1. That the hospital should be placed on a large area of ground, so that the pavilions can be widely separated from the administrative buildings and from one another.

2. That the wards should be only one story in height, and be ventilated by openings along the ridge of the roof.

3. That the ward-pavilions should be put up, not to remain for generations to come, but only for so long as they are free from infection; and that, when once they are infected, they should be destroyed, and replaced with entirely new structures.

The Germans were the first to make practical use of these new ideas in the construction of civil hospitals. As early as 1867, a one-story pavilion was erected in Berlin by Dr. Esse, and in the same year a one-story pavilion hospital was planned and soon built in Leipsic. Here at home the simple practical structures, which proved so useful during the war, did not find the favor with the founders of our new hospitals that they deserved. The Roosevelt Hospital, opened in 1871, has one one-story pavilion to show as the result of the experiences of the war; but New York City has had six other large new hospitals, all of which are massive, manystoried buildings, costing immense sums of money; and one of these, the last, opened 1876, is seven stories, and on a space of ground 70 by 175 feet. In Boston the one-story pavilion plan with ridge-ventilation has been adopted; and there are two or three pavilions erected on the grounds of the Massachusetts General, and one or more on the grounds of the Boston City Hospital, which surpass any in this country, except perhaps one lately constructed in Philadelphia.

In 1873 the writer read a paper before the State Charities Aid Association of New York, in which certain modifications of the usual plan of the one-story pavilion or barrack hospitals were proposed. The principal changes suggested were: to separate each. pavilion into two distinct buildings; one, the ward proper, to contain only the patients and their beds; the other, connected with the ward by a short elbow corridor, to contain all the service-rooms, the bath, closets, dining, and nurses' room. The aim was: (1) to avoid the danger which is to be apprehended from the proximity of the numerous partitions, doors, &c., as affording places for harboring infection, and from the emanations of water-closets, drains, sinks, and dining-rooms; (2) to diminish the risk of the foul air of one ward reaching other wards by means of the corridors; (3) to leave the ends of the ward free, so that a current of air can

pass through the ward as readily from end to end as from side to side; (4) that, if need be, on account of the ward becoming infected, it can be destroyed, leaving intact the basement and the service-rooms. We also proposed that the ward should be raised several feet from the ground, and be placed on open arches, - the object being to do away with a cellar or basement, and remove all danger from ground-air.

In 1875 we were called upon to express our views in regard to the best plan for the Johns Hopkins Hospital of Baltimore, Md., when the following formulated views were prepared, and forwarded to the trustees, and later published in the annual report of the State Charities Aid Association for 1876. These views were presented last year at the Saratoga Conference of Charities, by the late Theodore Roosevelt, and are printed in the report of the proceedings. The excuse for giving them at this time is that we feel our inability to put our views in more concise form.

I. A site should be selected which affords the best sanitary conditions, removed from sources rendering the air impure, and from surrounding obstructions to its free circulation. Rather than erect a hospital in a crowded district, surrounded by buildings, it is better to place it as far as practicable from the centre of population, and to have in connection with it a system of small reception hospitals, containing not more than six beds, with ambulance-wagons for conveyance of patients.

II. The grounds should be well drained and cultivated, so as to give a large supply of foliage.

III. The administrative building, drug-room, kitchen, laundry, and bathhouse should be separated from the wards and to the leeward, so as not to obstruct the prevailing winds during the summer months.

IV. The post-mortem, pathological, and dispensary buildings should be separated, in fact isolated, from the rest of the hospital, and have a different set of medical men and attendants.

V. The patients should be divided, according to their diseases, into not less than four classes:

Class 1: Non-infected cases, and those not liable to become so, nor to infect others; as, rheumatism, diseases of the heart, liver, kidneys, &c.

Class 2: Non-infected cases, and those not dangerous to others, but liable to become infectious; as, slight wounds, scalp-wounds with fracture of skull, &c.

Class 3: Non-infected cases, but liable to become so, and dangerous to others; as, severe wounds, burns, &c.

Class 4: Infected and contagious cases; as, pyæmia, septicemia, erysipelas, gangrene, &c.

VI. For the treatment of all classes of patients, it is very desirable to have every ward in a separate one-story pavilion; for the treatment of cases coming under Classes 2 and 3, it is essential that the wards should be in

one-story pavilions; for the treatment of Class 4, isolated huts or tents are absolutely necessary.

VII. The pavilions for the first and second classes may be permanent in character, but those for the third class should be more or less temporary. Those for the fourth class should be frequently destroyed and renewed.

VIII. Every pavilion should consist of two distinct parts: (a) The ward, placed on a high basement made permanently dry, with its axis running north and south; say 30 x 100 feet, allowing at least 120 feet of surface area, and high enough to give not less than 1,800 cubic feet of air-space to each bed. There should be one window to each bed. In the temporary pavilions for severe cases, the surface area and the cubic air-space for each bed should be much greater.

(b) The service-room building, containing the dining-room, water-closets, &c., should be near the north end of the ward, connecting with it by means of a short corridor, thus leaving both ends of the ward free, and diminishing the risk of infection from the service-rooms.

IX. The pavilions should be distant not less than three times their height from each other and from all other buildings.

X. Unless the severity of the climate demands a closed corridor, the communication between the buildings should be by open walks, under a covered way, with tramway-carriages for conveying food and patients to the wards. If corridors are used, the wards should be raised high enough to allow the corridors to be raised wholly above the ground, and have their tops serve as walks, on a level with the floor of the wards.

The corridors should connect with the service-rooms, and not with the wards.

XI. The object in ventilation is to secure a frequent and complete change of the air in the wards.

For ventilating and heating one-story buildings, such as we have proposed, the simplest and most successful method is by means of open fires. Hot water as an auxiliary should be used in preference to steam or hot air.

XII. The number of beds in the hospital should be great enough to permit three or four beds in each ward to be always empty; and the number of wards should be sufficient to allow one in twelve to be vacated, and left open to the air and light for purification.

XIII. A lying-in service should never be carried on in connection with a general hospital.

We are not forgetful of the fact that the success of a hospital depends more upon its good management than upon the character of the building; but we are satisfied that even with good management, the majority of hospitals now in use cannot be made to give results that will equal those to be attained in a properly constructed hospital.

Through the influence of the State Charities Aid Association, two new pavilions lately completed on Blackwell's Island, N.Y., have the main features as suggested above. The Mary Fletcher Hospital at Burlington, Vt., now in course of erection, will have one-story wards after somewhat the same plan; and a small hos

pital to be built at Orange, N.J., we hope will also be built on this plan. The Johns Hopkins Hospital will have the servicerooms separated from the wards by a straight, short corridor, but not with an elbow corridor as we suggested. We are not informed as to the details of construction of this hospital; but we regret to learn that they have decided to put half the wards in two-story buildings, instead of having each ward in a separate building as was at first decided.

STATISTICS.

Lawrence Tait has lately published a book giving statistics which cover ten years of almost all the English hospitals. His conclusions are strongly in favor of small hospitals. The average death-rate he gives is, for all hospitals, 6.24 per cent; for large hospitals, 9.88 per cent; for small hospitals, 5.17 per cent. For 1877, the death-rate at the Bellevue of New York - our largest surgical hospital was something over 11 per cent. Strange to some, but to us not unexpected, is the fact that at the magnificent seven-story new New-York Hospital, the death-rate for the past year has been also something over 11 per cent. It is true, they point out 27 deaths as being caused by injuries; but they cannot claim that their average class of patients was worse than those received in the public pauper-hospital at Bellevue.

COST IN HOSPITAL BUILDING.

The New-York Hospital, just referred to, intended for 150 beds, cost, together with the land, buildings, and furniture, about $1,000,000. The original contract for the building alone was $432,000. The running expenses last year were $66,000, with an average of a little over 100 patients continually in the wards. This would give an outlay for each bed of $6,666, or, on the basis of 100 patients, of $10,000 to each bed in use, and a running expense of $660 a year for each bed in use. We will call it an outlay of $5,000, and a running expense of $500. This would, perhaps, be too high an estimate for all of the other new large hospitals (seven in number), but we know that the building of one of the least expensive cost over $2,000 to each bed. As we have before said, all these hospitals are several stories high. The cost of the one-story pavilions at Boston, that at Philadelphia, and those on Blackwell's Island, was under $500 for each bed. Leaving out the price of the ground, we would say that the hospi

tal building, on which was expended more than $600 for each bed, cost too much; unless in a case where the administrative or school buildings were elaborate and connected with a small hospital. In this country, the hospital run at a cost of less than $250, or more than $350, to each bed in continuous use for a year, is either badly constructed or badly managed.

LISTER'S ANTISEPTIC DRESSING FOR WOUNDS.

Disinfectants have proved ineffectual in the endeavor to make them take the place of cleanliness and good ventilation; and even where the ward is vacated, and perfectly saturated in every crevice with powerful disinfectants, the evil influence of foul air is removed only for a very short time. But antiseptics applied to certain classes of wounds, according to a prescribed method known as Lister's Dressing, have been the means of saving many lives. To protect a certain number of wounds from the bad influence of foul air, is good so far as it goes; but it does not settle the whole question of hospital building. It diminishes the risks of a limited. number of patients; but the general effect of foul air on all, and its special influence on many, will continue to keep up the deathrate far beyond what it should be.

NEW YORK, May 20, 1878.

DEBATE ON HOSPITALS.

PROF. R. C. KEDZIE, M.D., said that it could be demonstrated that solid walls, when not covered with wall-paper, paint, or similar covering, were porous to such a degree that considerable ventilation of a room could be effected through them, even when doors and windows were shut. He thought it advisable in building hospitals, to observe this law of physics, and not render the walls impervious to air; the constant percolation of air through the walls would serve to disinfect the rooms in some degree.

DR. REAMY (of Cincinnati) related an instance where, after a man had died of small-pox, his suit of clothes was hung up in an old shed in the open air, and left there for about four months. A tramp then came along, and stole the clothes, took the small-pox, and died; thus showing that some of the germs of a disease will be retained even in a porous substance. Therefore, although it does not argue any thing against the kind of buildings suggested, yet it shows that even such a wall may become infected in time,