The Evolution of the Modern Hospital.—The evolution of the modern hospital affords one of the most marvellous evidences of the advance of scientific and humanitarian principles which the world has ever seen. At the outset hospitals were probably founded by the healthy more for their own comfort than out of any regard for the sick. Nowadays the healthy, whilst they realize that the more efficient they can make the hospital, the more certain, in the human sense, is their own chance of prolonged life and health, are, as the progress of the League of Mercy has shown in recent years, genuinely anxious for the most part to do something as individuals in the days of health in the cause of the sick. Formerly the hospital was merely a building or buildings, very often unsuitable for the purposes to which it was put, where sick and injured people were retained and more frequently than not died. In other words the hygienic condition, the methods of treatment and the hospital atmosphere were all so relatively unsatisfactory as to yield a mortality in serious cases of 40%. Nowadays, despite, or possibly because of, the fact that operative interference is the rule rather than the exception in the treatment of hospital patients, and in consequence of the introduction of antiseptic and aseptic methods, the mortality in hospitals is, in all the circumstances, relatively less, and probably materially less, than it is even amongst patients who are attended in their own homes. Originally hospitals were unsystematic, crowded, ill-organized necessities which wise people refused to enter, if they had any voice in the matter. At the present time in all large cities, and in crowded communities in civilized countries, great hospitals have been erected upon extensive sites which are so planned as to constitute in fact a village with many hundreds of inhabitants. This type of modern hospital has common characteristics. A multitude of separate buildings are dotted over the site, which may cover 20 acres or upwards. In one such institution, within an area of 20 acres, there are 6 m. of drains, 29 m. of water and steam pipes, 3 m. of roof gutters, 42 m. of electric wires, and 42 separate buildings, which to all intents and purposes constitute a series of distinct, isolated hospitals, in no case containing more than forty-six patients. On the continent of Europe buildings of this class are usually of one storey; in the United States, owing to the difficulty of obtaining suitable sites and for reasons of economy, some competent authorities strenuously advocate high buildings with many storeys for town hospitals. In England the majority have two to three storeys each, the ward unit containing a ward for twenty beds and two isolation wards for one and two beds respectively. The two storeys in modern fever hospitals, however, are absolutely distinct—that is, there is no internal staircase going from one ward to the others, for each is entered separately from the outside. This system carries to its extreme limits the principle of separating the patients as much as possible into small groups; the acute cases are usually treated in the upper ward, and as they become convalescent are removed downstairs. In this way the necessity for an entirely separate convalescent block is done away with and the patients are kept under the same charge nurse, an arrangement which promotes necessary discipline. The unit of these hospitals is the pavilion, not the ward, and consists of an acute ward, a convalescent ward, separation wards, nurses’ duty rooms, store-rooms for linen, an open-air balcony upstairs into which beds can be wheeled in suitable weather, and a large airing-ground for convalescent patients directly accessible from the downstairs ward. Each of the pavilions is raised above the ground level, so that air can circulate freely underneath. The wall, floor and air spaces in the scarlet fever wards of one of these hospitals are respectively 12 ft., 156 ft. and 2028 ft. per bed; and in the enteric and diphtheria wards they have been increased to 15 ft., 195 ft. and 2535 ft. respectively. The provision of so large a floor and linear space, especially in the diphtheria wards, is an experiment the effect of which will be watched with considerable interest. A building of this type is a splendid example of the separate pavilion hospital, and is doing great service in the treatment of fevers wherever it has been introduced. Some idea of a hospital village, some of the wards of which we have been describing, may be gathered from the circumstances that it costs from £300,000 to £400,000, that it usually contains from 500 to 700 beds, and that the staff numbers from 350 to 500 persons. The medical superintendent lives in a separate house of his own. The nurses are provided with a home, consisting of several blocks of buildings under the control of the matron; the charge nurses usually occupy the main block; where the dining and general sitting-rooms are placed; the day assistant-nurses another block; and lastly, by a most excellent arrangement, the night nurses, 80 to 120 in number, have one whole block entirely given up to their use. The female servants have a second home under the control of the housekeeper, and the male servants occupy a third home under the supervision of the steward. The two main ideas aimed at are to disconnect the houses occupied by the staff from the infected area, and to place the members of each division of the staff together, but in separate buildings, under their respective heads. These objects are highly to be commended, as they have important bearings upon the well-being and discipline of the whole establishment and constitute a lesson for all who have to do with buildings where a great number of people are constantly employed.
The Hospital City.—We have shown that the modern hospital where an adequate site is available under the most favourable conditions has developed into a hospital village. No one who is familiar with the existing disadvantages of many of the sites and their surroundings of town hospitals in many a large city can have any doubt that, if the well-being of the patients and the good of the whole community, combined with economical and administrative reasons, together with the provision of an adequate system for the instruction and training of medical students and nurses, are to be the first considerations with those responsible for the hospitals of the future, the time will come, and is probably not far distant, when each great urban community will provide for the whole of its sick by removing them to a hospital city, which will be situated upon a specially selected and most salubrious site some distance from the town itself. The atmosphere of a great city grows less and less suitable to the rapid and complete recovery of patients who may undergo the major operations or be suffering from the severe and acute forms of disease. Asepsis, it is true, has reduced the average residence in hospital from about 35 to less than 20 days. It has thereby added quite one million working days each year to the earning power of the artisan classes in London alone. Medical opinion is more and more favouring the provision of convalescent and suburban hospitals, to which patients suffering from open wounds may be removed from the city hospitals. This course, which entails much additional expenditure, is advocated to overcome the difficulty arising from the fact that, in operation and other cases, the patients cease to continue to make rapid progress towards recovery after the seventh or ninth day’s residence in a city hospital. A change of such cases to the country restores the balance and completes the recovery with a rapidity often remarkable.
Thinking out the problem here presented in all its bearings, realizing the great and ever-increasing cost of sites for hospitals in great cities, the heavy consequential taxes and charges which they have to meet there, and all the attendant disadvantages and drawbacks, the present writer has ventured upon an anticipation which he hopes may prove intelligent and well-founded. Nearly every difficulty in regard to the cost of hospitals and in respect to all the many problems presented by securing the material required, under present systems, for the efficient training of students and nurses, would be removed by the erection of the Hospital City, which, he foresees, must ultimately be recognized by intelligent communities throughout the civilized world. Why should we not have, on a carefully selected site well away from the contaminations of the town, and adequately provided with every requisite demanded from the site of the most perfect modern hospital which the mind of man can conceive, a “Hospital City”? Here would be concentrated all the means for relieving and treating every form of disease to the abiding comfort of all responsible for their adequacy and success. At the present time all the traffic and all the citizens give way to fire engines and the ambulance in the public streets. Necessarily the means of transit to and from the “Hospital City,” and its rapidity, would be the most perfect in the world. So the members of the medical staff, the friends of the patients, and all who had business in the “Hospital City,” would find it easier and less exacting in time and energy to be attached to one of the hospitals located therein than to one situated in the centre of a big population in a crowded town. To meet the urgent and accident cases a few receiving houses, or outpost relief stations, with a couple of wards, would be situated in various quarters of the working city, where patients could be temporarily treated, and whence they could be removed to the “Hospital City” by an efficient motor ambulance service. The writer can see such a “Hospital City” established, can realize the comfort it will prove in practice to the medical profession, to the patients’ friends, to those who have to manage the hospitals and train the medical and nursing students, and indeed to all who may go there as well as to the whole community. The initial cost of hospital buildings should be reduced at once to a quarter or less of the present outlay. They could then be built of the cheapest but most suitable material, which would have many advantages, whilst the actual money forthcoming from the realization and sale of the existing hospital sites in many cities would, in all probability, produce a sum which in the whole might prove adequate, or nearly adequate, or even in some cases more than adequate, to defray the entire cost of building the “Hospital City” and of equipping it too. The cost of administration and working must be everywhere reduced to a minimum. The hygienic completeness of the whole city, its buildings and appliances, must expedite recovery to the maximum extent. In all probability the removal of the sick from contact with the healthy would tend in practice so to increase the healthiness of the town population, i.e. of the workers of the city proper, as to free them from some of the most burdensome trials which now cripple their resources and diminish materially the happiness of their lives. Probably the United States (where a city has sometimes sprung up in twelve months) may be the home where this idea may first find its realization in accomplished fact. The writer may never live to see such a city in actual working or in its entirety, but he makes bold to believe its adoption will one day solve the more difficult of the problems involved in providing adequately for the sick in crowded communities. He has formulated the idea because it seems desirable to encourage discussion as to the best method of checking the growing tendency to make hospital buildings everywhere too costly. If the idea of the “Hospital City” commends itself to the profession and the public, the practice of treating all the hospital accommodation in each city as a whole will gradually increase and spread, until most of the present pressing difficulties may disappear altogether. That is a consummation devoutly to be wished.
The Problem of Hospital Administration.—A study of the hospital problem in various countries, and especially in different portions of the English-speaking world, convinces the writer that, apart from local differences, the features presented are everywhere practically identical. A number of hospitals under independent administration, dependent in whole or in part on voluntary contributions, administered under different regulations originally representing the idiosyncracies of individual managers for the time being, without any standard of efficiency or any system of co-operation, which would bring the whole of the medical establishments of each or all of the great cities of the world under one administration which the combined wisdom and experience of hospital managers as a whole might agree to be the best, must mean in practice a material gain in every way to each and all of the hospitals and their supporters on economical, scientific and other grounds. Such an absence of system throughout the world has everywhere led to overlapping, to the perpetuation of many abuses, to the admission of an increasing number of patients whose social position does not entitle them to claim free medical relief at all, and, often too, to the admission of patients belonging to a humbler grade of society who are already provided for by the rates in institutions which they do not care to enter and who find their way to the wards of hospitals which were established to provide for patients of an entirely different social grade. These evils have continued to grow and increase almost everywhere, despite many and varied attempts to grapple with and remove them. Amongst these attempts we may mention the assembling of hospital conferences, the establishment of special funds and committees, and the holding of inquiries of various kinds in London and other British cities and also in the United States. The most remarkable proof of the impossibility of inducing those responsible to act together and enforce the necessary reforms is afforded by the historical fact that the famous Commission on Hospital Abuse, known as Sir William Fergusson’s Commission, in 1871, after an exhaustive inquiry, made the following recommendations: (1) to improve the administration of poor-law medical relief; (2) to place all free dispensaries under the control of the poor-law authorities; (3) to establish an adequate system of provident dispensaries; (4) to curtail the unrestricted system of gratuitous relief, partly by the selection of cases possessing special clinical interest and partly by the exclusion of those who on social grounds are not entitled to gratuitous medical advice; (5) the payment of the medical staff engaged in both in- and out-patient work, and the payment of fees by patients in the pay wards and in the consultation departments of the voluntary hospitals. Other commissions have since been appointed, have reported, and have disappeared, with the result that nothing practical had been done up to 1910 in the way of reform. Yet it is an undoubted fact that, if the foregoing recommendations of Sir William Fergusson’s Commission had been carried out in their entirety at the time they were made, practically all the abuses from which British hospitals afterwards suffered would have been removed, and the charitable public might have been saved several millions of pounds sterling. It may be well, therefore, briefly to indicate exactly what these changes amount to, and how they can be made effective at any time by those responsible for the working of a hospital.
There is no doubt that all the facts available tend to prove that the voluntary hospitals are used to an increasing extent by persons able to make payment or partial payment for the treatment which they receive. The evidence and statistics demonstrating these facts may be readily gathered from a study of the Report (1909) and Evidence of the Royal Commission on the Poor Laws and Relief of Distress (Lord George Hamilton’s Commission) and in the authorities mentioned at the end of this article. The underlying cause of the abuse was that no means existed whereby persons of moderate income could obtain efficient treatment and hospital care when ill at a rate which they could afford to pay. The system, or want of system, whereby medical relief is granted to practically all applicants by the voluntary hospitals grew up without any combined attempt to organize it efficiently or to check abuses. Such a system rests upon a wrong basis, and the best interests of every class of the population demand its abolition in favour of one which shall afford the maximum of justice (1) to the poor, (2) to those who can afford to pay in part or in whole the cost of their medical treatment and care at a hospital, (3) to the medical profession, (4) to the subscribers and supporters of voluntary hospitals, whose gifts should be strictly applied to the purposes they were intended to serve, and (5) to the ratepayers, who are entitled to a guarantee that the maximum efficiency is secured by the poor-law system of medical relief. The remedy is very simple and easy of application. Every voluntary hospital, while admitting all accidents and urgent cases needing immediate attention, should institute a system whereby each applicant would be asked to prove that he or she was a fit object of charity. The only real attempt at reform, up to 1909, was the appointment by many of the larger hospitals of almoners to ascertain whether certain selected patients were in a position to pay or not. By putting the burden of proof of eligibility to receive free medical relief upon the patients and their friends, all abuse of every kind must speedily cease. There would be no hardship entailed upon the patients by such a system, as experience has proved, but, to make it effective, the system of providing for in- and out-patients in Great Britain requires radical change, for, in existing circumstance, if a voluntary hospital attempted to enforce this simple method, it would be met with the difficulty that, where it was found that a patient or his friends could pay at any rate something, no department connected with British hospitals existed—as is the case in regard to hospitals in the United States—enabling such in-patients to be transferred to accommodation provided in paying wards. In the same way, directly the out-patients were dealt with under such a system, it would be made apparent, where a case could be properly treated, under the poor law, that no plan of co-operation to secure this was organized under existing conditions. If the patient, being of a better class, were suffering from a minor ailment, and could be properly dealt with at a provident dispensary, the fees of which he could easily pay, the same absence of co-operation must make it practically impossible readily to enforce the system. When, again, an out-patient of the better class was entitled, from the severity of his ailment, to receive the advantages of a consultation by the medical staff, no method existed whereby this aid could be rendered to him, and his transfer afterwards to the care of a medical practitioner attached to some provident dispensary, or resident near the patient’s home, could be properly carried out. It follows that adequate reform required that methods should be adopted with a view to some part or all the cost of treatment being provided by the patient or his friends through an entire reorganization of the system of medical relief not only at the voluntary hospitals, but under the poor-law system. The reforms required in regard to voluntary hospitals are that every large hospital shall have connected with the in-patient department, in separate buildings, but under the administration of the managers, pay wards for the reception of those patients who are able to pay some part or all of the cost of treatment; that, as regards out-patients, the existing out-patient department should be abolished; that in substitution for it each hospital should have a casualty department and a department for consultation. In the casualty department every applicant should be seen once, and be there disposed of by being handed on to the consultation department; if his case was sufficiently important, he should then be transferred to some provident or poor-law dispensary, or be referred to a private medical attendant. It would no doubt take time to overcome the incidental difficulties which would necessarily arise in effecting so radical a reform as is here contemplated, but if all voluntary hospitals adopted the same system, and were to be brought into active co-operation with provident dispensaries and poor-law dispensaries and private medical practitioners, the new system might be successfully introduced and made effective within twelve months, and probably within six months, from the date of its commencement. This opinion is based upon the assumption that the provident dispensaries would be standardized, and that every one of them would be brought up to a state of the highest efficiency. In the town of Northampton the Royal Victoria Dispensary has been worked with the maximum of success, so far as the patients and the medical practitioners are concerned. In London and in other large towns like Manchester and elsewhere the provident dispensary has not succeeded as it has done in Northampton, because so many members of the medical profession are not alive to the importance of making it their first business to provide that every patient connected with the provident dispensary who attends at the surgery of a private medical practitioner shall receive at least equal attention and accommodation to that afforded to every other private patient, whatever the fee he may pay. In the same way, poor-law dispensaries must be radically reformed. Everything which tends to excite a feeling of shame on the part of the patient attending the poor-law dispensary, such as the printing of the word “pauper” at the beginning of the space on which the patient’s name is entered, must be abolished, and the class of medical service and all the arrangements for the treatment of the patients, however poor, at the poor-law dispensary, must be made at least as efficient as those provided by voluntary hospitals. There undoubtedly is considerable overlapping between the voluntary hospitals and the poor law in Great Britain. The Royal Commission on the Poor Laws and Relief of Distress (1909) deals with this point with a view to set up a standard of medical relief to be granted by each class and type of hospitals, provides for adequate co-operation between all classes of institutions; and these reforms may be commended. It is too often forgotten that the function of the poor law is the relief of destitution, while it should be the object and duty of each voluntary hospital and indeed of all hospitals other than poor-law institutions to apply their resources entirely to the prevention of destitution, by stepping in to grant free medical relief to the provident and thrifty when, through no fault of their own, they meet with an accident or are overtaken by disease. An adequate system of co-operation would preserve the privilege of the voluntary hospitals, which save such patients from the necessity of requiring the relief which it is the object of the poor law to supply.
We have dealt with the relative advantages and disadvantages of rate-supported hospitals and voluntary hospitals. We should regard the establishment of a complete state-provided or rate-provided system of gratuitous medical relief, either for indoor patients or for out-door patients, or for both, as a grave evil. Such a system must eventually lead to the extinction of voluntary hospitals. If this disaster ever happens, it must result in the gravest evils, for it could not fail to injure the morale of all classes and tend to harden unnecessarily the relations between the rich and poor, who, under the voluntary system, have come to share each other’s sufferings and to be animated by respect and confidence towards each other.
Hospital Construction. Locality and Site.—Hospitals are required for the use of the community in a certain locality, and to be of use they must be within reach of the centre of population. Formerly the greater difficulty of locomotion made it necessary that they should be actually in the midst of towns and cities, and to some extent this continues to prevail. It is now proved to demonstration that this is not the best plan. Fresh and pure air being a prime necessity, as well as a considerable amount of space of actual area in proportion to population, it would certainly be better to place hospitals as much in the outskirts as is consistent with considerations of usefulness and convenience. In short, the best site would be open fields; but if that be impracticable, a large space, “a sanitary zone” as it is called by Tollet, should be kept permanently free between them and surrounding buildings, certainly never less than double the height of the highest building. In the selection of a site various factors must be taken into consideration. If the hospital is to be used as the clinical school of a university or medical college, then the most suitable ground available within easy reach of the university or college must be secured. If, on the other hand, the hospital is not to be used as a teaching school, a site more in the country should be favoured. In any case ample ground must be purchased to permit of the wards receiving the maximum of sunlight, an abundant supply of fresh air, and leave room for possible future extensions. The site should be self-contained; it should be in such a position as to prevent the hospital being shadowed by other buildings in the neighbourhood, and, unless the site is alongside a public park, it should be entirely surrounded by streets of from 40 to 60 ft. in width. It is also necessary to secure that adequate water mains serve the site, and that the system of sewers be ample for all sewage purposes.
The difference between the expense of purchase of land in a town and in the environs is generally considerable, and this is therefore an additional reason for choosing a suburban locality. Even with existing hospitals it would be in most cases pecuniarily advantageous to dispose of the present building and site and retain only a receiving house in the town. St Thomas’s in London, the Hôtel-Dieu in Paris and the Royal Infirmary in Manchester, are all good examples where this might have been carried out. In none, however, has this been done; these hospitals have been rebuilt, at enormous outlay, in the cities as before, although not exactly in the same locality.
As regards the actual site itself, where circumstances admit of choice, a dry gravelly or sandy soil should be selected, in a position where the ground water is low and but little subject to fluctuations of level, and where the means of drainage are capable of being effectually carried out. There should also be a cheerful sunny aspect and some protection from the coldest winds.
Form of Building.—A form of building must be selected which answers the following conditions: (a) the freest possible circulation of air round each ward, with no cul-de-sac or enclosed spaces where air can stagnate; (b) free play of sunlight upon each ward during some portion at least of the day; (c) the possibility of isolating any ward, or group of wards, effectually, in case of infectious disease breaking out; (d) the possibility of ventilating every ward independently of any other part of the establishment. Those conditions can only be fulfilled by one system, viz. a congeries of houses or pavilions, more or less connected with each other by covered ways, so as to facilitate convenient and economical administration. The older plans of huge blocks of buildings, arranged in squares or rectangles, enclosing spaces without free circulation of air, are obviously objectionable. Even when arranged in single lines or crosses they are not desirable, as the wards either communicate with each other or with common passages or corridors, rendering separation impossible. On this point it may be remarked that some of the buildings of the 18th century were more wisely constructed than many of those in the first half of the 19th century, and that the older buildings have been from time to time spoilt by ignorant additions made in later times.