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]

To preside 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.

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.

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.

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—

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.”

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.

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.

4. Pay and Rations.

4. Pay and Rations.—In the great Civil Hospitals the Head-Nurses have, on an average, 50l. 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 12s. 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, 18s. a-week, lodging and board, fuel, light, and partial clothing—18s. a-week is 46l. 16s. 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 20l., rising to 50l. 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.

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:

(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.

(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.

If not commutable,

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

(1.) Shall the Nurse cook her own Rations?

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

(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.

(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]

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.

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.

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.

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.

8. Matrons 200l. 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 200l. and a house, the other great Hospitals, 150l., and a house. The London Hospital gives 150l., 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. 200l. 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.

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.

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.

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.

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.

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,—

(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.

(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.

(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.

(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.

(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 are on from 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.

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 24⎫ ⎬ ⎭there are⎧ ⎨ ⎩1 Sister. 2 Nurses.

30 there are⎧ ⎪ ⎨ ⎪ ⎩1 Sister. 2 Nurses. 1 Scrubber.

34 there are⎧ ⎨ ⎩1 Sister. 3 Nurses.

40 there are⎧ ⎪ ⎨ ⎪ ⎩1 Sister. 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.

(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.

(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.

(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 Orderlies6 Netley Wards;

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

(9.) 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.

(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.

(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 15s. 6d. 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 favour of large wards }£207,775

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

Or cost for each bed 5775 / 25 = £231

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

Wards with 9 beds £427,775

Wards with 25 beds 231,000

Saving £196,775

Deduct cost of Netley, already incurred 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

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.