2. Restraint is again a thing which must be left to our masters, and to them solely—but an ugly, sorrowful, little truth may here be told. Restraining and non-restraining processes, and their results may be seen, both where, in the same Hospital, one or more of the Surgeons orders restraint never to be used to his patients, however violent, and others order it to be used in violent cases: and where the rule of the Hospital is to restrain violent cases, removing the restraint so soon as the paroxysm is over, or as soon as amelioration renders the sudden return of paroxysms less likely. I am not speaking of lunatic asylums, but of delirium, particularly delirium tremens, in hospitals. Lunatics occasionally enter the Civil Hospitals, but, of course, as soon as that supreme earthly misery is ascertained, they are removed to the proper refuge. It is my humble opinion and firm belief that mechanical restraint excites a patient much less, and quiets him much sooner, than the prolonged struggle with his attendant’s arms and hands, which must otherwise be resorted to.
The coercion apparatus ought also to be good, not cheap, and always in perfect order. The least thing out of order either causes pain, which when it can be avoided is cruel, or it endangers the efficiency of the whole. The strength and cunning of these patients resembles those of madmen, which for the time being they are.
Restraint renders the usual complement of ward servants able to manage many cases. Non-restraint means that some person must stand or sit by or upon the patient’s bed, and hold and struggle with him often for hours—also that generally this person must be a stranger to the ward. Extra attendants are most injurious to discipline. Could there be a set of casualty or equivalent wards, with its own Head-Nurse, the sick would gain much.
But if necessary to adopt the little ward with every ward—in that case the Nurse must manage the three additional patients—twenty-four or twenty-five are, indeed, too few.
IV. In all Hospitals, let the construction be as simple as it can be. Let its splendour be its lofty airy wards, with plenty of windows; water in all due abundance on each floor; an ample, not excessive, supply of linen, polished impervious walls and ceilings, well-laid and bees-waxed oak floors, and a thorough not excessive, supply of good apparatus of the various necessary kinds. But every unneeded closet, scullery, sink, lobby, represents both a place which must be cleaned, and which must take hands and time to clean, and a hiding or skulking place for patients or servants disposed to do wrong; and of such no Hospital will ever be free. And every cornice, every brass lock or handle, which could be replaced by a plain china or ebony one; every decoration, or flourish, or ledge, on doors, windows, tables, beds, presses, &c., represents either a collection of dust or a great waste of hands, time, and strength in unnecessary cleaning and dusting. These are not crotchets, but the result of close observation of the practical working of these matters. Every five minutes wasted upon cleaning what had better not have been there to be cleaned, is something taken from and lost by the sick. Let the appurtenances of the wards be simple and complete, but as plain and as undecorated as it is possible to be.
Polished impervious walls and ceilings are of the first consequence in Hospitals. It is perhaps hardly necessary to state that, if Parian cement be used, it must not and need not be of the kind lining the wards and corridors at Guy’s Hospital, which is as rough as the roughest plaster, of a dark and dirty colour, and which nothing could improve but being lime-washed twice a-year; it should be polished like that used at the Lariboisière Hospital at Paris, and of a pure white.
In building a new Hospital, some covered arcade or some place where the patients might take exercise in wet weather, and where inspection could be exercised over them, without fuss, is worth contriving. In St. Thomas’s, the patients walk under the covered arcades of the court.
Both in Bethanien and in the Charité Hospitals at Berlin there are reserve wards,—or rather in the Charité there is a reserve Hospital, into which most of the sick are moved for six months in the year, to change the air alternately of all the wards, which during the time receive a thorough cleaning. Great stress is laid at Berlin on thus providing, when building a new Hospital, a certain reserve space, which obviates the necessity of less efficient and far more costly steps afterwards.
V. Let us, by all means, consider as settled, that the Nurses’ food is sent them cooked. Possibly, in the long run, the undoubted advantages of this plan will be found to be over-balanced by its disadvantages; but let us begin by trying it. I submit that their dinners, and possibly suppers, should alone be sent them cooked, and that each Nurse should receive a fixed weekly quantity of groceries, and a daily or two days’ allowance of bread.
For packing up the Nurse’s meals sent her from the kitchen, a Vienna custom might be useful. Each Nurse to have a long, strong, straw basket, properly named or numbered. Some contain five dishes and covers, but two or three would here be sufficient for every purpose, including an occasional slice of pudding. The dishes strong tin, with a tin cover, and if the Nurse prefers eating her dinner out of it rather than the dignity of plates, and the trouble of washing them up, the Matron should let her take hers her own way. If taken by hand, two baskets of this sort can be carried with ease. But if the Matron, as a general procedure, sends each Nurse a hot little dinner, of a good well-cooked portion of meat and vegetables, one such dish and cover will do for one Nurse, and three, five, or six can be accommodated out of the same basket, or one large basket, carried by two men, would serve all the Nurses round. The dishes should, in either case, be numbered or named, not the Nurse’s name, but the ward.
A dish and cover of strong, coarse earthenware is used in the Vienna Hospital, as a grander edition of dinner, &c. The tin ones keep warm without fire for a long time. If the meal arrives when the Nurse cannot eat it, put by on the hob, or some provision for warming in the scullery, it will keep warm and good till she can eat it.
VI. Supposing that we serve each Pavilion by one Nurse, I submit that—
1. The Nurse’s day-room should be on the ground floor.
2. The Ward-Master should sleep in his room on the second or highest floor; should the Nurses sleep in the Pavilion, the Ward-Master should still sleep in it.
In the event of the Pavilions being arranged end to end, as already suggested, the difficulty in regard to Nurses’ and Ward-Masters’ rooms would be materially diminished.
3. I think, but am not sure, that the Orderlies had better sleep away from their wards, but I would leave this to be settled by the Doctors. In cases of sudden outbursts of danger, delirium, or drunkenness, from the results of concealed spirits, and of the Surgeon being sent for, it is useful to have, at once, other than the Night Orderly at hand. And a part of what has been said as to the importance of the Head Nurse sleeping near her ward, applies to the Orderlies. Yet there are important reasons why the Orderlies should not be or feel too much at home in their wards; and if the authorities are disposed to try the plan of lodging the Orderlies together, away from their wards, they are probably right, though I should not be surprised if, after a fair trial, it were found better to revert to the having them near the ward. The Pavilion Plan, which, on the one hand, gives all concerned more liberty of doing wrong than the block plan, and which, on the other, renders it more difficult to call in help, whether of supervisor or of Orderlies, if help is suddenly wanted in the night, makes it the more desirable to let the authorities take quite their own way, as to this.
4. I think the Orderlies had better have their cooked meals sent them into the wards. Of course, they can only eat together in detachments; but in many cases, the absence of even one of the Orderlies would be very inconvenient. Perhaps just as the bell rings to summon to the common meal, something is going on which requires all the ward service; the man either goes late to a cold dinner, or goes away just when he is wanted. If his dinner is brought to him in one of these emergencies, it is put by to keep warm till it is over. Regularity as to meals, as far as possible, should be strictly attended to; and is, in all well-regulated wards: and it is well, where, as in some Hospitals, there is a fixed hour for meals; but it would seem better that the meals should come to the ward servants than the ward servants go to their meals.
5. In the case of Civil Hospitals served by women, it is very important that each Head-Nurse, and each set of Assistant-Nurses, should sleep, eat, and live in the ward and its appertaining rooms, and not assemble together more than can be avoided. With Orderlies the case is partly different. Still I would not unnecessarily bring them all together, any more than allow them to be too much at home in their wards.
6. If the Orderlies do not sleep in the Pavilion they should not have a day-room.
7. To each ward should be attached a scullery, small, but not too small, which only muddles things and work, well provided with cold, and, if possible, with warm water; and it should be law that no patient enters the scullery unless sent there by the Nurse to help in washing up, &c.; and, as a rule, they ought not to be sent there. Make them useful in the ward; keep the scullery for the Nurse and Orderlies.
8. From this scullery let the Nurse get the water she requires—Orderlies ditto.
Let the Orderlies eat their meals in it, if they do not eat them away from the ward. The food of the Orderlies is generally different from that of most of the patients, and it answers better for them to eat their meals not under the noses of the patients. In emergencies, of no rare occurrence, the Orderly must watch a patient and eat his dinner at the same time, and so must the Nurse; but, as a rule, it is undoubtedly better that ward-servants should not eat under the observation of the patients.
In the scullery all the cleaning must take place, which is not done in the lavatory.
In the scullery extras are to be warmed, drinks ditto, hot-bricks heated, water-bottles filled, &c., &c., &c., and none of these things are to be done at the ward-fire.
On the other hand, there is no way so good of making poultices, a thing humble but important, as for the Nurse to stand at a small table in front of the ward-fire, to make the poultices there, spread them, and forthwith apply them.
Sometimes in a large ward, where the Surgeon orders them extensively, a large iron pot is filled with poultice, and then quickly spread and applied. Sometimes the pot is filled and the poultices spread in the scullery or kitchen, to avoid the mess in the ward. When a number of poultices are thus spread away from the sight of the patients, even by very clever Nurses, some arrive too large, or too small, or too broad, or too narrow; and either the poultice has to be returned, or, as of course usually takes place, to be put on the wound it does not fit.
I would not trust any Nurse, including myself, to make a number of poultices of the right size, unless within sight of the patients. Rather than do this it is better to make the poultice-pot (wood does not hold heat, this must be of iron), in the scullery, to take it into the ward, and there spread and apply the poultices.
But a large iron pot of linseed poultice seldom contains the article nearly so well made, as when made in smaller consecutive quantities in a wooden bowl. The bowl does not keep warm above a certain time. Where the poultice is made in a mass, even by very clever Nurses, it never is so well made as when the Nurse makes the poultices in the wooden bowl. These must be forthwith spread, applied, and the bowl re-filled, if more are wanted.
This is another reason why the person who washes the wound should also make the poultice, as also why the Orderlies should clean the ward, why the Nurse should as far as possible be relieved of all “mental labour,” and why kept as much as possible to “manual labour.” All severe wounds she should wash and dress herself, and many a wound becomes severe, when the patient is allowed to fiddle over it himself. Some wounds will not bear being left uncovered, and of course in some cases the Nurse will wash the wound, and immediately afterwards apply the poultice. In general, the Surgeon will consider the wounds take no harm from being washed all round, and then poulticed all round. This requires not to be over-hurried, and not to lose a moment’s time. A careful Nurse will never apply a poultice without having first seen the wound: carelessness, haste, idleness, over-work, and prudery, each and all produce very sorry results as to this.
I think, therefore, poultices should be made in the ward, and immediately after the table cleared away, and the slight mess also. In some Hospitals they place a straw carpet just round the table, and also carry it to any bed which requires an extra mess in dressing or cleaning.
9. A regular store closet is hardly desirable. A good arrangement is this:—
At the end of the ward, nearest the Nurse’s room, or the ward-door, a large press for linen.
By it or opposite it another press, for stimulants, dangerous medicines, stock medicines, such as castor oil and one or two others which are always to be at hand, though not ordered for any particular case, stock lotions (as few as possible), lint, old soft linen, stronger but not coarse ditto for pads, &c., cotton wool, tow, oilskin, splints and pads, &c., &c. Of all these things, the Nurse should always have a certain reserve on hand.
It will be well worth while to see that these presses are made commodiously for their purpose. The linen press should have broad deep shelves, and the different kinds of things should be sorted apart; the other press should have broad deep shelves for the heavier things, and separate shelves for the bottles; the stimulants by themselves in one row, the stock medicines in another, unless these and the stock laudanum were together, but they are better apart, and the dangerous things upon the topmost shelf; another row for sweet oil, mustard, stock lotions, &c., another row for ointments. Each bottle and pot to be distinctly labelled in whatever is reckoned the most lasting manner; opinions differ as to labels and letters cut in the glass. The latter are boring by night, if something is suddenly wanted, and it is just then that mistakes are to be guarded against. A strong clear PRINTED label, securely fastened to the bottle, is preferable, to be renewed when necessary, as Orderlies’ thumbs even while holding a bottle, if the Nurse’s hands are on the bed, wear labels out. There is a great saving of time and of chance of mistakes effected by clearly printing the directions for the administration of medicine, “once,” “twice a day,” “every three hours,” &c., and affixing them to each medicine bottle.
Of both these presses the Nurse should have the key or keys. One key might do for both, but it may be best to have two keys.
It is a very good plan where the shape of all medicine bottles and of those for liniments is distinctly different; and where, e. g., square bottles are used for poisons, or blue bottles for poisons, and square for lotions.
A small narrow shelf over each patient’s bed, or over his locker, solely for his medicines and wine. When these are on the locker it is less convenient. Where the medicines are not dangerous, it is better to have them thus at each bed, than concentrated away from the beds. Dangerous medicines should never be left at a patient’s bed.
The two presses will answer all demands. As, however, it does not do not to have a supply of everything that may be wanted always in readiness, a stand or table in the ward should have upon it a small supply of whatever may be suddenly wanted—a little lint, linen, tow, and two or three vessels. The supply of lint, &c., to be small enough for the Nurse to keep account of it, and for the patients to know that account is kept of it.
In constant daily use in the surgical wards of the great Vienna Hospital is a thing called in Teutonic style “Apparat.” The Nurse carries it round for herself, when preparing and dressing the patients, and carries it after the Surgeon when he makes his rounds. The system of both dressing and washing is in some respects so different from the English one, that the fittings would vary.
This concentration of what is wanted for dressing and washing wounds, and for attending the Surgeon in his inspection of them, and of what is at once wanted on any bleeding, fit, &c., is very useful; all the more from its being in a compact portable form, which can be thus successively carried to each bed. An English carpenter would make a lighter and handier thing. Brass basins, which are there used, are not desirable. Of course, one must be most especially anxious not to introduce any novelty, particularly any foreign novelty, faster than can be avoided, and we may consider it better either to leave the general system unaltered of rushing on some emergency to the dressing table drawer, or closet, and thence bringing successively the things wanted, or at all events not to extend concentration further than the excellent plan, so far as it goes, of the London Hospital, where each Head Nurse attends the Surgeons with a large basket in her hand, containing most of the dressings required, spunges, and one or two little matters also usefully at hand. The apparat has the advantage of carrying with itself the basins used for washing. In the Military Hospital of Vienna a tray attends each Surgeon, without basins.
10. It is important to have the Nurse’s room opening at once into the ward, and, upon the whole, I should incline to its having but one door, although it may be thought better there should be a second, so that she can leave her room without being seen to do so by the patients. Also, by all means, let the scullery be opposite the Nurse’s room, and not between the ward and the room. As an invariable Hospital rule, rather more than elsewhere in Military Hospitals, publicity may be considered to be a very great police, and a still greater protection. It is far better that twenty-four patients should see the Nurse’s door than one or none; and that her room should open full upon the ward than into an intervening scullery.
In contemplating a Military Hospital, we contemplate a place through which, one year with another, all characters, including a few of the vilest, pass. These are not theoretical matters. The more repulsive the subject, the more prevention is better than cure. Guard against too many closets, sinks, &c., &c., &c.
At the end of the ward there should be a lavatory, with a row, or two opposite rows, of white earthenware basins fixed in a stand, with outlet tubes and plugs: each basin should have a hot and cold water-pipe: and there should be not less than one to each four beds. There should also be in the lavatory a hot and cold water-pipe, from which a portable bath can be filled.
At the furthest end of the ward should be a water-closet, with not less than one soil-pan to each eight beds: and white earthen or porcelain urinals in the same proportion. In the London Civil Hospitals water-closets are now in general use throughout the wards, but not in all of the great Hospitals. In all the Civil Hospitals, it is usual that the patients’ water-closets have no inside bolt or lock, and that there is only accommodation for one inside. In some London Civil Hospitals the male patients, able to take exercise, are expected to make use of urinals out of doors. These matters one, two, or three experienced army surgeons had better pronounce upon; other things are to be considered than the recommendations of architect, plumber, or even sanitarian.
There is in a Berlin Hospital a very useful piece of prosaic apparatus—adjoining the water-closet, a sink, with a high, large, deep, round, pierced basin of stone, above a large hole, into which the contents of a bed-pan can be at once emptied, and from which the bed-pan is at once effectually cleansed. Adjoining this is a sink into which all other slops are emptied. In mentioning this pierced basin or sink solely for emptying and cleansing bed-pans, &c., which is used at the Bethanien Hospital at Berlin, and is far better than emptying the said vessels into the often-occupied water-closet, and then cleansing them in an awkward fashion between the water-closet and the sink, it is necessary to add that the cock ought to extend far enough over the sink for the bed-pan, &c., to be thoroughly cleansed by a stream of water falling directly into it. The Nurse stands at the sink, empties the pail, &c., in it, without fear of splashing, and rinses and fills it, without stirring from the place. Now this absence of splashing water and of moving about from sink to pump, or cock, saves mess and time. The oblong sink, usual in England, has by no means the same advantages.
(The partition containing the sink would be an appropriate receptacle for the bed-pans to hang by hooks or nails on the wall pending their use.)
In Civil Hospitals, two baths, in an airy closet at the end of the ward, to be locked at all times when not in actual use, are a very great advantage. Bringing a bath into a ward, which in many urgent cases must be done when the baths are distant, is a messing discomfort. Still it had better be left to surgeons to say whether, in Military Hospitals, it would not be preferable to have, in each ward, only a portable bath, on wheels, covered with india-rubber, to be brought into the ward for any urgent case; and to take all the men able to walk, or safely to be carried, to the Hospital baths. Of these, some trustworthy, or intended and supposed to be trustworthy, man, who ought to rank as a non-commissioned officer, should have charge. An intelligent and respectable-looking man, a serjeant, has charge of the baths in the Garrison Hospital at Vienna.
In a great London Civil Hospital, St. Thomas’s, it is the very admirable practice for each patient (of course with necessary exceptions) to be bathed on his or her admission. The Sisters are responsible for examining each woman in the bath, which is within the female wards, and for at once reporting before suffering them to go to bed, any case of suspected pregnancy, syphilis, or contagious disease. A man does the same for the men, who are bathed apart from the wards. This arrangement is an excellent one. On the other hand, severe cases, just able to be carried to baths, get no good by going through the air, and being jolted up and down stairs.
In planning a Military Hospital, in which the service of women is to be introduced, it is important to obtain the advice of experienced Army Surgeons as to the arrangement of appurtenances of the wards to be used by the patients alone. Endeavour to prevent the system of holes and corners. It is best that the Nurse’s door should command the view of those who come in or out of the lavatory, and in or out of the water-closet. This whole section is both ugly and important.
11. To sum up. I think it would work the best to have no store-closet, only two well-appointed presses, by which a certain amount of cleaning is saved, and a corner avoided.
Could two cupboards or presses in the wall be arranged for the ward linen and the ward stores, it would be preferable to presses placed against the walls. Take care, however, that the wall is sufficiently thick, so that the presses are not damp, and if this cannot be provided against, keep to presses separate from the wall.
Believe that all this is neither theory nor fidget—but practice.
The furthest end of the ward should contain a lavatory, a water-closet, and the pierced basin for emptying and cleaning bed-pans is a very useful thing. At the other end of the ward, the Nurse’s little room, her door opening full upon the ward. If the upper half were of glass, with a curtain before it, allowing the Nurse to see the ward without being seen, it would be all the more useful. At St. Thomas’s, a window opens into the ward, the Sister drawing a blind when she chooses, and a door opens into the passage, just within the ward doors, opposite the scullery, so that the Sister enters the scullery, in which there is a water-closet, for the accommodation of herself and Nurses, without traversing her ward. Whether door or window, the Nurse should see at once all that is going on in her ward. I prefer a door; yet, if there is to be a ward for one, it may be best and most central to have the Nurse’s window on the large ward, and her door open on the passage. Opposite the Nurse’s room should be a scullery, not too small. The scullery should be well provided with cold, and, if possible, warm water.
If a supply of hot water can be obtained by turning a cock, this is best. Provision should be made in the ward scullery for keeping poultices warm which is every now and then wanted. It is not right to wash eating-vessels and poultice pans, &c., in the same sink; and this should be considered in arranging the scullery. If each ward washes its own bandages, which it ought not to do, the second sink will come in usefully for this. It is worth while, in enforcing extreme simplicity, to prevent jumbling together eating-vessels and things for wounds and sores. Sinks are infinitely most handy when made deep, somewhat in the shape of broad round basins, with hole at bottom; it saves much splashing and mess; the cock to overhang full the middle of the sink. The Wall against the sink should have some protection.
Such a scullery, with complete efficient simple apparatus for its various purposes, places for washing up and cleaning, and for ward purposes and cookery, so that the Nurse can warm the drinks, prepare fomentations, &c., without jostling the Orderlies, who are washing up or cleaning, will be a very great comfort, simplification, and promoter of order, cleanliness, efficiency, and work. At one corner a decent little table for Orderlies’ meals, above it their separate safes for their bread, cold rations, &c., &c.; each to have and keep his key; each to have his locker.
Each floor and ward will require a scullery. It is far better for each ward to contain its own appointments—and all the other stores to be together, apart. On the second floor might be the Ward-Master’s room; vice the Nurse’s room.
12. Nurses’ quarters, if we are driven to their not sleeping near their wards, should be adjoining the Matron’s two rooms, and separate water-closet, in a part of the Hospital as central as can be managed without trespassing on our betters. I would simplify these quarters as much as possible—either a series of very small rooms, or one great space partitioned off each into a little cell, with a window, bed, washing table, chest of drawers, and a very small wardrobe, with space to hang up three or four gowns, deep enough for another row for shawl, &c., at top a shelf for bonnet and caps, at bottom a deep drawer for boots and shoes. These things will be a convenient riddance to the chest of drawers, and comfort to the women. In each cell very strong hooks to hang up and air a little gowns taken off at night, and one or two chairs. The nurses must wash their hands, &c., in the rooms off their wards, and I think it must be understood as a rule that they leave their quarters in the morning and return to them at night. Optional carpet.
Each cell to be numbered either with number or with name of Pavilion. Opposite this space a small lumber room, wherein each nurse may deposit her box, thereby hindering dissemination of bugs. Opposite also a running open cupboard, with partitions numbered or named as rooms, containing each Nurse’s broom, dustpan, &c., each with a key.
Also pump, sink, water closet.
When furnishing begins, it will be well worth while to see that all articles of furniture, whether for wards or Nurse’s quarters, admit of being easily swept and scrubbed underneath, and swept and dusted at top. Chests of drawers, &c., with too narrow space between bottom and ground, harbour dust, or sadly waste a few precious minutes in the most busy part of every day. As few high pieces of furniture as possible, to gather dust and be out of easy reach; as few as possible of cumbrous articles difficult to move from the wall, to sweep and dust behind, &c.
There ought to be, near the Superintendent’s quarters, one or two small rooms, where, necessity occurring, sick Nurses might be lodged. We cannot hope always to escape having sick Nurses; and there would be serious objection in a Military Hospital, where only one Nurse sleeps on each floor, to having the Nurse ill in her room for more than 2 or 3 days at the outside. Or there might be one good-sized airy room, with two or three dark washable curtains dividing it into little dormitories, so that one Nurse, whom the Superintendent must engage and watch, could attend them all. And as Her Majesty’s Nurses must have allowed them such decent comfort as can be, but no fastidiousness, I think the cubicles in one room would be best. Not to be called so, however, by any means, as it would sound Latin and “Puseyitical.” The Nurse’s ward to be locked and key kept by Superintendent, except when tenanted. I should hope three beds would answer thoroughly, as well as that the ward would be empty eleven months out of the twelve.
Considering the awkwardness of illness among Nurses, when it did occur in a Military Hospital, it would be worth while that, adjoining the little ward, there should be a little room for any one infectious case which might occur; e. g., supposing one Nurse ill in the ward with bronchitis, it would not do to put another with small-pox into the ward,—at least it would be very impolitic. The ward should have a water-closet and a little sink of its own, and a little cell, but with window and fireplace, for the attending Nurse to lie down in. When not used, once a month’s, or week’s at the most, cleaning by a charwoman would be enough. It should be always clean and ready for use. In the Civil Hospitals, few years pass without sundry Head-Nurses and Nurses dying, not a few Nurses being warded, and sundry Head-Nurses ill in their rooms. The peculiarity of Military Hospitals makes this little preparation for what is certain every now and then to occur seem desirable and economical; to hire lodgings in the neighbouring town would be in all ways a worse plan.
13. Endeavour, if possible, to obtain a classification of the severe and non-severe cases, and let the Nurses be only appointed to the wards of severe cases. The convalescent cases to be successively removed to the convalescent pavilions, whether they bear or not that name. No convalescent ward in any of the floors of the Pavilions to be served by Nurses.
14. It will be found excellent in many respects not to allow the Nurses’ names to be used in the ward of the Hospital, or among each other, so far as the Matron takes cognizance of. In the great London Hospitals the name of a Nurse is never heard, except occasionally to each other as a solace, partly very natural, partly harmless vanity. She is Sister or Nurse of such and such a ward. In hasty parlance she is distinguished from the others by the name of the ward only. In it she is always addressed as Sister or Nurse.
Thus a Sister of St. Thomas’s Hospital, whose services in the War Hospitals of the East I can never forget, was always at St. Thomas’s spoken of out of her ward as Sister of George, or, more commonly, Sister George; and spoken to quickly or called to in a hurry as George.
All this, the only course of all the great and, I believe, of the smaller London Hospitals, works excellently, in many ways.
15. Arrangements should be made that foul linen remains for the least possible time out of the laundry. As regards the laundry deposits, the best plan is that of the London Hospital, where each ward has a bin of its own marked accordingly. To similar bins all the foul linen should be, at least, daily carried, unless it is judged best to receive and wash all the linen in a heap, returning numbers only to each ward. The former plan is preferable. In any case the linen of the “foul wards” should be received and washed apart. During the time, which ought to be as short as possible, between dirty linen leaving the patients and reaching the bin or bins, a large box in the scullery is making the best of a bad business—the presence of foul Hospital linen always is that—and is preferable to a closet.
16. Washing bandages, a very important thing. Shall a washerwoman be told off for that particular purpose? or shall the Orderlies of each ward do it alla meglio? The former is the better plan; if not adopted, the Nurse must see well to the matter.
17. It would depend upon what sort of work is usually going on in the Surgical Wards of a Military Hospital in peace whether it will be worth either a press with glass front, in which splints, pads, &c., &c., are excellently arranged, as at St. Bartholomew’s; or the pad-basket and splint-rack, which are also excellent, provided in London Hospital. The splint-rack, enabling the Surgeon at once to see and choose of all shapes and sizes, is perhaps only suited for an accident ward, and would be out of place in a military ward in peace. It may be better to have these stores entirely in some dispenser’s or store-keeper’s jurisdiction, and to let the Nurse confine herself to padding, &c., any splint sent by the Surgeon into the ward. Let our masters take exactly their own way about this.
Bandages, lint, &c., &c., &c. should perhaps rest entirely with the Dispenser, otherwise it would be useful in the greater Hospitals, to have under the Matron a Nurse charged with preparing them and giving them out, writing in a book the date, amount of each, and the ward they are given to. In a small Hospital the Matron could do this herself.
While speaking of lint, it seems a duty to state that, in some of the Military Hospitals, in certain County and even London Hospitals, and also in Workhouses, and in the practice of private Surgeons, a preparation of cotton has been recently substituted in the dressing of wounds for charpie or Surgeons’ lint, properly so called. So miserable an economy at the expense of the sick is not adopted in several, at least, of the London endowed Hospitals, probably in none. For all purposes for which lint is necessary cotton fibre should be totally disused, in the army and everywhere else. It is irritating and injurious to wounds. It increases human suffering; it delays patients in Hospital, and, in doing so, of course, increases the cost which such a substitution has been intended to reduce. Nurses should be particularly careful never to use this material, which is easily distinguished, even by the touch. Any Surgeon may tell the best of it from lint by submitting it to microscopic examination, and on doing so he will readily discover that characteristic of cotton fibre which renders it so ill adapted for surgical dressings. It does not absorb the discharges from wounds, as linen lint does. The fibre is ragged instead of being smooth, and it is apt to become matted together, and to adhere to the surface and edges.
18. It is essential to have as few women as can efficiently do their work. Supposing the Hospital were for one thousand patients, not taking into account that some wards would probably be foul wards, where I earnestly hope female service will not be, at present at all events, introduced, and that some wards would be for slight or convalescent cases, where I hope it never will be—supposing each Nurse served seventy-five patients, supposing one Nurse, at the very least, was told off for the linen, fourteen or fifteen Nurses would serve the Hospital. I conclude the Matron to have no cognizance of the laundry.
The Superintendent[18] will require a store room, or at least a store closet, and hers should be well appointed. It would depend upon the other arrangements of the quarters, whether the world in general, when sent for to fetch what it wanted, enter from the same side as the door of the Superintendent’s bed-room, or from the other side. And it would depend upon the nature and amount of stores of which she had charge, in the larger Military Hospitals, whether or not she should have a Nurse told off for this also. Economy is essential; but useless fiddling over every duster or scrubbing-flannel given out, &c., &c., &c., sadly hinders the Matron’s time from more important things.
Housekeepers must be avoided, and every woman must have a distinct and sufficient share of work, and each be distinctly and equally under the Matron. Still it would be advantageous if we could from the first include in the staff of Nurses for the larger Hospitals, one or two places which could be filled by efficient persons who yet were unfitted for the ward work, which calling will be, and ought to be, laborious and wearing enough. Many a woman would never do to look after a Pavilion and seventy-five men; who yet, in charge of linen or stores, would be most valuable, and influence most beneficially the Nurses, whom yet she might be unfit to govern. The system of the Sœurs de St. Vincent, who, in theory and fact, subject entirely to the will of the Superiors in general practice, are yet selected and trained for spécialités, who remain long in these spécialités, which spécialités include such requiring more or less of physical strength, seems to be one giving many useful hints for us.
I. After much anxious thought, re-consideration of all things, and pondering, I submit—
1. That three Orderlies will efficiently serve a ward of from 28 to 30 patients, including night-duty.
2. That each of two wards of 30 each, should there be two such under the same Head Nurse, on the same flat, ought to be entirely separate in all other respects.
3. That if night-duty be required, each such ward should have an Orderly on night-duty.
4. That each such ward should have a scullery.
With regard to these questions, I further submit—
1. Economy of hands, combined with efficiency of service, is an urgent thing in all Hospitals; most of all in Military Hospitals,
On the score of expense;
On that of efficiency of inspection;
From the nature of Military Hospitals, where the aim should be throughout to combine great simplicity with thorough efficiency;
From the importance of training the staff, male and female, of Military Hospitals, for service in War Hospitals, where every man or woman who can be spared is better away.
2. Yet economy of hands, carried too far, becomes, like all other such economies, penny wise and pound foolish.
3. Without doubt, large wards can be efficiently served by fewer hands than small or moderate wards. But, as sanitary considerations limit the size of wards to from 24 to 30 patients, let us make this the basis of all calculation.
4. The more it is considered, the more essential it appears, to train Nurses, from the first, to do efficiently a great deal of work. A small staff of respectable, laborious, and thoroughly efficient women seems the thing to be aimed at; whether considering Military Hospitals by themselves, or as a training-school for Hospital war-service.
5. It would be better to give each Nurse one great ward; but wards above a certain size are inadmissible for sanitary reasons.
6. The care of 24 to 30 patients is not sufficient duty, by a great deal, for a Nurse.
7. Therefore, upon the whole, and as decidedly the lesser of two evils, I recommend assigning to each Nurse two wards.
8. It is less difficult, and less objectionable, that she should have charge of two wards on one floor, than of two wards on two floors.
9. As regards the Nurse, I recommend therefore, upon the whole, to give each Nurse the charge of two wards of 30 men each; the wards to be on the same floor; but, except as being under the same Head Nurse, entirely separate.
10. It is important to repeat that the Nurse (who is Head Nurse), will be set free of two things, which consume much of a Civil Head Nurse’s time.
(1). “Settling the diets,” and fetching, besides waiting for, portions of those diets (e. g. wine) and medicine.
(2). Distribution of Diets.—It is quite possible that, in no long time, it may be found desirable to assign this duty to the Nurse. But it would be better to try to have it efficiently, which implies honestly, discharged by the Ward-Master. It will relieve the Nurse daily of considerable time; and it charges the Ward-Master with a definite duty which he can perform. The more he has defined duties, the less he will be inclined to fidget and disturb the Nurse. He is pretty certain to do this; but definite duties will diminish the tendency.
I should avoid giving the Ward-Masters too few wards. Otherwise they will make themselves insufferable obstructions, one way or another, to the Nurses. I should say that each Ward-Master, in charge of a Pavilion of six wards of 30 each, besides the small wards for one, would not have at all too much to do. Where there are no Nurses, the Ward-Master should have Assistant Ward-Masters in their place.
N.B. Wine might be treated as medicine, and, as such, delivered by the Nurse. Wine and medicine are usually, in the Civil Hospitals, given from the Apothecary’s shop at the same time. Or it might be considered desirable to leave this duty to the Ward-Master. In either case, it will never do to serve a bad case at once with all his wine, and either to let him stupify himself by swallowing it at once to make sure that he has it; or to set it by his bed-side for the flies to spoil it, or for a dishonest comrade, or here and there an Orderly, to drink it. The Nurse should receive, whether directly or from the Ward-Master, the wine of such patients, and should administer it in successive small fresh portions. The intelligent administration of wine ordered to bad cases is one of those momentous minutiæ by which, I do believe, and believe more and more, many lives are, by God’s blessing, annually saved in English Hospitals which would be lost elsewhere. Of course the only Regulation about wine should be to specify whether the Ward-Master or the Nurse should administer it.
11. Relieved of the loss of time incurred by fetching and waiting, and relieved at starting, at all events, and we will hope permanently, of the time consumed in distributing the diets, I certainly consider that a Nurse of the class of which, please God, Her Majesty’s must all be, (strong, laborious, active, and conscientious women,) can efficiently serve two wards of 30 men each.
Orderlies.
12. I should prefer wards of 30 each to wards of 25 each.
13. In forming rules for the proportion of Orderlies to sick, it is important to consider that the duty varies extremely according to the appurtenances of the ward.
14. I consider extreme plainness and simplicity to be proper and indispensable to a Military Hospital. Let us take for granted (and may it prove correct to do so), that in none of Her Majesty’s Hospitals Orderlies’ time will be wasted in cleaning any ornamental things, whether unnecessary furniture, flourishes, or cornices, &c., &c., on necessary furniture; supernumerary shelves, nooks and corners, &c., &c. Once provided, all these things must be carefully and constantly cleaned, or they become receptacles of dust and breeders of fleas; and to clean them involves enormous waste of time. A few minutes daily wasted on each of many things, make an enormous sum.
15. But it is very true economy to supply, if possible—which in old buildings it often is not—every ward of every hospital with a constant supply of water, (taking care that it is not wasted by mischievous or childish patients); and to give every ward of every Hospital the use, under proper control, of a lift by which, at fixed hours, food, medicine, linen and fuel are brought into the wards.
Believe that this is not theory, but the result of practical observation, much extended.
16. Now, these two things—supply of water (if hot and cold so much the better, and supply of water imports, of course, the appliance for getting rid of it, and of the contents of bed-pans, &c., &c., by one or more sinks) and the use of lifts can be applied to a new Hospital; can possibly, not certainly, be applied to some of the old Hospitals within the Kingdom,—can certainly not be applied to many of the Army Hospitals abroad.
17. Upon an average, these two things make the difference of one Orderly’s duty to a ward of 30 men.
18. And a ward of 30 men, so supplied, would be efficiently served by half a nurse and three Orderlies, including night-duty.
19. Without these two things (it is a mere comparative question as to loss of time and absence of thorough cleanliness, whether the water is brought from a pump in the court, or a stream some hundred yards off, above or below), and many, if not most, Army Hospitals abroad, must always remain without these two things, I consider that one Orderly to every seven patients will not be too much; while it is certain that, other things being equal, the ward with the appliances and the three Orderlies will be better served than the ward without the appliances and with the four Orderlies. Where there is no Nurse, one Orderly for 7 patients will always be advisable.
In these memoranda as to Orderlies’ work, &c., no notice whatever has been taken of the possible abolition of scrubbing, because it does not do to count unhatched chickens. If, however, that formidable weekly business could be got rid of, as well as the bi-weekly or daily washings of bed-head-floors, &c. the labour of the Orderlies would be, without underrating that required for keeping oiled floors cleaned, very materially lightened.
Night-duty of Orderlies.
20. Convalescent wards, which will be of great use in many ways, will be of use here. With them Nurses will have nothing to do. It is possible enough that, in course of time, the Medical Officers will desire to have Nurses there, and that it may be useful to place there elderly, still efficient Nurses; but let this come or not as it will, and let us keep quite clear of them, at all events, till the Nursing-service be tried and established in Army Hospitals. In these wards, night-duty will probably be quite unnecessary, though in that case either an Orderly or Assistant Ward-Master ought to sleep at hand; and night-duty is a service which must be spared wherever it can be spared, and rendered as efficient as possible wherever it is really wanted.
I have before submitted that in Paris, Vienna and Berlin, the average of severe cases in Army Hospitals, in time of peace, is very considerably lower than in Civil Hospitals.
This quite as much applies to English Army Hospitals. Whether the ordinary wards would require night-duty I do not know. If they often did, I should prefer having a regular night-duty in them. If they seldom required it, I would not have it.
21. In Civil Hospitals, served by women, I should undoubtedly prefer assigning the night-duty to one Assistant Nurse.
22. But Orderlies are in sundry respects different, and, upon the whole, I recommend not to have night Orderlies, but to let each Orderly in turn do the night-duty.
23. It is important to remember—the more so as it is often forgotten—that to lay more upon human nature than its Maker has made it to bear, is to do a foolish, let alone a wicked thing. Upon an average, all men and women can dispense with, or abridge sleep for more or less time. Upon an average, all men and women, after a laborious day, require a good night, in the long run. When they do not have it, either health, efficiency, or sobriety, or all go.
Believe, again, that this is not theory, but the result of practical observation, much extended.
A strong soldier is no exception to the general rule. In the long run, if made to do night-duty after a laborious day, he will either go to sleep, or drink to keep awake, or he will get knocked up before his time. And this it is part of his business to be in time of war; therefore, in peace-service, it is economical to let him last his time. It is then sound economy to give watchers sufficient sleep.