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Notes on Hospitals, 3rd edition 1863 T he 1863 edition of Notes on Hospitals is so massively augmented and rewritten that it is effectively a new book. As well, Nightingale removed the appendixes of the 1859 edition, which reprinted her ‘‘Answers to Written Questions’’ and her three articles from The Builder. A new preface boldly asserts the need for a Hippocratic oath for hospitals akin to that for doctors: that they should ‘‘do the sick no harm,’’ even though it was ‘‘a strange principle to enunciate as the very first requirement.’’ Nevertheless, Nightingale considered it necessary to state such a principle, especially for hospitals in large crowded cities, which had mortality rates higher than those that occurred for the same class of diseases in patients treated at home. By 1863 some progress had been made in Britain on Nightingale’s ideas of hospital reform. The massive army hospital at Netley opened in 1863, not what it should be, Nightingale thought, but substantially improved from its original plans. The model pavilion hospital for Woolwich, designed by Douglas Galton, with much input from Nightingale , was under way in that same year, to open as the Herbert Hospital in 1865. Designs for civil pavilion hospitals had been drawn up by that time, although none had actually been built. Nightingale was acutely aware of how tough a struggle it was to convince hospital boards of the new ideas, and her correspondence from this period, and for decades following, shows how often basic points had to be remade. The situation at the new hospitals at Winchester and Derby, where Nightingale had strong allies, serve as examples of the tenacity of the old guard, who took much time and effort to be persuaded. The reason for a new book, as given in the new preface, was not just the need to spread understanding of the progress that had been made since 1858, but also to spread knowledge of those principles that had not yet been established. Nightingale then outlined the five subjects of the book, of which only the first two had been treated in the original 1858 paper: (1) an overview of actual sanitary conditions / 79 in hospitals and (2) a list of defects. Nightingale regrouped the sixteen defects of the 1858 paper into ten, but expanded the content considerably. Next came three completely new sections, the first of which put forward (desirable) principles of construction, with examples of improved plans, for both hospitals and convalescent institutions . The second section reported the statistical form adopted by the International Statistical Congress, and the third was a proposed form for recording outcomes for a long list of types of surgery, supplied by surgeons she canvassed. In the introductory section, Nightingale fleshed out the ‘‘four defects’’ of her original paper. To the first defect—that of large numbers under one roof—she added the dangers of mismanagement and liability to unforeseen events increasing with size. The Scutari Barrack Hospital furnished ‘‘confirmation,’’ she said, for it contained ‘‘perhaps the largest number of sick ever at one time under the same roof,’’ 2500, where (during its worst time) two out of every five patients died. She added the example of the Hôtel-Dieu in Paris, before its reconstruction , when it held 1200 beds. A major established hospital in peacetime, it housed 2000 and up to 4000 or even 7000 sick, with bedsharing , and one in four there died. In the expanded 1863 edition, Nightingale explained that the cost of land was too high in cities and towns to secure adequate light and ventilation for hospitals. Town hospitals were typically three or four storeys high, whereas country hospitals could be spread out over a larger surface area. Desirably, Nightingale always argued, hospitals would be one storey high, at most two. When she could not stop hospitals from building in towns she retreated to urging their pairing with a convalescent institution in the country, moving patients into it as quickly as possible. To her, a central location was needed only for accidents and emergencies. While only four plans were included in the second edition of Notes on Hospitals, as an appendix, the third edition contained eleven full pages of plans, placed in the appropriate section of the book, along with many smaller plans and figures, also placed where they fit in the text. The four provided in the second edition reappear here, namely, the two positive French plans (Lariboisière and Vincennes) and the two negative British plans (Netley and King...

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