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 single-patient hut is the best for the patients in the acute stages; for economical reasons the châlet 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 châlet 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 non-absorbent 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 commended, 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 612 ft. long; this gives 712 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 10 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 1312 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 112 ft. per second, except at the point of entry, where it should not exceed 5 ft. per second, and at the
