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ON THE
CONSTRUCTION OF HOSPITALS.
AN ADDRESS
O.V THE GENERAL PKIXCIPLES IVIIIC II SHOULD
BE OBSERVED IN THE
CONSTRUCTION OF HOSPFFALS,
pcUbcrcb to tbc ^ntisb 3|tcbit;il Association ut ;^''rcbs,
July 20, 1S69,
WITH THE DISCUSSION WHICH TOOK PLACE THEREON.
^^K DOUGLAS GAT. TON, C.B. F.R.S.
LATE A CAPTAIN ROYAL ENGINEERS ,
HONORARY MEMBER OF THE BRITISH MEDICAL ASSOCIATION.
Prhttcd by permission <if the Council of the British Medical Association.
^""onbon ; \ ^ ^
M A C ]\I I L L A N AND C O.'
1869.
r The Rr.'Jif of Trairs/ntiniT and Ref^roducttou is reserved A
LONDON :
K. iLAV, SONS, AND ■lAVI.OK, rRIMKRS,
DUF.AD STREET HILI,.
CONTENTS.
PAGE
PREFACE ; vii
ADDRESS I
Sites of Hospitals 3
Clear area on which a Hospital should stand 5
Form and Distribution of the Parts 5
Basis of Hospital Constniction is the Ward 5
Conditions which regulate the Size of Wards 6
Conditions which regulate the Form of Wards 8
Maintenance of Purity in the Air 8
Superficial Area per bed 18
Way in which Space in a Ward should be laid out .... 20
Cubic Space resulting from these Conditions 2i
Materials for, and other details of, Ward Constniction ... 22
Ward Offices 28
Nurse's Room 28
Ward Sculleiy 29
Ablution Room, Water Closets, &c 30
Drainage 33
Proportion of Ward Offices to Wards 3-).
Unit of Hospital Construction 35
Aggregation of W^ard Units in the Construction of
A Hospital .-35
Administrative Buildings 41
Economical Considerations affecting Hospital Con-
struction . 44
Application of Principles to existing Hospitals . . 45
Cost of some existing Hospitals 54
Conclusion 55
CONTEXTS.
DISCUSSION : —
Dk. Kkn.nkdy . . .
Mk. IIltchinso.n . .
Sir James Simpson .
Dr. Rumsev
Dk. STE\v.\Rr . . .
Dr. Hughes Bennett
Dr. M.vcleod . . .
i>.\(;e
57
65
72
73
76
APPENDIX :-
Ventilating Fireplaces
81
LIST OF ILLUSTRATIONS.
PACE
Plan of Ward and Ward Offices 35
Plan of King's College Hospital, London 46
Plan of Wards and Ward Oflices at the Royal \'icturia
Hospital, Netley , il>.
Plan of Military Regimental Hospital 48
General Plan of Swansea New Hospital 49
General Plan of the Lariboisiere Hospital, Paris 50
General Plan of New Hospital at Leeds 5 '
General Plan of Herbert Hospital, Woolwich 53
Sketch of the Ends of the Southern Pavilions of the Herbert
Hospital, showing the Elevation of the Central Corridor . 54
Elevation, showing Air and Smoke Flues 86
Section of a Room showing Air-duct and Flue //-'.
Section of Grate i/>.
Plan of Grate and Air-chamber //'.
Fireplaces in Use at the Herbert Hospital 89
Grate adopted by the War Department 91
PREFACE.
The question of Hospital Construction embraces so
wide a field that a detailed account of the subject
would occupy far more time than a meeting like
that of the British Medical Association at Leeds could
afford. Each hospital, like each house, must be
suited to the special wants and the special circum-
stances of the locality in which it is placed. To these
the architect must adapt each design which he makes,
but in the adaptation he must not depart from the
fixed principles which should govern all designs.
I have in the following address, therefore, endea-
voured to confine myself to enunciating what those
principles are which seem to me to form the starting-
point from which all architects should proceed.
Improved Hospital Construction in England may
be said to date from the Report of the Royal Com-
mission ^ on the Sanitar)' State of the Ami)-, of 1857,
1 This Commission consisted of tlie Right Hon. Sidney Herbert.
Mr. Augustus Stafford, Sir Henry Storks, K.C.B., Dr. Andrew Smith
and Mr. Ale.xander (late Directors-Genera] of the Army Medical De-
jiartment), Sir TJiomas Phillips, Sir James Clark, Eart. M.D.. Sir J
Ranald Martin. M.D., and John Sutherland, Esq.. M.D.
viii PREFACE.
presided over by the late Lord Herbert of Lea,
which, for the first time, laid down those principles,
without the observance of w'hich no hospital can
be kept thoroughly clean and healthy.
Amongst the first hospitals in Avhich the principles
so enunciated were practically embodied were those
constructed according to the plans of the Commis-
sion - for improving Barracks and Hospitals of 1858,
and illustrated in their report.
At a subsequent period similar principles, adapted
more especially for Lidia and other warm climates,
were laid down by the Army Sanitary Commission
in their suggestions for improving the sanitary con-
dition of Indian stations, and are now being carried
out in India. Since these reports ^' have been laid
before Parliament similar principles of Hospital con-
struction have been generally adopted in recent
hospitals in this country and abroad.
- This Commission consisted of the late Lord Herbert of Lea (then
the Right Hon. Sidney Herbert), J- Sutherland, Esq., ISLD., Deputy
Inspector-General of Hospitals Burrell, M.D., and the author of this
address.
•'Amongst the jniblications on this subject, Miss Florence Nightingale's
works, and especially her " Notes on Hospitals,'' must be mentioned as
liaving contributed largely to the spread of sound principles of Hospital
construction in this and other countries.
ADDRESS.
A HOSPITAL or infirmary may be defined as a
building intended for the reception and treatment
of sick and injured persons, under conditions more
favourable for recovery than such persons could
otherwise command.
It follows as a necessary feature of hospital con-
struction that the building should be so arranged
as to enable a small staff of medical men, nurses,
and assistants to minister to the necessities of a
large number of sick. Now this can only be done
by bringing many sick together in one establishment,
and placing several sick in one room.
The first object of a hospital is that it should
enable the sick to recover in the shortest possible
time. It is now recognised by all that, in addition
to skilled attendance, medicine, and food, the fol-
lowing are essential requirements for ensuring speedy
recovery.
I. Pure air; that is to say, that there should be
no appreciable difference in purity between the air
inside the ward and that outside the building.
B
2 CONSTRUCTION OF HOSPITALS.
2. That the air supplied to the ward should be
capable of being warmed to any required extent.
3. Pure water, and that it should be so supplied
as to ensure the removal of all impurities to a
distance from the hospital.
4. The most perfect cleanliness within and around
the building.
In respect of this latter requirement, I may quote
from the Report of Mr. Simon, the Medical Officer
of the Privy Council, of 1864: —
" Tliat which makes the healthiest house makes likewise the
healthiest hospital ; the same fastidious and universal cleanli-
ness, the same nev-er-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 dust-bins. It is but the same principle of management, but
with immeasurably greater vigilance and skill ; for the esta-
blishment which has to be kept in such exquisite perfection of
cleanliness is an establishment which never rests from fouling
itself ; nor are there any products of its foulness — not even the
least odorous of such products — which ought not to be regarded
as poisonous."
In order to give effect to these principles, it is
necessary to consider :
1. 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 ; these rooms form the
principal units of hospital construction.
CONSTRUCTION OF HOSPITALS.
3. The distribution of these units, and of the
other necessary accessories, which when combined
constitute the hospital.
1. Sites of Hospitals.
The local climate should be healthy ; there should
be nothing to prevent a perfectly free circulation of
air over the district. There should be no nuisances,
damp ravines, muddy creeks or ditches, undrained
or marshy ground, close to the site, or in such a
position that the prevailing wands would blow the
effluvia arising from them over the hospital. The
natural drainage outlets should be sufficient and
available.
To test the healthiness of a site an inquiry into
the rate of sickness and mortality in the district will
afford valuable information as to its suitableness for
sick. But care should be taken not to be guided by
the mortality alone ; for it by no means follows that a
district with a low rate of mortality is suitable for
sick. The nature of the diseases, and the facility,
or otherwise, with which convalescences and reco-
veries take place, must also be taken into account.
The qualities of a site most favourable to a hos-
pital in this country may be described to be a
situation in the open country, upon porous and dry
soil, with free circulation of air round it, but
B 2
CONSTRUCTION OF HOSPITALS.
sheltered from the north and east ; raised above the
plain, with the ground falling from the hospital in all
directions, so as to facilitate drainage.
No doubt it is impossible to secure a perfect site
for every hospital, but in the construction of a
hospital it will be necessary to discount any de-
parture from these qualifications by increased floor
space and cubic space for the patients, or by en-
gineering arrangements outside the building, — that is
to say, by increased expenditure.
But in any case the site selected for a hospital
should not receive the drainage of any higher ground.
Clay soils and retentive soils generally should be
as far as practicable avoided. 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 sufficient distance to prevent stagnation of
air and damp, otherwise the shelter from an evil
recurring only at intervals may be purchased by loss
of healthiness at all other times.
CONSTRUCTION OF HOSPITALS. 5
Clear area upon which a Hospital should stand.
There should be no buildings near a hospital except
those immediately connected with its object. As
regards the minimum area upon which to erect a
hospital, the Chirurgical Society of Paris in 1864 laid
down as an axiom that the clear space in which a
hospital should stand should not afibrd a less area
j than nearly 540 square feet_to_e,cich patient, — that is to
1 say, that a hospital for 80 patients should stand in the
\ centre of an acre of ground ; and they further said
that the proportional area should be greater as the
number of patients increases. In this country it has
been held sufficient to allot an acre to lOO patients.
There is, however, a limit to the number of sick
which can be aggregated together on one site, and
in one hospital, to which a further reference will be
made.
2. Form and Distribution of the Parts of a
Hospital.
After the selection of the site, the most important
question is the structural arrangement of the building,
which must be such as to secure free circulation
of air.
Basis of Hospital construction is the Ward.
The basis upon which the structural arrangements
rest is the ward. The first thing is to obtain good
CONSTRUCTION OF HOSPITALS.
healthy wards ; everything else, such as administra-
tion, means of access, and discipline, must be made
subsidiary to the question as to how the sick are to
get well in the shortest possible time, and at the least
expense, and this, so far as the structure is concerned,
is mainly determined by the form of the wards.
Conditions zuJiicJt, rcgnlate the size of Wards.
The size of a ward depends upon the number of
patients which it should contain, and upon the cubic
space and floor space which should be allotted to each
patient.
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 atmosphere, 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 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 hos-
pital should be so laid out as to enable the largest
number of patients to be nursed by a given number
of nurses.
The number to be placed in a ward will therefore
depend upon the number which can be efficiently
CONSTRL/CTION OF HOSPITALS. 7
nursed, and the form of the ward must be as much
calculated to facilitate nursing as to ensure free
circulation and change of air.
I\Iiss Nightingale says that " a head-nurse can
" efficiently supervise, a night-nurse can carefully
" watch, 32 beds in one ward; whereas with 32 beds
" in four wards, this is impossible." (Appendix to
Report of Committee on Cubic Space in Metro-
politan Workhouses ; Paper on Nursing, by Florence
Nightingale.)
Miss Nightingale further shows (in her " Notes on
Hospitals," 1863) 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 428/. 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 220/. per bed.
It has followed, from these considerations, that
/ from 20 to ^2 beds have been taken as the unit for
) ward construction. 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.
Hence the actual ward-figure for each hospital
depends on the nature, and to some extent on the
size, of the hospital. Small wards are also required
for occasionally isolating bad cases.
CONSTRUCTION OF HOSPITALS.
Conditions ivJiich regulate the form of Wards.
The general form of ward construction is the next
consideration, and this is mainly governed by the
question of the renewal of air.
Maintenance of Purity in the A ir.
The purity of the air within an inhabited space,
enclosed on all sides, is necessarily vitiated by the
emanations proceeding from the bodies of those who
inhabit it, and especially by the effect on it of their
respirations. With persons suffering from disease,
especially infectious fevers, or from wounds, or sores,
these emanations are greater in quantity, and more
poisonous in quality, than from persons in health.
Stagnation in the movement of the air leads to rapid
putrefaction of these emanations. If they diffused
themselves uniformly throughout the space, as is the
case with the carbonic acid which is thrown off from
the body, ventilation would be comparatively simple,
and, whatever the cubic space, the air would attain a
permanent degree of purity, or rather impurity, theo-
retically dependent upon the rate at which emanations
are produced, and the rate at which fresh air is
admitted : hence the same supply of air will equally
well ventilate any space, but the larger the cubic space,
the longer it will be before the air in it attains its
permanent condition of impurity, and the more easily
CONSTRUCTION OF HOSPITALS. 9
will the supply of fresh air be brought in without
altering the temperature, and without causing injurious
draughts.
Upon the assumption that the impurities in a
ward diffuse themselves equally throughout the
atmosphere of the ward, the amount of air which
should be removed, and its place supplied with fresh
air, is at least 3^000 cubic feet per patient per hour;
but this must depend to some extent upon the
emanations of the patients, which vary with the
diseases or injuries they are suffering from.
The number of patients in a ward varies from day
to day, and the character of their diseases varies :
hence the amount of impure emanations in a ward
is variable.
On these considerations, it is advantageous to keep
the ventilation of each ward independent of other
wards or rooms ; and, whilst ample means of renewing
the air of the wards should be provided, yet these
means should be under the supervision of some one
in a position to be constantly aware of the ward
requirements, and responsible for their being always
efficiently maintained in action.
The change of air may be effected in various ways :
for instance, the air may be drawn out by a fan ; or it
may be removed by a shaft whose action depends on
the difference of the temperature of the air in the shaft
and that in the outer atmosphere : of this the ordi-
nary fireplace is one example ; a sun-light is another
lo CONSTRUCTION OF HOSPITALS.
example ; a heated shaft connected with flues led
from holes in the wall near the patients' beds, through
each of which air is drawn into the shaft, is another
example. The place of the air which is thus with-
drawn is then taken by fresh air, which in cold
weather must be warmed before it is passed into the
ward if an equable temperature is to be maintained
in the ward. Instead of withdrawing the air from
the ward, fans or pumps, or (as Dr. Arnott proposed)
a machine on the principle of a gas-holder, may be
used to force fresh air into the ward, and thus to
drive out the air previously in the ward.
It is thus quite possible so to arrange the ventila-
tion mechanically that a specified quantity of air at
a fixed temperature shall be forced into the ward
by day and by night. Theoretically it would seem
absolutely certain that, if a flue-opening were pro-
vided close to the bed of each hospital patient, and if
the fixed proportion of air were drawn away by this
flue, the whole of the emanations from the patients
should go with it. But this is not so in practice.
Unless the patient were enclosed in a case, part of
the emanations would pass into the other parts of
the ward. Moreover, mechanical ventilating arrange-
ments are always to some extent more or less
affected by variations in the temperature of the outer
air and by the direction of the wind, and conse-
quently require careful and constant supervision.
Practically, hospitals dependent upon such means
CONSTRUCTION OF HOSPITALS. ii
alone for ventilation have not been healthy. It
may be that the process is not in accordance with
Nature's mode of providing fresh air. To explain
my meaning I cannot do better than quote from the
remarks on the subject by IMiss Nightingale. In her
" Notes oft Hospitals " she says : —
" Nature affords air both to sick and healthy of varj'ing
temperature at different hours of the day, night, and season ;
always apportioning the quantity of moisture to the temperature,
and providing continuous free movement everywhere. We all
know how necessary the variations of weather, temperature,
season are for maintaining health in healthy people. Have we
any right to assume that the natural law is different in sickness ?
In looking solely at combined warming and ventilation to ensure
to the sick a certain amount of air at 60°, paid for by contract,
are we acting in accordance with physiological law? Is it a
likely way to enable the constitution to rally under serious
disease or injury, to undercook all the patients, day and night,
during all the time they are in hospital, at one fixed temperature ?
I believe not ; on the contrary, I am strongly of opinion — I
would go further and say, I am certain — that the atmospheric
hjgiene of the sick-room ought not to be very different from the
atmospheric hygiene of a healthy house. Continuous change
of the atmosphere of a sick ward to a far greater extent than
would pay a contractor to maintain, together with the usual
variations of temperature and moisture given by nature in the
external atmosphere, are elements as essential as any other
elements to the rapid recovery of the sick in most cases."
But there is also this consideration. The emana-
tions from the body do not uniformly diffuse them-
selves ; they hang about as the smoke of tobacco
may be said to do. In wards in which a fixed
quantity of air is forced, there is not even a uniform
12 CONSTRUCTION OF HOSPITALS.
degree of impurity ; at times the air may be tolerably
pure in one place, but very impure in another ; con-
sequently it seems to be necessary, in order to ensure
the purity of the air of a ward, that means should
exist for absolutely sweeping out all the impure air
from the ward occasionally, and starting afresh with
pure air. This is best effected by the direct action
of currents of fresh air brought in by open windows
placed on opposite sides of the wards. The distance
between windows for this purpose must not be too
great to prevent their efficient action in moving the
air. Experience shows that a width of twenty-four
feet affords very satisfactory results, but that opposite
windows for such an object should in no case be more
than from thirty to thirty-five feet apart. The space
between the windows should not be obstructed by
walls or partitions.
The same object renders it necessary to limit the
number of patients — that is to say, the sources of im-
pure emanations — placed between opposite windows
to two.
In the Herbert Hospital the width of the wards is
twenty-six feet : in the new St. Thomas's Hospital it
is twenty-eight feet ; and in the new Hotel Dieu in
Paris, twenty-nine feet ; but these two hospitals are
important medical schools. In the new Leeds Hos-
pital, also a medical school, it is twenty-seven feet
six inches.
In the day-time, and when the weather admits of
CONSTRUCTION OF HOSPITALS. 13
open windows, a ward with windows opening on both
sides can easily be kept fresh ; but for other seasons
it is necessary to provide openings for the escape of
impure air and for the admission of fresh air which
shall not cause draughts.
The use of open windows is incompatible with
the economical application of mechanical arrange-
ments for renewing the air in wards ; moreover, the
ventilating requirements of each ward should be
kept independent of those of other wards. This will
be best effected by keeping a separate fire for each
ward. If one fire is provided for each ward, it is
best on other considerations to place it in an open
fireplace in the ward.
The most powerful engine of ventilation for draw-
ing out the air is an open fireplace. The way in
which an ordinary open fireplace acts to create cir-
culation of air in a room with closed doors and
windows, is as follows.
The air is drawn along the floor towards the grate,
it is then warmed by the radiating heat of the fire,
and part is carried up the chimney with the smoke,
whilst the remainder flows upwards near the chimney-
breast, to the ceiling. It passes along the ceiling,
and, as it cools in its progress towards the opposite
wall, descends to the floor, to be again drawn towards
the fireplace. It follows from this, that with an open
fireplace in a room, the best position in which to
deliver the fresh air required to take the place of
!4 CONSTRUCTION OF HOSPITALS.
I that whicli has passed up the chimney, is at some
I convenient point in the chimney-breast, between the
/ chimney-piece and the top of the room, for the air
thus falls into the upward current, and mixes with the
air of the room without perceptible disturbance.
In order to prevent the temperature of the ward
from being lowered by the extraction of air, to
maintain an equable temperature, and to prevent
draughts, it is absolutely necessary to supply warmed
air to replace that removed by the fireplace or by
other openings. This may be done by placing coils
of pipe, or flanged pipes, heated by steam or hot
water, in convenient places, so as to allow the air
drawn into the ward by the fireplace, or otherwise, to
be warmed. But this plan is rendered unnecessary
by the use of ventilating fireplaces,^ constructed on
the principle of those used in militaiy hospitals and
barracks : these fireplaces are constructed in such a
manner as to utilize a portion of the heat generated
by the fire, and which would otherwise pass away by
the chimney, in warming fresh air which is admitted
into the ward ; and they are, besides aiding the
ventilation in a remarkable degree, very economical
of fuel.
In hospitals, arrangements should be made, either
by providing gas jets in the chimney, or by warming
the chimney-flue by means of an adjacent spare flue,
to keep up a current in the chimney when the fire
^ See Appendix.
CONSTRUCTION OF HOSPITALS. 15
is out ; but it may almost be accepted as an axiom
that, in this climate, when it is necessary to keep the
Avindows closed, it is desirable to have a fire lighted.
It is not however sufficient, in this method of
airing wards, to trust only to the fireplace and
Avindows. In addition to the ventilation by means
of the fireplaces, outlets for heated and impure air
should be provided by means of shafts carried up
from the ceiling to above the roof, which will act
when the fire is out, and will prevent at such times
stagnation in the upper part of the wards. The
degree of action in these shafts depends upon the
height of the shaft and upon the difi"erence between
the temperature in the ward and the temperature
out of doors. I have found that an adequate change
of air will not be satisfactorily obtained in all cases
without a sectional area of at least one inch to every
fifty cubic feet of space in the room for the upper
floors, that is, immediately under the roof; of one
inch to every fifty-five cubic feet in rooms on the
floors below ; and of one inch to every sixty cubic
feet for rooms on the lower floors : but this to some
extent depends on the heights of the rooms. It is
preferable to allot these areas according to the cubic
space in the rooms than according to the number of
beds, because the number of beds may be varied
according to the nature of disease ; and the larger
the cubic space necessary for a patient, the larger
also should be the means of changing the air, because
I6 CONSTRUCTION OF HOSPITALS.
the permanent contamination of the air varies, not
with the cubic space, but with the amount of fresh
air admitted.
These shafts should, where the fireplaces are in the
side walls, be placed if possible on the same side as
the fireplaces; but if the fireplaces are in the centre
of the wards, the shafts should be placed in the
corners of the room furthest removed from the grates,
as in that position they will be least liable to down
draughts.
Each gas jet burning in the wards at night should
be covered with a bottomless lantern connected with
an extraction shaft or tube, so as to carry off the
products of combustion ; in wards which have the
roof only above them, a gas sun-light, with direct
communication with the outer air, is a convenient
and powerful engine of ventilation.
Means for the admission of air of the ordinary
temperature should be provided direct from the open
air, independent of the windows and doors ; for this
purpose, Sherringham's ventilators should be placed
between the windows near the ceiling, which should
afford a combined area of at least one square inch
for every hundred cubic feet of space in the room :
eminent surgeons are of opinion that for bad surgical
cases openings of equal size should be placed close
to the floor under the beds, so as to allow the impure
air to be swept out from under the beds, but these
latter should be capable of being easily and securely
CONSTRUCTION OF HOSPITALS. 17
closed, otherwise they create unpleasant draughts
near the floor. The Sherringham ventilator placed
near the ceiling admits the air without perceptible
draught ; but these ventilators will also be found
frequently to act as outlets when they are open on
the leeward side of a ward.
The simple methods of admitting air into, and
removing air from, wards which I have here described,
are those which after much consideration I have pre-
ferred to more mechanical and complicated methods,
which might possibl)' be shown to be theoretically
more perfect. But the theoretically perfect method
of supplying a known quantity of air hourly into the
ward, and neither more nor less, requires, if its action
is not to be disturbed, that the windows shall not
be opened, and that an open fireplace shall not be
used. I believe, however, that health will be best
secured by using open fireplaces, and by keeping the
windows open when it is possible to do so, so as to
sweep out the foul air, and introduce occasionally far
more pure air than the quantity pronounced to be
theoretically necessary. The inlets and outlets I
propose are supplementary to the windows when
these cannot be opened, and are not intended to
supplant them.
All openings for the admission of fresh air should be
capable of being easily examined and cleaned through-
out their whole length, and should be thoroughly
cleaned at least once a year.
C
CONSTRUCTION OF HOSPITALS.
Superficial A rca per bed.
The next most important element in the question
of ward construction is the superficial area to be
allotted to the patients, for on this depend the
distance of the sick from each other, the facility
of moving about the sick, shifting beds, clean-
liness, and other points of nursing. If there be a
medical school attached to the hospital, the question
of area has to be considered with reference to afford-
ing the largest amount of accommodation practicable
for the teacher and his pupils.
A ward with windows improperly placed, so as not
to give sufficient light, or where the beds are so placed
that the nurse must necessarily obstruct the light in
attending to her patients, will require a large floor-
space, because the bed-space must be so arranged,
and of such dimensions, as to allow of sufficient light
falling on the beds. In well-constructed wards with
opposite windows, the greatest economy of surface
area can be effected, because the area can be best
allotted with reference both to light and to room for
work. Miss Nightingale, in her paper on the "Train-
ing of Nurses," in the Appendix to the Report of the
Committee on Cubic Space in Metropolitan Work-
houses, says that in an infirmary ward, 24 feet in
width, with a window for every two beds, a 7 feet
6 inch bed-space along the walls would probably be
sufficient for nursing purposes. This would give 90
CONSTRUCTION OF HOSPITALS. 19
square feet per_bed, and there should be as little
reduction as possible below this amount for average
cases of sickness, but this space is much too small
for fever or lying-in wards.
The practice in regard to area differs considerably
in different hospitals. In the naval hospitals it is
about 78 square feet per bed. In the Herbert Hos-
pital, where there is no medical school, it is 99 square
feet per bed. In the Royal Victoria Hospital at Netley,
where there is a medical school, it is 103 square feet.
In St. George's Hospital it is 69 square feet, a very small
area for so important a school. From this minimum it
varies to 138 square feet in Guy's Hospital. In the new
Hotel Dieu, at Paris, the space per bed will be from
104 to no square feet, and in the new St. Thomas's
Hospital it will be 112 square feet. This latter area
is considered sufficient both for nursing and teaching
purposes. It will thus be seen that the question of area
must be settled with reference to the existence or non-
existence of a clinical school in the building and the
number of pupils likely to follow the medical officer.
As the present paper refers exclusively to new
hospitals, which we must suppose will not be con-
structed in unhealthy localities, we may fix the area
at about 90 square feet per bed in this climate, with
the understanding that the area shall be increased if
the building is designed for a medical school, or
where from unavoidable circumstances an unfavour-
able site must be selected.
C 2
CONSrnUCTIOX OF HOSPITALS.
Way in zvhich the Space in a Ward should be
laid out.
The next consideration is the allotment of the
superficial area. The width between the opposite
windows affords the limit in one direction, and con-
venience for nursing requires that there shall be a
window near each bed: hence the superficial area
must be so allotted as to afford convenient space for
nursing purposes between the sides of adjacent beds,
and between the feet of opposite beds.
If there is a window for each bed, the wa.ll-space
between every two windows should be six or eight
inches wider than the bed, and in this case the width
of the window, whatever that may be, would practi-
cally represent the distance between the beds. If
there are two beds between every two windows, the
distance between the adjacent beds of each pair of
beds along the wall-space should not be less than
three feet for facility of nursing.
If 7 feet 6 inches be set apart as the total linear
space to be allowed for each bed along the side wall,
this, with a superficial area per bed of 90 square
feet, would give a ward 24 feet wide, which is a
favourable width for ventilation ; and, allowing a
few inches between the bed-head and the wall, this
width would give about 10 feet between the pro-
jecting ends of opposite beds.
CONSTRUCTION OF HOSPITALS.
Cubic Space resulting from these Conditio}: s.
Assuming that these areas and distances are
sufficient, then a ward height of 12 feet, which is
scarcely sufficient except for small wards, would affi^rd
1,080 cubic feet per bed. A height of 13 feet would
allow 1,170 cubic feet, and a height of 14 feet, which
is the height of the Herbert Hospital wards, would
give 1,260 cubic feet.
Long wards require more height for efficient venti-
lation than short wards.
In a good situation, and for ordinary cases of
disease and operations, those spaces which are enough
for nursing and ward administration would, with good
ventilation, be sufficient for all sanitary purposes ; but
for cases of severe fevers, such as typhus and other
epidemic diseases, a much larger space and area would
be required. In ordinary hospitals, when severe cases
of this class come into the hospital, the simplest plan
is to leave the bed adjacent to that occupied by
the patient vacant.
It is, however, very much the practice to build
special hospitals for these classes of cases. The
aggregation of a mass of virulent emanations in one
hospital, and in one ward, renders it necessary to
provide a very large extent of floor-space and cubic
space. This means very much increased expense for
construction and nursin^.
CONSTRUCTION OF HOSPITALS.
I am afraid that statistics go to show that special
hospitals, where a number of fever cases are brought
together, afford a higher death-rate than is due to the
disease. These expensive structures cannot therefore
be said to have secured the rapid recovery of the sick.
Yet this class of cases is eminently that which should
be treated in hospitals. Is it, however, desirable to
aggregate all such virulent sources of emanations
together in one ward in one hospital .'' Would it not
be better to separate them amongst other patients in
an ordinary hospital .''
Whilst the mortality from this class of diseases is
high in special hospitals, it is low in shed buildings,
and even in no buildings at all. If, therefore, it be
necessary to make special provision for epidemic
disease cases, would it not be better to make such
special provision in small hut wards, attached to
ordinary hospitals, but separate from each other,
and from the hospital proper .'' A simple, inex-
pensive hut for a few beds, capable of perfect
ventilation, and admitting of being occasionally
pulled down and rebuilt with fresh materials at no
great expense, would in all probability afford more
recoveries from fever and wounds than the most costly
special hospital wards.
Materials foj', and other details of, IVard Construction.
Having considered the principles which govern the
size and general form of wards, the next point is the
CONSTRUCTION OF HOSPITALS. 23
description of materials to be used for the walls, ceil-
ings, floors, and windows.
With a view to economise heat in winter, and to
keep the rooms cool in summer, the walls should be
hollow, and all hospital wards should be ceiled, unless
the roof is constructed of a good non-conducting
material.
The best lining for a hospital ward would be an
impervious 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,
acquires a peculiar smell. In a discussion in 1862, in
the French Academy of Medicine, a case was men-
tioned in which an analysis had been made of the
plaster of a hospital wall, and j,6 per centof organic
matter was found in the plaster. No doubt the ex-
pensive process which is sometimes termed enamelling
the walls, which consists of painting and varnish-
ing 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 appears to be the best
material at present known for walls, but it is costly,
and it can only be applied on brick or stone walls,
and not on wood-work or partitions, because, being
24 CONSTRUCTION OF HOSPITALS.
very inelastic, it is liable to crack. Cracks in a
hospital ward are inadmissible, as they get filled with
impurities, and harbour insects. The numerous joints
required for glazed bricks, or tiles, render the use of
these questionable as a lining for wards. The want of
elasticity in Parian cement is unfavourable to its use
in ceilings.
In default of Parian cement, which is costly, and
which it is quite possible it may hereafter be found
necessary to remove at distant intervals and replace
with fresh materials, the safest arrangement is plaster
lime-whited or painted, which should be periodically
scraped so as to remove the tainted surface, and be
then again lime-whited or painted. Of course these
arrangements require the wards to be periodically
vacated.
When plaster is used, it is essential, for the reasons
before mentioned, that at the expiration of very few
years the whole outer coat of plaster should be re-
moved from the walls and ceilings, and new plaster
substituted. The walls and ceilings should be quite
plain, and free from all projections, angles, or orna-
ments which could catch or accumulate dust.
The floor should be as non-absorbent as possible,
and for the sake of warmth to the feet it must in this
country be of wood. Oak, or other close hard wood,
with close joints, oiled and beeswaxed, and rubbed to
a polish, makes a very good floor, and absorbs very
little moisture. It is impossible to pay too much
CONS TR UCriON OF HOSPITA LS. 25
attention to the joints : they should be Hke those of
the best parqiieterie, affording no inlet for the lodge-
ment of dirt; for the impurities which become
lodged in the cracks of a hospital floor are eminently
objectionable. There should be no sawdust, 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, and
that it should be so formed as to prevent emanations
from patients in the lower ward from passing into the
upper wards.
The floors of the Herbert Hospital are formed
of concrete, supported by iron joists, over which
the oak boards are laid. An economical and non-
absorbent surface for the floor can be obtained by
first laying rough deal boards and covering them
with thin, closely-laid oak boards. This floor should
be cleaned like the French parquet, by frottage. A
very good hospital floor is that used at Berlin, which
is oiled, lacquered, and polished, so as to resemble
French polish. It is damp-rubbed and dry-rubbed
every morning, which removes the dust. Its only
objection is want of durability. Both of the processes
above mentioned render the floor non-absorbent, and
both processes do away with the necessity of scour-
ing, which is objectionable from the quantity of damp
it introduces into the ward. The French floor stands
the most wear and tear, but must be cleaned by
a frottcnr, which cleaning is more laborious than
26 CONSTRUCTION OF HOSPITALS.
scrubbing, and does not remove the dust. The wet
and dry rubbing process of cleaning above mentioned
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 rubbing.
All wood-work in a ward should be painted and
varnished, so as to admit of easy washing and dry-
ing. The cleanest and most durable material is
varnished light-coloured wainscot oak.
The form of the windows must be considered in
their aspect of affording light as a necessary means
of promoting health, of affording ventilation, of
facilitating 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 2 feet or 2 feet 6 inches from the
floor — so that the patients can see out — to within i
foot from the ceiling. The windows should, as has
been already explained, be placed on each side of
the ward, with not more than two beds between each
window, so that plenty of light may be thrown on
each bed for facility of nursing. In wards affording
about i,200 cubic feet per bed, and with one window
to two beds, the space between the end wall and
the first window should be 4 feet 6 inches, and the
CONSTRUCTIOIV OF HOSPITALS. 27
( space between the adjacent windows 9 feet, the
windows themselves being 4 feet 6 inches wide,
and the sides splayed about 6 inches on each side
into the ward. An end window to a long ward is a
great element of cheerfulness, and materially assists
the renewal of the air at night.
It is essential to cleanliness that every part of
the ward should be light. One superficial foot of
window-space to from 50 to 55 cubic feet of space,
will afford a light and cheerful room, but this depends
much on situation and upon the walls being light-
coloured.
As it is essential in this climate to economise heat
in wards, with so much outer wall as the provision
of windows on both sides requires, it is desirable to
make the windows of plate-glass ; double windows of
ordinary glass would secure the same object and faci-
litate ventilation, but they are troublesome to clean,
and almost always give a gloomy appearance to
a room.
The best form of sash for ventilation in this
climate is the ordinary sash, opening at top and
bottom ; but windows inade 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
I do not think that the air of the wards can be so
thoroughly changed by means of these windows as by
means of the ordinary sash.
28 CONSTRUCTION OF HOSPITALS.
Ward Offices.
The ward offices are of two kinds : —
1. Those which are necessary for facihtating the
nursing- and administration of the wards, as the
nurse's room and ward scullery.
2. Those which are required for the direct use
of the sick, so as to prevent any unnecessary pro-
cesses 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-establishment
attached to every hospital, with hot, cold, vapour,
sulphur, medicated, shower, and douche baths.
Hot and cold water should be laid on to all ward
offices in which the use of either is constantly required,
because of the economy of labour in the current
working of the hospital. For the same reason, when
the wards are on two floors, lifts should be provided
to carry up coals, trays, bedding, and even patients.
Mi.ss Nightingale (" Notes on Ho.spitals ") estimates
that a convenient arrangement of lifts and laying on
hot and cold water economises in attendance as
much as one attendant to thirty sick.
Nurse s Room.
The nurse's room should be sufficiently large to
contain a bed and to be the nurse's sitting-room. It
CONSTRUCTION OF HOSPITALS. 29
should be light, airy, and well ventilated, as a cheer-
ful 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, ^\■ith a window
opening into each.
Ward Scullery.
There should be a ward scullery attached to each
ward, and adjacent or opposite to 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, prepare fomenta-
tions, &c. The best sink for washing up and cleaning
the utensils is a white glazed fire-clay sink, with hot
and cold water laid on. Care should be taken that the
communication between the waste-pipe and the drain
be made in the most careful manner, as hereafter
described, otherwise foul air is certain to find its way
into the hospital. Shelves or racks should be provided
for ward cookery, but it is undesirable to have many
cupboards or closed recesses for putting away things,
as they become in time receptacles for dirt and rubbish.
There should be no dark corners in the scullery, and
it should have ample windovv'-space. The scullery
30 CONSTRUCTION OF HOSPITALS.
should be large enough for the assistant nurses to sit
in, to have their meals comfortably.
There should be provided in, or adjacent to, the
scullery or nurse's room, 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 baskets,
boxes, 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 ; consequently I do not advocate any struc-
tural provision for the retention of these in or near
the hospital.
A b hit ion Room, Water Closets, &c.
The ward offices of the second class ought to be as
near as possible to the ward, but cut off from it by a
lobby, with windows on each side, and with separate
ventilation and warming, so as to prevent the possi-
bility of foul air passing from the ward offices into the
wards. They are therefore most conveniently placed
at the end of the ward, furthest from the entrance
and nurse's room ; and distributed at each side, so
as to enable the ward to have an end window.
The ablution-room should contain a small bath-
room with one fixed bath of copper, supplied with
hot and cold water. Terra-cotta when once warmed
CONSTRUCTION OF HOSPITALS. 31
has the advantage of retaining the heat longer than
almost any other material, and 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.
A lavatory table of impervious material, such as
slate or 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 to be used conveniently by male
patients standing abreast. It is undesirable to have
closed receptacles under the basins, as they only
accumulate dirt ; nothing should be kept in these
offices but what is required for constant use, and
everything in use should be open to inspection. All
fittings should be light-coloured, as they then show
any want of cleanliness. There should also be room
for a portable bath for each ward ; this bath should
be on noiseless wheels, and hot and cold water taps
should be provided at a convenient height for filling,
and there should be a sink on the floor level for
running off the water out of the bottom of the bath
after it has been used.
The water-closets should never be against the inner
wall, but always against the outer wall of the com-
32 CONSTRUCTION OF HOSPITALS.
partment in which they are placed. A pan of a
hemispherical shape, never of a conical shape, with
a syphon, and abundantly supplied with water to
flush it out with a large forcible stream, is by far the
best contrivance for the water-closet of a hospital.
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 with
an ample supply of water ; this sink should be
arranged to be flushed out like a water-closet pan.
The space underneath should not be closed in ; if
it is, the enclosed part will be made a receptacle for
rubbish. Walls of ablution-rooms and water-closets
should be covered with white glazed tile, slate ena-
melled or plain, or Parian cement ; plaster is not a
good covering for them on account of their liability
to be splashed, and of the necessity for the walls to
be frequently washed down.
There should be private water-closets for the nurses,
Avho should not use those of the patients ; and also
water-closets for the patients when not in their wards.
The ablution-room and water-closets should have
plenty of windows opening to the outer air. 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, and
CONSTRUCTION OF HOSPITALS. 33
warmed air should be supplied to them independently
both of the wards and of the lobbies which cut them
off from the wards, which latter should also be care-
fully ventilated and warmed separately. Care in
these details is essential to prevent any of the air
from these conveniences passing into the wards,
especially in cold weather, and thus becoming a
source of danger to the patients. All wood-work,
such as seats to water-closets, should be of non-
absorbent wood.
Drainage.
No drain should pass under any part of hospital
buildings, because it is so difficult to ensure that brick
or earthenware drains shall be kept permanently air-
tight in their whole length, and the smallest outlet
may be a source of great evil ; therefore all those
appliances which are connected with drain-pipes, such
as sinks, water-closet pans, &c., should be placed
against the outside wall, so that the waste-pipes may
be carried at once outside. They should also be
placed under a window, so as to free them easily
from smell should any arise, and to throw upon them
abundance of light, and so avoid the accumulation of
dirt. It is undesirable to build drain-pipes into walls.
Every precaution should be taken to prevent any
drain smell from entering the building. The waste-
pipes which convey away the refuse water should be
D
34 CONSTRUCTION OF HOSPITALS.
all trapped just under the outlet from the basin, bath,
urinal, or sink with which they are connected ; they
should pass into a waste soil-pipe, carried up to above
the roof, and open at the top, so as to allow of an
outlet for the gases displaced in the pipe when water
is suddenly thrown into it from sinks" or water-closets.
This waste soil-pipe should be led into a trap at the
bottom, to cut it off from the drain outside the
building, and this outside drain should have a venti-
lation to allow of the escape of the gases generated
in it, so as to prevent these gases from being able to
force their way into the hospital. All such drain
ventilation should be passed through charcoal filters.
Proportion of Ward Offices to Wards.
These ward 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 a ward of
thirty-two beds. For instance, three water-closets
per ward will suffice for a ward of thirty-two beds, but
two at least will be required for even a twelve-bed
ward. The superficial area to be added in the wards
of thirty-two beds for these appliances would be
about thirty square feet per bed, whereas in wards of
twenty beds each it would come to nearly fifty square
feet per bed. I point this out to show how much
cheaper in first construction large wards are than
smaller ones.
CONSTRUCTION OF HOSPITALS.
35
Unit of Hospital Constructioii.
The ward with its ward offices here described is
the unit or basis of hospital construction. It is a
Scale
"{LL1-.J1 ^° ?'
10 40 SO 60 TO 80 90 roo r:
Fig. I. — WARD AND WARD OFFICES.
small hospital, which may be increased to any required
size by the addition of similar units.
3. Aggregation of Ward Units in the Con-
struction of a Hospital.
The principles upon which these units of ward con-
struction, or, as they are generally termed, pavilions,
should be added, are as follow : —
1. There should be free circulation of air between
the pavilions.
2. The space between the pavilions should be
exposed to sunshine, and the sunshine should fall on
D 2
36 CONSTRUCTION OF HOSPITALS.
the windows, for which purpose it is desirable that
the pavilions should be placed on a north and south
line.
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.
This is the smallest width between pavilions which
will prevent the lower wards from being gloomy in
this climate ; and where there is not a free movement
of air round the buildings, this distance should be
increased.
4. The arrangement of the pavilions should be such
as to allow of convenient covered communication
between the wards, without interfering with the light
and ventilation, and therefore the top of the covered
«\ corridor uniting the ends of pavilions should not be
^ carried above the ceiling of the ground-floor ward.
Indeed, whilst it is necessary to make the ground-
floor ward twelve to fourteen or fifteen feet high,
it would be unnecessary for purposes of communi-
cation to give the corridor a greater height than
from eight to nine feet, or possibly ten 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 in the open air. Each block of
wards — that is, each pavilion — should have its own
staircase.
CONSTRUCTION OF HOSPITALS. 37
5. No ward should be so placed as to form a
passage-room to other wards.
6. As a general rule, there should not be more tlian
two floors of wards in a pavilion. If there are three
floors or more, the distances between the pavilions
become very considerable, because of the rule, which
ought to be absolutely observed, of placing the pavi-
lions 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. Besides, when two
wards open into a common staircase, there is, with
every care, to some extent a community of ventilation.
When there are as many as four wards one over the
other, the staircase becomes a powerful shaft for draw-
ing up to its upper part the impure air of the lower
wards, which is then liable to penetrate into the upper
wards. Similarly, heated impure air from the windows
of the lower wards has occasionally a tendency to
pass into the windows of the wards above. On these
grounds, no hospital should have more than two floors
of wards one over the other ; and if there is a base-
ment under sick wards, it should not be used for any
purpose, such as cooking, from which smells could
penetrate into the wards, and, when possible, it is best
not to continue the staircase into the basement.
7. There is a limit to the numbers which should be
congregated under one roof. This limit will depend
very much on the nature of the cases. After consider-
ing well the experience of military hospitals, into
38 CONSTRUCTION OF HOSPITALS.
which many slight cases are received, it was decided
that no more than 136 cases should be placed in one
double pavilion, divided into two equal halves in such
a way that the communication between the halves
was cut off by through ventilation. In town hospitals,
where the cases are of a more severe character, a
similar double pavilion should probably not contain
above 80 to 100 beds.
The size of 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 containing the numbers of beds I have men-
tioned ; 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.
If economy in this matter were of no consequence,
then any small number would answer, but in practice
economy is best realized by increasing the number of
beds up to the point at which a single administration
can superintend them. This, Miss Nightingale says,
might be done to the extent of 1,000 beds, but such
an extensive hospital is not to be desired.^
Bearing in mind these principles, it may be accepted
^ In the late American war some of the pavilion hut hospitals con-
tained as many as from 2,000 to 3,000 beds. The statistics of recoveries
in these hospitals, so far as I have been able to ascertain them, were
not particularly favourable, but without an analysis of the cases it is
impossible to say to what cause this was due.
CONSTRUCTION OF HOSPITALS. 39
as a rule that, so far as the sick are concerned, they
would be better placed in wards all on one floor,
opening out of a common 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-storey buildings. The pavilions would
be nearer together than in the case of wards on two
floors, and consequently the distance to be traversed
by the medical officers would be from twenty-eight to
thirty feet horizontally between the pavilions in the
case of the one-storey hospital, as compared with
ascending from fourteen to sixteen feet by a staircase
in the case of a two-storey building. On the other
hand, the cost of drainage will be somewhat greater,
and facilities for supplying hot and cold water to the
ward offices will be less, in the one-storey hospital.
On town sites it is absolutely essential to build
hospitals as compactly as possible, and there is no
doubt that economy in the current expenses will be
best secured by a compact building with wards on two
floors, provided with lifts and other labour-saving
appliances.
In addition to the larger wards, it is necessary to
have a few wards of one or two beds each for special
cases ; but these should be as few as possible, so as
to economise labour in nursing, and their position
must be adapted in each hospital to suit the arrange-
ments of the principal wards, so as to afford easy
supervision by the nurses.
40 CONSTRUCTION OF HOSPITALS.
It Is moreover desirable that if convalescent pa- .
tients remain in the hospital they should have rooms
in which they can dine and spend the day apart from
the other sick ; the situation of these rooms should
be such as not to interfere with the light and air of
the wards. This class of patients also requires a
chapel. It is, however, worthy of consideration
whether, as a rule, patients who are able to move
about in this way should be retained in hospitals ;
or, indeed, whether it would not be better to en-
deavour to establish convalescent institutions on the
principle of the recently erected Atkinson-Morley
Convalescent Hospital at Wimbledon, in direct and
immediate connexion with a certain number of other
hospitals. It is anticipated that this convalescent
establishment will enable the authorities of St.
George's Hospital to free their hospital beds in
London much more rapidly, and thus receive many
more patients in the course of the year ; at the
same time, it must be borne in mind that assem-
blies of mere convalescents present some disciplinary
difficulties.
Arrangements for the several requirements above
described must all be made subservient to the broad
general principle of giving air and light to the wards.
All corridors connecting the wards should be kept
as low as possible, so as not to impede the circulation
of air between the pavilions ; they should be lighted
by windows on both sides, capable of opening wide.
COiXSTRUCTJON OF HOSPITALS. 41
or of being removed altogether in warm weather, and
they should be provided with ample means of venti-
lation, and supplied with fresh warmed air in cold
weather.
The staircases should be treated similarly as to
light and ventilation, and it is desirable to cut off the
connecting corridors from adjacent staircases by
swing-doors. These arrangements prevent draughts,
and cause the passages and staircases effectually to cut
off the ventilation of one pavilion from that of another.
The staircases for patients should be broad and
easy ; the rise of each step should not exceed four
inches in height, and the tread should be at least one
foot in width ; there should be a handrail on each
side, and a landing after every six or eight steps.
4. Administrative Buildings.
Having thus provided for the wards, the accom-
modation must be supplemented by the arrangements
for what is called the administration.
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.
The necessary subsidiary accommodation may be
briefly described as follows : —
I. Examining room, surgery and drug store, and
42 CONSTRUCTION OF HOSPITALS.
operating theatre; the latter should have roof-light
from the north, and an airy operation ward should
be placed near to it. A dead-house and post-mortem,
room should be provided, quite outside, and if pos-
sible detached from, the hospital. These rooms
should be quite plain, and without projections or
ornaments which would form a resting-place for dust.
2. Apartments for house-surgeon, matron, nurses,
and servants.
The nurses should have airy bedrooms, with every
accommodation for ablution, &c. attached, away
from the wards, so that they may obtain pure air
and complete rest while they sleep.
3. Stores for bedding and linen ; kitchen ; and
provision stores.
The kitchen, and all those stores between which
and the wards there is a constant movement, should
be as central as possible, so as to save labour ; but
the kitchen should be carefully cut off from the cor-
ridor connecting the pavilions. The kitchen should
be fitted up with adequate means of cooking rapidly
and economically ; the cooking apparatus should be
adapted to cook a variety of food, and to secure the
greatest digestibility and economy in the nutritive
value of food : these are matters essential to recovery.
The hospital laundry should be detached from the
hospital. Special care should be taken to make the
buildings airy and very light, with ample means of
ventilation for removing the steam, which is heavily
CONSTRUCTION OF HOSPITALS. 43
charged with organic impurity, and with ample space
for the washers. They should have separate drying
and ironing rooms.
4. Those hospitals which afford outdoor relief
require a dispensary for outdoor sick. This is in
reality a separate establishment, and should always
have an entrance separate from the hospital ; indeed
it might be detached except for the convenience of
the medical men, and in order to have one drug store
and one place for making up medicines. The extent
of dispensary accommodation must depend entirely
upon the local circumstances, and upon the extent
and nature of the population to be accommodated.
The position and general construction of the admi-
nistrative buildings should be made quite subservient
to the accommodation for the sick, and to the broad
general principle that they should not interfere
with the circulation of the air round, or the light of
the wards.
In order to ensure cleanliness and absence of smell,
which are such material points in a hospital, it is
essential that all these places, as well as all receptacles
for brushes or pails, or for foul linen, should have
ample windows opening direct to the open air, and
be also ventilated by shafts carried up to above the
roof of the building. I do not think that this point
can be enforced too strongly upon the architect of a
hospital. There should be no dark corners. Light
means cleanliness.
4+ CONSTRUCTION OF HOSPITALS.
5. Economical Considerations affecting Hospital
Construction.
There remain to be said a few words on economy.
I have shown how the size of wards may depend, to
a great extent, upon economical considerations ; that
is to say, that if each ward is made to contain the
largest number of patients which one head-nurse can
effectually supervise, the number of nurses to be main-
tained will be reduced to a minimum, whilst if the
patients be divided amongst several small wards, the
number of nurses must be increased. The ward
ofhces for a small ward of say twenty beds will
nearly suffice for a much larger one. Therefore large
wards are more economical than small ones, both
in first construction and in current maintenance.
Again, if the ward walls are formed of an im-
pervious polished material, which will allow of being
cleaned by simple washing, and the floors are also
impervious, the wards can be kept almost constantly
full ; whereas a ward with plastered walls must be
periodically emptied to allow of their being scraped
and cleaned ; and hence a hospital with the cheaper
form of wall-surface in the wards requires more wards
to accommodate annually the same number of patients.
It is the same with the water supply, and the provi-
sion of other appliances for saving trouble to the
attendants. The outlay for these things saves current
expenditure by diminishing the number of attendants.
CONSTRUCTION OF HOSPITALS. 45
Again, the form of fireplaces or of cooking apparatus
is very important, in order that economy of fuel,
which also means saving of labour, may be obtained.
In deciding upon the first outlay these matters
should be carefully weighed. Where a hospital is
likely to be fully occupied at all times, it may be the
truest economy to make it thoroughly complete with
all labour-saving appliances, so that the current ex-
penditure may be as small as possible.
The wards and ward offices form barely half the
hospital. The administrative arrangements take up
as much space again. Thus in a hospital for about
120 beds, I find that whilst there were allotted to the
patients in the wards 1,200 cubic feet per bed, the
cubic contents of the whole hospital amounted to
nearly 2,800 cubic feet per bed.
Whilst it may be real economy to adopt somewhat
expensive materials and other appliances in the wards,
the same expense is quite unnecessary in the subsidiary
accommodation, and thus saving may be effected.
6. Application of Principles to existing
Hospitals.
Before considering how these principles have been
applied in modern hospitals, I would point out one
or two cases of hospitals where they have been
eminently disregarded.
For instance, in King's College Hospital, situated
in a very dense population, the wards are built round
46
CONSTRUCTION OF HOSPITALS
narrow courts, in a manner to preclude the free cir-
culation of air ; and instead of having windows to the
open air on each side, the wards are placed back to
Fig. 2. — king's college hospital, LONDON.
back, and the wards on one side have openings into
each other, instead of into the open air.
1 m ■ g-
-H fl
Fig 3. — WARDS AND WARD OFFICES AT THE ROYAL VICTORIA HOSPITAL, NETLEY.
A. Water-Closets and Ablution Rooms ; B. Wards ; C. Corridor ; D. Nurses.
In the Netley Hospital, the south side of the hos-
pital is covered by a corridor which cuts off the fresh
CONSTRUCTION OF HOSPITALS. 47
air from the wards on one side, and the circulation of
air is impeded on the other side, where the ward
windows open, by projections for the water-closets,
&c. The nurses' rooms open only into the corridor,
and the ward offices are not properly cut off from
the wards.
Again, in Queen Charlotte's Lying-in Hospital, the
/ building is an oblong, divided by a central passage,
I from which the wards open out on each side ; the
f central wards have windows on one side only, and the
i impure air of the wards is liable to pass into the cor-
I ridors and staircases, and permeate between the wards.
In the pavilion system this is an impossibility. The
impurities of each ward are cut off from the other
wards, and each pavilion becomes a separate hospital,
in which the number of sick under one roof may be
limited to any desired extent.
At the same time it must be borne in mind that
the complement to the Pavilion system of the sepa-
ration of the sick, is that the pavilions should be
so arranged as to ensure circulation of air between
the pavilions ; if they are placed close together, and
stagnant gloomy courts formed between them, they
will not form proper hospitals for the recovery of
the sick.
As an instance of defective pavilion construction I
would adduce the Marine Hospital at Woolwich, in
which the pavilions project from a central corridor,
many of them on the north side. The wards are
48
CONSTRUCTION OF HOSPITALS.
on three floors ; the building containing the central
corridor is carried up to the same height as the
pavilions ; the distance between the pavilions is not
twice the height of the pavilions ; consequently a
gloomy hospital, without free circulation of air, and
without the possibility of sunshine entering some of
the wards, is the result.
A very important merit of the pavilion system is that
it lends, itself to almost any site. In its simplest form it
would consist of one ward unit as above described, with
a small ward and the necessary additions for adminis-
tration. Such a hospital on one floor could accommo-
date from thirty to thirty-four patients. The ordinary
regimental hospital for the army consists of two ward
c
D
b
■CQ^^^GP
2
Fig. 4. — MILITARY REGIMENTAL HOSPITAL.
A A. Wards ; B B. Administrative Department.
units or pavilions, united by the administrative offices,
and with smaller wards carried out at right angles to
the main line of building. The kitchen is placed
behind and outside the building, separated by a
covered corridor, with open sides. In order to ensure
through light and ventilation to the centre of the
building, the front of the administrative portion is
CONSTRUCTION OF HOSPITALS. 49
retired behind the small wards, and there are three
glazed arches in the centre, one of which is the door
giving entrance to the hospital. In some cases these
hospitals have wards on two floors, and contain 136
beds.
Very good examples of this comparatively simple
form of pavilion hospital are also the Royal Hants
County Hospital at Winchester, and the Buckingham-
shire County Hospital at Aylesbury. A good illus-
tration of the adaptability of the system to any site is
Fig. 5. — GENERAL PLAN OF SWANSEA NEW HOSPITAL.
A. Administration ; B. Men's Wards ; C. Women's Wards and Out-patients;
D. Operating Room and Eye Ward.
afforded by the new hospital for 100 beds at Swansea,
now in course of erection by Mr. Graham, architect.
In this case the site is triangular, and the adminis-
trative block, operating theatre, &c., are placed at the
apex of the triangle, which faces the prevailing wind,
whilst the pavilions run down each side ; and both
sides of the wards receive sunlight and air.
I wish to call especial attention to this hospital,
because it appears to me to embody most fully all the
E
50
CONSTRUCTION OF HOSPITALS.
sanitary requirements I have enumerated, with great
simphcity of form.
The hospital will accommodate 66 males, 32 females,
and 2 eye-cases. The dispensary is designed to meet
the requirements of a population of about 50,000, for
the most part artisans and labourers. The provision
for the nursing staff is ample : besides the three head
nurses, accommodation is provided for nine day nurses
and three night nurses. The floor space per bed is
100 feet; the cubic space 1,600 feet.
When larger hospitals are required, necessitating
the adoption of several pavilions, they require in this
climate to be united by a corridor. In hospitals of
more than one storey high, this corridor should not
extend above the ground-floor, consequently each
Pavilion must have its own staircase. In the Lari-
Fig. 6. — GENERAL PLAN OF THE LARIBOISiSrE HOSPITAL, PARIS.
A A, Administration ; B B, Wards for Patients ; C, Courtyard.
boisiere Hospital at Paris, the pavilions are parallel,
and there are ten of them, of which five arc on one
CONSTRUCTION OF HOSPITALS. 51
side and five on the other side of a court, surrounded
by an open arched corridor. The four outside pavi-
lions are devoted to administrative purposes. The
court is closed at the ends by buildings also connected
with the administration, the chapel, and the baths.
There are three pavilions on each side for the sick ;
they have three floors of wards, to which access is
given in each pavilion from the corridor by means of
an easy staircase. The wards have no end windows,
and the ward offices are not sufficiently cut off" from
the wards. The pavilions are only 64 feet apart,
whilst the walls are 54 feet high.
The new hospital at Leeds is somewhat on the
same plan, but the central court is narrower, and the
pavilions, three in number, on one side of the central
court, and two on the other, are solely occupied by
the sick. They each contain two floors of wards.
The hospital accommodates 350 patients. The
administrative accommodation, including a dispensary
for outdoor patients, is placed in the basement, above
which the sick-wards rise. This is one of the newest
of modern hospitals, and was built by Mr. Gilbert
Scott. No expense has been spared in its construc-
tion. The corridors connecting the pavilions have a
terrace roof raised above the level of the floor of the
upper wards, and a glass roof which rises almost as
high as the roofs of the upper wards has been placed
over the central court. This tends to prevent the
free circulation of air in the central court and adjacent
E 2
52
CONSTRUCTION OF HOSPITALS.
corridor, and the height of this roof and of the terrace
FTio.fp53alCIO_
Fig. 7. — GENERAL PLAN OF NEW HOSPITAL AT LEEDS.
I I, Wards for Patients ; A A, Administration; C, Courtyard.
above the corridor may somewhat stagnate the air in
the courts between the northern pavilions.
In the Vincennes Hospital there are four pavilions
joined by twos together to a central staircase. These
pairs of pavilions so united are parallel to each other,
and each pair forms one side of a square, the upper
end of which is closed by a block of building for
administrative purposes, including kitchen and other
appurtenances. There are four floors of wards, which
are certainly too many, and there are no lifts ; con-
sequently the administration of the hospital is
laborious.
CONSTRUCTION OF HOSPITALS.
53
The Herbert Hospital affords another illustration
of the method of uniting pavilions in twos, end to end ;
but in this case the staircases are, as it were, strung
on to the corridor, which is purposely kept low
between the double pavilions, so as to allow the
sunshine to reach the space between the pavilions on
the north of the corridor. In the centre the pavilions
ADMINISTRATION
SCALE
rig. 8. — GENERAL FLAN OK HERBERT HOSPITAL, WOOLWICH.
are single, and placed on the south side of the corridor,
and the central space on the north side is occupied by
the administrative offices. The principal part of the
service of the hospital is carried on in a basement
passage, so as to avoid interference with the ward
floors. This arrangement, whilst strictly adhering to
sanitary principles, reduces to a minimum the distance
54
CONSTRUCTION OF HOSPITALS.
to be traversed in proceeding from the central part to
every other part of the hospital.
Pig^ g — SKETCH OF THE ENDS OF THE SOUTHERN PAVILIONS OF THE HERBERT
HOSPITAL, SHOWING THE ELEVATION OF THE CENTRAL CORRIDOR.
Cost of some existing Hospitals.
The Leeds Hospital accommodates 350 patients,
and cost 197/. per bed. The Herbert Hospital accom-
modates 650 patients, and cost 320/. per bed ; but of
this expense at least 150/. per bed was due to the
peculiar site, which necessitated at one end an exten-
sive removal of earth to obtain a platform, and at
the other the construction of an expensive basement,
so as to place the wards on a level.
The Royal Hants County Hospital cost, exclusive
of the chapel, land, and incidental expenses, 229/. per
bed. This amount includes accommodation for out-
patients, and provides 108 beds.
The actual cost of the Swansea Hospital, including
the out-patients' department, was 142/. per bed, but
the space occupied by the dispensary and out-patients'
department is equivalent to thirty beds, so that if the
hospital were for in-patients only, the cost would be
109/. lOi-. per bed. It is quite certain that, with care
COiXSTRUCTION OF HOSPITALS. 55
and attention to economy in the design, there is no
reason why a hospital for in-patients only on a
favourable site should exceed from 90/. to 120/. per
bed.
Conclusion.
I am unable, in an address limited for time as this
one necessarily is, to do more than glance at the
general principles of hospital construction, but I must
point out that it is in their detailed application that
so many errors are committed.
The architect should make his whole desi^rn sub-
servient to these principles ; he should be permeated
by them ; his watchwords should be — light, air, speedy
removal of refuse, and great facility of cleansing.
The smallest number of parts compatible with the
requirements of the hospital should be arranged in the
simplest form, and solely with reference to the wants
of the patients, and to the way in which the service can
be carried on with the smallest number of attendants.
The architecture should be an expression of the
need, and nothing more. Any sacrifice of sanitary
requirements to architectural features is wrong ; it
adds uselessly to the cost. Ornament means too
frequently the creation of corners and projections,
which delay and stagnate the air, and form receptacles
for dirt ; it means present outlay and continual cost,
in repairs.
While so much suffering remains unprovided for in
4 ;,.-.?.< ^ ■■■, ^>,^»-^v-v--< f/'C'":
56 CONSTRUCTION OF HOSPITALS.
the world, it is melancholy to see a large portion of
the money which has been gathered with so much
difficulty for the relief of that suffering diverted from
its main object, in order to create a monument of the
architect's taste.
I would add one more caution. Do not build for a
long futurity. Buildings used for the reception of
sick become permeated with organic impurities, and it
is a real sanitary advantage that they should be pulled
down and entirely rebuilt on a fresh site periodically.
I trust I have not trespassed too much on your
time. The hospital is the handmaid of the physician.
If he is to cure disease, he must place the patient in
conditions to enable Nature to do her part, not in
conditions which would thwart both nature and all
the art which the physician can bring to bear.
These conditions it is the part of the medical man
to lay down. My part has been to endeavour to
show how the architect must shape his building so
that it shall be in accordance with what the physician
has declared to be necessary.
To the world in general the question I have dis-
cussed is technical and dry, but to you, w^hose daily
life is spent in efforts to allay the sufferings of your
fellow-creatures, it is fraught with deep interest ; and
my only regret in coming before you to-day is that
you have not had a more efficient exponent of this
important subject.
DISCUSSION.
Dr. Evory Kennedy (of Dublin), in opening the
discussion, said that he was extremely gratified with
Captain Galton's most instructive and comprehensive
paper, and that he could not conceive the question
discussed in it put more fairly and practically. Ven-
tilation had hitherto occupied our attention as the
great question in connexion with our hospitals, and a
great question it ought to be. The necessity that
existed in hospitals for special arrangements and
provisions to secure the exhaustion and re-supply of
air throughout the wards and passages could not be
overrated, and every improvement such as is so well
insisted upon in Captain Galton's paper should be
adopted to carry out these objects, and especially the
primary one of exhausting the chambers and passages.
When this was effectually accomplished, the re- supply
of pure air followed as a matter of course. But even
admitting that all the most approved appliances were
rendered available ; with this object he agreed fully
with Captain Galton that they would be well sup-
plemented by the presence of the ordinary chimneys.
58 DISCUSSION.
and that additional advantage would be derived
from them, no matter what other plan for ventilating
was adopted. Dr. Kennedy regretted, however,
Captain Galton having sanctioned by his authority
the construction of Pavilion Hospitals on the principle
adopted at Leeds, St. Thomas's, and elsewhere, pro-
vided an interspace of only double the height of the
building was given. The proximity of the blocks, ad-
mitted to be a defect in the Lariboisiere Hospital in
Paris, was corrected to a certain extent in St. Thomas's,
where Mr. Curry allowed an interspace of 125 feet
between the blocks generally, and of 200 feet in the
centre court ; but in all these neAv structures Dr.
Kennedy thought a' principle of extreme importance
had been lost sight of as a means of securing the
exhaustion and change in the stagnating air of the
hospital wards, namely, the influence of the external
atmospheric currents; parallel blocks necessarily hold-
ing a mass of stagnated air between them, and thus
intercepting and precluding the operation of the
currents. It was attention to this important matter
that, in his mind, rendered the Swansea Hospital with
its divaricating blocks of pavilions much preferable ;
and hospitals conducted on this plan, especially where
the approximating ends of the blocks are, as far as
practicable, detached from one another, so as to
permit of a free transmission of currents throughout
the whole line of each block, must necessarily prove
more healthy. Although at the Leeds and St.
DISCUSSION. 59
Thomas's Hospitals it is now too late to correct this
grave defect, there are defects, particularly in the
construction of the former, quite remediable, and
which Dr. Kennedy did not doubt the managers
would rectify on the first attack of er}^sipelas, pyaemia,
or hospital gangrene with which they may be visited.
He alluded to the closed corridors and the magnificent
glass-covered court or winter garden in the centre of
the building, and to which access existed from all
the wards under cover. The simple removal of the
windows in the corridors would do much for purify-
ing the atmosphere of the hospital, and securing
currents in the present stagnating mass of air that
necessarily pervades the wards. But the massing all
the wards of the hospital into a common atmospheric
mass, having every part of it loaded with every
miasm or poison that may originate in any part of
the building, is so palpable a mistake, that when once
zymotic disease shows itself, the glass roof must be
removed, the corridors opened by the removal of the
Avindows at least ; and thus an approximation to that
isolation that ought to have been kept in view in the
original structure, and which has been thus marred,
may be established. Dr. Kennedy thought, however,
it would be a great pity that the winter garden should
be lost to the patients; its advantages might be con-
tinued to them by removing it to a vacant piece
of ground which, he understood, belonged to the
managers, close to the hospital, and connecting the
6o DISCUSSION.
two by a covered way. He remarked that another
and not less important subject to which Captain
Galton had called attention, and with his observations
on which he (Dr. Kennedy) had been much struck,
was that conveyed in the latter part of Captain
Galton's paper, upon the existence in hospitals of
organic impurities, and the necessity of their removal
and future prevention. His observations upon the
use of Parian cement upon the walls and ceilings, as
well as the objections urged to angles and corners,
were valuable. None of these hints should be lost
sight of in our new structures, and even ought to be
applied, when practicable, in correcting the defects of
our old buildings. We were still in our infancy in
our investigation of those laws which bear upon
hospitalism, and yet the Jews were familiar with
some of those practical influences that were only now
opening upon us. He referred to what is said in
Leviticus xiv. 39 — 45, upon the Jews cleansing the
walls of their houses infected with lej^rosy by scrap-
ing and purification, and, if necessary, removing alto-
gether out of their cities the materials of their stone
houses. There existed, no doubt, a miasmatic atom
or germ which, although so minute and impalpable as
to escape our detection as yet, and which ventilation
cannot reach, yet adheres to the walls, charges the
atmosphere, and even permeates the solid structure
of a hospital. This poison it is that constitutes hos-
pitals, as is seen, the habitat or residence of certain
DISCUSSION. 6 1
zymotic diseases, some of which, as metria, pyaemia,
and hospital gangrene, are rarely seen out of them.
It works often for a considerable time latent, until the
law of cumulation develops it into a more active or
poisonous state ; and eventually a state of complete
saturation is arrived at. The poison or miasm is
now so confirmed that the disease which was in the
first instance perhaps due to self-poisoning or spo-
radic laws, or may have been contracted secondarily,
becomes now a hospital disease or pure endemic.
When this is the case, the disease spreads and actually
destroys from a susceptible person being simply ex-
posed to the atmospheric or endemic poison that
pervades the hospital ; and patients who resort to
these institutions for the cure of minor and curable
ailments are struck down with a disease very de-
structive, nay generally fatal, in its character. In con-
clusion. Dr. Kennedy added that great obscurity had
hitherto enveloped the inquiry into these hospital
diseases ; however, public attention had now been
called to them, and when it became generally known
that the three principles he had insisted upon, and
had elsewhere fully treated of under the terms habitat,
awnilation, and satia-ation, were actually in daily
operation in many of the great hospitals throughout
Europe, and that a large proportion of our hospital
mortality is due to the defects in the constniction of
these buildings into which we invite the sick to resort ;
when these facts became generally knoiun, the first
62 DISCUSSION.
step, in his opinion, had really been taken towards
the correction of a gigantic evil. In short, he had no
doubt but that effectual means would be forthwith
taken by all concerned to lessen an unavoidable
mortality, now that the removal of its chief cause was
shown to be within our own control.
Mr. Jonathan Hutchinson (London) had been
connected with four hospitals, and for some years he
had taken great interest in this question. The four
hospitals with which he had been connected repre-
sented different management, and were built on
different plans. One with which he had been con-
nected for six years was badly managed as regarded
accommodation, but the most successful as regarded
treatment. He differed a little from some of the
principles at present in vogue as to hospital construc-
tion and hospital dangers ; but he would state his
own great appreciation of the able and very excellent
paper which Captain Galton had read, and he would
also refer with admiration to the zeal and energy of
Sir James Simpson in carrying on his work. But he
could not help feeling exceeding doubt as to a move-
ment which had taken so strong a hold upon the
public mind. He felt that the notion was wrong that
hospital efficiency was increased by increasing venti-
lation. In his opinion it was not the quantity of air,
but the freedom from the germs of organic disease,
which should be the chief desideratum. Just as the
DISCUSSIO.Y. 63
physician dealt with the germs of contagious disease,
so the surgeon should be prepared to deal with
septicaemia, erysipelas, and hospital gangrene. If
he had time, he could give strong evidence that
these diseases spread by contagion, and would spread
in hospitals, but would stop if the cases were sepa-
rated. Fresh air only diluted the germ — it did not
get rid of it. This led to a very important question
as to how hospitals might be built ; and he thought
he could rightly say that nine-tenths of the cases
admitted might be taken into any kind of hospital
and do equally well. Three-fourths of the surgery
cases were simple fractures, and in cases in which
there was no risk of contamination. Extra pre-
cautions had to be used in a small minority of the
cases ; and there need not be that large expenditure
as to many of them which was entailed under
ordinary circumstances ; but when there were huts
to resort to, he found there was no special risk of
contagious disease. Then, as regarded ventilation, he
really could not see, from experience, that increase
of ventilation materially diminished the risk. He
believed that in some ways it increased it. He did
not believe that hospital gangrene was influenced
by ventilation. If in hospitals there were one ward
which had no communication with others, there would
be no case of hospital gangrene. Such was the result
of the evidence afforded in the London Hospital,
with which he was connected. Their experience of
64 DISCUSSION.
epidemics was that, though they had none for six or
seven years, at last there was a violent outbreak. He
appealed to every hospital surgeon whether it was
not the testimony of nurses and patients alike that
too great ventilation acted injuriously, and was
fraught with danger. Nurses said that, if they had
the chance, patients would shut the windows. He
(Mr. Hutchinson) coincided with that prejudice of the
patients, and was not astonished that there were so
many cases of bronchitis contracted by patients when
lying in bed, because of the draughts from the open
windows blowing right down upon them. Then there
was an interesting suggestion which might modify
their future belief as to the causes of mortality in
hospitals. All the while that they were studying the
ventilation of hospitals, they were using numerous
specific agents for disinfection. Take the palatial
institution built in Leeds — a finer institution as re-
garded comfort he riever had the opportunity of
seeing. But he should look with great interest at the
statistics of the next ten years as compared v/ith the
statistics of the last ten years of the old and badly-
ventilated building which had just been abandoned.
It was possible that in the future there might be a
great diminution in the number of cases of septicaemia
and erysii3elas ; but he thought it could not be seen
that any great improvement had been made in the
isolation of contagious diseases. He had himself seen
some small wards used for that purpose. The con-
DISCUSSION. 6s
trast between the next ten years and the past might
be fallacious. Some might say it was due to ven-
tilation, while all the while it might be owing to the
employment of carbolic acid. Carbolic acid might
possess a virtue which a circulation of air did not ;
and it was one of the most important points, whether
the vapour given off from carbolic acid could or could
not destroy the germs of specific disease. If it could,
it would save a great deal of cost.
Sir James Simpson was not opposed to hospitals,
but he was against hospitals as at present con-
structed ; and he thought they required very great
reform. Most gentlemen in the room knew the test
which had been applied by various writers latterly in
reference to the mortality in the hospitals — viz. taking
the results of the major amputations of the limbs,
— that is, of the thigh, the leg, and arm and forearm —
as a test of the healthiness of the different insti-
tutions. He had had now upwards of 6,000 cases of
limb-amputation reported to him, the results of a
portion of which were published, but others were not
yet completed. Of these results he had only calcu-
lated some lately. Captain Galton had not alluded
to the size of hospitals, but that seemed to be a
matter of very great moment. In the large Parisian
hospitals, one man out of every one and a half died
when the limbs were amputated — three out of every
five — a terrible mortality. When they came to
F
66 DISCUSSION.
Britain, they found that in the hospitals that had
more than 300 beds the ratio was not so great as
one in one and a half, but still the mortality was
frightful ; it was one in two and a half He had
obtained the statistics of about 2,000 patients in
provincial hospitals ; and there he found that of
hospitals that contained less than 300 beds and down
to 1 50, the mortality was one in four, greatly less
than in London. When they came down to hospitals
with from 150 to 25 beds, the mortality was about
one in five or five and a half ; and when they came
to cottage hospitals, the mortality was only one in
seven. But further, in country practice, when the
patients were isolated and each placed in a separate
room, the mortality in the four limb-amputations
w^as, amongst practitioners in general, only about
one in nine ; and where the country surgeon was
in the habit of operating, it was found that the
mortality diminished to one in twelve. Patients in
the country were treated in their own dwellings or
isolated rooms, and the question was, seeing that
the patients recovered in a proportion so immensely
greater in poor cottages than in rich hospitals,
should not our great hospitals be changed from
palaces into villages^ from mansions into cottages .?
An architect could construct for the purpose a
splendid village as well as a splendid palace. Or,
for humanity's sake, shall we — if this reform is
totally resisted — be driven to yet another alternative.
DISCUSSION. 67
viz. instead of having operative cases sent from the
country into city hospitals, why should not the
patients in our city hospitals requiring any serious
operation be sent, for their own sakes, into the
country village and cottage, to be submitted there
to the surgeon's knife ? The day before he left
Edinburgh he had received a letter from a gentle-
man who was one of the grandest specimens he
ever knew of an accomplished country doctor. He
alluded to Dr. Dewar, sen., who formerly practised
at Dunfermline, and was beloved and respected by
all. This practitioner, though living within fifteen
miles of Edinburgh, had never sent a case to any
infirmary ; and, although he could not state defi-
nitely the number that came under his care, he
was certain they exceeded fifty ; perhaps, in all,
they amounted to fifty-three. Of these fifty all re-
covered except one, and that also would have
recovered but for removal on the ninth day. Sup-
posing these fifty cases had been sent to the nearest
large hospital, instead of one death there would have
been twenty, taking the usual average of deaths
from limb-amputation in such institutions. He was
inclined to think that a building of one storey was pro-
bably the best plan for hospitals ; and that, in time, all
would come to that opinion. He noticed the results
of the Commission appointed to inquire into the
health of barracks ; and which held that all stables
for Her Majesty's cavalry should henceforth be
F 2
68 DTSCUSSrON.
built of a single storey, with no sleeping-places and
residences for men overhead. They unanimously
came to this conclusion, after due examination,
because they found such stables were the healthiest
and safest for the horses, and horses cost some 30/.
apiece. But what in this respect is healthiest and
safest for the horse is no doubt the same for the
sick man. Then, commenting on the construction
of the Leeds Hospital, he stated that probably the
roof in the central garden would yet require to be
removed, and that the windows in the corridors
should be taken out in order to effect proper venti-
lation. He also observed that if they would take
the windows out of the enormous staircase in King's
College, and let the air pass in freely, it would
probably make it a far more healthy hospital. In
a conversation with the matron at the Leeds Hos-
pital, he found that she had been at St. Thomas's
Hospital, London, and she told him that they only
sent to the iron cottage hospital, which existed in
the grounds there, " extreme cases " which were not
likely to recover elsewhere. But if, he urged,
'.' extreme cases " were sent for recovery to this
cottage hospital, why should other cases be denied
the same benefit, and the hospital be made entirely
of cottages .? Captain Galton had spoken of putting
up barracks for treatment. In Germany, that was
done at this hour ; and the benefit of such hos-
pitals had been felt during the late war between
D/SCUSSJOA\ 69
Prussia and Austria. He did not say the palaces
should be giv^en up, but he thought they ultimately
would, and, in the meantime, a great revolution
should probably be made in them. For, modifying
their present hospitals, it might be thought worthy
of consideration that they should adopt Sir Sydney
Waterlovv's plan in regard to dwellings far the arti-
sans of London ; namely, that they should divide
each flat so that it does not communicate with
another flat except by a staircase perfectly open to
the external air — and that each flat or landing has
for itself a separate open balcony from which the
tenements on that flat separately enter. Perhaps
by building up all those doors in the wards of our
present mansioned hospitals which open upon the
staircases, and by using the staircases only as means
of reaching external balconies to each flat or ward,
much could be done to isolate entirely the indi-
vidual wards, making each of them self-ventilated,
and preventing the air from them all commixing
in the common staircases and corridors, and re-
entering Avards in more or less of this foul state.
We might thus perhaps change a large mansioned
hospital into a series of cottage wards — perfectly
separate in their ventilation from each other. The
matters expired and exhaled, and the discharges
from patients and their wounds, did not only aff'ect
more or less the patients in the same ward — and
hence the p:reat advantages of isolation — but even
70 DISCUSSION.
those in other wards which it could reach by
common staircases and corridors. Dr. Rumsey had
just informed him, for example, of the foetid effluvia
arising from a hepatic abscess being smelled, when
the abscess was opened, by patients placed in wards
at a very great distance along the corridor in the
hospital at Netley. Other exhalations and effluvia
— though not thus traceable by their foetidity —
passed doubtlessly from ward to ward, and affected
more or less diseased human beings when they
were aggregated together. The time, often minutes,
properly allotted to each speaker, prevented him
discussing Avhat he had long ago written upon, viz.
the probable diffusion by contagion, alluded to by
Mr. Hutchinson, of some forms of surgical fever or
pyaemia ; just as some forms of puerperal fever
spread by inoculation and contact ; but in reference
to Mr. Hutchinson's remark, that the use of carbolic
acid might possibly prevent this mischance, and
reduce the danger of operations, he would beg to
state that in the great hospitals of Glasgow and
Edinburgh the mortality from amputations, as shown
by their statistics, had not decreased, but the
reverse, since carbolic acid began to be used, and
the number of deaths from compound fractures was
increased, and not diminished.
Dr. Rumsey (Cheltenham) said he rose to state a
little more in detail a fact to which Sir James Simp-
DISCUSSION. 7 1
son had alluded. Two or three months ago he went
over the magnificent hospital at Netley, and was at
once struck with its grand defect — namely, that all
the wards were erected parallel and in close juxta-
position, so that there was no possibility of thorough
ventilation, except by means of the long corridor
into which they all opened. As showing the defect
of the corridor system, he was informed by one of
the professors that, in a case of hepatic abscess, which
contained highly foetid pus, and had been opened
in a ward at the extreme end of the corridor, the
first announcement that the horrible smell was per-
ceived in the hospital was made, loudly enough, from
a ward at the other end of the corridor, a third of a
mile distant, showing that the putrid air had been
carried by the corridor to that distance. He thought
a stronger condemnation of the corridor plan, and
of the side-by-side construction of wards, to which
the corridor gave access, could not be brought for-
ward. It was a most important element in the
construction of pavilion hospitals that the pavilions,
instead of being parallel, should diverge, as was the
case at Swansea. He wished that Dr. Oppert were
here present, for that gentleman could have described
to them the construction of the Alexandrow Hospital
at St. Petersburg, — the pavilion wards of which
spring from a polygonal corridor, and diverge very
widely from alternate facets of the polygon, at a
greater angle than those at Swansea, and therefore
72 DISCUSSION.
allow of a much freer circulation of air between the
pavilions.
Dr. Stewart (London) said he had been at
Netley, and found that, owing to the frequent pre-
valence of cold blustering weather, the windows for
the most part were kept closed. Ventilation had
been found almost impossible, owing to the high
winds which frequently prevail. Having gone re-
peatedly over the wards, he had asked the attendants
how they managed to keep them in a healthy state.
They replied that they did the best they could, but
it was a matter of difficulty. It had been pointed
out to the Commission entrusted with the con-
struction of Netley Hospital, that the corridor was
utterly offensive, and that it would be impossible to
keep any effluvia from permeating the whole of the
wards. Some alterations in the plan were made,
but the worst objection was carried through. A
motion was brought forward by Mr. Sidney Herbert
in reference to this hospital, recommending that it
should be given up altogether. Unfortunatel}^ the
question of construction was mixed up with that of
the site, which was a good one ; and those in favour
of the construction, by showing what an admirable site
it was, managed to gain the attention of the House
of Commons, and succeeded in turning the building
into a hospital after all. They represented that it
was not intended to be properly a hospital, but only
DISCUSSION. 73
a convalescent home; but, when the hospital came
into use, so many large parties of soldiers constantly
coming home were sent to it, that the hospital was
generally very full. He might mention that the
corridor was a close one.
Dr. Hughes Bennett (Edinburgh) said that he
feared he belonged to that comparatively small
section of the profession that desired to base its
knowledge on the sure foundation of unquestionable
truth, rather than upon vague opinion and fallacious
assumption. We were constantly hearing all kinds
of hypotheses advanced, unsupported by the slightest
research or proof. Hence his anxiety for the appoint-
ment of committees, with grants of money, which
would enable them to settle positively doubtful points
in medicine. What they had just heard, and what
they were constantly hearing, as to the construction
of hospitals, was a good illustration of professional
discussions. The cause of epidemics and endemics,
it must be admitted, was as yet unknown, and con-
stituted one of the most difficult investigations it was
possible to enter upon ; yet the most contradictory
opinions regarding it were now brought forward, in
order to influence the structure of hospitals. The
medical department of the Royal Infirmary of Edin-
burgh, of which he was a physician, was one of the
best ever planned ; and, so far as he knew, no epi-
demic had ever originated in it. It was a model
74 DISCUSSION.
hospital ; but it was now so old that its walls could
no longer stand, and they were about to replace it by
a new one. Those walls, however, were as capable of
absorbing organic germs and miasmata as those of
any similar institution ; yet no harm had resulted.
For a long time it was maintained that free ventila-
tion was the best remedy for preventing the spread
of disease in hospitals; but they had just heard a
speaker maintain that ventilation was more injurious
than beneficial, and that the constant open windows
produced worse maladies than those which it was
intended in this way to remove. While opposed,
however, to the theory of free ventilation, he adopted
the revived and fashionable hypothesis of " organic
germs," and their destructibility by means of carbolic
acid. But had any one seen these germs ? or had
they any existence except in the imagination .-' Our
modern microscopes enabled us to examine particles
much more minute than the smallest vegetable spores
or animal ova. Surely, then, those who attributed to
germs the origin of numerous diseases, and sought to
modify the construction of hospitals because of their
influence, should at least take some pains to find
them and show them to others. No one, however,
had done this. There was no proof whatever that
such germs had any reality ; and yet here was a large
body of scientific and medical men considering how
to build hospitals, and probably waste thousands of
pounds in order to prevent the evils of such imaginary
DISCUSSION. 75
existences. Then statistics were had recourse to, on
which to form conclusions ; and these also were too
frequently only assumptions. Sir J. Simpson had
adopted deaths from amputations as a test of hos-
pital mortality. Without impugning the facts brought
forward, should we consider the test a good one .-'
He (Dr. Bennett) thought not. Other causes influ-
enced the results of amputations, besides the badness
of hospitals. The inhabitants of large towns, for
example, such as Manchester and Leeds, were more
liable to sink under the shock of such operations, than
the robust labourers in the country. As an example
of the assertions so constantly advanced instead of
proof, he might refer to the statement that a country
practitioner had had fifty amputations with only one
death. But they had also been told that that prac-
titioner had lost his notes ; and, if so, little confidence
ought to be placed in such an assertion, when the
point to be ascertained was the ratio of the dead to
the sur\'ivors. Medical men were very apt, from
memory, to exaggerate the number of their successful
cases. What was required were carefully-taken records
to determine with exactitude the nature of the case
and the results of treatment. He therefore considered
it advisable, in all medical investigations, to abolish
such vague generalities, and in future seek to advance
medical knowledge and practice on the indisputable
grounds that scientific investigation alone could
furnish.
76 DISCUSSION.
Dr. George H. B, Macleod (Glasgow) said he
would not have ventured to address the meeting but
for the remark that had been made by Sir James
Simpson regarding the high mortality attending
operations in the hospital to which he was surgeon.
The Infirmary of Glasgow was placed in the midst
of a very dense population, in the oldest part of the
town, and part of the house was old and not well
constructed. The cases admitted into the wards
were often very severe — in fact, as severe as it was
possible to conceive. He had been connected more
or less closely with the institution since the outset
of his professional life, and he w^as convinced that
since carbolic acid had come to be used in the treat-
ment of the surgical cases much good had been
done. He had no theory and no prejudice whatever
regarding carbolic acid, and only desired to discover
the principle on which its action depended, and to
learn the truth regarding its value ; and he could
certainly assert that its employment in the manage-
ment of compound fractures had been followed by the
best results. He would have great pleasure in show-
ing Sir James Simpson cases at present in the wards
of the Glasgow Infirmary which he believed it would
have been utterly impossible to save from amputa-
tion by any method of treatment known to him
before he began to use carbolic acid dressings. As
to the mortality after amputation, he was aware of
the figures on which Sir James Simpson's assertion
DISCUSSION. 77
regarding Glasgow Infirmary was founded, but he
would remind his audience how extremely fallacious
statistics were unless very carefully collected, and
that without any eye to prove a position and without
ample explanations. Without entering into so wide
a question, he would content himself with remarking,
that admitting — which he was by no means prepared
to do — that the mortality after amputation had been
augmented in Glasgow since carbolic acid dress-
ings had been introduced, it was possible that too
much was expected of such applications, and that
limbs were tried to be saved by the use of carbolic
acid which otherwise would have been amputated
early (and so probably saved), till it was too late
for successful operation. Some remarks had been
made by Sir James Simpson with regard to a series
of fifty amputations in private practice, followed by
only one death. Unfortunately the operator had
lost his notes, and only spoke from a vague memory ;
but he (Dr. Macleod) would have the honour of
recording in the Surgical Section that day the same
results from fifty amputations at the ankle (many of
them performed in the Glasgow Infirmary), and of
which the notes were not lost. The one set might
go to balance the other. As he was speaking, he
might add a remark or two which had occurred to
him while listening to the very able paper of Captain
Galton. During the Crimean War, he (Dr. Macleod)
had ample experience of the use of both huts and
78 DISCUSSION.
tents in the treatment of sick and wounded, and he
claimed having first suggested to the Government
the construction, and submitted to them the plans,
of such v/ooden hospitals as had proved such a
success on the Dardanelles. Nothing could be more
perfect than the adaptability of such temporary struc-
tures to the use of an army. When any complication
arose, such as secondary haemorrhage, purulent infec-
tion, gangrene, &c., the removal of the patient into
tents was always followed by the best results ; but
to be healthy, both huts and tents had to be fre-
quently moved, as the very ground on which they
were erected became impregnated wnth deleterious
emanations. He was much delighted to hear that
Sir James Simpson had now come to the same con-
clusion as himself regarding the size and proper site
for hospitals, as many years ago he had read a paper
at the Social Science meeting at Glasgow, in which
he advocated small establishments in the country to
which patients might be sent for operation, and at
that time also this question of the difference of mor-
tality in town and country practice was stated by him.
Small hospitals scattered throughout a city might
provide for the immediate wants of the injured, and
so avoid the great danger of transport. A great deal
had been said about the internal arrangements of
hospitals, but he would plead for more attention to
their external surroundings. He had always thought
that a fundamental error in the establishment of
DISCUSSION. 79
hospitals was placing them in cities and among many
buildings. The larger and older a hospital became,
the worse was it adapted for its purpose. He hoped
the time would come when small buildings placed
among fields and gardens, and having all the aids to
recovery which amusements, flowers, and music could
contribute, would be the type of our hospitals, and not
the present huge piles of courts and towers crowded
into the heart of our q-reat manufacturing centres.
APPENDIX.
VENTILA TING FIRE PL A CES.
There are few details of domestic architecture of greater
importance in this country than our fireplaces, since as a
rule we are dependent on them for comfort during nearly
three-fourths of the year. Now, the design of a chimney
fire being simply to warm a room, it is necessary first of all
to contrive matters so that the room shall be actually
warmed ; secondly, that it shall be warmed with the smallest
expense of fuel possible ; and, thirdl}^, that in warming it
the air of the room be preserved perfectly pure and fit
for respiration, and free from smoke and all disagreeable
smells.
In order to take measures with certainty for warming a
room by means of an open chimney fire, it will be necessary
to consider /low or in what manner such a fire communicates
heat to a room.
In a room warmed by an ordinary fireplace the heat is
obtained from the direct radiation into the room of the heat
from the incandescent fire, and from the reflected heat from
the sides and back of the grate. Nearly seven-eighths of
the heat generated by the coal passes with the smoke up
the chimney, and carries with it out of the room a large
G
82 APPENDIX.
quantity of air, amounting, in even moderate-sized rooms,
when the chimney is heated, to as much as from 14,000
cubic feet to 20,000 cubic feet in an hour.
This air must be drawn into the room from somewhere,
and unless some arrangement is made for supplying the
room with warmed fresh air, cold air finds its way into the
room through the chinks of the windows and doors, or
wherever it can get in most easily, and thus the temperature
at the end of the room furthest from the fire is kept low,
the occupants are subjected to draughts, and, if there are
two fireplaces in the same room, one of which is not
lio-hted, the air is even frequently drawn down the vacant
chimney.
It is essential to health that the air of a room should be
renewed, and the oppressive feelings consequent upon the
use of close stoves, as in Germany, or hot-Avater pipes, as
contrasted with open fireplaces, arise from the want of a
sufficient supply of fresh air.
The experiments made by the Barrack and Hospital Im-
provement Committee, presided over by the late Lord
Herbert, showed that, for a room occupied by several per-
sons to be even moderately ventilated, it was necessary that
the quantity of air renewed should amount to at least 1,000
cubic feet per occupant per hour, and they laid down the
rule that, assuming each occupant to have 600 cubic feet
of space, the air of the room should be completely renewed
twice in an hour.
General Morin, the head of the Conservatoire des
Arts et Metiers, in Paris, who more than any man has
made ventilation his study, has laid down that the air of
an ordinary sitting-room should be renewed five times in
an hour.
The quantity of air theoretically necessary must depend
APPENDIX. 83
upon the number of occupants of a room, but the power of
the chimney as a ventilating agent is a fixed quantity, and
the number of occupants vary: hence the size of the fire-
place and chimney must be fixed with reference to the pro-
bable normal use of the room.
In a room furnished with an ordinary open fireplace,
with closed doors and windows, the circulation of air pro-
ceeds as follows : —
The air is drawn along the floor towards the grate, it is
then wanned by the radiating heat of the fire, and part is
carried up the chimney witli the smoke, whilst the re-
mainder flows upwards near the chimney-breast towards the
ceiling. It passes along the ceiling, and, as it cools in its
progress towards the opposite wall, descends to the floor, to
be again drawn towards the fireplace. It follows from this
that the best position in which to deliver the fresh warm air
required to take the place of that which has passed up the
chimney, is at some convenient point in the chimney-breast,
between the chimney-piece and the top of the room, for the
air thus falls, consequently, into the current, and mixes with
the air of the room without perceptible disturbance.
The ventilating fireplace was designed with the object of
obviating the above-named objections to the common fire-
])lace, and of providing such adequate means of ventilating
the soldiers' rooms in cold weather when the wintlows are
shut as would not be liable to be deranged.
The limit to which the heat from the fire can be so
utilized will be the point at which it cools down the chim-
ney, so as to check the draught and combustion of the fuel.
With respect to the application of the grate to existing
buildings, the recess in which an ordinary fire-grate would
be fixed forms the chamber in which the air is warmed.
In order to afford focilities for the occasional cleansing of
G 2
84 APPENDIX.
this chamber, and those parts of the air-channels connected
with it, the front of the stove is secured by screws, so that
it can be easily removed, thus rendering the air-chambers
accessible.
The stove was designed with the object of being applied
to existing chimney openings. In so applying it, the air-
chamber is to be left as large as possible, thoroughly
cleansed from old soot, and rendered clean with cement,
and lime-whited. Should the fireplace be deeper than
I ft. 6 in., which is the depth required for the curved iron
smoke-flue, then a lining of brickwork is to be built up at
the back, to reduce it to that dimension. The chimney-
bars, if too high, must be lowered to suit the height of the
stove, or to a height above the hearth of 3ft. 3 in.; they
must also be straightened, to receive the covering of the air-
chambers. These coverings should be of 3 in. York or
other flagging, cut out to receive the curved iron smoke-flue,
and also to form the bottom of the warm-air flue in the
chimney-breast. In new buildings the air-chambers may
be rectangular ; they must be 4in. narrower than the ex-
treme dimensions of the moulded frame of the stove, so as
to give a margin of 2 in. in width all round for a bedding of
hair mortar.
Mr. Edward Deane, of i, Arthur Street East, E.G., has
recently undertaken to provide and fix these ventilating fire-
places ; but they are not patented. The stove is of the best
cast-iron, and consists of three pieces, properly connected by
screws. The first piece forms the moulded projecting frame ;
the second, the body of the grate ; and the third, the nozzle
or connexion with the smoke-flue, the bottom flange of
which is bolted to the back of the grate. The stoves are
of three sizes : — The largest has an opening for fire of
rft. 9 in. wide, and was intended for rooms containing
APPENDIX. 85
from 8,000 to 12,000 cubic feet; it weighs about 3 cwt.
1 qr. 10 lbs. The second, or medium size, has an oi)en-
ing for lire i ft. 5 in. wide, and was intended for rooms
containing from 3,600 to 8,400 cubic feet ; it weighs about
2 cwt. 3 qrs. 5 lbs. The third, or smallest size, has an
opening for fire i ft. 3 in. wide, and was intended for rooms
containing 3,600 cubic feet and under; it weighs about
2 cwt. 2 qrs.
The figures appended show an elevation, section, and
plan of the second or medium-size stove, the extreme
dimensions of which are 40 inches wide by 43 inches
high; the projecting moulded frame enables the stove to
be applied to any existing chimney-opening.
The fireplace has a lining of fire-lumps in five pieces ;
two sides, one back-piece, and two bottom pieces, moulded
to the form shown in the woodcut. The bottom is partly
solid, being made of two fire-lumps placed one on each
side, and supporting an intermediate cast-iron fire-grating,
which occupies about one-third of the bottom of the grate ;
by this means, whilst the draught is checked and the con-
sumption of fuel reduced, a sufficient supply of air for com-
bustion at the bottom to secure a cheerful fire is obtained.
A clear space, half an inch deep, is formed between the
back lump and iron back to receive a supply of air through
the ash-pit under the grate, which passes through a slit in
the fire-lump immediately above the fire. The air thus
brought into contact with the heated coal is received at a
high temperature, in consequence of passing through the
heated fire-lump, and is forced into contact with the gases
from the coal by means of the piece of fire-lump which
projects over the fire at the back of the grate, and thus a
more perfect combustion of the smoke is eftected than with
an ordinary grate ; in fact, with care, almost perfect com-
86
APPENDIX.
bustion of the fuel, and consequent utilization of the heat,
can be obtained.
Fig. lO. — ELEVATION, SHOWING AIR AND
SMOKE FLUES.
Fig. 12. — SECTION OF GR.\TE.
Fig. II. — SECTION OF A ROOM SHOWING
AIR-DUCT AND FLUE.
Fig. 13. — PLAN OF GR.\TE AND AIR-CHAUCER.
I'he flame, heated gases from combustion, and such small
amount of smoke as e.\:ists, are compelled, by the form of
APPENDIX. 87
the back of the grate and the iron part of the smoke- flue,
to impinge upon a large heating surface, so as to subtract
as much heat as possible out of them before they pass into
the chimney, and the heat thus extracted is employed to
warm air taken directly from the outer air. The air is
warmed by the iron back of the stove and srnoke-flue, upon
both of which broad flanges are cast so as to obtain a large
surface of metal to give off the heat. This giving-ofF
surface (amounting in the case of No. i grate to i3'5
S(]^uare feet) is sufficient to prevent the fire in the grate
from ever rendering the back so hot as to burn the air it
is employed to heat. The fresh air, after it has been
warmed, is passed into the room near the ceiling by the
flue shown in the woodcut.
The flue which has been adopted for barracks is carried
up by the side of the smoke-flue in the chimney-breast. It
will be seen from the illustration that there is in the air-
chamber of No. I grate a heating surface for warming the
air of about 13 '5 square feet.
The mode of admitting external air into this chamber
must depend upon the locality of the fireplace. If the
fireplace be built in an external wall, the opening for fresh
air can be made in the back ; but if in an internal wall, it
will be necessary to construct a channel from the outside,
either between the flooring of the room and the ceiling
joists of the room below (if there be independent ceiling
joists), or between the floor boards and the plaster ceiling,
in the spaces between the joists, or by a tube or hollow
beam carried below the ceiling of the room altogether. In
any case, however, these horizontal ducts should contain
one superficial inch of sectional area for every 100 cubic
feet of room space ; the grating covering the opening to
the outer air need not be larger in total area than the flue,
APPENDIX.
so that the clear area through the grating would only be
about half that of the flue. If the shafts are of consider-
able length, the sectional area should be rather more ; but
if there be a direct communication with the outer air, the
sectional area should be rather less than that recommended.
There is one point connected with the flue which must be
carefully attended to — viz. the fresh air should be taken
from places where impurities cannot affect it, and the flue
must be so arranged and constructed as to aftbrd easy means
of being periodically thoroughly examined and cleaned. In
barracks the rule is that such cleansing should take place at
least once a year.
The area of the grate of No. i stove is 84 square inches,
of which 58 are solid, and 26 afford space in the centre for
the passing of air. The front is open, and air is passed on
to the coal from the back in the manner already described.
The grate will contain about 18 to 20 lbs. of coal; when
the fire is maintained for from twelve to fifteen hours, a
total consumption of about 2-5 lbs. per hour, or 40 lbs. for
sixteen hours, will suftice to maintain a good fire. For
soldiers' rooms the daily allowance in winter with No. i grate
is nearly 46 lbs. per diem ; but this is more than a careful
economy would recjuire.
In new buildings it would be possible, and indeed de-
sirable, to extend this heating surface considerably by carry-
ing up the smoke-flue inside the warm-air flue. This plan
has been adopted in the fireplaces for the wards of the
Herbert Hospital, where the fireplace is in the centre of the
ward, and the chimney consequently passes under the floor,
and is placed in the centre of the flue which brings in the
fresh air to be warmed by the fireplace : by this means a
heating surface for the fresh air, of above 36 square feet
additional to that of each fireplace, has been obtained.
APPENDIX.
89
The annexed woodcut shows these fireplaces.
Fio;. 14.
o^gsci
a. n. Fresh Air Flues,
b. b . Smoke Flue
C.C. Fire Clay Vm.l^SSSr
go APPENDIX.
The fire stands in an iron cradle fitted to the fire-clay back
and sides, and a current of air is brought through the fire-clay
at the back, where it becomes heated, on to the top of the
fire to assist the combustion, and thus prevent smoke. The
top of the stove is coved inside, to lead the smoke easily
into the chimney. Tlie main body of the stove is a mass
of fire-clay, with flues cast in it, up which the fresh air
passes from the horizontal air-flue already mentioned, in
which the chimney-flue is laid. Thus all the parts of the
stove employed to warm the fresh air with which the fire
has direct contact, are of fire-clay.
The area of the horizontal chimney-flue in the Herbert
Hospital fireplaces is about no square inches. The
horizontal chimney-flue terminates in a vertical flue in the
side wall, which should be rather larger in area than the
horizontal flue. This vertical flue is carried in the upper
floors to a height of double the length of the horizontal flue,
and is carried down to the basement, where it can be swept.
The horizontal flue is swept by pushing a brush along it to
force the soot into the \'ertical flue. There is placed a
spare flue by the side of the vertical flue, terminating in a
fireplace in the basement, which enables the vertical flue
to be warmed, so as either to make it draw when the fire is
first lighted, or to enable a current to be maintained for
ventilating purposes through the fireplace when the fire is
not lighted. The ward floor should be so aiTanged as to
enable the air-flue to be easily and thoroughly cleaned
periodically.
The principle of these arrangements for utilizing to
some extent the heat in the chimney has been adopted
for barracks in the case of grates for married soldiers ; these
would be useful as cottage grates. These latter grates have
been made for the "War Department by Messrs. Benhani, of
APPENDIX.
91
Wigmore Street, London. They have a small oven, and an
open fire ; warmed air is introduced into the room by means
of an iron flue carried u^) from the fire-brick lining of the
stove inside the chimney, and introduced into the room
near the ceiling through a louvred opening : by this means
the heat of the smoke is utihzed. This description of grate
Fig. If.
A. Fire-lump with waim-air flue through bacls.
H. Warm-air pipe to fit into socket on hob, in lengths of i ft. 3 in. each.
C Bend to fit socket of the abose pipe.
D. Mouth-piece with Louvre front to fit on bend.
No. I of these 6 in. long supplied with each range.
Increa'ied heating surface for the hot air is provided by means of a grating
inside the socket at K.
was devised for the purpose of combining a power of cook-
ing for a cottage with great compulsory economy of fuel
92 APPENDIX.
(see fig. 15). It must, however, always be observed that
in proportion as the heat is removed from the chimney, so
is the draught, i.e. the efifect of the chimney as a pumping
engine to remove the air, diminished, and the combustion
of the fuel to some extent checked.
Numerous experiments have been made on the fireplace,
and it will suihce to recapitulate some of those made by
independent persons.
Experiments made upon the quantity of air supplied and
the temperature maintained show that the air is generally
admitted into the rooms at a temperature of from 20 deg.
to 30 deg. Fahr. above that of the outer air. The design of
the grate was intended to preclude the possibility of such a
temperature as would in any way injure the air introduced ;
and the experiments made by Dr. Parkes in a hospital
ward at Chatham, in April 1864, illustrate the hygrometric
efifect with the grate in use. The greatest difference be-
tween the dry and wet bulbs in the ward was : — On the
17th, 8'5 deg.; on the 18th, 6-o deg.; on the 19th, 5-5
deg.; on the 20th, 6-5 deg.; on the 21st, 5*0 deg. On
examining the record of the dry and wet bulbs durmg these
days, no evidence can be seen at any time of any unusual
or improper dryness of the atmosijhere. The difference
between the two bulbs was certainly always greater in the
ward, but it was not material. The temperature of the
rooms was invariably found to be so equable that when the
grate was in full action, and the windows and other means
of ventilation closed, thermometers placed in different parts
of the room, near the cciHng and floor, in corners furthest
from the fire, and on the side nearest to it, but sheltered
from the radiating effect of the fire, did not vary more than
about I deg. Fahr. The variation of temperature in a room
warmed by a fire, by radiation, without the action of warmed
APPENDIX. 93
air, will be found to be from 4 deg. to 6 deg. Fahr., and
sometimes even much more in cold weather.
The amount of air delivered through the fresh air shaft
varies somewhat with the direction of the wind. The inlet
shaft no doubt acts best when the windows, doors, and other
inlets are closed, as it then becomes the sole inlet for the
room ; a velocity of as much as nine or ten feet per second
has been observed in the inlet, but this is exceptional.
In the ventilation of barrack-rooms or hospitals, it was
not intended that the fresh air warmed by the grate should
be the Avhole supply of fresh air, nor that the chimney
should be the sole means employed for the removal of the
air to be extracted. In ordinary houses, however, the grate,
if adopted, might be used in such a manner as to perform
the Avhole functions of ventilation. In this case it is of
course necessary to remember that the ventilating power is
a fixed quantity, and that in originally settling the size of
grate for a particular room it will be necessary to bear in
mind the general object for which the room is to be em-
ployed and the number of persons by whom it is required
to be occupied Avith efficient ventilation, because all experi-
ments show that no room can be considered even tolerably
ventilated unless at least 1,000 cubic feet of air per occu-
pant are renewed per hour ; consequently a room 20 feet
long by 15 feet wide and 10 feet high {i.e. with 3,000 cubic
feet of space), with three people in it, would not require the
air to be changed much more than once an hour ; whilst,
if occupied by twelve or fourteen people, it would require
change five times an hour. Of course if the normal use of
the room was for three people it would not be worth while
to provide for the extra number by which it might be occu-
pied, as their Avants in such a temporary case could be met
by open AvindoAvs.
94 APPENDIX.
General Morin, with the object of utilizing the grate as
the sole means of ventilation for a room, lays down the
principle that the whole of the air shall be renewed fi\e
times in the hour. To perform this effectually, it is neces-
sary that the area of the top of the chimney shall afford
about one square inch of area for every loo cubic feet of
content of the room, and that the area of the fresh air inlet
should afford about 14 square inches for every 100 cubic
feet of content of the room. But on an average this
quantity of air is more than is necessary. The Barrack
and Hospitnl Improvement Committee's proposal would
resolve itself into this— viz. that the air in barrack-rooms
should be completely changed about twice in an hour, inas-
much as they required a cubic space of 600 cubic feet per
man, and for all ordinary purposes this would jjrobably
suffice ; as, however, this proposal was based on a limited
number of occupants, with a more crowded room the amount
must be increased..
General IMorin made numerous experiments on this
form of ventilation in 1864-5-6, with fireplaces constructed
in the form in use for barracks, and with others in which
tlie chimney was utilized for warming the air. The details
of the experiments are published in the "Annales du Con-
servatoire des Arts et Metiers" for the years in question.
It will here suffice to state that whilst Avith an ordinary
fireplace the heat which is utilized in a room is only \ of
the heat given off by the coal, or -125, in these experiments
the heat utilized in the room was -355 of the heat given off
by the coal, or I; therefore, to produce the same degree of
warmth in a room, this grate requires little more than one-
tliird of the quantity of coal required by an ordinary grate.
The ventilation Avas effected by passing a volume of air
through the room in one hour equal to five times the cubic
APPENDIX. 95
contents of the room. An equable temperature was main-
tained during the experiment. There was no perceptible
draught, and although the doors fitted badly, scarcely any
air was drawn in through the crevices.
In conclusion, the merits which are claimed for this fire-
place are : — ■
1. That it ventilates the room.
2. That it maintains an equable temperature in all parts
of the room, and prevents all draughts.
3. That the heat from radiation is thrown into the room
better than from other grates.
4. That the fire-brick lining prevents the fire from going
out, even when left untouched for a long time, and prevents
the rapid changes of temperature which occur in rooms in
cold Aveather from that cause.
5. That it economises fuel partly by making use of the
spare heat, which otherwise would all pass up the chimney,
and partly by ensuring by its construction a more complete
combustion, and thereby diminishing smoke.
6. That it prevents smoky chimneys by the ample supply
of wanned air to the room, and by the draught created in
the neck of the chimney.
THE END.
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