1. Proper military and medical advice should be taken as to whether it would be advisable to draw a distinction between the venereal and the other patients.
In the Vienna Military Hospital they are locked up by themselves in particular wards, but are allowed to see their comrades at visiting hours.
In the Berlin Military Hospital they are locked up in wards, and allowed to receive no visits whatever, excepting, of course, from the Chaplain and the proper Military and Medical Officers; and in the case of dying patients from their nearest friends.
Nor are they allowed exercise in the grounds.
This excellent regulation makes them heartily tired of the venereal wards, and even this is a very salutary thing.
In the Vienna and Berlin Civil Hospitals, the venereal patients of both sexes are also placed in locked wards, and allowed no visitors. Nor are they allowed exercise in the grounds or garden.
In the two Paris Venereal Hospitals no visitors are allowed.
Now, as the more disagreeable the subject, the more necessary it is to be explicit upon it when entered upon, this wholesome discipline exists in a very faint degree in our great Civil Hospitals,—a thing not to be lost sight of in introducing any change in the Army Hospitals.
The three greatest London Hospitals have venereal wards. The female patients never leave the ward. The male patients take exercise in the court. In one case the rule is, that this should be at different hours from the other patients; the rule is not strictly adhered to.
The exercise question should, in Military Hospitals, be left entirely to the Surgeons; they may fairly consider it enters into the question of treatment, which is different from the Continental treatment. The enforcement of different hours of exercise from those of the other patients is good, as is every brand which can, quietly and effectually, affix disgrace to these wards.
Deprivation of visitors, if it could be done, would be very salutary. In the great London Civil Hospitals, men and women visit the male venereal wards; women alone the female wards (and melancholy things are the visiting hours there; here and there a heart-broken mother, abundance of prostitutes, and no lack of procuresses. A firm and vigilant Head Nurse will sometimes refuse admitting one of the two latter sorts to some patient, whom she knows they are endeavouring to make sure of again; but as the rules admit female visitors, and she is by rights only entitled to eject a visitor whose behaviour is disorderly in the ward, the Head Nurse can only do this in point of fact by straining the rules, and cannot do it often). The female visitors of the male venereal wards are usually, on the average, much less disreputable than those to the equivalent female wards; and are generally wives, mothers, and sisters, seldom prostitutes. There can be no doubt, however, that it would be much better if the patients of neither male nor female foul wards were allowed visitors, unless in the comparatively very rare cases of extreme danger; it would, in that case, be necessary that the Hospital should supply them with linen, and either supply them with groceries or forbid their receiving them from without.
In various essential respects the patients of a Military Hospital are different from those of a Civil Hospital. Were it possible to prevent all female visitors to the wards, except in dangerous cases, this would be best. If the existing rules or practice do not compel the sentries to refuse entrance to all disorderly women, however orderly their behaviour, such a rule, at any rate, should be enforced. And if all visitors, male and female, including, of course, soldiers, could be refused admittance to the venereal wards, always excepting cases of great danger, it would be very desirable. At all events, it would be very desirable to have all female visitors, without exception, excluded from these wards. These things are, I do consider, very important. But I would not press them, if refused.
Let the female service obtain, please God (I do not write these words pro formâ,—if possible, I feel every day more intensely how solely it is to Him we must trust in this difficult work,—the more so that, if possible, I feel every day more intensely the importance of, if He grants it success, improving secular Hospital nursing, leaving the English Sisterhoods, which will always have great advantages, and, I believe, great disadvantages, with reference to Hospital nursing, to take their share in this great field, which has plenty of room for both), let, I say, the female service obtain a firm footing in the Army Hospitals, and with it, and by cautious degrees, sundry ameliorations will creep in insensibly as to decorum among other things. Those solemn beautiful words I have always felt so full of meaning to us, “In quietness and in confidence shall be your strength.”
2. Military as well as Medical advice should also be taken upon the following point:
In most, not all, the great London Hospitals the patients, whose names are on their bed-tickets, are called by the numbers 1, 2, 3, &c., suspended over each bed; sometimes a patient’s name is never heard in the ward.
Now, very possibly, this would not at all do in a Military Hospital, and, if so, there is not another word to be said about it.
Otherwise, very few things so effectually save time, as the numbering plan. (In Civil Hospitals it is also excellent in other ways, of much less consequence in a Military Hospital, which will never, I conclude, be afflicted with “gentlemen,” Mr. So-and-So, and Master So-and-So, which latter inscription is frequently to be read on the letters of little boys in Hospitals, whose friends, on visiting days, also enquire for them by that title). But few things, I repeat, so effectually save time as numbering instead of naming the patients (names, of course, to be on bed-tickets). If, however, the officers consider it “unsoldierly,” give it up at once.
3. The regulations lately in force contained in plain strong language prohibition of swearing and indecent language in Hospitals; they are quoted from the Articles of War. It would be well to retain this in any new Regulations; and the retention of this Rule is not the less important when women are put in charge of Military wards, since, though it is not their business to maintain discipline, it is their duty to call in those whose duty it is when discipline is infringed. And it is important that this prohibition of swearing and foul language should not be looked upon as an individual or collective crotchet, or female innovation, but remain the rule of the Service. Such language would never be used in the Nurse’s presence unless by her own fault. But it should be unheard in the ward, whether she is in it or not. The old definite words should be transcribed.
I do not like writing any part of the above, not because it can, in any sense, be said to strain the necessary principle of reserve, save for strictly business purposes, as to all which is, strictly speaking, Hospital business, but because of the extreme caution necessary as to this sort of topics. Still life is so uncertain that the possible introduction of permanent Female Service into Army Hospitals has determined me on writing what I had rather not have written.
The question of ventilation is so all-important, so much doubt still seems to exist as to the comparative merits of natural and artificial ventilation, so much has been said in favour of the latter, because it is seen adopted in the finest hospital in the world, the Lariboisière, that I have added a few practical remarks upon this system. The conclusion is, that even at the Lariboisière, without opening the windows occasionally, and especially in the morning, real freshness is never obtained in the wards, and that, therefore, if there must be artificial ventilation, that is the best which allows the most of the windows being opened.
On the men’s side, Thomas’ system, or that of injecting air at given points, by means of two high-pressure steam engines, each working a large fan, is adopted. On the female side, Duvoir’s system affords ventilation by extracting air at given points. In both, a number of shafts and openings provide for the exit of the air.
Persons at the Lariboisière Hospital, who ought to be good judges, including foremost the Director, an experienced and able administrator, consider the ventilation on the male side the most expensive and the best, both for day and night, being the coolest in summer and the warmest in winter. In winter two great advantages are assigned to this side: first, the heating being provided by the Hospital, the wards are warmable at pleasure; whereas that of the female side is provided by the contractor at a fixed degree of heat, which, in extra cold weather, is augmented: from 15° to 18° C are the usual limits of the winter temperature on the female side, while that on the male side is usually several degrees higher. Secondly, the system of heating on the male side permits the windows to be opened: while on the female side objections are often made to opening the windows in winter, which it is alleged interferes with the heating.
Per contrà. How difficult it is to learn any facts by hearsay we know. Other persons who ought to be good judges think the male side apt to be too warm in winter, especially at night, and consider the temperature on the female side quite sufficient.
Both sides are ventilated both by the windows and by the machinery by day in summer. Both sides are ventilated, each by its own different machinery, by night in summer, except that, exceptionally on hot summer nights, a window is opened two or three times in the night, or five minutes every hour.
Both sides are considered to be ventilated in winter mainly by the machinery by day; and both sides are entirely ventilated in winter by the machinery by night.
As far as can be made out from conflicting accounts, (conflicting from the very simple reason that one person will consider a ward, or drawing room, for that matter, airy which another will consider close; one, pleasantly warm, another too hot or too cold), it is practically found impossible to freshen the ward of a morning without opening some windows, and to keep it fresh during the day without now and then doing the same; and it is easier to open the windows on the male side in winter than on the female side.
The ventilation on both sides is considered to work with equal efficiency during the whole of the day.
Of the eighteen wards, the ventilation on entering the wards at five a.m., when the ward nightwatch has generally not opened a single window, is certainly surprisingly good; i.e. the air is surprisingly little bad. But neither here, any more than anywhere else, are the wards effectually freshened, until the windows are, of course with proper caution, opened.
In both these particulars, no difference is to be observed between the male and female side.
In repeating that the Director, and other persons who ought to be good judges, consider the machinery of the male side the most expensive and the best, I add these things:
First. Since this machinery was erected, so far as concerns the steam engine, it is said that equally efficient and much less expensive engines have been erected in other Hospitals, among others, Necker and Beaujon. In both Hospitals, the plans of Duvoir and Van Heecke are in use, one on either side. But certainly, the system of outlets at Beaujon for the foul air is by no means so good as at the Lariboisière.
Secondly. If an accident happened to the machinery of the male side, which is in communication with the steam engine, the results might be very serious. Twice a stove has burst on that side, happily without damaging anything else than furniture near it; had patients been near it, they must have been hurt or killed: and an accident on a large scale might blow up not a small part of the Hospital.
More or less danger is inseparable from powerful steam machinery, or powerful machinery of any kind: the question is one of degree.
Thirdly. Both sides of the Hospital have one thing in common. Except the sculleries of the 3 ground floor wards on the male side, which have each a stove or fire place, the kitchens or sculleries attached to all the other wards are warmed by hot water. Undoubtedly this saves much mess, much cleaning of stoves &c., and much bringing of fuel and consequent dirt. But the absence of fire is always a loss to the service of a ward. Sundry things, some one or other, often all of which are constantly wanted in a large ward, e.g. warming broth or drink, cooking for an extra bad case, warming poultices, warming (not airing) linen for ditto, &c., &c., &c., are much more slowly done by water than fire heat, and it is a question, variously answered, whether some of these things are as well done by the slow water method, as by the quick fire heat. Occasionally the hot water is not forthcoming, a nuisance alike to the ward attendants of the ward whose scullery is thus heated, and to those of the wards supplied with stoves, which have then to do, in driblets, considerable extra duty.
During the hot months the smell of the latrines is very little perceptible in the wards, generally not at all: but the test of this, as of the ventilation, is in winter, when the large window close to the latrines is generally closed, and the smell is very offensive.
1. They have in common the superiority over common floorings—that they are not scrubbed, and the damp thus arising is avoided.
2. As regards labour, so far as Civil Hospitals are concerned, where the ward service is done by women, parquets would be more laborious than scrubbing; a large ward, to be kept in a proper state, requires a certain amount of frottage (the peculiar polishing of parquets) every day; and this frottage is held to be unfit, from the fatigue it causes and the strength it requires, to be done by women, and is always done by men. Certainly Ward Nurses could never be required to frotter; it is altogether a man’s business.
3. As regards labour, so far as Military or Naval Hospitals are concerned, where men preponderate in the ward service, it is my impression (for of course I cannot pretend any certainty as to this), that sailors who are proverbially handy (a different quality from either laboriousness or endurance, though they have these too) would, with instruction and painstaking, accomplish in time frottage; that civilians would under the same conditions; that soldier orderlies (infinitely, I humbly think, the best material for the staple of military ward service), would generally make bad frotteurs.
4. As regards labour, cleaning oiled boards, though a laborious business, is much less so than either scrubbing or frottéing; and is fully within the power of average strong women: none other should nurse. (What subdivision of cleaning the ward, and of nursing properly so-called, might both improve the work done and relieve the Nurses, is another thing; my impression remains, that it is better to consider these things to a certain extent as distinct duties, discharged by women ranking alike; and that in a ward of forty, served by a Head Nurse and three Nurses, to charge one with the main ward cleaning, is better economy of strength and time than to divide it among the three).
5. As regards labour, any Orderly giving his mind to it for a day at the shortest, or a week at the longest, ought to learn thoroughly how to clean polished oiled boards well, always supposing him to be properly taught a very simple thing, which, like everything else, can be done well, ill, or indifferently.
6. Apart from the question of labour augmented or spared, the advantages of oiled and polished boards I believe to be these:—
(1.) Prevention of dust.
(2.) More easy purification of the air of the ward in the morning.
The air of every ward becomes more or less impure during the night, and the floor and furniture more or less dusty. Making the beds in the morning adds to the dust the night has accumulated.
The dust is more thoroughly destroyed by the cleaning necessary to oiled and polished boards of the Bethanien variety, than by any other cleaning I have seen. It is fairly destroyed; whereas both parquets and boards generally retain a little.
Also, the water, with which the oiled boards after being swept are cleaned, freshens the ward and purifies it of the closeness remaining of the night air, in a very speedy and remarkable manner, which is even more evident as well as more useful in winter than in summer—as in winter it is not possible to admit as much air from the windows as in summer, especially when it is most wanted, in the cold, close, early mornings.
The advantages of oiled and polished boards as counteracting the spread of miasma, which is strongly dwelt on at Berlin by competent authorities, I have not alluded to, as probably parquets are considered equal in these respects to them.
Stains, mess, and dirt falling on polished oiled boards are much more easily cleaned than on parquets.
1. Take a common hair broom, a broom with a hard brush, a cloth of coarse flax, and one or two pails of cold water.
2. Sweep the floor and skirtings with the hair broom.
3. Dip the cloth in a pail, wring it gently between the hands, so as to have the whole equally wet, not running. Throw it on the ground, reverse the hard broom, and placing the reversed handle upon the cloth, clean the floor close to the skirtings, not the skirtings themselves, and the corners. When the cloth becomes dry, rinse it and re-wet it in the same pail.
4. Then wet the cloth somewhat more, wringing it as before, throw it on the floor at the end furthest from the door, and placing the brush of the hard broom upon it, brush, firmly and quickly, each board in the direction that the boarding runs, about as far as the arms can reach, standing, not kneeling. A small ward can be at once brushed wet, a large one must be divided into parts, and each part be successively brushed wet and brushed dry. When the cloth becomes dry, rinse it and re-wet it.
5. To brush dry, rinse and well wring the cloth, brush as before. The firmer you can press, the better and quicker the floor will be dried. When the cloth becomes wet, rinse it and wring it as before.
6. Change the water when dirty. More or less water must be used, according as the floor is trod by dirty boots and shoes.
7. Aim at drying the floor by one dry brushing; if not, it must be dry brushed a second time. Once should suffice.
8. Ten minutes, at the furthest, after the dry rubbing is over, the floor ought to be thoroughly dry. When it is quite dry, sweep quickly over it with the hair broom.
9. On putting by the cleaning materials, rinse well the cloth in clean water.
1. Brush the skirtings with a small hard brush, and wipe them dry with a rag, as the cloth would be too large, and wet the walls.
2. Use more water to clean the floor, which will probably require two dry brushings.
3. Clean the brooms and pails.
1. Throw warm, not hot, water on the floor, and brush firmly and quickly, wet and dry. A very little soda in each pailful will be an improvement. More than very little will injure the flooring.
[A new cloth, which it is economical to cut from a great piece which makes into some or many dozens, should be steeped for a night in a pail once filled with boiling water, and in the morning rinsed and wrung several times in clean cold water, then used at once. Two or three new cloths can be steeped in the same pail.]
1. Wherever practicable build the hospital on arches; but, for the sake of discipline, they should be locked up.
2. If practicable, let the laundry, if served by women, be removed from sight of the place where the patients take exercise, and of the ward windows.
3. In a Civil Hospital it is objectionable to give the female patients right to take exercise in corridors which the officers and servants have constantly to traverse to go to and from the wards. In a Military Hospital it is of little comparative disadvantage that the patients should do this, although,
4. In building a hospital it might be well worth while to contrive that the covered space, essential to give the patients power of taking exercise, should be used solely for that purpose.
5. In Germany, the general opinion is in favour of small wards, twenty beds are considered the desirable maximum; twelve, per se, better than twenty.
Ditto in Belgium, under the same restriction, although, in practice, there are wards containing larger numbers.
In the old Hospitals at Paris, the number of patients is too large. The Charité has long great wards of 100 and 120 patients. At St. Louis (which is mostly for cutaneous, not venereal, diseases, where the patients usually are long under treatment and able to go about, and where there is little acute illness,) wards of eighty and seventy beds are the rule, smaller wards the exception. This may be considered an exceptional class of patients. The Charité, somewhat densely pressed upon by neighbourhood, is also not considered a favourably circumstanced Hospital as to air.
Putting aside for a moment the sanitary question, which we have fully discussed elsewhere, and which appears to be decided in favour of wards of from twenty to thirty patients, we will look upon the question of administration. The moment we consider that a great public Hospital has to provide efficient attendance for all the sick it receives, that it must be economical of attendance, both because the expense of attendance, as well as the other requirements of the sick, commands all practicable economy; and because efficient attendance in sufficient numbers is difficult to obtain; it becomes evident that it is far better for the sick to have larger wards, efficiently served by as few attendants as is compatible with efficiency.
This, which is the fair statement of the case, strikes those who have watched the working of the system of small wards in North Germany as more true than ever.
Such persons consider that the size and numbers of the wards at the Lariboisière Hospital, viz., thirty-four beds, including the two in the little ward, are good: that preserving the existing considerable space between the beds, and supposing the same ratio of conditions as to windows, &c., and the small ward for two at the end, wards of forty or fifty would be equally healthy for the sick, but that the number fifty should not be surpassed.
Assuming, however, that thirty patients in a ward, or thirty-two, are the maximum number, sanitary and administrative necessities being conciliated, let us see what we do in our Military Hospitals at home.
In most of our Regimental Hospitals the number of wards and of holes and corners, in comparison with the number of sick, is quite extraordinary.
In a hospital for a battalion 500 or 600 strong, we shall find eight or ten wards of small size, a small kitchen, everything, in fact, on a small scale, just as if a large French Hospital had suddenly collapsed.
How much more sensible would it not be to have one or, at most, two large wards for thirty sick each, with a small casualty ward and an itch ward!
How much less expensive such a structure would be in erecting and administering, and how much more easy would be the discipline and oversight, not to mention the greater facility of ventilation!
6. There is nothing at the Lariboisière Hospital answering to casualty wards. Besides the eighteen wards of thirty-four each, the Hospital contains two little (and inconveniently placed), wards of ten beds each, which, when medical cases overflow, are made medical wards; and which are closed when the ordinary wards suffice. But of casualty wards, for offensive, or noisy cases, there are none, and the double-bedded little ward at the end of each large ward is intended to answer this purpose; also, but subsidiary to this, to allow now and then a patient of the better class to have the comparative privacy.
This latter consideration does not apply to a Military Hospital. As to allowing Non-Commissioned Officers for instance to be in the little wards, discipline would, I think, very soon suffer.
But if casualty wards are provided for extra offensive, and noisy cases, it seems to me that any Hospital would be much better without these small wards attached to each larger one.
Apart from the purposes which the casualty wards answer, they are a nuisance. If convalescent patients are put into them, they are comparatively removed from inspection, and often play tricks there. Patients requiring much attention can seldom be put there, however their condition otherwise fits them for the little ward, because the ward attendants, and especially the Sister (as in secularly served Hospitals the Head Nurse), find it impossible to serve the inmates of the little ward properly, if there are also many serious cases in the large ward.
I submit therefore that the small ward is only an incubus, if casualty wards are provided. One thing is certain: a patient requiring much attendance, put into a little ward, ought to have an extra attendant to himself, by day and by night; otherwise, either he is more or less neglected, or he unduly monopolises the service of the ward attendants.
It remains a question for far others than women to settle, whether offensive and delirious cases are under more favourable conditions of cure when scattered in little wards, than when assembled in a large, or in several small wards. On this subject, I can only add my confirmed belief that a large airy ward, provided with a few small wards, and with complete ward attendance, is a much better place for the care and attendance of such cases, than small wards attached to the ordinary wards.
7. Avoid many holes and corners. I could not recommend a dining room for patients attached to each ward, or floor, or pavilion. If there is any dining room, let all the convalescent patients of the wards not being convalescent wards, dine together in a room apart from the wards, and let the rest dine each at his bed side. If not, let each patient dine at his bed side.
At the Lariboisière Hospital, each ward has a vestiary, a doubtful arrangement. The nature of a Military Hospital renders it proper to have but one vestiary under charge of some man.
8. If possible, let all foul linen be delivered daily, twice perhaps better than once daily, into the laundry, so as to remain the shortest possible time in the neighbourhood of the ward; otherwise, do what you will, foul Hospital linen will fairly, to say the ugly truth—stink, and its temporary receptacle will stink also. I would not make this temporary receptacle a room. A large chest in the scullery, a region under constant purification by fire and air, would be, as already hinted, p. 88, the least bad place for an accumulation inevitable to all Hospitals, but which should accumulate for as little time as possible.
9. Provide from the first room for storing and issuing dried clean linen, as well as laundry room.
10. In badly-planned Hospitals artificial ventilation is an excellent auxiliary for expelling the foul air, engendered in the ward, especially at night; but windows only can be relied upon for introducing good air. Let Hospitals, therefore, be so constructed as to admit of opening one or more windows as much as possible all the year round, with as little chance of draught as may be to individual patients, which can be done by providing double windows, opening above and below, or by some similar expedient.
There are no words in regard to which there is more misconception, or more nonsense talked and written, than the two words “contagion” and “infection;” and as the word “infectious” has been used in these Notes, it is necessary to say what it does mean, and what it does not mean. The word “contagion” appears to have been first used by certain classical writers to signify the spread of scab among sheep; and it would have been well for humanity if the word had been restricted to this very primitive bucolic signification. It was not till centuries after Virgil’s death that the common sense of men had descended so low as to introduce it into the Medical vocabulary. This took place at a period when, from the neglect of sanitary arrangements, pestilence attacked whole masses of people, and when no one appears to have considered that nature had any laws for her guidance whatever. It was not until human intelligence had descended to this depth that men seem to have bethought themselves of Virgil’s term as affording them an adequate explanation for pestilence, and sufficient reason for not exerting themselves to prevent its recurrence. So it has continued ever since. The little word used in all innocence by the poet for poetic purposes has become the ground-work of every manner of false observation, false reasoning, neglect of sanitary laws, lazarettos, quarantine, and continually-threatened interruption to the commercial intercourse of mankind. No single word has ever done so much harm to the human race, or given such a proof of what a mighty thing a word is!
One would have thought that, after the sanitary experience of the last fifteen years, the word “contagion” would have disappeared from our language; but, even in the last document issued by the expiring Board of Health, written by their Medical Officer, Mr. Simon, and based on erroneous statistical evidence (Papers relating to the Sanitary state of the People of England, 1858), it is stated that “a further—practically speaking, unavoidable—cause of premature death in every civilized country is the risk of its current contagions.” [The italics are not mine.] And this refers to small pox, hooping cough, measels, and scarlatina, the mortality from which we are to presume, is “unavoidable.”
If this be Board of Health doctrine, it is certainly not sanitary doctrine. It would have astonished the Health of Towns Commission, and the first Board of Health.
“Contagion,” as its etymology implies, means the communication of disease from person to person by contact. It is often confused with “infection;” but it has quite a different meaning. Contagion presupposes the existence of certain germs, like the sporules of fungi, which can be bottled up and conveyed any distance, attached to clothing, merchandize, especially to woollen stuffs, for which it is supposed to have a particular affection, and to feathers, which of all articles it especially loves, so much so that, according to Quarantine laws, a live goose may be safely introduced from a plague country; but, if it happens to be eaten on the voyage, its feathers cannot be introduced without danger to the entire community. The absurdities connected with the doctrine are numberless. Suffice it to say that in the ordinary sense of the term there is no such thing as “contagion.” There are two or three diseases in which there is a specific virus which can be seen, tasted, smelt, and analysed, and which, in certain constitutions, propagates the original disease by inoculation, such as small-pox, cow-pox, and syphilis, but these are not “contagions” in the sense supposed.
With regard to the mysterious, imponderable, indivisible nonentities, which make up our “current contagions,” they may safely be dismissed into the limbo of extinct superstitions.
The word “contagion” therefore is altogether objectionable.
The word “infection” expresses a fact, without involving a hypothesis.
It is most necessary, however, that the meaning should be guarded; for, just as there is no such thing as “contagion,” there is no such thing as inevitable “infection.” Infection acts through the air. Poison the air breathed by individuals and we have infection. Shut up 150 healthy people in a Black Hole of Calcutta, and in twenty-four hours you have an infection produced, so powerful that it will in that time have destroyed nearly the whole of the inmates. Sick people are more susceptible than healthy people; and if you shut up sick people together, without a sufficient space and sufficient fresh air, you will have not only fever, but erysipelas, pyæmia, and the usual tribe of Hospital-generated epidemic diseases produced.
Again, if we have a Fever Hospital with over-crowded badly-ventilated wards, or with the air stagnant in them, we are quite certain to have the air become so infected as to poison the blood not only of the sick, so as to augment their mortality, but also of the medical attendants and nurses, so that they shall also become subjects of fever.
It will be seen at a glance that, in every such case and in every such example, the infection is not inevitable, but the simple result of gross carelessness and ignorance. In certain Hospitals it has been the custom to set apart wards for what are called “infectious” diseases; but, in reality, there ought to be no diseases considered such. It follows from what has been stated that, with proper sanitary precautions, diseases reputed to be peculiarly “infectious” may be treated in wards among other sick without any danger; just in the same way as, with proper sanitary precautions, a number of healthy people may be congregated together without becoming subject to the horrors of the Black Hole of Calcutta.
It is in the highest degree probable that we should never have heard of “infectious” wards, if the other wards of a Hospital had been supplied with sufficient space and air for the sick; and in too many cases it is to be feared that the presumed “infectious” cases are huddled away into small, ill-lighted, ill-ventilated rooms, a kind of Lazaretto, in fact, where, if they die, they have at least been kept from doing harm to the other sick in Hospital!
It is high time that common sense should deal with the question; for there does not seem to be much hope for a deliverance from these superstitions from any other quarter.
The “infectious” wards in Military Hospitals correspond, in some sense, to the “casualty” wards in Civil Hospitals, into which accidents, noisy, and erysipelatous cases are transferred, when necessary. The advantages of a separate set of wards for this class of cases have been already insisted upon in these Notes; not certainly because the cases are inevitably “infectious,” but because the segregation of such facilitates greatly administration and nursing, while it removes offensive and noisy patients out of the Hospital wards, whose inmates they would annoy. The question of infection or non-infection has nothing to do with the arrangement. No stronger condemnation of any Hospital or ward could be pronounced than the simple fact that any disease has attacked other patients than those first affected by it. “Infection” and incapable management, or bad construction, are, in Hospitals, convertible terms.
It may be useful to mention what the meaning is of the words “epidemic,” “endemic,” “sporadic,” and “zymotic.”
When a large number of people are attacked simultaneously with the same form of disease it is said to be epidemic. When a small number, as, e. g., the inhabitants of a single court or alley, are so attacked, it is said to be endemic. When scattered cases of the same disease happen, one here, one there, over a large surface, the disease is said to be sporadic. The term zymotic, which includes all diseases of the preceding categories and some others, implies the existence of certain changes in the constitution or in the blood, rendering persons so affected liable to the diseases in question.
It is a vulgar error to suppose that epidemics are occasioned by the spread of disease, from person to person, by infection or contagion; for it is an ascertained fact that, before any people is attacked epidemically, the disease attacks individuals in a milder form, one at a time, at distant intervals, for weeks or months before the epidemic appears. Before an epidemic of cholera, these cases consist generally of diarrhœa of more or less intensity, followed by a rapidly fatal case or two, very much resembling cholera. Even plague itself, as in the recent epidemic at Bengazi, begins with cases which cannot be distinguished from ordinary typhus-fever, the succeeding cases getting more and more intense, until the epidemic seizure takes place. Experience appears to show that without this antecedent preparatory stage, affecting more or less the entire population of a town or district, the occurrence of an epidemic is impossible—the epidemic being, in fact, the last or, so to speak, the retributive stage of a succession of antecedent phenomena extending over months or years, and all traceable to the culpable neglect of natural laws. It is simply worse than folly, after the penalty has been incurred, to cry out “contagion,” and call for the establishment of sanitary cordons and quarantine, instead of relying on measures of hygiène. Epidemics are lessons to be profited by: they teach, not that “current contagions” are “inevitable” but that, unless nature’s laws be studied and obeyed, she will infallibly step in and vindicate them, sooner or later.
In the words of the Registrar-General, which are as applicable to Armies as to States, “Sanitary measures and not quarantines are the real safe-guards of nations.”
I have just seen a paper by Sir John Hall, entitled “Observations on the Difficulties experienced by the Medical Department of the Army during the late War in Turkey.” In this somewhat singular document, which appears to be a defence of Sir John Hall’s own conduct, there are certain statements made about the female nursing establishment in the East which require a word of comment.
It will be observed that throughout the paper, the weapon which Sir John Hall uses against all civil interference in repairing the sufferings which proceeded from the defects of his own department is simply detraction.
As for Civil Commissions, they were useless, as for Civil Hospitals, they were costly, and their officers lived magnificently and were extravagantly paid. As for the nurses, they were benevolent, pious, well-intentioned persons, but what could they do? How could one woman nurse eighty sick? The medical men thought they could not.
Why had Miss Nightingale stores of port wine placed at her disposal, which she could give to the French Hospitals, while he, the principal Medical Officer of the Army, had no such stores at his disposal?
Sir John Hall must have already discovered that this old weapon is no longer of use in defending his position.
It would have been more to the purpose had he produced his requisitions for food, clothing, comforts, &c., and shown how they were refused or not complied with. At the very time I gave over part of our own private stores of port wine, &c., to the French Hospitals (for part only of what was given were Government stores at all), Sir John Hall might have obtained, out of the large wine store at Balaklava, any amount of wine he required, by merely asking for it. The simple statement of this fact would have been a better answer to M. Baudens[20] than assuming that I could obtain from Government stores and wine for the French Hospitals which he could not obtain for his own.
As to his statement about the Nurses, it simply shows ignorance of the whole matter. Nobody ever contemplated giving to a Nurse the entire charge of a number of sick in a Military General Hospital. It is no part of good Hospital nursing to do so. With proper Orderlies, a Nurse can very well attend to sixty or seventy sick. We were prevented, indeed, by the authorities, and by circumstances, from organizing a proper system of nursing, and were obliged to do all the good possible in the best possible way. But Sir John Hall’s method of estimating the efficiency of nursing, by dividing the number of sick by the number of Nurses, is simply absurd.
[2] As little reference as possible, no reference at all, if it can be avoided, should be made, on our part, to the Confidential Report, which, in 1855, was presented against the War-Nurses. The less scandal about women is reverted to the better—a truth all slanderers have always appreciated: “Calomniez, calomniez toujours: il en reste toujours quelque chose.” It would be far preferable if Nurses could enter the Army Hospitals quietly, and let by-gones be by-gones (the useful experience always excepted, which has been gained).
[3] The work was done under many difficulties, some inevitable, some which should have been spared. Things happened among us deeply to be regretted. Rebellion among some ladies and some nuns, and drunkenness among some nurses unhappily disgraced our body; minor faults justified pro tanto the common opinion that the vanity, the gossip, and the insubordination (which none more despise than those who trade upon them) of women make them unfit for, and mischievous in the Service, however materially useful they may be in it. Of all this, the material consequences might have been spared by some such “General Order” as the above, which, at least, prevents others from taking advantage and making capital of such faults.
[4] The Extra Diet Kitchens must, it is necessary to state, be under a separate roof from the General Kitchens, as long as the present system (or no-system) of cooking exists. But the sooner it is altered the better. There should be one kitchen only. But the Nurse should always superintend the administering of the Diets. She is unquestionably the proper person, also, to administer the medicines, &c. The Orderlies, to be of any use, must act under the direction of the Head-Nurse and not independently. It would seem hardly necessary to enunciate such a self-evident proposition.
[5] To all references which may here be made to Civil Hospitals I should wish to say, by way of preface:—
1. That I have always believed and I believe it more and more every day I live, that what is wrong in hospitals is to be patiently, laboriously, and, above all, quietly mended by efforts made from within them, if it pleases God to grant that blessing upon them without which all human efforts are vain, and not by accusations, investigations, and noise from without.
2. Also I have always believed, since I knew Hospitals at all, and I believe it more and more every day I live, that, with all their faults and shortcomings, which are easily learnt and more easily declaimed against, our great English hospitals are places in which more is done for the relief and cure of human misery, or, rather, of that large branch of it arising from disease, than in any other places in the world. Also that their faults are not essential to them, but that they may, by God’s blessing on the patient endeavours of many years, be very much modified.
[6] In their regulation dress they should always appear, except when they go on holidays.
But let the Queen pay for the transport of one box and one bag only, for each Nurse on duty; and if she takes more let her pay for it herself.
[7] I would allow each Nurse 1½ pint of porter or ale per diem, or, instead of the half-pint of porter, 1 oz. of brandy or a wineglass-full of wine, as she likes best. Most Nurses crave, and rightly, for a luncheon about 9 or 10 A.M., and drink some beer then. I would let them take their own time as to when they drink their day’s allowance. But, while trying to suit each Nurse’s varying tastes (and in Hospital duty the taste does vary) each Nurse must keep to one thing, say for a week or month.
[8] Better than a closet is a moveable dresser, only table-height, under which cleaning can be carried on.
There should be no projections in a ward or recess, which are only lodgments for flue and dust. The walls of a ward should be even, polished, impervious.
[9] With regard to children we might look forward to a time when a school might be formed for the children, if any, of such of Her Majesty’s Nurses as are widows. This would be an additional bond to the Service for the mothers. The children, of course, are not to be admitted into Hospital; and strict rules must be made (and kept to) as to when the mother should visit them. I do not anticipate that it would be possible ever to have married women in the Service. And it is hardly necessary to add, that no women but of unblemished character can ever be admitted.
[10] Should a woman, however, out of the higher orders, be found as efficient as one of the middle classes, as Matron, this should be no reason for excluding her.
[11] If it be desired to include some War-Nurses after 40 it would be better for the Superintendent-General, with the sanction of the Secretary of State, to take, at first starting, a few past the age, than, on their account, to alter the age. It stands to reason that, on the formation of the Staff, approved Nurses of the War-Service should be included in it, for the sake of the Service.
[12] It is better to omit the Belief. Singularly enough it is the one thing objected to by Dissenters and Roman Catholics.
[13] If the Surgeons are for the men doing it, I would not overpress this point. But, in the case of weak patients, it requires extra care, and it would be much better to leave it as the duty of the Nurse. At all events it will not answer to leave the enema and its administrator unspecified. The Medical Staff Regulations assign it to the Ward-Masters. It is a simple thing enough, but one by the careless or ignorant administration of which many a man (and woman) has been injured for life; and either the Ward-Master, the Assistant Ward-Master, or the Nurse should be responsible for it. I should prefer, as above stated, charging the Nurse with it; but if objected to by the Surgeons, I should at once let them assign it to whichever Non-commissioned Officer they chose.
[14] One Nurse might possibly be able to serve the whole Pavilion. The highest estimate is here taken.
[15] The floors are of deal; the length and breadth of the boards depending on circumstances. Wood skirtings run round the walls, following the recesses of the window and doors, 2½ in. in height and 1½ in. in thickness. The skirtings should have no indents in them, which form convenient lodgments for dust and take time to clean. A little rim must run round the top of the skirting, edging the wall. The skirting should thence descend, unindented, upon the floor. The boards are coloured and prepared, as follows: A new floor is rubbed over two or three times, with warm linseed-oil varnish, having some fine yellow-ochre, powdered, in it; then a coat of “laque-lustre,” a species of French polish, is laid over it, the result being a reddish-yellow colour, in which the grain and veining of the wood is shown. If, after being used some time, it begins to look worn, it is rubbed over with oil and a new coat of polish laid on it; but, as this takes a long time to dry, it is usual to fill up the worst parts with thin oil-colour, and then to take the yellow polish and lay it on, in two successive coats, leaving it to dry, if possible, for twenty-four hours, as it wears the better the firmer and drier it is. For old boards, that have been much used, considerably more laque-lustre is required than for new ones.
After laying on the laque-lustre it is desirable that the floor should not be trodden upon for six weeks, and it is also well occasionally, say about once a week, to polish it, which conduces much to make it serviceable.
[16] And this should be adhered to, the rare though extant cases of efficiency for Hospital nursing, past this age, notwithstanding.
[17] Great caution must be used in acting upon this. The Superintendent-General, or the Superintendents who are responsible to her, order the service of each Nurse. How far is it just to consider extra dangerous duties or stations meritorious in the Nurse who does or suffers from them? Others might have done the same, if so ordered. Others might have wished for such an order. Or a strong efficient Nurse who, in other respects, gives anxiety, may render extra useful service on an emergency, and suffer for it in health: and yet, during her whole service, have given more anxiety and less satisfaction than others who did not, perhaps had not the opportunity to, distinguish themselves by any extra useful service.
[18] The “Superintendent” and “Matron” are here used throughout as synonymous terms; because “Matron” is the shorter and more familiar name; although, for reasons before given, “Superintendent” would be the better word for Military Hospitals.
[19] If it be said that the Workhouse sick are ill-nursed, it is in proportion as this rule is broken, not as it is kept, that they are so.
[20] To M. Baudens, whose recent death is so much to be lamented, I cannot here but add a tribute of admiration for his wise and enlightened sanitary views, during the year of his superintendence over the Medical Department of the French army in the East, and of gratitude for his ready and magnanimous acceptance of our stores, when the French sick were really in want of them, after these had been refused by other French authorities.