by Mr Albert Napper at Cranleigh, Surrey, have fulfilled a most useful
function. Many of them are very efficient both in regard to equipment
and treatment. They have become essential to the well-being and
adequate medical care of rural populations, as they attract to the
country some of the best members of the profession, who are able, with
the aid of the cottage hospital, to keep themselves efficient and
up-to-date, so that all classes of the community are benefited in this
way by this type of hospital.
_Ear, Throat and Nose Hospitals._--The history of this type of
hospital bears out in every particular the reason we have given above
for the establishment of special hospitals in the first instance.
There can be no doubt that the best conducted throat hospitals have
been beneficial to the poorer inhabitants of great cities.
_Fever Hospitals._--Incidentally we have dealt with these
institutions, which are usually supported out of the rates and
administered by the medical officers of health, who are paid by the
county or municipal authorities.
_Maternity and Lying-in Hospitals._--This is one of the oldest types
of special hospitals, and has done a great deal of good in its time.
Owing to modern methods of treatment and hygienic developments the
maternity hospital never occupied a stronger position than it does
to-day.
_Mental Hospitals._--In Great Britain the insane are provided for in
asylums (see INSANITY, ad fin.), though such establishments, if
properly conducted, are essentially hospitals. Scientific and public
opinion tend towards the establishment of mental hospitals to which
all acute cases of mental disease should be first relegated for
treatment and diagnosis before they are consigned to a permanent
lunatic hospital. Too little attention on an organized plan has been
given to the continuous study of mental disease in its clinical and
pathological aspects. It is probable, therefore, that the advent of
the mental hospital may lead to important developments in treatment in
many ways.
_Ophthalmic Hospitals._--Of all special hospitals this is one which
would probably be the least necessary, providing general hospitals
everywhere were properly equipped and organized. No special hospital
has probably been so abused in the material sense by the free relief
of patients who could well afford to pay for their treatment at the
ophthalmic hospital. Several of the existing ophthalmic hospitals have
entailed an enormous expenditure, and their modern equipment is
wonderfully efficient.
_Orthopaedic Hospitals._--It is very doubtful whether this type oL
hospital is really desirable or necessary. Its necessity may be
advocated on the ground that orthopaedic cases may require prolonged
treatment, and that the pressure upon the beds of general hospitals by
acute cases is nowadays so great as to render the orthopaedic hospital
more necessary than ever before.
_Paralysis and Epileptic Hospitals._--Seeing that the percentage of
those who are at present attacked by paralysis and nervous disease
shows a continued tendency to increase under modern conditions of life
in large cities, hospitals of this type are necessary, and London at
any rate, like most foreign towns of importance, possesses, at
present, far too little accommodation for this class of case.
_Skin and Photo-Therapy._--Up to the end of the 19th century hospitals
for diseases of the skin were a constant cause of scandal and
criticism. The introduction of modern methods of treatment by light
and electricity, including photo-therapy, has given an importance to
this department and treatment which it did not previously possess. We
are of opinion that, on the whole, it is better and more economical to
treat these cases in properly equipped departments of general
hospitals than in separate institutions.
_Women's Hospitals._--These hospitals are not absolutely necessary,
but considering their popularity with the women themselves, and that
several of them have done excellent work, remembering too that women
constitute the majority of the population, there seems to be some
reason for their continuance.
_The Evolution of the Modern Hospital._--The evolution of the modern
hospital affords one of the most marvellous evidences of the advance of
scientific and humanitarian principles which the world has ever seen. At
the outset hospitals were probably founded by the healthy more for their
own comfort than out of any regard for the sick. Nowadays the healthy,
whilst they realize that the more efficient they can make the hospital,
the more certain, in the human sense, is their own chance of prolonged
life and health, are, as the progress of the League of Mercy has shown
in recent years, genuinely anxious for the most part to do something as
individuals in the days of health in the cause of the sick. 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. In other words the hygienic
condition, the methods of treatment and the hospital atmosphere were all
so relatively unsatisfactory as to yield a mortality in serious cases of
40%. Nowadays, despite, or possibly because of, the fact that operative
interference is the rule rather than the exception in the treatment of
hospital patients, and in consequence of the introduction of antiseptic
and aseptic methods, the mortality in hospitals is, in all the
circumstances, relatively less, and probably materially less, than it is
even amongst patients who are attended in their own homes. Originally
hospitals were unsystematic, crowded, ill-organized necessities which
wise people refused to enter, if they had any voice in the matter. At
the present time in all large cities, and in crowded communities in
civilized countries, 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 separate buildings are dotted over the
site, which may cover 20 acres or upwards. In one such institution,
within an area of 20 acres, there are 6 m. of drains, 29 m. of water and
steam pipes, 3 m. of roof gutters, 42 m. of electric wires, and 42
separate buildings, which to all intents and purposes constitute a
series of distinct, isolated hospitals, in no case containing more than
forty-six patients. On the continent of Europe buildings of this class
are usually of one storey; in the United States, owing to the difficulty
of obtaining suitable sites and for reasons of economy, some competent
authorities strenuously advocate high buildings with many storeys for
town hospitals. In England the majority have two to three storeys each,
the ward unit containing a ward for twenty beds and two isolation wards
for one and two beds respectively. The two storeys in modern fever
hospitals, however, are absolutely distinct--that is, there is no
internal staircase going from one ward to the others, for each is
entered separately from the outside. This system carries to its extreme
limits the principle of separating the patients as much as possible into
small groups; the acute cases are usually treated in the upper ward, and
as they become convalescent are removed downstairs. In this way the
necessity for an entirely separate convalescent block is done away with
and the patients are kept under the same charge nurse, an arrangement
which promotes necessary discipline. The unit of these hospitals is the
pavilion, not the ward, and consists of an acute ward, a convalescent
ward, separation wards, nurses' duty rooms, store-rooms for linen, an
open-air balcony upstairs into which beds can be wheeled in suitable
weather, and a large airing-ground for convalescent patients directly
accessible from the downstairs ward. Each of the pavilions is raised
above the ground level, so that air can circulate freely underneath.
The wall, floor and air spaces in the scarlet fever wards of one of
these hospitals are respectively 12 ft., 156 ft. and 2028 ft. per bed;
and in the enteric and diphtheria wards they have been increased to 15
ft., 195 ft. and 2535 ft. respectively. The provision of so large a
floor and linear space, especially in the diphtheria wards, is an
experiment the effect of which will be watched with considerable
interest. A building of this type is a splendid example of the separate
pavilion hospital, and is doing great service in the treatment of fevers
wherever it has been introduced. Some idea of a hospital village, some
of the wards of which we have been describing, may be gathered from the
circumstances that it costs from L300,000 to L400,000, that it usually
contains from 500 to 700 beds, and that the staff numbers from 350 to
500 persons. The medical superintendent lives in a separate house of his
own. The nurses are provided with a home, consisting of several blocks
of buildings under the control of the matron; the charge nurses usually
occupy the main block; where the dining and general sitting-rooms are
placed; the day assistant-nurses another block; and lastly, by a most
excellent arrangement, the night nurses, 80 to 120 in number, have one
whole block entirely given up to their use. The female servants have a
second home under the control of the housekeeper, and the male servants
occupy a third home under the supervision of the steward. The two main
ideas aimed at are to disconnect the houses occupied by the staff from
the infected area, and to place the members of each division of the
staff together, but in separate buildings, under their respective heads.
These objects are highly to be commended, as they have important
bearings upon the well-being and discipline of the whole establishment
and constitute a lesson for all who have to do with buildings where a
great number of people are constantly employed.
_The Hospital City._--We have shown that the modern hospital where an
adequate site is available under the most favourable conditions has
developed into a hospital village. No one who is familiar with the
existing disadvantages of many of the sites and their surroundings of
town hospitals in many a large city can have any doubt that, if the
well-being of the patients and the good of the whole community, combined
with economical and administrative reasons, together with the provision
of an adequate system for the instruction and training of medical
students and nurses, are to be the first considerations with those
responsible for the hospitals of the future, the time will come, and is
probably not far distant, when each great urban community will provide
for the whole of its sick by removing them to a hospital city, which
will be situated upon a specially selected and most salubrious site some
distance from the town itself. The atmosphere of a great city grows less
and less suitable to the rapid and complete recovery of patients who may
undergo the major operations or be suffering from the severe and acute
forms of disease. Asepsis, it is true, has reduced the average residence
in hospital from about 35 to less than 20 days. It has thereby added
quite one million working days each year to the earning power of the
artisan classes in London alone. Medical opinion is more and more
favouring the provision of convalescent and suburban hospitals, to which
patients suffering from open wounds may be removed from the city
hospitals. This course, which entails much additional expenditure, is
advocated to overcome the difficulty arising from the fact that, in
operation and other cases, the patients cease to continue to make rapid
progress towards recovery after the seventh or ninth day's residence in
a city hospital. A change of such cases to the country restores the
balance and completes the recovery with a rapidity often remarkable.
Thinking out the problem here presented in all its bearings, realizing
the great and ever-increasing cost of sites for hospitals in great
cities, the heavy consequential taxes and charges which they have to
meet there, and all the attendant disadvantages and drawbacks, the
present writer has ventured upon an anticipation which he hopes may
prove intelligent and well-founded. Nearly every difficulty in regard to
the cost of hospitals and in respect to all the many problems presented
by securing the material required, under present systems, for the
efficient training of students and nurses, would be removed by the
erection of the Hospital City, which, he foresees, must ultimately be
recognized by intelligent communities throughout the civilized world.
Why should we not have, on a carefully selected site well away from the
contaminations of the town, and adequately provided with every requisite
demanded from the site of the most perfect modern hospital which the
mind of man can conceive, a "Hospital City"? Here would be concentrated
all the means for relieving and treating every form of disease to the
abiding comfort of all responsible for their adequacy and success. At
the present time all the traffic and all the citizens give way to fire
engines and the ambulance in the public streets. Necessarily the means
of transit to and from the "Hospital City," and its rapidity, would be
the most perfect in the world. So the members of the medical staff, the
friends of the patients, and all who had business in the "Hospital
City," would find it easier and less exacting in time and energy to be
attached to one of the hospitals located therein than to one situated in
the centre of a big population in a crowded town. To meet the urgent and
accident cases a few receiving houses, or outpost relief stations, with
a couple of wards, would be situated in various quarters of the working
city, where patients could be temporarily treated, and whence they could
be removed to the "Hospital City" by an efficient motor ambulance
service. The writer can see such a "Hospital City" established, can
realize the comfort it will prove in practice to the medical profession,
to the patients' friends, to those who have to manage the hospitals and
train the medical and nursing students, and indeed to all who may go
there as well as to the whole community. The initial cost of hospital
buildings should be reduced at once to a quarter or less of the present
outlay. They could then be built of the cheapest but most suitable
material, which would have many advantages, whilst the actual money
forthcoming from the realization and sale of the existing hospital sites
in many cities would, in all probability, produce a sum which in the
whole might prove adequate, or nearly adequate, or even in some cases
more than adequate, to defray the entire cost of building the "Hospital
City" and of equipping it too. The cost of administration and working
must be everywhere reduced to a minimum. The hygienic completeness of
the whole city, its buildings and appliances, must expedite recovery to
the maximum extent. In all probability the removal of the sick from
contact with the healthy would tend in practice so to increase the
healthiness of the town population, i.e. of the workers of the city
proper, as to free them from some of the most burdensome trials which
now cripple their resources and diminish materially the happiness of
their lives. Probably the United States (where a city has sometimes
sprung up in twelve months) may be the home where this idea may first
find its realization in accomplished fact. The writer may never live to
see such a city in actual working or in its entirety, but he makes bold
to believe its adoption will one day solve the more difficult of the
problems involved in providing adequately for the sick in crowded
communities. He has formulated the idea because it seems desirable to
encourage discussion as to the best method of checking the growing
tendency to make hospital buildings everywhere too costly. If the idea
of the "Hospital City" commends itself to the profession and the public,
the practice of treating all the hospital accommodation in each city as
a whole will gradually increase and spread, until most of the present
pressing difficulties may disappear altogether. That is a consummation
devoutly to be wished.
_The Problem of Hospital Administration._--A study of the hospital
problem in various countries, and especially in different portions of
the English-speaking world, convinces the writer that, apart from local
differences, the features presented are everywhere practically
identical. A number of hospitals under independent administration,
dependent in whole or in part on voluntary contributions, administered
under different regulations originally representing the idiosyncracies
of individual managers for the time being, without any standard of
efficiency or any system of co-operation, which would bring the whole
of the medical establishments of each or all of the great cities of the
world under one administration which the combined wisdom and experience
of hospital managers as a whole might agree to be the best, must mean in
practice a material gain in every way to each and all of the hospitals
and their supporters on economical, scientific and other grounds. Such
an absence of system throughout the world has everywhere led to
overlapping, to the perpetuation of many abuses, to the admission of an
increasing number of patients whose social position does not entitle
them to claim free medical relief at all, and, often too, to the
admission of patients belonging to a humbler grade of society who are
already provided for by the rates in institutions which they do not care
to enter and who find their way to the wards of hospitals which were
established to provide for patients of an entirely different social
grade. These evils have continued to grow and increase almost
everywhere, despite many and varied attempts to grapple with and remove
them. Amongst these attempts we may mention the assembling of hospital
conferences, the establishment of special funds and committees, and the
holding of inquiries of various kinds in London and other British cities
and also in the United States. The most remarkable proof of the
impossibility of inducing those responsible to act together and enforce
the necessary reforms is afforded by the historical fact that the famous
Commission on Hospital Abuse, known as Sir William Fergusson's
Commission, in 1871, after an exhaustive inquiry, made the following
recommendations: (1) to improve the administration of poor-law medical
relief; (2) to place all free dispensaries under the control of the
poor-law authorities; (3) to establish an adequate system of provident
dispensaries; (4) to curtail the unrestricted system of gratuitous
relief, partly by the selection of cases possessing special clinical
interest and partly by the exclusion of those who on social grounds are
not entitled to gratuitous medical advice; (5) the payment of the
medical staff engaged in both in- and out-patient work, and the payment
of fees by patients in the pay wards and in the consultation departments
of the voluntary hospitals. Other commissions have since been appointed,
have reported, and have disappeared, with the result that nothing
practical had been done up to 1910 in the way of reform. Yet it is an
undoubted fact that, if the foregoing recommendations of Sir William
Fergusson's Commission had been carried out in their entirety at the
time they were made, practically all the abuses from which British
hospitals afterwards suffered would have been removed, and the
charitable public might have been saved several millions of pounds
sterling. It may be well, therefore, briefly to indicate exactly what
these changes amount to, and how they can be made effective at any time
by those responsible for the working of a hospital.
There is no doubt that all the facts available tend to prove that the
voluntary hospitals are used to an increasing extent by persons able to
make payment or partial payment for the treatment which they receive.
The evidence and statistics demonstrating these facts may be readily
gathered from a study of the Report (1909) and Evidence of the Royal
Commission on the Poor Laws and Relief of Distress (Lord George
Hamilton's Commission) and in the authorities mentioned at the end of
this article. The underlying cause of the abuse was that no means
existed whereby persons of moderate income could obtain efficient
treatment and hospital care when ill at a rate which they could afford
to pay. The system, or want of system, whereby medical relief is granted
to practically all applicants by the voluntary hospitals grew up without
any combined attempt to organize it efficiently or to check abuses. Such
a system rests upon a wrong basis, and the best interests of every class
of the population demand its abolition in favour of one which shall
afford the maximum of justice (1) to the poor, (2) to those who can
afford to pay in part or in whole the cost of their medical treatment
and care at a hospital, (3) to the medical profession, (4) to the
subscribers and supporters of voluntary hospitals, whose gifts should be
strictly applied to the purposes they were intended to serve, and (5) to
the ratepayers, who are entitled to a guarantee that the maximum
efficiency is secured by the poor-law system of medical relief. The
remedy is very simple and easy of application. Every voluntary hospital,
while admitting all accidents and urgent cases needing immediate
attention, should institute a system whereby each applicant would be
asked to prove that he or she was a fit object of charity. The only real
attempt at reform, up to 1909, was the appointment by many of the larger
hospitals of almoners to ascertain whether certain selected patients
were in a position to pay or not. By putting the burden of proof of
eligibility to receive free medical relief upon the patients and their
friends, all abuse of every kind must speedily cease. There would be no
hardship entailed upon the patients by such a system, as experience has
proved, but, to make it effective, the system of providing for in- and
out-patients in Great Britain requires radical change, for, in existing
circumstance, if a voluntary hospital attempted to enforce this simple
method, it would be met with the difficulty that, where it was found
that a patient or his friends could pay at any rate something, no
department connected with British hospitals existed--as is the case in
regard to hospitals in the United States--enabling such in-patients to
be transferred to accommodation provided in paying wards. In the same
way, directly the out-patients were dealt with under such a system, it
would be made apparent, where a case could be properly treated, under
the poor law, that no plan of co-operation to secure this was organized
under existing conditions. If the patient, being of a better class, were
suffering from a minor ailment, and could be properly dealt with at a
provident dispensary, the fees of which he could easily pay, the same
absence of co-operation must make it practically impossible readily to
enforce the system. When, again, an out-patient of the better class was
entitled, from the severity of his ailment, to receive the advantages of
a consultation by the medical staff, no method existed whereby this aid
could be rendered to him, and his transfer afterwards to the care of a
medical practitioner attached to some provident dispensary, or resident
near the patient's home, could be properly carried out. It follows that
adequate reform required that methods should be adopted with a view to
some part or all the cost of treatment being provided by the patient or
his friends through an entire reorganization of the system of medical
relief not only at the voluntary hospitals, but under the poor-law
system. The reforms required in regard to voluntary hospitals are that
every large hospital shall have connected with the in-patient
department, in separate buildings, but under the administration of the
managers, pay wards for the reception of those patients who are able to
pay some part or all of the cost of treatment; that, as regards
out-patients, the existing out-patient department should be abolished;
that in substitution for it each hospital should have a casualty
department and a department for consultation. In the casualty department
every applicant should be seen once, and be there disposed of by being
handed on to the consultation department; if his case was sufficiently
important, he should then be transferred to some provident or poor-law
dispensary, or be referred to a private medical attendant. It would no
doubt take time to overcome the incidental difficulties which would
necessarily arise in effecting so radical a reform as is here
contemplated, but if all voluntary hospitals adopted the same system,
and were to be brought into active co-operation with provident
dispensaries and poor-law dispensaries and private medical
practitioners, the new system might be successfully introduced and made
effective within twelve months, and probably within six months, from the
date of its commencement. This opinion is based upon the assumption that
the provident dispensaries would be standardized, and that every one of
them would be brought up to a state of the highest efficiency. In the
town of Northampton the Royal Victoria Dispensary has been worked with
the maximum of success, so far as the patients and the medical
practitioners are concerned. In London and in other large towns like
Manchester and elsewhere the provident dispensary has not succeeded as
it has done in Northampton, because so many members of the medical
profession are not alive to the importance of making it their first
business to provide that every patient connected with the provident
dispensary who attends at the surgery of a private medical practitioner
shall receive at least equal attention and accommodation to that
afforded to every other private patient, whatever the fee he may pay. In
the same way, poor-law dispensaries must be radically reformed.
Everything which tends to excite a feeling of shame on the part of the
patient attending the poor-law dispensary, such as the printing of the
word "pauper" at the beginning of the space on which the patient's name
is entered, must be abolished, and the class of medical service and all
the arrangements for the treatment of the patients, however poor, at the
poor-law dispensary, must be made at least as efficient as those
provided by voluntary hospitals. There undoubtedly is considerable
overlapping between the voluntary hospitals and the poor law in Great
Britain. The Royal Commission on the Poor Laws and Relief of Distress
(1909) deals with this point with a view to set up a standard of medical
relief to be granted by each class and type of hospitals, provides for
adequate co-operation between all classes of institutions; and these
reforms may be commended. It is too often forgotten that the function of
the poor law is the relief of destitution, while it should be the object
and duty of each voluntary hospital and indeed of all hospitals other
than poor-law institutions to apply their resources entirely to the
prevention of destitution, by stepping in to grant free medical relief
to the provident and thrifty when, through no fault of their own, they
meet with an accident or are overtaken by disease. An adequate system of
co-operation would preserve the privilege of the voluntary hospitals,
which save such patients from the necessity of requiring the relief
which it is the object of the poor law to supply.
We have dealt with the relative advantages and disadvantages of
rate-supported hospitals and voluntary hospitals. We should regard the
establishment of a complete state-provided or rate-provided system of
gratuitous medical relief, either for indoor patients or for out-door
patients, or for both, as a grave evil. Such a system must eventually
lead to the extinction of voluntary hospitals. If this disaster ever
happens, it must result in the gravest evils, for it could not fail to
injure the morale of all classes and tend to harden unnecessarily the
relations between the rich and poor, who, under the voluntary system,
have come to share each other's sufferings and to be animated by respect
and confidence towards each other.
_Hospital Construction. Locality and Site._--Hospitals are required
for the use of the community in a certain locality, and to be of use
they must be within reach of the centre of population. Formerly the
greater difficulty of locomotion made it necessary that they should be
actually in the midst of towns and cities, and to some extent this
continues to prevail. It is now proved to demonstration that this is
not the best plan. Fresh and pure air being a prime necessity, as well
as a considerable amount of space of actual area in proportion to
population, it would certainly be better to place hospitals as much in
the outskirts as is consistent with considerations of usefulness and
convenience. In short, the best site would be open fields; but if that
be impracticable, a large space, "a sanitary zone" as it is called by
Tollet, should be kept permanently free between them and surrounding
buildings, certainly never less than double the height of the highest
building. In the selection of a site various factors must be taken
into consideration. If the hospital is to be used as the clinical
school of a university or medical college, then the most suitable
ground available within easy reach of the university or college must
be secured. If, on the other hand, the hospital is not to be used as a
teaching school, a site more in the country should be favoured. In any
case ample ground must be purchased to permit of the wards receiving
the maximum of sunlight, an abundant supply of fresh air, and leave
room for possible future extensions. The site should be
self-contained; it should be in such a position as to prevent the
hospital being shadowed by other buildings in the neighbourhood, and,
unless the site is alongside a public park, it should be entirely
surrounded by streets of from 40 to 60 ft. in width. It is also
necessary to secure that adequate water mains serve the site, and that
the system of sewers be ample for all sewage purposes.
The difference between the expense of purchase of land in a town and
in the environs is generally considerable, and this is therefore an
additional reason for choosing a suburban locality. Even with existing
hospitals it would be in most cases pecuniarily advantageous to
dispose of the present building and site and retain only a receiving
house in the town. St Thomas's in London, the Hotel-Dieu in Paris and
the Royal Infirmary in Manchester, are all good examples where this
might have been carried out. In none, however, has this been done;
these hospitals have been rebuilt, at enormous outlay, in the cities
as before, although not exactly in the same locality.
As regards the actual site itself, where circumstances admit of
choice, a dry gravelly or sandy soil should be selected, in a position
where the ground water is low and but little subject to fluctuations
of level, and where the means of drainage are capable of being
effectually carried out. There should also be a cheerful sunny aspect
and some protection from the coldest winds.
_Form of Building._--A form of building must be selected which answers
the following conditions: (a) the freest possible circulation of air
round each ward, with no cul-de-sac or enclosed spaces where air can
stagnate; (b) free play of sunlight upon each ward during some portion
at least of the day; (c) the possibility of isolating any ward, or
group of wards, effectually, in case of infectious disease breaking
out; (d) the possibility of ventilating every ward independently of
any other part of the establishment. Those conditions can only be
fulfilled by one system, viz. a congeries of houses or pavilions, more
or less connected with each other by covered ways, so as to facilitate
convenient and economical administration. The older plans of huge
blocks of buildings, arranged in squares or rectangles, enclosing
spaces without free circulation of air, are obviously objectionable.
Even when arranged in single lines or crosses they are not desirable,
as the wards either communicate with each other or with common
passages or corridors, rendering separation impossible. On this point
it may be remarked that some of the buildings of the 18th century were
more wisely constructed than many of those in the first half of the
19th century, and that the older buildings have been from time to time
spoilt by ignorant additions made in later times.
The question next arises, is it better to have pavilions of two or
more storeys high, or to have single-storeyed huts or cottages
scattered more widely? For the treatment of tuberculosis there can be
no doubt that, for hygienic reasons, the _chalet_ or single-patient
hut is the best for the patients in the acute stages; for economical
reasons the _chalet_ has not been heretofore as popular as it deserves
to be, but if the welfare of the patient is to be the first
consideration there is no doubt that the _chalet_ will ultimately
prevail. It has the merit of being easily adapted to villages and
houses where there is a garden, and in this way poor families may
readily isolate and treat a member affected by tuberculosis at a cost
within their means. For hospital purposes, so long as the system of
placing hospital buildings in densely crowded areas prevails,
many-storeyed buildings for hospital purposes are likely to continue.
Should the proposal to institute a Hospital City ultimately prevail,
then it is probable that the majority of the pavilions will be
single-storeyed. Still some hospital authorities prefer the
multiple-storeyed system for administrative reasons, contending that
single-storeyed pavilions have no special advantages over two or
three-storeyed buildings, whereas the difficulties in administration
and service of a hospital building on the single-storey principle
outweigh any argument against the two- or three-storey building, if it
is properly designed and constructed. We hope that the time is
approaching when architects and those members of the public who have
to provide the money for hospital buildings will insist upon the
erection of simple structures, costing little, so that the whole cost
of hospital buildings may be, as it ought to be, reduced by at least
half when compared with the expenditure of the past.
The pavilions may be arranged in various ways; they may be joined at
one end by a corridor, or may be divided by a central corridor at
right angles to them. In fact, the plan is very elastic, and adapts
itself to almost any circumstances. A certain distance, not less than
twice the height of the pavilions, ought to be preserved between them.
By this means free circulation of air and plenty of light are secured,
whilst separation or isolation may be at once accomplished if
required.
_Foundations, Building Materials, &c._--It is of the first consequence
that a hospital should be dry; therefore the foundation and walls
ought to be constructed so as to prevent the inroads of damp. An
impervious foundation has the further advantage of preventing
emanations from the soil rising up in consequence of the suction force
produced by the higher temperature of the internal atmosphere of the
building itself. There should be free ventilation in the basement, and
the raising of the whole on arches is a good plan, now generally
carried out in hot climates. If the pavilions are two or more storeys
high, it is advisable to use fire-proof material as much as possible,
but single-storeyed huts may be of wood. In any case effectual means
of excluding damp must be employed. The interiors of wards ought to be
rendered as non-absorbent as possible, by being covered with
impervious coatings, such as glazed tiles (Parian, though much used,
is apt to crack), silicate paint, which is preferable to tiles, or the
like. The ceilings ought to be treated in the same way as the walls.
There must be a concrete floor between each flat, experience showing
that if a teak floor is laid hard on the concrete a very noisy floor
is the result, but if the teak is laid on strips of wood, leaving a
small space between the concrete and the floor, a more silent floor is
obtained. For the floors themselves various materials have been
suggested: in France there is a preference for flags (_dalles_), but
in England wood is more liked; and indeed hard well-fitting wood,
such as teak, oak or American willow, leaves nothing to be desired.
The surface should be waxed and polished or varnished. Even deal
floors can be rendered non-absorbent by waxing, by impregnating them
with solid paraffin as recommended by Dr Langstaff.
_Shape and Arrangement of Wards._--It is now generally agreed that
wards should have windows on at least two opposite sides. Three main
shapes have been proposed: (a) long wards with windows down each side,
and (generally) one at the farther end with balcony; 26 ft. is a good
width for a ward of twelve or fourteen beds, but for larger wards of
more than fourteen beds the width should be not less than 28 ft.; (b)
wards nearly square, with windows on three sides; and (c) circular
wards with windows all round. The first (a) is the form usually
adopted in pavilions; (b) is recommended by Dr C. F. Folsom (_Plans
for the Johns Hopkins Hospital_); and (c) has been suggested by Mr
John Marshall, F.R.S. (_Nat. Assoc. for Promotion of Social Science_,
1878). Of these (b) seems the least to be commended, and (c), now
comparatively common, has distinct advantages in an administrative
sense, when the wards are constructed as to floor space so as to allow
the same proportion of superficial space per bed in a circular ward to
that which is contained in a rectangular ward, as is the case at the
Great Northern Central Hospital, London. Some authorities object to a
chimney-stack up the centre of the circular ward, urging that it
prevents the nurses from having complete supervision over all the
beds. In practice this objection seems to us to have little force, and
it can be avoided by placing the fireplaces at the side of the
circular ward, if desirable, though this adds somewhat to the cost of
building.
Each bed should be a little distance, say from 8 in. to 1 ft. from the
wall, and each bed may be reckoned as 6(1/2) ft. long; this gives
7(1/2) ft. on each side. Between the ends of the beds about 10 ft.
space is necessary, so that 25 or 26 ft. of total breadth may be taken
as a favourable width. The wards of the Herbert Hospital are 26 ft.;
but some exceed this, as, for instance, St Thomas's, London, and the
New Royal infirmary, Edinburgh, 28; new Hotel Dieu, 29; and
Lariboisiere, 30. There seems no necessity for exceeding 26 for a ward
of twelve or fourteen beds, but if the breadth be greater there ought
to be more window space--the great difficulty being to get a wide
space thoroughly ventilated. There ought to be only two rows of beds,
one down each wall, with a window on each side of each bed.
For ventilation two things are required--sufficient space and
sufficiently frequent change or renewal of air. As regards space, this
must be considered with reference both to total space and to lateral
or floor space. Unless a minimum of floor space be laid down, we shall
always be in danger of overcrowding, for cubic space may be supplied
vertically with little or no advantage to the occupier. If we allow a
minimum distance of 4 ft. between the beds and 10 ft. between the ends
of the beds, this gives 100 sq. ft. of space per bed; less than this
is undesirable. In severe surgical cases, fever cases and the like, a
much larger space is required; and in the Edinburgh Infirmary 150 sq.
ft. is allowed. Cubic space must be regulated by the means of
ventilation; we can rarely change the air oftener than three times in
an hour, and therefore the space ought to be at least one-third of the
hourly supply. This ought not to be less than 4000 cubic ft. per bed,
even in ordinary cases of sickness--and the third of that is 1333
cubic ft. of space. With 100 sq. ft. of floor space a ward of 13(1/2)
ft. high would supply this amount, and there is but little to be
gained by raising the ceiling higher,--indeed 12 ft. is practically
enough. The experiments of Drs Cowles and Wood of Boston (see _Report
of State Board of Health of Massachusetts for 1879_) show that above
12 ft. there is little or no movement in the air except towards the
outlet ventilator; the space above is therefore of little value as
ventilation space. Authorities nowadays, however, fix 10 ft. 6 in. as
the maximum, and any height above this may be disregarded for purposes
of ventilation. Additional height adds also to the cost of
construction, increases the expense of warming, makes cleaning more
difficult, and to some extent hampers ventilation. Whatever be the
height of wards, the windows must reach to the ceiling, or there must
be ventilators in the ceiling or at the top of the side walls. If this
be not arranged for, a mass of foul air is apt to stagnate near the
ceiling, and sooner or later to be driven down upon the inmates. The
reasons for a large and constant renewal of air are, of course, the
immediate removal and dilution of the organic matter given off by the
inmates; as this is greater in quantity and more offensive and
dangerous in sickness than in health, the change of air in the former
case must be greater than in the latter. Hence in serious cases an
amount of air practically unlimited is desirable--the aim of true
ventilation being to approach as near as possible to the condition of
pure external air. Without going too much into details, a few general
rules may be laid down. (1) Fresh air ought, if possible, to be
brought in at the lowest part of the ward, warmed if necessary; (2)
foul air ought to be taken out at the highest part of the ward; (3)
fresh air should reach each patient without passing over the bed of
any other; (4) the vitiated air should be removed from each patient
without passing over the bed of any other; (5) 4000 cubic ft. of fresh
air per head per hour should be the minimum in ordinary cases of
sickness, to be increased without limit in severer cases; (6) the air
should move in no part of a ward at a greater rate than 1(1/2) ft. per
second, except at the point of entry, where it should not exceed 5 ft.
per second, and at the 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 deg. to 63 deg. 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, but
even in the best type of hospital there is still much to be desired in
this respect. It is essential for an architect in designing any
building to have before him an accurate idea of all the requirements,
and the use to which each foot of space is to be put; for unless he is
furnished with this information it is not possible for him to design
his building so as to give effect to all the details which are so
necessary. The following is an endeavour in a general way to enumerate
the various points which an architect should have before him in
designing the admission department of a general hospital:--
The admission department should be conveniently placed on the ground
floor of the hospital--or it may be a detached building--with a large
court where ambulance wagons or other vehicles may easily pass each
other on approaching or retiring from the institution. The entrance to
the admission department for patients should, if possible, be entirely
separate and distinct from that for the staff and students. An
additional entrance should be provided for patients' friends on
visiting days, in order that they may be able to enter the hospital
without passing through the patients' entrance, or coming into contact
with an accident case or other patient seeking admission. The main
entrance door should be protected by a covered porch so that patients
may be removed from the ambulance or cab to the examination room
without being exposed to the weather or the gaze of inquisitive
onlookers. This door should be sufficiently wide to allow two hand
ambulances or barrows to pass should they require to be brought out to
the ambulance or cab, and to facilitate this the floor of the entrance
hall should be as nearly as possible on a level with that of the
outside porch. Adjoining the entrance vestibule, lavatory
accommodation should be provided for males and females who may
accompany the patient. Lavatory accommodation should also be provided
for porters on duty, and all lavatories should have a cut-off
ventilating passage.
A recess to store ambulance barrows should adjoin the entrance, and
this recess must be in proportion to the size of the hospital, in
order that a hand ambulance may always be available when an accident
or urgent case arrives. The vestibule should lead into a large
waiting-hall with an inquiry office at its entrance, provided with a
telephone exchange, private exchange box, also letter and parcel
racks. If possible a window of the inquiry office should command a
view of the main entrance. A room should be provided for the medical
officer on duty, so that a medical officer may be always at hand and
that no delay will occur in attending to a patient on arrival.
Leading off from this waiting-hall, well-lit examination rooms should
be available for the thorough examination of patients, both male and
female, the number of rooms, of course, varying with the size of the
hospital and the amount of work to be done. Each of these rooms should
be fitted with a wash-hand basin and sink, and a plentiful supply of
hot and cold water.
Two rooms, with recovery rooms adjoining, should be fitted up as small
operating-rooms for the treatment of minor casualties. A special room
should also be furnished with an X-ray outfit, and arrangements should
be made whereby this room can be readily darkened so that suspected
fractures, &c. may be examined with the fluorescent screen.
Adjoining the admission department two small wards should be provided
for the accommodation of drunk or noisy cases unfit to be placed in
the general wards. To these "emergency wards" must be attached the
usual bathroom and lavatory accommodation, nurses' room, ward kitchen
and urine-test room or small lavatory. These wards should have double
windows in order to prevent noise being heard outside if the wards are
near other buildings.
The interior walls of the admission department should, as far as
possible, have a smooth and impervious surface, in order that they may
be easily cleaned. All angles should be avoided and all corners
rounded. Although glazed tiles are open to the criticism that they
have numerous joints, they probably make the most suitable wall yet
devised, as they can be easily washed down at very small cost. The
corridors and waiting-hall should be tiled to a height of 6 ft. 6 in.,
and the upper walls covered with Parian or Kean's cement, and be
treated with three coats of flat paint and two coats of enamel, or,
what is equally suitable and less costly, enamellette. The floors of
the passages and corridors throughout the department should be covered
with terrazzo, which is a mixture of Portland cement and marble chips.
A margin of 1 ft. round the rooms should be treated in this way, and
the terrazzo carried up this same distance on the wall to join the
tiles. The remainder of the floors should be covered with hard wood,
such as American maple or teak. As these floors require to be
frequently washed, oak is not so suitable. Oak very soon becomes
destroyed with water; the same trouble is experienced with pitch pine.
The doors should also be made of a hard wood, preferably teak, and
have no mouldings or grooves where dust can lodge. They should be wide
enough to admit an ambulance barrow or bed with ease. In no case
should the doors of an examination room be less than 3 ft. 6 in. in
width.
As an aid to a complete understanding of the varied work which has to
be provided for, and the most effective method of carrying it out, the
accompanying plans are given of an admission block designed to embody
the main principles which govern the construction of such a
department.
[Illustration: Plans of Ground Floor and Basement of a Hospital.]
All accidents and patients seeking admission to this hospital enter
through the central gateway, and on the left is shown the porters'
room, where a porter is always in readiness to attend to any
applicant. This room has suitable accommodation for parcels, letters,
telephones, &c., and adjoining it is a small lavatory for the use of
porters. At the side of the porters' room is the entrance to the
central waiting-hall, which is lit from the roof. On one side of this
hall are examination and dressing-rooms for males, with lavatory
accommodation; and on the other side similar provision for females,
with the addition of a nurses' duty room. At the end of the central
hall are two operating theatres, with recovery room adjoining each;
one theatre for males, and the other for females. Between these
theatres are rooms for sterilizers and dressings. An X-ray examination
room is provided beyond the male examination room on the right of the
hall. In the basement, under the entrance-hall and operating theatres
are two bathrooms for males and two for females, with W.C.'s for each.
The remainder of the basement is used as a store for patients'
clothes, and a hot-air chamber is provided for purposes of
disinfection. The basement can be reached by a lift or by a wide
staircase which is situated at the end of the waiting-hall.
In the above plan provision is made for a sitting-room for the medical
officer on duty. This is a new and essential feature in the admission
block unit of all hospitals in large cities, for it should secure that
no patient is kept waiting for many minutes before being seen. One of
the blots on the management of many hospitals is that regrettable
delays often take place, and much dissatisfaction and avoidable
suffering may arise from this difficulty in the administration of a
general hospital. We have given this plan of a model gatehouse or
admission block for a modern general hospital, because the block as it
stands contains all the elements necessary for a receiving-house block
in cities in connexion with a great Hospital city situated outside its
area, in fulfilment of the suggestion for a Hospital city made above.
Apart from its interest as a new feature which all new hospitals
should adopt, the gatehouse or admission block has an importance in
the wider sense, that it may come to form the key to the solution of
the problem of how best to provide hospital accommodation for the poor
in great cities under the best hygienic conditions, while protecting
them from the misery and danger of prolonged delay in first treatment,
especially in connexion with accidents and other cases of urgency.
BIBLIOGRAPHY.--Sir H. Burdett, _Cottage Hospitals, General, Fever and
Convalescent, their Construction, Management and Work_ (London, 1877,
1880 and 1896); Tollet, _Les Edifices hospitaliers depuis leur_
_origine jusqu'a nos jours_ (Paris, 1892); Sir H. Burdett, _Hospitals
and Asylums of the World_, with large portfolio of plans to a uniform
scale (London, 1893) (a supplement is published every year bringing
the information up to date, entitled _Burdett's Hospitals and
Charities_); J. S. Billings, _The Principles of Ventilation, Heating
and their Practical Application_ (New York, 1893); Galton, _Healthy
Hospitals_ (London, 1893); Tollet, _Les Hopitaux au XIX^e siecle_
(Paris, 1894); Billings and Hurd, _Suggestions to Hospital and Asylum
Visitors_ (Philadelphia, 1895); Oswald Kuhn, "Hospitals," _Handbuch
der Architektur_, 4th part, 5th half-volume, part i. (Stuttgart,
1897); _Plans for the Johns Hopkins Hospital_ (Baltimore, 1875);
_Report of State Board of Health for Massachusetts for 1879_.
(H. Bt.)
HOSPITIUM (Gr. [Greek: xenia, proxenia]), "hospitality," among the
Greeks and Romans, was of a twofold character: (1) private; (2) public.
(1) In Homeric times all strangers without exception were regarded as
being under the protection of Zeus Xenios, the god of strangers and
suppliants. It is doubtful whether, as is commonly assumed, they were
considered as _ipso facto_ enemies; they were rather guests. Immediately
on his arrival, the stranger was clothed and entertained, and no inquiry
was made as to his name or antecedents until the duties of hospitality
had been fulfilled. When the guest parted from his host he was often
presented with gifts ([Greek: xenia]), and sometimes a die ([Greek:
astragalos]) was broken between them. Each then took a part, a family
connexion was established, and the broken die served as a symbol of
recognition; thus the members of each family found in the other hosts
and protectors in case of need. Violation of the duties of hospitality
was likely to provoke the wrath of the gods; but it does not appear that
anything beyond this religious sanction existed to guard the rights of a
traveller. Similar customs seem to have existed among the Italian races.
Amongst the Romans, private hospitality, which had existed from the
earliest times, was more accurately and legally defined than amongst the
Greeks, the tie between host and guest being almost as strong as that
between patron and client. It was of the nature of a contract, entered
into by mutual promise, the clasping of hands, and exchange of an
agreement in writing (_tabula hospitalis_) or of a token (_tessera_ or
_symbolum_), and was rendered hereditary by the division of the tessera.
The advantages thus obtained by the guest were, the right of hospitality
when travelling and, above all, the protection of his host (representing
him as his patron) in a court of law. The contract was sacred and
inviolable, undertaken in the name of Jupiter Hospitalis, and could only
be dissolved by a formal act.
(2) This private connexion developed into a custom according to which a
state appointed one of the citizens of a foreign state as its
representative ([Greek: proxenos]) to protect any of its citizens
travelling or resident in his country. Sometimes an individual came
forward voluntarily to perform these duties on behalf of another state
([Greek: etheloproxenos]). The proxenus is generally compared to the
modern consul or minister resident. His duties were to afford
hospitality to strangers from the state whose proxenus he was, to
introduce its ambassadors, to procure them admission to the assembly and
seats in the theatre, and in general to look after the commercial and
political interests of the state by which he had been appointed to his
office. Many cases occur where such an office was hereditary; thus the
family of Callias at Athens were proxeni of the Spartans. We find the
office mentioned in a Corcyraean inscription dating probably from the
7th century B.C., and it continued to grow more important and frequent
throughout Greek history. There is no proof that any direct emolument
was ever attached to the office, while the expense and trouble entailed
by it must often have been very great. Probably the honours which it
brought with it were sufficient recompense. These consisted partly in
the general respect and esteem paid to a proxenus, and partly in many
more substantial honours conferred by special decree of the state whose
representative he was, such as freedom from taxation and public burdens,
the right of acquiring property in Attica, admission to the senate and
popular assemblies, and perhaps even full citizenship. Public hospitium
seems also to have existed among the Italian races; but the
circumstances of their history prevented it from becoming so important
as in Greece. Cases, however, occur of the establishment of public
hospitality between two cities (Rome and Caere, Livy v. 50), and of
towns entering into a position of clientship to some distinguished
Roman, who then became patronus of such a town. Foreigners were
frequently granted the right of public hospitality by the senate down to
the end of the republic. The public hospes had a right to entertainment
at the public expense, admission to sacrifices and games, the right of
buying and selling on his own account, and of bringing an action at law
without the intervention of a Roman patron.
A full bibliography of the subject will be found in the article in
Daremberg and Saglio, _Dictionnaire des antiquites_, to which may be
added R. von Jhering, _Die Gastfreundschaft im Altertum_ (1887); see
also Smith's _Dictionary of Greek and Roman Antiquities_ (3rd ed.,
1890).
HOSPODAR, a term of Slavonic origin, meaning "lord" (Russ. _gospodar_).
It is a derivative of _gospod_, "lord," and is akin to _gosudar_, which
primarily means "sovereign," and is now also used in Russia as a polite
form of address, equivalent to "sir." The pronunciation as _hospodar_ of
a word written _gospodar_ in all but one of the Slavonic languages which
retain the Cyrillic alphabet is not, as is sometimes alleged, due to the
influence of Little Russian, but to that of Church Slavonic. In both of
these g is frequently pronounced h. In Little Russian the title
_hospodar_ is specially applied to the master of a house or the head of
a family. The rulers of Walachia and Moldavia were styled _hospodars_
from the 15th century to 1866. At the end of this period, as the title
had been held by many vassals of Turkey, its retention was considered
inconsistent with the growth of Rumanian independence. It was therefore
discarded in favour of _domn_ (_dominus_, "lord"), which continued to be
the official princely title up to the proclamation of a Rumanian kingdom
in 1881.
HOST. (1) (Through the O. Fr. _oste_ or _hoste_, modern _hote_, from
Lat. _hospes_, a guest or host; _hospes_ being probably from an original
_hostipes_, one who feeds a stranger or enemy, from _hostis_ and the
root of _pascere_), one who receives another into his house and provides
him with lodging and entertainment, especially one who does this in
return for payment. The word is thus transferred, in biology, to an
animal or plant upon which a parasite lives. (2) (From Lat. _hostis_, a
stranger or enemy; in Med. Latin a military expedition), a very large
gathering of men, armed for war, an army, and so used generally of any
multitude. In biblical use the word is applied to the company of angels
in heaven; or to the sun, moon and stars, the "hosts of heaven," and
also to translate "Jehovah Sabaoth," the Lord God of hosts, the lord of
the armies of Israel or of the hosts of heaven. (3) (From Lat. _hostia_,
a victim or sacrifice), the sacrifice of Christ's body and blood in the
Eucharist, more particularly the consecrated wafer used in the service
of the mass in the Roman Church (see EUCHARIST).
HOSTAGE (through Fr. _ostage_, modern _otage_, from Late Lat.
_obsidaticum_, the state of being an obses or hostage; Med. Lat.
_ostaticum_, _ostagium_), a person handed over by one of two belligerent
parties to the other or seized as security for the carrying out of an
agreement, or as a preventive measure against certain acts of war. The
practice of taking hostages is very ancient, and has been used
constantly in negotiations with conquered nations, and in cases such as
surrenders, armistices and the like, where the two belligerents depended
for its proper carrying out on each other's good faith. The Romans were
accustomed to take the sons of tributary princes and educate them at
Rome, thus holding a security for the continued loyalty of the conquered
nation and also instilling a possible future ruler with ideas of Roman
civilization. This practice was also adopted in the early period of the
British occupation of India, and by France in her relations with the
Arab tribes in North Africa.[1] The position of a hostage was that of a
prisoner of war, to be retained till the negotiations or treaty
obligations were carried out, and liable to punishment (in ancient
times), and even to death, in case of treachery or refusal to fulfil the
promises made. The practice of taking hostages as security for the
carrying out of a treaty between civilized states is now obsolete. The
last occasion was at the treaty of Aix-la-Chapelle in 1748, when two
British peers, Henry Bowes Howard, 11th earl of Suffolk, and Charles,
9th Baron Cathcart, were sent to France as hostages for the restitution
of Cape Breton to France.
In modern times the practice may be said to be confined to two
occasions: (1) to secure the payment of enforced contributions or
requisitions in an occupied territory and the obedience to regulations
the occupying army may think fit to issue; (2) as a precautionary
measure, to prevent illegitimate acts of war or violence by persons not
members of the recognized military forces of the enemy. During the
Franco-Prussian War of 1870, the Germans took as hostages the prominent
people or officials from towns or districts when making requisitions and
also when foraging, and it was a general practice for the mayor and
_adjoint_ of a town which failed to pay a fine imposed upon it to be
seized as "hostages" and retained till the money was paid. The last case
where "hostages" have been taken in modern warfare has been the subject
of much discussion. In 1870 the Germans found it necessary to take
special measures to put a stop to train-wrecking by parties in occupied
territory not belonging to the recognized armed forces of the enemy, an
illegitimate act of war. Prominent citizens were placed on the engine of
the train "so that it might be understood that in every accident caused
by the hostility of the inhabitants their compatriots will be the first
to suffer." The measure seems to have been effective. In 1900 during the
Boer War, by a proclamation issued at Pretoria (June 19th), Lord Roberts
adopted the plan for a similar reason, but shortly afterwards (July 29)
it was abandoned (see _The Times' History of the War in S. Africa_, iv.
402). The Germans also, between the surrender of a town and its final
occupation, took "hostages" as security against outbreaks of violence by
the inhabitants. Most writers on international law have regarded this
method of preventing such acts of hostility as unjustifiable, on the
ground that the persons taken as hostages are not the persons
responsible for the act;[2] that, as by the usage of war hostages are to
be treated strictly as prisoners of war, such an exposure to danger is
transgressing the rights of a belligerent; and as useless, for the mere
temporary removal of important citizens till the end of a war cannot be
a deterrent unless their mere removal deprives the combatants of persons
necessary to the continuance of the acts aimed at (see W. E. Hall,
_International Law_, 1904, pp. 418, 475). On the other hand it has been
urged (L. Oppenheim, _International Law_, 1905, vol. ii., "War and
Neutrality," pp. 271-273) that the acts, the prevention of which is
aimed at, are not legitimate acts on the part of the armed forces of the
enemy, but illegitimate acts by private persons, who, if caught, could
be quite lawfully punished, and that a precautionary and preventive
measure is more reasonable than "reprisals." It may be noticed, however,
that the hostages would suffer should the acts aimed at be performed by
the authorized belligerent forces of the enemy.
In France, after the revolution of Prairial (June 18, 1799), the
so-called "law of hostages" was passed, to meet the insurrection in La
Vendee. Relatives of _emigres_ were taken from disturbed districts and
imprisoned, and were liable to execution at any attempt to escape.
Sequestration of their property and deportation from France followed on
the murder of a republican, four to every such murder, with heavy fines
on the whole body of hostages. The law only resulted in an increase in
the insurrection. Napoleon in 1796 had used similar measures to deal
with the insurrection in Lombardy (_Correspondance de Napoleon I._ i.
323, 327, quoted in Hall, _International Law_).
In May 1871, at the close of the Paris Commune, took place the massacre
of the so-called hostages. Strictly they were not "hostages," for they
had not been handed over or seized as security for the performance of
any undertaking or as a preventive measure, but merely in retaliation
for the death of their leaders E. V. Duval and Gustave Flourens. It was
an act of maniacal despair, on the defeat at Mont Valerien on the 4th of
April and the entry of the army into Paris on the 21st of May. Among the
many victims who were shot in batches the most noticeable were Monsignor
Darboy, archbishop of Paris, the Abbe Deguery, cure of the Madeleine,
and the president of the Court of Cassation, Louis Bernard Bonjean.