304 HOSPITAL sible to afford people the same advantages of treatment, attendance, nursing, and comforts at their own homes, al though in some cases the system of home treatment might be advantageously substituted, as has been done for so many years with so much success in Edinburgh and other towns of Scotland on the dispensary system. Another most im portant aspect of the question is the necessity for hospitals as places of instruction for those entering the profession of medicine. Although it would be wrong to subordinate in any serious way the claims of patients of any class to the requirements of teaching, it must yet be admitted that the only sound way of learning medicine and surgery is by clinical or bedside instruction, and we may therefore reasonably demand that those who owe their treatment and care to public charity should be willing so far to contribute to the general welfare. Now it is clear that in dealing with large classes of students it would hardly be possible to convey proper clinical instruction except in a hospital. For this purpose the provincial hospitals ought to be more largely utilized, in addition to the metropolitan ; at present the resources of the former are to a great extent wasted for teaching purposes. Assuming then the necessity for hospitals, there still re mains the question of the kind of hospital that should be constructed or approved of. It is certainly open to doubt whether we should continue to build monumental hospitals, and not rather construct slighter buildings, which may be destroyed and rebuilt from time to time, thus both scatter ing patients over a wider area and lessening the risk from long accumulation of infective material. This latter has been named the cottage or hut system of construction. The difficulties attending it are chiefly connected with original expense of site and with the current expenses of nursing and administration. On the other hand, it may be urged with some reason that with correct hygienic manage ment there is no reason why a large hospital should not be kept in a healthy condition. We may now consider the principles of hospital construc tion. 1. Locality and Site. Hospitals are required for the use of the community in a certain locality, and to be of use they must be within reach of the centre of population. Formerly the greater difficulty of locomotion made it necessary that they should be actually in the midst of towns and cities, and to some extent this continues to prevail. It is at least doubtful if this be the best plan. Fresh and pure air being a prime necessity, as well as a considerable amount of space of actual area in proportion to popu lation, it would certainly appear to be better to place hospitals as much in the outskirts as is consistent with considerations of use fulness and convenience. In short, the best site would be open fields; but, if that be impracticable, a large space a "sanitary zone," as it is called by Toilet should be kept permanently free between them and surrounding buildings, certainly never less than double the height of the highest building. The difference between the expense of purchase of land in a town and in the environs is generally considerable ; and this is therefore an additional reason for choosing a suburban locality. Even with existing hospitals it would be in most cases pecuniarily advantageous to dispose of the present building and site and retain only a receiving house in the town. St Thomas s in London, the Hotel-Dieu in Paris, and the Koyal Infirmary in Manchester are all good examples where this might have been carried out. In none, however, has this been done, the first two having been rebuilt, at enormous outlay, in the cities as before, although not exactly in the same locality, while the last is still retained with a few structural alterations. In Edinburgh, on the other hand, an open space of a much more favourable character has been obtained, which, although within the limits of the city, is almost rural in character. As regards the actual site itself, where circumstances admit of choice, a dry gravelly or sandy soil should be selected, in a posi tion where the ground water is low and but little subject to fluc tuations 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. 2. 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 ; (J) free play of sunlight upon each ward during at least some portion of the day ; (c) the possibility of isolating any ward, or group of wards, effectually, in case of infec tious 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 building, 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 last century were more wisely constructed than many of those in the first half of the present, 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 stories high, or to have single-storied huts or cottages, scattered more widely ? Where land is expensive the former plan is of course more econo mical, but where land is easily got the latter ought to be adopted. The pavilions may be arranged in various ways: they may be joined atone end by a corridor, or may be divided by a central corridor at right angles to them, &c. 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. 3. Foundations, Building Materials, &c. It is of the first con sequence 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 stories high it is advisable to use fire-proof material as much as possible, but single-storied 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, soluble glass, or the like. The ceilings ought to be treated in the same -u ay as the walls, or, perhaps better still, they might be made like the deck of a ship, without any lath and plaster, so as to have nothing but the tloor itself between room and room. 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 pitch-pine, leaves nothing to be desired. The surface should be waxed and polished or varnished. Even deal floors can be ren dered non-absorbent by waxing, by impregnating them with solid paraffin as recommended by Dr Langstaff, or by painting with soluble glass as suggested by Dr Luther of Philadelphia. 4. Shape and Arrangement of Wards. It is now generally agreed that wards should have windows on at least two opposite sides, and three main shapes have been proposed, viz., (a) long wards with windows down each side, and (generally) one at the further end ; (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 Folsom (Plans for the Johns Hopkins Hospital) ; and (c) has been suggested by Mr John Marshall,. F.E.S. (A at. Assoc. for Promotion of Social Science, 1878). Of these (b) seems the least to be commended, and (c) has not yet been tried in practice; we may therefore confine our atten tion to the long or oblong wards. The length is to be determined chiefly by the number of patients to be accommodated, but the breadth admits of less variation. Each bed should be a little dis tance, say from 8 inches to 1 foot from the wall, and each bed may be reckoned as 6^ feet long ; this gives 7J feet on each side. Between the ends of the beds about 10 feet space is necessary, so that 25 or 26 feet of total breadth may be taken as a favour able width. The wards of the Herbert Hospital are 26 feet; but some exceed this, as, for instance, St Thomas s, London, and the New Royal Infirmary, Edinburgh, 28 ; New Hotei-Dieu, 29 ; and Lariboisiere, 30. There seems no necessity for exceeding 26, 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 if possible a window to each bed, and never less than one to every two beds. 5. Ventilation, Warming, and Lighting. For ventilation two things are required, sufficient space and sufficiently frequent
change or renewal of air. As regards space, this must be considered
