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 HOSPITALS AND MEDICAL 
 EDUCATION 
 
 SAMUEL W. LAMBERT, M. D. 
 
 Dean of the Medical Faculty 
 
 November 25, 1908 
 
7 
 
 6-6// 
 .£?■ 
 
To Dr. James W. McLane, Messrs. W. Irving Clark and 
 W. Emlen Roosevelt, Committee in Behalf of the 
 Roosevelt Hospital, and 
 
 Messrs. Seth Low, W. Bayard Cutting and Dr. T. M. 
 Cheesman, Committee in Behalf of Columbia University. 
 
 Gentlemen — 
 
 Your appointment as Committees of your respective Boards 
 was authorized by the following resolutions : 
 
 Resolutions of the Board of Trustees of Roosevelt Hos- 
 pital, passed January 28th, 1908 : 
 
 Resolved, That a Committee of three, of which the President 
 of the Hospital shall be one, be appointed by the Presi- 
 dent to consider, in conjunction with any committee 
 that may be appointed for a similar purpose by the Trus- 
 tees of Columbia College (University), the general sub- 
 ject of methods of clinical instruction in the Hospital. 
 
 Resolved, That the same Committee of this Board be further 
 requested to consider plans for the development and 
 extension both of the existing buildings and the con- 
 struction of new buildings on the vacant land owned by 
 the Hospital on the west of the present buildings. 
 
 Resolution of the Board of Trustees of Columbia Univer- 
 sity, passed on February 3d, 1908 : 
 
 Resolved, That a select Committee of Three be appointed 
 by the Chairman to confer with the Committee appointed 
 by the Trustees of Roosevelt Hospital in reference to 
 extending the clinical facilities of the Hospital in con- 
 nection with the College of Physicians and Surgeons. 
 
 On April 10th, 1908, I sent you a statement of the reasons 
 for my asking that committees be appointed by your respec- 
 tive Boards to confer on the question of the nearer relation of 
 the Roosevelt Hospital and the College of Physicians and Sur- 
 geons. I presented then as I understood them the advantages 
 of increasing the teaching in the Hospital both to the Hospital 
 and the College. 
 
The subject has been thoroughly canvassed during the past 
 summer and I should like to present my present views on the 
 whole subject again. In the Spring I suggested that $1,000, 
 ooo would do much to accomplish the result desired, but my 
 investigations having forced me to conclude that the question 
 is a much larger and broader one and the scheme has developed 
 into one for enlarging Roosevelt Hospital, for increasing its 
 teaching and research functions and for making it second to 
 none in these particulars. As a result of this study the sum of 
 money required for the immediate needs of the hospital has in- 
 creased to over $6,000,000 and the completed plan calls for a 
 final expenditure of over $16,600,000. The result however, 
 will, I am sure, appeal to your Committees as an ideal to be 
 hoped for and to be worked for. In the desire to assist you to 
 present this matter to any prospective benefactors of the Hos- 
 pital in the form of a thorough and feasible plan which will 
 look to a gradual but continuous and practical development of 
 the Hospital, I beg to submit the following: 
 
 During the past five years there has been created in New 
 York a great interest in the hospital question in the City. 
 Several Committees have been at work studying the various 
 features of the problems of present needs and future develop- 
 ment. Two reports, destined to be of far reaching influence, 
 have been published within the past six months. Both reports 
 take a broad view of the whole situation and present conclu- 
 sions based upon scientific study and business principles. One 
 of these was issued by the Commission on Public Hospitals 
 appointed by his Honor Mayor McClellan, to consider the or- 
 ganization of the Municipal Hospitals. This report deals 
 largely with the situation in Brooklyn, Richmond County and 
 with the hospitals on Blackwell's Island. So far as new hospi- 
 tals in Manhattan are concerned its conclusions do not ma- 
 terially differ from those of the second report, which are 
 detailed below. Of the hospital needs of the west side of 
 Manhattan the report says: "in the relatively near future a 
 new general hospital with capacity for several hundred beds 
 should be constructed for the middle west side of the City in 
 the Borough of Manhattan." The second report develops the 
 question more elaborately and forms report No. 101 of the 
 State Charities Aid Association and presents an investigation 
 
concerning the need both present and future for new hospital 
 facilities in the City. This report outlines a general scheme 
 for hospital extension which it is hoped will be capable of in- 
 definite expansion and application to any possible demands 
 which may arise in the future. This co-ordinated scheme of 
 hospital relief demands three kinds of hospitals for acute dis- 
 eases classified according to size into 
 
 i. General hospitals, or hospitals of 1,000 to 1,500 beds. 
 
 2. Local hospitals, or hospitals of 100 to 200 beds. 
 
 3. Emergency relief stations, or small ambulance and dis- 
 pensary hospitals of 6 to 8 beds. 
 
 The scheme further adds hospitals for convalescents, hos- 
 pitals for incurables, hospitals for special diseases, such as 
 maternity hospitals and those for contagious diseases (including 
 tuberculosis), and there is suggested a plan for cooperative 
 home care of patients suffering from lesser ailments and of 
 those convalescing from acute diseases. 
 
 If this proposed scheme of hospital development be applied 
 to the present situation in New York, and particularly to the 
 present position of Roosevelt Hospital as a part of the general 
 hospital situation, some very interesting facts are manifest. 
 The report suggests that only two general hospitals (1,500 
 beds) will be needed by the year 1920. One of these is to be 
 the new Bellevue and the other a "pavilion" hospital* to be 
 built on Blackwell's Island. The only other hospital of any 
 size suggested for Manhattan is a local hospital of 100 beds to 
 be developed (by 1915) from an emergency relief station (to 
 be built at once) in the vicinity of 40th or 45th Street and 9th 
 or 10th Avenue. This latter suggestion is to meet the urgent 
 deficiency in hospital bed facility, both present and prospec- 
 tive, which exists in the middle west section of the city as 
 represented by the present ambulance district of Roosevelt 
 Hospital. 
 
 The chart showing the present bed capacity, the present 
 proper bed capacity and the beds needed in 1920, prepared 
 by Mr. Philip P. Jacobs and printed on pages 40 and 41 of this 
 
 * In this paper the plan of hospital construction of a number of isolated one or two-story 
 buildings is called a " pavilion " hospital, and the plan of a compact building containing four 
 or more stories is called a "barrack" hospital. Roosevelt Hospital presents both kinds of 
 construction 
 
report, emphasizes this striking want in the Roosevelt sphere 
 of work. Accepting the premises and calculations of the 
 report as a working hypothesis, the three ambulance districts 
 in greatest need of beds are in order of that need as follows: 
 
 PRESENT LACK OF BEDS, I905 
 
 PROBABLE LACK OF BEDS IN I92O 
 
 Gouverneur district 283 
 
 J. Hood Wright district 254 
 
 Roosevelt district 155 
 
 (Omitting the private beds of St. 
 Elizabeth) 
 
 J. Hood Wright district 781 
 
 Gouverneur district 360 
 
 Roosevelt district 357 
 
 (Known additions to present facil- 
 ities are included in this estimate) 
 
 The possible additions to the J. Hood Wright Hospital and 
 to St. Luke's in the same district leave little doubt but that 
 the deficiency for that district in hospital beds will be cared 
 for. There will remain in 1920 the same two bad spots of 
 lack of hospital beds which exist to-day, the lower East and 
 the middle West sections of Manhattan. This condition is 
 more evident when one compares the above figures with the 
 excess of beds in the Bellevue and Presbyterian districts, 
 which at present are 959 and 202 respectively, and which will 
 become in 1920 for Bellevue 1,614, ar >d for Presbyterian 59. 
 The excess in these two districts does much to overbalance 
 the lack in the intervening Flower district both present and 
 prospective. 
 
 This reports states very fully and ably the arguments in 
 favor of a hospital of 1,000 beds and upwards as against the 
 multiplication of 200 bed hospitals, both in regard to efficiency 
 of administration and to economy of expenditure. But the 
 action suggested in the report, namely, the placing of a second 
 general hospital on the East side, and on the Island at that, 
 does not seem to distribute the additional beds needed in the 
 best manner. A fairer conclusion to meet the conditions 
 would seem to favor the development of a general hospital 
 (1,000 bed hospital) on the middle West side, rather than as 
 proposed, a new local hospital of 100 beds, which would not 
 even meet the present demand for lacking beds. The loca- 
 tion of Roosevelt Hospital fits it for such a development, and 
 
a study of the present service supports the view that there is 
 urgently needed a hospital of at least its present size at once, 
 and that a hospital four times its size will do no more than 
 meet the conditions fifteen, or even ten, years from now. 
 
 The last report of the Roosevelt Hospital (1907; shows 
 that 428 patients from the ambulance service alone were re- 
 fused admission after entering the reception ward, generally 
 because of lack of room, and that for the same reason 1,914 
 patients in addition were taken to other institutions, or to 
 their homes without being brought in to the hospital at all. 
 These two groups of cases form more than half of the actual 
 cases treated by the ambulance in the year 1907 (2,342 out 
 of 4,113 patients treated). In other words, an average of over 
 six patients a day applied last year for emergency treatment 
 by ambulance call at the Roosevelt Hospital and were refused 
 more than the temporary treatment of the accident ward 
 because of lack of room, and were transferred elsewhere. 
 The hospital ambulance service averaged 14% calls per day, 
 one-fifth of which were unnecessary, to such an extent has 
 the abuse of the hospital ambulance system grown in New 
 York. 
 
 The service of the Roosevelt Hospital is made up not only 
 of the sick poor from its own neighborhood, which is a district 
 of great medical need, but it has a double source of supply 
 from two large dispensaries, its own and the Vanderbilt Clinic 
 of the College of Physicians and Surgeons, both of which re- 
 fer all their patients needing hospital care to the Roosevelt 
 Hospital. It also draws a large clientele because of its own 
 reputation and of that of its attending staff from a large area 
 outside of its own district, including the suburbs of New York 
 and many cities even at some distance. The location is most 
 accessible. At one of its corners there is a station of the Ele- 
 vated Railroad and at the same point the cars of three surface 
 lines pass, while a station of the subway is only one block dis- 
 tant, and it is in the center of a thickly populated tenement 
 and factory district. It would seem a justifiable inference to 
 claim for Roosevelt Hospital a manifest destiny and a future 
 development which will make it the large general hospital for 
 the west side of New York in contraposition to the new Belle- 
 vue which will fill the same position on the east side. This 
 
result should follow whether or no a large pavilion hospital be 
 built on Blackwell's Island or elsewhere. 
 
 Except for the necessary funds, the facilities at the com- 
 mand of Roosevelt Hospital to fulfil the plan here suggested are 
 ample. The location of the hospital is on high ground, and on 
 solid rock; its base is 77 feet above the Hudson River and as 
 near that water as would be possible at any point on the west 
 side of the city (where the location of the Hudson River R. R. 
 tracks make a duplication of the Bellevue site at 26th St. and 
 the East River impossible). At least in the upper stories it is 
 near enough to feel the influence of the river breezes. The 
 hospital site is surrounded on the east, south and southeast by 
 comparatively low tenements so that a free access of sunlight 
 and of the prevailing southerly winds is assured. On the west 
 there is a High School and on the north the block is occupied 
 by a large church and by the College of Physicians and Sur- 
 geons and its accessory buildings, the Sloane Maternity and 
 the Vanderbilt Clinic. No material change can be expected 
 to occur therefore, and the environment is as available for hos- 
 pital uses as any city site can be which does not abut on a 
 public park. The building of a " barrack " hospital in which 
 the wards are located in the upper stories will overcome the 
 most vital objections to that plan of construction, and on a site 
 such as has been just described it will fulfil the two essentials 
 of a healthy hospital by bringing the wards up into the sun 
 and air. The ground plan of the hospital is a city block, 200 x 
 800 feet, only two thirds of which are occupied'at present, and 
 as will be developed later occupied, in part, in an inadequate 
 manner. A "barrack" hospital of modern construction on a 
 ground plan of this size would easily support a thousand beds. 
 
 Roosevelt Hospital today has in it all the elements which 
 make up a large general hospital. It is a teaching hos- 
 pital. It is a research hospital. It has wards devoted to 
 medical specialties. But it is perfect in no one branch; its 
 present equipment does not permit of any approach to even an 
 appearance of successful endeavor to fulfil the efforts of its 
 workers. This statement must not be taken as an arraignment 
 of the hospital staff, either lay or professional. The best that 
 can be done with present facilities is undoubtedly done. But 
 Roosevelt Hospital fails to teach as well as it might because 
 
7 
 
 the organization for teaching is obsolete and inadequate. It 
 fails to accomplish the research into the newer fields of medi- 
 cine and of surgery which its service would permit and should 
 demand, because it lacks the financial ability to develop this 
 department. It fails to give the best care, both medical and 
 surgical, to all the patients who apply for aid, not that it fails 
 to give such care to the fortunate ones who are admitted to its 
 service, but it fails in the case of those individuals who are 
 transferred to other institutions and who average in the ambu- 
 lance service alone six in number daily. It possesses a division 
 of gynsecological surgery but it has no department for that 
 purest of all surgical science, the diseases of the eye. It has 
 a special medical ward for children, but none for the equally 
 important and equally special branch of medical work, that of 
 neurology. 
 
 In developing Roosevelt Hospital into a general hospital of 
 1,000 beds all these factors must be considered. The number 
 of specialties must be increased to include at least those men- 
 tioned above and perhaps some others, though a too close 
 specialization must be avoided. The principal additions to 
 the bed capacity .will of course fall into the two great divisions 
 of hospital work, the general surgical and the internal medical 
 wards, and both of these departments require at the present 
 time great increases to meet the demands of the present ser- 
 vice for, as already stated, many patients are refused admis- 
 sion because of lack of room alone. Cases from the subsidiary 
 dispensaries and those bringing independent admissions in 
 addition to those of the ambulance service are often denied 
 admission, or their reception postponed, although they may 
 present medical and surgical conditions requiring early opera- 
 tion, if not immediate treatment. 
 
 The development of Roosevelt into a general hospital of 
 1,000 beds must be considered from the very important point 
 of view of the buildings of the hospital. The present build- 
 ings can be divided into two groups of radical difference — 
 those which are fireproof and those which are not. The older 
 buildings are solidly constructed, but they are not fireproof. 
 Some of them, notably Ward 5 (a single-storied pavilion struc- 
 ture), were built before the days of aseptic surgery, and with 
 the distinct idea in mind that the building was to be tempo- 
 
8 
 
 rary, because, owing to the impossibility of keeping hospitals 
 free of contagion, especially that of wounds, it was necessary 
 to destroy and rebuild hospital pavilions at certain intervals. 
 Modern methods have changed all that, and modern hospitals 
 are composed of fireproof buildings constructed of brick and 
 iron. 
 
 Roosevelt owns two groups of buildings of the modern 
 type today. The Syms operating theatre with the neighbor- 
 ing accident and children's wards on 9th Avenue and the 
 building in the centre of the block, which contains the dis- 
 pensary, the rooms for private patients and the quarters for 
 the training school for nurses are fireproof, and should be 
 considered as permanent. But the general ward building and 
 the "Ward 5 " pavilion could be replaced to great advantage 
 by modern buildings, which would increase both the hospital's 
 capacity and its efficiency. 
 
 The general plan of the hospital has grown into that of de- 
 tached buildings running through the block from north to 
 south and connected for purposes of communication and ad- 
 ministration by a one-story corridor on the ground floor along 
 their north or 59th Street side. This cannot be improved 
 upon, for it embraces the best arrangement for furnishing 
 sunlight and air to wards whose long axis is north and south. 
 If any criticism of this plan may be offered, it is that it de- 
 mands rather a large ward unit if the available space is to be 
 given up to a single ward. This is now done in Ward 5, and 
 has shown the advantage of economy in general administra- 
 tion, though, perhaps, a lack of facility in conducting the 
 surgical service. The disadvantage in this respect can be 
 overcome by increasing the ward attendance, even if this de- 
 stroys to a certain extent the other advantage — the economy 
 of large wards. The " barrack " style of building is an essen- 
 tial of hospital construction in New York City, where the 
 the cost of land is prohibitive of the one or two-story pavilion 
 hospital, except where built by the city itself, and then only 
 upon peculiar sites like Blackwell's Island or in suburban dis- 
 tricts. If the separated barracks be built as is possible in the 
 Roosevelt scheme of construction, and if the wards be placed 
 in the upper stories of those barracks, all the advantages of 
 the European Pavilion system will be secured, so far as light, 
 
air and quiet are concerned, and in as perfect a manner as is 
 possible in a thickly populated environment. 
 
 The final plans should present new barrack pavilions on 
 the site of the "Ward 5 " building and on that of the present 
 medical and gynaecological building and two new barrack 
 pavilions on the unoccupied land on the corner of 59th Street 
 and 10th Avenue. It should provide for a new heating and 
 lighting plant sufficient for the whole hospital when com- 
 pleted. It should provide for facilities for teaching and for 
 research in connection with the increased medical and surgical 
 services to be created. In practical fulfilmeut of this idea the 
 present administration building could be left as it stands ; for 
 much has been done to perfect it in the last few years, and if 
 all patients were removed from it the room secured would 
 probably suffice for the administration of the enlarged hospi- 
 tal. The general ward building also might be retained for a 
 last substitution, because it also has been improved with new 
 iron balconies and made as modern as is possible. But the 
 present Ward 5 should be removed and the proposed new 
 buildings on the western end of the site should be added as 
 soon as the funds can be secured to build and endow them. 
 In this new scheme of buildings certain changes and rearrange- 
 ment of the departments could be secured. The details of 
 this are developed later and need not be presented, at this 
 place. One great advantage to be gained, however, may be 
 mentioned here, the transfer of the dispensary from its pres- 
 ent quarters to the ground floor of the proposed pavilion on 
 the site of Ward 5, where it could be in close relation with 
 the present accident ward. This could then become the sin- 
 gle reception and admitting office for the whole hospital. 
 
 Roosevelt Hospital has always been a great teaching hos- 
 pital and in its early years it presented medicine and surgery 
 to its student visitors in the best methods then known and 
 practiced. The clinics of Sands in surgery and of Delafield 
 and Draper in medicine were the most sought after of any in 
 the city. But methods have changed and the teaching of to- 
 day requires a more intimate relationship and contact on the 
 part of the student, both with his instructor and with the 
 patient. I have already presented to you the manner in which 
 this is accomplished by establishing in the hospital service the 
 
grade of clinical clerk, and I have shown the reasons why this 
 new system acts alike for the good of the student and for 
 the benefit of the patient. In reality I do not overstep the 
 bounds of fact when I claim, that by no other system of hos- 
 pital organization can the welfare of the patient be served 
 equally successfully. 
 
 One point remains to be developed, the fact that the adop- 
 tion of these educational methods will require the introduction 
 of certain details in the construction of the new buildings. 
 The addition of clinical clerks will involve a permanent in- 
 crease in the working staff, demanding increased laboratory 
 facilities and the addition of a staff record room to each ward- 
 unit where clerical work can be done. To each division of the 
 service there should also be added a study and work-room for 
 the chief attending medical or surgical officer and his assist- 
 ants. 
 
 The question of applying methods of scientific research to 
 the patients of a hospital is no longer subject to questioning 
 criticism. Such methods do not involve the old bugbear of 
 experimenting on hospital patients, implying as it did, that 
 such experiments were a detriment and menace to the sick and 
 suffering. On the contrary, medical research has led not 
 only to the better care of future patients, but also to the 
 better understanding and treatment of the individual who is 
 "experimented" upon. All forms of medical research are 
 closely linked with medical teaching and require the large 
 plants for scientific study which are to be found only in speci- 
 fically endowed institutes like the Rockefeller Institute in New 
 York and the Ayer Institute in Philadelphia, or at Columbia and 
 other large universities. Medical research requires also many 
 helpers in higher and lower positions, and no better assistance 
 can be secured in the lower grades than a sufficient number of 
 undergraduate students enthusiastic in their work, eager to 
 learn, and under the disciplinary control of their instructors. 
 The Roosevelt Hospital is fortunate in being situated opposite 
 the College of Physicians and Surgeons, with its scientific 
 establishments of pathology, bacteriology, clinical pathology, 
 pharmacology and chemistry. The hospital has depended in 
 the past for its higher investigations in pathology and bacter- 
 iology entirely upon the college laboratories. In the proposed 
 
plan of creating closer relations between the two institutions 
 this connection should be strengthened and extended to in- 
 clude the other departments mentioned above. The new 
 laboratories to be created on the hospital grounds should be 
 under the same control and supervision as the college labora- 
 tories. In other words, in all departments the same man 
 should be responsible for the work both in the College and 
 the Hospital. The pathologist of the Hospital, for example, 
 should be Professor of Pathology in the College, just as the 
 surgeons of the hospital are the professors of surgery in the 
 neighbouring institution. That the scientific value of such 
 departments as chemistry and pathology would be greatest in 
 the College would be counterbalanced by the fact that the 
 greatest reputation and importance would rest in the hospital, 
 in the practical clinical branches such as surgery and medicine. 
 In this way a balance would be struck and both institutions 
 would increase the scientific renown of its ally in the study, 
 teaching and investigation of medical art and science. 
 
 At present, there is in the Roosevelt Hospital a marked lack 
 of uniformity in the scheme of organization of its medical and 
 surgical staffs. No one of the four branches of medical practice 
 which are represented in the hospital service at present has an 
 organization similar to that of any other. Several possible 
 varieties of organization are represented. The medical service 
 has an attending staff of three physicians who divide the winter 
 months between them, and relegate the summer service to a 
 junior attending. The authority of this junior, however, is in 
 no way less than that of his senior colleagues, except in this 
 one particular of choice of season for work. As there are no 
 assistants on the medical service, enforced absences from duty 
 must be delegated by request of the physician on duty to some 
 one of his co-equal colleagues. The two surgical services are 
 each organized with a senior surgeon serving eight months and 
 a junior surgeon serving four months, the latter in the summer 
 only. There are two assistants to each division. Absences by 
 leave (vacation, etc.) of the surgeons must be filled by another 
 of the staff of equal grade, assistants by an assistant, attending 
 surgeon by an attending surgeon, except that some slight 
 latitude is allowed in that an assistant can substitute for his 
 chief for single periods of twenty-four hours. The gynsecologi- 
 
cal service has a single attending and a Junior attending, who 
 can substitute for his Senior in all things and for all periods of 
 time, subject only to the controlling wish of the Senior 
 himself. 
 
 In these three divisions a needed elasticity is secured by 
 extending the powers of the heads of the dispensary service, 
 and the chiefs of clinic in medicine and gynaecology may be 
 permitted to do duty in the wards by a vote of the visiting 
 committee of the Board of Trustees upon each special case as 
 it arises. The chief of clinic in surgery has recently been 
 advanced permanently to the position of second assistant on 
 one of the surgical divisions, to meet the increasing demands 
 for work. The final point to be brought out is that the division 
 for children's diseases has no attending staff of its own, but 
 is attached to the general medical service. These details of 
 organization are presented here because it is believed that the 
 co-existence of all of them in one institution cannot serve for 
 the best interests of the hospital, and it is believed that the 
 best system is not too good for the Roosevelt Hospital and 
 should prevail in all its divisions. 
 
 The oldest American idea of hospital organization (both 
 medical and surgical), is the one of multiple heads serving in 
 rotation for equal portions of the year. The arguments usually 
 offered in favor of such a plan of service are in themselves at 
 least in part condemnatory. The arguments are, that a change 
 of physicians is beneficial to the individual patient, that com- 
 petent physicians will not serve in the subordinate position 
 made necessary by the plan of a single head of division, and 
 that the rivalry of succeeding attending physicians is for the 
 good of the service. In recent years New York has been 
 visited by a number of eminent European physicians who have 
 made a study of our institutions and methods, and their judg- 
 ment with regard to these questions is significant. Prof. Von 
 Noorden, for example, condemns the American rotating system 
 of hospital service as follows: 
 
 "Excepting in the case of a very energetic and especially 
 qualified personality, they (attending physicians) possess no 
 satisfactory control over the service, the assistants and the 
 nurses. They are in general more like highly esteemed guests 
 than masters in the house." 
 
*3 
 
 The only seemingly favorable criticism which I have found 
 is by Prof. F. Miiller, of Munich (who represents the most 
 perfect development of the other extreme), in a series of 
 " Impressions of an American Journey." Even he finds more 
 disadvantages than advantages in this " American" system: 
 
 "This system has the advantage that many physicians are 
 connected with the hospital, who can use their influence in 
 behalf of the hospital and secure for themselves an incentive 
 to and advancement of their own knowledge and ability. 
 But the advantages which are secured to the physicians have 
 disadvantages as well added thereto. There is lacking a 
 uniform professional direction especially in a therapeutic sense 
 which is more important in a surgical than in a medical sense. 
 No one physician is responsible for the whole direction and 
 training of the assistants and of the nursing staff, which must 
 suffer thereby. One gets the impression from this American 
 system that the head of the nurses training school and the 
 interne assistant has greater influence on the conduct of the 
 service than the attending physician possesses." 
 
 In referring to the "one man system" of Johns Hopkins, 
 Miiller expresses the opinion "that this example will find in 
 the future a wide-spread imitative extension which will result 
 in a distinct advantage to the hospitals." 
 
 The arguments in favor of the system of rotation are 
 easily refuted. It is not true that equally competent physi- 
 cians will not serve as assistants one to the other. The 
 benefit of a change of physician occuring four times a year is 
 at best of petty consideration in comparison with the daily 
 consultation of one physician and his assistant, both of whom 
 are conversant with the progress of every individual case. 
 As a matter of fact the rivalry of the several members of a 
 rotating staff is not keen. They probably are the last persons 
 to be conscious of the comparisons passed upon them by the 
 house staff or other critics. 
 
 The single headed division would seem to be the logical 
 method of organization. A hospital is successful in proportion 
 as it approaches a military discipline, and a multiheaded army 
 is inconceivable. To compare hospital services with the work 
 of civil life it can be asserted confidently that no successful 
 business is conducted on such a plan. The single headed 
 division has reached its greatest development in Europe and 
 especially in military Germany. It has been implanted in 
 
14 
 
 America, notably in Johns Hopkins and in this city in the 
 Sloane Maternity and the Lying-in Hospital, in Mt. Sinai and 
 in the Hospital for Ruptured and Crippled. Roosevelt has it 
 in the Gynaecological service and had it formerly in the surgi- 
 cal service. No one thing ever increased the good name of 
 the Roosevelt Hospital more than the single headed surgical 
 service under Henry B. Sands and his remarkably talented 
 assistants Halstead, Hall and Hartley. Such a service refutes 
 every argument against the system. It is found wherever 
 medicine flourishes best and is an absolute essential for any 
 hospital which wishes to teach with the best results and to 
 further the highest medical research. The only argument to 
 be offered against it is that the chief of the service will neglect 
 it and turn the work over to his assistants. The remedy is 
 theoretically simple and lies in the hands of the Trustees. 
 But practically it is often difficult and it is always disagreeable 
 to apply a drastic remedy. Such neglect, however, is not 
 confined to hospitals of single headed divisions; every hospi- 
 tal has suffered from such faults in individual members of 
 its attending staff. This inefficiency on the other hand would 
 be controlled and corrected with greater ease in a hospital 
 which demands teaching from its attending staff. The outcry 
 of students against neglect is more certain and more loud 
 than that of the patients of a hospital. In fact no neglect 
 to patients may result from the elision of the attending 
 physician for they may be as well or even better cared for by 
 his assistant. 
 
 The enlargement of Roosevelt Hospital, if made possible, 
 will give an opportunity to create several divisions of equal 
 size, each possessing the same functions. Roosevelt already 
 has two surgical divisions, and it could with advantage 
 add other divisions to its medical work as well. In fact 
 an increase in work is possible in no other way. The crea- 
 tion of parallel and equivalent divisions will in itself accom- 
 plish the best method of developing a friendly rivalry and 
 kindly criticism between the several attending and resident 
 staffs. Such a rivalry, which utterly fails as between rotat- 
 ing services, would be the keenest possible between co-exist- 
 ent services, all of which have in common the three-fold 
 endeavor — of advancing human knowledge in medicine, of 
 
i5 
 
 teaching students and of serving the ill and suffering patients 
 of the institution. 
 
 The medical organization of a large general hospital of 
 1,000 beds would demand a clinical staff and a scientific staff, 
 each of which would be divided into the two general subdivis- 
 ions of attending, or non-resident, and subordinate, or resi- 
 dent. It would demand an unequal division into surgical beds, 
 medical beds and beds for specialties. An exact partition is 
 not possible on d priori grounds, but a tentative scheme for 
 eighteen single-headed divisions may be assumed as follows : 
 
 400 surgical beds in 4 divisions of 100 beds each. 
 400 medical beds in 8 divisions of 50 beds each. 
 
 50 beds for a children's division. 
 
 25 beds for a gynaecological division. 
 
 50 beds for an ophthalmological division. 
 
 25 beds for a neurological division. 
 
 25 beds for a nose, throat and ear division. 
 
 25 beds for a genito-urinary division. 
 
 This variation in size is warranted by the difference in the 
 service demanded. A surgical service should be large enough 
 to furnish active operative material and also to supply 
 beds for those surgical cases which require a long convales- 
 cence and but little active treatment. The large group of 
 fracture cases are barred from most surgical wards to-day 
 because they crowd out acute operative work. It is found in 
 practice that 50 beds is about the limit of acute medical cases 
 which one staff can intelligently handle. The other figures 
 are an attempt to estimate the demand for cases in such 
 specialties. 
 
 No mention is made here of private patients. It is believed 
 that the only good reason for a general hospital to take care 
 of the private patients of their attending staff is that the 
 hospital can make money out of that end of the business. It 
 is believed that it rarely pays a hospital to undertake such 
 work, and it is further believed that it is wise for an attend- 
 ing physician or surgeon to separate his public and hospital 
 service from his private practice. If, however, a general 
 hospital proposes to undertake this class of service, it is 
 
i6 
 
 almost self-evident that the hospital should provide a special 
 building' with operating rooms for the exclusive use of this 
 work, and a separate resident staff, who should be a paid 
 staff. It is true that the double duty has been tried by some 
 hospitals, and with success, and that Roosevelt is a notable 
 example of such a hospital, but friction will result from neglect 
 of one or the other subdivision sooner or later, and serious 
 complications can be surely avoided only by a separation of 
 these duties. 
 
 Each of the eighteen divisions indicated above should form 
 a single headed staff. The surgical and medical staffs should 
 consist of a chief attending or director; of at least four assist- 
 ants, one of whom should work mainly in the out-patient de- 
 partment as chief of clinic. There should be a resident whose 
 duties are at present new to New York institutions. They are 
 described in detail below. The resident interne staff on each 
 division could be reduced to that formerly in vogue, namely: 
 a house, a senior and a junior serving six months in each 
 grade, or 18 months in all. And finally there would be a 
 group of 4th year medical students to serve as clinical clerks. 
 The number of these should be in the proportion of one "to 
 every eight beds. 
 
 The new position of resident is required by the new posi- 
 tions of clinical clerks. He will have immediate oversight of 
 the house staff in general and of those lower members of it in 
 particular. In addition he will have general control of the 
 admissions and discharges and on the surgical side will have a 
 general oversight of the accident ward. Such a resident offi- 
 cer should be appointed for each division. It is believed that 
 these positions would be eagerly sought by members graduat- 
 ing from the house staff and that many men will hold this posi- 
 tion, if it be established, for periods of one, two or more years. 
 This position should differ from the other positions of the in- 
 terne staff in that it should be salaried. The services of the 
 medical specialties which consist of a smaller number of beds 
 than the general medical and surgical services would require a 
 smaller house staff. Those services which are operative in 
 nature, such as gynaecology and diseases of the eye, would re- 
 quire a single attending with only two assistants and a house 
 staff of two serving in two grades of six months each. Clinical 
 
i7 
 
 clerks could be admitted to these services in the same man- 
 ner as on the general wards, but perhaps in a different ratio, 
 say, one to twelve instead of one to eight beds. The non-op- 
 erative specialties, such as diseases of the nervous system, 
 would require the two assistants for the chief attending and a 
 house staff of perhaps a single resident, whose service might 
 be indefinite in time and whose duties could cover both those 
 of the resident on the general medical services and those of 
 the regular house staff. Clinical clerks would be admitted 
 also and in the same manner as in the general wards. The 
 service for diseases of children, consisting of fifty beds, would 
 require a similar organization to that already outlined for the 
 general medical service. It is believed that the position of 
 resident and house staff in these special services would be 
 sought after by men who had had previous hospital training, 
 either in general medicine or general surgery. 
 
 In addition to the clinical staff, the organization of which 
 has just been described, there must be a scientific staff to 
 direct and perform the work in the sciences allied to medicine 
 which are necessary in modern practice both to further and 
 complete the diagnosis and therapeutics of the individual 
 case, and to carry on the medical research into the causation 
 and study of disease. These scientific positions should in 
 some cases be separated from the clinical staff and in some 
 the same incumbent should hold both places. As distinguished 
 from the clinical division there should be scientific depart- 
 ments of Pathology, of Clinical Pathology, of Bacteriology 
 and of Chemistry. Each of these four divisions must have a 
 laboratory plant in which to work and a staff of workers, who 
 should be constantly in touch with the wards and the patients 
 of the hospital. The relation of these scientific departments 
 must be intimate also with the teaching of medicine. Medical 
 research of the broadest kind can be accomplished only in 
 connection with actual cases of disease on the one hand and 
 with that most eager seeker for knowledge, the medical 
 student, on the other. The relation of a hospital staff — both 
 clinical and scientific — to the teaching staff of a school of 
 medicine should be as intimate as possible if the best renown 
 is to come to both. Dr. Goldwater, the superintendent of 
 Mt. Sinai hospital, has recently written: 
 
i8 
 
 "I often think that the pre-eminence of Johns Hopkins 
 among American hospitals has been won with an ease that is 
 not creditable to other institutions. In wet-blanketing the 
 ardor of scientific enthusiasm, in shutting their doors in the 
 face of the research worker and its medical student, hospitals 
 have abandoned their claims to distinction and have stunted 
 their own growth. Sentimentality has commanded them to 
 lock up their priceless storehouses of knowledge and medical 
 science in America has been half starved in consequence." 
 
 To apply these cardinal principles to the case of the 
 Roosevelt Hospital and the College of Physicians and Surgeons 
 it must be pointed out that the heads of every division of the 
 hospital, both clinical and scientific, should be teaching officials 
 of the College as well. So far as the clinical staff is concerned 
 this is now true with some minor exceptions. It should be made 
 equally true not only of the scientific departments which already 
 exist, but also of those which should be created and there 
 should be no exceptions whatever, not even minor ones. 
 
 It is true that up to the present time, the work which has 
 been done in bacteriology and in pathology for the hospital 
 has been done very largely in the College laboratories. But 
 the connection has been poorly organized, the link between 
 the two institutions has been made through some minor official 
 of the College staff. Thus while the attending surgeon of the 
 hospital has been the Professor of Surgery at the College the 
 pathologist of the hospital has been only an instructor, or, at 
 most, an adjunct Professor of Pathology at the College. The 
 bacteriology at the hospital has been done by a so-called first 
 assistant to the hospital pathologist, who held a subordinate 
 position in the College of instructor of pathology and had no 
 connection with the department of bacteriology of the College 
 at all. Of chemistry the hospital has no service whatever. 
 Such an arrangement has led inevitably to friction in adminis- 
 tration and at times to serious delay or even failure in securing 
 results. The hospital has recently been presented with a new 
 laboratory building for the housing of some of the work of 
 this kind. Such a building is urgently needed and will supply 
 one of the means of carrying out an ideal organization. But it 
 should not remove from the College the burden of supplying the 
 means of carrying on the more advanced investigations of medi- 
 cal research in pathology, in bacteriology and in chemistry. 
 
*9 
 
 Each of these departments in the hospital should be organ- 
 ized somewhat as follows, taking the department of pathology 
 as an example: — Director of Pathology (the incumbent to be 
 also Professor of Pathology in the College of Physicians and 
 Surgeons). Assistant-Director (in charge of the Hospital 
 laboratory) with one worker to each medical or surgical 
 division, who should hold a combined scientific and clinical 
 position and be known as Pathologist and Assistant Physician, 
 or Surgeon, as the case might be. In the same way the Pro- 
 fessors of Bacteriology and of Chemistry at the College should 
 hold the positions of Consulting Bacteriologist or Chemist and 
 Director of laboratory. By such a scheme the duplication 
 of effort on both sides of 59th Street and the present 
 possibility of friction would be avoided. The hospital would 
 get better service from the College than now, and the College 
 would continue to do for the hospital, in a more feasible man- 
 ner, the work for their mutual benefit which it is now doing, 
 and which it is glad to do. 
 
 The financial side of this question presents several import- 
 ant features. From its fixed resources Roosevelt Hospital is 
 to-day unable to meet the demands of the present service as at 
 present administered. The hospital is working at an annual 
 deficit of from $8,000 to $15,000. This has been met of late 
 years by donations from its friends, prominent among whom 
 are certain of the Trustees. In addition to this deficit the 
 hospital is seriously threatened with a further deficit from the 
 collection of taxes upon its income-bearing real estate. If this 
 burden is to be added to the hospital liabilities, an additional 
 annual income of at least $12,000 must be furnished in order 
 to bring the hospital upon an even balance. The hospital 
 needs, therefore, in order to meet its present emergencies, an 
 added annual income of at least $25,000, which represents an 
 investment of $500,000 at 5$. 
 
 This sum, however, is a mere nothing compared to the 
 amount of money which is needed to develop Roosevelt Hos- 
 pital upon the plans as above outlined. The following pages 
 will show what is needed for the construction of the completed 
 hospital; for the endowment of its economic departments to 
 take care of the daily needs of the patients and the staff; for 
 the support of the teaching and research staff organizations 
 
which have been described in detail in the preceding pages. 
 A study of these estimates shows that the ultimate develop- 
 ment of the Roosevelt Hospital into a general hospital of 1,000 
 beds with the necessary modern equipment for medical re- 
 search for teaching and for scientific care of its patients will 
 require $16,500,000. Of this large sum $500,000 is needed to 
 meet the immediate needs of the present plant, and $6,000,000 
 to secure to the hospital the development and enlargement 
 which is urgently required at the present time. If this latter 
 sum can be secured the hospital will take its place at once 
 among the great hospitals of the world, and in the first rank 
 of such hospitals. 
 
 In regard to the expenditure of so large a sum of money as 
 the total ($16,500,000), which is asked for to convert Roosevelt 
 Hospital into the West side general hospital of New York 
 City, it is interesting to compare it with the amount which it 
 is proposed to expend upon Bellevue Hospital, the proposed 
 general hospital of the East side of New York. Bellevue 
 Hospital is being converted from a 1,000 bed hospital to a 
 2,000 bed hospital upon the modern basis of construction, 
 which involves its entire rebuilding and the destruction of 
 all of the old plant. This will cost in the neighborhood 
 of ten million of dollars, and not a single dollar is being pro- 
 vided for endowment. The maintenance of the hospital will 
 continue to be met from the annual taxes of the city. In the 
 case proposed for Roosevelt Hospital a sum of only half as 
 much again will convert a 200 bed hospital to one of a 1,000 
 beds and there will be provided, not only the entire plant but 
 a laboratory system for the furthering of medical knowledge, 
 both in research and in teaching, and in addition the entire 
 endowment necessary for adequate maintenance. 
 
 These ideas are being presented to you in the hope that 
 they may interest prospective donors to contribute to the 
 development of medical education in the City of New York 
 on a plane commensurate with the importance and dignity of 
 the position of the city in the United States. 
 
 The financial questions involved in bringing about the 
 development of Roosevelt Hospital as outlined above include 
 the securing of funds for three distinct purposes: 
 
I. Building funds to erect the new buildings of the 
 
 proposed enlarged hospital. 
 II. Endowment funds to provide the ordinary main- 
 tenance of hospital beds, including all expenses 
 except those to be strictly considered as educa- 
 tional and scientific. 
 III. Endowment funds to provide for the establishing 
 of a proper system of medical education and 
 medical research. 
 
 t. The new buildings required by the suggested plans 
 would naturally consist of three buildings of about the size 
 and shape of the present hospital structure known as the 
 " Pay-patient Pavilion." One of these new buildings would 
 be placed on the site of the present "Ward 5 " and the two 
 others on the vacant land on the western end of the hospital 
 property. These "barrack" pavilions would be made up in 
 large part of ward units, though some part of the most west- 
 erly one would contain a new hospital stable and hospital 
 morgue, and perhaps a medical teaching plant similar to the 
 Syms pavilion, which is designated for surgical educational 
 purposes. It is believed that each of these buildings would 
 cost about $250,000, irrespective of the peculiar uses to 
 which it might be put. The completed hospital would need 
 also an enlarged heating and lighting plant, with an enlarged 
 building therefor. If this is to be placed in the position of the 
 present installation it might demand the destruction of the 
 medical ward building. This is an old non-fireproof struc- 
 ture, which could profitably be removed to give place to a 
 new building constructed on modern lines. It is probable 
 that this change could be effected also at an expense of 
 $250,000. Until some skilled architect has drawn the plans 
 and specifications it is impossible, of course, to state accu- 
 rately the amount of money needed for building purposes, but 
 it seems fair to assume that $1,000,000 would suffice to con- 
 vert the present 250-bed Roosevelt Hospital into a modern 
 institution of 1,000 beds, so far as the mere matter of iron, 
 bricks and mortar is concerned. 
 
 2. The largest item of every hospital foundation is the 
 funded endowment needed to meet the annual running expenses. 
 
The Roosevelt Hospital has been caring for its patients 
 for several years past at the rate of from $2. 23 (1906) to $2. 28 
 (1907) per patient per day, after deducting the necessary ex- 
 penses for running the accident and dispensary services. The 
 expenses of supporting a hospital are continually increasing 
 both from greater demands of medical and surgical treatment 
 and from increasing cost of wages and supplies. I have for 
 the purposes of this estimate taken $2.50 as the total charge 
 against the single "patient-day" item when all expenses are 
 included. While this figure ($2.50) is perhaps too low for pres- 
 ent estimates on the Roosevelt Hospital of today, the relative 
 expense of a 1,000 bed hospital would be slightly reduced be- 
 cause the additional expenses for dispensary and accident 
 ward are more or less fixed and do not increase proportionate- 
 ly with the increase in the size of an hospital. Two dollars 
 and a half, therefore, may be considered a fair estimate of the 
 running expenses of a hospital, per bed per day, for the im- 
 mediate future. This figure as a basis of bed endowment for 
 the Roosevelt Hospital is subject to a 12$ reduction because 
 experience proves that only 80^ of its hospital days-care are 
 free and that the hospital is paid by the patients about 60$ of 
 the running expenses on 20$ of the service. 
 
 On this estimate each bed will cost per day $2.20 and per 
 year $803. Roosevelt Hospital already possesses an income 
 by which it supports 239 beds (of which 39 are for private 
 patients) with a deficit of about $25,000. The additional en- 
 dowment therefore, needed by Roosevelt Hospital, should it 
 become a 1,000 bed hospital, consists of two items: 
 
 I. To meet the present deficit of $25,000 
 
 per year requires at 5$ $500,000 
 
 II. To endow 800 beds with an individual 
 income of $803 per annum requires 
 $16,060 per bed or an income of $642, 
 
 400, which is 5$ on 12,848,000 
 
 or a total endowment additional to 
 
 present resources of $13,348,000 
 
 These figures show the absurdity of the position of most 
 New York hospitals which today still offer to endow a bed in 
 
2 3 
 
 perpetuity for $5,000, although that bed requires for its main- 
 tenance the income of $16,060. 
 
 3. The endowment of a proper system for teaching and 
 scientific research requires an endowment which will be best 
 understood if developed upon a divisional basis. The ques- 
 tion of salaries for the clinical workers in hospital services 
 has been brought forward during the past year in the discus- 
 sion on hospital organization held before the Mayor's Com- 
 mission. It seems wise for present purposes to assume that 
 the whole attending staff, both directors of divisions and 
 assistants who shall have the privilege of private practice 
 shall continue as heretofore to serve the hospital without sal- 
 ary, except insofar as the College pays for their teaching 
 work. Those assistants, however, who perform scientific 
 work both in research and diagnosis, and who devote practi- 
 cally all their time to the work, should be paid by the Hos- 
 pital or the College, or by both combined. Each of the 
 eighteen divisions would require a salaried and unsalaried 
 staff, as follows : 
 
 A sample Medical Division would be organized as follows : 
 
 SALARY FROM 
 HOSPITAL 
 
 Director (Professor in the College, either of 
 
 medicine or clinical medicine) None 
 
 1st assistant and attending physician None 
 
 2d assistant and attending physician to Dis- 
 pensary (Chief of Clinic) None 
 
 3d assistant and pathologist $2,400 
 
 4th assistant and bacteriologist , 2,400 
 
 Resident physician 1, 200 
 
 Interne staff: house physician None 
 
 senior " None 
 
 junior " None 
 
 Clinical clerks 4th year students 
 
 The educational budget for a medical division would be 
 $6,000, and there are contemplated eight such divisions. The 
 total income for the medical service should be $48,000, or the 
 income on $060,000. 
 
24 
 
 A sample Surgical Division would vary a little, but only a 
 little, from that of the Medical Division, as follows: 
 
 SALARY FROM 
 HOSPITAL 
 
 Director (Professor in College of surgery or 
 
 clinical surgery None 
 
 ist assistant and attending surgeon None 
 
 2d assistant and attending surgeon to Dispens- 
 ary (Chief of Clinic) None 
 
 3d assistant and registrar $1,000 
 
 4th assistant and pathologist 2,400 
 
 5th assistant and bacteriologist 2,400 
 
 Resident Surgeon 1,200 
 
 Interne staff: house surgeon None 
 
 senior " None 
 
 junior " None 
 
 Clinical clerks 4th year students 
 
 The surgical division requires one assistant more than 
 the medical and its budget is higher, $7,000; there are, how- 
 ever, but four such divisions. The total income for surgical 
 service, therefore, is $28,000 or the interest on $560,000. 
 
 The Special Services would be organized thus: 
 Operative services — (Gynaecology, eye, throat and ear and 
 genito-urinary surgery). 
 
 Non-operative services (neurology, children). 
 
 SALARY FROM 
 HOSPITAL 
 
 Director (Professor in College in specialty 
 
 represented) None 
 
 1 st assistant and attending specialist None 
 
 2d assistant and attending specialist to Dispens- 
 ary (Chief of Clinic) None 
 
 3d assistant and pathologist and bacteriologist. $2, 400 
 
 Resident specialist 1,000 
 
 Interne staff: house specialist None 
 
 junior " None 
 
 Clinical clerks 4th year students 
 
 This budget of $3,400 per division must be multiplied by 
 six and the resulting $20,400 is the income on $408,000. 
 
25 
 
 The scientific work would require an oversight by a group 
 of highers officials than the ones just mentioned as delegated 
 to the several divisions. The scientific divisions should be 
 linked to the similiar departments in the College and College 
 laboratories should be used for the greater and more general 
 problems while the Hospital laboratories should be the place 
 for routine diagnosis work and for subjects of investigation 
 of lesser importance. 
 
 SALARY FROM 
 HOSPITAL 
 
 In Pathology there should be a Director and 
 consulting Pathologist (the Professor of 
 Pathology at the College) None 
 
 ist assistant and pathologist $3,000 
 
 who should over-rank the clinical ward 
 workers and have charge of the hospital 
 laboratory. 
 
 The laboratory should have a il Diener " 720 
 
 And a supply fund 1,200 
 
 The same establishment must be provided for Bacteriology, 
 for Clinical Pathology and for Chemistry, and the annual budget 
 of $4,920 must be multiplied by four to make $19,680, which 
 is the interest on $393,600. 
 
 To summarize these items the total sum needed amounts 
 to $16,669,600, divided as detailed above as follows: 
 
 For new buildings $1,000,000 $1,000,000 
 
 Endowment for hospital expenses to 
 
 meet present deficit 500,000 
 
 To endow 800 new beds at $16,060 
 
 per bed 12,848,000 13,348,000 
 
 Endowment for teaching and medical 
 research : 
 8 Medical divisions at $120,000 
 
 each 960,000 
 
 4 Surgical divisions at $140,000 
 
 each 560,000 
 
 6 Special divisions at $68,000 each. 408,000 
 
 4 Laboratory services at $98,400 
 
 each 393,600 
 
 $2,321,600 
 
 Total $16,669,600 
 
26 
 
 Of this large sum $500,000 is needed to meet the deficit in 
 the present running expenses; $1,000,000 for new buildings; 
 $12,848,000 to furnish the endowment for the additional work 
 in the wards and $2,321,600 to supply the funds for teaching 
 and medical research both in the present hospital and in the 
 additions to be built. 
 
 It is desirable to consider these propositions from the 
 standpoint of the separate services in order that a correct 
 idea may be had of what portions of the total amount may be 
 necessary for urgent use, what parts may be desirable but 
 not immediately needed for present development, and what 
 proportion of the whole may conveniently and properly be 
 left to the future extension of the hospital plant. Such a 
 presentation also will serve as a useful index to direct the 
 proposed gifts of any prospective donor of funds to the 
 hospital. On studying the various items from this point of 
 view the following facts may be stated: 
 
 Each completed clinical division would require the follow- 
 ing endowment, apart from the necessary buildings: 
 
 A Medical Service of 50 beds would require an endowment 
 as follows: 
 
 For Hospital bed endowment $803,000 
 
 For teaching and research 120,000 
 
 $923,000 
 
 To endow a Surgical Service of 100 beds would require the 
 following amount of money: 
 
 For Hospital bed endowment. . . .$1,606,000 
 For teaching and research 140,000 
 
 $1,746,000 
 
 For a Special Service of 50 beds (e.g., Eye, Children) the fol- 
 lowing sums are needed: 
 
 For Hospital bed endowment $803,000 
 
 For teaching and research 68,000 
 
 $871,000 
 
27 
 
 For a Special Service of 25 beds (e.g., Throat and ear, Genito- 
 urinary, Gynaecology, Neurology) the needed endowment 
 amounts to: 
 
 For Hospital bed endowment $401,000 
 
 For teaching and research 68,000 
 
 $469,000 
 
 The present demands upon the service at Roosevelt Hos- 
 pital require an enlargement of the plant to about double its 
 present size. To fulfil these present needs for charitable ends, 
 for teaching and for research, the following five items of the 
 total foundation of $16,000,000 proposed above are urgently 
 needed: 
 
 I. The four laboratory services at $98,400 
 each would require a total endowment 
 of $393,6oo 
 
 II. The endowment to meet the present 
 
 deficit is 500,000 
 
 III. The erection of at least one of the pro- 
 posed new ''barrack" pavilions, prefer- 
 ably the one to replace the "ward 5 " 
 building, requires 250,000 
 
 IV. The endowment of 255 additional beds at 
 $16,060 each to meet the present de- 
 mands for hospital facilities, amounts 
 to 4,095,300 
 
 . V. The endowment of the teaching and re- 
 search staffs for the eight divisions 
 created by the above additions is, in 
 detail, as follows: 
 4 medical divisions at $1 20,000 
 
 each, or $480,000 
 
 2 surgical divisions at $140,000 
 
 each, or 280,000 
 
 2 special divisions (Children, 
 
 Gynaecology), at $68,000 
 
 each, or 136,000 
 
 and would make a total sum of $806,000 
 
28 
 
 These five items, forming the urgent needs of Roosevelt 
 Hospital to-day, present a total sum of $6,134,900, to be 
 secured in order to carry out the plans for modernizing the 
 methods of teaching' and research now in vogue, and for 
 meeting the demands for charity now being made on the 
 hospital. 
 
 The present hospital facilities provide approximately 250 
 (actually 238) beds, divided into two surgical divisions of 
 44 beds each. One medical division of 70 beds, one gynaeco- 
 logical division of 29 beds, one children's division of 12 beds 
 (part of the medical service) and private patients beds amount- 
 ing to 39. 
 
 These five divisions should be standardized as to beds on 
 the basis detailed above, with the possible exception of the 
 children's service. But it would seem wise to have the num- 
 ber on this children's service (12) increased to 25, and it 
 should be separated from the general medical service. 
 
 The additional endowment of 255 beds would complete the 
 surgical divisions to an 100 bed standard, the medical service 
 to 4 divisions of 50 beds each; the gynaecological service 
 would be left intact and the children's service would be made 
 a special service of 25 beds, which would be half that pro- 
 posed for the final establishment. 
 
 In an original appeal on this subject which was formulated 
 on May 19, 1905, it was suggested that one million dollars 
 would secure the advantages for teaching which in the present 
 statement is placed at six times as much. The original plan 
 was to enable the College and the Hospital to use the present 
 hospital plant for medical teaching upon the best modern 
 methods. The study of the whole situation has developed the 
 facts that the present hospital plant is about half the size it 
 must be to meet its philanthropic task ; and further, that 
 medical research cannot be divorced either from the general 
 hospital or from the teaching institution. The demand for 
 six millions instead of for one million dollars is made neces- 
 sary, therefore, by the urgent present requirements for an 
 hospital of twice the size of the present Roosevelt for teach- 
 ing facilities and for a teaching staff in the enlarged institution 
 and for a thoroughly equipped research plant in connection 
 with both. In other words, medical education at the College 
 
2 9 
 
 of Physicians and Surgeons and at the Roosevelt Hospital de- 
 mands both the million dollar fund needed to develop the 
 present Roosevelt and the five million dollar "University 
 Hospital " to be added to the present Roosevelt, both of which 
 were specifically mentioned in the appeal of May 19, 1905, 
 already referred to. 
 
 The addition at the present time of special services other 
 than those of children and gynaecology is a less urgent neces- 
 sity than the endowment of the general surgical and medical 
 services to a complete total of 200 surgical beds, 200 medical 
 beds and the addition of the much needed laboratory services. 
 The endowment for these additional special services would be, 
 as already stated, $871,000 for a service on the eye, and $469, 
 500 for each of the others suggested. At the present time 
 there is no question but that these special services are more 
 important from a College point of view than from a Hospital 
 point of view. They could undoubtedly be filled with patients 
 but unless the funds are provided by special endowment they 
 should not be considered at the present time. Whenever 
 these specialties are added to the hospital foundation, a fur- 
 ther demand must be made upon the proposed building funds, 
 probably to involve the equipment of one of the $250,000 
 " barrack " pavilions. The remainder of the total expenditures 
 of $16,669,600 will be needed ultimately for the develop- 
 ment of the service, the establishment of an additional 200 
 surgical beds and 200 medical beds, with the appropriate 
 buildings. 
 
 This detailed statement of expenditure needed for the de- 
 velopment of Roosevelt Hospital if adopted by the hospital 
 will give, it is hoped, an index for prospective donors of funds 
 desiring to advance medical education and research whereby 
 they may select the particular line of work which they may 
 wish to foster with the knowledge that the work will be carried 
 on in an institution where the best possible results may be as- 
 sured, and in that their benefactions may be for all time avail- 
 able for the sick poor in New York City, for medical education 
 in the whole country and for medical research in the civilized 
 world. 
 
 It is earnestly hoped that this presentation of the relation 
 of medical education and research to hospital organization 
 
3° 
 
 may assist your Committees in their work, and it is hereby 
 respectfully submitted. 
 
 Samuel W. Lambert, 
 
 Dean. 
 
 College of Physicians and Surgeons, 
 
 Medical Department of Columbia University, 
 
 Wednesday, November 25th, 1908 
 

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