In the first place, it has been found, that the crowding of many patients under one roof had the effect of exaspe rating several diseases, and of generating others, such as the hospital fever, and the hospital gangrene, which de rived their names from these charitable institutions. It was found that the mortality thus occasioned was beyond all comparison greater than under all the disadvantages of domestic treatment. The Hotel Dieu of Paris, previously to its reformation, was the grave of the sick poor of that metropolis. Hence a general outcry was raised against in firmaries. It seemed dangerous to go neat; them, and the conclusion at one time appeared plausible, that they ought to be abolished. This, however, has not been found ne cessary. The influence of contaminations of the atmo sphere has been more accurately ascertained. It is now found that no disadvantage arises from a plurality of pa tients being within one building. All the reformation ne cessary was, to avoid excessive crowding, and to resign the vain boast of the great numbers of patients contained in these places. The beds of infirmaries are now placed at proper distances. The wards are regularly ventilated. Frequent whitewashing of the walls, and cleansing of the floors, are 'practised ; and, in consequence of these obser vances, all the former evils have disappeared. It has been found that even contagious fevers may be safely treated under the same roof with promiscuous diseases, provided they are placed in separate wards, to the ventilation of which due care is devoted. This object, however, has more recently been prosecuted by the erection of sepa rate establishments, which we shall consider in the se quel.
Serious surgical cases, such as injuries of the cranium, compound fractures of the limbs, and gun-shot wounds, when a plurality of them are brought together, have a ten dency to generate an obstinacy in the healing process, and require still more care than in guarding against febrile contagion. This has often been experienced in military hospitals, in the spread of the hospital sore. When it oc curs, the dispersion of the patients is the most effectual method of stopping it.
Infirmaries are so constructed as to admit of thorough ventilation ; the windows are made to open both from above and from below ; in the former way, that fresh air may be admitted without a hurtful cold draught, and, in the latter, that the heavy polluted air, which is apt to rest in the in ferior part of the wards, may be more effectually dislodged, by seasonably opening the inferior sash. The practice of collecting urine for the manufacturers, to which the ser vants of infirmaries were formerly tempted by money, is now discontinued. The bedsteads are of iron. a material :o which contagious and other animal effluvia are less apt to adhere than to wood. The bed-clothes are more fre quently washed ; and, when it is convenient, they are re gularly aired. For this last purpose, there is probably room for further improvement. We have sometimes con templated a plan of having the beds of those patients who sit up through the day so contrived. that, with little labour, they might be elevated by some simple machinery, by the windows, to the roof of the building, and brought in again at pleasure. Flock and feather beds are not used. The preference is given to straw, chaff, and other materials, which, from their low value, admit of frequent renewal. In cases in which articles are used which cannot be fre quently renewed, they are exposed not only to frequent ventilation, but to purification by water.
There are other circumstances apt to occur in infirma ries, unfavourable to the recovery of the patients. They may be exposed to the sight of neighbouring patients in the agonies of death. This is remedied by having curtains or screens for the different beds, an arrangement which gives them the advantage of a more comfortable appearance, and more individual privacy. They are not employed in every
infirmary, partly on account of the expence, and partly from the obstruction which they give to ventilation ; but they ought always to be at hand, and rods to which they can be fixed should accompany each bed. The sight of epilep tics, the unpleasant noise which they make in their fits, and the shocking spectacle, and stunning noise, of patients under insanity, are obviated by providing separate wards to which these may be sent, and also such patients, occasion ally, as might annoy their neighbours by the piercing cries which under pain or delirium they emit. In some infir maries, for example that of Glasgow, every ward has three single bedded rooms at one end, a method admirably adapted to these purposes ; as a patient may be instantly moved to one of them, without formality or trouble.
For the convenience of the surgeon, it has in some places been common to perform surgical operations at the bed-side, in sight of the other patients of the ward. This, which could not fail often to shock their feelings, is avoided by the easy regulation of having a separate theatre allotted for all surgical operations. Accordingly no such practice exists in the British hospitals.
Some. disadvantages have arisen from negligence on the part of the different servants and officers connected with these institutions. To obviate these is a difficult task,and requires the utmost vigilance. It is equally requisite to see that no abuses are committed by any of the patients themselves, to the detriment of others. A system of in spection is for these purposes evidently necessary. Month ly or weekly inspections are therefore practised. The nurses are examined apart from the patients about the con duct of the latter, and they, in their turn, about their satis faction with the nurses. The medical gentlemen who re side in the house are under the direction of the attending physicians and surgeons ; and these, notwithstanding the of their station, and those principles of ho nour, by which they are supposed to be actuated, are not placed above inspection and admonition. Though a rude and frequent interference on the part of persons who are not adequate judges of medical duties is avoided, the in quiries of the house visitors have it for a part of their ob ject. to ascertain how the patients are satisfied with them. Opportunities are thus afforded for friendly and instruc tive explanations. The medical gentlemen derive grati fication from the interest which others take in their du ties ; and where all wish to do their duty, and possess that degree of patience which is necessary to every public character, a good understanding is cultivated. On occa sions of a different kind, flagrant errors and abuses have been fully exposed, and the means have thus been afforded of putting an end to them Different infirmaries enjoy different advantages for this species of vigilance, which often depend on the manner in which they are constituted. Where the number of managers is small, they have the best chance of maintaining harmony, and of understand ing their duty But they are apt to become remiss ; and, from a false delicacy, to overlook the omissions ofone ano ther, and of the principal officers. The duty of visiting the house is also apt to become too burdensome, when the turn to each comes frequently round. Where the num ber of managers is large, amounting, as in some instances, to hundreds, many of them arc unacquainted with the na ture of the institution, and either go through the lorms of duty in their turn without intelligence or care, or mar the business of the charity, by encouraging frequent and vexa tious complaints. 1t is pleasing. however, to find, that these ends arc in general so effectually and agreeably ob tained.