1?A PRESENTED TO, ^t gorneff 'gdnucrsifi?,, 1870, ANDREW DIC^CSON WH-ITE, LL.D., J^irs£ President of the University. RA 963.N9n863'™"''''''''"^ Notes on hospitals. 3 1924 012 356 485 Date Due Cornell University Library The original of tiiis book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924012356485 NOTES ON HOSPITALS. BY FLORENCE NIGHTINGALE Unlarged and for the Trust pari Re-written, LONDON : LONGMAN, GREEN, LONGMAN, ROBERTS, and GREEN. 1863. LONDON : SAVIIX AND EDWARDSj PRINTERS, CHANDOS-STREET, CO V ENT-GARDEN, PREFACE. It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle, because the actual mortality in hospitals, especially in those of large crowded cities, is very much higher than any calculation founded on the mortality of the same class of diseases among patients treated out o/" hospital would lead us to expect. The knowledge of this fact first induced me to examine into the influence exercised by hospital construction on the duration and death-rate of cases received into the wards ; and it led me to lay before the Social Science Association a paper reprinted with the present title. Since the publication of the first edition of that paper, great advances have been made in the adoption of sound principles of hospital construction ; and there are already a number of examples of new hospitals realizing all, or nearly all, the conditions required for the successful treat- ment of the sick and maimed poor. Besides this, much additional experience has been obtained in many important IV PREFACE. points, especially in the details of hospital buildings and fittings. In order to spread a knowledge of the progress already- made, as well as of those principles which may now be consi- dered as established, I have been asked to prepare the •present edition. In doing this, it has been necessary to re- write nearly the whole of it, and to make so many additions to the matter that it is in reality a new book. F. N. INDEX TO SUBJECTS. PAGE What it is proposed in this book to say i ^ I. SANITARY CONDITION OF HOSPITALS j Hospital influence on cases in hospital 2 High death rate in hospitals in large towns 3,4 Death rate not the only statistics wanted ^ Hospital-diseases and daily change in cases better tests . . . 6, 7 Explain what "infection" is, and do away with the idea "con- tagion" 8 — 10 Four Defects to which Hospital-diseases are due : 1. Agglomeration of sick under one roof 11, 12 2. Deficiency of space per bed 13, 14 3. Deficiency of fresh air i^, 16 Its greater necessity for sick 17 4. Deficiency of light 18, 19 Note on the Mortality of Hospital Nurses 20, 2 1 Note on the History of the Doctrine of Contagion 22 Note on the Crowding of many Patients into each led at the Hotel Dieu at Paris in past times 23, 24 II. DEFECTS IN EXISTING HOSPITAL PLANS AND CONSTRUCTION 25 I. Selection of Bad Sites and Bad Local Climates for Hospitals 26, 27 Comparison of London and Paris 28 — 30 Four elements for a good hospital position 29 Don't bring sick out of fresh air into foul, as in a town hospital 31 b VI INDEX TO SUBJECTS. PAGE 2. Construction of Hospitals so as to ■ prevent Fresh External Air 3^ By closed courts 33, 34 3. Defects in Ward Construction injurious to Ventilation 35 Defective height of wards 35 Too great width of wards between opposite windows . . 36 Arranging the beds along the dead walls 37 > 3^ Having more than two rows of beds between the windows 39 Having windows only on one side, and a closed corridor on the other 40 Having small wards through a large one 41 4. Defective means of Ventilation and Warming . . 4a 5. Defects in Drainage, Water-closets, &c 43 6. Absorbent Materials for Floors, Walls, &c. . . 44 7. Defective Hospital Kitchens 45 Importance of Cooking 46 8. Defective Hospital Laundries 47 How washerwomen "catch" disease 48 9. Defective Accommodation for Nursing and Discipline 49 J. Economy as to attendance 50 2. Ease of supervision 50 3, 4. Distribution of sick and position of nurses' rooms . 51 10. Defective Ward Furniture 5a Note on the relation which the size and arrangement of wards bears to the question of nursing and supervising .... 53 — _5j III. PRINCIPLES OF HOSPITAL CONSTRUCTION ... 56 What a pavilion is ^6 What should be the distance between the Pavilions .... 57 1. How MANY FLOORS TO THE PaVILION j8 2. How MANY WARDS TO THE FLOOR ^9, 60 3. How MANY BEDS TO THE WARD 61, 62 How many beds to the Pavilion 63 How many Pavilions to the Hospital 64 4. How MUCH SPACE TO THE BED 6^, 66 5. How MANY Beds to a Window 6^ 6. What are healthy Walls and Ceilings .... 68 7. What are healthy Floors 60, 70 8. Where and what should be the Sister's Room and Scullery -,j INDEX TO SUBJECTS. VU FAGK 9. Wheke and what should be the Bath-room and Lavatory 72 TO. Where and what should be the Water-closets and Sinks 7a — 74 ri. How to Ventilate Wards 7^ — 78 Never by artificial means 76 Always by adTaitting fresh air from without 77 12. How the Ward should be furnished 79 13. What the Bedding should be 80 Always hair 81 14. What should be the Water Supply 83 Soft water essential 83 15.' How the Hospital should be drained and sewered 83 16. Where and what should be thj? Kitchen .... 84 As to fuel 85 17. How to dispose of the foul Linen 86 French and English methods 87 Clean Linen Room 88 18. WherEj and how lighted, the Operating Room . 88 IV. IMPROVED HOSPITAL PLANS 90 Separate the sick from the administration 91 Simplicity of plan essential 92 I. FOR Small Hospitals g3 — 96 3. foe Large Hospitals 97 — 106 Lariboisidre Hospital, Paris 100 Vincennes Military Hospital ...lor Herbert Hospital, Woolwich 102 Malta Military Hospital : .... 104 Malta Workhouse and Hospital for Incurables . . . • loj V. CONVALESCENT HOSPITALS 107 Must be as like a home and as unlike a Hospital as possible. . 108 Vincennes Convalescent Institution for men no A string of Cottages the best 112 On Day-rooms and Convalescent Wards 113 Note on the Fincennes Institution 116 VI. CHILDREN'S HOSPITALS 124 Will you have one at all ? 1 24 Essentials of a Child's Hospital 125 Vm INDEX TO SUBJECTS. FACE Bathing i2<5 Playing 128 High Death-rate ^29 Lisbon Hospital ^^9 Note 131 VII. INDIAN MILITARY HOSPITALS i53 No water supply ^34 Convalescents in bed ^35 No drainage or sewerage i3<5 Bedding of hemp or straw 13 7 Construction '3° Immense wards ^39 Darkness 14° Overcrowding 141 Offensive ward offices J42 Bad cooking I43 Bad attendance ^44 Native hospitals 145 Provide nothing but medicine I47 Standard Plan • 148 16 general principles of construction for hospitals IN Indian climates 150 — ^SS VIII. HOSPITALS FOR SOLDIERS' WIVES 1^6 Example of a nest of rooms within rooms 157 IX. HOSPITAL STATISTICS 159 A. General Statistics of Hospitals 160 Seven elements required 161 Five results wanted 162 Additions recommended by Statistical Congress . ■ . 164 — 166 Hospital admission and discharge book 167 Annual tabular abstracts, i. In-patients 168 2. Out-patients 169 3. Cost of each patient . . .169 4. Sanitary statistics of wards. . 170 INDEX TO SUBJECTS. IX TAGS B. Proposal for improved Statistics of Surgical Operations 171 Two forms required 172 Table I. for surgical operations performed 172 Table II. for fatal complications and causes of death . . 1 73 482 fatal operations thus compared 174 Urgent need of some uniform system of publishing the sta- tistical records of hospitals 175 — 176 Nomenclature of operations intended to be used in filling up Tables I. and II 177 Nomenclature of complications occurring afler operations . 1 79 APPENDIX. On different systems of Hospital nursing . . . .181 Five systems 181 Which is the best 182 Necessity of public opinion ; no authority, whether reli- gious or secular, should always have its own way . . .184 Religious orders must always be kept up to the progress of the time by cordial and constant co-operation with secular authorities 18 j Secular authorities must always be kept up to a high standard by cordial and constant co-operation with reli- gious orders 186 Summary of results of the five systems 187 LIST OF PLANS. No. I. HOTEL DIEU to face page it 2. NETLEY HOSPITAL „ „ 37 3. BUCKS INFIRMARY „ „ 93 4. LARIBOISIERE HOSPITAL „ „ 100 J. VINCENNES MILITARY „ „ 101 6. HERBERT HOSPITAL, WOOLWICH , „ 102 7. VALETTA MILITARY , „ 104 8. MALTA POORHOUSE „ „ 104 9. MALTA INCURABLES „ „ 105 JO. CONVALESCENT "HOME" „ „ 112 II. LISBON, CHILDREN'S „ „ 130 THE PLANS OF LONDON AND PARIS TO BE INSERTED AT THE END. HOSPITAL GENERAL STATISTICAL FORM „ „ 160 TABLE L SURGICAL OPERATIONS PERFORMED ... „ „ 172 TABLE II. MORTALITY FROM SURGICAL OPERATIONS. „ „ 173 NOTES ON HOSPITALS. TT is proposed in the following pages to give — ist, a general account of the sanitary condition of existing hospitals ; and, a statement of those structural defects in hospitals which have influenced the progress of medical and surgical cases while under treatment in them ; 3rd, the principles of construction which ought to be kept in view in building new hospitals ; 4th, improved plans for hospitals and convalescent- institutions ; — and lastly, certain proposals adopted by the International Statistical Congress for improving the method of tabulating hospital statistics, together with a proposal for an uniform system of registering statistics of surgical opera- tions, their complications and results. I. SANITARY CONDITION OF HOSPITALS. No one, I think, who brings ordinary powers of obser- vation to bear on the sick and maimed, can fail to observe a remarkable difference in the aspect of cases, in their duration and in their termination in different hospitals. To the super- ficial observer there are two things only apparent — the disease and the remedial treatment, medical or surgical. It requires a considerable amount of experience, in hospitals of various 'constructions and varied administrations, to go beyond this, and to be able to perceive that conditions arising out of these elements have a very powerful effect indeed upon the ultimate issue of cases which pass through the wards. B a NOTES ON HOSPITALS. It is sometimes asserted that there is no such striking difference in the mortality of different hospitals as one would be led to infer from their great apparent difference in sanitary condition. There is, undoubtedly, some difficulty in arriving at correct statistical comparison to exhibit this. For, in the first place, different hospitals receive -very different propor- tions of the same class of diseases. The ages in one hospital may differ considerably from the ages in another. And the state of the cases on admission may differ very much in each hospital. These elements affect considerably the results of treatment, altogether apart from the sanitary state of hos- pitals. But the fact has sometimes been made use of in a way no one could have anticipated. A high and in- creasing death rate has been actually put forward, not as the result of these causes, but as the result of increasing celebrity ; which can have no other practical meaning than this : — that a greater number of people go there to die next year, because so many have died there this year ; a principle equally applicable in private practice, and according to which, the physician or surgeon, who loses the largest percentage of cases is the man most worthy of confidence. In the next place, accurate hospital statistics are much more rare than is generally imagined, and at the best they only give the mortality which has taken place in the hospitals, and take no cognizance of those cases which are discharged in a hopeless con- dition, to die immediately afterwards, apracticewhich is followed to a much greater extent by some hospitals than by others. We have known incurable cases discharged from one hospital, to which the deaths ought to have been accountedi and received into another hospital, to die there in a day or two after admission, thereby lowering the mortality rate of the first at the expense of the second. SANITARY CONDITION OF HOSPITALS. 3 Making every allowance for difficulties attending an inquiry into the comparative mortality of hospitals, there are nevertheless certain very startling facts, which ought to arrest the attention of every one interested in the welfare of sick or maimed. The Registrar-General, in his last Annual Report, has given a set of Occasional Tables on the Mortality of Public Institutions in England, which contain data of more than usual interest and importance on this subject. Returns were obtained from 106 hospitals, giving the number of inmates in each hospital on April 8th, 1861. This number is taken as an approximation to the average of inmates at each establishment. The number of deaths registered in each hospital during the year i85i is also given — so that, assum- ing the approximate accuracy of the data, the mortality per cent, in each hospital can be ascertained for the year. The following classified abstract contains the results of the inquiry, and they are certainly striking enough : — Mortality per Cent, in the principal Hospitals of England. i86j. Number of Special Inmatis on the 8th April, 186 1. Average Number of Inmates in each Hospital. Number of Deaths registered in the Year 1861. MORTALITV per Cent. on Inmates. In 106 Principal Hospitals of England 44 London Hospitals 12 Hospitals in Large Towns 25 County and Important Provincial Hospitals 30 Other Hospitals 13 Naval and Military Hospitals. ... 1 Royal Sea Bathing Infirmary (Margate) I Dane Hill Metropolitan Infirmary (Margate) ... 12709 120 7227 56-87 4214 1870 2248 1136 3000 133 108 ,76 90 38 231 133 108 3828 1555 886 457 470 17 14 90-84 83-16 39-41 40-23 15-67 n-78 12-96 B a 4 NOTES ON HOSPITALS. It will be seen that the hospitals are grouped according to locality. Now let us compare three of these groups with each other. We have 34 London hospitals, affording a mor- tality of no less than 90-84 per cent., very nearly every bed yielding a death in the course of the year. Next, we have iz hospitals in large provincial towns, Bristol, Birmingham, Liverpool, Manchester j &c., yielding a death rate of 83-16 per cent. And there are 25 county hospitals in country towns, the mortality in which is no more than 39'4i per cent. Here we have at once a hospital problem demanding solution. However the great differences in the death rates may be ex- plained, it cannot be denied that the most unhealthy hospitals are those situated within the vast circuit of the metropolis ; that the next lower death rate takes place in hospitals in densely populated large manufacturing and commercial towns, and that by far the most healthy hospitals are those of the smaller country towns. These results are quite reliable, and are preferable to those derived from individual hospitals. Otherwise, it might be stated that the death rate of certain hospitals situated in large towns is so enormous that every bed is cleared out in the year, and in some of them once in about 9 months. Facts such, as these (and it is not the first time that they have been placed before the public) have sometinies raised grave doubts as to the advantages to be derived from hos- pitals at all, and have led many an one to think that in all probability a poor sufferer would have a much better chance of recovery if treated at home. The sanitary state of any hospital ought not, however, to be inferred solely from the greater or less mortality. If the function of a hospital were to kill the sick, statistical com- parisons of this nature would be admissible. As, however SANITARY CONQITION OF HOSPITALS. 5 its proper function is to restore the sick to health as speedily as possible, the elements which really give information as to whether this is done or not, are those which show the propor- tion of sick restored to health, and the average time which has been required for this object ; a hospital which restored ail its sick to health after an average of six months' treatment, could not be considered as by any means so healthy as a hos- pital which returned all its sick recovered in, as many weeks. The proportion of recoveries, the proportion of deaths, and the average time in hospital, must all be taken into account in discussions of this nature, as well as the character of the cases and the proportion of different ages among the sick ; and this brings me to the great importance of correct hospital statistics as an essential element in hospital administration. Hospital mortality statistics have hitherto given little in- formation on the efficiency of the hospital, /'. e., as to the extent to which it fulfils the purpose it was established for, because there are elements in existence of which such statistics have hitherto taken no cognizance. In one set of hospitals, in the table, I find the mortality from lai to i^\ per cent, upon the cases treated, while in other hospitals the deaths reach from 83 to 90|- per cent. To judge by the mortality only in these cases would be most fallacious. Because in the first class of hospitals ailments not of a dangerous nature constitute a title to hospital admission, while, in the latter class of hos- pitals, dangerous and special diseases, at all times accompanied by a high rate of mortality, are largely admitted. Hence the duration of the cases admitted, and the general course and aspect of disease, afford important criteria whereby to judge of the healthiness or unhealthiness of any hospital, in addition to that afforded by the mortality statistics. Perhaps the most delicate test of anitary condition in NOTES ON HOSPITALS. hospitals is afforded by the progress and termination of surgical cases after operation, together with the complications which they present. The statistics of medical cases, although affording important data for our purpose, are of themselves imperfect indices of the healthiness of wards, but it is other- wise with operation cases. In these the constitution gives immediate evidence of suffering from the neglect of hygiene, and many a life is sacrificed from not recognising this fact. In another section I have dealt with this important subject, and have given the method of keeping the Statistics of Hos- pitals proposed by me, and adopted by the International Statistical Congress ; and also a proposal for registering sur- gical operations and their results. Careful observers are now generally convinced that the origin and spread of fever in a hospital, or the appearance and spread of hospital gangrene, erysipelas, and pyaemia generally, are much better tests of the defective sanitary state of a hospital than its mortality returns.* But I would go further, and state that to the experienced eye of a careful observing nurse, the daily, I had almost said hourly, changes which take place in patients, and which changes rarely come under the cognizance of the periodical medical visitor, afford a still more * The following suggestive passages from Mr. Paget's address, delivei-ed before the British Medical Association, 1862, have an important bearing on this subject: " In every case of erysipelas, pysemia, or the like, we ought to work till we can discover its probable origin ; we should have the strongest feeling that these dis- eases are not spontaneous nor inevitable. In every case, the hospital, or the house, or our own practice, should be brought to trial — to private trial, if you will, yet a just and tiue trial— a trial before our own conscience ; and if the hospital, the house, or the practice be found guilty, let it be condemned and amended." " Of all the remedies I have used or seen in use, I can find but one thing that I can call remedial for the whole disease, pyaemia: and that is a profuse supply of fresh air. It the three most remarkable recoveries I have seen, the patients might be said to have lain day and night in the wind— wind blowing all about their rooms." SANITARY CONDITION OF HOSPITALS. 7 important class of data, from which to judge of the general adaptation of a hospital for the reception and treatment of sick. One insensibly allies together restlessness, languor, feverishness, and general malaise, with closeness of wards, defective ventilation, defective structure, bad architectural and administrative arrangements, until it is impossible to resist the conviction that the sick are suffering from something quite other than the disease inscribed on their bed-ticket — and the inquiry insensibly arises in the mind, what can be the cause ? To this query many years' experience of hospitals in various countries and climates enables me to answer explicitly as the result of my own observation, that, even admitting to the full extent the great value of the hospital improvements of recent years, a vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable. What, then, are those defects to which such results are to be attributed ? I should state at once that to original defects in the sites and plans of hospitals, and to deficient ventilation and over- crowding accompanying such defects, is to be attributed a large proportion of the evil I have mentioned. The facts flow almost of necessity from ascertained sani- tary experience. But it is not often, excepting perhaps in the case of intelligent house-surgeons, that the whole process whereby the sick, who ought, to have had rapid recoveries, are retained week after week, or perhaps month after month, in hospital, is continuously observed. I have known a case of slight fever received into hospital, the fever pass off in less than a week, and yet the patient, from the foul state of the wards, not restored to health at the end of eight weeks. I appeal to all careful hospital officers whether each has not known, within his own experience, instances on a large NOTES ON HOSPITALS. and fatal scale of disease produced in hospital; I myself could fill a book with them. One such may be given. In a small hospital, in one of the healthiest counties in England, in nine months, twenty-four poor creatures ran the gauntlet of their lives from erysipelas alone, of which disease eight died ; and most of these after very trifling accidents or opera- tions. None of them ought to have produced erysipelas at all ; much less Jiave ended fatally. But pn the very threshold of the subject we shall probably be told that to ' contagion' and ' infection' is much of the un- healthy condition of some hospitals attributable, at least so far as concerns the occurrence of zymotic diseases. On the very threshold, therefore, we are obliged to make a digression, in order to discuss the meaning of these two familiar words, and to lay these spectres which have terrified almost all ages and nations. This is the more necessary, because on the exact influence exercised by these two presumed causes of hospital sickness and mortality depends to a great degree the possibility of our introducing efficient hospital attendance and nursing. Unfor- tunately both nurses* and medical men, as well as medical students, have died of zymotic diseases prevailing in hospitals. It Is an all-important question to decide whether the propaga- tion of such diseases is inevitable or preventible. If the former, then the whole question must be considered as to whether hospitals necessarily attended with results so fatal should exist at all. If the latter, then it is our duty to prevent their propagation. The idea of * contagion,' as explaining the spread of disease, appears to have been adopted at a time when, from the neglect of sanitary arrangements, epidemics attacked whole masses of * See Note A, at the end of this «ection. SANITARY CONDITION OF HOSPITALS. 9 people, and when men had ceased to consider that nature had any laws for her guidance. Beginning with the poets and historians, the word finally made its way into medical nomen- clature,* where it has remained ever since, affording to certain classes of minds, chiefly in the southern and less educated parts of Europe, a satisfactory reason for pestilence, and an adequate excuse for non-exertion to prevent its recurrence. And now, what does 'contagion' mean? It implies the communication of disease from person to person by contact. It pre-supposes the existence of certain germs like the sporules of fungi, which can be bottled up and conveyed any distance attached to clothing, to merchandize, especially to woollen stuffs, for which it is supposed to have a particular affection, and to feathers, which of all articles it especially loves — so much so, that, according to quarantine laws, a live goose may be safely introduced from a plague country ; but if it happen to be eaten on the voyage, its feathers cannot be admitted without danger to the entire community. There is no end to the absurdities connected with this doctrine. Suffice it to say, that in the ordinary sense of the word, there is no proof, such as would be admitted in any scientific inquiry, that there is any such thing as ' contagion.' There are two or three diseases in which there is a specific virus, which can be seen, tasted, smelt, and analysed, and which in certain constitutions propagates the original disease by inoculation — such as small-pox, cow-pox, &c. But these are not ' contagions' in the sense supposed.f * See Note B, at the end of this section. t Curiously enough, these directly communicable diseases were excluded from the operation of general quarantine law by the International Quarantine Con- ference of Paris, 1851, which restricted the objects of quarantine to plague, yellow fever, and cholera, while it gave a logical coup de grace to the ' contagion' hypothesis by abolishing the ' suspected bill of health.' TO NOTES ON HOSPITALS. The word 'infection,' which is often confounded with ' contagion,' expresses a fact, and does not involve a hypo- thesis. But just as there is no such thing as ' contagion,' there is no such thing as inevitable 'infection.' Infection acts through the air. Poison the air breathed by individuals, and there is infection. Shut up 150 healthy people in a Black- hole of Calcutta, and in twenty-four hours an infection is produced so intense that it will, in that time, have destroyed nearly the whole of the inmates. Sick people are more sus- ceptible than healthy people ; and if they be shut up without sufficient space and sufficient fresh air, there will be produced not only fever, but erysipelas, pyaemia, and the usual tribe of hospital-generated epidemic diseases. Again, if we have a fever hospital with over-crowded, badly- ventilated wards, we are quite certain to have the air become so infected as to poison the blood not only of the sick, so as to increase their mortality, but also of the medical attendants and nurses, so that they also shall become subjects of fever. It will be seen at a glance, that in every such case and in every such example, the 'infection' is not inevitable, but simply the result of carelessness and ignorance. As soon as this practical view of the subject is admitted and acted upon, we shall cease to hear of hospital contagions. In certain hospitals it has been the custom to set apart wards for what are called 'infectious' diseases, but in reality there ought to be no diseases so considered. With proper sanitary precautions, diseases reputed to be the most ' infec- tious' may be treated in wards among other sick without any danger. Without proper sanitary arrangements, a number of healthy people may be congregated together so as to become subject to the worst horrors of ' infection.' No stronger condemnation of any hospital or ward could SANITARY CO.DITION OF HOSPITALS. II be pronounced than the simple fact that any zymotic disease has originated in it, or that such diseases have attacked other patients than those brought in with them. And there can be no stronger condemnation of any town than the outbreak of fatal epidemics in it. Infection, and incapable management, or bad construction, are, in hospitals as well as in towns, convertible terms. It was necessary to say thus much to show to what hospital diseases are not necessarily due. To the following defects in site, construction, and management, as we think, they are mainly to be attributed. I, The agglomeration of a large number of sick under one roof It is a well-established fact that, other things being equal, the amount of sickness and mortality on different areas bears a ratio to the degree of density of the population. "Why should undue agglomeration of sick be any excep- tion to this law ? Is it not rather to be expected that, the constitutions of sick people being more susceptible than those of healthy people, they should suffer more from this cause ? There is a reason, of course, for everything, and in the present case the reason why agglomeration of a large number of sick under one roof leads to disaster, is the simple fact, that agglomeration argues either stern necessities of another kind, or great ignorance and danger of mismanagement, and, besides all this, it argues unforeseen events, and altogether such a deficiency in the general administrative arrangements, as is sure to be accompanied by want of proper ventilation, want of cleanliness, and other sanitary defects. If anything were wanting in confirmation of this fact, it would be the enormous mortality in the hospitals which contained perhaps the largest number of sick ever at one time under the same roof, viz., those at Scutari. The largest o» I a NOTES ON HOSPITALS. these too famous hospitals had at one time 3500 sick and wounded under its ropf, and it has happened that of Scutari patients two out of every five have died. In the hospital tents of the Crimea, although the sick were almost without shelter, without blankets, without proper food or medicines, the mortality was not above one-half what it was at Scutari ; but these tents had only a few beds in each. Nor was it even so high as this in the small Balaclava General Hospital, which had part of its sick placed in detached wooden huts. While in the well-ventilated detached huts of the Castle Hospital, on the heights above Balaclava, exposed to the sea breeze, at a subsequent period, the mortality among the wounded did not reach three per cent. It is not to fhe comparative healthi- ness of these small hospitals, however, that we appeal, as the only proof of the danger of surface over-crowding. It is to the fact of 80 cases of hospital gangrene having been recorded during one month at Scutari (and many, many more passed unrecorded) J to the fact that, out of 44 secondary amputa- tions of the lower extremities consecutively performed, 36 have died ; and to the cases of fever which broke out in the hospital, not by tens, but by hundreds. But by far the most remarkable illustration of the effects produced on the sick and maimed by agglomeration, is that afforded by the experience of the H6tel Dieu, at the latter end of the last century, and before its reconstruction. I am indebted to M. Husson's " Etude sur les Hopitaux" for a plan (No. i) of the H6tel Dieu, as it then was, showing the relation of all parts of the hospital on the same floor. It will be observed that there was direct atmospheric communi- cation through the entire suite of wards occupied by above 550 jeds on a single floor. The whole hospital contained 1300 beds. But the number of beds by no means represented the IlAmJ^r"!. PARIS. Hotel Dieii before theEire of 1772 . T&Jrt0,erd^t:iig,y J7JUl2lSirca>, Cmdmi'M If. ^ouaxja i^on^nLaii, Gxeeii 4: SANITARY CONDITION OF HOSPITALS. 13 number of sick, who were sometimes placed in the beds as close together as they could lie. In this way, from aooo to 5000 or even 7000 sick were sometimes in the hospital at one time. And one out of every four patients used to die. So late as the year 1788, each of the beds in the Hotel Dieu was intended to hold either two or four sick. There is an extremely curious notice of this subject in M. Husson's " Etude sur les H6pitauXj" given in Note C, at the end of this section. From this it appears that in the i6th century, notwithstanding the use of multiple beds, holding, in 1515, from 8 to I a patients each, the number of sick so far exceeded the bed accommodation that the beds, in 1530, were occupied by relays of patients, and that forms were provided on which the sick whose turn it was to be out of bed could rest in the mean time. The subject is almost too painful to dwell on, especially as we must take it for granted that the administration of the period acted according to the best of its judgment. Only let the warning be taken. And let us not reproduce, even on a small scale, the same structural defects or mismanagement which led to such terrible loss of life. Fortunately for humanity, every patient has long since t acquired the right to his own separate bed. 3. Deficiency of Space per bed, — Wherever cubic space is deficient, ventilation is bad. Cubic space and ventilation will therefore go hand in hand. The law holds good with regard to hospitals, barracks, and all inhabited places. If over-crowding, or its concomitant, bad ventilation, among healthy people, generates disease, it does so to a far greater extent among the sick in hospitals. In civil hospitals the amount of cubic space varies between 600 and aooo cubic feet per bed. In some military hospitals it used to be under 300 ; 14 NOTES ON HOSPITALS. and from 700 to 800 was considered a somewhat extravagant allowance. The old army practice of allotting from 600 to 800 cubic feet per bed in hospitals, under which army hos- pitals proved to be so unhealthy, was over-crowding. At Scutari, at one time, not even half the regulation- space was given ; and the great over-crowding con- sequent thereupon was one element in the disastrous result which followed. Any one in the habit of exa- mining hospitals with different relative amounts of cubic space cannot fail to have been struck with the very different appearance of the sick, and with the different state of the ward atmosphere. Cubic space is an essential element in the question of ventilation. It is impossible, with due regard to warmth, to ventilate a ward in a brick or stone hospital without mechanical means, when the space per bed is less than a certain amount. Crowded wards are, in fact, offen- sive, with all the windows open. In airy positions in the country less cubic space is essential than in closely-built towns. In detached huts or pavilions, especially if they be but one story high, less space is neces- sary than where numbers are massed together in large build- ings, or in more stories than one. Under all circumstances, however, the progress of the cases (in solidly-built hospitals) will betray any curtailment of space much below 1500 cubic feet. In Paris 1700, and in London 3000 and even 2500 cubic feet are now thought advisable. But query. Should there be a hospital at all in any position which requires such an amount of space ? Does not this very fact testify as loudly as it can. This is no fit place for sick ? The master of some large works in London lately men- tioned the following fact : — He was in the habit of sending SANITARY CONDITION OF HOSPITALS. I5 those of his workmen who met with accidents to two difFerent metropolitan hospitals. In one they recovered quickly : in the other they were frequently attacked with erysipelas, and some cases were fatal. On inquiry it appeared that in the former hospital a larger amount of space was allowed than in the latter, which is also so deficient in external ventilation and in construction, that nothing but artificial ventilation could effectively change its atmosphere. It is even more "important to have a sufficient surface-area between the adjoining and the opposite beds. Piling space above the patient is not all that is wanted. In the lofty corridors of Scutari I have seen two long rows of opposite beds with scarcely three feet from foot to foot. Certainly it cannot be thought too much, under any circumstances, to give to each bed a territory to itself of at least eight feet wide by twelve or thirteen feet long. 3. Deficiency of Ventilation. — The want of fresh air may be detected in the appearance of patients sooner than any other want. No care or luxury will compensate indeed for its absence. Unless the air within the ward can be kept as fresh as it \s without, the patients had better be away, ^hat must then be said when, as in some town situations, the air without is not fresh air at all ? Except in a few cases well known to physicians, the danger of admitting fresh air directly is very much exaggerated. Patients in bed are not peculiarly inclined to catch -cold,* and in England, where fuel is cheap, * 'Catching cold' in bed follows the same law as 'catching cold' when up. If the atmosphere is foul, and the lungs and skin cannot therefore relieve the system, then a draught upon the patient may give him cold. But this is the fault of the foul air, not of the fresh. In the wooden hospital huts before Sebastopol, with their pervious walls and open ridge ventilators, in which the patients sometimes said that they ' would get less snow if they were outside,' such a thing as ' catching cold ' was never heard of. The patients were well covered with blankets, and were all the better for the cold air. l6 NOTES ON HOSPITALS. somebody is indeed to blame, if the ward cannot be kept warm enough, and if the patients cannot have" bed-clothing enough, for as much air to be admitted from without as suffices to keep the ward fresh. No artificial ventilation will do this. Although in badly-constructed hospitals, or in countries where fuel is dear, and the winter very cold, artificial ventilation may be necessary, it never can compensate for the want of the open window. The ward is never fresh, and in the best hospitals at Paris, artificially ventilated, it will be found that, till the windows are opened, the air is close. A well-waged controversy has lately been car- ried on upon this very point, in Paris. Eminent autho- rities in England had decried the pavilion system, on the ground that the atmosphere of a certain Paris pavilion hospital was " detestable," not because of the pavilion archi- tecture, but because of its artificial ventilation defying the best pavilion building to ventilate its patients. What is all that luxury of magnificent windows for but to admit fresh air ? To shut up your patients tight in artificially warmed air, is to bake them in a slow oven. Open the Lariboisiere windows, warm it with open fires, drain it properly, and it will be one of the finest hospitals in the world. Natural ventilation, or that by open windows and open fire-places, is the only efficient means for procuring the life- spring of the sick — fresh air. But to obtain this the ward should be at least fifteen to sixteen feet high, and the distance between the opposite windows not more than thirty feet. The amount of fresh air required for ventilation has been hitherto very much underrated, because it has been assumed that the quantity of carbonic acid produced during res- piration was the chief noxious gas to be carried off. The total amount of this gas produced by an adult in SANITARY CONDITION OF HOSPITALS 1'] twenty-four hours is about 40,000 cubic inches, which, in a barrack-room, say, containing sixteen men, would give 370 cubic feet per diem. Allowing eight hours for the night occupation of such a room, when the. doors and windows may be supposed to be shut, the product of carbonic acid would be 133 cubic feet, or about fifteen and , a-half cubic feet per hour. This large quantity, if not speedily carried away, would undoubtedly be injurious to health ; but there are other gaseous poisons produced with the carbonic acid which have still greater power to injure. Every adult exhales by the lungs and skin forty-eight ounces, or three pints of water, in twenty-four hours. Sixteen men in a room would there- fore exhale in eight hours sixteen pints of water, and 123 cubic feet of carbonic acid, into the atmosphere of the room. With the watery vapour there is also exhaled a large quantity of organic matter, ready to enter into the putrefactive con- dition. This is especially the case during the hours of sleep, and as it is a vital law that all excretions are injurious to health if reintroduced into the system, it is easy to understand how the breathing of damp foul air of this kind, and the con- sequent re-introduction of excrementitious matter into the blood through the function of respiration, will tend to produce •disease. If this be so for the well, how much more will it be so for the sick ? — for the sick, the exhalations from whom are always highly morbid and dangerous, as they are one of nature's methods of eliminating noxious matter from the body, in order that it may recover health. Indeed, this is so well acknowledged that it has given rise to all the doctrine of infection — to a just horror of breathing what comes from the sick, even to the morbid fear of entering a cab in which a case of fever or small-pox has been for half an hour. Nay, c l8 NOTES ON HOSPITALS. we have heard a myth of scarlet fever being " carried in a bedside carpet." One would think the inference in people's minds, from these just (and unjust) terrors, would be to remove instantly every hindrance to the foul air being carried off ; but, instead of that, their inference is to shut it up or to run away from the sick. One would think that the first and last idea in construct- ing hospitals would be to contrive such means of ventilation as would be perpetually and instantly carrying off these morbid emanations. One would think that it would be the first thing taught to the attendants to manage such means of -ventilation. Often, however, it is Koi even the last thing taught to them. A much larger mass of air is required to dilute and cany away these emanations than is generally supposed, and the whole art of ventilation resolves itself into applying in any specific case the best method of renewing the air sufficiently without producing draughts, or occasioning excessive varieties in temperature. Trifling varieties are rather beneficial than otherwise in most cases. A cooler atmosphere at night acts like a tonic. 4. 'Deficiency of Light. — What is the proportionate in- fluence of the four defects enumerated in delaying recovery I am not competent to determine. Second only to fresh air, however, I should be inclined to rank light in importance for the sick. Direct sunlight, not only daylight, is necessary for speedy recovery, except, per- haps, in certain ophthalmic and a small number of other cases. Instances could be given, almost endless, where, in dark wards er in wards with a northern aspect, even when thoroughlv warmed, or in wards with borrowed light, even when SANITARY CONDITION OF HOSPITALS. 15 thoroughly ventilated, the sick could not by any means be made speedily to recover. The effect of light on health and disease has been long recognised in the medical profession as may be learned from the writings of Sir Andrew Wylie, Dr. Milne-Edwards, and Mr. Ward. Dark barrack-rooms, and barrack-rooms with northern aspects, will furnish a larger amount of sickness than light and sunny rooms. Among kindred effects of light I may mention, from experience, as quite perceptible in promoting recovery, the being able to see out of a window, instead of looking against a dead wall ; the bright colours of flowers ; the being able to read in bed by the light of a window close to the bed-head. It is generally said that the effect is upon the mind. Perhaps so ; but it is no less so upon the body on that account. All hospital buildings in this climate should be erected so that as great a surface as possible should receive direct sun- light — a rule which has been observed in several of our best hospitals, but, I am sorry to say, passed over in some of those most recently constructed. Window-blinds can always moderate the light of a light ward ; but the gloom of a dark ward is irremediable. The axis of a ward should be as nearly as possible north and south ; the windows on both sides, so that the sun shall shine in (from the time he rises till the time he sets) at one side or the other. There should be a window to at least every two beds, as is the case now in our best hospitals. Some foreign hospitals, in countries where the light is far more intense than in England, give one window to every bed. The window-space should be one-third of the wall-space. The windows should reach from two or three feet of the floor to one foot of the ceiling. The escape of heat may be diminished by plate or double glass. But while we can gene- c 2 20 NOTES ON HOSPITALS. rate warmth, we cannot generate daylight, or the purifying and curative effect of the sun's rays. Note A.— On the Mortality of Hospital Nukses. To show the great importance of this point, I give the following tables, kindly prepared by Dr. Farr, from returns furnished to me with the greatest readiness by fifteen of the metropolitan hospitals. Table I. gives the ages of living and dying among the nursing staff. Table II. gives the mortality fi-ora zymotic diseases, and the comparison between the nurses' mortality and the mortality of the female population of London. Tablk \.— Numbers and Ages of Matrons, Sisters, and Nurses {Living and Dying) in Fifteen London Hospitals. {Names of the hospitals,— St. Marys; St. George's; Westminster; Charing Cross; Middlesex; University College; Royal Free; King's College; St. Bartholomeiv's ; London; Guy's; St. Thomas'; Small Pox; Fever; and Consumption^ LIVING (1858). Matrons, Sisters | and Nurses Matrons and Sisters Nurses ■..-! Total of all 521 n8 403 Total. Ages Speci- fied. Ages mt Spe- cified 391 90 301 130 Specified Ages of the Living, March, 1858. Under 20. 28 25. 3°- 35 45 55 44 40. 93 71 45. 64 5o- 59 39 55. 34 60. 18 65- and up. DYING (1848—57). Total of all Ages. Total. Ages of the Dying. Ages Speci- fied. Ages mt Spe- clfied. Under 10. 20. 25- 30. 35- 40. 4S- 50. SS- 60. 65. 70 and up. Matrons, Sisters | and Nurses | * Matrons and Sisters (so dis- tinguished) Nurses 79 79 ... ... ... 4 II 8 18 8 10 7 6 2 5 19 60 >9 60 ... ... ... 4 2 9 I 7 4 14 8 3 7 S I 5 I I 5 In the returns of deaths, four Hospitals do not distinguish the Matrons and Sisters from the Nurses, and in this Table they are included with the Nurses. SANITARY CONDITION OF HOSPITALS. 21 Table II. — Tails of the Mortality of Matrons, Sisters, and Nurses, at different Ages, in Fifteen London Hospitals, compared with the Mortality cf the Female Population of London. Ages. Matrons, Sisters, and Nurses {I848-I867)- Female Population of London. : Annual Rate of Mortality to looo living at the respective Ages. By all returned Diseaies. By Zymotic Diseases. By Zymotic Diseases (1848-57)- By all returned . Diseases (1848-54). 25 to 35 35 — 45 45 — 55 55 — 6s 15-89 15.80 17.80 46-36 9-53 10.94 11.87 14.26 2.19 2-73 3-'7 4.94 9.92 14-65 20-36 36.02 The fatal zymotic diseases included in this table are fever and cholera, and it will be seen that these two diseases occasioned nearly 50 per cent, of the total mortality among the nursing staff as against 16 per cent, among the London female population. This single fact is quite enough to prove the very great importance of hospital hygiene. The calculated total mortality is also very much higher among the nurses, even if we assume that the deaths in the returns are all deaths due to hospital nursing, which is very doubtful. If we assume that the non-zymotic mortality among nurses ought to be the same as it is among the female population, and if to this we add the zymotic deaths among nurses, we find the total mortality among nurses to exceed the total mortality among the female population of the metropolis by about 40 per cent. Thelossofa well-trained nurse by preventible disease is a greater loss than is that of a good soldier from the same cause. Money cannot replace either, but a good nurse is more difficult to find than a good soldier. The data from which these tables have been deduced are imperfect, and it would be very desirable if in future all hospitals would keep a register of nurses. The following form would be one well calculated to give the required information. The subject is of additional importance in connexion with the proper working of a Superannuation Fund for nurses : — Form of Register of Sisters and Nurses in Hospital. Commenced from fanuary i, 1859. No. I 2 Name. Age when first Appointed. Date. State of Health on Leaving the Service : and, if 111, the Disease, its Duration, and pro- bable Cause. Date of Death, Cause of Death, and Fatal Disease. Of Appoint- ment. Dismisal, Resignation, or Super- annuation. Jane | Jones. > (Sister.) ) Mary ) Evans. > (Nurse.) 25 29 June 6, 1858. April 2, 1848. Resigned August 6, 1858. In good Health. July 7, 1854, Typhoid Fever, after 11 days' illness. 22 NOTES ON HOSPITALS. Note B. — On the History op the Doctrine of Contagion. The history of the doctrine of ' Contagion ' is giren by Dr. Adams in his translation of the works of Paulus jEgineta, vol. i, p. 284 — (Syden- ham Society). He says, in his comment, "the earlier ancient authors appear to have entertained no suspicions of contagion as a cause of febrile or of other complaints. " The works of the fathers of history and of medicine have likewise been ransacked in vain for any traces of the doctrine of contagion." Thucydides, and after him several of the Latin poets, describe the plague of Athens, which appears to have been a form of Dysentery, as communicable from person to person. The later Greek historians contain allusions to tlie infectious nature of certain diseases j but Procopius, though cognizant of one of the greatest pestilences, on record, was a non-conta- gionist. Virgil's allusions to contagious diseases among cattle will be found in Eel. I. Georg. III., 464. Aretaeus appears to be the first medical author who believed in con- tagion. Galen seems to have held the doctrine of infection. Of the later Greek and Arabian medical writers, some, were contagionists, and others make no allusion to the subject. Dr. Adams states, in regard to plague, a disease which, in later times, has been considered as the very type of all "contagious" pestilences, "The result of our investigations into the opinions of the ancients on this subject leads us to the conchasion that all, or at least the most intelligent of the medical authorities, held that the plague was communicated not by any specific virus, but in consequence of the atmo- sphere around the sick being contaminated by putrid ejffluvia." The obvious practical result of this view of infection is that abundance of pure air will prevent infection. All my own hospital experience con- firms this conclusion. If infection exists, it is preventible. If it exists, it is the result of carelessness, or of ignorance. " Contagion," as a doctrine on which distinct practical proceedings have been taken, appears to be of very modern invention ; and it has been highly injurious to civilization and humanity, from the loss of life which has from time to time followed from the practices which it inculcates, and from tlie immense tax which it has entailed upon commerce. Note C. "In 1788" (in the H6tel Dieu), "each bed was for two or for four sick." " Much has been said about beds in two shelves, one over the other in v\ liich up to eight and even twelve sick were said to have lain. No- SANITARY CONDITION OF HOSPITALS. 23 thing in the Archives justifies such an assertion. This tradition, derived from M. da Pastoret, doubtless originated in a passage of the Report of the Commissioners of the Academie des Sciences (1786, p. 19), where it is said that in 1752 the sick were four and six in the same bed, and that some were lying on the testers of the beds, * according to the testimony of a physician of the H&tel Dieu, who witnessed it.' This testimony is the more curious, because the ' Memoire of the Physicians of the Hotel Dieu,' presented in 1756, makes no allusion to this circumstance, although the form of the beds takes up a very large share of the Report. " That, at times of extraordinary over-crowding, some of the sick should have been placed even on the wooden roof of the bed, as in 1752, when the H6tel Dieu had to receive more than 4000 sick, this fact would not be very surprising; but this was only a momentary expedient, and can only have taken place, if it did take place, from the period of the 17th century; for before that period the beds of the H&tel Dieu had no testers. It was then in beds that the sick lay, or rather were heaped up. In iji_5, there were only 303 beds at the H6tel Dieu, 'in each of which, from want of space, are generally seen eight, ten, and twelve poor in one bed, so crowded that it is a great pity to see them.' " — (Letters Patent of Francis I., ijij.) — {Archives of the Assistance Pullique.) " 100 beds were placed in the new ward built by Cardinal Duprat in 1530. The following is an extract of the bargain made for the construc- tion of these beds. " Jehan Morel, carpenter, living at Paris, has bargained with the Governors to make proper beds to furnish the new ward which the Legate is building to adjoin Lostel-Dieu, i.e., up to the number of 100 beds, made as follows : — Each bed 6 feet long by 4 feet wide, the back 4 feet high, the division (or partition) the same height, all in plain panel, and all framed and open below ; in the front of which beds two hori- . zontal panels, on the pillow of which beds there shall be a board 6 inches in breadth or thereabouts, for the service of the poor ; under each of which beds there shall be a little form (bench) of the length of said beds, to be taken out to rest the said poor." (Extract from the Registers, 1^33.) The sick, being too many to lie all together in the sanie bed, necessarily relieved each other. And this little bench was no doubt intended to serve as a seat for those who were waiting their turn to lie down. " In the 1 7th century, the beds of the H6tel Dieu were covered with a tester standing upon four massive feet, with curtains which, when drawn, completely shut in the bed. "In 1781, Louis XVI. forbade more than two sick being placed in the same bed, and these were to be separated by a compartment or 24 NOTES ON HOSPITALS. division. This did not satisfy the physicians of the H6tel Dieu, and it was decided, " I. Tiiat all the beds, single and double, should be 6i feet high. 2. That all beds, single and double, should be 6 feet long over all. ' 3. That all single beds should be uniformly 3 feet wide over all. " 4. That all double beds should be alike 5 feet 2 inches wide over all. " 5. That the testers of all the said beds should have a strong cross- , beam, for a cord to be solidly fastened, by which the sick can raise them- selves." — (Delilerations, etc., 1781.) " In 1 79 1, the number of beds was still far from enough, as states a Report of the Commission of Hospitals: — 'In April, 1791, there were only 1650 to 1700 beds, of which j8o to J90 were large bedsj counting these for two, as well as those with divisions, the 1 700 beds gave about room for 2300 sick; the sick who had a bed a-piece being only 1700 j 1 100 others lay 2, 3, and even more in the large beds.' " (Report of the measures taken to accommodate at the H6tel Dieu, during the winter of 179^3 2500 sick, of whom 2000 in little beds, one in each bed, and ijoo in large beds, only two together. — -Archives of the Assistance Puhlique.) 25 II. DEFECTS IN EXISTING HOSPITAL PLANS AND CONSTRUCTION. Considering, then, that the conditions essential to the health of hospitals are principally these — I. Fresh Air. 3. Light. 3. Ample Space. 4. Sub- division of Sick into Separate Buildings or Pavilions — let us examine the causes in the usual ward construction which prevent us from obtaining these and other necessary condi- tions. The principal causes are as follow, viz. : — 1. Selection of Bad Sites and Bad Local Climates for Hospitals. 2. Construction of Hospitals on such a plan as to pre- vent Free Circulation of External Air, 3. Defects in Ward Construction injurious to Ventilation including : — Defective Height of Wards ; excessive Width of Wards between the Opposite Windows ; arranging the Beds along the Dead Walls ; having more than two Rows of Beds between the opposite Windows ; having Windows only on one Side, or having a closed Corridor connecting the Wards. 4 . Defective Means of Natural Ventilation and Warming. 5. Defects of Drainage, Waterclosets, Sinks, &c. 6. Using Absorbent Materials for Walls and Ceilings, and Washing Floors of Hospitals. 7. Defective Hospital Kitchens. a6 NOTES ON HOSPITALS. 8. Defective Hospital Laundries. 9. Defective Accommodation for Nursing and Discipline. 10. Defective Ward Furniture. I. Selection of Bad Sites and Bad Local Climates for Hos- pitals. — As the object to be attained in hospital construction is to have pure dry air for the sick, it will be evident that this condition cannot be fulfilled if a damp climate be selected. It is a well-known fact, e.g., that in the more damp localities of the south of England, certain classes of sick and of invalids linger, and do not recover their health. Again, retentive clay- subsoils keep the air over entire districts of the country always more or less damp. And soils of this character should not be selected as sites for hospitals. Self-draining, gravelly, or sandy subsoils are best. River banks, estuary shores, valleys, marshy or muddy ground, ought to be avoided. It may seem superfluous to state that a hospital should not be built over an old graveyard, or on other ground charged with organic matter, and yet this has been recently done. Although hospitals are intended for the recovery of health, people are very apt to forget this, and to be guided in the selection of sites by other considerations — such as cheapness, con- venience, and the like ; whereas, the professed object in view being to secure the recovery of the sick in the shortest time, and to obtain the smallest mortality, that object should be distinctly kept in view as one which must take precedence of all others. Similar remarks are applicable to the erection of hospitals in large cities and towns. If the recovery of the sick simply is to be the object of hospitals, they will not be built among dense unhealthy populations. If medical schools are the object, surely it is more instructive for students to watch DEFECTS IN EXISTING HOSPITAL PLANS. 27 the recovery fronij rather than the lingering in, sickness. Twice the number of cases would be brought under their notice in a hospital in which the sick recovered in half the time necessary in another. According to all analogy, the duration of cases, the chances against complete recovery, and, as has been shown, the rate of mortality, must be greater in town than in country hospitals. Land in towns is too expensive for hospitals to be so built as to secure the conditions of ventilation and of light, and of spreading the inmates over a large surface- area-r-conditions now known to be essential to speedy recovery^nstead of piling them up three or four stories high, in regions contaminated with coal smoke and nuisances. In country towns, and even in the larger manufacturing and commercial towns, there is no great difficulty in building hos- pitals in the purer atmosphere of the open country or suburbs. The distance from any part of the town likely to send its sick or maimed can never be very great ; and gratuitous medical and surgical service can be rendered without much inconve- nience by the officers of the hospital. The distance, also, to be traversed by friends on visiting days is not so great as to cause undue loss of time. No legitimate excuse can therefore be urged for constructing hospitals amid the smoke, foul air, and bustle of the densely-peopled seats of commerce and manufactures. It is otherwise with such a place as London. Here the distances are so great, and the outward spread of the population so rapid, that the question of hospital position assumes quite another aspect to what it does in provincial towns. The problem has been, besides, complicated by the nature of the hospital Foundations, which have been created at different periods of time, and under very different conditions 28 NOTES ON HOSPITALS. of population. The various metropolitan hospitals have been erected, and their positions determined on no general system of medical or surgical relief for the metropolis, and without any foresight, had it even been possible to exercise such, as to what would finally be the position of each hospital with reference to the population whose sick it was intended to receive. The practical result has been, that several of the largest and most important hospital establishments are concentrated within a comparatively narrow area of the metropolitan district. They receive their sick from a certain radius in every direction, extending often into and even beyond the district which would be allotted to other hospitals under a general system of hospital relief. And they receive their patients from distances of two, three, five, or more miles, or even from the country round. To illustrate this question as regards our metropolitan hospitals, I give a sketch-plan of London, on which are shown the distances of all the larger hospitals in direct lines from one central point, St. Paul's. Four hospitals only out of twenty-one are nearer than a mile. All the others are at distances varying from a mile to nearly five miles. The map shows that there are large areas of the metropolis which have to send their sick even greater distances than the average required by the French system, presently to be noticed ; and that, practically, the question of distance has been Tittle understood in controversies which have arisen on this subject. One result which follows from this arrangement of the Lon- don hospitals is, that a considerable proportion of the sick has been concentrated towards the heart of the metropolis, not un- frequently among dense masses of population and in unhealthy DEFECTS IN EXISTING HOSPITAL PLANS. 29 localities. It may be safely stated that, if all the existing general hospitals had been originally distributed at suitable distances from the middle of the metropolis, they would all have been placed as conveniently for the sick as they now are, and in much purer air. The question of moving existing hos- pitals has been mooted at different times, and has recently assumed a practical shape as regards one of them, St. Thomas's. A long and warm controversy has arisen on the subject, in which nearly every element incident to such questions has been discussed, with the ultimate probability that the future site of the hospital will be determined by no element incident to the question, but by circumstances only. It is worth while to consider briefly the main points which have been mooted in this important controversy. The elements which ought to determine the position of a hospital are the following : — First, and before all others, purity of the atmosphere. Second, the possibility of conveying the sick and maimed to it. Third, accessibility for medical officers, and for the friends of the sick. Fourth, convenient position for a medical school, if there be one. All of these elements are of importance, every one in its place. It is obviously of no use to build a hospital in the best air in the world, if neither patients nor medical officers can get to it. It is only in applying common sense to such a question, and by always giving a preponderance to the condition of highest importance — namely, pure air, when the other condi- tions can be at the same time reasonably obtained, that the best will be done for the sick. There is no doubt that suburban sites, nearest to the popu- 30 NOTES ON HOSPITALS. lation likely to apply for relief, afford the best solution the case admits of with the ordinary means of corLveyance. This is to a certain extent the system in Paris. Several of its best hospitals are in or close to the suburbs, and the sick are ad- mitted under a rule which requires all applicants to appear before the medical officers at a central bureau, whence they are sent to the hospitals where there are vacant beds. Acci- dents and other cases of urgency may, however, be admitted at once into any hospital on certificate of one of the hospital physicians or surgeons. If will be seen that under this sys- tem the patient has to leave his home and present himself at the bureau, and from the bureau he has to go to the hospital. Some of the establishments are at a considerable distance from the bureau. To illustrate the working of this system, I give a sketch- plan of Paris, showing the position of the Bureau of Admis- sion, close to the Hotel Dieu, the distance in yards (in a direct line) from this Bureau to each of the civil hospitals, and the number of beds they contain. It will be seen that four hospitals only are within a mile of the Bureau, and that the remaining twelve are at distances of from a mile and a half to two miles and a half in straight lines, to which probably a fourth should be added for bendings of streets, and from a third to a half for the average distance between the houses of the patients and the Bureau. There appears to be no practical difficulty attending this, so far at least as the distance is concerned ; but, as already stated, urgent cases are admitted at any hospital at once on the certificate of a medical officer. Of course the distances are all much less in Paris than they would be in London with a similar organization, and yet there are several special hospitals in London-^i?.^., DEFECTS IN EXISTING HOSPITAL PLANS. 31 those for consumption, small-pox, and fever — which are at a far greater distance from some of the districts yielding them cases., than are the distances in Paris. All are agreed that fresh country air is better for the sick than impure town air, and hence the whole question narrows itself within the compass of one of the conditions enumerated above — namely, accessibility. Any site which can be ob- tained, with pure air and sufficiently convenient means of access, will fulfil the required conditions. It has been pro- posed to extend the distance by using railway conveyance. To this there can be no possible objection, if it is necessary. A few years ago no one could have predicated that a consider- able portion of the metropolitan dead would be conveyed long distances by railway for interment, without inconvenience to friends, or injury to their feelings, and yet it has been done. The truth is, however, that in regard to hospital sites, no precise general rule can be laid down. If a new hospital Is wanted, the true way to deal with the question Is to determine whereabouts It must be ; next, to seek out all the sites which there Is a possibility of obtaining ; then to have each examined by competent persons with refe- rence to the elements already laid down, and to select the best. This has been done in selecting recent hospital sites, and It has answered well enough in practice. The evil arising out of a contrary procedure is, that parties are apt to be formed, especially among persons who are not sufficiently acquainted with the subject : one party advocating one site, another party another, and so the cause which all have at heart is injured. If we could suppose such a thing as all the metropolitan hospitals being removed to the furthest accessible healthy points from their present positions, there cannot be a doubt 32 NOTES ON HOSPITALS, that the sick would gain immensely by the change, except accidents or cases of severe and sudden illness. For these cases special wards would have to be provided at the points where they wquld be most required. There is no reason why all such cases should not be treated in this way, and sent to the suburban hospitals as soon as they were able to bear the journey. The hospital receiving-rooms and dis- pensaries for out-patients might be attached to these accident wards. Patients from the country would, of all others, benefit most by such a change, for they would be spared the addi- tional risk of coming from the fresh air of their homes into the foul air of the metropolis — a change attended with more or less additional risk to them. Even medical education would benefit by such a change. The quiet and studious habits of a college would be substi- tuted for the desultory lecture-hunting and hospital-walking of London. Education might thus take the place of simple instruction. 2. Construction of Hospitals on such a Plan as to prevent Free Circulation of External Air. — To build a hospital with one closed court with high walls, or what is worse, with two closed courts, is to stagnate the air even before it reaches the wards. This defect is one of the most serious that can be com- mitted in hospital architecture ; and it exists, nevertheless, in some form or other in nearly all the older hospitals, and in many even of recent construction* The air outside the hospital cannot be maintained in a state sufiiciently pure to be used for internal ventilation, unless there be entire freedom of movement. Anything which in- terferes with this is injurious. Neighbouring high walls. DEFECTS IN EXISTING HOSPITAL PLANS. 33 smoking chimneys, trees, high ground, are all. more or less hurtful ; but worse than all is bad construction of the hospital itself. Examples of bad plan and construction are common enough. One of these (Fig. i) is a block plan of the H6pital Necker at Paris. Fig. I. Block Plan- oi ! I n Paris. A. Wards. B. Chapel. c. Kitchen. D. Pharmacy. E. Offices and " Sisters.' F. Dwellings. G. Gallery. In this case, it is true, the size of the inner court is so con- siderable that, to a certain extent, it obviates the objection But where this principle of construction is applied in smaller 34 NOTES ON HOSPITALS. buildings, the evil of it becomes obvious. Fig. 2 represents another form of the same defective plan. None of these arrangements should ever be used for hospitals. Fig. 2. Block Plan of the Royal Free Hospital, London. All closed corners stagnate the air, more or less, even where the building forms but three sides of a square, as in Fig. 3, unless the wings are so short that they can hardly be called wings. Fig. 3. Block Plan of the London Hospital, London. The only safe plan, with this form of construction, is to leave the corners entirely open, as in Vincennes plan, where they are connected only by an arcade on the ground floor. (Plan No. 5.) Even in the true separate pavilion structure, unless the distance between the pavilions be double the height of the walls, the ventilation and light are seriously interfered with. DEFECTS IN EXISTING HOSPITAL PLANS. ^^ For this, among other reasons, two stories are better than three ; and one is preferable to two, provided it be erected upon an arched basement. To build a hospital in the midst of a crowded neighbour- hood of narrow streets and high houses, is to ensure a stag- nation of the air without, which no ventilation within, no cubic space, however ample, will be able to remedy. I shall return to this subject in discussing the question of what should be the relative position of different parts of a hospital. 3. Defects in Ward Construction injurious to Ventilation. — One of the most common causes of unhealthiness in hospitals is defective construction and arrangement of the ward-space of such a nature as to lead to difficulty of ventilation, or want of light. The expression, " a good ward," comprehends some- thing quite diiferent from mere appearance. No ward is in any sense a good ward in which the sick are not at all times supplied with pure air, light, and a due temperature. These are the results to be obtained from hospital architecture, and not external design or appearance. Again, no one of these ele- ments need be sacrificed in seeking to obtain another. Any one who feels himself in a difficulty in realizing all three may rest satisfied that hospital architecture is not his vocation. A few of the more common errors may be here introduced as illus- trative of this part of the subject : — Defective Height of Wards. — It is not possible to ventilate sufficiently a large ward of ten or twelve feet high. And again, it is not possible to ventilate a ward where there is a great height above the windows. A ward of thirty beds can be well ventilated with a height of about fifteen or sixteen feet, provided the windows reach to within one foot of the ceiling. Otherwise, the top of the ward becomes a reservoir D 2 36 NOTES ON HOSPITALS. for foul air. But a ward may be too high to be ventilated with sufficient ease. Good ventilation consists in emptying the hospital of foul air as speedily as possible'. Why have a greater height of ward than will allow the windows and ven- tilating arrangements to be easily managed ? It is more than probable that the decrease of facility for opening windows would lead to negligence, and so to the fine lofty ward be- coniing a reservoir of foul air. Too Great Width of Wards between the Opposite Win- dows. — It does not appear as if the air could be tho- roughly changed, if a distance of more than thirty feet inter- venes between the opposite windows : if, in other words, the ward is more than thirty feet wide. This is the true starting- point from which to determine the size of your ward, and the number of beds you will have in it. If you make your length too great in proportion to this width, your ward becomes a tunnel — a form fatal to good ventilation. This was the case with the great corridor wards. at Scutari. If, on the other hand, you make your wards too short in proportion to this width, you multiply corners in a greater ratio than you multiply sick. And direct experiment has shown that the movement of the air in the centre of a ward is three or four times as great as it is at the corners. The movement of the air in a hospital ward should always be slightly perceptible over the face and hands, and yet there should be no draughts. Arranging the Beds along the Dead Walls. — This de- prives the patient of the amount of light and air necessary to his recovery, and has, besides, the disadvantage that when the windows are opened the effluvia must blow over all the inter- vening beds before escaping. This arrangement is to be seen at Portsmouth Military Hospital (Fig. 4), Chatham Garrison GROUND PLAN of the SOUTH EASTERN WINC OF THE ROYAL VICTORIA HOSPITAL. NETLEY . SHOVflNOONE SIDE of EACH WARD COVERED by an EXTERNAL CORRIDOR. PlajdNon. o 10 Ji iitiWi I : M* e Scale SOFeet to OnoBuk ■i&)As^ lonioTi LciienLaii, &iee.Ti i C° DEFECTS IN EXISTING HOSPITAL PLANS. %1 Hospital, in the new part of the Edinburgh Infirmary, and at Netley Hospital. (Plan 2.) Fig. 4. Ward Construction — Portsmouth Military Hospital. Another striking example of the same defect Is given in Fig. 5, which formerly existed in the Accouchement Hos- pital at Paris. Fig. 5. Hfipital de la Clinique, Paris. (Former arrangement of Lying-in Wards.) Unfortunately, we have not to go abroad for existing ex- amples of this construction. The following plan (fig. 6), which represents the arrangement of a floor of Manchester Royal Infirmary, will tell its own tale. It will be seen that in all these examples free renewal of the air is impossible, except for the beds close to the windows. It is needless to point out that plans of this kind should be 38 notes on hospitals. Fig. 6. e • « o • • Manchester Royal Infirmary. 1. Fever wards (female.) 2. Sm-gical do. do. 3. Medical do. (male.) 4. Medical wards (female.) 5. Nurses' rooms. 6. Do. kitchens. abandoned in future. Another form of this arrangement is shown in Fig. 7, part of the old Marine Hospital at Woolwich. In this example there is no provision for Fig. 7. Wards of old Marine Hospital, Woolwich. A A. Wards. b. Interior passage. DEFECTS IN EXISTING HOSPITAL PLANS. 39 ventilation worthy of the name, and the wards are so arranged that the sick must of necessity be suppHed with common foul air. Having more than Two Rows of Beds between the Windows. — In the double wards, or wards back to back, of the new part of Guy's, of King's College, and of the Fever Hospital, this arrangement is seen. It is objectionable on every account. These double wards are from twelve to nearly twenty feet wider than they ought to be between the opposite windows for thorough ventilation. The partition down the middle with apertures makes matters rather worse ; complaint has been made that it beats down the draught on the heads of the inner rows of patients. It also prevents the head nurse from having that view of her whole ward at once, which she ought to have for proper care of it. The fol- lowing illustration. Fig. 8, from King's College Hospital, will show how these defects are produced. Fig. 8. Ward plan of King's College Hospital, London. Having Windows only on one Side, or having a closed Corridor connecting the Wards. — As it is a necessity of hospital 40 NOTES ON HOSPITALS. construction that every ward must have direct communi- cation with the external air by means of a sufficient number of windows on its opposite sides, and that every ward must have its own ventilation distinct and separate from that of every other ward ; it follows that to have a dead wall on one side, or to cover one of the sides by a corridor, is directly to inter- fere with the natural ventilation of the ward. To join all the ward doors and windows on one side by means of a cor- ridor is much more objectionable than even to have a dead wall, because the foul air of all the wards must neces- sarily pass into the corridor, and from the corridor into the wards indiscriminately. The whole hospital becomes in this way a complicated ward ; and hence, without extraordinary precautions, such as are not usually nor likely to be bestowed on such matters, these corridors are the certain means of en- gendering a hospital atmosphere. A similar objection exists against any form of hospital construction in which a door connects any two wards. If any one had wished to see the corridor plan in all its horrors, Scutari would have shown them to him on a colossal scale. But the evils connected with corridors may be seen on a smaller scale in some part of almost every hospital in London. Netley also has its cor- ridor. {Vide Plan No. 2.) I give another illustration. Fig. 9, from the Hopital St. Antoine, at Paris, in which it will be seen that the corridor, as well as the wards, is occupied by sick. This building was not, however, constructed for a hospital. The arrangement is obviously a bad one. Here is too another quite recent illustration. Fig. 10, of a grave structural defect in the new part of Glasgow In- firmary. The intention in this instance was evidently to DEFECTS IN EXISTING HOSPITAL PLANS. 41 ill! J K ISl Kl ISI 12 ISl ISl t.t.t; .jS _g iL !» fi^ oT 2:5 ^«* Q^^J /^^ s w's "T^ t » S a «3 a i ll •S bo p^; bo •^ ■^ 6 >^p ^=1 M U en ' ' fi h f3 ?. Xl Si m ^ S 2 m HH Ph < M O 42 NOTES ON HOSPITALS. adopt sound principles of construction, but it will be ob- served that at one end of the ward there are three beds, and at the other four beds between the opposite windows. The small wards, intended for the most serious cases, are placed in the vicinity of the sinks, baths, and water-closet, and have a direct communication with the ventilation of the larger wards. These arrangements are to be regretted, on account of the example. All of these defects in plan and construction of wards have a very serious influence on the question of defective ventilation and warming, which we will now discuss. 4. Defective Means of Ventilation and Warming. — When the question of ventilation first assumed a practical shape in this country, it was supposed that 600 cubic feet of air per hour were sufficient for a healthy adult, in a room where a number of people are congregated together. Subsequent ex- perience, however, has shown that this is by no means enough. As much as 1000 cubic feet have been found insufficient to keep the air free from closeness and smell ; and it is highly probable that the actual quantity required will ultimately be found to be at least 1500 cubic feet per hour per man. In sick wards we have more positive experience as to the quantity of air required to keep them sweet and healthy. It was found in a certain Parisian hospital, in which the ventilating arrangements were deficient, that pysemia and hospital gangrene had appeared among the patients. These diseases are said to have disappeared, on the introduction of ventilating arrangements, whereby 3500 cubic feet of air per bed per hour were supplied to the wards. Notwithstanding this large quantity, however, the ward-atmosphere was found not to be sufficiently pure. In other wards the quantity of air was increased to as much as 4000 or 5000 cubic feet DEFECTS IN EXISTING HOSPITAL PLANS. 43 per bed per hour. But again we say, do not trust to artificial means ; without natural ventilation the air will never h^ fresh. I have, in a preceding page, stated generally the importance, of the method of ventilation and warming employed, to the state of the ward-atmosphere. I will only repeat here, that if our object be to obtain a wholesome state of the air round the sick, we must have no air except what comes direct by win- dows or ventilating openings from the outer atmosphere, and we must have no other warming apparatus than the open fireplace. It is the safest warmer and ventilator. Air cooked by metal surfaces is especially to be avoided. It seems likely that we shall soon be enabled to have open fire- places in the middle of wards, the draught being carried under the floor. It is obvious that fireplaces in the side walls are in the wrong place. There is great loss and unequal dis- tribution of heat in consequence. But in order to obtain the benefit of a central fireplace, it is certainly not necessary to carry the chimney stalks up in the wards as has been done at Glasgow and in one Guards' hospital in London, making it look more like an Egyptian temple than a hospital. 5. Defects in Drainage, Water Closets, Sinks, ^c Hospital Sewers may become cesspools of the most dangerous description, if improperly made and placed. In one hospital I knew, if the wind changed so as to blow up the open mouths of the sewers, such change was frequently marked by outbreaks of fever among the patients, and by relapses among the con- valescents from fever. Where there are no means for externally ventilating the sewers, no traps, no sufficient water supply, no means for cleansing or flushing them, and where the bottoms are rough and uneven, such occurrences cannot fail to take place. The emanations from the deposits in the sewers are in such cases blown back through the pipe-drains into the water- 44 NOTES ON HOSPITALS, closets and sinks, and thence into the wards. Where sewers pass close to or under occupied rooms, the walls or covers being defective, exhalations will infallibly escape into those rooms. There are hospitals where such things exist at the present time. There can be no safety for the sick if any but water- *closets of the best construction are used, as also if they are not built externally to the main building, and cut off by a lobby, separately lighted and ventilated by cross windows, from the ward. The same thing may be said of sinks. I have known outbreaks of fever even among the healthy from an ill-constructed and ill-placed sink iti this country. The smell of latrines, which are not waterclosets, as used in French hospitals, is quite perceptible at the end of the ward nearest to them, and becomes, indeed, a very serious taint to the atmosphere, which might, with proper water- closets, be secured so fresh by their admirable plan of building in pavilions. The whole drainage should be carefully studied and pro- vided for, otherwise one may build a magnificent hospital, with abundant ventilation, and yet be distilling foul air from sewers into every ward of it. Not very long ago five fatal cases of fever occurred in rapid succession among the nurses in one of our civil hos- pitals, which were traced to a defective drain. 6. Using Absorbent Materials for Floors, Walls, and Ceilings of Hospitals, and Washing Floors. — The amount of organic matter given off by respiration and in other ways from the sick is such that the floors, walls, and ceilings of hospital wards — if not of impervious materials — become dangerous absorbents. The boards are in time saturated with organic matter DEFECTS IN EXISTING HOSPITAL PLANS. 45 from this cause, as well as from accidental filth, and want of due attention to cleansing, and only require moisture to give off noxious effluvia. When the floors are being washed, the smell of something quite other than soap and water is perfectly perceptible, and there cannot be a doubt that washing dirty floors is one cause of erysipelas, &c., in some hospitals. Common plaster is the material most usually employed for ward walls and ceilings. The objection to it is its being porous, and its faculty of absorbing emanations from the sick. When the surface is recently finished, plaster thus tends to purify the air of a sick ward. But, after a time, it becomes saturated with impurity. Occasionally a minute vegetation appears upon it, which can be scraped off and examined by the microscope, and also chemically. When ward walls and ceilings become fouled in this way, hospital diseases are very apt to invade the wards. It has happened that workmen employed in scraping and cleansing such wards have themselves suffered from severe illness. The usual remedy is frequent lime-washing with periodical scraping. Caustic lime decomposes the organic matter or covers it with a thin film for the time. The pro- cess is objectionable, because to be of use it requires to be frequently repeated, and the wards to be evacuated during the cleansing and drying. The latter part of the process requires to be very complete, before the ward is re-occupied, to prevent accidents to the sick. Plastered walls when not cleansed sufficiently, have led to increased impurity of the ward-air, and to hospital diseases. 7. Defective Hospital Kitchens. — Two facts every careful observer can establish from experience. I. The necessity for variety in food, as an essential ele- 46 NOTES ON HOSPITALS. ment of health, owing to the number of materials required to restore and preserve the human frame. In sickness it is still more important, because, the frame being in a morbid state, it is scarcely possible to prescribe beforehand with certainty what it will be able to digest and assimilate. The so-called ' fancies' of disease are in many cases valuable indications. a. The importance of cooking so as to secure the greatest digestibility and the greatest economy in nutritive value of food. Feeling the importance of this element in recovery, I have often been surprised by the primitive kitchens of some of our civil hospitals, with which little variety of cooking is possible. It shows how little diet and cooking are yet thought of as sanitary and curative agents. There still exists a confusion of ideas about 'spoiling' the sick, about ' too much indulgence' of the patients, and even yet compara- tively little is practically known as to what is, and what is not, essential for restoration to health. A hospital cook, instead of being the best obtainable cook, is sometimes put to the work because she is fit for little or nothing else, and her utensils are often as faulty as her performances. I have often seen the sick unable to eat the messes prepared for them in the name of diets, not so much because they were bad in quality, as because the cook had no clear idea of the class of stomachs for which he or she had to provide. It is singular that, while so much care is taken to provide good medicine properly made up, so little care is bestowed on the cooking of that which is of more importance than most medicines. The nurse or doctor only finds out perhaps next day, that the patient has lost appetite, or been sick, or has had a relapse, and nobody suspects that the men or women in the kitchen had occasioned it. DEFECTS IN EXISTING HOSPITAL PLANS. 47 Steps have been taken to educate hospital cooks for the army, so that in this department of the public service there will be less chance of the sick suiFering, as I have seen them suiFer, than there was formerly. But the generality of civil hospital kitchens have little to boast of; and defective hospital kitchens and bad cooking may be classed as among the causes of hospital unhealthiness. Besides this, the kitchen is not unfrequently situated in objectionable proximity to the wards : at the foot of a stair- case leading to them, if not under them. This should not be. In all, except the smallest class of hospitals for a few beds only, the kitchen should be detached, to keep the damp and fumes of cooking away from the sick. 8. Defective Hospital Laundries. — Not very long ago there was scarcely an army hospital which had such a thing as a laundry. The bedding was washed by contract. And the body linen in the smaller hospitals was generally washed, if such a term ought to be used, in a small wash-house, or lean-to shed, with or without a boiler, and without any means for drying, getting-up, or airing linen. The linen was taken out of the damp wash-house, possibly into the damp air, and there hung up for a longer or a shorter time ; and if the ' orderly ' were careful of his patients, he would complete the process by drying the linen, before it was put on, in front of the ward fire. In provincial hospitals, even of our largest cities, there is sometimes a too infrequent change of bed linen ; and fresh patients have been put into the last patients' sheets. The Barrack and Hospital Improvement Commission has led to great changes, still in progress, in this important part of hospital administration, and some of the best laundries in existence are now to be found attached to army hospitals 48 NOTES ON HOSPITALS, of the larger class. The importance of a good laundry to a hospital is by no means sufficiently appreciated. Neither are its dangers, if improperly placed. It would not be difficult to point to hospitals in which all the linen is washed within the hospital boundary, close under the ward windows, or in the basement of the hospital itself. I have even seen recent hospital plans in which it was proposed to place the laundry in this position, or even under the sick wards. A moment's consideration of what is likely to be the result to the atmo- sphere, and consequently to the sick of a hospital, by impregnating it with the steam of linen, fouled by the excre- tions of a number of sick people, would surely be sufficient to put a stop to such errors in construction ! May not some of the anomalous outbreaks of disease in hospitals be traced to this among other causes ? A great deal has been said about the communication of ' infectious' disease, both in civil and military hospitals, from patients' linen to washerwomen. The usual conclusion arrived at on such occasions, is that such and such a disease is ' very infectious ;' e.g. I was lately told in a civil hospital that the washerwomen became infected with fever from the patients' linen. Have those who put forward this doctrine of in- evitable * infection' among washerwomen ever examined the process of washing, the appliances by which it is done, and the place where the women wash ? If they will do so, they will very generally find a small, dark, wet, unventilated, and over- crowded little room or shed, in which there is hardly space to turn about — so full of steam loaded with organic matter that it is hardly possible to see across the room. Is it surprising that the linen is badly washed, that it is imperfectly dried, and that the washerwomen are poisoned by inhaling organic matter and foul air ? An ordinary hospital wash-house is a DEFECTS IN EXISTING HOSPITAL PLANS. 49 very likely place indeed to contract disease in, but it supplies equal reason for demurring in toto to the doctrine that the occurrence is inevitable, or that the disease is to blame.' Ignorance and mismanagement lie at the root of all such pre- sumed cases of ' infection.' And it would better serve the cause of humanity if, instead of citing such facts — if they be facts — as illustrations that such and such a disease is infectious, people would reform these washing establishments and convert them into proper laundries, from which properly cleansed and prepared linen could be supplied to the sick, and in which the health of the servants could be preserved from injury. Let hospital laundries be constructed in proper situations, with sufficient area and cubic space for each washer, with abundance of water, with proper means of drainage, and of ventilation for removing the vapour, and with properly- constructed drying and ironing rooms ; it will be all the better for the sick, and we shall cease to hear of washerwomen 'catching' fever. 9. Defective Accommodation for Nursing and Discipline. — ^Want of simplicity of construction in -not a few hospitals is destructive to discipline. Effectual and easy supervision is essential to proper care and nursing. And as everybody knows, a patient may often be saved by careful nursing when everything else will fail. It is at this point that the hospital architect may either facilitate or prevent recovery to the extent to which his plan renders nursing easy, or the reverse. Every unneeded closet, scullery, sink, lobby, and staircase represents both a place which must be cleaned, which must take hands and time to clean, and a hiding or skulking place for patients or servants disposed to do wrong. And of such no hospital will ever be free. Every five minutes wasted E 5© NOTES ON HOSPITALS. upon cleaning what had better not have been there to be cleaned, is something taken from and lost by the sick. But, on the other hand, there must be conveniences. From one of our most recently constructed hospitals, com- plaints have been made that there were no sufficient nursing conveniences, that nothing was at hand, that everything had to be sought. Where this is the case, the hospital adminis- tration must necessarily be both inefficient and costly. There are four essential points of construction, as regards nursing and discipline, in which hospitals are generally deficient, from want of due consideration on the part of hospital architects. They- are those points required to ensure : — i. Economy of attendance. 2. Ease of supervision. 3. Convenience as to number of sick in the same ward and on the same floor, so as to save extra attendants and unnecessary waste of time and strength on the stairs. 4. Sufficient accom- modation for nurses so as to overlook their wards. First. Economy as to Attendance. — I would rather not enumerate the instances where, often from the most various causes, one result arises, viz., that more time and care are given to passages, stairs, &c. &c., than to the sick. Extreme simplicity of construction and of detail is essential to obviate this. A convenient arrangement of lifts, and the laying of hot and cold water all over the building, economize attendance — certainly as much as one attendant to every thirty sick. Secondly. Ease of Supervision. — The system of scouts, watch, alarm, is well understood in many wards where patients would be puzzled to give the things names. Some patients will know both things and names. Attendants require in- spection as well as patients. "Whatever system of hospital construction is adopted should provide for easy supervision at DEFECTS IN EXISTING HOSPITAL PLANS. 51 unexpected times. The Vincennes plan (No. 5) is better adapted for this than the Lariboisiere plan (No. 4), inasmuch as there is a greater number of patients on the same level, and stairs are spared. Third and Fourth. Distribution of Sick in convenient num- bers for Attendance, andPosition of Nurses' Rooms. — Four wards of ten patients each, taking the average of patients as in London, cannot be efficiently overlooked by one head nurse. Were it allowable to have forty patients in one ward, this number could be fully overlooked by one head nurse. She ought to have her room so placed that she can command her whole ward, day and night, from a window looking into the ward. This cannot be the case if she has four wards. If she has two, they ought to be built end to end, with her room placed between and looking into both wards. Four wards of ten patients each cannot be attended by one night nurse, taking the average of London cases. Forty patients in one ward can be fully attended by one night nurse. Small wards are indeed objectionable in working a hos- pital. If we are to be guided, however, by the results of recent experience in hospital building, we shall probably come to the conclusion that, taking sanitary and administrative reasons together, thirty-two patients is a good ward-unit. Let us see what we have done in our older military hos- pitals at home. The first thing that will strike any one in most of our old regimental hospitals is the extraordinary number of wards and of holes and corners, in comparison with the num- ber of sick. In a hospital for a battalion 500 or 600 strong, you find eight or ten little bed-rooms, miscalled wards, a little kitchen — everything, in fact, on a little scale, like a col- E 2 52 NOTES ON HOSPITALS. lapsed hospital. How much more sensible would it be to have one, or at most two large wards for twenty-eight or thirty-two sick each, with a small ' casualty' ward ! How much less the expense of erection and administration, how much easier the discipline and oversight, how much better the ventilation ! In the recently erected military hospitals these errors have been avoided. To return to large civil general hospitals. The ' casualty' wards, as they are called, for noisy or offensive cases are much better placed apart, with a completely appointed staff of their own, than attached one small ward to each larger one. Patients requiring much attention, whose condition fits them the most for the small wards, cannot be put there, because either they are more or less neglected or they unduly mono- polize the service of the ward attendants. If convalescent patients are put into them, they are comparatively removed from inspection, and often play tricks there. If separate ' casualty' wards are provided as they ought to be, the small ward (often seen in French hospitals), at the end of the larger ward, is only an incubus. lo. Defective (Vard Furniture. — Hospital bedsteads should always be of iron, the rest of the furniture of oak. Hair is the only material yet discovered fit for hospital mat- tresses. It is not hard nor cold. It is easily washed. It does not retain miasma. Straw has the advantage of being easily renewed, but it is not desirable. It is too hard and too cold not to render necessary the use of a blanket under the patient, which use is likely to encourage bed-sores. I speak from actual experience of the fatal effect of using the paillasse with patients much reduced. It may lower their vital energy beyond repair. Patients also say the straw feels to them ' like sticks,' and "^ put their hands under them to move It.' DEFECTS IN EXISTING HOSPITAL PLANS. 53 Among defective ward appurtenances, very liable to be undervalued in the results, may be enumerated eating, drink- ing, and washing vessels, of tin or any other metal, on account of their greater difficulty in being kept clean. It requires some care to ensure that any dark-coloured vessel is clean, and any means, by which extra care of this kind can be avoided in a hospital, are cheap and safe. Notwithstanding the greater amount of breakage and of expense, glass or earthenware is therefore best. Some kinds of tin vessels cannot by any amount of cleaning be freed from an unclean smell. The more common and avoidable causes of hospital unhealthiness having been here enumerated, we will now discuss the principles on which hospitals should be con- structed. Note. — On the Proportion of Attendants to Sick in Different Classes of Hospitals. It is singular how little, even in civil hospitals, attention has been directed to the comparative cost of nursing in larger and smaller wards. In two civil hospitals in London, I found the annual cost of nursing each bed about one-third more in the one than in the other. It is true that the average number of constantly occupied beds was about one-third less in the former than in the latter hospital. But the difference of cost seems mainly attributable to the difference of the number of beds in each ward. And the efficiency of the nursing was certainly not less in the latter than in the former hospital. In civil hospitals the proportion is i to every 7, generally of attendants to patients, but is mainly determined by the size of the ward : In one of the hospitals alluded to, where there are quadruple wards of 44 or 48 patients, 11 or la in each compartment, the number of attendants is 7 to each quadruple ward. In exceptional cases extra night- nurses, sometimes extra day-nurses serve particular patients. The labour, both of cleaning and of night nursing, is much increased by the compart- ments being four, and separated by a large lobby. In the other hospital the proportion of attendants to sick in the diffe- rent wards was as follows : — 54 NOTES ON HOSPITALS. Patients. Attendants. ^^1 there were to each ward { ^Nurses. ( I Sister. 30 „ \ ^ Nurses. I I Scrubber. j I Sister. 34 » 1 3 Nurses. { 3 I Sister. 40 „ is Nurses. I Helper. In the Lariboisi^re Hospital at Paris, where the wards hold 32 beds, I sister, i nurse, and 2 orderlies on the men's side, i sister, 2 nurses, and I orderly on the female side, serve the ward efficiently. In this hospital there are no lifts. In all naval hospitals the regulation number of attendants is i to every 7 patients, or 2 attendants for each ward containing more than 7 patients and up to 14. In military hospitals the regulation number of orderlies is i to every 10 patients, irrespective of the size of the wards. The largest sized wards in the older class of military hospitals hold no more than 20 patients. But a ward of 20 patients cannot be efficiently served by two orderlies : nor (if the orderlies be men) with less than ^ Head Nurse — Female. 3 Orderlies. And the other ward of this head nurse ought to be on the same floor. The same number would quite as efficiently serve a ward of 3 a patients, provided there be lifts and a supply of hot and cold water all over the building. The army system of i orderly to 10 patients, with a number not exceeding 10 patients to a ward, is upset as immediately by one bad case among the 10, as by 9 to the 10. Lifts and a supply of "hot and cold water laid on all over the hospital, make, on an average, the difference of i attendant to every ward of 32 patients. And, other things being equal, it is certain that a ward with the appliances and without the extra attendant, will be better served than a ward without the appliances and with the extra attendant. Another thing is certain. A nurse must not be a scrubber. And a scrubber cannot be a nurse. Also, every night-nurse and every ward-attendant, scrubber included, must sleep and live and be entirely attached to the hospital which she serves. Otherwise it is obvious she will not serve it ; she will serve some one else — probably her family at home. Also, every nurse on night duty must have regular night refreshment supplied her by the hospital. DEFECTS IN EXISTING HOSPITAL PLANS. ^^ One orderly should be trained to be the frotteur to each military ward. He should also be the porter to fetch' and carry everything to and from the ward. The following is an illustratioaii of the cost of nursing in two military hospitals, one with large, the other with small wards : — A ward of 9 sick would require i day and one night orderly, and a- third of a nurse (that is, a nurse could superintend three such wards). A ward of 32 sick would require 2 day and i night orderlies and I nurse = 4 persons in all. Or if two such wards were on one floor, i nurse could serve both. We cannot count the cost of orderlies and nurses, including lodging, rations, wages, at less than 50Z. a year, which when capitalized at 3 per cerit. {^^ years' purchase), would amount to i6_5o/. for each. A ward of 9 sick would cost in nursing i6<,ol. x 2^ = 38^0^. or 42 7 i. i^s. 6d. per bed. A ward of 32 sick would cost for nursing, in perpetuity, i6^oL X 4 = 6600Z. = 220/. per bed. [One nurse to each ward is here allowed.] The cost of the two plans relatively for a hospital of 1000 sick would stand thus : — Wards with 9 beds = ^42 7,7 7 j Wards with 30 beds = 220,000 Capitalized difference of cost in favour of j large wards ^^207,77^ Suppose there be 25 sick to a ward, the cost would stand thus : — For each ward of 25 sick, 3 orderlies, at 1650/. . . = ^49.5° If two such are huilt in line close to each other, with the nurse's room between them, one nurse could superintend both wards, or half a nurse to a ward. The cost would be for the ward . . . 825 5775 ^ ' Or cost for each bed = sS2^i The comparative cost of wards with 9 beds and 25 beds would stand thus for 1000 sick: — Wards with 9 beds £\'^7>775 Wards with 25 beds 231,000 ^ ving ^196.77^ 5<5 III. PRINCIPLES OF HOSPITAL CONSTRUCTION. The first principle of hospital construction is to divide the sick among separate pavilions. By a hospital pavilion is meant a detached block of building, capable of containing the largest number of beds that can be placed safely in it, together with suitable nurses' rooms, ward sculleries, lavatories, baths, water-closets, all complete, proportioned to the number of sick, and quite unconnected w.ith any other pavilions of which the hospital may consist, or with the general administrative offices, except by light airy passages or corridors. A pavilion is indeed a separate detached hospital, which has, or ought to have, as little connexion in its ventilation with any other part of the hospital, as if it were really a separate establishment miles away. The essential feature of the pavilion construc- tion is that of breaking up hospitals of any size into a num- ber of separate detached parts, having a common administra- tion, but nothing else in common. And the object sought is that the atmosphere of no one pavilion or ward should diffuse itself to any .other pavilion or ward, but should escape into the open air as speedily as possible, while its place is supplied by the purest obtainable air from the outside. The question of a general hospital plan resolves itself, first of all, into obtaining the most healthy structure of the pavilion; and second, into arranging all the pavilions in PRINCIPLES OF HOSPITAL CONSTRUCTION. 57 the way best suited to obtain free external ventilation, plenty of light on all sides, and convenient means of communication. To realize these advantages, pavilions may be placed side by side, or in line. The arrangement of pavilions side by side should be adopted for hospitals of above 120 beds ; the arrangement in line is most suitable for small hospitals with fewer than 120 beds. In the larger class of hospitals the arrangement of pavi- lions side by side diminishes the distance to be traversed from block, to block, and thus materially facilitates the administra- tion. Besides this, it allows covered communications to be kept up between all parts of the hospital, without interfering with the lighting or ventilation of the wards. The distance between the blocks should not be less than double the height of the blocks. This rule is specially appli- cable to English climates, in which it is necessary to preserve as much space as possible for sunshine. A greater distance would be better ; but this would involve a greater cost for land, and a greater distance to be traversed by the hos- pital staiF. Generally the distance between the pavilions should be greater than twice their height in low confined localities, where there is not a free external movement of the air. If the wards are raised on basements, the rule as to distance should apply only to the height of the pavilion from the floor of the ground-floor ward. In very close positions it is difficult to say what distance will be found sufficient for free ventilation. Such localities are precisely those where no hospitals should be built. The first thing, however, is to determine the best con- struction for a pavilion, and in doing this, the following prin- ciples require to be kept in view : — 58 NOTES ON HOSPITALS. I. Number of Floors in a Pavilion. There should not be more than two floors of wards to the block. The most healthy hospitals have been those on one floor only ; and this because they require less scientific knowledge and practical care in ventilation. If another floor is added, a community of ventilation exists between the ward below and the ward above by the common staircase, and by filtration of air upwards through the floor. The risk from this can be dimi- nished by constant care in the use of doors and windows, and by introducing impervious floors. But, unfortunately, sys- tematic care in these matters is not to be looked for, especially that constant supervision necessary to keep the ventilation of three or more floors of wards quite independent of each other. [Who ever sees this, even in a private house, where there is an invalid ?] And hence there is a strong conviction in the minds of careful hospital physicians, surgeons, and nurses, that patients do not recover so well on upper floors. And there are instances in which the mortality of patients on upper floors has been higher than that of the floors below. More- over, a sick population requires more surface for health than a healthy population. And it is clear that, if patients are placed on three floors instead of on two, the surface over- crowding is increased by one-third, unless the distance between the pavilions is increased in a corresponding ratio. But the general administration of lofty hospitals is also far more diffi- cult and fatiguing than of those of moderate height : any increase of distance between the pavilions will add to the difficulty, and both difficulty and fatigue are very important considerations for efficiency and economy in this branch. To sum up. Hospitals on one floor require least care ; PRINCIPLES OF HOSPITAL CONSTRUCTION, 59 hospitals on two floors can be kept healthy with moderate average care and intelligence. Beyond this, care, intelligence, and fatigue, such as are rarely likely to be bestowed, are essentia] to maintain a moderate average amount of health, among either wards or nurses. Nobody but those who have had to do with running up and down lofty hospitals can have any idea of the waste of time and strength it entails. The objection usually urged is that hospitals in two floors cost more than in three or more floors. But I submit that this is not the question before us, which is how to construct a hospital with the requisite facilities for ventilation, adminis- tration, nursing, and health. The mode of construction in hospitals is, it is presumed, to be determined by that which is best for the recovery of the sick. If any other consideration is taken, such or such a per-centage of mortality is to be sacrificed to that other con- sideration. But it so happens that the safest for the sick is in reality the most economical mode of construction, 3. Number of Wards to a Floor. If the pavilions are single, i.e., if each staircase gives access to the end of the pavilion, as in the Lariboisiere and Lisbon plans, Nos. 4 and 11, there should be only one ward on each floor. The pavilion should never be divided so that a second ward or wards is placed beyond the first, to be reached by passing through the first. The reason is that the floor, however divided by cross-walls, can never be other than a single ward. The cross-walls only obstruct the ventilation. If the doors are accidentally left open, the foul air in one ward passes into the next, and the greatest improvement in 6o NOTES ON HOSPITALS. ventilation would be to pull down all the partitions and throw the pavilion open .from end to end, so as to have only one ward on the floor. To illustrate the meaning of this, here is a plan (fig. 1 1 ) of one wing of the Hdpital Necker at Paris, in which it will be seen that an excellently constructed ward, with windows on dl sides, is cut up by partitions into four wards. If the par- titions were removed, one cannot fail to see that the ventilation would be better, but in this case the ward would be too large. Fig. II. Plan of a wing of the Hopital Necker, Paris. If the pavilions are double, 2.^., if each staircase gives access to a ward right and left off the staircase, as in the Herbert Hospital No. 6 and in the Regimental Hospital plans, figs. 20, ai, provided the staircase be of spacious size, and thoroughly ventilated sides and top, two wards may be placed on each floor with safety ; and with this great advantage, that admi- nistration, nursing, and discipline are all facilitated, while expense in construction is saved. One staircase does the work of two for the same number of sick ; or rather, one staircase answers for double the number of sick. principles of hospital construction. 6l 3. Size of Wards, Pavilions, and Hospitals. The question, what is the best number of beds in a ward ? has been but little considered in England in regard either to health, economy, or efficiency of service. The more beds in one ward, the fewer the attendants necessary in proportion, and, within a certain limit, the greater the facility of super- vision. But the sanitary necessities of cubic space per bed, &c., impose the limit. After we have attained a certain number of beds per ward, the height of the ward becomes too little for its other dimensions. The ventilation becomes im- peded, a circumstance which can only be guarded against by making the ward higher than necessary. Additional cubic space has thus to be given ; and the construction ceases to be economical. Without the most perfect ventilation, there is always more danger of effluvia being driven by a draught till it accumulates in one part of a very large ward, as was the case in the long corridors of Scutari. Besides which, you may make your ward too large for the" chief attendant to overlook the whole at a glance, which he and still more she ought to be able to do. And you would have to double your supervision.* Wards of a small size are decidedly objectionable, because unfavourable to discipline, inasmuch as a small num- ber, when placed together in the same ward, more readily associate together for any breach of discipline than a larger number. It has been proved by experience that the presence of head nurses, whether male or female, one to each ward, is * See Note to Section II., on the relation which the size and arrangement ot wards bears to the question of nursing and supervision. 62 NOTES ON HOSPITALS. essential to discipline, and a sufficient number of such nurses cannot be allotted in smaller wards. One head nurse can easily overlook all the patients in one large ward. In four small ones it is almost impossible. The best size of wards for ensuring the two conditions of health and facility of administration and discipline, is from ao to 3a sick. Wards smaller than of 20 beds multiply both the atten- dance, unnecessarily, and the corners, unfavourably for venti- lation, in proportion to the number of patients. Wards larger than of 32 beds are undesirable, because they require a greater height of ceiling, and are hence more costly in con- struction and difficult to ventilate. In the event of a death taking place in the ward, the sur- vivors, when they are few in number, are far more likely to be affected by it than a larger number. Wards, again, much smaller than of 30 beds are more difficult to ventilate by natural means alone. A certain amount of space is requisite for diffusion, in order to secure perfect natural ventilation. Wards of a moderate size, like those indicated, are better for the purposes of ventilation than wards half the size ; and are less subject to a hospital atmosphere than wards of double the size. Where clinical instruction is intended, to admit even a class of six students into a ward of 13 sick is increasing the population in the cubic space by one-half. There is more than twice the room proportionally for students, in a ward of double the size. On the other hand, if the number of students be very large, a ward of ao patients, it must be at once ad- mitted, is too small. The size of the ward must be increased, and with it its height and its cubic space ; for, be it remem- PRINCIPLES OF HOSPITAL CONSTRUCTION. 63 bered, the whole of the proportions of the ward, not only its length, must increase with its number of beds ; for, if the ward be very long, in proportion to its height and breadth, it becomes not a ward but a corridor, and all corridors are ob- jectionable for sick, because it is impossible to ventilate them safely ; because, as already stated, in admitting air, the effluvia may be driven from one end and be accumulated at the opposite end faster than they can be taken out. The right proportion is a fixed one. As to the size of the pavilion. If the pavilion be single and in two floors, it will of course contain under one roof no more than the sick of the two wards, i.e., of 33 beds each, or 64 in all. With double pavilions and intervening staircases, the number would be double, i.e., 128 beds. Where small wards for special cases are required, they can always, as a point of construction in small hospitals, be attached to the pavilion, which would add a few more beds to the number which can be accommodated under a single roof. In good existing examples small wards have been thrown out separately from the staircase. Guided by these considerations, a hospital, consisting of two end to end pavilions, such as would be required for a county establishment receiving a small number of sick, would contain, say, 68 beds under one roof, i.e., 3a beds in each of the large, wards, and two beds in each of the small wards. A double pavilion hospital would contain double that number. It would thus be safe, so far as plan is concerned, to construct a large hospital of any administrable size of separate double pavi- lions, each containing, say, 136 beds. But in large hospitals the smaller class of special wards should always be grouped together, and completely separated from the other wards, because they are intended to contain either the most dangerous 64 NOTES ON HOSPITALS. and important cases, or noisy cases, or cases with ofFensive dis- charges, which it is always safest to remove from the general wards ; besides, small wards require, if possible, purer air than larger wards, and therefore more care in construction ; and in order to insure those cases which really require most nursing from neglect, they should always be placed under a completely appointed staff of their own : and not attached, one to each large ward, which renders, proper attendance extremely difficult. The next point is to determine what ought to be the size of a hospital ; in other words, how many beds it can contain with safety. But from what has been said, it will be observed that this question resolves itself into the previous one, viz., what should be the size of each hospital pavilion? because, if a pavilion of healthy construction is obtained, it is evident that the only limit to the size of the hospital will be an administrative one. A hospital may be constructed for any number of sick, until a point is arrived at, when some portion of the administrative arrangements, material or personal, has to be provided in duplicate. Any further extension beyond this ceases to be economical. Considering each pavilion as a separate unit in the hos- pital construction, any number of single or double pavilions could be put together up to accommodation for, say, looo beds, beyond which it would be difficult, if not impracticable, to have good administration with one set of officers. It is to be hoped, however, that few hospitals will ever be built for such a number now-a-days. The fewer hospitals required, and the smaller their number of sick, the better will it be for civilization. All I submit is, that the pavilion construction may, not should, be safely used up to this extent. principles of hospital construction. 65 4. Space and Area to the Bed. Having determined the number of beds per ward, the next point is to ascertain what amount of cubic space should be given to each patient. There is scarcely a point of hospital construction in which there has been so much error as in this. The chief element in the question, and that one which has been very generally overlooked, is the superficial area per bed. If it be — as it is — an essential condition to the healthy state of a hospital that there should be ample facility for the air moving around and in the immediate vicinity of the sick, it is quite clear that, if the beds are placed as close as they can stand, it matters very little whether you give your patient icoo cubic feet or ao,ooo cubic feet. To show the importance of this, it may be sufficient to state that, if a large building, say a church, be selected for a war hospital, on account of its spacious, light, cheerful aspect, if it be measured to ascertain its cubic contents, its height being no more than 60 feet, in such a building the very liberal war hospital allowance of 1 200 cubic feet per bed would render it necessary to place the beds on the floor so close together that not even a pathway would be left between them. Has not this, in times past, been one cause of the frightful mortality in these hospitals ? In some splendid new hospitals in India, where they give above looo cuSic feet per bed, the superficial area for each patient is only 34 square feet. But then the archi- tect has made such a spacious ward, no less than 43 feet high (!), that it is supposed to make amends. Let us inquire what is the smallest amount of superficial area we can do with. Hospital beds are generally from 3 feet to 3 feet 6 inches wide, and 6 feet 3 inches long, the bed space being In- creased to 7 feet by the bed being a little removed from the wall. 66 NOTES ON HOSPITALS. The mere surface required tohold the bed is hence from a i square feet to 34! square feet. It is quite clear that, whatever surface area is required for ventilation, administration, or for clinical instruction, must be in excess of this amount. There should be space sufficient between the sides of adjacent beds to avoid stagnation of air altogether. There should also be room for Free movement of three or four persons, for the use of a night-chair, without annoying the next patient, and also for a portable bath, when required. The distance from foot to foot of opposite beds should be sufficient to afford space for a mov- able dresser or table, benches on either side, and easy passage- way. In a well-constructed civil hospital in England, occupy- ing a healthy airy position, it cannot be said that 80 square feet besides the bed space, are too much. In round numbers, the superficial area per bed should be not less than 100 square feet. Wards for the numbers of beds already given need not be higher than 15 feet, which would allow 1500 cubic feet per bed. This ought to be quite sufficient in a well-con- structed hospital in a healthy position, and for the average class of cases received into civil hospitals. For small wards, however, neither this superficial area nor cubic space would be sufficient. In these wards the space per bed should be, as near as may be, 2500 cubic feet ; and this partly from the more severe nature of the cases, partly from the greater diffi- culty of ventilating this class of war&s. If, however, a hospital is built in the centre of a large city, where pure air is not to be had, or in a locality where the circulation of air outside is deficient, it is hard to say what amount of space would make the building healthy. We know of hospitals where aooo cubic feet per patient are not sufficient to make the wards safe. But these hospitals should not be there at all. PRINCIPLES OF HOSPITAL CONSTRUCTION. 67 A good proportion for a ward of 20 patients would be 80 feet long, 25 (or 26) feet wide, and i6'(or 15) feet high. This would give 1600 (or 1560) cubic feet to each bed. It would give II (or 12) feet between foot and foot, which is not too much where there is a clinical school. It would give an average of 16 feet to each 2 beds in width. Half the sick are supposed to be on each side the ward. 5. Number of Beds to a Window. One window at least should be allotted for every two beds ; the window to be not less than 4 feet 8 inches wide, the sill within 2 or 3 feet of the floor, so that the patient can see out, and up to within a foot of the ceiling. The pair of beds should have the width of the window between them on one side, and in the wall space between the windows the beds should be not less than 3 feet apart. With a very bad fever case, I would leave one bed empty, for the sake of isolating the patient. Miasma may be said, roughly speaking, to diminish as the square of the distance. With good ventilation, it is not found to extend much beyond 3 feet from the patient ; although miasma from the excre- tions may extend a considerably greater distance. Windows are to be placed opposite each other, and to be either double or filled with plate glass ; the former would be preferable, as affording the opportunity of indirect ventilation in all weather. But attendants find them too difficult to manage and to clean, so as to be cheerful. Windows opening as at Middlesex and Guy's Hospitals, in three or more parts, with an iron casting outside, to prevent a delirious patient from throwing himself out, are the best form of plate-glass window. No part of the ward ought to be dark. This is of the F 2 68 NOTES ON HOSPITALS. Utmost importance, in many cases. The light can always be modified for individual patients. But even for such patients to have light in the ward is not the less important. There are three reasons for this multiplicity of windows : — 1. Light. 2. Ventilation. 3. To enable patients to read in bed. The necessity of light for health is established by scientific inquiry and experience. The proportion of window space to cubic space in a room, but especially in a ward, is a point of the first importance. It has been los't sight of in English architecture, owing to the unfortunate window-tax, which has left its legacy in giving us a far smaller proportion of light than in French houses. In huts the proportion of window space to cubic space is far greater than in buildings. One main cause of the unhealthiness of large numbers of men congregated in one large building, even with sufficient cubic space, is the disproportionately small window space. For the same purpose of ensuring a sufficiency of light, the walls should always be light coloured, excepting perhaps for some few cases of ophthalmia. 6. Material for Walls and Ceilings of Wards. One of the most difficult points in ward construction is to find a good material for walls and ceilings. An impervious material capable of receiving a polish on a white or tinted surface would make the best lining for a hospital ward. What is wanted is such a surface as can be washed frequently with soap and water, without its being absorbed into the substance, and dried with towels, so as not to interfere with the current use of the ward. Parian cement PRINCIPLES OF HOSPITAL CONSTRUCTION. 69 is the nearest approach to a good material for this purpose hitherto discovered. But the polish is rather costly. And what is of more consequence, the manufacture has not yet reached such a point of perfection as to afford a surface of one uniform colour. Even the best becomes blotchy after a short time, and is liable to crack, especially when applied to ceilings. If manufacturers wish to bring this substance into general use for Hospitals, they must improve the material until the cement can be applied over any required extent of wall, and retain an uniform texture, colour, and polish. Various sili- cated surfaces have recently been introduced for walls. Some of these are worthy of trial — always bearing in mind that a good colour, and not a dull dirty one;, is necessary in all sick wards. It is possible that a sufficiently good sur- face might be obtained by applying some of the better class of light-coloured paints in repeated coats over unpolished Parian, and then varnishing and polishing the surface. All the woodwork should be painted and varnished in such a way as to admit of ready washing and drying. But the best material is polished or varnished wainscot oak. It is the cleanest, most durable, and most satisfactory in usev 7. Ward Floors. The materials used for floors may be oak wood, pine wood, or tiles. Oak wood, well seasoned, is the best. No sawdust or other organic matter capable of rotting should be placed underneath the floor. Concrete, or some similar indestruc- tible substance, would be the best for the purpose. The floors at the new Herbert Hospital, Woolwich, are formed of 70 NOTES ON HOSPITALS. concrete, supported by wrought-iron joists, over which the wood is laid. They are consequently fire-proof, as all hos- pital floors ought to be. The reason for using oak wood is, that it is capable of absorbing but a very small quantity of water. And it is very desirable to diminish even that capability, by saturating it with 'beeswax and turpentine. Beeswax is an inalterable substance. This floor should be cleaned like the French parquet, by frott'age. A hospital floor should never be scoured. A very good hospital floor is that used at Berlin, which is. oiled, lackered, and polished so as to resemble PVench polish. It is wet- rubbed and dry-rubbed every morning, which removes the dust. Its only objection is want of durability. Both processes render the floor non-absorbent — both pro- cesses do away with the necessity of scouring altogether. The French floor stands the most wear and tear, but must be cteaned by a frotteur, which cleaning is more laborious than scrubbing, and does not remove the dust. The Prussian floor requires re-preparing every three years. But the wet and dry rubbing, or process of cleaning, is far less laborious than either frottage or scrubbing, and completely removes the dust, and freshens the ward in the morning. By either process the sick would gain much in England. The Berlin flooring is by no means perfect, on account of this deficient durability of surface, and might be improved. Practically, with care, a well-laid oak floor, with a good bees-waxed sur- face, can always be kept clean by rubbing ; but the means of producing a really good impervious polished surface, with little labour, have yet to be discovered. The joints of the flooring must be fitted well together, and cemented with any impervious substance. The object PRINCIPLES OF HOSPITAL CONSTRUCTION. 71 isj of course, to prevent any water from entering the floor. Impervious, non-absorbent cement or composition would make a capital floor, used as it is in Italian houses. But, on account of its great conducting power, it would be necessary to furnish each patient with a pair of list shoes, and a small bedside carpet. Flooring of this kind, or of tiles, is better suited for a warm than for a cold climate. The stairs and landings should be of stone. The corri- dors should be floored with diamond-shaped flags or tiles, which stand better than those laid in the usual manner. The terraces over the corridors might be either covered with asphalte or glazed tile, to admit of convalescents walking on them, and of patients in bed being wheeled out on them. 8. Sisters' Rooms and Sculleries. There should be a " sister's" room on one side of the ward door. This room must have superficial area enough to be the nurse's bed-room and living-room, being, as she is, the head nurse or " sister" of her ward, and therefore in imme- diate command of it, night and day. A scullery should be attached to each ward, on the side of the passage opposite the nurse's room. The scullery must be supplied with complete, efiicient, simple apparatus for its various purposes, places for washing up and cleaning, and for ward cookery, so that the "sister" can warm the drinks, prepare fomentations, &c., without jostling the nurses or orderlies who are washing up. The best sink for a scullery is the new white porcelain sink recently introduced, with hot and cold water laid on. Care must be taken that the waste-pipe has no direct communi- cation with a closed drain, otherwise foul air is certain to find its way into the hospital. The scullery should be large 72 NOTES ON HOSPITALS. enough for the assistant nurses to sit in to have their meals comfortably. 9. Bath Rooms and Lavatories. Every hospital of any large size should have a separate bathing establishment at a convenient distance from the pavi- lions, but connected by the corridors. The walls of the bath house should be of white tiles, or cement, the floors of wood. The apartments should be suitably ventilated and warmed. They should contain hot and cold water baths, sulphureous water, hot air, medicated and vapour baths, shower baths, and douche. There should also be a small bath room with one fixed bath of white glazed terra-cotta supplied with hot and cold water adjoining each large ward. Terra-cotta has the advantage of retaining the heat longer than almost any other material, and of being always cleanly. A lavatory table with a row of sunk white porcelain basins, with outlet-tubes and plugs, each basin supplied with hot and cold water, should be placed in the same compart- ment as the bath, but separated from it by a partition and door. It is a common mistake to place these lavatory basins too near each other to be used conveniently by men-patients standing abreast. There should also be room for a portable bath to each ward, with a hot and cold water supply at hand, and means of running oiF the bath water after it has been used. 10. Water-closets and Sinks. The water-closets should be placed at the end of the ward opposite the entrance, and separated by a lighted and ventilated lobby. They should never be against the inner wall, but always against the outer wall of the compartment PRINCIPLES OF HOSPITAL CONSTRUCTION, 73 in which they are placed. They should be of the best con- ^ structlon. A syphon water-closet of a hemispherical shape, never of a conical shape, and abundantly supplied with water to flush it out with a large forcible stream, is by far the best contrivance of the kind for a hospital. The cost of water is a bagatelle in comparison with the advantages. The sink for ward slops, bed-pans, expectoration cups, &c,, which should have a compartment of its own, adjoining the water- closet, should be a high, large, deep, round, pierced basin of earthenware, above a large hole, with a cock extending far enough over the sink for the stream of water to fall directly , into the vessel to be cleansed. This is far preferable to the usual oblong sink. The scullery sink is, of course, to be entirely separate, and for entirely different purposes from this. The only way to ensure dryness and cleanliness in the com- partments where the water-closets and lavatory accommoda- tion are placed, is to cover the walls with white glazed tile, enamelled slate, or cement. It is, perhaps, hardly necessary to say that there must be private water-closets for the hospital ofiicers, for the nurses, who should not be compelled to use those of the patients, (and, of course, never those in the men's wards), also water- closets for the patients when not in their wards. Patients should not be allowed to use the ward ones, except when confined to their wards. All these water-closets fall under the same rules of health as those laid down. As the arrangement of this part of a hospital — viz., lava- tories, water-closets, &c. — is one of primary importance, a measured plan of the most improved arrangement of ward offices, such as has been introduced into recent military hos- pitkls (fig. 1 2), is given next page. 74 NOTES ON HOSPITALS. un [y , f - — S5RSS1 sssMSS fer^ « - /« , . 2 M _i" a, CO O X CO I -d s n o Cli J o a JS PRINCIPLES OF HOSPITAL CONSTRUCTION. 75 II. Ventilation of Wards. The doors, windows, and fire-places should be the chief means of ventilation for properly constructed wards. If a hospital must be ventilated artificially, it betrays a defect of original construction which no artificial ventilation can com- pensate ; it is an expensive and inefficient means of doing that which can be done cheaply and efficiently by construct- ing your building so as to admit the open-air around. In countries where fuel is dear and cold severe, the problem complicates itself, because it is supposed to require a smaller consumption of fuel to warm the fresh air as you admit it. Artificial ventilation means the use of some machine or method whereby air is drawn from without-^— sometimes, it is to be feared, without due care whence it comes — bringing the air into forcible contact with heated surfaces, generally of hot water vessels, and then introducing it into the ward for the use of the sick. The foul air is either expelled or drawn out of the ward by some mechanical means, and the fresh (if it is ever fresh) warmed air takes its place. In certain Parisian hospitals where this system is applied, the fresh warmed air enters the ward by pedestals down the centre ; and the foul air is extracted by openings close to the floor between the beds — the presumption being that the foul air is in this way taken off before mingling with the general air of the ward. It is a fact that one hospital at least in which this system is in full operation yields, notwithstanding its otherwise ex- cellent construction, a very high death-rate among its inmates. English physicians and surgeons, who have examined this hospital, concur in stating that the ward atmosphere is by no y6 NOTES ON HOSPITALS. means so pure as it is in a London hospital. These facts have led to considerable discussion, which it is necessary to notice. Here we have one of the best constructed hospitals in existence, professing to afford to each of its beds from 3500 to 5000 cubic feet of " fresh warmed air" per hour, introduced, and the foul air removed, in accordance with strictly correct scientific principle — and yet here is the result. It strikes one, on examining this process, that it is not in accordance with Nature's method of providing fresh air. She affords air, both to sick and healthy, of varying temperature at different hours of the day, night, and season — always ap- portioning the quantity of moisture to the temperature, pro- viding continuous free movement everywhere, and warming not by warm water in iron pipes, but by radiant heat. We all know how necessary the variations of weather, tempera- ture, season, are for maintaining health in healthy people. Have we any right to assume that the natural law is dif- ferent in sickness ? In looking solely at combined warming and ventilation, to ensure to the sick a certain amount of air at 60°, paid for by contract, are we acting in accordance with physiological law ? Is it a likely way to enable the constitu- tion to rally under serious disease or injury, to under-cook • all the patients, day and night, during all the time they are in hospital, at one fixed temperature ? I believe not. On the contrary, I am strongly of opinion, I would go farther and say, I am certain that the atmospheric hygiene of the sick room ought not to be very different from the atmo- spheric hygiene of a healthy house. Continuous change of the atmosphere of a sick ward to a far greater extent than would pay a contractor to maintain, together with the usual variations of temperature and moisture given by nature in the external atmosphere, are elements as essential as any PRINCIPLES OF HOSPITAL CONSTRUCTION, 77 Other elements to the rapid recovery of the sick in most cases. The best way to cure these beautiful but unhealthy build- ings would be to remove the warming and ventilating appa- ratus, to put in chimneys, with good radiating open fire-places, and to trust to their magnificent supply of windows for fresh air.* [This is done in Russia, where it is far colder than at Paris.] The administration would complain of the additional cost of fuel. But I would reply, you must consider how much you prolong the stay of sick in your hospital, and what per-centage of recoveries you prevent or delay, by this com- bined warming and ventilation. It does not matter what the present saving may appear to be ; the object of your magnifi- cent charities, perhaps the finest in the world, is to recover the largest number of sick in the shortest possible time. It is to be feared the statistics show that this end is not obtained. Natural ventilation and open radiating fire-places are the only suitable means of renewing and warming the air in hos- pitals. Whenever the weather permits of it, the windows of every sick-ward should be more or less open. During cold, boisterous weather, and at night, a sufficient renewal of the air can always be obtained, even if the windows cannot be opened, by the method recently introduced into English military hospitals of carrying up a few air-shafts from the ceilings of the wards to above the roof, and allowing fresh air to enter by * Why do not all learn the lesson taught by the experience of the invasions of France in 1814-15 ? At that date the hospital administration of Paris, not know- ing where to receive the sick and wounded, fitted up three of the unfinished " Abattoirs " for 6000 patients, — several of the buildings fortunately had neither doors nor windows, and had the wind blowing through them. The mortality was one-half among the patients in the " Abattoirs " of what it was in the ordinary hospital establishments.^HKjjo«. Etude, p. 39. 78 NOTES ON HOSPITALS. means of Sherringham's ventilators at the top of the ward walls, close to the ceilings. No other system is required but this, and it costs little or nothing ; besides which, it takes advantage of the natural laws of varying temperature and moisture. Fig. 13 shows the ventilating arrangements for a ward in plan. A foul-air shaft is carried up in each alternate wall- space between the windows, and a Sherringham's ventilating, inlet is placed close to the ceiling in each alternate wall-space opposite the shaft. Plan of Ward Ventilation, showing the position of Shafts and Inlets. Fig. 14 gives a section of the shafts and inlets. The shafts are louvred at the lower ends to prevent chance down- draughts falling on the beds. Fig. 15 is Sherringham's ventilator used as an inlet. It can be opened or shut by a weighted cord to regulate the amount of fresh air. If with these simple means, including windows, attendants cannot be trained to keep the rooms ventilated without draughts, there is a defect of intelligence, and attendance on the sick is not their calling. There should be one or more open fire-places', according to the size of the ward, but lofty, so that the throat of the chimney shall be above the patient's head and bed. PRINCIPLES OF HOSPITAL CONSTRUCTION. Fig. 14. 79 SECTION CEILINO Fig- 15- ..SHAFT L H LOWER WARD UPPER WARD FLOOR Sherringham's Ventilating Inlet. Section of Ward Ventilation. The chimney is indispensable as a ventilating shaft ; the fire sets it acting ; it takes the air from the ward so success- fully that, as has been proved by direct experiment, a single chimney will, in certain states of the wind, remove 60,000 cubic feet of air in an hour, or as much as the French con- tract system allows for 24 patients. 13. Ward Furniture. White window-curtains are used in some French hospitals, not to exclude the light, but to look cheerful. In most French hospitals, and in some in this country, the beds have curtains. They are not necessary. They interrupt ventila- tion and entail additional cost in washing. Where seclusion of a patient is required, a low moveable screen, not higher than the patient's head when he is sitting up in bed, is far prefer- able. Oak furniture should be supplied for wards. There 8o NOTES ON HOSPITALS. should be a light chair for each bed, two or three spare arm- chairs for patients who get up for the first time to sit at the ward fire ; there should be a small open bed-table for each bed ; two or more tables or moveable dressers down the centre of the ward, according to its dimensions ; one or two forms with backs would be found very useful. In some hospitals the allowance of furniture is more liberal, but the less ward fur- niture, speaking generally, the better. The use of glass or earthenware for all eating, drinking, and washing vessels is recommended from its great superiority in cleanliness, and in saving time and labour in cleaning. Tin vessels of certain kinds cannot, by any amount of cleaning, be freed from smell. 13. Bedding. No bedding but the hair mattress has yet been discovered that is fit for hospitals. Hair is indestructible. It does not readily retain miasma. And, if it does, heat easily disinfects it. It may be washed. It is not hard to the patient. It saves the objectionable use of a blanket under the patient. There have been repeated objections to the use of horsehair on account of the current expense. But this, under careful administration, is much less than is generally supposed. From special inquiries, I find that, allowing 5 per cent, for deterio- ration, the cost would stand as follows : — Cleaning and remaking. Loss of hair Interest at 5 per cent Total .... Straw paillasses, as already stated, are inadmissible. They Per Bed per. Ajinum. i» %id. to 2^d. ly. to 2d. 2S. 2S. sim- to :s. 4^^. PRINCIPLES OF HOSPITAL CONSTRUCTION. 8l are cold ; and, in some cases, the abstraction of heat from the spine lowers the patient's vital energy to a degree which does not leave him a chance of recovery. I am of opinion that the loss of life must have been great during the war from laying our patients on paillasses, which were either placed on wooden divans, or on the flagged corridors, with only a mat between. All bedsteads for hospital use should be of wrought iron, frequently painted of a light cheerful colour. This costs little ; and yet it has a far greater influence on the general appearance and comfort of a hospital ward than most people are aware of. Just in proportion to the discrepancy between the spacious, cheerful ward and its shabby dirty- looking furnishing, is the air of general discomfort which it presents. A head shelf to the bed is useful. The French military hospital bedsteads have one at the feet too. Sacking bottoms are preferable to iron bottoms, which are stated to harbour vermin between the interlacings, and it is said that the edges of the iron bands cut the bed-ticks. The Rheocline open iron springs, like snakes sitting on their bottom ring, make the easiest, best ventilated, freshest bed I know ; save your bed-ticks by sewing a sacking under them. Some cases, like compound fractures, require a firm bottom to the bed for the spHnts and apparatus to rest upon. A wooden frame or such like may be made to fit the bedstead for such cases. Every hospital should have dropsy and surgical bedsteads for raising a patient when he cannot be moved, for inclining him at a certain angle, &c., also water and air beds. For many purposes different forms of new spring bedsteads will be found very useful. 8a notes on hospitals, 14. Water Supply. One of the most essential sanitary provisions for a hos- pital is an abundant supply of pure, soft water. The ob- taining of such a supply pre- supposes a careful examination of the sources, and a chemical analysis, both quantitative and qualitative. It has frequently happened, especially in warm climates, that waters of a most impure character, containing poisonous amounts of dissolved organic matter, have been used for sick, without suspicion that the diarrhoea or dysentery of which they were dying was nothing more than a water disease. Absence of colour, taste, and smell is no criterion of sufficient purity ; for some of the most impure waters are often the most agreeable ; as, e.g., the water drawn from wells supplied by filtration through old grave- yards is often clear, bright, and sparkling, from being charged with carbonic acid derived from human remains in the soil ; and during an epidemic, poisonous. Hard water, containing sulphates or carbonates, is unfit for most hospital purposes — especially so for dressing wounds. Filtered rain water is generally the best for this purpose. In small hospitals, either spring or well-water should be selected after analysis, and if found to be hard, the roof water should be stored for surgical purposes. In large hospitals, where no other than a hard water supply can be obtained, it will be possible to soften the water by the lime process. But in large hospitals, where engine power is used, there is often much waste steam which can be usefully condensed for soft water. Of course, for all pharmaceutical purposes, the softer the water the better : and the same rule holds for the. cook- ing, especially of vegetables. Having obtained the best available water source, all the PRINCIPLES Of hospital construction. 83 water required for ordinary ward purposes should be laid on at pressure, hot and cold, all over the building, for sinks, ablution basins and baths ; but never from a cistern within the hospital. This would be to expose the water to impurity, and the hospital to damp. The consumption of water for an English hospital, including, besides patients, all its officers and servants (who may be roughly estimated as 150 for 500 patients), is on an -average of 35 gallons for each person per day. This includes baths, brewing, washing the pavements, but not laundry work, farther than the necessary wringing out of soiled sheets, &c., before sending to the laundry. Of this amount two-thirds at least should be soft water for personal use — one-third being for domestic purposes may be hard. In the laboratory of a hospital of this size, the steam boiler will supply 500 gallons of condensed water per day, to be used for all mixtures, decoc- tions, infusions, &c., and collected in iron or slate cisterns for the purpose. One gallon of soft water per patient per day is thus on an average required for the pharmacy. I may just allude to the difficulty, if you have one tap of soft water and one of hard, of making sure that the attendants never use the hard for soft-water purposes. There should be convenient means in or close to the wards for obtaining pure filtered drinking-water for the sick. 15. Drainage and Sewerage. No drain should ever pass under a hospital ; all sinks, water-closets, lavatories, and baths, should be so placed that the drainage should be conveyed directly away, without pass- ing under any part of the hospital. And for this purpose all drain pipes from them should be placed in the outer walls, but never agaitist any inner wall of the building. G 3 84 NOTES ON HOSPITALS. All drains or pipes for the purpose of conveying away water from any part of the hospital should be carefully trapped between the outer wall of the building and the sewer ; and all drains should be ventilated. An excellent arrange- ment has been adopted at the Herbert Hospital, by which all the ward drainage is discharged into vertical drain pipes in the outer walls, which drain pipes are carried from a trap in the main drain below, straight up above the roof of the build- ing, where they are left open to the air. This ensures thorough ventilation of the pipe, and prevents the possibility of the regurgitation of foul air into the building. A per- forated box of charcoal is placed over the upper opening of the drain pipe to destroy any noxious gas that might other- wise escape into the air above the building. 16. Kitchen. The kitchen should be placed away from the wards. Its walls and ceiling should be of light-coloured cement, for plaster has a tendency to fall off, from the vapour and effluvia of the kitchen. Hospital cooking apparatus should be capable of doing two sets of cooking : — 1. All the ordinary " diets." 3. Casual diets and " extras" for emergencies. It has been said that a good cook can cook with anything ; but cooking in a hos- pital is a very important part of the general administration, and requires to be done with the utmost regularity, efficiency, and economy. In providing apparatus, it is necesJsary to con- sider how many " diets" of the same kind will be required ; also what the nature of the cooking should be. Usually this consists of soups, farinaceous preparations, including pud- dings, stewed vegetables, roast joints, baked, meat, or meat roasted in a roasting oven, broiled beef-steak o>jnutton-chop PRINCIPLES OF HOSPITAL CONSTRUCTION. 85 (there should be no frying in a hospital, except for fish, and even fish, cooked after the French plan, in oil, is better ; if a patient can digest a fried steak, it is the best pf oof that he is fit to be discharged from hospital), tea and coffee. The " extra" articles usually required are beef-tea or warmed beef- juice, sago, &c. There should always be plenty of boiling water. The dimensions, as well as the number of parts of which any hospital cooking apparatus should consist, will depend, of course, on the size of the hospital. The cheapest fuel for boiling liquids on a large scale is common coal. Where stewing has to be done on a large scale, steam is the best agent. For stewing on a small scale, and preparing extra articles at irregular times, gas is by far the most convenient fuel. But its use requires to be carefully restricted to such purposes, otherwise it will be found too costly. Roasting is now very well and economically done in ovens constructed for the purpose, with ordinary fuel. Gas ovens are sometimes convenient ; but they are more expensive. Lately, many im- proved forms of hospital cooking apparatus, capable of per- forming these various processes, have been introduced. For small hospitals all the parts are generally combined in one small apparatus, placed in an ordinary kitchen fire-place. For large hospitals, the different parts are better separated. Of course, the same cooking apparatus and kitchen which answer for the patients are sufficient also for officers, nurses, and ser- vants, although tea and breakfast will probably be made in the respective quarters of each. The cooking apparatus, boilers, ovens, &c., if placed in the centre of the kitchen, after the French plan, instead of against the walls, will afford twice the amount of fire space. ^ 86 notes on hospitals. 17. Wash-house. How to dispose of the Foul Linen. — Of course it should never be treasured up in any ward, scullery, or closet In the hospital. The sooner it is sent away and in the wash-tub the better. In hospitals of a kw beds it should be thrown into a basket and carried straight away immediately ; but in large hospitals, where changes are constantly going on, it is neces- sary to have ready means of conveying it out of the building, and for this purpose nothing answers so well as foul-linen shoots. These should be built in the wall. The best mate- rial for them is glazed earthenware piping, 15 to 18 inches in diameter. They should have an open mouth, also of earthen- ware ; with a door, opening not near a ward, but from a staircase or well-ventilated passage. And they should end below in a small closet, out of which the linen should be taken as soon as the change is completed, and removed at once to the wash-house. To be quite safe, the pipe should be carried up to the roof of the building, though of a smaller diameter, to secure that the shaft is well ventilated. Hospital washing should never be done in or close to a hospital. In a small hospital, the kitchen may be put In the basement, provided it is not under a ward, and It is very well ventilated ; but the wash-house never. It at least should be always detached, and if within the hospital grounds at all, at the farthest attainable point in them, and to leeward. The reason, of course. Is, that pure air in a hospital is the sine qud non, while the surest method of obtaining foul air Is to combine the excretions of the patients with the steam of hot water, and give access for this combined result to the sick by staircases or open windows. The excellent new washing, drying, and wringing PRINCIPLES OF HOSPITAL CONSTRUCTION. 87 machines lately invented are so numerous that it would take too long to enumerate them. On the whole^ the laundry at the Wellington Barracks, which also washes for all the Guards' hospitals and barracks, and the new laundry at Haslar Naval Hospital, are the best I have seen. But every day brings in fresh inventions, and a reformer is always adopting the good ones. Admirable ones are attached to the new Herbert Hospital at Woolwich, and to Netley Hospital. The former is intended to wash for all the troops in garrison, as well as for the sick. I do not think that any reliable comparison has yet been made between the French system adopted at the Sal- p^triere and Lariboisiere hospitals and the English system. The French consists in filtering hot ley through the clothes, which are placed for that purpose in large tubs, with a com- partment at the bottom, from which the ley is pumped up by machinery, and allowed to flow over the top of the linen, through which it filters into the compartment, to be again raised by the machine. This plan is stated to be the most economical which has been tried in Paris. The essential characteristic of the Haslar one is boiling by steam, the. linen being afterwards placed in a rotating washing machine. The method in use in the Wellington Barracks consists in passing the linen through slowly rotating washing tubs, in which it undergoes a process of waulking by wooden rods. This latter plan is both economical and effectual. To ascertain which is the most really economical of the French and English plans, it would, be necessary to inquire not only into the relative cost of washing, but into the relative wear and tear. The hardness or softness of the water rpust also be taken into account. The softer water is the cheaper. 88 NOTES ON HOSPITALS. both in the consumption of soap and the Tvear and tear. Now the Paris water is in hardness to that of London as 30 to 16, and as ao to 3 to that of Glasgow. Probably the Paris method is the only economical one with the Paris water. All the water used at the new Herbert Hospital, including that for the laundry, has a hardness of 13°, which will be reduced to 5^° by Dr. Clarke's softening process. This will effect' a large economy in soap and linen, in addition to the advantage of having softer water for general hospital use. Clean Linen Room. — After passing through the laundry, the linen is returned to the hospital for use ; and any one who wishes to see perfect arrangements for storing and issuing clean linen must go to the Paris hospitals. Each hospital there is provided with one or more large well-lighted rooms, con- taining every arrangement for the mending, classification, and issuing of ward linen. The linen is stacked in open frame- work so as to admit currents of air through the piles — a thing of great importance. This is a point of administrative detail in which all English hospitals are wofuUy behindhand. Even in the most recent plans I have seen, there has either been no provision of the kind, or it has been a mere half-dark closet. The mending room ought to be a separate room from the clean linen store, and adjoining. There should be besides in each ward a lock-up movable press, best placed under the sill of the large end window, with a table-leaf on hinges for folding, for such articles as may be stored in the ward. 18. Operating Theatres. I need not say that surgical cases should never be placed higher than the first floor. It is important that an operating theatre should not only be on a level, but central between the PRINCIPLES OF HOSPITAL CONSTRUCTION. 89 men's and women's surgical wards. An operating theatre in a third story is very objectionable, particularly if patients have to be carried up a narrow flight of stairs and back after the operation has been performed. The proper place for an operating theatre is to be built out at the back of the centre ; and the board-room may be under it. It is not uncommon, in small country hospitals, to have a recess or small room leading from the operating theatre, in which the patients re- main until they have recovered, or at least recovered the imme- diate effects of the operation. But it is more and more becoming the practice of the best London hospitals to carry such patients back to their own ward, where it is believed (a belief in which I entirely concur) they have, if the ward is what it should be, better advantages, better chances, better care, nursing, and supervision. Of course there are excep- tional cases, as in ovariotomy, trephining, &c., which may require to be by themselves. But this is for the surgeon to decide upon. Operating theatres are best lighted by a good large sky- light and a steady northern light from one large window, quite up to the ceiling. There must be no conflicting lights from different windows, and no southern aspect. Now, as the ope- rating theatre is the only room in the hospital which ought to have one sole north light, this is very convenient, because it may occupy a situation which would not do for a ward. We will next consider the application of these principles to the improvement of hospital plans. 90 IV. IMPROVED HOSPITAL PLANS. Within the last few years very considerable advances have been made in hospital architecture in this country. A number of hospitals have been improved and added to on correct principles. Several new hospitals embodying these principles have been built, and the plans of many more are at present under discussion. The subject has also awakened renewed attention abroad; and quite recently two works of great importance have appeared on the subject in Paris. One of these is the "Etude sur les Hopitaux," by M. Armand Husson, Director of the General Administration of the Assistance PubUque, the other the " Rapport sur les Hopitaux Civils de la Ville de Londres," by MM, Blondel and Ser, of the same bureau. These works afford information of great interest on the whole question of Hospital administration, and I am indebted to them for several illustrations intro- duced into these pages. I have had the opportunity also of examining a number of new hospital plans for buildings which it is proposed to construct in different parts of the country. They have all borne marks of careful study of the subject ; but there are one or two points in which all of them present certain defects in common. I shall merely allude to these as points of experience, before proceeding to the general subject of this section. One of the most common mistakes in hospital plans, even in some of the most recent of those I have seen, is mixing up IMPROVED HOSPITAL PLANS. 91 together, in the same block, sick wards and administrative offices of all kinds. It need hardly be pointed out that such an attempt must necessarily lead to a very complicated struc- ture, containing large wards and an indefinite number of rooms of different sizes, all connected by passages and stairs more or less dark, badly ventilated, and diffusing a common atmosphere throughout the building. By this arrangement of parts, all the old complications of badly constructed hospitals are reproduced in another form. The usual excuse is that it is cheaper than to separate the sick from the administration, which is extremely doubtful. One thing is not at all doubtful, that such an arrangement exposes both sick and ad- ministrators to very unnecessary risks, and is one of the causes of fever among the latter, already mentioned, a danger which should never be incurred on any plea of economy. It is possible, no doubt, to ventilate more or less effectually a complicated building of this sort ; but practically it will never be done. Wherever any form of hospital construction requires much thought to be applied to its ventilation and other sanitary ar- rangements, it may be considered quite certain that the hos- pital is not a safe one for sick. Practically it is impossible to escape from this ; viz., that safe hospital construction must, at whatever (apparent) cost, contain a maximum of facility and a minimum of difficulty for keeping every part of the building healthy. It is a fundamental principle that the pavilions, whether single or double, should contain nothing but the sick and the offices immediately required for the ward. Everything else, board-rooms, chapels, quarters for officers and servants, except for the head nurse or nurses of each ward, stores, kitchens, laun- dries, should be placed in a separate building or buildings. It 93 NOTES ON HOSPITALS. would be better even that convalescent roomSj where it is determined that there should be such rooms, should be out of the main building, but accessible under cover ; for the obvious reason that convalescents require change of air which cannot be obtained under any circumstances in a hospital. The matron should always have her rooms as near to the nursing staff as possible. And as it is highly desirable that the day and night nurses of each ward should be kept as a separate staiF, lodged as near to the head nurse as possible, if room can be found for these near their own pavilion, it is better. Simplicity "of construction, involving, as it should always do, a provision of abundant light and ventilation through every part of the hospital in which sick are placed, can only be secured in hospitals of any size by separating the adminis- trative part from the sick part. The smallest country hos- pital should consist of at least two blocks of building. The utmost simplicity of plan is an essential of good hospital construction. Complication of plan interferes with light, ventilation, discipline, facility of supervision. Every hole and corner, every passage, every small ward, which need not have been there, interferes with these four vital conditions of a good hospital. Every skulking place which can be spared must be avoided. As an invariable hospital rule, rather more than elsewhere in military hospitals, publicity may be con- sidered as the best police and the best protection. It is far better that 30 patients should see the nurse's door than one or none. It is quite necessary that the chief ward attendant should be able to see the whole of her or his patients at once. When the architect has arrived at a clear idea of what a hospital pavilion means— what it should contain and what it should not contain — the next important matter is to deter- mine how the pavilions are to be arranged so as to form a Tlanli'^ML. BUCKS INFIRMARY. -+- Fl RST FLOOR PLAN 17M3L>t€a;.Ctn,iu>itA t londbn Longman, Gieen & C° IMPROVED HOSPITAL PLANS. 93 hospital. From what has been said, it will be obvious that the arrangement of parts will depend on the number of beds for which the hospital is to be built. The following principles will enable a good block plan to be made. 1. Small Hospitals. For hospitals intended to consist of two pavilions in line, the arrangement shown in fig. 16 might be followed. It con- sists of two wings, containing one ward on each floor of the wing, and a centre block for the administration. Fig. 16. Two Pavilions in line. A block plan of this kind, if erected in an airy position, would possess every requisite for health. The size of the administrative part of the building will depend upon the nature of the hospital management, and upon whether or not out-patients are to be received within the hospital. When the administration is of very limited extent, the arrangement in fig. 16 would be unobjectionable. But as a general rule, and especially where out-patients have to be received, as much of the administrative part of the building as possible should be detached behind the main line of the hospital, in the manner shown in the regimental hospital plans, figs. 30, ai. The plan and elevation of the New Bucks Infirmary (No. 3), intended for 53 beds, with the offices on the ground floor, and wards 16 feet high on the first floor, built by 94 NOTES ON HOSPITALS. Mr. Brandotij is the most recently completed civil hospital on the new plan, and has been found to answer very well. When the number of beds for which the hospital is in- tended exceeds what can be accommodated in a double pavi- lion of this form, the plan shown in fig. 17 may be adopted. This fig. shows a building consisting of two double pavilions and a centre. Wherever this form is adopted, the pavilions should be entirely cut off from the centre by spacious stair- cases carried up where the centre joins the pavilions. In a hospital of this form the centre should be one floor in height ; the pavilions would be in two floors. Fig. 17. ■J Hospital of two double Pavilions and Centre. A similar arrangement of parts is shown in fig. 18. In this case the administration is a separate block, two or three floors in height, connected with the pavilions, two floors in height, by a centre one floor in height. Fig. 18. Hospital of double Pavilion Wings with central administration. IMPROVED HOSPITAL PLANS. 95 Fig. 19 is one half of fig. 17, and consists of three pavi- lions, radiating from a common centre. If this plan is adopted, there should be a large central staircase at the point of junction. Fig. 19. Double Pavilion Hospital with projecting Centre. Another application of the pavilion principle is shown in figs. 30 and 3T, and is adapted for regimental hospitals, either for cavalry or infantry. For a full cavalry regiment one floor is sufficient. For an infantry regiment, double the accommoda- tion is required ; and the building is then erected in two floors. This is simply one of the double pavilions of the Herbert Hospital, with so much of the administration as is absolutely necessary arranged between the wards ; the remainder being in a block behind. Several cavalry hospitals on this plan have been constructed, and they are found to answer admirably. A pavilion hospital on the same plan is proposed for Malta, to receive the sick from barracks on the Cotonera side of the great harbour. These examples of block plans are taken from existing hospitals. The object, in buildings of this class, is to bring all parts of the hospital under one roof, more with a view to facility of communication throughout, than to securing the sanitary state of the hospital. Such plans can only be used within certdn limits. As a rule it is safer to consider every pavilion, containing the largest number of sick a pavilion ought 96 NOTES ON HOSPITALS. a . i o _ c^ =» "a " K S mil n u n N p4 emiS »ic , One Story JujJi . fj.M.'N.O.PQ. Suildmas Yrirfke cSiri 7%ree, Starief fii^h. P ^ R I S HOPITAL DE LARIBOI6IERE 612 BEDS. F{ Ground FlxiorWashhoikSe Orvtft£l'''^Fhor _Liiuti Stnre. 2 '^FlaoTDarmitaneS -far Female Attendants S. Sisters noamj T U.Baitis T Cha/od XYAmphiiheaire Z Manefft k Stores W Siaile andJ)eadJImise a a a a Ccrrrular one Story Tuofh, with (^en'Jhrace aio-i 'e. riaiTun^ Toujul the iuiZdtnaS, ojid carmetiina fhe^n t>hb Gardens / ,' TdV.-.^'? ."/^' ■ i" Z^7u^M X^-^^i^^'^. ^.on'loc 1.011^" .Tiai: 'jieet 4c pisoli-t';' y VINCENNES MILITARY HOSPITAL GROUN D PLAN. Scale of F«»t . Reference . A Officaf, {mardftoom Chanel, and AparbnmtsfoT GeiUTol KstailbSknient Kitchai , hmen Tiaorrof and Aaumunodaiion forlSSisUrS (uul 30S SoMwrj. Tharmacy^aths ■ laid Aa-miimt)didiim for 24 Offijrfrs mu/ 30S So/d^srs TortersLod^ GuardJloase Tunfral Chap(i,J)ead Haase , SCc. Ohixpel .Tmratf'.'UK .•.Vi7.-.fk-f^.nnr^Jf -oucLdxj i-on^iDi4jj jzeen t. C* IMPROVED HOSPITAL PLANS. lo^ valescentSj and also as a means of access between the first floors, when the weather permits. The hospital contains 6ia beds, divided amongst six separate pavilions, which are just as much distinct hospitals as if they were miles from each other. The block plan of this hospital is excellent, but the pavilions are too close together for their height ; or, rather, there should have been only two floors of wards instead of three. The small wards are badly placed, away from the sister, and close to the open privies of the ward. This hospital is warmed and ventilated, unfortunately, by artificial means, and has presented the anomaly, easily resolved by those acquainted with the sanitary requirements for sick, of one of the best hospitals in existence, so far as the block plan is concerned, yielding one of the highest rates of mortality. There is another hospital, the St. Jean, at Brussels, built upon a similar plan; and also a hospital at Bor- deaux. The Vincennes Military Hospital, for 637 beds, of which I give a ground plan (No. 5), shows another arrangement of pavilions. In this example, the pavilions for sick are double, with wards for non-commissioned officers, and rooms for sisters at the two extreme ends, but cut off by separate staircases. These pavilions form two sides of a square, the third side is formed by a block containing the chapel and the administrative offices and quarters. The fourth side of the square is open to the country. Each pavilion consists of three floors and an attic, and is connected with the administration by a glazed corridor as far as the central staircases. It consists, in fact, of two hospitals, one for 308, the other for 33 a sick, connected with one administration common to both. The disadvantages of the plan are that, if the whole building were used, there would be three floors and an attic occupied by sick, instead of two 102 NOTES ON HOSPITALS. floors only. The ward details are also objectionable in some important points. One advantage of the double pavilion adopted in this plan must be mentioned ; and that is, the facility with which a large number of sick can be superintended and nursed on the same floor, instead of entailing on the attendants the amount of running up and down stairs required in the Lari- boisiere plan. The Vincennes wards, however, are buUt for rather too many beds. But, on the other hand, the building is in an open, elevated situation in the country ; and each pavilion is divided from top to bottom by an unusually spacious staircase up to the roof. It is ventilated and warmed by the draught of a chimney and hot-water vessels. All the advantages of the Vincennes and Lariboisiere plans, without any of their disadvantages, and with greatly improved sanitary arrangements, will be realized in the new Herbert Hospital now under construction at Woolwich. (Plan No. 6.) This, when completed, will be by far the finest hospital establishment in the united kingdom, or indeed in Europe. It consists of four double and three single pavilions, with the ends in the free air. All the wards are raised on basements, those at the lower end of the ground are so lofty as to afford excel- lent accommodation for the museum, library, medical ofiicers' rooms, board-rooms, and stores. There are only two floors of wards to each pavilion, and the distance between the pavi- lions is double the height of the pavilion, measured from the floor of the lowest ward. Every ward has a large end window, commanding beautiful views; and the ablution and bath accommodation, together with water-closets, is placed in the free atmosphere at the end of the wards. Each large ward contains from 28 to 32 beds, with windows along the opposite PiaoiN^VI. f/iOM oove/i \ !l k /> C> V JS Ji JL O JL D aKoam) flait of THE HERBERT HOSPITAL. Sade ofl'eet- Zoo 30O '^C LoncLon Longman, Gieen 4', C IMPROVED HOSPITAL PLANS. I03 sides, one for every two beds ; and each ward has a nurse's room and scullery. Unfortunately the army regulation num- ber of cubic feet per bed has limited the height of the wards to 14 feet. There is a convalescents' day-room in the central pavilion. The kitchen is in a basement, also in the centre ; over it there is a library, and over the library the chapel. All the administrative offices and quarters are in a separate block in front. The axis of the wards is a little to the E. of north ; and each side will receive the sun's rays during some part of the day. At one end of the hospital there are separate lunatic wards with separate offices. At the other end is the operation theatre, with a few small wards for special cases. The total accommodation is for 650 beds, in 7 detached buildings, all connected together through the centre by a corridor one floor in height, with a basement corridor beneath, through which the whole of the service of the hospital, so far as regards the conveyance of diets, medicines, coals, and the removal of dust and foul linen, will be carried out. This is effected by a system of lifts and shoots. And the result will be, that the usual bustle observed in hospital passages will be altogether avoided. This hospital embodies the great administrative principle of an entire sepa- ration between what is immediately necessary for the sick and what is not so, and yet without interfering with the efficiency of the administration. Over the corridor there is an open terrace, to which convalescents in the first-floor wards will have easy access in fine weather. And the covered corridor below will be available for exercise in wet weather. Each ward is 36^ feet wide and 14 feet high, and each bed has 93 to 97 superficial feet, and, raoo to 1400 cubic feet. The walls will have a polished light-coloured surface. It is intended to warm the wards by two open fire-places along the centre of the wards, the flues being carried under the floor, and used for warming the air 104 NOTES ON HOSPITALS. admitted to the wards. The floors are of iron beams, filled in with concrete, and covered with oak boarding. The whole will be fire-proof, and the sick in the lower wards will not suiFer from noise in the wards overhead. Hot and cold water will be laid over the entire building ; and the supply, which is taken from chalk, and hard, will be softened by the lime process before being transmitted to the hospital. In Malta it is proposed to erect a general military hospital on the pavilion principle for 300 beds, with the pavilions differ- ently arranged from any existing example. A ground plan of this proposed hospital is given in Plan No. 7. The site, chosen as the most healthy in the garrison, is limited, and the arrangement of parts has to be conformed to the shape of the ground. But so flexible is the pavilion construction that it suits itself readily to this requirement. There will be six pavilions arranged side by side, each containing two floors of wards, and the whole connected by open arcades sufficient to afford shelter for sun and rain, but to leave ventilation perfectly free. The entire administration is detached and placed in front of the hospital ; but all parts of it are con- nected by convenient staircases with the corridors. The walls on the sides towards the sun, and the roof will be double to ensure coolness. The hospital will overlook the sea at a height of 170 feet above its level. Other two establishments are proposed to be erected by the enlightened local government of Malta. One of these is an asylum for 1000 aged and infirm persons, 500 of each sex. A ground plan of this proposed establishment is given. Plan No. 8. It consists of eight pavilions, each two floors in height, arranged in two squares, containing in all 29 wards for beds, with dining-rooms on the ground-floor. To each square there is a day-room placed in the centre. The whole Te-.MVurcc^ litk irMozSiru- Pla.nIT°7I[. PROPOSED GiiiRi^L JMIUITilir NOSPlimL VALETTA. PLAN OFGROUND FLOOR I A. BCD movU- ^ E.F Water Gesets Saihs, Mav/tfarcM ^ G^.S. JVztnses Rooms a,nd Scui/^/rcf %. I. CorrTjder.^ J.-Cnurts ^ ^ K' ExerciSina (rroiuuis Scale of Teet. Jt>.0 ^ LonioTL Lorigiaan, Gieen i; (]° SMGO f^R 8 TOKeSStA I ■ — ■ ■ ■ - ■ J ASYLUM FOR THE AOEO AND INFIRM M A LT A . -+- OfPURAT/NG- £STXBUS»M£/rr l>]a.ni^o"VIir. Sf*£0 FOR ORY CLOTHES i.i--J I II u rrr MA 7~r/fA SS MAK/A/G- D £F>Af?rM£f/T r "- TX T -1 * w^na fon 3S aaos. ! •: WAfio pod 36 aeos ^l^^.^ kikJ p. — L H . DAY. feOOM* r L ■ I '^l ■■ .1 . ■■ J WASM/^& 0£PAfiTA/l£/^T WAftO FOR 3S asOS • ~^— > kyARO POfi3£ s^os I I I . O A Y- ROO m' h -■^- lv/i/rofon3e aeos , — _ . ma/jo fon 3S beds J MENS S'oe /> O Ml N I STff A T/ OAI . WOMEN 'S SIO£ ^/^^^.erc-^jjrt r^- z^jJ^-iX Sire^c Ctm^za^<^'^ London Longman, Green & C° HOSPITAL FOR INCURABLES , MALTA PlanlT9IX. ^r^ E-d CH EN "" iiiiiiii 1 P 1 • • Lj Ui Ld > i I I AOMI NISTR ATION. T 6.J^Aierc^,lig,..i7j\dUlSlrtet^ rmAuiA. u: loTiioxt. Longman, Green Ic C° IMPROVED HOSPITAL PLANS. lOC establishment is connected by open arcades, with terraces over. Every block throughout the entire establishment is detached from every other. And the latrines, lavatories, and baths, which will be on the most improved English construction, are in de- tached square blocks in the angles, and accessible from the wards under open arcades. The administrative portion of the building is very complete, and the whole exemplifies an arrangement which, with some alterations in detail, might be adopted for a hospital of the same number of sick," if it ever were considered necessary to bring so many together. Connected with this establishment, it is proposed to build a hospital for 300 beds, on a plan shown in No. 9. This consists of two long pavilions similar in construction to those of the Herbert Hospital, and two smaller detached blocks for the treatment of special or offensive cases. It will be observed that each of the larger blocks has a dining-room and day- room — a matter of necessity in this building, for a considerable proportion of its inmates will be incurable, not acute cases. The sanitary details of both plans contain everything required for ensuring a healthy state of the buildings. They were prepared at the instance of the government of Malta, by Mr. T. H. Wyatt ; and when completed, they will place this small island in the foremost rank as regards its charitable institutions. These illustrations of hospital construction, when compared with what has been the past practice in this country, will show at once what ought to be done, and what ought not to be done, in planning buildings to be occupied by sick or maimed. Some recent plans, however, have, alas ! reproduced all the old errors in a novel form. Sometimes the wards have been improved in proportions, in light and facilities for ventilation. Io6 NOTES ON HOSPITALS. while the arrangements for baths, lavatories, and water-closets have been most objectionable. In other instances, kitchens and other offices have been placed under the sick wards, while the wards themselves were good. Again, as already men- tioned, the administrative parts of the building have been so mixed up with the portions allotted for sick as to introduce all the old objectionable dark corners and useless passages which constitute so large a proportion of the worst class of hospital buildings. Mistakes such as these can only be avoided by a very careful study and application of the principles laid down. It should never be forgotten that the first thing to be con- sidered is what is best for the sick, not what may appear to be cheapest — for the cheapness is only apparent — not what will make a good architectural elevation, for this is a point quite beside the question. The very first condition to be sought in planning a building is, that it shall be fit for its purpose. And the first architectural law is, that fitness is the foundation of beauty. The hospital architect may feel assured that, only when he has planned a building which will afford the best chance of speedy recovery to sick and maimed people, will his architecture and the economy which he seeks, be realized. 107 V. CONVALESCENT HOSPITALS. It is a rule without any exception, that no patient ought ever to stay a day longer in hospital than is absolutely essential for medical or surgical treatment. What, then, is to be done with those who are not yet fit for work-a-day life ? Every hospital should have its convalescent branch, and every county its convalescent home. The first necessity of a convalescent hospital is that it should not be like a hospital at all : and the very best kind of convalescent hospital would be a string of cottages. The reason for this is fourfold : — J . To get rid of the idea of being in hospital altogether from the minds of the inmates, and to substitute for it that of home. As long as they are hospital inmates, they feel as hospital inmates, they think as hospital inmates, they act as hospital inmates, not as people recovering. a. To secure a more free and bracing atmosphere than can ever be secured in any building containing a large number of inmates. 3. Because cottages may be more slightly built, and there- fore are less expensive than large, complicated, solid buildings. 4. Because in the point of view of moral discipline it is yet more important to separate men from women among con- valescents than among the sick. And of course this can be done much more easily and efficiently, and with far less trouble 108 NOTES ON HOSPITALS, to the administratlorij in separate houses than in separate parts of the same house. It is almost needless to repeat the A B C of all sanitary- lessons — that the best building, intended to hold a large number of inmates, can never be made so healthy as a cottage for a small number, if well constructed. All rules against curtains, against washing in the dormitory, &c., which must be maintained in hospitals, may be relaxed, at all events on the feniale side, in a properly built Convalescent Home. It should be a home. Each bed should be sepa- rated by a rod and iron staple, and curtain, about 6 or 7 feet high (to be pulled far back in the daytime) from the next bed ; and a wash-hand-stand should be permitted within this compartment. The number of beds for which each ward, whether for men or women, is constructed, should not exceed six, or be less than three : almost every hospital condition, in fact, is reversed. The indispensable hospital rule, that no patient should be sent to or admitted into the kitchen or ward scullery, is also reversed in a convalescent home, where the more the patients are occupied, the better. The men who are able for it should be employed in the garden, which is better for them than their in-door trades. The women who are able for it should do nearly all the household work, at least on their own side ; and a little sick cookery may well be taught them in the kitchen, but on a hot-plate, as convalescents should not be called upon to stand long at a hot kitchen fire. That all this must be done with discretion, and in subor- dination to the necessity of giving the convalescents constant fresh air, .and as much as possible of it out of doors, it is almost needless to say. CONVALESCENT HOSPITALS. 109 Some convalescents will want entire rest ; and this, with fresh air and good food, will be the main element of their recovery. This will be the case with those forms of uterine disease now sadly common among young female servants, from the use of stiff stays, and form of petticoats hanging from the waist. Others will be able to walk and yet not able to use their arms to do household work. With all, much care will be needed to prevent them damping their feet or clothes. The medical officer and head sisters will have to exercise constant vigilance in this matter of occupation. There are as yet few convalescent establishments. And as it is most probable that this class of accommodation will be extended, it is important to observe correct principles in future plans. Here are two or three illustrations of different kinds of buildings. Fig. 25 is a plan of the first floor of the Convalescent Institution at Walton-on-Thames. On the left are 4 women's wards, opening from a common inner passage. There is a corresponding number of men's wards on the right hand side of the plan. There is one ward for 9 beds, a wards for 11 beds each, one ward for la, one for 13, two for 14 and one for 15. The projecting ward behind, called the EUesmere Ward, is for 18 beds. The cubic feet per bed vary from 459 to 874, the average being about 628 cubic feet per bed. There are 117 beds on a floor, all of which, except 18 (in the EUes- mere Ward) are in rooms opening from inner passages, and having windows on one side only. The EUesmere Ward has windows on three sides. In general construction the building can only be considered as an inferior model of a provincial hospital. It is a praiseworthy attempt to meet a great want ; no NOTES ON HOSPITALS. but its details should certainly not be followed in future insti- tutions. Fig. 2g. WO ME N'S f4 BEDS O BED's\ J. First Floor Plan of the Convalescent Institution, Walton-on-Thames. Fig. a6 is a sketch plan of the Male Convalescent Institu- tion founded by the Emperor at Vincennes. It is constructed on a totally different principle from the English one. It con- sists of a long series of three-bedded rooms, bent on itself at j-ight angles, so as to form partial courts, the whole being connected by a corridor for communication. The arrange- ment of parts is simple and ingenious, while it enables a large number of rooms to obtain the benefit of direct light and air through the outer wall. For an interesting account of this establishment, vide Note, p. ii6, and the following sketch plan (for it is only a sketch to show the general arrangement), I am indebted to Colonel Clark Kennedy, who was kind enough to go over the establishment for the purpose. It will be see^i at once wherein this building differs in design from the preceding. In the first place, it has no in- ternal corridor. It has a corridor along one- end of all the rooms ; but the arch of the corridor, the door of the room, and the window at the opposite end of the room, are all in one line, so that a thorough ventilation is easily effected. Again, the rooms are intended each for three beds only — a CONVALESCENT HOSPITALS. in Fig. 26. Sketch Plan of Male Convalescent Institution, Vincennes. I Courts. 8 Pharmacy. 2 Chapel. 9 Stores. 3 Refectory. 10 Bureaux. 4 Parlour. II Directeur. fl Kitchen. 12 Connecting Corridors 6 Laundry. 13 Staircase. 7 Baths. 14 2ND Floor. Lingerie. Centre Pavilion over the Chapel, the Bibliotheque. Over the Refectories, the ' Salle de Chant ' and the ' Salle de Jeu.' Attics of main Building contain "Workshops. Infirmary Ward is in Court A. » number which diminishes materially the objections to corridors as a means of communication, provided they be ventilated with ordinary care. The whole suite of rooms on one side of a court of this building would hardly contain more beds than a single ward in a hospital. All the rooms are ventilated and warmed artificially on the usual Paris hospital method. Iia NOTES ON HOSPITALS. The plan consists simply of a number of separate rooms connected by a corridor, in which the convalescents sleep at night, while during the day they are out in the air, or follow- ing some occupation. The corridor construction, if properly ventilated, or, what is much better, if wholly or partially open, is not' objectionable as a means of communication in a building of this kind Intended for convalescents, who spend most of their time " out and about." For a hospital whose inmates are always confined to their wards, the structure would be objectionable. This building, together with its economy. Is worthy of careful examination by those engaged In planning convalescent establishments. It is, I believe, the largest building of the kind hitherto specially erected for the purpose. Of course, were it possible, it would be better to have more than one window for a bedroom to be occupied by three persons. And it would be highly advantageous if windows could be placed on two sides of the room. The best arrangement of buildings for convalescents Is, however, doubtless, that of a series of cottages ; and here Is a sketch of such a building (Plan No. lo) made at the request of the Committee for the Herbert memorial of the county of Wilts. It consists of four detached cottages, intended for twenty men and women. Two of the cottages are intended one for men and one for women. The centre cottage con- tains the sister's room, &c., together with two small wards for sick, or relapses, one for men and one for women. The fourth contains the kitchen and the men's and women's dining and day rooms. It Is intended to make the establishment as like a home and as unlike a hospital as possible, and to provide, at the same time, for strict discipline over the inmates. rianNoZ. A DESIGN FOR CONVALESCENT HOS PITA L ARRANGED AS COTTAGES . PRINCIPAL ELEVATIONS. Z. XvtAeH/. ^. JjtzrcUr. S. Stares 7. Ji£xz£L ServOTtts JtjXTmy S. Ctm;i'»jUs€£7it3edRMrrjts S Sisters lo. Baih U . CameCar JZ . Cavereii, Wc^ 23. GuriUTier J4' Sick l^ds GROUND PLAN FEMALES J^S.^^eierc^^ieijrJiiZlJJrea, CmS2aZ:A. ^oncLon Longman, Green &: C° CONVALESCENT HOSPITALS. no A plan such as this, while possessing all the advantages of a home, would admit of extension, merely by the addition of similar parts. The working plans were made by Mr. Thomas, of the War Office. It is scarcely necessary to say that convalescent establish- ments should be placed in healthy, cheerful positions, varying in local climate according to the class of cases for which they are intended. The best climates can easily be determined by the usual practice adopted by physicians with private con- valescents. Certain irritable chest cases do best in the moist relaxing sea-side climates of the S.W. of England. Diseases requiring a medium character of climate are usually sent to the southern districts, and to the Isle of Wight, If bracing sea-side climates are required, the S.E., E. and N.E. coasts and part of the N.W. coast are generally chosen. A large class of convalescents suffering from general constitutional debility are benefited by certain inland climates, such as Mal- vern, Clifton, Derbyshire, &c. I merely allude to this sub- ject of climates because it should not be overlooked in providing for the relief of convalescents. There are many places round London on dry, comparatively elevated, gra- velly soils, which would afford excellent sites for convalescent institutions. If convalescent homes are necessary for adults, they are doubly necessary for children ; the rule, never to keep a patient a day longer in hospital than is absolutely essential, applies rather more to children than to any others. It is necessary to say a few words on another proposal for* convalescents — namely, providing convalescent wards and day- rooms in hospitals. In dealing with this proposal, it is right to repeat : — 114 NOTES ON HOSPITALS. 1. That no patient should be kept in hospital a day longer than is absolutely essential— /,s Jl. EiiSf't CROUND PLOOR FRONT ADMINISTRATION UPPER FLOOR FRONT NURSES ROOMS. IZ. SeuUsry- 23 Jj order, ^Kc.. a-, /feajhr^ (yiamier JS. OjDerahi?n iRjWTn' 26 Cerwale^centJOiw^Remn, 17. Vi^iiaZe IS. Tassa^ IS. Siine^ ZO JVicrses' 2)irun^^07n. T.&.y0iermAm:i7JHt!l. —-^^ r--' 1 Plan and Section of Hospital, Dinapore m The wards can never be said to be light or airy ; *' as a general rule, hospitals are badly lighted and gloomy ;" doors are more common than windows. And these doors, when closed, leave the ward, if not absolutely dark, yet absolutely dismal and close. Indeed a dark ward must always be a close ward. Or " light enters from a couple of panes in the doors near the top, and when closed darkness is almost complete." There is in Indian hospitals hardly a room light enough to perform a surgical operation. And operations, it is stated, have to be performed in verandahs. The inner verandahs are generally used for sick wherever more room is wanted : the outer ones sometimes cut up for lavatories, destroying what ventilation there is. The superficial area per bed is almost invariably too small, and the wards almost as invariably too high ; the result to the sick b?ing that, with an apparently sufficient cubic space, the surface overcrowding is excessive. One of the worst examples of this is the recently constructed hospital at Trimulgherry INDIAN MILITARY HOSPITALS. 141 (Secunderabad), which consists of three wards, two of which contain no fewer than 228 beds each ; the wards are 4a feet high, and afford 100 1 cubic feet per bed, but the surface area Fig. 30. Plan of Hospital Ward, Trimulgherry (Secunderabad). 228 Beds. per bed is only 34 square feet. This surface overcrowding is greater than I have ever seen it in the smallest or the largest temporary war hospitals. Such facts strike one very forcibly in connexion with the high mortality among sick entering these and similar hospitals. This Trimulgherry hospital is an ipimense hall supported on pillars and arches, and the surface crowded with beds. The distance from outer air to outer air, free of the build- ing, is about 80 feet. The general hospital at Madras is constructed on a different principle from any others, but on as bad an one. It consists of a centre and two wings, and appears to be 14a NOTES ON HOSPITALS. intended for four rows of beds between the opposite doors and windows. Fig. 31. Plan and Section of General Hospital, Fort St. George, Madras. Section on A B. All the sanitary defects of barracks re-appear and with worse consequences in the hospitals : viz., bad water-supply, bad ventilation, no drainage, (Ferozepore says, " drainage not necessary,") offensive latrines, so offensive indeed that the patients have sometimes to leave a particular ward, no means of bathing, and hardly any of cleanliness. There are besides, however, two grave defects not felt in barracks, but peculiar and fatal to hospitals. INDIAN MILITARY HOSPITALS. I43 These are the cooking and the attendance. It is in several reports complained that under the present system the cooks (natives or Portuguese), are nothing but " miserable pre- tenders," because the pay is so small ; that the kitchens are no, better than, but just the same as the barrack kitchens. They are often small open sheds, without chimneys, the smoke finding its way out as it can, and with but few utensils ; sometimes the food is prepared on the ground. " But we are accustomed to this in India." It is added, that though common food is tolerably well prepared, there is nothing whatever that can be called sick cookery, nothing whatever to tempt the appetite or spare the digestion of the sick man, whom the hospital is for. In hospitals at home, trained cooks of the army hospital corps are now in charge of the cooking, under the direction of the purveyor, who is responsible that the diets are properly cooked. In India the chief quality in native cooks appears to be the " pursuit of cooking under difficulties ;" their ingenuity in bringing about an apparently good result, in a rude and often bad way, is frequently admired by the reporters, as if the end of cooking were " to make a pair of old boots look like a beefsteak." In England where the grass-fed meat is so much better than in India, it is found necessary to put the purveying of meat for hospitals . under the charge of the purveyor, for the sake of always obtaining the best quality. There does not appear to be any provision of this kind in India, where all is under the commissariat. As tO' the attendants, they are just the same as would be supplied to idle healthy men. Quantity, it would seem, is supposed to supply quality. In serious cases a " waiting man" is supplied " from the battalion, who is relieved daily." X44 NOTES ON HOSPITALS. That is, he goes on guard for 24 hours, as in the guard-room, so in the sick-room. It appears that mounting guard in the sick-room is disliked, and the guard sometimes neglects his patient. As to supposing that any nursing is required, the thing is totally out of the question. There are neither trained order- lies nor female nurses. A matron is sometimes " sanctioned," but " only for a complete battalion." If there are fewer sick they must do without. Every severe case, as has been stated, is allowed to have its comrade to itself in from the ranks, i.e., the case which requires the best nursing is to have the worst nurse. Something more is needed to make a nurse, as well as a sur- geon, than mere kindness. Wherever the above comrade- practice is found, we know beforehand that there can be no nursing, no discipline in that hospital, and any amount of drink. There is generally one hospital sergeant and a " plentiful supply of ward coolies." The hospital sergeant is for disci- pline, and under him are 79 coolies and bheesties in cold weather, 240 in hot weather. This for an European corps. The general impression, as regards the native attendants,* is that they are in some sense kind, but " as a rule, very inat- tentive," and when there is any pressure of sick they are " lazy," and " apathetic," and the sick, it need hardly be said, neglected, and " averse to be waited on by them." When at * And here comes in again the difficulty of difference in language. Our men dislike and despise the natives, and are regarded by them in return more as wild beasts than fellow-creatures. The native, however, makes much more effort to learn the Briton's language than does the Briton to learn the native's. It is difficult to give an idea of the evil effects of the gross ignorance of all that relates to the country in the ranks of our army in India. The commonest attempt at conver- sation gives rise to feelings of hnpatience and irritation, too often followed by personal ill-treatment. Where the Briton is sick, it is of course worse. INDIAN MILITARY HOSPITALS. 145 a hill Station, as Landour, the hospital sergeant is taken at random from the sick men themselves, sent up for conva- lescence ; it is needless to point out the consequences. This grievance has been repeatedly represented, but in vain. Nynee Tal has one hospital sergeant, one barber, one orderly, for its attendance. Lady Canning introduced female nurses at Allahabad, who are mentioned (in the Stational Return of Allahabad) as being a great comfort to the sick. Wherever there are general hospitals there should be female nurses, but only under the organization laid down by the Medical Regulations of October 1 859. It is a great mistake to put down a few women among a parcel of men (orderlies and patients) without exactly defining the women's duties and place. Lastly, there appears nowhere in India to be provided any means of drying hospital linen, even during the rains. It Is often complained that the washing is very bad and that the native washermen tear the linen, and at one cavalry hospital this keeps two tailors constantly employed in repairing the rents and injuries ; for native washing is done by beating the linen against large flat stones or wooden boards. If the British military hospitals are such, what must be said of those for our native troops ? Here the patients " diet themselves." Native Hospitals. — As regards construction, where native hospitals have been specially built, they resemble the smaller class of British hospital. One of the most complete of these is shown in fig. 32. There are wards within wards, com- pletely enclosed by other rooms, of which, although there are plenty, not one is suited for ward offices. But it must not be supposed that native hospitals are all as good as this. They are generally nothing but a shed, per- 74(5 NOTES ON HOSPITALS. Fig. 32. Plans, Sections, and Elevation of Native Hospital, Kumool Fort. Kumool Fort Hospital. Section on A B. PRIVY ■ IS 'k9' Section of Privy. li|f I COOKROOM Section of Cook-room. INDIAN MILITARY HOSPITALS. I47 haps a " gun-shedj" or a " cattle-shed," as at Kolapore, con- verted into a hospital, where the sick receive nothing but medicine. The patients cook their own diets, eating and drinking what they please. Or when too ill to cook for themselves, an orderly friend is detailed for the purpose. There are no conveniences ; sometimes the sick go home to wash, or bathe themselves in a tank. Such are the " ward offices usually provided for these establishments." In one native infantry hospital at Secunderabad it is stated that hos- pital gangrene frequently occurs from overcrowding, from the cachectic state of the patients, owing to the unhealthy character of their lines, and from a cesspool in the hospital enclosure, which last is, however, being remedied. At Rangoon, it is stated that the privies, for native regi- ments, are built of matting, " which is most objectionable, as allowing the escape of noxious effluvia." Is it then desired to keep the " noxious effluvia" in ? It is supposed that " caste" prejudices are such as to" pre- vent native hospitals being properly built, and supplied with requisites for sick. But this has to be proved by giving natives a properly constructed and provided hospital. There are plenty of " caste prejudices" in this country against good hospital construction ; but good hospital construction advances nevertheless. At Loodiana, one native doctor, one cooly, one water- carrier, one sweeper, are the attendants " sufficient for the ordinary wants of the sick." The present arrangements for the female hospital are said to be " sufficient," (which means none.) (Loodiana is now a native station). These native hospitals, again, combine all the disadvan- tages of civilization without any of its advantages. In one place the hospital was so overcrowded that for two years L 2 148 NOTES ON HOSPITALS. " gangrenous and spreading sores " were " frequent." Ill another it was so much out of repair that " it would before long be a ruin" (the best thing that could happen to it). If there is a privy it is a " small room, with no place in which the excrement can go to be cleared away." If there is a lavatory or bath, it is " two tubs out of repair," (does that mean that they cannot hold water ?) If there is a kitchen, as at Mercara, it is under the same shed as a privy, and cannot be used for the stench. Indeed the medical officer proposes that it should be turned into a privy. The sick generally cook under the nearest tree, and if unable to do so, a comrade cooks for them under the tree. Linen is washed and dried by caste comrades, or by the patients when not too ill. Each patient brings in his own- bedding ; generally his own bed- stead. " Each patient defers bathing, according to custom, till he is cured, when he retires to the nearest well, draws water, and undergoes the bath of cure," i.e., when he no longer wants it. Every report begs for a bath-room. These are the facts with regard to the constructive arrange- ments for sick and for administrative purposes in the various classes of Indian hospitals. Some of the recent military hospitals are superior to those described. They are erected on what is called the standard plan, supposed to contain every necessary requirement, and issued for the guidance of local authorities. Fig. 33 shows half of this plan. It consists of a large hut with sloping roof, supported by longitudinal and transverse arches, the latter of which divide it into six divisions, called wards, each of which is 48 feet long, 20 feet wide, and 1 8 feet high to the top of the wall. The building from end to end is intended for 96 beds, virtually in one long ward, at 1 080 cubic INDIAN MILITARY HOSPITALS. 149 feet, and 60 superficial feet per bed. The floor is raised 4 feet above the level of the ground ; but there is no circulation of air beneath the floor. There are six open fire-places in the closed verandah, which runs along one side of the -hospital. The verandah on the other side is open. There is roof ventilation along the entire length. There is a non-commissioned ofiicer's room at each end, with a door opening into the ward. Fio. 33- Standard Plan and Section of Hospital, Hazareebaugh. There are several favourable points in this construction, but it cannot by any means be taken as representing good hos- pital construction for a warm climate. There is no circulation of air beneath the floor ; the hut forms, in reality, one long ward with 96 beds in it— just four times too many ; and, as it is, the ventilation is obstructed by the transverse arches. The closed verandah along one side is inadmissible, if closed by 150 NOTES ON HOSPITALS. anything else but jalousies, — except, indeed, in very exposed situations, subject to high winds. But even in such positions it is better to place the end of the building to the wind, and to leave the sides without closed verandahs, than it is to turn the side to the wind with closed verandahs. The wall space per bed is smaller than I ever remember to have seen in any European hospital ; pairs of beds appear to have only about 7 feet allotted to them. It is true there is a door or window between every two pairs of beds ; but these, if used for ventilation, will necessarily expose the sick in the beds directly to draughts of air, which cannot fail to be injurious in not a few diseases. This plan exhibits no improvement in hospital lighting ; for, although the ward is 18 feet high, exclusive of the open roof, the openings in the verandahs and the arches in the longi- tudinal Walls are only 9 feet high. There are no ward offices ; and the building can only be considered as an improved camp hospital. It is very important to inquire on what general principles hospitals for Indian climates should hereafter be constructed. The defects in the present plans, taken in connexion with the local conditions described in the Reports, appear to indi- cate what these principles should be — e.g., malaria is a con- stant product of the Indian soil. It rarely rises more than a few feet above the surface of the ground ; but all who sleep within its sphere suffer more or less. I . Out of this fact comes one great general principle — ^viz., that sick men in India should always sleep as high above the ground as the circumstances of the case admit of; the height will vary with locality. In high, well-drained positions, 4 or 5 feet will be enough ; but in low, malarial districts, the sick should always be placed on upper floors. In every instance iiMUiAN MILITARY HOSPITALS. 151 there should be a free current of air between the ward floor and the ground. 3. In a warm climate it cannot be safe to agglomerate a large number of sick in one yard. It is unsafe in Europe. It cannot be less unsafe in India, What is wanted in a warm climate is a very free movement of the air around the sick, without exposing them -to blasts or great variations of tempe- rature. And all emanations from the sick should be dis- charged at once into the open air. To realize these advan- tages, the best method obviously is to subdivide the sick in separate detached buildings, containing, say, 24 beds each, or thereabouts, so arranged as to obtain the full benefit of pre- vailing healthy winds, 3. In all hospitals, but especially in hospitals in warm climates, the question as regards space is not simply one of cubic feet per bed ; but it is mainly one of superficial area. What is wanted is .a large body of comparatively pure air around each bed. The extent of area and space will of course differ according to the healthiness of the position. In high airy districts the surface area might approach to that of a cooler latitude, viz., 100 square feet, with 1500 cubic feet, which is now the regulation in Her Majesty's service for warm climate hospitals. In low, hot, moist, malarial localities, it would be better to have no hospitals. But as there must be sick, the space and area per bed should be increased in a cor- responding degree, from 100 up to, say, 120 or 130 square feet, with from 1500 up to, say, 2000 cubic feet. 4. In a sick ward, simplicity of construction is essential to good ventilation. There should be no transverse arches or thick pillars, no double verandahs nor corridors. The ward should be perfectly open from end to end, and from side to side. The window space and door space should be 1^2 NOTES ON HOSPITALS. sufficient for light and ventilation. Dark hospitals are unfit for sick. It is not necessary for light and heat to go together. The doors and windows should be on opposite sides. Verandahs are required for shelter from the sun. They should always be single and open, and of sufficient width to affiard the,requisite shade. Verandahs should never be constructed or used to supplement the sick accommodation, or for dining- rooms, or for convalescent day-rooms. All such accommoda- tion should be provided at the end of the block and not along its sides. 5. In permanent hospitals the wards should be ceiled. They are more comfortable, cooler, and they look cleaner. The space between the ceiling and the roof should be freely ventilated to allow the hot air to escape. Double walls, where practicable, having a ventilating space between the outer and the inner wall, with openings above and below to allow a cur- rent of air to pass up, will always be cooler than any other construction, except the walls be very thick. 6. The question of wall space for beds is of great importance in hot climates. It is inadmissible to place a bed close beside an open door. Any arrangement of doors and windows which allows the wind to blow directly upon the sick should be avoided in future. There should be a space of at least three and a half feet between every two adjoining beds, if the beds are arranged in pairs. But it would be much better to con- struct wards which would allow the beds to'stand at equal distances from each other. If each bed is allowed as a minimum 100 square feet of surface, and 1500 cubic feet, the bed might have from 8 to ] o linear feet of wall space. With wards 15 feet high, which is quite enough, an 8 feet wall space would enable the ward to be about 35 feet wide. A 10 feet INDIAN MILITARY HOSPITALS. I53 wall space would reduce the width to lo feet, which is rather narrow for comfort. When the larger amounts of cubic space and superficial area are given, the wall space per bed need not exceed lo feet, and the additional surface should be thrown into the width of the ward, the height (15 feet) being retained. As, in hot climates, all convalescents musi be removed to convalescent wards, and as thus only serious cases, generally of fever or dysentery, will remain, the conclusion is, how doubly important a sufficient space and area ! 7. Each ward should have its own ward offices. Or if two wards are placed in line, end to end, certain of the ward offices might be placed in the space between them outside the verandahs. These might be the ablution and bath-rooms, and scullery. The hospital sergeant's room must always be attached to and overlook one ward, if not both, and if not both, the orderly's room must overlook the other. Each ward should have a separate water-closet accessible from the verandah, but so arranged as to prevent the patient going out or holding communication with persons outside ; and yet with a perfectly free cross ventilation between the closet and the ward. 8. Each ward, in such a climate as India, should have a bath with hot and cold water laid on. There should be a basin-stand with sunk basins and water laid on. 9. Were it not that there is not a hospital in India which Is drained, it might appear quite superfluous to have to state that no building is fit for sick that is not thoroughly drained to an outlet. 10. Every hospital should have an abundant supply of pure water laid on, for all purposes. The present supply by water-carriers and bullocks is perfectly absurd. n. Ventilation should always be ensured by a sufficient 154 NOTES ON HOSPITALS. number of louvred ventilating turrets carried straight from the ceiling of the ward through the roof. They should be so louvred as to prevent rain beating in, and they should be pro- tected at the ceiling in such way as to prevent casual blasts of air in high winds from, blowing upon the sick. Fresh air should always be admitted abundantly at the eaves. The fresh-air ventilator should be carried all the way round the hospital ; there should be louvres to throw air-currents up to- wards the ceiling ; the ventilation should be sufficient at ordi- nary times without doors or windows, but the doors and windows should be jalousied to be used for increasing the ven- tilation in still weather. The windows should always be glazed, which they are not at all invariably in India. I a. Each hospital kitchen should be supplied with Improved cooking apparatus. 13. All the administrative offices should be in one block by themselves ; the wards should only be for sick. If the hospital were on an upper floor, the administrative offices and stores might occupy the ground floor. 14. The medical and nursing attendants should never have to pass all their day upon the road, in going backwards and forwards, as is not at all unfrequently the case in India. Con- venient quarters should be provided, and the regimental orderlies' rooms should be attached to their respective wards. 15. Each hospital should be provided with a covered ambulatory for convalescents. 16. Convalescent wards, and especially convalescent day and dining-rooms, are a necessity of all hot-climate military hospitals, more particularly during epidemics. Because a soldier must be in hospital or in barracks. To leave him, when recovering from fever or dysentery, among the fever and dysentery cases, or to make him return from a day-room to INDIAN MILITARY HOSPITALS. 155 sleep among them, is to consign him to an almost certain relapse. He should sleep in a convalescent ward, and eat and live in a convalescent day-room. But these convalescent wards must have a completely appointed nursing staff of their own, the same as sick wards have. Otherwise the convales- cents will play tricks, and make themselves worse instead of better. And the day-roorri must be included in the super- vision. Convalescent accommodation will enable the hospital to be cleared much sooner than if convalescents are left to sleep, eat, and pass their time among men in all stages of the same epidemic malady from which they themselves may be re- covering. 1^6 VIII. HOSPITALS FOR SOLDIERS' WIVES AND CHILDREN. Of late years a small number of hospitals for sick wives and children of soldiers have been erected in this country, on account of the very defective accommodation in married soldiers' quarters rendering due care of the sick, espe- cially of cases of confinements, all but impossible. These new hospitals are constructed on the same plan as that adopted for regimental hospitals, figs. 21, 2a. One half of the building is set apart for general cases, and the other for confinements. A small delivery ward is provided at one end of the long ward instead of the bath-iroom, which is not required ; but in every other respect the plans are similar. Each hospital has a matron and such additional attendants as she may require. Wherever these hospitals have been provided, they have been of the greatest use. There are female hospitals also in India, but they are constructed on a totally different plan. Some of them, as at Kurrachee and Deesa, Lucknow, Raneegunge and Ferozepore, appear to be very complete, with female at- tendants. In the Madras Presidency, they are too often, as at Bangalore, Trichinopoly, and Kamptee, merely men's wards appropriated to women, and justly stated to be " objectionable in every way." Elsewhere they are rather bare. Indeed, as at Baroda, Kirkee, Poena, Darjeeling, the sick women and HOSPITALS FOR SOLDIERS' WIVES AND CHILDREN, I57 children " have to be attended at their own quarters," either because " there is no matron," or because the " ward is too small," or, &c. &c. Curiously enough, it is generally stated that the " present arrangement is conducive to comfort." What arrangement ? Of having no matron ? While it is added, that a lying-in ward and a matron are " much wanted." At Darjeeling the women and children are treated in their own quarters, which *.' would be satisfactory enough if the married quarters were not so dark and damp as they are." Some- times it Is said that " the arrangements are quite equal to those for the men." The construction of these hospitals appears to be the same as that of small regimental hospitals. The following plan and section of a female hospital at Meean Meer (one of the most recently built in India) shows that they require quite as much structural improvement. It is a nest of rooms within rooms ; and the same may be said of it Fig. 34. Plan and Section of Female Hospital, Meean Meer. is8 NOTES ON HOSPITALS. that one of our engineers said of the Pacha's new fort on the Dardanelles, that " he would be much safer outside of it," '^•^.vi.* X.V A*> Section on C D. 159 IX. HOSPITAL STATISTICS. In the first edition of my Notes on Hospitals the defects of existing systems of hospital statistics were pointed out, and it was proposed to collect and tabulate certain elements for each hospital on one uniform plan. This plan was laid before the London meeting of the International Statistical Congress, and was adopted by the Congress with a few ad- ditions. The special question of statistics of surgical opera- tions had subsequently to be considered. In the present section will be given the substance of my former communica- tions, as well as the new proposal for tabulating all opera- tions on one uniform plan. These methods, if generally used, would enable us to ascertain the mortality in different hospitals, as well as from different diseases and injuries at the same and at different ages, the relative frequency of different diseases and injuries among the classes which enter hospitals in different countries, and in different districts of the same country. They would enable us to ascertain how much of each year of life is wasted by ill- ness, — what diseases and ages press most heavily on the re- sources of particular hospitals. For example, it was found that a very large proportion of the limited finances of one hos- pital was swallowed up by one preventible disease, — Rheu- matism, — to the exclusion of many important cases or other diseases from the benefits of the hospital treatment. l6o NOTES ON HOSPITALS. The relation of the duration of cases to the general utility of a hospital requires also to be shown, because it must be obvious that if, by any sanitary means or improved treatment, the duration of cases could be reduced to one-half, the utility of the hospital would be doubled, so far as its funds are con- cerned. This section is divided into two heads, the first referring to the general method laid before the Congress ; the second, to an additional proposal for a uniform method of recording the results of surgical operations. A. General Statistics of Hospitals. In the appended Table for registering Hospital Statistics, the nomenclature agreed to at the Paris meeting of the Statis- tical Congress has been adopted, with two or three slight modifications, referring chiefly to rare diseases ; and the pro- posed classification is essentially the same as that used by the Registrars-General of the United Kingdom. The form itself has been in use for many years in the Re- gistrar-General's ofiice, for the registration of deaths ; and has hence the advantage of having been fully tried by experience. Each Table is divided vertically into columns containing the ages in monthly and yearly periods from under i year to 5, Above 5 the ages are given quinquennially. The disease list is divided into two sections, one printed on the left hand, the other on the right of the sheet. The left- hand division contains the diseases more frequently admitted into hospital ; the right-hand the rarer forms of disease. This arrangement is necessary for the purpose of limiting the size of the Tables. HOSPITAL GENERAI> STATISTICAL FORM. This Sheet will serve for the Chissitieatioii of Cases hi Hospitals under the following headings: — "Remaining, ist January "- "Admitted" — "Cured (or Relieved)" — "Dead" — "Discharged ineurable, for Irregularities, or at their own Request "- " Remaining, 31st Deeember " — " Duration of Cases in Days." irrite the N'nmc of Hosjutal, the Sex, the required Heading, and Date, irith the Pen. Ages Months. CLASS I.— OuDEit I. (ZvMOTio Diseases.) J. Small IVix Mt'JlslfS \Vlinoiiiii^ CVmgli .... Oioiip Wciirlatina tjuiiisy DilTlitlu'i-iii t'uryzLL, (.'atarrli, luliiu'uzii (.^phtluiliiiiH ipurulfut) . . Ervsipolus Metriii (imerpoml Fever) . Pj'iuinia Huspital gaiigivno . . . Ciirliuiule, JBi'il .... llysi'iittTV Dianha'a CliMlria Typhoid Fuvor ttyphia) . . Tyuhus . Kelap»iujj Fovt-r (typhiuia) Asii» . . , lU'iiiittent I'ovlt . . . . Klaniinatisiu UTUi^Iiti OUDEH II. GiHutrrlioia Primary Sypliilia .... Set-i'iiilary Sypliilia . . . Tt-rtiary Syvihilis . , . . OTJlEli^ OuDElt III. Scurvy Purpura I a. Delirium tre- Aleolu>l } mens . . . ( b. Iutoiui)erauoo OTillSli.'S OUDEII IV. Thrush . Worms . . CLA.SS II.— OuDKU I. (OONdTlTUTIONAL Diseases. ) Gout Dropsy Gaui-'.er CankiT ^utima) JVlurtitieatiuu OTJIEUS OitUEU II. Scrofula Tabrreulosia iVIeseiiterica . Pbtliisis Hiemitptysia ...... I'neumotlHUax Hvtln.etipliahia (with tu- bercular (ioposit) . . . OTJJEHS CLASS III.— OiiuEH I ^LOOAL DlSliASES.) A. Brain, spinal marrow, uud nerves. JMeningitia • Ceplialitia tiufUnliug acute hyitroeepliahmj . . . • Taralvsis Cliniea Mama KviUv^y Hysteria ....... Totiinus ^idiopathic) . . . CouvulaiiuiB OTilEiiS 3 ; 6 n. Scnsu uigiuis. OphthiilinitiB (iio{ pui-iileut UiitiiniL-t Amina'osis ...•■■ GliiiicMUKi Mill iitlier ilia- oiises uf tlio eyo .... Otorrhoea Otitis ,; • ■ DiafnosB null other diswisus of tlui e;ir OrilKliS Obdbr II. Cnrditia rericarilitia ElidoiiiuiUtia ■ V ,* ■ ■ Disoase of Heart Valves . Heart HyiJortropby . . . ,, AUopliy ....•• , , Fatty ilegeueratiou Aueuriam of heart . . . Aii"'ui"i8ia of aorta, &e. Angina l^eotovjs . . . . Fainting I'hleliltis Vaiix OTHERS nnnpn TTT_ 10 15 20 25 30 35 40 45 50 65 60 65 70 75 80 85 90 95 and upwards. Most of the diseases in the fullowinff marginal list are of less Frequeut occur- rence in hospitals | and all, with some exceptions, are r/tiMVf/ us "Others in tiieir respective oi-ders in the left-hand column. They will bedistinRuiahed in abatract- ing the diaensea by writing the itiji-s uf the persona at- tacked, cuied, ur dead, Aic, against the particular dis- ease in the nmigin below. Tliua, a pel-sou a^ed IK would, if admitted for " iiiumps," be indicated in the body of this sheet by a tick against " Others" of Class I. Order I. ; and his ago (1(>) would be written against "mumps" in tlie innrgin. And so of other diaeases. The diseases not found printed in the mar- gin must bo written in tlieir proper eom^iartments. A Bumniary of the facta in the margin should be given in an appendix to the gene- ral Table. CLASS I. OllDER I. varioloid varicella niilinria mumps erythema dysentery with abscess .,f liver (phiced tu yellow fever Ordeu II. leprosy (Greek elephnn- tiasis) yaws fflaiidera nydroiihobia iualiy;iiant pustule necusia' • luffffiiiii h}/ ptmc- tiirr in ilissn-titm or h;/ haiiiitiiuj the purls of thud .mi- ma Is. Order III. rickets bronehocelo cretinism ergotism Order IV. phthiriasis II !/iiii tills, tape ii-inm, i- (iisfinoni.sf,ai hnr. In the n,,.it'.,/ tutilv t/in/ vill /.<■ ,i,lil,nra- /•/sis" in the eapital ttibte, should he distinuaished here, and the ,ii,es slj/ed. inononiaiiia \placcd to niiiniii^ larynj^iHunis stridulus The dip-rent purls of the ei/e iitliiehed hi/ injiamma- tioti should be distintjuished here. neuralgia (tic doulou- reux' neuroma Order IT. arteritis atlieroma (of arteriofl) Order III. hydrothorax empyema pleuripnoumonia (placed to pneumonia) coiiL'isticin of lungt .placed to pneumonia] enipliysenui (of hmga) svairious melauosia Order IV. glossitis stoinatitia pharyngitia lesopliagitia Histini/iiish here the fol- lowioii rariifie.1 of /u'liiia, ((// of which are classed in the capiUil table under hernia : contH'nital femoral or crural imjuinal scrotal umbilical ventral Order V. di uresis stricture of urethra (not a conaequonce of gonorrhoea) In cases of stone and gra cc/, the composition of substances should be speci- fied here. Order VI, orchitis liysteritia ovarian tumour uterine tumour polypus of uterus Order VII. fragilitoa ossium inoTlities oaaium Order VIII. i!ipi8taxi8 Laryugitia ((Edema of the glottis) Bronchitis Pleurisy l^eumonia Asthma OTIJEiiS Order IV. Gastritis Euteritis Peritonitis Coustipation Colic ^ Ileus (Obstruction of bowels) Intussusceptiou .... Hernia Stricture of oesophagus . Stricture of intestinal tube Ulceration of intestinal tube Dyspepsia Pyrosis Gastralgia Hfflmatemesis Apoplexy Mehena Haemorrhoids Fistula Pancreatic disease . . . Spleen disease Hepatitis Jaundice Gall Stones CiiThosia Ascites OTHERS Order V. Nephritis Ischuria Nephria (Bright's disease, AlbuminuxLa) .... Diabetes Stone (uric Acid, &c.) . . Gravel [uric Acid, &c. . . Heematuria Cystitis Disease of Prostate Gland OTHEHS Order VI. Varicocele Hydrocele Ovarian Dropsy .... OTHEHS Order VII. Synovitis Ostitis (including periosti- tis and endostitis) . . . Exostosis Curvature of Spine . . . Caries Necrosis Muscular Atrophy . . . OTHERS Order VIII. Phlegmon Whitlow Abscess (external) . . , Ulcer (external) .... OTHER SKIJ^ diseases . CLASS IV.— Order I. (Developmental Diseases.) Spina bifida OTHER malformations . Teething OTHERS Order II. Chlorosis Childbirth (SSoTL. Paramenia (including Ainenorrhoea, Leucor- rhoea, Turn of Life, Cli- macteria) CLASS V ViOLBNT Deaths ob Diseases. Order I. — (Accident.) Bum Scald Fracture Contusion Concussion , Gunshot wound .... Cut, stab Poisoning OTHEItS Order III. — (Homi- cide.) Order IV. — (Soioidk. Gunshot wound .... Cut, stab Poisoning OTHERS Sudden deaths (cause not ascertained) Causes not specified or ill- defined Total . , . 1 ; / 1 mm snoma oe auiiitffuisnea here. neuralgia (tic doulou- reux" neui'oma Order II. arteritis atheroma (of arteries) Order III. hydrothorax empyema plouripneimionia (placed to piu'umonia) congfstion of lungs (placed to pneumonia) emphysema (of lungs) spurious melanosis Order IV, glossitis stomatitis pharyngitis tesophagitis Disri)t}/uish here the fol- lowing varieties of hernia, all of tvhich are classed in the capital table under hernia: congenital fnnoral or crural inguinal scrotal umbilical ventral Order V. diuresis stricture of urethra (not a consequence of gonorrhoea) In cases of stone and gravel, the composition of substances should be speci- Jied hei-e. Order VI, orchitis hysteritis ovarian tumour uterine tumour polypus of uterus Order VII. frngilitas ossium moTlities ossium Order VIII. roseola urticaria eczema herpes pemphigus ecthyma impetigo acne mentagra lichen prurigo psoriasis pityriasis ichthyosis 7» abscess and ulcer the parts affected should be dis- tinguished hei'e. CLASS IV. malfoiinations anus imperforatus cyanosis decay of old a^e atrophy and debility CLASS V. Order I. explosion of powder, eas, &G. (phiced to burti) chilblains frost-bite lightning, (where struck and how ?) sun-stroke (statecircum- stances) The circumstances attend- ing deatiis by violence should be shown in detail; as, for example, how many persons, at their several ages, were burnt by their clothes taking fire, how many died by fall- ing from scaffolds or heights, how many were poisoned by arsenic, opium, quack medt- cine, over-dose, ^-c. Gun- shot wounds should be dis- tinguished as regards th€ species of weapon,— rifle, pistol, cannon, ^c.,- other wounds, as wheVier in- flicted by knife, dagger, ^c. When cases of prtvaiionf drowning, hanging, suffo- cation, fall within observa- tion, they should be placed to Others" in the general Table, and Oie particulars should be stated here. All violent deatlis should fall under one or other of the three orders: Acddent^Ho- micide-^~Suicide. IToface p. IQCf] HOSPITAL STATISTICS. l6l In allotting the diseases between these two columns, ad- vantage has been taken of the experience gained in filling up the forms by diiFerent hospitals. The facts In regard to the diseases In the left-hand column, being those of most frequent occurrence in hospitals, are to be entered directly in the columns of the Table. The name of any disease not found in the left-hand column Is to be looked . for in the right-hand one, and the ages of the persons affected are to be placed after the name. The class and order in which the case stands is then to be sought for In the left-hand column, and a mark or marks, as the case may be, are to be placed in the " age" column in the line " others." Should any yery rare case present itself, not Included in the right-hand column, it should be written-ln under its proper class and order, and entered in the left-hand column under the head " others" as before. These exceptional cases will only afford statistical results of value after periods of years ; and they should be extracted separately. It Is proposed that one and the same form should be used for each statistical element. Seven elements are required to enable us to tabulate the results of hospital experience ; they are as follow : — I. Remaining in hospital on the first day of the year, a. Admitted during the year. 3. Recovered or relieved during the year. 4. Discharged Incurable, unrelieved, for Irregularities, or at their own request. 5. Died during the year. 6. Remaining in hospital on the last day of the year. 7. Mean duration of cases In days and fractions of a day. These seven elements printed as separate headings and M l62 NOTES ON HOSPITALS. attached to copies of the same form, or written-in, would fur- nish us with the means of tabulating every fact we require. Provision can be made for different sexes in one of two ways.: the column for each age may be subdivided for males and females ; or it might be more convenient to have two sets of forms, one for each sex. ' Again, surgical cases and injuries may be included in the same form with medical cases ; or, in large hospitals, a sepa- rate set of forms might be devoted to surgical cases. For small hospitals, one set of seven forms might easily be made to contain the annual statistics of ages, sexes, and dis- eases (medical and surgical) ; but for very large hospitals, pos- sibly four sets might be required. The primary object of these Tables is to obtain an uniform record of facts from which to deduce statistical results, among which the following may be mentioned : — I. The total sick population — i.e., the number of beds con- stantly occupied during the year by each disease for each age and sex. a. The number of cases of each age, sex, and disease sub- mitted to (medical or surgical) treatment during the year. 3. The average duration in days and parts of a day of each disease for each sex and age. 4. The mortality from each disease for each sex and age. 5. The annual proportion of recoveries to beds occupied and to cases treated for each age, sex, and disease. In reducing the data to give the annual results, either per- centages or per-thousands may be used. The number of beds constantly occupied may be obtained by taking the mean of the numbers remaining at the beginning and end of the year, if the hospital has been fully occupied ; or HOSPITAL STATISTICS. 163 the mean of the numbers remaining at the beginning and end of each quarter ; or oftener, if the hospital be irregularly occu- pied ; or, the total number of days spent in hospital by all the cases during the year might be obtained ; and by dividing the sum by ^6^y the mean daily sick would be arrived at. [The total daily " diets" issued during the year divided by 365 would give the same result.] The " sick treated" during the year may be obtained by taking the mean of the admissions, and of the discharges from all causes, including deaths. With fixed data, arrived at on these principles, we can readily obtain the proportionate mortality, not only of the whole hospital, but of every ward of it, and also the propor- tionate mortality and duration of cases for each age, sex, and disease. It need hardly be pointed out of what great practical value these and similar results would become, if obtained over a large number of hospitals. The laws which regulate diseased action would become better known, the results of particular methods of treatment, as well as of special operations, would be better ascertained than they are at present. As regards their sanitary condition, hospitals might be compared with hospitals and wards with wards. The whole question of hospital economics as influenced by diets, medicines, comforts, could be brought under examination and discussion. The liability of particular ages, sexes, occupations, and classes of the community to particular forms of disease might be ascertained ; other data, such as " married" or " single," previous attacks of illness of the same or of different kinds, birthplace, &c., might be added for comparison, and hospital M % 164 NOTES ON HOSPITALS. experience might thus be made to subserve sanitary improve- ment. The data for these latter comparisons would have to be kept separately, as indeed they generally are in all well-regu- lated hospitals. The present proposal for improved hospital statistics is confined to those points bearing directly on the welfare of sick admitted to the wards. The work has been materially assisted by the kindness of the authorities of St. Thomas's, University College, and St. Mary's Hospitals, who have been at great pains in having the experimental sheets (sent to them) accurately filled up, and to whom grateful acknowledgments are here expressed. These forms are now in use in St. Bartholomew's Hospital and In London Hospital ; and the recommendations of the Statistical Congress have led to a greater uniformity in keeping the records of several other large hospitals. The forms are intended solely for the tabulation of cases, whether of in-patients or out-patients, but the Congress con- sidered it to be advisable that certain other data should be recorded; and it made the following recommendations, in which I cordially agree. I. The publication in the Annual Report of a tabular STATEMENT, not only of the total number of patients, but also of the total number of cases of disease, under the various heads, distinguishing the diseases which have supervened in the hospital. «. That in the registration of cases, not only the disease for which the patient is admitted, but also those by which he is subsequently aflFected, be separately recorded. HOSPITAL STATISTICS. 165 3. That not only the date of admission into hospital, but the date of attack be recorded. 4. That the date of admission be noted, so as to be com- pared with the disease, occupation, and age of the patients. 5. That in transferring patients from medical to surgical wards, or vice versa, an uniform method of record be adopted. 6. That the exact locality in which the disease originated should, as far as possible, be recorded. 7. That a system of registration of oa/-patients at hos- pitals and dispensaries be adopted on a similar classi- fication (as far as practicable) to that of the in-patients. 8. That in hospital statistics the average proportion of empty beds be noted, both for the whole year, and also for the different seasons. 9. That the average cost of each in- and uaZ-patient be noted under the different heads of {a) food, &c., (3) officers and nurses, (c) drugs, &c., (d) sundries. 1 o. . That in all hospitals supported by private subscrip- tions, both the number of in- and oa/-patients be noted, and also the number of letters of recommen- dation given. 1 1 . That previous diseases of patients, and diseases and habits of parents, be (as far as possible) noted. 12. That in hospitals there be tabulated : — The number of beds. The number of storeys. The number of wards. The length, breadth, and height of wards. The number of beds per ward. ,l66 NOTES ON HOSPITALS. The cubic feet per bed. The superficial area per bed. Number of windows, with their dimensions. Means of ventilation. Drainage. Water-closets or latrines. Water supply. HOSPITAL STATISTICS. 167 g o t3 rt r^ D Goo •a ■■'^ o o 'S Oh S* CO C fq .a T3 u o ^ ui I- C si CO ifcl M o 2 o "6 ^ i ■^ •S .2 &i O o W) ffi rt« g o o pq O o ^ t:) ,xH P3 j_( 2 •^5-S •^ ^ o S O (U O.C1 j3 U -t-t •*-> Remarks. (Previous Diseases of Patients and of Parents.) Duration of Case in Hos- pital in Days and Quarters. a Of Transfer to other Division of Hos- pital. Of Dis- charge, (Relieved) or (un- relieved), or other- wise. Of Death. Of Re- covery. Of Attack. Disease or Accident. Trade or Occupa- tion. Resi- dence, and Place where taken ill, or Injured. Sex, M.or F. < & Date of Admis- sion. d 0. ^ ^ ° 3 '^ o .iS « CO CJ W ••? _ >- .2 W 3 rt '^ O a « s s "^ ■•a a S iS "*" .£1 g «-S S e g ^^ m U O «. =■ ^= & (9 u t: n u J3 u =" " H Sh 3^ . *^ -^ *" ' — u "a -^ oj *S S T3 0) ^ a> " 5a 3 a a ^ ^ -S « s S *^ ^-', ^ 4J r ■iii S s n u Rt 7 -fi 4J s-s 1. ■s 1 1 a 9 u i68 NOTES ON HOSPITALS. ft-, -o o .a S a K o J3 :§ .3 .1. 3 a a < bo a '$ o I Ml e o O « IS g E S o 1 1 1 i ■ (4 s .1 q S [x^ § .1 1 1^ s h s 1 ik; s s (4 s Total Cases of Disease • treated .t (4 s Admissions. h s No. of Letters of Recom- mendation.* (4 § .... n ^ 3 Quarter Quarter Quarter Quarter 1 H iS- K p e o .2 i2 5: ►J a 'E. 3 I ° U3 E- HOSPITAL STATISTICS. 169 Eh 15 M l-H H fi 4' London 3000 „ 44S . S. - Ctty of London/ ^SOO 6 - Tever . 3000 ,. Zoo 7 _ St £etrlholomewS S€0 „ S^SO S. ^ Kmjs CoUe^ ISOO „ 2SZ^ S. ^ Chari^ Cross .ZOOO ■„ IZO lO _ JVesbnzTisier 3ooo „ 191 JI _ St. Georjes . ^-^oo „ SSO IZ — 3roTnnio7v Consurrwium/ 6Soo „ ZIO 13 _ St. Mary's SSoo „ ISO M' __ Fres Hospital - ZZoo , IIO IS — Unwersiify College '3ooo „ 23^ Iff _ Middlesex Sooo „ Soo 27 _ BniLshylryiT^r in/&spiiaL ^ 2^00 „ 30 1$. _ Cify of ZondoT^y, D" D" IS'OO ., 23. _ Gertercd, D" D" Jjombet/v ZooO ,. 30 ZO -J Qiieen Charlalte's H" SOOO- „ SO ZZ. - Greai j\lortkerny Mospital Z7S0 „ SO GerTucm HoSpiial, DalsioTV . . . . -ifSOO „ S-f Sm-aUTocc Jlospxial, Mififaie . JOOO , lOO sriyyn r il i ^-r TOO Zoo 360 ifSO Soo ,ff, . SCALE . I '^ ' } r- X^ I" — r JSOo J76o yicrctS ^7-\\^' Wi c I c 1 u ;^!l --^^^Lju SKETCH PLAN OF PARIS. To shcyy the Tclatxye JJOSttian, of the Ecsjritals , ancL thar distance in direct Izncs from, the C enZTdl BnrecuL Trherc FaZi£nts circ adTnttCcd.. / . Jitvrea-ri of ^ddrmssioTL. Hotel Dieiv Direct distance frcnvlBurcaTi JLd Charzte , , ,, La Pitze . ■ . ,. Cochin, JVecTf.er , . ,, . EvfaThts .MctleuLes „ SccLvJan Jjorihoisiere S~ Louis Sf ^nCainc . CZim^ucs - SWidi - Loirrcine - J^ Euffenxe . J\faiscm d \AccciccheniCTtt. lOOlards 828 Beds 14-50 1350 2300 3000 3000 4^500 3500 2800 Z900 TOO ZOOO 2300 Z300 2000 4^7^ 6Z0 11'9 581 698 4^ie 612 810 -4-64^ -152 336 276 4^05 308 I. G. NeOhercltft..miJI.MR StCmdzM St, W. LoncUia Lon^maii Gree a — IjCL unaTiie 4^— La Pitie. 5 _ CcchiTt 6 _ JVecTcer 7— En^oTLts SMcdad.es, J 8 _ IBeauiffTL 9 Ijorwoisiere JO^ Sf Lonis 12 _ CZim^ues 13- SWidi 14^ — Loztrrctne .. 1450 . 47^ . 1350 620 ., 2300 119 .. 3000 381 . 3000 698 . 4^500 416 . 3500 . 612 2800 810 .. 2900 464^ , 700 -152 ZOOO 336 .. 2300 276 2300 4^05 2000 308 ingman Green & C