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diff --git a/old/52877-0.txt b/old/52877-0.txt deleted file mode 100644 index 8f3b223..0000000 --- a/old/52877-0.txt +++ /dev/null @@ -1,8654 +0,0 @@ -The Project Gutenberg EBook of Subsidiary Notes as to the Introduction of -Female Nursing into Military Hospitals in , by Florence Nightingale - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - - - -Title: Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and War - -Author: Florence Nightingale - -Release Date: August 22, 2016 [EBook #52877] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK INTRODUCTION OF FEMALE NURSING *** - - - - -Produced by MWS, Fay Dunn and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive/American Libraries.) - - - - - - - - - -Transcriber’s Note - - -Words in italics are marked with _underscores_. Words in small capitals -are shown in UPPER CASE. - -There are three parts to this book, each starting with page 1. The -first and last parts are marked “PRIVATE AND CONFIDENTIAL.”, these -words were underlined in the original. - -Footnotes have been moved to the end of each part. - -Variant spelling and inconsistent hyphenation are retained, a few -palpable printing errors have been corrected. - -The key for the plan of the Lariboisière Hospital was originally -handwritten. No changes have been made to this for missing or irregular -use of accents or cedillas. - -The tables of numbers of nurses near the end of the book were -originally printed in landscape, with some sideways printing. The -columns and rows have been swapped to make these tables easier to read -on small screens. - - - - - SUBSIDIARY NOTES - - AS TO THE - - INTRODUCTION OF FEMALE NURSING - - INTO - - MILITARY HOSPITALS - - IN PEACE AND IN WAR. - - Presented by request to the Secretary of State for War. - - LONDON: - PRINTED BY HARRISON AND SONS, ST. MARTIN’S LANE, W.C. - 1858. - - - - -CONTENTS. - - - PAGES - - DIGEST v–x - - Thoughts submitted by Order, concerning-- - I. Hospital Nurses 1–9 - II. Nurses in Civil Hospitals 9–14 - III. Nurses in Her Majesty’s Hospitals 15–19 - - Systems of Female Nursing in the War Hospitals of the - different Nations engaged in the Crimean War 19–26 - - Note in regard to the Russian Nurses employed in the - War Hospitals of the Crimea 26–28 - - * * * * * - - Subsidiary Notes as to the Introduction of Female - Nursing into Military Hospitals in Peace and - in War 1–63 - - Addenda with regard to Female Nursing in a Military - Hospital on the Pavilion or Lariboisière Plan 63–90 - - Addenda as to Mixed Nursing, by Nurses and Orderlies, - in Military Hospitals, on the Double Pavilion or - Vincennes Plan 91–117 - - Additional Hints as to Ventilation, Hospital Floors, - and Cautions in Ward-building suggested by the - Lariboisière Hospital 118–127 - - Note on Contagion and Infection 128–132 - - Note on Observations by the Principal Medical Officer of - the Army in the East 132, 133 - - * * * * * - - Thoughts submitted as to an Eventual Nurses’ Provident - Fund 1–19 - - Note as to the Number of Women employed as Nurses in - Great Britain 20, 21 - - Note as to Teaching Nursing 22, 23 - - - - -ILLUSTRATION. - - - Plan of the Lariboisière Hospital at Paris p. 63 - - - - -DIGEST. - - - PAGES - - THOUGHTS SUBMITTED BY ORDER 1–28 - - CONCERNING - - I. HOSPITAL NURSES. - II. NURSES IN CIVIL HOSPITALS. - III. NURSES IN HER MAJESTY’S HOSPITALS. - - I. Hospital Nurses 1–9 - Twenty Observations on how to improve Hospital - Nursing. - - II. Nurses in Civil Hospitals 9–14 - Twenty-three Heads for Regulations as to Nursing in - Civil Hospitals. - - III. Nurses in Her Majesty’s Hospitals 15–19 - Twenty-two suggestions in the event of the - introduction of Female Nursing into Military - Hospitals. - - Various systems of Female Nursing during the Crimean War - in the Military Hospitals 19–28 - Of the French and Sardinians 19–22 - Russians 22, 23, 26–28 - English 23 - - Proposed Duties of Female Nurses in Military General - Hospitals 23, 24 - - The Hospital Serjeant, or Ward Master will not be - superseded--he will still have too much to do for any - one man properly to perform, and part of his duties must - be given to another officer 24–26 - - NOTE IN REGARD TO THE RUSSIAN NURSES EMPLOYED IN - THE WAR-HOSPITALS OF THE CRIMEA 26–28 - - - SUBSIDIARY NOTES AS TO THE INTRODUCTION OF FEMALE NURSING - INTO MILITARY HOSPITALS IN PEACE AND IN WAR 1–133 - - I. Five Conditions essential to this service 1–3 - - II. Our Nurses were of four kinds 3 - Absolute subordination to the Medical Officer as to - Medical Orders essential and practised by us 4 - - - III. 1. Qualified subordination essential of - Superintendent-General to Director-General and - Principal Medical Officer 4–6 - 2. Also of Matron and Nurses to Principal Medical - Officer and Staff-Surgeons 6, 7 - 3. Female service can only be introduced gradually, - and introduction regulated by Director-General 7–9 - - IV. 1. Shall Roman Catholic Sisters be introduced? 9, 10 - 2. Or Anglican Sisters? 10 - 3. Power of Police in Civil Hospitals 11 - ″ ″ Military ″ 12–15 - 4. Pay and Rations of Nurses 15–20 - On the whole it would seem best, where practicable, - to board the Nurses, not to “ration” them, nor - to let them “find themselves.” Community of - cooking implies economy of nourishment 17–20 - 5. Washing to be “put out” 20, 21 - 6. Cleaning their own Rooms 21–23 - 7. Nurses to keep keys of closet in Wards 23 - 8. Pay, dress, and duties of Matrons 24–28 - More properly named Superintendents 27 - Lady Volunteers had better begin by being Nurses, - not Superintendents _ex-officio_ 28 - 9. Sundry Regulations as to Nurses 29–31 - 10. Have the Patients’ Diets sent hot, and ready - divided, from kitchen 31 - 11. What Ward duties the Nurses should do themselves 31 - And why 32, 33 - Patients should not be made quasi Orderlies 34 - Visitors in Military Hospitals 35 - 12. Regulation-Number of Orderlies--depends on the - size of wards whether sufficient 35–41 - What is the regulation-attendance in Naval - Hospitals 37 - What in Civil Hospitals 38 - Comparative Cost of Nursing in larger and smaller - wards 39–41 - 13. Hospital floors 42–51 - Sanitary necessities 42 - Trial of Hospital floors, oiled and polished with - “_laque_” as in Berlin Hospitals, recommended on - sanitary grounds and for ease of cleaning 43–51 - 14. Ventilation of Wards 51–52 - 15. Special Wards, whether desirable or not 53–54 - 16. Opinion as to Superintendent-General paying - Nurses’ wages, and as to Governor’s jurisdiction - over Nurses 54–56 - 17. Wages and Pensions of Nurses 56–60 - Three rules in raising Wages 56 - Five general principles as to Wages and Pensions 58 - Six applications of the foregoing principles 58, 59 - Seven heads for Regulations as to Nurses’ Wages - and Pensions 59, 60 - 18. Proportion of Nurses to Patients 61, 62 - 19. Precautions in sending Nurses on Foreign Service 62 - Hospital Laundries 63 - - ADDENDA, WITH REGARD TO FEMALE NURSING IN A MILITARY - HOSPITAL ON THE PAVILION, OR LARIBOISIÈRE PLAN 63–90 - - I. Four conditions to be considered in adopting the - Pavilion Plan 63 - 1. Economy of attendance 64 - 2. Facility of supervision 65 - 3. Desirableness of _doubling_ the Pavilion, - in a Military Hospital, in order to give to each - Nurse but one floor to serve 65 - 4. Nurse to sleep near her Ward 66 - Importance of lighting by gas 67 - - II. 1. One Nurse must serve the whole Pavilion, in a - Military Hospital, if _single_ Pavilions be - adopted 68 - 2. Nurses’ day in such a Pavilion 68, 69 - 3. What the responsibility of Nurses is for - discipline of Ward or Pavilion 70, 71 - 4. Importance of Lifts 71 - - III. 1. “Casualty” Cases should be in a completely - appointed set of Wards, apart 72 - And why 73 - 2. Restraint or non-restraint in Violent Cases 74 - - IV. Simplicity of Construction essential to Discipline 75 - Polished impervious Walls. - Covered Exercising Place. - Reserve Wards 76 - - V. Nurses’ Meals to be sent them Cooked 76 - - VI. Arrangements for a Pavilion and its Wards 77–90 - 2. Where should Wardmaster sleep? 77 - 3. And Orderlies sleep? 77 - 4. And dine? 78 - 7, 8, Scullery to each Ward, and what to be done in it 79 - Poultice-making 79 - 9. Presses in Ward 80, 81 - 10. Nurses’ Room 82 - Lavatory, Water-Closet, Sink 83 - Baths 84 - 11. Summary of arrangements 85 - Scullery Appurtenances 86 - 12. Nurses’ Sleeping Quarters 86 - Ward for Sick Nurses 87 - 13. Classification of Patients 88 - 14. Nurses to be called by their Wards 88 - 15. Foul Linen 88 - 16. Washing Bandages 89 - 17. Splints, &c., where to be kept 89 - Cotton Lint never to be used 89 - 18. Classification of Nurses 90 - Superintendent’s Store Room 90 - - ADDENDA AS TO MIXED NURSING BY NURSES AND ORDERLIES - IN MILITARY HOSPITALS ON THE DOUBLE PAVILION - PLAN 91–117 - - I. ORDERLIES’ DUTIES 91–108 - - Proportion of Nurses, Ward Masters, and Orderlies to - Sick 91–93 - Wine to be always administered by Nurse 93 - Orderlies--their Duties vary according to - appurtenances of Ward 94 - If Hot and Cold Water are laid on, and there are - Lifts, one Orderly’s Service saved to each 30 Sick 94, 95 - Night-Duty of Orderlies 95–108 - Scheme of Night-Service for three Orderlies watching - by turns 96, 97 - Exercise for Orderlies 97 - Night Refreshment for Orderlies 98, 99 - Where are the Night Orderlies to sleep? 100 - Comparative Merits of different Systems of Night - Nursing in Home and in Foreign Hospitals 101–3 - An Assistant Ward Master should go round the Wards - at Night 104 - Extraordinary System of Night-Nursing in the Army - at present 105–8 - - II. TWELVE SUNDRIES IN ORGANIZING A MILITARY - HOSPITAL 108–114 - - 1. Nurses’ Room 108 - 2. Medical Officer’s Room 108 - 3. Water-Closets 109 - 4. Warm and Cold Water Supply 109 - 5. Corridors 109 - 6. Lobby 110 - 7. Material of Ward Utensils 110 - 8. Reserve Wards 111–112 - Necessity of Annual Cleansing of the whole of a - Hospital - 9. Occasional Revision of Rules 113 - 10. Defect in German Organization of Nursing 113 - 11. Nurses’ Exercise 113 - 12. Number of Ward Masters 114 - - III. REGULATIONS 114–117 - 1. Deprivation of Visitors salutary in certain Wards 114–16 - 2. Numbering Patients saves time 117 - 3. Prohibition of Swearing 117 - Conclusion 117 - - ADDITIONAL HINTS AS TO PAVILION HOSPITALS SUGGESTED BY THE - CONSTRUCTION OF THE LARIBOISIÈRE HOSPITAL AT PARIS 118–127 - - I. Ventilation 118–120 - Artificial Ventilation never freshens a Ward - II. Oiled Boards versus Parquets 120–124 - Cleaning polished and oiled Boards much less - laborious, and freshens the Ward much more than - the _frottage_ of _Parquets_. - Mode of Cleaning them at Berlin 122–124 - III. Ten Cautions in Building Hospital Pavilions 124–127 - Size of Wards. Our own Regimental Hospitals - extraordinary for their many holes and corners 125 - Casualty Wards 126 - - “CONTAGION” AND “INFECTION” DEFINED 128–132 - - Idea of “Contagion” invented by Men to excuse - themselves for the neglect of all Sanitary - arrangements 128 - In the ordinary sense of the word, no such thing - as “Contagion” 129 - Nor as _inevitable_ “Infection” 130 - “Infection” and Incapable Management, or Bad - Construction, convertible terms 131 - “Epidemics” do not _spread_--they develop - themselves in Constitutions made ripe for them - by Sanitary neglects 131 - - Note on certain “Observations” by Sir John Hall 132, 133 - - * * * * * - - THOUGHTS SUBMITTED AS TO AN EVENTUAL NURSES’ - PROVIDENT FUND 1–19 - - Actual Wages and Prospects of Nurses 1–3 - Some further Provision desirable 4–6 - Of what Nature? 6–15 - With regard to Kind? 6–8 - With regard to Persons? 8 - With regard to Objects? 9–15 - Material Objects? 9–12 - Children, in the case of Nurses, a Temptation to - Petty Dishonesty and taking Bribes 11, 12 - Sanitary Objects? 13 - Moral Objects? 13–15 - Hospitals not places for Penitents 14, 15 - Rules to be followed in giving Assistance 15–17 - Prospects of Eventual Support 18, 19 - - Note as to the Number of Women employed as Nurses - in Great Britain 20, 21 - Tables of Ages, &c. 21 - Note as to Teaching Nursing--Institution at Madras 22, 23 - - * * * * * - - - - -_PRIVATE AND CONFIDENTIAL._ - - - - -THOUGHTS SUBMITTED BY ORDER CONCERNING - - I. HOSPITAL-NURSES. - II. NURSES IN CIVIL HOSPITALS. - III. NURSES IN HER MAJESTY’S HOSPITALS. - - -I. HOSPITAL-NURSES. - -[Sidenote: Definite Objects: road to them to be found out.] - -1. It would appear desirable to consider that definite objects are to -be attained; and that the road leading to them is to a large extent to -be found out--therefore to consider all plans and rules, for some time -to come, as in a great measure tentative and experimental. - -[Sidenote: Presumed Main Object.] - -2. The main object I conceive to be, to improve hospitals, by improving -hospital-nursing; and to do this by improving, or contributing towards -the improvement, of the class of hospital-nurses, whether nurses or -head-nurses. - -[Sidenote: Presumed Intentions.] - -3. This I propose doing, not by founding a Religious Order; -but by training, systematizing, and morally improving as far -as may be permitted, that section of the large class of women -supporting themselves by labour, who take to hospital-nursing for -a livelihood,--by inducing, in the long run, some such women to -contemplate usefulness, and the service of God in the relief of man, -as well as maintenance, and by incorporating with both these classes -a certain proportion of gentlewomen who may think fit to adopt this -occupation without pay, but under the same rules, and on the same -strict footing of duty performed under definite superiors. These two -latter elements, if efficient (if not, they would be mischievous rather -than useless), I consider would elevate and leaven the mass. - -[Sidenote: Religious Orders.] - -4. It may or may not be desirable to incorporate into the work, either -temporarily or permanently, members of Religious Orders, whether -English or Roman Catholic, or both, who may, with the consent of their -Superiors, enter hospitals nursed under the above system, upon the -definite understanding of entire obedience to secular authorities in -secular matters, and of abstinence from proselytism. - -[Sidenote: Their Advantages.] - -5. Great and undoubted advantages as to character, decorum, order, -absence of scandal, protection against calumny, together with, -generally speaking, security for some amount of religious fear, love, -and self-sacrifice, are found in the system of female Religious Orders. - -[Sidenote: Advantages of Hired Labour.] - -6. On the other hand, the majority of women in all European countries -are, by God’s providence, compelled to work for their bread, and are -without vocation for Orders. - -In England the channels of female labour are few, narrow, and -over-crowded. In London and in all large towns, there are accordingly a -large number of women who avowedly live by their shame; a larger number -who occupy a hideous border-land, working by day and sinning by night; -and a large number, whether larger or smaller than the latter class is -a doubtful problem, who preserve their chastity, and struggle through -their lives as they can, on precarious work and insufficient wages. -Vicious propensities are in many cases the cause, remediless by the -efforts of others, of the two first classes: want of work, insufficient -wages, the absence of protection and restraint, are the cause in many -more. - -Perhaps the work most needed now is rather to aim at alleviating the -misery, and lessening the opportunities and the temptations to gross -sin, of the many; than at promoting the spiritual elevation of the few, -always supposing that this latter object is best effected in an Order. - -At any rate, to promote the honest employment, the decent maintenance -and provision, to protect and to restrain, to elevate in purifying, so -far as may be permitted, a number, more or less, of poor and virtuous -women, is a definite and large object of useful aim, whether success be -granted to it or not. - -The Orders remain for the reception of those women who either are or -believe themselves drawn to enter them, or who experience their need of -them. - -[Sidenote: Main Object of Hospitals: Distinct Functions of Hospital -Clergy and Hospital Nurses.] - -7. The care of the sick is the main object of hospitals. The care of -their souls is the great province of the clergy of hospitals. The care -of their bodies is the duty of the nurses. Possibly this duty might -be better fulfilled by religious nurses than by Sisters of any Order; -because the careful, skilful, and frequent performance of certain -coarse, servile, personal offices is of momentous consequence in many -forms of severe illness and severe injury, and prudery, a thing which -appears incidental, though not necessarily so, to Female Orders, is -adverse to or incompatible with this. - -[Sidenote: Objections to Amalgamating Members of Orders with Secular -Nurses.] - -8. Grave and peculiar difficulties attend the incorporation of members -of Orders, especially of Roman Catholic Orders, into the work. And, -both with reference to the Queen’s hospitals, and still more to -the civil hospitals, I humbly submit that much thought, and some -consultation with a few impartial and judicious men, should precede -the experiment of their introduction. This appears to me one of the -most important questions for decision. Should it be decided in favor -of their introduction, I trust it may be resolved to do so only -tentatively and experimentally. - -I confess that, subject to correction or modification from further -experience or information, my belief, the result of much anxious -thought and actual experience, is, that their introduction is certain -to effect far more harm in some ways than it can effect good in -others; that a great part of the advantages of the system of Orders -is lost when their members are partially incorporated in a secular, -and therefore, as they consider, an inferior system; and that their -incorporation, especially as regards the Roman Catholic Sisters, will -be a constant source of confusion, of weakness, of disunion, and of -mischief. - -Saint Vincent de Paule well knew mankind, when he imposed, amongst -other things, the rule on the Sisters of his Order never to join in -any work of charity with the Sisters of any other Order. This rule was -mentioned to me on an occasion which gave it weight, by the Superior -of the Sisters of Charity of one of the two Sardinian Hospitals on the -Heights of Balaklava, in the spring of 1856, and by the _Mère Générale_ -at Paris, October 1854, when she was solicited by me, with the assent -and sanction, both of the English and of the French Governments, to -grant some of her Sisters to us at Scutari. - -[Sidenote: Ladies] - -9. As regards ladies, not members of Orders, peculiar difficulties -attend their admission: yet their eventual admixture to a certain -extent in the work is an important feature of it. Obedience, -discipline, self-control, work understood as work, hospital service -as implying masters, civil and medical, and a mistress, what service -means, and abnegation of self, are things not always easy to be learnt, -understood, and faithfully acted upon, by ladies. Yet they cannot fail -in efficiency of service or propriety of conduct--propriety is a large -word--without damaging the work, and degrading their element. Their -dismissal (like that of Sisters) must always be more troublesome, if -not more difficult than that of the other nurses. - -It might be better not to invite this element; to let it come if it -will learn, understand, and do what has to be learnt, understood, and -done: if not, it is better away. - -It appears to me, but I may be quite mistaken, that, in the beginning, -many such persons will offer themselves, but few persevere; that in -time a sufficient number will form an important element of the work; -more is not desirable. - -It seems to me important that ladies, as such, should have no separate -status; but should be merged among the head-nurses, by whatever name -these are called. Thus efficiency would be promoted, sundry things -would be checked, and the leaven would circulate. - -There are many women, daughters and widows of the middle classes, who -would become valuable acquisitions to the work, but whose circumstances -would compel them to find their maintenance in it. These persons would -be far more useful, less troublesome, would blend better and more -truly with women of the higher orders, who were in the work, and would -influence better and more easily the other nurses, as head-nurses, than -as ladies. Whether or not the better judgment of others agrees with -mine, my meaning will be understood. - -In truth the only lady in a hospital should be the chief of the women, -whether called Matron or Superintendent. The efficiency of her -office requires that she should rank as a lady and an officer of the -hospital. At the same time, I think it important that every Matron and -Superintendent, (unless during war-service, when the rough-and-ready -life and work required will probably be best undergone by women of a -higher class) should be a person of the middle classes, and if she -requires and receives a salary, so much the better. She will thus -disarm one source of opposition and jealousy, and enough will remain, -inseparable from her office. - -The quasi-spiritual dignity of Sisters of Mercy is a thing _sui -generis_. But the real and faithful discharge of the duties of the -wards of a General Hospital, whether with reference to superiors, -companions, or patients, is incompatible with the status, as such, -of ladies. The real dignity of a gentlewoman is a very high and -unassailable thing, which silently encompasses her from her birth to -her grave. Therefore, I can conceive no woman who knows, either from -information or from experience, what hospital duties are, not feeling -as strongly as I do, that either the assertion or the reception of the -status as such of a lady, is against every rule and feeling of common -sense, of the propriety of things, and of her own dignity. - -[Sidenote: Religion.] - -10. The question of the mode of Religion is an all-important one, and -the choice of a mode bears far more directly upon this work than may, -at first sight, appear. To give up the common ground of membership of -the National Church is to give up a great source of strength. - -[Sidenote: St. John’s House.] - -St. John’s House, if it steers clear of the rock of prudery, -undoubtedly possesses great advantages over a system of hospital -nursing by promiscuous instruments. Not because it includes a -Sisterhood, a system, in which I, for one, humbly but entirely -disbelieve; but because the laborious, servile, anxious, trying -drudgery of real hospital work (and to be anything but a nuisance it -must ever remain a very humble and very laborious drudgery), requires, -like every duty, if it is to be done aright, the fear and love of God. -And in practice, apart from theory, no real union can ever be formed -between sects. The work now proposed, however, must essentially forbear -to avail itself of the bond of union of the National Church. - -[Sidenote: Only Women of Unblemished Character should be employed.] - -11. None but women of unblemished character should be suffered to -enter the work, and any departure from chastity should be visited with -instant final dismission. All applications on behalf of late inmates of -penitentiaries, reformatories, of all kinds and descriptions, should be -refused. The first offence of dishonesty, and, at the very furthest, -the third offence of drunkenness, should ensure irreversible dismissal. -No nurse dismissed, from whatever cause, should be suffered to return. - -[Sidenote: Provision for Old Age.] - -12. It is very important, if possible, to make provision for the -disabled age of deserving nurses. It does not seem to me, I speak -very diffidently, desirable to concentrate them in one or more large -buildings. I believe half the inmates of half the alms-houses, &c., -are not on speaking terms with each other. John Bull is of a peculiar -idiosyncrasy: nowhere are there such homes as in England, but life in -community does not seem congenial here. A pension and the option of -ending their days in solitary quiet, or with some friend or relation, -would probably be the most comfortable arrangement for nurses. - -[Sidenote: Progressive Increase of Wages.] - -13. Many women are valuable as nurses, who are yet unfit for promotion -to head-nurses. It appears to me that it would be very desirable to -have an intermediate recompense: say, after ten years’ good service, to -raise nurses’ wages; after a second ten years, to raise them further. - -[Sidenote: Fixed Age for Admission and Retirement.] - -14. There should be an age for the reception and for the retirement -both of nurses and head-nurses. I think no head-nurse should be under -thirty. - -[Sidenote: Simplicity of Rules, Definition of Authorities.] - -15. Simplicity of rules, placing the nurses, in some respects, -absolutely under the Medical man, and, in others, absolutely under the -Female Superintendent, is very important; also, at the outset, to have -a clear and recorded definition of these respective limits. - -[Sidenote: Economy.] - -16. Economy is very important, with regard to the eventual extension of -the work. - -[Sidenote: Commencement: Training.] - -17. In the event of the nurses not being trained in Her Majesty’s -service, advantage, it seems to me, would attend their beginning in a -great established hospital; unless indeed it should be judged best to -select and train a staff of nurses first in a smaller and quieter one. -Yet much that would be unpleasant in the larger place would probably -be beneficial. The restraint, control, contact with the masters, work, -and order of things of a great and settled place, would materially help -with reference to the nurses. - -[Sidenote: Limits.] - -18. Common sense will assuredly make the fixed resolve; both to fulfil -one’s duty, and to keep within it. It is as essential to do the latter -as the former, and often more difficult, especially for women; most -especially for hospital-nurses. - -[Sidenote: Encumbrance of Public Support or Patronage.] - -19. It appears to me most important to be free, once and for ever, from -the injurious, untrue, and derogatory appendage of public patronage: -what is called support in these days always ends in patronage. This -work, truly understood, never has been, never will be, never can be, a -popular work; for many reasons, one of which is that the public, of all -orders, never can know anything of the real nature of hospital-work. -With the best intentions, it will therefore make perpetual and impeding -mistakes in “supporting” or patronizing it. Its support and patronage -are equally injurious in different ways as regards our masters the -medical men, ourselves the nurses, and people who are neither medical -men nor nurses. - -[Sidenote: Caution, Non-expectation, and Trust.] - -20. I end as I began. Let nothing be done rashly. Let us not be -fettered with many rules at first. Let us take time to see how things -work; what is found to answer best; how the work proceeds; how far it -pleases God to accept and bless it. Let us be prepared, as I know well -we must be, for disappointments of every sort and kind. What can any of -us do in anything, what are any of us meant to do in anything, but our -duty, leaving the event to God? His Will be done in earth, as it is in -Heaven. - - -II. NURSES IN CIVIL HOSPITALS. - -[Sidenote: Isolation of each Head Nurse and her Nurses.] - -1. The isolation of each head-nurse and her nurses appears to me very -important. The head-nurse should be within reach and view of her -ward both day and night. Associating the nurses in large dormitories -tends to corrupt the good, and make the bad worse. Small airy rooms -contiguous to the ward are best. The ward should have but one entrance, -and the head-nurse’s room should be close to it, so that neither -nurse nor patient can leave, nor any one enter the ward, without her -knowledge. - -[Sidenote: All to Rank and be Paid alike, with Progressive Increase of -Wages.] - -2. All the nurses should rank and be paid alike, with progressive -increase of wages after each ten years’ good service, or a slow annual -rise, which is better. - -[Sidenote: Night Nurses.] - -3. The night-nurses should be on duty 12 hours, with instant dismissal -if found asleep; 8 hours should be allowed for sleep, and 4 hours for -daily exercise, private occupation, or recreation. If they have no time -to themselves for their mending, making, &c., they do it at night, -sometimes innocently, sometimes to the injury of the patients. I would -not however prohibit occupation at night; as sometimes the ward-duty is -slight; and doing something is far better and more awakening than doing -nothing. This is one of the matters the head-nurse should constantly -look to. I do not fancy, but at present am not positive about, cleaning -or scrubbing at night. The night-nurse should have a reversible lamp, -or something that without disturbing the patient, gives her light, -brighter than the dim fire or gas-light properly maintained in the -wards at night. She should have a room to herself. - -[Sidenote: Day Nurses.] - -4. The day-nurses should have eight hours’ sleep, and if it be -possible, 4 hours daily for exercise, private occupation or recreation. -They may have one room. - -[Sidenote: Nurses to fetch nothing.] - -5. All provisions, &c., &c., should be as much as possible brought into -the wards, or to the ward-doors, by lifts. Nothing should be fetched -by the nurses. This would save much time; would enable the nurses to -do more work, and yet have more leisure; and above all, would obviate -the great demoralization consequent on the nurses, patients, and -men-servants congregating in numbers several times daily. - -[Sidenote: Patients to fetch nothing.] - -6. The patients should be made as useful as possible, consistently with -their capacities, inside the ward; but should be permitted to fetch -nothing to it. - -[Sidenote: Scrubbing.] - -7. I strongly incline to have the scrubbing done in each ward, by a -nurse assigned for that purpose, and for general attendance when the -scrubbing is done. There should be hours for the scrubbing, before and -after which it should not be done. This whole matter is one on which I -am not positive at present. - -[Sidenote: Distribution of Ward Work.] - -8. At present, I incline to something of the following scale. Two -wards, single are best, but it might be one double ward, with 40 beds, -served by 1 head-nurse and 3 nurses. The head-nurse to superintend all -things, and to do the dressings not done by the surgeons and dressers, -assisted mainly by one nurse, whom she thus instructs in nursing. -Another nurse to do the scrubbing, and mainly the cleaning, and when -these are over to mind the ward during the remaining hours in turn or -in conjunction with the first nurse. The third to be night-nurse. In -the morning, before dressing begins, and before the night-nurse goes -off duty, all three nurses to clean the ward, make the beds, wash the -helpless patients, &c. - -[Sidenote: Hours of Dressing and Poulticing,] - -9. Hours of morning and evening poulticing and dressing to be fixed. - -[Sidenote: and of Medicine.] - -10. Hours of administration of medicine, always except at night given -by head-nurse, to be fixed. - -[Sidenote: Hours of Exercise, and Holidays.] - -11. Hours of exercise of head-nurse and nurses to be fixed, and -arranged with reference to the ward-duties. A fixed occasional holiday -given in turn to the nurses is good. An annual longer holiday for them -and for the head-nurses is good; a fortnight is, I think, a good limit. -The holidays cause inconvenience, no doubt, but on the whole do, I -think, far more good than harm. The holidays should be distributed in -rotation during a fixed time of year, and comprehended in two or three -months, or four at the very outside; and no woman declining her holiday -at the proper time should be allowed it at any other. - -[Sidenote: Permission of Matron for extra time out.] - -12. No head-nurse or nurse should be out of the hospital before or -after the limit of her daily exercise time, two hours, without written -permission of the Matron. The Matron, I think, should put the cause -and amount of the extension in writing, and report the same to the -Treasurer or Chief Officer, at the next general meeting, whenever it -is called, of the Officers of the Hospital. She will find this a great -protection against petitions. There is not a doubt that the fewer -extraordinary absences, the better. - -[Sidenote: Place of Exercise.] - -13. Were it possible to have a small garden (in college gardens much -effect and much refreshment is produced by a green sward, a few -trees, some shrubs, a fountain, and some seats), in this, at strictly -separated hours, the men-patients, the women patients, the head-nurses -and nurses, the men-servants, if they choose, which perhaps is not -likely, could walk or sit down. This arrangement would little interfere -with its enjoyment by the dignitaries and their children, who require -it quite as much, and would be found in its results practically and -not poetically useful. Hospitals are, and perhaps must be, in or near -crowded thoroughfares. Streets are miserable places to walk in during -great part of the year. Nurses want and unconsciously crave for fresh -air, and often half-an-hour is better than more, given them close -to their work--and away from the streets, it would be often a great -preservative. - -[Sidenote: Caution.] - -14. I should, however, be very cautious as to introducing music or -anything of that sort. Hospitals are not tea-gardens, nor homes, nor -meant to be either. Great quiet and some severity of discipline are -necessary, and ought to be exacted. - -[Sidenote: Dress.] - -15. I think the head-nurses should wear a regulation dress, and the -nurses another; if we adopt the honest word livery, in use in the -hospitals, it will perhaps do no harm. Caps, dresses, aprons, should -be prescribed: whether or not out-of-door dress should be prescribed -is to be considered apart. Each should have three dresses yearly. -Better, I think, avoid washing stuffs; they require endless change to -look decent. Head-nurses and nurses might wear the same dress, and some -difference in the cap would be quite distinction enough. - -[Sidenote: Wages.] - -16. I incline towards giving the head-nurses £50 a-year, one or two -rooms (one room with an alcove and curtain would be best), fuel and -light. The nurses lodging; the night-nurse a room to herself, the -others together; entire board, fuel, light, and good wages to be -decided upon. - -[Sidenote: Furniture.] - -17. The nurses’ rooms should be supplied with plain comfortable -furniture. In the large Hospitals the head-nurse furnishes her own -room or rooms, which doubtless promotes her comfort and her care of -the furniture, both desirable things; yet the tendency of many to -accumulate decorations, which take time to clean, &c., is a drawback. -I should be inclined, as an experiment, to try the furnishing plan, or -at least to have some scale as to furniture allowed. A bed, arm-chair, -and sofa; a chest of drawers, wash-hand table or shelf; book-case -or shelves; a little table, and a larger one, a couple of chairs, a -footstool, and a cupboard with broad shelves, are the utmost that can -be required. - -[Sidenote: Visitors.] - -18. A difficult and important point to settle is the amount of liberty -allowed as to receiving visits. It is desirable on all accounts to make -head-nurses and nurses feel comfortable, and, as it were, at home: -it is also better they should not be unnecessarily out; also London -distances are great, and even omnibus-fare is a consideration; also -it is important to remember that these women are apt to feel and say: -“We are not in a nunnery,” nor should they be. Still upon the whole, -considering the nuisance of ordinary visitors, and the greater nuisance -of extraordinary (_e. g._, visitors to some head-nurses, kind friends -come to see how we are getting on, &c., &c., &c.), I think if it were -possible to make the rule that no visitors are allowed, it would be -a great gain. I am not sure, at present, whether it is possible or -not--still less whether it is possible to keep such a rule, if made. -But, at all events, nurses and head-nurses should only be permitted -to receive visitors on certain days and hours of the week; and those -hours and days should be strictly kept to. In Military Hospitals a -still more rigid rule will be necessary. - -[Sidenote: Discharged Patients.] - -19. No discharged patients, however previously well-conducted, should -be allowed to visit the wards. - -[Sidenote: Graduated scale of Pensions.] - -20. Apart from raising the wages of good nurses after every ten years’ -service, I think it would well answer to establish a graduated scale -of pensions, for both head-nurses and nurses; beginning with a small -pension after ten years’ good service, increasing every five years -afterwards. Many women are quickly worn out in this life; and it is -equally undesirable to turn faithful worn-out servants adrift without -any provision, or to retain them in duties for which they are become -unfit. It is a question whether there should not be a compulsory -stoppage from wages, in order to entitle the nurses to pension under -conditions. - -[Sidenote: No occasional Wards.] - -21. Have no occasional wards, or wards for accidental and peculiar -patients. - -[Sidenote: Head-Nurse to each Ward.] - -22. Every ward, or set of wards, should be under a head-nurse. -Discipline is always defective under other arrangements. - -[Sidenote: Religious Influence.] - -23. This turns greatly upon a previous question. Every endeavour should -be used to bring the women under the influence of religion, God’s -instrument for saving, strengthening, and comforting souls. So far as -this work depends on rule, system, and superintendence, great things -may be done at any rate--so far as moral influence is concerned, it -can only be hoped for in the channels appointed by Him who turneth all -hearts whithersoever He will. - - -III. NURSES IN HER MAJESTY’S HOSPITALS. - -[Sidenote: Two kinds of Hospital Service for Females.] - -1. If their introduction is eventually commanded by the Queen’s -Government, it will be advisable to consider that their service admits -of two distinct kinds. - -[Sidenote: The one: its Advantages;] - -2. “Their chief duties” may be “taking charge of the linen and -superintending the issue of extras.” - -They will thus contribute materially to the comfort and well-being -of the sick; the real difficulties which undoubtedly beset the -introduction of women into ward service will be avoided; and, an -important consideration, not lightly to be discarded, their exclusion -from the ward service will materially diminish the opposition of -adverse masters, some of whom are also unscrupulous masters. - -[Sidenote: The other: its Advantages.] - -3. On the other hand, I suppose, the experience of every woman, -admitted to ward service in hospitals where women were not before, -is that many lives are actually saved by such admission, which would -otherwise, humanly speaking, be lost. In time of war some ciphers may -be safely added to the many. Any other great emergency, I suppose, but -do not speak from experience, would give the same result. - -That the experience of many surgeons is identical, their conduct has -proved; no other testimony, under present circumstances, can rationally -be expected from them. - -[Sidenote: Both to be Weighed.] - -4. It is often right to begin with the smaller and less-opposed good, -and to introduce gradually, and, as it pleases God, the remainder. It -may be our duty to do this, as to this matter. - -[Sidenote: Practical Superiority of the Second.] - -5. Practically, it is of little avail to superintend, ever so -carefully, the issue of extras to the sick, unless there is permission -and opportunity to pour the nourishment, perhaps in continual drops, -down the throat of reluctant agony, or delirium, or stupor. And it is -of little avail to have this permission, unless there be also that of -raising the decent covering under which cholera, erysipelas, or the -oppression of long recumbency, or the discharging wound, or the recent -operation lie, and seeing to matters within. It is a further question, -whether the painful cleansing of painful wounds, and the important -minor dressings, as poulticing, which things, generally speaking, never -have been done, and never will be done by surgeons, are best left to -nurses, orderlies, or the patients themselves. - -[Sidenote: Its real and great Difficulties.] - -6. At the same time, nothing is more pernicious than to under-rate the -objections of opponents. There is no doubt that the admission of women -to ward service is beset with difficulties. These Naval and Military -Hospitals are, and must ever be, peculiar Hospitals, essentially -different in important details from the Civil Hospitals. - -Sisters of Mercy, as regards the ward service, are decorous and kind, -and sometimes inefficient and prudish. Nurses are careful, efficient, -often decorous, and always kind, sometimes drunken, sometimes unchaste. - -Misconduct of women is far more pernicious in a Military or Naval -Hospital than in any other, as regards the result of things--the crime -is, of course, equally crime everywhere. - -[Sidenote: Condense numbers as much as possible.] - -7. It appears to me desirable to simplify and condense, as much as -possible, female service in these Hospitals. Let there be as few women, -and these few as efficient and as respectable as can be. Let all that -can really be done by men be so done. - -[Sidenote: Only Head Nurses.] - -8. Head-nurses are alone, I think, desirable to be employed; I -mean persons of the character, responsibility, and efficiency, of -head-nurses in other Hospitals. - -[Sidenote: Classify the Patients.] - -9. The patients should be distinctly classed, though, of course, this -is not the Female Superintendent’s business. - -There are many pros and cons to the formation of convalescent wards. - -It is a question whether convalescent or chronic patients require -female nurses at all. - -Of such chronic cases, probably 100 would be efficiently served by one -nurse, having orderlies under her. Of acute cases, probably, one nurse -should take charge of not more than fifty, possibly not more than forty. - -[Sidenote: Qualification of Nurses.] - -10. The nurses should be strong, active women, of not less than -thirty, nor, I think, more than sixty years of age, of unblemished -character, and should be irreversibly dismissed for the first offence -of unchastity, drunkenness, or dishonesty, or proved impropriety of any -kind. - -[Sidenote: Wages.] - -11. Their wages, I think, the same as those of head-nurses in Civil -Hospitals--certainly, not more. - -[Sidenote: Pensions.] - -12. Their pension on the same graduated scale. - -[Sidenote: Rules.] - -13. Their rules should be simple, very definite, should leave them at -the absolute disposal of the surgeon as to ward matters, and at the -absolute disposal of the Female Superintendent in all other matters. -Their dress should be uniform. - -[Sidenote: Duties.] - -14. Their duties should be strictly defined, and be consistent with -the Code of Army Hospital Regulations, the revision of which has been -announced. - -[Sidenote: Means of Steadying them.] - -15. Give them plenty to do, and great responsibility--two effectual -means of steadying women. - -[Sidenote: Lodging.] - -16. The nurse’s lodging in view of her ward renders her far more -efficient; but this requires some special arrangement. It would not do -to have the chance of the nurse’s being suddenly taken ill, with only -patients and orderlies within immediate reach. Were the nurses’ rooms -so arranged that two or more were on one floor (as is the case in all -Hospitals), and so arranged as to be entirely separate, and yet, when -so desired, easily accessible to each other, which might easily be -contrived, this would probably answer all purposes. - -[Sidenote: Food.] - -17. Their food should be sent them cooked with some slight variety. -With the plainest intentions nature often revolts from the perpetual -joint of excellent meat in Hospital air and life. The occasional -“potage,” fish, &c., of other systems, are in fact, a refreshing and -palatable change. If, however, avoiding names that shock and frighten, -some slight change of diet could be contrived, the effect would be -good. This is practical and not at all romantic, though it may look the -latter. - -[Sidenote: Opinion of honest Military Authority desirable.] - -18. Could the honest opinions be had of a few good Military and -Surgical Authorities before beginning, it would be good. - -[Sidenote: Female Superintendent-General.] - -19. The Female Superintendent-General’s own powers and responsibilities -must be absolutely fixed, and so as not to clash with those of the -Officer (should such an Officer be appointed, as has been elsewhere -recommended), who shall superintend the Hospital attendants. - -[Sidenote: Confidential Reports.] - -20. Confidential reports must be so modified, as far as women are -concerned, that the humble boon granted to pickpockets, of being -informed of accusations laid to their charge, must be extended to Her -Majesty’s nurses. - -[Sidenote: Permanency of the System.] - -21. In framing the system and the Superintendent’s own office, let it -be attempted to secure the permanent efficient working, please God, in -ordinary hands. To aim at the best conceivable may lead to failure. -Genius works with ordinary materials, but never constructs an edifice -which it alone can inhabit. - -[Sidenote: Quietness.] - -22. “In quietness and in confidence shall be your strength.” Quietness -has been from the beginning of its publicity the one thing wanting in -this work. I know the fuss, which from its beginning surrounded it, was -abhorrent to us and was the act of others: but the work, which is all -we care for, has throughout suffered from it. It is equally injurious -and impeding as regards surgeons, nurses, and people, who are neither. -External help in this coarse, repulsive, servile, noble work, for it -is all these things, is truly the reed which pierced the hand that -leant upon it. One hospital, naval, military, or civil, nursed well, -and gradually training a few nurses, would do more good to the cause -than an endless amount of meetings, testimonials, pounds, and speeches, -to say nothing of newspaper puffings, which to-morrow might turn into -revilings. This never will, never can be a popular work. Few good -ones are, for few are without the stern fructifying element of moral -restraint and influence; and though the streams of this are many, its -source is one. Hearts are not touched without Religion. Religion was -not given us from above in impressions and generalities, but in habits -of thought and action, in love of God and of mankind, carried into -action. - - * * * * * - -[Sidenote: Various Systems of Female Nursing compared.] - -A very short comparison will here be made between the methods of Female -Nursing in the Military Hospitals of - Russia, - England, - France, and - Sardinia, -as exemplified in the last War. - -[Sidenote: French and Sardinian Hospital Service.] - -To do this, a sketch must be partly repeated, which has been already -given, of the organic difference between the Hospital Service of each -nation. - -The essential characteristic of the French is, the importance given in -the field to the Divisional Hospital Service over the Regimental. - -The Regimental Medical Service treats only those ephemeral cases which -are to be exempted from duty for a day or two. Cases of wounds or -disease likely to last for a term of weeks are sent to the Divisional -Ambulance in the field; those, where disease may possibly last for -months, to the General Hospitals at the base of operations. - -The Medical Service of the Sardinians closely resembles the above -in its formation. In the late War, their General Ambulances were at -Balaklava; their General Hospitals at Jeni Koi on the Bosphorus. They -had no Divisional or Regimental Hospitals. - -[Sidenote: English.] - -In our Army, as is well known, the Regiment establishes its Regimental -Hospital wherever it goes. Theoretically, it is exclusively a -Regimental system of Hospitals; however much, practically, it breaks -down. - -[Sidenote: Russian.] - -The Russian system can scarcely bear a comparison with ours; -because their Regiments are Divisions. They had a regular system of -transporting the sick and wounded upon the North side of Sebastopol, -then upon Mackenzie’s Heights, then upon Bakschi-Serai, and lastly upon -Simpheropol. - -[Sidenote: Female Nurses.] - -The adaptation of Female Nursing to the different systems in the - French, - Sardinian, - Russian, and - English Armies -has now to be noticed. - -[Sidenote: Sardinian and French Female Nurses.] - -The Sardinians had Sisters of Charity, both in the General Ambulances -in the Crimea, and in the General Hospitals on the Bosphorus. - -The principal duties of these admirable women appear to have been the -care of the linen and small stores, and the cooking, much of which they -did with their own hands, for sick officers and men. These duties were -admirably performed. They appeared, besides, to have a certain charge -in the wards, the power of giving “_douceurs_,” the administration -of extras, the seeing to the cleanliness of beds and patients, and -something more precise with regard to sick Officers; but their duties -seemed to be somewhat undefined in their relation to the Infirmiers. -Whether the Sœur or the Infirmier Major were in charge, to see the -duties about the patient properly executed, was rather a problem. - -This was still more the case in the French Hospitals, where the “Sœur” -in the wards appeared more of a “consolatrice” and an administratrix of -extras: although, out of the wards, her admirable housekeeping, both in -the kitchen and the linen-store, was predominant. - -The French “Sœurs” were not admitted to the Divisional Ambulances -in the front: it was whispered, because of the corruption of -the French Intendance, upon whom they tacitly exercised a very -inconvenient “surveillance.” They served in all the General Hospitals -at Constantinople; and to their admirable services, M. Baudens, -Inspecteur-Général en Crimée, has rendered an “_éclatant témoignage_” -in his “Mission Médicale en Orient,” published in the numbers of the -“Revue des Deux Mondes,” of February 15, April 1, and June 1, 1857. - -In these French Hospitals of Constantinople, the “Sœurs” appeared to do -all the cooking for the sick Officers and that of the extras for the -men. - -I do not think that, in either French or Sardinian Hospitals, the -care of bed-sores and such like, which can only be done by women, was -sufficiently given to the “Sœurs.” - -I have heard complaints made of this kind both by Officers and men; and -“Sœurs,” both French and Sardinian, have been to me to look at the way -in which we treated bed-sores, and to borrow air-pillows and water-beds. - -There is such a difference however in different Hospitals, in time of -war and of peace, &c., that I would not be understood to mean that any -of these remarks apply absolutely or generally, but only to Hospitals I -have seen. - -It may be as well to mention that, talking of “French” and “Sardinian” -Sisters, they all come from one “Maison Mère,” that of the “Filles -de la Charité de S. Vincent de Paule,” at Paris. There is a “Maison -Succursale,” at Turin. But all are of the same Order, and under the -same head. - -Let me mention Sœur Cordero, the excellent Superioress of all the -Sisters employed in the Sardinian Hospitals of the war, with the -warmest affection and respect. She was a woman of high rank, of the -most captivating manners, but of the utmost simplicity of character, -and of unfailing devotion to right and to God. - -[Sidenote: Russian.] - -It remains to mention the Russian system, which, as regards the -organization of the duties of the “Sisters,” appeared to me by far the -best I have known. I am at a loss to conceive what is meant by the -following sentence in the Report by two of our Army Medical Officers on -the “Russian Medical Department,” presented to the House of Commons. -Speaking of the Sisters of Mercy, who are generally widows of officers, -it is said “their chief duties appeared to be in taking charge of the -linen and superintending the issue of extras.” This is founded on error -of observation--as the Russian system seems to be the only perfectly -organized system of female attendance in Military Hospitals, which was -developed in the Crimean War. In it, the Sister has charge of all that -relates to the bed-side of the patient; she receives the orders from -the Medical Officer, attends him in his rounds; he confers with her -afterwards; she even reports the “felchers” or dressers, as also the -orderlies, as far as regards their discharge of duties at the bed-side -of the patient. The orderlies are, of course, under the control of a -Non-commissioned Officer, in all that pertains to discipline, clothing, -meals, &c. The “felchers” are under a superior “felcher,” and under the -Medical Officers. - -There are female nurses, wives and widows of soldiers, under the -“Sisters,” who are generally, as has been stated, widows of Officers. - -This appears the nearest approach to good organization I have met with. - -But again I say there may be much difference among the Russian Military -Hospitals. I would not be considered as laying down an absolute -experience. - -[Sidenote: English.] - -It has been said elsewhere what was the system or no system pursued -in the English Military Hospitals, as to Female Nursing. It was a -new thing, and no General Order or Warrant was ever issued as to the -duties of the nurses. Many duties clearly devolved upon the Female -Superintendent-General, as she was afterwards called in “General -Orders,” which never should devolve upon her again. - -[Sidenote: Proposed Duties of Female Nurses in Military Hospitals.] - -But it may be now clearly enunciated what the duties of Female Nurses -should be, and many reasons will subsequently be given why there never -will be discipline in Military Hospitals till they are as follow: - -Women only of the character, efficiency, and responsibility of Head -Nurses in other Hospitals should be admitted into Military ones. They -should have charge and be responsible for all that pertains to the -bed-side of the patient; for his cleanliness, and that of his linen, -bed, and utensils; for all the minor dressings, not performed by -Surgeons or Dressers; for the administration of medicines, and of the -meals; for the obedience of the patient and orderlies to the orders of -the Medical Officer. They should receive the orders of the latter, and -always attend him in his visits. - -Till the above is done by women, the same want of discipline, now to -be observed in Military Hospitals, and often already noticed, will -continue,--such is my firm belief, the result of much experience. - -[Sidenote: Duties which should be left to men.] - -There will be abundance left for the Ward Master or Serjeant to do -in taking Military charge of the Hospital and its inhabitants, in -being Office Clerk, &c., _i. e._, keeping the Admission books, making -States, Returns, Accounts, and other documents, without his being -Head-Nurse, without his superintending the Orderlies at the bed-side, -his administering medicines, &c., which can only be satisfactorily done -by a woman. And, when done by her, there will still be ample work for -two men, where one does now the work of three. - -The first should do the Military part, the second should compound, -take charge of Medical and Surgical stores, of Returns and Accounts -connected with these; and, where there is no Purveyor, of Purveyor’s -and Barrack stores, provisions, cooking, washing, diets, and extras, -including Returns and Accounts connected with these. - -As it is, there is one Hospital Serjeant, who is Ward-Master, Serjeant, -Steward, Clerk, Dispenser, Purveyor’s Clerk, and Head-Nurse--a kind of -“Maître Jacques,” as in Molière’s “Avare.” - -One man cannot do all these things. - -A Female should be the Head-Nurse--a Serjeant should be the Serjeant -and Clerk--a Ward-Master the Steward, Dispenser, Ward-Master, and -Purveyor’s Clerk. - -And here I must deplore the confusion unavoidable in these definitions -of proposed duties, while we have no separate system for Regimental and -General Hospitals. - -What Dr. Menzies declared, in his evidence as to the General Hospitals -at Scutari, is strictly true, and one great cause of our failure at -Scutari:--“I have followed the general rules for Regimental Hospitals, -so far as I could.” - -While Regimental Hospitals are what they are, females never can be -admitted there. On the other hand, if General Hospitals be established, -one happy consequence will be that the cooking and washing will -be taken out of the hands of the Hospital Serjeant, and regularly -organized, it is hoped under a Captain-Superintendent of Orderlies. All -Purveyor’s and Barrack stores, that is, Hospital stores and furniture -will, it is hoped, fall under the charge of a Steward; Medical and -Surgical stores under that of an Apothecary. - -It will only remain to place a female Head-Nurse in charge of all that -concerns the bed-side of a patient, and the duties of the Orderlies -about the bed-side, and a Ward-Master in charge of everything else -belonging to the Orderlies and Patients. - -But, if it should be determined to retain everywhere the old Regimental -system, it is only just to add this very strong testimony and appeal in -favour of the old Hospital Sergeant, who indeed deserves it:-- - - “I may take this opportunity of stating my conviction that, from - the very arduous, constant, and responsible duties of the Hospital - Sergeant, and his influence for good or ill among the non-commissioned - officers and men of the regiment, it is particularly required for the - good of the service that he should be put at least on the same footing - in rank and pay as a first-class staff sergeant. He ought to pass - an examination by a Board of Medical Officers as to his fitness for - compounding medicines on the same footing as a druggist in England. My - Hospital Sergeant, who has been eight years a sergeant, three of which - as Hospital Sergeant, receives at present 1_s._ 10_d._ pay per diem, - and an allowance of 4_d._ per diem as Hospital Orderly; at the same - time that there are sergeants in the ranks of the regiment four years - junior to him as a non-commissioned officer who are receiving 2_s._ - 10_d._ pay per diem. - - “My experience leads me to consider that the regimental bandsmen are - not, as a body, likely to be sufficiently strong or able men for the - duty of carrying the wounded to be consigned to them. - “(Signed) - THOMAS LONGMORE, - “_Surgeon 19th Regiment_.” - - - - -NOTE IN REGARD TO THE RUSSIAN NURSES EMPLOYED IN THE WAR-HOSPITALS OF -THE CRIMEA. - - -The Russian nurses, in the opinion of their Master, the famous -surgeon, Pirogoff, did other things besides what the Army Medical -Director-General told the House of Commons they did. But it is to be -observed-- - -In the first place, that much allowance is to be made for the confusion -incident to Scotch and Russian surgeons talking French together, and -going over many subjects in a very short time. - -And in the second, that very likely some extra confusion arose in -the minds of our Army Medical Officers from the fact of two entirely -different sets of women having served in the Russian War Hospitals, -viz.: - -(1.) The Sisters of the Elevation of the Cross. - -(2.) The “Frauen des Barmherzigen Wittwen Instituts,” (mentioned -in a very cold manner in pages 4, 26, and implicitly, 27, of -Professor Pirogoff’s pamphlet, “Die Gemeinschaft der Schwestern zur -Kreuz-erhöhung. Berlin: 1856”); who are those spoken of at pp. 22, 23, -above. - -The Widows were so instituted, about forty years or more ago, by Mary -of Wirtemberg, during so many years the venerated Empress-Mother. It is -quite possible that in the war-pressure their services proved rather -nondescript, they being neither sisters nor nurses, strictly speaking; -or perhaps the sole reason why Professor Pirogoff has not one good word -for them is, that they were not under his orders. - -The Sisters of the Elevation of the Cross were a body of secular women, -with a few Sisters of Mercy, formed by the Grand Duchess Helena, and -placed by her under the orders of the famous civilian Surgeon Pirogoff, -to whom the supreme surgical command in Sevastopol was virtually -given. Several things are incidentally mentioned concerning them in -his pamphlet, quite inconsistent with the constitution of an ordinary -religious order. - -One or two things in the pamphlet are incongruous enough to English -ideas:--the narrative given, however simply and succinctly, of the -performances of the sisters by name, the publication of the Professor’s -evident disagreement with the first “Oberin,” or Superior, who served -ten months, (the second, whom he so highly praises, had only served -two when he wrote); the improvement, by which the Sisters’ concerns -were “sat upon” by the Comité of Oberin, Chaplain, Doctor, and elder -Sisters, &c., &c. - -But the division of Professor Pirogoff’s war-nurses into three -categories is a pregnant hint for future service, please God we yield -it. These three categories consisted of (1) the “Verband-Schwestern,” -or those who assisted the Surgeon in the dressings, and the -“Feld-scherer” (Dresser) in preparing them. (2) The “Apothekerinnen,” -or those who were in charge of all medical appliances for immediate -use, and who superintended the “Feld-scherer” (Dresser) in the -administration of medicines. (3) The “Wirthinnen,” who looked after -the diets, clean linen, &c., of the patients, and the order of the -hospital. Each “category” was responsible for carrying out the orders -of the medical officers. To every Hospital-_Baracke_ (hut) was attached -one sister of each of the above descriptions. - -In ordinary service the less nurses know of each other’s wards the -better--in war service it is essential that as few women should serve -as many sick as possible; and it is impossible to attempt assigning to -each nurse the entire supervision of a ward. I think the categories, -modified, of course, and adapted to the Queen’s service, might be most -useful. - -Another point usefully proved by Professor Pirogoff’s pamphlet is the -extreme importance, if it be possible, of placing the nurses clearly -under the orders of the Principal Medical Officer, though a further -point is, if possible, to be secured, viz., that of the Principal -Medical Officer being favourable to their service. As women they -should be entirely under the control of their female superior, yet the -Principal Medical Officer should have a certain clear amount of power -in ordering that Superior as to their employment at particular stations -and on particular services. - -The _Transport Abtheilung_ of the Russian sisters seems to have been -an admirable, though very unpretending service. We might take a useful -hint from it. Three Sisters accompanied the more numerous[1] convoys of -Sick Transport from Simpheropol to Perekop, and provided the sick with -tea, sugar, clean linen, medical and surgical appliances, &c., on the -way. - -FOOTNOTES: - -[1] According to Professor Pirogoff sick were almost daily sent -from Simpheropol to Perekop. They could not, therefore, be always -accompanied by Sisters. - - - - -SUBSIDIARY NOTES AS TO THE INTRODUCTION OF FEMALE NURSING INTO MILITARY - HOSPITALS IN PEACE AND IN WAR. - - -It is, perhaps, advisable first to speak of some of those difficulties -met with in the War Hospitals of the East, in order that such may be -prevented for others who may in future be Superintendents-General of -Nurses in Military Hospitals whether in peace or in war. - - -I. - -No one ought to undertake a matter of duty of this kind without first -obtaining the consent of the War Office to five conditions. - -1. That every month, each of her sub-Superintendents shall furnish -her with an abstract of the requisitions made by her on the Purveyor, -whether for Nurses’ consumption, or for that of Patients, and that she -furnish the War Office with an abstract of these. It is then the part -of the Purveyor to disprove her accounts, instead of its being, as -before, her part to disprove his. - -2. That it be made a point of honour, not of grace, with the War -Department, to submit to her any Report, confidential[2] or otherwise, -made concerning the Female Nursing Staff; a condition, without which it -would be impossible to have respectable women in the Military Service. - -3. That the powers of the Superintendent-General shall be strictly -defined, and put in “General Orders” in the first place, and not in -the last, in order that there may not be the useless and endless -correspondence which there was in the first Superintendent-General’s -case (and for what?). - -4. That the Superintendent-General have the power of communicating -directly with the War Department; and that her Money-Accounts be sent -in by her directly to that Department. - -5. That it be made a point of honour that the Medical Officers -communicate to the Superintendent-General, or Local Superintendent, any -complaint they may have against the Nurses for disobedience. - -In March 1856 the following appeared in “General Orders.” Had it but -been seventeen months earlier how much it might have saved![3] The -definition of the Superintendent-General’s powers and duties, therein -contained, is all that is wanted to prevent irregularities disastrous -to the Service. - -GENERAL ORDERS. - - _March 1856._ - -“It is notified, by order of the Secretary of State for War, that Miss -Nightingale is recognized by Her Majesty’s Government as the General -Superintendent of the Female Nursing Establishment of the Military -Hospitals of the Army. No lady, sister, or nurse is to be transmitted -from one Hospital to another, or into any Hospital, without previous -consultation with her. Her instructions, however, require her to have -the approval of the Principal Medical Officer, in her exercise of the -responsibility thus vested in her. - -“The Principal Medical Officer will communicate with Miss Nightingale -upon all subjects connected with the Female Nursing Establishment, and -will give his directions through that lady.” - - -II. - -_Nurses._ - -1. Our Nurses were of four sorts. - - Nuns. - Sisters (Anglican). - Ladies. - Nurses. - -The Nuns were received not as Nuns, but as Nurses. - -Their (so called) training told sometimes against us; sometimes for us. -The same with the “Sisters” (Anglican). - -The Ladies were useful, exactly in proportion as they approached the -professional, and not the dilettante, mode of thought. - -A larger proportion of paid Nurses than of Ladies did well, and this -under circumstances of peculiar temptation. Paid Nurses are always the -most useful. - -2. There should always be a proportion of Nurses in Army Hospitals - - To preside in Extra Diet Kitchens,[4] - ″ in Linen Stores. - To teach the Orderlies to nurse in the Wards. - -The proportion of Roman Catholic “Sœurs,” in French Military Hospitals, -is as small as this would be; they undertake even less duty than this: -in Military Hospitals they do much less than in Civil Hospitals. - -Women in Military Hospitals should all be contracted servants, whether -Nuns, Ladies, or professional Nurses. - -There should be a retiring pension to each woman. - -3. Miss Nightingale took service on the ground of being under the -Principal Medical Officer, and, consequently, of not interfering with -him. - -There was no _imperium in imperio_ in her case. - -This exists in the case of the French “Sœurs de Charité,” and existed -in individual instances among the “Sisters” under Miss Nightingale; -_i. e._, they gave articles of diet, &c., as from Sisters, not in -obedience to Medical orders. This was immediately put a stop to by -her. That the Medical Officer is sole master of diets, is an axiom of -medicine, and of common sense. - -This involved our only _answering_ the Extra Diet Rolls in our -kitchens; not originating either in quantity or quality. - -Afterwards, although frequent were the insinuations that we -transgressed the above maxim, no evidence of the fact was ever -obtained, except the following, which is given _verbatim_ and -_literatim_, as “put into Court” by a First Class Staff-Surgeon, in -charge of one of the divisions of the Barrack Hospital, Scutari. He -alleged “that the Nurses were in the habit of giving diets without -leave;” and when pressed for the facts, produced the annexed statement -in “W. J. Northcott’s” handwriting. - - “2447. Pte. John M‘Cormick, L. T. Corps, age twenty, 11 Company, - admitted into 6 Ward, F. Corridor. Admitted with Febris C. C., - April 30th, 1856. On or about the 10th of May I was confined in the - Garrison Cells, Scutari, for allowing food and drink to be brought to - this Patient, by one of Miss Nightingale’s Nurses; and at the time - it was brought I were on duty at the Victoria Barracks, Scutari, - three-quarters of a mile from the Hospital, and never saw the Nurse, - food, or drink that was administerd to the above-named Patient, and - I never saw the docter that ordered me to be confind. I was confind - by order of 1st Class Staff-Surgeon Prendergast. About two and a half - hours after I were aquanted with the case. - - “(Signed) - 173. W. J. NORTHCOTT, - “A.W.M., M S.C.” - - -III. - -[Sidenote: 1. Lay down distinctly the communication which is to take -place between Director-General and Superintendent-General, and (in war -and abroad) Principal Medical Officer and Superintendent-General, and -the qualified subordination of the latter.] - -1. In defining the office and duties of the Superintendent-General of -Nurses, her direct communication with, and qualified subordination to, -the Director-General of the Army Medical Department, and, abroad and -in war, with and to the Principal Medical Officer of the district, -or equivalent, must be very exactly defined. If the formation and -government of a body of women to serve in the Hospitals of the Army -Medical Department, and in these alone, is contemplated, the less -the Director-General and the Superintendent-General have to do with -each other, in matters of detail, the better, and the less chance of -collision. For very weighty moral and practical reasons, the sole -government of the women must belong to the Superintendent-General, and -to the Matrons, whom she delegates, and who are themselves responsible -and amenable to her. But it will never _work_ to introduce female -service into the Army Hospitals, and to leave the Director-General -of the Army Medical Department, which, like everything else in the -Army, is and must be a hierarchy, no other power in connection with -it, than to write and encourage confidential reports against it. There -ought to be a definition of the Superintendent-General’s position as -regards him, and also, as regards the Principal Medical Officer of the -district, abroad and in war. It is useless, and would be dangerous to -evade this; it ought to be deliberately settled, and distinctly stated. -In the “General Orders” of March 1856, the Superintendent-General’s -complete power over the women, and qualified subordination to the -Principal Medical Officer, are well and definitively expressed. - -It is impossible to appoint the work of the Nurses without the -concurrence of the Director-General. It does not do to put a woman -into a great ward, or several smaller wards, of men, with several -orderlies, without clearly defining her position there. To put her -under the orderlies would be to make her being there at all much worse -than useless; but she cannot have assigned to her the responsibility of -the ward or wards, and consequently, authority over both orderlies and -patients, herself being responsible to the Surgeon and Matron, without -the concurrence of the Chief of the Army Medical Department. - -Nor, without such concurrence, can the duties of the Nurses be -assigned. At this moment there are extant two sets of Regulations--the -old Army Hospital Regulations, and those of 1855 made for the late -Medical Staff Corps. In these Regulations, both the former and the -latter, every duty a Nurse can discharge is assigned to different -men. The responsibility of the ward, the administration of diets -and medicines, the application of poultices, fomentations, leeches, -enemas, and minor dressings, are all in so many words assigned as the -duties of Assistant-Surgeons, of Hospital-Serjeants, and Orderlies; and -of Assistant-Surgeons, of Ward-Masters and Orderlies of the Medical -Staff Corps. The Regulations in general are being revised;--so much -the better. But the new body of Orderlies, announced in the “Gazette” -as the Hospital Corps, will, of course, receive rules from the -Director-General; and if these things are not settled with him, there -will be contradictory rules in operation, which will most materially -thwart the working of the Female Service. - -We have ourselves experienced this, as to the administration of -medicines, which one Principal Medical Officer took away from the -Nurses, saying that it was the duty of the Assistant-Surgeons, in which -he was borne out by an existing Regulation. And it would really seem as -if this were the intention of the said Regulation, for it is there laid -down that the medicines are to be administered twice-a-day, as if this -were a property of medicine. - -The existence of these Regulations proved also a great stumbling-block -in the Castle Hospital, after the war-pressure was over. - -Unless the Director-General, and in war and abroad, the Principal -Medical Officer, are brought into regular communication with the -Superintendent-General of Nurses, by the Rules, they will, at every -inspection of Hospitals, revert to the procedure of giving orders -and making alterations, which in fact amount to reprimands on the -Superintendent-General, and on her Matrons, through the medium of some -Clerk or Orderly. There should be, therefore, a distinct channel of -communication laid down between the Director-General, and in war and -abroad, the Principal Medical Officer and the Superintendent-General of -Nurses. - -[Sidenote: 2. Also between Principal Medical Officer and Matron, -Staff-Surgeons and Matron, Staff-Surgeons and Nurses, and the qualified -subordination of the Matron and Nurses.] - -2. Also, and in the same way, there should be distinct rules for direct -communication between the Principal Medical Officer of each Hospital, -and the Matron, and between the Staff (or equivalent) Surgeons of the -Hospital, and the Matron; if not also between these latter and the -Nurses. - -The constitution of a General Hospital is about to be organized in -England. In the large War Hospitals there was the Principal Medical -Officer, a Staff-Surgeon in charge of each Division, then the -Assistant-Surgeon, who answered to what, as is now proposed, is called -the Prescribing Medical Officer of the Wards. As regards the Matrons -and Nurses, it must not be proposed to ignore all but these Prescribing -Medical Officers. Certainly, it would never do to give the Superior -Surgeons of the Hospital no _say_ as to the nursing. In 999 cases out -of 1,000, the Superior and older Surgeon is the one who understands and -cares much the most about the men, and who, therefore, in the long run, -would more appreciate and be fairer to Matrons and Nurses who did their -duty by them. The Superior and older Surgeons too, in general, have -far more correct ideas of the importance of discipline in a ward, and -of the ways of maintaining it, than the Assistant-Surgeons. Moreover, -as far as one can judge on a mysterious subject, generally speaking, -the older and Superior Surgeon is the honester man. He must be brought -into direct communication with the Matron; this will effect good, and -prevent mischief. So also let the Staff-Surgeon of the Division, or -equivalent, be placed in direct communication with the Nurses of the -wards of his Division; this will effect good and prevent mischief. If -the Nurse is to trust to receiving the orders of the Staff-Surgeon, -through the medium of the Assistant-Surgeon, she will often find -herself in a false position. - -[Sidenote: 3. All the General Hospitals cannot be undertaken at once. -(The material of Head-nurses to be created.) Secretary of State -should be made aware that the Female Service can only be introduced -gradually. Director-General must have a voice in the introduction. -Director-General and Superintendent-General differing, Secretary of -State to decide.] - -3. Now, as to the introduction of Nurses into all General -Hospitals--this gets rid of many difficulties, but at a fearful cost. - -For years to come, the difficulty will be not to extend the work, -but to serve such Hospitals as must be undertaken, with respectable -and efficient women. The material has, in a great degree, to be -created; abundance of applications will be received--the prospect -of a pension alone will do that--but the real choice will be very -limited. In these Military Hospitals each Nurse must be a Head Nurse, -and a trustworthy woman. Many a woman who will make a respectable and -efficient Assistant-Nurse under the eye of a vigilant Head-Nurse, -will not do at all when put in a military ward or wards, herself the -only woman, and Head-Nurse over the Orderlies. As a body, the mass -of Assistant-Nurses are too low in moral principle, and too flighty -in manner, to make any use of here. Supposing all the Head-Nurses of -the great Civil Hospitals[5] offered themselves, there are perhaps -not many who could be recommended for a _Military_ Hospital. Some, -who are very highly to be thought of, would never bear transplanting -into the _res dura et_ servitii _novitas_ of the Army Hospitals. -The class from which the Head-Nurses are mainly drawn, tradesmen’s -and servants’ widows, &c., will volunteer in numbers, but, in the -majority of cases, intending only to lead the idle life of many a -London Head-Nurse--“mental, not manual labour”--“Superintendence”-- -_i. e._, standing by while the Orderlies do her work and their own. -The material has to be created. The rarest powers can do nothing -effective in this, in 3, 6, or 12 months. To lay a solid foundation -will take the patient, anxious labour of years. To begin with one -Hospital would have great advantages. Netley, if it is proceeded with, -might be the one, though, in most respects, a Hospital in an ordinary -vulgar seaport would be far preferable. Then let the work gradually be -extended. It is much more to be feared that the line will be taken of -forcing prematurely than of opposing its extension. If it is attempted -to occupy all the General Hospitals at once, how is the gratuitous -repetition to be avoided of the inevitable misfortune of Scutari, -viz., that of beginning on a large scale, with a number of strangers? -It certainly should be left to the Director-General to regulate the -introduction of Nurses into the General Hospitals--and there is far -more reason to fear that he, if unfavourable to the change, will -hurry, than obstruct such introduction; indeed it might be better to -settle that matter beforehand with the Secretary of State, letting -the Director-General be apprised of it, viz., that time is required to -effect the gradual introduction of the Female Service with which the -Superintendent-General has been charged. - -To sum up. A rule must be introduced by which the Director-General -is brought into communication with the Superintendent-General, and -her qualified subordination to him distinctly expressed. Let the -Principal Medical Officer in war also communicate directly with the -Superintendent-General or the person performing her functions in the -War-Hospitals, and her qualified subordination to him be distinctly -expressed. The same with each Principal Medical Officer of a Hospital, -and the Matron of that Hospital. No alteration in these Regulations -can, of course, be made without the consent of the Secretary of State. -In case the Director-General and Superintendent-General finally differ -as to any new arrangements, the matter should be referred to the -Secretary of State. - -The Superintendent-General should issue special regulations for nurses, -after conference with the Director-General, and under the sanction -of the Secretary of State; also, local regulations for the Matrons -with the consent of the Principal Medical Officer and sanction of the -Governor of any General Hospital. - -If the Matron differ with the Principal Medical Officer, the decision -should rest with the Governor of the Hospital. - - -IV. - -As to some miscellaneous considerations, of no small importance-- - -[Sidenote: 1. Roman-Catholic Sisters?] - -1. It is necessary for a Superintendent-General to have counted the -cost, and to be prepared or not prepared to include Roman Catholic -Sisters among the Nurses. This will deprive her of some valuable women; -of one (speaking for the present time,) who is invaluable; of many -decorous, not very useful women. The question is perhaps settled by -the fact, that where you have the Roman Catholic Sister, you cannot be -secure from the Roman Catholic Direction, with all its many strings, -and machinery of opposition. Abroad the cause of the Roman Catholic -Church is often the cause of religion; and the Romish Priest serves -both zealously at the same time, and with a pure heart. In England, -and in matters of England, the first aim of the Direction is too -often to damage what is not Roman, and the second to promote what is -Christian. Upon the whole I must think Roman-Catholic Sisters are -better out of, than in, the Army Hospitals. It would be right to think -well over how far they could be entirely dispensed with, in the event -of having soon to undertake a War Service. - -In the event of a decision being made to dispense altogether with -Roman Sisters, it would be as well to be prepared (though we never can -speculate on the tactics of the Roman faction, and after what occurred -during the Crimean war, it may think it better to take things quietly) -for a battle, (_not_ confined to the Army Medical Department,) for -the production of an Inspector-General’s letter assigning “reasons” -for preferring Nuns to secular Nurses, and for the delivery of sundry -opinions of similar purport, ranging from that line to the one taken -in the paper emanating from the Army Medical Department, extolling the -Russian Nurses, “who were all Sisters of Mercy, and mostly widows of -officers.” - -[Sidenote: 2. Anglican Sisters?] - -2. The nature of the Service and Rules would, unless in war service, -perhaps exclude English “Sisters” from the Nurses. They supplied us -with some valuable women in the last war, and their Lady-Superior -behaved ever generously, loyally, and well towards us. - -The principle and detail of most sisterhoods render them unsuited -for admixture with the secular element; and the comfortable belief -into which the good women (of both branches) practically, if not -theoretically, settle, that secular women are too bad to be mended or -influenced, unfortunately makes their usefulness among Nurses nearly -null. It would never do to unsettle any of the Sisters; but if it so -happened that any voluntarily offered to serve as bonâ fide Nurses, -some valuable individuals might thus be acquired; but this should not -at all be pressed. - -It would certainly remove a difficulty in declining Roman Catholic -Sisters, if the rule should be to decline also English Catholic -Sisters, forming the Staff entirely of secular women. - -[Sidenote: 3. Whom is the Nurse to summon in case of disorderliness in -the Ward?] - -3. In Civil Hospitals there are three distinct elements of government. -First, the Civil Authority; the chief being the Treasurer, or the -equivalent civilian, whose subordinate is called diversely Steward, -Superintendent, House Governor; second, the Physicians and Surgeons -(duly represented, in case of holidays or illness, by the Assistant -Physicians or Surgeons), Apothecary and House Surgeon; and third, the -chief of the Nurses--the Matron. - -It requires of course temper, discretion, forbearance, and fortunate -circumstances which do not always happen, for these authorities not to -spend a portion of their time in quarrelling with each other; but the -ruts are old and deep, and the wheels move on, though they often stick. -The Civil Authority is a very important element, especially when the -chief is a man of judgment and firmness, who keeps himself paramount -over all, and does not delegate all to his subordinate the Steward. The -Steward and the Matron generally find their duties disposed to clash. - -In some Hospitals the rules are inexplicit in assigning power to the -Matron over all the women. But this apart. The Steward represents and -wields the police of the Hospital. He progresses through the wards, he -perceives, or the Head Nurse reports to him, something disorderly. He -rectifies it (or not, as the case and the man may be). She thus, over -and above her relation to the Matron, has to appeal to, and to account -to, the Steward. - -This power of police and discipline, wielded by the Civil Authority -of the Hospital, is of immense moment in regulating the good order -of the Hospital; it acts in sundry important ways which need not be -particularized. - -Now, in the case of Military Hospitals, there is one important -simplification of the business, which need not be enlarged upon. All -the patients are men. But there are two things which do not simplify -the machinery of the Military Hospital. The attendants, in the plan -proposed, are not (and cannot be) all Nurses, under the Matron; nor -all Orderlies, under an Officer; there are Nurses under a Matron, -and Orderlies under some Officer; and there is no Civil element. -The Doctors both prescribe, and hitherto have governed. An Officer -orders flogging, &c.; but the Doctors practically both prescribe, and -hitherto have governed. And a Military Hospital must, and should ever -remain, essentially different from a Civil Hospital; both different -in discipline and detail, and altogether a rougher and ruder place. -It should never for a moment be forgotten that the soldier is a very -peculiar individual, old and stern as is his trade. A regiment, if one -thinks _into_ it, is a curious thing. The Hospital which receives these -men when ill and wounded, whether regimental or general, is, and ought -to be, a place essentially different in many things from the great -Civil Hospital. The moral standard of the patients of the Military -Hospital, their readiness to obey, their good feeling to each other, -are strikingly higher than in the Civil Hospital; but the soldier is -what, amidst all his faults, he has been made by the habit and spirit -of discipline, which has become an instinct and a second nature, and -which ennobles his own. Relax discipline, and in proportion as you do -so, there remains of the soldier a being with as much or more of the -brute than the man. - -Discipline then being the pivot upon which the good order of all -military things, Military Hospitals included, turns, it follows, that -if you set down a few women (they should not be many) in a great -Military Hospital, unless they can become effectually incorporated into -the general spirit of discipline of the place, they will only injure -themselves and the whole. - -As women, the more entirely they are under the government of the -Matron, herself under the government of the Superintendent-General, the -better. As Ward Nurses, the more entirely they are under the orders -of their Surgeons, the better; but they have not only to obey the -Surgeons, they have to enforce the Surgeons’ orders among the patients, -and both for so doing, and for the cleanliness, &c., of the ward, they -have to give orders to the Orderlies. - -In the case where a rule will work, by which, if the Nurse has to -complain of an Orderly, she reports the same to the Matron, who lays -the complaint before the chief of the Orderlies (whatever may be fixed -upon as his name); well and good; but a more direct procedure will also -be found necessary. - -Every firm and discreet woman (none other is fit for a male ward, -least of all for a military ward), will avoid collisions, reports, -and violent outbreaks in the ward as much as possible. But still, -every now and then these things will happen, and though by all -means to be avoided if possible, when they do come, they clear the -ward-atmosphere like a storm, provided the discipline be strict. Every -now and then--and every experienced Head Nurse will tell the same -story--some disobedience, slovenliness, truculence, or sly impudence, -will arise in the ward, and she will find she cannot put it down -alone. If she remain helplessly deprecating or scolding the men, her -position becomes at once an unseemly and a dangerous one, as that of -all contemned authority is. In such a case, in the Civil Hospital, the -Head Nurse goes straight, according to the nature of the case, to the -House Surgeon or to the Steward, unless the visiting hour be at hand, -and she judges it best to refer to the Surgeon. Discretion is again -here required, as in everything in Hospitals; but between the Surgeon -and the Steward, a firm, discreet Head Nurse will generally get the -ringleader expelled, and two or three others, named or unnamed, warned -of a similar fate. After this sort of explosion, the ward is quiet and -orderly for months. The thing is seldom done, but the patients know it -can be done at any time, and that it will be done, in such or such a -contingency. - -Now the soldier cannot be turned out of Hospital, and he knows -he cannot. It becomes the more important not to suffer an hour’s -relaxation of discipline there. If, therefore, such an outbreak, either -on the part of patients or orderlies, should happen in a Military -Hospital, the Nurse ought to be able to summon at once the proper -authority and afterwards to report the whole to the Matron, but first -to bring direct the proper authority into the ward. Whether it be the -Captain of Orderlies or the Orderly Medical Officer, or, as in case -of emergencies, is generally preferable, the Staff-Surgeon himself, -she ought to have power at once to bring the proper authority into the -ward, to put down confusion and restore discipline at once, and then -afterwards to report to the Matron what has passed. - -It must never be forgotten, that in every Regiment we must calculate -upon there being two or three thorough scoundrels, five or six men -who are not far off from being so, and an indeterminate number whom -discipline saves from ranking after them. One year with another, -characters no doubt as vile as the worst that disgrace our gaols pass -through the General Hospitals. - -Another thing to be remembered is, that whatever classification may -be carried out, we may be certain beforehand that numbers of patients -from a vile cause will be in the ordinary surgical wards of every -General Hospital in time of peace. Very severe cases of this sort give -heavy work, and little trouble. They suffer much generally, alike -from disease and treatment; are frightened, if not ashamed, about -themselves; and are generally extra-submissive and quiet. These cases, -however, generally would belong to the separated wards; which latter -contain usually a large admixture of patients who suffer comparatively -little, and who require to be dealt with with unswerving firmness. For -reasons somewhat too technical to write, it is to be hoped, upon the -whole, that female service will not be, _at first, at all events_, -extended to these wards. The disgusting and comparatively painless -secondary condition will, I fear, find its way into the ordinary -surgical wards, as it does into the equivalent wards of every Civil -Hospital. - -All these things would increase the mistake of laying any bar between -the Staff Surgeon and the Nurse. In all matters of discipline, -generally speaking, the Staff Surgeon will give much more support than -the Assistant Surgeon. - -A short definite rule should therefore be made, saying whom the Nurse -is to summon in the event of disorderliness in the ward. - -One thing more. There is nothing more dangerous than to undervalue the -objections of opponents. Let us give them their full weight, and while -firmly holding our course, and trusting to God to guide it, draw useful -cautions from the objections which we quietly and steadily confront. - -In the great Military Hospitals, of Roman-Catholic countries, -intelligent, well-behaved, Army Surgeons, while explaining everything -with thorough business-like precision, if spoken to of the Paris Army -Hospitals, before the recently introduced Sœurs de St. Vincent served -there, and asked what they think upon the whole of the service of women -in Army Hospitals--after a little hesitation, and being urged to speak -plainly, will generally say that they prefer in Civil Hospitals the -service of Sœurs to those of hired nurses--but they deprecate either -Sisters or any women in Military Hospitals. 1. Because the presence of -women, however virtuous and guarded, would excite passions and produce -unfavourable results in many cases. 2. Because they were unnecessary, -the Orderlies being efficient, faithful, kind, and sufficient. - -Of the second reason one can judge nothing by a walk through a -hospital, as it does not always follow that what the master says is -enough is so--though this is one of the mysteries it is good to know -and not good to reveal. Of the first there is no doubt. The question -remains, striking the balance of good and evil--Do chaste, guarded, -and efficient nurses on the whole contribute more to the economy of -human life, the order, cleanliness, and decency of a Military Hospital -than they do harm? Possibly the former effects are usual and general; -the latter exceptional and rare: after all, most soldiers are men and -not beasts. But it is well and necessary to bear in mind both the -existence of this danger, and the exaggerated fears many Army Surgeons -conscientiously as well as unconscientiously have of it. - -I therefore very earnestly hope that the work will not be encumbered, -at first at all events, with the charge of the venereal wards. And -it is most important, for the favourable result of the anxious and -difficult experiment about to be made, of permanently introducing -female service into Army Hospitals, that we should be quite clear of -the convalescent patients, and should only attend patients severely ill -or severely injured. - - -[Sidenote: 4. Pay and Rations.] - -4. PAY AND RATIONS.--In the great Civil Hospitals the Head-Nurses -have, on an average, 50_l._ a-year, no board, an allowance of fuel and -light, and the use of one or two, generally unfurnished, rooms. The -Assistant-Nurses, on an average, receive about 12_s._ a-week, [£31 per -annum] no board, lodging, with the use of some furniture, sometimes an -allowance of fuel and light, apart from the use of both in the wards. - -Both Guy’s and St. Bartholomew’s Hospitals now give partial board to -the Assistant-Nurses, and St. Thomas’s is about to adopt the same plan. - -St. Mary’s Hospital gives board to both Head and Assistant-Nurses. - -In the last war Her Majesty’s Nurses received, on an average, 18_s._ -a-week, lodging and board, fuel, light, and partial clothing--18_s._ -a-week is 46_l._ 16_s._ yearly. Incorporated into a permanent Service, -and with a pension, they ought not to receive the latter amount until -after approved years of Service. - -It is certainly a different thing to undertake service in a Hospital -in Smithfield or the Borough, and to undertake to go, at a moment’s -notice, to any part of the world. But the Army Service involves this; -and the pension it involves makes a reasonable equivalent for the -additional wear and tear of climate, travel, &c. Going abroad is a -regular part of the Service undertaken. - -Any artificial inducements should be avoided; at the same time their -condition should be made a comfortable one. Wages, say 20_l._, rising -to 50_l._ a-year, rations, an allowance of fuel and light, and a small -furnished room, would be enough, and not too much. To this should -be added a fixed annual gift of a few strong articles of regulation -dress;[6] avoiding multiplicity, and securing the things being all -good of their kind. In the last war they had too many things, and -some were rubbish. They ought to be well able to supply themselves -with linen, shoes, &c., whether at home or when ordered abroad. The -articles to be given annually should be three strong dark gowns, six -strong aprons, six caps, six collars, one bonnet--and let the things -be good--biennially or triennially, one summer and one winter cloak. -In India, &c., this might be modified. Their room should be furnished, -because, in removing to and fro, it is better to release them from the -cares and the pretences of furniture; also, because, instead of many -gimcracks, you can thus furnish their rooms with a few comfortable, -strong, plain things, presenting a certain military simplicity, which -ought to pervade a Military Hospital. - -Their wages abroad should not be increased. Whether they serve at home -or abroad concerns the Superintendent-General alone, and is no merit or -title for additional advantages on their part. - -[Sidenote: Shall Rations be commutable for Mess-money in the United -Kingdom?] - -If the principle of rations is considered preferable by the War -Department, it is important to give no extra trouble that can be -helped. If not, it is to be considered whether or not it would be well -to get rid of the rations, in the three kingdoms at all events, for -these reasons: - -[Sidenote: (1.) Because such commutation allows greater variety.] - -(1.) These women are Head-Nurses. They will think themselves more -comfortable “finding themselves” than managing on the substantial and -somewhat unvarying provisions of the rations. Some take coffee rather -than tea; some tea rather than coffee; many would rather pay for white -sugar than not pay for brown. Considering the nature of nursing-work, -when faithfully done, it is better they should enjoy and be refreshed -by simple meals to their taste than by unpalatable larger portions; -especially if _the former can be done at no additional cost or trouble -to the Queen_. - -[Sidenote: (2.) Because it averts complaints.] - -(2.) You thus relieve the Superintendent and Matrons of all -communication with the department of the Purveyor-General; of all the -mistakes, accidental or otherwise, which might occur; of all complaints -of quantity or quality of provisions; of amenities such as those -experienced at Balaclava General Hospital, &c., &c., &c. - -Of five London Hospitals, the three endowed Hospitals pay all their -Head-Nurses in money, and give no board. (This is strictly correct, -although, to avoid a long unimportant detail, I have simplified things -in this paragraph, and in the two concerning the pay of Head-Nurses and -Nurses.) The London Hospital gives its Head-Nurses wages, and a fixed -quarterly payment _vice_ the rations of bread, meat, and vegetables, -to which they are by the rules entitled. This change was made not very -long ago, to end the frequent complaints of quantity, quality, and -price, made, perhaps with foundation, by the Nurses. The Westminster -Hospital paid its Head-Nurses partly in money, partly in rations of -cooked provisions, and there were repeated and general complaints of -the quality, quantity, and cooking of the provisions issued to them. - -It is therefore to be considered whether the simpler and better plan -be not to give the Nurses a fixed money payment, and let them “find -themselves,” unless the War Department object to rations not being -issued in part payment. - -Abroad in many cases, in war in all cases, rations would be desirable. -A fixed calculation as to expense should be made. - -Experience and consideration will probably give rise to the following -conclusion--except in war and in retired stations abroad, not to -have Rations; still less to let the Nurses “find themselves,” for -the following reasons:--(1.) It is important that the Nurses should -not have this excuse for being absent from their duties--“that they -have been to get provisions.” (When absent, it should be in pursuit -of health and exercise.) (2.) If the Nurse is to cook for herself, -greater accommodation will be required than the _one_ room recommended, -otherwise the necessary cleanliness cannot be observed. To commute -the Rations for mess-money, to put this mess-money in charge of the -Matron, wherever there is a market; wherever there is none, to let her -“_draw_” for such provisions on her own indent, as she thinks best, -upon the Purveyor, appears to me the safest course. For with regard to -this question of dieting the Nurses it should never be forgotten that, -in all cases (how much more in those where great physical fatigue and -mental anxiety are involved) that principle is the best, if such can be -established, which settles diet with a view to producing the highest -physical efficiency. Variety and mode of cooking are two essential -elements in this. And there can be no doubt that, if a Matron will -take the trouble to consult the tastes of her Nurses, together with -the above conditions, a better diet might be laid down than could -be secured by leaving them solely to their unassisted vagaries and -ignorance of what is really the best diet. Community of cooking also -implies economy. Also the Nurse ought not to be permitted to starve -herself, to save money. Her time is too valuable to allow of her -cooking her own dinner; but she should always prepare her own breakfast -and tea, when and of what she prefers herself, if she feels inclined to -do so. - -[Sidenote: If not commutable,] - -Where, however, the system of rations must be adopted, three ways -remain of working it:-- - -[Sidenote: (1.) Shall the Nurse cook her own Rations?] - -(1.) Let each Nurse receive, and cook her own rations. - -[Sidenote: (2.) Shall the Matron cook and send them?] - -(2.) Let the rations be delivered _en masse_ to the Matron, who has -them cooked, sending her proportion to each Nurse. - -[Sidenote: (3.) Shall the Matron have each Nurse’s Dinner cooked for -her, as she likes best?] - -(3.) Let the Matron, requiring a small payment to cover expenses, -arrange that each Nurse can receive her dinner cooked as she wishes -it. There is something of this sort at the London Hospital; where the -Nurses (and Assistant Nurses) have the right of sending their joint to -be boiled or baked in one of the kitchen stoves. - -Of these different ways, the first would be liked best by the women--a -thing to be considered, in subordination, and as a help to their -respectability and their efficiency--still it is, for some reasons -stated above, objectionable. However, in this, as in far more important -things, it is essential to consider everything as tentative and -experimental for some years to come. Do not be fettered by too many -rules at first: try different things, and see which answers best. - -With regard to rations, it is as well to explain that there were two -ways of drawing them for the nurses during the war. In some of the -Crimean Hospitals, it was arranged that the same ration should be -drawn for a Nurse as that appointed by Regulation for a Medical Staff -Orderly. This answered, as may be supposed, exceedingly ill. There -was considerably more of some articles, such as bread and meat, than -the women could eat; and the surplus had to be wasted or returned to -the Purveyor--a serious complication. Of some articles, such as tea -and sugar, there was as much too little; and these had to be drawn as -extras, except such as the Superintendent-General found it easier and -more simple, as she generally did, to provide herself. - -The other method was for the Local Superintendent to draw daily on the -Purveyor for such articles as she judged necessary; and by thus drawing -_en masse_, a considerable saving was, of course, effected for the -Queen, the tastes and health of women were consulted, and there was no -complication of accounts. - -Where rations are to be drawn at all the latter method should be always -followed; and as the former might be understood by the word “rations,” -it would be better to call them by some other name, as it must be -obvious that such a method could never answer for women. - -The experiment which I should wish to try, by which greater variety -could be secured, but which could only be practised where there was -a market at hand, would be for a commutation to be made of rations -for money. Each nurse to supply her quota of “mess money,” the “mess -money” to be all expended on the “mess,” and the Matron to manage the -“mess” day by day, and arrange for the cooking to be done in common. If -each nurse’s dinner is to be cooked separately, it necessarily entails -great waste of nourishment. The Nurses would not like this so well as -“finding themselves,” but it would ensure them a far better diet.[7] - -[Sidenote: Wages and Mess-money must be distinct.] - -It would be a question whether the Queen should pay the -Superintendent-General so much for each Nurse’s wages, and so much -for board, the latter to be retained by the Superintendent-General, -or whether the Superintendent-General or each Matron, with the -Superintendent-General’s consent, should arrange with the Nurses. -This is important, as which ever way it is settled, there must not be -disputes between Matron, Nurses, or still less Superintendent-General, -as to what amount of wages is to be allotted to the board, or what -savings can be effected in the coals, &c. - -On the whole it would seem best for the Nurse’s pay to be so much -in money for herself, and so much in money for food into the -Superintendent-General’s hands. But the question of how much is a -serious business. - - -[Sidenote: 5. Washing, how to be done? Rule to compel the Nurses to -_put it out_.] - -5. WASHING.--Except in war-emergencies, this must not be suffered to -be done by the Nurses, they must be compelled to put it out. I would -not trouble the Authorities about this; the Nurses can afford it, and -the more things are simplified the better. In out-of-the-way districts, -the Matron might arrange with a laundress, the Nurses making a fair -payment. In war-emergencies, if possible, provide a strong washerwoman, -but this would have to be settled each case on its merits. Except in -emergencies they must not wash; it takes up far too much time; it takes -up strength which is wanted for other things; and washing and drying -either in wards or nurses’ rooms is unhealthy and objectionable. There -must be a rule as to this: some worthy souls would scrub at every rag, -rather than pay a few pence weekly. The Nurse ought, however, to be -compelled to have certain changes of linen weekly, which some will not, -if they pay for it themselves. - - -[Sidenote: 6. Cleaning their own Rooms. No Orderly, on any pretence, -must enter a Nurse’s Room. Scrubbing the only thing the Matron may -arrange for a Soldier’s Wife to do. Nurse must do nothing of her own in -Ward, or Ward-kitchen, or Orderlies’ Kitchen.] - -6. CLEANING THEIR OWN ROOMS.--I well foresee sundry difficulties in -the little rooms at the entrance of their wards, where I hope it will -be managed to quarter the Nurses. But there is no other way of fairly -and really working a ward; and I trust this plan will receive a fair -trial. For efficiency, also for comfort, it is most objectionable to -make the Nurse sleep at a distance from the patients. This is one of -the points on which theories, and the practical working of things, -are very divergent. It is an excellent thing when the Head-Nurse’s -room opens into the ward and when part of the upper part is of glass, -with a thick curtain, so that she can see into the ward, without being -seen. Let each Head-Nurse have a small room, with a window opening -into external air, with a curtain making an alcove, behind which there -should be a small iron bedstead, with good bedding, and a washing -table; and in the foreground a table, a small one for meals, a chest -of drawers, and a comfortable arm-chair, two chairs, and I should add -a sofa. Each room should have a few shelves on the wall, and a large -cupboard or small closet with broad shelves, and space at the bottom -to stow away the Nurse’s box. Simplification and avoiding all trouble -which can be spared to the Departments are very important. I would not -therefore insist upon a little kitchen for the Nurses, nor upon a very -capital arrangement in some of the Sisters’ rooms in Guy’s Hospital, -where, behind a decent little door _in_ the sitting-room, there is a -sink, with water laid on, a little safe for meat, &c., at top, and -a complete little apparatus of the very few utensils required for -cooking one woman’s meals; so that a Nurse can cook and wash-up, in -her own room, without carrying things out of it. This is much better -than a kitchen, if the Nurse is to cook her own meals; but, as above -stated, I would rather she did not. One room, with a curtain making an -alcove, is much better than two. The Queen is saved fuel; the Nurse -is saved cleaning two rooms; and if fuel is only issued for one, she -sleeps in a warm room, instead of one where there never is a fire, -and where her things get damp and spoiled. Often, where Head-nurses -have two rooms, one is built without a fire-place. Condense and -simplify all things--one great object is to form a body of useful -hard-working women, of simple self-helping habits. Two Nurses’ rooms -should be together, but separate. Sudden illness might occur, and the -two women should be at each other’s summons. The Quartermaster-General -_must_ grant a _cabinet_ between the two: this is _must_, not _may_. -The Superintendent-General must see to this herself, at first at all -events: there _is_ a singular obtuseness in the small officials, by -whom these things are managed: if not overlooked, they will be sure to -put the construction in a particularly awkward, exposed place. These -things do enter into an Englishwoman’s daily comfort or misery--it is -worth arranging them decently in the first instance. - -Now as to the cleaning of these rooms. Head Nurses generally are far -too much disposed to make servants of their nurses; put orderlies for -nurses, and this objectionable tendency would be a hundred-fold more -objectionable. The Matron must make it an absolute rule, that the -only thing an orderly does for a nurse is to carry her box in and out -on the two grand occasions of her entering and leaving the Hospital. -The one thing which in a Civil Hospital, an Assistant Nurse should -be allowed to do for the Head Nurse, is the cleaning her fire-place, -a thing done in a few minutes, and with satisfaction, by women who -have done it all their lives; but a dirty tedious messing business to -those who have not. But never mind: the orderly must never enter the -Nurse’s room: she must do it, and learn to do it. The prosaic little -business of black-lead, ashes, and mess lying on the threshold of the -work will do good rather than harm. And even black-lead is unnecessary, -as a varnish now obtainable looks better. The orderly must never -enter the Nurse’s room--a _sine quâ non_. The Nurses should have, at -their choice, a carpet, not nailed down, or none. In either case the -room will require scrubbing, once a week if no carpet, (which is best -and cleanest in Hospital life), seldomer, if carpet. Now the Nurses -should not be required to scrub their own rooms--it is useless waste -of strength--it makes their hands coarse and hard, and less able to -attend to the delicate manipulation which they may be called upon to -execute--and with all the _nursing proper_ which ought to fall upon -them, and not upon the orderlies, their time can be better occupied -than in cleaning their own rooms. Also, while trying to keep clear, on -the one hand, of the tribe of “fine ladies,” it will be possible, on -the other, if such menial offices are to be performed, to fall into the -opposite mistake and to fail in obtaining the class of women desirable -to fill such important trusts. Let the Matron consent to a charwoman, -soldier’s wife, or some one person named and defined, and found, to be -paid by the Head Nurse, to come for the two hours, which, at furthest, -this business will take. It would be well worth while for the Matron -to look out and provide two or three strong women to do this, by fixed -rotation--each Nurse making a fair payment--and to ascertain that they -are in and out of the Hospital by a particular hour, so as to prevent -these external persons doing other things than scrubbing. But do not -trouble the Departments as to this--the more things are simplified, and -the fewer expenses are in connection with the Nurses, by far the better. - -Take the trouble to see that a tidy useful fire-place is in each -Nurse’s one room. Some fire-places will consume thrice the fuel of one -which can do ten times more work. A compact useful little fire-place, -to burn as little fuel, and do as much business (in a very small way) -as possible, is a thing of daily use, economy, and comfort. - -The nurse should not do anything of her own in the ward, or the ward -or orderlies’ scullery, if there is such a place. This is a matter -requiring some decision. - - -[Sidenote: 7. In each Ward to be Closet, with Shelves, Table with -Drawers, Nurse with Keys. Nothing to be kept in Nurse’s Room. Linen, -Dressings, Stimulants to be kept in Ward Closets.] - -7. Let there be in each ward a closet, or, better still, a dresser,[8] -with broad shelves, and a large table with large drawers, of which -closet or dresser, and drawers, the nurse has the sole keys. Let -the articles of linen which are kept in the ward be there; also the -bandages, lint, old linen, oilsilk, ointments, &c., &c., which should -always be, some at hand, some in reserve; also the wine and brandy -ordered for the men. Let the nurse never be allowed to deposit Hospital -property in her room, which, if there is no place for it, she _must_ -do, and it is much better she should not. - -[Sidenote: 8. Matrons 200_l._ per annum, Quarters, and a Maid. A woman -for the Linen, ranking and paid as a Nurse, but never entering the -wards.] - -8. With regard to the Matrons, though as Locke says of tutors, there -are all kinds of persons to be found, it is certain the right persons -are not always found; and these officers will take time to find, at the -outset especially. Let them be (if it be possible) of the middle class; -if it be possible, middle aged, active women, widows of officers or -army surgeons. A vast deal of struggle is ever going on in professional -life; a vast deal of silent, decorous misery ever follows on the -premature deaths, the compelled early retirements, the sundry chances -and changes which ever abound in the army of England. So far as it -goes, and _cæteris paribus_, it would be right, just, and expedient -to give a preference for these matronships to widows of officers and -army surgeons. Try to secure thorough principle, sense, activity, and -steady discreet ways; never mind a little vulgarity of manner; that the -different orders should have their indefinable perpetual distinctions -of manner as of other things, is perhaps for a long time to come in -the essence of things. Two or three women of the stamp of the Matrons -of a few of our Civil Hospitals would be very valuable. If the Matron -do not get tired of what, unless one keeps one’s secret thoughts -fixed on the meaning and the end of all things, is coarse, thankless, -up-hill work enough--she will in the course of years accomplish great -good. But she must have principle, sense, heart, and a firm cheerful -mind. She must be not under thirty and, if possible, not over forty, -on appointment. Should her being without children be made a _sine quâ -non_? Children--poor little things--are wanted nowhere in the way of -business, but do not be too strict about this: they are sometimes -pledges to other things than fortune--thoughts, anxieties, and labours -for them, concentrate and steady a mother’s heart--there will be fewer -adventurers. Maternal _nurses_ must upon the whole be discouraged, -because upon the whole the disadvantages seem to overweigh the -advantages.[9] But the Matron’s office and duties are different; she is -not fixed to a great ward of patients; and her having children should -not be a bar, especially if they did not live with her. Young and -grown-up daughters are much in a Matron’s way; sons matter much less. - -The greatest Civil Hospital gives its Matron 200_l._ and a _house_, -the other great Hospitals, 150_l._, and a _house_. The London Hospital -gives 150_l._, and a couple of good well-furnished rooms, and a -servant. A _house_ is an impediment to a Matron’s duty. She is seen -arriving in the wards, and she is more or less hindered in entering -them. From her rooms she issues and re-issues, unexpectedly, and much -more efficiently. 200_l._ and quarters is not at all too much. - -The Matron must be responsible for the storing, mending, and -distribution of the linen, and for returning to the laundry any linen -not properly washed or dried. Linen ought never to be dried in the -wards, a process both inconvenient and unwholesome. The Matron ought -to have a steady, respectable woman, certainly not below the rank and -pay of a nurse, to be responsible to, and under her, for the linen, -otherwise the proper care of the linen will take up far too much of -her time. This is important. If, however, a Nurse should be thus set -aside for the Laundry, she must not be allowed to enter the wards; -otherwise she will unconsciously become a gossip and mischief-maker. -I would term her “Linen Nurse,” not Assistant. The Matron should also -have a steady, properly paid servant. A Matron of the proper sort has -quite other things to do at a leisure moment, than to keep her wardrobe -in order. She must have a servant; but it seems to be advisable to -simplify things, and condense payments as much as possible; and I would -rather consider this in the salary, and let the Matron find and pay -her own servant. Try to have the servant’s room near the Matron’s. -These minutiæ, once provided for, enter much into the daily working and -comfort of things. - -The dress of the Matrons is a difficult thing to settle. Sometimes -a Matron is afflicted with a taste for either gorgeous or elegant -apparel, which the Nurses are invariably proud of, admire and humbly -emulate. This sort of thing would be really out of place in a Military -Hospital, and would moreover sadly discompose the Nurses with their -plain caps and gowns. How would it be to allow the Matrons the choice -between a Regulation dress and a plain black or brown silk gown? - -It will take much thought to decide whether the Matrons should all be -paid alike, or whether climate and size of Hospital enter into this. -On the one hand they undertake a service, of which almost the first -regulation very properly is, that they undertake to go to all parts of -the world as soon as sent; on the other hand, certainly some climates -wear health and life much quicker than at home. - -The Matrons out of the three kingdoms have increased responsibility, -and can do more mischief, if incompetent or untrustworthy. - -If the Matron has increased pay abroad, it would not do not to augment -that of the Nurses. This is an important matter; and as it is on all -accounts necessary that Matrons and Nurses should on their engagement -thoroughly understand the nature of the service they undertake and, of -course, a serious part of the service is that it involves sudden and -long removals, it would be necessary to define upon what terms they -go abroad. Yet it never would do, for reasons which will readily be -perceived, to make the foreign stations objects of desire to Matrons -and Nurses. These stations will always be so far the most anxious, that -they will always be the most removed from the Superintendent-General’s -inspection and immediate rectification of anything that goes wrong. -They will also be, in various ways, the most trying to Nurses. The -rules once settled, every Matron and Nurse refusing to go abroad -when ordered, ought at once to be discharged, and to forfeit all -re-admittance into the service and all pensions. On the whole, I -think the Matrons should all be paid alike. But inasmuch as foreign -service necessitates more wear and tear to the constitution, one year -should count as equal to two years of service for pension, in case of -disability. The same should be made applicable to the Nurses. As the -advantage is distant, it would, in a great measure, do away with any -desire for foreign service. - -Volunteering for foreign or war-service must be the exception--careful -selection the rule. The “adventurers” will be generally ready to -volunteer, and it would be too much to hope that we shall always, -perhaps ever, be entirely free from that tribe; the most we can hope is -soon to discover and get rid of them. Foreign stations will never do -for an untried Matron or Nurse. At the same time it is most desirable -not to change the Executive officers of any Hospital more than can be -avoided. - -But let there not be too many rules at first; see how things work, and -take one step at a time. - -The selection of exclusively middle-class Matrons seems to be -important.[10] Their order will disarm one source of opposition and -jealousy; plenty more will remain, inseparable from the work; but it is -good to get this out of the way. - -The name of Matron is the same as in Civil Hospitals. In many respects -the office and duties are different: _e. g._, the Matron in Military -Hospitals must exercise a far more constant supervision in the wards. -But this will require great discretion on her part. It is the practice -of most Civil Hospitals for the Matron never to enter the wards till -the Nurse’s dressings are over. It would be advantageous to modify -this. But, at the same time, the Matron must understand Hospital -Nursing, or she may make very serious mistakes in either reprimanding -or directing the Nurse as to technical matters. She must be a person -who knows herself what she has to see that others know; or she will -get herself, with or without the Nurse, into very injurious errors. -There is much in a name; and, in some respects, that of Superintendent -would better denote her office, as regards the Nurses, would add to her -authority, which is desirable, and would point her out as acting under -the Superintendent-General. - -Incorporate among the Nurses whatever women of the higher orders may -be admitted into the Service at first. If inefficient and unfit they -are far better altogether eliminated. If thoroughly efficient as Ward -Nurses, if thoroughly obedient and respectful to the Matron, if they -have sense and heart to gradually leaven, not coldly withdraw from -occasional companionship with the other Nurses, they will, in the -course of time, effect quietly a great deal of good. - -There should be some Rule of this kind-- - -Any Matron or Nurse who may receive permission to serve Her Majesty -without pay shall be, in all respects, bound by and amenable to the -Regulations on pain of dismissal from the service, without permission -of re-entering it. - -If this cannot be done, money can easily be returned in one shape or -other; but it would have a good moral effect on the Nurses to allow of -the admixture of unpaid Nurses, provided they are strictly bound by the -same Regulations, and distinguished by no sort of peculiar designation. - -The Surgeons will dislike these unpaid Nurses; but, in the long run -a firm, discreet woman, _who is an efficient Nurse_, can get on with -any Surgeon _who has his sick at heart_. The Matron also will not -at all like them, at first, but will find that she can rely upon -them and that they quietly and effectually help her with the other -Nurses: and, if she has her heart in her work, she will end by being -just, though, perhaps, always a little extra strict with and jealous -of them. The other Nurses will have, at the first, a strong little -touch of republicanism towards them, which will gradually wear off, -and, with God’s help, a higher and truer moral tone, and a simpler -and more useful kind of habits among them will prevail, than would -otherwise be the case. As for the patients, with all their faults, -trust them--trust the English soldier, and the peasantry from which he -springs. What these poor fellows are we know, and need not discuss. -They are worth suffering a good deal for; please God in the long run -good will be done. If only we can keep clear of the false, pernicious, -and derogatory system of puffery and fuss which others, for their own -purposes, and from vague, silly good-feeling have wound around this -work--a work essentially unpopular the moment we come to details! We -have learnt what reality is and what its presence or absence in this -business imports. As for the many and great other difficulties of the -work, they must be appreciated, they need not be dreaded. The purpose -is a good and noble one, and God grant it success! All we have to do -is, to do our utmost, and leave the event to Him. - -[Sidenote: 9. Nurses--begin with few at first.] - -9. As for the Nurses the material must be formed. If a few respectable -soldiers’ widows, including, and all the better, non-commissioned -officers’ widows, could be found, _cæteris paribus_, a preference -should be given to widows of the Service. - -Except in emergencies Nurses should not be taken under thirty, or above -forty[11] years of age. These women are Head Nurses. Most of the Civil -Hospitals take no Head Nurse after forty. - -One caution in engaging Nurses is perhaps not sufficiently attended -to. Certificates, without personal inquiry and answers to distinct -questions, are not worth the paper on which they are written. - -As to engaging any Nurses out of the great Hospitals, for sundry -reasons, this should be done as little as may be. - -Let us begin, for the sake of God and this His work, with few women. -Extension is easy--to occupy too much ground at first would be, I do in -my conscience believe, an irretrievable mistake. - -No unnecessary Nurses should be suffered in Hospital; and no Nurse in -charge of wards should be required to do needlework for the Hospital. -There should be no superfluous hands; and the less a Nurse enters -another’s ward the better. - -In case of suspension of a Nurse for misconduct, temporary assistance -must, however, be obtained; and this might be either appointing another -Nurse, to do, for the time, such duty in the suspended ward as she -could do in addition to her own, or putting in a temporary substitute. - -All such dislocation of the Service, necessary and useful for -emergencies and holidays, should, nevertheless, be made to take place -as seldom as may be. - -No Nurse, during her suspension, should be allowed to enter any ward of -the hospital. - -Any Nurse asking or accepting a present, whether in money or in kind, -from any patient, or friend of any patient, whether during his illness -or after his death, recovery, or departure, must be at once suspended -from duty, her pay immediately cease, and the Superintendent-General be -apprised of it, who, if satisfied of the truth of the charge, should -immediately dismiss her. - -Two hours daily for exercise or recreation should be allotted to the -Nurses, during which two hours they are to be considered relieved of -the responsibility of their wards. But I would not be too absolute in -requiring them to go out: sometimes to lie down or sit still for an -hour or two will do more good than a walk. Give them two hours for -optional exercise. Head-Nurses cannot have more of fixed leisure. They -must get time for private occupation as they can: very often not at -all; and no Nurse fit for her place will, of course, in emergent states -of her ward, leave it. Also the Matron must not worry herself or them, -if an anxious Nurse sits up part of a night or a whole night with bad -cases. - -To a certain degree the Matron will find it better to allow a little -liberty and choice, in the matter of times and hours, (always excepting -after proper hours, _i. e._, after dark) to the Nurses, who are -Head-Nurses, than to attempt making them mere machines. An uniform -system, as far as possible, and a little range to each, will answer -best. But do not hurry the uniform system too much; take time: this is -very important. - -The Nurse should, every morning, at an hour to be fixed by the Chaplain -or Matron, read aloud in the ward, the Confession, the Lord’s Prayer, -the Collect for the Week, the Collect for Grace, and the Benediction; -and every evening, at an hour to be fixed by the Chaplain or Matron, -she should read aloud in the ward the Confession, the Lord’s Prayer, -the Thanksgiving, the Collect for Aid, and the Benediction.[12] This -would Christianize things, instead of heathenizing them; and I believe -not a soldier would dream that his conscience was injured by it. The -Roman Catholics and Presbyterians might be allowed quite to refrain, -if they chose, which they would not. It would be necessary for the -Chaplain-General to approve of and direct in this, and best to wait a -year or two before beginning it. - -The prayers should be very short, the whole not more than five or six -minutes each time, and the Nurse should read them, the men joining at -the proper times. - -In some Civil Hospitals the prayers are far too long and are gabbled -over by some patient, perhaps the worst character and the best scholar -in the ward, or are stumbled through by some little boy, upon whom the -others cast the distasteful office, with circumstances of irreverence, -partly unintentional and partly shocking. At St. Bartholomew’s Hospital -the very short morning and the very short evening prayers are printed -clearly on each side of a card, which is affixed to each bed; and each -morning and evening the Head-Nurse reads them aloud: the difference is -very great. - -[Sidenote: 10. Have the Diets sent hot and ready-divided from the -Kitchen.] - -10. The Colney-Hatch Lunatic Asylum has a diet system worth inquiring -into; nothing is fetched by the Nurse, the Medical Officer writes the -diets on a large slate which is ready for him outside the ward. - -The great advantage of this seems to be, that the Nurse’s time is -set free from a good deal of arithmetic and some writing; also that -each man’s portion is served him _hot_ from the kitchen, not cut up -laboriously by the Nurse. In most Hospitals the Nurse cuts and divides -the diets; in the London Hospital she moreover weighs them. All this -takes a great deal of time. If the patients can get the divided -portions _hot_ from the kitchen, it is far preferable. - -At St. George’s Hospital the portions are sent hot and divided from the -kitchen. - -[Sidenote: 11. The less any Patient is made into an Orderly by the -Surgeon the better. The Nurse should have Regulations to invoke to -allow her to do her duty.] - -11. It should be distinctly settled by whom poulticing, fomenting, -and all minor dressings, applying leeches and blisters, and giving -enemas,[13] are to be done. - -It would be advisable to consider whether the Nurse ought not to -instruct the Orderlies in some things. This, if it did not clash with -Orderlies’ Rules, would make these men, especially those ordered for -foreign service, much more useful than they are now, without such -teaching. - -It will, however, be essential that there should be no clashing -between the Nurses’ Regulations and those already or to be issued to -the Orderlies. And for this, among other reasons, it is essential -to establish a direct channel of communication between the -Director-General and Superintendent-General of Nurses. - -[Sidenote: Ward Medical Officer to give Directions to Nurse.] - -I think, upon the whole and with reference to preventing, as far as -rules can do it, the obstruction of the Nurse’s duty, by adverse or -inexperienced Medical Officers giving orders to Ward or Assistant -Ward-Master, Orderlies, or patients, instead of to her, that it is -better to charge him to give the Nurse his orders as to the sick. - -All the above-mentioned things should be done by the Nurse, _i. e._, by -her habitually and as a rule; occasionally letting an orderly do them, -under her own eye, in order that he may learn, as well by doing them -sometimes himself as by often seeing her. - -The reasons why all these things must be clearly settled beforehand are -these:-- - -I. Adverse Medical Officers will make all use of counter-regulations. - -II. Medical Officers who give fair play will find it impossible to -settle the matter, if, on ordering, _e. g._, leeches, the Orderly -shows Rule so and so by which he does it, and the Nurse Rule so and -so by which she does it. The existence of the old regulations and the -arrival of the new ones, about the Medical Staff Orderlies, were made -great use of against our work, by some of the Medical Officers, after -the heavy pressure of the war was over. So, at Scutari, a Principal -Medical Officer took away and would not restore the practice of the -nurses giving medicines, in which he was borne out by an existing rule. -Contradictory rules are miserable things. - -Unless the Matron’s authority is supported by the Principal Medical -Officer the Patients always suffer. The Nurse is the only proper person -to be responsible for the directions of the Medical Officers being -carried out in a General Hospital. - -III. It will enable the Matron to stop all nonsensical prudery, on -the part of the nurses, and to require that they should do what they -undertake to do, and not pass off to an Orderly, still less to a -patient, the duties they should discharge themselves. - -As a general rule there is a good deal of this false modesty on the -part of Nurses, especially of Head Nurses. In individual cases it is -a serious thing to shake even false ideas of decorum: in laying down -general Rules it is the more important to lay down as duties what -are such. Suppose an application of what the French call “la petite -chirurgie” ordered. The Head Nurse “never dreams of doing such things.” -The Nurse, following her superior’s false shame of duty, transfers the -business to an ignorant patient. In some cases great harm has arisen -thereby to the Patient. In other cases, but not the majority, after -such an order given, the Head Nurse goes quietly to the bed, draws the -curtain round it, and makes the application herself--saying “she always -did that herself, as it was a business requiring care, as the patient -was often disposed to resist, and as she was thus certain that it was -properly and effectively done.” I have always admired and respected -such women; but they are not the majority. Very often patients are -allowed or left to do things for themselves, which they cannot do -properly, or when they ought not to be trusted to inflict the pain on -themselves which doing things properly often causes. - -The practice of allowing some particular patient to become a sort of -half orderly in the ward, letting him always attend some particular -case, or give general help in severe cases, is most reprehensible. It -is never allowed, whether in Civil or in Military Hospitals, without -very bad consequences to the discipline of the ward. Where extra -help, in lifting, &c., is required, let the Nurse require the most -convalescent of the patients to help, but let her carefully refrain -from selecting any patient or allowing any patient to put himself -forward, as a regular help or quasi-Orderly. As an almost invariable -rule it will be found that the less patients do for each other the -better for themselves, and for the discipline and the good feeling of -the ward. Let them be made useful in the wards, as far as possible, -in such lighter cleaning, &c., as a patient can properly do (here, -again, discretion is required, or a lazy Orderly will lay undue -burdens on a willing patient); but the less they do for each other -undoubtedly the better for all parties. I would not, however, expressly -exempt the patients from being made useful in nursing the sick. A -lazy or ill-conditioned patient might make it a handle to refuse to -do or grumble at doing things which he ought to do, such as (a thing -frequently required) giving and emptying a bed-pan to an ordinary -patient who cannot leave his bed, while the Nurse and Orderlies -are doing other things in the ward; assisting to move a helpless -patient, if all the Orderlies are not at hand; sometimes watching or -attending for an hour or so a critical case, &c., &c., &c. What the -Superintendent-General and all Superintendents must be especially -vigilant against is selecting any particular patient or allowing a -willing patient constantly or often to do these things, and to become a -quasi-Orderly to the ward or to any patient in it. - -Assistant-Surgeons, partly from inexperience and partly from spite, -sometimes make this sort of quasi-Orderly of a patient. The Nurse -should have the power of respectfully saying, in such a case, “The -Regulations order me to do so and so, sir: I beg you to let me do my -duty.” - -It is an important and should be, if possible, an invariable rule that -no discharged patient is ever to enter any ward. Soldiers are, in -many respects, on a different footing, as to each other, from Civil -patients. The above provision is perhaps rendered thereby (not the -less, but) the more important for the good order of the ward. Still -this, desirable in (and the rule in several) Civil Hospitals, might -be considered by Military as well as Medical Officers to interfere -too much with the feeling of comradeship which, in its measure, is -so essential a part of the soldier’s very peculiar condition. The -following rules however might, at all events, be carried out. Some of -them are actually in the “Hospital Regulations.” - -As quietness is indispensable in Hospitals, every duty should be -performed with the least possible noise, more especially at night. -Every patient must be in bed by 8 o’clock in winter, and 9 in summer; -and no conversation must be permitted after that time. Patients should -be made useful in the wards, as far as possible; but should fetch -nothing into them. And no discharged patient should be permitted to -enter any ward, except in the fixed visiting hours. The Governor, where -there is a Governor, or the Principal Medical Officer, will fix the -visiting hours; which shall not be more than two hours during each of -three days of the week. [Take proper advice as to whether this maximum -is too short. It is fully enough for Civil Hospitals, but Military -Hospitals are in sundry respects essentially different.] - -In the discipline of all Military Hospitals, besides the prohibition -of all swearing and foul language included in the Articles of War, is -included the non-admission, or if by oversight admitted among visitors, -the immediate expulsion of all disorderly persons. (Query--whether not -to specify prostitutes.) - -I very much wish that Hospital Sentries in General Hospitals might keep -out all visitors, except in the fixed visiting hours. And I very much -wish that a stringent rule were made as to female visitors, both in -Regimental and in General Hospitals. Proper Military as well as Medical -advice should be taken on this point. It might not do to exclude them -altogether; and, if soldiers’ wives come, it might be better to admit -also all respectable-looking women, for it would be useless attempting -defining as to sisters, aunts, friends, &c., &c.; though, except in -the case of dying patients, all women, except their wives and mothers, -are better away. I do not know what amount of strictness in practice -is shown in enforcing the Regulations in English Army Hospitals; but -if, at present, equivocal women, as well as ascertained prostitutes, -are not excluded (which very possibly they are) they should be. At -the same time, a sentry may often be honestly puzzled as to equivocal -or non-equivocal appearance, in these days of over-dressing. And some -mistake, made by a stupid or brutal sentry, might lead to endangering -the rule. This whole matter must be referred to men. - -[Sidenote: 12. Orderlies’ Attendance.] - -12. With regard to the question of the “Regulation” number of -Orderlies, viz., 1 to every 10 patients, it is to be observed,-- - -[Sidenote: (1.) 40-Bed Ward Minimum Size for Regulation Number of 1 -Attendant to 10 Patients.] - -(1.) A ward of 40 patients might be efficiently served (but it would be -hard work) with - - 1 Head Nurse--Female. - 3 Orderlies. - -With no number under 40 of patients to a ward, can the Regulation -proportion of 1 attendant to 10 patients be adhered to. - -[Sidenote: (2.) 20-Bed Ward requires 3½ Attendants.] - -(2.) With a ward of 20 patients (cut, scheme, and arrange the hours and -duties as you will), you cannot efficiently serve it with less than - - ½ Head-Nurse--Female. - 3 Orderlies. - -And the other ward of this Head Nurse ought to be on the same floor. - -N. B.--The same number would quite as efficiently serve a ward of 25 or -even 30 patients. - -[Sidenote: (3.) 10-Bed Ward cannot be served by 1 Orderly + ⅕ Nurse.] - -(3.) The Army system of 1 Orderly to 10 patients, with a number not -exceeding 10 patients to a ward, is upset as immediately by one bad -case among the 10, as by 9 to the 10. - -For, is the same Orderly to be on duty for the 24 hours? - -The difficulty is practically got over by the Army, with a permission -that any “bad case” may select any one he likes of his comrades (out of -the Depôt) to be “told off,” to attend upon him. - -This extraordinary regulation is equivalent to (and affords little -other practical result, than) granting opportunity for any quantity -of spirits, and illicit food, to be smuggled into Hospital, and it is -clear that it would be totally inadmissible in a General Hospital, -where the whole system of nursing would be under the most stringent -discipline and supervision. - -[Sidenote: (4.) Female Nurses not to be Substitutes for Orderlies.] - -(4.) The introduction of Female Nurses into Military Hospitals is not -intended to supply the place of Orderlies, but to perform a class of -duties which never has been performed at all in the Army. Few other -Hospital duties of those generally called such have been hitherto -fulfilled, in Military Hospitals, except - diet-carrying, - sweeping, - and writing. - -[Sidenote: (5.) Naval Hospitals Regulation Number of Attendants 1 to 7 -Patients.] - -(5.) In all Naval Hospitals, the Regulation number of attendants is -1 to every 7 patients, or 2 attendants for each ward containing more -than 7 patients and up to 14. These Attendants or Nurses, in sailor’s -language, have charge of the linen, bedding, and ward furniture, under -the Ward Matron, and they are responsible for the proper care of the -sick, and the due administration of the medicine, wine, and other -medical comforts. They are on duty all day and watch at night in their -turn, which is regulated by the Medical Officer in charge of the ward, -in this or similar fashion:--a group of three contiguous wards is -allotted during the night to two nurses, one begins her duty at 9 and -ends at 1 o’clock, when she is relieved by another, who watches till -6. She patrols the three wards, resting in that one where there may be -a case requiring more than ordinary attention. If there should be a -case of fever, delirium, or other sharp seizure, extra Nurses, both men -and women, are assigned to the charge of that special case, according -to the urgency of its wants. The great majority of Naval patients are -either convalescent, or suffering from trivial complaints, which do not -impair their activity. They can therefore take care of themselves, and -assist the Nurse during the day in cleaning the wards, &c.--and we know -what good housemaids seamen make. The Nurses are paid one shilling a -night for night watching. They have under the most severe circumstances -two-and-a-half nights in bed for half a night out of bed. - -At Haslar Naval Hospital the system of Orderlies, as understood from -the Principal Medical Officer, is as follows:--12 Orderlies are on a -floor, to look after, say, 90 patients. These are divided for night -duty into three divisions of 4 each; of these 4-- - 2 are on from 9 to 2, A. M. - 2 ″ ″ 2 to 8. - -The Head-Quarter room or ward is the one which has the most severe -cases; this ward, then, the Watcher at night sits in, and makes the -rounds of the others every now and then to see if anything is required. -This system will of course be modified, according to the nature of the -cases in Hospital. The other attendants do not sleep in the wards. The -Nurses are male or female according to the discretion of the Principal -Medical Officer. - -[Sidenote: Civil Hospitals have even 9 Attendants to 44 Patients.] - -In Civil Hospitals the number is as great of attendants to patients, -and is mainly determined by the size of the ward: - -_E.g._, in one Hospital, where there are quadruple wards of 44 -patients, 11 in each compartment, though the average number of patients -is 48, the number of attendants is 7. - -In exceptional cases extra Night-Nurses, sometimes extra Day-Nurses -serve particular patients. The labour, both of cleaning and of -night-nursing, is much increased by the wards being four, separated by -a large lobby. - -In another of the large London Hospitals, where there are to each ward, - - PATIENTS. ATTENDANTS. - - 22 } there are { 1 Sister. - 24 } { 2 Nurses. - - { 1 Sister. - 30 ″ { 2 Nurses. - { 1 Scrubber. - - { 1 Sister. - 34 ″ { 3 Nurses. - - { 1 Sister. - 40 ″ { 3 Nurses. - { 1 Helper. - -In the Lariboisière Hospital at Paris, where the wards hold 32 beds, 1 -Sister, 1 Nurse, and 2 Orderlies on the Men’s side, 1 Sister, 2 Nurses, -and 1 Orderly on the Female side, serve the ward efficiently. - -[Sidenote: (6.) Same Number of Men will not do same amount of Work as -an equal Number of Women would.] - -(6.) One woman does the work of more than a man in a Hospital, speaking -of the duties discharged by Under Nurses in Civil Hospitals; for men -are not accustomed to these duties in England, as women are from their -childhood. - -From this it is by no means to be inferred that women of the class -of Under Nurses in Civil Hospitals should be employed in Military -Hospitals, which unquestionably they should not. But it is to be -inferred that the work will not be done efficiently, with a smaller -number of men than would be employed of women. - -[Sidenote: (7.) Hospital Attendance an entirely new subject in the -Army.] - -(7.) The question of attendance has scarcely been intelligently -considered in the Army at all. And hardly any practical answer has yet -been given to such questions as the above. - -I conceive it to be practically impossible to serve 4 wards, as -proposed at Netley, viz., of 9 beds each, with - - 1 Head Nurse, - 4 Orderlies. - -For, as has been said, one bad case in each ward, makes this economy as -unmanageable as nine. - -[Sidenote: (8.) Hospital Wards in the Army little else than -Barrack-Rooms at present.] - -(8.) A ward in a Military Hospital now may often be little else than a -barrack-room, with an Inspection by a Medical Officer twice a day. It -is designed to make it by the new Regulations into a place where the -sick must be and always will be suitably attended. But this cannot be -done by such a scheme as-- - - 1 Female Head Nurse } to { 50 Patients, in (say) - 6 Orderlies } { 6 Netley Wards; - -though this attendance would be more than sufficient for 50 cases in -one ward; but such a ward is considered in a sanitary sense too large. -Two wards of 30 beds each on the same floor would be efficiently served -by such a Staff, however; and there would be no sanitary objection. - -[Sidenote: (9.) Regulation as to 1 Orderly to 10 Patients requires -modifying.] - -(9.) The Regulation number of one Orderly to ten patients therefore -requires modifying. Practically it is broken every day and in the -extraordinary manner above mentioned, which gives the most critical -cases to be attended by the rawest hands. - -[Sidenote: (10.) One Orderly should be the _Frotteur_.] - -(10.) The question of Hospital floors will be fully discussed farther -on. An Orderly should be trained to be the _frotteur_ to each ward. He -should also be the porter to fetch and carry every thing to and from -the ward. - -[Sidenote: (11.) Comparison of Cost of Nursing with larger and smaller -Wards.] - -(11.) The plan of Netley, with its wards for 9 sick, is by far the -costliest for administration, as the following facts will prove: - - I. It is proposed to provide the Hospital with Orderlies and Nurses - to conduct the nursing in wards of 9 sick, as mentioned. - - II. On sanitary grounds wards may safely be large enough to - accommodate 25 to 30 sick. - -We may therefore choose the larger wards, being guided only by the cost -of the nursing. - - III. A ward of 9 sick would require 1 day and 1 night Orderly, and - a-third of a Nurse (that is, a Nurse could superintend three - such wards.) - - A ward of 30 sick would require 2 day and 1 night Orderlies and - 1 Nurse = 4 persons in all. - -Or if two such wards were on one floor, 1 Nurse could serve both. - - IV. We cannot count the cost of Orderlies and Nurses, including - lodging, rations, wages, at less than £50 a year, which when - capitalized at 3 per cent. (33 years’ purchase), would amount to - £1,650 for each. - - V. A ward of 9 sick would cost in nursing £1,650 × 2⅓ = £3,850, - or £427 15_s._ 6_d._ per bed. - - VI. A ward of 30 sick would cost for nursing, in perpetuity, £1,650 - × 4 = £6,600 = £220 per bed. - [One Nurse to each ward is here allowed.] - - VII. The cost of the two plans relatively for a Hospital of 1,000 - sick would stand thus: - - Wards with 9 beds = £427,775 - Wards with 30 beds = 220,000 - --------- - Capitalized difference of cost in } £207,775 - favour of large wards } - - Netley has cost already Land = £30,000 - Works 89,000 - --------- - £119,000 - -It hence appears that, if works and site were both sacrificed, and -fresh land purchased, and wards for 30 sick built on it, the country -would actually save the difference between the two sums of = £88,775. - - Suppose the sanitary requirement of 25 sick to a ward, which is - the best number, be combined with the greatest economy of - administration, the cost would stand thus: - - For each ward of 25 sick, 3 Orderlies, at £1,650 = £4,950 - If two such are built in line, close to each - other, with the Nurse’s room between them, - one Nurse could superintend both wards, or - half a Nurse to a ward. The cost would be - for the ward 825 - ------- - 5,775 - - 5775 - Or cost for each bed ---- = £231 - 25 - - - The comparative cost of wards with 9 beds and - 25 beds, would stand thus for 1000 sick: - - Wards with 9 beds £427,775 - Wards with 25 beds 231,000 - --------- - Saving £196,775 - Deduct cost of Netley, already incurred 119,000 - --------- - Saving from abandoning Netley = £77,775 - - The cost of the administration per 1000 beds at Netley - and Aldershot would stand as follows: - Netley £427,775 - Aldershot, pavilions, with 3 superimposed wards - and 25 sick in each, would require 3 Orderlies - and 1 Nurse[14] to each ward, and would cost - £264 per bed in perpetuity, or per 1000 sick 264,000 - --------- - Difference of cost in favour of Aldershot £163,775 - -Some abatement would have to be made, as regards the cost of Netley, as -there are a few wards with 16 or 18 sick. - -If we take money at 4 per cent., the calculation will be as follows: - - Small wards, 2 Orderlies and a third of a Nurse, - at £50 per annum; money at 4 per cent., - per 1000 sick £324,000 - Wards of 30. 3 Orderlies and a Nurse, money - at 4 per cent., per 1000 sick 166,000 - --------- - Extra cost of small wards 158,000 - Cost of Netley 119,000 - --------- - Saving in giving it up £39,000 - -[Sidenote: 13. Hospital Floors.] - -13. FLOORS.--In building a new Hospital or laying a new floor we shall -hope to see, by degrees, everywhere introduced the only safe Hospital -floor. In the expense the difference between oak and the best white -deal ought never to be considered. The staircases and passages should -always be of stone. When once an oak floor is well done with bees’-wax -it is no longer an absorbing surface. There cannot be a doubt that the -frequent washing of the floors, in London Hospitals, is one main cause -of Erysipelas and Hospital Gangrene. - -But, with regard to deal flooring,-- - -(1.) The best way with a pine floor already laid is to close the -joints, plane the surface quite smooth, and then saturate the wood with -beeswax and turpentine, either at once, or after the wood has been -saturated with “drying” linseed oil well rubbed in. - -(2.) Enough beeswax should be used to fill up the grain of the wood, -and rubbing with a brush will then smooth the surface. It will be -polished somewhat, but not slippery. The amount of polish depends on -the brushing. - -(3.) The surface should be kept clean by using a brush with a cloth -tied over it, and if offensive liquids are spilt, they should be -immediately removed, the surface washed with soap and water, and -immediately dried. - -(4.) List slippers, which ought to be part of Hospital furniture, -effectually obviate risk of slipping. It would hardly be possible, -however, to make deal floors as slippery as oak _parquet_, because -the surface (except of very fine deal, such as is used for musical -instruments) never takes so high a polish. - -(5.) Dry rubbing, which is done with sand, or with sandstone, is not -well adapted for ordinary sick wards, on account of the dust; unless -it be very carefully done. The rationale of it is to remove a certain -amount of the surface of the floor. It answers very well on board ship. -A certain amount of surface cleaning may be done by rubbing with a -hard short brush; it is, however, defective. The wood becomes in time -saturated with organic matter, and only wants moisture to give off -noxious effluvia. - -(6.) Scrubbing is absolutely objectionable, for this reason. In any -schoolroom, reading-room, institute, which is much inhabited, a smell, -while the floor is being scrubbed, is very perceptible, quite different -from that of soap and water. It is the exhalation from the organic -matter which has entered the floor from the feet and breath of the -inhabitants. How much more dangerous this in Hospital Wards need hardly -be said. - -There is at Bethanien Hospital, at Berlin, a very admirable flooring, -which would be worth trying in England. The floors throughout are -wood, prepared in the following manner:--The floor is first oiled with -linseed oil, and then rubbed over with a peculiar “laque” varnish, the -technical process of which will be found in the note,[15] and polished, -so as to resemble French polish. Every three years or so the rooms and -wards are successively emptied for a fortnight, when a new flooring is -laid, re-oiled, varnished with the laque varnish, and thoroughly dried. -Every day the floors are wet-rubbed by means of a piece of sacking or -coarse webbing at the end of a long, hard broom, the performer stands -for the performance, also while immediately afterwards, having wrung -the sacking completely dry, she goes over the ground again with the -dry sacking. One, or, in case of the weekly extra wet-rubbing, two dry -rubbings, dry the floor completely in a few minutes from the cessation -of the wet-rubbing, never more than ten minutes. Three or four times a -year the ward floors are thoroughly wetted with water thrown on, and -the floors scrubbed with a long brush. Neither soap, soda, &c., is -used. - -The great advantages of this are:-- - -(1.) That it purifies the air exceedingly and freshens the wards. - -(2.) That it reduces the daily accumulation of dust to a minimum. - -(3.) That it dries completely within ten minutes from being wet-rubbed. - -(4.) That a woman, standing, can thoroughly clean a ward with some -hours less time, and greatly less fatigue, than scrubbing. - -(5.) That wet scrubbing is sometimes and ought to be always forbidden -and dry rubbing substituted, on the score of the unhealthiness of -scrubbing. - -(6.) That it would relieve us of all external scrubbers in the Nurses’ -own rooms. Each Nurse would sweep, wet-brush and dry-brush her bed-room -and day-room herself, daily, would once-a-week give a little extra -wash, and would wash the wooden skirting which runs along the bottom -of the walls. As the bed-room must be tiny and the day-room small -(it would be better if we could keep to one room, which would take a -quarter of an hour daily, and the grand weekly purification not more -than one hour, even to a slow performer) a short time daily and a -moderate time weekly will do it. - -One disadvantage of this very simple, very efficient, and excellent -flooring is, that it shows scratches. Furniture must always be lifted, -not dragged. In a Military Hospital where men are always at hand, this -would matter less as to the wards, and the Nurses could help each other -once a week in their bed-rooms, and manage alone in their day-rooms. - -There are four other examples of this flooring in Berlin Hospitals. - -(1.) Bethesda Siechenhaus, a small old house, about to be rebuilt and -enlarged, in a suburb of Berlin, where three Deaconesses, with a man -and woman servant, take excellent care of about forty infirm old women -and imbecile children. These patients, of the class to be found in the -infirmary wards of our workhouses, move about little, and have few -visitors, so that the flooring, which is the same as at Bethanien, is -less used. - -(2.) St. Hedwig’s Hospital, where 250 male and female medical and -surgical patients are nursed by Roman Catholic Sisters of St. Charles -Borromæus (head quarters at Nancy), with female servants and male -nurses. The house is new; the flooring the same as at Bethanien. -The Superior, an intelligent German, speaks much of its excellence -for hospital purposes; it is being introduced, though as yet very -partially, into France. - -(3.) The great Charité Hospital, the town-hospital for 1,200 patients, -spite its French name. It consists of two buildings; the old one, -used in winter; and a splendid new one, into which all the patients, -except the lunatics and the small-pox and the venereal cases, are moved -for the six summer months. The flooring throughout is of the same -wood (deal) as at Bethanien, but has much more laque. The more laque -is used, the brighter the floor shines, but the sooner it requires -re-oiling and laque varnishing. The Charité floors are re-oiled with -laque every year; they are cleaned in the same way as at Bethanien, -only with more dry rubbing. On bad days, when the numerous students -have passed through, the ward floors occasionally require to be -cleaned; but, in general, even on these occasions, it is enough to -sweep them, and to clean the next morning as usual. - -(4.) The principal Military Hospital, the Garnison Lazareth in the -Hirsch Allée, for 800 patients, usually not filled. The flooring is -the same as at Bethanien, except that no laque is used. It is oiled -generally, not always, yearly. - -The Ober Inspector, a Landwehr civilian, who is supreme over the -Hospital, and an Ober-Stabs-Arzt, both speak very strongly as to the -superiority of this flooring over all others for Hospital use, and -in particular over flooring which requires scrubbing. It has only -been introduced of late years. They consider it equal to any amount -of hospital wear and tear. The military patients, like those of the -Charité, Bethanien, and St. Hedwig’s, wear hospital slippers, with -soles thick enough to admit of their walking in the garden, when fine; -when not fine, they are not allowed to go out. This flooring would not -stand the constant tread of nailed shoes. But often, on bad days as on -fine ones, great numbers of soldiers come to visit their sick comrades, -and leave the floor very dirty; generally it is enough to sweep the -floor after the visitors are gone, and to clean it as usual next -morning; sometimes it is necessary to clean it the same afternoon. - -The flooring is cheap. Somewhat more expense attends laying it down -than the ordinary boards, and a certain expense attends the re-oiling, -but the constant outlay for soap and soda is entirely saved, except -a little soda in the grand annual purification, with hot water, in -addition to the daily one with cold; the time and labour attending -scrubbing is saved, and above all the great gain to the sick arising -from its use is secured. - -The strong, decided way in which the old grey-headed Army Surgeon, and -the middle-aged business-looking Civilian, spoke of the merits of this -flooring, and of its capacities, was exceedingly satisfactory. - -(5.) Two years ago the greater part of the boards in the Kaiserswerth -Institution, which are of deal, were oiled, both on sanitary grounds, -and to rid the Sisters of the drain on time and strength in scrubbing. -They are considered far preferable to the old ones, and to answer in -every respect. Yet the Kaiserswerth floorings would not answer the -English requirement of extreme cleanliness. They are substantially -clean, but, like those of the Military Hospital of Berlin, it -takes examination to ascertain that they are so, and from the same -cause--there is no “laque.” Also the colour is not at all so agreeable -as the Bethanien colour. These oiled boards last a year only. A -moderate amount of laque is required to add to their durability. - -The sum of the information, condensed as much as possible, on this -subject is;-- - -I. The boards, which are always of deal, can be prepared in three ways: - -(I.) Laquering, only suitable for reception rooms, or when by some -chance a ward is wanted to be got ready in a hurry; it takes less time; -after two or three days, the room or ward can be used, and it shines -brighter, but it lasts a much shorter time than the other procedures, -as it stands less the incessant treading incident to all ward floors; -it is also more expensive. Let us consider it wholly unsuitable for -wards. - -(II.) Oiled boards, with more or less laque. - -The Charité boards have a great deal of laque. - -The Bethanien and St. Hedwig’s boards much less. - -(III.) Oiled boards without any laque-- - -As in the Military Hospital. - -II. Much laque makes the floors shine brighter; requires more time to -clean them; and earlier re-preparation than where less laque is used. - -The Charité boards would be unmeaningly splendid for an English -Hospital, and quite out of place in a Military one; besides entailing -some unnecessary annual expense, and some daily finicking care. - -III. A small quantity of laque, as at Bethanien, gives an amount of -polish to the floors, which enables the eye at once to ascertain -whether they are clean or not; considerably improves the appearance -of the floor; and, according to all high authority, adds both to the -durability of the floor, and the healthiness of the Hospital. It -renders the whole flooring less subject to cracks, to dirt and dust -getting into holes and corners; and, above all, by filling up the grain -of the floor, it prevents the saturation, by organic matter, which -otherwise takes place and which scrubbing only makes more mischievous. - -IV. Where no laque is used, the absence of all polish on the dark-brown -floors makes examination necessary, to see whether they are thoroughly -clean or not. This flooring would never satisfy the eye or the mind of -an English Inspector-General or Surgeon. But the main objection to the -absence of laque certainly consists in the sanitary one above stated. - -V. All the various authorities agree in estimating very highly the -superiority of this flooring to flooring requiring scrubbing. They all -agree in their reasons for this preference, viz.:-- - -(I.) The dampness which remains in a ward more or less time after it -has been scrubbed, is completely avoided. - -(II.) The tendency to miasma is greatly counteracted, both by getting -rid of the damp, which encourages and spreads the exhalation of the -organic saturations; and by making the floor impervious, preventing -dirt, and with dirt miasma, finding its way into holes, chinks, and -corners of the floor. - -(III.) The mode of cleaning this flooring, while it avoids damp, daily -purifies the ward air. - -(IV.) The floor, and its mode of cleaning, get rid more than by any -other way of dust, and of the miasma dust often conveys. - -(V.) The time, labour, and expense of scrubbing are saved. - -(VI.) The Berlin authorities consider that these oiled boards, with -a small quantity of laque, are, on the whole, decidedly cheaper than -the common boards; that the boards last rather longer; and that the -avoidance of scrubbing saves more than the extra preparation and its -renewal cost, apart from the sanitary gain. - -VI. Against these advantages, the following disadvantages are to be -placed: - -(I.) This flooring shows where most used, instead of the uniform -appearance of the white scrubbed boards. - -(II.) Scratches show, and remain upon it; so all furniture must be -lifted, not dragged over it. - -(III.) The tread sounds a little more, little, but more, than on white -boards. - -(IV.) It would not stand the constant tread of nailed shoes; and -patients of a ward so floored, ought to wear slippers with moderately -thick soles. (The German Doctors consider the use of slippers -preferable to that of shoes, by the patients, as keeping a ward much -quieter, cleaner, and disturbing the severe cases less.) - -(V.) Carpets could not be nailed on it, as the floor should be daily -cleaned. Several Hospital authorities whose rooms are thus floored, -have large pieces of carpet round the furniture most used, bed, -tables, sofas, &c.; these are daily taken up and dusted while the -floor is being cleaned. To many English minds, the sight and feel of -a carpet is essential to the idea or feeling of comfort; and it might -be sound policy, in the event of a trial being made of this flooring, -to leave the Officers, Military and Medical (I do not mean patients), -in possession of scrubbed rooms and carpets. The Superintendent might -have one or two pieces of carpet for her rooms; and the Nurses should -dispense with carpet. - -Both in the new part of the Charité and at Bethanien, long broad -corridors run along the back of the wards which open into them. The -corridors are floored like the wards. In those of the Charité a piece -of long carpet is laid in the midst of the corridors, where patients -walk not a little. At Bethanien, a long piece of matting is laid in -the midst of the corridors, where the patients walk freely. Carpet of -either kind is not considered to benefit the floors, but to diminish -the noise. In the wards of Guy’s Hospital, for the same reason, a long -piece of matting is laid along the middle of the floors. - -VII. This flooring is unsuited for stairs, though so used in some -Hospitals, as, in case of fire, oiled wood would burn rather quicker -than common wood. Hospital stairs should be of stone. - -VIII. It is also unsuitable for kitchens, wash-houses, water-closets, -and sinks. The floor round a stove or fire-place in a ward or room -should be protected by a strong plate of lead or tin. - -It might also be as well to floor operation-rooms with flooring, -admitting of scrubbing, because these oiled boards do not well stand -sand or bran, and our Surgeons might be discomposed at missing one or -other of these things. Sand or bran mixed with blood would make a mess, -the traces of which would show a little on this flooring. For the rest, -it is particularly easy to wipe blood off it. After each operation, one -or two minutes, a wet cloth of the kind here mentioned, and a broom, -remove the blood that has fallen, and leave a clean floor; or if there -has been a very great mess, five minutes, a wet cloth to lap up the -blood, &c., another wet cloth, a pail, and a broom, do all: after the -operations are over, a few minutes’ whole or partial cleaning, as the -case may be, make all tidy again. Still, many English Surgeons expect -to have sand or bran thrown on the floor before, or just after the -first blood has fallen, and might object to standing some minutes on -the bloody floor, which spoils boots, &c. Red floorcloth, of sufficient -size, round the operating-table, might answer every purpose. - -IX. On laying down the oiled boards for the first time, six weeks -should pass after the oiling and laquering before the ward is inhabited. - -X. After subsequent re-preparation of the floors, the longer the wards -are left vacant the more the floor both hardens and shines; but for -practical purposes the interval of a fortnight is enough. - -XI. The flooring, so prepared, or re-prepared, ought, on an average, -to last about three years. In case of any extra miasma, it is often -desirable to hasten the re-preparation, and to have it done after two -years’ use. To do it annually is, unless in some emergency, quite -unnecessary. - -Although the process cannot be said to be by any means perfect, on -account of the deficient durability of the surface, it would be well -worth while to try it in England, and, if it answers and if it were -improved, the sick would gain much, and the Hospital staff would gain -much--the latter much more even in Civil, than in Military Hospitals. - -But it would be incurring a great responsibility to have the whole of a -large new Hospital floored in this way, because, - -I. An English climate has made, and makes, so many things which are -good and suitable abroad, unsuitable and sometimes pernicious for -England. - -II. Our coal-fires, whether assisting or assisted by our atmosphere, -certainly give us an amount of soot and dirt unknown abroad. At Berlin, -all fire-places are stoves, where sometimes coal, sometimes coal and -wood are burnt. - -This flooring might not stand well either the damp climate, or the -smoky atmosphere and amount of flying soot of England: but it would be -well worth trying; as also trying to improve it. - -By all accounts, a great deal depends upon the manner in which these -boards are prepared; a little more or a little less, whether of oil or -laque, makes a great and lasting difference. It would never answer to -make an English carpenter or painter do this from written or printed -directions. - -If we obtain a trial of this floor--the best course would be, to let -an English carpenter prepare a number of boards and skirtings, of due -size, suitable for the new flooring of some few wards in one of Her -Majesty’s hospitals, which requires new flooring; then to desire either -the proper tradesman, or the Queen’s Minister at Berlin, to order the -house-painter, Schonby, No. 5, Michael Kirchplatz, Berlin, to send an -experienced, trustworthy foreman, with the proper tools and materials, -and for this man, with a complement of English workmen, to prepare the -boards. - -The mode of cleaning is extremely simple, though of course there -is a knack to be learnt; and, like everything else, it can be done -well, indifferently, or ill. Any English man or woman accustomed to -cleaning would understand the thing in one morning, and would, if he -or she opened instead of shutting the mind to the outlandish thing, be -proficient in it in a week. All these things sound abstruse on paper, -and are far more simple and more easily learnt by seeing done than by -reading. The foreman ought to give one or two lessons to one or two -Orderlies, or Nurses, as the case may be. - - -[Sidenote: 14. Ventilation of Wards.] - -14. VENTILATION.--The amount of fresh air required for ventilation has -been hitherto very much underrated, because it has been assumed that -the quantity of carbonic acid produced during respiration was the chief -noxious gas to be carried off. The total amount of this gas produced by -an adult in 24 hours is about 40,000 cubic inches, which in a Barrack -room of 16 men would give 370 cubic feet per diem. Allowing 8 hours -for the night occupation of such a room, when the doors and windows -may be supposed to be shut, the product of carbonic acid would be 123 -cubic feet, or about 15½ cubic feet per hour. This large quantity if -not speedily carried away would undoubtedly be injurious to health; but -there are other gaseous poisons produced with the carbonic acid which -have still greater power to injure. Every adult exhales by the lungs -and skin 48 ounces or 3 pints of water in 24 hours. Sixteen men in a -Barrack-room would therefore exhale in 8 hours 16 pints of water and -15½ cubic feet of carbonic acid in the atmosphere of the room. With the -watery vapour there is also exhaled a large quantity of organic matter -ready to enter into the putrefactive condition. This is especially the -case during the hours of sleep. And as it is a law that all excretions -are injurious to health if reintroduced into the system it is easy to -understand how the breathing of damp foul air of this kind, and the -consequent reintroduction of excrementitious matter into the blood -through the functions of respiration will tend to produce disease. - -This will be still more the case in sick wards overcrowded with sick, -the exhalations from whom are always highly morbid and dangerous, as -they are nature’s method of eliminating noxious matter from the body, -in order that it may recover health. - -A much larger mass of air is required to dilute and carry away these -emanations than is generally supposed. And the whole art of ventilation -resolves itself into applying in any specific case the best method -of renewing the air sufficiently, without producing draughts or -occasioning great varieties in temperature. - -When the question of ventilation first assumed a practical shape in -this country, it was supposed that 600 cubic feet of air per hour -were sufficient for a healthy adult, in a room where a number of -people are congregated together. Subsequent experience however has -shown that this is by no means enough. As much as 1,000 cubic feet -have been found insufficient to keep the air free from closeness and -smell; and it is highly probable that the actual quantity required -will ultimately be found to be at least 1,500 cubic feet per hour per -man. In sick wards we have more positive experience as to the quantity -of air required to keep them sweet and healthy. It has been found in -certain Parisian Hospitals, in which the ventilating arrangements were -deficient, that pyœmia and Hospital gangrene had appeared among the -sick in consequence. These diseases disappeared on the introduction -of ventilating arrangements, whereby 2,000 cubic feet of fresh air -per bed per hour were supplied to the wards. Notwithstanding this -large quantity, however, the ward atmosphere was found not to possess -sufficient freshness or purity: and the quantity of air had to be -increased in subsequent ventilating arrangements. As much as 4,000 -to 5,000 cubic feet per bed per hour have been supplied in certain -Hospitals. At the rate of 4,000 cubic feet, the ward atmosphere is -found perfectly fresh. - -[Sidenote: Night Ventilation.] - -At one of our largest London Hospitals it will be perceived that -above the one door of each ward is a large ventilator, ordered to be -open day and night--that beyond this ventilator, which opens into the -landing-place, is a large window which opens into the external air; -and thus admits fresh air into the ward at night, diminishing the -foul night atmosphere. This night ventilation system is good; but it -requires careful watching, as chilly patients, Nurses, and sometimes -Sisters, are very apt to give, after they conclude the rounds are over -for the night, a sly pull at the rope and to shut the window, and thus -imbibe the foul air directly generated, in quiet. - - -[Sidenote: Special Wards, whether desirable or not.] - -15. SPECIAL WARDS.--It may be laid down as an axiom in the management -of sick affected with certain zymotic diseases, such as fevers, -cholera, dysentery, &c., that they should be distributed over a -wide superficial area, and have a large allowance of cubic space. -Agglomeration of such cases in small ill-ventilated wards is quite -sufficient of itself to occasion a high proportionate mortality -among the sick. In mild climates and seasons very little protection -is necessary from the change of temperature; so that the sick from -epidemic diseases can be camped out and exposed to the full influence -of the atmosphere, not only without danger, but often with great -benefit. It is only when the temperature is low and variable, and the -season inclement, that danger is likely to accrue from this exposure. -And hence the necessity of inquiring how we can best combine the -requisite elevation of temperature and the most suitable amount of -cubic space and ventilation for the treatment of these diseases in -Hospitals. - -Medical Men generally are satisfied that these ends cannot be safely -arrived at by agglomerating sick in fever wards in Hospitals. And hence -has arisen a practice, which experience appears to have approved, -of intermingling a small number of fever cases in wards containing -a certain number of sick from other diseases. The practice appears -to be not only perfectly safe, but advantageous for the sick. It -is known, however, that if the proportion of fever cases exceeds a -certain number, the other cases in the ward are apt to become affected -with fever. It would appear as if, so far as the fever is concerned, -the cubic space occupied by other diseases was to a certain extent -available for the use of the fever cases. But the proportion of such -cases, that can be advantageously placed among the general sick of any -ward, will depend upon the size of the ward, the means of ventilation, -the number of cubic feet per patient, the position of the windows, the -exposure of the building, and other similar circumstances. - -Again, it is doubtful whether the preservation of an uniform -temperature in any Hospital, even in one set apart for chest -complaints, is beneficial for the sick, or whether it be beneficial to -agglomerate consumptive cases, without very special precautions, under -the same roof. Without discussing the validity of the opinions held in -Southern Europe as to the contagious nature of consumption, it may be -very fairly doubted whether a number of cases placed under a common -roof, and breathing a common atmosphere, would not yield a higher rate -of mortality than the same cases would do if distributed through the -wards of a well-ventilated Hospital, among other diseases. - -The subject is worthy of examination. At all events the phenomena -observed in this disease in the warmer climates of Europe have led -to the popular belief above stated; and it would appear to point -to a higher rate of mortality as a not unlikely result of the -establishment of special Hospitals or wards for consumptive diseases, -unless extraordinary care were taken to ventilate them properly, and -to imitate the natural variations of temperature which appear to be -necessary for recovery. - - -[Sidenote: 16. Proposed Regulations as to Payments, by -Superintendent-General.] - -16. All salaries and wages of Matrons and Nurses should be paid, on -the Superintendent-General’s order, from the Hospital chest, to the -Matron, who should pay the wages and other expenses of the Nurses, and -account for all monies received by her on such orders. All outfits and -travelling expenses, in cases of transfer, &c., should be provided on -the order of the Superintendent-General. - -[Sidenote: Opinion as to Superintendent-General paying Wages and -Salaries.] - -There would be considerable difficulty in the way of making -all payments at a distance to Nurses, direct from the -Superintendent-General, otherwise than by orders on the Hospital chest -or Treasury. But there can be no doubt that the Nurses ought to be paid -by the Matron and by no one else. The service of Nurses in Hospital -is a peculiar service, and if not successfully conducted by influence -never can be by coercive discipline. It would be a great mistake, -therefore, to throw away any means of influence which we can command, -and the “eye of the maid-servant is to the hand of her mistress” now as -it was 2,000 years ago. The fact of paying and being paid helps greatly -to establish the proper mutual relations between the superior and the -subordinate. The Matron would draw from the Hospital Treasury, on the -orders of the Superintendent-General, and would account to her. As a -matter of discipline, it would make no material difference whether the -orders of the Superintendent-General, in favour of the Matron, for the -pay of the Nurses, are cashed by the Hospital Treasurer or by a banker, -always supposing that the Treasurer is bound to honour those orders, -as any other banker would. - -[Sidenote: Matrons abroad may dismiss Nurses under appeal.] - -The Matron, in any Hospital out of Great Britain and Ireland, should -be able, with the concurrence of the Governor of the Hospital, to -dismiss and send home any Nurse; or the Governor himself, on his own -responsibility, may direct the Matron to do so, under appeal, however, -in either case, to the Superintendent-General, who shall decide, after -the arrival of the Nurse, whether she is to be dismissed or whether she -may be placed in another Hospital. - -It should be secured, not left to chance, that the Matron be -immediately made acquainted with any complaint of the Medical Officers -against a Nurse. - -[Sidenote: Matron to draw Rations and Extras.] - -The Matron should be able to draw from the Purveyor, on her own indent, -with the sanction of the Governor of the Hospital, such rations and -extras as she may consider necessary for the Nursing establishment, and -make the arrangements for cooking. In the United Kingdom the Matron -should be able to make arrangements, subject to the approval of the -Superintendent-General, for commuting rations for mess-money, not pay. - -The Governor is responsible for the sufficiency of all supplies -and none ought to be expended, without his sanction. This might be -indispensable, if there were danger that supplies might run short. - -[Sidenote: Opinion as to Governor’s jurisdiction over Nurses.] - -Upon both these latter points, supposing the Governor of a General -Hospital to exist, he must have power to maintain the discipline of the -Hospital, in all its Departments, as a General commanding a division -has, in regard to every regiment composing it. But he ought to exercise -it only through the Matron, as commanding a corps. He must also have -power to require the exclusion from the Hospital of any Nurse whose -conduct he may find to be inconsistent with maintenance of discipline, -and this power he would enforce, on his own responsibility, by -directing the Matron to remove the offending Nurse from the Hospital. -The conduct of the Nurse would become the subject of investigation -afterwards, in terms of the established regulations. But practically -such a case could hardly occur, unless by the fault of the Matron, who -would, of her own accord, desire to remove a Nurse, on being satisfied -that such a measure was necessary or expedient. It would be proper, -too, both for her own justification and for the maintenance of the -Governor’s supremacy in the Hospital, that the Matron should obtain -his concurrence in the removal of a Nurse from the Hospital. The -proceedings, in all such cases, would, of course, be reported by the -Matron to the Superintendent-General. - -Whether the Governor has the power of removing the Matron, who clearly -and properly ranks among the officers under him, should be settled and -not left to be disputed about in a distant station. At all events, -if he has this power over her, it must be guarded, as extending only -to suspension from office, in cases of alleged flagrant neglect or -misconduct, till the whole matter can be remitted and decided on by the -Superintendent-General. - - -[Sidenote: 17. Nurses’ Wages.] - -17. Generally, as to the question of wages and pensions, a regulation -that Nurses shall have a small annual increase of wages is better than -one giving an increase after five or three years. - -[Sidenote: Efficiency of Nurses does not increase by springs and -starts, like Grasshoppers.] - -Efficiency does not go by starts and springs, like grasshoppers, but -makes “a small annual increase,” like the wages proposed. - -Nay, I appeal to everyone with experience in these matters whether the -greatest improvement is not made the first year, the second year a -little less, and so on the third and fourth, till, when the fifth year -comes, if improvement has not been made by that time, it never will be. - -[Sidenote: The first five years a constant improvement. Afterwards if -there has not been improvement made before, no hope at all.] - -For trust-worthiness is the true efficiency of a Nurse. And it may -safely be said that, if by the end of the first year she has not -improved in trust-worthiness, she had better go; and if she have not -almost reached her culminating point by the fifth year, she certainly -will not improve afterwards. - -[Sidenote: Three principles in Wages.] - -The reasonable principle I believe to be, 1, to begin improving the -wages at as early a period as possible; 2, to let them increase till -the Nurse reaches her maximum of efficiency; and, 3, after that to make -no more increase. - -[Sidenote: By rate of Wages to retain those who are efficient.] - -Because the object is to induce the young and efficient women to stay, -not the old ones. They will stay long enough, because the old ones -nobody else will take. - -[Sidenote: By rate of Pension to reward those who have been efficient.] - -The rate of pension ought, on the other hand, to increase with the -number of years’ service, and continue increasing till the end. The -principle of pensioning is different from that of wages. After the -woman has reached her maximum of efficiency, which certainly will be -not later than forty-five, probably not later than forty years of age, -the inducement to stay should be the improvement of pension. This -compensates for any apparent injustice in the first principle towards -an old servant. - -[Sidenote: Civil Service an Example.] - -No other system appears to be founded on common sense; and it is one -generally acknowledged in the Civil Service, where salaries are made to -rise as soon as possible. Military Hospitals must not be made training -schools for Nurses; else it would be better to admit them much younger -than at the age of thirty years. - -[Sidenote: Opinion as to Wages and Pensions.] - -If a Nurse cannot enter the Service till after she is thirty, the -majority will no doubt be some years above thirty when they enter, say -an average of thirty-five; and five years appear a very long probation -for a person at that age before increase of wages begins. In most -cases, in Civil Departments, there is only one year of such probation -before increase begins, though the persons are much younger when they -enter. A maximum might be fixed, beyond which the wages should not -rise, and when the increase of pension would be sufficient inducement -to remain. Very few Nurses can be expected to continue really efficient -till sixty years of age; but it is often difficult to say that a person -is disabled, though she may have become less active and efficient. -If there is no retiring allowance there will be great reluctance to -dismiss her, and it might, in that case, be cruel. The better plan -would be to promise a small pension after ten or twelve years’ service, -on a scale so graduated thereafter as to offer an inducement to remain, -at the same time that it would afford facility for enforcing retirement -without injustice. This would be economy. The “Nursing Sisters” grant -£20 after twelve years’ service. - -After a time there may probably be difficulty in dismissing persons who -have done good service for ten years, but have declined in efficiency, -unless there is a retiring allowance. They may be reluctant to retire; -and, if so, it would be almost impossible to dismiss them, without -some kind of provision. This is a difficulty which is encountered in -every employment in which there is no such provision. Persons who can -hardly be said to be disabled but who have become less efficient are -retained, because, if dismissed, they have no means of livelihood. - -I have consulted the best authorities upon these points; and I find the -following general principles admitted:-- - - -GENERAL PRINCIPLES AS TO WAGES AND PENSIONS. - -[Sidenote: (1.) Same Salary at first.] - -(1.) At whatever age a Nurse enters the Service she shall begin with -the same salary. - -[Sidenote: (2.) Same Annual rate of increase.] - -(2.) The annual rate of increase shall be the same for all ages of -entrance. - -[Sidenote: (3.) Maximum Salary fixed.] - -(3.) The maximum salary shall not exceed £. - -[Sidenote: (4.) Pension for Service after Ten Years.] - -(4.) The pension for service shall not begin until ten years of -completed service. - -[Sidenote: (5.) Amount of Pension a certain Percentage on mean Salary -of preceding year.] - -(5.) The amount of pension shall be a certain percentage on the salary -during the year preceding that on which she is pensioned. - - -APPLICATIONS OF THE FOREGOING PRINCIPLES. - -[Sidenote: (1.) Annual rise of Wages till the maximum of efficiency.] - -(1.) That the wages of Nurses shall rise annually, for a definite -number of years, attaining their maximum, on an average, at the age -forty-five, when the Nurses are found to be most efficient. - -[Sidenote: (2.) After five years’ Service Pension for Disability.] - -(2.) That, after five years’ service, the Nurse shall, in the case of -ABSOLUTE DISABILITY, become entitled to a pension during the period of -her disability. - -[Sidenote: (3.) Pension on a Scale graduated on the Wages.] - -(3.) The pension will be on a scale graduated on the wages. It will be -twenty per cent. of the annual wages in the year of service, 5–6, and -the rate to be granted will rise progressively two per cent. per annum, -until the rate on the wages becomes seventy per cent. - -[Sidenote: (4.) All Nurses to retire at Sixty.] - -(4.) All Nurses will be placed on the Retired List at the age of -sixty.[16] - -[Sidenote: (5.) Nurses to serve again who are Pensioned for Disability, -when Disability ceases before Sixty.] - -(5.) Those Nurses who are pensioned at an earlier age, for disability, -will, if called upon, be liable to serve when that disability ceases, -or to forfeit their pension. They must therefore bring an annual -medical certificate of disability to the Superintendent-General, in -order to receive their pension. - -[Sidenote: (6.) Nurses partially Disabled to receive partial Pension.] - -(6.) Nurses who are partially disabled will only be entitled to -a certain proportion of the pension allowed in the scale, to be -determined, on representation made by the Superintendent-General. - - -[Sidenote: Example.] - -Example. - - COMPLETED YEARS - AGE. OF SERVICE. WAGES. PENSION. - - 30 0 £20? } - 31 1 22 } - 32 2 24 } Gratuity - 33 3 26 } - 34 4 28 } - ---------------------------------------- - 35 5 30 × ·2 = £6 - 40 10 40 ·3 12 - 45 15 50 ·4 20 - 50 20 50 ·5 25 - 55 25 50 ·6 30 - 60 30 50 ·7 35 - -These principles, if admitted, would suggest the following heads for -regulations as to Nurses’ wages and pensions:-- - -[Sidenote: (1.) Amount of Wages, first year, £20.] - -(1.) At whatever age a Nurse enters the service, the amount of wages -paid to her during her first year of service, will be £20. - -[Sidenote: (2.) Annual rate of increase up to £50, when it ceases.] - -(2.) There will be an annual rate of increase of wages equal to 10 per -cent, of the first year’s wages, until the yearly wages amount to £50, -beyond which there will be no further increase. - -[Sidenote: (3.) No Pension till Ten Years’ Service completed, nor for -Disability till Five Years.] - -(3.) A pension will be awarded for service to any Nurse, who may -retire, on account of age, at the expiry of ten full years’ service, -but in case of disability, a Nurse shall receive a pension after -five years’ service, or a gratuity, according to circumstances, if -discharged for disability, before she has completed five years of -service. - -[Sidenote: (4.) Rate of Pension.] - -(4.) Rate of Pension. The pension will be on a scale graduated on the -wages. It will be 30 per cent. of the wages received by the Nurse in -her tenth year of service, and the pension granted to Nurses who have -served more than ten years, will rise at the rate of 2 per cent. of the -wages for every additional year of service, until the pension amounts -to 70 per cent. of the wages received during the year preceding its -grant, beyond which no higher pension will be granted, except in cases -of special devotedness to the public service, when an addition to the -regulated rate of any pension may be granted on special recommendation, -made by the Superintendent-General of Nurses, setting forth the nature -of the service for which such augmented pension is to be granted.[17] -But no such pension shall exceed the amount of £50. - -[Sidenote: (5.) Nurses, Pensioned for Disability, whose Disability -ceases, may be called on for Service.] - -(5.) Any Nurse pensioned for disability, may be called on for service -in the event of such disability ceasing before the age of sixty, in -which case her wages will be the same as they would have been, had she -not been disabled. - -(6.) Every Nurse who has completed her sixtieth year, must retire from -the service on her rate of pension. - -(7.) Any Nurse, temporarily or permanently disabled in the service, who -has served more than five and under ten years, will be entitled to a -lower rate of pension, according to the circumstances of each case, as -represented by the Superintendent-General. - -[Sidenote: 18. Number of Nurses to Patients.] - -18. Nurses should be selected and appointed by the -Superintendent-General of Nurses for each General Hospital, in a -proportion not exceeding one nurse for every twenty-five cases. - -There is nothing so fatal to discipline as to require by regulations -what it is known and admitted cannot be performed. Such rules are made -to be broken. Therefore, is it not better, instead of fixing a number -to fix a limit, and say “not exceeding one to every 25 or 30 patients,” -leaving it to the Superintendent-General to economize Nurses, and not -appoint the full number permitted, unless when really necessary? In one -case she might consider one nurse for fifty or even sixty sufficient; -in another, one for every twenty-five might be few enough. Why tie up -her hands against economy as well as against extravagance? - -At the same time it is necessary to state-- - -(1.) That, by all accounts, at home and abroad, in the English and in -foreign armies, the proportion of severe cases is very considerably -less, in time of peace, in a Military Hospital than in a Civil one, -especially in the surgical wards. - -(2.) That the Nurse’s time, being relieved of the waste incurred by -fetching and waiting for things, the cleaning of the ward being done by -Orderlies, and, an important item, the Ward-Master being responsible -for the serving the patients’ food, twenty-five sick are not enough, on -an average, to occupy, properly, her time. - -(3.) That idleness, always pernicious, is never more so than to -Hospital-Nurses. - -(4.) That petting the patients, by way of filling up time, would be, of -the two, more pernicious than idleness. - -(5.) That it is most important, apart from these reasons, to train and -accustom these Nurses to serve efficiently large numbers of patients, -so as to make them useful in war-service, where every woman who can be -spared is better away; and where a small efficient staff would, please -God, do excellent service. - -(6.) That it is not in human nature, taking its average, supposing the -Regulations lay down that the proportion is not to exceed 25, for many -Nurses not to murmur at having more; whereas they ought from the first -to understand, that the service is a very laborious one, and that none -but women able and willing to undergo and render laborious service, -ought to enter it, or be suffered to remain in it. - -(7.) Care must be taken therefore that in fixing this minimum, no use -may be made of it dangerous to the service, either in the Hospital work -itself, or in provoking adverse criticisms upon these Regulations in -quite different places. Twenty-five cases are not generally enough. - -[Sidenote: 19. Precautions in sending Nurses abroad.] - -19. It would be expedient to take the advice of an able and honest -man of business as to whether the Superintendent-General should, on -engaging a Matron or Nurse, have her signature to a bond or not. -On the one hand, we know what bonds are to loose consciences, and -if the promulgation of the Regulations give undoubted power to the -Superintendent-General and to her Matrons on foreign stations, I -should prefer having no bond. But this is for a man of business to -answer. It is important to remember that the power of instant dismissal -for misconduct, and of sending the Nurse home must be retained, -which renders the service different from ordinary female service. A -discharged governess or servant, if she insisted on remaining at her -own expense at the foreign station, could not be sent home forcibly -by her late mistress; now it is essential that an offending Nurse be -forthwith passed on board the first returning ship. Also performances -similar to those of one or two of the women in the War-Hospitals who, -on hearing of good situations, misbehaved in order to be discharged, -ought to be effectually prevented. A lawyer must advise, first, if -it can be; secondly, how it can be done. The Superintendent-General, -on sending abroad Nurses, ought to have some security either that -they remain there and do their duty, or that they be sent home for -her judgment if they fail in duty. To have them either going abroad -as Nurses by way of securing a free passage, and then looking out -for lucrative situations, or accepting the offers which might, and, -occasionally, undoubtedly would, be made to them, would be most -injurious to the Service. Can it be prevented by any stronger measure -than the instant forfeiture of all claim to the eventual pension? If -so, it should. Could this power be extended to the washerwomen who -would probably be sent with the Nurses ordered to War or out-of-the-way -foreign stations? Perhaps it will simplify things not to include them -in the Regulations. - -[Sidenote: Hospital Laundries.] - -The persons provided by the Officer, whoever he may be, to attend to -the hospital linen under the orders of the Matron, will be pretty -sure to give the Matron trouble. But it is much better to begin very -modestly, and to avoid alarming the Attendance Department; and so to -be content with the people provided in the linen store, and not at -all to invade the regions of the kitchen. By degrees, please God the -work prospers, it may be extended. I fear a laundry of men, except in -war-service, will be a costly and inefficient concern. Yet a laundry -of women, exempt from the control of the Matron, would be probably the -worse evil of the two. And it is both right and expedient to move very -slowly, and to begin with the nursing service alone. Ultimately, if we -invade both laundry and kitchen, I should still wish, in both, to have -as few women as possible. The fewer women are about an Army Hospital -the better. - - - - -ADDENDA WITH REGARD TO FEMALE NURSING IN A MILITARY HOSPITAL ON THE -PAVILION OR LARIBOISIÈRE PLAN. - - -[Illustration: _PARIS_ - -Hospital de Lariboisière - -612 Lits. - - A. Bureaux. - B. à rez de chaussée Cuisine. au 1ᵉʳ Etage Logements d’employés - --au 2ᵐᵉ Etage Dortoirs des Garcons de Service. - C. idem Pharmacie. idem idem - -- idem Chambres des Elèves internes. - D E F G H I J K. Chauffoirs. - L M N O P Q. Batiments de Malades. - R. à rez de chaussée Buanderie. au 1ᵉʳ Etage Lingerie. - au 2ᵉᵐᵉ Etage Dortoirs des filles de Service. - S. Communauté. - T U. Bains. - V. Chapelle - X Y. Amphithèatres. - Z. Manège et Magasins - W. Ecurie. Remise et Salle des Morts. -] - -1. In considering the Pavilion Plan to be in future received as the -sanitary necessity for Hospital construction, we must look upon it as -susceptible of many modifications. - -And, particularly in adapting it for a Military Hospital, we must -ask by what modification can it be made, 1. Most economical as to -attendance, a greater amount of which is rendered necessary than by -other plans of construction. - -2. Easy as to supervision; and, of course, a Hospital spread over the -extent of space now proved to be essential by sanitary knowledge, -whether built on the Pavilion plan or not, must multiply the amount of -supervision over that required in the concentrated over-crowding of the -old Hospital system (over-crowding not with regard to cubic space in -the wards, but to the superficial area on the ground). - -3. Economical as to the number of sick to be accommodated on the same -floor, so as to save unnecessary waste of time and strength on the -stairs to both Ward-Masters and Nurses. Each Nurse should have, in time -of peace, not less than from 50–60 patients under her charge. - -4. Efficient as to convenient accommodation for Nurses and -Ward-Masters, near to the wards of which they are in charge. - -[Sidenote: 1. Pavilion Plan indispensable on Sanitary grounds. Its -Difficulties, on the score of Discipline in Military Hospitals, to be -openly met and guarded against.] - -1. The Pavilion Plan, while it is incontestably superior, on sanitary -grounds, to any other, while it perhaps may be made equally economical, -with regard to building, is more expensive than the older crowded -and badly-constructed Hospitals, not only as to ground, but because -each separate entrance, staircase, set of appurtenances, represents -an additional cost of materials, and of hands to keep them clean and -in order. Human life is, however, a more expensive article than any -other. If human beings, and especially sick human beings, are to be -spread over as much space as possible, which is now known to be an -essential to health and more especially to recovery, this must be done -under any system and can be best done under the Pavilion system. It -of course necessarily entails a greater amount and cost of attendance -and of supervision. Pure air and light are the prime necessities of a -hospital. These are best secured by the Pavilion Plan, and therefore -it is the cheapest in the end. As to the hands, there never ought, -never will, never can, be a superfluity of hands in a well-regulated -Hospital. The duty of the hands consists of two parts--to keep the -Hospital clean; to attend the sick. I had rather not enumerate the -instances where I have seen that, often from the most various causes, -one result arises--that more time and care is given to floors, -stairs, &c., &c., &c., than to the sick. Extreme cleanliness is of -vital importance; this should be combined with extreme simplicity -of detail, and with providing for considerable numbers at once. You -can effectually clean a large ward in much less time than two small -ones; a long stair than two short ones, &c. Extreme, _not finicking_, -cleanliness, thorough ventilation, for which an ample supply of -opposite windows will certainly in the long run prove infinitely the -best plan, and careful nursing, are probably the main conditions, -humanly speaking, of a large proportion of cures--subsidiary to the -medical or surgical treatment. - -Sanitary necessities are never to be rejected, on account of the -trouble they give or of the means of cleanliness which they render -necessary. Because the saving of life, not the saving of trouble, is -the object of all sanitary appliances, Hospitals among the number. And -the saving of life is the only real economy. If you have saved “hands” -and trouble, and lost life, you have been extravagant. The object is -not to banish appliances which will cost trouble in keeping them -clean, but to discover those appliances which can be kept clean, at -least cost of labour. And this is perfectly possible. - -[Sidenote: 2. Easy Supervision to be provided for.] - -2. The Vincennes modification of the Pavilion plan has been adopted, -among other reasons, for the greater facility of supervision it -affords. The Military Superior, the Surgeon, the Matron, can at any -instant pop in upon any ward of a Hospital which has one roof. Each -pavilion may, unless the matter be specially considered with a view -to providing this effectual supervision, perceive the approach of any -inspector. The system of scouts, watch, alarm, is well understood in -many hundred wards, whose patients would be puzzled to give the things -names. Military patients will know both things and names. Remember -that Ward-Masters, Orderlies, and Nurses require inspection as well as -patients. Whatever system of Hospital construction is adopted should -provide for easy supervision, at unexpected times. - -[Sidenote: 3. If from 24–30 Patients be the right Number, Sanitarily -speaking, for a Ward, the Pavilion Plan should, in a Military Hospital, -be so arranged that more than one such Ward should be on the same -floor, for facility of Supervision.] - -3. The more we see of different systems, the more we see the great -mistake of giving a Nurse too little to do. - -Twenty-four ordinary sick or surgical cases are too few for a Head -Nurse. - -In a Military Hospital, the proportion of heavy cases is in ordinary -times considerably below the average proportion of such cases in a -Civil Hospital, open, as the latter is, to accidents, and to the cases -of dangerous disease always more or less rife in low and crowded -neighbourhoods. - -Upon an average, a third or a fourth of the cases in the ordinary -surgical wards of a Military Hospital will be ulcers from causes honest -and dishonest. What these men will require is rest (the cleanliness -which is often so irksome a novelty to the corresponding Civilian -patient is routine to the soldier), and very simple treatment. - -It is most important, if possible, to form a staff of active, -laborious, useful women, who, if ordered on war-service, can at once -cope with numbers, and serve efficiently a considerable number of heavy -cases. - -Relieved of all cleaning, and relieved of the great loss of time -incurred by fetching, waiting, &c., &c., none of these Nurses, who -are, in fact, Head Nurses, should serve less than forty men. And, as I -before submitted, I had rather she served fifty or sixty than forty. - -Give them twenty-four patients, and either they will become idle, -finicking women, or they will take to petting the patients, a thing to -be sedulously avoided everywhere, most of all in Military Hospitals. - -[Sidenote: 4. Importance of the Head Nurse sleeping close to her Ward.] - -4. The more we see of different systems, the more apparent becomes the -importance of the Head Nurse (all these are Head Nurses) sleeping close -to the ward:-- - -As regards the efficiency of her service:-- - -As regards the saving her own time, strength, and securing her a -modicum of comfort in a work where, if she does her duty, she will -never have a superfluity of comfort. Time, strength, and this modicum -of comfort, enter much into a Nurse’s health--and health is essential -both for efficiency and economy. - -Where the Nurse sleeps at a distance from her ward, her efficiency, -both as to superintendence and work, especially at night, in dangerous -cases, is seriously impaired. - -If she sleeps at a distance from her ward, her comfort, also, such as -it is, is destroyed. Whatever a Nurse does for herself, she must do -by fits and starts. A really efficient Head Nurse is never able to -make anything for herself, though she often would far rather save the -money it costs to “put it out.” The most simple mendings, even the feat -of stowing away the laundress’ supply of a Saturday evening, become, -when a ward is heavy, or when there are two or three of those cases -of urgent danger, so many of which, by God’s blessing, the assiduous -care of these women saves, year by year, in our Hospitals, a procedure -done in several acts. The misery of dividing her small effects (the -smaller the better) between a day-room and a distant sleeping-room, -the unseemliness and inconvenience of carrying things backwards and -forwards, cannot be described. - -If it be possible, the Nurses must sleep adjoining their wards; and it -will not do to give each only 24 patients. - -It would be considerably better, if feasible, to have two Nurses in -contiguous rooms; but in the Pavilion Plan this would involve bringing -one Nurse away from her ward; and rather than this, the next best, -though inferior plan is to put one Nurse immediately above and below -the other, with a distinct bell which she can in a moment ring from -her bed into the other Nurse’s room, to summon her if needed. - -[Sidenote: Importance of Lighting Hospital Wards by Gas, with Sanitary -Precautions.] - -Some years ago gas was laid on in the Sisters’ rooms in Guy’s Hospital. -In the other Hospitals there is an allowance of candle to each -Sister. The disadvantages of gas are its alleged unhealthiness and -its certainly being disagreeable to some eyes. Its advantage is its -cheapness. Liberty to buy a candle and not use the gas is allowed at -Guy’s. As it will be a very important thing to conduct the Nursing -Service as economically as possible, and as there must not be any -wretched false economy as to essential matters, which in the end always -proves waste, it will be well to save as much as can be in matters not -essential. It would be worth while to ascertain the average amount -of saving which the substitution of gas for an allowance of candle -has effected at Guy’s. Gas is used in the wards of St. Bartholomew’s, -St. Thomas’s, and Guy’s, day and night. It appears, when ventilation -is properly attended to, to answer well, and to do no harm. At night -the gas is lowered so as to leave the ward just light enough to see -all that is done in it: if bleeding, &c. occurs, it can in an instant -be raised, and the ward lighted up. London Hospital burns gas in the -evening, and throughout the passages at night; but when the night watch -begins at nine, the wards are dark, except the Nurse’s candle. A spare -candle, un-lighted, is always at hand. - -It is very important for the order of a ward that the attendant in -charge, and also any inspector suddenly entering, should see at once -all that is going on in the ward. Where there are dangerous cases, this -is of great moment; and where there are not, it is equally necessary -for the police of the ward. A candle or a rushlight give insufficient -light. Properly lowered, gas at night does not disturb the patients. -After a night or two, those who are accustomed to sleep in the dark get -used to it. If the Nurse sleeps adjoining the ward, there _must_ be -sufficient light in the ward at night. If the gas-fittings are properly -tight and if every gas-burner has a ventilator, so that the products -of combustion are effectually conveyed away, for each gas-jet consumes -as much air as eleven men, it would be greatly preferable that there -should be a low gas light in the wards at night. - -[Sidenote: II.--1. Should it be necessary to serve one Pavilion with -one Nurse means by which this could be effected.] - -II.--1. Suppose the Lariboisière plan retained, as proposed at -Aldershot, for a Military Hospital, with wards of twenty-four beds -each--then, with fear and trembling, but with the firm conviction -that it is better for human nature, most of all, for nursing human -nature, to have somewhat too much than a great deal too little to do, -I respectfully recommend that one Nurse serve the three wards of each -Pavilion. - -One woman cannot sleep alone in the Pavilion. The Nurses must sleep -together near the Matron’s quarters. If the Nurses sleep away from -the wards there should be some way by which a Nurse can at once be -summoned, in case of any urgency in her ward, and it would be well -to consider this in the distribution of quarters. Either the Matron -should lock the Nurses’ quarters at night, and any summons should be -brought to her and by her referred to the Nurse; or the summons should -go straight to the Nurse’s door. There are difficulties both ways, -even supposing these summons should be unfrequent. The Nurse of each -Pavilion should inhabit the room on the ground-floor ward, where the -heaviest surgical cases will be probably placed, whence she can better -command the movements of the Pavilion, and attend the entrance of the -Surgeon. - -[Sidenote: 2. Head Nurse’s Day in a Pavilion Hospital.] - -2. Her day might be something like this (in time, perhaps, God will -bless us with some Army Chaplain who will get up early and give us a -very short service morning and evening):-- - -She should be effective, and enter the Pavilion about 6 A.M., go -through the wards, read prayers in one by turns at the appointed hour, -and give out the linen wanted. (Six is the nominal hour when the Head -Nurses of one great London Hospital enter on their duty.) Here must -be no nominal hours, all must be real, though not overstrained. Then -the dressings, &c., attendance on Surgeons, &c. With 72 patients on -different floors, she must train the Orderlies to do the lighter -dressings (by training I mean real teaching, not leaving the Orderly to -find them out himself); she must see all the wounds of all her wards -which she does not dress herself at least every other day (which she -can do by seeing some in the morning and some in the evening), and she -must dress the heavy cases of all the wards herself. All this, with -method, and not losing time by fetching and waiting, an efficient Head -Nurse can do. - -She must be responsible for the linen of the wards; but this must be -simplified as much as can be, so as to secure responsibility, yet -relieve the Nurse of unnecessary time spent over it. - -The Nurse should be relieved of all writing and counting, on the score -of loss of time incurred. It will not do to charge a Nurse, with -seventy-two patients on three different floors, with serving each man -his portion of diet; the diets of two wards would get cold while she -was serving the first. It will be better to make the Ward-Master of -Pavilion wards responsible for the serving the diets. There must, of -course, be a card at each bed, or some other record, showing the diet -the man is ordered. The Nurse must know at a moment’s glance what each -patient is ordered. - -The largest London wards are the two male accident wards in the -London Hospital. Each Head Nurse has charge of five wards of 12 beds, -separated (and in some respects impeded) by two lobbies. Very often -there are fifteen beds in each ward (not by over crowding), and these -Head Nurses are often to be seen in charge of seventy-five patients -each, including many serious, and some urgent cases. The two lobbies, -the small wards, and the duty of some daily writing and arithmetic -in settling the diets, with some daily loss of time in fetching and -waiting for medicine, render a Head-Nurse’s service, as regards -“manual” labour, less efficient than it might be; even where she is -most efficient. - -Relieve the Nurses as much as possible of all writing and arithmetic. -If it could be possible to relieve them altogether of the “settling” -the diets, so much, by a great deal, the better. In the Lariboisière -system, with one Nurse to each Pavilion, it is utterly impossible to -prevent the Nurse losing daily time and strength on the stairs. But, -relieved of writing, of arithmetic, of losing time by “settling” and -fetching, such women as it will be our aim to procure can get through -the duty of seventy-two patients, although with the serious drawback of -their being in separate wards and on separate floors. - -If, however, the Pavilion plan were so modified as to have two -pavilions end to end, with an intervening staircase, so spacious and -well ventilated as to cut off the ventilation of the two wards on the -same plane, then all the conditions as to health, and facility of -nursing and supervision, would be much more easily obtained. Of this -more hereafter. - -[Sidenote: 3. Responsibility of Nurse for Discipline of her Ward or -Wards--how Modified in Military Hospitals.] - -3. As to the Nurse’s responsibility for the good order of the three -wards in a pavilion, supposing the three wards are served by one Nurse, -there must always be a clear difference between this responsibility -in the Head Nurse of a Civil and a Military Hospital. The Civil Head -Nurse, whose assistants are all Nurses, who with herself are under the -Matron, is charged with, and responsible for, the good order of the -ward, and it becomes her duty, the moment she finds herself unable to -do this alone, at once to call in the Steward, or equivalent Officer, -in whose hands is the police of the Hospital. - -The Military Head-Nurse’s Assistants are Orderlies, _i. e._ men and -soldiers, who, with the patients, are under military discipline. Of -this military discipline, the military power from the Commandant down -to the Non-Commissioned Officers acting as Ward-Masters, &c., is in -charge; the duty of the Military Nurse is, I apprehend, in case of -any insubordination which she cannot put down at once, to call in the -Ward-Master or equivalent, before calling in the superior Military or -the Surgical Officer; it being, however, well understood on all sides, -that she has the right of direct appeal to the superior Military or -the Surgical Officer, if the Ward-Master does not do his duty, or -in the event of a grave irregularity, if he is not at hand, besides -its being her duty to report such to the Matron, if the case admits -of being deferred till that can be done. It is impossible to settle -details until the regulations as to the new Hospital Corps are fixed; -and whatever regulations, whether for Nurses or for Orderlies are -made, some difficulty, and much discretion will be inevitable and -necessary in working them. But it is necessary to bear in mind that -whereas in the Civil Hospital the Head Nurse, under the control of, and -responsible to, the Officers, including the Matron of the Hospital, -is solely in charge of both the nursing and the discipline of her -ward, both as to patients and as to Assistant Nurses; in the Military -Hospital, she is in charge of the nursing, and the Ward-Master of the -discipline, both of patients and Orderlies. To be in charge of the -nursing, implies to have power to enforce discipline, but this is -rather, in ordinary cases, to call in the military power, beginning -from the lowest or Ward-Master’s grade and reporting this to the -Matron, than to invoke herself the military superiors. Therefore it -would be well worth while trying how far it would answer to serve the -three wards by one Nurse, who, in each ward where she successively is, -is bound, on perceiving any irregularity, to call in the Ward-Master, -and, in contingencies, to appeal directly to the Surgeon and the -Captain of Orderlies, and to make the discipline of the three wards -the charge of the Ward-Master, who is bound to go through the wards -when the Nurse is not in them. The Ward-Master, in order to fulfil his -charge, must enter all the wards, while the Nurse is in one of them; so -that the patients of one ward, who may know that they are safe from the -Nurse for half an hour or more, as she is in another ward, know that -they are not safe from the Ward-Master. - -In a military Hospital we must bear in mind that it is essential that -the discipline over patients and orderlies should be exercised by men, -and that the Ward-Masters must be the lowest and immediate deposits of -this power of discipline. - -All these things must be settled with the concurrence of the -Director-General. - -It is a great comfort that the Hospital staff returns to soldiers. We -shall get on infinitely better with them than we could have done with -the late Medical Staff Corps, though, after all, in the long run, we -should manage with them too. If only God helps us with the sort of -women required, thoroughly efficient Nurses, laborious active women, -discreet as well as well-conducted, and aware (a little) of the sort -of work and place, they are in!--let us trust this to Him, when the -time comes, and depend upon it, to give each Nurse plenty to do will -become one great means of forming such women--provided, which must be -strenuously kept in view, they are made to do it. - -[Sidenote: 4. Importance of Lifts.] - -4. It is very important to have the system of lifts throughout the -Hospital, although here, as throughout, the plan of Pavilions renders -them much more requisite, and makes them work less efficiently than -the block plan. Lifts, to carry meals and medicine, linen, coals, &c., -&c., to and from the first and second floor wards, are very preferable -to the Orderlies carrying them up and down. One sort of load ought -certainly not to be brought up and down by lifts, but to be carried up -and down by men, viz., coffins and the dead. Using the lift for this -purpose (as is done in one Civil Hospital) is on all and every account -thoroughly objectionable. - -The system of lifts is the more important, because although there is -no objection to the washing of tea cups, drinking cups, and medicine -vessels at the sink in the scullery, it is certainly neither necessary -nor safe to wash the dinner dishes close to the sick wards. By a little -arrangement, the whole of these could be removed by lifts to a scullery -beside the kitchen, and there cleansed and set aside for next day’s use. - -[Sidenote: III.--1. Casualty Wards for noisy and offensive cases should -be separate from the ordinary Wards, and under a completely-appointed -Staff of their own--both for Sanitary and administrative reasons.] - -III.--1. Sanitary necessities can never be interfered with. The -concentrating offensive and noisy cases together, while entirely -separating them from each other, in a completely appointed set of -wards, is a far more efficient working thing than appending a small -ward to each ward. - -St. Thomas’s (a very admirable Hospital in very many things) has a -casualty ward (for such cases) for men and one, adjoining but separate, -for women, under the charge of one Sister. Baths are in the wards. - -Guy’s had the same provision with, however, the drawback that there was -not a Sister in charge, but a Nurse over other Nurses, with higher pay, -but not a Sister or Head Nurse. However excellent such a Nurse may be, -every ward _must_ be under the same regular government as is general in -the Hospital, if discipline and order are not to suffer. Every ward or -set of wards should be under a completely appointed staff. - -St. Bartholomew’s had a set of casualty wards, including two of about -ten beds each, several small wards of two and one bed each, including -two with gratings and other melancholy necessary appliances to prevent -extremely violent delirious patients from becoming suicides. These -wards were often partially empty, never quite so. They were long served -like the casualty wards of Guy’s; but some years ago they were placed -under the charge of the Sister of the male operation ward immediately -above, who received in consequence a small annual increase of wages. - -London Hospital sent its noisome, offensive, and extra-infectious -cases to its other wards--small wards for one patient each, and, like -Guy’s, not under the regular management of a regular Head Nurse. - -It most certainly appears that the plan of concentrating these cases -together, but with (as at St. Bartholomew’s) small wards where -extra-violent patients can be put separately, the whole under one staff -of Nurses, is far the best working plan. - -And for this reason. Occasionally, a very offensive case requires -little nursing beyond the fixed daily dressings, and can lie quietly -enough in his bed or ward. But noisy cases almost always, and offensive -cases generally, require close watching. Now the moment we have a -patient in a little room at the end of the ward, it is our duty to -go in and out and see after him, and supposing him to be a violent, -delirious case, he is, unless under strong restraint, unsafe alone; and -even then the restraint requires looking to. In very many cases the -frequent inspection of Nurse and Orderlies would not be enough, and the -man ought to have a watcher. - -We can never send one of the Orderlies of the ward, wanted for its -regular duty, to sit down in one of these little rooms; and we can -never keep a fixed extra Orderly idling about, unless the little ward -is inhabited. We must then fall back upon extra Orderlies, put in when -the case wants close watching--of course not otherwise. - -At night, also, the watching which suffices for the ward will often not -suffice for the extra case--and he must have a watcher apart. - -The plan of extra Orderlies or extra Nurses is a very bad one, to be -avoided as much and as long as possible; it very seriously interferes -with the discipline of wards. - -Recollect that each offensive or extra-infectious case, put into the -little ward, ought to represent a great amount of separation and -care, which it will be difficult to secure. His mug, utensils of all -descriptions, bandages, &c., ought to be washed separately from those -of the patients of the large ward. Is this easily secured? - -In the two Borough Hospitals they at once remove a case of erysipelas -or gangrene, occurring in any ward, erysipelas from venereal wards -included, into the casualty ward. In the two other great Hospitals -it is only when the erysipelas or gangrene becomes severe that the -removal is made. Now at once to remove these cases from the ordinary -wards is very advantageous. - -St. Bartholomew’s larger wards for male and female casualty cases, two -small wards for two patients each, and two grated wards for one each, -are very efficient. The wards are all contiguous, and, as has been -said, under the charge of a remarkably efficient Sister, who has charge -also of the male operation ward immediately above. The little casualty -wards, of course, add to the work, and greatly to the anxiety of -watching; but certainly violent delirium tremens’ cases, alone and in -a secure ward which can be darkened, appear often to quiet much sooner -than where several of these wretches lie shouting to and at each other. -Delirium tremens will never be a thing unknown in a Military Hospital. - -One such case in the little ward adjoining the Pavilion Ward would be -a heavy infliction on the severe cases in the latter; the noise would -be heard throughout it. And unless the ward were properly secured, or -unless the man were under strong restraint--and then that would require -constant looking to--he would not be safe a moment alone; while the -Orderly was emptying slops or bringing in his dinner, something might -occur. - -[Sidenote: 2. Restraint or Non-restraint in Delirium Tremens.] - -2. Restraint is again a thing which must be left to our masters, and -to them solely--but an ugly, sorrowful, little truth may here be told. -Restraining and non-restraining processes, and their results may be -seen, both where, in the same Hospital, one or more of the Surgeons -orders restraint never to be used to his patients, however violent, and -others order it to be used in violent cases: and where the rule of the -Hospital is to restrain violent cases, removing the restraint so soon -as the paroxysm is over, or as soon as amelioration renders the sudden -return of paroxysms less likely. I am not speaking of lunatic asylums, -but of delirium, particularly delirium tremens, in hospitals. Lunatics -occasionally enter the Civil Hospitals, but, of course, as soon as -that supreme earthly misery is ascertained, they are removed to the -proper refuge. It is my humble opinion and firm belief that mechanical -restraint excites a patient much less, and quiets him much sooner, than -the prolonged struggle with his attendant’s arms and hands, which -_must_ otherwise be resorted to. - -The coercion apparatus ought also to be good, not cheap, and always in -perfect order. The least thing out of order either causes pain, which -when it can be avoided is cruel, or it endangers the efficiency of the -whole. The strength and cunning of these patients resembles those of -madmen, which for the time being they are. - -Restraint renders the usual complement of ward servants able to manage -many cases. Non-restraint means that some person must stand or sit by -or upon the patient’s bed, and hold and struggle with him often for -hours--also that generally this person must be a stranger to the ward. -Extra attendants are most injurious to discipline. Could there be a -set of casualty or equivalent wards, with its own Head-Nurse, the sick -would gain much. - -But if necessary to adopt the little ward with every ward--in that case -the Nurse must manage the three additional patients--twenty-four or -twenty-five are, indeed, too few. - -[Sidenote: IV. Simplicity of Construction essential to Discipline.] - -IV. In all Hospitals, let the construction be as simple as it can be. -Let its splendour be its lofty airy wards, with plenty of windows; -water in all due abundance on each floor; an ample, not excessive, -supply of linen, polished impervious walls and ceilings, well-laid and -bees-waxed oak floors, and a thorough not excessive, supply of good -apparatus of the various necessary kinds. But every _unneeded_ closet, -scullery, sink, lobby, represents both a place which must be cleaned, -and which must take hands and time to clean, and a hiding or skulking -place for patients or servants disposed to do wrong; and of such no -Hospital will ever be free. And every cornice, every brass lock or -handle, which could be replaced by a plain china or ebony one; every -decoration, or flourish, or ledge, on doors, windows, tables, beds, -presses, &c., represents either a collection of dust or a great waste -of hands, time, and strength in unnecessary cleaning and dusting. These -are not crotchets, but the result of close observation of the practical -working of these matters. Every five minutes wasted upon cleaning what -had better not have been there to be cleaned, is something taken from -and lost by the sick. Let the appurtenances of the wards be simple and -complete, but as plain and as undecorated as it is possible to be. - -[Sidenote: Polished Walls.] - -Polished impervious walls and ceilings are of the first consequence -in Hospitals. It is perhaps hardly necessary to state that, if Parian -cement be used, it must not and need not be of the kind lining the -wards and corridors at Guy’s Hospital, which is as rough as the -roughest plaster, of a dark and dirty colour, and which nothing could -improve but being lime-washed twice a-year; it should be polished like -that used at the Lariboisière Hospital at Paris, and of a pure white. - -[Sidenote: Covered Exercising Place.] - -In building a new Hospital, some covered arcade or some place where -the patients might take exercise in wet weather, and where inspection -could be exercised over them, without fuss, is worth contriving. In St. -Thomas’s, the patients walk under the covered arcades of the court. - -[Sidenote: Reserve Wards.] - -Both in Bethanien and in the Charité Hospitals at Berlin there are -reserve wards,--or rather in the Charité there is a reserve Hospital, -into which most of the sick are moved for six months in the year, to -change the air alternately of all the wards, which during the time -receive a thorough cleaning. Great stress is laid at Berlin on thus -providing, when building a new Hospital, a certain reserve space, which -obviates the necessity of less efficient and far more costly steps -afterwards. - -[Sidenote: V. Nurses’ Meals.] - -V. Let us, by all means, consider as settled, that the Nurses’ food is -sent them cooked. Possibly, in the long run, the undoubted advantages -of this plan will be found to be over-balanced by its disadvantages; -but let us begin by trying it. I submit that their dinners, and -possibly suppers, should alone be sent them cooked, and that each Nurse -should receive a fixed weekly quantity of groceries, and a daily or two -days’ allowance of bread. - -For packing up the Nurse’s meals sent her from the kitchen, a Vienna -custom might be useful. Each Nurse to have a long, strong, straw -basket, properly named or numbered. Some contain five dishes and -covers, but two or three would here be sufficient for every purpose, -including an occasional slice of pudding. The dishes strong tin, with a -tin cover, and if the Nurse prefers eating her dinner out of it rather -than the dignity of plates, and the trouble of washing them up, the -Matron should let her take hers her own way. If taken by hand, two -baskets of this sort can be carried with ease. But if the Matron, as -a general procedure, sends each Nurse a hot little dinner, of a good -well-cooked portion of meat and vegetables, one such dish and cover -will do for one Nurse, and three, five, or six can be accommodated out -of the same basket, or one large basket, carried by two men, would -serve all the Nurses round. The dishes should, in either case, be -numbered or named, not the Nurse’s name, but the ward. - -A dish and cover of strong, coarse earthenware is used in the Vienna -Hospital, as a grander edition of dinner, &c. The tin ones keep warm -without fire for a long time. If the meal arrives when the Nurse -cannot eat it, put by on the hob, or some provision for warming in the -scullery, it will keep warm and good till she can eat it. - -[Sidenote: VI. Arrangements for a Pavilion served by one Nurse.] - -VI. Supposing that we serve each Pavilion by one Nurse, I submit that-- - -[Sidenote: 1. Nurse’s Day-room.] - -1. The Nurse’s day-room should be on the ground floor. - -[Sidenote: 2. Ward-Master’s Sleeping-room.] - -2. The Ward-Master should sleep in his room on the second or highest -floor; should the Nurses sleep in the Pavilion, the Ward-Master should -still sleep in it. - -In the event of the Pavilions being arranged end to end, as already -suggested, the difficulty in regard to Nurses’ and Ward-Masters’ rooms -would be materially diminished. - -[Sidenote: 3. Where should Orderlies Sleep?] - -3. I think, but am not sure, that the Orderlies had better sleep away -from their wards, but I would leave this to be settled by the Doctors. -In cases of sudden outbursts of danger, delirium, or drunkenness, from -the results of concealed spirits, and of the Surgeon being sent for, -it is useful to have, at once, other than the Night Orderly at hand. -And a part of what has been said as to the importance of the Head -Nurse sleeping near her ward, applies to the Orderlies. Yet there are -important reasons why the Orderlies should not be or feel too much at -home in their wards; and if the authorities are disposed to try the -plan of lodging the Orderlies together, away from their wards, they -are probably right, though I should not be surprised if, after a fair -trial, it were found better to revert to the having them near the ward. -The Pavilion Plan, which, on the one hand, gives all concerned more -liberty of doing wrong than the block plan, and which, on the other, -renders it more difficult to call in help, whether of supervisor or of -Orderlies, if help is suddenly wanted in the night, makes it the more -desirable to let the authorities take quite their own way, as to this. - -[Sidenote: 4. Where should Orderlies Dine?] - -4. I think the Orderlies had better have their cooked meals sent them -into the wards. Of course, they can only eat together in detachments; -but in many cases, the absence of even one of the Orderlies would be -very inconvenient. Perhaps just as the bell rings to summon to the -common meal, something is going on which requires all the ward service; -the man either goes late to a cold dinner, or goes away just when he is -wanted. If his dinner is brought to him in one of these emergencies, -it is put by to keep warm till it is over. Regularity as to meals, -as far as possible, should be strictly attended to; and is, in all -well-regulated wards: and it is well, where, as in some Hospitals, -there is a fixed hour for meals; but it would seem better that the -meals should come to the ward servants than the ward servants go to -their meals. - -[Sidenote: 5. Should Orderlies be brought together?] - -5. In the case of Civil Hospitals served by women, it is very important -that each Head-Nurse, and each set of Assistant-Nurses, should sleep, -eat, and live in the ward and its appertaining rooms, and not assemble -together more than can be avoided. With Orderlies the case is partly -different. Still I would not unnecessarily bring them all together, any -more than allow them to be too much at home in their wards. - -[Sidenote: 6. Should Orderlies have a Day-room in Pavilion?] - -6. If the Orderlies do not sleep in the Pavilion they should not have a -day-room. - -[Sidenote: 7. Scullery to each Ward.] - -7. To each ward should be attached a scullery, small, but not too -small, which only muddles things and work, well provided with cold, -and, if possible, with warm water; and it should be law that no patient -enters the scullery unless sent there by the Nurse to help in washing -up, &c.; and, as a rule, they ought not to be sent there. Make them -useful in the ward; keep the scullery for the Nurse and Orderlies. - -[Sidenote: 8. What should be done in the Scullery?] - -8. From this scullery let the Nurse get the water she -requires--Orderlies ditto. - -Let the Orderlies eat their meals in it, if they do not eat them away -from the ward. The food of the Orderlies is generally different from -that of most of the patients, and it answers better for them to eat -their meals not under the noses of the patients. In emergencies, of no -rare occurrence, the Orderly must watch a patient and eat his dinner at -the same time, and so must the Nurse; but, as a rule, it is undoubtedly -better that ward-servants should not eat under the observation of the -patients. - -In the scullery all the cleaning must take place, which is not done in -the lavatory. - -In the scullery extras are to be warmed, drinks ditto, hot-bricks -heated, water-bottles filled, &c., &c., &c., and none of these things -are to be done at the ward-fire. - -[Sidenote: Poultice-making.] - -On the other hand, there is no way so good of making poultices, a thing -humble but important, as for the Nurse to stand at a small table in -front of the ward-fire, to make the poultices there, spread them, and -forthwith apply them. - -Sometimes in a large ward, where the Surgeon orders them extensively, -a large iron pot is filled with poultice, and then quickly spread and -applied. Sometimes the pot is filled and the poultices spread in the -scullery or kitchen, to avoid the mess in the ward. When a number of -poultices are thus spread away from the sight of the patients, even by -very clever Nurses, some arrive too large, or too small, or too broad, -or too narrow; and either the poultice has to be returned, or, as of -course usually takes place, to be put on the wound it does not fit. - -I would not trust any Nurse, including myself, to make a number of -poultices of the right size, unless within sight of the patients. -Rather than do this it is better to make the poultice-pot (wood does -not hold heat, this must be of iron), in the scullery, to take it into -the ward, and there spread and apply the poultices. - -But a large iron pot of linseed poultice seldom contains the article -nearly so well made, as when made in smaller consecutive quantities in -a wooden bowl. The bowl does not keep warm above a certain time. Where -the poultice is made in a mass, even by very clever Nurses, it never is -so well made as when the Nurse makes the poultices in the wooden bowl. -These must be forthwith spread, applied, and the bowl re-filled, if -more are wanted. - -This is another reason why the person who washes the wound should also -make the poultice, as also why the Orderlies should clean the ward, why -the Nurse should as far as possible be relieved of all “mental labour,” -and why kept as much as possible to “manual labour.” All severe wounds -she should wash and dress herself, and many a wound becomes severe, -when the patient is allowed to fiddle over it himself. Some wounds will -not bear being left uncovered, and of course in some cases the Nurse -will wash the wound, and immediately afterwards apply the poultice. -In general, the Surgeon will consider the wounds take no harm from -being washed all round, and then poulticed all round. This requires -not to be over-hurried, and not to lose a moment’s time. A careful -Nurse will never apply a poultice without having first seen the wound: -carelessness, haste, idleness, over-work, and prudery, each and all -produce very sorry results as to this. - -I think, therefore, poultices should be made in the ward, and -immediately after the table cleared away, and the slight mess also. -In some Hospitals they place a straw carpet just round the table, and -also carry it to any bed which requires an extra mess in dressing or -cleaning. - -[Sidenote: 9. Presses in Ward.] - -9. A regular store closet is hardly desirable. A good arrangement is -this:-- - -At the end of the ward, nearest the Nurse’s room, or the ward-door, a -large press for linen. - -By it or opposite it another press, for stimulants, dangerous -medicines, stock medicines, such as castor oil and one or two others -which are always to be at hand, though not ordered for any particular -case, stock lotions (as few as possible), lint, old soft linen, -stronger but not coarse ditto for pads, &c., cotton wool, tow, oilskin, -splints and pads, &c., &c. Of all these things, the Nurse should always -have a certain reserve on hand. - -It will be well worth while to see that these presses are made -commodiously for their purpose. The linen press should have broad deep -shelves, and the different kinds of things should be sorted apart; the -other press should have broad deep shelves for the heavier things, -and separate shelves for the bottles; the stimulants by themselves in -one row, the stock medicines in another, unless these and the stock -laudanum were together, but they are better apart, and the dangerous -things upon the topmost shelf; another row for sweet oil, mustard, -stock lotions, &c., another row for ointments. Each bottle and pot to -be distinctly labelled in whatever is reckoned the most lasting manner; -opinions differ as to labels and letters cut in the glass. The latter -are boring by night, if something is suddenly wanted, and it is just -then that mistakes are to be guarded against. A strong clear PRINTED -label, securely fastened to the bottle, is preferable, to be renewed -when necessary, as Orderlies’ thumbs even while holding a bottle, if -the Nurse’s hands are on the bed, wear labels out. There is a great -saving of time and of chance of mistakes effected by clearly printing -the directions for the administration of medicine, “once,” “twice a -day,” “every three hours,” &c., and affixing them to each medicine -bottle. - -Of both these presses the Nurse should have the key or keys. One key -might do for both, but it may be best to have two keys. - -It is a very good plan where the shape of all medicine bottles and of -those for liniments is distinctly different; and where, _e. g._, square -bottles are used for poisons, or blue bottles for poisons, and square -for lotions. - -A small narrow shelf over each patient’s bed, or over his locker, -solely for his medicines and wine. When these are on the locker it is -less convenient. Where the medicines are not dangerous, it is better -to have them thus at each bed, than concentrated away from the beds. -Dangerous medicines should never be left at a patient’s bed. - -The two presses will answer all demands. As, however, it does not -do not to have a supply of everything that may be wanted always in -readiness, a stand or table in the ward should have upon it a small -supply of whatever may be suddenly wanted--a little lint, linen, tow, -and two or three vessels. The supply of lint, &c., to be small enough -for the Nurse to keep account of it, and for the patients to know that -account is kept of it. - -[Sidenote: “Apparat” in German Hospitals.] - -In constant daily use in the surgical wards of the great Vienna -Hospital is a thing called in Teutonic style “Apparat.” The Nurse -carries it round for herself, when preparing and dressing the -patients, and carries it after the Surgeon when he makes his rounds. -The system of both dressing and washing is in some respects so -different from the English one, that the fittings would vary. - -This concentration of what is wanted for dressing and washing wounds, -and for attending the Surgeon in his inspection of them, and of what -is at once wanted on any bleeding, fit, &c., is very useful; all the -more from its being in a compact portable form, which can be thus -successively carried to each bed. An English carpenter would make a -lighter and handier thing. Brass basins, which are there used, are -not desirable. Of course, one must be most especially anxious not to -introduce any novelty, particularly any foreign novelty, faster than -can be avoided, and we may consider it better either to leave the -general system unaltered of rushing on some emergency to the dressing -table drawer, or closet, and thence bringing successively the things -wanted, or at all events not to extend concentration further than -the excellent plan, so far as it goes, of the London Hospital, where -each Head Nurse attends the Surgeons with a large basket in her hand, -containing most of the dressings required, spunges, and one or two -little matters also usefully at hand. The _apparat_ has the advantage -of carrying with itself the basins used for washing. In the Military -Hospital of Vienna a tray attends each Surgeon, without basins. - -[Sidenote: 10. Nurse’s Room.] - -10. It is important to have the Nurse’s room opening at once into the -ward, and, upon the whole, I should incline to its having but one door, -although it may be thought better there should be a second, so that she -can leave her room without being seen to do so by the patients. Also, -by all means, let the scullery be opposite the Nurse’s room, and not -between the ward and the room. As an invariable Hospital rule, rather -more than elsewhere in Military Hospitals, publicity may be considered -to be a very great police, and a still greater protection. It is far -better that twenty-four patients should see the Nurse’s door than one -or none; and that her room should open full upon the ward than into an -intervening scullery. - -In contemplating a Military Hospital, we contemplate a place through -which, one year with another, all characters, including a few of the -vilest, pass. These are not theoretical matters. The more repulsive the -subject, the more prevention is better than cure. Guard against too -many closets, sinks, &c., &c., &c. - -[Sidenote: Lavatory.] - -At the end of the ward there should be a lavatory, with a row, or -two opposite rows, of white earthenware basins fixed in a stand, -with outlet tubes and plugs: each basin should have a hot and cold -water-pipe: and there should be not less than one to each four beds. -There should also be in the lavatory a hot and cold water-pipe, from -which a portable bath can be filled. - -[Sidenote: Water-closet.] - -At the furthest end of the ward should be a water-closet, with not -less than one soil-pan to each eight beds: and white earthen or -porcelain urinals in the same proportion. In the London Civil Hospitals -water-closets are now in general use throughout the wards, but not in -all of the great Hospitals. In all the Civil Hospitals, it is usual -that the patients’ water-closets have no inside bolt or lock, and -that there is only accommodation for one inside. In some London Civil -Hospitals the male patients, able to take exercise, are expected to -make use of urinals out of doors. These matters one, two, or three -experienced army surgeons had better pronounce upon; other things are -to be considered than the recommendations of architect, plumber, or -even sanitarian. - -[Sidenote: Sink.] - -There is in a Berlin Hospital a very useful piece of prosaic -apparatus--adjoining the water-closet, a sink, with a high, large, -deep, round, pierced basin of stone, above a _large_ hole, into which -the contents of a bed-pan can be at once emptied, and from which the -bed-pan is at once effectually cleansed. Adjoining this is a sink into -which all other slops are emptied. In mentioning this pierced basin or -sink solely for emptying and cleansing bed-pans, &c., which is used at -the Bethanien Hospital at Berlin, and is far better than emptying the -said vessels into the often-occupied water-closet, and then cleansing -them in an awkward fashion between the water-closet and the sink, it is -necessary to add that the cock ought to extend far enough over the sink -for the bed-pan, &c., to be thoroughly cleansed by a stream of water -falling directly into it. The Nurse stands at the sink, empties the -pail, &c., in it, without fear of splashing, and rinses and fills it, -without stirring from the place. Now this absence of splashing water -and of moving about from sink to pump, or cock, saves mess and time. -The oblong sink, usual in England, has by no means the same advantages. - -(The partition containing the sink would be an appropriate receptacle -for the bed-pans to hang by hooks or nails on the wall pending their -use.) - -[Sidenote: Baths.] - -In Civil Hospitals, two baths, in an airy closet at the end of the -ward, to be locked at all times when not in actual use, are a very -great advantage. Bringing a bath into a ward, which in many urgent -cases must be done when the baths are distant, is a messing discomfort. -Still it had better be left to surgeons to say whether, in Military -Hospitals, it would not be preferable to have, in each ward, only a -portable bath, on wheels, covered with india-rubber, to be brought -into the ward for any urgent case; and to take all the men able to -walk, or safely to be carried, to the Hospital baths. Of these, some -trustworthy, or intended and supposed to be trustworthy, man, who -ought to rank as a non-commissioned officer, should have charge. An -intelligent and respectable-looking man, a serjeant, has charge of the -baths in the Garrison Hospital at Vienna. - -In a great London Civil Hospital, St. Thomas’s, it is the very -admirable practice for each patient (of course with necessary -exceptions) to be bathed on his or her admission. The Sisters are -responsible for examining each woman in the bath, which is within the -female wards, and for at once reporting before suffering them to go to -bed, any case of suspected pregnancy, syphilis, or contagious disease. -A man does the same for the men, who are bathed apart from the wards. -This arrangement is an excellent one. On the other hand, severe cases, -just able to be carried to baths, get no good by going through the air, -and being jolted up and down stairs. - -In planning a Military Hospital, in which the service of women is to -be introduced, it is important to obtain the advice of experienced -Army Surgeons as to the arrangement of appurtenances of the wards to -be used by the patients alone. Endeavour to prevent the system of -holes and corners. It is best that the Nurse’s door should command the -view of those who come in or out of the lavatory, and in or out of the -water-closet. This whole section is both ugly and important. - -[Sidenote: 11. Summary.] - -11. To sum up. I think it would work the best to have no store-closet, -only two well-appointed presses, by which a certain amount of cleaning -is saved, and a corner avoided. - -Could two cupboards or presses in the wall be arranged for the ward -linen and the ward stores, it would be preferable to presses placed -against the walls. Take care, however, that the wall is sufficiently -thick, so that the presses are not damp, and if this cannot be provided -against, keep to presses separate from the wall. - -Believe that all this is neither theory nor fidget--but practice. - -The furthest end of the ward should contain a lavatory, a water-closet, -and the pierced basin for emptying and cleaning bed-pans is a very -useful thing. At the other end of the ward, the Nurse’s little room, -her door opening full upon the ward. If the upper half were of glass, -with a curtain before it, allowing the Nurse to see the ward without -being seen, it would be all the more useful. At St. Thomas’s, a window -opens into the ward, the Sister drawing a blind when she chooses, and a -door opens into the passage, just within the ward doors, opposite the -scullery, so that the Sister enters the scullery, in which there is -a water-closet, for the accommodation of herself and Nurses, without -traversing her ward. Whether door or window, the Nurse should see at -once all that is going on in her ward. I prefer a door; yet, if there -is to be a ward for one, it may be best and most central to have the -Nurse’s window on the large ward, and her door open on the passage. -Opposite the Nurse’s room should be a scullery, not too small. The -scullery should be well provided with cold, and, if possible, warm -water. - -If a supply of hot water can be obtained by turning a cock, this -is best. Provision should be made in the ward scullery for keeping -poultices warm which is every now and then wanted. It is not right to -wash eating-vessels and poultice pans, &c., in the same sink; and this -should be considered in arranging the scullery. If each ward washes its -own bandages, which it ought not to do, the second sink will come in -usefully for this. It is worth while, in enforcing extreme simplicity, -to prevent jumbling together eating-vessels and things for wounds and -sores. Sinks are infinitely most handy when made deep, somewhat in -the shape of broad round basins, with hole at bottom; it saves much -splashing and mess; the cock to overhang full the middle of the sink. -The Wall against the sink should have some protection. - -Such a scullery, with complete efficient simple apparatus for its -various purposes, places for washing up and cleaning, and for ward -purposes and cookery, so that the Nurse can warm the drinks, prepare -fomentations, &c., without jostling the Orderlies, who are washing up -or cleaning, will be a very great comfort, simplification, and promoter -of order, cleanliness, efficiency, and work. At one corner a decent -little table for Orderlies’ meals, above it their separate safes for -their bread, cold rations, &c., &c.; each to have and keep his key; -each to have his locker. - -Each floor and ward will require a scullery. It is far better for each -ward to contain its own appointments--and all the other stores to be -together, apart. On the second floor might be the Ward-Master’s room; -_vice_ the Nurse’s room. - -[Sidenote: 12. Nurses’ Sleeping Quarters.] - -12. Nurses’ quarters, if we are driven to their not sleeping near -their wards, should be adjoining the Matron’s two rooms, and separate -water-closet, in a part of the Hospital as central as can be managed -without trespassing on our betters. I would simplify these quarters as -much as possible--either a series of very small rooms, or one great -space partitioned off each into a little cell, with a window, bed, -washing table, chest of drawers, and a very small wardrobe, with space -to hang up three or four gowns, deep enough for another row for shawl, -&c., at top a shelf for bonnet and caps, at bottom a deep drawer for -boots and shoes. These things will be a convenient riddance to the -chest of drawers, and comfort to the women. In each cell very strong -hooks to hang up and air a little gowns taken off at night, and one -or two chairs. The nurses must wash their hands, &c., in the rooms -off their wards, and I think it must be understood as a rule that -they leave their quarters in the morning and return to them at night. -Optional carpet. - -Each cell to be numbered either with number or with name of Pavilion. -Opposite this space a small lumber room, wherein each nurse may deposit -her box, thereby hindering dissemination of bugs. Opposite also a -running open cupboard, with partitions numbered or named as rooms, -containing each Nurse’s broom, dustpan, &c., each with a key. - -Also pump, sink, water closet. - -[Sidenote: Furnishing.] - -When furnishing begins, it will be well worth while to see that all -articles of furniture, whether for wards or Nurse’s quarters, admit of -being easily swept and scrubbed underneath, and swept and dusted at -top. Chests of drawers, &c., with too narrow space between bottom and -ground, harbour dust, or sadly waste a few precious minutes in the most -busy part of every day. As few high pieces of furniture as possible, to -gather dust and be out of easy reach; as few as possible of cumbrous -articles difficult to move from the wall, to sweep and dust behind, &c. - -There ought to be, near the Superintendent’s quarters, one or two -small rooms, where, necessity occurring, sick Nurses might be lodged. -We cannot hope always to escape having sick Nurses; and there would -be serious objection in a Military Hospital, where only one Nurse -sleeps on each floor, to having the Nurse ill in her room for more -than 2 or 3 days at the outside. Or there might be one good-sized airy -room, with two or three dark washable curtains dividing it into little -dormitories, so that one Nurse, whom the Superintendent must engage and -watch, could attend them all. And as Her Majesty’s Nurses must have -allowed them such decent comfort as can be, but no fastidiousness, I -think the cubicles in one room would be best. Not to be called so, -however, by any means, as it would sound Latin and “Puseyitical.” The -Nurse’s ward to be locked and key kept by Superintendent, except when -tenanted. I should hope three beds would answer thoroughly, as well as -that the ward would be empty eleven months out of the twelve. - -Considering the awkwardness of illness among Nurses, when it did occur -in a Military Hospital, it would be worth while that, adjoining the -little ward, there should be a little room for any one infectious case -which might occur; _e. g._, supposing one Nurse ill in the ward with -bronchitis, it would not do to put another with small-pox into the -ward,--at least it would be very impolitic. The ward should have a -water-closet and a little sink of its own, and a little cell, but with -window and fireplace, for the attending Nurse to lie down in. When not -used, once a month’s, or week’s at the most, cleaning by a charwoman -would be enough. It should be always clean and ready for use. In the -Civil Hospitals, few years pass without sundry Head-Nurses and Nurses -dying, not a few Nurses being warded, and sundry Head-Nurses ill in -their rooms. The peculiarity of Military Hospitals makes this little -preparation for what is certain every now and then to occur seem -desirable and economical; to hire lodgings in the neighbouring town -would be in all ways a worse plan. - -[Sidenote: 13. Classification of Cases.] - -13. Endeavour, if possible, to obtain a classification of the severe -and non-severe cases, and let the Nurses be only appointed to the wards -of severe cases. The convalescent cases to be successively removed to -the convalescent pavilions, whether they bear or not that name. No -convalescent ward in any of the floors of the Pavilions to be served by -Nurses. - -[Sidenote: 14. Nurses to be called by the Names of their Wards.] - -14. It will be found excellent in many respects not to allow the -Nurses’ names to be used in the ward of the Hospital, or among each -other, so far as the Matron takes cognizance of. In the great London -Hospitals the name of a Nurse is never heard, except occasionally to -each other as a solace, partly very natural, partly harmless vanity. -She is Sister or Nurse of such and such a ward. In hasty parlance she -is distinguished from the others by the name of the ward only. In it -she is always addressed as Sister or Nurse. - -Thus a Sister of St. Thomas’s Hospital, whose services in the War -Hospitals of the East I can never forget, was always at St. Thomas’s -spoken of out of her ward as Sister of George, or, more commonly, -Sister George; and spoken to quickly or called to in a hurry as George. - -All this, the only course of all the great and, I believe, of the -smaller London Hospitals, works excellently, in many ways. - -[Sidenote: 15. Foul Linen--how to be Disposed of.] - -15. Arrangements should be made that foul linen remains for the least -possible time out of the laundry. As regards the laundry deposits, the -best plan is that of the London Hospital, where each ward has a bin of -its own marked accordingly. To similar bins all the foul linen should -be, at least, daily carried, unless it is judged best to receive and -wash all the linen in a heap, returning numbers only to each ward. The -former plan is preferable. In any case the linen of the “foul wards” -should be received and washed apart. During the time, which ought to -be as short as possible, between dirty linen leaving the patients and -reaching the bin or bins, a large box in the scullery is making the -best of a bad business--the presence of foul Hospital linen always is -that--and is preferable to a closet. - -[Sidenote: 16. Washing Bandages.] - -16. Washing bandages, a very important thing. Shall a washerwoman -be told off for that particular purpose? or shall the Orderlies of -each ward do it _alla meglio_? The former is the better plan; if not -adopted, the Nurse must see well to the matter. - -[Sidenote: 17. Splints--Bandages, Lint, &c., where to be kept.] - -17. It would depend upon what sort of work is usually going on in the -Surgical Wards of a Military Hospital in peace whether it will be worth -either a press with glass front, in which splints, pads, &c., &c., are -excellently arranged, as at St. Bartholomew’s; or the pad-basket and -splint-rack, which are also excellent, provided in London Hospital. -The splint-rack, enabling the Surgeon at once to see and choose of all -shapes and sizes, is perhaps only suited for an accident ward, and -would be out of place in a military ward in peace. It may be better -to have these stores entirely in some dispenser’s or store-keeper’s -jurisdiction, and to let the Nurse confine herself to padding, &c., any -splint sent by the Surgeon into the ward. Let our masters take exactly -their own way about this. - -Bandages, lint, &c., &c., &c. should perhaps rest entirely with the -Dispenser, otherwise it would be useful in the greater Hospitals, to -have under the Matron a Nurse charged with preparing them and giving -them out, writing in a book the date, amount of each, and the ward they -are given to. In a small Hospital the Matron could do this herself. - -[Sidenote: Cotton Lint never to be used.] - -While speaking of lint, it seems a duty to state that, in some of -the Military Hospitals, in certain County and even London Hospitals, -and also in Workhouses, and in the practice of private Surgeons, a -preparation of cotton has been recently substituted in the dressing -of wounds for _charpie_ or Surgeons’ lint, properly so called. So -miserable an economy at the expense of the sick is not adopted in -several, at least, of the London endowed Hospitals, probably in none. -For all purposes for which lint is necessary cotton fibre should be -totally disused, in the army and everywhere else. It is irritating -and injurious to wounds. It increases human suffering; it delays -patients in Hospital, and, in doing so, of course, increases the cost -which such a substitution has been intended to reduce. Nurses should -be particularly careful never to use this material, which is easily -distinguished, even by the touch. Any Surgeon may tell the best of it -from lint by submitting it to microscopic examination, and on doing -so he will readily discover that characteristic of cotton fibre which -renders it so ill adapted for surgical dressings. It does not absorb -the discharges from wounds, as linen lint does. The fibre is ragged -instead of being smooth, and it is apt to become matted together, and -to adhere to the surface and edges. - -[Sidenote: 18. Classification of Women.] - -18. It is essential to have as few women as can efficiently do their -work. Supposing the Hospital were for one thousand patients, not taking -into account that some wards would probably be foul wards, where I -earnestly hope female service will not be, at present at all events, -introduced, and that some wards would be for slight or convalescent -cases, where I hope it never will be--supposing each Nurse served -seventy-five patients, supposing one Nurse, at the very least, was told -off for the linen, fourteen or fifteen Nurses would serve the Hospital. -I conclude the Matron to have no cognizance of the laundry. - -[Sidenote: Superintendent’s Store room.] - -The Superintendent[18] will require a store room, or at least a store -closet, and hers should be well appointed. It would depend upon the -other arrangements of the quarters, whether the world in general, when -sent for to fetch what it wanted, enter from the same side as the door -of the Superintendent’s bed-room, or from the other side. And it would -depend upon the nature and amount of stores of which she had charge, in -the larger Military Hospitals, whether or not she should have a Nurse -told off for this also. Economy is essential; but useless fiddling -over every duster or scrubbing-flannel given out, &c., &c., &c., sadly -hinders the Matron’s time from more important things. - -Housekeepers must be avoided, and every woman must have a distinct -and sufficient share of work, and each be distinctly and equally -under the Matron. Still it would be advantageous if we could from -the first include in the staff of Nurses for the larger Hospitals, -one or two places which could be filled by efficient persons who yet -were unfitted for the ward work, which calling will be, and ought to -be, laborious and wearing enough. Many a woman would never do to look -after a Pavilion and seventy-five men; who yet, in charge of linen or -stores, would be most valuable, and influence most beneficially the -Nurses, whom yet she might be unfit to govern. The system of the Sœurs -de St. Vincent, who, in theory and fact, subject entirely to the will -of the Superiors in general practice, are yet selected and trained for -spécialités, who remain long in these spécialités, which spécialités -include such requiring more or less of physical strength, seems to be -one giving many useful hints for us. - - - - -ADDENDA AS TO MIXED NURSING BY NURSES AND ORDERLIES IN MILITARY -HOSPITALS ON THE DOUBLE PAVILION PLAN. - - -I. After much anxious thought, re-consideration of all things, and -pondering, I submit-- - -1. That three Orderlies will efficiently serve a ward of from 28 to 30 -patients, including night-duty. - -2. That each of two wards of 30 each, should there be two such under -the same Head Nurse, on the same flat, ought to be entirely separate in -all other respects. - -3. That if night-duty be required, each such ward should have an -Orderly on night-duty. - -4. That each such ward should have a scullery. - -With regard to these questions, I further submit-- - -1. Economy of hands, combined with efficiency of service, is an urgent -thing in all Hospitals; most of all in Military Hospitals, - - On the score of expense; - On that of efficiency of inspection; - From the nature of Military Hospitals, where the aim should be - throughout to combine great simplicity with thorough efficiency; - From the importance of training the staff, male and female, of - Military Hospitals, for service in War Hospitals, where every man - or woman who can be spared is better away. - -2. Yet economy of hands, carried too far, becomes, like all other such -economies, penny wise and pound foolish. - -3. Without doubt, large wards can be efficiently served by fewer hands -than small or moderate wards. But, as sanitary considerations limit the -size of wards to from 24 to 30 patients, let us make this the basis of -all calculation. - -4. The more it is considered, the more essential it appears, to train -Nurses, from the first, to do efficiently a great deal of work. A small -staff of respectable, laborious, and thoroughly efficient women seems -the thing to be aimed at; whether considering Military Hospitals by -themselves, or as a training-school for Hospital war-service. - -5. It would be better to give each Nurse one great ward; but wards -above a certain size are inadmissible for sanitary reasons. - -6. The care of 24 to 30 patients is not sufficient duty, by a great -deal, for a Nurse. - -7. Therefore, upon the whole, and as decidedly the lesser of two evils, -I recommend assigning to each Nurse two wards. - -8. It is less difficult, and less objectionable, that she should have -charge of two wards on one floor, than of two wards on two floors. - -9. As regards the Nurse, I recommend therefore, upon the whole, to -give each Nurse the charge of two wards of 30 men each; the wards to -be on the same floor; but, except as being under the same Head Nurse, -entirely separate. - -10. It is important to repeat that the Nurse (who is Head Nurse), will -be set free of two things, which consume much of a Civil Head Nurse’s -time. - -(1). “Settling the diets,” and fetching, besides waiting for, portions -of those diets (_e. g._ wine) and medicine. - -(2). Distribution of Diets.--It is quite possible that, in no long -time, it may be found desirable to assign this duty to the Nurse. -But it would be better to try to have it efficiently, which implies -honestly, discharged by the Ward-Master. It will relieve the Nurse -daily of considerable time; and it charges the Ward-Master with a -definite duty which he can perform. The more he has defined duties, the -less he will be inclined to fidget and disturb the Nurse. He is pretty -certain to do this; but definite duties will diminish the tendency. - -I should avoid giving the Ward-Masters too few wards. Otherwise they -will make themselves insufferable obstructions, one way or another, to -the Nurses. I should say that each Ward-Master, in charge of a Pavilion -of six wards of 30 each, besides the small wards for one, would not -have at all too much to do. Where there are no Nurses, the Ward-Master -should have Assistant Ward-Masters in their place. - -N.B. Wine might be treated as medicine, and, as such, delivered by the -Nurse. Wine and medicine are usually, in the Civil Hospitals, given -from the Apothecary’s shop at the same time. Or it might be considered -desirable to leave this duty to the Ward-Master. In either case, it -will never do to serve a bad case at once with all his wine, and either -to let him stupify himself by swallowing it at once to make sure that -he has it; or to set it by his bed-side for the flies to spoil it, or -for a dishonest comrade, or here and there an Orderly, to drink it. The -Nurse should receive, whether directly or from the Ward-Master, the -wine of such patients, and should administer it in successive small -fresh portions. The intelligent administration of wine ordered to bad -cases is one of those momentous _minutiæ_ by which, I do believe, and -believe more and more, many lives are, by God’s blessing, annually -saved in English Hospitals which would be lost elsewhere. Of course the -only Regulation about wine should be to specify whether the Ward-Master -or the Nurse should administer it. - -11. Relieved of the loss of time incurred by fetching and waiting, and -relieved at starting, at all events, and we will hope permanently, of -the time consumed in distributing the diets, I certainly consider that -a Nurse of the class of which, please God, Her Majesty’s must all be, -(strong, laborious, active, and conscientious women,) can efficiently -serve two wards of 30 men each. - - -_Orderlies._ - -12. I should prefer wards of 30 each to wards of 25 each. - -13. In forming rules for the proportion of Orderlies to sick, it is -important to consider that the duty varies extremely according to the -appurtenances of the ward. - -14. I consider extreme plainness and simplicity to be proper and -indispensable to a Military Hospital. Let us take for granted (and may -it prove correct to do so), that in none of Her Majesty’s Hospitals -Orderlies’ time will be wasted in cleaning any ornamental things, -whether unnecessary furniture, flourishes, or cornices, &c., &c., on -necessary furniture; supernumerary shelves, nooks and corners, &c., -&c. Once provided, all these things must be carefully and constantly -cleaned, or they become receptacles of dust and breeders of fleas; and -to clean them involves enormous waste of time. A few minutes daily -wasted on each of many things, make an enormous sum. - -15. But it is very true economy to supply, if possible--which in old -buildings it often is not--every ward of every hospital with a constant -supply of water, (taking care that it is not wasted by mischievous -or childish patients); and to give every ward of every Hospital the -use, under proper control, of a lift by which, at fixed hours, food, -medicine, linen and fuel are brought into the wards. - -Believe that this is not theory, but the result of practical -observation, much extended. - -16. Now, these two things--supply of water (if hot and cold so much -the better, and supply of water imports, of course, the appliance for -getting rid of it, and of the contents of bed-pans, &c., &c., by one -or more sinks) and the use of lifts can be applied to a new Hospital; -can possibly, not certainly, be applied to some of the old Hospitals -within the Kingdom,--can certainly not be applied to many of the Army -Hospitals abroad. - -17. Upon an average, these two things make the difference of one -Orderly’s duty to a ward of 30 men. - -18. And a ward of 30 men, so supplied, would be efficiently served by -half a nurse and three Orderlies, including night-duty. - -19. Without these two things (it is a mere comparative question as to -loss of time and absence of thorough cleanliness, whether the water is -brought from a pump in the court, or a stream some hundred yards off, -above or below), and many, if not most, Army Hospitals abroad, must -always remain without these two things, I consider that one Orderly to -every seven patients will not be too much; while it is certain that, -other things being equal, the ward with the appliances and the three -Orderlies will be better served than the ward without the appliances -and with the four Orderlies. Where there is no Nurse, one Orderly for 7 -patients will always be advisable. - -In these memoranda as to Orderlies’ work, &c., no notice whatever -has been taken of the possible abolition of scrubbing, because it -does not do to count unhatched chickens. If, however, that formidable -weekly business could be got rid of, as well as the bi-weekly or daily -washings of bed-head-floors, &c. the labour of the Orderlies would be, -without underrating that required for keeping oiled floors cleaned, -very materially lightened. - - -_Night-duty of Orderlies._ - -20. Convalescent wards, which will be of great use in many ways, -will be of use here. With them Nurses will have nothing to do. It -is possible enough that, in course of time, the Medical Officers -will desire to have Nurses there, and that it may be useful to place -there elderly, still efficient Nurses; but let this come or not as it -will, and let us keep quite clear of them, at all events, till the -Nursing-service be tried and established in Army Hospitals. In these -wards, night-duty will probably be quite unnecessary, though in that -case either an Orderly or Assistant Ward-Master ought to sleep at hand; -and night-duty is a service which must be spared wherever it can be -spared, and rendered as efficient as possible wherever it is really -wanted. - -I have before submitted that in Paris, Vienna and Berlin, the -average of severe cases in Army Hospitals, in time of peace, is very -considerably lower than in Civil Hospitals. - -This quite as much applies to English Army Hospitals. Whether the -ordinary wards would require night-duty I do not know. If they often -did, I should prefer having a regular night-duty in them. If they -seldom required it, I would not have it. - -21. In Civil Hospitals, served by women, I should undoubtedly prefer -assigning the night-duty to one Assistant Nurse. - -22. But Orderlies are in sundry respects different, and, upon the -whole, I recommend not to have night Orderlies, but to let each Orderly -in turn do the night-duty. - -23. It is important to remember--the more so as it is often -forgotten--that to lay more upon human nature than its Maker has made -it to bear, is to do a foolish, let alone a wicked thing. Upon an -average, all men and women can dispense with, or abridge sleep for more -or less time. Upon an average, all men and women, after a laborious -day, require a good night, in the long run. When they do not have it, -either health, efficiency, or sobriety, or all go. - -Believe, again, that this is not theory, but the result of practical -observation, much extended. - -A strong soldier is no exception to the general rule. In the long -run, if made to do night-duty after a laborious day, he will either -go to sleep, or drink to keep awake, or he will get knocked up before -his time. And this it is part of his business to be in time of war; -therefore, in peace-service, it is economical to let him last his time. -It is then sound economy to give watchers sufficient sleep. - -[Sidenote: Scheme of Night-Service for Three Orderlies watching by -turns.] - -24. Supposing regular night duty required, in a ward of 30 men, -supplied as above, and served by half a Nurse and three Orderlies, -it might be worked thus: the Principal Medical Officer would decide -whether the same Orderly should do the night duty for a week, or the -three on successive nights: probably the latter. The Orderly might come -on night duty at 9 P.M., and remain on duty until 9 A.M., thus taking -his share in the heavy morning work of cleaning the ward, &c. In all -well-ordered Hospitals it is required that this should be done by 10 -A.M., in some by 9 A.M. Earlier is undesirable in the English latitude -(in other climates it is different), unless either the patients are to -be disturbed earlier than English Surgeons consider right; or the ward, -&c. cleaning is hurried through. A large ward, got into thorough order -by 9 A.M., is in very good time. Of course it may happen occasionally -to be got ready somewhat earlier, but this refers to the average. - - -SCHEME FOR THREE ORDERLIES A. B. C. SERVING WARD X. - -Monday, 3 P.M. A goes to bed, after taking his share of the morning -work, eating his dinner, and helping to clear away ward dinner, &c. 9 -P.M. A comes on night duty, after 5 hours’ sleep, and allowing 1 hour -for undressing, dressing, and eating his supper. - -Tuesday, 9 A.M. A goes off duty, having watched until 6 A.M., having -breakfasted, having taken his share of the morning work, and leaving -the ward clean. Let him have the option of one or two hours’ fresh air, -either now, or before 3 P.M.; let him sleep full three hours; let him -have his hot portion of dinner taken to him at the usual hour, unless -all the Orderlies on night duty are served together at a different -hour; and let him, 3 P.M., return on duty, washed and shaved. B goes to -bed, &c.; 9 P.M. B comes on night duty. - -Wednesday, 9 A.M. B goes off duty; 3 P.M., C goes to bed, &c.; 9 P.M., -C comes on night duty, &c. - -I have reckoned 12 hours for the Orderly to be off duty. It is better -for him to have eight than seven hours’ sleep, and one or two hours’ -fresh air are more healthy, and make a man last longer than going -to and from his bed and his ward. An English soldier comes on duty -clean, washed, and shaved, a once national peculiarity it is highly -desirable he at all events should retain--at any rate that of thorough -cleanliness--the shaving is unfortunately now not certain; for this and -for his meals, some little time must be given. I think you will get -more, and get it longer, out of the man by giving him 12 hours on night -duty and 12 hours off. Still it will not do to interfere too much with -analogies, and the proper authorities must decide whether this is too -much. - -[Sidenote: Exercise for Orderlies.] - -25. Again, leaving the question for decision to the proper authorities, -I had rather each Orderly had one hour or two hours for exercise each -afternoon or each alternate afternoon, care of course being taken that -he did not exercise himself in some tap. He should report himself to -the Nurse, or to the Ward-Master, or Assistant Ward-Master on going and -on his return. So should the Night-Orderly when coming on and going -off duty. Also in many emergencies of no very unfrequent occurrence at -home, and constantly abroad, the Orderly must dispense with recreation -time. But as a rule, it is certain that fresh air is necessary to -preserve health in Hospital duty. Doctors of all kinds know and act on -this as regards themselves. - -The waste of time and strength, at present too often incurred by the -endless fetching, heavy carrying, &c., of many Hospitals is in a -considerable degree counteracted by its forcing the Nurses into other -than ward air; the air of a Hospital Court is better than that of the -best ventilated wards as it is, not as it might be. The same applies, -in its degree, to Orderlies. But it is better, and far more economical, -to avoid the fetching and carrying as much as possible; to keep the -ward attendants in the ward to their duty under the supervision of the -chief and responsible ward-servant; and to give each in turn a short -daily recreation, if possible. - -[Sidenote: Night Refreshment for Orderlies necessary.] - -26. Now comes a thing I am very anxious about concerning night duty, -the more anxious because it is important, and because I am afraid it -is an innovation. I have watched the night duty with particularly -anxious interest, in each Hospital I have entered, feeling at once its -importance and its difficulties, and of the following principle I am -thoroughly certain. - -The Orderly doing night duty should either be allowed refreshment -during the night, or the recurrence of this night refreshment should be -considered in allotting the rations. - -In none of the Civil Hospitals, so far as I know, is night refreshment -given. The Nurses usually on board wages, apportion, when they can, -some from their food. In one Hospital there exists a rule that no -Night Nurse is to take refreshment during her watch, the intention -being to keep her more vigilantly to her duty. This is one instance -among many of the serious and cruel mistakes which men of business or -benevolence, or both, make, when legislating on matters which they do -not understand. It is, fortunately for the fine Hospital where it is -the rule, practically disregarded; the Head Nurses knowing well that a -Nurse watching and fasting in a ward from 9 to 9, or even from 9 till -the breakfast hour of 6, would either soon be unfit for duty, or put -drams in her pocket, or doze through the night. - -A strong soldier, required to watch in a ward and fast from 9 P.M. till -9 A.M., or 6 A.M., or shortly before, would stand the trial quite as -ill as a Nurse. There is an admirable rule at two foreign Hospitals -where I have served. Sisters watch in some wards, Men Nurses in others; -and each watcher receives from the house, on going on night duty, a -bottle of beer, a can with about six or eight cups of coffee, milk and -sugar in proportion, and three slices of bread and butter. The Sister’s -bottle of beer is about one pint; the Man-Nurse’s double; his coffee -can is also a good deal larger. The rule of allowing sufficient for -three solid refreshments (which of course can if desired be made by the -watcher two or three) during the night, is an excellent one. - -I think it would be very sound economy to allow each Orderly on night -duty, a proportion of beer or porter, of coffee or tea, and of bread -and butter, or bread and cheese, to take at his own time during his -watch, besides his supper before going on duty, and his breakfast just -before 6, (both Nurse and Orderlies ought to have breakfasted by 6, -and to begin the day duty at 6, and I wish it began by opening the -windows and repeating the short prayers for 5 or 6 reverent minutes). -Of course it may be considered preferable to reckon this night-ration -in the Orderly’s rations. Or suppose the bread and beer or porter to be -reckoned in the rations, and a can of coffee given him for the night -watch. Settle details as is best, and of course analogies must be -considered; but in truth hospital watching is a very peculiar business; -important, unobtrusive, most peculiarly trying, and the bright side of -very few Hospitals. Each watcher should undoubtedly have refreshment -for the night. - -The Nurse should have her groceries in the lump, and refresh herself -as she likes out of them. Her watching, if she does her duty, will be, -when she has bad cases, severe enough; but I would not provide her with -extra refreshment; as the watching is not prescribed and regular duty. - -There should be as little extra watching on the part of Orderlies as -is possible; when it is indispensable the extra watcher should have -the same night-ration. I submit my strong impressions on the subject -of this night refreshment now, because, small as it may seem, it very -largely enters into the working of a night watch. - -I have suggested the division of the Night Orderly’s sleep, because, -if A. comes on duty at 6 A.M., and is sent to bed at noon or 1 to get -ready for his night watch at 9 P.M., he is scarcely fit for a long -sleep, and supposing the patients dine at noon (an excellent hour) he -has not, or scarcely, taken his share of the clearing away which, -got over in time, enables the other Orderlies, one or both, to have a -short recreation in the afternoon. Also if sent to bed at one he has -not eight hours’ sleep, as out of that he has to undress, dress, and -sup. Also he has to remain on duty from 9 P.M. to 9 P.M. next night, -which is much too long as a rule. If he does not go to bed before his -watch, and goes off duty at 9 A.M. next morning, whatever time may be -then allowed him for sleep, he cannot, as a rule, be depended upon for -performing his watch duty efficiently. - -[Sidenote: Where are the Night Orderlies to Sleep by Day?] - -27. If the Ward Orderlies watch by turns, it should be arranged that -the men who sleep before and after the watch can do so quietly. This -is by no means always attended to, as to Nurses in Civil Hospitals. -Upon the whole, I cannot think it would answer to have always the same -watchers, as regards Orderlies. The other Orderlies, supposing them -lodged apart from the wards, will certainly go seldom enough to their -quarters during day, except during their exercise time. It may be -thought essential to retain soldiers under very primitive notions as -to quarters. So though in a dormitory of women, I think little cells, -parted either with a partition or a curtain, the whole thoroughly -airy, are in all respects preferable to unparted rooms, it may be, -by some, thought better that the Orderlies shall sleep in large airy -wards, not parted by curtains or partitions. I know, however, one high -Military authority, at least; who considers the same reasons apply to -men as to women in this. Soldiers are generally able to go to sleep -whenever ordered. Indeed their general capacity of doing whatever they -are bid is one of their many fine points. The Orderlies’ wards must be -under some sort of inspection, and noise must not be suffered in them. -Non-Commissioned Officers, either Ward or Assistant Ward-Masters, or -some special functionary (but such I would not multiply) must sleep -near, and have general charge of the order and quiet of such wards. I -conclude that one or more Assistant Ward-Masters, at all events, must -watch, and as they must sleep by day, this will fit in well enough. - -I should avoid putting the Orderlies in a too much out of the way part -of the Hospital; they should know themselves liable to inspecting -visits any time. I am not sure that Ward or Assistant Ward-Masters -would not be much better guardians of the Orderlies’ wards than any -special functionary. Drink is the vice of these men, noble fellows -as, as a body, they are, and I should avoid quartering any man too -comfortably and solely in one particular post. Cases have been where -the duenna of the Nurses’ dormitory was herself a determined, disguised -drunkard, and reported others accordingly as she was bribed or not with -drink for herself. - -The whole question of Orderlies sleeping near or away from their -wards should be well considered by the proper authority, two or three -experienced Army-Surgeons. Upon the whole, I think it would be well to -try the quartering them separately: there is much to be said on both -sides as usual. - -[Sidenote: Comparative Merits of Different Systems of Night Nursing.] - -28. In several foreign Hospitals a certain number of Night Watchers, -both Sisters, and Men-Nurses, are told off for night-duty for four -weeks, during which they are exempted from all labour by day, and -receive better food than the usual diet. They also receive good -night-refreshment. - -In one Hospital the following is the arrangement. The wards usually -contain from 10 to 13 beds, and there are many small wards for three, -two, or one, bad cases or operation cases. All the wards open upon a -corridor. The Sisters do not watch in the men’s wards. - - A Sister watches in the female medical wards } - ″ surgical ″ } 5 - ″ children’s wards and girls’ ward } - A Man-Nurse ″ male medical wards } Watchers - ″ surgical wards and boys’ ward} - -An operation-case, or an extra bad or anxious case, or a case requiring -special attendance and put in a single ward, has an Extra-Watcher. -Often there are no Extra-Watchers: sometimes there are several at once. -The Extra-Watcher is either a Sister or a Man-Nurse, taken from among -the other Sisters or Men-Nurses, who, after his or her day’s duty, does -the extra watch. - -As regards all English hospitals, civil or military, the advantages of -this system are these:-- - -1. It severs certain persons for night-duty, who have full time for -sleep and refreshment in the air during day, and who are allowed to do -no other work. - -2. It secures these persons good food and refreshment at night. - -3. These persons know their sick, and, being told on coming on duty, of -any change, &c., are as much at home in their posts by night as others -are by day. - -4. When it is found that a Sister cannot sleep by day, and, therefore, -that her health breaks, she is not allowed to finish the four weeks and -become ill, but is put to another duty and another Sister appointed to -the watch. - -(Many a strong Nurse cannot sleep at day.) - -5. The persons so appointed get into the way of it, if they stand it at -all, and the system is found a great relief to the whole house and a -great gain to the sick, in the place of another system of dividing the -night between two Sisters and two Men-Nurses, who each watch half of -the watch. - -_Per contrà._ - -I. The great London hospitals are places very far from perfect: some -things may, please God, be, with time, patience, and extreme quietness, -very much improved; but some things will never be perfect and never can -be. But they are places where I do believe, and so far as I know, the -sick are cared for in a way that is done nowhere else. The proportion -of heavy cases in every London ward, cannot, I think, be met except by -having a watcher in each. An English physician or surgeon would not -consider that his cases could otherwise receive the attendance and the -watching, the observation of possible change and prevention of possible -mischief, which they ought to receive. - -It is right to bear in mind,-- - -1. That small wards multiply exceedingly the demand for Watchers: -four wards, of 10 patients each, taking the average of patients as in -London, would not be attended, according to the English notion, by -one Watcher; 40 patients in one ward would be fully attended by one -Watcher. The London Hospital has two Night-Nurses for its quadruple -wards. An extra Night-Nurse has frequently to be put on, on account of -the difficulty the subdivision of the ward gives to the watching. - -2. That the average of severe cases in each ward of London hospitals -is very considerably more than the proportionate average of severe -cases in each ward of the foreign hospitals in question. In all foreign -hospitals with which I am acquainted the proportion of accidents is -comparatively small to those of the London hospitals. The docks, the -manufactures, the crowded and dangerous works, &c., &c., with us, -account for this. - -3. That, striking the balance for and against, it is necessary that -each London ward should be watched by a Nurse; at the same time, that -without doubt a certain number of troublesome, ill-conditioned patients -(no ward of any Hospital is without such) sleep soundly and let their -neighbours sleep soundly when the Watcher only looks into the ward at -frequent intervals, who would, if the Watcher sate in the ward the -whole night, make it their business to require attendance from the -Watcher during the whole night, or at least much oftener than by the -other plan. - -II. The second flaw of the above system, as it applies to London -Hospitals, is, that it renders Extra-Watchers so often indispensable. - -The employment of Extra Watchers can never be wholly prevented, but it -should be the endeavour of every Hospital to employ such as seldom as -can possibly be. Extra watching is most injurious to the health of all -ward-servants, and to the sobriety, and therefore morality, of many -paid ward servants. - -This is a very important reason, I humbly consider, for avoiding as -much as possible small wards. - -I do consider small wards very objectionable in working a Hospital. - -But it is right to remember that we have been told of England, of -Austria and of Prussia that the proportion of severe cases in Military -Hospitals in time of peace is considerably smaller than in Civil -Hospitals. Night watching is not done in the Military Hospitals either -of Vienna or Berlin. Orderlies, or an Orderly, sleep in each ward, and -watching is only done to bad cases. - -How far English Army Surgeons consider night watching desirable in the -Army Hospitals I will presently tell. - -I should think the convalescent wards, among many important advantages, -would receive a number of patients who require no night watching. An -Orderly ought to be at hand here, but not watching. - -If night duty is considered requisite in the ordinary wards, I do -not see how the English standard of things could be met, excepting by -having one Watcher in each ward where there is regular night watching. - -I think, however, that the foreign system of night watching above -detailed might give very useful hints for women in war service, and for -emergencies of cholera, &c., &c., in home service; and with regard to -supervision in the latter. - -I think, with submission to the proper authorities (the two or three -experienced Army Surgeons I have so often adverted to) feeling strongly -that awkward mistakes might occur in several of these matters without -them, as civilians and women cannot and ought not to trust their -own judgments respecting such, that in a large Military Hospital, -an Assistant Ward-Master ought to go round the wards at night. Not -with any idea of his rendering assistance to the Watchers over bad -cases. The Nurses must do their duty of Head-Nurses, and see to this -themselves. Perambulation through a large Hospital at night in point -of fact excludes the possibility of doing anything in any one ward, -unless in some exceptional occurrence which only proves the rule. The -object is the important one of seeing that the Orderlies are awake, -sober, alert, and at their duty, and that the patients are quiet and in -bed. The Nurse would hear any noise, but there is such a thing as quiet -drinking, as well as noisy drinking. - -In St. George’s there is a Night-Matron, chief over the Night-Nurses, -who goes through the Hospital every hour during the night-watch. - -I have heard this spoken of by experienced Authorities of other -Hospitals with approbation and envy, and some idea was entertained -of introducing it into another great Hospital. In Civil Hospitals, I -think, but I do not know, that the benefits of this Night-Matron may be -perhaps more imaginary than real. The Head-Nurses at St. George’s sleep -away from their wards; a great mistake, I humbly consider. - -But Military Hospitals are entirely different in sundry essential -respects. I think a non-commissioned officer, Assistant Ward-Master -for instance, ought to make his rounds every night. When once such a -service takes place, every hour is better than three or four times a -night. He must be “up to” sundry things--taking the wards in uncertain -rotation, sometimes returning suddenly on his steps, &c., &c., &c. - -It will be worth securing, if possible (this parenthesis will be -understood), that the Nurse’s water-closet should be within her room, -if not, as close to it as may be. - -[Sidenote: Present State of Night-Nursing in Military Hospitals.] - -29. The following extraordinary system of Night Nursing is that which -prevails in the Army at present: - -The “nursing is managed” either by means of patients “told off in -watches” through the night for the purpose of attending to other -patients, or by means of soldiers sent in from the ranks to attend -specially upon each bad case; or by Orderlies “arranging it among -themselves,” without any exemption meanwhile from day duty. - -Upon each and all of these systems or no-systems it is hardly necessary -to make any comment. It is difficult to tell which is the worst. - -In the principal, indeed the only General Hospital in England, “Nursing -is managed by comrade-patients told off in three watches of two hours -each for the night.” [_sic._] - -“Orderlies are likewise warned and often sit up for the purpose.” - -These passages are given _verbatim et literatim_, because they are so -remarkable. - -And it is necessary to add that these patients being the relapses among -the “Invalids” are nearly the worst cases we have. - -Were it the report of a Head-Nurse in a Civil Hospital to her Resident -Medical Officer, it would undoubtedly cost her her place. One scarcely -knows whether to pity more the sick patient or the orderly patient. One -scarcely knows how to estimate the amount of medical comforts intended -to be consumed by the sick patient which will actually be consumed by -the sitting-up patient, and necessarily so. And the expedient which -turns over the man who is too ill to be left at all to the care of men -who ought to be recovering themselves, but who are pulled out of their -beds for two hours to _nurse_ (for the first time perhaps in their -lives,) and a very “serious” case too, is to say the least of it a -singular one. - -At Woolwich Artillery Hospital the cases which require constant -attention are about 2 per cent. There are now 545 patients in Hospital, -and 11 cases consequently, each requiring one Orderly to itself. The -Orderlies, according to Regulation, are 55, so that one-fifth part -of the Orderly service is required for these cases. Yet there is -no system or arrangement for such. The Orderlies arrange (or do not -arrange) among themselves to do the reliefs day and night. Of the 11 -cases at this time in Woolwich Hospital with 11 Orderlies sitting -up with them, it so happens, as I am informed, that only one would -require, if such were together in wards where regular night nursing was -established, an attendant specially to itself. - -It is needless to enlarge upon the cruelty of the above practice. The -one serious case is disturbed in the day by the goings to and fro, the -noise and bustle of the light cases--while these are disturbed at night -by the sitting-up necessary for the one bad case, which may be besides, -and too often is, a noisy or offensive one. The bad economy is as -obvious. It often happens that 11 cases who might all, if in one ward, -be attended and as efficiently attended, by one Night Orderly, require -each an Orderly to itself in as many different wards. - -In the “Garrison Hospital” at Chatham, “when any case assumes such -a character as to require more than the usual care and watching, a -Requisition is immediately sent to the Commanding Officer of the Corps -to which the man belongs for a steady well-conducted soldier and who -generally is the man’s own comrade” [so much the worse] “to nurse him, -and to attend upon him throughout his illness, but who is relieved by -another as often as the Medical Officer in charge of the case considers -necessary.” - -The following is the average number of sick in Army General Hospitals -in time of peace at home, for whom night-nursing is considered -necessary by the Medical Officers. But it is important to add that this -number would be probably estimated as very much higher if proper means -of night-nursing were at their disposal. - -Of constantly sick mean proportion per cent. requiring night nursing: - - General Hospital, Fort Pitt {Medical Division 5 - {Surgical ″ 1 - Garrison Hospital 2 - -These cases are usually scattered through the wards. - -It is but fair to add that the best Medical Officers themselves -desire another system, or rather are aware that there is at present -no system at all, and would gladly accept one. “With means for good -night-nursing,” they say, “arrangements in accordance might be -introduced. At present we like to have a case requiring much attendance -amongst cases that require little, in order that the patients or -comrades may assist.” - -What are the consequences of such “assistance” to the cases in question -has already been fully stated throughout these notes. - -[Sidenote: Poor-Law Regulation for Nursing in Union Workhouses.] - -“With respect to the use of [the inmates as] servants, they require -the strictest superintendence on the part of the * * officers. The -employment of [the inmates] in offices of trust is inexpedient, -inasmuch as it tends to impair the discipline of the house. In -offices of mere labour, which can be performed under trustworthy -superintendence, [the inmates] may be useful. Where responsibility is -involved, paid servants should be engaged.” - -The above is one of the regulations of what?--not of a Charitable -Institution but of the Poor Law; and the house of which it treats so -tenderly and wisely is--a Workhouse![19] If paupers are to be thus -cared for, how should it be with our soldiers? If any “office” can be -called one “of trust,” surely it is that of carrying out the orders -of the Medical man in a critical case, a case of life or death! Can -any “responsibility” be “involved,” greater than this? Yet these are -just the cases left to the “Comrade Patients.” For ordinary cases the -ordinary attendance is given; for serious cases, the untrained and -unskilled attendance. Yet, if the Hospitals are not for these serious -cases, what are they for? For these alone, however, is no systematic -provision made. One would think that every bad case took the Hospital -by surprise. Imagine the orders of the Medical Officers carried out -by nurses (?) changed “every two hours,” and who are, in fact, sleepy -patients! - -The system of Military nursing and management, as described by Army -Medical Officers themselves in the above quotations, and which is, -we are expressly told, to be re-enacted at the Royal Victoria Netley -Hospital, is precisely the one which led, as a matter of course, to -the calamities, as far as nursing was concerned, in the Hospitals -in the East, and which will lead to them again so long as it is -continued. Even in the case of invalids, who may not require such -careful attendance as sick, the system of nursing by comrades is most -objectionable; and if the attendance at Netley can only be carried out -on such a plan, it is doubtful whether Netley should be used even for -an Invalid Hospital. - -The question has been asked the Netley Committee, By whom are your -Invalids to be nursed, when sick? And it has been answered, that they -are to _nurse each other_! - - -II. NURSE’S ROOM, &c. - -[Sidenote: Nurse’s Room.] - -It is essential that between every two wards, in a hospital where the -blocks are built end to end, there should be, as at the new Military -Hospital of Vincennes, a lobby with a thorough supply of pure fresh air. - -If it were possible, where the Head Nurse, or rather in a Military -Hospital the Nurse, has charge of two such wards on the same floor, to -let her have a long, narrow room, with screened windows, opening into -both wards, the door opening into the passage in the midst, it is worth -contriving. - -[Sidenote: Medical Officer’s Room.] - -2. The Medical Officer’s room should be on the ground floor at the -entrance and apart from everything else. - -The servant or whoever cleans the room, should not be a Ward-Orderly, -(ward-attendance cannot be kept too entirely separate from all other -concerns). - -[Sidenote: Water-Closets.] - -3. The ward water-closet should have a pane of glass at top, so that -a faint gas-light in the lavatory at night can light sufficiently the -closet, and the (bed-pan) sink. - -The water-closet should be constructed, as is done often in those of -English railway stations, so that each visitor involuntarily, on rising -or on opening the door, purifies the concern. - -Besides the ward water-closet, there should be general water-closets, -and urinals separate from the wards, for the use, during the day, of -those patients who can leave the wards. - -The latrines at the Lariboisière Hospital are a good example, both for -what should be avoided in construction, and what should be imitated in -position. - -The sort of latrine used there would never do for England. - -The men able to go out are expected to use by day an urinal in a corner -of the little garden belonging to each pavilion. - -At night no sick men are allowed to leave the ward on that or any other -pretence; they must use the latrines. - -The latrines are at the furthest end of the ward. Opposite the one -door is a partially glazed door, beyond this is a large window, grated -in network as well as with panes and frame. On one side opens a space -where the men, able to get up, are expected to wash, and which, -moreover, contains two latrines, each separated by a partition and -secured by a door. The same arrangement prevails on the female side. - -The rule of having the water-closet on the furthest side of the ward, -removing all pretence of leaving the ward by night, is excellent. - -[Sidenote: Warm and Cold-Water Supply.] - -4. The importance, immense addition of efficiency, and ultimate economy -of carrying warm and cold water into every ward, and the necessity -of intending and contriving this in the first construction of a -Hospital,--subsequent additions and alterations being generally less -effectual, and always more expensive--cannot too frequently be repeated. - -[Sidenote: Corridors.] - -5. Corridors as proposed at Netley are useful and objectionable. They -lie between one side of the wards and air. They make oversight of the -patients more difficult; and when a number of patients are walking up -and down them, the serious cases in the wards are disturbed. On the -other hand, it is desirable to have some place of exercise and yet -shelter for patients, capable of being heated and of being overlooked. -There ought to be no accumulation of patients at the same time suffered. - -With regard, however, to corridors inside the building, if there -are none it is all the better for the sick; that each ward should -have two rows of large windows opening direct into the outer air is -indispensable, as has often been said already. - -[Sidenote: Lobby.] - -6. Provided this double range of windows be secured, double wards of -thirty on the same floor would cause no disadvantage to the sick. - -But, if such be determined on, let especial care be taken to separate -the two, not by a showy hall, but by a lobby and an ample staircase, -extending from top to bottom of the building, and communicating freely -with the open air at the roof, as well as by the stair-windows: -admitting a thorough current of external air, so that, of a morning -especially, the two wards do not mutually send the close air into each -other. - -The lobby should not be turned into a vestibule. Thorough air is all -that is wanted. Patients should not be suffered to remain in it. - -[Sidenote: Material of Ward Utensils.] - -7. The material of the different utensils required for ward service -should be settled. In the use of glass or earthenware for all -eating, drinking, and washing vessels there is great superiority as -to cleanliness, and the saving of time and labour in cleaning these -materials, to those of tin or other metal. Still two things have to be -weighed against these great advantages. First, if these vessels are -cleaned by Ward-Orderlies, the amount of breakage would be much greater -in proportion than as done by Nurses, and it is imperative to have as -few women as possible in the service of Military Hospitals. Secondly, -it is very important to avoid even the appearance, especially at first, -of anything like introducing luxury into Army Hospitals; and I can -quite understand this appearing like luxury. - -The material of one description of ward-vessels should in particular be -left to the Surgeons. In sending to distant foreign or war-stations, -urinals of tin have one material advantage over those of glass or -china, that they do not break so easily; but, as to home-service, -these tin urinals cannot, by any amount of cleaning, be freed from an -unclean smell. In Vienna General Hospital, where economy is exceedingly -attended to, all the urinals are of glass, as the superior cleanliness -is considered well worth the additional expense. A damaged or broken -glass or earthenware urinal is dangerous; and if there is difficulty in -obtaining the immediate issue of a new for a damaged one, it is better -to have tin. - -In Vienna General Hospitals the patients’ eating vessels were formerly -of tin; but were some time ago furnished of earthenware, for the same -reasons as those given above; also because the hot tin vessels were -found awkward to the patients. (I do not think much of this latter -reason; in hospitals, there is little fear of food reaching the -patients too hot). In Vienna and Berlin Military Hospitals the eating -vessels are all of tin. - -[Sidenote: Reserve Wards.] - -8. In building a large new Hospital, the question of whether or not -reserve wards, or Pavilions, should be provided is an important -question, to be referred to the proper Authorities. In one German -Hospital is a Sommer-Lazareth, or separate Hospital, which most of the -sick occupy during the six summer months. This is considered the best -plan; but so expensive that well-considered arrangements in designing -the building may render its adoption unnecessary. In another German -Hospital is a group of wards on each of two floors, into which the male -and female patients, especially the surgical cases, are successively -moved; both in order that during this time the other wards may be -thoroughly cleaned; also to change the air; also in case of some sudden -epidemic, &c. - -In every Hospital a thorough cleaning of the wards is essential. In -three of the great London Hospitals this is done every year, in one -every three years. Nuisance as it is, for the time being, it is such -a complete purification of places which want purifying, that having -it done every year is preferable to every three years. For the same -reasons bare white walls, whitewashed every year, and oftener if there -has been some sudden outburst of any zymotic disease or Hospital -gangrene are preferable to all colour. But polished impervious cement -is, it is needless to repeat, the only really safe Hospital wall. When -the cleaning time of a great London Hospital draws near, the number -of patients is gradually reduced, and none but urgent cases taken in. -The cleaning usually begins with the topmost ward of one part of the -building, or of several parts of the building at once. The patients are -usually moved to the ward immediately beneath. The ward goes through a -complete purification, also reparation of whatever wants repair. All -its furniture ditto; the bedsteads in particular. Afterwards windows -and doors are left wide open for two or three days, and nights so -far as feasible. In about a week from its commencement the cleaning -is over; the patients moved back; and the ward or wards so cleaned -recommence their usual taking-in--and so on. The cleaning of a great -London Hospital usually takes two full months; and a great nuisance -it is for the time, but the place benefits by it the whole remaining -ten. It is excellent economy to have plenty of hands, so as to have -the cleaning part, in distinction to the airing part, done as quickly -as thorough cleaning admits of. It is very bad economy to put too much -of this great extra cleaning upon the Nurses. This would of course -not apply to a Military Hospital, where it is important the Orderlies -should become as thoroughly qualified as may be for foreign and war -service. It is necessary that whatever exterior help is called in, -should be closely overlooked; contractors and contractors’ servants -being seldom overmuch troubled with conscience. - -Now it might be exceedingly worth while to have one or more reserve -Pavilions, with a view to this annual cleaning. - -If the flooring of polished oiled boards should be found to answer -(that it should receive a fair trial is very desirable, as it might -result in a material benefit to our Hospitals), it would be doubly -useful, when, every third year or so, the oiling and polishing required -renewal, to leave the newly-oiled wards empty for a fortnight. An -additional week or two would additionally harden and improve the -flooring; but a fortnight would suffice. - -It might also be right to have reserve wards for what must occur every -now and then in a Military Hospital, an influx of patients beyond the -usual number, or an outbreak of cholera, or some malignant epidemic, -which it might be desirable to isolate from the other patients. - -It may now be confidently expected that, under the new _régime_, the -progress in improvement of Military Hospitals will proceed rapidly; -that it will be quietly done is almost as certain--real improvement -and noisy philanthropy being fearfully inconsistent with each other, -especially in that momentous machine called the Army of England, which -is no safe plaything. - -Dr. Helm, the Director of the Vienna General Hospital, in a little -pamphlet published some time ago, insists on the importance, in -designing a new Hospital, of providing Reserve wards, especially with a -view to dangerous epidemics. They should admit, he urges, of easy and -complete isolation from all the remaining parts of the building. - -[Sidenote: Occasional Revision of Rules.] - -9. Dr. Esse, Director of the Charité, at Berlin, in a practical and -systematic, but pedantic and pudding-headed, little book on Hospitals, -published in 1857, strongly urges the importance of occasionally -revising and altering the rules of Hospital Officers and servants, and -all the Charité instructions end with this proviso of alteration. It is -one of our many unavoidable difficulties that it is necessary to begin -our work under definite rules, while it is also necessary to consider -the service, for some years to come, as tentative and experimental. It -is well to bear in mind what cannot be expressed. - -[Sidenote: Defect in some Systems of Nursing.] - -10. In admiring much, very much about the German Hospitals, it -becomes necessary not to omit a warning. A number of women, all equal -among themselves, with no female Superior or Superiors whatever, -under the sole control of men, in an ascending scale from the -Abtheilungs-Inspectoren or Oberkrankenpfleger, through Doctors of -sundry ranks, to the Director himself, such is the system followed, -as in the great Charité Hospital at Berlin, so in the great General -Hospital at Vienna; and this cardinal mistake leads to many others. - -[Sidenote: Nurses’ Exercise.] - -11. It is desirable that the Rules should give daily exercise to the -Nurses, or rather that the Rules should give them the right of daily -exercise; that the Superintendent should encourage and exhort them to -take fresh air daily when feasible, leaving them sometimes to take a -little quiet in their rooms. But in war service, and sundry foreign -stations in time of peace, not merely exigencies of service (which at -home will and ought often enough to curtail or abrogate exercise time), -but various other reasons might render it very undesirable to give the -Nurses right to two hours’ daily exercise. It must be impressed upon -all Superintendents, that it is essential in the long run to the health -of Nurses to have fresh air; but in many foreign stations it might be -far better for the Superintendent to take, or rather send, them out for -one _vice_ two hours, &c. - -In war and foreign service, the exercise time must be at the discretion -of the Superintendent. - -There may be awkwardness enough on sundry home stations in allowing -each Nurse two hours at her own discretion outside of the Hospital -every day. Still it is right to look things in the face. The Rules do -not contemplate a Sisterhood, but a staff of secular women, bound by -strict rules in all that concerns the duty they undertake, left to -themselves as to sundry things which in Sisterhoods are ruled. (How -and by what measures in process of time strong and quiet religious -influence may be brought to bear upon this staff, is the question of -vital importance as to the whole; without it, I doubt whether the -service of women would, in the long run, answer in Military Hospitals, -which are and must remain very peculiar places; with it, it might -please God to suffer good service to be done Him). Nurses trusted to do -their duty in wards must be trusted to walk out alone if they choose, -and I would not attempt to restrict it, though the Superintendent must -see to this, so far as she can without doing or encouraging spy-work, -a thing which has many advantages, and is often done in various, very -various ways, but which in the long run brings no blessing, and _pro -tanto_, degrades all who are concerned with it. - -[Sidenote: Number of Ward-Masters.] - -12. In Vienna Military Hospital each set of five or six wards, with 30 -or 40 patients, sometimes 20, in each, had a Sergeant and a Corporal -over the Orderlies. (Berlin Military Hospital is served by Civil male -Nurses). - -I think a Ward-Master would be enough for each Pavilion of six wards -of 30 patients each, in three stories, each couple of wards being in -charge of a Nurse, and each ward served by three Orderlies. - - -III. REGULATIONS. - -[Sidenote: Query as to depriving certain Patients of Visitors.] - -1. Proper military and medical advice should be taken as to whether it -would be advisable to draw a distinction between the venereal and the -other patients. - -In the Vienna Military Hospital they are locked up by themselves in -particular wards, but are allowed to see their comrades at visiting -hours. - -In the Berlin Military Hospital they are locked up in wards, and -allowed to receive no visits whatever, excepting, of course, from the -Chaplain and the proper Military and Medical Officers; and in the case -of dying patients from their nearest friends. - -Nor are they allowed exercise in the grounds. - -This excellent regulation makes them heartily tired of the venereal -wards, and even this is a very salutary thing. - -In the Vienna and Berlin Civil Hospitals, the venereal patients of both -sexes are also placed in locked wards, and allowed no visitors. Nor are -they allowed exercise in the grounds or garden. - -In the two Paris Venereal Hospitals no visitors are allowed. - -Now, as the more disagreeable the subject, the more necessary it is to -be explicit upon it when entered upon, this wholesome discipline exists -in a very faint degree in our great Civil Hospitals,--a thing not to be -lost sight of in introducing any change in the Army Hospitals. - -The three greatest London Hospitals have venereal wards. The female -patients never leave the ward. The male patients take exercise in the -court. In one case the rule is, that this should be at different hours -from the other patients; the rule is not strictly adhered to. - -The exercise question should, in Military Hospitals, be left entirely -to the Surgeons; they may fairly consider it enters into the question -of treatment, which is different from the Continental treatment. The -enforcement of different hours of exercise from those of the other -patients is good, as is every brand which can, quietly and effectually, -affix disgrace to these wards. - -Deprivation of visitors, if it could be done, would be very salutary. -In the great London Civil Hospitals, men and women visit the male -venereal wards; women alone the female wards (and melancholy things -are the visiting hours there; here and there a heart-broken mother, -abundance of prostitutes, and no lack of procuresses. A firm and -vigilant Head Nurse will sometimes refuse admitting one of the two -latter sorts to some patient, whom she knows they are endeavouring -to make sure of again; but as the rules admit female visitors, and -she is by rights only entitled to eject a visitor whose behaviour -is disorderly in the ward, the Head Nurse can only do this in point -of fact by straining the rules, and cannot do it often). The female -visitors of the male venereal wards are usually, on the average, much -less disreputable than those to the equivalent female wards; and are -generally wives, mothers, and sisters, seldom prostitutes. There can -be no doubt, however, that it would be much better if the patients of -neither male nor female foul wards were allowed visitors, unless in -the comparatively very rare cases of extreme danger; it would, in that -case, be necessary that the Hospital should supply them with linen, and -either supply them with groceries or forbid their receiving them from -without. - -In various essential respects the patients of a Military Hospital are -different from those of a Civil Hospital. Were it possible to prevent -all female visitors to the wards, except in dangerous cases, this -would be best. If the existing rules or practice do not compel the -sentries to refuse entrance to all disorderly women, however orderly -their behaviour, such a rule, at any rate, should be enforced. And if -all visitors, male and female, including, of course, soldiers, could -be refused admittance to the venereal wards, always excepting cases of -great danger, it would be very desirable. At all events, it would be -very desirable to have all female visitors, without exception, excluded -from these wards. These things are, I do consider, very important. But -I would not press them, if refused. - -Let the female service obtain, please God (I do not write these words -_pro formâ_,--if possible, I feel every day more intensely how solely -it is to Him we must trust in this difficult work,--the more so that, -if possible, I feel every day more intensely the importance of, if He -grants it success, improving secular Hospital nursing, leaving the -English Sisterhoods, which will always have great advantages, and, I -believe, great disadvantages, with reference to Hospital nursing, to -take their share in this great field, which has plenty of room for -both), let, I say, the female service obtain a firm footing in the Army -Hospitals, and with it, and by cautious degrees, sundry ameliorations -will creep in insensibly as to decorum among other things. Those solemn -beautiful words I have always felt so full of meaning to us, “In -quietness and in confidence shall be your strength.” - -[Sidenote: Query as to Numbering Patients.] - -2. Military as well as Medical advice should also be taken upon the -following point: - -In most, not all, the great London Hospitals the patients, whose names -are on their bed-tickets, are called by the numbers 1, 2, 3, &c., -suspended over each bed; sometimes a patient’s name is never heard in -the ward. - -Now, very possibly, this would not at all do in a Military Hospital, -and, if so, there is not another word to be said about it. - -Otherwise, very few things so effectually save time, as the numbering -plan. (In Civil Hospitals it is also excellent in other ways, of much -less consequence in a Military Hospital, which will never, I conclude, -be afflicted with “gentlemen,” Mr. So-and-So, and Master So-and-So, -which latter inscription is frequently to be read on the letters of -little boys in Hospitals, whose friends, on visiting days, also enquire -for them by that title). But few things, I repeat, so effectually -save time as numbering instead of naming the patients (names, of -course, to be on bed-tickets). If, however, the officers consider it -“unsoldierly,” give it up at once. - -[Sidenote: Regulations as to Swearing.] - -3. The regulations lately in force contained in plain strong language -prohibition of swearing and indecent language in Hospitals; they are -quoted from the Articles of War. It would be well to retain this in -any new Regulations; and the retention of this Rule is not the less -important when women are put in charge of Military wards, since, though -it is not their business to maintain discipline, it is their duty to -call in those whose duty it is when discipline is infringed. And it is -important that this prohibition of swearing and foul language should -not be looked upon as an individual or collective crotchet, or female -innovation, but remain the rule of the Service. Such language would -never be used in the Nurse’s presence unless by her own fault. But it -should be unheard in the ward, whether she is in it or not. The old -definite words should be transcribed. - -[Sidenote: Conclusion.] - -I do not like writing any part of the above, not because it can, in -any sense, be said to strain the necessary principle of reserve, save -for strictly business purposes, as to all which is, strictly speaking, -Hospital business, but because of the extreme caution necessary as -to this sort of topics. Still life is so uncertain that the possible -introduction of permanent Female Service into Army Hospitals has -determined me on writing what I had rather not have written. - - - - -ADDITIONAL HINTS AS TO PAVILION HOSPITALS SUGGESTED BY THE CONSTRUCTION -OF THE LARIBOISIÈRE HOSPITAL AT PARIS. - - -I.--_Ventilation._ - -The question of ventilation is so all-important, so much doubt still -seems to exist as to the comparative merits of natural and artificial -ventilation, so much has been said in favour of the latter, because it -is seen adopted in the finest hospital in the world, the Lariboisière, -that I have added a few practical remarks upon this system. The -conclusion is, that even at the Lariboisière, without opening the -windows occasionally, and especially in the morning, real freshness -is never obtained in the wards, and that, therefore, if there must be -artificial ventilation, that is the best which allows the most of the -windows being opened. - -On the men’s side, Thomas’ system, or that of injecting air at given -points, by means of two high-pressure steam engines, each working a -large fan, is adopted. On the female side, Duvoir’s system affords -ventilation by extracting air at given points. In both, a number of -shafts and openings provide for the exit of the air. - -Persons at the Lariboisière Hospital, who ought to be good judges, -including foremost the Director, an experienced and able administrator, -consider the ventilation on the male side the most expensive and the -best, both for day and night, being the coolest in summer and the -warmest in winter. In winter two great advantages are assigned to this -side: first, the heating being provided by the Hospital, the wards -are warmable at pleasure; whereas that of the female side is provided -by the contractor at a fixed degree of heat, which, in extra cold -weather, is augmented: from 15° to 18° C are the usual limits of the -winter temperature on the female side, while that on the male side is -usually several degrees higher. Secondly, the system of heating on the -male side permits the windows to be opened: while on the female side -objections are often made to opening the windows in winter, which it is -alleged interferes with the heating. - -_Per contrà._ How difficult it is to learn any facts by hearsay we -know. Other persons who ought to be good judges think the male side -apt to be too warm in winter, especially at night, and consider the -temperature on the female side quite sufficient. - -Both sides are ventilated both by the windows and by the machinery by -day in summer. Both sides are ventilated, each by its own different -machinery, by night in summer, except that, exceptionally on hot summer -nights, a window is opened two or three times in the night, or five -minutes every hour. - -Both sides are considered to be ventilated in winter mainly by the -machinery by day; and both sides are entirely ventilated in winter by -the machinery by night. - -As far as can be made out from conflicting accounts, (conflicting -from the very simple reason that one person will consider a ward, or -drawing room, for that matter, airy which another will consider close; -one, pleasantly warm, another too hot or too cold), it is practically -found impossible to freshen the ward of a morning without opening some -windows, and to keep it fresh during the day without now and then doing -the same; and it is easier to open the windows on the male side in -winter than on the female side. - -The ventilation on both sides is considered to work with equal -efficiency during the whole of the day. - -Of the eighteen wards, the ventilation on entering the wards at five -a.m., when the ward nightwatch has generally not opened a single -window, is certainly surprisingly good; _i.e._ the air is surprisingly -little bad. _But neither here, any more than anywhere else, are the -wards effectually freshened, until the windows are, of course with -proper caution, opened._ - -In both these particulars, no difference is to be observed between the -male and female side. - -In repeating that the Director, and other persons who ought to be good -judges, consider the machinery of the male side the most expensive and -the best, I add these things: - -First. Since this machinery was erected, so far as concerns the steam -engine, it is said that equally efficient and much less expensive -engines have been erected in other Hospitals, among others, Necker and -Beaujon. In both Hospitals, the plans of Duvoir and Van Heecke are -in use, one on either side. But certainly, the system of outlets at -Beaujon for the foul air is by no means so good as at the Lariboisière. - -Secondly. If an accident happened to the machinery of the male side, -which is in communication with the steam engine, the results might be -very serious. Twice a stove has burst on that side, happily without -damaging anything else than furniture near it; had patients been near -it, they must have been hurt or killed: and an accident on a large -scale might blow up not a small part of the Hospital. - -More or less danger is inseparable from powerful steam machinery, or -powerful machinery of any kind: the question is one of degree. - -Thirdly. Both sides of the Hospital have one thing in common. Except -the sculleries of the 3 ground floor wards on the male side, which -have each a stove or fire place, the kitchens or sculleries attached -to all the other wards are warmed by hot water. Undoubtedly this saves -much mess, much cleaning of stoves &c., and much bringing of fuel -and consequent dirt. But the absence of fire is always a loss to the -service of a ward. Sundry things, some one or other, often all of which -are constantly wanted in a large ward, _e.g._ warming broth or drink, -cooking for an extra bad case, warming poultices, warming (not airing) -linen for ditto, &c., &c., &c., are much more slowly done by water than -fire heat, and it is a question, variously answered, whether some of -these things are as well done by the slow water method, as by the quick -fire heat. Occasionally the hot water is not forthcoming, a nuisance -alike to the ward attendants of the ward whose scullery is thus heated, -and to those of the wards supplied with stoves, which have then to do, -in driblets, considerable extra duty. - -During the hot months the smell of the latrines is very little -perceptible in the wards, generally not at all: but the test of this, -as of the ventilation, is in winter, when the large window close to the -latrines is generally closed, and the smell is very offensive. - - -II.--_Oiled Boards_ versus _Parquets_. - -1. They have in common the superiority over common floorings--that they -are not scrubbed, and the damp thus arising is avoided. - -2. As regards labour, so far as Civil Hospitals are concerned, where -the ward service is done by women, _parquets_ would be more laborious -than scrubbing; a large ward, to be kept in a proper state, requires -a certain amount of _frottage_ (the peculiar polishing of _parquets_) -every day; and this _frottage_ is held to be unfit, from the fatigue -it causes and the strength it requires, to be done by women, and is -always done by men. Certainly Ward Nurses could never be required to -_frotter_; it is altogether a man’s business. - -3. As regards labour, so far as Military or Naval Hospitals are -concerned, where men preponderate in the ward service, it is my -impression (for of course I cannot pretend any certainty as to this), -that sailors who are proverbially handy (a different quality from -either laboriousness or endurance, though they have these too) would, -with instruction and painstaking, accomplish in time _frottage_; that -civilians would under the same conditions; that soldier orderlies -(infinitely, I humbly think, the best material for the staple of -military ward service), would generally make bad _frotteurs_. - -4. As regards labour, cleaning oiled boards, though a laborious -business, is much less so than either scrubbing or _frottéing_; and -is fully within the power of average strong women: none other should -nurse. (What subdivision of cleaning the ward, and of nursing properly -so-called, might both improve the work done and relieve the Nurses, is -another thing; my impression remains, that it is better to consider -these things to a certain extent as distinct duties, discharged by -women ranking alike; and that in a ward of forty, served by a Head -Nurse and three Nurses, to charge one with the main ward cleaning, is -better economy of strength and time than to divide it among the three). - -5. As regards labour, any Orderly giving his mind to it for a day at -the shortest, or a week at the longest, ought to learn thoroughly -how to clean polished oiled boards well, always supposing him to be -properly taught a very simple thing, which, like everything else, can -be done well, ill, or indifferently. - -6. Apart from the question of labour augmented or spared, the -advantages of oiled and polished boards I believe to be these:-- - -(1.) Prevention of dust. - -(2.) More easy purification of the air of the ward in the morning. - -The air of every ward becomes more or less impure during the night, -and the floor and furniture more or less dusty. Making the beds in the -morning adds to the dust the night has accumulated. - -The dust is more thoroughly destroyed by the cleaning necessary to -oiled and polished boards _of the Bethanien variety_, than by any other -cleaning I have seen. It is fairly destroyed; whereas both _parquets_ -and boards generally retain a little. - -Also, the water, with which the oiled boards after being swept are -cleaned, freshens the ward and purifies it of the closeness remaining -of the night air, in a very speedy and remarkable manner, which is even -more evident as well as more useful in winter than in summer--as in -winter it is not possible to admit as much air from the windows as in -summer, especially when it is most wanted, in the cold, close, early -mornings. - -The advantages of oiled and polished boards as counteracting the -spread of miasma, which is strongly dwelt on at Berlin by competent -authorities, I have not alluded to, as probably _parquets_ are -considered equal in these respects to them. - -Stains, mess, and dirt falling on polished oiled boards are much more -easily cleaned than on parquets. - - -NOTE. - -_Mode of Cleaning Ward and Room Floors at Bethanien, Berlin._ - - -I. DAILY. - -1. Take a common hair broom, a broom with a hard brush, a cloth of -coarse flax, and one or two pails of cold water. - -2. Sweep the floor and skirtings with the hair broom. - -3. Dip the cloth in a pail, wring it gently between the hands, so as -to have the whole equally wet, not running. Throw it on the ground, -reverse the hard broom, and placing the reversed handle upon the cloth, -clean the floor close to the skirtings, not the skirtings themselves, -and the corners. When the cloth becomes dry, rinse it and re-wet it in -the same pail. - -4. Then wet the cloth somewhat more, wringing it as before, throw it -on the floor at the end furthest from the door, and placing the brush -of the hard broom upon it, brush, firmly and quickly, each board in -the direction that the boarding runs, about as far as the arms can -reach, standing, not kneeling. A small ward can be at once brushed wet, -a large one must be divided into parts, and each part be successively -brushed wet and brushed dry. When the cloth becomes dry, rinse it and -re-wet it. - -5. To brush dry, rinse and well wring the cloth, brush as before. The -firmer you can press, the better and quicker the floor will be dried. -When the cloth becomes wet, rinse it and wring it as before. - -6. Change the water when dirty. More or less water must be used, -according as the floor is trod by dirty boots and shoes. - -7. Aim at drying the floor by one dry brushing; if not, it must be dry -brushed a second time. Once should suffice. - -8. Ten minutes, at the furthest, after the dry rubbing is over, the -floor ought to be thoroughly dry. When it is quite dry, sweep quickly -over it with the hair broom. - -9. On putting by the cleaning materials, rinse well the cloth in clean -water. - - -II. WEEKLY. - -1. Brush the skirtings with a small hard brush, and wipe them dry with -a rag, as the cloth would be too large, and wet the walls. - -2. Use more water to clean the floor, which will probably require two -dry brushings. - -3. Clean the brooms and pails. - - -III. ANNUALLY. - -1. Throw warm, not hot, water on the floor, and brush firmly and -quickly, wet and dry. A very little soda in each pailful will be an -improvement. More than very little will injure the flooring. - -[A new cloth, which it is economical to cut from a great piece which -makes into some or many dozens, should be steeped for a night in a pail -once filled with boiling water, and in the morning rinsed and wrung -several times in clean cold water, then used at once. Two or three new -cloths can be steeped in the same pail.] - - -III.--_Cautions in Hospital-Building.--Often repeated, but oftener -neglected._ - -1. Wherever practicable build the hospital on arches; but, for the sake -of discipline, they should be locked up. - -2. If practicable, let the laundry, if served by women, be removed from -sight of the place where the patients take exercise, and of the ward -windows. - -3. In a Civil Hospital it is objectionable to give the female patients -right to take exercise in corridors which the officers and servants -have constantly to traverse to go to and from the wards. In a Military -Hospital it is of little comparative disadvantage that the patients -should do this, although, - -4. In building a hospital it might be well worth while to contrive -that the covered space, essential to give the patients power of taking -exercise, should be used solely for that purpose. - -5. In Germany, the general opinion is in favour of small wards, twenty -beds are considered the desirable maximum; twelve, _per se_, better -than twenty. - -Ditto in Belgium, under the same restriction, although, in practice, -there are wards containing larger numbers. - -In the old Hospitals at Paris, the number of patients is too large. -The Charité has long great wards of 100 and 120 patients. At St. -Louis (which is mostly for cutaneous, not venereal, diseases, where -the patients usually are long under treatment and able to go about, -and where there is little acute illness,) wards of eighty and seventy -beds are the rule, smaller wards the exception. This may be considered -an exceptional class of patients. The Charité, somewhat densely -pressed upon by neighbourhood, is also not considered a favourably -circumstanced Hospital as to air. - -Putting aside for a moment the sanitary question, which we have fully -discussed elsewhere, and which appears to be decided in favour of wards -of from twenty to thirty patients, we will look upon the question of -administration. The moment we consider that a great public Hospital -has to provide efficient attendance for all the sick it receives, -that it must be economical of attendance, both because the expense of -attendance, as well as the other requirements of the sick, commands all -practicable economy; and because efficient attendance in sufficient -numbers is difficult to obtain; it becomes evident that it is far -better for the sick to have larger wards, efficiently served by as few -attendants as is compatible with efficiency. - -This, which is the fair statement of the case, strikes those who have -watched the working of the system of small wards in North Germany as -more true than ever. - -Such persons consider that the size and numbers of the wards at the -Lariboisière Hospital, viz., thirty-four beds, including the two in the -little ward, are good: that preserving the existing considerable space -between the beds, and supposing the same ratio of conditions as to -windows, &c., and the small ward for two at the end, wards of forty or -fifty would be equally healthy for the sick, but that the number fifty -should not be surpassed. - -Assuming, however, that thirty patients in a ward, or thirty-two, are -the maximum number, sanitary and administrative necessities being -conciliated, let us see what we do in our Military Hospitals at home. - -In most of our Regimental Hospitals the number of wards and of -holes and corners, in comparison with the number of sick, is quite -extraordinary. - -In a hospital for a battalion 500 or 600 strong, we shall find eight -or ten wards of small size, a small kitchen, everything, in fact, on a -small scale, just as if a large French Hospital had suddenly collapsed. - -How much more sensible would it not be to have one or, at most, two -large wards for thirty sick each, with a small casualty ward and an -itch ward! - -How much less expensive such a structure would be in erecting and -administering, and how much more easy would be the discipline and -oversight, not to mention the greater facility of ventilation! - -6. There is nothing at the Lariboisière Hospital answering to -casualty wards. Besides the eighteen wards of thirty-four each, the -Hospital contains two little (and inconveniently placed), wards of -ten beds each, which, when medical cases overflow, are made medical -wards; and which are closed when the ordinary wards suffice. But of -casualty wards, for offensive, or noisy cases, there are none, and the -double-bedded little ward at the end of each large ward is intended to -answer this purpose; also, but subsidiary to this, to allow now and -then a patient of the better class to have the comparative privacy. - -This latter consideration does not apply to a Military Hospital. As to -allowing Non-Commissioned Officers for instance to be in the little -wards, discipline would, I think, very soon suffer. - -But _if_ casualty wards are provided for extra offensive, and noisy -cases, it seems to me that any Hospital would be much better without -these small wards attached to each larger one. - -_Apart from the purposes which the casualty wards answer_, they are -a nuisance. If convalescent patients are put into them, they are -comparatively removed from inspection, and often play tricks there. -Patients requiring much attention can seldom be put there, however -their condition otherwise fits them for the little ward, because the -ward attendants, and especially the Sister (as in secularly served -Hospitals the Head Nurse), find it _impossible_ to serve the inmates of -the little ward properly, if there are also many serious cases in the -large ward. - -I submit therefore that the small ward is only an incubus, if casualty -wards are provided. One thing is certain: a patient requiring much -attendance, put into a little ward, ought to have an extra attendant -to himself, by day and by night; otherwise, either he is more or less -neglected, or he unduly monopolises the service of the ward attendants. - -It remains a question for far others than women to settle, whether -offensive and delirious cases are under more favourable conditions of -cure when scattered in little wards, than when assembled in a large, or -in several small wards. On this subject, I can only add my confirmed -belief that a large airy ward, provided with a few small wards, and -with complete ward attendance, is a much better place for the care and -attendance of such cases, than small wards attached to the ordinary -wards. - -7. Avoid many holes and corners. I could _not_ recommend a dining room -for patients attached to each ward, or floor, or pavilion. If there is -any dining room, let all the convalescent patients of the wards not -being convalescent wards, dine together in a room apart from the wards, -and let the rest dine each at his bed side. If not, let each patient -dine at his bed side. - -At the Lariboisière Hospital, each ward has a vestiary, a doubtful -arrangement. The nature of a Military Hospital renders it proper to -have but one vestiary under charge of some man. - -8. If possible, let all foul linen be delivered daily, twice perhaps -better than once daily, into the laundry, so as to remain the shortest -possible time in the neighbourhood of the ward; otherwise, do what you -will, foul Hospital linen will fairly, to say the ugly truth--stink, -and its temporary receptacle will stink also. I would not make this -temporary receptacle a room. A large chest in the scullery, a region -under constant purification by fire and air, would be, as already -hinted, p. 88, the least bad place for an accumulation inevitable -to all Hospitals, but which should accumulate for as little time as -possible. - -9. Provide from the first room for storing and issuing dried clean -linen, as well as laundry room. - -10. In badly-planned Hospitals artificial ventilation is an -excellent auxiliary for expelling the foul air, engendered in the -ward, especially at night; but windows only can be relied upon for -introducing good air. Let Hospitals, therefore, be so constructed as -to admit of opening one or more windows as much as possible all the -year round, with as little chance of draught as may be to individual -patients, which can be done by providing double windows, opening above -and below, or by some similar expedient. - - - - -NOTE ON CONTAGION AND INFECTION. - - -There are no words in regard to which there is more misconception, -or more nonsense talked and written, than the two words “contagion” -and “infection;” and as the word “infectious” has been used in these -Notes, it is necessary to say what it does mean, and what it does not -mean. The word “contagion” appears to have been first used by certain -classical writers to signify the spread of scab among sheep; and it -would have been well for humanity if the word had been restricted to -this very primitive bucolic signification. It was not till centuries -after Virgil’s death that the common sense of men had descended so low -as to introduce it into the Medical vocabulary. This took place at a -period when, from the neglect of sanitary arrangements, pestilence -attacked whole masses of people, and when no one appears to have -considered that nature had any laws for her guidance whatever. It was -not until human intelligence had descended to this depth that men -seem to have bethought themselves of Virgil’s term as affording them -an adequate explanation for pestilence, and sufficient reason for not -exerting themselves to prevent its recurrence. So it has continued -ever since. The little word used in all innocence by the poet for -poetic purposes has become the ground-work of every manner of false -observation, false reasoning, neglect of sanitary laws, lazarettos, -quarantine, and continually-threatened interruption to the commercial -intercourse of mankind. No single word has ever done so much harm to -the human race, or given such a proof of what a mighty thing a word is! - -One would have thought that, after the sanitary experience of the -last fifteen years, the word “contagion” would have disappeared from -our language; but, even in the last document issued by the expiring -Board of Health, written by their Medical Officer, Mr. Simon, and -based on erroneous statistical evidence (Papers relating to the -Sanitary state of the People of England, 1858), it is stated that “a -further--practically speaking, unavoidable--cause of premature death in -every civilized country is the risk of its _current contagions_.” [The -italics are not mine.] And this refers to small pox, hooping cough, -measels, and scarlatina, the mortality from which we are to presume, is -“unavoidable.” - -If this be Board of Health doctrine, it is certainly not sanitary -doctrine. It would have astonished the Health of Towns Commission, and -the first Board of Health. - -“Contagion,” as its etymology implies, means the communication of -disease from person to person by contact. It is often confused -with “infection;” but it has quite a different meaning. Contagion -presupposes the existence of certain germs, like the sporules of -fungi, which can be bottled up and conveyed any distance, attached to -clothing, merchandize, especially to woollen stuffs, for which it is -supposed to have a particular affection, and to feathers, which of all -articles it especially loves, so much so that, according to Quarantine -laws, a live goose may be safely introduced from a plague country; -but, if it happens to be eaten on the voyage, its feathers cannot be -introduced without danger to the entire community. The absurdities -connected with the doctrine are numberless. Suffice it to say that in -the ordinary sense of the term there is no such thing as “contagion.” -There are two or three diseases in which there is a specific virus -which can be seen, tasted, smelt, and analysed, and which, in certain -constitutions, propagates the original disease by inoculation, such as -small-pox, cow-pox, and syphilis, but these are not “contagions” in the -sense supposed. - -With regard to the mysterious, imponderable, indivisible nonentities, -which make up our “current contagions,” they may safely be dismissed -into the limbo of extinct superstitions. - -The word “contagion” therefore is altogether objectionable. - -The word “infection” expresses a fact, without involving a hypothesis. - -It is most necessary, however, that the meaning should be guarded; -for, just as there is no such thing as “contagion,” there is no such -thing as _inevitable_ “infection.” Infection acts through the air. -Poison the air breathed by individuals and we have infection. Shut up -150 healthy people in a Black Hole of Calcutta, and in twenty-four -hours you have an infection produced, so powerful that it will in that -time have destroyed nearly the whole of the inmates. Sick people are -more susceptible than healthy people; and if you shut up sick people -together, without a sufficient space and sufficient fresh air, you will -have not only fever, but erysipelas, pyæmia, and the usual tribe of -Hospital-generated epidemic diseases produced. - -Again, if we have a Fever Hospital with over-crowded badly-ventilated -wards, or with the air stagnant in them, we are quite certain to have -the air become so infected as to poison the blood not only of the sick, -so as to augment their mortality, but also of the medical attendants -and nurses, so that they shall also become subjects of fever. - -It will be seen at a glance that, in every such case and in every -such example, the infection is not inevitable, but the simple result -of gross carelessness and ignorance. In certain Hospitals it has -been the custom to set apart wards for what are called “infectious” -diseases; but, in reality, there ought to be no diseases considered -such. It follows from what has been stated that, with proper sanitary -precautions, diseases reputed to be peculiarly “infectious” may be -treated in wards among other sick without any danger; just in the same -way as, with proper sanitary precautions, a number of healthy people -may be congregated together without becoming subject to the horrors of -the Black Hole of Calcutta. - -It is in the highest degree probable that we should never have heard of -“infectious” wards, if the other wards of a Hospital had been supplied -with sufficient space and air for the sick; and in too many cases it is -to be feared that the presumed “infectious” cases are huddled away into -small, ill-lighted, ill-ventilated rooms, a kind of Lazaretto, in fact, -where, if they die, they have at least been kept from doing harm to the -other sick in Hospital! - -It is high time that common sense should deal with the question; for -there does not seem to be much hope for a deliverance from these -superstitions from any other quarter. - -The “infectious” wards in Military Hospitals correspond, in some sense, -to the “casualty” wards in Civil Hospitals, into which accidents, -noisy, and erysipelatous cases are transferred, when necessary. The -advantages of a separate set of wards for this class of cases have -been already insisted upon in these Notes; not certainly because the -cases are inevitably “infectious,” but because the segregation of -such facilitates greatly administration and nursing, while it removes -offensive and noisy patients out of the Hospital wards, whose inmates -they would annoy. The question of infection or non-infection has -nothing to do with the arrangement. No stronger condemnation of any -Hospital or ward could be pronounced than the simple fact that any -disease has attacked other patients than those first affected by it. -“Infection” and incapable management, or bad construction, are, in -Hospitals, convertible terms. - -It may be useful to mention what the meaning is of the words -“epidemic,” “endemic,” “sporadic,” and “zymotic.” - -When a large number of people are attacked simultaneously with the same -form of disease it is said to be _epidemic_. When a small number, as, -_e. g._, the inhabitants of a single court or alley, are so attacked, -it is said to be _endemic_. When scattered cases of the same disease -happen, one here, one there, over a large surface, the disease is said -to be _sporadic_. The term _zymotic_, which includes all diseases of -the preceding categories and some others, implies the existence of -certain changes in the constitution or in the blood, rendering persons -so affected liable to the diseases in question. - -It is a vulgar error to suppose that epidemics are occasioned by the -spread of disease, from person to person, by infection or contagion; -for it is an ascertained fact that, before any people is attacked -epidemically, the disease attacks individuals in a milder form, one at -a time, at distant intervals, for weeks or months before the epidemic -appears. Before an epidemic of cholera, these cases consist generally -of diarrhœa of more or less intensity, followed by a rapidly fatal -case or two, very much resembling cholera. Even plague itself, as -in the recent epidemic at Bengazi, begins with cases which cannot -be distinguished from ordinary typhus-fever, the succeeding cases -getting more and more intense, until the epidemic seizure takes place. -Experience appears to show that without this antecedent preparatory -stage, affecting more or less the entire population of a town or -district, the occurrence of an epidemic is impossible--the epidemic -being, in fact, the last or, so to speak, the retributive stage of a -succession of antecedent phenomena extending over months or years, and -all traceable to the culpable neglect of natural laws. It is simply -worse than folly, after the penalty has been incurred, to cry out -“contagion,” and call for the establishment of sanitary cordons and -quarantine, instead of relying on measures of hygiène. Epidemics are -lessons to be profited by: they teach, not that “current contagions” -are “inevitable” but that, unless nature’s laws be studied and obeyed, -she will infallibly step in and vindicate them, sooner or later. - -In the words of the Registrar-General, which are as applicable to -Armies as to States, “Sanitary measures and not quarantines are the -real safe-guards of nations.” - - -NOTE. - -I have just seen a paper by Sir John Hall, entitled “Observations on -the Difficulties experienced by the Medical Department of the Army -during the late War in Turkey.” In this somewhat singular document, -which appears to be a defence of Sir John Hall’s own conduct, there are -certain statements made about the female nursing establishment in the -East which require a word of comment. - -It will be observed that throughout the paper, the weapon which -Sir John Hall uses against all civil interference in repairing the -sufferings which proceeded from the defects of his own department is -simply detraction. - -As for Civil Commissions, they were useless, as for Civil Hospitals, -they were costly, and their officers lived magnificently and were -extravagantly paid. As for the nurses, they were benevolent, pious, -well-intentioned persons, but what could they do? How could one woman -nurse eighty sick? The medical men thought they could not. - -Why had Miss Nightingale stores of port wine placed at her disposal, -which she could give to the French Hospitals, while he, the principal -Medical Officer of the Army, had no such stores at his disposal? - -Sir John Hall must have already discovered that this old weapon is no -longer of use in defending his position. - -It would have been more to the purpose had he produced his requisitions -for food, clothing, comforts, &c., and shown how they were refused or -not complied with. At the very time I gave over part of our own private -stores of port wine, &c., to the French Hospitals (for part only of -what was given were Government stores at all), Sir John Hall might have -obtained, out of the large wine store at Balaklava, any amount of wine -he required, by merely asking for it. The simple statement of this fact -would have been a better answer to M. Baudens[20] than assuming that I -could obtain from Government stores and wine for the French Hospitals -which he could not obtain for his own. - -As to his statement about the Nurses, it simply shows ignorance of the -whole matter. Nobody ever contemplated giving to a Nurse the entire -charge of a number of sick in a Military General Hospital. It is no -part of good Hospital nursing to do so. With proper Orderlies, a Nurse -can very well attend to sixty or seventy sick. We were prevented, -indeed, by the authorities, and by circumstances, from organizing a -proper system of nursing, and were obliged to do all the good possible -in the best possible way. But Sir John Hall’s method of estimating the -efficiency of nursing, by dividing the number of sick by the number of -Nurses, is simply absurd. - -FOOTNOTES: - -[2] As little reference as possible, no reference at all, if it can -be avoided, should be made, on our part, to the Confidential Report, -which, in 1855, was presented against the War-Nurses. The less scandal -about women is reverted to the better--a truth all slanderers have -always appreciated: “Calomniez, calomniez toujours: il en reste -toujours quelque chose.” It would be far preferable if Nurses could -enter the Army Hospitals quietly, and let by-gones be by-gones (the -useful experience always excepted, which has been gained). - -[3] The work was done under many difficulties, some inevitable, some -which should have been spared. Things happened among us deeply to be -regretted. Rebellion among some ladies and some nuns, and drunkenness -among some nurses unhappily disgraced our body; minor faults justified -_pro tanto_ the common opinion that the vanity, the gossip, and the -insubordination (which none more despise than those who trade upon -them) of women make them unfit for, and mischievous in the Service, -however materially useful they may be in it. Of all this, the material -consequences might have been spared by some such “General Order” as -the above, which, at least, prevents others from taking advantage and -making capital of such faults. - -[4] The Extra Diet Kitchens _must_, it is necessary to state, be -under a separate roof from the General Kitchens, as long as the -present system (or no-system) of cooking exists. But the sooner it is -altered the better. There should be one kitchen only. But the Nurse -should always superintend the administering of the Diets. She is -unquestionably the proper person, also, to administer the medicines, -&c. The Orderlies, to be of any use, must act under the direction of -the Head-Nurse and not independently. It would seem hardly necessary to -enunciate such a self-evident proposition. - -[5] To all references which may here be made to Civil Hospitals I -should wish to say, by way of preface:-- - -1. That I have always believed and I believe it more and more every -day I live, that what is wrong in hospitals is to be patiently, -laboriously, and, above all, quietly mended by efforts made from within -them, if it pleases God to grant that blessing upon them without which -all human efforts are vain, and not by accusations, investigations, and -noise from without. - -2. Also I have always believed, since I knew Hospitals at all, and I -believe it more and more every day I live, that, with all their faults -and shortcomings, which are easily learnt and more easily declaimed -against, our great English hospitals are places in which more is done -for the relief and cure of human misery, or, rather, of that large -branch of it arising from disease, than in any other places in the -world. Also that their faults are not essential to them, but that they -may, by God’s blessing on the patient endeavours of many years, be very -much modified. - -[6] In their regulation dress they should always appear, except when -they go on holidays. - -But let the Queen pay for the transport of one box and one bag only, -for each Nurse on duty; and if she takes more let her pay for it -herself. - -[7] I would allow each Nurse 1½ pint of porter or ale _per diem_, or, -instead of the half-pint of porter, 1 oz. of brandy or a wineglass-full -of wine, as she likes best. Most Nurses crave, and rightly, for a -luncheon about 9 or 10 A.M., and drink some beer then. I would let them -take their own time as to when they drink their day’s allowance. But, -while trying to suit each Nurse’s varying tastes (and in Hospital duty -the taste does vary) each Nurse must keep to one thing, say for a week -or month. - -[8] Better than a closet is a moveable dresser, only table-height, -under which cleaning can be carried on. - -There should be no projections in a ward or recess, which are only -lodgments for flue and dust. The walls of a ward should be even, -polished, impervious. - -[9] With regard to children we might look forward to a time when -a school might be formed for the children, if any, of such of Her -Majesty’s Nurses as are widows. This would be an additional bond to -the Service for the mothers. The children, of course, are not to be -admitted into Hospital; and strict rules must be made (and kept to) as -to when the mother should visit them. I do not anticipate that it would -be possible ever to have married women in the Service. And it is hardly -necessary to add, that no women but of unblemished character can ever -be admitted. - -[10] Should a woman, however, out of the higher orders, be found as -efficient as one of the middle classes, as Matron, this should be no -reason for excluding her. - -[11] If it be desired to include some War-Nurses after 40 it would -be better for the Superintendent-General, with the sanction of the -Secretary of State, to take, at first starting, a few past the age, -than, on their account, to alter the age. It stands to reason that, on -the formation of the Staff, approved Nurses of the War-Service should -be included in it, for the sake of the Service. - -[12] It is better to omit the Belief. Singularly enough it is the one -thing objected to by Dissenters and Roman Catholics. - -[13] If the Surgeons are for the men doing it, I would not overpress -this point. But, in the case of weak patients, it requires extra -care, and it would be much better to leave it as the duty of the -Nurse. At all events it will not answer to leave the enema and its -administrator unspecified. The Medical Staff Regulations assign it -to the Ward-Masters. It is a simple thing enough, but one by the -careless or ignorant administration of which many a man (and woman) -has been injured for life; and either the Ward-Master, the Assistant -Ward-Master, or the Nurse should be responsible for it. I should -prefer, as above stated, charging the Nurse with it; but if objected -to by the Surgeons, I should at once let them assign it to whichever -Non-commissioned Officer they chose. - -[14] One Nurse might possibly be able to serve the whole Pavilion. The -highest estimate is here taken. - -[15] The floors are of deal; the length and breadth of the boards -depending on circumstances. Wood skirtings run round the walls, -following the recesses of the window and doors, 2½ in. in height and -1½ in. in thickness. The skirtings should have no indents in them, -which form convenient lodgments for dust and take time to clean. A -little rim must run round the top of the skirting, edging the wall. The -skirting should thence descend, unindented, upon the floor. The boards -are coloured and prepared, as follows: A new floor is rubbed over -two or three times, with warm linseed-oil varnish, having some fine -yellow-ochre, powdered, in it; then a coat of “laque-lustre,” a species -of French polish, is laid over it, the result being a reddish-yellow -colour, in which the grain and veining of the wood is shown. If, after -being used some time, it begins to look worn, it is rubbed over with -oil and a new coat of polish laid on it; but, as this takes a long time -to dry, it is usual to fill up the worst parts with thin oil-colour, -and then to take the yellow polish and lay it on, in two successive -coats, leaving it to dry, if possible, for twenty-four hours, as it -wears the better the firmer and drier it is. For old boards, that have -been much used, considerably more laque-lustre is required than for new -ones. - -After laying on the laque-lustre it is desirable that the floor should -not be trodden upon for six weeks, and it is also well occasionally, -say about once a week, to polish it, which conduces much to make it -serviceable. - -[16] And this should be adhered to, the rare though extant cases of -efficiency for Hospital nursing, past this age, notwithstanding. - -[17] Great caution must be used in acting upon this. The -Superintendent-General, or the Superintendents who are responsible to -her, order the service of each Nurse. How far is it just to consider -extra dangerous duties or stations meritorious in the Nurse who does -or suffers from them? Others might have done the same, if so ordered. -Others might have wished for such an order. Or a strong efficient Nurse -who, in other respects, gives anxiety, may render extra useful service -on an emergency, and suffer for it in health: and yet, during her whole -service, have given more anxiety and less satisfaction than others who -did not, perhaps had not the opportunity to, distinguish themselves by -any extra useful service. - -[18] The “Superintendent” and “Matron” are here used throughout as -synonymous terms; because “Matron” is the shorter and more familiar -name; although, for reasons before given, “Superintendent” would be the -better word for Military Hospitals. - -[19] If it be said that the Workhouse sick are ill-nursed, it is in -proportion as this rule is broken, not as it is kept, that they are so. - -[20] To M. Baudens, whose recent death is so much to be lamented, -I cannot here but add a tribute of admiration for his wise and -enlightened sanitary views, during the year of his superintendence over -the Medical Department of the French army in the East, and of gratitude -for his ready and magnanimous acceptance of our stores, when the French -sick were really in want of them, after these had been refused by other -French authorities. - - - - - LONDON: - PRINTED BY HARRISON AND SONS, - ST. MARTIN’S LANE, W.C. - - - - -_PRIVATE AND CONFIDENTIAL._ - - - - -THOUGHTS SUBMITTED AS TO AN EVENTUAL NURSES’ PROVIDENT FUND. - - -I. WAGES AND PROSPECTS OF NURSES. - -II. DESIRABILITY OF SOME FURTHER PROVISION. - -III. OF WHAT NATURE? - - 1. With regard to kind? - 2. ″ persons? - 3. ″ objects? - -IV. SUGGESTIONS AS TO THE RULES TO BE FOLLOWED. - -V. PROSPECTS OF EVENTUAL SUPPORT. - - -I. WAGES AND PROSPECTS OF NURSES. - -[Sidenote: The two Classes of Hospital Nurses.] - -1. The nurses of the great London hospitals are divided into two -classes: head-nurses or sisters, and nurses or assistant-nurses. These -latter are, generally, subdivided into day and night-nurses. - -[Sidenote: Head-Nurses or Sisters.] - -2. The head-nurses, on an average, receive about £50 a-year and no -board, or lower wages and partial board; the use of one or two rooms, -generally unfurnished, and an allowance of fuel and light. Sometimes -uniform outer-clothing is included. Sometimes two pints of beer daily -are added to the above. - -[Sidenote: Nurses or Assistant-Nurses. - Day Nurses.] - -3. The day-nurses, on an average, receive about 12_s._ a-week and no -board, or lower wages and partial board; lodging, with the use of some -furniture; sometimes an allowance of fuel and light apart from the use -of both in the wards. Sometimes uniform outer-clothing is added to the -above; sometimes they have also an allowance of one pint of beer daily. - -[Sidenote: Night Nurses.] - -4. The night-nurses, on an average, receive about 10_s._ a-week and no -board; lodging, with the use of some furniture; sometimes an allowance -of fuel and light apart from the use of both in the wards. Sometimes -they live in their own lodgings, near the hospital, receiving the same -wages. - -[Sidenote: Retiring Pensions and Payments at St. Bartholomew’s.] - -5. I am informed that St. Bartholomew’s Hospital has no fixed scale of -pensions, nor is the term of service defined. But pensions have been -granted to worn-out sisters of from £15 to £25; as also pensions of -smaller amount to some worn-out nurses. - -[Sidenote: At St. Thomas’s.] - -6. St. Thomas’s Hospital, in like manner, has given, without any fixed -rule, pensions to worn-out sisters, of from £30 to £50. A gift in -money has been granted on the retirement of a sister; and the same has -been done in the case of nurses who may have received injuries in the -discharge of their duties; and in a very few instances of long and -faithful service they have been pensioned. - -[Sidenote: At Guy’s Hospital.] - -7. Guy’s Hospital for a long time generously provided for its -superannuated sisters, but the plan in practice being found very -objectionable, was a few years since given up, and the authorities -established a Superannuation Fund for the Servants of the Hospital. - -It is compulsory on sisters, optional to nurses, to belong to it. -Each subscriber receives a book containing printed rules, with tables -of rates of ages, payments, and pensions, and also blank leaves. -The subscriber selects the amount of pension for which she wishes -to subscribe. At each quarterly payment of wages, a proportion is -paid into the fund; entered in the subscriber’s book, and properly -attested; the hospital makes a payment of equal amount into the fund -on the subscriber’s account. If the subscriber die before attaining -the age when the pension begins, the amount paid by the subscriber -is disposable by will, and in case of intestacy reverts to the next -of kin. The pensions, one-half of which are thus purchased by the -subscriber, and one-half presented by the hospital, vary, if I remember -rightly, from £15 to £50. In February 1857, no nurse subscribed; to -which three remarks apply:--first, that every good work takes time to -grow; secondly, that not a few of the sisters, having looked forward to -benefiting by the old system of superannuation, rather grudged their -own payments than sought to induce their nurses to subscribe; thirdly, -that many of the nurses were really unable to make the payment. - -[Sidenote: At the Non-Endowed Hospitals.] - -8. The non-endowed hospitals, I believe, but write from very imperfect -information, grant few pensions. Sometimes they grant a gift of £25 -or less to a retiring head-nurse. Sometimes they employ a head-nurse, -become too old for her work, as an extra and inferior nurse. Sometimes -they grant a worn-out head-nurse an asylum in the incurable ward of the -hospital. I believe the pensions to old nurses are still fewer than -the few to head-nurses. Definite information could easily be procured. -Their funds do not permit such a diversion from their main and primary -object, for which they are often, as it is, inadequate. - -[Sidenote: At County Hospitals.] - -9. Of the wages and prospects of eventual provision of the nurses of -the county hospitals I know nothing; but understand that the former are -lower than, and the latter as entirely blank as those of the nurses of -the non-endowed London hospitals. - - -II. DESIRABILITY OF SOME FURTHER PROVISION. - -[Sidenote: Unfitness of Nurses for any other work.] - -1. It may be safely taken for granted as a rule, with few exceptions, -that a thorough hospital nurse can seldom turn herself to any other -business. Her life and work are altogether peculiar; she acquires -a knowledge and habits which incapacitate her from all ordinary -occupations, grows into fitness for them, and out of fitness for all -others. - -[Sidenote: Shortness of their time of capacity for Service.] - -2. No less so, that the time during which a hospital nurse can work and -lay by, is short, compared with the average duration of other kinds -of service. Apart from all excess of their own, their work and its -concomitants wear out hospital nurses fast. In every large hospital -you will see many women of 40, whom you would suppose 60, and strength -often decays as prematurely as appearance. Well-ventilated bed-rooms, -more sleep, and better food, would be materially in their favour; but -the work can never be other than one which wears out most constitutions -fast. - -[Sidenote: Character of Nurses as a Class.] - -3. In the London hospitals there are some women of excellent character -and of great efficiency; many the reverse, in one or both respects; -many between the two classes, who generally end by ranking in the -second. - -4. To augment the number of the first class, to reduce the number of -the second, to induce the intermediate eventually to rank with the -first, and not with the second, is the desire of every hospital. - -5. It is most important, in all things, in none more than in hospital -matters, to moderate expectations, not to hope too much from any -measure, or set of measures, and to keep well in view the stern prosaic -realities of things. The hospitals of great towns are not asylums where -a few or many selected patients can be received and petted; but great -receptacles of all sick comers. Their foundations lie down and deep in -the human sin and misery for which they in part provide, and the traces -of their purpose and nature must ever remain impressed upon them. They -are also schools for the practical education of a great profession, -important to mankind and dangerous to its members. - -Hospital nurses are not women attempting or following “counsels -of perfection,” (whatever incorporation of other elements may be -eventually effected), but some of those many women whom God has -ordained to earn their bread by toil, (and in the large towns of -England honest ways of earning that bread are for women but too scarce -and too overcrowded), and upon whom He has laid the same condition as -on all the souls He has made, to keep the commandments to enter into -life. A very mixed class they must ever remain: to improve the class, -by God’s blessing, would be to effect a great benefit both to the -hospitals and to these immortal souls. - -[Sidenote: Probable beneficial results of a prospect of eventual -provision, depending on character.] - -6. Among several things which might be done or tried, with the view, -if it please God to prosper the endeavour, of eventually improving the -class of hospital nurses, the establishment of some definite prospect -of eventual provision, dependent upon good character, appears very -important. - -7. It would tend to augment the number of steady respectable women, who -are anxious to keep a good moral and require a good business character, -whose aim it is to do their duty, to give satisfaction to their -superiors, to keep their places in the same hospital, and eventually to -end their days out of the workhouse. - -8. It would tend to diminish the number of ill-conducted women, who -wander from hospital to hospital; whose wages go in drink or finery, -or both; who would be disgusted at the idea of regularly laying by for -their future support, and who would resent strict investigation into -character. - -9. It would tend to induce the intermediate class of women, who -hesitate between good and bad companions, to incline to the former, and -to break off from the latter, by the favourable result of provident and -economical habits on their actual conduct; and by the effect which the -prospect of a decent support in their age, dependent upon these habits, -would produce. - - -III. OF WHAT NATURE? - - 1. With regard to kind? - 2. ″ persons? - 3. ″ objects? - -[Sidenote: Kinds of possible assistance, three.] - -1. With regard to kind. - -There are three kinds of possible assistance. - -[Sidenote: Pensions.] - -First. Granting free pensions to efficient and well-conducted sisters -and nurses, under fixed regulations. - -[Sidenote: Facilities for Saving.] - -Second. Providing sisters and nurses with a secure channel of investing -their savings; giving them thus the important assistance of saving -their time, trouble, and expense, in obtaining information as to such -secure investment. - -[Sidenote: Additions to Savings.] - -Third. Combining, with the second, a certain proportion of pecuniary -aid. - -As to the first. It would be wise economy if the endowed hospitals, who -alone could do it, were to grant such pensions; but whether they are -likely to do more than they do now I am quite ignorant. - -Whether our labours in this field should take the direction of the -second or third, is one of the most difficult questions with reference -to a thing which is rife with difficulties. Towards solving it, I -submit that it would be expedient to employ an able and honest man of -business to procure-- - -[Sidenote: Information and Advice to be procured on the Subject.] - -I. The rules, working, and results so far of the Servants’ Provident -Society. - -II. Of several of the various partly self-supporting and partly -assisted provident societies of the different trades’ and city unions. - -III. Of some dozen benefit societies in large towns. - -IV. Of Guy’s Hospital Superannuation Fund. - -V. To take the practical opinion of two experienced actuaries. - -VI. Also of the Treasurer and Matron of St. Bartholomew’s; - -Of the Treasurer, Resident Medical Officer, and Matron of St. Thomas’s; - -Of the Treasurer and Matron of Guy’s Hospital; - -Of the Chairman of the House-Committee, House-Governor, and Matron of -the London Hospital; - -Of the equivalent authorities of St. George’s, and of two or three -other hospitals (including King’s College). - -[Sidenote: It is not possible for Nurses to purchase Annuities out of -their Savings.] - -My impression is that it is not possible, in the majority of cases, for -either head-nurses or nurses to purchase annuities out of their savings. - -I. Their work wears them out comparatively soon. - -II. During its continuance they require to live well _i. e._, to have a -sufficiency of good plain food. - -III. They are obliged to put out and pay for either the whole or nearly -the whole of their washing, making, and mending (and most properly -obliged). - -Thus apart altogether from the consideration that many nurses are -widows with families, and many others burdened with helpless or infirm -relations, and that, in many of these cases, the smallest saving out -of their wages is impossible, I doubt whether it can be reasonably -expected that, as a class, hospital nurses should lay by out of their -unassisted savings a provision for their age.[21] - -[Sidenote: Persons to be assisted.] - - -2. With regard to persons. - -Shall the Fund be open exclusively to nurses belonging to the proposed -Institution under Miss Nightingale? - - Or extended to those of the London hospitals? - - Or extended to all Hospitals in England? - - Or in the three kingdoms? - - Or in Her Majesty’s dominions in general? - -Shall the Fund be extended to private and monthly nurses, including -midwives, as well as to hospital-nurses? - -I submit that we should consult, on these points, the authorities -of the principal hospitals and a few men of experience in business -besides. (Philanthropists by trade are, as is well known, the worst -possible authorities on subjects of this kind.) - -My impression is that the Fund should certainly be extended to the -three kingdoms. Whether it should be extended to the empire would -depend entirely, in my judgment, upon the check and scrutiny it would -be possible to exert, on accounts, monies, and certificates, in distant -parts. Upon this men of business should advise. - -I think the Fund might eventually be open to private nurses, midwives, -and monthly nurses.[22] - -I think it perhaps might be open to the St. John’s House nurses and -to those of any institution which does not provide its servants with a -pension. The Nursing Sisters’ Society, I believe, have recently decided -on granting their sisters £20 a-year, after twelve years’ service, a -wise, generous, and, if properly worked, economical measure. We must -avoid the very appearance of disfavour to other nursing institutions. - -[Sidenote: Objects to be sought.] - - -3. With regard to objects. - -Shall the objects be - - Material? - Sanitary? - Moral? - -Or shall they be restricted either to the first only or the first -and second? Here, again, I submit that we should consult hospital -authorities and a few men of business and of experience, as to the -feasibility, often a distinct thing from desirability, of these things. - -Upon the whole, and weighing many opposite difficulties, my impression -is strongly in favour of attempting to combine the three. - - -Material objects. - -[Sidenote: Material Objects to be sought.] - -The benefit and provident societies embrace many objects: annuities, -payments on illness, payments at burial, provision for children’s -apprenticeships, provision for children at death, and other things. - -[Sidenote: Provision after Superannuation.] - -I. It appears to me that the main if not the only object of the Fund -should be to provide annuities. - -[Sidenote: During Illness.] - -II. It would be a question whether or not to arrange for payments -during illness.[23] Every now and then ward air gets down the throat of -almost every nurse, and every few years or so there is an illness. In -many cases a nurse’s pay stops either when or soon after she becomes -a patient. Some check upon malingering, a thing well known where the -name is not, is essential to every hospital. Of course it presses -heaviest upon those who do not require it. After an illness, before -returning into the wards, the best thing is a short thorough change of -air. Often a severe illness is, and oftener still would be prevented -by a week’s change of air, when the peculiar hospital-languor, so well -known in hospitals, and so indescribable outside of them, first fairly -sets in. The means of change of air, either before or after illness, -are often deficient. Still, useful as some such provision would be, -in many cases every year, it appears to me so subordinate to the -great object of furnishing these women with some provision on their -superannuation, that if it in the least impeded or rendered the latter -less secure, I should unhesitatingly give it up. - -[Sidenote: Burial Payments.] - -III. With burial payments I think the Fund should have nothing to do. - -[Sidenote: Payments for Children.] - -IV. As to payments for children, whether on apprenticeship or at -death:--Upon the whole, after much anxious thought, I think it -undesirable to encourage mothers, as such. This is one of the many -points, as to hospitals, where theories and experience differ much from -each other. - -[Sidenote: Reasons against the last Form of Aid.] - -A very large proportion of nurses are mothers, often widows, with -large families, whom they support and put to service out of their -wages, too often eked out by improper means, _i. e._, bribes and petty -dishonesty. Many of these women are moral, sober, industrious, and -doubly anxious to retain their places, on account of their children; -still there are serious embarrassments in employing them. The wages -of hospital nurses are not and never can be enough to supply a proper -support for children, in addition to the support the mothers ought -themselves to have. Consequently when children are in whole or in part -lodged, fed, clothed, “educated,” and put to service out of the £50 -a-year of the head-nurse, or out of the 12_s._ a-week of the nurse, -the mother either stints herself of proper food, proper strong drink -(we deal with practice not with theory), proper warm clothing, for the -children’s sake, or she supplies the deficiency by improper means. If -the nurse cannot afford to live well and abstains from dishonesty, one -of two things infallibly happens--either she takes to drink, as the -fallacious support of an exhausted frame, or her strength fails and -she breaks down, after a few months’, sometimes a few years’ struggle. -When once she has taken to drink, one of two things invariably follows -(dishonesty may be presumed to ensue upon, though it often does not -precede habits of drink); she is or becomes unguarded, and is soon -found out, and sinks into the miserable second and far too numerous -class of characterless hospital nurses, unless drink shortly finishes -her; or, in the other case, she is cautious and guarded--she then -becomes sly, dishonest, and thoroughly venal; she extorts gifts and -takes bribes from her patients and their friends--and the friends of -hospital patients, like others, are of various kinds; she commits -constant acts of petty but often most dangerous dishonesty, possibly -remaining an efficient and clever nurse, sometimes a favourite -nurse; and, so far as regards the crime which has taken the name of -immorality, a moral woman. A certain proportion of nurses are all the -above, excepting drink; for though, almost without exception, every -nurse who drinks takes bribes, some take bribes and do not drink. - -Of course widows and unmarried women who are not mothers do the above -things; but there cannot be a doubt of the additional and terrible -temptation to women burdened with children, to make money in various -ways out of their patients. Even in the most favourable cases (and it -is to be feared they are few) where the real good principle of the -mother restrains her from venality, there are still serious objections. -The time when a nurse can go out must necessarily be comparatively very -limited. The time that is enough for the moderate demands of friendship -or acquaintance is miserably insufficient for the natural yearnings -of the mother, especially if the children are young and helpless. The -consequence is that, either openly or by stealth, she goes to them -or has them brought to her at unallowed times; or, if the rules of -the hospital are lax as to visitors, the children are perpetually -with her: and let it be remembered, that the head-nurse’s room or -rooms are usually at the entrance of the ward, that being infinitely -the best place. It is difficult to say whether such a practice is -most objectionable as regards the children, or the patients, or the -hospital; and whether it is most objectionable when the children are -young, or adolescent, or grown up. It is objectionable in all and every -one of these cases. And no less objectionable is it in the case of the -assistant-nurse, who where the rules are lax will receive her children -either in the ward or in the nurses’ kitchen; or where they are strict, -will have the children come about the hospital and will meet them on -the sly. - -These things enter immensely, minute as they seem, into the discipline -of wards and of the hospital; and discipline means a great deal. - - -Sanitary objects. - -[Sidenote: Sanitary Objects.] - -[Sidenote: To discourage admission of women physically unfit.] - -A good many nurses enter hospital service who are quite unfit for it. -Often consumptive and ruptured women, those suffering from piles or -prolapsus, &c., present themselves, are admitted, struggle on for a -time, and break down with or without taking to drink. Undoubtedly, none -but strong healthy women should enter hospital service; the work will -wear them out quite soon enough, and some of the above complaints are -particularly liable to follow the work. - -Here again men of business must advise: the fund ought to have some -efficient though not infallible security as to the average good health -on joining of its members. Life Insurance rules as to this would be to -the point. - -Believe me, all these things are important. - - -Moral objects. - -[Sidenote: Moral Objects attainable.] - -The most difficult part of a difficult thing, only perhaps it is at the -same time the most important. - -[Sidenote: Need of Certificates.] - -I. I think that every nurse, before joining the Fund, should produce -a certificate from her matron, stating her to be a respectable woman. -In plain words, for the word respectable is certainly capable of most -wondrous extension, the certificate should state her to be, in the -matron’s belief, and to the best of her knowledge, a chaste woman, and -should specify whether she be spinster, wife, or widow. In either of -the latter cases, the marriage certificate, and in the last that of the -husband’s death, should accompany the matron’s. - -The matron’s certificate should, I consider, also state her to be -sober; and it would be a question whether it should not also state her -to have served for not less than a year in the hospital. The vagabond -class are a terrible drag upon the whole order; and some of these -might, from the novelty of the thing, be disposed to join it at first. - -II. An important question would be: Should the matron’s certificate -be renewed every year, and should the continuance of the nurse’s -membership depend on its production? Men of business must advise as to -this: I am quite unversed as to the details of Provident Societies. - -So far as regards the contributor’s own money, the contract once -entered into, must certainly be open to no further question; unless -there has been fraud in the preliminary statement on which it was -based. With regard to any _assistance_ that may be given the question -is different. - -III. The preliminary certificate I do consider very important, and the -subsequent ones, if they can be required. - -[Sidenote: Hospitals are not places for Penitents.] - -Until the hospitals are swept of the many mothers who are not wives, -now unhappily to be found in them, no real good can be done. Hospitals -are not, and never can be, places for “penitents;” and they are about -the most dangerous places where sham penitents can be. - -This is precisely what so many people of very different kinds cannot -or will not see; some from ignorance, some from knowledge, some from -the vague, silly, kind feeling which does such mischief when exerted on -practical matters. - -Suffer me to submit, without wearying patience by urging proof,-- - -i. That real penitents are wrongly placed in hospital service, because -their admission breaks down the standard which respectable women -who are hospital nurses feel (quite as keenly as their superiors -do in their own concerns) ought at once to restrain and to protect -those engaged in this very peculiar, very trying, and very exposed -work and life. (I have invariably observed that real penitents are -extra-prudish, and comparatively inefficient, in their hospital duty. -It will at once be perceived how inevitable this result is.) - -ii. That sincere but unconfirmed penitents, in addition to the above, -are most dangerously and improperly placed in a situation, to them, of -very peculiar trial. - -iii. That sham penitents, who unhappily abound, are dangerous -everywhere, extra-dangerous in hospitals, whether to superiors, -companions, or patients. - -iv. That although the class must ever be a very mixed one, it is most -important to have a standard. Let it be necessary for every nurse to -enter hospital with a good character, and to leave it on losing it. -Deception, hypocrisy, and successful guilt will be found in hospitals, -as elsewhere; but the class must be raised, and therefore improved, -by requiring the condition of good character; though guilt may -occasionally mask itself behind it. - -v. That although, for various and very differing reasons, the -certificates will be not unseldom untrustworthy, still the same -reasoning will apply. Upon the whole the tendency will be, by -requiring the condition of good character, to improve a class which, -containing, as it does, many well-conducted women, is sadly degraded -and contaminated by many vile ones. - -vi. I do not overlook the fact that honest certificates, especially if -annually renewed, might give the matrons some perplexity, from reasons -which need not be enlarged upon. Still, it seems to me, it would be -well worth trying. - - -IV. RULES TO BE FOLLOWED IN GIVING ASSISTANCE. - -Lastly. With regard to rules to be followed in giving assistance of -whatever kind. - -[Sidenote: Need of Advice with a view above all to Security.] - -It seems to me most important that we should obtain the opinions both -of hospital authorities and of a few able men of business, before -laying down rules. The whole matter is so essentially mixed up with the -tangible point of securing that the savings of these poor women should -avail them in their age, that it is urgent to have sound practical -advice as to letting nothing else imperil this. Security seems the -cardinal point of the whole, and that is a question for men of business -to answer. - -[Sidenote: Suggestions in detail.] - -The following suggestions toward obtaining it are offered. - -1. Security of invested savings to be the first and main thing to be -secured. Every other object should be subordinate to this. - -2. If we decide upon aiding their savings, let the security of this aid -be the main point. Invest all donations, annual or not; unless, should -any hospitals contribute annually, it might be fairly considered that -those contributions should be annually used. - -3. The aim should be to enable all hospital nurses, of good character, -to provide annuities for themselves, whether with or without -assistance. I think assistance will be necessary. - -4. Also to enable private and monthly nurses, and midwives, to do the -same, but without requiring the certificate of character, which, not to -be a mockery, ought to be an effectual one; and these persons are not -under a fixed superior. - -5. The pensions should, if it be possible, range from £13 or £15 a-year -to £50 a-year: say £13, £20, £30, £40, £50. - -6. Each hospital nurse to produce, before being allowed to join the -Fund, a certificate from her matron of chastity, general good conduct, -and a statement as to her being unmarried, married, or a widow, also -of her having served in one hospital not less than a year. Also -her marriage certificate, if a wife, and, if a widow, that and the -certificate of her husband’s death. In the event of her marriage or -re-marriage afterwards, the marriage-certificate to be produced, and -her altered name and the fact of her marriage duly recorded in the -Fund-book. (All this is important: aliases and fictitious marriages are -sadly common, in this class). - -7. If possible the certificate to be produced once a-year, and, on -its failure, the contributor to cease to have a title to assistance. -_Assistance_ in the form of an addition to the annuity may be made -_contingent_; the annuity which the premiums provide must be absolute: -most of the vices tend to shorten life, that is, to diminish the number -of annual payments, so that the fund would not be likely to incur -losses through them. - -8. Private and monthly nurses, and midwives, to produce, before being -allowed to join the Fund, a certificate from the Clergyman of the -parish, stating his belief that the subscriber is a respectable woman, -unmarried, married, or a widow; and in the latter cases, marriage and -death certificates. On any after-marriage or re-marriage, certificate -to be produced and altered name registered, on pain of expulsion from -the Fund. I should not attempt an annual certificate for this migratory -and “independent” class. - -9. Each nurse, before being allowed to join the Fund, to undergo -whatever examination is undergone by women before they are allowed -to effect Life Insurances, as to her being, at the date of joining, -a healthy woman. (Physicians ought to advise here as to inserting -provisions technical enough to be effective). - -10. Payments to be made weekly, monthly, quarterly, or annually, as -shall be advised. Amounts to run from 6_d._ or 1_s._ a week upwards. -For the plan to work, it ought to allow small payments on an ascending -scale. - -Many will only be able to make very small payments. - -Few will be able to make other than small payments. - -11. Payments made by a subscriber dying before attaining pension to be -devisable by will, and in case of intestacy, divided among next of kin. - -12. All possible safe curtailment of office expenses. - -13. Treasurers, or equivalent civil chiefs, of all hospitals that -subscribe, to be on the committee or council, or by whatever name the -equivalent may be termed. - - -V. PROSPECTS OF EVENTUAL SUPPORT. - -[Sidenote: Support by the Nurses themselves.] - -1. I believe that many head-nurses would thoroughly appreciate and -thankfully avail themselves of such a Fund. - -2. I think that many nurses would do the same, and, in time, many more. -Many cannot contribute to it; many will not. - -[Sidenote: Support from the Hospitals.] - -3. What aid the hospitals might be disposed to give I do not know. -I rather think none at first. If the thing works and works well, I -think they would probably contribute. But it must never be forgotten -that, excepting the endowed hospitals (the financial position of St. -George’s I do not know) the London hospitals find their income scarcely -sufficient, often not sufficient, to meet their expenditure. They -cannot be expected, nor would they perhaps be justified, to curtail -the number of the sick they relieve, in order to provide for the -superannuated nurses of those sick. It is true, however, that it might -enable them to get better nurses, which is surely economy. - -[Sidenote: Support from the Public in general.] - -4. I do not think that much lasting public interest is likely to attend -the Fund. The interest the public has, for the last few years, taken in -hospitals has been fictitious and almost mischievous. The public can -never really know what hospitals are, nor is it feasible or desirable -that it should. What eventual good may be done in them must be done -quietly and with great patience. What good may be done among the nurses -must be done by infusing, if it may be, a higher and truer spirit of -duty, by increased discipline and protection, and by ameliorating, in -some material points, among which the aim contemplated by the Fund -ranks very high, a condition which, to the end of time, must remain -severe, rough, dangerous, and in all senses trying. In the details of -all these things, most especially in all that concerns discipline, -which involves protection, the public, with the best intentions, will -only be an obstacle, and John Bull is sadly prone to pull up anything -he plants or anything he waters, to see how it grows. - -I think anything like appeals to or solicited support from the public -might, in various ways, seriously embarrass the Superintendent of a -very difficult and a very important though, at the same time, a very -humble branch of Her Majesty’s Service. I should be very anxious to -avoid this: it would be perpetuating the evils of publicity, and -sacrificing the greater good for the lesser. - -[Sidenote: Necessity of Advice.] - -5. In conclusion I again submit that it would be desirable to ascertain -from the hospital authorities above mentioned, and if possible from -three or four able and honest men accustomed to business, their opinion -as to the scope and details of this plan. In matters of spirit and of -discipline we should probably rely on other judgment; but these are -matters of business; and in which, without binding ourselves to follow, -it seems most important to obtain and to weigh, the opinions of men -long conversant with business. - -_January 23, 1858._ - - - - -NOTE AS TO THE NUMBER OF WOMEN EMPLOYED AS NURSES IN GREAT BRITAIN. - - -To show the importance of an Institute for Nurses, it must be stated -that 25,466 were returned, at the census of 1851, as nurses by -profession, exclusive of 39,139 nurses in domestic service,[24] and -2,882 midwives. The numbers of different ages are shown in table A, and -in table B their distribution over Great Britain. - -To increase the efficiency of this class, and to make as many of them -as possible the disciples of the true doctrines of health, would be a -great national work. - - - - -TABLES OF AGE AND DISTRIBUTION. - - -TABLE A. - -GREAT BRITAIN. - - AGES. - - - | NURSES. | Nurse (not | Nurse - | |Domestic Servant)|(Domestic Servant)| - +--------------+-----------------+------------------+ - | All Ages. | 25,466 | 39,139 | - +--------------+-----------------+------------------+ - |Under 5 Years.| ... | ... | - +--------------+-----------------+------------------+ - | 5 — | ... | 508 | - +--------------+-----------------+------------------+ - | 10 — | ... | 7259 | - +--------------+-----------------+------------------+ - | 15 — | ... | 10,355 | - +--------------+-----------------+------------------+ - | 20 — | 624 | 6537 | - +--------------+-----------------+------------------+ - | 25 — | 817 | 4174 | - +--------------+-----------------+------------------+ - | 30 — | 1118 | 2495 | - +--------------+-----------------+------------------+ - | 35 — | 1359 | 1681 | - +--------------+-----------------+------------------+ - | 40 — | 2223 | 1468 | - +--------------+-----------------+------------------+ - | 45 — | 2748 | 1206 | - +--------------+-----------------+------------------+ - | 50 — | 3982 | 1196 | - +--------------+-----------------+------------------+ - | 55 — | 3456 | 833 | - +--------------+-----------------+------------------+ - | 60 — | 3825 | 712 | - +--------------+-----------------+------------------+ - | 65 — | 2542 | 369 | - +--------------+-----------------+------------------+ - | 70 — | 1568 | 204 | - +--------------+-----------------+------------------+ - | 75 — | 746 | 101 | - +--------------+-----------------+------------------+ - | 80 — | 311 | 25 | - +--------------+-----------------+------------------+ - |85 and Upwards| 147 | 16 | - - -TABLE B. - -AGED 20 YEARS OF AGE, AND UPWARDS. - - - | | Nurse | Nurse | - | | (not | | - | | Domestic |(Domestic | - | | Servant) | Servant) | - +----------------------------+----------+----------+ - |Great Britain and Islands in| | | - | the British Seas. | 25,466 | 21,017 | - +----------------------------+----------+----------+ - | | | | - |England and Wales. | 23,751 | 18,945 | - +----------------------------+----------+----------+ - | | | | - |Scotland. | 1543 | 1922 | - +----------------------------+----------+----------+ - | | | | - |Islands in the British Seas. 172 | 150 | - +----------------------------+----------+----------+ - |1st Division. | | | - | London. | 7807 | 5061 | - +----------------------------+----------+----------+ - |2nd Division. | | | - | South Eastern. | 2878 | 2514 | - +----------------------------+----------+----------+ - |3rd Division. | | | - | South Midland. | 2286 | 1252 | - +----------------------------+----------+----------+ - |4th Division. | | | - | Eastern Counties. | 2408 | 959 | - +----------------------------+----------+----------+ - |5th Division. | | | - | South Western Counties. | 3055 | 1737 | - +----------------------------+----------+----------+ - |6th Division. | | | - | West Midland Counties. | 1225 | 2283 | - +----------------------------+----------+----------+ - |7th Division. | | | - | North Midland Counties. | 1303 | 957 | - +----------------------------+----------+----------+ - |8th Division. | | | - | North Western Counties. | 970 | 2135 | - +----------------------------+----------+----------+ - |9th Division. | | | - | Yorkshire. | 1074 | 1023 | - +----------------------------+----------+----------+ - |10th Division. | | | - | Northern Counties. | 402 | 410 | - +----------------------------+----------+----------+ - |11th Division. | | | - | Monmouth and Wales. | 343 | 614 | - - - - -NOTE AS TO TEACHING NURSING. - - -There is, at Madras, an Institution called the Military Female -Orphan Asylum, which trains 200 orphan girls, daughters of European -soldiers. They enter in infancy, and, as they attain a proper age, -they are married to soldiers or others. There is always an abundance -of applicants for them, and every endeavour is made to train them to -be useful soldiers’ wives. Dr. MacPherson, the excellent Principal -Medical Officer of the Turkish Contingent, when at Kertch, who is now -in charge of this Asylum, was the person, I believe, who introduced -amongst the senior girls, a system of training, to enable them to -officiate as nurses, an all-important element in their education. Below -is a syllabus of the theoretical branches taught, a practical knowledge -being acquired in the Hospital attached to the Institution. It would be -well if all women underwent a similar training. - - -_Course of Instruction for the Class of Sick Nurses, at the Military -Female Orphan Asylum._ - -Popular and Regional Anatomy and Physiology. - -A general knowledge of the human body, its various organs, and their -uses. - - -Sanitation. - -To be made acquainted with every subject relating to health, viz.: -Food--Exercise--Clothing--Cleanliness--Ventilation, &c. - - -Sick-room Management. - -Administration of Medicines, Application of Leeches, Lotions, -Fomentations, &c. Cleanliness, Darkening of the Apartment, Quietness, -&c. Cooking for the Sick. Diet for Infants. - - -Household Medicine and Surgery. - -To be taught how to act in emergencies, viz.: in cases of -Fainting--Hysterics--Convulsions of Children--Burns--Stings of -Insects--Wounds, &c.; and the simplest mode of treating the diseases -most commonly met with in India, viz.: - - External Inflammation, - Cholera, - Fever, - Dysentery, - Sore Eyes, - Bowel Complaints, - Cutaneous Eruptions. - -How to prepare Poultices, Fomentations, and Lotions. - ″ dress Wounds, Sores, and Blisters. - ″ apply Bandages. - -FOOTNOTES: - -[21] If the sisters and nurses, as a rule, were fed as well as lodged -at all the Hospitals, &c., the class of women would, in a very short -time, be entirely changed; this kind of employment would not then, with -the reduced money payment, be so much an object of desire to widows -with families, particularly if compelled to subscribe to a pension -fund, which should be compulsory. - -[22] At first it would be unwise to attempt too much. If extended -to Her Majesty’s dominions or private nurses, it would be almost -impossible to control abuses. - -[23] Every institution ought to provide for its nurses during illness, -but in fact it is not done. - -[24] A curious fact will be shown by Table A, viz., that 18,122 out of -39,139, or nearly one-half of all the Nurses, in domestic service, are -between 5 and 20 years of age. - - - - - -End of the Project Gutenberg EBook of Subsidiary Notes as to the -Introduction of Female Nur, by Florence Nightingale - -*** END OF THIS PROJECT GUTENBERG EBOOK INTRODUCTION OF FEMALE NURSING *** - -***** This file should be named 52877-0.txt or 52877-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/2/8/7/52877/ - -Produced by MWS, Fay Dunn and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive/American Libraries.) - - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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