JOHNS HOPKINS HOSPITAL. 
Reports and Papers 
RELATING TO 
CONSTRUCTION AND ORGANIZATION. 
No. 3. 
Washington, D. C., Jan. 11th, 1877- 
Mr. Francis T. King, 
President of the Johns Hopkins Hospital: 
Dear Sir : 
I have the honor to inform yon that since the publica- 
tion of my Report No. 2, with sketch plans for the Johns 
Hopkins Hospital, I have continued my studies of the 
subject with the following results. 
Having obtained a leave of absence for three months, 
I sailed from Boston, Oct. 7th, 1876, landed at Queens- 
town, Oct. 16th, and re embarked at Liverpool for New 
York, Dec. 16th, having in the interval visited Dublin, 
London, Oxford, Cambridge, Leeds, Liverpool, Manches- 
ter, Edinburgh, Glasgow, Amsterdam, Bonn, Leipzig, 
Berlin, Dresden, Vienna, Venice, Verona, Milan and Paris, 
and having at these points examined Hospitals and Medi- 
cal Schools, so far as the limited time at my disposal 
would permit. 
I endeavored to meet and confer with those who have 
given the most attention to the subject of Hospital Con- 2 
struction and Organization, showing them the sketch 
plans, and obtaining their opinions and criticisms as far 
as possible, and was accompanied throughout the journey 
by Dr. E. M. Hunt, President of the section of Public 
Hygiene of the American Medical Association, who gave 
me the benefit of his observations on the same subjects as 
viewed from an independent stand-point. 
I do not propose here to go into any details as to the 
Hospitals and Medical Schools which I visited, or to specify 
individual opinions, but will briefly state the general 
results. 
I am glad to be able to report that the method of connect- 
ing the Hospital with the Medical Department of the Uni- 
versity, and the objects and character of the Medical School 
as suggested in my first Report seem to meet with general, 
and for the most part, unqualified approval on the part of 
those, both in this country and in Europe, who have given 
most attention to, and had most practical experience in, 
the subject of medical education. 
A few American Physicians, however, doubt whether 
there are a sufficient number of Medical students in the 
United States, possessed of the requisite preliminary educa- 
tion, and who will be willing to devote four years to 
Medical studies, to warrant the course proposed, but they 
say that the experiment is worth trying at all events. 
On the other hand some of the German Physicians, as 
for instance Prof. Thiersch, Dean of the Medical Faculty 
of the University of Leipzig, think that the course of study 
for the Physician should be at least six years as in 
Sweden, or in the new school at Geneva, taking the 
ground that the graduate in medicine should know all 
the resources of his art. It does not seem to me, however, 
that the purpose of an educational institution is to turn 
out perfect scholars, so much as it is to fit men to go on 
studying and investigating for the rest of their lives.\ I 
consider it very desirable for instance, that a man intend- 
ing to be a first class Physician should learn enough of the art of drawing to be able to sketch distinctly any 
peculiarity of form of the body or its organs, in part 
because it also trains him to observe closely, in part 
because it is a powerful aid to bis memory and as a means 
of explanation, but I do not think it necessary that he 
shall be qualified to lecture ex cathedra, and without pre- 
vious preparation, upon any medical subject selected at 
random, in the style that would be expected of a Professor. 
For the purposes of a person beginning his medical 
studies it seemed to me that the English schools were 
superior. Of these the largest, and by many considered 
the best, is that of Edinburgh, and its superiority seems 
in a great degree to be due to the peculiar system of 
what are called extra mural lectures which prevails there. 
Any man who can pass a moderately severe examination 
can lecture on any subject in the medical curriculum that 
he chooses, and his certificate that the student has attended 
his lectures is of equal value before the examining board 
with that of the professor. The details of the arrange- 
ment and of the method of testing the fitness of candidates 
merit careful examination. I can only here state the 
result, which is, that the professor is constantly stimulated 
to do his best, and cannot fall into a rut without suffer- 
ing from the competition of his extra mural rivals over 
whom he has some advantages, but by no means enough 
to enable him to rely solely on them to retain his pupils. 
In the larger Medical Schools of France and Germany, 
the best results can only be obtained by those who go 
there with a very considerable stock of preliminary know- 
ledge. 
In the German Schools there seems to me to be a little 
too much of the forcing process in the stimulating to and 
requiring of original work, instead of trying to fit a man 
to do original work. 
The student is led to think that his highest aim should be 
to do some experiment which no one has done before, and 
for this purpose he may work for a year in the laboratory, 4 
and yet acquire but a tithe of the knowledge which he goes 
there to obtain. As a rule it seems better that specialism 
should follow and not precede general culture; if the 
foundation is narrow the superstructure cannot be wide 
or firm. 
Witli regard to the general plan of the Hospital, I can 
only say, that it is approved by the majority of the experts 
to whom I submitted it. I do not think we have much to 
learn from Europe as regards the general principles of 
Hospital construction and management, or as regards 
methods of heating and ventilation, in fact these things 
cannot be said as yet to be settled on any scientific basis 
of observed facts, and there are nearly as many opinions 
as persons. I found for instance, distinguished professors 
who preferred the old fashioned corridor plan to that of 
wards with opposite windows, who thought that there 
might be too much ventilation, putting draughts out 
of the question, and who spoke of a “ stuffy atmosphere 
as a good thing for certain cases.” | Surprise was freely 
expressed at my coming from America to Europe to learn 
about Hospitals. , 
The general tendency in the most recent Hospitals is, 
however, towards! one story wards, especially for surgical 
and obstetrical cases, or those for which the best possible 
surroundings are desired, and towards separation and 
isolation of the several buildings. 
Thus in the new City Hospital, “ Friedrichshain,” at 
Berlin, the plans of whibh were prepared in accordance 
with the advice of Professor Virchow, there are six two 
story pavilions, four one story, and two for isolating pur- 
poses, with an administration building, a kitchen and 
laundry building, a pathological building, a bath house 
and a nurses' home, and all these buildings are entirely 
isolated from each other, without any connecting corridors 
whatever, being scattered over a lot about 900 by 1200 
feet, and containing acres. 5 
I present herewith a copy of a description of this Hos- 
pital, with detailed plans and drawings of all its parts, 
by the architects M. M. Gropius and Schmieden, which 
merits careful examination, and also a set of plans of the 
new Military Hospital at Templehof, Berlin, by the same 
architects. 
I did not find it possible to obtain positive reliable data 
as to the effects of various plans of Hospital construction or 
ventilation. As a rulejeach person thought that the system 
with which he was most familiar was the best1, although 
in a few instances the reverse of this was the case, but 
when I attempted to go behind the dogmatic assertions 
and find out upon what they were founded the result was 
negative.) Mortality statistics are of no use for this pur- 
pose, since the character of the patients received varies so 
much. I tried at first to get the statistics of certain classes 
of cases, such as compound fractures and dislocation, and 
outbreaks of erysipelas and septicaemia, but I was soon 
convinced that these depend far more on the methods of 
treatment, and especially on care in the use of disinfectants 
and antiseptics, and in the preservation of cleanliness, than 
in the construction of the wards, and /that where what is 
known as Lister's method is regularly and properly em- 
ployed in a Hospital, its healthfulness cannot at all be 
estimated by statistics of the class of cases above referred to.| 
Indeed, I came back more thoroughly impressed and con- 
vinced than ever, that the thing of prime importance in a 
Hospital is minute care of, and cleanliness in every part 
and person about it, and in the management and supervi- 
sion which will ensure this, while without it the most per- 
fect Hospital that can be built soon deteriorates and gives 
only second or third rate results. 
It was very interesting to observe how in some of the 
older Hospitals, such as the Rotunda in Dublin, Guy’s 
and St. Bartholomew’s in London, the City Hospitals at 
Bonn, and in part of the Charite at Berlin, the defects of 
construction and plan were compensated for by the mode 
♦ of management, while on the other hand in Hospitals 
admitted to be ranch superior in plan, such as the Lari- 
boisere, St. Thomas, and the Herbert, it having been 
apparently taken for granted that they were so perfect 
that it did not matter how they were managed, the evil 
results are plainly visible in the appearance of the build- 
ings, or in the Hospital diseases which have from time to 
time prevailed in them. Setting aside however the source 
of fallacy arising from difference in modes of management, 
it is extremely difficult, and in the limited time at my 
disposal, it was impossible to obtain more than the most 
vague and general statements, as to the relative merits of 
the different Hospitals. 
The English Hospitals which I saw may he divided into 
two classes, 1st. Those supported by large endowments, 
mostly of ancient date, such as Guy’s, St. Thomas’ and 
St. Bartholomew's. These are close corporations with a 
great number of theoretical governors—but really man- 
aged by two or three persons who are never medical men, 
and from whom very little information is to be had. 
The second class are supported by annual subscriptions 
which can be obtained in England more easily than in 
any country under the sun, and for almost any object 
which can be proposed. The subscribers are usually 
entitled to vote, whence it happens that in case of a dis- 
pute, a wealthy person interested can make his footmen-, 
boot-blacks, etc., subscribers and governors, and thus get 
votes enough to carry his point. 
Under the present organization of the Local Govern- 
ment Board in England, it is possible that if an Hospital 
become notoriously unhealthy—an inspection of it by a 
competent medical officer may be made, but these reports 
must be kept secret and confidential, at the will of the 
Trustees or Governors. * * * * 
I have said above that the sketch plan of this Hospital 
is approved by the majority of those who have seen it, 
and I was able to meet and confer with those in England 7 
and Germany who have given most attention to this sub- 
ject. 
Some however, think that the buildings are spread over 
too great a space, thus increasing the labor and cost of 
administration. This objection has weight and should 
be fairly considered, to avoid it, it would be necessary 
either to give up the central garden, and have the pavi- 
lions radiate from one corridor as in the Herbert —or to 
use two stories of wards, or to combine these plans. It 
is not possible to say how much healthier one story wards 
are, than those of two or more, or how much better re- 
sults will be obtained by having the wards separated, and 
giving to each the greatest possible air space The general 
opinion is that these one story isolated wards are the best 
of all, but I cannot learn what increased percentage of 
recoveries they will insure. 
All arguments from statistics as to the healthfulness of 
two and three story Pavilion Hospitals are equally good 
for the old fashioned convent or corridor plan. The records 
for instance of the old Pennsylvania Hospital for the last 
ten years, show results not much if any inferior to those 
of the Pavilion Episcopal Hospital for the same period. 
Nevertheless it is almost unanimously agreed that there 
is danger in the old fashioned compact style of building, 
that while with care it may go on for a long time with 
good results, yet that there is always danger of epidemics' 
of hospitalism, and that when these do occur, it is almost 
impossible to control them. Much the same feeling seems 
to have grown up with regard to one story versus two 
story wards—the usual statement being that patients cer- 
tainly do as well in one story buildings, and may do 
better—that the one story buildings are easier to venti- 
late, especially in summer, that if any local cause of dis- 
ease occurs in a ward its effects are limited to that ward, 
and that the benefit of all doubts therefore, ought to be 
given to the one story plan. In deciding the question, several things, which I shall 
hereafter refer to, should be considered, as well as the 
matter of cost, the importance of which I am by no means 
inclined to under-estimate, but now 1 will only say, that 
after careful reflection, I advise the Trustees to adhere to 
the principle of the central garden, and to the one story 
pavilion, with the exception of the two nearest the adminis- 
trative building which may be two stories, while advant- 
age be taken of the space thus gained, to obtain more 
room on the Broadway front, and elevation for the build- 
ings. 
With reference to the details of the individual wards 
the plan most approved is that in No. 1, Plate II. 
Very strong doubts are expressed by many however, as 
to the desirability of keeping all the service rooms at the 
north end, and a few are very urgent that the nurse shall 
have a separate room connected with the ward. These 
remarks apply especially to the .male wards in connection 
with the employment of female nurses, and they are 
specially urged by some of the most prominent of the 
female nurses themselves. 
In previous reports, I have refrained from alluding to 
the subject of female nurses, to the organization of the 
training school or to the relations which it should have to 
the Hospital, because I had not sufficient information to 
feel authorized to advise on the subject. I have inquired 
carefully as to the working of the nursing systems in the 
several Hospitals which I visited, and in addition to what 
has been published on the subject, which is almost exclu- 
sively by those favorable to what is known as the Night- 
ingale system, I have also consulted the opinions of those 
most experienced in Hospital management, which opinions 
are by no means as favorable as I had anticipated, and 
are unanimous in the statement that one of the most 
difficult problems in connection with this Hospital will 
be the organization of its system of nurses if anything 
like the Nightingale plan is to be adopted. 9 
As the time has now come when some decision must be 
made as to the scope and character of the training school, 
and the kind of nurses we should endeavor to obtain and 
provide for, I will briefly state the opinions I have formed. 
As I understand the intention of the Sounder and the 
opinions of the Trustees, this training school is not to be 
put in the hands of any religious order, and I therefore 
exclude all such from consideration. 
Miss Nightingale’s views as to female nurses, and their 
amplification and exposition by Mrs. Wardroper and Miss 
Lees—and by publications of the Bellevue Hospital train- 
ing school are well known. 
By this school, it is held that female nurses should he 
as far as possible, refined, educated women, fitted to move 
in good society—who should be thoroughly trained in 
everything pertaining to the management of the sick— 
from the washing of bed-pans, to the regulation of tem- 
perature and ventilation, and the noting of symptoms for 
the physician—who shall he good cooks and seamstresses— 
gentlewomen also, thoroughly kind-hearted, yet with 
firmness and decision, and power of control of unruly 
patients They should know as much as the Surgeon 
about the dressing of wounds, and as much as the Physi- 
cian about the meaning of symptoms—yet they must have 
no tendency to become medical women, or to set up their 
own opinions in practice. They must, of course, be of 
unspotted morals and chastity. 
It is acknowledged, that to secure and retain such 
women is difficult—and that to do it, the accommodations 
and arrangements must be of a special kind. It is in- 
sisted, that women of this kind, must not be subordinate 
to any man—that it is only a woman who can understand 
and manage them—that the Superintendent of the female 
nurses should be the sole head of all the women employed 
in the Hospital--and that she should not herself be sub- 
ordinate to the Superintendent of the Hospital, but should 
report only to the hoard of Trustees, nay, logically the conclusion is, that the hoard of trustees itself should he 
composed partly of women, in order to carry out the prin- 
ciple, that no woman shall be subordinate to a man. 
Upon these views, I would remark that I do not believe 
it is possible to obtain such women for nurses, except from 
religious motives, that the great majority of the nurses in 
the St. Thomas Hospital, are not of this character, but 
are of the class from which the better kind of English 
domestic servants are obtained, that the denunciations of 
attempts to govern women by men are not worth consider- 
ing, except as indicating that those who utter them, are 
not desirable persons to be associated with in an institu- 
tion of this kind, and that I think that the experience as 
to female nurses of European Hospitals or training schools, 
or the opinions of those connected with such schools, are 
not of much value to us here in Baltimore, since the cir- 
cumstances are so different, and the class of women whom 
we may expect to induce to enter and remain as nurses, is so 
unlike the class from which European Hospitals are sup- 
plied, that failure will probably be the result of attempting 
to transplant their methods here. 
The opinions of those connected with the training school 
for nurses at New Haven, appear to me much more worthy 
of consideration Instead of attempting to establish an 
independent female hierarchy, which will consider from 
the very commencement, that one of its main objects is to 
endeavor to be independent of all males, who are to be 
considered as the natural enemies of the organization, I 
find in the New Haven Hospital, a superintendent of the 
female nurses, who devotes her time and attention to teach- 
ing the women how to nurse—and a matron who is the 
hohsekeeper of the establishment, each of these attending 
to her own department, and reporting to the authorities of 
the Hospital. The establishment at New Haven is but a 
small one, but the same principle will apply in this Hos- 
pital. The superintendent of the training school will 
have plenty to do to attend to that, if she does it properly, 11 
and I can see no possible good in having her also attempt 
to supervise the kitchen, the laundry, etc. 
The accommodations provided in the building for the 
nurses, are in my judgment ample and of a very superior 
quality, and I do not recommend any change in this re- 
spect. 
I do not think it wise, that it shall be insisted on that 
women alone shall do the nursing and cleansing about a 
ward. As a rule, I agree with the general opinion that 
women are better nurses than men, but two or three of the 
best nurses I ever saw were males, and tor some cases all 
physicians would strongly prefer such to any woman. A 
really well trained first class male nurse can always find 
employment, but there are very few such, and in this 
country there is no place where they can be trained. If 
the right sort of material presents itself, I think it will be 
worth while for the authorities of this Hospital, to try the 
experiment of training a few, say half a dozen male nurses, 
for whom I am sure there will be no lack of employment. 
One great difficulty with both male and female nurses, is 
that if of a superior class, they wish to become doctors and_ 
doctresses. 
As I understand the duties of a female nurse, they lie 
mainly in the ward itself, that is her room, the absence 
of which is by some complained of, and her place for rest 
while on duty is in the middle of it.’ 
If a female nurse is a properly organized and healthy' 
woman, she will certainly at times be subject to strong 
temptation under which occasionally one will fall, and 
this occurs in all hospitals where women are employed, 
without any exception whatever. Something may be 
done however, to remove opportunities—and 1 believe the 
construction proposed effects this as far as it is worth while 
to attempt it. 
Into the details of some changes proposed in the Ser- 
vice building, I will not here enter, but will pass on to the vexed question of heating and ventilation, which 
formed one of the main subjects of my inquiries abroad. 
Upon this also I am sorry to say, that I was able to ob- 
tain but little positive information that will be of use to us, 
although there, as here, dogmatically expressed opinions, 
for which the authors could give no good reasons, are 
abundant. 
It would be useless to repeat these, but I think that the 
Trustees should be informed that the principal authori- 
ties whom I consulted prefer systems of aspiration to 
those of impulsion, but that the general opinion is that 
although it is possible to effect the ventilation of this Hos- 
pital by means of one great aspirating chimney, the prac- 
tical difficulties in the way of adjustment will be so great, 
that it is not proper to attempt it. There is a general feel- 
ing of timidity about attempting to use large and power- 
ful but complex systems, and a tendency to heat and ven- 
tilate each building by itself, which is in fact to give up 
the problem of concentration and simplification as inso- 
luble. 
The data obtainable from English hospitals are of little 
use in this country, owing to the marked difference in 
climate. As a general rule, the wards are insufficiently 
heated in England—and various methods are being tried 
to supplement the open fire-places which are not satisfac- 
tory, and yet whose efficacy it is considered almost criminal 
to doubt. In the latest and best of the German hospi- 
tals, the principle has been adopted of making the heat- 
ing and ventilation of each building independent of every 
other. The results as I have observed, were good, but the 
arrangements are complicated, and require careful super- 
intendence. I saw but one case in which the fan or im- 
pulsion system was used with good results, and that was 
at the Grand Opera House in Vienna. 
It is my opinion, that those who condemn the fan, do so 
from want of experience of the proper kinds of fans and 
ducts, the failures usually arising from insufficient size, and that the results which have been obtained from its 
use in the large hospitals for the insane in the United 
States, are such as to warrant the statement that for at 
least half the year it is the better and cheaper mode of 
ventilation. 
Nevertheless, the weight of authority is on the side of 
making the ventilation of each building separate and dis- 
tinct, and we have to consider how this can be best accom- 
plished. Although there is no instance in which the heat- 
ing of so extended a group of buildings has been effected 
by hot water from one point as distant as is the kitchen 
in this case, yet as I am assured by your Architect, and by 
other Engineers entitled to he considered as experts, that 
it can easily be done, I recommend that this Hospital shall 
he heated by hot water coils, placed in the basements of 
the several buildings, and supplied from boilers placed in 
the basement of the kitchen building, as shown in sketch 
plans. I prefer hot water to steam as a means of Hospital 
heating, because it gives heating surfaces of a lower tem- 
perature, which temperature is readily controlled, because 
it makes less noise, and demands less constant care in 
firing, and because I believe it is less costly for manage- 
ment and repairs than steam. 
We can best make the ventilation of each ward sepa- 
rate and distinct, by giving it in addition to valved ridge 
openings, an aspirating chimney which shall rise about 30 
feet above the level of the ceiling of the ward, and into 
which shall empty a duct running longitudinally beneath 
the centre of the floors of the ward, or by placing two 
double fire-places in the centre of the ward, which fire- 
places will give plenty of ventilation, but very little 
heat. 
If the aspirating chimney for each ward be used, the 
question is as to the best means of furnishing the heat to 
drive it. It may be done by a steam coil, supplied by a 
central boiler, by a fire at the base, by a steam jet, or by 
gas jets. 1 think that of these the gas or steam jets, would be extremely expensive, that the fire at the base would be 
the most certain, and that the steam coil, if it would do 
the work economically, would be much the most conve- 
nient. 
I find so much diversity of opinion among engineers, as 
to the best means of effecting the desired rarefaction of the 
air in such a chimney, that I can make no positive recom- 
mendation—the question is one that is within the pro- 
vince of your Architect, rather than of your medical 
adviser, and still further inquiry, and perhaps experiment 
will be required before a decision can be judiciously made. 
What we require, is that the apparatus for each of the 
Common Pavilions and Pay Wards, shall be competent to 
introduce, thoroughly distribute and remove air in each 
ward, at the rate of one cubic foot per second per bed—and 
in the service rooms at the rate of half cubic foot per second 
per patient. For the isolating wards, the apparatus must 
have capacity for double this amount. We must have the 
means of heating this air from 0° to 75° F., and to secure 
the distribution above referred to, the outgoing air must 
be taken from near the level of the floor during cold 
weather. 
The dangerous thing in a hospital ward is not a gas, 
but dust—an excessively fine organic dust. 
The work above described, must be done without pro- 
ducing draughts or currents that will be so perceptible as 
to cause discomfort, and it must be done in still warm days 
as well as in cold windy ones. 
Taking these requirements, it is the business of the 
Engineer to meet them in the cheapest way, and in this 
word “ cheapest,” lies his difficulty. 
Whatever may be the plan of ventilation' adopted, the 
ventilation for each of the isolating wards, pay wards, 
nurses’ home and buildings connected with the adminis- 
tration should be separate and distinct. 
With reference to each of these last mentioned build- 
ings, the sketch plans submitted are generally approved, 15 
and I shall recommend their adoption with some minor 
changes in detail, such as the removal of the disinfecting 
oven to a small separate building, etc. 
I paid especial attention to the arrangement of foreign 
dispensaries for the treatment of out-door cases, the largest 
of which is at St. Bartholomew’s in London, where the 
daily attendance is from 600 to 1000 patients. 
I soon became convinced that the general waiting room 
should he high, light and thoroughly ventilated, and 
that the whole dispensary should be a building of one 
story only, giving facilities for roof light and ventilation. 
This conclusion had previously been reached by your 
architect, and I submit herewith plans prepared by him 
for such a building, which I recommend shall be ap- 
proved. 
I find that in Europe and especially in England, conva- 
lescent hospitals as distinguished from convalescent wards 
are coming more and more into use, and those hospitals 
and infirmaries which cannot afford to support separate 
institutions of this kind, usually manage to pay for a few 
beds in independent convalescent institutions. Many of 
these convalescent hospitals are kept open only during 
warm weather, and their arrangement may therefore be 
very simple and cheap. 
Some however are planned for occupation in cold 
weather, such as that connected with the Royal Infirmary 
at Manchester—which has an enclosed winter garden 
with glass roof, and is in many ways specially worthy of 
commendation. 
Glasgow has two convalescent establishments, one on 
the sea shore and one in the highlands, which permits a 
choice by tbe physicians to suit the needs of the patients. 
The sexes are not separated in such institutions, nor is 
it considered desirable that they should be. 
The greatest difficulty in their management, is to pre- 
vent them from being filled up with chronic and incurable 
cases, and we shall find this to occur also in Baltimore. The time has now come when a final decision should he 
made as to the general plan of the Hospital, since owing 
to the peculiar contour of the surface of the lot it is desir- 
able that the work of grading and laying foundations 
should go on together, and if this work is to he com- 
menced this spring, your architect should commence the 
detailed and working drawings as soon as possible, to have 
them ready by the time they will he needed. 
The responsibility of recommending one particular plan 
for your Hospital, to the exclusion of all others, I feel to 
be very great. The whole subject of hospital construc- 
tion and ventilation is at present in a revolutionary con- 
dition,—with almost every existing hospital there is more 
or less dissatisfaction, while from the most recent attempts 
to produce a perfect structure, the results are not yet 
known, and it is utterly impossible to present a plan 
which will not he strongly objected to by some of those 
considered as authorities on this subject. 
In the University organization you can proceed gradu- 
ally and tentatively, getting the most important thing, 
namely the brains, first, and leaving the buildings to be 
the natural outgrowth of your necessities, but for the Hos- 
pital the buildings must, to a considerable extent at least, 
be first decided on. It is desirable that the foundations 
of all the buildings on the west front be laid before grad- 
ing is commenced, in order to avoid excavations in the 
newly deposited earth. These buildings in the plan pro- 
posed are the largest and most costly of the Hospital, and 
after their plans are thus fixed, but little variation is pos- 
sible in the rest of the institution. 
In recommending to the Trustees, as I now do, that the 
sketch plans which I lay before them be approved, and 
that authority be granted to direct the architect to pro- 
ceed with his working drawings in accordance with them, 
which drawings as to details are to be subject to the ap- 
proval of the Building Committee, I am influenced by the 
following considerations. 17 
1st. Will the sick in these wards be placed in the best 
possible conditions as to light, pure air, warmth, etc., so 
that there shall be nothing in the surroundings to hinder 
their recovery? The answer to this is yes, and it may be 
considered as unanimous, for the advocates of other plans 
do not claim that their plans are better as regards the 
sick, but that they are as good. 
2nd. So far as the medical department of the Univer- 
sity is concerned, and as giving the necessary facilities for 
the education of physicians, and for advancing our know- 
ledge of disease, are these plans satisfactory? The 
answer is yes, and is I believe unanimous. 
3rd. So tar as the training of nurses is concerned, are 
these plans suited to induce the class of women whom it 
is desired to secure —to enter and remain in this Hospital? 
To this also, the answer is in the main, affirmative, 
although doubts are expressed by some. 
4th. Are the plans practicable, and to be approved from 
the point of view of the Architect and Engineer? The 
answer is yes. 
5th. Can as good results be obtained by some other 
plan which shall cost much less in construction, or in 
administration, or in both, or if the results may perhaps 
be not quite so good, cannot relief be afforded to a greater 
number of people with the same expenditure ? In other 
words, taking all things together, cannot the money be 
better employed in building a cheaper Hospital, which 
shall also be more compact and cheaper to manage, and 
which if not certainly as good in the hygenic, educational 
or architectural point of view, will yet afford a sufficiently 
good care to a larger number of persons. 
Upon this question there are great differences of opinion. 
Some hold that the expenditure upon the buildings of an 
hospital should never exceed $1000.00 per bed, and that 
the cost of administering it should never exceed $1.00 per 
day per patient, while others say that the best possible 
results should be aimed at regardless of the cost. 18 
As I have above stated, I feel warranted in saying to the 
Trustees, that the plan submitted is from the point of view 
of the physician, the hygienist, the architect, the edu- 
cator, and the investigator, in all respects, as good as, and 
in some better, than that of any Hospital now in existence, 
or which has been proposed. 
I must also say that constructed as your Architect pro- 
poses to construct it, it will be a solid and substantial 
group of buildings, and a comparatively costly one. 
It will also be more expensive to manage than the great 
majority of Hospitals of its size in existence, but it will 
accomplish more. 
If I supposed that the number of sick poor in the City 
of Baltimore in urgent need of the aid of this charity was 
in excess of the number who can be provided for in this 
plan, I should advise such an amount of change and con- 
solidation, as would admit of doing the greatest good to 
the greatest number. 
As I have no reason to think this, or that even 300 beds 
would not at the present time be sufficient to meet the 
demands upon this charity, I advise the adoption of the 
plan presented, but I recognize fully that this is not a 
medical, architectural or scientific question, but one of 
finance, which belongs peculiarly to the Trustees to deter- 
mine, and the decision of which—whatever it may be, 
will be unsatisfactory to a certain number of outside par- 
ties. The question of cost in this case means, first, the 
time when the Hospital shall be opened to patients ; sec- 
ond, the number to be cared for. I base my recommenda- 
tion upon the belief, that in this particular case, it is best 
for the sake of the sick, of the school, and of suffering 
humanity throughout the world, to try to give to what 
patients we do receive, the very best possible facilities for 
treatment which modern science can suggest, and that the 
result cannot fail to be a valuable one. 
I do not, and cannot say that the plan I have recom- 
mended is the best possible plan, but I believe it complies with the direction of the Founder, that “ it shall provide 
for an Hospital, which shall in construction and arrange- 
ment, compare favorably with any other institution of like 
character in this country or in Europe.” Certainly I have 
seen nothing which I think superior, or in some respects 
equal to it, and if it has a medical, surgical and nursing 
statf, and a superintendence of corresponding quality, I 
am quite sure that the results of treatment obtained in it 
will not be surpassed elsewhere. 
Very respectfully, 
Your obedient servant, 
JOHN S. BILLINGS, 
Surgeon U. S. Army.