Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and War

by Florence Nightingale

When the question of ventilation first assumed a practical shape in this country, it was supposed that 600 cubic feet of air per hour were sufficient for a healthy adult, in a room where a number of people are congregated together. Subsequent experience however has shown that this is by no means enough. As much as 1,000 cubic feet have been found insufficient to keep the air free from closeness and smell; and it is highly probable that the actual quantity required will ultimately be found to be at least 1,500 cubic feet per hour per man. In sick wards we have more positive experience as to the quantity of air required to keep them sweet and healthy. It has been found in certain Parisian Hospitals, in which the ventilating arrangements were deficient, that pyœmia and Hospital gangrene had appeared among the sick in consequence. These diseases disappeared on the introduction of ventilating arrangements, whereby 2,000 cubic feet of fresh air per bed per hour were supplied to the wards. Notwithstanding this large quantity, however, the ward atmosphere was found not to possess sufficient freshness or purity: and the quantity of air had to be increased in subsequent ventilating arrangements. As much as 4,000 to 5,000 cubic feet per bed per hour have been supplied in certain Hospitals. At the rate of 4,000 cubic feet, the ward atmosphere is found perfectly fresh.

Night Ventilation.

At one of our largest London Hospitals it will be perceived that above the one door of each ward is a large ventilator, ordered to be open day and night—that beyond this ventilator, which opens into the landing-place, is a large window which opens into the external air; and thus admits fresh air into the ward at night, diminishing the foul night atmosphere. This night ventilation system is good; but it requires careful watching, as chilly patients, Nurses, and sometimes Sisters, are very apt to give, after they conclude the rounds are over for the night, a sly pull at the rope and to shut the window, and thus imbibe the foul air directly generated, in quiet.

Special Wards, whether desirable or not.

15. Special Wards.—It may be laid down as an axiom in the management of sick affected with certain zymotic diseases, such as fevers, cholera, dysentery, &c., that they should be distributed over a wide superficial area, and have a large allowance of cubic space. Agglomeration of such cases in small ill-ventilated wards is quite sufficient of itself to occasion a high proportionate mortality among the sick. In mild climates and seasons very little protection is necessary from the change of temperature; so that the sick from epidemic diseases can be camped out and exposed to the full influence of the atmosphere, not only without danger, but often with great benefit. It is only when the temperature is low and variable, and the season inclement, that danger is likely to accrue from this exposure. And hence the necessity of inquiring how we can best combine the requisite elevation of temperature and the most suitable amount of cubic space and ventilation for the treatment of these diseases in Hospitals.

Medical Men generally are satisfied that these ends cannot be safely arrived at by agglomerating sick in fever wards in Hospitals. And hence has arisen a practice, which experience appears to have approved, of intermingling a small number of fever cases in wards containing a certain number of sick from other diseases. The practice appears to be not only perfectly safe, but advantageous for the sick. It is known, however, that if the proportion of fever cases exceeds a certain number, the other cases in the ward are apt to become affected with fever. It would appear as if, so far as the fever is concerned, the cubic space occupied by other diseases was to a certain extent available for the use of the fever cases. But the proportion of such cases, that can be advantageously placed among the general sick of any ward, will depend upon the size of the ward, the means of ventilation, the number of cubic feet per patient, the position of the windows, the exposure of the building, and other similar circumstances.

Again, it is doubtful whether the preservation of an uniform temperature in any Hospital, even in one set apart for chest complaints, is beneficial for the sick, or whether it be beneficial to agglomerate consumptive cases, without very special precautions, under the same roof. Without discussing the validity of the opinions held in Southern Europe as to the contagious nature of consumption, it may be very fairly doubted whether a number of cases placed under a common roof, and breathing a common atmosphere, would not yield a higher rate of mortality than the same cases would do if distributed through the wards of a well-ventilated Hospital, among other diseases.

The subject is worthy of examination. At all events the phenomena observed in this disease in the warmer climates of Europe have led to the popular belief above stated; and it would appear to point to a higher rate of mortality as a not unlikely result of the establishment of special Hospitals or wards for consumptive diseases, unless extraordinary care were taken to ventilate them properly, and to imitate the natural variations of temperature which appear to be necessary for recovery.

16. Proposed Regulations as to Payments, by Superintendent-General.