The blueprints, at first glance, seem ordinary enough. The usual operating theater, examination rooms, reference library and doctors' offices. Then you notice the fire pole offering speedy transit between floors. You hear about the treehouse condos, the mud pit, the prop room crammed with gorilla suits, Bozo wigs and joy buzzers.

And finally, you meet Hunter "Patch" Adams, M.D., professional clown and lunatic force behind "the world's first silly hospital."

Seriously.

For the last two decades, the eccentric Arlington physician has chased his dream wearing balloon pants and a rubber nose, preaching his philosophy of joy and holistic healing to anyone who would listen:

What if some doctors got together, built their own hospital, gave it a wacky name and decided not to charge patients anything at all? What if they refused to carry malpractice insurance? What if they provided the ultimate house call, letting patients actually move in with them?

What if Patch Adams isn't so crazy after all?

With public attention focused on the shortcomings of the American health care system, Adams's proposal for a utopian medical commune seems to have more legitimacy than the fantasy he first imagined 23 years ago.

He's kept it alive with an almost maniacal passion and a determination to buck the system, winning legions of admirers, saving a few lives and breaking some hearts along the way.

Still, despite untold hours of unpaid labor and nearly $1 million raised, the Gesundheit Institute remains basically a blueprint. An elegant workshop is the only building erected on its woodsy 310 acres in rural Pocahontas County, W.Va. There are no patients. There is no hospital.

That matters little to many of the volunteers who have sacrificed for Gesundheit and this graying hippie doctor with a waist-length ponytail and purposefully mismatched socks.

And it matters not at all to Adams. He readily admits as much as he tours the globe, offering his unorthodox brand of inspiration -- to a new-age conference in Italy, to sick children in Russia, to medical students in Philadelphia.

"You understand it may never be built," he gently told the students, who gave him a standing ovation. "That's not the point."

The point is to never give up. And the real story of Gesundheit is about how people in a cynical world manage to sustain a dream for 23 years. Or more importantly, about how it sustains them.

Adams is a galumphing 6-foot-5 man so overbearingly upbeat that his friends call him the Sledgehammer of Love. His optimism belies a darker side, that of a suicidal college freshman who committed himself to a locked psychiatric ward and willed himself to be happy forever after.

"Loneliness," he decided, "is a medical emergency." Happiness "is a revolutionary act."

He considers that the most important diagnosis of his career, and it is the founding tenet of Gesundheit, which over the years has attracted both traditional physicians and alternative healers alike. These care givers admit that Gesundheit fulfills a personal need as much as greater social ones. Their common bond is Adams, who half rues the power of his own charisma.

"Leadership is a very complicated thing," Adams mused. "I am a leader. One person can say a sentence, and it has no impact; someone who is a leader can say the same sentence, and 10,000 people die."

When he takes his sermon on the road, he unabashedly manipulates strangers' emotions with his own tears and excitement. Speeches usually end with the 48-year-old Adams surrounded by skeptics-turned-admirers, who embrace him and promise to spend vacation time tilling Gesundheit's soil, or to join the staff if and when the hospital ever opens.

"Some people think he's Hitler. Some people think he's God," said a longtime friend. "He's human. He's definitely human."

Born in Washington and raised overseas, Adams describes himself as a science-fair nerd who turned into an anti-establishment teenager when his military family resettled in Virginia during the 1960s. It was then that his liberal ideals took root.

His magnetism and unwavering belief in his dream has drawn hundreds for days, weeks, even decades. For 12 years, volunteers helped to provide free care to an estimated 15,000 patients from a series of rented houses in Northern Virginia and West Virginia, stopping when crowding and overwork made it clear they needed a real facility.

After that, the effort moved exclusively to Pocahontas County, which sits just over the Virginia border, deep within the Monongahela National Forest. There, supporters came to plant organic gardens, build trails, clear brush. And for a long time, that was enough.

Then two summers ago, the core group of about a dozen Gesundheiters decided to actually set a deadline for building the hospital. Some had invested thousands of dollars in this dream, expecting no return on investment other than the chance to give of themselves. Now they declared that they wanted to be practicing medicine in Pocahontas County within a year.

"They feared they'd be in perpetual dreamland," recalled former board member Gareth Branwyn, a 38-year-old writer who met Adams as a patient. "One of the big schisms was the definition of what Gesundheit was. It became absolutely polarized."

For some, and especially for Adams, he said, "Gesundheit is much more of a lifestyle or attitude, about people finding a source of happiness or passion in their lives."

Laid bare was the widespread frustration and doubt over how to push on, and for what. There was also friction over a $375,000 Arlington house purchased in Adams's name and used as Gesundheit headquarters. Those living in West Virginia, in a ramshackle farmhouse without indoor plumbing, resented the comparative luxury in Arlington. They believed that every cent available should be invested in building a hospital, even if it meant only operating a small outpatient clinic at first. Adams resisted. It should be all or nothing, he said.

"Experts in fund-raising say you've got to look prosperous to get donations," explained Adams, who has plowed family inheritances into Gesundheit as well as money he's earned from being a doctor, a clown, even a goatherd. The house eventually was sold at a $36,000 loss.

But the battle of wills nearly destroyed the dream. Last winter, the board of directors walked away.

"In 23 years, I had just one discouraging day," Adams conceded. "Them leaving just made me wonder if it is worth it. I don't know if any of us fully understands what happened. We've made a million mistakes."

He remains vague on time lines. In Pocahontas County, the institute's entrance is marked by a pink plastic flamingo and small painted sign. In a drive down the dirt road, the only obvious signs of progress are a man-made pond and the three-story workshop. A tree swing marks the spot where the 40-bed hospital is supposed to stand one day, where patients, care givers and families would live together for free under one huge roof. For staff, whether surgeon or janitor, that housing perk would compensate for an annual salary of $3,000.

Adams talks about a promised gift of more than $1 million, which could have a clinic operating within two years, but he has been saying Gesundheit is "on the verge" for at least a decade, and promises have had a way of never materializing. Donations often come as $5 or $10 gifts from individuals inspired by reading about Adams or hearing him speak. He spends more than $11,000 a year in postage just answering his mail.

"WOW!!" began a typical letter in Adams' fat files, a valentine in purple handwriting from a young medical student. "You'll never know the immense love that I feel for you!!" And from an admiring physician: "As an authority on psychopathology, you sound absolutely and intentionally out of control."

With adulation comes expectation, however. "Too many people have been left dangling," said Blair Voyvodic of Ontario, Canada, a 35-year-old general practitioner and "hard-core hippie" whose interest in holistic care drew him to Gesundheit in the 1980s. He heads the new board that was formed early this year to save the dream. It inherited assets of more than $900,000, and its new members, Voyvodic said, intend to improve fiscal accountability and establish a building fund.

Potential donors are particularly skittish about a hospital with no malpractice insurance. And Adams's philosophy of humor as medicine might well mean orthopedists in google-eye glasses. More than 1,200 foundations have rejected the nonprofit charity's grant applications.

Adams refuses to consider defeat. "People are influenced by what we're doing," he said. "My goal . . . is for them to believe in their own dreams. We don't consider Gesundheit a prototype; it's an alternative. If it inspires people to go off and try their own dreams, it's a success."

Adams misses the daily interaction with patients and often wonders if he will ever return to hands-on doctoring, which he gave up 10 years ago to devote himself to fund-raising.

In the meantime, he'll continue to perform with his "traveling medicine show," as he calls it; the speaking fees and honoraria are a good bit of his income and also Gesundheit's. He'll make his annual clowning pilgrimage through the former Soviet Union, delighting in such antics as waltzing through Customs in a gorilla suit and handing the dour Moscow officials a rubber banana instead of his passport.

"Humor is not for the cautious," he warned. "Using humor in medicine, using humor in profound suffering, is taking a risk. I've gone to dying patients dressed in angel wings and carrying a harp."

In the basement office he calls "my cave," the floor-to-ceiling bookshelves are compulsively organized, Bach's organ masterpieces a shelf away from the complete scripts of Monty Python. He lives in the rented Arlington house with his wife, who works at the new Postal Museum in the District, and their two sons, who are 17 and 6.

"I don't burn out because I love my life," Adams said. "I don't do what I don't want to do. How many humans in our society truly wake up and say, 'My life is rich, and my life is valuable'?"

There is still pain and suffering, too. Hints of Adams's locked-away anguish surface in a favorite poem, about a woman at a zoo and her own caged passions.

He recited it to the 100 or so medical students attending the recent conference in Philadelphia. Tears coursed down his cheeks as he cried out the last lines: "You know what I was, you see what I am: Change me, change me!"

Bounding back to the microphone a few minutes later, he asked to hear the students' dreams. "I want to be in a community where I would know all my patients, know their families, know all their friends," a young man volunteered. A young woman ventured, "My dream to heal is to allow patients to heal me."

Adams danced about excitedly, the clown evangelist. "Yes!" he shouted. And then he turned somber. "Don't blame anybody if you lose your idealism," he lectured the future physicians. "Nobody takes it from you. You give it up."