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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.) - - - - - - -</pre> - - -<h1 class="faux">SUBSIDIARY NOTES AS TO THE INTRODUCTION OF FEMALE NURSING INTO MILITARY HOSPITALS IN PEACE AND IN WAR.</h1> - -<div class="transnote"> -<h2 class="nopagebreak" title="">Transcriber’s Note</h2> - -<p>There are three parts to this book, each starting with page 1.</p> - -<p>Footnotes have been moved to the end of each part.</p> - -<p>Variant spelling and inconsistent hyphenation are retained, a few -palpable printing errors have been corrected.</p> - -<p>To make some tables easier to read on small screens some words have been repeated, for example each occurence of the word “idem” in the key of the <a href="#plan" title="">plan of the <span lang="fr" xml:lang="fr">Lariboisière</span> Hospital</a> has been replaced by the words it represents.</p> - -<p>The key for the <a href="#plan" title="">plan of the <span lang="fr" xml:lang="fr">Lariboisière</span> Hospital</a> was originally -handwritten. No changes have been made to this for missing or -irregular use of accents or cedillas.</p> - -<p>The <a href="#TABLES_OF_AGE_AND_DISTRIBUTION" title="">tables of numbers of nurses</a> 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.</p> - -</div> - -<div class="cover"> - <img width="374" height="600" src="images/cover_small.jpg" alt="Cover" /> - <hr class="chap" /> -</div> - -<div class="chapter"> -<p class="title title1 gap">SUBSIDIARY NOTES</p> -<p class="title gap">AS TO THE</p> -<p class="title title2 gap">INTRODUCTION OF FEMALE NURSING</p> -<p class="title gap">INTO</p> -<p class="title title3 gap_less">MILITARY HOSPITALS</p> -<p class="title title4 gap">IN PEACE AND IN WAR.</p> -<hr class="short gap_more gap_none_under" /> -<p class="title title4 gothic">Presented by request to the Secretary of State for War.</p> -<hr class="short gap_none_under" /> -<p class="title title5 gap">LONDON:</p> -<p class="title title6">PRINTED BY HARRISON AND SONS, <abbr title="SAINT">ST.</abbr> MARTIN’S LANE, W.C.</p> -<p class="title title6">1858.</p> - -<hr class="chap" /> -</div> -<div class="chapter"> -<h2>CONTENTS.</h2> - -<table class="toc" summary="Contents"> -<tr><th colspan="3" class="pages">PAGES</th></tr> -<tr><td colspan="2" class="content"><span class="smcap">Digest</span></td><td class="pages"><a href="#Page_v" title="Page v">v–x</a></td></tr> -<tr class="new"><td colspan="3" class="content">Thoughts submitted by Order, concerning—</td></tr> -<tr><td class="no">I.</td><td class="content">Hospital Nurses</td><td class="pages"><a href="#Page_1a" title="Page 1">1–9</a></td></tr> -<tr><td class="no">II.</td><td class="content">Nurses in Civil Hospitals</td><td class="pages"><a href="#Page_9a" title="Page 9">9–14</a></td></tr> -<tr><td class="no">III.</td><td class="content">Nurses in Her Majesty’s Hospitals</td><td class="pages"><a href="#Page_15a" title="Page 15">15–19</a></td></tr> -<tr class="new"><td colspan="2" class="content">Systems of Female Nursing in the War Hospitals of the different Nations engaged in the Crimean War</td><td class="pages"><a href="#Page_19a" title="Page 19">19–26</a></td></tr> -<tr class="new"><td colspan="2" class="content">Note in regard to the Russian Nurses employed in the War Hospitals of the Crimea</td><td class="pages"><a href="#Page_26a" title="Page 26">26–28</a></td></tr> - -<tr class="new"><td colspan="3"><hr class="tb" /></td></tr> - -<tr class="new"><td colspan="2" class="content">Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and in War</td><td class="pages"><a href="#Page_1" title="Page 1">1–63</a></td></tr> -<tr class="new"><td colspan="2" class="content">Addenda with regard to Female Nursing in a Military Hospital on the Pavilion or <span lang="fr" xml:lang="fr">Lariboisière</span> Plan</td><td class="pages"><a href="#Page_63" title="Page 63">63–90</a></td></tr> -<tr class="new"><td colspan="2" class="content">Addenda as to Mixed Nursing, by Nurses and Orderlies, in Military Hospitals, on the Double Pavilion or <span lang="fr" xml:lang="fr">Vincennes</span> Plan</td><td class="pages"><a href="#Page_91" title="Page 91">91–117</a></td></tr> -<tr class="new"><td colspan="2" class="content">Additional Hints as to Ventilation, Hospital Floors, and Cautions in Ward-building suggested by the <span lang="fr" xml:lang="fr">Lariboisière</span> Hospital</td><td class="pages"><a href="#Page_118" title="Page 118">118–127</a></td></tr> -<tr class="new"><td colspan="2" class="content">Note on Contagion and Infection</td><td class="pages"><a href="#Page_128" title="Page 128">128–132</a></td></tr> -<tr class="new"><td colspan="2" class="content"><span class="pagenum"><a name="Page_iv" id="Page_iv">[iv]</a></span>Note on Observations by the Principal Medical Officer of the Army in the East</td><td class="pages"><a href="#Page_132" title="Page 132">132, 133</a></td></tr> - -<tr class="new"><td colspan="3"><hr class="tb" /></td></tr> - -<tr class="new"><td colspan="2" class="content">Thoughts submitted as to an Eventual Nurses’ Provident Fund</td><td class="pages"><a href="#Page_1p" title="Page 1">1–19</a></td></tr> -<tr class="new"><td colspan="2" class="content">Note as to the Number of Women employed as Nurses in Great Britain</td><td class="pages"><a href="#Page_20p" title="Page 20">20, 21</a></td></tr> -<tr class="new"><td colspan="2" class="content">Note as to Teaching Nursing</td><td class="pages"><a href="#Page_22" title="Page 22p">22, 23</a></td></tr> -</table> - -<hr class="chap" /> -</div> -<div class="chapter"> - -<h2>ILLUSTRATION.</h2> - -<table summary="Illustrations"> -<tr class="new"><td colspan="2" class="content">Plan of the <span lang="fr" xml:lang="fr">Lariboisière</span> Hospital at Paris</td><td class="pages">p. <a href="#Page_63" title="Page 63">63</a></td></tr> -</table> - -<hr class="chap" /> -</div> -<div class="chapter"> - -<h2>DIGEST.</h2> - -<p class="pagenum"><a name="Page_v" id="Page_v">[v]</a></p> - -<table class="digest" summary="Digest First Part"> -<tr><th colspan="3" class="pages">PAGES</th></tr> -<tr class="new"><td colspan="2" class="content">THOUGHTS SUBMITTED BY ORDER</td><td class="pages"><a href="#Page_1a" title="Page 1">1–28</a></td></tr> -<tr><td colspan="3" class="subtitle">CONCERNING</td></tr> -<tr><td class="no">I.</td><td class="content"><span class="smcap">Hospital Nurses.</span></td><td class="pages"> </td></tr> -<tr><td class="no">II.</td><td class="content"><span class="smcap">Nurses in Civil Hospitals.</span></td><td class="pages"> </td></tr> -<tr><td class="no">III.</td><td class="content"><span class="smcap">Nurses in Her Majesty’s Hospitals.</span></td></tr> -<tr class="new"><td class="no pad">I.</td><td class="content">Hospital Nurses</td><td class="pages"><a href="#Page_1a" title="Page 1">1–9</a></td></tr> -<tr><td class="no"> </td><td class="content">Twenty Observations on how to improve Hospital - Nursing.</td><td class="pages"> </td></tr> -<tr class="new"><td class="no pad">II.</td><td class="content">Nurses in Civil Hospitals</td><td class="pages"><a href="#Page_9a" title="Page 9">9–14</a></td></tr> -<tr><td class="no"> </td><td class="content">Twenty-three Heads for Regulations as to Nursing in - Civil Hospitals.</td><td class="pages"> </td></tr> -<tr class="new"><td class="no pad">III.</td><td class="content">Nurses in Her Majesty’s Hospitals</td><td class="pages"><a href="#Page_15a" title="Page 15">15–19</a></td></tr> -<tr><td class="no"> </td><td class="content">Twenty-two suggestions in the event of the introduction - of Female Nursing into Military Hospitals.</td><td class="pages"> </td></tr> -<tr class="new"><td colspan="2" class="content in">Various systems of Female Nursing during the Crimean War - in the Military Hospitals</td><td class="pages"><a href="#Page_19a" title="Page 19">19–28</a></td></tr> -<tr><td colspan="2" class="content in2">Of the French and Sardinians</td><td class="pages"><a href="#Page_19a" title="Page 19">19–22</a></td></tr> -<tr><td colspan="2" class="content in3">Russians</td><td class="pages"><a href="#Page_22a" title="Page 22">22, 23</a>, <a href="#Page_26a" title="Page 26">26–28</a></td></tr> -<tr><td colspan="2" class="content in3">English</td><td class="pages"><a href="#Page_23a" title="Page 23">23</a></td></tr> - -<tr class="new"><td colspan="2" class="content in">Proposed Duties of Female Nurses in Military General - Hospitals</td><td class="pages"><a href="#Page_23a" title="Page 23">23, 24</a></td></tr> -<tr><td colspan="2" class="content in">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</td><td class="pages"><a href="#Page_24a" title="Page 24">24–26</a></td></tr> -<tr class="new"><td colspan="2" class="content in"><span class="smcap">Note in regard to the Russian Nurses employed in - the War-Hospitals of the Crimea</span></td><td class="pages"><a href="#Page_26a" title="Page 26">26–28</a></td></tr> -</table> - -<hr class="tb" /> - -<p class="pagenum"><a name="Page_vi" id="Page_vi">[vi]</a></p> - -<table class="digest continued" summary="Digest Second Part"> -<tr class="new"><td colspan="2" class="content">SUBSIDIARY NOTES AS TO THE INTRODUCTION OF FEMALE NURSING - INTO MILITARY HOSPITALS IN PEACE AND IN WAR</td><td class="pages"><a href="#Page_1" title="Page 1">1–133</a></td></tr> -<tr class="new"><td class="no pad">I.</td><td class="content">Five Conditions essential to this service</td><td class="pages"><a href="#Page_1" title="Page 1">1–3</a></td></tr> -<tr class="new"><td class="no pad">II.</td><td class="content">Our Nurses were of four kinds</td><td class="pages"><a href="#Page_3" title="Page 3">3</a></td></tr> -<tr><td class="no"> </td><td class="content">Absolute subordination to the Medical Officer as to - Medical Orders essential and practised by us</td><td class="pages"><a href="#Page_4" title="Page 4">4</a></td></tr> -<tr class="new"><td class="no pad">III.</td><td class="content">1. Qualified subordination essential of - Superintendent-General to Director-General and - Principal Medical Officer</td><td class="pages"><a href="#Page_4" title="Page 4">4–6</a></td></tr> -<tr><td class="no"> </td><td class="content">2. Also of Matron and Nurses to Principal Medical - Officer and Staff-Surgeons</td><td class="pages"><a href="#Page_6" title="Page 6">6, 7</a></td></tr> -<tr><td class="no"> </td><td class="content">3. Female service can only be introduced gradually, - and introduction regulated by Director-General</td><td class="pages"><a href="#Page_7" title="Page 7">7–9</a></td></tr> -<tr class="new"><td class="no pad">IV.</td><td class="content">1. Shall Roman Catholic Sisters be introduced?</td><td class="pages"><a href="#Page_9" title="Page 9">9, 10</a></td></tr> -<tr><td class="no"> </td><td class="content">2. Or Anglican Sisters?</td><td class="pages"><a href="#Page_10" title="Page 10">10</a></td></tr> -<tr><td class="no"> </td><td class="content">3. Power of Police in Civil Hospitals</td><td class="pages"><a href="#Page_11" title="Page 11">11</a></td></tr> -<tr><td class="no"> </td><td class="content in-1"><span class="ditto">Power of Police in </span>Military <span class="ditto">Hospitals</span></td><td class="pages"><a href="#Page_12" title="Page 12">12–15</a></td></tr> -<tr><td class="no"> </td><td class="content">4. Pay and Rations of Nurses</td><td class="pages"><a href="#Page_15" title="Page 15">15–20</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">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</td><td class="pages"><a href="#Page_17" title="Page 17">17–20</a></td></tr> -<tr><td class="no"> </td><td class="content">5. Washing to be “put out”</td><td class="pages"><a href="#Page_20" title="Page 20">20, 21</a></td></tr> -<tr><td class="no"> </td><td class="content">6. Cleaning their own Rooms</td><td class="pages"><a href="#Page_21" title="Page 21">21–23</a></td></tr> -<tr><td class="no"> </td><td class="content">7. Nurses to keep keys of closet in Wards</td><td class="pages"><a href="#Page_23" title="Page 23">23</a></td></tr> -<tr><td class="no"> </td><td class="content">8. Pay, dress, and duties of Matrons</td><td class="pages"><a href="#Page_24" title="Page 24">24–28</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">More properly named Superintendents</td><td class="pages"><a href="#Page_27" title="Page 27">27</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Lady Volunteers had better begin by being Nurses, - not Superintendents <i>ex-officio</i></td><td class="pages"><a href="#Page_28" title="Page 28">28</a></td></tr> -<tr><td class="no"> </td><td class="content">9. Sundry Regulations as to Nurses</td><td class="pages"><a href="#Page_29" title="Page 29">29–31</a></td></tr> -<tr><td class="no"> </td><td class="out">10. Have the Patients’ Diets sent hot, and ready - divided, from kitchen</td><td class="pages"><a href="#Page_31" title="Page 31">31</a></td></tr> -<tr><td class="no"> </td><td class="out">11. What Ward duties the Nurses should do themselves</td><td class="pages"><a href="#Page_31" title="Page 31">31</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">And why</td><td class="pages"><a href="#Page_32" title="Page 32">32, 33</a></td></tr> -<tr><td class="no"> </td><td class="content">Patients should not be made quasi Orderlies</td><td class="pages"><a href="#Page_34" title="Page 34">34</a></td></tr> -<tr><td class="no"> </td><td class="content">Visitors in Military Hospitals</td><td class="pages"><a href="#Page_35" title="Page 35">35</a></td></tr> -<tr><td class="no"> </td><td class="out">12. Regulation-Number of Orderlies—depends on the - size of wards whether sufficient</td><td class="pages"><a href="#Page_35" title="Page 35">35–41</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">What is the regulation-attendance in Naval - Hospitals</td><td class="pages"><a href="#Page_37" title="Page 37">37</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">What in Civil Hospitals</td><td class="pages"><a href="#Page_38" title="Page 38">38</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Comparative Cost of Nursing in larger and smaller - wards</td><td class="pages"><a href="#Page_39" title="Page 39">39–41</a></td></tr> -<tr><td class="no"> </td><td class="out">13. Hospital floors - <span class="pagenum"><a name="Page_vii" id="Page_vii">[vii]</a></span></td><td class="pages"><a href="#Page_42" title="Page 42">42–51</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Sanitary necessities</td><td class="pages"><a href="#Page_42" title="Page 42">42</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Trial of Hospital floors, oiled and polished with - “<i>laque</i>” as in Berlin Hospitals, recommended on - sanitary grounds and for ease of cleaning</td><td class="pages"><a href="#Page_43" title="Page 43">43–51</a></td></tr> -<tr><td class="no"> </td><td class="out">14. Ventilation of Wards</td><td class="pages"><a href="#Page_51" title="Page 51">51–52</a></td></tr> -<tr><td class="no"> </td><td class="out">15. Special Wards, whether desirable or not</td><td class="pages"><a href="#Page_53" title="Page 53">53–54</a></td></tr> -<tr><td class="no"> </td><td class="out">16. Opinion as to Superintendent-General paying - Nurses’ wages, and as to Governor’s jurisdiction - over Nurses</td><td class="pages"><a href="#Page_54" title="Page 54">54–56</a></td></tr> -<tr><td class="no"> </td><td class="out">17. Wages and Pensions of Nurses</td><td class="pages"><a href="#Page_56" title="Page 56">56–60</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Three rules in raising Wages</td><td class="pages"><a href="#Page_56" title="Page 56">56</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Five general principles as to Wages and Pensions</td><td class="pages"><a href="#Page_58" title="Page 58">58</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Six applications of the foregoing principles</td><td class="pages"><a href="#Page_58" title="Page 58">58, 59</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Seven heads for Regulations as to Nurses’ Wages - and Pensions</td><td class="pages"><a href="#Page_59" title="Page 59">59, 60</a></td></tr> -<tr><td class="no"> </td><td class="out">18. Proportion of Nurses to Patients</td><td class="pages"><a href="#Page_61" title="Page 61">61, 62</a></td></tr> -<tr><td class="no"> </td><td class="out">19. Precautions in sending Nurses on Foreign Service</td><td class="pages"><a href="#Page_62" title="Page 62">62</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Hospital Laundries</td><td class="pages"><a href="#Page_63" title="Page 63">63</a></td></tr> -<tr class="new"><td colspan="2" class="content"><span class="smcap">Addenda, with regard to Female Nursing in a Military - Hospital on the Pavilion, or <span lang="fr" xml:lang="fr">Lariboisière</span> Plan</span></td><td class="pages"><a href="#Page_63" title="Page 63">63–90</a></td></tr> -<tr class="new"><td class="no pad">I.</td><td class="content">Four conditions to be considered in adopting the - Pavilion Plan</td><td class="pages"><a href="#Page_63" title="Page 63">63</a></td></tr> -<tr><td class="no"> </td><td class="content">1. Economy of attendance</td><td class="pages"><a href="#Page_64" title="Page 64">64</a></td></tr> -<tr><td class="no"> </td><td class="content">2. Facility of supervision</td><td class="pages"><a href="#Page_65" title="Page 65">65</a></td></tr> -<tr><td class="no"> </td><td class="content">3. Desirableness of <em>doubling</em> the Pavilion, - in a Military Hospital, in order to give to each - Nurse but one floor to serve</td><td class="pages"><a href="#Page_65" title="Page 65">65</a></td></tr> -<tr><td class="no"> </td><td class="content">4. Nurse to sleep near her Ward</td><td class="pages"><a href="#Page_66" title="Page 66">66</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Importance of lighting by gas</td><td class="pages"><a href="#Page_67" title="Page 67">67</a></td></tr> -<tr class="new"><td class="no pad">II.</td><td class="content">1. One Nurse must serve the whole Pavilion, in a - Military Hospital, if <em>single</em> Pavilions be - adopted</td><td class="pages"><a href="#Page_68" title="Page 68">68</a></td></tr> -<tr><td class="no"> </td><td class="content">2. Nurses’ day in such a Pavilion</td><td class="pages"><a href="#Page_68" title="Page 68">68, 69</a></td></tr> -<tr><td class="no"> </td><td class="content">3. What the responsibility of Nurses is for</td></tr> -<tr><td class="no"> </td><td class="content">discipline of Ward or Pavilion</td><td class="pages"><a href="#Page_70" title="Page 70">70, 71</a></td></tr> -<tr><td class="no"> </td><td class="content">4. Importance of Lifts</td><td class="pages"><a href="#Page_71" title="Page 71">71</a></td></tr> -<tr class="new"><td class="no pad">III.</td><td class="content">1. “Casualty” Cases should be in a completely - appointed set of Wards, apart</td><td class="pages"><a href="#Page_72" title="Page 72">72</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">And why</td><td class="pages"><a href="#Page_73" title="Page 73">73</a></td></tr> -<tr><td class="no"> </td><td class="content">2. Restraint or non-restraint in Violent Cases</td><td class="pages"><a href="#Page_74" title="Page 74">74</a></td></tr> -<tr class="new"><td class="no pad">IV.</td><td class="content">Simplicity of Construction essential to Discipline<span class="pagenum"><a name="Page_viii" id="Page_viii">[viii]</a></span></td><td class="pages"><a href="#Page_75" title="Page 75">75</a></td></tr> -<tr><td class="no"> </td><td class="content">Polished impervious Walls.</td></tr> -<tr><td class="no"> </td><td class="content">Covered Exercising Place.</td></tr> -<tr><td class="no"> </td><td class="content">Reserve Wards</td><td class="pages"><a href="#Page_76" title="Page 76">76</a></td></tr> -<tr class="new"><td class="no pad">V.</td><td class="content">Nurses’ Meals to be sent them Cooked</td><td class="pages"><a href="#Page_76" title="Page 76">76</a></td></tr> -<tr class="new"><td class="no pad">VI.</td><td class="content">Arrangements for a Pavilion and its Wards</td><td class="pages"><a href="#Page_77" title="Page 77">77–90</a></td></tr> -<tr><td class="no"> </td><td class="content">2. Where should Wardmaster sleep?</td><td class="pages"><a href="#Page_77" title="Page 77">77</a></td></tr> -<tr><td class="no"> </td><td class="content">3. And Orderlies sleep?</td><td class="pages"><a href="#Page_77" title="Page 77">77</a></td></tr> -<tr><td class="no"> </td><td class="content">4. And dine?</td><td class="pages"><a href="#Page_78" title="Page 78">78</a></td></tr> -<tr><td class="no"> </td><td class="out1">7, 8, Scullery to each Ward, and what to be done in it</td><td class="pages"><a href="#Page_79" title="Page 79">79</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Poultice-making</td><td class="pages"><a href="#Page_79" title="Page 79">79</a></td></tr> -<tr><td class="no"> </td><td class="content">9. Presses in Ward</td><td class="pages"><a href="#Page_80" title="Page 80">80, 81</a></td></tr> -<tr><td class="no"> </td><td class="out">10. Nurses’ Room</td><td class="pages"><a href="#Page_82" title="Page 82">82</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Lavatory, Water-Closet, Sink</td><td class="pages"><a href="#Page_83" title="Page 83">83</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Baths</td><td class="pages"><a href="#Page_84" title="Page 84">84</a></td></tr> -<tr><td class="no"> </td><td class="out">11. Summary of arrangements</td><td class="pages"><a href="#Page_85" title="Page 85">85</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Scullery Appurtenances</td><td class="pages"><a href="#Page_86" title="Page 86">86</a></td></tr> -<tr><td class="no"> </td><td class="out">12. Nurses’ Sleeping Quarters</td><td class="pages"><a href="#Page_86" title="Page 86">86</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Ward for Sick Nurses</td><td class="pages"><a href="#Page_87" title="Page 87">87</a></td></tr> -<tr><td class="no"> </td><td class="out">13. Classification of Patients</td><td class="pages"><a href="#Page_88" title="Page 88">88</a></td></tr> -<tr><td class="no"> </td><td class="out">14. Nurses to be called by their Wards</td><td class="pages"><a href="#Page_88" title="Page 88">88</a></td></tr> -<tr><td class="no"> </td><td class="out">15. Foul Linen</td><td class="pages"><a href="#Page_88" title="Page 88">88</a></td></tr> -<tr><td class="no"> </td><td class="out">16. Washing Bandages</td><td class="pages"><a href="#Page_89" title="Page 89">89</a></td></tr> -<tr><td class="no"> </td><td class="out">17. Splints, <abbr title="etcetera">&c.</abbr>, where to be kept</td><td class="pages"><a href="#Page_89" title="Page 89">89</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Cotton Lint never to be used</td><td class="pages"><a href="#Page_89" title="Page 89">89</a></td></tr> -<tr><td class="no"> </td><td class="out">18. Classification of Nurses</td><td class="pages"><a href="#Page_90" title="Page 90">90</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Superintendent’s Store Room</td><td class="pages"><a href="#Page_90" title="Page 90">90</a></td></tr> -<tr class="new"><td colspan="2" class="content"><span class="smcap">Addenda as to Mixed Nursing by Nurses and Orderlies - in Military Hospitals on the Double Pavilion - Plan</span></td><td class="pages"><a href="#Page_91" title="Page 91">91–117</a></td></tr> -<tr class="new"><td class="no pad">I.</td><td class="content"><span class="smcap">Orderlies’ Duties</span></td><td class="pages"><a href="#Page_91" title="Page 91">91–108</a></td></tr> -<tr><td class="no"> </td><td class="content">Proportion of Nurses, Ward Masters, and Orderlies to - Sick</td><td class="pages"><a href="#Page_91" title="Page 91">91–93</a></td></tr> -<tr><td class="no"> </td><td class="content">Wine to be always administered by Nurse</td><td class="pages"><a href="#Page_93" title="Page 93">93</a></td></tr> -<tr><td class="no"> </td><td class="content">Orderlies—their Duties vary according to - appurtenances of Ward</td><td class="pages"><a href="#Page_94" title="Page 94">94</a></td></tr> -<tr><td class="no"> </td><td class="content">If Hot and Cold Water are laid on, and there are - Lifts, one Orderly’s Service saved to each 30 Sick</td><td class="pages"><a href="#Page_94" title="Page 94">94, 95</a></td></tr> -<tr><td class="no"> </td><td class="content">Night-Duty of Orderlies</td><td class="pages"><a href="#Page_95" title="Page 95">95–108</a></td></tr> -<tr><td class="no"> </td><td class="content">Scheme of Night-Service for three Orderlies watching - by turns</td><td class="pages"><a href="#Page_96" title="Page 96">96, 97</a></td></tr> -<tr><td class="no"> </td><td class="content"><span class="pagenum"><a name="Page_ix" id="Page_ix">[ix]</a></span>Exercise for Orderlies</td><td class="pages"><a href="#Page_97" title="Page 97">97</a></td></tr> -<tr><td class="no"> </td><td class="content">Night Refreshment for Orderlies</td><td class="pages"><a href="#Page_98" title="Page 98">98, 99</a></td></tr> -<tr><td class="no"> </td><td class="content">Where are the Night Orderlies to sleep?</td><td class="pages"><a href="#Page_100" title="Page 100">100</a></td></tr> -<tr><td class="no"> </td><td class="content">Comparative Merits of different Systems of Night - Nursing in Home and in Foreign Hospitals</td><td class="pages"><a href="#Page_101" title="Page 101">101–3</a></td></tr> -<tr><td class="no"> </td><td class="content">An Assistant Ward Master should go round the Wards - at Night</td><td class="pages"><a href="#Page_104" title="Page 104">104</a></td></tr> -<tr><td class="no"> </td><td class="content">Extraordinary System of Night-Nursing in the Army - at present</td><td class="pages"><a href="#Page_105" title="Page 105">105–8</a></td></tr> -<tr class="new"><td class="no pad">II.</td><td class="content"><span class="smcap">Twelve Sundries in organizing a Military - Hospital</span></td><td class="pages"><a href="#Page_108" title="Page 108">108–114</a></td></tr> -<tr><td class="no"> </td><td class="content">1. Nurses’ Room</td><td class="pages"><a href="#Page_108" title="Page 108">108</a></td></tr> -<tr><td class="no"> </td><td class="content">2. Medical Officer’s Room</td><td class="pages"><a href="#Page_108" title="Page 108">108</a></td></tr> -<tr><td class="no"> </td><td class="content">3. Water-Closets</td><td class="pages"><a href="#Page_109" title="Page 109">109</a></td></tr> -<tr><td class="no"> </td><td class="content">4. Warm and Cold Water Supply</td><td class="pages"><a href="#Page_109" title="Page 109">109</a></td></tr> -<tr><td class="no"> </td><td class="content">5. Corridors</td><td class="pages"><a href="#Page_109" title="Page 109">109</a></td></tr> -<tr><td class="no"> </td><td class="content">6. Lobby</td><td class="pages"><a href="#Page_110" title="Page 110">110</a></td></tr> -<tr><td class="no"> </td><td class="content">7. Material of Ward Utensils</td><td class="pages"><a href="#Page_110" title="Page 110">110</a></td></tr> -<tr><td class="no"> </td><td class="content">8. Reserve Wards</td><td class="pages"><a href="#Page_111" title="Page 111">111–112</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Necessity of Annual Cleansing of the whole of a - Hospital</td></tr> -<tr><td class="no"> </td><td class="content">9. Occasional Revision of Rules</td><td class="pages"><a href="#Page_113" title="Page 113">113</a></td></tr> -<tr><td class="no"> </td><td class="out">10. Defect in German Organization of Nursing</td><td class="pages"><a href="#Page_113" title="Page 113">113</a></td></tr> -<tr><td class="no"> </td><td class="out">11. Nurses’ Exercise</td><td class="pages"><a href="#Page_113" title="Page 113">113</a></td></tr> -<tr><td class="no"> </td><td class="out">12. Number of Ward Masters</td><td class="pages"><a href="#Page_114" title="Page 114">114</a></td></tr> -<tr class="new"><td class="no pad">III.</td><td class="content"><span class="smcap">Regulations</span></td><td class="pages"><a href="#Page_114" title="Page 114">114–117</a></td></tr> -<tr><td class="no"> </td><td class="content">1. Deprivation of Visitors salutary in certain Wards</td><td class="pages"><a href="#Page_114" title="Page 114">114–16</a></td></tr> -<tr><td class="no"> </td><td class="content">2. Numbering Patients saves time</td><td class="pages"><a href="#Page_117" title="Page 117">117</a></td></tr> -<tr><td class="no"> </td><td class="content">3. Prohibition of Swearing</td><td class="pages"><a href="#Page_117" title="Page 117">117</a></td></tr> -<tr><td class="no"> </td><td class="content in-1">Conclusion</td><td class="pages"><a href="#Page_117" title="Page 117">117</a></td></tr> -<tr class="new"><td colspan="2" class="content"><span class="smcap">Additional Hints as to Pavilion Hospitals suggested by the - Construction of the <span lang="fr" xml:lang="fr">Lariboisière</span> Hospital at Paris</span></td><td class="pages"><a href="#Page_118" title="Page 118">118–127</a></td></tr> -<tr class="new"><td class="no pad">I.</td><td class="content">Ventilation</td><td class="pages"><a href="#Page_118" title="Page 118">118–120</a></td></tr> -<tr><td class="no"> </td><td class="content">Artificial Ventilation never freshens a Ward</td><td class="pages"> </td></tr> -<tr class="new"><td class="no pad">II.</td><td class="content">Oiled Boards versus Parquets</td><td class="pages"><a href="#Page_120" title="Page 120">120–124</a></td></tr> -<tr><td class="no"> </td><td class="content">Cleaning polished and oiled Boards much less - laborious, and freshens the Ward much more than - the <i>frottage</i> of <i>Parquets</i>.</td><td class="pages"> </td></tr> -<tr><td class="no"> </td><td class="content">Mode of Cleaning them at Berlin</td><td class="pages"><a href="#Page_122" title="Page 122">122–124</a></td></tr> -<tr class="new"><td class="no pad">III.</td><td class="content"><span class="pagenum"><a name="Page_x" id="Page_x">[x]</a></span>Ten Cautions in Building Hospital Pavilions</td><td class="pages"><a href="#Page_124" title="Page 124">124–127</a></td></tr> -<tr><td class="no"> </td><td class="content">Size of Wards. Our own Regimental Hospitals - extraordinary for their many holes and corners</td><td class="pages"><a href="#Page_125" title="Page 125">125</a></td></tr> -<tr class="new"><td colspan="2" class="content">Casualty Wards</td><td class="pages"><a href="#Page_126" title="Page 126">126</a></td></tr> -<tr class="new"><td colspan="2" class="content"><span class="smcap">“Contagion” and “Infection” Defined</span></td><td class="pages"><a href="#Page_128" title="Page 128">128–132</a></td></tr> -<tr><td class="no"> </td><td class="content">Idea of “Contagion” invented by Men to excuse - themselves for the neglect of all Sanitary - arrangements</td><td class="pages"><a href="#Page_128" title="Page 128">128</a></td></tr> -<tr><td class="no"> </td><td class="content">In the ordinary sense of the word, no such thing - as “Contagion”</td><td class="pages"><a href="#Page_129" title="Page 129">129</a></td></tr> -<tr><td class="no"> </td><td class="content">Nor as <em>inevitable</em> “Infection”</td><td class="pages"><a href="#Page_130" title="Page 130">130</a></td></tr> -<tr><td class="no"> </td><td class="content">“Infection” and Incapable Management, or Bad - Construction, convertible terms</td><td class="pages"><a href="#Page_131" title="Page 131">131</a></td></tr> -<tr><td class="no"> </td><td class="content">“Epidemics” do not <em>spread</em>—they develop - themselves in Constitutions made ripe for them - by Sanitary neglects</td><td class="pages"><a href="#Page_131" title="Page 131">131</a></td></tr> -<tr><td class="no"> </td><td class="content">Note on certain “Observations” by Sir John Hall </td><td class="pages"><a href="#Page_132" title="Page 132">132, 133</a></td></tr> -</table> - -<hr class="tb" /> - -<table class="digest continued" summary="Digest Third Part"> - -<tr class="new"><td colspan="2" class="content"><span class="smcap">Thoughts Submitted as to an Eventual Nurses’ - Provident Fund</span></td><td class="pages"><a href="#Page_1p" title="Page 1">1–19</a></td></tr> -<tr><td class="no"> </td><td class="content">Actual Wages and Prospects of Nurses</td><td class="pages"><a href="#Page_1p" title="Page 1">1–3</a></td></tr> -<tr><td class="no"> </td><td class="content">Some further Provision desirable</td><td class="pages"><a href="#Page_4p" title="Page 4">4–6</a></td></tr> -<tr><td class="no"> </td><td class="content">Of what Nature?</td><td class="pages"><a href="#Page_6p" title="Page 6">6–15</a></td></tr> -<tr><td class="no"> </td><td class="content">With regard to Kind?</td><td class="pages"><a href="#Page_6p" title="Page 6">6–8</a></td></tr> -<tr><td class="no"> </td><td class="content">With regard to Persons?</td><td class="pages"><a href="#Page_8p" title="Page 8">8</a></td></tr> -<tr><td class="no"> </td><td class="content">With regard to Objects?</td><td class="pages"><a href="#Page_9p" title="Page 9">9–15</a></td></tr> -<tr><td class="no"> </td><td class="content">Material Objects?</td><td class="pages"><a href="#Page_9p" title="Page 9">9–12</a></td></tr> -<tr><td class="no"> </td><td class="content">Children, in the case of Nurses, a Temptation to - Petty Dishonesty and taking Bribes</td><td class="pages"><a href="#Page_11p" title="Page 11">11, 12</a></td></tr> -<tr><td class="no"> </td><td class="content">Sanitary Objects?</td><td class="pages"><a href="#Page_13p" title="Page 13">13</a></td></tr> -<tr><td class="no"> </td><td class="content">Moral Objects?</td><td class="pages"><a href="#Page_13p" title="Page 13">13–15</a></td></tr> -<tr><td class="no"> </td><td class="content">Hospitals not places for Penitents</td><td class="pages"><a href="#Page_14p" title="Page 14">14, 15</a></td></tr> -<tr><td class="no"> </td><td class="content">Rules to be followed in giving Assistance</td><td class="pages"><a href="#Page_15p" title="Page 15">15–17</a></td></tr> -<tr><td class="no"> </td><td class="content">Prospects of Eventual Support</td><td class="pages"><a href="#Page_18p" title="Page 18">18, 19</a></td></tr> -<tr><td class="no"> </td><td class="content">Note as to the Number of Women employed as Nurses - in Great Britain</td><td class="pages"><a href="#Page_20p" title="Page 20">20, 21</a></td></tr> -<tr><td class="no"> </td><td class="content">Tables of Ages, <abbr title="etcetera">&c.</abbr></td><td class="pages"><a href="#Page_21p" title="Page 21">21</a></td></tr> -<tr><td class="no"> </td><td class="content">Note as to Teaching Nursing—Institution at Madras</td><td class="pages"><a href="#Page_22p" title="Page 22">22, 23</a></td></tr> -</table> - -<hr class="chap" /> -</div> -<div class="chapter"> -<p><span class="pagenum"><a name="Page_1a" id="Page_1a">[1]</a></span></p> - -<p class="private">PRIVATE AND CONFIDENTIAL.</p> - -<h2 title="Thoughts submitted by Order, concerning—"><span class="smcap">Thoughts submitted by order concerning</span></h2> -<ul class="list_sub_head"> -<li class="pad1"><a href="#I1" title="">I.</a> <span class="smcap">Hospital-Nurses.</span></li> -<li class="pad2"><a href="#II1" title="">II.</a> <span class="smcap">Nurses in Civil Hospitals.</span></li> -<li><a href="#III1" title="">III.</a> <span class="smcap">Nurses in Her Majesty’s Hospitals.</span></li> -</ul> -<hr class="tb" /> - -<h3 id="I1">I. <span class="smcap">Hospital-Nurses.</span></h3> - -<div class="sidenote">Definite -Objects: road -to them to be -found out.</div> - -<p>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.</p> - -<div class="sidenote">Presumed -Main Object.</div> - -<p>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.</p> - -<div class="sidenote">Presumed -Intentions.</div> - -<p>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,<span class="pagenum"><a name="Page_2a" id="Page_2a">[2]</a></span> -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.</p> - -<div class="sidenote">Religious -Orders.</div> - -<p>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.</p> - -<div class="sidenote">Their -Advantages.</div> - -<p>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.</p> - -<div class="sidenote">Advantages of -Hired Labour.</div> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_3a" id="Page_3a">[3]</a></span>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">Main Object of -Hospitals: -Distinct -Functions of -Hospital -Clergy and -Hospital -Nurses.</div> - -<p>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.</p> - -<div class="sidenote">Objections to -Amalgamating -Members of -Orders with -Secular Nurses.</div> - -<p>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 -<span class="pagenum"><a name="Page_4a" id="Page_4a">[4]</a></span>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.</p> - -<p>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.</p> - -<p>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 <i lang="fr" xml:lang="fr">Mère Générale</i> 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.</p> - -<div class="sidenote">Ladies</div> - -<p>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 -<span class="pagenum"><a name="Page_5a" id="Page_5a">[5]</a></span>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>In truth the only lady in a hospital should be the chief -of the women, whether called Matron or Superintendent. -<span class="pagenum"><a name="Page_6a" id="Page_6a">[6]</a></span>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.</p> - -<p>The quasi-spiritual dignity of Sisters of Mercy is a -thing <i>sui generis</i>. 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.</p> - -<div class="sidenote">Religion.</div> - -<p>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.</p> - -<div class="sidenote"><abbr title="Saint">St.</abbr> John’s -House.</div> - -<p><abbr title="Saint">St.</abbr> 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 -<span class="pagenum"><a name="Page_7a" id="Page_7a">[7]</a></span>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.</p> - -<div class="sidenote">Only Women -of -Unblemished -Character -should be -employed.</div> - -<p>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.</p> - -<div class="sidenote">Provision for -Old Age.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<div class="sidenote">Progressive -Increase of -Wages.</div> - -<p>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.</p> - -<div class="sidenote">Fixed Age for -Admission and -Retirement.</div> - -<p>14. There should be an age for the reception and for -<span class="pagenum"><a name="Page_8a" id="Page_8a">[8]</a></span>the retirement both of nurses and head-nurses. I think no -head-nurse should be under thirty.</p> - -<div class="sidenote">Simplicity of -Rules, -Definition of -Authorities.</div> - -<p>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.</p> - -<div class="sidenote">Economy.</div> - -<p>16. Economy is very important, with regard to the -eventual extension of the work.</p> - -<div class="sidenote">Commencement: -Training.</div> - -<p>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.</p> - -<div class="sidenote">Limits.</div> - -<p>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.</p> - -<div class="sidenote">Encumbrance -of Public -Support or -Patronage.</div> - -<p>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 -<span class="pagenum"><a name="Page_9a" id="Page_9a">[9]</a></span>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.</p> - -<div class="sidenote">Caution, Non-expectation, -and Trust.</div> - -<p>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.</p> - -<h3 id="II1">II. <span class="smcap">Nurses in Civil Hospitals.</span></h3> - -<div class="sidenote">Isolation of -each Head -Nurse and her -Nurses.</div> - -<p>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.</p> - -<div class="sidenote">All to Rank -and be Paid -alike, with -Progressive -Increase of -Wages.</div> - -<p>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.</p> - -<div class="sidenote">Night Nurses.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, they do it at night, sometimes<span class="pagenum"><a name="Page_10a" id="Page_10a">[10]</a></span> -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.</p> - -<div class="sidenote">Day Nurses.</div> - -<p>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.</p> - -<div class="sidenote">Nurses to -fetch nothing.</div> - -<p>5. All provisions, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<div class="sidenote">Patients to -fetch nothing.</div> - -<p>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.</p> - -<div class="sidenote">Scrubbing.</div> - -<p>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.</p> - -<div class="sidenote">Distribution of -Ward Work.</div> - -<p>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<span class="pagenum"><a name="Page_11a" id="Page_11a">[11]</a></span> -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, <abbr title="etcetera">&c.</abbr></p> - -<div class="sidenote">Hours of -Dressing and -Poulticing,</div> - -<p>9. Hours of morning and evening poulticing and -dressing to be fixed.</p> - -<div class="sidenote">and of -Medicine.</div> - -<p>10. Hours of administration of medicine, always except -at night given by head-nurse, to be fixed.</p> - -<div class="sidenote">Hours of -Exercise, and -Holidays.</div> - -<p>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.</p> - -<div class="sidenote">Permission of -Matron for -extra time out.</div> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_12a" id="Page_12a">[12]</a></span></p> - -<div class="sidenote">Place of -Exercise.</div> - -<p>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.</p> - -<div class="sidenote">Caution.</div> - -<p>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.</p> - -<div class="sidenote">Dress.</div> - -<p>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.</p> - -<div class="sidenote">Wages.</div> - -<p>16. I incline towards giving the head-nurses <abbr title="50 pounds">£50</abbr> -a-year, one or two rooms (one room with an alcove and -curtain would be best), fuel and light. The nurses<span class="pagenum"><a name="Page_13a" id="Page_13a">[13]</a></span> -lodging; the night-nurse a room to herself, the others -together; entire board, fuel, light, and good wages to be -decided upon.</p> - -<div class="sidenote">Furniture.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<div class="sidenote">Visitors.</div> - -<p>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 (<i>e. g.</i>, visitors to some head-nurses, kind -friends come to see how we are getting on, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>), -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<span class="pagenum"><a name="Page_14a" id="Page_14a">[14]</a></span> -week; and those hours and days should be strictly kept to. -In Military Hospitals a still more rigid rule will be necessary.</p> - -<div class="sidenote">Discharged -Patients.</div> - -<p>19. No discharged patients, however previously well-conducted, -should be allowed to visit the wards.</p> - -<div class="sidenote">Graduated -scale of -Pensions.</div> - -<p>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.</p> - -<div class="sidenote">No occasional -Wards.</div> - -<p>21. Have no occasional wards, or wards for accidental -and peculiar patients.</p> - -<div class="sidenote">Head-Nurse to -each Ward.</div> - -<p>22. Every ward, or set of wards, should be under a -head-nurse. Discipline is always defective under other -arrangements.</p> - -<div class="sidenote">Religious -Influence.</div> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_15a" id="Page_15a">[15]</a></span></p> - -<h3 id="III1">III. <span class="smcap">Nurses in Her Majesty’s Hospitals.</span></h3> - -<div class="sidenote">Two kinds of -Hospital -Service for -Females.</div> - -<p>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.</p> - -<div class="sidenote">The one: its -Advantages;</div> - -<p>2. “Their chief duties” may be “taking charge of the -linen and superintending the issue of extras.”</p> - -<p>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.</p> - -<div class="sidenote">The other: its -Advantages.</div> - -<p>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.</p> - -<p>That the experience of many surgeons is identical, their -conduct has proved; no other testimony, under present -circumstances, can rationally be expected from them.</p> - -<div class="sidenote">Both to be -Weighed.</div> - -<p>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.</p> - -<div class="sidenote">Practical -Superiority of -the Second.</div> - -<p>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<span class="pagenum"><a name="Page_16a" id="Page_16a">[16]</a></span> -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.</p> - -<div class="sidenote">Its real and -great -Difficulties.</div> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">Condense -numbers as -much as -possible.</div> - -<p>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.</p> - -<div class="sidenote">Only Head -Nurses.</div> - -<p>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.</p> - -<div class="sidenote">Classify the -Patients.</div> - -<p>9. The patients should be distinctly classed, though, -of course, this is not the Female Superintendent’s business.</p> - -<p><span class="pagenum"><a name="Page_17a" id="Page_17a">[17]</a></span></p> - -<p>There are many pros and cons to the formation of convalescent -wards.</p> - -<p>It is a question whether convalescent or chronic patients -require female nurses at all.</p> - -<p>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.</p> - -<div class="sidenote">Qualification -of Nurses.</div> - -<p>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.</p> - -<div class="sidenote">Wages.</div> - -<p>11. Their wages, I think, the same as those of head-nurses -in Civil Hospitals—certainly, not more.</p> - -<div class="sidenote">Pensions.</div> - -<p>12. Their pension on the same graduated scale.</p> - -<div class="sidenote">Rules.</div> - -<p>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.</p> - -<div class="sidenote">Duties.</div> - -<p>14. Their duties should be strictly defined, and be -consistent with the Code of Army Hospital Regulations, -the revision of which has been announced.</p> - -<div class="sidenote">Means of -Steadying -them.</div> - -<p>15. Give them plenty to do, and great responsibility—two -effectual means of steadying women.</p> - -<div class="sidenote">Lodging.</div> - -<p>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<span class="pagenum"><a name="Page_18a" id="Page_18a">[18]</a></span> -other, which might easily be contrived, this would probably -answer all purposes.</p> - -<div class="sidenote">Food.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<div class="sidenote">Opinion of -honest -Military -Authority -desirable.</div> - -<p>18. Could the honest opinions be had of a few good -Military and Surgical Authorities before beginning, it -would be good.</p> - -<div class="sidenote">Female Superintendent-General.</div> - -<p>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.</p> - -<div class="sidenote">Confidential -Reports.</div> - -<p>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.</p> - -<div class="sidenote">Permanency of -the System.</div> - -<p>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.</p> - -<div class="sidenote">Quietness.</div> - -<p>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<span class="pagenum"><a name="Page_19a" id="Page_19a">[19]</a></span> -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.</p> - -<h2 class="faux" title="Various Systems of Female Nursing compared."></h2> - -<hr class="short" /> -<div class="sidenote">Various -Systems of -Female -Nursing -compared.</div> - -<p>A very short comparison will here be made between the -methods of Female Nursing in the Military Hospitals of</p> - -<ul> -<li>Russia,</li> -<li>England,</li> -<li>France, and</li> -<li>Sardinia,</li> -</ul> - -<p class="noindent">as exemplified in the last War.</p> - -<div class="sidenote">French and -Sardinian -Hospital -Service.</div> - -<p>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.</p> - -<p>The essential characteristic of the French is, the importance -given in the field to the Divisional Hospital -Service over the Regimental.</p> - -<p>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<span class="pagenum"><a name="Page_20a" id="Page_20a">[20]</a></span> -in the field; those, where disease may possibly last for -months, to the General Hospitals at the base of operations.</p> - -<p>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.</p> - -<div class="sidenote">English.</div> - -<p>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.</p> - -<div class="sidenote">Russian.</div> - -<p>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.</p> - -<div class="sidenote">Female -Nurses.</div> - -<p>The adaptation of Female Nursing to the different -systems in the</p> - -<ul> -<li>French,</li> -<li>Sardinian,</li> -<li>Russian, and</li> -<li>English Armies</li> -</ul> - -<p class="noindent">has now to be noticed.</p> - -<div class="sidenote">Sardinian and -French -Female -Nurses.</div> - -<p>The Sardinians had Sisters of Charity, both in the -General Ambulances in the Crimea, and in the General -Hospitals on the Bosphorus.</p> - -<p>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 “<i lang="fr" xml:lang="fr">douceurs</i>,” the -administration of extras, the seeing to the cleanliness of<span class="pagenum"><a name="Page_21a" id="Page_21a">[21]</a></span> -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 <span lang="fr" xml:lang="fr">Sœur</span> or the Infirmier Major were in charge, -to see the duties about the patient properly executed, -was rather a problem.</p> - -<p>This was still more the case in the French Hospitals, -where the “<span lang="fr" xml:lang="fr">Sœur</span>” in the wards appeared more of a -“<span lang="fr" xml:lang="fr">consolatrice</span>” and an administratrix of extras: although, -out of the wards, her admirable housekeeping, both in the -kitchen and the linen-store, was predominant.</p> - -<p>The French “<span lang="fr" xml:lang="fr">Sœurs</span>” were not admitted to the Divisional -Ambulances in the front: it was whispered, because -of the corruption of the French <span lang="fr" xml:lang="fr">Intendance</span>, upon whom -they tacitly exercised a very inconvenient “surveillance.” -They served in all the General Hospitals at Constantinople; -and to their admirable services, <span lang="fr" xml:lang="fr"><abbr title="Monsieur">M.</abbr> Baudens, -Inspecteur-Général en Crimée</span>, has rendered an “<i lang="fr" xml:lang="fr">éclatant -témoignage</i>” in his “<cite class="plain" lang="fr" xml:lang="fr">Mission Médicale en Orient</cite>,” published -in the numbers of the “<cite class="plain" lang="fr" xml:lang="fr">Revue des Deux Mondes</cite>,” -of February 15, April 1, and June 1, 1857.</p> - -<p>In these French Hospitals of Constantinople, the -“<span lang="fr" xml:lang="fr">Sœurs</span>” appeared to do all the cooking for the sick -Officers and that of the extras for the men.</p> - -<p>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 -“<span lang="fr" xml:lang="fr">Sœurs</span>.”</p> - -<p>I have heard complaints made of this kind both by -Officers and men; and “<span lang="fr" xml:lang="fr">Sœurs</span>,” 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.</p> - -<p>There is such a difference however in different Hospitals,<span class="pagenum"><a name="Page_22a" id="Page_22a">[22]</a></span> -in time of war and of peace, <abbr title="etcetera">&c.</abbr>, that I would not be -understood to mean that any of these remarks apply -absolutely or generally, but only to Hospitals I have -seen.</p> - -<p>It may be as well to mention that, talking of “French” -and “Sardinian” Sisters, they all come from one “<span lang="fr" xml:lang="fr">Maison -Mère</span>,” that of the “<span lang="fr" xml:lang="fr">Filles de la Charité de S. Vincent -de Paule</span>,” at Paris. There is a “<span lang="fr" xml:lang="fr">Maison Succursale</span>,” -at Turin. But all are of the same Order, and under the -same head.</p> - -<p>Let me mention <span lang="fr" xml:lang="fr">Sœur Cordero</span>, 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.</p> - -<div class="sidenote">Russian.</div> - -<p>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 -<span class="pagenum"><a name="Page_23a" id="Page_23a">[23]</a></span>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, <abbr title="etcetera">&c.</abbr> The “felchers” are under a superior -“felcher,” and under the Medical Officers.</p> - -<p>There are female nurses, wives and widows of soldiers, -under the “Sisters,” who are generally, as has been -stated, widows of Officers.</p> - -<p>This appears the nearest approach to good organization -I have met with.</p> - -<p>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.</p> - -<div class="sidenote">English.</div> - -<p>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.</p> - -<div class="sidenote">Proposed -Duties of -Female -Nurses in -Military -Hospitals.</div> - -<p>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:</p> - -<p>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 -<span class="pagenum"><a name="Page_24a" id="Page_24a">[24]</a></span>should receive the orders of the latter, and always attend -him in his visits.</p> - -<p>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.</p> - -<div class="sidenote">Duties which -should be left -to men.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, <i>i. e.</i>, -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, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<p>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.</p> - -<p>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.”</p> - -<p>One man cannot do all these things.</p> - -<p>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.</p> - -<p>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.</p> - -<p>What Dr. Menzies declared, in his evidence as to the -<span class="pagenum"><a name="Page_25a" id="Page_25a">[25]</a></span>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.”</p> - -<p>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.</p> - -<p>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.</p> - -<p>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:—</p> - -<blockquote> - -<p>“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<i><abbr title="shilling">s.</abbr></i> 10<i><abbr title="pence">d.</abbr></i> pay per diem, and -an allowance of 4<i><abbr title="pence">d.</abbr></i> per diem as Hospital Orderly; at the same -<span class="pagenum"><a name="Page_26a" id="Page_26a">[26]</a></span>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<i><abbr title="shillings">s.</abbr></i> 10<i><abbr title="pence">d.</abbr></i> pay per diem.</p> - -<p>“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.</p> - -<p class="signed"> -“(Signed<span class="spread-out_date">)</span> -<span class="smcap">Thomas Longmore</span><span class="spread-out_date">,</span><br /> -“<i>Surgeon 19th Regiment</i>.” -</p> -</blockquote> - -<hr class="short" /> -<h2><span class="smcap">Note in Regard to the Russian Nurses Employed -in the War-Hospitals of the Crimea.</span></h2> - -<p>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—</p> - -<p>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.</p> - -<p>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.:</p> - -<p>(1.) The Sisters of the Elevation of the Cross.</p> - -<p>(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 <a href="#Page_22a" title="Page 22"><abbr title="pages">pp.</abbr> 22, 23, -above</a>.</p> - -<p><span class="pagenum"><a name="Page_27a" id="Page_27a">[27]</a></span></p> - -<p>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.</p> - -<p>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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr></p> - -<p>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 -<span class="pagenum"><a name="Page_28a" id="Page_28a">[28]</a></span>“Wirthinnen,” who looked after the diets, clean linen, <abbr title="etcetera">&c.</abbr>, -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-<i lang="de" xml:lang="de">Baracke</i> (hut) -was attached one sister of each of the above descriptions.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The <i lang="de" xml:lang="de">Transport Abtheilung</i> 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<a name="Anchor_1" id="Anchor_1" href="#Footnote_1" class="fnanchor" title="Go to footnote 1.">[1]</a> convoys of Sick -Transport from Simpheropol to Perekop, and provided the -sick with tea, sugar, clean linen, medical and surgical -appliances, <abbr title="etcetera">&c.</abbr>, on the way.</p> -<p><span class="pagenum"><a name="Page_1" id="Page_1">[1]</a></span></p> - -<div class="footnotes"> -<h3 title="">Footnote:</h3> - -<ul> - <li><p><a name="Footnote_1" id="Footnote_1"></a><a href="#Anchor_1">[1]</a> -According to Professor Pirogoff sick were almost daily sent from Simpheropol -to Perekop. They could not, therefore, be always accompanied by -Sisters.</p></li> -</ul> -</div> - -<hr class="short" /> -</div> - -<div class="chapter"> - -<h2 title="Subsidiary Notes as to the Introduction of Female -Nursing into Military Hospitals in Peace and in -War"><span class="smcap">Subsidiary Notes as to the Introduction of Female -Nursing into Military Hospitals in Peace and in -War.</span></h2> - -<p>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.</p> - -<h3 title="">I.</h3> - -<p>No one ought to undertake a matter of duty of this -kind without first obtaining the consent of the War Office to -five conditions.</p> - -<p>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.</p> - -<p>2. That it be made a point of honour, not of grace, with the -War Department, to submit to her any Report, confidential<a name="Anchor_2" id="Anchor_2" href="#Footnote_2" class="fnanchor" title="Go to footnote 2.">[2]</a> or -otherwise, made concerning the Female Nursing Staff; a condition, -without which it would be impossible to have respectable -women in the Military Service.</p> - -<p>3. That the powers of the Superintendent-General shall be -<span class="pagenum"><a name="Page_2" id="Page_2">[2]</a></span>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?).</p> - -<p>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.</p> - -<p>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.</p> - -<p>In March 1856 the following appeared in “General Orders.” -Had it but been seventeen months earlier how much it might -have saved!<a name="Anchor_3" id="Anchor_3" href="#Footnote_3" class="fnanchor" title="Go to footnote 3.">[3]</a> The definition of the Superintendent-General’s -powers and duties, therein contained, is all that is wanted to -prevent irregularities disastrous to the Service.</p> - -<p class="center"><span class="smcap">General Orders.</span></p> - -<p class="date"> -<i>March 1856.</i><br /> -</p> - -<p>“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.</p> - -<p><span class="pagenum"><a name="Page_3" id="Page_3">[3]</a></span></p> - -<p>“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.”</p> - -<h3 title="">II.<br /><i>Nurses.</i></h3> - -<p>1. Our Nurses were of four sorts.</p> - -<ul> -<li>Nuns.</li> -<li>Sisters (Anglican).</li> -<li>Ladies.</li> -<li>Nurses.</li> -</ul> - -<p>The Nuns were received not as Nuns, but as Nurses.</p> - -<p>Their (so called) training told sometimes against us; sometimes -for us. The same with the “Sisters” (Anglican).</p> - -<p>The Ladies were useful, exactly in proportion as they approached -the professional, and not the dilettante, mode of thought.</p> - -<p>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.</p> - -<p>2. There should always be a proportion of Nurses in Army -Hospitals</p> - -<ul> -<li>To preside in Extra Diet Kitchens,<a name="Anchor_4" id="Anchor_4" href="#Footnote_4" class="fnanchor" title="Go to footnote 4.">[4]</a></li> -<li><span class="ditto">To preside</span> in Linen Stores.</li> -<li>To teach the Orderlies to nurse in the Wards.</li> -</ul> - -<p>The proportion of Roman Catholic “<span lang="fr" xml:lang="fr">Sœurs</span>,” 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.</p> - -<p>Women in Military Hospitals should all be contracted servants, -whether Nuns, Ladies, or professional Nurses.</p> - -<p>There should be a retiring pension to each woman.</p> - -<p>3. Miss Nightingale took service on the ground of being -under the Principal Medical Officer, and, consequently, of not -<span class="pagenum"><a name="Page_4" id="Page_4">[4]</a></span>interfering with him.</p> - -<p>There was no <i>imperium in imperio</i> in her case.</p> - -<p>This exists in the case of the French “<span lang="fr" xml:lang="fr">Sœurs de Charité</span>,” -and existed in individual instances among the “Sisters” under -Miss Nightingale; <i>i. e.</i>, they gave articles of diet, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<p>This involved our only <em>answering</em> the Extra Diet Rolls in -our kitchens; not originating either in quantity or quality.</p> - -<p>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 <i>verbatim</i> -and <i>literatim</i>, 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.</p> - -<blockquote> - -<p>“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.</p> - -<p class="signed"> -“(Signed<span class="spread-out_date">)</span> -173. <span class="smcap">W. J. Northcott</span><span class="spread-out_date">,</span><br /> -“A.W.M., M S.C.” -</p> -</blockquote> - -<h3 title="">III.</h3> - -<div class="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.</div> - -<p>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<span class="pagenum"><a name="Page_5" id="Page_5">[5]</a></span> -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 <em>work</em> 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.</p> - -<p>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.</p> - -<p>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, -<span class="pagenum"><a name="Page_6" id="Page_6">[6]</a></span>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.</p> - -<p>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.</p> - -<p>The existence of these Regulations proved also a great -stumbling-block in the Castle Hospital, after the war-pressure -was over.</p> - -<p>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.</p> - -<div class="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.</div> - -<p>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.</p> - -<p>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 o<span class="pagenum"><a name="Page_7" id="Page_7">[7]</a></span>f 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 <em>say</em> 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.</p> - -<div class="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.</div> - -<p>3. Now, as to the introduction of Nurses into all General -Hospitals—this gets rid of many difficulties, but at a fearful -cost.</p> - -<p>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<a name="Anchor_5" id="Anchor_5" href="#Footnote_5" class="fnanchor" title="Go to footnote 5.">[5]</a> offered themselves, -<span class="pagenum"><a name="Page_8" id="Page_8">[8]</a></span>there are perhaps not many who could be recommended -for a <em>Military</em> Hospital. Some, who are very highly to be -thought of, would never bear transplanting into the <span lang="la" xml:lang="la"><i>res dura et</i> -<em class="plain">servitii</em> <i>novitas</i></span> of the Army Hospitals. The class from which -the Head-Nurses are mainly drawn, tradesmen’s and servants’ -widows, <abbr title="etcetera">&c.</abbr>, 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>i. e.</i>, -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<span class="pagenum"><a name="Page_9" id="Page_9">[9]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>If the Matron differ with the Principal Medical Officer, the -decision should rest with the Governor of the Hospital.</p> - -<h3 title="">IV.</h3> - -<p>As to some miscellaneous considerations, of no small importance—</p> - -<div class="sidenote">1. Roman-Catholic -Sisters?</div> - -<p>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 -<span class="pagenum"><a name="Page_10" id="Page_10">[10]</a></span>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.</p> - -<p>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, -(<i>not</i> 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.”</p> - -<div class="sidenote">2. Anglican -Sisters?</div> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">3. Whom is -the Nurse to -summon in -case of -disorderliness -in the Ward?</div> - -<p>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 -<span class="pagenum"><a name="Page_11" id="Page_11">[11]</a></span>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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, -<abbr title="etcetera">&c.</abbr>; 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 -<span class="pagenum"><a name="Page_12" id="Page_12">[12]</a></span>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 <em>into</em> 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.</p> - -<p>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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, of the ward, they have to -give orders to the Orderlies.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_13" id="Page_13">[13]</a></span>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.</p> - -<p>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.</p> - -<p>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.</p> -<p><span class="pagenum"><a name="Page_14" id="Page_14">[14]</a></span></p> -<p>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, <em>at first, at all events</em>, 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.</p> - -<p>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.</p> - -<p>A short definite rule should therefore be made, saying whom -the Nurse is to summon in the event of disorderliness in the -ward.</p> - -<p>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.</p> - -<p>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 -<span lang="fr" xml:lang="fr">Sœurs de <abbr title="Saint">St.</abbr> Vincent</span> 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 <span lang="fr" xml:lang="fr">Sœurs</span> to those of hired nurses—but they deprecate -either Sisters or any women in Military Hospitals. 1. -<span class="pagenum"><a name="Page_15" id="Page_15">[15]</a></span>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.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">4. Pay and -Rations.</div> - -<p>4. <span class="smcap">Pay and Rations.</span>—In the great Civil Hospitals the -Head-Nurses have, on an average, 50<i><abbr title="pounds">l.</abbr></i> 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<i><abbr title="shillings">s.</abbr></i> a-week, [<abbr title="31 pounds">£31</abbr> 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.</p> - -<p>Both Guy’s and <abbr title="Saint">St.</abbr> Bartholomew’s Hospitals now give partial -board to the Assistant-Nurses, and <abbr title="Saint">St.</abbr> Thomas’s is about -to adopt the same plan.</p> - -<p><abbr title="Saint">St.</abbr> Mary’s Hospital gives board to both Head and Assistant-Nurses.</p> - -<p>In the last war Her Majesty’s Nurses received, on an -<span class="pagenum"><a name="Page_16" id="Page_16">[16]</a></span>average, 18<i><abbr title="shillings">s.</abbr></i> a-week, lodging and board, fuel, light, and partial -clothing—18<i><abbr title="shillings">s.</abbr></i> a-week is 46<i><abbr title="pounds">l.</abbr></i> 16<i><abbr title="shillings">s.</abbr></i> yearly. Incorporated into -a permanent Service, and with a pension, they ought not to -receive the latter amount until after approved years of Service.</p> - -<p>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, <abbr title="etcetera">&c.</abbr> Going abroad is a regular part of the -Service undertaken.</p> - -<p>Any artificial inducements should be avoided; at the same -time their condition should be made a comfortable one. -Wages, say 20<i><abbr title="pounds">l.</abbr></i>, rising to 50<i><abbr title="pounds">l.</abbr></i> 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;<a name="Anchor_6" id="Anchor_6" href="#Footnote_6" class="fnanchor" title="Go to footnote 6.">[6]</a> 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, <abbr title="etcetera">&c.</abbr>, 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, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_17" id="Page_17">[17]</a></span></p><div class="sidenote">Shall Rations -be commutable -for Mess-money -in the -United -Kingdom?</div> - -<p>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:</p> - -<div class="sidenote">(1.) Because -such -commutation -allows greater -variety.</div> - -<p>(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 <em>the former can be done at no additional -cost or trouble to the Queen</em>.</p> - -<div class="sidenote">(2.) Because it -averts -complaints.</div> - -<p>(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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr></p> - -<p>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 -<i>vice</i> 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.</p> - -<p>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.</p> - -<p>Abroad in many cases, in war in all cases, rations would be -desirable. A fixed calculation as to expense should be -made.</p> -<p><span class="pagenum"><a name="Page_18" id="Page_18">[18]</a></span></p> -<p>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 <em>one</em> 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 “<em>draw</em>” 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.</p> - -<div class="sidenote">If not -commutable,</div> - -<p>Where, however, the system of rations must be adopted, -three ways remain of working it:—</p> - -<div class="sidenote">(1.) Shall the -Nurse cook -her own -Rations?</div> - -<p>(1.) Let each Nurse receive, and cook her own rations.</p> - -<div class="sidenote">(2.) Shall the -Matron cook -and send -them?</div> - -<p>(2.) Let the rations be delivered <i>en masse</i> to the Matron, -who has them cooked, sending her proportion to each Nurse.</p> - -<div class="sidenote">(3.) Shall the -<span class="pagenum"><a name="Page_19" id="Page_19">[19]</a></span>Matron have -each Nurse’s -Dinner cooked -for her, as she -likes best?</div> - -<p>(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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>en masse</i>, 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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_20" id="Page_20">[20]</a></span> -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.<a name="Anchor_7" id="Anchor_7" href="#Footnote_7" class="fnanchor" title="Go to footnote 7.">[7]</a></p> - -<div class="sidenote">Wages and -Mess-money -must be -distinct.</div> - -<p>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, <abbr title="etcetera">&c.</abbr></p> - -<p>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.</p> - -<div class="sidenote">5. Washing, -how to be -done? Rule -to compel the -Nurses to <em>put -it out</em>.</div> - -<p>5. <span class="smcap">Washing.</span>—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 -<span class="pagenum"><a name="Page_21" id="Page_21">[21]</a></span>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.</p> - -<div class="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.</div> - -<p>6. <span class="smcap">Cleaning their own rooms.</span>—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 <em>in</em> the -sitting-room, there is a sink, with water laid on, a little safe for -meat, <abbr title="etcetera">&c.</abbr>, 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 -<span class="pagenum"><a name="Page_22" id="Page_22">[22]</a></span>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 <em>must</em> grant -a <em>cabinet</em> between the two: this is <em>must</em>, not <em>may</em>. The Superintendent-General -must see to this herself, at first at all events: -there <em>is</em> 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.</p> - -<p>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 <i>sine quâ non</i>. 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 -<em>nursing proper</em> which ought to fall upon them, and not upon -the orderlies, their time can be better occupied than in cleaning -<span class="pagenum"><a name="Page_23" id="Page_23">[23]</a></span>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.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="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.</div> - -<p>7. Let there be in each ward a closet, or, better still, a -dresser,<a name="Anchor_8" id="Anchor_8" href="#Footnote_8" class="fnanchor" title="Go to footnote 8.">[8]</a> 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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, 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 <em>must</em> do, and it is much better she should not.</p> -<p><span class="pagenum"><a name="Page_24" id="Page_24">[24]</a></span></p> -<div class="sidenote">8. Matrons -200<i><abbr title="pounds">l.</abbr></i> per -annum, -Quarters, and -a Maid. -A woman for -the Linen, -ranking and -paid as a -Nurse, but -never entering -the wards.</div> - -<p>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 <i>cæteris paribus</i>, 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 <i>sine -quâ non</i>? 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 <em>nurses</em> must upon the whole be discouraged, -because upon the whole the disadvantages seem to overweigh -the advantages.<a name="Anchor_9" id="Anchor_9" href="#Footnote_9" class="fnanchor" title="Go to footnote 9.">[9]</a> 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<span class="pagenum"><a name="Page_25" id="Page_25">[25]</a></span> -did not live with her. Young and grown-up daughters are -much in a Matron’s way; sons matter much less.</p> - -<p>The greatest Civil Hospital gives its Matron 200<i><abbr title="pounds">l.</abbr></i> and a <em>house</em>, -the other great Hospitals, 150<i><abbr title="pounds">l.</abbr></i>, and a <em>house</em>. The London -Hospital gives 150<i><abbr title="pounds">l.</abbr></i>, and a couple of good well-furnished -rooms, and a servant. A <em>house</em> 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<i><abbr title="pounds">l.</abbr></i> -and quarters is not at all too much.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_26" id="Page_26">[26]</a></span>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?</p> - -<p>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.</p> - -<p>The Matrons out of the three kingdoms have increased -responsibility, and can do more mischief, if incompetent or -untrustworthy.</p> - -<p>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.</p> - -<p>Volunteering for foreign or war-serv<span class="pagenum"><a name="Page_27" id="Page_27">[27]</a></span>ice 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.</p> - -<p>But let there not be too many rules at first; see how things -work, and take one step at a time.</p> - -<p>The selection of exclusively middle-class Matrons seems to -be important.<a name="Anchor_10" id="Anchor_10" href="#Footnote_10" class="fnanchor" title="Go to footnote 10.">[10]</a> 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.</p> - -<p>The name of Matron is the same as in Civil Hospitals. In -many respects the office and duties are different: <i>e. g.</i>, 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.</p> - -<p>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 -<span class="pagenum"><a name="Page_28" id="Page_28">[28]</a></span>time, effect quietly a great deal of good.</p> - -<p>There should be some Rule of this kind—</p> - -<p>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.</p> - -<p>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.</p> - -<p>The Surgeons will dislike these unpaid Nurses; but, in the long -run a firm, discreet woman, <em>who is an efficient Nurse</em>, can get on -with any Surgeon <em>who has his sick at heart</em>. 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.</p> - -<p><span class="pagenum"><a name="Page_29" id="Page_29">[29]</a></span></p><div class="sidenote">9. Nurses—begin -with few -at first.</div> - -<p>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, -<i>cæteris paribus</i>, a preference should be given to widows -of the Service.</p> - -<p>Except in emergencies Nurses should not be taken under -thirty, or above forty<a name="Anchor_11" id="Anchor_11" href="#Footnote_11" class="fnanchor" title="Go to footnote 11.">[11]</a> years of age. These women are Head -Nurses. Most of the Civil Hospitals take no Head Nurse -after forty.</p> - -<p>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.</p> - -<p>As to engaging any Nurses out of the great Hospitals, for -sundry reasons, this should be done as little as may be.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>No Nurse, during her suspension, should be allowed to enter -any ward of the hospital.</p> - -<p>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 depar<span class="pagenum"><a name="Page_30" id="Page_30">[30]</a></span>ture, -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.</p> - -<p>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.</p> - -<p>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>i. e.</i>, 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.</p> - -<p>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.<a name="Anchor_12" id="Anchor_12" href="#Footnote_12" class="fnanchor" title="Go to footnote 12.">[12]</a> 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.</p> - -<p><span class="pagenum"><a name="Page_31" id="Page_31">[31]</a></span></p> - -<p>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.</p> - -<p>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 <abbr title="Saint">St.</abbr> 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.</p> - -<div class="sidenote">10. Have the -Diets sent hot -and ready-divided -from -the Kitchen.</div> - -<p>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.</p> - -<p>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 <em>hot</em> 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 <em>hot</em> from the -kitchen, it is far preferable.</p> - -<p>At <abbr title="Saint">St.</abbr> George’s Hospital the portions are sent hot and -divided from the kitchen.</p> - -<div class="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.</div> - -<p>11. It should be distinctly settled by whom poulticing, -fomenting, and all minor dressings, applying leeches and -blisters, and giving enemas,<a name="Anchor_13" id="Anchor_13" href="#Footnote_13" class="fnanchor" title="Go to footnote 13.">[13]</a> are to be done.</p> -<p><span class="pagenum"><a name="Page_32" id="Page_32">[32]</a></span></p> -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">Ward Medical -Officer to give -Directions to -Nurse.</div> - -<p>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.</p> - -<p>All the above-mentioned things should be done by the -Nurse, <i>i. e.</i>, 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.</p> - -<p>The reasons why all these things must be clearly settled -beforehand are these:—</p> - -<p>I. Adverse Medical Officers will make all use of counter-regulations.</p> - -<p>II. Medical Officers who give fair play will find it impossible -to settle the matter, if, on ordering, <i>e. g.</i>, 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.</p> - -<p>Unless the Matron’s authority is supported by the Principal -<span class="pagenum"><a name="Page_33" id="Page_33">[33]</a></span>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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 -<span class="pagenum"><a name="Page_34" id="Page_34">[34]</a></span>the ward. Let them be made useful in the wards, as far as -possible, in such lighter cleaning, <abbr title="etcetera">&c.</abbr>, 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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, -<abbr title="etcetera">&c.</abbr> 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.</p> - -<p>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.”</p> - -<p>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.”</p> - -<p>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 -<span class="pagenum"><a name="Page_35" id="Page_35">[35]</a></span>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.]</p> - -<p>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.)</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>; 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.</p> - -<div class="sidenote">12. Orderlies’ -Attendance.</div> - -<p>12. With regard to the question of the “Regulation” number -of Orderlies, viz., 1 to every 10 patients, it is to be -observed,—</p> - -<div class="sidenote">(1.) 40-Bed -Ward -Minimum Size -for Regulation -Number of -1 Attendant to -10 Patients.</div> - -<p>(1.) A ward of 40 patients might be efficiently served (but -it would be hard work) with</p> - -<p><span class="pagenum"><a name="Page_36" id="Page_36">[36]</a></span></p> -<ul> -<li>1 Head Nurse—Female.</li> -<li>3 Orderlies.</li> -</ul> - -<p>With no number under 40 of patients to a ward, can the -Regulation proportion of 1 attendant to 10 patients be adhered -to.</p> - -<div class="sidenote">(2.) 20-Bed -Ward requires -3½ Attendants.</div> - -<p>(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</p> - -<ul> -<li>½ Head-Nurse—Female.</li> -<li>3 Orderlies.</li> -</ul> - -<p>And the other ward of this Head Nurse ought to be on the -same floor.</p> - -<p>N. B.—The same number would quite as efficiently serve a -ward of 25 or even 30 patients.</p> - -<div class="sidenote">(3.) 10-Bed -Ward cannot -be served by -1 Orderly + ⅕ -Nurse.</div> - -<p>(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.</p> - -<p>For, is the same Orderly to be on duty for the 24 hours?</p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">(4.) Female -Nurses not to -be Substitutes -for Orderlies.</div> - -<p>(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</p> - -<ul> -<li>diet-carrying,</li> -<li>sweeping,</li> -<li>and writing.</li> -</ul> - -<div class="sidenote">(5.) Naval -Hospitals -Regulation -Number of -Attendants 1 to -7 Patients.</div> - -<p>(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 -<span class="pagenum"><a name="Page_37" id="Page_37">[37]</a></span>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, <abbr title="etcetera">&c.</abbr>—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.</p> - -<p>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—</p> -<ul> -<li>2 are on from 9 to 2, <span class="smcap">A. M.</span></li> -<li>2 <span class="ditto">are on from</span> 2 to 8.</li> -</ul> - -<p>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.</p> - -<div class="sidenote">Civil Hospitals -have even 9 -Attendants to -44 Patients.</div> - -<p>In Civil Hospitals the number is as great of attendants to -patients, and is mainly determined by the size of the ward:</p> - -<p><i>E.g.</i>, in one Hospital, where there are quadruple war<span class="pagenum"><a name="Page_38" id="Page_38">[38]</a></span>ds of -44 patients, 11 in each compartment, though the average -number of patients is 48, the number of attendants is 7.</p> - -<p>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.</p> - -<p>In another of the large London Hospitals, where there are -to each ward,</p> - -<table class="staffing" summary="Staffing Levels"> -<tr><th colspan="3"><span class="smcap">Patients.</span></th><th colspan="2"><span class="smcap">Attendants.</span></th></tr> -<tr><td class="no">22<br /> <br />24</td><td class="cb">⎫<br />⎬<br />⎭</td><td class="ta">there are</td><td class="cb">⎧<br />⎨<br />⎩</td><td>1 Sister.<br /> <br />2 Nurses.</td></tr> - -<tr><td class="no">30</td><td> </td><td class="ditto ta">there are</td><td class="cb">⎧<br />⎪<br />⎨<br />⎪<br />⎩</td><td>1 Sister.<br /> <br />2 Nurses.<br /> <br />1 Scrubber.</td></tr> - -<tr><td class="no">34</td><td> </td><td class="ditto ta">there are</td><td class="cb">⎧<br />⎨<br />⎩</td><td>1 Sister.<br /> <br />3 Nurses.</td></tr> - -<tr><td class="no">40</td><td> </td><td class="ditto ta">there are</td><td class="cb">⎧<br />⎪<br />⎨<br />⎪<br />⎩</td><td>1 Sister.<br /> <br />3 Nurses.<br /> <br />1 Helper.</td></tr> - -</table> - -<p>In the <span lang="fr" xml:lang="fr">Lariboisière</span> 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.</p> - -<div class="sidenote">(6.) Same -Number of -Men will not -do same -amount of -Work as an -equal Number -of Women -would.</div> - -<p>(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.</p> - -<p>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.</p> - -<div class="sidenote">(7.) Hospital -Attendance an -entirely new -subject in the -Army.</div> - -<p>(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.</p> - -<p>I conceive it to be practically impossible to serve 4 wards, as -proposed at Netley, viz., of 9 beds each, with</p> - -<p class="pagenum"><a name="Page_39" id="Page_39">[39]</a></p> -<ul> - <li>1 Head Nurse,</li> - <li>4 Orderlies.</li> -</ul> - -<p>For, as has been said, one bad case in each ward, makes this -economy as unmanageable as nine.</p> - -<div class="sidenote">(8.) Hospital -Wards in the -Army little else -than Barrack-Rooms -at -present.</div> - -<p>(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—</p> - -<table class="staffing" summary="Staffing Levels for Netley Wards"> -<tr><td class="longer">1 Female Head Nurse</td><td rowspan="2" class="cb">⎫<br />⎬<br />⎭</td><td rowspan="2" class="to">to</td><td rowspan="2" class="cb">⎧<br />⎨<br />⎩</td><td class="longer">50 Patients, in (say)</td></tr> -<tr><td class="longer">6 Orderlies</td><td class="longer">6 Netley Wards;</td></tr> -</table> - -<p>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.</p> - -<div class="sidenote">(9.) Regulation -as to 1 Orderly -to 10 Patients -requires -modifying.</div> - -<p>(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.</p> - -<div class="sidenote">(10.) One -Orderly should -be the -<i>Frotteur</i>.</div> - -<p>(10.) The question of Hospital floors will be fully discussed -farther on. An Orderly should be trained to be the <i>frotteur</i> -to each ward. He should also be the porter to fetch and carry -every thing to and from the ward.</p> - -<div class="sidenote">(11.) -Comparison of -Cost of -Nursing with -larger and -smaller Wards.</div> - -<p>(11.) The plan of Netley, with its wards for 9 sick, is by far -the costliest for administration, as the following facts will -prove:</p> - -<p class="pseudo_list">I. It is proposed to provide the Hospital with Orderlies -and Nurses to conduct the nursing in wards of 9 sick, -as mentioned.</p> - -<p class="pseudo_list">II. On sanitary grounds wards may safely be large enough -to accommodate 25 to 30 sick.</p> - -<p class="noindent">We may therefore choose the larger wards, being guided only -by the cost of the nursing.</p> - -<p class="pseudo_list">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.)</p> -<p><span class="pagenum"><a name="Page_40" id="Page_40">[40]</a></span></p> - -<p class="pseudo_list_cont">A ward of 30 sick would require 2 day and 1 night -Orderlies and 1 Nurse = 4 persons in all.</p> - -<p class="noindent">Or if two such wards were on one floor, 1 Nurse could serve -both.</p> - -<p class="pseudo_list">IV. We cannot count the cost of Orderlies and Nurses, including -lodging, rations, wages, at less than <abbr title="50 pounds">£50</abbr> a year, -which when capitalized at 3 per cent. (33 years’ purchase), -would amount to <abbr title="1,650 pounds">£1,650</abbr> for each.</p> - -<p class="pseudo_list">V. A ward of 9 sick would cost in nursing <abbr title="1,650 pounds">£1,650</abbr> × 2⅓ = -<abbr title="3,850 pounds">£3,850</abbr>, or <abbr title="427 pounds 15 shillings and 6 pence">£427 15<i><abbr title="shillings">s.</abbr></i> 6<i><abbr title="pence">d.</abbr></i></abbr> per bed.</p> - -<p class="pseudo_list">VI. A ward of 30 sick would cost for nursing, in perpetuity, -<abbr title="1,650 pounds">£1,650</abbr> × 4 = <abbr title="6,600 pounds">£6,600</abbr> = <abbr title="220 pounds">£220</abbr> per bed.<br /> -[One Nurse to each ward is here allowed.]</p> - -<p class="pseudo_list">VII. The cost of the two plans relatively for a Hospital of -1,000 sick would stand thus:</p> - -<table class="costs" summary="cost of the two plans"> - <tr> - <td> </td> - <td>Wards with 9 beds</td> - <td class="equals">=</td> - <td class="tdr"><abbr title="427,775 pounds">£427,775</abbr></td> - </tr> - <tr> - <td> </td><td>Wards with 30 beds</td> - <td class="equals">=</td> - <td class="tdr">220,000</td> - </tr> - <tr> - <td class="tdr" colspan="2">Capitalized difference of cost in<br /> - favour of large wards</td> - <td class="equals taller">}</td><td class="tdr total"><abbr title="207,775 pounds">£207,775</abbr></td> - </tr> -</table> - -<table class="costs" summary="Netley costs"> - <tr> - <td class="netley">Netley has cost already Land</td> - <td class="equals">=</td> - <td class="tdr"><abbr title="30,000 pounds">£30,000</abbr></td> - </tr> - <tr> - <td class="netley">Works</td> - <td colspan="2" class="tdr">89,000</td> - </tr> - <tr> - <td colspan="2"> </td> - <td class="tdr total"><abbr title="119,000 pounds">£119,000</abbr></td> - </tr> -</table> - -<p>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 = <abbr title="88,775 pounds">£88,775</abbr>.</p> - -<p class="sub">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:</p> - -<table class="costs" summary="Cost with 25 to a ward"> - <tr> - <td class="back">For each ward of 25 sick, 3 Orderlies, at <abbr title="1,650 pounds">£1,650</abbr></td> - <td class="equals botm">=</td> - <td class="tdr botm"><abbr title="4,950 pounds">£4,950</abbr></td> -</tr> - <tr> - <td class="back" colspan="2">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</td> - <td class="tdr botm">825</td> - </tr> - <tr> - <td colspan="2"> </td> - <td class="tdr total">5,775</td> - </tr> - <tr> - <td class="back">Or cost for each bed 5775 / 25</td> - <td class="equals botm">=</td> - <td class="tdr"><abbr title="231 pounds">£231</abbr></td> - </tr> -</table> - -<p class="sub">The comparative cost of wards with 9 beds and -25 beds, would stand thus for 1000 sick:</p> - -<table class="costs" summary="Cost of 9 and 25 beds compared"> - <tr> - <td class="netley">Wards with 9 beds</td> - <td colspan="2" class="tdr"><abbr title="427,775 pounds">£427,775</abbr></td> - </tr> - <tr> - <td class="netley">Wards with 25 beds</td> - <td colspan="2" class="tdr">231,000</td> - </tr> - <tr> - <td colspan="2" class="netley">Saving</td> - <td class="tdr total botm"><abbr title="196,775 pounds">£196,775</abbr></td> - </tr> - <tr> - <td colspan="2" class="back">Deduct cost of Netley, already incurred</td> - <td class="tdr">119,000</td> - </tr> - <tr> - <td class="back">Saving from abandoning Netley</td> - <td class="equals">=</td> - <td class="tdr total botm"><abbr title="77,775 pounds">£77,775</abbr></td> - </tr> -</table> - -<p class="sub">The cost of the administration per 1000 beds at Netley and Aldershot would stand as follows:</p> - -<table class="costs" summary="Administration costs"> - <tr> - <td class="back" colspan="2">Netley</td> - <td class="tdr"><abbr title="427,775 pounds">£427,775</abbr></td> - </tr> - <tr> - <td class="back" colspan="2">Aldershot, pavilions, with 3 superimposed wards - and 25 sick in each, would require 3 Orderlies and - 1 Nurse<a name="Anchor_14" id="Anchor_14" href="#Footnote_14" class="fnanchor" title="Go to footnote 14.">[14]</a> to each ward, and would cost <abbr title="264 pounds">£264</abbr> per - bed in perpetuity, or per 1000 sick</td> - <td class="tdr botm">264,000</td> - </tr> - <tr> - <td class="back" colspan="2">Difference of cost in favour of Aldershot</td> - <td class="tdr total botm"><abbr title="163,775 pounds">£163,775</abbr></td> - </tr> -</table> - -<p>Some abatement would have to be made, as regards the cost -of Netley, as there are a few wards with 16 or 18 sick.</p> - -<p>If we take money at 4 per cent., the calculation will be as -follows:</p> - -<table class="costs" summary="Abatement calculation"> - <tr> - <td class="back" colspan="2">Small wards, 2 Orderlies and a third of a Nurse, - at <abbr title="50 pounds">£50</abbr> per annum; money at 4 per cent., - per 1000 sick</td> - <td class="tdr botm"><abbr title="324,000 pounds">£324,000</abbr></td> - </tr> - <tr> - <td class="back" colspan="2">Wards of 30. 3 Orderlies and a Nurse, money - at 4 per cent., per 1000 sick</td> - <td class="tdr botm">166,000</td> - </tr> - <tr> - <td class="netley" colspan="2">Extra cost of small wards</td> - <td class="tdr total botm">158,000</td> - </tr> - <tr> - <td class="netley" colspan="2">Cost of Netley</td> - <td class="tdr botm">119,000</td> - </tr> - <tr> - <td class="netley" colspan="2">Saving in giving it up</td> - <td class="tdr total botm"><abbr title="39,000 pounds">£39,000</abbr></td> - </tr> -</table> - -<p><span class="pagenum"><a name="Page_42" id="Page_42">[42]</a></span></p><div class="sidenote">13. Hospital -Floors.</div> - -<p>13. <span class="smcap">Floors.</span>—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.</p> - -<p>But, with regard to deal flooring,—</p> - -<p>(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.</p> - -<p>(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.</p> - -<p>(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.</p> - -<p>(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 -<i>parquet</i>, because the surface (except of very fine deal, such as -is used for musical instruments) never takes so high a polish.</p> - -<p>(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.</p> - -<p>(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<span class="pagenum"><a name="Page_43" id="Page_43">[43]</a></span> -floor from the feet and breath of the inhabitants. How much -more dangerous this in Hospital Wards need hardly be said.</p> - -<p>There is at <span lang="de" xml:lang="de">Bethanien</span> 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,<a name="Anchor_15" id="Anchor_15" href="#Footnote_15" class="fnanchor" title="Go to footnote 15.">[15]</a> 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. Nei<span class="pagenum"><a name="Page_44" id="Page_44">[44]</a></span>ther soap, -soda, <abbr title="etcetera">&c.</abbr>, is used.</p> - -<p>The great advantages of this are:—</p> - -<p>(1.) That it purifies the air exceedingly and freshens the -wards.</p> - -<p>(2.) That it reduces the daily accumulation of dust to a -minimum.</p> - -<p>(3.) That it dries completely within ten minutes from being -wet-rubbed.</p> - -<p>(4.) That a woman, standing, can thoroughly clean a ward -with some hours less time, and greatly less fatigue, than scrubbing.</p> - -<p>(5.) That wet scrubbing is sometimes and ought to be -always forbidden and dry rubbing substituted, on the score of -the unhealthiness of scrubbing.</p> - -<p>(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.</p> - -<p>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.</p> - -<p>There are four other examples of this flooring in Berlin -Hospitals.</p> - -<p>(1.) <span lang="de" xml:lang="de">Bethesda Siechenhaus</span>, 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 <span lang="de" xml:lang="de">Bethanien</span>, is less -used.</p> - -<p><span class="pagenum"><a name="Page_45" id="Page_45">[45]</a></span></p> - -<p>(2.) <abbr title="Saint">St.</abbr> Hedwig’s Hospital, where 250 male and female -medical and surgical patients are nursed by Roman Catholic -Sisters of <abbr title="Saint">St.</abbr> Charles Borromæus (head quarters at Nancy), -with female servants and male nurses. The house is new; the -flooring the same as at <span lang="de" xml:lang="de">Bethanien</span>. The Superior, an intelligent -German, speaks much of its excellence for hospital purposes; -it is being introduced, though as yet very partially, into -France.</p> - -<p>(3.) The great <span lang="fr" xml:lang="fr">Charité</span> 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 <span lang="de" xml:lang="de">Bethanien</span>, -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 <span lang="fr" xml:lang="fr">Charité</span> floors are re-oiled with -laque every year; they are cleaned in the same way as at <span lang="de" xml:lang="de">Bethanien</span>, -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.</p> - -<p>(4.) The principal Military Hospital, the <span lang="de" xml:lang="de">Garnison Lazareth</span> -in the <span lang="de" xml:lang="de">Hirsch Allée</span>, for 800 patients, usually not filled. The -flooring is the same as at <span lang="de" xml:lang="de">Bethanien</span>, except that no laque is -used. It is oiled generally, not always, yearly.</p> - -<p>The <span lang="de" xml:lang="de">Ober Inspector</span>, a <span lang="de" xml:lang="de">Landwehr</span> civilian, who is supreme -over the Hospital, and an <span lang="de" xml:lang="de">Ober-Stabs-Arzt</span>, 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 <span lang="fr" xml:lang="fr">Charité</span>, <span lang="de" xml:lang="de">Bethanien</span>, -and <abbr title="Saint">St.</abbr> 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<span class="pagenum"><a name="Page_46" id="Page_46">[46]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>(5.) Two years ago the greater part of the boards in the -<span lang="de" xml:lang="de">Kaiserswerth</span> 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 -<span lang="de" xml:lang="de">Kaiserswerth</span> 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 <span lang="de" xml:lang="de">Bethanien</span> colour. These oiled boards last a year -only. A moderate amount of laque is required to add to their -durability.</p> - -<p>The sum of the information, condensed as much as possible, -on this subject is;—</p> - -<p><span class="smrom">I.</span> The boards, which are always of deal, can be prepared in -three ways:</p> - -<p>(<span class="smrom">I.</span>) 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.</p> - -<p><span class="pagenum"><a name="Page_47" id="Page_47">[47]</a></span></p> - -<p>(<span class="smrom">II.</span>) Oiled boards, with more or less laque.</p> - -<p>The <span lang="fr" xml:lang="fr">Charité</span> boards have a great deal of laque.</p> - -<p>The <span lang="de" xml:lang="de">Bethanien</span> and <abbr title="Saint">St.</abbr> Hedwig’s boards much less.</p> - -<p>(<span class="smrom">III.</span>) Oiled boards without any laque—</p> - -<p>As in the Military Hospital.</p> - -<p><span class="smrom">II.</span> Much laque makes the floors shine brighter; requires -more time to clean them; and earlier re-preparation than -where less laque is used.</p> - -<p>The <span lang="fr" xml:lang="fr">Charité</span> 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.</p> - -<p><span class="smrom">III.</span> A small quantity of laque, as at <span lang="de" xml:lang="de">Bethanien</span>, 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.</p> - -<p><span class="smrom">IV.</span> 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.</p> - -<p><span class="smrom">V.</span> 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.:—</p> - -<p>(<span class="smrom">I.</span>) The dampness which remains in a ward more or less -time after it has been scrubbed, is completely avoided.</p> - -<p>(<span class="smrom">II.</span>) 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.</p> - -<p>(<span class="smrom">III.</span>) The mode of cleaning this flooring, w<span class="pagenum"><a name="Page_48" id="Page_48">[48]</a></span>hile it avoids -damp, daily purifies the ward air.</p> - -<p>(<span class="smrom">IV.</span>) The floor, and its mode of cleaning, get rid more than -by any other way of dust, and of the miasma dust often -conveys.</p> - -<p>(<span class="smrom">V.</span>) The time, labour, and expense of scrubbing are saved.</p> - -<p>(<span class="smrom">VI.</span>) 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.</p> - -<p><span class="smrom">VI.</span> Against these advantages, the following disadvantages -are to be placed:</p> - -<p>(<span class="smrom">I.</span>) This flooring shows where most used, instead of the -uniform appearance of the white scrubbed boards.</p> - -<p>(<span class="smrom">II.</span>) Scratches show, and remain upon it; so all furniture -must be lifted, not dragged over it.</p> - -<p>(<span class="smrom">III.</span>) The tread sounds a little more, little, but more, than -on white boards.</p> - -<p>(<span class="smrom">IV.</span>) 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.)</p> - -<p>(<span class="smrom">V.</span>) 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, <abbr title="etcetera">&c.</abbr>; 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.</p> - -<p>Both in the new part of the <span lang="fr" xml:lang="fr">Charité</span> and at <span lang="de" xml:lang="de">Bethanien</span>, 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 <span lang="fr" xml:lang="fr">Charité</span> a piece of long carpet is laid in the midst of the -corridors, where patients walk not a little. At <span lang="de" xml:lang="de">Bethanien</span>, a<span class="pagenum"><a name="Page_49" id="Page_49">[49]</a></span> -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.</p> - -<p><span class="smrom">VII.</span> 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.</p> - -<p><span class="smrom">VIII.</span> 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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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, <abbr title="etcetera">&c.</abbr> Red floorcloth, of sufficient -size, round the operating-table, might answer every -purpose.</p> - -<p><span class="smrom">IX.</span> On laying down the oiled boards for the first time, six -weeks should pass after the oiling and laquering before the -ward is inhabited.</p> - -<p><span class="smrom">X.</span> 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.</p> - -<p><span class="smrom">XI.<span class="pagenum"><a name="Page_50" id="Page_50">[50]</a></span></span> 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.</p> - -<p>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.</p> - -<p>But it would be incurring a great responsibility to have the -whole of a large new Hospital floored in this way, because,</p> - -<p><span class="smrom">I.</span> An English climate has made, and makes, so many things -which are good and suitable abroad, unsuitable and sometimes -pernicious for England.</p> - -<p><span class="smrom">II.</span> 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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, <span lang="de" xml:lang="de">Schonby</span>, No. 5, <span lang="de" xml:lang="de">Michael Kirchplatz</span>, -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.</p> - -<p>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 wo<span class="pagenum"><a name="Page_51" id="Page_51">[51]</a></span>man -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.</p> - -<div class="sidenote">14. Ventilation -of Wards.</div> - -<p>14. <span class="smcap">Ventilation.</span>—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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_52" id="Page_52">[52]</a></span> any -specific case the best method of renewing the air sufficiently, -without producing draughts or occasioning great varieties in -temperature.</p> - -<p>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.</p> - -<div class="sidenote">Night -Ventilation.</div> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_53" id="Page_53">[53]</a></span></p> -<div class="sidenote">Special Wards, -whether -desirable or -not.</div> - -<p>15. <span class="smcap">Special Wards.</span>—It may be laid down as an axiom in -the management of sick affected with certain zymotic diseases, -such as fevers, cholera, dysentery, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_54" id="Page_54">[54]</a></span> 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.</p> - -<p>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.</p> - -<div class="sidenote">16. Proposed -Regulations as -to Payments, -by Superintendent-General.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, should be provided on the order of the -Superintendent-General.</p> - -<div class="sidenote">Opinion as to -Superintendent-General -paying -Wages and -Salaries.</div> - -<p>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 Tr<span class="pagenum"><a name="Page_55" id="Page_55">[55]</a></span>easurer -is bound to honour those orders, as any other banker would.</p> - -<div class="sidenote">Matrons -abroad may -dismiss Nurses -under appeal.</div> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">Matron to -draw Rations -and Extras.</div> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">Opinion as to -Governor’s -jurisdiction -over Nurses.</div> - -<p>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<span class="pagenum"><a name="Page_56" id="Page_56">[56]</a></span> -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.</p> - -<p>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.</p> - -<div class="sidenote">17. Nurses’ -Wages.</div> - -<p>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.</p> - -<div class="sidenote">Efficiency of -Nurses does -not increase by -springs and -starts, like -Grasshoppers.</div> - -<p>Efficiency does not go by starts and springs, like grasshoppers, -but makes “a small annual increase,” like the wages -proposed.</p> - -<p>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.</p> - -<div class="sidenote">The first five -years a -constant -improvement. -Afterwards if -there has not -been -improvement -made before, -no hope at all.</div> - -<p>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.</p> - -<div class="sidenote">Three -principles in -Wages.</div> - -<p>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.</p> - -<div class="sidenote">By rate of -Wages to -retain those -who are -efficient.</div> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_57" id="Page_57">[57]</a></span></p> - -<div class="sidenote">By rate of -Pension to -reward those -who have been -efficient.</div> - -<p>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.</p> - -<div class="sidenote">Civil Service -an Example.</div> - -<p>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.</p> - -<div class="sidenote">Opinion as to -Wages and -Pensions.</div> - -<p>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 <abbr title="20 pounds">£20</abbr> after twelve years’ -service.</p> - -<p>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 a<span class="pagenum"><a name="Page_58" id="Page_58">[58]</a></span>lmost -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.</p> - -<p>I have consulted the best authorities upon these points; and -I find the following general principles admitted:—</p> - -<p class="neohead"><span class="smcap">General Principles as to Wages and Pensions.</span></p> - -<div class="sidenote">(1.) Same -Salary at first.</div> - -<p>(1.) At whatever age a Nurse enters the Service she shall -begin with the same salary.</p> - -<div class="sidenote">(2.) Same -Annual rate of -increase.</div> - -<p>(2.) The annual rate of increase shall be the same for all -ages of entrance.</p> - -<div class="sidenote">(3.) Maximum -Salary fixed.</div> - -<p>(3.) The maximum salary shall not exceed £<span class="spread-out_space"> </span>.</p> - -<div class="sidenote">(4.) Pension -for Service -after Ten -Years.</div> - -<p>(4.) The pension for service shall not begin until ten years -of completed service.</p> - -<div class="sidenote">(5.) Amount -of Pension a -certain Percentage -on -mean Salary -of preceding -year.</div> - -<p>(5.) The amount of pension shall be a certain percentage on -the salary during the year preceding that on which she is pensioned.</p> - -<p class="neohead"><span class="smcap">Applications of the foregoing Principles.</span></p> - -<div class="sidenote">(1.) Annual -rise of Wages -till the -maximum of -efficiency.</div> - -<p>(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.</p> - -<div class="sidenote">(2.) After five -years’ Service -Pension for -Disability.</div> - -<p>(2.) That, after five years’ service, the Nurse shall, in the -case of <span class="smcap">ABSOLUTE DISABILITY</span>, become entitled to a pension -during the period of her disability.</p> - -<div class="sidenote">(3.) Pension -on a Scale -graduated on -the Wages.</div> - -<p>(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.</p> - -<div class="sidenote">(4.) A<span class="pagenum"><a name="Page_59" id="Page_59">[59]</a></span>ll -Nurses to -retire at Sixty.</div> - -<p>(4.) All Nurses will be placed on the Retired List at the age -of sixty.<a name="Anchor_16" id="Anchor_16" href="#Footnote_16" class="fnanchor" title="Go to footnote 16.">[16]</a></p> - -<div class="sidenote">(5.) Nurses to -serve again -who are -Pensioned for -Disability, -when -Disability -ceases before -Sixty.</div> - -<p>(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.</p> - -<div class="sidenote">(6.) Nurses -partially -Disabled to -receive partial -Pension.</div> - -<p>(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.</p> - -<div class="sidenote">Example.</div> - -<p class="center">Example.</p> - -<table class="yearsin" summary="pension by completed years"> - <tr><th class="tdc"><span class="smcap">Age.</span></th><th class="tdc"><span class="smcap">Completed Years<br />of Service.</span></th><th class="tdl"><span class="smcap">Wages.</span></th><th class="tdl"><span class="smcap">Pension.</span></th></tr> - <tr><td class="tdc">30</td><td class="years">0</td><td class="wages_pounds"><abbr title="20 pounds">£20</abbr>?</td><td colspan="2">Gratuity</td></tr> - <tr><td class="tdc">31</td><td class="years">1</td><td class="wages">22</td><td colspan="2">Gratuity</td></tr> - <tr><td class="tdc">32</td><td class="years">2</td><td class="wages">24</td><td colspan="2">Gratuity</td></tr> - <tr><td class="tdc">33</td><td class="years">3</td><td class="wages">26</td><td colspan="2">Gratuity</td></tr> - <tr class="line"><td class="tdc">34</td><td class="years">4</td><td class="wages">28</td><td colspan="2">Gratuity</td></tr> - <tr class="postline"><td class="tdc">35</td><td class="years">5</td><td class="wages">30 × ·2 =</td><td class="tdl">£6</td></tr> - <tr><td class="tdc">40</td><td class="years tens">10</td><td class="wages">40 <span class="hidden">×</span> ·3</td><td class="tdl">12</td></tr> - <tr><td class="tdc">45</td><td class="years tens">15</td><td class="wages">50 <span class="hidden">×</span> ·4</td><td class="tdl">20</td></tr> - <tr><td class="tdc">50</td><td class="years tens">20</td><td class="wages">50 <span class="hidden">×</span> ·5</td><td class="tdl">25</td></tr> - <tr><td class="tdc">55</td><td class="years tens">25</td><td class="wages">50 <span class="hidden">×</span> ·6</td><td class="tdl">30</td></tr> - <tr><td class="tdc">60</td><td class="years tens">30</td><td class="wages">50 <span class="hidden">×</span> ·7</td><td class="tdl">35</td></tr> -</table> - -<p>These principles, if admitted, would suggest the following -heads for regulations as to Nurses’ wages and pensions:—</p> - -<div class="sidenote">(1.) Amount -of Wages, first -year, £20.</div> - -<p>(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.</p> - -<div class="sidenote">(2.) Annual -rate of increase -up to <abbr title="50 pounds">£50</abbr>, -when it ceases.</div> - -<p>(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 <abbr title="50 pounds">£50</abbr>, beyond which there will be no further -increase.</p> - -<div class="sidenote">(3.) No -Pension till -Ten Years’ -Service -completed, nor -for Disability -till Five -Years.</div> - -<p>(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 circumst<span class="pagenum"><a name="Page_60" id="Page_60">[60]</a></span>ances, -if discharged for disability, before she has completed -five years of service.</p> - -<div class="sidenote">(4.) Rate of -Pension.</div> - -<p>(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.<a name="Anchor_17" id="Anchor_17" href="#Footnote_17" class="fnanchor" title="Go to footnote 17.">[17]</a> But no such -pension shall exceed the amount of £50.</p> - -<div class="sidenote">(5.) Nurses, -Pensioned for -Disability, -whose -Disability -ceases, may be -called on for -Service.</div> - -<p>(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.</p> - -<p>(6.) Every Nurse who has completed her sixtieth year, must -retire from the service on her rate of pension.</p> - -<p>(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.</p> - -<div class="sidenote">18. Number of -Nurses to -Patients.</div> - -<p>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<span class="pagenum"><a name="Page_61" id="Page_61">[61]</a></span> -cases.</p> - -<p>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?</p> - -<p>At the same time it is necessary to state—</p> - -<p>(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.</p> - -<p>(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.</p> - -<p>(3.) That idleness, always pernicious, is never more so than -to Hospital-Nurses.</p> - -<p>(4.) That petting the patients, by way of filling up time, -would be, of the two, more pernicious than idleness.</p> - -<p>(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.</p> - -<p>(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.</p> - -<p><span class="pagenum"><a name="Page_62" id="Page_62">[62]</a></span></p> - -<p>(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.</p> - -<div class="sidenote">19. -Precautions -in sending -Nurses abroad.</div> - -<p>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.</p> - -<div class="sidenote">Hospital<span class="pagenum"><a name="Page_63" id="Page_63">[63]</a></span> -Laundries.</div> - -<p>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.</p> - -<hr class="chap" /> -<h2><span class="smcap">Addenda with regard to Female Nursing in a Military -Hospital on the Pavilion or <span lang="fr" xml:lang="fr">Lariboisière</span> Plan.</span></h2> - -<div class="figcenter"> - <a title="larger image of plan of Hospital de Lariboisière" class="nodec" href="images/plan_large.jpg" name="plan" id="plan"><img width="450" height="525" src="images/plan.jpg" alt="Hospital de Lariboisière" /></a> - <p class="caption" lang="fr" xml:lang="fr"><i>PARIS</i></p> - <p class="caption" lang="fr" xml:lang="fr"><a title="larger image of plan of Hospital de Lariboisière" href="images/plan_large.jpg">Hospital de Lariboisière</a></p> - <p class="caption" lang="fr" xml:lang="fr">612 Lits.</p> - -<p class="caption noindent left" lang="fr" xml:lang="fr"> -A. Bureaux.<br /> -B. à rez de chaussée Cuisine. au <abbr title="premier">1ᵉʳ</abbr> Etage Logements d’employés —au <abbr title="deuxième">2ᵐᵉ</abbr> Etage Dortoirs des Garcons de Service.<br /> -C. <span class="ditto">à rez de chaussée</span> Pharmacie. <span class="ditto">au <abbr title="premier">1ᵉʳ</abbr> Etage Logements d’employés</span> —<span class="ditto">au <abbr title="deuxième">2ᵐᵉ</abbr> Etage</span> Chambres des Elèves internes.<br /> -D E F G H I J K. Chauffoirs.<br /> -L M N O P Q. Batiments de Malades.<br /> -R. à rez de chaussée Buanderie. au <abbr title="premier">1ᵉʳ</abbr> Etage Lingerie. au <abbr title="deuxième">2ᵉᵐᵉ</abbr> Etage Dortoirs des filles de Service.<br /> -S. Communauté.<br /> -T U. Bains.<br /> -V. Chapelle<br /> -X Y. Amphithèatres.<br /> -Z. Manège et Magasins<br /> -W. Ecurie. Remise et Salle des Morts.<br /> -</p> -</div> - -<p>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.</p> - -<p>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.</p> - -<p>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).</p> - -<p>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.</p> - -<p>4. Efficient as to convenient ac<span class="pagenum"><a name="Page_64" id="Page_64">[64]</a></span>commodation for Nurses and -Ward-Masters, near to the wards of which they are in charge.</p> - -<div class="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.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, 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, <abbr title="etcetera">&c.</abbr> Extreme, -<em>not finicking</em>, 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.</p> - -<p>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 appliance<span class="pagenum"><a name="Page_65" id="Page_65">[65]</a></span>s -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.</p> - -<div class="sidenote">2. Easy -Supervision to -be provided for.</div> - -<p>2. The <span lang="fr" xml:lang="fr">Vincennes</span> 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.</p> - -<div class="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.</div> - -<p>3. The more we see of different systems, the more we see -the great mistake of giving a Nurse too little to do.</p> - -<p>Twenty-four ordinary sick or surgical cases are too few for -a Head Nurse.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Relieved of all cleaning, and relieved of the great loss of -time incurred by fetching, waiting, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, 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 ser<span class="pagenum"><a name="Page_66" id="Page_66">[66]</a></span>ved -fifty or sixty than forty.</p> - -<p>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.</p> - -<div class="sidenote">4. Importance -of the Head -Nurse -sleeping close -to her Ward.</div> - -<p>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:—</p> - -<p>As regards the efficiency of her service:—</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>If it be possible, the Nurses must sleep adjoining their -wards; and it will not do to give each only 24 patients.</p> - -<p>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 <span class="pagenum"><a name="Page_67" id="Page_67">[67]</a></span>distinct -bell which she can in a moment ring from her bed into -the other Nurse’s room, to summon her if needed.</p> - -<div class="sidenote">Importance of -Lighting -Hospital -Wards by Gas, -with Sanitary -Precautions.</div> - -<p>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 -<abbr title="Saint">St.</abbr> Bartholomew’s, <abbr title="Saint">St.</abbr> 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, <abbr title="etcetera">&c.</abbr> 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.</p> - -<p>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 <em>must</em> 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.</p> - -<p><span class="pagenum"><a name="Page_68" id="Page_68">[68]</a></span></p> - -<div class="sidenote">II.—1. Should -it be necessary -to serve one -Pavilion with -one Nurse -means by -which this -could be -effected.</div> - -<p>II.—1. Suppose the <span lang="fr" xml:lang="fr">Lariboisière</span> 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.</p> - -<p>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.</p> - -<div class="sidenote">2. Head -Nurse’s Day in -a Pavilion -Hospital.</div> - -<p>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):—</p> - -<p>She should be effective, and enter the Pavilion about 6 <span class="smcap">A.M.</span>, -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, <abbr title="etcetera">&c.</abbr>, attendance on Surgeons, <abbr title="etcetera">&c.</abbr> 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 efficien<span class="pagenum"><a name="Page_69" id="Page_69">[69]</a></span>t Head -Nurse can do.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <span lang="fr" xml:lang="fr">Lariboisière</span> 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.</p> - -<p>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<span class="pagenum"><a name="Page_70" id="Page_70">[70]</a></span> -health, and facility of nursing and supervision, would be much -more easily obtained. Of this more hereafter.</p> - -<div class="sidenote">3. -Responsibility -of Nurse for -Discipline of -her Ward or -Wards—how -Modified in -Military -Hospitals.</div> - -<p>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.</p> - -<p>The Military Head-Nurse’s Assistants are Orderlies, <i>i. e.</i> -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, <abbr title="etcetera">&c.</abbr>, 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 i<span class="pagenum"><a name="Page_71" id="Page_71">[71]</a></span>s 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.</p> - -<p>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.</p> - -<p>All these things must be settled with the concurrence of the -Director-General.</p> - -<p>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.</p> - -<div class="sidenote">4. Importance -of Lifts.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, to and from the first and -second floor wards, are very preferable to the Orderlies carryin<span class="pagenum"><a name="Page_72" id="Page_72">[72]</a></span>g -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.</p> - -<p>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.</p> - -<div class="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.</div> - -<p>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.</p> - -<p><abbr title="Saint">St.</abbr> 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.</p> - -<p>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 <em>must</em> 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.</p> - -<p><abbr title="Saint">St.</abbr> 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.</p> - -<p>London Hospital sent its <span class="pagenum"><a name="Page_73" id="Page_73">[73]</a></span>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.</p> - -<p>It most certainly appears that the plan of concentrating -these cases together, but with (as at <abbr title="Saint">St.</abbr> 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, ought to be washed -separately from those of the patients of the large ward. Is this -easily secured?</p> - -<p>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 gangre<span class="pagenum"><a name="Page_74" id="Page_74">[74]</a></span>ne -becomes severe that the removal is made. Now at once to -remove these cases from the ordinary wards is very advantageous.</p> - -<p><abbr title="Saint">St.</abbr> 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.</p> - -<p>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.</p> - -<div class="sidenote">2. Restraint or -Non-restraint -in Delirium -Tremens.</div> - -<p>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, whi<span class="pagenum"><a name="Page_75" id="Page_75">[75]</a></span>ch -<em>must</em> otherwise be resorted to.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">IV. Simplicity -of Construction -essential to -Discipline.</div> - -<p>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 <em>unneeded</em> 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, <abbr title="etcetera">&c.</abbr>, 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<span class="pagenum"><a name="Page_76" id="Page_76">[76]</a></span> -is possible to be.</p> - -<div class="sidenote">Polished -Walls.</div> - -<p>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 <span lang="fr" xml:lang="fr">Lariboisière</span> -Hospital at Paris, and of a pure white.</p> - -<div class="sidenote">Covered -Exercising -Place.</div> - -<p>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 <abbr title="Saint">St.</abbr> Thomas’s, the patients walk -under the covered arcades of the court.</p> - -<div class="sidenote">Reserve -Wards.</div> - -<p>Both in <span lang="de" xml:lang="de">Bethanien</span> and in the <span lang="fr" xml:lang="fr">Charité</span> Hospitals at Berlin there -are reserve wards,—or rather in the <span lang="fr" xml:lang="fr">Charité</span> 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.</p> - -<div class="sidenote">V. Nurses’ -Meals.</div> - -<p>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.</p> - -<p>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.<span class="pagenum"><a name="Page_77" id="Page_77">[77]</a></span> -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.</p> - -<p>A dish and cover of strong, coarse earthenware is used in -the Vienna Hospital, as a grander edition of dinner, <abbr title="etcetera">&c.</abbr> 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.</p> - -<div class="sidenote">VI. -Arrangements -for a Pavilion -served by one -Nurse.</div> - -<p>VI. Supposing that we serve each Pavilion by one Nurse, -I submit that—</p> - -<div class="sidenote">1. Nurse’s -Day-room.</div> - -<p>1. The Nurse’s day-room should be on the ground floor.</p> - -<div class="sidenote">2. Ward-Master’s -Sleeping-room.</div> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">3. Where -should -Orderlies -Sleep?</div> - -<p>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,<span class="pagenum"><a name="Page_78" id="Page_78">[78]</a></span> -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.</p> - -<div class="sidenote">4. Where -should -Orderlies -Dine?</div> - -<p>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.</p> - -<div class="sidenote">5. Should -Orderlies be -brought -together?</div> - -<p>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.</p> - -<div class="sidenote">6. Should -Orderlies have -a Day-room in -Pavilion?</div> - -<p>6. If the Orderlies do not sleep in the Pavilion they should -not have a day-room.</p> - -<div class="sidenote">7. Scullery to -each Ward.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>; 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.</p> - -<div class="sidenote">8. What should -be done in the -Scullery?</div> - -<p>8. From this scullery let the Nurse get the water she requires—Orderlies -ditto.</p> - -<p>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<span class="pagenum"><a name="Page_79" id="Page_79">[79]</a></span> -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.</p> - -<p>In the scullery all the cleaning must take place, which is not -done in the lavatory.</p> - -<p>In the scullery extras are to be warmed, drinks ditto, hot-bricks -heated, water-bottles filled, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, and none of -these things are to be done at the ward-fire.</p> - -<div class="sidenote">Poultice-making.</div> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_80" id="Page_80">[80]</a></span></p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">9. Presses in -Ward.</div> - -<p>9. A regular store closet is hardly desirable. A good -arrangement is this:—</p> - -<p>At the end of the ward, nearest the Nurse’s room, or the -ward-door, a large press for linen.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, cotton -wool, tow, oilskin, splints and pads, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr> Of all these -things, the Nurse should always have a certain reserve on -hand.</p> - -<p>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<span class="pagenum"><a name="Page_81" id="Page_81">[81]</a></span> -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, <abbr title="etcetera">&c.</abbr>, 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 <span class="smcap">PRINTED</span> 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,” <abbr title="etcetera">&c.</abbr>, and -affixing them to each medicine bottle.</p> - -<p>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.</p> - -<p>It is a very good plan where the shape of all medicine bottles -and of those for liniments is distinctly different; and where, -<i>e. g.</i>, square bottles are used for poisons, or blue bottles for -poisons, and square for lotions.</p> - -<p>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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, to be small enough for the Nurse to keep -account of it, and for the patients to know that account is -kept of it.</p> - -<div class="sidenote">“<span lang="de" xml:lang="de">Apparat</span>” in -German -Hospitals.</div> - -<p>In constant daily use in the surgical wards of the great -Vienna Hospital is a thing called in Teutonic style “<span lang="de" xml:lang="de">Apparat</span>.” -The Nurse carries it round for herself, when preparing a<span class="pagenum"><a name="Page_82" id="Page_82">[82]</a></span>nd -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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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 <i lang="de" xml:lang="de">apparat</i> 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.</p> - -<div class="sidenote">10. Nurse’s -Room.</div> - -<p>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.</p> - -<p>In contem<span class="pagenum"><a name="Page_83" id="Page_83">[83]</a></span>plating 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, -<abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr></p> - -<div class="sidenote">Lavatory.</div> - -<p>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.</p> - -<div class="sidenote">Water-closet.</div> - -<p>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.</p> - -<div class="sidenote">Sink.</div> - -<p>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 <em>large</em> 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, <abbr title="etcetera">&c.</abbr>, which is used at the <span lang="de" xml:lang="de">Bethanien</span> -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, <abbr title="etcetera">&c.</abbr>, to be thoroughly cleansed by a stream of water -falling directly into it. The Nurse stands at the sink, empties -the pail, <abbr title="etcetera">&c.</abbr>, in it, without fear of splashing, and rinses <span class="pagenum"><a name="Page_84" id="Page_84">[84]</a></span>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.</p> - -<p>(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.)</p> - -<div class="sidenote">Baths.</div> - -<p>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.</p> - -<p>In a great London Civil Hospital, <abbr title="Saint">St.</abbr> 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.</p> - -<p>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 wa<span class="pagenum"><a name="Page_85" id="Page_85">[85]</a></span>ter-closet. -This whole section is both ugly and important.</p> - -<div class="sidenote">11. Summary.</div> - -<p>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.</p> - -<p>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.</p> - -<p>Believe that all this is neither theory nor fidget—but -practice.</p> - -<p>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 <abbr title="Saint">St.</abbr> 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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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<span class="pagenum"><a name="Page_86" id="Page_86">[86]</a></span> -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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>; each to have and keep his key; each to -have his locker.</p> - -<p>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; <i>vice</i> the Nurse’s room.</p> - -<div class="sidenote">12. Nurses’ -Sleeping -Quarters.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<p>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 partitio<span class="pagenum"><a name="Page_87" id="Page_87">[87]</a></span>ns -numbered or named as rooms, containing each Nurse’s -broom, dustpan, <abbr title="etcetera">&c.</abbr>, each with a key.</p> - -<p>Also pump, sink, water closet.</p> - -<div class="sidenote">Furnishing.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, 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, <abbr title="etcetera">&c.</abbr></p> - -<p>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.</p> - -<p>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; <i>e. g.</i>, 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 cha<span class="pagenum"><a name="Page_88" id="Page_88">[88]</a></span>rwoman -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.</p> - -<div class="sidenote">13. -Classification -of Cases.</div> - -<p>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.</p> - -<div class="sidenote">14. Nurses to -be called by the -Names of their -Wards.</div> - -<p>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.</p> - -<p>Thus a Sister of <abbr title="Saint">St.</abbr> Thomas’s Hospital, whose services in -the War Hospitals of the East I can never forget, was always -at <abbr title="Saint">St.</abbr> 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.</p> - -<p>All this, the only course of all the great and, I believe, of -the smaller London Hospitals, works excellently, in many -ways.</p> - -<div class="sidenote">15. Foul Linen—how -to be -Disposed of.</div> - -<p>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<span class="pagenum"><a name="Page_89" id="Page_89">[89]</a></span> -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.</p> - -<div class="sidenote">16. Washing -Bandages.</div> - -<p>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 <i lang="it" xml:lang="it">alla meglio</i>? The former is -the better plan; if not adopted, the Nurse must see well to -the matter.</p> - -<div class="sidenote">17. Splints—Bandages, -Lint, -<abbr title="etcetera">&c.</abbr>, where to -be kept.</div> - -<p>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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, are excellently arranged, as at -<abbr title="Saint">St.</abbr> 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, <abbr title="etcetera">&c.</abbr>, any splint sent by the Surgeon into the ward. -Let our masters take exactly their own way about this.</p> - -<p>Bandages, lint, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr> 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.</p> - -<div class="sidenote">Cotton Lint -never to be -used.</div> - -<p>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 <i>charpie</i> 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<span class="pagenum"><a name="Page_90" id="Page_90">[90]</a></span> -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.</p> - -<div class="sidenote">18. -Classification -of Women.</div> - -<p>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.</p> - -<div class="sidenote">Superintendent’s -Store -room.</div> - -<p>The Superintendent<a name="Anchor_18" id="Anchor_18" href="#Footnote_18" class="fnanchor" title="Go to footnote 18.">[18]</a> 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, <abbr title="etcetera">&c.</abbr>, -<abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, sadly hinders the Matron’s time from more important -things.</p> - -<p>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 ad<span class="pagenum"><a name="Page_91" id="Page_91">[91]</a></span>vantageous -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 <span lang="fr" xml:lang="fr">Sœurs de <abbr title="Saint">St.</abbr> Vincent</span>, who, in theory and -fact, subject entirely to the will of the Superiors in general -practice, are yet selected and trained for <span lang="fr" xml:lang="fr">spécialités</span>, who remain -long in these <span lang="fr" xml:lang="fr">spécialités</span>, which <span lang="fr" xml:lang="fr">spécialités</span> include such requiring -more or less of physical strength, seems to be one giving many -useful hints for us.</p> - -<hr class="chap" /> -<h2><span class="smcap">Addenda as to Mixed Nursing by Nurses and Orderlies -in Military Hospitals on the Double Pavilion Plan.</span></h2> -<h3 title="" class="faux"><span class="smcap">Orderlies’ Duties</span></h3> - -<p>I. After much anxious thought, re-consideration of all -things, and pondering, I submit—</p> - -<p>1. That three Orderlies will efficiently serve a ward of from -28 to 30 patients, including night-duty.</p> - -<p>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.</p> - -<p>3. That if night-duty be required, each such ward should -have an Orderly on night-duty.</p> - -<p>4. That each such ward should have a scullery.</p> - -<p>With regard to these questions, I further submit—</p> - -<p>1. Economy of hands, combined with efficiency of service, -is an urgent thing in all Hospitals; most of all in Military -Hospitals,</p> - -<p>On the score of expense;</p> - -<p>On that of efficiency of inspection;</p> -<p><span class="pagenum"><a name="Page_92" id="Page_92">[92]</a></span></p> - -<p class="sub">From the nature of Military Hospitals, where the aim should -be throughout to combine great simplicity with thorough -efficiency;</p> - -<p class="sub">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.</p> - -<p>2. Yet economy of hands, carried too far, becomes, like all -other such economies, penny wise and pound foolish.</p> - -<p>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.</p> - -<p>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.</p> - -<p>5. It would be better to give each Nurse one great ward; but -wards above a certain size are inadmissible for sanitary reasons.</p> - -<p>6. The care of 24 to 30 patients is not sufficient duty, by a -great deal, for a Nurse.</p> - -<p>7. Therefore, upon the whole, and as decidedly the lesser of -two evils, I recommend assigning to each Nurse two wards.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>(1). “Settling the diets,” and fetching, besides waiting for, -portions of those diets (<i>e. g.</i> wine) and medicine.</p> - -<p>(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<span class="pagenum"><a name="Page_93" id="Page_93">[93]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<i>minutiæ</i> 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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_94" id="Page_94">[94]</a></span></p> -<p class="neohead"><i>Orderlies.</i></p> - -<p>12. I should prefer wards of 30 each to wards of 25 each.</p> - -<p>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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, on necessary furniture; supernumerary -shelves, nooks and corners, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr> 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.</p> - -<p>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.</p> - -<p>Believe that this is not theory, but the result of practical -observation, much extended.</p> - -<p>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, -<abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<p>17. Upon an average, these two things make the difference -of one Orderly’s duty to a ward of 30 men.</p> - -<p>18. And a ward of 30 men, so supplied, would be efficiently -served by half a nurse and three Orderlies, including night-duty.</p> - -<p>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,<span class="pagenum"><a name="Page_95" id="Page_95">[95]</a></span> -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.</p> - -<p>In these memoranda as to Orderlies’ work, <abbr title="etcetera">&c.</abbr>, 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, -<abbr title="etcetera">&c.</abbr> the labour of the Orderlies would be, without -underrating that required for keeping oiled floors cleaned, very -materially lightened.</p> - -<p class="neohead"><i>Night-duty of Orderlies.</i></p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_96" id="Page_96">[96]</a></span></p> - -<p>21. In Civil Hospitals, served by women, I should undoubtedly -prefer assigning the night-duty to one Assistant Nurse.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Believe, again, that this is not theory, but the result of -practical observation, much extended.</p> - -<p>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.</p> - -<div class="sidenote">Scheme of -Night-Service -for Three -Orderlies -watching by -turns.</div> - -<p>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 -<span class="smcap">P.M.</span>, and remain on duty until 9 <span class="smcap">A.M.</span>, thus taking his share in -the heavy morning work of cleaning the ward, <abbr title="etcetera">&c.</abbr> In all well-ordered -Hospitals it is required that this should be done by 10 -<span class="smcap">A.M.</span>, in some by 9 <span class="smcap">A.M.</span> 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, <abbr title="etcetera">&c.</abbr> cleaning is hurried through. -A large ward, got into thorough order by 9 <span class="smcap">A.M.</span>, is in very -good time. Of course it may happen occasionally to be got -ready somewhat earlier, but this refers to the average.</p> - -<p><span class="pagenum"><a name="Page_97" id="Page_97">[97]</a></span></p> -<p><span class="smcap">Scheme for Three Orderlies A. B. C. Serving Ward X.</span></p> - -<p>Monday, 3 <span class="smcap">P.M.</span> A goes to bed, after taking his share of -the morning work, eating his dinner, and helping to clear away -ward dinner, <abbr title="etcetera">&c.</abbr> 9 <span class="smcap">P.M.</span> A comes on night duty, after 5 hours’ -sleep, and allowing 1 hour for undressing, dressing, and eating -his supper.</p> - -<p>Tuesday, 9 <span class="smcap">A.M.</span> A goes off duty, having watched until 6 <span class="smcap">A.M.</span>, -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 <span class="smcap">P.M.</span>; 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 <span class="smcap">P.M.</span>, return on duty, washed and shaved. B goes to -bed, <abbr title="etcetera">&c.</abbr>; 9 <span class="smcap">P.M.</span> B comes on night duty.</p> - -<p>Wednesday, 9 <span class="smcap">A.M.</span> B goes off duty; 3 <span class="smcap">P.M.</span>, C goes to -bed, <abbr title="etcetera">&c.</abbr>; 9 <span class="smcap">P.M.</span>, C comes on night duty, <abbr title="etcetera">&c.</abbr></p> - -<p>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.</p> - -<div class="sidenote">Exercise for -Orderlies.</div> - -<p>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 a<span class="pagenum"><a name="Page_98" id="Page_98">[98]</a></span>ll -kinds know and act on this as regards themselves.</p> - -<p>The waste of time and strength, at present too often incurred -by the endless fetching, heavy carrying, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<div class="sidenote">Night -Refreshment -for Orderlies -necessary.</div> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>A strong soldier, required to watch in a ward and fast from -9 <span class="smcap">P.M.</span> till 9 <span class="smcap">A.M.</span>, or 6 <span class="smcap">A.M.</span>, 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<span class="pagenum"><a name="Page_99" id="Page_99">[99]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>I have suggested the division of the Night Orderly’s sleep, -because, if A. comes on duty at 6 <span class="smcap">A.M.</span>, and is sent to bed at -noon or 1 to get ready for his night watch at 9 <span class="smcap">P.M.</span>, 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<span class="pagenum"><a name="Page_100" id="Page_100">[100]</a></span> -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 <span class="smcap">P.M.</span> to 9 <span class="smcap">P.M.</span> 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 <span class="smcap">A.M.</span> 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.</p> - -<div class="sidenote">Where are the -Night -Orderlies to -Sleep by Day?</div> - -<p>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.</p> - -<p>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 <span class="pagenum"><a name="Page_101" id="Page_101">[101]</a></span>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.</p> - -<p>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.</p> - -<div class="sidenote">Comparative -Merits of -Different -Systems of -Night -Nursing.</div> - -<p>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.</p> - -<p>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.</p> - -<table class="watchers" summary="watchers"> -<tr> - <td class="people"> - A Sister watches in the female medical wards - </td> - <td class="peudobrace" rowspan="5"> - </td> - <td class="postbrace" rowspan="5">5 Watchers - </td> -</tr> -<tr> - <td class="people"> - <span class="ditto">A Sister watches in the female</span> surgical <span class="ditto">wards</span> - </td> -</tr> -<tr> - <td class="people"> - <span class="ditto">A Sister watches in the</span> children’s wards and girls’ ward - </td> -</tr> -<tr> - <td class="people"> - A Man-Nurse <span class="ditto">watches in the</span> male medical wards - </td> -</tr> -<tr> - <td class="people"> - <span class="ditto">A Man-Nurse watches in the male</span> surgical wards and boys’ ward - </td> -</tr> -</table> - -<p>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.</p> - -<p>As regards all English hospitals, civil or military, the -advantages of this system are these:—</p> - -<p>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.</p> - -<p>2. It secures these persons good<span class="pagenum"><a name="Page_102" id="Page_102">[102]</a></span> food and refreshment at -night.</p> - -<p>3. These persons know their sick, and, being told on coming -on duty, of any change, <abbr title="etcetera">&c.</abbr>, are as much at home in their posts -by night as others are by day.</p> - -<p>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.</p> - -<p>(Many a strong Nurse cannot sleep at day.)</p> - -<p>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.</p> - -<p><i>Per contrà.</i></p> - -<p>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.</p> - -<p>It is right to bear in mind,—</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_103" id="Page_103">[103]</a></span>to those of the London hospitals. The docks, the manufactures, -the crowded and dangerous works, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, with us, -account for this.</p> - -<p>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.</p> - -<p>II. The second flaw of the above system, as it applies to -London Hospitals, is, that it renders Extra-Watchers so often -indispensable.</p> - -<p>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.</p> - -<p>This is a very important reason, I humbly consider, for -avoiding as much as possible small wards.</p> - -<p>I do consider small wards very objectionable in working a -Hospital.</p> - -<p>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.</p> - -<p>How far English Army Surgeons consider night watching -desirable in the Army Hospitals I will presently tell.</p> - -<p>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.</p> - -<p>If night duty<span class="pagenum"><a name="Page_104" id="Page_104">[104]</a></span> 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.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, in home -service; and with regard to supervision in the latter.</p> - -<p>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.</p> - -<p>In <abbr title="Saint">St.</abbr> George’s there is a Night-Matron, chief over the -Night-Nurses, who goes through the Hospital every hour -during the night-watch.</p> - -<p>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 <abbr title="Saint">St.</abbr> George’s sleep away from their -wards; a great mistake, I humbly consider.</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr></p> - -<p><span class="pagenum"><a name="Page_105" id="Page_105">[105]</a></span></p> - -<p>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.</p> - -<div class="sidenote">Present State -of Night-Nursing -in -Military -Hospitals.</div> - -<p>29. The following extraordinary system of Night Nursing is -that which prevails in the Army at present:</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.” [<i>sic.</i>]</p> - -<p>“Orderlies are likewise warned and often sit up for the purpose.”</p> - -<p>These passages are given <i>verbatim et literatim</i>, because they -are so remarkable.</p> - -<p>And it is necessary to add that these patients being the -relapses among the “Invalids” are nearly the worst cases we -have.</p> - -<p>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 <em>nurse</em> (for -the first time perhaps in their lives,) and a very “serious” case -too, is to say the least of it a singular one.</p> - -<p>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 requir<span class="pagenum"><a name="Page_106" id="Page_106">[106]</a></span>ed -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.</p> - -<p>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.</p> - -<p>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.”</p> - -<p>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.</p> - -<p class="hang">Of constantly sick mean proportion per cent. requiring night -nursing:</p> - -<table class="staffing" summary="percentage requiring night nursing"> - <tr> - <td class="longer"> General Hospital, Fort Pitt Medical Division</td> - <td class="tdr">5</td> - </tr> - <tr> - <td class="longer"> General Hospital, Fort Pitt Surgical <span class="ditto">Division</span></td> - <td class="tdr">1</td> - </tr> - <tr> - <td class="longer">Garrison Hospital</td> - <td class="tdr">2</td> - </tr> -</table> - -<p>These cases are usually scattered through the wards.</p> - -<p>It is but fair to add that the best Medical Officers<span class="pagenum"><a name="Page_107" id="Page_107">[107]</a></span> 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.”</p> - -<p>What are the consequences of such “assistance” to the -cases in question has already been fully stated throughout these -notes.</p> - -<div class="sidenote">Poor-Law -Regulation for -Nursing in -Union Workhouses.</div> - -<p>“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.”</p> - -<p>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!<a name="Anchor_19" id="Anchor_19" href="#Footnote_19" class="fnanchor" title="Go to footnote 19.">[19]</a> 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!</p> - -<p>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<span class="pagenum"><a name="Page_108" id="Page_108">[108]</a></span> 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.</p> - -<p>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 <em>nurse each other</em>!</p> - -<h3 title="">II. <span class="smcap">Nurse’s Room</span>, <abbr title="etcetera">&c.</abbr></h3> - -<div class="sidenote">Nurse’s Room.</div> - -<p>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 <span lang="fr" xml:lang="fr">Vincennes</span>, a lobby with a -thorough supply of pure fresh air.</p> - -<p>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.</p> - -<div class="sidenote">Medical -Officer’s Room.</div> - -<p>2. The Medical Officer’s room should be on the ground floor -at the entrance and apart from everything else.</p> - -<p>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).</p> - -<div class="sidenote">Water-Closets.</div> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_109" id="Page_109">[109]</a></span> -wards.</p> - -<p>The latrines at the <span lang="fr" xml:lang="fr">Lariboisière</span> Hospital are a good example, -both for what should be avoided in construction, and what -should be imitated in position.</p> - -<p>The sort of latrine used there would never do for England.</p> - -<p>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.</p> - -<p>At night no sick men are allowed to leave the ward on that -or any other pretence; they must use the latrines.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">Warm and -Cold-Water -Supply.</div> - -<p>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.</p> - -<div class="sidenote">Corridors.</div> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">Lobby.<span class="pagenum"><a name="Page_110" id="Page_110">[110]</a></span></div> - -<p>6. Provided this double range of windows be secured, double -wards of thirty on the same floor would cause no disadvantage -to the sick.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">Material of -Ward -Utensils.</div> - -<p>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.</p> - -<p>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.</p> - -<p>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; <span class="pagenum"><a name="Page_111" id="Page_111">[111]</a></span>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.</p> - -<div class="sidenote">Reserve Wards.</div> - -<p>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, <abbr title="etcetera">&c.</abbr></p> - -<p>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 <span class="pagenum"><a name="Page_112" id="Page_112">[112]</a></span>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.</p> - -<p>Now it might be exceedingly worth while to have one or more -reserve Pavilions, with a view to this annual cleaning.</p> - -<p>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.</p> - -<p>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.</p> - -<p>It may now be confidently expected that, under the new -<i>régime</i>, 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.</p> - -<p>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<span class="pagenum"><a name="Page_113" id="Page_113">[113]</a></span> the remaining -parts of the building.</p> - -<div class="sidenote">Occasional -Revision of -Rules.</div> - -<p>9. Dr. Esse, Director of the <span lang="fr" xml:lang="fr">Charité</span>, 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 <span lang="fr" xml:lang="fr">Charité</span> 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.</p> - -<div class="sidenote">Defect in some -Systems of -Nursing.</div> - -<p>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 <span lang="fr" xml:lang="fr">Charité</span> -Hospital at Berlin, so in the great General Hospital at Vienna; -and this cardinal mistake leads to many others.</p> - -<div class="sidenote">Nurses’ -Exercise.</div> - -<p>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 <i>vice</i> two hours, <abbr title="etcetera">&c.</abbr></p> - -<p>In war and foreign service, the exercise time must be at the -discretion of the Superintendent.</p> - -<p>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 -<span class="pagenum"><a name="Page_114" id="Page_114">[114]</a></span>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 -<i>pro tanto</i>, degrades all who are concerned with it.</p> - -<div class="sidenote">Number of -Ward-Masters.</div> - -<p>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).</p> - -<p>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.</p> - -<h3 title="">III. <span class="smcap">Regulations.</span></h3> - -<div class="sidenote">Query as to -depriving -certain -Patients of -Visitors.</div> - -<p>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.</p> - -<p>In the Vienna Military Hospital they are locked up by -themselves in particular wards, but are allowed to see their -comrades at visiting hours.</p> - -<p>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.</p> - -<p>Nor are <span class="pagenum"><a name="Page_115" id="Page_115">[115]</a></span>they allowed exercise in the grounds.</p> - -<p>This excellent regulation makes them heartily tired of the -venereal wards, and even this is a very salutary thing.</p> - -<p>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.</p> - -<p>In the two Paris Venereal Hospitals no visitors are -allowed.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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,<span class="pagenum"><a name="Page_116" id="Page_116">[116]</a></span> -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.</p> - -<p>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.</p> - -<p>Let the female service obtain, please God (I do not write -these words <i>pro formâ</i>,—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.”</p> - -<div class="sidenote">Query as to -Numbering -Patients.</div> - -<p>2. Military as well as Medical advice should also be taken -upon the following point:</p> - -<p>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, <abbr title="etcetera">&c.</abbr>, suspended over each bed; sometimes a<span class="pagenum"><a name="Page_117" id="Page_117">[117]</a></span> -patient’s name is never heard in the ward.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="sidenote">Regulations as -to Swearing.</div> - -<p>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.</p> - -<div class="sidenote">Conclusion.</div> - -<p>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.</p> - -<hr class="chap" /> - -<p><span class="pagenum"><a name="Page_118" id="Page_118">[118]</a></span></p> - -<h2><span class="smcap">Additional Hints as to Pavilion Hospitals suggested -by the construction of the <span lang="fr" xml:lang="fr">Lariboisière</span> Hospital -at Paris.</span></h2> - -<h3 title="">I.—<em>Ventilation.</em></h3> - -<p>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 <span lang="fr" xml:lang="fr">Lariboisière</span>, that I have added a few -practical remarks upon this system. The conclusion is, that -even at the <span lang="fr" xml:lang="fr">Lariboisière</span>, 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.</p> - -<p>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.</p> - -<p>Persons at the <span lang="fr" xml:lang="fr">Lariboisière</span> 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.</p> - -<p><i>Per contrà.</i> 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 <span class="pagenum"><a name="Page_119" id="Page_119">[119]</a></span>side quite -sufficient.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The ventilation on both sides is considered to work with -equal efficiency during the whole of the day.</p> - -<p>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>i.e.</i> the -air is surprisingly little bad. <em>But neither here, any more -than anywhere else, are the wards effectually freshened, until -the windows are, of course with proper caution, opened.</em></p> - -<p>In both these particulars, no difference is to be observed -between the male and female side.</p> - -<p>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:</p> - -<p>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 <span lang="fr" xml:lang="fr">Lariboisière</span>.</p> - -<p>Secondly. If an accident happened to the machi<span class="pagenum"><a name="Page_120" id="Page_120">[120]</a></span>nery 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.</p> - -<p>More or less danger is inseparable from powerful steam -machinery, or powerful machinery of any kind: the question is -one of degree.</p> - -<p>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 <abbr title="etcetera">&c.</abbr>, 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, <i>e.g.</i> warming -broth or drink, cooking for an extra bad case, warming -poultices, warming (not airing) linen for ditto, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, <abbr title="etcetera">&c.</abbr>, -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.</p> - -<p>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.</p> - -<h3 title="">II.—<em>Oiled Boards</em> versus <em>Parquets</em>.</h3> - -<p>1. They have in common the superiority over common floorings—that -they are not scrubbed, and the damp thus arising is -avoided.</p> - -<p>2. As re<span class="pagenum"><a name="Page_121" id="Page_121">[121]</a></span>gards labour, so far as Civil Hospitals are concerned, -where the ward service is done by women, <i>parquets</i> would be -more laborious than scrubbing; a large ward, to be kept in a -proper state, requires a certain amount of <i>frottage</i> (the peculiar -polishing of <i>parquets</i>) every day; and this <i>frottage</i> 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 <i>frotter</i>; it is -altogether a man’s business.</p> - -<p>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 <i>frottage</i>; 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 <i>frotteurs</i>.</p> - -<p>4. As regards labour, cleaning oiled boards, though a -laborious business, is much less so than either scrubbing or -<i>frottéing</i>; 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).</p> - -<p>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.</p> - -<p>6. Apart from the question of labour augmented or spared, -the advantages of oiled and polished boards I believe to be -these:—</p> - -<p>(1.) Prevention of dust.</p> - -<p>(2.) More easy purification<span class="pagenum"><a name="Page_122" id="Page_122">[122]</a></span> of the air of the ward in the -morning.</p> - -<p>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.</p> - -<p>The dust is more thoroughly destroyed by the cleaning -necessary to oiled and polished boards <em>of the <span lang="de" xml:lang="de">Bethanien</span> variety</em>, -than by any other cleaning I have seen. It is fairly destroyed; -whereas both <i>parquets</i> and boards generally retain a little.</p> - -<p>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.</p> - -<p>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 -<i>parquets</i> are considered equal in these respects to them.</p> - -<p>Stains, mess, and dirt falling on polished oiled boards are -much more easily cleaned than on parquets.</p> - -<h4 title=""><span class="smcap">Note.</span><br /> - - <i>Mode of Cleaning Ward and Room Floors at <span lang="de" xml:lang="de">Bethanien</span>, Berlin.</i></h4> - -<h5 title="">I. <span class="smcap">Daily.</span></h5> - -<p>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.</p> - -<p>2. Sweep the floor and skirtings with the hair broom.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_123" id="Page_123">[123]</a></span> -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.</p> - -<p>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.</p> - -<p>6. Change the water when dirty. More or less water must -be used, according as the floor is trod by dirty boots and -shoes.</p> - -<p>7. Aim at drying the floor by one dry brushing; if not, it -must be dry brushed a second time. Once should suffice.</p> - -<p>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.</p> - -<p>9. On putting by the cleaning materials, rinse well the -cloth in clean water.</p> - -<h5 title="">II. <span class="smcap">Weekly.</span></h5> - -<p>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.</p> - -<p>2. Use more water to clean the floor, which will probably -require two dry brushings.</p> - -<p>3. Clean the brooms and pails.</p> - -<h5 title="">III. <span class="smcap">Annually.</span></h5> - -<p>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.</p> - -<p>[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, an<span class="pagenum"><a name="Page_124" id="Page_124">[124]</a></span>d 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.]</p> - -<h3 title="">III.—<i>Cautions in Hospital-Building.—Often repeated, but -oftener neglected.</i></h3> - -<p>1. Wherever practicable build the hospital on arches; but, -for the sake of discipline, they should be locked up.</p> - -<p>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.</p> - -<p>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,</p> - -<p>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.</p> - -<p>5. In Germany, the general opinion is in favour of small -wards, twenty beds are considered the desirable maximum; -twelve, <i>per se</i>, better than twenty.</p> - -<p>Ditto in Belgium, under the same restriction, although, in -practice, there are wards containing larger numbers.</p> - -<p>In the old Hospitals at Paris, the number of patients is too -large. The <span lang="fr" xml:lang="fr">Charité</span> has long great wards of 100 and 120 -patients. At <abbr title="Saint">St.</abbr> 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 <span lang="fr" xml:lang="fr">Charité</span>, somewhat densely -pressed upon by neighbourhood, is also not considered a -favourably circumstanced Hospital as to air.</p> - -<p>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<span class="pagenum"><a name="Page_125" id="Page_125">[125]</a></span> -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.</p> - -<p>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.</p> - -<p>Such persons consider that the size and numbers of the -wards at the <span lang="fr" xml:lang="fr">Lariboisière</span> 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, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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!</p> - -<p>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!</p> - -<p>6. There is not<span class="pagenum"><a name="Page_126" id="Page_126">[126]</a></span>hing at the <span lang="fr" xml:lang="fr">Lariboisière</span> 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.</p> - -<p>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.</p> - -<p>But <em>if</em> 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.</p> - -<p><em>Apart from the purposes which the casualty wards answer</em>, 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 <em>impossible</em> to serve the inmates of the -little ward properly, if there are also many serious cases in the -large ward.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_127" id="Page_127">[127]</a></span> -attendance of such cases, than small wards attached to the -ordinary wards.</p> - -<p>7. Avoid many holes and corners. I could <em>not</em> 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.</p> - -<p>At the <span lang="fr" xml:lang="fr">Lariboisière</span> 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.</p> - -<p>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.</p> - -<p>9. Provide from the first room for storing and issuing dried -clean linen, as well as laundry room.</p> - -<p>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.</p> - -<hr class="chap" /> - -<p><span class="pagenum"><a name="Page_128" id="Page_128">[128]</a></span></p> - -<h2><span class="smcap">Note on Contagion and Infection.</span></h2> - -<p>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!</p> - -<p>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 <em>current contagions</em>.” [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 <span class="pagenum"><a name="Page_129" id="Page_129">[129]</a></span>“unavoidable.”</p> - -<p>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.</p> - -<p>“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.</p> - -<p>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.</p> - -<p>The word “contagion” therefore is altogether objectionable.</p> - -<p>The word “infection” expresses a fact, without involving a -hypothesis.</p> - -<p>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 <em>inevitable</em> “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, a<span class="pagenum"><a name="Page_130" id="Page_130">[130]</a></span>nd the usual -tribe of Hospital-generated epidemic diseases produced.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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!</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_131" id="Page_131">[131]</a></span> -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.</p> - -<p>It may be useful to mention what the meaning is of the -words “epidemic,” “endemic,” “sporadic,” and “zymotic.”</p> - -<p>When a large number of people are attacked simultaneously -with the same form of disease it is said to be <em>epidemic</em>. When -a small number, as, <i>e. g.</i>, the inhabitants of a single court or -alley, are so attacked, it is said to be <em>endemic</em>. When scattered -cases of the same disease happen, one here, one there, over a -large surface, the disease is said to be <em>sporadic</em>. The term -<em>zymotic</em>, 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.</p> - -<p>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 measur<span class="pagenum"><a name="Page_132" id="Page_132">[132]</a></span>es -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.</p> - -<p>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.”</p> - -<hr class="chap" /> - -<h2 title="Note on Observations by the Principal Medical Officer of the Army in the East"><span class="smcap">Note.</span></h2> - -<p>I have just seen a paper by Sir John Hall, entitled -“<cite class="plain">Observations on the Difficulties experienced by the Medical -Department of the Army during the late War in Turkey</cite>.” -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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?</p> - -<p>Sir John Hall must have already discovered that this old -weapon is no longer of use in defending his position.</p> - -<p>It would have been more to the purpose had he produced -his requisitions for food, clothing, comforts, <abbr title="etcetera">&c.</abbr>, 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, <abbr title="etcetera">&c.</abbr>, to -the French Hospitals (for part only of what was given were -Government stores at all), Sir John Hall might have obtained,<span class="pagenum"><a name="Page_133" id="Page_133">[133]</a></span> -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 <span lang="fr" xml:lang="fr"><abbr title="Monsieur">M.</abbr> -Baudens</span><a name="Anchor_20" id="Anchor_20" href="#Footnote_20" class="fnanchor" title="Go to footnote 20.">[20]</a> than assuming that I could obtain from Government -stores and wine for the French Hospitals which he could not -obtain for his own.</p> - -<p>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.</p> - -<div class="footnotes"> -<h3 title="">Footnotes:</h3> - -<ul> -<li> - <p><a name="Footnote_2" id="Footnote_2" href="#Anchor_2" title="Return to text.">[2]</a> -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: -“<span lang="fr" xml:lang="fr">Calomniez, calomniez toujours: il en reste toujours quelque chose.</span>” 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).</p> -</li> - -<li> - <p><a name="Footnote_3" id="Footnote_3" href="#Anchor_3" title="Return to text.">[3]</a> -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 -<i>pro tanto</i> 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.</p> -</li> - -<li> - <p><a name="Footnote_4" id="Footnote_4" href="#Anchor_4" title="Return to text.">[4]</a> -The Extra Diet Kitchens <em>must</em>, 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, <abbr title="etcetera">&c.</abbr> 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.</p> -</li> - -<li> - <p><a name="Footnote_5" id="Footnote_5" href="#Anchor_5" title="Return to text.">[5]</a> -To all references which may here be made to Civil Hospitals I should -wish to say, by way of preface:—</p> -<p>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.</p> -<p>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.</p> -</li> - -<li> - <p><a name="Footnote_6" id="Footnote_6" href="#Anchor_6" title="Return to text.">[6]</a> -In their regulation dress they should always appear, except when they -go on holidays.</p> -<p>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.</p> -</li> - -<li> - <p><a name="Footnote_7" id="Footnote_7" href="#Anchor_7" title="Return to text.">[7]</a> -I would allow each Nurse 1½ pint of porter or ale <i>per diem</i>, or, instead -of the half-pint of porter, 1 <abbr title="ounces">oz.</abbr> of brandy or a wineglass-full of wine, as she -likes best. Most Nurses crave, and rightly, for a luncheon about 9 or -10 <span class="smcap">A.M.</span>, 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.</p> -</li> - -<li> - <p><a name="Footnote_8" id="Footnote_8" href="#Anchor_8" title="Return to text.">[8]</a> -Better than a closet is a moveable dresser, only table-height, under -which cleaning can be carried on.</p> -<p>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.</p> -</li> - -<li> - <p><a name="Footnote_9" id="Footnote_9" href="#Anchor_9" title="Return to text.">[9]</a> -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.</p> -</li> - -<li> - <p><a name="Footnote_10" id="Footnote_10" href="#Anchor_10" title="Return to text.">[10]</a> -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.</p> -</li> - -<li> - <p><a name="Footnote_11" id="Footnote_11" href="#Anchor_11" title="Return to text.">[11]</a> -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.</p> -</li> - -<li> - <p><a name="Footnote_12" id="Footnote_12" href="#Anchor_12" title="Return to text.">[12]</a> -It is better to omit the Belief. Singularly enough it is the one thing -objected to by Dissenters and Roman Catholics.</p> -</li> - -<li> - <p><a name="Footnote_13" id="Footnote_13" href="#Anchor_13" title="Return to text.">[13]</a> -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.</p> -</li> - -<li> - <p><a name="Footnote_14" id="Footnote_14" href="#Anchor_14" title="Return to text.">[14]</a> -One Nurse might possibly be able to serve the whole Pavilion. The -highest estimate is here taken.</p> -</li> - -<li> - <p><a name="Footnote_15" id="Footnote_15" href="#Anchor_15" title="Return to text.">[15]</a> -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 <abbr title="inches">in.</abbr> in height and 1½ <abbr title="inches">in.</abbr> 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. -</p> -<p> -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.</p> -</li> - -<li> - <p><a name="Footnote_16" id="Footnote_16" href="#Anchor_16" title="Return to text.">[16]</a> -And this should be adhered to, the rare though extant cases of efficiency -for Hospital nursing, past this age, notwithstanding.</p> -</li> - -<li> - <p><a name="Footnote_17" id="Footnote_17" href="#Anchor_17" title="Return to text.">[17]</a> -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.</p> -</li> - -<li> - <p><a name="Footnote_18" id="Footnote_18" href="#Anchor_18" title="Return to text.">[18]</a> -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.</p> -</li> - -<li> - <p><a name="Footnote_19" id="Footnote_19" href="#Anchor_19" title="Return to text.">[19]</a> -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.</p> -</li> - -<li> - <p><a name="Footnote_20" id="Footnote_20" href="#Anchor_20" title="Return to text.">[20]</a> -To <span lang="fr" xml:lang="fr"><abbr title="Monsieur">M.</abbr> Baudens</span>, 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.</p> -</li> -</ul> - -</div> - -<hr class="chap" /> - -</div> - -<div class="chapter"> -<p class="printed_by"> -LONDON:<br /> -PRINTED BY HARRISON AND SONS,<br /> -<abbr title="SAINT">ST.</abbr> MARTIN’S LANE, W.C.<br /> -</p> - -<hr class="chap" /> - -</div> - -<div class="chapter"> - -<p><span class="pagenum"><a name="Page_1p" id="Page_1p">[1]</a></span></p> -<p class="private">PRIVATE AND CONFIDENTIAL.</p> - -<h2 title="Thoughts submitted as to an eventual -Nurses’ Provident Fund.">THOUGHTS SUBMITTED AS TO AN EVENTUAL -NURSES’ PROVIDENT FUND.</h2> - -<p>I. <span class="smcap">Wages and Prospects of Nurses.</span></p> - -<p>II. <span class="smcap">Desirability of some further Provision.</span></p> - -<p>III. <span class="smcap">Of what Nature?</span></p> - -<ul> - <li>1. With regard to kind?</li> - <li>2. <span class="ditto">With regard to</span> persons?</li> - <li>3. <span class="ditto">With regard to</span> objects?</li> -</ul> - -<p>IV. <span class="smcap">Suggestions as to the Rules to be followed.</span></p> - -<p>V. <span class="smcap">Prospects of Eventual Support.</span></p> - -<hr class="short" /> - -<h3 title="">I. <span class="smcap">Wages and Prospects of Nurses.</span></h3> - -<div class="sidenote">The two -Classes of -Hospital -Nurses.</div> - -<p>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.</p> - -<div class="sidenote">Head-Nurses -or Sisters.</div> - -<p>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.</p> - -<p class="pagenum"><a name="Page_2p" id="Page_2p">[2]</a></p> -<div class="sidenote">Nurses or Assistant-Nurses.</div> - -<div class="sidenote">Day Nurses.</div> - -<p>3. The day-nurses, on an average, receive about 12<i><abbr title="shillings">s.</abbr></i> 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.</p> - -<div class="sidenote">Night Nurses.</div> - -<p>4. The night-nurses, on an average, receive about 10<i><abbr title="shillings">s.</abbr></i> 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.</p> - -<div class="sidenote">Retiring -Pensions and -Payments at <abbr title="Saint">St.</abbr> -Bartholomew’s.</div> - -<p>5. I am informed that <abbr title="Saint">St.</abbr> 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.</p> - -<div class="sidenote">At -<abbr title="Saint">St.</abbr> Thomas’s.</div> - -<p>6. <abbr title="Saint">St.</abbr> 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.</p> - -<div class="sidenote">At Guy’s -Hospital.</div> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_3p" id="Page_3p">[3]</a></span> -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.</p> - -<div class="sidenote">At the Non-Endowed -Hospitals.</div> - -<p>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.</p> - -<div class="sidenote">At County -Hospitals.</div> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_4p" id="Page_4p">[4]</a></span></p> -<h3 title="">II. <span class="smcap">Desirability of some further Provision.</span></h3> - -<div class="sidenote">Unfitness of -Nurses for any -other work.</div> - -<p>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.</p> - -<div class="sidenote">Shortness of -their time of -capacity for -Service.</div> - -<p>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.</p> - -<div class="sidenote">Character of -Nurses as a -Class.</div> - -<p>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.</p> - -<p>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.</p> - -<p>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 an<span class="pagenum"><a name="Page_5p" id="Page_5p">[5]</a></span>d -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.</p> - -<p>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.</p> - -<div class="sidenote">Probable -beneficial -results of a -prospect of -eventual -provision, -depending on -character.</div> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_6p" id="Page_6p">[6]</a></span></p> - -<p>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.</p> - -<h3 title="">III. <span class="smcap">Of what Nature?</span></h3> - -<ul> - <li>1. With regard to kind?</li> - <li>2. <span class="ditto"> With regard to</span> persons?</li> - <li>3. <span class="ditto"> With regard to</span> objects?</li> -</ul> - -<div class="sidenote">Kinds of -possible -assistance, -three.</div> - -<p>1. With regard to kind.</p> - -<p>There are three kinds of possible assistance.</p> - -<div class="sidenote">Pensions.</div> - -<p>First. Granting free pensions to efficient and well-conducted -sisters and nurses, under fixed regulations.</p> - -<div class="sidenote">Facilities for -Saving.</div> - -<p>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.</p> - -<div class="sidenote">Additions to -Savings.</div> - -<p>Third. Combining, with the second, a certain proportion -of pecuniary aid.</p> - -<p>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.</p> - -<p>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—</p> - -<div class="sidenote">Information<span class="pagenum"><a name="Page_7p" id="Page_7p">[7]</a></span> -and Advice to -be procured on -the Subject.</div> - -<p><span class="smrom">I.</span> The rules, working, and results so far of the -Servants’ Provident Society.</p> - -<p><span class="smrom">II.</span> Of several of the various partly self-supporting and -partly assisted provident societies of the different trades’ -and city unions.</p> - -<p><span class="smrom">III.</span> Of some dozen benefit societies in large towns.</p> - -<p><span class="smrom">IV.</span> Of Guy’s Hospital Superannuation Fund.</p> - -<p><span class="smrom">V.</span> To take the practical opinion of two experienced -actuaries.</p> - -<p><span class="smrom">VI.</span> Also of the Treasurer and Matron of <abbr title="Saint">St.</abbr> Bartholomew’s;</p> - -<ul> - <li>Of the Treasurer, Resident Medical Officer, and -Matron of <abbr title="Saint">St.</abbr> Thomas’s;</li> - - <li>Of the Treasurer and Matron of Guy’s Hospital;</li> - - <li>Of the Chairman of the House-Committee, House-Governor, -and Matron of the London Hospital;</li> - - <li>Of the equivalent authorities of <abbr title="Saint">St.</abbr> George’s, -and of two or three other hospitals (including King’s -College).</li> -</ul> - -<div class="sidenote">It is not -possible for -Nurses to -purchase -Annuities out -of their -Savings.</div> - -<p>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.</p> - -<p><span class="smrom">I.</span> Their work wears them out comparatively soon.</p> - -<p><span class="smrom">II.</span> During its continuance they require to live well -<i>i. e.</i>, to have a sufficiency of good plain food.</p> - -<p><span class="smrom">III.</span> 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).</p> - -<p>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.<a name="Anchor_21" id="Anchor_21" href="#Footnote_21" class="fnanchor" title="Go to footnote 21.">[21]</a></p> -<p><span class="pagenum"><a name="Page_8p" id="Page_8p">[8]</a></span></p> -<div class="sidenote">Persons to be -assisted.</div> - -<p>2. With regard to persons.</p> - -<p>Shall the Fund be open exclusively to nurses belonging -to the proposed Institution under Miss Nightingale?</p> - -<ul> - - <li>Or extended to those of the London hospitals?</li> - - <li>Or extended to all Hospitals in England?</li> - - <li>Or in the three kingdoms?</li> - - <li>Or in Her Majesty’s dominions in general?</li> - -</ul> - -<p>Shall the Fund be extended to private and monthly -nurses, including midwives, as well as to hospital-nurses?</p> - -<p>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.)</p> - -<p>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.</p> - -<p>I think the Fund might eventually be open to private -nurses, midwives, and monthly nurses.<a name="Anchor_22" id="Anchor_22" href="#Footnote_22" class="fnanchor" title="Go to footnote 22.">[22]</a></p> - -<p><span class="pagenum"><a name="Page_9p" id="Page_9p">[9]</a></span></p> - -<p>I think it perhaps might be open to the <abbr title="Saint">St.</abbr> 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.</p> - -<div class="sidenote">Objects to be -sought.</div> - -<p>3. With regard to objects.</p> - -<p>Shall the objects be</p> - -<ul> - <li>Material?</li> - <li>Sanitary?</li> - <li>Moral?</li> -</ul> - -<p class="noindent">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.</p> - -<p>Upon the whole, and weighing many opposite difficulties, -my impression is strongly in favour of attempting to combine -the three.</p> - -<h4 title="">Material objects.</h4> - -<div class="sidenote">Material -Objects to be -sought.</div> - -<p>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.</p> - -<div class="sidenote">Provision after -Superannuation.</div> - -<p><span class="smrom">I.</span> It appears to me that the main if not the only object -of the Fund should be to provide annuities.</p> - -<div class="sidenote">During -Illness.</div> - -<p><span class="smrom">II.</span> It would be a question whether or not to arrange -for payments during illness.<a name="Anchor_23" id="Anchor_23" href="#Footnote_23" class="fnanchor" title="Go to footnote 23.">[23]</a> 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<span class="pagenum"><a name="Page_10p" id="Page_10p">[10]</a></span> -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.</p> - -<div class="sidenote">Burial -Payments.</div> - -<p><span class="smrom">III.</span> With burial payments I think the Fund should have -nothing to do.</p> - -<div class="sidenote">Payments for -Children.</div> - -<p><span class="smrom">IV.</span> 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.</p> - -<div class="sidenote">Reasons -against the -last Form of -Aid.</div> - -<p>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>i. e.</i>, 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,<span class="pagenum"><a name="Page_11p" id="Page_11p">[11]</a></span> -clothed, “educated,” and put to service out of the £50 a-year -of the head-nurse, or out of the 12<i><abbr title="shillings">s.</abbr></i> 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.</p> - -<p>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 <span class="pagenum"><a name="Page_12p" id="Page_12p">[12]</a></span>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.</p> - -<p>These things enter immensely, minute as they seem, -into the discipline of wards and of the hospital; and discipline -means a great deal.</p> - -<h4 title="">Sanitary objects.</h4> -<p><span class="pagenum"><a name="Page_13p" id="Page_13p">[13]</a></span></p> -<div class="sidenote">Sanitary -Objects.</div> - -<div class="sidenote">To discourage -admission of -women -physically -unfit.</div> - -<p>A good many nurses enter hospital service who are -quite unfit for it. Often consumptive and ruptured women, -those suffering from piles or prolapsus, <abbr title="etcetera">&c.</abbr>, 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.</p> - -<p>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.</p> - -<p>Believe me, all these things are important.</p> - -<h4 title="">Moral objects.</h4> - -<div class="sidenote">Moral Objects -attainable.</div> - -<p>The most difficult part of a difficult thing, only perhaps -it is at the same time the most important.</p> - -<div class="sidenote">Need of -Certificates.</div> - -<p><span class="smrom">I.</span> 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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_14p" id="Page_14p">[14]</a></span></p> - -<p><span class="smrom">II.</span> 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.</p> - -<p>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 <em>assistance</em> that may be given the question is different.</p> - -<p><span class="smrom">III.</span> The preliminary certificate I do consider very -important, and the subsequent ones, if they can be required.</p> - -<div class="sidenote">Hospitals are -not places for -Penitents.</div> - -<p>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.</p> - -<p>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.</p> - -<p>Suffer me to submit, without wearying patience by -urging proof,—</p> - -<p>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.)</p> - -<p><span class="pagenum"><a name="Page_15p" id="Page_15p">[15]</a></span></p> - -<p>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.</p> - -<p>iii. That sham penitents, who unhappily abound, are -dangerous everywhere, extra-dangerous in hospitals, -whether to superiors, companions, or patients.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<h3 title="">IV. <span class="smcap">Rules to be followed in giving Assistance.</span></h3> - -<p>Lastly. With regard to rules to be followed in giving -assistance of whatever kind.</p> - -<div class="sidenote">Need of Advice -with a view -above all to<span class="pagenum"><a name="Page_16p" id="Page_16p">[16]</a></span> -Security.</div> - -<p>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.</p> - -<div class="sidenote">Suggestions in -detail.</div> - -<p>The following suggestions toward obtaining it are offered.</p> - -<p>1. Security of invested savings to be the first and main -thing to be secured. Every other object should be subordinate -to this.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_17p" id="Page_17p">[17]</a></span> -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).</p> - -<p>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. <em>Assistance</em> in the form of an addition to the -annuity may be made <em>contingent</em>; 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.</p> - -<p>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.</p> - -<p>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).</p> - -<p>10. Payments to be made weekly, monthly, quarterly, -or annually, as shall be advised. Amounts to run from -6<i><abbr title="pence">d.</abbr></i> or 1<i><abbr title="shilling">s.</abbr></i> a week upwards. For the plan to work, it ought -to allow small payments on an ascending scale.</p> - -<p>Many will only be able to make very small payments.</p> - -<p><span class="pagenum"><a name="Page_18p" id="Page_18p">[18]</a></span></p> - -<p>Few will be able to make other than small payments.</p> - -<p>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.</p> - -<p>12. All possible safe curtailment of office expenses.</p> - -<p>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.</p> - -<h3 title="">V. <span class="smcap">Prospects of eventual Support.</span></h3> - -<div class="sidenote">Support by the -Nurses -themselves.</div> - -<p>1. I believe that many head-nurses would thoroughly -appreciate and thankfully avail themselves of such a -Fund.</p> - -<p>2. I think that many nurses would do the same, and, in -time, many more. Many cannot contribute to it; many -will not.</p> - -<div class="sidenote">Support from -the Hospitals.</div> - -<p>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 <abbr title="Saint">St.</abbr> 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.</p> - -<div class="sidenote">Support from -the Public in -general.</div> - -<p>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<span class="pagenum"><a name="Page_19p" id="Page_19p">[19]</a></span> -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.</p> - -<p>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.</p> - -<div class="sidenote">Necessity of -Advice.</div> - -<p>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.</p> - -<p><i>January 23, 1858.</i></p> - -<hr class="chap" /> - -<p><span class="pagenum"><a name="Page_20p" id="Page_20p">[20]</a></span></p> -<h2><span class="smcap">Note as to the Number of Women employed as -Nurses in Great Britain.</span></h2> - -<p>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,<a name="Anchor_24" id="Anchor_24" href="#Footnote_24" class="fnanchor" title="Go to footnote 24.">[24]</a> and 2,882 midwives. The -numbers of different ages are shown in table A, and in -table B their distribution over Great Britain.</p> - -<p>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.</p> - -<hr class="chap" /> - -<p><span class="pagenum"><a name="Page_21p" id="Page_21p">[21]</a></span></p> -<h3 title=""><a name="TABLES_OF_AGE_AND_DISTRIBUTION" id="TABLES_OF_AGE_AND_DISTRIBUTION" class="nodec">TABLES OF AGE AND DISTRIBUTION.</a></h3> - -<h4 title=""><span class="smcap">Table A.</span><br /> - -<span>GREAT BRITAIN.</span><br /> - -<span class="smaller">AGES.</span></h4> - -<table class="nurses" summary="nurses by age"> -<tr> - <th> - NURSES. - </th> - <th class="num"> - Nurse<br />(not<br />Domestic Servant) - </th> - <th class="num"> - Nurse<br /><br />(Domestic Servant) - </th> -</tr> -<tr> - <td> - All Ages. - </td> - <td class="num"> - 25,466 - </td> - <td class="num"> - 39,139 - </td> -</tr> -<tr> - <td> - Under 5 Years. - </td> - <td class="num"> - ... - </td> - <td class="num"> - ... - </td> -</tr> -<tr> - <td> - <span class="hidden">0</span>5 — - </td> - <td class="num"> - ... - </td> - <td class="num"> - 508 - </td> -</tr> -<tr> - <td> - 10 — - </td> - <td class="num"> - ... - </td> - <td class="num"> - 7259 - </td> -</tr> -<tr> - <td> - 15 — - </td> - <td class="num"> - ... - </td> - <td class="num"> - 10,355 - </td> -</tr> -<tr> - <td> - 20 — - </td> - <td class="num"> - 624 - </td> - <td class="num"> - 6537 - </td> -</tr> -<tr> - <td> - 25 — - </td> - <td class="num"> - 817 - </td> - <td class="num"> - 4174 - </td> -</tr> -<tr> - <td> - 30 — - </td> - <td class="num"> - 1118 - </td> - <td class="num"> - 2495 - </td> -</tr> -<tr> - <td> - 35 — - </td> - <td class="num"> - 1359 - </td> - <td class="num"> - 1681 - </td> -</tr> -<tr> - <td> - 40 — - </td> - <td class="num"> - 2223 - </td> - <td class="num"> - 1468 - </td> -</tr> -<tr> - <td> - 45 — - </td> - <td class="num"> - 2748 - </td> - <td class="num"> - 1206 - </td> -</tr> -<tr> - <td> - 50 — - </td> - <td class="num"> - 3982 - </td> - <td class="num"> - 1196 - </td> -</tr> -<tr> - <td> - 55 — - </td> - <td class="num"> - 3456 - </td> - <td class="num"> - 833 - </td> -</tr> -<tr> - <td> - 60 — - </td> - <td class="num"> - 3825 - </td> - <td class="num"> - 712 - </td> -</tr> -<tr> - <td> - 65 — - </td> - <td class="num"> - 2542 - </td> - <td class="num"> - 369 - </td> -</tr> -<tr> - <td> - 70 — - </td> - <td class="num"> - 1568 - </td> - <td class="num"> - 204 - </td> -</tr> -<tr> - <td> - 75 — - </td> - <td class="num"> - 746 - </td> - <td class="num"> - 101 - </td> -</tr> -<tr> - <td> - 80 — - </td> - <td class="num"> - 311 - </td> - <td class="num"> - 25 - </td> -</tr> -<tr> - <td> - 85 and Upwards - </td> - <td class="num"> - 147 - </td> - <td class="num"> - 16 - </td> -</tr> -</table> - -<h4 title=""><span class="smcap">Table B.</span><br /> - -AGED 20 YEARS OF AGE, AND UPWARDS.</h4> - -<table class="nurses location" summary="nurses by location"> -<tr> - <th> - - </th> - <th class="num"> - Nurse<br />(not<br />Domestic Servant) - </th> - <th class="num"> - Nurse<br /><br />(Domestic Servant) - </th> -</tr> -<tr> - <td> - Great Britain and Islands in the British Seas. - </td> - <td class="num"> - 25,466 - </td> - <td class="num"> - 21,017 - </td> -</tr> -<tr> - <td> - England and Wales. - </td> - <td class="num"> - 23,751 - </td> - <td class="num"> - 18,945 - </td> -</tr> -<tr> - <td> - Scotland. - </td> - <td class="num"> - 1543 - </td> - <td class="num"> - 1922 - </td> -</tr> -<tr> - <td> - Islands in the British Seas. - </td> - <td class="num"> - 172 - </td> - <td class="num"> - 150 - </td> -</tr> -<tr> - <td> - 1st Division.<br />London. - </td> - <td class="num"> - 7807 - </td> - <td class="num"> - 5061 - </td> -</tr> -<tr> - <td> - 2nd Division.<br />South Eastern. - </td> - <td class="num"> - 2878 - </td> - <td class="num"> - 2514 - </td> -</tr> -<tr> - <td> - 3rd Division.<br />South Midland. - </td> - <td class="num"> - 2286 - </td> - <td class="num"> - 1252 - </td> -</tr> -<tr> - <td> - 4th Division.<br />Eastern Counties. - </td> - <td class="num"> - 2408 - </td> - <td class="num"> - 959 - </td> -</tr> -<tr> - <td> - 5th Division.<br />South Western Counties. - </td> - <td class="num"> - 3055 - </td> - <td class="num"> - 1737 - </td> -</tr> -<tr> - <td> - 6th Division.<br />West Midland Counties. - </td> - <td class="num"> - 1225 - </td> - <td class="num"> - 2283 - </td> -</tr> -<tr> - <td> - 7th Division.<br />North Midland Counties. - </td> - <td class="num"> - 1303 - </td> - <td class="num"> - 957 - </td> -</tr> -<tr> - <td> - 8th Division.<br />North Western Counties. - </td> - <td class="num"> - 970 - </td> - <td class="num"> - 2135 - </td> -</tr> -<tr> - <td> - 9th Division.<br />Yorkshire. - </td> - <td class="num"> - 1074 - </td> - <td class="num"> - 1023 - </td> -</tr> -<tr> - <td> - 10th Division.<br />Northern Counties. - </td> - <td class="num"> - 402 - </td> - <td class="num"> - 410 - </td> -</tr> -<tr> - <td> - 11th Division.<br />Monmouth and Wales. - </td> - <td class="num"> - 343 - </td> - <td class="num"> - 614 - </td> -</tr> -</table> - -<hr class="chap" /> - -<p><span class="pagenum"><a name="Page_22p" id="Page_22p">[22]</a></span></p> -<h2><span class="smcap">Note as to teaching Nursing.</span></h2> - -<p>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.</p> - -<h3 title=""><i>Course of Instruction for the Class of Sick Nurses, at the -Military Female Orphan Asylum.</i></h3> - -<h5 title="">Popular and Regional Anatomy and Physiology.</h5> - -<p>A general knowledge of the human body, its various -organs, and their uses.</p> - -<h5 title="">Sanitation.</h5> - -<p>To be made acquainted with every subject relating to -health, viz.: Food—Exercise—Clothing—Cleanliness—Ventilation, -<abbr title="etcetera">&c.</abbr></p> - -<h5 title="">Sick-room Management.</h5> - -<p>Administration of Medicines, Application of Leeches, -Lotions, Fomentations, <abbr title="etcetera">&c.</abbr> Cleanliness, Darkening of -the Apartment, Quietness, <abbr title="etcetera">&c.</abbr> Cooking for the Sick. -Diet for Infants.</p> - -<p><span class="pagenum"><a name="Page_23p" id="Page_23p">[23]</a></span></p> -<h5 title="">Household Medicine and Surgery.</h5> - -<p>To be taught how to act in emergencies, viz.: in cases -of Fainting—Hysterics—Convulsions of Children—Burns—Stings -of Insects—Wounds, <abbr title="etcetera">&c.</abbr>; and the simplest mode -of treating the diseases most commonly met with in India, -viz.:</p> - -<ul> - <li>External Inflammation,</li> - <li>Cholera,</li> - <li>Fever,</li> - <li>Dysentery,</li> - <li>Sore Eyes,</li> - <li>Bowel Complaints,</li> - <li>Cutaneous Eruptions.</li> -</ul> - -<p>How to prepare Poultices, Fomentations, and Lotions.</p> -<p><span class="ditto">How to</span> dress Wounds, Sores, and Blisters.</p> -<p><span class="ditto">How to</span> apply Bandages.</p> - -<div class="footnotes"> -<h3 title="">Footnotes:</h3> - -<ul> - -<li> - <p><a name="Footnote_21" id="Footnote_21" href="#Anchor_21" title="Return to text.">[21]</a> -If the sisters and nurses, as a rule, were fed as well as lodged at -all the Hospitals, <abbr title="etcetera">&c.</abbr>, 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.</p> -</li> - -<li> - <p><a name="Footnote_22" id="Footnote_22" href="#Anchor_22" title="Return to text.">[22]</a> -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.</p> -</li> - -<li> - <p><a name="Footnote_23" id="Footnote_23" href="#Anchor_23" title="Return to text.">[23]</a> -Every institution ought to provide for its nurses during illness, but -in fact it is not done.</p> -</li> - -<li> - <p><a name="Footnote_24" id="Footnote_24" href="#Anchor_24" title="Return to text.">[24]</a> -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.</p> -</li> - -</ul> -</div> - -</div> - - - - - - - - -<pre> - - - - - -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-h.htm or 52877-h.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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