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having the general character of a small country dwelling, with one nurse, who is also cook and general manager, under the direction of a committee of benevolent persons. The success of these rural hospitals seems to be complete, if we may trust to the evidence of the author of a recent book* about them. They seem, however, to be specially adapted to a state of society quite unlike anything found in an American town or village. In so far as they show the advantages of having only a small number of sick under a single roof, their experience is to be noted as of value.
In the establishment of new hospitals for cities and towns, we may reasonably hope that the warnings of past experience and the results of recent investigations will be remembered. The time of great collections of sick people under one roof has gone by. Every diseased person is now to be regarded as an element of more or less danger to those about him, and the effort must be made to reduce this danger to the smallest possible amount consistent with such association of the sick as may be required for purposes of economy, of convenience, of professional care, and of nursing.
It must always be kept in view that the chief purpose of a hospital is the restoration of the sick to health in the shortest possible time. If other considerations stand in the way of this grand object, they must, when fairly recognized as obstructions, be put aside.
When it is made to appear that the mortality of hospitals increases in geometrical ratio with the number of their inmates who breathe a common atmosphere, the opinion of the world will demand that they be subdivided until the minimum of disease is reached. When it is clearly understood that great and many-storied hospitals generate a poison which may infect either the healthy or unhealthy body; that they lower the vitality of those who breathe their air; that the chances of life to sick or well are diminished by living within their walls,-in short, when it is understood that such hospitals are among the preventable causes of death, public opinion will demand that they be demolished, and that the sick shall be
Handy Book of Cottage Hospitals, by Horace Swete. London. 1870.
taken care of in such manner that these dangers shall not be encountered.
That all the terrible evils above enumerated may fairly be charged upon such hospitals as the Hotel Dieu of Paris, or the Rotundo Lying-in Hospital of Dublin, within a period of tifty years, we think no physician will deny. Since that time reforms have been slowly made, and they are still going on.
At the present moment such ideas are prevalent in the medical profession concerning "hospital influence,” that no surgeon can be found rash enough to undertake the operation of ovariotomy in any great hospital of America or Europe. In houses of ordinary convenience, and in rooms supplied with air of unquestionable purity, this operation is attended with no greater mortality than amputation of the leg or armfar less than the amputation of the thigh,—but in our great hospitals death from ovariotomy is found to be almost certain. Such considerations lead to the conviction that we have by no means attained the standard of healthfulness in hospitals at which we must aim, and which will finally be reached.
This growing faith, having a foundation in the daily observation of physicians, the evidence of statistics of hospital mortality, and the studies of experimental philosophers of the present day, tends strongly towards the segregation, and against the aggregation of the sick. On the other hand, it must always be recognized that the care of the sick can be economized by placing them in such position that the wants of large numbers can be met by a simple organization of physicians and surgeons, as well as of nurses and cooks and attendants. The service of the most eminent physicians and surgeons can, perhaps, only in this way be secured to the poor ; and the advantages of medical and surgical education and comparison which hospitals afford to the young men who are to be the physicians and surgeons of the future can hardly be over-estimated.
What, then, can we do? How secure these advantages to the whole community, and avoid the special dangers to hospital inmates ? All plans to accomplish these objects point in the same direction. They all look to the breaking up of great hospitals, except for purposes of administration, into completely detached parts, so that each shall have its own atmosphere and borrow nothing from its neighbors; and they all insist upon this atmosphere, which the patients are compelled to breathe, being as free from the impurities which hospitals constantly generate, as the ingenuity of man can possibly provide.
These being the sanitary requirements which the improved knowledge and benevolence of the world will finally insist upon, whether they prove to be more or less convenient or expensive, we think they are met by detached pavilions of the simplest construction, and by building them of one story in height, and no more. Such requirements will demand that architectural pretensions shall be set aside. Stately piles of
. hospital buildings will, we think, in the future, be regarded as the monuments of those who have needlessly died within their walls, rather than of the charity and benevolence of their founders.
All systems of supplying the needed amounts of fresh air to hospitals of more than one story have failed. The most elaborate artificial contrivances do not meet this fundamental want. From the Lariboisière at Paris to the City Hospital at Boston, they are failures, one and all, and the machinery for suction or propulsion being found inadequate, resort is had to natural currents of wind, or to such movements of air as can be established by its own weight when heat is applied or removed. With hospitals of one story better ventilation can be had both in winter and summer, by means infinitely more simple, and capable of management by persons of ordinary intelligence; greater air-space can be afforded, and the inmates can get the benefit of the outer air and sunshine just as soon as they are able to walk.
Another point of infinite importance in the building of hospitals, is to guard against the slow and gradual contamination of the wards themselves by emanations from the sick. We think that this requirement may be met by having wards enough to leave one or more at all times unoccupied, and completely exposed to the purifying effects of air and sun. This can readily be done with one-storied pavilions.
It is evident that a great hospital arranged on this plan would, in some respects, be less, and in others, more expensive. Greater ground-space would be required,—the greater
the better. The cost of construction would be very much less than in the many-storied palaces, but the cost of administration would certainly be greater. Fuel, and the service of the hospital, would be additionally expensive. Whether these would be counterbalanced by the cheapness of the original outlay for buildings, we are unable to say,–probably they would not. But this is not a mere question of cost, not one of ordinary economy, but of economy of life, and it cannot be put aside with the usual arguments of thrift.
We do not enter upon the minute details of hospital construction for several reasons. They involve the discussion of a great number of questions, and would tend to make less prominent the radical errors which we think have been committed in the past, and which should first be corrected.
Many of the difficulties, indeed, which have occasioned much controversy and book-making, would disappear if our recommendation of one-storied wards, completely detached from each other, were adopted. The vexed question of hospital ventilation would be simplified.
Suction and propulsion by artificial methods, which require for their working that windows shall be kept closed, and that the machinery be worked by skill of the highest order capable of appreciating not only changes of temperature and season and atmospheric pressure, but of insuring the efficiency of the whole apparatus by day and night, would be replaced by a system in which the opening and closing of windows and ridge-valves would always be simple and practicable. The heating-apparatus, whether of steam, hot water, or furpaces, might also be so arranged under each ward as to warm the floor, and thus remove the evil of a difference of temperature of from ten to twenty degrees between the top and bottom of the room, as is now generally found in winter. Every ward should also have one or more capacious fireplaces, for burning any fuel which may be convenient. Open fire-places cannot be exclusively depended on for heating a ward in so severe a climate as ours, but in many months of the year they would be sufficient for this purpose. At all times their additional ventilation would be of the greatest value, while the radiant heat from flame, by warning the floor and the furniture and the clothing and bodies of the
inmates without a corresponding heating of the intervening air, supplies the needed warmth in the most advantageous way possible for the sick. The cheerful effect of an open fire in a sick-room or ward can never be dispensed with.
Communication by a common atmosphere being absolutely cut off by completely detached pavilions, the largest hospital need have no greater mortality by reason of its size or extent than one which would be represented by the number of beds in a single ward. Should the pests of hospitals appear in one of these subdivisions, another would be vacant and ready for instant occupancy, while the infected one could, in turn, be exposed to air and sunlight, and, if need be, artificial disinfection.
The importance of putting a hospital on solid ground, and on soil which may, to a great extent, purify itself by aeration if human contrivances fail, as they are sure to do sooner or later, is too obvious to require discussion.
Circumstances may sometimes require that hospitals shall be less fortunately placed, but we are inclined to believe that rather than build them on such soil as that occupied by our two great hospitals of Boston, it would have been better to bring in gravel enough from the surrounding country to raise their foundations at least fifteen feet above their present level. If the patients could not be carried to the neighboring gravel hills, the hills should have been brought to them.
Concerning the arrangement of wards and nurse-rooins and water-closets and bathing-rooms, as well as kitchens and administration, the best materials for floors and walls and other details of importance, much useful knowledge will be found in the books to which we have already referred, especially those of Miss Nightingale and Capt. Galton, and in a valuable report on the barracks and hospitals of the United States Army, by John S. Billings, Assistant Surgeon U.S. A., and in Circular No. 2, Surgeon-General's office, 1871.