(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.
The Charité boards have a great deal of laque.
The Bethanien and St. 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.
The Charité boards 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 at Bethanien, 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 the Charité and at Bethanien, long broad
corridors run along the back of the wards which open into them. The
corridors are floored like the wards. In those of the Charité a piece
of long carpet is laid in the midst of the corridors, where patients
walk not a little. At Bethanien, a long 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.
[Sidenote: 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 in any 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.
[Sidenote: 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.
[Sidenote: 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.
[Sidenote: 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.
[Sidenote: 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.
[Sidenote: 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.
[Sidenote: 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.
[Sidenote: 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 be proper,
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.
[Sidenote: 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.
[Sidenote: 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.
[Sidenote: 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.
[Sidenote: 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.
[Sidenote: 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.
[Sidenote: By rate of Pension to reward those who have been efficient.]
The rate of pension ought, on the other hand, to increase with the
number of years’ service, and continue increasing till the end. The
principle of pensioning is different from that of wages. After the
woman has reached her maximum of efficiency, which certainly will be
not later than forty-five, probably not later than forty years of age,
the inducement to stay should be the improvement of pension. This
compensates for any apparent injustice in the first principle towards
an old servant.
[Sidenote: Civil Service an Example.]
No other system appears to be founded on common sense; and it is one
generally acknowledged in the Civil Service, where salaries are made to
rise as soon as possible. Military Hospitals must not be made training
schools for Nurses; else it would be better to admit them much younger
than at the age of thirty years.
[Sidenote: Opinion as to Wages and Pensions.]
If a Nurse cannot enter the Service till after she is thirty, the
majority will no doubt be some years above thirty when they enter, say
an average of thirty-five; and five years appear a very long probation
for a person at that age before increase of wages begins. In most
cases, in Civil Departments, there is only one year of such probation
before increase begins, though the persons are much younger when they
enter. A maximum might be fixed, beyond which the wages should not
rise, and when the increase of pension would be sufficient inducement
to remain. Very few Nurses can be expected to continue really efficient
till sixty years of age; but it is often difficult to say that a person
is disabled, though she may have become less active and efficient.
If there is no retiring allowance there will be great reluctance to
dismiss her, and it might, in that case, be cruel. The better plan
would be to promise a small pension after ten or twelve years’ service,
on a scale so graduated thereafter as to offer an inducement to remain,
at the same time that it would afford facility for enforcing retirement
without injustice. This would be economy. The “Nursing Sisters” grant
£20 after twelve years’ service.
After a time there may probably be difficulty in dismissing persons who
have done good service for ten years, but have declined in efficiency,
unless there is a retiring allowance. They may be reluctant to retire;
and, if so, it would be almost impossible to dismiss them, without
some kind of provision. This is a difficulty which is encountered in
every employment in which there is no such provision. Persons who can
hardly be said to be disabled but who have become less efficient are
retained, because, if dismissed, they have no means of livelihood.
I have consulted the best authorities upon these points; and I find the
following general principles admitted:--