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Full text of "An address on the general principles which should be observed in the construction of hospitals : delivered to the British Medical Association at Leeds, July 29, 1869, with the discussion which took place thereon"

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TRUCTION OF HOSPITALS 



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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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