and the Royal Infirmary in Manchester, are all good examples where this might have been carried out. In none, however, has this been done; these hospitals have been rebuilt, at enormous outlay, in the cities as before, although not exactly in the same locality. As regards the actual site itself, where circumstances admit of choice, a dry gravelly or sandy soil should be selected, in a position where the ground water is low and but little subject to fluctuations of level, and where the means of drainage are capable of being effectually carried out. There should also be a cheerful sunny aspect and some protection from the coldest winds. Form of Building.-A form of building must be selected which answers the following conditions: (a) the freest possible circulation of air round each ward, with no cul-de-sac or enclosed spaces where air can stagnate; (b) free play of sunlight upon each ward during some portion at least of the day; (c) the possibility of isolating any ward, or group of wards, effectually, in case of infectious disease breaking out; (d) the possibility of ventilating every ward independently of any other part of the establishment. Those conditions can only be fulfilled by one system, viz. a congeries of houses or pavilions, more or less connected with each other by covered ways, so as to facilitate convenient and economical administration. The older plans of huge blocks of buildings, arranged in squares or rectangles, enclosing spaces without free circulation of air, are obviously objectionable. Even when arranged in single lines or crosses they are not desirable, as the wards either communicate with each other or with common passages or corridors, rendering separation impossible. On this point it may be remarked that some of the buildings of the 18th century were more wisely constructed than many of those in the first half of the 19th century, and that the older buildings have been from time to time spoilt by ignorant additions made in later times.

The question next arises, is it better to have pavilions of two or more storeys high, or to have single-storeyed huts or cottages scattered more widely? For the treatment of tuberculosis there can be no doubt that, for hygienic reasons, the châlet or singlepatient hut is the best for the patients in the acute stages; for economical reasons the chalet has not been heretofore as popular as it deserves to be, but if the welfare of the patient is to be the first consideration there is no doubt that the chalet will ultimately prevail. It has the merit of being easily adapted to villages and houses where there is a garden, and in this way poor families may readily isolate and treat a member affected by tuberculosis at a cost within their means. For hospital purposes, so long as the system of placing hospital buildings in densely crowded areas prevails, many-storeyed buildings for hospital purposes are likely to continue. Should the proposal to institute a Hospital City ultimately prevail, then it is probable that the majority of the pavilions will be single-storeyed. Still some hospital authorities prefer the multiple-storeyed system for administrative reasons, contending that single-storeyed pavilions have no special advantages over two or three-storeyed buildings, whereas the difficulties in administration and service of a hospital building on the single-storey principle outweigh any argument against the two- or three-storey building, if it is properly designed and constructed. We hope that the time is approaching when architects and those members of the public who have to provide the money for hospital buildings will insist upon the erection of simple structures, costing little, so that the whole cost of hospital buildings may be, as it ought to be, reduced by at least half when compared with the expenditure of the past.

The pavilions may be arranged in various ways; they may be joined at one end by a corridor, or may be divided by a central corridor at right angles to them. In fact, the plan is very elastic, and adapts itself to almost any circumstances. A certain distance, not less than twice the height of the pavilions, ought to be preserved between them. By this means free circulation of air and plenty of light are secured, whilst separation or isolation may be at once accomplished if required.

Foundations, Building Materials, &c.-It is of the first consequence that a hospital should be dry; therefore the foundation and walls ought to be constructed so as to prevent the inroads of damp. An impervious foundation has the further advantage of preventing emanations from the soil rising up in consequence of the suction force produced by the higher temperature of the internal atmosphere of the building itself. There should be free ventilation in the basement, and the raising of the whole on arches is a good plan, now generally carried out in hot climates. If the pavilions are two or more storeys high, it is advisable to use fire-proof material as much as possible, but single-storeyed huts may be of wood. In any case effectual means of excluding damp must be employed. The interiors of wards ought to be rendered as non-absorbent as possible, by being covered with impervious coatings, such as glazed tiles (Parian, though much used, is apt to crack), silicate paint, which is preferable to tiles, or the like. The ceilings ought to be treated in the same way as the walls. There must be a concrete floor between each flat, experience showing that if a teak floor is laid hard on the concrete a very noisy floor is the result, but if the teak is laid on strips of wood, leaving a small space between the concrete and the floor, a more silent floor is obtained. For the floors themselves various materials have been suggested: in France there is a preference for flags (dalles), but in England wood is more liked; and

indeed hard well-fitting wood, such as teak, oak or American willow, leaves nothing to be desired. The surface should be waxed and polished or varnished. Even deal floors can be rendered nonabsorbent by waxing, by impregnating them with solid paraffin as recommended by Dr Langstaff.

Shape and Arrangement of Wards.—It is now generally agreed that wards should have windows on at least two opposite sides. Three main shapes have been proposed: (a) long wards with windows down each side, and (generally) one at the farther end with balcony; 26 ft. is a good width for a ward of twelve or fourteen beds, but for larger wards of more than fourteen beds the width should be not less than 28 ft.; (b) wards nearly square, with windows on three sides; and (c) circular wards with windows all round. The first (a) is the form usually adopted in pavilions; (b) is recommended by Dr C. F. Folsom (Plans for the Johns Hopkins Hospital); and (c) has been suggested by Mr John Marshall, F.R.S. (Nat. Assoc. for Promotion of Social Science, 1878). Of these (b) seems the least to be com mended, and (c), now comparatively common, has distinct advantages in an administrative sense, when the wards are constructed as to floor space so as to allow the same proportion of superficial space per bed in a circular ward to that which is contained in a rectangular ward, as is the case at the Great Northern Central Hospital, London. Some authorities object to a chimney-stack up the centre of the circular ward, urging that it prevents the nurses from having complete supervision over all the beds. In practice this objection seems to us to have little force, and it can be avoided by placing the fireplaces at the side of the circular ward, if desirable, though this adds somewhat to the cost of building.

Each bed should be a little distance, say from 8 in. to 1 ft. from the wall, and each bed may be reckoned as 6 ft. long; this gives 7 ft. on each side. Between the ends of the beds about 10 ft. space is necessary, so that 25 or 26 ft. of total breadth may be taken as a favourable width. The wards of the Herbert Hospital are 26 ft.; but some exceed this, as, for instance, St Thomas's, London, and the New Royal infirmary, Edinburgh, 28; new Hôtel Dieu, 29; and Lariboisière, 30. There seems no necessity for exceeding 26 for a ward of twelve or fourteen beds, but if the breadth be greater there ought to be more window space-the great difficulty being to get a wide space thoroughly ventilated. There ought to be only two rows of beds, one down each wall, with a window on each side of each bed. For ventilation two things are required-sufficient space and sufficiently frequent change or renewal of air. As regards space, this must be considered with reference both to total space and to lateral or floor space. Unless a minimum of floor space be laid down, we shall always be in danger of overcrowding, for cubic space may be supplied vertically with little or no advantage to the occupier. If we allow a minimum distance of 4 ft. between the beds and io ft. between the ends of the beds, this gives 100 sq. ft. of space per bed; less than this is undesirable. In severe surgical cases, fever cases and the like, a much larger space is required; and in the Edinburgh Infirmary 150 sq. ft. is allowed. Cubic space must be regulated by the means of ventilation; we can rarely change the air oftener than three times in an hour, and therefore the space ought to be at least one-third of the hourly supply. This ought not to be less than 4000 cubic ft. per bed, even in ordinary cases of sickness and the third of that is 1333 cubic ft. of space. With 100 sq. ft. of floor space a ward of 133 ft. high would supply this amount, and there is but little to be gained by raising the ceiling higher, indeed 12 ft. is practically enough. The experiments of Drs Cowles and Wood of Boston (see Report of State Board of Health of Massachusetts for 1879) show that above 12 ft. there is little or no movement in the air except towards the outlet ventilator; the space above is therefore of little value as ventilation space. Authorities nowadays, however, fix 10 ft. 6 in. as the maximum, and any height above this may be disregarded for purposes of ventilation. Additional height adds also to the cost of construction, increases the expense of warming, makes cleaning more difficult, and to some extent hampers ventilation. Whatever be the height of wards, the windows must reach to the ceiling, or there must be ventilators in the ceiling or at the top of the side walls. If this be not arranged for, a mass of foul air is apt to stagnate near the ceiling, and sooner or later to be driven down upon the inmates. The reasons for a large and constant renewal of air are, of course, the immediate removal and dilution of the organic matter given off by the inmates; as this is greater in quantity and more offensive and dangerous in sickness than in health, the change of air in the former case must be greater than in the latter. Hence in serious cases an amount of air practically unlimited is desirable-the aim of true ventilation being to approach as near as possible to the condition of pure external air. Without going too much into details, a few general rules may be laid down. (1) Fresh air ought, if possible, to be brought in at the lowest part of the ward, warmed if necessary; (2) foul air ought to be taken out at the highest part of the ward; (3) fresh air should reach each patient without passing over the bed of any other; (4) the vitiated air should be removed from each patient without passing over the bed of any other; (5) 4000 cubic ft. of fresh air per head per hour should be the minimum in ordinary cases of sickness, to be increased without limit in severer cases; (6) the air should move in no part of a ward at a greater rate than 1 ft. per second, except at the point of entry, where it should not exceed 5 ft. per second, and at the

outlet, where the rate may be somewhat higher; about 64 sq. in., of inlet and outlet sectional area ought to be supplied per head as a minimum; (7) every opportunity ought to be taken of freely flushing the wards with air, by means of open windows, when this can be done with safety. Warming is a question of great importance in most climates, especially in such a climate as that of Great Britain, where every system of ventilation must involve either the warming of some portion of the incoming air, or the contriving its delivery without too great lowering of temperature; at the same time it cannot be too strongly insisted upon that the tendency is too much in the direction of allowing warmth to supersede freshness of air. There are very few cases of disease (if any) that are not more injured by foul air than by low temperature; and in the zymotic diseases, such as typhus, enteric fever, smallpox, &c., satisfactory results have been obtained even in winter weather by almost open-air treatment. At the same time a reasonable warmth is desirable on all grounds if it can be obtained without sacrificing purity of atmosphere. For all practical purposes 60° to 63° F. is quite sufficient, and surgical and lying-in cases do well in lower temperatures. Various plans of warming have been recommended, but probably a combination is the best. It is inadvisable to do away altogether with radiant heat, although it is not always possible to supply sufficient warmth with open-air fire-places alone. A portion of the air may be warmed by being passed over a heating apparatus before it enters the ward, by having an air-chamber round the fire-place or stove, or by the use of radiators in the ward itself. In each case, however, the air must be supplied independently to each ward, so that no general system of air supply is applicable.

The lighting of the ward at night will be most conveniently done by means of electricity in the form of a lamp for each bed, where gas is used each jet should have a special ventilator to carry off combustion products, as in the Edinburgh Infirmary. The Furniture of Wards should be simple, clean and nonabsorbent; the bedsteads of iron, mattresses hair, laid on spring bottoms without sacking. No curtains should be permitted.

The water-supply ought to be on the constant-system, and plentiful; 50 gallons per head per diem may be taken as a fair minimum

estimate.

Hospital Saturday Funds. The publication of a book by Sir Henry Burdett led to the adoption of the system in several of the British Colonies, and as a result of the action taken in the British Empire the Uniform System of Accounts has recently been set up and adopted by the principal hospitals of the United States of America. The prince of Wales (George V.) testified to the value of this system in enforcing control over expenditure, and Sir Henry Burdett adapted it for the use of the authorities of all charities of every class. It is probable that no single reform has had a greater influence for good upon the administration of charitable institutions than the evolution and enforcement of the uniform system of accounts. Nursing. The arrangements for nursing the sick have greatly improved in recent times, although controversy still goes on as to the best method of carrying it out. In arranging for the nursing in a hospital both efficiency and economy have to be considered. No ward in a general hospital for acute cases should contain more than 24 beds. In hospitals with clinical schools the proportion of nurses to patients should be about one nurse to every three patients, and if possible every ward should have a probationer on duty at night in addition to the night nurse. In all well-conducted hospitals it is now arranged that the nurses on night duty have a hot meal served in the general dining-room during the night, and this is only possible where a nurse and a probationer are allowed for cach ward. The nurses' quarters should be separate from the hospital proper, and connected by a conservatory or covered way. Each nurse should have a separate bedroom, measuring not less than 12 ft. long, 9 ft. broad and 10 ft. high. A bath should be allowed for every eight rooms, and the water-closets and sinks should, if possible, be in sanitary towers cut off from the main block of buildings.

Circumstances must to a large extent determine the arrangement, but it seems desirable on the whole that the work of a nurse should be confined to a single ward at a time if possible. The duties of nurses ought also to be distinctly confined to attendance on the sick, and no menial work, such as scrubbing floors and the like, should be demanded of them; a proper staff of servants ought to be employed for such purposes. It is also desirable that a separate pavilion for lodging the nurses should be set apart, and that fair and reasonable time for rest and recreation should be allowed. Some discussion has taken place as to the advisability of placing the nursing of a hospital in the hands of a sisterhood or a separate corporation. It will, however, be admitted that the best plan is for the nursing staff of each hospital to be special and under one nected with some main institution outside. The nursing must, of course, be carried on in accordance with the directions and treatment of the physicians and surgeons.

Each ward should have attached to it a small kitchen for any special cooking that may be required, a room for the physician or surgeon, and generally a room with one or two separate beds. No cooking should be done in the wards, nor ought washing, airing or drying of linen to be allowed there.

Hospital Economics.-There is no doubt that the voluntary system of hospital government is far more economical than any system of state or rate-supported hospitals. That the present condition of the voluntary hospitals in regard to economy is all that can be wished is not, of course, true. Still, resting as this system does upon the goodwill of the public for its continuance and maintenance, it is satisfactory to note that there is a continuous improvement in system and method, which makes for economy. It has taken many years to perfect and enforce the uniform system of hospital accounts, but this system with the co-operation of the great funds has produced economical results of the first importance. This system originated at the Queen's Hospital, Birmingham, in 1869, and was devised by an eminent Birmingham accountant, William Laundy, and Sir Henry Burdett. It proved so fruitful in practice that six years later it was introduced at the " Dreadnought " Seamen's Hospital, the first London hospital to use it, and was then adopted spontaneously by a few of the best-administered hospitals where the managers were keen in enforcing economy. In 1891, in order to secure for comparative purposes an identical classification of the items and charges included in the system, a glossary or index of classification was prepared and published in the Hospital Annual of that year. This index enabled the same classification of the many items included in the expenditure of a great institution to be adopted generally. In the same year a committee of hospital secretaries, at the instigation of the Metropolitan Hospital Sunday Fund, revised and elaborated the index of classification, and the new index was adopted by a general meeting of hospital secretaries in January 1892. The Council of the Metropolitan Hospital Sunday Fund approved it, and the Uniform System of Accounts was formulated by that body for the use of the metropolitan hospitals. In 1906 the whole of this system was inquired into on behalf of the King's Fund by Mr John G. Griffiths, F.C.A., when a committee of hospital secretaries and representatives of the King's Fund prepared a further revision of the system. This was completed in the course of the year and adopted by the King's, the Hospital Sunday and the

General. The kitchen, laundry, dispensary and other offices must be in a separate pavilion or pavilions, away from the wards, but within convenient access. A separate pavilion for isolation of infectious cases is desirable. This may be a wooden hut, or in some cases even a tent; either is probably preferable to a permanent block of buildings. A disinfecting chamber ought to be provided where heat can be applied to clothes and bedding, for the destruction both of vermin and of the germs of disease. It is advisable to expose all bedding and clothing to its influence after each occasion of wear. Although this may entail additional expense from the deterioration of fabric, it is worth the outlay to secure immunity from disease. This plan is rigidly followed at the Royal South Hants Infirmary at Southampton. It is of great importance that the wards should be periodically emptied and kept unoccupied for not less than one month in each year, and longer if possible. During such period thorough cleansing and flushing with air could be carried out, so as to prevent any continuous deposit of organic

matter.

Gate House or Admission Block.-If the efficiency of a hospital and the regular and smooth working of its departments are to be secured, the proper management and control of the admission department is of the greatest importance. When one considers for a moment the number of applicants of all ages in various stages of disease, and the number of accident cases of every degree of severity who present themselves every day seeking admission, it will be evident that the most careful supervision must be exercised on the very threshold. It is essential that every precaution be taken against the admission of an unsuitable case, or the refusal, without careful examination, of any patient seeking admission. It is only necessary to instance the case of a patient with delirium tremens being admitted to a general ward at a late hour, or a case of infectious disease admitted through an overlook, or a case refused admission and expiring on the way home, in order to illustrate the danger and trouble which might arise should the supervision exercised over this department not be systematic, stringent and thorough. To secure this proper control it is necessary that the admission department should be designed on a definite plan suitable for the purposes in view. It is not sufficient to utilize any available rooms, say, in the basement of the building, where patients may be casually interviewed by a house surgeon or physician. This department should be as carefully designed and equipped as any other depart ment of the hospital.

Within recent years much more attention has been devoted to the details of construction than was formerly considered necessary,

The admission department should be conveniently placed on the ground floor of the hospital-or it may be a detached buildingwith a large court where ambulance wagons or other vehicles may easily pass each other on approaching or retiring from the institution. The entrance to the admission department for patients should, if possible, be entirely separate and distinct from that for the staff and students. An additional entrance should be provided for patients' friends on visiting days, in order that they may be able to enter the hospital without passing through the patients' entrance, or coming into contact with an accident case or other patient seeking admission. The main entrance door should be protected by a covered porch so that patients may be removed from the ambulance or cab to the examination room without being exposed to the weather or the gaze of inquisitive onlookers. This door should be sufficiently wide to allow two hand ambulances or barrows to pass should they require to be brought out to the ambulance or cab, and to facilitate this the floor of the entrance hall should be as nearly as possible on a level with that of the outside porch. Adjoining the entrance vestibule, lavatory accommodation should be provided for males and females who may accompany the patient. Lavatory accommodation should also be provided for porters on duty, and all lavatories should have a cut-off ventilating passage.

A recess to store ambulance barrows should adjoin the entrance, and this recess must be in proportion to the size of the hospital, in order that, a hand ambulance may always be available when an accident or urgent case arrives. The vestibule should lead into a large waiting-hall with an inquiry office at its entrance, provided with a telephone exchange, private exchange box, also letter and parcel racks. If possible a window of the inquiry office should command a view of the main entrance. A room should be provided for the medical officer on duty, so that a medical officer may be always at hand and that no delay will occur in attending to a patient on arrival.

RECOVER

ROOM MALE

XRAY TANJ

MALL OPERATING THEATRE

FEMALE

As an aid to a complete understanding of the varied work which has to be provided for, and the most effective method of carrying it out, the accompanying plans are given of an admission block de

AREA

HALL

OPERATING THEATAL

L

PARCELS LETTERS PORTERS

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signed to embody the main principles which govern the construction of such a department,

All accidents and patients seeking admission to this hospital enter through the central gateway, and on the left is shown the porters' room, where a porter is always in readiness to attend to any applicant. This room has suitable accommodation for parcels, letters, telephones, &c.. and adjoining it is a small lavatory for the use of porters, At the side of the porters' room

Leading off from this waiting-hall, well-lit examination rooms should be available for the thorough examination of patients, both male and female, the number of rooms, of course, varying with the size of the hospital and the amount of work to be done. Each of these rooms should be fitted with a wash-hand basin and sink, and a plentiful supply of hot and cold water. Two rooms, with recovery rooms adjoining, should be fitted up as small operating-rooms for the treatment of minor casualties. A special room should also be furnished with an X-ray outfit, and arrangements should be made whereby this room can be readily darkened so that suspected fractures, &c., may be examined with the fluorescent screen.

Adjoining the admission department two small wards should be provided for the accommodation of drunk or noisy cases unfit to be placed in the general wards. To these "emergency wards must be attached the usual bathroom and lavatory accommodation, nurses' room, ward kitchen and urine-test room or small lavatory. These wards should have double windows in order to prevent noise being heard outside if the wards are near other buildings.

The interior walls of the admission department should, as far as possible, have a smooth and impervious surface, in order that they may be easily cleaned. All angles should be avoided and all corners rounded. Although glazed tiles are open to the criticism that they have numerous joints, they probably make the most suitable wall yet devised, as they can be easily washed down at very small cost. The corridors and waiting-hall should be tiled to a height of 6 ft. 6 in., and the upper walls covered with Parian or Kean's cement, and be treated with three coats of flat paint and two coats of enamel, or, what is equally suitable and less costly, enamellette. The floors of the passages and corridors throughout the department should be covered with terrazzo, which is a mixture of Portland cement and marble chips. A margin of 1 ft. round the rooms should be treated in this way, and the terrazzo carried up this same distance on the wall to join the tiles. The remainder of the floors should be covered with hard wood, such as American maple or teak. As these floors require to be frequently washed, oak is not so suitable. Oak very soon becomes destroyed with water; the same trouble is experienced with pitch pine. The doors should also be made of a hard wood,

is the entrance to the central waiting-hall, which is lit from the roof. On one side of this hall are examination and dressing-rooms for males, with lavatory accommodation; and on the other side similar provision for females, with the addition of a nurses' duty room. At the end of the central hall are two operating theatres, with recovery room adjoining each; one theatre for males, and the other for females. Between these theatres are rooms for sterilizers and dressings. An X-ray examination room is provided beyond the male examination room on the right of the hall. In the basement, under the entrance-hall and operating theatres are two bathrooms for males and two for females, with W.C.'s for each. The remainder of the basement is used as a store for patients' clothes, and a hotair chamber is provided for purposes of disinfection. The basement can be reached by a lift or by a wide staircase which is situated at the end of the waiting-hall.

In the above plan provision is made for a sitting-room for the medical officer on duty. This is a new and essential feature in the admission block unit of all hospitals in large cities, for it should secure that no patient is kept waiting for many minutes before being seen. One of the blots on the management of many hospitals is that regrettable delays often take place, and much dissatisfaction and avoidable suffering may arise from this difficulty in the administration of a general hospital. We have given this plan of a model gatehouse or admission block for a modern general hospital, because the block as it stands contains all the elements necessary for a receiving-house block in cities in connexion with a great Hospital city situated outside its area, in fulfilment of the suggestion for a Hospital city made above. Apart from its interest as a new feature which all new hospitals should adopt, the gatehouse or admission block has an importance in the wider sense, that it may come to form the key to the solution of the problem of how best to provide hospital accommodation for the poor in great cities under the best hygienic conditions, while protecting them from the misery and danger of prolonged delay in first treatment, especially in connexion with accidents and other cases of urgency.

BIBLIOGRAPHY.-Sir H. Burdett, Cottage Hospitals, General, Fever and Convalescent, their Construction, Management and Work (London, 1877 1880 and 1896); Tollet, Les Edifices hospitaliers depuis leur