Health in the Hospital

IN preparing to do the duty of society towards the wounded or sick soldier, the first consideration is, What is a Military Hospital ? No two nations seem to have answered this question in the same way ; yet it is a point of the first importance to them all.

When England went to war last time, after a peace of forty years, the only idea in the minds of her military surgeons was

of Regimental Hospitals. There was to be a place provided as an infirmary for a certain number of soldiers; a certain number of orderlies were to be appointed as nurses ; and the regimental doctor and hospital-sergeant were to have the charge of the inmates. In each of these Regimental Hospitals there might be patients ill of a great variety of disorders, from the gravest to the lightest, all to be treated by the same doctor or doctors. These doctors had to make out statements of all the diets, as well as all the medicines required by their patients, and send in their requisitions ; and it might be said that arrangements had to be separately made for every individual patient in the whole army. The doctors went to work each in his own way, even in the case of epidemics. There was no knowing, except by guess, what diseases were the most to be apprehended in particular places or circumstances ; nor what remarkable phenomena of disease were showing themselves on any extended scale; nor what improvements could be suggested in the treatment. There was no possibility of such systematic cleanliness and such absolute regularity of management as can be secured by organization on a large scale. Yet the medical officers preferred the plan to any other. One plea was, that the medical officers and the patients were acquainted with and attached to each other : and this was very true. Another consideration was, that each surgeon liked to have his field of duty to himself, and found it an advantage to have a large variety of ailments to treat, to the constant improvement of his experience. They said that doctors and patients and nurses all liked the Regimental Hospital best, and this was clear proof that it was the best. They could at that time say also, that every soldier and every doctor had a horror of General Hospitals, where the mortality was so excessive during the Peninsular War that being carried to the General Hospital was considered the same thing as being sentenced to death.

Such being the state of opinion and feeling in the profession, it naturally happened that British army-surgeons stuck to their Regimental Hospitals as long as they could, and, when compelled to cooperate in a General Hospital, made the institution as like as possible to a group of Regimental Hospitals,— resisting all effective organization, and baffling all the aims of the larger institution.

In busy times, no two Regimental Hospitals were alike in their management, because the scheme was not capable of expansion. The surgeon and his hospital-sergeant managed everything. The surgeon saw and treated the cases, and made out his lists of articles wanted. It was his proper business to keep the books, — to record the admissions, and make the returns, and keep the accounts, and post up all the documents: but professional men do not like this sort of work, when they want to be treating disease ; and the books were too often turned over to the hospital-sergeant. His indispensable business was to superintend the wards, and the attendance on the patients, the giving them their medicines, etc., which most of us would think enough for one man: but be had besides to keep up the military discipline in the establishment, — to prepare the materials for the surgeon’s duty at the desk, — to take charge of all the orders for the diet of all the patients, and see them fulfilled,— to keep the record of all the provisions ordered and used in every department,-—and to take charge of the washing, the hospital stores, the furniture, the surgery, and the dispensary. In short, the hospital-sergeant had to be at once ward-master, steward, dispenser, sergeant, clerk, and purveyor ; and, as no man can be a six-sided official, more or fewer of his duties were deputed to the orderly, or to anybody within call.

Nobody could dispute the superior economy and comfort of having a concentration of patients arranged in the wards according to their ailments, with a general kitchen, a general laundry, a dispensary and surgery, and a staff of officials, each with his own distinct business, instead of as many jacks-of-all-trades, each doing a little of everything. Yet the obstinacy of the fight made by the surgeons for the system of Regimental Hospitals was almost insuperable. There was no desire on any hand to abolish their hospitals, which must always be needed for slight, and also for immediately pressing cases. What was asked of them was to give way when epidemics, or a sudden influx of wounded, or protracted cases put a greater strain upon the system than it would bear.

The French, meantime, had three sorts of hospitals,-—the Divisional ones coming between the Regimental and the General. Only the very slightest cases ever enter their Regimental Hospital; those which may last weeks are referred to the Divisional; and those which may last months, with prospect of recovery, to the General Hospital. The Sardinian plan was nearly the same. The Russians had Divisional Hospitals at various stations; and all cases were carried to them.

The Regimental Hospitals are wherever the regiments are. The advantage is, that aid can be immediately rendered, — not only in case of wounds, but of cholera, in which it is desirable to lay a patient down in the nearest bed to which he can be conveyed. The disadvantages are the hap-hazard quality of the site, the absence of quiet and seclusion, and the liability of being near the scene of conflict. These things cause the French to prefer the Divisional Hospital, which, while still within reach, is set farther back from the force, in a picked situation, and managed on a large scale and with nicer exactitude.

The General Hospital is understood to be at the base of operations: and this supposes, as a part of its organization, a system of transport, not only good of its kind, but adequate to any demands consequent on a great battle, or the spread of an epidemic in the camp. The nearer the hospital is to the active force, the better, of course ; but there are conditions to be fulfilled first. It must be safe from the enemy. It must be placed in a permanent station. It must be on a good road, and within immediate reach of markets. It ought also to be on the way home, for the sake of the incurable or the incapacitated who must be sent home.

In the Regimental Hospital, the surgeon may be seen going from the man who has lost a finger to a fever patient,— and then to one who has ophthalmia,— passing on to a fellow raving in delirium tremens, — next to whom is a sufferer under bronchitis, who will not be allowed to go out of doors for weeks to come ; and if half a dozen are brought in with cholera in the course of the day, the officials do not know which way to turn. It is possible that the surgeon may be found making starch over the kitchen fire, because there is nobody at hand who understands how to make starched bandages; or be may be at the desk, casting up columns of figures, or writing returns, when he is urgently wanted at the bedside. Such things can hardly happen now; but they have happened within ten years. The Russians, meantime, would be carrying all manner of patients to one of their hospital-stations,— each sufferer to the hospital of his own division. The French would leave the men with scratches and slight diarrhœa and delirium tremens in the Regimental Hospital, — would send the fever and bronchitis and scorbutic patients to the Divisional,— and any gravely wounded, or rheumatic, or other very long cases to the General Hospital at the base of operations.

Such arrangements, however, are of no use, if the last be not so organized as to render it fit to supply what the others cannot give, and to answer purposes which the others cannot even propose.

When doctors and soldiers alike shuddered at the mention of the General Hospital as a necessary institution at or near the seat of war, they were thinking of what they had seen or heard of during the Peninsular Campaigns. There were such infirmaries wherever there was a line of march in Spain ; and they seemed to be all alike. Hospital gangrene set in among the wounded, and fever among the sick, so that the soldiers said, “ To send a poor fellow to the hospital is to send him to death.” Yet there was nothing else to be done; for it was impossible to treat the seriously sick and wounded at the spot where they fell. During that war, nearly twice the number which composed the army passed through the hospitals every year; and of these there were known deaths to the amount of thirteen thousand five hundred ; and thousands more were never the same men again. When the case was better understood,— as during the last year in the Crimea, — the mortality in the hospitals barely exceeded that of the Guards in their barracks at home ! Recovery had become the rule, and death a remarkable event. General Hospitals had come to surpass all other means of curing patients, while fulfilling their own peculiar service to society through new generations.

What are the functions of General Hospitals, besides curing the sick and wounded ? some readers may ask, who have never particularly attended to the subject.

The first business of such institutions is undoubtedly to restore as many as possible of the sufferers brought into them: and this includes the duty of bringing in the patients in the most favorable way, receiving them in an orderly and quiet manner, doctoring, nursing, feeding,clothing, and cleaning them, keeping their minds composed and cheerful, and their manners creditable, promoting their convalescence, and dismissing them in a state of comfort as to equipment. This is the first duty, in its many subdivisions. The next is to obviate, as far as possible, future disease in any army. The third grows out of this. It is to improve the science of the existing generation by a full use of the peculiar opportunities of observation afforded by the crop of sickness and wounds yielded by an army in action. To take these in their reverse order.

There must be much to learn from any great assemblage of sickness, under circumstances which can he fully ascertained, even at home, — and much more in a foreign climate. The medical body of every nation has very imperfect knowledge of classes and modifications of diseases; so that one of the strongest desires of the most learned physicians is for an improved classification and constantly improving nomenclature of diseases; and hospital-records afford the most direct way to this knowledge. Thus, while the phenomena are frittered away among Regimental or unorganized General Hospitals, a well-kept record in each wellorganized hospital will do more than all other means to promote the scientific understanding of disease.

The statistics of disease in armies, the ascertainment of the numbers who sicken and who die of particular diseases, would save more lives in future generations than can be now appreciated; but what can the regimental surgeon do towards furnishing any trustworthy materials to such an inquiry ? A dozen doctors, with each his smattering of patients, can learn and teach but little while they work apart: whereas a regular system of inquiry and record, in action where the sick are brought in in battalions, is the best possible agency. Not only are these objects lost when surgeons are allowed to make the great hospital a mere receptacle for a cluster of small and desultory hospitals, but the advantages of a broad study of diseases and their treatment are lost. Inestimable facts of treatment are learned by watching, at the same time and in the same place, a ward full of patients ill of the same disease. People of all countries know this by the special learning which their physicians obtain in large civil hospitals: and the same thing happens in military hospitals, with the additional advantage that the information and improved art tend to the special safety of the future soldiery, in whatever climate they may be called on to serve.

There has long been some general notion of the duty of army-surgeons to record what they saw in foreign campaigns; but no benefit has been reaped till of late. The works of French field-surgeons have long been justly celebrated; but I do not know that in the statistics and the nomenclature of disease they have done much more than others. The English surgeons carried or sent home in 1810 a mass of papers about the Walcheren fever, and afterwards of the diseases of the Peninsular force : but the DirectorGeneral of the Medical Department considered such a bulk of records troublesome, and ordered them to be burnt! Such an act will never be perpetrated again : but directors will have a more manageable mass of documents to deal with henceforth. With a regular system of record, at a central station of observation, much more may be done with much less fatigue to all parties.

But how is it to be done? may well be asked. In the hurry and confusion of a war, and amidst the pressure of hundreds of new cases in a day, what can the surgeons of the hospital be expected to do for science, or even for the improvement of medical and surgical practice? — The answer is seen in the new arrangements in England, where a statistical branch has been established in the Army Medical Department. Of course, no one but the practising surgeon or physician can furnish the pathological facts in each individual case; but this is what every active and earnest practitioner does always and everywhere, when he sees reason for it. His note-book or hospitaljournal provides that raw material which the statistical department is to arrange and utilize. The result will be that a flood of light will be cast on matters affecting the health and life of soldiers and other men, in regard to which we might have gone on groping for centuries among the confusion of regimental records, without getting what we wanted. As to the method of proceeding, I may have something to say farther on. Meantime, we must turn to the primary object of the institution of the Military Hospital,— the cure of the wounded and sick of the army.

In the case of active war, foreign or civil, the General Hospital is usually an extemporized establishment, the building a makeshift, and the arrangements such as the building will admit. In Spain, the British obtained any houses they could get; and the soldiers were sometimes crowded into half a dozen of them in one town. In the last war, the great buildings at Scutari were engaged three months before they were wanted for extensive use; so that there was plenty of time for making them clean, airy, warm, and commodious, and for storing them with all conveniences. This was not done; and the failure and its consequences afford a lesson by which every people engaged in war should profit. A mere outline of what was not done at Scutari may be an indication of what should be done with all convenient speed elsewhere.

There was a catgut manufactory close at hand, which filled the neighborhood with stench. Half a dozen dead dogs festered under the windows in the sun; and a dead horse lay in the aqueduct for six weeks. The drain-pipes within the building were obstructed and had burst, spreading their contents over the floors and walls. The sloping boarded divans in the wards, used for sleeping-places, were found, after the building became crowded, to be a cover for a vast accumulation of dead rats, old rags, and the dust of years. Like all large stone buildings in the East, it was intolerably cold in winter, with its stagnant air, its filthy damps, and its vaultings and chill floors. This wonderful building was very grandly reported of to England, for its size and capacity, its imposing character, and so forth ; and the English congratulated themselves on the luck of the wounded in having such a hospital. Yet, in the next January, fourteen hundred and eighty were carried out dead.

It appears that nobody knew how to go to work. Everybody writes to somebody else to advise them to “ observe ”; and there are so many assurances that everybody means to “ observe,” that there seems to have been no leisure to effect anything. One thinks that this, that, or the other should be attended to; and another states that the matter is under consideration. It was some weeks before anybody got so far in definiteness as to propose whitewash. Somebody understood that somebody else was intending to have the corridors scoured; and representations were to be made to the Turkish authorities about getting the drain-pipes mended. The Turkish authorities wished to employ their own -workmen in putting in the stoves; and on the 18th of December the responsible British officer hoped the stoves would be put up immediately, but could not be certain, as Turkish workmen were in question. This was a month after large companies of wounded and sick had been sent in from the seat of war. Even then, nothing had been done for ventilation, or, on any sufficient scale, for putting the poor sufferers comfortably to bed.

These things confirm the necessity of a regulated coöperation between the sanitary, the medical, and the military officers of an army. The sanitary officer should be secure of the services of engineers enough to render the hospital, as well as the camp, safely habitable. As soon as any building is taken possession of for a hospital, men and their tools should be at command for exploring the drains and making new ones, — for covering or filling up ditches, — for clearing and purifying the water-courses, and leading in more water, if needed,—for removing all nuisances for a sufficient distance round, — and for improving to the utmost the means of access to the house. There must be ventilating spaces in the roof, and in the upper part of all the wards and passages. Every vaulted space, or other receptacle of stagnant air, should have a current established through it. All decaying wood in the building should be removed, and any portion ingrained with dirt should be planed clean. A due water-supply should be carried up to every story, and provided for the bathrooms, the wash-houses, and the kitchen. Every edifice in America is likely to be already furnished with means of warmth ; and the soldiers are probably in no danger of shivering over the uncertain promise of stoves on the 18th of December.

Next comes the consideration of storeplaces, which can be going forward while busy hands are cleaning every inch of ceiling, walls, floors, and windows within. There must he sheds and stables for the transport service; and a surgery and dispensary planned with a view to the utmost saving of time and trouble, so that medicines and utensils may he within reach and view, and the freest access allowed to applicants. The kitchens must have the best stoves and boilers, dressers and scales, and apparatus of every kind that is known to the time ; for more lives depend on perfect food being administered with absolute punctuality than upon any medical treatment. There must be large and abundant and airy store-places for the provisions, and also for such stocks of linen and bedding as perhaps nobody ever dreamed of before the Crimean War.

The fatal notions of Regimental Hospital management caused Infinite misery at Scutari. In entering the Regimental Hospital, the soldier carries his kit, or can step into his quarters for it: and the regulations, therefore, suppose him to be supplied with shirts and stockings, towel and soap, brushes and comb. This supposition was obstinately persevered in at Scutari, till private charity had shamed the authorities into providing for the men’s wants. When the wounded were brought from the Alma, embarked on crowded transports straight from the battle-field, how could they bring their kits ? Miss Nightingale, and benevolent visitors from England, bought up at Constantinople, and obtained from home, vast supplies of bodyand bed-linen, towels, basins, and -water-cans ; and till they did so, the poor patients lay on a single blanket or coarse canvas sheet, in their one shirt, perhaps soaked in blood and dirt. There were some stores in the hospital, though not enough ; and endless difficulty was made about granting them, lest any man should have brought his kit, and thus have a double supply. Amidst the emergencies of active war, it seems to be an obvious provision that every General Hospital should have in store, with ample bedding, body-linen enough for as many patients as can occupy the beds, — the consideration being kept in view, that, where the sick and wounded are congregated, more frequent changes of linen are necesssary than under any other circumstances.

The excellent and devoted managers of the hospitals of the Union army need no teaching as to the daily administration of the affairs of the wards. They will never have to do and dare the things that Miss Nightingale had to decide upon, because they have happily had the privilege of arranging their hospitals on their own principles. They will not know the exasperation of seeing sufferers crowded together on a wooden divan (with an under-stratum of dead rats and rotting rags) while there is an out-house full of bedsteads laid up in store under lock and key. Not being disposed to acquiesce in such a state of things, and failing in all attempts to get. at the authority which had charge of the locked door, Miss Nightingale called to an orderly or two, and commanded them to break open the door. They stared; but she said she assumed the responsibility ; and presently there were as many men in bed as there were bedsteads. Her doctrine and practice have always been,-—instant and silent obedience to medical and disciplinary orders, without any qualification whatever ; and by her example and teaching in this respect she at length overcame the jealousy and prejudices of authorities, medical and military : but in such a case as the actual presence of necessaries for the sick, sent out by Government or by private charity for their use, she claimed the benefit, and helped her patients to it, when there was no other obstruction in the way than forms and rules never meant to apply to the case.

What the jealousy was appeared through very small incidents. A leading medical officer declared, in giving evidence, that the reason why the patients’ meals were sometimes served late and cold, or halfcooked, was, that Miss Nightingale and her nurses were forever in the way in the general kitchen, keeping the cooks from the fire : whereas the fact was, that neither Miss Nightingale nor any nurse had ever entered the general kitchen, on any occasion whatever. Their way was to have a kitchen of their own. The very idea of that kitchen was savory in the wards; for out of it came, always at the right moment, arrowroot, hot and of the pleasantest consistence, — rice puddings, neither hard on the one hand nor clammy on the other,— cool lemonade for the feverish, cans full of hot tea for the weary, and good coffee for the faint. When the sinking sufferer was lying with closed eyes, too feeble to make moan or sign, the hospital spoon was put between his lips, with the mouthful of strong broth or hot wine which rallied him till the watchful nurse came round again. The meat from that kitchen was tenderer than any other ; the beef-tea was more Savory. One thing that came out of it was a lesson on the saving of good cookery. The mere circumstance of the boiling water being really boiling there made a difference of two ounces of rice in every four puddings, and of more than half the arrowroot used. The same quantity of arrowroot which made a pint, thin and poor, in the general kitchen, made two pints, thick and good, in Miss Nightingale’s.

Then there was the difference in readiness and punctuality. Owing to cumbrous forms and awkward rules, the orderlies charged with the business were running round almost all day about the food for their wards; and the patients were disgusted with it at last. There were endless orders and details, whenever the monotonous regular diet was departed from; whereas the establishment of several regular diets, according to the classifications in the wards, would have simplified matters exceedingly. When everything for dysentery patients, or for fever patients, or for certain classes of wounded was called “ extra diet,” there were special forms to be gone through, and orders and contradictions given, which threw everything into confusion, under the name of discipline. The authority of the ward would allow some extra, —• butter, for instance ; and then a higher authority, seeing the butter, and not knowing how it came there, would throw it out of the window, as “ spoiling the men.” Between getting the orders, and getting the meat and extras, and the mutual crowding of the messengers, some of the dinners were not put on the fire till an hour or two after the fainting patient should have had his meal: and then, of course, he could not take it. The cold mutton-chop with its opaque fat, the beef with its caked gravy, the arrowroot stiff and glazed, all untouched, might be seen by the bedsides in the afternoons, while the patients were lying back, sinking for want of support. Probably the dinners had been brought up on a tray, cooling all the way up-stairs and along the corridors ; and when brought in, there was the cutting up, in full view of the intended eaters, — sometimes on the orderly’s own bed, when the tables were occupied. Under such a system, what must it have been to see the quick and quiet nurses enter, as the clock struck, with their hot-water tins, hot morsels ready-cut, hot plates, bright knife and fork and spoon, — and all ready for instant eating ! This was a strong lesson to those who would learn ; and in a short time there was a great change for the better. The patients who were able to sit at table were encouraged to rise, and dress, and dine in cheerful company, and at the proper hour. It was discovered, that, if an alternation was provided of soups, puddings, fish, poultry, and vegetables, with the regular beef dinner, the great mass of trouble about extras was swept away at once ; for these varieties met every case in hospital except the small number which required slops and cordials, or something very unusual. By this clearance, time was saved to such an extent that punctuality became possible, and the refusal of food almost ceased.

All these details point to the essential badness of the system of requisitions. In the old days, when war was altogether a mass of formalities, —and in peace times, when soldiers and their guardians had not enough to do, and it was made an object and employment to save the national property by hedging round all expenditure of that property with difficulties, the system of requisitions might suit the period and the parties. Amidst the rapid action and sharp emergencies of war it is out of place. It was found intolerable that nothing whatever could be had, — not a dose of medicine, nor a candle, nor a sheet, nor a spoon or dish, nor a bit of soap,—without a series of permits, and applications, and orders, and vouchers, which frittered away the precious hours, depressed the sick, worried their nurses, and wasted more of money’s worth in official time, paper, and expensive cross-purposes than could possibly have been saved by all the ostentatious vigilance of the method. The deck-loads of vegetables at Balaklava, thrown overboard because they were rotten before they were drawn, were not the only stores wasted for want of being asked for. When the Scutari hospitals had become healthy and comfortable, there was a thorough opening-out of all the stores which had before been made inaccessible by forms. No more bedsteads, no more limejuice, no more rice, no more beer, no more precious medicines were then locked away, out of the reach or the knowledge of those who were dying, or seeing others die, for want of them.

One miserable consequence of the cumbrous method was, that there was no certainty at any hour of some essential commodity not falling short. It would have been a dismal day for the most suffering of the patients when there was not fuel enough to cook “ extras,” if Miss Nightingale had not providently bought four boat-loads of wood to meet such a contingency. It was a dreadful night in the hospital, when, as cholera patients were brought in by the score, the surgeons found there were no candles to be had. In that disease, of all maladies, they had to tend their patients in the dark all night; and a more shocking scene can scarcely be conceived.

Every great influx of patients was terrible, whether from an epidemic or after a battle ; but experience and devotedness made even this comparatively easy before the troops turned homewards.

The arrival of a transport was, perhaps, the first intimation of the earlier battles. Then all was hurry-skurry in the hospitals ; everybody was willing to help, but the effectual organization was not yet ready.

Of every hundred on board the transport, an average of ten had died since leaving the Crimea. The names and causes of death of these men ought to be recorded; but the surgeons of the transport are wholly occupied in despatching their living charge to the hospital; and the surgeons there have enough to do in receiving them. Attempts are made to obtain the number and names and injuries of the new patients : there may or may not be a list furnished from the ship ; and the hospital surgeons inquire from bed to bed : but in such a scene mistakes are sure to arise ; and it was found, in fact, that there was always more or less variation between the numbers recorded as received or dead and the proper number. No one could wonder at this who had for a moment looked upon the scene. The poor fellows just arrived had perhaps not had their clothes off since they were wounded or were seized with cholera, and they were steeped in blood and filth, and swarming with vermin. To obtain shirts and towels was hard work, because it had to be proved that they brought none with them. They were laid on the floor in the corridors, as close as they could be packed, thus breathing and contaminating the air which was to have refreshed the wards within. If laid upon so-called sheets, they entreated that the sheets might be taken away ; for they were of coarse canvas, intolerable to the skin. Before the miserable company could be fed, made clean, and treated by the surgeons, many were dead; and a too large proportion were never to leave the place more, though struggling for a time with death. It was amidst such a scene that Florence Nightingale refused to despair of five men so desperately wounded as to be set aside by the surgeons. The surgeons were right. As they said, their time was but too little for the cases which were not hopeless. And Florence Nightingale was right in finding time, if she could, to see whether there was really no chance. She ascertained that these five were absolutely given over; and she and her assistants managed to attend to them through the night. She cleaned and comforted them, and had spoonfuls of nourishment ready whenever they could be swallowed. By the morning round of the surgeons, these men were ready to be operated upon ; and they were all saved.

It would have been easier work at a later period. Before many months were over, the place was ready for any number to be received in peace and quietness. Instead of being carried from one place to another, because too many had been sent to one hospital and too few to another, the poor fellows were borne in the shortest and easiest way from the boat to their beds. They were found eager for cleanliness ; and presently they were clean accordingly, and lying on a good bed, between clean, soft sheets. They did not come in scorbutic, like their predecessors ; and they had no reason to dread hospital gangrene or fever. Every floor and every pane in the windows was clean ; and the air came in pure from the wide, empty corridors. There was a change of linen whenever it was desired ; and the shirts came back from the wash perfectly sweet and fresh. The cleaning of the wards was done in the mornings, punctually, quickly, quietly, and thoroughly. The doctors came round, attended by a nurse who received the orders, and was afterwards steady in the fulfilment of them. The tables of the medicines of the day were hung up in the ward; and the nurse went round to administer them with her own hand. Where she was, there was order and quietness all day, and the orderlies were worth twice as much as before the women came. Their manners were better; and they gave their minds more to their business. The nurse found time to suit each patient who wished it with a book or a newspaper, when gifts of that sort arrived from England. Kind visitors sat by the beds to write letters for the patients, undertaking to see the epistles forwarded to England. When the invalids became able to rise for dinner, it was a turningpoint in their case ; and they were soon getting into the apartment where there were games and books and meetings of old comrades. As I have said before, those who died at these hospitals were finally scarcely more than those who died in—not the hospitals — but the barracks of the Guards at home.

What were the changes in organization needed to produce such a regeneration as this ?

They were such as must appear to Americans very simple and easy. The wonder will be rather that they were necessary at last than that they should have been effected with any difficulty. But Americans have never known what it is to have a standing army as a longestablished and prominent national institution ; and they can therefore hardly conceive of the strength of the classspirit which grows up in the various departments of the military organization. This jealousy, egotism, and stiffness of prejudice were much aggravated by the long peace, in which a great rusting of the apparatus of the system took place, without at all impairing the complacency of those who formed a part of it. The old medical officers were incapable, pedantic, and jealous; and no proper relation had ever been established between them and the military authorities. The imbecility of the system cost the lives of others than the soldiers who died in hospital. Brave men arose, as in all such crises, to bear the consequences of other men’s mistakes, and the burden of exposing them; and several physicians and surgeons died, far from home, in the effort to ameliorate a system which they found unworkable. The greatest benefactor in exhibiting evils and suggesting remedies, Dr. Alexander, lived to return home, and instigate reforms, and receive the honors which were his due ; but he soon sank under the consequences of his labors. So did Lord Herbert, the Secretary of War, to whom, in conjunction with Miss Nightingale, the British army, at home, in India, and everywhere, owes its redemption from special sickness and undue mortality. In America the advantages may be enjoyed without tax or drawback. The citizens are accustomed to organize themselves for action of all sorts; and no stiff-necked classes stand in the way of good management. The difficulty in America must rather be to understand how anything so perverse as the management of British military hospitals ten years ago can have existed to so late a date.

It was supposed, ten years since, that there must be nine separate departments in every Military General Hospital, and the officials bore titles accordingly; but there was such an odd confusion in their functions that every one of the nine was often seen doing the business of some other. The medical officers were drawing corks and tasting wines and inspecting provisions, when they should have been by the bedside. The purveyor was counting the soldiers’ money, and noting its amount, when he should have been marketing, or ordering the giving out of the provisions for the day. The paymaster Could scarcely find time to discharge the bills, so much was his day filled up with doing eternal sums about the stoppages in the pay of the patients. There were thirteen kinds of stoppages in the army, three of which were for the sick in hospital : the paymaster could never be quite certain that he had reckoned rightly with every man to the last penny ; the men were never satisfied ; and the confusion was endless. The commissariat, the purveyor, and the paymaster were all kept waiting to get their books made up, while soldiers were working the sums, — being called from their proper business to help about the daily task of the stoppages. Why there should not be one uniform stoppage out of the pay of men in hospital no person of modern ideas could see; and the paymaster’s toils would have been lessened by more than one-half, if he had had to reckon the deduction from the patients’ pay at threepence or fonrpenee each, all round, instead of having to deal with thousands per day individually, under three kinds of charge upon the pay.

The commandant’s post was the hardest,— he being supposed to control every province, and have every official under his orders, and yet being powerless in regard to two or three departments, the business of which he did not understand. The officers of those departments went each his own way ; and all unity of action in the establishment was lost. This is enough to say of the old methods.

In the place of them, a far simpler system was proposed at the end of the war. The eternal dispute as to whether the commandant should be military or medical, a soldier or a civilian, was set aside by the decision that he should be simply the ablest administrator that could be found, and be called the Governor, to avoid the military title. Why there should be any military management of men who are sick as men, and not as soldiers, it is difficult to see; and when the patients are about to leave the hospital, a stated supervision from the adjutant-general’s department is all that can be required. Thus is all the jealousy between military and medical authority got rid of. The Governor’s authority must be supreme, like that of the commandant of a fortress, or the commander of a ship. He will not want to meddle in the doctors' professional business; and in all else he is to be paramount, — being himself responsible to the War-Office. The office, as thus declared, is equivalent to three of the nine old ones, namely, the Commandant, the Adjutant-General, and the Quartermaster-General.

Next to the Governor, the Chief Medical Officer must be the most important man in the establishment. He is to be concerned with professional business only, and to see that all under him are to be devoted in the same way. For this purpose there must be an end to the system of requisitions. There must be a Steward, taking his orders from the Governor alone, and administering a simple and liberal system of diets and appliances of all sorts. It is his business to provide everything for the consumption of the establishment, and to keep the contractors up to their duty. The Treasurer’s function speaks for itself. All the accounts and payments under the Governor’s warrant are in his charge.

There is one more office, rendered necessary by the various and active service always going on, — the superintendent of that service, or Captain of the Wards. He is to have the oversight of the orderlies, cooks, washers, and storekeepers ; he is to keep order throughout the house ; and he is to be referred to in regard to everything that is wanted in the wards, except what belongs to the department of the medical officers or the steward.

As for the medical department, there is now a training provided for such soldiers as wish to qualify themselves for hospital duty. Formerly, the hospital was served by such men as the military officers thought fit to spare for the purpose ; and they naturally did not send the best. These men knew nothing of either cleaning wards or nursing patients. Their awkwardness in sweeping and scouring and making beds was extreme; and they were helpless in case of anything being wanted to a blister or a sore. One was found, one day, earnestly endeavoring to persuade his patient to eat his poultice. It is otherwise now. The women, where there are any, ought to have the entire charge of the sweeping and cleaning,—the housemaid’s work of the wards ; and as to the rest, the men of the medical-staff corps have the means of learning how to dress a blister, and poultice a sore, and apply plasters, lint, and bandages, and administer medicine, and how to aid the sick in their ablutions, in getting their meals with the least fatigue, and so on.

Of female nurses it is not necessary to say much in America, any more than in England or France. They are not admissible into Regimental Hospitals, in a general way; but in great military and civil hospitals they are a priceless treasure.

The questions in regard to them are two. Shall their office be confined to the care of the linen and stores, and the supplying of extra diets and comforts ? If admitted to officiate in the wards, how far shall that function extend ?

In England, there seems to be a strong persuasion that some time must elapse, and perhaps a generation of doctors must pass away, before the ministration of female nurses in military hospitals can become a custom, or even an unquestioned good. No rational person can doubt what a blessing it would be to the patients to have such nurses administer nourishment, when the rough orderlies would not have discernment or patience to give the frequent spoonful when the very life may hang upon it. Nobody doubts that wounds would be cleansed which otherwise go uncleansed, — that much irritation and suffering would be relieved which there are otherwise no hands to undertake. Nobody doubts that many lives would be saved in every great hospital from the time that fevered frames and the flickerings of struggling vitality were put under the charge of the nurses whom Nature made. But the difficulties and risks are great. On the whole, it seems to be concluded by those who know best, that only a few female nurses should be admitted into military and naval hospitals : that they should be women of mature age and ascertained good sense, thoroughly trained to their business : that they should be the women who have been, or who would be, the head nurses in other hospitals, and that they should be paid on that scale: that they should have no responsibility, — being wholly subject to the surgeons in ward affairs, and to their own superintendent in all others : that no enthusiasts or religious devotees should be admitted, — because that very qualification shows that they do not understand the business of nursing: that everything that can be as well done by men should be done by trained orderlies: that convalescents should, generally speaking, be attended on by men, — and if not, that each female nurse of convalescents should have a hundred or so in her charge, whereas of the graver cases forty or fifty are as many as one nurse can manage, with any amount of help from orderlies. These proposals give some idea of what is contemplated with regard to the ordinary nurses in a General Military Hospital. The superintendent of the nurses in each institution must be a woman of high quality and large experience. And she will show her good sense, in the first place, by insisting on a precise definition of her province, that there may be no avoidable ill-will on the part of the medical officers, and no cause of contention with the captain of service, or whatever the administrator of the interior may be called. She must have a decisive voice in the choice of her nurses; and she will choose them for their qualifications as nurses only, after being satisfied as to their character, health, and temper.

No good nurse can endure any fuss about her work and her merits. Enthusiasts and devotees find immediately that they are altogether out of place in a hospital,—or, as we may now say, they would find this, if they were ever to enter a hospital : for, in fact, they never now arrive there. The preparation brings them to a knowledge of themselves ; and the two sorts of women who really and permanently become nurses are those who desire to make a living by a useful and valued and well-paid occupation, and those who benevolently desire to save life and mitigate suffering, with such a temper of sobriety and moderation as causes them to endure hardship and ill-usage with firmness, and to dislike praise and celebrity at least as much as hostility and evil construction. The best nurses are foremost in perceiving the absurdity and disagreeableness of such heroines of romance as flourished in the press seven years ago, — young ladies disappointed in love, who went out to the East, found their lovers in hospital, and went off with them, to be happy ever after, without any anxiety or shame at deserting their patients in the wards without leave or notice. Not of this order was Florence Nightingale, whose practical hard work, personal reserve, and singular administrative power have placed her as high above impeachment for feminine weaknesses as above the ridicule which commonly attends the striking out of a new course by man or woman. Those who most honor her, and most desire to follow her example, are those who most steadily bring their understandings and their hearts to bear upon the work which she began. Her ill-health has withdrawn her from active nursing and administration; but she has probably done more towards the saving of life by working in connection with the War-Office in private than by her best-known deeds in her days of health. Through her, mainly, it is that every nation has already studied with some success the all-important subject of Health in the Camp and in the Hospital. It now lies in the way of American women to take up the office, and, we may trust, to “ better the instruction.”