Chapter XI: Part II: The Practice of Horticulture (9)

_Special Hospitals._--Up to about 1840 the general hospital was, speaking generally, the only hospital in existence. Twenty years later, as the population increased and medical science became more and more active, some of the more ardent members of the medical profession, especially amongst the younger men, pressed continuously for opportunities to develop the methods of treatment in regard to special diseases for which neither accommodation nor appliances were at that time forthcoming in general hospitals. In a few cases, where the managers of the great general hospitals were men of action and initiative special departments were introduced, and an attempt was made to make them efficient. The conservative spirit which, on the whole, represents the British character for the most part, resulted, however, in a steady resistance being offered by the older members of the medical staffs and existing committees to the advocates of special departments. In the result, especially as such special departments as there were in connexion with general hospitals were too often starved for want of means and men for their development and improvement, the younger spirits called their friends together and began to start special hospitals. To-day every really efficient clinical general hospital has within its walls special departments of almost every description, which have been made as efficient and up-to-date as money and knowledge can make them. Unfortunately the causes already referred to led to the establishment of hundreds of the smaller special hospitals, many of which were started in unsuitable buildings, and some of which have ever since maintained a struggling existence. Others, on the contrary, through the energy of their original promoters and the excellence of the work they have done, have obtained a position of authority and reputation which has had a very important bearing for good upon the development of medical science in the treatment of disease. If the world had to-day to organize the very best system of hospital accommodation which could be evolved, there is no doubt that few or none of the special hospitals would find any place in that system. As matters stand, however, the special hospital has had to be accepted, and nothing which King Edward's Hospital Fund has done in London has met with greater popularity and professional approval than the labours which its council have undertaken in promoting the amalgamation of the smaller special hospitals of certain kinds, so as to secure the provision of one really efficient special hospital for each speciality. No doubt this policy of amalgamation will be steadily pursued, and in the course of years every great city will gradually reorganize its hospital methods so as to secure that, whether the patients are treated in a general hospital or in a special hospital, the average efficiency in every institution shall be as high and as good as possible.

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 (see INSANITY, 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 oL
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 by light
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 L300,000 to L400,000, 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 securing the 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 the maximum 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 Hotel-Dieu in Paris and
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, the _chalet_ or single-patient
hut is the best for the patients in the acute stages; for economical
reasons the _chalet_ has 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 the _chalet_ will 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 6(1/2) ft. long; this gives
7(1/2) 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 Hotel Dieu, 29; and
Lariboisiere, 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 13(1/2)
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 (see _Report
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 1(1/2) ft. per
second, except at the point of entry, where it should not exceed 5 ft.
per second, and at the outlet, 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 deg. to 63 deg. 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 Wards_ should 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.