np) Sra Rae ene Pudisanie nari NG Cor Area ie ais more pO LaNG span Ba aeati en) iat ix Verein ey saa #i uh ‘ eh ite yet are ae: ye ae eae pera nyy x es a) fs Eat ties Bi cigs ee rete ida pry ee tia ee ee ee Gide se Bee Bee os acon Dianna erreur EN ea a ns peat, aoe eet Lack tae Pes eh Ws an na crater ie erie 2 ite ten ee ieee CP RLRIRE IP Aided Sepa aIea iN ately s os Bi & wi Beaty aie PUM a LEI) aon Sere NaC nh pa Ueno Be aaa aean cn ESE SRO SESS MEARE ican Nace ee eae Bet i Dereon Re rn Ta Irate se Motte ose ain nv “IVIIESOH BZOVITIA HOINVINVYO es Q HANDY BOOK OF COTTAGE HOSPITALS, Pave 2 oer ILLUSTRATED WITH PLATES AND WOODCUTS. BY HORACE SWETE, M.D, Honorary Medical Superintendent of the West of England Sanatorium or Convalescent Home, at Weston-super-Mare ; and formerly Surgeon to the Wrington Village Hospital. LONDON : Hamitten, Apams AnD Co., Paternoster Row. WESTON-SUPER-MARE : Ropsins AND Scotney, Hien StREER C oF » y% We CORNELL UNIVERSITY} LIBRARY TO THE REV. JOHN VANE, MA, CHAPLAIN TO HER MAJESTY, RECTOR OF WRINGTON AND BURRINGTON, AND PRESIDENT OF THE WRINGTON VILLAGE HOSPITAL, THIS ‘€ ee BOOK”’ IS ‘INSCRIBED, IN REMEMBRANCE OF THE MANY KINDNESSES SHOWN BY HIM TO THE AUTHOR, DURING’ A RESIDENCE OF THIRTEEN YEARS IN HIS BARISH, AND THE VALUABLE ASSISTANCE AFFORDED BY HIM IN FOUNDING THE WRINGTON VILLAGE HOSPITAL. PREFACE. In bringing the subject of Cottage Hospitals before the notice of the public, it has been the ‘utention of the Author to show how simply and inexpensively a Cottage Hospital may be managed. Many of the details entered into may seem trite and common place; but it has been desired to make the little book in reality what it is entitled, a ‘‘Hanpy Boox.” Those who take the initiative in the work of promoting Cottage Hospitals are for the most part busy men, and for such many of the details have been worked out. The plan of the work was arranged several years since ; but circumstances preventedthe Author from carrying out his intentions at that time. He therefore placed the papers and notes he had collected at the disposal of Dr. Warne, who was writing a very able and useful pamphlet on the subject. He has not, therefore, hesitated to quote largely from Dr. Warrne’s pamphlet, feeling that, with the single exception of the admission of patients by-governor’s notes, Dr. Warine’s views were identical with his own. To Mr. Naeper, and the Medical Officers and Secretaries of the Cottage Hospitals described, his thanks are especially due ; vi. as well as to Mr. Berxetey Hitt, and Messrs. ALLEN and M. Wuirwitt, through whose kindness he has been able to include in the work several useful illustrations; whilst to Dr. Wynter and the: Editor of ‘‘Good Words,” he is indebted for the privilege of re-publishing the views of Cranleigh and East Grinstead Village Hospitals. The other blocks have been faithfully executed by Mr. T. B. Power, of Bristol. The description of the various Cottage Hospitals is by no means as complete as could be wished, having, in many instances, to be culled from the published reports. The Author trusts to be able to rectify this in a future edition ; and will be thankful to those Medical Officers of Cottage Hospitals who have already assisted him, if they will send full information of the Institutions in which they are interested. x Should the publication of this little work be the means of giving any fresh impetus to the advancement of the Cottage Hospital movement, the labour of its compilation will be amply repaid. DuUNMARKLYN, WEsTON-sUPER-Marz, June 21, 1870. CONTENTS. ' -Cuap. < Introductory. Cuap. I. The Principles and History of the Cottage Hospital movement. Cuar. IT. The Cottage Hospital and its Furniture, Cuar, IV. The Foundation and Management of the Cottage Hospital. Cuap. V. The Officers of the Cottage Hospital ; the Nurse and her Duties. Cuar. VI, Out-patients ; Wards for Infectious cases ; Ambulances ; the evil of mixing up other schemes with the Cottage Hospital. Cuap. VIL. Description of the existing Cottage Hospitals. Caar. VIII General and Statistical results of the treatment of cases in Cottage Hospitals. | Cuar. IX. The future aspect of the Cottage Hospital movement ; Sugges- tions for the formation of a National Association for their promotion. APPENDIX. Papers on the subject, published in 1862 and 1866; Forms; Esti- mates for Furnishing, Cost of Surgical Instruments, &c. ¢ ILLUSTRATIONS. Cranleigh Village Hospital Longton Cottage Hospital ... 0... 0 .0e see ee Ground Plan of Cottage Hospital of 12 beds Interior of Wrington Village Hospital Design and plan of Cottage Hospital of 6 beds ... Cottage Hospital Ambulance East Grinstead Cottage Hospital’ ‘St. Mary’s, Dorking Wrington Village, Hospital ‘ to face page ” ” ” “FRONTISPIECE 41 44 50 65 « 120 « 128 «. 181 -- 183 CHAPTER I. INTRODUCTORY. Ove of the most important problems of political economy, is that of deciding how to help the poor to help themselves, rather than to demoralize and to degrade thern to the tank of ‘*paupers” by indiscriminate alms-giving. Many of our modern senators are beginning’ to see that giving relief to the sick poor in the shape of a loan, has more the effect of telieving the over-burdened ratepayer than forcing the poor man, whose preserit means of subsistence has been cut off by sickness, to sell his little ‘‘sticks of furniture,’’ and go into ‘the house,” The system of cottage hospitals, which this little book advocates, is founded on the principle, ab mitio, of helping the poor to help themselves. It was an era in the history of hospitals when Mr. Narrer, of Cranleigh, showed that all the good effects of a hospital might be obtained with a zealous, ear- nest surgeon and a good nurse, in a simple cottage, like that of the poor man; and that, putting aside the, perhaps time- honoured, custom of providing gratuitously all the appliances and diet of the hospital, the poor were not only thankful for the aid afforded in the little Cottage Hospital, but were able and willing to pay a weekly instalment towards their maintenance. . 2 In olden times, ‘Charity Universal,” inscribed on the portals of some of our noblest hospitals, was a grand motto; but the experience of those who work most amongst the poorer classes, has shown the demoralizing and pauperising effects of giving to too great a degree; whilst the free tickets of the subscribers are often largely taken advantage of, by a class well able to pay both for advice and medicine, to impose on the hospital funds; indeed, many openly become subscribers, that their servants and others employed by them may obtain cheap doctoring at the hospital. The prejudice against the new system was so great, that in the first five years after Mr. Napper pioneered the way, only eight of these hospitals were opened. As the founder of one of the early cottage hospitals, J can bear testimony to the difficulty of overcoming the prejudice of not only the county gentry, but medical men, to the system. In the succeeding five years the number of new cottage hospitals was multiplied tenfold; and it is on account of the numerous applications for information, as to how such an Institution should be started and managed, that I now compile this ‘‘ Handy Book,” knowing that the feeling of distrust, as to the objects of these hospitals, will diminish as their true nature becomes more widely understood. The great obstacle to the movement has been the opposi- tion of medical men practising in the neighbourhood, where a new cottage hospital has been proposed. I myself painfully experienced this when starting that at Wrington ; but its five years’ work has done much to remove this feeling. 3 Many, formerly much opposed to the movement, are now giving it their aid, and a new cottage hospital will soon be commenced in consequence, in a neighbouring district. The principles of the Cottage Hospital movement I laid before the Meeting of the Bristol and Bath Branch of the British Medical Association in 1866.’ (The paper is reprinted in the appendix of this book.) The simplest way to look at the matter is to consider the cottage hospital, if formed on the original model of Cranleigh, to be a receiving home for the patients of any medical man residing near enough to the hospital to make use of it. There he will find an efficient nurse, clean and well-ventilated rooms, with properly constructed beds ; and there he will be enabled to carry out his treatment, and operate, if necessary, feeling that more success must attend his efforts than if his patient remained in the crowded, and often dirty, cottage of the poor. It is necessary for the effective working of these little hospitals, that ome medical man should act as super- intendent or director. One head must manage the whole. Very often the proposal to start a new cottage hospital will emanate from a young practitioner, both because, being a beginner in practice, he has more time than his older brethren, and because he yearns for the hospital work he has so recently left; still this should cause no ill-feeling to so good a movement. The older practitioner, by acting in concert with him, will often gain a useful friend, and one who can relieve him of a good deal of hard work, by 4 looking after a troublesome case in the hospital; whilst as the senior, superintending his own case, he can lose no meed of credit due to him for the result. Again, the cottage hospital does not diminish the fees of neighbouring medical men, and it has been laid down as an axiom, and carried out in many of the institutions now established, that if any operation be performed on a patient having a parish order, and which would entitle the medical officer to an extra fee, that fee will be handed over to him, just as if the operation were performed in the patient’s own cottage. That this is no myth, the returns for Cranleigh will show, 4s in the first four years of its work £36 was paid in extra fees-to parish medical officers. Boards .of Guardians are beginning to find that the patient in the cottage hospital is able to return to his work sooner than if he remained in his own home, and that therefore the ratepayers are benefited by any operation performed there, perhaps the only argument they will listen to. I believe much would be done to remove any prejudice with regard to the establishment of a cottage hospital, if the promoters called together the neighbouring medical men, and thoroughly explained these matters. In all cases, too, the rector or vicar of the parish should be invited to have a voice in the matter. The clergyman and doctor going hand in hand in so good awork, will generally obtain a, fair hearing from their wealthier neighbours, from whom the sinews of war, in the shape of the necessary funds, are most likely .to be obtained ; and here I may observe that this movement has been much promoted by the clergy. The 5 cottage at Cranleigh, the first used as a hospital, was given, rent free, by the Rev. Mr. Saprs, the rector of the parish, who did much by his influence and purse to help Mr. Naprer in the, then, new work, At Wrington I could never have overcome the apparently insurmountable difficulties without the help and encouragement of the Rev. Mr. Vans, the venerable | rector of that parish. And looking over the reports of more than fifty cottage hospitals, the clergy are nearly always in the foremost place ; frequently working as secretaries— no small labour—when a new institution has to be established. In only two instances have I been told that any opposition has emanated from the clergy. In country places the prejudice against any new thing is very often a considerable hindrance to the founding of a cottage hospital. The Squire has always looked on the County Infirmary as the legitimate place to which an accident should be sent, and cannot understand why his own family doctor should want to have a hospital. Farmers are pro- bably still more prejudiced’: the usual sentence, ‘‘It was well enough in my father and grandfather’s time without; and why won’t it do now?” we must be prepared to hear. Still, time and experience of the work in other places will gradually break down these prejudices, and the way will be cleared for fresh operations. That. there is room for many more of these little hospitals cannot be doubted by anyone conversant with the distribution of hospital beds throughout this country. Whilst, as I-stated to the Medical Association, there is one bed in London, to every 716 of the population, there are counties where the proportion does not equal one 6 {n 3000; and two counties where the population is over 50,000, and not a single hospital bed to be had, if required. At the date of that calculation there were nine millions of our population without any hospital accommodation, save that at the workhouse infirmary. Since then, about 40 cottage hospitals have been opened, with an average of six beds each; so that, allowing one bed to be sufficient for every 1000 persons, there is still scope for 1760 beds, to meet the wants of the population. One of the advantages of cottage hospitals, as will be shown in the pages of this little work, is the small amount of expense in starting them ; a fair average deduction, made from the perusal of a large number of reports, being—that to establish a hospital on the Cranleigh model, the cpst should not exceed £100; and the annual amount of subscriptions required to keep it up, another £100, supple- mented by the patients’ payments, which will generally reach to £25 or £30, thus making the whole amount up to £20 a-bed. In making this statement, it must be borne in mind that the cottage hospital does not necessarily mean a building of any architectural pretensions; but such a cottage as a well-to-do working-man or small farmer might occupy, with some little alterations to fit it for its purpose. Many cottage hospitals, as will be hereafter seen, are really beau- tiful buildings ; but this is a part of the luxury, not the necessity of the movement. It is my intention, as far as I have been able to obtain information, to describe the cottage hospitals now in existence, so that the reader, who may wish - 7 to help in establishing a new one, may have some idea of what is required, and suit the design to the means and charity of the neighbourhood. In some places—at New Bromwich, Dudley, Sherborne, and Crewkerne—the intended cottage hospital has expanded into a large general hospital, more suited to the wants of those neighbourhoods. ; It has been feared by some that the establishment of cottage hospitals must tend to diminish the funds of our older institutions. This, I think, closer investigation will not prove to be the case; but rather that the purses of those who have never before given to hospitals, have been opened, and they have been enabled to experience the luxury of aiding others. This may arise, first, from the fact that small subscriptions are gladly received ; whereas many of out county infirmaries have a stated subscription of one or two guineas per annum ; and, secondly, as the work is carried on before the eyes of the subscribers, he personally knows something of the wants of nearly every case taken in, and feels convinced that the small donation he has been - able to afford, is doing the work he wished it to do, and not expended in large staff expenses, however necessary they may be. At the Hambrook and Wrington cottage hospitals, not far from the Bristol Royal Infirmary, the subscription lists show that the majority of the contributors, with the exception of a few wealthy landowners, who support both institutions, are those who have not before subscribed to the funds of a hospital. I believe it is very rarely found that a subscription has been withdrawn from the county infirmary, in consequence of the establishment of the hospital in the village. 8 Premising, therefore, that there is room for the establish- ment of cottage hospitals ; that’ they neither injure medical men, nor the finances of the larger and older hospitals, it may be well to shew in what way this movement is of value. 1st, to the poor, suffeting from sickness or accident. 2nd, to the medical men practising in the neighbourhood ; and 3rd, to the public generally living near, who may not themselves require to take advantage of the hospital. To the sick and suffering poor. To those who visit their poorer neighbours, the sick room of the cottager is a familiar object, the cottage itself generally consisting, at the best, of a kitchen and back shed, with perhaps two bedrooms, which are often without a fireplace ; the windows, small, low, and frequently not made to open; the labouring man, who has met with a severe accident, with difficulty is carried up the narrow staircase—generally of the step-ladder description—and is placed on a bed utterly unfit for the treatment of a broken limb, and which his restless tossings has disordered. Per- haps he ‘may possess a coverlid or counterpane ; but more generally the top covering of the sick man’s bed is the collection of unused clothes in the house; the floor, occu- pied by some ingeniously-constructed temporary bedding for the wife and younger children; no useful sanitary arrangements to be obtained; the patient parched with thirst, and with the capricious appetite of illness, turns his head away from the badly-cooked food; the wife, tired out with bad nights, and ‘worrited” with the children, who are constantly crying; added to which may be the close, 9 sickening steam of ‘‘ washing out a few things,"” which some neighbour, with well-meant kindness has dropped in to do, keeping up an incessant chatter of village gossip that drives the sick man wild, and here we have a tolerably fair picture of _ the cottage home in sickness. It may be that the patient lives in one of those villages happily now on the increase, where the squire’s and the vicar’s wife and daughter vie with each other in helping the poor ; where the clean sheets from the Vicarage, and nourishing broth from the Hall, with the superintendence of the village nurse from one of our excellent training institutions, does much to remedy the state of things we have described. Still, I doubt even then, with all the clinging to home of our English character, whether the sick labourer would not be better off in the cottage hospital. ‘He would not have far to go; he would arrive at a cottage much like his own, his wife by his side, and the clergyman of his parish, to whose voice and kind words he is accus- tomed, his visitor.’ The time of the wife or elder daughter, that would haye been taken up in nursing, may now be em- ployed in doing something to add to the income of the family, during the sickness of the husband and father. The sick man will there have the advantage of pure air, and be saved the inconvenience of a crowded room ; the hospital though in many: instances, not much differing from his own cottage, will have windows to admit bright sunlight and air; the food will be well cooked, and the necessary medicines promptly given, which greatly increase his chance of safety or rapid recovery. The absence of noise, together with the quiet and regularity of a hospital, will tend much towards this good result, And this is even more manifest in the cottage hospital than in the 10 county or city infirmary, where the numerous staff of doctors, pupils, and nurses, the clinical lecture, case-taking, and the excitement of seeing many others suffering, and perhaps dying, around him, cannot be conducive to the well-doing of our country poor; added to which.he is able to have the atten- tion of the doctor he is accustomed to, who has successfully brought his wife and children through many difficulties, and who is endeared to him by frequent kindnesses shown in sickness—for the majority of these little hospitals are open to all medical men choosing to make‘use of them. The patient in these hospitals is able to be visited by those near and dear to him; whereas, if taken to the county infirmary, in many cases the distance and expense of the journey would prevent him from enjoying this satisfaction, and would add to the discomfort and the feeling that he was cast among strangers, however kind and attentive they might be. Dr. Warne, in his interesting pamphlet on Cottage Hospitals, remarks on this subject :—‘‘ Separation from those near and dear to us is at all times trying: how peculiarly so must it be, when one of the parties has met with a grievous accident, which renders the question whether they will ever meet again in this world problematical to the last degree. Under such circumstances, to transfer a loved one to a distance, too great for a daily pilgrimage, with no means, even in these days of cheap postage, of receiving a daily bulletin of the sufferer’s welfare, and to consign him to the care of utter strangers, must be inconceivably painful. So much for the friends left behitid; and now a word for the patient himself. What, it may fairly be asked, could exercise “11 ‘ a more depressing influence than such a separation from all near and dear to him, and that too at a time when it is of the utmost importance to be cheered and comforted ? There cannot be a doubt that such a separation must exercise a most prejudicially depressing influence. Here the cottage hospital steps in, and offers a means of reducing this evil to a minimum; by its means the separation is rendered more nominal than real; the near proximity of the hospital allows of daily personal inquiries, and of interviews under certain very slight restrictions. The old familiar faces are still more or less around the ‘poor sufferer; the clergyman, the doctor, the nurse, are people with whom he has been acquainted, by sight at any rate, for many years,—perhaps all his life long; and at the same time that he receives every comfort and attendance that he could have in a large county hospital, he does not lose sight entirely of those who are perhaps as dest to him as life itself.” Dr. Warine also, draws attention to ‘‘the re that arises in fatal cases, from the corpse not being kept in the crowded cottage of the poor, but in the mortuary chamber which should be attached to every cottage hospital, where the dead may remain without inconvenience to the patients during the interval between death and interment.”’ It is very sad to see the coffin containing the remains of one of the cottager’s family, compelled to be kept in the one and only room the living are able to occupy, where the usual meals and all family intercourse and gccupations must of necessity be carried on. There is another point in which the value of a hospital in the immediate neighbourhood of the poor man’s cottage or : 12 sphere ot work is so obvious, that, if it were not for the prejudice in the minds of many in favour of large hospital institutions, hardly needs enlarging upon—the case of severe accidents, endangering the safety of life or limb. Time lost is often life lost, in a serious accident, where loss of blood is frequently great. Not long since there was an account in the public papers of a severe casualty on a new railway in course of formation, where the thigh of the poor sufferer was severely crushed, with considerable injury to the blood vessels. The accident happened within two or three miles of two cottage hospitals, both having the good’ fortune to possess excellent surgeons on their staff, yet the authorities decided to send the poor man to the county infirmary, a distance of twelve miles. Three hours were lost in transit, and death ensued from shock and loss of blood. Now, it is not unreasonable to infer, that had the patient been at once received into one of the little hospitals near, two hours of valuable time, at least, would have been saved. Many similar instances must occur to the recollection of medical men, where, if means of attending to the sufferers from accidents were at hand, valuable lives would have been saved. This is the more painful, as the man who is stricken down is generally the bread-winner of the family, and the life lost is not simply the sad trial to the widow and children, but represents a positive pecuniary burden on the ratepayers of the neighbourhood. ‘The value of Cottage Hospitals to medical men practising in , their neighbourhood. : Whilst the greatest amount of benefit of this system is felt by the sufferer received into the hospital, no small 13 amount of comfort and help is derived from it by the medical practitioners. The safe and speedy recovery of the patient is not only a fsource of deep gratification in itself, but is an earnest of future success in his profession to the practitioner. The country surgeon often refuses to operate, and sends his patient to the nearest town hospital, not because he considers himself incompetent to cope with the case, but because he feels that the difficulties of after treatment, and the entire absence of surgical comforts in the poor man’s cottage, will militate against a successful] result. With a cottage hospital near, these obstacles at once vanish. Statistics, as will be shown, prove that the patient has a far better chance in the little hospital than in the county or city infirmary. Nor is surgical skill wanting. Many an embryo Cooper or Liston has wasted his talents in the country, feeling the power to act, but his conscience not permitting him to jeopardise his patient. The time has gone by when good surgeons were only to be found in towns, medical and surgical education being so much advanced by the frequent examinations now insisted on by the Medical Council. Idle or ignorant students are weeded out at an early part of their career, so that the young surgeon really has a thorough knowledge of the groundwork of the profession. I would by no means by these remarks be considered to undervalue the surgical skill of the older country practitioners. Many an -operation that would have made a sensation in the operating theatre of a town hospital has been successfully performed in the cottage, of the labourer by the country doctor. In a case of railway injury received into the first 5 ‘ t 14 little cottage hospital, where both legs were crushed; Mr. Naprer sends for the assistance of a brother practitioner to remove the injured limb, and then quietly sits down and ligatures the main artery of the thigh whilst waiting for help, no trivial operation even with efficient assistance. There is no lack of skill in country places; only the opportunity of bringing it into action is wanting. The cottage hospital will often save the country practitioner miles of hard riding, and enable him to visit his patient in a critical case much more frequently than would have been possible, whilst he was living on some desolate hillside, with- out proper road or approach, and probably six or seven miles from the doctor’s door. It is well known that the success of the treatment of many severe cases depends more on little attentions frequently displayed, than even on the skill that originates some new and striking plan of cure. The oppor- tunity of giving this attention is lost when the patient lives at a distance from a medical man, whose daily work is too often represented by forty or fifty miles’ travelling a day. Another very great advantage is the capability of meeting and consulting over a difficult case with brother practitioners. . As this can be reciprocal in the hospital, any delicacy in requesting a friend to come and help, without the possibility of giving him a fee, is removed.’ The cottage hospital being open to all medical men, it will necessarily tend to promote unity of feeling. Amongst medical neighbours, except in consultation or in a hospital, medical men see little of one another’s work; the feeling of honour and delicacy which is inseparable from the profession, preventing them from talking over cases entrusted to their care, and ignorance of 15 the details and true nature-of a case which is sometimes curiously misrepresented by the public, may tempt one surgeon to look superciliously on the work of another; whilst the open consultation and treatment of the patients in the cottage hospital will, to a great degree, if not entirely, remove this feeling. The country practitioner is benefited also by knowing that in the hospital his instructions are properly carried out; those acquainted with the habits and prejudices of . the poor will at once see what is gained by this. How often the doctor orders medicine, which after arriving at the sick man’s cottage, would be supposed at once to be given in the proper dose ; not so, the bottle is not unfrequently put on the shelf till the “Vicar” or ‘*Madam” calls, who are supposed to know by the colour and smell, or if the patient can induce the effort to be made, by the taste whether the “ stuff” is all right. It is rarely then the whole dose is taken. When the patient is able to pay a little for his medicine, it is given in- half doses to make it last the longer. Any new symptom is supposed to have been caused by the medicine, and it is constantly laid aside till the doctor’s next visit. Even if given regularly the nursing is irregular and lacking in proper knowledge. Food, more important than physic, is given at long intervals, and of a kind that the sick man loathes, or if taken, cannot digest. In cases of accident the bandages are frequently altered, and the advice of the last neighbour who drops in taken in preference to that of the surgeon, who is doing all his skill and experience can suggest for the sufferer. The want of a hospital in the country frequently tends to drain interesting and instructive cases from the practice of the 16 medical men. The British Medical Journal states :—“ The system of draining all instructive cases {rom country districts is detrimental to the practitioner, inasmuch as it deprives him of the means of exercising and maintaining his manipulative skill, which is a great grievance in every way, inasmuch as the practice of the art in its highest and most critical, as well as in ordinary cases, is a great delight: it is a grievance, moreover, in a pecuniary point of view, inasmuch as it necessarily inculcates the notion that where there is a want of practice, there must be a want of skill; hence the higher classes are led to call in the aid of metropolitan celebrities on every slight occasion. Knowing as we do the fertility of resource that characterises the country practitioner, and his ability in the treatment of disease, we look upon this drawback to his career as an exceedingly annoying one, and we hail with much pleasure any means by which it may be obviated.” ’ The Lancet also says :—‘*The management of cases of accident and severe illness amongst the poor in rural districts constantly offers the most serious difficulties to the surgeon. In remote villages, in isolated districts, and in localities where the hospital is distant, the patient must suffer greatly from the absence of all the appliances and the kind of nursing and attendance which only such an institution can afford. A well devised effort made in the village of Cranleigh, successfully meets these shortcomings in that district, and may serve as a model to be usefully copied elsewhere. It is a sensible and useful development of local philanthropy for which we desire permanence and a rich fruition of useful works.”’ 17 The value of Cottage Hospitals to the public generally huving near, who may not themselves require to take advantage of them: The wealthier inhabitants of villages will often receive a benefit themselves from the charity they have bestowed on the poor, in providing a hospital for their Kelp in- sickness. The benefit done to the profession, by enabling them to exercise and perfect their skill, will not only keep a really good surgeon in the country, but it will also keep him up to the mark. Severe accidents and disease do not alone happen to the poor. It is true that the rich man can put in motion the telegraph, and summon to his aid the hospital surgeon of eminence, but there are not a few cases where mortification. may set in before the skilful operator can arrive, and where the knife of the village surgeon, deftly used, may save the life of the squire at the hall, To the earnest surgeon, the means of exercising his skill has far more charms than the sordid interests of the ledger and day-book ; and advanced pro- fessional income presents less temptation to keep the young surgeon in the country than a well-conducted cottage hospital, with its means for properly carrying out his treatment. In a word, professional success and credit are more alluring than fees. The Times, January 3rd, 1866, speaking of the advantage of cottage hospitals, says :—‘ The lessons the surgeon learns day by day in these hospitals are, in time of need, of value in the ancestral hall. Thus the peasant’s misfortune may be the means of saving the life of the « squire.” Nor is the means of securing the services of -a good operating surgeon in time of need the only benefit to be c 18 derived ; a good nurse is of very little less importance in 4 country district far from towns. Though I do not approve of the system of sending the nurse out of the hospital to exercise her skill, which should be retained for any sudden emergency, yet there have been many occasions where, it has been of ‘incalcu- lable importance to be able to send a nurse at a moment’s notice to the sick room of the more wealthy patient. I could mention more than one case where the timely aid thus afforded in the middle of the night, has done more to eradicate lingering prejudices against the cottage hospital system, than any amount of argument from the ‘promoters; The rich man, who has himself experienced the difference, almost immediately felt, when the cottage hospital nurse has arrived, comfortably adjusted his bed, and almost by magic made the recreant leeches to “take,” is not ‘long in being convinced of the benefit of such a person being at hand in his village. Many of the remarks previously made will also show how the little hospital has acted in relieving the ratepayers of some portion of their parochial burdens. The expenses of the undertaker, and the subsequent care of widows and orphans, far outbalance the weekly sum alloyed by the board of guardians to maintain a patient in the cottage hospital, and by receiving all the advantages to be obtained there, save the life of the recipient of such parish aid. I do not allude to the regular pauper, for whom the workhouse infirmary is. provided, but to the stalwart labourer, who, when prostrated by accident or disease, and having neglected to enter any provident club, is forced by the claims of his numerous family to call the relieving officer to his aid, and thus, however reluc~ tantly, to become a burden, on the ratepayers. 19 The rich may also feel that whatever their bounty may supply to the poor reaches its proper destmation, and in these institutions is carefully used. At Fowey Cottage Hospital a large proportion of the funds are given in kind,—dinners, fruit, wine, &c., being sent from the rich man’s table to his sick neighbour. Not many weeks since I saw at the Memorial Cottage Hospital, at Capel, in Surrey, a poor woman suffering from a painful and fatal disorder, whilst on the table by her side lay a beautiful bouquet of hothouse ferns and flowers. Who- ever the kind donor might have been, he would have been more than repaid had he witnessed the pleasure the gift produced. These little attentions add greatly to the comfort of the poor, and like ‘the cup of cold water,” react to the benefit of the giver ; for is it not written, “Tnasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto mz.” 20 CHAPTER II, THE PRINCIPLES & HISTORY OF THE COTTAGE HOSPITAL MOVEMENT. The principles upon which Mr. Nappzr, in 1859, originated the cottage hospital system are three-fold :— 1st—A small number of beds, so that the work of a hospital may be carried on in a cottage like that of a poor man, and with a single nurse. 2nd—Equality of privilege to subscribers in recommending patients, the patient paying a certain sum, according to his means, weekly, towards his maintenance. 3rd—Whilst one medical man takes the general superin- tendence of the work, the cottage hospital is open to all who choose to make use of it, and all extra fees due from the union are paid to medical men while attending on their cases in the hospital. The number of beds.—-This should certainly not exceed six, but in thinly populated districts, four will be found sufficient, There are two reasons for this ; first, in the cottage that will be most likely available for the purpose, the rooms will be small, and a large number of beds will produce all the evils of overcrowding ; and, secondly, a larger number will neces. 21 sitate a second nurse; to ensure economic working, there should never be more than one, with additional help. It is the amount of large staff expenses that causes the drain upon the funds of our hospitals. Equality of privilege to, subscribers.—In all cottage hos- Pitals accidents and emergencies should be at once admitted, without waiting for any note of recommendation. In other cases the patient is enjoined to procure from a subscriber a note, as a guarantee that the applicant is a proper person to be admitted; these notes, on Mr. Napper’s principle, are issued to subscribers as they may want them, entirely irrespec- tive of the amount of their subscription ; thus the farmer or shopkeeper has as much right to recommend patients as the squire, though the amount of their subscription is pro- bably much smaller. That ‘this is an ‘important principle I will endeavour to show. ‘The cottage hospital is founded to afford the privilege of a certain number of beds to supply the. wants of the district : this has been found by experience to be about one bed to every 1000 people. If the old principle of governors’ notes (found to lead to much of the abuse of our larger hospitals) be carried out here, the rich man could at once fill the little hospital with his nominees, so that it would really become the appendage of the Hall. Dr. Warne, I am aware, takes a different view : he says, ‘‘ In deciding upon the sum to be paid weekly for maintenance, it should be borne in mind that no cases, excepting those of an emergent cha- racter, are admitted without a letter of recommendation frorh a subscriber, and that his subscription ws intended to make up wholly or in part the difference between the sum paid by the 22 patient and the actual outlay, . . . . In other words, by this rule, the subscriber who recommends the patient, pays 5s. a week towards his maintenance, and placing the weekly cost at 7s., this would only leave 2s. per week to be contri- buted by the patient.’’ Now this statement is not only at variance with the original scheme, but it seems to sap the very foundation of the movement, and instead of the cottage hospital supplying beds to those who really need them most, . they will be secured to those whose friends are able to pay the most. On this point Mr, Napper writes :—‘‘ Accidents and cases of emergency are at all times admitted without orders ; but all other applicants must be recommended by a subscriber. The hospital is mainly supported by donations and small annual subscriptions, but the number of beds being necessarily small, subscribers, whilst recommending, are. not entitled to order the admission of patients, and as a standing tule, such only are admitted as cannot be efficiently treated at their own homes ; whilst infectious, incurable, and consumptive - diseases are excluded.” The simplest way of looking at the matter is to remember that the cottage hospital of six beds, in a purely rural district {many of those started in manufacturing places, have developed into general hospitals), supplies the necessary accommodation for 6000 people; that having been once started and furnished, it will cost about £120 per annum to keep up, about £25 to 430 of which will be paid by patients, so that in a country neighbourhood, having a population of 6000, £90 to £100 will have to be obtained annually. In so small a community the 10s. subscription of the farmer or shopkeeper should be as f 23 ‘valuable as the £2 2s. of the more wealthy landowner., Both know the poor sufferer equally well; the smaller subscriber pos- sibly more intimately than the larger ; the point necessary to be obtained is the recommendation of a proper case, and the probable amount of weekly payment that can be fairly expected from the applicant is thus arrived at; thus the feelings of the small subscriber, whose purse has been perhaps only recently opened to.help in hospital work, are not hurt by finding that the smallness of the amount he has been able, and perhaps even denied himself, to give, has not debarred him from the privilege of recommending a poor man to the hospital. It may be well to fix a limit below which a recom- mendation cannot be granted. In the Wrington Village Hospital any subscriber of 1os. and upwards is permitted to recommend patients, but the number of notes is not restricted to the amount given, the secretary at first supplying him with a few forms, and renewing the supply as they are used. The amount the patient should pay weekly is not always: easily decided. Practically, I find 6d. a-day to be most suited to the patient’s means. In cases where the union has to help, 2s. 6d. a week will perhaps be the outside amount. Some patients, however, will be able and willing to pay 5s., or even 8s. a week ; this amount, when fixed, should be paid weekly, in: advance ; or at any rate not be allowed to accumulate from week to week. My own experience has been that the patients’ are more satisfied to pay ; it renders them independent, and: takes away the feeling they dislike “of being beholden to any one.”’ As a patient at the Wrington Village Hospital said to me, in true Somerset vernacular, ‘‘ Thur, when I’ve a pay’d 24 the money I do knaw I’ve a right to ring thic bell,” alluding to the handbell for the patient to ring when they require the attention of the nurse. If the patient is very poor, still it is better he should pay even 6d. a week-than nothing at all. ‘The British Medical Journal, Oct. 20, 1860, remarks on this subject :—-The major portion of the receiptsare of course obtained by donations and subscriptions from the wealthy in the neighbourhood ; but the principle of self-aid, no matter how small, is'established by the system of weekly payments, and we are delighted to find that a remote village in Surrey has set the example in a manner which must sooner or later be followed by our great metropolitan hospitals. When we see poor agricultural labourers thus contributing towards the expenses of their maintenance arid care, how can we feel anything but disgust for a system which fills St. George’s and other West-end hospitals with plethoric butlers and lady's maids, whose salaries are amply sufficient to provide all their medical wants outside of the hospital ? It is not the first time that the country has taught the town “how to do it.” One medical man should superintend the general work of the hospital.—In otder to command success it is absolutely necessary that one head should manage the whole. This point was brought-before a sectional committee on cottage hospitals, at the Bristol meeting of the British Medical Asso- ciation in 1863, when the prevailing opinion appeared to be that one surgeon only should take the entire charge of the cottage hospital, whilst the whole medical community of the district should be invited to co-operate, by lending assistance in any cases in which they might be interested. Thus, if a 25 practitioner of the neighbourhood had a case for admission, he should by courtesy be privileged to visit his patient and advise with the medical officers respecting the mode of treat- ment to be followed ; aud if a case for operation, he should have the option of performing it himself, or leaving it to the care of the hospital attendant. By this means-the cottage hospital is made subservient to the interests of the whole medical body of' the district. In the arrangement of the guardians of the poor with their medical officers, a certain scale of extra fees is allowed in case of severe accident or operation ; thus £5 is paid for an amputation, £2 for a fractured’ leg, and so on. It has been laid down as an axiom in the management of cottage hos- Pitals, that these fees should be paid to the union officer if he attended his patient in the cottage hospital, just the same as if he had done so in the poor man’s own cottage. This is the case at Cranleigh, where £36 was paid in extra fees during the first four years of the existence of the village hospital. It has also been the case at Bourton-on-the-Water, Hatfield, Broad Oak, Cheesham, Iver, Litcham, and many other cottage hospitals. In some unions, however, the pay- ment of extra fees is commuted in the annual salary, as is the case at Wrington and Bromyard. History of the Cottage Hospital Movement.—Although some desultory efforts had been made in one or two places, the commencement of an organised movement first originated at Cranleigh, in 1859. For some time Mr. Naprer, who was practising in that neighbourhood, had felt the necessity of some quiet room, in which a severe D 26 case of accident or disease occurring amongst the poorer classes under his charge might be placed, and where the advantage of careful nursing might be obtained. Whilst he was consulting on the best plan for carrying the idea into effect, the rector of the parish, the Rev. Mr. Sapre, riding over the common on his way to solicit the aid of his principal parishioners in the good work, happened to hear of a severe accident that had just occurred, and that the poor sufferer had been carried into the nearest cottage. Hastening thither, he found Mr. Napprr, with the assistance of his dispenser, the policeman, and an old woman (the druggist volunteered his aid, but had fainted and was useless) engaged in amputating the poor man’s thigh. This case showed so uneéquivocally the importance of pressing on, with the inten- tion of having some room or place with proper appliances for such cases, that Mr. Sarre at once placed at Mr. Napper’s disposal a small cottage, rent free, which, after being white- washed and simply furnished, was in a few weeks opened as the first cottage hospital. Very much at the same time, Mr. A. Davis, of Fowey, in Cornwall, opened a house for patients. ‘He says he hada room in a cottage for severe cases before Mr. Napper started ‘the Cranleigh Village Hospital, but cannot claim being the originator of the cottage hospital system. At Middlesborough, in Yorkshire, a similar work (as far as having a hospital on a small scale is concemed) was commenced. ‘ The plan of having a small hospital or weekly payment by patients, was not however now for the first time introduced. At Wellow, a small village in Nottinghamshire, there has for many 27 years been a hospital, but on what principles I have no know- ledge: I have repeatedly made attempts to gain information, but have not been able to do so, At Southam, also, near Warwick, : a hospital of a few beds was established by the late Mr. Situ, in 1818, solely for eye and ear cases. The patients received into this institution paid for the first nineteen years, men 6s., women 58., children 4s., and 3s, 6d. per week towards their maintenance. This hospital, in: 1863, was , opened for ordinary cases, to which four beds were allotted, and in 1868 two new wards were built, enabling the committee to open a cottage hospital of 12 beds. Whilst, therefore, the principles of the movement were not entirely new ; still no small amount of credit is due to Mr. Napper for thoroughly organising the system, and still more for showing practically that all the comforts and appliances of a hospital can be obtained in a humble cottage. This simplicity Iam glad to find Mr. Nappgr still carries out. When I visited Cranleigh a short time since, I found the cottage and its fittings just as when first opened. It has been frequently wished to build a cottage on a more extended scale, but he is unwilling to alter the style of the mother cottage hospital, the very humble .character of which has encouraged the institution of similar hospitals in other places; whilst the expenses of a building of greater pretensions would only deter others from following so useful an example. The frontispiece gives a very faithful view of the Cranleigh Village Hospital, a more detailed description of which will be found in another chapter. The publication of the first report of this interesting field of work, led to many enquiries among 28 medical men as to the feasibility of opening cottage hospitals in other rural places. Fowey Village Hospital was opened in 1860 ; one at Bourton-on-the-Water in 1861, and the number of new institutions increased year by year, till at the present time about 60 of these useful little hospitals are at work, and several more in course of erection. I have taken some trouble to gain correct information on this point, and the following list can be depended on as an accurate account of the number at present established, and the year in which they were opened, An asterisk is prefixed to those institutions which partake more of the nature of general, than cottage hospitals :— 1859. Cranleigh gga eee = Surrey. *Middlesborough 2h. aaa Yorkshire. 1860. Fowey 20.0... eee see eee eee © Cornwall. _ 186r. Bourton-on-the Water ... .... ... Gloucestershire. 1862. : Par Consols ... 0.4.0 04.004. eee Cornwall. 1863. ‘East Grinstead : Surrey. Tver... 4.0 eee eves eee) eee ~ Buckinghamshire. “Walsall ... 0... see 0... ee vee Staffordshire. St. Mary’s, Dorking ... ...... Surrey. Southam wee ues eevee uae) Warwickshire. 1864. Wrington ses eee vee vee) eee ~- SOMersetshire. Ditchinham ... ... 0.0... Norfolk. Ilfracombe ... ... 2... ... Devonshire. '_ 29 1865. St. Andrew’s ... Tewkesbury Guisborough ... Wallasey... *Weston-super-Mare 1866. *Yeatman, Sherborne Buckhurst Hill Capel Memorial Reigate ... *Crewkerne ue 6 Aide! ants Oswestry and Ellesmere.. Rugeley ... Cromer ca *Barrow-in-Furness ., Harrow ... Crimond.. Petworth.. Great Booklist ‘closed’ in » 1867) ee 1867. Sudbury ... woah! ies Mansfield Woodhouse ... Fareham, Shedfield... ..- Fairford.. Hatfield, Bioad Oak Congleton Driffield... Fifeshire. Gloucestershire. Yorkshire, Cheshire. Somersetshire. Dorset. Essex. Surrey. Surrey. Somersetshire. Shropshire. Staffordshire, Norfolk. Lancashire. Middlesex. Lanarkshire. Surrey. Surrey. Suffolk. Nottinghamshire. Hampshire. Gloucestershire. Essex, Cheshire. Yorkshire. Wirksworth Dunster... Malvern Hambrook Savernake Richmond Charmouth Scarborough ... Warminster . Mildenhall Litcham... Melksham Weybread Longton Tetbury... Burford... Alton *Shepton Mallet ... Cheesham Bromyard Speen Newick... Burford... Clearwell Bromley Bangor Bournemouth... 30 1868. 1869: Derbyshire. Somersetshire. Worcestershire. Gloucestershire. Wiltshire. Yorkshire. Dorsetshire. | Yorkshire, Wiltshire. Suffolk. Norfolk. Wiltshire. Suffolk Staffordshire. Gloucestershire. Oxfordshire. Hampshire. _Somersetshire. Buckinghamshire. Herefordshire, Berkshire. Sussex, Shropshire. Gloucestershire. Kent. | County Down, Ireland, . Hampshire. 31 1870. Wate ae he wee? Ge ++ see see Gloucestershire. Royston vee eee nee uae wee ~© Cambridgeshire. Walker ees uee ase eee eee) Northumberland. Ashford Sth: Gein labe? Ade? eee KOH *Wakefield ... 2... ... .... ... Yorkshire.. Leek ...0 21.0 00. wee ee) ws. = Staffordshire. IN COURSE OF FORMATION. *Harrowgate ... ... ... ... .. Yorkshire. Shaftesbury... ... ... .. ... Dorsetshire. Chalfont wee ues ee) eee ee ~= Buckinghamshire. *West Bromwich ... ... ... ..- Staffordshire. *Dudley ses see eee ee wee» Worcestershire. *Kendal cee cee eee vee vee ~ Westmoreland. Tavistock ...0 ..0 «2 «4. «+ Devonshire. Market Rasen see wae wee eee» Lincolnshire. *Petersfield ... ... «4. +. ... Hampshire, Trowbridge ... 4. w+... + Wiltshire. 32 CHAPTER III. THE COTTAGE HOSPITAL AND ITS FURNITURE. Whether it is intended by the promoters to build for the special purpose, or to alter an existing building, the cot- tage element should not be lost sight of. A purely cottage hospital should not have more than three beds in a room ; these rooms should be bedrooms, not wards. In building or selecting a cottage for a hospital, all ideas of existing county or general hospitals should be laid aside, and the mind imbued with the idea that it is the cottage that is to be con- verted into the hospital, and not that the hospital is to be built with regular wards, sister's rooms, &c., in the outward form of a cottage. ‘ The accommodation that is absolutely necessary for a hospital with six beds, to be worked with one nuyse, is as follows :—A good kitchen, which is used by patients who are well enough to sit up and enjoy conversation, &c.; a more comfortable room, to be used as a committee-room, and by any patient able to leave the bedroom, but not sufficiently strong to sit in the kitchen ; this room will be found of great advantage, but is not absolutely necessary ; three bedrooms, two of which are fitted for three beds, and the other with a single bed for a severe case ; this room will require a good window and a fireplace, as it will be used as the .operating t 33 room of the institution, A nurse’s bedroom—this should be situated as near the patients’ bedrooms as possible, so that she may be easily called at night by any patient requiring attention. If there is another small room on the bedroom floor, it should be fitted up as a bath-room. The offices should consist of back-kitchen, wash-house, house for coal, &c., shed for ambulance or wheel-chair; and, what is. most impor- tant, a room lighted by a skylight, to be used as a mortuary chamber, where, if required by a jury in case of a coroner’s inquest, a fost mortem examination may be made. This room or building should be accessible by some other mode of entrance than that through the hospital. A jury may there view a body, or a post mortem examination be‘ made, without any patient in the hospital ‘being aware of what is going on. A plot of ground attached to the house is a very great advan- tage, and should, if possible, be secured. Not only, is a back — yard almost indispensable, but a small garden, with bright sweet-scented flowers, adds much to the cheerfulness of the aspect of the place, and allows recreation to be taken by the convalescing patient without fatigue. The flowers grown here should be the old-fashioned sort, such as cottagers delight in— sweet briar, marjoram, boy’s love, with a few roses and bright , scarlet geraniums. These will please the poor sufferers, and add much to the home character of the cottage hospital. There are two points which are of the first importance, and should be carefully attended to in the selection of a site of a — cottage already in existence. 1st, the supply of water, and, 2ndly, the capabilities for effective drainage ‘A good spring of water is of the utmost value ; and proper means {or collecting E 34 rain water is not much less needed. A couple of good sound wine pipes, placed side by side, so that the overflow of one will fill the other will, perhaps, be sufficient to collect the rain water of the sized building that is desired ; they should be well painted outside, and provided with covers ; these are easily kept clean and sweet, and require no pump to be attached to them, Ifa building of any pretensions is intended to be erected, a good tank or cistern for rain water should not be left out of the specifications. To this there should be a proper man-hole, so that it may have a thorough cleansing at intervals. Soot, which is washed down from the roofs, and speedily decomposes, together with decaying leaves and other vegetable matter, will find its way into the cistern, necessitating a thorough cleansing at least once every year. It is not likely, at any rate, in rural districts, that an organised system of drainage will be found ; and as the cottage hospital should set a good example in sanitary matters, no drainage from it should be allowed to find its way into neighbouring ditches or streams, and thus help to pollute the supply of water in the adjoining neighbourhood. If the water system of latrines be adopted, a properly constructed cesspool will be found the most effective plan of getting rid of the drainage of the institution, even if the dry earth system be preferred, (which I most strongly advocate) a cesspool will be required for the liquid drainage. Here is one reason for the necessity of a a piece of ground around the building. The cesspool should be placed as far from the cottage as possible, due regard being had to the most advantageous position for periodical cleansing, and 35 that'any overflow will not be injurious to neighbouring houses. The cesspool should be constructed of sufficient size to require opening only once or twice in each year, which ought to be done during the cold weather. The top covering should not be less than three feet below the mould of the garden, the lower half of the pit and the floor being cemented and made watertight, the upper half built of dry wall without mortar ; by this means the solid particles are retained in the lower half, whilst the more fluid are absorbed into the ground around, and are thus rendered inocuous where a garden is: attached to the hospital. t The introduction of the dry earth system is of great advantage in getting rid of the danger of deteriorating the air by the products of decomposition, and, indeed in the cases of typhoid or enteric fever, disseminating infection. This is extremely simple, and presents very little practical difficulty. The principle was brought into use by the Rev, Mr. Movutz, a Dorsetshire clergyman. It is a well known fact that deleterious gases are absorbed by charcoal or car~- bonaceous matter, and especially by the earth, the ordinary mould of the gatden, especially if the subsoil be clay, is well adapted for the purpose. At the Convalescent Home, at "Weston-super-Mare, where there are thirty patients, as well as six Officials, this system has been in operation most effec- tively from the opening of the institution, two years since, although the earth which is used is largely composed of sea sand, and is probably the worst that could be found for the purpose. At the Cranleigh Village Hospital, an earth com- mode is used in the wards ; and at the Surrey County School, 36 in the same parish, the system is carried out on a large scale with the utmost perfection. The earth, which must be dry, (and therefore care must be taken to keep up a proper stock - of it) is placed in the hopper, and when used removed dazly, and at once dug into the ground, the ground being thus regu- larly day by day trenched over, and properly manured. The results to vegetation need hardly be stated. At the Conva- lescent Home mentioned, where the garden has been formed of little more than sand from the sea shore, the crops of brocoli, radishes, &c., exceed that of any in the neighbour- hood. An improved earth closet has been lately constructed by Lieut.-Colonel Barrp, of the Bengal Staff Corps. It is more simple, and less likely to get out of order, and has the advantage of not requiring the earth to, be sifted, and specially \prepared for its use. Whilst thus advocating the use of the dry earth system, I must strongly deprecate the proposal of some of its sup- porters to re-dry the earth and again employ it. Those who have studied the present accepted theories of the propagation of enteric fevers, will at once see the danger of such a process. The earth, when used, should be forthwith dug in, and the supply of fresh earth taken from another part of the garden. Whilst, therefore, the introduction of the dry earth system will overcome much difficulty, it is necessary to have proper drains to the cesspool for the liquid sewage of the hospital. The pipes used for this purpose should be of glazed stoneware, properly provided with an effective eject. Any waste water pipes from the bath, or rain water shooting, &c., should each 37 have separate ejects: this is most important. The best system of drainage is often rendered positively dangerous to the inhabitants by the neglect of this simple precaution, I have found cottage hospitals where the waste-pipe of the bath led into drains without an eject, the idea being that, as it was only water from the bath, no eject was required, and forgetting that the waste-pipe then became a ventilating shaft from the drains, .A narrow tube carried from the cesspool up a wall or tree, will be of great service in preventing the accu- mulation of gases of an injurious character. It is also a very important matter that the position of the sink in the back kitchen should be properly considered. Some of the most fatal fevers have been traced to the leakage from the sink and wash-house communicating with the well; a few yards of extra piping from the pump, will enable both pump and sink to be placed at such a distance from the well, that such contamination is avoided. Still, even then, thoroughly well jointed glazed stoneware pipes should be used, as in a gravelly soil distance does not always imply safety. Where the water system is used, the supply pipe should be at least two inches! in: diameter, and be provided with an ordinary stop-cock, so as to ensure thorough flushing. To ensure this, if the syphon pan, known by the name of the Board of Health sanitary pan, be used (and they are cheap as well as effective), any overflow pipes of clear water may be placed so as to enter above the syphon, which will considerably aid the flushing of the drains. If, however, the style of cottage sought for is not to be found, and there is a difficulty in procuring funds, the pro- 38 moters need not be discouraged; the first attempt at a cottage hospital may be made in a very humble building ; the work can be commenced with three beds instead of six. The cottage at Cranleigh is very small, the bedrooms being almost entirely in the roof, with dormer windows; yet the results of treatment have been excellent. At Bourton-on- the-Water the difficulty was to get a proper approach, as the patients had to be carried down a narrow lane, still the work progresses ; whilst at Wrington, the only house that could be obtained was extremely dilapidated, and had always been considered the very nest of fever. In the best room down- Stairs, from twenty to thirty sheep were penned at night. The sanitary condition was frightful, and I had much difficulty in inducing the committee to allow the trial to be made. A little repair, thorough cleansing, and proper drainage, con- verted the old house into a thoroughly comfortable and cheerful little hospital. It has been well said, ‘Little beginnings make great endings,” ‘and beginning the work humbly at first is not the less likely to lead to complete success. In any old house selected, the walls should be thoroughly scraped, and where the plaster of the wall is saturated with dirt, as will probabiy be the case in the lower rooms, it should be hacked off and fresh plastered. No paper hangings should be allowed in any hospital: they are a fertile cause of keeping up a deleterious atmosphere. Not only are they, except they be of the most expensive kind, absorbent, but the size used to prepare the walls for papering is, by its decomposition, itself a nuisance. The walls should be well white dmed, not white- 39 washed with whiting, as most painters will propose, but a good coating’ of freshly-slacked lime well applied ; they may then be coloured to please the eye. The best colour for this pur- pose is a warm buff. At Savernake the walls are, coloured green, but this has the objection that the colour contains particles of salts of copper (frequently the arsenite) which are very -irritating, and the arsenite positively poisonous to those living in rooms thus coloured. At the Capel Memorial the colour is a pale yellow, very trying to the eyes ; and both this and the green make patients look paler and worse than they really are. ; Much has been said lately, as regards hospitals, about ‘cubic capacity.” It is an undeniable truth that, for pur- poses of health, every individual réquires a certain amount ‘of air ; and much of the tardiness of recovery from illness is owing to.the amount in a room which the patient occupies both day and night not being large enough. In hospitals where many are congregated in the same room, 1000 cubic feet to each bed ought to be secured; where~ only two or three occupy the same room, 800, or even 600 might do, but this should be the lowest limit. In towns, where the outside air is less pure than in the country, this is especially necessary. Now, there are many cottage hospitals where it is impossible to obtain more than 500 cubic feet per bed, and yet the results have not been discouraging. This is owing to the fact that what air is admitted, is of the purest quality, and that the lattice windows and ill-fitting doors allow a consider- able amount of fresh air to pass through the rooms; and also that in these small rooms there are rarely more than two 40 beds, the mischief increasing in ratio to the number placed in the same room. The advantage of this segregation of: patients into small rooms rather than wards, will be again referred to in-a later chapter, when treating of the statistics of the results of the treatment in cottage hospitals. Where a new house is built for the purpose, a room for three beds should not be less than 14ft. by 16ft. and roft. in height, Every room should, if possible, have an open fireplace : where this cannot be obtained, a ventilator (Sheringham’s) should be placed in the outer wall, ‘In deciding on the architectural plans and material of any new hospital, regard should be had to the usual style of building in the country. Not only is this cheaper where the workmen are accustomed to their work, but there is a greater unity of design in following the pre- vailing style, when it is not positively unfit for the purpose intended. A Gloucestershire stone house, with its roof of slabs of Pennant grit, would look quite out of place amidst the brick and weather-tiled cottages of Surrey; whilst to import stone to a brick country, or to carry large quantities of brick to a place where the best building stone could be raised on the site itself, would be greatly adding to’ the expense. As the selection of the material is guided by the geological nature of the country ; so the style of the building must be in a great measure guided ‘by the nature of the material, a very different architectural plan being. suitable for brick and for stone buildings. In the Midland Counties, where brick is largely used, cottage hospitals have been constructed very cheaply. Longton Cottage Hospital, in LONGTON COTTAGE HOSPITAL. GROUND PLAN FIRST FLOOR PLAN 41 Staffordshire, built, as the accompanying cut will show, with some taste, did not exceed £700. REFERENCE TO GROUND PLANS OF THE LONGTON COTTAGE HOSPITAL. T. Naden, Esq., Architect, Birmingham. A Hall. ¥F Children’s Ward, 14 by 13. B Surgery, 14 by 12. G Bath Rooms, 6 by 6. C Kitchen, 14 by 12, Hf Ice House. D Women’s Wards, 14 by 18. ZI Wash House. E Men’s Ward, 14 by 13. The first floor rooms are all bedrooms or special wards; 14 by 10. A very éffective hospital for twelve beds has been built at Sudbury, in Suffolk, for £800. This has two pavilion wards of six beds each, of one storey, with an open timber roof ; one ward on either side of a central executive block. Pho- tographs of the Sudbury Hospital, and of the interior of the pavilion wards are published, and if referred to will give at once an idea of the building. In the West of England, where most buildings are erected of stone, with freestone dressings and quoins, the expense is somewhat greater. Perhaps the cheapest mode of erecting cottages, is that in use in Surrey, where the lower half is built of brick, and the upper timber framed, with lath and plaster walls, weather-tiled on the outside. The frontispiece, and the view of the East Grinstead Cottage Hospital, are very good specimens of this style. It should, however, be always carefully borne in mind, that whatever style or architectural plan is selected, no idea of a picturesque or well ‘‘ broken up” building should be for a moment allowed to interfere with the design most suitable F 42 for a hospital. To avoid this, I should recommend that the ground plan be first designed, and that in all cases medical men be consulted as to the most complete design. I have seen hospitals where the nurse’s room was placed as far as possible from the patients she was intended to look after, and where the operation-room was at the end of a long and tortuous passage, with no ward communicating with it, obliging the poor sufferer, doomed to undergo a severe operation, to be carried a considerable distance to and from his bed. “In another case the room for post-mortem examinations had no window, only one small grating, so that an examination, on. the results of which, perhaps, the life of an accused prisoner may depend, must be conducted by candle-light. All these arise from the design of the outside being considered first, and any details of the actual work of a hospital being made subser- vient to it. In seeking information as to the structure of a cottage hospital, what I ask to see is the. ground plan, caring very little for the outside ; not that I would-undervalue a building of a pleasing exterior ; but that is only what the outward clothing is to the inward man. At the present time many new cottage hospitals are being erected ; and a memorial hospital to the late Marquis of West- minster is proposed to be built at Shaftesbury. When this is the case, the spirit which actuates such endeavours fre- quently leads to the expenditure of a considerable amount of funds ; nor would it be well to check an intention of founding a permanent memorial to some dear friend, whose good deeds live in the memories of his neighbours, and are justly handed down to posterity by the foundation of an institution 43 for the relief of the sick and needy. of future generations, in the parish in which he was known and _ beloved; here is a rock on which the most promising scheme may split, and the desire for zsthetic ornamentation may, unless carefully guided in a right direction by those who know practically the real wants of a hospital, prevent much of the usefulness intended by the benevolent founders. 4 The Capel Memorial Hospital, built in 1864, to the glory of God and the good cf the parish, by Mrs. Charlotte Broadwood, as a memorial to her late husband, the Rev. John Broadwood, of Lyne, in the parish of Capel, is in a measure an example of the necessity of this care being.taken. It is a substantial and beautiful structure, well built, and thoroughly well found in everything ; there is really not a want either for surgeon or patient that is not supplied ; yet a more practical consideration of the ground plan before deciding on the exterior, would have made it a much more valuable model for imitation. Dr. Warine writes :—‘‘ Whilst I would desire heartily to commend the spirit which has actuated this worthy lady to the imitation of others, I feel bound to ‘ enter a caveat’ to the edifice being taken as the deau zdeal of a cottage hospital. It is truly a memorial hospital or a village hospital, but it has no claim to the designation of a cottage hospital. It is a fine stone building, in which the cottage element has been sacri- ficed: to the desire of having everything as complete as possible. The money expended on the building would have been sufficient to build three cottage hospitals, such as those which the promoters of the system contemplated, and which it is desirable to see established.” 44 From the published accounts of several cottage hospitals, it appears that a very good building, to give room for six beds, unless in an extremely expensive neighbourhood, should be erected for £500. For the erection of a general hospital’ of 12 beds, where it is intended to carry out the pavilion system of wards, I would advise, if sufficient ground be obtained, that the whole of the wards, day-room, and operating-room be on the ground floor, having only servants’ rooms, store-rooms, and special wards on the upper. floor. Much painful carrying of patients upstairs would be avoided, especially in cases of accident ; a convalescing patient will be able to creep into the day-room, or even out of doors, at an earlier date than would be possible, if getting up and down stairs had to be accomplished. The whole building should be erected on arches, so as to raise the floor at least three feet above ground. In front and at each side this elevation might be carried out as a dry terrace walk, somewhat similar to the platform of a railway station ; and indeed many of the stations now built will give useful hints on the subject. The overhanging roofs are excellent to shelter the patient, when able to enjoy his first sitting out in the sun after a long and painful illness. The cut opposite, gives a plan I have designed, after the model of the Sudbury Cottage Hospital. The exterior may be treated in almost any style preferred by the architect. REFERENCE TO CUT. A Hall and Passages. #f Kitchen. B Nurses’ Room. I Back Kitchen. C Surgery. J Kitchen Offices, GARDEN SKY LIGHT GARDEN GROUND PLAN OF A COTTAGE HOSPITAL FOR TWELVE BEDS. 45 D Pavilion Wards, 30 by 15. K Surgical Stores, &c. £ Day Room, L Post-mortem Room. F Special Ward. M Verandah. G Operation Room. W Terrace Walk. . Special Wards and Servants’ Rooms over B C E and H. _ Acurious but very effective ground plan is that adopted at ‘Royston, in Cambridgeshire. What the elevation is I do not know. ‘The subjoined cut shows the general details of this plan, though I have somewhat altered it. SOUTH CARDEN NORTH A Pavilion Wards ; the fire-places # Dispensary. are constructed underneath the G Porch. windows looking outwards. H W. C. under stair head. B Day-room or Convalescent I Conservatory leading to gar- room, i den. C Kitchen. K Post-mortem room with sky- D Back Kitchen. light. E Stores, 46 At Royston, the triangular space is cut up into staircase and offices. I have thrown the staircase back, and placed the offices outside the building, and have added a porch, with inside glazed doors, so as to convert the triangular space into a day-room. The two pavilion wards, 14ft. by raft, and roft. high, are intended for two beds each, giving a cubic capacity of 84oft. per bed. The upper storey has the same treatment over the kitchen, being nurses’ room and operating room, and two pavilion wards, as in the lower storey ; the trian- gular space again being used as a day-room. The space between the two wards is the garden, and I have introduced in the angle a conservatory or glass-house, both above and below, where patients may sit out who are not yet able to go into the garden. Very much may be made of this design, but. it seems difficult to combine with the plan a pleasing exterior. The Cottage Hospital Furniture,—Following out the same idea as that in describing the building required, the furniture should be suitable to the cottage; and except when specially adapted to the purpose of sickness, such as is usually found there. The promoters should never forget that not only is this for purposes of economy, but to give the patient the home impression which is impossible to be attained in the regular hospital ward, The Entrance Hall and Staircase.—The furniture here needed is very little indeed. A mat, scraper, and com- fortable form or bench, on which any person waiting may sit down, will be sufficient. The alms box should have a place here, with some appropriate motto, or a scroll over it. 47 This may be painted on sheet zinc. Many of the ladies of the neighbourhood will probably be found adepts in this work and likely to assist in mottoes for decoration, such as ‘‘ Peace be to this House,” ‘It is more blessed to give than to receive,” &c. A board, with a few of the more important rules, and another with donors, benefactors, and contributors, will not be out of place in the entrance hall or passage. The staircase should neither be carpeted or polished, either being a very fertile cause of a patient’s falling, and perhaps compli- cating the injury he has already received. It should have a good hand-rail ; a bar of iron on the wall side, standing out three inches from the wall (if the space will allow) is a great help to a weakly patient in getting upstairs. If the staircase is narrow, a portion of the outside rail may be made mov- able, with a hinge and bolt. This is done at the Hambrook Village Hospital, where the turns in the stairs are very awkward for carrying up:a patient. An adjunct to this part of the building is an invalid chair, properly constructed. An old arm chair, with iron handles, screwed on back and front, the front handles being level with the seat of the chair, and the back, with the head rail, will be sufficient, if nothing better can be obtained. Alderman’s invalid carrying chair is not very costly, and as the handles fold down, takes little space ; it has the advantage of the weight of the person being carried working on a pivot, so that the level position is always kept up. A very comfortable and cheap carrying chair is in use at Hambrook, made of wicker-work, with three webbing loops 48 at each side, through which poles may be inserted at the required height ; it has a foot-board hung on webbing, and a board, which, when inserted under the cushion or seat, enable a case of fracture of the lower limbs to be comfortably carried. This chair is both light and cheap, which is no small advantage. . The Kitchen.—A good fire grate will be a necessity, with boiler and oven ; the close range is certainly the best, as with a little expenditure of coals, it enables food to be kept hot or warmed at any time. Some of these ranges have high pressure boilers, which supply hot water to the bath or any part of the building, They, however, require a considerable amount of attention, If not kept perfectly clear from clinkers, they do not get warm enough to boil the water, and when a bath is wanted on an emergency, no hot water is to be obtained. Should the water of the district be hard, they soon fill with rock, and the outside of the iron burns away. Besides this, if the supply of water be not regularly given, or the ball-tap gets out of order, they sometimes explode. Ifit is required to have a constant supply of hot water, it is better to have a separate boiler for the purpose in the back kitchen, unconnected with the fire place. Such boilers are not very expensive, and are more easy to keep in order. The kitchen table and dresser should be such as are found in the better class of cottages. Serviceable Windsor chairs are the best for wear ; the low-backed ones being the most comfortable, In rural districts, the old-fashioned settle will be greatly welcomed by the patients; the high back and overhanging head-board is a capital contrivance for keeping off the 49. draughts. When the cooking is done, it can be wheeled round to the fire, and there is sufficient room for the patient, who is hardly able to sit up, 'to rest his legs. The floor of this kitchen need not be carpeted ; a roll of cocoa nut matting can be laid down before the fire ; but if the floor be of brick or tile, it will be found sufficiently warm without any covering. By not having the patients kept in too much luxury, to which they are unaccustomed, they will not feel so much the want of it on their return to their own cottages; when, though not yet perfectly well, they can no longer keep a bed from the more urgent wants of another applicant. A shelf for books, an American clock, and a cheap vase or two for flowers, which should always be filled, if possible, complete the furniture of the cottage hospital kitchen. © The brighter articles of ironmongery will find a place on the _ mantel shelf ; pots and pans being consigned to the humbler, but not less useful back kitchen. In selecting crockery for the patients, it-will cost very little, if any more, to have good stone ware, white, with a coloured rim, with the name of the hospital on a ribbon or garter. Any respectable china ware-— houseman will get this done, and their bright and cleanly look will set off the kitchen dresser to advantage ; the bedroom ware may also be of the same pattern. The estimate given in the appendix include the prices of these. The walls of this and every other room should be decorated with pictures and mottoes, At the Wrington Village. Hospital, a ribbon over the kitchen fire place has the well-known lines of Bonar, illuminated on it. ‘He liveth long who liveth well; all other life is short and vain.” Many other useful mottoes will suggest themselves. 50 The National Society have published a very good set of mottoes, well and brightly illuminated, at cheap prices—4d. and 8d. each, they are about two and half feet by nine inches. The coloured pictures of the J//ustrated London, and the Lllustrated Midland News, are excellent for the purpose of decorating our cottage hospitals ; they are not difficult to procure from those who take in those papers. The plain gold bead or the Oxford frames are made so cheaply, that this expense can generally be met. Where great economy is an object, they-may be pasted on calico, strained on a table or against the wall. In pasting the back of the picture it should be thoroughly wetted and left a little time to soak, bubbles being prevented by this mode of procedure. An edging of the oak paper mouldings, used for panelling rooms, should be then pasted round the pictures, which may, when dry, be sized with Russian glue, and varnished with crystal varnish, employed for varnishing wall papers, and being then cut round, are ready to put up. Holes may be punched round them for brass eyelets, which may be obtained from any shoemaker, and they may then be changed from room to room, so as to give the pleasure of fresh pictures at a small expense. In pasting the moulding, care should be taken to adjust the shadows rightly ; the moulding may be reduced in size, according to the size of the picture, one strip making three different patterns of these sham frames. I adopted this plan at Wrington five years since, and at the little hospital they look as bright and cheerful as when first put up. On the opposite side is a diagram of the interior of the Wrington Village Hospital. Itis not very artistic, but it givesa fair idea of the style of the interior of a cottage hospital. 51 The Day or Convalescent Room.—This will be ‘also used as a committee or board-room, and will, if the cottage be large enough, prove a useful addition to the other rooms. As a tule, in cottage hospitals, both with the view of keeping up the home character of the institution, as well as lessening the staff expenses, the patients who can leave their rooms will sit in the kitchen ; but there are times of the day, as for instance, when cooking is going on, that another room, in which convalescent patients may sit, will be most useful. This room may open out of the kitchen: at any rate there should be a door from the kitchen into it, so that the nurse, whilst engaged there, may still have command of the day-room. I have, however, been in one or two, otherwise well-arranged cottage hospitals, where there has been no day-room, and the patients not being allowed in the kitchen, are obliged to occupy the same bedroom whilst in the hospital. This is clearly a mistake. The very fact of finding themselves well enough to leave their room, gives fresh life and hopes to the patients, and I have never in my experience found the privilege of sitting altogether in the kitchen in any way abused. Indeed, the cottage hospital kitchen is the most cheerful room of the whole ; and by this means bedroom windows can be opened, and the beds and linen thoroughly aired before the patient again goes to his room, giving that feeling of freshness which all know so well, after being confined with illness to the same room for days, and perhaps weeks. The day-room, as a step for the now convalescing patient, from his bedroom to the general kitchen, will be more comfortably furnished. A carpeted floor, and a couch or 52 reclining plane, will not be out of place here. A very useful and cheap couch may be easily constructed of a simple frame of deal, with webbing, made with a foot- board ; the lower legs may be six inches high, and the upper two feet ; a mattress, covered with American’ leather, with the pillow attached to it, will be all that is required to make it a useful resting couch ; the deal may be stained and varnished, so that it will be a very respectable piece of furniture. A chiffonnier book-case will be valuable ; the lower cupboard may contain the books of the institution, and the book-case will hold the cottage hospital library. A proper representation, through the clergyman of the parish, or some subscriber, will generally ensure a free grant of useful and entertaining books from the Society for Promoting Christian Knowledge, or the Religious Tract Society; and here I would remark, that though every bed should be provided with a Bible and Prayer- book, and there should also be a large-print copy of each in the kitchen or day-room ; yet that, while books of a strictly devotional character should form a portion of the library, it ought not to be restricted to books of religion only. Cheerful reading, as well as cheerful surroundings, such as pictures, flowers, &c., will all help the convalescing patient to cast off the natural depression of spirits caused by illness. We do not, in the upper classes of society, see the patient recovering from illness, or confined to his couch with a frac- tured limb, always reading the Holy volume, or religious books, and yet many expect the poor to do nothing else, and think it is’ wrong ,to supply them with any light or entertaining literature. The two excellent societies I have i : =f 53 mentioned have more liberal notions. Their catalogues, while. they contain no works that can injure the mind, have a large number of cheerful books specially adapted for the working classes. In making the selection, children’s books should not be forgotten ; indeed picture books are a great source of. pleasure to children of a large growth. A benevolent lady in the West of England has provided many hospitals with cards that can be easily held in the ‘hand of the sick man, covered with pictures, little tales, hymns, and useful pithy sayings, in large readable type. These are sized and varnished, and are lent about from bed to bed. I have seen much pleasure. given in this way to the poor sufferer who had not strength enough to hold a book, or was unable to concentrate his mind sufficiently toread one. While speaking of books, it will not be out of | place to mention the very useful scrolls of texts and hymns, in large type, now sold; they may be hung on an upright staff of wood, with a foot to it, so that they may be placed where the invalid can read them from the position he is perhaps compelled to occupy in bed. I need not say that the day-room, as well as all the rooms in the cottage hospital, should be decorated with pictures, and that the bouquet of flowers should not be forgotten. On the table of this room should be found the visitor's book, with column for date, name, residence, and remarks. The case book, containing the name of the patient, with the nature of the disease and result of treatment, will be looked at with interest by many visitors. The promoters of every cottage hospital should feel that their hospital ought to be a model for imitation by-others ;. 54 and visitors will carry away with them impressions which may often decide the question whether or not to start a similar institution in another locality. Thus, good will’not only be done to the poor of the immediate neighbourhood of their own hospital, but will be carried on in like manner in more distant parts. Each hospital will be a centre of influence, radiating far and wide. The Bedrooms.—The number of beds in these rooms should not exceed three. Two will be quite enough if the room is no larger than 10 feet each way. No carpet, except a slip by the bedside will be required here. At Savernake the managers object even to that ; but a carpet to keep the cold from the feet of a sick person on his ‘getting out of bed is certainly a necessity, and no useless luxury. The kind of bedstead will of course depend on the price that can be afforded. A good iron bedstead can be obtained for 18s. ; it should not be on castors, as for cases of fracture a firm bed is of the greatest importance. If these beds are used, a straw paillasse will be required for each, which will cost 8s. The beds should not be wider than 3ft. 6in., and ought to be 6ft. 6in. in length, which will not be too long for a tall man, when the space occupied by the pillow is taken into account, 114d. will represent the cost of the food consumed by the nurse and occasional charwoman. In the same way, in estimating the results of the treatment of cottage hospitals, the nature of the cases must be taken into account ; the statistics of operative surgery being kept distinct from cases of general surgery and medicine. It has, during the last few years, become a question of considerable importance, and one that has much occupied the attention of the leading members of the profession, whether small wards with few beds are not productive of better results: than the grouping of a number of cases in large wards. The late Sir J. Simpson, in comparing the loss of life in amputation of the limb, in the practice of London Hospitals and in country practice, states that, taking the statistics of the 171 four major amputations of the limb, viz., amputation of the thigh, leg, arm, and forearm, as tests of the comparative success of surgery, or surgical operations under different conditions :—<“< I had found that these four amputations were fatal in private country and provincial practice in the propor- tion of about one in every nine cases operated on ; while the same amputations were fatal in large and metropolitan hos- pitals in about one in every three cases operated on. These operations. therefore—and proportionally all others—were, 1° inferred, three times as dangerous in the wards of large and metropolitan hospitals as in private rural practice.” He further states—British Medical Journal, 1869, page 394—“ That there is necessity for some change in our hospital system. If, for example, the 214 patients who were subject to limb amputa- tions at St. Bartholomew’s, from 1863, to 1868, had been sent out of the rich palatial hospital in which they were placed, into villages or cottages—and perhaps from the city into the country—some of these lives would, I believe, have probably been saved. But even if 25, or one ‘half only of these human beings were preserved by such a charige, are we not, by every principle of humanity and sympathy, bound to try and effect it.” Latterly, in America, some hospitals, much larger than any in London, have been constructed on the cottage or village or single-storey system—the poor patients recovering more rapidly and steadily in them. Twenty years ago Sir J. Smson pointed out the value of ‘small iron hospitals. In the precincts of a large London hos- pital there is at present a small cottage hospital constructed of iron. On inquiry, I found it used for ovariotomy, pyemia, 172 and other such dangerous operations and diseases. <«‘ But if such cottage hospitals are deemed more safe for such great operations as ovariotomy, would they not also be more safe for amputations? And. if safer for amputations, would they not be safer for all surgical operations? And if safer for all surgical cases, would they not, on the same principle, be safer likewise for all medical cases ?” The late Professor Trousszau published a letter in the French papers, in which he showed how infinitely superior the Necker Hospital was to any other, and suggested whether it was. not owing to the simple fact that instead of having wards consisting of 10, 20, or 30 beds, the rooms held only one, and sometimes two beds. 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THE FUTURE ASPECT or txt COTTAGE HOSPITAL MOVEMENT ; SUGGESTIONS ror tus FORMATION OF A NATIONAL ASSOCIATION FOR THEIR PROMOTION. Perusal of the foregoing pages will have shown .that the institution of cottage hospitals has not been a mere upstart scheme of pseudo philanthropy ; but one that has taken deep root in the country, that has spread its usefulness far and wide, and may be considered only now in its infancy. The details of the various hospitals given will show that they are what I laid down they would be A relief to the sick and suffering poor ; A benefit to medical men practising in their neighbourhood ; And of value to the public generally living near, who may not themselves require to take advantage of them. The tabulated statistics of expenses and results will also carry out my. assertion, that they are inexpensive to start and work, and highly successful in their results. To sum up ina few words, cottage hospitals benefit the patient by— Removing him from his overcrowded sorta to a room with good arrangements, where he can have good nursing and - ; frequent medical visits ; 178 Enabling his wife and elder children still to earn their living, which close attention to himself would prevent ; Showing him how a cottage, much like his own, and with similar furniture, can be kept in a clean, tidy, and whole- some condition. They benefit the medical man by— Bringing his serious cases amongst the poor close to his own door, and thus saving him much wear and tear, and consequent expense ; as well as preventing the drain of useful and instructive cases from his practice to large towns ; . Enabling him to operate with greater chance of success, and therefore with greater credit to himself than in the cottage of the poor. They benefit the public by— A diminution of pauperism, and consequent saving of rates, the patients getting well faster than they would at home. Promoting a better knowledge of nursing the sick, and thus introducing skilled nurses in our poorer districts. Supplying country medical men with the means of increasing their experience, and keeping up their skill in surgery ; a large portion of the public being unable to procure the services of any other medical men than those who live in the district. ; But the promotion and greater spread of the cottage hos- pital system will do more than this. It has indeed done more already. The evils attendant on our present system of hospital administration have been promi- 179 nently brought forward within the last few years. The monstrous abuses of the out-patient’s room and _ free governor’s notes, have attracted the especial care and attention of a most influential committee, and the work commenced at the little cottage at Cranleigh, has not only been imitated in other like villages, but has by its success in its self-supporting plan, struck a blow at the root of the evils of the larger and older institutions. , The cottage hospital and the provident dispensary are not how new schemes. They have stood the test of at least 10 years’ experience, and are capable of teaching lessons to others by that experience. The work is still, however, in its infancy. The future of the cottage hospital movement is one of considerablé promise ; and should it at any time be amalgamated, as I trust it will, with some new arrangement of our system of Poor-law medi~ cal relief, not only will the sick poor be benefited, and the rates lowered, but the parish doctor, now viewed in many places as a member of a lower order of the profession, will be placed in his right position, not as too often he is—the servant to do the bidding of boards of guardians, and in some respects even the relieving officer’s drudge. Much has been said for and against the present system of Poor-law medical relief, and, to those who are ignorant of the details, the answer appears plausible, if the medical officer is not satisfied with ‘the salary and: treatment he receives, he can give up the office; and also that if he did give it up, there are always many to accept it on the same terms. 180 This seems very true, and will generally carry conviction with it, until the truth of the matter—the point where the shoe pinches—is known. The whole system is based, not as it should be, on the necessities of the poor, but the relief of the ratepayers. Guardians are elected frequently because they are prepared to oppose any increase of salaries to officers, forgetting that the truest economy is to provide the best and quickest means to enable the sick to get well and strong enough to work again, There are many unions where the medical officer receives 24d. to 3d. a visit, for which he has to provide necessary medicines, keep of horse, turnpike fees, and general wear and tear. The result of this is the actual robbery of one of three parties, the doctor, the poor, or the ratepayer. If the parish doctor gives that attendance.and medicine which he does to the club patients or out-patients of the hospital (and for the credit of the profession it may be boldly stated that this is almost invariably the case), he robs himself and his children, as the miserable pittance, called by boards of guardians a salary, cannot defray his expenses. If, on the other hand, he gives the poor the barest necessary attendance, the cheapest drugs, and puts every difficulty in the way of obtaining his services, he robs the poor; whilst, if he gives the poor patient that meed of attention only which carries on his cure, feeling that he cannot rob his children to give the most expensive drugs when cheaper ones will, at any rate, get the patient well, the ratepayer is robbed, as every additional day’s want of strength that keeps the poor man from his work, causes additional expense on the rates. 181 The position of district medical officer is one provided by the Poor-law Act, and must therefore be filled up. It is easy to say the parish’ doctor, if not satisfied, may resign. The fact is—and many country boards of guardians know it-to be so—he is obliged to keep the parish appointment to prevent another medical man stepping into a district, and thus “diminishing still more the smal income he is able to obtain for his family. The present arrangement of the Poor-laws do not only oblige a medical man to accept, in country districts, a miser- able pittance for his attention on the poor; but they have very much lowered the position and income of the medical profession. The minimum fees paid by the Act—and when- ever did a board of guardians pay more than the minimum— have come to be considered by the middle-classes, who can remunerate a doctor, to be the correct amount that should be, asked ; whilst the mixing up the work of the druggist and surgeon cannot fail to impart tothe general public’a lower idea of the profession in country and town, and gives rise to the common expression, So-and-so is only attended by the ‘parish doctor. Mr. Gatuorne Harpy has done much to remove this stigma, by proposing that ‘dispensarids and dispensers should be established, and thus at once altering the position of the parish doctor, surrounded by his bottles, etc., to that of the Pieseaibing payee or anigeen, _* There is soiinind in my opinion ‘that would raise hte position, of the medical profession in country districts more than the ‘promotion of cottage hospitals; especially if they can be 182 amalgamated with the Poor-law medical service. I feel the time will come when the Poor-law medical officer will be a branch of the civil service, under Government pay and direction, when competitive examinations will collect together the best men, and when the parish doctor will be a position not held simply as a matter of ‘tactics to keep the rest of his professional work together, but as an adequately remunerated part of his practice; or as a service, apart from pri- vate practice, in which the best of our hospital students may look forward to spending the first few years of their professional life, and laying by a store of professional experience which is mainly to be gained in attendance on the poor, and of operative skill from the practice of the cottage hospital. In the foregoing remarks I do not wish to reflect on the Poor-law medical officers ; they number amongst their ranks some of the most excellent and highly-educated men in the profession. I merely wish to draw attention to the fact, that however skilful the medical man may be, a large portion of the public will look upon him as the parzsh doctor. 1 write from experience as to the difficulties that beset his position, and the short-comings of the Poor-law Board, having acted as parish doctor in the: earlier part of my professional life, both in town and country. There is much temptation to enlarge on this topic, but it is only introduced here to shew the importance of spreading cottage hospitals throughout the country. It would greatly help this work forward if some central 183. society were formed—a National Association, for instance, for the promotion of cottage hospitals. Many of the difficulties that present themselves in the formation of cottage hospitals would be greatly diminished if the promoters could fall back on the decisions of some central body: The proposed institutions would no longer be a unit, the necessity for which depended on the opinions of its promoters ; but an integral part of a large and powerful association, through whose influence boards of guardians might be more easily propitiated, and professional opposition smoothed down. A quarterly paper or journal, not only giving information as to the erection of hospitals, but also detailing important and successful cases treated in them, would give considerable encouragement to the movement. A great deal of labour would thus be saved in forming rules, etc., aS a common code could be fixed, and used by all hospitals associated together. To sum up in a few words, Such a National Association would be an advantage in starting new institutions ; In formjng a general scheme of rules ; In diffusing a knowledge of sick nursing ; In diffusing a knowledge of sick cooking ; In helping, by a central fund, poorer districts to commence a cottage hospital ; In arranging a méeting of medical officers of cottage hospitals annually, where matters of interest’ with regard to them might be discussed ; 184 In undertaking the arrangement. of Ts affecting Poor- law unions, &c. ; In publishing a quarterly paper, with information as to the promotion of cottage hospitals, plans for building, &c. This idea I only bring forward as a suggestion, the details of which may be worked out at some future time. I have thus fulfilled my intended plan of this Handy Book. From a careful consideration of the principles and history of the movement, with a more practical knowledge of the best means of managing a cottage hospital, I trust a fresh impetus will be given to the work; whilst the description of the « - cottage hospitals now existing, and their statistical results, though not so perfect as I could have wished, will perhaps prove the means of encouraging fresh promoters of new hospitals. Any work that tends to ameliorate the condition of our poor must be a good work. The foregoing pages will, I hope, shew that it is even a better work to help the poor to help themselves, than to add to the indiscriminate charity abounding, and which is so often taken advantage of by those who are not the objects intended by the donors. May this little book induce benevolently-disposed persons to help our sick poor, and thus to realize for themselves the benefits announced by Divine authority :— «Blessed be he that provideth for the sick and needy ; the Lord shall deliver him in the time of trouble.” Apyendix, A PLEA FOR VILLAGE HOSPITALS. ' A LETTER’ ADDRESSED TO SAMUEL MARTYN, ESQ., M.D., PHYSICIAN TO THE BRISTOL GENERAL HOSPITAL. Wrington, near Bristol, March 12th, 1862. Dear Dz, Marrrn, I write in reply to your question, “ What is your experience in regard to the benefit or otherwise of sending country patients to Hospitals in Towns?” By the word “ Country,” I suppose you refer to cases such as occur in my own practice, at a considerable distance from a town ; that is to say, from 10 to 15 or 20 miles, : I wish I could give you the experience of a longer period, having only practised in the country eight years ; but such as it is, you shall have it. And I find that the more cases of accident I see here, the more the opinion formed before I left Bristol is strengthened--namely, not to send cases of accident from the country into Town Hospitals. And I am not sure whether the same opinion would not apply in a -great measure to medical cases. No one would be more ready to admit the value of a hospital, the skill of its staff, the judgment of its nurses, the attention of its dressers, and the comparative purity of its air to ‘that of the atmos- phere around, than myself. It would be an act of the deepest ingratitude were country medical men to depreciate those Insti- tutions, from whose wards they gained their skill and knowledge ; but the question you have placed before me is not the benefit of li. APPENDIX. hospitals, but the benefit of Town Hospitals to Country patients. As I lave answered that question in apparently so sweeping a manner, you must allow me to give you the reasons on which I have based my opinion, and the substitute I propose for Town Hospitals, as far as our poorer country patients are concerned, that they may have some of the advantages which their fellow-sufferers in our towns enjoy First, then. The distance a patient has to be taken to the Hospital stands foremost in my list of objections. Every one must feel, that the sooner a surgeon attends to a severe. wound, the better it must be for the patient. I believe time lost is too often—life, or at least a limb— lost. In accidents this is particularly the case. I have been often asked by the friends of a patient, or perhaps by some parochial authority anxious to save the parish rates, Would it not be better to take the poor man to the Infirmary ? He has met with the accident probably two or three miles from home ; has already been carried there in a jolting cart ; and his pallid countenance, feeble pulse, and agonized look, give weight to his answer,—“ Don’t send me to Bristol, Sir; let me die here.”” On my own part there is never any hesitation. The wound being dressed, and the bandage adjusted, a little ordinary care soon shows that I have been right in attending him at his own little cottage. In nine cases out of ten such an accident would have been seriously complicated by the additional ride of ten or twelve miles, to say nothing of the city pitching, dreaded by our country patients, as increasing the jolting of a Coburg cart, far more than the journey over parish or turnpike roads. In severe surgical cases, requiring immediate operation, not the result of any casualty, the Toss of time is frequently the loss of life. Some few years since I had the satisfaction of saving the life of a poor old man nearly eighty- two, labouring under a severe and complicated surgical affection Chernia strangulated, with ascites of long standing.) No case apparently called more for the benefits of a hospital, but I believe he would never have reached Bristol alive. The cottage wascrazy and old, and the room so low, that neither I or the medical friend who assisted me, could stand upright, and we had some difficulty in avoid- ing the numerous holes in the rotted floor. The hour was a little after midnight, and the only candles to be had were miserable tallow dips. It was truly surgery under difficulties ; still the poor fellow recovered and lived for three years after, and though he could have had every skill and comfort ina hospital, it would not have been much use to him had he died on the journey to it. APPENDIX. iii, ‘Secondly. To a country patient the atmosphere of a hospital 1s inferior to that of his cottage, in the country, in about the same ratio as it is vastly superior to that of the majority of the dwellings of the labouring-classes in towns. Of course, dirty and close,dwellings are to be occasionally met with in our villages ; but I think in looking back on my experience in hospitals in Bristol and London, and when I was medigal officer to the poor of Clifton, and comparing it with my country practice, I am justified in laying down the foregoing remarks as an axiom. Surgical cases, I may say, almost invariably, do well in the country. Taking the statistics of the matter—the average duration of illness amongst the paupers of England is 28 days. That of the country parish which I attend is only 21.5 days—this includes medical as well ag surgical cases. Now it would be the height of presumption to assert that the skill of the country practitioners is greater than that of town, nor are the food, and many of the comforts supplied the poor, so good. Indeed, if we are to be judged by the “ Saturday Reviewer,” we must lay claim to no skill at all, but must submit to be considered unlettered country apothecaries. I cannot, then, but consider the purity of our atmosphere the reason of our success in surgery ; the rapidity with which wounds in ordinarily sober men heal, is some- thing astonishing when compared with those in hospitals ; the same remark applies when contrasting cases in Bristol with those in London. / Thirdly. And I think, perhaps, one of the most important objec- tions, is the continued state of excitement a country patient is kept up in, in the wards of a large and well-conducted hospital. The country patient, being admitted into a ward, is placed amidst a state of things he perhaps hardly dreamt of. Instead of the small whitewashed cottage room, with its low ceiling and accustomed furniture, he finds himself in, to him, quite a palatial room, lofty ; with from twelve to fourteen other sufferers, away from his home and wife, and daily and nightly in the presence of severe suffering, and perhaps | death, Add to this the daily round of surgeons and class of zealous pupils, the case-taking, and clinical remarks forming the bedside lec- ture on his own peculiar case ; and is there not enough to excite a man, entirely unaccustomed to mix much with his fellow men ? I have known many leave hospitals where they were deriving much benefit, from an intense desire after their own small cottage room, and to get away from those suffering and dying on each side of them. Now to iv. APPENDIX. the poor of our towns these remarks do not all apply ; they like the very excitement our poor dread ; constantly mixing with others, they are not shy at the visits of so many. Indeed, when a Dresser, at the Bristol Infirmary, I have been often asked by a patient, “ What have I done to offend the doctors, they have not lectured oh me.” Many would reply to the questions asked with the greatest alacrity, and be quite delighted and flattered to have their case all written out by the _ House Surgeon. Not so our poor, they consider themselves “put upon,” and we are often seriously inconvenienced to make an accurate account of an interesting and useful case. I have thus mentioned three reasons which appear to me to justify my opinion. We have first to send our patient a consider- able distance; then he has to wrestle with an atmosphere much more impure than the one to which he ‘is accustomed ; and, superadded to that, he has to combat with a source of excitement to which he is altogether a stranger, when his mind ought to be as calm and quiet as possible, to give his case every advantage of the skill and appli- ances a large hospital affords. On account, then, of these reasons, I do not send surgical cases to either of the Bristol Hospitals, as, in spite of frequently rough-and-ready-surgery, sometimes ata distance from home, a cask stave and some thatching straw, with any old linen, and, im more than one roadside case, a hempen halter supply- ing the place of the nicely-shaped and comfortably-padded splint and bandage, the results of our country practice do not come below that of hospitals, but rather the reverse. With regard to medical cases, I do not hold so positive an opinion. Il health has come on more gradually ; time is not perhaps always of such vital importance ; and the value of combined and experienced opinions in an obscure case greatly overbalances the difficulties in the way. Still, in acute disease, I would give the preference to the patient re- maining in the country, particularly in fever, where the mortality is comparatively small, and where atmospheric influence is perhaps most peculiarly felt. Many consider that the appliances, regular food, and luxuries of a hospital, together with experienced nurses, are to be gained at any sacrifice, and are not to be met with in the country. With regard to surgical appliances, they may and ought to be used as freely in the country asin town. The kindness of neighbours as nurses is proverbial ; and with regard to luxuries for our patients, we are more as one family in our villages. Country sympathy is quicker APPENDIX. Vv. than town, because the cause of it is more brought home to our minds. When Roger breaks his leg, or Thomas, who married the housemaid at the Court, and who has the tidiest children in our village school, gets his arm crushed in a thrashing machine, the doctor has not to ask for broth, wine, and other necessaries, but rather to be careful lest the patient gets too many good things, as sympathy is quickly excited, and soon bears fruit amongst our country gentry and their families, What then should be substituted for hospitals at such a distance, as we fully appreciate the benefits of placing our suffering poor in some place where they may enjoy more rest and quietness than in their own cottage, surrounded by a numerous family. - Tothis I could answer, “Village Hospitals.” The Village Hos- pital isa very unpretending edifice. A comfortable cottage, in a good position, sufficiently large to contain two or three good rooms, a neighbourly good soul who has “ seen better days,” perhaps, and is comparatively skilled in nursing, and a zealous earnest surgeon, is all the arrangement and staff required. Many country parts of England are admirably adapted for such local institutions. There are villages larger than others which by common consent become a kind of centre to the half dozen villages around. Here we find the Doctor and Lawyer reside; here are a few good shops, and a Reading Room ; and here also we should have our Village Hospital. At Cranleigh, near Guildford, the plan has answered well, and all honour is due to Mr. Napper and others who have pioneered the way in this new field of hospital work. The sufferer from an accident would not have far to go ; he would arrive at a cottage much like his own, his wife by his side ; and theclergyman of his own parish to whose voice and kind words he is accustomed, his visitor. The Doctor will not be followed by a troop of admiring pupils, nor will he have the eclat of a large hospital ; but he will be well rewarded by the results of his practice, and the advantage of studying more closely than he could do in a crowded cottage, cases not only inter- esting to himself, but deeply important perhaps to the welfare of future patients. I hope the time will soon come when our large country villages will be able to offer these advantages, not only to their own poor, but to those of the villages immediately surrounding them. Believe me, yours sincerely, ; HORACE SWETE. vi. APPENDIX. P.S.—Since writing the above, I have had the pleasure of visiting the Village Hospitals at Cranleigh and Bourton-on-the-water, and have found them admirably adapted for the purpose in view. Every patient pays something towards his maintenance, so that these little hospitals are partially self-supporting. * This Letter having been of much service in drawing attention to the necessity for Cottage Hospitals, copies for circulation may be obtained of the Publishers, at 3d. per dozen, or 2s. per 100. VILLAGE HOSPITALS: THEIR POSITION WITH REGARD TO COUNTY INFIRMARIES, UNIONS, AND THE PROFESSION, Read before the Bath and Bristol Branch of the British Medical Association, January 25th, 1866; and reprinted from the British-Medical Journal, May 12, Ir will be remembered well by those present to-night, the wretched condition as to medical stores and appliances, in which our army was, when, twelve years since, the Crimean war commenced. We cannot easily forget the call for nurses, drugs, lint, etc., that, day after day, came to us from Scutari and Balaklava ; and we can still less easily efface from our remembrance the devoted band of sisters, headed by Florence Nightingale, who left their homes of luxury and plenty, for the privilege of aiding our wounded soldiers in the East. This state of things was acrying evil—one that reflected great discredit on the Executive, and which called forth all the warm sympathies of our profession for their brethren in the army, who, whilst possessed both of the will and the skill to alleviate misery, yet were denied almost the most simple surgical necessaries. It may be received as an axiom, that out of evil comes good. Should our army again have to take the field, the medical depart- ment ef both forces will no longer feel the want of hospital appli- ances. The exertions of the late Lord Herbert of Lea have placed the medical department on a new footing; and military hospitals and schools of medicine have arisen in various places. Nor has the good stopped here. Miss Nightingale has brought the experience she gained in the East to bear on our civil hospitals. Nursing institutions are arising in our principal towns, and a great impetus has been given to the enlargement and building of hospitals. Since the date of the Crimean war, nearly twenty county or large hos- pitals have been built, or are in process of building, whilst nine of our old established institutions are undergoing considerable enlarge- ment. vili APPENDIX, In the year 1859, two new hospital plans arose: that of Cottage hospitals, of a small number of beds, from twelve to twenty ; and Village hospitals, of a simpler character still. Nor must we con- found the two plans, though the names of village and cottage hospitals are often used synonymously. The Cottage hospital system was, I believe, first established at Middlesborough, in Yorkshire. The system is that of furnishing small houses with hospital beds, in simple style, where patients are admitted by recommendation notes. The nursing in most of these is done by voluntary sisters. In some, I am happy to say, the surgeon is paid for his attendance. The funds are aided by gifts in kind, of food or wine, the patients paying nothing. Of these small hospitals there are about ten—at Middlesborough, North Ormsby, Marske, Stockton, Darlington, Hartlepool, West Hartlepool, Wal- sall, and Weston-super-Mare. These have effected much good, at a small cost, providing hospital accommodation to many living at a considerable distance from a county infirmary. Most of these hos- pitals are for accidents and surgical cases only, and are situated in the immediate neighbourhood of factories or iron-works. That at Marske is, I am informed, entirely supported by the Messrs. Pease, and is somewhat of the nature of the small surgical hospitals at the slate-works of North Wales. The Village hospital system was also commenced in 1859, by Mr. Albert Napper, at Cranleigh, in Surrey. Mr. Davis, of Fowey, who, very shortly afterwards, opened a village hospital in that place, had a room for occasional casualties ; but is willing to give Mr. Napper the credit of commencing the first village hospital, with a regular nurse. In conjunction with the rector of the parish, the Rev. Mr. Sapte, Mr. Napper raised subscriptions, to furnish a small cottage in the village with beds for four patients; engaging a suitable woman as nurse, the rector giving a cottage rent-free for the purpose, And here I may observe that, in nearly all cases of the establishment of village hospitals, the clergy and doctor have gone hand in hand; and I have no doubt that, the more these institutions flourish, the greater will be the bond of union between these two sister pro- fessions. The main principles on which Mr. Napper proceeded, and whieh have been followed out by those starting village hospitals on the Cranleigh model, were these : 1. Weekly payments by the patients towards their maintenance. APPENDIX. ix. 2. Payments of extra union fees to medical men in whose districts accidents, etc., occurred. 8. Permission to neighbouring medical men to operate, or continue their attendance on these cases, whilst taking advantage of the hospital and nurse. These] principles have been worked at Cranleigh more than six years, and have now been followed by ten similar little hospitals ; whilst the present year -will see the opening of several more on the same, model. The following are the dates of opening of the several village hospitals. 1859—Cranleigh (Surrey.) 1860—Fowey (Cornwall.) 1861—Bourton-on-the-Water (Gloucestershire.) 1862—Par Consols, added to the Fowey. 1863—Iver (Buckinghamshire) ; St. Mary’s, Dorking (Surrey) ; East Grinstead (Sussex.) 1864—Wrington (Somerset) ; Ilfracombe (North Devon.) 1865—Tewkesbury (Gloucestershire) ; Capel (Surrey.) Most of these are very humble cottages ; that at Cranleigh remarkably so. The cost of establishing such a hospital is but small. That of fur- nishing one for six beds, and accommodation fora nurse, should not exceed £100 ; the annual expense being about £20 per bed, one-fifth of which should be paid by the patient. The class of patients ad- mitted are the respectable poor, journeymen, etc. ; not those usually in receipt of parish relief, for whom the union infirmary is provided. I will now speak of the relation of the village hospital to the county?infirmary. ’ Before‘ cottage and village hospitals were opened, there was a feeling that a hospital could not be properly conducted without a large staff of surgeons and physicians, with a troop of paid officials —kouse-surgeon, matron, nurses, etc. ; and thus it was only in large towns that a hospital was to be found. Hence the opinion gained ground that they were not needed for the country; and that the existing town® hospitals were quite sufficient for the wants’ of the population. But statistics show that, in the whole of England— numbering in 1861 20,066,224—there are only 15,202 beds available for our sick and iujured poor, and about as many more in workhouse infirmaries. London has one bed to every 509 persons of all ranks. b Xe APPENDIX. The six principal towns in the provinces have one bed to every 716 persons. Allowing the remaining hospital beds at the rate of one to 1000 people, there will be still about nine millions without hospital accommodation, or a deficit of 9000 beds—a wide scope for the foundation of village hospitals. The distribution of these beds, ex- cluding the City and immediate environs of London, is as follows : 1 bed to 700 people .........s.scesereoneeeeeennes Gloucestershire. . & 900 ave ...Bedfordshire, Devonshire. 1 ,, 900—1000 .... ... Sussex. _ 1000—1100 ........ Reeseaseoa Sateaseeeesmes Cumberland, Kent, Leices- ter, Northumberland, Hun- tingdon, Lancashire, Here- fordshire. 1. sy 1200—1300 ......0e ceceeeecreeeereees «Oxfordshire, Somerset, and Hampshire. Ly E500 etna seavsesaveeee peedaieee tee -Berkshire, Cambridgeshire. Derby, Northamptonshire, Warwickshire. 1% 1700—2000 ......:ceeesenereccreenees re Cheshire, Dorset, Hertford- shire, Norfolk, Nottingham, Shropshire, Staffordshire, Yorkshire. de 55 2000—3000 ..... ace dVonmevacves sagacaedeue »Durham, Lincolnshire, Suf- 4 folk, Wiltshire, Worcester- shire. Ly BODO 4000... eeceecseceeaeeneseseneeenene Buckinghamshire, Cornwall, Essex. he as 9000 Surrey. 1 , 56,000 Monmouthshire None in 22,000 -...-Rutlandshire. 9 GOON) —, re epaeneoatsciiardeucdapnesaeuons Westmoreland. Middlesex, and, in part, Surréy are supplied by London. In Sur- rey, éxcept the metropolitan hospitals of Guy’s and St. Thomas’s, there were none till the Cranleigh Village Hospital was opened ; since then the Surrey County Hospital at Guildford has, been built for fifty-eight patients. These statistics have been compiled from the census of 1861 and the Medical Directory of the present year. Beds for eye and ear cases, children, and lying-in patients, have been taken into account ; but not any beds in workhouses, lunatic asylums, or military hospitals APPENDIX. xi. It is clear, therefore, that the hospital accommodation at present existing in the country is not sufficient for the wants of the popula- tion, independently of the distance patients have to travel; and I would in this ‘respect draw particular attention to cases of hernia, compound fractures, and gunshot-wounds. It has not been an uncommon thing to hear of hernia cases going from surgeon to sur- geon, and at last taking a long railway journey to some county infir- mary, where the operator has only time to see his ‘patient, already beyond operative interference. It has been frequently urged in opposition to the establishment of village hospitals, that though they might be very good things, yet they would, and must, injure older establishments that were doing good, by diminishing their funds, and taking cases from their medi- cal staff. These objections are, however, seldom found to be urged by members of the medical profession. First, it is alleged that the village hospitals take from the funds of the older hospitals. This seems, at first sight, a very valid objection. But how does it act practically? Looking over the sub- scription-list of our village hospital at Wrington, I find only the names of nine or ten who are subscribers to the Bristol hospitals ; whilst there are nearly four times that number who never gave to any hospital before. Nor have I found that those who subscribe to the village hospital have withdrawn their subscriptions from the town institution. I have the same opinion from the surgeons of other village hospitals; so that it may be broadly stated that, whilst the establishment of villagé hospitals does not impair the finances of our county infirmaries, it opens the purses of many who have never helped hospitals to provide for the wants of our sick poor. They not only do not injure the finances of town hospitals, but indirectly add to them by relieving them from expensive coun- try patients, and allowing the pouniry subscribers to benefit town patients. Secondly, the establishment of village hospitals may be said to take many cases of interest from ‘town hospitals. In order to under- stand the bearings of this question, we must inquire what class of cases are usually sent by country medical men to town +ospitals. This is determined partly by the love of the individual surgeon for the duties of his profession ; and partly, I am sorry to say, by finan- xii. APPENDIX. cial considerations. Some country surgeons will, to avoid trouble, especially when the extra fees allowed by the Poor-law Board are commuted (a very reprehensible plan), send nearly every accident, hernia, or obscure case, to the county infirmary ; whilst others err on the other extreme, and attempt operative interference in diffi- cult or obscure cases, where, the patient would be more benefited by the appliances and combined skill of the staff of a large hospital. On the one hand, the beds of the infirmary are filled with cases which had better be treated at home; whilst, on the other, really instructive cases are kept back from the surgical staff and their pupils. Now, the establishment of village hospitals will afford room for cases of fracture, simple and compound, hernia, and a host of minor cases, which seldom do credit to the surgeon, where a long journey has preceded his treatment; whilst I have no doubt that obscure cases will be brought more under the notice of the village surgeon, who will forward them to the county infirmary. ‘ The position of village hospitals and county infirmaries, in my opinion, should be this. The village hospitals should admit cases which could, under any circumstances, be treated by the medical man at their own houses, but with far greater prospect of success in the village hospital; but they should not admit cases of great doubt or difficulty (not emergencies), which might be treated with greater benefit to the patients in a county infirmary. Since I have had charge of the little hospital at Wrington, I have advised two or three patients to go into the Bristol hospitals, though I have never shirked the responsibility of any case where delay or a long journey would be dangerous to life or limb. For instance, it might be necessary to tie a large vessel, or to excise a joint, on account of severe accident or emergency ; and this should be done at the village hospital, life and limb being thereby saved ; but a chronic case of disease; or aneurism, requiring such treatment, except under peculiar circumstances, where country air or other weighty considerations _might alter our opinion, should, I think, be sent to the county infirmary. The position of village hospitals to unions may affect the pocket or the credit of the union medical officer. To take in a case of fracture or amputation, where an extra fee is allowed by the Poor Law Board, would almost amount to a robbery of the ill-paid and hard-worked parish doctor. Now, it has been laid down as an axiom, in the establishment of most village hospitals, that the APPENDIX. xiii. admission of such patients should not prevent the medical man, to whom such fee was due, from receiving it. In Cranleigh, £36 have been paid over to various parish medical men during the first four years of its existence. In Bourton-on-the-Water, also, these’ fees have been paid. If it be shown that patients recover, and thus relieve the rates, even a Board of Guardians, of a moderate amount of enlightenment, will not refuse their payment; though we all know that, if our patient be removed to the county infirmary, we never catch a sight of our fee. But a more serious infliction may fall on the parish doctor than, the loss of fees. He may lose credit ; and worse, see the meed of credit, that ought and would have been his, transferred to another. Now, in the constitution of village hospitals, this can only happen to the officers of the workhouse, as the beds of the village hospitals are open to all medical men, either by direct rule or by courtesy. In no case would a medical man, I believe, be refused the oppor- tunity of operating on his own patient. If he does not choose to avail himself of this permission, the village hospital must not be blamed if another surgeon does take a little of the credit which he might have obtained. In the case of the workhouse medical officer, it must be under- stood that there are two classes of paupers—the permanent work- house pauper, and the poor man who obtains a note for the medical officer simply because he has met with some severe accident or illness. For the former the village hospital is not intended: the fifteen thousand beds in our workhouse infirmaries are the proper place for the regular pauper. In the latter case, except in the instance of an indolent parish doctor, the patient neither would nor ought to be, sent to the house at all; and his introduction to the village hospital will do much to prevent him feeling the sting of poverty, though the parish will pay something weekly to the village hospital towards his maintenance. I think, therefore, that it may be laid down that the establishment of village hospitals will not injure the pocket or the credit of the parish medical man, or abstract from the sick-wards of our workhouses those cases for whom the beds were provided. We now arrive at a third point—the position of village hospitals with regard to the profession generally. Here many of the argu- ments which I have before used will apply ; but, in addition to that, xiv. APPENDIX. we have to consider the charge of increasing gratuitous institutions, and thus diminishing the fair profits which should accrue to our country medical brethren. The Journal of this Association, which in 1860 most warmly recommended the scheme to its associates, is now constantly carping at the promoters of village hospitals. Like our Government, with the change of Prime Ministers comes a change of opinions. It was the leader of the Journal on March 3rd, 1860, which induced me to go over to Cranleigh, in Surrey, and see for myself whether the plan could not be adopted at Wrington. The Journal says: “ We commend the scheme to the notice of our associates in rural dis- tricts. The principle is excellent.” In November, 1861, our Journal says: “The benefits derived from such village hospitals are manifest. It brings the blessings of hospital ‘accommodation home to the dvuor of the villager; it enables him to enjoy fresh air and home; it gives him immediate relief; and it gives the provincial surgeon, Saturday Reviewers notwithstanding, the means of making himself equal to all emergencies which may occur in his profession.” But on January 3rd, 1863, the editor asks Mr. Napper, “Why he gives his services gratuitously to the village: hospital ? and on what principle of equity or ethics should he give his time and services to it ?” In October, 1863, he becomes still more dispirited on the subject, and “fears that, if village hospitals are established, an enormous system of professional demoralization will be established,throughout the country ;” and hints that they may be “a kind of advertisement to their medical promoters, who, whilst engaged in the ‘glorious cause of humanity,’ do not forget their own personal advantages.” Our editor again recurs to the subject last week, though in a more quiet and milder mood. Now, whilst I entirely agree with the spirit of opposition to gra- tuitous medical services which dictated these remarks, I cannot help remarking that they show a most complete ignorance both of village hospital work and of the professional life of a country doctor. Our good editor, whilst he is ably conducting the Journal of the Asso- ciation, thinks little of the hard-working life of the majority of country doctors, forced to pay income-tax not only to Government, but to the poor in the shape of medicines and attendance, wear and tear, far beyond the pittance called by courtesy a salary from the Board of Guardians. They are forced, I say ; because, their office being a legal one, which must be taken by some one, there is no one APPENDIX. Xv. else in the neighbourhood to take it, unless the surgeon be willing to see another competitor for professional subsistence added to those already around him, taking clubs at a low annual payment, but still immeasurably greater than the parish pittance, and taking them at that payment because they have been fixed so for years, and he is surrounded by men who, perhaps, will do them for sixpence a head less. If Dr. Markham can look back on personal experience like this, I do not think he will accuse the promoters of village hospitals of demoralizing the profession when they are doing what they can, as far as others do'so, irrespectively of the “glorious cause of humanity,” to help themselves by saving themselves miles of hard riding, by having their severe cases in the little hospital hard by their own gate. We cannot honestly call such services gratuitous, and go cap in hand to the public and ask therh to pay us a salary for helping ourselves. Where gratuitous services pinch the country doctor, is where medical men in large towns, sometimes holding a high position, give gratuitous advice, and where the farmer, who could, if he would, pay his own doctor, goes to market in a smock- frock, and then to “ the excellent and skilful doctor” for “cheap advice. I hope our city friends are not aware of this; but I have heard the remark made by many in the neighbourhood of our larger towns. = I have before stated that, as the beds of a village hospital are open toall medical men, no one can feel aggrieved on that score. How, then, is the income of the neighbouring practitioner influenced by the establishment of a village hospital ? Let us take Cranleigh. Out of one hundred cases, sixty-seven were indigent, and obliged to have parish relief to help them when sickness came ; and, in ten of these cases, £36 was paid to various parish doctors. Seven patients were incapable of remunerating a surgeon; and sixteen were in very humble circumstances, where the surgeon might send in a bill, but where payment would be very doubtful. Inthe Wrington Vil- lage Hospital, where I can speak more authoritatively, seventeen were patients in clubs or parish, whom I was bound to attend with- out any further fee ; two were domestic servants, who would have been attended by any family doctor, if the village hospital had not been established ; and three were sent in and attended by a neigh- pouring medical man, who had already been paid by them what they could afford, and who felt he could no longer send in a medical bill to them. xvi. APPENDIX. Now, with regard to the ethical relations of village hospitals to the profession, I feel they will do more to promote unity and bind us together than anything that has lately been started amongst coun- try medical men. Where we are ignorant of the details and nature of a case, we may be tempted to look-superciliously on the work and opinions of others; but the establishment of village hospitals will lead us to know more professionally of one another, and thus carry out the principles of our Association in promoting unity and frater- nization in our profession. I have thus given a sketch of the subject, as my object has been to draw out the opinions of the members of our Branch. I have purposely refrained from taking up your time by giving you details of the working and internal arrangements of village hospitals. Many of you have seen the reports of these useful institutions ; and Tam engaged in preparing a few pages for the press, which will enter more fully into minutie. I will, therefore, sum up my remarks in the following opinions. There is a want of hospital accommodation in our country places. The establishment of Village Hospitals will not tend to lessen the funds or instructive cases in our county infirmaries; whilst they will probably bring to light many obscure cases. They will not interfere with the justly-earned fees of the parish doctor, nor take away his credit ; for he may follow his patients to the hospital. They will not financially injure the neighbouring members of our profession, as the class of patients are non-paying ones. They diminish the labour and wear and tear of the country prac- titioner, and tend to promote good feeling amongst neighbouring medical men Patient's Name an Desiguation. From the usual] Medical Atten- dant or other person. To be signed by! a Subscriber, To be signed by a responsi: le person, subject to the approval of the Manager. APPENDIX. COTTAGE HOSPITAL. LETTER OF RECOMMENDATION, With which all the Applicants must be provided, except in cases of severe accident or sudden emergencies. NAME AND AGE, OCCUPATION, ADDRESS. STATEMENT OF THE NATURE OF THE CASE. ‘(Date) (Signed) . SUBSCRIBER’8 RECOMMENDATION. I hereby recommend the above-named asa fit person to be admitted into the Cottage Hospital. The terms of h admission to be a contribution of Shillings* per week towards *The payments range from 3s. 6d. to 78. per week, maintenance. HOSPITAL GUARANTEE. I hereby ensure the payment of the above-named weekly contribution, so long as _ continues a patient of this hospital. And I further under- take to remove h when required to do so by the manager, land in the event of death to pay all funeral expenses. (Signed) N.B.—Applications to be addressed to the Manager uf the Cottage Hospital. Consumptive, infections, and incurable diseases are not admissible. The nurse is strictly forbidden to receive money from the patienta. ¢ xviii. APPENDIX. COTTAGE HOSPITAL DIETARY TABLES. CRANLEIGH, Ordinary Diet.—Meat (uncooked) 1b. daily ; butter 4lb., tea, 2ozs. weekly, Bread and cheese ad libitum. WRINGTON. Ordinary Diet—Meat }lb., bread Ub., potatoes Hb., beer 1 pint, rice or arrowroot 2ozs. daily ; tea 3ozs., sugar 4lb. weekly. TEWKESBURY. Ordinary Diet—Meat 3\bs. (for males), and 2lbs. (for females), sugar 4lb., butter 4 to 6ozs. weekly. The ordinary diet for adults is subject to such alteration or modi- fication as may be deemed advisable by the medical officer. With him also rests the power of ordering extras, as eggs, poultry, fish, jellies, wine, brandy, ale, or porter. Sick Diet, consisting of broth, tea, puddings, sago, arrowroot, milk, &c., is ordered as required by the medical attendant in each individual case. NORTH LONSDALE, BARROW-IN-FURNESS. Full Diet —One pint tea or coffee, bread and butter, or boiled bread and milk, 60z. cooked meat, 80z. potatoes, 40z. bread, 1 pint soup, or half pint beer, pudding as ordered, 1 pint tea, bread and butter, boiled bread and milk, or 2oz. cheese, half pint bitter beer, bread. Half Diet.—One pint tea or coffee, bread and butter, or boiled bread and milk, 40z. cooked meat, 80z. potatoes, 40z. bread, 1 pint soup, or half pint bitter beer, pudding as ordered, 1 pint tea, bread and butter, boiled bread and milk, or half pint beer, bread and butter. Milk Diet.—One pint tea or coffee, bread, or boiled bread and milk, 1 pint and half rice milk, or half pint milk, 120z. rice pudding, or 1 pint beef tea, bread, 1 pint tea, bread and butter, boiled bread and milk, or 1 pint beef tea, bread. : Low Diet.—Bread, tea, beef tea, or milk and tea as may be ordered. Extras to be specially ordered.—Mutton chops, beef steaks, beef for beef tea, fish, eggs, jelly, porter, wine, or spirits. ; APPENDIX. xix. ORDER PAPER. / —___ COTTAGE HOSPITAL. COTTAGE HOSPITAL. § Mr. Supply to the Institution Supply Matron or Manager. Date. It is requested that no article shall be supplied to the Institution with- out this or a similar order. Date Demand for payment must be sent to the Secretary on or before ( the ————— of each month for the eens’ next Committee, when all accounts GQ will be paid. ~ CASE PAPER TO BE AFFIXED TO THE BED’S HEAD, COTTAGE HOSPITAL. NATURE OF CASE— of the Parish of aged admitted 187 under the care of CASE. DIET. TREATMENT. APPENDIX. xx. *3eq3TUr WI.) JO WBUITEYD * oP : +7981100 PUNOJ PUB POUIUAEX*] “quapuainiadng ** oaTMIOX | “QDUBUDIUIN AT v€vp sad peony jad asuadxe atnioay —I bgonto| -IpaTe "surIpuns| pre ‘sur UBIO IOS “B08 nad xo sul “poo E (eas “s0.58AA! spaxey odds SOXRWL SOUL AA § "SOTIa0 RAEI, USE N SoTpuRy) 8030 Ay's syuay peed oe “VOLT satqu; | “qwoyT -259,4 } "SBA AN Wi “AIL “TyNg] ‘Prog “LNQODOY WALLOOUXA “LX.1OODV DONVN'SLNIVIC 40 HINOW FHL YOd YUALIGNAdXA—MWOOT ASNTdXA APPENDIX. xxi. ESTIMATE OF THE COST OF FURNISHING A COTTAGE HOSPITAL FOR SIX PATIENTS AND A NURSE. The prices affixed are taken from the receipted bills of the Wrington Village Hospital ; 5 per cent. being deducted for cash. ENTRANCE HALL. £s. a £8. d. Form ome jouw nee. oe OF 8 QD Scraper... sie eve «ws 0.2 6 Door Mat ... axe wee - 0 4 6 Alms Box ... See wats ws O 5 0 017 0 DAY ROOM. Carpet and Hearth Rug—2nd hand ... 3 0 0 Table res ie wes . 1 5 060 Four Chairs cat ae - O16 O Arm Chair sid et ws: fd tO Couch—2nd hand ... aoa «. 110.0 Chiffonnier Book Case soi «= 8 3 0 Fireirons and Fender * a 07 6 11 2 6 KITCHEN. One-flap Table wes ee - 100 Six Chairs ie a «. 019 6 Fender and Irons... we 010 0 Wash Tub and Bench . sis ov Lb O Meat Safe... exe wae -. 110 0 Earthenware, &c. ... sa me 11 2 Ironmongery soe wei - 40 0 Mop, Broom, &c._ ... see ow OTL 5 Scales and Weights... eee -w- O16 6 Buzket and Slop-pail aa « O 7 8 12 9 8 TWO BEDROOMS. Six Allen’s Patent Hospital Beds -- 18 0 0 Six Wool Mattresses ... i ~ 6 6 0 Six Sets Sheeting, ene &e.. «15 9 8 Chamber Linen... - 8 0 0 Six Chairs sia woe -- 018 0 Six Strips Bedside Carpet ere we Ll 6 Six Lockers wos ee «wo 2 2 0 Two Commodes _... cee «ws: 1 0 © Two Bed Tables... HE ~- 010 0 Two Bed Rests... ase -. 016 0 Two Double Washstands_... ~~ 1 8 0 Ware for ditto oats ety we I 1 4 Two Toilet Glasses... aat5 -~ O 7 0 Two small Tables ... ae - 0 9 0 : Two Sets Fireirons and Fenders - O18 6 53 11 7 XXii. APPENDIX. NORSE’S BEDROOM. Tron bedstead BSS ca Palliasse ie Millpuff Bed oo nee aoe Bedding and Linen... sis ass Chest of Drawers ... i sie Two Chairs oa wee ee Small Table ais Ps seis Bedside Carpet... wa ex EXTRAS. Large Press for Linen, the lower a pan \ for patients’ clothes, &c.. Clothes Horse ee oss Screen ... es Steaming ‘Apparatus ‘for Chest Cases .. Long Bath eee a's ai Hip Bath ae ace ies Two Bed Slippers ... aoe oe Four Spitting Cups ves ae Inhaler te aes wae Surgical Dressing Tray Dispensing Apparatus, Bottles, Mea-] sure, Scales, &c... Account Books, Admission Book, Rules Prescription Cards, &c. Deduct discount for cash ... wae To this may be added, if the funds allow— Hospital Ambulance ies Or a Wheel Chair, second hand’ Water Bed, 6ft. by 3ft., Maw’s ... oe Two Water Bottles, india rubber... ... Carrying Chair... 20. see ee wee American Operating Chair... ae Dispensing Cabinet, fitted up . one 100 010 0 110 0 216 0 110 0 0 60 0 5 0 0 5 8 2 3 400 010 6 100 08 0 210 0, 015 0 070 0 5 0 08 6¢ 0 5 0 5 0 0 3.8 0 1817 0 £105 0 0 £5 0 0 £100 0 0 £20 0 0 wee £8 to £10 < se 8 10 6 -~ O 8 0 10s. to 210 0 wee - 14 0 0 - £16 to 25 0 0 Estimate of a complete Set of Surgical Instruments for a Cottage Hospital, from Maw and Son's price list. Case of Instruments for capital ones rations . aoe nee ane tee Minor operations see Ses ees. Ber ee Cupping ... 0. ces cee nee tee I 16 10 0 216 0 - 2 3 0 APPENDIX, xxii. Eye Operations... ... 1. we ae 2 4 0 Trachetomy ... .. ww 118 6 Pullies and Dislocation “Apparatus w 1 5 6 Brodies Catheters... ... .. - 3 8 O Instruments for post-mortem examinations 317 0 Enema syringe .., .s. soe ss oe 010 0 Electro Magnetic Apparatus... ... 212 0 Laryngoscopic Instruments... ... .. 1 8 O Stomach Pump... 2. 2. vee vee 1:12 0 Ear Syringe ... ... see see eee eee 0 8 O Propane js; os aun wie, Goi eee ave 10 12 6 Clinical Thermometer... ... -. 012 0 Syringe for Subcutaneous Injections 012 6 Set of Ferguson’s Speculums ... 13 0 Richards’ Spray Producer... ... ... O16 6 Watson’s Inhaler ... ... see ae O 7 6 Clendon’s Chloroform Inhaler ae ce O 7 6 Fracture Cradles (set) .. - 10 0 Fracture Swing Cradle (Salter’ 8) «we 3 9 0 Fracture Splints (Liston’s)... ... .. 0 8 0 Fracture Splints (Cline’s) ... ... ... 012 6 Fracture Splints (M‘Intyre’ 3) 2 5 0 Two Sets Arm Splints... ... - 0 9 0 Chemical Test Stand and Drawers 116 0 £53 13 0 Less 5 per cent... .. 213 6 51 0 6 In the above estimate, instruments for operations, which are not likely to be performed at a cottage hospital are purposely omitted, such as lithotomy, ovariotomy, &c; as also are those which every surgeon carries in his pocket case. 7 Price list of miscellaneous fittings, which may be required in cottage hospitals, Tron enamelled bath with taps, &c., 5ft. by 2ft. 6in., £3 5s. to £3 10s. Close kitchen range, from £4 10s. to £6. Ditto with high pressure boilers to feed bath, £10 to £14. Copper barrelled force pump to supply upper floor, without supply pipe, £6. Strong iron garden seats, 6ft., with deal seats, £1. Moule’s earth closet apparatus, £1 15s. to £2. Moule’s commode, £2 15s. Colonel Baird’s earth closet apparatus, £2 15s. Tron tanks for the earth closets, 3s. 6d. to 10s. XXxiv. APPENDIX. Norz A.—Satrer’s Fracture Swine Crapie.—Although I have given in the estimate of surgical instruments, Mr. Maw’s price for Salter's swing, I prefer having it made by an ordinary blacksmith, with the alterations depicted in the cut. These alterations I suggested at the time Mr. Salter first introduced his apparatus to the King’s College Medical Society. They were shortly afterwards put into practical use at the Bristol Royal Infirmary, Mr. Hore, the then house surgeon, adding some impor- tant improvements to the iron support for the leg, enabling it to be made longer or shorter as occasion required, and the foot piece to be inclined to either side, or placed at a different angle. In Salter'’s swing cradle the fractured limb depends from a single point; consequently the cradle in which the injured limb rests, is easily moved as on a pivot, by any sudden starting of the patient ; the wheels only resting on the lower rail and then not very steadily. Now, in my improvements, I place the wheels, which are grooved, in proximity to both upper and lower rail, so that steadiness is at once attained. The point below the wheels carries a straight iron bar with a cross bar terminating in a hook at each end, fixed at right angles toit. A similar bar traverses the long iron bar, and is fixed at the required length by a thumb screw. The leg rest is made of sheet iron, also with hooks, and is suspended at the required height by chains or webbing to the upper hooks. I prefer webbing to chains, as by having the hooks sharp, the required length is more easily attained than by using links of a chain. I have used the apparatus for some years, and provided it for the Wrington Village Hospital, made by the village black- smith, the cost only amounting to £1 8s. Note B to Pact 26.—WetLow Hosrrrau.—Since the foregoing pages have been sent to press, I have received a letter from Mr. W. Squire Warp, giving me some particulars of this hospital. He states that pre- viously to 1842 he had established a few beds for operation cases ; but at that date a cottage hospital of six beds was opened under the management of a regulax board, the present Speaker of the House of Commons being APPENDIX. XXV, the chairman. Amongst its supporters were the Dukes of Portland. and Newcastle, the Marquis of Lichfield, and the Earls of Manvers and Scarborough. One nurse only was employed, with occasional assistance. From want of time to attend to it, this hospital was unfortunately closed in 1867. During the 25 years it was opened, nearly all the great operations were performed in it with unvarying success, and as Mr. Warp says, without carbolic acid. Amongst the operations were lithotomy, lithotrity, many amputations of the thigh and leg, shoulder joint, excisions of joints, and operations for hernia, rémoval of tumours, necrosis cataract, &c. In detailing this account, it must have given Mr. Warp sincere gratification in the success of his little hospital, to be able to say, “ all recovered.” The history of the operations he so kindly sent me, and which is one of the greatest possible interest, is summed up with the following remarks :— “ I think the complicated treatment of carbolic acid is totally useless, at least worse than useless, where we have country air.” I merely make the quotation, as it is due toone whose operative practice has been so successful, without being myself in any way responsible for the opinion. After this account, I think the honour of having established the first cottage hospital under a single nurse, must be given to Mr. Wm. Squire Warp, and that of adopting the plan of receiving payment from patients, to the late Mr. Suir, of Southam. Still, this does not detract from the credit due to Mr. Napper for organizing a system uniting the two plans, the previous existence of which he was totally ignorant, and the principles of which I have enlarged upon in these pages as those of the Cotraae Hospirau SysTEM ON THE CRANLEIGH MopEL. \ ROBBINS AND SCOTNEY PRINTERS, ‘WESTON-8UPER-MARE. BY THE SAME AUTHOR. ° Preparing for Publication, uniform with the “« Handy Book of Cottage Hospitals,” “HANDY BOOK OF. CONVALESCENT HOMES.” LONDON : Hamitton, ADAMS AND Co., PaTERNOSTER Row. WESTON-SUPER-MARE 3 RopsBins AND Scotney, HicH STREET, ieee eee let Saree ad Ss inet es aa Sere Sse a tt 3 essttrs CRC Steet tesatrees seca reboots SeeGsis Nes us a ne pi Asin : Pietra ae Aird re incase aie Seseceetatoas : SS : eens Sages : Seferetrer te te Serene tr sets witeeeee ret = Becks ites patanaiect Soe eet ASUS : Setenerts: a rae a ae eee i sy so i Sere Site ay