Notes on Hospitals

Preface

It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle, because the actual mortality in hospitals, especially in those of large crowded cities, is very much higher than any calculation founded on the mortality of the same class of diseases among patients treated out of hospital would lead us to expect. The knowledge of this fact first induced me to examine into the influence exercised by hospital construction on the duration and death-rate of cases received into the wards ; and it led me to lay before the Social Science Association a paper reprinted with the present title. Since the publication of the first edition of that paper, great advances have been made in the adoption of sound principles of hospital construction; and there are already a number of examples of new hospitals realizing all, or nearly all, the conditions required for the successful treat¬ ment of the sick and maimed poor. Besides this, much additional experience has been obtained in many important i v PREFACE.

points, especially in the details of hospital buildings and fittings.

In order to spread a knowledge of the progress already made, as well as of those principles which may now be consi¬ dered as established, I have been asked to prepare the present edition. In doing this, it has been necessary to re¬ write nearly the whole of it, and to make so many additions to the matter that it is in reality a new book.

F. N.

Index To Subjects

PAGE

What it is proposed in this book to say . ..i

I. SANITARY CONDITION OF HOSPITALS ...... i

Hospital influence on cases in hospital.2

High death rate in hospitals in large towns.3, 4

Death rate not the only statistics wanted.5

Hospital-diseases and daily change in cases better tests . . . 6 , 7

Explain what “ infection” is, and do away with the idea “ con¬ tagion” .8—10

Four Defects to which Hospital-diseases are due :

1. Agglomeration of sick under one roof.11, 12

2. Deficiency of space per bed.13, 14

3. Deficiency of fresh air. 13 , 16

Its greater necessity for sick.. . . . 1 7

4. Deficiency of light. . 18, 19

Note on the Mortality of Hospital Nurses .20, 21

Note on the History of the Doctrine of Contagion .22

Note on the Crowding of many Patients into each led at the Hotel

Dieu at Paris in past times .23, 24

II. DEFECTS IN EXISTING HOSPITAL PLANS AND

CONSTRUCTION.25

1. Selection of Bad Sites and Bad Local Climates for Hospitals. 26 , 27

Comparison of London and Paris.28—30

Four elements for a good hospital position ..... 29

Don’t bring sick out of fresh air into foul, as in a town hospital.3 1

VI INDEX TO SUBJECTS,

PAGE

2. Construction of Hospitals so as to prevent Fresh

External Air. 3 2

By closed courts. 33 > 34

3. Defects in Ward Construction injurious to

Ventilation. 35

Defective height of wards.35

Too great width of wards between opposite windows . . 36

Arranging the beds along the dead walls.37, 38

Having more than two rows of beds between the windows 39 Having windows only on one side, and a closed corridor

on the other.40

Having small wards through a large one.41

4. Defective means of Ventilation and Warming . . 42

5. Defects in Drainage, Water-closets, &c.43

6. Absorbent Materials for Floors, Walls, &c. . . 44

7. Defective Hospital Kitchens.45

Importance of Cooking.46

8. Defective Hospital Laundries.47

How washerwomen “ catch” disease.48

9. Defective Accommodation for Nursing and Discipline 49

J. Economy as to attendance. 5°

2. Ease of supervision.50

3, 4. Distribution of sick and position of nurses' rooms . 51

10. Defective Ward Furniture.52

Note on the relation which the size and arrangement of wards hears to the question of nursing and supervising .... 53—35

III. PRINCIPLES OF HOSPITAL CONSTRUCTION ... 56

What a pavilion is ... ’.56

What should be the distance between the Pavilions . . . ; 37

1. How MANY FLOORS TO THE PAVILION.38

2 . How MANY WARDS TO THE FLOOR.39, 60

3. HOW MANY BEDS TO THE WARD . . '.. < 51 , 62

How many beds to the Pavilion. 63

How many Pavilions to the Hospital.64

4. How MUCH SPACE TO THE BED.< 5 ^ <53

3. How many Beds to a Window.<57

6. What are healthy Walls and Ceilings .... 68

7. What are healthy Floors. y Q

8. Where and what should be the Sister’s Room and

Scullery . .

INDEX TO SUBJECTS.

9. Where and what should be the Bath-room and

Lavatory . . ■. 72

10. Whe-re and what should be the Water-closets and

11. How to Ventilate Wards.. . 75—78

Never by artificial means.76

Always by admitting fresh air from without.77

12. How the Ward should be furnished.79

13. What the Bedding should be ........ 80

Always hair.81

14. What should be the Water Supply.82

Soft water essential. 83

15. How the Hospital should be drained and sewered 83

16. Where and what should be-the Kitchen . . . . 84

As to fuel . 83

17. How to dispose of the foul Linen ...... 86

French and English methods . 87

Clean Linen Room.88

18. Where, and how lighted, the Operating Room . 88

IV. IMPROVED HOSPITAL PLANS . .... . . . . 90

Separate the sick from the administration.91

Simplicity of plan essential.92

1. for Small Hospitals.93—96

2. for Large Hospitals.. 97—106

Lariboisiere Hospital, Paris ..100

Vincennes Military Hospital. ... 101

Herbert Hospital, Woolwich.. . . .102

Malta Military Hospital. 104

Malta Workhouse and Hospital for Incurables . . . .103

V. CONVALESCENT HOSPITALS.107

Must be as like a home and as unlike a Hospital as possible. . 108

Vincennes Convalescent Institution for men.no

A string of Cottages the best.112

On Day-rooms and Convalescent Wards.113

Note on the Vincennes Institution .116

VI. CHILDREN’S HOSPITALS.124

Will you have one at all ? ..124

Essentials of a Child’s Hospital.123 vm

INDEX TO SUBJECTS.

Bathing .. 126

Playing. ..128

High Death-rate.. . 129

Lisbon Hospital.129

VII. INDIAN MILITARY HOSPITALS.133

No water supply..134

Convalescents in bed.135

No drainage or sewerage.136

Bedding of hemp or straw.137

Construction.138

Immense wards.139

Darkness.140

Overcrowding. 141

Offensive ward offices.142

Bad cooking.143

Bad attendance.144

Native hospitals . 145

Provide nothing but medicine ... 147

Standard Plan.148

16 GENERAL PRINCIPLES OF CONSTRUCTION FOR HOSPITALS

in Indian climates . -.130—155

VIII. HOSPITALS FOR SOLDIERS’ WIVES.156

Example of a nest of rooms within rooms.137

IX. HOSPITAL STATISTICS.139

A. General Statistics of Hospitals.160

Seven elements required . j<5i

Five results wanted.K5 2

Additions recommended by Statistical Congress . . 164—166

Hospital admission and discharge book.jgy

Annual tabular abstracts, 1. In-patients.jgg

3. Cost of each patient . . .169

4. Sanitary statistics of wards. . 170

INDEX TO SUBJECTS. ix

PAGB

B. Proposal for improved Statistics of Surgical

Operations ...171

Two forms required . . . ..172

Table I. for surgical operations performed.172

Table II. for fatal complications and causes of death . .173

482 fatal operations thus compared. .174

Urgent need of some uniform system of publishing the sta¬ tistical records of hospitals .175—17 6

Nomenclature of operations intended to be used in filling

up Tables I. and II. . . ..177

Nomenclature of complications occurring after operations .179

Appendix

On different systems of Hospital nursing .... 181

Five systems ..181

Which is the best.182

Necessity of public opinion; no authority, whether reli¬ gious or secular, should always have its Own way . . .184

Religious orders must always be kept up to the progress of the time by cordial and constant co-operation with

secular authorities.185

Secular authorities must always be kept up to a high standard by cordial and constant co-operation with reli¬ gious orders.186

Summary of results of the five systems.187

LIST OF PLANS.

No. i. HOTEL DIEU... to face f age 12

2. NETLEY HOSPITAL.. „ „ 37

3. BUCKS INFIRMARY „ » 93

4. LARIBOISIERE HOSPITAL. » » 100

- 5. VINCENNES MILITARY.. „ „ 101

6. HERBERT HOSPITAL, WOOLWICH. „ „ 102

7. VALETTA MILITARY .. » » io 4

8. MALTA POORHOUSE.• • » » IO +

9. MALTA INCURABLES. » » io 5

10. CONVALESCENT “HOME” . » » 112

11. LISBON, CHILDREN’S. „ „ 130

THE PLANS OF LONDON AND PARIS TO BE INSERTED AT THE END.

HOSPITAL GENERAL STATISTICAL FORM ...... „ „ 160

TABLE I. SURGICAL OPERATIONS PERFORMED ... „ „ i? 2

TABLE II. MORTALITY FROM SURGICAL OPERATIONS. „ „ 173

NOTES ON HOSPITALS.

TT is proposed in the following pages to give—ist, a general 1 account of the sanitary condition of existing hospitals; 2nd, a statement of those structural defects in hospitals which have influenced the progress of medical and surgical cases while under treatment in them; 3rd, the principles of construction which ought to be kept in view in building new hospitals ; 4th, improved plans for hospitals and convalescentinstitutions ;—and lastly, certain proposals adopted by the International Statistical Congress for improving the method of tabulating hospital statistics, together with a proposal for an uniform system of registering statistics of surgical opera¬ tions, their complications and results.

I. SANITARY CONDITION OF HOSPITALS.

No one, I think, who brings ordinary powers of obser¬ vation to bear on the sick and maimed, can fail to observe a remarkable difference in the aspect of cases, in their duration and in their termination in different hospitals. To the super¬ ficial observer there are two things only apparent—the disease and the remedial treatment, medical or surgical. It requires a considerable amount of experience, in hospitals of various constructions and varied administrations, to go beyond this, and to be able to perceive that conditions arising out of these elements have a very powerful effect indeed upon the ultimate issue of cases which pass through the wards.

NOTES ON HOSPITALS.

It is sometimes asserted that there is no such striking difference in the mortality of different hospitals as one would be led to infer from their great apparent difference in sanitary condition. There is, undoubtedly, some difficulty in arriving at correct statistical comparison to exhibit this. For, in the first place, different hospitals receive very different propor¬ tions of the same class of diseases. The ages in one hospital may differ considerably from the ages in another. And the state of the cases on admission may differ very much in each hospital. These elements affect considerably the results of treatment, altogether apart from the sanitary state of hos¬ pitals. But the fact has sometimes been made use of in a way no one could have anticipated. A high and in¬ creasing death rate has been actually put forward, not as the result of these causes, but as the result of increasing celebrity; which can have no other practical meaning than this :—that a greater number of people go there to die next year, because so many have died there this year; a principle equally applicable in private practice, and according to which, the physician or surgeon who loses the largest percentage of cases is the man most worthy of confidence.

In the next place, accurate hospital statistics are much more rare than is generally imagined, and at the best they only give the mortality which has taken place in the hospitals, and take no cognizance of those cases which are discharged in a hopeless con¬ dition, to die immediately afterwards, a practice which is followed to a much greater extent by some hospitals than by others.

We have known incurable cases discharged from one hospital, to which the deaths ought to have been accounted and received into another hospital, to die there in a day or two after admission, thereby lowering the mortality rate of the first at the expense of the second.

SANITARY CONDITION OF HOSPITALS.

Making every allowance for difficulties attending an inquiry into the comparative mortality of hospitals, there are nevertheless certain very startling facts, which ought to arrest the attention of every one interested in the welfare of sick or maimed. The Registrar-General, in his last Annual Report, has given a set of Occasional Tables on the Mortality of Public Institutions in England, which contain data of more than usual interest and importance on this subject. Returns were obtained from 106 hospitals, giving the number of inmates in each hospital on April 8th, 1861. This number is taken as an approximation to the average of inmates at each establishment. The number of deaths registered in each hospital during the year 1861 is also given—so that, assum¬ ing the approximate accuracy of the data, the mortality per cent, in each hospital can be ascertained for the year. The following classified abstract contains the results of the inquiry, and they are certainly striking enough

Mortality per Cent, in the principal Hospitals of England. i86j.

—

Number of Special Inmates on the 8th April, 1861.

Number of Inmates

Hospital.

Number of Deaths registered in the Year 1861.

Mortality

Inmates.

In 106 Principal Hospitals of England

12709

56-87

24 London Hospitals

90-84

12 Hospitals in Large Towns

83-16

25 County and Important Provincial

Hospitals

30 Other Hospitals

40-23

13 Naval and Military Hospitals ...

15-67

1 Royal Sea Bathing Infirmary

(Margate)

12-78

1 Dane Hill Metropolitan Infirmary

(Margate)

r 4

12-96

NOTES ON HOSPITALS.

It will be seen that the hospitals are grouped according to locality. Now let us compare three of these groups with each other. We have 24'London hospitals, affording a mor¬ tality of no less than 90*84 per cent., very nearly every bed yielding a death in the course of the year. Next, we have 12 hospitals in large provincial towns, Bristol, Birmingham, Liverpool, Manchester, &c., yielding a death rate of 83*16 per cent. And there are 23 county hospitals in country towns, the mortality in which is no more than 39*41 per cent. Here we have at once a hospital problem demanding solution. However the great differences in the death rates may be ex¬ plained, it cannot be denied that the most unhealthy hospitals are those situated within the vast circuit of the metropolis; that the next lower death rate takes place in hospitals in densely populated large manufacturing and commercial towns, and that by far the most healthy hospitals are those of the smaller country towns.

These results are quite reliable, and are preferable to those derived from individual hospitals. Otherwise, it might be stated that the death rate of certain hospitals situated in large towns is so enormous that every bed is cleared out in the year, and in some of them once in about 9 months.

Facts such as these (and it is not the first time that they have been placed before the public) have sometimes raised grave doubts as to the advantages to be derived from hos¬ pitals at all, and have led many an one to think that in all probability a poor sufferer would have a much better chance of recovery if treated at home.

The sanitary state of any hospital ought not, however, to be inferred solely from the greater or less mortality. If the function of a hospital were to kill the sick, statistical com¬ parisons of this nature would be admissible. As, however.

SANITARY CONDITION OF HOSPITALS.

its proper function is to restore the sick to health as speedily as possible, the elements which really give information as to whether this is done or not, are those which show the propor¬ tion of sick restored to health, and the average time which has been required for this object; a hospital which restored all its sick to health after an average of six months’ treatment, could not be considered as by any means so healthy as a hos¬ pital which returned all its sick recovered in as many weeks. The proportion of recoveries, the proportion of deaths, and the average time in hospital, must all be taken into account in discussions of this nature, as well as the character of the cases and the proportion of different ages among the sick ; and this brings me to the great importance of correct hospital statistics as an essential element in hospital administration.

Hospital mortality statistics have hitherto given little in¬ formation on the efficiency of the hospital, i. <?., as to the extent to which it fulfils the purpose it was established for, because there are elements in existence of which such statistics have hitherto taken no cognizance. In one set of hospitals, in the table, I find the mortality from 124- to 154- per cent, upon the cases treated, while in other hospitals the deaths reach from 83 to 904- per cent. To judge by the mortality only in these cases would be most fallacious. Because in the first class of hospitals ailments not of a dangerous nature constitute a title to hospital admission, while, in the latter class of hos¬ pitals, dangerous and special diseases, at all times accompanied by a high rate of mortality, are largely admitted. Hence the duration of the cases admitted, and the general course and aspect of disease, afford important criteria whereby to judge of the healthiness or unhealthiness of any hospital, in addition to that afforded by the mortality statistics.

Perhaps the most delicate test of anitary condition in

Notes on hospitals.

hospitals is afforded by the progress and termination of surgical cases after operation, together with the complications which they present. The statistics of medical cases, although affording important data for our purpose, are of themselves imperfect indices of the healthiness of wards, but it is other¬ wise with operation cases. In these the constitution gives immediate evidence of suffering from the neglect of hygiene, and many a life is sacrificed from not recognising this fact. In another section I have dealt with this important subject, and have given the method of keeping the Statistics of Hos¬ pitals proposed by me, and adopted by the International Statistical Congress; and also a proposal for registering sur¬ gical operations and their results.

Careful observers are now generally convinced that the origin and spread of fever in a hospital, or the appearance and spread of hospital gangrene, erysipelas, and pyaemia generally, are much better tests of the defective sanitary state of a hospital than its mortality returns.* But I would go further, and state that to the experienced eye of a careful observing nurse, the daily, I had almost said hourly, changes which take place in patients, and which changes rarely come under the cognizance of the periodical medical visitor, afford a still more

* The following suggestive passages from Mr. Paget’s address, delivered before the British Medical Association, 1862, have an important bearing on this subject:

u In every case of erysipelas, pyaemia, or the like, we ought to work till we can discover its probable origin; we should have the strongest feeling that these dis¬ eases are not spontaneous nor inevitable. In every case, the hospital, or the house or our own practice, should be brought to trial—to private trial, if you will, yet a just and true trial—a trial before our own conscience; and if the hospital the house, or the practice be found guilty, let it be condemned and amended.” *

“ Of all the remedies I have used or seen in use, I can find but one thing that I can call remedial for the whole disease, pyaemia: and that is a profuse supply of fresh air. I-> the three most remarkable recoveries I have seen, the patients might be said to have lain day and night in the wind—wind blowing all about their rooms.”

SANITARY CONDITION OF HOSPITALS.

important class of data, from which to judge of the general adaptation of a hospital for the reception and treatment of sick. One insensibly allies together restlessness, languor, feverishness, and general malaise , with closeness of wards, defective ventilation, defective structure, bad architectural and administrative arrangements, until it is impossible to resist the conviction that the sick are suffering from something quite other than the disease inscribed on their bed-ticket— and the inquiry insensibly arises in the mind, what can be the cause ? To this query many years’ experience of hospitals in various countries and climates enables me to answer explicitly as the result of my own observation, that, even admitting to the full extent the great value of the hospital improvements of recent years, a vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable.

What, then, are those defects to which such results are to be attributed ?

I should state at once that to original defects in the sites and plans of hospitals, and to deficient ventilation and over¬ crowding accompanying such defects, is to be attributed a large proportion of the evil I have mentioned.

The facts flow almost of necessity from ascertained sani¬ tary experience. But it is not often, excepting perhaps in the case of intelligent house-surgeons, that the whole process whereby the sick, who ought to have had rapid recoveries, are retained week after week, or perhaps month after month, in hospital, is continuously observed. I have known a case of slight fever received into hospital, the fever pass off in less than a week, and yet the patient, from the foul state of the wards, not restored to health at the end of eight weeks.

I appeal to all careful hospital officers whether each has not known, within his own experience, instances on a large

NOTES ON HOSPITALS.

and fatal scale of disease produced in hospital; I myself could fill a book with them. One such may be given. In a small hospital, in one of the healthiest counties in England, in nine months, twenty-four poor creatures ran the gauntlet of their lives from erysipelas alone, of which disease eight died; and most of these after very trifling accidents or opera¬ tions. None of them ought to have produced erysipelas at all; much less have ended fatally.

But on the very threshold of the subject we shall probably be told that to c contagion’ and c infection’ is much of the un¬ healthy condition of some hospitals attributable, at least so far as concerns the occurrence of zymotic diseases. On the very threshold, therefore, we are obliged to make a digression, in order to discuss the meaning of these two familiar words, and to lay these spectres which have terrified almost all ages and nations.

This is the more necessary, because on the exact influence exercised by these two presumed causes of hospital sickness and mortality depends to a great degree the possibility of our introducing efficient hospital attendance and nursing. Unfor¬ tunately both nurses* and medical men, as well as medical students, have died of zymotic diseases prevailing in hospitals. It is an all-important question to decide whether the propaga¬ tion of such diseases is inevitable or preventible. If the former, then the whole question must be considered as to whether hospitals necessarily attended with results so fatal should exist at all. If the latter, then it is our duty to prevent their propagation.

The idea of c contagion,’ as explaining the spread of disease appears to have been adopted at a time when, from the neglect of sanitary arrangements, epidemics attacked whole masses of

* See Note A, at the end of this section.

SANITARY CONDITION OF HOSPITALS.

people, and when men had ceased to consider that nature had any laws for her guidance. Beginning with the poets and historians, the word finally made its way into medical nomen¬ clature,* where it has remained ever since, affording to certain classes of minds, chiefly in the southern and less educated parts of Europe, a satisfactory reason for pestilence, and an adequate excuse for non-exertion to prevent its recurrence.

And now, what does f contagion’ mean ? It implies the communication of disease from person to person by contact. It pre-supposes the existence of certain germs like the sporules of fungi, which can be bottled up and conveyed any distance attached to clothing, to merchandize, especially to woollen stuffs, for which it is supposed to have a particular affection, and to feathers, which of all articles it especially loves—so much so, that, according to quarantine laws, a live goose may be safely introduced from a plague country ; but if it happen to be eaten on the voyage, its feathers cannot be admitted without danger to the entire community. There is no end to the absurdities connected with this doctrine. Suffice it to say, that in the ordinary sense of the word, there is no proof, such as would be admitted in any scientific inquiry, that there is any such thing as c contagion.’

There are two or three diseases in which there is a specific virus, which can be seen, tasted, smelt, and analysed, and which in certain constitutions propagates the original disease by inoculation—such as small-pox, cow-pox, -&c. But these are not c contagions’ in the sense supposed.f

* See Note B, at the end of this section.

t Curiously enough, these directly communicable diseases were excluded from the operation of general quarantine law by the International Quarantine Con¬ ference of Paris, 1851, which restricted the objects of quarantine to plague, yellow fever, and cholera, while it gave a logical coup de grace to the ‘ contagion’ hypothesis by abolishing the < suspected bill of health.’

NOTES ON HOSPITALS.

IO

The word ‘infection/ which is often confounded with ‘ contagion/ expresses a fact, and does not involve a hypo¬ thesis. But just as there is no such thing as 4 contagion/ there is no such thing as inevitable ‘infection.’ Infection acts through the air. Poison the air breathed by individuals, and there is infection. Shut up 150 healthy people in a Blackhole. of Calcutta, and in twenty-four hours an infection is produced so intense that it will, in that time, have destroyed nearly the whole of the inmates. Sick people are more sus¬ ceptible than healthy people; and if they be shut up without sufficient space and sufficient fresh air/there will be produced not only fever, but erysipelas, pyaemia, and the usual tribe of hospital-generated epidemic diseases.

Again, if we have a fever hospital with over-crowded, badlyventilated wards, we are quite certain to have the air become so infected as to poison the blood not only of the sick, so as to increase their mortality, but also of the medical attendants and nurses, so that they also shall become subjects of fever.

It will be seen at a glance, that in every such case and in every such example, the ‘infection’ is not inevitable, .but simply the result of carelessness and ignorance. As soon as this practical view of the subject is admitted and acted upon, we shall cease to hear of hospital contagions.

In certain hospitals it has been the custom to set apart wards for what are called ‘ infectious’ diseases, but in reality there ought to be no diseases so considered. With proper sanitary precautions, diseases reputed to be the most ‘ infec¬ tious’ may be treated in wards among other sick without any danger. Without proper sanitary arrangements, a number of healthy people may be congregated together so as to become subject to the worst horrors of ‘ infection.’

No stronger condemnation of any hospital or ward could

SANITARY CO DITION OF HOSPITALS. 3 I

be pronounced than the simple fact that any zymotic disease has originated in it, or that such diseases have attacked other patients than those brought in with them. And there can be no stronger condemnation of any town than the outbreak of fatal epidemics in it. Infection, and incapable management, or bad construction, are, in hospitals as well as in towns, convertible terms.

It was necessary to say thus much to show to what hospital diseases are not necessarily due. To the following defects in site, construction, and management, as we think, they are mainly to be attributed.

i. The agglomeration of a large number of sick under one roof It is a well-established fact that, other things being equal, the amount of sickness and mortality on different areas bears a ratio to the degree of density of the population.

Why should undue agglomeration of sick be any excep¬ tion to this law ? Is it not rather to be expected that, the constitutions of sick people being more susceptible than those of healthy people, they should suffer more from this cause ?

There is a reason, of course, for everything, and in the present case the reason why agglomeration of a large number of sick under one roof leads to disaster, is the simple fact, that agglomeration argues either stern necessities of another kind, or great ignorance and danger of mismanagement, and, besides all this, it argues unforeseen events, and altogether such a deficiency in the general administrative arrangements, as is sure to be accompanied by want of proper ventilation, want of cleanliness, and other sanitary defects.

If anything were wanting in confirmation of this fact, it would be the enormous mortality in the hospitals which contained perhaps the largest number of sick ever at one time under the same roof, viz., those at Scutari. The largest o^ la

NOTES ON HOSPITALS.

these too famous hospitals had at one time a$00 sick and wounded under its roof, and it has happened that of Scutari patients two out of every five have died. In the hospital tents of the Crimea, although the sick were almost without shelter, without blankets, without proper food or medicines, the mortality was not above one-half what it was at Scutari; but these tents had only a few beds in each. Nor was it even so high as this in the small Balaclava General Hospital, which had part of its sick placed in detached wooden huts. While in the well-ventilated detached huts of the Castle Hospital, on the heights above Balaclava, exposed to the sea breeze, at a subsequent period, the mortality among the wounded did not reach three per cent. It is not to the comparative healthi¬ ness of these small hospitals, however, that we appeal, as the only proof of the danger of surface over-crowding. It is to the fact of 80 cases of hospital gangrene having been recorded during one month at Scutari (and many, many more passed unrecorded); to the fact that, out of 44 secondary amputa¬ tions of the lower extremities consecutively performed, 36 have died; and to the cases of fever which broke out in the hospital, not by tens, but by hundreds.