Addenda with regard to Female Nursing in a Military Hospital on the Pavilion or Lariboisière Plan.
PARIS
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612 Lits.
A. Bureaux.
B. à rez de chaussée Cuisine. au 1ᵉʳ Etage Logements d’employés —au 2ᵐᵉ Etage Dortoirs des Garcons de Service.
C. à rez de chaussée Pharmacie. au 1ᵉʳ Etage Logements d’employés —au 2ᵐᵉ Etage Chambres des Elèves internes.
D E F G H I J K. Chauffoirs.
L M N O P Q. Batiments de Malades.
R. à rez de chaussée Buanderie. au 1ᵉʳ Etage Lingerie. au 2ᵉᵐᵉ Etage Dortoirs des filles de Service.
S. Communauté.
T U. Bains.
V. Chapelle
X Y. Amphithèatres.
Z. Manège et Magasins
W. Ecurie. Remise et Salle des Morts.
1. In considering the Pavilion Plan to be in future received as the sanitary necessity for Hospital construction, we must look upon it as susceptible of many modifications.
And, particularly in adapting it for a Military Hospital, we must ask by what modification can it be made, 1. Most economical as to attendance, a greater amount of which is rendered necessary than by other plans of construction.
2. Easy as to supervision; and, of course, a Hospital spread over the extent of space now proved to be essential by sanitary knowledge, whether built on the Pavilion plan or not, must multiply the amount of supervision over that required in the concentrated over-crowding of the old Hospital system (over-crowding not with regard to cubic space in the wards, but to the superficial area on the ground).
3. Economical as to the number of sick to be accommodated on the same floor, so as to save unnecessary waste of time and strength on the stairs to both Ward-Masters and Nurses. Each Nurse should have, in time of peace, not less than from 50–60 patients under her charge.
4. Efficient as to convenient accommodation for Nurses and Ward-Masters, near to the wards of which they are in charge.
1. Pavilion Plan indispensable on Sanitary grounds. Its Difficulties, on the score of Discipline in Military Hospitals, to be openly met and guarded against.
1. The Pavilion Plan, while it is incontestably superior, on sanitary grounds, to any other, while it perhaps may be made equally economical, with regard to building, is more expensive than the older crowded and badly-constructed Hospitals, not only as to ground, but because each separate entrance, staircase, set of appurtenances, represents an additional cost of materials, and of hands to keep them clean and in order. Human life is, however, a more expensive article than any other. If human beings, and especially sick human beings, are to be spread over as much space as possible, which is now known to be an essential to health and more especially to recovery, this must be done under any system and can be best done under the Pavilion system. It of course necessarily entails a greater amount and cost of attendance and of supervision. Pure air and light are the prime necessities of a hospital. These are best secured by the Pavilion Plan, and therefore it is the cheapest in the end. As to the hands, there never ought, never will, never can, be a superfluity of hands in a well-regulated Hospital. The duty of the hands consists of two parts—to keep the Hospital clean; to attend the sick. I had rather not enumerate the instances where I have seen that, often from the most various causes, one result arises—that more time and care is given to floors, stairs, &c., &c., &c., than to the sick. Extreme cleanliness is of vital importance; this should be combined with extreme simplicity of detail, and with providing for considerable numbers at once. You can effectually clean a large ward in much less time than two small ones; a long stair than two short ones, &c. Extreme, not finicking, cleanliness, thorough ventilation, for which an ample supply of opposite windows will certainly in the long run prove infinitely the best plan, and careful nursing, are probably the main conditions, humanly speaking, of a large proportion of cures—subsidiary to the medical or surgical treatment.
Sanitary necessities are never to be rejected, on account of the trouble they give or of the means of cleanliness which they render necessary. Because the saving of life, not the saving of trouble, is the object of all sanitary appliances, Hospitals among the number. And the saving of life is the only real economy. If you have saved “hands” and trouble, and lost life, you have been extravagant. The object is not to banish appliances which will cost trouble in keeping them clean, but to discover those appliances which can be kept clean, at least cost of labour. And this is perfectly possible.
2. Easy Supervision to be provided for.
2. The Vincennes modification of the Pavilion plan has been adopted, among other reasons, for the greater facility of supervision it affords. The Military Superior, the Surgeon, the Matron, can at any instant pop in upon any ward of a Hospital which has one roof. Each pavilion may, unless the matter be specially considered with a view to providing this effectual supervision, perceive the approach of any inspector. The system of scouts, watch, alarm, is well understood in many hundred wards, whose patients would be puzzled to give the things names. Military patients will know both things and names. Remember that Ward-Masters, Orderlies, and Nurses require inspection as well as patients. Whatever system of Hospital construction is adopted should provide for easy supervision, at unexpected times.
3. If from 24–30 Patients be the right Number, Sanitarily speaking, for a Ward, the Pavilion Plan should, in a Military Hospital, be so arranged that more than one such Ward should be on the same floor, for facility of Supervision.
3. The more we see of different systems, the more we see the great mistake of giving a Nurse too little to do.
Twenty-four ordinary sick or surgical cases are too few for a Head Nurse.
In a Military Hospital, the proportion of heavy cases is in ordinary times considerably below the average proportion of such cases in a Civil Hospital, open, as the latter is, to accidents, and to the cases of dangerous disease always more or less rife in low and crowded neighbourhoods.
Upon an average, a third or a fourth of the cases in the ordinary surgical wards of a Military Hospital will be ulcers from causes honest and dishonest. What these men will require is rest (the cleanliness which is often so irksome a novelty to the corresponding Civilian patient is routine to the soldier), and very simple treatment.
It is most important, if possible, to form a staff of active, laborious, useful women, who, if ordered on war-service, can at once cope with numbers, and serve efficiently a considerable number of heavy cases.
Relieved of all cleaning, and relieved of the great loss of time incurred by fetching, waiting, &c., &c., none of these Nurses, who are, in fact, Head Nurses, should serve less than forty men. And, as I before submitted, I had rather she served fifty or sixty than forty.
Give them twenty-four patients, and either they will become idle, finicking women, or they will take to petting the patients, a thing to be sedulously avoided everywhere, most of all in Military Hospitals.
4. Importance of the Head Nurse sleeping close to her Ward.
4. The more we see of different systems, the more apparent becomes the importance of the Head Nurse (all these are Head Nurses) sleeping close to the ward:—
As regards the efficiency of her service:—
As regards the saving her own time, strength, and securing her a modicum of comfort in a work where, if she does her duty, she will never have a superfluity of comfort. Time, strength, and this modicum of comfort, enter much into a Nurse’s health—and health is essential both for efficiency and economy.
Where the Nurse sleeps at a distance from her ward, her efficiency, both as to superintendence and work, especially at night, in dangerous cases, is seriously impaired.
If she sleeps at a distance from her ward, her comfort, also, such as it is, is destroyed. Whatever a Nurse does for herself, she must do by fits and starts. A really efficient Head Nurse is never able to make anything for herself, though she often would far rather save the money it costs to “put it out.” The most simple mendings, even the feat of stowing away the laundress’ supply of a Saturday evening, become, when a ward is heavy, or when there are two or three of those cases of urgent danger, so many of which, by God’s blessing, the assiduous care of these women saves, year by year, in our Hospitals, a procedure done in several acts. The misery of dividing her small effects (the smaller the better) between a day-room and a distant sleeping-room, the unseemliness and inconvenience of carrying things backwards and forwards, cannot be described.
If it be possible, the Nurses must sleep adjoining their wards; and it will not do to give each only 24 patients.
It would be considerably better, if feasible, to have two Nurses in contiguous rooms; but in the Pavilion Plan this would involve bringing one Nurse away from her ward; and rather than this, the next best, though inferior plan is to put one Nurse immediately above and below the other, with a distinct bell which she can in a moment ring from her bed into the other Nurse’s room, to summon her if needed.
Importance of Lighting Hospital Wards by Gas, with Sanitary Precautions.
Some years ago gas was laid on in the Sisters’ rooms in Guy’s Hospital. In the other Hospitals there is an allowance of candle to each Sister. The disadvantages of gas are its alleged unhealthiness and its certainly being disagreeable to some eyes. Its advantage is its cheapness. Liberty to buy a candle and not use the gas is allowed at Guy’s. As it will be a very important thing to conduct the Nursing Service as economically as possible, and as there must not be any wretched false economy as to essential matters, which in the end always proves waste, it will be well to save as much as can be in matters not essential. It would be worth while to ascertain the average amount of saving which the substitution of gas for an allowance of candle has effected at Guy’s. Gas is used in the wards of St. Bartholomew’s, St. Thomas’s, and Guy’s, day and night. It appears, when ventilation is properly attended to, to answer well, and to do no harm. At night the gas is lowered so as to leave the ward just light enough to see all that is done in it: if bleeding, &c. occurs, it can in an instant be raised, and the ward lighted up. London Hospital burns gas in the evening, and throughout the passages at night; but when the night watch begins at nine, the wards are dark, except the Nurse’s candle. A spare candle, un-lighted, is always at hand.
It is very important for the order of a ward that the attendant in charge, and also any inspector suddenly entering, should see at once all that is going on in the ward. Where there are dangerous cases, this is of great moment; and where there are not, it is equally necessary for the police of the ward. A candle or a rushlight give insufficient light. Properly lowered, gas at night does not disturb the patients. After a night or two, those who are accustomed to sleep in the dark get used to it. If the Nurse sleeps adjoining the ward, there must be sufficient light in the ward at night. If the gas-fittings are properly tight and if every gas-burner has a ventilator, so that the products of combustion are effectually conveyed away, for each gas-jet consumes as much air as eleven men, it would be greatly preferable that there should be a low gas light in the wards at night.
II.—1. Should it be necessary to serve one Pavilion with one Nurse means by which this could be effected.
II.—1. Suppose the Lariboisière plan retained, as proposed at Aldershot, for a Military Hospital, with wards of twenty-four beds each—then, with fear and trembling, but with the firm conviction that it is better for human nature, most of all, for nursing human nature, to have somewhat too much than a great deal too little to do, I respectfully recommend that one Nurse serve the three wards of each Pavilion.
One woman cannot sleep alone in the Pavilion. The Nurses must sleep together near the Matron’s quarters. If the Nurses sleep away from the wards there should be some way by which a Nurse can at once be summoned, in case of any urgency in her ward, and it would be well to consider this in the distribution of quarters. Either the Matron should lock the Nurses’ quarters at night, and any summons should be brought to her and by her referred to the Nurse; or the summons should go straight to the Nurse’s door. There are difficulties both ways, even supposing these summons should be unfrequent. The Nurse of each Pavilion should inhabit the room on the ground-floor ward, where the heaviest surgical cases will be probably placed, whence she can better command the movements of the Pavilion, and attend the entrance of the Surgeon.
2. Head Nurse’s Day in a Pavilion Hospital.
2. Her day might be something like this (in time, perhaps, God will bless us with some Army Chaplain who will get up early and give us a very short service morning and evening):—
She should be effective, and enter the Pavilion about 6 A.M., go through the wards, read prayers in one by turns at the appointed hour, and give out the linen wanted. (Six is the nominal hour when the Head Nurses of one great London Hospital enter on their duty.) Here must be no nominal hours, all must be real, though not overstrained. Then the dressings, &c., attendance on Surgeons, &c. With 72 patients on different floors, she must train the Orderlies to do the lighter dressings (by training I mean real teaching, not leaving the Orderly to find them out himself); she must see all the wounds of all her wards which she does not dress herself at least every other day (which she can do by seeing some in the morning and some in the evening), and she must dress the heavy cases of all the wards herself. All this, with method, and not losing time by fetching and waiting, an efficient Head Nurse can do.
She must be responsible for the linen of the wards; but this must be simplified as much as can be, so as to secure responsibility, yet relieve the Nurse of unnecessary time spent over it.
The Nurse should be relieved of all writing and counting, on the score of loss of time incurred. It will not do to charge a Nurse, with seventy-two patients on three different floors, with serving each man his portion of diet; the diets of two wards would get cold while she was serving the first. It will be better to make the Ward-Master of Pavilion wards responsible for the serving the diets. There must, of course, be a card at each bed, or some other record, showing the diet the man is ordered. The Nurse must know at a moment’s glance what each patient is ordered.
The largest London wards are the two male accident wards in the London Hospital. Each Head Nurse has charge of five wards of 12 beds, separated (and in some respects impeded) by two lobbies. Very often there are fifteen beds in each ward (not by over crowding), and these Head Nurses are often to be seen in charge of seventy-five patients each, including many serious, and some urgent cases. The two lobbies, the small wards, and the duty of some daily writing and arithmetic in settling the diets, with some daily loss of time in fetching and waiting for medicine, render a Head-Nurse’s service, as regards “manual” labour, less efficient than it might be; even where she is most efficient.
Relieve the Nurses as much as possible of all writing and arithmetic. If it could be possible to relieve them altogether of the “settling” the diets, so much, by a great deal, the better. In the Lariboisière system, with one Nurse to each Pavilion, it is utterly impossible to prevent the Nurse losing daily time and strength on the stairs. But, relieved of writing, of arithmetic, of losing time by “settling” and fetching, such women as it will be our aim to procure can get through the duty of seventy-two patients, although with the serious drawback of their being in separate wards and on separate floors.
If, however, the Pavilion plan were so modified as to have two pavilions end to end, with an intervening staircase, so spacious and well ventilated as to cut off the ventilation of the two wards on the same plane, then all the conditions as to health, and facility of nursing and supervision, would be much more easily obtained. Of this more hereafter.
3. Responsibility of Nurse for Discipline of her Ward or Wards—how Modified in Military Hospitals.
3. As to the Nurse’s responsibility for the good order of the three wards in a pavilion, supposing the three wards are served by one Nurse, there must always be a clear difference between this responsibility in the Head Nurse of a Civil and a Military Hospital. The Civil Head Nurse, whose assistants are all Nurses, who with herself are under the Matron, is charged with, and responsible for, the good order of the ward, and it becomes her duty, the moment she finds herself unable to do this alone, at once to call in the Steward, or equivalent Officer, in whose hands is the police of the Hospital.
The Military Head-Nurse’s Assistants are Orderlies, i. e. men and soldiers, who, with the patients, are under military discipline. Of this military discipline, the military power from the Commandant down to the Non-Commissioned Officers acting as Ward-Masters, &c., is in charge; the duty of the Military Nurse is, I apprehend, in case of any insubordination which she cannot put down at once, to call in the Ward-Master or equivalent, before calling in the superior Military or the Surgical Officer; it being, however, well understood on all sides, that she has the right of direct appeal to the superior Military or the Surgical Officer, if the Ward-Master does not do his duty, or in the event of a grave irregularity, if he is not at hand, besides its being her duty to report such to the Matron, if the case admits of being deferred till that can be done. It is impossible to settle details until the regulations as to the new Hospital Corps are fixed; and whatever regulations, whether for Nurses or for Orderlies are made, some difficulty, and much discretion will be inevitable and necessary in working them. But it is necessary to bear in mind that whereas in the Civil Hospital the Head Nurse, under the control of, and responsible to, the Officers, including the Matron of the Hospital, is solely in charge of both the nursing and the discipline of her ward, both as to patients and as to Assistant Nurses; in the Military Hospital, she is in charge of the nursing, and the Ward-Master of the discipline, both of patients and Orderlies. To be in charge of the nursing, implies to have power to enforce discipline, but this is rather, in ordinary cases, to call in the military power, beginning from the lowest or Ward-Master’s grade and reporting this to the Matron, than to invoke herself the military superiors. Therefore it would be well worth while trying how far it would answer to serve the three wards by one Nurse, who, in each ward where she successively is, is bound, on perceiving any irregularity, to call in the Ward-Master, and, in contingencies, to appeal directly to the Surgeon and the Captain of Orderlies, and to make the discipline of the three wards the charge of the Ward-Master, who is bound to go through the wards when the Nurse is not in them. The Ward-Master, in order to fulfil his charge, must enter all the wards, while the Nurse is in one of them; so that the patients of one ward, who may know that they are safe from the Nurse for half an hour or more, as she is in another ward, know that they are not safe from the Ward-Master.
In a military Hospital we must bear in mind that it is essential that the discipline over patients and orderlies should be exercised by men, and that the Ward-Masters must be the lowest and immediate deposits of this power of discipline.
All these things must be settled with the concurrence of the Director-General.
It is a great comfort that the Hospital staff returns to soldiers. We shall get on infinitely better with them than we could have done with the late Medical Staff Corps, though, after all, in the long run, we should manage with them too. If only God helps us with the sort of women required, thoroughly efficient Nurses, laborious active women, discreet as well as well-conducted, and aware (a little) of the sort of work and place, they are in!—let us trust this to Him, when the time comes, and depend upon it, to give each Nurse plenty to do will become one great means of forming such women—provided, which must be strenuously kept in view, they are made to do it.
4. Importance of Lifts.
4. It is very important to have the system of lifts throughout the Hospital, although here, as throughout, the plan of Pavilions renders them much more requisite, and makes them work less efficiently than the block plan. Lifts, to carry meals and medicine, linen, coals, &c., &c., to and from the first and second floor wards, are very preferable to the Orderlies carrying them up and down. One sort of load ought certainly not to be brought up and down by lifts, but to be carried up and down by men, viz., coffins and the dead. Using the lift for this purpose (as is done in one Civil Hospital) is on all and every account thoroughly objectionable.
The system of lifts is the more important, because although there is no objection to the washing of tea cups, drinking cups, and medicine vessels at the sink in the scullery, it is certainly neither necessary nor safe to wash the dinner dishes close to the sick wards. By a little arrangement, the whole of these could be removed by lifts to a scullery beside the kitchen, and there cleansed and set aside for next day’s use.
III.—1. Casualty Wards for noisy and offensive cases should be separate from the ordinary Wards, and under a completely-appointed Staff of their own—both for Sanitary and administrative reasons.
III.—1. Sanitary necessities can never be interfered with. The concentrating offensive and noisy cases together, while entirely separating them from each other, in a completely appointed set of wards, is a far more efficient working thing than appending a small ward to each ward.
St. Thomas’s (a very admirable Hospital in very many things) has a casualty ward (for such cases) for men and one, adjoining but separate, for women, under the charge of one Sister. Baths are in the wards.
Guy’s had the same provision with, however, the drawback that there was not a Sister in charge, but a Nurse over other Nurses, with higher pay, but not a Sister or Head Nurse. However excellent such a Nurse may be, every ward must be under the same regular government as is general in the Hospital, if discipline and order are not to suffer. Every ward or set of wards should be under a completely appointed staff.
St. Bartholomew’s had a set of casualty wards, including two of about ten beds each, several small wards of two and one bed each, including two with gratings and other melancholy necessary appliances to prevent extremely violent delirious patients from becoming suicides. These wards were often partially empty, never quite so. They were long served like the casualty wards of Guy’s; but some years ago they were placed under the charge of the Sister of the male operation ward immediately above, who received in consequence a small annual increase of wages.
London Hospital sent its noisome, offensive, and extra-infectious cases to its other wards—small wards for one patient each, and, like Guy’s, not under the regular management of a regular Head Nurse.
It most certainly appears that the plan of concentrating these cases together, but with (as at St. Bartholomew’s) small wards where extra-violent patients can be put separately, the whole under one staff of Nurses, is far the best working plan.
And for this reason. Occasionally, a very offensive case requires little nursing beyond the fixed daily dressings, and can lie quietly enough in his bed or ward. But noisy cases almost always, and offensive cases generally, require close watching. Now the moment we have a patient in a little room at the end of the ward, it is our duty to go in and out and see after him, and supposing him to be a violent, delirious case, he is, unless under strong restraint, unsafe alone; and even then the restraint requires looking to. In very many cases the frequent inspection of Nurse and Orderlies would not be enough, and the man ought to have a watcher.
We can never send one of the Orderlies of the ward, wanted for its regular duty, to sit down in one of these little rooms; and we can never keep a fixed extra Orderly idling about, unless the little ward is inhabited. We must then fall back upon extra Orderlies, put in when the case wants close watching—of course not otherwise.
At night, also, the watching which suffices for the ward will often not suffice for the extra case—and he must have a watcher apart.
The plan of extra Orderlies or extra Nurses is a very bad one, to be avoided as much and as long as possible; it very seriously interferes with the discipline of wards.
Recollect that each offensive or extra-infectious case, put into the little ward, ought to represent a great amount of separation and care, which it will be difficult to secure. His mug, utensils of all descriptions, bandages, &c., ought to be washed separately from those of the patients of the large ward. Is this easily secured?
In the two Borough Hospitals they at once remove a case of erysipelas or gangrene, occurring in any ward, erysipelas from venereal wards included, into the casualty ward. In the two other great Hospitals it is only when the erysipelas or gangrene becomes severe that the removal is made. Now at once to remove these cases from the ordinary wards is very advantageous.
St. Bartholomew’s larger wards for male and female casualty cases, two small wards for two patients each, and two grated wards for one each, are very efficient. The wards are all contiguous, and, as has been said, under the charge of a remarkably efficient Sister, who has charge also of the male operation ward immediately above. The little casualty wards, of course, add to the work, and greatly to the anxiety of watching; but certainly violent delirium tremens’ cases, alone and in a secure ward which can be darkened, appear often to quiet much sooner than where several of these wretches lie shouting to and at each other. Delirium tremens will never be a thing unknown in a Military Hospital.
One such case in the little ward adjoining the Pavilion Ward would be a heavy infliction on the severe cases in the latter; the noise would be heard throughout it. And unless the ward were properly secured, or unless the man were under strong restraint—and then that would require constant looking to—he would not be safe a moment alone; while the Orderly was emptying slops or bringing in his dinner, something might occur.
2. Restraint or Non-restraint in Delirium Tremens.
2. Restraint is again a thing which must be left to our masters, and to them solely—but an ugly, sorrowful, little truth may here be told. Restraining and non-restraining processes, and their results may be seen, both where, in the same Hospital, one or more of the Surgeons orders restraint never to be used to his patients, however violent, and others order it to be used in violent cases: and where the rule of the Hospital is to restrain violent cases, removing the restraint so soon as the paroxysm is over, or as soon as amelioration renders the sudden return of paroxysms less likely. I am not speaking of lunatic asylums, but of delirium, particularly delirium tremens, in hospitals. Lunatics occasionally enter the Civil Hospitals, but, of course, as soon as that supreme earthly misery is ascertained, they are removed to the proper refuge. It is my humble opinion and firm belief that mechanical restraint excites a patient much less, and quiets him much sooner, than the prolonged struggle with his attendant’s arms and hands, which must otherwise be resorted to.
The coercion apparatus ought also to be good, not cheap, and always in perfect order. The least thing out of order either causes pain, which when it can be avoided is cruel, or it endangers the efficiency of the whole. The strength and cunning of these patients resembles those of madmen, which for the time being they are.
Restraint renders the usual complement of ward servants able to manage many cases. Non-restraint means that some person must stand or sit by or upon the patient’s bed, and hold and struggle with him often for hours—also that generally this person must be a stranger to the ward. Extra attendants are most injurious to discipline. Could there be a set of casualty or equivalent wards, with its own Head-Nurse, the sick would gain much.
But if necessary to adopt the little ward with every ward—in that case the Nurse must manage the three additional patients—twenty-four or twenty-five are, indeed, too few.
IV. Simplicity of Construction essential to Discipline.
IV. In all Hospitals, let the construction be as simple as it can be. Let its splendour be its lofty airy wards, with plenty of windows; water in all due abundance on each floor; an ample, not excessive, supply of linen, polished impervious walls and ceilings, well-laid and bees-waxed oak floors, and a thorough not excessive, supply of good apparatus of the various necessary kinds. But every unneeded closet, scullery, sink, lobby, represents both a place which must be cleaned, and which must take hands and time to clean, and a hiding or skulking place for patients or servants disposed to do wrong; and of such no Hospital will ever be free. And every cornice, every brass lock or handle, which could be replaced by a plain china or ebony one; every decoration, or flourish, or ledge, on doors, windows, tables, beds, presses, &c., represents either a collection of dust or a great waste of hands, time, and strength in unnecessary cleaning and dusting. These are not crotchets, but the result of close observation of the practical working of these matters. Every five minutes wasted upon cleaning what had better not have been there to be cleaned, is something taken from and lost by the sick. Let the appurtenances of the wards be simple and complete, but as plain and as undecorated as it is possible to be.
Polished Walls.
Polished impervious walls and ceilings are of the first consequence in Hospitals. It is perhaps hardly necessary to state that, if Parian cement be used, it must not and need not be of the kind lining the wards and corridors at Guy’s Hospital, which is as rough as the roughest plaster, of a dark and dirty colour, and which nothing could improve but being lime-washed twice a-year; it should be polished like that used at the Lariboisière Hospital at Paris, and of a pure white.
Covered Exercising Place.
In building a new Hospital, some covered arcade or some place where the patients might take exercise in wet weather, and where inspection could be exercised over them, without fuss, is worth contriving. In St. Thomas’s, the patients walk under the covered arcades of the court.
Reserve Wards.
Both in Bethanien and in the Charité Hospitals at Berlin there are reserve wards,—or rather in the Charité there is a reserve Hospital, into which most of the sick are moved for six months in the year, to change the air alternately of all the wards, which during the time receive a thorough cleaning. Great stress is laid at Berlin on thus providing, when building a new Hospital, a certain reserve space, which obviates the necessity of less efficient and far more costly steps afterwards.
V. Nurses’ Meals.
V. Let us, by all means, consider as settled, that the Nurses’ food is sent them cooked. Possibly, in the long run, the undoubted advantages of this plan will be found to be over-balanced by its disadvantages; but let us begin by trying it. I submit that their dinners, and possibly suppers, should alone be sent them cooked, and that each Nurse should receive a fixed weekly quantity of groceries, and a daily or two days’ allowance of bread.
For packing up the Nurse’s meals sent her from the kitchen, a Vienna custom might be useful. Each Nurse to have a long, strong, straw basket, properly named or numbered. Some contain five dishes and covers, but two or three would here be sufficient for every purpose, including an occasional slice of pudding. The dishes strong tin, with a tin cover, and if the Nurse prefers eating her dinner out of it rather than the dignity of plates, and the trouble of washing them up, the Matron should let her take hers her own way. If taken by hand, two baskets of this sort can be carried with ease. But if the Matron, as a general procedure, sends each Nurse a hot little dinner, of a good well-cooked portion of meat and vegetables, one such dish and cover will do for one Nurse, and three, five, or six can be accommodated out of the same basket, or one large basket, carried by two men, would serve all the Nurses round. The dishes should, in either case, be numbered or named, not the Nurse’s name, but the ward.
A dish and cover of strong, coarse earthenware is used in the Vienna Hospital, as a grander edition of dinner, &c. The tin ones keep warm without fire for a long time. If the meal arrives when the Nurse cannot eat it, put by on the hob, or some provision for warming in the scullery, it will keep warm and good till she can eat it.
VI. Arrangements for a Pavilion served by one Nurse.
VI. Supposing that we serve each Pavilion by one Nurse, I submit that—
1. Nurse’s Day-room.
1. The Nurse’s day-room should be on the ground floor.
2. Ward-Master’s Sleeping-room.
2. The Ward-Master should sleep in his room on the second or highest floor; should the Nurses sleep in the Pavilion, the Ward-Master should still sleep in it.
In the event of the Pavilions being arranged end to end, as already suggested, the difficulty in regard to Nurses’ and Ward-Masters’ rooms would be materially diminished.
3. Where should Orderlies Sleep?
3. I think, but am not sure, that the Orderlies had better sleep away from their wards, but I would leave this to be settled by the Doctors. In cases of sudden outbursts of danger, delirium, or drunkenness, from the results of concealed spirits, and of the Surgeon being sent for, it is useful to have, at once, other than the Night Orderly at hand. And a part of what has been said as to the importance of the Head Nurse sleeping near her ward, applies to the Orderlies. Yet there are important reasons why the Orderlies should not be or feel too much at home in their wards; and if the authorities are disposed to try the plan of lodging the Orderlies together, away from their wards, they are probably right, though I should not be surprised if, after a fair trial, it were found better to revert to the having them near the ward. The Pavilion Plan, which, on the one hand, gives all concerned more liberty of doing wrong than the block plan, and which, on the other, renders it more difficult to call in help, whether of supervisor or of Orderlies, if help is suddenly wanted in the night, makes it the more desirable to let the authorities take quite their own way, as to this.
4. Where should Orderlies Dine?
4. I think the Orderlies had better have their cooked meals sent them into the wards. Of course, they can only eat together in detachments; but in many cases, the absence of even one of the Orderlies would be very inconvenient. Perhaps just as the bell rings to summon to the common meal, something is going on which requires all the ward service; the man either goes late to a cold dinner, or goes away just when he is wanted. If his dinner is brought to him in one of these emergencies, it is put by to keep warm till it is over. Regularity as to meals, as far as possible, should be strictly attended to; and is, in all well-regulated wards: and it is well, where, as in some Hospitals, there is a fixed hour for meals; but it would seem better that the meals should come to the ward servants than the ward servants go to their meals.
5. Should Orderlies be brought together?
5. In the case of Civil Hospitals served by women, it is very important that each Head-Nurse, and each set of Assistant-Nurses, should sleep, eat, and live in the ward and its appertaining rooms, and not assemble together more than can be avoided. With Orderlies the case is partly different. Still I would not unnecessarily bring them all together, any more than allow them to be too much at home in their wards.
6. Should Orderlies have a Day-room in Pavilion?
6. If the Orderlies do not sleep in the Pavilion they should not have a day-room.
7. Scullery to each Ward.
7. To each ward should be attached a scullery, small, but not too small, which only muddles things and work, well provided with cold, and, if possible, with warm water; and it should be law that no patient enters the scullery unless sent there by the Nurse to help in washing up, &c.; and, as a rule, they ought not to be sent there. Make them useful in the ward; keep the scullery for the Nurse and Orderlies.
8. What should be done in the Scullery?
8. From this scullery let the Nurse get the water she requires—Orderlies ditto.
Let the Orderlies eat their meals in it, if they do not eat them away from the ward. The food of the Orderlies is generally different from that of most of the patients, and it answers better for them to eat their meals not under the noses of the patients. In emergencies, of no rare occurrence, the Orderly must watch a patient and eat his dinner at the same time, and so must the Nurse; but, as a rule, it is undoubtedly better that ward-servants should not eat under the observation of the patients.
In the scullery all the cleaning must take place, which is not done in the lavatory.
In the scullery extras are to be warmed, drinks ditto, hot-bricks heated, water-bottles filled, &c., &c., &c., and none of these things are to be done at the ward-fire.
Poultice-making.
On the other hand, there is no way so good of making poultices, a thing humble but important, as for the Nurse to stand at a small table in front of the ward-fire, to make the poultices there, spread them, and forthwith apply them.
Sometimes in a large ward, where the Surgeon orders them extensively, a large iron pot is filled with poultice, and then quickly spread and applied. Sometimes the pot is filled and the poultices spread in the scullery or kitchen, to avoid the mess in the ward. When a number of poultices are thus spread away from the sight of the patients, even by very clever Nurses, some arrive too large, or too small, or too broad, or too narrow; and either the poultice has to be returned, or, as of course usually takes place, to be put on the wound it does not fit.
I would not trust any Nurse, including myself, to make a number of poultices of the right size, unless within sight of the patients. Rather than do this it is better to make the poultice-pot (wood does not hold heat, this must be of iron), in the scullery, to take it into the ward, and there spread and apply the poultices.
But a large iron pot of linseed poultice seldom contains the article nearly so well made, as when made in smaller consecutive quantities in a wooden bowl. The bowl does not keep warm above a certain time. Where the poultice is made in a mass, even by very clever Nurses, it never is so well made as when the Nurse makes the poultices in the wooden bowl. These must be forthwith spread, applied, and the bowl re-filled, if more are wanted.
This is another reason why the person who washes the wound should also make the poultice, as also why the Orderlies should clean the ward, why the Nurse should as far as possible be relieved of all “mental labour,” and why kept as much as possible to “manual labour.” All severe wounds she should wash and dress herself, and many a wound becomes severe, when the patient is allowed to fiddle over it himself. Some wounds will not bear being left uncovered, and of course in some cases the Nurse will wash the wound, and immediately afterwards apply the poultice. In general, the Surgeon will consider the wounds take no harm from being washed all round, and then poulticed all round. This requires not to be over-hurried, and not to lose a moment’s time. A careful Nurse will never apply a poultice without having first seen the wound: carelessness, haste, idleness, over-work, and prudery, each and all produce very sorry results as to this.
I think, therefore, poultices should be made in the ward, and immediately after the table cleared away, and the slight mess also. In some Hospitals they place a straw carpet just round the table, and also carry it to any bed which requires an extra mess in dressing or cleaning.
9. Presses in Ward.
9. A regular store closet is hardly desirable. A good arrangement is this:—
At the end of the ward, nearest the Nurse’s room, or the ward-door, a large press for linen.
By it or opposite it another press, for stimulants, dangerous medicines, stock medicines, such as castor oil and one or two others which are always to be at hand, though not ordered for any particular case, stock lotions (as few as possible), lint, old soft linen, stronger but not coarse ditto for pads, &c., cotton wool, tow, oilskin, splints and pads, &c., &c. Of all these things, the Nurse should always have a certain reserve on hand.
It will be well worth while to see that these presses are made commodiously for their purpose. The linen press should have broad deep shelves, and the different kinds of things should be sorted apart; the other press should have broad deep shelves for the heavier things, and separate shelves for the bottles; the stimulants by themselves in one row, the stock medicines in another, unless these and the stock laudanum were together, but they are better apart, and the dangerous things upon the topmost shelf; another row for sweet oil, mustard, stock lotions, &c., another row for ointments. Each bottle and pot to be distinctly labelled in whatever is reckoned the most lasting manner; opinions differ as to labels and letters cut in the glass. The latter are boring by night, if something is suddenly wanted, and it is just then that mistakes are to be guarded against. A strong clear PRINTED label, securely fastened to the bottle, is preferable, to be renewed when necessary, as Orderlies’ thumbs even while holding a bottle, if the Nurse’s hands are on the bed, wear labels out. There is a great saving of time and of chance of mistakes effected by clearly printing the directions for the administration of medicine, “once,” “twice a day,” “every three hours,” &c., and affixing them to each medicine bottle.
Of both these presses the Nurse should have the key or keys. One key might do for both, but it may be best to have two keys.
It is a very good plan where the shape of all medicine bottles and of those for liniments is distinctly different; and where, e. g., square bottles are used for poisons, or blue bottles for poisons, and square for lotions.
A small narrow shelf over each patient’s bed, or over his locker, solely for his medicines and wine. When these are on the locker it is less convenient. Where the medicines are not dangerous, it is better to have them thus at each bed, than concentrated away from the beds. Dangerous medicines should never be left at a patient’s bed.
The two presses will answer all demands. As, however, it does not do not to have a supply of everything that may be wanted always in readiness, a stand or table in the ward should have upon it a small supply of whatever may be suddenly wanted—a little lint, linen, tow, and two or three vessels. The supply of lint, &c., to be small enough for the Nurse to keep account of it, and for the patients to know that account is kept of it.
“Apparat” in German Hospitals.
In constant daily use in the surgical wards of the great Vienna Hospital is a thing called in Teutonic style “Apparat.” The Nurse carries it round for herself, when preparing and dressing the patients, and carries it after the Surgeon when he makes his rounds. The system of both dressing and washing is in some respects so different from the English one, that the fittings would vary.
This concentration of what is wanted for dressing and washing wounds, and for attending the Surgeon in his inspection of them, and of what is at once wanted on any bleeding, fit, &c., is very useful; all the more from its being in a compact portable form, which can be thus successively carried to each bed. An English carpenter would make a lighter and handier thing. Brass basins, which are there used, are not desirable. Of course, one must be most especially anxious not to introduce any novelty, particularly any foreign novelty, faster than can be avoided, and we may consider it better either to leave the general system unaltered of rushing on some emergency to the dressing table drawer, or closet, and thence bringing successively the things wanted, or at all events not to extend concentration further than the excellent plan, so far as it goes, of the London Hospital, where each Head Nurse attends the Surgeons with a large basket in her hand, containing most of the dressings required, spunges, and one or two little matters also usefully at hand. The apparat has the advantage of carrying with itself the basins used for washing. In the Military Hospital of Vienna a tray attends each Surgeon, without basins.
10. Nurse’s Room.
10. It is important to have the Nurse’s room opening at once into the ward, and, upon the whole, I should incline to its having but one door, although it may be thought better there should be a second, so that she can leave her room without being seen to do so by the patients. Also, by all means, let the scullery be opposite the Nurse’s room, and not between the ward and the room. As an invariable Hospital rule, rather more than elsewhere in Military Hospitals, publicity may be considered to be a very great police, and a still greater protection. It is far better that twenty-four patients should see the Nurse’s door than one or none; and that her room should open full upon the ward than into an intervening scullery.
In contemplating a Military Hospital, we contemplate a place through which, one year with another, all characters, including a few of the vilest, pass. These are not theoretical matters. The more repulsive the subject, the more prevention is better than cure. Guard against too many closets, sinks, &c., &c., &c.
Lavatory.
At the end of the ward there should be a lavatory, with a row, or two opposite rows, of white earthenware basins fixed in a stand, with outlet tubes and plugs: each basin should have a hot and cold water-pipe: and there should be not less than one to each four beds. There should also be in the lavatory a hot and cold water-pipe, from which a portable bath can be filled.
Water-closet.
At the furthest end of the ward should be a water-closet, with not less than one soil-pan to each eight beds: and white earthen or porcelain urinals in the same proportion. In the London Civil Hospitals water-closets are now in general use throughout the wards, but not in all of the great Hospitals. In all the Civil Hospitals, it is usual that the patients’ water-closets have no inside bolt or lock, and that there is only accommodation for one inside. In some London Civil Hospitals the male patients, able to take exercise, are expected to make use of urinals out of doors. These matters one, two, or three experienced army surgeons had better pronounce upon; other things are to be considered than the recommendations of architect, plumber, or even sanitarian.
Sink.
There is in a Berlin Hospital a very useful piece of prosaic apparatus—adjoining the water-closet, a sink, with a high, large, deep, round, pierced basin of stone, above a large hole, into which the contents of a bed-pan can be at once emptied, and from which the bed-pan is at once effectually cleansed. Adjoining this is a sink into which all other slops are emptied. In mentioning this pierced basin or sink solely for emptying and cleansing bed-pans, &c., which is used at the Bethanien Hospital at Berlin, and is far better than emptying the said vessels into the often-occupied water-closet, and then cleansing them in an awkward fashion between the water-closet and the sink, it is necessary to add that the cock ought to extend far enough over the sink for the bed-pan, &c., to be thoroughly cleansed by a stream of water falling directly into it. The Nurse stands at the sink, empties the pail, &c., in it, without fear of splashing, and rinses and fills it, without stirring from the place. Now this absence of splashing water and of moving about from sink to pump, or cock, saves mess and time. The oblong sink, usual in England, has by no means the same advantages.
(The partition containing the sink would be an appropriate receptacle for the bed-pans to hang by hooks or nails on the wall pending their use.)
Baths.
In Civil Hospitals, two baths, in an airy closet at the end of the ward, to be locked at all times when not in actual use, are a very great advantage. Bringing a bath into a ward, which in many urgent cases must be done when the baths are distant, is a messing discomfort. Still it had better be left to surgeons to say whether, in Military Hospitals, it would not be preferable to have, in each ward, only a portable bath, on wheels, covered with india-rubber, to be brought into the ward for any urgent case; and to take all the men able to walk, or safely to be carried, to the Hospital baths. Of these, some trustworthy, or intended and supposed to be trustworthy, man, who ought to rank as a non-commissioned officer, should have charge. An intelligent and respectable-looking man, a serjeant, has charge of the baths in the Garrison Hospital at Vienna.
In a great London Civil Hospital, St. Thomas’s, it is the very admirable practice for each patient (of course with necessary exceptions) to be bathed on his or her admission. The Sisters are responsible for examining each woman in the bath, which is within the female wards, and for at once reporting before suffering them to go to bed, any case of suspected pregnancy, syphilis, or contagious disease. A man does the same for the men, who are bathed apart from the wards. This arrangement is an excellent one. On the other hand, severe cases, just able to be carried to baths, get no good by going through the air, and being jolted up and down stairs.
In planning a Military Hospital, in which the service of women is to be introduced, it is important to obtain the advice of experienced Army Surgeons as to the arrangement of appurtenances of the wards to be used by the patients alone. Endeavour to prevent the system of holes and corners. It is best that the Nurse’s door should command the view of those who come in or out of the lavatory, and in or out of the water-closet. This whole section is both ugly and important.
11. Summary.
11. To sum up. I think it would work the best to have no store-closet, only two well-appointed presses, by which a certain amount of cleaning is saved, and a corner avoided.
Could two cupboards or presses in the wall be arranged for the ward linen and the ward stores, it would be preferable to presses placed against the walls. Take care, however, that the wall is sufficiently thick, so that the presses are not damp, and if this cannot be provided against, keep to presses separate from the wall.
Believe that all this is neither theory nor fidget—but practice.
The furthest end of the ward should contain a lavatory, a water-closet, and the pierced basin for emptying and cleaning bed-pans is a very useful thing. At the other end of the ward, the Nurse’s little room, her door opening full upon the ward. If the upper half were of glass, with a curtain before it, allowing the Nurse to see the ward without being seen, it would be all the more useful. At St. Thomas’s, a window opens into the ward, the Sister drawing a blind when she chooses, and a door opens into the passage, just within the ward doors, opposite the scullery, so that the Sister enters the scullery, in which there is a water-closet, for the accommodation of herself and Nurses, without traversing her ward. Whether door or window, the Nurse should see at once all that is going on in her ward. I prefer a door; yet, if there is to be a ward for one, it may be best and most central to have the Nurse’s window on the large ward, and her door open on the passage. Opposite the Nurse’s room should be a scullery, not too small. The scullery should be well provided with cold, and, if possible, warm water.
If a supply of hot water can be obtained by turning a cock, this is best. Provision should be made in the ward scullery for keeping poultices warm which is every now and then wanted. It is not right to wash eating-vessels and poultice pans, &c., in the same sink; and this should be considered in arranging the scullery. If each ward washes its own bandages, which it ought not to do, the second sink will come in usefully for this. It is worth while, in enforcing extreme simplicity, to prevent jumbling together eating-vessels and things for wounds and sores. Sinks are infinitely most handy when made deep, somewhat in the shape of broad round basins, with hole at bottom; it saves much splashing and mess; the cock to overhang full the middle of the sink. The Wall against the sink should have some protection.
Such a scullery, with complete efficient simple apparatus for its various purposes, places for washing up and cleaning, and for ward purposes and cookery, so that the Nurse can warm the drinks, prepare fomentations, &c., without jostling the Orderlies, who are washing up or cleaning, will be a very great comfort, simplification, and promoter of order, cleanliness, efficiency, and work. At one corner a decent little table for Orderlies’ meals, above it their separate safes for their bread, cold rations, &c., &c.; each to have and keep his key; each to have his locker.
Each floor and ward will require a scullery. It is far better for each ward to contain its own appointments—and all the other stores to be together, apart. On the second floor might be the Ward-Master’s room; vice the Nurse’s room.
12. Nurses’ Sleeping Quarters.
12. Nurses’ quarters, if we are driven to their not sleeping near their wards, should be adjoining the Matron’s two rooms, and separate water-closet, in a part of the Hospital as central as can be managed without trespassing on our betters. I would simplify these quarters as much as possible—either a series of very small rooms, or one great space partitioned off each into a little cell, with a window, bed, washing table, chest of drawers, and a very small wardrobe, with space to hang up three or four gowns, deep enough for another row for shawl, &c., at top a shelf for bonnet and caps, at bottom a deep drawer for boots and shoes. These things will be a convenient riddance to the chest of drawers, and comfort to the women. In each cell very strong hooks to hang up and air a little gowns taken off at night, and one or two chairs. The nurses must wash their hands, &c., in the rooms off their wards, and I think it must be understood as a rule that they leave their quarters in the morning and return to them at night. Optional carpet.
Each cell to be numbered either with number or with name of Pavilion. Opposite this space a small lumber room, wherein each nurse may deposit her box, thereby hindering dissemination of bugs. Opposite also a running open cupboard, with partitions numbered or named as rooms, containing each Nurse’s broom, dustpan, &c., each with a key.
Also pump, sink, water closet.
Furnishing.
When furnishing begins, it will be well worth while to see that all articles of furniture, whether for wards or Nurse’s quarters, admit of being easily swept and scrubbed underneath, and swept and dusted at top. Chests of drawers, &c., with too narrow space between bottom and ground, harbour dust, or sadly waste a few precious minutes in the most busy part of every day. As few high pieces of furniture as possible, to gather dust and be out of easy reach; as few as possible of cumbrous articles difficult to move from the wall, to sweep and dust behind, &c.
There ought to be, near the Superintendent’s quarters, one or two small rooms, where, necessity occurring, sick Nurses might be lodged. We cannot hope always to escape having sick Nurses; and there would be serious objection in a Military Hospital, where only one Nurse sleeps on each floor, to having the Nurse ill in her room for more than 2 or 3 days at the outside. Or there might be one good-sized airy room, with two or three dark washable curtains dividing it into little dormitories, so that one Nurse, whom the Superintendent must engage and watch, could attend them all. And as Her Majesty’s Nurses must have allowed them such decent comfort as can be, but no fastidiousness, I think the cubicles in one room would be best. Not to be called so, however, by any means, as it would sound Latin and “Puseyitical.” The Nurse’s ward to be locked and key kept by Superintendent, except when tenanted. I should hope three beds would answer thoroughly, as well as that the ward would be empty eleven months out of the twelve.
Considering the awkwardness of illness among Nurses, when it did occur in a Military Hospital, it would be worth while that, adjoining the little ward, there should be a little room for any one infectious case which might occur; e. g., supposing one Nurse ill in the ward with bronchitis, it would not do to put another with small-pox into the ward,—at least it would be very impolitic. The ward should have a water-closet and a little sink of its own, and a little cell, but with window and fireplace, for the attending Nurse to lie down in. When not used, once a month’s, or week’s at the most, cleaning by a charwoman would be enough. It should be always clean and ready for use. In the Civil Hospitals, few years pass without sundry Head-Nurses and Nurses dying, not a few Nurses being warded, and sundry Head-Nurses ill in their rooms. The peculiarity of Military Hospitals makes this little preparation for what is certain every now and then to occur seem desirable and economical; to hire lodgings in the neighbouring town would be in all ways a worse plan.
13. Classification of Cases.
13. Endeavour, if possible, to obtain a classification of the severe and non-severe cases, and let the Nurses be only appointed to the wards of severe cases. The convalescent cases to be successively removed to the convalescent pavilions, whether they bear or not that name. No convalescent ward in any of the floors of the Pavilions to be served by Nurses.
14. Nurses to be called by the Names of their Wards.
14. It will be found excellent in many respects not to allow the Nurses’ names to be used in the ward of the Hospital, or among each other, so far as the Matron takes cognizance of. In the great London Hospitals the name of a Nurse is never heard, except occasionally to each other as a solace, partly very natural, partly harmless vanity. She is Sister or Nurse of such and such a ward. In hasty parlance she is distinguished from the others by the name of the ward only. In it she is always addressed as Sister or Nurse.
Thus a Sister of St. Thomas’s Hospital, whose services in the War Hospitals of the East I can never forget, was always at St. Thomas’s spoken of out of her ward as Sister of George, or, more commonly, Sister George; and spoken to quickly or called to in a hurry as George.
All this, the only course of all the great and, I believe, of the smaller London Hospitals, works excellently, in many ways.
15. Foul Linen—how to be Disposed of.
15. Arrangements should be made that foul linen remains for the least possible time out of the laundry. As regards the laundry deposits, the best plan is that of the London Hospital, where each ward has a bin of its own marked accordingly. To similar bins all the foul linen should be, at least, daily carried, unless it is judged best to receive and wash all the linen in a heap, returning numbers only to each ward. The former plan is preferable. In any case the linen of the “foul wards” should be received and washed apart. During the time, which ought to be as short as possible, between dirty linen leaving the patients and reaching the bin or bins, a large box in the scullery is making the best of a bad business—the presence of foul Hospital linen always is that—and is preferable to a closet.
16. Washing Bandages.
16. Washing bandages, a very important thing. Shall a washerwoman be told off for that particular purpose? or shall the Orderlies of each ward do it alla meglio? The former is the better plan; if not adopted, the Nurse must see well to the matter.
17. Splints—Bandages, Lint, &c., where to be kept.
17. It would depend upon what sort of work is usually going on in the Surgical Wards of a Military Hospital in peace whether it will be worth either a press with glass front, in which splints, pads, &c., &c., are excellently arranged, as at St. Bartholomew’s; or the pad-basket and splint-rack, which are also excellent, provided in London Hospital. The splint-rack, enabling the Surgeon at once to see and choose of all shapes and sizes, is perhaps only suited for an accident ward, and would be out of place in a military ward in peace. It may be better to have these stores entirely in some dispenser’s or store-keeper’s jurisdiction, and to let the Nurse confine herself to padding, &c., any splint sent by the Surgeon into the ward. Let our masters take exactly their own way about this.
Bandages, lint, &c., &c., &c. should perhaps rest entirely with the Dispenser, otherwise it would be useful in the greater Hospitals, to have under the Matron a Nurse charged with preparing them and giving them out, writing in a book the date, amount of each, and the ward they are given to. In a small Hospital the Matron could do this herself.
Cotton Lint never to be used.
While speaking of lint, it seems a duty to state that, in some of the Military Hospitals, in certain County and even London Hospitals, and also in Workhouses, and in the practice of private Surgeons, a preparation of cotton has been recently substituted in the dressing of wounds for charpie or Surgeons’ lint, properly so called. So miserable an economy at the expense of the sick is not adopted in several, at least, of the London endowed Hospitals, probably in none. For all purposes for which lint is necessary cotton fibre should be totally disused, in the army and everywhere else. It is irritating and injurious to wounds. It increases human suffering; it delays patients in Hospital, and, in doing so, of course, increases the cost which such a substitution has been intended to reduce. Nurses should be particularly careful never to use this material, which is easily distinguished, even by the touch. Any Surgeon may tell the best of it from lint by submitting it to microscopic examination, and on doing so he will readily discover that characteristic of cotton fibre which renders it so ill adapted for surgical dressings. It does not absorb the discharges from wounds, as linen lint does. The fibre is ragged instead of being smooth, and it is apt to become matted together, and to adhere to the surface and edges.
18. Classification of Women.
18. It is essential to have as few women as can efficiently do their work. Supposing the Hospital were for one thousand patients, not taking into account that some wards would probably be foul wards, where I earnestly hope female service will not be, at present at all events, introduced, and that some wards would be for slight or convalescent cases, where I hope it never will be—supposing each Nurse served seventy-five patients, supposing one Nurse, at the very least, was told off for the linen, fourteen or fifteen Nurses would serve the Hospital. I conclude the Matron to have no cognizance of the laundry.
Superintendent’s Store room.
The Superintendent[18] will require a store room, or at least a store closet, and hers should be well appointed. It would depend upon the other arrangements of the quarters, whether the world in general, when sent for to fetch what it wanted, enter from the same side as the door of the Superintendent’s bed-room, or from the other side. And it would depend upon the nature and amount of stores of which she had charge, in the larger Military Hospitals, whether or not she should have a Nurse told off for this also. Economy is essential; but useless fiddling over every duster or scrubbing-flannel given out, &c., &c., &c., sadly hinders the Matron’s time from more important things.
Housekeepers must be avoided, and every woman must have a distinct and sufficient share of work, and each be distinctly and equally under the Matron. Still it would be advantageous if we could from the first include in the staff of Nurses for the larger Hospitals, one or two places which could be filled by efficient persons who yet were unfitted for the ward work, which calling will be, and ought to be, laborious and wearing enough. Many a woman would never do to look after a Pavilion and seventy-five men; who yet, in charge of linen or stores, would be most valuable, and influence most beneficially the Nurses, whom yet she might be unfit to govern. The system of the Sœurs de St. Vincent, who, in theory and fact, subject entirely to the will of the Superiors in general practice, are yet selected and trained for spécialités, who remain long in these spécialités, which spécialités include such requiring more or less of physical strength, seems to be one giving many useful hints for us.