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303 HOSPITAL 303 There was thus collected in one enormous ward a larger number of patients than any hospital in England contained altogether, if we except the Royal Naval Hospital at Has- lar. In addition, however, to the above inordinate num ber, there were in the three stories placed above this great ward 1926 patients, which number might be increased to 259G, without reckoning the serving staff of the institu tion or (including the wards on the Pont Double) a total in one block of building equal to 3418, which might be increased to 4320. The law forbade the hospital authori ties to refuse admission to anyone, and in 1773 there were 5000 patients in the hospital, which occupied a space of little more than 3 English acres, giving a total gross area of only 30 square feet per head. The gross area per bed of the modern Hotel-Dieu is just ten times this amount, being 311 square feet, according to M. Toilet ; but even this is much too small, 100 square metres (1076 square feet) being the minimum proposed by Toilet, who estimates the general average per inhabitant of Paris at 430 square feet, whereas that of London is nearly double. We cannot point to any such overcrowding in England as that of the old Hotel-Dieu, but in many cases there has been enough to produce very grave results. The ill effects are seen in outbreaks of erysipelas, hospital gangrene, and sur gical fever among surgical cases, and in puerperal fever in lying-in cases, whilst in all communicable diseases the danger of spreading is greatly intensified. It was observed in 1877 in the General Lying-in Hospital, the year before it was closed for alterations, that when only two or three women were in a ward, puerperal disease rarely showed it self, but that when, in consequence of pressure of applica tions, five or six were put in, disease generally broke out. Similar results have been observed elsewhere. Another great cause of mortality has been inefficient ven tilation. If we can scatter our sick population and give them individually plenty of space in their wards, we shall have done much, but, if we do not also change the air sufficiently often we may still have evil results with all our care. Formerly no arrangements were made for ventilation in hospitals, schools, barracks, churches, or indeed in any buildings whatsoever. An immense deal remains to be de sired in this direction still, but in recent hospitals, at least, more or less efficient means have been introduced, whilst efforts have been made to improve the conditions of the old. The want of fresh air aggravates all diseases, increases the power of infection, retards the convalescence, and hastens the death of patients ; moreover, it lowers the tone of the healthy, and is the most potent of all agents in the propagation of phthisis or destructive lung disease. The labours of the Royal Commission of 1857, appointed to inquire into the health of the army, &quot;brought out in full relief the disastrous effects of want of proper ventilation in the sleeping rooms of our soldiers. It was there shown that the death-rate of Her Majesty s Foot Guards was more than 20 per 1000 per annum, 67 per cent, greater than the death-rate at the same ages in Manchester, our most unhealthy town, double the general death-rate of England, and nearly three times that of the most healthy country districts. As regards phthisis alone the death-rate was 10-8 per 1000 from 1830-1836, and .11-9 from 1837 to 1846, or an average of 11 4 per 1000 for the period, an amount more than the total mortality of the civil male population of England and Wales at the same ages. In the army generally the proportion was 7 86. Since the evil was recognized steps have been taken to remedy the conditions, particularly in the direction of giving more space in barrack-rooms, and securing a certain standard of air renewal. The results are seen in the present death-rate from phthisis, which is reduced to 2 - 5 per 1000, about one- third of the old, and not much above that of the best dis tricts in England. It is still, however, too high, as a large number of men are invalided for disease who go to swell the returns of sickness and mortality in civil life. That this is mainly owing to defective air renewal is evident from the fact that in civil life starvation, crowding, and poverty are insufficient to produce the same evil results we have seen in our army, because, in all likelihood, the very wretchedness of the dwellings of the poor has brought about an amount of involuntary air renewal, which has been their safeguard. Defective arrangements for the removal of excreta have constituted another cause of mortality. Water closets opening directly out of wards, and sinks, waste-pipes, bath- j pipes, &c., in direct communication with the sewers, have j been the means of introducing sewer poison into hospitals, and diphtheria, and aggravating every other form of malady. A want of constant attention to the details of cleanliness has been a fertile source of hospital disease. Dr B. W. Richardson has traced out in a very instructive way the re markable immunity of the Jews from epidemic and other diseases, and has shown that their religious attention to the details of the periodic cleansing enjoined by the Mosaic law appears to be the main cause of this notable circum stance. An instructive instance of the importance of this point is recorded by Mr W. Cadge, surgeon of the Nor wich Infirmary, which institution had long suffered from surgical diseases, such as erysipelas, pysemia, and the like. These, it was supposed, were mainly due to the age and structural defects of the building, so that it was determined to pull it down and reconstruct it throughout. In the meantime a change of administration took place, and a new matron was introduced, who effected an entire alteration in and unremitting attention to every detail of cleanliness, both of building, clothing, bedding, and person. The result was an immediate cessation of the dreaded complications which had so vexed the hospital, and from that time there i has been no return of them. Faulty diet had also, doubtless, its influence on mor tality, although its effects would be less easy to trace. One singular feature in the last century was the enormous j allowance of beer given to patients in hospital, from two j to three pints being common, and the allowance sometimes reaching half a gallon per diem. The absence of fresh the populace at large, probably introduced a scorbutic taint I which may have had some part in aggravating or modify ing disease. Some influence must also be allowed to the indiscrimin ate mixture of cases. The evil of this, especially in the more or less crowded state of the older hospitals, was re cognized even in the last century, and was referred to by Tenon among others Although the danger is materially lessened when ample space per bed is allowed, it is still unadvisable, not to say unfair, to place contagious cases with other patients. The argument has been advanced that by distributing infectious cases there is less danger of concentration of poison than when they are congregated together by themselves. With proper hygienic precautions, however, this concentration may be minimized, whilst the isolation of such cases gives the greatest immunity to others. This question of concentration has been pushed still further, so as to bear against the existence of all hospitals whatsoever, and so far as lying-in hospitals are concerned we have seen that the objections are well founded. But when we consider the subject in its various aspects it must be admitted that it would be difficult to do without hos pitals in some form or another. It would hardly be poe-
 * producing surgical and puerperal diseases, enteric fever,
 * the arrangements, and in particular insisted on an absolute
 * vegetables from the diet, not only of hospitals but also of