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terrible powers of disease,—the spreading flames, as it were, of some infections, and the explosive fuel of others; and any air in which they are let accumulate, soon becomes a very atmosphere of death. Against this danger, ventilation is the one possiblo safeguard,-ventilation which, with continuous current, shall always be bearing away, as rapidly as evolved, every volatile taint which rises from the sick. So that, for hospital hygiene, ventilation requires preëminent regard. And if ever the phrase 'well ventilated’ may be (though it never ought to be) at all indulgently construed in respect of a common dwelling-house, it must never, in respect of a hospital, be construed but with the utmost conceivable strictness.”
Dr. Evory Kennedy,* of Dublin, excited renewed interest in the question of hospital reform, by a paper on zymotic diseases and puerperal fever, presented to the Obstretrical Society in 1869. Dr. Kennedy's position as an ex-president of the Irish College of Physicians, and ex-master of the Dublin Lying-in Hospital, gave his opinions a wide influence throughout the medical world, and led to a discussion of the hospital system in its application to midwifery by the Dublin practitioners, which, in completeness as well as brilliancy, has been rarely equalled in medical literature. Dr. Kennedy did a very praiseworthy work in making known the convictions of his mind concerning the influence of great lying-in hospitals in propagating fatal diseases, and a very brave work in meeting the natural conservatism and pride of his brethren with reference to an institution like the Dublin Hospital, whose foundation dates back more than a century, whose wards have in this period received 200,000 patients, and whose fame is known throughout the world. But he bore himself nobly in the fight, and is now receiving the reward of good service. He has strengthened the hands of all hospital reformers. Dr. Kennedy showed from the hospital records that the deaths in that establishment had been to the whole number of patients received, one in 72 for the whole period of its existence, rising in some years to one in 30 to 40, once to one in 19, and once to one in 14; while the death-rates from all the accidents of childbirth in a series of years for the whole population of England
Dublin “Quarterly Journal of Medical Sciences.” 1869.
and Wales had been one in 223, of Scotland one in 225, and of London one in 239. Dr. Kennedy contended that a great portion of this mortality was preventible, that it had its origin in the hospital, at times haunting certain wards, and was propagated from one patient to another chiefly by infection of the atmosphere of the building, and that the remedy would only be found in breaking up this great establishment, and providing detached cottages, each of which should give accommodation to two patients, and no more.
Dr. Kennedy's argument corresponds with that of Dr. Simpson, the one referring to parturient women, with special reference to their danger from puerperal fever, and the other to amputations of the limbs, with special reference to surgical fever. These two affections (metria and pyæmia) have many pathological resemblances which are now universally recognized, and they are, of all known diseased conditions, those which every practitioner most dreads to meet. In hospitals they are almost always fatal.
Mr. Paget, one of the most eminent of living surgeons and pathologists, stated, in 1862, that, "in every case of erysipelas, pyæmia, or the like, we ought to work till we discover the probable origin ; we should have the strongest feeling that these diseases are not spontaneous nor inevitable. In every case the hospital or the house or our own practice should be brought to trial,—to private trial if you will, yet a just trial, -a trial before our own conscience; and if the hospital, the house or the practice be found guilty, let it be condemned and amended. Of all the remedies I have used, or seen in use, I can find but one thing that I can call remedial for the whole disease pyæmia,—and that is a profuse supply of fresh air.”
American experience with civil hospitals corresponds with that of Europe. Except in our largest cities, there have not been in the past so large a number of destitute persons as would require other hospitals than those attached to almshouses. Great lying-in hospitals do not exist in America ; and, with the warnings we have had on this subject, it is to be hoped that the care of this class of patients may always continue to be in small and detached establishments. New York, Philadelphia, Boston, Cincinnati, and other cities have great
general hospitals, and some of them, through the fame of their surgeons, attract very large numbers of surgical cases.
The following table will show the comparative mortality from the amputation of limbs in four American hospitals, viz. : the New York Hospital, the Pennsylvania Hospital, the Boston City Hospital, and the Massachusetts General IIospital, contrasted with the mortality in nine London hospitals. The American figures are derived from a pamphlet entitled " Amputations at the Massachusetts General Hospital,” compiled by Dr. James R. Chadwick, in 1871; the English figures are taken from Dr. Simpson's essay on Hospitalism. The American statistics extend, in the case of the Massachusetts General Hospital, as far back as 1823; the London statistics are for different periods, but all included between 1861 and 1868. Both the American and English figures include amputations for disease, and primary and secondary amputations for injury.
This contrast is in our favor; but, when it is remembered that our hospitals are smaller than those of London, the difference is only such as might be expected in accordance with the rules of Simpson and Kennedy, that the mortality is (other things being equal) proportional to the size of the hospital, or the aggregation of the sick in one establishment.
We are not aware of any effort having been made to collect amputation statistics in private practice in the United States, but can see no reason why they should not present similar results to those collected in Great Britain. It is to our military rather than to our civil hospitals that we must look for instruction in hospital hygiene. This experience has been on a prodigious scale during the recent civil war. tunities for comparison of various methods of providing for
Such opporgreat numbers of sick and wounded men have never before been presented to the world ; and, fortunately for the interests both of humanity and science, the army authorities, early in the war, saw the wisdom of leaving this department to be managed by the medical profession whose special training had fitted them for the work. Had the European customs and traditions—hampering the medical department with the authority of general officers—been followed in our army, such results could never have been reached.
This freedom of the medical staff gave opportunity for the trial of hospitals in every form. Churches, warehouses, factories, private dwellings were thus occupied for our wounded ; wherever lumber could be got rude buildings were made on any plan which seemed best to the medical officers; tents were used when they could be had, and were made comfortably warm by stoves, open fire-places, and underground pits from which the smoke was ingeniously conveyed to the outer air.
Finally, and as the result of all these improvised means of sheltering those who were disabled by sickness or wounds, there was gradually formed a system of hospital construction, of which the distinguishing features were these : 1st, buildings of one story ; 2d, ventilation in summer directly through the ridge in its whole length, a:d in winter by wooden shafts, warmed by the smoke-pipe of the heating-apparatus, whatever it might be, and leading straight through the roof. They were, in all cases, detached pavilions, and freely exposed to air and light, but in these respects can claim no originality: Never before in the history of great wars has been found such immunity from erysipelas, surgical fever, and kindred affections to which all great hospitals are liable, as in these simple constructions.
The truth of the remark of Sir James Paget concerning pyæmia, which we have already quoted, was constantly illustrated.
The soldiers got, within these buildings, that most powerful of all remedial agents, and that most important of all preservers of vitality, fresh air; and as soon as they could crawl out of doors there were no stairs to prevent them from so doing.
These lessons have not failed to instruct the medical profession everywhere. In the European wars which have since occurred, we find that wherever American experience has been followed (and this has been very general) the results have been good and satisfactory. The opinions of French and German surgeons seem to be entirely in accord with those of the United States, and both are founded on very wide observation, and their testimony is to this effect.
The chance of recovery to both sick and wounded is better in the rudest barracks to which air has perfectly free access, or in tents, than in the most elaborate and completely appointed hospitals of great cities, in which the plans for supplying air are artificial.
An application of these principles to civil hospitals already established, both here and in Europe, is by no means readily accomplished.
These establishments are rooted in conservatism. Connecting the piety and charity of the past with the relief of suffering in the present generation, they seem hardly less sacred than the Church itself. They are great monuments of benevolence; and this is out
; wardly expressed by architecture of the most imposing and enduring character. To destroy them and to build barracks in their stead would be thought sacrilegious. They can, however, be amended and improved ; and this is already being dove in some instances. Meanwhile the whole subject of new hospital construction is undergoing change.
In England, Capt. Galton, already well known in connection with improvements in heating-apparatus, has recently written an excellent treatise * on hospital architecture, giving much useful instruction, but stopping just short of what seems to us to be the essential reform of the future.
Another indication of the need of change is found in the apparent popularity of what are known in England as " Cottage Hospitals,” designed for from three to six or eight beds,
The Construction of Hospitals, by Douglas Galton. London. 1869. † He protests against piling up the sick in many successive layers or stories, but is willing to compromise for two. The advantages which come from the simple forms of ventilation which may be used in a building of one story he does not appear to