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

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

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

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

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

General Principles as to Wages and Pensions.

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

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

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

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

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

Applications of the foregoing Principles.

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

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

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

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

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

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

Example.

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

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

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

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

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

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

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

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

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

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

At the same time it is necessary to state—

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

As regards the efficiency of her service:—

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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