(9.) Regulation as to 1 Orderly to 10 Patients requires modifying.(9.) The Regulation number of one Orderly to ten patients therefore requires modifying. Practically it is broken every day and in the extraordinary manner above mentioned, which gives the most critical cases to be attended by the rawest hands.(10.) One Orderly should be theFrotteur.(10.) The question of Hospital floors will be fully discussed farther on. An Orderly should be trained to be thefrotteurto each ward. He should also be the porter to fetch and carry every thing to and from the ward.(11.) Comparison of Cost of Nursing with larger and smaller Wards.(11.) The plan of Netley, with its wards for 9 sick, is by far the costliest for administration, as the following facts will prove:I. It is proposed to provide the Hospital with Orderlies and Nurses to conduct the nursing in wards of 9 sick, as mentioned.II. On sanitary grounds wards may safely be large enough to accommodate 25 to 30 sick.We may therefore choose the larger wards, being guided only by the cost of the nursing.III. A ward of 9 sick would require 1 day and 1 night Orderly, and a-third of a Nurse (that is, a Nurse could superintend three such wards.)A ward of 30 sick would require 2 day and 1 night Orderlies and 1 Nurse = 4 persons in all.Or if two such wards were on one floor, 1 Nurse could serve both.IV. We cannot count the cost of Orderlies and Nurses, including lodging, rations, wages, at less than£50a year, which when capitalized at 3 per cent. (33 years’ purchase), would amount to£1,650for each.V. A ward of 9 sick would cost in nursing£1,650× 2⅓ =£3,850, or£427 15s.6d.per bed.VI. A ward of 30 sick would cost for nursing, in perpetuity,£1,650× 4 =£6,600=£220per bed.[One Nurse to each ward is here allowed.]VII. The cost of the two plans relatively for a Hospital of 1,000 sick would stand thus:Wards with 9 beds=£427,775Wards with 30 beds=220,000Capitalized difference of cost infavour of large wards}£207,775Netley has cost already Land=£30,000Works89,000£119,000It hence appears that, if works and site were both sacrificed, and fresh land purchased, and wards for 30 sick built on it, the country would actually save the difference between the two sums of =£88,775.Suppose the sanitary requirement of 25 sick to a ward, which is the best number, be combined with the greatest economy of administration, the cost would stand thus:For each ward of 25 sick, 3 Orderlies, at£1,650=£4,950If two such are built in line, close to each other, with the Nurse’s room between them, one Nurse could superintend both wards, or half a Nurse to a ward. The cost would be for the ward8255,775Or cost for each bed 5775 / 25=£231The comparative cost of wards with 9 beds and 25 beds, would stand thus for 1000 sick:Wards with 9 beds£427,775Wards with 25 beds231,000Saving£196,775Deduct cost of Netley, already incurred119,000Saving from abandoning Netley=£77,775The cost of the administration per 1000 beds at Netley and Aldershot would stand as follows:Netley£427,775Aldershot, pavilions, with 3 superimposed wards and 25 sick in each, would require 3 Orderlies and 1 Nurse[14]to each ward, and would cost£264per bed in perpetuity, or per 1000 sick264,000Difference of cost in favour of Aldershot£163,775Some abatement would have to be made, as regards the cost of Netley, as there are a few wards with 16 or 18 sick.If we take money at 4 per cent., the calculation will be as follows:Small wards, 2 Orderlies and a third of a Nurse, at£50per annum; money at 4 per cent., per 1000 sick£324,000Wards of 30. 3 Orderlies and a Nurse, money at 4 per cent., per 1000 sick166,000Extra cost of small wards158,000Cost of Netley119,000Saving in giving it up£39,00013. Hospital Floors.13.Floors.—In building a new Hospital or laying a new floor we shall hope to see, by degrees, everywhere introduced the only safe Hospital floor. In the expense the difference between oak and the best white deal ought never to be considered. The staircases and passages should always be of stone. When once an oak floor is well done with bees’-wax it is no longer an absorbing surface. There cannot be a doubt that the frequent washing of the floors, in London Hospitals, is one main cause of Erysipelas and Hospital Gangrene.But, with regard to deal flooring,—(1.) The best way with a pine floor already laid is to close the joints, plane the surface quite smooth, and then saturate the wood with beeswax and turpentine, either at once, or after the wood has been saturated with “drying” linseed oil well rubbed in.(2.) Enough beeswax should be used to fill up the grain of the wood, and rubbing with a brush will then smooth the surface. It will be polished somewhat, but not slippery. The amount of polish depends on the brushing.(3.) The surface should be kept clean by using a brush with a cloth tied over it, and if offensive liquids are spilt, they should be immediately removed, the surface washed with soap and water, and immediately dried.(4.) List slippers, which ought to be part of Hospital furniture, effectually obviate risk of slipping. It would hardly be possible, however, to make deal floors as slippery as oakparquet, because the surface (except of very fine deal, such as is used for musical instruments) never takes so high a polish.(5.) Dry rubbing, which is done with sand, or with sandstone, is not well adapted for ordinary sick wards, on account of the dust; unless it be very carefully done. The rationale of it is to remove a certain amount of the surface of the floor. It answers very well on board ship. A certain amount of surface cleaning may be done by rubbing with a hard short brush; it is, however, defective. The wood becomes in time saturated with organic matter, and only wants moisture to give off noxious effluvia.(6.) Scrubbing is absolutely objectionable, for this reason. In any schoolroom, reading-room, institute, which is much inhabited, a smell, while the floor is being scrubbed, is very perceptible, quite different from that of soap and water. It is the exhalation from the organic matter which has entered thefloor from the feet and breath of the inhabitants. How much more dangerous this in Hospital Wards need hardly be said.There is atBethanienHospital, at Berlin, a very admirable flooring, which would be worth trying in England. The floors throughout are wood, prepared in the following manner:—The floor is first oiled with linseed oil, and then rubbed over with a peculiar “laque” varnish, the technical process of which will be found in the note,[15]and polished, so as to resemble French polish. Every three years or so the rooms and wards are successively emptied for a fortnight, when a new flooring is laid, re-oiled, varnished with the laque varnish, and thoroughly dried. Every day the floors are wet-rubbed by means of a piece of sacking or coarse webbing at the end of a long, hard broom, the performer stands for the performance, also while immediately afterwards, having wrung the sacking completely dry, she goes over the ground again with the dry sacking. One, or, in case of the weekly extra wet-rubbing, two dry rubbings, dry the floor completely in a few minutes from the cessation of the wet-rubbing, never more than ten minutes. Three or four times a year the ward floors are thoroughly wetted with water thrown on, and the floors scrubbed with a long brush. Neither soap, soda,&c., is used.The great advantages of this are:—(1.) That it purifies the air exceedingly and freshens the wards.(2.) That it reduces the daily accumulation of dust to a minimum.(3.) That it dries completely within ten minutes from being wet-rubbed.(4.) That a woman, standing, can thoroughly clean a ward with some hours less time, and greatly less fatigue, than scrubbing.(5.) That wet scrubbing is sometimes and ought to be always forbidden and dry rubbing substituted, on the score of the unhealthiness of scrubbing.(6.) That it would relieve us of all external scrubbers in the Nurses’ own rooms. Each Nurse would sweep, wet-brush and dry-brush her bed-room and day-room herself, daily, would once-a-week give a little extra wash, and would wash the wooden skirting which runs along the bottom of the walls. As the bed-room must be tiny and the day-room small (it would be better if we could keep to one room, which would take a quarter of an hour daily, and the grand weekly purification not more than one hour, even to a slow performer) a short time daily and a moderate time weekly will do it.One disadvantage of this very simple, very efficient, and excellent flooring is, that it shows scratches. Furniture must always be lifted, not dragged. In a Military Hospital where men are always at hand, this would matter less as to the wards, and the Nurses could help each other once a week in their bed-rooms, and manage alone in their day-rooms.There are four other examples of this flooring in Berlin Hospitals.(1.)Bethesda Siechenhaus, a small old house, about to be rebuilt and enlarged, in a suburb of Berlin, where three Deaconesses, with a man and woman servant, take excellent care of about forty infirm old women and imbecile children. These patients, of the class to be found in the infirmary wards of our workhouses, move about little, and have few visitors, so that the flooring, which is the same as atBethanien, is less used.(2.)St.Hedwig’s Hospital, where 250 male and female medical and surgical patients are nursed by Roman Catholic Sisters ofSt.Charles Borromæus (head quarters at Nancy), with female servants and male nurses. The house is new; the flooring the same as atBethanien. The Superior, an intelligent German, speaks much of its excellence for hospital purposes; it is being introduced, though as yet very partially, into France.(3.) The greatCharitéHospital, the town-hospital for 1,200 patients, spite its French name. It consists of two buildings; the old one, used in winter; and a splendid new one, into which all the patients, except the lunatics and the small-pox and the venereal cases, are moved for the six summer months. The flooring throughout is of the same wood (deal) as atBethanien, but has much more laque. The more laque is used, the brighter the floor shines, but the sooner it requires re-oiling and laque varnishing. TheCharitéfloors are re-oiled with laque every year; they are cleaned in the same way as atBethanien, only with more dry rubbing. On bad days, when the numerous students have passed through, the ward floors occasionally require to be cleaned; but, in general, even on these occasions, it is enough to sweep them, and to clean the next morning as usual.(4.) The principal Military Hospital, theGarnison Lazarethin theHirsch Allée, for 800 patients, usually not filled. The flooring is the same as atBethanien, except that no laque is used. It is oiled generally, not always, yearly.TheOber Inspector, aLandwehrcivilian, who is supreme over the Hospital, and anOber-Stabs-Arzt, both speak very strongly as to the superiority of this flooring over all others for Hospital use, and in particular over flooring which requires scrubbing. It has only been introduced of late years. They consider it equal to any amount of hospital wear and tear. The military patients, like those of theCharité,Bethanien, andSt.Hedwig’s, wear hospital slippers, with soles thick enough to admit of their walking in the garden, when fine; when not fine, they are not allowed to go out. This flooring would not stand the constant tread of nailed shoes. But often, on bad days as on fine ones, great numbers of soldiers come to visit their sick comrades, and leavethe floor very dirty; generally it is enough to sweep the floor after the visitors are gone, and to clean it as usual next morning; sometimes it is necessary to clean it the same afternoon.The flooring is cheap. Somewhat more expense attends laying it down than the ordinary boards, and a certain expense attends the re-oiling, but the constant outlay for soap and soda is entirely saved, except a little soda in the grand annual purification, with hot water, in addition to the daily one with cold; the time and labour attending scrubbing is saved, and above all the great gain to the sick arising from its use is secured.The strong, decided way in which the old grey-headed Army Surgeon, and the middle-aged business-looking Civilian, spoke of the merits of this flooring, and of its capacities, was exceedingly satisfactory.(5.) Two years ago the greater part of the boards in theKaiserswerthInstitution, which are of deal, were oiled, both on sanitary grounds, and to rid the Sisters of the drain on time and strength in scrubbing. They are considered far preferable to the old ones, and to answer in every respect. Yet theKaiserswerthfloorings would not answer the English requirement of extreme cleanliness. They are substantially clean, but, like those of the Military Hospital of Berlin, it takes examination to ascertain that they are so, and from the same cause—there is no “laque.” Also the colour is not at all so agreeable as theBethaniencolour. These oiled boards last a year only. A moderate amount of laque is required to add to their durability.The sum of the information, condensed as much as possible, on this subject is;—I.The boards, which are always of deal, can be prepared in three ways:(I.) Laquering, only suitable for reception rooms, or when by some chance a ward is wanted to be got ready in a hurry; it takes less time; after two or three days, the room or ward can be used, and it shines brighter, but it lasts a much shorter time than the other procedures, as it stands less the incessant treading incident to all ward floors; it is also more expensive. Let us consider it wholly unsuitable for wards.(II.) Oiled boards, with more or less laque.TheCharitéboards have a great deal of laque.TheBethanienandSt.Hedwig’s boards much less.(III.) Oiled boards without any laque—As in the Military Hospital.II.Much laque makes the floors shine brighter; requires more time to clean them; and earlier re-preparation than where less laque is used.TheCharitéboards would be unmeaningly splendid for an English Hospital, and quite out of place in a Military one; besides entailing some unnecessary annual expense, and some daily finicking care.III.A small quantity of laque, as atBethanien, gives an amount of polish to the floors, which enables the eye at once to ascertain whether they are clean or not; considerably improves the appearance of the floor; and, according to all high authority, adds both to the durability of the floor, and the healthiness of the Hospital. It renders the whole flooring less subject to cracks, to dirt and dust getting into holes and corners; and, above all, by filling up the grain of the floor, it prevents the saturation, by organic matter, which otherwise takes place and which scrubbing only makes more mischievous.IV.Where no laque is used, the absence of all polish on the dark-brown floors makes examination necessary, to see whether they are thoroughly clean or not. This flooring would never satisfy the eye or the mind of an English Inspector-General or Surgeon. But the main objection to the absence of laque certainly consists in the sanitary one above stated.V.All the various authorities agree in estimating very highly the superiority of this flooring to flooring requiring scrubbing. They all agree in their reasons for this preference, viz.:—(I.) The dampness which remains in a ward more or less time after it has been scrubbed, is completely avoided.(II.) The tendency to miasma is greatly counteracted, both by getting rid of the damp, which encourages and spreads the exhalation of the organic saturations; and by making the floor impervious, preventing dirt, and with dirt miasma, finding its way into holes, chinks, and corners of the floor.(III.) The mode of cleaning this flooring, while it avoids damp, daily purifies the ward air.(IV.) The floor, and its mode of cleaning, get rid more than by any other way of dust, and of the miasma dust often conveys.(V.) The time, labour, and expense of scrubbing are saved.(VI.) The Berlin authorities consider that these oiled boards, with a small quantity of laque, are, on the whole, decidedly cheaper than the common boards; that the boards last rather longer; and that the avoidance of scrubbing saves more than the extra preparation and its renewal cost, apart from the sanitary gain.VI.Against these advantages, the following disadvantages are to be placed:(I.) This flooring shows where most used, instead of the uniform appearance of the white scrubbed boards.(II.) Scratches show, and remain upon it; so all furniture must be lifted, not dragged over it.(III.) The tread sounds a little more, little, but more, than on white boards.(IV.) It would not stand the constant tread of nailed shoes; and patients of a ward so floored, ought to wear slippers with moderately thick soles. (The German Doctors consider the use of slippers preferable to that of shoes, by the patients, as keeping a ward much quieter, cleaner, and disturbing the severe cases less.)(V.) Carpets could not be nailed on it, as the floor should be daily cleaned. Several Hospital authorities whose rooms are thus floored, have large pieces of carpet round the furniture most used, bed, tables, sofas,&c.; these are daily taken up and dusted while the floor is being cleaned. To many English minds, the sight and feel of a carpet is essential to the idea or feeling of comfort; and it might be sound policy, in the event of a trial being made of this flooring, to leave the Officers, Military and Medical (I do not mean patients), in possession of scrubbed rooms and carpets. The Superintendent might have one or two pieces of carpet for her rooms; and the Nurses should dispense with carpet.Both in the new part of theCharitéand atBethanien, long broad corridors run along the back of the wards which open into them. The corridors are floored like the wards. In those of theCharitéa piece of long carpet is laid in the midst of the corridors, where patients walk not a little. AtBethanien, along piece of matting is laid in the midst of the corridors, where the patients walk freely. Carpet of either kind is not considered to benefit the floors, but to diminish the noise. In the wards of Guy’s Hospital, for the same reason, a long piece of matting is laid along the middle of the floors.VII.This flooring is unsuited for stairs, though so used in some Hospitals, as, in case of fire, oiled wood would burn rather quicker than common wood. Hospital stairs should be of stone.VIII.It is also unsuitable for kitchens, wash-houses, water-closets, and sinks. The floor round a stove or fire-place in a ward or room should be protected by a strong plate of lead or tin.It might also be as well to floor operation-rooms with flooring, admitting of scrubbing, because these oiled boards do not well stand sand or bran, and our Surgeons might be discomposed at missing one or other of these things. Sand or bran mixed with blood would make a mess, the traces of which would show a little on this flooring. For the rest, it is particularly easy to wipe blood off it. After each operation, one or two minutes, a wet cloth of the kind here mentioned, and a broom, remove the blood that has fallen, and leave a clean floor; or if there has been a very great mess, five minutes, a wet cloth to lap up the blood,&c., another wet cloth, a pail, and a broom, do all: after the operations are over, a few minutes’ whole or partial cleaning, as the case may be, make all tidy again. Still, many English Surgeons expect to have sand or bran thrown on the floor before, or just after the first blood has fallen, and might object to standing some minutes on the bloody floor, which spoils boots,&c.Red floorcloth, of sufficient size, round the operating-table, might answer every purpose.IX.On laying down the oiled boards for the first time, six weeks should pass after the oiling and laquering before the ward is inhabited.X.After subsequent re-preparation of the floors, the longer the wards are left vacant the more the floor both hardens and shines; but for practical purposes the interval of a fortnight is enough.XI.The flooring, so prepared, or re-prepared, ought, on an average, to last about three years. In case of any extra miasma, it is often desirable to hasten the re-preparation, and to have it done after two years’ use. To do it annually is, unless in some emergency, quite unnecessary.Although the process cannot be said to be by any means perfect, on account of the deficient durability of the surface, it would be well worth while to try it in England, and, if it answers and if it were improved, the sick would gain much, and the Hospital staff would gain much—the latter much more even in Civil, than in Military Hospitals.But it would be incurring a great responsibility to have the whole of a large new Hospital floored in this way, because,I.An English climate has made, and makes, so many things which are good and suitable abroad, unsuitable and sometimes pernicious for England.II.Our coal-fires, whether assisting or assisted by our atmosphere, certainly give us an amount of soot and dirt unknown abroad. At Berlin, all fire-places are stoves, where sometimes coal, sometimes coal and wood are burnt.This flooring might not stand well either the damp climate, or the smoky atmosphere and amount of flying soot of England: but it would be well worth trying; as also trying to improve it.By all accounts, a great deal depends upon the manner in which these boards are prepared; a little more or a little less, whether of oil or laque, makes a great and lasting difference. It would never answer to make an English carpenter or painter do this from written or printed directions.If we obtain a trial of this floor—the best course would be, to let an English carpenter prepare a number of boards and skirtings, of due size, suitable for the new flooring of some few wards in one of Her Majesty’s hospitals, which requires new flooring; then to desire either the proper tradesman, or the Queen’s Minister at Berlin, to order the house-painter,Schonby, No. 5,Michael Kirchplatz, Berlin, to send an experienced, trustworthy foreman, with the proper tools and materials, and for this man, with a complement of English workmen, to prepare the boards.The mode of cleaning is extremely simple, though of course there is a knack to be learnt; and, like everything else, it can be done well, indifferently, or ill. Any English man or woman accustomed to cleaning would understand the thing in one morning, and would, if he or she opened instead of shutting the mind to the outlandish thing, be proficient in it in a week. All these things sound abstruse on paper, and are far more simple and more easily learnt by seeing done than by reading. The foreman ought to give one or two lessons to one or two Orderlies, or Nurses, as the case may be.14. Ventilation of Wards.14.Ventilation.—The amount of fresh air required for ventilation has been hitherto very much underrated, because it has been assumed that the quantity of carbonic acid produced during respiration was the chief noxious gas to be carried off. The total amount of this gas produced by an adult in 24 hours is about 40,000 cubic inches, which in a Barrack room of 16 men would give 370 cubic feet per diem. Allowing 8 hours for the night occupation of such a room, when the doors and windows may be supposed to be shut, the product of carbonic acid would be 123 cubic feet, or about 15½ cubic feet per hour. This large quantity if not speedily carried away would undoubtedly be injurious to health; but there are other gaseous poisons produced with the carbonic acid which have still greater power to injure. Every adult exhales by the lungs and skin 48 ounces or 3 pints of water in 24 hours. Sixteen men in a Barrack-room would therefore exhale in 8 hours 16 pints of water and 15½ cubic feet of carbonic acid in the atmosphere of the room. With the watery vapour there is also exhaled a large quantity of organic matter ready to enter into the putrefactive condition. This is especially the case during the hours of sleep. And as it is a law that all excretions are injurious to health if reintroduced into the system it is easy to understand how the breathing of damp foul air of this kind, and the consequent reintroduction of excrementitious matter into the blood through the functions of respiration will tend to produce disease.This will be still more the case in sick wards overcrowded with sick, the exhalations from whom are always highly morbid and dangerous, as they are nature’s method of eliminating noxious matter from the body, in order that it may recover health.A much larger mass of air is required to dilute and carry away these emanations than is generally supposed. And the whole art of ventilation resolves itself into applying inany specific case the best method of renewing the air sufficiently, without producing draughts or occasioning great varieties in temperature.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 doubtedwhether 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.16. All salaries and wages of Matrons and Nurses should be paid, on the Superintendent-General’s order, from the Hospital chest, to the Matron, who should pay the wages and other expenses of the Nurses, and account for all monies received by her on such orders. All outfits and travelling expenses, in cases of transfer,&c., should be provided on the order of the Superintendent-General.Opinion as to Superintendent-General paying Wages and Salaries.There would be considerable difficulty in the way of making all payments at a distance to Nurses, direct from the Superintendent-General, otherwise than by orders on the Hospital chest or Treasury. But there can be no doubt that the Nurses ought to be paid by the Matron and by no one else. The service of Nurses in Hospital is a peculiar service, and if not successfully conducted by influence never can be by coercive discipline. It would be a great mistake, therefore, to throw away any means of influence which we can command, and the “eye of the maid-servant is to the hand of her mistress” now as it was 2,000 years ago. The fact of paying and being paid helps greatly to establish the proper mutual relations between the superior and the subordinate. The Matron would draw from the Hospital Treasury, on the orders of the Superintendent-General, and would account to her. As a matter of discipline, it would make no material difference whether the orders of the Superintendent-General, in favour of the Matron, for the pay of the Nurses, are cashed by the Hospital Treasurer or by a banker, always supposing that the Treasurer is bound to honour those orders, as any other banker would.Matrons abroad may dismiss Nurses under appeal.The Matron, in any Hospital out of Great Britain and Ireland, should be able, with the concurrence of the Governor of the Hospital, to dismiss and send home any Nurse; or the Governor himself, on his own responsibility, may direct the Matron to do so, under appeal, however, in either case, to the Superintendent-General, who shall decide, after the arrival of the Nurse, whether she is to be dismissed or whether she may be placed in another Hospital.It should be secured, not left to chance, that the Matron be immediately made acquainted with any complaint of the Medical Officers against a Nurse.Matron to draw Rations and Extras.The Matron should be able to draw from the Purveyor, on her own indent, with the sanction of the Governor of the Hospital, such rations and extras as she may consider necessary for the Nursing establishment, and make the arrangements for cooking. In the United Kingdom the Matron should be able to make arrangements, subject to the approval of the Superintendent-General, for commuting rations for mess-money, not pay.The Governor is responsible for the sufficiency of all supplies and none ought to be expended, without his sanction. This might be indispensable, if there were danger that supplies might run short.Opinion as to Governor’s jurisdiction over Nurses.Upon both these latter points, supposing the Governor of a General Hospital to exist, he must have power to maintain the discipline of the Hospital, in all its Departments, as a General commanding a division has, in regard to every regiment composing it. But he ought to exercise it only through the Matron, as commanding a corps. He must also have power to require the exclusion from the Hospital of any Nurse whose conduct he may find to be inconsistent with maintenance of discipline, and this power he would enforce, on his own responsibility, by directing the Matron to remove the offending Nurse from the Hospital. The conduct of the Nurse would become the subject of investigation afterwards, in terms of the established regulations. But practically such a case could hardly occur, unless by the fault of the Matron, who would, of her own accord, desire to remove a Nurse, on being satisfied that such a measure was necessary or expedient. It would beproper, too, both for her own justification and for the maintenance of the Governor’s supremacy in the Hospital, that the Matron should obtain his concurrence in the removal of a Nurse from the Hospital. The proceedings, in all such cases, would, of course, be reported by the Matron to the Superintendent-General.Whether the Governor has the power of removing the Matron, who clearly and properly ranks among the officers under him, should be settled and not left to be disputed about in a distant station. At all events, if he has this power over her, it must be guarded, as extending only to suspension from office, in cases of alleged flagrant neglect or misconduct, till the whole matter can be remitted and decided on by the Superintendent-General.17. Nurses’ Wages.17. Generally, as to the question of wages and pensions, a regulation that Nurses shall have a small annual increase of wages is better than one giving an increase after five or three years.Efficiency of Nurses does not increase by springs and starts, like Grasshoppers.Efficiency does not go by starts and springs, like grasshoppers, but makes “a small annual increase,” like the wages proposed.Nay, I appeal to everyone with experience in these matters whether the greatest improvement is not made the first year, the second year a little less, and so on the third and fourth, till, when the fifth year comes, if improvement has not been made by that time, it never will be.The first five years a constant improvement. Afterwards if there has not been improvement made before, no hope at all.For trust-worthiness is the true efficiency of a Nurse. And it may safely be said that, if by the end of the first year she has not improved in trust-worthiness, she had better go; and if she have not almost reached her culminating point by the fifth year, she certainly will not improve afterwards.Three principles in Wages.The reasonable principle I believe to be, 1, to begin improving the wages at as early a period as possible; 2, to let them increase till the Nurse reaches her maximum of efficiency; and, 3, after that to make no more increase.By rate of Wages to retain those who are efficient.Because the object is to induce the young and efficient women to stay, not the old ones. They will stay long enough, because the old ones nobody else will take.
(9.) Regulation as to 1 Orderly to 10 Patients requires modifying.
(9.) The Regulation number of one Orderly to ten patients therefore requires modifying. Practically it is broken every day and in the extraordinary manner above mentioned, which gives the most critical cases to be attended by the rawest hands.
(10.) One Orderly should be theFrotteur.
(10.) The question of Hospital floors will be fully discussed farther on. An Orderly should be trained to be thefrotteurto each ward. He should also be the porter to fetch and carry every thing to and from the ward.
(11.) Comparison of Cost of Nursing with larger and smaller Wards.
(11.) The plan of Netley, with its wards for 9 sick, is by far the costliest for administration, as the following facts will prove:
I. It is proposed to provide the Hospital with Orderlies and Nurses to conduct the nursing in wards of 9 sick, as mentioned.
II. On sanitary grounds wards may safely be large enough to accommodate 25 to 30 sick.
We may therefore choose the larger wards, being guided only by the cost of the nursing.
III. A ward of 9 sick would require 1 day and 1 night Orderly, and a-third of a Nurse (that is, a Nurse could superintend three such wards.)
A ward of 30 sick would require 2 day and 1 night Orderlies and 1 Nurse = 4 persons in all.
Or if two such wards were on one floor, 1 Nurse could serve both.
IV. We cannot count the cost of Orderlies and Nurses, including lodging, rations, wages, at less than£50a year, which when capitalized at 3 per cent. (33 years’ purchase), would amount to£1,650for each.
V. A ward of 9 sick would cost in nursing£1,650× 2⅓ =£3,850, or£427 15s.6d.per bed.
VI. A ward of 30 sick would cost for nursing, in perpetuity,£1,650× 4 =£6,600=£220per bed.[One Nurse to each ward is here allowed.]
VII. The cost of the two plans relatively for a Hospital of 1,000 sick would stand thus:
It hence appears that, if works and site were both sacrificed, and fresh land purchased, and wards for 30 sick built on it, the country would actually save the difference between the two sums of =£88,775.
Suppose the sanitary requirement of 25 sick to a ward, which is the best number, be combined with the greatest economy of administration, the cost would stand thus:
The comparative cost of wards with 9 beds and 25 beds, would stand thus for 1000 sick:
The cost of the administration per 1000 beds at Netley and Aldershot would stand as follows:
Some abatement would have to be made, as regards the cost of Netley, as there are a few wards with 16 or 18 sick.
If we take money at 4 per cent., the calculation will be as follows:
13. Hospital Floors.
13.Floors.—In building a new Hospital or laying a new floor we shall hope to see, by degrees, everywhere introduced the only safe Hospital floor. In the expense the difference between oak and the best white deal ought never to be considered. The staircases and passages should always be of stone. When once an oak floor is well done with bees’-wax it is no longer an absorbing surface. There cannot be a doubt that the frequent washing of the floors, in London Hospitals, is one main cause of Erysipelas and Hospital Gangrene.
But, with regard to deal flooring,—
(1.) The best way with a pine floor already laid is to close the joints, plane the surface quite smooth, and then saturate the wood with beeswax and turpentine, either at once, or after the wood has been saturated with “drying” linseed oil well rubbed in.
(2.) Enough beeswax should be used to fill up the grain of the wood, and rubbing with a brush will then smooth the surface. It will be polished somewhat, but not slippery. The amount of polish depends on the brushing.
(3.) The surface should be kept clean by using a brush with a cloth tied over it, and if offensive liquids are spilt, they should be immediately removed, the surface washed with soap and water, and immediately dried.
(4.) List slippers, which ought to be part of Hospital furniture, effectually obviate risk of slipping. It would hardly be possible, however, to make deal floors as slippery as oakparquet, because the surface (except of very fine deal, such as is used for musical instruments) never takes so high a polish.
(5.) Dry rubbing, which is done with sand, or with sandstone, is not well adapted for ordinary sick wards, on account of the dust; unless it be very carefully done. The rationale of it is to remove a certain amount of the surface of the floor. It answers very well on board ship. A certain amount of surface cleaning may be done by rubbing with a hard short brush; it is, however, defective. The wood becomes in time saturated with organic matter, and only wants moisture to give off noxious effluvia.
(6.) Scrubbing is absolutely objectionable, for this reason. In any schoolroom, reading-room, institute, which is much inhabited, a smell, while the floor is being scrubbed, is very perceptible, quite different from that of soap and water. It is the exhalation from the organic matter which has entered thefloor from the feet and breath of the inhabitants. How much more dangerous this in Hospital Wards need hardly be said.
There is atBethanienHospital, at Berlin, a very admirable flooring, which would be worth trying in England. The floors throughout are wood, prepared in the following manner:—The floor is first oiled with linseed oil, and then rubbed over with a peculiar “laque” varnish, the technical process of which will be found in the note,[15]and polished, so as to resemble French polish. Every three years or so the rooms and wards are successively emptied for a fortnight, when a new flooring is laid, re-oiled, varnished with the laque varnish, and thoroughly dried. Every day the floors are wet-rubbed by means of a piece of sacking or coarse webbing at the end of a long, hard broom, the performer stands for the performance, also while immediately afterwards, having wrung the sacking completely dry, she goes over the ground again with the dry sacking. One, or, in case of the weekly extra wet-rubbing, two dry rubbings, dry the floor completely in a few minutes from the cessation of the wet-rubbing, never more than ten minutes. Three or four times a year the ward floors are thoroughly wetted with water thrown on, and the floors scrubbed with a long brush. Neither soap, soda,&c., is used.
The great advantages of this are:—
(1.) That it purifies the air exceedingly and freshens the wards.
(2.) That it reduces the daily accumulation of dust to a minimum.
(3.) That it dries completely within ten minutes from being wet-rubbed.
(4.) That a woman, standing, can thoroughly clean a ward with some hours less time, and greatly less fatigue, than scrubbing.
(5.) That wet scrubbing is sometimes and ought to be always forbidden and dry rubbing substituted, on the score of the unhealthiness of scrubbing.
(6.) That it would relieve us of all external scrubbers in the Nurses’ own rooms. Each Nurse would sweep, wet-brush and dry-brush her bed-room and day-room herself, daily, would once-a-week give a little extra wash, and would wash the wooden skirting which runs along the bottom of the walls. As the bed-room must be tiny and the day-room small (it would be better if we could keep to one room, which would take a quarter of an hour daily, and the grand weekly purification not more than one hour, even to a slow performer) a short time daily and a moderate time weekly will do it.
One disadvantage of this very simple, very efficient, and excellent flooring is, that it shows scratches. Furniture must always be lifted, not dragged. In a Military Hospital where men are always at hand, this would matter less as to the wards, and the Nurses could help each other once a week in their bed-rooms, and manage alone in their day-rooms.
There are four other examples of this flooring in Berlin Hospitals.
(1.)Bethesda Siechenhaus, a small old house, about to be rebuilt and enlarged, in a suburb of Berlin, where three Deaconesses, with a man and woman servant, take excellent care of about forty infirm old women and imbecile children. These patients, of the class to be found in the infirmary wards of our workhouses, move about little, and have few visitors, so that the flooring, which is the same as atBethanien, is less used.
(2.)St.Hedwig’s Hospital, where 250 male and female medical and surgical patients are nursed by Roman Catholic Sisters ofSt.Charles Borromæus (head quarters at Nancy), with female servants and male nurses. The house is new; the flooring the same as atBethanien. The Superior, an intelligent German, speaks much of its excellence for hospital purposes; it is being introduced, though as yet very partially, into France.
(3.) The greatCharitéHospital, the town-hospital for 1,200 patients, spite its French name. It consists of two buildings; the old one, used in winter; and a splendid new one, into which all the patients, except the lunatics and the small-pox and the venereal cases, are moved for the six summer months. The flooring throughout is of the same wood (deal) as atBethanien, but has much more laque. The more laque is used, the brighter the floor shines, but the sooner it requires re-oiling and laque varnishing. TheCharitéfloors are re-oiled with laque every year; they are cleaned in the same way as atBethanien, only with more dry rubbing. On bad days, when the numerous students have passed through, the ward floors occasionally require to be cleaned; but, in general, even on these occasions, it is enough to sweep them, and to clean the next morning as usual.
(4.) The principal Military Hospital, theGarnison Lazarethin theHirsch Allée, for 800 patients, usually not filled. The flooring is the same as atBethanien, except that no laque is used. It is oiled generally, not always, yearly.
TheOber Inspector, aLandwehrcivilian, who is supreme over the Hospital, and anOber-Stabs-Arzt, both speak very strongly as to the superiority of this flooring over all others for Hospital use, and in particular over flooring which requires scrubbing. It has only been introduced of late years. They consider it equal to any amount of hospital wear and tear. The military patients, like those of theCharité,Bethanien, andSt.Hedwig’s, wear hospital slippers, with soles thick enough to admit of their walking in the garden, when fine; when not fine, they are not allowed to go out. This flooring would not stand the constant tread of nailed shoes. But often, on bad days as on fine ones, great numbers of soldiers come to visit their sick comrades, and leavethe floor very dirty; generally it is enough to sweep the floor after the visitors are gone, and to clean it as usual next morning; sometimes it is necessary to clean it the same afternoon.
The flooring is cheap. Somewhat more expense attends laying it down than the ordinary boards, and a certain expense attends the re-oiling, but the constant outlay for soap and soda is entirely saved, except a little soda in the grand annual purification, with hot water, in addition to the daily one with cold; the time and labour attending scrubbing is saved, and above all the great gain to the sick arising from its use is secured.
The strong, decided way in which the old grey-headed Army Surgeon, and the middle-aged business-looking Civilian, spoke of the merits of this flooring, and of its capacities, was exceedingly satisfactory.
(5.) Two years ago the greater part of the boards in theKaiserswerthInstitution, which are of deal, were oiled, both on sanitary grounds, and to rid the Sisters of the drain on time and strength in scrubbing. They are considered far preferable to the old ones, and to answer in every respect. Yet theKaiserswerthfloorings would not answer the English requirement of extreme cleanliness. They are substantially clean, but, like those of the Military Hospital of Berlin, it takes examination to ascertain that they are so, and from the same cause—there is no “laque.” Also the colour is not at all so agreeable as theBethaniencolour. These oiled boards last a year only. A moderate amount of laque is required to add to their durability.
The sum of the information, condensed as much as possible, on this subject is;—
I.The boards, which are always of deal, can be prepared in three ways:
(I.) Laquering, only suitable for reception rooms, or when by some chance a ward is wanted to be got ready in a hurry; it takes less time; after two or three days, the room or ward can be used, and it shines brighter, but it lasts a much shorter time than the other procedures, as it stands less the incessant treading incident to all ward floors; it is also more expensive. Let us consider it wholly unsuitable for wards.
(II.) Oiled boards, with more or less laque.
TheCharitéboards have a great deal of laque.
TheBethanienandSt.Hedwig’s boards much less.
(III.) Oiled boards without any laque—
As in the Military Hospital.
II.Much laque makes the floors shine brighter; requires more time to clean them; and earlier re-preparation than where less laque is used.
TheCharitéboards would be unmeaningly splendid for an English Hospital, and quite out of place in a Military one; besides entailing some unnecessary annual expense, and some daily finicking care.
III.A small quantity of laque, as atBethanien, gives an amount of polish to the floors, which enables the eye at once to ascertain whether they are clean or not; considerably improves the appearance of the floor; and, according to all high authority, adds both to the durability of the floor, and the healthiness of the Hospital. It renders the whole flooring less subject to cracks, to dirt and dust getting into holes and corners; and, above all, by filling up the grain of the floor, it prevents the saturation, by organic matter, which otherwise takes place and which scrubbing only makes more mischievous.
IV.Where no laque is used, the absence of all polish on the dark-brown floors makes examination necessary, to see whether they are thoroughly clean or not. This flooring would never satisfy the eye or the mind of an English Inspector-General or Surgeon. But the main objection to the absence of laque certainly consists in the sanitary one above stated.
V.All the various authorities agree in estimating very highly the superiority of this flooring to flooring requiring scrubbing. They all agree in their reasons for this preference, viz.:—
(I.) The dampness which remains in a ward more or less time after it has been scrubbed, is completely avoided.
(II.) The tendency to miasma is greatly counteracted, both by getting rid of the damp, which encourages and spreads the exhalation of the organic saturations; and by making the floor impervious, preventing dirt, and with dirt miasma, finding its way into holes, chinks, and corners of the floor.
(III.) The mode of cleaning this flooring, while it avoids damp, daily purifies the ward air.
(IV.) The floor, and its mode of cleaning, get rid more than by any other way of dust, and of the miasma dust often conveys.
(V.) The time, labour, and expense of scrubbing are saved.
(VI.) The Berlin authorities consider that these oiled boards, with a small quantity of laque, are, on the whole, decidedly cheaper than the common boards; that the boards last rather longer; and that the avoidance of scrubbing saves more than the extra preparation and its renewal cost, apart from the sanitary gain.
VI.Against these advantages, the following disadvantages are to be placed:
(I.) This flooring shows where most used, instead of the uniform appearance of the white scrubbed boards.
(II.) Scratches show, and remain upon it; so all furniture must be lifted, not dragged over it.
(III.) The tread sounds a little more, little, but more, than on white boards.
(IV.) It would not stand the constant tread of nailed shoes; and patients of a ward so floored, ought to wear slippers with moderately thick soles. (The German Doctors consider the use of slippers preferable to that of shoes, by the patients, as keeping a ward much quieter, cleaner, and disturbing the severe cases less.)
(V.) Carpets could not be nailed on it, as the floor should be daily cleaned. Several Hospital authorities whose rooms are thus floored, have large pieces of carpet round the furniture most used, bed, tables, sofas,&c.; these are daily taken up and dusted while the floor is being cleaned. To many English minds, the sight and feel of a carpet is essential to the idea or feeling of comfort; and it might be sound policy, in the event of a trial being made of this flooring, to leave the Officers, Military and Medical (I do not mean patients), in possession of scrubbed rooms and carpets. The Superintendent might have one or two pieces of carpet for her rooms; and the Nurses should dispense with carpet.
Both in the new part of theCharitéand atBethanien, long broad corridors run along the back of the wards which open into them. The corridors are floored like the wards. In those of theCharitéa piece of long carpet is laid in the midst of the corridors, where patients walk not a little. AtBethanien, along piece of matting is laid in the midst of the corridors, where the patients walk freely. Carpet of either kind is not considered to benefit the floors, but to diminish the noise. In the wards of Guy’s Hospital, for the same reason, a long piece of matting is laid along the middle of the floors.
VII.This flooring is unsuited for stairs, though so used in some Hospitals, as, in case of fire, oiled wood would burn rather quicker than common wood. Hospital stairs should be of stone.
VIII.It is also unsuitable for kitchens, wash-houses, water-closets, and sinks. The floor round a stove or fire-place in a ward or room should be protected by a strong plate of lead or tin.
It might also be as well to floor operation-rooms with flooring, admitting of scrubbing, because these oiled boards do not well stand sand or bran, and our Surgeons might be discomposed at missing one or other of these things. Sand or bran mixed with blood would make a mess, the traces of which would show a little on this flooring. For the rest, it is particularly easy to wipe blood off it. After each operation, one or two minutes, a wet cloth of the kind here mentioned, and a broom, remove the blood that has fallen, and leave a clean floor; or if there has been a very great mess, five minutes, a wet cloth to lap up the blood,&c., another wet cloth, a pail, and a broom, do all: after the operations are over, a few minutes’ whole or partial cleaning, as the case may be, make all tidy again. Still, many English Surgeons expect to have sand or bran thrown on the floor before, or just after the first blood has fallen, and might object to standing some minutes on the bloody floor, which spoils boots,&c.Red floorcloth, of sufficient size, round the operating-table, might answer every purpose.
IX.On laying down the oiled boards for the first time, six weeks should pass after the oiling and laquering before the ward is inhabited.
X.After subsequent re-preparation of the floors, the longer the wards are left vacant the more the floor both hardens and shines; but for practical purposes the interval of a fortnight is enough.
XI.The flooring, so prepared, or re-prepared, ought, on an average, to last about three years. In case of any extra miasma, it is often desirable to hasten the re-preparation, and to have it done after two years’ use. To do it annually is, unless in some emergency, quite unnecessary.
Although the process cannot be said to be by any means perfect, on account of the deficient durability of the surface, it would be well worth while to try it in England, and, if it answers and if it were improved, the sick would gain much, and the Hospital staff would gain much—the latter much more even in Civil, than in Military Hospitals.
But it would be incurring a great responsibility to have the whole of a large new Hospital floored in this way, because,
I.An English climate has made, and makes, so many things which are good and suitable abroad, unsuitable and sometimes pernicious for England.
II.Our coal-fires, whether assisting or assisted by our atmosphere, certainly give us an amount of soot and dirt unknown abroad. At Berlin, all fire-places are stoves, where sometimes coal, sometimes coal and wood are burnt.
This flooring might not stand well either the damp climate, or the smoky atmosphere and amount of flying soot of England: but it would be well worth trying; as also trying to improve it.
By all accounts, a great deal depends upon the manner in which these boards are prepared; a little more or a little less, whether of oil or laque, makes a great and lasting difference. It would never answer to make an English carpenter or painter do this from written or printed directions.
If we obtain a trial of this floor—the best course would be, to let an English carpenter prepare a number of boards and skirtings, of due size, suitable for the new flooring of some few wards in one of Her Majesty’s hospitals, which requires new flooring; then to desire either the proper tradesman, or the Queen’s Minister at Berlin, to order the house-painter,Schonby, No. 5,Michael Kirchplatz, Berlin, to send an experienced, trustworthy foreman, with the proper tools and materials, and for this man, with a complement of English workmen, to prepare the boards.
The mode of cleaning is extremely simple, though of course there is a knack to be learnt; and, like everything else, it can be done well, indifferently, or ill. Any English man or woman accustomed to cleaning would understand the thing in one morning, and would, if he or she opened instead of shutting the mind to the outlandish thing, be proficient in it in a week. All these things sound abstruse on paper, and are far more simple and more easily learnt by seeing done than by reading. The foreman ought to give one or two lessons to one or two Orderlies, or Nurses, as the case may be.
14. Ventilation of Wards.
14.Ventilation.—The amount of fresh air required for ventilation has been hitherto very much underrated, because it has been assumed that the quantity of carbonic acid produced during respiration was the chief noxious gas to be carried off. The total amount of this gas produced by an adult in 24 hours is about 40,000 cubic inches, which in a Barrack room of 16 men would give 370 cubic feet per diem. Allowing 8 hours for the night occupation of such a room, when the doors and windows may be supposed to be shut, the product of carbonic acid would be 123 cubic feet, or about 15½ cubic feet per hour. This large quantity if not speedily carried away would undoubtedly be injurious to health; but there are other gaseous poisons produced with the carbonic acid which have still greater power to injure. Every adult exhales by the lungs and skin 48 ounces or 3 pints of water in 24 hours. Sixteen men in a Barrack-room would therefore exhale in 8 hours 16 pints of water and 15½ cubic feet of carbonic acid in the atmosphere of the room. With the watery vapour there is also exhaled a large quantity of organic matter ready to enter into the putrefactive condition. This is especially the case during the hours of sleep. And as it is a law that all excretions are injurious to health if reintroduced into the system it is easy to understand how the breathing of damp foul air of this kind, and the consequent reintroduction of excrementitious matter into the blood through the functions of respiration will tend to produce disease.
This will be still more the case in sick wards overcrowded with sick, the exhalations from whom are always highly morbid and dangerous, as they are nature’s method of eliminating noxious matter from the body, in order that it may recover health.
A much larger mass of air is required to dilute and carry away these emanations than is generally supposed. And the whole art of ventilation resolves itself into applying inany specific case the best method of renewing the air sufficiently, without producing draughts or occasioning great varieties in temperature.
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 doubtedwhether 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.
16. All salaries and wages of Matrons and Nurses should be paid, on the Superintendent-General’s order, from the Hospital chest, to the Matron, who should pay the wages and other expenses of the Nurses, and account for all monies received by her on such orders. All outfits and travelling expenses, in cases of transfer,&c., should be provided on the order of the Superintendent-General.
Opinion as to Superintendent-General paying Wages and Salaries.
There would be considerable difficulty in the way of making all payments at a distance to Nurses, direct from the Superintendent-General, otherwise than by orders on the Hospital chest or Treasury. But there can be no doubt that the Nurses ought to be paid by the Matron and by no one else. The service of Nurses in Hospital is a peculiar service, and if not successfully conducted by influence never can be by coercive discipline. It would be a great mistake, therefore, to throw away any means of influence which we can command, and the “eye of the maid-servant is to the hand of her mistress” now as it was 2,000 years ago. The fact of paying and being paid helps greatly to establish the proper mutual relations between the superior and the subordinate. The Matron would draw from the Hospital Treasury, on the orders of the Superintendent-General, and would account to her. As a matter of discipline, it would make no material difference whether the orders of the Superintendent-General, in favour of the Matron, for the pay of the Nurses, are cashed by the Hospital Treasurer or by a banker, always supposing that the Treasurer is bound to honour those orders, as any other banker would.
Matrons abroad may dismiss Nurses under appeal.
The Matron, in any Hospital out of Great Britain and Ireland, should be able, with the concurrence of the Governor of the Hospital, to dismiss and send home any Nurse; or the Governor himself, on his own responsibility, may direct the Matron to do so, under appeal, however, in either case, to the Superintendent-General, who shall decide, after the arrival of the Nurse, whether she is to be dismissed or whether she may be placed in another Hospital.
It should be secured, not left to chance, that the Matron be immediately made acquainted with any complaint of the Medical Officers against a Nurse.
Matron to draw Rations and Extras.
The Matron should be able to draw from the Purveyor, on her own indent, with the sanction of the Governor of the Hospital, such rations and extras as she may consider necessary for the Nursing establishment, and make the arrangements for cooking. In the United Kingdom the Matron should be able to make arrangements, subject to the approval of the Superintendent-General, for commuting rations for mess-money, not pay.
The Governor is responsible for the sufficiency of all supplies and none ought to be expended, without his sanction. This might be indispensable, if there were danger that supplies might run short.
Opinion as to Governor’s jurisdiction over Nurses.
Upon both these latter points, supposing the Governor of a General Hospital to exist, he must have power to maintain the discipline of the Hospital, in all its Departments, as a General commanding a division has, in regard to every regiment composing it. But he ought to exercise it only through the Matron, as commanding a corps. He must also have power to require the exclusion from the Hospital of any Nurse whose conduct he may find to be inconsistent with maintenance of discipline, and this power he would enforce, on his own responsibility, by directing the Matron to remove the offending Nurse from the Hospital. The conduct of the Nurse would become the subject of investigation afterwards, in terms of the established regulations. But practically such a case could hardly occur, unless by the fault of the Matron, who would, of her own accord, desire to remove a Nurse, on being satisfied that such a measure was necessary or expedient. It would beproper, too, both for her own justification and for the maintenance of the Governor’s supremacy in the Hospital, that the Matron should obtain his concurrence in the removal of a Nurse from the Hospital. The proceedings, in all such cases, would, of course, be reported by the Matron to the Superintendent-General.
Whether the Governor has the power of removing the Matron, who clearly and properly ranks among the officers under him, should be settled and not left to be disputed about in a distant station. At all events, if he has this power over her, it must be guarded, as extending only to suspension from office, in cases of alleged flagrant neglect or misconduct, till the whole matter can be remitted and decided on by the Superintendent-General.
17. Nurses’ Wages.
17. Generally, as to the question of wages and pensions, a regulation that Nurses shall have a small annual increase of wages is better than one giving an increase after five or three years.
Efficiency of Nurses does not increase by springs and starts, like Grasshoppers.
Efficiency does not go by starts and springs, like grasshoppers, but makes “a small annual increase,” like the wages proposed.
Nay, I appeal to everyone with experience in these matters whether the greatest improvement is not made the first year, the second year a little less, and so on the third and fourth, till, when the fifth year comes, if improvement has not been made by that time, it never will be.
The first five years a constant improvement. Afterwards if there has not been improvement made before, no hope at all.
For trust-worthiness is the true efficiency of a Nurse. And it may safely be said that, if by the end of the first year she has not improved in trust-worthiness, she had better go; and if she have not almost reached her culminating point by the fifth year, she certainly will not improve afterwards.
Three principles in Wages.
The reasonable principle I believe to be, 1, to begin improving the wages at as early a period as possible; 2, to let them increase till the Nurse reaches her maximum of efficiency; and, 3, after that to make no more increase.
By rate of Wages to retain those who are efficient.
Because the object is to induce the young and efficient women to stay, not the old ones. They will stay long enough, because the old ones nobody else will take.