outlet, where the rate may be somewhat higher; about 64 sq. in. of inlet and outlet sectional 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 that of Great Britain, where every system of ventilation must involve either the warming of some portion of the incoming air, or the contriving its delivery without too great lowering of temperature; at the same time it cannot be too strongly insisted 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, smallpox, &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 inadvisable to do away altogether with radiant heat, although it is not always possible to supply sufficient warmth with open-air 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 radiators in the ward itself. In each case, however, the air must be supplied independently to each ward, so that no general system of air supply is applicable.
The lighting of the ward at night will be most conveniently done by means of electricity in the form of a lamp for each bed, where gas is used each jet should have a special ventilator to carry off combustion products, as in the Edinburgh Infirmary.
The Furniture of Wards should be simple, clean and non-absorbent; the bedsteads of iron, mattresses hair, laid on spring bottoms without sacking. No curtains should be permitted.
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.
The closets ought to be of the simplest construction, the pans of earthenware all in one piece, the flushing arrangements simple but perfect, and 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.
Each ward should have attached to it 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.
Hospital Economics.—There is no doubt that the voluntary system of hospital government is far more economical than any system of state or rate-supported hospitals. That the present condition of the voluntary hospitals in regard to economy is all that can be wished is not, of course, true. Still, resting as this system does upon the goodwill of the public for its continuance and maintenance, it is satisfactory to note that there is a continuous improvement in system and method, which makes for economy. It has taken many years to perfect and enforce the uniform system of hospital accounts, but this system with the co-operation of the great funds has produced economical results of the first importance. This system originated at the Queen’s Hospital, Birmingham, in 1869, and was devised by an eminent Birmingham accountant, William Laundy, and Sir Henry Burdett. It proved so fruitful in practice that six years later it was introduced at the “Dreadnought” Seamen’s Hospital, the first London hospital to use it, and was then adopted spontaneously by a few of the best-administered hospitals where the managers were keen in enforcing economy. In 1891, in order to secure for comparative purposes an identical classification of the items and charges included in the system, a glossary or index of classification was prepared and published in the Hospital Annual of that year. This index enabled the same classification of the many items included in the expenditure of a great institution to be adopted generally. In the same year a committee of hospital secretaries, at the instigation of the Metropolitan Hospital Sunday Fund, revised and elaborated the index of classification, and the new index was adopted by a general meeting of hospital secretaries in January 1892. The Council of the Metropolitan Hospital Sunday Fund approved it, and the Uniform System of Accounts was formulated by that body for the use of the metropolitan hospitals. In 1906 the whole of this system was inquired into on behalf of the King’s Fund by Mr John G. Griffiths, F.C.A., when a committee of hospital secretaries and representatives of the King’s Fund prepared a further revision of the system. This was completed in the course of the year and adopted by the King’s, the Hospital Sunday and the Hospital Saturday Funds. The publication of a book by Sir Henry Burdett led to the adoption of the system in several of the British Colonies, and as a result of the action taken in the British Empire the Uniform System of Accounts has recently been set up and adopted by the principal hospitals of the United States of America. The prince of Wales (George V.) testified to the value of this system in enforcing control over expenditure, and Sir Henry Burdett adapted it for the use of the authorities of all charities of every class. It is probable that no single reform has had a greater influence for good upon the administration of charitable institutions than the evolution and enforcement of the uniform system of accounts.
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 for the nursing in a hospital both efficiency and economy have to be considered. No ward in a general hospital for acute cases should contain more than 24 beds. In hospitals with clinical schools the proportion of nurses to patients should be about one nurse to every three patients, and if possible every ward should have a probationer on duty at night in addition to the night nurse. In all well-conducted hospitals it is now arranged that the nurses on night duty have a hot meal served in the general dining-room during the night, and this is only possible where a nurse and a probationer are allowed for each ward. The nurses’ quarters should be separate from the hospital proper, and connected by a conservatory or covered way. Each nurse should have a separate bedroom, measuring not less than 12 ft. long, 9 ft. broad and 10 ft. high. A bath should be allowed for every eight rooms, and the water-closets and sinks should, if possible, be in sanitary towers cut off from the main block of buildings.
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 a 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 though it may be connected 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.
General.—The kitchen, laundry, dispensary and other offices must be in a separate pavilion or pavilions, away from the wards, but within convenient access. A separate pavilion for isolation of infectious cases is desirable. This may be a wooden hut, or in some cases even a tent; either is probably preferable to a permanent block of buildings. A disinfecting chamber ought to be provided where heat can be applied to clothes and bedding, for the destruction both of vermin 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 the 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. 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 cleansing and flushing with air could be carried out, so as to prevent any continuous deposit of organic matter.
Gate House or Admission Block.—If the efficiency of a hospital and the regular and smooth working of its departments are to be secured, the proper management and control of the admission department is of the greatest importance. When one considers for a moment the number of applicants of all ages in various stages of disease, and the number of accident cases of every degree of severity who present themselves every day seeking admission, it will be evident that the most careful supervision must be exercised on the very threshold. It is essential that every precaution be taken against the admission of an unsuitable case, or the refusal, without careful examination, of any patient seeking admission. It is only necessary to instance the case of a patient with delirium tremens being admitted to a general ward at a late hour, or a case of infectious disease admitted through an overlook, or a case refused admission and expiring on the way home, in order to illustrate the danger and trouble which might arise should the supervision exercised over this department not be systematic, stringent and thorough.
To secure this proper control it is necessary that the admission department should be designed on a definite plan suitable for the purposes in view. It is not sufficient to utilize any available rooms, say, in the basement of the building, where patients may be casually interviewed by a house surgeon or physician. This department should be as carefully designed and equipped as any other department of the hospital.
Within recent years much more attention has been devoted to the details of construction than was formerly considered necessary,
