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Cottage Hospitals - Editorial

The first attempt to establish a cottage hospital was made at Cranley in 1859, and we lost no time in bringing it under the favourable notice of our readers.

Since then many others have been established, and in seven years, or in 1866, there were 16 in full work, and no less than 67 in course of establishment. Nevertheless a great many more are needed throughout the country. It has been calculated, on satisfactory data, that to supply the proper amount of hospital accommodation in rural districts, setting aside London and the six principal cities - one bed to every thousand inhabitants is the requisite proportion. Taking Mr. Swete's statistics as the basis of the calculation; it appears that there are no less than 9 millions of people in Great Britain unprovided with hospital accommodation.

To meet this state of things 9,000 more beds are required; and allowing six beds on an average, to each hospital, there is scope and necessity for 1,500 cottage hospitals, scattered throughout the country, to meet the demand.

The advantages of cottage hospitals in villages, and even in towns, are many. Besides those which affect the patients themselves of which we will hereafter speak, there are other benefits which ought not to be lost sight of. Country surgeons and physicians are often obliged to send off their poorer patients to some county hospitals where they and their cases are lost sight of either partially or entirely, and valuable experience is thus lost to country surgeons and physicians which they might bring to bear upon any class.

It is thus decidedly for the interest of the well to do classes in villages and small towns to support any movement for the establishment of a cottage hospital where it may be requisite in their own immediate district. The bringing of patients near the local surgeons and physicians where cottage hospitals are conveniently situated is an important point too. As regards the patients themselves the advantages are various. It cannot but be promotive of cure in many cases where patients are not saddened by isolation from every relative of friend in a town or county hospital, even were their position favourable otherwise to their restoration to health; but of this there is good reason to doubt. 

We find it stated by some authorities that the proportion of deaths in cottage hospitals is no greater than in the London hospitals, where the most eminent and experienced surgeons of the day are engaged. This itself is much to say, but we are not inclined to accept as anything like all that can be said in favour of cottage hospitals.

Even were no larger proportion of cures effected in them than in London hospitals, a most important question to the poor man remains to be investigated, namely, how long time on average it will take to cure any given case in a London hospital by comparison with the time requisite for just such a case in a cottage hospital. 

Of course, much depends on the stamina, and on other conditions; but something like reliable statistics, we think, might be ascertained on so material and important a point to a poor head of a family. The assertion that as many deaths in proportion occur in cottage hospitals with some half-dozen patients in each, as in the London hospitals - for that is what the ostensible recommendation, to which we have alluded, of cottage hospitals by comparison with the London hospitals comes to, - we are by no means inclined to rest satisfied with in the face of the following declaration - not as to cases in cottage hospitals certainly, but as to those in cottage and other homes, to which the nearest thing is a cottage hospital. The cases referred to are not such as are casually treated in cottage hospitals, neither nor indeed in London hospitals with certain exceptions - they are cases of child-birth in cottages and other homes on the one hand, and in town maternity hospitals on the other.

The differences in mortality in these respectively is enormous, and we cannot think that as between cottage hospitals and town or county hospitals in other cases such a difference can be all at once reduced to nil. Sir. James Y. Simpson, one of the highest authorities in the kingdom on such a subject as that on which he writes, says, in a letter to The Times - on Hospital Reform :- 

"In my address to the Public Health Section of the Social Science Congress at Belfast, I stated, as the result of Dr. Leon Le Fort's semi-official investigations, that out of 934,781 parturient women delivered at their own poor and often very wretched homes, 4,405 died, or 1 in every 212; while out of 888,512 delivered in maternity hospitals, where every kind of professional care and comfort was bestowed upon them, 30,394 died or 1 in every 29. These statistics apply to hospital practice as compared with dispensary or home practice among the same class of women in the leading cities and medical schools of Europe. To the general law of excessive mortality of hospital as compared with home practice, London is no exception. I find from the statistics published by Dr.Barnes that out of 4,000 women confined in the 4 chief maternity hospitals of London 142 or 1 in every 28, whilst out of 18,383 confined at their own homes as dispensary or out-patients in connexion with the hospitals of St. Thomas and Guy, 53 died or in every 346.

That something similar must occur in any extensive enough statistical comparison of the general mortality in London hospitals on the one hand, and cottage hospitals on the other, we have no doubt.

Considering the good they do, cottage hospitals are most economical and easily supported establishments. In an account of them by Dr.Andrew Wynter in Good Words, for May 1866, he gives the following statement of the receipts and expenditure at the Cranley Cottage Hospital during four years 1859 to 1863 for 100 patients.

Receipts
Donations and Subscriptions 542-05-05
From Patients 131-04-06
Total 673-09-11

Expenditure
For Patients, salaries, wine, beer 411-05-05
Insurance, & printing 34-17-06
Repairs and improvements 73-11-04
Furniture 92-11-06
Total 612-12-06

If we divide the total expenditure by 4, we find that the annual cost, including furniture and repairs, was but little more than 150 per annum; and, indeed, that the cost of the patients but little exceeded 100 for the treatment of 25 patients or 5 at the total cost of each case. This cost is not all paid by subscription or donation; on the contrary, the hospitals are made as far as possible self supporting, after they are once established, by weekly payments from the patients or their friends, who, under careful supervision, are also allowed to provide food etc. In this case the sum contributed on the part of patients themselves was 131, an example of independence to our London artisans and others of the poorer classes.

There should be a cottage hospital in every village ten miles distant from a town or county hospital. 

With regard to the expense of fitting up an hospital for six beds, Mr Napper, whose experience in the matter at Cranley, gives great weight to his opinion, places the cost at 70. The cost of fitting up each bed he places at 9-7s-6d = 56-7s-0d leaving about 13 for a kitchen- range, dresser, bath, clock, easy-chair, table, etc; but in the estimate no mention is made of crockery, cooking utensils, and some other minor articles. Dr. Waring estimates the cost of furnishing at 80. This sum added to 20 for repairs, will give a total of 100.

With this amount in hand, raised by private donations, sermons, bazaars or otherwise, any one would be fully justified in at once establishing a cottage hospital of six beds (inclusive of one for the nurse) in any district with 5,000 inhabitants placed beyond ready access to another hospital.

Cottages of course, can often or generally be had for the purpose, ready built, at rents of 12 as at East Grinstead, where Dr. Rogers presides, to 16 as at Tewkesbury; but it is not considered advisable to exceed the latter sum except under special circumstances. One great fear which those experienced in the working of cottage hospitals have is, that the system may be elaborated into some costly or ponderous arrangements which would diminish the chances both of the multiplication of such hospitals, and of effecting all the good of which the more primitive and economical system is capable. The subject of fever cases has been considered, but it has been thought better to exclude these, and to rent temporarily a separate cottage for any special occasions of the kind.

Memorial cottage hospitals are not a bad idea if the limits be not extended, and the purposes be confined simply to the cure of such cases as those at present undertaken in cottage hospitals. When the erection of a cottage hospital is contemplated, the best plan is to place the matter in the hands of a respectable local architect, with instructions to conform as nearly as possible to the character of the neighbouring cottages, striving, however, for as much air and light as possible. The rooms required, according to Dr. Waring in - Cottage Hospitals by E.J.Waring M.D. 1867.

"upstairs 
1 men's ward for 3 beds - 
2 a women's ward for 2 beds
3 a small ward with one bed for a case requiring separation
4 a nurse's bed-room - 
5 an operating room lighted from above, to contain the medical 

and surgical stores - 
6 a bath room.

On the ground floor
7 a kitchen
8 scullery
9 sitting-room
10 store room and larder
11 water closet.

In addition to these there should be a small mortuary chamber with a sky-light, and sheds or cellars for coal and wood. Such a building, he adds, I am informed by those capable of judging should cost about 400 ; but this would differ according to the price of materials, which varies much in different localities.

The surroundings of cottage hospitals, drainage etc ought to be carefully looked to. A proposal was made last year by Mr. Horace Swete, to establish a National Cottage Hospital Association. He considered that such an association would be of value - 

1 - in starting new cottage hospitals
2- in framing a general scheme of rules for their more efficient operation.
3 - in diffusing through their means a sound knowledge of sick nursing and sick cookery.
4 - in helping by a central fund, poorer districts to commence cottage hospitals.
5 - in arranging meetings of cottage hospital medical officers annually, for the discussion of matters connected with this class of institutions.
6 - in undertaking the arrangement of questions concerning poor-law unions etc.
7 - in publishing a quarterly paper with information as to the progress and working of the system.
8 - in furnishing plans for building and other such information as might be required.

The experiment made by the Marchioness of Ailesbury in establishing a cottage hospital at Savernake near Marlborough, appears to have succeeded admirably. At the annual meeting held under the presidency of the Marquis of Ailesbury, the report was read by the Rev. J.O.Stephens, hon. sec. To the institution, and the document showed that during the past year an addition of 144 had been made to the endowment fund.

It was also reported that 79 cases had been received into the hospital, of 9 beds only, 40 of which were discharged cured, 28 relieved, 2 pronounced incurable and 2 fatalities. 

Source: Submitted by Alan Longbottom
The Builder 1868 Vol XXVI p145 . 29th February 1868



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