Hospital reform has been also promoted by the more precise knowledge we now have concerning air and its contents, coming from the studies of chemists and microscopists; and of ventilation and the need of a great supply of pure air for the preservation of health and, a fortiori, for the cure of disease. Great progress has been made in both these fields of exact knowledge, and their application to existing hospitals has been made by physicians and surgeons of both civil and military service in all parts of the world.

It is evident enough to those who have not been immediately engaged in the discussion which has arisen during the past few years, that the old hospital system is not approved, and that very radical changes must be made. The dispute still goes on in all European countries and in America, and the end is not yet. It is, however, clearly foreshadowed, and must be met by those who would establish hospitals which can bear the criticism of the future. It will not be surprising if our successors of the twentieth century shall look back with something of the same wonder and pity upon our great hospitals of to-day with which we regard the descriptions of the old Hotel Dieu of Paris, or St. Thomas of London, in the last century. They will surely do so, if the present mortality of the great hospitals of those cities shall be reduced to the present mortality of the hospitals of fifty beds in the same countries. If the present mortality after amputations in the great hospitals of New York and Boston can be reduced to the mortality after amputations in private dwellings, there will be good reason for the claim of increasing knowledge of the causes of death.

A hundred years ago the Hotel Dieu often sheltered at one time, and under one continuous roof, two and three thousand patients suffering from bodily injuries and every form of sickness, mingled indiscriminately with diseases now known to be infectious, in wards without adequate provision of either air or light, and two, and often three, patients were laid in one bed. One out of every four who entered the hospital died. London hospitals of that period were better; but even there patients were mixed up and crowded in the wards in a manner which would now be regarded as wicked.

From that period to the present time, physiology, pathology,

*

chemistry and the physical sciences have been advancing, and never more rapidly than now. Their application to hospital construction and to hospital reforms has been slow but inevitable. The power of unpolluted air to maintain health, and the vitally depressing effect of foul air on both the sick and the well, have been partially recognized. Such hospitals as the Hotel Dieu, or the Beaujon, or the Charité of thirty years ago, are no longer built; but we find Lariboisière, with its high rooms and separate pavilions, and enormously complicated system of artificial ventilation, which expresses the recognized need of what, unfortunately, it fails to supply. Patients suffering from diseases known to be infectious are now separated from others, or at least the attempt at separation is made. But the demand for greater security against preventable sickness, both in and out of hospitals, is very far from being satisfied.

The question recurs constantly, and with increasing force, not only whether our hospitals present every opportunity for the restoration of health, but whether they do not contain in themselves forces which actually oppose or retard or prevent recovery. The wards of a hospital, it is to be remembered, are, unlike any portion of an ordinary dwelling, occupied continuously, day and night. Its occupants give rise, in addition to the usual excretions from the breath and the skin, to special forms of impurity. Suppurating surfaces throw into the air pus-cells in a state of decay; the urine and focal discharges add to this dangerous material, quicken its decomposition, and make it still more dangerous; the special poisons of special diseases (if such things exist) mingle with this foul "stirabout." t The result of all this is, that a pernicious atmosphere is generated, which unless special and constant pains be taken to get rid of it, fastens itself upon woodwork, clothing, and everything which holds moisture. It is not

The student of medicine in Paris at that period cannot fail to remember the dark, low, gloomy wards in which he followed Chomel and Louis and Roux and Velpeau, in the early morning, in an atmosphere oppressive with foul animal odors which had accumulated through the night, nor to recall the terrible mortality which followed surgical operations executed with consummate skill.

+ Professor Huxley is responsible for this word. In his address to the British Association, at Liverpool, he says, in speaking of the air of inclosed places, "Ordinary air is no better than a sort of stirabout of excessively minute solid particles."

difficult to see why hospitals should sometimes tend to lower the vital force of their inmates, nor is it strange that special diseases should sometimes haunt their walls. From the time when oxygen was discovered to the present moment, the value of unpolluted air, as a remedy, has been more and more clearly seen. Angus Smith and Pettenkofer are but following the path marked out by Lavoisier and Priestley; and the world at large is gradually becoming convinced that here, indeed, we have the true elixir of life. To secure it in abundance is the most essential thing in the reform of hospitals. With it all else becomes simple and practicable; without it no real progress can ever be made.

Among those who have made practical demonstration of the value of unpolluted air to the recovery of the sick, and who have led the way in hospital reform in these latter days, the name of Miss Florence Nightingale is conspicuous. Her noble personal efforts in the Crimean War, and the book on hospitals which followed, have made the world her debtor. It was an application of heroic impulses, with the teachings of science, to a great work; and it fixed the attention of all thinking people in every civilized country.

If the Crimean War was the direct means of destroying, it was also the indirect means of saving lives in all subsequent time through the terrible lessons of hygienic neglect, which it made known in such a manner that no one could fail to understand them. The "Notes on Hospitals" brought the subject before the builders and supporters of these establishments with a force which is plainly felt at the present time. Government commissions were ordered to examine them. Comparisons of mortality in the various British hospitals were made by the registrar-general. Hospital reform became at once a subject of general and popular concern.

Dr. Simpson,* of Edinburgh, took up the subject of hospitalism with characteristic energy. Recognizing the many elements of doubt which are included in the usual contrasts of hospitals and their results, he fixed upon the amputations of limbs as affording the best standard of comparison, and pursued his inquiries in this direction until a great number of

* Works of Sir J. Y. Simpson. Vol. II.

these cases had been collected from town and country, from hospitals of all sizes and grades, and from surgeons not attached to hospitals, in Scotland and England. The whole number of cases of amputation of thigh, leg, arm and forearm was 4,187, and these, which had occurred in almost equal proportions in hospitals and in country practice at the homes of the patients, showed that the ratio of mortality in the smaller provincial hospitals was less than half as great as in the great hospitals of London. This was indeed a startling fact. Moreover, out of 2,089 amputations in hospital practice, 855 died; out of 2,098 amputations in country practice, 226 died.

The difference, astonishing as it appears in the above figures, is, however, far greater when certain special amputations are compared. Thus, in hospital practice, out of 244 cases of amputation of the arm between the elbow and the wrist, 40 died; while in country practice, after 377 cases of the same operation, only two died. To return to limb amputations in general, Dr. Simpson showed that in hospitals of from 300 to 600 beds, one in two and a half die; in hospitals of from 100 to 300 beds, one in four die; in hospitals of from 25 to 100 beds, one in five and a half die; in cottage hospitals under 25 beds, one in seven die; and in isolated rooms in country practice, one in nine die. Dr. Simpson also refers to the enormous difference in the mortality from pyœmia (surgical fever) after amputations in hospitals and in private practice. This generally admitted fact is attested by a comparison of statistics collected by various writers.

Taking all these figures as the basis of his argument, Dr. Simpson presented his views of hospitalism at great length in a series of propositions, which are most strikingly put, and which have made a permanent impression. They have been disputed in every form, but their general correctness, we think, is now pretty well established. His conclusion is that

in the treatment of the sick there is ever danger in their aggregation, and safety only in their segregation; and that hospitals should be constructed so as to avoid as far as possible the former, and secure as far as possible the latter condition.

A report on hospital hygiene in Great Britain was made to the government, in 1864, by Dr. Bristowe and Mr. Holmes, one a physician and the other a surgeon, who were appointed by the medical officer of the privy council, Mr. Simon, to give the subject thorough examination. This was by far the most complete exposition of hospitals and the hospital system which had been made. It deals with an infinity of details, and in its conclusions must be regarded as a defence of British hospitals against the criticism of the advancing knowledge of the period. While protesting against the death-rates being taken as a certain index of the salubrity or success of any hospital, and pointing out the many sources of error in the comparisons of hospital results, it admits the proved danger of erysipelas, pyœmia and cognate diseases in both surgical and lying-in wards, and insists upon the infinite importance of better ventilation, better drainage, greater bed space and more scrupulous cleanliness, as means of preventing the occurrence and the spread of these causes of death. Mr. Simon's remarks upon the report of the commission, in the same volume, are of extreme interest, and touch upon many points of hospital hygiene, all of which are made clearer by his philosophical and masterly treatment. The following extract will give his views of several important points: "That which makes the healthiest house, makes likewise the healthiest hospital; the same fastidious and universal cleanliness, the same never-ceasing vigilance against the thousand forms in which dirt may disguise itself in air, in soil and water, in walls and floors and ceilings, in dress and bedding and furniture, in pots and pans and pails, in sinks and drains and dust-bins, it is but the same principle of management, but with immeasurably greater vigilance and skill; for the establishment which has to be kept in such exquisite perfection of cleanliness, is an establishment which never rests from fouling itself; nor are there any products of its foulness, not even the least odorous of such products, which ought not to be regarded as poisons. Above all, this applies to the fouling of the air within hospital wards by exhalations from the persons of the sick. In such exhalations are embodied the most

*Sixth Report of the Medical Officer of the Privy Council.