28 FEBRUARY 1885, Page 17


Tins work, which is far more readable than its title and appearance promise, for once justifies the plea which so many authors consider necessary to excuse their rushing into print,—it satisfies a public want. The writer who revives an ancient or propounds a modern system of philosophy, pens a moral essay or a scientific treatise, is equally convinced and anxious to convince his readers that he is thereby performing a mighty social duty. Hardly a book published owes its raison d'etre to any personal considerations of the author, any more than a candidate for Parliamentary honours offers himself to a constituency on other than strictly impersonal grounds. One may generally avoid with

advantage any book that is written." to fulfil a public want," as in most cases, if it needs this apologetic introduction, its

acquaintance is not worth making. However, the work now ender consideration may fairly claim this position, if, indeed, any justification ler its appearance be needed.

It is the most complete, in truth the only systematic treatise in -the English language on "the arrangement, management,

tind construction of hospitals, in their hygienic, administrative, and structural relations." . The work is, of course, far from exhaustive ; but the subject is so large, itself and its side-issues so rife with theory, speculation, and fact, that in the present indefinite and unsettled condition of sanitary science, an -attempt to grasp the whole question would result simply in a heterogeneous accumulation of conflicting statements and opposing facts. The authors have, therefore, contented themselves with describing, as concisely as they can, the leading hospitals of the civilised world, illustrating by sketches and plans their architecture and general principles of administration. The work is divided into three sections, of which the first deals with hospital construction and management, the second gives typical examples of these institutions in various countries, and he third is an interesting description of the organisation of medical relief in the metropolis. Dealing each with his own subject, the authors—the doctor and the architect—have very -clearly and fully set forth the more important and interesting features, viewed from both medical and architectural standpoints. As is shown by the frequent discussions of sanitary authorities, in the building of hospitals no minutia is considered too minute.

To the unlearned, it seems of little consequence whether a ward

be -round or square, whether its angles be obtuse or sharp, its roof flat or pointed; such small matters of detail it is difficult to realise as affecting the broad principles of sanitation ; yet it is

found that these variations of form and character make all the -difference in the health or otherwise of patients, and can almost be measured by death-rate statistics. The most innocent-looking smoke and corners may materially impede the circulation of air, favour stagnation, and foster the accumulation of disease germs; the brightest curtain may be but the cloak of contagion, the most picturesque object only a nidus for infection. Science, whose eyes are the microscope, sees what is hidden from our unaided vision, and through the medium of her Powerful spectacles she shows us the magnitude of minutim. The cholera bacillus long lay hid in obscurity, and the luscious juice of the ripest fruit formed a tempting vehicle for its

-deadly potency ; but Science must needs inspect -this among

other curiosities. The hidden germ was brought to light, and immediately subjected to torture. He has been tried by fire and water, by chemistry and electricity, and his capabilities fully tested. The chief difficulty with him

has been not that he is invincible, for he can be destroyed ;

but that his powers of endurance are a little stronger than those -of „humanity, for though we can kill him by heat, cold, or chemical agencies, unfortunately we kill his victim first. Later -on, no doubt, the scrutinising eyes of Science will perceive a means of coping with him ; but at present she is obliged to cir csmvent him and his fellows by shunning their company. For t'tis reason, that we are -not yet able to meet the dangers of disease, we turn our attention in the direction of avoiding them; —in the direction, therefore, of discountenancing germs, and constructing our hospitals in such a manner that no place shall be found where they can rest in undisturbed security.

Abroad, disinfectants are the panacea for all unsanitary conditions,—a confidence Which has been described as "ridiculous, were it not for the dangers of the false security thereby -engendered." In England, the progress of sanitation is in the way of prevention, and the healthiness of air which owes its purity to the aroma of deodorants is considered more than cjuestionable. Full and perfect ventilation is the best disinfectant, and most of the difficulties of sanitary science lie in the difficulty of obtaining this. Hospitals must be situated in

the midst of crowded cities, as it is here they are most needed; yet, at the same time, a certain standard of pure air must be

maintained, or they are almost worse than useless. The air, to begin with, is not beyond reproach ; extra precaution must, therefore, be taken that the supply be plentiful, that nothing shall hinder its free and unimpeded circulation ; and so in the con struction everything must be taken into account. There is still, of course, so much difference of opinion on the effects of various conditions, that we find in the several types of hospitals exemplified in this book one system chosen by notable authorities on the very grounds for which it is rejected by others. •

However, considering how short a time this question has been under discussion, it is not remarkable that the theosgr of the construction of hospitals has not yet been sedum(' to a science. Until the sixteenth century, these institutions were almost entirely in the hands of religious Orders, awl, as a consequence, their scientific aspect was that which received the least consideration. With other ecclesiastical scandals of the day, public feeling was also outraged by the misconduct of those to whom was entrusted hospital administration; and with the Reformation came reform in this direction likewise, the duty being transferred to the management of laymen. The .history of hospitals, so far as science is concerned, may, therefore, be considered to date only from this era, as previous to it there had been little medical knowledge or skill brought to bear on their construction and conduct. Since then we have made rapid strides in sanitation, and this system has proportionately progressed. Somewhat disappointing it is, nevertheless, to discover that our death-rates have not decreased in the same ratio ; we find, for instance, that the mortality in Guy's Hospital from• 1780-90 was 10-2 per cent., while from 1850-60 it was 9-2 per cent.,—a diminution of only one per cent. in the progress of nearly a century. In defence, it is sometimes urged that with advancing civilisation the standard of health deteriorates, the difficulties of living contributing so largely to the wear-and-tear of man's constitution ; -but, on the other hand, so much is gained in hygienic improvements that these should at least balance the other disadvantages. There are, again, many evils belonging to old hospitals, even if extensively improved; and it is hardly fair to judge the mortality of the institutions of the present day by that of those which were built so long ago, and have, in addition, accumulated the dangers of a long existence. So decided are these, that it has been gravely considered whether it Would not be wiser in all cases that 'hospitals should be of only -temporary construction, te be periodically destroyed and rebuilt, either on the old or some other site. No matter -what care be taken in planning and management, after a time the place seems to become saturated with the germs of disease, the unwholesome atmosphere of sickness defies all efforts of disinfection, and particular wards, if not the whole building, become a hindrance to, rather than a promoter of health.

An important event in hospital construction was the introduction of what is known as the pavilion system. To H. Tenon is due the credit of this plan, which consists in dividing the building into separate blocks, each of which may be said to form a little hospital of itself. These are joined or not by connecting corridors, which may be utilised as ambulatories for the patients. The principle of the system is the isolation of inmates in sections, each block being cut off from communication with the rest. It is to obviate the dangers of large numbers of sick people aggregated under the same roof that the pavilion system has been devised. On this question "Mr. Lawson Tait, of Birmingham, after an exhaustive statistical inquiry, in an essay of equal value and authority, states that the whole of his statistics prove that after the number of beds in a hospital exceeds one hundred, the risk to life becomes so much increased that it is questionable whether any hospital should be of larger size than this, If circumstances make it necessary that the hospital should be larger, most undoubtedly special arrangements and precautions should be taken to obviate the extra risk which is involved." The Lariboisiere Hospital, in Paris, was the first important example of • the pavilion system, which is theoretically the most sanitary, thoughin practice it is not without

disadvantages. In our own country, St. Thomas's is a magnificent specimen of this type ; but the cost of site, foundation, and construction was so considerable as to elicit a great deal of adverse criticism on the suitability of the pavilion plan -in this particular case. In it we may boast roureelves possessed of perhaps the grandest hospital in the world, though it has been designated also one of the greatest failures.

We find it not a little astonishing to read of the bad management and overcrowding which have existed in the hospitals of civilised countries since the days of civilisation. Of the old Hotel Dieu—the principal hospital in Paris—it is stated that a large proportion of the beds were made for four patients, and six were not infrequently crowded in. M. Husson, in his Etude stir lea Thipitatez, considers it "not very surprising that at times of extraordinary overcrowding some of the sick should have been placed even on the wooden roofs of the beds, as in 1752, when the Hotel Dieu had to receive more than 4,C00 sick

but this was a temporary expedient, and could only have taken place, if it did take place, during part of the eighteenth century ; for before that period the beds of the Hotel Dieu had no testers, and then the sick lay in beds,or rather were heaped up in them. In 1515 there were only 303 beds at the Hotel Dieu, in each of which, from want of space, were ordinarily seen eight, ten, and twelve poor in one bed ; so crowded were they that it was pitiable to see them." Such a state of things would prove decidedly surprising to the modern hospital patient, who grumbles if his bread be a sixteenth of an inch too thick, and makes a protest in favour of its being.buttered on both sides!

Dr. Mount's paper on the "Organisation of Medical Relief in the Metropolis" is extremely interesting, and deals very frilly with the subject. Of the out-patient system, which has of late been receiving so much attention, he says :—

"Of all the abuses of the present hospital system, that of the treatment of out-patients is undoubtedly one of the most flagrant. It has been estimated that when the population of London was smaller than it is now, a million annually, one in four of the people, received advice and medicine gratuitously, one in two at Liverpool, and one in three and a half at Birmingham. The average attendance of each patient is from three to seven hours before their cases can be attended to; the ooat Of medicines alone for 600,000 persona who annually resort to thirteen of the best hospitals in London was estimated to be 215,000; and the time given to the diagnosis and treatment of their diseases is so infinitesimally small as to be well-nigh valueless."

It is difficult, however, to substitute any other method which would ensure better results, both to the general public and to students of medicine, who are greatly interested in seeing as many patients as possible, as a means of knowledge and experience. A system less open to abuse would probably be con siderably less useful. An interesting account is given of Dr. Bardon Sanderson's proposed annularward, in his evidence before the Fever Commissioners in 1832. On the ground of the importance of isolating and destroying the air infected by small-pox patients, he suggested a circular ward, consfructed to hold twelve patients, allowing to each a liberal quantum of air, which, entering by ventilating arrangements in the outer wall, should by an aspirator be drawn into a central chamber, where it might be subjected to a high temperature or other powerful agent for the destruction of the contagion germs. Such a hospital, Dr.

Sanderson proposed, should be built in tower fashion, one ward above another, a central chamber passing through each and conducting the foul air to a gas-furnace at the top, where it might be purified of all infection. So excellent a suggestion will doubtless be utilised in the future, but at present no attempt has been made to carry it into practice. It promises to be a most effectual means of destroying contagion.

In conclusion, we may testify to the admirable character of lIospital Construction and Management, which bears the mark of careful and accurate work, while. it is at the same time very readable and interesting.