HOSPITAL 305 with reference both to total space and to lateral or floor space. Un less 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 feet between the beds and 10 feet between the ends of the beds, this gives 100 square feet 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 New In firmary 150 square feet is allowed. Cubic space must be regulated by the means of ventilation ; we can rarely change the air oftener than three times 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 feet per bed, even in ordinary cases of sickness, and the third of that is 1333 cubic feet of space. With 100 square feet of floor space a ward of 134 f c t high would supply this amount, and there is but little to be gained by raising the ceiling higher, ndeed, 12 feet is practically enough. The experiments of Drs Cowles ami Wood of Hoston (see Report of State Board of Health of Massachusetts for 1879) show that above 12 feet 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. 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 win dows must reacli 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 ; and, 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 ex- t^rnal 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 feet 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 li feet per second, except at the point of entry, where it should not exceed 5 feet per second, and at the outlet, where the rate may be somewhat higher ; about 64 square inches of inlet and oiitlet sec tional 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 ours, where every system of ventila tion must involve either the warming of some portion of the in coming air, or the contriving its delivery without too great lower ing of temperature ; at the same time it cannot be too strongly in sisted 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, small-pox, &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 to 63 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 unadvisable to do away altogether with radiant heat, although it is not always possible to supply sufficient warmth with open 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 hot-water pipes in the ward itself. In each case, however, the air must be supplied independently to each ward, so that no general system of ventilation is applicable. The lighting of wards at night will be most conveniently done by means of gas, in the form of a jet over each bed, with a special ven tilator to carry off combustion products, as in the Edinburgh New Infirmary. 6. Furniture, of Wards. This should be simple, clean, and non- absorbent ; the bedsteads of iron, mattresses hair, laid on spring bottoms without sacking. No curtains should be permitted. 7. Water. 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. 8. Closets, Baths, &c. The closets ought to be of the simplest construction, the pans of earthenware all in one piece, the flushing arrangements moved by opening the door, 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. 9. Each ward should have attached to it a room for the nurse from which she can look into the ward, 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. 10. Nursing. The arrangements for nursing the sick have greatly improved in recent times, although controversy still goes on as to the best method of carrying it out. In arranging lor the nursing in a hospital both efficiency and economy have to" be con sidered. Miss Nightingale recommends large wards of 32 beds each, as at the Herbert Hospital, on the ground that one head-nurse is sufficient for such a number by day and one nurse by night. In the Edinburgh New Infirmary the wards are not so large, the medical being arranged for 21, and the surgical for 14 patients. Circumstances must to a large extent determine the arrangement, but it seems desirable on the whole that the work of a nurse should be confined to a single ward at a time if possible. The duties of nurses ought also to be distinctly confined to attendance on the sick, and no menial work, such as scrubbing floors and the like, should be demanded of them ; a proper staff of servants ought to be employed for such purposes. It is also desirable that a separate pavilion for lodging the nurses should be set apart, and that fair and reasonable time for rest and recreation should be allowed. Some discussion has taken place as to the advisability of placing the nursing of a hospital in the hands of a sisterhood or separate corporation. It will, however, be admitted that the best plan is for the nursing staff of each hospital to be special and under one head within the establishment itself, even although it may be con nected with some main institution outside. The nursing must of course be carried on in accordance with the directions and treatment of the physicians and surgeons. 11. The kitchen, laundry, dispensary, and other offices must be in a separate pavilion or pavilions, away from the wards, but with in convenient access. 12. A separate pavilion for isolation of infectious cases is desir able. This may be a wooden hut, or in some cases even a tent ; cither is probably preferable to a permanent block of building. 13. A Disinfecting Chamber ought to be provided, where heat can be applied to clothes and bedding, for the destruction both of ver min and of the germs of disease. It is advisable to expose all bedding and clothing to its influence after each occasion of wear. Although this may entail additional expense from deterioration of fabric, it is worth the outlay to secure immunity from disease. This plan is rigidly followed at the Royal South Hants Infirmary at Southampton. 14. It is of great importance that the wards should be periodically emptied, and kept unoccupied for not less than one month in each year, and longer if possible. During such period thorough cleans ing and flushing with air could be carried out, so as to prevent any continuous deposit of organic matter. Up to quite lately hospital accommodation was confined to the larger towns, but the desirability of having it more accessible in smaller towns and villages has made itself more and more felt. Accordingly in many places cottage hospitals have been established with advantage. One great advantage of the pavilion system is that the principles of its construction and arrangements are equally applicable to large and small establishments, so that we may either look upon a large hospital as an extension of a cottage hospital, or upon a small one as a section of a pavilion one. The importance of increased accommodation for the recep tion of infectious cases is now very generally acknowledged, as shown not only by the establishment of the Metropolitan Asylums Hospitals, but also of others in various parts of the country. In some instances they have apparently been the means of arresting the spread of disease and protecting the locality from epidemics. Paying Hospitals, Pay-Wards, Provident Dispensaries. The general object for which hospitals have been established may be stated to be the gratuitous medical and surgical treatment of the indigent sick. Many abuses have, how-
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