We will take now the special hospitals in detail.Cancer Hospitals.—The justification for efficient cancer hospitals must be found in the circumstance that most scientific men of experience believe that, if adequate resources were placed at the disposal of the medical profession, the origin of cancer might be discovered, and so the human race would be freed from one of the most awful diseases which affect humanity. Pending such a discovery the experience of the cancer department connected with the Middlesex Hospital in London proves to demonstration that the provision of adequate and special accommodation for the exclusive treatment of cases of cancer is not only desirable but necessary on humanitarian grounds alone.Hospitals for Consumption.—For many years it was held that this group of hospitals was not a necessity, and the patients were treated in the ordinary medical wards of the general hospitals. Since the contagious character of tuberculosis became known, and improved methods of treatment have been developed, every one agrees that this type of special hospital is desirable, though it is believed by the more advanced school of scientists that before long it may be happily rendered obsolete owing to the discovery of methods of treatment which will stay the disease at its commencement and restore the patient to health.Children’s Hospitals.—These hospitals were very much opposed at the outset. There can be no doubt that the children’s ward or wards in a big voluntary hospital is a most valuable asset to the managers, so long as the children are treated in separate wards. There is no reason of course why a hospital should confine its work to the treatment of children, exclusively. Still this special hospital is popular with the public; it has led to many discoveries and developments in the treatment of children’s diseases; on the whole the administration of these establishments has been good; and we believe they will continue to flourish, however many children’s wards may be provided in general hospitals. Children’s hospitals with country branches for the treatment of chronic ailments, such as hip disease, are a valuable addition to the relief of suffering in cities.Cottage Hospitals.—These hospitals, established originally in 1859 by Mr Albert Napper at Cranleigh, Surrey, have fulfilled a most useful function. Many of them are very efficient both in regard to equipment and treatment. They have become essential to the well-being and adequate medical care of rural populations, as they attract to the country some of the best members of the profession, who are able, with the aid of the cottage hospital, to keep themselves efficient and up-to-date, so that all classes of the community are benefited in this way by this type of hospital.Ear, Throat and Nose Hospitals.—The history of this type of hospital bears out in every particular the reason we have given above for the establishment of special hospitals in the first instance. There can be no doubt that the best conducted throat hospitals have been beneficial to the poorer inhabitants of great cities.Fever Hospitals.—Incidentally we have dealt with these institutions, which are usually supported out of the rates and administered by the medical officers of health, who are paid by the county or municipal authorities.Maternity and Lying-in Hospitals.—This is one of the oldest types of special hospitals, and has done a great deal of good in its time. Owing to modern methods of treatment and hygienic developments the maternity hospital never occupied a stronger position than it does to-day.Mental Hospitals.—In Great Britain the insane are provided for in asylums (seeInsanity, ad fin.), though such establishments, if properly conducted, are essentially hospitals. Scientific and public opinion tend towards the establishment of mental hospitals to which all acute cases of mental disease should be first relegated for treatment and diagnosis before they are consigned to a permanent lunatic hospital. Too little attention on an organized plan has been given to the continuous study of mental disease in its clinical and pathological aspects. It is probable, therefore, that the advent of the mental hospital may lead to important developments in treatment in many ways.Ophthalmic Hospitals.—Of all special hospitals this is one which would probably be the least necessary, providing general hospitals everywhere were properly equipped and organized. No special hospital has probably been so abused in the material sense by the free relief of patients who could well afford to pay for their treatment at the ophthalmic hospital. Several of the existing ophthalmic hospitals have entailed an enormous expenditure, and their modern equipment is wonderfully efficient.Orthopaedic Hospitals.—It is very doubtful whether this type o£ hospital is really desirable or necessary. Its necessity may be advocated on the ground that orthopaedic cases may require prolonged treatment, and that the pressure upon the beds of general hospitals by acute cases is nowadays so great as to render the orthopaedic hospital more necessary than ever before.Paralysis and Epileptic Hospitals.—Seeing that the percentage of those who are at present attacked by paralysis and nervous disease shows a continued tendency to increase under modern conditions of life in large cities, hospitals of this type are necessary, and London at any rate, like most foreign towns of importance, possesses, at present, far too little accommodation for this class of case.Skin and Photo-Therapy.—Up to the end of the 19th century hospitals for diseases of the skin were a constant cause of scandal and criticism. The introduction of modern methods of treatment bylight and electricity, including photo-therapy, has given an importance to this department and treatment which it did not previously possess. We are of opinion that, on the whole, it is better and more economical to treat these cases in properly equipped departments of general hospitals than in separate institutions.Women’s Hospitals.—These hospitals are not absolutely necessary, but considering their popularity with the women themselves, and that several of them have done excellent work, remembering too that women constitute the majority of the population, there seems to be some reason for their continuance.
We will take now the special hospitals in detail.
Cancer Hospitals.—The justification for efficient cancer hospitals must be found in the circumstance that most scientific men of experience believe that, if adequate resources were placed at the disposal of the medical profession, the origin of cancer might be discovered, and so the human race would be freed from one of the most awful diseases which affect humanity. Pending such a discovery the experience of the cancer department connected with the Middlesex Hospital in London proves to demonstration that the provision of adequate and special accommodation for the exclusive treatment of cases of cancer is not only desirable but necessary on humanitarian grounds alone.
Hospitals for Consumption.—For many years it was held that this group of hospitals was not a necessity, and the patients were treated in the ordinary medical wards of the general hospitals. Since the contagious character of tuberculosis became known, and improved methods of treatment have been developed, every one agrees that this type of special hospital is desirable, though it is believed by the more advanced school of scientists that before long it may be happily rendered obsolete owing to the discovery of methods of treatment which will stay the disease at its commencement and restore the patient to health.
Children’s Hospitals.—These hospitals were very much opposed at the outset. There can be no doubt that the children’s ward or wards in a big voluntary hospital is a most valuable asset to the managers, so long as the children are treated in separate wards. There is no reason of course why a hospital should confine its work to the treatment of children, exclusively. Still this special hospital is popular with the public; it has led to many discoveries and developments in the treatment of children’s diseases; on the whole the administration of these establishments has been good; and we believe they will continue to flourish, however many children’s wards may be provided in general hospitals. Children’s hospitals with country branches for the treatment of chronic ailments, such as hip disease, are a valuable addition to the relief of suffering in cities.
Cottage Hospitals.—These hospitals, established originally in 1859 by Mr Albert Napper at Cranleigh, Surrey, have fulfilled a most useful function. Many of them are very efficient both in regard to equipment and treatment. They have become essential to the well-being and adequate medical care of rural populations, as they attract to the country some of the best members of the profession, who are able, with the aid of the cottage hospital, to keep themselves efficient and up-to-date, so that all classes of the community are benefited in this way by this type of hospital.
Ear, Throat and Nose Hospitals.—The history of this type of hospital bears out in every particular the reason we have given above for the establishment of special hospitals in the first instance. There can be no doubt that the best conducted throat hospitals have been beneficial to the poorer inhabitants of great cities.
Fever Hospitals.—Incidentally we have dealt with these institutions, which are usually supported out of the rates and administered by the medical officers of health, who are paid by the county or municipal authorities.
Maternity and Lying-in Hospitals.—This is one of the oldest types of special hospitals, and has done a great deal of good in its time. Owing to modern methods of treatment and hygienic developments the maternity hospital never occupied a stronger position than it does to-day.
Mental Hospitals.—In Great Britain the insane are provided for in asylums (seeInsanity, ad fin.), though such establishments, if properly conducted, are essentially hospitals. Scientific and public opinion tend towards the establishment of mental hospitals to which all acute cases of mental disease should be first relegated for treatment and diagnosis before they are consigned to a permanent lunatic hospital. Too little attention on an organized plan has been given to the continuous study of mental disease in its clinical and pathological aspects. It is probable, therefore, that the advent of the mental hospital may lead to important developments in treatment in many ways.
Ophthalmic Hospitals.—Of all special hospitals this is one which would probably be the least necessary, providing general hospitals everywhere were properly equipped and organized. No special hospital has probably been so abused in the material sense by the free relief of patients who could well afford to pay for their treatment at the ophthalmic hospital. Several of the existing ophthalmic hospitals have entailed an enormous expenditure, and their modern equipment is wonderfully efficient.
Orthopaedic Hospitals.—It is very doubtful whether this type o£ hospital is really desirable or necessary. Its necessity may be advocated on the ground that orthopaedic cases may require prolonged treatment, and that the pressure upon the beds of general hospitals by acute cases is nowadays so great as to render the orthopaedic hospital more necessary than ever before.
Paralysis and Epileptic Hospitals.—Seeing that the percentage of those who are at present attacked by paralysis and nervous disease shows a continued tendency to increase under modern conditions of life in large cities, hospitals of this type are necessary, and London at any rate, like most foreign towns of importance, possesses, at present, far too little accommodation for this class of case.
Skin and Photo-Therapy.—Up to the end of the 19th century hospitals for diseases of the skin were a constant cause of scandal and criticism. The introduction of modern methods of treatment bylight and electricity, including photo-therapy, has given an importance to this department and treatment which it did not previously possess. We are of opinion that, on the whole, it is better and more economical to treat these cases in properly equipped departments of general hospitals than in separate institutions.
Women’s Hospitals.—These hospitals are not absolutely necessary, but considering their popularity with the women themselves, and that several of them have done excellent work, remembering too that women constitute the majority of the population, there seems to be some reason for their continuance.
The Evolution of the Modern Hospital.—The evolution of the modern hospital affords one of the most marvellous evidences of the advance of scientific and humanitarian principles which the world has ever seen. At the outset hospitals were probably founded by the healthy more for their own comfort than out of any regard for the sick. Nowadays the healthy, whilst they realize that the more efficient they can make the hospital, the more certain, in the human sense, is their own chance of prolonged life and health, are, as the progress of the League of Mercy has shown in recent years, genuinely anxious for the most part to do something as individuals in the days of health in the cause of the sick. Formerly the hospital was merely a building or buildings, very often unsuitable for the purposes to which it was put, where sick and injured people were retained and more frequently than not died. In other words the hygienic condition, the methods of treatment and the hospital atmosphere were all so relatively unsatisfactory as to yield a mortality in serious cases of 40%. Nowadays, despite, or possibly because of, the fact that operative interference is the rule rather than the exception in the treatment of hospital patients, and in consequence of the introduction of antiseptic and aseptic methods, the mortality in hospitals is, in all the circumstances, relatively less, and probably materially less, than it is even amongst patients who are attended in their own homes. Originally hospitals were unsystematic, crowded, ill-organized necessities which wise people refused to enter, if they had any voice in the matter. At the present time in all large cities, and in crowded communities in civilized countries, great hospitals have been erected upon extensive sites which are so planned as to constitute in fact a village with many hundreds of inhabitants. This type of modern hospital has common characteristics. A multitude of separate buildings are dotted over the site, which may cover 20 acres or upwards. In one such institution, within an area of 20 acres, there are 6 m. of drains, 29 m. of water and steam pipes, 3 m. of roof gutters, 42 m. of electric wires, and 42 separate buildings, which to all intents and purposes constitute a series of distinct, isolated hospitals, in no case containing more than forty-six patients. On the continent of Europe buildings of this class are usually of one storey; in the United States, owing to the difficulty of obtaining suitable sites and for reasons of economy, some competent authorities strenuously advocate high buildings with many storeys for town hospitals. In England the majority have two to three storeys each, the ward unit containing a ward for twenty beds and two isolation wards for one and two beds respectively. The two storeys in modern fever hospitals, however, are absolutely distinct—that is, there is no internal staircase going from one ward to the others, for each is entered separately from the outside. This system carries to its extreme limits the principle of separating the patients as much as possible into small groups; the acute cases are usually treated in the upper ward, and as they become convalescent are removed downstairs. In this way the necessity for an entirely separate convalescent block is done away with and the patients are kept under the same charge nurse, an arrangement which promotes necessary discipline. The unit of these hospitals is the pavilion, not the ward, and consists of an acute ward, a convalescent ward, separation wards, nurses’ duty rooms, store-rooms for linen, an open-air balcony upstairs into which beds can be wheeled in suitable weather, and a large airing-ground for convalescent patients directly accessible from the downstairs ward. Each of the pavilions is raised above the ground level, so that air can circulate freely underneath. The wall, floor and air spaces in the scarlet fever wards of one of these hospitals are respectively 12 ft., 156 ft. and 2028 ft. per bed; and in the enteric and diphtheria wards they have been increased to 15 ft., 195 ft. and 2535 ft. respectively. The provision of so large a floor and linear space, especially in the diphtheria wards, is an experiment the effect of which will be watched with considerable interest. A building of this type is a splendid example of the separate pavilion hospital, and is doing great service in the treatment of fevers wherever it has been introduced. Some idea of a hospital village, some of the wards of which we have been describing, may be gathered from the circumstances that it costs from £300,000 to £400,000, that it usually contains from 500 to 700 beds, and that the staff numbers from 350 to 500 persons. The medical superintendent lives in a separate house of his own. The nurses are provided with a home, consisting of several blocks of buildings under the control of the matron; the charge nurses usually occupy the main block; where the dining and general sitting-rooms are placed; the day assistant-nurses another block; and lastly, by a most excellent arrangement, the night nurses, 80 to 120 in number, have one whole block entirely given up to their use. The female servants have a second home under the control of the housekeeper, and the male servants occupy a third home under the supervision of the steward. The two main ideas aimed at are to disconnect the houses occupied by the staff from the infected area, and to place the members of each division of the staff together, but in separate buildings, under their respective heads. These objects are highly to be commended, as they have important bearings upon the well-being and discipline of the whole establishment and constitute a lesson for all who have to do with buildings where a great number of people are constantly employed.
The Hospital City.—We have shown that the modern hospital where an adequate site is available under the most favourable conditions has developed into a hospital village. No one who is familiar with the existing disadvantages of many of the sites and their surroundings of town hospitals in many a large city can have any doubt that, if the well-being of the patients and the good of the whole community, combined with economical and administrative reasons, together with the provision of an adequate system for the instruction and training of medical students and nurses, are to be the first considerations with those responsible for the hospitals of the future, the time will come, and is probably not far distant, when each great urban community will provide for the whole of its sick by removing them to a hospital city, which will be situated upon a specially selected and most salubrious site some distance from the town itself. The atmosphere of a great city grows less and less suitable to the rapid and complete recovery of patients who may undergo the major operations or be suffering from the severe and acute forms of disease. Asepsis, it is true, has reduced the average residence in hospital from about 35 to less than 20 days. It has thereby added quite one million working days each year to the earning power of the artisan classes in London alone. Medical opinion is more and more favouring the provision of convalescent and suburban hospitals, to which patients suffering from open wounds may be removed from the city hospitals. This course, which entails much additional expenditure, is advocated to overcome the difficulty arising from the fact that, in operation and other cases, the patients cease to continue to make rapid progress towards recovery after the seventh or ninth day’s residence in a city hospital. A change of such cases to the country restores the balance and completes the recovery with a rapidity often remarkable.
Thinking out the problem here presented in all its bearings, realizing the great and ever-increasing cost of sites for hospitals in great cities, the heavy consequential taxes and charges which they have to meet there, and all the attendant disadvantages and drawbacks, the present writer has ventured upon an anticipation which he hopes may prove intelligent and well-founded. Nearly every difficulty in regard to the cost of hospitals and in respect to all the many problems presented by securingthe material required, under present systems, for the efficient training of students and nurses, would be removed by the erection of the Hospital City, which, he foresees, must ultimately be recognized by intelligent communities throughout the civilized world. Why should we not have, on a carefully selected site well away from the contaminations of the town, and adequately provided with every requisite demanded from the site of the most perfect modern hospital which the mind of man can conceive, a “Hospital City”? Here would be concentrated all the means for relieving and treating every form of disease to the abiding comfort of all responsible for their adequacy and success. At the present time all the traffic and all the citizens give way to fire engines and the ambulance in the public streets. Necessarily the means of transit to and from the “Hospital City,” and its rapidity, would be the most perfect in the world. So the members of the medical staff, the friends of the patients, and all who had business in the “Hospital City,” would find it easier and less exacting in time and energy to be attached to one of the hospitals located therein than to one situated in the centre of a big population in a crowded town. To meet the urgent and accident cases a few receiving houses, or outpost relief stations, with a couple of wards, would be situated in various quarters of the working city, where patients could be temporarily treated, and whence they could be removed to the “Hospital City” by an efficient motor ambulance service. The writer can see such a “Hospital City” established, can realize the comfort it will prove in practice to the medical profession, to the patients’ friends, to those who have to manage the hospitals and train the medical and nursing students, and indeed to all who may go there as well as to the whole community. The initial cost of hospital buildings should be reduced at once to a quarter or less of the present outlay. They could then be built of the cheapest but most suitable material, which would have many advantages, whilst the actual money forthcoming from the realization and sale of the existing hospital sites in many cities would, in all probability, produce a sum which in the whole might prove adequate, or nearly adequate, or even in some cases more than adequate, to defray the entire cost of building the “Hospital City” and of equipping it too. The cost of administration and working must be everywhere reduced to a minimum. The hygienic completeness of the whole city, its buildings and appliances, must expedite recovery to the maximum extent. In all probability the removal of the sick from contact with the healthy would tend in practice so to increase the healthiness of the town population,i.e.of the workers of the city proper, as to free them from some of the most burdensome trials which now cripple their resources and diminish materially the happiness of their lives. Probably the United States (where a city has sometimes sprung up in twelve months) may be the home where this idea may first find its realization in accomplished fact. The writer may never live to see such a city in actual working or in its entirety, but he makes bold to believe its adoption will one day solve the more difficult of the problems involved in providing adequately for the sick in crowded communities. He has formulated the idea because it seems desirable to encourage discussion as to the best method of checking the growing tendency to make hospital buildings everywhere too costly. If the idea of the “Hospital City” commends itself to the profession and the public, the practice of treating all the hospital accommodation in each city as a whole will gradually increase and spread, until most of the present pressing difficulties may disappear altogether. That is a consummation devoutly to be wished.
The Problem of Hospital Administration.—A study of the hospital problem in various countries, and especially in different portions of the English-speaking world, convinces the writer that, apart from local differences, the features presented are everywhere practically identical. A number of hospitals under independent administration, dependent in whole or in part on voluntary contributions, administered under different regulations originally representing the idiosyncracies of individual managers for the time being, without any standard of efficiency or any system of co-operation, which would bring the whole of the medical establishments of each or all of the great cities of the world under one administration which the combined wisdom and experience of hospital managers as a whole might agree to be the best, must mean in practice a material gain in every way to each and all of the hospitals and their supporters on economical, scientific and other grounds. Such an absence of system throughout the world has everywhere led to overlapping, to the perpetuation of many abuses, to the admission of an increasing number of patients whose social position does not entitle them to claim free medical relief at all, and, often too, to the admission of patients belonging to a humbler grade of society who are already provided for by the rates in institutions which they do not care to enter and who find their way to the wards of hospitals which were established to provide for patients of an entirely different social grade. These evils have continued to grow and increase almost everywhere, despite many and varied attempts to grapple with and remove them. Amongst these attempts we may mention the assembling of hospital conferences, the establishment of special funds and committees, and the holding of inquiries of various kinds in London and other British cities and also in the United States. The most remarkable proof of the impossibility of inducing those responsible to act together and enforce the necessary reforms is afforded by the historical fact that the famous Commission on Hospital Abuse, known as Sir William Fergusson’s Commission, in 1871, after an exhaustive inquiry, made the following recommendations: (1) to improve the administration of poor-law medical relief; (2) to place all free dispensaries under the control of the poor-law authorities; (3) to establish an adequate system of provident dispensaries; (4) to curtail the unrestricted system of gratuitous relief, partly by the selection of cases possessing special clinical interest and partly by the exclusion of those who on social grounds are not entitled to gratuitous medical advice; (5) the payment of the medical staff engaged in both in- and out-patient work, and the payment of fees by patients in the pay wards and in the consultation departments of the voluntary hospitals. Other commissions have since been appointed, have reported, and have disappeared, with the result that nothing practical had been done up to 1910 in the way of reform. Yet it is an undoubted fact that, if the foregoing recommendations of Sir William Fergusson’s Commission had been carried out in their entirety at the time they were made, practically all the abuses from which British hospitals afterwards suffered would have been removed, and the charitable public might have been saved several millions of pounds sterling. It may be well, therefore, briefly to indicate exactly what these changes amount to, and how they can be made effective at any time by those responsible for the working of a hospital.
There is no doubt that all the facts available tend to prove that the voluntary hospitals are used to an increasing extent by persons able to make payment or partial payment for the treatment which they receive. The evidence and statistics demonstrating these facts may be readily gathered from a study of the Report (1909) and Evidence of the Royal Commission on the Poor Laws and Relief of Distress (Lord George Hamilton’s Commission) and in the authorities mentioned at the end of this article. The underlying cause of the abuse was that no means existed whereby persons of moderate income could obtain efficient treatment and hospital care when ill at a rate which they could afford to pay. The system, or want of system, whereby medical relief is granted to practically all applicants by the voluntary hospitals grew up without any combined attempt to organize it efficiently or to check abuses. Such a system rests upon a wrong basis, and the best interests of every class of the population demand its abolition in favour of one which shall afford the maximum of justice (1) to the poor, (2) to those who can afford to pay in part or in whole the cost of their medical treatment and care at a hospital, (3) to the medical profession, (4) to the subscribers and supporters of voluntary hospitals, whose gifts should be strictly applied to the purposes they were intended to serve, and (5) to the ratepayers, who are entitled to a guarantee that themaximum efficiency is secured by the poor-law system of medical relief. The remedy is very simple and easy of application. Every voluntary hospital, while admitting all accidents and urgent cases needing immediate attention, should institute a system whereby each applicant would be asked to prove that he or she was a fit object of charity. The only real attempt at reform, up to 1909, was the appointment by many of the larger hospitals of almoners to ascertain whether certain selected patients were in a position to pay or not. By putting the burden of proof of eligibility to receive free medical relief upon the patients and their friends, all abuse of every kind must speedily cease. There would be no hardship entailed upon the patients by such a system, as experience has proved, but, to make it effective, the system of providing for in- and out-patients in Great Britain requires radical change, for, in existing circumstance, if a voluntary hospital attempted to enforce this simple method, it would be met with the difficulty that, where it was found that a patient or his friends could pay at any rate something, no department connected with British hospitals existed—as is the case in regard to hospitals in the United States—enabling such in-patients to be transferred to accommodation provided in paying wards. In the same way, directly the out-patients were dealt with under such a system, it would be made apparent, where a case could be properly treated, under the poor law, that no plan of co-operation to secure this was organized under existing conditions. If the patient, being of a better class, were suffering from a minor ailment, and could be properly dealt with at a provident dispensary, the fees of which he could easily pay, the same absence of co-operation must make it practically impossible readily to enforce the system. When, again, an out-patient of the better class was entitled, from the severity of his ailment, to receive the advantages of a consultation by the medical staff, no method existed whereby this aid could be rendered to him, and his transfer afterwards to the care of a medical practitioner attached to some provident dispensary, or resident near the patient’s home, could be properly carried out. It follows that adequate reform required that methods should be adopted with a view to some part or all the cost of treatment being provided by the patient or his friends through an entire reorganization of the system of medical relief not only at the voluntary hospitals, but under the poor-law system. The reforms required in regard to voluntary hospitals are that every large hospital shall have connected with the in-patient department, in separate buildings, but under the administration of the managers, pay wards for the reception of those patients who are able to pay some part or all of the cost of treatment; that, as regards out-patients, the existing out-patient department should be abolished; that in substitution for it each hospital should have a casualty department and a department for consultation. In the casualty department every applicant should be seen once, and be there disposed of by being handed on to the consultation department; if his case was sufficiently important, he should then be transferred to some provident or poor-law dispensary, or be referred to a private medical attendant. It would no doubt take time to overcome the incidental difficulties which would necessarily arise in effecting so radical a reform as is here contemplated, but if all voluntary hospitals adopted the same system, and were to be brought into active co-operation with provident dispensaries and poor-law dispensaries and private medical practitioners, the new system might be successfully introduced and made effective within twelve months, and probably within six months, from the date of its commencement. This opinion is based upon the assumption that the provident dispensaries would be standardized, and that every one of them would be brought up to a state of the highest efficiency. In the town of Northampton the Royal Victoria Dispensary has been worked with the maximum of success, so far as the patients and the medical practitioners are concerned. In London and in other large towns like Manchester and elsewhere the provident dispensary has not succeeded as it has done in Northampton, because so many members of the medical profession are not alive to the importance of making it their first business to provide that every patient connected with the provident dispensary who attends at the surgery of a private medical practitioner shall receive at least equal attention and accommodation to that afforded to every other private patient, whatever the fee he may pay. In the same way, poor-law dispensaries must be radically reformed. Everything which tends to excite a feeling of shame on the part of the patient attending the poor-law dispensary, such as the printing of the word “pauper” at the beginning of the space on which the patient’s name is entered, must be abolished, and the class of medical service and all the arrangements for the treatment of the patients, however poor, at the poor-law dispensary, must be made at least as efficient as those provided by voluntary hospitals. There undoubtedly is considerable overlapping between the voluntary hospitals and the poor law in Great Britain. The Royal Commission on the Poor Laws and Relief of Distress (1909) deals with this point with a view to set up a standard of medical relief to be granted by each class and type of hospitals, provides for adequate co-operation between all classes of institutions; and these reforms may be commended. It is too often forgotten that the function of the poor law is the relief of destitution, while it should be the object and duty of each voluntary hospital and indeed of all hospitals other than poor-law institutions to apply their resources entirely to the prevention of destitution, by stepping in to grant free medical relief to the provident and thrifty when, through no fault of their own, they meet with an accident or are overtaken by disease. An adequate system of co-operation would preserve the privilege of the voluntary hospitals, which save such patients from the necessity of requiring the relief which it is the object of the poor law to supply.
We have dealt with the relative advantages and disadvantages of rate-supported hospitals and voluntary hospitals. We should regard the establishment of a complete state-provided or rate-provided system of gratuitous medical relief, either for indoor patients or for out-door patients, or for both, as a grave evil. Such a system must eventually lead to the extinction of voluntary hospitals. If this disaster ever happens, it must result in the gravest evils, for it could not fail to injure the morale of all classes and tend to harden unnecessarily the relations between the rich and poor, who, under the voluntary system, have come to share each other’s sufferings and to be animated by respect and confidence towards each other.
Hospital Construction. Locality and Site.—Hospitals are required for the use of the community in a certain locality, and to be of use they must be within reach of the centre of population. Formerly the greater difficulty of locomotion made it necessary that they should be actually in the midst of towns and cities, and to some extent this continues to prevail. It is now proved to demonstration that this is not the best plan. Fresh and pure air being a prime necessity, as well as a considerable amount of space of actual area in proportion to population, it would certainly be better to place hospitals as much in the outskirts as is consistent with considerations of usefulness and convenience. In short, the best site would be open fields; but if that be impracticable, a large space, “a sanitary zone” as it is called by Tollet, should be kept permanently free between them and surrounding buildings, certainly never less than double the height of the highest building. In the selection of a site various factors must be taken into consideration. If the hospital is to be used as the clinical school of a university or medical college, then the most suitable ground available within easy reach of the university or college must be secured. If, on the other hand, the hospital is not to be used as a teaching school, a site more in the country should be favoured. In any case ample ground must be purchased to permit of the wards receiving the maximum of sunlight, an abundant supply of fresh air, and leave room for possible future extensions. The site should be self-contained; it should be in such a position as to prevent the hospital being shadowed by other buildings in the neighbourhood, and, unless the site is alongside a public park, it should be entirely surrounded by streets of from 40 to 60 ft. in width. It is also necessary to secure that adequate water mains serve the site, and that the system of sewers be ample for all sewage purposes.The difference between the expense of purchase of land in a town and in the environs is generally considerable, and this is therefore an additional reason for choosing a suburban locality. Even with existing hospitals it would be in most cases pecuniarily advantageous to dispose of the present building and site and retain only a receiving house in the town. St Thomas’s in London, the Hôtel-Dieu in Parisand the Royal Infirmary in Manchester, are all good examples where this might have been carried out. In none, however, has this been done; these hospitals have been rebuilt, at enormous outlay, in the cities as before, although not exactly in the same locality.As regards the actual site itself, where circumstances admit of choice, a dry gravelly or sandy soil should be selected, in a position where the ground water is low and but little subject to fluctuations of level, and where the means of drainage are capable of being effectually carried out. There should also be a cheerful sunny aspect and some protection from the coldest winds.Form of Building.—A form of building must be selected which answers the following conditions: (a) the freest possible circulation of air round each ward, with no cul-de-sac or enclosed spaces where air can stagnate; (b) free play of sunlight upon each ward during some portion at least of the day; (c) the possibility of isolating any ward, or group of wards, effectually, in case of infectious disease breaking out; (d) the possibility of ventilating every ward independently of any other part of the establishment. Those conditions can only be fulfilled by one system, viz. a congeries of houses or pavilions, more or less connected with each other by covered ways, so as to facilitate convenient and economical administration. The older plans of huge blocks of buildings, arranged in squares or rectangles, enclosing spaces without free circulation of air, are obviously objectionable. Even when arranged in single lines or crosses they are not desirable, as the wards either communicate with each other or with common passages or corridors, rendering separation impossible. On this point it may be remarked that some of the buildings of the 18th century were more wisely constructed than many of those in the first half of the 19th century, and that the older buildings have been from time to time spoilt by ignorant additions made in later times.The question next arises, is it better to have pavilions of two or more storeys high, or to have single-storeyed huts or cottages scattered more widely? For the treatment of tuberculosis there can be no doubt that, for hygienic reasons, thechâletor single-patient hut is the best for the patients in the acute stages; for economical reasons thechâlethas not been heretofore as popular as it deserves to be, but if the welfare of the patient is to be the first consideration there is no doubt that thechâletwill ultimately prevail. It has the merit of being easily adapted to villages and houses where there is a garden, and in this way poor families may readily isolate and treat a member affected by tuberculosis at a cost within their means. For hospital purposes, so long as the system of placing hospital buildings in densely crowded areas prevails, many-storeyed buildings for hospital purposes are likely to continue. Should the proposal to institute a Hospital City ultimately prevail, then it is probable that the majority of the pavilions will be single-storeyed. Still some hospital authorities prefer the multiple-storeyed system for administrative reasons, contending that single-storeyed pavilions have no special advantages over two or three-storeyed buildings, whereas the difficulties in administration and service of a hospital building on the single-storey principle outweigh any argument against the two- or three-storey building, if it is properly designed and constructed. We hope that the time is approaching when architects and those members of the public who have to provide the money for hospital buildings will insist upon the erection of simple structures, costing little, so that the whole cost of hospital buildings may be, as it ought to be, reduced by at least half when compared with the expenditure of the past.The pavilions may be arranged in various ways; they may be joined at one end by a corridor, or may be divided by a central corridor at right angles to them. In fact, the plan is very elastic, and adapts itself to almost any circumstances. A certain distance, not less than twice the height of the pavilions, ought to be preserved between them. By this means free circulation of air and plenty of light are secured, whilst separation or isolation may be at once accomplished if required.Foundations, Building Materials, &c.—It is of the first consequence that a hospital should be dry; therefore the foundation and walls ought to be constructed so as to prevent the inroads of damp. An impervious foundation has the further advantage of preventing emanations from the soil rising up in consequence of the suction force produced by the higher temperature of the internal atmosphere of the building itself. There should be free ventilation in the basement, and the raising of the whole on arches is a good plan, now generally carried out in hot climates. If the pavilions are two or more storeys high, it is advisable to use fire-proof material as much as possible, but single-storeyed huts may be of wood. In any case effectual means of excluding damp must be employed. The interiors of wards ought to be rendered as non-absorbent as possible, by being covered with impervious coatings, such as glazed tiles (Parian, though much used, is apt to crack), silicate paint, which is preferable to tiles, or the like. The ceilings ought to be treated in the same way as the walls. There must be a concrete floor between each flat, experience showing that if a teak floor is laid hard on the concrete a very noisy floor is the result, but if the teak is laid on strips of wood, leaving a small space between the concrete and the floor, a more silent floor is obtained. For the floors themselves various materials have been suggested: in France there is a preference for flags (dalles), but in England wood is more liked; and indeed hard well-fitting wood, such as teak, oak or American willow, leaves nothing to be desired. The surface should be waxed and polished or varnished. Even deal floors can be rendered non-absorbent by waxing, by impregnating them with solid paraffin as recommended by Dr Langstaff.Shape and Arrangement of Wards.—It is now generally agreed that wards should have windows on at least two opposite sides. Three main shapes have been proposed: (a) long wards with windows down each side, and (generally) one at the farther end with balcony; 26 ft. is a good width for a ward of twelve or fourteen beds, but for larger wards of more than fourteen beds the width should be not less than 28 ft.; (b) wards nearly square, with windows on three sides; and (c) circular wards with windows all round. The first (a) is the form usually adopted in pavilions; (b) is recommended by Dr C. F. Folsom (Plans for the Johns Hopkins Hospital); and (c) has been suggested by Mr John Marshall, F.R.S. (Nat. Assoc. for Promotion of Social Science, 1878). Of these (b) seems the least to be commended, and (c), now comparatively common, has distinct advantages in an administrative sense, when the wards are constructed as to floor space so as to allow the same proportion of superficial space per bed in a circular ward to that which is contained in a rectangular ward, as is the case at the Great Northern Central Hospital, London. Some authorities object to a chimney-stack up the centre of the circular ward, urging that it prevents the nurses from having complete supervision over all the beds. In practice this objection seems to us to have little force, and it can be avoided by placing the fireplaces at the side of the circular ward, if desirable, though this adds somewhat to the cost of building.Each bed should be a little distance, say from 8 in. to 1 ft. from the wall, and each bed may be reckoned as 6½ ft. long; this gives 7½ ft. on each side. Between the ends of the beds about 10 ft. space is necessary, so that 25 or 26 ft. of total breadth may be taken as a favourable width. The wards of the Herbert Hospital are 26 ft.; but some exceed this, as, for instance, St Thomas’s, London, and the New Royal infirmary, Edinburgh, 28; new Hôtel Dieu, 29; and Lariboisière, 30. There seems no necessity for exceeding 26 for a ward of twelve or fourteen beds, but if the breadth be greater there ought to be more window space—the great difficulty being to get a wide space thoroughly ventilated. There ought to be only two rows of beds, one down each wall, with a window on each side of each bed.For ventilation two things are required—sufficient space and sufficiently frequent change or renewal of air. As regards space, this must be considered with reference both to total space and to lateral or floor space. Unless a minimum of floor space be laid down, we shall always be in danger of overcrowding, for cubic space may be supplied vertically with little or no advantage to the occupier. If we allow a minimum distance of 4 ft. between the beds and 10 ft. between the ends of the beds, this gives 100 sq. ft. of space per bed; less than this is undesirable. In severe surgical cases, fever cases and the like, a much larger space is required; and in the Edinburgh Infirmary 150 sq. ft. is allowed. Cubic space must be regulated by the means of ventilation; we can rarely change the air oftener than three times in an hour, and therefore the space ought to be at least one-third of the hourly supply. This ought not to be less than 4000 cubic ft. per bed, even in ordinary cases of sickness—and the third of that is 1333 cubic ft. of space. With 100 sq. ft. of floor space a ward of 13½ ft. high would supply this amount, and there is but little to be gained by raising the ceiling higher,—indeed 12 ft. is practically enough. The experiments of Drs Cowles and Wood of Boston (seeReport of State Board of Health of Massachusetts for 1879) show that above 12 ft. there is little or no movement in the air except towards the outlet ventilator; the space above is therefore of little value as ventilation space. Authorities nowadays, however, fix 10 ft. 6 in. as the maximum, and any height above this may be disregarded for purposes of ventilation. Additional height adds also to the cost of construction, increases the expense of warming, makes cleaning more difficult, and to some extent hampers ventilation. Whatever be the height of wards, the windows must reach to the ceiling, or there must be ventilators in the ceiling or at the top of the side walls. If this be not arranged for, a mass of foul air is apt to stagnate near the ceiling, and sooner or later to be driven down upon the inmates. The reasons for a large and constant renewal of air are, of course, the immediate removal and dilution of the organic matter given off by the inmates; as this is greater in quantity and more offensive and dangerous in sickness than in health, the change of air in the former case must be greater than in the latter. Hence in serious cases an amount of air practically unlimited is desirable—the aim of true ventilation being to approach as near as possible to the condition of pure external air. Without going too much into details, a few general rules may be laid down. (1) Fresh air ought, if possible, to be brought in at the lowest part of the ward, warmed if necessary; (2) foul air ought to be taken out at the highest part of the ward; (3) fresh air should reach each patient without passing over the bed of any other; (4) the vitiated air should be removed from each patient without passing over the bed of any other; (5) 4000 cubic ft. of fresh air per head per hour should be the minimum in ordinary cases of sickness, to be increased without limit in severer cases; (6) the air should move in no part of a ward at a greater rate than 1½ ft. per second, except at the point of entry, where it should not exceed 5 ft. per second, and at theoutlet, where the rate may be somewhat higher; about 64 sq. in. of inlet and outlet sectional area ought to be supplied per head as a minimum; (7) every opportunity ought to be taken of freely flushing the wards with air, by means of open windows, when this can be done with safety.Warming is a question of great importance in most climates, especially in such a climate as that of Great Britain, where every system of ventilation must involve either the warming of some portion of the incoming air, or the contriving its delivery without too great lowering of temperature; at the same time it cannot be too strongly insisted upon that the tendency is too much in the direction of allowing warmth to supersede freshness of air. There are very few cases of disease (if any) that are not more injured by foul air than by low temperature; and in the zymotic diseases, such as typhus, enteric fever, smallpox, &c., satisfactory results have been obtained even in winter weather by almost open-air treatment. At the same time a reasonable warmth is desirable on all grounds if it can be obtained without sacrificing purity of atmosphere. For all practical purposes 60° to 63° F. is quite sufficient, and surgical and lying-in cases do well in lower temperatures. Various plans of warming have been recommended, but probably a combination is the best. It is inadvisable to do away altogether with radiant heat, although it is not always possible to supply sufficient warmth with open-air fire-places alone. A portion of the air may be warmed by being passed over a heating apparatus before it enters the ward, by having an air-chamber round the fire-place or stove, or by the use of radiators in the ward itself. In each case, however, the air must be supplied independently to each ward, so that no general system of air supply is applicable.The lighting of the ward at night will be most conveniently done by means of electricity in the form of a lamp for each bed, where gas is used each jet should have a special ventilator to carry off combustion products, as in the Edinburgh Infirmary.The Furniture of Wardsshould be simple, clean and non-absorbent; the bedsteads of iron, mattresses hair, laid on spring bottoms without sacking. No curtains should be permitted.The water-supply ought to be on the constant system, and plentiful; 50 gallons per head per diem may be taken as a fair minimum estimate.The closets ought to be of the simplest construction, the pans of earthenware all in one piece, the flushing arrangements simple but perfect, and the supply of water ample. Each ward should have its own closets, lavatories, &c., built in small annexes, with a cross-ventilated vestibule separating them from the ward. All the pipes should be disconnected from the drains, the closets by intercepting traps, the sink and waste pipes by being made to pour their contents over trapped gratings. The soil pipes should be ventilated, and placed outside the walls, protected as may be necessary from frost. Each ward should have a movable bath, which can be wheeled to the patient’s bedside.Each ward should have attached to it a small kitchen for any special cooking that may be required, a room for the physician or surgeon, and generally a room with one or two separate beds. No cooking should be done in the wards, nor ought washing, airing or drying of linen to be allowed there.Hospital Economics.—There is no doubt that the voluntary system of hospital government is far more economical than any system of state or rate-supported hospitals. That the present condition of the voluntary hospitals in regard to economy is all that can be wished is not, of course, true. Still, resting as this system does upon the goodwill of the public for its continuance and maintenance, it is satisfactory to note that there is a continuous improvement in system and method, which makes for economy. It has taken many years to perfect and enforce the uniform system of hospital accounts, but this system with the co-operation of the great funds has produced economical results of the first importance. This system originated at the Queen’s Hospital, Birmingham, in 1869, and was devised by an eminent Birmingham accountant, William Laundy, and Sir Henry Burdett. It proved so fruitful in practice that six years later it was introduced at the “Dreadnought” Seamen’s Hospital, the first London hospital to use it, and was then adopted spontaneously by a few of the best-administered hospitals where the managers were keen in enforcing economy. In 1891, in order to secure for comparative purposes an identical classification of the items and charges included in the system, a glossary or index of classification was prepared and published in theHospital Annualof that year. This index enabled the same classification of the many items included in the expenditure of a great institution to be adopted generally. In the same year a committee of hospital secretaries, at the instigation of the Metropolitan Hospital Sunday Fund, revised and elaborated the index of classification, and the new index was adopted by a general meeting of hospital secretaries in January 1892. The Council of the Metropolitan Hospital Sunday Fund approved it, and the Uniform System of Accounts was formulated by that body for the use of the metropolitan hospitals. In 1906 the whole of this system was inquired into on behalf of the King’s Fund by Mr John G. Griffiths, F.C.A., when a committee of hospital secretaries and representatives of the King’s Fund prepared a further revision of the system. This was completed in the course of the year and adopted by the King’s, the Hospital Sunday and the Hospital Saturday Funds. The publication of a book by Sir Henry Burdett led to the adoption of the system in several of the British Colonies, and as a result of the action taken in the British Empire the Uniform System of Accounts has recently been set up and adopted by the principal hospitals of the United States of America. The prince of Wales (George V.) testified to the value of this system in enforcing control over expenditure, and Sir Henry Burdett adapted it for the use of the authorities of all charities of every class. It is probable that no single reform has had a greater influence for good upon the administration of charitable institutions than the evolution and enforcement of the uniform system of accounts.Nursing.—The arrangements for nursing the sick have greatly improved in recent times, although controversy still goes on as to the best method of carrying it out. In arranging for the nursing in a hospital both efficiency and economy have to be considered. No ward in a general hospital for acute cases should contain more than 24 beds. In hospitals with clinical schools the proportion of nurses to patients should be about one nurse to every three patients, and if possible every ward should have a probationer on duty at night in addition to the night nurse. In all well-conducted hospitals it is now arranged that the nurses on night duty have a hot meal served in the general dining-room during the night, and this is only possible where a nurse and a probationer are allowed for each ward. The nurses’ quarters should be separate from the hospital proper, and connected by a conservatory or covered way. Each nurse should have a separate bedroom, measuring not less than 12 ft. long, 9 ft. broad and 10 ft. high. A bath should be allowed for every eight rooms, and the water-closets and sinks should, if possible, be in sanitary towers cut off from the main block of buildings.Circumstances must to a large extent determine the arrangement, but it seems desirable on the whole that the work of a nurse should be confined to a single ward at a time if possible. The duties of nurses ought also to be distinctly confined to attendance on the sick, and no menial work, such as scrubbing floors and the like, should be demanded of them; a proper staff of servants ought to be employed for such purposes. It is also desirable that a separate pavilion for lodging the nurses should be set apart, and that fair and reasonable time for rest and recreation should be allowed. Some discussion has taken place as to the advisability of placing the nursing of a hospital in the hands of a sisterhood or a separate corporation. It will, however, be admitted that the best plan is for the nursing staff of each hospital to be special and under one head within the establishment itself, even though it may be connected with some main institution outside. The nursing must, of course, be carried on in accordance with the directions and treatment of the physicians and surgeons.General.—The kitchen, laundry, dispensary and other offices must be in a separate pavilion or pavilions, away from the wards, but within convenient access. A separate pavilion for isolation of infectious cases is desirable. This may be a wooden hut, or in some cases even a tent; either is probably preferable to a permanent block of buildings. A disinfecting chamber ought to be provided where heat can be applied to clothes and bedding, for the destruction both of vermin and of the germs of disease. It is advisable to expose all bedding and clothing to its influence after each occasion of wear. Although this may entail additional expense from the deterioration of fabric, it is worth the outlay to secure immunity from disease. This plan is rigidly followed at the Royal South Hants Infirmary at Southampton. It is of great importance that the wards should be periodically emptied and kept unoccupied for not less than one month in each year, and longer if possible. During such period thorough cleansing and flushing with air could be carried out, so as to prevent any continuous deposit of organic matter.Gate House or Admission Block.—If the efficiency of a hospital and the regular and smooth working of its departments are to be secured, the proper management and control of the admission department is of the greatest importance. When one considers for a moment the number of applicants of all ages in various stages of disease, and the number of accident cases of every degree of severity who present themselves every day seeking admission, it will be evident that the most careful supervision must be exercised on the very threshold. It is essential that every precaution be taken against the admission of an unsuitable case, or the refusal, without careful examination, of any patient seeking admission. It is only necessary to instance the case of a patient with delirium tremens being admitted to a general ward at a late hour, or a case of infectious disease admitted through an overlook, or a case refused admission and expiring on the way home, in order to illustrate the danger and trouble which might arise should the supervision exercised over this department not be systematic, stringent and thorough.To secure this proper control it is necessary that the admission department should be designed on a definite plan suitable for the purposes in view. It is not sufficient to utilize any available rooms, say, in the basement of the building, where patients may be casually interviewed by a house surgeon or physician. This department should be as carefully designed and equipped as any other department of the hospital.Within recent years much more attention has been devoted to the details of construction than was formerly considered necessary,but even in the best type of hospital there is still much to be desired in this respect. It is essential for an architect in designing any building to have before him an accurate idea of all the requirements, and the use to which each foot of space is to be put; for unless he is furnished with this information it is not possible for him to design his building so as to give effect to all the details which are so necessary. The following is an endeavour in a general way to enumerate the various points which an architect should have before him in designing the admission department of a general hospital:—The admission department should be conveniently placed on the ground floor of the hospital—or it may be a detached building—with a large court where ambulance wagons or other vehicles may easily pass each other on approaching or retiring from the institution. The entrance to the admission department for patients should, if possible, be entirely separate and distinct from that for the staff and students. An additional entrance should be provided for patients’ friends on visiting days, in order that they may be able to enter the hospital without passing through the patients’ entrance, or coming into contact with an accident case or other patient seeking admission. The main entrance door should be protected by a covered porch so that patients may be removed from the ambulance or cab to the examination room without being exposed to the weather or the gaze of inquisitive onlookers. This door should be sufficiently wide to allow two hand ambulances or barrows to pass should they require to be brought out to the ambulance or cab, and to facilitate this the floor of the entrance hall should be as nearly as possible on a level with that of the outside porch. Adjoining the entrance vestibule, lavatory accommodation should be provided for males and females who may accompany the patient. Lavatory accommodation should also be provided for porters on duty, and all lavatories should have a cut-off ventilating passage.A recess to store ambulance barrows should adjoin the entrance, and this recess must be in proportion to the size of the hospital, in order that a hand ambulance may always be available when an accident or urgent case arrives. The vestibule should lead into a large waiting-hall with an inquiry office at its entrance, provided with a telephone exchange, private exchange box, also letter and parcel racks. If possible a window of the inquiry office should command a view of the main entrance. A room should be provided for the medical officer on duty, so that a medical officer may be always at hand and that no delay will occur in attending to a patient on arrival.Leading off from this waiting-hall, well-lit examination rooms should be available for the thorough examination of patients, both male and female, the number of rooms, of course, varying with the size of the hospital and the amount of work to be done. Each of these rooms should be fitted with a wash-hand basin and sink, and a plentiful supply of hot and cold water.Two rooms, with recovery rooms adjoining, should be fitted up as small operating-rooms for the treatment of minor casualties. A special room should also be furnished with an X-ray outfit, and arrangements should be made whereby this room can be readily darkened so that suspected fractures, &c. may be examined with the fluorescent screen.Adjoining the admission department two small wards should be provided for the accommodation of drunk or noisy cases unfit to be placed in the general wards. To these “emergency wards” must be attached the usual bathroom and lavatory accommodation, nurses’ room, ward kitchen and urine-test room or small lavatory. These wards should have double windows in order to prevent noise being heard outside if the wards are near other buildings.The interior walls of the admission department should, as far as possible, have a smooth and impervious surface, in order that they may be easily cleaned. All angles should be avoided and all corners rounded. Although glazed tiles are open to the criticism that they have numerous joints, they probably make the most suitable wall yet devised, as they can be easily washed down at very small cost. The corridors and waiting-hall should be tiled to a height of 6 ft. 6 in., and the upper walls covered with Parian or Kean’s cement, and be treated with three coats of flat paint and two coats of enamel, or, what is equally suitable and less costly, enamellette. The floors of the passages and corridors throughout the department should be covered with terrazzo, which is a mixture of Portland cement and marble chips. A margin of 1 ft. round the rooms should be treated in this way, and the terrazzo carried up this same distance on the wall to join the tiles. The remainder of the floors should be covered with hard wood, such as American maple or teak. As these floors require to be frequently washed, oak is not so suitable. Oak very soon becomes destroyed with water; the same trouble is experienced with pitch pine. The doors should also be made of a hard wood, preferably teak, and have no mouldings or grooves where dust can lodge. They should be wide enough to admit an ambulance barrow or bed with ease. In no case should the doors of an examination room be less than 3 ft. 6 in. in width.As an aid to a complete understanding of the varied work which has to be provided for, and the most effective method of carrying it out, the accompanying plans are given of an admission block designed to embody the main principles which govern the construction of such a department.Plans of Ground Floor and Basement of a Hospital.All accidents and patients seeking admission to this hospital enter through the central gateway, and on the left is shown the porters’ room, where a porter is always in readiness to attend to any applicant. This room has suitable accommodation for parcels, letters, telephones, &c., and adjoining it is a small lavatory for the use of porters. At the side of the porters’ room is the entrance to the central waiting-hall, which is lit from the roof. On one side of this hall are examination and dressing-rooms for males, with lavatory accommodation; and on the other side similar provision for females, with the addition of a nurses’ duty room. At the end of the central hall are two operating theatres, with recovery room adjoining each; one theatre for males, and the other for females. Between these theatres are rooms for sterilizers and dressings. An X-ray examination room is provided beyond the male examination room on the right of the hall. In the basement, under the entrance-hall and operating theatres are two bathrooms for males and two for females, with W.C.’s for each. The remainder of the basement is used as a store for patients’ clothes, and a hot-air chamber is provided for purposes of disinfection. The basement can be reached by a lift or by a wide staircase which is situated at the end of the waiting-hall.In the above plan provision is made for a sitting-room for the medical officer on duty. This is a new and essential feature in the admission block unit of all hospitals in large cities, for it should secure that no patient is kept waiting for many minutes before being seen. One of the blots on the management of many hospitals is that regrettable delays often take place, and much dissatisfaction and avoidable suffering may arise from this difficulty in the administration of a general hospital. We have given this plan of a model gatehouse or admission block for a modern general hospital, because the block as it stands contains all the elements necessary for a receiving-house block in cities in connexion with a great Hospital city situated outside its area, in fulfilment of the suggestion for a Hospital city made above. Apart from its interest as a new feature which all new hospitals should adopt, the gatehouse or admission block has an importance in the wider sense, that it may come to form the key to the solution of the problem of how best to provide hospital accommodation for the poor in great cities under the best hygienic conditions, while protecting them from the misery and danger of prolonged delay in first treatment, especially in connexion with accidents and other cases of urgency.Bibliography.—Sir H. Burdett,Cottage Hospitals, General, Fever and Convalescent, their Construction, Management and Work(London, 1877, 1880 and 1896); Tollet,Les Édifices hospitaliers depuis leurorigine jusqu’à nos jours(Paris, 1892); Sir H. Burdett,Hospitals and Asylums of the World, with large portfolio of plans to a uniform scale (London, 1893) (a supplement is published every year bringing the information up to date, entitledBurdett’s Hospitals and Charities); J. S. Billings,The Principles of Ventilation, Heating and their Practical Application(New York, 1893); Galton,Healthy Hospitals(London, 1893); Tollet,Les Hôpitaux au XIXesiècle(Paris, 1894); Billings and Hurd,Suggestions to Hospital and Asylum Visitors(Philadelphia, 1895); Oswald Kuhn, “Hospitals,”Handbuch der Architektur, 4th part, 5th half-volume, part i. (Stuttgart, 1897);Plans for the Johns Hopkins Hospital(Baltimore, 1875);Report of State Board of Health for Massachusetts for 1879.
Hospital Construction. Locality and Site.—Hospitals are required for the use of the community in a certain locality, and to be of use they must be within reach of the centre of population. Formerly the greater difficulty of locomotion made it necessary that they should be actually in the midst of towns and cities, and to some extent this continues to prevail. It is now proved to demonstration that this is not the best plan. Fresh and pure air being a prime necessity, as well as a considerable amount of space of actual area in proportion to population, it would certainly be better to place hospitals as much in the outskirts as is consistent with considerations of usefulness and convenience. In short, the best site would be open fields; but if that be impracticable, a large space, “a sanitary zone” as it is called by Tollet, should be kept permanently free between them and surrounding buildings, certainly never less than double the height of the highest building. In the selection of a site various factors must be taken into consideration. If the hospital is to be used as the clinical school of a university or medical college, then the most suitable ground available within easy reach of the university or college must be secured. If, on the other hand, the hospital is not to be used as a teaching school, a site more in the country should be favoured. In any case ample ground must be purchased to permit of the wards receiving the maximum of sunlight, an abundant supply of fresh air, and leave room for possible future extensions. The site should be self-contained; it should be in such a position as to prevent the hospital being shadowed by other buildings in the neighbourhood, and, unless the site is alongside a public park, it should be entirely surrounded by streets of from 40 to 60 ft. in width. It is also necessary to secure that adequate water mains serve the site, and that the system of sewers be ample for all sewage purposes.
The difference between the expense of purchase of land in a town and in the environs is generally considerable, and this is therefore an additional reason for choosing a suburban locality. Even with existing hospitals it would be in most cases pecuniarily advantageous to dispose of the present building and site and retain only a receiving house in the town. St Thomas’s in London, the Hôtel-Dieu in Parisand the Royal Infirmary in Manchester, are all good examples where this might have been carried out. In none, however, has this been done; these hospitals have been rebuilt, at enormous outlay, in the cities as before, although not exactly in the same locality.
As regards the actual site itself, where circumstances admit of choice, a dry gravelly or sandy soil should be selected, in a position where the ground water is low and but little subject to fluctuations of level, and where the means of drainage are capable of being effectually carried out. There should also be a cheerful sunny aspect and some protection from the coldest winds.
Form of Building.—A form of building must be selected which answers the following conditions: (a) the freest possible circulation of air round each ward, with no cul-de-sac or enclosed spaces where air can stagnate; (b) free play of sunlight upon each ward during some portion at least of the day; (c) the possibility of isolating any ward, or group of wards, effectually, in case of infectious disease breaking out; (d) the possibility of ventilating every ward independently of any other part of the establishment. Those conditions can only be fulfilled by one system, viz. a congeries of houses or pavilions, more or less connected with each other by covered ways, so as to facilitate convenient and economical administration. The older plans of huge blocks of buildings, arranged in squares or rectangles, enclosing spaces without free circulation of air, are obviously objectionable. Even when arranged in single lines or crosses they are not desirable, as the wards either communicate with each other or with common passages or corridors, rendering separation impossible. On this point it may be remarked that some of the buildings of the 18th century were more wisely constructed than many of those in the first half of the 19th century, and that the older buildings have been from time to time spoilt by ignorant additions made in later times.
The question next arises, is it better to have pavilions of two or more storeys high, or to have single-storeyed huts or cottages scattered more widely? For the treatment of tuberculosis there can be no doubt that, for hygienic reasons, thechâletor single-patient hut is the best for the patients in the acute stages; for economical reasons thechâlethas not been heretofore as popular as it deserves to be, but if the welfare of the patient is to be the first consideration there is no doubt that thechâletwill ultimately prevail. It has the merit of being easily adapted to villages and houses where there is a garden, and in this way poor families may readily isolate and treat a member affected by tuberculosis at a cost within their means. For hospital purposes, so long as the system of placing hospital buildings in densely crowded areas prevails, many-storeyed buildings for hospital purposes are likely to continue. Should the proposal to institute a Hospital City ultimately prevail, then it is probable that the majority of the pavilions will be single-storeyed. Still some hospital authorities prefer the multiple-storeyed system for administrative reasons, contending that single-storeyed pavilions have no special advantages over two or three-storeyed buildings, whereas the difficulties in administration and service of a hospital building on the single-storey principle outweigh any argument against the two- or three-storey building, if it is properly designed and constructed. We hope that the time is approaching when architects and those members of the public who have to provide the money for hospital buildings will insist upon the erection of simple structures, costing little, so that the whole cost of hospital buildings may be, as it ought to be, reduced by at least half when compared with the expenditure of the past.
The pavilions may be arranged in various ways; they may be joined at one end by a corridor, or may be divided by a central corridor at right angles to them. In fact, the plan is very elastic, and adapts itself to almost any circumstances. A certain distance, not less than twice the height of the pavilions, ought to be preserved between them. By this means free circulation of air and plenty of light are secured, whilst separation or isolation may be at once accomplished if required.
Foundations, Building Materials, &c.—It is of the first consequence that a hospital should be dry; therefore the foundation and walls ought to be constructed so as to prevent the inroads of damp. An impervious foundation has the further advantage of preventing emanations from the soil rising up in consequence of the suction force produced by the higher temperature of the internal atmosphere of the building itself. There should be free ventilation in the basement, and the raising of the whole on arches is a good plan, now generally carried out in hot climates. If the pavilions are two or more storeys high, it is advisable to use fire-proof material as much as possible, but single-storeyed huts may be of wood. In any case effectual means of excluding damp must be employed. The interiors of wards ought to be rendered as non-absorbent as possible, by being covered with impervious coatings, such as glazed tiles (Parian, though much used, is apt to crack), silicate paint, which is preferable to tiles, or the like. The ceilings ought to be treated in the same way as the walls. There must be a concrete floor between each flat, experience showing that if a teak floor is laid hard on the concrete a very noisy floor is the result, but if the teak is laid on strips of wood, leaving a small space between the concrete and the floor, a more silent floor is obtained. For the floors themselves various materials have been suggested: in France there is a preference for flags (dalles), but in England wood is more liked; and indeed hard well-fitting wood, such as teak, oak or American willow, leaves nothing to be desired. The surface should be waxed and polished or varnished. Even deal floors can be rendered non-absorbent by waxing, by impregnating them with solid paraffin as recommended by Dr Langstaff.
Shape and Arrangement of Wards.—It is now generally agreed that wards should have windows on at least two opposite sides. Three main shapes have been proposed: (a) long wards with windows down each side, and (generally) one at the farther end with balcony; 26 ft. is a good width for a ward of twelve or fourteen beds, but for larger wards of more than fourteen beds the width should be not less than 28 ft.; (b) wards nearly square, with windows on three sides; and (c) circular wards with windows all round. The first (a) is the form usually adopted in pavilions; (b) is recommended by Dr C. F. Folsom (Plans for the Johns Hopkins Hospital); and (c) has been suggested by Mr John Marshall, F.R.S. (Nat. Assoc. for Promotion of Social Science, 1878). Of these (b) seems the least to be commended, and (c), now comparatively common, has distinct advantages in an administrative sense, when the wards are constructed as to floor space so as to allow the same proportion of superficial space per bed in a circular ward to that which is contained in a rectangular ward, as is the case at the Great Northern Central Hospital, London. Some authorities object to a chimney-stack up the centre of the circular ward, urging that it prevents the nurses from having complete supervision over all the beds. In practice this objection seems to us to have little force, and it can be avoided by placing the fireplaces at the side of the circular ward, if desirable, though this adds somewhat to the cost of building.
Each bed should be a little distance, say from 8 in. to 1 ft. from the wall, and each bed may be reckoned as 6½ ft. long; this gives 7½ ft. on each side. Between the ends of the beds about 10 ft. space is necessary, so that 25 or 26 ft. of total breadth may be taken as a favourable width. The wards of the Herbert Hospital are 26 ft.; but some exceed this, as, for instance, St Thomas’s, London, and the New Royal infirmary, Edinburgh, 28; new Hôtel Dieu, 29; and Lariboisière, 30. There seems no necessity for exceeding 26 for a ward of twelve or fourteen beds, but if the breadth be greater there ought to be more window space—the great difficulty being to get a wide space thoroughly ventilated. There ought to be only two rows of beds, one down each wall, with a window on each side of each bed.
For ventilation two things are required—sufficient space and sufficiently frequent change or renewal of air. As regards space, this must be considered with reference both to total space and to lateral or floor space. Unless a minimum of floor space be laid down, we shall always be in danger of overcrowding, for cubic space may be supplied vertically with little or no advantage to the occupier. If we allow a minimum distance of 4 ft. between the beds and 10 ft. between the ends of the beds, this gives 100 sq. ft. of space per bed; less than this is undesirable. In severe surgical cases, fever cases and the like, a much larger space is required; and in the Edinburgh Infirmary 150 sq. ft. is allowed. Cubic space must be regulated by the means of ventilation; we can rarely change the air oftener than three times in an hour, and therefore the space ought to be at least one-third of the hourly supply. This ought not to be less than 4000 cubic ft. per bed, even in ordinary cases of sickness—and the third of that is 1333 cubic ft. of space. With 100 sq. ft. of floor space a ward of 13½ ft. high would supply this amount, and there is but little to be gained by raising the ceiling higher,—indeed 12 ft. is practically enough. The experiments of Drs Cowles and Wood of Boston (seeReport of State Board of Health of Massachusetts for 1879) show that above 12 ft. there is little or no movement in the air except towards the outlet ventilator; the space above is therefore of little value as ventilation space. Authorities nowadays, however, fix 10 ft. 6 in. as the maximum, and any height above this may be disregarded for purposes of ventilation. Additional height adds also to the cost of construction, increases the expense of warming, makes cleaning more difficult, and to some extent hampers ventilation. Whatever be the height of wards, the windows must reach to the ceiling, or there must be ventilators in the ceiling or at the top of the side walls. If this be not arranged for, a mass of foul air is apt to stagnate near the ceiling, and sooner or later to be driven down upon the inmates. The reasons for a large and constant renewal of air are, of course, the immediate removal and dilution of the organic matter given off by the inmates; as this is greater in quantity and more offensive and dangerous in sickness than in health, the change of air in the former case must be greater than in the latter. Hence in serious cases an amount of air practically unlimited is desirable—the aim of true ventilation being to approach as near as possible to the condition of pure external air. Without going too much into details, a few general rules may be laid down. (1) Fresh air ought, if possible, to be brought in at the lowest part of the ward, warmed if necessary; (2) foul air ought to be taken out at the highest part of the ward; (3) fresh air should reach each patient without passing over the bed of any other; (4) the vitiated air should be removed from each patient without passing over the bed of any other; (5) 4000 cubic ft. of fresh air per head per hour should be the minimum in ordinary cases of sickness, to be increased without limit in severer cases; (6) the air should move in no part of a ward at a greater rate than 1½ ft. per second, except at the point of entry, where it should not exceed 5 ft. per second, and at theoutlet, where the rate may be somewhat higher; about 64 sq. in. of inlet and outlet sectional area ought to be supplied per head as a minimum; (7) every opportunity ought to be taken of freely flushing the wards with air, by means of open windows, when this can be done with safety.
Warming is a question of great importance in most climates, especially in such a climate as that of Great Britain, where every system of ventilation must involve either the warming of some portion of the incoming air, or the contriving its delivery without too great lowering of temperature; at the same time it cannot be too strongly insisted upon that the tendency is too much in the direction of allowing warmth to supersede freshness of air. There are very few cases of disease (if any) that are not more injured by foul air than by low temperature; and in the zymotic diseases, such as typhus, enteric fever, smallpox, &c., satisfactory results have been obtained even in winter weather by almost open-air treatment. At the same time a reasonable warmth is desirable on all grounds if it can be obtained without sacrificing purity of atmosphere. For all practical purposes 60° to 63° F. is quite sufficient, and surgical and lying-in cases do well in lower temperatures. Various plans of warming have been recommended, but probably a combination is the best. It is inadvisable to do away altogether with radiant heat, although it is not always possible to supply sufficient warmth with open-air fire-places alone. A portion of the air may be warmed by being passed over a heating apparatus before it enters the ward, by having an air-chamber round the fire-place or stove, or by the use of radiators in the ward itself. In each case, however, the air must be supplied independently to each ward, so that no general system of air supply is applicable.
The lighting of the ward at night will be most conveniently done by means of electricity in the form of a lamp for each bed, where gas is used each jet should have a special ventilator to carry off combustion products, as in the Edinburgh Infirmary.
The Furniture of Wardsshould be simple, clean and non-absorbent; the bedsteads of iron, mattresses hair, laid on spring bottoms without sacking. No curtains should be permitted.
The water-supply ought to be on the constant system, and plentiful; 50 gallons per head per diem may be taken as a fair minimum estimate.
The closets ought to be of the simplest construction, the pans of earthenware all in one piece, the flushing arrangements simple but perfect, and the supply of water ample. Each ward should have its own closets, lavatories, &c., built in small annexes, with a cross-ventilated vestibule separating them from the ward. All the pipes should be disconnected from the drains, the closets by intercepting traps, the sink and waste pipes by being made to pour their contents over trapped gratings. The soil pipes should be ventilated, and placed outside the walls, protected as may be necessary from frost. Each ward should have a movable bath, which can be wheeled to the patient’s bedside.
Each ward should have attached to it a small kitchen for any special cooking that may be required, a room for the physician or surgeon, and generally a room with one or two separate beds. No cooking should be done in the wards, nor ought washing, airing or drying of linen to be allowed there.
Hospital Economics.—There is no doubt that the voluntary system of hospital government is far more economical than any system of state or rate-supported hospitals. That the present condition of the voluntary hospitals in regard to economy is all that can be wished is not, of course, true. Still, resting as this system does upon the goodwill of the public for its continuance and maintenance, it is satisfactory to note that there is a continuous improvement in system and method, which makes for economy. It has taken many years to perfect and enforce the uniform system of hospital accounts, but this system with the co-operation of the great funds has produced economical results of the first importance. This system originated at the Queen’s Hospital, Birmingham, in 1869, and was devised by an eminent Birmingham accountant, William Laundy, and Sir Henry Burdett. It proved so fruitful in practice that six years later it was introduced at the “Dreadnought” Seamen’s Hospital, the first London hospital to use it, and was then adopted spontaneously by a few of the best-administered hospitals where the managers were keen in enforcing economy. In 1891, in order to secure for comparative purposes an identical classification of the items and charges included in the system, a glossary or index of classification was prepared and published in theHospital Annualof that year. This index enabled the same classification of the many items included in the expenditure of a great institution to be adopted generally. In the same year a committee of hospital secretaries, at the instigation of the Metropolitan Hospital Sunday Fund, revised and elaborated the index of classification, and the new index was adopted by a general meeting of hospital secretaries in January 1892. The Council of the Metropolitan Hospital Sunday Fund approved it, and the Uniform System of Accounts was formulated by that body for the use of the metropolitan hospitals. In 1906 the whole of this system was inquired into on behalf of the King’s Fund by Mr John G. Griffiths, F.C.A., when a committee of hospital secretaries and representatives of the King’s Fund prepared a further revision of the system. This was completed in the course of the year and adopted by the King’s, the Hospital Sunday and the Hospital Saturday Funds. The publication of a book by Sir Henry Burdett led to the adoption of the system in several of the British Colonies, and as a result of the action taken in the British Empire the Uniform System of Accounts has recently been set up and adopted by the principal hospitals of the United States of America. The prince of Wales (George V.) testified to the value of this system in enforcing control over expenditure, and Sir Henry Burdett adapted it for the use of the authorities of all charities of every class. It is probable that no single reform has had a greater influence for good upon the administration of charitable institutions than the evolution and enforcement of the uniform system of accounts.
Nursing.—The arrangements for nursing the sick have greatly improved in recent times, although controversy still goes on as to the best method of carrying it out. In arranging for the nursing in a hospital both efficiency and economy have to be considered. No ward in a general hospital for acute cases should contain more than 24 beds. In hospitals with clinical schools the proportion of nurses to patients should be about one nurse to every three patients, and if possible every ward should have a probationer on duty at night in addition to the night nurse. In all well-conducted hospitals it is now arranged that the nurses on night duty have a hot meal served in the general dining-room during the night, and this is only possible where a nurse and a probationer are allowed for each ward. The nurses’ quarters should be separate from the hospital proper, and connected by a conservatory or covered way. Each nurse should have a separate bedroom, measuring not less than 12 ft. long, 9 ft. broad and 10 ft. high. A bath should be allowed for every eight rooms, and the water-closets and sinks should, if possible, be in sanitary towers cut off from the main block of buildings.
Circumstances must to a large extent determine the arrangement, but it seems desirable on the whole that the work of a nurse should be confined to a single ward at a time if possible. The duties of nurses ought also to be distinctly confined to attendance on the sick, and no menial work, such as scrubbing floors and the like, should be demanded of them; a proper staff of servants ought to be employed for such purposes. It is also desirable that a separate pavilion for lodging the nurses should be set apart, and that fair and reasonable time for rest and recreation should be allowed. Some discussion has taken place as to the advisability of placing the nursing of a hospital in the hands of a sisterhood or a separate corporation. It will, however, be admitted that the best plan is for the nursing staff of each hospital to be special and under one head within the establishment itself, even though it may be connected with some main institution outside. The nursing must, of course, be carried on in accordance with the directions and treatment of the physicians and surgeons.
General.—The kitchen, laundry, dispensary and other offices must be in a separate pavilion or pavilions, away from the wards, but within convenient access. A separate pavilion for isolation of infectious cases is desirable. This may be a wooden hut, or in some cases even a tent; either is probably preferable to a permanent block of buildings. A disinfecting chamber ought to be provided where heat can be applied to clothes and bedding, for the destruction both of vermin and of the germs of disease. It is advisable to expose all bedding and clothing to its influence after each occasion of wear. Although this may entail additional expense from the deterioration of fabric, it is worth the outlay to secure immunity from disease. This plan is rigidly followed at the Royal South Hants Infirmary at Southampton. It is of great importance that the wards should be periodically emptied and kept unoccupied for not less than one month in each year, and longer if possible. During such period thorough cleansing and flushing with air could be carried out, so as to prevent any continuous deposit of organic matter.
Gate House or Admission Block.—If the efficiency of a hospital and the regular and smooth working of its departments are to be secured, the proper management and control of the admission department is of the greatest importance. When one considers for a moment the number of applicants of all ages in various stages of disease, and the number of accident cases of every degree of severity who present themselves every day seeking admission, it will be evident that the most careful supervision must be exercised on the very threshold. It is essential that every precaution be taken against the admission of an unsuitable case, or the refusal, without careful examination, of any patient seeking admission. It is only necessary to instance the case of a patient with delirium tremens being admitted to a general ward at a late hour, or a case of infectious disease admitted through an overlook, or a case refused admission and expiring on the way home, in order to illustrate the danger and trouble which might arise should the supervision exercised over this department not be systematic, stringent and thorough.
To secure this proper control it is necessary that the admission department should be designed on a definite plan suitable for the purposes in view. It is not sufficient to utilize any available rooms, say, in the basement of the building, where patients may be casually interviewed by a house surgeon or physician. This department should be as carefully designed and equipped as any other department of the hospital.
Within recent years much more attention has been devoted to the details of construction than was formerly considered necessary,but even in the best type of hospital there is still much to be desired in this respect. It is essential for an architect in designing any building to have before him an accurate idea of all the requirements, and the use to which each foot of space is to be put; for unless he is furnished with this information it is not possible for him to design his building so as to give effect to all the details which are so necessary. The following is an endeavour in a general way to enumerate the various points which an architect should have before him in designing the admission department of a general hospital:—
The admission department should be conveniently placed on the ground floor of the hospital—or it may be a detached building—with a large court where ambulance wagons or other vehicles may easily pass each other on approaching or retiring from the institution. The entrance to the admission department for patients should, if possible, be entirely separate and distinct from that for the staff and students. An additional entrance should be provided for patients’ friends on visiting days, in order that they may be able to enter the hospital without passing through the patients’ entrance, or coming into contact with an accident case or other patient seeking admission. The main entrance door should be protected by a covered porch so that patients may be removed from the ambulance or cab to the examination room without being exposed to the weather or the gaze of inquisitive onlookers. This door should be sufficiently wide to allow two hand ambulances or barrows to pass should they require to be brought out to the ambulance or cab, and to facilitate this the floor of the entrance hall should be as nearly as possible on a level with that of the outside porch. Adjoining the entrance vestibule, lavatory accommodation should be provided for males and females who may accompany the patient. Lavatory accommodation should also be provided for porters on duty, and all lavatories should have a cut-off ventilating passage.
A recess to store ambulance barrows should adjoin the entrance, and this recess must be in proportion to the size of the hospital, in order that a hand ambulance may always be available when an accident or urgent case arrives. The vestibule should lead into a large waiting-hall with an inquiry office at its entrance, provided with a telephone exchange, private exchange box, also letter and parcel racks. If possible a window of the inquiry office should command a view of the main entrance. A room should be provided for the medical officer on duty, so that a medical officer may be always at hand and that no delay will occur in attending to a patient on arrival.
Leading off from this waiting-hall, well-lit examination rooms should be available for the thorough examination of patients, both male and female, the number of rooms, of course, varying with the size of the hospital and the amount of work to be done. Each of these rooms should be fitted with a wash-hand basin and sink, and a plentiful supply of hot and cold water.
Two rooms, with recovery rooms adjoining, should be fitted up as small operating-rooms for the treatment of minor casualties. A special room should also be furnished with an X-ray outfit, and arrangements should be made whereby this room can be readily darkened so that suspected fractures, &c. may be examined with the fluorescent screen.
Adjoining the admission department two small wards should be provided for the accommodation of drunk or noisy cases unfit to be placed in the general wards. To these “emergency wards” must be attached the usual bathroom and lavatory accommodation, nurses’ room, ward kitchen and urine-test room or small lavatory. These wards should have double windows in order to prevent noise being heard outside if the wards are near other buildings.
The interior walls of the admission department should, as far as possible, have a smooth and impervious surface, in order that they may be easily cleaned. All angles should be avoided and all corners rounded. Although glazed tiles are open to the criticism that they have numerous joints, they probably make the most suitable wall yet devised, as they can be easily washed down at very small cost. The corridors and waiting-hall should be tiled to a height of 6 ft. 6 in., and the upper walls covered with Parian or Kean’s cement, and be treated with three coats of flat paint and two coats of enamel, or, what is equally suitable and less costly, enamellette. The floors of the passages and corridors throughout the department should be covered with terrazzo, which is a mixture of Portland cement and marble chips. A margin of 1 ft. round the rooms should be treated in this way, and the terrazzo carried up this same distance on the wall to join the tiles. The remainder of the floors should be covered with hard wood, such as American maple or teak. As these floors require to be frequently washed, oak is not so suitable. Oak very soon becomes destroyed with water; the same trouble is experienced with pitch pine. The doors should also be made of a hard wood, preferably teak, and have no mouldings or grooves where dust can lodge. They should be wide enough to admit an ambulance barrow or bed with ease. In no case should the doors of an examination room be less than 3 ft. 6 in. in width.
As an aid to a complete understanding of the varied work which has to be provided for, and the most effective method of carrying it out, the accompanying plans are given of an admission block designed to embody the main principles which govern the construction of such a department.
All accidents and patients seeking admission to this hospital enter through the central gateway, and on the left is shown the porters’ room, where a porter is always in readiness to attend to any applicant. This room has suitable accommodation for parcels, letters, telephones, &c., and adjoining it is a small lavatory for the use of porters. At the side of the porters’ room is the entrance to the central waiting-hall, which is lit from the roof. On one side of this hall are examination and dressing-rooms for males, with lavatory accommodation; and on the other side similar provision for females, with the addition of a nurses’ duty room. At the end of the central hall are two operating theatres, with recovery room adjoining each; one theatre for males, and the other for females. Between these theatres are rooms for sterilizers and dressings. An X-ray examination room is provided beyond the male examination room on the right of the hall. In the basement, under the entrance-hall and operating theatres are two bathrooms for males and two for females, with W.C.’s for each. The remainder of the basement is used as a store for patients’ clothes, and a hot-air chamber is provided for purposes of disinfection. The basement can be reached by a lift or by a wide staircase which is situated at the end of the waiting-hall.
In the above plan provision is made for a sitting-room for the medical officer on duty. This is a new and essential feature in the admission block unit of all hospitals in large cities, for it should secure that no patient is kept waiting for many minutes before being seen. One of the blots on the management of many hospitals is that regrettable delays often take place, and much dissatisfaction and avoidable suffering may arise from this difficulty in the administration of a general hospital. We have given this plan of a model gatehouse or admission block for a modern general hospital, because the block as it stands contains all the elements necessary for a receiving-house block in cities in connexion with a great Hospital city situated outside its area, in fulfilment of the suggestion for a Hospital city made above. Apart from its interest as a new feature which all new hospitals should adopt, the gatehouse or admission block has an importance in the wider sense, that it may come to form the key to the solution of the problem of how best to provide hospital accommodation for the poor in great cities under the best hygienic conditions, while protecting them from the misery and danger of prolonged delay in first treatment, especially in connexion with accidents and other cases of urgency.
Bibliography.—Sir H. Burdett,Cottage Hospitals, General, Fever and Convalescent, their Construction, Management and Work(London, 1877, 1880 and 1896); Tollet,Les Édifices hospitaliers depuis leurorigine jusqu’à nos jours(Paris, 1892); Sir H. Burdett,Hospitals and Asylums of the World, with large portfolio of plans to a uniform scale (London, 1893) (a supplement is published every year bringing the information up to date, entitledBurdett’s Hospitals and Charities); J. S. Billings,The Principles of Ventilation, Heating and their Practical Application(New York, 1893); Galton,Healthy Hospitals(London, 1893); Tollet,Les Hôpitaux au XIXesiècle(Paris, 1894); Billings and Hurd,Suggestions to Hospital and Asylum Visitors(Philadelphia, 1895); Oswald Kuhn, “Hospitals,”Handbuch der Architektur, 4th part, 5th half-volume, part i. (Stuttgart, 1897);Plans for the Johns Hopkins Hospital(Baltimore, 1875);Report of State Board of Health for Massachusetts for 1879.