SECTION II.

HOSPITALS.

General Remarks.

Of late years a great number of works (English, French, German, and American) have been written on the construction of hospitals. This has been especially owing to the celebrated Notes on Hospitals, published by Miss Nightingale, after the Crimean war-a work the importance of which it is impossible to over-rate-and to the very useful pamphlets of Mr. Roberton, of Manchester. Among military writers, Robert Jackson in this, as in all other points, takes the first rank, and his observations on the construction of hospitals are conceived entirely in the spirit of the best writings of the present day. In the short space which can be given to the subject here, we can merely condense what has been best said on the subject, as applied especially to military hospitals. In the first place, however, a few words are necessary on the general question.

1

Although the establishment of hospitals is a necessity, and marks the era of an advanced civilization, it must always be remembered that if the crowding of healthy men has its danger, the bringing together within a confined area many sick persons is far more perilous. The risks of contamination of the air, and of impregnation of the materials of the building with morbid substances, are so greatly increased, that the greatest care is necessary that hospitals shall not become pest-houses, and do more harm than good. We must always remember, indeed, that a number of sick persons are merely brought together in order that medical attendance and nursing may be more easily and perfectly performed. The risks of aggregation are encountered for this reason; otherwise it would be far better that sick persons should be separately treated, and that there should be no chance that the rapidly changing, and in many instances putrefying substances of one sick body should pass into the bodies of the neighboring patients. There is, indeed, a continual sacrifice of life from diseases caught in, or aggravated by hospitals. The many advantages of hospitals more than counterbalance this sacrifice, but it should be the first object to lessen the chance of injury to the utmost. The risk of transference or aggravation of disease is least in the best ventilated hospitals. A great supply of air, by immediately diluting and rapidly carrying away the morbid substances evolved in such quantities from the bodies and excretions of the sick, reduces the risk to its minimum, and perhaps removes it altogether. But the supply of air must be enormous; there must be a minimum of not less than 4,000 cubic feet per head per hour for ordinary cases; and the supply must be practically unlimited for the acute and febrile diseases.

The causes of the greater contamination of the air of hospitals are these :

See

1 For fuller details, Captain Galton's work on Hospitals should be consulted. also Five Essays on Hospital Plans, contributed for the Johns Hopkins Hospital Scheme (Wood & Co., New York); Report on the Manchester Royal Infirmary, by J. Netten Radcliffe, Esq.; Reports on St. Mary's Hospital, Paddington, by F. de Chaumont, M.D; chapter in Roth and Lex, Milit. Gesundheitspflege; paper in the Practitioner, March, 1877; article "Hospital," Encyclopædia Britannica, 9th edition; Das Allgemeine Krankenhaus der stadt Berlin im Friedrichshain, von A. Hagemeyer, Berlin, 1879.

1. More organic effluvia are given off from the bodies and excretions of sick men. These are only removed by the most complete ventilation.

2. The medical and surgical management of the sick necessarily often exposes to the air excretions, dressings, foul poultices, soiled clothes, etc., and the amount of substances thus added to the air is by no means inconsiderable, even with the best management.

3. The walls and floors of hospitals absorb organic matters and retain them obstinately, so that in some cases of repeated attacks of hospital gangrene in a ward it has been found necessary to destroy even the whole wall. Continual drippings on the floor of substances which soak into the boards and through crevices, and collect under the floor, also occur, and thus collections exist of putrefying matters which constantly contaminate the air.

4. The bedding and furniture also absorb organic substances, and are a great cause of insalubrity.

5. Till very recently, even in the best hospitals, the water-closets and urinals were badly arranged, and air passed from these places into the wards.

In addition to the necessary amount to dilute and remove these substances, the freest supply of air is also now known to be a curative means of the highest moment; in the cases of the febrile diseases, both specific and symptomatic, it is indeed the first essential of treatment; sometimes, especially in typhus and small-pox, it even lessens duration, and in many cases it renders convalescence shorter.'

There can be no doubt, that the necessity for an unlimited supply of air is the cardinal consideration in the erection of hospitals, and, in fact, must govern the construction of the buildings. For many diseases, especially the acute, the merest hovels with plenty of air are better than the most costly hospitals without it. It is ill-judged humanity to overcrowd febrile patients into a building, merely because it is called a hospital, when the very fact of the overcrowding lessens or even destroys its usefulness. In times of war, it should never be forgotten by medical officers that the rudest shed, the slightest covering, which will protect from the weather, is better than the easy plan so often suggested and acted on, of putting the beds a little closer together.

The recognition that the ample supply of pure air is the first essential of a good hospital, led Miss Nightingale to advocate with so much energy and success the view which may be embodied in the two following rules:

1. The sick should be distributed over as large an area as possible, and each sick man should be as far removed as possible from his neighbor.

2. The sick should be placed in small detached and perfectly ventilated buildings, so that there should be no great number of persons in one building, and no possibility of the polluted air of one ward passing into another.

How is this perfect Purity of Air to be secured?

This is a matter partly of construction, partly of superintendence. (a) There should be detached buildings, so disposed as to get the freest air and the greatest light. They should be at considerable distances apart, so that 1,000 sick should be spread like a village; and in the wards each

1 For examples of the value of a great supply of fresh air on some diseases, see note in former editions of this work.

man ought to have not less than 100, if possible 120, feet of superficial, and from 1,500 to 2,000 feet of cubic space. With detached buildings, the size of a hospital, as pointed out by Miss Nightingale, is dependent merely on the facility of administration. When the hospitals consist of a single building the smallest hospitals are the best.

(b) The ventilation should be natural, i.e., dependent on the movement of the outer air, and on inequalities of weight of the external and internal air. The reason of this is, that a much more efficient ventilation can be obtained at a cheaper cost than by any artificial means. Also, by means of open doors and windows, we can obtain at any moment any amount of ventilation in a special ward, whereas local alterations of this kind are not possible in any artificial system. The amount of air, also, which any artificial system can cheaply give is comparatively limited. The amount of air should be restricted only by the necessity of not allowing its movement to be too perceptible.

The best arrangements for natural ventilation for hospitals appear to be these-1st. Opposite windows reaching nearly to the ceiling, on the sides of a ward (not wider than 24 feet, and containing only two rows of beds) and a large end window. 2d. Additional openings, to secure, as far as possible, a vertical movement of the air from below upward; and this will be best accomplished as follows: '

A tube opening at once to the external air should run transversely along the floor of the ward to each bed, and should end in a box placed under the bed, and provided with openings at the top and sides, which can be more or less closed. In the box, coils of hot-water pipes should be introduced to warm the air when necessary. The area of the tube should not be less than 72 square inches to each bed; and the area of the openings in the box at least four times larger. The fresh air, warmed to any degree and moistened, if necessary, by placing wet cloths in the box, or medicated by placing chlorine, iodine, or other substances, will then pass under each bed, and ventilate that space so often unaired; and then, ascending round the sides of the bed, will at once dilute and carry up the products of respiration and transpiration to the ceiling. It would be a simple matter so to arrange the hot-water pipes as to be able to cut off all or some of the pipes under a particular bed from the hot-water current if desired, and so to give a fever patient air of any temperature, from cold to hot, desired by the physician. In the low and exhausted stages of fever warm air is often desirable. By this simple plan, we could deal more effectually with the atmosphere round our patients, as to warmth, dryness, humidity, and medication, than by any other. At the same time, the open fireplace and chimney, and the open doors and windows, might be preserved." For the exit of the foul air, channels in the ridge should be provided, warmed by gas if possible.

To facilitate this system of ventilation, it is desirable to have the buildings one-storied only; but it can be applied with two stories. Only then the discharge tubes must be placed at the sides, and run up in the thickness of the walls.'

1 A plan similar to this has been devised by Dr. S. Hale, and adopted in some of the Australian hospitals. It is an excellent arrangement, but seems rather unnecessarily complicated by taking the air under the floor, and elevating the beds on a dais.

The introduction of vertical tubes is also useful, as giving the air an upward direction and allowing a considerable supply without draughts.

When the ceiling is flat the outlets may be advantageously placed at the sides close to the ceiling, but with a one-storied or upper ward an open roof is better.

But not only should there be good ventilation, but the wards ought to be every year empty for two or three weeks, and during the time thoroughly exposed to the air, every door and window being open.

(c) The strictest rules should be laid down with regard to the immediate removal from the wards of all excreta, dirty dressings, foul linen, etc. Nothing that can possibly give off anything to the air should be allowed to remain a single moment. Dressings of foul wounds should be sprinkled with deodorants.

(d) The walls should be of impermeable material. Cements of different kinds are now used, especially Parian; large slabs of properly colored tiles, joined by a good cement, and good Portland cement well painted, would, however, be better. Parian cracks and spaces form behind it. Ceiling should be either cemented or frequently limewashed. Great care should be taken with the floors. On the whole, good oak laid on concrete seems the best material; but the joinings should be perfect, so that no fluid may pass through and collect below the floor. Possibly it might be well to cover the floor with a good oil-cloth, or material of the like kind, which would prevent substances from sinking into the boards, and would lessen the necessity of washing the floors, but might be itself removed, and

FIG. 69.-Ward for Twenty Ward-beds. A, ward; B, nurse's-room, with ward-window; C, scullery; D, water-closet and ward-sink; E, bath-room and ablution-room; F, ventilated lobbies.

frequently washed. The practice of waxing and dry-rubbing the floors, and other similar plans, is intended to answer the same purpose. Dr. Langstaff, of Southampton, strongly recommends solid paraffin. The paraffin is melted and then poured on the floor, and ironed into it with a box-iron, heated from the interior by burning charcoal; it penetrates about a quarter of an inch into the wood. The excess of paraffin is scraped off, and the floor is brushed with a hard brush; a little paraffin in turpentine is then put on, and the flooring is good for years.'

(e) The furniture in a ward should be reduced to the minimum; and as far as possible, everything should be of iron. The bedding should also be reduced in size, as much as can be. Thick mattresses should be discarded, and thin mattresses, made easy and comfortable by being placed on springs, employed. The material for mattresses should be

2

An experience of some years in the Southampton Infirmary has proved the advantage of this flooring. It has also been introduced with satisfactory results into the Bristol Infirmary, according to information received from Mr. Eassie, C. E.

2 The wire mattress bedstead, as arranged by Dr. Reed, in use in the Manchester Royal Infirmary, and made by Messrs. Chorlton & Dugdale, seems an excellent and very comfortable form.

horse-hair (18 b weight to each mattress), or coir fibre, which, on the whole, are least absorbent. Straw, which absorbs very little, is bulky, and is said to be cold. All flock and woollen mattresses should be discarded. Blankets and coverlets should be white or yellowish in color, and should be frequently thoroughly aired, fumigated, and washed.

(f) The arrangement of the water-closets and urinals is a matter of the greatest moment. Every ward should have a urinal, so that the common practice of retaining urine in the utensils may be discontinued. If the urine is kept for medical inspec

The

FIG. 70.—Section of Ward to show the Bed. tion, it should be in closed vessels. removal of excreta must be by water. In hospitals, nothing else can be depended upon, as regards certainty and rapidity. The best arrangement for closets is not the handle and plug, which very feeble patients will not lift; but a self-acting water supply connected with the door, and flowing when it is open. This plan is better than the self-acting spring seat,

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FIG. 71.-Drawing to show Beds and Windows.

which is not always easily depressed by a thin patient; and also, by leaving the open door, it gives us the means of pouring in any quantity of water, and of thoroughly flushing the pan and pipe. The closets are best arranged in nearly detached lobbies, at one end of the ward, and separated from it by a thorough cross ventilation, as shown in the plan which is copied from Miss Nightingale's work. A further improvement may be made by throwing the closets still further out, with an intercepting lobby, as shown in Fig. 72.

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WARD

FIG. 72.-Closets (W. C.) and Lavatory (L.) with intervening ventilated lobbies (7.).

In this way, provided the site of the hospital is originally well chosen, perfect purity of air can be obtained, and the first requisite of a good hospital is secured.

Next to the supply of pure air, and to the measures for preventing contamination (which embrace construction, ventilation, cleanliness, and latrine arrangements), come the arrangements for medical treatment.

Medical treatment includes

1. Supply of Food.-The diet of the sick is now becoming a matter of scientific precision; and it is probable that every year greater and greater importance will be attached to it. Hence the necessity of a perfect central kitchen, and of means for

Dr. Buchanan has suggested a plan of vertical ventilation in the vestibule, in cases where cross ventilation is not available. This, of course, need not to be in a new building, although it might be useful in the adaptation of an existing one. The addition of a slop sink, for the emptying of bed-pans, etc., would also be useful.