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Title: Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and War
Author: Nightingale, Florence
Language: English
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Transcriber’s Note


Words in italics are marked with _underscores_. Words in small capitals
are shown in UPPER CASE.

There are three parts to this book, each starting with page 1. The
first and last parts are marked “PRIVATE AND CONFIDENTIAL.”, these
words were underlined in the original.

Footnotes have been moved to the end of each part.

Variant spelling and inconsistent hyphenation are retained, a few
palpable printing errors have been corrected.

The key for the plan of the Lariboisière Hospital was originally
handwritten. No changes have been made to this for missing or irregular
use of accents or cedillas.

The tables of numbers of nurses near the end of the book were
originally printed in landscape, with some sideways printing. The
columns and rows have been swapped to make these tables easier to read
on small screens.



  SUBSIDIARY NOTES

  AS TO THE

  INTRODUCTION OF FEMALE NURSING

  INTO

  MILITARY HOSPITALS

  IN PEACE AND IN WAR.

  Presented by request to the Secretary of State for War.

  LONDON:
  PRINTED BY HARRISON AND SONS, ST. MARTIN’S LANE, W.C.
  1858.



CONTENTS.


                                                                 PAGES

  DIGEST                                                           v–x

  Thoughts submitted by Order, concerning--
         I. Hospital Nurses                                        1–9
        II. Nurses in Civil Hospitals                             9–14
       III. Nurses in Her Majesty’s Hospitals                    15–19

  Systems of Female Nursing in the War Hospitals of the
        different Nations engaged in the Crimean War             19–26

  Note in regard to the Russian Nurses employed in the
        War Hospitals of the Crimea                              26–28

         *       *       *       *       *

  Subsidiary Notes as to the Introduction of Female
        Nursing into Military Hospitals in Peace and
        in War                                                    1–63

  Addenda with regard to Female Nursing in a Military
        Hospital on the Pavilion or Lariboisière Plan            63–90

  Addenda as to Mixed Nursing, by Nurses and Orderlies,
        in Military Hospitals, on the Double Pavilion or
        Vincennes Plan                                          91–117

  Additional Hints as to Ventilation, Hospital Floors,
        and Cautions in Ward-building suggested by the
        Lariboisière Hospital                                  118–127

  Note on Contagion and Infection                              128–132

  Note on Observations by the Principal Medical Officer of
       the Army in the East                                   132, 133

         *       *       *       *       *

  Thoughts submitted as to an Eventual Nurses’ Provident
        Fund                                                      1–19

  Note as to the Number of Women employed as Nurses in
        Great Britain                                           20, 21

  Note as to Teaching Nursing                                   22, 23



ILLUSTRATION.


  Plan of the Lariboisière Hospital at Paris                     p. 63



DIGEST.


                                                                 PAGES

  THOUGHTS SUBMITTED BY ORDER                                     1–28

                     CONCERNING

       I. HOSPITAL NURSES.
      II. NURSES IN CIVIL HOSPITALS.
     III. NURSES IN HER MAJESTY’S HOSPITALS.

       I. Hospital Nurses                                          1–9
          Twenty Observations on how to improve Hospital
            Nursing.

      II. Nurses in Civil Hospitals                               9–14
          Twenty-three Heads for Regulations as to Nursing in
            Civil Hospitals.

     III. Nurses in Her Majesty’s Hospitals                      15–19
          Twenty-two suggestions in the event of the
            introduction of Female Nursing into Military
            Hospitals.

     Various systems of Female Nursing during the Crimean War
       in the Military Hospitals                                 19–28
       Of the French and Sardinians                              19–22
            Russians                                     22, 23, 26–28
            English                                                 23

     Proposed Duties of Female Nurses in Military General
       Hospitals                                                23, 24

     The Hospital Serjeant, or Ward Master will not be
       superseded--he will still have too much to do for any
       one man properly to perform, and part of his duties must
       be given to another officer                               24–26

     NOTE IN REGARD TO THE RUSSIAN NURSES EMPLOYED IN
       THE WAR-HOSPITALS OF THE CRIMEA                           26–28


  SUBSIDIARY NOTES AS TO THE INTRODUCTION OF FEMALE NURSING
    INTO MILITARY HOSPITALS IN PEACE AND IN WAR                  1–133

       I. Five Conditions essential to this service                1–3

      II. Our Nurses were of four kinds                              3
          Absolute subordination to the Medical Officer as to
              Medical Orders essential and practised by us           4


     III. 1. Qualified subordination essential of
               Superintendent-General to Director-General and
               Principal Medical Officer                           4–6
          2. Also of Matron and Nurses to Principal Medical
               Officer and Staff-Surgeons                         6, 7
          3. Female service can only be introduced gradually,
               and introduction regulated by Director-General      7–9

      IV. 1. Shall Roman Catholic Sisters be introduced?         9, 10
          2. Or Anglican Sisters?                                   10
          3. Power of Police in Civil Hospitals                     11
               ″        ″       Military  ″                      12–15
          4. Pay and Rations of Nurses                           15–20
             On the whole it would seem best, where practicable,
               to board the Nurses, not to “ration” them, nor
               to let them “find themselves.” Community of
               cooking implies economy of nourishment            17–20
          5. Washing to be “put out”                            20, 21
          6. Cleaning their own Rooms                            21–23
          7. Nurses to keep keys of closet in Wards                 23
          8. Pay, dress, and duties of Matrons                   24–28
             More properly named Superintendents                    27
             Lady Volunteers had better begin by being Nurses,
               not Superintendents _ex-officio_                     28
          9. Sundry Regulations as to Nurses                     29–31
         10. Have the Patients’ Diets sent hot, and ready
               divided, from kitchen                                31
         11. What Ward duties the Nurses should do themselves       31
             And why                                            32, 33
          Patients should not be made quasi Orderlies               34
          Visitors in Military Hospitals                            35
         12. Regulation-Number of Orderlies--depends on the
               size of wards whether sufficient                  35–41
             What is the regulation-attendance in Naval
               Hospitals                                            37
             What in Civil Hospitals                                38
             Comparative Cost of Nursing in larger and smaller
               wards                                             39–41
         13. Hospital floors                                     42–51
             Sanitary necessities                                   42
             Trial of Hospital floors, oiled and polished with
               “_laque_” as in Berlin Hospitals, recommended on
               sanitary grounds and for ease of cleaning         43–51
         14. Ventilation of Wards                                51–52
         15. Special Wards, whether desirable or not             53–54
         16. Opinion as to Superintendent-General paying
               Nurses’ wages, and as to Governor’s jurisdiction
               over Nurses                                       54–56
         17. Wages and Pensions of Nurses                        56–60
             Three rules in raising Wages                           56
             Five general principles as to Wages and Pensions       58
             Six applications of the foregoing principles       58, 59
             Seven heads for Regulations as to Nurses’ Wages
               and Pensions                                     59, 60
         18. Proportion of Nurses to Patients                   61, 62
         19. Precautions in sending Nurses on Foreign Service       62
             Hospital Laundries                                     63

  ADDENDA, WITH REGARD TO FEMALE NURSING IN A MILITARY
    HOSPITAL ON THE PAVILION, OR LARIBOISIÈRE PLAN               63–90

       I. Four conditions to be considered in adopting the
               Pavilion Plan                                        63
          1. Economy of attendance                                  64
          2. Facility of supervision                                65
          3. Desirableness of _doubling_ the Pavilion,
               in a Military Hospital, in order to give to each
               Nurse but one floor to serve                         65
          4. Nurse to sleep near her Ward                           66
             Importance of lighting by gas                          67

      II. 1. One Nurse must serve the whole Pavilion, in a
               Military Hospital, if _single_ Pavilions be
               adopted                                              68
          2. Nurses’ day in such a Pavilion                     68, 69
          3. What the responsibility of Nurses is for
               discipline of Ward or Pavilion                   70, 71
          4. Importance of Lifts                                    71

     III. 1. “Casualty” Cases should be in a completely
               appointed set of Wards, apart                        72
             And why                                                73
          2. Restraint or non-restraint in Violent Cases            74

      IV. Simplicity of Construction essential to Discipline        75
          Polished impervious Walls.
          Covered Exercising Place.
          Reserve Wards                                             76

       V. Nurses’ Meals to be sent them Cooked                      76

      VI. Arrangements for a Pavilion and its Wards              77–90
          2. Where should Wardmaster sleep?                         77
          3. And Orderlies sleep?                                   77
          4. And dine?                                              78
       7, 8, Scullery to each Ward, and what to be done in it       79
             Poultice-making                                        79
          9. Presses in Ward                                    80, 81
         10. Nurses’ Room                                           82
             Lavatory, Water-Closet, Sink                           83
             Baths                                                  84
         11. Summary of arrangements                                85
             Scullery Appurtenances                                 86
         12. Nurses’ Sleeping Quarters                              86
             Ward for Sick Nurses                                   87
         13. Classification of Patients                             88
         14. Nurses to be called by their Wards                     88
         15. Foul Linen                                             88
         16. Washing Bandages                                       89
         17. Splints, &c., where to be kept                         89
             Cotton Lint never to be used                           89
         18. Classification of Nurses                               90
             Superintendent’s Store Room                            90

  ADDENDA AS TO MIXED NURSING BY NURSES AND ORDERLIES
      IN MILITARY HOSPITALS ON THE DOUBLE PAVILION
      PLAN                                                      91–117

       I. ORDERLIES’ DUTIES                                     91–108

          Proportion of Nurses, Ward Masters, and Orderlies to
            Sick                                                 91–93
          Wine to be always administered by Nurse                   93
          Orderlies--their Duties vary according to
            appurtenances of Ward                                   94
          If Hot and Cold Water are laid on, and there are
            Lifts, one Orderly’s Service saved to each 30 Sick  94, 95
          Night-Duty of Orderlies                               95–108
          Scheme of Night-Service for three Orderlies watching
            by turns                                            96, 97
          Exercise for Orderlies                                    97
          Night Refreshment for Orderlies                       98, 99
          Where are the Night Orderlies to sleep?                  100
          Comparative Merits of different Systems of Night
            Nursing in Home and in Foreign Hospitals             101–3
          An Assistant Ward Master should go round the Wards
            at Night                                               104
          Extraordinary System of Night-Nursing in the Army
            at present                                           105–8

      II. TWELVE SUNDRIES IN ORGANIZING A MILITARY
          HOSPITAL                                             108–114

          1. Nurses’ Room                                          108
          2. Medical Officer’s Room                                108
          3. Water-Closets                                         109
          4. Warm and Cold Water Supply                            109
          5. Corridors                                             109
          6. Lobby                                                 110
          7. Material of Ward Utensils                             110
          8. Reserve Wards                                     111–112
             Necessity of Annual Cleansing of the whole of a
               Hospital
          9. Occasional Revision of Rules                          113
         10. Defect in German Organization of Nursing              113
         11. Nurses’ Exercise                                      113
         12. Number of Ward Masters                                114

     III. REGULATIONS                                          114–117
          1. Deprivation of Visitors salutary in certain Wards  114–16
          2. Numbering Patients saves time                         117
          3. Prohibition of Swearing                               117
             Conclusion                                            117

  ADDITIONAL HINTS AS TO PAVILION HOSPITALS SUGGESTED BY THE
      CONSTRUCTION OF THE LARIBOISIÈRE HOSPITAL AT PARIS       118–127

       I. Ventilation                                          118–120
          Artificial Ventilation never freshens a Ward
      II. Oiled Boards versus Parquets                         120–124
          Cleaning polished and oiled Boards much less
            laborious, and freshens the Ward much more than
            the _frottage_ of _Parquets_.
          Mode of Cleaning them at Berlin                      122–124
     III. Ten Cautions in Building Hospital Pavilions          124–127
          Size of Wards. Our own Regimental Hospitals
            extraordinary for their many holes and corners         125
            Casualty Wards                                         126

  “CONTAGION” AND “INFECTION” DEFINED                          128–132

          Idea of “Contagion” invented by Men to excuse
            themselves for the neglect of all Sanitary
            arrangements                                           128
          In the ordinary sense of the word, no such thing
            as “Contagion”                                         129
          Nor as _inevitable_ “Infection”                          130
          “Infection” and Incapable Management, or Bad
            Construction, convertible terms                        131
          “Epidemics” do not _spread_--they develop
            themselves in Constitutions made ripe for them
            by Sanitary neglects                                   131

          Note on certain “Observations” by Sir John Hall     132, 133

         *       *       *       *       *

  THOUGHTS SUBMITTED AS TO AN EVENTUAL NURSES’
    PROVIDENT FUND                                                1–19

          Actual Wages and Prospects of Nurses                     1–3
          Some further Provision desirable                         4–6
          Of what Nature?                                         6–15
          With regard to Kind?                                     6–8
          With regard to Persons?                                    8
          With regard to Objects?                                 9–15
          Material Objects?                                       9–12
          Children, in the case of Nurses, a Temptation to
            Petty Dishonesty and taking Bribes                  11, 12
          Sanitary Objects?                                         13
          Moral Objects?                                         13–15
          Hospitals not places for Penitents                    14, 15
          Rules to be followed in giving Assistance              15–17
          Prospects of Eventual Support                         18, 19

          Note as to the Number of Women employed as Nurses
            in Great Britain                                    20, 21
          Tables of Ages, &c.                                       21
          Note as to Teaching Nursing--Institution at Madras    22, 23

         *       *       *       *       *



_PRIVATE AND CONFIDENTIAL._



THOUGHTS SUBMITTED BY ORDER CONCERNING

    I. HOSPITAL-NURSES.
   II. NURSES IN CIVIL HOSPITALS.
  III. NURSES IN HER MAJESTY’S HOSPITALS.


I. HOSPITAL-NURSES.

[Sidenote: Definite Objects: road to them to be found out.]

1. It would appear desirable to consider that definite objects are to
be attained; and that the road leading to them is to a large extent to
be found out--therefore to consider all plans and rules, for some time
to come, as in a great measure tentative and experimental.

[Sidenote: Presumed Main Object.]

2. The main object I conceive to be, to improve hospitals, by improving
hospital-nursing; and to do this by improving, or contributing towards
the improvement, of the class of hospital-nurses, whether nurses or
head-nurses.

[Sidenote: Presumed Intentions.]

3. This I propose doing, not by founding a Religious Order;
but by training, systematizing, and morally improving as far
as may be permitted, that section of the large class of women
supporting themselves by labour, who take to hospital-nursing for
a livelihood,--by inducing, in the long run, some such women to
contemplate usefulness, and the service of God in the relief of man,
as well as maintenance, and by incorporating with both these classes
a certain proportion of gentlewomen who may think fit to adopt this
occupation without pay, but under the same rules, and on the same
strict footing of duty performed under definite superiors. These two
latter elements, if efficient (if not, they would be mischievous rather
than useless), I consider would elevate and leaven the mass.

[Sidenote: Religious Orders.]

4. It may or may not be desirable to incorporate into the work, either
temporarily or permanently, members of Religious Orders, whether
English or Roman Catholic, or both, who may, with the consent of their
Superiors, enter hospitals nursed under the above system, upon the
definite understanding of entire obedience to secular authorities in
secular matters, and of abstinence from proselytism.

[Sidenote: Their Advantages.]

5. Great and undoubted advantages as to character, decorum, order,
absence of scandal, protection against calumny, together with,
generally speaking, security for some amount of religious fear, love,
and self-sacrifice, are found in the system of female Religious Orders.

[Sidenote: Advantages of Hired Labour.]

6. On the other hand, the majority of women in all European countries
are, by God’s providence, compelled to work for their bread, and are
without vocation for Orders.

In England the channels of female labour are few, narrow, and
over-crowded. In London and in all large towns, there are accordingly a
large number of women who avowedly live by their shame; a larger number
who occupy a hideous border-land, working by day and sinning by night;
and a large number, whether larger or smaller than the latter class is
a doubtful problem, who preserve their chastity, and struggle through
their lives as they can, on precarious work and insufficient wages.
Vicious propensities are in many cases the cause, remediless by the
efforts of others, of the two first classes: want of work, insufficient
wages, the absence of protection and restraint, are the cause in many
more.

Perhaps the work most needed now is rather to aim at alleviating the
misery, and lessening the opportunities and the temptations to gross
sin, of the many; than at promoting the spiritual elevation of the few,
always supposing that this latter object is best effected in an Order.

At any rate, to promote the honest employment, the decent maintenance
and provision, to protect and to restrain, to elevate in purifying, so
far as may be permitted, a number, more or less, of poor and virtuous
women, is a definite and large object of useful aim, whether success be
granted to it or not.

The Orders remain for the reception of those women who either are or
believe themselves drawn to enter them, or who experience their need of
them.

[Sidenote: Main Object of Hospitals: Distinct Functions of Hospital
Clergy and Hospital Nurses.]

7. The care of the sick is the main object of hospitals. The care of
their souls is the great province of the clergy of hospitals. The care
of their bodies is the duty of the nurses. Possibly this duty might
be better fulfilled by religious nurses than by Sisters of any Order;
because the careful, skilful, and frequent performance of certain
coarse, servile, personal offices is of momentous consequence in many
forms of severe illness and severe injury, and prudery, a thing which
appears incidental, though not necessarily so, to Female Orders, is
adverse to or incompatible with this.

[Sidenote: Objections to Amalgamating Members of Orders with Secular
Nurses.]

8. Grave and peculiar difficulties attend the incorporation of members
of Orders, especially of Roman Catholic Orders, into the work. And,
both with reference to the Queen’s hospitals, and still more to
the civil hospitals, I humbly submit that much thought, and some
consultation with a few impartial and judicious men, should precede
the experiment of their introduction. This appears to me one of the
most important questions for decision. Should it be decided in favor
of their introduction, I trust it may be resolved to do so only
tentatively and experimentally.

I confess that, subject to correction or modification from further
experience or information, my belief, the result of much anxious
thought and actual experience, is, that their introduction is certain
to effect far more harm in some ways than it can effect good in
others; that a great part of the advantages of the system of Orders
is lost when their members are partially incorporated in a secular,
and therefore, as they consider, an inferior system; and that their
incorporation, especially as regards the Roman Catholic Sisters, will
be a constant source of confusion, of weakness, of disunion, and of
mischief.

Saint Vincent de Paule well knew mankind, when he imposed, amongst
other things, the rule on the Sisters of his Order never to join in
any work of charity with the Sisters of any other Order. This rule was
mentioned to me on an occasion which gave it weight, by the Superior
of the Sisters of Charity of one of the two Sardinian Hospitals on the
Heights of Balaklava, in the spring of 1856, and by the _Mère Générale_
at Paris, October 1854, when she was solicited by me, with the assent
and sanction, both of the English and of the French Governments, to
grant some of her Sisters to us at Scutari.

[Sidenote: Ladies]

9. As regards ladies, not members of Orders, peculiar difficulties
attend their admission: yet their eventual admixture to a certain
extent in the work is an important feature of it. Obedience,
discipline, self-control, work understood as work, hospital service
as implying masters, civil and medical, and a mistress, what service
means, and abnegation of self, are things not always easy to be learnt,
understood, and faithfully acted upon, by ladies. Yet they cannot fail
in efficiency of service or propriety of conduct--propriety is a large
word--without damaging the work, and degrading their element. Their
dismissal (like that of Sisters) must always be more troublesome, if
not more difficult than that of the other nurses.

It might be better not to invite this element; to let it come if it
will learn, understand, and do what has to be learnt, understood, and
done: if not, it is better away.

It appears to me, but I may be quite mistaken, that, in the beginning,
many such persons will offer themselves, but few persevere; that in
time a sufficient number will form an important element of the work;
more is not desirable.

It seems to me important that ladies, as such, should have no separate
status; but should be merged among the head-nurses, by whatever name
these are called. Thus efficiency would be promoted, sundry things
would be checked, and the leaven would circulate.

There are many women, daughters and widows of the middle classes, who
would become valuable acquisitions to the work, but whose circumstances
would compel them to find their maintenance in it. These persons would
be far more useful, less troublesome, would blend better and more
truly with women of the higher orders, who were in the work, and would
influence better and more easily the other nurses, as head-nurses, than
as ladies. Whether or not the better judgment of others agrees with
mine, my meaning will be understood.

In truth the only lady in a hospital should be the chief of the women,
whether called Matron or Superintendent. The efficiency of her
office requires that she should rank as a lady and an officer of the
hospital. At the same time, I think it important that every Matron and
Superintendent, (unless during war-service, when the rough-and-ready
life and work required will probably be best undergone by women of a
higher class) should be a person of the middle classes, and if she
requires and receives a salary, so much the better. She will thus
disarm one source of opposition and jealousy, and enough will remain,
inseparable from her office.

The quasi-spiritual dignity of Sisters of Mercy is a thing _sui
generis_. But the real and faithful discharge of the duties of the
wards of a General Hospital, whether with reference to superiors,
companions, or patients, is incompatible with the status, as such,
of ladies. The real dignity of a gentlewoman is a very high and
unassailable thing, which silently encompasses her from her birth to
her grave. Therefore, I can conceive no woman who knows, either from
information or from experience, what hospital duties are, not feeling
as strongly as I do, that either the assertion or the reception of the
status as such of a lady, is against every rule and feeling of common
sense, of the propriety of things, and of her own dignity.

[Sidenote: Religion.]

10. The question of the mode of Religion is an all-important one, and
the choice of a mode bears far more directly upon this work than may,
at first sight, appear. To give up the common ground of membership of
the National Church is to give up a great source of strength.

[Sidenote: St. John’s House.]

St. John’s House, if it steers clear of the rock of prudery,
undoubtedly possesses great advantages over a system of hospital
nursing by promiscuous instruments. Not because it includes a
Sisterhood, a system, in which I, for one, humbly but entirely
disbelieve; but because the laborious, servile, anxious, trying
drudgery of real hospital work (and to be anything but a nuisance it
must ever remain a very humble and very laborious drudgery), requires,
like every duty, if it is to be done aright, the fear and love of God.
And in practice, apart from theory, no real union can ever be formed
between sects. The work now proposed, however, must essentially forbear
to avail itself of the bond of union of the National Church.

[Sidenote: Only Women of Unblemished Character should be employed.]

11. None but women of unblemished character should be suffered to
enter the work, and any departure from chastity should be visited with
instant final dismission. All applications on behalf of late inmates of
penitentiaries, reformatories, of all kinds and descriptions, should be
refused. The first offence of dishonesty, and, at the very furthest,
the third offence of drunkenness, should ensure irreversible dismissal.
No nurse dismissed, from whatever cause, should be suffered to return.

[Sidenote: Provision for Old Age.]

12. It is very important, if possible, to make provision for the
disabled age of deserving nurses. It does not seem to me, I speak
very diffidently, desirable to concentrate them in one or more large
buildings. I believe half the inmates of half the alms-houses, &c.,
are not on speaking terms with each other. John Bull is of a peculiar
idiosyncrasy: nowhere are there such homes as in England, but life in
community does not seem congenial here. A pension and the option of
ending their days in solitary quiet, or with some friend or relation,
would probably be the most comfortable arrangement for nurses.

[Sidenote: Progressive Increase of Wages.]

13. Many women are valuable as nurses, who are yet unfit for promotion
to head-nurses. It appears to me that it would be very desirable to
have an intermediate recompense: say, after ten years’ good service, to
raise nurses’ wages; after a second ten years, to raise them further.

[Sidenote: Fixed Age for Admission and Retirement.]

14. There should be an age for the reception and for the retirement
both of nurses and head-nurses. I think no head-nurse should be under
thirty.

[Sidenote: Simplicity of Rules, Definition of Authorities.]

15. Simplicity of rules, placing the nurses, in some respects,
absolutely under the Medical man, and, in others, absolutely under the
Female Superintendent, is very important; also, at the outset, to have
a clear and recorded definition of these respective limits.

[Sidenote: Economy.]

16. Economy is very important, with regard to the eventual extension of
the work.

[Sidenote: Commencement: Training.]

17. In the event of the nurses not being trained in Her Majesty’s
service, advantage, it seems to me, would attend their beginning in a
great established hospital; unless indeed it should be judged best to
select and train a staff of nurses first in a smaller and quieter one.
Yet much that would be unpleasant in the larger place would probably
be beneficial. The restraint, control, contact with the masters, work,
and order of things of a great and settled place, would materially help
with reference to the nurses.

[Sidenote: Limits.]

18. Common sense will assuredly make the fixed resolve; both to fulfil
one’s duty, and to keep within it. It is as essential to do the latter
as the former, and often more difficult, especially for women; most
especially for hospital-nurses.

[Sidenote: Encumbrance of Public Support or Patronage.]

19. It appears to me most important to be free, once and for ever, from
the injurious, untrue, and derogatory appendage of public patronage:
what is called support in these days always ends in patronage. This
work, truly understood, never has been, never will be, never can be, a
popular work; for many reasons, one of which is that the public, of all
orders, never can know anything of the real nature of hospital-work.
With the best intentions, it will therefore make perpetual and impeding
mistakes in “supporting” or patronizing it. Its support and patronage
are equally injurious in different ways as regards our masters the
medical men, ourselves the nurses, and people who are neither medical
men nor nurses.

[Sidenote: Caution, Non-expectation, and Trust.]

20. I end as I began. Let nothing be done rashly. Let us not be
fettered with many rules at first. Let us take time to see how things
work; what is found to answer best; how the work proceeds; how far it
pleases God to accept and bless it. Let us be prepared, as I know well
we must be, for disappointments of every sort and kind. What can any of
us do in anything, what are any of us meant to do in anything, but our
duty, leaving the event to God? His Will be done in earth, as it is in
Heaven.


II. NURSES IN CIVIL HOSPITALS.

[Sidenote: Isolation of each Head Nurse and her Nurses.]

1. The isolation of each head-nurse and her nurses appears to me very
important. The head-nurse should be within reach and view of her
ward both day and night. Associating the nurses in large dormitories
tends to corrupt the good, and make the bad worse. Small airy rooms
contiguous to the ward are best. The ward should have but one entrance,
and the head-nurse’s room should be close to it, so that neither
nurse nor patient can leave, nor any one enter the ward, without her
knowledge.

[Sidenote: All to Rank and be Paid alike, with Progressive Increase of
Wages.]

2. All the nurses should rank and be paid alike, with progressive
increase of wages after each ten years’ good service, or a slow annual
rise, which is better.

[Sidenote: Night Nurses.]

3. The night-nurses should be on duty 12 hours, with instant dismissal
if found asleep; 8 hours should be allowed for sleep, and 4 hours for
daily exercise, private occupation, or recreation. If they have no time
to themselves for their mending, making, &c., they do it at night,
sometimes innocently, sometimes to the injury of the patients. I would
not however prohibit occupation at night; as sometimes the ward-duty is
slight; and doing something is far better and more awakening than doing
nothing. This is one of the matters the head-nurse should constantly
look to. I do not fancy, but at present am not positive about, cleaning
or scrubbing at night. The night-nurse should have a reversible lamp,
or something that without disturbing the patient, gives her light,
brighter than the dim fire or gas-light properly maintained in the
wards at night. She should have a room to herself.

[Sidenote: Day Nurses.]

4. The day-nurses should have eight hours’ sleep, and if it be
possible, 4 hours daily for exercise, private occupation or recreation.
They may have one room.

[Sidenote: Nurses to fetch nothing.]

5. All provisions, &c., &c., should be as much as possible brought into
the wards, or to the ward-doors, by lifts. Nothing should be fetched
by the nurses. This would save much time; would enable the nurses to
do more work, and yet have more leisure; and above all, would obviate
the great demoralization consequent on the nurses, patients, and
men-servants congregating in numbers several times daily.

[Sidenote: Patients to fetch nothing.]

6. The patients should be made as useful as possible, consistently with
their capacities, inside the ward; but should be permitted to fetch
nothing to it.

[Sidenote: Scrubbing.]

7. I strongly incline to have the scrubbing done in each ward, by a
nurse assigned for that purpose, and for general attendance when the
scrubbing is done. There should be hours for the scrubbing, before and
after which it should not be done. This whole matter is one on which I
am not positive at present.

[Sidenote: Distribution of Ward Work.]

8. At present, I incline to something of the following scale. Two
wards, single are best, but it might be one double ward, with 40 beds,
served by 1 head-nurse and 3 nurses. The head-nurse to superintend all
things, and to do the dressings not done by the surgeons and dressers,
assisted mainly by one nurse, whom she thus instructs in nursing.
Another nurse to do the scrubbing, and mainly the cleaning, and when
these are over to mind the ward during the remaining hours in turn or
in conjunction with the first nurse. The third to be night-nurse. In
the morning, before dressing begins, and before the night-nurse goes
off duty, all three nurses to clean the ward, make the beds, wash the
helpless patients, &c.

[Sidenote: Hours of Dressing and Poulticing,]

9. Hours of morning and evening poulticing and dressing to be fixed.

[Sidenote: and of Medicine.]

10. Hours of administration of medicine, always except at night given
by head-nurse, to be fixed.

[Sidenote: Hours of Exercise, and Holidays.]

11. Hours of exercise of head-nurse and nurses to be fixed, and
arranged with reference to the ward-duties. A fixed occasional holiday
given in turn to the nurses is good. An annual longer holiday for them
and for the head-nurses is good; a fortnight is, I think, a good limit.
The holidays cause inconvenience, no doubt, but on the whole do, I
think, far more good than harm. The holidays should be distributed in
rotation during a fixed time of year, and comprehended in two or three
months, or four at the very outside; and no woman declining her holiday
at the proper time should be allowed it at any other.

[Sidenote: Permission of Matron for extra time out.]

12. No head-nurse or nurse should be out of the hospital before or
after the limit of her daily exercise time, two hours, without written
permission of the Matron. The Matron, I think, should put the cause
and amount of the extension in writing, and report the same to the
Treasurer or Chief Officer, at the next general meeting, whenever it
is called, of the Officers of the Hospital. She will find this a great
protection against petitions. There is not a doubt that the fewer
extraordinary absences, the better.

[Sidenote: Place of Exercise.]

13. Were it possible to have a small garden (in college gardens much
effect and much refreshment is produced by a green sward, a few
trees, some shrubs, a fountain, and some seats), in this, at strictly
separated hours, the men-patients, the women patients, the head-nurses
and nurses, the men-servants, if they choose, which perhaps is not
likely, could walk or sit down. This arrangement would little interfere
with its enjoyment by the dignitaries and their children, who require
it quite as much, and would be found in its results practically and
not poetically useful. Hospitals are, and perhaps must be, in or near
crowded thoroughfares. Streets are miserable places to walk in during
great part of the year. Nurses want and unconsciously crave for fresh
air, and often half-an-hour is better than more, given them close
to their work--and away from the streets, it would be often a great
preservative.

[Sidenote: Caution.]

14. I should, however, be very cautious as to introducing music or
anything of that sort. Hospitals are not tea-gardens, nor homes, nor
meant to be either. Great quiet and some severity of discipline are
necessary, and ought to be exacted.

[Sidenote: Dress.]

15. I think the head-nurses should wear a regulation dress, and the
nurses another; if we adopt the honest word livery, in use in the
hospitals, it will perhaps do no harm. Caps, dresses, aprons, should
be prescribed: whether or not out-of-door dress should be prescribed
is to be considered apart. Each should have three dresses yearly.
Better, I think, avoid washing stuffs; they require endless change to
look decent. Head-nurses and nurses might wear the same dress, and some
difference in the cap would be quite distinction enough.

[Sidenote: Wages.]

16. I incline towards giving the head-nurses £50 a-year, one or two
rooms (one room with an alcove and curtain would be best), fuel and
light. The nurses lodging; the night-nurse a room to herself, the
others together; entire board, fuel, light, and good wages to be
decided upon.

[Sidenote: Furniture.]

17. The nurses’ rooms should be supplied with plain comfortable
furniture. In the large Hospitals the head-nurse furnishes her own
room or rooms, which doubtless promotes her comfort and her care of
the furniture, both desirable things; yet the tendency of many to
accumulate decorations, which take time to clean, &c., is a drawback.
I should be inclined, as an experiment, to try the furnishing plan, or
at least to have some scale as to furniture allowed. A bed, arm-chair,
and sofa; a chest of drawers, wash-hand table or shelf; book-case
or shelves; a little table, and a larger one, a couple of chairs, a
footstool, and a cupboard with broad shelves, are the utmost that can
be required.

[Sidenote: Visitors.]

18. A difficult and important point to settle is the amount of liberty
allowed as to receiving visits. It is desirable on all accounts to make
head-nurses and nurses feel comfortable, and, as it were, at home:
it is also better they should not be unnecessarily out; also London
distances are great, and even omnibus-fare is a consideration; also
it is important to remember that these women are apt to feel and say:
“We are not in a nunnery,” nor should they be. Still upon the whole,
considering the nuisance of ordinary visitors, and the greater nuisance
of extraordinary (_e. g._, visitors to some head-nurses, kind friends
come to see how we are getting on, &c., &c., &c.), I think if it were
possible to make the rule that no visitors are allowed, it would be
a great gain. I am not sure, at present, whether it is possible or
not--still less whether it is possible to keep such a rule, if made.
But, at all events, nurses and head-nurses should only be permitted
to receive visitors on certain days and hours of the week; and those
hours and days should be strictly kept to. In Military Hospitals a
still more rigid rule will be necessary.

[Sidenote: Discharged Patients.]

19. No discharged patients, however previously well-conducted, should
be allowed to visit the wards.

[Sidenote: Graduated scale of Pensions.]

20. Apart from raising the wages of good nurses after every ten years’
service, I think it would well answer to establish a graduated scale
of pensions, for both head-nurses and nurses; beginning with a small
pension after ten years’ good service, increasing every five years
afterwards. Many women are quickly worn out in this life; and it is
equally undesirable to turn faithful worn-out servants adrift without
any provision, or to retain them in duties for which they are become
unfit. It is a question whether there should not be a compulsory
stoppage from wages, in order to entitle the nurses to pension under
conditions.

[Sidenote: No occasional Wards.]

21. Have no occasional wards, or wards for accidental and peculiar
patients.

[Sidenote: Head-Nurse to each Ward.]

22. Every ward, or set of wards, should be under a head-nurse.
Discipline is always defective under other arrangements.

[Sidenote: Religious Influence.]

23. This turns greatly upon a previous question. Every endeavour should
be used to bring the women under the influence of religion, God’s
instrument for saving, strengthening, and comforting souls. So far as
this work depends on rule, system, and superintendence, great things
may be done at any rate--so far as moral influence is concerned, it
can only be hoped for in the channels appointed by Him who turneth all
hearts whithersoever He will.


III. NURSES IN HER MAJESTY’S HOSPITALS.

[Sidenote: Two kinds of Hospital Service for Females.]

1. If their introduction is eventually commanded by the Queen’s
Government, it will be advisable to consider that their service admits
of two distinct kinds.

[Sidenote: The one: its Advantages;]

2. “Their chief duties” may be “taking charge of the linen and
superintending the issue of extras.”

They will thus contribute materially to the comfort and well-being
of the sick; the real difficulties which undoubtedly beset the
introduction of women into ward service will be avoided; and, an
important consideration, not lightly to be discarded, their exclusion
from the ward service will materially diminish the opposition of
adverse masters, some of whom are also unscrupulous masters.

[Sidenote: The other: its Advantages.]

3. On the other hand, I suppose, the experience of every woman,
admitted to ward service in hospitals where women were not before,
is that many lives are actually saved by such admission, which would
otherwise, humanly speaking, be lost. In time of war some ciphers may
be safely added to the many. Any other great emergency, I suppose, but
do not speak from experience, would give the same result.

That the experience of many surgeons is identical, their conduct has
proved; no other testimony, under present circumstances, can rationally
be expected from them.

[Sidenote: Both to be Weighed.]

4. It is often right to begin with the smaller and less-opposed good,
and to introduce gradually, and, as it pleases God, the remainder. It
may be our duty to do this, as to this matter.

[Sidenote: Practical Superiority of the Second.]

5. Practically, it is of little avail to superintend, ever so
carefully, the issue of extras to the sick, unless there is permission
and opportunity to pour the nourishment, perhaps in continual drops,
down the throat of reluctant agony, or delirium, or stupor. And it is
of little avail to have this permission, unless there be also that of
raising the decent covering under which cholera, erysipelas, or the
oppression of long recumbency, or the discharging wound, or the recent
operation lie, and seeing to matters within. It is a further question,
whether the painful cleansing of painful wounds, and the important
minor dressings, as poulticing, which things, generally speaking, never
have been done, and never will be done by surgeons, are best left to
nurses, orderlies, or the patients themselves.

[Sidenote: Its real and great Difficulties.]

6. At the same time, nothing is more pernicious than to under-rate the
objections of opponents. There is no doubt that the admission of women
to ward service is beset with difficulties. These Naval and Military
Hospitals are, and must ever be, peculiar Hospitals, essentially
different in important details from the Civil Hospitals.

Sisters of Mercy, as regards the ward service, are decorous and kind,
and sometimes inefficient and prudish. Nurses are careful, efficient,
often decorous, and always kind, sometimes drunken, sometimes unchaste.

Misconduct of women is far more pernicious in a Military or Naval
Hospital than in any other, as regards the result of things--the crime
is, of course, equally crime everywhere.

[Sidenote: Condense numbers as much as possible.]

7. It appears to me desirable to simplify and condense, as much as
possible, female service in these Hospitals. Let there be as few women,
and these few as efficient and as respectable as can be. Let all that
can really be done by men be so done.

[Sidenote: Only Head Nurses.]

8. Head-nurses are alone, I think, desirable to be employed; I
mean persons of the character, responsibility, and efficiency, of
head-nurses in other Hospitals.

[Sidenote: Classify the Patients.]

9. The patients should be distinctly classed, though, of course, this
is not the Female Superintendent’s business.

There are many pros and cons to the formation of convalescent wards.

It is a question whether convalescent or chronic patients require
female nurses at all.

Of such chronic cases, probably 100 would be efficiently served by one
nurse, having orderlies under her. Of acute cases, probably, one nurse
should take charge of not more than fifty, possibly not more than forty.

[Sidenote: Qualification of Nurses.]

10. The nurses should be strong, active women, of not less than
thirty, nor, I think, more than sixty years of age, of unblemished
character, and should be irreversibly dismissed for the first offence
of unchastity, drunkenness, or dishonesty, or proved impropriety of any
kind.

[Sidenote: Wages.]

11. Their wages, I think, the same as those of head-nurses in Civil
Hospitals--certainly, not more.

[Sidenote: Pensions.]

12. Their pension on the same graduated scale.

[Sidenote: Rules.]

13. Their rules should be simple, very definite, should leave them at
the absolute disposal of the surgeon as to ward matters, and at the
absolute disposal of the Female Superintendent in all other matters.
Their dress should be uniform.

[Sidenote: Duties.]

14. Their duties should be strictly defined, and be consistent with
the Code of Army Hospital Regulations, the revision of which has been
announced.

[Sidenote: Means of Steadying them.]

15. Give them plenty to do, and great responsibility--two effectual
means of steadying women.

[Sidenote: Lodging.]

16. The nurse’s lodging in view of her ward renders her far more
efficient; but this requires some special arrangement. It would not do
to have the chance of the nurse’s being suddenly taken ill, with only
patients and orderlies within immediate reach. Were the nurses’ rooms
so arranged that two or more were on one floor (as is the case in all
Hospitals), and so arranged as to be entirely separate, and yet, when
so desired, easily accessible to each other, which might easily be
contrived, this would probably answer all purposes.

[Sidenote: Food.]

17. Their food should be sent them cooked with some slight variety.
With the plainest intentions nature often revolts from the perpetual
joint of excellent meat in Hospital air and life. The occasional
“potage,” fish, &c., of other systems, are in fact, a refreshing and
palatable change. If, however, avoiding names that shock and frighten,
some slight change of diet could be contrived, the effect would be
good. This is practical and not at all romantic, though it may look the
latter.

[Sidenote: Opinion of honest Military Authority desirable.]

18. Could the honest opinions be had of a few good Military and
Surgical Authorities before beginning, it would be good.

[Sidenote: Female Superintendent-General.]

19. The Female Superintendent-General’s own powers and responsibilities
must be absolutely fixed, and so as not to clash with those of the
Officer (should such an Officer be appointed, as has been elsewhere
recommended), who shall superintend the Hospital attendants.

[Sidenote: Confidential Reports.]

20. Confidential reports must be so modified, as far as women are
concerned, that the humble boon granted to pickpockets, of being
informed of accusations laid to their charge, must be extended to Her
Majesty’s nurses.

[Sidenote: Permanency of the System.]

21. In framing the system and the Superintendent’s own office, let it
be attempted to secure the permanent efficient working, please God, in
ordinary hands. To aim at the best conceivable may lead to failure.
Genius works with ordinary materials, but never constructs an edifice
which it alone can inhabit.

[Sidenote: Quietness.]

22. “In quietness and in confidence shall be your strength.” Quietness
has been from the beginning of its publicity the one thing wanting in
this work. I know the fuss, which from its beginning surrounded it, was
abhorrent to us and was the act of others: but the work, which is all
we care for, has throughout suffered from it. It is equally injurious
and impeding as regards surgeons, nurses, and people, who are neither.
External help in this coarse, repulsive, servile, noble work, for it
is all these things, is truly the reed which pierced the hand that
leant upon it. One hospital, naval, military, or civil, nursed well,
and gradually training a few nurses, would do more good to the cause
than an endless amount of meetings, testimonials, pounds, and speeches,
to say nothing of newspaper puffings, which to-morrow might turn into
revilings. This never will, never can be a popular work. Few good
ones are, for few are without the stern fructifying element of moral
restraint and influence; and though the streams of this are many, its
source is one. Hearts are not touched without Religion. Religion was
not given us from above in impressions and generalities, but in habits
of thought and action, in love of God and of mankind, carried into
action.

         *       *       *       *       *

[Sidenote: Various Systems of Female Nursing compared.]

A very short comparison will here be made between the methods of Female
Nursing in the Military Hospitals of
          Russia,
          England,
          France, and
          Sardinia,
as exemplified in the last War.

[Sidenote: French and Sardinian Hospital Service.]

To do this, a sketch must be partly repeated, which has been already
given, of the organic difference between the Hospital Service of each
nation.

The essential characteristic of the French is, the importance given in
the field to the Divisional Hospital Service over the Regimental.

The Regimental Medical Service treats only those ephemeral cases which
are to be exempted from duty for a day or two. Cases of wounds or
disease likely to last for a term of weeks are sent to the Divisional
Ambulance in the field; those, where disease may possibly last for
months, to the General Hospitals at the base of operations.

The Medical Service of the Sardinians closely resembles the above
in its formation. In the late War, their General Ambulances were at
Balaklava; their General Hospitals at Jeni Koi on the Bosphorus. They
had no Divisional or Regimental Hospitals.

[Sidenote: English.]

In our Army, as is well known, the Regiment establishes its Regimental
Hospital wherever it goes. Theoretically, it is exclusively a
Regimental system of Hospitals; however much, practically, it breaks
down.

[Sidenote: Russian.]

The Russian system can scarcely bear a comparison with ours;
because their Regiments are Divisions. They had a regular system of
transporting the sick and wounded upon the North side of Sebastopol,
then upon Mackenzie’s Heights, then upon Bakschi-Serai, and lastly upon
Simpheropol.

[Sidenote: Female Nurses.]

The adaptation of Female Nursing to the different systems in the
           French,
           Sardinian,
           Russian, and
           English Armies
has now to be noticed.

[Sidenote: Sardinian and French Female Nurses.]

The Sardinians had Sisters of Charity, both in the General Ambulances
in the Crimea, and in the General Hospitals on the Bosphorus.

The principal duties of these admirable women appear to have been the
care of the linen and small stores, and the cooking, much of which they
did with their own hands, for sick officers and men. These duties were
admirably performed. They appeared, besides, to have a certain charge
in the wards, the power of giving “_douceurs_,” the administration
of extras, the seeing to the cleanliness of beds and patients, and
something more precise with regard to sick Officers; but their duties
seemed to be somewhat undefined in their relation to the Infirmiers.
Whether the Sœur or the Infirmier Major were in charge, to see the
duties about the patient properly executed, was rather a problem.

This was still more the case in the French Hospitals, where the “Sœur”
in the wards appeared more of a “consolatrice” and an administratrix of
extras: although, out of the wards, her admirable housekeeping, both in
the kitchen and the linen-store, was predominant.

The French “Sœurs” were not admitted to the Divisional Ambulances
in the front: it was whispered, because of the corruption of
the French Intendance, upon whom they tacitly exercised a very
inconvenient “surveillance.” They served in all the General Hospitals
at Constantinople; and to their admirable services, M. Baudens,
Inspecteur-Général en Crimée, has rendered an “_éclatant témoignage_”
in his “Mission Médicale en Orient,” published in the numbers of the
“Revue des Deux Mondes,” of February 15, April 1, and June 1, 1857.

In these French Hospitals of Constantinople, the “Sœurs” appeared to do
all the cooking for the sick Officers and that of the extras for the
men.

I do not think that, in either French or Sardinian Hospitals, the
care of bed-sores and such like, which can only be done by women, was
sufficiently given to the “Sœurs.”

I have heard complaints made of this kind both by Officers and men; and
“Sœurs,” both French and Sardinian, have been to me to look at the way
in which we treated bed-sores, and to borrow air-pillows and water-beds.

There is such a difference however in different Hospitals, in time of
war and of peace, &c., that I would not be understood to mean that any
of these remarks apply absolutely or generally, but only to Hospitals I
have seen.

It may be as well to mention that, talking of “French” and “Sardinian”
Sisters, they all come from one “Maison Mère,” that of the “Filles
de la Charité de S. Vincent de Paule,” at Paris. There is a “Maison
Succursale,” at Turin. But all are of the same Order, and under the
same head.

Let me mention Sœur Cordero, the excellent Superioress of all the
Sisters employed in the Sardinian Hospitals of the war, with the
warmest affection and respect. She was a woman of high rank, of the
most captivating manners, but of the utmost simplicity of character,
and of unfailing devotion to right and to God.

[Sidenote: Russian.]

It remains to mention the Russian system, which, as regards the
organization of the duties of the “Sisters,” appeared to me by far the
best I have known. I am at a loss to conceive what is meant by the
following sentence in the Report by two of our Army Medical Officers on
the “Russian Medical Department,” presented to the House of Commons.
Speaking of the Sisters of Mercy, who are generally widows of officers,
it is said “their chief duties appeared to be in taking charge of the
linen and superintending the issue of extras.” This is founded on error
of observation--as the Russian system seems to be the only perfectly
organized system of female attendance in Military Hospitals, which was
developed in the Crimean War. In it, the Sister has charge of all that
relates to the bed-side of the patient; she receives the orders from
the Medical Officer, attends him in his rounds; he confers with her
afterwards; she even reports the “felchers” or dressers, as also the
orderlies, as far as regards their discharge of duties at the bed-side
of the patient. The orderlies are, of course, under the control of a
Non-commissioned Officer, in all that pertains to discipline, clothing,
meals, &c. The “felchers” are under a superior “felcher,” and under the
Medical Officers.

There are female nurses, wives and widows of soldiers, under the
“Sisters,” who are generally, as has been stated, widows of Officers.

This appears the nearest approach to good organization I have met with.

But again I say there may be much difference among the Russian Military
Hospitals. I would not be considered as laying down an absolute
experience.

[Sidenote: English.]

It has been said elsewhere what was the system or no system pursued
in the English Military Hospitals, as to Female Nursing. It was a
new thing, and no General Order or Warrant was ever issued as to the
duties of the nurses. Many duties clearly devolved upon the Female
Superintendent-General, as she was afterwards called in “General
Orders,” which never should devolve upon her again.

[Sidenote: Proposed Duties of Female Nurses in Military Hospitals.]

But it may be now clearly enunciated what the duties of Female Nurses
should be, and many reasons will subsequently be given why there never
will be discipline in Military Hospitals till they are as follow:

Women only of the character, efficiency, and responsibility of Head
Nurses in other Hospitals should be admitted into Military ones. They
should have charge and be responsible for all that pertains to the
bed-side of the patient; for his cleanliness, and that of his linen,
bed, and utensils; for all the minor dressings, not performed by
Surgeons or Dressers; for the administration of medicines, and of the
meals; for the obedience of the patient and orderlies to the orders of
the Medical Officer. They should receive the orders of the latter, and
always attend him in his visits.

Till the above is done by women, the same want of discipline, now to
be observed in Military Hospitals, and often already noticed, will
continue,--such is my firm belief, the result of much experience.

[Sidenote: Duties which should be left to men.]

There will be abundance left for the Ward Master or Serjeant to do
in taking Military charge of the Hospital and its inhabitants, in
being Office Clerk, &c., _i. e._, keeping the Admission books, making
States, Returns, Accounts, and other documents, without his being
Head-Nurse, without his superintending the Orderlies at the bed-side,
his administering medicines, &c., which can only be satisfactorily done
by a woman. And, when done by her, there will still be ample work for
two men, where one does now the work of three.

The first should do the Military part, the second should compound,
take charge of Medical and Surgical stores, of Returns and Accounts
connected with these; and, where there is no Purveyor, of Purveyor’s
and Barrack stores, provisions, cooking, washing, diets, and extras,
including Returns and Accounts connected with these.

As it is, there is one Hospital Serjeant, who is Ward-Master, Serjeant,
Steward, Clerk, Dispenser, Purveyor’s Clerk, and Head-Nurse--a kind of
“Maître Jacques,” as in Molière’s “Avare.”

One man cannot do all these things.

A Female should be the Head-Nurse--a Serjeant should be the Serjeant
and Clerk--a Ward-Master the Steward, Dispenser, Ward-Master, and
Purveyor’s Clerk.

And here I must deplore the confusion unavoidable in these definitions
of proposed duties, while we have no separate system for Regimental and
General Hospitals.

What Dr. Menzies declared, in his evidence as to the General Hospitals
at Scutari, is strictly true, and one great cause of our failure at
Scutari:--“I have followed the general rules for Regimental Hospitals,
so far as I could.”

While Regimental Hospitals are what they are, females never can be
admitted there. On the other hand, if General Hospitals be established,
one happy consequence will be that the cooking and washing will
be taken out of the hands of the Hospital Serjeant, and regularly
organized, it is hoped under a Captain-Superintendent of Orderlies. All
Purveyor’s and Barrack stores, that is, Hospital stores and furniture
will, it is hoped, fall under the charge of a Steward; Medical and
Surgical stores under that of an Apothecary.

It will only remain to place a female Head-Nurse in charge of all that
concerns the bed-side of a patient, and the duties of the Orderlies
about the bed-side, and a Ward-Master in charge of everything else
belonging to the Orderlies and Patients.

But, if it should be determined to retain everywhere the old Regimental
system, it is only just to add this very strong testimony and appeal in
favour of the old Hospital Sergeant, who indeed deserves it:--

 “I may take this opportunity of stating my conviction that, from
 the very arduous, constant, and responsible duties of the Hospital
 Sergeant, and his influence for good or ill among the non-commissioned
 officers and men of the regiment, it is particularly required for the
 good of the service that he should be put at least on the same footing
 in rank and pay as a first-class staff sergeant. He ought to pass
 an examination by a Board of Medical Officers as to his fitness for
 compounding medicines on the same footing as a druggist in England. My
 Hospital Sergeant, who has been eight years a sergeant, three of which
 as Hospital Sergeant, receives at present 1_s._ 10_d._ pay per diem,
 and an allowance of 4_d._ per diem as Hospital Orderly; at the same
 time that there are sergeants in the ranks of the regiment four years
 junior to him as a non-commissioned officer who are receiving 2_s._
 10_d._ pay per diem.

 “My experience leads me to consider that the regimental bandsmen are
 not, as a body, likely to be sufficiently strong or able men for the
 duty of carrying the wounded to be consigned to them.
  “(Signed)
  THOMAS LONGMORE,
  “_Surgeon 19th Regiment_.”



NOTE IN REGARD TO THE RUSSIAN NURSES EMPLOYED IN THE WAR-HOSPITALS OF
THE CRIMEA.


The Russian nurses, in the opinion of their Master, the famous
surgeon, Pirogoff, did other things besides what the Army Medical
Director-General told the House of Commons they did. But it is to be
observed--

In the first place, that much allowance is to be made for the confusion
incident to Scotch and Russian surgeons talking French together, and
going over many subjects in a very short time.

And in the second, that very likely some extra confusion arose in
the minds of our Army Medical Officers from the fact of two entirely
different sets of women having served in the Russian War Hospitals,
viz.:

(1.) The Sisters of the Elevation of the Cross.

(2.) The “Frauen des Barmherzigen Wittwen Instituts,” (mentioned
in a very cold manner in pages 4, 26, and implicitly, 27, of
Professor Pirogoff’s pamphlet, “Die Gemeinschaft der Schwestern zur
Kreuz-erhöhung. Berlin: 1856”); who are those spoken of at pp. 22, 23,
above.

The Widows were so instituted, about forty years or more ago, by Mary
of Wirtemberg, during so many years the venerated Empress-Mother. It is
quite possible that in the war-pressure their services proved rather
nondescript, they being neither sisters nor nurses, strictly speaking;
or perhaps the sole reason why Professor Pirogoff has not one good word
for them is, that they were not under his orders.

The Sisters of the Elevation of the Cross were a body of secular women,
with a few Sisters of Mercy, formed by the Grand Duchess Helena, and
placed by her under the orders of the famous civilian Surgeon Pirogoff,
to whom the supreme surgical command in Sevastopol was virtually
given. Several things are incidentally mentioned concerning them in
his pamphlet, quite inconsistent with the constitution of an ordinary
religious order.

One or two things in the pamphlet are incongruous enough to English
ideas:--the narrative given, however simply and succinctly, of the
performances of the sisters by name, the publication of the Professor’s
evident disagreement with the first “Oberin,” or Superior, who served
ten months, (the second, whom he so highly praises, had only served
two when he wrote); the improvement, by which the Sisters’ concerns
were “sat upon” by the Comité of Oberin, Chaplain, Doctor, and elder
Sisters, &c., &c.

But the division of Professor Pirogoff’s war-nurses into three
categories is a pregnant hint for future service, please God we yield
it. These three categories consisted of (1) the “Verband-Schwestern,”
or those who assisted the Surgeon in the dressings, and the
“Feld-scherer” (Dresser) in preparing them. (2) The “Apothekerinnen,”
or those who were in charge of all medical appliances for immediate
use, and who superintended the “Feld-scherer” (Dresser) in the
administration of medicines. (3) The “Wirthinnen,” who looked after
the diets, clean linen, &c., of the patients, and the order of the
hospital. Each “category” was responsible for carrying out the orders
of the medical officers. To every Hospital-_Baracke_ (hut) was attached
one sister of each of the above descriptions.

In ordinary service the less nurses know of each other’s wards the
better--in war service it is essential that as few women should serve
as many sick as possible; and it is impossible to attempt assigning to
each nurse the entire supervision of a ward. I think the categories,
modified, of course, and adapted to the Queen’s service, might be most
useful.

Another point usefully proved by Professor Pirogoff’s pamphlet is the
extreme importance, if it be possible, of placing the nurses clearly
under the orders of the Principal Medical Officer, though a further
point is, if possible, to be secured, viz., that of the Principal
Medical Officer being favourable to their service. As women they
should be entirely under the control of their female superior, yet the
Principal Medical Officer should have a certain clear amount of power
in ordering that Superior as to their employment at particular stations
and on particular services.

The _Transport Abtheilung_ of the Russian sisters seems to have been
an admirable, though very unpretending service. We might take a useful
hint from it. Three Sisters accompanied the more numerous[1] convoys of
Sick Transport from Simpheropol to Perekop, and provided the sick with
tea, sugar, clean linen, medical and surgical appliances, &c., on the
way.

FOOTNOTES:

[1] According to Professor Pirogoff sick were almost daily sent
from Simpheropol to Perekop. They could not, therefore, be always
accompanied by Sisters.



SUBSIDIARY NOTES AS TO THE INTRODUCTION OF FEMALE NURSING INTO MILITARY
  HOSPITALS IN PEACE AND IN WAR.


It is, perhaps, advisable first to speak of some of those difficulties
met with in the War Hospitals of the East, in order that such may be
prevented for others who may in future be Superintendents-General of
Nurses in Military Hospitals whether in peace or in war.


I.

No one ought to undertake a matter of duty of this kind without first
obtaining the consent of the War Office to five conditions.

1. That every month, each of her sub-Superintendents shall furnish
her with an abstract of the requisitions made by her on the Purveyor,
whether for Nurses’ consumption, or for that of Patients, and that she
furnish the War Office with an abstract of these. It is then the part
of the Purveyor to disprove her accounts, instead of its being, as
before, her part to disprove his.

2. That it be made a point of honour, not of grace, with the War
Department, to submit to her any Report, confidential[2] or otherwise,
made concerning the Female Nursing Staff; a condition, without which it
would be impossible to have respectable women in the Military Service.

3. That the powers of the Superintendent-General shall be strictly
defined, and put in “General Orders” in the first place, and not in
the last, in order that there may not be the useless and endless
correspondence which there was in the first Superintendent-General’s
case (and for what?).

4. That the Superintendent-General have the power of communicating
directly with the War Department; and that her Money-Accounts be sent
in by her directly to that Department.

5. That it be made a point of honour that the Medical Officers
communicate to the Superintendent-General, or Local Superintendent, any
complaint they may have against the Nurses for disobedience.

In March 1856 the following appeared in “General Orders.” Had it but
been seventeen months earlier how much it might have saved![3] The
definition of the Superintendent-General’s powers and duties, therein
contained, is all that is wanted to prevent irregularities disastrous
to the Service.

GENERAL ORDERS.

  _March 1856._

“It is notified, by order of the Secretary of State for War, that Miss
Nightingale is recognized by Her Majesty’s Government as the General
Superintendent of the Female Nursing Establishment of the Military
Hospitals of the Army. No lady, sister, or nurse is to be transmitted
from one Hospital to another, or into any Hospital, without previous
consultation with her. Her instructions, however, require her to have
the approval of the Principal Medical Officer, in her exercise of the
responsibility thus vested in her.

“The Principal Medical Officer will communicate with Miss Nightingale
upon all subjects connected with the Female Nursing Establishment, and
will give his directions through that lady.”


II.

_Nurses._

1. Our Nurses were of four sorts.

          Nuns.
          Sisters (Anglican).
          Ladies.
          Nurses.

The Nuns were received not as Nuns, but as Nurses.

Their (so called) training told sometimes against us; sometimes for us.
The same with the “Sisters” (Anglican).

The Ladies were useful, exactly in proportion as they approached the
professional, and not the dilettante, mode of thought.

A larger proportion of paid Nurses than of Ladies did well, and this
under circumstances of peculiar temptation. Paid Nurses are always the
most useful.

2. There should always be a proportion of Nurses in Army Hospitals

     To preside in Extra Diet Kitchens,[4]
           ″    in Linen Stores.
     To teach the Orderlies to nurse in the Wards.

The proportion of Roman Catholic “Sœurs,” in French Military Hospitals,
is as small as this would be; they undertake even less duty than this:
in Military Hospitals they do much less than in Civil Hospitals.

Women in Military Hospitals should all be contracted servants, whether
Nuns, Ladies, or professional Nurses.

There should be a retiring pension to each woman.

3. Miss Nightingale took service on the ground of being under the
Principal Medical Officer, and, consequently, of not interfering with
him.

There was no _imperium in imperio_ in her case.

This exists in the case of the French “Sœurs de Charité,” and existed
in individual instances among the “Sisters” under Miss Nightingale;
_i. e._, they gave articles of diet, &c., as from Sisters, not in
obedience to Medical orders. This was immediately put a stop to by
her. That the Medical Officer is sole master of diets, is an axiom of
medicine, and of common sense.

This involved our only _answering_ the Extra Diet Rolls in our
kitchens; not originating either in quantity or quality.

Afterwards, although frequent were the insinuations that we
transgressed the above maxim, no evidence of the fact was ever
obtained, except the following, which is given _verbatim_ and
_literatim_, as “put into Court” by a First Class Staff-Surgeon, in
charge of one of the divisions of the Barrack Hospital, Scutari. He
alleged “that the Nurses were in the habit of giving diets without
leave;” and when pressed for the facts, produced the annexed statement
in “W. J. Northcott’s” handwriting.

 “2447. Pte. John M‘Cormick, L. T. Corps, age twenty, 11 Company,
 admitted into 6 Ward, F. Corridor. Admitted with Febris C. C.,
 April 30th, 1856. On or about the 10th of May I was confined in the
 Garrison Cells, Scutari, for allowing food and drink to be brought to
 this Patient, by one of Miss Nightingale’s Nurses; and at the time
 it was brought I were on duty at the Victoria Barracks, Scutari,
 three-quarters of a mile from the Hospital, and never saw the Nurse,
 food, or drink that was administerd to the above-named Patient, and
 I never saw the docter that ordered me to be confind. I was confind
 by order of 1st Class Staff-Surgeon Prendergast. About two and a half
 hours after I were aquanted with the case.

  “(Signed)
  173. W. J. NORTHCOTT,
  “A.W.M., M S.C.”


III.

[Sidenote: 1. Lay down distinctly the communication which is to take
place between Director-General and Superintendent-General, and (in war
and abroad) Principal Medical Officer and Superintendent-General, and
the qualified subordination of the latter.]

1. In defining the office and duties of the Superintendent-General of
Nurses, her direct communication with, and qualified subordination to,
the Director-General of the Army Medical Department, and, abroad and
in war, with and to the Principal Medical Officer of the district,
or equivalent, must be very exactly defined. If the formation and
government of a body of women to serve in the Hospitals of the Army
Medical Department, and in these alone, is contemplated, the less
the Director-General and the Superintendent-General have to do with
each other, in matters of detail, the better, and the less chance of
collision. For very weighty moral and practical reasons, the sole
government of the women must belong to the Superintendent-General, and
to the Matrons, whom she delegates, and who are themselves responsible
and amenable to her. But it will never _work_ to introduce female
service into the Army Hospitals, and to leave the Director-General
of the Army Medical Department, which, like everything else in the
Army, is and must be a hierarchy, no other power in connection with
it, than to write and encourage confidential reports against it. There
ought to be a definition of the Superintendent-General’s position as
regards him, and also, as regards the Principal Medical Officer of the
district, abroad and in war. It is useless, and would be dangerous to
evade this; it ought to be deliberately settled, and distinctly stated.
In the “General Orders” of March 1856, the Superintendent-General’s
complete power over the women, and qualified subordination to the
Principal Medical Officer, are well and definitively expressed.

It is impossible to appoint the work of the Nurses without the
concurrence of the Director-General. It does not do to put a woman
into a great ward, or several smaller wards, of men, with several
orderlies, without clearly defining her position there. To put her
under the orderlies would be to make her being there at all much worse
than useless; but she cannot have assigned to her the responsibility of
the ward or wards, and consequently, authority over both orderlies and
patients, herself being responsible to the Surgeon and Matron, without
the concurrence of the Chief of the Army Medical Department.

Nor, without such concurrence, can the duties of the Nurses be
assigned. At this moment there are extant two sets of Regulations--the
old Army Hospital Regulations, and those of 1855 made for the late
Medical Staff Corps. In these Regulations, both the former and the
latter, every duty a Nurse can discharge is assigned to different
men. The responsibility of the ward, the administration of diets
and medicines, the application of poultices, fomentations, leeches,
enemas, and minor dressings, are all in so many words assigned as the
duties of Assistant-Surgeons, of Hospital-Serjeants, and Orderlies; and
of Assistant-Surgeons, of Ward-Masters and Orderlies of the Medical
Staff Corps. The Regulations in general are being revised;--so much
the better. But the new body of Orderlies, announced in the “Gazette”
as the Hospital Corps, will, of course, receive rules from the
Director-General; and if these things are not settled with him, there
will be contradictory rules in operation, which will most materially
thwart the working of the Female Service.

We have ourselves experienced this, as to the administration of
medicines, which one Principal Medical Officer took away from the
Nurses, saying that it was the duty of the Assistant-Surgeons, in which
he was borne out by an existing Regulation. And it would really seem as
if this were the intention of the said Regulation, for it is there laid
down that the medicines are to be administered twice-a-day, as if this
were a property of medicine.

The existence of these Regulations proved also a great stumbling-block
in the Castle Hospital, after the war-pressure was over.

Unless the Director-General, and in war and abroad, the Principal
Medical Officer, are brought into regular communication with the
Superintendent-General of Nurses, by the Rules, they will, at every
inspection of Hospitals, revert to the procedure of giving orders
and making alterations, which in fact amount to reprimands on the
Superintendent-General, and on her Matrons, through the medium of some
Clerk or Orderly. There should be, therefore, a distinct channel of
communication laid down between the Director-General, and in war and
abroad, the Principal Medical Officer and the Superintendent-General of
Nurses.

[Sidenote: 2. Also between Principal Medical Officer and Matron,
Staff-Surgeons and Matron, Staff-Surgeons and Nurses, and the qualified
subordination of the Matron and Nurses.]

2. Also, and in the same way, there should be distinct rules for direct
communication between the Principal Medical Officer of each Hospital,
and the Matron, and between the Staff (or equivalent) Surgeons of the
Hospital, and the Matron; if not also between these latter and the
Nurses.

The constitution of a General Hospital is about to be organized in
England. In the large War Hospitals there was the Principal Medical
Officer, a Staff-Surgeon in charge of each Division, then the
Assistant-Surgeon, who answered to what, as is now proposed, is called
the Prescribing Medical Officer of the Wards. As regards the Matrons
and Nurses, it must not be proposed to ignore all but these Prescribing
Medical Officers. Certainly, it would never do to give the Superior
Surgeons of the Hospital no _say_ as to the nursing. In 999 cases out
of 1,000, the Superior and older Surgeon is the one who understands and
cares much the most about the men, and who, therefore, in the long run,
would more appreciate and be fairer to Matrons and Nurses who did their
duty by them. The Superior and older Surgeons too, in general, have
far more correct ideas of the importance of discipline in a ward, and
of the ways of maintaining it, than the Assistant-Surgeons. Moreover,
as far as one can judge on a mysterious subject, generally speaking,
the older and Superior Surgeon is the honester man. He must be brought
into direct communication with the Matron; this will effect good, and
prevent mischief. So also let the Staff-Surgeon of the Division, or
equivalent, be placed in direct communication with the Nurses of the
wards of his Division; this will effect good and prevent mischief. If
the Nurse is to trust to receiving the orders of the Staff-Surgeon,
through the medium of the Assistant-Surgeon, she will often find
herself in a false position.

[Sidenote: 3. All the General Hospitals cannot be undertaken at once.
(The material of Head-nurses to be created.) Secretary of State
should be made aware that the Female Service can only be introduced
gradually. Director-General must have a voice in the introduction.
Director-General and Superintendent-General differing, Secretary of
State to decide.]

3. Now, as to the introduction of Nurses into all General
Hospitals--this gets rid of many difficulties, but at a fearful cost.

For years to come, the difficulty will be not to extend the work,
but to serve such Hospitals as must be undertaken, with respectable
and efficient women. The material has, in a great degree, to be
created; abundance of applications will be received--the prospect
of a pension alone will do that--but the real choice will be very
limited. In these Military Hospitals each Nurse must be a Head Nurse,
and a trustworthy woman. Many a woman who will make a respectable and
efficient Assistant-Nurse under the eye of a vigilant Head-Nurse,
will not do at all when put in a military ward or wards, herself the
only woman, and Head-Nurse over the Orderlies. As a body, the mass
of Assistant-Nurses are too low in moral principle, and too flighty
in manner, to make any use of here. Supposing all the Head-Nurses of
the great Civil Hospitals[5] offered themselves, there are perhaps
not many who could be recommended for a _Military_ Hospital. Some,
who are very highly to be thought of, would never bear transplanting
into the _res dura et_ servitii _novitas_ of the Army Hospitals.
The class from which the Head-Nurses are mainly drawn, tradesmen’s
and servants’ widows, &c., will volunteer in numbers, but, in the
majority of cases, intending only to lead the idle life of many a
London Head-Nurse--“mental, not manual labour”--“Superintendence”--
_i. e._, standing by while the Orderlies do her work and their own.
The material has to be created. The rarest powers can do nothing
effective in this, in 3, 6, or 12 months. To lay a solid foundation
will take the patient, anxious labour of years. To begin with one
Hospital would have great advantages. Netley, if it is proceeded with,
might be the one, though, in most respects, a Hospital in an ordinary
vulgar seaport would be far preferable. Then let the work gradually be
extended. It is much more to be feared that the line will be taken of
forcing prematurely than of opposing its extension. If it is attempted
to occupy all the General Hospitals at once, how is the gratuitous
repetition to be avoided of the inevitable misfortune of Scutari,
viz., that of beginning on a large scale, with a number of strangers?
It certainly should be left to the Director-General to regulate the
introduction of Nurses into the General Hospitals--and there is far
more reason to fear that he, if unfavourable to the change, will
hurry, than obstruct such introduction; indeed it might be better to
settle that matter beforehand with the Secretary of State, letting
the Director-General be apprised of it, viz., that time is required to
effect the gradual introduction of the Female Service with which the
Superintendent-General has been charged.

To sum up. A rule must be introduced by which the Director-General
is brought into communication with the Superintendent-General, and
her qualified subordination to him distinctly expressed. Let the
Principal Medical Officer in war also communicate directly with the
Superintendent-General or the person performing her functions in the
War-Hospitals, and her qualified subordination to him be distinctly
expressed. The same with each Principal Medical Officer of a Hospital,
and the Matron of that Hospital. No alteration in these Regulations
can, of course, be made without the consent of the Secretary of State.
In case the Director-General and Superintendent-General finally differ
as to any new arrangements, the matter should be referred to the
Secretary of State.

The Superintendent-General should issue special regulations for nurses,
after conference with the Director-General, and under the sanction
of the Secretary of State; also, local regulations for the Matrons
with the consent of the Principal Medical Officer and sanction of the
Governor of any General Hospital.

If the Matron differ with the Principal Medical Officer, the decision
should rest with the Governor of the Hospital.


IV.

As to some miscellaneous considerations, of no small importance--

[Sidenote: 1. Roman-Catholic Sisters?]

1. It is necessary for a Superintendent-General to have counted the
cost, and to be prepared or not prepared to include Roman Catholic
Sisters among the Nurses. This will deprive her of some valuable women;
of one (speaking for the present time,) who is invaluable; of many
decorous, not very useful women. The question is perhaps settled by
the fact, that where you have the Roman Catholic Sister, you cannot be
secure from the Roman Catholic Direction, with all its many strings,
and machinery of opposition. Abroad the cause of the Roman Catholic
Church is often the cause of religion; and the Romish Priest serves
both zealously at the same time, and with a pure heart. In England,
and in matters of England, the first aim of the Direction is too
often to damage what is not Roman, and the second to promote what is
Christian. Upon the whole I must think Roman-Catholic Sisters are
better out of, than in, the Army Hospitals. It would be right to think
well over how far they could be entirely dispensed with, in the event
of having soon to undertake a War Service.

In the event of a decision being made to dispense altogether with
Roman Sisters, it would be as well to be prepared (though we never can
speculate on the tactics of the Roman faction, and after what occurred
during the Crimean war, it may think it better to take things quietly)
for a battle, (_not_ confined to the Army Medical Department,) for
the production of an Inspector-General’s letter assigning “reasons”
for preferring Nuns to secular Nurses, and for the delivery of sundry
opinions of similar purport, ranging from that line to the one taken
in the paper emanating from the Army Medical Department, extolling the
Russian Nurses, “who were all Sisters of Mercy, and mostly widows of
officers.”

[Sidenote: 2. Anglican Sisters?]

2. The nature of the Service and Rules would, unless in war service,
perhaps exclude English “Sisters” from the Nurses. They supplied us
with some valuable women in the last war, and their Lady-Superior
behaved ever generously, loyally, and well towards us.

The principle and detail of most sisterhoods render them unsuited
for admixture with the secular element; and the comfortable belief
into which the good women (of both branches) practically, if not
theoretically, settle, that secular women are too bad to be mended or
influenced, unfortunately makes their usefulness among Nurses nearly
null. It would never do to unsettle any of the Sisters; but if it so
happened that any voluntarily offered to serve as bonâ fide Nurses,
some valuable individuals might thus be acquired; but this should not
at all be pressed.

It would certainly remove a difficulty in declining Roman Catholic
Sisters, if the rule should be to decline also English Catholic
Sisters, forming the Staff entirely of secular women.

[Sidenote: 3. Whom is the Nurse to summon in case of disorderliness in
the Ward?]

3. In Civil Hospitals there are three distinct elements of government.
First, the Civil Authority; the chief being the Treasurer, or the
equivalent civilian, whose subordinate is called diversely Steward,
Superintendent, House Governor; second, the Physicians and Surgeons
(duly represented, in case of holidays or illness, by the Assistant
Physicians or Surgeons), Apothecary and House Surgeon; and third, the
chief of the Nurses--the Matron.

It requires of course temper, discretion, forbearance, and fortunate
circumstances which do not always happen, for these authorities not to
spend a portion of their time in quarrelling with each other; but the
ruts are old and deep, and the wheels move on, though they often stick.
The Civil Authority is a very important element, especially when the
chief is a man of judgment and firmness, who keeps himself paramount
over all, and does not delegate all to his subordinate the Steward. The
Steward and the Matron generally find their duties disposed to clash.

In some Hospitals the rules are inexplicit in assigning power to the
Matron over all the women. But this apart. The Steward represents and
wields the police of the Hospital. He progresses through the wards, he
perceives, or the Head Nurse reports to him, something disorderly. He
rectifies it (or not, as the case and the man may be). She thus, over
and above her relation to the Matron, has to appeal to, and to account
to, the Steward.

This power of police and discipline, wielded by the Civil Authority
of the Hospital, is of immense moment in regulating the good order
of the Hospital; it acts in sundry important ways which need not be
particularized.

Now, in the case of Military Hospitals, there is one important
simplification of the business, which need not be enlarged upon. All
the patients are men. But there are two things which do not simplify
the machinery of the Military Hospital. The attendants, in the plan
proposed, are not (and cannot be) all Nurses, under the Matron; nor
all Orderlies, under an Officer; there are Nurses under a Matron,
and Orderlies under some Officer; and there is no Civil element.
The Doctors both prescribe, and hitherto have governed. An Officer
orders flogging, &c.; but the Doctors practically both prescribe, and
hitherto have governed. And a Military Hospital must, and should ever
remain, essentially different from a Civil Hospital; both different
in discipline and detail, and altogether a rougher and ruder place.
It should never for a moment be forgotten that the soldier is a very
peculiar individual, old and stern as is his trade. A regiment, if one
thinks _into_ it, is a curious thing. The Hospital which receives these
men when ill and wounded, whether regimental or general, is, and ought
to be, a place essentially different in many things from the great
Civil Hospital. The moral standard of the patients of the Military
Hospital, their readiness to obey, their good feeling to each other,
are strikingly higher than in the Civil Hospital; but the soldier is
what, amidst all his faults, he has been made by the habit and spirit
of discipline, which has become an instinct and a second nature, and
which ennobles his own. Relax discipline, and in proportion as you do
so, there remains of the soldier a being with as much or more of the
brute than the man.

Discipline then being the pivot upon which the good order of all
military things, Military Hospitals included, turns, it follows, that
if you set down a few women (they should not be many) in a great
Military Hospital, unless they can become effectually incorporated into
the general spirit of discipline of the place, they will only injure
themselves and the whole.

As women, the more entirely they are under the government of the
Matron, herself under the government of the Superintendent-General, the
better. As Ward Nurses, the more entirely they are under the orders
of their Surgeons, the better; but they have not only to obey the
Surgeons, they have to enforce the Surgeons’ orders among the patients,
and both for so doing, and for the cleanliness, &c., of the ward, they
have to give orders to the Orderlies.

In the case where a rule will work, by which, if the Nurse has to
complain of an Orderly, she reports the same to the Matron, who lays
the complaint before the chief of the Orderlies (whatever may be fixed
upon as his name); well and good; but a more direct procedure will also
be found necessary.

Every firm and discreet woman (none other is fit for a male ward,
least of all for a military ward), will avoid collisions, reports,
and violent outbreaks in the ward as much as possible. But still,
every now and then these things will happen, and though by all
means to be avoided if possible, when they do come, they clear the
ward-atmosphere like a storm, provided the discipline be strict. Every
now and then--and every experienced Head Nurse will tell the same
story--some disobedience, slovenliness, truculence, or sly impudence,
will arise in the ward, and she will find she cannot put it down
alone. If she remain helplessly deprecating or scolding the men, her
position becomes at once an unseemly and a dangerous one, as that of
all contemned authority is. In such a case, in the Civil Hospital, the
Head Nurse goes straight, according to the nature of the case, to the
House Surgeon or to the Steward, unless the visiting hour be at hand,
and she judges it best to refer to the Surgeon. Discretion is again
here required, as in everything in Hospitals; but between the Surgeon
and the Steward, a firm, discreet Head Nurse will generally get the
ringleader expelled, and two or three others, named or unnamed, warned
of a similar fate. After this sort of explosion, the ward is quiet and
orderly for months. The thing is seldom done, but the patients know it
can be done at any time, and that it will be done, in such or such a
contingency.

Now the soldier cannot be turned out of Hospital, and he knows
he cannot. It becomes the more important not to suffer an hour’s
relaxation of discipline there. If, therefore, such an outbreak, either
on the part of patients or orderlies, should happen in a Military
Hospital, the Nurse ought to be able to summon at once the proper
authority and afterwards to report the whole to the Matron, but first
to bring direct the proper authority into the ward. Whether it be the
Captain of Orderlies or the Orderly Medical Officer, or, as in case
of emergencies, is generally preferable, the Staff-Surgeon himself,
she ought to have power at once to bring the proper authority into the
ward, to put down confusion and restore discipline at once, and then
afterwards to report to the Matron what has passed.

It must never be forgotten, that in every Regiment we must calculate
upon there being two or three thorough scoundrels, five or six men
who are not far off from being so, and an indeterminate number whom
discipline saves from ranking after them. One year with another,
characters no doubt as vile as the worst that disgrace our gaols pass
through the General Hospitals.

Another thing to be remembered is, that whatever classification may
be carried out, we may be certain beforehand that numbers of patients
from a vile cause will be in the ordinary surgical wards of every
General Hospital in time of peace. Very severe cases of this sort give
heavy work, and little trouble. They suffer much generally, alike
from disease and treatment; are frightened, if not ashamed, about
themselves; and are generally extra-submissive and quiet. These cases,
however, generally would belong to the separated wards; which latter
contain usually a large admixture of patients who suffer comparatively
little, and who require to be dealt with with unswerving firmness. For
reasons somewhat too technical to write, it is to be hoped, upon the
whole, that female service will not be, _at first, at all events_,
extended to these wards. The disgusting and comparatively painless
secondary condition will, I fear, find its way into the ordinary
surgical wards, as it does into the equivalent wards of every Civil
Hospital.

All these things would increase the mistake of laying any bar between
the Staff Surgeon and the Nurse. In all matters of discipline,
generally speaking, the Staff Surgeon will give much more support than
the Assistant Surgeon.

A short definite rule should therefore be made, saying whom the Nurse
is to summon in the event of disorderliness in the ward.

One thing more. There is nothing more dangerous than to undervalue the
objections of opponents. Let us give them their full weight, and while
firmly holding our course, and trusting to God to guide it, draw useful
cautions from the objections which we quietly and steadily confront.

In the great Military Hospitals, of Roman-Catholic countries,
intelligent, well-behaved, Army Surgeons, while explaining everything
with thorough business-like precision, if spoken to of the Paris Army
Hospitals, before the recently introduced Sœurs de St. Vincent served
there, and asked what they think upon the whole of the service of women
in Army Hospitals--after a little hesitation, and being urged to speak
plainly, will generally say that they prefer in Civil Hospitals the
service of Sœurs to those of hired nurses--but they deprecate either
Sisters or any women in Military Hospitals. 1. Because the presence of
women, however virtuous and guarded, would excite passions and produce
unfavourable results in many cases. 2. Because they were unnecessary,
the Orderlies being efficient, faithful, kind, and sufficient.

Of the second reason one can judge nothing by a walk through a
hospital, as it does not always follow that what the master says is
enough is so--though this is one of the mysteries it is good to know
and not good to reveal. Of the first there is no doubt. The question
remains, striking the balance of good and evil--Do chaste, guarded,
and efficient nurses on the whole contribute more to the economy of
human life, the order, cleanliness, and decency of a Military Hospital
than they do harm? Possibly the former effects are usual and general;
the latter exceptional and rare: after all, most soldiers are men and
not beasts. But it is well and necessary to bear in mind both the
existence of this danger, and the exaggerated fears many Army Surgeons
conscientiously as well as unconscientiously have of it.

I therefore very earnestly hope that the work will not be encumbered,
at first at all events, with the charge of the venereal wards. And
it is most important, for the favourable result of the anxious and
difficult experiment about to be made, of permanently introducing
female service into Army Hospitals, that we should be quite clear of
the convalescent patients, and should only attend patients severely ill
or severely injured.


[Sidenote: 4. Pay and Rations.]

4. PAY AND RATIONS.--In the great Civil Hospitals the Head-Nurses
have, on an average, 50_l._ a-year, no board, an allowance of fuel and
light, and the use of one or two, generally unfurnished, rooms. The
Assistant-Nurses, on an average, receive about 12_s._ a-week, [£31 per
annum] no board, lodging, with the use of some furniture, sometimes an
allowance of fuel and light, apart from the use of both in the wards.

Both Guy’s and St. Bartholomew’s Hospitals now give partial board to
the Assistant-Nurses, and St. Thomas’s is about to adopt the same plan.

St. Mary’s Hospital gives board to both Head and Assistant-Nurses.

In the last war Her Majesty’s Nurses received, on an average, 18_s._
a-week, lodging and board, fuel, light, and partial clothing--18_s._
a-week is 46_l._ 16_s._ yearly. Incorporated into a permanent Service,
and with a pension, they ought not to receive the latter amount until
after approved years of Service.

It is certainly a different thing to undertake service in a Hospital
in Smithfield or the Borough, and to undertake to go, at a moment’s
notice, to any part of the world. But the Army Service involves this;
and the pension it involves makes a reasonable equivalent for the
additional wear and tear of climate, travel, &c. Going abroad is a
regular part of the Service undertaken.

Any artificial inducements should be avoided; at the same time their
condition should be made a comfortable one. Wages, say 20_l._, rising
to 50_l._ a-year, rations, an allowance of fuel and light, and a small
furnished room, would be enough, and not too much. To this should
be added a fixed annual gift of a few strong articles of regulation
dress;[6] avoiding multiplicity, and securing the things being all
good of their kind. In the last war they had too many things, and
some were rubbish. They ought to be well able to supply themselves
with linen, shoes, &c., whether at home or when ordered abroad. The
articles to be given annually should be three strong dark gowns, six
strong aprons, six caps, six collars, one bonnet--and let the things
be good--biennially or triennially, one summer and one winter cloak.
In India, &c., this might be modified. Their room should be furnished,
because, in removing to and fro, it is better to release them from the
cares and the pretences of furniture; also, because, instead of many
gimcracks, you can thus furnish their rooms with a few comfortable,
strong, plain things, presenting a certain military simplicity, which
ought to pervade a Military Hospital.

Their wages abroad should not be increased. Whether they serve at home
or abroad concerns the Superintendent-General alone, and is no merit or
title for additional advantages on their part.

[Sidenote: Shall Rations be commutable for Mess-money in the United
Kingdom?]

If the principle of rations is considered preferable by the War
Department, it is important to give no extra trouble that can be
helped. If not, it is to be considered whether or not it would be well
to get rid of the rations, in the three kingdoms at all events, for
these reasons:

[Sidenote: (1.) Because such commutation allows greater variety.]

(1.) These women are Head-Nurses. They will think themselves more
comfortable “finding themselves” than managing on the substantial and
somewhat unvarying provisions of the rations. Some take coffee rather
than tea; some tea rather than coffee; many would rather pay for white
sugar than not pay for brown. Considering the nature of nursing-work,
when faithfully done, it is better they should enjoy and be refreshed
by simple meals to their taste than by unpalatable larger portions;
especially if _the former can be done at no additional cost or trouble
to the Queen_.

[Sidenote: (2.) Because it averts complaints.]

(2.) You thus relieve the Superintendent and Matrons of all
communication with the department of the Purveyor-General; of all the
mistakes, accidental or otherwise, which might occur; of all complaints
of quantity or quality of provisions; of amenities such as those
experienced at Balaclava General Hospital, &c., &c., &c.

Of five London Hospitals, the three endowed Hospitals pay all their
Head-Nurses in money, and give no board. (This is strictly correct,
although, to avoid a long unimportant detail, I have simplified things
in this paragraph, and in the two concerning the pay of Head-Nurses and
Nurses.) The London Hospital gives its Head-Nurses wages, and a fixed
quarterly payment _vice_ the rations of bread, meat, and vegetables,
to which they are by the rules entitled. This change was made not very
long ago, to end the frequent complaints of quantity, quality, and
price, made, perhaps with foundation, by the Nurses. The Westminster
Hospital paid its Head-Nurses partly in money, partly in rations of
cooked provisions, and there were repeated and general complaints of
the quality, quantity, and cooking of the provisions issued to them.

It is therefore to be considered whether the simpler and better plan
be not to give the Nurses a fixed money payment, and let them “find
themselves,” unless the War Department object to rations not being
issued in part payment.

Abroad in many cases, in war in all cases, rations would be desirable.
A fixed calculation as to expense should be made.

Experience and consideration will probably give rise to the following
conclusion--except in war and in retired stations abroad, not to
have Rations; still less to let the Nurses “find themselves,” for
the following reasons:--(1.) It is important that the Nurses should
not have this excuse for being absent from their duties--“that they
have been to get provisions.” (When absent, it should be in pursuit
of health and exercise.) (2.) If the Nurse is to cook for herself,
greater accommodation will be required than the _one_ room recommended,
otherwise the necessary cleanliness cannot be observed. To commute
the Rations for mess-money, to put this mess-money in charge of the
Matron, wherever there is a market; wherever there is none, to let her
“_draw_” for such provisions on her own indent, as she thinks best,
upon the Purveyor, appears to me the safest course. For with regard to
this question of dieting the Nurses it should never be forgotten that,
in all cases (how much more in those where great physical fatigue and
mental anxiety are involved) that principle is the best, if such can be
established, which settles diet with a view to producing the highest
physical efficiency. Variety and mode of cooking are two essential
elements in this. And there can be no doubt that, if a Matron will
take the trouble to consult the tastes of her Nurses, together with
the above conditions, a better diet might be laid down than could
be secured by leaving them solely to their unassisted vagaries and
ignorance of what is really the best diet. Community of cooking also
implies economy. Also the Nurse ought not to be permitted to starve
herself, to save money. Her time is too valuable to allow of her
cooking her own dinner; but she should always prepare her own breakfast
and tea, when and of what she prefers herself, if she feels inclined to
do so.

[Sidenote: If not commutable,]

Where, however, the system of rations must be adopted, three ways
remain of working it:--

[Sidenote: (1.) Shall the Nurse cook her own Rations?]

(1.) Let each Nurse receive, and cook her own rations.

[Sidenote: (2.) Shall the Matron cook and send them?]

(2.) Let the rations be delivered _en masse_ to the Matron, who has
them cooked, sending her proportion to each Nurse.

[Sidenote: (3.) Shall the Matron have each Nurse’s Dinner cooked for
her, as she likes best?]

(3.) Let the Matron, requiring a small payment to cover expenses,
arrange that each Nurse can receive her dinner cooked as she wishes
it. There is something of this sort at the London Hospital; where the
Nurses (and Assistant Nurses) have the right of sending their joint to
be boiled or baked in one of the kitchen stoves.

Of these different ways, the first would be liked best by the women--a
thing to be considered, in subordination, and as a help to their
respectability and their efficiency--still it is, for some reasons
stated above, objectionable. However, in this, as in far more important
things, it is essential to consider everything as tentative and
experimental for some years to come. Do not be fettered by too many
rules at first: try different things, and see which answers best.

With regard to rations, it is as well to explain that there were two
ways of drawing them for the nurses during the war. In some of the
Crimean Hospitals, it was arranged that the same ration should be
drawn for a Nurse as that appointed by Regulation for a Medical Staff
Orderly. This answered, as may be supposed, exceedingly ill. There
was considerably more of some articles, such as bread and meat, than
the women could eat; and the surplus had to be wasted or returned to
the Purveyor--a serious complication. Of some articles, such as tea
and sugar, there was as much too little; and these had to be drawn as
extras, except such as the Superintendent-General found it easier and
more simple, as she generally did, to provide herself.

The other method was for the Local Superintendent to draw daily on the
Purveyor for such articles as she judged necessary; and by thus drawing
_en masse_, a considerable saving was, of course, effected for the
Queen, the tastes and health of women were consulted, and there was no
complication of accounts.

Where rations are to be drawn at all the latter method should be always
followed; and as the former might be understood by the word “rations,”
it would be better to call them by some other name, as it must be
obvious that such a method could never answer for women.

The experiment which I should wish to try, by which greater variety
could be secured, but which could only be practised where there was
a market at hand, would be for a commutation to be made of rations
for money. Each nurse to supply her quota of “mess money,” the “mess
money” to be all expended on the “mess,” and the Matron to manage the
“mess” day by day, and arrange for the cooking to be done in common. If
each nurse’s dinner is to be cooked separately, it necessarily entails
great waste of nourishment. The Nurses would not like this so well as
“finding themselves,” but it would ensure them a far better diet.[7]

[Sidenote: Wages and Mess-money must be distinct.]

It would be a question whether the Queen should pay the
Superintendent-General so much for each Nurse’s wages, and so much
for board, the latter to be retained by the Superintendent-General,
or whether the Superintendent-General or each Matron, with the
Superintendent-General’s consent, should arrange with the Nurses.
This is important, as which ever way it is settled, there must not be
disputes between Matron, Nurses, or still less Superintendent-General,
as to what amount of wages is to be allotted to the board, or what
savings can be effected in the coals, &c.

On the whole it would seem best for the Nurse’s pay to be so much
in money for herself, and so much in money for food into the
Superintendent-General’s hands. But the question of how much is a
serious business.


[Sidenote: 5. Washing, how to be done? Rule to compel the Nurses to
_put it out_.]

5. WASHING.--Except in war-emergencies, this must not be suffered to
be done by the Nurses, they must be compelled to put it out. I would
not trouble the Authorities about this; the Nurses can afford it, and
the more things are simplified the better. In out-of-the-way districts,
the Matron might arrange with a laundress, the Nurses making a fair
payment. In war-emergencies, if possible, provide a strong washerwoman,
but this would have to be settled each case on its merits. Except in
emergencies they must not wash; it takes up far too much time; it takes
up strength which is wanted for other things; and washing and drying
either in wards or nurses’ rooms is unhealthy and objectionable. There
must be a rule as to this: some worthy souls would scrub at every rag,
rather than pay a few pence weekly. The Nurse ought, however, to be
compelled to have certain changes of linen weekly, which some will not,
if they pay for it themselves.


[Sidenote: 6. Cleaning their own Rooms. No Orderly, on any pretence,
must enter a Nurse’s Room. Scrubbing the only thing the Matron may
arrange for a Soldier’s Wife to do. Nurse must do nothing of her own in
Ward, or Ward-kitchen, or Orderlies’ Kitchen.]

6. CLEANING THEIR OWN ROOMS.--I well foresee sundry difficulties in
the little rooms at the entrance of their wards, where I hope it will
be managed to quarter the Nurses. But there is no other way of fairly
and really working a ward; and I trust this plan will receive a fair
trial. For efficiency, also for comfort, it is most objectionable to
make the Nurse sleep at a distance from the patients. This is one of
the points on which theories, and the practical working of things,
are very divergent. It is an excellent thing when the Head-Nurse’s
room opens into the ward and when part of the upper part is of glass,
with a thick curtain, so that she can see into the ward, without being
seen. Let each Head-Nurse have a small room, with a window opening
into external air, with a curtain making an alcove, behind which there
should be a small iron bedstead, with good bedding, and a washing
table; and in the foreground a table, a small one for meals, a chest
of drawers, and a comfortable arm-chair, two chairs, and I should add
a sofa. Each room should have a few shelves on the wall, and a large
cupboard or small closet with broad shelves, and space at the bottom
to stow away the Nurse’s box. Simplification and avoiding all trouble
which can be spared to the Departments are very important. I would not
therefore insist upon a little kitchen for the Nurses, nor upon a very
capital arrangement in some of the Sisters’ rooms in Guy’s Hospital,
where, behind a decent little door _in_ the sitting-room, there is a
sink, with water laid on, a little safe for meat, &c., at top, and
a complete little apparatus of the very few utensils required for
cooking one woman’s meals; so that a Nurse can cook and wash-up, in
her own room, without carrying things out of it. This is much better
than a kitchen, if the Nurse is to cook her own meals; but, as above
stated, I would rather she did not. One room, with a curtain making an
alcove, is much better than two. The Queen is saved fuel; the Nurse
is saved cleaning two rooms; and if fuel is only issued for one, she
sleeps in a warm room, instead of one where there never is a fire,
and where her things get damp and spoiled. Often, where Head-nurses
have two rooms, one is built without a fire-place. Condense and
simplify all things--one great object is to form a body of useful
hard-working women, of simple self-helping habits. Two Nurses’ rooms
should be together, but separate. Sudden illness might occur, and the
two women should be at each other’s summons. The Quartermaster-General
_must_ grant a _cabinet_ between the two: this is _must_, not _may_.
The Superintendent-General must see to this herself, at first at all
events: there _is_ a singular obtuseness in the small officials, by
whom these things are managed: if not overlooked, they will be sure to
put the construction in a particularly awkward, exposed place. These
things do enter into an Englishwoman’s daily comfort or misery--it is
worth arranging them decently in the first instance.

Now as to the cleaning of these rooms. Head Nurses generally are far
too much disposed to make servants of their nurses; put orderlies for
nurses, and this objectionable tendency would be a hundred-fold more
objectionable. The Matron must make it an absolute rule, that the
only thing an orderly does for a nurse is to carry her box in and out
on the two grand occasions of her entering and leaving the Hospital.
The one thing which in a Civil Hospital, an Assistant Nurse should
be allowed to do for the Head Nurse, is the cleaning her fire-place,
a thing done in a few minutes, and with satisfaction, by women who
have done it all their lives; but a dirty tedious messing business to
those who have not. But never mind: the orderly must never enter the
Nurse’s room: she must do it, and learn to do it. The prosaic little
business of black-lead, ashes, and mess lying on the threshold of the
work will do good rather than harm. And even black-lead is unnecessary,
as a varnish now obtainable looks better. The orderly must never
enter the Nurse’s room--a _sine quâ non_. The Nurses should have, at
their choice, a carpet, not nailed down, or none. In either case the
room will require scrubbing, once a week if no carpet, (which is best
and cleanest in Hospital life), seldomer, if carpet. Now the Nurses
should not be required to scrub their own rooms--it is useless waste
of strength--it makes their hands coarse and hard, and less able to
attend to the delicate manipulation which they may be called upon to
execute--and with all the _nursing proper_ which ought to fall upon
them, and not upon the orderlies, their time can be better occupied
than in cleaning their own rooms. Also, while trying to keep clear, on
the one hand, of the tribe of “fine ladies,” it will be possible, on
the other, if such menial offices are to be performed, to fall into the
opposite mistake and to fail in obtaining the class of women desirable
to fill such important trusts. Let the Matron consent to a charwoman,
soldier’s wife, or some one person named and defined, and found, to be
paid by the Head Nurse, to come for the two hours, which, at furthest,
this business will take. It would be well worth while for the Matron
to look out and provide two or three strong women to do this, by fixed
rotation--each Nurse making a fair payment--and to ascertain that they
are in and out of the Hospital by a particular hour, so as to prevent
these external persons doing other things than scrubbing. But do not
trouble the Departments as to this--the more things are simplified, and
the fewer expenses are in connection with the Nurses, by far the better.

Take the trouble to see that a tidy useful fire-place is in each
Nurse’s one room. Some fire-places will consume thrice the fuel of one
which can do ten times more work. A compact useful little fire-place,
to burn as little fuel, and do as much business (in a very small way)
as possible, is a thing of daily use, economy, and comfort.

The nurse should not do anything of her own in the ward, or the ward
or orderlies’ scullery, if there is such a place. This is a matter
requiring some decision.


[Sidenote: 7. In each Ward to be Closet, with Shelves, Table with
Drawers, Nurse with Keys. Nothing to be kept in Nurse’s Room. Linen,
Dressings, Stimulants to be kept in Ward Closets.]

7. Let there be in each ward a closet, or, better still, a dresser,[8]
with broad shelves, and a large table with large drawers, of which
closet or dresser, and drawers, the nurse has the sole keys. Let
the articles of linen which are kept in the ward be there; also the
bandages, lint, old linen, oilsilk, ointments, &c., &c., which should
always be, some at hand, some in reserve; also the wine and brandy
ordered for the men. Let the nurse never be allowed to deposit Hospital
property in her room, which, if there is no place for it, she _must_
do, and it is much better she should not.

[Sidenote: 8. Matrons 200_l._ per annum, Quarters, and a Maid. A woman
for the Linen, ranking and paid as a Nurse, but never entering the
wards.]

8. With regard to the Matrons, though as Locke says of tutors, there
are all kinds of persons to be found, it is certain the right persons
are not always found; and these officers will take time to find, at the
outset especially. Let them be (if it be possible) of the middle class;
if it be possible, middle aged, active women, widows of officers or
army surgeons. A vast deal of struggle is ever going on in professional
life; a vast deal of silent, decorous misery ever follows on the
premature deaths, the compelled early retirements, the sundry chances
and changes which ever abound in the army of England. So far as it
goes, and _cæteris paribus_, it would be right, just, and expedient
to give a preference for these matronships to widows of officers and
army surgeons. Try to secure thorough principle, sense, activity, and
steady discreet ways; never mind a little vulgarity of manner; that the
different orders should have their indefinable perpetual distinctions
of manner as of other things, is perhaps for a long time to come in
the essence of things. Two or three women of the stamp of the Matrons
of a few of our Civil Hospitals would be very valuable. If the Matron
do not get tired of what, unless one keeps one’s secret thoughts
fixed on the meaning and the end of all things, is coarse, thankless,
up-hill work enough--she will in the course of years accomplish great
good. But she must have principle, sense, heart, and a firm cheerful
mind. She must be not under thirty and, if possible, not over forty,
on appointment. Should her being without children be made a _sine quâ
non_? Children--poor little things--are wanted nowhere in the way of
business, but do not be too strict about this: they are sometimes
pledges to other things than fortune--thoughts, anxieties, and labours
for them, concentrate and steady a mother’s heart--there will be fewer
adventurers. Maternal _nurses_ must upon the whole be discouraged,
because upon the whole the disadvantages seem to overweigh the
advantages.[9] But the Matron’s office and duties are different; she is
not fixed to a great ward of patients; and her having children should
not be a bar, especially if they did not live with her. Young and
grown-up daughters are much in a Matron’s way; sons matter much less.

The greatest Civil Hospital gives its Matron 200_l._ and a _house_,
the other great Hospitals, 150_l._, and a _house_. The London Hospital
gives 150_l._, and a couple of good well-furnished rooms, and a
servant. A _house_ is an impediment to a Matron’s duty. She is seen
arriving in the wards, and she is more or less hindered in entering
them. From her rooms she issues and re-issues, unexpectedly, and much
more efficiently. 200_l._ and quarters is not at all too much.

The Matron must be responsible for the storing, mending, and
distribution of the linen, and for returning to the laundry any linen
not properly washed or dried. Linen ought never to be dried in the
wards, a process both inconvenient and unwholesome. The Matron ought
to have a steady, respectable woman, certainly not below the rank and
pay of a nurse, to be responsible to, and under her, for the linen,
otherwise the proper care of the linen will take up far too much of
her time. This is important. If, however, a Nurse should be thus set
aside for the Laundry, she must not be allowed to enter the wards;
otherwise she will unconsciously become a gossip and mischief-maker.
I would term her “Linen Nurse,” not Assistant. The Matron should also
have a steady, properly paid servant. A Matron of the proper sort has
quite other things to do at a leisure moment, than to keep her wardrobe
in order. She must have a servant; but it seems to be advisable to
simplify things, and condense payments as much as possible; and I would
rather consider this in the salary, and let the Matron find and pay
her own servant. Try to have the servant’s room near the Matron’s.
These minutiæ, once provided for, enter much into the daily working and
comfort of things.

The dress of the Matrons is a difficult thing to settle. Sometimes
a Matron is afflicted with a taste for either gorgeous or elegant
apparel, which the Nurses are invariably proud of, admire and humbly
emulate. This sort of thing would be really out of place in a Military
Hospital, and would moreover sadly discompose the Nurses with their
plain caps and gowns. How would it be to allow the Matrons the choice
between a Regulation dress and a plain black or brown silk gown?

It will take much thought to decide whether the Matrons should all be
paid alike, or whether climate and size of Hospital enter into this.
On the one hand they undertake a service, of which almost the first
regulation very properly is, that they undertake to go to all parts of
the world as soon as sent; on the other hand, certainly some climates
wear health and life much quicker than at home.

The Matrons out of the three kingdoms have increased responsibility,
and can do more mischief, if incompetent or untrustworthy.

If the Matron has increased pay abroad, it would not do not to augment
that of the Nurses. This is an important matter; and as it is on all
accounts necessary that Matrons and Nurses should on their engagement
thoroughly understand the nature of the service they undertake and, of
course, a serious part of the service is that it involves sudden and
long removals, it would be necessary to define upon what terms they
go abroad. Yet it never would do, for reasons which will readily be
perceived, to make the foreign stations objects of desire to Matrons
and Nurses. These stations will always be so far the most anxious, that
they will always be the most removed from the Superintendent-General’s
inspection and immediate rectification of anything that goes wrong.
They will also be, in various ways, the most trying to Nurses. The
rules once settled, every Matron and Nurse refusing to go abroad
when ordered, ought at once to be discharged, and to forfeit all
re-admittance into the service and all pensions. On the whole, I
think the Matrons should all be paid alike. But inasmuch as foreign
service necessitates more wear and tear to the constitution, one year
should count as equal to two years of service for pension, in case of
disability. The same should be made applicable to the Nurses. As the
advantage is distant, it would, in a great measure, do away with any
desire for foreign service.

Volunteering for foreign or war-service must be the exception--careful
selection the rule. The “adventurers” will be generally ready to
volunteer, and it would be too much to hope that we shall always,
perhaps ever, be entirely free from that tribe; the most we can hope is
soon to discover and get rid of them. Foreign stations will never do
for an untried Matron or Nurse. At the same time it is most desirable
not to change the Executive officers of any Hospital more than can be
avoided.

But let there not be too many rules at first; see how things work, and
take one step at a time.

The selection of exclusively middle-class Matrons seems to be
important.[10] Their order will disarm one source of opposition and
jealousy; plenty more will remain, inseparable from the work; but it is
good to get this out of the way.

The name of Matron is the same as in Civil Hospitals. In many respects
the office and duties are different: _e. g._, the Matron in Military
Hospitals must exercise a far more constant supervision in the wards.
But this will require great discretion on her part. It is the practice
of most Civil Hospitals for the Matron never to enter the wards till
the Nurse’s dressings are over. It would be advantageous to modify
this. But, at the same time, the Matron must understand Hospital
Nursing, or she may make very serious mistakes in either reprimanding
or directing the Nurse as to technical matters. She must be a person
who knows herself what she has to see that others know; or she will
get herself, with or without the Nurse, into very injurious errors.
There is much in a name; and, in some respects, that of Superintendent
would better denote her office, as regards the Nurses, would add to her
authority, which is desirable, and would point her out as acting under
the Superintendent-General.

Incorporate among the Nurses whatever women of the higher orders may
be admitted into the Service at first. If inefficient and unfit they
are far better altogether eliminated. If thoroughly efficient as Ward
Nurses, if thoroughly obedient and respectful to the Matron, if they
have sense and heart to gradually leaven, not coldly withdraw from
occasional companionship with the other Nurses, they will, in the
course of time, effect quietly a great deal of good.

There should be some Rule of this kind--

Any Matron or Nurse who may receive permission to serve Her Majesty
without pay shall be, in all respects, bound by and amenable to the
Regulations on pain of dismissal from the service, without permission
of re-entering it.

If this cannot be done, money can easily be returned in one shape or
other; but it would have a good moral effect on the Nurses to allow of
the admixture of unpaid Nurses, provided they are strictly bound by the
same Regulations, and distinguished by no sort of peculiar designation.

The Surgeons will dislike these unpaid Nurses; but, in the long run
a firm, discreet woman, _who is an efficient Nurse_, can get on with
any Surgeon _who has his sick at heart_. The Matron also will not
at all like them, at first, but will find that she can rely upon
them and that they quietly and effectually help her with the other
Nurses: and, if she has her heart in her work, she will end by being
just, though, perhaps, always a little extra strict with and jealous
of them. The other Nurses will have, at the first, a strong little
touch of republicanism towards them, which will gradually wear off,
and, with God’s help, a higher and truer moral tone, and a simpler
and more useful kind of habits among them will prevail, than would
otherwise be the case. As for the patients, with all their faults,
trust them--trust the English soldier, and the peasantry from which he
springs. What these poor fellows are we know, and need not discuss.
They are worth suffering a good deal for; please God in the long run
good will be done. If only we can keep clear of the false, pernicious,
and derogatory system of puffery and fuss which others, for their own
purposes, and from vague, silly good-feeling have wound around this
work--a work essentially unpopular the moment we come to details! We
have learnt what reality is and what its presence or absence in this
business imports. As for the many and great other difficulties of the
work, they must be appreciated, they need not be dreaded. The purpose
is a good and noble one, and God grant it success! All we have to do
is, to do our utmost, and leave the event to Him.

[Sidenote: 9. Nurses--begin with few at first.]

9. As for the Nurses the material must be formed. If a few respectable
soldiers’ widows, including, and all the better, non-commissioned
officers’ widows, could be found, _cæteris paribus_, a preference
should be given to widows of the Service.

Except in emergencies Nurses should not be taken under thirty, or above
forty[11] years of age. These women are Head Nurses. Most of the Civil
Hospitals take no Head Nurse after forty.

One caution in engaging Nurses is perhaps not sufficiently attended
to. Certificates, without personal inquiry and answers to distinct
questions, are not worth the paper on which they are written.

As to engaging any Nurses out of the great Hospitals, for sundry
reasons, this should be done as little as may be.

Let us begin, for the sake of God and this His work, with few women.
Extension is easy--to occupy too much ground at first would be, I do in
my conscience believe, an irretrievable mistake.

No unnecessary Nurses should be suffered in Hospital; and no Nurse in
charge of wards should be required to do needlework for the Hospital.
There should be no superfluous hands; and the less a Nurse enters
another’s ward the better.

In case of suspension of a Nurse for misconduct, temporary assistance
must, however, be obtained; and this might be either appointing another
Nurse, to do, for the time, such duty in the suspended ward as she
could do in addition to her own, or putting in a temporary substitute.

All such dislocation of the Service, necessary and useful for
emergencies and holidays, should, nevertheless, be made to take place
as seldom as may be.

No Nurse, during her suspension, should be allowed to enter any ward of
the hospital.

Any Nurse asking or accepting a present, whether in money or in kind,
from any patient, or friend of any patient, whether during his illness
or after his death, recovery, or departure, must be at once suspended
from duty, her pay immediately cease, and the Superintendent-General be
apprised of it, who, if satisfied of the truth of the charge, should
immediately dismiss her.

Two hours daily for exercise or recreation should be allotted to the
Nurses, during which two hours they are to be considered relieved of
the responsibility of their wards. But I would not be too absolute in
requiring them to go out: sometimes to lie down or sit still for an
hour or two will do more good than a walk. Give them two hours for
optional exercise. Head-Nurses cannot have more of fixed leisure. They
must get time for private occupation as they can: very often not at
all; and no Nurse fit for her place will, of course, in emergent states
of her ward, leave it. Also the Matron must not worry herself or them,
if an anxious Nurse sits up part of a night or a whole night with bad
cases.

To a certain degree the Matron will find it better to allow a little
liberty and choice, in the matter of times and hours, (always excepting
after proper hours, _i. e._, after dark) to the Nurses, who are
Head-Nurses, than to attempt making them mere machines. An uniform
system, as far as possible, and a little range to each, will answer
best. But do not hurry the uniform system too much; take time: this is
very important.

The Nurse should, every morning, at an hour to be fixed by the Chaplain
or Matron, read aloud in the ward, the Confession, the Lord’s Prayer,
the Collect for the Week, the Collect for Grace, and the Benediction;
and every evening, at an hour to be fixed by the Chaplain or Matron,
she should read aloud in the ward the Confession, the Lord’s Prayer,
the Thanksgiving, the Collect for Aid, and the Benediction.[12] This
would Christianize things, instead of heathenizing them; and I believe
not a soldier would dream that his conscience was injured by it. The
Roman Catholics and Presbyterians might be allowed quite to refrain,
if they chose, which they would not. It would be necessary for the
Chaplain-General to approve of and direct in this, and best to wait a
year or two before beginning it.

The prayers should be very short, the whole not more than five or six
minutes each time, and the Nurse should read them, the men joining at
the proper times.

In some Civil Hospitals the prayers are far too long and are gabbled
over by some patient, perhaps the worst character and the best scholar
in the ward, or are stumbled through by some little boy, upon whom the
others cast the distasteful office, with circumstances of irreverence,
partly unintentional and partly shocking. At St. Bartholomew’s Hospital
the very short morning and the very short evening prayers are printed
clearly on each side of a card, which is affixed to each bed; and each
morning and evening the Head-Nurse reads them aloud: the difference is
very great.

[Sidenote: 10. Have the Diets sent hot and ready-divided from the
Kitchen.]

10. The Colney-Hatch Lunatic Asylum has a diet system worth inquiring
into; nothing is fetched by the Nurse, the Medical Officer writes the
diets on a large slate which is ready for him outside the ward.

The great advantage of this seems to be, that the Nurse’s time is
set free from a good deal of arithmetic and some writing; also that
each man’s portion is served him _hot_ from the kitchen, not cut up
laboriously by the Nurse. In most Hospitals the Nurse cuts and divides
the diets; in the London Hospital she moreover weighs them. All this
takes a great deal of time. If the patients can get the divided
portions _hot_ from the kitchen, it is far preferable.

At St. George’s Hospital the portions are sent hot and divided from the
kitchen.

[Sidenote: 11. The less any Patient is made into an Orderly by the
Surgeon the better. The Nurse should have Regulations to invoke to
allow her to do her duty.]

11. It should be distinctly settled by whom poulticing, fomenting,
and all minor dressings, applying leeches and blisters, and giving
enemas,[13] are to be done.

It would be advisable to consider whether the Nurse ought not to
instruct the Orderlies in some things. This, if it did not clash with
Orderlies’ Rules, would make these men, especially those ordered for
foreign service, much more useful than they are now, without such
teaching.

It will, however, be essential that there should be no clashing
between the Nurses’ Regulations and those already or to be issued to
the Orderlies. And for this, among other reasons, it is essential
to establish a direct channel of communication between the
Director-General and Superintendent-General of Nurses.

[Sidenote: Ward Medical Officer to give Directions to Nurse.]

I think, upon the whole and with reference to preventing, as far as
rules can do it, the obstruction of the Nurse’s duty, by adverse or
inexperienced Medical Officers giving orders to Ward or Assistant
Ward-Master, Orderlies, or patients, instead of to her, that it is
better to charge him to give the Nurse his orders as to the sick.

All the above-mentioned things should be done by the Nurse, _i. e._, by
her habitually and as a rule; occasionally letting an orderly do them,
under her own eye, in order that he may learn, as well by doing them
sometimes himself as by often seeing her.

The reasons why all these things must be clearly settled beforehand are
these:--

I. Adverse Medical Officers will make all use of counter-regulations.

II. Medical Officers who give fair play will find it impossible to
settle the matter, if, on ordering, _e. g._, leeches, the Orderly
shows Rule so and so by which he does it, and the Nurse Rule so and
so by which she does it. The existence of the old regulations and the
arrival of the new ones, about the Medical Staff Orderlies, were made
great use of against our work, by some of the Medical Officers, after
the heavy pressure of the war was over. So, at Scutari, a Principal
Medical Officer took away and would not restore the practice of the
nurses giving medicines, in which he was borne out by an existing rule.
Contradictory rules are miserable things.

Unless the Matron’s authority is supported by the Principal Medical
Officer the Patients always suffer. The Nurse is the only proper person
to be responsible for the directions of the Medical Officers being
carried out in a General Hospital.

III. It will enable the Matron to stop all nonsensical prudery, on
the part of the nurses, and to require that they should do what they
undertake to do, and not pass off to an Orderly, still less to a
patient, the duties they should discharge themselves.

As a general rule there is a good deal of this false modesty on the
part of Nurses, especially of Head Nurses. In individual cases it is
a serious thing to shake even false ideas of decorum: in laying down
general Rules it is the more important to lay down as duties what
are such. Suppose an application of what the French call “la petite
chirurgie” ordered. The Head Nurse “never dreams of doing such things.”
The Nurse, following her superior’s false shame of duty, transfers the
business to an ignorant patient. In some cases great harm has arisen
thereby to the Patient. In other cases, but not the majority, after
such an order given, the Head Nurse goes quietly to the bed, draws the
curtain round it, and makes the application herself--saying “she always
did that herself, as it was a business requiring care, as the patient
was often disposed to resist, and as she was thus certain that it was
properly and effectively done.” I have always admired and respected
such women; but they are not the majority. Very often patients are
allowed or left to do things for themselves, which they cannot do
properly, or when they ought not to be trusted to inflict the pain on
themselves which doing things properly often causes.

The practice of allowing some particular patient to become a sort of
half orderly in the ward, letting him always attend some particular
case, or give general help in severe cases, is most reprehensible. It
is never allowed, whether in Civil or in Military Hospitals, without
very bad consequences to the discipline of the ward. Where extra
help, in lifting, &c., is required, let the Nurse require the most
convalescent of the patients to help, but let her carefully refrain
from selecting any patient or allowing any patient to put himself
forward, as a regular help or quasi-Orderly. As an almost invariable
rule it will be found that the less patients do for each other the
better for themselves, and for the discipline and the good feeling of
the ward. Let them be made useful in the wards, as far as possible,
in such lighter cleaning, &c., as a patient can properly do (here,
again, discretion is required, or a lazy Orderly will lay undue
burdens on a willing patient); but the less they do for each other
undoubtedly the better for all parties. I would not, however, expressly
exempt the patients from being made useful in nursing the sick. A
lazy or ill-conditioned patient might make it a handle to refuse to
do or grumble at doing things which he ought to do, such as (a thing
frequently required) giving and emptying a bed-pan to an ordinary
patient who cannot leave his bed, while the Nurse and Orderlies
are doing other things in the ward; assisting to move a helpless
patient, if all the Orderlies are not at hand; sometimes watching or
attending for an hour or so a critical case, &c., &c., &c. What the
Superintendent-General and all Superintendents must be especially
vigilant against is selecting any particular patient or allowing a
willing patient constantly or often to do these things, and to become a
quasi-Orderly to the ward or to any patient in it.

Assistant-Surgeons, partly from inexperience and partly from spite,
sometimes make this sort of quasi-Orderly of a patient. The Nurse
should have the power of respectfully saying, in such a case, “The
Regulations order me to do so and so, sir: I beg you to let me do my
duty.”

It is an important and should be, if possible, an invariable rule that
no discharged patient is ever to enter any ward. Soldiers are, in
many respects, on a different footing, as to each other, from Civil
patients. The above provision is perhaps rendered thereby (not the
less, but) the more important for the good order of the ward. Still
this, desirable in (and the rule in several) Civil Hospitals, might
be considered by Military as well as Medical Officers to interfere
too much with the feeling of comradeship which, in its measure, is
so essential a part of the soldier’s very peculiar condition. The
following rules however might, at all events, be carried out. Some of
them are actually in the “Hospital Regulations.”

As quietness is indispensable in Hospitals, every duty should be
performed with the least possible noise, more especially at night.
Every patient must be in bed by 8 o’clock in winter, and 9 in summer;
and no conversation must be permitted after that time. Patients should
be made useful in the wards, as far as possible; but should fetch
nothing into them. And no discharged patient should be permitted to
enter any ward, except in the fixed visiting hours. The Governor, where
there is a Governor, or the Principal Medical Officer, will fix the
visiting hours; which shall not be more than two hours during each of
three days of the week. [Take proper advice as to whether this maximum
is too short. It is fully enough for Civil Hospitals, but Military
Hospitals are in sundry respects essentially different.]

In the discipline of all Military Hospitals, besides the prohibition
of all swearing and foul language included in the Articles of War, is
included the non-admission, or if by oversight admitted among visitors,
the immediate expulsion of all disorderly persons. (Query--whether not
to specify prostitutes.)

I very much wish that Hospital Sentries in General Hospitals might keep
out all visitors, except in the fixed visiting hours. And I very much
wish that a stringent rule were made as to female visitors, both in
Regimental and in General Hospitals. Proper Military as well as Medical
advice should be taken on this point. It might not do to exclude them
altogether; and, if soldiers’ wives come, it might be better to admit
also all respectable-looking women, for it would be useless attempting
defining as to sisters, aunts, friends, &c., &c.; though, except in
the case of dying patients, all women, except their wives and mothers,
are better away. I do not know what amount of strictness in practice
is shown in enforcing the Regulations in English Army Hospitals; but
if, at present, equivocal women, as well as ascertained prostitutes,
are not excluded (which very possibly they are) they should be. At
the same time, a sentry may often be honestly puzzled as to equivocal
or non-equivocal appearance, in these days of over-dressing. And some
mistake, made by a stupid or brutal sentry, might lead to endangering
the rule. This whole matter must be referred to men.

[Sidenote: 12. Orderlies’ Attendance.]

12. With regard to the question of the “Regulation” number of
Orderlies, viz., 1 to every 10 patients, it is to be observed,--

[Sidenote: (1.) 40-Bed Ward Minimum Size for Regulation Number of 1
Attendant to 10 Patients.]

(1.) A ward of 40 patients might be efficiently served (but it would be
hard work) with

          1 Head Nurse--Female.
          3 Orderlies.

With no number under 40 of patients to a ward, can the Regulation
proportion of 1 attendant to 10 patients be adhered to.

[Sidenote: (2.) 20-Bed Ward requires 3½ Attendants.]

(2.) With a ward of 20 patients (cut, scheme, and arrange the hours and
duties as you will), you cannot efficiently serve it with less than

          ½ Head-Nurse--Female.
          3 Orderlies.

And the other ward of this Head Nurse ought to be on the same floor.

N. B.--The same number would quite as efficiently serve a ward of 25 or
even 30 patients.

[Sidenote: (3.) 10-Bed Ward cannot be served by 1 Orderly + ⅕ Nurse.]

(3.) The Army system of 1 Orderly to 10 patients, with a number not
exceeding 10 patients to a ward, is upset as immediately by one bad
case among the 10, as by 9 to the 10.

For, is the same Orderly to be on duty for the 24 hours?

The difficulty is practically got over by the Army, with a permission
that any “bad case” may select any one he likes of his comrades (out of
the Depôt) to be “told off,” to attend upon him.

This extraordinary regulation is equivalent to (and affords little
other practical result, than) granting opportunity for any quantity
of spirits, and illicit food, to be smuggled into Hospital, and it is
clear that it would be totally inadmissible in a General Hospital,
where the whole system of nursing would be under the most stringent
discipline and supervision.

[Sidenote: (4.) Female Nurses not to be Substitutes for Orderlies.]

(4.) The introduction of Female Nurses into Military Hospitals is not
intended to supply the place of Orderlies, but to perform a class of
duties which never has been performed at all in the Army. Few other
Hospital duties of those generally called such have been hitherto
fulfilled, in Military Hospitals, except
                        diet-carrying,
                        sweeping,
                        and writing.

[Sidenote: (5.) Naval Hospitals Regulation Number of Attendants 1 to 7
Patients.]

(5.) In all Naval Hospitals, the Regulation number of attendants is
1 to every 7 patients, or 2 attendants for each ward containing more
than 7 patients and up to 14. These Attendants or Nurses, in sailor’s
language, have charge of the linen, bedding, and ward furniture, under
the Ward Matron, and they are responsible for the proper care of the
sick, and the due administration of the medicine, wine, and other
medical comforts. They are on duty all day and watch at night in their
turn, which is regulated by the Medical Officer in charge of the ward,
in this or similar fashion:--a group of three contiguous wards is
allotted during the night to two nurses, one begins her duty at 9 and
ends at 1 o’clock, when she is relieved by another, who watches till
6. She patrols the three wards, resting in that one where there may be
a case requiring more than ordinary attention. If there should be a
case of fever, delirium, or other sharp seizure, extra Nurses, both men
and women, are assigned to the charge of that special case, according
to the urgency of its wants. The great majority of Naval patients are
either convalescent, or suffering from trivial complaints, which do not
impair their activity. They can therefore take care of themselves, and
assist the Nurse during the day in cleaning the wards, &c.--and we know
what good housemaids seamen make. The Nurses are paid one shilling a
night for night watching. They have under the most severe circumstances
two-and-a-half nights in bed for half a night out of bed.

At Haslar Naval Hospital the system of Orderlies, as understood from
the Principal Medical Officer, is as follows:--12 Orderlies are on a
floor, to look after, say, 90 patients. These are divided for night
duty into three divisions of 4 each; of these 4--
          2 are on from 9 to 2, A. M.
          2  ″      ″   2 to 8.

The Head-Quarter room or ward is the one which has the most severe
cases; this ward, then, the Watcher at night sits in, and makes the
rounds of the others every now and then to see if anything is required.
This system will of course be modified, according to the nature of the
cases in Hospital. The other attendants do not sleep in the wards. The
Nurses are male or female according to the discretion of the Principal
Medical Officer.

[Sidenote: Civil Hospitals have even 9 Attendants to 44 Patients.]

In Civil Hospitals the number is as great of attendants to patients,
and is mainly determined by the size of the ward:

_E.g._, in one Hospital, where there are quadruple wards of 44
patients, 11 in each compartment, though the average number of patients
is 48, the number of attendants is 7.

In exceptional cases extra Night-Nurses, sometimes extra Day-Nurses
serve particular patients. The labour, both of cleaning and of
night-nursing, is much increased by the wards being four, separated by
a large lobby.

In another of the large London Hospitals, where there are to each ward,

          PATIENTS.              ATTENDANTS.

              22 }   there are  { 1 Sister.
              24 }              { 2 Nurses.

                                { 1 Sister.
              30         ″      { 2 Nurses.
                                { 1 Scrubber.

                                { 1 Sister.
              34         ″      { 3 Nurses.

                                { 1 Sister.
              40         ″      { 3 Nurses.
                                { 1 Helper.

In the Lariboisière Hospital at Paris, where the wards hold 32 beds, 1
Sister, 1 Nurse, and 2 Orderlies on the Men’s side, 1 Sister, 2 Nurses,
and 1 Orderly on the Female side, serve the ward efficiently.

[Sidenote: (6.) Same Number of Men will not do same amount of Work as
an equal Number of Women would.]

(6.) One woman does the work of more than a man in a Hospital, speaking
of the duties discharged by Under Nurses in Civil Hospitals; for men
are not accustomed to these duties in England, as women are from their
childhood.

From this it is by no means to be inferred that women of the class
of Under Nurses in Civil Hospitals should be employed in Military
Hospitals, which unquestionably they should not. But it is to be
inferred that the work will not be done efficiently, with a smaller
number of men than would be employed of women.

[Sidenote: (7.) Hospital Attendance an entirely new subject in the
Army.]

(7.) The question of attendance has scarcely been intelligently
considered in the Army at all. And hardly any practical answer has yet
been given to such questions as the above.

I conceive it to be practically impossible to serve 4 wards, as
proposed at Netley, viz., of 9 beds each, with

               1 Head Nurse,
               4 Orderlies.

For, as has been said, one bad case in each ward, makes this economy as
unmanageable as nine.

[Sidenote: (8.) Hospital Wards in the Army little else than
Barrack-Rooms at present.]

(8.) A ward in a Military Hospital now may often be little else than a
barrack-room, with an Inspection by a Medical Officer twice a day. It
is designed to make it by the new Regulations into a place where the
sick must be and always will be suitably attended. But this cannot be
done by such a scheme as--

    1 Female Head Nurse }  to   { 50 Patients, in (say)
    6 Orderlies         }       {  6 Netley Wards;

though this attendance would be more than sufficient for 50 cases in
one ward; but such a ward is considered in a sanitary sense too large.
Two wards of 30 beds each on the same floor would be efficiently served
by such a Staff, however; and there would be no sanitary objection.

[Sidenote: (9.) Regulation as to 1 Orderly to 10 Patients requires
modifying.]

(9.) The Regulation number of one Orderly to ten patients therefore
requires modifying. Practically it is broken every day and in the
extraordinary manner above mentioned, which gives the most critical
cases to be attended by the rawest hands.

[Sidenote: (10.) One Orderly should be the _Frotteur_.]

(10.) The question of Hospital floors will be fully discussed farther
on. An Orderly should be trained to be the _frotteur_ to each ward. He
should also be the porter to fetch and carry every thing to and from
the ward.

[Sidenote: (11.) Comparison of Cost of Nursing with larger and smaller
Wards.]

(11.) The plan of Netley, with its wards for 9 sick, is by far the
costliest for administration, as the following facts will prove:

  I. It is proposed to provide the Hospital with Orderlies and Nurses
       to conduct the nursing in wards of 9 sick, as mentioned.

  II. On sanitary grounds wards may safely be large enough to
       accommodate 25 to 30 sick.

We may therefore choose the larger wards, being guided only by the cost
of the nursing.

  III. A ward of 9 sick would require 1 day and 1 night Orderly, and
       a-third of a Nurse (that is, a Nurse could superintend three
       such wards.)

       A ward of 30 sick would require 2 day and 1 night Orderlies and
       1 Nurse = 4 persons in all.

Or if two such wards were on one floor, 1 Nurse could serve both.

  IV. We cannot count the cost of Orderlies and Nurses, including
       lodging, rations, wages, at less than £50 a year, which when
       capitalized at 3 per cent. (33 years’ purchase), would amount to
       £1,650 for each.

  V. A ward of 9 sick would cost in nursing £1,650 × 2⅓ = £3,850,
       or £427 15_s._ 6_d._ per bed.

  VI. A ward of 30 sick would cost for nursing, in perpetuity, £1,650
       × 4 = £6,600 = £220 per bed.
       [One Nurse to each ward is here allowed.]

  VII. The cost of the two plans relatively for a Hospital of 1,000
       sick would stand thus:

                 Wards with 9 beds   = £427,775
                 Wards with 30 beds  =  220,000
                                      ---------
   Capitalized difference of cost in } £207,775
               favour of large wards }

       Netley has cost already Land  =  £30,000
       Works                             89,000
                                      ---------
                                       £119,000

It hence appears that, if works and site were both sacrificed, and
fresh land purchased, and wards for 30 sick built on it, the country
would actually save the difference between the two sums of = £88,775.

  Suppose the sanitary requirement of 25 sick to a ward, which is
       the best number, be combined with the greatest economy of
       administration, the cost would stand thus:

  For each ward of 25 sick, 3 Orderlies, at £1,650 = £4,950
  If two such are built in line, close to each
       other, with the Nurse’s room between them,
       one Nurse could superintend both wards, or
       half a Nurse to a ward. The cost would be
       for the ward                                     825
                                                    -------
                                                      5,775

                             5775
       Or cost for each bed  ----              =       £231
                              25


  The comparative cost of wards with 9 beds and
    25 beds, would stand thus for 1000 sick:

        Wards with 9 beds                          £427,775
        Wards with 25 beds                          231,000
                                                  ---------
        Saving                                     £196,775
    Deduct cost of Netley, already incurred         119,000
                                                  ---------
    Saving from abandoning Netley =                 £77,775

  The cost of the administration per 1000 beds at Netley
    and Aldershot would stand as follows:
  Netley                                           £427,775
  Aldershot, pavilions, with 3 superimposed wards
    and 25 sick in each, would require 3 Orderlies
    and 1 Nurse[14] to each ward, and would cost
    £264 per bed in perpetuity, or per 1000 sick    264,000
                                                  ---------
     Difference of cost in favour of Aldershot     £163,775

Some abatement would have to be made, as regards the cost of Netley, as
there are a few wards with 16 or 18 sick.

If we take money at 4 per cent., the calculation will be as follows:

  Small wards, 2 Orderlies and a third of a Nurse,
    at £50 per annum; money at 4 per cent.,
    per 1000 sick                                  £324,000
  Wards of 30. 3 Orderlies and a Nurse, money
    at 4 per cent., per 1000 sick                   166,000
                                                  ---------
        Extra cost of small wards                   158,000
        Cost of Netley                              119,000
                                                  ---------
        Saving in giving it up                      £39,000

[Sidenote: 13. Hospital Floors.]

13. FLOORS.--In building a new Hospital or laying a new floor we shall
hope to see, by degrees, everywhere introduced the only safe Hospital
floor. In the expense the difference between oak and the best white
deal ought never to be considered. The staircases and passages should
always be of stone. When once an oak floor is well done with bees’-wax
it is no longer an absorbing surface. There cannot be a doubt that the
frequent washing of the floors, in London Hospitals, is one main cause
of Erysipelas and Hospital Gangrene.

But, with regard to deal flooring,--

(1.) The best way with a pine floor already laid is to close the
joints, plane the surface quite smooth, and then saturate the wood with
beeswax and turpentine, either at once, or after the wood has been
saturated with “drying” linseed oil well rubbed in.

(2.) Enough beeswax should be used to fill up the grain of the wood,
and rubbing with a brush will then smooth the surface. It will be
polished somewhat, but not slippery. The amount of polish depends on
the brushing.

(3.) The surface should be kept clean by using a brush with a cloth
tied over it, and if offensive liquids are spilt, they should be
immediately removed, the surface washed with soap and water, and
immediately dried.

(4.) List slippers, which ought to be part of Hospital furniture,
effectually obviate risk of slipping. It would hardly be possible,
however, to make deal floors as slippery as oak _parquet_, because
the surface (except of very fine deal, such as is used for musical
instruments) never takes so high a polish.

(5.) Dry rubbing, which is done with sand, or with sandstone, is not
well adapted for ordinary sick wards, on account of the dust; unless
it be very carefully done. The rationale of it is to remove a certain
amount of the surface of the floor. It answers very well on board ship.
A certain amount of surface cleaning may be done by rubbing with a
hard short brush; it is, however, defective. The wood becomes in time
saturated with organic matter, and only wants moisture to give off
noxious effluvia.

(6.) Scrubbing is absolutely objectionable, for this reason. In any
schoolroom, reading-room, institute, which is much inhabited, a smell,
while the floor is being scrubbed, is very perceptible, quite different
from that of soap and water. It is the exhalation from the organic
matter which has entered the floor from the feet and breath of the
inhabitants. How much more dangerous this in Hospital Wards need hardly
be said.

There is at Bethanien Hospital, at Berlin, a very admirable flooring,
which would be worth trying in England. The floors throughout are
wood, prepared in the following manner:--The floor is first oiled with
linseed oil, and then rubbed over with a peculiar “laque” varnish, the
technical process of which will be found in the note,[15] and polished,
so as to resemble French polish. Every three years or so the rooms and
wards are successively emptied for a fortnight, when a new flooring is
laid, re-oiled, varnished with the laque varnish, and thoroughly dried.
Every day the floors are wet-rubbed by means of a piece of sacking or
coarse webbing at the end of a long, hard broom, the performer stands
for the performance, also while immediately afterwards, having wrung
the sacking completely dry, she goes over the ground again with the
dry sacking. One, or, in case of the weekly extra wet-rubbing, two dry
rubbings, dry the floor completely in a few minutes from the cessation
of the wet-rubbing, never more than ten minutes. Three or four times a
year the ward floors are thoroughly wetted with water thrown on, and
the floors scrubbed with a long brush. Neither soap, soda, &c., is
used.

The great advantages of this are:--

(1.) That it purifies the air exceedingly and freshens the wards.

(2.) That it reduces the daily accumulation of dust to a minimum.

(3.) That it dries completely within ten minutes from being wet-rubbed.

(4.) That a woman, standing, can thoroughly clean a ward with some
hours less time, and greatly less fatigue, than scrubbing.

(5.) That wet scrubbing is sometimes and ought to be always forbidden
and dry rubbing substituted, on the score of the unhealthiness of
scrubbing.

(6.) That it would relieve us of all external scrubbers in the Nurses’
own rooms. Each Nurse would sweep, wet-brush and dry-brush her bed-room
and day-room herself, daily, would once-a-week give a little extra
wash, and would wash the wooden skirting which runs along the bottom
of the walls. As the bed-room must be tiny and the day-room small
(it would be better if we could keep to one room, which would take a
quarter of an hour daily, and the grand weekly purification not more
than one hour, even to a slow performer) a short time daily and a
moderate time weekly will do it.

One disadvantage of this very simple, very efficient, and excellent
flooring is, that it shows scratches. Furniture must always be lifted,
not dragged. In a Military Hospital where men are always at hand, this
would matter less as to the wards, and the Nurses could help each other
once a week in their bed-rooms, and manage alone in their day-rooms.

There are four other examples of this flooring in Berlin Hospitals.

(1.) Bethesda Siechenhaus, a small old house, about to be rebuilt and
enlarged, in a suburb of Berlin, where three Deaconesses, with a man
and woman servant, take excellent care of about forty infirm old women
and imbecile children. These patients, of the class to be found in the
infirmary wards of our workhouses, move about little, and have few
visitors, so that the flooring, which is the same as at Bethanien, is
less used.

(2.) St. Hedwig’s Hospital, where 250 male and female medical and
surgical patients are nursed by Roman Catholic Sisters of St. Charles
Borromæus (head quarters at Nancy), with female servants and male
nurses. The house is new; the flooring the same as at Bethanien.
The Superior, an intelligent German, speaks much of its excellence
for hospital purposes; it is being introduced, though as yet very
partially, into France.

(3.) The great Charité Hospital, the town-hospital for 1,200 patients,
spite its French name. It consists of two buildings; the old one,
used in winter; and a splendid new one, into which all the patients,
except the lunatics and the small-pox and the venereal cases, are moved
for the six summer months. The flooring throughout is of the same
wood (deal) as at Bethanien, but has much more laque. The more laque
is used, the brighter the floor shines, but the sooner it requires
re-oiling and laque varnishing. The Charité floors are re-oiled with
laque every year; they are cleaned in the same way as at Bethanien,
only with more dry rubbing. On bad days, when the numerous students
have passed through, the ward floors occasionally require to be
cleaned; but, in general, even on these occasions, it is enough to
sweep them, and to clean the next morning as usual.

(4.) The principal Military Hospital, the Garnison Lazareth in the
Hirsch Allée, for 800 patients, usually not filled. The flooring is
the same as at Bethanien, except that no laque is used. It is oiled
generally, not always, yearly.

The Ober Inspector, a Landwehr civilian, who is supreme over the
Hospital, and an Ober-Stabs-Arzt, both speak very strongly as to the
superiority of this flooring over all others for Hospital use, and
in particular over flooring which requires scrubbing. It has only
been introduced of late years. They consider it equal to any amount
of hospital wear and tear. The military patients, like those of the
Charité, Bethanien, and St. Hedwig’s, wear hospital slippers, with
soles thick enough to admit of their walking in the garden, when fine;
when not fine, they are not allowed to go out. This flooring would not
stand the constant tread of nailed shoes. But often, on bad days as on
fine ones, great numbers of soldiers come to visit their sick comrades,
and leave the floor very dirty; generally it is enough to sweep the
floor after the visitors are gone, and to clean it as usual next
morning; sometimes it is necessary to clean it the same afternoon.

The flooring is cheap. Somewhat more expense attends laying it down
than the ordinary boards, and a certain expense attends the re-oiling,
but the constant outlay for soap and soda is entirely saved, except
a little soda in the grand annual purification, with hot water, in
addition to the daily one with cold; the time and labour attending
scrubbing is saved, and above all the great gain to the sick arising
from its use is secured.

The strong, decided way in which the old grey-headed Army Surgeon, and
the middle-aged business-looking Civilian, spoke of the merits of this
flooring, and of its capacities, was exceedingly satisfactory.

(5.) Two years ago the greater part of the boards in the Kaiserswerth
Institution, which are of deal, were oiled, both on sanitary grounds,
and to rid the Sisters of the drain on time and strength in scrubbing.
They are considered far preferable to the old ones, and to answer in
every respect. Yet the Kaiserswerth floorings would not answer the
English requirement of extreme cleanliness. They are substantially
clean, but, like those of the Military Hospital of Berlin, it
takes examination to ascertain that they are so, and from the same
cause--there is no “laque.” Also the colour is not at all so agreeable
as the Bethanien colour. These oiled boards last a year only. A
moderate amount of laque is required to add to their durability.

The sum of the information, condensed as much as possible, on this
subject is;--

I. The boards, which are always of deal, can be prepared in three ways:

(I.) Laquering, only suitable for reception rooms, or when by some
chance a ward is wanted to be got ready in a hurry; it takes less time;
after two or three days, the room or ward can be used, and it shines
brighter, but it lasts a much shorter time than the other procedures,
as it stands less the incessant treading incident to all ward floors;
it is also more expensive. Let us consider it wholly unsuitable for
wards.

(II.) Oiled boards, with more or less laque.

The Charité boards have a great deal of laque.

The Bethanien and St. Hedwig’s boards much less.

(III.) Oiled boards without any laque--

As in the Military Hospital.

II. Much laque makes the floors shine brighter; requires more time to
clean them; and earlier re-preparation than where less laque is used.

The Charité boards would be unmeaningly splendid for an English
Hospital, and quite out of place in a Military one; besides entailing
some unnecessary annual expense, and some daily finicking care.

III. A small quantity of laque, as at Bethanien, gives an amount of
polish to the floors, which enables the eye at once to ascertain
whether they are clean or not; considerably improves the appearance
of the floor; and, according to all high authority, adds both to the
durability of the floor, and the healthiness of the Hospital. It
renders the whole flooring less subject to cracks, to dirt and dust
getting into holes and corners; and, above all, by filling up the grain
of the floor, it prevents the saturation, by organic matter, which
otherwise takes place and which scrubbing only makes more mischievous.

IV. Where no laque is used, the absence of all polish on the dark-brown
floors makes examination necessary, to see whether they are thoroughly
clean or not. This flooring would never satisfy the eye or the mind of
an English Inspector-General or Surgeon. But the main objection to the
absence of laque certainly consists in the sanitary one above stated.

V. All the various authorities agree in estimating very highly the
superiority of this flooring to flooring requiring scrubbing. They all
agree in their reasons for this preference, viz.:--

(I.) The dampness which remains in a ward more or less time after it
has been scrubbed, is completely avoided.

(II.) The tendency to miasma is greatly counteracted, both by getting
rid of the damp, which encourages and spreads the exhalation of the
organic saturations; and by making the floor impervious, preventing
dirt, and with dirt miasma, finding its way into holes, chinks, and
corners of the floor.

(III.) The mode of cleaning this flooring, while it avoids damp, daily
purifies the ward air.

(IV.) The floor, and its mode of cleaning, get rid more than by any
other way of dust, and of the miasma dust often conveys.

(V.) The time, labour, and expense of scrubbing are saved.

(VI.) The Berlin authorities consider that these oiled boards, with
a small quantity of laque, are, on the whole, decidedly cheaper than
the common boards; that the boards last rather longer; and that the
avoidance of scrubbing saves more than the extra preparation and its
renewal cost, apart from the sanitary gain.

VI. Against these advantages, the following disadvantages are to be
placed:

(I.) This flooring shows where most used, instead of the uniform
appearance of the white scrubbed boards.

(II.) Scratches show, and remain upon it; so all furniture must be
lifted, not dragged over it.

(III.) The tread sounds a little more, little, but more, than on white
boards.

(IV.) It would not stand the constant tread of nailed shoes; and
patients of a ward so floored, ought to wear slippers with moderately
thick soles. (The German Doctors consider the use of slippers
preferable to that of shoes, by the patients, as keeping a ward much
quieter, cleaner, and disturbing the severe cases less.)

(V.) Carpets could not be nailed on it, as the floor should be daily
cleaned. Several Hospital authorities whose rooms are thus floored,
have large pieces of carpet round the furniture most used, bed,
tables, sofas, &c.; these are daily taken up and dusted while the
floor is being cleaned. To many English minds, the sight and feel of
a carpet is essential to the idea or feeling of comfort; and it might
be sound policy, in the event of a trial being made of this flooring,
to leave the Officers, Military and Medical (I do not mean patients),
in possession of scrubbed rooms and carpets. The Superintendent might
have one or two pieces of carpet for her rooms; and the Nurses should
dispense with carpet.

Both in the new part of the Charité and at Bethanien, long broad
corridors run along the back of the wards which open into them. The
corridors are floored like the wards. In those of the Charité a piece
of long carpet is laid in the midst of the corridors, where patients
walk not a little. At Bethanien, a long piece of matting is laid in
the midst of the corridors, where the patients walk freely. Carpet of
either kind is not considered to benefit the floors, but to diminish
the noise. In the wards of Guy’s Hospital, for the same reason, a long
piece of matting is laid along the middle of the floors.

VII. This flooring is unsuited for stairs, though so used in some
Hospitals, as, in case of fire, oiled wood would burn rather quicker
than common wood. Hospital stairs should be of stone.

VIII. It is also unsuitable for kitchens, wash-houses, water-closets,
and sinks. The floor round a stove or fire-place in a ward or room
should be protected by a strong plate of lead or tin.

It might also be as well to floor operation-rooms with flooring,
admitting of scrubbing, because these oiled boards do not well stand
sand or bran, and our Surgeons might be discomposed at missing one or
other of these things. Sand or bran mixed with blood would make a mess,
the traces of which would show a little on this flooring. For the rest,
it is particularly easy to wipe blood off it. After each operation, one
or two minutes, a wet cloth of the kind here mentioned, and a broom,
remove the blood that has fallen, and leave a clean floor; or if there
has been a very great mess, five minutes, a wet cloth to lap up the
blood, &c., another wet cloth, a pail, and a broom, do all: after the
operations are over, a few minutes’ whole or partial cleaning, as the
case may be, make all tidy again. Still, many English Surgeons expect
to have sand or bran thrown on the floor before, or just after the
first blood has fallen, and might object to standing some minutes on
the bloody floor, which spoils boots, &c. Red floorcloth, of sufficient
size, round the operating-table, might answer every purpose.

IX. On laying down the oiled boards for the first time, six weeks
should pass after the oiling and laquering before the ward is inhabited.

X. After subsequent re-preparation of the floors, the longer the wards
are left vacant the more the floor both hardens and shines; but for
practical purposes the interval of a fortnight is enough.

XI. The flooring, so prepared, or re-prepared, ought, on an average,
to last about three years. In case of any extra miasma, it is often
desirable to hasten the re-preparation, and to have it done after two
years’ use. To do it annually is, unless in some emergency, quite
unnecessary.

Although the process cannot be said to be by any means perfect, on
account of the deficient durability of the surface, it would be well
worth while to try it in England, and, if it answers and if it were
improved, the sick would gain much, and the Hospital staff would gain
much--the latter much more even in Civil, than in Military Hospitals.

But it would be incurring a great responsibility to have the whole of a
large new Hospital floored in this way, because,

I. An English climate has made, and makes, so many things which are
good and suitable abroad, unsuitable and sometimes pernicious for
England.

II. Our coal-fires, whether assisting or assisted by our atmosphere,
certainly give us an amount of soot and dirt unknown abroad. At Berlin,
all fire-places are stoves, where sometimes coal, sometimes coal and
wood are burnt.

This flooring might not stand well either the damp climate, or the
smoky atmosphere and amount of flying soot of England: but it would be
well worth trying; as also trying to improve it.

By all accounts, a great deal depends upon the manner in which these
boards are prepared; a little more or a little less, whether of oil or
laque, makes a great and lasting difference. It would never answer to
make an English carpenter or painter do this from written or printed
directions.

If we obtain a trial of this floor--the best course would be, to let
an English carpenter prepare a number of boards and skirtings, of due
size, suitable for the new flooring of some few wards in one of Her
Majesty’s hospitals, which requires new flooring; then to desire either
the proper tradesman, or the Queen’s Minister at Berlin, to order the
house-painter, Schonby, No. 5, Michael Kirchplatz, Berlin, to send an
experienced, trustworthy foreman, with the proper tools and materials,
and for this man, with a complement of English workmen, to prepare the
boards.

The mode of cleaning is extremely simple, though of course there
is a knack to be learnt; and, like everything else, it can be done
well, indifferently, or ill. Any English man or woman accustomed to
cleaning would understand the thing in one morning, and would, if he
or she opened instead of shutting the mind to the outlandish thing, be
proficient in it in a week. All these things sound abstruse on paper,
and are far more simple and more easily learnt by seeing done than by
reading. The foreman ought to give one or two lessons to one or two
Orderlies, or Nurses, as the case may be.


[Sidenote: 14. Ventilation of Wards.]

14. VENTILATION.--The amount of fresh air required for ventilation has
been hitherto very much underrated, because it has been assumed that
the quantity of carbonic acid produced during respiration was the chief
noxious gas to be carried off. The total amount of this gas produced by
an adult in 24 hours is about 40,000 cubic inches, which in a Barrack
room of 16 men would give 370 cubic feet per diem. Allowing 8 hours
for the night occupation of such a room, when the doors and windows
may be supposed to be shut, the product of carbonic acid would be 123
cubic feet, or about 15½ cubic feet per hour. This large quantity if
not speedily carried away would undoubtedly be injurious to health; but
there are other gaseous poisons produced with the carbonic acid which
have still greater power to injure. Every adult exhales by the lungs
and skin 48 ounces or 3 pints of water in 24 hours. Sixteen men in a
Barrack-room would therefore exhale in 8 hours 16 pints of water and
15½ cubic feet of carbonic acid in the atmosphere of the room. With the
watery vapour there is also exhaled a large quantity of organic matter
ready to enter into the putrefactive condition. This is especially the
case during the hours of sleep. And as it is a law that all excretions
are injurious to health if reintroduced into the system it is easy to
understand how the breathing of damp foul air of this kind, and the
consequent reintroduction of excrementitious matter into the blood
through the functions of respiration will tend to produce disease.

This will be still more the case in sick wards overcrowded with sick,
the exhalations from whom are always highly morbid and dangerous, as
they are nature’s method of eliminating noxious matter from the body,
in order that it may recover health.

A much larger mass of air is required to dilute and carry away these
emanations than is generally supposed. And the whole art of ventilation
resolves itself into applying in any specific case the best method
of renewing the air sufficiently, without producing draughts or
occasioning great varieties in temperature.

When the question of ventilation first assumed a practical shape in
this country, it was supposed that 600 cubic feet of air per hour
were sufficient for a healthy adult, in a room where a number of
people are congregated together. Subsequent experience however has
shown that this is by no means enough. As much as 1,000 cubic feet
have been found insufficient to keep the air free from closeness and
smell; and it is highly probable that the actual quantity required
will ultimately be found to be at least 1,500 cubic feet per hour per
man. In sick wards we have more positive experience as to the quantity
of air required to keep them sweet and healthy. It has been found in
certain Parisian Hospitals, in which the ventilating arrangements were
deficient, that pyœmia and Hospital gangrene had appeared among the
sick in consequence. These diseases disappeared on the introduction
of ventilating arrangements, whereby 2,000 cubic feet of fresh air
per bed per hour were supplied to the wards. Notwithstanding this
large quantity, however, the ward atmosphere was found not to possess
sufficient freshness or purity: and the quantity of air had to be
increased in subsequent ventilating arrangements. As much as 4,000
to 5,000 cubic feet per bed per hour have been supplied in certain
Hospitals. At the rate of 4,000 cubic feet, the ward atmosphere is
found perfectly fresh.

[Sidenote: Night Ventilation.]

At one of our largest London Hospitals it will be perceived that
above the one door of each ward is a large ventilator, ordered to be
open day and night--that beyond this ventilator, which opens into the
landing-place, is a large window which opens into the external air;
and thus admits fresh air into the ward at night, diminishing the
foul night atmosphere. This night ventilation system is good; but it
requires careful watching, as chilly patients, Nurses, and sometimes
Sisters, are very apt to give, after they conclude the rounds are over
for the night, a sly pull at the rope and to shut the window, and thus
imbibe the foul air directly generated, in quiet.


[Sidenote: Special Wards, whether desirable or not.]

15. SPECIAL WARDS.--It may be laid down as an axiom in the management
of sick affected with certain zymotic diseases, such as fevers,
cholera, dysentery, &c., that they should be distributed over a
wide superficial area, and have a large allowance of cubic space.
Agglomeration of such cases in small ill-ventilated wards is quite
sufficient of itself to occasion a high proportionate mortality
among the sick. In mild climates and seasons very little protection
is necessary from the change of temperature; so that the sick from
epidemic diseases can be camped out and exposed to the full influence
of the atmosphere, not only without danger, but often with great
benefit. It is only when the temperature is low and variable, and the
season inclement, that danger is likely to accrue from this exposure.
And hence the necessity of inquiring how we can best combine the
requisite elevation of temperature and the most suitable amount of
cubic space and ventilation for the treatment of these diseases in
Hospitals.

Medical Men generally are satisfied that these ends cannot be safely
arrived at by agglomerating sick in fever wards in Hospitals. And hence
has arisen a practice, which experience appears to have approved,
of intermingling a small number of fever cases in wards containing
a certain number of sick from other diseases. The practice appears
to be not only perfectly safe, but advantageous for the sick. It
is known, however, that if the proportion of fever cases exceeds a
certain number, the other cases in the ward are apt to become affected
with fever. It would appear as if, so far as the fever is concerned,
the cubic space occupied by other diseases was to a certain extent
available for the use of the fever cases. But the proportion of such
cases, that can be advantageously placed among the general sick of any
ward, will depend upon the size of the ward, the means of ventilation,
the number of cubic feet per patient, the position of the windows, the
exposure of the building, and other similar circumstances.

Again, it is doubtful whether the preservation of an uniform
temperature in any Hospital, even in one set apart for chest
complaints, is beneficial for the sick, or whether it be beneficial to
agglomerate consumptive cases, without very special precautions, under
the same roof. Without discussing the validity of the opinions held in
Southern Europe as to the contagious nature of consumption, it may be
very fairly doubted whether a number of cases placed under a common
roof, and breathing a common atmosphere, would not yield a higher rate
of mortality than the same cases would do if distributed through the
wards of a well-ventilated Hospital, among other diseases.

The subject is worthy of examination. At all events the phenomena
observed in this disease in the warmer climates of Europe have led
to the popular belief above stated; and it would appear to point
to a higher rate of mortality as a not unlikely result of the
establishment of special Hospitals or wards for consumptive diseases,
unless extraordinary care were taken to ventilate them properly, and
to imitate the natural variations of temperature which appear to be
necessary for recovery.


[Sidenote: 16. Proposed Regulations as to Payments, by
Superintendent-General.]

16. All salaries and wages of Matrons and Nurses should be paid, on
the Superintendent-General’s order, from the Hospital chest, to the
Matron, who should pay the wages and other expenses of the Nurses, and
account for all monies received by her on such orders. All outfits and
travelling expenses, in cases of transfer, &c., should be provided on
the order of the Superintendent-General.

[Sidenote: Opinion as to Superintendent-General paying Wages and
Salaries.]

There would be considerable difficulty in the way of making
all payments at a distance to Nurses, direct from the
Superintendent-General, otherwise than by orders on the Hospital chest
or Treasury. But there can be no doubt that the Nurses ought to be paid
by the Matron and by no one else. The service of Nurses in Hospital
is a peculiar service, and if not successfully conducted by influence
never can be by coercive discipline. It would be a great mistake,
therefore, to throw away any means of influence which we can command,
and the “eye of the maid-servant is to the hand of her mistress” now as
it was 2,000 years ago. The fact of paying and being paid helps greatly
to establish the proper mutual relations between the superior and the
subordinate. The Matron would draw from the Hospital Treasury, on the
orders of the Superintendent-General, and would account to her. As a
matter of discipline, it would make no material difference whether the
orders of the Superintendent-General, in favour of the Matron, for the
pay of the Nurses, are cashed by the Hospital Treasurer or by a banker,
always supposing that the Treasurer is bound to honour those orders,
as any other banker would.

[Sidenote: Matrons abroad may dismiss Nurses under appeal.]

The Matron, in any Hospital out of Great Britain and Ireland, should
be able, with the concurrence of the Governor of the Hospital, to
dismiss and send home any Nurse; or the Governor himself, on his own
responsibility, may direct the Matron to do so, under appeal, however,
in either case, to the Superintendent-General, who shall decide, after
the arrival of the Nurse, whether she is to be dismissed or whether she
may be placed in another Hospital.

It should be secured, not left to chance, that the Matron be
immediately made acquainted with any complaint of the Medical Officers
against a Nurse.

[Sidenote: Matron to draw Rations and Extras.]

The Matron should be able to draw from the Purveyor, on her own indent,
with the sanction of the Governor of the Hospital, such rations and
extras as she may consider necessary for the Nursing establishment, and
make the arrangements for cooking. In the United Kingdom the Matron
should be able to make arrangements, subject to the approval of the
Superintendent-General, for commuting rations for mess-money, not pay.

The Governor is responsible for the sufficiency of all supplies
and none ought to be expended, without his sanction. This might be
indispensable, if there were danger that supplies might run short.

[Sidenote: Opinion as to Governor’s jurisdiction over Nurses.]

Upon both these latter points, supposing the Governor of a General
Hospital to exist, he must have power to maintain the discipline of the
Hospital, in all its Departments, as a General commanding a division
has, in regard to every regiment composing it. But he ought to exercise
it only through the Matron, as commanding a corps. He must also have
power to require the exclusion from the Hospital of any Nurse whose
conduct he may find to be inconsistent with maintenance of discipline,
and this power he would enforce, on his own responsibility, by
directing the Matron to remove the offending Nurse from the Hospital.
The conduct of the Nurse would become the subject of investigation
afterwards, in terms of the established regulations. But practically
such a case could hardly occur, unless by the fault of the Matron, who
would, of her own accord, desire to remove a Nurse, on being satisfied
that such a measure was necessary or expedient. It would be proper,
too, both for her own justification and for the maintenance of the
Governor’s supremacy in the Hospital, that the Matron should obtain
his concurrence in the removal of a Nurse from the Hospital. The
proceedings, in all such cases, would, of course, be reported by the
Matron to the Superintendent-General.

Whether the Governor has the power of removing the Matron, who clearly
and properly ranks among the officers under him, should be settled and
not left to be disputed about in a distant station. At all events,
if he has this power over her, it must be guarded, as extending only
to suspension from office, in cases of alleged flagrant neglect or
misconduct, till the whole matter can be remitted and decided on by the
Superintendent-General.


[Sidenote: 17. Nurses’ Wages.]

17. Generally, as to the question of wages and pensions, a regulation
that Nurses shall have a small annual increase of wages is better than
one giving an increase after five or three years.

[Sidenote: Efficiency of Nurses does not increase by springs and
starts, like Grasshoppers.]

Efficiency does not go by starts and springs, like grasshoppers, but
makes “a small annual increase,” like the wages proposed.

Nay, I appeal to everyone with experience in these matters whether the
greatest improvement is not made the first year, the second year a
little less, and so on the third and fourth, till, when the fifth year
comes, if improvement has not been made by that time, it never will be.

[Sidenote: The first five years a constant improvement. Afterwards if
there has not been improvement made before, no hope at all.]

For trust-worthiness is the true efficiency of a Nurse. And it may
safely be said that, if by the end of the first year she has not
improved in trust-worthiness, she had better go; and if she have not
almost reached her culminating point by the fifth year, she certainly
will not improve afterwards.

[Sidenote: Three principles in Wages.]

The reasonable principle I believe to be, 1, to begin improving the
wages at as early a period as possible; 2, to let them increase till
the Nurse reaches her maximum of efficiency; and, 3, after that to make
no more increase.

[Sidenote: By rate of Wages to retain those who are efficient.]

Because the object is to induce the young and efficient women to stay,
not the old ones. They will stay long enough, because the old ones
nobody else will take.

[Sidenote: By rate of Pension to reward those who have been efficient.]

The rate of pension ought, on the other hand, to increase with the
number of years’ service, and continue increasing till the end. The
principle of pensioning is different from that of wages. After the
woman has reached her maximum of efficiency, which certainly will be
not later than forty-five, probably not later than forty years of age,
the inducement to stay should be the improvement of pension. This
compensates for any apparent injustice in the first principle towards
an old servant.

[Sidenote: Civil Service an Example.]

No other system appears to be founded on common sense; and it is one
generally acknowledged in the Civil Service, where salaries are made to
rise as soon as possible. Military Hospitals must not be made training
schools for Nurses; else it would be better to admit them much younger
than at the age of thirty years.

[Sidenote: Opinion as to Wages and Pensions.]

If a Nurse cannot enter the Service till after she is thirty, the
majority will no doubt be some years above thirty when they enter, say
an average of thirty-five; and five years appear a very long probation
for a person at that age before increase of wages begins. In most
cases, in Civil Departments, there is only one year of such probation
before increase begins, though the persons are much younger when they
enter. A maximum might be fixed, beyond which the wages should not
rise, and when the increase of pension would be sufficient inducement
to remain. Very few Nurses can be expected to continue really efficient
till sixty years of age; but it is often difficult to say that a person
is disabled, though she may have become less active and efficient.
If there is no retiring allowance there will be great reluctance to
dismiss her, and it might, in that case, be cruel. The better plan
would be to promise a small pension after ten or twelve years’ service,
on a scale so graduated thereafter as to offer an inducement to remain,
at the same time that it would afford facility for enforcing retirement
without injustice. This would be economy. The “Nursing Sisters” grant
£20 after twelve years’ service.

After a time there may probably be difficulty in dismissing persons who
have done good service for ten years, but have declined in efficiency,
unless there is a retiring allowance. They may be reluctant to retire;
and, if so, it would be almost impossible to dismiss them, without
some kind of provision. This is a difficulty which is encountered in
every employment in which there is no such provision. Persons who can
hardly be said to be disabled but who have become less efficient are
retained, because, if dismissed, they have no means of livelihood.

I have consulted the best authorities upon these points; and I find the
following general principles admitted:--


GENERAL PRINCIPLES AS TO WAGES AND PENSIONS.

[Sidenote: (1.) Same Salary at first.]

(1.) At whatever age a Nurse enters the Service she shall begin with
the same salary.

[Sidenote: (2.) Same Annual rate of increase.]

(2.) The annual rate of increase shall be the same for all ages of
entrance.

[Sidenote: (3.) Maximum Salary fixed.]

(3.) The maximum salary shall not exceed £.

[Sidenote: (4.) Pension for Service after Ten Years.]

(4.) The pension for service shall not begin until ten years of
completed service.

[Sidenote: (5.) Amount of Pension a certain Percentage on mean Salary
of preceding year.]

(5.) The amount of pension shall be a certain percentage on the salary
during the year preceding that on which she is pensioned.


APPLICATIONS OF THE FOREGOING PRINCIPLES.

[Sidenote: (1.) Annual rise of Wages till the maximum of efficiency.]

(1.) That the wages of Nurses shall rise annually, for a definite
number of years, attaining their maximum, on an average, at the age
forty-five, when the Nurses are found to be most efficient.

[Sidenote: (2.) After five years’ Service Pension for Disability.]

(2.) That, after five years’ service, the Nurse shall, in the case of
ABSOLUTE DISABILITY, become entitled to a pension during the period of
her disability.

[Sidenote: (3.) Pension on a Scale graduated on the Wages.]

(3.) The pension will be on a scale graduated on the wages. It will be
twenty per cent. of the annual wages in the year of service, 5–6, and
the rate to be granted will rise progressively two per cent. per annum,
until the rate on the wages becomes seventy per cent.

[Sidenote: (4.) All Nurses to retire at Sixty.]

(4.) All Nurses will be placed on the Retired List at the age of
sixty.[16]

[Sidenote: (5.) Nurses to serve again who are Pensioned for Disability,
when Disability ceases before Sixty.]

(5.) Those Nurses who are pensioned at an earlier age, for disability,
will, if called upon, be liable to serve when that disability ceases,
or to forfeit their pension. They must therefore bring an annual
medical certificate of disability to the Superintendent-General, in
order to receive their pension.

[Sidenote: (6.) Nurses partially Disabled to receive partial Pension.]

(6.) Nurses who are partially disabled will only be entitled to
a certain proportion of the pension allowed in the scale, to be
determined, on representation made by the Superintendent-General.


[Sidenote: Example.]

Example.

        COMPLETED YEARS
   AGE.   OF SERVICE.    WAGES.    PENSION.

    30         0          £20?   }
    31         1           22    }
    32         2           24    } Gratuity
    33         3           26    }
    34         4           28    }
   ----------------------------------------
    35         5           30 × ·2 = £6
    40        10           40   ·3   12
    45        15           50   ·4   20
    50        20           50   ·5   25
    55        25           50   ·6   30
    60        30           50   ·7   35

These principles, if admitted, would suggest the following heads for
regulations as to Nurses’ wages and pensions:--

[Sidenote: (1.) Amount of Wages, first year, £20.]

(1.) At whatever age a Nurse enters the service, the amount of wages
paid to her during her first year of service, will be £20.

[Sidenote: (2.) Annual rate of increase up to £50, when it ceases.]

(2.) There will be an annual rate of increase of wages equal to 10 per
cent, of the first year’s wages, until the yearly wages amount to £50,
beyond which there will be no further increase.

[Sidenote: (3.) No Pension till Ten Years’ Service completed, nor for
Disability till Five Years.]

(3.) A pension will be awarded for service to any Nurse, who may
retire, on account of age, at the expiry of ten full years’ service,
but in case of disability, a Nurse shall receive a pension after
five years’ service, or a gratuity, according to circumstances, if
discharged for disability, before she has completed five years of
service.

[Sidenote: (4.) Rate of Pension.]

(4.) Rate of Pension. The pension will be on a scale graduated on the
wages. It will be 30 per cent. of the wages received by the Nurse in
her tenth year of service, and the pension granted to Nurses who have
served more than ten years, will rise at the rate of 2 per cent. of the
wages for every additional year of service, until the pension amounts
to 70 per cent. of the wages received during the year preceding its
grant, beyond which no higher pension will be granted, except in cases
of special devotedness to the public service, when an addition to the
regulated rate of any pension may be granted on special recommendation,
made by the Superintendent-General of Nurses, setting forth the nature
of the service for which such augmented pension is to be granted.[17]
But no such pension shall exceed the amount of £50.

[Sidenote: (5.) Nurses, Pensioned for Disability, whose Disability
ceases, may be called on for Service.]

(5.) Any Nurse pensioned for disability, may be called on for service
in the event of such disability ceasing before the age of sixty, in
which case her wages will be the same as they would have been, had she
not been disabled.

(6.) Every Nurse who has completed her sixtieth year, must retire from
the service on her rate of pension.

(7.) Any Nurse, temporarily or permanently disabled in the service, who
has served more than five and under ten years, will be entitled to a
lower rate of pension, according to the circumstances of each case, as
represented by the Superintendent-General.

[Sidenote: 18. Number of Nurses to Patients.]

18. Nurses should be selected and appointed by the
Superintendent-General of Nurses for each General Hospital, in a
proportion not exceeding one nurse for every twenty-five cases.

There is nothing so fatal to discipline as to require by regulations
what it is known and admitted cannot be performed. Such rules are made
to be broken. Therefore, is it not better, instead of fixing a number
to fix a limit, and say “not exceeding one to every 25 or 30 patients,”
leaving it to the Superintendent-General to economize Nurses, and not
appoint the full number permitted, unless when really necessary? In one
case she might consider one nurse for fifty or even sixty sufficient;
in another, one for every twenty-five might be few enough. Why tie up
her hands against economy as well as against extravagance?

At the same time it is necessary to state--

(1.) That, by all accounts, at home and abroad, in the English and in
foreign armies, the proportion of severe cases is very considerably
less, in time of peace, in a Military Hospital than in a Civil one,
especially in the surgical wards.

(2.) That the Nurse’s time, being relieved of the waste incurred by
fetching and waiting for things, the cleaning of the ward being done by
Orderlies, and, an important item, the Ward-Master being responsible
for the serving the patients’ food, twenty-five sick are not enough, on
an average, to occupy, properly, her time.

(3.) That idleness, always pernicious, is never more so than to
Hospital-Nurses.

(4.) That petting the patients, by way of filling up time, would be, of
the two, more pernicious than idleness.

(5.) That it is most important, apart from these reasons, to train and
accustom these Nurses to serve efficiently large numbers of patients,
so as to make them useful in war-service, where every woman who can be
spared is better away; and where a small efficient staff would, please
God, do excellent service.

(6.) That it is not in human nature, taking its average, supposing the
Regulations lay down that the proportion is not to exceed 25, for many
Nurses not to murmur at having more; whereas they ought from the first
to understand, that the service is a very laborious one, and that none
but women able and willing to undergo and render laborious service,
ought to enter it, or be suffered to remain in it.

(7.) Care must be taken therefore that in fixing this minimum, no use
may be made of it dangerous to the service, either in the Hospital work
itself, or in provoking adverse criticisms upon these Regulations in
quite different places. Twenty-five cases are not generally enough.

[Sidenote: 19. Precautions in sending Nurses abroad.]

19. It would be expedient to take the advice of an able and honest
man of business as to whether the Superintendent-General should, on
engaging a Matron or Nurse, have her signature to a bond or not.
On the one hand, we know what bonds are to loose consciences, and
if the promulgation of the Regulations give undoubted power to the
Superintendent-General and to her Matrons on foreign stations, I
should prefer having no bond. But this is for a man of business to
answer. It is important to remember that the power of instant dismissal
for misconduct, and of sending the Nurse home must be retained,
which renders the service different from ordinary female service. A
discharged governess or servant, if she insisted on remaining at her
own expense at the foreign station, could not be sent home forcibly
by her late mistress; now it is essential that an offending Nurse be
forthwith passed on board the first returning ship. Also performances
similar to those of one or two of the women in the War-Hospitals who,
on hearing of good situations, misbehaved in order to be discharged,
ought to be effectually prevented. A lawyer must advise, first, if
it can be; secondly, how it can be done. The Superintendent-General,
on sending abroad Nurses, ought to have some security either that
they remain there and do their duty, or that they be sent home for
her judgment if they fail in duty. To have them either going abroad
as Nurses by way of securing a free passage, and then looking out
for lucrative situations, or accepting the offers which might, and,
occasionally, undoubtedly would, be made to them, would be most
injurious to the Service. Can it be prevented by any stronger measure
than the instant forfeiture of all claim to the eventual pension? If
so, it should. Could this power be extended to the washerwomen who
would probably be sent with the Nurses ordered to War or out-of-the-way
foreign stations? Perhaps it will simplify things not to include them
in the Regulations.

[Sidenote: Hospital Laundries.]

The persons provided by the Officer, whoever he may be, to attend to
the hospital linen under the orders of the Matron, will be pretty
sure to give the Matron trouble. But it is much better to begin very
modestly, and to avoid alarming the Attendance Department; and so to
be content with the people provided in the linen store, and not at
all to invade the regions of the kitchen. By degrees, please God the
work prospers, it may be extended. I fear a laundry of men, except in
war-service, will be a costly and inefficient concern. Yet a laundry
of women, exempt from the control of the Matron, would be probably the
worse evil of the two. And it is both right and expedient to move very
slowly, and to begin with the nursing service alone. Ultimately, if we
invade both laundry and kitchen, I should still wish, in both, to have
as few women as possible. The fewer women are about an Army Hospital
the better.



ADDENDA WITH REGARD TO FEMALE NURSING IN A MILITARY HOSPITAL ON THE
PAVILION OR LARIBOISIÈRE PLAN.


[Illustration: _PARIS_

Hospital de Lariboisière

612 Lits.

  A.   Bureaux.
  B.   à rez de chaussée Cuisine. au 1ᵉʳ Etage Logements d’employés
         --au 2ᵐᵉ Etage Dortoirs des Garcons de Service.
  C.   idem              Pharmacie.    idem           idem
         -- idem         Chambres des Elèves internes.
  D E F G H I J K. Chauffoirs.
  L M N O P Q.  Batiments  de Malades.
  R.   à rez de chaussée Buanderie. au 1ᵉʳ Etage Lingerie.
         au 2ᵉᵐᵉ Etage Dortoirs des filles de Service.
  S.   Communauté.
  T U. Bains.
  V.   Chapelle
  X Y. Amphithèatres.
  Z.   Manège et Magasins
  W.   Ecurie. Remise et Salle des Morts.
]

1. In considering the Pavilion Plan to be in future received as the
sanitary necessity for Hospital construction, we must look upon it as
susceptible of many modifications.

And, particularly in adapting it for a Military Hospital, we must
ask by what modification can it be made, 1. Most economical as to
attendance, a greater amount of which is rendered necessary than by
other plans of construction.

2. Easy as to supervision; and, of course, a Hospital spread over the
extent of space now proved to be essential by sanitary knowledge,
whether built on the Pavilion plan or not, must multiply the amount of
supervision over that required in the concentrated over-crowding of the
old Hospital system (over-crowding not with regard to cubic space in
the wards, but to the superficial area on the ground).

3. Economical as to the number of sick to be accommodated on the same
floor, so as to save unnecessary waste of time and strength on the
stairs to both Ward-Masters and Nurses. Each Nurse should have, in time
of peace, not less than from 50–60 patients under her charge.

4. Efficient as to convenient accommodation for Nurses and
Ward-Masters, near to the wards of which they are in charge.

[Sidenote: 1. Pavilion Plan indispensable on Sanitary grounds. Its
Difficulties, on the score of Discipline in Military Hospitals, to be
openly met and guarded against.]

1. The Pavilion Plan, while it is incontestably superior, on sanitary
grounds, to any other, while it perhaps may be made equally economical,
with regard to building, is more expensive than the older crowded
and badly-constructed Hospitals, not only as to ground, but because
each separate entrance, staircase, set of appurtenances, represents
an additional cost of materials, and of hands to keep them clean and
in order. Human life is, however, a more expensive article than any
other. If human beings, and especially sick human beings, are to be
spread over as much space as possible, which is now known to be an
essential to health and more especially to recovery, this must be done
under any system and can be best done under the Pavilion system. It
of course necessarily entails a greater amount and cost of attendance
and of supervision. Pure air and light are the prime necessities of a
hospital. These are best secured by the Pavilion Plan, and therefore
it is the cheapest in the end. As to the hands, there never ought,
never will, never can, be a superfluity of hands in a well-regulated
Hospital. The duty of the hands consists of two parts--to keep the
Hospital clean; to attend the sick. I had rather not enumerate the
instances where I have seen that, often from the most various causes,
one result arises--that more time and care is given to floors,
stairs, &c., &c., &c., than to the sick. Extreme cleanliness is of
vital importance; this should be combined with extreme simplicity
of detail, and with providing for considerable numbers at once. You
can effectually clean a large ward in much less time than two small
ones; a long stair than two short ones, &c. Extreme, _not finicking_,
cleanliness, thorough ventilation, for which an ample supply of
opposite windows will certainly in the long run prove infinitely the
best plan, and careful nursing, are probably the main conditions,
humanly speaking, of a large proportion of cures--subsidiary to the
medical or surgical treatment.

Sanitary necessities are never to be rejected, on account of the
trouble they give or of the means of cleanliness which they render
necessary. Because the saving of life, not the saving of trouble, is
the object of all sanitary appliances, Hospitals among the number. And
the saving of life is the only real economy. If you have saved “hands”
and trouble, and lost life, you have been extravagant. The object is
not to banish appliances which will cost trouble in keeping them
clean, but to discover those appliances which can be kept clean, at
least cost of labour. And this is perfectly possible.

[Sidenote: 2. Easy Supervision to be provided for.]

2. The Vincennes modification of the Pavilion plan has been adopted,
among other reasons, for the greater facility of supervision it
affords. The Military Superior, the Surgeon, the Matron, can at any
instant pop in upon any ward of a Hospital which has one roof. Each
pavilion may, unless the matter be specially considered with a view
to providing this effectual supervision, perceive the approach of any
inspector. The system of scouts, watch, alarm, is well understood in
many hundred wards, whose patients would be puzzled to give the things
names. Military patients will know both things and names. Remember
that Ward-Masters, Orderlies, and Nurses require inspection as well as
patients. Whatever system of Hospital construction is adopted should
provide for easy supervision, at unexpected times.

[Sidenote: 3. If from 24–30 Patients be the right Number, Sanitarily
speaking, for a Ward, the Pavilion Plan should, in a Military Hospital,
be so arranged that more than one such Ward should be on the same
floor, for facility of Supervision.]

3. The more we see of different systems, the more we see the great
mistake of giving a Nurse too little to do.

Twenty-four ordinary sick or surgical cases are too few for a Head
Nurse.

In a Military Hospital, the proportion of heavy cases is in ordinary
times considerably below the average proportion of such cases in a
Civil Hospital, open, as the latter is, to accidents, and to the cases
of dangerous disease always more or less rife in low and crowded
neighbourhoods.

Upon an average, a third or a fourth of the cases in the ordinary
surgical wards of a Military Hospital will be ulcers from causes honest
and dishonest. What these men will require is rest (the cleanliness
which is often so irksome a novelty to the corresponding Civilian
patient is routine to the soldier), and very simple treatment.

It is most important, if possible, to form a staff of active,
laborious, useful women, who, if ordered on war-service, can at once
cope with numbers, and serve efficiently a considerable number of heavy
cases.

Relieved of all cleaning, and relieved of the great loss of time
incurred by fetching, waiting, &c., &c., none of these Nurses, who
are, in fact, Head Nurses, should serve less than forty men. And, as I
before submitted, I had rather she served fifty or sixty than forty.

Give them twenty-four patients, and either they will become idle,
finicking women, or they will take to petting the patients, a thing to
be sedulously avoided everywhere, most of all in Military Hospitals.

[Sidenote: 4. Importance of the Head Nurse sleeping close to her Ward.]

4. The more we see of different systems, the more apparent becomes the
importance of the Head Nurse (all these are Head Nurses) sleeping close
to the ward:--

As regards the efficiency of her service:--

As regards the saving her own time, strength, and securing her a
modicum of comfort in a work where, if she does her duty, she will
never have a superfluity of comfort. Time, strength, and this modicum
of comfort, enter much into a Nurse’s health--and health is essential
both for efficiency and economy.

Where the Nurse sleeps at a distance from her ward, her efficiency,
both as to superintendence and work, especially at night, in dangerous
cases, is seriously impaired.

If she sleeps at a distance from her ward, her comfort, also, such as
it is, is destroyed. Whatever a Nurse does for herself, she must do
by fits and starts. A really efficient Head Nurse is never able to
make anything for herself, though she often would far rather save the
money it costs to “put it out.” The most simple mendings, even the feat
of stowing away the laundress’ supply of a Saturday evening, become,
when a ward is heavy, or when there are two or three of those cases
of urgent danger, so many of which, by God’s blessing, the assiduous
care of these women saves, year by year, in our Hospitals, a procedure
done in several acts. The misery of dividing her small effects (the
smaller the better) between a day-room and a distant sleeping-room,
the unseemliness and inconvenience of carrying things backwards and
forwards, cannot be described.

If it be possible, the Nurses must sleep adjoining their wards; and it
will not do to give each only 24 patients.

It would be considerably better, if feasible, to have two Nurses in
contiguous rooms; but in the Pavilion Plan this would involve bringing
one Nurse away from her ward; and rather than this, the next best,
though inferior plan is to put one Nurse immediately above and below
the other, with a distinct bell which she can in a moment ring from
her bed into the other Nurse’s room, to summon her if needed.

[Sidenote: Importance of Lighting Hospital Wards by Gas, with Sanitary
Precautions.]

Some years ago gas was laid on in the Sisters’ rooms in Guy’s Hospital.
In the other Hospitals there is an allowance of candle to each
Sister. The disadvantages of gas are its alleged unhealthiness and
its certainly being disagreeable to some eyes. Its advantage is its
cheapness. Liberty to buy a candle and not use the gas is allowed at
Guy’s. As it will be a very important thing to conduct the Nursing
Service as economically as possible, and as there must not be any
wretched false economy as to essential matters, which in the end always
proves waste, it will be well to save as much as can be in matters not
essential. It would be worth while to ascertain the average amount
of saving which the substitution of gas for an allowance of candle
has effected at Guy’s. Gas is used in the wards of St. Bartholomew’s,
St. Thomas’s, and Guy’s, day and night. It appears, when ventilation
is properly attended to, to answer well, and to do no harm. At night
the gas is lowered so as to leave the ward just light enough to see
all that is done in it: if bleeding, &c. occurs, it can in an instant
be raised, and the ward lighted up. London Hospital burns gas in the
evening, and throughout the passages at night; but when the night watch
begins at nine, the wards are dark, except the Nurse’s candle. A spare
candle, un-lighted, is always at hand.

It is very important for the order of a ward that the attendant in
charge, and also any inspector suddenly entering, should see at once
all that is going on in the ward. Where there are dangerous cases, this
is of great moment; and where there are not, it is equally necessary
for the police of the ward. A candle or a rushlight give insufficient
light. Properly lowered, gas at night does not disturb the patients.
After a night or two, those who are accustomed to sleep in the dark get
used to it. If the Nurse sleeps adjoining the ward, there _must_ be
sufficient light in the ward at night. If the gas-fittings are properly
tight and if every gas-burner has a ventilator, so that the products
of combustion are effectually conveyed away, for each gas-jet consumes
as much air as eleven men, it would be greatly preferable that there
should be a low gas light in the wards at night.

[Sidenote: II.--1. Should it be necessary to serve one Pavilion with
one Nurse means by which this could be effected.]

II.--1. Suppose the Lariboisière plan retained, as proposed at
Aldershot, for a Military Hospital, with wards of twenty-four beds
each--then, with fear and trembling, but with the firm conviction
that it is better for human nature, most of all, for nursing human
nature, to have somewhat too much than a great deal too little to do,
I respectfully recommend that one Nurse serve the three wards of each
Pavilion.

One woman cannot sleep alone in the Pavilion. The Nurses must sleep
together near the Matron’s quarters. If the Nurses sleep away from
the wards there should be some way by which a Nurse can at once be
summoned, in case of any urgency in her ward, and it would be well
to consider this in the distribution of quarters. Either the Matron
should lock the Nurses’ quarters at night, and any summons should be
brought to her and by her referred to the Nurse; or the summons should
go straight to the Nurse’s door. There are difficulties both ways,
even supposing these summons should be unfrequent. The Nurse of each
Pavilion should inhabit the room on the ground-floor ward, where the
heaviest surgical cases will be probably placed, whence she can better
command the movements of the Pavilion, and attend the entrance of the
Surgeon.

[Sidenote: 2. Head Nurse’s Day in a Pavilion Hospital.]

2. Her day might be something like this (in time, perhaps, God will
bless us with some Army Chaplain who will get up early and give us a
very short service morning and evening):--

She should be effective, and enter the Pavilion about 6 A.M., go
through the wards, read prayers in one by turns at the appointed hour,
and give out the linen wanted. (Six is the nominal hour when the Head
Nurses of one great London Hospital enter on their duty.) Here must
be no nominal hours, all must be real, though not overstrained. Then
the dressings, &c., attendance on Surgeons, &c. With 72 patients on
different floors, she must train the Orderlies to do the lighter
dressings (by training I mean real teaching, not leaving the Orderly to
find them out himself); she must see all the wounds of all her wards
which she does not dress herself at least every other day (which she
can do by seeing some in the morning and some in the evening), and she
must dress the heavy cases of all the wards herself. All this, with
method, and not losing time by fetching and waiting, an efficient Head
Nurse can do.

She must be responsible for the linen of the wards; but this must be
simplified as much as can be, so as to secure responsibility, yet
relieve the Nurse of unnecessary time spent over it.

The Nurse should be relieved of all writing and counting, on the score
of loss of time incurred. It will not do to charge a Nurse, with
seventy-two patients on three different floors, with serving each man
his portion of diet; the diets of two wards would get cold while she
was serving the first. It will be better to make the Ward-Master of
Pavilion wards responsible for the serving the diets. There must, of
course, be a card at each bed, or some other record, showing the diet
the man is ordered. The Nurse must know at a moment’s glance what each
patient is ordered.

The largest London wards are the two male accident wards in the
London Hospital. Each Head Nurse has charge of five wards of 12 beds,
separated (and in some respects impeded) by two lobbies. Very often
there are fifteen beds in each ward (not by over crowding), and these
Head Nurses are often to be seen in charge of seventy-five patients
each, including many serious, and some urgent cases. The two lobbies,
the small wards, and the duty of some daily writing and arithmetic
in settling the diets, with some daily loss of time in fetching and
waiting for medicine, render a Head-Nurse’s service, as regards
“manual” labour, less efficient than it might be; even where she is
most efficient.

Relieve the Nurses as much as possible of all writing and arithmetic.
If it could be possible to relieve them altogether of the “settling”
the diets, so much, by a great deal, the better. In the Lariboisière
system, with one Nurse to each Pavilion, it is utterly impossible to
prevent the Nurse losing daily time and strength on the stairs. But,
relieved of writing, of arithmetic, of losing time by “settling” and
fetching, such women as it will be our aim to procure can get through
the duty of seventy-two patients, although with the serious drawback of
their being in separate wards and on separate floors.

If, however, the Pavilion plan were so modified as to have two
pavilions end to end, with an intervening staircase, so spacious and
well ventilated as to cut off the ventilation of the two wards on the
same plane, then all the conditions as to health, and facility of
nursing and supervision, would be much more easily obtained. Of this
more hereafter.

[Sidenote: 3. Responsibility of Nurse for Discipline of her Ward or
Wards--how Modified in Military Hospitals.]

3. As to the Nurse’s responsibility for the good order of the three
wards in a pavilion, supposing the three wards are served by one Nurse,
there must always be a clear difference between this responsibility
in the Head Nurse of a Civil and a Military Hospital. The Civil Head
Nurse, whose assistants are all Nurses, who with herself are under the
Matron, is charged with, and responsible for, the good order of the
ward, and it becomes her duty, the moment she finds herself unable to
do this alone, at once to call in the Steward, or equivalent Officer,
in whose hands is the police of the Hospital.

The Military Head-Nurse’s Assistants are Orderlies, _i. e._ men and
soldiers, who, with the patients, are under military discipline. Of
this military discipline, the military power from the Commandant down
to the Non-Commissioned Officers acting as Ward-Masters, &c., is in
charge; the duty of the Military Nurse is, I apprehend, in case of
any insubordination which she cannot put down at once, to call in the
Ward-Master or equivalent, before calling in the superior Military or
the Surgical Officer; it being, however, well understood on all sides,
that she has the right of direct appeal to the superior Military or
the Surgical Officer, if the Ward-Master does not do his duty, or
in the event of a grave irregularity, if he is not at hand, besides
its being her duty to report such to the Matron, if the case admits
of being deferred till that can be done. It is impossible to settle
details until the regulations as to the new Hospital Corps are fixed;
and whatever regulations, whether for Nurses or for Orderlies are
made, some difficulty, and much discretion will be inevitable and
necessary in working them. But it is necessary to bear in mind that
whereas in the Civil Hospital the Head Nurse, under the control of, and
responsible to, the Officers, including the Matron of the Hospital,
is solely in charge of both the nursing and the discipline of her
ward, both as to patients and as to Assistant Nurses; in the Military
Hospital, she is in charge of the nursing, and the Ward-Master of the
discipline, both of patients and Orderlies. To be in charge of the
nursing, implies to have power to enforce discipline, but this is
rather, in ordinary cases, to call in the military power, beginning
from the lowest or Ward-Master’s grade and reporting this to the
Matron, than to invoke herself the military superiors. Therefore it
would be well worth while trying how far it would answer to serve the
three wards by one Nurse, who, in each ward where she successively is,
is bound, on perceiving any irregularity, to call in the Ward-Master,
and, in contingencies, to appeal directly to the Surgeon and the
Captain of Orderlies, and to make the discipline of the three wards
the charge of the Ward-Master, who is bound to go through the wards
when the Nurse is not in them. The Ward-Master, in order to fulfil his
charge, must enter all the wards, while the Nurse is in one of them; so
that the patients of one ward, who may know that they are safe from the
Nurse for half an hour or more, as she is in another ward, know that
they are not safe from the Ward-Master.

In a military Hospital we must bear in mind that it is essential that
the discipline over patients and orderlies should be exercised by men,
and that the Ward-Masters must be the lowest and immediate deposits of
this power of discipline.

All these things must be settled with the concurrence of the
Director-General.

It is a great comfort that the Hospital staff returns to soldiers. We
shall get on infinitely better with them than we could have done with
the late Medical Staff Corps, though, after all, in the long run, we
should manage with them too. If only God helps us with the sort of
women required, thoroughly efficient Nurses, laborious active women,
discreet as well as well-conducted, and aware (a little) of the sort
of work and place, they are in!--let us trust this to Him, when the
time comes, and depend upon it, to give each Nurse plenty to do will
become one great means of forming such women--provided, which must be
strenuously kept in view, they are made to do it.

[Sidenote: 4. Importance of Lifts.]

4. It is very important to have the system of lifts throughout the
Hospital, although here, as throughout, the plan of Pavilions renders
them much more requisite, and makes them work less efficiently than
the block plan. Lifts, to carry meals and medicine, linen, coals, &c.,
&c., to and from the first and second floor wards, are very preferable
to the Orderlies carrying them up and down. One sort of load ought
certainly not to be brought up and down by lifts, but to be carried up
and down by men, viz., coffins and the dead. Using the lift for this
purpose (as is done in one Civil Hospital) is on all and every account
thoroughly objectionable.

The system of lifts is the more important, because although there is
no objection to the washing of tea cups, drinking cups, and medicine
vessels at the sink in the scullery, it is certainly neither necessary
nor safe to wash the dinner dishes close to the sick wards. By a little
arrangement, the whole of these could be removed by lifts to a scullery
beside the kitchen, and there cleansed and set aside for next day’s use.

[Sidenote: III.--1. Casualty Wards for noisy and offensive cases should
be separate from the ordinary Wards, and under a completely-appointed
Staff of their own--both for Sanitary and administrative reasons.]

III.--1. Sanitary necessities can never be interfered with. The
concentrating offensive and noisy cases together, while entirely
separating them from each other, in a completely appointed set of
wards, is a far more efficient working thing than appending a small
ward to each ward.

St. Thomas’s (a very admirable Hospital in very many things) has a
casualty ward (for such cases) for men and one, adjoining but separate,
for women, under the charge of one Sister. Baths are in the wards.

Guy’s had the same provision with, however, the drawback that there was
not a Sister in charge, but a Nurse over other Nurses, with higher pay,
but not a Sister or Head Nurse. However excellent such a Nurse may be,
every ward _must_ be under the same regular government as is general in
the Hospital, if discipline and order are not to suffer. Every ward or
set of wards should be under a completely appointed staff.

St. Bartholomew’s had a set of casualty wards, including two of about
ten beds each, several small wards of two and one bed each, including
two with gratings and other melancholy necessary appliances to prevent
extremely violent delirious patients from becoming suicides. These
wards were often partially empty, never quite so. They were long served
like the casualty wards of Guy’s; but some years ago they were placed
under the charge of the Sister of the male operation ward immediately
above, who received in consequence a small annual increase of wages.

London Hospital sent its noisome, offensive, and extra-infectious
cases to its other wards--small wards for one patient each, and, like
Guy’s, not under the regular management of a regular Head Nurse.

It most certainly appears that the plan of concentrating these cases
together, but with (as at St. Bartholomew’s) small wards where
extra-violent patients can be put separately, the whole under one staff
of Nurses, is far the best working plan.

And for this reason. Occasionally, a very offensive case requires
little nursing beyond the fixed daily dressings, and can lie quietly
enough in his bed or ward. But noisy cases almost always, and offensive
cases generally, require close watching. Now the moment we have a
patient in a little room at the end of the ward, it is our duty to
go in and out and see after him, and supposing him to be a violent,
delirious case, he is, unless under strong restraint, unsafe alone; and
even then the restraint requires looking to. In very many cases the
frequent inspection of Nurse and Orderlies would not be enough, and the
man ought to have a watcher.

We can never send one of the Orderlies of the ward, wanted for its
regular duty, to sit down in one of these little rooms; and we can
never keep a fixed extra Orderly idling about, unless the little ward
is inhabited. We must then fall back upon extra Orderlies, put in when
the case wants close watching--of course not otherwise.

At night, also, the watching which suffices for the ward will often not
suffice for the extra case--and he must have a watcher apart.

The plan of extra Orderlies or extra Nurses is a very bad one, to be
avoided as much and as long as possible; it very seriously interferes
with the discipline of wards.

Recollect that each offensive or extra-infectious case, put into the
little ward, ought to represent a great amount of separation and
care, which it will be difficult to secure. His mug, utensils of all
descriptions, bandages, &c., ought to be washed separately from those
of the patients of the large ward. Is this easily secured?

In the two Borough Hospitals they at once remove a case of erysipelas
or gangrene, occurring in any ward, erysipelas from venereal wards
included, into the casualty ward. In the two other great Hospitals
it is only when the erysipelas or gangrene becomes severe that the
removal is made. Now at once to remove these cases from the ordinary
wards is very advantageous.

St. Bartholomew’s larger wards for male and female casualty cases, two
small wards for two patients each, and two grated wards for one each,
are very efficient. The wards are all contiguous, and, as has been
said, under the charge of a remarkably efficient Sister, who has charge
also of the male operation ward immediately above. The little casualty
wards, of course, add to the work, and greatly to the anxiety of
watching; but certainly violent delirium tremens’ cases, alone and in
a secure ward which can be darkened, appear often to quiet much sooner
than where several of these wretches lie shouting to and at each other.
Delirium tremens will never be a thing unknown in a Military Hospital.

One such case in the little ward adjoining the Pavilion Ward would be
a heavy infliction on the severe cases in the latter; the noise would
be heard throughout it. And unless the ward were properly secured, or
unless the man were under strong restraint--and then that would require
constant looking to--he would not be safe a moment alone; while the
Orderly was emptying slops or bringing in his dinner, something might
occur.

[Sidenote: 2. Restraint or Non-restraint in Delirium Tremens.]

2. Restraint is again a thing which must be left to our masters, and
to them solely--but an ugly, sorrowful, little truth may here be told.
Restraining and non-restraining processes, and their results may be
seen, both where, in the same Hospital, one or more of the Surgeons
orders restraint never to be used to his patients, however violent, and
others order it to be used in violent cases: and where the rule of the
Hospital is to restrain violent cases, removing the restraint so soon
as the paroxysm is over, or as soon as amelioration renders the sudden
return of paroxysms less likely. I am not speaking of lunatic asylums,
but of delirium, particularly delirium tremens, in hospitals. Lunatics
occasionally enter the Civil Hospitals, but, of course, as soon as
that supreme earthly misery is ascertained, they are removed to the
proper refuge. It is my humble opinion and firm belief that mechanical
restraint excites a patient much less, and quiets him much sooner, than
the prolonged struggle with his attendant’s arms and hands, which
_must_ otherwise be resorted to.

The coercion apparatus ought also to be good, not cheap, and always in
perfect order. The least thing out of order either causes pain, which
when it can be avoided is cruel, or it endangers the efficiency of the
whole. The strength and cunning of these patients resembles those of
madmen, which for the time being they are.

Restraint renders the usual complement of ward servants able to manage
many cases. Non-restraint means that some person must stand or sit by
or upon the patient’s bed, and hold and struggle with him often for
hours--also that generally this person must be a stranger to the ward.
Extra attendants are most injurious to discipline. Could there be a
set of casualty or equivalent wards, with its own Head-Nurse, the sick
would gain much.

But if necessary to adopt the little ward with every ward--in that case
the Nurse must manage the three additional patients--twenty-four or
twenty-five are, indeed, too few.

[Sidenote: IV. Simplicity of Construction essential to Discipline.]

IV. In all Hospitals, let the construction be as simple as it can be.
Let its splendour be its lofty airy wards, with plenty of windows;
water in all due abundance on each floor; an ample, not excessive,
supply of linen, polished impervious walls and ceilings, well-laid and
bees-waxed oak floors, and a thorough not excessive, supply of good
apparatus of the various necessary kinds. But every _unneeded_ closet,
scullery, sink, lobby, represents both a place which must be cleaned,
and which must take hands and time to clean, and a hiding or skulking
place for patients or servants disposed to do wrong; and of such no
Hospital will ever be free. And every cornice, every brass lock or
handle, which could be replaced by a plain china or ebony one; every
decoration, or flourish, or ledge, on doors, windows, tables, beds,
presses, &c., represents either a collection of dust or a great waste
of hands, time, and strength in unnecessary cleaning and dusting. These
are not crotchets, but the result of close observation of the practical
working of these matters. Every five minutes wasted upon cleaning what
had better not have been there to be cleaned, is something taken from
and lost by the sick. Let the appurtenances of the wards be simple and
complete, but as plain and as undecorated as it is possible to be.

[Sidenote: Polished Walls.]

Polished impervious walls and ceilings are of the first consequence
in Hospitals. It is perhaps hardly necessary to state that, if Parian
cement be used, it must not and need not be of the kind lining the
wards and corridors at Guy’s Hospital, which is as rough as the
roughest plaster, of a dark and dirty colour, and which nothing could
improve but being lime-washed twice a-year; it should be polished like
that used at the Lariboisière Hospital at Paris, and of a pure white.

[Sidenote: Covered Exercising Place.]

In building a new Hospital, some covered arcade or some place where
the patients might take exercise in wet weather, and where inspection
could be exercised over them, without fuss, is worth contriving. In St.
Thomas’s, the patients walk under the covered arcades of the court.

[Sidenote: Reserve Wards.]

Both in Bethanien and in the Charité Hospitals at Berlin there are
reserve wards,--or rather in the Charité there is a reserve Hospital,
into which most of the sick are moved for six months in the year, to
change the air alternately of all the wards, which during the time
receive a thorough cleaning. Great stress is laid at Berlin on thus
providing, when building a new Hospital, a certain reserve space, which
obviates the necessity of less efficient and far more costly steps
afterwards.

[Sidenote: V. Nurses’ Meals.]

V. Let us, by all means, consider as settled, that the Nurses’ food is
sent them cooked. Possibly, in the long run, the undoubted advantages
of this plan will be found to be over-balanced by its disadvantages;
but let us begin by trying it. I submit that their dinners, and
possibly suppers, should alone be sent them cooked, and that each Nurse
should receive a fixed weekly quantity of groceries, and a daily or two
days’ allowance of bread.

For packing up the Nurse’s meals sent her from the kitchen, a Vienna
custom might be useful. Each Nurse to have a long, strong, straw
basket, properly named or numbered. Some contain five dishes and
covers, but two or three would here be sufficient for every purpose,
including an occasional slice of pudding. The dishes strong tin, with a
tin cover, and if the Nurse prefers eating her dinner out of it rather
than the dignity of plates, and the trouble of washing them up, the
Matron should let her take hers her own way. If taken by hand, two
baskets of this sort can be carried with ease. But if the Matron, as
a general procedure, sends each Nurse a hot little dinner, of a good
well-cooked portion of meat and vegetables, one such dish and cover
will do for one Nurse, and three, five, or six can be accommodated out
of the same basket, or one large basket, carried by two men, would
serve all the Nurses round. The dishes should, in either case, be
numbered or named, not the Nurse’s name, but the ward.

A dish and cover of strong, coarse earthenware is used in the Vienna
Hospital, as a grander edition of dinner, &c. The tin ones keep warm
without fire for a long time. If the meal arrives when the Nurse
cannot eat it, put by on the hob, or some provision for warming in the
scullery, it will keep warm and good till she can eat it.

[Sidenote: VI. Arrangements for a Pavilion served by one Nurse.]

VI. Supposing that we serve each Pavilion by one Nurse, I submit that--

[Sidenote: 1. Nurse’s Day-room.]

1. The Nurse’s day-room should be on the ground floor.

[Sidenote: 2. Ward-Master’s Sleeping-room.]

2. The Ward-Master should sleep in his room on the second or highest
floor; should the Nurses sleep in the Pavilion, the Ward-Master should
still sleep in it.

In the event of the Pavilions being arranged end to end, as already
suggested, the difficulty in regard to Nurses’ and Ward-Masters’ rooms
would be materially diminished.

[Sidenote: 3. Where should Orderlies Sleep?]

3. I think, but am not sure, that the Orderlies had better sleep away
from their wards, but I would leave this to be settled by the Doctors.
In cases of sudden outbursts of danger, delirium, or drunkenness, from
the results of concealed spirits, and of the Surgeon being sent for,
it is useful to have, at once, other than the Night Orderly at hand.
And a part of what has been said as to the importance of the Head
Nurse sleeping near her ward, applies to the Orderlies. Yet there are
important reasons why the Orderlies should not be or feel too much at
home in their wards; and if the authorities are disposed to try the
plan of lodging the Orderlies together, away from their wards, they
are probably right, though I should not be surprised if, after a fair
trial, it were found better to revert to the having them near the ward.
The Pavilion Plan, which, on the one hand, gives all concerned more
liberty of doing wrong than the block plan, and which, on the other,
renders it more difficult to call in help, whether of supervisor or of
Orderlies, if help is suddenly wanted in the night, makes it the more
desirable to let the authorities take quite their own way, as to this.

[Sidenote: 4. Where should Orderlies Dine?]

4. I think the Orderlies had better have their cooked meals sent them
into the wards. Of course, they can only eat together in detachments;
but in many cases, the absence of even one of the Orderlies would be
very inconvenient. Perhaps just as the bell rings to summon to the
common meal, something is going on which requires all the ward service;
the man either goes late to a cold dinner, or goes away just when he is
wanted. If his dinner is brought to him in one of these emergencies,
it is put by to keep warm till it is over. Regularity as to meals,
as far as possible, should be strictly attended to; and is, in all
well-regulated wards: and it is well, where, as in some Hospitals,
there is a fixed hour for meals; but it would seem better that the
meals should come to the ward servants than the ward servants go to
their meals.

[Sidenote: 5. Should Orderlies be brought together?]

5. In the case of Civil Hospitals served by women, it is very important
that each Head-Nurse, and each set of Assistant-Nurses, should sleep,
eat, and live in the ward and its appertaining rooms, and not assemble
together more than can be avoided. With Orderlies the case is partly
different. Still I would not unnecessarily bring them all together, any
more than allow them to be too much at home in their wards.

[Sidenote: 6. Should Orderlies have a Day-room in Pavilion?]

6. If the Orderlies do not sleep in the Pavilion they should not have a
day-room.

[Sidenote: 7. Scullery to each Ward.]

7. To each ward should be attached a scullery, small, but not too
small, which only muddles things and work, well provided with cold,
and, if possible, with warm water; and it should be law that no patient
enters the scullery unless sent there by the Nurse to help in washing
up, &c.; and, as a rule, they ought not to be sent there. Make them
useful in the ward; keep the scullery for the Nurse and Orderlies.

[Sidenote: 8. What should be done in the Scullery?]

8. From this scullery let the Nurse get the water she
requires--Orderlies ditto.

Let the Orderlies eat their meals in it, if they do not eat them away
from the ward. The food of the Orderlies is generally different from
that of most of the patients, and it answers better for them to eat
their meals not under the noses of the patients. In emergencies, of no
rare occurrence, the Orderly must watch a patient and eat his dinner at
the same time, and so must the Nurse; but, as a rule, it is undoubtedly
better that ward-servants should not eat under the observation of the
patients.

In the scullery all the cleaning must take place, which is not done in
the lavatory.

In the scullery extras are to be warmed, drinks ditto, hot-bricks
heated, water-bottles filled, &c., &c., &c., and none of these things
are to be done at the ward-fire.

[Sidenote: Poultice-making.]

On the other hand, there is no way so good of making poultices, a thing
humble but important, as for the Nurse to stand at a small table in
front of the ward-fire, to make the poultices there, spread them, and
forthwith apply them.

Sometimes in a large ward, where the Surgeon orders them extensively,
a large iron pot is filled with poultice, and then quickly spread and
applied. Sometimes the pot is filled and the poultices spread in the
scullery or kitchen, to avoid the mess in the ward. When a number of
poultices are thus spread away from the sight of the patients, even by
very clever Nurses, some arrive too large, or too small, or too broad,
or too narrow; and either the poultice has to be returned, or, as of
course usually takes place, to be put on the wound it does not fit.

I would not trust any Nurse, including myself, to make a number of
poultices of the right size, unless within sight of the patients.
Rather than do this it is better to make the poultice-pot (wood does
not hold heat, this must be of iron), in the scullery, to take it into
the ward, and there spread and apply the poultices.

But a large iron pot of linseed poultice seldom contains the article
nearly so well made, as when made in smaller consecutive quantities in
a wooden bowl. The bowl does not keep warm above a certain time. Where
the poultice is made in a mass, even by very clever Nurses, it never is
so well made as when the Nurse makes the poultices in the wooden bowl.
These must be forthwith spread, applied, and the bowl re-filled, if
more are wanted.

This is another reason why the person who washes the wound should also
make the poultice, as also why the Orderlies should clean the ward, why
the Nurse should as far as possible be relieved of all “mental labour,”
and why kept as much as possible to “manual labour.” All severe wounds
she should wash and dress herself, and many a wound becomes severe,
when the patient is allowed to fiddle over it himself. Some wounds will
not bear being left uncovered, and of course in some cases the Nurse
will wash the wound, and immediately afterwards apply the poultice.
In general, the Surgeon will consider the wounds take no harm from
being washed all round, and then poulticed all round. This requires
not to be over-hurried, and not to lose a moment’s time. A careful
Nurse will never apply a poultice without having first seen the wound:
carelessness, haste, idleness, over-work, and prudery, each and all
produce very sorry results as to this.

I think, therefore, poultices should be made in the ward, and
immediately after the table cleared away, and the slight mess also.
In some Hospitals they place a straw carpet just round the table, and
also carry it to any bed which requires an extra mess in dressing or
cleaning.

[Sidenote: 9. Presses in Ward.]

9. A regular store closet is hardly desirable. A good arrangement is
this:--

At the end of the ward, nearest the Nurse’s room, or the ward-door, a
large press for linen.

By it or opposite it another press, for stimulants, dangerous
medicines, stock medicines, such as castor oil and one or two others
which are always to be at hand, though not ordered for any particular
case, stock lotions (as few as possible), lint, old soft linen,
stronger but not coarse ditto for pads, &c., cotton wool, tow, oilskin,
splints and pads, &c., &c. Of all these things, the Nurse should always
have a certain reserve on hand.

It will be well worth while to see that these presses are made
commodiously for their purpose. The linen press should have broad deep
shelves, and the different kinds of things should be sorted apart; the
other press should have broad deep shelves for the heavier things,
and separate shelves for the bottles; the stimulants by themselves in
one row, the stock medicines in another, unless these and the stock
laudanum were together, but they are better apart, and the dangerous
things upon the topmost shelf; another row for sweet oil, mustard,
stock lotions, &c., another row for ointments. Each bottle and pot to
be distinctly labelled in whatever is reckoned the most lasting manner;
opinions differ as to labels and letters cut in the glass. The latter
are boring by night, if something is suddenly wanted, and it is just
then that mistakes are to be guarded against. A strong clear PRINTED
label, securely fastened to the bottle, is preferable, to be renewed
when necessary, as Orderlies’ thumbs even while holding a bottle, if
the Nurse’s hands are on the bed, wear labels out. There is a great
saving of time and of chance of mistakes effected by clearly printing
the directions for the administration of medicine, “once,” “twice a
day,” “every three hours,” &c., and affixing them to each medicine
bottle.

Of both these presses the Nurse should have the key or keys. One key
might do for both, but it may be best to have two keys.

It is a very good plan where the shape of all medicine bottles and of
those for liniments is distinctly different; and where, _e. g._, square
bottles are used for poisons, or blue bottles for poisons, and square
for lotions.

A small narrow shelf over each patient’s bed, or over his locker,
solely for his medicines and wine. When these are on the locker it is
less convenient. Where the medicines are not dangerous, it is better
to have them thus at each bed, than concentrated away from the beds.
Dangerous medicines should never be left at a patient’s bed.

The two presses will answer all demands. As, however, it does not
do not to have a supply of everything that may be wanted always in
readiness, a stand or table in the ward should have upon it a small
supply of whatever may be suddenly wanted--a little lint, linen, tow,
and two or three vessels. The supply of lint, &c., to be small enough
for the Nurse to keep account of it, and for the patients to know that
account is kept of it.

[Sidenote: “Apparat” in German Hospitals.]

In constant daily use in the surgical wards of the great Vienna
Hospital is a thing called in Teutonic style “Apparat.” The Nurse
carries it round for herself, when preparing and dressing the
patients, and carries it after the Surgeon when he makes his rounds.
The system of both dressing and washing is in some respects so
different from the English one, that the fittings would vary.

This concentration of what is wanted for dressing and washing wounds,
and for attending the Surgeon in his inspection of them, and of what
is at once wanted on any bleeding, fit, &c., is very useful; all the
more from its being in a compact portable form, which can be thus
successively carried to each bed. An English carpenter would make a
lighter and handier thing. Brass basins, which are there used, are
not desirable. Of course, one must be most especially anxious not to
introduce any novelty, particularly any foreign novelty, faster than
can be avoided, and we may consider it better either to leave the
general system unaltered of rushing on some emergency to the dressing
table drawer, or closet, and thence bringing successively the things
wanted, or at all events not to extend concentration further than
the excellent plan, so far as it goes, of the London Hospital, where
each Head Nurse attends the Surgeons with a large basket in her hand,
containing most of the dressings required, spunges, and one or two
little matters also usefully at hand. The _apparat_ has the advantage
of carrying with itself the basins used for washing. In the Military
Hospital of Vienna a tray attends each Surgeon, without basins.

[Sidenote: 10. Nurse’s Room.]

10. It is important to have the Nurse’s room opening at once into the
ward, and, upon the whole, I should incline to its having but one door,
although it may be thought better there should be a second, so that she
can leave her room without being seen to do so by the patients. Also,
by all means, let the scullery be opposite the Nurse’s room, and not
between the ward and the room. As an invariable Hospital rule, rather
more than elsewhere in Military Hospitals, publicity may be considered
to be a very great police, and a still greater protection. It is far
better that twenty-four patients should see the Nurse’s door than one
or none; and that her room should open full upon the ward than into an
intervening scullery.

In contemplating a Military Hospital, we contemplate a place through
which, one year with another, all characters, including a few of the
vilest, pass. These are not theoretical matters. The more repulsive the
subject, the more prevention is better than cure. Guard against too
many closets, sinks, &c., &c., &c.

[Sidenote: Lavatory.]

At the end of the ward there should be a lavatory, with a row, or
two opposite rows, of white earthenware basins fixed in a stand,
with outlet tubes and plugs: each basin should have a hot and cold
water-pipe: and there should be not less than one to each four beds.
There should also be in the lavatory a hot and cold water-pipe, from
which a portable bath can be filled.

[Sidenote: Water-closet.]

At the furthest end of the ward should be a water-closet, with not
less than one soil-pan to each eight beds: and white earthen or
porcelain urinals in the same proportion. In the London Civil Hospitals
water-closets are now in general use throughout the wards, but not in
all of the great Hospitals. In all the Civil Hospitals, it is usual
that the patients’ water-closets have no inside bolt or lock, and
that there is only accommodation for one inside. In some London Civil
Hospitals the male patients, able to take exercise, are expected to
make use of urinals out of doors. These matters one, two, or three
experienced army surgeons had better pronounce upon; other things are
to be considered than the recommendations of architect, plumber, or
even sanitarian.

[Sidenote: Sink.]

There is in a Berlin Hospital a very useful piece of prosaic
apparatus--adjoining the water-closet, a sink, with a high, large,
deep, round, pierced basin of stone, above a _large_ hole, into which
the contents of a bed-pan can be at once emptied, and from which the
bed-pan is at once effectually cleansed. Adjoining this is a sink into
which all other slops are emptied. In mentioning this pierced basin or
sink solely for emptying and cleansing bed-pans, &c., which is used at
the Bethanien Hospital at Berlin, and is far better than emptying the
said vessels into the often-occupied water-closet, and then cleansing
them in an awkward fashion between the water-closet and the sink, it is
necessary to add that the cock ought to extend far enough over the sink
for the bed-pan, &c., to be thoroughly cleansed by a stream of water
falling directly into it. The Nurse stands at the sink, empties the
pail, &c., in it, without fear of splashing, and rinses and fills it,
without stirring from the place. Now this absence of splashing water
and of moving about from sink to pump, or cock, saves mess and time.
The oblong sink, usual in England, has by no means the same advantages.

(The partition containing the sink would be an appropriate receptacle
for the bed-pans to hang by hooks or nails on the wall pending their
use.)

[Sidenote: Baths.]

In Civil Hospitals, two baths, in an airy closet at the end of the
ward, to be locked at all times when not in actual use, are a very
great advantage. Bringing a bath into a ward, which in many urgent
cases must be done when the baths are distant, is a messing discomfort.
Still it had better be left to surgeons to say whether, in Military
Hospitals, it would not be preferable to have, in each ward, only a
portable bath, on wheels, covered with india-rubber, to be brought
into the ward for any urgent case; and to take all the men able to
walk, or safely to be carried, to the Hospital baths. Of these, some
trustworthy, or intended and supposed to be trustworthy, man, who
ought to rank as a non-commissioned officer, should have charge. An
intelligent and respectable-looking man, a serjeant, has charge of the
baths in the Garrison Hospital at Vienna.

In a great London Civil Hospital, St. Thomas’s, it is the very
admirable practice for each patient (of course with necessary
exceptions) to be bathed on his or her admission. The Sisters are
responsible for examining each woman in the bath, which is within the
female wards, and for at once reporting before suffering them to go to
bed, any case of suspected pregnancy, syphilis, or contagious disease.
A man does the same for the men, who are bathed apart from the wards.
This arrangement is an excellent one. On the other hand, severe cases,
just able to be carried to baths, get no good by going through the air,
and being jolted up and down stairs.

In planning a Military Hospital, in which the service of women is to
be introduced, it is important to obtain the advice of experienced
Army Surgeons as to the arrangement of appurtenances of the wards to
be used by the patients alone. Endeavour to prevent the system of
holes and corners. It is best that the Nurse’s door should command the
view of those who come in or out of the lavatory, and in or out of the
water-closet. This whole section is both ugly and important.

[Sidenote: 11. Summary.]

11. To sum up. I think it would work the best to have no store-closet,
only two well-appointed presses, by which a certain amount of cleaning
is saved, and a corner avoided.

Could two cupboards or presses in the wall be arranged for the ward
linen and the ward stores, it would be preferable to presses placed
against the walls. Take care, however, that the wall is sufficiently
thick, so that the presses are not damp, and if this cannot be provided
against, keep to presses separate from the wall.

Believe that all this is neither theory nor fidget--but practice.

The furthest end of the ward should contain a lavatory, a water-closet,
and the pierced basin for emptying and cleaning bed-pans is a very
useful thing. At the other end of the ward, the Nurse’s little room,
her door opening full upon the ward. If the upper half were of glass,
with a curtain before it, allowing the Nurse to see the ward without
being seen, it would be all the more useful. At St. Thomas’s, a window
opens into the ward, the Sister drawing a blind when she chooses, and a
door opens into the passage, just within the ward doors, opposite the
scullery, so that the Sister enters the scullery, in which there is
a water-closet, for the accommodation of herself and Nurses, without
traversing her ward. Whether door or window, the Nurse should see at
once all that is going on in her ward. I prefer a door; yet, if there
is to be a ward for one, it may be best and most central to have the
Nurse’s window on the large ward, and her door open on the passage.
Opposite the Nurse’s room should be a scullery, not too small. The
scullery should be well provided with cold, and, if possible, warm
water.

If a supply of hot water can be obtained by turning a cock, this
is best. Provision should be made in the ward scullery for keeping
poultices warm which is every now and then wanted. It is not right to
wash eating-vessels and poultice pans, &c., in the same sink; and this
should be considered in arranging the scullery. If each ward washes its
own bandages, which it ought not to do, the second sink will come in
usefully for this. It is worth while, in enforcing extreme simplicity,
to prevent jumbling together eating-vessels and things for wounds and
sores. Sinks are infinitely most handy when made deep, somewhat in
the shape of broad round basins, with hole at bottom; it saves much
splashing and mess; the cock to overhang full the middle of the sink.
The Wall against the sink should have some protection.

Such a scullery, with complete efficient simple apparatus for its
various purposes, places for washing up and cleaning, and for ward
purposes and cookery, so that the Nurse can warm the drinks, prepare
fomentations, &c., without jostling the Orderlies, who are washing up
or cleaning, will be a very great comfort, simplification, and promoter
of order, cleanliness, efficiency, and work. At one corner a decent
little table for Orderlies’ meals, above it their separate safes for
their bread, cold rations, &c., &c.; each to have and keep his key;
each to have his locker.

Each floor and ward will require a scullery. It is far better for each
ward to contain its own appointments--and all the other stores to be
together, apart. On the second floor might be the Ward-Master’s room;
_vice_ the Nurse’s room.

[Sidenote: 12. Nurses’ Sleeping Quarters.]

12. Nurses’ quarters, if we are driven to their not sleeping near
their wards, should be adjoining the Matron’s two rooms, and separate
water-closet, in a part of the Hospital as central as can be managed
without trespassing on our betters. I would simplify these quarters as
much as possible--either a series of very small rooms, or one great
space partitioned off each into a little cell, with a window, bed,
washing table, chest of drawers, and a very small wardrobe, with space
to hang up three or four gowns, deep enough for another row for shawl,
&c., at top a shelf for bonnet and caps, at bottom a deep drawer for
boots and shoes. These things will be a convenient riddance to the
chest of drawers, and comfort to the women. In each cell very strong
hooks to hang up and air a little gowns taken off at night, and one
or two chairs. The nurses must wash their hands, &c., in the rooms
off their wards, and I think it must be understood as a rule that
they leave their quarters in the morning and return to them at night.
Optional carpet.

Each cell to be numbered either with number or with name of Pavilion.
Opposite this space a small lumber room, wherein each nurse may deposit
her box, thereby hindering dissemination of bugs. Opposite also a
running open cupboard, with partitions numbered or named as rooms,
containing each Nurse’s broom, dustpan, &c., each with a key.

Also pump, sink, water closet.

[Sidenote: Furnishing.]

When furnishing begins, it will be well worth while to see that all
articles of furniture, whether for wards or Nurse’s quarters, admit of
being easily swept and scrubbed underneath, and swept and dusted at
top. Chests of drawers, &c., with too narrow space between bottom and
ground, harbour dust, or sadly waste a few precious minutes in the most
busy part of every day. As few high pieces of furniture as possible, to
gather dust and be out of easy reach; as few as possible of cumbrous
articles difficult to move from the wall, to sweep and dust behind, &c.

There ought to be, near the Superintendent’s quarters, one or two
small rooms, where, necessity occurring, sick Nurses might be lodged.
We cannot hope always to escape having sick Nurses; and there would
be serious objection in a Military Hospital, where only one Nurse
sleeps on each floor, to having the Nurse ill in her room for more
than 2 or 3 days at the outside. Or there might be one good-sized airy
room, with two or three dark washable curtains dividing it into little
dormitories, so that one Nurse, whom the Superintendent must engage and
watch, could attend them all. And as Her Majesty’s Nurses must have
allowed them such decent comfort as can be, but no fastidiousness, I
think the cubicles in one room would be best. Not to be called so,
however, by any means, as it would sound Latin and “Puseyitical.” The
Nurse’s ward to be locked and key kept by Superintendent, except when
tenanted. I should hope three beds would answer thoroughly, as well as
that the ward would be empty eleven months out of the twelve.

Considering the awkwardness of illness among Nurses, when it did occur
in a Military Hospital, it would be worth while that, adjoining the
little ward, there should be a little room for any one infectious case
which might occur; _e. g._, supposing one Nurse ill in the ward with
bronchitis, it would not do to put another with small-pox into the
ward,--at least it would be very impolitic. The ward should have a
water-closet and a little sink of its own, and a little cell, but with
window and fireplace, for the attending Nurse to lie down in. When not
used, once a month’s, or week’s at the most, cleaning by a charwoman
would be enough. It should be always clean and ready for use. In the
Civil Hospitals, few years pass without sundry Head-Nurses and Nurses
dying, not a few Nurses being warded, and sundry Head-Nurses ill in
their rooms. The peculiarity of Military Hospitals makes this little
preparation for what is certain every now and then to occur seem
desirable and economical; to hire lodgings in the neighbouring town
would be in all ways a worse plan.

[Sidenote: 13. Classification of Cases.]

13. Endeavour, if possible, to obtain a classification of the severe
and non-severe cases, and let the Nurses be only appointed to the wards
of severe cases. The convalescent cases to be successively removed to
the convalescent pavilions, whether they bear or not that name. No
convalescent ward in any of the floors of the Pavilions to be served by
Nurses.

[Sidenote: 14. Nurses to be called by the Names of their Wards.]

14. It will be found excellent in many respects not to allow the
Nurses’ names to be used in the ward of the Hospital, or among each
other, so far as the Matron takes cognizance of. In the great London
Hospitals the name of a Nurse is never heard, except occasionally to
each other as a solace, partly very natural, partly harmless vanity.
She is Sister or Nurse of such and such a ward. In hasty parlance she
is distinguished from the others by the name of the ward only. In it
she is always addressed as Sister or Nurse.

Thus a Sister of St. Thomas’s Hospital, whose services in the War
Hospitals of the East I can never forget, was always at St. Thomas’s
spoken of out of her ward as Sister of George, or, more commonly,
Sister George; and spoken to quickly or called to in a hurry as George.

All this, the only course of all the great and, I believe, of the
smaller London Hospitals, works excellently, in many ways.

[Sidenote: 15. Foul Linen--how to be Disposed of.]

15. Arrangements should be made that foul linen remains for the least
possible time out of the laundry. As regards the laundry deposits, the
best plan is that of the London Hospital, where each ward has a bin of
its own marked accordingly. To similar bins all the foul linen should
be, at least, daily carried, unless it is judged best to receive and
wash all the linen in a heap, returning numbers only to each ward. The
former plan is preferable. In any case the linen of the “foul wards”
should be received and washed apart. During the time, which ought to
be as short as possible, between dirty linen leaving the patients and
reaching the bin or bins, a large box in the scullery is making the
best of a bad business--the presence of foul Hospital linen always is
that--and is preferable to a closet.

[Sidenote: 16. Washing Bandages.]

16. Washing bandages, a very important thing. Shall a washerwoman
be told off for that particular purpose? or shall the Orderlies of
each ward do it _alla meglio_? The former is the better plan; if not
adopted, the Nurse must see well to the matter.

[Sidenote: 17. Splints--Bandages, Lint, &c., where to be kept.]

17. It would depend upon what sort of work is usually going on in the
Surgical Wards of a Military Hospital in peace whether it will be worth
either a press with glass front, in which splints, pads, &c., &c., are
excellently arranged, as at St. Bartholomew’s; or the pad-basket and
splint-rack, which are also excellent, provided in London Hospital.
The splint-rack, enabling the Surgeon at once to see and choose of all
shapes and sizes, is perhaps only suited for an accident ward, and
would be out of place in a military ward in peace. It may be better
to have these stores entirely in some dispenser’s or store-keeper’s
jurisdiction, and to let the Nurse confine herself to padding, &c., any
splint sent by the Surgeon into the ward. Let our masters take exactly
their own way about this.

Bandages, lint, &c., &c., &c. should perhaps rest entirely with the
Dispenser, otherwise it would be useful in the greater Hospitals, to
have under the Matron a Nurse charged with preparing them and giving
them out, writing in a book the date, amount of each, and the ward they
are given to. In a small Hospital the Matron could do this herself.

[Sidenote: Cotton Lint never to be used.]

While speaking of lint, it seems a duty to state that, in some of
the Military Hospitals, in certain County and even London Hospitals,
and also in Workhouses, and in the practice of private Surgeons, a
preparation of cotton has been recently substituted in the dressing
of wounds for _charpie_ or Surgeons’ lint, properly so called. So
miserable an economy at the expense of the sick is not adopted in
several, at least, of the London endowed Hospitals, probably in none.
For all purposes for which lint is necessary cotton fibre should be
totally disused, in the army and everywhere else. It is irritating
and injurious to wounds. It increases human suffering; it delays
patients in Hospital, and, in doing so, of course, increases the cost
which such a substitution has been intended to reduce. Nurses should
be particularly careful never to use this material, which is easily
distinguished, even by the touch. Any Surgeon may tell the best of it
from lint by submitting it to microscopic examination, and on doing
so he will readily discover that characteristic of cotton fibre which
renders it so ill adapted for surgical dressings. It does not absorb
the discharges from wounds, as linen lint does. The fibre is ragged
instead of being smooth, and it is apt to become matted together, and
to adhere to the surface and edges.

[Sidenote: 18. Classification of Women.]

18. It is essential to have as few women as can efficiently do their
work. Supposing the Hospital were for one thousand patients, not taking
into account that some wards would probably be foul wards, where I
earnestly hope female service will not be, at present at all events,
introduced, and that some wards would be for slight or convalescent
cases, where I hope it never will be--supposing each Nurse served
seventy-five patients, supposing one Nurse, at the very least, was told
off for the linen, fourteen or fifteen Nurses would serve the Hospital.
I conclude the Matron to have no cognizance of the laundry.

[Sidenote: Superintendent’s Store room.]

The Superintendent[18] will require a store room, or at least a store
closet, and hers should be well appointed. It would depend upon the
other arrangements of the quarters, whether the world in general, when
sent for to fetch what it wanted, enter from the same side as the door
of the Superintendent’s bed-room, or from the other side. And it would
depend upon the nature and amount of stores of which she had charge, in
the larger Military Hospitals, whether or not she should have a Nurse
told off for this also. Economy is essential; but useless fiddling
over every duster or scrubbing-flannel given out, &c., &c., &c., sadly
hinders the Matron’s time from more important things.

Housekeepers must be avoided, and every woman must have a distinct
and sufficient share of work, and each be distinctly and equally
under the Matron. Still it would be advantageous if we could from
the first include in the staff of Nurses for the larger Hospitals,
one or two places which could be filled by efficient persons who yet
were unfitted for the ward work, which calling will be, and ought to
be, laborious and wearing enough. Many a woman would never do to look
after a Pavilion and seventy-five men; who yet, in charge of linen or
stores, would be most valuable, and influence most beneficially the
Nurses, whom yet she might be unfit to govern. The system of the Sœurs
de St. Vincent, who, in theory and fact, subject entirely to the will
of the Superiors in general practice, are yet selected and trained for
spécialités, who remain long in these spécialités, which spécialités
include such requiring more or less of physical strength, seems to be
one giving many useful hints for us.



ADDENDA AS TO MIXED NURSING BY NURSES AND ORDERLIES IN MILITARY
HOSPITALS ON THE DOUBLE PAVILION PLAN.


I. After much anxious thought, re-consideration of all things, and
pondering, I submit--

1. That three Orderlies will efficiently serve a ward of from 28 to 30
patients, including night-duty.

2. That each of two wards of 30 each, should there be two such under
the same Head Nurse, on the same flat, ought to be entirely separate in
all other respects.

3. That if night-duty be required, each such ward should have an
Orderly on night-duty.

4. That each such ward should have a scullery.

With regard to these questions, I further submit--

1. Economy of hands, combined with efficiency of service, is an urgent
thing in all Hospitals; most of all in Military Hospitals,

  On the score of expense;
  On that of efficiency of inspection;
  From the nature of Military Hospitals, where the aim should be
     throughout to combine great simplicity with thorough efficiency;
  From the importance of training the staff, male and female, of
     Military Hospitals, for service in War Hospitals, where every man
     or woman who can be spared is better away.

2. Yet economy of hands, carried too far, becomes, like all other such
economies, penny wise and pound foolish.

3. Without doubt, large wards can be efficiently served by fewer hands
than small or moderate wards. But, as sanitary considerations limit the
size of wards to from 24 to 30 patients, let us make this the basis of
all calculation.

4. The more it is considered, the more essential it appears, to train
Nurses, from the first, to do efficiently a great deal of work. A small
staff of respectable, laborious, and thoroughly efficient women seems
the thing to be aimed at; whether considering Military Hospitals by
themselves, or as a training-school for Hospital war-service.

5. It would be better to give each Nurse one great ward; but wards
above a certain size are inadmissible for sanitary reasons.

6. The care of 24 to 30 patients is not sufficient duty, by a great
deal, for a Nurse.

7. Therefore, upon the whole, and as decidedly the lesser of two evils,
I recommend assigning to each Nurse two wards.

8. It is less difficult, and less objectionable, that she should have
charge of two wards on one floor, than of two wards on two floors.

9. As regards the Nurse, I recommend therefore, upon the whole, to
give each Nurse the charge of two wards of 30 men each; the wards to
be on the same floor; but, except as being under the same Head Nurse,
entirely separate.

10. It is important to repeat that the Nurse (who is Head Nurse), will
be set free of two things, which consume much of a Civil Head Nurse’s
time.

(1). “Settling the diets,” and fetching, besides waiting for, portions
of those diets (_e. g._ wine) and medicine.

(2). Distribution of Diets.--It is quite possible that, in no long
time, it may be found desirable to assign this duty to the Nurse.
But it would be better to try to have it efficiently, which implies
honestly, discharged by the Ward-Master. It will relieve the Nurse
daily of considerable time; and it charges the Ward-Master with a
definite duty which he can perform. The more he has defined duties, the
less he will be inclined to fidget and disturb the Nurse. He is pretty
certain to do this; but definite duties will diminish the tendency.

I should avoid giving the Ward-Masters too few wards. Otherwise they
will make themselves insufferable obstructions, one way or another, to
the Nurses. I should say that each Ward-Master, in charge of a Pavilion
of six wards of 30 each, besides the small wards for one, would not
have at all too much to do. Where there are no Nurses, the Ward-Master
should have Assistant Ward-Masters in their place.

N.B. Wine might be treated as medicine, and, as such, delivered by the
Nurse. Wine and medicine are usually, in the Civil Hospitals, given
from the Apothecary’s shop at the same time. Or it might be considered
desirable to leave this duty to the Ward-Master. In either case, it
will never do to serve a bad case at once with all his wine, and either
to let him stupify himself by swallowing it at once to make sure that
he has it; or to set it by his bed-side for the flies to spoil it, or
for a dishonest comrade, or here and there an Orderly, to drink it. The
Nurse should receive, whether directly or from the Ward-Master, the
wine of such patients, and should administer it in successive small
fresh portions. The intelligent administration of wine ordered to bad
cases is one of those momentous _minutiæ_ by which, I do believe, and
believe more and more, many lives are, by God’s blessing, annually
saved in English Hospitals which would be lost elsewhere. Of course the
only Regulation about wine should be to specify whether the Ward-Master
or the Nurse should administer it.

11. Relieved of the loss of time incurred by fetching and waiting, and
relieved at starting, at all events, and we will hope permanently, of
the time consumed in distributing the diets, I certainly consider that
a Nurse of the class of which, please God, Her Majesty’s must all be,
(strong, laborious, active, and conscientious women,) can efficiently
serve two wards of 30 men each.


_Orderlies._

12. I should prefer wards of 30 each to wards of 25 each.

13. In forming rules for the proportion of Orderlies to sick, it is
important to consider that the duty varies extremely according to the
appurtenances of the ward.

14. I consider extreme plainness and simplicity to be proper and
indispensable to a Military Hospital. Let us take for granted (and may
it prove correct to do so), that in none of Her Majesty’s Hospitals
Orderlies’ time will be wasted in cleaning any ornamental things,
whether unnecessary furniture, flourishes, or cornices, &c., &c., on
necessary furniture; supernumerary shelves, nooks and corners, &c.,
&c. Once provided, all these things must be carefully and constantly
cleaned, or they become receptacles of dust and breeders of fleas; and
to clean them involves enormous waste of time. A few minutes daily
wasted on each of many things, make an enormous sum.

15. But it is very true economy to supply, if possible--which in old
buildings it often is not--every ward of every hospital with a constant
supply of water, (taking care that it is not wasted by mischievous
or childish patients); and to give every ward of every Hospital the
use, under proper control, of a lift by which, at fixed hours, food,
medicine, linen and fuel are brought into the wards.

Believe that this is not theory, but the result of practical
observation, much extended.

16. Now, these two things--supply of water (if hot and cold so much
the better, and supply of water imports, of course, the appliance for
getting rid of it, and of the contents of bed-pans, &c., &c., by one
or more sinks) and the use of lifts can be applied to a new Hospital;
can possibly, not certainly, be applied to some of the old Hospitals
within the Kingdom,--can certainly not be applied to many of the Army
Hospitals abroad.

17. Upon an average, these two things make the difference of one
Orderly’s duty to a ward of 30 men.

18. And a ward of 30 men, so supplied, would be efficiently served by
half a nurse and three Orderlies, including night-duty.

19. Without these two things (it is a mere comparative question as to
loss of time and absence of thorough cleanliness, whether the water is
brought from a pump in the court, or a stream some hundred yards off,
above or below), and many, if not most, Army Hospitals abroad, must
always remain without these two things, I consider that one Orderly to
every seven patients will not be too much; while it is certain that,
other things being equal, the ward with the appliances and the three
Orderlies will be better served than the ward without the appliances
and with the four Orderlies. Where there is no Nurse, one Orderly for 7
patients will always be advisable.

In these memoranda as to Orderlies’ work, &c., no notice whatever
has been taken of the possible abolition of scrubbing, because it
does not do to count unhatched chickens. If, however, that formidable
weekly business could be got rid of, as well as the bi-weekly or daily
washings of bed-head-floors, &c. the labour of the Orderlies would be,
without underrating that required for keeping oiled floors cleaned,
very materially lightened.


_Night-duty of Orderlies._

20. Convalescent wards, which will be of great use in many ways,
will be of use here. With them Nurses will have nothing to do. It
is possible enough that, in course of time, the Medical Officers
will desire to have Nurses there, and that it may be useful to place
there elderly, still efficient Nurses; but let this come or not as it
will, and let us keep quite clear of them, at all events, till the
Nursing-service be tried and established in Army Hospitals. In these
wards, night-duty will probably be quite unnecessary, though in that
case either an Orderly or Assistant Ward-Master ought to sleep at hand;
and night-duty is a service which must be spared wherever it can be
spared, and rendered as efficient as possible wherever it is really
wanted.

I have before submitted that in Paris, Vienna and Berlin, the
average of severe cases in Army Hospitals, in time of peace, is very
considerably lower than in Civil Hospitals.

This quite as much applies to English Army Hospitals. Whether the
ordinary wards would require night-duty I do not know. If they often
did, I should prefer having a regular night-duty in them. If they
seldom required it, I would not have it.

21. In Civil Hospitals, served by women, I should undoubtedly prefer
assigning the night-duty to one Assistant Nurse.

22. But Orderlies are in sundry respects different, and, upon the
whole, I recommend not to have night Orderlies, but to let each Orderly
in turn do the night-duty.

23. It is important to remember--the more so as it is often
forgotten--that to lay more upon human nature than its Maker has made
it to bear, is to do a foolish, let alone a wicked thing. Upon an
average, all men and women can dispense with, or abridge sleep for more
or less time. Upon an average, all men and women, after a laborious
day, require a good night, in the long run. When they do not have it,
either health, efficiency, or sobriety, or all go.

Believe, again, that this is not theory, but the result of practical
observation, much extended.

A strong soldier is no exception to the general rule. In the long
run, if made to do night-duty after a laborious day, he will either
go to sleep, or drink to keep awake, or he will get knocked up before
his time. And this it is part of his business to be in time of war;
therefore, in peace-service, it is economical to let him last his time.
It is then sound economy to give watchers sufficient sleep.

[Sidenote: Scheme of Night-Service for Three Orderlies watching by
turns.]

24. Supposing regular night duty required, in a ward of 30 men,
supplied as above, and served by half a Nurse and three Orderlies,
it might be worked thus: the Principal Medical Officer would decide
whether the same Orderly should do the night duty for a week, or the
three on successive nights: probably the latter. The Orderly might come
on night duty at 9 P.M., and remain on duty until 9 A.M., thus taking
his share in the heavy morning work of cleaning the ward, &c. In all
well-ordered Hospitals it is required that this should be done by 10
A.M., in some by 9 A.M. Earlier is undesirable in the English latitude
(in other climates it is different), unless either the patients are to
be disturbed earlier than English Surgeons consider right; or the ward,
&c. cleaning is hurried through. A large ward, got into thorough order
by 9 A.M., is in very good time. Of course it may happen occasionally
to be got ready somewhat earlier, but this refers to the average.


SCHEME FOR THREE ORDERLIES A. B. C. SERVING WARD X.

Monday, 3 P.M. A goes to bed, after taking his share of the morning
work, eating his dinner, and helping to clear away ward dinner, &c. 9
P.M. A comes on night duty, after 5 hours’ sleep, and allowing 1 hour
for undressing, dressing, and eating his supper.

Tuesday, 9 A.M. A goes off duty, having watched until 6 A.M., having
breakfasted, having taken his share of the morning work, and leaving
the ward clean. Let him have the option of one or two hours’ fresh air,
either now, or before 3 P.M.; let him sleep full three hours; let him
have his hot portion of dinner taken to him at the usual hour, unless
all the Orderlies on night duty are served together at a different
hour; and let him, 3 P.M., return on duty, washed and shaved. B goes to
bed, &c.; 9 P.M. B comes on night duty.

Wednesday, 9 A.M. B goes off duty; 3 P.M., C goes to bed, &c.; 9 P.M.,
C comes on night duty, &c.

I have reckoned 12 hours for the Orderly to be off duty. It is better
for him to have eight than seven hours’ sleep, and one or two hours’
fresh air are more healthy, and make a man last longer than going
to and from his bed and his ward. An English soldier comes on duty
clean, washed, and shaved, a once national peculiarity it is highly
desirable he at all events should retain--at any rate that of thorough
cleanliness--the shaving is unfortunately now not certain; for this and
for his meals, some little time must be given. I think you will get
more, and get it longer, out of the man by giving him 12 hours on night
duty and 12 hours off. Still it will not do to interfere too much with
analogies, and the proper authorities must decide whether this is too
much.

[Sidenote: Exercise for Orderlies.]

25. Again, leaving the question for decision to the proper authorities,
I had rather each Orderly had one hour or two hours for exercise each
afternoon or each alternate afternoon, care of course being taken that
he did not exercise himself in some tap. He should report himself to
the Nurse, or to the Ward-Master, or Assistant Ward-Master on going and
on his return. So should the Night-Orderly when coming on and going
off duty. Also in many emergencies of no very unfrequent occurrence at
home, and constantly abroad, the Orderly must dispense with recreation
time. But as a rule, it is certain that fresh air is necessary to
preserve health in Hospital duty. Doctors of all kinds know and act on
this as regards themselves.

The waste of time and strength, at present too often incurred by the
endless fetching, heavy carrying, &c., of many Hospitals is in a
considerable degree counteracted by its forcing the Nurses into other
than ward air; the air of a Hospital Court is better than that of the
best ventilated wards as it is, not as it might be. The same applies,
in its degree, to Orderlies. But it is better, and far more economical,
to avoid the fetching and carrying as much as possible; to keep the
ward attendants in the ward to their duty under the supervision of the
chief and responsible ward-servant; and to give each in turn a short
daily recreation, if possible.

[Sidenote: Night Refreshment for Orderlies necessary.]

26. Now comes a thing I am very anxious about concerning night duty,
the more anxious because it is important, and because I am afraid it
is an innovation. I have watched the night duty with particularly
anxious interest, in each Hospital I have entered, feeling at once its
importance and its difficulties, and of the following principle I am
thoroughly certain.

The Orderly doing night duty should either be allowed refreshment
during the night, or the recurrence of this night refreshment should be
considered in allotting the rations.

In none of the Civil Hospitals, so far as I know, is night refreshment
given. The Nurses usually on board wages, apportion, when they can,
some from their food. In one Hospital there exists a rule that no
Night Nurse is to take refreshment during her watch, the intention
being to keep her more vigilantly to her duty. This is one instance
among many of the serious and cruel mistakes which men of business or
benevolence, or both, make, when legislating on matters which they do
not understand. It is, fortunately for the fine Hospital where it is
the rule, practically disregarded; the Head Nurses knowing well that a
Nurse watching and fasting in a ward from 9 to 9, or even from 9 till
the breakfast hour of 6, would either soon be unfit for duty, or put
drams in her pocket, or doze through the night.

A strong soldier, required to watch in a ward and fast from 9 P.M. till
9 A.M., or 6 A.M., or shortly before, would stand the trial quite as
ill as a Nurse. There is an admirable rule at two foreign Hospitals
where I have served. Sisters watch in some wards, Men Nurses in others;
and each watcher receives from the house, on going on night duty, a
bottle of beer, a can with about six or eight cups of coffee, milk and
sugar in proportion, and three slices of bread and butter. The Sister’s
bottle of beer is about one pint; the Man-Nurse’s double; his coffee
can is also a good deal larger. The rule of allowing sufficient for
three solid refreshments (which of course can if desired be made by the
watcher two or three) during the night, is an excellent one.

I think it would be very sound economy to allow each Orderly on night
duty, a proportion of beer or porter, of coffee or tea, and of bread
and butter, or bread and cheese, to take at his own time during his
watch, besides his supper before going on duty, and his breakfast just
before 6, (both Nurse and Orderlies ought to have breakfasted by 6,
and to begin the day duty at 6, and I wish it began by opening the
windows and repeating the short prayers for 5 or 6 reverent minutes).
Of course it may be considered preferable to reckon this night-ration
in the Orderly’s rations. Or suppose the bread and beer or porter to be
reckoned in the rations, and a can of coffee given him for the night
watch. Settle details as is best, and of course analogies must be
considered; but in truth hospital watching is a very peculiar business;
important, unobtrusive, most peculiarly trying, and the bright side of
very few Hospitals. Each watcher should undoubtedly have refreshment
for the night.

The Nurse should have her groceries in the lump, and refresh herself
as she likes out of them. Her watching, if she does her duty, will be,
when she has bad cases, severe enough; but I would not provide her with
extra refreshment; as the watching is not prescribed and regular duty.

There should be as little extra watching on the part of Orderlies as
is possible; when it is indispensable the extra watcher should have
the same night-ration. I submit my strong impressions on the subject
of this night refreshment now, because, small as it may seem, it very
largely enters into the working of a night watch.

I have suggested the division of the Night Orderly’s sleep, because,
if A. comes on duty at 6 A.M., and is sent to bed at noon or 1 to get
ready for his night watch at 9 P.M., he is scarcely fit for a long
sleep, and supposing the patients dine at noon (an excellent hour) he
has not, or scarcely, taken his share of the clearing away which,
got over in time, enables the other Orderlies, one or both, to have a
short recreation in the afternoon. Also if sent to bed at one he has
not eight hours’ sleep, as out of that he has to undress, dress, and
sup. Also he has to remain on duty from 9 P.M. to 9 P.M. next night,
which is much too long as a rule. If he does not go to bed before his
watch, and goes off duty at 9 A.M. next morning, whatever time may be
then allowed him for sleep, he cannot, as a rule, be depended upon for
performing his watch duty efficiently.

[Sidenote: Where are the Night Orderlies to Sleep by Day?]

27. If the Ward Orderlies watch by turns, it should be arranged that
the men who sleep before and after the watch can do so quietly. This
is by no means always attended to, as to Nurses in Civil Hospitals.
Upon the whole, I cannot think it would answer to have always the same
watchers, as regards Orderlies. The other Orderlies, supposing them
lodged apart from the wards, will certainly go seldom enough to their
quarters during day, except during their exercise time. It may be
thought essential to retain soldiers under very primitive notions as
to quarters. So though in a dormitory of women, I think little cells,
parted either with a partition or a curtain, the whole thoroughly
airy, are in all respects preferable to unparted rooms, it may be,
by some, thought better that the Orderlies shall sleep in large airy
wards, not parted by curtains or partitions. I know, however, one high
Military authority, at least; who considers the same reasons apply to
men as to women in this. Soldiers are generally able to go to sleep
whenever ordered. Indeed their general capacity of doing whatever they
are bid is one of their many fine points. The Orderlies’ wards must be
under some sort of inspection, and noise must not be suffered in them.
Non-Commissioned Officers, either Ward or Assistant Ward-Masters, or
some special functionary (but such I would not multiply) must sleep
near, and have general charge of the order and quiet of such wards. I
conclude that one or more Assistant Ward-Masters, at all events, must
watch, and as they must sleep by day, this will fit in well enough.

I should avoid putting the Orderlies in a too much out of the way part
of the Hospital; they should know themselves liable to inspecting
visits any time. I am not sure that Ward or Assistant Ward-Masters
would not be much better guardians of the Orderlies’ wards than any
special functionary. Drink is the vice of these men, noble fellows
as, as a body, they are, and I should avoid quartering any man too
comfortably and solely in one particular post. Cases have been where
the duenna of the Nurses’ dormitory was herself a determined, disguised
drunkard, and reported others accordingly as she was bribed or not with
drink for herself.

The whole question of Orderlies sleeping near or away from their
wards should be well considered by the proper authority, two or three
experienced Army-Surgeons. Upon the whole, I think it would be well to
try the quartering them separately: there is much to be said on both
sides as usual.

[Sidenote: Comparative Merits of Different Systems of Night Nursing.]

28. In several foreign Hospitals a certain number of Night Watchers,
both Sisters, and Men-Nurses, are told off for night-duty for four
weeks, during which they are exempted from all labour by day, and
receive better food than the usual diet. They also receive good
night-refreshment.

In one Hospital the following is the arrangement. The wards usually
contain from 10 to 13 beds, and there are many small wards for three,
two, or one, bad cases or operation cases. All the wards open upon a
corridor. The Sisters do not watch in the men’s wards.

  A Sister watches in the female medical wards              }
                ″                surgical  ″                } 5
                ″         children’s wards and girls’ ward  }
  A Man-Nurse   ″         male medical wards                } Watchers
                ″              surgical wards and boys’ ward}

An operation-case, or an extra bad or anxious case, or a case requiring
special attendance and put in a single ward, has an Extra-Watcher.
Often there are no Extra-Watchers: sometimes there are several at once.
The Extra-Watcher is either a Sister or a Man-Nurse, taken from among
the other Sisters or Men-Nurses, who, after his or her day’s duty, does
the extra watch.

As regards all English hospitals, civil or military, the advantages of
this system are these:--

1. It severs certain persons for night-duty, who have full time for
sleep and refreshment in the air during day, and who are allowed to do
no other work.

2. It secures these persons good food and refreshment at night.

3. These persons know their sick, and, being told on coming on duty, of
any change, &c., are as much at home in their posts by night as others
are by day.

4. When it is found that a Sister cannot sleep by day, and, therefore,
that her health breaks, she is not allowed to finish the four weeks and
become ill, but is put to another duty and another Sister appointed to
the watch.

(Many a strong Nurse cannot sleep at day.)

5. The persons so appointed get into the way of it, if they stand it at
all, and the system is found a great relief to the whole house and a
great gain to the sick, in the place of another system of dividing the
night between two Sisters and two Men-Nurses, who each watch half of
the watch.

_Per contrà._

I. The great London hospitals are places very far from perfect: some
things may, please God, be, with time, patience, and extreme quietness,
very much improved; but some things will never be perfect and never can
be. But they are places where I do believe, and so far as I know, the
sick are cared for in a way that is done nowhere else. The proportion
of heavy cases in every London ward, cannot, I think, be met except by
having a watcher in each. An English physician or surgeon would not
consider that his cases could otherwise receive the attendance and the
watching, the observation of possible change and prevention of possible
mischief, which they ought to receive.

It is right to bear in mind,--

1. That small wards multiply exceedingly the demand for Watchers:
four wards, of 10 patients each, taking the average of patients as in
London, would not be attended, according to the English notion, by
one Watcher; 40 patients in one ward would be fully attended by one
Watcher. The London Hospital has two Night-Nurses for its quadruple
wards. An extra Night-Nurse has frequently to be put on, on account of
the difficulty the subdivision of the ward gives to the watching.

2. That the average of severe cases in each ward of London hospitals
is very considerably more than the proportionate average of severe
cases in each ward of the foreign hospitals in question. In all foreign
hospitals with which I am acquainted the proportion of accidents is
comparatively small to those of the London hospitals. The docks, the
manufactures, the crowded and dangerous works, &c., &c., with us,
account for this.

3. That, striking the balance for and against, it is necessary that
each London ward should be watched by a Nurse; at the same time, that
without doubt a certain number of troublesome, ill-conditioned patients
(no ward of any Hospital is without such) sleep soundly and let their
neighbours sleep soundly when the Watcher only looks into the ward at
frequent intervals, who would, if the Watcher sate in the ward the
whole night, make it their business to require attendance from the
Watcher during the whole night, or at least much oftener than by the
other plan.

II. The second flaw of the above system, as it applies to London
Hospitals, is, that it renders Extra-Watchers so often indispensable.

The employment of Extra Watchers can never be wholly prevented, but it
should be the endeavour of every Hospital to employ such as seldom as
can possibly be. Extra watching is most injurious to the health of all
ward-servants, and to the sobriety, and therefore morality, of many
paid ward servants.

This is a very important reason, I humbly consider, for avoiding as
much as possible small wards.

I do consider small wards very objectionable in working a Hospital.

But it is right to remember that we have been told of England, of
Austria and of Prussia that the proportion of severe cases in Military
Hospitals in time of peace is considerably smaller than in Civil
Hospitals. Night watching is not done in the Military Hospitals either
of Vienna or Berlin. Orderlies, or an Orderly, sleep in each ward, and
watching is only done to bad cases.

How far English Army Surgeons consider night watching desirable in the
Army Hospitals I will presently tell.

I should think the convalescent wards, among many important advantages,
would receive a number of patients who require no night watching. An
Orderly ought to be at hand here, but not watching.

If night duty is considered requisite in the ordinary wards, I do
not see how the English standard of things could be met, excepting by
having one Watcher in each ward where there is regular night watching.

I think, however, that the foreign system of night watching above
detailed might give very useful hints for women in war service, and for
emergencies of cholera, &c., &c., in home service; and with regard to
supervision in the latter.

I think, with submission to the proper authorities (the two or three
experienced Army Surgeons I have so often adverted to) feeling strongly
that awkward mistakes might occur in several of these matters without
them, as civilians and women cannot and ought not to trust their
own judgments respecting such, that in a large Military Hospital,
an Assistant Ward-Master ought to go round the wards at night. Not
with any idea of his rendering assistance to the Watchers over bad
cases. The Nurses must do their duty of Head-Nurses, and see to this
themselves. Perambulation through a large Hospital at night in point
of fact excludes the possibility of doing anything in any one ward,
unless in some exceptional occurrence which only proves the rule. The
object is the important one of seeing that the Orderlies are awake,
sober, alert, and at their duty, and that the patients are quiet and in
bed. The Nurse would hear any noise, but there is such a thing as quiet
drinking, as well as noisy drinking.

In St. George’s there is a Night-Matron, chief over the Night-Nurses,
who goes through the Hospital every hour during the night-watch.

I have heard this spoken of by experienced Authorities of other
Hospitals with approbation and envy, and some idea was entertained
of introducing it into another great Hospital. In Civil Hospitals, I
think, but I do not know, that the benefits of this Night-Matron may be
perhaps more imaginary than real. The Head-Nurses at St. George’s sleep
away from their wards; a great mistake, I humbly consider.

But Military Hospitals are entirely different in sundry essential
respects. I think a non-commissioned officer, Assistant Ward-Master
for instance, ought to make his rounds every night. When once such a
service takes place, every hour is better than three or four times a
night. He must be “up to” sundry things--taking the wards in uncertain
rotation, sometimes returning suddenly on his steps, &c., &c., &c.

It will be worth securing, if possible (this parenthesis will be
understood), that the Nurse’s water-closet should be within her room,
if not, as close to it as may be.

[Sidenote: Present State of Night-Nursing in Military Hospitals.]

29. The following extraordinary system of Night Nursing is that which
prevails in the Army at present:

The “nursing is managed” either by means of patients “told off in
watches” through the night for the purpose of attending to other
patients, or by means of soldiers sent in from the ranks to attend
specially upon each bad case; or by Orderlies “arranging it among
themselves,” without any exemption meanwhile from day duty.

Upon each and all of these systems or no-systems it is hardly necessary
to make any comment. It is difficult to tell which is the worst.

In the principal, indeed the only General Hospital in England, “Nursing
is managed by comrade-patients told off in three watches of two hours
each for the night.” [_sic._]

“Orderlies are likewise warned and often sit up for the purpose.”

These passages are given _verbatim et literatim_, because they are so
remarkable.

And it is necessary to add that these patients being the relapses among
the “Invalids” are nearly the worst cases we have.

Were it the report of a Head-Nurse in a Civil Hospital to her Resident
Medical Officer, it would undoubtedly cost her her place. One scarcely
knows whether to pity more the sick patient or the orderly patient. One
scarcely knows how to estimate the amount of medical comforts intended
to be consumed by the sick patient which will actually be consumed by
the sitting-up patient, and necessarily so. And the expedient which
turns over the man who is too ill to be left at all to the care of men
who ought to be recovering themselves, but who are pulled out of their
beds for two hours to _nurse_ (for the first time perhaps in their
lives,) and a very “serious” case too, is to say the least of it a
singular one.

At Woolwich Artillery Hospital the cases which require constant
attention are about 2 per cent. There are now 545 patients in Hospital,
and 11 cases consequently, each requiring one Orderly to itself. The
Orderlies, according to Regulation, are 55, so that one-fifth part
of the Orderly service is required for these cases. Yet there is
no system or arrangement for such. The Orderlies arrange (or do not
arrange) among themselves to do the reliefs day and night. Of the 11
cases at this time in Woolwich Hospital with 11 Orderlies sitting
up with them, it so happens, as I am informed, that only one would
require, if such were together in wards where regular night nursing was
established, an attendant specially to itself.

It is needless to enlarge upon the cruelty of the above practice. The
one serious case is disturbed in the day by the goings to and fro, the
noise and bustle of the light cases--while these are disturbed at night
by the sitting-up necessary for the one bad case, which may be besides,
and too often is, a noisy or offensive one. The bad economy is as
obvious. It often happens that 11 cases who might all, if in one ward,
be attended and as efficiently attended, by one Night Orderly, require
each an Orderly to itself in as many different wards.

In the “Garrison Hospital” at Chatham, “when any case assumes such
a character as to require more than the usual care and watching, a
Requisition is immediately sent to the Commanding Officer of the Corps
to which the man belongs for a steady well-conducted soldier and who
generally is the man’s own comrade” [so much the worse] “to nurse him,
and to attend upon him throughout his illness, but who is relieved by
another as often as the Medical Officer in charge of the case considers
necessary.”

The following is the average number of sick in Army General Hospitals
in time of peace at home, for whom night-nursing is considered
necessary by the Medical Officers. But it is important to add that this
number would be probably estimated as very much higher if proper means
of night-nursing were at their disposal.

Of constantly sick mean proportion per cent. requiring night nursing:

    General Hospital, Fort Pitt    {Medical Division     5
                                   {Surgical   ″         1
    Garrison Hospital                                    2

These cases are usually scattered through the wards.

It is but fair to add that the best Medical Officers themselves
desire another system, or rather are aware that there is at present
no system at all, and would gladly accept one. “With means for good
night-nursing,” they say, “arrangements in accordance might be
introduced. At present we like to have a case requiring much attendance
amongst cases that require little, in order that the patients or
comrades may assist.”

What are the consequences of such “assistance” to the cases in question
has already been fully stated throughout these notes.

[Sidenote: Poor-Law Regulation for Nursing in Union Workhouses.]

“With respect to the use of [the inmates as] servants, they require
the strictest superintendence on the part of the * * officers. The
employment of [the inmates] in offices of trust is inexpedient,
inasmuch as it tends to impair the discipline of the house. In
offices of mere labour, which can be performed under trustworthy
superintendence, [the inmates] may be useful. Where responsibility is
involved, paid servants should be engaged.”

The above is one of the regulations of what?--not of a Charitable
Institution but of the Poor Law; and the house of which it treats so
tenderly and wisely is--a Workhouse![19] If paupers are to be thus
cared for, how should it be with our soldiers? If any “office” can be
called one “of trust,” surely it is that of carrying out the orders
of the Medical man in a critical case, a case of life or death! Can
any “responsibility” be “involved,” greater than this? Yet these are
just the cases left to the “Comrade Patients.” For ordinary cases the
ordinary attendance is given; for serious cases, the untrained and
unskilled attendance. Yet, if the Hospitals are not for these serious
cases, what are they for? For these alone, however, is no systematic
provision made. One would think that every bad case took the Hospital
by surprise. Imagine the orders of the Medical Officers carried out
by nurses (?) changed “every two hours,” and who are, in fact, sleepy
patients!

The system of Military nursing and management, as described by Army
Medical Officers themselves in the above quotations, and which is,
we are expressly told, to be re-enacted at the Royal Victoria Netley
Hospital, is precisely the one which led, as a matter of course, to
the calamities, as far as nursing was concerned, in the Hospitals
in the East, and which will lead to them again so long as it is
continued. Even in the case of invalids, who may not require such
careful attendance as sick, the system of nursing by comrades is most
objectionable; and if the attendance at Netley can only be carried out
on such a plan, it is doubtful whether Netley should be used even for
an Invalid Hospital.

The question has been asked the Netley Committee, By whom are your
Invalids to be nursed, when sick? And it has been answered, that they
are to _nurse each other_!


II. NURSE’S ROOM, &c.

[Sidenote: Nurse’s Room.]

It is essential that between every two wards, in a hospital where the
blocks are built end to end, there should be, as at the new Military
Hospital of Vincennes, a lobby with a thorough supply of pure fresh air.

If it were possible, where the Head Nurse, or rather in a Military
Hospital the Nurse, has charge of two such wards on the same floor, to
let her have a long, narrow room, with screened windows, opening into
both wards, the door opening into the passage in the midst, it is worth
contriving.

[Sidenote: Medical Officer’s Room.]

2. The Medical Officer’s room should be on the ground floor at the
entrance and apart from everything else.

The servant or whoever cleans the room, should not be a Ward-Orderly,
(ward-attendance cannot be kept too entirely separate from all other
concerns).

[Sidenote: Water-Closets.]

3. The ward water-closet should have a pane of glass at top, so that
a faint gas-light in the lavatory at night can light sufficiently the
closet, and the (bed-pan) sink.

The water-closet should be constructed, as is done often in those of
English railway stations, so that each visitor involuntarily, on rising
or on opening the door, purifies the concern.

Besides the ward water-closet, there should be general water-closets,
and urinals separate from the wards, for the use, during the day, of
those patients who can leave the wards.

The latrines at the Lariboisière Hospital are a good example, both for
what should be avoided in construction, and what should be imitated in
position.

The sort of latrine used there would never do for England.

The men able to go out are expected to use by day an urinal in a corner
of the little garden belonging to each pavilion.

At night no sick men are allowed to leave the ward on that or any other
pretence; they must use the latrines.

The latrines are at the furthest end of the ward. Opposite the one
door is a partially glazed door, beyond this is a large window, grated
in network as well as with panes and frame. On one side opens a space
where the men, able to get up, are expected to wash, and which,
moreover, contains two latrines, each separated by a partition and
secured by a door. The same arrangement prevails on the female side.

The rule of having the water-closet on the furthest side of the ward,
removing all pretence of leaving the ward by night, is excellent.

[Sidenote: Warm and Cold-Water Supply.]

4. The importance, immense addition of efficiency, and ultimate economy
of carrying warm and cold water into every ward, and the necessity
of intending and contriving this in the first construction of a
Hospital,--subsequent additions and alterations being generally less
effectual, and always more expensive--cannot too frequently be repeated.

[Sidenote: Corridors.]

5. Corridors as proposed at Netley are useful and objectionable. They
lie between one side of the wards and air. They make oversight of the
patients more difficult; and when a number of patients are walking up
and down them, the serious cases in the wards are disturbed. On the
other hand, it is desirable to have some place of exercise and yet
shelter for patients, capable of being heated and of being overlooked.
There ought to be no accumulation of patients at the same time suffered.

With regard, however, to corridors inside the building, if there
are none it is all the better for the sick; that each ward should
have two rows of large windows opening direct into the outer air is
indispensable, as has often been said already.

[Sidenote: Lobby.]

6. Provided this double range of windows be secured, double wards of
thirty on the same floor would cause no disadvantage to the sick.

But, if such be determined on, let especial care be taken to separate
the two, not by a showy hall, but by a lobby and an ample staircase,
extending from top to bottom of the building, and communicating freely
with the open air at the roof, as well as by the stair-windows:
admitting a thorough current of external air, so that, of a morning
especially, the two wards do not mutually send the close air into each
other.

The lobby should not be turned into a vestibule. Thorough air is all
that is wanted. Patients should not be suffered to remain in it.

[Sidenote: Material of Ward Utensils.]

7. The material of the different utensils required for ward service
should be settled. In the use of glass or earthenware for all
eating, drinking, and washing vessels there is great superiority as
to cleanliness, and the saving of time and labour in cleaning these
materials, to those of tin or other metal. Still two things have to be
weighed against these great advantages. First, if these vessels are
cleaned by Ward-Orderlies, the amount of breakage would be much greater
in proportion than as done by Nurses, and it is imperative to have as
few women as possible in the service of Military Hospitals. Secondly,
it is very important to avoid even the appearance, especially at first,
of anything like introducing luxury into Army Hospitals; and I can
quite understand this appearing like luxury.

The material of one description of ward-vessels should in particular be
left to the Surgeons. In sending to distant foreign or war-stations,
urinals of tin have one material advantage over those of glass or
china, that they do not break so easily; but, as to home-service,
these tin urinals cannot, by any amount of cleaning, be freed from an
unclean smell. In Vienna General Hospital, where economy is exceedingly
attended to, all the urinals are of glass, as the superior cleanliness
is considered well worth the additional expense. A damaged or broken
glass or earthenware urinal is dangerous; and if there is difficulty in
obtaining the immediate issue of a new for a damaged one, it is better
to have tin.

In Vienna General Hospitals the patients’ eating vessels were formerly
of tin; but were some time ago furnished of earthenware, for the same
reasons as those given above; also because the hot tin vessels were
found awkward to the patients. (I do not think much of this latter
reason; in hospitals, there is little fear of food reaching the
patients too hot). In Vienna and Berlin Military Hospitals the eating
vessels are all of tin.

[Sidenote: Reserve Wards.]

8. In building a large new Hospital, the question of whether or not
reserve wards, or Pavilions, should be provided is an important
question, to be referred to the proper Authorities. In one German
Hospital is a Sommer-Lazareth, or separate Hospital, which most of the
sick occupy during the six summer months. This is considered the best
plan; but so expensive that well-considered arrangements in designing
the building may render its adoption unnecessary. In another German
Hospital is a group of wards on each of two floors, into which the male
and female patients, especially the surgical cases, are successively
moved; both in order that during this time the other wards may be
thoroughly cleaned; also to change the air; also in case of some sudden
epidemic, &c.

In every Hospital a thorough cleaning of the wards is essential. In
three of the great London Hospitals this is done every year, in one
every three years. Nuisance as it is, for the time being, it is such
a complete purification of places which want purifying, that having
it done every year is preferable to every three years. For the same
reasons bare white walls, whitewashed every year, and oftener if there
has been some sudden outburst of any zymotic disease or Hospital
gangrene are preferable to all colour. But polished impervious cement
is, it is needless to repeat, the only really safe Hospital wall. When
the cleaning time of a great London Hospital draws near, the number
of patients is gradually reduced, and none but urgent cases taken in.
The cleaning usually begins with the topmost ward of one part of the
building, or of several parts of the building at once. The patients are
usually moved to the ward immediately beneath. The ward goes through a
complete purification, also reparation of whatever wants repair. All
its furniture ditto; the bedsteads in particular. Afterwards windows
and doors are left wide open for two or three days, and nights so
far as feasible. In about a week from its commencement the cleaning
is over; the patients moved back; and the ward or wards so cleaned
recommence their usual taking-in--and so on. The cleaning of a great
London Hospital usually takes two full months; and a great nuisance
it is for the time, but the place benefits by it the whole remaining
ten. It is excellent economy to have plenty of hands, so as to have
the cleaning part, in distinction to the airing part, done as quickly
as thorough cleaning admits of. It is very bad economy to put too much
of this great extra cleaning upon the Nurses. This would of course
not apply to a Military Hospital, where it is important the Orderlies
should become as thoroughly qualified as may be for foreign and war
service. It is necessary that whatever exterior help is called in,
should be closely overlooked; contractors and contractors’ servants
being seldom overmuch troubled with conscience.

Now it might be exceedingly worth while to have one or more reserve
Pavilions, with a view to this annual cleaning.

If the flooring of polished oiled boards should be found to answer
(that it should receive a fair trial is very desirable, as it might
result in a material benefit to our Hospitals), it would be doubly
useful, when, every third year or so, the oiling and polishing required
renewal, to leave the newly-oiled wards empty for a fortnight. An
additional week or two would additionally harden and improve the
flooring; but a fortnight would suffice.

It might also be right to have reserve wards for what must occur every
now and then in a Military Hospital, an influx of patients beyond the
usual number, or an outbreak of cholera, or some malignant epidemic,
which it might be desirable to isolate from the other patients.

It may now be confidently expected that, under the new _régime_, the
progress in improvement of Military Hospitals will proceed rapidly;
that it will be quietly done is almost as certain--real improvement
and noisy philanthropy being fearfully inconsistent with each other,
especially in that momentous machine called the Army of England, which
is no safe plaything.

Dr. Helm, the Director of the Vienna General Hospital, in a little
pamphlet published some time ago, insists on the importance, in
designing a new Hospital, of providing Reserve wards, especially with a
view to dangerous epidemics. They should admit, he urges, of easy and
complete isolation from all the remaining parts of the building.

[Sidenote: Occasional Revision of Rules.]

9. Dr. Esse, Director of the Charité, at Berlin, in a practical and
systematic, but pedantic and pudding-headed, little book on Hospitals,
published in 1857, strongly urges the importance of occasionally
revising and altering the rules of Hospital Officers and servants, and
all the Charité instructions end with this proviso of alteration. It is
one of our many unavoidable difficulties that it is necessary to begin
our work under definite rules, while it is also necessary to consider
the service, for some years to come, as tentative and experimental. It
is well to bear in mind what cannot be expressed.

[Sidenote: Defect in some Systems of Nursing.]

10. In admiring much, very much about the German Hospitals, it
becomes necessary not to omit a warning. A number of women, all equal
among themselves, with no female Superior or Superiors whatever,
under the sole control of men, in an ascending scale from the
Abtheilungs-Inspectoren or Oberkrankenpfleger, through Doctors of
sundry ranks, to the Director himself, such is the system followed,
as in the great Charité Hospital at Berlin, so in the great General
Hospital at Vienna; and this cardinal mistake leads to many others.

[Sidenote: Nurses’ Exercise.]

11. It is desirable that the Rules should give daily exercise to the
Nurses, or rather that the Rules should give them the right of daily
exercise; that the Superintendent should encourage and exhort them to
take fresh air daily when feasible, leaving them sometimes to take a
little quiet in their rooms. But in war service, and sundry foreign
stations in time of peace, not merely exigencies of service (which at
home will and ought often enough to curtail or abrogate exercise time),
but various other reasons might render it very undesirable to give the
Nurses right to two hours’ daily exercise. It must be impressed upon
all Superintendents, that it is essential in the long run to the health
of Nurses to have fresh air; but in many foreign stations it might be
far better for the Superintendent to take, or rather send, them out for
one _vice_ two hours, &c.

In war and foreign service, the exercise time must be at the discretion
of the Superintendent.

There may be awkwardness enough on sundry home stations in allowing
each Nurse two hours at her own discretion outside of the Hospital
every day. Still it is right to look things in the face. The Rules do
not contemplate a Sisterhood, but a staff of secular women, bound by
strict rules in all that concerns the duty they undertake, left to
themselves as to sundry things which in Sisterhoods are ruled. (How
and by what measures in process of time strong and quiet religious
influence may be brought to bear upon this staff, is the question of
vital importance as to the whole; without it, I doubt whether the
service of women would, in the long run, answer in Military Hospitals,
which are and must remain very peculiar places; with it, it might
please God to suffer good service to be done Him). Nurses trusted to do
their duty in wards must be trusted to walk out alone if they choose,
and I would not attempt to restrict it, though the Superintendent must
see to this, so far as she can without doing or encouraging spy-work,
a thing which has many advantages, and is often done in various, very
various ways, but which in the long run brings no blessing, and _pro
tanto_, degrades all who are concerned with it.

[Sidenote: Number of Ward-Masters.]

12. In Vienna Military Hospital each set of five or six wards, with 30
or 40 patients, sometimes 20, in each, had a Sergeant and a Corporal
over the Orderlies. (Berlin Military Hospital is served by Civil male
Nurses).

I think a Ward-Master would be enough for each Pavilion of six wards
of 30 patients each, in three stories, each couple of wards being in
charge of a Nurse, and each ward served by three Orderlies.


III. REGULATIONS.

[Sidenote: Query as to depriving certain Patients of Visitors.]

1. Proper military and medical advice should be taken as to whether it
would be advisable to draw a distinction between the venereal and the
other patients.

In the Vienna Military Hospital they are locked up by themselves in
particular wards, but are allowed to see their comrades at visiting
hours.

In the Berlin Military Hospital they are locked up in wards, and
allowed to receive no visits whatever, excepting, of course, from the
Chaplain and the proper Military and Medical Officers; and in the case
of dying patients from their nearest friends.

Nor are they allowed exercise in the grounds.

This excellent regulation makes them heartily tired of the venereal
wards, and even this is a very salutary thing.

In the Vienna and Berlin Civil Hospitals, the venereal patients of both
sexes are also placed in locked wards, and allowed no visitors. Nor are
they allowed exercise in the grounds or garden.

In the two Paris Venereal Hospitals no visitors are allowed.

Now, as the more disagreeable the subject, the more necessary it is to
be explicit upon it when entered upon, this wholesome discipline exists
in a very faint degree in our great Civil Hospitals,--a thing not to be
lost sight of in introducing any change in the Army Hospitals.

The three greatest London Hospitals have venereal wards. The female
patients never leave the ward. The male patients take exercise in the
court. In one case the rule is, that this should be at different hours
from the other patients; the rule is not strictly adhered to.

The exercise question should, in Military Hospitals, be left entirely
to the Surgeons; they may fairly consider it enters into the question
of treatment, which is different from the Continental treatment. The
enforcement of different hours of exercise from those of the other
patients is good, as is every brand which can, quietly and effectually,
affix disgrace to these wards.

Deprivation of visitors, if it could be done, would be very salutary.
In the great London Civil Hospitals, men and women visit the male
venereal wards; women alone the female wards (and melancholy things
are the visiting hours there; here and there a heart-broken mother,
abundance of prostitutes, and no lack of procuresses. A firm and
vigilant Head Nurse will sometimes refuse admitting one of the two
latter sorts to some patient, whom she knows they are endeavouring
to make sure of again; but as the rules admit female visitors, and
she is by rights only entitled to eject a visitor whose behaviour
is disorderly in the ward, the Head Nurse can only do this in point
of fact by straining the rules, and cannot do it often). The female
visitors of the male venereal wards are usually, on the average, much
less disreputable than those to the equivalent female wards; and are
generally wives, mothers, and sisters, seldom prostitutes. There can
be no doubt, however, that it would be much better if the patients of
neither male nor female foul wards were allowed visitors, unless in
the comparatively very rare cases of extreme danger; it would, in that
case, be necessary that the Hospital should supply them with linen, and
either supply them with groceries or forbid their receiving them from
without.

In various essential respects the patients of a Military Hospital are
different from those of a Civil Hospital. Were it possible to prevent
all female visitors to the wards, except in dangerous cases, this
would be best. If the existing rules or practice do not compel the
sentries to refuse entrance to all disorderly women, however orderly
their behaviour, such a rule, at any rate, should be enforced. And if
all visitors, male and female, including, of course, soldiers, could
be refused admittance to the venereal wards, always excepting cases of
great danger, it would be very desirable. At all events, it would be
very desirable to have all female visitors, without exception, excluded
from these wards. These things are, I do consider, very important. But
I would not press them, if refused.

Let the female service obtain, please God (I do not write these words
_pro formâ_,--if possible, I feel every day more intensely how solely
it is to Him we must trust in this difficult work,--the more so that,
if possible, I feel every day more intensely the importance of, if He
grants it success, improving secular Hospital nursing, leaving the
English Sisterhoods, which will always have great advantages, and, I
believe, great disadvantages, with reference to Hospital nursing, to
take their share in this great field, which has plenty of room for
both), let, I say, the female service obtain a firm footing in the Army
Hospitals, and with it, and by cautious degrees, sundry ameliorations
will creep in insensibly as to decorum among other things. Those solemn
beautiful words I have always felt so full of meaning to us, “In
quietness and in confidence shall be your strength.”

[Sidenote: Query as to Numbering Patients.]

2. Military as well as Medical advice should also be taken upon the
following point:

In most, not all, the great London Hospitals the patients, whose names
are on their bed-tickets, are called by the numbers 1, 2, 3, &c.,
suspended over each bed; sometimes a patient’s name is never heard in
the ward.

Now, very possibly, this would not at all do in a Military Hospital,
and, if so, there is not another word to be said about it.

Otherwise, very few things so effectually save time, as the numbering
plan. (In Civil Hospitals it is also excellent in other ways, of much
less consequence in a Military Hospital, which will never, I conclude,
be afflicted with “gentlemen,” Mr. So-and-So, and Master So-and-So,
which latter inscription is frequently to be read on the letters of
little boys in Hospitals, whose friends, on visiting days, also enquire
for them by that title). But few things, I repeat, so effectually
save time as numbering instead of naming the patients (names, of
course, to be on bed-tickets). If, however, the officers consider it
“unsoldierly,” give it up at once.

[Sidenote: Regulations as to Swearing.]

3. The regulations lately in force contained in plain strong language
prohibition of swearing and indecent language in Hospitals; they are
quoted from the Articles of War. It would be well to retain this in
any new Regulations; and the retention of this Rule is not the less
important when women are put in charge of Military wards, since, though
it is not their business to maintain discipline, it is their duty to
call in those whose duty it is when discipline is infringed. And it is
important that this prohibition of swearing and foul language should
not be looked upon as an individual or collective crotchet, or female
innovation, but remain the rule of the Service. Such language would
never be used in the Nurse’s presence unless by her own fault. But it
should be unheard in the ward, whether she is in it or not. The old
definite words should be transcribed.

[Sidenote: Conclusion.]

I do not like writing any part of the above, not because it can, in
any sense, be said to strain the necessary principle of reserve, save
for strictly business purposes, as to all which is, strictly speaking,
Hospital business, but because of the extreme caution necessary as
to this sort of topics. Still life is so uncertain that the possible
introduction of permanent Female Service into Army Hospitals has
determined me on writing what I had rather not have written.



ADDITIONAL HINTS AS TO PAVILION HOSPITALS SUGGESTED BY THE CONSTRUCTION
OF THE LARIBOISIÈRE HOSPITAL AT PARIS.


I.--_Ventilation._

The question of ventilation is so all-important, so much doubt still
seems to exist as to the comparative merits of natural and artificial
ventilation, so much has been said in favour of the latter, because it
is seen adopted in the finest hospital in the world, the Lariboisière,
that I have added a few practical remarks upon this system. The
conclusion is, that even at the Lariboisière, without opening the
windows occasionally, and especially in the morning, real freshness
is never obtained in the wards, and that, therefore, if there must be
artificial ventilation, that is the best which allows the most of the
windows being opened.

On the men’s side, Thomas’ system, or that of injecting air at given
points, by means of two high-pressure steam engines, each working a
large fan, is adopted. On the female side, Duvoir’s system affords
ventilation by extracting air at given points. In both, a number of
shafts and openings provide for the exit of the air.

Persons at the Lariboisière Hospital, who ought to be good judges,
including foremost the Director, an experienced and able administrator,
consider the ventilation on the male side the most expensive and the
best, both for day and night, being the coolest in summer and the
warmest in winter. In winter two great advantages are assigned to this
side: first, the heating being provided by the Hospital, the wards
are warmable at pleasure; whereas that of the female side is provided
by the contractor at a fixed degree of heat, which, in extra cold
weather, is augmented: from 15° to 18° C are the usual limits of the
winter temperature on the female side, while that on the male side is
usually several degrees higher. Secondly, the system of heating on the
male side permits the windows to be opened: while on the female side
objections are often made to opening the windows in winter, which it is
alleged interferes with the heating.

_Per contrà._ How difficult it is to learn any facts by hearsay we
know. Other persons who ought to be good judges think the male side
apt to be too warm in winter, especially at night, and consider the
temperature on the female side quite sufficient.

Both sides are ventilated both by the windows and by the machinery by
day in summer. Both sides are ventilated, each by its own different
machinery, by night in summer, except that, exceptionally on hot summer
nights, a window is opened two or three times in the night, or five
minutes every hour.

Both sides are considered to be ventilated in winter mainly by the
machinery by day; and both sides are entirely ventilated in winter by
the machinery by night.

As far as can be made out from conflicting accounts, (conflicting
from the very simple reason that one person will consider a ward, or
drawing room, for that matter, airy which another will consider close;
one, pleasantly warm, another too hot or too cold), it is practically
found impossible to freshen the ward of a morning without opening some
windows, and to keep it fresh during the day without now and then doing
the same; and it is easier to open the windows on the male side in
winter than on the female side.

The ventilation on both sides is considered to work with equal
efficiency during the whole of the day.

Of the eighteen wards, the ventilation on entering the wards at five
a.m., when the ward nightwatch has generally not opened a single
window, is certainly surprisingly good; _i.e._ the air is surprisingly
little bad. _But neither here, any more than anywhere else, are the
wards effectually freshened, until the windows are, of course with
proper caution, opened._

In both these particulars, no difference is to be observed between the
male and female side.

In repeating that the Director, and other persons who ought to be good
judges, consider the machinery of the male side the most expensive and
the best, I add these things:

First. Since this machinery was erected, so far as concerns the steam
engine, it is said that equally efficient and much less expensive
engines have been erected in other Hospitals, among others, Necker and
Beaujon. In both Hospitals, the plans of Duvoir and Van Heecke are
in use, one on either side. But certainly, the system of outlets at
Beaujon for the foul air is by no means so good as at the Lariboisière.

Secondly. If an accident happened to the machinery of the male side,
which is in communication with the steam engine, the results might be
very serious. Twice a stove has burst on that side, happily without
damaging anything else than furniture near it; had patients been near
it, they must have been hurt or killed: and an accident on a large
scale might blow up not a small part of the Hospital.

More or less danger is inseparable from powerful steam machinery, or
powerful machinery of any kind: the question is one of degree.

Thirdly. Both sides of the Hospital have one thing in common. Except
the sculleries of the 3 ground floor wards on the male side, which
have each a stove or fire place, the kitchens or sculleries attached
to all the other wards are warmed by hot water. Undoubtedly this saves
much mess, much cleaning of stoves &c., and much bringing of fuel
and consequent dirt. But the absence of fire is always a loss to the
service of a ward. Sundry things, some one or other, often all of which
are constantly wanted in a large ward, _e.g._ warming broth or drink,
cooking for an extra bad case, warming poultices, warming (not airing)
linen for ditto, &c., &c., &c., are much more slowly done by water than
fire heat, and it is a question, variously answered, whether some of
these things are as well done by the slow water method, as by the quick
fire heat. Occasionally the hot water is not forthcoming, a nuisance
alike to the ward attendants of the ward whose scullery is thus heated,
and to those of the wards supplied with stoves, which have then to do,
in driblets, considerable extra duty.

During the hot months the smell of the latrines is very little
perceptible in the wards, generally not at all: but the test of this,
as of the ventilation, is in winter, when the large window close to the
latrines is generally closed, and the smell is very offensive.


II.--_Oiled Boards_ versus _Parquets_.

1. They have in common the superiority over common floorings--that they
are not scrubbed, and the damp thus arising is avoided.

2. As regards labour, so far as Civil Hospitals are concerned, where
the ward service is done by women, _parquets_ would be more laborious
than scrubbing; a large ward, to be kept in a proper state, requires
a certain amount of _frottage_ (the peculiar polishing of _parquets_)
every day; and this _frottage_ is held to be unfit, from the fatigue
it causes and the strength it requires, to be done by women, and is
always done by men. Certainly Ward Nurses could never be required to
_frotter_; it is altogether a man’s business.

3. As regards labour, so far as Military or Naval Hospitals are
concerned, where men preponderate in the ward service, it is my
impression (for of course I cannot pretend any certainty as to this),
that sailors who are proverbially handy (a different quality from
either laboriousness or endurance, though they have these too) would,
with instruction and painstaking, accomplish in time _frottage_; that
civilians would under the same conditions; that soldier orderlies
(infinitely, I humbly think, the best material for the staple of
military ward service), would generally make bad _frotteurs_.

4. As regards labour, cleaning oiled boards, though a laborious
business, is much less so than either scrubbing or _frottéing_; and
is fully within the power of average strong women: none other should
nurse. (What subdivision of cleaning the ward, and of nursing properly
so-called, might both improve the work done and relieve the Nurses, is
another thing; my impression remains, that it is better to consider
these things to a certain extent as distinct duties, discharged by
women ranking alike; and that in a ward of forty, served by a Head
Nurse and three Nurses, to charge one with the main ward cleaning, is
better economy of strength and time than to divide it among the three).

5. As regards labour, any Orderly giving his mind to it for a day at
the shortest, or a week at the longest, ought to learn thoroughly
how to clean polished oiled boards well, always supposing him to be
properly taught a very simple thing, which, like everything else, can
be done well, ill, or indifferently.

6. Apart from the question of labour augmented or spared, the
advantages of oiled and polished boards I believe to be these:--

(1.) Prevention of dust.

(2.) More easy purification of the air of the ward in the morning.

The air of every ward becomes more or less impure during the night,
and the floor and furniture more or less dusty. Making the beds in the
morning adds to the dust the night has accumulated.

The dust is more thoroughly destroyed by the cleaning necessary to
oiled and polished boards _of the Bethanien variety_, than by any other
cleaning I have seen. It is fairly destroyed; whereas both _parquets_
and boards generally retain a little.

Also, the water, with which the oiled boards after being swept are
cleaned, freshens the ward and purifies it of the closeness remaining
of the night air, in a very speedy and remarkable manner, which is even
more evident as well as more useful in winter than in summer--as in
winter it is not possible to admit as much air from the windows as in
summer, especially when it is most wanted, in the cold, close, early
mornings.

The advantages of oiled and polished boards as counteracting the
spread of miasma, which is strongly dwelt on at Berlin by competent
authorities, I have not alluded to, as probably _parquets_ are
considered equal in these respects to them.

Stains, mess, and dirt falling on polished oiled boards are much more
easily cleaned than on parquets.


NOTE.

_Mode of Cleaning Ward and Room Floors at Bethanien, Berlin._


I. DAILY.

1. Take a common hair broom, a broom with a hard brush, a cloth of
coarse flax, and one or two pails of cold water.

2. Sweep the floor and skirtings with the hair broom.

3. Dip the cloth in a pail, wring it gently between the hands, so as
to have the whole equally wet, not running. Throw it on the ground,
reverse the hard broom, and placing the reversed handle upon the cloth,
clean the floor close to the skirtings, not the skirtings themselves,
and the corners. When the cloth becomes dry, rinse it and re-wet it in
the same pail.

4. Then wet the cloth somewhat more, wringing it as before, throw it
on the floor at the end furthest from the door, and placing the brush
of the hard broom upon it, brush, firmly and quickly, each board in
the direction that the boarding runs, about as far as the arms can
reach, standing, not kneeling. A small ward can be at once brushed wet,
a large one must be divided into parts, and each part be successively
brushed wet and brushed dry. When the cloth becomes dry, rinse it and
re-wet it.

5. To brush dry, rinse and well wring the cloth, brush as before. The
firmer you can press, the better and quicker the floor will be dried.
When the cloth becomes wet, rinse it and wring it as before.

6. Change the water when dirty. More or less water must be used,
according as the floor is trod by dirty boots and shoes.

7. Aim at drying the floor by one dry brushing; if not, it must be dry
brushed a second time. Once should suffice.

8. Ten minutes, at the furthest, after the dry rubbing is over, the
floor ought to be thoroughly dry. When it is quite dry, sweep quickly
over it with the hair broom.

9. On putting by the cleaning materials, rinse well the cloth in clean
water.


II. WEEKLY.

1. Brush the skirtings with a small hard brush, and wipe them dry with
a rag, as the cloth would be too large, and wet the walls.

2. Use more water to clean the floor, which will probably require two
dry brushings.

3. Clean the brooms and pails.


III. ANNUALLY.

1. Throw warm, not hot, water on the floor, and brush firmly and
quickly, wet and dry. A very little soda in each pailful will be an
improvement. More than very little will injure the flooring.

[A new cloth, which it is economical to cut from a great piece which
makes into some or many dozens, should be steeped for a night in a pail
once filled with boiling water, and in the morning rinsed and wrung
several times in clean cold water, then used at once. Two or three new
cloths can be steeped in the same pail.]


III.--_Cautions in Hospital-Building.--Often repeated, but oftener
neglected._

1. Wherever practicable build the hospital on arches; but, for the sake
of discipline, they should be locked up.

2. If practicable, let the laundry, if served by women, be removed from
sight of the place where the patients take exercise, and of the ward
windows.

3. In a Civil Hospital it is objectionable to give the female patients
right to take exercise in corridors which the officers and servants
have constantly to traverse to go to and from the wards. In a Military
Hospital it is of little comparative disadvantage that the patients
should do this, although,

4. In building a hospital it might be well worth while to contrive
that the covered space, essential to give the patients power of taking
exercise, should be used solely for that purpose.

5. In Germany, the general opinion is in favour of small wards, twenty
beds are considered the desirable maximum; twelve, _per se_, better
than twenty.

Ditto in Belgium, under the same restriction, although, in practice,
there are wards containing larger numbers.

In the old Hospitals at Paris, the number of patients is too large.
The Charité has long great wards of 100 and 120 patients. At St.
Louis (which is mostly for cutaneous, not venereal, diseases, where
the patients usually are long under treatment and able to go about,
and where there is little acute illness,) wards of eighty and seventy
beds are the rule, smaller wards the exception. This may be considered
an exceptional class of patients. The Charité, somewhat densely
pressed upon by neighbourhood, is also not considered a favourably
circumstanced Hospital as to air.

Putting aside for a moment the sanitary question, which we have fully
discussed elsewhere, and which appears to be decided in favour of wards
of from twenty to thirty patients, we will look upon the question of
administration. The moment we consider that a great public Hospital
has to provide efficient attendance for all the sick it receives,
that it must be economical of attendance, both because the expense of
attendance, as well as the other requirements of the sick, commands all
practicable economy; and because efficient attendance in sufficient
numbers is difficult to obtain; it becomes evident that it is far
better for the sick to have larger wards, efficiently served by as few
attendants as is compatible with efficiency.

This, which is the fair statement of the case, strikes those who have
watched the working of the system of small wards in North Germany as
more true than ever.

Such persons consider that the size and numbers of the wards at the
Lariboisière Hospital, viz., thirty-four beds, including the two in the
little ward, are good: that preserving the existing considerable space
between the beds, and supposing the same ratio of conditions as to
windows, &c., and the small ward for two at the end, wards of forty or
fifty would be equally healthy for the sick, but that the number fifty
should not be surpassed.

Assuming, however, that thirty patients in a ward, or thirty-two, are
the maximum number, sanitary and administrative necessities being
conciliated, let us see what we do in our Military Hospitals at home.

In most of our Regimental Hospitals the number of wards and of
holes and corners, in comparison with the number of sick, is quite
extraordinary.

In a hospital for a battalion 500 or 600 strong, we shall find eight
or ten wards of small size, a small kitchen, everything, in fact, on a
small scale, just as if a large French Hospital had suddenly collapsed.

How much more sensible would it not be to have one or, at most, two
large wards for thirty sick each, with a small casualty ward and an
itch ward!

How much less expensive such a structure would be in erecting and
administering, and how much more easy would be the discipline and
oversight, not to mention the greater facility of ventilation!

6. There is nothing at the Lariboisière Hospital answering to
casualty wards. Besides the eighteen wards of thirty-four each, the
Hospital contains two little (and inconveniently placed), wards of
ten beds each, which, when medical cases overflow, are made medical
wards; and which are closed when the ordinary wards suffice. But of
casualty wards, for offensive, or noisy cases, there are none, and the
double-bedded little ward at the end of each large ward is intended to
answer this purpose; also, but subsidiary to this, to allow now and
then a patient of the better class to have the comparative privacy.

This latter consideration does not apply to a Military Hospital. As to
allowing Non-Commissioned Officers for instance to be in the little
wards, discipline would, I think, very soon suffer.

But _if_ casualty wards are provided for extra offensive, and noisy
cases, it seems to me that any Hospital would be much better without
these small wards attached to each larger one.

_Apart from the purposes which the casualty wards answer_, they are
a nuisance. If convalescent patients are put into them, they are
comparatively removed from inspection, and often play tricks there.
Patients requiring much attention can seldom be put there, however
their condition otherwise fits them for the little ward, because the
ward attendants, and especially the Sister (as in secularly served
Hospitals the Head Nurse), find it _impossible_ to serve the inmates of
the little ward properly, if there are also many serious cases in the
large ward.

I submit therefore that the small ward is only an incubus, if casualty
wards are provided. One thing is certain: a patient requiring much
attendance, put into a little ward, ought to have an extra attendant
to himself, by day and by night; otherwise, either he is more or less
neglected, or he unduly monopolises the service of the ward attendants.

It remains a question for far others than women to settle, whether
offensive and delirious cases are under more favourable conditions of
cure when scattered in little wards, than when assembled in a large, or
in several small wards. On this subject, I can only add my confirmed
belief that a large airy ward, provided with a few small wards, and
with complete ward attendance, is a much better place for the care and
attendance of such cases, than small wards attached to the ordinary
wards.

7. Avoid many holes and corners. I could _not_ recommend a dining room
for patients attached to each ward, or floor, or pavilion. If there is
any dining room, let all the convalescent patients of the wards not
being convalescent wards, dine together in a room apart from the wards,
and let the rest dine each at his bed side. If not, let each patient
dine at his bed side.

At the Lariboisière Hospital, each ward has a vestiary, a doubtful
arrangement. The nature of a Military Hospital renders it proper to
have but one vestiary under charge of some man.

8. If possible, let all foul linen be delivered daily, twice perhaps
better than once daily, into the laundry, so as to remain the shortest
possible time in the neighbourhood of the ward; otherwise, do what you
will, foul Hospital linen will fairly, to say the ugly truth--stink,
and its temporary receptacle will stink also. I would not make this
temporary receptacle a room. A large chest in the scullery, a region
under constant purification by fire and air, would be, as already
hinted, p. 88, the least bad place for an accumulation inevitable
to all Hospitals, but which should accumulate for as little time as
possible.

9. Provide from the first room for storing and issuing dried clean
linen, as well as laundry room.

10. In badly-planned Hospitals artificial ventilation is an
excellent auxiliary for expelling the foul air, engendered in the
ward, especially at night; but windows only can be relied upon for
introducing good air. Let Hospitals, therefore, be so constructed as
to admit of opening one or more windows as much as possible all the
year round, with as little chance of draught as may be to individual
patients, which can be done by providing double windows, opening above
and below, or by some similar expedient.



NOTE ON CONTAGION AND INFECTION.


There are no words in regard to which there is more misconception,
or more nonsense talked and written, than the two words “contagion”
and “infection;” and as the word “infectious” has been used in these
Notes, it is necessary to say what it does mean, and what it does not
mean. The word “contagion” appears to have been first used by certain
classical writers to signify the spread of scab among sheep; and it
would have been well for humanity if the word had been restricted to
this very primitive bucolic signification. It was not till centuries
after Virgil’s death that the common sense of men had descended so low
as to introduce it into the Medical vocabulary. This took place at a
period when, from the neglect of sanitary arrangements, pestilence
attacked whole masses of people, and when no one appears to have
considered that nature had any laws for her guidance whatever. It was
not until human intelligence had descended to this depth that men
seem to have bethought themselves of Virgil’s term as affording them
an adequate explanation for pestilence, and sufficient reason for not
exerting themselves to prevent its recurrence. So it has continued
ever since. The little word used in all innocence by the poet for
poetic purposes has become the ground-work of every manner of false
observation, false reasoning, neglect of sanitary laws, lazarettos,
quarantine, and continually-threatened interruption to the commercial
intercourse of mankind. No single word has ever done so much harm to
the human race, or given such a proof of what a mighty thing a word is!

One would have thought that, after the sanitary experience of the
last fifteen years, the word “contagion” would have disappeared from
our language; but, even in the last document issued by the expiring
Board of Health, written by their Medical Officer, Mr. Simon, and
based on erroneous statistical evidence (Papers relating to the
Sanitary state of the People of England, 1858), it is stated that “a
further--practically speaking, unavoidable--cause of premature death in
every civilized country is the risk of its _current contagions_.” [The
italics are not mine.] And this refers to small pox, hooping cough,
measels, and scarlatina, the mortality from which we are to presume, is
“unavoidable.”

If this be Board of Health doctrine, it is certainly not sanitary
doctrine. It would have astonished the Health of Towns Commission, and
the first Board of Health.

“Contagion,” as its etymology implies, means the communication of
disease from person to person by contact. It is often confused
with “infection;” but it has quite a different meaning. Contagion
presupposes the existence of certain germs, like the sporules of
fungi, which can be bottled up and conveyed any distance, attached to
clothing, merchandize, especially to woollen stuffs, for which it is
supposed to have a particular affection, and to feathers, which of all
articles it especially loves, so much so that, according to Quarantine
laws, a live goose may be safely introduced from a plague country;
but, if it happens to be eaten on the voyage, its feathers cannot be
introduced without danger to the entire community. The absurdities
connected with the doctrine are numberless. Suffice it to say that in
the ordinary sense of the term there is no such thing as “contagion.”
There are two or three diseases in which there is a specific virus
which can be seen, tasted, smelt, and analysed, and which, in certain
constitutions, propagates the original disease by inoculation, such as
small-pox, cow-pox, and syphilis, but these are not “contagions” in the
sense supposed.

With regard to the mysterious, imponderable, indivisible nonentities,
which make up our “current contagions,” they may safely be dismissed
into the limbo of extinct superstitions.

The word “contagion” therefore is altogether objectionable.

The word “infection” expresses a fact, without involving a hypothesis.

It is most necessary, however, that the meaning should be guarded;
for, just as there is no such thing as “contagion,” there is no such
thing as _inevitable_ “infection.” Infection acts through the air.
Poison the air breathed by individuals and we have infection. Shut up
150 healthy people in a Black Hole of Calcutta, and in twenty-four
hours you have an infection produced, so powerful that it will in that
time have destroyed nearly the whole of the inmates. Sick people are
more susceptible than healthy people; and if you shut up sick people
together, without a sufficient space and sufficient fresh air, you will
have not only fever, but erysipelas, pyæmia, and the usual tribe of
Hospital-generated epidemic diseases produced.

Again, if we have a Fever Hospital with over-crowded badly-ventilated
wards, or with the air stagnant in them, we are quite certain to have
the air become so infected as to poison the blood not only of the sick,
so as to augment their mortality, but also of the medical attendants
and nurses, so that they shall also become subjects of fever.

It will be seen at a glance that, in every such case and in every
such example, the infection is not inevitable, but the simple result
of gross carelessness and ignorance. In certain Hospitals it has
been the custom to set apart wards for what are called “infectious”
diseases; but, in reality, there ought to be no diseases considered
such. It follows from what has been stated that, with proper sanitary
precautions, diseases reputed to be peculiarly “infectious” may be
treated in wards among other sick without any danger; just in the same
way as, with proper sanitary precautions, a number of healthy people
may be congregated together without becoming subject to the horrors of
the Black Hole of Calcutta.

It is in the highest degree probable that we should never have heard of
“infectious” wards, if the other wards of a Hospital had been supplied
with sufficient space and air for the sick; and in too many cases it is
to be feared that the presumed “infectious” cases are huddled away into
small, ill-lighted, ill-ventilated rooms, a kind of Lazaretto, in fact,
where, if they die, they have at least been kept from doing harm to the
other sick in Hospital!

It is high time that common sense should deal with the question; for
there does not seem to be much hope for a deliverance from these
superstitions from any other quarter.

The “infectious” wards in Military Hospitals correspond, in some sense,
to the “casualty” wards in Civil Hospitals, into which accidents,
noisy, and erysipelatous cases are transferred, when necessary. The
advantages of a separate set of wards for this class of cases have
been already insisted upon in these Notes; not certainly because the
cases are inevitably “infectious,” but because the segregation of
such facilitates greatly administration and nursing, while it removes
offensive and noisy patients out of the Hospital wards, whose inmates
they would annoy. The question of infection or non-infection has
nothing to do with the arrangement. No stronger condemnation of any
Hospital or ward could be pronounced than the simple fact that any
disease has attacked other patients than those first affected by it.
“Infection” and incapable management, or bad construction, are, in
Hospitals, convertible terms.

It may be useful to mention what the meaning is of the words
“epidemic,” “endemic,” “sporadic,” and “zymotic.”

When a large number of people are attacked simultaneously with the same
form of disease it is said to be _epidemic_. When a small number, as,
_e. g._, the inhabitants of a single court or alley, are so attacked,
it is said to be _endemic_. When scattered cases of the same disease
happen, one here, one there, over a large surface, the disease is said
to be _sporadic_. The term _zymotic_, which includes all diseases of
the preceding categories and some others, implies the existence of
certain changes in the constitution or in the blood, rendering persons
so affected liable to the diseases in question.

It is a vulgar error to suppose that epidemics are occasioned by the
spread of disease, from person to person, by infection or contagion;
for it is an ascertained fact that, before any people is attacked
epidemically, the disease attacks individuals in a milder form, one at
a time, at distant intervals, for weeks or months before the epidemic
appears. Before an epidemic of cholera, these cases consist generally
of diarrhœa of more or less intensity, followed by a rapidly fatal
case or two, very much resembling cholera. Even plague itself, as
in the recent epidemic at Bengazi, begins with cases which cannot
be distinguished from ordinary typhus-fever, the succeeding cases
getting more and more intense, until the epidemic seizure takes place.
Experience appears to show that without this antecedent preparatory
stage, affecting more or less the entire population of a town or
district, the occurrence of an epidemic is impossible--the epidemic
being, in fact, the last or, so to speak, the retributive stage of a
succession of antecedent phenomena extending over months or years, and
all traceable to the culpable neglect of natural laws. It is simply
worse than folly, after the penalty has been incurred, to cry out
“contagion,” and call for the establishment of sanitary cordons and
quarantine, instead of relying on measures of hygiène. Epidemics are
lessons to be profited by: they teach, not that “current contagions”
are “inevitable” but that, unless nature’s laws be studied and obeyed,
she will infallibly step in and vindicate them, sooner or later.

In the words of the Registrar-General, which are as applicable to
Armies as to States, “Sanitary measures and not quarantines are the
real safe-guards of nations.”


NOTE.

I have just seen a paper by Sir John Hall, entitled “Observations on
the Difficulties experienced by the Medical Department of the Army
during the late War in Turkey.” In this somewhat singular document,
which appears to be a defence of Sir John Hall’s own conduct, there are
certain statements made about the female nursing establishment in the
East which require a word of comment.

It will be observed that throughout the paper, the weapon which
Sir John Hall uses against all civil interference in repairing the
sufferings which proceeded from the defects of his own department is
simply detraction.

As for Civil Commissions, they were useless, as for Civil Hospitals,
they were costly, and their officers lived magnificently and were
extravagantly paid. As for the nurses, they were benevolent, pious,
well-intentioned persons, but what could they do? How could one woman
nurse eighty sick? The medical men thought they could not.

Why had Miss Nightingale stores of port wine placed at her disposal,
which she could give to the French Hospitals, while he, the principal
Medical Officer of the Army, had no such stores at his disposal?

Sir John Hall must have already discovered that this old weapon is no
longer of use in defending his position.

It would have been more to the purpose had he produced his requisitions
for food, clothing, comforts, &c., and shown how they were refused or
not complied with. At the very time I gave over part of our own private
stores of port wine, &c., to the French Hospitals (for part only of
what was given were Government stores at all), Sir John Hall might have
obtained, out of the large wine store at Balaklava, any amount of wine
he required, by merely asking for it. The simple statement of this fact
would have been a better answer to M. Baudens[20] than assuming that I
could obtain from Government stores and wine for the French Hospitals
which he could not obtain for his own.

As to his statement about the Nurses, it simply shows ignorance of the
whole matter. Nobody ever contemplated giving to a Nurse the entire
charge of a number of sick in a Military General Hospital. It is no
part of good Hospital nursing to do so. With proper Orderlies, a Nurse
can very well attend to sixty or seventy sick. We were prevented,
indeed, by the authorities, and by circumstances, from organizing a
proper system of nursing, and were obliged to do all the good possible
in the best possible way. But Sir John Hall’s method of estimating the
efficiency of nursing, by dividing the number of sick by the number of
Nurses, is simply absurd.

FOOTNOTES:

[2] As little reference as possible, no reference at all, if it can
be avoided, should be made, on our part, to the Confidential Report,
which, in 1855, was presented against the War-Nurses. The less scandal
about women is reverted to the better--a truth all slanderers have
always appreciated: “Calomniez, calomniez toujours: il en reste
toujours quelque chose.” It would be far preferable if Nurses could
enter the Army Hospitals quietly, and let by-gones be by-gones (the
useful experience always excepted, which has been gained).

[3] The work was done under many difficulties, some inevitable, some
which should have been spared. Things happened among us deeply to be
regretted. Rebellion among some ladies and some nuns, and drunkenness
among some nurses unhappily disgraced our body; minor faults justified
_pro tanto_ the common opinion that the vanity, the gossip, and the
insubordination (which none more despise than those who trade upon
them) of women make them unfit for, and mischievous in the Service,
however materially useful they may be in it. Of all this, the material
consequences might have been spared by some such “General Order” as
the above, which, at least, prevents others from taking advantage and
making capital of such faults.

[4] The Extra Diet Kitchens _must_, it is necessary to state, be
under a separate roof from the General Kitchens, as long as the
present system (or no-system) of cooking exists. But the sooner it is
altered the better. There should be one kitchen only. But the Nurse
should always superintend the administering of the Diets. She is
unquestionably the proper person, also, to administer the medicines,
&c. The Orderlies, to be of any use, must act under the direction of
the Head-Nurse and not independently. It would seem hardly necessary to
enunciate such a self-evident proposition.

[5] To all references which may here be made to Civil Hospitals I
should wish to say, by way of preface:--

1. That I have always believed and I believe it more and more every
day I live, that what is wrong in hospitals is to be patiently,
laboriously, and, above all, quietly mended by efforts made from within
them, if it pleases God to grant that blessing upon them without which
all human efforts are vain, and not by accusations, investigations, and
noise from without.

2. Also I have always believed, since I knew Hospitals at all, and I
believe it more and more every day I live, that, with all their faults
and shortcomings, which are easily learnt and more easily declaimed
against, our great English hospitals are places in which more is done
for the relief and cure of human misery, or, rather, of that large
branch of it arising from disease, than in any other places in the
world. Also that their faults are not essential to them, but that they
may, by God’s blessing on the patient endeavours of many years, be very
much modified.

[6] In their regulation dress they should always appear, except when
they go on holidays.

But let the Queen pay for the transport of one box and one bag only,
for each Nurse on duty; and if she takes more let her pay for it
herself.

[7] I would allow each Nurse 1½ pint of porter or ale _per diem_, or,
instead of the half-pint of porter, 1 oz. of brandy or a wineglass-full
of wine, as she likes best. Most Nurses crave, and rightly, for a
luncheon about 9 or 10 A.M., and drink some beer then. I would let them
take their own time as to when they drink their day’s allowance. But,
while trying to suit each Nurse’s varying tastes (and in Hospital duty
the taste does vary) each Nurse must keep to one thing, say for a week
or month.

[8] Better than a closet is a moveable dresser, only table-height,
under which cleaning can be carried on.

There should be no projections in a ward or recess, which are only
lodgments for flue and dust. The walls of a ward should be even,
polished, impervious.

[9] With regard to children we might look forward to a time when
a school might be formed for the children, if any, of such of Her
Majesty’s Nurses as are widows. This would be an additional bond to
the Service for the mothers. The children, of course, are not to be
admitted into Hospital; and strict rules must be made (and kept to) as
to when the mother should visit them. I do not anticipate that it would
be possible ever to have married women in the Service. And it is hardly
necessary to add, that no women but of unblemished character can ever
be admitted.

[10] Should a woman, however, out of the higher orders, be found as
efficient as one of the middle classes, as Matron, this should be no
reason for excluding her.

[11] If it be desired to include some War-Nurses after 40 it would
be better for the Superintendent-General, with the sanction of the
Secretary of State, to take, at first starting, a few past the age,
than, on their account, to alter the age. It stands to reason that, on
the formation of the Staff, approved Nurses of the War-Service should
be included in it, for the sake of the Service.

[12] It is better to omit the Belief. Singularly enough it is the one
thing objected to by Dissenters and Roman Catholics.

[13] If the Surgeons are for the men doing it, I would not overpress
this point. But, in the case of weak patients, it requires extra
care, and it would be much better to leave it as the duty of the
Nurse. At all events it will not answer to leave the enema and its
administrator unspecified. The Medical Staff Regulations assign it
to the Ward-Masters. It is a simple thing enough, but one by the
careless or ignorant administration of which many a man (and woman)
has been injured for life; and either the Ward-Master, the Assistant
Ward-Master, or the Nurse should be responsible for it. I should
prefer, as above stated, charging the Nurse with it; but if objected
to by the Surgeons, I should at once let them assign it to whichever
Non-commissioned Officer they chose.

[14] One Nurse might possibly be able to serve the whole Pavilion. The
highest estimate is here taken.

[15] The floors are of deal; the length and breadth of the boards
depending on circumstances. Wood skirtings run round the walls,
following the recesses of the window and doors, 2½ in. in height and
1½ in. in thickness. The skirtings should have no indents in them,
which form convenient lodgments for dust and take time to clean. A
little rim must run round the top of the skirting, edging the wall. The
skirting should thence descend, unindented, upon the floor. The boards
are coloured and prepared, as follows: A new floor is rubbed over
two or three times, with warm linseed-oil varnish, having some fine
yellow-ochre, powdered, in it; then a coat of “laque-lustre,” a species
of French polish, is laid over it, the result being a reddish-yellow
colour, in which the grain and veining of the wood is shown. If, after
being used some time, it begins to look worn, it is rubbed over with
oil and a new coat of polish laid on it; but, as this takes a long time
to dry, it is usual to fill up the worst parts with thin oil-colour,
and then to take the yellow polish and lay it on, in two successive
coats, leaving it to dry, if possible, for twenty-four hours, as it
wears the better the firmer and drier it is. For old boards, that have
been much used, considerably more laque-lustre is required than for new
ones.

After laying on the laque-lustre it is desirable that the floor should
not be trodden upon for six weeks, and it is also well occasionally,
say about once a week, to polish it, which conduces much to make it
serviceable.

[16] And this should be adhered to, the rare though extant cases of
efficiency for Hospital nursing, past this age, notwithstanding.

[17] Great caution must be used in acting upon this. The
Superintendent-General, or the Superintendents who are responsible to
her, order the service of each Nurse. How far is it just to consider
extra dangerous duties or stations meritorious in the Nurse who does
or suffers from them? Others might have done the same, if so ordered.
Others might have wished for such an order. Or a strong efficient Nurse
who, in other respects, gives anxiety, may render extra useful service
on an emergency, and suffer for it in health: and yet, during her whole
service, have given more anxiety and less satisfaction than others who
did not, perhaps had not the opportunity to, distinguish themselves by
any extra useful service.

[18] The “Superintendent” and “Matron” are here used throughout as
synonymous terms; because “Matron” is the shorter and more familiar
name; although, for reasons before given, “Superintendent” would be the
better word for Military Hospitals.

[19] If it be said that the Workhouse sick are ill-nursed, it is in
proportion as this rule is broken, not as it is kept, that they are so.

[20] To M. Baudens, whose recent death is so much to be lamented,
I cannot here but add a tribute of admiration for his wise and
enlightened sanitary views, during the year of his superintendence over
the Medical Department of the French army in the East, and of gratitude
for his ready and magnanimous acceptance of our stores, when the French
sick were really in want of them, after these had been refused by other
French authorities.



  LONDON:
  PRINTED BY HARRISON AND SONS,
  ST. MARTIN’S LANE, W.C.



_PRIVATE AND CONFIDENTIAL._



THOUGHTS SUBMITTED AS TO AN EVENTUAL NURSES’ PROVIDENT FUND.


I. WAGES AND PROSPECTS OF NURSES.

II. DESIRABILITY OF SOME FURTHER PROVISION.

III. OF WHAT NATURE?

        1. With regard to kind?
        2.       ″        persons?
        3.       ″        objects?

IV. SUGGESTIONS AS TO THE RULES TO BE FOLLOWED.

V. PROSPECTS OF EVENTUAL SUPPORT.


I. WAGES AND PROSPECTS OF NURSES.

[Sidenote: The two Classes of Hospital Nurses.]

1. The nurses of the great London hospitals are divided into two
classes: head-nurses or sisters, and nurses or assistant-nurses. These
latter are, generally, subdivided into day and night-nurses.

[Sidenote: Head-Nurses or Sisters.]

2. The head-nurses, on an average, receive about £50 a-year and no
board, or lower wages and partial board; the use of one or two rooms,
generally unfurnished, and an allowance of fuel and light. Sometimes
uniform outer-clothing is included. Sometimes two pints of beer daily
are added to the above.

[Sidenote: Nurses or Assistant-Nurses.
           Day Nurses.]

3. The day-nurses, on an average, receive about 12_s._ a-week and no
board, or lower wages and partial board; lodging, with the use of some
furniture; sometimes an allowance of fuel and light apart from the use
of both in the wards. Sometimes uniform outer-clothing is added to the
above; sometimes they have also an allowance of one pint of beer daily.

[Sidenote: Night Nurses.]

4. The night-nurses, on an average, receive about 10_s._ a-week and no
board; lodging, with the use of some furniture; sometimes an allowance
of fuel and light apart from the use of both in the wards. Sometimes
they live in their own lodgings, near the hospital, receiving the same
wages.

[Sidenote: Retiring Pensions and Payments at St. Bartholomew’s.]

5. I am informed that St. Bartholomew’s Hospital has no fixed scale of
pensions, nor is the term of service defined. But pensions have been
granted to worn-out sisters of from £15 to £25; as also pensions of
smaller amount to some worn-out nurses.

[Sidenote: At St. Thomas’s.]

6. St. Thomas’s Hospital, in like manner, has given, without any fixed
rule, pensions to worn-out sisters, of from £30 to £50. A gift in
money has been granted on the retirement of a sister; and the same has
been done in the case of nurses who may have received injuries in the
discharge of their duties; and in a very few instances of long and
faithful service they have been pensioned.

[Sidenote: At Guy’s Hospital.]

7. Guy’s Hospital for a long time generously provided for its
superannuated sisters, but the plan in practice being found very
objectionable, was a few years since given up, and the authorities
established a Superannuation Fund for the Servants of the Hospital.

It is compulsory on sisters, optional to nurses, to belong to it.
Each subscriber receives a book containing printed rules, with tables
of rates of ages, payments, and pensions, and also blank leaves.
The subscriber selects the amount of pension for which she wishes
to subscribe. At each quarterly payment of wages, a proportion is
paid into the fund; entered in the subscriber’s book, and properly
attested; the hospital makes a payment of equal amount into the fund
on the subscriber’s account. If the subscriber die before attaining
the age when the pension begins, the amount paid by the subscriber
is disposable by will, and in case of intestacy reverts to the next
of kin. The pensions, one-half of which are thus purchased by the
subscriber, and one-half presented by the hospital, vary, if I remember
rightly, from £15 to £50. In February 1857, no nurse subscribed; to
which three remarks apply:--first, that every good work takes time to
grow; secondly, that not a few of the sisters, having looked forward to
benefiting by the old system of superannuation, rather grudged their
own payments than sought to induce their nurses to subscribe; thirdly,
that many of the nurses were really unable to make the payment.

[Sidenote: At the Non-Endowed Hospitals.]

8. The non-endowed hospitals, I believe, but write from very imperfect
information, grant few pensions. Sometimes they grant a gift of £25
or less to a retiring head-nurse. Sometimes they employ a head-nurse,
become too old for her work, as an extra and inferior nurse. Sometimes
they grant a worn-out head-nurse an asylum in the incurable ward of the
hospital. I believe the pensions to old nurses are still fewer than
the few to head-nurses. Definite information could easily be procured.
Their funds do not permit such a diversion from their main and primary
object, for which they are often, as it is, inadequate.

[Sidenote: At County Hospitals.]

9. Of the wages and prospects of eventual provision of the nurses of
the county hospitals I know nothing; but understand that the former are
lower than, and the latter as entirely blank as those of the nurses of
the non-endowed London hospitals.


II. DESIRABILITY OF SOME FURTHER PROVISION.

[Sidenote: Unfitness of Nurses for any other work.]

1. It may be safely taken for granted as a rule, with few exceptions,
that a thorough hospital nurse can seldom turn herself to any other
business. Her life and work are altogether peculiar; she acquires
a knowledge and habits which incapacitate her from all ordinary
occupations, grows into fitness for them, and out of fitness for all
others.

[Sidenote: Shortness of their time of capacity for Service.]

2. No less so, that the time during which a hospital nurse can work and
lay by, is short, compared with the average duration of other kinds
of service. Apart from all excess of their own, their work and its
concomitants wear out hospital nurses fast. In every large hospital
you will see many women of 40, whom you would suppose 60, and strength
often decays as prematurely as appearance. Well-ventilated bed-rooms,
more sleep, and better food, would be materially in their favour; but
the work can never be other than one which wears out most constitutions
fast.

[Sidenote: Character of Nurses as a Class.]

3. In the London hospitals there are some women of excellent character
and of great efficiency; many the reverse, in one or both respects;
many between the two classes, who generally end by ranking in the
second.

4. To augment the number of the first class, to reduce the number of
the second, to induce the intermediate eventually to rank with the
first, and not with the second, is the desire of every hospital.

5. It is most important, in all things, in none more than in hospital
matters, to moderate expectations, not to hope too much from any
measure, or set of measures, and to keep well in view the stern prosaic
realities of things. The hospitals of great towns are not asylums where
a few or many selected patients can be received and petted; but great
receptacles of all sick comers. Their foundations lie down and deep in
the human sin and misery for which they in part provide, and the traces
of their purpose and nature must ever remain impressed upon them. They
are also schools for the practical education of a great profession,
important to mankind and dangerous to its members.

Hospital nurses are not women attempting or following “counsels
of perfection,” (whatever incorporation of other elements may be
eventually effected), but some of those many women whom God has
ordained to earn their bread by toil, (and in the large towns of
England honest ways of earning that bread are for women but too scarce
and too overcrowded), and upon whom He has laid the same condition as
on all the souls He has made, to keep the commandments to enter into
life. A very mixed class they must ever remain: to improve the class,
by God’s blessing, would be to effect a great benefit both to the
hospitals and to these immortal souls.

[Sidenote: Probable beneficial results of a prospect of eventual
provision, depending on character.]

6. Among several things which might be done or tried, with the view,
if it please God to prosper the endeavour, of eventually improving the
class of hospital nurses, the establishment of some definite prospect
of eventual provision, dependent upon good character, appears very
important.

7. It would tend to augment the number of steady respectable women, who
are anxious to keep a good moral and require a good business character,
whose aim it is to do their duty, to give satisfaction to their
superiors, to keep their places in the same hospital, and eventually to
end their days out of the workhouse.

8. It would tend to diminish the number of ill-conducted women, who
wander from hospital to hospital; whose wages go in drink or finery,
or both; who would be disgusted at the idea of regularly laying by for
their future support, and who would resent strict investigation into
character.

9. It would tend to induce the intermediate class of women, who
hesitate between good and bad companions, to incline to the former, and
to break off from the latter, by the favourable result of provident and
economical habits on their actual conduct; and by the effect which the
prospect of a decent support in their age, dependent upon these habits,
would produce.


III. OF WHAT NATURE?

             1. With regard to kind?
             2.      ″         persons?
             3.      ″         objects?

[Sidenote: Kinds of possible assistance, three.]

1. With regard to kind.

There are three kinds of possible assistance.

[Sidenote: Pensions.]

First. Granting free pensions to efficient and well-conducted sisters
and nurses, under fixed regulations.

[Sidenote: Facilities for Saving.]

Second. Providing sisters and nurses with a secure channel of investing
their savings; giving them thus the important assistance of saving
their time, trouble, and expense, in obtaining information as to such
secure investment.

[Sidenote: Additions to Savings.]

Third. Combining, with the second, a certain proportion of pecuniary
aid.

As to the first. It would be wise economy if the endowed hospitals, who
alone could do it, were to grant such pensions; but whether they are
likely to do more than they do now I am quite ignorant.

Whether our labours in this field should take the direction of the
second or third, is one of the most difficult questions with reference
to a thing which is rife with difficulties. Towards solving it, I
submit that it would be expedient to employ an able and honest man of
business to procure--

[Sidenote: Information and Advice to be procured on the Subject.]

I. The rules, working, and results so far of the Servants’ Provident
Society.

II. Of several of the various partly self-supporting and partly
assisted provident societies of the different trades’ and city unions.

III. Of some dozen benefit societies in large towns.

IV. Of Guy’s Hospital Superannuation Fund.

V. To take the practical opinion of two experienced actuaries.

VI. Also of the Treasurer and Matron of St. Bartholomew’s;

Of the Treasurer, Resident Medical Officer, and Matron of St. Thomas’s;

Of the Treasurer and Matron of Guy’s Hospital;

Of the Chairman of the House-Committee, House-Governor, and Matron of
the London Hospital;

Of the equivalent authorities of St. George’s, and of two or three
other hospitals (including King’s College).

[Sidenote: It is not possible for Nurses to purchase Annuities out of
their Savings.]

My impression is that it is not possible, in the majority of cases, for
either head-nurses or nurses to purchase annuities out of their savings.

I. Their work wears them out comparatively soon.

II. During its continuance they require to live well _i. e._, to have a
sufficiency of good plain food.

III. They are obliged to put out and pay for either the whole or nearly
the whole of their washing, making, and mending (and most properly
obliged).

Thus apart altogether from the consideration that many nurses are
widows with families, and many others burdened with helpless or infirm
relations, and that, in many of these cases, the smallest saving out
of their wages is impossible, I doubt whether it can be reasonably
expected that, as a class, hospital nurses should lay by out of their
unassisted savings a provision for their age.[21]

[Sidenote: Persons to be assisted.]


2. With regard to persons.

Shall the Fund be open exclusively to nurses belonging to the proposed
Institution under Miss Nightingale?

     Or extended to those of the London hospitals?

     Or extended to all Hospitals in England?

     Or in the three kingdoms?

     Or in Her Majesty’s dominions in general?

Shall the Fund be extended to private and monthly nurses, including
midwives, as well as to hospital-nurses?

I submit that we should consult, on these points, the authorities
of the principal hospitals and a few men of experience in business
besides. (Philanthropists by trade are, as is well known, the worst
possible authorities on subjects of this kind.)

My impression is that the Fund should certainly be extended to the
three kingdoms. Whether it should be extended to the empire would
depend entirely, in my judgment, upon the check and scrutiny it would
be possible to exert, on accounts, monies, and certificates, in distant
parts. Upon this men of business should advise.

I think the Fund might eventually be open to private nurses, midwives,
and monthly nurses.[22]

I think it perhaps might be open to the St. John’s House nurses and
to those of any institution which does not provide its servants with a
pension. The Nursing Sisters’ Society, I believe, have recently decided
on granting their sisters £20 a-year, after twelve years’ service, a
wise, generous, and, if properly worked, economical measure. We must
avoid the very appearance of disfavour to other nursing institutions.

[Sidenote: Objects to be sought.]


3. With regard to objects.

Shall the objects be

    Material?
    Sanitary?
    Moral?

Or shall they be restricted either to the first only or the first
and second? Here, again, I submit that we should consult hospital
authorities and a few men of business and of experience, as to the
feasibility, often a distinct thing from desirability, of these things.

Upon the whole, and weighing many opposite difficulties, my impression
is strongly in favour of attempting to combine the three.


Material objects.

[Sidenote: Material Objects to be sought.]

The benefit and provident societies embrace many objects: annuities,
payments on illness, payments at burial, provision for children’s
apprenticeships, provision for children at death, and other things.

[Sidenote: Provision after Superannuation.]

I. It appears to me that the main if not the only object of the Fund
should be to provide annuities.

[Sidenote: During Illness.]

II. It would be a question whether or not to arrange for payments
during illness.[23] Every now and then ward air gets down the throat of
almost every nurse, and every few years or so there is an illness. In
many cases a nurse’s pay stops either when or soon after she becomes
a patient. Some check upon malingering, a thing well known where the
name is not, is essential to every hospital. Of course it presses
heaviest upon those who do not require it. After an illness, before
returning into the wards, the best thing is a short thorough change of
air. Often a severe illness is, and oftener still would be prevented
by a week’s change of air, when the peculiar hospital-languor, so well
known in hospitals, and so indescribable outside of them, first fairly
sets in. The means of change of air, either before or after illness,
are often deficient. Still, useful as some such provision would be,
in many cases every year, it appears to me so subordinate to the
great object of furnishing these women with some provision on their
superannuation, that if it in the least impeded or rendered the latter
less secure, I should unhesitatingly give it up.

[Sidenote: Burial Payments.]

III. With burial payments I think the Fund should have nothing to do.

[Sidenote: Payments for Children.]

IV. As to payments for children, whether on apprenticeship or at
death:--Upon the whole, after much anxious thought, I think it
undesirable to encourage mothers, as such. This is one of the many
points, as to hospitals, where theories and experience differ much from
each other.

[Sidenote: Reasons against the last Form of Aid.]

A very large proportion of nurses are mothers, often widows, with
large families, whom they support and put to service out of their
wages, too often eked out by improper means, _i. e._, bribes and petty
dishonesty. Many of these women are moral, sober, industrious, and
doubly anxious to retain their places, on account of their children;
still there are serious embarrassments in employing them. The wages
of hospital nurses are not and never can be enough to supply a proper
support for children, in addition to the support the mothers ought
themselves to have. Consequently when children are in whole or in part
lodged, fed, clothed, “educated,” and put to service out of the £50
a-year of the head-nurse, or out of the 12_s._ a-week of the nurse,
the mother either stints herself of proper food, proper strong drink
(we deal with practice not with theory), proper warm clothing, for the
children’s sake, or she supplies the deficiency by improper means. If
the nurse cannot afford to live well and abstains from dishonesty, one
of two things infallibly happens--either she takes to drink, as the
fallacious support of an exhausted frame, or her strength fails and
she breaks down, after a few months’, sometimes a few years’ struggle.
When once she has taken to drink, one of two things invariably follows
(dishonesty may be presumed to ensue upon, though it often does not
precede habits of drink); she is or becomes unguarded, and is soon
found out, and sinks into the miserable second and far too numerous
class of characterless hospital nurses, unless drink shortly finishes
her; or, in the other case, she is cautious and guarded--she then
becomes sly, dishonest, and thoroughly venal; she extorts gifts and
takes bribes from her patients and their friends--and the friends of
hospital patients, like others, are of various kinds; she commits
constant acts of petty but often most dangerous dishonesty, possibly
remaining an efficient and clever nurse, sometimes a favourite
nurse; and, so far as regards the crime which has taken the name of
immorality, a moral woman. A certain proportion of nurses are all the
above, excepting drink; for though, almost without exception, every
nurse who drinks takes bribes, some take bribes and do not drink.

Of course widows and unmarried women who are not mothers do the above
things; but there cannot be a doubt of the additional and terrible
temptation to women burdened with children, to make money in various
ways out of their patients. Even in the most favourable cases (and it
is to be feared they are few) where the real good principle of the
mother restrains her from venality, there are still serious objections.
The time when a nurse can go out must necessarily be comparatively very
limited. The time that is enough for the moderate demands of friendship
or acquaintance is miserably insufficient for the natural yearnings
of the mother, especially if the children are young and helpless. The
consequence is that, either openly or by stealth, she goes to them
or has them brought to her at unallowed times; or, if the rules of
the hospital are lax as to visitors, the children are perpetually
with her: and let it be remembered, that the head-nurse’s room or
rooms are usually at the entrance of the ward, that being infinitely
the best place. It is difficult to say whether such a practice is
most objectionable as regards the children, or the patients, or the
hospital; and whether it is most objectionable when the children are
young, or adolescent, or grown up. It is objectionable in all and every
one of these cases. And no less objectionable is it in the case of the
assistant-nurse, who where the rules are lax will receive her children
either in the ward or in the nurses’ kitchen; or where they are strict,
will have the children come about the hospital and will meet them on
the sly.

These things enter immensely, minute as they seem, into the discipline
of wards and of the hospital; and discipline means a great deal.


Sanitary objects.

[Sidenote: Sanitary Objects.]

[Sidenote: To discourage admission of women physically unfit.]

A good many nurses enter hospital service who are quite unfit for it.
Often consumptive and ruptured women, those suffering from piles or
prolapsus, &c., present themselves, are admitted, struggle on for a
time, and break down with or without taking to drink. Undoubtedly, none
but strong healthy women should enter hospital service; the work will
wear them out quite soon enough, and some of the above complaints are
particularly liable to follow the work.

Here again men of business must advise: the fund ought to have some
efficient though not infallible security as to the average good health
on joining of its members. Life Insurance rules as to this would be to
the point.

Believe me, all these things are important.


Moral objects.

[Sidenote: Moral Objects attainable.]

The most difficult part of a difficult thing, only perhaps it is at the
same time the most important.

[Sidenote: Need of Certificates.]

I. I think that every nurse, before joining the Fund, should produce
a certificate from her matron, stating her to be a respectable woman.
In plain words, for the word respectable is certainly capable of most
wondrous extension, the certificate should state her to be, in the
matron’s belief, and to the best of her knowledge, a chaste woman, and
should specify whether she be spinster, wife, or widow. In either of
the latter cases, the marriage certificate, and in the last that of the
husband’s death, should accompany the matron’s.

The matron’s certificate should, I consider, also state her to be
sober; and it would be a question whether it should not also state her
to have served for not less than a year in the hospital. The vagabond
class are a terrible drag upon the whole order; and some of these
might, from the novelty of the thing, be disposed to join it at first.

II. An important question would be: Should the matron’s certificate
be renewed every year, and should the continuance of the nurse’s
membership depend on its production? Men of business must advise as to
this: I am quite unversed as to the details of Provident Societies.

So far as regards the contributor’s own money, the contract once
entered into, must certainly be open to no further question; unless
there has been fraud in the preliminary statement on which it was
based. With regard to any _assistance_ that may be given the question
is different.

III. The preliminary certificate I do consider very important, and the
subsequent ones, if they can be required.

[Sidenote: Hospitals are not places for Penitents.]

Until the hospitals are swept of the many mothers who are not wives,
now unhappily to be found in them, no real good can be done. Hospitals
are not, and never can be, places for “penitents;” and they are about
the most dangerous places where sham penitents can be.

This is precisely what so many people of very different kinds cannot
or will not see; some from ignorance, some from knowledge, some from
the vague, silly, kind feeling which does such mischief when exerted on
practical matters.

Suffer me to submit, without wearying patience by urging proof,--

i. That real penitents are wrongly placed in hospital service, because
their admission breaks down the standard which respectable women
who are hospital nurses feel (quite as keenly as their superiors
do in their own concerns) ought at once to restrain and to protect
those engaged in this very peculiar, very trying, and very exposed
work and life. (I have invariably observed that real penitents are
extra-prudish, and comparatively inefficient, in their hospital duty.
It will at once be perceived how inevitable this result is.)

ii. That sincere but unconfirmed penitents, in addition to the above,
are most dangerously and improperly placed in a situation, to them, of
very peculiar trial.

iii. That sham penitents, who unhappily abound, are dangerous
everywhere, extra-dangerous in hospitals, whether to superiors,
companions, or patients.

iv. That although the class must ever be a very mixed one, it is most
important to have a standard. Let it be necessary for every nurse to
enter hospital with a good character, and to leave it on losing it.
Deception, hypocrisy, and successful guilt will be found in hospitals,
as elsewhere; but the class must be raised, and therefore improved,
by requiring the condition of good character; though guilt may
occasionally mask itself behind it.

v. That although, for various and very differing reasons, the
certificates will be not unseldom untrustworthy, still the same
reasoning will apply. Upon the whole the tendency will be, by
requiring the condition of good character, to improve a class which,
containing, as it does, many well-conducted women, is sadly degraded
and contaminated by many vile ones.

vi. I do not overlook the fact that honest certificates, especially if
annually renewed, might give the matrons some perplexity, from reasons
which need not be enlarged upon. Still, it seems to me, it would be
well worth trying.


IV. RULES TO BE FOLLOWED IN GIVING ASSISTANCE.

Lastly. With regard to rules to be followed in giving assistance of
whatever kind.

[Sidenote: Need of Advice with a view above all to Security.]

It seems to me most important that we should obtain the opinions both
of hospital authorities and of a few able men of business, before
laying down rules. The whole matter is so essentially mixed up with the
tangible point of securing that the savings of these poor women should
avail them in their age, that it is urgent to have sound practical
advice as to letting nothing else imperil this. Security seems the
cardinal point of the whole, and that is a question for men of business
to answer.

[Sidenote: Suggestions in detail.]

The following suggestions toward obtaining it are offered.

1. Security of invested savings to be the first and main thing to be
secured. Every other object should be subordinate to this.

2. If we decide upon aiding their savings, let the security of this aid
be the main point. Invest all donations, annual or not; unless, should
any hospitals contribute annually, it might be fairly considered that
those contributions should be annually used.

3. The aim should be to enable all hospital nurses, of good character,
to provide annuities for themselves, whether with or without
assistance. I think assistance will be necessary.

4. Also to enable private and monthly nurses, and midwives, to do the
same, but without requiring the certificate of character, which, not to
be a mockery, ought to be an effectual one; and these persons are not
under a fixed superior.

5. The pensions should, if it be possible, range from £13 or £15 a-year
to £50 a-year: say £13, £20, £30, £40, £50.

6. Each hospital nurse to produce, before being allowed to join the
Fund, a certificate from her matron of chastity, general good conduct,
and a statement as to her being unmarried, married, or a widow, also
of her having served in one hospital not less than a year. Also
her marriage certificate, if a wife, and, if a widow, that and the
certificate of her husband’s death. In the event of her marriage or
re-marriage afterwards, the marriage-certificate to be produced, and
her altered name and the fact of her marriage duly recorded in the
Fund-book. (All this is important: aliases and fictitious marriages are
sadly common, in this class).

7. If possible the certificate to be produced once a-year, and, on
its failure, the contributor to cease to have a title to assistance.
_Assistance_ in the form of an addition to the annuity may be made
_contingent_; the annuity which the premiums provide must be absolute:
most of the vices tend to shorten life, that is, to diminish the number
of annual payments, so that the fund would not be likely to incur
losses through them.

8. Private and monthly nurses, and midwives, to produce, before being
allowed to join the Fund, a certificate from the Clergyman of the
parish, stating his belief that the subscriber is a respectable woman,
unmarried, married, or a widow; and in the latter cases, marriage and
death certificates. On any after-marriage or re-marriage, certificate
to be produced and altered name registered, on pain of expulsion from
the Fund. I should not attempt an annual certificate for this migratory
and “independent” class.

9. Each nurse, before being allowed to join the Fund, to undergo
whatever examination is undergone by women before they are allowed
to effect Life Insurances, as to her being, at the date of joining,
a healthy woman. (Physicians ought to advise here as to inserting
provisions technical enough to be effective).

10. Payments to be made weekly, monthly, quarterly, or annually, as
shall be advised. Amounts to run from 6_d._ or 1_s._ a week upwards.
For the plan to work, it ought to allow small payments on an ascending
scale.

Many will only be able to make very small payments.

Few will be able to make other than small payments.

11. Payments made by a subscriber dying before attaining pension to be
devisable by will, and in case of intestacy, divided among next of kin.

12. All possible safe curtailment of office expenses.

13. Treasurers, or equivalent civil chiefs, of all hospitals that
subscribe, to be on the committee or council, or by whatever name the
equivalent may be termed.


V. PROSPECTS OF EVENTUAL SUPPORT.

[Sidenote: Support by the Nurses themselves.]

1. I believe that many head-nurses would thoroughly appreciate and
thankfully avail themselves of such a Fund.

2. I think that many nurses would do the same, and, in time, many more.
Many cannot contribute to it; many will not.

[Sidenote: Support from the Hospitals.]

3. What aid the hospitals might be disposed to give I do not know.
I rather think none at first. If the thing works and works well, I
think they would probably contribute. But it must never be forgotten
that, excepting the endowed hospitals (the financial position of St.
George’s I do not know) the London hospitals find their income scarcely
sufficient, often not sufficient, to meet their expenditure. They
cannot be expected, nor would they perhaps be justified, to curtail
the number of the sick they relieve, in order to provide for the
superannuated nurses of those sick. It is true, however, that it might
enable them to get better nurses, which is surely economy.

[Sidenote: Support from the Public in general.]

4. I do not think that much lasting public interest is likely to attend
the Fund. The interest the public has, for the last few years, taken in
hospitals has been fictitious and almost mischievous. The public can
never really know what hospitals are, nor is it feasible or desirable
that it should. What eventual good may be done in them must be done
quietly and with great patience. What good may be done among the nurses
must be done by infusing, if it may be, a higher and truer spirit of
duty, by increased discipline and protection, and by ameliorating, in
some material points, among which the aim contemplated by the Fund
ranks very high, a condition which, to the end of time, must remain
severe, rough, dangerous, and in all senses trying. In the details of
all these things, most especially in all that concerns discipline,
which involves protection, the public, with the best intentions, will
only be an obstacle, and John Bull is sadly prone to pull up anything
he plants or anything he waters, to see how it grows.

I think anything like appeals to or solicited support from the public
might, in various ways, seriously embarrass the Superintendent of a
very difficult and a very important though, at the same time, a very
humble branch of Her Majesty’s Service. I should be very anxious to
avoid this: it would be perpetuating the evils of publicity, and
sacrificing the greater good for the lesser.

[Sidenote: Necessity of Advice.]

5. In conclusion I again submit that it would be desirable to ascertain
from the hospital authorities above mentioned, and if possible from
three or four able and honest men accustomed to business, their opinion
as to the scope and details of this plan. In matters of spirit and of
discipline we should probably rely on other judgment; but these are
matters of business; and in which, without binding ourselves to follow,
it seems most important to obtain and to weigh, the opinions of men
long conversant with business.

_January 23, 1858._



NOTE AS TO THE NUMBER OF WOMEN EMPLOYED AS NURSES IN GREAT BRITAIN.


To show the importance of an Institute for Nurses, it must be stated
that 25,466 were returned, at the census of 1851, as nurses by
profession, exclusive of 39,139 nurses in domestic service,[24] and
2,882 midwives. The numbers of different ages are shown in table A, and
in table B their distribution over Great Britain.

To increase the efficiency of this class, and to make as many of them
as possible the disciples of the true doctrines of health, would be a
great national work.



TABLES OF AGE AND DISTRIBUTION.


TABLE A.

GREAT BRITAIN.

 AGES.


 |    NURSES.   |    Nurse (not   |       Nurse
 |              |Domestic Servant)|(Domestic Servant)|
 +--------------+-----------------+------------------+
 |   All Ages.  |      25,466     |       39,139     |
 +--------------+-----------------+------------------+
 |Under 5 Years.|         ...     |          ...     |
 +--------------+-----------------+------------------+
 |     5 —      |         ...     |          508     |
 +--------------+-----------------+------------------+
 |    10 —      |         ...     |         7259     |
 +--------------+-----------------+------------------+
 |    15 —      |         ...     |       10,355     |
 +--------------+-----------------+------------------+
 |    20 —      |         624     |         6537     |
 +--------------+-----------------+------------------+
 |    25 —      |         817     |         4174     |
 +--------------+-----------------+------------------+
 |    30 —      |        1118     |         2495     |
 +--------------+-----------------+------------------+
 |    35 —      |        1359     |         1681     |
 +--------------+-----------------+------------------+
 |    40 —      |        2223     |         1468     |
 +--------------+-----------------+------------------+
 |    45 —      |        2748     |         1206     |
 +--------------+-----------------+------------------+
 |    50 —      |        3982     |         1196     |
 +--------------+-----------------+------------------+
 |    55 —      |        3456     |          833     |
 +--------------+-----------------+------------------+
 |    60 —      |        3825     |          712     |
 +--------------+-----------------+------------------+
 |    65 —      |        2542     |          369     |
 +--------------+-----------------+------------------+
 |    70 —      |        1568     |          204     |
 +--------------+-----------------+------------------+
 |    75 —      |         746     |          101     |
 +--------------+-----------------+------------------+
 |    80 —      |         311     |           25     |
 +--------------+-----------------+------------------+
 |85 and Upwards|         147     |           16     |


TABLE B.

AGED 20 YEARS OF AGE, AND UPWARDS.


 |                            |  Nurse   |  Nurse   |
 |                            |  (not    |          |
 |                            | Domestic |(Domestic |
 |                            | Servant) | Servant) |
 +----------------------------+----------+----------+
 |Great Britain and Islands in|          |          |
 | the British Seas.          |  25,466  |  21,017  |
 +----------------------------+----------+----------+
 |                            |          |          |
 |England and Wales.          |  23,751  |  18,945  |
 +----------------------------+----------+----------+
 |                            |          |          |
 |Scotland.                   |   1543   |    1922  |
 +----------------------------+----------+----------+
 |                            |          |          |
 |Islands in the British Seas.     172   |     150  |
 +----------------------------+----------+----------+
 |1st Division.               |          |          |
 | London.                    |   7807   |    5061  |
 +----------------------------+----------+----------+
 |2nd Division.               |          |          |
 | South Eastern.             |   2878   |    2514  |
 +----------------------------+----------+----------+
 |3rd Division.               |          |          |
 | South Midland.             |   2286   |    1252  |
 +----------------------------+----------+----------+
 |4th Division.               |          |          |
 | Eastern Counties.          |   2408   |     959  |
 +----------------------------+----------+----------+
 |5th Division.               |          |          |
 | South Western Counties.    |   3055   |    1737  |
 +----------------------------+----------+----------+
 |6th Division.               |          |          |
 | West Midland Counties.     |   1225   |    2283  |
 +----------------------------+----------+----------+
 |7th Division.               |          |          |
 | North Midland Counties.    |   1303   |     957  |
 +----------------------------+----------+----------+
 |8th Division.               |          |          |
 | North Western Counties.    |    970   |    2135  |
 +----------------------------+----------+----------+
 |9th Division.               |          |          |
 | Yorkshire.                 |   1074   |    1023  |
 +----------------------------+----------+----------+
 |10th Division.              |          |          |
 | Northern Counties.         |    402   |     410  |
 +----------------------------+----------+----------+
 |11th Division.              |          |          |
 | Monmouth and Wales.        |    343   |     614  |



NOTE AS TO TEACHING NURSING.


There is, at Madras, an Institution called the Military Female
Orphan Asylum, which trains 200 orphan girls, daughters of European
soldiers. They enter in infancy, and, as they attain a proper age,
they are married to soldiers or others. There is always an abundance
of applicants for them, and every endeavour is made to train them to
be useful soldiers’ wives. Dr. MacPherson, the excellent Principal
Medical Officer of the Turkish Contingent, when at Kertch, who is now
in charge of this Asylum, was the person, I believe, who introduced
amongst the senior girls, a system of training, to enable them to
officiate as nurses, an all-important element in their education. Below
is a syllabus of the theoretical branches taught, a practical knowledge
being acquired in the Hospital attached to the Institution. It would be
well if all women underwent a similar training.


_Course of Instruction for the Class of Sick Nurses, at the Military
Female Orphan Asylum._

Popular and Regional Anatomy and Physiology.

A general knowledge of the human body, its various organs, and their
uses.


Sanitation.

To be made acquainted with every subject relating to health, viz.:
Food--Exercise--Clothing--Cleanliness--Ventilation, &c.


Sick-room Management.

Administration of Medicines, Application of Leeches, Lotions,
Fomentations, &c. Cleanliness, Darkening of the Apartment, Quietness,
&c. Cooking for the Sick. Diet for Infants.


Household Medicine and Surgery.

To be taught how to act in emergencies, viz.: in cases of
Fainting--Hysterics--Convulsions of Children--Burns--Stings of
Insects--Wounds, &c.; and the simplest mode of treating the diseases
most commonly met with in India, viz.:

                    External Inflammation,
                    Cholera,
                    Fever,
                    Dysentery,
                    Sore Eyes,
                    Bowel Complaints,
                    Cutaneous Eruptions.

How to prepare Poultices, Fomentations, and Lotions.
   ″   dress Wounds, Sores, and Blisters.
   ″   apply Bandages.

FOOTNOTES:

[21] If the sisters and nurses, as a rule, were fed as well as lodged
at all the Hospitals, &c., the class of women would, in a very short
time, be entirely changed; this kind of employment would not then, with
the reduced money payment, be so much an object of desire to widows
with families, particularly if compelled to subscribe to a pension
fund, which should be compulsory.

[22] At first it would be unwise to attempt too much. If extended
to Her Majesty’s dominions or private nurses, it would be almost
impossible to control abuses.

[23] Every institution ought to provide for its nurses during illness,
but in fact it is not done.

[24] A curious fact will be shown by Table A, viz., that 18,122 out of
39,139, or nearly one-half of all the Nurses, in domestic service, are
between 5 and 20 years of age.





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