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Primarily, all hospitals are the outcome of ideas evolved direct or in a perpetuated state, of something which has already been done. In this work much that is original has been introduced and it is safe to say that not one hospital which is being built today but has some innovation which is the outcome of existing conditions either good or bad.

This paper will deal with hospitals containing from twenty to one hundred and fifty beds, and it might be said here that the number of beds in any hospital is the index to the scope of the building, but does not in any way give an idea of its size. As an illustration of this, a hospital with but two wards, containing ten beds each (Fig. 1), would be a wenty-bed hospital, but while it fulfils all the requirements of such an institution, its cost of construction, its maintenance and organization are wholly out of proportion to a hospital with twenty private rooms, and it is a common error to figure the cost of a hospital by the number of beds it contains.

Often, too often, the argument is advanced that $1,000 per bed is approximately correct for the calculation of cost of a hospital, but this is a fallacy.

One often hears that Dr. A has a hospital in Allentown of ordinary construction, containing all modern conveniences and twenty beds, which cost $18,000 complete; why, therefore, cannot Dr. B build a hospital of twenty beds in Bennington for $900 per bed when as a matter of fact Dr. A's institution contains two wards of eight beds each and four private rooms (Fig. 2), whereas Dr. B wants no wards, but twenty private rooms. Moreover, Dr. A.'s two wards, if divided, would make but two rooms each, which would mean that if his building were divided into the units tha Or. B requires he would have practically eight private rooms or ten at the most, cost $18,000.

How, then, can we arrive at a basis for figuring such buildings so that there may be some uniform method of ascertaining their cost? No sliding scale or rule of thumb can be devised for this.

Recently in planning a hospital for one hundred and fifty beds, my attention was directed by those who were going to build to the fact that a Masonic temple in the same town was about the size of the hospital being planned, and that inasmuch as the temple had cost but $150,000, the hospital

ought not cost in excess of that amount, despite the fact that the latter was six stories in height, divided wholly into private rooms and suites with baths, and contained an unusual amount of plumbing, electric work and special contrivances, all of which had to be multiplied by six. This hospital will cost, owing to advantageous contracts, about $1,000 per bed.

The only definite basis for figuring the cost of a hospital is to ascertain the number of beds required, private rooms and wards to house these, the extent of administrative rooms, by which is meant offices, diet kitchens, toilet and service rooms and servants' and nurses' quarters (if no separate provision is made for the latter); then decide what would be the best material or method for building, have preliminary drawings made and figure the approximate cost. No architect or contractor, or even a hospital superintendent, however much he may have had to do with the erection of such buildings, can answer the question, “How much will a twenty-bed hospital cost?" or "How much will a twentybed hospital cost containing an office, nurses' rooms and diet kitchens, two six-bed wards, or three four-bed wards and eight rooms with the necessary rooms that go with them, two operating rooms, etc?” A wide guess can be made, but there is such a difference of opinion as to what constitutes proper arrangement and size of rooms and the thousand other points, that it is practically impossible to determine. All of this particularly applies to the smaller hospitals, for in the greater number of instances the idea of having a hospital precedes the obtaining of funds for its erection by so great a period that there is no basis for exact figuring.

I wish I could bring to you a realization of these conditions. Each of you has his individual problem for solution in mind with no definite knowledge of what is entailed. You order that your hospital shall contain twenty beds or eighty beds, or probably one hundred fifty beds, with so many wards and so many private rooms, or all wards or all private rooms, some with private baths, and compute the cost of construction and maintenance on the number of beds instead of the actual extent of your building and the arrangement of its interior. You appreciate that besides requiring a larger and more costly building, it requires more nurses and consequently larger and more service rooms to care for forty-eight patients in private rooms than it would to care for the same number if you had eight wards of six beds each.

There can be no difference of opinion on one point in the construction of hospitals, namely, the obtaining of the most in construction at the minimum expenditure. The single building is the best for this purpose for many reasons. (Fig. 3.) The first requisite in planning a hospital is to make it a basic unit so that while in itself it contains everythng complete for such an institution, it should be a neucleus for future enlargement without in the least disturbing the general arrangement, or in the first unit of enlargement, for increasing the general service.

In the latter would be included also the administration department, the toilet and service rooms and the operating and kitchen departments.

In a hospital of simple plan, this could be readily accomplished by extending along the main axis. (Fig. 4.) But primarily, this basic unit should be built so that it fulfills certain fixed requirements as follows:

First. Compactness. Second. The maximum of specific requirements in erection at the least cost. Third. The maximum efficiency in maintenance at the least possible cost.

The first can be obtained by making superimposed stories, a regular shaped plan and the size of rooms and ceiling heights that will be best suited to the needs of the hospital, basing the calculation for these on an intermediate rather than a minimum or a maximum.

Second, the elimination of all unnecessary features which are usually adopted to "make a show" or because some institution with unlimited means has these luxuries to gratify a whim not at all in accordance with utility. I do not wish it to be understood that I advocate prison-like hospitals, but marble and tile walls and ceilings, costly woodwork, offices and elaborate board rooms do not serve their purpose to any better advantage and probably not as well as neat, simple and homelike treatment.

Third, by the erection of the buildings upon a simple plan which contains the first two requisites, namely, compactness and maximum of specific requirements and a conservation of the so-called working parts of the hospitals so as to make what might be called the mechanical plant simple in installation and operation.

The different items under this heading have been taken up separately, namely, the superimposed bathrooms, service rooms and toilets, the greatest facility in handling the food from the main kitchen to the diet kitchens and from the special diet kitchens, the drug room, the installation of the signal systems to expedite the work of nurses and attendants, and proper arrangement for the facilitating of the routine work. Also the installation of the special apparatus on each floor so that such floors may be handled independently without the increase of labor or the necessity of large quantities of supplies.

This particularly applies to such apparatus as bed-pan sterilizers, warming closets, and general preparation tables in service rooms, linen room arrangements and diet kitchen arrangements.

The organization of hospitals I need not dwell upon at any length as this subject has been fully treated by Dr. A. J. Ochsner in "The Organization, Construction and Management of Hospitals" (Cleveland Press, Chicago), and it would be somewhat aside from the scope of this paper to give the many methods followed for such organization because you are all familiar with the form which you are following or will follow in this particular branch and have at your command much more detailed information than I could give you at this time.

. There is one subject which requires special comment. After you have perfected your organization, the selection of a building committee should be carefully considered. The fewer members there are on such committees, the better the results in all particulars. A good working committee of three can accomplish considerably more than a larger committee, and if the chairman of such a committee is given discretionary powers to make all preliminary arrangements, it is needless to say that this will expedite matters. The building committee of three can then take up the final arrangements and adhere to a definite system of developing the needs of the hospitals for the present and for the future.

In general, it is a safe rule to follow that the time expended on perfecting plans should be sufficient to develop all of the ideas perfectly before the finished plans are started. This will obviate changes which are difficult to make, as well as expensive, and will result in the completion of the plans and the consequent expediting of the erection of the building.

The specifying of materials for the building should be left entirely in the hands of the hospital expert who in all instances ascertains the local conditions of both labor and material, and whose wide knowledge of the subject gives him the advantage of being able to make the fine discrimination between what is best suited at the least cost and what would be considered as luxurious or expensive, and would under no circumstances serve the purpose to any greater advantage.

So much has been said upon the location of hospitals that only the general requirements for such location are given. You appreciate that the larger the ground and the farther from the street that the hospital is placed, the more advantageous is the location. The principles which have been laid down so often are, that there should be,

1st: An abundance of sunlight,
2nd: An absence of noise,
3rd: Freedom from dust,
4th: Freedom from smoke,
5th: The advantages of a natural system of ventilation,
6th: A proper disposal of all sewerage,
7th: The construction of a building which will have all

the elements of safety from fire,
8th: Accessibility.

For smaller hospitals, up to one hundred and fifty beds, depending entirely upon conditions, either the straight plan or the L-shaped plan is the best for many reasons.

Either of these forms is readily enlarged with the conservation of all the requirements in building and maintenance mentioned. Those marked A, C and D (Fig. 5) are especially recommended. In A the slight shading at the north of the building indicates that between 8 a. m. and 4 p. m. there is practically no sunlight at this wall, but this would be of no great consequence, inasmuch as there could be east and west windows in the rooms facing this part of the building, and as the operating rooms are always placed to the north, the direct north and south plans shown at A is the one that is usually adopted. The one at B running east and west is not recom

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