1911 Encyclopedia Britannica
(Lat. hospitalis, the adjective of houpes, host or guest), a term now in general use for institutions in which medical treatment is given to the sick or injured. The place where a guest was received was in Lat. hospitium (Fr. hospice), but the terms hospitalis (sc. domus), hospitale (sc. cubiculum) and hospitalia (sc. cubicula) came into use in the same sense. Hence were derived on the one hand the Fr. hospital, hopital, applied to establishments for temporary occupation by the sick for the purpose of medical treatment, and hospice to places for permanent occupation by the poor, infirm, incurable or insane; on the other, the form hotel, which became restricted (except in the case of hotel-Dieu) to private or public dwelling-houses for ordinary occupation. In English, while "hostel" retained the earlier sense and "hotel" has become confined to that of a superior inn, "hospital" was used both in the sense of a permanent retreat for the poor infirm or for the insane, and also for a regular institution for the temporary reception of sick cases; but modern usage has gradually restricted it mainly to the latter, other words, such as almshouse and asylum, being preferred in the former cases.
The Origin of Hospitals
In spite of contrary opinions the germ of the hospital system may be seen in pre-Christian times (see Charity And Charities). Pinel goes SO far as to declare that there were asylums distinctly set apart for the insane in the temples of Saturn in ancient Egypt. But this is probably an exaggeration, the real historical facts pointing to the existence of medical schools in connexion with the temples generally, to the knowledge that the. priests possessed what medical science existed, and finally to the rite of "Incubation," which involved the visit of sick persons to the temple, in the shade of which they slept, that the god might inform them by dreams of the treatment they ought to follow. The temples of Saturn are known to have existed some 4000 years before Christ; and that those temples were medical schools in their earliest form is beyond question. The reason why no records of these temples have survived is due to the fact that they were destroyed in a religious revolution which swept away the very name of Saturn from the monuments in the country. Professor Georg Ebers of Leipzig, whose possession of that important handbook of Egyptian medicine called the Papyrus Ebers constitutes him an authority, says the Heliopolis certainly had a clinic united to the temple. The temples of Dendera, Thebes and Memphis, are other examples. Those early medical works, the Books of Hermes, were preserved in the shrines. Patients coming to them paid contributions to the priests. The most famous temples in Greece for the cure of disease were those of Aesculapius at Cos and Trikka, while others at Rhodes, Cnidus, Pergamum and Epidaurus were less known but frequented. Thus it is clear that both in Egypt and in Greece the custom of laying the sick in the precincts of the temples was a national practice.
Alexandria again was a famous medical centre. Before describing the European growth of the hospital system in modern times, to which its development in the Roman Empire is the natural introduction, it will be well to dispose very briefly of the facts relating to the hospital system in the East. Harun al-Rashid (A.D. 763-809) attached a college to every mosque, and to that again a hospital. He placed at Bagdad an asylum for the insane open to all believers; and there was a large number of public infirmaries for the sick without payment in that city. Benjamin, the Jewish traveller, notes an efficient scheme for the reception of the sick in A.D.1173, which had long been in existence. The Buddhists no less than the Mahommedans had their hospitals, and as early as 260 B.C. the emperor Asoka founded the many hospitals of which Hindustan could then boast. The one at Surat, made famous by travellers, and considered to have been built under the emperor's second edict, is still in existence. These hospitals contained provision so extensive as to be quite comparable to modern institutions. In China the only records that remain are those of books of very early date dealing with the theory of medicine. To return to India, the hospitals of Asoka were swept away by a revival of Brahmanism, and a practical hiatus exists between the hospitals he introduced and those that were refounded by the British ascendancy. Hadrian's reign contains the first notice of a military hospital in Rome. At the beginning of the Christian era we hear of the existence of open surgeries (of various price and reputation), the specialization of the medical profession, and the presence of women practitioners, often as obstetricians. Iatria, or tabernae-medicae, are described by Galen and Placetus: many towns built them at their own cost. These iatria attended almost entirely to out-patients, and the system of medicine fostered by them continued without much development down to the middle of the 18th century. It is to be noted that these out-patients paid reasonable fees. In Christian days no establishments were founded for the relief of the sick till the time of Constantine. A law of Justinian referring to various institutions connected with the church mentions among them the Nosocomia, which correspond to our idea of hospitals. In A.D. 3 70 Basil had one built for lepers at Caesarea. St Chrysostom founded a hospital at Constantinople. At Alexandria an order of 600 Parabolani attended to the sick, being chosen for the purpose for their experience by the prelate of the city (A.D. 416). Fabiola, a rich Roman lady, founded the first hospital at Rome possessed of a convalescent home in the country. She even became a nurse herself. St Augustine founded one at his see of Hippo. These Nosocomia fell indeed almost entirely into the hands of the church, which supported them by its revenues when necessary and controlled their administration. Salerno became famous as a school of medicine; its rosiest days were between A.D. I 000 and 1 050. Frederick II. prescribed the course for students there, and founded a rival school at Naples. At this period the connexion between monasteries and hospitals becomes a marked one. The crusaders also created another bond between the church and hospital development, as the route they traversed was marked by such foundations. Lepers were some of the earliest patients for whom a specialized treatment was recognized, and in 1118 a leprosarium was built in London for isolation purposes. Russia seems the one country where the interconnexion of hospital and monastery was not to be observed. After the period already reached, the 13th century, hospitals became common enough to demand individual or at any rate national treatment.
History of the Hospital Movement
We have now to consider the principles upon which the provision of the best form of medical care in hospitals can be secured for all classes of people. Though hospitals cannot be claimed as a direct result of Christianity, no doubt it softened the relations between men, and gradually tended to instil humanitarian views and to make them popular with the civilized peoples of the world. These principles, as civilization grew, education improved, and the tastes and requirements of the common people were developed, made men and women of many races realize that the treatment of disease in buildings set apart exclusively for the care of the sick was, in fact, a necessity in urban districts. The establishment of a hospital freed the streets of the abuses attendant upon beggars and other poor creatures, who made their ailments the chief ground of appeal for alms. As the knowledge of hygiene and of the doctrine of cleanliness and purity in regard not only to dwellings and towns, but also in relation to food of all descriptions, including water, became known and appreciated, hospitals were found to be of even greater importance, if that is possible, to the healthy in crowded communities, than to the sick. It took many centuries before sound hygiene really began to occupy the position of importance which it is now known to possess, not only in regard to the treatment and cure of disease, but to its prevention and eradication. So the history of the world shows, that, whereas a few of the larger towns in most countries contained hospitals of sorts, up to and including the middle ages, it was not until the commencement of the 18th century that inhabitants of important but relatively small towns of from 50,000 to 100,000 inhabitants began to provide themselves with a hospital for the care of the sick. Thus, twenty-three of the principal English counties appear to have had no general hospital prior to 1710, while London itself at that date, so far as the relief of the sick was concerned, was mainly, if not entirely, dependent upon St Bartholomew's and St Thomas's Hospitals. These facts are interesting to note, because we are enabled from them to deduce from recent events that hospital buildings in the past, though the planning of most of them was faulty to begin with and became more and more faulty as extensions were added to the original buildings, did in fact suffice to satisfy the requirements of the medical profession for nearly two centuries. In other words, under the old condition of affairs the life of a building devoted to the care of the sick might be considered as at least 150 years. To-day, under the conditions which modern science impose upon the management, probably few hospital buildings are likely to be regarded as efficient for the purpose of treating the sick for more than from 30 to 50 years.
The foregoing statement is based upon the history of British hospitals of importance throughout the country, but the same remark will apply in practice to hospital buildings almost everywhere throughout the world. In truth, hospitals have been more developed and improved in Great Britain than in other countries, though, since the last quarter of the 19th century, German scientists especially have added much to the efficiency of the accommodation for the sick, not only at hospitals but in private clinics, and many German ideas have been accepted and copied by other countries. In Great Britain hospitals for the treatment of general and special diseases are mainly maintained upon what is known as the voluntary system. On the European continent, hospitals as a rule are maintained by the state or municipalities, and this system is so fully developed in Sweden and elsewhere that a sound economical principle has been embroidered upon the hospital system, to the great physical and moral advantage of all classes of the community. The system referred to confers great benefits upon inhabitants in large towns by bringing the poor-law and voluntary institutions into more intimate association, although they may be managed by separate governing bodies. The plan pursued is to demand payment from all patients who are admitted to the hospital under a scale of charges divided into three or four grades. The first grade pays a substantial sum and obtains anything or everything the patient may care to have or to pay for, subject to the control of the medical attendant. The second pays much less, but a remunerative rate, for all they receive at the hospital; and the third and fourth classes are very poor people or paupers, who are paid for on a graduated scale by the poor-law authorities, or the communal government, or the municipality. Under this system well-to-do thrifty artisans and improvident paupers are all treated by one staff, controlled by one administration, and are located in immediate proximity to each other though in separate pavilions. We have no doubt, as the result of many years' investigation and an accurate knowledge of the working of the system, that this is the true principle to enforce in providing adequate medical relief for large urban populations everywhere throughout the world. It should be accompanied by a system of government insurance, whereby all classes who desire to be thrifty may pay a small annual premium in the days of health, and secure adequate hospital treatment and care when ill. Provided that pay wings were added to the existing voluntary and municipal hospitals, it should be found that the relatively small annual premium of per annum should enable the policyholders to defray the cost of medical treatment in a pay ward or at a consultation department of a great hospital as a matter of business. In the United States of America most large towns have great hospitals, usually known as city hospitals, administered and mainly supported by the municipality. Many such institutions have pay wards, but nowhere, so far as we have been able to discover, has the system of medical relief in its entirety been organized as yet upon the business system we have just referred to.
As to the relative merits and demerits of the systems of government of municipal hospitals and voluntary hospitals a few words may be useful. There can be no doubt that the voluntary hospital in Great Britain has had a remarkable effect for good upon all classes in the making of modern England. The management of these institutions is frequently representative of all classes of the people, while the voluntary system, as the Hospital Sunday collections all over the country, and all over the English-speaking world, prove, has united all creeds in the good work of caring and providing for the sick and injured members of each community. Again the voluntary system makes for efficiency in the administration of all hospitals. Each voluntary hospital is dependent upon its popularity and efficiency, in large measure, for the financial support it receives. In this way an ill-managed voluntary hospital, or one which has ceased to fulfil any useful public purpose, is sure to disappear in due course under the voluntary system. Voluntary hospitals are always open to, as well as supported by, the public, and, owing largely to the example so prominently set by King Edward VII. and members of the royal family, more people every year devote some time in some way to the cause of the hospitals. Attached to the voluntary hospitals are the principal medical and nursing schools upon which the public depend for the supply of doctors and nurses. The education of students and nurses in a clinical hospital makes that hospital the most desirable place for everybody when they are really ill. In such a hospital no patient can be overlooked, no wrong or imperfect diagnosis can long remain undiscovered and unrectified, and nowhere else have the patients so continuous a guarantee that the treatment they receive will be of the best, while the provision made for their comfort and welfare, owing to the unceasing and ever varying quality of the criticism to which the work of everybody, from the senior physician to the humblest official, is subjected in a clinical hospital, is unequalled anywhere else. At a great voluntary hospital, not only do hundreds of medical students and nurses work in the wards, but thousands of people, in the persons of the patients' friends, and those members of the public who take an interest in hospitals, pass through the wards in the course of every year. Again, each voluntary hospital has to live by competition, a fact which guarantees that everything in the way of new treatment and scientific development shall in due course find its proper place within the walls of such an establishment. Open as they are to the full inspection of everybody whose knowledge and presence can promote efficiency, the voluntary hospitals have shown, especially since the last quarter of the 19th century, a continuous development and improvement. Here the patients are treated with invariable kindness and consideration, as human beings rather than cases, to the great benefit of the whole human family as represented by the officials, the patients and the students, with their relations and friends, the honorary medical officers, hundreds of medical practitioners and nurses, who receive their medical training in the hospitals, and the ever-increasing number of governors and supporters by whose contributions voluntary hospitals live. The great missionary and social value of the voluntary hospitals to the whole community cannot be questioned, and they have been of inestimable value to the churches by inculcating the higher principles of humanity, while removing the many acerbities which might otherwise prevail between rich and poor in large cities.
The voluntary hospitals are attended, however, by certain disadvantages which do not attach to municipal institutions. A municipality which undertakes the provision of hospitals for the entire community is largely able to plan out the urban area, and to provide that each hospital site selected shall not only be suitable for the purpose, but that it shall be so chosen as to contribute to make the whole system of hospital provision easily accessible to all classes who may require its aid. The voluntary hospitals, on the contrary, have grown up without any comprehensive plan of the districts or any real regard to the convenience or necessities of their poorer inhabitants. Voluntary hospital sites were almost invariably selected to suit the convenience of the honorary medical staff and the general convenience of the hospital economy rather than to save the patients and their friends long journeys in search of medical aid. The best of the municipal systems too enables economy to be enforced in the administration by a plan which provides a central office in every town where the number of vacant beds in each hospital is known, so that the average of occupied beds in all the hospitals can be well maintained from an economical point of view. This speedy and ready inter-communication between all hospitals in a great city, which might perfectly well be secured under the voluntary system if the managers could only be brought into active co-operation, prevents delay in the admission of urgent cases, promotes the absence of waste by keeping the average of beds occupied in each establishment high and uniform, and has often proved a real gain to the poor by the diminution in cost to the patients and their friends, who under the best municipal systems can find a hospital within reasonable distance of their home in a large city wherever it may be placed. Another advantage of the municipal system should be that central control makes for economical administration. Unfortunately a close study of this question tends to prove that municipal hospitals for the most part have resulted in a dead monotony of relative inefficiency, often entailing great extravagance in buildings, and accompanied by much waste in many directions. Existing municipal hospital systems are attended by several grave disadvantages. The administration shows a tendency to lag and grow sleepy and inert. The absence of competition, and the freedom from continuous publicity and criticism such as the voluntary hospitals enjoy, make for inefficiency and indifferent work. Rate-supported hospitals, as a rule, are administered by permanent officials who reside in houses usually situated on the hospital sites, and who are paid salaries which attract the younger men, who, once appointed, tend to continue in office for a long period of years. This fixture of tenure is apt to cause a decline in the general interest in the work of the municipal hospital, due mainly to the absence of a continuous criticism from outside, and so the average of efficiency, both in regard to treatment and other important matters, may become lower and lower. Those who have habitually inspected great ratesupported hospitals must have met instances over and over again where a gentleman who has held office for twenty or thirty years has frankly stated that his income is fixed, that his habits have become crystallized, that he finds the work terribly monotonous, and yet, as he hopes ultimately to retire upon a pension, he has felt there was no course open to him but to continue in office, even though he may feel conscientiously that a change would be good for the patients, for the hospital and for himself. Under the voluntary system evils of this kind are seldom or never met with, nor have these latter establishments, within living memory, ever been so conducted as to exhibit the grave scandals which have marred the administration of rate-supported hospitals not only in Great Britain but in other parts of the world. We believe that the more thoroughly the advantages and disadvantages of rate-supported and voluntary hospitals for the care of the sick are weighed and considered, and the more accurate and full the knowledge which is added to the judgment upon which a decision can be based, the more certain will it be that every capable administrator will come to the conclusion that on the whole it is good for the sick and for the whole community that these establishments should, at any rate in Great Britain, be maintained upon the voluntary system. Of course it is essential to have rate-supported hospitals where cases of infectious disease and the poorest of the people who are dependent largely upon the poor-law for their maintenance can be cared for. It is satisfactory to be able to state that of late years the administration of both these types of rate-supported hospitals has greatly improved. The added importance now given all over the country to medical officers of health, and the disposition exhibited, both by parliament and government departments, to make the position of these officers more important and valuable than ever before, have tended largely to improve the administrative efficiency of hospitals for infectious diseases. No doubt the whole community would benefit if residents in every part of the country could be moved to take a personal interest in the infectious hospital in their immediate neighbourhood. Amongst the smaller of these establishments there has been so marked an inefficiency at times as to cause much avoidable suffering. The existence of such inefficiency casts a grave reflection upon the local authorities and others who are responsible for the evils which undoubtedly exist in various places at the present time. Unfortunately knowledge has not yet sufficiently spread to enable the public to overcome its fear and dread of infectious maladies. It is therefore very difficult to induce people to take an active interest in one of these hospitals, but we look forward to the time when, owing to the activity of the medical officers of health who have immediate charge of buildings of this kind, this difficulty may be overcome, when the avoidable dangers and risks and the appalling discomfort which a poor sufferer from a severe infectious disease in a rural district may suddenly have to encounter under existing circumstances, would be rendered impossible.
The poor-law infirmary in large cities, so far as the buildings and equipment are concerned, very often leaves little to desire. Poor-law infirmaries lack, however, the stimulus and the checks and advantages which impartial criticism continuously applied brings to a great voluntary hospital. Such disadvantages might be entirely removed if parliament would decide to throw open every poor-law infirmary for clinical purposes, and to have connected with each such establishment a responsible visiting medical staff, consisting of the best qualified men to be found in the community which each hospital serves. The old prejudice against hospital treatment has disappeared, for the least intelligent members of the population now understand that, when a citizen is sick, there is no place so good as the wards of a welladministered hospital. Looking at the question of hospital provision in Great Britain, and indeed in all countries at the present time, it may be said, that there is everywhere evidence of improvement and development upon the right lines, so that never before in the history of the world has the lot of the sick man or woman been so relatively fortunate and safe as it is in the present day. Probably it is not too much to say that to-day hospitals occupy the most important position in the social economy of nations.
Classification of Hospitals
Having dealt with hospitals as a whole it may be well very briefly to classify them in groups, and explain as tersely as possible what they represent and how far it may be desirable to eliminate by consolidation or to increase by disintegration the number of special hospitals.
These establishments consist of two kinds, (a) clinical and (b) non-clinical, each of which, under the modern system, should include every department of medicine and surgery, and every appliance and means for the alleviation of suffering, the healing of wounds, the reduction of fractures, the removal of mal-formations and foreign growths, the surgical restoration of damaged and diseased organs and bones, and everything of every kind which experience and knowledge prove to be necessary to the rapid cure of disease. The clinical hospital means an institution to which a medical school is attached, where technical instruction is given by able and qualified teachers to medical students and others. A non-clinical hospital is one which is not attached to a medical school, and where no medical instruction is organized.
Up to about 1840 the general hospital was, speaking generally, the only hospital in existence. Twenty years later, as the population increased and medical science became more and more active, some of the more ardent members of the medical profession, especially amongst the younger men, pressed continuously for opportunities to develop the methods of treatment in regard to special diseases for which neither accommodation nor appliances were at that time forthcoming in general hospitals. In a few cases, where the managers of the great general hospitals were men of action and initiative special departments were introduced, and an attempt was made to make them efficient. The conservative spirit which, on the whole, represents the British character for the most part, resulted, however, in a steady resistance being offered by the older members of the medical staffs and existing committees to the advocates of special departments. In the result, especially as such special departments as there were in connexion with general hospitals were too often starved for want of means and men for their development and improvement, the younger spirits called their friends together and began to start special hospitals. To-day every really efficient clinical general hospital has within its walls special departments of almost every description, which have been made as efficient and up-to-date as money and knowledge can make them. Unfortunately the causes already referred to led to the establishment of hundreds of the smaller special hospitals, many of which were started in unsuitable buildings, and some of which have ever since maintained a struggling existence. Others, on the contrary, through the energy of their original promoters and the excellence of the work they have done, have obtained a position of authority and reputation which has had a very important bearing for good upon the development of medical science in the treatment of disease. If the world had to-day to organize the very best system of hospital accommodation which could be evolved, there is no doubt that few or none of the special hospitals would find any place in that system. As matters stand, however, the special hospital has had to be accepted, and nothing which King Edward's Hospital Fund has done in London has met with greater popularity and professional approval than the labours which its council have undertaken in promoting the amalgamation of the smaller special hospitals of certain kinds, so as to secure the provision of one really efficient special hospital for each speciality. No doubt this policy of amalgamation will be steadily pursued, and in the course of years every great city will gradually reorganize its hospital methods so as to secure that, whether the patients are treated in a general hospital or in a special hospital, the average efficiency in every institution shall be as high and as good as possible.
We will take now the special hospitals in detail.
The justification for efficient cancer hospitals must be found in the circumstance that most scientific men of experience believe that, if adequate resources were placed at the disposal of the medical profession, the origin of cancer might be discovered, and so the human race would be freed from one of the most awful diseases which affect humanity. Pending such a discovery the experience of the cancer department connected with the Middlesex Hospital in London proves to demonstration that the provision of adequate and special accommodation for the exclusive treatment of cases of cancer is not only desirable but necessary on humanitarian grounds alone.
Hospitals for Consumption
For many years it was held that this group of hospitals was not a necessity, and the patients were treated in the ordinary medical wards of the general hospitals. Since the contagious character of tuberculosis became known, and improved methods of treatment have been developed, every one agrees that this type of special hospital is desirable, though it is believed by the more advanced school of scientists that before long it may be happily rendered obsolete owing to the discovery of methods of treatment which will stay the disease at its commencement and restore the patient to health.
These hospitals were very much opposed at the outset. There can be no doubt that the children's ward or wards in a big voluntary hospital is a most valuable asset to the managers, so long as the children are treated in separate wards. There is no reason of course why a hospital should confine its work to the treatment of children, exclusively. Still this special hospital is popular with the public; it has led to many discoveries and developments in the treatment of children's diseases; on the whole the administration of these establishments has been good; and we believe they will continue to flourish, however many children's wards may be provided in general hospitals. Children's hospitals with country branches for the treatment of chronic ailments, such as hip disease, are a valuable addition to the relief of suffering in cities.
These hospitals, established originally in 1859 by Mr Albert Napper at Cranleigh, Surrey, have fulfilled a most useful function. Many of them are very efficient both in regard to equipment and treatment. They have become essential to the well-being and adequate medical care of rural populations, as they attract to the country some of the best members of the profession, who are able, with the aid of the cottage hospital, to keep themselves efficient and up-to-date, so that all classes of the community are benefited in this way by this type of hospital.
Ear, Throat and Nose Hospitals
The history of this type of hospital bears out in every particular the reason we have given above for the establishment of special hospitals in the first instance. There can be no doubt that the best conducted throat hospitals have been beneficial to the poorer inhabitants of great cities.
Fever Hospitals. - Incidentally we have dealt with these institutions, which are usually supported out of the rates and administered by the medical officers of health, who are paid by the county or municipal authorities.
Maternity and Lying-in Hospitals
This is one of the oldest types of special hospitals, and has done a great deal of good in its time. Owing to modern methods of treatment and hygienic developments the maternity hospital never occupied a stronger position than it does to-day.
In Great Britain the insane are provided for in asylums (see Insanity, ad fin.), though such establishments, if properly conducted, are essentially hospitals. Scientific and public opinion tend towards the establishment of mental hospitals to which all acute cases of mental disease should be first relegated for treatment and diagnosis before they are consigned to a permanent lunatic hospital. Too little attention on an organized plan has been given to the continuous study of mental disease in its clinical and pathological aspects. It is probable, therefore, that the advent of the mental hospital may lead to important developments in treatment in many ways.
Of all special hospitals this is one which would probably be the least necessary, providing general hospitals everywhere were properly equipped and organized. No special hospital has probably been so abused in the material sense by the free relief of patients who could well afford to pay for their treatment at the ophthalmic hospital. Several of the existing ophthalmic hospitals have entailed an enormous expenditure, and their modern equipment is wonderfully efficient.
It is very doubtful whether this type of hospital is really desirable or necessary. Its necessity may be advocated on the ground that orthopaedic cases may require prolonged treatment, and that the pressure upon the beds of general hospitals by acute cases is nowadays so great as to render the orthopaedic hospital more necessary than ever before.
Paralysis and Epileptic Hospitals
Seeing that the percentage of those who are at present attacked by paralysis and nervous disease shows a continued tendency to increase under modern conditions of life in large cities, hospitals of this type are necessary, and London at any rate, like most foreign towns of importance, possesses, at present, far too little accommodation for this class of case.
Skin and Photo-Therapy
Up to the end of the 19th century hospitals for diseases of the skin were a constant cause of scandal and criticism. The introduction of modern methods of treatment by light and electricity, including photo-therapy, has given an importance to this department and treatment which it did not previously possess. We are of opinion that, on the whole, it is better and more economical to treat these cases in properly equipped departments of general hospitals than in separate institutions.
These hospitals are not absolutely necessary, but considering their popularity with the women themselves, and that several of them have done excellent work, remembering too that women constitute the majority of the population, there seems to be some reason for their continuance.
The Evolution of the Modern Hospital
The evolution of the modern hospital affords one of the most marvellous evidences of the advance of scientific and humanitarian principles which the world has ever seen. At the outset hospitals were probably founded by the healthy more for their own comfort than out of any regard for the sick. Nowadays the healthy, whilst they realize that the more efficient they can make the hospital, the more certain, in the human sense, is their own chance of prolonged life and health, are, as the progress of the League of Mercy has shown in recent years, genuinely anxious for the most part to do something as individuals in the days of health in the cause of the sick. Formerly the hospital was merely a building or buildings, very often unsuitable for the purposes to which it was put, where sick and injured people were retained and more frequently than not died. In other words the hygienic condition, the methods of treatment and the hospital atmospher e were all so relatively unsatisfactory as to yield a mortality in serious cases of 40%. Nowadays, despite, or possibly because of, the fact that operative interference is the rule rather than the exception in the treatment of hospital patients, and in consequence of the introduction of antiseptic and aseptic methods, the mortality in hospitals is, in all the circumstances, relatively less, and probably materially less, than it is even amongst patients who are attended in their own homes. Originally hospitals were unsystematic, crowded, ill-organized necessities, which wise people refused to enter, if they had any voice in the matter. At the present time in all large cities, and in crowded communities in civilized countries, great hospitals have been erected upon extensive sites which are so planned as to constitute in fact a village with many hundreds of inhabitants. This type of modern hospital has common characteristics. A multitude of separate buildings are dotted over the site, which may cover 20 acres or upwards. In one such institution, within an area of 20 acres, there are 6 m. of drains, 29 m. of water and steam pipes, 3 m. of roof gutters, 42 m. of electric wires, and 42 separate buildings, which to all intents and purposes constitute a series of distinct, isolated hospitals, in no case containing more than forty-six patients. On the continent of Europe buildings of this class are usually of one storey; in the United States, owing to the difficulty of obtaining suitable sites and for reasons of economy, some competent authorities strenuously advocate high buildings with many storeys for town hospitals. In England the majority have two to three storeys each, the ward unit containing a ward for twenty beds and two isolation wards for one and two beds respectively. The two storeys in modern fever hospitals, however, are absolutely distinct - that is, there is no internal staircase going from one ward to the others, for each is entered separately from the outside. This system carries to its extreme limits the principle of separating the patients as much as possible into small groups; the acute cases are usually treated in the upper ward, and as they become convalescent are removed downstairs. In this way the necessity for an entirely separate convalescent block is done away with and the patients are kept under the same charge nurse, an arrangement which promotes necessary discipline. The unit of these hospitals is the pavilion, not the ward, and consists of an acute ward, a convalescent ward, separation wards, nurses' duty rooms, store-rooms for linen, an open-air balcony upstairs into which beds can be wheeled in suitable weather, and a large airing-ground for convalescent patients directly accessible from the downstairs ward. Each of the pavilions is raised above the ground level, so that air can circulate freely underneath. The wall, floor and air spaces in the scarlet fever wards of one of these hospitals are respectively 12 ft., 156 ft. and 2028 ft. per bed; and in the enteric and diphtheria wards they have been increased to 15 ft., 195 ft. and 2535 ft. respectively. The provision of so large a floor and linear space, especially in the diphtheria wards, is an experiment the effect of which will be watched with considerable interest. A building of this type is a splendid example of the separate pavilion hospital, and is doing great service in the treatment of fevers wherever it has been introduced. Some idea of a hospital village, some of the wards of which we have been describing, may be gathered from the circumstances that it costs from £300,000 to £400,000, that it usually contains from soo to 700 beds, and that the staff numbers from 350 to 500 persons. The medical superintendent lives in a separate house of his own. The nurses are provided with a home, consisting of several blocks of buildings under the control of the matron; the charge nurses usually occupy the main block, where the dining and general sitting-rooms are placed; the day assistant-nurses another block; and lastly, by a most excellent arrangement, the night nurses, 80 to 120 in number, have one whole block entirely given up to their use. The female servants have a second home under the control of the housekeeper, and the male servants occupy a third home under the supervision of the steward. The two main ideas aimed at are to disconnect the houses occupied by the staff from the infected area, and to place the members of each division of the staff together, but in separate buildings, under their respective heads. These objects are highly to be commended,as they have important bearings upon the well-being and discipline of the whole establishment and constitute a lesson for all who have to do with buildings where a great number of people are constantly employed.
The Hospital City
We have shown that the modern hospital where an adequate site is available under the most favourable conditions has developed into a hospital village. No one who is familiar with the existing disadvantages of many of the sites and their surroundings of town hospitals in many a large city can have any doubt that, if the well-being of the patients and the good of the whole community, combined with economical and administrative reasons, together with the provision of an adequate system for the instruction and training of medical students and nurses, are to be the first considerations with those responsible for the hospitals of the future, the time will come, and is probably not far distant, when each great urban community will provide for the whole of its sick by removing them to a hospital city, which will be situated upon a specially selected and most salubrious site some distance from the town itself. The atmosphere of a great city grows less and less suitable to the rapid and complete recovery of patients who may undergo the major operations or be suffering from the severe and acute forms of disease. Asepsis, it is true, has reduced the average residence in hospital from about 35 to less than 20 days. It has thereby added quite one million working days each year to the earning power of the artisan classes in London alone. Medical opinion is more and more favouring the provision of convalescent and suburban hospitals, to which patients suffering from open wounds may be removed from the city hospitals. This course, which entails much additional expenditure, is advocated to overcome the difficulty arising from the fact that, in operation and other cases, the patients cease to continue to make rapid progress towards recovery after the seventh or ninth day's residence in a city hospital. A change of such cases to the country restores the balance and completes the recovery with a rapidity often remarkable.
Thinking out the problem here presented in all its bearings, realizing the great and ever-increasing cost of sites for hospitals in great cities, the heavy consequential taxes and charges which they have to meet there, and all the attendant disadvantages and drawbacks, the present writer has ventured upon an anticipation which he hopes may prove intelligent and well-founded. Nearly every difficulty in regard to the cost of hospitals and in respect to all the many problems presented by securing the material required, under present systems, for the efficient training of students and nurses, would be removed by the erection of the Hospital City, which, he foresees, must ultimately be recognized by intelligent communities throughout the civilized world. Why should we not have, on a carefully selected site well away from the contaminations of the town, and adequately provided with every requisite demanded from the site of the most perfect modern hospital which the mind of man can conceive, a "Hospital City" ? Here would be concentrated all the means for relieving and treating every form of disease to the abiding comfort of all responsible for their adequacy and success. At the present time all the traffic and all the citizens give way to fire engines and the ambulance in the public streets. Necessarily the means of transit to and from the "Hospital City," and its rapidity, would be the most perfect in the world. So the members of the medical staff, the friends of the patients, and all who had business in the "Hospital City," would find it easier and less exacting in time and energy to be attached to one of the hospitals located therein than to one situated in the centre of a big population in a crowded town. To meet the urgent and accident cases a few receiving houses, or outpost relief stations, with a couple of wards, would be situated in various quarters of the working city, where patients could be temporarily treated, and whence they could be removed to the "Hospital City" by an efficient motor ambulance service. The writer can see such a "Hospital City" established, can realize the comfort it will prove in practice to the medical profession, to the patients' friends, to those who have to manage the hospitals and train the medical and nursing students, and indeed to all who may go there as well as to the whole community. The initial cost of hospital buildings should be reduced at once to a quarter or less of the present outlay. They could then be built of the cheapest but most suitable material, which would have many advantages, whilst the actual money forthcoming from the realization and sale of the existing hospital sites in many cities would, in all probability, produce a sum which in the whole might prove adequate, or nearly adequate, or even in some cases more than adequate, to defray the entire cost of building the "Hospital City" and of equipping it too. The cost of administration and working must be everywhere reduced to a minimum. The hygienic completeness of the whole city, its buildings and appliances, must expedite recovery to the maximum extent. In all probability the removal of the sick from contact with the healthy would tend in practice so to increase the healthiness of the town population, i.e. of the workers of the city proper, as to free them from some of the most burdensome trials which now cripple their resources and diminish materially the happiness of their lives. Probably the United States (where a city has sometimes sprung up in twelve months) may be the home where this idea may first find its realization in accomplished fact. The writer may never live to see such a city in actual working or in its entirety, but he makes bold to believe its adoption will one day solve the more difficult of the problems involved in providing adequately for the sick in crowded communities. He has formulated the idea because it seems desirable to encourage discussion as to the best method of checking the growing tendency to make hospital buildings everywhere too costly. If the idea of the "Hospital City" commends itself to the profession and the public, the practice of treating all the hospital accommodation in each city as a whole will gradually increase and spread, until most of the present pressing difficulties may disappear altogether. That is a consummation devoutly to be wished.
The Problem of Hospital Administration
A study of the hospital problem in various countries, and especially in different portions of the English-speaking world, convinces the writer that, apart from local differences, the features presented are everywhere practically identical. A number of hospitals under independent administration, dependent in whole or in part on voluntary contributions, administered under different regulations originally representing the idiosyncracies of individual managers for the time being, without any standard of efficiency or any system of co-operation, which would bring the whole of the medical establishments of each or all of the great cities of the world under one administration which the combined wisdom and experience of hospital managers as a whole might agree to be the best, must mean in practice a material gain in every way to each and all of the hospitals and their supporters on economical, scientific and other grounds. Such an absence of system throughout the world has everywhere led to overlapping, to the perpetuation of many abuses, to the admission of an increasing number of patients whose social position does not entitle them to claim free medical relief at all, and, often too, to. the admission of patients belonging to a humbler grade of society who are already provided for by the rates in institutions which they do not care to enter and who find their way to the wards of hospitals which were established to provide for patients of an entirely different social grade. These evils have continued to grow and increase almost everywhere, despite many and varied attempts to grapple with and remove them. Amongst these attempts we may mention the assembling of hospital conferences, the establishment of special funds and committees, and the holding of inquiries of various kinds in London and other British cities and also in the United States. The most remarkable proof of the impossibility of inducing those responsible to act together and enforce the necessary reforms is afforded by the historical fact that the famous Commission on Hospital Abuse, known as Sir William Fergusson's Commission, in 1871, after an exhaustive inquiry, made the following recommendations: (r) to improve the administration of poor-law medical relief; (2) to place all free dispensaries under the control of the poor-law authorities; (3) to establish an adequate system of provident dispensaries; (4). to curtail the unrestricted system of gratuitous relief, partly by the selection of cases possessing special clinical interest and partly by the exclusion of those who on social grounds are not entitled to gratuitous medical advice; (5) the payment of the medical staff engaged in both inand out-patient work, and the payment of fees by patients in the pay wards and in the consultation departments of the voluntary hospitals. Other commissions have since been appointed, have reported, and have disappeared, with the result that nothing practical had been done up to 1910 in the way of reform. Yet it is an undoubted fact that, if the foregoing recommendations of Sir William Fergusson's Commission had been carried out in their entirety at the time they were made, practically all the abuses from which British hospitals afterwards suffered would have been removed, and the charitable public might have been saved several millions of pounds sterling. It may be well, therefore, briefly to indicate exactly what these changes amount to,. and how they can be made effective at any time by those responsible for the working of a hospital.
There is no doubt that all the facts available tend to prove that the voluntary hospitals are used to an increasing extent by persons able to make payment or partial payment for the treatment which they receive. The evidence and statistics demonstrating these facts may be readily gathered from a study of the Report (1909) and Evidence of the Royal Commission on the Poor Laws and Relief of Distress (Lord George Hamilton's Commission) and in the authorities mentioned at the end of this article. The underlying cause of the abuse was that no means existed whereby persons of moderate income could obtain efficient treatment and hospital care when ill at a rate which they could afford to pay. The system, or want of system, whereby medical relief is granted to practically all applicants by the voluntary hospitals grew up without any combined attempt to organize it efficiently or to check abuses. Such a system rests upon a wrong basis, and the best interests of every class of the population demand its abolition in favour of one which shall afford the maximum of justice (I) to the poor, (2) to those who can afford to pay in part or in whole the cost of their medical treatment and care at a hospital, (3) to the medical profession, (4) to the subscribers and supporters of voluntary hospitals, whose gifts should be strictly applied to the purposes they were intended to serve, and (5) to the ratepayers, who are entitled to a guarantee that the maximum efficiency is secured by the poor-law system of medical relief. The remedy is very simple and easy of application. Every voluntary hospital, while admitting all accidents and urgent cases needing immediate attention, should institute a system whereby each applicant would be asked to prove that he or she was a fit object of charity. The only real attempt at reform, up to 1909, was the appointment by many of the larger hospitals of almoners to ascertain whether certain selected patients were in a position to pay or not. By putting the burden of proof of eligibility to receive free medical relief upon the patients and their friends, all abuse of every kind must speedily cease. There would be no hardship entailed upon the patients by such a system, as experience has proved, but, to make it effective, the system of providing for inand out-patients in Great Britain requires radical change, for, in existing circumstance, if a voluntary hospital attempted to enforce this simple method, it would be met with the difficulty that, where it was found that a patient or his friends could pay at any rate something, no department connected with British hospitals existed - as is the case in regard to hospitals in the United States - enabling such in-patients to be transferred to accommodation provided in paying wards. In the same way, directly the out-patients were dealt with under such a system, it would be made apparent, where a case could be properly treated under the poor law, that no plan of co-operation to secure this was organized under existing conditions. If the patient, being of a better class, were suffering from a minor ailment, and could be properly dealt with at a provident dispensary, the fees of which he could easily pay, the same absence of co-operation must make it practically impossible readily to enforce the system. When, again, an outpatient of the better class was entitled, from the severity of his ailment, to receive the advantages of a consultation by the medical staff, no method existed whereby this aid could be rendered to him, and his transfer afterwards to the care of a medical practitioner attached to some provident dispensary, or resident near the patient's home, could be properly carried out. It follows that adequate reform required that methods should be adopted with a view to some part or all the cost of treatment being provided by the patient or his friends through an entire reorganization of the system of medical relief not only at the voluntary hospitals, but under the poor-law system. The reforms required in regard to voluntary hospitals are that every large hospital shall have connected with the in-patient department, in separate buildings, but under the administration of the managers, pay wards for the reception of those patients who are able to pay some part or all of the cost of treatment; that, as regards out-patients, the existing out-patient department should be abolished; that in substitution for it each hospital should have a casualty department and a department for consultation. In the casualty department every applicant should be seen once, and be there disposed of by being handed on to the consultation department; if his case was sufficiently important, he should then be transferred to some provident or poor-law dispensary, or be referred to a private medical attendant. It would no doubt take time to overcome the incidental difficulties which would necessarily arise in effecting so radical a reform as is here contemplated, but if all voluntary hospitals adopted the same system, and were to be brought into active co-operation with provident dispensaries and poor-law dispensaries and private medical practitioners, the new system might be successfully introduced and made effective within twelve months, and probably within six months, from the date of its commencement. This opinion is based upon the assumption that the provident dispensaries would be standardized, and that every one of them would be brought up to a state of the highest efficiency. In the town of Northampton the Royal Victoria Dispensary has been worked with the maximum of success, so far as the patients and the medical practitioners are concerned. In London and in other large towns like Manchester and elsewhere the provident dispensary has not succeeded as it has done in Northampton, because so many members of the medical profession are not alive to the importance of making it their first business to provide that every patient connected with the provident dispensary who attends at the surgery of a private medical practitioner shall receive at least equal attention and accommodation to that afforded to every other private patient, whatever the fee he may pay. In the same way, poorlaw dispensaries must be radically reformed. Everything which tends to excite a feeling of shame on the part of the patient attending the poor-law dispensary, such as the printing of the word "pauper" at the beginning of the space on which the patient's name is entered, must be abolished, and the class of medical service and all the arrangements for the treatment of the patients, however poor, at the poor-law dispensary, must be made at least as efficient as those provided by voluntary hospitals. There undoubtedly is considerable overlapping between the voluntary hospitals and the poor law in Great Britain. The Royal Commission on the Poor Laws and Relief of Distress (1909) deals with this point with a view to set up a standard of medical relief to be granted by each class and type of hospitals, provides for adequate co-operation between all classes of institutions; and these reforms may be commended. It is too often forgotten that the function of the poor law is the relief of destitution, while it should be the object and duty of each voluntary hospital and indeed of all hospitals other than poor-law institutions to apply their resources entirely to the prevention of destitution, by stepping in to grant free medical relief to the provident and thrifty when, through no fault of their own, they meet witli an accident or are overtaken by disease. An adequate system of co-operation would preserve the privilege of the voluntary hospitals, which save such patients from the necessity of requiring the relief which it is the object of the poor law to supply.
We have dealt with the relative advantages and disadvantages of rate-supported hospitals and voluntary hospitals. We should regard the establishment of a complete state-provided or rate-provided system of gratuitous medical relief either for indoor patients or for out-door patients, or for both, as a grave evil. Such a system must eventually lead to the extinction of voluntary hospitals. If this disaster ever happens, it must result in the gravest evils, for it could not fail to injure the morale of all classes and tend to harden unnecessarily the relations between the rich and poor, who, under the voluntary system, have come to share each other's sufferings and to be animated by respect and confidence towards each other.
Hospital Construction. Locality and Site. - Hospitals are required for the use of the community in a certain locality, and to be of use they must be within reach of the centre of population. Formerly the greater difficulty of locomotion made it necessary that they should be actually in the midst of towns and cities, and to some extent this continues to prevail. It is now proved to demonstration that this is not the best plan. Fresh and pure air being a prime necessity, as well as a considerable amount of space of actual area in proportion to population, it would certainly be better to place hospitals as much in the outskirts as is consistent with considerations of usefulness and convenience. In short, the best site would be open fields; but if that be impracticable, a large space, "a sanitary zone" as it is called by Toilet, should be kept permanently free between them and surrounding buildings, certainly never less than double the height of the highest building. In the selection of a site various factors must be taken into consideration. If the hospital is to be used as the clinical school of a university or medical college, then the most suitable ground available within easy reach of the university or college must be secured. If, on the other hand, the hospital is not to be used as a teaching school, a site more in the country should be favoured. In any case ample ground must be purchased to permit of the wards receiving the maximum of sunlight, an abundant supply of fresh air, and leave room for possible future extensions. The site should be self-contained; it should be in such a position as to prevent the hospital being shadowed by other buildings in the neighbourhood, and, unless the site is alongside a public park, it should be entirely surrounded by streets of from 40 to 60 ft. in width. It is also necessary to secure that adequate water mains serve the site, and that the system of sewers be ample for all sewage purposes.
The difference between the expense of purchase of land in a town and in the environs is generally considerable, and this is therefore an additional reason for choosing a suburban locality. Even with existing hospitals it would be in most cases pecuniarily advantageous to dispose of the present building and site and retain only a receiving house in the town. St Thomas's in London, the Hotel-Dieu in Paris and the Royal Infirmary in Manchester, are all good examples where this might have been carried out. In none, however, has this been done; these hospitals have been rebuilt, at enormous outlay, in the cities as before, although not exactly in the same locality.
As regards the actual site itself, where circumstances admit of choice, a dry gravelly or sandy soil should be selected, in a position where the ground water is low and but little subject to fluctuations of level, and where the means of drainage are capable of being effectually carried out. There should also be a cheerful sunny aspect and some protection from the coldest winds.
Form of Building
A form of building must be selected which answers the following conditions: (a) the freest possible circulation of air round each ward, with no cul-de-sac or enclosed spaces where air can stagnate; (b) free play of sunlight upon each ward during some portion at least of the day; (c) the possibility of isolating any ward, or group of wards, effectually, in case of infectious disease breaking out; (d) the possibility of ventilating every ward independently of any other part of the establishment. Those conditions can only be fulfilled by one system, viz. a congeries of houses or pavilions, more or less connected with each other by covered ways, so as to facilitate convenient and economical administration. The older plans of huge blocks of buildings, arranged in squares or rectangles, enclosing spaces without free circulation of air, are obviously objectionable. Even when arranged in single lines or crosses they are not desirable, as the wards either communicate with each other or with common passages or corridors, rendering separation impossible. On this point it may be remarked that some of the buildings of the 18th century were more wisely constructed than many of those in the first half of the 19th century, and that the older buildings have been from time to time spoilt by ignorant additions made in later times.
The question next arises, is it better to have pavilions of two or more storeys high, or to have single-storeyed huts or cottages scattered more widely? For the treatment of tuberculosis there can be no doubt that, for hygienic reasons, the chalet or singlepatient hut is the best for the patients in the acute stages; for economical reasons the chalet has not been heretofore as popular as it deserves to be, but if the welfare of the patient is to be the first consideration there is no doubt that the chalet will ultimately prevail. It has the merit of being easily adapted to villages and houses where there is a garden, and in this way poor families may readily isolate and treat a member affected by tuberculosis at a cost within their means. For hospital purposes, so long as the system of placing hospital buildings in densely crowded areas prevails, many-storeyed buildings for hospital purposes are likely to continue. Should the proposal to institute a Hospital City ultimately prevail, then it is probable that the majority of the pavilions will be single-storeyed. Still some hospital authorities prefer the multiple-storeyed system for administrative reasons, contending that single-storeyed pavilions have no 'special advantages over two or three-storeyed buildings, whereas the difficulties in administration and service of a hospital building on the single-storey principle outweigh any argument against the twoor three-storey building, if it is properly designed and constructed. We hope that the time is approaching when architects and those members of the public who have to provide the money for hospital buildings will insist upon the erection of simple structures, costing little, so that the whole cost of hospital buildings may be, as it ought to be, reduced by at least half when compared with the expenditure of the past.
The pavilions may be arranged in various ways; they may be joined at one end by a corridor, or may be divided by a central corridor at right angles to them. In fact, the plan is very elastic, and adapts itself to almost any circumstances. A certain distance, not less than twice the height of the pavilions, ought to be preserved between them. By this means free circulation of air and plenty of light are secured, whilst separation or isolation may be at once accomplished if required.
Foundations, Building Materials, &c. - It is of the first consequence that a hospital should be dry; therefore the foundation and walls ought to be constructed so as to prevent the inroads of damp. An impervious foundation has the further advantage of preventing emanations from the soil rising up in consequence of the suction force produced by the higher temperature of the internal atmosphere of the building itself. There should be free ventilation in the basement, and the raising of the whole on arches is a good plan, now generally carried out in hot climates. If the pavilions are two or more storeys high, it is advisable to use fire-proof material as much as possible, but single-storeyed huts may be of wood. In any case effectual means of excluding damp must be employed. The interiors of wards ought to be rendered as non-absorbent as possible, by being covered with impervious coatings, such as glazed tiles (Parian, though much used, is apt to crack), silicate paint, which is preferable to tiles, or the like. The ceilings ought to be treated in the same way as the walls. There must be a concrete floor between each flat, experience showing that if a teak floor is laid hard on the concrete a very noisy floor is the result, but if the teak is laid on strips of wood, leaving a small space between the concrete and the floor, a more silent floor is obtained. For the floors themselves various materials have been suggested: in France there is a preference for flags (dalles), but in England wood is more liked; and indeed hard well-fitting wood, such as teak, oak or American willow, leaves nothing to be desired. The surface should be waxed and polished or varnished. Even deal floors can be rendered nonabsorbent by waxing, by impregnating them with solid paraffin as recommended by Dr Langstaff.
Shape and Arrangement of Wards
It is now generally agreed that wards should have windows on at least two opposite sides. Three main shapes have been proposed: (a) long wards with windows down each side, and (generally) one at the farther end with balcony; 26 ft. is a good width for a ward of twelve or fourteen beds, but for larger wards of more than fourteen beds the width should be not less than 28 ft.; (b) wards nearly square, with windows on three sides; and (c) circular wards with windows all round. The first (a) is the form usually adopted in pavilions; (b) is recommended by Dr C. F. Folsom (Plans for the Johns Hopkins Hospital); and (c) has been suggested by Mr John Marshall, F.R.S. (Nat. Assoc. for Promotion of Social Science, 1878). Of these (b) seems the least to be commended, and (c), now comparatively common, has distinct advantages in an administrative sense, when the wards are constructed as to floor space so as to allow the same proportion of superficial space per bed in a circular ward to that which is contained in a rectangular ward, as is the case at the Great Northern Central Hospital, London. Some authorities object to a chimney-stack up the centre of the circular ward, urging that it prevents the nurses from having complete supervision over all the beds. In practice this objection seems to us to have little force, and it can be avoided by placing the fireplaces at the side of the circular ward, if desirable, though this adds somewhat to the cost of building.
Each bed should be a little distance, say from 8 in. to P ft. from the wall, and each bed may be reckoned as 62 ft. long; this gives 72 ft. on each side. Between the ends of the beds about 10 ft. space is necessary, so that 25 or 26 ft. of total breadth may be taken as a favourable width. The wards of the Herbert Hospital are 26 ft.; but some exceed this, as, for instance, St Thomas's, London, and the New Royal infirmary, Edinburgh, 28; new Hotel Dieu, 29; and Lariboisiere, 30. There seems no necessity for exceeding 26 for a ward of twelve or fourteen beds, but if the breadth be greater there ought to be more window space - the great difficulty being to get a wide space thoroughly ventilated. There ought to be only two rows of beds, one down each wall, with a window on each side of each bed.
For ventilation two things are required - sufficient space and sufficiently frequent change or renewal of air. As regards space, this must be considered with reference both to total space and to lateral or floor space. Unless a minimum of floor space be laid down, we shall always be in danger of overcrowding, for cubic space may be supplied vertically with little or no advantage to the occupier. If we allow a minimum distance of 4 ft. between the beds and Po ft. between the ends of the beds, this gives Poo sq. ft. of space per bed; less than this is undesirable. In severe surgical cases, fever cases and the like, a much larger space is required; and in the Edinburgh Infirmary 150 sq. ft. is allowed. Cubic space must be regulated by the means of ventilation; we can rarely change the air oftener than three times in an hour, and therefore the space ought to be at least one-third of the hourly supply. This ought not to be less than 4000 cubic ft. per bed, even in ordinary cases of sickness - and the third of that is 1333 cubic ft. of space. With 100 sq. ft. of floor space a ward of 132 ft. high would supply this amount, and there is but little to be gained by raising the ceiling higher, - indeed 12 ft. is practically enough. The experiments of Drs Cowles and Wood of Boston (see Report of State Board of Health of Massachusetts f or 1879) show that above 12 ft. there is little or no movement in the air except towards the outlet ventilator; the space above is therefore of little value as ventilation space. Authorities nowadays, however, fix 10 ft. 6 in. as the maximum, and any height above this may be disregarded for purposes of ventilation. Additional height adds also to the cost of construction, increases the expense of warming, makes cleaning more difficult, and to some extent hampers ventilation. Whatever be the height of wards, the windows must reach to the ceiling, or there must be ventilators in the ceiling or at the top of the side walls. If this be not arranged for, a mass of foul air is apt to stagnate near the ceiling, and sooner or later to be driven down upon the inmates. The reasons for a large and constant renewal of air are, of course, the immediate removal and dilution of the organic matter given off by the inmates; as this is greater in quantity and more offensive and dangerous in sickness than in health, the change of air in the former case must be greater than in the latter. Hence in serious cases an amount of air practically unlimited is desirable - the aim of true ventilation being to approach as near as possible to the condition of pure external air. Without going too much into details, a few general rules may be laid down. (P) Fresh air ought, if possible, to be brought in at the lowest part of the ward, warmed if necessary; (2) foul air ought to be taken out at the highest part of the ward; (3) fresh air should reach each patient without passing over the bed of any other; (4) the vitiated air should be removed from each patient without passing over the bed of any other; (5) 4000 cubic ft. of fresh air per head per hour should be the minimum in ordinary cases of sickness, to be increased without limit in severer cases; (6) the air should move in no part of a ward at a greater rate than P 2 ft. per second, except at the point of entry, where it should not exceed 5 ft. per second, and at the outlet, where the rate may be somewhat higher; about 64 sq. in. of inlet and outlet sectional area ought to be supplied per head as a minimum; (7) every opportunity ought to be taken of freely flushing the wards with air, by means of open windows, when this can be done with safety.
Warming is a question of great importance in most climates, especially in such a climate as that of Great Britain, where every system of ventilation must involve either the warming of some portion of the incoming air, or the contriving its delivery without too great lowering of temperature; at the same time it cannot be too strongly insisted upon that the tendency is too much in the direction of allowing warmth to supersede freshness of air. There are very few cases of disease (if any) that are not more injured by foul air than by low temperature; and in the zymotic diseases, such as typhus, enteric fever, smallpox, &c., satisfactory results have been obtained even in winter weather by almost open-air treatment. At the same time a reasonable warmth is desirable on all grounds if it can be obtained without sacrificing purity of atmosphere. For all practical purposes 60Â° to 63Â° F. is quite sufficient, and surgical and lying-in cases do well in lower temperatures. Various plans of warming have been recommended, but probably a combination is the best. It is inadvisable to do away altogether with radiant heat, although it is not always possible to supply sufficient warmth with open-air fire-places alone. A portion of the air may be warmed by being passed over a heating apparatus before it enters the ward, by having an air-chamber round the fire-place or stove, or by the use of radiators in the ward itself. In each case, however, the air must be supplied independently to each ward, so that no general system of air supply is applicable.
The lighting of the ward at night will be most conveniently done by means of electricity in the form of a lamp for each bed, where gas is used each jet should have a special ventilator to carry off combustion products, as in the Edinburgh Infirmary.
The Furniture of Wards should be simple, clean and nonabsorbent; the bedsteads of iron, mattresses hair, laid on spring bottoms without sacking. No curtains should be permitted.
The water-supply ought to be on the constant system, and plentiful; 50 gallons per head per diem may be taken as a fair minimum estimate.
The closets ought to be of the simplest construction, the pans of earthenware all in one piece, the flushing arrangements simple but perfect, and the supply of water ample. Each ward should have its own closets, lavatories, &c., built in small annexes, with a crossventilated vestibule separating them from the ward. All the pipes should be disconnected from the drains, the closets by intercepting traps, the sink and waste pipes by being made to pour their contents over trapped gratings. The soil pipes should be ventilated, and placed outside the walls, protected as may be necessary from frost. Each ward should have a movable bath, which can be wheeled to the patient's bedside.
Each ward should have attached to it a small kitchen for any special cooking that may be required, a room for the physician or surgeon, and generally a room with one or two separate beds. No cooking should be done in the wards, nor ought washing, airing or drying of linen to be allowed there.
There is no doubt that the voluntary system of hospital government is far more economical than any system of state or rate-supported hospitals. That the present condition of the voluntary hospitals in regard to economy is all that can be wished is not, of course, true. Still, resting as this system does upon the goodwill of the public for its continuance and maintenance, it is satisfactory to note that there is a continuous improvement in system and method, which makes for economy. It has taken many years to perfect and enforce the uniform system of hospital accounts, but this system with the co-operation of the great funds has produced economical results of the first importance. This system originated at the Queen's Hospital, Birmingham, in 1869, and was devised by an eminent Birmingham accountant, William Laundy, and Sir Henry Burdett. It proved so fruitful in practice that six years later it was introduced at the "Dreadnought" Seamen's Hospital, the first London hospital to use it, and was then adopted spontaneously by a few of the best-administered hospitals where the managers were keen in enforcing economy. In 1891, in order to secure for comparative purposes an identical classification of the items and charges included in the system, a glossary or index of classification was prepared and published in the Hospital Annual of that year. This index enabled the same classification of the many items included in the expenditure of a great institution to be adopted generally. In the same year a committee of hospital secretaries, at the instigation of the Metropolitan Hospital Sunday Fund, revised and elaborated the index of classification, and the new index was adopted by a general meeting of hospital secretaries in January 1892. The Council of the Metropolitan Hospital Sunday Fund approved it, and the Uniform System of Accounts was formulated by that body for the use of the metropolitan hospitals. In 1906 the whole of this system was inquired into on behalf of the King's Fund by Mr John G. Griffiths, F.C.A., when a committee of hospital secretaries and representatives of the King's Fund prepared a further revision of the system. This was completed in the course of the year and adopted by the King's, the Hospital Sunday and the Hospital Saturday Funds. The publication of a book by Sir Henry Burdett led to the adoption of the system in several of the British Colonies, and as a result of the action taken in the British Empire the Uniform System of Accounts has recently been set up and adopted by the principal hospitals of the United States of America. The prince of Wales (George V.) testified to the value of this system in enforcing control over expenditure, and Sir Henry Burdett adapted it for the use of the authorities of all charities of every class. It is probable that no single reform has had a greater influence for good upon the administration of charitable institutions than the evolution and enforcement of the uniform system of accounts.
The arrangements for nursing the sick have greatly improved in recent times, although controversy still goes on as to the best method of carrying it out. In arranging for the nursing in a hospital both efficiency and economy have to be considered. No ward in a general hospital for acute cases should contain more than 24 beds. In hospitals with clinical schools the proportion of nurses to patients should be about one nurse to every three patients, and if possible every ward should have a probationer on duty at night in addition to the night nurse. In all well-conducted hospitals it is now arranged that the nurses on night duty have a hot meal served in the general dining-room during the night, and this is only possible where a nurse and a probationer are allowed for each ward. The nurses' quarters should be separate from the hospital proper, and connected by a conservatory or covered way. Each nurse should have a separate bedroom, measuring not less than 12 ft. long, 9 ft. broad and io ft. high. A bath should be allowed for every eight rooms, and the water-closets and sinks should, if possible, be in sanitary towers cut off from the main block of buildings.
Circumstances must to a large extent determine the arrangement, but it seems desirable on the whole that the work of a nurse should be confined to a single ward at a time if possible. The duties of nurses ought also to be distinctly confined to attendance on the sick, and no menial work, such as scrubbing floors and the like, should be demanded of them; a proper staff of servants ought to be employed for such purposes. It is also desirable that a separate pavilion for lodging the nurses should be set apart, and that fair and reasonable time for rest and recreation should be allowed. Some discussion has taken place as to the advisability of placing the nursing of a hospital in the hands of a sisterhood or a separate corporation. It will, however, be admitted that the best plan is for the nursing staff of each hospital to be special and under one head within the establishment itself, even though it may be connected with some main institution outside. The nursing must, of course, be carried on in accordance with the directions and treatment of the physicians and surgeons.
The kitchen, laundry, dispensary and other offices must be in a separate pavilion or pavilions, away from the wards, but within convenient access. A separate pavilion for isolation of infectious cases is desirable. This may be a wooden hut, or in some cases even a tent; either is probably preferable to a permanent block of buildings. A disinfecting chamber ought to be provided where heat can be applied to clothes and bedding, for the destruction both of vermin and of the germs of disease. It is advisable to expose all bedding and clothing to its influence after each occasion of wear. Although this may entail additional expense from the deterioration of fabric, it is worth the outlay to secure immunity from disease. This plan is rigidly followed at the Royal South Hants Infirmary at Southampton. It is of great importance that the wards should be periodically emptied and kept unoccupied for not less than one month in each year, and longer if possible. During such period thorough cleansing and flushing with air could be carried out, so as to prevent any continuous deposit of organic matter.
Gate House or Admission Block
If the efficiency of a hospital and the regular and smooth working of its departments are to be secured, the proper management and control of the admission department is of the greatest importance. When one considers for a moment the number of applicants of all ages in various stages of disease, and the number of accident cases of every degree of severity who present themselves every day seeking admission, it will be evident that the most careful supervision must be exercised on the very threshold. It is essential that every precaution be taken against the admission of an unsuitable case, or the refusal, without careful examination, of any patient seeking admission. It is only necessary to instance the case of a patient with delirium tremens being admitted to a general ward at a late hour, or a case of infectious disease admitted through an overlook, or a case refused admission and expiring on the way home, in order to illustrate the danger and trouble which might arise should the supervision exercised over this department not be systematic, stringent and thorough.
To secure this proper control it is necessary that the admission department should be designed on a definite plan suitable for the purposes in view. It is not sufficient to utilize any available rooms, say, in the basement of the building, where patients may be casually interviewed by a house surgeon or physician. This department should be as carefully designed and equipped as any other department of the hospital.
Within recent years much more attention has been devoted to the details of construction than was formerly considered necessary, but even in the best type of hospital there is still much to be desired in this respect. It is essential for an architect in designing any building to have before him an accurate idea of all the requirements, and the use to which each foot of space is to be put; for unless he is furnished with this information it is not possible for him to design his building so as to give effect to all the details which are so necessary. The following is an endeavour in a general way to enumerate the various points which an architect should have before him in designing the admission department of a general hospital: The admission department should be conveniently placed on the ground floor of the hospital - or it may be a detached building - with a large court where ambulance wagons or other vehicles may easily pass each other on approaching or retiring from the institution. The entrance to the admission department for patients should, if possible, be entirely separate and distinct from that for the staff and students. An additional entrance should be provided for patients' friends on visiting days, in order that they may be able to enter the hospital without passing through the patients' entrance, or coming into contact with an accident case or other patient seeking admission. The main entrance door should be protected by a covered porch so that patients may be removed from the ambulance or cab to the examination room without being exposed to the weather or the gaze of inquisitive onlookers. This door should be sufficiently wide to allow two hand ambulances or barrows to pass should they require to be brought out to the ambulance or cab, and to facilitate this the floor of the entrance hall should be as nearly as possible on a level with that of the outside porch. Adjoining the entrance vestibule, lavatory accommodation should be provided for males and females who may accompany the patient. Lavatory accommodation should also be provided for porters on duty, and all lavatories should have a cut-off ventilating passage.
A recess to store ambulance barrows should adjoin the entrance, and this recess must be in proportion to the size of the hospital, in order that a hand ambulance may always be available when an accident or urgent case arrives. The vestibule should lead into a large waiting-hall with an inquiry office at its entrance, provided with a telephone exchange, private exchange box, also letter and parcel racks. If possible a window of the inquiry office should command a view of the main entrance. A room should be provided for the medical officer on duty, so that a medical officer may be always at hand and that no delay will occur in attending to a patient on arrival.
Leading off from this waiting-hall, well-lit examination rooms should be available for the thorough examination of patients, both male and female, the number of rooms, of course, varying with the size of the hospital and the amount of work to be done. Each of these rooms should be fitted with a wash-hand basin and sink, and a plentiful supply of hot and cold water.
Two rooms, with recovery rooms adjoining, should be fitted up as small operating-rooms for the treatment of minor casualties. A special room should also be furnished with an X-ray outfit, and arrangements should be made whereby this room can be readily darkened so that suspected fractures, &c., may be examined with the fluorescent screen.
Adjoining the admission department two small wards should be provided for the accommodation of drunk or noisy cases unfit to be placed in the general wards. To these "emergency wards" must be attached the usual bathroom and lavatory accommodation, nurses' room, ward kitchen and urine-test room or small lavatory. These wards should have double windows in order to prevent noise being heard outside if the wards are near other buildings.
The interior walls of the admission department should, as far as possible, have a smooth and impervious surface, in order that they may be easily cleaned. All angles should be avoided and all corners rounded. Although glazed tiles are open to the criticism that they have numerous joints, they probably make the most suitable wall yet devised, as they can be easily washed down at very small cost. The corridors and waiting-hall should be tiled to a height of 6 ft. 6 in., and the upper walls covered with Parian or Kean's cement, and be treated with three coats of flat paint and two coats of enamel, or, what is equally suitable and less costly, enamellette. The floors of the passages and corridors throughout the department should be covered with terrazzo, which is a mixture of Portland cement and marble chips. A margin of I ft. round the rooms should be treated in this way, and the terrazzo carried up this same distance on the wall to join the tiles. The remainder of the floors should be covered with hard wood, such as American maple or teak. As these floors require to be frequently washed, oak is not so suitable. Oak very soon becomes destroyed with water; the same trouble is experienced with pitch pine. The doors should also be made of a hard wood, preferably teak, and have no mouldings or grooves where dust can lodge. They should be wide enough to admit an ambulance barrow or bed with ease. In no case should the doors of an examination room be less than 3 ft. 6 in. in width.
As an aid to a complete understanding of the varied work which has to be provided for, and the most effective method of carrying it out, the accompanying plans are given of an admission block de signed to embody the main principles which govern the construction of such a department.
All accidents and patients seeking admis - ' sion to this hospital enter -- through the central gate - way, and on the left is w X-9 CLOThES shown the porters' room, where a porter is always in readiness to attend to „o, any applicant. This room has suitable ac commodation for parcels, letters, telephones, &c., e so/ and adjoining it is a small lavatory for the use of porters. At the side of the porters' room is the entrance to the central waiting-hall, which is lit from the roof. On one side of this hall are examination and dressing-rooms for males, with lavatory accommodation; and on the other side similar provision for females, with the addition of a nurses' duty room. At the end of the central hall are two operating theatres, with recovery room adjoining each; one theatre for males, and the other for females. Between these theatres are rooms for sterilizers and dressings. An X-ray examination room is provided beyond the male examination room on the right of the hall. In the basement, under the entrance-hall and operating theatres are two bathrooms for males and two for females, with W.C.'s for each. The remainder of the basement is used as a store for patients' clothes, and a hotair chamber is provided for purposes of disinfection. The basement can be reached by a lift or by a wide staircase which is situated at the end of the waiting-hall.
In the above plan provision is made for a sitting-room for the medical officer on duty. This is a new and essential feature in the admission block unit of all hospitals in large cities, for it should secure that no patient is kept waiting for many minutes before being seen. One of the blots on the management of many hospitals is that regrettable delays often take place, and much dissatisfaction and avoidable suffering may arise from this difficulty in the administration of a general hospital. We have given this plan of a model gatehouse or admission block for a modern general hospital, because the block as it stands contains all the elements necessary for a receiving-house block in cities in connexion with a great Hospital city situated outside its area, in fulfilment of the suggestion for a Hospital city made above. Apart from its interest as a new feature which all new hospitals should adopt, the gatehouse or admission block has an importance in the wider sense, that it may come to form the key to the solution of the problem of how best to provide hospital accommodation for the poor in great cities under the best hygienic conditions, while protecting them from the misery and danger of prolonged delay in first treatment, especially in connexion with accidents and other cases of urgency.