-WiM- Me 'Mt 
Extracted from the Transactions of the American Public 
Health Association. 
THE SANITARY RELATIONS OF HOSPITALS 
WILLIAM PEPPER, A. M., M. D., 
Professor of Clinical Medicine in the University of Pennsylvania 
READ AT THE ANNUAL MEETING IN PHILADELPHIA, NOVEMBER 10, 1874. 
The object of the writer is to offer a few practical suggestions on the sub- 
ject of hospital construction as bearing on the result of treatment. This 
question, although somewhat restricted, cannot be denied a large share of 
importance. The rapid increase in the size of cities both in this country 
and abroad, is rendering necessary a rapid increase in the number and size 
of hospitals. Public attention, also, is being forcibly attracted to a consid- 
eration of the proper construction and management of these institutions in 
consequence of the real importance of the subject, and of the rapid growth 
of a spirit of intelligence and philanthropic interest in all great sanitary 
questions. 
This interest has been evidenced, and, at the same time, greatly stimulated 
by the numerous publications which have been made of late years bearing 
on the question of the sanitary relations of hospitals, and especially has 
this been so since the appearance of the well-known article on “ Hospital- 
ism,” by the late Sir James Y. Simpson, of Edinburgh, in which he endeav- 
ored to show that large hospitals are banes rather than blessings, and that 
the plans of construction hitherto followed are erroneous and lead to dis- 
astrous results. The numerous severe wars which have occurred during 
the last decade have also furnished interesting and valuable evidence as 
to the results of the treatment of surgical and medical cases in tents or bar- 
rack hospitals, and thus have added great importance to the study of the san- 
itary value and efficiency of the large civic hospitals in various countries. 
The results of this investigation have been, it must be acknowledged, of 
a startling and momentous character. It has been shown that some few of 
the largest and most popular hospitals in this country and abroad are actu- 
ally productive of so large a rate of mortality among their inmates, and 
especially among those suffering from severe wounds or who have undergone 
serious surgical operations, as to make it doubtful whether their existence is 
not an injury and a curse to the community in which they are situated. 
It has been further shown that in others, where no such deplorable con- 
dition of things exists, the death-rate is still alarmingly high. In examining 
into the causes of this excessive mortality further, it has been shown that a 
considerable part of it is due to the frequent occurrence in such hospitals of 
cases of disease of a peculiarly fatal class such as pyaemia (or surgical THE SANITARY RELATIONS OF HOSPITALS. 
fever), hospital gangrene, erysipelas, and the like, affecting surgical pa- 
tients especially, and which are known to be due in many instances to the 
diffusion of septic poisonous emanations. 
Simpson collected an extensive set of statistics of mortality of certain 
wounds and operations in private practice and in small rural hospitals, from 
which he drew the conclusions above stated ; and the results derived from 
tent and barrack-hospital practice during recent wars, confirm the statement 
that in large city hospitals the rate of mortality, after wounds and surgical op- 
erations in particular, and of all diseases in general, is frequently higher than 
in similar cases treated in private practice, or in small isolated hospitals. 
Up to this point the facts are conclusive. But the more important and dif- 
ficult question of their signification remains to be solved, Simpson at- 
tempted this in his usual trenchant manner. Assuming that this excessive 
mortality was directly and essentially connected with the hospital itself, he 
employed the term “ Hospitalism,” to imply a peculiar fatal septic influence 
generated in large hospitals, and the more intensely the larger the hospital, 
which proved the cause of death in many cases which would have recovered 
under other circumstances. The conclusion followed readily that it was our 
duty to demolish these pest-houses, and to erect “ wooden, or brick, or iron 
villages ” as a substitute. 
His data and conclusions were vigorously assailed by various authors, 
notably by Mr. Holmes and Mr. Callender; and the more recent writers 
who have adopted his views have usually expressed them in a modified and 
more cautious manner. Still it cannot be doubted that the drift of popular 
opinion, both in and out of the profession, has been setting against the erec- 
tion or continued use of large hospitals, and in favor of substituting com- 
paratively small isolated buildings, on the general plan of the barrack first 
used with so much success in our recent war. I have of late had such fre- 
quent occasion to meet with this opinion while superintending the erection 
of the new University Hospital in this city, which is to be a large building, 
consisting of a main central structure with lateral three-story pavilions con- 
nected by a main corridor, as to lead me to examine seriously the ques- 
tion of the justifiability of erecting such a structure for hospital purposes. 
And I beg now to offer a few informal and undeveloped thoughts on the 
subject, in support of the view which I strongly embrace, that there 
has as yet been no good reason advanced for an abandonment of this or 
some analogous mode of hospital construction. 
In the first place, I confess myself unable to appreciate very highly any 
of the statistics which have been advanced on this question, for the follow- 
ing reasons : 
a. That the class of cases, the severity of the lesions, the constitutional 
condition and morale of the patients, are not shown to be analogous in the 
two sets of figures. This holds good both in rural and military as compared 
with civic practice. 
b. That in the most convincing set of statistics, those drawn from 
private practice, it is certain that the returns do not represent fairly the 
average result in any given district. THE SANITARY RELATIONS OF HOSPITALS. 
3 
c. That the statistics bear only on certain classes of cases (wounds and 
operations), out of the many for which hospital accommodation must be 
provided (fractures, medical cases, etc.). 
d. That at most the statistics prove nothing against such hospitals, per se, 
but only against certain remediable abuses and errors in their construction 
and administration. Thus, for instance, it is evident that if certain well- 
known conditions, requisite for health, and especially for the successful treat- 
ment of serious diseases, be neglected or willfully departed from, increased 
mortality will inevitably result, whether the cases be treated in a large hos- 
pital or in small isolated barracks. 
I fail to see why these last conditions, perfect cleanliness, thorough ven- 
tilation and insolation, ample allowance of air or ward space to each patient 
(i. e. entire absence of overcrowding) ; careful grouping of cases, so as to 
avoid accumulation of cases of certain classes in the same ward ; uniform 
and suitable temperature ; skillful, assiduous nursing and treatment,— cannot 
be as well obtained in large hospitals as in isolated small structures. 
It is of course evident (as pointed out by Ashhurst and Holmes) that, if 
the hospital authorities allow their buildings to become so overcrowded 
that the patients are deprived of the needed amount of pure fresh air, 
while at the same time the milder cases are turned into “ out-patients,” and 
the wards contain a disproportionate accumulation of grave cases of sup- 
purating wounds, extensive burns, compound fractures, serious operations, 
or, in the medical wards, of erysipelas and infectious fevers, an increase 
in the death-rate will occur. Not only will more per centum die than in 
another hospital where the wards are filled with cases of mixed character, 
mild with severe, but more will die per centum of any one of these classes 
of grave cases than would die if treated in a hospital where there was no 
such unnecessary and criminal “overcrowding.” Or if, again, actuated by 
an utterly false conception of their duties to the community, the authorities 
of any hospital are induced to erect additional wards on their grounds, so as 
to interfere with the supply of light and fresh air to the original structure, 
or to convert rooms inadequately supplied with the necessary conditions into 
wards, it must inevitably follow that the sanitary condition of the hospital 
will suffer, and that a corresponding elevation of the death-rate will present 
itself. 
Many of my hearers may be familiar with a now notorious case, tlmt 
of the Norfolk and Norwich General Hospital (England), which has 
recently been made the subject of an able invective by Dr. Beverley, one of 
the surgeons connected with it. According to his statistics, and they are 
unquestioned, this hospital, up to the year 1862, stood almost alone in 
the success that attended its surgical practice; 910 persons had been oper- 
ated on for stone, and 792 had recovered. On two occasions 40 cases of 
stone had been operated on without the occurrence of a single death. Yet 
during many years the hospital had been receiving a large but not an exces- 
sive and disproportionate number of cases of wounds and burns, and cases 
requiring surgical operation. Still, until 1862, the existence of “hospital- 
ism,” that fatal septic influence, was not suspected. Since that time an 4 
THE SANITARY RELATIONS OF HOSPITALS. 
excessive number of the above cases has been admitted, great overcrowding 
has resulted, and the governors have even modified the original plan by 
building more wards so as to interfere with ventilation. 
The pressure upon the accommodation of the hospital may be judged 
of from these figures ; 
1854 to 1863. 
1864 to 1873. 
Surgical Operations . . 
1666 
25I3 
Wounds 
359 
779 
Fractures, Burns, and Scalds 
271 
491 
It is perhaps needless to say that a frightful increase in mortality has 
occurred in this once model hospital. Yet I can conceive of nothing more 
fallacious than any argument against large general hospitals based upon 
such cases as these. The conclusion the only warrantable conclusion 
that can be drawn is, that so long as the business of the hospital was kept 
within its legitimate limits, hospitalism was unknown ; but with the advent 
of unjustifiable overcrowding came also this dreaded and fatal result. 
I cannot lay too much stress upon this question of overcrowding and 
imperfect ventilation, because I truly believe that the prevalence of these 
defects in most large hospitals of any considerable age, popularity, and 
wealth, has been chiefly responsible for the unfavorable results charged 
against so many of them. It is to be observed, also, that this evil of over- 
crowding is most apt to be constant and extreme in those very institutions 
where it can least be tolerated, and which are, for obvious reasons, most 
apt to be selected for statistical investigation. I refer to the large municipal 
hospitals in the principal cities both on the continent of Europe and in 
America. As these depend for support upon appropriations made by the 
municipal government, and are compelled to receive all applicants, there is 
usually no power in the hands of the hospital authorities to prevent the 
most flagrant and fatal overcrowding. When it is borne in mind further 
that the patients gathered in such institutions are from the most abject and 
enfeebled classes of the community; that in many instances the buildings 
themselves are wanting in the requirements for a successful hospital, 
and that it is frequently impossible to obtain from the city authorities a 
sufficient annual sum to properly conduct the ordinary affairs of the insti- 
tution, much less to supply it with the artificial forced ventilation which is 
needed in such buildings, it will be no source of wonder that the rate of 
mortality in the municipal hospitals of Paris, Vienna, Berlin, New York, and 
Philadelphia, should be disgracefully high. 
On the other hand, in hospitals which depend upon private subscriptions 
for support, the income is scarcely ever large enough to enable the hospital 
authorities to admit a very excessive number of patients, and thus one very 
powerful check upon overcrowding exists. If, further, as is the case in 
very many of the hospitals in this country and England managed by private THE SANITARY RELATIONS OF HOSPITALS. 
5 
corporations, a constant, energetic, and intelligent care is exerted in the 
avoidance of all defects or abuses of administration, and in the improve- 
ment of the means of ventilation and heating, it may be confidently asserted 
that a rate of mortality will be secured so low as to compare favorably with 
the results obtained in the treatment of strictly analogous cases in isolated 
barrack wards.1 
In using the term “ avoiding overcrowding,” I do not express all that I 
conceive to be the duty of hospital authorities in this direction. It seems 
to me indispensable, no matter on what plan a hospital is constructed, that 
certain wards should be rigidly and invariably kept in reserve, only to be oc- 
cupied when from time to time the various wards in use are vacated in regular 
rotation for purposes of complete cleansing, or, if necessary, of renovation. 
The frequency and extent of such renovation must depend upon the char- 
acter of cases treated in the ward, and particularly upon the occurrence of 
the slightest evidence of septic infection. It is to be remarked here, that 
such renovation of the wards of a large hospital can be more readily and 
far more economically effected than can the destruction and restoration of a 
temporary barrack. In the ordinary course of events, even when not the 
slightest evidence of infection has been developed, each ward should be 
successively vacated, say once in three or four years for three or four 
months, the beds scraped and repainted, all utensils renewed, the floors 
planed and treated anew in the original manner adopted, the ceilings and 
walls thoroughly cleansed and coated afresh with some non-absorbent ap- 
plication, the remaining wood-work scraped and repainted. If any serious 
cases of infection have occurred, it would be easy to hack the walls and ceil- 
ings and to replaster them, and to entirely renew the flooring. 
I have had ample opportunity of observing the entire success of even 
less thorough renovation of old wards which had become alarmingly infected. 
Perhaps in few, if any, hospitals in the world is a larger proportion of cases 
of wounds, compound fractures, and cases requiring surgical operation, 
treated than in the Pennsylvania Hospital in this city. On more than one 
occasion, during my acquaintance with the administration of that noble 
charity, has one or another of its surgical wards become infected with 
pyaemia, or erysipelas, or gangrene, to such an extent as to induce a re- 
moval of the patients to a distant ward, a complete closure for several 
months, and a thorough cleansing of the infected ward. In every case, 
after the reopening of the ward, the results of treatment have been as favor- 
able as in an entirely new structure. In no instance, save only in the occa- 
sional occurrence of a few cases of facial erysipelas, have I known the med- 
ical wards of that institution to present any conditions which would justify 
the belief that the patients there treated were subjected to any depressing 
septic influence. 
1 Since reading the above paper, a letter has been published in the Philadelphia Medi- 
ical Times, November 21, 1874, by one of the surgeons of the Pennsylvania Hospital (to 
which reference is made further on), which confirms in the strongest possible manner the 
views here presented. It may be mentioned that the present building of the Pennsylvania 
Hospital has been in constant and most active use for 120 years. 6 
In the case of Bellevue Hospital, New York, and of the Philadelphia Hos- 
pital in this city, the very unfavorable results obtained at certain times are, 
as I have already suggested, plainly attributable to gross defects of con- 
struction, and to a degree of overcrowding only to be pardoned on the score 
of the culpable penury of the city authorities in regard to this vital question 
of public health. 
THE SANITARY RELATIONS OF HOSPITALS. 
In the remarks I have made I have assumed that the large hospital was 
constructed so as to present the necessary conditions for successful treat- 
ment of the sick. lam sure that many of the great hospitals now in exist- 
ence deserve richly to be razed with the ground for their utter failure to 
comply with these simple requirements. But I cannot draw from this the 
conclusion that it may not be desirable to erect new hospitals as they are 
required, of large, even of palatial dimensions, but in more strict conformity 
with sanitary conditions. These are simply : 
Free exposure to light and sun. 
Free supply of pure air, both by natural and artificial ventilation, and 
thorough removal of the exhausted or foul air. 
Means for securing a uniform degree of pleasant heat; and to favor ab- 
solute cleanliness, as by the entire absence in the wards of cracks, recessed 
angles, etc., where dirt may collect. 
The employment of the most non-absorbent surfaces, and their coating 
with non-absorbent applications. 
Entire separation of wards. 
Entire separation of all water-closets, slop-hoppers, etc., from the wards, 
and independent arrangements for thorough ventilation of the former. 
Existence of spare wards, to be used from time to time. 
It is desirable, also, that there should be in connection with every large 
general hospital, a couple or more of isolated wards, each, if possible, 
containing also several separate small chambers,—for certain classes of 
cases which are not suitable for admission into a general ward. Such would 
seem to be, among surgical cases, extensive burns, wounds, or operations 
causing exposure of very extensive suppurating surfaces ; cases of traumatic 
erysipelas, or of gangrene ; and among medical cases, infectious fevers, ery- 
sipelas, dysentery, etc. 
I am convinced that all of these are readily obtainable in a well con- 
structed hospital at the present day ; and I am assured, from the ability and 
energy with which questions of ventilation, heating, and construction in gen- 
eral are now being investigated, that still better results will soon be achieved. 
I have thus imperfectly attempted to express some of the reasons which 
make me feel that the charges hitherto brought against large hospitals do 
not prove any essential defect, but merely that errors in construction or ad- 
ministration have frequently been committed. 
A second important argument in favor of large hospitals seems to me to 
be found in the economy of their construction and administration. 
In the discussion of the relative merits of different styles of hospitals, 
the importance of these considerations appears to be frequently overlooked. 
It is easy to say that it is not necessary for a city to provide hospitals for its THE SANITARY RELATIONS OF HOSPITALS. 
sick poor; but that if it does, it is its plain duty to supply the very best 
kind, irrespective of expense. I think it will rather be held that it is the 
imperative duty of cities to supply ample hospital accommodation within its 
limits ; and also that, looking to the enormous drain which the provision 
and maintenance of hospitals makes upon private and public funds, it is ob- 
ligatory that this should be done in the most economical manner consistent 
with efficiency. 
a. The first element of expense in connection with the hospital is the ground. 
It is necessary that this should be well situated as regards elevation and 
surroundings ; it is necessary, also, that it should be of ample size, so as to 
ensure abundant supply of air and light. But it is also necessary that it 
should be in a central location, so that patients may the more readily be 
transported to its wards, but chiefly in order that it may secure the constant, 
assiduous services of the experienced and skillful physicians and surgeons in 
the community. It is needless to say that if the site were chosen so far from 
the centre of population of the city as to be where land is cheap, it would 
probably be so far distant from the residences of the leading medical men 
that the hospital would be compelled to depend upon salaried medical offi- 
cers permanently attached to it. It will be conceded by all that no more 
unfortunate result could happen. Yet it may safely be asserted that to erect 
hospitals on the plan of isolated tents, or one-story barracks, will require 
much more than twice as much ground as is needed for a hospital of equal 
capacity built on the improved pavilion plan. It is sufficient to contemplate 
the difficulty of replacing the present hospital accommodation of London 
by a large series of “ brick, wooden, or iron villages,” as urged by Simpson. 
b. It is frequently asserted that the original cost of construction is greatly 
less in the case of barrack hospitals. This, of course, is true of light 
wooden structures, or of canvas tents. But it seems to me that it has not 
yet been demonstrated that such accommodations are suitable for a perma- 
nent hospital organization in our climate, and for the class of patients who 
seek shelter in our large city hospitals. When it comes to a more substan- 
tial barrack built solidly of brick, and furnished independently with all the 
needed conveniences, I doubt if such accommodation can be provided, 
ready for use, at a cost of much less than $4OO or $5OO per patient, which 
approaches the cost per patient of large, handsome, permanent pavilion 
hospitals, constructed in the highest possible style of architectural thorough- 
ness. 
Add to this that the great, the characteristic advantage claimed for bar- 
racks and tents is that it can be afforded to tear them down and replace 
them by new structures at certain intervals. For it must not be overlooked 
that even the warmest advocates of barracks acknowledge that there is dan- 
ger of septic infection if their wards are long occupied by a serious class of 
surgical cases. It is difficult to conceive how it would be possible to suc- 
cessfully conduct the large hospitals of such a city as this on a plan which 
required the erection of buildings at a cost of S4OO or SSOO per bed, which 
were destined to destruction at the expiration of five years, or sooner if evi- 
dences of septic poisoning made their appearance. I have already pointed 8 
THE SANITARY RELATIONS OF HOSPITALS. 
out that if anything less thorough than entire demolition and reconstruction 
is intended, it is quite as easy to renovate the wards in a large hospital as in 
an isolated barrack. And let me remark that in advising the construction 
of two or more outstanding barracks in connection with every large general 
hospital for the reception of certain classes of cases, I had reference to very 
inexpensive wooden structures, of strictly temporary character, and designed 
to be invariably demolished after a few years’ use ; though, as already re- 
marked, I think it yet remains to be shown that such structures are as well 
adapted for continuous occupation in all seasons by the enfeebled class of 
patients who fill city hospitals, as the wards of a well-constructed hospital of 
large size. 
c. It is only necessary to allude to the very great increase in the difficulty 
and cost of administration of a hospital of large capacity constructed on the 
plan of detached barracks. It would include a far larger outlay for heating 
apparatus and fuel, greater expense in the kitchen department, in attend- 
ance, etc. But this is too self-evident to require further attention. 
Thirdly, in addition to the advantages of economy possessed by large 
pavilion hospitals, must be mentioned the great importance of facilities for 
clinical instruction in connection with hospitals in large cities. The di- 
vision of a hospital into a series of widely detached small buildings must 
inevitably prevent anything like systematic clinical instruction before large 
classes. It would be manifestly impossible to transport very many of the 
most instructive cases of disease or injury to any central building where 
accommodations were provided for lectures. And yet, so far as the health 
and vital interests of the community are concerned, there is but one feature 
of hospitals, namely, the sanitary interests of their inmates, which is of more 
profound importance than the full clinical instruction which should always 
be conducted in connection with them. 
It is impossible to overestimate the practical importance of the question 
we have been considering. It can scarcely be supposed, if the unbounded 
abuse which has of late years been heaped upon large hospitals of per- 
manent construction, should be continued, that the private generosity 
upon which so many of them, in America and England, depend for their 
entire support, will not be checked. It cannot be doubted that for 
certain classes of cases, isolated barrack or tent hospitals of temporary 
character are the best possible form. It is very certain that, in times of 
war, when a sudden and temporary increase in the demand for hospital 
accommodation arises, such structures have been highly efficient, and that 
reliance should be placed exclusively upon them, instead of allowing the 
permanent civic hospitals to be overcrowded by the reception of unusual 
numbers of serious cases. It is also evident that for military and marine 
stations, where the hospital site can be selected without reference to the 
surrounding population, where the cost of administration is defrayed by 
governmental appropriations, where the extent of accommodation required 
may vary rapidly and even the permanence of the institution is indefinite, 
where the medical staff is immediately attached to the hospital, and no 
demand exists for clinical facilities, that barrack hospitals present many THE SANITARY RELATIONS OF HOSPITALS. 
9 
points of advantage. On the other hand, I have endeavored to suggest 
some of the practical considerations which make it probable that most of 
the necessary hospital work of great cities can be done, and well done, in 
large, substantial buildings, located in central positions. 
As to the question of the actual relative merits of large hospitals and of 
isolated barracks, there probably exists considerable diversity of opinion. 
I can merely say that I am not aware of any statistics in existence which 
afford us the means of positively determining the question. It appears to 
me that there is needed for that purpose a large series of observations upon 
the mortality in a well-constructed and well-administered general hospital in 
one of our large cities, and in isolated barrack or tent wards in the same 
location, receiving the same run of cases, which should be subjected to the 
same method of treatment. It will not, I trust, be long before such sets of 
statistics are before the world. In the mean time, the general considerations 
I have attempted to express, as well as others, which time will not permit 
me to touch upon, compel me still to believe that it is possible to construct a 
large hospital with such due provision for ventilation, and to administer it 
with such constant, unswerving regard, not to the grand total of cases 
treated and operations performed, but to the sanitary conditions of the in- 
mates, as that it shall prove a safe shelter for the sick and suffering, a suc- 
cessful field for medical and surgical practice, and one of the noblest gifts 
of an enlightened, intelligent, Christian community to the poor who are 
intrusted to their care. 
I will not close without one word of appeal to all who hear me in behalf 
of this important subject. The papers and discussions which have been 
prepared by some of my colleagues, who have devoted much study to the 
construction of hospitals, are of themselves sufficient to show how much 
attention is being devoted to this question, and how much advance is being 
made in our knowledge of the materials and mode of construction, and of 
the methods of heating, ventilating, and disinfection ; and to assure us that 
eventually the best modes of securing all the sanitary requisites in a hos- 
pital will be clearly determined. 
But there is a matter of at least equal importance, on which, as a medical 
man connected with several hospitals, I may speak wdthout hesitation. I 
allude to the vast importance of the proper administration of hospitals. 
The single instance I have quoted to you of the Norwich Hospital is suffi- 
cient to demonstrate the terrible results which may follow an injudicious 
or careless mode of conducting such an institution. It is too much the 
custom in all great hospitals, here and elsewhere, to trust the control of the 
sanitary interests of the hospital solely to the medical staff, while in many 
instances the governors or managers are little more than the trustees and 
executors of a trust fund invested for the support of the institution. It 
must be acknowledged, however, that for manifest reasons, the medical staff 
are not the best persons to keep watch over the sanitary condition of the 
hospital. Conscious of their own pure zeal in relieving suffering and dis- 
ease, willing to lavish their time and best efforts in the service of the poor 
without remuneration, they are too frequently tempted to urge or sanction THE SANITARY RELATIONS OF HOSPITALS. 
the admission of deserving cases into the hospital wards beyond their strict 
lawful capacity. Intensely interested as they are in the treatment of the 
dangerous cases which constantly fill the wards, there is a risk that their 
attention is too closely riveted upon the actual duties of the day, to allow 
them to take at the same time a comprehensive view of the general results 
of the administration of the hospital as a whole, and of the sanitary con- 
dition of the building. To secure constant and critical attention to these 
all important matters, there is needed a superintendent possessing a high 
degree of ability, executive power, and acquaintance with hygienic laAvs ; 
as well as more study and watchfulness on the part of the managing board 
of these institutions, which should invariably contain a full proportion of 
medical men not connected in any way with the medical service of the hos- 
pital. It is impossible that, with a clear business-like inspection of the re- 
sults of the operations of the hospital, and of its general sanitary condition, 
such as would be given by a board composed partly of experienced men 
of business, partly of medical men, any grave departure from the correct 
principles of administration, or from average success in the results, should 
remain unnoticed and fail to receive whatever attention might be needed 
to rectify it. So that I would close by repeating my firm conviction that, 
with correct modes of construction and organization, and with a proper 
system of administration rigidly enforced, large permanent hospitals will 
be found to yield good average results in the treatment of medical and 
surgical cases, and that very many of the grave charges which have been 
brought against them will prove to have been evoked by the abuse, not by 
the proper use of these institutions.