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PRINCIPLES
OF
HOSPITAL CONSTEUCTIOK
  ARMY
 MEDICAL
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   At a  meeting  of the  Trustees of the Roosevelt  Hospital,
held March 28, 1865, it was
   Resolved, That  it be referred to a Special  Committee, consisting of Dr.
Delafleld,  Mr. Trimble, and Mr. Muller, to prepare or have prepared, and to
report to this Board, a plan for the Hospital Building of this Institution ; and
that the sum of $1,000 be appropriated for the expenses of said Committee.
   In  accordance with the above resolution, the Committee
requested Dr.  Stephen Smith, of this city, to prepare a Report
on Hospital Construction ;  authorizing him to  visit all the
principal hospitals in this country, and  to obtain  the  best
works on the  subject, whether  published at home or abroad.
The Committee felt assured that in this mode alone could they
expect  to obtain  all  the knowledge which was absolutely
requisite to  have  such a plan for hospital  buildings as  was
contemplated by the Trustees of the  Roosevelt Hospital.
   At  the regular meeting in  November following, the Com-
mittee presented  an elaborate report, by Dr.  Smith, on the
subject of hospitals, with descriptions,  plans, and elevations of
a number of the most approved hospitals in different parts of
the world ;  and, also, an abstract of the report, presenting in
distinct  propositions  the several principles of hospital con-
struction, which had been set  forth in  Dr. Smith's valuable
work.
   Whereupon  it was ordered, that 250 copies of the Abstract
should be printed for the use of the Board. 
 
PRINCIPLES
HOSPITAL    CONSTEUCTION.
  I.—A  Civil Hospital, designed  for the treatment of acute conditions of
                                                           location.
diseases, both Medical and Surgical, should be located so as to
be easily accessible by that class of people who will seek ad-
mission to its wards, and by the attending medical officers.

  II.—When a country site can be selected which will fully country  site
                                                           preferred.
answer the foregoing requisites, it should be  preferred  to a
location within the limits of a populous town.

  III.—But if these conditions can not be fulfilled, except by site-when the
                                                           choice is limit-
locafcing  the hospital  within  the  corporate boundaries of a  ed to the city.
town, a district should be selected as  far removed from popu-
lous suburbs as a due regard to accessibility and availability
will permit,

   iy.—Within the limits finally fixed upon, a  site should be Advantages to bo
                                                           secured in lo-
chosen which will secure the following advantages :           cation.
       1. A sufficient amount of ground.
       2. Freedom from the immediate neighborhood of  pres-
           ent and prospective   nuisances;  as  manufactur-
           ing  establishments  having  foul  and  unhealthy
           emanations,  a  crowded  tenant-house  population,
           depots for cattle and swine, etc., etc.
       3. Sufficient elevation  to render  the surface and sub-
           soil drainage perfect, and to give  to the hospital
           grounds proper exposure to the currents of air.
       4. A  subsoil porous and self-draining,  and as  free as
           possible from organic matter ; hence avoiding old
           grave-yards,  cattle-yards, etc. 
2
                  5. A large and constant supply of fresh water.
                  6. Easy transportation of the sick.

preparation  of    y._[n the preparation of the grounds the grading should
 the grounds.                                                .,  ..  .
            have special reference  to the surface  and subsoil drainage, in
            order to render the soil and foundation work of the  hospital
            dry.  All sewers leading from the grounds should be provided
            with ample means of flashing, and  the interior should be  so
            arranged as to be inspected without difficulty on the grounds.
            Drain-pipes should be  tapped outside of the building.   No
            drain or  sewer should  pass under any building, but should
            lead as directly from the grounds as possible.

separation of the    yi.—In  the arrangement of the  hospital  buildings,  there
 sick from the
 administration,  should be a complete separation of the sick from the adminis-
            tration.   For  this purpose it is necessary  that there should
            be properly constructed and independent  buildings  devoted
            exclusively  to  the sick, and  others  devoted  exclusively to the
            administration.

Aggregation  of    yn.—It is  important that the sick should be distributed
 the sick disap-
 proved,      over as  large  a surface area as is compatible with  efficient
            management, and  that  excessive  aggregation under one roof
            should  be  avoided.   Hence  the  necessity  of  several  in-
            dependent buildings for the sick, and of a sufficiently  large
            area, to constitute an improved hospital.

pavilion  hospi-    VIII.—The  practical application   of  these principles  to
            hospital construction gave  origin to  the pavilion plan, now
            universally  adopted throughout Europe as the only  method of
            securing  the proper sanitary conditions of these institutions.
            Miss Nightingale thus  describes a pavilion:  " By  a  hospital
            pavilion is meant, a detached block  of building, capable of con-
            taining the  largest  number of beds  that can be placed  safely
            in  it, together with suitable nurses' rooms,  ward  sculleries, 
3
lavatories, baths, water-closets, all complete, proportioned to
the number of sick ;  and quite unconnected with  any other
pavilions of which  this hospital may consist, or with the gen-
eral administrative offices, except by light airy passages  or
corridors. A pavilion is, indeed, a separate, detached hospital,
which has, or ought to have, as little connection in its ventila-
tion with any other part of the hospital as if it were really a
separate establishment miles away.7'

  IX.—The  pavilions should  be arranged  on parallel lines Arrangement of
                                                             pavilions  o n
running nearly  north and south.  The two long walls of the  the grounds.
buildings will  thus receive  the  full sweep  of  the  prevailing
winds, and also the  direct rays of the sun, during the larger
portion  of each day.   They should be separated  from each
other a distance so great  that the intervening court will  be
exposed to the unobstructed sunlight and  air.   Miss Nightin-
gale  gives the  following  rule : " The  distance between the
blocks should not be less than twice  the height of the blocks."
Recent  English' hospital  pavilions  are  separated  100 feet:
but it is evident that the distance should depend much upon
the elevation of the  site and its natural  exposure to sunlight
and the  currents of  air.    In  exposed positions,  where the
winds constantly sweep the  sides  of the building,  and the
direct sunlight  falls upon both sides of the ward the greater
part  of the  day, a separation of 75 or even 60 feet  may be
sufficient.

   X.—It is advised by some writers, as Miss Nightingale, that Number  of
                     J                                        stones.
the hospital  should never have more  than two stories of wards.
But in  the pavilion plan,  which admits  of such wide distri-
bution  of the  sick,  there  is no  sufficient evidence  against
three stories of wards.  Certainly, in  a town like New York,
where  land  is  expensive, it is  desirable to concentrate  the
buildings upon as limited an area  as is  compatible with  the
healthiness of the institution ;  and there  is no  satisfactory 
4
Construction of
 pavilion.
            proof that a pavilion with three stories of wards may not be
            as healthy as one of but two stories, provided each ward has
            an independent and effective ventilation.

              XI.—The length of each pavilion  should  be proportionate
            to the size of the ward and of the  accessory rooms.  The fun-
            damental  principles to be observed in its construction are, first,
            such separate and independent methods of ventilation, by nat-
            ural means, of the wards, halls, stairways, water-closets, bath-
            rooms,  and  other apartments,  that  each will be  constantly
            flushed with pure air, and the emanations of one can not by any
            possibility escape into another;  second, the materials  of the
            internal portion of the building  should be as1 nearly as possible
            non-absorbent; third, such distribution of the sick as will give
            to each patient proper  surface area and air space ;  fourth,
            facility of nursing and administration.

width of ward.    XII.—The width of  the ward  portion  should   never be
            more than 30 feet, in order  that the opposing windows may be
            brought sufficiently near  to each other for complete through-
            and-through ventilation.

size of wards.     XIII.—Small wards complicate the administration by adding
            to the number of attendants and the ward appliances, and can
            not be as thoroughly ventilated and disinfected as large wards,
            owing to the increase of walls, wood work, dead corners, furni-
            ture, etc.  The ward should be designed, therefore,  to  accom-
            modate as many beds as is compatible  with  efficient nursing
            and administration, and a due regard to the cubic air space and
            surface area to each patient.

^ace.' °f air    XIV.—The amount of cubic air space  necessary to each
            patient depends upon the freedom and effectiveness of the ven-
            tilation ; but in  a hospital located within a large town, the
            allowance  should be for not less than  1,800 feet.  In the civil 
5
hospitals of Paris, it is  fixed at 1,700 ;• in those of London, at
2,000 ; while in some of the most recent hospitals it is raised
to 2,500.
   XV.—It is a  well-established  fact  that  the  impure air surface area to
                                                            each bed.
emanating from  the person  or   excretions of the sick di-
minishes  as  the  square of the distance, and hence the ne-
cessity of a  sufficient  separation  of the beds  to prevent the
injurious reaction of the sick upon one another.  As a rule, each
bed should have a space of 8 feet on the average, with 12 feet
between foot and foot.  Beds should be at least 3 feet apart.
One hundred square feet to each bed is now recommended.
   XVI.—In accordance  with the foregoing principles, the Number  of Pa-
                                                            tients  to  a
number  of patients to each  ward is  now  generally fixed at  ward.
from twenty-five to thirty-two.
   XVII.—If twenty-eight patients  to  a  ward  be taken as Proportions of
a medium, and  1,800  cubic  feet  of air  as  the average, which
is  nearly the  standard adopted  in Paris and  London, the
following proportions  of  the  ward  might  be  adopted :
Length,  110 feet; breadth, 28 feet ; height,  17  feet.   This
would give about 1,800 cubic feet to each patient.  If there
are three  stories  of wards, the height of each may vary, that
of the first being greatest, and that of the third being least,
owing to the difference of exposure to air  and sunlight of the
 different stories.  The following table exhibits the proportion
of wards in the most recent hospitals of France and England :
    PROPORTIONS OF WARDS.            FRENCH.     ENGLISH.
                                         Ft.  In.        Ft.  In.
  Length of ward...................    HI  6       128 0
  Breadth.........................     30  0        30 0
  Height..........................     1T-0        IT G
  Space between end wall and windows.     5  0         6 4
  Breadth of windows...............      48         48
  Space  between windows...........      9  2        11 4
  Height of windows................     13  0        13 6
  Cubic space per window...........   1,760  0     2,100 0 
6
Height of ceii-    The  height  of ceiling should not be less than fourteen, nor
 lag.
            more than eighteen feet.. An excess of cubic air space above
            the sick is not available, and too often furnishes a stratum of
            foul air, which  is  not sufficiently moved by the currents of air.

Number and size    XVIII.—The windows should be  multiplied to as great an
 of windows.
            extent as is compatible with the safety  of the wall.  There
            should be at least one window to every two beds.   A window
            to every bed  is   the rule  in  many  recent  hospitals.   The
            windows should  extend from within three or four feet of the
            floor to near the ceiling ; the upper part of the windows should
            be square  instead of oval,  and they  should be arranged op-
            posite to each  other.   Stained  glass may be used, or outside
            blinds.  Double windows, so arranged as to secure ventilation,
            are important,  as they serve to  retain heat.

water-ciosets   XIX.—The water-closets should be placed at the end of the
 and sinks.                                         x
            ward, opposite the entrance, and be  so isolated from the ward
            that emanations  from the former can by no  possibility pene-
            trate  to the latter.  There should  be between them a well-
            ventilated  lobby,  and the water-closet should  have its own
            separate ventilation by opposite windows.   The sink for the
            ward slops, expectoration cups, bed-pans, etc., should be in an
            apartment  adjoining the water-closet, and should consist of a
            deep basin supplied with a vertical stream of water.
Baths and lava-
 tories,
              XX.—In the same end of the  building, but in the opposite
            corner  or angle, should  be arranged the  ward baths  and
            lavatories,  with  an  equally well-ventilated  lobby  as  the
            water-closet.

^cuiiery, 117'    XXL~At the end of  the ward, corresponding  with the
            entrance, should be arranged   the  accessory  rooms.   The
            nurse's room should immediately join the ward, with a window
            opening  into it, so placed that at a  glance she can survey the 
                            7
 entire ward.  Adjoining this room should be  the room of the
• assistant  nurse.    In  immediate  proximity  should  be  the
 clothes  room  of the ward.  On the opposite side of  the hall
 should be the ward scullery, with conveniences for warming
 drinks,  cooking light articles, washing dishes, preparing fo-
 mentations,  etc.   In immediate relation, a small ward dining-
 room should be arranged  for patients  not able  to  go to  the
 general table ; or, of sufficient size to.accommodate the entire
 ward, when  there is no general table.

   XXII.—There must  be  provided  in  this part of the build- L|fts and foul
                           1                x                   linen shoots.
 ing, lifts for conveying articles to and from the wards and the
 basement, as food, coal, etc., etc.   It is also desirable to have,
 separately constructed,  a foul linen shoot, through which dirty
 and soiled articles of the  beds can  be sent  to the basement
 without contact with any  ward  articles.   Miss Nightingale
 says : " These  should be built in the wall.  The best materials
 for them is  glazed earthenware piping, 15  to 18  inches in
 diameter.  They should have an  open mouth also of earthen-
 ware, with a door, opening not near a ward, but from  a stair-
 case or well-ventilated passage ;  and they should end  below
 in a  small closet, out of which the linen should  be taken as
 soon  as the change is completed, and removed at once to the
 wash-house."

  XXIII.—If there are three stories of wards, there should be convalescents'
                                                             room.
 a day-room on  the second  or middle floor, where the conva-
lescent patients of the pavilion can pass their  leisure hours in
reading,  conversation, and games.  In many recent hospitals,
a separate  building is assigned to this special purpose.

  XXIV.—On the  first ward-floor, at the main  entrance  to Medical officers'
                                                             room.
the pavilion, and near  the stair-way leading to the several
wards, the  rooms  for  the resident medical officers  of  the 
           division  should  be arranged, with  speaking tubes,  or  other
           means of immediate communication with the wards and other
           departments of the hospital.

construction of   XXV.—For the accommodation of these accessory rooms of
 the extremities                                   #          i  • i -i •
 of the pavii- the wards, a greater  or less extension of the building  is re-
 '0nS-                                           -,       r.
           quired, according to  the  number  and size of the  rooms.  In
           general,  the two ends of the pavilion are made considerably
           wider than the central or that devoted to the  wards, and those
           rooms are located in the extensions.  Occasionally, also, the
           buildings terminate in  towers, and  then  the  accessory rooms
           are placed in them.   Whatever plan is adopted, the principle
           should not be lost sight of, that angles, corners, jutting  walls,
           etc., are  to be avoided as far  as  possible ; and, also, that as
           few accessory rooms should be provided as will serve the pur-
           poses of  good and efficient administration.   Towers are always
           very expensive,  and are more ornamental than useful.
Basement.
Heating.
  XXVI.—The basement should  be elevated,  at least half
the height being above ground ; it should  be constructed on
arches, and be supplied with large windows for the purpose of
free ventilation.  As it is to be devoted to the administration,
care should  be taken in  its subdivision to  render every part
accessible and well adapted for its particular service.

  XXVII.—The wards should be heated by open fireplaces,
placed along the sides  of the wall;  the adjacent rooms may be
heated by  stoves.   If any artificial  method of heating  be
adopted  it should be  subordinate  to  the open fireplace, and
not the principal means.

  XXVIII.—Natural  ventilation, as by  windows, doors, and
fireplaces in use, should be adopted and enforced.  All artifi-
cial methods of ventilation have failed when practically applied
to hospital buildings, and  if  employed in any form, should be
subsidiary to natural ventilation. 
9
  XXIX.—The exterior walls may  be built of brick.   The
interior walls should be of the most non-absorbent material
obtainable.  Parian cement is  much used abroad, also stucco.
There should be  as little wood-work as possible ; and  the
wood, both  of  the floors, windows, and  doors,  should be
treated with beeswax and turpentine, to render it non-absorb-
ent.  Georgia or  Florida pine, or oak,  is the most suitable
wood.

  XXX.—The  administration  building  is  designed  to  ac-  Administration
                                                             building.
commodate the apartments of the resident officers, the offices of
administration, etc., etc.  -It should  be central, and arranged
on  a plan best adapted to secure the rapid  and efficient  dis-
charge of all the details of administration.  Subordinate offices,
as  that of clerk,  steward, apothecary, etc., etc., should  be in
immediate communication with the chief office.

  XXXI.—The kitchen  is generally located in the basement  Kitchen.
of  the central building; but when the extent  of the ground
permits, it should be in a separate building or wing.

  XXXII.—The operating theatre is usually constructed in the  operating thea-
                                                             tre.
upper story of  the  central building ; but when practicable, it
should be near the surgical wards, in order to avoid the trans-
portation of the wounded or injured, as well as those who have
been recently operated  upon.

  XXXIII.—The steam apparatus   should be  confined to  a  steam appara-
separate building, but so central as to waste but little heat in
the passage of water and steam through the tubes.

  XXXIV.—-The wash-house  should  be separated as  com-  wasu-house.
pletely as possible from other departments, as it is  the recep-
tacle  of  the foul  linen.  When practicable, it  should  be
removed from the  hospital grounds.
Materials of
 building. 
10
corridors.        XXXV.—All the buildings should communicate by means
            of corridors, which should be but one story high, with a base-
            ment.  The basement  should communicate directly between
            the  kitchen and laundry, and the basements of the pavilions.
            By means of lifts the wards communicate with this passagQ-
            way, and receive from and send to  the  appropriate  build-
            ing, food, clothes, coal,  etc., etc.   A  railway may run in this
            part of the corridor so  quietly as to be unobserved.  The first
            story of the corridor is intended to be the passage-way of offi-
            cers to the pavilion ;  it  should be  completely open in the
            summer,  but  with provision for closing it, if required, in
            winter.

Fire-Proof.        XXXVI.—It is extremely desirable that all the buildings
            should be fire-proof throughout.  The stair-ways should be of
            stone or  iron,  and  wood-work be  dispensed  with  wherever
            practicable in all parts of the building.
Wards tor conta-
 gious diseases.
  XXXVII.—Small wards for contagious diseases should be
provided in a part of the  pavilions farthest removed from the
centre of the grounds.
^vLrfuppiied1.    XXXVIIL—Hot and cold  water  should be  supplied  in
           abundance to every part of the hospital.