Hospital

HOSPITAL, a term now in general use for institutions in which medical treatment is given to the sick or injured. The place where a guest was received was in Lat. hospitium (Fr. hospice), but the adjective hospitalis came into use in the same sense. Hence were derived on the one hand the Fr. hospital, hopital, applied to establishments for temporary occupation by the sick for the purpose of medical treatment, and hospice to places for permanent occupation by the poor, infirm, incurable or insane; on the other, the form hotel, which became restricted (except in the case of hotel-Dieu) to private or public dwelling-houses for ordinary occupation. In English, while "hostel" retained the ear lier sense and "hotel" has become confined to that of a superior inn (q.v.), "hospital" was used both in the sense of a permanent retreat for the poor infirm or for the insane, and also for a regu lar institution for the temporary reception of sick cases; but mod ern usage has gradually restricted it mainly to the latter, other words, such as almshouse and asylum, being preferred in the former cases.

The Origin of Hospitals.--In

spite of contrary opinions the germ of the hospital system may be seen in pre-Christian times (see CHARITY). The temples of Saturn are known to have been in existence some 4,00o years before Christ ; and that these temples were medical schools in their earliest form is beyond question. But though hospitals cannot be claimed as a direct result of Christianity, no doubt it tended to instil humanitarian views, and as civilization grew men and women of many races came to realize that the treatment of disease in buildings set apart exclusively for the care of the sick was, in fact, a necessity in urban districts. As the knowledge of hygiene increased hospitals were found to be of even greater importance, if that is possible, to the healthy in crowded communities, than to the sick. So the history of the world shows, that, whereas a few of the larger towns in most countries contained hospitals of sorts, up to and including the middle ages, it was not until the commencement of the 18th century that towns of from 50,000 to ioo,000 inhabitants began to provide themselves with hospitals for the care of the sick. Thus, 23 of the principal English counties appear to have had no general hospital prior to 171o, while London itself at that date was mainly, if not entirely, dependent upon St. Bartholomew's and St. Thomas's Hospitals.

In Great Britain hospitals for the treatment of general and special diseases are generally maintained upon what is known as the voluntary system. On the European continent, hospitals as a rule are maintained by the state or municipalities, and this sys tem is so fully developed in Sweden and elsewhere that the poor law and voluntary institutions are brought into intimate associa tion, although they may be managed by separate governing bodies. The plan pursued is to demand payment from all patients who are admitted to the hospital under a scale of charges graduated accord ing to their means. In the United States most large towns have city hospitals, administered and mainly supported by the munici pality. Many such institutions have pay wards and they are rap idly being instituted in Great Britain. The great argument for their establishment is that whereas the very rich and very poor can command the best of medical treatment, the middle classes are unprovided for. As a result many persons who could afford to pay for medical advice and treatment used the hospitals without payment, and it became necessary early in the present century for the larger hospitals to appoint almoners who should question the patients or their friends as to their financial fitness to receive hospital relief without payment. While necessitous patients are treated as formerly without payment, others pay according to their means, the actual weekly sum being arranged between the almoner and the patient or his friends. Since national insurance came into force the funds for sickness benefit have accumulated till they amount to many millions of pounds. The hospitals maintain that they should receive a substantial portion of this sum in return for the services they render to the insured and the question is still under discussion between the interested parties. In 1923 the Hospital Saving Association was formed in London whereby for threepence a week contribution full medical treatment in hospital was assured. In 1926 it had attracted 370, 00o persons, had an income of over L200,000 a year, had paid to the hospitals over L I 2 7,000 for treatment given to 100,00o persons and had a surplus on the hospital budgets of £250,000.

Comparison of Voluntary and Rate-supported Systems.— As to the relative merits arid demerits of the systems of govern ment of municipal hospitals and voluntary hospitals a few words may be useful. The voluntary hospital in Great Britain has had a remarkable effect for good upon all classes in modern England. The management is frequently representative of all classes, while the Hospital Sunday and other similar collections unite all creeds in the good work of caring and providing for the sick and injured members of each community. Again, the voluntary system makes for efficiency in administration; an ill-managed voluntary hospital is sure to disappear in due course. Each voluntary hospital has to live by competition, a fact which guarantees that everything in the way of new treatment and scientific development shall find its proper place within its walls. Open as they are to the full inspec tion of everybody whose knowledge and presence can promote efficiency, they have shown, especially since the last quarter of the i 9th century, a continuous development and improvement. The voluntary hospitals are attended, however, by certain dis advantages which do not attach to municipal institutions. A municipality which undertakes the provision of hospitals for the entire community is largely able to plan out the urban area, and to provide that each hospital site selected shall not only be suitable for the purpose, but shall contribute to make the whole system of hospital provision easily accessible to all classes who may require its aid. The voluntary hospitals, on the contrary, have grown up without any comprehensive plan of the districts or any real regard to the convenience or necessities of their poorer inhabitants. The best municipal systems provide a central office where the number of vacant beds in each hospital is known, so that the average of occupied beds in all the hospitals can be well maintained from an economical point of view. This inter-communication between all rate-supported hospitals in a city, which might be secured under the voluntary system, prevents delay in the admission of urgent cases, and makes for economy by keeping the average of beds occupied in each establishment high and uniform. On the other hand, the absence of competition, and the freedom from continu ous publicity and criticism such as the voluntary hospitals enjoy, make for inefficiency and indifferent work. Of course it is essen tial to have rate-supported hospitals where cases of infectious disease and the poorest of the people can be cared for, and of late years the administration of both these types of rate-supported hospitals has greatly improved, largely owing to the importance now accorded to medical officers of health. The poor-law infirmary in large cities, so far as the buildings and equipment are concerned, very often leaves little to desire. Poor-law infirmaries lack, how ever, the stimulus and the checks and advantages which impartial criticism continuously applied brings to a great voluntary hospital.

The Evolution of the Modern Hospital.

The evolution of the modern hospital affords one of the most marvellous evi dences of the advance of scientific and humanitarian principles which the world has ever seen. 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. The hygienic condition, the meth ods of treatment and the hospital atmosphere were all so relatively unsatisfactory as to yield a mortality in serious cases of 40%. At the present time in all large cities, 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 sep arate buildings are dotted over the site, wards for male and female patients, residential blocks for medical officers, nurses, servants, administration block, store-rooms, kitchens, etc., and the whole institution may cover 20 acres or upwards. In one such institution, within an area of 20 acres, there are 6m. of drains, 29m. of water and steam pipes, 3m. of roof gutters, 42m. of electric wires.

Classification of Hospitals.

Hospitals may be described as general or special. At the larger institutions of both kinds there are more or less extensive facilities for education in medicine and in nursing. The general hospital should be fully equipped in all respects to cope with any variety of disease or injury, even though early transference of the patient to a special hospital may be found necessary in some cases. Special hospitals began to come into existence about 186o. Some of these; e.g., for cancer, diseases of women, consumption, diseases of children, etc., have fully estab lished themselves by reason of their efficiency. Others have been, and are being, grouped or merged into larger special hospitals of the same kind. At the same time the large general hospitals are extending their special departments so that the present tendency is towards centralization. At the present day the largest special hospitals are those for infectious fevers and for mental disease.

Cottage Hospitals.

A particular variety of general hospital is that introduced in England in 1859. It contains a small num ber of beds, and although originally pre-existing buildings were adapted for hospital purposes, nowadays a cottage hospital is built for the purpose and usually is efficient, though small. The local medical practitioners, as a rule, constitute the visiting staff, and often one or more consultants are appointed from the great general hospitals who operate when requested. Cottage hospitals are on a voluntary basis but they may receive financial help from the local authority or from the great hospital funds.

Convalescent Homes.

The disadvantages of treating patients in a building situated, as are most great general hospitals, in the working part of a city, together with the pressure on their accom modation, has led to the founding of ancillary convalescent homes in the country or at the seaside. Many of the chief hospitals in England have such convalescent homes. An extension of the idea consists in the provision of country hospitals for open-air and sun light treatment, especially for chronic diseases; e.g., surgical tu berculosis. Some eminent authorities favour the removal of hos pitals to the country altogether, small first-aid centres alone being kept up in the working city and an efficient ambulance system be ing set up between them and the hospitals. It is difficult to see how such a system could work satisfactorily in a city the size of Lon don or New York, but for far smaller communities it has much to recommend it.

The Problem of Hospital Administration.

A study of the hospital problem in various countries, and especially in different portions of the English-speaking world, indicates that, apart from local differences, the features presented are everywhere practically identical. A number of hospitals under independent administra tion, dependent in whole or in part on voluntary contributions, administered under different regulations originally representing the idiosyncracies of individual managers for the time being, with out any standard of efficiency or any system of co-operation, must mean in practice overlapping and wastage on economical, sci entific and other grounds. These evils are present almost every where, despite many and varied attempts to grapple with and remove them. Amongst these attempts are the assembling of hos pital conferences, the establishment of special funds and commit tees and the holding of enquiries of various kinds in London and other British cities and also in the United States. One of the most valuable contributions towards their solution is insistence by the great distributing funds that institutions wishful to receive grants in aid shall keep their accounts on a uniform specified plan. By this means it has become possible for the participating institu tions and the central distributing funds to compare individual items of expenditure, and thus indicate directions in which economies may be effected as well as to compare sources of revenue and indicate directions in which efforts should be made towards obtaining the large sums of money necessary yearly for the efficient upkeep of the hospitals in accordance with advances gained in medical, constructional and administrative knowledge.

At the same time there is produced a healthy rivalry between all the bodies concerned which, upon the whole, reacts favourably on the treatment of patients within the hospital walls.

(W. S. L.-B.) Twentieth Century Development.—At the beginning of the century two special points are to be noted : I. The development of operating and clinical methods led to an increasing specialization in the departments of general medicine and surgery in hospitals.

2. From the architectural point of view, simplicity and com fort were being increasingly sought and buildings and hospital premises were being to an increasing extent adapted to the neces sities of sanitation and hygiene.

General Features.—Attempts to create large hospitals out side urban centres and in favourable climatic conditions have been to a large extent successful. In the case of old hospitals, where it was difficult to make rapid changes, the various services have been installed in special buildings and annexes, divided one from an other, each dealing with a special subject ; e.g., surgery, clinical work, ophthalmic work, otolaryngology, children's diseases, gynae cology, epidemics, etc. Whereas in Anglo-Saxon hospitals the principle of placing hospitals under independent management maintained by voluntary aid has been adhered to, in continental countries there has been an increasing tendency to centralize hos pitals by placing them under municipal, local or national authority.

Statistics.—Hospitals were more frequented in than in previous years. This fact must be attributed not to the increase in the tendency to disease, but to the addition of a large number of buildings and wards which allowed of a larger number of patients being received. The dissemination the principles of hygiene has familiarized the public with medical methods and has caused a marked increase in the number of patients under treatment. Various statistics show the movements of patients in hospitals during the years preceding the war. In 1913, 106 hos pitals in London (general hospitals, children's clinics, gynaeco logical hospitals, anti-tubercular hospitals, etc.), with 9,171 beds, dealt with 134,749 patients and were attended by persons.

In 1912, the Paris Department of Public Relief (l'administra tion generale de L'assistance publique) admitted to its general hospitals (Andral, Beaujon, Boucicaut, Broussais, Charite, Cochin, Hotel-Dieu, Laennec, Lariboisiere, Necker, Pitie, St. Antoine, St. Louis and Tenon) 147,828 patients, and 46,601 patients to the special hospitals (St. Louis, Maternity, Broca, etc.) . Germany, in 1912, had 9,054 hospitals with 535,579 beds. This figure in cludes general hospitals, military and naval hospitals, lunatic asylums, sanatoria, maternity homes, special clinics, children's hospitals, homes for the blind, etc. In 1912, the medical institutes of Vienna dealt in all with 82,939 patients. In the United States there was a noticeable increase in the number of hospitals and clinics, and there was a considerable development of the speciali zation of medical and surgical departments.

In

1924, the number of hospitals in London was 118, the number of beds, 13,460, the number of patients treated 177,300 and the number of consultations 6,67 7,000 (as against 5,020,000 in 1913) . Among the principal hospitals included in these general figures, St. Thomas's Hospital alone received 10,139 in-patients and gave 488,600 consultations ; St. Bartholomew's Hospital received 8,648 in-patients and had 344,226 out-patients, the London Hos pital 17,331 in-patients and 553,965 out-patients, Guy's Hospital 9,495 in-patients and 487,452 out-patients. In Paris, the number of sick persons received was 238,912 in 1923, of whom were in the general hospitals, 43,403 in the special hospitals, 29, 329 in the children's hospitals, 2,071 in the mental hospitals and 10,315 in various homes and asylums.

War Conditions.—The World War of 1914 compelled hos pitals to adapt themselves rapidly to new requirements. Exist ing hospitals were transformed, large numbers of extra establish ments were improvised and various other special measures were adopted : (a) Permanent military hospitals, already existing in time of peace, were specially adapted for the reception of sick and wounded soldiers; (b) Civil hospitals were placed, together with their staff, under the direction of the military authorities; (c) Hospitals were installed in public or private buildings, such as hotels, schools, private houses, etc., to receive and deal with the flow of wounded from the front.

(d) Hospitals in the zone of military operations were carried on in permanent premises or under canvas, even underground, nursing posts and relief posts dealing with first aid to the wounded before their evacuation to the rear; (e) As described in the article MEDICAL SERVICE (ARMY), am bulances of every type were employed. Trains, barges, liners and even aeroplanes, specially built or converted and equipped, were used for the transport of sick and wounded to base and home hospitals.

(f) Special hospitals for orthopaedic, tuberculous, neurasthenic, paralysed and gassed cases were organized. Electro-therapeutical, hydro-therapeutic, helio-therapeutic, massage and special sec tions were also developed.

(g) Convalescent homes were set up and many private man sions were used for this purpose. Convalescent camps were formed near the base hospitals overseas.

(h) Temporary hospitals were erected to receive influenza pa tients, and malaria camps were organized.

Quarantine

Stations.—Quarantine stations, which before the war were limited to maritime ports, were, after the war, set up on the borders of Poland, Czechoslovakia, Rumania, Hungary and the Baltic States, for the supervision of travellers arriving from countries contaminated by exanthematic typhus and relaps ing fever. Three model stations, set up by the International Red Cross Committee at Narwa in Estonia, Riga in Latvia and Inid in Finland, dealt with the reception, supervision and disinfection of thousands of prisoners arriving from Russia on the convoys of repatriated prisoners between 1919-22.

Special Hospitals.

The Italian Red Cross has been most active in districts affected by malaria, and with this end in view has organized the anti-malaria sanatorium of Massalubrense, to gether with a number of motor ambulances. In Georgia, the tropical institute of Tiflis is engaged in centralizing the work of the various clinics and hospital stations. In 1913 12,500 malaria patients were treated in the hospitals of Tiflis. In the case of Oriental countries may be mentioned the leper hospitals (the Indies and Siam), hospitals for the treatment of snake bites (Siamese Red Cross at Bangkok), and the anti-epidemic and summer hospitals of the Chinese Red Cross at Shanghai. Hospi tals have been supplemented by dispensaries, preventive homes, consulting offices, convalescent homes and mountain sanatoria and seaside hospitals. Venereal disease and dermatological hospitals have considerably developed. Cancer hospitals have improved, especially as regards radio-therapeutic services. (E. MY.; X.) H. C. Burdett, Hospitals and Asylums of the World, 4 vols., with folio plans (1892-93) ; S. V. Pearson, State Pro vision of Sanatoriums (1913) ; E. V. Mitchell, Hospitals and the Law (1915) ; D. J. Macintosh, Construction, Equipment and Manage ment of a General Hospital (1916) ; J. A. Hornsby and R. E. Schmidt, The Modern Hospital (2nd. edn., 1918) ; E. F. Stevens, The American Hospital of the Twentieth Century (1918) ; L. C. Catlin, The Hospital as a Social Agent in the Community (1918) ; H. P. Adams, Cottage Hospitals (1921) ; H. F. Parsons, Isolation Hospitals (new edn., 1922) ; F. E. Chapman, Hospital Organization and Operation (1924) ; J. E. Stone, Hospital Accounts and Financial Control (1924) , and Hospital Organization and Management (1927) ; J. J. Weber, First Steps in Organizing a Hospital (1924) ; R. H. Steen, Modern Mental Hospitals (1927) ; H. J. McMurrich, Treatment of the Sick Poor (1929) ; R. W. Chambers, Hospitals and the State (1028).

During the loth century, and more particularly in the period from 1914 to 1925, the development of hospitals in the United States has been unprecedented. This development may be con sidered under the heads of (a) the present trend of hospitals as a social factor, (b) the present day construction, (c) specific examples and (d) statistics of 1925 and the increase during the period in question.

Hospitals as a Social Factor.—While there is a continued de velopment and refinement of the care of the sick in the hos pital to-day, the conception of the function of this institution has materially broadened, with a rapidly increasing tendency to regard it as a community health centre from which to radiate all health activities, particular emphasis being placed upon the development of out-patient departments (this as a means of teaching and prac tising preventive medicine and thereby obviating the necessity of the hospital bed), district nursing and social service. In the larger cities medical centres are being developed, in which case the foregoing community functions are associated with the instruc tion of student bodies in various branches, including medicine, nursing, public-health work, social service, and, in many instances, dentistry. The tendency to develop isolated speciality hospitals is being replaced by provisions for the specialities as departments of the general hospital or by the affiliation of already existing speciality hospitals with existing general hospitals. The different types of schools teaching health work, with the various hospitals, form these medical centre groups, in which are included convales cent homes as an integral or co-ordinated part.

Present-day Construction.

While in the earlier period hos pital development in the United States was largely patterned after the developments in Europe, the present trend of large insti tutions is toward the "skyscraper hospital"---as St. Luke's Hos pital Annex, in Chicago, with 19 storeys ; the Jefferson hospital in Philadelphia, with 17 storeys ; and the new Presbyterian hospital of the medical centre (opened March 16, 1928) of New York city, with 22 storeys. This tendency is extending even into the country districts where the value of land is not a factor, for example, the University hospital at Ann Arbor, Mich., with its nine storeys, and the Charlotte Hungerford hospital at Torrington, Conn., with its eight storeys, the former being a teaching hospital and the latter a community hospital serving 35,000 people.

Economy and effectiveness of administration is claimed by the promoters of the multi-storey hospital movement. This type of construction and administration, which is distinctly American, is not being followed in the United States to the entire exclusion of the methods commonly pursued in Europe. The hospital move ment in the large American cities is typified in the medical centre in the City of New York, in which the Columbia university Col lege of Physicians and Surgeons, Columbia University School of Dental and Oral Surgery, Presbyterian hospital, Sloane hospital for women, Squier Urological Clinic, Vanderbilt Clinic, The Babies' hospital, Neurological institute, State Psychiatric insti tute and hospital, Presbyterian Hospital school of nursing and the Harkness Pavilion for Private Patients have reconstructed their institutions on a single plot of ground, having jointly under taken all the branches of medical teaching, research and care of the sick, their simultaneous constructional programmes involv ing $25,000,000.

Increase in Recent Years.

At the close of the year 1927 a complete census of all the hospital facilities in the United States, however owned and controlled and for whatever type of patient, showed that there were 6,807 hospitals. Of the total num ber of institutions of this character in the world, approximately 5o% are in the United States. These hospitals provided a total of 895,279 beds, of which 41,961 were bassinets. This represents an increase of 59,00o beds and bassinets in two years. Of the total number specified 373,364 beds were devoted to the care of mental and nervous diseases,—an increase of 32,000 since 1925. This would seem to indicate that more than half of the increase in hospital beds in the past two years has been for mental cases. The total figures given for 1927 should be compared with those of 1914 which were : 5,037 hospitals with 532,481 beds.

There have been omitted from the foregoing figures 462 institu tions with a bed capacity of which, for one reason or an other, have not come in the class of so-called "registered hos pitals." While the development of the large institutions has made un usual progress, the growth of the small institutions in the smaller communities seems to have a special significance and to be in dicative of the popularisation of the hospital in the public mind. In 1920 44% of the 3,027 counties in the United States had com munity hospitals; the record for 1925 shows an increase to Nearly 52% of all the hospitals in the United States are of 4o beds or less. The close of 1927 finds recorded 408 new buildings planned, with $109,179,000 involved in a year's construction; the total value of hospital properties being variously estimated between $4,000,000,000 and $5,000,000,000.

In the year 1926 the 55 privately owned hospitals of all types in New York city receiving partial support from the United Hos pital Fund reported 11,978 hospital beds of which 78% were used, 232,157 cases, 3,446,176 days of hospital care, the average number of days' stay being 14.1; treated 710,297 cases in out patient departments and had a total of 2,616,226 out-patient de partment visits,—this being independent of the State and munic ipal hospitals in New York city. All types of hospitals in New York city, excepting those for the insane, proprietary and United States Government hospitals, provided 32,097 beds of which were used, treated 519,222 patients and gave 8,881,763 days of hospital care, the average number of days' stay being 17; treated 1,151,871 cases in out-patient departments and had a total of 3,960,204 out-patient department visits.

BIBLIOGRAPHY.-Keports by counsel on medical education anaBibliography.-Keports by counsel on medical education ana hospitals of American Medical Association ; Corwin, The Hospital Situation in Greater New York; Private archives and surveys of Joint Administrative Board, New York ; Surveys of Architectural Forum, New York; Reports of United Hospital Fund. (C. C. B.)