Workhouse Nursing - The story of a successful experiment

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Title: Workhouse Nursing - The story of a successful experiment
Author: Nightingale, Florence
Language: English
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WORKHOUSE NURSING:

THE STORY OF A SUCCESSFUL EXPERIMENT.

_London:_
MACMILLAN AND CO.
1867.

The accompanying account of the Improvements introduced by the Select
Vestry of Liverpool into the Workhouse Hospital Wards under their
control, may perhaps be interesting to you, and possibly might prove
suggestive and serviceable, if similar improvements should be required
in your district.

As the time and strength of the Lady Superintendent of the Nurses
employed in the Workhouse Hospital are very fully occupied, enquiries or
requests for further information should not be addressed to her, but to
the Chairman of the Workhouse Committee of the Select Vestry (and of the
Hospital Sub-Committee),

T. H. SATCHELL, Esq.
_48, Lord Street_,
Liverpool;

_Or_,

H. J. HAGGER, Esq.
_Parish Offices_,
Liverpool.

WORKHOUSE NURSING:
_THE STORY OF A SUCCESSFUL EXPERIMENT._

The following pages contain a brief account of the experiment
successfully tried by the Select Vestry of Liverpool (the guardians of
the poor)—the introduction of trained Nurses into the male wards of the
Workhouse Infirmary. That experiment having resulted so successfully as
to induce the Vestry to extend the system to the remainder of the
infirmary, it may be interesting to those who are concerned in the
management of workhouses elsewhere to learn something of its history and
progress. It is the writer’s object to explain—

1. The grounds on which the Vestry were led to undertake the experiment,
as stated in the preliminary report of Mr. Carr, the governor, and that
of the sub-committee of the Vestry appointed to consider the proposed
scheme; and the replies received to inquiries addressed by them to
institutions and persons connected with the training and employment of
skilled nurses in London and Liverpool, with letters on the subject from
Miss Nightingale and Sir John M^cNeill.

2. The results of the experiment, so far as hitherto ascertained.

The Liverpool Vestry had previously made considerable efforts to improve
the workhouse infirmaries. The medical men had been encouraged to make
requisition for every material appliance that could facilitate the cure
of the sick; and paid female officers were appointed at the rate of one
to each 150 or 200 beds, to superintend the giving of medicines and
stimulants, and so forth: but of course so small a number, even had they
been trained nurses, could do no real nursing, and could exercise little
supervision over the twenty drunken or unreliable[1] pauper nurses who
were under the nominal direction of each paid officer. An appeal was
made to the Vestry to consummate the good work they had thus partially
commenced, and it was urged that Liverpool should assume the lead in the
task of workhouse reform. The following considerations were submitted to
the Select Vestry:—

“That Liverpool could commence this movement with great effect, and
with the certainty that her example would be widely followed.

“That she had in times past taken a leading part in such reform. The
introduction of the New Poor Law produced little change in Liverpool;
so many of its wisest provisions were already in operation there, some
of them for twenty or thirty years.

“That she had already established a system of attention to the sick
poor in their own houses, which, if only by restoring heads of
families to health and work, saved the parish many times the sum that
it cost to private benevolence.

“That, lastly and especially, the proposed reform ought to commence in
Liverpool, because in her workhouse the guardians had already, by
their liberality, provided the sick with everything in the shape of
diet and medical comforts that could conduce to recovery; and what was
now wanting to give effect to their wise benevolence was, that their
system should be administered and their intentions carried out by
efficient and reliable nurses, in the stead of unreliable paupers.”

The appeal further urged that—

“Successful efforts have been made in many directions to improve the
nursing of the sick, and the workhouses must soon be the object of
similar endeavours. Those poor sufferers whose disease is protracted
and hopeless are refused admission into ordinary hospitals, and must
come to the workhouse; and the mere duration of the illness is in such
cases sufficient to reduce to poverty the most industrious, careful,
and temperate—men who, while they could work, paid regularly their
contribution to the poor-rate. Surely, these are entitled to at least
as great care as that which sickness at once assures to the imprisoned
felon, however criminal, for whom well-paid nurses are provided by the
State.

“As to the other class of inmates of the workhouse infirmary—those
whose ailments are curable—mere economy requires that the most
efficient means should be taken to cure them as speedily as possible,
so as to preserve them and their families from becoming paupers.

“Thus justice and expediency alike counsel the introduction into the
workhouse of the best known system of nursing. Probably nothing which
the skill and kindness of medical men can do, no food or physical
appliances which the guardians can supply, no oversight or care which
they, acting through pauper nurses, can bring to bear, are wanting in
the Liverpool workhouse; but it is to be feared that much of this
care, liberality, and thought fails of its object for want of a
sufficient number of reliable and duly qualified nurses to carry out
the instructions given, to administer food and medicine to the
patients, to dress their wounds, and so forth.”

This appeal was supported by two letters of Miss Nightingale and Sir
John M^cNeill, G.C.B., President of the Board of Supervision (the Scotch
Poor Law Board).

_Letter from_ Miss Nightingale.

115, Park Street, W.
_February 5, 1864._

My dear Sir,

I will not delay another day expressing how much I admire, and how
deeply I sympathize with the Workhouse plan.

First let me say that Workhouse sick and Workhouse Infirmaries
require quite as much care as (I had almost said more than)
Hospital sick. There is an even greater work to be accomplished in
Workhouse Infirmaries than in Hospitals.

In days long ago, when I visited in one of the largest London
Workhouse Infirmaries, I became fully convinced of this.

How gladly would I have become the Matron of a Workhouse.

But of a Visitor’s visit, the only result is to break the
Visitor’s heart. She sees how much could be done and cannot do it.

Liverpool is of all places the one to try this great Reform in.
Its example is sure to be followed. It has an admirable body of
Guardians; it is a thorough practical people; it has, or soon will
have again, money.

Lord Russell once said (what is quite true), that the Poor Law was
never meant to supersede private charity.

But whatever may be the difficulties about Pauperism, in two
things most people agree—viz. that Workhouse sick ought to have
the best practical nursing, as well as Hospital sick—and that a
good wise Matron may save many of these from life-long pauperism,
by first nursing them well, and then rousing them to exertion, and
helping them to employment.

In such a scheme as is wisely proposed, there would be four
elements.

1. The Guardians, one of whose functions is to check pauperism.
They could not be expected to incur greater cost than at present,
_unless_ it is proved that it cures or saves life.

2. The Visiting or Managing Committee of the Guardians, whose
authority must not (and need not) in any way be interfered with.

3. The Governor, the Medical Officer, and Chaplain.

4. (And under the Governor) the proposed Superintendent of Nurses
and her nursing staff.

There is no reason why all these parts of the machine should not
work together.

The funds are provided to pay the extra nursing for a time.

The difficulty is to find the Lady to govern it.

When appointed, she must be authorized—indeed appointed—by the
Guardians. She must be their Officer; and must be invested by the
Governor with authority to superintend her Nurses in conformity
with regulations to be agreed upon.

So far, I see no more difficulty than there was in settling our
relations as Nurses to the government officials in the Crimean
War.

The cases are somewhat similar.

As to the funds, it is just possible that eventually the Guardians
might take all the cost on themselves, as soon as they saw the
great advantages and economy of good nursing.

If Liverpool succeeds, the system is quite sure to extend itself.

The Fever Hospital is one of the Workhouse Infirmaries. That is
the place to shew what skilful nursing can do. The patients are
not all paupers. How many families might be rescued from pauperism
by saving the lives of their heads, and by helping the
hard-working to more speedy convalescence!

Hopefully yours,
(Signed) FLORENCE NIGHTINGALE.

_Extract from a letter from the_ Right Honourable Sir John M^cNeill,
G.C.B., _dated Granton House, Edinburgh, 28th Feb., 1864_.

There can be no doubt, I think, that it would be a mistake to have
pauper nurses mixed up with paid nurses, and I think I expressed
that opinion when we conversed about those things. Paupers might,
however, be employed to scrub and to do other menial work, under
the orders of the paid nurses. If the paid nurses are to do much
good they must have a recognised authority in their wards. Without
authority there cannot be due responsibility, and things must get
into confusion. A nurse carrying out the instructions of the
medical officer must have authority to do so, and resistance to
that authority must be treated as a breach of discipline.

To put this upon a right footing from the first, would be
indispensable to success. The more a nurse does by influence, and
kindly influence, the better; but dealing with the promiscuous
inmates of a workhouse, the knowledge that there is authority in
reserve to be exercised if necessary, prevents the necessity of
resorting to it, and makes the patients duly appreciate the
kindness which keeps it in reserve.

With regard to all such matters, a great deal will depend upon the
good-will, the good sense, and good feeling of the Governor and
Matron, but especially of the Governor. He can do much to promote
or to mar the success of the experiment, and so can the medical
men; but if they be men of sense and right feeling, they cannot
fail to perceive how vast an addition to their own comfort the
permanent establishment of such a system as you propose to
introduce experimentally, must produce.

The position of a medical man dependent for the execution of his
instructions upon nurses who are neither intelligent nor
trustworthy, is very painful, and tends to deteriorate his own
character, both as a man and as a practitioner, by rendering him
callous to preventible suffering which he is denied the proper
means of relieving, and by compelling him to forego the use of
remedies which require intelligence and conscientious care in
administering them. The house Governor, if he be a conscientious
man, must be kept in continual anxiety about the conduct of
ignorant, and often worthless pauper nurses in the hospital, and
is driven at length to be satisfied with a low moral and
intellectual standard in the nurses, and a corresponding standard
of care and comfort in the hospital.

The Select Vestry took the subject into their serious consideration,
and instituted most careful inquiries in various quarters. Among
other steps, they called for a report on the probable operation of
the proposed system from Mr. Carr, the Governor of the Workhouse.
That report ran as follows:—

_Extract from the Journal of the Governor of the Workhouse._

Liverpool, Thursday, _April 14, 1864_.

In compliance with the instructions of the Workhouse Committee, I
have carefully considered the proposal made to the Committee by a
Liverpool gentleman, on the subject of nursing the sick in the
Workhouse Hospital, and beg in reference thereto to report—

That, practically, the proposal amounts to this—that there shall
not be any pauper nurses in the hospital, but that there shall be
appointed in lieu a staff of duly qualified paid nurses and
servants, with a head superintendent, under whom the whole of the
nursing of the sick shall be conducted on the best known
principles.

This proposal rests its claim to favourable consideration on the
presumption that the present system of nursing the sick in the
Workhouse Hospital is defective. The Committee are aware what that
system is. It may thus be briefly stated. Certain wards of the
workhouse are set apart as hospital wards. They do not form an
hospital worked as a whole, but are divided into five portions,
each forming a distinct set of wards, in close proximity to the
wards of the healthy paupers, and in five different parts of the
workhouse. These five sets of wards I shall call the Workhouse
Hospital. The hospital is divided into eleven sections. At the
head of each section there is an intelligent paid superintendent
nurse, and under each such superintendent nurse there is placed a
staff of pauper nurses, with the aid of whom she is required to
work her division, according to certain rules and regulations made
and provided for that purpose. A copy of these rules is appended
hereto; from which it will be seen that the burden of the
responsibility of carrying out the orders of the medical officers,
devolves upon the head nurses or superintendents of divisions. The
pauper nurses clean up the wards, carry the food, and give general
assistance to the superintendent—the duties of nursing in detail,
that is to say, the bedside nursing, falling chiefly upon them.
They are not permitted, however, to serve any patient with
stimulants, beer, porter, or medicines requiring exactness or
care; all such duties are discharged by the superintendent nurse.
The proposal now made to the Committee, means that the paid staff
shall be increased, so that the sick shall be cared for by
responsible officers only, and not left, even partially, to the
care of pauper nurses.

There is no doubt that pauper nurses are unreliable, inefficient,
and many of them very worthless; and it is only by careful
watching, and the utmost stringency of regulations, that they can
be made serviceable in the hospital. No stringency of regulations,
however, could guard against the most flagrant abuses, if these
women were employed to discharge duties of trust, such as serving
out the stimulants, &c. so that their services in attending upon
the sick are limited and common-place. There is therefore, in my
mind, no doubt, and I cannot see how any doubt can exist, that to
remove these women, and appoint in their places women of
character, trained as nurses, will tend to improve the position of
the sick, and more rapidly restore many of them to health.

To displace these pauper women, however, involves a complete
change in all the hospital arrangements, and suggests the
difficulty of finding and keeping up a supply of suitable nurses
to undertake the work at, as it would no doubt often happen, short
notice. The Committee are aware, too, that owing to the fact that
the paupers have hitherto been required to attend upon the sick,
the accommodation for paid officers is very limited, and that the
adoption of the proposal would render it necessary at once to
provide additional rooms for the additional staff. The Committee
are also aware that the Workhouse Hospital differs from other
hospitals in this—that it forms a part only of a mixed
establishment, and that there are great difficulties to be
overcome in completely cutting off every connexion or species of
intercourse between the hospital departments and the healthy
inmates, without which the scheme under consideration could hardly
succeed. If any good is to result from the adoption of this
proposal, the sick should be placed absolutely and entirely in the
hands of a paid staff, without the assistance, in any form, of any
one of the pauper inmates. Cut off the hospital department from
the healthy wards; and do not, under any pretext, suffer
communication between the sick and the healthy, and you strike at
the root of every species of workhouse abuse; but if, under any
pretext, you suffer a large number of healthy paupers to pass
daily into the sick departments, as they now do, the adoption of
the proposal will effect little good.

But the question has to be still further investigated on the
ground of expense; and it has to be decided the number, pay,
allowances, and accommodation of the necessary staff to work it
out. Now, although I entertain very strong opinions as to the
undesirability of employing paupers to discharge responsible
duties of any kind, because to do so destroys the value of the
workhouse test, and tends to reconcile them to pauperism; and
although I view the particular work of nurse-tending as the very
worst kind of work for paupers, inasmuch as, while so employed,
they are better fed, have more freedom of action than they
otherwise would, and can make their places emolumental—thereby
holding out a positive inducement to pauperism; and although I
have no doubt that the displacement of these women would be
followed by the immediate application for discharges by a large
per-centage of them; and although, at this moment, many other
weighty considerations press upon me in favour of the immediate
adoption of the proposal under consideration, I feel unwilling, in
view of the difficulties to be overcome, some of which I have
indicated, to incur the weighty responsibility of recommending
such a course on my own unaided judgment. I have abstained,
therefore, from taking up the question of expense, &c. but take
the liberty respectfully to suggest, that a sub-committee be
appointed to report upon the whole question in all its details. It
shall be my anxious desire and pleasure to assist the labours of
such sub-committee by every means in my power.

According to the recommendation of Mr. Carr, a Sub-Committee was
appointed, consisting of men of great experience in parochial
business, who went up to London, and had interviews with the medical
and other officers of the two metropolitan hospitals where nursing
has been brought to the greatest perfection—St. Thomas’s and King’s
College Hospitals. Finding that some of these gentlemen wished for
more information respecting the Workhouse Hospital system before
they would venture to express decided opinions as to the economical
results of the proposed reform, the Liverpool Visitors drew up a
statement on several points affecting this question, with written
inquiries, to which answers were returned, verbally or in writing,
by the gentlemen consulted. This statement, with the replies which
it elicited, is here given at length:—[2]

STATEMENT AND QUESTIONS OF THE LIVERPOOL SUB-COMMITTEE.

The population of the Parish of Liverpool is about 270,000.

The expenditure from the poor’s-rate in and about the relief of
the poor is about 100,000_l_. per annum.

Of this about 40,000_l_. is distributed in out-door relief as
money and bread. (Of course sickness is one great cause of persons
seeking relief, though to what extent this cause operates, even
directly, I cannot on so short a notice ascertain or even
estimate.)

The expenses (direct) of treating the out-door sick are:—

Salaries of Medical Officers, &c. £1,800
Medicines, &c. 1,378
£3,178

The cost of maintaining the Workhouse Hospital may be estimated as
follows:—

Maintenance of Patients £9,700
Salaries of Medical Officers 485
Medicines, &c. 1,050
£11,235

The Hospital contains accommodation for over 1,000 patients, and
has often 1,000 in it. The cases at present are:—

Medical 485
Surgical 345
Fever 120
Smallpox 20

The weekly discharges are from twenty to thirty per cent. of the
whole number in the hospital.[3]

The present workhouse staff consists of fourteen paid officers
(who are superintendents, but not trained nurses), and about 150
paupers acting as nurses, but not paid. It has been proposed to
add a trained hospital matron and trained nurses, such as those
trained in the Nightingale School, and assistant nurses, so as to
give one trained day-nurse and one paid assistant to about every
three pauper nurses, and a trained night-nurse on every flat; it
is further proposed to pay the paupers who act as nurses, wages.
The cost of this would be about 2,000_l_. per annum.

Does your experience of hospitals lead you to believe that the
cost of this improved system would be “in part,” “wholly,” or
“more than” repaid to the ratepayers by curing people more
quickly, by curing those who otherwise might have become chronic
cases, and by enabling those to resume their work who must
otherwise have remained or died, and by thus diminishing the
duration or amount of that part of pauperism which is the result
of sickness?

REPLIES OF PHYSICIANS, &c. OF ST. THOMAS’S HOSPITAL.

1. _Reply of_ R. H. Goolden, Esq., M.D.

“I have no doubt but that the plan suggested, if properly carried
out, would be in the end a saving to the ratepayers, the restoration
to health relieving the parish of constant burdens.”

2. _Reply of_ John Simon, Esq.

“I do not feel myself competent to measure at all exactly what might
be the pecuniary result of the proposed system. But in my opinion
the substitution of skilled for unskilled attendance would be of
great advantage to the sick, and would of course tend to diminish
that part of the pauperism which results from sickness.”

3. _Reply of_ Sydney Jones, Esq., M.B.

“In my opinion the improved system of nursing recommended would
amply repay the expense incurred.”

4. _Reply of_ J. S. Bristowe, Esq., M.D.

“I believe that the introduction of paid nurses into the Liverpool
Workhouse Infirmary would be of inestimable benefit to the sick poor
received into the institution, and would thus amply justify the
expense which it is proposed to incur. I also think it very probable
that the cost of nursing would be repaid in many other ways to the
ratepayers.”

5. _Reply of_ Edward Clapton, Esq., M.D.

“I believe it would be quite repaid.”

REPLIES FROM THE PHYSICIANS, &c. OF KING’S COLLEGE HOSPITAL.

1. _Reply of_ Henry Smith, Esq. _Assistant Surgeon_.

“I believe, from a long experience of hospitals and other
institutions, that the cost of an improved system of nursing as
proposed for the Liverpool Workhouse Hospital would certainly be ‘in
part’ repaid by restoring the patients to health more quickly.”

2. _Copy of a Letter from_ Miss Jones, _Lady Superintendent of St.
John’s House Nursing Schools, and Matron of King’s College
Hospital_.

King’s College Hospital, _May 4, 1864_.

Dear Sir,

The inclosed paper was sent to me yesterday, with the request that
I would obtain from some of the medical staff of this Hospital
answers to the question proposed at the end of the paper, in order
to enable the Vestry in some degree to judge whether that body
would be justified, or otherwise, in sanctioning the introduction
to their Workhouse Hospital of an improved system of nursing the
sick, at the probable annual money cost named in the inclosed
paper.

I have accordingly submitted the paper to as many of the medical
staff as I could see in the short time.

I inclose a note from Mr. Henry Smith, one of the surgeons, who
has had considerable experience as to the loss and gain of good
and bad nursing.

Dr. Wm. O. Priestly, the Physician Accoucheur to this Hospital,
formerly of Middlesex Hospital, had not time during his visit to
do more than read the paper and give me a verbal answer. He said,
“I have no hesitation in saying that the saving would be certain
and great.”

The Assistant Physician Accoucheur, who has until last week had
charge of the medical patients here, as House Physician (Mr. H. L.
Kempthorne), says, “The value of trained efficient nursing cannot
be overrated in the management of acute diseases, and especially
fevers, and would speak for itself in the saving of life, humanly
speaking.

“In chronic cases, the eye of the trained nurse would soon detect
the malingerer, and thus save the parish the expense of
maintaining one who could well keep himself.

“In the prevention and amelioration of disease this plan would
soon show its importance in the effects of cleanliness,
ventilation, and other points carried out systematically and
intelligently.

“The moral influence of the trained nurses by precept and example
must in time diffuse itself through the medium of the pauper
nurses to the paupers in hospital, the workhouse, and thence to
the parish at large.”

I regret my inability to obtain fuller testimony to-day, but
professional men are busy, and their visits to the hospital only
on stated days.

If I can be of further use in any way, pray command me.

I am, Sir,
Very faithfully yours,
(Signed) M. J.
_Superintendent of St. John’s._

After collecting and considering all the information within their
reach, the Sub-Committee reported as follows:—

The Sub-Committee appointed on the 14th ultimo to consider and
report as to a suggested alteration in the Staff of the Workhouse
Hospital, report,

That the superiority, as nurses, of trained, experienced, and
responsible women to the pauper women upon whom, under the present
system, the actual nursing of the sick inmates of the workhouse
devolves, is so apparent, that they conceive it to be unnecessary
to offer any further observations upon this part of the subject.
The points which have mainly occupied your Committee’s attention
are the following:—

1. The cost of introducing a staff of trained nurses into the
Workhouse Hospital, or any portion thereof.
2. The practicability of providing sufficient accommodation in the
Workhouse for such an increase of officers.
3. The supply of trained nurses.

1. Your Committee are of opinion that the substitution throughout
the Workhouse Hospital of trained nurses, for the present pauper
nurses, would involve a direct expenditure of from 2,000_l._ to
2,500_l._ per annum. Should it be decided, in the first instance, to
introduce the nurses into the male hospital only, it is probable
that a sum of 800_l._ per annum would be found sufficient for the
purpose. Evidence has been laid before the Committee to show that in
those hospitals where the improved system of nursing has been
introduced, the increased cost thereof has been more than
compensated for by the saving, from the reduction of the time during
which the patients are under treatment—the effect, as is alleged, of
good and efficient nursing. Whilst your Committee admit the force of
the argument, that if this be so in the case of hospitals, where the
sick only are burdens upon the funds of the institution, much more
must it be so in the case of the parish, where, as often happens,
the whole family are chargeable upon the rates in consequence of the
sickness of its head; they think it necessary to point out that one
great difference between the workhouse hospital and an ordinary
infirmary consists in this, that while in the latter (as a rule)
none but acute and supposed curable cases are admitted, the former
is, in many cases, the refuge of those who, as incurables, cannot
gain admittance to other asylums. There can, however, be no doubt
that the saving resulting from the rapidity and completeness of the
cures effected by good nursing, will be a considerable set-off
against the increased cost of the nursing staff; though your
Committee can offer no decided opinion as to the probable extent of
the saving so effected.

2. Your Committee believe that accommodation equal at least, if not
superior, to that afforded to the nurses in the London hospitals,
can be provided in the Workhouse at a moderate outlay. It is
estimated that, for the male hospital, a sum of from 400_l._ to
500_l._ would suffice to provide the rooms and to furnish them.

3. With reference to the supply of suitable nurses, your Committee
have to report that, as the authorities of the Nightingale Training
School for nurses have offered to render to the Select Vestry all
the assistance in their power in obtaining trained nurses, no great
difficulty on this point need be apprehended.

Were your Committee as sanguine as some of the hospital authorities
whom they have consulted, as to the happy results to be expected
from the introduction of trained nurses into the Workhouse, they
would at once, with the utmost confidence, recommend that the whole
of the hospital should, at the cost of the parish, be supplied with
this class of officers; but, looking upon it as they do, as an
experiment (at least in its economical results), they unanimously
recommend that the system should, in the first instance, be tried in
the male hospital.

J. W. CROPPER, _Chairman_.

_May 5, 1864._

The report of the Sub-Committee met with the approval of the Vestry.
Some delay in the adoption of its recommendations was caused by a
severe outbreak of fever in the town, which for the time absorbed
all the resources of the Vestry and its officers. But on the 18th of
May, 1865, a Lady Superintendent who had received a thorough
training at Kaiserswerth and St. Thomas’s, twelve Nightingale nurses
from St. Thomas’s, eighteen probationers, and fifty-two of the old
pauper nurses were placed in charge of the patients in the male
wards of the Workhouse Infirmary. By the judicious management of Mr.
Carr, the most admirable arrangements were made for the
accommodation of the nurses. Each superior nurse had a little room
to herself, and the ex-pauper nurses were entirely separated from
the other inmates of the Workhouse. It was hoped that by taking the
best of the able-bodied inmates, separating them from the other
paupers, and paying them small wages (say 5_l._ a year) they might
be made available as assistant nurses, and that many of them might
be elevated into independence and usefulness. It will be seen from
the foregoing report of the Governor (p. 10), that he always
distrusted this part of the plan adopted; and after the system had
been at work a year, this attempt to utilize pauper nurses in a
workhouse hospital was found to have utterly failed. It was proved
that in a town like Liverpool, with very few exceptions, those
able-bodied women only become inmates of the Workhouse who are
either tainted in character, or are exceptionally ill-educated and
inefficient. The experiment, however, was not wholly useless. It
conclusively established two facts: that such women are utterly
unfit to be trusted as nurses; and that their employment in that
capacity does not effect all the saving that might be supposed. It
might be thought that the choice lay between such employment and
maintaining the pauper in idleness, while paying a nurse in her
stead. But it was found—as the Governor had always predicted—that
when sent back from the hospital to the able-bodied wards, nearly
the whole of these women left the Workhouse, and relieved the parish
from the charge of their maintenance. Many of these women, when
employed as nurses, remain in the Workhouse for the sake of what
they can pick up or extort. And moreover, when they left it, the
training they had received, such as it was, rendered them more
intelligent, and perhaps not more unreliable nurses than those
usually employed by the poor. It is not unlikely that in country
places the unfitness of able-bodied paupers to become assistant
nurses may be far less than it has been found to be in a great
seaport town like Liverpool. They may probably be less universally
tainted in character, and after a year or two of employment as
under-nurses they may be able to maintain themselves in that
capacity out-of-doors, thus not only relieving the parish of their
own maintenance, but assisting to diminish sickness and pauperism
among their neighbours. The point is one which must be left to local
knowledge and experience. It might be well, however, not to promise
them payment till after some length of probationary service. It was
always after pay-day that the ex-pauper nurses were most liable to
get drunk and misbehave.[4] With the exception of the failure of the
nurses taken from the pauper class, the first year’s trial was
sufficiently successful to induce a continuance of the experiment.
It was impossible, however, to judge the result by statistics. None
that were available could be considered as an evidence of success or
failure, for several reasons. The season was very unhealthy, and to
relieve the pressure on the space and resources of the hospital,
steps were taken to treat slight cases outside, as will be seen from
the following extract from the Minutes of the Finance Committee,
24th November, 1865:—

“The district medical officers, Dr. Gee, Mr. Barnes, and the
Governor of the workhouse being in attendance, pursuant to
resolution of the Workhouse Committee at its meeting yesterday,
the practicability of limiting the admissions to the Workhouse
Hospital was considered, and the district medical officers were
requested to co-operate with the relieving officers in limiting
such admissions to those cases that cannot be properly treated
outside the Workhouse.”

The endeavour to limit the admissions to serious cases would of
course affect the returns, both as regards the time taken in curing,
and the proportion of deaths. Even had there been no exceptional
disturbing element, there is a defect in the statistics of workhouse
hospitals which affects all inferences from them, in the absence of
any careful classified list of cases kept by the medical officers,
such as might fairly enable one to form a judgment from mere
statistical tables. These, then, are not reliable as means of
judgment, unless extending over a long period. The character of
seasons, and nature of cases admitted, varies so much from year to
year as to invalidate any deductions, unless founded on complete and
minutely kept medical records. The following extracts, however, from
the reports of the Governor, and the surgical and medical officers
of the Workhouse, bear decisive witness to the value of the “new
system,” especially as contrasted with the “old system,” which in
1865-66 still prevailed in the female wards. All these reports bear
emphatic testimony to the merits and devotion of the Lady
Superintendent and her staff. The medical men, it is noteworthy,
speak strongly of the better discipline and far greater obedience to
their orders observable where the trained nurses are employed—a
point the more important because it is that on which, before
experience has reassured them, medical and other authorities have
often been most doubtful.

_From the Report of the Governor._

Thursday, _May 10, 1866_.

The main feature in the new system of nursing consists in the
superseding of pauper nurses, and appointing in their places
competent trained nurses from the Nightingale School. These latter
to have the assistance of “probationary nurses,” or in other
words, women of intelligence and of good character desirous of
entering upon the duties of nursing the sick as a profession. A
third class was also created, designated “Assistants.” These were
selected from the old pauper nurses, and it was decided that they
should be paid, clothed, and receive rations equal in quality and
quantity to those issued to the officers of the workhouse. The
nurses, probationers, and assistants were placed under the control
of a “Lady Superintendent,” who was empowered to employ them in
the manner to her seeming best for the proper care of the sick.

The Committee will be prepared to hear that the change was
immediately followed by the most marked improvement in every
respect. The most casual observer could not avoid perceiving it.
This applies not only to the state of the wards, the care of the
sick, but is particularly observable in the demeanour of the
patients, upon whom the humanizing influences of a body of women
of character, devotedly discharging their duties, has produced
evident fruits.

The question has often been asked whether the “new system is
likely to succeed?” The “old system” meant nothing more than this,
that old, ignorant, and unreliable pauper women, many of whom were
of doubtful character, were entrusted with the discharge, without
pay, of responsible duties. These have been displaced, and active,
intelligent, reliable women, trained and skilled as nurses, with
good characters and pay, have been appointed to supersede them. It
would be a great discredit if these latter did not discharge their
duties incomparably better than the former could do. That they do
so I am happy to be in a position to testify.

In the opening paragraph of this report it is stated that
“assistant nurses” were appointed and placed upon pay from the
ranks of the paupers. This I was always opposed to. Their
employment has resulted in complete failure, as the following
figures will prove. The total number appointed to this date is
141. Of these sixty-seven have been dismissed through drunkenness
and other misconduct, and sixteen have resigned; while it is
positively true that there is not one of the whole number to whom
I could entrust the duties of serving out wine or other
stimulants, or, in fact, any duty requiring the exercise of
integrity.

The experience of the past year renders it certain that the Poor
Law, as now existing, offers no impediments to the successful
working out of the most complete scheme for the efficient nursing
of the sick, in the manner advocated by the best friends of
hospital nursing.

(Signed) GEO. CARR.

_From the Report of_ Robert Gee, Esq. M.D. _Physician to the
Workhouse Hospital_.

5, Abercromby Square, Liverpool,
_May 10, 1866_.

Sir,

In the medical wards of a general hospital the cases vary so much
in nature and degree from year to year, as to render it impossible
to give a reliable statistical comparison of the value of a paid
as distinguished from an unpaid staff of nurses. I am, therefore,
necessarily compelled to report in general terms on the nursing of
the last ten months in the male medical wards; premising that what
I say in approbation of the new system, and the new staff of
nurses must not be construed as an unfavourable reflection on the
_whole_ of the previous staff. The paid superintending nurses of
departments, and a few of the unpaid pauper nurses, deserve great
credit for their conduct, though their qualifications for the
service were decidedly inferior to those of the trained
“Nightingale” staff.

With regard to the latter I can cordially bear testimony to their
ability, and to their unwearied and uniformly kind attention to
the patients under their charge. As to their nursing in its
specific sense, I may state my belief that in every case my
directions and those of the House Surgeons have been rigidly
carried out. The medicines, stimulants, &c. &c. have been
carefully administered, and the other numerous but less agreeable
duties have been faithfully and efficiently attended to. Under
their charge I have perceived a marked improvement in the
demeanour of the patients—in fact, the discipline of the wards is
completely changed. There has been no disorder or irregularity,
but a sense of comfort, order, and quiet pervades the whole
department. I believe further, that every patient leaving the
wards has been more or less morally elevated during his location
there.

_From the Report of_ J. H. Barnes, Esq., _Surgeon_.

_March 21, 1866._

Since my connexion with the hospital last August we have had
somewhat approaching a hundred operations, many of them of a
serious and dangerous character, requiring not only prompt
assistance at the time, but most persevering attention night and
day for a long time after. Almost all these operations have been
in the male hospital, and I have no hesitation in saying that what
success has attended them has been greatly owing to the most
efficient assistance rendered by the trained nurses; and from my
experience of the assistance received from the pauper nurses, in
the few cases of operation performed in the female hospital, I
should feel great diffidence in undertaking on that side such
operations as I have had on the other side: indeed on one or two
occasions the pauper nurses ran away, and when induced to assist
were so nervous and frightened as to be of little service.

Without any wish to speak harshly of the unpaid nurses employed on
the female side of the hospital (who, I believe, strive to do
their best, more especially since a feeling of emulation has been
set up by the introduction of the paid trained nurses, of whom
they are jealous), I am compelled to state my conviction that on
that side my directions are not carried out with that necessary
promptitude and skill that they are on the other side, and that in
all I do there I feel as if I were working with blunted
instruments. There is no want of inclination, but simply a want of
ability. That _integrity of disposition, promptitude of action,
tact in manipulation, gentleness of demeanour and kindly
consideration_ necessary to make a nurse are not found, or _to be_
found in the inmates of a workhouse, and no amount of education
can work out of them what never was in them. Almost always obtuse,
and too often unprincipled, as a class they are thoroughly
unreliable, and quite unfitted to take charge of the sick and
helpless, or the stimulants necessary for them. On this last point
I have been informed by a former resident surgeon that he has
known the pauper nurses appropriate the patient’s stimulants, or
withhold giving to a dying patient that ordered for him, that they
might take it themselves after his death. It is difficult to bring
home and prove these things, and I do not wish to say they now
occur, but if we wish to put such conduct out of the region of
possibility it can only be done by the employment of persons
superior to the temptation so to act.

Persons of one class, as a rule, favour their own class, and there
is a far better chance of double-dealers being detected when under
the observation and care of a trained nurse, than when under the
care of one of themselves. That such is the case my own experience
testifies.

As far, therefore, as my experience extends of the system of
trained nurses, whether regarding the saving of life, the
restoration to health, or the relief of the suffering, it has been
an undoubted success.

These reports were duly considered by the authorities; and after
some discussion, it was resolved entirely to discontinue, in the
male hospital ward, the employment of paupers as assistant nurses,
and to substitute an additional number of probationers. A
Sub-Committee of the Workhouse Committee was appointed to
superintend and report upon the working of the system. These
gentlemen devoted much time and attention to the subject, and at the
close of the year undertook a minute inquiry into the operation of
the old and new systems; examining personally the various officers
of the Workhouse, from the Governor down to the pauper nurses in the
female wards. Increased experience brought out in a yet stronger
light the superior advantages of the employment of trained nurses.
The very able, clear, and conclusive report of the Sub-Committee
leaves little more to be said on the subject. It determined the
Vestry to adopt the system in permanence, and to extend it to the
whole of the Workhouse Infirmary, a year before the period fixed for
the trial of the experiment had expired. It will be seen that the
report of the second year’s experience has a peculiar value, as
bearing on the question whether, or how far, women may be competent
to undertake one of the most delicate and difficult kinds of
feminine work—one requiring special knowledge as well as special
habits of punctual regularity, obedience, and thoughtfulness—without
receiving any special training or education for such a duty. If the
reforms about to be introduced into the pauper hospitals in London
and elsewhere are not to end in failure and disappointment,
provision must be made for training the nurses to be employed there,
either before they enter the hospitals or within them.

The report of the Sub-Committee of Superintendence is as follows:—

The Special Committee on Nursing, pursuant to resolution of the
Workhouse Committee of the 7th of March instant, report,

That the Men’s Hospital (exclusive of fever patients) is at
present exclusively nursed by skilled, _i. e._ specially trained
nurses and paid assistants, who are themselves undergoing training
as nurses; the staff consisting of the Superintendent, nine of the
nurses originally sent from the Nightingale School, five nurses
who have been trained in the Workhouse, and fifteen probationary
or assistant nurses.

Of the character of the nursing in this portion of the Workhouse,
your Committee have heard but one opinion. The Governor and the
Medical Officers concur in speaking of it in terms of the highest
praise, and throughout the whole period during which the Committee
have superintended it, no single circumstance has come to their
knowledge calculated to make them speak of it otherwise than in
terms of approval.

The nursing of the women’s wards continues to be done by paupers
under the superintendence of paid officers. The superintendence of
these officers is of necessity very imperfect, as not only has
each charge of from 150 to 200 patients, but these patients are
located in several rooms, each ward containing about twenty
patients. The only portion of the nursing, properly so called,
which these officers undertake, is the administration of
stimulants and in some exceptional cases of medicine. The bulk of
it, as the giving of medicine, the dressing of wounds, the
distribution of food, is left to be done by paupers. So much has
from time to time been said of the untrustworthiness of pauper
nurses, of the evils resulting to those patients who are placed
exclusively under them, of the mischievous consequences upon the
discipline of the Workhouse of a large number of petty offices
being filled by able-bodied women, that your Committee believe
they rightly interpret the feeling of the Select Vestry, as they
undoubtedly do that of the general public, in supposing that the
actual nursing of the sick in the Liverpool Workhouse can no
longer be left in the hands of pauper nurses.

Starting from this point, your Committee considered that they had
principally to inquire what sort of nursing can be most
advantageously substituted for that of nursing by paupers. Two
courses only appeared to be open to them—either to increase the
number of paid officers, giving to each such a number of patients
as she could reasonably be expected to look after, and treating
each as an independent officer; or to extend over the whole
hospital the system now in existence in the men’s wards. Your
Committee were much aided in forming a judgment upon this point,
by what has taken place during the last few months in the fever
hospital.

Here, originally, the paid attendants were in precisely the same
position, with precisely similar duties as the paid officers in
the women’s hospital; but the number of patients rapidly
diminishing, and no corresponding reduction taking place in the
number of officers, the staff was so large that Dr. Gee felt able
to call upon the officers to act as nurses. The result was what
might have been anticipated, that although an improvement upon the
old system of nursing by paupers was perceptible, the state of the
nursing was still far short of the standard reached in the men’s
wards.

The officers were told to nurse, and they did their best, but
never having themselves been taught, their attempts in a great
measure failed; they were paid and retained as nurses, without
being efficient nurses.

Your Committee therefore recommend that as soon as the requisite
number of trained nurses can be procured, the nursing in the
women’s hospital, and afterwards in the fever hospital, be placed
in the hands of trained and skilled nurses, acting under the
direction and control of Miss Jones, the present Superintendent.
The expenses (beyond the item of wages) attendant upon the
necessary increase in the number of nurses will not be great, as
all that will be necessary will be to convert two of the rooms now
used for sick boys into sleeping apartments for the nurses. In
making this recommendation, the Committee are glad to know that
they are fortified by the unanimous opinion of the Governor and
the Medical Officers of the Workhouse.

Your Committee are bound to add that they can produce no
statistics shewing that the nursing in the men’s hospital has been
of any economical advantage to the Parish; but as it needs no
argument to prove that the cheapest course that can be taken with
a sick pauper is to cure him as quickly as possible; as it is
evident that the care and attention of a skilled nurse must tend
to a more speedy recovery; as the order and discipline of a
well-regulated ward is more distasteful to many of the more
worthless inmates, than the laxer management of a room in the
hands of a pauper nurse; and as the abolition of a large number of
petty offices for able-bodied paupers must lead to many of them
leaving the Workhouse, there are strong grounds for hoping that
the economical results of the change cannot but be beneficial.

With regard to the future, your Committee recommend that the
Department of Nursing should be placed under the direction of a
small committee of your body, and that all changes in the staff
should be made only by them. From information they have received,
your Committee have reason to believe that if, after the Workhouse
is supplied with Nurses, the two classes of nurses, _i.e._ trained
nurses and probationers, be maintained, the cost of the Department
may be considerably lessened by training nurses for other
hospitals; the cost of the probationers being either paid for by a
Government grant, or by the bodies for whom the nurses may be
trained.

THOMAS H. SATCHELL,
RICHARD BRIGHT,
THOMAS OWEN.

_March 15, 1867._

This report was unanimously adopted by the Workhouse Committee and
by the Vestry; and already the new system has been extended to the
Female Wards. It is in contemplation to extend it also to the Fever
Hospital, as soon as a sufficient number of suitable nurses shall
have been trained.

It will be observed that the report contemplates the training of
probationers for other Workhouse Infirmaries. And it is, indeed, to
be hoped that in this and other ways the Liverpool Workhouse
Hospital may serve as a normal school, from which the system there
adopted may spread. The _special_ expenses of such a school would
naturally be borne by the parishes which profited by its services in
educating nurses for them, or by the Government. But this point is
one which, as yet, has hardly demanded practical consideration.

The experiment whose results have been recorded, could hardly have
been tried at all—certainly could not have achieved such rapid
success—had it not been for the powerful and liberal assistance of
Miss Nightingale, and the Trustees of the Nightingale Fund. Feeling
how very important was the extension of the system of superior
professional nursing, now gradually gaining ground in general
hospitals, to workhouses, they sent, to assist in the initial
experiment made in this direction, a lady superintendent and twelve
superior nurses—a very expensive and quite invaluable contribution.
To the Liverpool Vestry and its officers belongs the credit of
having overcome all the difficulties, and persevered in spite of all
the discouraging incidents, which necessarily attended an attempt to
introduce a new system of management into such an institution as a
Workhouse Hospital, combining as it does two subjects so different
in their aspects and conditions of treatment, so difficult to deal
with together, as pauperism and sickness. Of the Lady Superintendent
I shall say little. When a lady leaves a happy home, and goes
through a long and laborious course of training to fit herself for
such a situation, purely because, feeling that she possessed the
capacity for nursing, and the requisite health, energy, strength,
and spirits, she desired to devote such powers to the service of
those who stood most in need of them, human praise or criticism of
her choice is out of place. One of the incidental results of her
exertions has to her, no doubt, been even a higher reward than that
improvement in the condition of the sick, in their progress towards
recovery, and their material comfort, which has been the direct
object of her labours. The improvement in the tone and behaviour of
the patients has been wonderful. Many of the inmates of a pauper
hospital are persons of the worst character, and its wards, under
the control of pauper nurses, often present scenes so disgusting
that the respectable poor shrink from them with utter abhorrence,
and after once becoming acquainted with them, will often rather die
than return thither. When the trained nurses were first introduced,
the most offensive language was frequently heard in the wards; and
the Lady Superintendent has repeatedly been obliged to call upon the
Governor two or three times during one Sunday to use his authority
to put a stop to actual fighting. Now, though his support is always
promptly rendered, she is rarely compelled to apply for it; the
feeling of the wards promptly suppresses all offensive language or
unseemly behaviour in the presence of the nurses. The following
letter from Sir H. Verney, Chairman of the Nightingale Committee,
serves to illustrate the influence of the nurses upon the conduct of
the patients; he came down to Liverpool to inspect the Hospital, and
ascertain the progress of the work:—

Liverpool, _October 3, 1866_.

My dear Sir,

By the kindness of Mr. Carr I have paid a visit to the Workhouse,
and have been greatly interested by remarking the change among the
male pauper sick, effected since I was here about two years since.
I conclude that this is owing to the nursing by a class of females
so entirely different to those who nursed the male paupers at that
time, and who still nurse the female sick. I have always seen that
the influence of respectable and well-educated females over the
most debased men is very striking. Men of that character,
accustomed to intercourse with only degraded women, feel the
restraining and humanizing power of virtuous and well-mannered
females. They have never been admitted into intercourse with such
before, and they are most beneficially affected by it. I have been
told that the police officers, who sometimes come to the Workhouse
on business, and who see the sick paupers, are much astonished.
They see the men whom they have known as the very worst
characters, conducting themselves with propriety and decency, and
giving no cause of complaint.

I am sure that the Workhouse Committee must rejoice and feel
thankful that there is such a change in the condition of the poor
creatures brought under their rule.

Miss Jones, and her nurses and probationers, must have had much
difficulty at first—indeed their work is still very trying; but
the improved demeanour of the men must be highly gratifying and
encouraging to them. I walked through the female sick wards; they
were clean and sweet, but I could not help contrasting the pauper
nurses who attended them, with the intelligent-looking respectable
attendants of the men.

I thank you for the note of introduction which procured admission
for me, and

I am,
Yours very faithfully,
HARRY VERNEY.

Such, and so entirely satisfactory to the Guardians, were the
results of the experiment of nursing by trained nurses, as tried for
two years in the Male Wards of the Liverpool Workhouse Infirmary. It
is in order to render those results, the experience acquired in this
initiatory attempt, available for the assistance and encouragement
of others, that they have been thus briefly recorded. Much more
might have been said; but what is here set down is sufficient to
explain all that practical men would wish to know, and it would be
presumption to waste the time of such men with comments and
inferences which they are perfectly able to make for themselves.

One suggestion, in conclusion, I may be permitted to offer. In all
unions or parishes where additional accommodation may be required,
whether for patients or for healthy paupers, it is eminently
desirable that in providing it regard should be had to the entire
separation, at once or at a future time, of the sick and infirm from
the able-bodied, as will be the case, at least partially, under the
new régime introduced in the Metropolis by Mr. Gathorne Hardy’s
Bill. Miss Nightingale has from the first held and expressed a
strong opinion in favour of the separation of the hospital and
workhouse administrations. The Governor of the Liverpool Workhouse,
Mr. Carr, expressed himself decidedly in the same sense; and the
Chairman of the Workhouse Committee and of the Sub-Committee
appointed to superintend the Hospital, has been induced by practical
experience warmly to advocate the absolute separation of the
Workhouse and the Infirmary. So large a proportion of the
able-bodied inmates of the workhouse are drunken, lazy, and vicious,
that, if the poor-law relief is not to become a temptation and an
injury to the honest and struggling poor, the discipline must be
almost of a penal character. The paramount object must be to make
the workhouse, if not absolutely unpleasant, less agreeable than the
condition of laborious and striving poverty. On the other hand, in a
hospital the paramount and almost the only object is to promote
recovery and to mitigate suffering; all other considerations yield
to this, and consequently the treatment must necessarily be liberal
in spirit and indulgent in fact. The modes of treatment necessary
for the good management of the hospital patient and of the
able-bodied pauper, respectively, are distinct—almost opposite: the
infirmary and the workhouse must be controlled on divergent, and
even contrary principles; and by bringing the two together under one
roof and one administration, they injure each other. The indulgence
of the infirmary creeps into the workhouse, or the sternness of
workhouse rules cripples the benevolent energy which should rule the
infirmary. And the treatment of the able-bodied pauper becomes too
lax, or he is tempted to scheme, and does scheme, to get himself
transferred to the more comfortable quarters close at hand; a desire
so prevalent as to give rise to malingering—the wilful production of
disease: while, partly no doubt in order to counteract this
tendency, there is in such mixed establishments an unconscious
disposition to treat the hospital patient with the same stern
economy that is justly made the rule in dealing with able-bodied
pauperism, but which, in the infirmary, is not only cruel, but in
the long run is not truly economical. Another most serious evil is
entailed upon the hospital by connexion with the workhouse. The
habits and traditions prevalent among the habitual
paupers—able-bodied paupers—in the workhouse (at least in the
workhouse of a large town), are too often deeply infected with
cunning, deception, and dishonesty of all sorts, against which
strict precaution and stern repression are requisite; and it is most
important that no communication should be allowed, whereby these
habits of vice and stratagem might be introduced into the hospital,
where indulgence is the rule, and where many things strictly denied
to the inmates of the workhouse, as stimulants for instance, are
necessarily permitted. The introduction of workhouse tricks into a
hospital, where they cannot be met by workhouse control, must bring
in an element of confusion, disorder, and waste, and therefore the
intercommunication which might introduce those tricks should be as
effectually prevented as possible, which it cannot be while the two
institutions are, as at present, combined. The two systems—to use an
English word in its French sense—demoralize each other; and even in
the English sense, their union demoralizes the individuals subject
to each.

When this is better understood and more clearly apprehended, as it
soon will be, through the experience of several Unions in which the
separation has been already resolved on—it is probable that it will
be enforced by law. This may be expected to take place in no very
long time; and then it will be found that any expenditure incurred
in providing increased accommodation on a plan which does not
recognise the necessity of separation has been, in part at least,
thrown away; and the work will have to be done, and the money to be
spent, over again.

Footnotes

[1]Liverpool is a seaport, and a receptacle where the poverty and
vice of Great Britain and Ireland seem to accumulate; and it is
probably on this account that the able-bodied female paupers are
peculiarly vicious and worthless.

[2]Among the replies of the London medical officers, one which
seemed especially to impress the Sub-Committee was given by the
senior honorary medical officer of St. Thomas’s. Mr. Hagger
asked him, “If you had to cure the sick by contract at so much a
head, and had to choose between unpaid pauper nurses allotted to
you gratis, or paying yourself for skilled nurses, which would
you choose?” “To pay for skilled nurses, certainly,” was the
unhesitating answer.

[3]In the opinion of the medical men of the Liverpool Workhouse
Hospital, 647 of its present number of patients would be
admissible to an ordinary hospital, and

Men—Medical 40
” Surgical 80
Women—Medical 40
” Surgical 60
220 would not be admissible.

[4]In a training school for superior nurses, it will _never_ be
desirable to employ pauper under-nurses, as they interfere with
the efficiency of the probationers, who are being trained as
superior nurses. The latter are apt to delegate to the paupers
much of the hard but most instructive part of their work. In
ordinary workhouse hospitals, when there are no probationers, a
certain number of pauper assistants may perhaps be useful in
aiding thoroughly trained nurses.

LONDON: R. CLAY, SON, AND TAYLOR, PRINTERS.

Transcriber’s Notes

--Retained publication information from the printed exemplar (this
eBook is in the public domain in the country of publication.)

--Only in the text versions, delimited italicized text with
_underscores_.

--Silently corrected several typos.

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