Additional Hints as to Pavilion Hospitals suggested by the construction of the Lariboisière Hospital at Paris.
I.—Ventilation.
The question of ventilation is so all-important, so much doubt still seems to exist as to the comparative merits of natural and artificial ventilation, so much has been said in favour of the latter, because it is seen adopted in the finest hospital in the world, the Lariboisière, that I have added a few practical remarks upon this system. The conclusion is, that even at the Lariboisière, without opening the windows occasionally, and especially in the morning, real freshness is never obtained in the wards, and that, therefore, if there must be artificial ventilation, that is the best which allows the most of the windows being opened.
On the men’s side, Thomas’ system, or that of injecting air at given points, by means of two high-pressure steam engines, each working a large fan, is adopted. On the female side, Duvoir’s system affords ventilation by extracting air at given points. In both, a number of shafts and openings provide for the exit of the air.
Persons at the Lariboisière Hospital, who ought to be good judges, including foremost the Director, an experienced and able administrator, consider the ventilation on the male side the most expensive and the best, both for day and night, being the coolest in summer and the warmest in winter. In winter two great advantages are assigned to this side: first, the heating being provided by the Hospital, the wards are warmable at pleasure; whereas that of the female side is provided by the contractor at a fixed degree of heat, which, in extra cold weather, is augmented: from 15° to 18° C are the usual limits of the winter temperature on the female side, while that on the male side is usually several degrees higher. Secondly, the system of heating on the male side permits the windows to be opened: while on the female side objections are often made to opening the windows in winter, which it is alleged interferes with the heating.
Per contrà. How difficult it is to learn any facts by hearsay we know. Other persons who ought to be good judges think the male side apt to be too warm in winter, especially at night, and consider the temperature on the female side quite sufficient.
Both sides are ventilated both by the windows and by the machinery by day in summer. Both sides are ventilated, each by its own different machinery, by night in summer, except that, exceptionally on hot summer nights, a window is opened two or three times in the night, or five minutes every hour.
Both sides are considered to be ventilated in winter mainly by the machinery by day; and both sides are entirely ventilated in winter by the machinery by night.
As far as can be made out from conflicting accounts, (conflicting from the very simple reason that one person will consider a ward, or drawing room, for that matter, airy which another will consider close; one, pleasantly warm, another too hot or too cold), it is practically found impossible to freshen the ward of a morning without opening some windows, and to keep it fresh during the day without now and then doing the same; and it is easier to open the windows on the male side in winter than on the female side.
The ventilation on both sides is considered to work with equal efficiency during the whole of the day.
Of the eighteen wards, the ventilation on entering the wards at five a.m., when the ward nightwatch has generally not opened a single window, is certainly surprisingly good; i.e. the air is surprisingly little bad. But neither here, any more than anywhere else, are the wards effectually freshened, until the windows are, of course with proper caution, opened.
In both these particulars, no difference is to be observed between the male and female side.
In repeating that the Director, and other persons who ought to be good judges, consider the machinery of the male side the most expensive and the best, I add these things:
First. Since this machinery was erected, so far as concerns the steam engine, it is said that equally efficient and much less expensive engines have been erected in other Hospitals, among others, Necker and Beaujon. In both Hospitals, the plans of Duvoir and Van Heecke are in use, one on either side. But certainly, the system of outlets at Beaujon for the foul air is by no means so good as at the Lariboisière.
Secondly. If an accident happened to the machinery of the male side, which is in communication with the steam engine, the results might be very serious. Twice a stove has burst on that side, happily without damaging anything else than furniture near it; had patients been near it, they must have been hurt or killed: and an accident on a large scale might blow up not a small part of the Hospital.
More or less danger is inseparable from powerful steam machinery, or powerful machinery of any kind: the question is one of degree.
Thirdly. Both sides of the Hospital have one thing in common. Except the sculleries of the 3 ground floor wards on the male side, which have each a stove or fire place, the kitchens or sculleries attached to all the other wards are warmed by hot water. Undoubtedly this saves much mess, much cleaning of stoves &c., and much bringing of fuel and consequent dirt. But the absence of fire is always a loss to the service of a ward. Sundry things, some one or other, often all of which are constantly wanted in a large ward, e.g. warming broth or drink, cooking for an extra bad case, warming poultices, warming (not airing) linen for ditto, &c., &c., &c., are much more slowly done by water than fire heat, and it is a question, variously answered, whether some of these things are as well done by the slow water method, as by the quick fire heat. Occasionally the hot water is not forthcoming, a nuisance alike to the ward attendants of the ward whose scullery is thus heated, and to those of the wards supplied with stoves, which have then to do, in driblets, considerable extra duty.
During the hot months the smell of the latrines is very little perceptible in the wards, generally not at all: but the test of this, as of the ventilation, is in winter, when the large window close to the latrines is generally closed, and the smell is very offensive.
II.—Oiled Boards versus Parquets.
1. They have in common the superiority over common floorings—that they are not scrubbed, and the damp thus arising is avoided.
2. As regards labour, so far as Civil Hospitals are concerned, where the ward service is done by women, parquets would be more laborious than scrubbing; a large ward, to be kept in a proper state, requires a certain amount of frottage (the peculiar polishing of parquets) every day; and this frottage is held to be unfit, from the fatigue it causes and the strength it requires, to be done by women, and is always done by men. Certainly Ward Nurses could never be required to frotter; it is altogether a man’s business.
3. As regards labour, so far as Military or Naval Hospitals are concerned, where men preponderate in the ward service, it is my impression (for of course I cannot pretend any certainty as to this), that sailors who are proverbially handy (a different quality from either laboriousness or endurance, though they have these too) would, with instruction and painstaking, accomplish in time frottage; that civilians would under the same conditions; that soldier orderlies (infinitely, I humbly think, the best material for the staple of military ward service), would generally make bad frotteurs.
4. As regards labour, cleaning oiled boards, though a laborious business, is much less so than either scrubbing or frottéing; and is fully within the power of average strong women: none other should nurse. (What subdivision of cleaning the ward, and of nursing properly so-called, might both improve the work done and relieve the Nurses, is another thing; my impression remains, that it is better to consider these things to a certain extent as distinct duties, discharged by women ranking alike; and that in a ward of forty, served by a Head Nurse and three Nurses, to charge one with the main ward cleaning, is better economy of strength and time than to divide it among the three).
5. As regards labour, any Orderly giving his mind to it for a day at the shortest, or a week at the longest, ought to learn thoroughly how to clean polished oiled boards well, always supposing him to be properly taught a very simple thing, which, like everything else, can be done well, ill, or indifferently.
6. Apart from the question of labour augmented or spared, the advantages of oiled and polished boards I believe to be these:—
(1.) Prevention of dust.
(2.) More easy purification of the air of the ward in the morning.
The air of every ward becomes more or less impure during the night, and the floor and furniture more or less dusty. Making the beds in the morning adds to the dust the night has accumulated.
The dust is more thoroughly destroyed by the cleaning necessary to oiled and polished boards of the Bethanien variety, than by any other cleaning I have seen. It is fairly destroyed; whereas both parquets and boards generally retain a little.
Also, the water, with which the oiled boards after being swept are cleaned, freshens the ward and purifies it of the closeness remaining of the night air, in a very speedy and remarkable manner, which is even more evident as well as more useful in winter than in summer—as in winter it is not possible to admit as much air from the windows as in summer, especially when it is most wanted, in the cold, close, early mornings.
The advantages of oiled and polished boards as counteracting the spread of miasma, which is strongly dwelt on at Berlin by competent authorities, I have not alluded to, as probably parquets are considered equal in these respects to them.
Stains, mess, and dirt falling on polished oiled boards are much more easily cleaned than on parquets.
Note.
Mode of Cleaning Ward and Room Floors at Bethanien, Berlin.
I. Daily.
1. Take a common hair broom, a broom with a hard brush, a cloth of coarse flax, and one or two pails of cold water.
2. Sweep the floor and skirtings with the hair broom.
3. Dip the cloth in a pail, wring it gently between the hands, so as to have the whole equally wet, not running. Throw it on the ground, reverse the hard broom, and placing the reversed handle upon the cloth, clean the floor close to the skirtings, not the skirtings themselves, and the corners. When the cloth becomes dry, rinse it and re-wet it in the same pail.
4. Then wet the cloth somewhat more, wringing it as before, throw it on the floor at the end furthest from the door, and placing the brush of the hard broom upon it, brush, firmly and quickly, each board in the direction that the boarding runs, about as far as the arms can reach, standing, not kneeling. A small ward can be at once brushed wet, a large one must be divided into parts, and each part be successively brushed wet and brushed dry. When the cloth becomes dry, rinse it and re-wet it.
5. To brush dry, rinse and well wring the cloth, brush as before. The firmer you can press, the better and quicker the floor will be dried. When the cloth becomes wet, rinse it and wring it as before.
6. Change the water when dirty. More or less water must be used, according as the floor is trod by dirty boots and shoes.
7. Aim at drying the floor by one dry brushing; if not, it must be dry brushed a second time. Once should suffice.
8. Ten minutes, at the furthest, after the dry rubbing is over, the floor ought to be thoroughly dry. When it is quite dry, sweep quickly over it with the hair broom.
9. On putting by the cleaning materials, rinse well the cloth in clean water.
II. Weekly.
1. Brush the skirtings with a small hard brush, and wipe them dry with a rag, as the cloth would be too large, and wet the walls.
2. Use more water to clean the floor, which will probably require two dry brushings.
3. Clean the brooms and pails.
III. Annually.
1. Throw warm, not hot, water on the floor, and brush firmly and quickly, wet and dry. A very little soda in each pailful will be an improvement. More than very little will injure the flooring.
[A new cloth, which it is economical to cut from a great piece which makes into some or many dozens, should be steeped for a night in a pail once filled with boiling water, and in the morning rinsed and wrung several times in clean cold water, then used at once. Two or three new cloths can be steeped in the same pail.]
III.—Cautions in Hospital-Building.—Often repeated, but oftener neglected.
1. Wherever practicable build the hospital on arches; but, for the sake of discipline, they should be locked up.
2. If practicable, let the laundry, if served by women, be removed from sight of the place where the patients take exercise, and of the ward windows.
3. In a Civil Hospital it is objectionable to give the female patients right to take exercise in corridors which the officers and servants have constantly to traverse to go to and from the wards. In a Military Hospital it is of little comparative disadvantage that the patients should do this, although,
4. In building a hospital it might be well worth while to contrive that the covered space, essential to give the patients power of taking exercise, should be used solely for that purpose.
5. In Germany, the general opinion is in favour of small wards, twenty beds are considered the desirable maximum; twelve, per se, better than twenty.
Ditto in Belgium, under the same restriction, although, in practice, there are wards containing larger numbers.
In the old Hospitals at Paris, the number of patients is too large. The Charité has long great wards of 100 and 120 patients. At St. Louis (which is mostly for cutaneous, not venereal, diseases, where the patients usually are long under treatment and able to go about, and where there is little acute illness,) wards of eighty and seventy beds are the rule, smaller wards the exception. This may be considered an exceptional class of patients. The Charité, somewhat densely pressed upon by neighbourhood, is also not considered a favourably circumstanced Hospital as to air.
Putting aside for a moment the sanitary question, which we have fully discussed elsewhere, and which appears to be decided in favour of wards of from twenty to thirty patients, we will look upon the question of administration. The moment we consider that a great public Hospital has to provide efficient attendance for all the sick it receives, that it must be economical of attendance, both because the expense of attendance, as well as the other requirements of the sick, commands all practicable economy; and because efficient attendance in sufficient numbers is difficult to obtain; it becomes evident that it is far better for the sick to have larger wards, efficiently served by as few attendants as is compatible with efficiency.
This, which is the fair statement of the case, strikes those who have watched the working of the system of small wards in North Germany as more true than ever.
Such persons consider that the size and numbers of the wards at the Lariboisière Hospital, viz., thirty-four beds, including the two in the little ward, are good: that preserving the existing considerable space between the beds, and supposing the same ratio of conditions as to windows, &c., and the small ward for two at the end, wards of forty or fifty would be equally healthy for the sick, but that the number fifty should not be surpassed.
Assuming, however, that thirty patients in a ward, or thirty-two, are the maximum number, sanitary and administrative necessities being conciliated, let us see what we do in our Military Hospitals at home.
In most of our Regimental Hospitals the number of wards and of holes and corners, in comparison with the number of sick, is quite extraordinary.
In a hospital for a battalion 500 or 600 strong, we shall find eight or ten wards of small size, a small kitchen, everything, in fact, on a small scale, just as if a large French Hospital had suddenly collapsed.
How much more sensible would it not be to have one or, at most, two large wards for thirty sick each, with a small casualty ward and an itch ward!
How much less expensive such a structure would be in erecting and administering, and how much more easy would be the discipline and oversight, not to mention the greater facility of ventilation!
6. There is nothing at the Lariboisière Hospital answering to casualty wards. Besides the eighteen wards of thirty-four each, the Hospital contains two little (and inconveniently placed), wards of ten beds each, which, when medical cases overflow, are made medical wards; and which are closed when the ordinary wards suffice. But of casualty wards, for offensive, or noisy cases, there are none, and the double-bedded little ward at the end of each large ward is intended to answer this purpose; also, but subsidiary to this, to allow now and then a patient of the better class to have the comparative privacy.
This latter consideration does not apply to a Military Hospital. As to allowing Non-Commissioned Officers for instance to be in the little wards, discipline would, I think, very soon suffer.
But if casualty wards are provided for extra offensive, and noisy cases, it seems to me that any Hospital would be much better without these small wards attached to each larger one.
Apart from the purposes which the casualty wards answer, they are a nuisance. If convalescent patients are put into them, they are comparatively removed from inspection, and often play tricks there. Patients requiring much attention can seldom be put there, however their condition otherwise fits them for the little ward, because the ward attendants, and especially the Sister (as in secularly served Hospitals the Head Nurse), find it impossible to serve the inmates of the little ward properly, if there are also many serious cases in the large ward.
I submit therefore that the small ward is only an incubus, if casualty wards are provided. One thing is certain: a patient requiring much attendance, put into a little ward, ought to have an extra attendant to himself, by day and by night; otherwise, either he is more or less neglected, or he unduly monopolises the service of the ward attendants.
It remains a question for far others than women to settle, whether offensive and delirious cases are under more favourable conditions of cure when scattered in little wards, than when assembled in a large, or in several small wards. On this subject, I can only add my confirmed belief that a large airy ward, provided with a few small wards, and with complete ward attendance, is a much better place for the care and attendance of such cases, than small wards attached to the ordinary wards.
7. Avoid many holes and corners. I could not recommend a dining room for patients attached to each ward, or floor, or pavilion. If there is any dining room, let all the convalescent patients of the wards not being convalescent wards, dine together in a room apart from the wards, and let the rest dine each at his bed side. If not, let each patient dine at his bed side.
At the Lariboisière Hospital, each ward has a vestiary, a doubtful arrangement. The nature of a Military Hospital renders it proper to have but one vestiary under charge of some man.
8. If possible, let all foul linen be delivered daily, twice perhaps better than once daily, into the laundry, so as to remain the shortest possible time in the neighbourhood of the ward; otherwise, do what you will, foul Hospital linen will fairly, to say the ugly truth—stink, and its temporary receptacle will stink also. I would not make this temporary receptacle a room. A large chest in the scullery, a region under constant purification by fire and air, would be, as already hinted, p. 88, the least bad place for an accumulation inevitable to all Hospitals, but which should accumulate for as little time as possible.
9. Provide from the first room for storing and issuing dried clean linen, as well as laundry room.
10. In badly-planned Hospitals artificial ventilation is an excellent auxiliary for expelling the foul air, engendered in the ward, especially at night; but windows only can be relied upon for introducing good air. Let Hospitals, therefore, be so constructed as to admit of opening one or more windows as much as possible all the year round, with as little chance of draught as may be to individual patients, which can be done by providing double windows, opening above and below, or by some similar expedient.