The hospital has had its periods of advancement and of decline. It has experienced its golden ages and its dark ages. Like other fundamental institutions, it has existed on sentiment, interest, tradition, and custom. Nevertheless, it holds an important place in the life of the people.
There were three periods in the history of the hospital when it attained a relatively high degree of development—in ancient India, in medieval Europe, and at the present time in the United States, Canada, and some of the European countries. But never before in its history has it approached the skill and science which it now offers in the care of the sick.
In the early history of the hospital, very little rational attempt was made to improve it. Even as late as the eighteenth century there was a cultural lag between hospital improvement and the scientists. They did not apply their knowledge to hospitals. It was not until other groups began to exert a dominating influence that the attitude toward the hospital began to be changed from the primary level to a more intellectual level. The culture of the nineteenth century, the strong humanitarian movements, the development of science, were forces favorable to hospital advancement. The transition of the hospital from the old order to the new fills a classical chapter in the history of the achievement of the hospital.
As a result of the abuses which entered into the medieval hospitals, the care of the patients was grossly neglected. With the dawn of the Renaissance in Western Europe, the care of the sick and injured began to be improved. Physicians studied the ancient Greek writers, whose works had been copied and preserved by the monks in the monasteries. Anatomy became a recognized study. Dissection was performed, which had been forbidden by the church. The dissemination of knowledge and the opportunity for clinical study were encouraged. Other more concrete factors that contributed directly to the care of the sick and the improvement of the hospital were: sanitary science; control of pain, hemorrhage, infection ; changes in hospital construction, the basic principles by which the hospital is governed, its organization, standardization, departmentalization.
I. Contributing Factors
Sanitary Science. In the reign of Queen Elizabeth attempts were made to reduce the number of residents in dwelling houses. When the epidemics of cholera and jail, or typhus, fever broke out, with their devastating consequences, further efforts were made to control the spread of contagious diseases. Early in the eighteenth century, many authors began writing on the importance of air. Foremost among these was Boerhaave of the medical school of Leyden. He and his students became the "prime movers" in the development and practical application of sanitary science in treating the sick. The work of John Howard, the English philanthropist, was effective in drawing public opinion to the subject Of reform in sanitary conditions, which resulted in improved management of both hospitals and prisons.
Control of Pain, Hemorrhage, and Infection. The gradual improvement in medical science, too, was a major factor in improving the care of the sick. Better care of the sick and injured in the hospital came about largely through the works of Sydenham in the latter part of the seventeenth century. Of him Haggard says, "Thomas Sydenham gave medicine the form it holds today. He made it a discipline to which experimental science and mathematical science could make their contributions."' Until this time medicine had not gone beyond the curative medicine of the Greek physicians, Hippocrates and Celsus. In the sixteenth century, Ambroise Pare, the famous military surgeon, with his contemporaries abolished the use of the cautery for the control of hemorrhage, and introduced the ligature. Almost three centuries later, through the work of Long and Morton, who demonstrated the use of ether (1842), the fear of pain and surgery received its final blow.
In the nineteenth century, as a result of the advance made in the basic sciences, further improvement took place in the hospitals. Through the classical work of Pasteur, proving the germ theory of disease, Lister (who accepted Pasteur's work) introduced his doctrine of antisepsis, by the use of the carbolic spray. In this way the dreaded infection of surgical wounds was brought under control.
But the most outstanding contribution to hospital safety was made by the famous English nurse, Florence Nightingale. As a result of her work as a hospital organizer and administrator, men, women, and children today approach the hospital with confidence instead of fear, and look upon it as a place where efficient and scientific help may be obtained.
In the nineteenth century three other factors influenced the hospital in the care of the sick. Steam sterilization was introduced in 1886. Thus marked the beginning of surgical asepsis —the sterilization of everything that comes in contact with the wound. In 1895 Roentgen's
X ray became a valuable adjunct as a diagnostic and therapeutic measure, and the use of physical therapy, hydrotherapy, and heliotherapy began to assume a more prominent place.
II. Contributions
As long as the Church of Rome had control of the hospital, no change was made in its construction. The hospital was considered as a church institution. The wards were clustered around the chapel, for life centered in the chapel.
It was not until the latter part of the nineteenth century that a change was made in its structure. Medical men and surgeons began to concern themselves with the problem of hospital design and construction. Until this time very little attention had been given to it. The French Academy of Sciences is given credit for being the first among the scientific bodies to promulgate principles and rules for hospital design.
The importance of proper ventilation and air were more fully recognized. To meet these requirements, the pavilion system was adopted in preference to the old block system. By the pavilion system is meant a detached block of buildings separate from any other pavilion the hospital may have, or administrative offices. The first hospital to be built on the new plan was erected in Stonehouse, England (1756-64). It was proportioned to the number of sick that it might accommodate, as well as being capable of containing, the largest number of beds that might be placed in it with safety, together with suitable nurses' rooms, wards, utility rooms, lavatories, baths, and water closets.2
The modern hospital (especially in a large community) has its reception rooms, solariums, dining rooms, diet kitchens, toilets, baths, nurses' living quarters, recreation rooms, laundry, power plant, mortuary, store, and other accommodations housed separately. Sometimes the surgical unit, too, is isolated except for connecting passages. It may occupy the top floor, have a skylight and side windows, and anesthetizing, recovery, and sterilizing rooms. In some institutions, the obstetrical unit is also isolated, except for connecting passages.
The site of the hospital, too, has received consideration. It is to be built where ample fresh air can be obtained, away from neighboring buildings, the dust of the streets, railroads, traffic, and manufacturing plants, and the wards are to be exposed to sunlight at least part of the day.
It has become a recognized fact that in the present era no building or group of buildings has more care, pains, and expense lavished upon it than the hospital, and none imposes greater and more complex problems upon the architect.
III. Basic Principles
Since the hospital no longer fulfills the double role of being a place for the sick and an almshouse, as it did during its early history, sound basic principles have been formulated whereby it is governed, for the protection of both its patients and itself. These are as follows:
1. "The primary objective of the hospital is the service it can render the sick and injured, reward, financial gain, and other activities being secondary considerations.
2. "The ethical principles governing the entire personnel are the same as those governing the physician as an individual.
3. "Patience, delicacy, and respect for confidence are regarded as characteristic of the acts of all dealing with the sick in the hospital.
4. "The hospital is expected to employ only those of upright character and sound morals.'"
The patient is the focus of attention in the hospital. Its attitude, therefore, is that whatever effort is necessary for securing or expending money is put forth for the purpose of providing the most efficient and effective care for the patient to the best advantage.
For various reasons a hospital code of ethics is essential in governing each member of its personnel. The hospital deals with two great phenomena, life and death. Often the confidence of the patient in the physician, or the one caring for him, may be a deciding factor in his life. Again, any discussion before the patient of his case may result in misapprehension. Real evils may be magnified, or new ones may be created; for patients are not usually acquainted with medical terminology.
The confidential information, too, of the patient, pertaining to himself, his relatives, his friends, or what has been obtained through observations or examination, is to be held as a sacred trust. It is incumbent upon each one connected with the hospital to avoid any indiscretion or fault that would "decrease efficiency or lessen the trust of the patient." All personal feelings are to be submerged, and kindness, consideration, forbearance, firmness, and the comfort of the patient, made the rule in service.
IV. Standardization
A distinctive aspect in the advancement of the hospital has been its standardization, characteristically termed the "hospital-betterment period." The standardization of hospitals in the United States began in 1918 through the efforts of the American College of Surgeons, which has explained the movement in these words : "Hospital standardization is, essentially, an effort to have all hospitals emulate the practices and ideals of those that are achieving the best results for the good of the patient."4 Its program is the dissemination of knowledge of advanced methods and principles that have been successfully used in the more progressive institutions; to study practices and interchange opinions; to be alert for every new idea that may improve hospital service, as well as closely observing its effectiveness; to conduct surveys ; and to rate each hospital annually so that there may be no relaxing of its requirements.
Standardization has been purely voluntary, but hospitals have nobly co-operated with the movement. To assist hospitals, a minimum standard has been set up, the basic principles of which are as follows :
"1. A modern physical plant, properly equipped for the comfort, safety, and scientific care of the patient.
"2. Clearly stated constitution, bylaws, rules, and regulations, setting forth organizations, duties, responsibilities, and relations.
"3. A carefully selected governing board having complete and supreme authority for the management of the institution.
"4. A competent, well-trained executive officer or administrator with authority and responsibility to carry out the policies of the institution as authorized by the governing board.
"5. An adequate number of efficient personnel, properly organized and under competent supervision.
"6. An organized medical staff of ethical, competent physicians and surgeons for the efficient care of the patients and for carrying out professional policies of the hospital, subject to the approval of the governing board.
"7. Adequate diagnostic and therapeutic facilities with efficient technical service and under competent medical supervision.
"8. Accurate and complete medical records, promptly written and filed in an accessible manner so as to be available for study, reference, follow-up, and research.
"9. Group conferences of the administrative staff and of the medical staff to review regularly and thoroughly their respective activities in order to keep the service and the scientific work on the highest plane of efficiency.
"10. A humanitarian spirit in which the best care of the patient is always the primary consideration." 5
The approved hospital is considered to be one of the greatest assets in a community, for two specific reasons : (a) the patient is assured of scientific care, and (b) to encourage cooperation between hospitals, and provide opportunities for the exchange of ideas which has been made effective through hospital conferences.
—To be continued in April
References
Howard W. Haggard, M. D., "The Doctor in History," p. 273, New Haven, Yale University Press, 1934-
The New International Encyclopedia, Art., "Hospitals," 2d ed., Vol. XI, p. soo.
Malcolm T. MacEachren, M. D., "Hospital Organization and Management," pp. 768-770, Chicago, Physician's Record Company, 1935.
Twenty-third Annual Hospital Standardization Report," Bulletin of the American College of Surgeons, p. 271, Chicago, American College of Surgeons, October, 1940.
Id., pp. 271, 272.
