Notes on the Sanitary Condition of Hospitals,
and on Defects in the Construction
of Hospital Wards
1858 — National Association of Social Science
Feeling very desirous of contributing whatever aid I can to improvement in Hospital construction and administration — especially at this time, when several new hospitals are being built — it has occurred to me to transmit a few notes on defects which have come under my own observation in an extended experience of these institutions.
No one, I think, who brings ordinary powers of observation to bear on the sick and maimed can fail to observe a remarkable difference in the aspect of cases, in their duration and in their termination in different hospitals. To the superficial observer there are two things only apparent — the disease and the remedial treatment, medical or surgical. It requires a considerable amount of experience, in hospitals of various constructions and varied administrations, to go beyond this, and to be able to perceive that conditions arising out of these have a very powerful effect indeed upon the ultimate issue of cases which pass through the wards.
It is sometimes asserted that there is no such striking difference in the mortality of different hospitals as one would be led to infer from their great apparent difference in sanitary condition. There is, undoubtedly, some difficulty in arriving at correct statistical comparison to exhibit this. For, in the first place, different hospitals receive very different proportions of the same class of diseases. The ages in one hospital may differ considerably from the ages in another. And the state of the cases on admission may differ very much in each hospital. These elements, no doubt, affect considerably the results of treatment, altogether apart from the sanitary state of hospitals.
In the next place accurate hospital statistics are much more rare than is generally imagined, and at the best they only give the mortality which has taken place in the hospitals, and take no cognizance of those cases which are discharged in a hopeless condition, to a much greater extent from some hospitals than from others.
We have known incurable cases discharged from one hospital, to which the deaths ought to have been accounted, and received into another hospital, to die there in a day or two after admission.
Again, the sanitary state of any hospital ought not to be inferred solely from the greater or less mortality. If the function of a hospital were to kill the sick, statistical comparisons of this nature would be admissible. As, however, its proper function is to restore the sick to health as speedily as possible, the elements which really give information as to whether this is done or not, are those which show the proportion of sick restored to health, and the average time which has been required for this object; a hospital which restored all its sick to health after an average of six months’ treatment, could not be considered as by any means so healthy as a hospital which returned all its sick recovered in as many weeks. The proportion of recoveries, the proportion of deaths, and the average time in hospital must all be taken into account in discussions of this nature, as well as the character of the cases and the proportion of different ages among the sick.
Hospital mortality statistics give little information on the point, because there are elements in existence of which such statistics take no cognizance, In one set of metropolitan hospitals, for example, I find the mortality about two and a-half per cent. upon the cases treated, while in other metropolitan hospitals the deaths reach from about twelve to sixteen per cent. To judge by the mortality in these cases would be most fallacious. Because in the first class of hospitals every ailment, however slight, constitutes a title to hospital admission, while, in the latter class of hospitals, special diseases only, at all times accompanied by a high rate of mortality, are admitted. Hence the duration of the cases admitted, and the general course and aspect of disease afford important criteria whereby to judge of the healthiness or unhealthiness of any hospital in addition to that afforded by the mortality statistics. Besides, careful observers are now generally convinced that the origin and spread of fever in a hospital, or the appearance and spread of hospital gangrene, erysipelas and pyæmia generally, are much better tests of the defective sanitary state of a hospital than its mortality returns. But I would go further, and state that to the experienced eye of a careful observing nurse, the daily, I had almost said hourly, changes which take place in patients, and which changes rarely come under the cognizance of the periodical medical visitor, afford a still more important class of data, from which to judge of the general adaptation of a hospital for the reception and treatment of sick. One insensibly allies together restlessness, languor, feverishness, and general malaise, with closeness of wards, defective ventilation, detective structure, bad architectural and administrative arrangements, until it is impossible to resist the conviction that the sick are suffering from something quite other than the disease inscribed on their bed-ticket¾and the inquiry insensibly arises in the mind, what can be the cause? To this query many years’ experience of hospitals in various countries and climates enables me to answer explicitly as the result of my own observation, that, even admitting to the full extent the great value of the hospital improvements of recent years, a vast deal of the suffering, and some at least of the mortality in these establishments, is avoidable.
What, then, are those defects to which such results are to be attributed?
I should state at once that to original defects in the sites and plans of hospitals, and to deficient ventilation and overcrowding accompanying such defects, is to be attributed a large proportion of the evil I have mentioned.
The facts flow almost of necessity from ascertained sanitary experience. But it is not often, excepting perhaps in the case of intelligent house surgeons, that the whole process whereby the sick, who ought to have had rapid recoveries, are retained week after week, or perhaps month after month, in hospital, is continuously observed. I have known a case of slight fever received into hospital, the fever pass off in less than a week, and yet the patient, from the foul state of the wards, not restored to health at the end of eight weeks.
The defects to which such occurrences are mainly to be attributed are four: —
1. The agglomeration of a large number of sick under the same roof.
2. Deficiency of space.
3. Deficiency of ventilation.
4. Deficiency of light.
These are the four radical defects in hospital construction.
But on the very threshold of the subject we shall probably be told that not to these defects, but to “contagion” and “infection,” is much of the unhealthy condition of some hospitals attributable, at least so far as concerns the occurrence of zymotic diseases. On the very threshold, therefore, we are obliged to make a digression in order to discuss the meaning of these two familiar words, and to lay these spectres which have terrified almost all ages and nations.
This is the more necessary, because on the exact influence exercised by these two presumed causes of hospital sickness and mortality depends to a great degree the possibility of our introducing efficient hospital attendance and nursing. Unfortunately both nurses and medical men, as well as medical students, have died of zymotic diseases prevailing in hospitals. It is an all-important question to decide whether the propagation of such diseases is inevitable or preventible. If the former, then the whole question must be considered as to whether hospitals necessarily attended with results so fatal should exist at all. If the latter, then it is our duty to prevent their propagation.
The idea of “contagion,” as explaining the spread of disease, appears to have been adopted at a time when, from the neglect of sanitary arrangements, epidemics attacked whole masses of people, and when men had ceased to consider that nature had any laws for her guidance. Beginning with the poets and historians, the word finally made its way into medical nomenclature, where it has remained ever since, affording to certain classes of minds, chiefly in the southern and less educated parts of Europe, a satisfactory explanation for pestilence and an adequate excuse for non-exertion to prevent its recurrence.
And now, what does ‘contagion’ mean? It implies the communication of disease from person to person by contact. It pre-supposes the existence of certain germs like the sporules of fungi, which can be bottled up and conveyed any distance attached to clothing, to merchandize, especially to woollen stuffs, for which it is supposed to have a particular affection, and to feathers, which of all articles it especially loves — so much so, that, according to quarantine laws, a live goose may be safely introduced from a plague country; but if it happen to be eaten on the voyage, its feathers cannot be admitted without danger to the entire community. There is no end to the absurdities connected with this doctrine. Suffice it to say, that in the ordinary sense of the word, there is no proof, such as would be admitted in any scientific inquiry, that there is any such thing as “contagion.”
There are two or three diseases in which there is a specific virus, which can be seen, tasted, smelt, and analysed, and which in certain constitutions propagates the original disease by inoculation¾such as small-pox, cow-pox, &c. But these are not ‘contagions’ in the sense supposed.
The word ‘infection,’ which is often confounded with ‘contagion,’ expresses a fact, and does not involve a hypothesis. But just as there is no such thing as ‘contagion,’ there is no such thing as inevitable ‘infection.’ Infection acts through the air. Poison the air breathed by individuals and there is infection. Shut up 150 healthy people in a Black-hole of Calcutta, and in twenty-four hours an infection is produced so intense that it will, in that time, have destroyed nearly the whole of the inmates. Sick people are more susceptible than healthy people; and if they be shut up without sufficient space and sufficient fresh air, there will be produced not only fever, but erysipelas, pyæmia, and the usual tribe of hospital-generated epidemic diseases.
Again, if we have a fever hospital with over-crowded, badly-ventilated wards, we are quite certain to have the air become so infected as to poison the blood not only of the sick, so as to increase their mortality, but also of the medical attendants and nurses, so that they also shall become subjects of fever.
It will be seen at a glance, that in every such case and in every such example, the ‘infection’ is not inevitable, but simply the result of carelessness and ignorance. As soon as this practical view of the subject is admitted and acted upon, we shall cease to hear of hospital contagions.
In certain hospitals it has been the custom to set apart wards for what are called ‘infectious’ diseases, but in reality there ought to be no diseases so considered. With proper sanitary precautions, diseases reputed to be the most ‘infectious’ may be treated in wards among other sick without any danger. Without proper sanitary arrangements, a number of healthy people may be congregated together so as to become subject to the worst horrors of “infection.”
No stronger condemnation of any hospital or ward could be pronounced than the simple fact that any zymotic disease has originated in it, or that such diseases have attacked other patients than those brought in with them. And there can be no stronger condemnation of any town than the outbreak of fatal epidemics in it. Infection, and incapable management, or bad construction, are in hospitals as well as in towns, convertible terms.
It was necessary to say thus much to show to what hospital diseases are not necessarily due. To the following defects in site, construction, and management, as we think, they are mainly to be attributed.
1. The agglomeration of a large number of sick under one roof.
It is a well-established fact that, other things being equal, the amount of sickness and mortality on different areas bears a ratio to the degree of density of the population.
Why should undue agglomeration of sick be any exception to this law? Is it not rather to be expected that, the constitutions of sick people being more susceptible than those of healthy people, they should suffer more from this cause?
But if anything were wanting in confirmation of this fact, it would be the enormous mortality in the hospitals which contained perhaps the largest number of sick ever at one time under the same roof, viz., those at Scutari. The largest of these too famous hospitals had at one time 2500 sick and wounded under its roof, and it has happened that of Scutari patients two out of every five have died. In the hospital tents of the Crimea, although the sick were almost without shelter, without blankets, without proper food or medicines, the mortality was not above one-half what it was at Scutari. Nor was it even so high as this in the small Balaclava General Hospital, while in the huts of the Castle Hospital, on the heights above Balaclava, at a subsequent period, the mortality among the wounded did not reach three per cent. It is not to this, however, that we appeal, as the only proof of the danger of surface over-crowding. It is to the fact of 80 cases of hospital gangrene having been recorded during one month at Scutari (and many, many more, passed unrecorded); to the fact that, out of 44 secondary amputations of the lower extremities consecutively performed, 36 died; and to the cases of fever which broke out in the hospital, not by tens but by hundreds.
All experience tells the same tale, both among sick and well. Men will have a high rate of mortality in large barracks, a low one in separate huts, even with a much less amount of cubic space.
The example which France and Belgium have lately set us of separating their hospitals into a number of distinct pavilions, containing generally not more than 100 sick each, should be elsewhere imitated. It may be useful, by way of illustrating good and bad hospital structure, to annex plans of the newest civil and military hospitals constructed in Paris, in contrast with plans of the newest civil and military hospitals constructed in England.
The Lariboisière as a civil hospital, the Vincennes as a military one, exhibit the latest and the best specimens of hospital construction in Paris.
King’s College as a civil hospital, Netley as a military one, are among the latest — would we could say the best¾plans of hospital construction in England.
The Lariboisière, as will be seen from the plan, contains 600 beds, under six different roofs.
In the Vincennes plan the pavilions are end to end, two and a-half in each wing, and contain about 600 beds in four pavilions and two half-pavilions.
Netley Hospital is to contain 1000 sick and invalids, under two roofs,
2. Deficiency of Space. — Wherever cubic space is deficient, ventilation is bad. Cubic space and ventilation will therefore go hand in hand. The law holds good with regard to hospitals, barracks, and all inhabited places. Deficiency of cubic space is confounded by unskilful sanitary statisticians with surface over-crowding in towns, although the things are quite different, and lead to different results. In a recent paper it has been argued that because the statistics of disease in towns of different densities do not show so large a proportionate mortality from consumption as takes place in the army, thereforethe allegation that the army mortality is caused by overcrowding and bad ventilation is incorrect. We happen to know that deficient external ventilation and over-crowding in barracks, as regards cubic space, stand as follows:–
The cavalry barracks, as a whole, are the least over-crowded, and have the freest external movement of air. Next come the infantry; and the most crowded and the least ventilated externally are the Guards’ barracks; so that the mortality from consumption which follows the same order of increase in the different arms augments with increase of crowding, and difficulty of ventilation.
If over-crowding or its concomitant, bad ventilation, among healthy people, generates disease, it does so to a far greater extent among the sick in hospitals. In civil hospitals the amount of cubic space varies between 600 and 2000 cubic feet per bed. In some military hospitals it is under 300; and from 700 to 800 appear to be considered a somewhat extravagant allowance. The army regulation as to cubic space in hospitals is over-crowding. At Scutari, at one time, not even half the regulation-space was given; and the great over-crowding consequent thereupon was one element in the disastrous result which followed. Any one in the habit of examining hospitals with different relative amounts of cubic space cannot fail to have been struck with the very different appearance of the sick, and with the different state of the ward atmosphere. It is impossible to ventilate a ward in a brick or stone hospital by natural means, when the cubic space is less than a certain amount. Crowded wards are, in fact, offensive, with all the windows open.
In the country less cubic space is essential than in towns. In detached huts or pavilions, especially if they be but one story high, less cubic space is necessary than where numbers are massed together.
Under all circumstances, however, the progress of the cases (in solidly-built hospitals) will betray any curtailment of space much below 1500 cubic feet. In Paris 1700, and in London 2000 and even 2500 cubic feet are now thought advisable.
The master of some large works in London lately mentioned the following fact: — He was in the habit of sending those of his workmen who met with accidents to two different metropolitan hospitals. In one they recovered quickly: in the other they were frequently attacked with erysipelas, and some cases were fatal. On inquiry it appeared that in the former hospital a larger amount of cubic space was allowed than in the latter, which is also so deficient in external ventilation and in construction, that nothing but artificial ventilation could effectively change its atmosphere.
It is no less important to have a sufficient surface-area between the adjoining and the opposite beds. Piling cubic space above the patient is not all that is wanted. In the lofty corridors of Scutari I have seen two long rows of opposite beds with scarcely three feet from foot to foot. Certainly it cannot be thought too much, under any circumstances, to give to each bed a territory to itself of at least eight feet wide by twelve feet long.
3. Deficiency of Ventilation. — The want of fresh air may be detected in the appearance of patients sooner than any other want. No care or luxury will compensate indeed for its absence. Unless the air within the ward can be kept as fresh as it is without, the patients had better be away. Except in a few cases well known to physicians the danger of admitting fresh air directly is very much exaggerated. Patients in bed are not peculiarly inclined to catch cold, and in England, where fuel is cheap, somebody is indeed to blame, if the ward cannot be kept warm enough, and if the patients cannot have bed-clothing enough, for as much air to be admitted from without as suffices to keep the ward fresh. No artificial ventilation will do this. Although in badly-constructed hospitals, or in countries where fuel is dear, and the winter very cold, artificial ventilation may be necessary, it never can compensate for the want of the open window. The ward is never fresh, and in the best hospitals at Paris, artificially ventilated, it will be found that, till the windows are opened in the morning, the air is close. Natural ventilation, or that by open windows and open fireplaces, is the only efficient means for procuring the life-spring of the sick — fresh air. But to obtain this the ward should be at least sixteen feet high, and the distance between the opposite windows not more than thirty feet. The amount of fresh air required for ventilation has been hitherto very much underrated, because it has been assumed that the quantity of carbonic acid produced during respiration was the chief noxious gas to be carried off. The total amount of this gas produced by an adult in twenty-four hours is about 40,000 cubic inches, which, in a barrack-room, say, containing sixteen men, would give 370 cubic feet per diem. Allowing eight hours for the night occupation of such a room, when the doors and windows may be supposed to be shut, the product of carbonic acid would be 123 cubic feet, or about fifteen and a-half cubic feet per hour. This large quantity, if not speedily carried away, would undoubtedly be injurious to health; but there are other gaseous poisons produced with the carbonic acid which have still greater power to injure. Every adult exhales by the lungs and skin forty-eight ounces, or three pints of water in twenty-four hours. Sixteen men in a room would therefore exhale in eight hours sixteen pints of water, and 123 cubic feet of carbonic acid into the atmosphere of the room. With the watery vapour there is also exhaled a large quantity of organic matter, ready to enter into the putrefactive condition. This is especially the case during the hours of sleep, and as it is a vital law that all excretions are injurious to health if reintroduced into the system, it is easy to understand how the breathing of damp foul air of this kind, and the consequent re-introduction of excrementitious matter into the blood through the function of respiration will tend to produce disease.
If this be so for the well, how much more will it be so for the sick? — for the sick, the exhalations from whom are always highly morbid and dangerous, as they are one of nature’s methods of eliminating noxious matter from the body, in order that it may recover health.
One would think that the first and last idea in constructing hospitals would be to contrive such means of ventilation as would be perpetually and instantly carrying off these morbid emanations. One would think that it would be the first thing taught to the attendants to manage such means of ventilation. Often, however, it is not even the last thing taught to them.
A much larger mass of air is required to dilute and carry away these emanations than is generally supposed, and the whole art of ventilation resolves itself into applying in any specific case the best method of renewing the air sufficiently without producing draughts, or occasioning excessive varieties in temperature. Trifling varieties are rather beneficial than otherwise in most cases. A cooler atmosphere at night acts like a tonic.
4. Deficiency of Light. — What is the proportionate influence of the four defects enumerated in delaying recovery I am not competent to determine.
Second only to fresh air, however, I should be inclined to rank light in importance for the sick. Direct sunlight, not only daylight, is necessary for speedy recovery, except, perhaps, in ophthalmic and a small number of other cases. Instances could be given, almost endless, where, in dark wards or in wards with a northern aspect, even when thoroughly warmed, or in wards with borrowed light, even when thoroughly ventilated, the sick could not by any means be made speedily to recover. The effect of light on health and disease has been ably discussed in an article on light in the August number, 1858, of the North British Review. Its importance has been long recognised in the medical profession, as may be learned from the writings of Sir Andrew Wylie, Dr. Milne Edwards, and Mr. Ward. Dark barrack-rooms, and barrack-rooms with northern aspects, will furnish a larger amount of sickness than light and sunny rooms.
Among kindred effects of light I may mention, from experience, as quite perceptible in promoting recovery, the being able to see out of a window, instead of looking against a dead wall; the bright colours of flowers; the being able to read in bed by the light of a window close to the bed-head. It is generally said that the effect is upon the mind. Perhaps so; but it is no less so upon the body on that account.
All hospital buildings in this climate should be erected so that as great a surface as possible should receive direct sunlight — a rule which has been observed in several of our best hospitals, but, I am sorry to say, passed over in some of those most recently-constructed. Window-blinds can always moderate the light of a light ward; but the gloom of a dark ward is irremediable.
The axis of a ward should be as nearly as possible north and south; the windows on both sides, so that the sun shall shine in (from the time he rises till the time he sets) at one side or the other. There should be a window to at least every two beds, as is the case now in our best hospitals. Some foreign hospitals, in countries where the light is far more intense than in England, give one window to every bed. The window-space should be one-third of the wall-space. The windows should reach from two or three feet of the floor to one foot of the ceiling. The escape of heat may be diminished by plate or double glass. But while we can generate warmth, we cannot generate daylight, or the purifying and curative effect of the sun’s rays.
Considering, then, that the conditions essential to the health of hospitals are principally these —
1. Fresh Air. 2. Light. 3. Ample Space. 4. Subdivision of Sick into Separate Buildings or Pavilions — let us examine the causes in the usual ward construction which prevent us from obtaining these and other necessary conditions. The principal causes are as follow, viz.: —
1. Defective Means of Natural Ventilation and Warming.
2. Defective Height of Wards.
3. Excessive Width of Wards between the Opposite Windows.
4. Arranging the Beds along the Dead Walls.
5. Having more than two Rows of Beds between the Opposite Windows.
6. Having Windows only on one Side, or having a closed Corridor connecting the Wards.
7. Using Absorbent Materials for Walls and Ceilings, and Washing Floors of hospitals.
8, Defective Condition of Waterclosets.
9. Defective Ward Furniture.
10. Defective Accommodation for Nursing and Discipline.
11. Defective Hospital Kitchens.
12. Defective Hospital Laundries.
13. Selection of Bad Sites and Bad Local Climates for Hospitals.
14. Erecting Hospitals in Towns.
15. Defects of Sewerage.
16. Construction of Hospitals without Free Circulation of External Air.
1. Defective Means of Ventilation and Warming. — When the question of ventilation first assumed a practical shape in this country, it was supposed that 600 cubic feet of air per hour were sufficient for a healthy adult, in a room where a number of people are congregated together. Subsequent experience, however, has shown that this is by no means enough. As much as 1000 cubic feet have been found insufficient to keep the air free from closeness and smell; and it is highly probable that the actual quantity required will ultimately be found to be at least 1500 cubic feet per hour per man.
In sick wards we have more positive experience as to the quantity of air required to keep them sweet and healthy. It has been found in certain Parisian hospitals, in which the ventilating arrangements were deficient, that pyæmia and hospital gangrene had appeared among the patients. These diseases disappeared, on the introduction of ventilating arrangements, whereby 2500 cubic feet of air per bed per hour were supplied to the wards. Notwithstanding this large quantity, however, the ward-atmosphere was found not to be sufficiently pure. In other wards the quantity of air was increased to as much as 4000 or 5000 cubic feet per bed per hour¾an amount which keeps the wards perfectly sweet. But again we say, do not trust to artificial means; without natural ventilation the air will never be fresh.
In this country, have no other than the open fireplace. It is the safest warmer and ventilator. Heated air from metal surfaces is especially to be avoided. It seems likely that we shall soon be enabled to have open fireplaces in the middle of wards, the draught being carried under the floor. It is obvious that fireplaces in the side walls are in the wrong place. There is great loss and unequal distribution of heat in consequence.
2. Defective Height of Wards.¾It is not possible to ventilate sufficiently a ward of ten or twelve feet high. And again, it is not possible to ventilate a ward where there is a great height above the windows. A ward of thirty beds can be well ventilated with a height of about sixteen or seventeen feet, provided the windows reach to within one foot of the ceiling. Otherwise, the top of the ward becomes a reservoir for foul air.
3. Too Great Width of Wards between the Opposite Windows. — It does not appear as if the air could be thoroughly changed, if a distance of more than thirty feet intervenes between the opposite windows: if, in other words, the ward is more than thirty feet wide. This is the true starting-point from which to determine the size of your ward, and the number of beds you will have in it. If you make your length too great in proportion to this width, your ward becomes a tunnel¾a form fatal to good ventilation. This was the case with the great corridor wards at Scutari.
If, on the other hand, you make your wards too short in proportion to this width, you multiply corners in a greater ratio than you multiply sick. And direct experiment has shown that the movement of the air in the centre of a ward is three or four times as great as it is at the corners. The movement of the air in a hospital ward should always be slightly perceptible over the face and hands, and yet there should be no draughts.
4. Arranging the Beds along the Dead Walls. — This deprives the patient of the amount of light and air necessary to his recovery, and has, besides, the disadvantage that when the windows are opened the effluvia must blow over all the intervening beds before escaping. This arrangement is to be seen at Portsmouth Military Hospital, Chatham Garrison Hospital, in the new part of the Edinburgh Infirmary, and is proposed at Netley Hospital.
5. Having more than Two Rows of Beds between the Windows. — In the double wards, or wards back to back, of the new part of Guy’s, of King’s College, and of the Fever Hospital, this arrangement is seen. It is objectionable on every account. These double wards are from twelve to nearly twenty feet wider than they ought to be between the opposite windows for thorough ventilation. The partition down the middle with apertures makes matters rather worse; complaint has been made that it beats down the draught on the heads of the inner rows of patients. It also prevents the head nurse from having that view of her whole ward at once, which she ought to have for proper care of it. The only hospital in which this arrangement of four rows of beds could be comparatively unobjectionable, would be in a one-storied hut hospital, ventilated through the ceiling, like that of Dr. Parkes, at Renkioi. But his were magnificent huts, and the partition was little more than a bulkhead. In the ordinary huts of the Sardinian camp-hospitals at Balaclava I have seen this arrangement produce pernicious effects.
6. Having Windows only on one Side, or having a closed Corridor connecting the Wards. — As it is a necessity of hospital construction that every ward ought to have direct communication with the external air by means of a sufficient number of windows on its opposite sides, it follows that to have a dead wall on one side, or to cover one of the sides by a corridor, is directly to interfere with the natural ventilation of the ward. To join all the ward doors and windows on one side by means of a corridor is much more objectionable than even to have a dead wall, because the foul air of all the wards must necessarily pass into the corridor; and hence, without extraordinary precautions, such as are not usually nor likely to be bestowed on such matters, these corridors are the certain means of engendering a hospital atmosphere. If any one had wished to see the corridor plan in all its horrors, Scutari would have shown them to him on a colossal scale. But the evils connected with corridors may be seen on a smaller scale in almost every hospital in London, and Netley also is to have its corridor.
This country is much indebted to Mr. Roberton, of Manchester, to the Medical Staff of the Middlesex Hospital, and to the Army Sanitary Commission for their advocacy of the pavilion system of hospital construction, in opposition to the corridor system, as also for their enlightened labours in the cause of good hospital construction generally.
7. Using Absorbent Materials for Floors, Walls, and Ceilings of Hospitals, and Washing Floors. ¾ The amount of organic matter given off by respiration and in other ways from the sick is such that the floors, walls, and ceilings of hospital wards¾if not of impervious materials, become dangerous absorbents.
The boards are in time saturated with organic matter, and only require moisture to give off noxious effluvia. When the floors are being washed, the smell of something quite other than soap and water is perfectly perceptible, and there cannot be a doubt that washing floors is one cause of erysipelas, &c., in some hospitals.
In Scutari, where the wards were overcrowded, the cases offensive, and the floors ill-laid, rotten and dirty, the accumulated saturations of weeks and months were such that the floors could not be scoured without poisoning the patients.
There is no remedy for this but filling up the grain of the wood (which ought to be oak) with bees-wax and turpentine, like the French parquet, or oiling and lackering, i.e., saturating the floor with linseed-oil, and then rubbing it over with a peculiar laque varnish, and polishing it so as to resemble French polish, like the Berlin hospital floors. Both processes render the floor non-absorbent — both processes do away with the necessity of scouring altogether. The French floor standsthe most wear and tear, but must be cleaned by a frotteur, which cleaning is more laborious than scrubbing, and does not remove the dust. The Prussian floor requires re-preparing every three years. But the wet and dry rubbing, or process of cleaning is far less laborious than either frottage or scrubbing, and completely removes the dust, and freshens the ward in the morning. By either process the sick would gain much in England. The Berlin flooring is by no means perfect, on account of this deficient durability of surface, and might be improved.
As to the walls and ceilings of wards, plaster, or brick white-washed, are equally objectionable. Pure, white, polished, non-absorbent cement is the only material fit for hospital walls. If any one has inhabited the wards of War Hospitals, after several weeks or months of constant occupation by sick and wounded, where little or no attempt had been made to lime-wash the uneven dirty plaster-walls, saturated with organic matter, he will not wonder at the stress which is here laid upon the importance of impervious walls.
8. Defective Condition of Waterclosets. — It is hardly necessary to say more than this. There can be no safety for the sick if any but watercloscts of the best construction are used, as also if they are not built externally to the main building, and cut off by a lobby, separately lighted and ventilated, from the ward. The same thing may be said of sinks. I have known outbreaks of fever even among the healthy from an ill-constructed and ill-placed sink in this country.
The smell of latrines, which are not waterclosets, as used in French hospitals, although externally built, is quite perceptible at the end of the ward nearest to them.
9. Defective Ward Furniture. — Hospital bedsteads should always be of iron, the rest of the furniture of oak. Hair is the only material yet discovered fit for hospital mattresses. It is not hard nor cold. It is easily washed. It does not retain miasma. Straw has the advantage of being easily renewed, but it is not desirable. It is too hard and too cold not to render necessary the use of a blanket under the patient, which use is likely to encourage bed-sores. I speak from actual experience of the fatal effect of using the paillasse with patients much reduced. It may lower their vital energy beyond repair.
For all eating, drinking, and washing vessels, and for other utensils, the use of glass or earthenware is superior to that of tin or any other metal, on account of its greater cleanliness. Notwithstanding the greater amount of breakage and of expense, glass or earthenware is therefore best wherever possible. Some kinds of tin vessels cannot by any amount of cleaning be freed from an unclean smell.
10. Defective Accommodation for Nursing and Discipline. — Simplicity of construction in hospitals is essential to discipline. Effectual and easy supervision is essential to proper care and nursing.
Every unneeded closet, scullery, sink, lobby, and staircase represents both a place which must be cleaned, which must take hands and time to clean, and a hiding or skulking place for patients or servants disposed to do wrong. And of such no hospital will ever be free. Every five minutes wasted upon cleaning what had better not have been there to be cleaned, is something taken from and lost by the sick.
In considering the pavilion plan to be in future received as the sanitary necessity for hospital construction, we must look upon it as susceptible of many modifications. In deciding which of these shall be adopted, there are four essentials to be considered as regards the head of nursing and discipline. 1. Economy of attendance. 2. Ease of supervision. 3. Convenience as to number of sick in the same ward and on the same floor, so as to save extra attendants and unnecessary waste of time and strength on the stairs. 4. Efficiency as to accommodation for nurses so as to overlook their wards.
First. Economy as to attendance.— I would rather not enumerate the instances where I have seen that, often from the most various causes, one result arises, viz., that more time and care are given to passages, stairs, &c. &c., than to the sick. Extreme simplicity of construction and of detail is essential to obviate this. A convenient arrangement of lifts, and the laying of hot and cold water all over the building economize attendance — certainly as much as one attendant to every thirty sick.
Secondly. Ease of Supervision. — The system of scouts, watch, alarm, is well understood in many wards where patients would be puzzled to give the things names. Some patients will know both things and names. Attendants require inspection as well as patients. Whatever system of hospital construction is adopted should provide for easy supervision at unexpected times. The Vincennes plan is better adapted for this than the Lariboisière plan, inasmuch as there is a greater number of patients on the same level, and stairs are spared.
Third and Fourth. Distribution of Sick in convenient numbers for attendance, and Position of Nurses’ Rooms. — Four wards of ten patients each, taking the average of patients as in London, cannot be efficiently overlooked by one head nurse. Forty patients in one ward can be fully overlooked by one head nurse. She ought to have her room so placed that she can command her whole ward, day and night, from a window looking into the ward. This cannot be the case if she has four wards. If she has two, they ought to be built end to end, with her room placed between and looking into both wards.
Four wards of ten patients each cannot be attended by one night nurse, taking the average of London cases. Forty patients in one ward can be fully attended by one night nurse.
Small wards are indeed objectionable in working a hospital.
If we are to be guided, however, by the results of recent experience in hospital building, we shall probably come to the conclusion that, taking sanitary and administrative reasons together, thirty-two patients is a good ward-unit.
Let us see what we do in our military hospitals at home. The first thing that will strike any one in most of our regimental hospitals is the extraordinary number of wards, and of holes and corners in comparison with the number of sick. In a hospital for a battalion 500 or 600 strong, you find eight or ten little bed-rooms, miscalled wards, a little kitchen, everything, in fact, on a little scale, like a collapsed French hospital. How much more sensible would it be to have one, or at most two large wards for thirty sick each, with a small “casualty” ward!
How much less the expense of erection and administration, how much easier the discipline and oversight, how much better the ventilation!
To return to large general hospitals. These “casualty” wards, as they are called, for noisy or offensive cases are much better placed apart, with a completely appointed staff of their own, than attached one small ward to each larger one. Patients requiring much attention, whose condition fits them the most for the small wards, cannot be put there, because either they are more or less neglected or they unduly monopolize the service of the ward attendants. If convalescent patients are put into them, they are comparatively removed from inspection, and often play tricks there. If separate ‘casualty’ wards are provided as they ought to be, the small ward (often seen in French hospitals), at the end of the larger ward, is only an incubus.
11. Defective Hospital Kitchens. — Two facts every careful observer can establish from experience.
1. The necessity for variety in food, as an essential element of health, owing to the number of materials required to preserve the human frame. In sickness it is still more important, because, the frame being in a morbid state, it is scarcely possible to prescribe beforehand with certainty what it will be able to digest and assimilate. The so-called ‘fancies’ of disease are in many cases valuable indications.
2. The importance of cooking so as to secure the greatest digestibility and the greatest economy in nutritive value of food.
Yet so little was either of these elements of health understood in the late Crimean war, so little is either understood up to this hour in the diets, rations, and cooking of either sick or well in the army, that we still see the everlasting sameness of ration, the eternal boiled meat of the “full,” “half,” and ‘low’ diet of the hospital kitchen. As the present Quartermaster-General says, “the men live upon boiled meat for twenty-one years.”
In the war hospitals of the East it was practically learnt, though never theoretically acknowledged, that in order to make the patient eat at all, he must not be fed on this hard boiled never-varying meat of ‘full’ or ‘half’ diet.
Hence the wasteful and violent expenditure of “extras,” as they are called, which, in the hands of inexperienced surgeons, left to their own unassisted inventions, often laid them open to criticism.
But no attempt was made to compose a better or more varied diet hardly any, till the arrival of Soyer, to improve the system of cooking.
Some few improvements have lately been made in the hospital kitchens of the army at home; what variety of cooking there is even now in the barracks is often done at the expense of, and by the men themselves. A proper system of hospital diets will ere long be introduced in the army hospitals.
I have often been surprised by the primitive kitchens of some of our civil hospitals, with which little variety of cooking is possible.
These things show how little diet and cooking are even yet thought of as sanitary and curative agents. There still exists a confusion of ideas about “spoiling” the sick, about “too much indulgence” of the patients, and even yet comparatively little is practically known as to what is, and what is not, essential for restoration to the utmost vigour.
12. Defective Hospital Laundries. — It is hardly necessary to go back to the time in the Crimean war when in a Scutari hospital six shirts were washed in a month for a number of 2000 patients, which was constantly changing; when the number per man per month of all articles of all descriptions washed was less than three. The pestilential filth of that time is known now to all. But it is not so well known that even now there is scarcely an army hospital which has such a thing as a laundry. The bedding is generally washed by the barrack department; no one appears to know how. It is done by contract. And the body linen is generally washed, if such a term ought to be used, in a small wash-house, or lean-to shed, with or without a boiler, and without any means for drying, getting-up, or airing linen. The linen is taken out of the damp wash-house, possibly into the damp air, and there hung up for a longer or a shorter time; and if the ‘orderly’ be careful of his patients, he will complete the process by drying the linen, before it is put on, in front of the ward fire.
A great deal has been said about the communication of ‘infectious’ disease, both in civil and military hospitals, from patients’ linen to washerwomen. The usual conclusion arrived at on such occasions, is that such and such a disease is “very infectious;” e.g. I was lately told in a civil hospital that the washerwomen became infected with fever from the patients’ linen. Have those who put forward this doctrine of inevitable ‘infection’ among washerwomen ever examined the process of washing, the appliances by which it is done, and the place where the women wash? If they will do so, they will very generally find a small, dark, wet, unventilated, and overcrowded little room or shed, in which there is hardly space to turn about — so full of steam loaded with organic matter that it is hardly possible to see across the room. Is it surprising that the linen is badly washed, that it is imperfectly dried, and that the washerwomen are poisoned by inhaling organic matter and foul air? An ordinary hospital washhouse is a very likely place indeed to contract disease in, but it supplies equal reason for demurring in toto to the doctrine that the occurrence is inevitable, or that the disease is to blame. Ignorance and mismanagement lie at the root of all such presumed cases of ‘infection.’ And it would better serve the cause of humanity if, instead of citing such facts¾if they be facts¾as illustrations that such and sucish a dease is infectious, people would reform these washing establishments and convert them into proper laundries, from which properly cleansed and prepared linen could be supplied to the sick, and in which the health of the servants could be preserved from injury.
Let laundries be constructed with sufficient area and cubic space for each washer, with abundance of water, with proper means of drainage, and of ventilation for removing the vapour, and with properly-constructed drying and ironing rooms, and we shall cease to hear of washerwomen “catching” fever.
13. Selection of Bad Sites and Bad Local Climates for Hospitals. — As the object to be attained in hospital construction is to have pure dry air for the sick, it will be evident that this condition cannot be fulfilled if a damp climate be selected. It is a well-known fact, e.g., that in the more damp localities of the south of England, certain classes of sick and of invalids linger, and do not recover their health. Again, retentive clay subsoils keep the air over entire districts of the country always more or less damp. And soils of this character should not be selected as sites for hospitals. Self-draining, gravelly, or sandy subsoils are best. River banks, estuary shores, valleys, marshy or muddy ground, ought to be avoided. It may seem superfluous to state that a hospital should not be built over an old graveyard, or on other ground charged with organic matter. Although hospitals are intended for the recovery of health, people are very apt to forget this, and to be guided in the selection of sites by other considerations — such as cheapness, convenience, and the like; whereas, the professed object in view being to secure the recovery of the sick in the shortest time, and to obtain the smallest mortality, that object should be distinctly kept in view as one which must take precedence of all others.
A doctrine has recently been promulgated in a Government Report, that we are only to consider what is best for the majority of the sick in a hospital. If we cannot do the best possible for all the sick, by all means let us leave the rest at home. In practice a hospital may be found only to benefit a majority, and to inflict suffering on the remainder. Let us use our intelligence to see whether we cannot have hospitals constructed so as to be of equal benefit to all.
14. Erecting Hospitals in Towns. — Nearly all that has been said under the last head, mutatis mutandis, may be repeated here. If the recovery of the sick is to be the object of hospitals, they will not be built in towns. If medical schools are the object, surely it is more instructive for students to watch the recovery from, rather than the lingering in, sickness. Twice the number of cases would be brought under their notice in a hospital in which the sick recovered in half the time necessary in another.
According to all analogy, the duration of cases, the chances against complete recovery, the rate of mortality, must be greater in town than in country hospitals.
Land in towns is too expensive for hospitals to be so built as to secure the conditions of ventilation and of light, and of spreading the inmates over a large surface-area, instead of piling them up three or four stories high — conditions now known to be essential to recovery.
15. Defects in Drainage. — Sewers may become cesspools of the most dangerous description, if improperly made and placed. At Scutari, if the wind changed so as to blow up the open mouths of the sewers, such change was frequently marked by outbreaks of fever among the patients, and by relapses among the convalescents from fever. Where there are no means for externally ventilating the sewers, no means for cleansing or flushing them, and where the bottoms are rough and uneven, such occurrences cannot fail to take place. The emanations from the deposits in the sewers were blown back through the pipe-drains into the privies, and thence into the corridors and wards where the sick were lying. Where sewers pass close to or under occupied rooms, the walls or covers being defective, exhalations will infallibly escape into those rooms. Such could be distinctly perceived in Scutari hospitals, and cases of cholera distinctly traced to such a cause.
Not very long ago five fatal cases of fever occurred in rapid succession among the nurses in one of our civil hospitals, which were traced to a defective drain.
Where a main sewer is too large, as is the case at Netley Hospital, mischief may also ensue.
16. Construction of Hospitals without Free Circulation of External Air. — To build a hospital with one closed court with high walls, or what is worse, with two closed courts, is to stagnate the air even before it reaches the wards.
All closed corners stagnate the air, even where the building forms but three sides of a square, unless the wings are so short that they can hardly be called wings. The only safe plan is to leave the corners entirely open, as at Vincennes, where they are connected only by an arcade on the ground floor.
Even in the pavilion structure, unless the distance between the pavilions be double the height of the walls, the ventilation and light are seriously interfered with.
For this, among other reasons, two stories are better than three; and one is preferable to two, provided it be erected upon an arched basement.
To build a hospital in the midst of a crowded neighbourhood of narrow streets and high houses, is to insure a stagnation of the air without, which no ventilation within, no cubic space, however ample, will be able to remedy.
I have here given the defects; few have had so sad or so large an experience of their results as I have had. I appeal to those who are wiser, and have more practical power than I have, for the remedies — to architects, to hospital committees, to civil and royal engineers, to medical officers, to officers of health, to all the men of science and benevolence of whom our country is so justly proud. It is hard that in a country, where everything is done by a despotic Government, such advances in the sanitary construction of hospitals should have been made, and that our England, which ought to take the lead in everything good, should be left behind.
Source: Transactions of the National Association for the Promotion of Social Science, 1858, ed. George W. Hastings, (London: John W. Parker), 1859, pp. 462-482.