302 HOSPITAL During the present century the increase of hospitals has continued, seven general and many special having been founded in London alone. Dr Steele gives statistics of 27 metropolitan hospitals, having an aggregate of nearly 6000 beds, and receiving about 46,000 in-patients annually. This does not take into account the infirmaries attached to the workhouses or the metropolitan asylums hospitals. In addition to this probably from ten to twelve times the number of out-patients are treated in the course of the year. Hospitals are usually divided into General and Special. In General Hospitals cases of all kinds are admitted in some, whilst in others certain classes are excluded. Thus cases of contagious zymotic disease are not admitted now in many instances, especially in London since the estab lishment of the metropolitan asylums, fever and small pox hospitals. Lying-in cases, venereal cases, &c., are also frequently excluded. Special Hospitals are of various kinds, such as lying-in hospitals, ophthalmic, lock (for venereal diseases), cancer, consumption, &c., besides fever and small-pox hospitals. At the end of the last and beginning of this century fever Lospitals were generally called " houses of recovery," with a view of not alarming the people too much who had to resort to them. Special hospitals are also set apart for the treatment of diseases of children. Besides the various civil hospitals there are also naval and military hospitals for the cure of sailors and soldiers. Although hospitals have been intended as a blessing and benefit to the poor, they have too often proved the reverse, on account of the ignorance, on the part of their adminis trators, of the true principles of health. So much was this the case formerly that it has been not infrequently debated whether hospitals are or are not gigantic evils ; and even where it is admitted that they are of value in cases of actual disease, it is still doubtful if they are really of benefit in cases of confinement It may be of use to consider briefly the statistics of mortality at different times and in different places. It is very difficult to compare former death-rates with present or recent if we consider cases in bulk, because previous to the present century it was but little the custom to classify cases ; so that a preponderance of surgical cases might exist at one period and of medical at another, with a corresponding variation of the death-rate. Of course in some exceptional instances we can point to remarkable dif ferences due to known causes of unhealthiness. Thus in the H6tel Dieu of Paris, in the last century, a terrible mor tality occurred, amounting to 1 in 4^, or 220 per 1000 (Tenon) ; and in the British hospitals at Scutari the mor tality reached between 400 and 500 per 1000. In both of those cases there was inordinate crowding, such as is hardly likely to be met with again. But in dealing with ordinary hospitals there are so many modifying causes that the comparison, without careful analysis, may be mislead ing. Thus Dr Steele has shown that in the last century (1730-1800) the death-rate of St Thomas s was 86 per 1000, whilst that of Guy s was 119 ; but this, as he points out, may have arisen from the latter being looked upon as an asylum for incurables. In 1875 the death-rates of the general hospitals in London ranged from 72 per 1000 in the Royal Free to 127 in King s College ; in the Edinburgh Royal Infirmary it was 92, and in the Glasgow 118. But it is when we examine the mortality of special cases that the most instructive lessons are to be learned ; and the best for this purpose are surgical cases and lying-in cases. From these we gather that the mortality is pretty generally in the ratio of the size of the hospital and the consequent aggregation of patients, the crowding together of patients in the wards, the deficiency of ventilation, defective sewer age arrangements, and the want of constant attention to the details of cleanliness. Thus Sir James Simpson showed in his paper on " Hospitalism " the following statistics of mortality from amputations : Deaths per 1000. St Bartholomew s 366 London Hospital, Whitechapel 473 Guy s 382 St George s 388 Nine London hospitals 411 Royal Infirmary, Edinburgh 433 ,, ,, Glasgow 391 Eleven large and Metropolitan hospitals .... 410 On the other hand, amputations in country practice give a death-rate of only 108 per 1000. Comparing the results with the size of the hospital, that is, the aggregation of cases, we find : Deaths per 1000. Large Parisian hospitals, with more than 600 beds (Husson) 620 English hospitals, 301 to 600 beds 410 201 to 300 , 300 ,, 101 to 200 230 ,, 25 to 100 ,, 180 Cottage hospitals under 25 beds 140 Isolated rooms in country practice 108 The question of lying-in cases is even more remarkable. Dr Lefort, having collected the statistics of 888,302 de livered in hospitals, and of 934,781 delivered at home, shows that in hospitals 35 per 1000 die, and at home 4f. Dr Steele gives the statistics of the four great lying-in hospitals of London, compared with the "extern -maternity" charities of Guy s, St Bartholomew s, and St Thomas s : o C a "3.5
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O ^ "8 ~i to to fcbc c , tjj, t ^ 1 &^ ~ > |t I J I, a o s U 1-1 1-1 1-1 c/i ^ t/2 Deaths per ) 1000 28-2 157 14-8 13-5 4-1 3-1 3 5 i Baron Meydell, chief of the sanitary department of St Petersburg, has shown that in the largest lying-in hospital there, in which 2000 women are confined in a year, the death-rate is from 30 to 40 per 1000; in the second, in which about 1000 women per annum are received, only 25 die ; in the third, where 400 are received, only 20 die per 1000; in the small detached asylums of 2 or 3 beds, of which there are 11 in different parts of the city, giving accom modation to 1600 women per annum, or about 155 each, only 9 per 1000 die ; whilst amongst those confined in their own homes, including the poorest and most wretched, only 5 per 1000 die (Rapport du Congres International <T Hygiene et de Sauvetage, Brussels, 1876, vol. i. p. 226). These numbers correspond with the observations above. It can also be shown that outbreaks of disease are coin cident with individual overcrowding, whether the hospital be large or small. Thus the terrible mortality of the Hotel- Dieu of Paris in the last century was due as much to actual overcrowding as to the enormous aggregation of patients. The extraordinary spectacle was to be seen there of two or three small-pox patients, or several surgical cases, or some times even four parturient women, lying in one bed. A large proportion of the beds were purposely made for four patients, and six were frequently crowded in. In the Salle St Charles and St Antoine there were 139 large beds (in tended for four patients each, but often holding six), and 38 small beds for one patient each. Those beds were gene rally full, giving under ordinary conditions 558 patients, and in times of pressure 836. To this might be added the Salle St Roch, opening directly from and really forming part of the great ward ; this contained 35 large beds and 3 small, normal number of patients 143, with a possible increase to 213. This gives a grand total of 701 patients
as a normal amount, with a possible increase to 1049,
