AC e> Nig B 1656 a SUBSIDIARY NOTES AS '10 THE Itroduction of female nuksing MILITARY HOSPITALS IN PKACK AND IN WAR. 3$Mgenttb hu, «quest lo the ^urctarg of Stale for ®lur. L K D N : ..IXTKD BV HARRISON AXD SOSE, fcT. MARTIN'S LANK, W.C 1S58. THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF DR. AND MRS. ELMER BELT SUBSIDIARY NOTES AS TO THE INTRODUCTION OF FEMALE NURSINCx MILITARY HOSPITALS IN PKACIi AND IN WAI I^Kseuteb bu request to tijc ^ctretarg of ^tatt for Winx. LONDON: PRINTED BY HARRISON AND SONS, ST. MARTIN'S LANE, W-C. 1858. CONTENTS. Digest PAGES V— X Thoughts submitted by Order, concerning— I. Hospital Nurses II. Nurses in Civil Hospitals III. Nurses in Her Majesty's Hospitals .. 1—9 9—14 15—19 Systems of Female Nursing in the War Hospitals of the different Nations engaged in the Crimean War .... 19 — 26 Note in regard to the Russian Nurses employed in the War Hospitals of the Crimea 26—28 Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and in War 1 — 63 Addenda with regard to Female Nursing in a Military Hospital on the Pavilion or Lariboisiere Plan .... 63 — 90 Addenda as to Mixed Nursing, by Nurses and Orderlies, in Military Hospitals, on the Double Pavilion or Vincennes Plan 91 — 117 Additional Hints as to Ventilation, Hospital Floors, and Cautions in Ward-building suggested by the Lari- boisiere Hospital 118 — 127 Note on Contagion and Infection 128—132. IV CONTENTS. PAGES. Note on Observations by the Principal Medical Officer o the Army in the East 132, 133 Thoughts submitted as to an Eventual Nurses' Provident Fund , 1—1 Note as to the Number of Women employed as Nurses in Great Britain 20, 21 Note as to Teaching Nursing 22, 23 I L L U S T I? A T I N. Plan of the Lariboisi^re Hospital at Paris p. 63 DIGEST. PAGES THOUGHTS SUBMITTED BY ORDER 1-28 CONCERNING I. Hospital Nurses. II. Nurses in Civil Hospitals. III. Nurses in Her Majesty's Hospitals. I. Hospital Nurses .. .. .. .. .. 1-9 Twenty Observations on how to improve Hospital Nursing. II. Nurses in Civil Hospitals .. .. .. .. 9-14 Twenty-three Heads for Regulations as to Nursing in Civil Hospitals. III. Nurses in Her Majesty's Hospitals .. .. .. 15-19 Twenty-two suggestions in the event of the introduc- tion of Female Nursing into Military Hospitals. Various systems of Female Nursing during the Crimean War in the Military Hospitals 19-28 Of the French and Sardinians 19-22 Russians 22,23,26-28 English 23 Proposed Duties of Female Nurses in Military General Hospitals 23,24 The Hospital Serjeant, or Ward Master will not be super- seded — he will still have too much to do for any one man properly to perform, and part of his duties must be given to another officer . . . . . . . . . . . . 24-26 Note in regard to the Russian Nurses employed in THE War-Hospitals of the Crimea . . .. .. 26-28 VI DIGEST. PAGES SUBSIDIARY NOTES AS TO THE INTRODUCTION OF FEMALE NURSING INTO MILITARY HOSPITALS IN PEACE AND IN WAR 1-133 I. Five Conditions essential to this service . . . . 1-^ II. Our Nurses were of four kinds. . .. .. .. ' 3 Absolute subordination to the Medical Officer as to Medical Orders essential and practised by us . . 4 III. 1. Qualified subordination essential of Superintendent- General to Director-General and Principal Medical Officer 4-6 2, Also of Matron and Nurses to Principal Medical Officer and Staff-Surgeons . . , . . . 6, 7 3. Female service can only be introduced gradually, and introduction regulated by Director-General . . 7-9 V. 1, Shall Roman Catholic Sisters be introduced.-' .. 9, 10 2. Or Anglican Sisters ? .. .. .. .. 10 3. Power of Police in Civil Hospitals . . , . .. 11 ,, ,, Military ,, 12-15 4. Pay and Rations of Nurses . . , . . . . . 15-20 On the whole it would seem best, where practicable, to board the Nurses, not to " ration" them, nor to let them "find themselves." Community of cooking implies economy of nourishment . . 1 7-20 5. Washing to be " put out " .. .. .. .. 20,21 6. Cleaning their own Rooms . . . . . . . , 21—23 7. Nurses to keep keys of closet in Wards . . . . 23 8. Pay, dress, and duties of Matrons . . .. .. 24-28 More properly named Superintendents . . . . 27 Lady Volunteers had better begin by being Nurses, not Superintendents ex-officio . . . . . . 28 9. Sundry Regulations as to Nurses . . . . . . 29-31 10. Have the Patients' Diets sent hot, and ready divided, from kitchen .. .. .. .. .. 31 11. What Ward duties the Nurses should do themselves 31 And why 32, 33 Patients should not be made quasi Orderlies . . . . 34 Visitors in Military Hospitals .. . ., ., 35 12. Regulation-Number of Orderlies — depends on the size of wards whether sufficient .. .. .. 35-41 What is the regulation -attendance in Naval Hospitals 37 What in Civil Hospitals 38 Comparative Cost of Nursing in larger and smaller wards 39-41 DIGEST. Vll PAGES 13. Hospital floors 42-51 Sanitary necessities . . . . . . . . . . 42 Trial of Hospital floors, oiled and polished with "laque," as in Berlin Hospitals, recommended on sanitary grounds and for ease of cleaning . . 43-51 14. Ventilation of Wards 51-52 15. Special Wards, whether desirable or not . . . . 53-54 1 6. Opinion as to Superintendent-General paying Nurses' wages, and as to Governor's jurisdiction over Nurses 54-56 17. Wages and Pensions of Nurses .. .. .. 56-60 Three rules in raising Wages . . . . . . 56 Five general principles as to Wages and Pensions . , 58 Six applications of the foregoing principles. . . . 58, 59 Seven heads for Regulations as to Nurses' Wages and Pensions . . . . . . . . . . 59, 60 18. Proportion of Nurses to Patients .. .. .. 61,62 19. Precautions in sending Nurses on Foreign Service. . 62 Hospital Laundries . . . . . . . . . . 63 Addenda, with regard to Female Nursing in a Mili- tary Hospital on the Pavilion, or Lariboisiere Plan 63-90 I. Four conditions to be considered in adopting the Pavilion Plan 63 1. Economy of attendance .. .. .. .. 64 2. Facility of supervision . . . . . . . . 65 3. Desirableness of doubling the Pavilion, in a Military Hospital, in order to give to each Nurse but one floor to serve . . . . . . . . . . 65 4. Nurse to sleep near her Ward . . . . . . &Q Importance of lighting by gas . . . . . . 67 II. 1. One Nurse must serve the whole Pavilion, in a Military Hospital, if single Pavilions be adopted . . 68 2. Nurses' day in such a Pavilion . . . . . . 68, 69 3. What the responsibility of Nurses is for discipline of Ward or Pavilion . . . . . . . . . . 70, 71 4. Importance of Lifts .. .. .. •• 71 ill. 1. "Casualty" Cases should be in a completely appointed set of Wards, apart . . . . . . 72 And why . . . . . . . . • • • • * 3 2. Restraint or non-restraint in Violent Cases . . 74 VUl DIGEST. IV. Simplicity of Construction essential to Discipline Polished impervious Walls. Covered Exercising Place. Reserve Wards . . PAGES 75 76 V. Nurses' Meals to be sent them Cooked 76 VI. Arrangements for a Pavilion and its Wards 2. Where should Wardmaster sleep ? 3. And Orderlies sleep ? 4. And dine? 7, 8, Scullery to each Ward, and what to be done in it. Poultice-making 9. Presses in Ward 10. Nurses' Room Lavatory, Water-Closet, Sink Baths 11. Summary of arrangements Scullery Appurtenances 12. Nurses' Sleeping Quarters Ward for Sick Nurses 13. Classification of Patients 14. Nurses to be called by their Wards 15. Foul Linen . . 16. Washing Bandages . . 17. Splints, &c., where to be kept Cotton Lint never to be used 18. Classification of Nurses Superintendent's Store Room 77-90 77 77 78 79 79 80, 81 82 83 84 85 86 86 87 89 89 89 90 90 Addenda as to Mixed Nursing by Nurses and Order- lies IN Military Hospitals on the Double Pavi- lion Plan .. .. .. .. .. .. .. 91-117 I. Orderlies' Duties . . . . . . . . . . 91-108 Proportion of Nurses, Ward Masters, and Orderlies to Sick 91-93 Wine to be always administered by Nurse . . . . 93 Orderlies — their Duties vary according to appurte- nances of Ward . . . . . . . . . . 94 If Hot and Cold Water are laid on, and there are Lifts, one Orderly's Service saved to each 30 Sick . . 94, 95 Night-Duty of Orderlies 95-108 Scheme of Night- Service for three Orderlies watching by turns 96, 97 DIGEST. IX PAGES Exercise for Orderlies .. .. .. .. .. 97 Night Refreshment for Orderlies 98, 99 Where are the Night Oiderlies to sleep ? . . . . 100 Comparative Merits of different Systems of Night Nursing in Home and in Foreign Hospitals . . 101-3 An Assistant Ward Master should go round the Wards at Night 104 Extraordinary System of Night-Nursing in the Army at present . . . . . . . . . . . . 105-8 II. Twelve Sundries in organizing a Military HoSPiTAL 108-114 1. Nurses' Room .. .. .. .. .. 108 2. Medical Officer's Room 108 3. Water-Closets 109 4. Warm and Cold Water Supply . . . . . . 109 5. Corridors 109 6. Lobby 110 7. Material of Ward Utensils 110 8. Reserve Wards 111-112 Necessity of Annual Cleansing of the whole of a Hospital 9. Occasional Revision of Rules .. .. .. 113 10. Defect in German Organization of Nursing . . 113 11. Nurses' Exercise .. .. .. .. .. 113 12. Number of Ward Masters .. .. .. .. il4 III. Regulations .. .. .. .. 114-117 1. Deprivation of Visitors salutary in certain Wards. . 114-16 2. Numbering Patients saves time .. .. .. 117 3. Prohibition of Swearing .. .. .. .. 117 Conclusion .. .. .. .. .. .. 117 Additional Hints as to Pavilion HosriTALS suggested BY the Construction of the Lariboisiere Hospi- tal at Paris 118-127 I. Ventilation 118-120 Artificial Ventilation never freshens a Ward II. Oiled Boards versus Parquets .. .. .. .. 120-124 Cleaning polished and oiled Boards much less laborious, and freshens the Ward much more than \)as, frottage of Parquets. Mode of Cleaning them at Berlin . . . . . . 122-124 DIGEST. III. Ten Cautions in Building Hospital Pavilions . . Size of Wards. Our own Regimental Hospitals extra- ordinary for their many holes and corners . . Casualty Wards . . "Contagion" and "Infection" Defined Idea of " Contagion " invented by Men to excuse themselves for the neglect of all Sanitary arrange- ments . . In the ordinary sense of the word, no such thing as "Contagion" Nor as inevitable '' Infection " "Infection" and Incapable Management, or Bad Construction, convertible terms " Epidemics " do not spread — they develop themselves in Constitutions made ripe for them by Sanitary neglects Note on certain " Observations " by Sir John Hall . PAGES 124-127 125 126 128-132 128 129 130 131 131 132, 133 Thoughts Submitted as to Provident Fund AN Eventual Nurses' to Petty Actual Wages and Prospects of Nurses Some further Provision desirable Of what Nature ? With regard to Kind ? , . With regard to Persons ? With regard to Objects ? Material Objects ? Children, in the case of Nurses, a Temptation Dishonesty and taking Bribes Sanitary Objects ? Moral Objects ? . . Hospitals not places for Penitents Rules to be followed in giving Assistance Prospects of Eventual Support Note as to the Number of Women employed as Nurses in Great Britain Tables of Ages, &c. Note as to Teaching Nursing — Institution at Madras. 1-19 1-3 4-6 6-15 6-8 8 9-15 9-12 11, 12 13 13-15 14, 15 15-17 18, 19 20, 21 21 22, 23 PRIVATE AND CONFIDENTIAL. Thoughts submitted by order concerning I. Hospital-Nurses. II. Nurses in Civil Hospitals. III. Nurses in Her Majesty's Hospitals. I. Hospital-Nurses. found out. Presumed Main 01)jcft,. 1. It would appear desirable to consider that definite Definite objects are to be attained ; and that the road leading to Objects : road to them to be 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. 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. 3. This I propose doing, not by founding a Religious Order ; but by training, systematizing, and morally im- proving 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 useful- B Presumed Intentions. HOSPITAL NURSES IN GENERAL. Eellgious Orders. Their Advantages. Advantages of Hired Labour. ness, 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 per- formed under definite superiors. These two latter elements, if efl&cient (if not, they would be mischievous rather than useless), I consider would elevate and leaven the mass. 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. 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. 6. On the other hand, the majority of women in all European countries are, by God^s providence, compelled to work for their bread, and are without vocation for Orders. In England the channels of female labour are few, narrow, and over-crowded. In London and in all large towns, there are accordingly a large number of women who avowedly live by their shame; a larger number who occupy a hideous border-land, working by day and sinning by night ; and a large number, whether larger or smaller than the latter class is a doubtful problem, who preserve their chastity, and struggle through their lives as they HOSPITAL NURSES IN GENERAL. 3 can, on precarious work and insufficient wages. Vicious propensities are in many cases the cause, remediless by the efforts of others, of the two first classes : want of work, insufficient wages, the absence of protection and restraint, are the cause in many more. Perhaps the work most needed now is rather to aim at alleviating the misery, and lessening the opportunities and the temptations to gross sin, of the many ; than at pro- moting the spiritual elevation of the few, always supposing that this latter object is best effected in an Order. At any rate, to promote the liouest employment, the decent maintenance and provision, to protect and to restrain, to elevate in purifying, so far as may be permit- ted, a number, more or less, of poor and virtuous women, is a definite and large object of useful aim, whether success be granted to it or not. The Orders remain for the reception of those women who either are or believe themselves drawn to enter them, or who experience their need of them. 7. The care of the sick is the main object of hospitals. Main Object of The care of their souls is the great pro\ince of the clergy cTs^Lct ' of hospitals. The care of their bodies is the duty of the Functions of Hospital nurses. Possibly this duty might be better fulfilled by Clergy and religious nurses than by Sisters of any Order; because Nurses^ the cai'eful, skilful, and frequent performance of certain coarse, servile, personal offices is of momentous conse- quence in many forms of severe iUness and severe injury, and prudery, a thing which appears incidental, though not necessarily so, to Female Orders, is adverse to or incompatible with this. 8. Grave and peculiar difficulties attend the incorpora- ^, . ,. ^ ^ Objections to tion of members of Orders, especially of Roman Catholic Amalgamating Orders, into the work. And, both with reference to the Orders with Queen's hospitals, and still more to the civil hospitals, I SecularNurses. b2 4 HOSPITAL NURSES IN GENERAL. humbly submit that much thought, and some consulta- tion with a few impartial and judicious men, should pre- cede 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 experi- mentally. 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 secu- lar, and therefore, as they consider, an inferior system; and that their incorporation, especially as regards the Roman Catholic Sisters, will be a constant source of confusion, of weakness, of disunion, and of mischief. Saint Vincent de Paule well knew mankind, when he imposed, amongst other things, the rule on the Sisters of his Order never to join in any work of charity with the Sisters of any other Order. This rule was mentioned to me on an occasion which gave it weight, by the Superior of the Sisters of Charity of one of the two Sardinian Hospitals on the Heights of Balaklava, in the spring of 1856, and by the Mere Generale 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. Ladies. 9. As regards ladies, not members of Orders, peculiar difficulties attend their admission : yet their eventual admixture to a certain extent in the work is an impor- tant feature of it. Obedience, discipline, self-control, work understood as work, hospital service as implying HOSPITAL NURSES IN GENERAL. 5 masters, civil and medical, and a mistress, what service means, and abnegation of self, are things not always easy to be learnt, understood, and faithfully acted upon, by ladies. Yet they cannot fail in efficiency of service or propriety of conduct — propriety is a large word — without damaging the work, and degrading their element. Their dismissal (like that of Sisters) must always be more troublesome, if not more difficult than that of the other nurses. It might be better not to invite this element ; to let it come if it will learn, understand, and do what has to be learnt, understood, and done : if not, it is better away. It appears to me, but I may be quite mistaken, that, in the beginning, many such persons will offer themselves, but few persevere ; that in time a sufficient number will form an important element of the work; more is not desirable. It seems to me important that ladies, as such, should have no separate status; but should be merged among the head-nurses, by whatever name these are called. Thus efficiency would be promoted, sundry things would be checked, and the leaven would circulate. There are many women, daughters and widows of the middle classes, who would become valuable acquisitions to the work, but whose circumstances would compel them to find their maintenance in it. These persons would be far more useful, less troublesome, would blend better and more truly with women of the higher orders, who were in the work, and would influence better and more easily the other nurses, as head-nurses, than as ladies. Whether or not the better judgment of others agrees with mine, my meaning will be understood. In truth the only lady in a hospital should be the chief of the women, whether called Matron or Superintendent. 6 HOSPITAL NURSES IN GENERAL. 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 Superinten- dent, (unless during war-service, when the rough-and-ready life and work required wiU probably be best undergone by women of a higher class) should be a person of the middle classes, and if she requires and receives a salary, so much the better. She will thus disarm one source of opposition and jealousy, and enough will remain, inseparable from her office. The quasi-spiritual dignity of Sisters of Mercy is a thing sui generis. But the real and faithful discharge of the duties of the wards of a General Hospital, whether with reference to superiors, companions, or patients, is incompatible with the status, as such, of ladies. The real dignity of a gentlewoman is a very high and unassailable thing, which silently encompasses her from her birth to her grave. Therefore, I can conceive no woman who knows, either from information or from experience, what hospital duties are, not feeling as strongly as I do, that either the assertion or the reception of the status as such of a lady, is against every rule and feeling of common sense, of the propriety of things, and of her own dignity . Eeligion. 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. St. Jolin's St. John's House, if it steers clear of the rock of prudery, undoubtedly possesses great advantages over a system of hospital nursing by promiscuous instruments. Not because it includes a Sisterhood, a system, in which I, for one, humbly but entirely disbelieve ; but because the HOSPITAL NURSES IN GENERAL. laborious, servile, anxious, trying drudgery of real hospi- tal 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. 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. 12. It is very important, if possible, to make provision for the disabled age of deserving nurses. It does not seem to me, I speak very diffidently, desirable to concentrate them in one or more large buildings. I believe half the inmates of half the alms-houses, &c., are not on speaking terms with each other. John Bull is of a peculiar idio- syncrasy : 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 an'angement for nurses. 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 recom- pense : say, after ten years^ good service, to raise nurses' wages ; after a second ten years, to raise them further. 1-A. There should be an age for the reception and for Only Women of Unblemished Character should be employed. Provision for Old Affc. Progressive Increase of Wages, Fixed Age for 8 HOSPITAL NURSES IN GENEKAL. Admission and lietirenicnt. Simplicity of Rules, Definition of Autliorities. Economy, Commence- ment: Training. Limits. Encumbrance of Public Support or Patronage. the retirement both of nurses and head-nurses. I think no head-nurse should be under thirty. 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 im- portant ; also, at the outset, to have a clear and recorded definition of these respective limits. 16. Economy is very important, with regard to the eventual extension of the work. 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 pro- bably 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. 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. 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, trulyunderstood, 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 NURSES IN CIt^L HOSriTALS. 9 are equally injurious in different ways as regards our Caution, Non- expectation, masters the medical men, ourselves the nurses, and people and Trust. who are neither medical men nor nurses. 20. I end as I began. Let nothing be done rashly. Let us not be fettered with many rules at first. Let us take time to see how things work ; what is found to answer best ; how the work proceeds ; how far it pleases God to accept and bless it. Let us be prepared, as I know well we must be, for disappointments of every sort and kind. What can any of us do in anything, what are any of us meant to do in anything, but our duty, leaving the event to God? His Will be done in earth, as it is in Heaven. II. Nurses in Civil Hospitals. 1 . The isolation of each head-nurse and her nurses isolation of appears to me very important. The head-nurse should vr*^'!*; | j be within reach and view of her ward both day and night. Nurses. Associating the nurses in large dormitories tends to cor- rupt 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. 2. All the nurses should rank and be paid alike, with All to Rank /. /•. 1 X ) 1 and be Paid progressive increase ot wages alter each ten years good ^y^^^ ^^^q^ service, or a slow annual rise, which is better. Progressive Increase of Wages. 3. The night-nurses should be on duty 12 hours, with Niglit Nurses. instant dismissal if found asleep ; 8 hours should be allowed for sleep, and 4 hours for daily exercise, private occupation, or recreation. If they have no time to themselves for their mending, making, &c., they do it at night, sometimes 10 NURSES IN CIVIL HOSPITALS. Day Nurses. Nurses to fetch nothing Patients to fetch nothing. Scrubbing. Distribution of Ward Work. innocently, sometimes to the injury of the patients. I would not however prohibit occupation at night ; as some- times 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. 4. The day-nurses should have eight hours^ sleep, and if it be possible, 4 hours daily for exercise, private occupa- tion or recreation. They may have one room. 5. All provisions, &c., &c., should be as much as possible brought into the wards, or to the ward-doors, by lifts. Nothing should be fetched by the nurses. This would save much time ; would enable the nurses to do more work, and yet have more leisure; and above all, would obviate the great demoralization consequent on the nurses, patients, and men-servants congregating in num- bers several times daily. 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. 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. 8. At present, I incline to something of the following scale. Two wards, single are best, but it might be one double ward, with 40 beds, served by 1 head-nurse and 3 NURSES IN CIVIL HOSPITALS. 11 nurses. The head-nurse to superintend all things, and to do the dressings not done by the surgeons and dressers, assisted mainly by one nurse, whom she thus instructs in nursing. Another nurse to do the scrubbing, and mainly the cleaning, and when these are over to mind the ward during the remaining hours in turn or in conjunction with the first nurse. The third to be night-nurse. In the morning, before dressing begins, and before the night- nurse goes off duty, all three nurses to clean the ward, make the beds, wash the helpless patients, &c. 9. Hours of morning and evening poulticing and dressing to be fixed. 10. Hours of administration of medicine, always except at night given by head-nurse, to be fixed. 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. 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 Ofiicer, 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. Hours of Dressing and Poulticing, and of Medicine. Hours of Exercise, and Holidays. Permission of Matron for extra time out. 12 NURSES m CIVIL HOSPITALS. Place of Exercise. Caution. Dress. Wages. 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 crowdci thoroughfares. Streets are miserable places to walk in during great part of the year. Nurses want and uncon- sciously 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. 14. I should, however, be very cautious as to intro- ducing 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. 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 re- quire 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. 16. I incline towards giving the head-nurses £50 a-year, one or two rooms (one room with an alcove and curtain would be best), fuel and light. The nurses NURSES m CTVIL HOSPITALS. 13 lodging; the night-nurse a room to herself, the others together; entire board, fuel, light, and good wages to be decided upon. 1 7. The nurses' rooms should be supplied with plain com- Furniture. fortable 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 decora- tions, which take time to clean, &c., is a drawback. I should be inclined, as an experiment, to try the furnishing plan, or at least to have some scale as to furniture allowed. A bed, arm-chair, and sofa ; a chest of drawers, wash-hand table or shelf; book-case or shelves; a little table, and a larger one, a couple of chairs, a footstool, and a cup- board with broad shelves, are the utmost that can be required. 18. A difficult and important point to settle is the Visitors, 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 dis- tances are great, and even omnibus-fare is a consideration; also it is important to remember that these women are apt to feel and say: "We are not in a nunnery,'^ nor should they be. Still upon the whole, considering the nuisance of ordinary visitors, and the greater nuisance of extraordinary {e.g., visitors to some head-nurses, kind friends come to see how we are getting on, &c., &c., &c.), I think if it were possible to make the rule that no visitors are allowed, it would be a great gain. I am not sure, at present, whether it is possible or not — still less whether it is possible to keep such a rule, if made. But, at all events, nurses and head-nurses should only be per- mitted to receive visitors on certain days and hours of the 14 NUKSES IN HER MAJESTY'S HOSPITALS. Discharged Patients. Graduated scale of Pensions. No occasional Wards. Head-Nurse to each Ward. Religious Influence. week ; and those hours and days should be strictly kept to. In Military Hospitals a still more rigid rule will be neces- sary. 19. No discharged patients, however previously well- conducted, should be allowed to visit the wards. 20. A-part 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 after- wards. 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. 21. Have no occasional wards, or wards for accidental and peculiar patients. 22. Every ward, or set of wards, should be under a head-nurse. Discipline is always defective under other arrangements. 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. 15 III. Nurses in Her Majesty's Hospitals. 1. If tlieir introduction is eventually commanded by the Queen's Government, it will be advisable to consider that their service admits of two distinct kinds. 2. " Their chief duties" may be " taking charge of the linen and superintending the issue of extras." They will thus contribute materially to the comfort and well-being of the sick; the real difficulties which un- doubtedly 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. 3. On the other hand, I suppose, the experience of every woman, admitted to ward service in hospitals where women were not before, is that many lives are actually saved by such admission, which would otherwise, humanly speaking, be lost. In time of war some ciphers may be safely added to the many. Any other great emergency, I suppose, but do not speak from experience, would give the same result. That the experience of many surgeons is identical, their conduct has proved; no other testimony, under present circumstances, can rationally be expected from them. 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. 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 Two kinds of Hospital Service for Females. The one : its Advantages; The other : its Advantages. Both to be Weighed. Practical Superiority of the Second. 16 NURSES IN ITER MAJESTY'S HOSPITALS. Its real and great Difficulties. Condense numbers as m\icli as j)Ossible. Only Head Nurses. Classify the Patients. 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 them- selves. 6. At the same time, nothing is more pernicious than to under-rate the objections of opponents. There is no doubt that the admission of women to ward service is beset with difficulties. These Naval and Military Hospitals are, and must ever be, peculiar Hospitals, essentially different in important details from the Civil Hospitals. Sisters of Mercy, as regards the ward service, are deco- rous and kind, and sometimes inefficient and prudish. Nurses are careful, efficient, often decorous, and always kind, sometimes drunken, sometimes unchaste. Misconduct of women is far more pernicious in a Mili- tary or Naval Hospital than in any other, as regards the result of things — the crime is, of course, equally crime everywhere. 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. 8. Head-nurses are alone, I think, desirable to be employed; I mean persons of the character, responsi- bility, and efficiency, of head-nurses in other Hospitals. 9. The patients should be distinctly classed, though, of course, this is not the Female Superintendent's busi- ness. NURSES IN TIKH .AIA.IKSTV S HOSPITALS. 17 There are many pros and cons to the formation of con- valescent wai'ds. It is a question whether convalescent or chronic patients require female nurses at all. Of such chronic cases, probably 100 would be efficiently served by one nurse, having orderlies under her. Of acute cases, probably, one nurse should take charge of not more than fifty, possibly not more than forty. 10. The nurses shoidd 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 dis- missed for the first offence of unchastity, drunkenness, or dishonesty, or proved impropriety of any kind. 11. Their wages, I think, the same as those of head- nurses in Civil Hospitals — certainly, not more. 12. Their pension on the same graduated scale. 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. 14-. Their duties should be strictly defined, and be consistent with the Code of Army Hospital Regulations, the revision of which has been announced. 15. Give them plenty to do, and great responsibility — two effectual means of steadying women. 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 c Qualification of Nurses. Wages. Pensions. Rules. Duties. Means of Steadying them. Lodging. 18 NURSES IN HER MAJESTY^S HOSPITALS. other, which might easily be contrived, this woukl pro- bably answer all purposes. Food. 17. Their food should be sent them cooked with some slight variety. With the plainest intentions nature often revolts from the perpetual joint of excellent meat in Hos- pital air and life. The occasional " potage/' fish, &c., of other systems, are in fact, a refreshing and palatable change. If, however, avoiding names that shock and frighten, some slight change of diet could be contrived, the effect would be good. This is practical and not at all romantic, though it may look the latter, 18. Could the honest opinions be had of a few good Military and Surgical Authorities before beginning, it would be good. 19. The Female Superintendent-CreneraFs 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. 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. 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. Quietness. 22. " In quietness and in confidence shall be your strength." Quietness has been from the beginning of its publicity the one thing wanting in this work. I know the fuss, which from its beginning surrounded it, was abhorrent to us and was the act of others : but the work, which is all Opinion of honest i\Iilitary Authority desirable. Female Super- intendent- General. Confidential Keports. I'ermanency of tlie System. FRENCH AND SARDINIAN HOSPITAL SERVICE. 19 we care for, has throughout suifered 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 tew nurses, would do more good to the cause than an endless amount of meetings, testimo- nials, 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. A very short comparison will here be made between the methods of Female Nursing in the iNIilitary Hospitals of Russia, England, France, and Sardinia, as exemplified in the last War. To do this, a sketch must be partly repeated, which has been already given, of the organic difference between the Hospital Service of each nation. The essential characteristic of the French is, the im- portance given in the field to the Divisional Hospital Service over the Regimental. The Regimental Medical Service treats only those ephemeral cases which are to be exempted from duty for a day or two. Cases of wounds or disease likely to last for a term of weeks are sent to the Divisional Ambulance Various Sj stems of Female Nursing compared. Frencii and Sardinian Hospital Service. 20 FRENCH AND SARDINIAN FEMALE NURSES. English. Bussian. Female Nurses. Sardinian and French Female Nurses. in the field; those, where disease may possibly last for months, to the General Hospitals at the base of opera- tions. 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 Eegimental Hospitals. In our Army, as is well known, the Regiment esta- blishes its Regimental Hospital wherever it goes. Theo- retically, it is exclusively a Regimental system of Hospitals ; however much, practically, it breaks down. 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 Sim- pheropol. The adaptation of Female Nursing to the different systems in the French, Sardinian, Russian, and English Armies has now to be noticed. The Sardinians had Sisters of Charity, both in the General Ambulances in the Crimea, and in the General Hospitals on the Bosphorus. The principal duties of these admirable women appear to have been the care of the linen and small stores, and the cooking, much of which they did with their own hands, for sick officers and men. These duties were admirably performed. They appeared, besides, to have a certain charge in the wards, the power of giving " douceurs," the administration of extras, the seeing to the cleanliness of FRENCH AND SARDINIAN FEMALE NURSES. 21 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 Soeur or the Infirmier Major were in charge, to see the duties about the patient properly executed, was rather a problem. This was still more the case in the French Hospitals, where the '' Soeur" in the wards appeared more of a " consolatrice" and an administratrix of extras : although, out of the wards, her admirable housekeeping, both in the kitchen and the linen- store, was predominant. The French " Soeurs" were not admitted to the Divi- sional Ambulances in the front : it was whispered, because of the corruption of the French Intendance, upon whom they tacitly exercised a very inconvenient " surveillance." They served in all the General Hospitals at Constan- tinople; and to their admirable services, M. Baudens, Inspecteur-General en Crimee, has rendered an " tclatant temoignage" in his " Mission INIedicale en Orient," pub- lished in the numbers of the " Revue des Deux Mondes," of February 15, April 1, and June 1, 1857. In these French Hospitals of Constantinople, the " Soeurs " appeared to do all the cooking for the sick Officers and that of the extras for the men. I do not think that, in either French or Sardinian Hospitals, the care of bed-sores and such like, which can only be done by women, was sufficiently given to the " Soeurs." I have heard complaints made of this kind both by Officers and men; and " Soeurs," both French and Sardi- nian, have been to me to look at the way in which we treated bed-sores, and to borrow air-pillows and water- beds. There is such a diflPerence however in different Hospi- 22 EUSSIAN FEMALE NURSES. talsj in time of war and of peace, &c., that I would not be understood to mean that any of these remarks apply absolutely or generally, but only to Hospitals I have seen. It may be as well to mention that, talking of " French" and " Sardinian" Sisters, they all come from one " Maison Mere," that of the " Filles de la Charite de S. Vincent de Paule," at Paris. There is a " JSIaison Succursale," at Turin. But all are of the same Order, and under the same head. Let me mention Soeur Cordero, the excellent Superioress of all the Sisters employed in the Sardinian Hospitals of the war, with the warmest affection and respect. She was a woman of high rank, of the most captivating manners, but of the utmost simplicity of character, and of unfailing devotion to right and to God. flussian. 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 PUOrOSED AKKANGEMENTS. 23 discharge of duties at the bed-side of the patient. The orderHes are, of course, under the control of a Non- commissioned Officer, in all that pertains to discipline, clothing, meals, &c. The " felchers" are under a superior "felcher,^' and unrler the Medical Officers. There are female nui^ses, wives and widows of soldiers, under the " Sisters,^* who are generally, as has been stated, widows of Officers. This appears the nearest approach to good organization I have met with. But again I say there may be much difference among the Russian Military Hospitals. I would not be con- sidered as laying down an absolute experience. It has been said elsewhere what was the system or no system pursued in the English Military Hospitals, as to Female Nursing. It Avas 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. But it may be now clearly enunciated what the duties of Female Nurses should be, and many reasons will subse- quently be given why there never will be discipline in Military Hospitals till they are as follow : Women only of the character, efficiency, and responsi- bility of Head Nurses in other Hospitals should be admit- ted 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 medi- cines, and of the meals ; for the obedience of the patient and orderlies to the orders of the Medical Officer. They English. Proposed Duties of Female Nurses in Military Hospitals. 24 PKOl'OSED DISTRIBUTION should receive the orders of the latter, and always attend him in his visits. Till the above is done by vromen, the same want of dis- cipline, now to be observed in Military Hospitals, and often already noticed, will continue, — such is my firm belief, the result of much experience. Duties which There will be abundance left for the Ward Master or to men. Serjeant to do in taking Military charge of the Hospital and its inhabitants, in being Office Clerk, &c., i. e., keeping the Admission books, making States, Returns, Accounts, and other documents, without his being Head- Nurse, without his superintending the Orderlies at the bed-side, his administering medicines, &c., which can only be satisfactorily done by a woman. And, when done by her, there will still be ample work for two men, where one does now the work of three. The first should do the Military part, the second should compound, take charge of Medical and Surgical stores, of Returns and Accounts connected with these ; and, where there is no Purveyor, of Purveyor's and Barrack stores, provisions, cooking, washing, diets, and extras, including Returns and Accounts connected with these. As it is, there is one Hospital Serjeant, who is Ward- Master, Serjeant, Steward, Clerk, Dispenser, Purveyor's Clerk, and Head-Nurse — a kind of " Maitre Jacques," as in Moliere's " Avare,'^ One man cannot do all these things. A Female should be the Head-Nurse — a Serjeant should be the Serjeant and Clerk — a Ward-Master the Steward. Dispenser, Ward-Master, and Purveyor's Clerk. And here I must deplore the confusion unavoidable in these definitions of proposed duties, while we have no separate system for Regimental and General Hospitals. What Dr. Menzies declared, in his evidence as to the OF DUTIES. 25 General Hospitals at Scutari, is strictly true, and one great cause of our failure at Scutari : — " I have followed the general rules for Regimental Hospitals, so far as I could." While Regimental Hospitals are what they are, females never can be admitted there. On the other hand, if General Hospitals be established, one happy consequence will be that the cooking and washing will be taken out of the hands of the Hospital Serjeant, and regularly orga- nized, it is hoped under a Captain- Superintendent of Orderlies. All Purveyor's and Barrack stores, that is. Hospital stores and furniture will, it is hoped, fall under the charge of a Steward; Medical and Surgical stores under that of an Apothecary. It will only remain to place a female Head-Nurse in charge of all that concerns the bed-side of a patient, and the duties of the Orderlies about the bed-side, and a Ward-Master in charge of everything else belonging to the Orderlies and Patients. But, if it should be determined to retain everywhere the old Regimental system, it is only just to add this very strong testimony and appeal in favour of the old Hospital Sergeant, who indeed deserves it : — • " I may take this opportunity of stating my conviction that, from the very arduous, constant, and responsible duties of the Hospital Sergeant, and his influence for good or ill among the non-commissioned officers and men of the regiment, it is parti- cularly 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 Ser- geant, who has been eight years a sergeant, three of which as Hospital Sergeant, receives at present Is. lOd. pay per diem, a7^.d an allowance of 4id. per diem as Hospital Orderly ; at the same D 26 RUSSIAN WAR-NURSES time that there are sergeants in the ranks of the regiment four years junior to him as a non-commissioned officer who are receiving 2s. XOd. pay per diem. " My experience leads me to consider that the regimental bandsmen are not, as a body, likely to be sufficiently strong or able men for the duty of carrying the wounded to be consigned to them. " Signed) Thomas Longmoke, " Surgeon IQth Begiment." Note in Regard to the Russian Nurses Employed IN THE War-Hospitals of the Crimea. The Russian nurses^ in the opinion of their Master, the famous surgeon, Pirogoff, did other things besides what the Army Medical Director-General told the House of Commons they did. But it is to be observed — In the first place, that much allowance is to be made for the confusion incident to Scotch and Russian surgeons talking French together, and going over many subjects in a very short time. And in the second, that very likely some extra confu- sion arose in the minds of our Army Medical Ofiicers from the fact of two entirely different sets of women having served in the Russian War Hospitals, viz. : (1.) The Sisters of the Elevation of the Cross. (2.) The " Erauen des Barmherzigen Wittwen Instituts," (mentioned in a very cold manner in pages 4, 26, and implicitly, 27, of Professor Pirogoff's pamphlet, " Die Gemeinschaffc der Schwestern zur Kreuz-erhohung. Ber- lin : 1856") ; who are those spoken of at pp. 22, 23, above. IN THE CRIMEA. 27 The Widows were so instituted, about forty years or more ago, by Mary of Wirtemberg, during so many years the venerated Empress-Mother. It is quite possible that in the war-pressure their services proved rather nondescript, they being neither sisters nor nurses, strictly speaking ; or perhaps the sole reason why Professor Pirogoff has not one good word for them is, that they were not under his orders. The Sisters of the Elevation of the Cross were a body of secular women, with a few Sisters of Mercy, formed by the Grand Duchess Helena, and placed by her under the orders of the famous civilian Surgeon Pirogoff, to whom the supreme surgical command in Sevastopol was virtually given. Several things are incidentally mentioned con- cerning them in his pamphlet, quite inconsistent with the constitution of an ordinary religious order. One or two things in the pamphlet are incongruous enough to English ideas : — the narrative given, however simply and succinctly, of the performances of the sisters by name, the pubhcation of the Professor's evident disagree- ment 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 Comite of Oberin, Chaplain, Doctor, and elder Sisters, &c., &c. But the division of Professor Pirogoff's war-nurses into three categories is a pregnant hint for future service, please God we yield it. These three categories consisted of (1) the "Verband-Schwestern,'' or those who assisted the Surgeon in the dressings, and the '^ Feld-scherer'' (Dresser) in preparing them. (2) The "^ Apothekerinnen," or those who were in charge of all medical appliances for immediate use, and who superintended the " Feld-scherer" (Dresser) in the administration of medicines. (3) The 28 RUSSIAN WAR NORSES. " Wirthinnen/' who looked after the diets, clean linen, &c., of the patients, and the order of the hospital. Each " category" was responsible for carrying out the orders of the medical officers. To every Hospital-^aracA-e (hut) was attached one sister of each of the above descriptions. In ordinary service the less nurses know of each other's wards the better — in war service it is essential that as few women should serve as many sick as possible ; and it is impossible to attempt assigning to each nurse the entire supervision of a ward. I think the categories, modified, of course, and adapted to the Queen's service, might be most useful. Another point usefully proved by Professor PirogoflPs 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 ser- vices. The Transport Abtheilung of the E-ussian 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* convoys of Sick Transport from Simpheropol to Perekop, and provided the sick with tea, sugar, clean linen, medical and surgical appliances, &c., on the way. * According to Professor Pirogoff sick were almost daily sent from Sim- pheropol to Perekop. They could not, therefore, be always accompanied by Sisters. Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and in War. It is, perhaps, advisable first to speak of some of those difficulties met with iu the War Hospitals of tlie East, in order that such may be prevented for others who may in future be Superintendents- General of Nurses iu Military Hospitals whether in peace or in war. I. No one ought to undertake a matter of duty of this kind without first obtaining the consent of the War Office to five conditions. 1. That every month, each of her sub-Superintendents shall furnish her with an abstract of the requisitions made by her on the Purveyor, whether for Nurses' consumption, or for that of Patients, and that she furnish the War Office with an abstract of these. It is then the part of the Purveyor to disprove her accounts, instead of its being, as before, her part to disprove his. 2. That it be made a point of honour, not of grace, with the War Department, to submit to her any Eeport, confidential* or otherwise, made concerning the Pemale Nursing Staff; a con- dition, without which it would be impossible to have respect- able women in the Military Service. * As little reference as possible, no reference at all, if it can be avoided, sliould be made, on our pa»"t, to the Confidential Report, which, in 1855, was presented against the War-Nurses. The less scandal about women is reverted to the better— a truth all slanderers have always appreciated : " Calomniez, calomniez toujours : il en restc toujours quelque chose." It would be far preferable if Nurses could enter the Army Hospitals quietly, and let by-gones be by-gones (the useful expea'ience always excepted, which has been gained). A 2 FIVE CONDITIONS ESSENTIAL TO THIS SERVICE. 3. That the powers of the Superintendent- General shall be strictly defined, and put in " Greneral 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 Super- intendent- Greneral' s case (and for what ?), 4. That the Superintendent- General have the power of com- municating directly with the War Department ; and that her Money-Accounts be sent in by her directly to that Depart- ment. 5. That it be made a point of honour that the Medical Officers commimicate to the Superintendent- General, or Local Superintendent, any complaint they may have against the Nurses for disobedience. In March 1856 the following appeared in " General Orders." Had it but been seventeen months earlier how much it might have saved!* The definition of the Superintendent-General's powers and duties, therein contained, is all that is wanted to prevent irregularities disastrous to the Service. Geneeal Ordees. Marcl 1856. " It is notified, by order of the Secretary of State for War, that Miss Nightingale is recognized by Her Majesty's Government as the General Superintendent of the Female Nursing Establishment of the Military Hospitals of the Army. No lady, sister, or nurse is to be transmitted from one Hospital to another, or into any Hospital, without previous consultation with her. Her instructions, however, require her to have the approval of the Principal Medical Officer, in her exercise of the responsibility thus vested in her. * The work was done under many difficulties, some inevitable, some which should have been spared. Things happened among us deeply to be regretted. Eebellion among some ladies and some nuns, and drunkenness among some nurses unhappily disgraced our body ; minor faults justified -pro tanto the common opinion that the vanitj^ the gossip, and the insub- ordination (which none more despise than those who trade upon them) of women make them unfit for, and mischievous in the Service, however mate- rially 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. NURSES OF FOUR SORTS. 3 " 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." 11. Nv/rses. 1. Our Nurses were of four sorts. Nuns. Ladies. Sisters (Anglican). Nurses. The Nuns were received not as Nuns, but as Nurses. Their (so called) training told sometimes against us ; some- times for us. The same with the " Sisters" (Anglican). The Ladies were useful, exactly in proportion as they ap- proached the professional, and not the dilettante, mode of thought. A larger proportion of paid Nurses than of Ladies did well, and this under circumstances of peculiar temptation. Paid Nurses are always the most useful. 2. There should always be a proportion of Nurses in Army Hospitals To preside in Extra Diet Kitchens,* „ in Linen Stores. To teach the Orderlies to nurse in the Wards. The proportion of Roman Catholic " Soeurs," in French Military Hospitals, is as small as this would be ; they under- take even less duty than this : in Military Hospitals they do much less than in Civil Hospitals. Women in Military Hospitals should all be contracted ser- vants, whether Nuns, Ladies, or professional Nurses. There should be a retiring pension to each woman. * The Extra Diet Kitchens must, it is necessary to state, be under a separate roof from the General Kitchens, as long as the present system (or no-system) of cooking exists. But the sooner it is altered the better. There should be one kitchen only. But the Nurse should always superin- tend the administering of the Diets. She is unquestionably the proper person, also, to administer the medicines, &c. The Orderlies, to be of any use, must act under the direction of the Head-lSTurse and not indepen- dently. It would seem hardly necessary to enunciate such a self-evident proposition. a2 4 QUALIFIED SUBORDINATION OF 3. Miss Nightingale took service on the ground of being under the Principal Medical OflBcer, and, consequently, of not interfering with him. There was no imperium in imperio in her case. This exists in the case of the French " Soeurs de Charite," and existed in individual instances among the' " Sisters" under Miss Nightingale ; i. e., they gave articles of diet, &c., as from Sisters, not in obedience to Medical orders. This was imme- diately put a stop to by her. That the Medical Officer is sole master of diets, is an axiom of medicine, and of common sense. This involved our only answering the Extra Diet Eolls in our kitchens ; not originating either in quantity or quality. Afterwards, although frequent were the insinuations that we transgressed the above maxim, no evidence of the fact was ever obtained, except the following, which is given verbatim and literatim, as "put into Court" by a Eirst 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. North- cott's " handwriting. " 2447. Pte. John M'Cormick, L. T. Corps, age twenty, 11 Com- pany, admitted into 6 Ward, F. Corridor. Admitted with Febris C. C, April 30th, 1856. On or about the 10th of May I was con- fined 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 Vic- toria Barracks, Scutari, three-quarters of a mile from the Hospital, and never saw the Nurse, food, or drink that was administerd to the above-named Patient, and I never saw the docter that ordered me to be confind. I was confind by order of 1st Class Staff-Surgeon Prendergast. About two and a half hours after I were aquanted with the case. " (Signed) 173. W. .J. Northcott, " A.W.M,, M S.C." III. 1. Lay clown 1. In defining the office and duties of the Superintendent- istmct y t e Qg,-igj,.-^| gf jvj'urges her direct communication with, and qualified communica- ... . tion whieh is subordination to, the Director-General of the Army Medical to take place Department, and, abroad and in war, with and to the Principal SUPEKINTENDENT-GENEEAL TO DIRECTOR-GENERAL. 5 Medical Officer of the district, or equivalent, must be very exactly defined. If the formation and government of a body of women to serve in the Hospitals of the Army Medical Depart- ment, and in these alone, is contemplated, the less the Director- Greneral 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 Superinten- dent-General, and to the Matrons, whom she delegates, and who are themselves responsible and ameuable to her. But it will never loorh 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 Medi- cal Ofiicer 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 Ofiicer, are well and definitively expressed. It is impossible to appoint the work of the Nurses without the concurrence of the Director-General. It does not do to put a woman into a great ward, or several smaller wards, of men, with several orderlies, without clearly defining her posi- tion 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 Depart- ment. 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 Stafli" Corps. In these Regulations, both the former and the latter, every duty a Nurse can discharge is assigned to diftercnt men. The between Director- General and Superin- tendent- General, and (in war and abroad) Principal Medical Officer and Superin- tendent- General, and the qualified subordination of the latter. 6 QUALIFIED SUBORDINATION OF MATRON TO responsibility of the ward, the administration of diets and medicines, the application of poultices, fomentations, leeches, enemas, and minor dressings, are all in so many words assigned as the duties of Assistant-Surgeons, of Hospital- Serjeants, and Orderlies ; and of Assistant-Surgeons, of "Ward-Masters and Orderlies of the Medical Staff Corps. The Regulations in general are being revised ; — so much the better. But the new body of Orderlies, announced in the" Gazette" as the Hospital Corps, will, of course, receive rules from the Director- General ; and if these things are not settled with him, there will be con- tradictory rules in operation, which will most materially thwart the working of the Female Service. We have ourselves experiencedthis, as to the administration of medicines, which one Principal Medical Officer took away from the Nurses, saying that it was the duty of the Assistant- Surgeons, in which he was borne out by an existing Regulation. And it would really seem as if this were the intention of the said Regulation, for it is there laid down that the medicines are to be administered twice-a-day, as if this were a property of medicine. The existence of these Regulations proved also a great stumbling-block in the Castle Hospital, after the war-pressure was over. Unless the Director- General, and in war and abroad, the Principal Medical Officer, are brought into regular communica- tion with the Superintendent- General of Nurses, by the Rules, they will, at every inspection of Hospitals, revert to the pro- cedure 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. 2. Also, and in the same way, there should be distinct rules between for direct communication between the Principal Medical Officer Principal of each Hospital, and the Matron, and between the Staff (or Medical Officer . . and Matron, equivalent) Surgeons of the Hospital, and the Matron ; if not Staff-Surgeons also between these latter and the Nurses. Staff-Sur"-eons '^^^ constitution of a General Hospital is about to be orga- 2. Also PRINCIPAL MEDICAL OFFICER. and Nurses, and the qualified subordination of the Matron and Nurses. nized iu England. In the large "War Hospitals there was the Principal Medical Officer, a StafF-Surgeou in charge of each Division^ then the Assistant-Surgeon, who answered to what, as is now proposed, is called the Prescribing Medical Officer of the "Wards. As regards the Matrons and Nurses, it must not be proposed to ignore all but these Prescribing Medical Officers. Certainly, it would never do to give the Superior Surgeons of the Hospital no say as to the nursing. In 999 cases out of 1,000, the Superior and older Surgeon is the one who under- stands and cares much the most about the men, and who, there- fore, in the long run, would more appreciate and be fau-er to Matrons and Nurses who did their duty by them. The Supe- rior 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 com- munication with the Nurses of the wai'ds 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. 3. Now, as to the introduction of Nurses into all Greneral Hospitals — this gets rid of many difficulties, but at a fearful cost. For years to come, the difficulty will be not to extend the work, but to serve such Hospitals as must be undertaken, with respectable and efficient women. The material has, in a great Head-nurses to degree, to be created ; abundance of applications will be re- J^*^ created.) ceived — the prospect of a pension alone will do that — but the State should real choice will be very limited. In these Military Hospitals ^® ^^^^ a\rare each Nurse must be a Head Nurse, and a trustworthy woman. FemaleServlco Many a woman who will make a respectable and efficient ^J^^ ^^h be Assistant-Nurse under the eye of a vigilant Head-Nurse, will ^graduaUy not do at all when put in a military ward or wards, herself the Director- only woman, and Head-Nurse over the Orderlies. As a bodv .^^^^'"'''^ P"!* . '' J. . . . -.^ , . •^' nave a voice in the mass oi Assistant-Nurses are too low m moral principle, the 3. All the General Hospitals cannot be undertaken at once. (The material of MATERIAL OF NURSES FOR MILITARY HOSPITALS introduction. Director- General and Superin- tendent- General differing. Secretary of State to decide. and too flighty in manner, to make any use of here. Supposing all the Head-Nurses of the great Civil Hospitals* offered them- selves, there are perhaps not many who could be recommended for a Military Hospital. Some, who are very highly to be thought of, would never bear transplanting into the res dura et servitii novitas of the Army Hospitals. The class from which the Head-Nurses are mainly drawn, tradesmen's and servants' widows, &c., will volunteer in numbers, but, in the majority of cases, intending only to lead the idle life of many a London Head-Nurse — "mental, not manual labour" — "Superinten- dence" — i. e., standing by while the Orderlies do her work and their own. Tlie 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, witli a number of strangers ? It certainly should be left to the Director- General to regulate the introduction of Nurses into tlie General Hospitals — and there is far more reason to fear that * To all references which may here be made to Civil Hospitals I should wish to say, by way of preface : — 1. That I have always believed and I believe it more and more every day I live, that what is wrong in hospitals is to be patiently, laboriously, and, above all, quietly mended by efforts made from within them, if it pleases God to grant that blessing upon them without which all human efforts are vain, and not by accusations, investigations, and noise from without. 2. Also I have always believed, since I knew Hospitals at all, and I believe it more and more every day I live, that, with all their faults and shortcomings, which are easily learnt and more easily declaimed against, our great English hospitals are places in which more is done for the relief and cure of human misery, or, rather, of that large branch of it arising from disease, than in any other places in the world. Also that their faults are not essential to them, but that they may, by God's blessing on the patient endeavours of many years, be very much modified. HAS TO BE CREATED. \) he, if unfavourable to the change, will hurry, than obstruct sucli introduction ; indeed it might be better to settle that matter beforehand with the Secretary of State, letting the Directoi'- General be apprised of it, viz., that time is required to effect the gradual introduction of the Female Service with which the Superintendent-General has been charged. To sum up. A rule must be introduced by which the Director-General is brought into communication with the Superintendent-General, and her qualified subordination to him distinctly expressed. Let the Principal Medical Officer in war also communicate directly with the Superintendent- General or the person performing her functions in the War-Hospitals, and her qualified subordination to him be distinctly expressed. The same with each Principal Medical Officer of a Hospital, and the Matron of that Hospital. No alteration in these Regulations can, of course, be made without the consent of the Secretary of State. In case the Director-General and Super>- intendent- General finally differ as to any new arrangements, the matter should be referred to the Secretary of State. The Superintendent-General should issue special regulations for nurses, after conference with the Director- General, and under the sanction of the Secretary of State ; also, local regu- lations for the Matrons with the consent of the Principal Medical Officer and sanction of the Governor of any General Hospital. If the Matron differ with the Principal Medical Officer, the decision should rest with the Governor of the Hospital. IV. As to some miscellaneous considerations, of no small import- 1. It is necessary for a Superintendent-General to have counted the cost, and to be prepared or not prepared to include Eoman Catholic Sisters among the Nurses. This will deprive her of some valuable women ; of one (speaking for the pre- sent 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, witli all its many strings, and machinery of opposition. Abroad the cause of the 1. Romau- Catholic Sisters "i 10 SISTERS — ROMAN-CATHOLIC AND ANGLICAN. 2. Anglican Sisters ] 3. Whom is Roman Catholic Churcli is often the cause of religion ; and the Eomish Priest serves both zealously at the same time, and with a pure heart. In England, and in matters of England, the first aim of the Direction is too often to damage what is not Eoman, and the second to promote what is Christian. Upon the whole I must think Eoman-Catholic Sisters are better out of, than in, the Army Hospitals. It would be right to think well over how far they could be entirely dispensed with, in the event of having soon to undertake a War Service. In the event of a decision being made to dispense alto- gether with Eoman Sisters, it would be as well to be pre- pared (though we never can speculate on the tactics of the Eoman faction, and after what occurred during the Crimean war, it may think it better to take things quietly) for a battle, {not confined to the Army Medical Department,) for the pro- duction of an Inspector- G-eneral'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 oue taken in the paper emanating from the Army Medical Department, extolling the Eussian Nurses, "who were all Sisters of Mercy, and mostly widows of officers." 2. The nature of the Service and Eules would, unless in war service, perhaps exclude English "Sisters" from the Nurses. They supplied us with some valuable women in the last war, and their Lady-Superior behaved ever generously, loyally, and well towards us. The principle and detail of most sisterhoods render them unsuited for admixture with the secular element ; and the comfortable belief into which the good women (of both branches) practically, if not theoretically, settle, that secular women are too bad to be mended or influenced, unfortunately makes their usefulness among Nurses nearly null. It would never do to unsettle any of the Sisters ; but if it so happened that any voluntarily ofiered to serve as bona fide Nurses, some valuable individuals might thus be acquired ; but this should not at all be pressed. It would certainly remove a difficulty in declining Eoman Catholic Sisters, if the rule should be to decline also English Catholic Sisters, forming the Staff entirely of secular women. 3. In Civil Hospitals there are three distinct elements of POWER OF POLICE IN CIVIL HOSPITALS. 1 1 government. First, the Civil Authority ; the chief being the the Nurse to Treasurer, or the equivalent civilian, whose subordinate is called ^"™gc*'of "^ diversely Steward, Superintendent, House Governor ; second, disordcriiness the Physicians and Surgeons (duly represented, in case of "^ *'^'^ ^ '^ holidays or illness, by the Assistant Physicians or Surgeons), Apothecary and House Surgeon ; and third, the chief of the Nurses — the Matron. It requires of course temper, discretion, forbearance, and fortunate circumstances which do not always happen, for these authorities not to spend a portion of their time in quaiTelling with each other ; but the ruts are old and deep, and the wheels move on, though they often stick. The Civil Authority is a very important element, especially when the chief is a man of judgment and firmness, who keeps himself paramount over all, and does not delegate all to his subordinate the Steward. The Steward and the Matron generally find their duties disposed to clash. In some Hospitals the rules are inexplicit in assigning power to the Matron over all the women. But this apart. The Steward represents and wields the police of the Hospital. He progresses through the wards, he perceives, or the Head Nurse reports to him, something disorderly. He rectifies it (or not, as the case and the man may be). She thus, over and above her relation to the Matron, has to appeal to, and to account to, the Steward. This power of police and discipline, wielded by the Civil Authority of the Hospital, is of immense moment in regulating the good order of the Hospital ; it acts in sundry important ways which need not be particularized. Now, in the case of Military Hospitals, there is one impor- tant 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 Ofiicer ; there are Nurses under a Matron, and Orderlies under some Officer; and there is no Civil element. The Doctors both pre- scribe, and hitherto have governed. An Officer orders fiogging, &c. ; but the Doctors practically both prescribe, and hitherto have governed. And a Militaiy Hospital must, and should ever 12 POWER OF POLICE AND DISCIPLINE remain, essentially different from a Civil Hospital ; both different in discipline and detail, and altogether a rougher and ruder place. It should never for a moment be forgotten that tlie soldier is a very peculiar individual, old and stern as is his ti'ade. A regiment, if one thinks into it, is a curious thing. The Hospital which receives these men when ill and wounded, whether regimental or general, is, and ought to be, a place essentially different in many things from the great Civil Hospital. The moral standard of the patients of the Military Hospital, their readiness to obey, their good feeling to each other, are strikingly higher than in the Civil Hospital ; but the soldier is what, amidst all his faults, he has been made by the habit and spirit of discipline, w^hich has become an instiiTct and a second nature, and which ennobles his own. Relax discipline, and in proportion as you do so, there remains of the soldier a being with as much or more of the brute than the man. Discipline then being the pivot upon which the good order of all military things. Military Hospitals included, turns, it follows, that if you set down a few women (they should not be many) in a great Military Hospital, unless they can become effectually incorporated into the general spirit of discipline of the place, they will only injure themselves and the whole. As women, the more entirely they are under the government of the Matron, herself under the government of the Superin- tendent- General, the better. As "Ward Nurses, the more entirely they are under the orders of their Surgeons, the better ; but they have not only to obey the Surgeons, they have to enforce the Surgeons' orders among the patients, and both for so doing, and for the cleanliness, &c., of the ward, they have to give orders to the Orderlies. In the case where a rule will work, by which, if the Nurse has to complain of an Orderly, she reports the same to the Matron, who lays the complaint before the chief of the Orderlies (whatever may be fixed upon as his name) ; well and good ; but a more direct procedure will also be found necessary. Every firm and discreet woman (none other is fit for a male ward, least of all for a military ward), will avoid collisions, reports, and violent outbreaks in the ward a» much as possible. IN MILITARY HOSPITALS. 13 Tjut still, every now mid then these thiiigs will happen, and though by all means to be avoided if possible, when they do come, they clear the ward-atmosphere like a storm, provided the discipline be strict. Every now and then — and every experienced Head Nurse will tell the same story — some diso- bedience, 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 tbat it will be done, in such or such a contingency. Now the soldier cannot be turned out of Hospital, and he knows he cannot. It becomes the more important not to suffer an hour's relaxation of discipline there. If, therefore, such an outbreak, either on the part of patients or orderlies, should happen in a Military Hospital, the Nurse ought to be able to summon at once the proper authority and afterwards to report the whole to the Matron, but first to bring direct the proper authority into the ward. Whether it be the Captain of Order- lies or the Orderly Medical Officer, or, as in case of emergen- cies, is generally preferable, the Staff-Surgeon himself, she ought to have power at once to bring the proper authority into the ward, to put down confusion and restore discipline at once, and then afterwards to report to the Matron what has passed. It must never be forgotten, that in every Kegiment 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 inde- terminate number whom discipline saves from ranking after them. One year with another, characters no doubt as vile as 14 TO WHAT WARDS FEMALE SERVICE APPLICABLE. the worst that disgrace our gaols pass through the General Hospitals. Another thing to be remembered is, that whatever classifica- tion 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. Eor reasons somewhat too technical to write, it is to be hoped, upon the whole, that female service will not be, at first, at all events, extended to these wards. The disgusting and comparatively painless secondary condition will, I fear, find its way into the ordinary surgical wards, as it does into the equivalent wards of every Civil Hospital. All these things woidd increase the mistake of laying any bar between the Staff Surgeon and the Nurse. In all matters of discipline, generally speaking, the Staff Surgeon will give much more support than the Assistant Surgeon. A short definite rule should therefore be made, saying whom the Nurse is to summon in the event of disorderliness in the ward. One thing more. There is nothing more dangerous than to undervalue the objections of opponents. Let us give them their full weight, and while firmly holding our course, and trusting to God to guide it, draw useful cautious from the objections which we quietly and steadily confront. In the great Military Hospitals, of Eoman-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 Soeurs de St. Yincent 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 PAY AND RATIONS. 15 of Soeurs to those of hired nurses — but they deprecate either Sisters or any women in Military Hospitals. 1. Because the presence of women, however virtuous and guarded, would excite passions and produce unfavourable results in many cases. 2. Because they were unnecessary, the Orderlies being eflBcient, faithful, kind, and suflBcient. 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 eflicient 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 neces- sary to bear in mind both the existence of this danger, and the exaggerated fears many Army Surgeons conscientiously as well as unconscientiously have of it. I therefore very earnestly hope that the work will not be encumbered, at first at all events, with the charge of the vene- real 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. 4. Pat akd Eatioks. — In the great Civil Hospitals the 4. Pay and Head-Nurses have, on an average, 501. 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 125. a-week, [£31 per annum] no board, lodging, with the use of some furniture, sometimes an allowance of fuel and light, apart from the use of both in the wards. Both Guy's and St. Bartholomew's Hospitals now give par- tial board to the Assistant-Nurses, and St. Thomas's is about to adopt the same plan. St. Mary's Hospital gives board to both Head and Assistant- Nurses. 16 RATIONS TO BE COMMUTABLE In the last war Her Majesty's Nurses received, on an average, ISs. a-week, lodging and board, fuel, light, and partial clothing — ISs. a-week is 4 PAY AND DRESS Hospital property in her room, whicli, if there is no place for it, she must do, and it is much better she should not. 8. Matrons g. "With regard to the Matrons, though as Locke says of annum tutors, there are all kinds of persons to be found, it is certain Quarters, and the right persons are not always found ; and these officers will A woman for ^^^ time to find, at the outset especially. Let them be (if it the Linen, be possible) of the middle class ; if it be possible, middle aged, rankmg and active women, widows of officers or army surgeons. A vast Nurse, but deal of struggle is ever going on in professional life ; a vast never entenng (jg^j ^f silent, decorous misery ever follows on the premature the wards. ^ , , ^. ^ , •' . ^ , ^ '^ , deaths, the compelled early retirements, the sundry chances and changes which ever abound m the army of England. So far as it goes, and cceteris paribus^ it would be right, just, and expedient to give a preference for these matronships to widows of officers and army surgeons. Try to secure thorough principle, sense, activity, and steady discreet ways ; never mind a little vulgarity of manner ; that the difierent 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 appoint- ment. Should her being without children be made a sine qua, non? Children — poor little things — are wanted no- where 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 nwrses must upon the whole be discouraged, because upon the whole the disadvantages seem to overweigh the advantages.* But the Matron's office and duties are dif- * 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 OF MATRONS. 25 ferent;" she is not fixed to a great ward of patients; and her having children should not be a bar, especially if they did not live with her. Young and grown-up daughters are much in a Matron's way ; sons matter much less. The greatest Civil Hospital gives its Matron 200?. and a house, the other great Hospitals, 150?., and a house. The London Hospital gives 150Z., and a couple of good well-furnished rooms, and a servant. A house is an impediment to a Matron's duty. She is seen arriving in the wards, and she is more or less hindered in entering them. From her rooms she issues and re-issues, unexpectedly, and much more efficiently. 200?. and quarters is not at all too much. The Matron must be responsible for the storing, mending, and distribution of the linen, and for returning to the laundry any linen not properly washed or dried. Linen ought never to be dried in thewards, a processboth inconvenient and unwholesome. The Matron ought to have a steadj , respectable woman, certainly not below the rank and pay of a nurse, to be responsible to, and under her, for the linen, otherwise the propercareof 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 uncon- sciously become a gossip and mischief-maker. I wo\ild 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 minutiae, once provided for, enter much into the daily working and comfort of things. The dress of the Matrons is a difficult thing to settle. Some- times a Matron is afilicted with a taste for either gorgeous or 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. 26 PAY AND DRESS OF MATRONS. elegant apparel, which the Nurses are invariably proud of, admire and humbly emulate. This sort of thing would be really out of place in a Military Hospital, and would moreover sadly discom- pose the Nurses with their plain caps and gowns. How would it be to allow the Matrons the choice between a Regulation dress and a plain black or brown silk gown ? It will take much thought to decide whether the Matrons should all be paid alike, or whether climate and size of Hospital enter into this. On the one hand they undertake a service, of which almost the first regulation very properly is, that they undertake to go to all parts of the world as soon as sent ; on the other hand, certainly some climates wear health and life much quicker than at home. The Matrons out of the three kingdoms have increased responsibility, and can do more mischief, if incompetent or untrustworthy. If the Matron has increased pay abroad, it would not do not to augment that of the Nurses. This is an important matter ; and as it is on all accounts necessary that Matrons and Nurses should on their engagement thoroughly understand the nature of the service they undertake and, of course, a serious part of the service is that it involves sudden and long removals, it would be necessary to define upon what terms they go abroad. Yet it never would do, for reasons which will readily be perceived, to make the foreign stations objects of desire to Matrons and Nurses. These stations will always be so far the most anxious, that they will always be the most removed from the Superintendent-Greneral'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 discliarged, and to forfeit all re-admittance into the service and all pensions. On the whole, I think the Matrons should all be paid alike. But inasmuch as foreign service necessitates more wear and tear to the constitution, one year should count as equal to two years of service for pension, in case of disability. The same should be made applicable to the Nurses. As the advantage is distant, it would, in a great measure, do away with any desire for foreign service. VOLUNTEERING FOR FOREIGN SERVICE. 27 Volunteering for foreign or war-service must be the ex- ception — careful selection the rule. The " adventurers" vrill 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 ia most desirable not to change the Executive officers of any Hospital more than can be avoided. But let thei'e not be too many rules at first ; see how things work, and take one step at a time. The selection of exclusively middle-class Matrons seems to be important.* Their order will disarm one source of oppo- sition and jealousy ; plenty more will remain, inseparable from the work ; but it is good to get this out of the way. The name of Matron is the same as in Civil Hospitals. In many respects the office and duties are different: e.g., the Matron in Military Hospitals must exercise afar more constant supervision in the wards. But this will require great discretion on her part. It is the practice of most Civil Hospitals for the Matron never to enter the wards till the Nurse's dressings are over. It would be advantageous to modify this. But, at the same time, the Matron must understand Hospital Nursing, or she may make very serious mistakes in either reprimanding or directing the Nurse as to technical matters. She must be a person who knows herself what she has to see that others know; or she will get herself, with or without the Nurse, into very injurious errors. There is much in a name ; and, in some respects, that of Superintendent would better denote her office, as regards the Nurses, would add to her authority, which is desirable, and would point her out as acting under the Superintendent-General. Incorporate among the Nurses whatever women of the higher orders may be admitted into the Service at first. If inefficient and unfit they are far better altogether eliminated. If thoroughly efficient as Ward Nurses, if thoroughly obedient and respectful to the Matron, if they have sense and heart to * Should a woman, however, out of the higher orders, be found as effi- cient as one of the middle classes, as Matron, this should be no reason for excluding her. 28 UNPAID NURSES. gradually leaven, not coldly withdraw from occasional compa- nionship with the other Nurses, they will, in the course of time, effect quietly a great deal of good. There should be some "Rule of this kind — Any Matron or Nurse who may receive permission to serve Her Majesty without pay shall be, in all respects, bound by and amenable to the Regulations on pain of dismissal from the ser- vice, without permission of re-entering it. If this cannot be done, money can easily be returned in one shape or other; but it would have a good moral effect on the Nurses to allow of the admixture of unpaid Nurses, pro- vided they are strictly bound by the same Eegulations, and distinguished by no sort of peculiar designation. The Surgeons will dislike these unpaid Nurses ; but, in the long run a firm, discreet woman, wlio is an efficient Nurse, can get on with any Surgeon who has his sick at heart. The Matron also will not at all like them, at first, but will find that she can rely upon them and that they quietly and effectually help her with the other Nurses : and, if she has her heart in her work, she will end by being just, though, perhaps, always a little extra strict with and jealous of them. The other Nurses will have, at the first, a strong little touch of republicanism towards them, which will gradually wear off, and, with Grod'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-feel- ing have wound around this work — a work essentially unpo- pular 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. VARIOUS RULES AS TO NURSES. 29 9. As for the Nurses tlie material must be formed. If ,^- .^^^^^T a few respectable soldiers' widows, including, and all the ^^^at first. better, non-commissioned officers' widows, could be found, ccBteris parihiis, a preference should be given to widows of the Service. Except in emergencies Nurses should not be taken under thirty, or above forty* years of age. These women are Head Nurses. Most of the Civil Hospitals take no Head Nurse after forty. One caution in engaging Nurses is perhaps not sufficiently attended to. Certificates, without personal inquiry and answers to distinct questions, are not worth the paper on which they are written. As to engaging any Nurses out of the great Hospitals, for sundry reasons, this should be done as little as may be. Let us begin, for the sake of God and this His work, with few women. Extension is easy — to occupy too much ground at first would be, I do in my conscience believe, an irretrievable mistake. No unnecessary Nurses should be suffered in Hospital ; and no Nurse in charge of wards should be required to do needle- work for the Hospital. There should be no superfluous hands ; and the less a Nui'se enters another's ward the better. In case of suspension of a Nurse for misconduct, temporary assistance must, however, be obtained ; and this might be either appointing another Nurse, to do, for the time, such duty in the suspended ward as she could do in addition to her own, or putting in a temporary substitute. All such dislocation of tlie Service, necessary and useful for emei'gencies and holidays, should, nevertheless, be made to take place as seldom as may be. No Nurse, during her suspension, should be allowed to enter any ward of the hospital. Any Nurse asking or accepting a present, whether in money * 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 Sei'vice. 30 PRAYERS TO BE READ BY NURSE. or in kind, from any patient, or friend of any patient, whether during his illness or after his death, recovery, or departure, must be at once suspended from duty, her pay immediately cease, and the Superintendent- General be apprised of it, who, if satisfied of the truth of the charge, should immediately dismiss her. Two hours daily for exercise or recreation should be allotted to the Nurses, during which two hours they are to be consi- dered 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. Grive them two hours for optional exercise. Head- Nurses canuot have more of fixed leisure. They must get time for private occupation as they can : very often not at all ; and no Nurse fit for her place will, of course, in emergent states of her ward, leave it. Also the Matron must not worry herself or them, if an anxious Nurse sits up part of a night or a whole night with bad cases. To a certain degree the Matron will find it better to allow a little liberty and choice, in the matter of times and hours, (always excepting after proper hours, i. e., after dark) to the Nurses, who are Head-Nurses, than to attempt making them mere machines. An uniform system, as far as possible, and a little range to each, will answer best. But do not hurry the uniform system too much ; take time : this is very important. The Nurse should, every morning, at an hour to be fixed by the Chaplain or Matron, read aloud in the ward, the Confes- sion, 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 Thanks- giving, the Collect for Aid, and the Benediction.* This would Christianize things, instead of heathenizing them ; and I believe not a soldier would dream that his con- science 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 * It is better to omit the Belief. Singularly enough it is the one thing objected to by DiBsenters and Koman Catholics. WHAT THE NURSES ARE TO DO THEMSELVES. 31 Chaplain-Greneral to approve of and direct in this, and best to wait a year or two before beginning it. The prayers should be very short, the whole not more than five or six minutes each time, and the Nurse should read them, the men joining at the proper times. In some Civil Hospitals the prayers are far too long and are gabbled over by some patient, perhaps the worst character and the best scholar in the ward, or are stumbled through by some little boy, upon whom the others cast the distasteful office, with circumstances of irreverence, partly unintentional and partly shocking. At St. Bartholomew's Hospital the very short morning and the very short evening prayers are printed clearly on each side of a card, which is affixed to each bed ; and each morning and evening the Head-Nurse reads them aloud : the difference is very great. 10. The Colney-Hatch Lunatic Asylum has a diet system worth inquiring into ; nothing is fetched by the Nurse, the Medical Officer writes the diets on a large slate which is ready for him outside the ward. The great advantage of this seems to be, that the Nurse's time is set free from a good deal of arithmetic and some writing; also that each man's portion is served him hot from the kitchen, not cut up laboriously by the Nurse. In most Hospitals the Nurse cuts and divides the diets ; in the Loudon Hospital she moreover weighs them. All this takes a great deal of time. If the patients can get the divided portions liot from the kitchen, it is far preferable. At St. George's Hospital the portions are sent hot and divided from the kitchen. 11. It should be distinctly settled by whom poulticing, fomenting, and all minor dressings, applying leeches and blisters, and giving enemas,* are to be done. * 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 respon- sible for it. I should prefer, as above stated, charging the Nurse with it ; 10. Have the Diets sent hot and ready- divided from the Kitchen. 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. 33 WHAT THE NURSES ARE TO DO THEMSELVES 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' Eules, would make these men, especially those ordered for foreign service, much more useful than they are now, without such teaching. It will, however, be essential that there should be no clashing between the Nurses' Regulations and those already or to be issued to the Orderlies. And for this, among other reasons, it is essential to establish a direct channel of communication between the Director- General and Superintendent-General of Nurses. Ward Medical I think, upon the whole and with reference to preventing, Officer to give as far as rules can do it, the obstruction of the Nurse's duty, Nurse. ^7 adverse or inexperienced Medical Officers giving orders to Ward or Assistant "Ward-Master, Orderlies, or patients, instead of to her, that it is better to charge him to give the Nurse his orders as to the sick. All the above-mentioned things should be done by the Nurse, i. e., by her habitually and as a rule ; occasionally letting an orderly do them, under her own eye, in order that he may leax'n, as well by doing them sometimes himself as by often seeing her. The reasons why all these things must be clearly settled beforehand are these : — I. Adverse Medical Officers will make all use of counter- regulations. II. Medical Officers who give fair play will find it impossible to settle the matter, if, on ordering, e.g., leeches, the Orderly shows Eule 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 regu- lations 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 medi- cines, in which he was borne out by an existing rule. Contra- dictory rules are miserable things. but if objected to by the Surgeons, I should at once let them assign it to whichever Non-commissioned Officer they chose. AKD WHY. 33 ITnless the Matron's authority is supported by the Principal Medical Officer the Patients always suffer. The Nurse is the only proper person to be responsible for the directions of the Medical Officers being carried out in a General Hospital. Ill, It will enable the Matron to stop all nonsensical pru- dery, 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 them- selves. As a general rule there is a good deal of this false modesty on the part of Nurses, especially of Head Nurses. In individual cases it is a serious thing to shake even false ideas of decorum : in laying down general Rules it is the more important to lay down as duties what are such. Suppose an application of what the French call " la petite chirurgie" ordered. The Head Nurse " never dreams of doing such things." The Nurse, following her superior's false shame of duty, transfers the business to an ignorant patient. In some cases great harm has arisen thereby to the Patient. In other cases, but not the majority, after such an order given, the Head Nurse goes quietly to the bed, draws the curtain round it, and makes the application herself — saying " she always did that herself, as it was a business requiring care, as the patient was often disposed to resist, and as she was thus certain that it was properly and effectively done." I have always admired and respected such women ; but they are not the majority. Very often patients are allowed or left to do things for themselves, which they cannot do properly, or when they ought not to be trusted to inflict the pain on themselves which doing things properly often causes. The practice of allowing some particular patient to become a sort of half orderly in the ward, letting him always attend some particular case, or give general help in severe cases, is most reprehensible. It is never allowed, whether in Civil or in Military Hospitals, without very bad consequences to the discipline of the ward. Where extra help, in lifting, &c., is required, let the Nurse require the most convalescent of the patients to help, but let her carefully refrain from selecting any patient or allowing any patient to put himself forward, as a regular help or quasi -Orderly. As an almost invariable rule it c 34 REGULATION NUMBER OF ORDERLIES, will be found that the less patients do for each other the better for themselves, and for the discipline and the good feeling of the ward. Let them be made useful in the wards, as far as possible, in such lighter cleaning, &c., as a patient can pro- perly 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 nxirsing 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 Order- lies are doing other things in the ward; assisting to move a helpless patient, if all the Orderlies are not at hand; sometimea watching or attending for an hour or so a critical case, &c., &c., &c. What the Superintendent- General and all Superin- tendents must be especially vigilant against is selecting any particular patient or allowing a willing patient constantly or often to do these things, and to become a quasi- Orderly to the ward or to any patient in it. Assistant-Surgeons, partly from inexperience and partly from spite, sometimes make this sort of quasi-Orderly of a patient. The Nurse should have the power of respectfully saying, in such a case, " The Regulations order me to do so and so, sir : I beg you to let me do my duty." It is an important and should be, if possible, an invariable rule that no discharged patient is ever to enter any ward. Soldiers are, in many respects, on a different footing, as to each other, from Civil patients. The above provision is perhaps rendered thereby (not the less, but) the more important for the good order of the ward. Still this, desirable in (and the rule in several) Civil Hospitals, might be considered by Military as well as Medical Officers to interfere too much with the feeling of comradeship which, in its measure, is so essential a part of the soldier's very peculiar condition. The following rules however might, at all events, be carried out. Some of them are actually in the " Hospital Regulations." As quietness is indispensable in Hospitals, every duty should be performed with the least possible noise, more especially at HOW FAR APPLICABLE. 35 night. Every patient must be in bed by 8 o'clock in winter, and 9 in summer ; and no conversation must be permitted after that time. Patients should be made useful iu the wards, as far as possible ; but should fetch nothing into them. And no dis- charged 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 OflScer, will fix the visiting hours ; which shall not be more than two hours during each of three days of the week. [Take proper advice as to whether this maximum is too short. It is fully enough for Civil Hospitals, but Military Hospitals are in sundry respects essentially different.] In the discipline of all Military Hospitals, besides the pro- hibition of all swearing and foul language included in the Articles of War, is included the non-admission, or if by over- sight admitted among visitors, the immediate expulsion of all disorderly persons. (Query — whether notto specify prostitutes.) I very much wish that Hospital Sentries in General Hospi- tals might keep out all visitors, except in the fixed visiting hours. And I very much wish that a stringent rule were made as to female visitors, both in Regimental and in General Hospitals. Proper Military as well as Medical advice should be taken on this point. It might not do to exclude them altogether ; and, if soldiers' wives come, it might be better to admit also all respectable-looking women, for it would be useless attempting defining as to sisters, aunts, friends, &:c., &c. ; though, except in the case of dying patients, all women, except their wives and mothers, are better away. I do not know what amount of strictness in practice is shown in enforcing the Regulations in English Army Hospitals ; but if, at present, equivocal women, as well as ascertained prostitutes, are not excluded (which very possibly they are) they should be. At the same time, a sentry may often be honestly puzzled as to equivocal or non-equivocal appearance, in these days of over-dressing. And some mistake, made by a stupid or brutal sentry, might lead to endangering the rule. This whole matter must be referred to men. 12. With regard to the question of the " Regulation" num- ber of Orderlies, viz., 1 to every 10 patients, it is to be observed, — (1.) A ward of 40 patients might be efficiently served (but it would be hard work) with 2 12. Orderlies' Attendance. (I.) 40-Bed Ward Minimum Sjze 36 NUMBER OF ATTENDANTS TO BE MAINLY Head Nurse- Orderlies. for Regulation 1 Head Nurse — Female. Number of 1 Attendant to 10 Patients. „ . -i .i With no number under 40 of patients to a ward, can the Regulation proportion of 1 attendant to 10 patients be adhered to. (2.) 20-Bed (2.) "With a ward of 20 patients (cut, scheme, and arrange Si Att'^T"7^ the hours and duties as you will), you cannot efficiently serve it with less than (3.) lO-Bed Ward cannot be served by 1 Orderly + i Nurse. (4.) Female Nurses not to be Substitutes f» 40 » ( Attendants. 1 Sister. 2 Nurses. 1 Sister. 2 Nm-ses. 1 Scrubber. 1 Sister. 3 Nurses. 1 Sister. 3 Nurses. 1 Helper. (6.) Same Number of Men will not do same amount of Work as an equal Number of Women would. (7.) Hospital Attendance an entirely new subject in the Army. In the Lariboisiere Hospital at Paris, where the wards hold 32 beds, 1 Sister, I Nurse, and 2 Orderlies on the Men's side, 1 Sister, 2 Nurses, and 1 Orderly on the Pemale side, serve the ward efficiently. (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. Prom 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. (7.) The question of attendance has scarcely been intelli- gently considered in the Army at all. And hardly any prac- tical answer has yet been given to such questions as the above. I conceive it to be practically impossible to serve 4 wards, as proposed at Netley, viz., of 9 beds eacli, with IN LARGER AND SMALLER WARDS. 39 1 Head Nurse, 4 Orderlies. For, as lias been said, one bad case in each ward, makes this economy as unmanageable as nine. (8.) A ward in a Military Hospital now may often be little else than a barrack-room, with an Inspection by a Medical Officer twice a day. It is designed to make it by the new Regulations into a place where the sick must be and always will be suitably attended. But this cannot be done by such a, scheme as — 1 Female Head Nurse 6 Orderlies } - { 50 Patients, in (say) 6 Netley Wards ;' though this attendance would be more than sufficient for 50 cases in one ward ; but such a ward is considered in a sanitary sense too large. Two wards of 30 beds each on the same floor would be efficiently served by such a Staff, however ; and there would be no sanitary objection. (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. (10.) The question of Hospital floors will be fully discussed farther on. An Orderly should be trained to be the frotteur to each ward. He should also be the porter to fetch and carry every thing to and from the ward. (11.) The plan of Netley, with its wards for 9 sick, is by far the costliest for administration, as the following facts will prove : I. It is proposed to provide the Hospital with Orderlies and Nurses to conduct the nursing in wards of 9 sick, as mentioned. II. On sanitary grounds wards may safely be large enough to accommodate 25 to 30 sick. We may therefore choose the larger wards, being guided only by the cost of the nursing. III. A ward of 9 sick would require 1 day and 1 night Or- derly, and a-third of a Nurse (that is, a Nurse could superintend three such wards.) (8.) Hospital Wards in the Army little else than Barrack- Rooms at present. (9.) Regulation as to 1 Orderly to 10 Patients requires modifying. (10.) One Orderly should be the Frotteur. (11.) Comparison of Cost of Nursing with larger and smaller Wards. 40 COMPARATIVE COST OP NURSING A ward of 30 sick would require 2 day and 1 night Orderlies and 1 Nurse = 4 persons in all. Or if two such wards were on one floor, 1 Nurse could serve both. IV. We cannot count the cost of Orderlies and Nurses, in- cluding lodging, rations, wages, at less than £50 a year, which when capitalized at 3 per cent. (33 years' pur- chase), would amount to £1,650 for each, V. A ward of 9 sick would cost in nursing £1,650 X 2i = £3,850, or £427 15*. 6d. per bed. VI. A ward of 30 sick would cost for nursing, in perpetuity, £1,650 X 4 = £6,600 = £220 per bed. [One Nurse to each ward is here allowed.] VII. The cost of the two plans relatively for a Hospital of 1,000 sick would stand thus : Wards with 9 beds = £427,775 Wards with 30 beds = 220,000 Capitalized difierence of cost in | pan? 77*? favour of large wards J Netley has cost already Land = £30,000 Works 89,000 £119,000 It hence appears that, if works and site were both sacrificed, and fresh land purchased, and wards for 30 sick built on it, the country would actually save the difference between the two sums of = £88,775. Suppose the sanitary requirement of 25 sick to a ward, which is the best number, be combined with the greatest eco- nomy of administration, the cost would stand thus : Por each ward of 25 sick, 3 Orderlies, at £l,650=£4,950 If two such are built in line, close to each other, with the Nurse's room between them, one Nurse could superintend both wards, or half a Nurse to a ward. The cost would be for the ward 825 5,775 IN LARGER AND SMALLER WARDS. 41 5775 Or cost for each bed -— - = £231 The comparative cost of wards with 9 beds and 25 beds, would stand thus for 1000 sick : "Wards with 9 beds . . . . £427,775 "Wards with 25 beds . . . . 231,000 Saving £196,775 Deduct cost of Netley, already incurred 1 19,000 Saving from abandoning Netley = . . £77,775 The cost of the administration per 1000 beds at Netley and Aldershot would stand as follows : Netley £427,775 Aldershot, pavilions, with 3 superimposed wards and 25 sick in each, would require 3 Orderlies and 1 Nurse* to each ward, and would cost £264 per bed in perpetuity, or per 1000 sick . . . . 264,000 Difference of cost in favour of Aldershot £163,775 Some abatement would have to be made, as regards the cost of Netley, as there are a few wards with 16 or 18 sick. If we take money at 4 per cent., the calculation will be as follows : Small wards, 2 Orderlies and a third of a Nurse, at £50 per annum ; money at 4 per cent., per 1000 sick £324,000 "Wards of 30. 3 Orderlies and a Nurse, money at 4 per cent., per 1000 sick . . . . 166,000 Extra cost of small wards . . . . 158,000 Cost of Netley . . . . 119,000 Saving in giving it up . . . . £39,000 * One Nurse might possibly be able to serve the whole Pavilion. The highest estimate is here taken. 42 SANITARY NECESSITIES AS TO HOSPITAL FLOORS 13. Hospital 13. Flooes. — 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 consi- dered. The staircases and passages should always be of stone. When once an oak floor is well done with bees'-wax it is no longer an absorbing surface. There cannot be a doubt that the frequent washing of the floors, in London Hospitals, is one main cause of Erysipelas and Hospital Gangrene. But, with regard to deal flooring, — (1.) The best way with a pine floor already laid is to close the joints, plane the surface quite smooth, and then saturate the wood with beeswax and turpentine, either at once, or after the wood has been saturated with " drying " linseed oil well rubbed in. {2.) Enough beeswax should be used to fill up the grain of the wood, and rubbing vrith a brush will then smooth the sur- face. It will be polished somewhat, but not slippery. The amount of polish depends on the brushing. (3.) The surface should be kept clean by using a brush wiih a cloth tied over it, and if offensive liquids are spilt, they should be immediately removed, the surface washed with soap and water, and immediately dried. (4.) List slippers, which ought to be part of Hospital furni- ture, effectually obviate risk of slipping. It would hardly be possible, however, to make deal floors as slippery as oak parquet, because the surface (except of very fine deal, such as is used for musical instruments) never takes so high a polish. (5.) Dry rubbing, wliich is done with sand, or with sand- stone, 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 sui'face cleaning may be done by rubbing with a hard short brush ; it is, however, defective. The wood becomes in time saturated with organic matter, and only wants moisture to give off noxious effluvia. (6.) Scrubbing is absolutely objectionable, for this reason. In any schoolroom, reading-room, institute, which is much inhabited, a smeD, while the floor is being scrubbed, is very AND THEIR CLEANING. 43 perceptible, quite different from that of soap and water. It is the exhalation from the organic matter which has entered the floor from the feet and breath of the inhabitants. How much more dangerous this in Hospital Wards need hardly be said. There is at Bethanien Hospital, at Berlin, a very admirable flooring, which would be worth trying in England. The floors throughout are wood, prepared in the following manner : — The floor is first oiled with linseed oil, and then rubbed over with a peculiar " laque" varnish, the technical process of which will be found in the note,* and polished, so as to resemble French polish. Every there years or so the rooms and wards are suc- cessively emptied for a fortnight, when a new flooring is laid, re-oiled, varnished with the laque vai*nish, 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 per- formance, 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 * 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, 22 in. in height and l^in. in thickness. The skirtings should have no indents in them, which form convenient lodgments for dust and take time to clean. A little rim must run round the top of the skirting, edging the wall. The skirting should thence descend, unindented, upon the floor. The boards are coloured and prepared, as follows : A new floor is rubbed over two or three times, with warm linseed- oil varnish, having some fine yellow-ochre, powdered, in it ; then a coat of " laque -lustre," a species of French pohsh, is laid over it, the result being a reddish-yellow colour, in which the grain and vetning of the wood is shown. If, after being used some time, it begins to look worn, it is rubbed over with oil and a new coat of polish laid on it ; but, as this takes a long time to dry, it is usual to fill up the worst parts with thin oil-colour, and then to take the yellow polish and lay it on, in two successive coats, leaving it to dry, if possible, for twenty-four hours, as it wears the better the firmer and drier it is. For old boards, that have been much used, considerably more laque- lustre is required than for new ones. After laying on the laque-lustre it is desirable that the floor should not be trodden upon for six weeks, and it is also well occasionally, say about once a week, to polish it, which conduces much to make it serviceable. 44 " LACKERING^' USED AT BERLIN year the ward floors are thoroughly wetted with water thrown on, and the floors scrubbed with a long brush. Neither soap, soda, &c., is used. The great advantages of this are : — (1.) That it purifies the air exceedingly and freshens the wards. (2.) That it reduces the daily accumulation of dust to a minimum. (3.) That it dries completely within ten minutes from being wet-rubbed. (4.) That a woman, standing, can thoroughly clean a ward with some hours less time, and greatly less fatigue, than scrub- bing. (5.) That wet scrubbing is sometimes and ought to be always forbidden and dry rubbing substituted, on the score of the unhealthiness of scrubbing. (6.) That it would relieve us of all external scrubbers in the Nurses' own rooms. Each Nurse would sweep, wet-brush and dry-brush her bed-room and day-room herself, daily, would once-a-week give a little extra wash, and would wash the wooden skirting which runs along the bottom of the walls. As the bed-room must be tiny and the day-room small (it would be better if we could keep to one room, which would take a quarter of an hour daily, and the grand weekly purifica- tion not more than one hour, even to a slow performer) a short time daily and a moderate time weekly wiU do it. One disadvantage of this very simple, very eflBcient, and excellent flooring is, that it shows scratches. Furniture must always be lifted, not dragged. In a Military Hospital where men are always at hand, this would matter less as to the wards, and the Nurses could help each other once a week in their bed-rooms, and manage alone in their day-rooms. There are four other examples of this flooring in Berlin Hospitals. (1.) Bethesda Siechenhaus, a small old house, about to be rebuilt and enlarged, in a suburb of Berlin, where three Deaconesses, with a man and woman servant, take excellent care of about forty infirm old women and imbecile children. These patients, of the class to be found in the infirmary wards of our workhouses, move about little, and have few visitors, so FOR HOSPITAL FLOORS. 45 that the flooring, which is the same as at Bethanien, is less used. (2.) St. Hedwig's Hospital, where 250 male and female medical and surgical patients are nursed by Roman Catholic Sisters of St. Charles Borromaeus (head quarters at Nancy), with female servants and male nurses. The house is new ; the flooring the same as at Bethanien. The Superior, an intelligent German, speaks much of its excellence for hospital purposes ; it is being introduced, though as yet very partially, into France. (3.) The great Charity 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 flooriug throughout is of the same wood (deal) as at Betha- nien, 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 Charite floors are re-oiled with laque every year ; they are cleaned in the same way as at Beth- anien, only with more dry rubbing. On bad days, when the numerous students have passed through, the ward floors occa- sionally require to be cleaned ; but, in general, even on these occasions, it is enough to sweep them, and to clean the next morning as usual. (4.) The principal Military Hospital, the Garnison Lazareth in the Hirsch Allee, for 800 patients, usually not filled. The flooring is the same as at Bethanien, except that no laque is used. It is oiled generally, not always, yearly. The Ober Inspector, a Landwehr civilian, who is supreme over the Hospital, and an Ober-Stabs-Arzt, both epeak very strongly as to the superiority of this flooriug 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 Charity, Betha- nien, and St. Hedwig's, wear hospital slippers, with soles thick enough to admit of their walking in the garden, when fine ; when not fine, they are not allowed to go out. This flooring would not stand the constant tread of nailed shoes. 4^ SANITARY NECESSITY FOR But often, on bad daya as on fine ones, great numbers of soldiers come to visit their sick comrades, and leave the floor very dirty ; generally it is enough to sweep the floor after the visitors are gone, and to clean it as usual next morning; sometimes it is necessary to clean it the same afternoon. The flooring is cheap. Somewhat more expense attends laying it down than the ordinary boards, and a certain expense attends the re-oiling, but the constant outlay for soap and soda is entirely saved, except a little soda in the grand annual purification, with hot water, in addition to the daily one with cold ; the time and labour attending scrubbing is saved, and above all the great gain to the sick arising from its use is secured. The strong, decided way in which the old grey-headed Army Surgeon, and the middle-aged business-looking Civilian, spoke of the merits of this flooring, and of its capacities, was exceed- ingly satisfactory. (5.) Two years ago the greater part of the boards in the Kaiserswerth Institution, which are of deal, were oiled, both on sanitary grounds, and to rid the Sisters of the drain on time and strength in scrubbing. They are considered far preferable to the old ones, and to answer in every respect. Yet the Kaiserswerth floorings would not answer the English require- ment of extreme cleanliness. They are substantially clean, but, like those of the Military Hospital of Berlin, it takes examina- tion to ascertain that they are so, and from the same cause — there is no " laque." Also the colour is not at all so agreeable as the Bethanien colour. These oiled boards last a year only. A moderate amount of laque is required to add to their durability. The sum of the information, condensed as much as possible, on this subject is ; — I. The boards, which are always of deal, can be prepared in three ways: (i.) Laquering, only suitable for reception rooms, or when by some chance a ward is wanted to be got ready in a hurry ; it takes less time ; after two or three days, the room or ward can be used, and it shines brighter, but it lasts a much shorter time than the other procedures, as it stands less the incessant ABOLISHING SCRUBBING. 47 treading incident to all ward floors ; it is also more expensive. Let us consider it wholly unsuitable for wards. (ii.) Oiled boards, with more or less laque. The Charite boards have a great deal of laque. The Bethanien and St. Hed wig's boards much less. (in.) Oiled boards without any laque — As in the Military Hospital. II. Much laque makes the floors shine brighter ; requires more time to clean them ; and earlier re-preparation than where less laque is used. The Charity boards would be unmeaningly splendid for an English Hospital, and quite out of place in a Military one ; besides entaihng some unnecessary annual expense, and some daily finicking care. III. A small quantity of laque, as at Bethanien, gives an amount of polish to the floors, which enables the eye at once to ascertain whether they are clean or not ; considerably improves the appearance of the floor ; and, according to all high authority, adds both to the durability of the floor, and the healthiness of the Hospital. It renders the whole flooring less subject to cracks, to dirt and dust getting into holes and corners ; and, above all, by filling up the grain of the floor, it prevents the saturation, by organic matter, which otherwise takes place and which scrubbing only makes more mischievous. IV. Where no laque is used, the absence of all polish on the dark-brown floors makes examination necessary, to see whether they are thoroughly clean or not. This flooring would never satisfy the eye or the mind of an English Inspector- General or Surgeon. But the main objection to the absence of laque certainly consists in the sanitary one above stated. V. All the various authorities agree in estimating very highly the superiority of this flooring to flooring requiring scrubbing. They all agree in their reasons for this preference, viz. : — (i.) The dampness which remains in a ward more or less time after it has been scrubbed, is completely avoided. (ii.) The tendency to miasma is greatly counteracted, both by getting rid of the damp, which encourages and spreads the exhalation of the organic saturations ; and by making the floor impervious, preventing dirt, and with dirt miasma, finding its way into holes, chinks, and corners of the floor. 48 BERLIN " lackering" PROCESS MAY BE FURTHER (ill.) The mode of cleaning this flooring, while it avoids damp, daily purifies the ward air. (iv.) The floor, and its mode of cleaning, get rid more than by any other way of dust, and of the miasma dust often conveys. (v.) The time, labour, and expense of scrubbing are saved. (ti.) The Berlin authorities consider that these oiled boards, with a small quantity of laque, are, on the whole, decidedly cheaper than the common boards ; that the boards last rather longer; and that the avoidance of scrubbing saves more than the extra preparation and its renewal cost, apart from the sanitary gain. VI. Against these advantages, the following disadvantages are to be placed : (i.) This flooring shows where most used, instead of the uniform appearance of the white scrubbed boards. (ii.) Scratches show, and remain upon it ; so all furniture must be lifted, not dragged over it. (hi.) The tread sounds a little more, little, but more, than on white boards. (iv.) It would not stand the constant tread of nailed shoes ; and patients of a ward so floored, ought to wear slippers with moderately thick soles. (The German Doctors consider the use of slippers preferable to that of shoes, by the patients, as keeping a ward much quieter, cleaner, and disturbing the severe cases less.) (y.) 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 furni- ture most used, bed, tables, sofas, &c. ; these are daily taken up and dusted while the floor is being cleaned. To many English minds, the sight and feel of a carpet is essential to the idea or feeling of comfort ; and it might be sound policy, in the event of a trial being made of this flooring, to leave the Officers, Military and Medical (I do not mean patients), in possession of scrubbed rooms and carpets. The Superinten- dent might have one or two pieces of carpet for her rooms ; and the Nurses should dispense with carpet. Both in the new part of the Charite and at Bethanien, long broad corridors run along the back of the wards which open into them. The corridors are floored like the wards. In those IMPROVED FOR HOSPITAL FLOORS. 49 of the Charite a piece of long carpet is laid in the midst of the corridors, where patients walk not a little. At Bethanien, a long piece of matting is laid in the midst of the corridors, where the patients walk freely. Carpet of either kind is not considered to benefit the floors, but to diminish the noise. In the wards of Guy's Hospital, for the same reason, a long piece of matting is laid along the middle of the floors. Tir. 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 sliould be (of stone. viH. It is also unsuitable for kitchens, wash-houses, water- closets, and sinks. The floor round a stove or fire-place in a ward or room should be protected by a strong plate of lead or tin. It might also be as well to floor operation-rooms with floor- ing, admitting of scrubbing, because these oiled boards do not well stand sand or bran, and our Surgeons might be disqora- posed ai 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 par- ticularly 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, &g., another wet cloth, a pail, and a broom, do all : after the operations are over, a few minutes' whole or partial cleaning, as the case may be, make all tidy again. Still, many English Surgeons expect to have sand or bran thrown on the floor before, or just after the first blood has fallen, and might object to standing some minutes on the bloody floor, which spoils boots, &c. Eed floorcloth, of sufii^ cient size, round the operating-table, might answer everj purpose. IX. On laying down the oiled boards for the first time, six weeks should pass after the oiling and laquering before the ward is inhabited. X. After subsequent re^preparation of the floors, the longer the wards are left vacant the more the floor both hardens and shines ; but for practical purposes the interval of a fortnight i» enough. 50 PRACTICAL SUGGESTIONS AS TO FLOORS. XI. The flooring, so prepared, or re-prepared, ouglit, 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, un- less in some emergency, quite unnecessary. Although the process cannot be said to be by any means perfect, on account of the deficient durability of the surface, it would be well worth while to try it in England, and, if it answers and if it were improved, the sick would gain much, and the Hospital staff would gain much — the latter much more even in Civil, than in Military Hospitals. But it would be incurring a great responsibility to have the whole of a large new Hospital floored in this way, because, I. An English climate has made, and makes, so many things which are good and suitable abroad, unsuitable and sometimes pernicious for England. II. Our coal-fires, whether assisting or assisted by our atmo- sphere, certainly give us an amount of soot and dirt unknown abroad. At Berlin, all fire-places are stoves, where sometimes coal, sometimes coal and wood are burnt. This flooring might not stand well either the damp climate, or the smoky atmosphere and amount of flying soot of England : but it would be well worth trying ; as also trying to improve it. By all accounts, a great deal depends upon the manner in which these boards are prepared ; a little more or a little less, whether of oil or laque, makes a great and lasting differ- ence. It would never answer to make an English carpenter or painter do this from wribten or printed directions. If we obtain a trial of this floor — the best course would be, to let an English carpenter prepare a number of boards and skirtings, of due size, suitable for the new flooring of some few wards in one of Her Majesty's hos- pitals, which requires new flooring ; then to desire either the proper tradesman, or the Queen's Minister at Berlin, to order the house-painter, Schouby, No. 5, Michael Kirchplatz, Berlin, to send an experienced, trustworthy foreman, with the proper tools and materials, and for this man, with a comple- ment of English workmen, to prepare the boards. The mode of cleaning is extremely simple, though of course VENTILATION. 51 there is a knack to be learnt ; and, like everything else, it can be done well, indifferently, or ill. Any English man or woman accustomed to cleaning would understand the thing in one morning, and would, if he or she opened instead of shutting the mind to the outlandish thing, be proficient in it in a week. All these things sound abstruse on paper, and are far more simple and more easily learnt by seeing done than by reading. The foreman ought to give one or two lessons to one or two Orderlies, or Nurses, as the case may be. 14. Yentilatiok. — The amount of fresh air required for H. Veutilatioji 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. Tlie 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 15|- cubic feet per hour. This large quantity if not speedily carried away would un- doubtedly be injurious to health ; but there are other gaseous poisons produced with the carbonic acid whicli liave still greater power to injure. Every adult exhales by the lungs and skin 48 ounces or 3 pints of water in 24 hours. Sixt< eii men in a Barrack-room would therefore exhale in 8 liours IG pints of water and 15 i cubic feet of carbonic acid in the atmo- sphere 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 reiutroduction of excrementitious matter into the blood through the functions of respiration will tend to produce disease^ This will be still more the case in sick wards overcrowded with sick, the exhalations from whom are always highly morbid and dangerous, as they are nature's method of eliminating noxious matter from the body,in orderthat it mayrecover health. A much larger mass of air is required to dilute and carrj d2 52 NIGHT VENTILATION. away these emanations than is generally supposed. And the whole art of ventilation resolves itself into applying in any specific case the best method of renewing the air sufficiently, without producing draughts or occasioning great varieties in temperature. When the question of ventilation first assumed a practical shape in this country, it was supposed that 600 cubic feet of air per hour were sufficient for a healthy adult, in a room where a number of people are congregated together. Subsequent ex- perience 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 pyoemia and Hospital gan- grene had appeared among the sick in consequence. These diseases disappeared on the introduction of ventilating arrange- ments, whereby 2 ,000 cubic feet of fresh air per bed per hour were supplied to the wards. Notwithstanding this large quan- tity, 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. Night At one of our largest London Hospitals it will be per- Ventilation. ggiygfj 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 gene- rated, in quiet. SPECIAL WARDS. 53 15. Special Wakds. — It may be laid- down as an axiom in Special Wards, .J. whether the management of sick affected with certain zymotic diseases, desirable or such as fevers, cholera, dysentery, &c., that Lhey should be dis- not. tributed over a wide superficial area, and have a large allowance of cubic space. Agglomeration of such cases in small ill-venti- lated wards is quite sufficient of itself to occasion a high pro- portionate 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 ia 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 ot these diseases in Hospitals. Medical Men generally are satisfied that these ends cannot be safely arrived at by agglomerating sick in fever wards in Hos- pitals. 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 avail- able 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 windovrs, the exposure of tlie building, and other similar circumstances. Again, it is doubtful whether the preservation of an uniform temperature in any Hospital, even in one set apart for chest complaints, is beneficial for the sick, or whether it be beneficial to agglomerate consumptive cases, without very special precau- tions, under the same roof. Without discussing the validity 54 WAGES, HOW TO BE PAID. of the opinions held in Southern Europe as to the contagious nature of consumption, it may be very fairly doubted whether a number of eases placed under a common roof, and breathing a common atmosphere, would not yield a higher rate of mortality than the same cases would do if distributed through the wards of a well-ventilated Hospital, among other diseases. The subject is worthy of examination. At all events the phenomena observed in this disease in the warmer climates of Europe have led to the popular belief above stated; and it would appear to point to a higher rate of mortality as a not unlikely result of the establishment of special Hospitals or wards for consumptive diseases, unless extraordinary care were taken to ventilate them properly, and to imitate the natural variations "of temperature which appear to be necessary for recovery. U. Proposed 16, All salaries and wages of Matrons and Nurses should be Regulations as p^itJ^ on the Superiutendent-General's order, from the Hospital by Superin-' chest, to the Matron, who should pay the wages and other tendent- expenses of the Nurses, and account for all monies received by her on such orders. AU outfits and travelling expenses, iu cases of transfer, &c., should be provided on the order of the Superintendent- General . Opinion as to There would be considerable difficulty in the way of making Superin- ^11 payments at a distance to Nurses, direct from the Superin- General paying tendent- General, otherwise than by orders on the Hospital Wages and chest or Treasury. But there can be no doubt that the Niu-ses Salaries, Qy^g]^^, 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 Superin- tendent-General, and would account to her. As a matter of dis- cipline, it would make no material diflerence whether the orders of the Superintendent- General, iu favour of the GOVERNOR TO BE SUPREME. 55 Matron, for the pay of the Nurses, are cashed by the Hospital Treasurer or by a banker, always supposing that the Treasurer is bound to honour those orders, as any other banker would. The Matron, in any Hospital out of Great Britain and Ireland, should be able, with the concurrence of the Grovernor of the Hospital, to dismiss and send home any Nurse ; or the Governor himself, on his own responsibility, may direct the Matron to do so, under appeal, however, in either case, to the Superintendent- General, who shall decide, after the arrival of the Nurse, whether she is to be dismissed or whether she may be placed in another Hospital. It should be secured, not left to chance, that the Matron be immediately made acquainted with any complaint of the Medical OflBcers against a Nurse. The Matron should be able to draw from the Purveyor, on her own indent, with the sanction of the Governor of the Hos- pital, 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 Superin- tendent-General, for commuting rations for mess-money, not pay. The Governor is responsible for the sufficiency of all supplies and none ought to be expended, without his sanction. This might be indispensable, if there were danger that supplies might run short. 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 com- posing 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 respon- sibility, 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 esta- blished regulations. But practically such a case could hardly occur, unless by the fault of tlie Matron, who would, of her Matrons abroad may dismiss Nurses under appeal. Matron to draw Rations and Extras. Opinion as to Governor's jurisdiction over Nurses. 66 Three fRlNClPLES iN raising Wages. It. Nurses' Wages. Efficiency of Nurses does not increase by springs and starts, like Grasshoppers. The first five years a constant improvement. Afterwards if there has not been improvement made before, no hope at all. Three principles in By rate of Wages to own accofd, desire to remove a Nurse, on being satisfied that such a measure was necessary or expedient. It would be proper, too, both for her own justification and for the mainte- nance 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 Superin- tendent- General . "Whether the Governor has the power of removing the Matron, who clearly and properly ranks among the officera 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. 17. Generally, as to the question of wages and pension*, a regulation that Nurses shall have a small annual increase of wages is better than one giving an increase after five or three years. Efficiency does not go by starts and springs, like grass- hoppers, but makes " a small annual increase," like the wages proposed. Nav, 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. Tor 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. The reasonable principle I believe to be, 1, to begin improv- ing 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. Because the' object is to induce the young and efficient RATE or TENSIOK, 57 wonieu to stay, not the old ones. They will stay long enough, because the old ones nobody else will take. 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 effici- ency, which certainly will be not later than forty-five, probably not later than forty years of age, the inducement to stay should bo the improvement of pension. This compensates for any apparent injustice in the first principle towards an old Bervant. No other system appears to be founded on common sense; and it is one generally acknowledged in the Civil Service, w here salaries are made to rise as soon as possible. Military Hos- pitals must not be made trainiug schools for Nurses ; else it would be better to admit them much younger than at the age of thirty years. 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 Depart- ments, there is only one year of such probation before increase begins, though the persons are much younger w^hen 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 allow- ance 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 aff'ord facility for enforcing retirement without injustice. This would be eco- nomy. The " Nursing Sisters" grant £20 after twelve years' service. After a time there may probably be difficulty in dismissing persons who have done good service for ten years, but have retain those who are eilicient. By rate of Peusioa to reward those who have been efficient. Civil Service an Example- Opinion as to Wages and Pensions. 58 GENERAL PRINCIPLES AS TO decliued in efficiency, unless there is a retiring allowance. They may be reluctant to retire ; and, if so, it would be almost impossible to dismiss tliem, without some kind of provision, Tliis 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 liveli- hood. I Have consulted tbe best authorities upon these points ; and I find the following general principles admitted : — Oeneeal Pbinciples as to Wages and Pensions. (1.) Same Salary at first. (2.) Same Annual rate of increase. (3.) Maximum Salary fixed. (4.) Pension for Service after Ten Years. (5.) Amount of Pension a certain Per- centage on mean Salary of preceding year. (1.) Annual rise of Wages till the maximum of efficiency. (2.) After fire years' Service Pension for Disability. (3.) Pension on a Scale graduated on the Wages. (1.) At whatever age a Nurse enters the Service she shall begin with the same salary. (2.) The annual rate of increase shall be the same for all ages of entrance. (3.) The maximum salary shall not exceed £> . (4.) The pension for service shall not begin until ten years of completed service. (5.) The amount of pension shall be a certain percentage on the salary during the year preceding that on which she is pen- sioned. Applications of the fobegoino Pbinciples, (1.) That the wages of Nurses shall rise annually, for a defi- nite number of years, attaining their maximum, on an average, at the age forty-five, when the Nurses are found to be most efficient. (2.) That, after five years' service, the Nurse shall, in the case of ABSOLUTE disability, become entitled to a pension during the period of her disability. (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. WAGES AND PENSIONS. 59 (4.) All JNurseswill be placed on the Eetired List at the age of sixty.* (5.) Those Nurses who are pensioned at an earlier age, for disability, will, if called upon, be liable to serve when that disability ceases, or to forfeit their pension. They must therefore bring an annual medical certificate of disability to the Superintendent-General, in order to receive their pension. (G.) 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 Super- intendent-General, Example. Age. 30 31 32 83 3i Completed Yeaus OE Service. 1 2 3 4 Wages. £20? 22 24 26 28 Pension. -^ cs 35 40 45 50 55 60 5 10 15 20 25 30 SOX -2 40 -3 50 .4 50 -5 50 -0 50 -7 = XO 12 20 25 30 35 (4.) All Nurses to retire at Sixty. ^^5.) Nurses to serve again who are Pensioned for Disability, when Disability ceases before Sixty. (6.) Nurses partially Disabled to receive partial Pension. Example These principles, if admitted, would suggest the following heads for regulations as to Nurses' wages and pensions : — (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. (2.) There will be an annual rate of increase of wages equal to 10 per cent, of the first year's wages, until the yearly wages amount to £50, beyond which there will be no further increase. (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' * And this should be adhered to, the rare though extant cases of effici- ency for Hospital nursing, past this age, notwithstanding. (1.) Amount of Wages, first year, Jt2Q. (2.) Annual rate of increase up to £50, when it ceases. (3.) No Pension till Ten Years' Service completed, nor for Disability 60 RATE OF PENSION. till Five Years. (4.) Rate of Peusion. (5.) Karses, Peasioned for Disability, whose Disability ceases, may be called on for Service. 18. Number of Nurses to Patients. service, but in case of disability, a Nurse shall receive a pension after five years' service, or a gratuity, according to circum- stances, if discharged for disability, before she has completed five years of service. (■1.) Rate of Pension. The pension will be on a scale gradu- ated on the wages. It will be 30 per cent, of the wages re- ceived 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.* But no such pension shall exceed the amount of £50. (5.) Any Nurse pensioned for disability, may be called on for service in the event of such disability ceasing before the age of sixty, in which case her wages will be the same as they would have been, had she not been disabled. (6.) Every Nurse who has completed her sixtieth year, must retire from the service on her rate of pension. (7.) Any Nurse, temporarily or permanently disabled in tho service, who has served more than five and under ten years, will be entitled to a lower rate of pension, according to the circum- stances of each case, as represented by the Superintendent- Greneral. 18. Nurses should be selected and appointed by the Super- * Great caution must be used in acting upon this. The Superin- tendent-General, or the Superintendents who are responsible to her, order the service of each Nurse. How far is it just to consider extra dangerou. Tlie 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 Hos- pitals, not only as to ground, but because each separate entrance, staircase, set of appurtenances, represents an addi- tional cost of materials, and of hands to keep them clean and in order. Human life is, however, a more expensive article tliau 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 super- vision. Pure air and light are the prime necessities of a hos- pital. These are best secured by the Pavilion Plan, and there- fore it is the cheapest in the end. As to the hands, there never ought, never will, never can, be a superfluity of hands in a well- regulated Hospital. The duty of the hands consists of two parts — to keep the Hospital clean ; to attend the sick. I had rather not enumerate the instances where I have seen that, often from the most various causes, one result arises — that more time and care is given to floors, stairs, &c-, &c., &c , than to the sick. Extreme cleanliness is of vital importance ; this should be combined with extreme simplicity of detail, and with providing for considerable numbers at once. You can efiectually clean a large ward in much less time than two small ones ; a long stair than two short ones, &c. Extreme, not finiching, cleanliness, thorough ventilation, for which an ample supply of opposite windows will certainly in the long run prove infinitely the best plan, and careful nursing, are probably the main conditions, humanly speaking, of a large proportion of cures — subsidiary to the medical or surgical treatment, Sanitary necessities are never to be rejected, on account of the trouble they give or of the means of cloanliness 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, OF PAVILION PLAN. 65 If you have saved " hands" and tronble, and lost lite, you have been extravagant. The object is not to banish appliances which will cost trouble in keeping them clean, but to discover those appliances which can be kept clean, at least cost of labour. And this is perfectly possible. 2. The Vincennes modification of the Pavilion plan has been 2. F.asy adopted, among other reasons, for the greater facility of super- j^^ provided for. vision 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 inspec- tor. 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. Eemember 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. 3. The more we see of different systems, the more we see 3. If from the great mistake of giving a Nurse too little to do. f^^r~h^ th Twenty-four ordinary sick or surgical cases are too few for right Number, a Head Nurse. Sanitarily In a Military Hospital, the proportion of heavy cases ^ Ward 'the is in ordinary times considerably below the average pro- Pavilion Plan portion of such cases in a Civil Hospital, open, as the latter Military is, to accidents, and to the cases of dangerous disease always Hospital, more or less rife in low and crowded neighbourhoods. ^, ^/° arranged ° _ tliat more than Upon an average, a third or a fourth of the cases in the one such Ward ordinary surgical wards of a Military Hospital will be ulcers should be on 1 T* 1 nxTi 1 *n tnc saimc iloor, from causes honest and dishonest. What these men will re- for facility of quire is rest (the cleanliness which is often so irksome a novelty Supervision, to the corresponding Civilian patient is routine to the soldier), and very simple treatment. It is most important, if possible, to form a staff of active, laborious, useful women, who, if ordered on war-service, can at once cope with numbers, and serve efficiently a considerable number of heavy cases. Believed of all cleaning, and relieved of the great loss of time incurred by fetching, waiting, &c., &c., none of these 66 nurse's lodging near her ward important. Nurses, who are, in fact, Head Nurses, should serve less than forty men. And, as I before submitted, I had rather she served fifty or sixty than forty. Give them twenty-four patients, and either they will become idle, finicking women, or they will take to petting the patients, a thing to be sedulously avoided everywhere, most of all in Military Hospitals. 4. Importance 4. The more we see of difierent systems, the more apparent of the Head becomes the importance of the Head Nurse (aU these are Head Nurse , ^ ^ sleeping close Nurses) sleeping close to the ward : — to her Ward. ^g regards the efficiency of her service : — As regards the saving her own time, strength, and securing her a modicum of comfort in a work where, if she does her duty, she will never have a superfluity of comfort. Time, strength, and this modicum of comfort, enter much into a Nurse's health — and health is essential both for efficiency and economy. Where the Nurse sleeps at a distance from her ward, her efficiency, both as to superintendence and work, especially at night, in dangerous cases, is seriously impaired. If she sleeps at a distance from her ward, her comfort, also, such as it is, is destroyed. Whatever a Nurse does for herself, she must do by fits and starts. A really efficient Head Nurse is never able to make anything for herself, though she often would far rather save the money it costs to " put it out." The most simple mendings, even the feat of stowing away the laundress' supply of a Satui'day evening, become, when a Avard is heavy, or when there are two or three of those cases of urgent danger, so many of which, by God's blessing, the assiduous care of these women saves, year by year, in our Hospitals, a procedure done in several acts. The misery of dividing her small effects (the smaller the better) between a day-room and a distant sleeping-room, the unseemliness and inconvenience of carrying things backwards and forwards, cannot be described. If it be possible, the Nurses must sleep adjoining their wards; and it will not do to give each only 24 patients. It would be considerably better, if feasible, to have two Nurses in contiguous rooms ; but in the Pavilion Plan this would involve bringing one Nurse away from her ward ; and GAS IN HOSPITAL WARDS. 67 rather than this, the next best, though iuferior pUm is to put one Nurse immediately above and below the other, with a dis- tinct bell which she can in a moment ring from her bed ii^to the other Nurse's room, to summon her if needed. Some years ago gas was laid on in the Sisters' rooms in Importance of Guy's Hospital. In the other Hospitals there is an allow- r|^'^*'-f^ ance of candle to each Sister. The disadvantages of gas are Wards by Gas, its alleged unhealthiness and its certainly being disagree- '^^^^ Sanitary able 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 au allowance of candle has effected at Guy's. Gas is used in the w^ards of St. Bartholomew's, St. Thomas's, and Guy's, day and night. It appears, when ventilation is properly attended to, to answer well, and to do no harm. At night the gas is lowered so as to leave the ward just light enough to see all that is done in it : if bleeding, &c. occurs, it can in an instant be raised, and the ward lighted up. London Hospital burns gas in the evening, and throughout the passages at night ; but when the night watch begins at nine, the wards are dark, except the Nurse's candle. A spare candle, un-lighted, is always at hand. It is very important for the order of a ward that the attendant in charge, and also any inspector suddenly entering, should see at once all that is going on in the ward. Where there are dangerous cases, this is of great moment ; and where there are not, it is equally necessary for the police of the ward. A candle or a rushlight give insufficient light. Properly lowered, gas at night does not disturb the patients. After a night or two, those who are accustomed to sleep in the dark get used to it. If the Nurse sleeps adjoining the ward, there must be sufficient light in the ward at night. If the gas-fittings are properly tight and if every gas-burner has a ventilator, so that the products of combustion are effectually conveyed away, for each gas-jet consumes as much air as eleven E 2 68 HOW ONE NURSE COULD MANAGE II.— 1. Should it be necessary to serve one Pavilion with one Nurse means by which this could be effected. 2 Head Nurse's Day in a Pavilion Hospital. men J it would be greatly preferable that there should be a low gas light in the wards at night. II. — 1. Suppose the Lariboisiere plan retained, as proposed at Aldershot, for a Military Hospital, with wards of twenty- four beds each — then, with fear and trembling, but with the firm conviction that it is better for human nature, most of all, for nursing human nature, to have somewhat too much than a great deal too little to do, I respectfully recommend that one Nurse serve the three wards of each Pavilion. One woman cannot sleep alone in the Pavilion. The Nurses must sleep together near the Matron's quarters. If the Nurses sleep away from the wards there should be ^ome 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. 2. Her day might be something like this (in time, perhaps, God will bless us with some Army Chaplain who will get up early and give us a very short service morning and evening) : — She should be effective, and enter the Pavilion about 6 a.sj., go through the wards, read prayers in one by turns at the appointed hour, and give out the linen wanted. (Six is the nominal hour when the Head Nurses of one great London Hospital enter on their duty.) Here must be no nominal hours, all must be real, though not overstrained. Then the dressings, &c., attendance on Surgeon'^, &c. With 72 patients on different floors, she must train the Orderlies to do the lighter dressings (by training I mean real teaching, not leaving the Orderly to find them out himself) ; she must see all the wounds of all her wards which she does not dress herself at least every other day (which she can do by seeing some in the morning and some in the evening), and she must dress the ONE PAVILION. 69 heavy cases of all tlie wards herself. All this, with method, and not losing time by fetching and waiting, an efficient Head Nurse can do. She must be responsible for the linen of the wards ; but this must be simplified as much as can be, so as to secure respon- sibility, yet relieve the Nurse of unnecessary time spent over it. The Nurse should be relieved of all writing and counting, on the score of loss of time incurred. It will not do to charge a Nurse, with seventy-two patients on three different floors, with serving each man his portion of diet; the diets of two wards would get cold while she was serving the first. It will be better to make the Ward-Master of Pavilion wards responsible for the serving the diets. There must, of course, be a card at each bed, or some othci' record, showing the diet the man is ordered. The Nurse must know at a moment's glance what each patient is ordered. The largest London wards are the two male accident wards in the London Hospital. Each Head Nurse has charge of five wards of 12 beds, separated (and in some respects impeded) by two lobbies. Very often there are fifteen beds in each ward (not by over crowding), and these Head Niu-ses are often to be seen in charge of seventy-five patients each, includ- ing many serious, and some urgent cases. The two lobbies, the small wards, and tlie duty of some daily writing and arith- metic 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. Selieve 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 Lariboisiere 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 draw- back of their being in separate wards and on separate floors. If, however, the Pavilion plan were so modified as to have two pavilions end to end, with an intervening staircase, so 70 NURSE S RESPONSIBILITY FOR DISCIPLINE, 3. Responsibility of Nurse for Discipline of her Ward or Wards —how Modified iti Military Hospitals. spacious and well ventilated as to cut off the ventilation of the two wards on the same plane, then all the conditions as to health, and facility of nursing and supervision, would be much more easily obtained. Of this more hereafter. 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 differ- ence between this responsibility in the Head Nurse of a Civil and a Military Hospital. The Civil Head Nurse, whose assistants are all Nurses, who with herself are under the Matron, is charged with, and responsible for, the good order of the ward, and it becomes her duty, the moment she finds herself unable to do this alone, at once to call in the Steward, or equivalent Officer, in whose hands is the police of the Hospital. The Military Head-Nurse's Assistants are Orderlies, i.e. men and soldiers, who, with the patients, are under military discipline. Of this military discipline, the military power from the Commandant down to the Non-Commissioned Officers acting as Ward-Masters, &c., is in charge ; the duty of the Military Nurse is, I apprehend, in case of any insubordination which she cannot put down at once, to call in the Ward-Master or equivalent, before calling in the superior Military or the Surgical Officer ; it being, however, well understood on all sides, that she has the right of direct appeal to the superior Military or the Surgical Officer, if the Ward-Master does not do his duty, or in the event of a grave irregularity, if he is not at hand, besides its being her duty to report such to the Matron, if the case adaiits 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 HOW MODIFIED IN MILITARY HOSPITALS. 71 patients and Orderlies. To be in charge of the nursing, implies to have power to enforce discipline, but this is rather, in ordinary cases, to call in the military power, beginning from the lowest or Ward-Master's grade and reporting this to the Matron, than to invoke herself the military superiors. Therefore it would be well worth while trying how far it would answer to serve the three wards by one Nurse, who, in each ward where she successively is, is bound, on perceiving any irregularity, to call in the AVard-Master, and, in contin- gencies, 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 tlie wards, while the Nurse is in one of them ; so that the patients of one ward, who may know that they are safe from the Nurse for half an hour or more, as she is in another ward, know that they are not safe from the Ward-Master. In a military Hospital we must bearin mind that it is essential that the discipline over patients and orderlies should be exer- cised by men, and that the Ward-Masters must be the lowest and immediate deposits of this power of discipline. All these things must be settled with the concurrence of the Director-General. It is a great comfort that the Hospital staff returns to soldiers. We shall get on infinitely better with them than we could have done with the late Medical Staff Corps, though, after all, in the long run, we should manage with them too. If only God helps us with the sort of women required, thoroughly efficient Nurses, laborious active women, discreet as well as well-conducted, and aware (a little) of the sort of work and place, they are in ! — let us trust this to Him, when the time comes, and depend upon it, to give each Nurse plenty to do will become one great means of forming such women — pro- vided, which must be strenuously kept in view, they are made to do it. 4. It is very important to have the system of lifts through- 4. imjjortance out the Hospital, although here, as throughout, the plan of "^ Lifts. Pavilions renders them much more requisite, and makes them work less efficiently than the block plan. Lifts, to carry meals 72 CASUALTY WARDS SHOULD BE SEPARATE III.— 1. CasualtyWards for noisy and ofTensive cases should be separate from the ordinary Wards, and under a completely- appointed Staff of their own — both for Sanitary and administrative and medicine, linen, coals, &c., &c., to and from the first and second floor wards, are very preferable to the Orderlies carrying them up and down. One sort of load ought certainly not to be brought up and down by lifts, but to be cari'ied up and down by men, viz., coffins and the dead. Using the lift for this purpose (as is done in one Civil Hospital) is on all and every account thoroughly objectionable. The system of lifts is the more important, because although there is no objection to the washing of tea cups, drinking cups, and medicine vessels at the sink in the scullery, it is certainly neither necessary nor safe to wash the dinner dishes close to the sick wards. By a little arrangement, the whole of these could be removed by lifts to a scullery beside the kitchen, and there cleansed and set aside for next day's use. III. — 1. Sanitary necessities can never be interfered with. The concentrating offensive and noisy cases together, while entirely separating them from each other, in a completely appointed set of wards, is a far more efficient working thing than appending a small ward to each ward. St. Thomas's (a very admirable Hospital in very many things) has a casualty ward (for such cases) for men and one, adjoining but separate, for women, under the charge of one Sister. Baths are in the wards. Guy's had the same provision with, however, the drawback that there was not a Sister in charge, but a Nurse over other Nurses, with higher pay, but not a Sister or Head Nurse. However excellent such a Nurse may be, every ward must be under the same regular government as is general in the Hos- pital, if discipline and order ai'e not to sufier. Every ward or set of wards should be under a completely appointed stafi'. St. Bartholomew's had a set of casualty wards, including two of about ten beds each, several small wards of two and one bed each, including two with gratings and other melancholy necessary appliances to prevent extremely violent delirious patients from becoming suicides. These wards were often partially empty, never quite so. They were long served like the casualty wards of Guy's ; but some years ago they were placed under the charge of the Sister of the male operation ward immediately above, who received in consequence a small annual increase oj' wages. AND COMPLETE IN THEMSELVES. 73 London Hospital sent its noisome, offensive, and extra- infectious cases to its other wards — small wards for one patient each, and, like Guy's, not under the regular management of a regular Head Nurse. It most certainly appears that the plan of concentrating these cases together, but with (as at St. Bartholomew's) small wards where extra-violent patients can be put sepa- rately, the whole under one staff of Nurses, is far the best working plan. And for this reason. Occasionally, a very offensive case requires little nursing beyond the fixed daily dressings, and can lie quietly enough in his bed or ward. But noisy cases almost always, and offensive cases generally, require close watching. Now the moment we have a patient in a little room at the end of the ward, it is our duty to go in and out and see after him, and supposing him to be a violent, delirious case, he is, unless under strong restraint, unsafe alone ; and even then the restraint requires looking to. In very many cases the frequent inspection of Nurse and Orderlies would not be enough, and the man ought to have a watcher. We can never send one of the Orderlies of the ward, wanted for its regular duty, to sit down in one of these little rooms ; and we can never keep a fixed extra Orderly idling about, uuless the little ward is inhabited. We must then fall back upon extra Orderlies, put in when the case wants close watching — of course not otherwise. At night, also, the watching which suffices for the ward will often not suffice for the extra case — and he must have a watcher apart. The plan of extra Orderlies or extra Nurses is a very bad one, to be avoided as much and as long as possible ; it very seriously interferes with the discipline of wards. llecollect that each offensive or extra-infectious case, put into the little ward, ought to represent a great amount of separa- tion and care, which it will be difficvilt to secure. His mug, utensils of all descriptions, bandages, &c., ought to be washed separately from those of the patients of the large ward. Is this easily secured ? In the two Borough Hospitals they at once remove a case of erysipelas or gangrene, occurring in any ward, erysipelas from 74 RESTRAINT IN VIOLENT CASES. venereal wards included, into the casualty ward. In the two other great Hospitals it is only when the erysipelas or gangrene becomes severe that the removal is made. Now at once to remove these cases from the ordinary wards is very advan- tageous. St. Bartholomew's larger wards for male and female casualty cases, two small wards for two patients each, and two grated wards for one each, are very efficient. The wards are all con- tiguous, 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 cer- tainly violent delirium tremens' cases, alone and in a secure ward which can be darkened, appear often to quiet much sooner than where several of these wretches lie shouting to and at each other. Delirium tremens will never be a thing unknown in a Military Hospital. One such case in the little ward adjoining the Pavilion Ward would be a heavy infliction on the severe cases in the latter ; the noise would be heard throughout it. And unless the ward were properly secured, or unless the man were under strong restraint — and then that would require constant looking to — he would not be safe a moment alone ; while the Orderly was emptying slops or bringing in his dinner, something might occur. 2. Restraint or 2. Eestraint is again a thing which must be left to our mas- Non-restraint ters, and to them solely — but an ugly, sorrowful, little truth may here be told. Eestraining 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 ascer- tained, they are removed to the proper refuge. It is my humble opinion and firm belief that mechanical restraint excites a in Delirium Tremens. SIMPLICITY OF CONSTRUCTION. 75 patieut much less, aud quiets him much sooner, than the prolonged struggle with his attendant's arms and hands, which must otherwise be resorted to. The coercion apparatus ought also to be good, not cheap, and always in perfect order. The least thing out of order either causes pain, which when it can be avoided is cruel, or it endan- gers the efficiency of the whole. The strength and cunning of these patients resembles those of madmen, which for the time being they are. Restraint renders the usual complement of ward servants able to manage many cases. Non-restraint means that some person must stand or sit by or upon the patient's bed, and hold and struggle with him often for hours — also that generally this person must be a stranger to the ward. Extra attendants are most injurious to discipline. Could there be a set of casualty or equivalent wards, with its own Head-Xurse, the sick would gain much. But if necessary to adopt the little ward with every ward — in that case the Nurse must manage the three addi- tional patients — twenty-four or twenty-five are, indeed, too few. IV. In all Hospitals, let the construction be as simple as it ^^- Simplicity can be. Let its splendour be its lofty airy wards, with plenty of essential to windows; water in all due abundance on each floor; an ample, Discipline, not excessive, supply of linen, polished impervious walls and ceUings, well-laid and bees-waxed oak floors, and a thorough not excessive, supply of good apparatus of the various neces- sary kinds. But every unneeded closet, scullery, sink, lobby, represents both a place which must be cleaned, and which must take hands and time to clean, and a hiding or skulking place for patients or servants disposed to do wrong ; and of such no Hospital will ever be free. Aud every cornice, every brass lock or handle, which could be replaced by a plain china or ebony one ; every decoration, or flourish, or ledge, on doors, windows, tables, beds, presses, &c., represents either a collection of dust or a great waste of hands, time, and strength in un- necessary 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 76 NURSES' MEALS. Polished Walls. Covered Exercising Place. Eeserve Wards. V. Nurses' Meals. from and lost by tlie sick. Let the appurtenances of the wards be simple and complete, but as plain and as undecorated aa it is possible to be. Polished impervious walls and ceilings are of the first con- sequence 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 Lari- boisiere Hospital at Paris, and of a pure white. In building a new Hospital, some covered arcade or some place where the patients miglit take exercise in wet weather, and where inspection could be exercised over them, without fuss, is worth contriving In St. Thomas's, the patients walk under the covered arcades of the court. Both in Bethanien and in the Charite Hospitals at Berlin there are reserve wards, — or rather in the Charite 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 Hos- pital, a certain reserve space, which obviates the necessity of less efi&cient and far more costly steps afterwards. V. Let us, by all means, consider as settled, that the Nurses' food is sent them cooked. Possibly, in the long run, the undoubted advantages of this plan will be found to be over-balanced by its disadvantages ; but let us begin by trying it. I submit that their dinners, and possibly suppers, should alone be sent them cooked, and that each Nurse should receive a fixed weekly quantity of groceries, and a daily or two days' allowance of bread. For packing up the Nurse's meals sent her from the kitchen, a Vienna custom might be useful. Each Nurse to have a long, strong, straw basket, properly named or numbered. Some contain five dishes and covers, but two or three would here be sufiicient 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 waishi}ig them up, the QUARTERS FOR ORDERLIES. 77 Matron should let her take hers her own way. If taken by hand, two baskets of this sort can be carried with ease. But if the Matron, as a general procedure, sends each Nurse a hot little dinner, of a good well-cooked portion of meat and vegetables, one such dish and cover will do for one Nurse, and three, five, or six can be accommodated out of the same basket, or one large basket, carried by two men, would serve all the Nurses round. The dishes should, in either case, be numbered or named, not the Nurse's name, but the ward. A dish and cover of strong, coarse earthenware is used in the Vienna Hospital, as a grander edition of dinner, &c. The tin ones keep warm without fire for a long time. If the meal arrives when the Nurse cannot eat it, put by on the hob, or some provision for warming in the scuUery, it will keep warm and good till she can eat it. VI. Supposing that we serve each Pavilion by one Nurse, I submit thai — 1. The Nurse's day -room should be on the ground floor. 2. The Ward-Master should sleep in his room on the second or highest floor ; should the Nurses sleep in the Pavilion, the Ward-Master should still sleep in it. In the event of the Pavilions being arranged end to end, as already suggested, the difliculty in regard to Nurses' and Ward- Masters' rooms would be materially diminished. 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 tlie 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, VI. Arrangements for a Pavilion served by one Nurse. 1. Nurse's Day-room. 2. Ward- Master's Sleeping-room. 3. Where should Orderlies Sleep .' 78 WARD SCULLERY. 4. Where should Orderlies Dine ? 5. Should Orderl'es be brought together ? 6. Should Orderlies have a Day. room in Pavilion ? 7. Scullery to each Ward. 8. What should be done in the Scullery ? which, on the one hand, gives all concerned more liberty of doing wrong than the block plan, and which, on the other, renders it more diflBcult 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. 4. I think the Orderlies had better have their cooked meals sent them into the wards. Of course, they can only eat toge- ther 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. Eegularity 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 Hospi- tals, 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. 5. In the case of Civil Hospitals served by women, it is very important that each Head-Nurse, and each set of Assis- tant-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. 6. If the Orderlies do not sleep in the Pavilion they should not have a day-room. 7. To each ward should be attached a scvJlery, 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 tip, &c. ; and, as a rule, they ought not to be sent there. Make them useful in the ward ; keep the scullery for the Nurse and Orderlies. 8. Prom this scullery let the Nurse get the water she re- quires—Orderlies ditto. Let the Orderlies eat their meals in it, if they do not eat POULTICE-MAKING. 79 them away from the ward. The food of the Orderlies is gene- rally different from that of most of the patients, and it answers better for them to eat their meals not under the noses of the patients. In emergencies, of no rare occurrence, the Orderly must watch a patient and eat his dinner at the same time, and so must the Nurse ; but, as a rule, it is undoubtedly better that ward-servants should not eat under the observation of the patients. In the scullery all the cleaning must take place, which is not done in the lavatory. In the scullery extras are to be warmed, drinks ditto, hot- bricks heated, water-bottles filled, &c., is 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 ] 2 hours off". Still it will not do to interfere too much with analogies, and the proper authorities must decide whether this is too much. 25. Again, leaving the question for decision to the proper Exercise for authorities, I had rather each Orderly had one hour or two hours Orderlies. for exercise each afternoon or each alternate afternoon, care of course being taken that he did not exercise him self 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 NIGHT DUTY Night Kefreshment for Orderlies necessary. recreation time. But as a rule, it is certain that fresh air ia necessary to preserve health in Hospital duty. Doctors of all kinds know and act on this as regards themselves. The vraste of time and strength, at present too often incurred by the endless fetching, heavy carrying, kc, of many Hospitals is in a considerable degree counteracted by its forcing the Nurses into other than w^ard 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. 26. IsTow comes a thing I am very anxious about concerning night duty, the more anxious because it is important, and because I am afraid it is an innovation. I have watched the night duty with particularly anxious interest, in each Hospital I have entered, feeling at once its importance and its difficulties, and of the following principle I am thoroughly certain. The Orderly doing night duty should either be allowed refreshment during the night, or the recurrence of this night refreshment should be considered in allotting the rations. In none of the Civil Hospitals, so far as I know, is night refreshment given. The Nurses usually on board wages, apportion, when they can, some from their food. In one Hospital there exists a rule that no Night Nurse is to take refreshment during her watch, the intention being to keep her more vigilantly to her duty. This is one instance among many of the serious and cruel mistakes which men of business or bene- volence, 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 award from 9 to 9, or even from 9 till the breakfast hour of 6, would cither soon be unfit for duty, or put drams in her pocket, or doze through the night. A strong soldier, required to watch in a ward and fast from 9 P.M. till 9 A.M., or 6 a.m., or shortly before, would stand the trial quite as ill as a Nurse. There is an admirable rule at OF ORDERLIES. 99 two foreign Hospitals where I have served. Sisters watch in some wards, Men Nurses in others ; and each watcher receives from the house, on going on night duty, a bottle of beer, a can with about six or eight cups of coffee, milk and sugar in propor- tion, 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 desii'ed be made by the watcher two or three) during the night, is an excellent one. I think it would be very sound economy to allow each Orderly on night duty, a proportion of beer or porter, of coffee or tea, and of bread and butter, or bread and cheese, to take at his own time during his watch, besides his supper before going on duty, and his breakfast just before 6, (both Nurse and Orderlies ought to have breakfasted by 6, and to begin the day duty at 6, and I wish it began by opening the windows and repeating the short prayers for 5 or 6 reverent minutes). Of course it may be considered preferable to reckon this night-ration in the Orderly's rations. Or suppose the bread and beer or porter to be reckoned in the rations, and a can of coffee given him for the night watch. Settle details as is best, and of course analogies must be considered ; but in truth hospital watching is a very peculiar business ; important, unobtrusive, most ]ieculiarly trying, and the bright side of very few Hospitals. Each watcher should undoubtedly have refreshment forthe night. The Nurse should have her groceries in the lump, and refresh herself as she likes out of them. Her watching, if she does her duty, will be, when she has bad cases, severe enough; but I would not provide her w4th exti'a refreshment ; as the watch- ing is not prescribed and regular duty. There should be as little extra watching on the part of Orderlies as is possible ; when it is indispensable the extra W'atcher should have the same night-ration. I submit ray strong impressions on the subject of this night refreshment now, because, small as it may seem, it very largely enters into the working of a night watch. I have suggested the division of the Night Orderly's sleep, because, if A. comes on duty at 6 a.m., and is sent to bed at noon or 1 to get ready for his night watch at 9 p.m., he is g2 100 NIGHT-DUTY scarcely fit for a long sleep, and supposing the patients dine at noon (an excellent hour) he has not, or scarcely, taken his share of the clearing away which, got over in time, enables the other Orderlies, one or both, to have a short recreation in the afternoon. Also if sent to bed at one he has not eight hours' sleep, as out of that he has to undress, dress, and sup. Also he has to remain on duty from 9 p.m. to 9 p.m. next night, which is much too long as a rule. If he does not go to bed before his watch, and goes off duty at 9 a.m. next morning, whatever time may be then allowed him for sleep, he cannot, as a rule, be depended upon for performing his watch duty efficiently. Where are the 27. If the Ward Orderlies watch by turns, it should be arranged Night that the men who sleep before and after the watch can do so Sleep by Day 1 qi^^^tly. 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 parti- tions. 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) niust sleep near, and have general charge of the order and quiet of such wards. I conclude that one or more Assistant Ward-Masters, at all events, must watch, and as they must sleep by day, this will fit in well enough. I should avoid putting the Orderlies in a too much out of the way pare of the Hospital ; they should know themselves liable to inspecting visits any time. I am not sure that Ward or OF ORDERLIES. 101 Assistant Ward-Masters would not be much better guardians of the Orderlies' wards than any special functionary. Drink is the vice of these men, noble fellows as, as a body, they are, and I should avoid quartering any man too comfortably and solely in one particular post. Cases have been where the duenna of the Nurses' dormitory was herself a determined, disguised drunk- ard, and reported others accordingly as she was bribed or not with drink for herself The whole question of Orderlies sleeping near or away from their wards should be well considered by the proper authority, two or three experienced Army-Surgeons. Upon the whole, I think it would be well to try the quartering them separately : there is much to be said on both sides as usual. 28. In several foreign Hospitals a certain number of Night Watchers, both Sisters, and Men-Nurses, are told off for niglit- duty for four weeks, during which they are exempted from all labour by day, and receive better food than the usual diet. They also receive good night-refreshment. In one Hospital the following is the arrangement. The wards usually contain from 10 to 13 beds, and there are many small wards for three, two, or one, bad cases or operation cases. All the wards open upon a corridor. The Sisters do not watch in the men's wards. Comparative Merits of Different Systems of Night Nursiusr. A Sister watches in the female medical wards „ _ surgical „ „ children's wards and girls' ward A Man-Nurse „ male medical wards i j^ „ surgical wards and boys' ward J xo 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 MejvNui'ses, who, after his or her day's duty, does the extra watch. As regards all English hospitals, civil or military, the advantages of this system are these : — I. 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. 102 NIGHT-DUTY 2. It secures these persons good food and refreshment at night. 8. These persons know their sick, and, being told on coming on duty, of any change, &c., are as much at home in their posts by night as others are by day. 4. "When it is found that a Sister cannot sleep by day, and, therefore, that her health breaks, she is not allowed to finish the four weeks and become ill, but is put to another duty and another Sister appointed to the watch. (Many a strong Nurse cannot sleep at day.) 5. The persons so appointed get into the way of it, if they stand it at all, and the system is found a great relief to the whole house and a great gain to the sick, in the place of another system of dividing the night between two Sisters and two Men-Nurses, who each watch half of the watch. Per contra. I. The great London hospitals are places very far from perfect : some things may, please Grod, be, with time, patience, and extreme quietness, very much improved ; but some things will never be perfect and never can be. But they are places where I do believe, and so far as I know, the sick are cared for in a way that is done nowhere else. The proportion of heavy cases in every London ward, cannot, I think, be met except by having a watcher in each. An English physician or surgeon would not consider that his cases could otherwise receive the attendance and the watching, the observation of possible change and prevention of possible mischief, which they ought to receive. It is right to bear in mind, — 1. That small wards multiply exceedingly the demand for "Watchers : four wards, of 10 patients each, taking the average of patients as in London, would not be attended, according to the English notion, by one "Watcher ; 40 patients in one ward would be fully attended by one "Watcher. The London Hospital has two Night-Nurses for its quadruple wards. An extra Night-Nurse has frequently to be put on, on account of the difficulty the subdivision of the ward gives to the watching. 2. That the average of severe cases in each ward of London hospitals is very considerably more than the proper-- tionate average of severe cases in each ward of the foreign hos- OF ORDERLIES. 103 pitals in question. In all foreign hospitals with which I am acquainted the proportion of accidents is compaz'atively small to those of the London hospitals. The docks, the manufac- tures, the crowded and dangerous woi*ks, &c., &c., with us, account for this. 3. That, striking the balance for and against, it is neces- sary 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 tlie Watcher during the whole night, or at least much oftener than by the other plan. II. The second flaw of the above system, as it applies to London Hospitals, is, that it renders Extra- Watchers so often indispensable. The employment of Exti'a 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 watch- ing is most injurious to the health of all ward-servants, and to the sobriety, and therefore morality, of many paid ward servants. This is a very important reason, I humbly consider, for avoiding as much as possible small wards. I do consider small wards very objectionable in working a Hospital. But it is right to remember that we have been told of England, of Austria and of Prussia that the proportion of severe cases in Military Hospitals in time of peace is considerably smaller than in Civil Hospitals. Night watching is not done in the Military Hospitals either of Vienna or Berlin. Orderlies, or an Orderly, sleep in each ward, and watching is only done to bad cases. How far English Army Surgeons consider night watching desirable in the Army Hospitals I will presently tell. I should think the convalescent wards, among many impor- tant advantages, would receive a number of patients who require no night watching. An Orderly ought to be at hand here, but not watchins:. 104 NIGHT DUTY If night duty is considered requisite in the ordinary wards, I do not see how the English standard of things could be met, excepting by having one Watcher in each wai-d where there is regular night watching. I think, however, that the foreign system of night watching above detailed might give very useful hints for women in war service, and for emergencies of cholera, &c., &c., in home service ; and with regard to supervision in the latter. I think, with submission to the proper authorities (the two or three experienced Army Surgeons I have so often adverted to) feeling strongly that awkward mistakes might occur in sevei'al of these matters without them, as civilians and women cannot and ought not to trust their own judgments respecting such, that in a large Military Hospital, an Assistant Ward- Master ought to go round the wards at night. Not with any idea of his rendering assistance to the Watchers over bad cases. The Nurses must do their duty of Head-Nurses, and see to this themselves. Perambulation through a large Hospital at night in point of fact excludes the possibility of doing anything in any one ward, unless in some exceptional occurrence which only proves the rule. The object is the important one of seeing that the Orderlies are awake, sober, alert, and at their duty, and that the patients are quiet and in bed. The Nurse would hear any noise, but there is such a thing as quiet drinking, as well as noisy drinking. In St. George's there is a Night-Matron, chief over the Night-Nurses, who goes through the Hospital every hour during the night-watch. I have heard this spoken of by experienced Authorities of other Hospitals with approbation and envy, and some idea was entertained of introducing it into another great Hospital. In Civil Hospitals, I think, but I do not know, that the benefits of this Night-Matron may be perhaps more imaginary than real. The Head-Nurses at St. George's sleep away from their wards ; a great mistake, I humbly consider. But Military Hospitals are entirely different in sundry essen- tial 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" OF ORDEELIES. 105 sundry things — taking the wards in uncertain rotation, some- times returning suddenly on his steps, &c., &c., &c. It will be worth securing, if possible (this parenthesis will be understood), that the Nurse's water-closet should be within her room, if not, as close to it as may be. 29. The following extraordinary system of Night Nursing is Present State that which prevails in the Army at present : Nursiif"''in The " nursing is managed" either by means of patients " told Military off in watches" through the night for the purpose of attending Hospitals. to other patients, or by means of soldiers sent in from the ranks to attend specially upon each bad case ; or by Orderlies " arranging it among themselves," without any exemption meanwhile from day duty. Upon each and all of these systems or no-systems it is hardly necessary to make any comment. It is difficult to tell which ia the worst. In the principal, indeed the only General Hospital in Eng- land, " Nursing is managed by comrade-patients told off in three watches of two hours each for the night." [sic.'] " Orderlies are likewise warned and often sit up for the pur- pose." These passages are given verbatim et literatim, because they are so remarkable. And it is necessary to add that these patients being the relapses among the " Invalids" are nearly the worst cases we have. Were it tlie 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 expe- dient which turns over the man who is too ill to be left at all to the care of men who ought to be recovering themselves, but who are pulled out of their beds for two hours to nurse (for the first time perhaps in their lives,) and a very " serious" case too, is to say the least of it a singular one. At "Woolwich Artillery Hospital the cases which require constant attention are about 2 per cent. There are now 545 patients in Hospital, and 11 cases consequently, each requiring 106 NIGHT NUESING IN one Orderly to itself. The Orderlies, according to Regulation, are 55, so that one-fifth part of the Orderly service is required for these cases. Yet there is no system or arrangement for such. The Orderlies arrange (or do not arrange) among them- selves to do the reliefs day and night. Of the 11 cases at this time in Woolwich Hospital vrith 11 Orderlies sitting up with them, it so happens, as I am informed, that only one would require, if such were together in wards where regular night nursing was established, an attendant specially to itself. It is needless to enlarge upon the cruelty of the above prac- tice. 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 hap- pens that 11 cases who might all, if in one ward, be attended and as efficiently attended, by one .Night Orderly, require each an Orderly to itself in as many different wards. In the "Garrison Hospital" at Chatham, "when any case assumes such a character as to require more than the usual care and watching, a Eequisition is immediately sent to the Com- manding 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 at- tend upon him throughout his illness, but who is relieved by another as often as the Medical Officer in charge of the case considers necessary." The following is the average number of sick in Army Gene- ral Hospitals in time of peace at home, for whom night-nursing is considered necessary by the Medical Officers. But it is im- portant to add that this number would be probably estimated as very much higher if proper means of night-nursing were at their disposal. Of constantly sick mean proportion per cent, requiring night nursing : ^ 1 TT -J- 1 TT 1. -n-i-j- f Medical Division 5 General Hospital, Fort Pitt | gurgical „ 1 Garrison Hospital 2 These cases are usually scattered through the wards. MILITAP.Y HOSPITALS. 107 It is but fair to add that the best Medical Officers themselves desire another system, or rather are aware that there is at pre- sent no system at all, and would gladly accept one. " With means for good night-nursing," they say, " arrangements in accordance might be introduced. At present we like to have a case requiring much attendance amongst cases that require little, in order that the patients or comrades may assist." What are the consequences of such "assistance" to the cases in question has already been fully stated throughout these notes. " With respect to the use of [the inmates as] servants, they require the strictest superintendence on the part of the * * officers. The employment of [the inmates] in offices of trust is inexpedient, inasmuch as it tends to impair the discipline of the house. In offices of mere labour, which can be performed under trustworthy superintendence, [the inmates] may be useful. Where responsibility is involved, paid servants should be engaged." The above is one of the regulations of what ? — not of a Charitable Institution but of the Poor Law ; and the house of which it treats so tenderly and wisely is — a Workhouse !* 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, how- ever, is no systematic provision made. One would think that every bad case took the Hospital by surprise. Imagine the orders of the Medical Officers carried out by nurses (?) changed "every two hours," and who are, in fact, sleepy patients ! The system of Military nursing and management, as described by Army Medical Officers themselves in the above quotations, Poor-Law Eesrulation for Nursins? in Union Work- houses. • If it be said that the AVorkhouse sick are ill-nursed, it is in proportion as this rule is broken, not as it is kept, that they are so. 108 TAVELVE SUNDRIES IN PLANNING and whicli is, we are expressly told, to be re-enacted at the Eoyal Victoria Netley Hospital, is precisely the one which led, as a matter of course, to the calamities, as far as nursing was con- cerned, 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 atten- dance at Netley can only be carried out on such a plan, it is doubtful whether Netley should be used even for an Invalid Hospital. The question has been asked the Netley Committee, By whom are your Invalids to be nursed, when sick ? And it has been answered, that they are to nurse each other ! II. Ntjkse's Eoom, &c. Nurse's Room. It is essential that between every two wards, in a hospital where the blocks are built end to end, there should be, as at the new Military Hospital of Vincennes, a lobby with a thorough supply of pure fresh air. If it were possible, where the Head Nurse, or rather in a Military Hospital the Nurse, has charge of two such wards on the same floor, to let her have a long, narrow room, with screened windows, opening into both wards, the door opening into the passage in the midst, it is worth contriving. Medical 2. The Medical Officer's room should be on the ground floor cers oom. ^^ ^^^ entrance and apart from everything else. The servant or whoever cleans the room, should not be a Ward- Orderly, (ward-attendance cannot be kept too entirely separate from all other concerns). Water-Closets. 3, The ward water-closet should have a pane of glass at top, so that a faint gas-light in the lavatory at night can light sufficiently the closet, and the (bed-pan) sink. The water-closet should be constructed, as is done often in those of English railway stations, so that each visitor involuntarily, on rising or on opening the door, purifies the concern. Besides the ward water-closet, there should be general A NEW MILITARY HOSPITAL. 109 water-closets, and urinals separate from the wards, for the use, during the day, of those patients who can leave the wards. The latrines at the Lariboisiere Hospital are a good example, both for what should be avoided in construction, and what should be imitated in position. The sort of latrine used there would never do for England. The men able to go out ai'e expected to use by day an urinal in a corner of the little garden belonging to each pavilion. At night no sick men are allowed to leave the ward on that or any other pretence ; they must use the latrines. The latrines are at the furthest end of the ward. Opposite the one door is a partially glazed door, beyond this is a large window, grated in network as well as with panes and frame. On one side opens a space where the men, able to get up, are expected to wash, and which, moreover, contains two latrines, each separated by a partition and secured by a door. The same arrangement prevails on the female side. The rule of having the water-closet on the furthest side of the ward, removing all pretence of leaving the ward by night, is excellent. 4. The importance, immense addition of efficiency, and Warm and ultimate economy of carrying warm and cold water into every Cold- Water 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. 5. Corridors as proposed at JSTetley are useful and objection- Corridora. able. 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 suffi?red. 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. 110 TWELVE SUNDRIES IN PLANNING Lobby. Material of Ward Utensils. 6. Provided this double range of windows be secured, double wards of thirty on the same floor would cause no disadvantage to the sick. But, if such be determined on, let especial care be taken to separate the two, not by a showy hall, but by a lobby and an ample staircase, extending from top to bottom of the building, and communicating freely with the open air at the roof, as well as by the stair-window s : admitting a thorough current of external air, so that, of a morning especially, the two wards do not mutually send the close air into each other. The lobby should not be turned into a vestibule. Thorough air is all that is wanted. Patients should not be suffered to remain in it. 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 su- periority 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 advan- tages. Pirst, if these vessels are cleaned by Ward- Orderlies, the amount of breakage would be much greater in proportion than as done by Nurses, and it is imperative to have as few women as possible in the service of Military Hospitals. Secondly, it is very important to avoid even the appearance, especially at first, of anything like introducing luxury into Army Hospitals ; and I can quite understand this appearing like luxury. The material of one description of ward- vessels should in par- ticular be left to the Surgeons. In sending to distant foreign or war-stations, urinals of tin have one material advantage over those of glass or china, that they do not break so easily ; but, as to home-service, these tin urinals cannot, by any amount of cleaning, be freed from an unclean smell. In Vienna General Hospital, where economy is exceedingly attended to, all the urinals are of glass, as the superior cleanliness is considered well worth the additional expense. A damaged or broken glass or earthenware urinal is dangerous ; and if there is difficulty in obtaining the immediate issue of a new for a damaged one, it is better to have tin. In Vienna General Hospitals the patients' eating vessels A NEW MILITARY HOSPITAL. Ill were formerly of tin ; but were some time ago furnished of earthenware, for the same reasons as those given above ; also because the hot tin vessels were found awkward to the patients. (I do not think much of this latter reason ; in hospitals, there is little fear of food reaching the patients too hot). In Vienna and Berlin Military Hospitals the eating vessels are all of tin. 8. In building a large new Hospital, the question of whether RescrveWards. or not reserve wards, or Pavilions, should be provided is an important question, to be referred to the proper Authorities. In one German Hospital is a Sommer-Lazareth, or separate Hospital, which most of the sick occupy during the six summer months. This is considered the best plan ; but so expensive that well-considered arrangements in designing the building may render its adoption unnecessary. In another German Hospital is a group of wards on each of two floors, into which the male and female patients, especially the surgical cases, are successively moved ; both in order that during this time the other wards may be thoroughly cleaned; also to change the air; also in case of some sudden epidemic, &c. In every Hospital a thorough cleaning of the wards is essen- tial. 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, 'white- washed every year, and oftener if there has been some sudden outburst of any zymotic disease or Hospital gangrene are pre- ferable 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 num- ber 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 immedi- ately 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 112 TWELVE SUNDRIES IN PLANNING cleaning is over ; the patients moved back ; and the ward or wards so cleaned recommence their usual taking-in — and so on. The cleaning of a great London Hospital usually takes two full months ; and a great nuisance it is for the time, but the place benefits by it the whole remaining ten. It is excellent economy to have plenty of hands, so as to have the cleaning part, in distinction to the airing part, done as quickly as thorough cleaning admits of. It is very bad economy to put too much of this great extra cleaning upon the Nurses. This would of course not apply to a Military Hospital, where it is important the Orderlies should become as thoroughly qualified as may be for foreign and war service. It is necessary that whatever exterior help is called in, should be closely overlooked; contractors and contractors' servants being seldom overmuch troubled with conscience. Now it might be exceedingly worth while to have one or more reserve Pavilions, with a view to this annual cleaning. If the flooring of polished oiled boards should be found to answer (that it should receive a fair trial is very desirable, as it might result in a material benefit to our Hospitals), it would be doubly useful, when, every third year or so, the oiling and polishing required renewal, to leave the newly-oiled wards empty for a fortnight. An additional week or two would additionally harden and improve the flooring ; but a fortnight would sufilce. It might also be right to have reserve wards for what must occur every now and then in a Military Hospital, an influx of patients beyond the usual number, or an outbreak of cholera, or some malignant epidemic, which it might be desirable to isolate from the other patients. It may now be confidently expected that, under the new regime, 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 fear- fully inconsistent with each other, especially in that momen- tous machine called the Army of England, which is no safe plaything. Dr. Helm, the Director of the Vienna General Hospital, in a little pamphlet published some time ago, insists on the impor- tance, in designing a new Hospital, of providing Eeserve wards, A NEW MILITARY HOSPITAL- 113 especially with a view to dangerous epidemics. They should admit, he ui-ges, of easy and complete isolation from all the re- maining parts of the building. 9. Dr. Esse, Director of the Charite, 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 Charite 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. 10. In admiring much, very much about the Grerman Hospi- tals, it becomes necessary not to omit a warning. A number of women, all equal among themselves, with no female Superior or Superioi's whatever, under the sole control of men, in an ascending scale from the Abtheilungs-Inspectoren or Oberkran- kenpfleger, through Doctors of sundry ranks, to the Director himself, such is the system followed, as in the great Charite Hospital at Berlin, so in the great General Hospital at Vienna ; and this cardinal mistake leads to many others. 11. It is desirable that the Rules should give daily exercise to the Nurses, or rather that the Eules 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 then- 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 impi'essed upon all Superintendents, that it is essential in the long run to the health of Nurses to have fresh air ; but in many foreign sta- tions it might be far better for the Superintendent to take, or rather send, them out for one vice two hours, &c. In war and foreign service, the exercise time must be at the discretion of the Superintendent. There may be awkwardness enough on sundry home stations in allowinsj each Nurse two hours at her own discretion out- Occasional Revision of Rules. Defect in some Systems of Nursing. Nurses' Exercise. 114 REGULATIONS AS TO Number of Ward- Masters side of the Hospital every day. Still it is riglit to look things in the face. The Rules do not contemplate a Sisterhood, but a staff of secular women, bound by strict rules in all that concerns the duty they undertake, left to themselves as to sundry things which in Sisterhoods are ruled. (How and by what measures in process of time strong and quiet religious influence may be brought to bear upon this staff, is the question of vital impor- tance 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 re- strict it, though the Superintendent must see to this, so far as she can without doing or encouraging spy-work, a thing which has many advantages, and is often done in various, very various ways, but which in the long run brings no blessing, and pro tanto, degrades all who are concerned with it. 12. In Vienna Military Hospital each set of five or six wards, with 30 or 40 patients, sometimes 20, in each, had a Sergeant and a Corporal over the Orderlies, (Berlin Military Hospital is served by Civil male Nurses). I think a Ward-Master would be enough for each Pavilion of six wards of 30 patients each, in three stories, each couple of wards being in charge of a Nurse, and each ward served by three Orderlies. III. Eegulations. Query as to depriving certain Patients of Visitors. 1. Proper military and medical advice should be taken as to wliether it would be advisable to draw a distinction between the venereal and the other patients. In the Vienna Military Hospital they are locked up by themselves in particular wards, but are allowed to see their comrades at visiting hours. In the Berlin Military Hospital they are locked up in wards, and allowed to receive no visits whatever, excepting, of course, from the Chaplain and the proper Military and Medical Oflficers ; and in the case of dying patients from their nearest friends. VISITORS. 1 15 Nor are they allowed exercise in the grounds. This excellent regulation makes them heartily tired of the venereal wards, and even this is a very salutary thing. In the Vienna and Berlin Civil Hospitals, the venereal patients of both sexes are also placed in locked wards, and allowed no visitors. Nor are they allowed exercise in the grounds or garden. In the two Paris Venereal Hospitals no visitors are allowed. Now, as the more disagreeable the subject, the more necessary it is to be explicit upon it when entered upon, this wholesome discipline exists in a very faint degree in our great Civil Hospitals, — a thing not to be lost sight of in introducing any change in the Army Hospitals. The three greatest London Hospitals have venereal wards. The female patients never leave the ward. The male patients take exercise in the court. In one case the rule is, that this should be at different hours from the other patients ; the rule is not strictly adhered to. The exercise question should, in Military Hospitals, be left entirely to the Surgeons ; they may fairly consider it enters into the question of treatment, which is different from the Continental treatment. The enforcement of different hours of exercise from those of the other patients is good, as is every brand which can, quietly and effectually, affix disgrace to these wards. Deprivation of visitors, if it could be done, would be very salutary. In the great London Civil Hospitals, men and women visit the male venereal wards ; women alone the female wards (and melancholy things are the visiting hours there ; here and there a heart-broken mother, abundance of prostitutes, and no lack of procuresses. A firm and vigilant Head Nurse will sometimes refuse admitting one of the two latter sorts to some patient, whom she knows they are endeavouring to make sure of again ; but as the rules admit female visitoi's, 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 equi- H 2 116 REGULATIONS. valent female wards; and are generally wives, mothers, and sisters, seldom prostitutes. There can be no doubt, however, that it would be much better if the patients of neither male nor female foul wards were allowed visitors, unless in the comparatively very rare cases of extreme danger ; it would, in that case, be necessary that the Hospital should supply them with linen, and either supply them with groceries or forbid their receiving them from without. In various essential respects the patients of a Military Hospital are different from those of a Civil Hospital. Were it possible to prevent all female visitors to the wards, except in dangerous cases, this would be best. If the existing rules or practice do not compel the sentries to refuse entrance to all disorderly women, however orderly their behaviour, such a rule, at any rate, should be enforced. And if all visitors, male and female, including, of course, soldiers, could be refused admittance to the venereal wards, always excepting cases of great danger, it would be very desirable. At all events, it would be very desirable to have all female visitors, without exceptiou, excluded from these wards. These things are, I do consider, very important. But I would not press them, if refused. Let the female service obtain, please God (I do not write these words fro forma, — 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 disad- vantages, with reference to Hospital nursing, to take their share in tliis great field, Avhich has plenty of room for both), let, I say, the female service obtain a firm footing in the Army Hos- pitals, and with it, and by cautious degrees, sundry ameliora- tions 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." Query as to 2. Military as well as Medical advice should also be taken upon the following point : \\\ most, not all, the great London Hospitals the patients, Nuralieriu Patients, SWEARING. — CONCLUSION. 117 whose names are on tlieir bed-tickets, are called by the numbers 1, 2, 3, &c., suspended over each bed; sometimes a patient's name is never heard in the ward. Now, very possibly, tliis would not at all do in a Military Hospital, and, if so, there is not another word to be said about it. Otherwise, very few things so effectually save time, as the numbering plan. (In Civil Hospitals it is also excellent in other ways, of much less consequence in a Mihtary Hospital, which will never, I conclude, be afflicted with " gentlemen," Mr. So-aud-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 etfectually 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. 3. The regulations lately in force contained in plain strong language prohibition of swearing and indecent language in Hospitals ; they are quoted i'rom the Articles of War. It would be well to retain this in any new Regulations ; and the retention of this Eule 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 tlie 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. 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 un- certain that the possible iutroduction of permanent "Female Service into Army Hospitals has determined me on writing what I had rather not have written. Kegulations as to Swearing. Conclusion. 118 VENTILATION AT THE Additional Hints as to Pavilion Hospitals suggested BY THE construction OF THE LaBIBOISIEBE HoSPITAL AT PaEIS. I . — Ventilation . The question of ventilation is so all-important, so much doubt still seems to exist as to the comparative merits of natural and artificial ventilation, so much has been said in favour of the latter, because it is seen adopted in the finest hospital in the world, the Lariboisiere, that I have added a few practical remarks upon this system. The conclusion is, that even at the Lariboisiere, without opening the windows occa- sionally, and especially in the morning, real freshness is never obtained in the wards, and that, therefore, if there must be artificial ventilation, that is the best which allows the most of the windows being opened. On the men's side, Thomas' system, or that of injecting air at given points, by means of two high-pressure steam engines, each working a large fan, is adopted. On the female side, Duvoir's system afibrds ventilation by extracting air at given points. In both, a number of shafts and openings provide for the exit of the air. Persons at the Lariboisiere 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 warm- able 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. Fer contra. How difficult it is to learn any facts by hear- say we know. Other persons who ought to be good judges LARIBOISIERE HOSPITAL. 119 think the male side apt to be too warm in winter, eapecially at night, and consider the temperature on the female side quite sufficient. Both sides are ventilated both by the windows and by the machinery by day in summer. Both sides are ventilated, each by its own different machinery, by night in summer, except that, exceptionally on hot summer nights, a window is opened two or three times in the night, or five minutes every hour. Both sides are considered to be ventilated in winter mainly by the machinery by day ; and both sides are entirely venti- lated in winter by the machinery by night. As far as can be made out from conflicting accounts, (conflict- ing from the very simple reason that one person will consider a ward, or drawing room, for that matter, airy which another will consider close ; one, pleasantly warm, another too hot or too cold), it is practically found impossible to freshen' the ward of a morning without opening some windows, and to keep it fresh during the day without now and then doing the same ; and it is easier to open the windows on the male side in winter than on the female side. The ventilation on both sides is considered to work with equal efiiciency during the whole of the day. Of tlie eighteen wards, the ventilation on entering the wards at five a.m., when the ward nightwatch has generally not opened a single window, is certainly surprisingly good ; i.e. the air is surprisingly little bad. £ut neither here, any more than anywhere else, are the wards effectually freshened, until the windows are, of course loith proper caution, opened. In both these particulars, no difterence is to be observed between the male and female side. In repeating that the Director, and other persons who ought to be good judges, consider the machinery of the male side the most expensive and the best, I add these things : Eirst. Since this machinery was erected, so far as concerns the steam engine, it is said that equally efiicieut 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 Lariboisiere. 120 VENTILATION AT THE Secondly. If an accident happened to the machinery of the male side, which is in communication with the steam engine, the results might be very serious. Twice a stove has burst on that side, happily without damaging anything else than furniture near it; had patients been near it, they must have been hurt or killed : and an accident on a large scale micrht blow up not a small part of the Hospital. More or less danger is inseparable from powerful steam machinery, or powerful machinery of any kind : the question is one of degree. Thirdly. Both sides of the Hospital have one thing in common. Except the sculleries of the 3 ground floor wards on the male side, which have each a stove or fire place, the kitchens or sculleries attached to all the other wards are warmed by hot water. Undoubtedly this saves much mess, much cleaning of stoves &c., and much bringing of fuel and conse- quent dirt. But the absence of fire is always a loss to the service of a ward. Sundry things, some one or other, often all of which are constantly wanted in a large ward, e.g. warm- ing broth or drink, cooking for an extra bad case, warming poultices, warming (not airing) linen for ditto, &c., &c., &c., are much more slowly done by water than fire heat, and it is a question, variously answered, whether some of these things are as well done by the slow water method, as by the quick fire heat. Occasionally the hot water is not forthcoming, a nuisance alike to the ward attendants of the ward whose scullery is thus heated, and to those of the wards supplied with stoves, which have then to do, in driblets, considerable ex- tra duty. During the hot months the smell of the latrines is very little perceptible in the wards, generally not at all : but the test of this, as of the ventilatiori, is in winter, w'hen the large window close to the latrines is generally closed, and the smell is very offensive. II. — Oiled Boards versus Parquets. 1. They have in common the superiority over common floor- ings — that they are not scrubbed, and the damp thus arising is avoided. LARIBOISIEKE HOSPITAL. 121 2. As regards labour, so far as Civil Hospitals are concerned, where tlie ward service is done by women, parquets would be more laborious than scrubbing ; a large ward, to be kept in a proper state, requires a certain amount oifrottage (the peculiar polishing of parquets) every day ; and this frottage is held to be unfit, from tlie fatigue it causes and the strength it requires, to be done by women, and is always done by men. Certainly Ward Nurses could never be required to frotter ; it is altogether a man's business. 3. As regards labour, so far as Military or Naval Hospitals are concerned, where men preponderate in the ward service, it is my impression (for of course I cannot pretend any certainty as to this), that sailors who are proverbially handy (a different quality from either laboriousness or endurance, though they have these too) would, with instruction and painstaking, accomplish in time frottage ; that civilians would under the same conditions ; that soldier orderlies (infinitely, I humbly think, the best material for the staple of military ward service), would generally make bad frotteurs. 4. As regards labour, cleaning oiled boards, though a laborious business, is much less so than either scrubbing or frotteing ; and is fully within the power of average strong women : none other should nurse. (What subdivision of clean- ing 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 tlie main ward cleaning, is better economy of strength and time than to divide it among the three). 5. As regards labour, any Orderly giving his mind to it for a day at the shortest, or a week at the longest, ouglit to learn thoroughly how to clean polished oiled boards well, always supposing him to be properly taught a very simple thing, which, like everything else, can be done well, ill, or indifferently. 6. Apart from the question of labour augmented or spared, the advantages of oiled and polished boards I believe to be these : — (1.) Prevention of dust. 122 OILED BOARDS (2.) More easy purification of the air of the ward in the morning. The air of every ward becomes more or less impure during the night, and the floor and furniture more or less dusty. Making the beds in the morning adds to the dust the night has accumulated. The dust is more thoroughly destroyed by the cleaning necessary to oiled and polished boards of the Bethanien variety, than by any other cleaning I have seen. It is fairly destroyed ; whereas both parquets and boards generally retain a little. Also, the water, with which the oiled boards after being swept are cleaned, freshens the ward and purifies it of the close- ness remaining of the night air, in a very speedy and remark- able manner, which is even more evident as well as more useful in winter than in summer — as in winter it is not possible to admit as much air from the windows as in summer, especially when it is most wanted, in the cold, close, early mornings. The advantages of oiled and polished boards as counteracting the spread of miasma, which is strongly dwelt on at Berlin by competent authorities, I have not alluded to, as probably parquets are considered equal in these respects to them. Stains, mess, and dirt falling on polished oiled boards are much more easily cleaned than on parquets. Note. Mode of Cleaning Ward and Boom Floors at Bethanien, Berlin. I. Daily. 1. Take a common hair broom, a broom with a hard brush, a cloth of coarse flax, and one or two pails of cold water. 2. Sweep the floor and skirtings with the hair bi'oom. 3. Dip the cloth in a pail, wring it gently between the hands, so as to have the whole equally wet, not running." Throw it on the ground, reverse the hard broom, and placing the reversed handle upon the cloth, clean the floor close to the skirtings, not the skirtings themselves, and the corners. When the cloth becomes dry, rinse it and re-wet it in the same pail. 4. Then wet the cloth somewhat more, wringing it as before, throw it on the floor at the end i'urthest from the door, VERSUS PARQUETS, 123 and placing the brush of the hard broom upon it, brush, firmly and quickly, each board iu the direction that the boarding runs, about as far as the arms can reach, standing, not kneel- ing. A small ward can be at once brushed wet, a large one must be divided into parts, and each part be successively brushed wet and brushed dry. When the cloth becomes dry, rinse it and re-wet it. 5. To brush dry, rinse and well wring the cloth, brush as before. The firmer you can press, the better and quicker the floor will be dried. When the cloth becomes wet, rinse it and wring it as before. 6. Change the water when dirty. More or less water must be used, according as the floor is trod by dirty boots and shoes. 7. Aim at drying the floor by one dry brushing ; if not, it must be dry brushed a second time. Once should suffice. 8. Ten minutes, at the furthest, after the dry rubbing is over, the floor ought to be thoroughly dry. When it is quite dry, sweep quickly over it with the hair broom. 9. On putting by the cleaning materials, rinse well the cloth in clean water. II. Weekly. 1. Brush the skirtings with a small hard brush, and wipe them dry with a rag, as the cloth would be too large, and wet the walls. 2. Use more water to clean the floor, which will probably require two dry brushings. 3. Clean the brooms and pails. III. Annually. 1. Throw warm, not hot, water on the floor, and brush firmly and quickly, wet and dry. A very little soda iu each pailful will be an improvement. More than very little will injure the flooring. [A new cloth, which it is economical to cut from a great 124 A PEW CAUTIONS piece which makes iuto some or many dozens, should be steeped for a night in a pail once filled with boiling water, and in the morning rinsed and wrung several times in clean cold water, then used at once. Two or three new cloths can be steeped in the same pail.] III. — Cautions in Hospital'Building . — Often rejyeated, hut oftener nerjlected. 1. Wherever practicable build the hospital on arches ; but, for the sake of discipline, they should be locked up. 2. If practicable, let the laundry, if served by women, be removed from sight of the place where the patients take exercise, and of the ward windows. 3. In a Civil Hospital it is objectionable to give the female patients right to take exercise in corridors which the officers and servants have constantly to traverse to go to and from the wards. In a Military Hospital it is of little comparative dis- advantage that the patients should do this, although, 4. In building a hospital it might be well worth while to contrive that the covered space, essential to give the patients power of taking exercise, should be used solely for that purpose. 5. In Germany, the general opinion is in favour of small wards, twenty beds are considered the desirable maximum ; twelve, j^er se, better than twenty. Ditto in Belgium, under the same restriction, although, in practice, there are wards containing larger numbers. In the old Hospitals at Paris, the number of patients is too large. The Charite has long great wards of 100 and 120 patients. At St. Louis (which is mostly for cutaneous, not venereal, diseases, where the patients usually are long under treatment and able to go about, and where there is little acute illness,) wards of eighty aud seventy beds are the rule, smaller wards the exception. This may be considered an ex- ceptional class of patients. The Charit6, somewhat densely pressed upon by neighbourhood, is also not considered a favourably circumstanced Hospital as to air. Putting aside for a moment the sanitary question, which we have fully discussed elsewhere, and which appears to be TN PAVILION-BUILDTNG. 125 decided m favour of wards of from twenty to thirty patients, we will look upon the question of administration. The moment we consider that a great public Hospital has to pro- vide efficient attendance for all the sick it receives, that it must be economical of attendance, both because the expense of attendance, as well as the other requirements of the sick, commands all practicable economy ; and because efficient attendance in sufficient numbers is difficult to obtain ; it becomes evident that it is far better for the sick to have larger wards, efficiently served by as few attendants as is compatible with efficiency. This, which is the fair statement of the case, strikes those who have watched the working of the system of small wards in North Germany as more true than ever. Such persons consider that tlie size and numbers of the wards at the Lariboisiere Hospital, viz., thirty-four beds, in- cluding the two in the little ward, are good : that preserving the existing considerable space between the beds, and supposing tlie same ratio of conditions as to windows, &c., and the small ward for two at the end, wards of forty or fifty would be equally healthy for the sick, but that the number fifty should not be surpassed. Assuming, however, that thii'ty patients in a ward, or thirty- two, are the maximum number, sanitary and administrative necessities being conciliated, let us see what we do in our Military Hospitals at home. In most of our Regimental Hospitals the number of wards and of holes and corners, in comparison with the number of sick, is quite extraordinary. In a hospital for a battalion 500 or 600 strong, we shall find fight or ten wards of small size, a small kitchen, everything, in fact, on a small scale, just as if a large French Hospital had suddenly collapsed. How much more sensible would it not be to have one or, at most, two large wards for thirty sick each, with a small casualty ward and an itch ward ! How much less expensive such a structure would be in erecting and administering, and how much more easy would be tlie discipline and oversight, not to mention tlie greater facility of ventilation 1 126 A FEW CAUTIONS 6. There is nothing at the Lariboisiere Hospital answering to casualty wards. Besides the eighteen wards of thirty-four each, the Hospital contains two little (and inconveniently placed), wards of ten beds each, which, when medical cases overflow, are made medical wards ; and which are closed when the ordinary wards suffice. But of casualty wards, for offensive, or noisy cases, there are none, and the double- bedded little ward at the end of each large ward is intended to answer this purpose ; also, but subsidiary to this, to allow now and then a patient of the better class to have the comparative privacy. This latter consideration does not apply to a Military Hospital. As to allowing Non-Commissioned Officers for instance to be in the little wards, discipline would, I think, very soon suffer. But if casualty wards are provided for extra offensive, and noisy cases, it seems to me that any Hospital would be miich better without these small wards attached to each larger one. Apart from tlie purposes whicli the casualty loards answer, they are a nuisance. If convalescent patients are put into them, they are comparatively removed from inspection, and often play tricks there. Patients requiring much attention can seldom be put there, however their condition otherwise fits them for the little ward, because the ward attendants, and especially the Sister (as in secularly served Hospitals the Head Nurse), find it impossible to serve the inmates of the little ward properly, if there are also many serious cases in the large ward. I submit therefore that the small ward is only an incubus, if casualty wards are provided. One thing is certain : a patient requiring much attendance, put into a little ward, ought to have an extra attendant to himself, by day and by night ; otherwise, either he is more or less neglected, or he unduly monopolises the service of the ward attendants. It remains a question for far others than women to settle, whether offensive and delirious cases are under more favour- able 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 IN PAVILION-BUILDING. 127 airy ward, provided with a few small wards, and with complete ward attendance, is a much better place for the care and attendance of such cases, than small wards attached to tlie ordinary wards. 7. j^ void many holes and corners. I could «o^ recommend a dining room for patients attached to each ward, or floor, or pavilion. If there is any dining room, let all the convalescent patients of the wards not being convalescent wards, dine together in a room apart from the wards, and let the rest dine each at his bed side. If not, let each patient dine at his bed side. At the Lariboisiere Hospital, each ward has a vestiary, a doubtful arrangement. The nature of a INlilitary Hospital renders it proper to have but one vestiary under charge of some man. 8. If possible, let all foul linen be delivered daily, twice perhaps better than once daily, into the laundry, so as to remain the shortest possible time in the neiglibourhood of the ward ; otherwise, do what you will, foul Hospital linen will fairly, to say the ugly truth — stink, and its temporary recept- acle will stink also. I would not make this temporary receptacle a room. A large chest in the scullery, a region under constant purification by fire and air, would be, as already hinted, p. 88, the least bad place for an accumulation inevitable to all Hospitals, but which should accumulate for as little time as possible. 9. Provide from the first room for storing and issuing dried clean linen, as well as laundry room. - 10. In badly-planned Hospitals artificial ventilation is an excellent auxiliary for expelling the foul air, engendered in the ward, especially at night ; but windows only can be relied upon for introducing good air. Let Hospitals, therefore, be so con- structed 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 provid- ing double windows, opening above and below, or by some similar expedient. 128 "contagion" and " infection" defined. Note on Contagion and Infection. There are no words in regard to which there is more mis- conception, or more nonsense talked and written, than the two words "contagion" and "infection;" and as the word "infec- tious" 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 Yirgil'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 poat for poetic purposes has become the ground-work of every manner of false observation, false reason- ing, neglect of sanitary laws, lazarettos, quarantine, and con- tinually-threatened interruption to the commercial intercourse of mankind. No single word has ever done so much harm to the human race, or given such a proof of what a mighty thing a word is ! One would have thought that, after the sanitary experience of the last fifteen years, the word " contagion" would have disappeared from our language ; but, even in the last document issued by the expiring Board of Health, written by their Medical Officer, Mr. Simon, and based on erroneous statistical evidence (Papers relating to the Sanitary state of the People of England, 1858), it is stated that "a further — practically speaking, unavoidable — cause of premature death in every civi- lized country is the risk of its current contagions.'''' [The italics are not mine.] And this refers to small pox, hooping cough, " contagion" and " infection" defined. 129 nieasels, and scarlatina, the mortality from which we are to presume, is " unavoidable." If this be Board of Health doctrine, it is certainly not sanitary doctrine. It would have astonished the Health of Towns Commission, and the first Board of Health. "Contagion," as its etymology implies, means the commu- nication 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. SuflBce 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 sup- posed. With regard to the mysterious, imponderable, indivisible nonentities, which make up our " current contagions," they may safely be dismissed into the limbo of extinct superstitions. The word "contagion" therefore is altogether objectionable. The word "infection" expresses a fact, without involving a hypothesis. It is most necessary, however, that the meaning should be guarded ; for, just as there is no such thing as " contagion," there is no such thing as inevitable " infection." Infection acts through the air. Poison the air breathed by individuals and we have infection. Shut up 150 healthy people in a Black Hole of Calcutta, and in twenty-four hours you have an infection produced, so powerful that it will in that time have destroyed nearly the whole of the inmates. Sick people are more sus- ceptible than healthy people ; and if you shut up sick people I 130 " contagion" and " infection" defined. together, without a sufficient space and sufficient fresh air, you will have not only fever, but erysipelas, pyaemia, and the usual tribe of Hospital-generated epidemic diseases produced. Again, if we have a Fever Hospital with over-crowded badly- ventilated wards, or with the air stagnant in them, we are quite certain to have the air become so infected as to poison the blood not only of the sick, so as to augment their mortality, but also of the medical attendants and nurses, so that they shall also become subjects of fever. It will be seen at a glance that, in every such case and in every such example, the infection is not inevitable, but the simple result of gross carelessness and ignorance. In certain Hospitals it has been the custom to set apart wards for what are called "infectious" diseases; but, in reality, there ought to be no diseases considered such. It follows from what has been stated that, with proper sanitary precautions, diseases reputed to be peculiarly " infectious" may be treated in wards among other sick without any danger ; just in the same way as, with proper sanitary precautions, a number of healthy people may be congregated together without becoming subject to the horrors of tlie Black Hole of Calcutta. It is in the highest degree probable that we should never have heard of " infectious" wards, if the other wards of a Hospital had been supplied with sufficient space and air for the sick ; and in too many cases it is to be feared that the pre- sumed " infectious" cases are huddled away into small, ill- lighted, ill-ventilated rooms, a kind of Lazaretto, in fact, where, if they die, they have at least been kept from doing harm to the other sick in Hospital ! It is high time that common sense should deal with the question ; for there does not seem to be much hope for a deli- verance from these superstitions from any other quarter. The "infectious" wards in Military Hospitals correspond, in some sense, to the "casualty" wards in Civil Hospitals, into which accidents, noisy, and erysipelatous cases are trans- ferred, 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 "contagion" and " infection" defined. 131 aud noisy patients out of the Hospital wards, whose inmates they would annoy. The question of infection or non-infection has nothing to do with the arrangement. No stronger con- demnation of any Hospital or ward could be pronounced than the simple fact that any disease has attacked other patients than those first affected by it. " Infection" and incapable management, or bad construction, are, in Hospitals, convertible terms. It may be useful to mention what the meaning is of the words "epidemic," "endemic," "sporadic," and "zymotic." When a large number of people are attacked simultaneously with the same form of disease it is said to be epidemic. When a small number, as, e. g., the inhabitants of a single court or alley, are so attacked, it is said to be endemic. When scattered cases of the same disease happen, one here, one there, over a large surface, the disease is said to be sporadic. The term zymotic, which includes all diseases of the preceding categories and some others, implies the existence of certain changes in the constitution or in the blood, rendering persons so affected liable to the diseases in question. It is a vulgar error to suppose that epidemics are occasioned by the spread of disease, from person to person, by infection or contagion ; for it is an ascertained fact that, before any people is attacked epidemically, the disease attacks individuals in a milder form, one at a time, at distant intervals, for weeks or months before the epidemic appears. Before an epidemic of cholera, these cases consist gene- rally of diarrhoea 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 succes- sion of antecedent phenomena extending over months or yeai's, and all traceable to the culpable neglect of natural laws. It is simply worse than folly, after the penalty has been incurred, 132 NOTE. to cry out " coiitagiou," and call for the establishment of sauitary cordons and quarantine, instead of relying on measures of hygiene. Epidemics are lessons to be profited b}^ : they teach, not that " current contagions" are " inevitable" but that, unless nature's laws be studied and obeyed, she will infallibly step in and vindicate them, sooner or later. In the words of the Eegistrar- General, which are as appli- cable to Armies as to States, " Sanitar}^ measures and not qua- rantines are the real safe-guards of nations." Note . I have just seen a paper by Sir John Hall, entitled " Observations ou the Difficulties experienced by the Medical Department of the Army during the late War in Turkey." In this somewhat singular document, which appears to be a defence of Sir John Hall's own conduct, there are certain statements made about the female nursing establishment in the East whicli require a word of comment. It will be observed that throughout the paper, the weapon which Sir John Hall uses against all civil interference in re- pairing the sufferings which proceeded from the defects of his own department is simply detraction. As for Civil Commissions, they were useless, as for Civil Hospitals, they were costly, and their officers lived magnifi- cently and were extravagantly paid. As for the nurses, they were benevolent, pious, well-intentioned persons, but what could they do ? How could one woman nurse eighty sick ? The medical men thought they could not. Why had Miss Nightingale stores of port wine placed at her disposal, which she could give to the Ereneh Hospitals, while he, the principal Medical Officer of the Army, had no such stores at his disposal ? Sir John Hall must have already discovered that this old weapon is no longer of use in defending his position. It would have been more to the purpose had he produced his requisitions for food, clothing, comforts, &c., and shown how they were refused or not complied with. At the very time I gave over part of our own private stores of port wine^ &c., to NOTE. 133 the French Hospitals (for part only of what was given were Government stores at all), Sir John Hall might have ob- tained, out of the large wine store at Balaklava, any amount of wine he required, by merely asking for it. The simple statement of this fact would have been a better answer to M. Baudens* than assuming that I could obtain from Grovernment stores and wine for the French Hospitals which he could not obtain for his own. As to his statement about the Nurses, it simply shows ignorance of the whole matter. Nobody ever contemplated giving to a Nurse the entire charge of a number of sick in a Military General Hospital. It is no part of good Hospital nursing to do so. With proper Orderlies, a Nurse can very well attend to sixty or seventy sick. We were prevented, indeed, by the authorities, and by circumstances, from organ- izing 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 eiBciency of nursing, by dividing the number of sick by the number of Nurses, is simply absurd. * To M. Baudens, whose recent death is so much to be lamented, 1 cannot here but add a tribute of admiration for his wise and enlightened sanitary views, during the year of his sui)erintendence over the Medical Department of the French army in the East, and of gratitude for his ready and magnanimous acceptance of our stores, when the French sick were really in want of them, after these had been refused by other French authorities. LONDON : PRINTED BY HAURISON AND SONS, ST. martin's lane, W.O. PRIVATE AND CONFIDENTIAL. THOUGHTS SUBMITTED AS TO AN EVENTUAL NURSES' PROVIDENT FUND. I. Wages and Prospects op Nurses. II. Desirability of some further Provision. III. Of what Nature ? 1. With regard to kind? 2. „ persons ? 3. „ objects ? IV. Suggestions as to the Rules to be followed. V. Prospects of Eventual Support. I. Wages and Prospects of Nurses. 1. The nurses of the great London hospitals are divided The two into two classes : head-nurses or sisters, and nurses or Hospital assistant-nurses. These latter are, generally, subdivided Nurses. into day and night-nurses. 2. The head-nurses, on an average, receive about £50 Head-Nurses a-year and no board, or lower wages and partial board ; °^ ®™* the use of one or two rooms, generally unfurnished, and an allowance of fael and light. Sometimes uniform outer- ACTUAL WAGES Nurses or Assistant- Nurses. Day Nurses. Nisrht Nurses. Retiring Pensions and Payments atSt. Bartliolomew's At St. Thomas's. At Guy's Hospital. clothing is included. Sometimes two pints of beer daily are added to tlie above. 3. The day-nurses, on an average/receive about 12s. 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. 4. The night-nurses, on an average, receive about 10*. a- week and no board ; lodging, with the use of some furni- ture ; 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. 5. I am informed that St. Bartholomew's Hospital has no fixed scale of pensions, nor is the term of service de- fined. 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. 6. St. Thomas's Hospital, in like manner, has given, without any fixed rule, pensions to worn-out sisters, of from £30 to £50. A gift in money has been granted on the retirement of a sister; and the same has been done in the case of nurses who may have received injuries in the discharge of their duties ; and in a very few in- stances of long and faithful service they have been pen- sioned. 7. Guy's Hospital for a long time generously provided for its superannuated sisters, but the plan in practice being found very objectionable, was a few years since given up, and the authorities established a Superannuation Fund for the Servants of the Hospital. It is compulsory on sisters, optional to nurses, to belong to it. Each subscriber receives a book containing printed AND PROSPECTS OP NURSES. rules, with tables of rates of ages, payments, and pensions, and also blank leaves. The subscriber selects the amount of pension for which she wishes to subscribe. At each quarterly payment of wages, a proportion is paid into the fimd; entered in the subscriber's book, and pro- perly attested; the hospital makes a pajnnent 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 dis- posable by will, and in case of intestacy reverts to the next of kin. The pensions, one-half of which are thus pur- chased 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 groAv ; secondly, that not a few of the sisters, having looked forward to benefiting by the old system of superannua- tion, rather grudged their own payments than sought to induce their nui'ses to subscribe; thirdly, that many of the nurses were really unable to make the payment. 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 nui'se. 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. 9. Of the wages and prospects of eventual provision of the nurses of the county hospitals I know nothing; but understand that the former arc lower than, and the latter a2 At the Non- Endowed Hospitals. At County Hospitals. DESIRABILITY OP Unfitness of Nurses for any other work. Shortness of their time of capacity for Service. Character of Nurses as a Class. as entirely blank as those of the nurses of the non-endowed London hospitals. II. Desirability of some further Provision. 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 alto- gether pecuUar; she acqmres a knowledge and habits which incapacitate her from all ordinary occupations, grows into fitness for them, and out of fitness for aU. others. 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. 3. In the London hospitals there are some women of ex- cellent character and of great efficiency; many the reverse, in one or both respects ; many between the two classes, who generally end by ranking in the second. 4. To augment the number of the first class, to reduce the number of the second, to induce the intermediate eventually to rank with the first, and not with the second, is the desire of every hospital. 5. It is most important, in all things, in none more than in hospital matters, to moderate expectations, not to hope too much from any measure, or set of measures, and to keep well in view the stern prosaic realities of things. The hospitals of great towns are not asylums where a few SOME FURTHER PROVISION. or many selected patients gan 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 pro^dde^ and the traces of their purpose and nature must ever remain impressed upon them. They are also schools for the practical education of a great profession, important to mankind and dangerous to its members. Hospital nurses are not women attempting or following " counsels of perfection/^ (whatever incorporation of other elements may be eventually effected), but some of those many women whom God has ordained to earn their bread by toil, (and in the large towns of England honest ways of earning that bread are for women but too scarce and too overcrowded), and upon whom He has laid the same condi- tion as on all the souls He has made, to keep the command- ments 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. 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 provi- sion, dependent upon good character, appears very im- portant. 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 workhoixse. 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 dis- Probable beneficial results of a prospect of eventual provision, depending on character. THREE KINDS OF Kinds of possible assistance, three. Pensions. Facilities for Saving. Additions to Savings. gusted at the idea of regularly laying by for their future support, and who would resent strict investigation into character. 9. It would tend to induce the intermediate class of women, who hesitate between good and bad companions, to incline to the former, and to break off from the latter, by the favourable result of provident and economical habits on their actual conduct ; and by the effect which the prospect of a decent support in their age, dependent upon these habits, would produce. III. Or WHAT Nature ? 1. With regard to kind? 2. „ persons? 3. „ objects? 1. With regard to kind. There are three kinds of possible assistance. First. Granting free pensions to efl&cient and well-con- ducted sisters and nurses, under fixed regulations. 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 invest- ment. Third. Combining, with the second, a certain propor- tion of pecuniary aid. As to the first. It would be wise economy if the endowed hospitals, who alone could do it, were to grant such pensions ; but whether they are likely to do more than they do now I am quite ignorant. Whether our labours in this field should take the direction of the second or third, is one of the most diffi- cult questions with reference to a thing which is rife with difficulties. Towards solving it, I submit that it would POSSIBLE ASSISTANCE. be expedient to employ an able and honest man of business to procure — I. The rules, working, and results so far of the Servants^ Provident Society. II. Of several of the various partly self-supporting and partly assisted provident societies of the different trades' and city unions. III. Of some dozen benefit societies in large towns. IV. Of Guy's Hospital Superannuation Fund. V. To take the practical opinion of two experienced actuaries. VI. Also of the Treasurer and Matron of St. Bartholo- mew's ; Of the Treasurer, Resident Medical Officer, and Matron of St. Thomas's ; Of the Treasurer and Matron of Guy's Hospital ; Of the Chairman of the House-Committee, House- Governor, and INIatron of the London Hospital ; Of the equivalent authorities of St. George's, and of two or three other hospitals (including King's College). My impression is that it is not possible, in the majority of cases, for either head-nurses or nurses to purchase annuities out of their savings. I. Their work wears them out comparatively soon. II. During its continuance they require to live well i. e., to have a sufficiency of good plain food. III. They are obliged to put out and pay for cither the whole or nearly the whole of their washing, making, and mending (and most properly obliged) . Thus apart altogether from the consideration that many nurses are widows with families, and many others bur- dened with helpless or infirm relations, and that, in many of these cases, the smallest saving out of their wages is Informatiun and Advice to be procured on the Subject. It is not possible for Nurses to purchase Annuities out of their Savings. 8 TO WHOM IT SHOULD BE EXTENDED. 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.* Persons to be g. With regard to persons. Shall the Fund be open exclusively to nurses belonging to the proposed Institution under Miss Nightingale ? Or extended to those of the London hospitals ? Or extended to all Hospitals in England ? Or in the three kingdoms ? Or in Her Majesty^s dominions in general ? Shall the Fund be extended to private and monthly nurses, including midwives, as well as to hospital-nurses ? I submit that we should consult, on these points, the authorities of the principal hospitals and a few men of experience in business besides. (Philanthropists by trade are, as is well known, the worst possible authorities on subjects of this kind.) My impression is that the Fund should certainly be extended to the three kingdoms. Whether it should be extended to the empire would depend entirely, in ray judgment, upon the check and scrutiny it would be pos- sible to exert, on accounts, monies, and certificates, in distant parts. Upon this men of business should advise. I think the Fund might eventually be open to private nurses, midwives, and monthly nurses.f * If the sisters and nurses, as a rule, were fed as well as lodged at all the Hospitals, &c., the class of women would, in a very short time, be entirely changed ; this kind of employment would not then, with the reduced money payment, be so much an object of desire to widows with families, particularly if compelled to subscribe to a pension fund, which should be compulsory. + At first it would be unwise to attempt too much. If extended to Her Majesty's dominions or private nurses, it would be almost impos- sible to control abuses. OBJECTS TO BE SOUGHT IN GIVING IT. 9 I think it perhaps might be open to the St. John's House nurses and to those of any institution which does not provide its servants with a pension. The Nursing Sisters' Society, I believe, have recently decided on granting their sisters j620 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. 3. With regard to objects. ^^j^"^^. f^ ^« ° "^ sought. Shall the objects be Material ? Sanitary ? Moral? Or shall they be restricted either to the first only or the first and second ? Here, again, I submit that we should consult hospital authorities and a few men of business and of experience, as to the feasibility, often a distinct thing from desirability, of these things. Upon the whole, and weighing many opposite difficulties, my impression is strongly in favour of attempting to com- bine the three. Material objects. The benefit and provident societies embrace many Material 1 . , ... . .,1 , ', Objects to be objects : annuities, payments on illness, payments at sought. burial, provision for children's apprenticeships, provision for children at death, and other things. I. It appears to me that the main if not the only object Provision after of the Fund should be to provide annuities. ^"^™"''' II. It would be a question whether or not to arrange During for payments during illness.* Every now and then \iard ^^^^* * Every institution ought to provide for its nurses during illness, but in fact it is not done. 10 PROVISION OF ANNUITIES. Burial Payments. Payments for Children. Reasons against the last Form of Aid. air gets down the throat of almost every nurse, and every few years or so there is an illness. In many cases a nurse^s pay stops either when or soon after she becomes a patient. Some check upon malingering, a thing well known where the name is not, is essential to every hos- pital. 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 fiu'uishing 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. III. With burial payments I think the Fund should have nothing to do. IV. As to payments for children, whether on apprentice- ship 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. A very large proportion of nurses are mothers, often widows, with large families, whom they support and put to service out of their wages, too often eked out by improper means, i. e., bribes and petty dishonesty. Many of these women are moral, sober, industrious, and doubly anxious to retain their places, on account of their children ; still there arc serious embarrassments in employing them. PAYMENTS FOR CHILDREN UNDESIRABLE. 11 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. Con- sequently when children are in whole or in part lodged, fed, clothed, " educated," and put to service out of the £50 a- year of the head-nurse, or out of the ] 2s. a-weck 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 disho- nesty, 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 l»e presumed to ensue upon, though it often does not precede habits of drink) ; she is or be- comes unguarded, and is soon found out, and sinks into the miserable second and far too numerous class of cha- racterless 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, exceptmg drink; for though, almost without exception, every nurse who drinks takes bribes, some take bribes and do not drink. 12 nurses' children. Of course widows and unmarried women who are not mothers do the abo^'e things ; but there cannot be a doubt of the additional and terrible temptation to women burdened with children, to make money in various ways out of their patients. Even in the most favourable cases (and it is to be feared they are few) where the real good principle of the mother restrains her from venality, there are still serious objections. The time when a nui'se can go out must necessarily be comparatively very limited. The time that is enough for the moderate demands of friendship or acquaintance is miserably insuffi- cient 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 objection- able as regards the children, or the patients, or the hos- pital; and whether it is most" objectionable when the children are young, or adolescent, or grown up. It is objectionable in all and every one of these cases. And no less objectionable is it in the case of the assistant-nurse, who where the rules are lax will receive her children either in the ward or in the nurses^ kitchen ; or where they are strict, will have the children come about the hospital and will meet them on the sly. These things enter immensely, minute as they seem, into the discipline of wards and of the hospital ; and dis- cipline means a great deal. SANITARY AND MORAL OBJECTS. 13 Sanitary objects. A good many nurses enter hospital service who are quite unfit for it. Often consumptive and ruptured women, those suffering from piles or prolapsus, &c., present them- selves, are admitted, struggle on for a time, and break down with or without taking to drink. Undoubtedly, none but strong healthy women should enter hospital service; the work will wear them out quite soon enough, and some of the above complaints are particularly liable to follow the work. Here again men of business must advise : the fund ought to have some efficient though not infallible security as to the average good health on joining of its members. Life Insurance rules as to this would be to the point. Believe me, all these things are important. Sanitary Objects. To discourage admission of women pliysically unfit. Moral objects. The most difficult part of a difficult thing, only perhaps Moral Objects it is at the same time the most important. I. I think that every nurse, before joining the Fund, should produce a certificate from her matron, stating her to be a respectable woman. In plain words, for the word respectable is certainly capable of most wondrous exten- sion, the certificate should state her to be, in the matron's belief, and to the best of her knowledge, a chaste woman, and should specify whether she be spinster, wife, or widow. In either of the latter cases, the marriage certificate, and in the last that of the husband's death, should accompany the matron's. The matron's certificate should, I consider, also state her to be sober ; and it would be a question whether it should not also state her to have served for not less than attainable. Need of Certificates. 14 CERTIFICATES OP a year in the hospital. The vagabond class are a terrible drag upon the whole order ; and some of these might, from the novelty of the thing, be disposed to join it at first. II. An important question would be : Should the matron's certificate be renewed every year, and should the continuance of the nurse's membership depend on its pro- duction? Men of business must advise as to this : I am quite unversed as to the details of Provident Societies. So far as regards the contributor's own money, the contract once entered into, must certainly be open to no further question ; unless there has been fraud in the pre- liminary statement on w^hich it was based. With regard to any assistance that may be given the question is different. III. The preliminary certificate I do consider very important, and the subsequent ones, if they can be re- quired. Hospitals are Until the hospitals are swept of the many mothers who not places for , . i -i i i /• t • j_i ^ Penitents. ^^^ not wives, now unhappily to be louncl m them, no real good can be done. Hospitals are not, and never can be, places for " penitents ;" and they are about the most dan- gerous places where sham penitents can be. This is precisely what so many people of very different kinds cannot or will not see ; some from ignorance, some from knowledge, some from the vague, silly, kind feeling which does such mischief when exerted on practical matters. Suffer me to submit, without wearying patience by urging proof, — i. That real penitents are wrongly placed in hospital service, because their admission breaks down the standard which respectable women who are hospital nurses feel (quite as keenly as their superiors do in their own concerns) ought at once to restrain and to protect those engaged in this very peculiar, very trying, and very exposed work and GOOD CHARACTER. 15 life. (I have invariably observed that real penitents are extra-prudish, and comparatively inefficient, in their hos- pital duty. It will at once be perceived how inevitable this result is.) ii. That sincere but unconfirmed penitents, in addition to the above, are most dangerously and improperly placed in a situation, to them, of very peculiar trial. iii. That sham penitents, who unhappily abound, are dangerous everywhere, extra-dangerous in hospitals, whether to superiors, companions, or patients. iv. That although the class must ever be a very mixed one, it is most important to have a standard. Let it be necessary for every nurse to enter hospital with a good character, and to leave it on losing it. Deception, hypo- crisy, and successful guilt will be found in hospitals, as elsewhere ; but the class must be raised, and therefore improved, by requiring the condition of good character ; though guilt may occasionally mask itself behind it. V. That although, for various and very differing reasons, the certificates will be not unseldom untrustworthy, still the same reasoning will apply. Upon the wliole the ten- dency will be, by requiring the condition of good cha- racter, to improve a class which, containing, as it does, many well-conducted women, is sadly degraded and con- taminated by many vile ones. vi. I do not overlook the fact that honest certificates, especially if annually renewed, might give the matrons some perplexity, from reasons which need not be enlarged upon. Still, it seems to me, it would be well worth trying. . IV. Rules to be followed in giving Assistance. Lastly. With regard to rules to be followed in giving assistance of whatever kind. 16 SUGGESTIONS IN DETAIL Need of Advice It seems to me most important that we should with a view i • i • • ^ ^ r ■, -1 1 . • above all to obtain the opinions both oi hospital authorities and of a ecun y. ^^^ ^^^q ^en 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. Suggestions in The following suggestions toward obtaining it are offered. 1. Security of invested savings to be the first and main thing to be secured. Every other object should be subor- dinate to this. 2. If we decide upon aiding their savings, let the security of this aid be the main point. Invest all donations, annual or not; unless, should any hospitals contribute annually, it might be fairly considered that those contri- butions should be annually used. 3. The aim should be to enable all hospital nurses, of good character, to provide annuities for themselves, whether with or without assistance. I think assistance will be necessary. 4. Also to enable private and monthly nurses, and mid- wives, to do the same, but without requiring the certificate of character, which, not to be a mockery, ought to be an effectual one ; and these persons are not under a fixed superior. 5. The pensions should, if it be possible, range from £13 or £15 a-year to £50 a-year : say £13, £20, £30, £40, £50. 6. Each hospital nurse to produce, before being allowed to join the Eund, 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 FOR REGULATIONS. 17 in one hospital not less than a year. Also her mai'riage certificate^ if a wife, and, if a widow, that and the certifi- cate of her husband's death. In the event of her marriage or re-marriage afterwards, the marriage-certificate to be produced, and her altered name and the fact of her marriage duly recorded in the Fund-book. (All this is important : aliases and fictitious marriages are sadly common, in this class). 7. If possible the certificate to be produced once a-year, and, on its failure, the contributor to cease to have a title to assistance. Assistance in the form of an addition to the annuity may be made contingent ; the annuity which the premiums provide must be absolute : most of the vices tend to shorten life, that is, to diminish the number of annual payments, so that the fund would not be likely to incur losses through them. 8. Private and monthly nurses, and midwives, to produce, before being allowed to join the Fund, a certi- ficate 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 Fucd. I should not attempt an annual certificate for this migratory and '^ independent" class. 9. Each nurse, before being allowed to join the Fund, to undergo whatever examination is undergone by women before they are allowed to effect Life Insurances, as to her being, at the date of joining, a healthy woman. (Physicians ought to advise here as to inserting provi- sions technical enough to be eff'ective) . 10. Payments to be made weekly, monthly, quarterly, or annually, as shall be advised. Amounts to run from B 18 PROBABILITY OF 6d. or Is. a week upwards. For the plan to work, it ought to allow small payments on an ascending scale. Many will only be able to make very small payments. Few will be able to make other than small payments. 1 1 . Payments made by a subscriber dying before attain- ing pension to be devisable by will, and in case of intes- tacy, divided among next of kin. 12. All possible safe curtailment of office expenses. 13. Treasurers, or equivalent civil chiefs, of all hospitals that subscribe, to be on the committee or council, or by whatever name the equivalent may be termed. V. Prospects of eventual Support. Support by the 1. I believe that many head-nurses would thoroughly themselves, appreciate and thankfully avail themselves of such a Fund. 2. I think that many nurses would do the same, and, in time, many more. Many cannot contribute to it ; many will not. Support from 3. What aid the hospitals might be disposed to give I the Hospitals. tii-i n -to i i • do not know. 1 rather think none at nrst. It the thing works and works well, I think they would probably contri- bute. But it must never be forgotten that, excepting the endowed hospitals (the financial position of St. George's I do not know) the London hospitals find their income scarcely sufficient, often not sufficient, to meet their expenditure. They cannot be expected, nor would they perhaps be justified, to curtail the number of the sick they relieve, in order to provide for the superannuated nurses of those sick. It is true, however, that it might enable them to get better nurses, which is surely economy. Support from 4. I do not think that much lasting public interest is the Public in , . , , . , , i i t-i i mi • i i i • , general. hkely to attend the Fund. The interest the public has, EVENTUAL SUPPORT AND SUCCESS. 19 for the last few years, taken in hospitals has been fictitious and almost mischievous. The public can never really know what hospitals are, nor is it feasible or desirable that it should. What eventual good may be done in them must be done quietly and with great patience. What good may be done among the nurses must be done by infusing, if it may be, a higher and truer spirit of duty, by increased discipline and protection, and by ameliorating, in some material points, among which the aim contem- plated by the Fund ranks very high, a condition which, to the end of time, must remain severe, rough, dan- gerous, 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 inten- tions, will only be an obstacle, and John Bull is sadly prone to pull up anything he plants or anything he waters, to see how it grows. I think anything like appeals to or solicited support from the public might, in various ways, seriously embarrass the Superintendent of a very difficult and a very important though, at the same time, a very humble branch of Her Majesty^s Service. I should be very anxious to avoid this : it would be perpetuating the evils of publicity, and sacri- ficing the greater good for the lesser, 5. In conclusion I again submit that it would be desirable Necessity of to ascertain from the hospital authorities above men- "vice, tioned, 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 disci- phne we should probably rely on other judgment ; but these are matters of business; and in which, without binding ourselves to follow, it seems most important to obtain and to weigh, the opinions of men long conversant with business. January 23, 1858. . b 2 20 Note as to the Number of Women employed as Nurses in Great Britain. To show the importance of an Institute for Nurses, it must be stated that 25,466 were returned, at the census of 1851, as nurses by profession, exclusive of 39,139 nurses in domestic service,* and 3,882 midwives. The numbers of different ages are shown in table A, and in table B their distribution over Great Britain. To increase the efficiency of this class, and to make as many of them as possible the disciples of the true doctrines of health, would be a great national work. * 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 semce, are between 5 and 20 years of age. TABLES OF AGE AND DISTRIBUTION. 21 -3 » 3 S 3 S 1 OT °* i t~ 1-1 1 !0 SI o» 1 CI <^' CO "-^ I 1 o CI =o CO 03 CO 1-1 1 1! i i 1 CO CO o i r-1 CI X CI CO 5! i o 3 i ■ o i 1 : => 5| in" o» C) CO iz; a) ^ ^ a a 1 i 1 Q PS PL, P Q o H O tn PS W •S3IBAV pUB miaoranoj\[ ■uoisuidq^n CO ^ ■sax^tmoQ uiaq^JOfi •noisui(XH'»oi S 3 •aitqs^jox •aoisiAiQ q}6 ■* CO s i sai^unoQ uja}S3jV\ illJOXE •UOISIAIQ ms s 1 ■saijimoo pnEipijn ■noisiAi(j i[ii 1 '^ •ssnuuoj puBipiiv ^3aAV •[io!sui(T mg d< c> •sat}uno3 naa}S3jV^ mnos •notsiAiq' Tiig .O CO saiiunoo u.ia^sB'j^ •uoisiAig mt o S ^ » ■pUBIpipV qjnos •iioisiAid pag to CI 00 lO •nJajsBj q^nos ■UOISIAIQ pug CO 'ii uopuofj UOISIAIQ }«I 1 § •SB3S qsijijg aqi nr' SpUV![SX CJ o •puBHoas CO ex •sajB^vi pUR puBiSuj l~. OS CO ac? ■SBas qsijufi aq; ui spuEisi pu« niBjug luaiQ to t- Kurse (not Domestic Servant) Nurse (Domestic Servant) ... 22 Note as to teaching Nursing. There is, at Madras, an Institution called the Military Female Orphan Asylum, which trains 200 orphan girls, daughters of European soldiers. They enter in infancy, and, as they attain a proper age, they are married to soldiers or others. There is always an abundance of appli- cants for them, and every endeavour is made to train them to be useful soldiers' wives. Dr. MacPherson, the excel- lent Principal Medical Ofl&cer of the Turkish Contingent, when at Kertch, who is now in charge of this Asylum, was the person, I believe, who introduced amongst the senior girls, a system of training, to enable them to officiate as nurses, an all-important element in their education. Below is a syllabus of the theoretical branches taught, a practical knowledge being acquired in the Hospital attached to the Institution. It would be well if all women underwent a similar training. Course of Instruction for the Class of Sick Nurses, at the Military Female Orphan Asylum. Popular and Regional Anatomy and Physiology. A general knowledge of the human body, its various organs, and their uses. Sanitation. To be made acquainted with every subject relating to health, viz. : Food — Exercise — Clothing — Cleanliness — Ventilation, &c. Sick-room Management. Administration of Medicines, Application of Leeches, Lotions, Fomentations, &c. Cleanliness, Darkening of INSTRUCTION IN NURSING. 23 the Apartment, Quietness, &c. Cooking for the Sick. Diet for Infants. Household Medicine and Surgery. To be taught how to act in emergencies, viz. : in cases of Fainting — Hysterics — Convulsions of Children — Burns — Stings of Insects — Wounds, &c.; and the simplest mode of treating the diseases most commonly met with in India, viz. : External Inflammation, Cholera, Fever, Dysentery, Sore Eyes, Bowel Complaints, Cutaneous Eruptions. How to prepare Poultices, Fomentations, and Lotions. „ dress Wounds, Sores, and Blisters. „ apply Bandages. w-