off the w.c.'s &c. by placing them in a detached turret-building on two or more floors, access to which is obtained on each floor by means of a light covered bridge arranged to impede venti- lation as little as possible. In the Women's Hospital, Euston Road, and in the new Derby Infirmary, the w.c.'s, lavatories, and bath-rooms are placed in detached turrets, separated by an air space from the ward blocks ; access being afforded by means of covered bridges. The diagrams (Figs. 26 to 34) show these and other arrangements for the ward offices. Adjacent to the ablution-room there should be a bath- room with one fixed bath supplied with hot and cold water. Terra -cotta when once warmed has the advantage of re- taining the heat longer than almost any other material and 2i8 Healthy Hospitals. [ch. of being always cleanly, but it absorbs a great deal of heat at first. Hence when the bath is frequently used it is the best material ; but if the bath is seldom used, then copper is better, or polished French metal, which latter should be kept scrupulously clean or it acquires an offensive appearance. There should be no inclosed space round the bath, so that no dirt may accumulate ; a broad wooden bar round it affords all necessary support to the bather. A lavatory table of impervious material, such as slate or, what looks cleaner, common white marble, with a row of sunk white porcelain basins with outlet tubes and plugs, each basin supplied with hot and cold water, should be placed in the same compartment as the bath, but separated from it by a partition and door. It is a common mistake to place these lavatory basins too near each other, so that they cannot be used conveniently by patients standing abreast. Two feet six inches from centre to centre is a minimum distance. There should be a full delivery of water from hot and cold water taps ; and the waste-pipe should be large, to admit of rapid emptying. There should be a trap on the waste close under each basin, and each waste should deliver in the open air over a trapped gully. It is undesirable to have closed spaces under the basins, as they only accumulate dirt ; all parts under the ablution table^ and elsewhere, should have ample light ; nothing should be kept in these offices but what is required for constant use, and everything should be open to inspection and arranged for easy cleaning. All fittings should be light-coloured, as they then show any want of cleanliness. The waste-pipes, soil-pipes, and supply-pipes, both for hot and cold water, may usefully be painted in different colours so as to distinguish them at sight. There should be room for a portable bath for each ward, which should be provided with noiseless wheels, and hot and cold-water taps at a convenient height for filling ; and there should be a sink XV.] The Ward Unit. 219 on the floor-level for running off the water out of the bottom of the bath after it has been used. Water-closets should not be less than two feet ten inches wide by four feet long. They should never be placed against an inner Wall, but always against the outer wall of the com- partment. A pan of a hemispherical shape, never of a conical shape, with a syphon, abundantly supplied with water to flush it out with a large forcible stream, is the best contrivance for the water-closet of a hospital. On the male side the urinal is always a structural difficulty, and it is only by great attention that it can be kept inoffensive. Probably moveable utensils standing on a light-coloured non-porous slab would be best. The sink for slops, bed-pans, expectoration-cups, &c., which should have a compartment of its own, adjoining the water- closets, should be a high, large, deep, round pierced basin of earthenware, with a cock extending far enough over the sink for the stream of water to fall directly into the vessel to be cleaned, and of a large size with an ample supply of water ; this sink should have a separate service arranged to flush it out like a water-closet pan. The space round it should be sloped into it either by means of a leaded or what looks cleaner a pottery surface, and there should be as few angles as possible to allow of accumulation of dirt. The space underneath should not be closed in ; if it is, the enclosed part will be made a receptacle for rubbish. The place for the retention of utensils, for the inspection of the medical man, is best arranged in a cupboard, with a door shutting it off from the lobby in which the w. c. and slop-sink are placed, but with a large grated opening to the outer air, and preferably a glazed flue may be led from it direct to above the roof: sometimes a perforated zinc receptacle for this purpose is fixed outside a window. Walls of ablution-rooms and water-closets should be covered with white glazed tile, slate enamelled or plain, or Parian cement ; plaster is not a good covering for them on account 2 20 Healthy Hospitals. [ch. of their liability to be splashed, and of the necessity for the walls to be frequently washed down. The nurses should have separate private water-closets. They should not use those of the patients. There should also be water-closets for the patients who are well enough to leave their wards. Water-closets and the ablution-room should each have ample windows opening to the outer air, certainly not less in pro- portion than the wards. They should have shafts carried up to above the roof, to carry off the foul air, and ventilating openings to admit fresh air independently of the windows. Warmth should be supplied to them independently both of the wards and of the lobbies, which should cut them off entirely from the wards. The lobbies should also be carefully venti- lated by flues for extraction of air and by inlets for fresh air, and they should be well warmed. Care in these details is essential to prevent any of the air from these conveniences passing into the wards and thus becoming a source of danger to the patients, especially in cold weather. All woodwork, such as seats to water-closets, should be of non-absorbent wood. The floors, unless warmed, must be of non-absorbent wood, and the greatest care should be taken in the jointing. Drainage. — The following are the general principles to be observed with respect to the drainage of a hospital. (i) Drains should be made either of glazed stoneware pipes with cement joints, or preferably of strong cast-iron pipes jointed with carefully made lead joints, or with turned joints and bored sockets. In no case should a soil-pipe be built inside a wall. It should be so placed as to be always accessible. Junctions between pipes of different materials should take place outside the buildings. (2) The pipes should be generally 4 inches diameter. In rare instances need a drain-pipe for a hospital exceed 6 inches in diameter. XV.] The Ward Unit. 221 (3) Every drain should be laid with true gradients, in no case less than j-J^, but much steeper would be preferable. When from circumstances the drain is laid at a smaller inclination, flush-tanks at the head and at intervals in its length should be provided. The drains should be laid in straight lines from point to point. At every change of level or of direction there should be reserved a means of access to the drain. Between these points the drains should be proved to be water-tight by plugging up the lower end of the drain- pipe, and filling it with water, provided always the extreme pressure in the pipes should not exceed 3 feet of head of water. (4) No drain should be constructed so as to pass under any part of a hospital building, except in particular cases where it is unavoidable. In such cases the pipe should be of strong cast-iron, laid in a straight line between inspection chambers outside the building on each side, and the length of drain laid under the building should be freely ventilated at each end, with a flush-tank placed at the upper end. (5) Every drain should be arranged so as to be flushed and kept at all times free from deposit. (6) Every drain should be ventilated by at least two suitable openings, one at each end, so as to afford a current of air through the drain, and no pipe or opening should be used for ventilation unless carried upwards without angles or hori- zontal lengths, and with tight joints. The size of such pipes or openings should be fully equal to that of the drain-pipe ventilated. (7) The upper extremities of ventilating pipes should be at a distance from any windows or openings, so that there will be no danger of the escape of the foul air into the interior of the building from them. (8) The soil-pipes from all water-closets, and waste-pipes from slop-sinks for urine, should be continued above the eaves of the house for ventilation, and there terminate, with the ends open to the air ; and if such ends be at or near any 2 22 Healthy Hospitals. [ch. window of the house, it would be necessary to continue such pipes up to the ridge of the roof. Every such continuation should be of the full size of such soil or waste-pipes. The soil-pipe should terminate at its lower end in a properly ventilated disconnecting trap, so that a current of air would be constantly maintained through the pipe. (9) No rain-water pipe and no overflow or waste-pipe from any cistern or rain-water tank, or from any sink (other than a slop-sink for urine), or from any bath or lavatory, should pass directly to the soil-pipe ; but every such pipe should be disconnected therefrom, by passing through the wall to the outside of the building, and discharging with an end open to the air. (10) Waste-pipes from cisterns, sinks, baths, lavatory basins, &c. should be trapped close to the cistern, sink or bath or basin ; otherwise the deposit which takes place even from clean water would in time create an offensive smell. (11) All pipes for the removal of foul or the provision of fresh water should be carefully protected from frost. There should be an intercepting chamber between the drains from each building and the main drain of the hospital. The drains from operation room, post-mortem room, and mortuary, should especially be carefully intercepted. The main drain should be ventilated and arranged to be flushed independently. Proportion of Ward Offices to Wards. — These various offices will vary but little with the size of the ward ; that is to say, a ward of twenty beds will require nearly as large ward offices as one of thirty- two beds. The number of water-closets and lavatory basins depends to some extent on the severity of cases treated ; twelve per cent, of the number of beds may be assumed as a rough approximation in each case. But whilst three water-closets per ward will suffice for a ward of thirty-two beds, two at least will be required for wards con- taining eight to ten beds. The superficial area to be added to XV.] The Ward Unit. 223 the hospital in the case of wards of thirty-two beds for these appliances would be about 30 square feet per bed, whereas in wards of twenty beds each it might come to above 60 square feet per bed. The following table shows approximately for a few hospitals the superficial area of the space occupied by ward offices, passages, &c., exclusive of day or dining rooms, per bed in the ward unit. Hospital No. of Beds. Superficial Feet per bed. I. Eloi 62 30 2. Tenon 56 ( exclusive of ^ ( staircase 3. S. George's Union 32 20 4. Bichat 30 18 5. Johns Hopkins 28 64 6. S. Denis 16 67 This shows roughly how much cheaper large wards are than smaller ones in first construction. CHAPTER XVI. AGGREGATION OF WARD UNITS. The ward, with its ward offices as before described, is the unit or basis of hospital construction. It is a small hospital which would only require certain administrative additions to make it complete. It forms a basis for any hospital. It could be developed into a Cottage Hospital, an Isolation Hospital, a Children's Hospital, or indeed, under varied conditions of internal arrangement, into almost any other form of small hospital ; the principal ward being made larger or smaller according to the requirements of each case. And in addition to this, a large hospital of any required size might be formed by the addition of similar units. There are, however, two important considerations in reference to the number of wards which should be kept prominently in view, in designing a hospital. In the first place, the necessity of arranging the number of wards in proportion to the number of patients, so that in each year every ward shall be closed once for aeration, cleaning, and repairs. Such closing should preferably occupy one month, so that there should in large hospitals be one extra ward in every twelve. And in smaller hospitals there should be always one spare ward. This is a matter which is very much overlooked in the original design of a hospital. A main object of this resting is to flush the ward with air as we flush a drain with water; hence the object of having openings on floor levels which, if not used during the Aggregation of Ward Units. 225 occupation of the ward by patients, would be of great utility for the aeration of the ward. Secondly, it is always desirable, and indeed it is essential, in infectious hospitals, that probationary wards should be provided to receive supposed cases of infectious disease until a satisfactory diagnosis has been established. Johns Hopkins Hospiteil P/an or Site Scale 4O0 soort -^< A . Administrative Offices. B. Private Paying Patients. C. Bathing Establishment. D. Dispensary and Drug Stores. E. Kitchen and Domestic Apartments. F. Nurses' Home. H. Sick Wards. /. Sick Wards. K. Isolation Wards. L. Lecture Theatre and Students' Building M. Out-patients Department. O. Mortuary and Post Mortem Room. P. Laundry and Wash-house. R. Chapel. 6". Green House. Fig. 36. Many of the more recent forms of hospital units and their aggregation into hospitals are given in the admirable work of Dr. Mouat and Mr. Saxon Snell on hospital con- Q A. Wards. B. Orderlies Barrack Room. C. Corridor. D. Day Room. E. Orderly. F. Bath Room. G. Lavatories and W.C's. H. Yard. /. Med. Comfts. K. Kitchen. L. Larder. M. Surgery. N, Scullery. O. Staircase. Fig. 36 a. P. Lobby. Q. Open Porch. K. Wood and Coals. S. Cook's Room. T. Wine and Beer, V. Pack Store. W. Waiting Room. Aggregation of Ward Units. 227 struction, and in Mr. Burdett's ' Hospitals and Asylums of the World.' The plan of the Johns Hopkins Hospital (Fig. 36) affords a good illustration of the arrangements of buildings on a site. Whilst the Johns Hopkins Hospital shows a carefully devised plan for a large hospital, the accompanying plan of the new Military Hospital at Holywood, Belfast, shows a convenient grouping of the several buildings required for a small hospital. This hospital is arranged to afford the necessary height of 13 feet for the wards and their appurtenances ; whilst the subsidiary accommodation, including the Day Room and Orderlies' Barrack Room in the main or ward building, is limited for economy to to feet high. The upper floor contains two wards similar to those on the ground floor and, in addition, a ten-bed ward over the Day Room and Orderlies' Barrack Room, opening from the staircase on a lower level. The upper floor of the administrative building contains the Hospital Sergeant's quarters, Linen Rooms, and other such stores. Aggregation of ward units in the construction of a hospital. — The principles upon which these units of ward construction, or, as they are generally termed, pavilions, should be arranged when aggregated are as follow : — (i) There should be free circulation of air around and between the pavilions. (2) The space between the pavilions should be exposed to sunshine, and the sunshine should fall on the windows and walls. The arrangement by which sunshine will always fall to the largest extent on the space between pavilions and also be distributed most evenly over the wall surface, is obtained in this country by placing the pavilions on a north and south line or axis, because the slanting rays of the sun fall in the morning on the eastern, and in the evening on Q2 228 Healthy Hospitals. [ch. the western side. With an east and west axis one side of each pavilion and part of the area between the pavilions is sunless for most of the year : this might possibly have advantages for a hospital in- a southern climate, but in a hot climate, just as much as in a cold climate, direct sunshine is necessary to promote healthy conditions. A place from which sunshine is always excluded is never healthy. (3) The distance between adjacent pavilions should not be less than twice the height of the pavilion reckoned from the floors of the ground-floor ward to the eaves, if with a very sloping roof, or to half the height of the roof, with a steep roof. This is the smallest width between pavilions which will prevent the wards from being gloomy in this climate. Where there is not a free movement of air round the buildings, the distance should be increased. In the new wards of the Western Fever Hospital at Fulham, whilst the two-story fever blocks are placed 70 feet apart, the diphtheria blocks are placed 113 feet from the fever blocks. As regards the question of wards on one floor or wards superimposed in two or even more floors, it may be accepted that, so far as the sick are concerned, they would, as a rule, be better placed on one floor in a ward unit well raised off the ground without anything over them. These units could be entirely separate, or they could open out of a common open verandah or glazed corridor ; and if land is cheap, and the site fairly level, it is probable that such an arrangement might be more economical than building two- story buildings. The pavilions might be nearer together than in the case of wards on two floors, and consequently the distance to be traversed by the medical men on visiting the wards would be from 30 to o^^ feet horizontally between the pavilions in the case of the one-story hospital, as com- pared with ascending from 14 to 16 feet by a staircase in the case of a two-story building. On the other hand, the cost of drainage may be somewhat greater, and facilities for XVI.] Aggregation of Ward Units. 229 supplying hot and cold water to the ward offices will be less, in the one-story hospital. On town sites it is sometimes absolutely essential to build hospitals as compactly as possible ; in these cases, whilst the first cost may be greater, the current expenses would probably be less in a building with wards on two floors provided with lifts and other labour-saving appliances. A new town hos- pital should not be commenced unless the funds admit of an area adequate to healthy construction. But where a town hospital has to be remodelled on an existing site, it may be necessary to accept special arrangements in order to mitigate some departure from entirely satisfactory hygienic conditions. The necessity for superimposed wards, which in some town hospitals cannot be limited to two floors only, would render a special construction of staircases advisable to prevent com- munication of air between wards. The proximity of a noisy street would require special arrangements in the foundation of the buildings containing wards, to prevent the patients from feeling the vibration of heavy drays, and might even compel a corridor system of ward construction next the street instead of the pavilion system in order to ensure quiet for the patients. But where space admits, the location of each single ward unit, or possibly a double ward unit ss a small separate hospital, is preferable to the aggregation of patients in large buildings. Unless connected together by means of covered corridors this would entail, no doubt, more exposur-e to nurses, attendants and doctors than their aggregation in palatial buildings ; but where nurses and attendants have been provided with proper protection against the weather, in going to and from the wards to the administrative buildings, such exposure has not been found injurious to health. Whilst separation of the ward unit has been the principal feature of modern hospital construction in Germany and more recently in the United States, the complete separation of ward units in this country has only been adopted in some of the 230 Healthy Hospitals. [ch. Metropolitan Asylums Board and other Infectious Hospitals. In the aggregation and connexion of ward units, except under special circumstances, there should not be more than two floors of wards in a pavilion. If there are three floors or more, in addition to the increase of patients under one roof, the distances between the pavilions become very con- siderable if the rule, which ought to be absolutely observed, is adhered to, of placing the pavilions at a distance apart equal to at least twice the height of the pavilion, measured from the floor level of the ward nearest to the ground. Moreover, heated impure air from the windows of the lower wards has occasionally a tendency to pass into the windows of the wards above. Besides, when two wards open upon a common staircase^ there is to some extent, danger of a com- munity of ventilation. On these grounds it is not desirable that a hospital should have more than two floors of wards one over the other ; and the basement or lower story under sick wards should not be utilized for purposes such as cooking, &c., from which smells might penetrate into the wards. When possible, it is best not to continue the staircase into the basement. When there are as many as four wards, one over the other, the staircase becomes a powerful shaft for drawing up the impure air of the lower wards, and the upper part of the staircase therefore requires special care in ventilation to pre- vent impure air from penetrating into the upper wards. In the case of Fever Hospitals for the Metropolitan Asylums Board recently erected by Messrs. Harston, for two floors of wards, the objection to the staircase forming a shaft for impure air between the lower and upper ward has been met by cutting off the staircase entirely from the entrance to the lower wards. The pavilions are connected by means of a covered way consisting of a roof on columns. From this covered way there is a direct separate entrance marked A to the lower XVI.] Aggregatio7t of Ward Units. 231 Western ferer HoapLtal of Metrop Aaylums Board ward, whilst the staircase leading to the upper ward has a separate entrance marked B so arranged as to give access from the covered way only to the upper wards. An outside staircase is also pro- vided at the further end of the ward for escape in case of fire. Covered communi- cation between wards on the several floors of parallel pavilions in large hospitals is gene- rally obtained by a block of superimposed corridors, with a stair- case at each pavilion ; this interferes with sun- shine and circulation of air. To prevent com- munity of air between the two floors of wards in the Colchester Mili- tary Hospital the stair- case has been placed intermediate between the pavilions Fig. 38. It is, however, a defective feature in hospital construction to unite parallel ward units, which consist of two or three or more superimposed floors of wards, by solid corridors on each floor so as to form closed courts. Hence the communication between parallel pavilions should ,„9 19 Staircaee in event- oF Fire 20 30 4-0 eo Scale of Feet Fig- 37- 232 Healthy Hospitals. [CH. be arranged with as little interference as possible with the light and flow of air between the pavilions. Colchester Military Hospital. ^^ — n I-I iJ a a 5ca/e. 5 10 so 30 40 so 1 t— I I 1 U.^:::^:.:^ 100 r: A. Ward. F. W.C. B. Orderly. G. Balcony. C. Scullery. H. Foul Linen. D. Lobby. /. Corridor. E. Bath, Lavatory. Fig. 38. K. Store. L. Stairs. Zi. Upper ditto. M. Porch. The staircase leading to the two ward units in a double XVI,] Aggregation of Ward Units. 233 pavilion should break the air connexion between them. To effect this neither ward unit should in any way trench upon the staircase, which should be amply lighted, warmed War a Nur3e ca Scullery Bridge to \ A dja c ent Pq vilio n I Corridors rr Lift ■ma/I] -VJ 7111 ; '/ 1 i . '---•'i III I II Lii; I I I I -I'-l'jJIU I Corridors Bridge to Adjacenc Pavilion Nurse 03 Sculfdry Ward First Floor- Fig- 39- and ventilated independently of either ward. An arrangement of this sort has been adopted by Mr. Keith Young in the new Derby Infirmary. To secure the object above mentioned, the staircase should be 234 Healthy Hospitals. [CH. entirely detached, as shown in Figs. 39, 39^, and connected with all adjacent wards by means of light bridges ; an open bridge would be best, but it would probably be desired to have a roof and glazed sides, in which case it should not Corrt'dor d Feet Migh ' Leading to Adjacent Pavilion iiii 1 1 1 I I JuUi-iXL._J Lobby Nurse T3 fti-c: C3 \Corridor8Ft.High j Leading to I Acfjacent Pavilion Scullery yVard Ground Floor Fig. 39 a. exceed 7 feet 6 inches or 8 feet in height, and be provided with ample cross-ventilation. The centre of the staircase would afford a space for two lifts, one for patients and attendants, the other, a small one XVI.] Aggregation of Ward Units. 235 for food, coal, &c., both carried down to the subway in the basement. This detached staircase would largely discount one of the objections to superimposed wards and would probably be the safest arrangement for a town site when several floors of wards exist If a covered corridor unites the ends of pavilions on the ground floor only, its roof should not at most be carried above the floor level of the first-floor ward. For, whilst the floor of the first-floor ward would be from 14 to 16 feet above the ground-floor wardj it would be unnecessary for purposes of communication to give the corridor a greater height than 7 feet 6 inches or 8 feet ; there is however this consideration, that if the top of the corridor is made level with the ward floors of upstairs wards, it affords a convenient terrace on to which the beds of patients can be wheeled, so as to allow them to lie out in the open air. But a more convenient place, because more sheltered from wind, would be afforded by a broad verandah in front of the end-ward window, or, as shown in Figs. 31 and 34, by a broad verandah running along the side of the ward. The communication on the upper-ward floors between adjacent pavilions would be effected by means of bridges, which might be open, or covered and with glazed sides^ as desired ; these would be supported on light columns, and would afford places on to which patients could be rolled out of the wards into sunshine if desired, and would allow of the free flow of air underneath. The girder support- ing the bridge could have ample depth above the floor of the bridge, so as to leave as much space as possible between the top of the lower corridor and the floor of the bridge for the free passage of air. At Antwerp, and at Mons, bridges connect the upper wards with the adjacent buildings. In the Women's Hospital in the Euston Road, of which 236 Healthy Hospitals. [ch. Mr. Brydon was architect, in order to obtain the maximum of aeration on the restricted site on which the hospital is built, the connexions between the administrative buildings and the wards on the upper floors are all made by means of bridges, which admit of circulation of air underneath. The treads of a hospital staircase intended for patients should preferably be i foot wide by 4^-inch rise, and in no case should they exceed from 5| to 6-inch rise. There should be a handrail on each side. There should be a landing after every eight steps, for the easy ascent and descent of patients. There should be nothing combustible in or near the staircase. To prevent panic in cases of fire a subsidiary staircase at the opposite end of the ward may be advisable. This can be conveniently carried down from an open balcony in front of the end window of the ward. But if the wards are free from combustible material, and if superimposed wards are separated by fire-proof floors, the risk from fire ought to be small. It is, however, essential that every hospital should be provided with simple and easily-applied means for checking the spread of fire. Adjacent to every ward and on every floor hydrants with hose should be placed. There should also be a hand engine available, and fire buckets always kept filled ; extincteurs would also be useful. Glass grenades are questionable, as the pieces of glass from a grenade thrown on to a fire to extinguish a chimney on fire have flown back into the ward among the patients. It may be assumed that, whatever the apparatus, the members of the hospital staff should be accustomed to its use by periodical exercises. The service of a hospital with more than one floor of wards can conveniently be carried on by subways under the lower corridor connecting the ward units. The connection of the subway with the ward floors must be by lifts. It would probably be found more economical to have lifts of two sorts, one for carrying patients or attendants about 7 feet x 4 feet XVI.] Aggregation of Ward Units. 237 wide, the other for coals, food, &c., about 2 feet 6 inches X 2 feet 6 inches. High-pressure hydraulic power is at present the safest and most convenient force for working lifts, but electricity may eventually take its place. The larger lift would bring up patients and take down the dead to the subways, whence the body would be conveyed to the mortuary. It has already been explained that there is a limit to the numbers which should be congregated under one roof But the limit may be safely made to depend to some extent on the nature of the cases. With military hospitals, into which in time of peace many slight cases are received, it was decided that as many as 136 cases might be placed in one double pavilion, divided into two equal halves in such a way that the communication between the halves was cut ofT by through ventilation. Of course in time of war, with wounded men, other conditions would prevail. In town hospitals, where the cases are of a more severe character, a similar double pavilion would probably not contain above 80 to 100 beds. An increased size in any given hospital ought not to be determined by increasing the number of beds in any one building, but by increasing the number of units, each con- taining from 80 to 100 beds ; and the extent to which these units should be multiplied would, if the units have been properly constructed and arranged, be determined not so much by the number of patients as by considerations of economy in administering the hospital. At the same time it is not advisable to have very large hospitals. It would be more convenient to the inhabitants of a town to have two hospitals of 500 beds each, semng a particular district of the town, rather than one large hospital of ],ooo beds, which would after all only be convenient for one of the districts ; and in selecting sites and making arrangements for new hospitals it should be remembered that 238 Healthy Hospitals. the actual area per bed required for a hospital should be increased in proportion to the increase in the number of beds ; thus if 80 beds per acre are assumed as the admissible number for a hospital of 250 to 400 beds, a smaller number of beds per acre should be adopted in the case of a hospital with 1000 beds. CHAPTER XVII. ADMINISTRATIVE BUILDINGS. The accommodation for the wards must be supplemented by the arrangements for what is called the administration. But it is beyond the scope of these notes to enter very fully into this part of hospital construction. The position and general construction of the administrative buildings should be made quite subservient to the accommo- dation for the sick, and to the broad general principle that these buildings should not interfere with the circulation of the air around or the light of the wards. The first point is to consider what is the smallest amount of this subsidiary accommodation which will suffice, and to provide that amount, and no more. Many rooms mean many servants, much cleaning, and consequent additional expense. As already mentioned, the necessary subsidiary accommo- dation falls under, firstly, that connected with the admission, treatment, and discharge of the patients : secondly, that con- nected with boarding the patients : and thirdly, that connected with general supervision. (i) Rooms co7tnected with admission, treatment, and discharge of patients. Reception, examination, and discharge rooms. — These are required, however small the hospital may be. They are placed near the entrance. There is a waiting room, examination room, and patients' bath room. The doors of these should all be wide enough to admit of the passage of a stretcher on wheels. 240 Healthy Hospitals. [CH. In hospitals where the patient's clothes are taken from him on entering, and where he is supplied with complete hospital clothing, the linen clothes would be sent to be washed and the woollen clothes to be passed through the disinfection chambers, after which they would then be returned to the store, conveniently near the discharge room, labelled for delivery to the patient when he leaves the hospital. Whilst in the store they ought to be unfolded, examined, and refolded at least once a fortnight as a preservative against moths. In the case of Infectious Hospitals the discharge room con- sists of an undressing room where the hospital clothing is taken off and left, a bath room where the patient bathes, beyond which is a dressing room where the patient resumes his own clothes and departs. Section through rows seats in Operation The or SLtrt '. a/" 0^ ~ /-'Jo '',-° >» Fig. 40. Dispensary and drug store. — The former should be in a fairly central position. Where there is an out-patient depart- ment it may be convenient that it should supply the latter as well as the hospital. It requires a still room fitted with necessary appliances next to it. The Splint Room should be conveniently placed with respect to the surgical wards and to the operation room. It should be light, and should have a small workshop attached, with the necessary tools for the work connected with splints, bandages, &c. Operating Room. — The doors should be double, of varnished oak or hard wood, about 5 feet wide, to allow ample room for :v]i.] A dministrative Buildings. 241 beds on wheels to be wheeled in and out. The floors should preferably be of marble terrazzo or of some substance which would not absorb the fluids that necessarily fall upon it. The lower half of the walls should be of some glazed or polished material, durable, easily washed or cleaned, and of a P/an or Operating Theatre Surgical KJinih j Gott/nge/i ig Mstrsa restful colour, which would not absorb light. The upper part may be of plaster, similarly coloured or painted. Operation theatres in small hospitals have sometimes had their walls entirely covered with sheets of glass. In the operating theatre of medical and surgical schools seats must be carefully arranged to enable the students to see over each other's heads when seated. 242 Healthy Hospitals. [CH. There should be ample light, and no dark corners where dirt or dust might accumulate, either under the seats or other- wise. There should be windows in the sides, and a large window, if possible, to the north as well as top lights, but the windows should be so distributed as to avoid glare. Figure 41 shows a plan of the operating theatre of the Section of Surgical Klinik Oporatino Theatre St Gottinger) Fig, 42. Chirurgische Klinik at Gottingen, which was completed at the end of 1889 : the section of the theatre is shown in Fig. 42. This theatre is of a half-elliptical form, and large enough to hold two operating tables at the same time. The section shows how light penetrates to every part. The students come in on the upper gallery, and the patients are brought in through the centre on the ground floor from the waiting room without encountering the students, and pass XVII.] Administrative Buildings. 243 out to the room for patients operated upon, whence they are taken to their wards. There are vertical windows on the side. The principal window is to the north, and is 14 feet 6 inches wide and 16 feet high : it is furnished with shutters, which can cover it nearly up to the ceiling, and thus if desired the whole light can be made to fall on the operating table from the ceiling. A semicircular form of operating theatre is sometimes preferred. It must not be omitted to mention that a room close at hand for the administration of anaesthetics is necessary ; and that it is convenient to place the room, for applications of plaster of Paris bandages, in connexion with the operation room. The tables and shelves for instruments, &c. may advantageously be made of glass or very hard wood, for cleanliness ; it is needless to say that the most scrupulous cleanliness should be observed in every part of the room. Adjacent separate wards are occasionally provided, either as resting wards or as wards for certain cases to remain in after operations. But in the more recent hospitals this practice does not appear to prevail largely. Special baths are becoming a recognized branch of hospital treatment, and these should be provided in addition to the baths required for each ward. These consist of medicated, vapour, Turkish, and electric baths, as well as permanent water-baths. They might with advantage be placed where they could be made available for out-patients as well as patients in the hospital. A dead-house and post-mortem room should be provided, quite outside and detached from the hospital : it should have a surgeon's room and dressing room, as well as a room in which the coffin would be placed previous to removal of the body. R 2 244 Healthy Hospitals. [CH. SneTCH PLAN OP CornoiNFD PoST-MonTtrM Rooms and MoRTUARf HAVINC PACll-ITies FOR INQUESTS . SuiTAate TOR HoSPITAU* 111 (0 Public Entramco in QMAl-l. PROVIIiCI/M. TOYVN9. HospiT^u ■ ^1 BuiLoincs Ya.rd . !" ^ t: rt u Pi a.J=i ■" com ^"n~ T) o! ^§ o 1^ r go o p o ■a c 8.-2 o c c ° 2 MO •a S "< "c; -io: f^'g- 45- e a hi) (U c . §«a SOIL'S i W P d. Pi fi, p p < J XVIII.] Hospitals for Incurables, etc. 257 St. Pol-sur-Mer, Ver-sur-Mer, Cette, Cannes, &c., which contain in all probably from 1,800 to 2,000 beds. The statistics of these hospitals are stated to show that with a stay averaging 423 days, from 75 to 80 per cent, of the cases are entirely cured of scrofulous and tubercular diseases. The proportion of cures increases and the period for re- maining in hospital decreases when the children are sent at the commencement of the manifestation of the disease. The diagram annexed shows the arrangement at Banyuls- sur-Mer, which accommodates above 200 patients. It is situated on the sea-shore, where the children spend most of their time. They are accommodated in dormitories (in which the cubic space amounts to between 600 and 700 cubic feet), day-rooms, school-rooms, and refectory, and there is moreover an establishment for baths and hydrotherapeutic treatment. Dr. Leroux has recently published an interesting account of all these establishments, entitled ' Hopitaux Marins.' A hospital for children in a town is not advisable. It can only be looked upon as an adjunct to an out-patient department. Children, as a rule, are better cared for in their own homes than in a hospital, but in cases of accidents and acute diseases they may require special care and treatment which their homes would not afford ; such are appropriate cases for a town hospital. There is the additional consideration that the hospital provides means of affording clinical instruction to medical men. With regard to the question of providing hospitals in towns solely for children, it is of universal hospital experience that the intermingling of ages is desirable. Sick children can never be left alone for a moment. It might almost be said a nurse is required for every child. This is why in a general hospital it is much better for the children to be mixed as far as possible with the adults, and if judiciously distributed it does the woman in the next bed as s 258 Healthy Hospitals. [ch» much good as it does the child, or the man as it does the little boy. If there must be a children's ward in a general hospital, let it be for the infants. If there is a separate children's hospital the age of admission on the female side would preferably include 15 years. A child's ward-nurse ought to feel for each child as if her happiness were bound up in its recovery. The general arrangements as to fresh air, &c., would follow those already described ; small special baths would be required. Children's water-closets must be self-acting, with no possibility for a child to fasten itself in or to communicate with another child when inside ; they should be well lighted night and day. A children's hospital should be provided with establish- ments for bathing, playing indoors and out, large garden grounds, gymnastic grounds and halls, both in and out of doors ; gymnastics should be under a professor, and out- patients should be always admitted to the exercises ; there should be school-rooms : and a ' sister ' should be appointed to superintend these places. It is desirable that singing in chorus be taught, and that a chapel should be provided for secular as well as religious teaching by a chaplain ; here only should the boys and girls meet. Before closing these observations on children's hospitals, it is desirable to add a few remarks upon school infirmaries or sanatoria. A boarding school of any size requires special provision for the reception and treatment of the sick members of its community. Broadly speaking, each school should possess — (i) Adequate accommodation for the reception and treat- ment of such of its inmates as may be suffering {a) from ordinary non-infectious illness, or [U) from the effects of accident and injury. XVIII.] Hospitals for Incurables, etc. 259 (2) Separate accommodation for — {a) temporary and separate isolation for those who have been exposed to any of the several forms of infectious disease, but in whom the disease has not yet manifested itself ; {b) the treatment of those actually suffering from infectious disease. In this case there should be provision for isolating and treating separately from each other two or more different infectious diseases, should they occur simul- taneously. The amount of accommodation for sick or injured in a school depends to some extent upon the average age of the scholars. Amongst young children the incidence of infectious diseases is more frequent, whilst accidents and injuries will prevail more amongst older boys. It has been laid down by the medical officers of the Schools Association, that where the average age of a school does not exceed 12 years, the infirmary accommodation should be at the rate of 5 per cent, of the boarders ; and that with an average age of 15 years the allowance should be from 6 to 7 per cent. Cases of infectious and non-infectious disease are best treated in separate buildings, and in order to provide adequate isolation for these, some addition to the above percentages would be necessary. For ordinary diseases and accidents the floor space should not be less than 100 square feet with about 1,300 to 1,400 cubic feet, according to the height of the wards ; the infectious wards should not afford less than 2,000 cubic feet of space, and 140 to 1 60 square feet of floor space. The wards should vary in size from 2-bed wards upwards ; it would probably be more convenient in any school to limit the size of wards to 8 or 12 beds as a maximum. With a small separate hospital the accommodation, as to wards and ward offices with all necessary conveniences, would S 2 26o Healthy Hospitals. [ch. follow, on a smaller scale, that which has been laid down for hospitals ; and such a building would require accommodation for a trained nurse as matron and other nurses and servants in proportion to its size. A surgery, with hot and cold water, cupboards and shelves for instruments and drugs ; and an examination room would be required, in which any boys requiring to see the doctor would be examined. A waiting-room, a day and dining-room, and an exercising ground or garden for con- valescents would be desirable, if the school hospital were at all large. In small schools where an establishment of this sort is impracticable, separate rooms with water-closet, slop-sink, and bath-room with hot and cold water laid on must be allotted (i) to ordinary cases, (2) to infectious cases, with additional rooms and a small ward kitchen for the special nurse who would be appointed to take charge. No refuse or foul linen should be retained on the premises. The several rooms should not communicate with each other : they should be continuously isolated if possible, by being approached by means of a separate staircase. The school drainage should be intercepted from the hospital drainage. Convalescent Homes. — It may be useful to make a few remarks upon these as adjuncts to a hospital. Every hospital should possess a convalescent home in a healthy open position and in a suitable climate. If possible it should be placed by the sea. It is an axiom that no patient (especially a child) should remain in hospital longer than necessary. Hence a con- valescent institution should be as like a home and as unlike a hospital as possible. But whilst there should be as little as possible in a convalescent home to remind the patients of a hospital, xviii.] Hospitals for Incurables, etc. 261 yet, as relapses are occasionally unavoidable, it is necessary that some provision should be made for sick rooms and nursing. During relapses continual supervision is essential, con- sequently there must be two small wards, one for males and one for females, with the sister's room between them, looking into both, placed in a central position. In a convalescent home absolute separation of males and females is essential, especially as a safeguard against im- morality. To see the men and women patients going out walking together is to see that there is no discipline. Hence the best form of convalescent home is probably that of separate cottages holding each not more than 8 patients ; the males in one, and the females in another. The men and women should never meet except in the dining-room. All the cottages would be connected with the dining and day-rooms by means of a covered way or corridor. If the corridor is glazed and warmed, it would afford a place for exercise in cold or wet weather. The sleeping rooms of a convalescent home should have as efficient a system of ventilation as hospital wards ; but as they are occupied by night only, the cubic and floor space might be more restricted. The convalescents' beds maybe separated by curtains about 6 or 7 feet high on a rod to be pulled quite back in the day- time. Patients on the female side should never be obliged to go to lavatories, a washhand-stand would therefore be provided for them within their compartments. Three or four beds is a good number for each convalescent room. Children are best placed to sleep in the rooms with women, if they can be so placed judiciously, otherwise they would require the supervision of a nurse at night. 262 Healthy Hospitals. [ch. In the case of a child occupying the next bed to a woman, the curtain may always be drawn far back. There must be baths ; one bath-room to 8 patients is the smallest calculation. There should also be smaller baths for children ; close supervision whilst bathing is most important for children. A nurse or bathing-woman must always be present. An ablution-room would be provided for the males. The number of water-closets would be in the proportion of I to 8 patients. There should be a water-closet or two adapted for children, so that they should never be able to lock themselves in. These would also require the closest supervision. For occupation, men would be preferably employed in the garden under a gardener than at indoor trades in the day- room. When indoors the women should be occupied in household work as much as possible, at least on their own side, but never without permission from the medical officer, and under the surveillance of the sister. They may even do cooking, if with a hot plate in the kitchen ; but some who are able to walk, may not be able to use their arms. Of course such indoor work must never interfere with outdoor exercise. Some convalescents will want entire rest ; all must be pre- vented from damping their feet. Indeed, frequently the treatment will be entire rest with good food and fresh air. In the daytime feeble children should be with the women, but noisy ones must have a good airy play-room. A garden, not too pretty to play about in and make ' houses' in, is a great desideratum for children ; and they must not be mixed up with the men. The convalescent home would require supervision by a matron or sister, for whom a bed-room and sitting-room in a central position must be provided. Under her there would be the necessary nurses; these would best be distributed XVIII.] Hospitals for Incui^ables, etc. 26 J among the cottages. The servants would be lodged near the kitchen and stores. A porter or gardener would live on the male side, or in a lodge near the gate. A kitchen with scullery, larder, &c., would be provided ; also a linen and mending-room, well lighted and warmed, and a small store-room. All refuse should be removed daily to a distance. A surgery would be necessary for the medical man who would periodically visit the institute. Infections Hospitals. — Although the general features of construction in infectious hospitals are the same as those of other hospitals, there are a few points connected with their general working in their bearing on the public, which it will be convenient to note. In the first place, Dr. Sykes, in his valuable treatise on Public Health Problems, says : ' Probationary wards should never fail to be provided in all infectious hospitals. It is sometimes extremely difficult to diagnose an infectious case correctly at the onset. In the meantime, the rest of the family or of the household in crowded dwellings may run great risk. The medical attendant is justified in advising isolation, and with proper dwelling accommodation this may be carried out ; he is not the less justified in advising removal to hospital where the accommodation is inadequate. It therefore remains for the hospital authorities to provide such means of isolation as may avoid both the retention of such cases in crowded dwell- ings and the infection of the patient, if after removal to hospital it should ultimately transpire that a non-infectious or less dangerous malady develops itself.' In the next place, the safety of the public requires that there shall be strict precautions observed as to the communication between the hospital employes and the outside world. It will be useful to show what those precautions are. It must be borne in mind that, while the public must 264 Healthy Hospitals. continue to be jealously guarded not only against actual risk, but even against apprehension, vexatious and unnecessarily irksome restrictions ought not to be lightly imposed. The precautions which are adopted in the hospitals of the Metropolitan Asylums Board to secure these objects are classed under the following heads, viz. : (i) Visitors to Patients; (2) Staff ; (3) Patients' Letters ; (4) Disinfecting Machines ; (5) Destruction of Refuse, &c. (i) Visitors to Patients. The following regulation is in force at the present time, viz. : — Visitors will be required to wear a wrapper (to be provided by the Board) covering their dress and head, when in the wards, and to wash their hands and faces with carbolic soap and water before leaving the hospital, or to use such other mode of disinfection as may be directed by the medical superintendent. (3) The Staff. — No member of the staff, except when employed on ambulance duty, and messengers specially named for outdoor duty, is permitted to leave the hospital premises without having first changed his or her uniform, clothing, and stockings. No member of the staff going out with the intention of sleeping away from the hospital is permitted to leave the hospital without having first changed all his or her wearing apparel, and, except in case of ex- emption by the medical superintendent or matron, taken a bath. Subordinate officers, upon leaving the service of the Board, must satisfy either the steward or the matron that their clothing has been cleansed and disinfected, and that they have taken a bath. (3) Letters. — Patients' letters are baked before being posted. (4) Disinfecting Machines. — All the hospitals are provided with a super-heated steam disinfecting machine of modern type. (5) All refuse is destroyed. CHAPTER XIX. LYING-IN INSTITUTIONS. However great is the necessity for ventilation, freedom from contamination of air, and absolute cleanliness in the medical and surgical wards of a general hospital, it may be safely asserted that these necessities are tenfold greater in the wards of a lying-in institution. The great susceptibility of lying-in women to poisonous emanations, and the excessively poisonous emanations from lying-in women, constitute a hospital influence on lying-in cases brought together in institutions, second to no influence we know of exercised by the most ' infectious ' or ' contagious ' disease ; and yet the raison d etre of lying-in wards is that they shall be continuously occupied by a succession of cases. The conditions of hospital construction which have led to the greatly diminished mortality in recent years in these institutions appear to have been due to the greater isolation and separation of the cases. Inspector-General Massy, C.B., in a report to the Army Medical Department in 1869^ mentions a small lying-in hut hospital at the Colchester Camp, used exclusively for lying-in women. It was an ordinary wooden hut ; had a nurse's room at either end ; and the centre was divided into four small wards for one patient, each 10 feet, by 9 feet 10 inches, by 10 feet. Ablution was performed in the wards; there was no water-closet in the ward, and the excreta were at once removed by hand. In five years 252 women were confined in this hospital without a single death. 266 Healthy Hospitals. [ch. At Waterford the lying-in hospital consisted of a small house, in which one ward was used for the delivery of patients and two rooms received four beds each. (There were two such wards.) The mortality was i in 1328 in a period of 23 years. These hospitals seem to have owed their immunity from disaster to the limited number of cases accommodated at one time in the hospital, and to extreme care in management. The Hospital Tenon has provided a small establishment containing a separate ward for each lying-in patient. The wards occupy two floors ; each ward is entered through a small lobby from an open gallery, so that there is no air communication between the wards. The floor space in each is about 150 superficial feet, and the ward is nearly 10 feet high ; the floors are of cement or of marble terrazzo. Each ward has an ordinary casement window in the side opposite the door, and an open fireplace. Opening out of the entrance lobby is a small scullery with sink, &c. Hot and cold water is laid on to a fixed wash-hand-basin in the ward. The matron has a duty-room at the end of the gallery on each floor, with which each patient can communicate by means of an electric bell. After each occupation the walls of the room are scraped and whitewashed. In the system adopted at the Lying-in Clinical Institution in Berlin, a special room is provided into which the patient is taken for the delivery, and then is taken back to her ward. The annexed Figure 46 shows a small portion of this establish- ment, which will suffice to explain the general arrangements of the lying-in wards. The wards are in separate pavilions, and contain 4, 3, and 2 beds each. But whatever be the structural arrangement, success depends on cleanliness in the nursing ; all the architect can do is to facilitate cleanliness. In the Tenon Hospital, as well XIX.] Lying-in Institutions. 267 as in the Berlin Hospital, the most scrupulous cleanliness is observed, and the delivery-room and the walls and ceilings of the wards are frequently scraped and whitewashed. The following summary of the principles which should be Lying-in Hlinik, Berlin mrrnHd GQMistrea 1. Ante-Room. 2. Nurses' Room. 3. Bath Closet. 4. Students' Room. 5. Ward, 4 beds. 5". Ward, 3 beds. S*". Room for Midwives. 6. Delivery' Room. Fig. 46. observed in constructing these institutions is reproduced from Miss Nightingale's notes on lying-in hospitals : — Lying-in institutions must be in the immediate neighbour- hood of great towns or centres of population. There should never be more than four beds in a ward, or single-bed wards might be arranged in groups of four. Also, it must always be borne in mind that four beds mean eight patients. Including the infant, there are two patients to each bed to use up the air, which is besides used up by a necessarily far larger number of attendants than in any general hospital. The general arrangement suggested is shown in Fig. 47. There should be two floors, or eight beds at most in a pavilion, but it would be preferable to have wards on one 268 Healthy Hospitals. [CH. A. Administration. B. Kitchen and Stores. C. Delivery Pavilion with curtain di- visions. D. Ward Pavilions. Fig. 47- XIX.] Lying-in Institutions. 269 floor only. If on two floors, it is desirable that every alternate pavilion should consist of a ward on one floor only, unless the pavilions be so far apart as to cover an extent of ground which would make administration difficult. The minimum of ward cubic space for a lying-in woman, even where the delivery ward is, as it ought always to be, separate, is 2.300 cubic feet in a single-bed ward, and 1,900 cubic feet, per bed, in a four-bed ward. In wooden huts, where the air comes in at every seam, this cubic space may be less. As it is a principle that superficial area signifies more than cubic space, the surface of floor for each bed should not be less than 150 square feet per bed in a four-bed ward, and in a single-bed ward not less than 190 square feet, because this is the total available space for all purposes in a single-bed ward. This space has to be occupied, not only by the lying-in woman and her infant, and perhaps a pupil midwife washing and dressing it at the fire, but often by the midwife, an assistant, possibly the medical officer and pupil midwives. In a four-bed ward there is space common to all the beds. There should be two beds and two windows on each side of the four-bed ward. In a single-bed ward the bed should not be placed directly between window and door ; and it must never be in an angle ^. There must be room for attendants on both sides of the bed. There should be two delivery wards for each floor of a lying- in institution, so arranged and connected under cover that the lying-in women may be removed after delivery to their own ward. And for this purpose the corridors must admit of being warmed during winter, especially at night, so as to be of a tolerably equable temperature. ^ It may be mentioned here that pying the angles of wards was reta- in one Lying-in Institution the tively much worse than that of the medical record of the beds occu- other beds differently placed. 27b Healthy Hospitals. [ch; Unlimited hot and cold water should be laid on day and night ; a water-closet sink, bath sink, clean linen, must.be close at hand. The delivery ward ought to be separate in every lying-in institution ; it must be separate in an institution of more than four or five beds, though in separate compartments. The delivery ward should be so lighted and arranged that it can be divided, by curtains only, into three if not four compartments, with one window to each bed. The curtains, of washing material, are only just high enough to exclude sight, not high enough to exclude light or air, and are made so as to pull entirely back when not wanted. Each area enclosed by the curtains should of course be sufficiently ample for pupils, attendants, and patient ; also for a low truck on broad wheels covered with india-rubber, to be brought in, on which the bedstead with the clean warm bedclothes is placed, and the newly-delivered woman conveyed to her ward. Every delivery bed should stand in a superficial area of not less than 200 square feet, and a cubic space of not less than 2,400 cubic feet. Each delivery bed should have window light on either side, and also ample passage room all round and on both sides the bed. Care should be taken that no delivery bed should stand exactly between door and window, on account of draughts. The reason why there must be two delivery wards for each floor of a lying-in institution, to be used alternately, one ' off ' and one ' on,' is, that one delivery ward on each floor must be always vacant for thorough cleansing, lime-washing, and rest for a given period, say month and month about. Newly-delivered women cannot be removed from one floor to another. The position of the delivery wards should be as nearly as possible equidistant from the lying-in wards, and should be XIX.] Lying-in Institutions. 271 such that the women in labour, on their way to the delivery ward, need not pass the doors of other wards. A separate scullery to each delivery ward is indispensable, such scullery to be on at least an equal scale to that of ward sculleries. Hot and cold water to be constantly at hand, night and day. A sink-bath is desirable for immediately immersing soiled linen from the beds and the like in water. The scullery of the delivery ward should contain a linen- press, small range with oven, hot closet at side of the fireplace, sink with hot and cold water, &c. A small compartment should contain a slop-sink for emptying and cleansing bed- pans, and a sink in the floor, which is intended for filling and emptying a portable bath. Beyond the scullery, so as to be as far removed as may be from the traffic of the main corridor and the noises of the delivery ward, should be the bye-ward, with not less than 2,100 cubic feet of contents. One of such single-bed bye-wards should be attached to each delivery ward, for an exhausted case after delivery, till she is able to be moved to her own ward. All that has been said as to the necessity of impervious polished floors and walls for hospitals applies tenfold to lying-in institutions, where the decomposition of dead organic matter, and the recomposition of new organic matter, must be constantly going on. It is this, in fact, which makes lying-in institutions so dangerous to the inmates. And it may be said that the danger increases in a geometrical ratio with the number of in-cases. With respect to the sculleries, lavatories, and water-closets of the other wards it must be borne in mind that the necessary consumption of hot and cold water is at least double or triple that of any general hospital. Sinks and water-closet sinks must be everywhere conveniently situated. There should be a scullery to each four beds ; and the 2/2 Healthy Hospitals. [ch. scullery needs to be much larger and more convenient than in a general hospital. All the ward appurtenances, scullery, lavatory, &c., should stand empty for thorough cleansing, when the ward to which they belong stands empty in rotation for this purpose, and should not be used for any other ward. Therefore, for each four-bed ward, or group of four one- bed wards, or for each floor of each pavilion, there must be one scullery, with a plentiful and unfailing supply of hot and cold water, with sinks and every convenience. The reason of this is twofold : — (i) To allow each scullery, with the other ward offices, to be thoroughly cleansed and whitewashed with its own group of four beds. (2) The work in a scullery and in all the other ward appurtenances day and night, night and day, is many-fold that which it is in a general hospital scullery. In a lying-in hospital the infants, most exacting of all patients, must frequently be in the scullery. Even under the very best circumstances there are many lying-in cases among weakly women where the mother's state is such as to render it necessary for a * crying ' infant to be washed and dressed elsewhere than in its mother's ward. These infants are best washed, in that case, in the scullery, which should be so arranged that infants can be washed and dressed without being exposed to a thorough draught, and that nurses and babies may not be hustling one another. There must be a good press in each scullery; in which a supply of clean linen and other necessaries will have to be kept. Besides this, general hospital patients ought never to be allowed to enter the scullery. Fixed baths are not necessary. But there must be the means for filling with hot water moveable infants' baths at all hours at a moment's notice. XIX.] Lying-in Institutions. 273 There should also be a moveable bath for each ward for the lying-in women, with the means of supplying it with hot and cold water and for emptying it. Lying-in patients are not able to use either fixed baths or lavatory. Glazed earthenware sinks should alone be used, as being by far the safest and cleanest. No dispensary, or dispenser, is needed in a lying-in institution. A medical officer's room is necessary. The medical officer is not resident. A waiting-room is necessary. There must be a room where the head midwife can examine a woman. A segregation ward is necessary, completely isolated, where a sick case, brought in with small-pox, erysipelas or the like, could be delivered and entirely separated from the others ; and a ward to which a case of puerperal fever or peritonitis could be transferred. The segregation ward must have a nurse's room, and other necessary ward adjuncts, such as sink, slop-sink, &c. The question may, however, arise whether an infectious case originating in a ward should be removed from the ward, or whether all other occupants should be removed : and, indeed, it would always be advisable in Lying-in Hospitals of any size to provide for one ward to be always at rest ; such an arrangement would meet emergencies of this kind. It is also frequently desired by medical men, in order to meet symptoms suggestive of possible blood-poisoning, to surround the patient with fresh air, or, as it were, to flush her with fresh air. To this end a verandah would be a convenient adjunct to a ward ; indeed, a balcony on to which a patient could be moved into the open air may sometimes offer less risk in such circum- stances than the enclosing walls of a ward with its floor and furniture. It has, no doubt, been found that domiciliary confinements have generally afforded better results than those in hospitals ; T 2 74 Healthy Hospitals. but experience shows, on the other hand, that with adequate attention to structural arrangements, especially if combined with absolute cleanliness, the Lying-in Hospital ought to produce results scarcely less favourable than the home ; and the hospital is certainly of manifest advantage for difficult cases. CHAPTER XX. REMARKS ON TEMPORARY STRUCTURES, AND CONCLUSION. Before closing these observations upon the construction of hospitals, it may be desirable to say a few words upon move- able hospitals. The argument has been often advanced that it would be preferable for all hospitals to be of a temporary character, so that the materials of which they are composed could be periodically burnt and new hospitals constructed. This argument has great force in the case of buildings constructed like many of those which exist in our principal towns. That is to say buildings, which in many places will be found suitable for the collection of organic matter under conditions favourable for decomposition^ and where a nidus is afforded for the development of organisms whose presence is assumed to be a concomitant of diseases. There are few hospitals in this country the interstices of whose floors, skirting boards, walls, and ceilings are not filled with organic matter in such a condition. No doubt walls can as a rule be scraped and plastered. But it would not be safe to restore such buildings without removing floors and ceilings, and with- out scraping and replastering the walls in such a manner as would be nearly tantamount to a rebuilding of the structure ; and there would still remain the chances of pollution from the long occupation of the ground. On the other hand, in the case of hospitals constructed on the principles laid down in this treatise — with that destroyer of T 2 276 Healthy Hospitals. [ch. organisms, sunlight, penetrating to every part — with impervious floors, walls, and interspaces between buildings, in which there are no dark places for the lodging of impurities, the same conditions would not prevail, and a long occupation with periodical emptying, cleansing, and aeration of all parts, both in the occupation of the patients and otherwise, would keep the building in a hygienic state. On these grounds with a hospital which is intended to have any degree of permanence, or which is certain to be used at recurring intervals, as is the case with infectious hospitals, a brick building is preferable to one of wood or to a moveable hospital. In regard to temporary hospitals in towns there is the further consideration that sites for temporary occupation would be difficult to obtain at short notice ; wooden structures would be liable to fire ; iron structures would be hot in summer and cold in winter. Hence the most practicable plan is to have permanent structures for town hospitals adequate to meet the needs of the urban population, who would thus be secure of being treated with the best available professional skill ; and to supplement these hospitals by sanatoria in the country, to which convalescing patients could be moved. The moveable hospital is of course a necessity in war, but when it has been applied in this country by local authorities to meet outbreaks of infectious disease, with the idea that it might be taken to, and erected near, the locality of such an out- break, it has been found, first, — that time is required to obtain and prepare a site with necessary adjuncts of water and provision for refuse : and, secondly, that even if the materials were stored ready, some further time is necessary to erect and prepare the hospital for occupation, all of which operations postpone very considerably the date at which the hospital would be available for the reception of sick, and this necessary delay causes more inconvenience than would be experienced by carrying the patients a reasonable distance in XX.] Temporary Structures, and Conclusion. 277 a properly appointed ambulance to a permanent hospital in some fixed position. The subject of moveable hospitals for purposes of war assumed prominence during the wars of the last thirty to thirty-five years largely through the efforts of the managers of the Red Cross Society. The principle was laid down, and has practically been accepted by governments, that if the soldier has the right to receive the best equipment to enable him to fight when he enters the field of battle, he has equally the right to expect the best care which surgery and medicine can afi"ord, if he has the misfortune to be wounded on the field of battle. The late Empress Augusta of Germany, who took so strong a personal interest in the solution of the question, off"ered prizes at the Antwerp Exhibition of 1885, and again in 1889 at Berlin, when not only buildings but appliances of all sorts for fitting them up were exhibited. The exhibition was based upon the assumption that the arrangements for aid to sick and wounded in war cannot be satisfactory unless they are made quite independent of the chance resources which may be found in the neighbourhood of a field of battle. The basis laid down was that the unit of accommodation should provide for 60 patients in moveable hospital huts, with accommodation for the necessary staff", viz. % medical men, 1 subordinates, i cook, and 6 attendants for service on the sick. The programme assumed that three huts about 50 feet long and 16 feet wide would each accommodate 20 sick, and that two additional huts would accommodate the personnel and the necessary administrative requirements. These were fitted up in every detail with moveable articles re- quired, whether for the patients or for providing for their wants. It is beyond the province of this treatise to discuss the details of this question, which, moreover, would require much space. 278 Healthy Hospitals. [ch. The hospitals which may be required in the rear of an army or at the base of operations would usually be reached by the aid of railway transport, and would possess a character of greater permanence. A few remarks upon the materials used in such quasi- permanent buildings will not be out of place. These materials are generally corrugated iron, wood, Willesden paper or oiled canvas on wood frames. As regards iron, it has the great defect for hospital purposes of being hotter and colder than other material, it must there- fore be lined with wood, and the interspace packed with some non-conducting material. Sawdust is not desirable, as it may decompose ; slag cotton is preferable, because it contains no organic matter. But iron has the further defect of being impervious to air. One of the chief advantages of a temporary hospital of wood is that its walls are permeable to air at all points ; but the walls must be made double, and if in a cold country the interspace should be filled in by a porous material. It was the permeability to air and the porosity of the walls which proved the chief element in the comparative healthiness of the hospital huts erected in the American War of Secession and the Franco-German War of 1870-1871. The paper or oiled canvas types of temporary moveable hospitals, which have attained to some degree of use by various local authorities in England, are the Daeker or Ducker. They consist of a waterproof material stretched upon wooden frames which are of definite shapes and numbered so as to be put up rapidly and form a weather- proof hut ready for patients. But others and at least equally convenient forms were shown at the exhibitions of portable huts for military purposes already mentioned. Although it is beyond the province of this work to enter into the details of this class of hospital, it may be observed that British troops have generally had to provide XX.] Temporary Structures, and Conclusion. 279 for a hot climate rather than for that of the continent of Europe. Surgeon- General Marston, C.B., suggested one of the best forms of hut for affording protection against heat in summer. The object was to make as near an approach as possible to the condition of a person provided with a large thick umbrella as a protection against the sun or rain ; that is to say, the roof should be of such material and construction as to exclude the heat of the sun's rays. The hut should be provided with verandahs, and capable of free ventilation all round ; as well as shelter from wind when desired. There are certain other conditions which it may be well to summarize. The roof should be non-conducting. For a very hot climate cork slabs covered with waterproof Willesden paper were used ; under this was an air space, below which was a ceiling formed of inch boards laid with narrow interstices to allow of the circulation of air from the ward, and also air was admitted at the eaves, between the ceiling and the roof, near to the ridge ; ventilating tubes were carried from this air- space through the roof. This arrangement of roof was suitable for hot weather, because if the air in the interspace were confined, it would become very hot ; therefore circulation of this air was de- sirable. But for cold weather in order to retain the heat it would be advisable that the interspace should be closed so as to allow of no change of air. Therefore in such cases the ceiling should be fitted close, the admission of air at the eaves should be stopped, and the tubes should be carried from the wards through both ceiling and roof, and thus the air in the interspace would form a cushion to retain heat. The temporary wards for a hot climate had walls boarded to a height of 4 feet from the floor level, and to a depth of 2 feet from the top (the bottom board at floor level being hung to open outwards); between these boarded parts the 28o Healthy Hospitals. [CH. ^^^" 50.C Qkift- XX.] Temporary Structures, and Conclusion. 281 wall was formed of matting which could be rolled up when desired. The roof was continued over the walls to form a verandah 7 feet 6 inches wide all round, on to which patients' beds could be wheeled. At one corner of the verandah the earth closets and ablution rooms were placed, and being railed off from the verandah by an open railing, there was no air connexion between them and the ward. The ward floor and verandah were on the same level and raised from 18 inches to 2 feet off the ground, with free circulation of air underneath. The plan and elevation of this hut is shown in Fig. 48, and fuller particulars will be found in the Report of the Army Medical Department for 1884. The main arrangements shown would — with the necessary modifications for protection from cold — be applicable in temperate climates for hospital purposes, where temporary accommodation for a limited period was wanted. The object of this book, however, is not to give actual designs for hospitals, but to suggest the principles which should govern their design. These principles, if rightly appre- ciated, would apply as much to the creation of a permanent as to that of a temporary hospital. Conclusion. A considerable development has been taking place in the construction of hospitals in late years, especially in England, France, Germany, and America, and it seems probable that this activity will continue in this country under the influence of the County Councils and other bodies to whom the management of local affairs are being by degrees entrusted. The time therefore appeared to be opportune for bringing to a focus those principles which educated experience has shown to be essential, if we are to deprive of their powers of mischief 282 Healthy Hospitals. those agencies which always seem to arise from the congrega- tion of many persons under one roof; and, at the same time, to place the subject in a form which might be helpful to the medical man and the architect, as well as to those who are charged with obtaining the funds necessary for the erection of hospitals. It has been a matter of regret that whilst so much sickness and misery prevails which can be alleviated by the extension of hospitals, the cost of their construction has risen to almost prohibitory sums. This has not resulted entirely from the increased appreciation of the importance of providing light, air, and warmth, which are the first essentials of hospital construction, but it has been partly due to the desire to erect palatial structures, which shall impress the eye and become a standing advertisement of the originator or of the architect of the hospital. The principles enumerated in this book are not new ; they are well known, but they lie somewhat scattered through various publications, and the object of this treatise has been to bring them together, and by showing what points are essential to health in hospital construction, to enable those upon whom the regulation of the construction devolves to concentrate expenditure upon these matters alone. It is hoped that by bringing together this information, the erection of large, palatial hospitals in towns or other localities which are not suited to them will be discountenanced, and that the hospital architect, instead of seeking to erect a monu- ment of his skill and taste in architectural design, will be content to provide simple structures abundantly supplied with light and air, in which the interests of the patients and their recovery will be not alone the first, but the only consideration. INDEX. A. Ablution basins, p. 218. — rooms, 217-220, 262. Accommodation hospitals, 7, 18, 19. — payment for, 10, 11. Administrative buildings, 239-252. Aeration of soil, 24. — of wards, 224. Agglomeration of sick, 3, 35. Aggregation of ward units, 224, 227. Air, aqueous vapour in, 38, 39. — burning (E. A. Cowper's process), 67, 69-76. — capacity of, for moisture, 52. — CO2 in, 25, 39-46, 49, 50, 55. Billings' test, 42, 43. — change of, 49, 58, 78. — circulation of, 106, 148, 153. — composition of, 37-40. — currents, action of fireplaces and chimneys on, 81-84. — dust in, 38. — expansion of, 131. — filters, 62-64. — fresh, 6, 1 5. — ground, 24, 25. — measurement of, 59, 60, 84. — movement of (natural), 20, 77, 78, 80, 82. by application of heat, 20, 78, 84. by aspiration, 159-166. by propulsion, 92-99, 166-173. in chimney flues, 81, 86. — organic matter in, 44, 45-46. Angus Smith's test, 43. Carnelley's test, 44. — oxygen in, 37, 40, 45, ii5- — permeability of material to, 55-57. — pumps, 93, 94. — purification of (Key's process), 62- 66. — quantity for ventilation, 20, 47, 55. — temperature of, 50, 51. — velocity of, 39, 59, 79. in shafts, &c., 79, 82, 84. — vitiation of, 20, 35, 37, 39, 40-46, 49. Air, volume of, discharged by flue, 82, 85, 89-91. fan, 92-95. — warming, 65, 89, 100, 114, 119, 124, 127, 128. — weight of, 52, 77, 90, 115. Aitken, experiments on air and dust, 38. Anemometers, 60. Angus Smith, CO2 in air, 37. — organic matter in air, 43. Antwerp Exhibition, 277. — Hospital, 118, 167, 187, 188, 193, 235. Area for site of hospital, 32, 35, 36, 237. Areas of existing hospitals, 33-35. Arnott's air-pump, 94. Ashes, 249. Avraches Marine Hospital, 255. Axis of wards, 227. B. Balconies and verandahs, 195, 235, 273, 281. Banyuls-sur-Mer Marine Hospital, 255- 257. Barnes Hospital, 160, 165. Baths, 213, 217, 218, 243, 262, 272. Beaujon Hospital, 166, 167. Bed-space, 48, 185-187, 194, 196, 199. Beds, apportionment to cases, 192. — proportion of, to population, 7. Berck-sur-Mer, 255. Berlin Military and Civil Hospitals, 35, 193, 196. — Lying-in Klinik, 266, 267. Billings' test for CO2, 42, 43. Blackman's fan, 98, 157, 169. Bohm's ventilation, 157, 158. Bonn Hospital, 203. Bourges Hospital, 195. Bradford Hospital, 34. Breslau Clinical Hospitals, 196. Brydon, Mr., 236. Bunsen burner, 140. Burnley Hospital, 34, 149, 88-190. Candles, 141. Cannes Marine Hospital, 257. 284 Index. Carbonic acid gas, 25, 39-46, 49) 50j 66- Carnelley, Prof., 38-44, 210. Ceilings, 206, 208 Cette Marine Hospital, 257. Charing Cross Hospital, 33. Children's hospitals, 13, 224, 254-258. Chimneys, proportions for, 86. Cholera, 8, 21. Circular wards, 187-191. Clay soil, 26, 29. Cleanliness, 15-17, 79, 80, 267. — of soil, 27. Close stoves, 134, 135. Cockle, 114, 119, 155. Colchester Military Hospital, 186, 231, 232. Conclusion, 281, 282. Conducting power of materials, 103, 104. Conduction of heat, 100. Connexion of ward unit, 230. Convalescent hospitals, 13, 22, 254, 260- 263. Convection of Heat, 100. Corridor system of hospital, 4, 199. — between pavilion, 231, 235. Cottage hospitals, 2, 13, 22, 224. Cowls, 83. Cowper, E. A., burning ward air, 69-76. Crane's destructor, 249-251. Cubic space, 47, 55, 187- D. Daeker hospitals, 2 78. Day and sun rooms, 195, 196. Daylight, 138. De Chaumont experiments, 42, 58. Derby Infirmary, 155, 156, 230. Destructor, Crane's, 249-251. Dispensaries, 14. Distance between pavilions, 177, 228. Distribution of heat, 149-157. Donkin's formulae for impurity of air, 49. Doors, 204, 205, 239. Drainage, 220-222. Dresden Hospital, 181. Drug stores, 240. Dust in air, 38. Early history of hospitals, i, 2. Earth closet, 281. Eastern Hospital, Homerton, 35. Economy of construction, 192, 213, 222, 229, 239, 282. Edinburgh Infirmary, 34. Emmerich, Prof., 210. Fans, Blackman, 98, 157, 169. — Rittinger and Combes' formulae, 94, 96. — rotary, 94, 95. ■ — screw, 95, 96. Field hospitals, 3, 5, 6, 276, 277. Filters in air, 62-64. Flame, 140, 141. — temperature of, 102. Floor-space, 47, 48, 183-187. Floors, 208-212. — cleaning, 212. — non-absorbent, 212. — organic matter in, 209, 210. — raised, 181, 209. — warmed, 151. — wood, 211. Formula for weight of air discharged from flues, 90. — for area of flue, 90. Friction in air shafts, 82. Friederichshain Hospital, 196. Gas-light, 140. Glasgow Western Infirmary, 34, 169- 171. Glass, loss of light through, 201. — heat, 202. Gottingen Hospital, 203, 241, 242. Grates, Rumford, 107, 108. — Gallon, 109, 112. — Saxon Snell's Thermhydric, 112, 113. — Sylvester, 107. — Teale (Lionel), 108. Gravel soil, 26, 27. Grease trap, 248. Ground air, 24, 25. H. Haldane, experiments on air, 38, 41. Hamburg Hospital, 150-156, 175, 193, 209. Harston, Messrs., architects, 230. Healthiness of site, 22-30. Heat, conduction of, 100. — convection of, 100. ■ — distribution of, 149-15 1. — loss of, 104. — radiation of, loi, 102, 133. Heat imits, 131. Heating apparatus, 88, 89, 102, 103, 105-113. Herbert Hospital, 109-112, 193. Holywood Hospital, Belfast, 226, 227. Hopkins {see Johns Hopkins). Hospitals, accommodation, 7, 18, 19. — children's, 13, 224, 254-258. Index. 285 Hospitals, classification of, 13. — convalescent, 13, 22, 254, 260-263. — corridor system of, 4, 199. — cottage, 3, 13, 22, 224. — Daeker, 278. — definition of, 9. — early history of, 1, 2. — field, 3, 5, 6, 267, 277. — general, 13. — infections, 13, 31, 249, 254, 263, 264. — iron, 278. — isolation, 2, 22, 224. — lying-in, 1,13, 265-274. — maintenance of, 10, 11. — marine, 13, 22, 255-257. — Metropolitan Asylums Board, 7, 35. 67. i83> 230, 249. — military, i, 147, 187, 226, 232, 280. — origin of present construction, 3. — pavilion system of, 4, 174, 199, 227. — small-pox, 31, 32, 66. — wood, 278. Hot-water pipes, 88-91, 100, 121-128, 134. 135- — high pressure, 127, 128. — low pressure, 124-126, 135. Human body, temperature of, 50. Humidity, 51-55. I. Imbeciles, 14, 22. Incurables, 14, 254. Infection, 15, 254, 263. Infectious Hospitals, 13, 31, 254, 263, 264. — probationary wards in, 225, 263. — protection to public, 264. — protection to staff, 264. Infirmaries, workhouse, 14. Inlets, 79, 146, 170, 197. Inquest room, 243. Isolation hospitals, 2, 22, 224. — wards, 225, 263, 273. J- Jebb, Sir Joshua, 160. Johns Hopkins Hospital, 34, 161-164, 181, 194, 196, 209, 225, 227. Johnston, Miss, 210. K. Key's air- washing screen, 62-64. — system of ventilation, 169-171. King's College Hospital, 33. Kitchen, 247, 248, 263. L. Lariboissiere Hospital, 166. Laundry, 249. Leeds Hospital, 33. Leroux, Dr., 257. Lifts, 213, 236. Light, 15. — artificial, 139-144. — candle, 53, 141. — day, 138, 139. — electric, 144. — gas, 53, 140- — loss of, through glass, 20 x. — proportion in room, 198. Limit of size of hospital, 237. Linen, 215, 249. Liverpool Hospital, 34. Lunatics, 14, 22. Lying-in hospitals, 1,13, 265-274. M. Maintenance of hospitals, 10, 11. — patients, 247. Margate Hospital, 255, Marine Hospital, 13, 22, 255-257. Marston, Surgeon-General, 279-281. Marylebone Infirmary, 33, 193. Measurement of air, 59, 60, 84. Medical school, 245, 246. — student, education of, 9, 10. Menilmontant (Tenon) Hospital, 35, 167, 175, 193. 266. Metropolitan Asylums Board, 7, 35, 67, 183, 230, 249. Middlesex Hospital, 33. Miguel, Dr., bacteria in air, 38. Military hospitals, i, 147, 187, 226, 232, 280. Moabit Hospital, 200. Mons Hospital, 235. Montpelier Hospital, 35, 175, 178, 181, 182, 184, 185, 193, 209. Morin, General, 84, 160. Mortuary, 243, 244. Movement of air, by application of heat, 20, 78, 84. — by aspiration, 139-166. — by natural means, 20, 77, 78, 80, 82. — by propulsion, 92-99, 166-173. — in chimney flues, 8x, 86. N. Necker Hospital, 166. New York Hospital, 34, 168, 247. Nightingdale, Miss, lying-in hospital, 267. — Notes on hospitals, 192, 213. — Quain's Dictionary, nursing, 14, 198. Nitrogen, 37, 115. Norfolk and Norwich Hospital, 175, 193- North-Western Hospital, Haverstock Hill, 35- 286 Index. Number of patients, medical, 1 74. — per acre, 32. — per ward, 174, 175. — surgical, 1 74. — under one roof, 174, 176, 237. Nurses, 214, 252. Nursing, 191. — cost per bed of, 192. O. Operating theatre, 240-243. Organic matter in air, 44-46. Outlets, 79, 146, 170, 197. Out-patient's department, 245-247. Oxygen, i^, 40, 45, 115. Patients, separation of, 12, 13, 194. Pavilion system of construction, 4, 1 74, 199, 227. Peach, Mr., 107, 245. Peclet formula for co-efficient of resist- ance, 85. — windows, 202, Percolation, 26. Perkins, hot-water pipes, 127. Philadelphia Field Hospital, 5. Pipes, hot-water, 88-91, 100, 121-128, 134' 135- — steam, 89, 91, 128, 135. Play-rooms, 262. Porosity of materials, 55-57. Post-mortem room, 243-245. Probationary wards, 225, 263. Probationers, 253. Propulsion of air, 92-99, 166-173. Proximity of adjacent wards, 228. Pumps, air, 93-95. Putman, experiments on porosity of walls, 57. Q. Quain's Dictionary — Nursing, 198. R. Radiation in heat, 101, 102, 133. Ratio of infectious sick to population, 7. Reception of patients, 239. Red Cross Society, 277. Refuse, 215, 248, 249, 263. Renne-Sabran, 255. Ridge ventilation, 178-180. Roofs, 206, 279. Rudolf Stift, 157. Rumford grate, 107, 108. Rumsey, Dr., 174. Russell, Dr., CO2 in air, 38. St. Denis Hospital, 180, 181, 193. St. Eloi (Montpelier) Hospital, 35, 175, 178, 181, 182, 184, 185, 193, St. George's Hospital, 33. St. Pol-sur-Mer, 257. St. Thomas' Hospital, 34, 175, 193. Sanatoria, 258-260. Saxon Snell's Thermhydric grate, 112, 113- Scullery, ward, 214, 271, 272. Separation of patients, 12, 13, 194. — ward unit, 229. Servants in hospitals, 251. Shafts for ventilating, 81-84, 86-88, 147, 158. — velocity in, 84, 85, 148. Sherringham ventilator, 146. Sick, agglomeration of, 3, 35. Site, accessibility of, 21. — area per patient, 32, 35, 36. — compulsory purchase of, 36. — drainage of, 24. — elevation of, 23. — healthiness of, 22-30. Smallpox hospitals, 31, 32, 66. Smead, air-warmer, 119. — system of ventilation, 157. Soil, 16. — aeration of, 24. — cleanliness of, 25, 27. — disturbance of, 28. — level of water in, 24, 28. — porous, 29. — vapour from, 27. South-Eastern Hospital, 35. South- Western Hospital, 35. Splint room, 240. Staircases, 230-236. Steam pipes, 89, 91, 128-132. — exhaust steam, 132. — high pressure, 128. — low pressure, 129. Stores for clothing, 216, 249. Stoves, 135. Subways, 236. Sunshine, 174, 198. Surgeon's room, 214, 252. Sylvester grate, 107. — system of ventilation, 155, 160. Teale (Lionel) grate, 108. Temperature, 50, 51. Tenon (Menilmontant) Hospital, 35, 167, 175, 193, 266. Toilet, Mons., 83, 159. — ward, 181. Trowbridge's formulae, 89-91. Index. 287 u. Unit of hospital construction, i8, 174. University College Hospital, 33. Urinals, 219. V. Van Heecke's method of propulsion, 167. Vapour, 27, 51. Velocity of air-currents in shafts, 79, 82, 84, 88. Ventilation, 41. — arrested, 49. — aspiration, 159-166. — fireplaces for, 105. — propulsion, 92-99, 166-173. — ridge, 83, 159, 178-180. — shafts for, 81-84, 86-88, 147, 158. — Snaead, 157. — Sylvester, 155, 160. — windows for, 198, 202, ■203. Ventilators, Bohm's, 157, 158. — Hopper, 146. — Moore's, 146. — Sherringham's, 146. — vertical tubes, 81, 147. — Watson's, 84. Verandahs and balconies, 195, 235, 273, 281. Ver-sur-Mer, 257. Victoria Hospital, Glasgow, 169. W. Waddington, Mr., architect, 189. Walls, 205-208, 219. Ward offices, 213, 220. — for nursing, 214-216. — for use of patients, 216. Ward ofifices, in proportion to wards, 222. Ward unit, 174-224. — aggregation of, 224-227. — connexion of, 231. — separation of, 229. Wards, at rest, 224, 273. — circular, 187, 189, 191. — form of, 3, 19, 178-181, 187-191. — number of beds in, 175, 176, 192- 195- . — probationary, 225, 263. — rectangular, 189. — size of, 19, 185. Warmed floors, 136, 151. 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