' a, vi v\ vq o V. V 
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' v / 'A '“’I , / "V' H' . A y v- No. 32. 
STATE CHARITIES AID ASSOCIATION 
OF NEW YORK 
HAND-BOOK 
FOR 
HOSPITALS 
BY 
ABBY HOWLAND WOOLSEY 
MEMBER OF COMMITTEE ON HOSPITALS 
STATE CHARITIES AID ASSOCIATION 
THIRD EDITION 
NEW YORK 
27 WEST TWENTY-THIRD STREET 
G. P. PUTNAM’S SONS 
LONDON 
24 BEDFORD STREET, STRAND 
®Ij£ |)riss 
i895 Copyright, 1895 
BY 
STATE CHARITIES AID ASSOCIATION 
Ube Tknfcfcerbocfccr press, IRew TRocbelle, 1R. J1J. EDITORS’ PREFACE TO THIRD EDITION. 
The “Hand-Book for Hospitals,” written for the 
use of the visitors of the State Charities Aid Asso- 
ciation, by the late Miss Abby Howland Woolsey, 
member of the Committee on Hospitals, was pub- 
lished by the Association in 1877. A second edition, 
revised by the author, was published in 1883. 
Again out of print, another edition is now called 
for. No more recent publication can be found which, 
in all respects, supplies its place and, although one 
hesitates to alter a word of an original manuscript 
when the hand that penned it is still, no other course 
was left to the Managers of the Association but to 
appoint a special committee, to revise and edit this 
third edition of the “ Hand-Book.” 
Not often has a task so easy or so grateful been 
assigned to any committee. Twelve years have 
elapsed since the publication was last revised by the 
author, and yet the work then done was so thorough, 
the personal knowledge of the subject so exceptional, 
and the standard of excellence so high, that, beyond 
the bringing of statistics up to date, and the addition 
of some footnotes, to show the advance, within a 
very few years, of hygienic requirements, there were 
but few alterations to be made. 
The chapter on the care of the dependent insane 
is, in part, no longer applicable to the State of New 
York, where the “State Care Act” of 1890has caused Editors Preface to Third Edition. 
IV 
the removal of all the insane from the Poorhouses 
to State Hospitals ; but, as this little book has a 
circulation beyond our State, and where provision 
for the insane is not yet so far advanced, it was 
thought best to leave that chapter intact. 
We do not hesitate to say that every physician 
who may peruse these pages, every Commissioner 
of Charities and Superintendent of the Poor, every 
Superintendent of a hospital, will welcome the many 
practical suggestions to be found in this manual. 
It should be in the hands of all visitors to hospitals 
and other charitable institutions, and on the shelves 
of every library in this country. 
Charles Hitchcock, M.D., Chairman, 
George G. Wheelock, M.D., 
W. Gill Wylie, M.D. 
Special Committee on Revision of Hand-Book 
New York, 
October, 1895. CONTENTS. 
PAGE 
I. GENERAL SUGGESTIONS 3 
II. THE HOSPITAL BUILDING .... 
III. AIR-SUPPLY AND HEATING 39 
IV. DRAINAGE AND WATER-SUPPLY ... 58 
V. SOME INTERIOR DETAILS . . . -77 
VI. THE HOSPITAL LAUNDRY .... 94 
VII. HOSPITAL HOUSE-KEEPING . . . . 125 
VIII. THE NURSING SERVICE .... 148 
IX. CARE OF THE INSANE 178 
X. MATERNITY WARDS . . . . . 188 
XI. VILLAGE HOSPITALS 194 
XII. HOSPITAL DISINFECTION .... 209 
XIII. CONCLUSION ....... 231 
XIV. APPENDIX ....... 241 HAND-BOOK FOR HOSPITALS. Hand-Book for Hospitals. 
I. 
General Suggestions. 
The following pages were prepared in 1877 for 
the use of those members of the State Charities 
Aid Association whose duty it is to visit our public 
hospitals in New York County and other counties 
of the State. The rapid multiplication of hospitals 
of all sorts and the general increase of interest 
in such topics as the care of the sick and insane, 
institution management, hygiene, pauperism, tax- 
ation, and the distribution of public funds, have 
indicated the need of a second edition, which, care- 
fully revised and enlarged, is now offered to the 
public, and especially to all persons concerned in 
hospital work, with the hope that it may prove 
helpful and suggestive.1 
For many domestic details of an institution, such 
1 The second edition was published in 1883 ; the third, and 
present edition, in 1895.—Editors' Third Edition. 
3 4 
Hand-Book for Hospitals. 
as details of cleanliness, order, and the tone of 
discipline maintained ; for nursing, diet, and laun- 
dry work; the employments and general con- 
dition of the inmates, women make the best 
inspectors. 
If any argument were needed to justify the course 
pursued by the State Charities Aid Association in 
making men and women co-workers in its commit- 
tees, or to show that the administration of hospitals 
is within the province of housekeepers, as well as of 
business men, it would be found in the striking 
words quoted below: 
“ That which makes the healthiest house makes 
likewise the healthiest hospital; the same fastidious 
and universal cleanliness, the same never-ceasing 
vigilance against the thousand forms in which dirt 
may disguise itself in air, in 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 vigi- 
lance and skill; for the establishment 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 poisons. Above all, 
this applies to the fouling of the air within hospital 
wards by exhalations from the persons of the sick. 
In such exhalations are embodied the most terrible 
powers of disease, the spreading flames, as it were, 
of some infections and the explosive fuel of others; General Suggestions. 
5 
and any air in which they are allowed to accumulate 
soon becomes a very atmosphere of death.” 1 
We do not forget that the buildings our commit- 
tees visit are often old and ill-ventilated, and in 
some instances full of radical errors of system and 
plan ; but, at the same time, we desire to suggest 
the more excellent way. The making of improve- 
ments may be tedious and difficult, but they will 
never be made unless knowledge of right principles 
exists—principles that are of wider application than 
to hospitals merely, for they concern the arrange- 
ments of all asylums, poorhouses, almshouses for the 
aged and incurable, as well as for the sick. Where 
the hospital is simply an upper room in a poorhouse, 
it is even more important that correct principles in 
regard to system, ventilation, cleanliness, good order, 
nursing, and diet should be recognized by visitors, 
and when necessary pressed by them upon the at- 
tention of the authorities. 
Ambitious architecture.—It is a reasonable as- 
sumption that the purpose of public hospitals is 
to cure the sick. Yet, trite as the truth sounds, 
this prime object is constantly overlooked, and 
the welfare of patients and the public is uncon- 
sciously sacrificed on the one hand to mistaken 
economy, or, on the other, to a rage for showy 
structures. Too often the ambition of an architect 
or a building committee is to “ erect an edifice ” 
that will be an “ ornament to the town ” and a 
“monument of benevolence”; but too often, also, 
1 Mr. John Simon, Medical Officer of Health to the Privy Council 
of Great Britain, 6 
Hand-Book for Hospitals. 
the structure proves to be worth little else. The plan 
may copy from other hospitals in other places all 
the old blunders, but it makes the “ prettiest picture,” 
and is chosen accordingly. Too often the choice 
of a site is determined by political scheming, or a 
public building is made unsuitably massive and or- 
nate in order that money may be spent and somebody 
get a “ good job ” ; while behind the ambitious front 
foul air breeds disease, and scanty, unclean, and 
unwholesome rations are served to the sick and 
infirm poor by untrained, insufficient, unhappily, 
sometimes, vicious attendants. 
Visitors must remember that while parsimony in 
building-space, in diet, service, and certain other 
departments of administration often amounts to 
inhumanity, merely elaborate architecture is no help 
to the inmates and no index of the sanitary condition 
of an institution. The “ new building” may have 
its own radical errors, and be no substantial im- 
provement on the shabby old one. Hospital reform 
can dispense with architectural effects, for it begins 
with simplicity, and, within proper limits, with 
cheapness of construction. But undue economy is 
blameworthy ; a hospital may be too hastily and 
cheaply built. Good materials, correct drainage and 
plumbing, careful work, cost money. We urge that 
nothing be spent for show, but everything for safety 
and thoroughness. We must not dogmatize out of 
our own inexperience on these subjects; we must 
not look to politicians and contractors, real-estate 
agents, or simply to architects ; we must look to 
those who have made sanitary laws their special General Suggestions. 
7 
study for sound advice in regard to the construc- 
tion of our public institutions and the choice of 
building sites. 
The art of planning consists in securing the in- 
dispensable at all hazards, and as much more as may 
be possible ; that is, in wisely selecting, from advan- 
tages within reach, those which will most surely 
and effectually promote the end in view. The first 
question to be asked is: What is to be done with 
the inmates within these walls? The second: For 
how many inmates is this building designed ? and 
every part should be planned with the answer to 
these two inquiries distinctly in mind. Organize 
your building. Discriminate the departments. 
Place those departments nearest to each other 
whose purposes are most closely related. Separate 
the departments which are not related as widely as 
is consistent with a wise economy not only of money 
but of labor and time. Let each department form 
a whole. Let the division of the outer shell corre- 
spond to the division of functions. Do not compel 
the internal organization of the institution and the 
daily life of its inmates to conform to the mechani- 
cal ideas of the architect and builder; but compel 
the architect to shape and divide his entire structure 
so as most perfectly to correspond to the internal 
organization. Make the building fit, as a glove fits 
the hand.1 
Know your own mind.—Let visiting committees 
be sure what it is they want to accomplish when al- 
teration of an old building or the erection of a new 
1 F. H Wines, Illinois : Conference of Charities, Saratoga, 1876. 8 
Hand-Book for Hospitals. 
one is proposed. They will find it much easier to 
secure public consent for an improvement if they 
know their own wishes and can state these with 
exactness. Let them form a clear idea of the size 
and character of the plot of ground required, and 
have a well-considered plan ready, with full details, 
if necessary, and a careful estimate of the probable 
expense. The plans and estimates can be shown 
and discussed, and will often carry the point when 
arguments from hygiene would not be listened to 
patiently. Public officers usually consider it a 
merit if they can save the county from expense. 
Suggestions for improvements are met by them 
with the answer : “ It has always done well enough 
for us before ; we guess we ’ll let it do a little while 
longer,” and other pretexts. Committees should be 
able to demonstrate that with simple and suitable 
building plans and an honest use of building funds, 
more patients may be housed and treated and more 
good done for the same outlay as with an opposite 
course.1 Thus no community need be deterred by 
lack of large appropriations from building a hospital 
where one is needed, or be tempted, by the recol- 
lection of the sum that had been sunk in it, into 
continuing to use an old and poisoned building. 
Taxpayers will generally appreciate the argument 
found in the fact that a hospital on the cottage plan, 
if its wards become poisoned, can be rebuilt every 
ten years for the interest on the sum usually found 
necessary to construct an old-fashioned massive 
hospital, of the same number of beds, leaving re- 
1 Dr. John M. Woodworth: Public Health Papers, vol. 2. General Suggestions. 
9 
pairs to such a structure as the latter out of the 
question. 
What makes a hospital unhealthy ?—It is an 
established fact that massive, many-storied buildings 
after being occupied as general hospitals for years 
become soaked with infectious matter, and, under 
certain circumstances, are dangerous to patients. 
It is impossible to disinfect them permanently by 
any known means. The same is true of old frame- 
buildings long used as wards. Those who have 
studied the subject tell us that no building ought 
to be used as a hospital longer than ten or twelve 
years; but that after twenty years it should abso- 
lutely be considered as infected, and should be torn 
down.1 In the case of a substantial building, one 
expedient for securing safety would be the periodic 
removal of the entire inner surface of the walls, and 
fresh plastering. When a fever ward in the old 
New York Hospital was renovated in this way in 
1864, out of five masons who were removing the 
plaster three died of fever in a few days. A little 
volume on “ Hospitalism,” by Professor John Eric 
Erichsen, of University College, London, gives facts 
and statistics showing the extent and permanence 
of wall-poison in old buildings. Erichsen says that 
“ there is but one remedy possible for a pyaemia- 
stricken hospital—the pickaxe.” The greatest care, 
therefore, should be taken to keep an old hospital 
1 This is not meant to apply to the modern hospital structures of 
to-day, whose wall surfaces have been made especially to resist the 
absorption of germs and other deleterious substances. 
—Eds. Third Edition. Hand-Book for Hospitals. 
as sound and as safe as possible, not only by watch- 
ful nursing in individual cases and periodic fumi- 
gation of the wards, but by thorough cleanliness 
everywhere, and by an exact, prompt keeping up of 
repairs in petty ways. A shabby, run-down build- 
ing, with leaky pipes and full of cracks and pockets 
for the accumulation of dirt and slop, will more 
easily become poisoned. 
Hospitalism, or hospital infection, means a gen- 
eral unsanitary condition of the building, or of its 
atmosphere, showing itself in the recurrence of 
cases of erysipelas, puerperal fever, pyaemia, gan- 
grene, sepsis, and the like. These diseases, a case of 
any one of which will poison the air of the ward for 
the time and tend to poison the ward permanently, 
are apt to result from such causes as the following: 
improper classification and aggregation of too great 
a variety of cases under one roof; dirty walls and 
ceilings and old floors ; too many beds in a ward ; 
beds unaired, uncleansed ; carpets and stuffed furni- 
ture ; insufficient bathing of patients and too in- 
frequent changes of linen ; imperfect washing of 
bed- and body-linen, bandages, and towels; choked 
airflues ; bad ventilation ; bad drainage ; wrong posi- 
tion of the water-closets ; failure to isolate nurses as 
well as patients during and after infectious cases. 
All these causes are directly under the control of 
the lay authorities of a hospital and their agents. 
Other common sources of blood-poisoning among 
patients are a lack of thorough personal cleanliness 
and disinfection of hands, nails, hair, and clothing 
among doctors and attendants ; carelessness in cleans- General Suggestions. 
11 
ing instruments; the indiscriminate use of sponges 
for surgical cases (tow and cotton wads, which can 
be destroyed after one using, are recommended as 
substitutes for sponges) ; dangerous nearness of the 
post-mortem rooms, and unchecked communication 
between post-mortem rooms, or the out-door sick 
department, and the wards. The death-rate from 
such local causes, from bad construction and dirty 
ways, if honestly recorded, would be the right index 
of the sanitary condition of a hospital; the charac- 
ter of the cases admitted being always taken into 
proper account in tables of comparative mortality. 
Ratios of illness.—But foul air and other septic 
influences not only create special diseases and thus 
kill outright a certain percentage ; they lower the 
vital force of all the inmates of a hospital; they com- 
plicate the ailments and retard the cure of a large 
number of patients. The dead are not the only 
victims. Lyon Playfair has stated at a meeting of 
the British Social Science Association, computing 
for Glasgow, that for every death in that community 
thirty-four people were ill, each on an average eigh- 
teen and a half days; or, in other words, that for 
every death we must count six hundred and thirty 
days of illness. Until recently, the estimates forEng- 
land were higher, making for each death, two per- 
sons constantly sick, or seven hundred and thirty 
days’ disability; the count being based on cases of 
acute sickness or injury which incapacitates for the 
time from labor—chronic ailment or infirmity, such 
as paralysis or blindness, not included. In New 
York, taking working people alone, and tenement- 12 
Hand-Book for Hospitals. 
house populations where sound health is an excep- 
tion, the constant ratio of the sick to the well is 
often as high as one third.1 
A large portion of this ratio of disability repre- 
sents time spent by laboring people in the sick-wards 
of public institutions. When the bread-winner of a 
little family dies in a hospital in consequence of the 
evil atmosphere of the place, or other preventable 
cause, we lament the increase of the public burden. 
But the lingering illness of any laboring person in a 
hospital—or out of it for that matter—is also a pub- 
lic burden: it is a money loss directly and indi- 
rectly ; it increases the taxes and lessens, for the 
time, the number of producers; every case of sick- 
ness in a community being equivalent, on an average, 
to a loss of fifty dollars. Account must also be 
taken of the lowering of the ability to labor of those 
who survive; and the transmission to children born 
afterward of weak and sickly constitutions. Wise 
economy, no less than humanity, requires us to 
adopt the best plans of construction, the best meth- 
ods of management, for all our hospitals, poor- 
houses, and asylums, if we would avoid adding a 
complete institution-pathology to that of vice and 
misfortune. The right way in every respect is the 
cheapest way. Registration reports in Great Britain, 
conducted by Dr. Farr, show a steady decline in the 
death-rate; he estimates that from 1870 to 1880 
about a quarter of a million persons were saved 
from death, and three million saved from a sick-bed, 
1 Dr. A. N. Bell : Ninth Report, New York State Board of Char- 
ities. General Suggestions. 
13 
as a result of a better general knowledge and 
enforcement of sanitary laws, in that country.1 Im- 
proved hospital management, isolation of communi- 
cable cases, systematic disinfection, employment of 
trained nursing, have all aided in this result. 
Pauperism and medical charity.—A hospital 
may be so arranged as to kill more than it cures; 
and so administered as to spread the spirit of pau- 
perism among the well-to-do.2 It is one indication 
of good management if a public institution is made, 
as far as possible, self-supporting ; provided conva- 
lescents are not unduly detained in hospital for the 
sake of cheap labor, convalescing and being ill by 
turns, a common but false economy; and provided 
that “ paying patients ” are not multiplied to the 
exclusion of those destitute persons for whose relief 
public hospitals and insane asylums, supported by 
taxation, are established. 
No hardship is imposed on the poor when they 
are trained to be provident ; when for hospital or 
dispensary treatment those whom thorough inquiry 
has proved able to pay are required to pay a moder- 
ate sum, which otherwise would often be wasted in 
tawdry finery, or other forms of selfish indulgence. 
A carefully arranged system of medical relief is un- 
doubtedly a check to pauperism. It helps many a 
poor family to tide over the time of distress which 
sickness or accident brings. But indiscriminate med- 
ical charity may do as much harm as indiscriminate 
alms-giving of any other sort; and dispensary and 
1 See the Report of Massachusetts State Board of Health, 1883. 
2 Professor Huxley : Address at Baltimore. Hand-Book for Hospitals. 
hospital practice in New York City at least, shows a 
lamentable increase of late years in the number of 
patients of a better class who are not ashamed to 
accept the unpaid services and resources which 
should be reserved for the really poor. The multi- 
plication of dispensaries for special practice and 
clinical instruction adds to this difficulty. Hospital 
managers also often show a mistaken pride in mag- 
nifying the supposed amount of good that has been 
done, by their annual statements of the large number 
of free patients admitted. Where patients them- 
selves, or their relatives and friends are encouraged 
to pay even a little toward hospital care, self- 
respect and family interest are more likely to be 
preserved. 
If we do not adopt the broad assertion of some 
political economists that hospitals foster pauperism, 
we must admit that our ample charities, both public 
and private, and their lax administration have done 
something to encourage improvidence, and to 
weaken a sense of family obligation. The question 
is pertinent whether social welfare is not likely to 
be best promoted by reducing our system of poor- 
houses and hospitals with their attendant evils to a 
minimum ; by individualizing charity, and making 
the family—the home—the centre or unit of our 
efforts, through some well-organized plan which 
shall combine volunteer investigation into the cases 
of individual applicants, and personal knowledge 
of their wants, with official or professional relief. 
The family tie among the poor needs all the help 
we can give it; any thing that weakens it does harm General Suggestions. 
15 
to all. When the head of a household is in hospital, 
the little family is often scattered, and estrangement 
begins. John Burns, with a broken leg, surrounded 
by comforts at an up-town hospital, fretted to “ get 
home,” and after many evasions of the reason, at 
last it came out : “ They ’re very good to me here ; 
beefsteak and oysters, and ladies a-standing at the 
foot of the bed and asking me to try and think of 
something more that I want ; but if I was there I 
could mind the childer as I lay in bed, and she could 
go out to work and get bread for us all.” Or take a 
wife’s story from the same hospital. The usual 
preliminary questions were asked: “Are you a 
married woman?” “No, ma’am; not exactly.” 
“ Do you mean that you have lost your husband ? 
You are a widow ?” “ No, ma’am. I took sick and 
went to a hospital and he left me.” These are types 
of many cases. If these could have been equally 
well nursed at home, the children would not have 
gone hungry ; the wife and the husband need not 
have parted. 
Preventive measures are always wisest. Let the 
poor be taught and helped to avoid the causes of 
disease ; let there be strict sanitary legislation, and 
the honest enforcement of laws in regard to tene- 
ments, school-rooms, factories, and markets ; then, 
if we could have a good provident dispensary system, 
like the English system, supplemented by missionary 
nurses and diet kitchens, hospitals might become a 
much less costly item in our appropriation bills.1 
1 Dr. W. Gill Wylie: “ Relations of Hospitals to Pauperism.” 
Popular Science Monthly, October, 1876. 16 
Hand-Book for Hospitals. 
But hospitals, to a certain extent, will always be 
needed, and the main question recurs : How shall 
we cure the patients in the quickest and cheapest 
way ; how shall we reduce the dangers which inevit- 
ably spring from collections of sick and wounded 
people under one roof? Disperse the patients, we 
answer, as widely as may be consistent with economy 
and convenience of professional care and nursing ; 
classifying them strictly as to disease, age, sex, and 
condition, i. e., their liability to imbibe infection, or 
to cause infection in others. To accomplish this 
dispersion and classification, how should a hospital 
be built ? II. 
The Hospital Building. 
POPULAR interest in hospital reform in this country 
dates from 1861. Early in our Civil War the task 
of preparing a model plan for a government hospital 
in Washington was assigned to a committee of the 
United States Sanitary Commission: Dr. Wolcott 
Gibbs, Dr. C. R. Agnew, and the late Dr. Wm. H. 
Van Buren. The plan prepared, with some modifi- 
cations made by military authority, was followed. 
About the same time a distinguished French officer, 
addressing the French Academy on his former ex- 
perience as sanitary inspector of the army in the 
Crimea, said: 
“ An ideal hospital would be a small hospital, 
with small, detached wards, well ventilated, and with 
beds far apart, remote from centres of population, 
and surrounded by open walks and grounds. Hos- 
pitals that are situated in the outskirts of towns— 
in the open field, so to say—have always seemed to 
me more healthy, and have produced more cures 
than institutions smothered in populous quarters or 
simply surrounded by an ordinary city atmosphere. 
Though the air-supply be as generous as possible, 
and the ventilating apparatus complete, in reality 
the air of the wards, even at its best, will be just 
what the air of the street happens to be, no better. 18 
Hand-Book for Hospitals. 
Abundant air-supply will not suffice if the air itself 
is deprived of its life-giving qualities, or is inter- 
mixed with poisonous matters. Air is vitiated when 
it is scorched by contact with overheated iron sur- 
faces either in the ward or before entering it; when 
it is borrowed from close corridors, from staircases, 
and lobbies on which water-closets open ; or when it 
is drawn from dirty streets in a packed neighbor- 
hood, where perhaps other hospitals, or cemeteries, 
factories, tenement-houses, and many mephitic 
centres spread abroad their harmful emanations.”1 
The approved plan requires one-story wards, or, at 
most, two, raised on piers or arches, that the air may 
circulate freely; the ground beneath being coated 
with asphalt or other smooth dry surface; or, the 
wards may be placed over a fairly high, light and 
well-ventilated basement, which can be kept closed, 
or thrown open in suitable weather ; the wards are to 
be built of wood where the fire laws permit, or of 
brick, with a “ damp course ” of slate or asphaltum. 
There is to be nothing within the four walls except 
the patients, their beds, tables, and chairs; the 
water-closets and service-rooms, the drainage-pipes, 
and whatever is necessary to make each such ward 
almost an independent hospital, being built outside 
it, in what can be a permanent and even two-story 
annex. The wards, which may be grouped in vari- 
ous ways, must stand apart by a space three times 
their height, that one may not cast a shadow on the 
next. The roofs are preferably ridge-ventilated, and 
1 Michel Levy, Consulting Member of the Board of Health of 
France, 1862 : “La Salubrite des Hopitaux.” The Hospital Building. 
19 
the ceilings finished on the rafters, not plastered. 
Connecting corridors, when climate .requires them, 
are either entirely open or are well aired by side 
sashes, and never lead directly to the ward, but into 
the annex or service-building. The administrative 
offices and kitchen for a group of wards occupy a 
central position.1 
Detached wards have been used in Europe for 
several years with good results ; as at Kiel, Berlin, 
Leipzig, Heidelberg, Glasgow, Manchester, and at 
Rotherham, England, where there is a children’s 
hospital of one hundred and fifty beds, all in one- 
story pavilions. “ On the continent, the majority of 
those who have given much attention to the subject 
prefer wards of one-story, and isolation and separa- 
tion of the various buildings.” 2 
In America attempts in this direction have been 
made at the Roosevelt Hospital, New York ; and at 
the Presbyterian Hospital, Philadelphia. There are 
two very good one-story detached pavilion wards, 
for twenty-eight beds each, on the grounds of the 
City Hospital, Boston. The frames of these two 
wards are sheathed with boards, covered outside 
with corrugated iron ; the roofs are slate. They 
were cheaply constructed under the theory that after 
a few years’ use they ought to be destroyed and re- 
1 Hospital buildings should always be so constructed as readily to 
permit the addition of wings, which can be built, as occasion requires, 
to meet the needs of a growing community. Hence it is important, 
in purchasing land at the outset, to have enough space for new struc- 
tures.—Eds. Third Edition. 
2 Dr. J. S. Billings, U. S. A. Hand-Book for Hospitals. 
20 
placed by others of similar character. They have 
now been in use seven years and their sanitary con- 
dition has been excellent.1 The Massachusetts 
General Hospital has four one-story wards, two of 
them of the same temporary character, which have 
all proved satisfactory. The U. S. Marine Hospital 
service has adopted improved one-story plans for its 
new hospitals, which also furnish good models. 
The bed is the unit.—Hospital visitors, through- 
out the State, ought always to throw the weight of 
their advice in favor of the most enlightened prac- 
tice. The custom of piling sick people in layers 
three or four stories deep should be abandoned, and 
simpler buildings, detached, on wider spaces of land, 
substituted for the present dangerous agglomerations 
of cases. The bed is the unit of hospital administra- 
tion ; in addition to medical care, the precautions 
which surround it, the quality of the nursing, and 
the air-supply are the measure of the hospital’s suc- 
cess. Having established for this unit the best sani- 
tary conditions possible, we may proceed to group 
a few beds and make a ward, and, finally, to group 
detached wards and make a hospital. The cottage, 
or one-story pavilion plan, wherever it is possible to 
adopt it, not only for hospitals, but for our con- 
valescent homes, orphanages, asylums, and infirm- 
aries would break up the mechanical routine of our 
public institutions, which is inevitable where there 
is a large household with a limited number of at- 
tendants, and would give them something of the 
cheerfulness and naturalness of ordinary life. The 
1 Dr. G. H. Rowe, resident physician (1883). The Hospital Building. 
2 1 
true principle in providing for dependent and defec- 
tive persons is to classify them as closely as pos- 
sible, and to make each class in any one building 
small. 
The points in the argument for one-story wards 
may be summed up thus: 
1. Experience and science agree in showing that 
widely-detached, one-story wards allow the most 
thorough ventilation, and therefore the smallest 
chance for the accumulation of infectious particles. 
A gale of wind may prove a better disinfectant than 
a barrel of carbolic acid. 
2. They neutralize the evils of massing large 
numbers of cases, or varieties of cases, under one 
roof. They make classification of cases easy and 
natural. In the chance of a case of contagious 
disease showing itself, the ward only and not the 
whole hospital is endangered. 
3. One-story wards require less vigilance; dust 
and foul air find fewer lurking-holes and channels; 
cleanliness and ease of supervision are more readily 
secured. Two-story hospitals may be kept healthy 
for a few years with extreme care and intelligence. 
Hospitals of more than two stories ought never to 
be contemplated. 
4. A ward hopelessly poisoned by long occupation 
can, if detached, be torn down and another one built 
without disturbing the general order; and when 
additional accommodation is necessary, other wards 
can be added one by one. 
5. An advantage of one-story wards which visitors 
will recognize is the ease with which patients can be 22 
Hand-Book for Hospitals. 
taken, bed and all, out of doors in fine weather. 
Even the very feeble can be rolled out on the grass 
by an incline, if the height of the under-pinning 
allows, or be wrapped in a blanket and carried out, 
with no fatigue of “getting ready.” If fire occurs, 
the peril may be limited to one ward, while rescue 
of the patients is obviously easier.1 
Question of cost.—As to the expense of building 
a large hospital in detached cottages, it is possible 
that heating arrangements and service might be 
1 Since the above was written, the teaching of Pasteur, that germs 
or bacteria cause most diseases, has become generally accepted, and 
Lister’s practical and thorough use of antiseptics in the treatment of 
wounds has gradually taught the medical profession that cleanliness 
is the greatest law of surgery. Since the great importance of cleanli- 
ness has become generally recognized and its existence absolutely 
demanded by surgeons, supplemented by the rational use of anti- 
septics, it has been clearly and unmistakably shown that puerperal 
fever, hospital gangrene, erysipelas, and almost all forms of sepsis 
and pyaemia, originate more surely from a want of cleanliness in the 
hands of doctors and their assistants, or from unclean instruments, 
sponges, towels, etc., which come directly in contact with the wounds, 
than from infected walls or old buildings; and, to-day, where the 
best methods of practical surgery are carried out, even in old build- 
ings, patients rarely die of septic poison ; and hospital gangrene is 
practically an unknown disease to students of medicine. Puerperal 
fever is almost unknown even in public lying-in hospitals ; and sepsis 
after surgical operations is so rare, that even when a case of abdomi- 
nal surgery dies of sepsis, it is ordinarily known to be the fault of the 
operator or his assistants. Thus, some of the arguments for the build- 
ing of surgical wards, which can be readily destroyed and renewed, 
have to be abandoned in view of the teachings of modern surgery, 
and the blame for failure should be placed where it belongs ; viz., 
upon the surgeon and his assistants and employes, for a lack of proper 
cleanliness and proper surgical methods, and not upon the buildings. 
—Eds. Third Edition. The Hospital Building. 
23 
dearer; the cost of construction would be less than 
on the big-house plan, for massive walls, founda- 
tions and staircases would be unnecessary; greater 
ground-space would be needed, the more the better ; 
the allusion here is to out-of-town hospitals, where 
land in larger tracts may be had at cheaper rates. 
But hospital construction is not a question wholly 
of saving money; it is a question of saving life. 
“We are persuaded that the liabilities incurred by 
increasing the population to surface area are so 
manifold as to render it very unwise to construct 
two or more stories of wards for a permanent hos- 
pital. Nor do we believe that pavilions of more 
than one story are more economical in construction 
and management. The only plausible reason urged 
in favor of multiple stories of wards is the want of 
adequate ground-space, as in the location of hos- 
pitals in the built-up portions of cities. But it is 
questionable whether even that excuse will much 
longer avail; all modern scientific inquiries into the 
conditions under which the sick recover tend to 
prove that hospital sites should be selected where 
there is ample area, and hence in suburban rather 
than in urban districts.” 1 
The site.—In order to determine how nearly 
the ideal is reached, the first most important point 
to consider in visiting our public hospitals is their 
site. This is the point at which sins in hospital- 
building are generally first and irredeemably com- 
mitted. The site should be as open as possible, so 
as to secure the breeze from every quarter, and 
1 Dr. Stephen Smith. 24 
Hand-Book for Hospitals. 
somewhat elevated, so that all dampness can be 
drained off. Stagnant water or ponds or streams 
near by, used as receptacles of sewage, will make 
the finest building untenantable. Do not fail to 
examine the neighborhood with both eyes and nose, 
and to study the slope of the land and the character 
of the soil. Remember that if the recovery of the 
sick is the object of hospitals, these should never be 
built among dense populations or on bad soil; if 
medical schools are the avowed and sometimes legiti- 
mate object of hospitals, twice the number of cases 
can be brought under the notice of students in a 
given time, and thus medical education be better 
promoted in hospitals where a healthy, open site 
favors rapid recovery and discharge. Means of 
swift transportation are so much improved that, 
except for accident cases, absolutely no hospital 
provision need be made within the limits of towns. 
Our American towns, it is true, grow so fast that 
they sometimes spread and surround a hospital 
which may once have been in the outskirts. 
Wherever a new hospital is projected, let vis- 
itors use their influence in persuading the town 
authorities, or the benevolent persons who under- 
take the work, to put a smaller share of their fund 
into “ monumental structures ” and a larger share into 
land, thus securing the first necessity, an ample 
building site. If there is not money enough to build 
as large a hospital as the needs of the town require, 
let visitors recommend that enongh land be pro- 
vided at the outset, all the same, and held in reserve, 
and that part of the supposed need of hospital The Hospital Building. 
25 
accommodation be first supplied by one or two cot- 
tage wards on open ground. 
Wherever there is an old hospital, cramped and 
crowded, and money can be had for improvements, 
let visitors urge that the first improvement consist 
not in building a “ new wing,” but in buying adjoin- 
ing lots, if possible, so as to widen the air-space 
about the old buildings. For every fifty patients in 
a hospital there should be about one acre of site, so 
as to allow proper dispersion of wards. 
Size of hospital.—Before beginning to build a 
hospital, the proportion of sick poor likely to apply 
for admission should be carefully estimated, and the 
number of beds, that is, the size of the hospital, 
determined. Experience shows that one bed to 
every thousand inhabitants in a large town is a fair 
proportion. There are instances of towns where 
benevolent efforts of this sort have outrun the de- 
mand, and hospitals, fully equipped, remain with 
merely a handful of patients, the running expenses 
being almost as large as if the beds were all full. 
For fifty patients there should be accommodation 
for sixty beds, so that there may always be a few 
beds in reserve, and that wards may be emptied and 
cleansed in rotation. 
Care of grounds.—Foliage serves to filter the air 
of dust and absorb noxious gases. Trees and 
shrubs, therefore, are desirable near a hospital; but 
they should never be allowed to shade either the 
buildings or the grounds too densely. Decaying 
vegetation and dampness are objectionable; great 
care should be taken to keep gardens and ornamen- 26 
Hand-Book for Hospitals. 
tal grounds in order: and instead of deciduous trees 
the growth of trees and plants which tend to neutra- 
lize malarious influences—especially those contain- 
ing resinous balsams, such as pines, spruces, and 
hemlocks—should be encouraged. 
Building material.—Wood, or porous brick, is the 
best building material for country hospitals, with 
under-pinning of adequate strength and height. 
Poor brick, cheaply laid, makes a poor, shabby 
building; and experience has shown that brick asy- 
lums are no more fire-proof than wooden ones. 
Frame wards, well built and kept well painted, will 
prove strong, warm, and durable. 
Points of compass.—A hospital should never be 
built round a closed court. Whether it have one or 
more stories the long axis of all its wards should run 
as nearly as possible from northeast to southwest, 
so that the sun can dry the walls, and cheer the 
place by shining in at the windows, on one broad side 
or the other, the whole day ; the part of the ward 
presented to the north, or shadow side, being the 
narrow end. The ends of the wards should never 
terminate in lobbies, or be obstructed by service- 
rooms, water-closets, or staircases, but should open 
by windows or wide glass doors, with transom sashes 
above them, to the free air. Currents of air take 
the direction of the longest axis; the end-to-end 
ventilation is worth more than the cross-current, 
because a larger body of air is moved with the same 
amount of impetus ; it sweeps a ward clean in a few 
minutes, through and through, and exposes the 
patients who are in bed less to draughts. The annex The Hospital Building. 
27 
containing water-closets and other service-rooms 
should be built at the north end of the ward, but a 
little at one side, so as not to interrupt the air currents. 
Vital conditions.—Even the smallest hospital 
may be planned in a way to secure many of the ad- 
vantages of detached buildings ; the wards being 
separated by a ventilated corridor from the portion 
of the building reserved exclusively for administra- 
tive purposes, officers’ room, kitchen and store-room. 
The laundry and the dead-house must of course be 
constructed outside. Mixing up together indiscrimi- 
nately sick-wards and household rooms and offices is 
one of the most common mistakes; it increases the 
risks for both patients and officers, and forms one of 
the usual causes of low-fever cases among the latter. 
Simplicity is an essential of good hospital con- 
struction. Abundant light and ventilation through 
every part and on every side of a sick-ward 
can only be secured by separating the departments 
so far as possible. Complication of plan betrays 
ignorance of hospital requirements. Every hole and 
corner, every passage, every needless small room 
interferes with light, ventilation, cleanliness, dis- 
cipline, and facility of supervision—the vital condi- 
tions of a good hospital. “ Every skulking-place 
which can be spared must be avoided. Every five 
minutes spent upon cleaning what had better not 
have been there to be cleaned, is something taken 
from and lost by the sick. As an invariable hospital 
rule, publicity may be considered the best police 
and the best protection against filth and disorder.”1 
1 Florence Nightingale : “ Notes on Hospitals.” 28 
Hand-Book for Hospitals. 
Whatever the general plan of building may be, it 
is a serious error to build wards opening directly 
into one another, as at Bellevue and elsewhere, 
thus making a common atmosphere and doubling 
risks. In old buildings of this construction, let 
visitors inquire if it is not possible to close up 
the connection between rooms, and even to floor 
over staircases, removing the staircases and water- 
closets, and rebuilding them in spacious towers, 
outside the hospital, thus isolating one floor from 
another. 
Square wards, with beds all round, are generally 
undesirable. With square wards, some beds must 
be in corners, on sides away from windows, and the 
closets and baths are brought too near to the ward. A 
nurse needs to take in her ward at a glance, running 
her eye along the two rows of beds, as an officer 
does along the company line, and seeing at once the 
urgent necessity of any patient. But for the pa- 
tients themselves, sometimes, square wards, like 
the Warren Ward in Boston, have a pleasant aspect, 
and the “corner bed” gives a coveted chance for 
privacy now and then. In a square ward, also, the 
stove or fireplace and the air-shafts may be put 
in the centre of the ward, and thus more nearly equi- 
distant from all the beds; whereas in a long ward 
two fireplaces and two shafts are needed. Square 
wards, where these are preferred, should be small 
wards for a small number of beds, for the square 
should never be more than thirty feet. If that size 
is exceeded, the sunlight will not so completely reach 
all parts of the ward ; and the surface of the ground The Hospital Building. 
29 
beneath will be too far removed from the purifying 
effects of air and light. 
The size of a ward, and the number of beds which 
may properly be put in any given space, are fixed 
by sanitary necessity; but there is hardly a point in 
the arrangements of hospitals or of asylums for any 
purpose, as visitors will note, so much neglected as 
this. Large wards save extra nurses; one head 
nurse can overlook two or three assistant nurses and 
from twenty to thirty patients if they are not too 
much scattered. Small wards with from two to 
half a dozen beds are objectionable in working a 
large hospital. They increase labor, and are diffi- 
cult of supervision. The smaller the ward the 
larger should be the proportion of cubic space al- 
lowed to each bed in it; for small wards, where 
there are two sizes in use, are apt to be reserved for 
the worst cases. Besides, a certain amount of space 
is needed for diffusion of air; a large room is ven- 
tilated more easily than a small one, but, it has been 
said, you cannot ventilate a crowd, even in the open 
air. 
Cubic space.—As a rule, each bed in a medical 
ward should have at least eight feet of wall space; 
each bed in a surgical ward, ten feet of wall space. 
Room enough should be left between the head of 
the bed and the wall to allow a nurse to pass; and 
the aisle down the middle of the ward should be 
from ten to twelve feet wide. The width of the 
entire ward should be from twenty-eight to thirty 
feet, and the length may be twice, or three times, 
or four times the width, but never more than that. 30 
Hand-Book for Hospitals. 
Fourteen feet is a good height for the ward walls. 
A raftered ceiling and openings at the ridge, or on 
the car-roof plan, will increase the air space and im- 
prove the ventilation. In a hospital of say fifty or 
sixty beds, sixteen beds in a ward is a good basis of 
calculation for medical cases, the ward proportions 
in that case being sixty-four by thirty by fifteen feet, 
if the ceiling were flat. This gives an average of one 
hundred and twenty square feet of floor-area to 
each bed, and eighteen hundred cubic feet of air- 
space. 
Formerly, before the days of modern antiseptic 
surgery, it was necessary to give ampler air-space in 
the surgical than in the medical ward, and now where 
sepsis shows itself, the space needed is easily gained 
by removing a certain number of beds. Remove 
every alternate bed in a ward of the size described, 
and you have three thousand six hundred cubic feet 
of air-space for each surgical case. The Warren 
and Jackson cottage wards of the Massachusetts 
General Hospital give, the one eighteen hundred 
and forty, the other three thousand cubic feet of 
space per bed. The larger figure is the much safer 
rule with severe surgical cases.1 As one or more 
nurses must always be on duty night and day, they 
must be considered in calculating the allowance of 
air. It is assumed that all the beds will not be full 
at the same time. The proper width and height of 
a ward are nearly fixed figures. The length may 
more properly vary. When a hospital grows and 
more room becomes necessary, short detached wards, 
1 Esmarch. The Hospital Building. 
31 
where the ends are left free, may be lengthened a 
little without any change in their width. 
Crowding is a relative term. A number of bad 
cases in a ward may overfill it in a sanitary sense, 
although half the beds are empty, because the air 
will be more rapidly fouled. The over-crowding of 
well people, if long continued, we know will pro- 
duce some variety of fever, while the over-crowding 
of wounded people, either accident cases, or cases of 
operation, or of suppurative disease, will be sure to 
develop hospital poison in some form or other. It 
is the nature of the cases, and not the number only, 
which causes contamination of the air and creates 
danger. 
A little knowledge of the character of the cases 
admitted to a hospital, and of the significance of 
their symptoms—knowledge which may be pos- 
sessed by any intelligent person, superintendent, 
visitor, or head nurse, without the least trespass on 
professional ground—would help the judicious dis- 
tribution of patients in certain wards. It is not 
enough understood, for instance, how sensitive to 
septic poison are cases of burns, nor what a source 
of danger they become to others when the suppura- 
ting surface is extensive, making isolation for them 
imperative. Lung diseases, sometimes, make as bad 
an atmosphere as surgical cases. 
If no regard is paid to the character of cases 
crowded into a ward, or if five people are to sleep 
in three beds, as has happened at times in public 
hospitals in New York City and vicinity, it hardly 
matters what the “ regulation ” cubic space may be. 32 
Hand-Book for Hospitals. 
Wards which to the inexperienced visitor seem 
fresh and pleasant by day, with the windows open 
and a summer breeze blowing, if inspected in winter 
and by night, or worse still, at five o’clock in the 
morning, might be found very foul. 
Professor Erichsen’s rules.—From experience 
in his own hospital, Erichsen gives seven as the 
number of patients with open wounds who can be 
put in one of his wards of fourteen-bed size with 
moderate safety. Among the simple rules which 
he lays down a few may be selected. They all 
concern points which properly come under the 
observation of a visitor, or a head nurse, and if 
enforced, would go a long way toward keeping the 
wards healthy. 
“ i. The isolation of patients suffering from old 
or foetid ulcerations, more especially those of a can- 
cerous character. 
“ 2. The separation of patients with suppurating 
wounds from one another by putting in the next 
bed unwounded patients. 
“ 3. Care not to allow more than one half of the 
patients in any given ward to have suppurating 
wounds, even if these wounds be trivial; nor more, 
if possible, than one third if severe. 
“ 4. Instantly to isolate all cases of septic disease, 
“ 5- To compel the nurses to wear dresses that 
can easily be, and that frequently are, washed. 
“6. The frequent purification of the bedding, the 
blankets more especially, which are often very 
imperfectly cleaned and purified, and, like all woolen 
fabrics, harbor infection long and tenaciously. The Hospital Building. 
“7- To close every surgical ward once a year, for 
a month, during which time it should be disinfected 
and cleaned. 
“ 8. And above all, and under all circumstances, 
to avoid over-crowding, for however short a time.” 1 
The ward windows should take up one third of 
the wall space ; this is one of the fixed laws of hos- 
pital construction. The windows should be on 
opposite sides, at least one window between every 
two beds in medical wards, and one window for 
each bed in surgical wards. We can warm a room 
artificially, but it is beyond our power to create an 
equivalent for sunshine and the vital influences, 
physical and moral, which it brings into a sick-room. 
Even in warm climates, in midsummer, it would be 
better to have windows enough and large enough, 
and to shield the ward from glare by outside blinds 
or canvas awnings. Inside slatted blinds are objec- 
tionable ; they are capital things for collecting dirt. 
Where they are not properly cared for, a thick paste 
of dust and organic filth can be scraped from the 
slats at any time. Hospital windows are much 
better without them. The window-sills should be 
within two feet of the floor, and the sashes not less 
than three feet wide, and reaching to within one 
foot of the ceiling. A transom or panel, ten inches 
deep, and as wide as the window-frame, should be 
hung in the wall over each window, hinged at the 
bottom, so that it would open at the top. Or the 
window should run up close to the ceiling, and its 
upper sash should be hinged for opening inward by 
1 Lectures on Hospitalism ; University College, London. 34 
Hand-Book for Hospitals. 
cord and pulley, or some proper mechanism ; other- 
wise all the upper part of the room will be a reser- 
voir of overheated and bad air. 
An excellent plan, and one which visitors can 
recommend as easy of adoption in old buildings, is 
to make the window-sashes in three cross-sections 
or flaps (instead of the ordinary two sashes), hinged, 
one or all, at their lower edge, opening inward at 
any desired angle, and closed by cord and pulley or 
some mechanical ratchet and crank. This plan is 
already in satisfactory use. The window-frame in 
this case is the better for being deep, as it prevents 
side draughts ; or a triangular piece of plank may 
be nailed to the upper part of the window-frame, 
projecting in a way to close the side opening when 
the upper sash is let down. Other forms of window 
ventilators are mentioned in the chapter on Air- 
Supply. 
In exposed places, where the sashes are double, 
the lower part of the outside sash may be made to 
hang on hinges and open outward by a metal rod or 
arm, while the upper panes of the inside sash, also 
hinged, let down inward. A steady current of air, 
slightly warmed by passing between the glasses, is 
thus secured, and the glass can be reached and kept 
clean. If double sashes slide up and down in the 
ordinary way they are troublesome to manage, and 
you get an additional and perhaps undesired cold 
draught from the opening across the middle. Large 
sashes hung with weights are heavy for a woman 
nurse to push ; ropes knot, rot, and break ; windows 
are left shut in cold weather, and ventilation comes The Hospital Building. 
35 
to an end. With hinged panes and cords passed 
through a screw eye, and hanging within easy reach, 
there is no excuse for negligence. Large panes are 
better than small ones, because there are fewer 
joinings and ledges ; and good thick glass is warmer, 
and in the end more satisfactory than a poor quality 
of glass. 
Lifts and staircases, required in two- or more- 
storied hospitals, add greatly to the expense of 
construction, and have many disadvantages. Where 
there are staircases visitors must note whether they 
are fire-proof, and fitted with strong handrails, and 
wide enough to allow a stretcher to pass up and 
make the turns on each platform. 
Extra staircases in a large building are necessary 
as means of escape in case of fire, but in ordinary 
use they are bad for discipline. It would be better 
in a small hospital to have one common entrance 
and only one main staircase, and to compel all the 
coming and going to be done by one channel under 
constant observation. Pharmacies or other offices 
into which attendants or patients are allowed to go 
and shut the door are subversive of discipline. 
There should be a window or hinged panel in the 
pharmacy or office door, and every one should be 
required to wait outside for the answer to the errand. 
Piazzas.—In two-story hospitals, where the wards 
for men are below and for women above, an upper 
piazza or out-door gallery should be provided for the 
women. It should open directly from the wards in 
such a way as not to intercept light and air, and if 
used as a sunning place for patients would be an 36 
Hand-Book for Hospitals. 
excellent thing. The floor should be on a level with 
the ward floor so that the convalescents, able to roll 
themselves about in chairs, may go in and out as 
they choose. The men also need their own sunning 
place. Window balconies are not enough ; men 
patients especially need space to move up and down 
in, and a place where they can smoke should be 
set apart for them ; it goes a long way toward 
keeping them good-humored and making them well. 
Pitching a roomy tent for them on the grass, where 
there is space enough for it, is a good plan in sum- 
mer. 
Panic from an alarm of fire is a distressing risk 
which must be constantly faced in buildings of mul- 
tiple stories. All public hospitals and poorhouses 
should be provided with fire-escapes ; and the duty 
is imperative of providing and keeping in ready 
condition, fire extinguishers, water-buckets, a suffi- 
cient length of hose conveniently reeled, force-pump, 
axes, ladders, or whatever may be necessary in the 
emergency of fire. Hospital employees should be 
drilled at stated times in the use of such apparatus. 
Day rooms.—A pleasant sitting-room, exposed to 
the sun, where convalescent patients may sit during 
the day to read or sew, aids their recovery. They 
are thus removed from those who are still confined 
to their beds in the wards, and a long day is made 
less tiresome. A separate dining-room also is re- 
quired, and is spoken of elsewhere. Visitors ought to 
urge all the points mentioned above wherever neces- 
sary ; they must beg also that in old hospitals, or in 
the absence of isolating huts, a separate room here The Hospital Building. 
37 
and there be kept in reserve for temporary use for 
special cases. 
Tents for summer.—The plea should be made at 
every old hospital for one detached ward, at least, 
for the surgical cases. Or, following what has been 
the custom at Charity Hospital, Berlin, and the Can- 
tonal Hospital, Geneva, the detached ward (which 
in that case might be a large wall tent, or might be 
built without heating apparatus other than a small 
stove), could be reserved for all the patients of one 
sex in summer, so as to give opportunity for emp- 
tying and airing for a month at a time the winter- 
used wards of the main building. During the five 
months of warm weather the expedient of tents for 
open-air treatment of the worst surgical cases has 
been successfully tried at the City Hospital, Boston. 
Two large tents are used for twenty patients each, 
and five smaller tents for special cases. In addition, 
there are small tents for commissary purposes, with 
water and drainage convenient, and the arrangement 
has proved highly satisfactory, and of great value in j 
the recovery of serious cases.1 
Isolating huts.—One or two little cottages or 
huts, for the purpose of isolating cases of infectious 
disease, should be built on the grounds of every 
hospital ; these huts to be burned up every two or 
three years. In the appendix will be found a de- 
scription of an isolating cottage for three beds, two 
patients, and a nurse. The plan was furnished by a 
member of the State Charities Aid Association, and 
the cottage was built on the grounds of the Presby- 
1 Dr. G. H. M. Rowe, Resident Physician and Superintendent. Hand-Book for Hospitals. 
terian Hospital, New York. It is a good model for 
such isolating huts elsewhere. Similar cottages 
have been built at the Woman’s Hospital. In a 
general hospital there should be two such huts, to 
prevent the scandal of the mixing of the sexes, 
which, gross as it seems, has, within the writer’s 
knowledge, been authorized by hospital officers 
either ignorant or indifferent concerning the require- 
ments of decency. 
New hospitals often receive a large proportion of 
chronic surgical cases—that is, tedious and offensive 
cases, requiring isolation. It is the part of wisdom 
to anticipate this need, and to make provision for 
such cases by building detached huts. Where there 
are enough wards to leave one or more at all times 
unoccupied, and completely exposed to the air and 
sun, the great danger of gradual contamination of 
wards is lessened. The rule given by experts is 
that one twelfth of all the beds in a hospital should 
be always empty. Much may be done to obviate 
the evils attendant on multiple-storied, obsolete old 
buildings, by rigorous cleansing of the wards, by 
conscientious, intelligent care of individual cases, 
and by antiseptic treatment where that method is 
pursued. But even with the best management, 
the majority of such hospitals cannot be made to 
give equally good results with those attained in a 
properly built hospital. Visitors must carefully 
note the maxims of construction and classification 
adopted by the Association, and enforced in these 
pages. They will be found summed up in the As- 
sociation’s fourth annual report, for 1876. III. 
Air-Supply and Heating. 
The air-space required for each bed has been 
stated, viz., from eighteen hundred to three thou- 
sand or more cubic feet; but what should be the 
air-supply ? It is not meant that a patient shall have 
his three thousand feet and no more ; for this quan- 
tity must be constantly changed, at least as often as 
once every hour, for the same bulk of entirely un- 
breathed air from out-of-doors. 
Clean air.—Every one connected with hospitals 
or asylums, visitors and nurses, should bear in mind 
—and it cannot be too often repeated—that we 
poison the air by our own exhalations, and that with 
sick people everything depends on getting them as 
much as possible out of their own atmosphere. But 
many people are afraid of clean air, and have to be 
urged to take it as if it were medicine. One would 
think from the objection many people, especially the 
poor and ignorant, have to fresh air, that it is a poison 
instead of a life preserver. Never fear fresh air ; it 
will be one of your most faithful allies in the treat- 
ment of disease. Provided a patient were kept warm 
enough, his chances of recovery would be much 
greater if he were hung outside of the ward win- 
dows, instead of being shut up within the ward walls.1 
1 Dr. Barnes : “ Notes on Surgical Nursing,” London. 40 
Hand-Book for Hospitals. 
Professor Esmarch says : “ The maxim must hold 
good for hospitals, that it is better for our surgical 
cases to have air a little too cold than foul air.” 
The change of air in a ward is rendered practica- 
ble by difference of in-door and out-door tempera- 
ture ; or by mechanical currents. The rapidity of the 
change depends on the size and number of openings, 
—of windows and doors,—and on the character of the 
wall-surface; and is increased by increased difference 
of temperature. The air-supply, however it is pro- 
vided, should not be subject to the fancy of patients, 
or even nurses unless they are trained ones. There 
should be fixed rules as to opening windows and 
ventilators, and employees should be required to 
obey them implicitly. To test the air of a ward the 
visitor should enter it directly after being in the 
open air fifteen minutes, and then notice whether 
there is any close smell. 
Night air.— If we breathe at all after dark we 
must breathe “ night air,” therefore the ventilation 
of the wards through the night should be carefully 
considered; for while air not vitalized by sunshine 
is less desirable, it must not be wholly shut out. In 
severely malarious regions evening air or early 
morning air should be cautiously admitted. It is a 
mistaken practice to let a ward get very close and 
foul (either by night or day), and then trust to spas- 
modic flushing with volumes of fresh air. The better 
way by night is to provide for a small, steady current 
of air, constantly flowing through the ward, and 
keeping the atmosphere fresh. The wards of a hos- 
pital, unlike the rooms of an ordinary house, are oc- Air-Supply and Heating. 
41 
cupied continuously, day and night. To the usual 
excretions from breath and skin are added special 
impurities. Suppurating w'ounds throw into the air 
pus-cells in a state of decay ; the urine and faecal 
discharges, poultices, and the contents of sputa cups, 
add to this dangerous mixture. The result is a “ foul 
stirabout ” of exceedingly minute solid particles, 
which, unless special and constant pains be taken 
to get rid of it, fastens itself upon wood-work, plaster, 
bedding, clothing, and everything which is in the 
least absorbent. In course of time, walls, ceilings, 
floors, and furniture receive dangerous deposits of 
infected dust. This is the explosive fuel which Mr. 
Simon warns us of. It is not strange that special dis- 
eases haunt the wards of old hospitals. The ventila- 
tion should be such as to leave no corner of a ward 
unsearched by a current. To build and manage a 
hospital in such a way as to secure enough pure air, 
winter and summer, is indispensable, if we are to 
maintain the right standard of hospital hygiene. 
Notice that the phrase used is pure air; ventilation 
plus cleanliness. 
How much is enough ?—The air-currents of the 
Warren Ward, in Boston, were measured on several 
occasions, in winter when fires were lighted, by the 
late Dr. George Derby. The supply of air was 
found to be enormous, and, what is important, there 
was no perceptible draught. On one trial air was 
found entering at the rate of five feet a second. 
There were four ducts which together gave 144,000 
cubic feet of air an hour. With twenty patients in 
the ward this was an allowance of seven thousand 42 
Hand-Book for Hospitals. 
cubic feet an hour for each, to be shared with the 
nurses, and with the doctors during their visiting 
time. Dr. Derby said : “ This is a great supply but 
there cannot be too much. On the whole, it is the 
best ventilated hospital ward I ever saw.”1 This 
was winter ventilation, and the method will be de- 
scribed when we come to speak of heating. 
Air-shafts.—Visitors do not always have the 
means of accurately measuring the quantity of air 
which enters a ward by the registers or air-shafts; a 
mathematical formula would be necessary, and an 
anemometer to determine the exact velocity of the 
wind. The best that visitors can usually do is to see 
that abundant and proper means of ventilation are 
provided, and that these means are really used. 
The sectional area of ventilating openings, where 
shafts are used, should average seventy-two square 
inches for each patient in a ward, doors and windows 
not counted. This includes inlets and outlets. 
Multiplying seventy-two square inches by the num- 
ber of patients, a visitor can judge whether there are 
air-flues enough and of sufficient size.* With an 
opening of say a foot square, and air coming in at 
five feet a second, and steadily kept at that rate, we 
should get in an hour eighteen thousand cubic feet 
of air. This is a fair supply for six persons ; but is 
less than half the quantity per patient which passed 
through the larger ducts of the Warren Ward, and 
which Dr. Derby did not find too much. The draft 
1 Annual Report of Mass. General Hospital, 1874. 
* Parkes’ “ Manual of Practical Hygiene ” gives tables of effective 
sizes of air-flues. A ir-Stipply and Heating. 
43 
at the point of entrance, with five feet velocity, 
would be about the same air-motion which is felt 
against the face in walking at the rate of three miles 
an hour in a still atmosphere. By the time the air 
has diffused itself in the room this velocity would 
probably not exceed, and ought not much to exceed, 
two feet a second, if it is cold air. 
Two or three large air-flues will be more effective 
than several small flues having an equal aggregate 
sectional area. With a view to reduce friction the 
inner surfaces should be smooth-finished, tight at 
the joints, and there should be few or no bends and 
angles—round flues being the best. The inlet and 
extraction flues are best kept equal in size. Care 
must be taken not to have foul air-flues too large, 
otherwise the current will play about in them or 
there will be down draughts. As a rule, air-flues 
should be short, and so built as to be easily got at 
and cleaned out. If there is any way of heating 
outlet tubes, they may be put anywhere in a ward. 
If there is no means of heating them, they must be 
near the ceiling, and fresh air admitted below on a 
different level. It is generally best not to put ex- 
traction flues in the outer walls; the cold chills the 
air, and foul flues are not apt to draw unless they 
are warm. All air-flues, like chimneys, must draw, 
or they are worthless. Recent experiments made at 
Kew Gardens, by Douglas Galton, William Eassie, 
and others, show that an efficient means of securing 
a constant increased movement of air through a pipe 
or chimney is to increase its diameter toward the top. 
Where a shaft is designed to take foul air from two Hand-Book for Hospitals. 
44 
or more rooms, one above another, the shaft must 
gradually widen in size at each story, in proportion 
to the additional amount of air to be withdrawn 
from that story. 
But in two-story hospitals, each ward should have 
its separate air-shafts or flues, with only the registers 
or openings required for that ward. The danger of 
interchange of air between hospital wards is very 
great, and can only be avoided by giving each 
story its own flues. Water-closets and sink-rooms 
should vent into special flues of their own. With 
superimposed stories, in order to ensure a constant 
upward current, all extraction flues require to be 
artificially heated. This can be done by some ad- 
joining chimney or stove-pipe, or by a vertical line 
of steam-pipe, or by a fire kept burning in summer 
as well as in winter at the lowest point, if it is a 
brick shaft. Even a gas flame or a lighted lamp 
inside a metal flue is a great help to suction. The 
light left burning on the hearth in sick-rooms at 
night serves a good purpose as an aid to ventila- 
tion, creating a small but steady current up the 
chimney. 
Lights.—If gas is burned it should be utilized in 
practicable places to warm an outlet tube, a sliding 
pane of glass or mica being inserted in front of the 
burner. Churches and public halls are often ar- 
ranged in this way. Every gas-pipe could have an 
outer casing, passing out at the ceiling or roof, to 
carry off the products of combustion and serve in 
its measure as a foul-air vent. The hanging lamps 
in the neat houses of some Shaker communities are A ir-Supply and Heating. 
45 
fitted in this way, with funnels over them and tin 
tubes running into the outer air. The lamp-smoke is 
thus got rid of, while the tube acts as an extraction 
flue for breathed air. It should be remembered that 
gas exercises a bad effect on the air of a room, ren- 
dering it impure and unwholesome. Ordinary gas- 
burners consume from three to four cubic feet of 
gas per hour; and it is found that one cubic foot of gas 
destroys the oxygen of at least eight cubic feet 
of air during combustion, besides producing impuri- 
ties. To dilute these impurities and to replace the 
oxygen, fresh air, for this purpose alone, must be 
brought in, to the amount of eighteen or twenty 
thousand cubic feet in the course of an evening for 
each burner lighted. Nearly as much air is needed 
for burning a pint of oil as for ten feet of gas. As 
little gas as possible should be burned in hospital 
wards. If, instead of gas, oil or kerosene lamps are 
used, it must be borne in mind that the commoner 
kinds of oil—that is, those that smell disagreeably 
—are extravagant, unhealthy, and dangerous. Both 
for health and safety, lamps of all kinds should be 
kept clean and in order, and only a good quality of 
oil or fluid used. Gas leaks should never be toler- 
ated. Electric lights will do away with many of the 
objections to the use of gas or lamps. 
Impure air is a very sluggish thing ; it is dead 
air; it will not find its own way always to a particu- 
lar hole in a wall and leave of its own accord; it 
must be compelled to go. A mining engineer has 
said that “ air is like a rope ; you can pull it better 
than you can push it.” There must be forced Hand-Book for Hospitals. 
46 
ventilation by some device or other in closed places, 
and the extraction method, by means of heated 
flues, is safest and simplest. Where there is a closed 
but heated chimney, running up through a room, a 
register for the exit of foul air may be put in such a 
chimney near the floor ; the opening must be shut 
when the stove or fire which warms the flue is 
lighted. 
Tobin’s tubes.—The system known as Tobin’s 
tubes has been found effectual in England for the 
admission of fresh air into old buildings. The room 
to be ventilated should have an open fire. All good 
English systems depend on open fires. On the 
opposite side tubes are brought through the outer 
wall at a point breast high ; they are bent at a right 
angle, and are carried up the face of the wall, five or 
six feet or more, like organ pipes ; they discharge 
fresh cold air, which mixes with the air of the 
room, and descends without creating draught. The 
tubes are better left exposed, as they are thus some- 
what warmed by the general air of the room, but 
different plans of concealing them are followed 
where that is desired. Other methods for the in- 
flow of fresh air, such as perforated cornices, per- 
forated bricks, or slatted openings in outer walls, 
must be left for architects to describe. Whatever 
scheme is adopted, it will be well to make it ample 
for a large influx of air at the summer temperature, 
because in colder weather a certain proportion of 
the openings can be closed or regulated. No ar- 
rangement of flues need be used in a one-story ward 
or a top-story ward, for openings at the roof-ridge, Air-Supply and Heating. 
47 
and windows, may serve all purposes. Revolving 
caps on air-flues only answer in a wind. In a calm 
all such devices obstruct ventilation. 
Ventilating' fans.—City hospitals are sometimes 
provided with forced ventilation by means of a fan, 
or by one central aspirating chimney, or both; the 
fan pumping fresh air in, the aspirating shaft being 
supposed to draw foul air out; but this is expensive, 
intricate and often untrustworthy machinery ; each 
ward needs a chimney to itself; no single aspirating 
chimney can do all the work which it will be set to 
do in a large hospital. Besides, when the wind 
shifts, or the temperature varies, the air-current is 
sometimes reversed, and the apparatus may be of 
no avail; while the use of open windows and fires is 
almost precluded—windows being used for light 
only, the cracks around them actually stuffed up, 
and the whole dependence placed on artificial venti- 
lation. City hospitals which desire and can afford 
to have a ventilating fan should run it by a separate 
engine, independent of the regular heating appa- 
ratus, so that it may work without break, day and 
night, in summer as well as in winter. If continuous 
use is not feasible, the fan should certainly be driven 
every morning and evening, say from 5 A. M. to 8 A. 
M., and from 7 P. M. to 10 P. M., for it is at these 
times that the air of a ward grows most foul and 
most needs to be thoroughly cleaned out. 
Open windows.—But ventilating apparatus which 
may be necessary in crowded cities, and with 
superimposed wards, would be superfluous in an 
open space where one only needs to keep up fires, 48 
Hand-Book for Hospitals. 
or to throw open the windows in order to ad- 
mit free air and sunshine. In some of the points 
vital to success visitors may feel that their little 
country hospitals have the best chance. The sim- 
plest and surest ventilating fixtures are open win- 
dows, open doors, and open fires. In the majority 
of instances opening the ward windows and doors 
must be the chief dependence. To ensure attention 
see that the window arrangements, whatever they 
may be, are not intricate, but simple, manageable, 
and always in repair. See also that the windows 
are systematically opened, and that some one person 
has the matter in charge; what is anybody’s busi- 
ness is nobody’s business, and is never done. 
Sashes may be left three inches down at the top 
on the sheltered side of a ward, in ordinary weather, 
without injury to any one. They can be open even 
in the winter, for a few minutes at a time, every hour 
or two, the patients being covered with blankets 
meanwhile to protect them. In summer weather 
windows of course should be left wide open con- 
stantly. But where there are windows only on one 
side of a room, the only door being opposite, these 
may all stand wide open and yet an observant vis- 
itor will find the air on each side of the door, and in 
the corners, or behind the door, very slowly stirred, 
if at all. It is still worse where the door is not op- 
posite the windows. All such rooms are unfit for 
surgical patients ; hence the best plan and the only 
one admissible in new constructions is to have win- 
dows on opposite sides of a ward and no blank 
walls anywhere. Where there are transoms over all Air-Supply and I leafing. 
49 
the windows, it is a good plan to open every other 
transom, and raise the opposite corresponding win- 
dow from below a few inches, placing vertically on 
the sill a board about twice as deep as the opening— 
that is, overlapping the sash when the window is 
up, and an inch or two removed from the window. 
An interchange of out-door and in-door air goes on 
without any direct draught upon the patients. 
Window ventilators.—There are several other 
devices and forms of window ventilators which are 
simple and effective for winter use. One has two 
bent tubes like stove-pipe elbows thrust inward 
through a strip of board, with valves in the mouths. 
This board maybe set at either the top of a lowered 
sash or at the bottom of a window, under the raised 
sash. The fresh air is driven to quite a high level 
by these tubes, then falls and mingles gradually 
with the air of the ward. Close wire-netting makes 
a useful shield, checking a draught by minutely di- 
viding the air-current as it passes through. Flannel 
or unbleached muslin ventilators may be easily pro- 
vided by stretching the cloth on light wooden frames 
about a foot in depth. The frames may be folding 
ones, hinged in the middle and fitting the top of the 
window as they are opened out, and the edges 
grooved to slip close over the window cords. The 
window is lowered at the top, the frame inserted 
and then pushed up into place. Whole window- 
sashes for ventilation are quickly made, for summer 
use, or in temporary huts, by stretching stout mus- 
lin on frames and fastening it with moulding strips 
and headed tacks. But all such dust-sifters are air- 50 
Hand-Book for Hospitals. 
stoppers, and windows so shielded must not be 
counted on as giving the same amount of air that an 
open window would give. Care must be taken to 
cleanse frequently all ventilators, and also all wire 
gauze, flannel, or cotton cloth used in the way 
described, or at the mouths of air-shafts. Another 
good window arrangement is a board or thin sheet 
of metal or extra glass sash, with leather sides per- 
manently rigged at an angle and dropped slightly 
forward like a wall pocket, in front of a lowered top 
sash. A triangle of wood may be nailed on each 
side of a window-frame, at the top, so as to close 
the side openings whenever a transom is let down. 
Currents of cold air thus admitted are first di- 
rected upward as they always should be. Currents 
of air admitted on a level with the beds are often 
undesirable ; they drive the odors of one bed across 
the rest, and are apt to chill the patients. Currents 
of fresh air admitted near the floor keep the feet 
cold. Even volumes of warm air sometimes come 
through wall registers with force enough to make a 
patient imagine there is a “draught,” and slily shut 
the register if it is within reach. Such registers 
may be fitted with a screen to turn the air upward. 
Vertical currents are safer for sick people than hori- 
zontal currents. The nearer the centre of a ward 
and the higher up the fresh cold air can be allowed 
to enter, the more perfect will be the circulation, 
especially if there are outlets for foul air in or near 
the floor, in which an outward flow is really kept up. 
Air-currents have a tendency to cling to and fol- 
low surfaces they come in contact with. Where in- Air-Supply and Heating. 
51 
lets for fresh air and outlet flues are on the same 
level, as, for instance, with a lowered window and a 
foul-air register near the ceiling, there will be a 
draught but no diffusion of air. Or if both open- 
ings are on a level near the floor, as with a window 
raised at the bottom and an open fire, the same 
thing will occur; the fresh air will escape too soon 
without diffusing itself properly. Openings for the 
two purposes should be on opposite sides of a room, 
if possible, and at different heights. 
Open fires.—Draughts are not ventilation; cold 
is not ventilation. To allow open windows in cold 
weather there must be an overplus of heat. The 
best winter ventilation accompanies the best mode 
of heating, namely, by open fires. Open fireplaces 
in the centre of a ward are a delightful provision. 
A slide at the back of the hearth, through which 
ashes fall into a fire-brick ash-pit and are removed 
from below, obviates some of the objections to open 
fires, such as noise and dust. One open fireplace, 
with a wide chimney throat, in each ward, with a fire 
in it, whenever cool weather allows, is all-impor- 
tant for cheerfulness and ventilation. But large 
wards in hospitals, heated by only one fireplace or 
stove, are sometimes wrongly believed to be “ well- 
ventilated,” because air is found rushing up the 
chimney or pipe. The main points are to know the 
quantity of required air, and the quantity of out- 
going air, and whether the diffusion of fresh air is 
general throughout the ward, and where the supply 
comes from. A large fire to burn very briskly re- 
quires from five to six hundred cubic feet of air a 52 
Hand-Book for Hospitals. 
minute, and will suck this air from wherever it can 
get it. The waste-pipe of a wash-basin or other 
sewer connection may feed a room with air in this 
dangerous, unsuspected way unless there is a stronger 
current of clean air from outside provided. 
Stoves of the right sort act in a measure very 
much as open fires do. They suck out the stagnant 
air, create a current, and thus encourage the entrance 
of fresh air. A pan of water should stand on every 
stove to modify the dryness of the air. Soapstone 
is the proper material for stoves, but even an iron 
stove, when it has an open Franklin grate, may be so 
arranged as to help ventilation, the smoke-pipe being 
double-cylindered and the outer casing used for 
warming fresh air, or for extracting the foul air of 
the ward. The latter method is the one adopted in 
the cottage ward described in the appendix. 
The heating arrangements in the Warren Ward, 
Boston, before alluded to, are as follows : In the 
centre of the ward, which is a square ward, is a 
chimney-stack, on two opposite faces of which are 
open fireplaces, and on the other two, open Franklin 
soapstone stoves, the flues of which are four iron 
pipes, placed inside the stack. For auxiliary heating 
there are four steam radiators hung beneath the 
floor and supplied with fresh air by four ducts from 
outside, with hot-air registers in the ward floor. 
Further ventilation upward is provided by foul-air 
registers in the ceiling, opening into a large centre- 
roof ventilator; and downward by twelve foul-air 
registers in the floor, connected with the chimney- 
stack by foul-air ducts running between the floor- Air-Supply and Heating. 
53 
ings. This method, which has been in use since 
1873, has proved so satisfactory that the authorities 
of the hospital have put it in practice in subsequent 
constructions.1 
Registers.—An undesirable detail of the plan 
described is the position of the hot-air registers. 
Hot-air registers should be put in the walls, rather 
than in the floors; floor registers tempt patients to 
sit or stand over them ; dirt collects in them ; and 
careless men have even been known to use such 
floor registers as spittoons. No registers used with 
heating apparatus, or at the mouths of ventilating 
flues, in either hospitals or houses, should be set 
permanently in the walls. They should be made 
movable by unscrewing the metal frame without 
breaking the plaster, so that the mouths of the flues 
may be regularly cleansed. Fluff collects and packs 
in such places, and they become literal hot-beds of 
disease. 
Fireplaces.—Some of the United States marine 
hospitals are warmed on the plan adopted in Her- 
bert Hospital, Woolwich, England. There are two 
Galton fireplaces, back to back, in the middle of the 
ward. The chimney is not allowed to obstruct the 
ward, for it passes downward and under the floor, 
and, on reaching the outer wall, enters and is carried 
up through the middle of a fresh-air flue. The latter 
has an opening into the ward near the ceiling. By 
this plan, a volume of outer fresh air is warmed sev- 
eral degrees in its passage to the ward, thus utilizing 
1 Dr. J. H. Whittemore, Resident Physician and Superintendent. 
(1883.) 54 
Hand-Book for Hospitals. 
the escaping heat of the chimney. Or the process 
may be reversed. If it is preferred that the smoke 
flue shall be carried directly up through the ward, 
instead of downward through the floor, it may be a 
pipe of fire-clay, so as to take up less room than 
an ordinary brick chimney. The fresh air may be 
brought in from outside by means of a tube laid 
under the floor to a point near the fireplace, or below 
the grate.. It is then conducted upward on both 
sides of the smoke flue, or in a larger tube forming 
an outer casing for the chimney. The air having 
been warmed in its passage, is then passed into the 
ward through one or more openings near the ceiling, 
around the top of the tube. This system is in use 
in the new wards of the London Hospital and else- 
where, and is found effectual. 
In some army-post hospitals, double fireplaces are 
used with success, fresh air being let in between the 
fireplaces and warmed before entering the ward. 
Properly built and managed, such a fireplace has 
been found to heat satisfactorily a room forty-eight 
by twenty-five by twelve feet, and to ventilate it at 
the rate of forty thousand cubic feet of air per hour, 
the out-door temperature being at freezing point.1 
Visitors must see that where there are ward fire- 
places the chimneys are not stopped up, and the 
empty spaces behind the blowers used as receptacles 
of rubbish, or cupboards for old shoes. A hospital 
visitor in a neighboring State writes : “ I have just 
1 Public Health Papers, vol. ii., p. 386. For descriptions of ven- 
tilating fireplaces, see also Sanitary Arrangements for Dwellings, 
Wm. Eassie, London, 1874. Air-Supply and Heating. 
55 
come from putting my head up the chimneys of our 
fever ward, where I made the discovery that four 
nice, open, wide chimneys, giving the best possible 
chance for ventilation, were neatly and tightly fitted, 
so as not to attract an eye that was not directed up 
them, with boards nailed in at the request of the 
patients, while at the same time four ventilators 
were tight shut, and also all six of the windows.” 
Furnaces.—In a large building, in such a climate 
as that of New York, open fires cannot be exclu- 
sively depended on. Some sort of heating appa- 
ratus will be needed in winter, and has advantages 
in the administration of a hospital, being labor-sav- 
ing, cleanly, and quiet. But the air introduced by 
furnaces into a ward is, unfortunately, often surface 
air, drawn through damp and dirty cellars, and then 
scorched by over-hot iron. Add to these objections 
the fact that the temptation with ignorant employees 
is to shut off all ingress for cold air to the furnace, 
either to increase the warmth, as they suppose, or to 
save the fuel. Steam coils, or preferably hot-water 
coils, hung beneath the ward floor, with ample sup- 
plies of fresh air directly from outside and taken at 
a level above the street dust, would be the best 
method of heating. The ground level is less often 
reached by fresh breezes than higher levels. To 
keep down dust, the ground about an air-box should 
be kept sprinkled with water. The box must have a 
wire netting at the mouth, must be kept away from 
all drain and sewer openings, and should run to the 
free air, not stopping under a piazza, for instance. 
The box or pipe might be of sheet metal; it must 56 
Hand-Book for Hospitals. 
be caulked tightly at the seams if wood is used, and 
wrapped with steam-pipe covering to keep out dust 
and cellar air. A thin flannel, often cleansed, may 
be stretched over the wire grating at the mouth, as 
an additional guard. The cellar or basement floor 
where a furnace stands should be impermeable. A 
concrete flooring with a coating of asphalt is the 
best. The evaporating pans of furnaces should be 
large and frequently cleaned out, as the water is 
liable to become impure. The air-box and air- 
chamber should be amply large. A large body of 
air gently heated is better than a small current of 
air heated to a greater degree, because the former 
is more likely to mix thoroughly with the air of a 
room and diffuse itself, instead of only rushing 
through. Have two air-boxes, to be opened or 
shut according to the direction of the wind. If pos- 
sible, take air from the sunshiny side of the build- 
ing. Each ward of a hospital must have its own 
separate hot-air pipes. The attempt to use one pipe 
to warm two wards or stories will result disastrously. 
It creates a common atmosphere, and may at any 
time spread contagion. 
Radiators.—Of all methods of heating, the most 
undesirable is that by means of direct radiators, 
or stacks of hot pipe carried into the wards, collect- 
ing dust in their coils and cooking this dust, and 
whatever other solid particles the air of the room 
contains, for the patients to breathe. Such radiators 
are only suitable for warming corridors and passages 
under favorable circumstances where volumes of 
fresh air are necessarily constantly admitted. But Air-Supply and Heating. 
57 
whatever the system, bright, open fires should be 
the accompaniment. Under all circumstances, when 
any heat is needed, have the open fires burning. Use 
steam-pipes and furnaces only as an addition to 
these. 
In pleasant weather with wide-open windows, or 
in winter with ample heating apparatus, the question 
of air-supply is not a difficult one. The really try- 
ing time for a hospital ward is in the intermediate 
season ; the dull days in early autumn before the 
fires are started, or in spring when they are “ banked,” 
and the mornings and evenings turn chilly, and the 
nurses and patients shut every crack, and the ward 
atmosphere stagnates. Then is the time for an 
armful of wood, or a hod of coal, and a bright, cheer- 
ing, open fire. But “ eternal vigilance ” is the price 
of hospital hygiene. If a superintendent is intelli- 
gent enough, and unremittingly attentive to little 
details, the vexed problems of ventilation and heat- 
ing will be very much simplified. An engineer 
cannot dictate the ventilation unless he is a very 
uncommon man ; only an enlightened person who 
has studied the subject and has sufficiently sensitive 
perceptions to tell whether air is clean or dirty can 
do this. The main object of the ordinary engineer 
is to save coal and get credit with the managers for 
economy. But what is thus saved in fuel is spent in 
flesh and blood. Drainage and Water-Supply. 
One of the radical necessities of a hospital is an 
abundant supply of water, free from the slightest 
taint or suspicion of impurity. Of equal importance 
is a safe and prompt method of taking away the 
fouled water of the house and the dejecta of the 
inmates. These are matters which visitors must 
carefully investigate, not resting satisfied with the 
assurance of interested persons that the drainage is 
“ all right.” They should understand what right 
drainage is, and see for themselves whether correct 
principles are followed in the institutions they visit. 
The evil consequence of defective plumbing is a 
familiar subject in cities. Similar evils exist in 
country neighborhoods, sometimes unrecognized. 
Clean water.—A good part of sanitary science 
may be summed up in one word—cleanliness : clean 
air, clean soil, clean water. But in many towns the 
soil is honeycombed with cesspools and wells alter- 
nately, while ponds and streams are poisoned by 
drains discharging directly into them, or by rain- 
water running over or through a surface made foul 
with house-slops and refuse. It is a common thing 
to see a well in such a position that it catches barn- 
yard or privy leakage, even if it is far enough from 
the house to escape the taint of kitchen and laundry Drainage and Water-Supply. 
59 
slops thrown out on the ground. Drinking-water, 
which organic matter has thus been allowed to foul, 
becomes a fruitful source of disease and death. The 
clearest, most sparkling water, is sometimes the 
worst poisoned. The safer plan for hospitals is to 
avoid the use of well-water for drinking and cooking ; 
and in the absence of a public supply of pure water, 
to substitute rain-water, filtered through finely-pow- 
dered animal charcoal, or carded asbestos. These 
filtering substances should be renewed, or cleansed, 
from time to time, by heating them. The charcoal 
can be made very hot in an iron pan over the fire, 
and asbestos is purified by holding it in an open flame. 
Soakage from cesspools.—An inverted cone, 
with its apex supposed to be at the bottom of a 
well and its base at the surface as broad in diameter 
as the well is deep, would correspond in a general 
way with the area from which a well draws moisture. 
The deeper the well the larger the area drained. 
But most wells drain a wider region than their 
depth indicates; and if sunk in an impervious 
stratum, or on a hillside, or where some dip in the 
subsoil favors it, may draw their supplies from 
several localities many rods apart. On a peopled 
hillside pollution of wells and of ground-air from 
vaults or leaky cesspools further up the slope be- 
comes inevitable. One of the reports of a health 
officer for Oxfordshire, England, gives a striking 
illustration of the distance which foul leakage may 
travel. In consequence of the escape of the con- 
tents of a barrel of petroleum which had been 
buried in an orchard, a circuit of wrells sixty feet 60 
Hand-Book for Hospitals. 
lower down and nine hundred feet distant became 
so tainted that the occupants of fifteen houses, 
containing eighty-two inhabitants, were unable for 
ten days to use the water for drinking or cooking. 
Had this soakage been sewage it would not have 
been so quickly detected, and the result might 
have been wholesale water-poisoning and an out- 
break of typhoid fever. Nine out of ten cesspools 
do leak, and are built purposely to leak, to get rid 
of the trouble of emptying them. The action of 
frost, the jarring of the earth, and other causes may 
practically prevent cesspools from being tight where 
tightness is the intention. 
Earth-filtering has been proved by a series of im- 
portant and interesting scientific experiments to be 
of little avail, as a barrier between wells and the in- 
fection that may come from cesspools, vaults, ceme- 
teries, or other sources of impurity, even if these lie 
at a considerable distance in a lower, wet stratum. 
The practical conclusion reached is that a building 
may stand on a thoroughly dry body of sand or 
gravel, with its cellar above the ordinary level of 
ground-water, and yet may be in danger of having 
not only its well-water but the air of its rooms con- 
taminated from leaching cesspools ; for if the drift 
of the leaching be toward the cellar, very wet sea- 
sons may extend the polluted moisture to the cellar 
walls. 
Ground-air.—Besides water-poisoning, the poison- 
ing of the contained air of the soil by the infiltra- 
tion of organic filth has a serious effect on health. 
The air with which the upper soil is permeated Drainage and Water-Supply. 
61 
vibrates to barometric changes in the outer atmos- 
phere and to changes of the thermometer, and will 
rise when the level of the water in the ground rises. 
Heavy rains may therefore aid in forcing the ground- 
air into cellars. Houses act as chimneys for the 
soil on which they stand, and especially in winter, 
when the surrounding ground is frozen, will suck the 
air from the pores in the soil, through the founda- 
tions and cellar floor, if these are not of air-tight 
material—cellars being usually warm and protected 
from frost. Air or gas having no other escape, will 
readily press through any ordinary brick or sand- 
stone wall.1 
It is for the reasons here indicated, among others, 
that hospital wards should be raised above the 
ground on piers or open arches. 
Ferments.—Every time a pailful of dirty water 
goes into a cesspool an equal bulk of foul gas must 
find its way somewhere, carrying infection with it. 
The likeliest way of escape for it is into the house 
by untrapped or badly trapped waste pipes. With 
the intention of diminishing the volume and pressure, 
cesspools are sometimes arranged with overflow 
pipes, or are used as catch-basins and connected with 
a sewer which carries off part of the liquid waste. 
But the foul sediment remains stored up and is sub- 
ject to dangerous fermentations. Grease and foul 
slime and soap often plaster the insides of pipes and 
1 See “ Filtering Capacity of Soils” : Report of Professor Raphael 
Pumpelly, Supplement No. ij, National Board of Health Bulletin. 
Also “ Relation of the Air to Dwelling and Soil” : Max von Petten- 
kofer. 62 
Hand-Book for Hospitals. 
cesspools and clog the outlets and overflows, causing 
backwater into a building. Small quantities of 
liquid deodorizers poured through the house pipes 
help to keep the traps and closet-pans clean, but can 
have no appreciable effect on the solid matter at the 
bottom of the cesspool. The overflow carries off a 
portion of the deodorizer immediately. The safer 
way is to empty, cleanse, and disinfect the cesspool 
itself often and at regular intervals, using chloride 
of lime freely, and at other times pouring down 
liquid disinfectants in much larger quantities than is 
commonly thought necessary. 
Privy vaults should be abolished. Where they 
exist, visitors must recommend that they be cleaned 
out, the foundation walls and all the surrounding 
foul earth removed, and the pit filled with clean 
earth well rammed down. Privy buildings should be 
set up on short piers or locust posts, on level ground, 
and stout boxes made tight inside with a wash of 
hot coal-tar should be provided as receivers. In 
small out-houses, a petroleum cask sawn in two 
makes two good pails ; but in large establishments 
a wheeled wagon or box is needed, which can be 
readily drawn off and emptied. A six-inch vent 
pipe through the roof should run up from under the 
seat, and an ample supply of dry, finely-powdered 
loam or sifted anthracite ashes should be at hand to 
throw down at every using. Care must be exercised 
by visitors in observing whether the out-houses are 
properly built and isolated, whether the contents of 
the boxes are kept fully covered, and whether the 
removal is done often enough and in a cleanly man- Drainage and Water-Sitpply. 
63 
ner. No liquid house-slops should be thrown in. 
The dryer the compost is kept, the better. If such 
out-houses are sufficiently remote from the water 
sources, and there is absolutely no odor attending 
them, they may be considered safe, but only as a 
temporary substitute for a good system of water- 
supply and sewerage. 
Sub-surface irrigation.—The best method for 
carrying off the liquid wastes, that is, bedroom, 
kitchen, and laundry slops, in country institutions 
(where there is no proper sewerage and no outfall 
into a large, rapid stream the purity of which is not 
a matter of importance), is by sub-surface irrigation. 
The character of the soil and the configuration of the 
ground must both be studied in deciding the size of 
the distributing area. Unless sub-soil drains are laid, 
heavy, clay soils must be excluded. The system 
requires the use of a flush tank, which may be dis- 
charged by hand, or, better, a Fields’ flush tank 
with automatic discharge, strainer, and grease trap. 
It must be protected from freezing, and occasionally 
cleaned out. Without such a tank, the fluid might 
escape at the first point of leakage, and there would 
be over-saturation of the soil. The tank stores up 
the fluids for a few hours, and then sends them sud- 
denly and copiously throughout the lines of open- 
jointed, small tile drains laid ten or twelve inches 
below the surface of the ground. There should be 
forty or fifty feet length of the tiles for each mem- 
ber of a household, in soil of average porosity. The 
foul driblets reach the ground at a great many 
points, and are oxidized by the air in the upper 64 
Hand-Book for Hospitals. 
soil ; and the roots of grasses take up a part of the 
harmful matter. There is no limit to the amount 
of liquid sewage which may be disposed of in the 
way described, provided the lines of drains are 
spread over a large-enough absorption ground in 
proper soil to take up the water, the ground sloping 
gently away from occupied buildings. A grassy 
field or lawn, or other fallow, undisturbed ground, is 
required, not deep cultivated or ploughed land. 
The plan has been in use for several years for the 
entire sewage of Lenox, Massachusetts; at the 
Women’s Prison, in Sherburne ; the Nursery and 
Child’s Hospital, Staten Island ; and at many houses 
in New Jersey and elsewhere. No trouble from 
frost has been known to occur. The flow should be 
rapid and intermittent, and is usually warm enough 
to thaw its own way into the ground.1 
Water-supply.—An insufficient supply of water 
is a frequent cause of annoyance and a source of 
danger in county-houses and suburban hospitals. 
Visitors must inquire into the best method of in- 
creasing the supply, and urge its adoption. There 
are wind-mills for pumping water from springs or 
streams, which may be brought into use where 
hand-pumping is out of place. The number of gal- 
lons of water required per day, per person, must 
vary with the construction of the building and the 
character of the inmates. Seven and a half gal- 
lons may be assumed as the minimum amount neces- 
’George E. Waring, Jr. : “Sanitary Drainage of Houses and 
Towns also, “Seventh and Eighth Annual Reports, State Board 
of Health of Massachusetts.” Drainage and VI ater-Supply. 
65 
sary for each person daily, in a poorhouse where 
there are no water-closets, and independently of full 
baths. Hospitals need more water than other insti- 
tutions ; for besides the incessant laundry work and 
general cleansing, the utmost personal cleanliness 
must be maintained, not only in the case of the 
patients, but by nurses and attendants. A surplus 
of water in case of fire is essential. 
Tanks.—With daily use of water-closets, and a 
full bath for each inmate even only once a week, 
the supply of water per day, per person, ought not 
to fall below thirty gallons. One person’s daily 
supply will fill four cubic feet of space, every cubic 
foot of room in a tank being equal to a volume of 
seven and a half gallons of water. It will be seen 
that water reservoirs must be amply large and kept 
constantly full. A cubic foot of water may be 
counted as weighing sixty-two and a half pounds. 
House tanks and their supports should be strong 
enough to bear the strain of many thousand pounds 
of weight which a full tank represents. Under no 
circumstances whatever should tanks intended for 
drinking-water be lined with lead or zinc or galvan- 
ized iron. Such tanks, if they are necessary, should 
be lined with tinned and planished copper, or they 
may be of slate joined with hydraulic cement. They 
should be kept covered, and all tanks and reservoirs 
should be examined and cleaned out at regular in- 
tervals. Tanks of standing water sometimes breed 
mosquitoes. In mosquito-infested places, it is well 
to fasten a breadth of muslin over house tanks to 
prevent this annoyance, if there are no covers. Care 66 
Hand-Book for Hospitals. 
must be taken to preserve and utilize rain-water by 
building tight cisterns; especially in deep-mining 
districts, the more roof-surface there is the better. 
No rain-water leader should ever discharge into a 
drain or cesspool. 
Overflow pipes from tanks or house cisterns 
containing water used for cooking or drinking, 
should never run into the soil pipe or drain pipe. 
Such overflows should discharge over an open sink 
in the kitchen or other suitable place. Overflows 
from water-closet tanks should empty into the closet- 
pan. Cistern overflows outside the building should 
be carried to some low points on the grounds and 
have an open outlet. 
Drainage.—The healthful arrangement of the 
drainage in its minutest details and an ample water- 
supply for flushing sinks and drains are essential. 
The two are interlinked. It is a fatal mistake to in- 
troduce water into a village or a building, without 
first providing proper means of disposing of the in- 
creased volume of foul liquid which the free use of 
water will occasion. 
Drain pipes within a building must of course be 
of iron, and they should be efficiently trapped either 
just inside or outside the walls. If continuous 
iron pipe is not used for outside drains, the material 
chosen should never be brick, or wood, or loose 
stones. Heavy, well-vitrified, salt-glazed, smooth 
round tile is required, beginning at from five to ten 
feet outside the foundation walls. These pipes 
must be laid carefully in a firm bed of gravel or con- 
crete. They should be well joined with hydraulic Drainage and Water-Supply. 
6 7 
cement, the cement being smoothed inside the pipes 
at the joints. The pipes should be kept out of the 
way of roots of trees, and should have the proper 
grade. A minimum velocity of three feet a second 
will usually prevent deposits in a drain. Drain pipes 
should have their own trench distinct from the one 
in which the water-supply pipes are laid. The quan- 
tity of sewage discharged every day will vary with 
the amount of water used. The rate commonly as- 
sumed by engineers ranges from thirty to sixty gal- 
lons of sewage per head, per day. A smooth, well- 
laid six-inch pipe, with a descent of one foot in one 
hundred feet, will discharge, when running full, about 
four hundred thousand gallons every twenty-four 
hours, and prove large enough for the largest institu- 
tion, or, excluding storm water, for a village of a 
thousand or more inhabitants; while in the case of 
small institutions, a four-inch drain is often all that 
is needed. 
Small sewers are better than large ones. They 
are more apt to run full at times, and are thus kept 
better scoured. Large sewers, except in heavy rains, 
usually carry only a sluggish trickle of sewage at the 
bottom, in contact with a large volume of warm, 
contained air. We have thus heat, moisture, dark- 
ness, and the presence of ammonia; all the condi- 
tions favorable to the development of noxious germs 
and gases. 
Exhaust steam in hospitals where steam is used 
must never be discharged into a drain. An upward 
rush of moist, warm vapor may at any time break 
through the small traps of waste-pipes, and fill a 68 
Hand-Book for Hospitals. 
room with its foul cloud, while fermentation in 
sewers is dangerously increased. 
Unseen leaks from foul drains running within 
or under partition walls will soak a wall or fill a par- 
tition space with sewage undiscovered. The drainage 
system of all buildings is subject to constant strains 
and injuries, stoppages, flaws in metal, displacements 
by frost or flood, or by settling of walls; and 
pipes, in a hospital especially, need inspection and 
periodic testing, as do steam-boilers and other 
machinery. Waste-pipes and water-pipes in a house, 
therefore, should be laid exposed to view through- 
out their length. In parts where it is thought best 
to conceal them, it should be done by wooden covers 
screwed on, not nailed, so that examinations may 
be more easily made. The best place for waste- 
pipes is along a wall, in full sight, at the proper in- 
cline, and hung by strong iron bands. Right-angle 
junctions must be avoided. 
Soil-pipes must always be of iron, well tarred 
inside and out. Lead soil-pipes are forbidden 
wherever there are competent boards of health; 
such pipes are often corroded and otherwise in- 
jured, and foul gases escape without other leakage 
to betray them. Some disinfecting fluids inju- 
diciously used will corrode lead traps and pipes. 
Cement joints are useless, and extreme care is 
needed to make lead joints perfectly tight. The 
lead must be poured in hot on a carefully packed 
stopper of oakum, and driven home, as it cools 
and shrinks, with tamping tools. The joints must 
then be tested by closing all outlets, filling the Drainage and Water-Supply. 
69 
whole pipe with water, and letting it stand twenty- 
four hours.1 
Every line of soil-pipe should stand as vertical as 
possible and should be carried up full size, say four 
inches in diameter, to a point near the roof ; and 
from that point, with diameter increased to six 
inches, through the roof and several feet above it. It 
should be kept ten feet, at least, away from chim- 
neys, dormer windows, and open rain-conductors 
that lead to cisterns, and its top should be two feet 
lower than the chimney tops, so that down draughts 
in the chimneys may not draw foul air in. There 
should be no return bend or cowl of any kind, as 
these check the air-current. A coarse wire basket, 
mushroom shape, may be needed, as a guard, to 
prevent malicious meddling. 
An inlet pipe for fresh air must be inserted near 
the foot of each line of soil-pipe, between that and 
the trap of the iron house drain. In towns, both 
trap and inlet pipe are usually under an area grating 
outside the building. In a country institution, the| 
inlet pipe may be led to a little distance under- 
ground and brought out behind a tree, or in the 
shrubbery. It should have the same diameter as the 
soil-pipe, say four inches; its mouth must be kept 
away from windows and air-shafts, should have a 
wire strainer, and should rise above the surface of 
the ground enough to prevent clogging by dead 
1 Soil-pipes and waste-water pipes should not discharge into the 
same receptacle ; the latter should be provided with a grease-trap 
(easily accessible for cleansing), and an overflow into a second recep- 
tacle or cesspool.—Eds. Third Edition, Hand-Book for Hospitals. 
70 
leaves or deep snow. This inlet allows free com- 
munication with the atmosphere, and a constant 
current through the whole length of the soil-pipe. 
I Stagnant, untrapped, unventilated pipes and drains 
are worse than no drains at all. Disease germs are 
generated in the slime and foul gas of house pipes 
as well as in sewers; but such germs may be carried 
off or rendered harmless by currents of clean air. A 
building without traps and vent-pipes, itself becomes 
the vent for any common sewer it may connect 
with ; or, as Colonel Waring expresses it: “A house 
is often only a vertical section of a horizontal street 
sewer.” 
Vent-pipes for foul air are sometimes run from 
under closet seats into a chimney. In this case a 
special copper vent-pipe carried up inside or along 
the side of the heated hue is necessary. It is unsafe 
to use a kitchen chimney as a vent; for fires go out 
at night, and there will be downward draughts ; or 
the pipe at the point where it enters the chimney 
may become choked with soot. All such ventilating 
pipes or shafts should gradually widen in diameter 
toward the top, whenever closets on more than one 
story vent into them. 
Bricks are so porous and absorbent that they are 
a poor material for flues or shafts through which 
currents of sewer air must pass. The Health Board 
of New York City orders that “no brick, sheet 
metal, or earthenware flue shall be used as a sewer 
ventilator; nor shall any chimney flue be used for 
this purpose.” 
Ward water-closets must be built entirely out- Drainage and Water-Supply. 
71 
side the ward building, and separate from the ward 
by a lobby or short corridor with swing-doors and 
opposite windows. No visitor should pass with- 
out protest any other arrangement. The water-flow 
should be free and abundant. Closets where the 
flow is controlled by a string on the door are often 
out of order. Closets where the flow is produced 
by pressure on the seat are always filthy. If auto- 
matic fixtures are used, the closets must be flushed 
with water every three minutes. There must be 
perfect self-working apparatus, or else perfect vigil- 
ance with a simpler plan—either will do—or there 
will be perpetual bad odors and contamination. The 
old style of pan-closets, with its filthy container, 
should be avoided. Every closet must be thoroughly 
trapped. It is dangerous to draw on the main 
water-pipe to flush a closet. Each closet must have 
its own cut-off or water-tank ; otherwise the foul air 
which collects above the trap, or the contents of 
the bowl may be sucked into the pipe when the 
water falls away in it, as often happens from the 
sudden turning of faucets elsewhere ; and the main 
water-supply will be tainted. Flushing from the 
supply pipes is never so effective as flushing from 
special tanks. 
Boxing in with wood should never be allowed 
in hospital closets. Wood so used easily becomes 
impregnated with foul water slopped about. A 
white earthenware closet on a tiled floor, with no 
woodwork except a hinged seat board of hard wood, 
and entirely open under the seat to ventilation and 
inspection, is the most cleanly and healthful arrange Hand-Book for Hospitals. 
72 
ment. There must be partitions necessarily dividing 
one closet from another, but the woodwork should 
be as flat and simple as possible, without panels or 
mouldings, and should be constantly freshened and 
kept sweet by careful cleansing, and a new coat of 
paint or shellac. The closet partitions should not 
reach to the ceiling, and the doors should not come 
down to the floor, but a space of four inches should 
be open at the bottom to secure ventilation, and 
a window behind the closets, opposite the doors, 
should give light and air. The seats should be at 
the ordinary level; there should be no step leading 
to them. The width of each compartment should 
be ample, say thirty-six or more inches ; as feeble or 
lame patients often require the help of an attendant. 
Three compartments would serve for a ward of six- 
teen or eighteen beds. Closets and baths for nurses 
should be provided distinct from those forward use. 
Stationary urinals should have porcelain basins, 
if heavy glass basins are not procurable ; and the 
best possible material for the slabs under and behind 
them would be heavy glass or large tiles. Slate 
slabs for this use are often unsatisfactory. They 
spot and stain and are absorbent. Where slate is 
used either for this purpose or as flooring and wall- 
facing in any room, large pieces should be chosen, 
so as to have few joinings, and the quality should 
be close and fine. Tiles, if used, should be large, 
well joined, and well fired with hard, strong glaze. 
The walls and floors of all service rooms should be 
of some hard, smooth, non-absorbent material; well- 
joined tiles are the neatest. Drainage and Water-Supply. 
73 
Flushing rims, or drip-pipes, around the edges of 
urinals, slop-sinks, closets, and basins, supplied with 
water from a special cistern, and worked either by 
hand with a special faucet and left running, or dis- 
charging automatically at regular intervals, are of 
great advantage. The sides of bowls and sinks are 
thus kept free from incrustations of filth. The sim- 
ple lead drip-pipe can easily be added to old closets ; 
the fixture is a cheap one. 
Buckets and utensils for night use must have 
covers. See that these and the bed-pans and com- 
modes for patients who are too ill to go to a closet 
are washed daily, covers and all, in hot water and 
soda, and that disinfectants, in cases of a commu- 
nicable character, or of dysentery, typhoid fever, and 
the like, are used to cover the discharges and to rinse 
the vessels afterward. All such vessels and pans 
should be left exposed to the weather, daily for sev- 
eral hours. The woodwork of commodes must be 
sweetened by an occasional rub with oil and tur- 
pentine. 
Lavatories, baths, and slop-sinks should be in 
windowed rooms detached from the wards in the 
same way as the water-closets ; and every bath, sink, 
and wash-basin must be separately and efficiently 
trapped as near each fixture as possible, and the trap 
protected against siphonage by a vent-pipe carried 
independently through the roof. Lavatory bowls 
with flushing rims are manufactured, and are the 
most cleanly kind. But do not multiply set basins. 
The better way is to have porcelain or polished 
marble or planished copper wash-sinks, and for 74 
Hand-Book for Hospitals. 
special patients china or tin hand-basins that may 
be numbered and kept separate. Zinc or lead-lined 
slop-sinks are very undesirable. Funnel-shaped 
sinks of copper, heavily tinned inside and out, not 
boxed in, and standing detached from the wall near 
an open window, are best. Frequent breakage of 
vessels will be prevented if the faucets do not over- 
hang the sink, but if a rubber tube attached to the 
faucet is used for rinsing. 
Hospital bath-tubs should stand free from the 
wall on all sides. Painted iron baths and sinks are 
objectionable. They require frequent fresh coats 
of paint, with the consequent inconvenience of turn- 
ing off the water and disuse for the time. Enamelled 
iron chips and scales. Heavy planished or tinned 
copper is a suitable material, wears well, and the old 
copper is worth something at the end ; but nothing 
is more cleanly and non-absorbent for hospital use 
than porcelain. All closets, sinks, lavatories, and 
baths must be most carefully examined by visitors 
to see that they are kept daily scrubbed and disin- 
fected and periodically flushed, and that the fixtures 
are of the best attainable pattern and are always in 
good order. No sink, or closet, or bath waste should 
ever have any odor.1 
A tinned copper bath-tub, full-sized, on rollers, 
ought to be on hand in every hospital, with appa- 
ratus for filling and emptying it, so that if the bath- 
room is remote, a very sick person can have a bath 
near his bedside. Any simple, country hospital can 
1 For details see file of American Architect; also “ House Drain- 
age and Sanitary Plumbing” ; Wm. Paul Gerhard, N. Y., 1882. Drainage and Water-Supply. 
75 
provide this convenience, which is not often enough 
thought of in the largest institutions. The expedi- 
ent, however, should only be resorted to in extreme 
cases, as the emanations from baths, especially warm 
ones, are bad for the rest of the ward. 
Visitors should ascertain what are the rules of the 
hospital as to the number of baths a week taken by 
convalescents and nurses, and whether these rules 
are enforced. The purity of the air of a ward and 
the general cleanliness will be promoted where fre- 
quent baths are insisted on. Inquiry should be 
made by visitors as to the abundance of the hot-water 
supply, or the method of getting hot water in the 
night, as well as by day, in all parts of the hospital. 
This is an important matter. 
Ice, which is so indispensable in hospitals, should 
be as pure and safe as the drinking-water. If it is 
cut from ponds or streams which receive drainage or 
seepage from foul sources, it is unfit for use. Water 
in freezing does not entirely free itself from the solid 
substances it may contain ; these to some extent re- 
main entangled in the meshes of the ice ; and germs 
of an infectious nature have been found to withstand 
a temperature many degrees below freezing. What- 
ever objection attaches to the use of contaminated 
drinking-water, attaches equally to ice frozen from 
it. Such ice will, moreover, taint the atmosphere 
of ice-chests, and poison the food with which it 
comes in contact.1 
Refrigerators and meat-rooms should never, under 
1 “Dangers of Impure Ice ” : Professor Raphael Pumpelly, U. S. 
Geological Survey. See Sanitarian, May 1882. 7 6 
Hand-Book for Hospitals. 
any circumstances, have direct connection with 
sewer or soil-pipe. The drip-tube, where convenient, 
may be carried through a wall and drip in the open 
air ; or it may drip into a wide pan, exposed to the 
air, and the pan may have trapped connection with 
some near waste-pipe. V. 
Some Interior Details. 
The question as to what makes the best wall-finish 
for a hospital is still an open one. Professor Petten- 
kofer, of Munich, says that much of the necessary 
ventilation goes on through the walls, and that men 
ought not to live in wall-tight rooms any more than 
they ought to wear water-proof clothing continually. 
To make a wall impermeable is somewhat like var- 
nishing a man’s skin to keep his under-clothing from 
being soiled.1 A good, hard-finish surface, which, 
after the wall has thoroughly settled and dried, can 
be painted a light, cheerful tint, and is then easily 
scrubbed down with soap-suds and dried, is so far 
the most generally approved in this country and in 
Europe.8 
Wet walls.—It has been frequently noticed that 
in new hospitals or in new wards added to old hos- 
pitals the results are at first not so good as was ex- 
pected ; cases turn out badly ; erysipelas and other 
hospital diseases appear. This state of things is 
partly accounted for by the fact that generally the 
new hospital or the new addition has been built un- 
der the pressure of necessity for more accommoda- 
1 Dr. J. S. Billings, U. S. A. 
2 Cement or Rock plaster, with little or no hair in it, is the best ma- 
terial now used.—Eds. Third Edition. 78 
Hand-Book for Hospitals. 
tion, and the wards are occupied too soon—before 
the walls are dried. The quantity of moisture held 
by such a mass of fresh mortar and plaster is very 
large. Wet walls are air-tight; this is one hygienic 
disadvantage. Besides, wherever there are warmth 
and moisture, emanations from the bodies of the sick 
will be absorbed and held by such damp walls, and 
eventually cause disease. Time is required to evap- 
orate the dampness and make the w'alls safe. Wet 
washing of new walls should never be attempted ; 
they should be scraped and dry rubbed. 
Wall finish.—Brick walls, whitewashed, are some- 
times chosen as healthiest for the workhouse hospi- 
tals in England. Where cheapness is an object, 
periodical scraping and whitewashing of walls and 
ceilings with lime, not kalsomine, will be found as 
safe and cheap a treatment as any. Visitors may 
do good service by noting how frequently the white- 
washing process is attended to. It should be done 
not less than twice a year, but the frequency should 
depend on the character of the cases for which the 
ward is used. Wards must be emptied in rotation 
for a week or more at a time, so that the scraping, 
which is a dangerous process to health, may be thor- 
oughly done. After ten or twelve years, if the hos- 
pital is a permanent building, the plaster ought to be 
torn out and replaced.1 The post hospital at West 
Point, for instance, is arranged with this necessity 
in view. Coarse, painted wire-netting is used in- 
1 No longer necessary in the latest improved modern hospital struc- 
tures, but important for old, or cheaply constructed buildings.-*-Eds. 
Third Edition. Some Interior Details. 
79 
stead of ordinary lathing. The plastering is laid on 
this, clinching on both sides of the wire, and the 
whole wall lining can be removed when desired. 
Curved corners.—In plastering the walls of a new 
hospital, it will not cost much more to round or 
curve all the angles and corners. There should be 
no sharp angles in the wall corners, or where walls 
and ceiling join. Late specifications for marine 
hospitals require that no ceilings be plastered. The 
rafters and beams are smooth-finished, filled and 
covered with two coats of “ pellucida ” varnish ; the 
open roof adding considerably to the air-space and 
helping ventilation. 
Floors.—New floors should be of Roman Mosaic, 
on proper foundation, or laid with hard, close-grained 
wood. Narrow strips of the heart of yellow pine, 
well filled with rosin, make the best floors ; the seams 
being tongued and caulked with white lead to insure 
an impervious surface, and the strips chosen and 
sawed with reference to the grain, so that there may 
be no chipping. Oak, in our climate, even when 
kiln-dried, shrinks and goes on shrinking, making 
bad cracks. Iron floor joists, filled between with 
hollow blocks of concrete, have the merit of being 
fire-proof. Carpenters should never be allowed to 
leave under floors, or choking the flues, sawdust, 
chips, or other substance likely to decay. Plasterers 
also need watching. 
Shellac makes a good surface for small hospital 
floors. It can be wiped off more readily than paint, 
and takes a good polish under a dry rub. It should 
not be washed with hot water. Dirt spots on waxed 80 
Hand-Book for Hospitals. 
or oiled wood should be cleaned off with turpentine 
before fresh oiling. Old floors with which nothing 
else can be done should have the cracks filled in 
carefully, and then the floors made neat and cheerful- 
looking by two or three coats of good gray paint 
and a broad, bright-painted border. A daily damp 
rub and dry rub with cloths will then effect the pur- 
pose of taking away the dust far more thoroughly 
than a flourish of brooms or any amount of mop- 
ping and slopping with dirty water. Old, unpainted 
floors must of course be scrubbed with hot water 
and soda; but the reckless use of water, even in 
that case, should always be avoided; it soaks into 
cracks, runs through to ceilings below, and leaves 
dampness ; it helps decay, makes wood floors spongy 
and porous, and creates pockets for dust and disease. 
The woodwork of a ward, of which there should 
be as little as possible, should be severely plain and 
flat, without angles, mouldings, or ledges to catch 
dust. It should be of hard wood, or kept freshly 
painted, or treated in a way to allow damp wiping 
and drying. Dust in a hospital is in good part or- 
ganic filth, and should be wiped away with damp 
and then dry cloths as the surest way of removing 
it. Feather dusters and dry flapping should be 
abolished. 
The hospital bed is the unit of the hospital. 
Hygiene, therefore, begins with the bed. For ordi- 
nary use, even when hair can be afforded, fresh oat 
straw makes safer beds; for the reason that hair 
beds are too expensive to be destroyed, and are sel- 
dom thoroughly cleansed, while straw beds may be Some Interior Details. 
81 
washed and freshly filled for every fresh patient, or 
as often as necessary. The best patent cotton felt 
mattresses are durable, and are divided in layers 
which can be removed singly and restored better 
than hair, etc. Woven wire beds have advantages for 
certain cases, a pair of blankets or a quilt being 
spread under the patient, and the permanent hair 
mattress, which is a prolific source of filth and infec- 
tion, got rid of. But for bad surgical cases, or 
seriously ill people, sometimes woven-wire beds 
are not steady enough, or are cold and hard, and a 
thin mattress of some kind must be added. Some 
cases will hopelessly infect and ruin mattresses, and 
for such, bed sacks and pillow sacks filled with straw 
must be used. Some of the hair mattresses may be 
made in sections, for if one section or division is 
spoiled, it costs less to renew it. Patients sometimes 
complain of such section mattresses that they sepa- 
rate and make cracks ; the sections should therefore 
be strongly tacked together. 
The top surface of the bed should be at a good 
height from the floor, for the convenience of doctors 
and nurses ; thirty inches is the approved height for 
the general run of cases, but the height will vary 
with the case. A high bed keeps the patient above 
the draughts and out of the layer of foul air which 
is apt to be near the floor, if anywhere, and the 
space under the bed is more readily seen and kept 
clean. For convalescents who can get in and out of 
bed and help themselves a low bed is more desirable. 
The bedsteads should be made entirely of iron, 
sides, end bars, and all, no wood being allowed in Hand-Book for Hospitals. 
the structure. They should be painted a cheerful 
color ; in some hospitals they are painted a bright 
red, and the effect is pleasant. 
An air-bed or water-bed for every surgical ward 
is necessary. A sectional air-bed, made by buckling 
together large india-rubber bags, about twelve or 
fourteen inches wide, and as long as the width of a 
hospital bed, say thirty inches, is used in the Gen- 
eral Hospital, New Haven. All or only part of the 
sections may be required. When empty they take 
up little room, and are a convenient form of bed for 
private family use in case of sickness, as well as for 
hospitals. A water-tank bed of a good pattern is in 
use in the Hartford Hospital, which cost about $48, 
including the iron bedstead. Where complete outfit 
can be afforded, there should be apparatus for lifting 
or holding up patients steadily and gently while the 
bed under them is changed or wounds are dressed. 
There are patent beds and fixtures for this purpose. 
The furnishings and apparatus of a hospital 
ward should be as few, as simple, and as easily kept 
in order as possible. The multipication of all sorts 
of contrivances means so much more needless labor 
and expense in cleaning and repairing them ; and 
the sight and use of a variety of appliances about 
him is exciting and exhausting to a weak and nervous 
patient. The bed, a small table with a drawer or un- 
der-shelf, and a chair for each patient, are the chief 
articles of ward furniture. The wooden furniture 
should be of a washable kind ; the chairs without 
upholstery, of as easy a shape as can be had ; the 
ordinary hard, small-seated “ hospital chair,” is Some Interior Details. 
83 
cruelly uncomfortable. A couple of large-wheeled 
rolling-chairs are needed ; and a few Boston rockers, 
and canvas—not carpet—camp-chairs, with arms, 
are a comfort to feeble patients. Where cushions 
are required they should be leather-covered, or 
calico pillows filled with chaff, which can be con- 
stantly emptied, washed, and refilled. Stuffed chairs, 
baize doors, worsted screens, and all fuzzy woolen 
surfaces of either furniture, bedding, or clothing 
are unclean and unwholesome. No bed-carpets or 
rugs should as a general thing be allowed, and no 
bed-curtains. If there are such, the rugs must be 
aired and shaken out-of-doors every day, and the 
curtains constantly changed and washed. 
A few bed-screens are needed, and may be easily 
made by stretching stout cotton or linen, on light 
folding clothes-horses. Use tape strings, so that the 
covers may be taken off, washed, and replaced, or 
use a light metal rod, fitting in a slot of the frame, 
and run through a hem on the edge of the linen. 
The frames should be painted, or treated in a way 
to allow washing them all over constantly with 
water or a little turpentine. Screens put about a 
bed where there is a case with offensive odor, may 
be made useful by keeping the linen cover wet with 
a brush dipped in evaporating fluid deodorizer. 
There should be a few bed-rests for each ward; 
and a few lightly made bed-trays or bed-benches 
for the meals of patients who are in bed. They 
should be long enough and high enough to clear the 
limbs, and are put across the lap, resting on the bed 
and taking all weight off the body. Common pine 84 
Hand-Book for Hospitals. 
treated with shellac answers. They should be two 
and one half feet long, about fourteen inches broad, 
and the legs or bench ends should be ten inches 
high. A low rim should run round three sides. A 
light-lifting chair, with handles so arranged as to 
keep the seat level in going up and down stairs, 
or a canvas and poles, are greatly needed in two- 
story buildings, for carrying new patients up stairs, 
and a stretcher on folding legs, for accident cases, 
should be at hand. 
Glass lotion pans and glass urinals are the best. 
Glass ought to be used for many more purposes in 
hospitals than is common. Brass dressing-basins, 
shallow, and with convex and concave sides, so as 
to fit different parts of the body, are useful. Papier- 
machd basins and pails seem light and neat, but they 
soon absorb liquid filth, and are undesirable. Ves- 
sels of tin are extremely objectionable, as they can- 
not long be kept free from bad odor. 
Medicine closet.—A locked cupboard with com- 
partments, either standing or hanging against the 
wall, is the best place for keeping medicines. The 
partitions should always be movable, for convenience 
in cleansing. A cupboard four feet high, three feet 
broad, and six or seven inches deep, gives twenty 
good-sized compartments, besides shelf-room for the 
ward medicines, all under lock and key. A shelf to 
pull out under the cupboard, and one or two deep 
drawers for lint and bandages, are useful. Station- 
ary medicine boxes on ward tables are objection- 
able ; still more so are open racks of shelves in 
which liquors and opiates are accessible to every Some Interior Details. 
85 
one. To save steps in a long ward, a cheap expedi- 
ent is a common tin puff-pan, such as are used for 
baking, or two fastened together, with a firm handle 
run across. Two dozen sockets would be light. 
These could be numbered to correspond with the 
beds, and half the doses carried round at one time; 
some of the sockets holding small glasses with water, 
for swallowing after the medicine.1 
Surgical dressing-table.—A great assistance in 
a surgical ward, helping to save delays in fetching 
and carrying, is a ward dressing-table on noise- 
less rollers. A light, common, little hard-wood 
table, such as is used for children to play at, would 
answer. It should be from three to four feet long, 
and about two feet wide ; should have a rim round 
the top, and should roll easily. There should be a 
shallow drawer for surgical'scissors and plaster, and 
a deeper drawer for clean rags, lint, and bandages. 
The top holds the basins, alcohol lamp, hot-water 
can for heating plaster, and any other needed arti- 
cle. A bar across each end serves as handle and 
towel-rack. The whole thing should be no higher 
than the bed, up to which it could be moved with 
very little exertion ; and it would take the place of 
the floor, two or three chairs, the bed-table, and the 
empty beds alongside, all of which are sometimes 
brought into requisition for the surgical dressing of 
one patient. Great care must be taken to cleanse 
every portion of this table and its drawers, and to 
1 In modern hospitals medicines are kept in separate rooms under 
charge of the nurse ; instruments are kept in the operating rooms.— 
Eds. Third Edition. 86 
Hand-Book for Hospitals. 
cleanse instruments which have been used, before 
putting them away.1 
For patient’s clothing which is in daily use, a 
locked and ventilated room or closet with hooks and 
shelves, near by but not in the ward, is essential; 
otherwise dirty bundles, “ back hair,” and old boots 
will be found under the patient’s bed, or between 
the mattresses. Some patients will be convales- 
cents, able to take out-door exercise ; others will be 
constantly in and out of bed, better one day and 
worse the next; and the nurse must have a place 
close at hand in which the outer garments, the hats, 
and boots can be kept and quickly reached. A good 
arrangement is a row of low, small closets built along 
the wall inside the day-room. Each patient could 
have a separate cupboard and the nurse would keep 
a common pass-key. The closets or rooms in which 
patients’ clothing and ward linen are kept should be 
constantly examined by the visitor. 
Managing and building committees, where these 
are all men, will find it an advantage to take counsel 
beforehand with some trained nurse, or some lady 
who has had experience in hospital service, in regard 
to ward apparatus and matters of interior detail. 
But hospital managing boards should always include 
women. A memorandum for the outfit of a ward of 
twenty beds is given in the appendix. 
Ward dining-room.—Visitors should insist on a 
separate room for every ward, to be used as a dining- 
1 Since accurate scientific knowledge of antisepsis has been applied 
to surgery, wounds are seldom disturbed by frequent dressings; and 
many former appliances are now obsolete.—Eds. Third Edition. Some Interior Details. 
room, a bright, well-ventilated, sunshiny room, re- 
moved from the water-closets and bath-rooms. No 
eating should ever go on in a ward unless food is 
carried to some really sick person in bed, or to some 
one whose presence at table would be offensive to 
others. Offensive or unsightly patients must be 
provided with meals in the ward, and explanation, if 
needed, be gently but firmly made to them. Meals 
are often carried to the bedside when a patient is 
perfectly able to—and might much better, for his 
own sake—go into an adjoining room. Or, what is 
worse, a long table is sometimes set out in the ward 
itself, for all, in the midst of the repulsive associa- 
tions of sick-beds ; cabbage and carbolic acid min- 
gling their fumes together. Get the convalescents 
away from their bedsides at the earliest possible mo- 
ment ; it is often the turning-point toward recovery. 
Give them a cheerful room, a neat table-cloth, always 
clean (a very little additional expense will prevent 
the abomination of a coffee-stained, greasy table- 
cloth), clean plates, bowls, and tumblers; somebody 
—convalescents in turn if you choose—to say a 
Christian grace before meals ; a little pleasant talk ; a 
glass of garden flowers ora basket of fruit and green 
leaves on the table ; and you have taken a long step 
toward curing your patients, perhaps both in body 
and heart. Look in unexpectedly at meal-times to see 
that the dining-room apparatus, the dishes, spoons, 
knives, forks, and tumblers, are clean, and sufficient 
in number, and that the food is decently served and 
of good quality. 
The general kitchen of a hospital is best situated 88 
Hand-Book for Hospitals. 
on the ground-floor of the administration building— 
never under wards—and the cook should have a 
proper number of assistants according to the size of 
the institution. A hand wagon with shelves for 
carrying the diet is necessary in large hospitals. In 
a large hospital also, a small special kitchen for 
extra diet, with a special attendant, is very desir- 
able ; and here, if need be, nurses may be taught 
simple, sick cookery, which is an important part of 
a nurse’s education. Nurses should not be allowed 
in the main kitchen. In some hospitals nurses are 
sent in squads to the cooking school, which is a 
recognized institution now, in cities. No cooking 
should be done in the ward or ward pantry. The 
large diet kitchens with ranges, sometimes attached 
to Avards in city hospitals, are objectionable, and are 
often misused. A large, light pantry with a dresser 
for the table furniture, a sink with hot and cold water, 
a good-sized table, and a gas-stove or spirit-lamp 
for heating drinks or boiling an egg, a little refriger- 
ator with a constant supply of ice for keeping drinks 
sweet and cool, are all the apparatus needed. 
Musical instruments in a hospital are good things 
if they are managed with good sense and strict re- 
gard for the comfort of the majority. In certain 
stages of illness and convalescence the soft, long- 
drawn strains of good organ music, or of a sympa- 
thetic human voice, are soothing and delightful. On 
the other hand, the loud, sharp stroke of a piano- 
forte played in season and out of season, and played 
in the false and slipshod manner common in such 
places, is exceedingly irritating to the nerves of Some Interior Details. 
89 
many sick persons, and therefore positively injuri- 
ous. Sore complaints have been made to the writer 
by hospital patients on this subject. If musical in- 
struments are kept near hospital wards no such thing 
as “practising” or indiscriminate thrumming for 
private amusement should on any account be al- 
lowed. If it is difficult wholly to prevent this abuse 
of instruments, they should be kept in some room 
out of hearing of the sick, and moved near the 
wards only on occasions of general worship or enter- 
tainment, or at times when they can be well and 
judiciously played for the comfort and pleasure of all. 
Nurse’s room.—A nurse, during the hours when 
she is on duty, ought always to command her ward. 
Her room, therefore, if it is attached to the ward, 
should overlook it by a window. But wherever it 
is possible each nurse should have her own sleeping- 
room, away from the ward, into which she should 
go only when off duty—never leaving the ward at 
other times. The efficiency of the nurse is so im- 
portant for her charge, that her health and comfort 
should be considered for this reason as well as for 
her own sake.1 
A small examining-room should be provided for 
each ward, especially for women’s wards. A strong, 
long table of the right height, with a thin mattress 
or cushion, would be needed, and facilities for hand- 
1 The Connecticut Training School for Nurses has just completed 
an excellent three-story brick building as a nurses’ dormitory, on the 
grounds of the General Hospital, New Haven. It cost a little over 
$12,000, accommodates thirty persons, and is a model of its kind. 
The Massachussets General Hospital has also a fine new building for 
its fifty or more women nurses, and so has Bellevue Hospital, New 
York (1883). Hand-Book for Hospitals. 
90 
washing; and a bed, perhaps, on which a patient 
could rest until the effects of anaesthetics pass off. 
Such a room could serve as the reception-room for 
new patients on admission to the ward, and for 
minor operations where the large operating-room is 
at a distance, or where there is no medical school 
and no general amphitheatre. 
Foul linen shoots in a hospital are non-essential— 
they are worse. All such linen shoots and dust-shafts 
are channels for foul air from one floor to another, 
as well as for flames in case of fire. Foul shoots 
should never be permitted in building new hospitals. 
Where shoots are in use already, visitors must notice 
if they are lined throughout with glazed tiles or 
hard-faced brick ; if they are carried up through the 
roof like chimneys and left open at the top, as they 
should be, with a suitable hood to keep out rain and 
snow. They should open below in the open air, 
and if possible on the sunny side of the building; 
and there should be a row of augur holes or blind 
slats along the bottom of the lowest door to help 
a continuous upward current of air. The shoots 
should be cleansed at regular intervals by sending 
strong sulphur fumes through them and by white- 
washing. Fresh air is the best everyday disinfec- 
tant. The plan of driving away one stench by 
means of another ought to go out of fashion. 
It cannot be too distinctly understood that cleanli- 
ness, ventilation, and dryness are the proper deodor- 
izers, and that artificial deodorizers will no more 
take their place than perfumes will serve in the 
place of soap and water.1 Examine the dust and 
1 Mr. John Simon. Some Interior Details. 
91 
linen shoots often at both ends ; smell up and down 
them; and do the same with dumb-waiters. See 
that the openings for dumb-waiters, and for all 
lifts large enough to admit a person, are protected 
by a fixed bar, waist-high, to prevent accidents. 
On no account ever tolerate the sending of soiled 
linen down in a dumb-waiter used for food. See 
that the soiled linen is not kept in the ward, or 
allowed to accumulate in lobbies, bath-rooms, or 
closets attached to the ward. It should be put at 
once, with no more shaking and handling than is 
absolutely necessary, into tight-covered vessels and 
sent to the laundry. It would even be better to 
put soiled clothes into stout bags, and tumble them 
out of the window into the yard, than allow them 
to lie about the wards. 
Steam-closets for “ airing ” mattresses and dry- 
ing sheets are often attached to the wards, in large 
city hospitals, where steam machinery is used for 
heating,—an unnecessary and undesirable arrange- 
ment ; such closets are much better omitted. Only 
clean mattresses and clean linen damp from the wash 
should be thus dried, never soiled articles. 
Visitors must see that dirty towels, wet umbrellas, 
muddy boots, apple skins, dead flowers, old poul- 
tices, and oiled rags are not stuffed out of sight into 
hot closets with a full head of steam turned on. 
Refuse-cans and bins.—See that poultices, old 
plasters and dressings are never thrown down shoots 
or into water-closets or sinks, but put into the ward 
refuse-cans and burned up at once. Galvanized iron 
pails with handles and tight covers should be provided 
for this purpose. Notice where these cans stand 92 
Hand-Book for Hospitals. 
during the day and night, and ask who is responsible 
for emptying them. Find out how often they are 
emptied, and how and where such offensive matter 
is burned. Burning in the stove or furnace or any 
ordinary fire must never be attempted. The boiler- 
house fire is sometimes used in right states of the 
wind, when the building is a detached one with its 
own chimney; but every hospital needs a covered 
pit constructed for such purposes on the grounds 
outside. The history of epidemics shows what is 
the risk of burning infected bedding and other arti- 
cles in the open air. 
Open and examine at every visit the refuse-cans 
and the bins into which sweepings are thrown. 
Constantly recurring cases of erysipelas and pyaemia 
in two beds on each side of a particular window of 
Middlesex Hospital, London, led to a search for the 
local cause. It was found in a dust-bin in the area 
below in the direct line of the window. This was 
cleaned out and left unused, and erysipelas and 
pyaemia disappeared from those two beds, to reap- 
pear after two or three years when the dust-bin, 
under a new officer, was again in use. 
Post-mortem rooms.—Important points for vis- 
itors to notice are the position and the general ar- 
rangements of the post-mortem building, and of the 
rooms devoted to out-patients, where there are such. 
The ventilation and thorough periodic cleansing of 
all these places are indispensable. 
“ The frequent nearness of the dead-house, and 
the practice of allowing [or requiring] house-surgeons 
to conduct the autopsies, is undoubtedly a frequent Some Interior Details. 
93 
and unsuspected cause of the propagation of disease. 
Yet who can be surprised at wounds becoming in- 
fected when they are dressed by the very hands 
which have recently conducted a post-mortem, or 
been immersed in the fluids of a body dead, per- 
haps, of infectious disease? The practice of allow- 
ing the same officer to discharge at the same time 
duties which are so antagonistic in a sanitary point 
of view as those in the ward, the operating-theatre, 
and the dead-house is most reprehensible.” 1 The 
utmost care in the change of clothing, in bathing the 
person, and washing the hands with carbolized water 
are hardly sufficient precautions. The hair, the 
beard, and finger nails often carry contagion. 
No covered corridor should connect the dead-house 
with the main building ; at least one hundred feet of 
open space should intervene, and it should be in the 
direction away from the prevailing wind. The post- 
mortem building should have its own special ar- 
rangements for ventilation and its own system of 
drains, with sewer connections distinct from those 
of the hospital. 
In many respects a large hospital can be managed 
more safely than a small one. Subdivision of duties 
is a protection. The necessity which compels one 
surgeon or one attendant to do a variety of work 
involves risk. It is unwise and dangerous to call in 
a nurse while on duty in the wards to assist at or do 
the after-work of an autopsy. 
1 Erichsen. VI 
The Hospital Laundry. 
A HOSPITAL laundry, with its adjuncts, the disin- 
fecting chamber and the linen-room, represents an 
essential portion of hospital service. The mode of 
its management will affect, for good or evil, the 
general sanitary condition of the institution, and 
sometimes determine the question of life or death in 
individual cases. 
The needs of the laundry service are so easily fore- 
seen, and the dangers which its various processes 
involve are so easily calculated, that in pre-arranging 
matters no point need be left for conjecture. The 
laundry should be taken into account in the original 
plan of a new hospital. It must be in a detached 
and ventilated building, never in, or if possible near, 
the hospital. Cooking must be done on the hospital 
premises, and a kitchen must be tolerated, provided 
it is well ventilated and is not under a ward. Cooking 
smells are not always unwholesome; laundry vapors 
are always so. Heat and moisture charged with or- 
ganic filth, and allowed to pour up into sick and sur- 
gical wards, make as uncivilized an exhibition as can 
well be found. Visitors to country or town hospitals 
need not envy the steam-laundry, and steam drying- 
rooms found sometimes under the ward windows of 
city institutions. Hand labor, grass bleaching, wind, The Hospital Laundry. 
95 
and sunshine are the best dependence for disinfect- 
ing and drying hospital linen. No other method 
will so thoroughly remove ordinary taints. 
An outside, airy drying-yard is a necessity ; use 
being made of an in-door drying-room only in pro- 
longed wet or freezing weather. Where grounds 
are not ample enough to provide for out-door drying, 
as they seldom are within city limits, hospitals 
should make special arrangements for a country 
laundry to which the soiled linen could be daily 
sent. The work, in such case, ought always to be 
kept under the control of the hospital authorities 
and should be supervised by a skilled woman. 
Women’s supervision.—The medical Director- 
General of the army hospitals of Berlin during the 
Franco-Prussian war, devotes several pages of an 
official report to setting forth the advantages of 
ladies’ supervision over laundry and kitchen affairs 
in hospitals, and illustrates the point by saying that 
the quick eye of a lady visitor, on one occasion in 
one of the Berlin hospitals, detected by its edge that 
a soiled bandage had not been washed but only 
ironed; a detail which the government inspector 
declared his inability to decide. The inability, we 
venture to say, would be shared, in a similar case, 
by most of the gentlemen managers, who make 
their hasty, perfunctory tours of inspection through 
our city hospitals. In the experience of the writer 
a hospital laundry was reported untidy by the in- 
specting committee of gentlemen, because “a tub 
of dark-looking liquid ” was standing in one corner. 
They had never seen indigo water. 96 
Hand-Book for Hospitals. 
Infection.—It would be acknowledged as an im- 
mense relief, in private families, if the washing-day 
nuisance could be got rid of. To some extent 
this is accomplished in England for the working- 
classes by the establishment of public wash-houses, 
where, for threepence an hour, a woman may have 
the use of tubs and hot water and drying-room for 
her week’s wash, and thus keep her little home free 
from this source of befouling and danger. In 
private houses the limitations of domestic architec- 
ture, as a rule, put the kitchen and laundry together, 
with a result which has been forcibly described : 
“ These rooms are not only one and the same, often, 
but they are so constructed and placed on the 
ground-floor that they communicate more or less 
directly with all other parts of the house. What is 
the consequence ? The house is filled with the ris- 
ing vapors of foul steam. The waste from cooking 
in its conversion to steam carries with it volatile 
portions of the food ; finely divided animal and 
vegetable matter in a state to take on putrefaction 
or fermentation, whenever the conditions of warmth 
and moisture are favorable. The body- and bed- 
linen of the family are saturated with the excretions 
of the skin. These excretions consist of the waste 
products of the body which have accumulated for a 
week perhaps. A part of the process of washing is 
the boiling of dirty clothes. A temperature at the 
boiling point will volatilize most of the excretions 
in the clothes and enable them to escape with the 
vapor, and these, sent off with violence, are driven 
into all parts of the kitchen and dining-room and The Hospital Laundry. 
97 
penetrate frequently sitting- and sleeping-rooms. 
They lodge on the meats, bread, and vegetables, 
adhere to tables, table-linen, plates, knives, and 
other furniture, to walls, bed-clothes, and carpets. 
Nor does this accumulation of putrefactive animal 
and organic waste from cooking and washing remain 
in its place of lodgment as inert matter. It forms 
a hot-bed in which germinate vast numbers of low 
organisms. Rub your hand over some neglected 
laundry wall; how begrimed it is, what a putrid 
odor!”1 
Much of this family nuisance may be abated by 
the intelligent supervision of the head of the house- 
hold, by care in cleansing and ventilation, and by 
the judicious use of whitewash and disinfectants. 
But if, now, we increase the size of the household 
until it reaches the numbers of one of our large 
hospitals, and then remember that it is a household 
of sick people, some of them ill with suppurative 
and offensive diseases, we can better understand the 
risks of the laundry service, the wisdom of isolating 
the laundry, and the need of skilled oversight. Let 
visiting committees bear in mind, and we cannot too 
strongly enforce it, that over and above the best 
plan of construction and the most approved ap- 
paratus something more is needed to preserve a 
house or a hospital from contamination by the ex- 
creta of the inmates. As Dr. Smith well says: 
“ The best machinery cannot be automatic ; the most 
inefficient can be made useful by intelligent care.” 
1 Dr. Stephen Smith. 98 
Hand-Book for Hospitals. 
One is almost tempted to adapt the familiar couplet 
and say; for modes of hospital construction 
“ let fools contest ; 
That which is best administered is best.” 
Position.—The worst possible position for a hos- 
pital laundry is in the basement. The bad air, 
helped by the constant heat, rises and pervades the 
building, either through the ordinary channels of 
lifts and staircases, or puffing out and in through 
the windows. If visiting committees find this de- 
partment arranged inside a hospital, and nothing 
better can be done, they must advise its removal to 
the top floor, where the clothes can be dried on the 
roof, and the foul vapors more rapidly carried away 
and diluted with the fresh upper air. It is better to 
provide the extra apparatus and pay for extra labor 
of pumping and hoisting than run the risk of filling 
the wards with the fumes which any basement laun- 
dry, no matter how well conducted, must generate. 
“ Why do you always smell dirty dish towels 
here?” asked a visitor, with a keen, fresh olfactory 
sense brought from the country, as he mounted 
the marble vestibule steps of one of the finest 
hospitals in New York. It was the unrecognized 
abiding atmosphere of the halls to which he gave 
this name. 
Wherever the laundry is put it should have its 
own ventilating chimney with a strong draught and 
its own direct drain-pipes and main sewer connec- 
tions and traps. The sudden letting off of a tub- 
ful of laundry slops will suck out the ordinary The Hospital Laundry. 
99 
traps of water-closets and basins in the same stack 
and make way for an instantaneous rush of pernicious 
vapor. 
The ventilation and drainage of a hospital laun- 
dry should be carefully studied and made thorough 
and complete, so that no damp, bad air need hang 
about the place, and no foul water stand in any pipe 
or trap. The floor should be drained to keep it dry, 
and the utmost care and cleanliness should be ob- 
served with the tubs and all utensils. Necessary 
repairs should be promptly made. The work of the 
laundry-women is particularly severe, and exposes 
them often to infection. Whatever humane precau- 
tion is needed to protect their health should be 
used. Fever epidemics sometimes occur among 
washerwomen in poorly arranged laundries; and 
felons, cases of inflammation of the eyes, and 
erysipelas are not infrequent. The laundry build- 
ing should be reserved for laundry and disin- 
fecting work only. It is a violation of sanitary 
principles to put bedrooms for employees in or over 
a laundry. 
The size of a hospital laundry will depend much 
upon the mode in which the work is done, whether 
by machinery or not. For fifty beds, and for work 
done chiefly by manual labor, a one-story building, 
thirty by thirty feet, would probably be sufficient. 
For a hospital of one hundred patients a one-story 
building, forty by forty feet, might be required.1 
This would give a capacity of four large rooms, each 
twenty feet square, giving space for disinfecting 
1 Mr. Carl Pfeiffer, Architect. Hand-Book for Hospitals. 
chamber, separate sorting-room, in-door drying-room, 
and other purposes. The same size would answer 
for double or triple the number of beds if steam 
machinery were used—the furnace and boiler being 
in a basement. Two or three large rooms are better 
than several small ones. They can be more easily 
aired and supervised. Where there is much ironing 
to be done, enough space for the ironing-boards or 
tables should be calculated for; it is these which 
take up room. 
Working capacity.—But size in these matters is 
of less importance than convenient arrangement of 
details and good system in management. An in- 
quiry into the working capacity of some of the city 
laundries for family washing shows that a great 
amount of work can be done in less space, with sim- 
pler methods, and with less consumption of fuel than 
is commonly supposed. In one of these establish- 
ments, very clean and evidently systematically man- 
aged, occupying one floor of an ordinary house, the 
writer found the work going on with eight women, 
in a room about fifteen by thirty feet altogether, 
leaving plenty of vacant space in front for office 
business. There were six tubs for hand-washing 
and rinsing, and a small round stove which held the 
water coil and supplied hot water; a ten-gallon 
clothes-boiler could stand on top. The consumption 
of fuel was two bushels, or four scuttles, of coal 
daily. A drying-room was partitioned off by plank- 
ing, sheathed, low ceiling and all, with sheet tin, and 
here a very small stove dried the clothes on a reel 
and kept relays of irons hot. On an average this The Hospital Laundry. 
laundry washed and ironed daily, by hand labor, 
about one hundred starched shirts, collars, and other 
pieces. The proprietor said that with bed-linen 
and towels, needing no starching, he could turn out 
a thousand pieces daily, or nearly as many in a day 
as the weekly wash for a hospital of fifty beds. 
This was washing for well people. The character 
of hospital washing would make special apparatus 
for disinfection necessary, and therefore require a 
different disposition of space, and, except for small 
hospitals, probably more time and more room. 
Some one space, or room should be strictly reserved 
in connection with a hospital laundry in which to 
receive and disinfect foul clothing and bandages. 
But granting that the proprietor may have some- 
what overestimated the capacity of his little stove 
for furnishing enough hot water rapidly, it is evi- 
dent that any hospital having available labor, and 
ground-space on which to put up some simple frame 
building, need never wait to complete a large and 
costly structure with elaborate steam appliances, 
in order to provide itself with an outside laundry 
and with that essential of all properly-managed hos- 
pitals, an ample and never-ceasing supply of clean 
fresh-washed linen. 
There has never been a machine invented equal 
in its operation in cleansing clothes to the thorough, 
old-fashioned hand-washing ; but in large hospitals 
hand-washing exclusively is out of the question ; a 
good washing-machine turned by hand or power is 
required. Where there is steam-power the use of 
steam machinery will be a saving of three fourths of 102 
Hand-Book for Hospitals. 
the time and labor. Two steam-washers will do the 
work of the largest hospital. A rough estimate puts 
the amount of washing for fifty beds, and for the 
necessary officers and attendants, at from one thou- 
sand to fifteen hundred pieces weekly. 
Apparatus.—So many improvements and inven- 
tions are being made that no special machinery can 
be mentioned. A laundry must be fitted up with 
the best attainable apparatus of whatever may be 
the most approved patent. One test of a good 
washing-machine is the little amount of lint that 
will hang about it. Where the washers are worked 
by steam this power will also serve to run a steam- 
wringer and mangle. Steam-wringers are cylindrical 
vats revolving with great velocity, and throwing off 
the water by centrifugal force. Four hundred revo- 
lutions a minute will suffice to wring the clothes so 
thoroughly that they will dry in seven minutes in a 
steam-heated drying-room. Such drying-rooms are 
fitted with sliding wooden drying-frames or horses, 
and are heated from below by coils of hot pipe. 
The space required is not large; ten feet by fifteen, 
with a ceiling not more than eight or nine feet high, 
is ample size for such a room in a hospital of two 
hundred beds. The walls may be sheathed with 
zinc. If the washing is thoroughly done this mode 
of steam-drying would be less objectionable, but in 
any case such a drying-room requires frequent dis- 
infection (which may be effected by burning roll 
sulphur) and constant ventilation by flues which will 
carry the damp vapor to a safe distance. In subur- 
ban hospitals a large vacant laundry room, where The Hospital Laundry. 
103 
ropes can be stretched, should be reserved for drying 
clothes in bad weather. 
A steam-vat for boiling clothes or a large copper 
clothes-boiler set in brick, with fire below or at the 
side, giving space also for heating flat-irons, will be 
needed. Where the ironing-room is a separate one, 
a small coal or gas-stove for the irons should stand 
in a brick-walled alcove. This is a precaution 
against fire, and in summer it keeps the ironing- 
room cooler. A soaking-tank, rinsing-tubs, a cop- 
per starch-kettle; all these must be provided. 
The best wash-tubs for hand-washing are slate. 
With porcelain tubs for rough work, the least crack 
or chip or imperfection in glazing will permit the 
absorption of foul matter. Two or more tubs 
should be reserved for the washing of the household 
apart from that of the wards and on different days. 
Soap-making.—Among the laundry fixtures 
should be a large kettle for soap-boiling, for 
where the meat diet is of good quality the waste 
fat of the hospital kitchen can be economized in 
this way and made to serve most cleansing pur- 
poses. In a carefully managed hospital of one 
hundred inmates, known to the writer, the fat 
saved and rendered served the uses of the kitchen, 
made oil for the machinery, and all the soap, both 
hard and soft, required by the household, except 
soap for surgical use ; while the sale of the surplus 
fat averaged enough to pay for the potash purchased 
for the manufacture. 
Disinfecting-room.—The room strictly set apart 
in the laundry for sorting and disinfecting foul and Hand-Book for Hospitals. 
104 
infected articles, should be a light and particularly 
well-ventilated room. It should have a copper vat 
specially reserved for boiling such articles. This 
may be a steam-vat, if the machinery is run by 
steam, or a large, tight-covered copper kettle with 
fire beneath, like, but distinct from, the boiler used 
for the ordinary washing. The service also requires 
a metal soaking-vat for foul bandages and cloths 
which need careful disinfection, but which must not 
be mixed with articles from poison cases. For com- 
plete outfit, there must be a heavy wooden metal- 
lined chest, or a chest with double walls of sheet 
metal and some material which is a poor conductor 
of heat between them. This must have a steam- 
gauge and thermometer, and an outlet, with valve, 
into the boiler-house chimney. In this box an en- 
tire mattress, or pillows, or parcels of cloth clothing 
can be baked by dry heat, from steam-coils arranged 
in the bottom of the box, or by live steam charged 
with disinfectants and driven through. Superheated 
steam has been found a valuable purifying agent. 
In several hospitals of Berlin, and other parts of 
Germany, such recently patented apparatus is now 
used for disinfection by heat, both moist and dry, 
the arrangement being similar to our own. A frame 
with crossbars, on which clothing may hang, is run 
in, by an upper door of the chest, and another frame, 
or wagon, run in below, carries the coils of copper 
tubes, one set perforated, one close, which are con- 
nected with the outside heating-pipes and used 
alternately. In large hospitals, a bricked closet or 
oven for use in baking or fumigating, into which a The Hospital Laundry. 
105 
single iron bedstead with all its bedding can be run, 
is required rather than a box.1 
Mattress-making.—A shed or room remote from 
the wards, in which straw beds may be emptied and 
filled, or hair mattresses, if these are used, may be 
picked over and re-made, is a necessity for every hos- 
pital. It is work which is always going on and 
which constantly involves risk of infection and for 
which, therefore, some special room must be re- 
served. This room, though distinct from the laun- 
dry, may very well be built over or in connection 
with it. There are hair-picking machines run by 
power, which facilitate the work where it is best to 
economize labor, but they are apt to break the 
hair and waste it, and hand-picking, though slower, 
is more thorough. 
Linen-room.—The room for the storage of the 
clean linen of a hospital should be near the matron’s 
or housekeeper’s quarters, well ventilated and 
lighted, and, if possible, constructed with an ex- 
posure to the sun. Like the laundry, it should be 
under the general charge of the matron, who, in a 
large hospital, should have a special assistant as 
linen-room woman to superintend and sort and 
mend the clean linen when it comes from the 
wash. 
Open-slatted shelves for the linen, round which 
1 Attached to the laundry of the building of the Society for the 
Prevention of Cruelty to Children (4th Avenue and 23d street, New 
York City), there is an excellent steam-cleaning and disinfecting ap- 
paratus, which seems simple in its working and efficacious,—Eds, 
Third Edition. 106 
Hand-Book for Hospitals. 
the sun and air can have free play, should be pro- 
vided. French hospitals furnish good models. 
Glass doors for the shelving are neat but trouble- 
some and unnecessary. Any space left below the 
shelves may be fitted with drawers for bundles of 
old linen and flannel and articles too much worn for 
their original use, but which can be made to serve 
some purpose. All drawers and shelves should be 
labelled distinctly, so that any article needed in 
haste can be found without difficulty. A good sew- 
ing-machine is part of a complete outfit, and a large 
table on which articles can be spread, examined, 
and folded. A room, or loft, apart from the linen- 
room proper, is needed, furnished with wide racks, 
where mattresses and pillows may be kept and 
aired when not in use. There should be a constant 
current of air drawing through, and the windows 
should be left open, day and night, in dry weather. 
A book with a lettered index, is required in the 
linen-room in which to keep a full account of all 
bed-, body-, and table-linen, and all the property of 
the hospital connected with the laundry and linen- 
room. When articles are worn out they should be 
credited, and when new supplies are purchased they 
should be charged to the account. Donations of 
goods or clothing made to the hospital, should also 
be accurately recorded. In this way, when an in- 
ventory is taken, a balance can easily be struck. 
This systematic way of keeping lists enables a new 
occupant of a position to learn at a glance on taking 
charge just what property owned by the hospital 
comes under her care. This book is written up by The Hospital Laundry. 
107 
the matron, and with its aid she should be able, at 
any time, to give a satisfactory and business-like 
statement to the managers or other inspecting offi- 
cers. This book may be called the linen-room ledger. 
For complete system there should be a day-book 
kept by the linen-room woman, in which are charged 
all articles issued to nurses or other employees, and 
in which signed receipts are entered as vouchers. 
When a general account is taken, the linen-room 
woman must see that all the articles are accounted 
for—either as issued to the wards, remaining in stock, 
or in the wash. When this is done she can counter- 
sign the record. If articles are used up or are miss- 
ing on a given date, the discrepancy is to be noted 
accurately in the ledger. Matron, linen-room wo- 
man, chief laundry-woman, and nurses ought to com- 
pare and settle the linen-accounts once a month at 
least. 
For recording the soiled linen taken from the 
wards to the laundry, printed slips are needed to be 
sent with the bundles. They should have a blank 
for date, for the number of the ward, and for the 
name of the nurse who sends, and of the chief 
laundry-woman who receives the parcels. Printed 
labels marked DISINFECT and POISON, are also 
needed. The apothecary can furnish the linen-room 
with common, printed poison labels which answer 
this use. 
A few simple printed forms and rules will save 
labor and systematize the work of a hospital laun- 
dry very much. Rules and directions plainly printed 
on cards and hung in the laundry will be found Hand-Book for Hospitals. 
108 
useful—How to make soap ; How to wash woollens ; 
How to disinfect. Printed rules as to the number 
and character of pieces allowed in the wash for 
patients and attendants, should be posted in the 
proper places. Neatly and legibly printed cards 
which can be tacked up conspicuously carry author- 
ity and furnish a reminder when verbal instructions 
might be overlooked. The ledger, day-book, printed 
slips and forms are among the first requirements of 
the linen department. 
Much of the hospital linen will be in constant use, 
coming and going. Each ward, in its own linen- 
closet, or in the closet of the nurse’s room and under 
her care, should have a day’s supply in advance, but 
no more. Articles sent to the wash from the wards 
should not be returned clean to the nurses directly ; 
they must be sent from the laundry to the linen- 
room for distribution, and at a fixed and convenient 
hour every day the nurses must come to the linen- 
room, make their requisitions, and receive their ward 
supplies. The linen-room woman must keep a mark- 
ing-pad and see that the linen is always neatly and 
clearly stamped with the proper hospital or ward 
mark. 
Outfit.—A memorandum is given in the appendix 
among ward outfit, of the articles needed in stock- 
ing a linen-room. It is the best economy to choose 
good, stout material for hospital wear, and to make 
and keep the supply of articles ample. It should 
be so ample that beds and patients can be kept per- 
fectly clean without risk of using damp linen. Dark- 
colored quilts and blankets are to be avoided. That The Hospital Laundry. 
109 
they “ do not show dirt,” is by no means a virtue— 
it is a serious objection. Draw-sheets should be 
supplied of yard-wide cotton, and three yards long. 
They are folded and used double. Tapes at the 
edges to tie them tight to the bedstead are useful. 
Besides rubber sheets and rubber pillow-cases, a roll 
of stout, tarred paper (or some similar cheap material, 
such as oiled muslin) must be kept in stock. It is 
wanted for use under certain foul cases, or with lying- 
in cases, instead of a rubber sheet, and is then burnt 
up. It is useful, also, to wrap infected cloths and 
dressings in, so that the parcels may be burnt with- 
out opening. Shirts, night-gowns, and wrappers are 
needed, but a hospital must generally depend upon 
outside charity to provide most of these articles of 
body-clothing. Bandage-muslin is usually a dispen- 
sary supply, but the matron can prevent waste by 
taking charge of it herself and issuing it from the 
linen-room. Where the outfit is complete, and the 
house-keeper’s supervision is what it should be, there 
will be less waste and misuse. 
The laundry service. — The immediate charge 
of a hospital laundry should be in the hands of a 
competent head laundress. The matron or house- 
keeper should be empowered to employ such a 
woman, and to employ and pay for all necessary as- 
sistants. The matron should be held accountable 
by the managers, and in turn should hold her head 
laundry-woman accountable for the way in which 
the work is done and for the proper and careful use 
of all fixtures. 
Laundry work properly begins at the moment Hand-Book for Hospitals. 
110 
when the clothing for beds or patients is changed 
in the wards, and properly divides itself in the fol- 
lowing way: 
1. Duties of the nurse. 
2. Duties of the head laundress. 
3. Duties of the laundry-maids. 
4. Duties of the linen-room woman. 
5. Duties of the matron. 
The suggestions which are given are of a practi- 
cal sort, and, for the sake of simplicity, are directly 
addressed to hospital employees. Visitors should 
observe all the stages of the work. Let them 
follow a garment from the ward to the laundry, and 
back to the linen-room, and notice how perfectly 
or imperfectly the system here enjoined is carried 
out. 
I. Duties of the nurse.—When bed- or body- 
clothing is to be changed, all the clean articles 
must be near at hand before a nurse begins to 
remove the soiled ones. Make the change as 
quickly as possible, and take the soiled clothing of 
each case out of the ward at once. Never leave an 
accumulating pile of soiled clothes in the ward until 
the last bed and patient have been put in order; an 
hour or two might pass before this work was ended, 
and the soiled clothing would infect the air all this 
time. The Hospital Laundry. 
111 
As soon as each parcel is taken out of the ward, 
it must be put by the nurse or some trustworthy 
assistant, with as little handling and shaking as need 
be, into a tight-covered metal can or zinc-lined box 
for removal at once to the laundry. 
In ordinary surgical cases all bandages and cloths 
used for the patient should be burned. Towels 
used for such cases should be placed at once in a 
solution of bichloride of mercury of the strength of 
i-iooo, or of carbolic acid of the strength of 1-20. 
After remaining in this solution for a half-hour they 
should be taken out and sent to the laundry to be 
boiled and washed as are other articles. 
All bandages or cloths used for wounds where 
there is excessive suppuration, must be tossed into 
a galvanized iron refuse-pail covered tightly, or 
stoneware jar covered, and as soon as the dressings 
are over must be carried out of the ward and 
burned ; or they may be tightly wrapped in tarred 
paper and burned, wrapper and all. The pail or jar 
should contain chloride of lime or strong disinfect- 
ing fluid enough to soak or cover the contents. 
The burning must be done outside the buildings, in 
the pit specially provided ; or, where there is an 
outside boiler-house, with its own chimney, the 
boiler fire may be used for this purpose.1 This 
1 Cremation is now regarded as the best method of disposing of 
bandages, soiled cloths and dressings, as well as of all other refuse 
and garbage of a hospital, and special apparatus is manufactured and 
sold for this purpose. 
A garbage cremator erected on the grounds of the World’s Fair, Hand-Book for Hospitals. 
112 
business the matron or the engineer, where there is 
one, will superintend. 
It is the nurse’s part to send the offensive material 
promptly out of the ward, and to see that it is de- 
livered to the proper officer. No refuse-pail used for 
the above purpose is ever to be allowed to stand in the 
ward, or bath-rooms, or closets, or to be sent up and 
down on a dumb-waiter. It must be carried out 
immediately, emptied, and rinsed with disinfectant, 
and then kept exposed to the open air, until the 
next dressing-hour. 
Bandages, cloths, and dressings from patients with 
erysipelas, pyaemia, gangrene, cancer, puerperal 
fever, or any communicable or infectious disease, 
must be put in a special pail containing disinfectants, 
not in the pail which is in daily use, or they may be 
tightly rolled in a sheet of tarred paper. They must 
be sent away at once, burned in the right place, and 
by the proper officer. 
Chicago, 1893, attracted much attention by successfully disposing of 
all the refuse and garbage on the grounds, without emitting odor or 
otherwise causing offence. 
A garbage cremator, erected by the same company on the grounds 
of the New York Hospital, 7 East 15th Street, New York City, 
consumes all the refuse and garbage from the wards and from the 
kitchen, butcher’s and baker’s shops, etc., etc., amounting to from 
1500 to 1800 pounds daily, in a satisfactory manner. The cost of 
this apparatus was about $1500. 
A similar garbage cremator, in connection with a steam disinfector, 
sterilizer, and porcelain tanks for infected clothing, is being erected 
on the grounds of the new St. Luke’s Hospital, 113th Street and 
Morningside Avenue, New York City, the whole plant costing about 
$4000.—Eds. Third Edition. The Hospital Laundry. 
113 
Doctors’ operating aprons, and hand towels, and 
all patients’ bedding, and body-clothing, used for 
these dangerous cases, which can be washed and 
are too valuable to be destroyed, must be put 
at once into a vessel containing a solution of 
carbolic acid of the strength of 1-20. After re- 
maining in this solution 12 hours they should be 
wrung out and boiled in a soapsuds solution (see 
p. 256) for one hour and washed in the usual 
way. 
The articles picked out to be used for such cases, 
should themselves, as far as possible, be marked in 
advance in such a way that they may be identified 
and used only for the same patient again and then 
destroyed. 
Cloth clothing, hats, boots, and other articles 
which cannot be washed, and which have been in 
contact with erysipelas or other communicable dis- 
ease, must be rolled in a tarred sheet or similar 
wrap, marked POISON, and sent at once to the 
laundry with a list. Blankets, mattresses, and 
pillows from such cases are to be treated in the 
same way. 
In the case of a new patient in the ward, the 
nurse will see that his cloth clothing when re- 
moved is made into a bundle and sent to the 
laundry to be cleansed, aired, and returned, and 
that his soiled underclothing is marked and sent to 
be washed. 
When clothing must wait until there is time 
to count it and make out lists, it should be 
kept in a closet or room provided for the pur- Hand-Book for Hospitals. 
114 
pose, with an open window, and used for nothing 
else. But soiled things should reach the laundry 
as promptly as possible—certainly within an hour 
from the time of the morning changing. Never, on 
any account, should they remain over-night away 
from the laundry. Covered cans or metal-lined 
boxes are better for taking away the clothes than 
baskets, in the interstices of which impurities 
gradually collect. If the hospital is not furnished 
with suitable utensils of this character, visitors must 
urge their provision. Stout linen bags and rubber 
sheets, for wrapping bundles tightly, can be used 
meanwhile. 
If an attendant can follow the nurse in her rounds 
of the ward, and collect the soiled clothes and 
keep count as she carries them out, it will save 
labor and handling, and will quicken the process 
of getting them to the laundry. Two washing lists 
should be made, dated and signed, on printed slips 
furnished from the linen-room, one to be sent to 
the laundry and the duplicate to be kept by the 
nurse for use on the return of her clothing from the 
linen-room. 
2. Duties of the head laundress.—When the 
soiled clothes are not brought (as they should be) 
directly to the laundry, the head laundress, promptly 
each morning and afternoon, at hours agreed on 
beforehand with the nurse, sends her assistants to 
collect and bring the bundles to the sorting-room of 
the laundry. 
All unwashable articles marked POISON are to 
be put into the disinfecting chest or box de- The Hospital Laundry. 
115 
scribed among the laundry fixtures, made hot and 
kept in dry heat for eight hours ; or they should 
be fumigated, or steamed with live steam com- 
bined with disinfectants whenever practicable, and 
according to the special laundry apparatus provided. 
They should be afterward thoroughly sunned and 
aired. 
Mattresses and pillows which reach the laundry 
marked POISON are to be baked or steamed, one by 
one, in the same way, first, in order to make it safe 
to handle them, and then ripped up, the hair and 
feathers steamed and aired, the covers washed and 
the articles re-made. Blankets marked POISON, if 
not destroyed, should be dry-baked eight hours at 
least, and then washed by themselves as flannels 
are. Boiling or steaming them would ruin them. 
The laundress must be thorough in all such work, 
recognizing the fact that the lives of patients may 
depend on her. 
The ordinary packages of linen and clothing 
the head laundress opens and counts, comparing 
them with the lists sent, sorting them in heaps, 
and recounting where there is any discrepancy. 
It is not necessary in washing ordinary articles 
to keep all those belonging to one ward by them- 
selves. Hospital property should all have been 
marked or stamped indelibly with the ward numbers 
beforehand, and pieces can thus easily be sorted 
when clean. But all articles of a kind should be 
washed by themselves: bedding in one lot, body- 
clothing in another; towels alone, flannels always 
by themselves. 116 
Hand-Book for Hospitals. 
Having sorted and counted the articles, the head 
laundry-woman will see that the cotton and linen 
pieces are put to soak as quickly as possible in hot 
water; soap is not usually necessary for this. She 
will then give out the required quantity of blueing 
and of soap, which should be of hospital manufac- 
ture ; and she will see that she has the necessaries for 
disinfecting uses on hand. Her further duties are 
in directing the work of her assistants and in iron- 
ing, folding, and counting. 
The clothing being all ironed or mangled neatly, 
the head laundress sorts it for the linen-room, ac- 
cording to the ward marks ; or if no marks are used, 
according to the numbers of each article noted on 
the list sent by the ward nurses. This sorting and 
counting is necessary as a check upon the laundry- 
maids, for whom the chief laundry-woman is respon- 
sible. No matter how ragged and worn the articles 
are they are to be returned as they came. They 
are made up into piles with the ward lists attached, 
and carried to the linen-room. 
The head laundress then sees that her tubs are 
thoroughly scrubbed, her laundry clean, baskets, 
ironing blankets, irons, iron-holders, clothes-pins 
and lines collected, and the windows thrown open 
awhile, that all may be ready and fresh for the next 
day. The laundry windows should always be kept 
lowered an inch at the top during the day in suit- 
able weather, and a ventilating pane of glass in each 
of them be left open at night. The work for the 
day being ended, the door is locked and the head 
laundress keeps the key. The Hospital Laundry. 
117 
3. Duties of the laundry-maids.—The laundry- 
maids having put all their wash to soak in very hot 
water, will next take the articles, a few at a time, 
washing each article as taken from the soaking tubs 
in hot soapsuds, using soap freely, but not allowing 
it to waste in the water. The water in the washing- 
tubs must be changed frequently, and only a few 
pieces taken from the soaking-tub at a time. 
The clothing when washed in this way is now 
partially wrung out and put over the fire or in the 
proper steam-vat to boil. Hospital clothes always 
require boiling in soapsuds. When there are no 
arrangements in the laundry for boiling the clothes 
they must be put, after a thorough washing in hot 
water and soap, into clean, hot soapsuds to soak for 
two hours. 
When boiled or soaked, dip the clothes out into 
clean, hot water with a little blueing in it, changing 
the water as often as it becomes soapy. Finally, 
pass the clothes through the wringer into baskets, 
and hang them in the open air to dry. • 
When the clothes are almost dry take them from 
the lines, shake and roll them for ironing. It is un- 
necessary to allow clothes to dry and then to dampen 
them again ; it is a waste of labor. In a hospital all 
the processes of washing and ironing are going on 
all the time, and there need be no delay. Iron with 
hot, clean irons and make every thing perfectly 
smooth. There should be no hospital clothes which 
require starch. 
The washing for the medical staff, house-keeper, 
nurses, and others should always be done by itself 118 
Hand-Book for Hospitals. 
on a day set apart, and in special tubs reserved for 
this purpose; and the bundles from the wards 
which accumulate during this time should be put to 
soak, or stored in a ventilated closet in the laundry 
until later in the day when they can be attended to. 
But any packages from the wards marked DISINFECT 
or POISON cannot wait; these must at once be put 
into the vats with the boiling-hot disinfectants and 
covered over. Bundles sent from the wards late in 
the afternoon should be counted, sorted, and put to 
soak over-night. 
4- Duties of the linen-room woman.—The cloth- 
ing and bedding for each ward as they come in to the 
linen-room from the wash are looked over. All ar- 
ticles too much torn and defaced to be used again 
are replaced by whole ones, and those which can be 
mended are kept patched and renewed by taking the 
best parts of discarded articles for this purpose : 
stockings being re-footed from the unworn portions 
of older pairs; sheets and other articles too far gone 
for their legitimate use being torn into strips for 
bandages, or kept to be used as large pieces, or made 
into small squares for poultice-cloths. Old pieces 
of bed-ticking not needed for patches can be used 
for floor-cloths in kitchen and entries. One division 
of the linen-room, or part of its shelves and drawers, 
should be kept for all these very necessary articles. 
No piece of cotton is so old that it cannot be used 
in some way in a hospital, and it is far more useful 
for surgical cases than new cotton would be ; even the 
oldest pieces can be made into pads. Half-worn 
stockings and gowns can be mended and made suit- The Hospital Laundry. 
119 
able for the decent burial of the poor. The matron 
and linen-room woman will find that there is use for 
every such garment. Proper burial clothes are 
rarely provided by the authorities in public hospi- 
tals; only one garment of very thin paper cambric 
is allowed at Bellevue Hospital, for instance, in cases 
where friends are unable to make provision. 
A careful note should be made by the linen-room 
woman of each article which she condemns, and of the 
numbers of new articles, or the quantity of new ma- 
terial, monthly, which has been supplied. Where 
new cloth or clothing is required the linen-room 
woman makes her requisition upon the housekeeper, 
and as much of the linen as can be comfortably 
made up in the house under the direction of the 
linen-room woman should be so made. Convales- 
cent women patients may now and then be employed 
in light mending and sewing in the linen-room, if the 
system is not carried too far and abused. Bandage- 
rolling may be done either in the linen-room, or in 
the wards by convalescents, to whom it would be a 
diversion. 
All the clothing being in order, buttons and strings 
sewed on, and good articles substituted for worn 
ones, the piles are re-counted and sent to each ward, 
with any additional articles for which requisition has 
been made indue form. The nurses receive the par- 
cels, receipt for them, compare them with their lists, 
and pile the articles neatly on the shelves of the 
ward linen-closet. It is to be supposed that the 
nurse of each ward is furnished with a little extra 
supply of clothing for emergencies, and that she and Hand-Book for Hospitals. 
120 
the linen-room woman have duplicate lists of all 
such property. 
5. Duties of the matron.—A house-keeper or ma- 
tron who understands her business will daily inspect 
and overhaul the laundry and linen-room, with all 
their adjuncts ; she will constantly make it known 
that she means to have the work well done ; and she 
will make the doing of it easier by suitable rules. 
She will take pains to select only women of good 
character and apparent sound health as laundry em- 
ployees, and will require her head laundress to en- 
force good discipline as well as thoroughness in 
work. She will have a careful oversight of the disin- 
fecting processes, informing herself of the character 
and uses of various chemicals, and the quantities 
required in each case; and will personally superin- 
tend the more important work of this kind, such as 
the disinfecting or destroying of mattresses, clothing 
and bedding used in erysipelas and other communi- 
cable diseases. One of the men attendants not con- 
nected with ward service should be specially charged 
with the heavier work of disinfection, acting in agree- 
ment with the head laundress; and the matron of 
the hospital must see that whoever has the hand- 
ling of infected articles understands the risk, is free 
from cuts or wounds, and is otherwise instructed 
how to protect and cleanse himself. If hair mattresses 
and pillows are never used for bad cases, but if straw 
beds and chaff pillows which can be burned are substi- 
tuted, the labor of the laundry people is lightened, 
hospital property is saved the wear and tear of 
steaming and disinfecting, and the risk of contagion The Hospital Laundry. 
from such sources is reduced to a minimum. The 
burning of bandages in exceptionally bad cases of 
suppurative disease, or of erysipelas, must not be 
thought extravagant. The danger justifies the pre- 
caution. No washing or disinfecting makes it safe to 
use them again. 
The matron will issue weekly to the head laun- 
dress the quantity of soap, starch, blueing, and dis- 
infectants required, keeping account of the quantities 
used ; and she will take note of the clothes-lines, 
ironing blankets, and other articles which are on 
hand, and of the condition of the laundry and all its 
apparatus. She will daily inspect the piles of clean 
clothing in the linen-room ready for the wards, 
and if dissatisfied with the color of articles will 
return them to the laundry to be rewashed ; the 
linen-room woman keeping a list of articles so re- 
turned. The matron must see that all soiled clothes 
are promptly brought to the laundry from the wards. 
She must see that the nurses are furnished with poi- 
son labels; and must require that these be securely 
fastened on all bundles needing disinfection. This 
she must insist on for protection of her laundry- 
women as well as for other reasons. 
The matron will require from the linen-room 
woman a monthly account of stock and losses, and 
of new articles needed, and will enter it with the 
requisitions from the head laundress in her linen and 
laundry ledger for inspection by the authorities of 
the hospital at any time. She will make no requisi- 
tions on the authorities for material or money, with- 
out herself going over the monthly statement of Hand-Book for Hospitals. 
122 
condemned articles, and personally inspecting these 
articles. 
The care and cleansing of all the bedding of the 
institution which is in general use, the washing of 
the blankets, bed-sacks and pillow-sacks at regular 
intervals, and remaking mattresses and pillows, is 
under the matron’s charge, and she will call on the 
laundry for necessary labor. 
The body-clothes, cloth clothing, boots, and hats 
of new patients which are sent by the nurses to the 
laundry, come under the matron’s general care. 
She must see that such articles are thoroughly 
washed or cleansed by one of the laundry-women 
whose business it is made to attend to this. They 
must be sponged, brushed, aired, and, if need be, 
steamed or baked before being hung up or stowed 
away in clothes closets. Verminous clothes should 
be burned. It is almost impossible to destroy body 
vermin. 
Another special duty which belongs to the ma- 
tron’s province in connection with the laundry ser- 
vice is the oversight of the clothes-shoots, where 
these are used. The builders of old-fashioned, 
many-storied hospitals thought such shoots were a 
convenience, but they are a certain channel for the 
return of foul air to the lobbies and wards. The 
matron must keep a constant sharp eye over the 
shafts to see that the soiled bundles do not lie too 
long, but are promptly taken out by the laundress 
two or three times a day; that soiled clothes are 
made into secure bundles by the nurses, and are not 
pitched down loose, catching on sills and roughnesses The Hospital Laundry. 
123 
and hanging until accidentally discovered and poked 
down, meanwhile spreading foulness all about them ; 
and that the shaft-doors on each floor and at the 
bottom are kept locked and the keys in charge of a 
responsible attendant,—this prevents various tricks 
and abuses. The mouths of the shoots, where the 
clothes lie, should be scrubbed out at least twice a 
week, with strong hot soft-soap suds, and once a 
month the fumes of burnt sulphur must be driven 
through the shaft. If the lining surface admits it, 
a monthly whitewashing, after the fumigation, as 
far as long-handled brushes can reach up and down 
for each floor, is desirable. Ventilation through 
and through the shafts, and out by the roof, will 
prove the best steady, every-day disinfectant. 
Apparatus varies so much in different hospitals, 
that it is not easy to fix the number of laundry- 
women who should be employed for any given 
number of beds. In a hospital where the steam 
machinery is complete, a capable head laundress 
with two or at most three assistants can do the 
washing for fifty patients, and their necessary at- 
tendants and medical officers ; an increase of ioo 
per cent, in the patients would probably require an 
addition of 33 per cent, to the laundry labor. The 
amount of washing necessary for hospital patients 
cannot be limited in quantity, but it may and 
should be in kind. For instance, white petticoats, 
white dresses, frilled and fluted gowns and jackets, 
and all such articles not fit for hospital use, should 
be excluded from the hospital laundry. Articles 
for employees of all grades, from the superintend- Hand-Book for Hospitals. 
124 
ent’s family and the house-keeper down, should be 
strictly limited both in number and kind, and the 
limits defined in a set of printed regulations hung 
up in the laundry and in the common rooms of the 
officers and attendants. 
Paying patients in private rooms should always 
pay a fixed price for their washing, and should be 
notified of this on their admission. No fluting, or 
extra fine washing of any sort should ever be under- 
taken by a hospital laundry, either for officers or 
private patients. Washing for nurses should always 
be done for them. No nurses should be allowed to 
go to the laundry. Hospital servants may be al- 
lowed the use of the laundry at certain fixed times, 
under careful restrictions ; or their washing may be 
done for them by the laundry-maids at the discre- 
tion of the matron, It is better for economy and 
discipline if all the servants’ washing is done for 
them in the regular way. 
All the various duties described in the preceding 
chapter should be apportioned among the subordi- 
nates of the hospital, but the matron or house- 
keeper is the officer who is especially responsible to 
the lady managers, or other authorities, for the well- 
doing of the work; and she should be constantly 
vigilant in supervision, keeping a high standard of 
neatness, thoroughness, and orderly conduct, to 
which she obliges her servants and assistants to 
conform. VII. 
Hospital House-keeping. 
In the following chapter, the best and most 
modern hospital methods and apparatus are de- 
scribed for the information of visitors; but simpler 
conditions and the absence of elaborate apparatus 
are no excuse for the neglect of either moral or 
sanitary precautions. The same necessities exist 
and the same principles apply whether the hospital 
is a large group of wards and buildings, or one or 
two rooms in a county house. 
Matron’s duties.—As the easiest way of showing 
how a hospital and its household should be man- 
aged in those domestic matters which visitors have 
a right to inquire into and criticise, we give, at the 
risk of repeating some things already said, a code of 
directions for a hospital matron,—directions which 
have been tested by several years of actual practice. 
In proportion as visitors can assure themselves that 
all the details mentioned in the following pages are 
faithfully and regularly attended to, they may rest 
satisfied that the matron is doing her duty, and 
that their hospital is well managed, so far as con- 
cerns this portion of their “ Woman’s Kingdom.” 
Household order.—A hospital matron is respon- 
sible in the sight of God for the moral and physical 
well-being of all her employees, and of all the sick, Hand-Book for Hospitals. 
so far as any of their interests are under her care. 
Every hospital has its own rules, laid down by its 
governing authorities, and these of course must 
be implicitly followed. There are, however, many 
details which go to make up the sum of comfort 
or discomfort in the household, and these will be to 
a great extent within the discretion of the matron. 
Where a corps of attendants is expected to follow 
the directions of heads of two or three different 
departments, it is somewhat as if two or three differ- 
ent families lived in one house, with one set of ser- 
vants on whom they all called at once. Something 
of this is inevitable in a hospital; but the friction 
is greatly lessened by frequent and friendly consul- 
tation among the heads of departments. The matron 
plans the work and keeps the run of it, and if direc- 
tions are given over her head or independently of 
her the work is thrown into confusion. There need 
be but little trouble on this point if there are good- 
will, disposition to accommodate, and, above all, 
a desire to serve the interests of the hospital first 
and always, instead of one’s own petty dignity. 
Much, too, may be done by the fixing of regular 
duties and regular hours for all attendants, and hold- 
ing them to strict punctuality and obedience to 
orders. 
If A thinks something is B’s duty, and B thinks 
it is A’s, neither will do it ; not necessarily out of 
ill-will, but from want of precision on the part of 
the matron in defining duties and instructions. Or, 
if there is “ a slight coolness ” between A and B, as 
sometimes happens in the best-regulated hospitals, Hospital House-keeping. 
127 
the work may stand still, and the sick—shame that 
it should be so—will be the ones to suffer. 
Many parts of hospital work must be done hour 
by hour, day by day, with something of the mechani- 
cal reiteration of clock-work. The medicines, the 
special diet, the clean linen, must come into the 
ward with the certainty of sunrise. The comfort of 
a large household of helpless persons cannot be se- 
cured in any other way. Everything must be 
thought out, planned out, provided for. Nothing 
must be left at loose ends with the foolish expecta- 
tion that “ somehow ” it will come out right. Disci- 
plinary methods of the “ happy-go-lucky ” sort 
sometimes earn a cheap and transient popularity 
with the lower quality of attendants and officers; 
but it is a mistake to believe that conscientious and 
intelligent persons like them. These prefer order 
and system, knowing that their work is made easier 
by them; and respect those officers most who 
steadily and yet kindly enforce them. 
The matron must of course set the example of 
punctuality and exactness. “ Like mistress, like 
maid.” A household can soon be trained into regu- 
larity and precision by the right methods ; employees 
will fall into line out of pride and pleasure in doing 
their work well, or because of the influence of exam- 
ple, or because they are afraid of losing their places. 
Moral atmosphere.—The matron should watch 
assiduously the moral atmosphere of her household, 
as well as the air it breathes, and do all in her power 
to keep both clean and pure. She should be careful 
how and where the employees are lodged ; that the 128 
Hand-Book for Hospitals. 
rooms or dormitories are always tidy; are warm 
enough in cold weather ; are well aired (servants’ 
rooms in even some of the best private houses are 
often reservoirs of foul air for the rest of the house) ; 
that the dormitories of the men and women attend- 
ants are entirely separate, with separate staircases 
and approaches, and that there is no coming or going 
between them. The men should be required in 
turn to make all their own beds and sweep out their 
own quarters; no women except the once-a-week 
scrubbers going into the men’s quarters on pretence 
of work, and the scrubbers working under close 
supervision. This is a very important matter to 
consider. Women servants should not go into the 
rooms of the male officers except at fixed, regular 
hours to do their work, and elderly, respectable 
persons should be chosen for this business, and 
should besides be under careful supervision. Women 
servants should not be allowed to go to the rooms 
of private men patients. The nurse of the private 
patient should do all the work of the room, except 
the weekly or semi-weekly scrubbing, which is always 
to be done under supervision. Women servants 
should not be allowed to receive professional visits 
from the house staff except in the presence of the 
matron. If any servant or attendant is ill enough 
to require medical care and nursing, the matron 
should at once apply to the superintendent for his 
or her admission to a ward as a regular patient. All 
this is also applicable to women nurses. House- 
servants should never go to the wards except on 
necessary business, nor should nurses or patients be Hospital House-keeping. 
allowed out of their wards except for good and 
well-known reasons. No loitering or gossiping in 
halls or on stairways should be tolerated. Having 
fixed and well-known hours for all necessary busi- 
ness is an important safeguard. Coming and going 
at other than these regular times must be satisfac- 
torily explained, or the delinquent warned, and, if 
necessary, discharged. No laxity in these matters 
should be tolerated for a moment. One bad or sly 
man or woman poisons the whole atmosphere, and 
no matter how valuable otherwise, should be speed- 
ily got rid of. Drunkenness need scarcely be enu- 
merated among causes for dismissal. Few hospital 
officers, however slipshod or time-serving, venture 
to affront the public by retaining drunken attend- 
ants about the sick and helpless. 
Servants should have time given them for church- 
going, rest, and recreation, and that time should not 
be encroached upon. But they should be required 
to return at a fixed hour, and never be allowed to 
remain out late at night. If late or absent some 
very good reason should be given for it. 
The matron should keep written records of the 
dates of coming and going, and of the wages of all 
attendants, and some note of their character and 
capacity, for the future protection of her own and 
other hospitals. She should also keep a record of 
the address of some friend of each in case of sick- 
ness or death. 
Servants’ quarters.—The matron should not fail 
to look into every attendant’s dormitory, under the 
beds, behind the doors, and into closets, at least Hand-Book for Hospitals. 
130 
once a day, and occasionally at other and tmexpected 
times. She should inspect every day, and also at 
unexpected times, all the bath-rooms and water- 
closets or privies used by the attendants, and allow 
no filth, rubbish, or torn paper to lie about ; news- 
paper does not easily dissolve in water, and if large 
quantities are used it sometimes chokes the pipes. 
There should be a regular disinfection and cleansing 
of all servants’ water-closets, at least twice a week, 
on fixed days. Things of this sort done “ now and 
then” or “frequently” are never thoroughly done. 
Fix the day and never allow it to pass over. Wher- 
ever the wall-surface admits, servants’ water-closets 
should be whitewashed at least once in three months ; 
if the labor can be had, once a month would be better. 
The servants’ hall or dining-room should be 
carefully overlooked, and neatness and propriety in 
table-service, dress, and manners strictly enforced. 
The table should be made comfortable, and the 
food, though plain, be as much varied and as good 
in quality as the hospital resources allow. 
The matron should carefully examine the quality 
of all raw material of food, and if she finds it inferior, 
should so report to the superintendent, or to the 
proper inspectors if they call directly upon her for 
such information. Bloodless and stringy beef, rank 
mutton, and stale vegetables are not economical even 
though they may “ go farther ” than wholesome food. 
The purchase of food and the making of house-diet 
tables will probably be in the hands of the superin- 
tendent or steward ; but within certain limits a good 
degree of variety can be had by putting brains into Hospital House-keeping. 
131 
the bill of fare ; and this is the matron’s part. Those 
on extra duty as firemen, night-watch, and night- 
nurses, should have a little extra food supplied. Fa- 
rinaceous foods are very nutritious, and should be 
freely used for that reason, over and above the reason 
that they are cheap. If the superintendent thinks 
best to allow a glass of milk once or twice a day at 
the servants’ table, it would be a good thing, and 
would perhaps prevent the very common misappro- 
priation of milk elsewhere. 
What is a clean hospital ?—The responsibility 
of the matron for the nursing and her control over 
the nurses vary in different hospitals. Where the 
organization allows there will be a head nurse in 
charge, who will be responsible for the discipline of 
the nurses. But the matron will certainly have un- 
der her care the cleaning and keeping clean of the 
sick-wards and all their belongings. Visitors cannot 
too strongly insist that everything in a hospital shall 
be kept scrupulously clean. Cleanliness and good dis- 
cipline go hand in hand. The faithful or unfaithful 
execution of the matron’s charge makes the difference 
between a healthy and an unhealthy hospital. Let 
her remember that human lives are at stake, and exe- 
cute her share of the hospital duty as if all these lives 
depended upon her alone. 
The first essential in keeping a hospital ward clean 
is to keep it perfectly free from dust. Dust in a ward 
is not only dirt—it is danger. The mode of cleaning 
must of course vary according to the surface to be 
cleaned, but the dust must be taken away, thoroughly, 
regularly, frequently; not stirred up and allowed 132 
Hand-Book for Hospitals. 
to settle again somewhere else, but taken away. The 
floors, walls, windows, door-frames, wainscot, cornices, 
mouldings, backs and top ledges of picture frames 
and mirrors, door-sills, tops of doors, mouths of the 
air-shafts, the swing-sashes over the doors, the cup- 
boards and tops of cupboards and wardrobes, fire- 
places, water-closets, bath-rooms, clothes-shafts, dust- 
shafts ; every square inch of surface everywhere must 
be kept absolutely free from dust. 
Intemperance in sweeping.—Do as little old- 
fashioned sweeping as possible in the wards. No one 
who has given much attention to these matters can 
look on with patience while an attendant flourishes 
a broom in a ward in the middle of a thick cloud of 
dust, not one tenth of which is got rid of, but which 
flies up and settles again on every ledge and cornice, 
drifts over the beds and bedclothes, and what is worst 
of all, drifts into the lungs and pores and eyes of the 
unfortunate sick who cannot get out of bed, or out 
of the ward. In sweeping, a great deal of dust will 
escape in spite of every care, and drift into fireplaces, 
register flues, ventilating flues, open places of every 
kind, corners and cracks of every kind ; therefore all 
such places must be carefully looked after and care- 
fully cleaned out at regular, frequent intervals. In 
such places as these, left unwatched too long, dust 
will be found packed and felted in thick rolls like 
bits of dirty blanket ; and such deposits as these are 
not only disgraceful evidences of ignorance and neg- 
lect, but contain germs of hospital disease. 
For the sweeping that cannot be avoided, use on 
hard floors soft hair brooms in long strokes which Hospital House-keeping. 
133 
carry the dust gently before them instead of allow- 
ing it to rise and diffuse itself through the air. Do 
not sweep from one end of the ward through to the 
other, driving all the dust along the whole ward. 
Begin in the middle, and sweep first one way, and 
then the other, constantly using a dust-pan; but 
sweep as little as possible in the wards. 
Feather-dusters should never be used, unless it 
may be to bring the dust down from high levels to 
lower ones, where it can be reached and taken away 
with damp cloths or carriage sponges ; nothing will 
really remove dust but damp cloths or sponges. Use 
as little water as possible, and use a little carbolic 
acid or soda in the cleaning water. Cleaners, unless 
watched, never change the water in their buckets 
often enough, but go on dabbing the floor with the 
dirty fluid ; this, and their propensity always to use 
too much water on the floors, should be watched and 
checked. 
Clean floors.—The ward floors in some modern 
hospitals are laid with glazed tiles ; very little sweep- 
ing will be needed on such floors, but more wiping. 
They should be washed with a carriage sponge wrung 
out nearly dry. With such floors great care must be 
taken not to crack or chip the tiles. Cracks and 
chips make pockets for dust and filth. The whole 
surface of floors and surbases of all the wards should 
be gone over at least twice a week. If you can com- 
mand the labor, go over the whole surface of the sur- 
gical wards every morning before “ doctor’s call.” 
Windows in wards, especially all surgical wards, 
should be washed, both wood-work and glass, once Hand-Book for Hospitals. 
134 
a week, including of course all transoms and swing- 
sashes over doors. 
All hard wood-work is kept in the best condition 
by an occasional good rubbing with linseed oil with 
a little spirits of turpentine in it. This gives the 
wood a handsome appearance and fresh odor, while 
it helps to fill the grain and render the wood non- 
absorbent. 
To sum up, do as little sweeping as possible; 
do as much dusting as possible; remember that 
dusting means taking away the dust; and for that 
purpose nothing is efficacious but rubbing with a 
damp cloth or sponge, and then with a dry cloth. 
Clean beds.—The beds are the most important 
articles of furniture in the wards, and should be 
looked after with great care to prevent dust, vermin, 
and filth. The condition of the wards, as to clean 
and sweet air, depends greatly on the condition of 
the beds. 
The matron should keep herself informed, by 
consultation with the head nurse, of every case of 
erysipelas, pyaemia, cancer, typhoid fever, or of dis- 
charging wounds, or of any other case in which the 
bed may be fouled or contaminated. All such beds 
should be taken out of the ward as soon as the 
patient leaves or dies; and the straw, if the beds 
are straw sacks, should be sent off the premises and 
burned in a pit on the grounds outside, and the 
sacks disinfected, washed, and refilled. If hair beds 
are in use for such cases, they must be promptly 
taken out of the ward, ripped, steamed with live 
steam, thoroughly disinfected, and made over, in Hospital House-keeping. 
135 
some room provided for this purpose outside of the 
hospital itself; but even this cannot be considered a 
perfect preventive of infection. Permanent hair beds 
are thought objectionable by many physicians. Hair 
is expensive, troublesome to pick and cleanse, and 
unless a hospital is very conscientiously and intelli- 
gently managed such mattresses are not made over 
as often as they should be, and infection is the fre- 
quent result. This is a strong argument in favor of 
wire-woven beds. 
No hair mattress should be used more than six 
months without being ripped, steamed with live 
steam, or otherwise disinfected, and made over, no 
matter what the case. No straw bed should be used 
more than three months without being washed and 
refilled, full and squarely, with clean straw, no mat- 
ter what the case. The matron or house-keeper 
should frequently examine the beds in each ward ; 
by remaking a few mattresses at a time, patching 
and mending those that need it, she will find that 
the work never accumulates so as to become a bur- 
den. If hair mattresses are made in sections they 
can be more easily turned and aired, they wear more 
evenly, and can be remade with less labor. 
Clean pillows.—With pillows the work must be 
equally constant and thorough. It is even more 
important to steam, disinfect, and remake the pil- 
lows, both hair and feather, from the cases above 
mentioned. All pillows should have periodic airing 
and cleansing, no matter what the case. They 
should be made over at least once in six months. 
Shake the feathers from the pillows to be cleaned 136 
Hand-Book for Hospitals. 
into a larger bag than the pillow sack—thin, un- 
bleached muslin will answer—tie up the bag, and 
steam bag, feathers, and all; or in ordinary cases 
hang the bag for some days in the air. Meanwhile 
wash thoroughly, disinfect, and mend the empty 
pillow sacks, and then refill them. A number of 
extra pillows should be kept for use on these oc- 
casions. Straw pillows, as well as straw beds, are 
best for some cases. In all these matters the ma- 
tron must confer with the head nurse, and issue for 
use such bedding as the sanitary requirements of 
the special case may dictate. 
Blankets should invariably be washed when 
spotted, stained, or dingy-looking, or when taken 
from the bed of a fever patient, or a bad surgical 
case, or when they have been used by a woman in 
confinement, or where there has been serious illness, 
or steady use. The blankets from infected beds 
should be not only washed, but disinfected, before 
being used again. There is a superstition that 
blankets need not be washed. But this is not appli- 
cable to hospitals. Blankets readily take up infec- 
tion ; their fuzzy surface is the very thing to catch 
organic particles and retain them until decomposi- 
tion takes place, and thus poison the wounds of 
surgical patients. Blankets too good to be washed 
should never be used in a hospital. 
Throughout the hospital the blankets and pillows 
should be taken, one or two dozen at a time (others 
being substituted from the extra supply in the linen- 
room), and hung in the sun and air for a day, once 
a fortnight. Once a week, where the supply of Hospital House-keeping. 
137 
bedding is ample,.would be better. In fact, where 
there is a good sunning-ground, no dry, sunny day 
ought to be lost. Advantage should be taken of 
every such day for airing out-of-doors—beds, bed- 
ding, blankets, mattresses, pillows, and every article 
of bed furniture of all the sick and convalescents. 
Sunshine and wind are capital every-day disinfect- 
ants for bedding, and if such airing-work is faith- 
fully done, the washing of blankets in general use 
will be less often necessary. 
The storing of blankets in summer requires at- 
tention. They are safer on the open shelves of the 
linen-room in the light and air, but they should be 
frequently taken down, examined, shaken out-of- 
doors, and returned to the shelves, which have been 
meantime wiped down with a damp cloth and then 
a dry one. All rooms or closets where mattresses 
and pillows are stored, should be kept aired by 
open windows in dry weather, by night as well as 
day. 
Steam-closets in connection with the wards, 
are a poor alternative for the open air for bedding. 
No soiled articles should ever be put into such 
closets. Steam-closets, if these exist, must be care- 
fully examined ; for, if the racks are stationary 
(they ought always to be movable), dust and fluff, 
i. e., filth and disease-germs will drift into and pack 
in them in large quantities. The smell of frying 
dust can be detected in these closets or about radi- 
ating stacks whenever they are in ignorant and slov- 
enly hands. 
Sheets and pillow-cases should be changed 138 
Hand-Book for Hospitals. 
throughout the wards at least twice a week; in 
some cases much oftener. They should be changed 
often enough to keep the beds with ordinary pre- 
cautions always clean. There should be no skimp- 
ing here. If laundry work must be economized, let 
it be economized in something else: say shirt- 
bosoms and frilled petticoats for the household, and 
not in the bedding or clothing for the sick. One 
musty, unchanged, and unaired bed will make a 
whole ward smell stuffy ; how much more twelve or 
twenty such beds. 
Ward bedside tables should be kept clean ; no 
dirt or rubbish allowed to accumulate in the drawers. 
Never allow newspapers to be used as table-covers ; 
nothing is more slovenly. See that the tops of all 
the tables are washed off every day. If covers are 
necessary, spread clean towels on them, never news- 
papers. 
Cupboards of all sorts inside the wards are ob- 
jectionable, and should be very carefully looked 
after, or they will become nests of slovenliness. No 
brooms, buckets, mops, damp dusters, or any thing 
of this sort should be allowed in them on any ac- 
count ; no dirty towels, no shoes, or clothing ; noth- 
ing but clean, new, dry articles, such as new band- 
ages, lint boxes, or medicines, if the doctors choose. 
Dumb-waiter shafts, whether for the service or 
for the food, should be carefully watched, shelves 
scoured, and shafts whitewashed. No article what- 
ever except food should be allowed in the food-lift. 
Dust-shafts are as dangerous as clothes-shoots 
in a hospital, and both need constant care. Fires in Hospital House-keeping. 
139 
hospitals have been started and distressing panics 
risked by half-burnt matches, bits of oiled rag, and 
sweepings lying at the bottom of dust-shafts. They 
must be emptied and swept out at least twice a day, 
regularly closed up and disinfected by fumes of 
burning sulphur, and frequently whitewashed if the 
surface allows. They may be compared to a large- 
sized, perpetually dirty drainage tube. They carry 
danger with them, and are a baci thing in hospitals. 
Refuse-cans are tight-covered, galvanized iron 
pails with handles, into which foul-dressings, poul- 
tices, and old plasters are thrown at the dressing 
hour. The matron should inspect these cans with 
the greatest care, never less than once a day, and at 
other unexpected times. They should never be 
allowed to stand inside a ward, or in any bathroom, 
closet, lift or dumb-waiter. A bracket shelf outside 
the window of some lobby, hall, or closet, on which 
they could stand in the open air, would be a good 
thing. But they should never stand long anywhere. 
Their contents are always burned. They should be 
daily rinsed with disinfecting fluid, both can and 
cover, after every using; and if they get a bad smell 
in spite of all care, should be destroyed at once and 
new ones provided. They are an unpleasant neces- 
sity, and should be made as little offensive and 
dangerous as possible. They should always contain 
chloride of lime or fluid disinfectant enough to cover 
whatever may be thrown in ; the lids should be 
tightly-fitting, and they should never be allowed, 
under any circumstances, to stand with any thing in 
them uncovered. There should be two or four cans Hand-Book for Hospitals. 
140 
to a ward, according to the number of beds, so that 
there may be a place for foul dressings at hand at all 
times, and the cans not in use should be airing or 
sunning outside. Every private patient’s room 
should have a refuse-can or cans of its own. 
The outside of the building and the court-yards 
will probably not be within the matron’s care. If 
they should be, she must see that every part is care- 
fully policed every day : ash-cans, garbage-cans, dust- 
bins emptied; scraps of paper, orange peel, and all 
rubbish collected and burned ; and if possible, where 
there is an abundant water-supply, the hose used for 
the windows and outside surfaces of the whole build- 
ing not less than once a fortnight in good weather. 
In proportion as all these details are attended to, 
and attended to with conscientious exactness, faith- 
fulness, and clock-work regularity, the wards will be 
fresh, sweet, and healthy. 
Nurses’ quarters.—The degree of control of the 
matron over the nurses varies in different hospitals, 
as we have said, but the care and cleansing of all the 
nurses’ quarters and dormitories will certainly be 
within her responsibility. She will also be required 
to see that their table is comfortable. 
She should carefully inspect the sleeping-quarters 
of all nurses, especially men orderlies, at least once 
a day, and at other unexpected times, and should 
exercise a careful supervision over the nurses’ bath- 
rooms and water-closets, thoroughly cleansing and 
disinfecting them at fixed, frequent intervals. If 
she finds a nurse’s room out of order in any way, 
she should after one warning, make a formal com- Hospital House-keeping. 
141 
plaint to the head of the nursing department or to 
the superintendent. If nurses are allowed bedside 
carpets, or rugs in their rooms, they should be 
shaken out every day, and put out in the air, and 
beaten at least every week. 
Clean water-closets.—The matron should in- 
spect all ward water-closets and other service- 
rooms at least once a day, and at other unexpected 
times. 
The closets should be washed out at least once a 
day with hot water and soft soap. If you can 
command the labor, wash them out twice a day, 
morning and evening. 
A weak alkali like soapsuds is not enough for 
disinfecting purposes. 
The apothecary should prepare and keep on 
hand the prescribed disinfecting agents, and issue 
them to the matron, with the necessary instruc- 
tions, whenever she calls for them. (See Chapter 
on Disinfection, pp. 209-230). 
Wherever the surface allows, walls should be 
scrubbed or whitewashed. Never allow litter and 
paper to lie about. 
There should be a hanging box or basket for 
paper—not one set on the floor—in every closet or 
privy. Furnish brown paper. Paper on an endless 
fixed roll for closet purposes is to be found in the 
shops. Don’t allow newspaper if you can help it; 
it is less soluble than other kinds, chokes the pipes, 
and is very slovenly. 
Privies.—The matron must daily examine the 
out-houses, where these exist, keep them freshly 142 
Hand-Book for Hospitals. 
whitewashed, and see that properly-sifted dry 
earth or ashes are at hand, and that chloride of 
lime is also regularly thrown in. Chloride of lime 
is a simple, cheap, and efficacious deodorizer. It 
helps to keep down gaseous emanations, and be- 
sides being thrown down should stand in large 
shallow vessels or boxes, slightly damped, in out- 
closets or privies ; it needs to be constantly re- 
newed. 
Infected articles burned. — If, in a hospital 
where steam is used, there is no metal vat or fix- 
ture in which hair, feathers, or other articles can 
be steamed and disinfected, the matron should 
ask for one at once. It is easily arranged on the 
premises of any building heated by steam, and 
is indispensable. Where there is no steam ma- 
chinery, a brick oven and tight-covered copper 
boiling kettle in some out-building, must suffice. 
But erysipelas bandages, or bandages from other 
infectious cases, should at once be burned. No 
washing or disinfecting makes it safe' to use them 
again. 
If there is an outside boiler-house and chimney 
on the grounds, its fire may perhaps safely be used, 
under the strict observation of the responsible offi- 
cer, for burning infected clothes and the contents of 
refuse-cans. But such a process of burning in ordi- 
nary fires, or stoves, or furnaces would be a sure 
way of returning noxious air to the wards, and it 
must never be attempted. It is best to burn all in- 
fected articles and refuse-can contents at a safe dis- 
tance, in a pit outside. Hospital House-keeping. 
143 
Patients’ clothing.—The cleansing and care of 
the clothing in which patients are admitted is part 
of the matron’s duty, as the nurses can only take 
time to put up the packages and send them to the 
cleansing-room. Besides the clothes-closets near 
the ward, a general clothes-room in the administra- 
tion building, well lighted and open to the air, in 
which to store the surplus clothes, handbags, and 
bundles of patients likely to be long ill, is necessary 
in a large hospital. The effects of the dead, also, 
must here be taken care of. These effects should 
never be retained longer than is absolutely necessary, 
and there should be rules fixing some limit of time 
and the final disposition to be made of them. A 
receipt book for the signatures of the persons to 
whom they are delivered should be provided. The 
utmost care will be required to keep any such room 
and its contents sweet and clean. For lack of 
proper care in all these respects vermin and disease 
are often introduced into hospitals. In a large 
public hospital in New York the writer has seen the 
garments of the newly-admitted patients, muddy 
shoes, and filthy under-clothing, rolled in a foul 
bundle and carried to the “ pawn shop,” which is 
the local name for the clothes-room, to be returned 
unwashed to the patient many weeks later, on dis- 
charge. 
The oversight of the laundry and personal re- 
sponsibility for some portions of the work are part 
of the matron’s charge, as described in detail in the 
chapter on the hospital laundry. She must daily 
inspect, direct, and advise in this important depart- 144 
Hand-Book for Hospitals. 
ment, and examine eveiy day if possible, and at 
unexpected times, the clean linen and the rooms 
and closets where it is kept. She must call the 
nurses’ attention to untidiness or wastefulness ; not 
forgetting in all cases, with nurses and with servants, 
to praise also, where she is able. Besides soap for 
ordinary use, carbolic soap, or other cleansing and 
disinfecting soap, should be freely issued for nurses 
and patients. 
Hospital diet.—The subject of cooking for the 
sick and special kitchen arrangements would make 
a volume by itself, and must be left for another 
occasion. See that the cooking utensils and ap- 
paratus are always scrupulously clean; this has a 
great deal to do with the flavor and wholesomeness 
of food. If one dish tastes of another it is a pretty 
sure sign of half-washed pots and pans. See that 
the material is all good of its kind. Report it at 
once if it is not. It would be preferable to have only 
one quality of such provisions as butter and tea; if 
there are two qualities the best should be reserved 
for the sick, and the second best for the well mem- 
bers of the household. All meals should be exactly 
punctual. Ward diets should be served neatly and 
attractively. No time or trouble should be spared 
to see that the food reaches the wards hot and 
palatable. A fixed bill of fare may be said to be 
indispensable in a large institution as a measure of 
economy both of material and labor, yet it has 
its disadvantages in that the delicate patient goes 
wearily to a table when he knows that he has to 
meet the inevitable Tuesday corned beef or Wednes- Hospital House-keeping. 
145 
day mutton. He is more likely to eat heartily if 
he is not sure what is coming. 
Kitchen and pantry waste-pipes often become 
clogged with grease unless there is an effective 
grease trap. To keep pipes clean, a hot solution 
of soda should be poured down them from time 
to time. 
Inventories.—One of the first cares of the matron 
should be to make an exact inventory of all furni- 
ture, kitchen and ward utensils, linen, and other 
property in her charge; and these inventories 
should be compared with the articles at least once 
a month, and deficiencies noted. 
In the care and issuing of the provisions and 
stores of all kinds, the matron should exercise con- 
stant vigilance and strict economy. Nothing is too 
small for attention. It is the little items, the half 
pints and the ounces, that make the difference in 
the long run. The ability of the managers to carry 
on the hospital without harassing care as to ways 
and means will depend greatly upon the matron 
or house-keeper. She should always keep in mind 
that it is other people’s money she is spending, 
and should hold herself to a strict account of it, 
so that nothing may be misused or wasted, but 
every penny made to yield its utmost value, and 
do its utmost good. Every penny of the hos- 
pital funds spent upon her friends and visitors, or 
upon herself beyond her necessary comforts, is dis- 
honestly spent. A set of pantry and store-room 
rules and a table of quantities are given in the 
appendix. Hand-Book for Hospitals. 
146 
Gossip and petty bribery.—A matron who re- 
spects herself and her work will be loyal to the 
institution she serves, and to her superiors in office ; 
she will neither do or say, nor allow others to do 
or say in her presence, anything that would injure 
or destroy the influence of other officers. She will 
not indulge in gossip or countenance it in others ; 
if any one comes to her with idle or mischievous 
tattle she will at once show them that they have 
mistaken her principles and her tastes. This zeal in 
tattling is no mark of loyalty to the interests of the 
institution, for the persons who are so eager to carry 
about twaddle concerning what Brown said that Jones 
said that Robinson did, are the very persons who 
are most ready to cover up a real wrong or breach 
of discipline which ought to be reported, if it hap- 
pens to be for their own interest to conceal it. A 
hospital officer of either sex who is a gossip, full of 
trivial talk about affairs concerning which he or she 
should be scrupulously reticent, is a melancholy 
spectacle. No such person is fit to be entrusted 
with the grave cares of a household of helpless and 
suffering people. 
A wise matron will never make the mistake of 
intimacies or familiarities with patients or attend- 
ants, or the still greater mistake of showing favor- 
itism to any one, or bribing any one—for it is 
essentially bribery—with special diet or special 
indulgences which are not equally shared by 
the rest. She will deal out even-handed justice 
and kindness to all, making no distinction in the 
public wards, except that of the greater necessity Hospital House-keeping. 
of the sick person. A matron who allows herself 
to make use of petty, selfish indulgences in order to 
persuade attendants to do their duty, sets the 
example, though she may not be conscious of what 
she is doing, of corruption in every branch of her 
household, an example of which attendants are 
sometimes only too ready to take advantage. 
There is no greater disgrace to a hospital than 
is suggested in the complaint: “ I could not get 
waited on; but So-and-so ” [who had influential 
friends or a little money] “ had everything he 
wanted.” 
There are hospital matrons and superintendents 
who are capable of keeping back for their own use 
a portion of the comforts and luxuries sent in as 
donations, to the sick, on the theory that they 
“have a right to their share.” Such persons will 
not scruple to get all they can out of a public or 
private charity: superfluities for their own tables, 
board and lodging for their “ visitors,” extra labor 
of all sorts in sewing-room, laundry, and kitchen; 
justifying their demands to themselves by saying: 
“ I guess the institution can stand it.” Types of 
this class may be found in every community, but any 
one showing the least trace of such a spirit is unfit 
for the responsible care of the sick and helpless. VIII. 
The Nursing Service. 
Hospital management, besides the house-keeping 
duties proper—that is, the kitchen and laundry 
work, the cleaning, the care of all the property and 
supplies, and the discipline of the household— 
includes another most important branch, namely, 
the nursing service. The following pages give a 
few hints on the duties of nurses, and the routine 
of ward work. 
A responsible head.—To ensure proper distribu- 
tion of labor and the best care of the sick in a 
hospital or infirmary, there should always be one 
responsible woman as head nurse for the whole 
establishment, whether there is a training-school or 
not, and all the nurses, both men and women, 
should be under her control. Her duties are dis- 
tinct from those of the matron or house-keeper, and 
are concerned only with the sick. A matron of the 
right sort will understand that the object of the 
hospital is the care and comfort of the sick, and 
that the entire household must be held tributary to 
this. In small hospitals of not more than a dozen 
beds, the two offices might be combined in one 
person ; but in most hospitals the two classes of 
duties, nursing and house-keeping, furnish enough 
work for and require the undivided attention of two The Nursing Service. 
149 
separate persons. It would be quite as detrimental 
to good order and efficient service to leave the 
nurses without a head as to leave a household of 
servants without a matron or housekeeper. The 
nursing head, being held responsible for the care of 
the sick,—that is, for the right execution of the 
object of the hospital,—should be the superior 
officer, and should be allowed a woman assistant as 
house-keeper. But where the wisdom of this ar- 
rangement is not recognized, great care must be 
taken to define responsibility. Both head nurse 
and house-keeper should then report to and take 
their instructions from whoever is their immediate 
superior; where there is a training-school, from the 
lady superintendent or principal so-called. 
Co-operation.—Whatever is the organization it 
will be found impossible to conduct hospital work 
in a peaceable and proper manner unless there is 
perfect accord between the head of the house-keep- 
ing and the head of the nursing department, and 
one sole purpose in all they do, namely, the order 
and general well-being of the whole establishment. 
Women who encourage petty differences, or who 
cannot set aside their own small personal jealousies 
for the sake of the serious business in hand, justify 
all the disparaging comments in which male boards 
of administration sometimes indulge. 
Value of competent heads,—Only trained and 
competent women should be chosen to fill the 
responsible positions of heads of departments; and 
hospital authorities will find it in the end the best 
plan for securing good management, as well as the Hand-Book for Hospitals. 
150 
best economy, to select such women, and to make 
their salaries and their surroundings inducements to 
them to value their places. 
Where the hospital income is small, and managers 
feel that the services of only one skilled woman can 
be afforded, the position of matron is generally the 
one which they first prefer to fill. If women, in ad- 
dition to their trained knowledge of bedside nursing, 
are well informed in house-keeping matters, they will 
find more ways of usefulness and self-support open 
to them. The varied duties of house-keeping and the 
mode in which they are performed have a most im- 
portant bearing on the welfare of the sick; and on 
that account, if for no other reason, a head nurse 
needs to understand them. 
Title of the office.—The nursing head may be 
called either superintendent, matron, or head nurse 
of the hospital. For convenience she will be called 
in the following suggestions, head nurse ; while the 
head nurse of each ward who, under the head nurse 
of the hospital, is responsible within her ward for 
strict fulfilment of doctor’s orders, and for obedience 
to hospital rules, will be spoken of as “first nurse” 
of the ward ; her assistants being “ second nurse ” 
and “ third nurse ” respectively. 
Duties of head nurse.—It should be the duty 
of the head nurse to know the general condition of 
every patient under her care, and to inform herself 
particularly of the nature and probable result of the 
more serious cases. She should know just what ma- 
terial she has to work with ; the number of assistant 
nurses allowed by the regulations; the kind of work The Nursing Service. 
151 
she may require of convalescents, and who these are ; 
convalescent free patients as a rule being required to 
assist in the light work of the ward. 
Convalescent helpers.—The question of a pa- 
tient’s ability or non-ability to work is strictly a 
medical one, and the head nurse should obtain a list 
of names of convalescents from the physician and 
submit it to him from time to time for such changes 
as he desires to make, in order that no injustice may 
be done. Free patients, or patients on any endow- 
ment equivalent to a free bed, able to perform light 
services, will sometimes shirk. The rare refusals to 
assist other sick in the wards, and most of the com- 
plaints, come from free patients. As a class, they 
are the most ignorant and the most disposed to grum- 
ble. On the other hand, a nurse, sometimes not un- 
derstanding as she should the condition of a patient, 
may report him as unwilling to help her, when, with 
an appearance of health, a stooping position or un- 
usual effort, as in pushing up a window, might be 
hazardous. 
Patients who are able to do light services are bet- 
ter and happier when employed than when left idle, 
and they often ask for something to do. Occupa- 
tion is frequently prescribed by an intelligent doctor 
as part of his mode of treatment of certain cases. A 
list of light occupations like the following may help 
the nurse in assigning convalescents to duty: 
Convalescents may collect the plates, cups, tum- 
blers, and spoons, from the bed-tables after meals; 
washing them in the appointed place ; dust the win- 
dow-sills, tables, and chairs with a damp cloth; be Hand-Book for Hospitals. 
152 
ready to bring a glass of water when needed, and to 
help at meal-time in carrying bowls and plates to the 
patients in bed ; go on errands to the head nurse, 
and hang out bed-clothing on galleries, piazzas, or 
elsewhere to air, where these services do not involve 
too much walking about; roll bandages; scrape 
lint; sort clean clothing; help in the linen-room 
when the house-keeper needs assistance in light 
mending; watch in the wards while nurses go to 
their meals, being ready to call them if needed ; col- 
lect and exchange library books; water and tend 
the ward plants; and such other little serviceable 
acts as do not make too great a drain upon the 
strength. 
An uncertain dependence.—But the nursing ser- 
vice must not count too much on the labor of in- 
valids and convalescents. It is an uncertain and 
inferior source of supply, and as trying to those who 
are responsible for getting the work done as the use 
of broken or imperfect tools to a skilled artisan. 
The real ward work and, above all, the real nursing, 
can only be done by an organized corps of sound- 
bodied and sound-minded persons ; and the employ- 
ment of convalescents is urged rather for its good 
effect upon them than for its value to the institu- 
tion. 
Grievances.—It should be noticed that hospital 
visitors do not always know what to look for, what 
to see in a ward ; they confuse essentials and non- 
essentials, and are sometimes disposed to listen too 
readily to complaints and to criticize managers and 
nurses when it is their own inexperience which is The Nursing Service. 
153 
chargeable. They should remember that the niceties 
and the exclusive service of private nursing are out 
of the question in a publie hospital, unless there 
were at least one nurse to every patient. They have 
only to call on their own recollection of cases of sick- 
ness in private families to understand this. Hospi- 
tal managers have a delicate and difficult task to 
accomplish ; they are responsible for the wise use of 
public funds ; the service is expensive, hospitals are 
not hotels or boarding-houses ; a few essentials are 
all that the best public institution hopes or professes 
to provide, and if essential points are met other 
things must be yielded. Many of the patients in 
the best public hospitals are under better physical 
conditions than ever before in their lives, and this 
alone sometimes makes them exacting. Besides, 
sickness, as a rule, is depressing. It often makes 
patients irritable and querulous. When the sick 
begin to get well they look at the world with other 
eyes and their small grievances disappear. 
Let the visitor encourage the sick to count their 
advantages, to compare their own condition with 
that of other patients who are worse off, and to con- 
sider, even though they are feeble and suffering, 
whether there is not something they can do to help 
and comfort their comrades in trouble. In a hospi- 
tal previously mentioned, the first gleam of content- 
ment in the face of a sick woman was kindled by the 
suggestion that she might teach the little German 
girl in the opposite bed to write upon her slate. 
From that time, although she was helpless and mor- 
tally ill, and died in the hospital, she never 4ost her 154 
Hand-Book for Hospitals. 
cheerful courage or ceased her efforts to amuse and 
teach and lead to better thoughts the poor sick 
people about her. 
Let the visitor put herself in the place of the 
nurse too, as well as of the patient, and picture what 
it must be to pass nights and days, not only in the 
midst of painful scenes, but responsible for the cease- 
less round of the most wearing of all sorts of work. 
As a general thing nurses of a good class—we do 
not refer to pauper helpers—mean well by the sick 
under their charge, and try, ignorantly though it 
may be, to do their best for them. If the few essen- 
tial comforts cannot easily be procured in a hos- 
pital, it is generally owing, not to the ill-will of the 
nurse, but to attempts at economy, unwise or en- 
forced in the wrong direction, or to incompetent, 
faulty, or clumsy management, or possible dishonesty 
in some office or bureau—causes over which nurses 
have not the slightest control. 
Complaints should not be ignored.—It is true 
that sometimes the only chance of redress a hos- 
pital patient may have is in an appeal to a kindly 
visitor. Poor people in public institutions are very 
helpless; they become parts of a great machine. 
While visitors receive complaints with caution, tak- 
ing carefully into account the character and conduct 
of the complainant, let them not fail to learn for 
themselves whether there is any real ground for 
dissatisfaction, weighing the probabilities, not gen- 
eralizing too hastily, and not expecting too many 
exceptions to rules in favor of this or that special 
prot6g<§ of their own. In the best hospitals the rules The Nursing Service. 
155 
are usually drawn with much thought and care ; 
they are intended for the comfort and protection of 
all the patients; there must be general rules, and 
they must be made for average conditions. It is 
the regular hours and duties, the order and quiet, 
the being taken off his own hands and being told, 
now, you must do this ; now, you must do that,— 
the assuming of the whole responsibility by some 
one else,—which is to many a patient an immense 
relief, perhaps without his knowing it; a framework 
that holds up the feeble man until he is able to act 
and think for himself. 
The number of nurses needed for a given num- 
ber of beds will depend upon the character of the 
cases. In an ordinary ward of sixteen or eighteen 
beds, mixed convalescents and sick—that is, those 
who can make their own beds and take their meals 
in the ward dining-room, and those who must spend 
the greater part of the time in bed—two or at most 
three regular day nurses will be sufficient. Includ- 
ing night nurses, there should be in a hospital at 
least one woman nurse to every six beds. No rule, 
however, can be laid down which will not have to 
give way to exigencies. One typhoid-fever patient, 
for instance, may need the constant attendance of 
one nurse by day and of another by night. The 
head nurse’s knowledge of the nature of the cases 
under treatment will help her in fairly dividing the 
work. This division being made, it is her further 
duty to see that all her subordinates faithfully and 
carefully carry out the orders received from doctors, 
from herself, and from the board of management as 156 
Hand-Book for Hospitals. 
given in the hospital rules. The head nurse is re- 
sponsible for the fulfilment of these duties by her 
assistants, and she should have a voice in the selec- 
tion of the nurses and the right to recommend for 
dismissal those whom she finds unfit for the posi- 
tion. A code of hospital rules is given in the 
appendix. 
Doctor’s call.—In a small hospital where one 
physician at a time visits the patients, the head 
nurse is the one that should always be present at 
the time of the attending physician’s visit, to accom- 
pany him from bed to bed, or ward to ward. She 
should at this time call to her and take with her 
the first nurse of each ward, and see that she takes 
down in writing all directions for the care of special 
patients. It greatly helps the prompt and efficient 
execution of medical orders for the head nurse her- 
self to be on hand to hear the orders given at each 
bedside, to learn precisely what the doctor requires, 
and therefore what she must require from her sub- 
ordinates. 
If the hospital is large, and several physicians 
visit, perhaps, at the same hour, the first nurse of 
each ward should make the rounds with the visiting 
doctor in her ward, and convey his orders to her 
assistants. The head nurse of the hospital mean- 
time should make a point of accompanying the 
physician who has the most serious cases of the 
hospital in charge. 
In all general hospitals there are apt to be patients 
who, after the first crisis of an illness or operation, 
are left to the discretion of the young house offi- The Nursing Service. 
157 
cers, and in the press of more serious cases they 
sometimes slip into a dangerous obscurity. The 
head nurse should keep such patients under close 
observation, and on noticing any change of symp- 
toms which may escape attention otherwise, she 
should ask for instructions. Unexpected deaths 
among “convalescents” or “chronics,” who have 
dragged along for months hardly attracting any 
attention, are not uncommon in hospitals. 
Diet-orders.—Directions for proper diet of pa- 
tients under treatment will be given by the physi- 
cian in his daily rounds, diet-sheets or cards being 
filled in by him with the proper articles and their 
quantities, and the hours at which special diet should 
be given. These orders are the head nurse’s authoriz- 
ation for either drawing on the general kitchen for 
diet, or for such raw material as she needs, so as to 
have the special diet prepared under her direction, 
as may be the rule. No cooking should be allowed 
in the ward pantry beyond warming drinks or mak- 
ing simple gruels. If assistant nurses are to be 
taught cooking, it should be taught elsewhere. It 
would be a good thing if a nurse or attendant could 
be detailed, each nurse in turn, as the diet-nurse of 
the ward, her business being to distribute the diets, 
see that those in bed are served in a neat and at- 
tractive way, and that their little fancies, so far as 
proper, are consulted. She should have nothing to 
do with the medicines or surgical dressings. She 
might take charge of the inventories and be the 
property nurse of her ward, and might perhaps do 
light sewing or mending. 158 
Hand-Book for Hospitals. 
Daily inspection.—Having received her instruc- 
tions and conveyed them to her subordinates, the 
rest of the day, with the exception of the necessary 
hours off duty for meals and recreation, will be 
given by the head nurse to seeing that her orders 
are being carried out. She will take care that the 
ward work is systematized and simplified as much 
as possible. She will assign convalescents to fixed 
duties. She will see that each first nurse has on 
hand the supply of basins, urinals, clean towels, 
soft rags, lint, soap—castile and carbolized—ban- 
dages, and disinfectants needed for each ward. She 
will daily inspect the ward closet where these things 
are kept, and give special directions for the proper 
cleansing and disinfecting of all vessels, which work 
properly belongs to the ward nurses. She will see 
that all the ward vessels are kept scrupulously clean. 
No crockery urinals should, if possible, be used; 
glass ones are now made. She will see that the 
ward attendants are furnished with disinfecting 
fluid, and with instructions how to rinse all these 
things; and will examine the ward vessels frequent- 
ly, holding the glass vessels up to the light to see 
if they are smeared and cloudy, and finding out 
whether the lids of the chamber vessels are covered 
with poisonous dew on the under surface. All these 
vessels contaminate the air if they are not carefully 
looked after. 
Nurses are responsible for the emptying and 
cleansing of all vessels, and they must do the work 
or see that it is properly done ; but in well and 
liberally managed hospitals a ward-maid is assigned The Ntirsing Service. 
159 
to each ward for women, and one or more orderlies 
to each ward for men ; these persons being under 
the direction of the woman nurse and relieving the 
nurses of manual work of this sort, and, what is 
more important, of the necessity it involves of too 
frequent absence from the ward. For certain ward 
duties in men’s wards men attendants are indis- 
pensable, as for lifting helpless patients and giving 
baths, though the woman nurse in charge must 
be held responsible, and superintend what is done. 
A sick person is usually rolled in a sheet for a full 
bath. 
Training assistants.—The head nurse will di- 
rect as to the proper way of bed-making, and the 
airing of beds and bedding, making sure that all 
blankets, mattresses, and pillows are exposed to the 
sun daily when possible, never less than twice a 
week, and always after a patient leaves. She will 
direct about the dressing and undressing of help- 
less patients, and of disposing promptly of soiled 
clothing, both outside and undergarments, accord- 
ing to rule ; and she will see that the daily morning 
dusting with a damp cloth of the tables, window- 
sills, chairs, and other surfaces, is attended to. The 
general cleaning of the wards belongs to the house- 
keeper’s department and will be done by her women ; 
but many little matters are under the care of the 
nurses, and the neglect of them may end in discom- 
fort and danger for the patients. It should be 
remembered that a nurse is not a scrubber, or a 
laundress, or even a cook, except in emergencies; 
and, although a good nurse should know how to 160 
Hand-Book for Hospitals. 
perform all these services, and should never hesitate 
to perform them on the ground that they are 
somebody else’s business, yet they should not, as a 
regular thing, be expected of her. Her special 
business of nursing, if thoroughly attended to, will 
take all her time and all her strength. 
Ventilation of wards.—The head nurse will con- 
stantly examine the thermometer to see that the 
heat does not exceed 68° or jo° during the day, 
or fall below 6o° at night, following the doctor’s 
directions, and requiring regular reports from the 
night nurses on this point. There should be a good 
thermometer in every ward. She will keep a careful 
watch over the ventilation of the wards, noticing 
whether on entering she finds a close, stuffy smell, 
and if so, at once applying the remedy, taking care 
that the ventilating system, whatever it is, is in 
use, or letting down the windows two or three 
inches from the top at intervals, on one or both 
sides of the ward, but in such a way as not to 
let the air blow directly on any patient lying in bed. 
There are always convalescents up and moving 
about, and the windows by their beds are the ones 
to let down. The head nurse will instruct her 
assistants in all these matters, not allowing them 
to fall into the vulgar error of confounding temper- 
ature and ventilation. It has been said to the 
writer: “ Such or such a room cannot be badly 
ventilated; the thermometer stands only at 68°, 
and never goes above 700.” But the air in a room 
where the thermometer stands only at 40° may 
be foul; cold air is not necessarily fresh air, The Nursing Service. 
161 
though it is a common blunder among nurses to 
suppose so. 
The night nursing is a serious matter and one 
to be carefully looked after. The head nurse ap- 
points her women for this duty with the same 
reference to the gravity of the cases as by day. 
Doctors’ orders must be faithfully followed all 
night, and a night nurse must know her business as 
thoroughly as a day nurse.1 If the head nurse is 
obliged to choose, let her rather put the inferior 
woman on day service where she is under closer 
supervision, and the superior one on night service. 
A large proportion of the sick will sleep quietly, but 
all seriously ill people need great care, particularly 
toward the chilly morning hours when the outside 
temperature may be suddenly lowered. The night 
nurse must make careful report of the night service 
on being relieved from duty; a written report for 
serious cases. Great care should be taken to make 
the connections perfect between day and night ser- 
vice. A light luncheon should be provided for the 
night nurses. 
Ward gossip.—The head nurse will despise and 
discountenance gossip and tattle, and will teach all 
her nurses to despise them, never allowing them to 
tattle about their patients or to listen to those who 
do. She will remember and teach her nurses to re- 
1 Before going on night duty, a nurse ought to have at the very 
least three or four months experience on day duty, and learn to under- 
stand the doses and effects of the different medicines likely to be 
given, especially sedatives, anodynes, etc., many of which are active 
poisons in over-doses.—Eds. Third Edition. Hand-Book for Hospitals. 
162 
member that the necessary or enforced confidences 
of hospital patients as to their diseases, their per- 
sonal history, their family life and troubles, are part 
of their misfortune, and as such are to be respected. 
If these matters come to her knowledge she will 
hold them sacred. She will encourage her nurses 
to avoid disputes and jealousies among themselves; 
to settle their little differences frankly before they 
grow and get the upper hand ; to help each other; 
to pull together, not apart. She will not let them 
count any service for the sick and helpless as 
“ menial ” service, if it is only the sweeping of a 
room, or the cooking of a mess of broth, or the 
emptying of a refuse-bucket. She will not slight or 
let them slight any thing, despising a poor and cheap 
quality of work as “ eye-service.” In all these re- 
spects she will train her nurses by example as well 
as by precept. 
An ill-managed ward.—Keeping in mind what 
has been said above, a visitor with correct ideas 
about order and cleanliness and discipline will soon 
learn to see whether a ward is well or ill managed. 
Does she feel a sense of oppression on going from 
the fresh air into the ward ? Is it a little difficult to 
breathe ? Is there a close smell, and do patients 
and nurses look flushed and languid ? The venti- 
lation is neglected here. Are the bedquilts all put 
on at a different angle, some touching the floor at 
the foot, others leaving the blankets exposed, with 
a general untidy, irregular look up and down the 
ward ? At what angle is the table to the bed, and 
the bedside carpet to the table ? Are there on the The Nursing Service. 
163 
table a roll of sticking-plaster, a bunch of lint, some 
sort of slop, and a wet circle where the basin was 
put down when the surgical dressings were made ? 
Are the clothes of the patient who has been in bed 
a day or two in a heap on the only chair allowed 
him, or festooned about his head ? Are the cups 
and plates of the last meal still on the bedside 
tables, long after the hour, and sticky spoons lying 
without any saucer or mug under them ? Are news- 
papers used as covers for the bedside tables, and 
are glasses of flowers standing, the dark color of the 
water in them showing that it has not been changed 
to-day ? Are unsightly vessels kept in full view of 
the ward, on the table or chair, or under the bed, or 
mixed up with a mug of beef tea, a tumbler of milk 
punch, and a sputa cup, all as close together as 
possible at the bed-head ? Are vessels rinsed in the 
bath-tub ; or are dishes or clothes washed there ?— 
an abominable practice. Is there a smear of beef 
tea or gruel on the bedclothes, and a stain of the 
same sort at the corners of that helpless patient’s 
mouth; and is the man in the next bed engaged in 
wiping his mouth on the back of his hand, or on the 
sheet ? 
An incomptent nurse.—Does the nurse stand 
with her hands on her hips, or fumbling with her 
fingers at something all the time she is speaking, 
answering the doctor’s questions with a “ Well, I 
guess so ”; or “ I rather think he slept about ” so 
long, or ate “ about ” so much ; or it was “ kind of 
middling ” this or that ? Does she discuss the 
patient with his friends or other nurses in his hear- 164 
Hand-Book for Hospitals. 
ing, or criticise before him the doctor’s directions, 
thus destroying his confidence in the physician ? 
Does she speak of him as “ the cancer man,” or “the 
man with a head ” if he has a scalp wound ; or sit on 
the edge of his bed, shaking it, and saying, “ You ’re 
nervous, that’s all,” when the patient is restless ? 
Does she permit loud talking and unnecessary pass- 
ing in and out ? Does she allow strangers to peep 
behind the screens out of mere curiosity ?—a com- 
mon practice, and one very offensive to most sick 
persons. Does she taste the sick man’s food in 
his presence with his spoon to see whether it is 
right, or snatch the towel his hands have been wiped 
on to tuck under his chin when she feeds him ; or 
bring in a clumsy china quart bowl full of milk, set- 
ting it down with the remark, “ Here’s your din- 
ner ? ”—the “ dinner ” standing untasted, because 
holding such a heavy bowl is out of the question for 
the patient, and drinking from it lying flat on his 
back is equally impossible. Is the poor fellow in 
the next bed trying to manage his dinner in the 
same position, tipping up the flaring bowl, while a 
little stream of milk from either corner of his mouth 
runs down his neck ? Does the nurse stick pins over 
the waist of her gown, ready to scratch or stab the 
patient ? Does she wear trailing skirts and loose 
frizzes of untidy hair ? Does she describe in por- 
tentous whispers all the diseases of her relatives and 
friends ? Where is the convalescent who should be 
on duty while the second nurse has gone to her din- 
ner, and who might be fanning that paralyzed man 
whom the flies are making uncomfortable ? The Nursing Service. 
165 
Such special evidences of incompetence and con- 
fusion show that there is no efficient oversight of 
the nursing in this hospital. There has been a sort 
of scrambling activity in the ward ; beds have been 
made, meals served, and dressings attended to—but 
how? How they should have been done can per- 
haps best be shown by sketching an orderly ward 
and the manner of caring for the sick in it. Though 
minor methods differ in hospitals, according to place 
and circumstance, the principles which should rule 
the nursing service are essentially the same every- 
where.1 
A well-managed ward.—It is a ward say of six- 
teen or twenty beds, and a number of the cases are 
serious ones. There are a first nurse and two 
others, her assistants. The matron’s part of the 
general cleaning will be well done by her servants 
later; the nurses only are on duty now. It is the 
hour for beginning the day’s work. They have 
stopped a moment in their own dining-room or the 
ward pantry, and taken the cup of tea or coffee or 
milk with a roll or cracker, which should be ready 
for them, and they have begun their work promptly, 
reaching the ward a few moments before the night 
nurse is relieved. There should always be an 
exactness amounting to “ snap ” about ward work, 
but snap does not mean “ slam.” The convales- 
cents are already moving, having been directed to 
1 The “ incompetent nurse ” above described, no longer exists (1895) 
in any of the New York City hospitals. In the hospital wards of 
poorhouses the nursing service (so-called) is lamentably deficient.— 
Eds, Third Edition, Hand-Book for Hospitals. 
166 
take the bedding off their beds and hang it over the 
chair at the foot ; to double back the mattress and 
shake up the pillow—it is the work of two minutes 
—and then go at once to the wash-room. Each 
patient finds his towel ready on a peg numbered to 
correspond with his bed. There is soap enough, 
and hot and cold water, and each patient is expected 
to have in the stout, washable cotton bag hanging 
from the peg, his tooth-brush, hair-brush, and comb. 
The washing over, the clothes put on, each patient 
can give a finishing touch to his toilet with a clothes- 
brush, several of which are hanging by chains fas- 
tened to the wash-room wall. 
Morning work.—Breakfast is now ready, and 
convalescents go directly to the ward dining-room, 
where one of the attendants superintends the meal. 
Meantime the nurses have been busy with the help- 
less patients. They have brought in basins of warm 
water, soap, and towels, and have washed the faces, 
necks, and hands of their sick people ; have smoothed 
their hair, given them water to rinse their mouths, 
and a bit of soft linen or their brushes to help in the 
cleansing. They have shaken up the pillows and 
straightened the sheets and bed covering, and taken 
away all basins, towels, and cups at once, leaving 
the tables cleared for the breakfast which is now 
to come. All this takes time ; sick persons must 
not be hurried ; a good nurse always remembers 
this. 
Fresh air and appetite.—Just before breakfast 
the nurse throws a light extra blanket over the 
patients who remain in bed, covering them head and The Nursing Service. 
167 
all. A large umbrella, opened, with a sheet or shawl 
thrown over both it and the patient is a handy 
device ; and she opens the doors and windows for a 
few minutes and lets the out-door air flow through 
the ward. This is not a thorough process of venti- 
lation, but it is better than nothing, and except in 
severe weather a ward can be perceptibly freshened 
in this way with very little lowering of the mercury. 
She then shuts the windows, turns down the blank- 
ets, and breakfast may come in. She finds that 
this simple freshening of the atmosphere makes the 
difference with some of the feebler patients between 
eating and not eating their breakfast. She has 
noticed that in private houses a sick person almost 
always eats with a better zest if he is able to bear 
being carried into another room for his meals. She 
cannot do this for her ward patient, but she does 
the next best thing she can. She brings a fresher 
atmosphere to him. In illustration of this matter 
it may be noticed that when the visiting doctor 
makes his rounds at dinner-time and takes down the 
surgical dressings, three dinners are usually carried 
away untasted, for every patient examined ; the 
dinner of the patient himself and that of the person 
on each side of him. It needs a robust appetite to 
overcome ward associations. 
Feeding patients.—Whatever the breakfast is, it 
has been put on little trays in the dining-room by 
the person in charge there, in accordance with the 
diet-sheet, and is brought to the bedsides. When- 
ever a patient can make out to feed himself, though 
the process may be a long one, he likes to do it, and 168 
Hand-Book for Hospitals. 
he is propped up in bed with one end of a clean 
towel tucked in his neck, and the other pulled down 
over the sheet; then his little tray of food is put 
before him. Nurses in the well-ordered ward we are 
describing have put the liquid food not in bowls, but 
in small mugs with handles and broad bottoms, and 
the patients find it easy to sip what they want. If 
the patient is one who needs to be slowly fed by the 
nurse, the same care as to propping up and protect- 
ing with a clean towel is taken, and the food is given 
in manageable mouthfuls. 
Breakfast over, the nurse or convalescent ap- 
pointed to this work carries away the cups and plates 
from the bed-tables, and the nurses go to their own 
meal in turn. Patients who are up and about come 
back now to the wards, make their beds, and put 
their tables in order. All quilts are spread at the 
same height from the floor, and all furniture and bed- 
carpets put at the same angle to the beds. No extra 
clothing of any kind is allowed tucked about the 
tables or beds, every article not in use being laid 
away by the nurses at once in a locked, light closet or 
room, outside the wards,—a well-ventilated closet,— 
with numbered shelves or pigeon-holes to correspond 
with the beds, and numbered pegs for hats and 
overcoats in the case of men patients. Messes of 
all kinds are cleared from the tables, convalescents 
being required to keep their own tables neat, though 
in all these matters the nurses help and give direc- 
tions. 
Liquors and medicines are kept in a locked 
closet in the ward, with numbered divisions, only the The Nursing Service. 
169 
first nurse or doctor having access to the closet. 
The hours at which doses are to be administered are 
carefully set down by the nurse in her note-book for 
serious cases and crossed off as each dose is given. 
Some such little plan proves of great assistance in 
preventing unfortunate blunders. Convalescents 
come at the proper hour to the medicine closet, 
where the nurse stands ready to give them their 
doses in accordance with the time noted for each on 
a slate hung by the closet. She has her bowl of 
fresh water and clean towel to wash the spoon or 
glass she uses for the patients in turn. 
Doctor’s rounds.—By this time in an orderly 
ward it is nearly nine o’clock. The nurses have re- 
turned from their breakfast and now begin the wash- 
ing of wounds, the bandaging and changing of 
poultices, and the house physician goes his rounds, 
accompanied by the first nurse of each ward, who 
gives him the report of the night, which, for all seri- 
ous cases, she has received from the night nurse in 
writing. This is the hour when the head nurse of 
the hospital will make a round of inspection, taking 
mental note of carelessness or inefficiency, for future 
use in instructing her nurses. At all times she tries 
to impress on them the importance of the utmost 
cleanliness in washing or handling wounds, and of 
exact attention to orders ; the success of a case often 
depending upon the nurse’s care. She reminds them 
that they must not take shelter in these matters 
behind the use of “ antiseptic treatment ” by the 
doctor. The most fastidious cleanliness is the best 
antiseptic. Hand-Book for Hospitals. 
Consulting doctor’s rounds.—By eleven o’clock, 
in a ward of the size and kind described, the dress- 
ings are finished and the untidy traces cleared away ; 
all unsightly vessels have been removed and washed, 
all light brushing up and dusting is done, and the 
whole ward and its adjuncts are in readiness for the 
physician of the visiting-staff, on his daily round of 
the wards. He is accompanied by the head nurse 
of the hospital or the first nurse of each ward in turn, 
the first nurse noting attentively all orders given, 
and writing down any special directions for serious 
cases. If the attending physician’s visit is made at 
a fixed hour every day, it of course helps very much 
in systematizing the ward work. 
A new patient is to be admitted, perhaps, this 
morning, and the head nurse has been notified by 
the superintendent to have a bed ready in this ward, 
and word comes to the first nurse accordingly. The 
new patient is sick enough to be put in a detached 
room, but the resources of the hospital are not suf- 
ficient for this. The nurse tries therefore to isolate 
him as far as she can, by selecting a bed next one 
occupied by a convalescent, say, who will, if rules 
are obeyed, spend most of his time away from the 
ward. She clears away every superfluous article from 
table and window-sill. She carefully makes the bed 
with reference to a long occupancy, protecting the 
mattress with rubber sheeting, spreading over it the 
under sheet and tucking it in firmly on all sides. 
Over this she puts a second rubber cloth covered 
by a draw-sheet, for the man on arriving must be 
bathed in bed. She adjusts the blanket, upper sheet, The Nursing Service. 
and quilt, doubling them back lengthwise of the bed, 
and placing the pillows as she wants them. She has 
towels, soft cloths, soap, basin, clean night-shirt and 
socks ready, and the screens at hand to shut off this 
part of the ward for the time as much as possible. 
Meanwhile the patient is to be removed to the 
hospital from some distant part of the town ; taken, 
it may be, out of the small tenement-house room 
which he has shared with all the other members of 
the family, who can ill spare him a warm wrap. If 
the hospital sends its own conveyance to fetch him, 
and the matter is within the province of the head 
nurse, she will make sure that a blanket is sent to 
cover the man in cool weather, and a mattress and 
pillow if the case requires it. She will see that he 
is carefully carried to the ward on the mattress or 
stretcher, or, if not ill enough for that, but still weak 
and forlorn, that there is ready a light, strong chair 
with arms, or a canvas seat with waist belt, and slung 
between poles, in which he can sit while two men 
attendants carry him up. 
First bath.—He is in the ward now, or, if the hos- 
pital is a model one, in the ward reception-room or 
examining-room, adjoining the bath-room ; at any 
rate, he is where the next step must be taken toward 
making him comfortable. If he is exhausted or ex- 
cited by the drive, the nurse lets him lie or sit still 
for a while, giving him a little simple nourishment, 
a few spoonfuls of beef tea, or a drink of milk; no 
spirits without orders ; after which, with permission 
of the doctor, she proceeds to undress him and to 
see that he gets as gently as possible the bath which 172 
Hand-Book for Hospitals. 
the rules of the hospital prescribe. Either the pa- 
tient will be put into the tub by the men orderlies, 
or, if he is too feeble for this, the nurse will herself 
wash him thoroughly with warm water and a soapy 
cloth, as he lies on the bed she has prepared, lightly 
covered with a sheet, or blanket, under which she 
passes her hand. A bath-brush should be used for 
the feet. Full directions for bathing patients are 
given in any good book on nursing. One or two 
good manuals of nursing should be in every ward 
library. 
In all cases the nurse should ask the doctor whether 
he sanctions the bath, and then should let no unwill- 
ingness on the part of the patient keep her from this 
duty. Having washed him, slipped away the draw- 
sheet and rubber-cloth, and dressed him, she covers 
him up, and gives him a little more nourishment if 
he is exhausted—Miss Nightingale’s rule is that new 
patients are to be considered on fever diet, that is, 
milk diet, until such time as the doctor gives his 
own orders—and she leaves the screens about his 
bed to let him rest. He will probably fall into the 
best sleep he has had for many days. Now a win- 
dow is let down in such a way that there is no direct 
draft upon him, for this warm bathing of unclean 
surfaces, when properly done, contaminates the air, 
and the vapors must be got rid of. For this reason 
all bathing should be done out of the ward when 
possible. 
The cloth clothing of the patient has of course 
before this been made into a bundle and sent to the 
cleansing-room, his soiled clothes to the laundry, and The Nursing Service. 
173 
all his little pocket treasures have been taken charge 
of by the nurse, who first shows them to him with 
the assurance that they are safe. The after-care of 
the patient is in accordance with the directions given 
by the doctor, which will be implicitly carried out. 
A competent nurse sets down in writing all in- 
formation likely to be called for as to pulse, temper- 
ature, and secretions, and is ready to answer the 
doctor’s questions promptly. She moves quickly 
and quietly; she wears a plain, washable gown and 
fresh white muslin cap, and her hair is simply and 
smoothly dressed. She knows the name of her pa- 
tient ; she keeps his mind free from anxiety, and 
does not discuss him in his presence with any one 
except the doctor. She does not allow the bed-pan 
or urinal to be conspicuous, but removes all vessels 
at once, washing and rinsing them with disinfectants 
in the sink provided for the purpose. The vessel 
which must be at hand for instant use she keeps, 
when washed, out of view. All sights of sickness in 
general in this orderly ward are kept out of the way 
as much as possible. This promotes cheerfulness as 
well as cleanliness, and cheerfulness is a medicine in 
itself. 
Nurses off duty.—The first press of ward work 
is now over. The head nurse takes this time to 
find out whether all that is needed for the next 
twenty-four hours is on hand, and makes requisi- 
tions on the house-keeper for what she wants, keep- 
ing her requisitions copied in a book for inspection 
by the proper authorities as an inventory of the 
supplies furnished her. This is a good hour, say Hand-Book for Hospitals. 
174 
between eleven and one o’clock, to send half the 
nurses off duty, and it should be insisted upon that 
three times a week at least they go away from the 
hospital entirely and into the open air. Their times 
for this recreation will necessarily depend upon the 
exigencies of the hospital service, and upon the hour 
at which the attending doctor makes his visit, but a 
watchful head nurse will see to it that her assistants 
are kept in good condition by out-door influences. 
Afternoon work.—Dinner-time comes now', and 
the rest of the day’s care of the patients repeats the 
morning work. When afternoon dressings are to be 
made, or baths given, the head nurse takes care to 
be on the spot to instruct those whom she noted in 
her morning rounds as inefficient. She calls the 
first nurse of the ward and has her do the work 
before her, or she does it herself and makes the 
assistant watch her in every thing. By such pains 
as this, all hospitals, whether they have training- 
schools connected with them or not, become schools, 
and at any rate train their own attendants, to the 
very great advantage of the institution. 
Men patients less exacting than women.—In 
the experience of the writer, and in that of most 
hospital visitors, men patients are more likely to be 
neglected than women. This is partly because they 
are usually less sensitive and less exacting than 
women patients, and partly because some women 
nurses when appointed to men’s wards are kept from 
a quiet, simple, official performance of duty by mock 
modesty ; while men nurses, whom it is the custom 
to employ in some hospitals, are in every way a The Nursing Service. 
175 
notoriously inferior class. Dr. Gross hardly over- 
states the case when he says that “ in the experience 
of the American physician, drunkenness and male 
nursing are almost synonymous terms.” 
Bathing and out-door air.—A hospital always 
has, or should have, its own general rules concerning 
bathing and out-door exercise, which it is the duty 
of the head nurse to see are observed. All patients, 
unless forbidden by the doctor, should be compelled 
to wash their whole persons twice a week. Those 
who are in bed should be sponged daily, or as often 
as the doctor permits. All patients able to leave 
the ward should be sent out of it, and kept out as 
often and as long as possible ; in this way the air 
remains purer for those who must stay in bed, and 
the convalescents themselves are put in healthier 
surroundings. Some sheltered piazza where wheeled 
chairs can stand, some room on the same level with 
the main ward where newspapers and games can 
be kept, are humane provisions, and essential to the 
best conditions for recovery. In a two-story hos- 
pital the women should have an upper piazza, the 
men patients using the lower floor. 
Poorhouse nursing.—Visitors must not assume 
that the orderly and careful system of nursing above 
described is inapplicable to county almshouses and 
asylums. There are such institutions which are 
models of excellence. The workhouse infirmary 
in Liverpool will be remembered as the scene of 
Agnes Jones’ life and services, and as the pioneer in 
the work of pauper hospital reform ; Crumpsall 
Infirmary, at Manchester, has fourteen hundred beds., 176 
Ha?id-Book for Hospitals. 
and with one exception is the largest known ; these, 
with the workhouse hospitals at Leeds, Glasgow, 
and others in London and elsewhere, have trained 
nurses, some of them trained superintendents, and 
rank among the very first in good management, 
order, and nursing. Irrespective of faulty construc- 
tion it ought to be possible to bring the one or two 
sick-wards of every poorhouse in our State, in their 
internal management, up to the standard of at least 
ordinary hospitals. Very few counties can claim to 
have reached this point. 
Deaths in poorhouses.—Official reports for 1882 
give a return of one thousand and ninety-nine deaths 
during the year, in the county poorhouses of New 
York State. These deaths imply a considerable 
amount of preceding sickness. Under right manage- 
ment, indeed, poorhouses are little else than infirm- 
aries. Where the efforts of local committees result 
in drafting away the children and the able-bodied 
vagrants, the county-house population comes to be 
more and more one of chronic invalids and defective 
and feeble-minded persons. Old and infirm people 
often need as tender care as the sick. In some 
poorhouses invalid and helpless persons are now in 
the majority. In all of them will be found (besides 
those who are broken in health by vice) decent but 
destitute persons, for whom, in the remoter districts, 
there is no other refuge in mortal illness than the 
poorhouse. 
Poorhouse nurse.—In addition to the improved 
hospital accommodations required in many counties, 
there is the sorely felt need in every poorhouse of The Nursing Service. 
177 
at least one intelligent, trained, and salaried nurse, 
whose services are demanded both by humanity and 
by a just regard for sound public economy. In 
small institutions, especially where there is no resi- 
dent doctor, or in remote places where medical 
visits are infrequent, the presence of a competent 
woman would be invaluable. She should have 
sound health, and a cheerful, kindly courage, not 
shrinking from sickness which is often the result of 
evil life, and knowing how to make the most of 
simple materials and to give relief by simple means. 
Much suffering and loss of life, which now occur un- 
seen by the public in our poorhouses, might thus be 
prevented. 1 
Infectious disease.—Wayfaring poor who are 
lodged for a night or two in poorhouses often bring 
contagion ; and the knowledge, on the part of the 
keeper and the nurse, of how to deal with smallpox 
or typhus fever or other pestilent disease dangerous 
to the household, is important. A refuge hut 
or tent should be used to isolate such patients, and 
poorhouse officers should provide themselves with 
the instructions of their State Board of Health on 
these subjects. 
1 In Rensselaer County the appeals of the Association’s local visit- 
ing committee have had a substantial response from the Board of 
Supervisors. Ample hospital wards for both sexes have been ar- 
ranged, and an experienced trained nurse is employed. Dutchess and 
Steuben and other counties are moving in the same direction. (1883). IX. 
Care of the Insane.1 
HUMANITY and public economy forbid the treat- 
ment of the insane under a uniform system adapted 
to sane paupers. Insane persons as a class should 
be separated from the poorhouse management. The 
proper construction and organization of hospitals for 
their benefit form a distinct subject, although many 
of the details as to general care and hygiene, already 
given in this hand-book, will apply to such hospitals.2 
Faults in buildings.—Unfortunately in New 
York, except in a single case, the insane ward, or 
asylum, is a regular part of every poorhouse estab- 
lishment, maintained out of the common fund, and 
under the direct control of the county superintend- 
ents of the poor. (See Foot-note.1) Serious evils 
1 Since this chapter of the Hand-Book was written the dependent 
insane have been removed from all the poorhouses and poorhouse 
asylums of the State of New York into State Hospitals (as should be 
the case everywhere), under the provisions of chapter 126 of the Laws 
of 1890, commonly known as the “ State Care Act.” But as this man- 
ual has a circulation beyond the borders of the State of New York, 
and where the dependent insane are unfortunately still kept in poor- 
houses, this chapter (with the elimination of two paragraphs relating 
to laws now obsolete), is left intact, and as last revised by the au- 
thor, in 1883.—Eds. Third Edition. 
2 See also “ Suggestions for the Use of Visitors to the Insane”— 
publication No. 22, State Charities Aid Association, and reports of the 
New York State Board of Charities. Care of the Insane. 
179 
are the manifest result of this plan. Among com- 
mon faults in the buildings themselves maybe noted : 
the small, over-crowded, and often very cold rooms ; 
the want of light and cheerfulness; narrow, steep 
staircases; bad air, bad drainage, improperly placed 
water-closets ; insufficient water-supply ; and faulty 
arrangements which interfere with complete and 
careful supervision. The prison-like buildings, the 
high fences, padlocks, bars, and grated windows, 
suggest force and resistance; places of detention, 
not of cure. 
Faults of management.—As almost invariable 
evils of poorhouse management of the insane we 
note : the want of systematic, skilled medical care ; 
lack of healthful occupation and of out-door amuse- 
ments ; lack of proper clothing; unregulated, un- 
suitable diet; that gross outrage on helplessness— 
opportunity given for improper association of the 
sexes ; inadequate number of paid attendants, with 
the usual temptation to resort in such case (espe- 
cially during the night) to mechanical restraint,— 
cribs, camisoles, hand-cuffs, belts, and shackles; and 
during the day, and in the absence of the keeper, 
the plan of locking up the insane department and 
taking away the key. 
The condition of the insane poor is pitiable in- 
deed. They are even more helpless than children. 
Their word goes for nothing; they have literally, in 
one sense, no friends—not even themselves. They 
need every humane safeguard which can be thrown 
around them. Ignorance is cruel. Fear is cruel. 
And this most helpless of all classes must often 180 
Hand-Book for Hospitals. 
suffer through the ignorance and fear as well as the 
incapacity of keepers and attendants. Insane hospi- 
tals are frequently built in secluded places ; they are 
less open to ordinary public inspection than other 
charities. Yet of all institutions they most need the 
constant, rigorous, humane supervision of disinter- 
ested persons, in order that the rights of the poor 
may be surely, steadily, and systematically pro- 
tected. 
Responsibility for the alleged abuses of insane 
asylums, involves all ranks from supervisors and 
superintendents of the poor down to the humblest 
attendant, but it begins with the public. Official 
inspections of public institutions are apt to be 
hurried and superficial, and made at expected times, 
when the place is in its best order. The event of 
the season over, the institution lapses into the old 
routine. A system, therefore, of frequent, unofficial, 
and unexpected visits by local committees would 
bring out the facts with more exactness as to the 
average condition. Recent State legislation in 
Pennsylvania provides for such inspection by mixed 
committees of men and women. 
Prompt treatment necessary.—The first efforts 
of visitors should be directed toward the enforce- 
ment of the law which forbids the detention of any 
case of recent insanity in any other place than a 
State hospital, or such other authorized asylum as 
the law directs. No time should be lost. To 
ensure hope of recovery the majority of the insane 
require prompt treatment, trained attendants, gen- 
erous diet, and all the skill which physicians can Care of the I?isane. 
181 
bring to bear on the case. All these can best be 
secured in establishments which command the right 
sort of professional service, and where some of the 
expenses which proper treatment entails may be 
economized by concentration. But individual pro- 
fessional care of individual cases by a good medical 
superintendent is the essential feature of successful 
asylum treatment; and therefore concentration of 
numbers should never be carried to a point which 
would make such individual care uncertain. 
Delay, a violation of law.—The sooner recent 
cases can have the advantages described, the larger 
will be the percentage of cures. The burdens of 
taxation are enormously increased by delay. Cases 
which might be cured under prompt and proper 
care, if detained in county poorhouses, pass by such 
neglect into the hopeless condition. The average 
duration of life of a person who has become incura- 
bly insane is eighteen years. “ The wrong done to 
the insane in thus jeopardizing their chances of re- 
covery, and the additional burden cast upon coun- 
ties and the State by any process of manufacturing 
cases of chronic insanity, are violations of law,” and 
should be recognized as such by visitors.1 
Moreover, cases legally considered “ chronic ” are 
not always incurable; and incurable patients may 
often be relieved by suitable treatment, and their 
lives made not only less distressing to themselves 
and to those about them, but useful, in a measure, 
to their families and to the State. 
State care.—The State Charities Aid Association, 
1 Dr, Ordronaux. 182 
Hand-Book for Hospitals. 
therefore, affirms its distrust of the plan of multi- 
plying county and district asylums under the poor- 
house system. It repeats its recommendation, that 
the State should take charge of all the work now 
attempted by the counties in behalf of the insane ; 
and once more urges, as the least expensive and most 
suitable measure, that enough simple cottages and 
dormitories to meet the need should be built on the 
grounds of the State Hospitals.1 Expert medical 
superintendence would be at once available ; classi- 
fication of patients could be readily made ; selected 
groups of patients could be cared for and furnished 
with occupation in the cottage colonies ; and in case 
of any access of mania such patient could be moved 
to the appropriate ward. Workshops should be 
provided, simple trades practised, and farm and 
dairy work carried on. An instance of what may be 
accomplished in this way is seen in the Willard 
Asylum at Ovid. The asylum and colony of Fitz- 
James at Clermont, France, is a notable example of 
the separation system of treating the insane and of 
the curative effects of occupation.2 
Insanity a disease.—The best service which vis- 
itors to the insane can render is to try to break down 
the mystery and terror which hang about lunatic peo- 
1 Third Annual Report, State Charites Aid Association, 1875. 
2 Since this was written the State Charities Aid Association has 
obtained legislation (Chap. 126, Laws of New York, 1890, and Chap. 
91, Laws of 1891), now in full operation, which has put into practise 
many of the above suggestions. See Annual Reports of the Associ- 
ation for the years 1886-1894 ; also Annual Reports of the New 
York State Commission in Lunacy, 1890-1894.—Eds. Third 
Edition. Care of the Insane. 
pie and the places where they are confined. Insanity 
is a disease. Patients should be cared for as sick 
persons, individually, not punished for being “ disa- 
greeable,” even when their insanity, as often hap- 
pens, is the result of evil ways. Insane persons are 
not insane in all directions. Talk to them on a 
variety of topics, and on some they may answer you 
rationally. Treat them courteously, gain their con- 
fidence, let them see that you are interested in them 
and they will give you less trouble. If a man wants 
to shout and sing, let him do it ; he will soon tire of 
it. If he wants to run up and down, do not shut 
him up; it hurts no one. If he must tear and de- 
stroy, let him spend his energy on old garments, or 
give him garments that he fancies ; do not excite 
him by tying his hands. 
Dress.—Refractory lunatics who tear off their 
clothing, frequently do it because their skin is so 
sensitive that they cannot endure the irritation 
which clothing occasions. Garments for lunatic pa- 
tients should be warm—for such patients are pecu- 
liarly sensitive to cold—but they should be soft, 
light, and varied in color and style. Dress is a 
moral element in the treatment of certain cases. 
Restraint.—Wherever visitors notice a large pro- 
vision of restraining appliances in an asylum without 
finding also strict rules for their use, they may safely 
infer the existence of abuses. Attendants, if they 
have the chance, find it easier for themselves to put 
excited patients in restraint than to try to overcome 
excitement by personal, individual effort in the ward. 
The gathering up of all the muffs and camisoles, 184 
Hand-Book for Hospitals. 
and their removal to the doctor’s office, mean greater 
personal attention on the part of nurses and attend- 
ants. The best “ appliances ” are fresh air, quiet, 
good food, warmth, suitable clothing, congenial oc- 
cupation, and a good attendant. 
The kindly courtesy shown by visitors toward 
patients will have its effect upon the attendants, and 
help to give a better tone to the ordinary intercourse 
in the ward. The little talk also may often make it 
manifest, even to casual visitors, that the seemingly 
quiet, inoffensive person is unquestionably insane, 
and that the physician who insists that the patient 
is unfit to be set at large is right. 
Food.—The effort in all public institutions to 
curtail expenses shows itself, generally, next to cur- 
tailing the number of employees, in the quality of 
the food. The diet is often injuriously cut down. 
The diet in lunatic asylums should be not only gen- 
erous and wholesome, but varied, and served in neat 
and attractive form. The insane as well as the sick 
often have unexplained but harmless fancies, and 
humoring these fancies is sometimes a help toward 
inducing a patient to take the required amount or 
kind of food. Visitors should note what is the man- 
agement in these matters, by occasionally timing 
their visits at the dinner-hour. 
How to find suitable occupation for the insane 
is a question which constantly comes up for solution 
where there are right thinking hospital officers. It 
is a matter which may well enlist the attention and 
help of visitors. “ Rightly understood, it means the 
creation around each patient of a new world, built Care of the Insane. 
185 
up out of his own awakened and directed activi- 
ties.” 1 Light employment should be urged, but 
not forced upon patients. They should be encour- 
aged to do things voluntarily, and to regard their 
work as done for the general good. Give insane 
people, as well as sick people, some interest outside 
of themselves, and, if possible, in behalf of others. 
Simple fancy work for sale might sometimes be tried, 
or braiding straw and weaving baskets, knitting lace, 
carving in wood, painting, or making artificial 
flowers. Many articles would be failures, but in- 
genuity would be stimulated and interest roused. 
Music might often be made available in the care 
of the insane. The influence which music exerts 
on certain people in certain moods ranks it among 
the more important directly curative agents—it is 
not occupation merely. Of course every sort of 
out-door exercise, whether for employment or amuse- 
ment, should be encouraged, with both men and 
women patients. But in order to furnish light and 
suitable work for all who require it, the hospital 
grounds must be ample. The out-door life is bene- 
ficial, even more than the occupation. It promotes 
healthy appetite and sleep. Pains should be taken 
to vary the occupations ; insane people are incapable 
of continuous labor, and it would be unwise to 
exact it from them. 
Vigilant oversight.—The cleanly condition of 
patients, the appropriate clothing, the good ventila- 
tion, the airy, cheerful, and well-warmed rooms, the 
farm, the gardens,—all the arrangements through- 
1 Dr. Mary Putnam Jacobi : yournal of Social Science, No. 15. 186 
Hand-Book for Hospitals. 
out the establishment should be such as indicate 
unceasing vigilance of skilled officials and attend- 
ants. There should be no “ airing courts ” therefore 
—that is, small yards surrounded by high walls or 
fences, where patients are turned out to air or to 
walk about. Where airing-courts are in use, attend- 
ants are apt to think that patients can come to no 
harm, and watchfulness is relaxed. “Airing-courts 
are a mistake, especially in the case of women pa- 
tients ; the system permits every insane propensity 
to run to weeds.” This is the judgment of Dr. John 
Fraser, the physician in charge of the pauper asy- 
lum for the counties of Fife and Kinross, Scotland. 
This asylum holds about three hundred patients, 
both acute cases and those of long standing. One 
paid attendant is allowed for every twelve patients. 
The features which distinguish this institution are : 
unlocked doors for all but the violent cases; a great 
amount of general freedom; regular occupation; 
the work in the garden, the laundry, the kitchen, 
and the sewing-room, making the asylum a bee- 
hive, and reducing the number of the actually idle 
to a minimum ; lastly, the disuse of airing-courts. 
The skill required in attendants for the insane 
differs from the skill of ordinary nursing.1 There 
should be special training, and the organization of 
training-schools for this purpose in connection with 
our large asylums has been found an imperative 
necessity. The attendant should be an even-tem- 
pered, gentle, forbearing, but firm person, truthful 
and self-controlled,—one who is untiring in efforts 
1 “The Training of Attendants for the Insane.” Pub No. 38, 
State Charities Aid Association, 1885. Care of the Insane. 
187 
to employ and divert her patients ; quick in noticing 
the symptoms of coming excitement, but never fret- 
ting the patient by too obvious notice, or too many 
and unnecessary checks. Women physicians in the 
women’s wards of insane asylums are in the highest 
degree desirable. Patients confide in them with great- 
er freedom, and with less excitement than is some- 
times caused by the presence of a male physician. 
Visitors should carefully note those points on 
which the well-being and the humane treatment of 
the patients closely depend ; namely, the character, 
capacity, and number of the attendants, and the 
manner in which the hospital service is organized. 
A certain amount of authority must be delegated 
by the superintendent, but never directly to the 
lower grade of attendants; it should be distributed 
through faithful and competent heads of depart- 
ments and divisions. Even in the finest hospitals, 
with a well-chosen corps of nurses, the service can 
never be of the best quality without sound organiza- 
tion, and without intelligent, disinterested, and high- 
grade oversight.1 
1 See the following publications of the State Charities Aid Associa- 
tion, upon the dependent insane : No. 22, “ Suggestions for the use of 
Visitors to the Insane,” 1880 ; No. 37, “ Lunacy Legislation in Eng- 
land. The Condition of Lunatics in Scotland,” 1884; No. 38, 
“ The Training of Attendants for the Insane,” 1885 ; No. 48, 
“ Legislation for the Insane of the State of New York,” 1888 ; No. 53, 
“ Proceedings of Public Meeting to Commemorate the Completion of 
State Care Legislation for the Insane,” 1891 ; Nos. 57 andbi, “First 
and Second Annual Reports of the Association to the State Commis- 
sion in Lunacy,” 1893 and 1894 ; Annual Reports (in part), of the 
Association to the State Board of Charities for the years, 1873-1894 ; 
No. 32, “ Chapter on the Care of the Insane, from Hand-Book for 
Hospitals.”—Third Edition, 1895. X. 
Maternity Wards. 
MATERNITY cases should never be allowed in a gen- 
eral hospital, and the plan, wherever tried, is sure 
to be abandoned sooner or later, as at Bellevue, 
after disastrous results. 
Mortality statistics.—“ It is well known that it 
is absolutely impossible to establish a maternity ward 
in a general hospital without exposing the women 
confined in it to the greatest possible peril of life; 
and in every instance, I believe, in which it has been 
attempted in London, the mortality has been so 
great that it has become necessary to close the 
ward. The fact is certain that a woman has a better 
chance of recovery after delivery in the meanest, 
poorest hovel, than in the best-conducted general 
hospital, furnished with every appliance that can add 
to her comfort, and with the best skill that a metrop- 
olis can afford. The statistics of Lefort on the rate 
of mortality following the delivery of nearly two 
million women in different parts of Europe—one 
half in their own homes, and the others in lying-in 
hospitals—are so distinct and definite in their results 
as to leave no doubt.” 1 The figures are these: 
1 Ehrichsen : “ Lectures on Hospitalism,” London, 1874. Visitors 
should also consult Miss Nightingale's Notes on Lying-in Institutions, 
London, 1871 ; and “ Traite de l’Art des Accouchements ” (Hygiene Maternity Wards. 
DELIVERIES. 
At Home. . . .934,781. 
In Hospital . .888,312. 
DEATHS. 
4,015, or i in 212. 
30,594, or 1 in 32 *. 
In considering the great body of facts which the 
history of both hospital and private obstetrical prac- 
tice furnishes, the late Dr. Joseph M. Smith wrote : 
“ There are two things which cannot fail to be sug- 
gested, and to make durable impressions on the mind. 
The first is the importance of preserving in absolute 
purity the persons, clothing, and bedding of the in- 
mates, and also the floors, furniture, and atmosphere 
of lying-in hospitals; and in case puerperal fever 
manifests itself, of adopting the most prompt and 
efficient means of extinguishing it—such as ablution, 
ventilation, fumigation, and, if necessary, dispersion 
of the patients. The second is the imperative duty 
of physicians ever to bear in mind the danger of their 
becoming agents of disseminating the disease in epi- 
demic puerperal-fever seasons, and to observe every 
precaution against such accidents. If, indeed, there 
des Mater nitds,) par S. Tarnier, chirugien en chef de la Maternite, et 
G. Chantreuil, ancien chef de clinique d’accouchements, Paris, 1882. 
1 Modern medicine teaches us that there is no reasonable doubt that 
puerperal fever is, with very rare exceptions, caused by a want of 
cleanliness in the hands of the physician or nurse, or in some sub- 
stance which comes in contact with the parts ; and since surgical 
cleanliness and the scientific use of antiseptics have become the 
puerperal fever has been reduced in well-conducted maternity hospi- 
tals to less than one third of one per cent., and therefore women are 
much safer from all preventable causes of death in good maternity 
hospitals than in their own homes. We hope soon to have some form 
of investigation or inquest so as to fix the blame for a case of puer- 
peral fever, whenever a woman dies of what is so plainly, a preventa- 
ble disease.—Eds. Third Edition. Hand-Book for Hospitals. 
190 
be any moral obligation resting on a medical man to 
his patients paramount to every other, it is that of 
refraining from attending a woman in labor, if there 
be the slightest chance of his conveying to her the 
germ of a mortal disease.” 
The chief points above indicated, and which we 
must regard in the construction and management 
of maternity wards, are the prevention of all inside 
local causes likely to create puerperal fever, and the 
exclusion of all outside causes. To this end it is one 
of the fundamental principles that there should be a 
double set of rooms, every alternate room being al- 
ways unoccupied. There should be complete isola- 
tion of the buildings ; each patient, so far as pos- 
sible, occupying a separate cottage, or room, with 
impermeable walls and not connected except by 
open corridor with any other apartment; and such 
internal watchfulness should be maintained that the 
chance of local production of the disease will be re- 
duced to the smallest possible ratio. Iron bedsteads 
should be used, and only straw beds allowed. An 
under sheet of some cheap waterproof material, such 
as coarse oiled muslin, is safer than a rubber sheet, 
because it is more likely to be burned, and the risk 
of infection to the next patient is avoided. Tarnier 
suggests papier gondronne' (tarred paper ) ; several 
thicknesses of newspaper, ora sheet of manilla paper, 
laid in the folds of a draw-sheet may answer the same 
purpose. Bed-sheets and blankets should be freshly 
sprayed with disinfectants. No sponges must be al- 
lowed ; wads of carded cotton can take their place, 
and are burned after one using; every catheter and Maternity Wards. 
191 
utensil should be kept fastidiously clean, and every 
person who enters the room scrutinized. The sys- 
tem of ventilation should be as perfect as nature 
and science can make it, and the temperature of 
the ward should never be above 68° Fahrenheit. 
After recovery, or at the end of the puerperal state, 
the patient may be removed to the common wait- 
ing-ward, the bed destroyed, and the room cleansed 
and disinfected for the next case. Blankets should 
be baked after one patient’s using, and all the bed- 
and body-clothing thoroughly disinfected, as de- 
scribed in Chapter VI. 
Suspected fever cases should be immediately 
isolated, and all rooms should be periodically emptied 
and fumigated. There should be enough nurses and 
helpers to prevent communication between suspected, 
or infected or non-infected patients. “ Strong disci- 
pline should be held in a maternity hospital over 
the physicians themselves, both resident and attend- 
ing, as well as over nurses, in the matters of rigid 
cleanliness and of non-intercourse.”1 
The Tarnier pavilion, built on the above general 
plan on the grounds of the Maternity hospital at 
Paris, and managed with the utmost care as to clean- 
liness, ventilation, and isolation, has given remark- 
able results. The mortality which was five in a 
hundred in the old hospital, has been reduced in the 
detached ward to less than six in a thousand. This 
is a two-story ward, with eight single bedrooms, 
four on each floor, all corner rooms. The offices and 
staircases are in the centre, but divided from the 
1 Dr. S. H. Chapman. Hand-Book for Hospitals. 
bedrooms by solid walls, only a fixed single pane of 
glass set in the office wall permitting the attendants 
to overlook what goes on in each room. The rooms 
do not communicate in any way with the lobby or 
office, or with each other. Rooms and offices all 
open on an open corridor or balcony running along 
each front. The corridor is roofed with glass, and 
this roof is detached from the main wall, so that the 
air, vivified by the sun’s rays, circulates perfectly. 
The bedroom walls and ceilings are hard-finished in 
stucco, and painted in oil colors, all corners and 
angles being rounded. The floors are of large slabs 
of slate or tile and have a slight incline, and the 
rooms are cleaned out by copious use of water. 
There is a fireplace in every room, the furniture, con- 
sisting only of bedstead, chair, table, and crib, is of 
iron; a bell-cord rings a bell in the office, and the 
lighting at night is by gas, the burner being outside 
the room and shining through a pane of glass.1 
The State Charities Aid Association has hith- 
erto recommended (in its report for 1875) that for 
obstetrical cases a sufficient number of one-story 
pavilion wards should be provided, to be used alter- 
nately, and containing never more than six rooms, 
with one patient in each. This is in view of a large 
hospital, and a large number of births annually. 
But poorhouse authorities and the managers of 
small hospitals, where lying-in cases are infrequent, 
should provide one or two cottages for this special 
1 See “ Traite de l’Art des Accouchements ” : Tarnier et Chantreuil, 
Paris, 1882, p. 801. Also, “ Hospitals; their Management and Con- 
struction (Lying-in Hospitals)” : Dr. W. G. Wylie, New York, 1877, 
pp. 139 and 172. Maternity JVards. 
193 
use, distinct from the main house or hospital wards. 
The cottages can be built on the same plan as the 
isolating hut described in the appendix, except that, 
to contain two beds for women and a third for a 
nurse, they should be twenty-five feet square instead 
of twenty feet. In calculating air-space and the 
number of attendants needed, it must be remem- 
bered that in a maternity ward one mother implies 
two patients.1 
1 It is certainly wise to advocate the best plans for all hospitals, 
but the visitors must understand that in the oldest hospitals as well as 
the newest, sepsis and puerperal fever (which is merely one form of 
sepsis) will depend upon the practical knowledge and ability of the 
physician to keep himself, his assistants, and all instruments and 
appliances aseptic or clean ; and not on the old walls, or bad air. It 
is true that the latter may do much harm in a general way, but to- 
day, even in old Bellevue Hospital, and for the past ten years, some 
of the best results have been obtained, even in abdominal surgery ; 
almost perfect results, so far as mortality is concerned. — Eds. 
Third Edition. XI. 
Village Hospitals. 
In many of our villages and towns, remote from 
large cities, there is often among laboring persons 
and the decent poor a considerable amount of suf- 
fering, and possibly loss of life, for the want of 
intelligent, timely care and nursing. This is es- 
pecially the case in factory villages where there are 
workshops, mills, and steam machinery, or in the 
neighborhood of mines and railways, where acci- 
dents are frequent. Ignorance of sanitary laws is 
to be expected in small isolated towns and among 
working people, and sickness as the result of igno- 
rance is common. To meet this want, village hos- 
pitals have been organized in a few places. Such 
little institutions containing four, or six, or eight 
beds, or one bed for every thousand inhabitants of 
the district, provided chiefly with a view to accident 
cases, might well be multiplied. 
A sunny and spacious dwelling-house could be 
bought or rented as a beginning, and modified to 
suit its purpose, though a new building, specially 
planned with open grounds about it, is best. A 
good nurse who also understands simple house- 
keeping should be put in charge, and a women’s 
committee should manage the house and provide, 
so far as necessary, by voluntary contributions, for Village Hospitals. 
195 
the running expenses. It would be well if this 
committee could represent all the various religious 
denominations of the place, one or more members 
being taken from each church, that the work might 
be non-sectarian, and might unite all classes in its 
support. Here, with the willing aid of the medical 
men of the village, injured persons could have 
prompt care, and sick cases appropriate food ; 
neither of these being attainable so easily and sys- 
tematically by the poor of a village in their scattered 
dwellings, even where private benevolence is ready 
to step in. Here would be found a shelter for the 
industrious unmarried mechanic or working-girl, 
who in time of sickness or accident is poorly off in 
a boarding-house, although ready to pay for relief. 
And here could be treated those respectable poor 
persons whose only other refuge in mortal sickness 
might be among paupers in the almshouse. 
Rules of admission must be carefully drawn, and 
the committee should insist on taking pay from 
every patient who can pay even a trifle. If a cot- 
tage hospital becomes free to any large extent, 
because the managers shirk the duty of inquiring 
into the circumstances of applicants, or find it too 
much trouble to collect payments, or because the 
hospital has a considerable endowment, it will cease 
to be the thrifty and popular little institution it 
ought to remain. It will degenerate into a sort of 
private poorhouse, and prove an evil rather than 
a help to the laboring people. 
The rules as to classes of cases admitted might 
sometimes be less stringently interpreted than is Hand-Book for Hospitals. 
196 
possible and right in crowded city hospitals ; the 
managers on occasion and with common consent 
making exception in favor of an incurable patient, 
or other special case of distress, where friends would 
engage to assume all expenses. On the other hand, 
rules as to the moral character of inmates should be 
strictly enforced in such small institutions, and pri- 
vate charity should not undertake to do what is 
more fitly delegated to town officers and the public 
workhouse. 
A simple and distinctive name : House of Mercy, 
Sheltering Arms, St. Elizabeth’s Home, or such 
similar title, would naturally suggest itself as appro- 
priate for a cottage institution, and would be found 
to have its conveniences. 
School of hygiene.—The cottages, if well con- 
ducted, would make useful impressions on chance 
visitors as well as inmates. The clean floors and 
spotless walls, the quiet, the order, the tidy beds, 
the appetizing food, the sunlight, and sweet air, 
would be suggestive of what might be possible at 
home. In the lack of competent local health offi- 
cers, the cottage with its visiting doctor and manag- 
ing committee might become a sort of little centre 
of sanitary instruction for the whole village, by 
means of simple lectures, or leaflets with rules about 
health, pure-water supply, disinfection, and other 
topics. Especially might this be the case in time of 
epidemic disease, though no infectious case should 
be taken into the hospital. A little library of use- 
ful reference could be kept, containing simple books 
on nursing, what to do till the doctor comes, and 
similar subjects. Village Hospitals. 
197 
The hospital kitchen might be made useful to out- 
siders in furnishing sick diet, good beef tea, and deli- 
cately cooked food, in exchange for tickets bought 
or subscribed for through the committee, the matron 
receiving due notice of what will be called for. The 
house might also be the home and headquarters of 
a missionary nurse, or of one or two ready trained 
nurses for outside service in neighboring families of 
the better class, a portion of their earnings accruing 
to the cottage fund. Cottage hospitals afford no 
scope for training nurses, and this work should not 
be attempted; but each competent matron might 
well have always under her direction as her assistant 
one young woman whom she could teach in the 
course of a year or two to take entire charge. 
In England there are between two and three 
hundred cottage hospitals in operation, a few of 
them in large towns, but in nearly all cases estab- 
lished by local, voluntary effort in small villages. 
Many of them have only three or four beds. Bur-' 
dett’s list gives the names of over a hundred with 
less than ten beds each. The cottage hospital move- 
ment has taken its place as one of the permanent 
charitable agencies of England.1 Each bed is usually 
occupied in the course of a year by six cases, varying 
from a month to two months or more in duration. 
If beds are sometimes empty it is a needful relief to 
the house officers, and a sanitary advantage to the 
cottage and its inmates. The patients, as a whole, 
it is estimated, contribute twelve per cent, of the 
total income. Some of the larger of these English 
cottage hospitals have been planned and built with 
1 Henry C. Burdett : “ Cottage Hospitals,” London, 1880. 198 
Hand-Book for Hospitals. 
reference to their use, but they are generally simple 
and home-like buildings, such as the few established 
in New York and New England, where the patient 
| is attended by the physician of his choice. The 
hard-worked country practitioner is a gainer by the 
plan. His time and labor are economized, and his 
case gets the benefit of the hospital resources and 
the kindly interest and care of all concerned. Open 
fires and the privacy, comfort, and friendly cheeri- 
ness of small wards for one or two beds make such 
little buildings attractive. 
The site.—However small a hospital is it can 
secure for itself many of the hygienic features of 
larger institutions by judicious planning and by the 
ceaseless oversight and personal care of individual 
cases, which so often determine the result as to 
successful or unsuccessful treatment. A properly 
constructed building adapted to its purpose is as 
important for the well-being of a small hospital as 
of a large one; and none of the principles enforced 
in the preceding chapters of this hand-book should 
be overlooked. The site should be airy and health- 
ful, and chosen with the probability in view that if 
the town is a growing one it may become necessary 
to enlarge the building. 
The drainage question is a serious one in all town 
and village institutions. The problem is the imme- 
diate and complete carrying away of the excreta 
and slop-water from the house. No hasty or igno- 
rant work will answer here. The utmost care must 
be taken both to avoid doing harm to neighbors, 
and receiving harm from the condition of neighbors’ Village Hospitals. 
premises and drains. If there can be sewer connec- 
tion, a hopper or other approved form of closet 
(avoiding the pan closet) should be selected, and 
sinks and closets should be thoroughly trapped. If 
there is no sewer, the first step toward safety is 
to clean out and fill in with fresh earth any old vault. 
A privy built above ground with water-tight tubs 
on a level floor, can be easily kept neat and clean 
by the use of dry sifted earth or ashes, fine charcoal, 
and occasional chloride of lime. 
The contents of the tubs must be kept daily covered 
with the dry earth, and thus deodorized, and must 
be periodically emptied and clean tubs substituted. 
No house slops must be emptied here or ever thrown 
out on the surface of the ground. No wooden 
trough or brick or loose-stone house drain is allow- 
able. The drain pipe, where not of iron outside the 
house, must be hard, salt-glazed, heavy drain-tile. 
Wherever there is a good-sized grass-plot or un- 
ploughed stretch of porous ground, the chamber and 
laundry slops can be disposed of by sub-surface 
irrigation ; see Chapter IV. for these subjects. Dirty 
water of any kind is even worse in a hospital or 
house than dry filth. Chamber slops and wash wa- 
ter are innocent, if cared for within four or five 
hours, but if left longer than this decompose, and 
even sooner than this in sickness or very hot weather. 
The kitchen pump and the kitchen sink stand 
side by side, and it is a natural and common mistake 
to class them together and dig only one trench for 
carrying off the sink slop and bringing in the water- 
pipe; but this penny-wise policy should be avoided, 200 
Hand-Book for Hospitals. 
and each set of pipes should be firmly and carefully 
laid in its own bed. Only rain-water filtered should 
ever be used in these little cottages for drinking and 
cooking, unless there is a town supply of undoubt- 
edly pure water. Storage tanks for drinking-water 
must never be lined with lead or zinc or galvanized 
iron. Planished tinned copper is best, and they 
must be kept covered. Seven and a half gallons of 
water for each person, each day, is the least quantity 
that will answer. This does not include full baths 
and water-closets. 
Water-closets and sinks must be cut off from 
the sick-wards by a passage-way with windows and 
swing doors, so that there may be no chance for the 
contamination of air, and there should be as little and 
as thorough plumbing work as possible. Every un- 
necessary foot of lead pipe in a house is an added 
danger to be avoided. 
Cellars must be looked after.—The risk of se- 
vere and sudden illness often lurks in country cel- 
lars. Darkness in itself is one source of pollution. 
Have plenty of cellar windows ; lay a floor with a 
coating of Neuchatel asphalt over concrete. White- 
wash the walls frequently. Keep the drain pipe, if 
there is one, in full sight, hung along the wall. If a 
furnace is wanted, choose a good one, with a large 
evaporating pan for water, and provide a large tight 
metal shaft as air-feeder, drawing air from a little 
above the ground-level. Allow nowhere in the cel- 
lar or outside of it any decaying or combustible 
rubbish. If the wards are built on purpose for 
hospital uses, there must be no closed cellar under Village Hospitals. 
201 
them ; they should stand on piers or open arches, 
with doors or shutters which can be closed in cold 
weather only. The cellar for vegetables, etc., should 
be under the service building. 
Space in the household department should be 
wisely divided for the sake of saving labor. The 
kitchen and pantries may be necessarily within the 
house, but should be kept as sweet and clean as can 
be. The laundry with its slops and its risks of in- 
fection must be in an outer shed. Stuffy closets, 
dark corners, crooked entries, should not exist. 
Everywhere there should be light and freshness, and 
simplicity of plan. The places where garbage and 
refuse-pails stand must be daily attended to, and 
dryness, sunlight, and ventilation secured. There 
should never be a closed cupboard under the kitchen 
sink, and garbage-cans must be of metal, and kept 
constantly scrubbed. Ashes must be sifted for privy 
use, and wood-ashes carefully saved for making soap 
and cleaning floors. 
Packing the rooms of a house too close together 
impedes ventilation. Every room has six sides : its 
four walls, its top, and its bottom. If a sick-ward is 
closely surrounded with a room below and rooms 
above and on two sides of it, the air it draws in must 
be, to a considerable extent, impure ; it will be air 
already breathed by somebody. Hence, the sick- 
ward should be detached on as many sides as possi- 
ble, and put as far off as convenience and economy 
of administration admit, from the ordinary living- 
rooms of the household. This may be done by an 
airy, well-lighted corridor or passage-way. Hand-Book for Hospitals. 
202 
Air and sunshine.—A sick-room should have the 
sun on it all day ; the windows therefore should look 
out on the southeast and southwest. A bow win- 
dow which may secure every ray of winter sun is an 
easy and valuable addition to any room which has 
the right exposure. The windows should let down 
easily from the top, and such openings can be pro- 
tected by wire gauze fixed permanently in the top 
of the window-frame. Other simple ventilating de- 
vices are described in the chapter on Air-Supply. 
No apparatus will do so much good at so little cost 
as a window board ; a piece of stout plank as long as 
the width of the window and six or eight inches 
broad. Raise the lower sash, insert the plank on 
edge, peg it at the ends to prevent rattling, and shut 
the sash down on it. The air enters at the point 
where the sashes overlap. If the window has double 
sashes in winter, the protection from cold is better, 
the air has a longer passage between the glasses, and 
can enter the room with the chill off, at the top in- 
stead of the middle of the window, and no board is 
needed. All four sashes of double windows should 
be movable. 
In plastering a ward all the angles may be 
rounded with very little added expense ; it helps 
cleanliness and the sweep of the air currents. All 
wood-work must be kept flat and plain, without 
grooves or mouldings. Care in arranging such de- 
tails when a room is fitted up wrill lessen the accu- 
mulation of dust and the labor of removing it. 
The first step should be to scrape off all the old 
wall-paper if there is any. Painted hard walls and Village Hospitals. 
203 
ceilings are the best for a small, inexpensive village 
hospital. 
The size of a ward should allow at least one 
hundred square feet of floor space, and fifteen hun- 
dred cubic feet of air space for each bed in it; the 
allowance ought not to fall below this if possible. 
Small rooms require greater air-supply in proportion 
than large ones. In dwelling-houses altered into 
hospitals the ceilings would probably be low, and 
this fact should be considered, and extra air-inlets 
arranged so as to keep up the average supply of 
fresh air required. Every person in a room uses, 
and renders unfit for further use, thirty-five hundred 
cubic feet of fresh air per hour; and every light, 
certainly every gas-light, kept burning, is equal to 
six more people. 
The heating of a small building is a simple mat- 
ter. There can be no excuse for doing without the 
advantages of open fires. The rooms chosen for the 
sick must be the ones, if there are such, that have 
open chimneys. Air-tights for wood or base-burning 
coal stoves may be used in the living-rooms, though 
soapstone stoves, either open or closed, are greatly 
preferable. All stoves should have shallow evapo- 
rating pans of water standing on them, and closed 
stoves must have air-jackets. An air-jacket is a 
sheet of tin or galvanized iron bent round the stove, 
and securely fastened to the floor, and with a 
space of five or six inches between stove and 
jacket. A door can be cut in the jacket to cor- 
respond with the stove door, and so permit making 
the fire and brushing up. A good-sized pipe, as 204 
Hand-Book for Hospitals. 
large as space allows, is laid above or between the 
floorings ; one mouth opens within the jacket, be- 
hind the stove, and the other end is carried through 
the wall out-of-doors. A wire gauze protects the 
mouth ; and a valve in the pipe, to regulate the 
draught, may be worked by a handle within the 
room. This pipe brings in fresh air, which is warmed 
between the jacket and the stove and pours up into 
the room. 
Air inlets.—If the smoke-pipe of the stove runs up 
in the room and enters the chimney toward the ceil- 
ing, the fresh-air tube brought in through the wall 
may be widened enough to make an outer casing for 
the smoke-pipe, instead of the stove itself having 
the jacket. The casing-pipe must stop before reach- 
ing the ceiling, and let the air warmed between the 
two pipes out into the room. A flaring edge or lip at 
the top of the air-pipe will help scatter the air with- 
out draught. This double-pipe arrangement is a 
good one, where there is an open Franklin stove 
with vertical stove-pipe. 
Air outlets.—Devices for letting fresh air in are 
more easily provided than ways of getting foul air 
out, unless there is an open fire. The best use to make 
of the heat of a long stove-pipe, if the stove must 
be a closed one, is to let the pipe warm an 
extraction flue for foul air. To do this encase the 
smoke-pipe in the room by another pipe, two inches 
larger all round. The outside pipe must reach 
down nearly to the floor and flare open at the 
mouth, standing on short legs, and braced if nec- 
essary by wires. The upper end should run with Village Hospitals. 
205 
the smoke-pipe, out-of-doors. The inner smoke-flue 
warms the space about it, and thus creates a current, 
and the foul air near the floor is sucked in and car- 
ried off. Any brick chimney running up through a 
room or passage-way, without a fireplace, but warmed 
by an adjoining flue, or by some stove-pipe entering 
it high up, may be made to lend its help in aid of 
good ventilation, a register being inserted in the 
chimney near the floor to carry off foul air. In all 
ventilating arrangements, the openings for bringing 
fresh air in and letting foul air out ought to be at 
different levels in the room, the one high up, the 
other low down, and on opposite sides, if possible. 
Two stories.—Where both men and women pa- 
tients are lodged in a two-story cottage, the men 
should take the lower rooms and the women the 
second floor. In the case of convalescents it would 
be wise to have a separate hour for meals, or else 
serve the sexes apart. The staircase should be 
strong, safe, and wide, allowing a litter to pass 
easily and make the turns. The need of an upper 
piazza, well supported and well railed, for the 
women’s use, must not be overlooked. Even a 
blind patient may be trusted on such a piazza for 
the measured walk up and down in the open air. 
There must be some provision made for the chance 
of fire. A Babcock or other fire extinguisher should 
be kept in a convenient place and tested now and 
then to see that it is in order for instant use. If 
this apparatus cannot be had, water-buckets should 
stand filled and ready. 
The first case of measles, erysipelas, or other 206 
Hand-Book for Hospitals. 
communicable disease, no matter how occasioned, 
will put a little hospital and its management to the 
test; so will the first death. The committee must 
think out and plan out in advance, when they first 
arrange the building, just what will be needed and 
what must be done in such emergency. An empty, 
tidy barn has sometimes served a good purpose, 
fitted up as an isolation ward for a chance infectious 
case occurring on the premises. A simple, outside 
hut, or in summer a tent, where there are grounds 
enough, should be provided, if possible, for this 
purpose. But if not, the room chosen should be an 
upper, attic room, remote from servants’ quarters, 
well aired, with no connection by door, stove-hole, or 
air-flue with any other room. It should have an 
open, bricked fireplace, and a light wood fire should 
burn, summer or winter, whenever the room is used. 
No carpets, trunks, or stuffed furniture should be 
allowed in it. They only cause trouble and risk. 
If already exposed to infection such articles must 
be left standing, and disinfected with the room at 
the close of the case. More particular instructions 
for this are given under the head of Disinfection. 
Working force.—For a little house with six or 
even eight beds, a matron who is also nurse, an 
assistant nurse who takes turns with her, one woman 
servant, and a man from outside once or twice a day 
for the rough work has been found a sufficient 
force. At times when most of the beds are full and 
there is a heavy wash and extra cleaning, a second 
servant would be required. But the lady managers 
need to be constant and conscientious in their own Village Hospitals. 
207 
attendance, purchasing the supplies, following up 
applications, and carrying on all the little incidental 
business of the house. A large share of moral 
enthusiasm is needed to run even a little hospital. 
The matron should be a salaried officer. The plan 
sometimes pursued of paying the matron so much 
per head for board of patients may save the com- 
mittee trouble, but is very undesirable, no matter 
how good a woman may be in charge. 
The expense of fitting up and maintaining a 
cottage hospital will vary with the locality and with 
the ideas of the founders. At Pittsfield, Mass., a 
rented building with rooms for eight beds was used 
for three years, when a new hospital connected by 
corridors and intended for thirteen beds was built 
on the adjoining ground. This new house includ- 
ing steam apparatus and the lot, cost $9,500. 
During the year 1882 there were sixty-six patients 
cared for, and the current expenses were $2,572.48. 
From paying patients $468 were received. This 
hospital is supported by current contributions 
mainly, from all denominations, Roman Catholics 
and Jews included. Women have wisely conducted 
its affairs from the beginning, under the gratuitous 
advice of a good lawyer, and resolved when plan- 
ning it to aim first at two things—good plumbing 
and an open fireplace in every room, an example 
worth following. The Sheltering Arms, Norwich, 
Conn., furnishes an excellent model of system, 
economy, and success in management. In New 
York, the Highland Hospital at Matteawan is a 
very good and useful little cottage hospital, with 208 
Hand-Book for Hospitals. 
a partially detached ward for men’s surgical cases; 
and other cottages elsewhere might be mentioned. 
Good building plans, which with some modica- 
tions may well be adopted, will be found in Circular 
No. io of the Surgeon-General’s office, U. S. A.1 
The buildings of the Nursery and Child’s Hospital, 
Staten Island, suggest very pretty elevations. 
1 In the library of the State Charities Aid Association, with other 
plans and suggestions available for correspondents. XII. 
Disinfection. 
It has been said in previous pages of this hand- 
book that dust in a hospital is not merely dirt, it is 
danger. Dust in hospital wards contains organic 
debris of all kinds; minute particles of animal 
matter thrown out from the lungs or bodies of the 
sick. Such particles float in the air currents and 
lodge wherever dirt of any kind finds lodgment. 
Dust and disease.—Scientific experiments made 
in Paris and elsewhere, have shown that the propor- 
tion of animal impurities in the dust swept up from 
badly cleansed hospital wards, averaged forty per 
cent.1 When burned this matter gave off a fetid 
odor like burnt horn, and as it decomposed became 
very offensive. Hospital clothing, bandages, and 
bedding always take up and retain filth and infection 
from wounds and unhealthy excretions of all kinds; 
and so do most basins, pans, and ward utensils. 
Where there are cases of foul suppurative disease, 
still more if infectious cases are present, generating 
and disseminating known infectious particles, the 
harmful power of the impurities thrown off into the 
air is greatly increased. But all products of hospital 
foulness, even the least odorous of such products, 
‘See Parkes’“ Hygiene ” ; also “Fragments of Science”: John 
Tyndall, F.R.S. 210 
Hand-Book for Hospitals. 
must be regarded and treated as poisons. When 
we are dealing with gunpowder, some one says, we 
do not content ourselves with keeping the majority 
of sparks out of the magazine; we do not let a 
single one enter. Disinfection means the quenching 
of just such sparks ; as applied in hospitals it is the 
science of destroying all hospital poisons. 
Prevention better than disinfection.—It would 
be well if there were in every hospital a special 
officer who should undertake the whole business both 
of ventilation and of scientific disinfection in all its 
details; but as this is not usual, the superintendent 
or matron will certainly be responsible for part of 
these duties. Disinfection is a complicated problem. 
It is not a magic art, performed with the aid of a 
small bit or a saucerful of some substance which 
removes all evils at once. There are many evils, in 
various conditions, and each must be attacked in 
the appropriate way. People must use their reason. 
This or that process must be employed according 
as we have to do with impure air, or sewage, or 
other solid or liquid filth, or foul rooms and walls 
and floors, or clothing, or utensils which have re- 
ceived deposits of infected dust, or have come in 
contact in any way with the products of disease. 
But prevention is better than disinfection. If sim- 
plicity of plan throughout the building, and smooth- 
ness of forms and surfaces are studied, and thus as 
little chance as possible given for the accumulation 
of harmful matter; if a part of the inevitable dirt 
is swept out by the air currents, and another portion 
1 Robert Angus Smith, F.R.S. Disinfection. 
is dislodged and taken away by the most fastidious 
cleanliness, there will be fewer occasions for resorting 
to chemical disinfection in hospitals. 
Simplicity in details.—Every item in the con- 
struction of a hospital, whether in the building or in 
its fixtures and utensils, has its significance; all the 
minutiae of personal oversight, their value. The 
flat, plain wood-work, the hard-finished walls, the 
well-joined floors free from cracks and chips, the 
polished tiles, the glass basins, the smooth, round 
flues, are all of sanitary importance. So are the 
washable gowns of the nurses, the washable furni- 
ture, and the linen instead of worsted screen-covers, 
and other details; because the fewer rough and 
angular and fuzzy surfaces, the fewer poke-holes 
there are, any one of which may be a nidus for in- 
fection, the better. Where there are plumbing fix- 
tures, it is obvious that they must be of the best 
pattern and kept scrupulously clean and in repair. 
Iron waste-pipes and traps, well ventilated and with 
abundant water-supply, are among the first essen- 
tials. 
Whatever is clean needs no disinfection ; but 
where filth is allowed to collect, decomposition is 
likely to occur ; and it has been often found that the 
older a putrefaction is, the more powerful must be 
the disinfecting agent applied. In some cases the 
particular chemical chosen becomes inappropriate 
under the changed conditions, and a different 
process must be used. New products are given off 
by putrifying substances which are not so easily 
disinfected or destroyed as the original substance, Hand-Book for Hospitals. 
212 
and which are sometimes very volatile and ex- 
tremely poisonous. For example, in neglected 
drains and cesspools, ferments start up which are 
dangerous and difficult to deal with. When the 
task was attempted, not long ago, of freeing the old 
surgical wards of Bellevue Hospital from the taint 
of pyaemia,—wards the cracks of whose walls and 
floors were filled with the filth of years,—it required 
the services of a professor of chemistry and the use 
of two or three tons of chlorine gas to produce 
an effect of even transitory value. The inference 
which visitors would do well to heed, is in favor of 
unremitting, every-day cleanliness. 
The preventive part which ventilation plays 
will be better understood if we remember that the 
buoying power of a liquid or a gas increases with its 
velocity in such a rapid geometric ratio, that while 
a water current of one foot velocity per second 
will float a grain of sand, a current of two feet per 
second will float a pebble sixty-four times as heavy. 
If we follow this reasoning backward, we can realize 
that the buoyancy of matter increases with the 
diminution of the size of its particles, in an equally 
rapid ratio. There are particles of a dangerous 
character yet so minute as to be invisible, or only 
visible as motes in a sunbeam ; and so light as never 
to settle except in an absolutely still atmosphere. 
Consequently, if they do not find a lodging-place in 
cracks, or on moist and fuzzy surfaces, or in the 
throats, eyes, nostrils, and pores of patients, they 
will follow the air currents wherever these currents 
lead ; whether outward through flues or windows, Disinfection. 
213 
upward by chimney draughts, or through doors and 
crevices leading to warmer rooms. Impure air left 
dark or motionless, especially if it is also damp or 
heated air, will breed impurity, as impure, stagnant 
water does. But air vitalized by light and motion 
will act upon and in a measure oxidize the harmful 
particles it contains, and thus tend to purify itself. 
This is the secret of sunshine and fresh air used as 
disinfectants. A gale of wind may be better than 
a hogshead of carbolic acid, and it is possible to 
imagine that a steam-engine and a ventilating fan 
might be used to fight an epidemic. Every part of 
a hospital ward at some time during the day should 
be flooded with sunshine; and a constant, steady, 
searching, and thorough out-draft from the ward, its 
bath-rooms, water-closets, and other offices, should 
be ensured. 
Where there are infectious cases the out-draft 
should be so powerful and in such a direction that 
under no circumstance should air from the sick-room 
move toward other rooms or stories in the same 
building. For such cases a room should be selected 
with wide, open hearth and chimney-throat, and a 
brisk fire should be kept burning in summer as well 
as in winter so as to determine the direction of the 
out-draft. The ordinary rule must be observed of 
putting the beds of patients ill with communicable 
disease in such position, if practicable, that physi- 
cians and attendants may stand to windward. Per- 
sons who come into a ward where there are 
infectious cases with their hair, beards, or cloth 
clothing damp with fog or rain, or who, coming from 214 
Hand-Book for Hospitals. 
out-of-doors in very cold weather, condense on their 
cloth garments the warm air of the room, may offer 
a lodging-place to floating infectious matter and carry 
it about, unconsciously to themselves, wherever they 
go.1 Professor Pumpelly suggests a hooded gown of 
smooth material to be worn in the room over the 
ordinary clothing of the physician ; and the National 
Health Society of London has lately exhibited such 
a dress—a hooded overall or mackintosh, glazed 
inside and out, and exposing only the face and 
hands. A similar garment is in use among New 
York physicians. 
Other preventive measures which will lessen 
risk and labor for all concerned are the instant isola- 
tion of suspected cases and of nurses who attend 
them, and the burning of foul bedding and bandages 
used for exceptionally hazardous cases. Do not dis- 
infect such articles; destroy them. No ordinary 
process of disinfection makes it safe to use them 
again. They should be tightly wrapped in tarred 
paper, carried instantly outside the hospital and 
burned without handling, in a pit provided for such 
purposes. The expense to the hospital of renewing 
bedding and bandages must not be weighed against 
the costly risk of communicating disease. 
The various preventive measures urged are the 
more important because the trouble attending the 
effective use of disinfectants is so great, there is 
often difficulty in getting trustworthy, pure chemi- 
cals, and the quantities required are sometimes very 
large. The pungent odor of some disinfectants is 
1 Professor Raphael Pumpelly. Disinfection. 
215 
misleading; persons are apt to err in regard to the 
quantity that may be relied on, and use too little. 
It should be remembered that deodorizers, or sub- 
stances which destroy bad smells, do not of necessity 
destroy the foul cause of the smell. Some disinfec- 
tants on the other hand have no odor. Some fluids 
will preserve articles immersed in them, but are not 
disinfecting agents ; notably alcohol which may pre- 
vent decomposition, but has little effect in arresting 
putrefaction when it has once commenced. Disin- 
fectants to be of practical value ought to work 
swiftly; the more rapidly they work the better. 
The inconvenience, to say the least, of having to 
resort to any agent or any process which requires 
twenty-four hours for its thorough working, is 
obvious. All disinfectants are themselves poisonous 
in large quantities, as are many medicines. It is 
difficult to use enough of any chemical to destroy 
infective matter without also risking life and injuring 
property. 
Disinfecting agents for which no chemical can ever 
prove an efficient substitute are : 
Draughts of air for all floating foulness ; 
Damp and dry rubbing for all easily detached 
foulness; 
Soap-and-water scrubbing for all adherent foulness.1 
Experiments in Germany, recently conducted 
under authority of the Imperial Board of Health,2 
to determine the best disinfectant for practical 
1 Dr. E. M. Hunt. 
s Robert Koch : “ Mittheilungen aus dem Kaiserlichen Gesundheit- 
samt,” Ier Band, Berlin, 1881. 216 
Hand-Book for Hospitals. 
use, result in showing that chlorine, bromine,1 and 
bichloride of mercury are the only certain disinfect- 
ants. These investigations, made by Dr. Koch, the 
distinguished mycologist, show that what science 
calls the germs or spores of micro-organisms resist 
the action of many agents which we have been 
accustomed to regard as effective. The difficulty 
increases with the extent to which these spores have 
been dessicated. Thus it appears that Koch no 
longer considers sulphurous acid as a good disinfect- 
ant, inasmuch as the strength and conditions essen- 
tial to its useful working are too extreme; that 
five-per-cent, solution of sulphate of iron, and five- 
per-cent. solution of chloride of zinc (Burnett’s fluid) 
are without action upon spores during an exposure 
of many days ; that chloride of lime in five-per-cent, 
solution requires several days to destroy spores 
certainly ; and permanganate of potash (Condy’s 
fluid), in a solution of like strength, a number 
of hours ; that carbolic acid in oil or alcohol has no 
value whatever as a disinfectant, and in water must 
be present to the amount of five per cent, and must 
be allowed to act for at least forty-eight hours to 
insure the full effect; that freshly prepared chlorine 
water or iodine water should remain in contact with 
the material to be disinfected for a length of time 
measured by hours rather than minutes ; but that 
bichloride of mercury (corrosive sublimate), is the 
most powerful agent at our disposal for disinfecting 
purposes, and when present in water in proportions 
/ Bromine is no longer recommended as a disinfectant, but as a 
deodorant cuN. by the Health Department of the City of New 
York. (See p. sol.)—Eds. Third Edition. Disinfection. 
varying from one part in four hundred to one part 
in a thousand is quickly and certainly destructive to 
all spores. 
Hospital visitors, however, should not be too 
hasty in adopting new theories solely because they 
are new. When we boast of the wonderful progress 
of the nineteenth century, we may temper our pride 
with the reflection that our National Board of 
Health, in its most recent researches in the science 
of disinfection, finds nothing better to recommend 
than the methods of Ulysses.1 
“ To Euryclea then addressed the king: 
‘ Bring hither fire, and hither sulphur bring’; 
With fire and sulphur, cure of noxious fumes, 
He purged the walls and blood-polluted rooms.” 
Fumigation of wards.—Every ward in a hospital, 
in turn, irrespective of the character of the cases it 
has contained, should be, at least once a year 
cleared, closed, fumigated with sulphur, and then 
thoroughly cleaned, whitewashed, and scoured. 
Empty the ward. Turn out every movable thing 
likely to be injured. If the iron bedsteads can be 
spared, let them stand with beds and bedding in the 
room during the fumigation. Furniture, beds, and 
bedding must all stay if they have been exposed to 
infection.2 If there are unpainted metal objects left 
in the room, coat them with grease ; sulphur fumes 
will corrode unprotected metals. Woven-wire beds 
must be carried out and cleansed by strong hot soap- 
1 Odyssey, book xxii. 
2 The exposure of beds and bedding to very hot dry air, where the 
proper appliances can be had, is efficacious. See Appendix F.—Eds, 
Third Edition. 218 
Hand-Book for Hospitals. 
suds, or by playing a hose on them out-of-doors, 
and dried quickly in the sun. If the wards have 
inside shutters, let them stay. Paste over with strips 
of paper all crevices and keyholes. Clean out and 
close all registers and air-flues and paste paper over 
them. Stuff the chimneys. Break up roll sulphur 
in lumps, putting it in coal scuttles or other iron 
pans, and set these in the corners as well as in the 
middle of the room, raised on bricks. The bricks 
should stand in any large vessel or tub which can 
hold a little water, or dry sand. This is a precaution 
against fire. 
As moisture increases the action of the fumes, the 
floors and walls of a ward should be thoroughly 
sprinkled and dashed with water. If the hospital 
has steam apparatus, the best way is to let steam 
escape into the room until the condensed moisture 
dampens the ceiling and trickles down the walls. A 
little trouble will make a temporary connection with 
the nearest heater or wall-coil for this purpose. 
When all is ready, set the sulphur on fire by hot 
coals, or by pouring on a little alcohol and firing it. 
In a large ward two or three persons must assist, in 
order that the igniting may be quickly done. Leave 
the room instantly, for the gas liberated is very 
irritating to the lungs. Keep the doors locked and 
leave the room standing closed for twenty-four 
hours. Then open all the windows wide to get rid of 
the stale fumes, opening them from the outside if 
practicable; and, still keeping the doors locked, 
leave the room standing for twenty-four hours more. 
If the fire has gone out without consuming all the Disinfection. 
219 
sulphur, relight it and close the room again. It will 
burn as long as there is oxygen to feed the fire. 
Thorough scouring.—Now is the time for stop- 
ping cracks in the plaster, wood-work, and cement, 
if there are any repairs needed ; after the fumiga- 
tion, not before. If you stop the cracks before you 
fumigate you shut in what germs of disease there 
may be, instead of driving them out and killing 
them. Then scour thoroughly everywhere, with hot 
soapsuds made of soft soap ; or else dry rub and then 
whitewash the ceiling as well as walls. Kalsomin- 
ing the ceiling is objectionable on account of the 
sizing used in the mixture, and because kalsomining 
is more expensive than whitewashing, and therefore, 
less apt to be frequently repeated. Cleansing the ceil- 
ing is a most important point. Scour the bedsteads 
all thoroughly with hot soapsuds and wipe them 
dry. Wash down also every other piece of furniture 
that will not be injured by washing, and set all back 
in their places. See that the ward is dry and that 
the ward thermometer marks 68° or yo°, before it is 
reoccupied. 
This process will take certainly three days for each 
ward. It should be put in effect at once, in any 
room or ward after any accidental case of infectious 
disease, or of malignant fever. The virtue of 
sulphurous acid gas is in arresting putrefaction in 
animal matters. The fumigation with sulphur, there- 
fore to be effective must be instantly applied, and 
at frequent intervals. In the case of a compactly 
built hospital of several stories, it is very desirable 
that the surgical wards should be put through this Hand-Book for Hospitals. 
220 
process at least once in six months. Every ward 
should go through it at least once a year; every 
isolating room at the close of every case. 
As a rule, whenever fumigation is practised, by 
whatever agent, the washing and dry rubbing of all 
exposed substances and surfaces should follow. 
Sulphur, it must be remembered, will bleach colored 
fabrics and will make the lime flake off on white- 
washed walls. The quantity of roll sulphur required 
for effectual fumigation depends on the cubic air- 
space of the ward. Use about three pounds for each 
thousand cubic feet of space. 
Chlorine gas may be used for fumigation in a 
large hospital where wards are impregnated with 
pyaemia, but only in immense volumes and always 
under the direction of an experienced chemist fa- 
miliar with its use. The method already described 
of closing cracks, pasting up outlets, and locking 
doors, and of cleansing afterward, must be followed. 
The process of setting free the gas creates heat, and 
heat helps the diffusion. Moisture also is an ad- 
vantage. The same dampening of the ward with 
water or steam should accompany the fumigation. 
Large shallow troughs of sheet lead, which can be 
rolled up and stored for use again, should be put on 
the floor to hold the mixture, and on mantle-shelves 
and other high ledges, for chlorine gas is heavy and 
will descend. The chemicals required, and their 
proportions as used by Professor Doremus at Belle- 
vue, are a sack of salt, or between two and three 
hundred pounds, about an equal weight of black 
oxide of manganese, and a carboy of sulphuric acid. Disinfection. 
221 
Like sulphur fumes, chlorine gas will bleach colors, 
will corrode metals, and is an irritating poison ex- 
tremely dangerous to breathe. 
Stained clothing and towels may be bleached and 
cleansed by throwing them for a minute or two into 
boiling water in which two ounces of chloride of 
lime to the gallon have been dissolved. The articles 
should be rinsed immediately in a solution of hypo- 
sulphite of soda, which destroys the residual chlorine 
and leaves the articles white and free from chlorine 
odor.1 The combination is sold in the shops in solu- 
tion as chlorinated soda, or Labarraque’s fluid. Or- 
dinary washing with soap and hot water should 
follow the bleaching at once. Corrosive sublimate 
or a strong solution of arsenic may be used to kill 
body vermin, but it is better to burn verminous 
clothes. The importance of grass bleaching, wind, 
and sunshine for disinfecting and drying ordinary 
hospital linen must be borne in mind. 
Dry heat and steaming.—There are three pro- 
cesses, either of which may be followed, according as 
the outfit of the laundry may allow, for disinfecting 
articles which cannot be washed, such as mattresses, 
pillows, outer cloth clothing, hats, dresses, and shoes. 
Articles of this kind which have come in contact 
with erysipelas or other infectious disease, if not 
destroyed, must be baked, steamed, or fumigated. 
For baking they must be put into the disinfecting 
chest mentioned among the laundry apparatus, and 
heated to 212° Fahrenheit, and kept as near that 
heat as possible for eight hours, and afterward 
1 Dr. Wolcott Gibbs, Harvard University. 222 
Hand-Book for Hospitals. 
sunned and aired. This degree of heat does not in- 
jure such fabrics as are commonly used for clothing. 
Or superheated steam charged, if desired, with chlo- 
rine may be used in the chest for steaming the articles 
described ; or they may be left in a closed ward, or 
room, while the room is fumigated; mattresses and 
pillows in that case being ripped open, the hair and 
feathers emptied and spread, and pockets in garments 
turned inside out. 
In all processes of disinfection by heat it must be 
borne in mind that some disease germs withstand a 
high degree of dry heat, their virulence having 
in some instances been found to survive a baking at 
over 300° Fahrenheit. It must be also understood 
that in boiling a large vat full of water and articles 
of clothing, the inside of the parcel may be below 
boiling-point long after the water is boiling. For 
this reason, but few pieces should be put in at a time, 
and they should be well poked about and stirred. 
In baking, i. e., disinfecting by dry heat, mattresses 
and bundles of clothing, the danger is greater that 
the interior will remain at too low a temperature 
even after the outside has become very hot. Mat- 
tresses and pillows, therefore, which have been made 
safe to handle by the baking process, must be after- 
ward ripped, emptied, the hair or feathers disin- 
fected anew, and sacks washed and refilled. 
Expectorations, excretions, and discharges from 
infectious cases must be received into vessels contain- 
ing fluid disinfectant, either solution of bichloride 
or Milk of Lime (see appendix F) or whatever the 
attending physician may order ; and foul handker- Disinfection. 
223 
chiefs and cloths, and scales shed from patients’ skin, 
must be immediately destroyed by burning when- 
ever practicable. Rubbing the patient with vaseline 
in certain cases will prevent the scattering of infec- 
tious particles. Plates, cups, glasses, spoons, and the 
like, used for communicable cases, must be rinsed with 
some safe disinfectant and washed separately. With 
any pestilent contagion care should be taken to keep 
a covered tub in the patient’s room, containing a 
solution of carbolic acid, (see appendix F). Bed 
linen, towels, clothing, and handkerchiefs should 
soak in this fluid for an hour. The tub and its 
contents may then be carried to the laundry and a 
second tub substituted. Wooden tubs which can 
afterward be broken up and burned are best. Wash- 
ing the hair of the patient with strong soapsuds and 
borax is a necessary precaution. 
Special hospitals.—All the precautions and 
methods recommended in this chapter as required 
with chance cases of infectious disease in general 
hospitals are equally applicable in hospitals especially 
intended for infectious cases, scarlet fever, diph- 
theria, and the like, or in maternity wards where 
puerperal fever occurs. 
Instrument boxes and the stock of surgical ap- 
pliances should be periodically aired and cleansed. 
It is a bad plan to keep splints, pads, and other such 
articles in any dark, unventilated place. Instru- 
ments likely to be needed for an operation should 
be laid, just before the time, in shallow block-tin or 
iron pans and covered with a five-per-cent, solution 
of carbolic acid. After use each instrument should 224 
Hand-Book for Hospitals. 
be handed to the nurse in attendance, who should 
wash it and lay it back in the solution.1 When an 
operation is over all instruments must of course be 
cleansed and thoroughly disinfected. Tyndall, in 
his experiments with vapors decomposed by light, 
found great difficulty in securing perfectly clean 
tubes. He speaks of surgical risks, and instances the 
case of a canula and trocar which is used for the 
evacuation of an abscess. It is difficult, he says, to 
see how the instrument can be cleansed by ordinary 
methods; it ought, in fact, to be made as hot as its 
temper will bear. But this is not done, and inflam- 
mation in a wound sometimes sets in as the result 
of careless and imperfect cleansing. 
Catheters, syringes, scissors, and all instru- 
ments which are in common use in a hospital ward, 
and under the ward nurse’s care, must be kept abso- 
lutely clean. To this end they must lie, after using, 
in an aqueous solution of carbolic acid, following 
the doctor’s directions as to the strength; and then 
must be carefully rinsed and dried ; or they may 
be dipped for a few minutes in a solution of bichlo- 
ride of mercury, rinsed, and passed and held in the 
flame of an alcohol lamp. Dangerous particles ad- 
here to all such instruments and often slip under the 
nurse’s or operator’s finger-nails, and unless dislodged 
and destroyed, may cause blood-poisoning in the 
next patient treated. Dried blood may be found 
on the corrugated handles of instruments and about 
the joints of scissors which have been cleaned more 
1 Boiling instruments in a 2 % solution of washing soda and allow- 
ing them to cool in the same is better.—Eds. Third Edition. Disinfection. 
225 
than once by ordinary methods. Scissor and other 
joints should work on an adjustable pivot instead of 
screw. The parts can then be separated more 
readily for more perfect cleansing. Sponges in 
surgical cases should never be used more than once. 
The only way to clean a sponge is to burn it. 
For hand-washing of doctors and nurses, car- 
bolic solution of five-per-cent, strength,1 one part of 
acid to twenty of water, should be kept ready bottled 
in quantity. A nail brush is indispensable. The 
National and New York State Boards of Health 
omit carbolic acid from their list of household dis- 
infectants on the ground of its cost and the diffi- 
culty of getting it pure, and the danger that from 
its strong odor it will occasion a false sense of se- 
curity with those who use it. Many scientific ex- 
perimenters have no faith whatever in its disinfectant 
properties. As yet, however, no substitute for 
carbolic acid for the uses above indicated has been 
generally adopted in hospitals by medical men. 
Calvert’s No. 1 is the quality required, and solutions 
must be made with boiling water and well shaken. 
Koch asserts that carbolized oil has no more effect 
than pure olive oil. 
For water-closets, sinks, and all waste-pipes 
there are no better constant disinfectants than 
thorough ventilation, and an abundant flush, i. e., 
rush of water, together with daily scrubbing with 
hot water, soft soap, and a scrubbing brush of every 
part of the fixtures which can be reached. 
1 Apt to produce local anaesthesia when used at this strength (2 % 
solution is sufficient). —Eds. Third Edition. 226 
Hand-Book for Hospitals. 
Bichloride of mercury.—If pipes and traps are 
of iron, as they should be, flush them with hot suds 
of soft soap until the pipes become quite warm ; fol- 
low this with a solution of bichloride of mercury 
(corrosive sublimate). A strength of one part of the 
drug to four hundred parts of water, or, say, thirty- 
eight grains to a quart, is preferable for disinfecting 
vessels and pipes in cases of a choleraic or typhoid 
nature, where it is necessary to render the dejecta 
instantly and absolutely harmless. A strength of 
one part to one thousand parts, or say fifteen grains 
to a quart, will disinfect most articles well drenched 
with it in the course of ten minutes. In preparing 
the solution the drug should be first boiled in a little 
water and with twice its own weight of common 
salt. It will then dissolve very quickly, and the so- 
lution so obtained may be diluted to any required 
extent. Bichloride of mercury cannot be used with 
lead pipes, or come in contact with brass or copper 
without injuring the surfaces ; it will not injure iron. 
As a small amount goes very far it is a cheap disin- 
fectant.1 It is a deadly poison, and its use must be 
guarded by all the customary precautions.2 
1 Dr. Wolcott Gibbs. 
2 Ward commodes, vessels, and other ward utensils, after having 
been used should be emptied at once and thoroughly cleaned with hot 
water and soap, and, if of a material which will endure heat, im- 
mersed in boiling water for from twenty minutes to a half-hour. In 
diseases, such as cholera, and others, in which contagion is communi- 
cated by the discharges from the intestinal tract, the vessels should, 
in addition to the above, be washed or cleaned with a solution of bi- 
chloride of mercury of the strength of i-iooo or 1-500.—Eds. Third 
Edition. Disinfection. 
227 
Cesspools must be kept drenched with bichloride 
solution1 freely poured through the house drains. 
Where the volume of sewage is large, and there is 
an overflow pipe, the stone slab or cover of the pool 
should be lifted off at frequent intervals, and enough 
chloride of lime or bichloride solution thrown down 
to alter immediately the entire contents of the pool, 
and so keep them harmless until they can be carted 
off. Otherwise part of the intended effect will be 
lost, for a certain proportion of any liquid disinfec- 
tant runs off by the overflow. When cesspools are 
emptied, after all the contents have been ladled out 
and carried away, chloride of lime in powder must 
be thrown to the bottom and freely dashed against 
the side walls. 
Drains and cesspools which receive laundry and 
kitchen slop, and the house pipes leading to them, 
must be treated in the same way. We cannot detect 
by appearance or odor or by chemical examination, 
any material difference between the contents of a 
cesspool filled with the decomposed discharges of a 
water-closet, and another filled with the decomposed 
discharges of a kitchen sink.2 Both are sources of 
danger ; both should be carefully watched, emptied, 
cleansed, and disinfected. 
Chloride of lime.—The volatile character of chlo- 
rine, and its rapid action in preventing harmful 
emanations, makes it a useful agent. Its most con- 
venient form for ordinary use is in chloride of lime. 
1 See appendix F, Disinfection and Disinfectants. Health Depart- 
ment of the City of New York, 1892.—Eds. Third Edition. 
2 Col. George E. Waring, Jr. 228 
Hand-Book for Hospitals. 
This is the best of all cheap disinfectants, but the 
odor is disagreeable to many, and the fumes are 
sometimes injurious. Offensive smells need not re- 
main a moment if we have this agent at hand. It 
may be used as a powder slightly moistened in privies, 
in refuse-pails, on solid or liquid impurities; or may 
be dissolved in water for such uses in the proportion 
of one ounce to one quart. It should be used when 
fresh, the test of strength being its continued odor, 
and in quantities sufficient to cover the bulk it is 
intended to disinfect. It injures iron pipes, and will 
act on lead pipes when it stands in them ; if passed 
through drains, therefore, it must be followed at 
once by a free rinsing. 
Quick-lime as compared with chloride of lime is a 
weak disinfectant; it is not volatile, and cannot 
affect dangerous floating particles in the air, but it is 
cheap in most towns, and can therefore be used in 
large quantities. It should be stone lime, finely 
broken and fresh slaked, and should be closely 
spread over foul heaps of decaying refuse if such 
are ever tolerated, or used in damp places and neg- 
lected privies very freely. Where actual washing 
with soap and water is difficult or impossible, owing 
to the character of the surface, abundant lime-wash- 
ing is an excellent substitute. This will keep whole- 
some the corners of a house or of a cellar where 
light and sunshine do not reach. Calx powder, 
made by pounding one bushel of dry fresh charcoal 
and two bushels of stone lime and mixing them, is 
of use. These substances absorb foul gases, dry up 
moisture, and help to retard decomposition. Quick- Disinfection. 
229 
lime must not be used where it is likely to be washed 
into drain pipes, for it may harden in them and ob- 
struct them. 
Removal of sewage.—Mention has been made 
in the chapter on Drainage and Water Supply of 
the danger to be feared from leaching cesspools, 
neglected privies, and other sources of impurity, such 
as leaky drains and gas-pipes in the neighborhood of 
dwellings. The experiments of Max von Petten- 
kofer, Dr. Ogden Doremus, Professor Pumpelly, and 
others, show how far infection may travel, and the 
risk we run of poisoning both the air we breathe and 
the water we drink when the soil about a house is 
saturated with polluted moisture. Any system of 
storing up and retaining for any length of time, the 
decomposing filth of a household, in either tight or 
leaching cesspools, is full of danger, which the most 
copious use of disinfectants will not wholly obviate. 
Wherever there are sewers, good water-fixtures are 
best. Where there are no sewers, as in the case of 
isolated institutions, well-built privies for solid mat- 
ter, the tubs being removed and emptied at short 
intervals, combined with sub-surface irrigation for 
slop-water is, with our present knowledge of the 
subject, the least objectionable plan we can follow. 
The final disposal of sewage and its indirect puri- 
fication have been effected for more than one 
hundred and thirty towns in England, for the cities 
of Berlin, Breslau, and Dantzic, and for a portion of 
Paris, by its frequent and systematic removal to 
agricultural lands for fertilizing purposes. Recent 
and seemingly satisfactory microscopic experiments 230 
Hand-Book for Hospitals. 
have been made with the sewage of Paris on the fields 
of Gennevilliers, to note the changes which it under- 
goes in the soil. The increased and wonderful pro- 
f ductiveness of the land since the plan was put in 
force, has induced the villagers to withdraw all 
opposition, and join in a treaty with the Parisians by 
which the delivery of sewage at Gennevilliers is to 
continue for twelve years.1 
1 Address of M. Durand-Claye, at the International Congress of 
Hygiene, held in Geneva, September, 1882. XIII. 
Conclusion. 
In conclusion let us return for a moment to the 
object for which our hospital building, its corps of 
nurses, its outfit, its superintendence exist, and to 
which they should be so carefully adapted. 
What the hospital exists for.—Let no one for- 
get that this primary object is the curing of the 
sick. A hospital is not founded solely to provide a 
field for experiments and break in raw young medi- 
cal men to practice. It is not founded and sup- 
ported, or should not be, to furnish “ jobs,” to har- 
bor malingerers, or to make places for professional 
or political “ friends.” The great motive, at least 
from the hospital visitor’s point of view, is charity, 
but charity in a certain direction ; therefore a hos- 
pital should not become a mere almshouse or asylum 
for incurables; necessary as such public charities 
are, they are apart from the purposes of a hospital. 
The ambition, which sometimes exists, to over- 
crowd, to run up the numbers, and show at the 
month’s or year’s end a long list of admissions and 
consequently less average expense, or less average 
mortality, often blinds hospital authorities to the 
moral as well as the sanitary evils of such a course. 
This is a matter which visitors have a right to look 
into, and they should notice whether any of the Hand-Book for Hospitals. 
232 
inmates are more properly almshouse cases; or con- 
valescents who are unwisely detained ; or station- 
house cases, such as inebriates, making use of the 
institution as a temporary shelter to get over a fit 
of excess; or mere hospital “ rounders,” it may be, 
waiting “ until after the election.” 
Inspectors for the State.—But in all inspection, 
let visitors bear in mind that hasty observation and 
loose generalization are worthless. Criticism of any 
branch of hospital organization will be valuable only 
so far as it is founded on actual experience and 
study. Intelligent visitors will endeavor to learn 
the best methods of caring for the sick and insane 
and dependent classes practiced in this country and 
in Europe; they will inform themselves of the laws 
bearing upon such subjects ; they will read the best 
books and reports, and so far as theoretic study can 
be of use, will educate themselves for the respon- 
sible position they have assumed. They will not 
confine themselves to ministrations to individual 
'patients ; for while these have their place and are 
pleasant and acceptable to the sick, there is a 
broader duty laid upon the members of this Asso- 
ciation. They will remember that they enter insti- 
tutions of public charity as inspectors for the State,1 
and they will use the opportunity which frequent 
visiting gives to study intelligently not only details, 
but systems and the faults of systems. They will 
perceive that they cannot immediately and single- 
handed redress wrongs or work reform in matters 
1 See the Act printed in Appendix G (Chapter 635, Laws of 1893). 
■Eds. Third Edition. Conclusion. 
233 
which may have been gradually going awry for 
years; but they will accurately record facts and 
make report thereon to the proper officer of their 
committee, adding such recommendations as their 
close observation and experience ought to suggest. 
Dress parades.—In most public institutions there 
is apt to be a certain amount of “ getting ready for 
the committee.” Managers make their visits at 
fixed periods, once a week or once a month. Their 
coming is announced, at all events known ; the 
wards are scrubbed ; the ventilating fan is set going; 
the water-works are “ all right ” for the time; at- 
tendants are at their duty; clean quilts are spread 
over dirty sheets; rubbish is shoved into corners ; 
and the matron or superintendent is at the commit- 
tee’s elbow to divert attention from doubtful places 
and topics. At best it is a dress parade in which the 
managers are the inspecting officers. Visitors must 
not allow themselves to be misled by such a hasty 
smoothing over of things on the surface. Their 
visits, to be effective, besides being frequent and 
leisurely, should be made at irregular and unexpected 
times. 
Points to observe.—Visitors should note, if pos- 
sible, the original cost and current expenses of any 
institution, and consider in what items the money 
seems to be consumed; what is the quality of the 
supplies furnished ; what is the system of purchasing, 
storing, and issuing supplies ; how the labor of the 
household is organized ; whether the hospital ser- 
vice is properly graded, and the oversight and the 
discipline what they should be; whether there is a Hand-Book for Hospitals. 
234 
continuous chain of responsibility running through 
the entire establishment from the top to the bottom ; 
whether precautions are taken to keep the sexes 
separate; what safeguards are employed against 
fire; whether the use of disinfectants is understood 
and systematically practised by the superintendent 
and matron, and the isolation of nurses as well as 
patients during and after the infection is enforced ; 
whether religious rites are allowed for the sick, and 
decent burial provided for the dead. 
The superintendence.—Visitors should ascertain 
what salaries are paid ; whether these are extrava- 
gant, or are such as the officers deserve, or are inad- 
equate to command the best service. They should 
especially observe the character and tone of the 
superintendence, and whether the chief officer is a 
competent person. To keep a set of books and 
answer questions in the office is not the whole of 
management. The spirit in which the work is con- 
ducted is all-important. The superintendent gives 
tone to the institution, and the attendants will never 
be more faithful to the interests of the hospital or 
more considerate of the welfare of the patients than 
are their superior officers. 
What makes a good hospital.—Bricks and mor- 
tar will not make a good hospital; neither will half 
a million of money. The factors are: clean air, 
clean water, plenty of clean bedding and clothing, 
well-cooked food, enlightened medical care, trained 
nursing, and a pure and cheerful moral atmosphere; 
above all, and including all, skilled, honest, intelli- 
gent, humane superintendence. “ A large hospital Conclusion. 
235 
is a complicated organization which cannot be made 
to work automatically, but of which the several parts 
require constant adjustment and attention to pre- 
vent the production of some of the very evils which 
it is designed to remedy. If constant, skilled super- 
intendence is not made an essential and integral 
part, the cheaper and more easily destroyed the 
institution is, the better.” 1 
The mere statistics of the vast and shifting 
throngs of miserable beings who pass through our 
public hospitals and asylums, men, women, and little 
children, help us to judge how weighty are the 
public and humane interests involved, and how 
costly and often cruel and morally disastrous must 
be the management which in any considerable degree 
is ignorant, lax, or corrupt. The most recent report 
of the State Board of Charities, dated 1894, shows 
the number of poor persons supported in the seventy 
almshouses, poorhouses, and State hospitals during 
the past year, as .... io3>339 
Of whom were insane .... 21,961 
Those, besides, who received temporary 
relief. . 100,925 
Taking New York City alone, there were 
in Bellevue and the island institutions 
on a given day : 3 
Sick and disabled 12,282 
Of whom were insane .... 6,459 
The inmates of State institutions for deaf, dumb, 
1 Dr. J. S. Billings, U. S. A. 
2 Report of the Commissioners of Charities and Correction, Feb- 
ruary i, 1895. 236 
Hand-Book for' Hospitals. 
blind, and idiotic persons ; of refuges, reformatories, 
incorporated orphan asylums and homes throughout 
the State are not included. But there may properly 
be added to the above figures, the count of some of 
the incorporated hospitals and dispensaries. In 
one hundred and twenty hospitals and forty-nine 
dispensaries according to returns made to the 
State Board, there were treated during the year end- 
ing Sept. 30, 1894: 
Charity patients ..... 45,302 
Dispensary beneficiaries . . . 768,545 
Public charities a public trust.—It is our duty 
to learn as far as possible, whether all these inmates 
and applicants represent genuine cases of distress, 
and if so whether they receive the benefit of every 
alleviation known to science and humanity ; whether 
our immense public expenditures secure in all the 
cases requiring it, wise, skilful, and kindly care. The 
money which supports town, county, and State in- 
stitutions is money raised by taxation and held in 
stewardship, and every citizen is under obligation to 
inform himself whether it is spent judiciously, or in 
a thriftless and dishonest way. Public offices of 
charity are in a peculiar sense public trusts. “ To 
fill administrative positions in public charities as 
they are sometimes filled, for political considerations, 
or for qualifications other than those of competency 
and character, should curse any man or body of men 
who by so doing jeopardize the lives of their fellows.1 
Women as inspectors and managers.—In many 
European cities women are considered among the 
1 Dr. John M. Woodworth. Conclusion. 
237 
most efficient public almoners, being not only better 
able than men to judge of the requirements of women 
and children, but discovering with greater facility fe- 
male impostors, the most dangerous and troublesome 
class with which Poor-law authorities have to deal. In 
this country there is a growing necessity that women 
should interest themselves in the problems of pau- 
perism, and that in visiting public hospitals and other 
charitable institutions they should know what they 
ought to observe, and what we all have a right, as citi- 
zens and taxpayers, to demand. Our leisure class is 
larger among women than among men, and women can 
better afford the time for the deliberate, careful, and 
constant inspection which our public charities need. 
Managing boards.—Nor is this all. Our hospitals 
and asylums furnish a field for the exercise of the or- 
ganizing skill and intelligence of women, not only as 
visitors, but as managers and officers. Few men can 
bring to bear on domestic details, whether of a hos- 
pital or private house, the quick natural perception 
and the trained faculties of an intelligent woman. Yet 
many of our hospitals present the curious spectacle 
of a responsible management exclusively in the hands 
of men, although a large part of their business is the 
care of women and children. It has come to be 
recognized that the specific duties of nursing are only 
properly performed when this branch of hospital ser- 
vice is under the direction of a committee of women ; 
and the State Charities Aid Association has already 
urged, with gratifying success, that schools for training 
nurses should be multiplied wherever there are hos- 
pitals. Such training-school committees, chiefly of wo- 
men, should be an integral part of the governing board. 238 
Hand-Book for Hospitals. 
Good nursing, besides bedside care, includes well- 
cooked food, cleanly wards, and plenty of fresh linen, 
and for these the nursing service must rely on the aid 
and co-operation of the domestic department of the 
hospital. It is, therefore, only when this department 
is administered judiciously, and in accordance with 
the best sanitary principles, that the welfare of the 
patients and the interests of the public are fully 
served. All the domestic affairs, as well as the nurs- 
ing, might very wisely be placed under the control of 
women, two or three of whom could be added to any 
existing board of commissioners or managers for this 
purpose, with the title of House Committee. 
Where new institutions are forming, it is not diffi- 
cult so to plan the government as to include women 
representatives ; and women themselves should be 
no longer content with visits of sympathy and the 
distribution of luxuries in hospitals, pleasant and 
acceptable as these offices are, or willing to limit 
their charitable service to the raising of money in 
the spending of which they have no part. Women 
of fortune, who give or bequeath large sums for 
the building or endowment of charities, make a 
mistake when they fail to secure to their own sex a 
voice in the management of such funds. Our public 
charitable institutions show the need of better sys- 
tems and more thorough supervision. Women may 
here well put to use on a wider scale, for the public 
good, the quick moral instinct, the housewifely 
habits, and the power of domestic organization, the 
exercise of which is their acknowledged “ sphere.” 
Common-sense virtues.—Yet the best organiza- Conclusion. 
239 
tion, the most perfect theory, the healthiest site, the 
most finely equipped building, the most carefully 
devised regulations, will be elaborate failures with- 
out good-sense and good-will and a ready co-opera- 
tion among managers, officers, visitors, doctors, and 
nurses. The common-sense virtues are particularly 
needed in public hospitals, where, among the pa- 
tients, there are many vicious and degraded persons 
and many impostors. 
Machine charity.—On the other hand we must 
guard ourselves against the hardening influence on 
the sympathies and conscience of routine or merely 
official charity. In dealing for any length of time 
with great numbers of unfortunate and morally in- 
firm people, we too often lose interest in individual 
cases and keen perception of individual necessities. 
The duty laid upon us is the saving of human beings, 
—making the most and best of each one of these 
multitudes of shipwrecked souls and bodies, for its 
own sake, and for our common good. In the ad- 
ministration of our charities we must “ heal in such 
a way that we shall not hurt, and succor in such 
a way as not to degrade.” While we value system 
and organization therefore, we should not let the 
method by which we work degenerate into a labor- 
saving mechanism of relief, perfectly adjusted in all 
its parts, but lacking “ the spirit of the living creature 
within the wheels.” 
Brotherhood.—“ There are problems enough to 
be solved to keep all of us, who have any leisure at 
all, well and wisely employed,—problems which 
never will be solved by mere almsgiving or institu- Hand-Book for Hospitals. 
240 
tionalism, or by any thing less than the living, loving 
co-operation of living hearts and hands. Into such 
channels of endeavor, if ours is in any sense a life 
of leisure, let us resolve in the Master’s name, to 
turn the stream of our activities.” 1 The poor have 
been left us in trust by the gracious Founder of our 
faith. Let us not be afraid of the name of fanatic 
or sentimentalist, or hesitate in bringing to our high 
calling all our best wisdom and the most refined 
resources of our Christian love. 
1 Rev. Henry C. Potter, D.D. : “ Sermons of the City.” APPENDIX. 
A. 
ISOLATING COTTAGE. 
Intended for infectious cases developed after admission ; built on 
the grounds of the Presbyterian Hospital, 70 th St., New York, Janu- 
ary, 1876 ; plan by Dr. W. Gill Wylie, State Charities Aid 
Association. 
The cottage is raised on locust posts a foot high, the space under 
the cottage having been excavated and then filled with ashes and con- 
crete. Neuchatel asphalt is a better material, the object being to 
secure a perfectly smooth surface or pavement under and around the 
building, so as to furnish no lodgment for dampness or dust. There 
is but one room, twenty feet square, with gable roof. There are two 
beds for patients, and one for a nurse screened off by a wooden par- 
tition which includes one of the windows. The windows are five feet 
by three, and of good quality of glass, and the building has light and 
air on all four sides. The roof, walls, and floor are double, and the 
interspace is ventilated by means of hinged boards opening outward 
at the top and bottom of the outer wall. The upper floor is of 
Georgia pine well laid. Registers open under each bed, and from 
these, between the floors, run tin tubes for drawing the foul air away. 
These tubes unite behind the stove in one flue which encases the 
smoke flue. The stove is an open Franklin ; the pipe being double, 
the inner smoke flue warms the space around it, and makes an aspira- 
ting chimney for foul air on a small scale. Fresh air descends into 
the room through box-shafts which reach down from the roof below 
the level of the eaves, and are fitted with an adjustable scatter-plate 
at their mouths. There are also transoms over the door and windows 
to assist in ventilation. The cottage was tested for the first time dur- 
ing a heavy snow-storm in the month of February, when the ther- 
mometer outside fell to 7°. After the first day or two, being then Appendix. 
242 
thoroughly warmed and dried, it was kept comfortable with a tem- 
perature ranging from 65° to 750, night and day, and although used 
for a bad case of exsection the air was always clean and good. The 
cost of the cottage without concrete pavement, and without stove 
and furniture was $279. 
B. 
OUTFIT FOR ONE WARD OF TWENTY BEDS. 
Wire-woven or iron bedsteads ....... 20 
Bedsacks for straw, if used ....... 20 
Hair mattresses, if used, weight 16 pounds .... 20 
Pillows, hair, weight 4 pounds ...... 20 
Pillows, feather, weight 4 pounds ...... 20 
Sheets ........... 120 
Pillow-cases . . . . . . . . . .120 
Blankets (40 pairs) ......... 80 
Coverlets .......... 40 
Draw sheets .......... 120 
Rubber sheets ......... 10 
Rubber pillow-cases ........ 10 
Hand towels .......... 144 
Bath towels .......... 72 
Doctors’ hand towels ........ 72 
Wringing towels, with sticks ....... 6 
Surgeons’ sleeved aprons ........ 6 
Stout bags for patient’s own brush and comb .... 40 
Roller-towels, for pantry . . . . . . .12 
Crash towels, do ........ 24 
Table-cloths .......... 6 
Feeding doylies or napkins ....... 48 
Mosquito nets .......... 6 
Chairs ........... 30 
Boston rockers, leather seat-cushions ..... 6 
Rolling chairs .......... 3 
Extension chairs ......... 2 
Bedside tables, with drawer ....... 20 Appendix. 
243 
Commodes .......... 4 
Bed-rests, hard wood ........ 6 
Bed-trays, do. do. ........ 6 
Ward table, large ......... I 
Dining-room table ......... I 
Pantry table and dresser ........ 1 
Refrigerator, small . . . . . . . . 1 
Looking-glasses, good quality ...... 4 
Towel-racks .......... 4 
Foot tubs .... ...... 4 
Foot-warmers, block tin ........ 6 
Tin basins .......... 6 
Crockery pitchers and basins ....... 2 
Glass lotion-basins ......... 6 
Nail-brushes .......... 6 
Hair-brushes ......... 6 
Dressing-combs . . . . . . . . .12 
Crockery bedpans ......... 6 
Glass urinals ......... 12 
Crockery chamber vessels, covered ...... 6 
Expectoration cups . . . . . . . . .12 
Spittoons .......... 4 
Soap dishes, no covers ........ 8 
Bed screens .......... 6 
Gas-stove .......... 1 
Clock ........... 1 
Match-safes .......... 4 
Brass dressing-basins, graduated sizes 4 
Spirit lamp 1 
Plaster heater ......... 1 
Surgical tray or table ........ 1 
Scissors 2 
Spatulas ........... 2 
Oakum basket ......... 1 
Bandage basket ......... 1 
Refuse cans, galvanized iron ....... 4 
Saucepans, graduated sizes ....... 4 
Brooms, common ......... 2 
Brooms, hair .......... 2 
Birch brooms for water-closets and sinks 4 244 
Appendix. 
Dust-pans . . ' . . . . . . . . 2 
Dust-brushes .......... 2 
Thermometers ......... 2 
Water-cooler .......... i 
Water-pitcher . . . . . . . . . . I 
Dish pans .......... 2 
Pint bowls .......... 24 
Dinner plates .......... 24 
Tea plates .......... 24 
Cups and saucers ......... 24 
Knives and forks ......... 24 
Carving knife and fork ........ 1 
Spoons, large .......... 24 
Spoons, small .......... 24 
Feeding cups .......... 6 
Tumblers .......... 24 
China mugs, half-pint .... ... 24 
Casters (1 set) 1 
Block-tin pitchers, 1 quart ....... 2 
China pitchers, graduated sizes ...... 6 
Sugar bowls .......... 2 
Knife tray .......... 1 
Tea tray, large ......... 1 
Tea trays, small ......... 6 
Tin teapots .......... 2 
Corkscrews .......... 2 
Salt sifters, large ......... 2 
Medicine cupboard, hanging ....... 1 
c. 
HOW TO WASH WOOLLENS. 
Put woollens into hot soap-suds by themselves, a few pieces at a 
time, and rub them only with the hand, not on a board. Never 
pound them in a machine. Rub no soap on them. Wash them 
quickly. 
When they are well washed in this way, rinse them in clean hot Appendix. 
245 
water of the same temperature, and re-rinse in clean water of the 
same heat, until all the soap-suds are out of them. 
Never leave them soaking, or lying damp. Squeeze or wring them 
immediately as dry as possible, hang them in the air awhile, and iron 
them before allowing them to become quite dry. They should be 
stretched and pulled while drying to prevent fulling. Never roll 
them up damp ; never sprinkle them. 
The removing of every particle of soap after washing flannels, and 
quick drying, are the important things to remember. 
Choose a dry, clear day. Avoid a freezing day. 
HOW TO MAKE SOFT SOAP. 
Every few days try out the accumulation of grease, and put it in an 
earthen crock. 
When you have twenty-five pounds, put it into a barrel and add 
fifteen pounds of potash, with a tea-kettleful of boiling water—that is, 
five or six quarts of water. 
Let it stand twenty-four hours, and add another tea-kettleful—five 
or six quarts—of water. 
When the potash has eaten up the grease (which will be in about 
two days) fill up the barrel with cold water, and stir it slowly until 
all the lumps are dissolved. 
HOW TO MAKE HARD SOAP. 
Mix six pounds of washing soda, three pounds of unslaked lime, 
and four gallons of boiling water. Let the mixture stand until it is 
perfectly clear; then drain off the water and pour on to the same 
alkaline mixture two gallons of cold water, to stand until it clears. 
Put into the warm liquid which was drained off, six pounds of 
clean fat. Boil until the liquor begins to harden, or about two hours, 
stirring most of the time. While boiling, thin with the two gallons 
of cold water which have become clear. Pouring this on from time 
to time, while the soap is boiling, prevents it from boiling over. 
Try the thickness of the soap by cooling a little on a plate. Just 
before taking it from the fire, put in a handful of salt. Wet a tub 
or box, to prevent sticking, and pour in the soap. When it is solid 
cut it into bars and put them on a board to dry. It is better they 
should dry a month or more. 246 
Appendix. 
This quantity of fat and alkalies will make forty pounds of excel- 
lent hard soap. For double the quantity of fat, double the other in- 
gredients. 
D. 
STORE-ROOM AND PANTRY REGULATIONS. 
1. The house-keeper or matron must keep herself informed daily 
of the exact number of patients in each ward who are on house diet, 
and will send to each ward, three times daily, the exact rations by 
weight and measure, for each patient, making no allowance for a 
single extra meal. She will use the same precautions in weight and 
measure for patients on extra diet, and for officers’ and attendants’ 
tables. 
2. She will receive the diet orders from the wards at a stated hour, 
and issue at a set time to cooks the material in all kinds needed for 
the day, as per diet orders ; and also for the officers’ and attendants’ 
tables. No servant shall, at any time, take her place in the store- 
room for this duty. All store-closets and pantries must be kept 
locked, and the keys held by the house-keeper, who alone should 
have access to them. 
All orders received and all material issued must be daily entered in 
a store-room book, with a statement of the total number on house 
diet and special diet, patients, officers, and attendants, for that day. 
3. Provisions and stores of all kinds must be weighed, measured, 
counted, and compared with the quantities ordered before they are 
drawn upon. No pass-book system should be allowed, but all trades- 
men should be required to send with their goods a ticket, or exact 
statement in writing, of quantity and price. These tickets should be 
carefully kept on file in the store-room, and sent in at stated times to 
the office to check the weekly or monthly bills. 
There should be no guessing or judging by the eye in measuring 
stores received or issuing rations. A common trick of tradesmen is 
to send more than is ordered as well as less. Accurate measurements 
and careful records will give the house-keeper a sense of security, and 
do much to keep down the expenses of the hospital. 
4. Meat bought in bulk must be cut up and trimmed in the presence 
of the house-keeper, and by her orders. All scraps and bones useful Appendix. 
247 
for soup must be put by themselves, and boiled down as soup stock, 
from which soups and gravies can be made. All scraps not suitable 
for this, when of beef or pork fat, must be fried out for cooking uses. 
All mutton suet and other trimmings unfit for frying with, must be 
weighed and added to the soap grease. No lard should at any time 
be bought for kitchen purposes. 
5. The house-keeper must be present in the kitchen at the hours 
for serving the ward meals, and must assure herself that rations are 
sent up in exact accordance with diet sheets, and that the food is hot 
and nicely served. 
6. Bread will be sent up in the loaf when many rations are required, 
and will be cut in the ward dining-room, and handed on the platter. 
Great waste of bread occurs from the habit of putting a large slice as 
a matter of course on every plate. No butter will be served with 
house diet at dinner ; a well-made gravy will take its place. 
7. No scrap-pails or slop-buckets will be allowed in any ward 
pantry. All broken food from the plates must be sent on platters to 
the kitchen, and sorted there for the soap grease or swill-pail. All 
undistributed food from the dish, and joints and bones from which 
meat has been cut, must be returned to the kitchen on the dishes, and 
served again in soups, stews, and puddings. The house-keeper will 
inspect all food so returned. Servants, left to themselves, toss 
everything into the swill-pail. The house-keeper will prevent waste 
by frequent inspection of the swill-pail immediately after a meal. 
8. No odds and ends of food will be allowed in the ward closets or 
pantries, on the chance of their being needed. All extra articles 
must be ordered in the regular way, and provided by the house-keeper 
as extra rations, and noted in the store-room book. 
QUANTITIES OF COOKED FOOD, FOR ONE MEAL, FOR ONE PERSON. 
Soup, gruel, milk, etc. ....... pt. I 
Meat, fresh or salt ........ oz. 6 
Fish, fresh or salt ........ oz. 6 
Vegetables ......... oz. 4 
Pudding, porridge, etc. ....... oz. 6 
Bread . . . . . . . . . . oz. 4 
Butter oz. 1 
Sugar oz. 1 
Cheese .......... oz. 1 
Pickles oz. 1 2 48 
Appendix. 
Stewed fruit ......... oz. 2 
Molasses (10 persons) ....... pt. 1 
Syrup do. ........ pt. I 
Vinegar do. ........ pt. 
The above quantities have been found abundant, the supplies be- 
ing issued for the total number, and there being always a certain 
number who do not take some of the articles. 
E. 
The following rules have been for several years in successful opera- 
tion in several of the principal hospitals of New York City (1883). 
They should be plainly printed on cards and put up in the office, 
halls, and common rooms, and in the bedrooms of each class of per- 
sons concerned. 
1. Hospital attendants shall be employed, with the approval of 
the managers, in such number as the services of the hospital may 
require. 
2. They shall be under the control of the superintendent, and of 
the heads of the several departments in which they may be employed. 
3. As far as practicable they shall have assigned to them their 
regular duties, but will be expected to yield willing obedience to any 
reasonable requirement. 
4. They shall give at least one week’s notice to the superintendent 
of their intention to leave the service of the hospital, and may re- 
quire the same notice when discharged, unless they be dismissed for 
gross misconduct. 
5. They shall not leave the hospital without the permission of the 
superintendent, who shall assign them their regular hours of duty and 
recreation. 
6. Those assigned to the wards as nurses shall attend to the gen- 
eral order of the ward and comfort of the patients, and behave them- 
selves with proper respect and decorum during the visits of the medical 
officers of the hospital. 
7. No officer, nurse, or other attendant shall receive any compen- 
sation, gift, or bequest from any patient, unless authorized to do so 
by the managers, through the superintendent. 
GENERAL RULES FOR ALL HOSPITAL ATTENDANTS. Appendix. 
2 49 
8. Nurses are not allowed to visit any other ward or its offices, 
either on or off duty, without special permission. 
HEAD NURSES. 
X. Must maintain quiet and order in their wards ; must accompany 
the house physician and visiting physician on their rounds, give entire 
attention to their instructions, and be ready to inform them correctly 
as to the condition of the patients. 
2. They will be held responsible for the entire charge of their 
wards ; for the nursing of the sick, cleanliness, warmth, ventilation, 
and general discipline ; and for the care and safety of all public and 
private property. They must study the interest of the hospital in 
preventing waste and destruction. 
3. They must see that the proper bed-card accompanies every 
patient, and that the card is sent to the house physician on the death 
or discharge of the patient. 
4. They must announce death, and, if possible, the approach of 
death, to the house physician and the superintendent, and upon the 
death of a patient must have the body at once quietly removed from 
the ward, under the direction of the house physician, cleansed, and 
carefully laid out by the assistant nurses. 
5. They must see that the order books are sent to the pharmacy 
immediately after the medical visits ; that the medicines correspond 
with the orders ; that the medicines and stimulants are correctly 
given ; that the diet is correctly distributed ; and that the specific in- 
structions put up in ward wash-closets, linen-closets, etc., are exactly 
obeyed. 
6. They must instruct the night nurses as to the care of the pa- 
tients during the night, and require of them an exact account of the 
condition of the patients in the morning. 
7. They must at once report to the superintendent any disobedi- 
ence of orders or unnecessary noise or disorder on the part of at- 
tendants, patients, or visitors to patients. 
8. When they leave their wards, for business or recreation, they 
must regularly assign an assistant to take charge during their absence, 
so that the wards may never be without a responsible head. 
ASSISTANT NURSES—DAY. 
Must aid the head nurse in any way she may require ; their specific 
duty being to wait on and keep tidy all helpless patients, and to keep Appendix. 
250 
beds, bedside tables, ward furniture, and utensils of every kind in 
good order, and perfectly neat and clean. 
ASSISTANT NURSES—NIGHT. 
1. Must aid the head nurse in any way she may require. 
2. Must see each and every patient in their wards at least once 
every half hour ; must have all lights put out or turned low at or be- 
fore 9 p.m. ; and enforce perfect order and quiet all night in the 
wards, adjacent halls, and stairways, reporting to the head nurse any 
disobedience or disorder. 
3. They must transmit to the head nurse any instructions they 
have received from the physician during the night, and inform him 
or her exactly as to the condition of the patients in the morning, 
4. They must at once report to the house physician any sudden 
unfavorable change in the condition of a patient. 
5. They must observe, with great care, the atmosphere and the 
temperature of the wards, especially in the early morning hours, and 
endeavor to keep the temperature uniform, and the air perfectly pure 
and sweet. This will be accounted one of the most important duties 
of the night nurse. 
Any nurse requiring medical advice will so report to the super- 
intendent. No nurse will be allowed to go off duty or apply for 
medical advice, except in cases of accident, without the knowledge 
and approval of the superintendent. 
The hours of duty will be for 
Day Nurses .... 6 a.m. to 8 p.m.1 
Night Nurses ... 8 p.m. to 6 a.m. 
RULES FOR PATIENTS. 
[To be printed on cards and put up in the wards, in dining-rooms 
and day-rooms, corridors and office.] 
i. Patients in this hospital are forbidden to use profane or in- 
decent language ; to express immoral or infidel sentiments ; to play 
at any game for money ; to smoke tobacco in the house ; to procure 
for themselves or others any intoxicating liquors ; or to have or circu- 
late any book, print, pamphlet, or newspaper of a vulgar, immoral, 
or indecent character. 
* With two hours off duty during the day, in turn, besides meals. Appendix. 
251 
2. No patient shall go into the dead-house, engine-rooms, laundry, 
kitchen, theatre, pharmacy, or public offices, or into any of the 
officers’ or attendants’ rooms, except on special business, or by special 
permission ; nor shall any patient leave his or her ward without the 
knowledge and consent of the head nurse. 
3. No male patient shall go into the women’s wards, nor any 
female patient into the men’s wards ; nor shall any patient leave the 
house without a pass properly signed by the house physician, and 
countersigned by the superintendent. 
4. All patients will remain quietly in their places during the visits 
of the physicians. 
5. Convalescent free patients are required to assist in any light 
work which the physicians do not disapprove. 
6. Convalescents will be responsible for the neatness of their beds 
and bedside tables, and all patients able to do so, will rise before 
breakfast, and go into the ward dining-room for their meals. 
7. Patients are required to comply promptly and cheerfully with 
the requests of the nurses, and behave themselves at all times in an 
orderly and quiet manner. 
8. Wilful disobedience of these rules will subject the offender to 
dismissal from the hospital. Wilful injury of the water apparatus, or 
of any furniture or property, will subject the offender to dismissal. 
In addition to the above, the following rules, adopted by the 
Bellevue Hospital Training School for Nurses, New York City, are 
appended (1895).—Eds. Third Edition. 
THE BELLEVUE TRAINING SCHOOL FOR NURSES, 
NEW YORK CITY. 
RULES FOR THE HOSPITAL. 
HEAD NURSES. 
I.—The hours of day duty are from 8 o’clock a.m. to 8 o’clock 
p.M. On arriving in her ward she will detain the night nurse no 
longer than is necessary to receive an exact account of the state of the 
patients ; then, after making out the census correctly (never reporting 
vacancies unless she has them), she will, with the assistance of the Appendix. 
252 
other nurses, proceed to arrange the wards and patients, so as to be 
ready for inspection promptly by io o’clock. 
II. She must accompany the medical officers during their visit, 
be ready to answer all inquiries, and faithfully and promptly execute 
all orders given. She must carefully write the orders at the time they 
are given on a pad and, after the doctor’s departure, enter them in 
the day order-book, from which the slate and T. I. D. list should 
each day be corrected. 
III. —She will be responsible for all medicines and treatment; 
must see that the prescription-book goes to the drug store at the 
proper time, and examine whether the medicines are correctly sent 
up. She must keep correct lists of all clothing sent to to the wash, 
and returned, verifying these each week, and seeing that nothing is 
lost. She must have the store-book ready for examination before io 
o’clock each morning. 
IV. —Each head nurse will be held responsible for the good condi- 
tion of her ward, including the kitchen, closets, and bath-room, and 
for the clean and serviceable condition of all utensils. 
V. —She must enforce the rules and discipline of the hospital, and 
in the interest thereof endeavor to prevent waste and destruction. It 
shall be her duty to report promptly to the superintendent every thing 
in the ward requiring attention, and any misbehavior or insubordina- 
tion of nurses, patients, or persons employed. The omission to do 
this will be considered a serious offence. 
VI. —She will be expected to pay special attention to the diet and 
extras of the patients, and see that one of her nurses superintends the 
serving of the meals decently and in order. 
VII. —Whenever obliged to leave the ward, she must see that it is 
in charge of a competent assistant. A nurse must always be visible 
in the ward, so as to give all officers and visitors prompt attention. 
Nurses are not to visit other wards, except in the performance of 
their duties ; they must not receive visits in the wards from friends 
or other nurses. They may always see friends in the superintendent’s 
room. 
VIII. A correct list must be kept of all clothing belonging to 
patients, and any money or valuables belonging to them must be 
promptly taken in charge by the head nurse, and deposited in the 
warden’s office. On the death of patients, any ring or other article of 
value found upon them must be removed before the body is taken 
from the ward, and sent to the office as soon as possible. Appendix. 
253 
IX. Head nurses must see that for each new patient (particularly 
“private patients”) a card of admittance be sent from the office, cor- 
rectly filled out; and that these cards are placed over the beds of the 
patients to whom they respectively belong. All births occurring in 
the ward must be at once reported at the office. 
X. —Each head nurse on taking charge of a ward must make out 
an inventory of all the articles belonging to that ward, comparing it 
with the one made out by her predecessor, and reporting any deficien- 
cies to the warden. 
XI. —The head nurse must see that all patients dangerously ill 
are attended by the priest or any clergyman they may desire, and 
that deference and respect be shown all such in the fulfilment of their 
duties. 
XII. —The head nurse must remember that it is part of her duty 
to instruct her assistants in the practical details of nursing ; teaching 
them to watch the symptoms and changes in the patients ; arrange for 
them to accompany her on her rounds with the doctors, and strive in 
every way to make them useful and efficient nurses. She will be 
responsible for the punctuality and neat appearance of her assistants, 
and must neither give nor take any hours out of time without per- 
mission. 
XIII. All nurses must maintain proper dignity, and observe de- 
corum and civility toward doctors, patients, and each other. 
I. —The assistant nurses will be directed in their work by the head 
nurses, and must willingly perform any duty assigned them. They 
must not shrink from any thing connected with the care of the sick 
as menial, remembering that nursing means constant self-sacrificing 
work. In the wards they will be instructed by the head nurses, and 
they will never make thorough nurses if they rely only on instruction 
given ; the best school is that of actual work, personal experience, 
and observation, and this is to be found in hospital wards alone, not 
in books and teaching. 
II. —During the absence of the head nurse, the nurse in charge 
must hold herself responsible for every thing occurring in the ward, 
taking the same interest in all connected with it, and, as far as pos- 
sible, taking the place of the head nurse. Receiving visitors in the 
ward is strictly prohibited. 
ASSISTANT NURSES. Appendix. 
254 
III. —Nurses, when off duty, are not permitted to return to the 
hospital or grounds without permission. 
IV. The attention of the nurses is particularly directed toward 
the uniformity and neatness of their appearance ; no deviation being 
allowed from the simple dress required by the school. 
V. —Nurses must not be absent from class or lecture without per- 
mission. 
NIGHT NURSES. 
I. —The hours of duty are from 8 o’clock P.M. to 8 o’clock A.M. On 
arriving at the ward she will receive from the day nurses directions for 
the treatment of the patients during the night ; she must read over 
the night orders that she may thoroughly understand them. She 
must reach the ward in time to do all this before 8 o’clock, so that the 
day nurses may leave promptly at that hour. She will receive from 
the day nurses the keys of the medicine closets, and she must tie them 
to a string attached to her waist. Under no circumstances may the 
medicine closets be left unlocked. 
II. —She will see that the lights are turned down, and that there is 
no noise or talking after 8 o’clock P.M. She will be responsible for 
the order and quiet of the wards until the following morning. She 
must move about noiselessly herself, and be very watchful, remember- 
ing how important and responsible her position is. 
III. She must faithfully carry out all orders given ; note the 
changes in the condition of the very sick patients ; report to the doc- 
tor when necessary, always sending him a written report either by an 
orderly or a man from the office. She need never act on any but a 
written reply. 
IV. She must arouse the convalescent patients in time for them 
to be dressed, and their beds made before breakfast, and try in every 
way to advance the work of the ward. She will receive the patients 
properly arranged at night, and must, as far as possible, leave them 
so in the morning. 
V. —She will refer to the night superintendent whenever necessary 
during the night. Besides making a verbal report to the head nurse, 
she will leave a properly written report of any thing noteworthy that 
may have occurred during the night; she must not remove her cap 
and apron until after reporting to the head nurse. 
VI. —Night nurses must pay special attention to the atmosphere of Appendix. 
255 
the wards, endeavoring to keep the temperature uniform, and the air 
pure, particularly in the early morning hours. 
VII. —It will be considered a serious offence for any night nurse 
to sleep while on duty, and a repetition of this offence will be fol- 
lowed by dismissal. 
VIII. —She must be in her room between the hours of 9 A.M. and 
4 P.M., or of 11 A.M. and 6 P.M., unless permission to the contrary is 
granted by the superintendent. Night nurses are expected to attend 
class regularly. 
F. 
DISINFECTANTS AND METHODS OF DISIN- 
FECTION, 
AS RECOMMENDED BY THE HEALTH DEPARTMENT OF THE 
CITY OF NEW YORK, DECEMBER, 1892. 
DISINFECTION AND DISINFECTANTS. 
Sunlight, pure air, and cleanliness are always very important agents 
in maintaining health and in protecting the body against many forms 
of illness. When, however, it becomes necessary to guard against 
such special dangers as accumulated filth or contagious diseases, dis- 
infection is essential. In order that disinfection shall afford complete 
protection, it must be thorough, and perfect cleanliness is better, 
even in the presence of contagious disease, than poor disinfection. 
All forms of fermentation, decomposition, and putrefaction, as well 
as the infectious and contagious diseases, are caused by minute living 
germs. The object of disinfection is to kill these germs. Decom- 
position and putrefaction should at all times be prevented by the im- 
mediate destruction, or removal from the neighborhood of the dwelling, 
of all useless putrescible substances. In order that as few articles as 
possible shall be exposed to infection by the germs causing the con- 
tagious diseases, it is important that all articles not necessary for 
immediate use in the care of the sick person, especially upholstered 
furniture, carpets, and curtains, should be removed from the sick 
room at the very beginning of the illness. 256 
Appendix. 
AGENTS FOR CLEANSING AND DISINFECTION. 
Too much emphasis cannot be placed upon the importance of sun- 
light, fresh air, and cleanliness, both as regards the person and the 
dwelling, in preserving health and protecting the body from all kinds 
of disease. Sunlight and fresh air should be freely admitted through 
open windows, and personal cleanliness should be attained by fre- 
quently washing the hands and body. 
Cleanliness in dwellings, and in all places where men go, may 
under ordinary circumstances be well maintained by the use of the 
two following solutions: 
1. Soap-suds Solution.—For simple cleansing, or for cleansing after 
the methods of disinfection by chemicals described below, one ounce 
of common soda should be added to twelve quarts of hot soap (soft 
soap) and water. 
2. Strong Soda Solution.—This, which is a stronger and more 
effective cleansing solution, is made by dissolving one-half pound of 
common soda in three gallons of hot water. The solution thus ob- 
tained should be applied by scrubbing with a hard brush. 
When it becomes necessary to arrest putrefaction or to prevent the 
spread of contagious diseases by killing the living germs which cause 
them, more powerful agents must be employed than those required 
for simple cleanliness, and these are called disinfectants. The fol- 
lowing are some of the most reliable disinfectants : 
3. Heat.—Complete destruction by fire is the best method of dis- 
posing of infected articles of small value, but continued high tem- 
peratures not as great as that of fire will destroy all forms of life ; 
thus, boiling or steaming in closed vessels for one-half hour will 
destroy all disease germs. 
4. Carbolic Acid Solution.—Dissolve six ounces of carbolic acid in 
one gallon of hot water. This makes approximately a five-per-cent, 
solution of carbolic acid, which, for many purposes, may be diluted 
with an equal quantity of water. The commercial colored impure 
carbolic acid should not be used to make this solution. Great care 
must be taken that the pure acid does not come in contact with the 
skin. 
5. Bichloride Solution (bichloride of mercury or corrosive subli- 
mate).—Dissolve sixty grains of pulverized corrosive sublimate and 
two tablespoonfuls of common salt in one gallon of hot water. This Appendix\ 
257 
solution must be kept in glass, earthen, or wooden vessels (not in 
metal vessels). 
The Carbolic and Bichloride Solutions are very poisonous when 
taken by the mouth, but are harmless when used externally. 
6. Milk of Lime.—This mixture is made by adding one quart of dry 
freshly-slaked lime to four or five quarts of water. (Lime is slaked 
by pouring a small quantity of water on a lump of quick-lime. The 
lime becomes hot, crumbles, and as the slaking is completed a white 
powder results. The powder is used to make Milk of Lime.) Air- 
slaked lime has no value as a disinfectant. 
7. Dry Chloride of Lime.—This must be fresh and kept in closed 
vessels or packages. It should have the strong pungent odor of 
chlorine. 
The proprietary disinfectants, which are so often widely advertised, 
and whose composition is kept secret, are relatively expensive and 
often unreliable and inefficient. It is important to remember that 
substances which destroy or disguise bad odors are not necessarily 
disinfectants. 
Note.—The cost of the Carbolic Solution is much greater than that of the other 
solutions, but generally is to be much preferred. When the cost is an important 
element, the Bichloride Solution may be substituted for all purposes for which the 
Carbolic Solution is recommended, except for the disinfection of discharges, eat- 
ing utensils and articles made of metal, and of clothing, bedding, etc., which is 
very much soiled. Its poisonous character, except for external use, must be kept 
constantly in mind. 
METHODS OF DISINFECTION IN INFECTIOUS AND CONTAGIOUS 
DISEASES. 
The diseases to be guarded against by disinfection are Scarlet 
Fever, Measles, Diphtheria, Tuberculosis (Consumption), Small-pox, 
Typhoid and Typhus Fever, Yellow Fever, and Cholera. 
i. Hands and Person.—Dilute the Carbolic Solution with an equal 
amount of water, or use the Bichloride Solution without dilution. 
Hands soiled in caring for persons suffering from contagious diseases, 
or soiled portions of the patient’s body, should be immediately and 
thoroughly washed with one of these solutions, and then washed with 
soap and water. The nails should always be kept perfectly clean. 
Before eating, the hands should be first washed in one of the above 
solutions, and then thoroughly scrubbed with soap and water by means 
of a brush. 258 
Appendix. 
2. Soiled Clothing, Towels, Napkins, Bedding, etc., should be im- 
mediately immersed in the Carbolic Solution, in the sick room, and 
soaked for twelve hours. They should then be wrung out and boiled 
in the Soap-suds Solution for one hour. Articles such as beds, woollen 
clothing, etc., which cannot be washed, should be referred to the 
Health Department for disinfection or destruction. 
3. Food and Drink.—Food thoroughly cooked and drinks that 
have been boiled are free from disease germs. Food and drinks, 
after cooking or boiling, if not immediately used, should be placed 
when cool in clean dishes or vessels and covered. In presence of an 
epidemic of Cholera or Typhoid Fever, milk, and water used for 
drinking, cooking, washing dishes, etc., should be boiled before 
using, and when Cholera is prevalent all persons should avoid eating 
uncooked fruit, fresh vegetables, and ice. 
4. Discharges of all kinds, from the mouth, nose, and bowels of 
patients suffering from contagious diseases, should be received into 
glass or earthen vessels containing the Carbolic Solution or Milk of 
Lime, or they should be removed on pieces of cloth, which are imme- 
diately immersed in one of these solutions. Special care should be 
observed to disinfect at once the vomited matter and the intestinal 
discharges from Cholera patients, as these alone contain the danger- 
ous germs. In Typhoid Fever the intestinal discharges, and in 
Diphtheria, Measles, and Scarlet Fever, the discharges from the 
throat and nose, all carry infection and should be treated in the same 
manner. The volume of the solution used to disinfect discharges 
should be at least twice as great as that of the discharge. After 
standing for an hour or more the disinfecting solution with the dis- 
charges may be thrown into the water-closet. Cloths, towels, nap- 
kins, bedding, or clothing, soiled by the discharges, must be at once 
placed in the Carbolic Solution and the hands of the attendants dis- 
infected, as described above. In convalescence from Measles and 
Scarlet Fever the scales from the skin (peeling) are also carriers of 
infection. To prevent the dissemination of disease by means of these 
scales, the skin should be carefully washed daily in warm soap and 
water. After use, the soap-suds should be thrown into the water- 
closet and the vessel rinsed out with a Carbolic Solution. 
5. The Sputum from Consumptive Patients.—The importance of 
the proper disinfection of the sputum (expectoration) from consump- 
tive patients is little understood. Consumption is a contagious dis- Appendix. 
259 
ease, and is always the result of transmission from the sick to the 
healthy or from animals to man. The sputum contains the germs 
which cause the disease, and in a large proportion of cases is the 
source of infection. After being discharged, unless properly disposed 
of, it may become dry and pulverized and float in the air as dust. 
This dust contains the germs and is the common cause of the disease 
through inhalation. In all cases, therefore, the sputum should be dis- 
infected when discharged. It should be received into covered cups 
containing the Carbolic or Milk of Lime Solution. Handkerchiefs 
soiled by it should be soaked in the Carbolic Solution and then boiled. 
Dust from the walls, mouldings, pictures, etc., in rooms that have 
been occupied by consumptive patients, contains the germs, and will 
produce tuberculosis in animals when used for their inoculation. 
Therefore, rooms should be thoroughly disinfected before they are 
again occupied. If the sputum of all consumptive patients were de- 
stroyed at once when discharged, a large proportion of the cases of 
the disease would be prevented. 
6. Closets, Kitchen and Hallway Sinks, etc.—Each time the closet 
is used for infected discharges, one pint of the Carbolic Solution 
should be poured into the pan (after it is emptied) and allowed to 
remain there. All discharges should be disinfected before being 
thrown into the closet. Sinks should be flushed at least once daily. 
7. Dishes, Knives, Forks, Spoons, etc., used by a patient should be 
kept for his exclusive use, and not removed from the room. They 
should be washed first in the Carbolic Solution, then in boiling hot 
soap-suds, and finally rinsed in hot water. These washing fluids 
should afterwards be thrown into the water-closet. The remains of 
the patient’s meals may be burned or thrown into a vessel containing 
the Carbolic Solution or Milk of Lime and allowed to stand for one 
hour before being thrown away. 
8. Roo?ns and their Contents.—Rooms which have been occupied 
by persons suffering from contagious disease should not be again oc- 
cupied until they have been thoroughly disinfected by the Health De- 
partment. For this purpose either careful fumigation with sulphur 
will be employed, or this combined with the following procedure : 
Carpets, curtains, and upholstered furniture which have been soiled 
by discharges, or which have been exposed to infection in the room 
during the illness, will be removed for disinfection by steam. Wood- 260 
Appendix. 
work, floors, and plain furniture will be thoroughly washed with the 
Soap-suds and Bichloride Solutions. 
9. Rags, Cloths, and Articles af Small Value, which have been 
soiled by discharges or infected in other ways, should be burned. 
10. In case of Death, the body should be completely wrapped in 
several thicknesses of cloth wrung out of the Carbolic or Bichloride 
Solution and placed in an hermetically sealed coffin. 
It is important to remember that an abundance of fresh air, sun- 
light, and absolute cleanliness not only helps protect the attendants 
from infection, but also aids in the recovery of the sick. 
METHODS OF CLEANLINESS AND DISINFECTION TO PREVENT THE 
OCCURRENCE OF ILLNESS. 
1. Water-closet Bowls and all Receptacles for Human Excrement 
should be kept perfectly clean by frequent flushing with a large 
quantity of water, and as often as necessary disinfected with the Car- 
bolic or Bichloride Solutions. The woodwork around and beneath 
them should be frequently scrubbed with hot Soap-suds Solution. 
2. Sinks and the Woodwork around and the floor beneath them 
should be frequently and thoroughly scrubbed with hot Soap-suds 
Solution. The sinks should be thoroughly flushed with a large quan- 
tity of water at least twice daily, and should be carefully cleaned twice 
a week or oftener by scrubbing. Several quarts of the Carbolic Solu- 
tion should be frequently thrown in the sink after it has been 
flushed. 
3. Cesspools and Privy Vaults.—An abundance of Milk of Lime or 
Chloride of Lime should be thrown into these daily, and their contents 
should be frequently removed. 
4. Cellars and Rooms in Cellars are to be frequently whitewashed, 
and, if necessary, the floors sprinkled with dry Chloride of Lime. 
Areas and Paved Yards should be cleaned, scrubbed, and, if necessary, 
washed with the Bichloride Solution. Gutters and Drains should be 
cleaned and when necessary sprinkled with Chloride of Lime or 
washed with Milk of Lime. 
5. Air-shafts.—Air-shafts should be first cleaned thoroughly, and 
then whitewashed. To prevent tenants throwing garbage down air- Appendix. 
261 
shafts, it is advisable to put wire netting outside of windows opening 
on shafts. Concrete or asphalt bottoms of shafts should be cleaned 
and washed with the Bichloride Solution, or sprinkled with Chloride 
of Lime. 
6. Hydrant Sinks, Garbage Receptacles, and Garbage should be 
cleaned daily, and sprinkled with dry Chloride of Lime. 
7. Refrigerators and Surfaces around and beneath them. Dumb 
waiters, etc., may be cleaned by scrubbing them with the hot Soap 
suds Solution. 
8. Traps.—All traps should be flushed daily with an abundance of 
water. If at any time they become foul, they may be cleaned by 
pouring considerable quantities of the hot Strong Soda Solution into 
them, followed by the Carbolic Solution. 
9. Urinals and the Floors around and underneath them should be 
cleaned twice daily with the hot Soap-suds Solution, and in addition 
to this, if offensive, they may be disinfected with the Carbolic Solu- 
tion. 
10. Vacant Rooms should be frequently aired. 
USE OF BROMINE SOLUTION AS A DEODORANT. 
This can be accomplished by a weak Solution of Bromine, which is a 
valuable agent for this purpose. The Bromine Solution, however, is 
only temporary in its action and must be used repeatedly. It should' 
be applied by sprinkling. Although somewhat corrosive in its action 
on metals, it is otherwise harmless. 
The Solution of Bromine must be prepared with great care, as the pure bromine 
from which it is made is dangerous. It is very caustic when brought in contact 
with the skin ; it is volatile and its fumes are extremely irritating if inhaled. In 
preparing this solution in large quantities, a pound bottle of bromine should be 
dropped into a barrel containing forty or fifty gallons of water, and then broken 
under water with an iron bar. The solution is completed by thoroughly stirring. 
To prepare a smaller quantity an ounce bottle of bromine may be dropped into a 
pail containing three or four gallons of water, and broken in the same way and 
with the same care. 
THE STERILIZATION OF MILK FOR FEEDING INFANTS. 
Sterilization is the process employed to destroy the germs contained 
in milk. Germs produce fermentation (souring) and render the milk 262 
Appendix. 
unfit to be used as an article of food for infants. Milk, as it reaches 
the city, even if great care has been taken in its collection and ship- 
ment, contains germs, and these will produce fermentation, although 
the milk is kept on ice. Unclean vessels hasten this process. No 
matter how good milk may be in the morning, when comparatively 
fresh, toward evening, unless it has been partly or completely steril- 
ized, it may be dangerous to an infant, and may cause fatal illness, 
even though it still tastes sweet. 
Complete sterilization destroys all the germs in milk, and so pre- 
vents permanently fermentative changes; by partial sterilization 
many of the germs may be destroyed, so that the milk will remain 
wholesome for at least twenty-four hours in the warmest weather. 
Milk is best sterilized for infants by steam. It may be sterilized 
at a high or low temperature ; that is, at the boiling temperature 
(2120 F.), which is high sterilization, or at a lower degree of heat ob- 
tained by modifying the steaming process. 
It has been found that milk sterilized at a high temperature (212° 
F.) is not desirable for prolonged use, as the high temperature causes 
certain changes in the milk, which make it less suitable as a food for 
infants. These changes are in part avoided if a temperature lower 
than boiling is used. It is recommended that the lowest temperature 
be used, for partial sterilization, which will keep the milk wholesome 
for twenty-four hours in the warmest weather (Koplik). 
The utensils necessary are— 
(a) A tin pail or pot, about ten inches deep by nine inches in diam- 
eter, provided with the ordinary tin cover, which has been perforated 
with eight holes, each an inch in diameter. The holes should be ar- 
ranged in a circle, midway between the border of the cover and its 
centre. The centre is also perforated with an opening of the same 
size. 
(b) A wire basket, with eight nursing bottles (as sold in the shops 
for this purpose). 
(c) Rubber corks for the bottles, and a bristle brush for cleaning 
them. 
Directions (Koplik)—Place the milk, pure or diluted (as the doctor 
may direct), in the nursing-bottles, and place the latter in the wire 
basket. Put only sufficient milk for one nursing in each bottle. Do 
not cork the bottles at first. Appendix. 
263 
Having previously poured about two inches of water in the tin 
pail or pot, and brought it to the boiling point, lower the basket of 
nursing bottles slowly into the pot. Do not allow the bottles to 
touch the water, or they will burst. Put on the perforated cover, and 
let the steaming continue for ten minutes ; then remove the cover and 
firmly cork each bottle. After replacing the cover, allow the steam- 
ing to continue fifteen minutes longer in the winter and twenty min- 
utes longer in the summer. The steam must be allowed to escape 
freely, or the temperature will rise too high. 
The process of sterilization is now completed. Place the basket of 
bottles in a cool dark place or in an ice chest. The bottles must not 
be opened until just before the milk is to be used, and then it may 
be warmed by plunging the bottle in warm water. If properly pre- 
pared the milk will taste but little like boiled milk. There will not 
be a thick ring around the inside of the bottle, and no butter will be 
seen floating on the surface. 
The temperature attained under the conditions stated above will 
not exceed in extreme cases 1880 F. 
Milk should be sterilized when it is as fresh as possible and only 
sufficient milk for twenty-four hours should be sterilized at one time. 
If, after nursing, the infant leaves some milk in the bottle, this 
should be thrown away. 
Care of the Bottles is Important.—After nursing, the bottles should 
be filled with a strong solution of washing soda, allowed to stand 
twenty-four hours, and then carefully cleaned with a bristle (bottle- 
brush. Minute particles of dry or stale milk allowed to remain ia 
the bottle are dangerous to the infant. The rubber corks and nipples 
should be boiled after using in strong soda solution for fifteen min- 
utes, and then rinsed and dried. 
After sterilizing, milk should never be put into unsterilized bottles, 
as this will spoil it. 
CONCLUSION. 
The general principles of disinfection outlined in this circular may 
be applied for the disinfection of all articles not specifically treated 
of, and which are similar in character to those considered. 
By order of the Board of Health, 
Charles G. Wilson, 
President. 
Emmons Clark, 
Secretary. 264 
Appendix. 
G. 
RIGHT OF ENTRANCE LAW—STATE CHARITIES AID ASSO- 
CIATION. GENERAL ALL COUNTIES—LAWS OF NEW 
YORK. CHAPTER 635, LAWS OF 1893. 
An Act in relation to the State Charities Aid Association. 
Approved by the Governor, May 6, 1893. Passed, three-fifths being present. 
The People of the State of New York, represented in Senate and 
Assemby, do enact as follows : 
Section i. Any Justice of the Supreme Court, on written applica- 
tion of the State Charities Aid Association through its President or 
other officer designated by its Board of Managers, may grant to such 
persons as may be named in said application, orders to enable such 
persons, or any of them, as visitors of such Association to visit, 
inspect, and examine, in behalf of said Association, any of the public 
charitable institutions owned by the State, and the County, Town, and 
City poorhouses and almshouses within the State. The persons so 
appointed to visit, inspect, and examine said institution or institutions 
shall reside in the county or counties from which said institution or 
institutions receive their inmates, and such appointment shall be made 
by the Justice of the Supreme Court of the judicial district in which 
said visitors reside. Each order shall specify the institution to be 
visited, inspected, and examined, and the name of each person by 
whom such visitation, inspection, and examination shall be made, and 
shall be in force for one year from the date on which it shall have 
been granted, unless sooner revoked. 
Sec. 2. All persons in charge of any such institution shall admit 
each person named in any such order into every part of such institu- 
tion, and render such person every possible facility to enable him to 
make in a thorough manner such visit, inspection, and examination, 
which are hereby declared to be for a public purpose, and to be made 
with a view to public benefit. Obedience to the orders herein 
authorized shall be enforced in the same manner as obedience is 
enforced to an order or mandate made by a court of record. 
Sec. 3. The State Charities Aid Association shall make annual 
of the results of its visits and inspections made under this Act Appendix. 
265 
to the State Board of Charities upon matters relating to the institutions 
subject to the visitation of said Board ; and to the State Commission 
in Lunacy upon matters relating to the institutions subject to inspec- 
tion or control by said Commission. Said report shall be made on 
or before the first day of December for each preceding fiscal year. 
Sec. 4. Chapter 323 of the Laws of eighteen hundred and eighty- 
one is hereby repealed. 
Sec. 5. This act shall take effect immediately. 
State of New York, 
Office of the Secretary of State, 
ss 
I have compared the preceding with the original law on file in this 
office, and do hereby certify that the same is a correct transcript there- 
from and of the whole of said original law. 
Frank Rice, 
Secretary of State. 
H. 
BOOKS OF REFERENCE. 
The following books and reports have been consulted in preparing 
this Hand-Book. Most of them are simple, practical treatises, and 
visitors would do well to look them up, either in some public library, 
or by applying to the librarian of the State Charities Aid Association, 
105 East 22d Street, New York : 
Notes on Hospitals ; Florence Nightingale, London. 
La Salubrite des Hopitaux ; Michel Levy, Paris. 
Etude sur les Hopitaux ; A. Husson, Paris. 
Das Baracken Lazareth der Koniglichen Charite ; Esse, Berlin. 
Das Augusta Hospital; Esse, Berlin. 
Verbandplatz und Feld-lazareth ; F. Esmarch, Berlin. 
Lazareth und Baracken ; R. Virchow, Berlin. 
Kriegslazarethe von Berlin, nebst einem Vorschlage zur Reform des 
Hospitalwesens ; Steinberg, Berlin. 
Plospitaler ; F. Oppert (3 ed.), Hamburg. 266 
Appendix. 
Circulars Nos. 4 and 10 ; Surgeon-General’s Office, U. S. A. 
Marine Hospital Service ; U. S. annual reports. 
Hospital Construction and Organization ; Johns Hopkins Hospital, 
Baltimore ; Dr. Stephen Smith and others, New York. 
Hospitals : History, Organization, Management, and Construction ; 
Dr. W. Gill Wylie, New York. 
Construction of Hospitals ; Douglas Galton, London. 
Cottage Hospitals ; H. C. Bur'dett, London. 
Sanitary Arrangements for Dwellings ; W. Eassie, London. 
Filth Diseases and their Prevention ; John Simon, Medical Officer 
to the Privy Council of Great Britain. (American ed.) 
Dangers of Impure Ice ; Professor Raphael Pumpelly, New York. 
Sanitary Engineering ; B. Latham, London. 
Water and Water Supply ; W. H. Corfield, London. 
Sanitary Drainage of Houses and Towns; G. E. Waring, Jr., 
Boston. 
House Drainage and Sanitary Plumbing; W. P. Gerhard, New 
York. 
National Board of Health ; Bulletins with Supplements ; Washing- 
ton, D. C. 
State Boards of Health, New York, New Jersey, Connecticut, and 
Massachusetts ; annual reports. 
American Public Health Association ; reports and papers. 
Manual of Practical Hygiene ; E. Parkes, London. 
The Air in Relation to Clothing, Dwelling, and Soil; Max von 
Pettenkofer, London. 
Hospitalism and the Causes of Death after Operations ; J. E. 
Erichsen, London. 
Fragments of Science (Dust and Disease); John Tyndall, F.R.S. 
Deaconesses ; or, The Official Help of Women in Charitable Insti- 
tutions ; Rev. J. S. Hbwson, D.D., London. 
Notes on Surgical Nursing ; Barnes, London. 
Notes on Lying-in Institutions ; Florence Nightingale, London. 
Traite de l’Art des Accouchements (Hygilne des Maternitds) ; S. 
Tarnier et G. Chantreuil, Paris. 
Care and Cure of the Insane ; Mortimer Granville, M.D., London. 
Private Care of the Insane ; R. L. Parsons, M.D., New York. 
Practicability and Value of Non-Restraint in Treating the Insane ; 
J. C. Shaw, M.D., New York. 
Care of the Insane ; Dr. Bucknill, London. Appendix. 
267 
Chapters in the History of the Insane in the British Isles ; D. H. 
Tuke, M.D., London. 
Reports of Board of Commissioners in Lunacy; Great Britain. 
National Association for the Protection of the Insane ; reports and 
proceedings, New York. 
Epidemics from a Chemical Standpoint; R. Ogden Doremus.M.D. 
Disinfectants and Disinfection; Robert Angus Smith, F.R.S., 
Edinburgh. 
Mittheilungen aus dem Kaiserlichen Gesundheitsamt; Ier Band, 
Berlin. 
Uber die Milzbrandimpfung ; Robert Koch, Kassel. 
State Boards of Charities, New York, Pennsylvania, Wisconsin, 
Province of Ontario, and others ; annual reports. 
National Conference of Charities ; annual reports and proceedings. 
Journal of Social Science. 
Sanitary Engineer. 
American Architect. 
Medical Record.1 
1 Among the most valuable of the recent publications relating to 
the subjects treated of in this Hand-Book is the volume of 720 pages 
on Hospitals, Dispensaries, and Nursing, being the Report of 
Section III. of the International Congress of Charities, Correction, 
and Philanthropy, held in Chicago, June 12-17, 1893. The sub- 
jects assigned to this section were : The Hospital Care of the Sick, 
Training of Nurses, Dispensary Work, and First Aid to the Injured. 
The volume contains, among many other valuable papers, contri- 
butions by John S. Billings, M.D., Lord Cathcart, Henry C. Bur- 
dett, Henry M. Hurd, M.D., and illustrated descriptions of the 
Roosevelt Hospital, New York, and the Johns Hopkins Hospital, 
Baltimore, Md. The 29 papers on the Nursing of the Sick are 
prefaced by an article “ Sick Nursing and Health Nursing,” by 
Florence Nightingale. (Published by the Johns Hopkins Press. 
Baltimore. 1894.)—Eds. Third Edition.