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Notes on Hospitals, 1st and 2nd editions 1858 and 1859 N otes on Hospitals is Nightingale’s first publication to focus on the problems of civil hospitals. Initially given as a paper at the meetings of the National Association for the Promotion of Social Science, in Liverpool in October 1858, it was duly published in the association’s Transactions. Nightingale then had it printed separately in 1859, with appendixes on her evidence for the royal commission on the Crimean War, and her three articles in The Builder. When she wrote Notes on Hospitals in 1858, Nightingale was still working on her massive Notes on the Health of the British Army. Civil hospitals get much attention in that report, as they do in her evidence to the royal commission, but the prime focus in them, naturally, was what went wrong in the war hospitals and what to do differently in the future. Here, her focus changes to regular civil hospitals, with Crimean War examples drawn in where a flagrant example served. The commonalities between the two types of institution are obvious as both were buildings whose mortality rates were affected by their design, location and administrative procedures. In Part 1 of Notes on Hospitals, Nightingale set out the problem of high hospital mortality rates. She named four defects of hospital construction : the agglomeration of large numbers under one roof, and defects in cubic space, light and ventilation, although later she noted that she could not determine their relative influences. Part 1 ends with a succinct statement of the principles of the pavilion model. In Part 2, she specified sixteen sanitary defects usual in ward construction , mainly elaborations of the four defects of Part 1. New sections appear on kitchens, laundry, site and sewers. Further details are given on the materials to be chosen. There is a strong plea for ‘‘natural ventilation,’’ meaning open windows and fireplaces, as opposed to ‘‘artificial ventilation.’’ That disease is not inevitable but preventible is a major theme in the paper. It was an ‘‘all-important question’’ to determine this for, if inevitable, one would have to consider whether / 43 hospitals should exist at all; if preventible, it was ‘‘our duty to prevent ’’ the propagation and spread of such diseases (see p 51 below). Nightingale’s campaign against ‘‘contagion’’ as a cause, with inevitable infection its result, drew on her classical knowledge. She quoted from late ancient authors, from those after the time of the ‘‘fathers of history and of medicine.’’ That contagion theory was favoured in the ‘‘southern and less educated parts of Europe’’ was a sign to her of decline. The ‘‘more intelligent’’ authors, like Thucydides (c460-399 bce), from the golden age of classical thought were not ‘‘contagionists .’’ Aretaeus, who lived centuries later, around 100 ce, appeared to be the ‘‘first medical author who believed in contagion. The word ‘‘infection’’ was ‘‘admissible,’’ Nightingale thought, so long as it did not imply inevitability, for it expressed a ‘‘fact,’’ not a mere ‘‘hypothesis,’’ such as germ theory. At this time she allowed for specific causes for ‘‘two or three diseases,’’ naming smallpox and cowpox. Otherwise she, as doctors of the time, assumed miasms to be the causal agent for infectious diseases. ‘‘Noxious gas,’’ ‘‘noxious matter’’ and ‘‘noxious effluvia’’ appear, each relative to a disease-causing substance in the air, a patient’s body, or in moisture, respectively (see pp 58, 59 and 64 below). In this 1858 paper, Nightingale was so confident that ‘‘sanitary precautions ’’ could prevent the spread of disease that she thought it unnecessary ‘‘to set apart wards’’ for infectious disease (see p 54 below). She would later abandon that view and, over time, argued for increasingly stringent measures for the isolation of infectious patients. In the 1859 edition, she dropped the contention that it was a ‘‘vulgar error’’ to suppose that epidemics ‘‘spread disease from person to person , either by infection or contagion.’’ Rather, epidemics did not spread but developed in constitutions ‘‘made ripe for them by neglect,’’ or by natural laws. Nightingale clearly exaggerated the good effects of ventilation at this time. In the 1858 paper, she asserted that ‘‘abundance of pure air will prevent infection,’’ a point she said was confirmed by ‘‘all my own hospital experience.’’ Today, we would agree with her subsequent point that infection was ‘‘preventible,’’ if not that ‘‘carelessness’’ or ‘‘ignorance’’ were always responsible for failure to prevent it. The section on defective hospital kitchens—Point 11—was mainly a plea for better nutrition for patients. At...

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