Note on Contagion and Infection.

There are no words in regard to which there is more misconception, or more nonsense talked and written, than the two words “contagion” and “infection;” and as the word “infectious” has been used in these Notes, it is necessary to say what it does mean, and what it does not mean. The word “contagion” appears to have been first used by certain classical writers to signify the spread of scab among sheep; and it would have been well for humanity if the word had been restricted to this very primitive bucolic signification. It was not till centuries after Virgil’s death that the common sense of men had descended so low as to introduce it into the Medical vocabulary. This took place at a period when, from the neglect of sanitary arrangements, pestilence attacked whole masses of people, and when no one appears to have considered that nature had any laws for her guidance whatever. It was not until human intelligence had descended to this depth that men seem to have bethought themselves of Virgil’s term as affording them an adequate explanation for pestilence, and sufficient reason for not exerting themselves to prevent its recurrence. So it has continued ever since. The little word used in all innocence by the poet for poetic purposes has become the ground-work of every manner of false observation, false reasoning, neglect of sanitary laws, lazarettos, quarantine, and continually-threatened interruption to the commercial intercourse of mankind. No single word has ever done so much harm to the human race, or given such a proof of what a mighty thing a word is!

One would have thought that, after the sanitary experience of the last fifteen years, the word “contagion” would have disappeared from our language; but, even in the last document issued by the expiring Board of Health, written by their Medical Officer, Mr. Simon, and based on erroneous statistical evidence (Papers relating to the Sanitary state of the People of England, 1858), it is stated that “a further—practically speaking, unavoidable—cause of premature death in every civilized country is the risk of its current contagions.” [The italics are not mine.] And this refers to small pox, hooping cough, measels, and scarlatina, the mortality from which we are to presume, is “unavoidable.”

If this be Board of Health doctrine, it is certainly not sanitary doctrine. It would have astonished the Health of Towns Commission, and the first Board of Health.

“Contagion,” as its etymology implies, means the communication of disease from person to person by contact. It is often confused with “infection;” but it has quite a different meaning. Contagion presupposes the existence of certain germs, like the sporules of fungi, which can be bottled up and conveyed any distance, attached to clothing, merchandize, especially to woollen stuffs, for which it is supposed to have a particular affection, and to feathers, which of all articles it especially loves, so much so that, according to Quarantine laws, a live goose may be safely introduced from a plague country; but, if it happens to be eaten on the voyage, its feathers cannot be introduced without danger to the entire community. The absurdities connected with the doctrine are numberless. Suffice it to say that in the ordinary sense of the term there is no such thing as “contagion.” There are two or three diseases in which there is a specific virus which can be seen, tasted, smelt, and analysed, and which, in certain constitutions, propagates the original disease by inoculation, such as small-pox, cow-pox, and syphilis, but these are not “contagions” in the sense supposed.

With regard to the mysterious, imponderable, indivisible nonentities, which make up our “current contagions,” they may safely be dismissed into the limbo of extinct superstitions.

The word “contagion” therefore is altogether objectionable.

The word “infection” expresses a fact, without involving a hypothesis.

It is most necessary, however, that the meaning should be guarded; for, just as there is no such thing as “contagion,” there is no such thing as inevitable “infection.” Infection acts through the air. Poison the air breathed by individuals and we have infection. Shut up 150 healthy people in a Black Hole of Calcutta, and in twenty-four hours you have an infection produced, so powerful that it will in that time have destroyed nearly the whole of the inmates. Sick people are more susceptible than healthy people; and if you shut up sick people together, without a sufficient space and sufficient fresh air, you will have not only fever, but erysipelas, pyæmia, and the usual tribe of Hospital-generated epidemic diseases produced.

Again, if we have a Fever Hospital with over-crowded badly-ventilated wards, or with the air stagnant in them, we are quite certain to have the air become so infected as to poison the blood not only of the sick, so as to augment their mortality, but also of the medical attendants and nurses, so that they shall also become subjects of fever.

It will be seen at a glance that, in every such case and in every such example, the infection is not inevitable, but the simple result of gross carelessness and ignorance. In certain Hospitals it has been the custom to set apart wards for what are called “infectious” diseases; but, in reality, there ought to be no diseases considered such. It follows from what has been stated that, with proper sanitary precautions, diseases reputed to be peculiarly “infectious” may be treated in wards among other sick without any danger; just in the same way as, with proper sanitary precautions, a number of healthy people may be congregated together without becoming subject to the horrors of the Black Hole of Calcutta.

It is in the highest degree probable that we should never have heard of “infectious” wards, if the other wards of a Hospital had been supplied with sufficient space and air for the sick; and in too many cases it is to be feared that the presumed “infectious” cases are huddled away into small, ill-lighted, ill-ventilated rooms, a kind of Lazaretto, in fact, where, if they die, they have at least been kept from doing harm to the other sick in Hospital!

It is high time that common sense should deal with the question; for there does not seem to be much hope for a deliverance from these superstitions from any other quarter.

The “infectious” wards in Military Hospitals correspond, in some sense, to the “casualty” wards in Civil Hospitals, into which accidents, noisy, and erysipelatous cases are transferred, when necessary. The advantages of a separate set of wards for this class of cases have been already insisted upon in these Notes; not certainly because the cases are inevitably “infectious,” but because the segregation of such facilitates greatly administration and nursing, while it removes offensive and noisy patients out of the Hospital wards, whose inmates they would annoy. The question of infection or non-infection has nothing to do with the arrangement. No stronger condemnation of any Hospital or ward could be pronounced than the simple fact that any disease has attacked other patients than those first affected by it. “Infection” and incapable management, or bad construction, are, in Hospitals, convertible terms.

It may be useful to mention what the meaning is of the words “epidemic,” “endemic,” “sporadic,” and “zymotic.”

When a large number of people are attacked simultaneously with the same form of disease it is said to be epidemic. When a small number, as, e. g., the inhabitants of a single court or alley, are so attacked, it is said to be endemic. When scattered cases of the same disease happen, one here, one there, over a large surface, the disease is said to be sporadic. The term zymotic, which includes all diseases of the preceding categories and some others, implies the existence of certain changes in the constitution or in the blood, rendering persons so affected liable to the diseases in question.

It is a vulgar error to suppose that epidemics are occasioned by the spread of disease, from person to person, by infection or contagion; for it is an ascertained fact that, before any people is attacked epidemically, the disease attacks individuals in a milder form, one at a time, at distant intervals, for weeks or months before the epidemic appears. Before an epidemic of cholera, these cases consist generally of diarrhœa of more or less intensity, followed by a rapidly fatal case or two, very much resembling cholera. Even plague itself, as in the recent epidemic at Bengazi, begins with cases which cannot be distinguished from ordinary typhus-fever, the succeeding cases getting more and more intense, until the epidemic seizure takes place. Experience appears to show that without this antecedent preparatory stage, affecting more or less the entire population of a town or district, the occurrence of an epidemic is impossible—the epidemic being, in fact, the last or, so to speak, the retributive stage of a succession of antecedent phenomena extending over months or years, and all traceable to the culpable neglect of natural laws. It is simply worse than folly, after the penalty has been incurred, to cry out “contagion,” and call for the establishment of sanitary cordons and quarantine, instead of relying on measures of hygiène. Epidemics are lessons to be profited by: they teach, not that “current contagions” are “inevitable” but that, unless nature’s laws be studied and obeyed, she will infallibly step in and vindicate them, sooner or later.

In the words of the Registrar-General, which are as applicable to Armies as to States, “Sanitary measures and not quarantines are the real safe-guards of nations.”

Note.

I have just seen a paper by Sir John Hall, entitled “Observations on the Difficulties experienced by the Medical Department of the Army during the late War in Turkey.” In this somewhat singular document, which appears to be a defence of Sir John Hall’s own conduct, there are certain statements made about the female nursing establishment in the East which require a word of comment.

It will be observed that throughout the paper, the weapon which Sir John Hall uses against all civil interference in repairing the sufferings which proceeded from the defects of his own department is simply detraction.

As for Civil Commissions, they were useless, as for Civil Hospitals, they were costly, and their officers lived magnificently and were extravagantly paid. As for the nurses, they were benevolent, pious, well-intentioned persons, but what could they do? How could one woman nurse eighty sick? The medical men thought they could not.

Why had Miss Nightingale stores of port wine placed at her disposal, which she could give to the French Hospitals, while he, the principal Medical Officer of the Army, had no such stores at his disposal?

Sir John Hall must have already discovered that this old weapon is no longer of use in defending his position.

It would have been more to the purpose had he produced his requisitions for food, clothing, comforts, &c., and shown how they were refused or not complied with. At the very time I gave over part of our own private stores of port wine, &c., to the French Hospitals (for part only of what was given were Government stores at all), Sir John Hall might have obtained, out of the large wine store at Balaklava, any amount of wine he required, by merely asking for it. The simple statement of this fact would have been a better answer to M. Baudens[20] than assuming that I could obtain from Government stores and wine for the French Hospitals which he could not obtain for his own.

As to his statement about the Nurses, it simply shows ignorance of the whole matter. Nobody ever contemplated giving to a Nurse the entire charge of a number of sick in a Military General Hospital. It is no part of good Hospital nursing to do so. With proper Orderlies, a Nurse can very well attend to sixty or seventy sick. We were prevented, indeed, by the authorities, and by circumstances, from organizing a proper system of nursing, and were obliged to do all the good possible in the best possible way. But Sir John Hall’s method of estimating the efficiency of nursing, by dividing the number of sick by the number of Nurses, is simply absurd.

Footnotes:

LONDON:
PRINTED BY HARRISON AND SONS,
ST. MARTIN’S LANE, W.C.

PRIVATE AND CONFIDENTIAL.

THOUGHTS SUBMITTED AS TO AN EVENTUAL NURSES’ PROVIDENT FUND.

I. Wages and Prospects of Nurses.

II. Desirability of some further Provision.

III. Of what Nature?

IV. Suggestions as to the Rules to be followed.

V. Prospects of Eventual Support.

I. Wages and Prospects of Nurses.

The two Classes of Hospital Nurses.

1. The nurses of the great London hospitals are divided into two classes: head-nurses or sisters, and nurses or assistant-nurses. These latter are, generally, subdivided into day and night-nurses.

Head-Nurses or Sisters.

2. The head-nurses, on an average, receive about £50 a-year and no board, or lower wages and partial board; the use of one or two rooms, generally unfurnished, and an allowance of fuel and light. Sometimes uniform outer-clothing is included. Sometimes two pints of beer daily are added to the above.

Nurses or Assistant-Nurses.

Day Nurses.

3. The day-nurses, on an average, receive about 12s. a-week and no board, or lower wages and partial board; lodging, with the use of some furniture; sometimes an allowance of fuel and light apart from the use of both in the wards. Sometimes uniform outer-clothing is added to the above; sometimes they have also an allowance of one pint of beer daily.

Night Nurses.

4. The night-nurses, on an average, receive about 10s. a-week and no board; lodging, with the use of some furniture; sometimes an allowance of fuel and light apart from the use of both in the wards. Sometimes they live in their own lodgings, near the hospital, receiving the same wages.

Retiring Pensions and Payments at St. Bartholomew’s.

5. I am informed that St. Bartholomew’s Hospital has no fixed scale of pensions, nor is the term of service defined. But pensions have been granted to worn-out sisters of from £15 to £25; as also pensions of smaller amount to some worn-out nurses.

At St. Thomas’s.

6. St. Thomas’s Hospital, in like manner, has given, without any fixed rule, pensions to worn-out sisters, of from £30 to £50. A gift in money has been granted on the retirement of a sister; and the same has been done in the case of nurses who may have received injuries in the discharge of their duties; and in a very few instances of long and faithful service they have been pensioned.

At Guy’s Hospital.

7. Guy’s Hospital for a long time generously provided for its superannuated sisters, but the plan in practice being found very objectionable, was a few years since given up, and the authorities established a Superannuation Fund for the Servants of the Hospital.

It is compulsory on sisters, optional to nurses, to belong to it. Each subscriber receives a book containing printed rules, with tables of rates of ages, payments, and pensions, and also blank leaves. The subscriber selects the amount of pension for which she wishes to subscribe. At each quarterly payment of wages, a proportion is paid into the fund; entered in the subscriber’s book, and properly attested; the hospital makes a payment of equal amount into the fund on the subscriber’s account. If the subscriber die before attaining the age when the pension begins, the amount paid by the subscriber is disposable by will, and in case of intestacy reverts to the next of kin. The pensions, one-half of which are thus purchased by the subscriber, and one-half presented by the hospital, vary, if I remember rightly, from £15 to £50. In February 1857, no nurse subscribed; to which three remarks apply:—first, that every good work takes time to grow; secondly, that not a few of the sisters, having looked forward to benefiting by the old system of superannuation, rather grudged their own payments than sought to induce their nurses to subscribe; thirdly, that many of the nurses were really unable to make the payment.

At the Non-Endowed Hospitals.

8. The non-endowed hospitals, I believe, but write from very imperfect information, grant few pensions. Sometimes they grant a gift of £25 or less to a retiring head-nurse. Sometimes they employ a head-nurse, become too old for her work, as an extra and inferior nurse. Sometimes they grant a worn-out head-nurse an asylum in the incurable ward of the hospital. I believe the pensions to old nurses are still fewer than the few to head-nurses. Definite information could easily be procured. Their funds do not permit such a diversion from their main and primary object, for which they are often, as it is, inadequate.

At County Hospitals.

9. Of the wages and prospects of eventual provision of the nurses of the county hospitals I know nothing; but understand that the former are lower than, and the latter as entirely blank as those of the nurses of the non-endowed London hospitals.

II. Desirability of some further Provision.

Unfitness of Nurses for any other work.

1. It may be safely taken for granted as a rule, with few exceptions, that a thorough hospital nurse can seldom turn herself to any other business. Her life and work are altogether peculiar; she acquires a knowledge and habits which incapacitate her from all ordinary occupations, grows into fitness for them, and out of fitness for all others.

Shortness of their time of capacity for Service.

2. No less so, that the time during which a hospital nurse can work and lay by, is short, compared with the average duration of other kinds of service. Apart from all excess of their own, their work and its concomitants wear out hospital nurses fast. In every large hospital you will see many women of 40, whom you would suppose 60, and strength often decays as prematurely as appearance. Well-ventilated bed-rooms, more sleep, and better food, would be materially in their favour; but the work can never be other than one which wears out most constitutions fast.

Character of Nurses as a Class.

3. In the London hospitals there are some women of excellent character and of great efficiency; many the reverse, in one or both respects; many between the two classes, who generally end by ranking in the second.

4. To augment the number of the first class, to reduce the number of the second, to induce the intermediate eventually to rank with the first, and not with the second, is the desire of every hospital.

5. It is most important, in all things, in none more than in hospital matters, to moderate expectations, not to hope too much from any measure, or set of measures, and to keep well in view the stern prosaic realities of things. The hospitals of great towns are not asylums where a few or many selected patients can be received and petted; but great receptacles of all sick comers. Their foundations lie down and deep in the human sin and misery for which they in part provide, and the traces of their purpose and nature must ever remain impressed upon them. They are also schools for the practical education of a great profession, important to mankind and dangerous to its members.

Hospital nurses are not women attempting or following “counsels of perfection,” (whatever incorporation of other elements may be eventually effected), but some of those many women whom God has ordained to earn their bread by toil, (and in the large towns of England honest ways of earning that bread are for women but too scarce and too overcrowded), and upon whom He has laid the same condition as on all the souls He has made, to keep the commandments to enter into life. A very mixed class they must ever remain: to improve the class, by God’s blessing, would be to effect a great benefit both to the hospitals and to these immortal souls.

Probable beneficial results of a prospect of eventual provision, depending on character.

6. Among several things which might be done or tried, with the view, if it please God to prosper the endeavour, of eventually improving the class of hospital nurses, the establishment of some definite prospect of eventual provision, dependent upon good character, appears very important.

7. It would tend to augment the number of steady respectable women, who are anxious to keep a good moral and require a good business character, whose aim it is to do their duty, to give satisfaction to their superiors, to keep their places in the same hospital, and eventually to end their days out of the workhouse.

8. It would tend to diminish the number of ill-conducted women, who wander from hospital to hospital; whose wages go in drink or finery, or both; who would be disgusted at the idea of regularly laying by for their future support, and who would resent strict investigation into character.

9. It would tend to induce the intermediate class of women, who hesitate between good and bad companions, to incline to the former, and to break off from the latter, by the favourable result of provident and economical habits on their actual conduct; and by the effect which the prospect of a decent support in their age, dependent upon these habits, would produce.

III. Of what Nature?

Kinds of possible assistance, three.

1. With regard to kind.

There are three kinds of possible assistance.

Pensions.

First. Granting free pensions to efficient and well-conducted sisters and nurses, under fixed regulations.

Facilities for Saving.

Second. Providing sisters and nurses with a secure channel of investing their savings; giving them thus the important assistance of saving their time, trouble, and expense, in obtaining information as to such secure investment.

Additions to Savings.

Third. Combining, with the second, a certain proportion of pecuniary aid.

As to the first. It would be wise economy if the endowed hospitals, who alone could do it, were to grant such pensions; but whether they are likely to do more than they do now I am quite ignorant.

Whether our labours in this field should take the direction of the second or third, is one of the most difficult questions with reference to a thing which is rife with difficulties. Towards solving it, I submit that it would be expedient to employ an able and honest man of business to procure—

Information and Advice to be procured on the Subject.

I. The rules, working, and results so far of the Servants’ Provident Society.

II. Of several of the various partly self-supporting and partly assisted provident societies of the different trades’ and city unions.

III. Of some dozen benefit societies in large towns.

IV. Of Guy’s Hospital Superannuation Fund.

V. To take the practical opinion of two experienced actuaries.

VI. Also of the Treasurer and Matron of St. Bartholomew’s;

It is not possible for Nurses to purchase Annuities out of their Savings.

My impression is that it is not possible, in the majority of cases, for either head-nurses or nurses to purchase annuities out of their savings.

I. Their work wears them out comparatively soon.

II. During its continuance they require to live well i. e., to have a sufficiency of good plain food.

III. They are obliged to put out and pay for either the whole or nearly the whole of their washing, making, and mending (and most properly obliged).

Thus apart altogether from the consideration that many nurses are widows with families, and many others burdened with helpless or infirm relations, and that, in many of these cases, the smallest saving out of their wages is impossible, I doubt whether it can be reasonably expected that, as a class, hospital nurses should lay by out of their unassisted savings a provision for their age.[21]

Persons to be assisted.

2. With regard to persons.

Shall the Fund be open exclusively to nurses belonging to the proposed Institution under Miss Nightingale?

Shall the Fund be extended to private and monthly nurses, including midwives, as well as to hospital-nurses?

I submit that we should consult, on these points, the authorities of the principal hospitals and a few men of experience in business besides. (Philanthropists by trade are, as is well known, the worst possible authorities on subjects of this kind.)

My impression is that the Fund should certainly be extended to the three kingdoms. Whether it should be extended to the empire would depend entirely, in my judgment, upon the check and scrutiny it would be possible to exert, on accounts, monies, and certificates, in distant parts. Upon this men of business should advise.

I think the Fund might eventually be open to private nurses, midwives, and monthly nurses.[22]

I think it perhaps might be open to the St. John’s House nurses and to those of any institution which does not provide its servants with a pension. The Nursing Sisters’ Society, I believe, have recently decided on granting their sisters £20 a-year, after twelve years’ service, a wise, generous, and, if properly worked, economical measure. We must avoid the very appearance of disfavour to other nursing institutions.

Objects to be sought.

3. With regard to objects.

Shall the objects be

Or shall they be restricted either to the first only or the first and second? Here, again, I submit that we should consult hospital authorities and a few men of business and of experience, as to the feasibility, often a distinct thing from desirability, of these things.

Upon the whole, and weighing many opposite difficulties, my impression is strongly in favour of attempting to combine the three.

Material objects.

Material Objects to be sought.

The benefit and provident societies embrace many objects: annuities, payments on illness, payments at burial, provision for children’s apprenticeships, provision for children at death, and other things.

Provision after Superannuation.

I. It appears to me that the main if not the only object of the Fund should be to provide annuities.

During Illness.

II. It would be a question whether or not to arrange for payments during illness.[23] Every now and then ward air gets down the throat of almost every nurse, and every few years or so there is an illness. In many cases a nurse’s pay stops either when or soon after she becomes a patient. Some check upon malingering, a thing well known where the name is not, is essential to every hospital. Of course it presses heaviest upon those who do not require it. After an illness, before returning into the wards, the best thing is a short thorough change of air. Often a severe illness is, and oftener still would be prevented by a week’s change of air, when the peculiar hospital-languor, so well known in hospitals, and so indescribable outside of them, first fairly sets in. The means of change of air, either before or after illness, are often deficient. Still, useful as some such provision would be, in many cases every year, it appears to me so subordinate to the great object of furnishing these women with some provision on their superannuation, that if it in the least impeded or rendered the latter less secure, I should unhesitatingly give it up.

Burial Payments.

III. With burial payments I think the Fund should have nothing to do.

Payments for Children.

IV. As to payments for children, whether on apprenticeship or at death:—Upon the whole, after much anxious thought, I think it undesirable to encourage mothers, as such. This is one of the many points, as to hospitals, where theories and experience differ much from each other.

Reasons against the last Form of Aid.

A very large proportion of nurses are mothers, often widows, with large families, whom they support and put to service out of their wages, too often eked out by improper means, i. e., bribes and petty dishonesty. Many of these women are moral, sober, industrious, and doubly anxious to retain their places, on account of their children; still there are serious embarrassments in employing them. The wages of hospital nurses are not and never can be enough to supply a proper support for children, in addition to the support the mothers ought themselves to have. Consequently when children are in whole or in part lodged, fed, clothed, “educated,” and put to service out of the £50 a-year of the head-nurse, or out of the 12s. a-week of the nurse, the mother either stints herself of proper food, proper strong drink (we deal with practice not with theory), proper warm clothing, for the children’s sake, or she supplies the deficiency by improper means. If the nurse cannot afford to live well and abstains from dishonesty, one of two things infallibly happens—either she takes to drink, as the fallacious support of an exhausted frame, or her strength fails and she breaks down, after a few months’, sometimes a few years’ struggle. When once she has taken to drink, one of two things invariably follows (dishonesty may be presumed to ensue upon, though it often does not precede habits of drink); she is or becomes unguarded, and is soon found out, and sinks into the miserable second and far too numerous class of characterless hospital nurses, unless drink shortly finishes her; or, in the other case, she is cautious and guarded—she then becomes sly, dishonest, and thoroughly venal; she extorts gifts and takes bribes from her patients and their friends—and the friends of hospital patients, like others, are of various kinds; she commits constant acts of petty but often most dangerous dishonesty, possibly remaining an efficient and clever nurse, sometimes a favourite nurse; and, so far as regards the crime which has taken the name of immorality, a moral woman. A certain proportion of nurses are all the above, excepting drink; for though, almost without exception, every nurse who drinks takes bribes, some take bribes and do not drink.

Of course widows and unmarried women who are not mothers do the above things; but there cannot be a doubt of the additional and terrible temptation to women burdened with children, to make money in various ways out of their patients. Even in the most favourable cases (and it is to be feared they are few) where the real good principle of the mother restrains her from venality, there are still serious objections. The time when a nurse can go out must necessarily be comparatively very limited. The time that is enough for the moderate demands of friendship or acquaintance is miserably insufficient for the natural yearnings of the mother, especially if the children are young and helpless. The consequence is that, either openly or by stealth, she goes to them or has them brought to her at unallowed times; or, if the rules of the hospital are lax as to visitors, the children are perpetually with her: and let it be remembered, that the head-nurse’s room or rooms are usually at the entrance of the ward, that being infinitely the best place. It is difficult to say whether such a practice is most objectionable as regards the children, or the patients, or the hospital; and whether it is most objectionable when the children are young, or adolescent, or grown up. It is objectionable in all and every one of these cases. And no less objectionable is it in the case of the assistant-nurse, who where the rules are lax will receive her children either in the ward or in the nurses’ kitchen; or where they are strict, will have the children come about the hospital and will meet them on the sly.

These things enter immensely, minute as they seem, into the discipline of wards and of the hospital; and discipline means a great deal.

Sanitary objects.

Sanitary Objects.

To discourage admission of women physically unfit.

A good many nurses enter hospital service who are quite unfit for it. Often consumptive and ruptured women, those suffering from piles or prolapsus, &c., present themselves, are admitted, struggle on for a time, and break down with or without taking to drink. Undoubtedly, none but strong healthy women should enter hospital service; the work will wear them out quite soon enough, and some of the above complaints are particularly liable to follow the work.

Here again men of business must advise: the fund ought to have some efficient though not infallible security as to the average good health on joining of its members. Life Insurance rules as to this would be to the point.

Believe me, all these things are important.

Moral objects.

Moral Objects attainable.

The most difficult part of a difficult thing, only perhaps it is at the same time the most important.

Need of Certificates.

I. I think that every nurse, before joining the Fund, should produce a certificate from her matron, stating her to be a respectable woman. In plain words, for the word respectable is certainly capable of most wondrous extension, the certificate should state her to be, in the matron’s belief, and to the best of her knowledge, a chaste woman, and should specify whether she be spinster, wife, or widow. In either of the latter cases, the marriage certificate, and in the last that of the husband’s death, should accompany the matron’s.

The matron’s certificate should, I consider, also state her to be sober; and it would be a question whether it should not also state her to have served for not less than a year in the hospital. The vagabond class are a terrible drag upon the whole order; and some of these might, from the novelty of the thing, be disposed to join it at first.

II. An important question would be: Should the matron’s certificate be renewed every year, and should the continuance of the nurse’s membership depend on its production? Men of business must advise as to this: I am quite unversed as to the details of Provident Societies.

So far as regards the contributor’s own money, the contract once entered into, must certainly be open to no further question; unless there has been fraud in the preliminary statement on which it was based. With regard to any assistance that may be given the question is different.

III. The preliminary certificate I do consider very important, and the subsequent ones, if they can be required.

Hospitals are not places for Penitents.

Until the hospitals are swept of the many mothers who are not wives, now unhappily to be found in them, no real good can be done. Hospitals are not, and never can be, places for “penitents;” and they are about the most dangerous places where sham penitents can be.

This is precisely what so many people of very different kinds cannot or will not see; some from ignorance, some from knowledge, some from the vague, silly, kind feeling which does such mischief when exerted on practical matters.

Suffer me to submit, without wearying patience by urging proof,—

i. That real penitents are wrongly placed in hospital service, because their admission breaks down the standard which respectable women who are hospital nurses feel (quite as keenly as their superiors do in their own concerns) ought at once to restrain and to protect those engaged in this very peculiar, very trying, and very exposed work and life. (I have invariably observed that real penitents are extra-prudish, and comparatively inefficient, in their hospital duty. It will at once be perceived how inevitable this result is.)

ii. That sincere but unconfirmed penitents, in addition to the above, are most dangerously and improperly placed in a situation, to them, of very peculiar trial.

iii. That sham penitents, who unhappily abound, are dangerous everywhere, extra-dangerous in hospitals, whether to superiors, companions, or patients.

iv. That although the class must ever be a very mixed one, it is most important to have a standard. Let it be necessary for every nurse to enter hospital with a good character, and to leave it on losing it. Deception, hypocrisy, and successful guilt will be found in hospitals, as elsewhere; but the class must be raised, and therefore improved, by requiring the condition of good character; though guilt may occasionally mask itself behind it.

v. That although, for various and very differing reasons, the certificates will be not unseldom untrustworthy, still the same reasoning will apply. Upon the whole the tendency will be, by requiring the condition of good character, to improve a class which, containing, as it does, many well-conducted women, is sadly degraded and contaminated by many vile ones.

vi. I do not overlook the fact that honest certificates, especially if annually renewed, might give the matrons some perplexity, from reasons which need not be enlarged upon. Still, it seems to me, it would be well worth trying.

IV. Rules to be followed in giving Assistance.

Lastly. With regard to rules to be followed in giving assistance of whatever kind.

Need of Advice with a view above all to Security.

It seems to me most important that we should obtain the opinions both of hospital authorities and of a few able men of business, before laying down rules. The whole matter is so essentially mixed up with the tangible point of securing that the savings of these poor women should avail them in their age, that it is urgent to have sound practical advice as to letting nothing else imperil this. Security seems the cardinal point of the whole, and that is a question for men of business to answer.

Suggestions in detail.

The following suggestions toward obtaining it are offered.

1. Security of invested savings to be the first and main thing to be secured. Every other object should be subordinate to this.

2. If we decide upon aiding their savings, let the security of this aid be the main point. Invest all donations, annual or not; unless, should any hospitals contribute annually, it might be fairly considered that those contributions should be annually used.

3. The aim should be to enable all hospital nurses, of good character, to provide annuities for themselves, whether with or without assistance. I think assistance will be necessary.

4. Also to enable private and monthly nurses, and midwives, to do the same, but without requiring the certificate of character, which, not to be a mockery, ought to be an effectual one; and these persons are not under a fixed superior.

5. The pensions should, if it be possible, range from £13 or £15 a-year to £50 a-year: say £13, £20, £30, £40, £50.

6. Each hospital nurse to produce, before being allowed to join the Fund, a certificate from her matron of chastity, general good conduct, and a statement as to her being unmarried, married, or a widow, also of her having served in one hospital not less than a year. Also her marriage certificate, if a wife, and, if a widow, that and the certificate of her husband’s death. In the event of her marriage or re-marriage afterwards, the marriage-certificate to be produced, and her altered name and the fact of her marriage duly recorded in the Fund-book. (All this is important: aliases and fictitious marriages are sadly common, in this class).

7. If possible the certificate to be produced once a-year, and, on its failure, the contributor to cease to have a title to assistance. Assistance in the form of an addition to the annuity may be made contingent; the annuity which the premiums provide must be absolute: most of the vices tend to shorten life, that is, to diminish the number of annual payments, so that the fund would not be likely to incur losses through them.

8. Private and monthly nurses, and midwives, to produce, before being allowed to join the Fund, a certificate from the Clergyman of the parish, stating his belief that the subscriber is a respectable woman, unmarried, married, or a widow; and in the latter cases, marriage and death certificates. On any after-marriage or re-marriage, certificate to be produced and altered name registered, on pain of expulsion from the Fund. I should not attempt an annual certificate for this migratory and “independent” class.

9. Each nurse, before being allowed to join the Fund, to undergo whatever examination is undergone by women before they are allowed to effect Life Insurances, as to her being, at the date of joining, a healthy woman. (Physicians ought to advise here as to inserting provisions technical enough to be effective).

10. Payments to be made weekly, monthly, quarterly, or annually, as shall be advised. Amounts to run from 6d. or 1s. a week upwards. For the plan to work, it ought to allow small payments on an ascending scale.

Many will only be able to make very small payments.

Few will be able to make other than small payments.

11. Payments made by a subscriber dying before attaining pension to be devisable by will, and in case of intestacy, divided among next of kin.

12. All possible safe curtailment of office expenses.

13. Treasurers, or equivalent civil chiefs, of all hospitals that subscribe, to be on the committee or council, or by whatever name the equivalent may be termed.

V. Prospects of eventual Support.

Support by the Nurses themselves.

1. I believe that many head-nurses would thoroughly appreciate and thankfully avail themselves of such a Fund.

2. I think that many nurses would do the same, and, in time, many more. Many cannot contribute to it; many will not.

Support from the Hospitals.

3. What aid the hospitals might be disposed to give I do not know. I rather think none at first. If the thing works and works well, I think they would probably contribute. But it must never be forgotten that, excepting the endowed hospitals (the financial position of St. George’s I do not know) the London hospitals find their income scarcely sufficient, often not sufficient, to meet their expenditure. They cannot be expected, nor would they perhaps be justified, to curtail the number of the sick they relieve, in order to provide for the superannuated nurses of those sick. It is true, however, that it might enable them to get better nurses, which is surely economy.

Support from the Public in general.

4. I do not think that much lasting public interest is likely to attend the Fund. The interest the public has, for the last few years, taken in hospitals has been fictitious and almost mischievous. The public can never really know what hospitals are, nor is it feasible or desirable that it should. What eventual good may be done in them must be done quietly and with great patience. What good may be done among the nurses must be done by infusing, if it may be, a higher and truer spirit of duty, by increased discipline and protection, and by ameliorating, in some material points, among which the aim contemplated by the Fund ranks very high, a condition which, to the end of time, must remain severe, rough, dangerous, and in all senses trying. In the details of all these things, most especially in all that concerns discipline, which involves protection, the public, with the best intentions, will only be an obstacle, and John Bull is sadly prone to pull up anything he plants or anything he waters, to see how it grows.

I think anything like appeals to or solicited support from the public might, in various ways, seriously embarrass the Superintendent of a very difficult and a very important though, at the same time, a very humble branch of Her Majesty’s Service. I should be very anxious to avoid this: it would be perpetuating the evils of publicity, and sacrificing the greater good for the lesser.

Necessity of Advice.

5. In conclusion I again submit that it would be desirable to ascertain from the hospital authorities above mentioned, and if possible from three or four able and honest men accustomed to business, their opinion as to the scope and details of this plan. In matters of spirit and of discipline we should probably rely on other judgment; but these are matters of business; and in which, without binding ourselves to follow, it seems most important to obtain and to weigh, the opinions of men long conversant with business.

January 23, 1858.