Digitized by tine Internet Arcliive in 2014 Iittps://arcliive.org/details/b20387118 NOTES ON MATTERS AFFECTING THR HEALTH, EFFICIENCY, AND HOSPITAL ADMINISTRATION OF THE BRITISH ARMY. NOTES ON MATTERS AFFECTING THE HEALTH, EFFICIENCY, AND HOSPITAI, ADMINISTRATION OF THE BRITISH ARMY, FOUNDED CHIEFLY ON THE EXl'ERIBNCE OF THE LATE WAR. BY FLORENCE NIGHTINGALE. grtsentcb by request to tbc ^fcrctarj) of ^^tutc for Wint. LONDON ; PRINTED BY HARRISON AND SONS, ST. MARTIN'S LANE, W.C. 1858. CONTENTS. PAGES. Instructions from Secretary of State Digest v — xix General Preface ... 1 — 12 Introductory 1, 2 Preface to Section I i — xxx Abstract of the Proceedings of the Director-General I. — Notes on the Sufferings and Privations of the Army, from April, 1854, to the beginning of 1855 .... 3 — G6 Appendix I to Section I i — xxx Abstract of the Correspondence of the Principal Medical Officer Appendix II to Section I xxxi— xlvii Abstract of the Correspondence of the Divisional and other Medical Officers Preface to Section II i— iv Mortality of Sick on Board the Sick Transport Ships il II. CONTENTS. .—Notes on the Deficiencies of Sick Transport PAGES. 67—80 Preface to Section III .... ^ ^^'^ Abstract of the Sanitary Recommendations made by the Medical Authorities regarding the Hospitals at Scutari Addenda on the subject of the need of Sanitary Reforms at Scutari xi*-xxxiv III —Notes on the causes of Disaster at Scutari 81—139 IV —Resume of the Evidence as to (1) the Crimea (2) the Sick Transport (3) the Scutari Hospitals in the Winter of 1854-5 140—151 v.— Further Hospital History —Notice of the first Em- ployment of Female Nurses, of the Employment of a Corps of Male Nurses, and of the Arrival of the Sanitary Commission .. - 152—163 VI.— Some General Conclusions from the Hospital History of 1854-55-56 164—176 Note on the Administration of Medicines VII.— Detached Memoranda on the Operation of the Regimental System of Hospital Treatment .... 177 — 199 VIII. — Notes on the existing Organization for General Hospitals 200—217 IX. — Propositions as to General Hospitals 218 — 234 CONTENTS. iii PAGES. Preface to Section X i— xliv Part I. — Authorities for the Statistics used in the Section, with an Inquiry as to their Sufficiency .... i— xxxiii Part II. — Abstract of Sanitary Recommendations made by the Medical Authorities, regarding the Camp in the Crimea xxxiv— xliv X. — Notes on the necessity of Special Sanitary Function- aries, in connection with Military Hospitals and with the Army in General, both abroad and at home 235—287 XI. — Notes on the Inaccuracy of Hospital Statistics and the necessity of a Statistical Department .... 288 — 332 Appendix I to Section XI i — xi Actual and Proposed Forms for Medical Statistics in the Army Appendix II xii — xvii Sources of the Statistics used in the Section Note to p.p. 315, 316. xviii — xxvii The Amount of the Soldier's Duties as a Cause of the Mortality in the Crimea xviii — xxii Further Remarks on the greater Mortality in certain Corps, with Statistics of the number constantly Sick XXIII — XXVII XII. — Education, Employment, and Promotion of Medical Officers 333—396 XIII. — Notes as to Pay and Stoppages 397_4()1 XIV. — Notes on the Dieting and Cooking of the Army .... 402—425 IV CONTENTS. PAGES. XV.— Notes on the Functions of the Commissariat in connection with the Supply of Food for the Army 426—448 XVL— On Washing and Canteens 448—456 XVII. — Soldiers' Wives 457—476 XVIII. — Construction of Hospitals, especially for the Army Concluding Remarks on the Mortality of Armies in Peace and in War Summary of Defects and Suggestions Walcheren Expedition 477—491 492—520 521—546 547—556 Appendix to Section XIV i— lviii Scheme of Rations for Soldiers i— viii Dr. Christison's Observations thereon viii — x Dr. Christison on the Soldier's Ration xi — xvii Dietary of Emigrant Ships xviii Notes on " Extra " Hospital Diets xix — xx Five Examples of Hospital Diets xx — xxxviii Receipts for Cooking in Military Hospitals .... xxxix — lviii Sanitary Notes on Encampments .... 557—563 Postscript on Sanitary Matters in India 565—567 DIGEST. PAGES Letter of Instructions from the Secretary of State . . Preface GENERAL PREFACE 1-12 History of the health of British armies . . . . 1 Walcheren Expedition . . . . . . . . . . 2 Peninsular War. . .. .. .. .. .. 3-5 Number of constantly sick in the Peninsular War compared with the same in the Crimea . . . . 5-7 Mortality compared . . . . . . 8, 9 General Hospitals compared . . . . . . . . 9, 10 Need of General Hospitals in time of peace . . .. 11, 12 Introductory . . . . . . . . . . . . . . 1, 2 PREFACE TO SECTION I i-xxx Abstract of the Proceedings of the Director-General : Commission sent to Turkey . . . . . . . . ii State of things at Gallipoli . . . . . . . . iii Director- General's recommendations as to clothing rejected . . . . . . . . . . iv, v Sanitary Report set aside as to the Hospital at Varna vi, vii Want of vegetables, &c., in the Crimea in October, 1854 . . . . . . . . . . . . viii, ix Sanitary correspondence in November, 1854 . . x, xi Anticipations of scurvy, it being already rife . . . xii, xiii Dr. Hall's Report in January, 1855 . . . . . . xiv, xv Clothing Store at Scutari . . . . . . . . xvi. Arrival of lime juice . . . . . . . . . . xvii Dr. Hall on Burials, and on representing evils . . xviii, xix Dr. Smith on Vermin . . . . . . . . . . xx Dr. Hall on Scutari . . . . . . . . . , xxi Dr. Smith preparing for the Sebastopol Committee . . xxii, xxiii DIGEST. PAGES Dr. Hall congratulates Dr. Smith on the state of the Army . . . . . . • • • • • • • • xxiv, xxv Sanitary awakening at Scutari xxvi Conclusions: 1. Sanitary xxvii 2. As to Supply xxviii Corrections . . . . . • • • • • • • xxix Observations . . . . . . • • • • • • xxx I. Notes on the Sufferings and Privations of the Army PROM April, 1854, to the beginning of 1855 . . . . 3-66 Lord Eaglan's Orders of May . . . . . . . . 4 Neglect of the Orders of May . . . . . . . . 5-7 Principal Medical Officer's position . . . . . . 8, 9 Evidence as to the Army's sufferings . . . . . . 10 Lord Cardigan's evidence .. .. .. .. 11, 12 Evidence of Medical Officers . . . . . . . . 13-15 What was the supposed ample supply of medical com- forts 16, 17 Actual supply up to December, 1854 . . . . . . 18-22 Evidence as to the privations of the Army . . . . 23-32 Zymotic preventible disease in the Army . . . . 33, 34 Evidence of Medical Officers . . . . . . 35-37 Evidence of Commanding Officers . . . . . . 38-42 System of Requisitions . . . . . . . . 43, 44 Evidence of Commanding Officers . . . . . . 45, 46 Evidence of Purveyor .. .. .. .. 47-49 Evidence of Commanding Officers . . . . . . 50 State of things at Scutari . . . . . . . . 51 Official views as to the Hospitals at Scutari . . . . 52-55 Actual supply of stores at Scutari, November, 1854. . 56, 57 ditto ditto January, 1855 . . 58, 59 Conclusions from the foregoing evidence . . . . 60-66 APPENDIX L TO SECTION I i-xxx Classified Abstract of the Correspondence of the Pkincipal Medical Officer 1. Diet in the Crimea during winter 1854-1855 i-iv 2. Clothing y 3 . Construction and repairs of Hospitals in Crimea. . v, vi 4. Hospital supplies, &c., Bulgaria and the Crimea vi-xii ^- ^cu^^ari xiii-xv 0. Camp sanitary arrangements xv-xviii DIGEST. vii PAGES Keview of the Principal Medical Oflficer's correspond- ence as to its practical bearing . . . . . . xviii-xxi Province of the Principal Medical Oflficer . . . . xxi, xxii General defects of procedure in reference to sanitary advice . . . . . . . . . . . . xxii-xxiv Methods of consultation followed in public depart- ments . . . . . . . . . . . . xxiv-xxvi Proposed rules for taking sanitary advice . . . . xxvi, xxvii Ditto on field service . . . . . . , . xxviii-xxx APPENDIX II. TO SECTION I xxxi-xlvii Abstract op the correspondence of the Divisional AND OTHER MeDICAL OFFICERS Cholera shows itself in Bulgaria, and is written against . . . . . . . . . . xxxii-xxxv Scurvy appears in the Crimea, and is written against xxxv Want of blankets, cooking places, and fuel repre- sented. . . . . . . . , . . . xxxvi-xxxix Want of medical comforts and transport to Balaklava represented . . . . . . . . . . . . xl, xli Green coffee, deficient rations. . . . . , . . xlii, xliii Board of Health recommended in March, 1855 . . xliv, xlv Concluding remarks . . . . . . . . . . xlvi, xlvii PREFACE TO SECTION IT i-iv Mortality on board sick transport ships II. Notes on the Deficiencies of Sick Transport . . 67-80 Want of combination . . . . 68-70 Evidence as to the state of the sick transports . . 71-80 PREFACE TO SECTION III. Abstract of the Sanitary Recommendations made by THE Medical Authorities regarding the Hospitals at Scutari . . . . . . . . . . . . i-xxxiv As to the General and Barrack Hospitals . . . . ii, iii Preparations made up to December, 1854 . . . . ir, v Correspondence up to February, 1855 . , . . vi, vii DIGEST, PAGES Eeview of the Recommendations Comparison of the actual evils with the recommenda- tions , . Addenda on the subject of the Need of Sanitary Reforms at Scutari Report made by Lord W. Paulet Dr. Cumming's Correspondence and Reports to the Director-General, April, 1855 Remarks on the Preceding Correspondence Sanitary defects discovered by the Sanitar}- Commis- sion . . Remedies applied by the same Understatement of mortality in Scutari Hospitals . . Mortality on board sick transports and at Scutari com- pared . . At Balaklava and at Scutari compared Correct statement of mortality in Scutari Hospitals Comparison with rate of mortality in London Hos- pitals Curious methods of calculating mortality in use Note as to Commandant's statements about ladies and nurses . . . . . . . , . . , , xxxii Note as to Dr. Dumbreck's ditto . . . . xxxiii, xxxiv Return of provisions supplied by Purveyor for extra diet kitchen, and nurses XI, xii xxi-xxxiv xxi, xxii xxii, xxiii xxiii, xxiv xxv xxvi, xxvii xxviii XXX, XXXI Notes on the causes of disaster at Scutari . . 81-139 Five causes of mortality in Scutari Hospitals. . . . 82 1. Overcrowding . . . . . . . . . . 83-86 2. Bad ventilation 87-89 3. Bad drainage . . . . . . . . . . 89-97 4. Dirt 97-110 As to deficiency of washing . . . . . . 97-108 As to floors and walls . . . . . . . . 108 As to personal cleanliness . . . . . . . . 109, 110 5. Want of Hospital comforts . . .. .. 111-121 As to bad cookery .. .. .. 111-115 As to shirts and utensils . . . . . . . , 115-121 Vicious system of requisitions. . . . . . . . 121-1 23 Want of means for receiving and issuing stores . . 123-126 Dr. Smith's representation of the Scutari case . . 126-132 Mortality among operations consequent upon the condition of the Hospitals 132, 133 DIGEST. ix rAGE« Dn Menzies' view of the case . . . . . . . . 133-135 Kcpresentations made by the Hospital Commissioners 135-139 IV. Kesume of the evidence as to (1) THE Crimea, (2) the Sick Tkansport, (3) the Scutaei Hospitals, in the WINTER OF 1854-1855 Note as to methods of computing mortality , . Decrease of mortality after sanitary improvements . . Note as to Hospital Kit . . The soldiers came to Scutari with nothing Private supply essential . , Pack store at Scutari V. Further Hospital history; Notice op the First Employment op Female Nurses, of the Employment OF A Corps of Male Nurses, and op the arrival of the Sanitary Commission.. .. .. .. .. 152-163 Duties and employments of the first female nurses . . 155-161 Soldiers' wives . . . . . . . . . . . . 162 Employment of Medical Staff Corps . . . . . . 163 Arrival of Sanitary Commission .. .. .. 163 VI. Some general Conclusions from the Hospital history of 1854, 1855, 1856 164-176 Six evils to be noticed in the Hospital history . . 164, 165 Five deficiencies in the provisions made by the Army Medical Department . . .. .. .. 166 Four expedients adopted during the Crimean War . . 167 Confusion between Medical and Purveying depart- ments . . 168, 169 Want of discipline in Military Hospitals . . . . 170 Want of responsibility in the Apothecary's department 171, 172 Want of training of Medical StatF Corps . . . . 172 Want of specialties in the Purveyor's department . . 173-175 V/ ant of Economy in dispensing .. .. .. 176 Note on the administration of medicines Vn. Detached Memoranda on the Operation of the Regimental System of Hospital Treatment . . . . 177-199 Exclusively regimental character of our whole Hospi- tal system 177-179 Three defects of the system 179-182 Nine defects in regimental Hospitals. . . . . . 183 Three desiderata for the Army Medical Department 184 Five obstacles to obtaining the same under the present system . . . . . . . . . . 185 140-15] 142-144 144-146 146-151 148 149 151 X DIGEST. ^ PAGES Permanent Divisional Hospitals desirable . . . . 186, 187 Duties of the Hospital-Serjeant 188 Organization required to perform these duties . . 189 Organization of General Hospitals necessary in time of peace •• 190,191 Two arguments urged in favour of Regimental Hos- pitals refuted • • • • 1^2 Absence of all system of attendance {not medical) in Army Hospitals 193, 195 Sketch of the Hospital Service— Of the French and Sardinians 195,196 Of the English 197, 198 Of the Russians 19^ Vni. Notes on the existing Okganization for General Hospitals 200-217 Nine Departments at present concerned in the management ; their duties, and deficiencies — ^ 1. Medical 200 2. Commissariat 201, 202 3. Purveyor's 203-209 4. Engineer's 209-212 5. Adjutant-General's . . . . . . . . 213 6. Quartermaster-General's . . . . . . 213 7. Contractor's . . . . . . . . . . 214 8. Paymaster's . . . . 214 9. Commandant's.. .. .. .. .. 215, 216 Note as to nine necessary conditions in organizing an Army Hospital System .. .. .. .. 216,217 IX. Propositions as to General Hospitals. . . . . . 218-234 Twelve regulations proposed as to organization . . 218, 219 Five departments proposed — their duties — 1. Governor's . . . . . . . . . . 220 2. Medical 221 3. Steward 222,223 4. Captain of Orderlies 224, 225 5. Treasurer . . . . . . . . . . 226 Necessity of the sanitary element 227-230 Necessity of providing a hospital-kit, &c 230-233 Necessity of training hospital attendants . . . . 233, 234 PREFACE TO SECTION X i-xliv Part I. Authorities for the Statistics used in the Section, with an Inquiry as to their sufficiency . . i-xxxiii DIGEST. XI PAGES Comparison of rates of mortality in army serving at home before and after 1845 . . . . . . . . ii How to correct the mortality for eacli arm of tlic service . . . . . . . . . . . . ii, iii Corrected Table of the mortality of each arm of the service at home during the ten years ending 1846 iv, v Table of mortality of army at home and abroad, 1839-1853 v-vii Excess of deaths in the army over those in civil life vii Kates of mortality in the army abroad before and after 1837 . . . . viii, ix Considerations of I. Eecruiting, and II. Invaliding, which prevent the accuracy of any comparison be- tween rates of mortality in the army and in civil life , .. .. X I. Statistics of Reicruiting . . . . . . . . xi-xv Their incompleteness . . . . . . . . . . xii Rejection of unhealthy lives in recruiting . . . . xiv Occupations of recruits . . . . . . . . xv II. Statistics of Invaliding . . . . . . . . xvi-xxxii Apparent reduction of mortality effected by invaliding in the army . . . . . . . . . . . . xvi At home . . . . . . . . . . . . xvii At home and abroad . . . . . . . . xviii Rate of invaliding to strength at home . . . . xviii Defect in this kind of statistics . . . . . . xix Strength, deaths, and invaliding in army at home and abroad . . . . . . . . . . . . xx Defect of system of averages in vital statistics . . xxi-xxv Tables showing the accumulated loss by death and invaliding . . . . . . . . . . . . xxvi-xxviii Loss of veterans to the Army as it is and as it might be . . . . . . . . . . . . xxviii-xxix Causes of invaliding. Actual numbers . . . . xxx, xxxi Proportions . . . . . . xxxii Summary . . . . . . . . . . . . xxxiii Part II. Abstract of Sanitary Recommendations made by the Army Medical Officers of the Expedition to the East xxxiv-xliv In Bulgaria . . . . . . . . . . , . xxxv At Scutari . . . . . . . . . . . . xxxv In the Crimea . . . . . . . . . . , . xxxvi On the Camp . . . , . . . . , . . . xxxvii-xli At Balaklava . . . . . . . . . . . . xlii-xliv General observations on the same . . . . . . xliv XII DIGEST. X. Notes on the Necessity or Special Sanitary Func- tionaries IN connection with Military Hospitals, and WITH THE Army in General both Abroad and at Home 235-287 What was done by the Sanitary Commission at Scutari 237, 238 At Balaklava 241, 242 At the Camp 243-245 Absence of sanitary knowledge in medical men . . 246 Excessive Mortality of the Army in time or Peace 274 Excessive amount of sickness in the army in time of peace . . 248-250 Excessive mortality from consumption in the Guards 251 Comparison of mortality of Guards and of Metropo- litan Police 252 Of City Police 253 Mortality of army ought to be less than that of civil life, and is double . . . . . . . . . . 253, 254 Mortality among pensioners within twelve months after being pensioned raises mortality of army still higher 555-261 Concluding remark , . . . . . . . . . 262 Overcrowding in our barracks one main cause . . 263, 264 And in our military hospitals. . . . . . . . 264-267 Four Propositions for carrying out Sanitary Im- provements in the Army . . . . . . . . 268, 269 Propositions for carrying out immediate sanitary im- provements in the army considered in further detail 270-287 1. Reconstitution of the Army Medical Board. . Five plans of introducing the sanitary department . . . . . . . . 270-272 Transition period to be provided for . . 272 Medical and sanitary functions essentially distinct . . . . . . . . 273 Examples— Scutari . . . . . . . . 274 Balaklava . . . . . . 275 Netley 276 Hygiene of buildings and towns a special function, should be made so in the army, leaving the personal hygiene of the men to the medical oflScers . . . . . . 276-281 2. Appointment of an immediate Sanitary Com- mission for Barracks and Hospitals . . . . 281-283 3. School of Military Hygiene 283-286 4. Revision of sanitary regulations . . . . 286, 287 DIGEST- xiii PAGES XI. Notes on the Inaccuracy of Hospital Statistics, and THE Necessity op a Statistical Department . . 288-332 Inaccuracy of the statistics of death . . . . . . 289-291 Standard of comparison as to mortality all over the civilized world is the percentage of deaths per annum ; in the army it is per week . . . . 292-295 What statistics are requisite for a Commander of the Forces 296 What he has now . . . . . . . . . . 297 Novel methods in the army of calculating mortality in hospitals 298-300 Way in which returns were made at Scutari. . . . 301, 302 Diseases and causes of diseases of Army in Crimea. . 303 Absence of any system for abstracting and publishing the Army Medical records . . . . . . . . 304-306 Necessity for a Pathological Department . . . . 306 Way in which cases were registered at Scutari . . 307 Necessity for a registrar . . . . . . . . 308 Excess of burials over reported deaths at Scutari . . 309 Utter confusion and inaccuracy of our hospital statistics . . . . . . . . . . . . 310 Ignorance as to the prevalence of scurvy in the army 311 Vital importance of accurate statistics of disease . . 312, 313 Comparison of zymotic disease in the army in the East, and in civil life . . . . . . . . 314 Comparison cf zymotic deaths and deaths from wounds in an army in time of war . . .. .. 315 Comparison of mortality in Army and in Naval Brigade 316 Account of a soldier's day in the trenches .. .. 317-319 Mortality in the Crimean army month by month . . 320, 321 Contrast shown by Naval Brigade 322 Imperfect nomenclature of disease . . . . . . 323 Necessity of a Statistical Department for the army in general 324-329 Principles for a Military Statistical Department . . 330-332 APPENDIX TO SECTION XI. Actual and Proposed Forms for Medical Statistics in the Army . . . . . . . . . . . . i-xi Medical statistics should indicate causation of disease i, ii Present form of classification . . . . . . . . ii Proposed form . . . . . . . . . . . . iii XIV DIGEST. Suggestions for constructing a sanitary nomenclature of disease . . • • • • ■ • • • ' ' Dr. Farr's classification of diseases of Crimean Army v-ix Dr. Farr's classification of diseases of infantry of line serving at home, and comparison with those of home population , . X, xi APPENDIX II. TO SECTION XI xii-xvii Sources of the Statistics used in the Section : Inaccuracies and discrepancies . . . • • • xii Results given must be regarded as only approxi- mations . . . . . . . . . • • • xiii No one of the official sources agrees with any other . xiii-xvii Four examples of palpable diversity . . NOTE TO PAGES 315, 316 : The amount of the Soldier's Duties as a Cause of THE Mortality in the Crimea . . . . . . xviii-xxii Further Eemarks on the Greater Mortality in certain Corps with Statistics of the Number Con- stantly Sick . . . . . . . . . . . . xxiii-xxvii Admissions into hospital and deaths, in the Crimea and at Scutari respectively, shown, regiment by regiment . . . . . . . . . . . . xxiv-xxvi Number constantly sick nowhere given in any report — attempted to be given here . . . . . . xxvii XII, Education, Employment, and Promotion of Medical Officers 333-390 Present course of the army medical officer . . 333-330 Appointment of Principal Medical Officer to the Expedition to the East . . . . . . . . 336 Logical defect of the whole course of the army medical officer 337-339, 343 Propositions for making the Medical Department purely medical .. .. . .. 339-341 Propositions for having an army pharmacopoeia, and a scheme of Hospital diets . . . . . . . . 342 Suggestions for a Hospital Course for Military Medical Officers 343-353 Four subjects of study 345 34^ DIGEST. XV PAGES Some of the Tutors must be civilians. . .. .. 348-350 Five subsidiary notes on this subject. . .. .. 350-363 Peoposed Army Medical Career 353-357 The First Class Staff" Surgeons should be executive officers 354-356 Consequent new scale of payment . . . . . . 356-361 Standing Commission of Inspection . . . . . . 358-365 Character of the inspections made in the Crimea . . 362, 363 Malingering 365-367 Ee-constitution of Director-General's office .. .. 368-373 Important functions of the Scientific Department . . 369 Proposed Organization of the Army Medical De- partment . , . . . . 370-373 Addenda as to the Selection of the Principal Medical Officer OF an Army on an Expedition, the System of Seniority and that of " Confidential Reports " . . 373-386 System of Seniority 376, 377 System of Confidential Reports 378, 379 Summary of objections felt to the present system of Inspections; to the degradation of a Scientific Department by making it do housekeeping and bookkeeping; to the ""^ working in the dark" by Confidential Reports " 380-382 Uncertainty as to promotion . . . . . . . . 382 Four necessary changes . . . . . . . . 383 True principle of promotion . . . . . . . . 384 Confidential Reports must be abolished . . . . 385 Substantive and relative rank . . . . . . 385, 386 Addenda as to the organization of General Hospitals 386-389 One executive head, with unquestioned responsibility, essential . . . . . . . . • • . . 387 Contrast of Military and Civil Hospitals . . . . 388 Addenda in illustration of the utility of a Standing Commission of Enquiry, as long as no scheme of go- verning General Hospitals exists . . . . . . 389-396 History of the fall of Scutari between two irrespon- sible powers, Lord Stratford de Redclifie and Dr. Menzies, the latter of whom applies for assistance to supply the wants of the hospitals yet asserts that **no want" exists XVI 406-408 408-410 410-412 413 DIGEST. PAGES XIII. Notes as to Pay and Stoppages 397-401 Vexatious action of the multifarious stoppage-system 397 Desirableness of facilitating to the soldier the remit- 1 . . 398, 399 tmg money home •• ,nn\(m Connection of a fixed ration and an uniform stoppage 400, 401 XIV. Notes on the Dieting and Cooking of the Aemy. . 402-425 Hospital kitchens and camp kitchens. . • • 402-40(3 Soyer's portable stoves. . Soyer s receipts for camp cooking Dr. Christison's eight principles of diet Dr. Christison's table of nutriment . . Salt meat not equal to fresh meat in nutritiveness . . 414 Proposed army ration— 28 oz. real nutriment— indis- pensable Actual army ration in the Crimea in the winter of 1854-1855 41'' System of rationing and " messing " .. 418 Hospital Diets : necessity of variety, importance of good cooking, necessity and abuse of ''extras," injustice of hospital stoppage .. .. 419-422 Memorandum regarding proposed ration for the soldier and variety in cooking it . . . . . . 423-425 XV. Notes on the Functions of the Commissariat in connection with the Supply of Food for the Army. . 426-448 Excessive and unnecessary use of salt meat and biscuit in the Crimea during the winter of 1854-5 . . 428-431 Actual issue of fresh meat, vegetable food, fresh bread, &c 432-434 Actual issue of fuel, blankets, &c. . . . . . . 435 Dietetic system in the army the merest hap-hazard. . 436 Mr. Alexander's letter . . .. .. .. 437 Dietary of the soldier must be fixed , . . . . . 438 East Indian Commissariat and French Intendance . . 439-444 Lord Raglan's rspecial intervention in particular exigencies . . . . . . . . . , , . 444, 445 Purveying in Regimental Hospitals according to " warrants," and not according to wants . . . . 446, 447 XVI. On Washing and Canteens 448-456 Washing 448-451 Canteens . . . . . . . . . . . . 451, 452 Reform as to drunkenness accomplished at Scutari. Means used . . . . . . , . . . . . 453-455 Canteens in the Crimea . . . . . . . . 456 DTGEST. XVU PAGES XVII. Soldiers' Wives 457-470 Women " allowed " in barracks .. .. .. 457 Women out of barracks .. .. .. .. 458 Hospital accommodation for sick women, nil . . 459 Leave to marry . . .. .. .. .. .. 460-462 Soldiers' wives in Bulgaria . . . . . . . , 462 Ditto in the Crimea . . . . . . . . . . 463 Ditto at Scutari 464-467 Four improvements recommended . . . . . . 468 Statistics as to soldiers' wives . . . . . . . . 469 What marriage is now with the soldier . . . . 470 Condition of the sick wives .. .. .. 471 Three suggestions for promoting a better morality . . 472 Mischief of recognizing women married without leave 473 Lodging-houses foe married soldiers . . . . 474-6 XYTIL Construction op Hospitals, especially for the Army 477-491 Pavilion system recommended, and why . . . . 477-479 Size of wards 479-482 Proportion and position of windows necessary for light and ventilation; importance of light for reco- very of sick 482-484 Best material for floors and walls . . . . . . 484-485 Hospital kitchen and laundry . . . . . . 486 Accommodation for nurses . . . . . . . . 487 Bedding 487 Water-supply and drainage . . . . . . . . 488, 489 Ventilation and warming. Necessity of artijidal ventilation shows defective construction . . . . 489, 490 CONCLUDING REMARKS .. 492-520 Sanitary Condition of the Army in time of Peace. . 493-609 Loss of life, of service, and of money value entailed on the country in the case of the army, taken on home service only . . . . . . . . . . 498, 499 Classes of disease from which this mortality arises on home service, and their causes . . . . . . 500 1. Consumption .. .. .. .. .. 501 2. Zymotic disease . . . . . . • . 602 Can this excessive mortality be prevented ? . . . . 503, 504 Reasons for seizing on this opportunity to do so . . 605-509 Character of our men for endurance and deliberate uncomplaining fortitude . . . . . . . • 607, 508 xviii mGE^T. PAGES Sanitary Condition of the Aemy in time op War . . 509-517 Zymotic disease the cause of the whole catastrophe in the Crimea • • n ^ ki»7 Mortality in the Scutari Hospitals a separate problem 514-517 Armies perish not by wounds, but by zymotic disease 517 Yalue of the soldier where enlistment is voluntary . . 518, 519 SUMMARY OF DEFECTS AND SUGGESTIONS . . 521-546 I. Field Service 521-524 Defects in sanitary instructions ^21 Defects as to supply Nine general defects of procedure 522-524 II. Field Hospitals in. General Hospitals 525-529 Twelve suggestions . . . . • • • • • • ^^5, 526 Five reasons for separating the office of Treasurer from that of Purveyor 527-529 IV. Sick Transport 529, 530 Y. Hospital Management. . . . • . • • • • 530, 531 YI. Sanitary Officers for Hospitals, Encampments, &c. 532-534 YII. Barracks 534, 535 YIII. Statistics 535-537 IX. Pay and Promotion op Medical Officers . . 537-542 X. Medical Education 542, 543 XI. Rations 543, 544 XII. Cooking 544 XIII. Hospital Construction 544-546 WALCHEREN EXPEDITION 547-556 APPENDIX TO SECTION XIY i-lviii Sir a. Tulloch's Scheme of Dietary for Soldiers .. i, ii Estimate of its probable Cost . . . . . . . . ii-viii Dr. Christison's Observations on the Dietary . . viii-x Dr. Christison's Observations on Soldiers' Rations. . xi-xvii Diet in emigrant ships. . . . . . . . . . xviii Notes upon " extra " hospital diets . . . . . . xix, xx Five Examples of Hospital Diets . . . . . . xx, xxxviii 1. Military Hospitals . . . . . . . , . . xxii 2. Naval . . . . . . . . . . . . xxiii 3. Guy's Hospital . . . . . , . . . . xxiv DIGEST. xix PAGES 4. Edinburgh Infirmary . . . . . . . . xxv-xxx 5. Proposed diets for Military Hospitals . . . . xxxi-xxxiil Nutritive value of the above . . . . xxxiv-xxxvi Instructions as to the above diets . . . . xxxvi-xxxviii Receipts for Hospital Diets and Drinks, by M. Soyer xxxix-lviii Broths . . . . . . . . . . . . ... xl-xlii Fish . . . . . . . . . . . . . . xliii-xlvii Meats . , . . . . . . . . . . . . xlvii, xlviii Puddings . . . . . . . . . . . . xlix-liii Drinks . . . . . . . . . . , . . . liv-lviii SANITARY NOTES ON ENCAMPMENTS .. 557-563 Suggestions 562, 563 POSTSCRIPT 565-567 On the necessity of immediate sanitary measures in India. LIST UK ILIAISTKATIONS. I*lan of Scutari to face p. ix Preface to Section III, p. 80 Diagram showing the Mortality in the Hospitals at Scutari and Koulali p. xxviii, Preface to Section III, p. 80 Diagram of the Causes of Mortality in t!ie Army in the East p. 315 Diagram of the Mortality in the Army in the East p. 820 Camp Kitchens p. 402 Plan of the Lariboisifere Hospital at Paris p. ■^79 War Office, Pall Mall, S.W., ISth February, 1857. Madam, Knowing, as I do, how anxiously you devoted yourself to improve the condition of our soldiers, especially with reference to their treatment in Hospital, I make no apology for asking your further assistance and advice, with the same object. Your personal experience and observa- tion, during the late War, must have furnished you with much important information relating not only to the medical care and treatment of the sick and wounded, but also to the sanatory requirements of the Army generally, and the communication of your opinions upon these sub- jects cannot fail to prove very valuable. It is with this view that I now have the honour to ask you to favour me with the results of that experience, on matters of so much importance to Her Majesty's Army. I need hardly add that, should you do so, they will meet with the most attentive consideration, and that I shall endeavour to further, so far as it lies in my power, the large and generous views which you entertain on this important subject. I have the honour to be. Madam, Your obedient Servant, (Signed) Pan mure. Miss Nightingale. b PREFACE. While tlie proof sheets of the following Notes'' were passing through the press, I received Appendix LXXIX to the Report of the Royal Commission on the Sanitary- State of the Army, containing a mass of correspondence on the care of the Sick and Wounded, and on the Sanitary state of the Army in the East, which had passed between the Director- General, the Principal Medical Officer of the Army in the East, and Medical Officers of Divisions, &c. The whole of these letters have been carefully gone over, and they appear to me to throw so much new light on the administrative defects inherent in the present system of the Army Medical Department, and on the causes of the calamities which befel the Army, during the late War, that I have prefixed to several Sections a classi- fied abstract of the principal documents, not only as con- firmatory of the statements I have made in the text but as indicating the administrative changes necessary for pre- venting similar calamities in future, as far as human foresight can do so. In making use of these documents, it is taken for granted that they include all the correspondence of any consequence bearing on the several subjects referred to, and that none has been kept back. PREFACE. In the following pages I have attempted to fulfil the request of the Secretary of State for War, so far as the state of my health has permitted me. The subject has expanded far beyond the limits which I at first assigned to it. Insensibly the question of Army Hospitals and their defects have become part of wider questions, involving the health and efficiency of the Army, and the means of preserving them. It may be said that such matters are beyond my sphere, but in reply I would state, first, that the Minister at War has requested me to give the results of my observation on these subjects ; and, second, that defects similar to those which occasioned so high a rate of mortality among the sick in Hospital, were the cause why so many healthy men came into Hospital at all. I have endeavoured to show that the Crimean experience History of the has not been solitary, but that, on the contrary, in our British various continental wars, like causes have produced like Armies, results, and in seeking to prevent similar disasters in future, it is wise to be guided by as many as possible of the lessons of the past. If I have analyzed more in detail 2 rREFACE. the documents connected with the Crimean war it is because these have been more accessible to me, and because ihej were the most closely connected with my immediate subject. Walcheren I have placed at p. 547 an Abstract of the facts re- See """^siT* specting the Walcheren Expedition, as an illustration of how an army may be lost by want of attention to the con- ditions on which the health of armies depends. The history would be incomplete were I not to introduce here a few of the most prominent facts relating to the sanitary condition of the army during the Peninsular War, in juxtaposition with the corresponding facts relating to the Army in the Crimea. ThePeninsular The leading details connected with the sanitary state of the army from December, 1811 to June, 1814, .are con- tained in a paper by the late Director- General of the Army Medical Department, Sir James McG rigor, in the sixth volume of the " Medico-Chirurgical Transactions." The campaign opened in the north of Portugal with the siege of Ciudad Eodrigo, in December, 1811, in very in- clement weather, and the troops had very little shelter. The wounded were ultimately taken to Coimbra, a distance of more than 40 leagues from the besieged city. A great many of them arrived frost-bitten, and tetanus was not unfrequent. The hospitals along the road appear to have been in a very bad sanitary condition, for "contagious typhus " was prevalent in them ; the words " contagious typhus'^ being apparently used as a technical method of expressing a bad sanitary state in the hospitals. In Feb- ruary, 1812, the siege of Badajos began. Rain fell heavily during the whole period. There was some intem- perance, much sickness, and there were above 5,000 wounded in hospital. Hospitals were established along the line of conmiunication to Lisbon, which were speedily PREFACE. 3 filled with sick and wounded. The chief diseases were pneumonia^ catarrh, continued fever, vernal intermittents, sore throat, rheumatism, and locked-jaw. From June till November, 1812, the army was actively employed, exposed to a burning sun, and to a temperature of 90° Fahr. through the day, followed by exposure from sleeping in the open air at night. Numerous hospitals were established along the lines of military operations. The sick had to be transported con- siderable distances. There was a heavy mortality in the hospitals, particularly in November, from intermittent, continued and typhoid fever and dysentery, proving more than anything else could do the defective sanitary state of the hospitals. In October, hospital gangrene prevailed extensively among the wounded, another proof of the condition in which the hospitals must have been at the time. Contagion'^ and the means of preventing it appear up to this time to have been the sanitary (?) creed and practice of the heads of the medical service. When the army reached the Agucda and the Coa, various sanitary measures were carried out by Lord Wellington, in concert with the Medical Department. While the Commander of the Forces took care that everything was done to re-clothe the men, to provide blankets, to procure abundant supplies, and to restore order and discipline, — and the soldiers were everywhere set to repairing habitations, building fire-places, and rendering themselves comfortable, — the Medical Depart- ment attended to the cleanliness and ventilation of the quarters and to the general health of the villages. All, therefore, that was right to be done was done and well done ; so well, indeed, that one can learn, without much fear of the consequences, that the most energetic means^^ were also taken to prevent " contagion,^' — so much to 4 PREFACE. be dreaded/' Whether the contagion/' or the seclusion and sanitary cordons commonly used to prevent it are most " to be dreaded/' enlightened sanitary opinion will now decide. The most sensible measure adopted, however, seeing that " Sir J. Pringle,in enumerating the causes of mortality in the army, has represented Hospitals themselves as one of the chief of them,'' was dividing the sick among a large number of small Hospitals instead of congregating them together in large buildings, which the Medical Department did not appear to be able to preserve in proper sanitary condition. The result of these various measures is stated to have been that typhus, and hospital gangrene soon disappeared, and in four months' time the army was eflPective and fit for the field, with the exception of the Guards and a few other regiments. The fate of the Guards in this campaign shews the great importance of sanitary precautions. In November, 1812, the fiower of the British army had been rendered so ineff'ective by fever, that even so late as the end of February, 1813, the Brigade had to be sent to Oporto, and it did not rejoin the Army till after the Battle of Vittoria in June. In August, 1813, the Army was en- camped in the mountain regions of the north of Spain, at a distance from the villages. They had moderate and wholesome labour in fortifying passes. They had abun- dance of good provisions, and there was little drunkenness or disorder among them. The diseases were so mild and trifling that it was found difficult to reduce them to distinct heads. Throughout the whole period the General Hospitals were scourged by fever and by hospital gangrene, which spread widely among the wounded after the Battles of Vittoria and Pampeluna. The hospitals were overcrowded with wounded. PREFACE. 5 During the winter of 1813-14 the army underwent great fatigue. They performed long and harassing marches during the day, and usually slept more or less in the open air at night among the Pyrenees. The weather was severe, the mountains deeply covered with snow, and the climate rigorous. The army notwithstanding retained its health and lost but few men. The cavalry alone suf- fered, which was posted in what were considered good quarters in towns and villages on the banks of the Ebro. Slight fevers and colds existed among the troops on the mountains, while, in the unhealthy quarters of the cavalry, there prevailed fever, typhus, diarrhoea, dysentery, and the usual tribe of zymotic maladies. The Peninsular army, it would appear, had its sanitary experience to gain as well as the Crimean. Mortality on board unhealthy and badly fitted transports was not wanting to complete the parallel. Sick and wounded were occasionally sent from Passages by sea to Bilboa and St. Andero. Hospital gan- grene prevailed ; simple fever passed on into typhus, aggra- vated no doubt through the infliction of quarantine regu- lations by the Spanish Government. The amount of sickness which prevailed during these Number of campaigns was enormous. During the whole Peninsular ^^ek^^jn^tlfe War, from 1808 to 1814^ the proportion of sick to 100 Peninsular - ^ A J or* .-I War, compared strength varied irom 9*4 to 33 ; the mean per centage with the same being about 21. The per centage of sick during the the Crimea. Walcheren Expedition was considerably higher, and varied between 7 per cent, and 58 per cent. ; the average being 32*5 per cent. But, during the seven months in the Crimea^ from October 1854 to April 1855 inclusive, the per centage of sick to strength varied from 24 to 51 ; the average being actually during the whole seven months nearly 39 per cent. This result I have obtained from an examination of the 6 PREFACE. Statistics, which will be found in detail at p. xxvii of the Appendix to Section XI, p. 332. No attempt has hitherto been made to arrive at this fact, though it is obviously most important. For the amount of men constantly sick shows the number of soldiers at all times to be deducted, as ineffective by reason of sickness, from the Strength of an Army. This must, on all occasions, therefore, be one of the most essential questions as regards the efficiency of an Army, or the result of a campaign. The Army Medical Statistics, however, do not appear hitherto to have contemplated the necessity of either Commanding Officer or Minister at War being informed what the number of men constantly inefficient, from sickness, in an army really is, and it cannot be ascertained correctly even for the Crimean Army."^' Statistically, the figures given in the following Table showing, approximately, the constantly sick in the Crimea, are certain to be incorrect, although deduced from the Adjutant-General's, and from Medical Returns. But, for sanitary purposes they give a rough idea of the disabled state of our Army during the seven months in question. Strength. Sick. Per-Centage of Sick. Effectives. October 1854 . . 18,547 4,508 24 2 14,039 November 22,047 6,744 30 -5 15,303 December 25,776 8,342 32 -3 17,434 January, 1855 . . 26,578 11,070 41 -6 15,508 February 27,045 13,428 49-6 13,617 March . . 25,003 12,772 51 • 12,231 April 23,047 9,982 43 8 13,065 * Two large folio volumes, laid before Parliament, by the late Director- General of the Army Medical Department, since this Preface was written, profess to give the Medical history of the Eussian War. These volumes contain many tables of figures, but from neither any nor all of them can PREFACE. 7 So tliat^ during this period^ the average of constantly Sick^^ in our Army was 38*9 per cent. In other words^ not more than 61 per cent, of the nomi- nal force on the plateau before Sevastopol were fit for duty. To keep up an army under such circumstances Avould re- quire 164 men to supply 100 men for duty. That is, if the besieging force actually on duty had amounted to 100,000 men, there Avould have been an additional 64,000 con- stantly in Hospital, requiring an army in themselves for guarding, medical attendance, and nursing; together with an immense transport train for Hospital equipments, medicines, comforts and supplies. A siege conducted on such principles requires two Armies, separately organized — one to combat with the enemy, and another to combat with disease ; and we know that those who fell before Sebastopol by disease were above seven times the number of those who fell by the sword. With an army as healthy as the force was at the end of the War, say with 5 per cent, of sick, an army of 100,000 men could be kept up with 105,260 men, 5,260 of whom would be in Hospital, instead of 64,000, as in the pre- ceding case. We may derive an additional idea of the importance of this point, from the fact that an army with 64,000 sick would require 1,140 more orderlies to attend them than the total sick in an army with 5,260 sick would amount to : 6,400 orderlies would be necessary, in the former case, and only 526 in the latter. To return to the Peninsula. We find from Sir J. McGrigor^s report that from Admissions December 21, 1811, to June 24, 1814, a period of two ^"^^^in^hT^^^ Peninsula and be extracted an iota of information as to the average number of men con- in the Crimea, stantly sick, during the War or any week of it. PRE FACE. Details of Mortality in certain Corps in the Peninsular War and in the Crimea. years and six months, there were admitted into Hospital in tlie Peninsula 339,870 cases, a number nearly equal to the whole force, passing through the Hospitals twice in each year/' 324,672 appear to have been discharged cured. There died 18,500, and there were invalided to England, 4,500. But, in the Crimea, during a period of six months only, viz., from October 1, 1854, to March 31, 1855, according to the shewing of Sir John Hall, " a number nearly equal to the whole force^' went twice through the Hospitals in - half a year. The average strength for the period was 28,623 ; the admissions in the Crimea alone 52,548. This is exclusive of those under treatment at Scutari. Enormous as was the mortality in the Peninsula, it was also a small matter in comparison with what took place in the Crimea. This actually averaged during eight months, viz., from October 1854 to May 1855, 60 per cent, per annum of the whole force. The regiments which suffered most in the Peninsula were those which had gone through the Walcheren cam- paign ; next, the new arrivals ; and, next to them, conva- lescents from General Hospitals. The mortality in the 1st battalion of the 1st regiment of the Guards in the Peninsula was excessive. From Sep- tember, 1812, to May 24, 1814, out of a total force of under 2,000 men, including recruits, 674 died in hospital, and 280 were invalided. Out of 300 men sent into General Hospital between October 20 and December 4, there died 140; 100 rejoined the 3rd battalion from General Hospitals, almost all of whom relapsed, and 40 died ; shewing a mor- tality of 180 out of an original strength of 300 men. One would think this a sufficient proof of the bad state in which these General Hospitals were. Malignant typhus seems to have been the scourge of these places. PREFACE. 9 In the Crimea, also, the mortality in certain Corps was in great excess of the general rate. In the 46th, 95th, 63rd, 33rd, 23rd, 44th, 28th, and 50th Regiments it ave- raged 73 per cent, from disease alone during the seven winter months from October 1854 to April 1855, a rate of mortality which would have extinguished the whole of these Regiments in ten months, or, in other words, a mor- tality of 125 per cent, per annum. The details are pre- sented in the following Table. Corps. Average Strength of Seven Months. Deaths within that period in the Crimea and Scutari. Whereof from Wounds & Injuries Received. Remains Mortality from Disease alone. Add Ten per Cent, for Deaths not Reported. Total Mortality in each Corps. 46 th Regiment 378 405 7 398 40 438 95th „ 417 354 32 322 32 354 63rd 448 353 15 338 34 372 33r(i 424 324 32 292 29 321 23rd 579 359 21 338 34 372 44th 598 316 11 305 30 335 28th 522 276 10 266 27 293 50th 520 327 19 308 31 339 3,886 2,714 147 2,567 257 2,824 But, if we go through the whole Crimean force. Regiment Admissions by Regiment, and mark what the Admissions into Scutari Hospitals from Hospitals were, and what the Deaths there during those ^^^(^nlfy ' fatal seven months, we shall see how much of the mortality Regiments, was due in the Crimean case also to the frightful state of the General Hospitals at Scutari ; how much it depended upon the number which each Regiment was unfortunately enabled to send to these pest-houses. I may again refer to the evidence on this point printed at p. xxiv of the same Appendix, p. 332. The hospital records of the Peninsula appear to begin General and end with the word fever, with an occasional digression unsuiccSuHu to point out how, in some cases, there was a tendency to ^^e Peninsula. 10 PBEFAOE. dissolution of the whole body, mortification of the extre- mities, deadly coldness, livid eruptions, yellowness of skin ; but there is little or nothing said about overcrowding, want of ventilation, want of drainage, bad water, and foul air. Every conceivable remedy appears to have been tried, from bleeding to Cayenne pepper, with equal success ; but nobody seems to have thought of trying the effect of pure air. The disasters of the Peninsular General Hospitals fore-shadowed the still greater disaster of the Scutari General Hospitals. But there is no record of any sanitary works having been adopted in the former which were carried out so successfully in the latter. Sir J. McGrigor appears to have been well aware that General Hospitals were indispensable, and had advantages when well regulated.'' " They offered,'' he says, the most comforts to the sick soldier." The usual practice seems to have been, wherever a station was selected, to open a separate hospital for the reception of fever and dysentery, a separate hospital or hospitals for wounded and chronic cases, and a convalescent hospital, from which the man was transferred to depot. But notwithstanding this classification, an enormous mortality arose among the sick, mainly, as it would appear, from overcrowding and defective ventilation, and which was only put a stop to by making every corps keep up its own hospital establish- ment. McGrigor admits the necessity of General Hos- pitals ; but, somehow or other, they were fatal to the sick, and the only way of preventing this was to have no General Hospital at all. Fortunately, we have the expe- rience of Scutari to prove tliat it is quite possible to have all the advantages of General Hospitals without the disad- vantages which led to their abandonment in the Penin- sula.* * The army in the Peninsula had a remarkable exemption from con- PREFACE. 11 To prevent, as far as human means can do so, the Need of frightful mortality which has usually been the result of Hospitals our General Hospitals during war, such Hospitals must ^^"p^^^^^ be organized and maintained in practical efficiency during peace. In this manner, alone, can the recurrence of such catastrophes as I have mentioned be warded off. In the following pages I have pointed out the leading adminis- trative defects, as they presented themselves in the General Hospitals in the East, and I have also pointed out the remedies suggested to me, by personal experience there. In order to carry out these suggestions suitable hospital buildings are necessary. I am not aware of the existence of any Army General Hospital in this Kingdom which would afford the requisite facilities for instructing officers in the administration, government, attendance, and medical service essential for General Hospitals, and where, at the same time, a clinical school might be advantageously established for candidates for admission to the service. The great establishment for invalids now being raised at Netley, all seem to be agreed, will not answer this purpose. Its wards are too small for clinical instruction. Its admi- nistration would be very costly, to render it effective. It sumption. It appears that out of a total mortality of 18,500 from wounds and disease, there were only 279 deaths from phthisis. At that period Sir J. McGrigor states that he found the mortality from consumption in the army in England in ordinary seasons to amount to one-fifth, or one-fourth, of the total mortality, while, in some regiments, it amounted to half the deaths. It is important to remark that the proportionate mortality from eon- sumption during the Crimean War was less even than in the Peninsula ; while the deaths from the same disease in the army on home stations have risen very much since the period of the Peninsular War. Fifty per cent., which was the maximum mortality from consumption in particular regi- ments in Sir J. McGrigor's time, has now become the average mortality in the Line regiments, while in the Guards it considerably exceeds that pro- portion. 12 PREFACE. is not constructed on a plan by which numbers of sick men constantly confined to bed could be safely brought together, and its distance is too great from any body of troops, for medical candidates to learn their sanitary and regimental duties. It would have been a great saving of cost to the country had a position been selected for the Hospital and a form of construction adopted suitable for all the objects in view, as regards both sick and invalids. But as there appears to be now no doubt that Netley would not answer as a General Hospital, for the purposes contemplated, some more suitable hospital provision will have to be made. The most likely place for such a hospital would be at Aldershot. A new Hospital is projected there, the plans of which could be easily modified, to afford the required facilities. There will, in all probability, be a large body of troops stationed there in future, and there would be plenty of space for a clinical school, affording all requisite means of study. August J 1857. P Pv E F A C E SECTION I. AbSTKACT of the PROCEEDmOS OF THE DiRECTOR-GeNEIIAL. The Director-General saw Lord Eaglan before the Expedi- tionary force sailed to the East, and, in conversation, advised a previous enquiry into the local peculiarities and diseases of the countries which were to be the seat of war. Lord Eaglan advised him to address the Military Secretary on the subject, which he did, February 21, 1854?, recommending that three Medical Officers, Drs. Dumbreck, Linton, and Mitchell should be dispatched to the Danube and Constantinople to make the requisite enquiries and to report to the Army Medical Depart- ment. On the same day he received the requisite authority from General Airey ; and, on February 27, Dr. Smith sent letters of appointment to the three Medical Officers he had named. Mr. Mitchell was dispatched to Constantinople and the districts south and west of Adrianople, Dr. Dumbreck to Vienna and thence through the Danubian provinces to Con- stantinople. He was directed to enquire into the climate and diseases of the Principalities and of Turkey. Dr. Linton was to proceed to Constantinople and towards the interior, taking the routes of Armies advancing to the Balkan, visitiug the luost likely places for halting and for encampments, enquiring into the diseases of these places and their neighbourhood, and noting any peculiarly healthy or unhealthy localities. Dr. Mitchell's enquiries were to be of the same nature. All three were furnished with the requisite introductions. These preliminary enquiries were in the highest degree important, and the proposal of them was most creditable to the judgment of the Director-General. The instructions were meagre — not defined enough, and not February 21, 1854. Commission of Enquiry. February 27, 1854. Letters of Appointment. II COMMISSION SENT TO TURKEY. March 7. Cholera Belts March 23. Tents. March 23. Dr. Dumbreck from Widdin. April 13. Peat Charcoal. April 13. Clothing. April rc- such as a mau thoroughly conversant with the subject might have issued, unless he wished to leave every latitude to his envoys and to trust to them, All, however, depended on the practical result. The next communication is one from the Director-General to the Deputy Secretary-at-War, for Cholera Belts, March 7. On March 23, Dr. Smith makes a very proper recommenda- tion to the Military Secretary for ventilating Bell Tents : he proposes a plan which would not have answered, but he suggests that some better method should be adopted, and that 500 tents and 300 marquees, properly ventilated, be sent, " with all possible speed," to Turkey. This excellent proposition, which would have saved much sickness, led to no result. On the same date, March 23, Dr. Dumbreck wrote to Dr. Smith, from "Widdin, announcing his arrival; Pever and Dysentery among the Turkish troops ; Widdin unhealthy and marshy ; Palanka more healthy ; winter climate most severe ; our men not sufficiently well clad to resist it — we cannot have too much bedding or supplies of food, without which our sol- diery, in these pestiferous places, would be decimated in a few weeks. Dr. Frasy, who had accompanied him from Belgrade, had been of great service. April 13 — Dr. Smith requests Military Secretary to send 20 cwt. Peat Charcoal to Turkey, for the Medical Officers. This was sent later. On the same date, apparently but not avowedly in conse- quence of Dr. Dumbreck's letter. Dr. Smith addresses the Horse Guards on the want of adaptation of clothing to the Turkish climate ; present clothing neither suitable for low nor for high temperatures, such as exist in Turkey ; suggests enquiry as to the practicability of improved clothing : — 1. To discontinue the red coat during summer. 2. To have a waterproof blouse. 3. A suitable head-dress, to protect the head from heat. 4. To discontinue the leather stock. 5. To have 1 or 2 flannel shirts. 1 or 2 prs. flannel drawers. 2 „ worsted stockings. On the same date Dr. Smith orders Dr. Forrest to Gallipoli; STATE OF THINGS AT GALLTPOLI. Ill with special instruction to examine the topography of tlie town and its vicinity, and to send a description and account of the water supply, requiring, also, full information on all subjects. 'No special sanitary information is asked for, in this letter. Dr. Forrest's report does not appear. April 17 — Dr. Dumbreck announces to Dr. Smith his arrival in Constantinople. He sends a list of places where Hospitals could be formed, and states that the diseases of the Danubian provinces are Fevers and Dysentery, especially along the marshy banks of the Danube, and in deep-sunk unventilated towns in gullies. He promises his Report. In reply to a letter from the Military Secretary to Dr. Smith, dated March 24, about the purification of water in the District, Dr. Smith writes, April 21, that the Medical OflScers sent to enquire will give every necessary information to General Brown and others about the water. April 28 — Dr. Smith sends to Military Secretary, with his own recommendations, an extract from Dr. Dumbreck's Eeport, given above, about clothing and food for troops. Dr. Forrest sent to Gallipoli. April 17. Dr. Dumbreck from Constantinople April 21. Purification of Water. April 28. Clothing. Immediately after the troops went to the East, the practical in- efficiency of the Army Medical Department began to shew itself. April 15, 1854, Mr. Alexander, writing to the Adjutant- General at Gallipoli, reports that the battalions " have arrived totally unprovided with necessary field equipments, except marquees." " The sick now under treatment in the field have but one solitary blanket to cover them." Mr. Alexander states that he had to write to Malta on the subject the very day he disembarked. The thermometer was then 28° Fahr., at night. Medical comforts were also wanting. April 18. Dr. Burrell, Principal Medical Officer, writes from Malta, " You have half frightened us with the want of com- forts." Dr. Burrell sent 300 sets of bedding, tents, &e. ; but could send no comforts, without a letter from Sir G. Brown. Mr. Alexander, unable to obtain blankets, seized and distri- buted them himself, on his own responsibility. April 29 — Dr. Menzies writes to Dr. Smith from Constan- tinople, announcing the arrival of Troops, and their being B 2 Gallipoli. April 15,1854. Mr. Alexander's Report. Malta. April 18. Dr. Burrell. Scutari. April 29. Dr. Menzies on Hospitals. IV director-general's recommenpattons quartered in the Barrack at Scutari. He says, " the Hospital arrangements have been nearly completed for the accommoda- tion of the sick of all the Corps now arrived, and are attended by their own Medical Officers, assisted by the Staff." This passage indicates the first appearance of that system of Hospital mismanagement which subsequently led to such disastrous consequences. 'No arrangements for General Hos- pitals were in contemplation, and Dr. Smith recommends none. Ma 2 '^^y 2— Letter from the Military Secretary to Dr. Smith, in Rejection of reply to his of April 13 and 28. Lord Hardinge admits the I^ecommenda- ij^portance of Dr. Smith's recommendations for the health and Clothing. safety of the Army, but states, that no change can be effected in the dress, tliat he hopes bedding enough for the Hospitals has been sent out, that none can be sent for the men, that it is of importance to proceed "only on accurate information," (apparently doubting Dr. Dumbreck's). He advises that Dr. Dumbreck's opinions be laid before Lord E,aglan, who will be aided by Officers " who will have acquired some experience of the country," and the Commander-in-Chief will be able to act on Lord Kaglan's advice. Results of Thus, the Commission sent by the Head of the Department Commission of charge of the Army's health, and authorized by the Horse Gruards in charge of the Array's efficiency, falls to the ground without effect. The Eeport from Dr. Dumbreck contains, as has been shown, — 1. Suggestions for improvements in the clothing of Troops, 2. Certaiu sanitary suggestions for occupied towns. The suggestions about clothing were urged by Dr. Smith on the Horse Guards, but rejected. And Dr. Smith issues no instructions on the Sanitary part, so that the Commission was a dead failure, in as far as any practical good is supposed to be the result of a Commission. No Eeport appears from either Dr. Linton or Mr. Mitchell. Perhaps, it was deemed unnecessary after this repulse. It would indeed be difficult to frame a system of adminis- tration more likely to lose an Army at any time than this. Here is the first downward step of our noble Army to destruc- tion. AS TO CLOTHING REJECTED. V For Horse Guards read Home Department, or General Board of Health ; for Head of a Department specially charged with the health of the Armj^ read Sanitary Adviser for Inter- ments' Act or Cliolera Investigation — and how differently the matter would have been managed! Were the proceeding the same, the temper and zeal of the adviser would be destroyed — science and observation would be subordinated to the decision of purely official rank; and the whole use of prac- tical scientific advice at once nullified. The consequent reac- tion on the whole Department would be fatal. What an honest adviser bo treated could do but resign is difficult to see. Whether or not the Medical Department were fit to advise on such a subject should have been decided before the Army went out. If the Department were incompetent, wliy sanction the Commission, and put the country to the expense of it? If it were competent, why reject its advice? The system of administration is unquestionably wrong which could bring about such a reductio ad ahsurdmi as this. If the Army Medical Department is to be of public service for sanitary purposes, its powers and functions will have to be defined far more distinctly than they hitherto have been. May 9 — Dr. Smith applies for tarpaulin for the floors of May 9. Hospital Marquees. Tarpaulin. May 11 — Dr. Smith applies for sick ships, and for the estab- May 11. lishment of a Hospital on a healthy Island. ^^^^ Ships. May 13 — He requests Dr. Dumbreck to lay his observations j^^y 13 about bedding for the Troops before Lord Eaglan. Not having Bedding, received information as to the health of the Army, he writes to "^aifd^Port^^^' the Principal Medical Officer, requesting to be kept informed : also, to know if preserved Potatoes, Ale, and Porter, which had been sent out, had been issued, and how they were liked. June 12 — In consequence of an application from Dr. Smith j^^^^^ 22 on this day, 20 filtering machines were ordered to be sent out Filtering for the Hospitals. Machines. June 13 — Dr. Smith repeats his recommendation for bedding j^^^ 23. and warm clothing, and sends a long extract from the Eeport Dr. of Dr. Dumbreck, on the prevention of disease in the country. ^Eeport ^ Dr. Dumbreck recommends — Small doses of quinine, VI HE SETS THE SANITARY REPORT ASIDE Warm clothing, Hourly Guards, "Warm hoods for night duties. Unhealthy towns to be cleansed on occupation, Pools of stagnant water drained, and ditches cleansed, Filters for Hospitals, Water searchers to precede Army, Open fire-places or stoves for Hospitals, Avoiding towns in deep valleys. In sending this Eeport, Dr. Smith recommends attention, especially, to the subject of Clothing. He directs attention to none of the Sanitary recommendations — and hence, so far as the health of the Army is concerned, the Sanitary advice of his own Commission was of no use to the Public Service : another ilJustration of the extremely imperfect nature of the Sanitary administration of the Army. Lord Hardinge put an end to the practical advice given in one part of the Heport, and Dr. Smith put an end to the rest. Such was the result of the preliminary Sanitary enquiry. Dr. Smith never issued any recommendations on the Report, except as to Clothing. The Army thus went to Bulgaria, without any guidance in Sanitary matters from the head of the Department, although Dr. Dumbreck's Eeport contains many good suggestions, and much good information. A recommendation for filtering water for the Hospitals had been forestalled by Dr. Smith. July 3. The next Sanitary communication relates to the Hospital at Varna. y^^.^^^ Dr. Dumbreck sends a copy to Dr. Smith of certain recom- mendations for improving the Hospital, made to General Tylden, E.E., of which Dr. Smith approves, July 3. Dr. Dumbreck recommends — Enlarging the windows, Apertures in the walls near the roof and ground for ven- tilation, Ee-arrangement of internal fittings, Openings in the roof of the wards. Boarding the central part of the ground floor. Drains near and leading from privies to be carefully looked to, AS TO THE HOSriTAL AT VARNA. VII AVestward privy to be closed, and used as a room for ablution, Hepairs, Stoves, Central court to be raised and made even. As far as can be judged, without personal knowledge of the A^arna buildings, but comparing this account of them with those at Scutari, these Sanitary recommendations were good, but not sufficient. Such as they were, their fate illustrates the utter want of any Sanitary organization, even at the very beginning of tlie War. The Principal Medical Officer considers certain Sanitary improvements absolutely necessary to make his Hospital habitable. In writing to Dr. Smith, June 23, he says he was in inces- sant personal communication, importuning every one to carry out his improvements.* The Officer Commanding at Varna did next to nothing to second his efforts. Sappers could not be spared. They would not ask aid from the Turks. Dr. Dumbreck at last saw Lord Eaglan who appears to have been always willing to render aid. He ordered labor to be given up for the work. Yet the progress made was slow and irregular. Answers were not even sent to his applications. The Hospital was, at last, only cleansed through the exertions of a Hanoverian Officer in the Eoyal Engineers. This history is an instructive specimen of the present Sani- tary adminstration in the Army. The Hospital at Varna would have been a second Scutari, if it had been used long enough. June 20 — Dr. Smith writes to the Principal Medical Officer, Turkey, to learn about coir or straw mats for the troops. June 29— Ditto. This was important, as securing the men in tents from damp. August 3 — Dr. Smith writes to the Principal Medical Officer, Turkey, to enquire about winter dress of Austrians and Rus- sians. August 21 — Dr. Hall writes from. Varna a full account in reply. * From having seen the same process at Scutari, I can well believe it. June 20. Mats. June 29. Mats. August 3. Winter Dress. August 21, Winter Dress. VI I r DR. HALL ON THE WANT OF VEGETABLT:S August 18. Winter Clothing. September IL Potatoes. October 27. Vegetables. October 28. Milk and Cocoa. November 16. Preserved Potatoes. November 2. Vegetables and Scurvy. August 18 ~ Dr. Smitli sends to the Duke of Newcastle the following requirements for the Army in Winter Quarters :— G0,000 Blankets, 40,000 Eugs, 40,000 Palliasses, 40,000 Bolsters. September 11 — In reply to a question from the Military Secretary, about sending out a ship-load of potatoes, Dr. Smith recommends that persons conversant with such s]ii])ments should be consulted before it is done. October 27 — Dr. Hall writes to Dr. Smith that the want of vegetables is being felt in the Camp before Sevastopol — that he has represented the want of Potatoes and Onions— that " it will be quite impossible for the Army to keep the Field, or to exist under canvass during winter." October 28— Dr. Smith writes to Dr. Hall to know tlie efficacy and utility of Moore's Concentrated Milk and Cocoa. November 16 — Dr. Smith replies to Dr. Hall's letter of October 27, — informs him that Preserved Potatoes are in the Commissariat Stores, Turkey. November 2 — Dr Hall intimates to Dr. Smith the appearance of Scurvy — the arrival of vegetables two days ago — the efforts made to have them regularly supplied. This, and the letter of the 27th October, are the only letters of Dr. Hall to Dr. Smith, in which any mention of vegetables appears. The great calamity is now drawing to its height. It is time to make a few observations. It does appear that the Director General and the Principal Medical Officer considered themselves responsible for such matters, partly Dietetic, partly Medical, partly belonging to personal hygiene, as blankets, vegetables, lime-juice, &c. It does not appear how far they were considered responsible for advising upon matters purely Dietetic, such as Rations, or how far these were left to hap-hazard. Had half the ingenuity, exercised in sending out Lime Juice, as will prese-jtly be seen, been expended in making that article unnecessary, the Army might have returned to the shores of England alive and well. IN THE CRIMEA IN OCTOBER. IX From this point, the correspondence seems to read as if the Medical Office were considered that of registering post mortem appearances, instead of keeping the patient in health — as if the business of the police were to record murders instead of preventing them. In order to make this intelligible, it is necessary to give a short summary of what the Army did receive in Vegetables and Blankets. Vegetables. 1854. November. December. 1855. Januarv. February. March. Issued to 5 or 6 Eegiments, only. To each man | lb. for 31 days ; or 2 potatoes and 1 onion, including Sick. To each man, ^ lb. per week, including Sick. Preserved Potatoes began to be issued in the latter part of this month, but chiefly to the Hospitals. Supply becomes regular about 24th. G Eegiments state supply irregular up to middle of month. 5 Regiments — supply insufficient. Mice. Issue of 2oz. to each man daily, from 15th November to middle of January, discontinued. Quantity in Stoee. Bice. November 15. At Balaclava, 74,000 lbs. At Scutari, 296,000 lbs. N.B. The men always declared that they would rather have lost their rum than their rice. Preserved Potatoes. November 1. At Balaclava, 32,400 lbs. October 1. At Scutari, 6,000 lbs. Peas. December 16. At Balaclava, 51,000 lbs. X CORRESPONDENCE IN Barley. October 1. ) Balaclava and Scutari, 65,000 lbs. jSTovember 1. J With regard to Blankets, the men, and even the sick, lay on the muddy floor of their tents till the end of December with nothing either under or over them, except tlie great coat and blanket, often wet from the trenches. In the first week of December, one blanket was given out to every two men. In the beginning of January, this was made up to one blanket to every man. The questions to be asked are — Why did not Dr. Smith at once recommend the Military Secretary, who appears to have been aware of the necessity, to send out Potatoes ? And what measures did Dr. Hall take to obtain the Pre- served Potatoes, of which he is advised by Dr. Smith ? November 3. Deodorizing. November 9. "Warming Hospital. November 15. Ale and Porter. December 17. Ale and Porter. November 17. Lime Juice. November 18. Warm Clothing. November 3 — Dr. Smith asks the Principal Medical Officer, Scutari, which deodorizing substance is the best ? November 9 — And about warming the Hospitals. November 15 — Dr. Smith asks Dr. Hall whether the Ale and Porter sent out were useful. December 17 — Dr. Hall replies that it was not. 147,000 gallons were in store at Scutari, from December 1. The sufi'erings of the men at this time, from being sometimes all day on fatigue duty at Balaclava without food, were great. Yet it occurred to no one to bring the Porter to Balaclava, and serve it out to them there. November 17 — Dr. Smith intimates the fact of Scurvy having appeared, to the Military Secretary, and advises the immediate transmission of a large supply of Lime and Lemon Juice for the use of the Porces in the Crimea. He suggests application to the Admiralty. November 18 — Dr. Smith intimates to Dr. Hall the sendinij out of large quantities of warm clothing for Troops and Hos- pitals, and requests Dr. Hall to see that the Hospitals have their share. These supplies, therefore, of warm clothing were announced. But the information does not appear to have been followed up NOVEMBER, 1854. XI at either end, in order that the warm clothing might be obtained by the Troops who wanted it. Dr. Hall intimates to a Surgeon of the Eifle Brigade that there was plenty of Warm Clothing, and urges him to get it at once for the Troops. Otherwise, we hear no more about it. And there is nothing in these letters to lead us to suppose that the Principal Medical Officer, or the Director General, know that the Sick are perish- ing ; or, that a great catastrophe is preparing. Januaiy 6. November 20 — The Horse Guards intimate to Dr. Smith, that 20,000 lbs. Lime Juice will be immediately shipped, con- signed to the Commissary General in the Crimea. There is none to spare at Malta, or in the Black Sea Pleet. November 21— Dr. Smith writes to Dr. Hall, that 40,000 lbs. Lime Juice are about to be shipped, consigned, as stated above. ISTovember 25 — Dr. Smith is informed that 20,016 lbs. Lime Juice, "being a further proportion of the 40,000 lbs., were shipped on board the ' Esk,' expected to sail to-day." November 27— Dr. Smith writes to Dr. Hall that 20,016 lbs. Lime Juice have been shipped on board the "Esk," expected to sail on the 25th ; and that 10,080 lbs. had been shipped on board the "Holyrood" on the 21st, expected to leave on the 24th. November 29 — Dr. Smith recommends Dr. Hall to see that 1 ounce and upwards per day be given. November 30 — Dr. Smith makes a further Bequisition for 40,000 lbs. Lime Juice. December 6 — Informs Dr. Hall that this supply will shortly be sent. December 11 — The Admiralty report that they have none to send, and suggest an application at Messina. December 16 — Sir Charles Trevelyan informs Horse Guards that orders have been sent to Malta to procure 40,000 gallons Lime or Lemon Juice, at Messina, and to forward it. December 19- — Dr. Smith sends a Eeport on Meat-biscuit, in reply to a query from Colonel Mundy. December 19 — Also intimates that, as there is great reason to fear Scurvy in the Army during winter, a fuU ration of vege- tables should be supplied four timesa week. He sends a Eeport on five kinds of dried vegetables which he recommends. November 20. Lime Juice. November 21. Lime Juice. November 25. Lime Juice. November 27 Lime Juice. November 29. Lime Juice. November 30. Lime Juice- December 6. Lime Juice. December 11. Lime Juice. December 16. Lime Juice. December 19. Meat Biscuit. December 19. Vegetables. XII THE DIRECTOR-GENERAL S Upon this, it is to be observed that, at the time that Dr. Smith finds " great reason to fear Scurvy in the Army during winter" this Army had many regiments in which not a single man was free from it, and that the account of Scorbutic Disease for the month of January, when his vegetables would arrive, runs thus. We calculate from Official Eeturns for January 1855, that there were in that month Total Admissions ) -j^^ ' into Hospital / ' (Primary) 290 Total Deaths in ) Hospital . . J 3,168 Therefore, — 1,000 per ann. ) . -j^^^ Per 1,000 per ann. ) 1173.5 strength . . J ' to strength . . J Per to Of these, the Admissions and Deaths from Diseases of the Scorbutic type are returned as follows : Admissions Deaths Scurvy 542 31 Scorbutic Dysentery . . 181 44 723 75 Or, 75 deaths from Scorbutic disease in that month, when from two- thirds to three-fourths of all the Disease in the Army were due to the Scorbutic type. The larger part, if not all, of the Admissions and Deaths, annexed below, which are for the same month of January, 1855, may be read, " Scorbutic type" or " Bad food," which is the same thing. Admissions Deaths Acute Dysentery . 865 1 210 ) Chronic „ 143 J 578 j pi. Scorbutic „ 181 44 0 Diarrhoea . 4,191 1,199 Acute Eheumatism . 342 58 0 0 Chronic ,, 84 9 CQ Prost-bite . 1,413 124 . Scorbutus 542 31 7,761 2,253 ANTICIPATIONS OF SCURVY. XIII Acute and Chronic Dysentery furnisli a mortality of 78 per cent. ; by far the most fatal disease in the Army. "We also learn that about the 2-ith of January the supply of vegetables became regulnr, after three months of privation. December 21 — Dr. Smith advises sending out Soap. January 2 — Dr. Hall is informed that 30 tons have been shipped. Por three mont?is this Army had not had the means of clean- liness, either as to their persons or clothing; and what the state of the men was, on arriving at Scutari, let tliose who saw it testify. December 22 — Dr. Smith is informed that 9,900 lbs. Lime Juice have been shipped on board the " Sidney Hall." December 27 — Dr. Smith informs Dr. Hall of it. December 23 — Dr. Smith writes to Dr. Hall to ask informa- tion about the steps taken to provide Eegimental Hospitals durins: the winter. Recommends Dr. Hall to volunteer an opinion on the subject to Lord Raglan, if he has not been con- sulted, and suggests trestles for Hospital beds. December 26 — Dr. Smith writes to Dr. Hall about the lamentable state of the sick — advises him to take boards and trestles from Scutari, if necessary — expects to send 4,000 iron bedsteads in a few days, which will place 10,000 bedsteads at his disposal— asks again for information. December 27 — Dr. Smith applies for 40,000 cholera belts ; and for supplying troops, on embarking, with these. January 6 — He makes a Requisition for 2,000 cotton shirts and 2,000 pairs cotton socks for invalids who may arrive at Chatham from Turkey. He forwards a letter, requesting repairs on board the sick ship "Libertas." He forwards instructions to the Principal Medical Officer, Scutari, about cooking Preserved Vegetables. This is curious. — Scutari is opposite a capital of upwards of G00,000 inhabitants, who live on vegetables — therefore any quantity is obtainable. In the Crimea preserved vegetables would have been of use ; but w hen they were at first offered to the men for sale, the men refused them, because they had no "instructions" for cooking them. December 21. Soap. January 2. Soap. December 22. Lime Juice. December 27. Lime Juice. December 23. Kegimental Hospitals. December 26. Bedsteads. December 27. Cholera Belts. January 6. Chatham Invalids. Sick Ships. Cooking Vegetables. XIV DR. hall's report January 8. Ships. January 10, Ships. January 11. Warm Clothing, January 12. Blankets, Scurvy, Lime Juice. January 8 — Dr. Smith requires information from StafF-Rur- geon Manifold, as to certain alleged defects on board the " Himalaya." January 10 — He writes to Colonel Mundy, requesting that the Sick Transports between Balaclava and Scutari be fitted up hke Hospital Ships. January 11 — He advises warm clothing being sent with every soldier going out. January 12 — Dr. Hall writes to Dr. Smith that " Fevers and Bowel Complaints are more frequent than ever;" also Frost- bites. Blankets and warm clothing have been distributed ; but these do not appear sufficient to protect the men from the weather." Shoes sent out, bad. " Symptoms of Scurvy have made their appearance in some cases ; but as yet the disease has not made much progress amongst the men," "and I hope by the arrival of the expected supply of Lime Juice, its further spread will be prevented." Wooden huts have arrived from England — efforts being made to get them up — some Com- manding Officers will do nothing — want of transport and almost impassable state of the roads. This is the substance of this most remarkable letter from the Head of the Department in charge of the health of 29,000 men, which was then at stake, to his Chief at home. 1. As to blankets — By the end of December, there were sufficient blankets at Balaclava to have given a third blanket to every man. Dr. Hall had been advised by Dr. Smith that a very large quantity of blankets had been sent out, November 18. Had vigorous effiDrts been made to give consequence to this information, it might have led to the discovery of these blankets, and of this provi- sion made by the Government. It was no wonder that they did " not appear sufficient to protect the men from the wea- ther," since, up to this time, only one blanket had been distri- buted to every man. Had an energetic communication been made home, a telegraphic message might have been sent out, which would have hastened the distribution of what was essen- tial to the life of the Army. For Lord Eaglan seems to have been always ready, 2. The expression " symptoms of Scurvy" seems quite inexpli- cable, as well as that of its " not having made much progress." IN JANUARY, 1855. XV The Army was dying, tuid of Scurvy. More than liali* the iDfantry were sick iu Hospital during this month ; and the mortality was 1,173 per 1,000 per annum ; greater than that of the Plague of 1665 at its highest rate. Yet there is nothing to indicate in these letters that either Principal Medical Officer or Director- Greneral know that an Army is dying, or that, if it is, it is any business of theirs. January 12 — Dr. Smith writes to Dr. Hall an Instruction ibr the first time involviug Sanitary duties. He is directed, if he has not already done so, " to make known in writing to the Commander-in-Chief whatever you consider is likely to deteri- orate the health of the Troops," and suggest whatever steps he may consider necest;ary ; by that only you will discharge your responsible and onerous duty." Por the first time, Dr. Smith's eyes seem open to his terrible responsibility. January 13 — Dr. Smith recommends corrugated iron Hos- pitals, to be sent to the East. January 16 — Dr. Smith again urges on the "War Department that at least 20,000 gallons Lime Juice should be shipped during the next two months, a part at a time. January 18 — He addresses two letters to Dr. Hall and Dr. P'orrest about the burial of dead animals and the Scutari graveyard. January 27 —In reply to a letter of General Wetherall, about flannel shirts. Dr. Smith states that, if flannel and cotton cannot both be sent, cotton are to be preferred January 23 — He had recommended both. January 24 — Dr. Smith objects to the issue of unground Coflee, and advises ground Coffee and Tea twice or oftener a week. ^^^^ Jciiiuary 12. Sanitary. January 13, Iron Hospitals. January 16. Lime Juice. January 1! Burials. January 27. Cotton Shirts. January 23. Flannel and Cotton shirts. January 24. Unground Coffee. * When Dr. Smith wrote this letter of the 24th January, 1855, he does not seem to have been aware that the troops had used not only unground coffee but f/ree7i coffee, from the month of November 1854, and, as far as is shown by the correspondence, he never appears to have been informed of the fact. His recommendation to use ground coffee, if sent to the Crimea at all, would have arrived there, it is true, after green coffee had ceased to be issued, and when the troops were supplied with roasted coffee, and coffee mills had been purchased and issued to them, to the number of XVI CLOTHING-STORE AT SCUTARI. January Clothinj January 31. Scutari Huts. February 2. Lime Juice. Dr. Dumbreck's Eeprcsenta- tion, in his Evidcncegiven before the Sebastopol Committee. With regard to the Tea, although 170,000 rations of Tea were at Balaclava in December, although more might have been had from the Navy, from Constantinople and Malta, nothing a])pears to have been recommended by the Principal Medical Officer on that score till March 22, when the Board of Health, applied for by him, met and advised Tea, Cocoa, and CotTee alternately. Both Fuel and Eoasted Coffee had then long since been issued. January 27 — Dr. Smith advises a Clothing Store at Scutari, for giving warm clothing to men discharged. This was after this supply had come for three months from private sources, and been classed as an " unnecessary" and " ostentatious" one ; after a Quarter-Master General's store had been established, December 5, (or seven weeks before), at Scutari for the purpose; and after the necessity had nearly ceased, for, owing to the distribution of warm clothing at the front, which was then taking place, no great want can be said to have existed after the middle of February, when Dr. Smith's recommendation would come out. January 31 — Dr. Smith writes to the Principal Medical Officer, Scutari, to negative the erection of buildings in the Hospital Square. [This was not attended to.] February 2 — On account of the reference to Lime Juice not having arrived at Balaclava, in Dr. Hall's letter of January 12, Dr. Smith urges the matter on the Military about 2.000, that they might grind for themselves, which was about the beginning of February, 1855. This notice of a trifling evil, like so many others, was made after a greater evil had been long and wholly disre- garded. With reference to this question of Coffee Dr. Dumbreck states that he " left the camp in front of Sevastopol, i. e., Lord Eaglan's Head-Quarters Camp, on the 13th of November, the evening before the great storm ; up to that time there were no wants that" he " saw that were not supplied." He says that ''there was a prospective scarcity of fuel;" that he '' was told that in some regiments they managed to roast their coffee that he " was told that certain Commanding Officers managed better than others, and that in some regiments they managed to roast their coffee, but that in others they left it undone ; but that is mere hearsay." That he " never had any direct evidence that green coffee was used ;" that " green coffee was issued to the troops, certainly ; but he supposed an attempt was made to roast it, in many instances." ARRIVAL OF LIME JUICE. XVII Secretary, and asks if anything had been done about his Eequisition of November 30, and if any report of the arrival of Lime Juice has been received. February 5 — He is informed that the "Holyrood" was landing her cargo on January 19, that it was presumed the "Esk" had landed hers, as she was ordered on other service, and that the " Sidney Hall " had not arrived. The history of this Lime Juice, which is now brought to a conclusion, is so painfully instructive, that it must here be summed up. The "Esk" J arrived with the Lime Juice on December 10, and though there is some controversy about the date within a few days, she had, at all events, landed her cargo by De- cember 20. This is nowhere denied. Dr. Hall had been advised in time by Dr. Smith both of her day of sailing, her name, her cargo, and even the name of its consignee, the Commissary-General, as also that the Lime Juice was for the use of the Troops. Yet it appears to have remained for Lord Eaglan to discover its existence on January 24 (six weeks after it was so grievously needed by an Army melting away from Scurvy), through his Order to the Commissary- General to send him returns of everything in store. Two days after, January 26, he placed his Adjutant- General in communication with Dr. Hall about the distribution of this Lime Juice — and, three days after, January 29, the serving it out as a part of the Eation formed the subject of a " General Order." It was regularly supplied from the first week of February. It appears to have been left to Lord Eaglan' s own detective power to be here his own Sanitary Officer. February 3 — Dr. Smith writes to the Secretary of the Board of Ordnance about patterns of Cholera Belts. Also about Charcoal sent to Scutari. February 5 — He again writes to the Principal Medical Officer, Scutari, about the Burial Ground, recommending decency in removing the dead, careful burial, and obtaining a burial-ground at a greater distance from the Hospital, February 5, 7 — He again urges sending out more Lime C PI February 5. Lime Juice. Summary of Proceedings about Lime Juice. Letters of November 21, 27. February 3. Cholera Belts. Charcoal . February 5. Burials. February 5, 7. Lime Juice. XVIII DR. HALL ON BURIALS February 8. Waterproofs, February 8. Asks for Information. February 8. Lime Juice. February 10. Warm Clothing. February 10. Quinine. February 10. Cholera Belts, February 11. Dr. Hall, on Burials of Dead and of Carcases. February 12. Cork Mattresses. February 12. Juice. Encloses, on the 5th, extract from Dr. Hall!s letter of January 12. February 8 — He sends to the Military Secretary an extract from Dr. Hall's letter about waterproof articles, and urges their being despatched. February 8 — Dr. Smith, " being positively without anything like detailed information touching the state of the sick and wounded in the camp, and the means available for their nou- rishment and treatment," requests Dr. Hall to send detailed information as to the state of the sick in each Division. February 8 — He is informed that directions have been sent to Malta about Lime Juice. Sir B. Hawes replies to Dr. Smith's letter of January 11, respecting warm clothing for Troops embarking for the East, states the Commander-in-Chief does not think it necessary, it will be enough if got at Scutari. Extract of a letter of Dr. Hall to Dr. Smith, recommending solution of amorphous quinine to be sent out. Dr. Smith to Mr. Wood, Ordnance Office, refers to his requisition of 9 December last, as pointing out best form of Cholera Belt. Dr. Hall replies to Dr. Smith's letter of January 18, requesting to know about the Burial of the Dead and of the carcases of animals ; that burial grounds are generally suffici- ently distant from tents, and graves dug sufficiently deep ; but both points are occasionally violated ; has seen dead carcases of animals lying about, in every direction, until he had pointed out the fatal results likely to follow. Some effi^rt to get them buried, but imperfectly. " Numerous dead bodies of horses lie about still in every direction, and it is my intention again to call the Commander-in-Chief's attention to the subject." Overcharged Turkish burial-ground, at Balaclava, had created alarm, and the cemetery had been closed. Turkish sick have been removed out of the town. Had represented the objec- tionable site chosen for new huts, near Balaclava, but was told that there was no other place available. " If we remain here during the summer, we shall, I am quite sure, pay the penalty." Quartermaster- General requests Dr. Smith's opinion about Cork Mattresses. Dr. Smith to Deputy Secretary-at-War. Informs him that • AND ON REPRESENTING EVILS. XIX a ton of chloride of zinc had been got ready to send to Smyrna. Dr. Hall replies to Dr. Smith's letter of January 12, respecting the fitting-up of Transport ships. Certain defects have been remedied. States that he had made verbal repre- sentations, as to the defective system, but can find no written communication anterior to December 4. " Much of my busi- ness with the Commander-in-Chief was necessarily transacted verbally, but I must say I have always found him ready to listen to any suggestions and willing to afford assistance." Early in the season had urged the need of better shelter and more care for the men. Adjutant- General replied " that the Commander-in-Chief thought I had travelled out of the question and he was not pleased." Thinks the "Avon" was properly supplied with comforts. "The paucity of bedpans was matter of necessity, when she was fitted out, and the sub- ject does not appear to have been brought under Dr. Lawson's notice afterwards." Hopes it will be found that he has always made due representations, either verbally or in writing, about the health of the Army. It is true I have not put on record, in writing, merely for the sake of putting on record, things I knew could not be complied with, and, had I written them, the Commander-in-Chief must have felt I knew they could not be complied with." In reading this letter the question which suggests itself is. What was the Principal Medical Officer there for ? "Was he there to judge as to whether things requisite for the sick or for securing the health of the Army, could be obtained or not? Was it not rather his duty to tell the Commander-in-Chief what was wanted ? Otherwise how could the Commander-in- Chief know anything of the matter ? Was he there to judge whether the state of mind of the Commander-in-Chief was such as would comply with his just demands, for the benefit of the troops ? This extraordinary mode of proceeding is the more to be regretted, as Dr. Hall states, in this very letter, that he has "always found" the Commander-in-Chief "ready to listen to any suggestions and willing to afford assistance." In place of simply doing his own duty and leaving other people to do theirs, C 2 PI Chloride of Zinc. February 12. Dr. Hall on his own Re- presentations. Remarks on Dr. Hall's mode of proceeding. XX DR. SMITH ON VERMIN. February 14. Preserved Meat. February 15. Steamer "Telegraph." February 18. February 21. Lime Juice. February 22. Scutari Burials. February 22. Scutari Huts. February 22. Specifics against Vermin. he assumes the functions of the Military Executive in addition to his own. As Principal Medical Officer he knows that the troops are perishing, but, placing himself in the position of the Military executive, he decides that, as Principal Medical Officer, he should do nothing, because he does not see how the Military executive can carry out his recommendations. There can be no proper medical discipline where such things can take place. Dr. Smith sends to Colonel Mundy his approval of preserved meat for the troops and recommends a quantity to be kept in the Commissariat stores. Eemonstrates with Colonel Mundy, about the state of steamer " Telegraph" and the want of provision for sickness occurring on board. Submits the necessity of preventing such things in future. Staff-Surgeon Odell writes to Dr. Smith and informs him what had been done to remove the above deficiencies on board the "Telegraph." Letter from Major-G-eneral Sir Charles Torke to Dr. Smith, enclosing letter of the 19th, from the Admiralty, about the lime juice which had been shipped on board the "Esk," " Holyrood," and " Sidney Hall." Dr. Cumming acknowledges Dr. Smith's letter of the 5th February, about the mode of removing corpses from the Hos- pital, to which Dr. Smith had taken objection, and replies " I have to observe that your proposal appears to me more objec- tionable than the mode now in use," which he describes ; also about the new burial-ground. Dr. Cumming writes, in reply to a letter of Dr. Smith of the 31st January, about objections to site of wooden buildings, in the Barrack Square. Dr. Smith to Under Secretary-for-"War, in reply to a letter of his of the 16th inst., advises a considerable number of spe- cifics for vermin, white precipitate, blue ointment, nicotine, stavesacre, infusion of tobacco, small tooth-combs, &c., good diet, change of clothing. A long letter on an abominable nuisance, arising from the sufferings of the preceding winter, and which was well nigh over, by this time. DR. HALL ON SCUTARI. XXI Extract of letter from Dr. Hall to Dr. Smith:—" I hope," he says, " the 40,000 gallons of lime-juice you mentioned are not far off at present, so that the ration may be continued to the whole Army." Is quite sure that lime-juice, vegetables, warm clothing, and better shelter, and two consecutive nights in bed, would eradicate scurvy and cure diarrhoea. Transports properly fitted up are coming into use. Castle Hospital pro- gressing. " I am quite pleased with the place and anticipate much more benefit by sending men there than down to Scu- tari. At Scutari the buildings are large, crowded, and difficult to keep well ventilated. Fever, consequently, has made its appearance and proved fatal to many, both officers and men." At the date of this letter the Sanitary Commission was on its way to the East, and it will be observed that nothing is even now pointed out to the Director- General, except the hopelessness of sending sick to Scutari. The deaths from fever are taken for granted as a necessary occurrence, only to be avoided by not going there. One would think that not one practical fact in Sanitary improvement had, as yet, been ascer- tained. Dr. Smith writes to Colonel Mundy, suggesting the employ- ment of Sick transports, to bring the sick home to England, touching at Malta and Gibraltar, to land bad cases. Dr. Smith to Under Secretary-for-War, asking that 40,000 gallons of lime juice should be sent to Balaclava, as speedily as possible. Dr. Smith to Under Secretary, "War Department. Explains the startling fact of 26 per cent, of the force at Gallipoli being the average amount of sick, by a statement of the Principal Medical Officer there, that the force consisted of weak and sickly men, left behind when the troops went to Yarna. The well-known unhealthy sanitary state of Gallipoli is considered to have nothing to do with the occurrence. Recommends re- placing the detachments by stronger men. Dr. Smith to Colonel Mundy, recommends hospitals at Princes' Islands, rather than additional temporary hospitals at Scutari. Dr. Eorrest to Dr. Smith, respecting objections against the buildings in the Barrack-square, Scutari. Dr. Smith sends Dr. Forrest's letter to Colonel Mundy. , February 23. Dr. Hall on Scurvy and on Scutari. Remarks on the above. February 27. Sending Sick Home. February 27. Lime-Juice. February 28. Sickness at Gallipoli. March 1. Sanatorium. March 2. Scutari Huts. March 3. XXII DR. SMITH PREPARING March 3. Mr. Koberts encloses a letter to Dr. Smith, about brewing beer in Turkey. March 3. Dr. Hall writes to Dr. Smith, enclosing estimate for mules required for the Army Medical Department, if the Army take the field. March 3. March 3— Dr. Smith requests the removal, by Lord Pan- Scutari Huts. jjj^j.g5g orders, of the buildings within the Barrack-square at Scutari. [This was never done.] March 6. Dr. Smith writes to Dr. Hall, sending a copy of Dr. J. Sweet Davy's letter from the " Spectator," about the contrast in the Dietary of dietary of a British Eegiment serving before Sebastopol and Army and Naval Brigade, durino: December and nearly the whole of Naval Brigade ^ '.t, ii-^.jn in Crimea. January, and strongly animadverting on the dmerent mode oi administration in the two services. Dr. Smith states that, if the dates are correct, " there are grounds for strictures unfa- vourable as regards the A.rmy," unless it can be shown that there were insurmountable difficulties, as to the dietary and cooking of the troops. Supposing the statements correct " I confess," he says, *'for my part, I can scarcely conceive why the troops should not have been at least somewhat better supplied, both as to quantity and quality of provisions, than it would appear they have been." Even admitting the difficulties. Dr. Smith does not see w^hy the men should not have been provided " with at least a larger amount of fresh provisions." Is anxiously expecting replies to his queries about the sani- tary state of the troops, and requests copies of all communica- tions and representations " made by you to the Commander of the Forces, in regard to duty, dietary, &c., as affecting the health of the troops." Remark. One would think that the fact, well known by this time, of an Army having all but perished, would have been of itself a sufficient reason for the severest animadversion from the Head of the Army Medical Department. But no ! The Sebastopol Committee is to have the doings of that Department before it, and Dr. Smith writes to his Principal Medical Officer, "I beg you to supply me, and that immediately," — with what? — " with every kind of information which you may deem likely to enable me to establish a character for it" (the department)^ " which the public appears desirous to prove that it does not I FOR THE SEBASTOPOL COMMITTEE. XXIII possess." "What hope for the Army after this ? He might as well have said, Never mind anything if you only enable me to free the Department from blame. Mr. Eoberts sends to Dr. Smith about Port wine for troops. Dr. Smith writes to Colonel Mundy, suggesting more vege- tables for the troops, as he has reason to believe that the troops in the Crimea are still without the periodical supply of vege- tables suggested by him on December 19th, 1854. In this month, the supply of Vegetables was regular through- out the whole Army, excepting in five Regiments. Dr. Smith writes to Colonel Mundy, as to the evils of issuing pay to men in Hospital, and suggests that everything, includ- ing tobacco, should be provided for the men by the Govern- ment. Dr. Smith writes to Dr. Cumming, at Scutari, requesting his best and most earnest efforts for ventilating the Hospitals : dreads the consequences, if this is not done. Asks about the measures adopted for ventilation. Hopes the foetor of the privies is " kept down," " which must, I fear, discharge their gases into the buildings and even into the surrounding atmos- phere. The abundant use of water and charcoal I look on as the best corrective of this." This letter was written in London, three days after the Sanitary Commission had inspected the Barrack Hospital at Scutari. It points out two of the most prominent of those sanitary defects which had converted these Hospitals into pest-houses. But why so late ? Why was it delayed till the end of the calamity ? Was there no medical officer who could have told Dr. Smith, before the Hospitals were occupied, that they were not ventilated and that the sewers " discharged their gases into the buildings:" a fact which was as true before they were occupied with sick as it was when Dr. Smith wrote ? The practical result was that the sick men sent down to these Hospitals, in the hope of life, were sacrificed to the utter want of sanitary knowledge or system in the Department. Dr. Smith writes to Dr. Cumming about pitching a marquee Hospital in the Princes' Islands. Mr. Roberts, in reply to Dr. Smith's letter of 7th, states that every exertion will continue to be made to supply the troops with vegetables. March 6. March 7. Vegetables. March 7. Pay not to be issued in Hospital. March 9, Ventilating, &c., Scutari Hospitals. Remark. March 9. Marquee Hospital. March 9. Vegetables, XXIV DR. HALL CONGRATULATES DR. SMITH March 10. Hospital Discipline. March 10, Charcoal, &c. Eemarks. March 12. Dr. Hall on the improved Health of the Army. Eemarks. March 12. Dr. Hall on Detraction. Dr. Smith to Colonel Mundy, about introducing proper Hospital discipline at Scutari : complains of visitors at improper times and suggests imiproved rules. To Dr. Hall from Dr. Smith, informing him of 80 tons of charcoal and 10 tons of chloride of lime, ordered to be sent to Balaclava, for the Camps, Hospitals, and town. Eequests re- plies to queries, about the health of the troops, previously sent. Lime-juice, as we have seen, is Dr. Smith's panacea for bad diet, in the case of Scurvy ; and peat charcoal is his panacea for neglect of Sanitary measures. In neither case does the idea of preventing the mischief ever appear to have been entertained. Dr. Hall writes to Dr. Smith and is " happy" to inform him " that thie improved state of health of the Army continues." (The mortality was then no less than at the rate of 56 percent, per annum !) Mentions the appointment of the Board of Health, by Greneral Order of the lOtli March. Had been over the 3rd Division, which is one of the most sickly. Some Command- ing Officers exert themselves more than others and their elforts are successful. Other Officers consider that the Government should bring everything to the soldier. " Camps, generally speaking, are much cleaner than they were." Scurvy dis- appearing and Bowel complaints better. Supplies of every kind ample. Trench Hospitals not nearly so good as ours now% " but a system of detraction has been commenced against our establishments and has been kept up, by interested parties, under the garb of philanthropy." One is tempted to ask, did Dr. Hall really know that, at the very time he was writing this unfounded statement, the sick in the Hospitals on the Bosphorus were perishing at the rate of 235 per cent, per annum on the sick population ? It is incre- dible that he knew it. The British Hospitals, for several months, had been in such a condition that nearly a third part of all the §ick had perished in them, and during the preceding month above one-half of those treated at Kulali had died. Had the British public nothing to do wdth this ? He goes on about these "detractors:" "Some," he says, have become so, " to regain lost moral reputation, and others to make their mission of importance, and they wish the world to believe that all the ameliorations in our institutions are entirely owing either to their own exertions or those of a few ON THE STATE OF THE ARMY. XXV nurses ; and I am sorry to say some of our own department have pandered to tbis and have been rewarded for it." One is tempted to ask — have no others been rewarded, who have nothing to show for the result of this same boasted Hospital system, but the wreck of an Army, which they did not even advise the most ordinary precautions, as to diet and clothing, to prevent, and the graves at Scutari ? Dr. Hall sends Dr. Smith with this letter copies of the issues of medical comforts at Balaclava, in refutation of the statements of the " Times" and "defies the 'Times' ' Commis- sioner to prove that he has issued all the things he says he has for the use of the sick." The distribution of the " Times' " Fund began at Scutari in November 1854, and in the Crimea in January 1855. The miseries endured in the Hospitals, as attested by the evidence of almost every Commanding Officer and almost every Medical Officer, both Divisional and Kegimental, in the Crimea, attested, too, by the statements in the abstracts. Appendix II to Section I, as well as the benefits conferred by the " Times' " and other private Eunds, every one now knows ; but these very benefits were the condemnation of the Hospital administration of the Department, and, rather than that they should be ad- mitted, rather than that any deficiency should be confessed in the Hospital stores, Dr. Hall has the hardihood to make a statement which is tantamount to accusing the " Times' " Com- missioner of peculation ! Of what possible assistance could the Director- General be to the Government, when he had to depend on such information as that given in this extraordinary document ? Major- General Sir C. Yorke informs the Director- General that 5,000 gallons of lime-juice had been directed to be sent from Malta to the Crimea. Dr. Smith transmits to Colonel Mundy extract from pro- ceedings of a Medical Board, consisting of Drs. Dumb reck and Eorrest, Mr. Menzies and Dr. Mapletou, who had all served in the East, recommending the evacuation of the " crowded and polluted" Hospitals, to the greatest practicable extent, and to bring the sick home. This letter was sent to the War Department the very day before the sanitary worky at Scutari were begun by the Sanitary Commission, and immediately before the striking improvement Remarks. Issues of Medical Comforts. March 12. Limc-Juice. March 16. Sick to be sent Home. Remark. XXVI SANITARY AWAKENING AT SCUTARI. March 23, Peat Charcoal. March 23. Sanitary Recommenda- tions for Scutari. Remarks. Conchwions. I. Sanitary. in health which followed. At that date the deaths on cases treated were no less than 315 per 1 ,000, or nearly one in three, and, when the sanitary works were almost completed, the deaths fell to 22 per 1,000 on cases treated. Dr. Smith sends extract of recommendation of Board of Medical Officers to Dr. Gumming, at Scutari, recommending peat charcoal for the burial-ground, &c. Dr. Smith sends to Dr. Gumming, at Scutari, other sanitary recommendations about the hospitals, as follow : — 1. Turning the Apothecary's and Purveyor's stores, at tlie General Hospital, into wards. 2. The " defective and unscientific" construction of the drains to be " seen to." 3. The state of the burial-ground, as already pointed out. 4. Mending the floors. 5. To improve the sanitary state of the eastern wing of the Barrack Hospital (how or in what respect is not stated). G. Huts in the square should be removed. 7. The Palace Hospital ought to be evacuated, on account of its "notoriously unhealthy position." 8. " It is said that the rooms for sick, at Kulali Barrack, are over stables." Stables should be rendered healthy. 9. What means have been taken to remedy " the offensive and pestilential state" of all the privies? Also the abandonment of the Turkish privy and the forma-, tion of another kind is recommended. This letter, like so many others in the correspondtnce, is so far behind its time, that one wonders why it was written, except to save the Department from the charge of absolute neglect of duty. The sanitary advice in it is not worth much, but it would have been better, had the letter been sent nine or ten months earlier. It would arrive at Scutari at the end of the first three weeks of the Sanitary works instituted by the Gommission, and wlien the mortality on cases treated had fallen from 315 to 144 per 1,000, in consequence.* I. It will be observed iu Dr. Smith's Gorrespondence— - 1. That, as far as sanitary recommendations are concerned, tlicse letters are most defective. * Dr. Cumming's singular reply to this letter of Dr. Smith is given verbatim, Preface to Section III (p. xiv). GENERAL CONCLUSIONS. XXVII 2. That there appears to have been no preliminary sanitary instruction sent to the Army in Bulgaria, even after the receipt of Dr. Dumb reek's Keport, prepared as tliat Eeport was by Dr. Smith's desire. 3. 'No instruction sent, to examine and prepare the Hospi- tals on the Bosphorus, before they were occupied. 4. No sanitary instruction issued for the guidance of Medi- cal Officers going to the Crimea, on any one subject, either regarding town or country. After sanitary neglects had become matter of public notoriety, a stir was made about individual cases, as, e.g., the drainage and graveyard at Scutari, but all this was after the evil was done and the penalty incurred. II. It will be seen that the recommendations affecting the II- As to personal hygiene of the soldier evince more information and Supply, practical insight. They are often enforced with vigour, as, e.y., in the case of Lime Juice, ventilated Tents, and, to a certain degree. Clothing. But the Army could not live on Lime Juice ; it appears to be Dr. Smith's idee fixe. There is little mention made of Vege- tables, or of unground Coffee, till the mischief was done. There is no mention at all of Fresh Meat, Bread, Fuel, Koasted Coffee or Cooking. The very essentials to life are neglected, and even the remedies are posthumous to the death of the Army in many cases, in others tardy and ill-timed.* * Fresh Meat. Average Quantity of Fresh Meat issued to each Man of the Five Divisions composing the Army, including the sick in cainx>. Per Month. lbs. oz.. December, 1854 6 4 Januar}', 1855 9 0 February, „ 8 2 Fresh Bread. Not a morsel issued to Sick till April 9, 1855, nor to the Troops till later. Green Coffee. From beginning November, 1854, till end January, 1865. Fuel. Cliarcoal. — Issue began December 8 — only to Troops in front. Woo S O il> ft O d LJ ^ o ^ ft O £3 ^ e3 I. 3 ^ Eh ^ oo 1854. ■ SCUTAKI. Oct. 1— Oct. 14 14 1,993 590 113 148 19-2 Oct. 15— Nov. 11 28 2,229 2,043 173 101 8-5 Nov. 12 — Dec. 9 2o 3,258 1,944 301 121 15-5 Scutari & Kululi. Dec. 10 to 1 Jan. 6, 1855 J 28 3,701 3,194 572 202 17*9 1855. Jan. 7— Jan. 31 25 4,520 3,072 986 319 321 Feb. l~Feb. 28 28 4,178 3,112 1,329 415 42-7 Kululi Feb. 1— Feb. 28 28 648 581 302 608 52-0 Scutari & Kululi. Feb. 25— Mar. 17 21 3,779 1,621 510 235 31-5 Mar. 18— Apr. 7 21 3,306 1,650 237 125 14-4 Apr. 8— Apr. 28 21 2,803 1,190 127 79 10-7 Apr. 29— May 19 21 2,018 1,350 70 60 5-2 May 20— June 9 21 1,504 996 48 56 4-8 June 10 — June 30 21 1,442 1,266 28 34 2-2 Compare {i. e., omitting the worst time, viz., Februarv.) 1854. 1855. Oct. 1— Jan. 31 123 3,140 10,843 2,145 203 19-8 1855. 1855. Feb. 25— June 30 126 2,501 8,073 1,020 118 12-6 Comparison with rate of Mortality in London Hospitals. In order to estimate how excessive was tlie rate of Mortality suffered under the conditions of the first winter, and how low it fell under the sanitary improvements of the summer, w^e must compare it with that of our London General Hospitals. But the comparison is one entirely in fiivour of Military Hos- pitals, because, whereas, in these, every man unfit for dutv is BIAGBAM RlJ?ES:S3CmKG THE MOimLXTT IH TEE HOSJI AT SCUTARI AND KULALI, FROM OCT" \^ 1854. TO SEPT" 30^" 1855. i PRECEDING CORRESPONDENCE. XXIX admitted, whethep his case be slight or severe, in the London General Hospitals every case is severe. Yet, we find, upon consulting the Eegistrar Greneral's Eeturns, Vol. xiii, No. 8, p. 67, that, in 1851, in the 11 General Hospitals of London, the Mortality per cent, on cases treated was 7' 6, the annual rate per cent, on sick population was 82. Even in the Eever Hospital, which might be thought to bear some comparison with the War Hospitals invaded by Epidemic Eever, the Mortality per cent, on cases treated was only 11, the annual rate of Mortality per cent, on sick population 110*5.* In the London General Hospitals, above mentioned, the highest rate of Mortality was at University College, being per cent, on cases treated 10 5 ; per cent, per annum on sick population 13i"8. The lowest rate of Mortality was at St. Thomas's, being per cent, on cases treated 5*5; per cent, per annum on sick population, 53. Now let us take the Military and Naval Hospitals in and near London, and we find the Deaths to 100 cases only 2"4 ; the Deaths to sick population annually per cent, only 39 — shewing that, as above stated, the sick population in a Military Hospital at home is a very different one, in the character of severity of its cases, from that in a Civil Hospital, which will be seen in a still more striking light, when we consider that London at the Army ages is nearly twice as healthy as the Army in London, and suffers little more than half its Mortality. The case therefore stands thus : — Mortality. Eate per Cent per Ank. Per Cent, on ON Sick Population. Cases Treated. 11 London General Hospitalsf 82 7-6 Fever Hospital 110-5 11-3 Military and Naval Hospitals ) 89 2-4 in London . . . . / Scutari and Ku- ] during 4 months 203 19-8 lali General V „ 4 weeks 319 321 Hospitals . . ) „ 4 weeks 415 42-7 Kulali . . . . „ 4 weeks 608 52 Scutari and Kulali, summer, 1855 34 2-2 With rate of Mortality in London Military and Naval Hospitals. * And this is nearly as great as the mortality from Yellow Fever in the Tropics between the beginning and end of ihe epidemic. + The mortality of the London General Hospitals is very much higher XXX REMARKS ON THE In the London G-enerai Hospitals, therefore, 8 out of every 100 cases admitted die. In the Scutari General Hospitals, for several months, 33 out of every 100 cases admitted died. And at Kulali, during one month, above 50 out of every 100 cases admitted died. In June 1855, again, when the Sanitary improvements were nearly completed, the Scutari rate of mortality fell to less tluui that of the London Military Hospitals, being 31 per cent, annually on sick population, and 2| per cent, on cases treated. Curious A singular Statistical problem is thus stated by the Corn- Method of inandant, for the official information of Her Majesty's Govern- ^^rate^o? ment, p. xi : — " Sickness has very much diminished and so has Mortality, ^j^g Mortality. In January last the number of deaths was 1,480, in February, 1,254, and in March, 424, every mouth showing a steady decrease over the preceding one. The average mortality, at present, is 5| per diem." This problem is much like the celebrated riddle, " Given the height of the mast, to tell the captain's name." Not given the numbers in Hospital, to tell whether there is a " steady decrease" in its mortality. The real fact, alas ! stood thus, — there was an appalling increase of mor- tality, up to the end of February, reaching nearly 43 per cent., in that month, of cases treated, from 32 per cent., which it was in January. The numbers in Hospital had diminished. Up to March 17 the mortality, although diminishing from what it was in February, which w^ould, indeed, had it continued, have swept away the whole Hospital population in three months, yet continued half as much again of what it was from October 1, 1854, to January 31, 1855. A " mortality of 5| per diem" does not sound alarming, cer- tainly, but it is 1,877 per annum. The fact, however, is useless without the strength — 1,877 Deaths on a strength of 8,000 than it ought to be — the sanitary conditions of the London Hospitals very, very much lower than they ought to be. The selection of severe cases cannot altogether explain this very high mortality. In drawing any com- parison, however, between the mortality in Civil and Military Hospitals, it must be remembered that the ages of cases admitted into the former differ from the ages in the latter, and that the class of constitutions admitted into Civil Hospitals is much worse than the class admitted into Military Hos- pitals. Civil Hospitals ought, therefore, to yield a higher rate of mor- tality. PRECEDING CORRESPONDENCE. XXXI I sick, which there was at one time, being a very different thing from 1,877 Deaths upon 3,000 sick, which there was at another time. I So incomplete was the information received by the Secretary Ijof State for War. f Various returns will be given elsewhere (derived from official Discrepancy of I sources) of the mortality in Hospital. None of these will be Returns. found to agree. It is, indeed, impossible that accuracy of returns can be secured under our present system or no system, j In these months of January, February, March, now under consideration, the variations in the returns of mortality are as follows :— * Commandant at Scutari. Medical Returns. Burial Eeturns. Adjutant- General's Eeturns. Infantry alone. January . . 1,480 1,235 1,473 1,193 February 1,254 1,329 1,151 1,261 March . . 424 555 418 587 Total 3,158 3,119 3,042 3,041 Note. — I may add two remarks, in parenthesis : — (I) I am singularly at a loss to understand what is meant Statement in by the following paragraph, in the Commandant's letter, ^Lrtterabout^ p. xn : — <' Ladies and " I have continual applications from the .... ladies Nurses." and nurses for extra expenses, such as field allowance, forage * The Deaths at Smyrna Hospital were 127, being from February 15 to March 31. This solves the difficulty of the excess of the Medical over the Commandant's Returns, supposing the Principal Medical Officer's Returns to contain these Deaths, during the above period, which, however, he expressly states they do not. But it increases the difficulty of explaining the excess of the Commandant's and Burial Returns over the Medical, during January ; and it makes the similarity of the Totals quite inexpli- cable, excepting upon the supposition of lost ground having ])een made up by different Authorities in different months. XXXII REMAUKS ON THE for horses, servants' allowance, &c. ; all of which, except tlicir rations, I do not consider myself at liberty to sanction." No such application was ever made to the Commandant by any of the "ladies and nurses" under my charge; and with, regard to " extra expenses," both for patients and nurses, these; were all privately undertaken. The sum of £9,537 125. H^d. was thus expended from private funds, of which Her Ma- jesty's Government repaid £2,601 14^. 2id. The salaries: and wages of the ladies and nurses, their travelling expenses,! outfits, and Eegulation Dress were the only other items paid by the Government. For those expenses of the Nursing Staff, defrayed by me in the East, not a halfpenny was ever advanced to me, with the exception of one credit of £1,000 and another of £1,500, granted me, upon my first going out, by Her Majesty's Government; the money afterwards was always advanced by me. The rations were issued by the Govern- ment, but at Scutari nearly all the " extras," including gene- rally tea, butter, wine, &c., both for patients and nurses, which were issued by us, were provided by private funds. The annexed schedule will shew what was supplied to us by the Purveyor in the Barrack Hospital from November 1854, to December 1855, a period of fourteen months, which com- prises all the time during which we issued " Diets" to the patients. The schedule includes all the Purveyor's issues to us, whether for these diets for patients or for rations for the nurses, The Government was throughout most liberal in sanctioning these efforts of private enterprise ; and nothing but thanks is due to them for their support. It is only in refutation of an unintelligible assertion that this statement ever would have been offered.* (2). The sentence about " Miss Nightingale's extensive esta- blishment," as tending to fill up the " Barrack" Hospital, and. with others, " requiring necessarily the admission of a propor- tionate number of workmen," " rendering the building more fit for a Barrack than a Hospital," is obscure. " Miss Nightingale's extensive establishment," consisting o1 * No mention is here made of the enormous distribution of private stores, independent of the above sums. PRECEDING CORRESPONDENCE. XXXIU space which, in corresponding quarters, was occupied by three Medical Officers and their servants, and in about the same space as was occupied by the Commandant. This was done ill order to make no pressure for room on an already over- crowded Hospital. It could not have been done with justice to the women's healtli, had not Miss JSTightingale taken a house in Scutari at private expense, to which every nurse attacked with fever was removed. The number was subsequently thinned by a part being moved into quarters in the General Hospital. Note. Tlie tardy and irrelevant, and, so to say, out-ol-date working of the Director- General's Department may be well illustrated by the following letter: — Dr. Dumbreck to A. Gumming, Esq. Army and Ordnance Medical Department, Sir, 18th May, 1855. Referring to the evidence of Miss Elizabeth Wheeler, page 329 of " The Report on the State of the Hospitals of the British Army," I am desired by the Director-General to request your attention to the system at one time apparently obtaining in the hospital under the immediate surveillance of Deputy Inspector-General of Hospitals Dr. M'Grigor, which permitted nurses to exercise their judgment and discretion in the selection of cases for the treatment of which stimulants might be applicable. This is a state of things calling for severe reprehension, and for your direct and stringent interference, should a recurrence of it be attempted in the hospitals under your superintendence. I have, reaking to read, like some torment invented by Dante for the ufernal Eegions. The first indication of the sanitary condition of the Army November 24. laving been the subject of communication between Dr. Hall gtate^ofArlny nd Head Quarters is in a reply given- to a note from the Adjutant- General, on November 24th, expressing Lord Eaglan's larm at the fact, mentioned in the morning state, of there lieing 2,010 sick in camp, and asking if cases were sent away. )r. Hall replies incidentally ; " that the sanitary condition of he Army was alarming enough, and with tlie severe duty and xposure the men had to undergo at that inclement season, I lad no doubt it would increase." " The prospects of the Army re miserable enough, and if we were to remain in the condi- lion we were then in, there would be a small army indeed by he time the winter was over." He shows, that out of a nomi- lal Army of 37,232 men, there were 2,160 sick present, and J»,843 sick absent ; 9,003 in all ; or about 25 per cent, of the brce. Sick w^ere taken to Balaclava daily, as far as possible. Regiments had been landed late in the day in heavy rain, and ^ome of them, the 46th for instance, without tents. [ It is a note-worthy fact, that 25 per cent, of the Army should tave gone on the sick list without apparently having led either jo previous remonstrance, or to the calling of a Medical Board ; uid that the subject is only mooted, for the first time, in con- |equence of the difficulty of getting the sick fast enough away, f But this was not the worst. In January 1855 upwards of »ifty per cent, of the force under arms before Sebastopol were I n the sick list, at the same time, or 12,025 sick out of 23,392 |l;ien, of w^hich sick there were 4,158 present and 7,867 absent, lltill no vigorous remonstrance. The unfortunate 46th, in ad- 'ition to its being landed without tents, actually served, at one llime, for six successive nights in the trenches. It was ''nearly jnmhilated by sickness, in the months of November and De- ember," and presented the apparent anomaly of losing more ihan its average strength. I Dr. Alexander reports to Dr. Hall that two men died from November 26. jxposure in the trenches, and many were brought in suffering. Alexander, XXXVIII REPIIESENTATIONS AS TO Recommends buildings being put up for Hospitals, cooking- places, and fuel. November 26. Makes similar representation, on the same day, to General Dr. Alexander. Codrington. States men in one Eegiment are ill off for boots, shirts, and warm clothing. If not remedied, sickness will in- crease and the mortality will be great. Again asks for blankets, fuel, and cooking-places. November 29. Eeports to General Codrington and to Dr. Hall thirteen deaths from Cholera. Encloses letter from Dr. Longmore, showing how the men will suffer unless protected, and their meals properly cooked. November 29, consequence of Dr. Alexander's letter of the 29th, Dr. 1854. Hall represents to the Quartermaster- General that " the want Dr. Hall. camp kettles, fuel and blankets, as well as proper shelter for the men, is being severely felt just now in the whole army, and I cannot too strongly urge the necessity of these wants being supplied as speedily as possible." It will be observed, that the administrative principle involved is that of representing wants and defects and not of foreseeing and providing for them, and that this was the principle by which the Army perished. December 2. Dr. Alexander to Dr. Hall. Former requisition for medi- Dr. Alexander, cines inadequately complied with. Only 4 oz. of calomel and 4 oz. of opium sent for 636 sick of Cholera, equal to 3 grains for each patient. There must be more at Balaclava. Eequestj that the full amount of the requisition be complied with. December 4 Dr. Alexander to General Codrington. Sickness rapidlj increasing. Great mortality among the troops, from exposure want of huts, cooking-places, fuel, &c. Again asks for blankets Soldier has to consume his " miserable ration" half raw. Arm^ will soon be rendered totally inefficient. Wants fuel, for ob taining something warm for the sick in Hospital, and for thos' brought in, in a state of collapse, from the trenches ; als( marquees and tents. A similar letter to Dr. Hall. December 6. Dr. Hall says in reply, December 5th, " the picture you dra^ Dr. Hall. ^^^q condition of the men is a melancholy, but, I fear, to true a one." Fuel and lights were issued to troops by yestei day's orfier. " It is not for want of representation matters ar as they are at present." [Where are these representation! BLANKETS, FUEL, RATIONS, 8iC., &C. XXXIX ind when were they made ?] Sends explanation about calomel, fee. Asks how the Light Division has not got its supply of Dlankets, &c. i Dr. Anderson represents to Major Wood that sickness in December 7. ^:he 9th Eegiment is not owing to the ground, but to exposure jbo damp, &c. I In reply to a letter from Dr. Hall, about the causes of sick- December 10. iness, Dr. Alexander says, Want of rest, exposure to cold and 1^^- wet, harassing duties, insulEcient nutritious food, no fuel for [cooking, want of clothing (almost bootless) and in rags. Only one miserable worn-out blanket. Tents not affording protec- ftion, and for several days full of mud. The details are terrible. He shows how easily all might ^have been mitigated. Rations have generally been — 1 lb. of fresh or salt meat 1 lb. biscuit. 1 oz. raw coffee. If oz. sugar. With rice or barley. 1 gill rum. Rice only issued four days and barley one day during the ' month. Vegetables were in use during the former part of the month, as well as meat, alternately fresh and salt, for the ^ latter portion salt only, not always full ration. Recommends ^ huts for men, with cooking-places (tents are totally insufficient) ' fuel, utensils, clothing, blankets. If not supplied, fears army j will shortly be totally ineffective. ! Dr. Alexander sends suggestions to Dr. Smith and recom- December 15. mends l^^- Alexander. Separate medical transport, with all necessary field appli- ances, cacolets, medicines. Hospital Staff Corps. Principal i Medical Officer to be limited to general superintendence. A |i Field Inspector to do Hospital-inspecting work, &c. I Staff-Surgeon Hanbury recommends to Dr. Smith lime-juice, December 17. in the treatment of Diarrhoea. Hanbury. ^ Dr. Hall sends a weekly state to General Estcourt, in reply December 19 Dr. Hall. ' XL AS TO WANT OF MEDICAL COMFORTS to a note from the Commander-in-Chief, in which lie says, " The duty is so heavy, the exposure so great, and the supply of food and the means of cooking it so uncertain, that it is not surprising disease prevails so extensively among the men, par- ticularly among the newly-arrived regiments." December 22. Dr. Alexander writes to Dr. Hall, about fuel for hospitals. December 25. Dr. Anderson reports to Dr. Hall on the dilapidated state of Dr. Anderson. ^ wing of Balaclava General Hospital. December 26. Dr. Hall sends to Lord Raglan letter from Dr. Humfrey, Dr. Hall. about fresh vegetables, which he respectfully but urgently recommends. He says, "i'atigue and exposure, added to same- ness and insufficiency of diet, will be sure to produce scurvy, though as yet very few cases of that complaint have been as yet returned." December 29. Dr. Anderson protests, to Lieutenant-Colonel Haines Dr. Anderson^ against a transport camp and bazar being established near th Hospital. December 29. " Head Quarters, Adjutant- « mh Bee. 1854. General's Memorandum. " Memorandum. "The Medical Officers in charge of the Sick of Divisions will report, daily, the quantity and description of medical comforts in their possession, and the issues they have made in the last twenty- four hours to each Regiment in the Division. (Signed) " J. B. B. Estcourt, " Adjutant-GeneraL' December 30. " Camp, 4th Division, " Sir, " With reference to the Memorandum of the 29th December, from' the Adjutant- General, directing medical officers in charge of the sick of Divisions to report daily of the quantity and description of medical comforts in their possession, and the issues they have made in the last twenty-four hours, to each Regiment in the Division, I beg to state that I have not any medical comforts in my charge and have never issued any to the Regiments in the Division, there never having been a depot of medical comforts in the Camp of the 4th Division. AND OP TRANSPORT TO BALACLAVA. XLI The Surgeons of the Regiments are obliged to send to Head Quarters or to Balaclava, when in need of those or of medicines. " I have the honour to be, " Sir, " Your obedient Servant, W. C. HUMFREY, " Deputy Inspector- General of Hospitals. " In charge 4th Division. "The Assistant Adjutant-General, " 4th Division." During the winter some amount of correspondence took iplaee between Dr. Humfrey and the authorities, relating [chiefly to deficiencies in transport for sick to Balaclava, and to the sufferings of the troops and sick in camp from want of [shelter and supplies. Dr. Alexander informs Dr. Hall that Scurvy has appeared land gangrene of the extremities. [This is what was called Frost -bite.] I Dr. Anderson calls the attention of Lieutenant-Colonel Haines to the filthy state of that part of Balaclava occupied by the Turks. Fever among them. Also the foetid mud at sick wharf emits malaria prejudicial to the health of the town. Dr. Hall encloses to General Airey a letter from Surgeon (Marshall, urging necessity of better shelter for the men, and ! pointing out the lamentable results of exposure. " I am quite convinced the consequences will be fearful, from the exhausted state the men are in." I Dr. Pine, Principal Medical Officer, 3rd Division, to Sir Richard England. — Refers to Memorandum of Dr. Hall, urging I Medical Officers to procure necessaries from Balaclava. States that they are totally without means of transport. Requisitions ' made are unattended to. Suggests that Lord Raglan be in- i formed. Health of troops failing rapidly. Unless they are [better housed, better fed, better clad, and less worked, the j Division will be speedily annihilated. This and Dr. Alexander's letter of December 2, with others, upon the difficulty of obtaining medical comforts or medicines from Balaclava, for want of transport, and want of attention to requisitions there, are worth comparing with the letter of Dr. Humfrey, December 30, stating that he, too, has always been December 30. Dr. Alexander. December 30. Dr. Anderson. January 5. Dr. Hall. January 5. Dr. Pine. Remark. XLII AS TO GREEN COFFEE, WANT OF Januaiy 6, Dr. Marshall. January 10. Dr. Pine, January 10. Dr. Linton. For November and December. January 15. Dr. Anderson. obliged to send to Balaclava, or to Head Quarters, for these medical comforts and medicines, having no depot of such in the Division. It is thereby proved that the 3rd, 4th, and Light Divisions, at least, if not all the Divisions, were dependent upon supplies which they had no means of procuring from Balaclava. And Dr. Hall's stormy denunciation of the " detractors" and attes- tation of the issues of supplies at Balaclava are not worth | much, since it appears that this Balaclava had to supply all, or nearly all, the divisions, as also that the sick were suffering and nearly destitute of these necessaries, owing to the difficulty of fetching them. Dr. Marshall reports to Dr. Hall gangrene of the feet, from cold, in the 2nd Division. . Dr. Pine to Lieutenant-Colonel Colborne. — Shows deficiency I of provisions. Men get food too late to cook it, before going to the trenches. Men have eaten their rations raw. Men coming from trenches get coffee only, because utensils will not cook meat and coffee at the same time. No transport. Sick cannot be removed often enough. Marquees have to be used as hospitals. Eecommends increase of ration — by the substi- tution of roasted coffee for green — by addition of more rice, by vegetables, and by fresh meat. Eecommends lime-juice — three meals a day. Dr. Linton writes to Dr. Hall and sends monthly sum- maries for 1854, in which he states the prevalence of disease in 1st Division to be attributable to duty, exposure, cold, wet, ij want of sufficient vegetables or lime-juice, want of protection from weather. 93rd Eegim-ent, under shelter at Kadikoi, have hitherto escaped. In the early part of November troops had fresh meat every other day, latterly salt meat alone. Little time for cooking. Fuel difficult to get ; water distant ; camp kettles lost or destroyed ; weather wet, stormy, and boisterous. Everything wet — blankets, great coats, clothes. Temperature below freezing : no winter clothing, no shirts or stockings, no- shelter. Men eat pork raw. G-reen coffee issued (January 10th), j a ration " utterly useless." No transport. Our ambulance has turned out a complete failure. French ambulances most useful. Dr. Anderson reports to Dr. Hall the mortality among the Turkish troops, at Balaclava, imperatively calling for inquiry. COOKING, DEP^ICIENCY OF RATIONS, &C. XLIII (Suggests inspection of their burial-ground : bodies not properly [Covered. " We sliall have a plague," if the part of the village occupied by the Turks be not cleaned. I Dr. Hume reports the Turkish tents, near his Hospital, as a 'nuisance, and recommends their removal. , Dr. Anderson reports to Lieutenant- Colonel Haines imper- [fect accommodation for sick brought down for embarkation, land advises that better be provided. I Dr. Anderson suggests to Colonel Harding to remove pedlars I from vicinity of Hospital, &c., and a sentry to prevent nui- Isances. [ Same date, reports to Dr. Hall men brought down labouring .under frost-bite, without stockings or shoes, or anything to j protect their feet. I These fearful cases of Frost-bite, so called, were brought I down, thus bootless and stockingless, to Scutari. I have seen [ cases so frost-bitten up to the knee. I Dr. Anderson reports, to Lieutenant-Colonel Haines, over- I crowded state of Medical Officers' quarters, in General Hos- pital, Balaclava. Same date to Dr. Hall, as to sick being sent (down without previous warning. Hospital overcrowded. ; Dr. Hume, Principal Medical Officer, 3rd Division, reports, to Dr. Hall, that both sick and well are on salt rations. Com- missariat officers cannot say when fresh meat will be again supplied. Troops stand in immediate need of fresh meat and \ lime-juice. j A similar letter sent, on the 9th February, to Colonel Wood. I Dr. Linton calls the attention of the Assistant Quarter- I master- General, 1st Division, to the great number of unburied \ carcases within the lines, and the filthy state of the Turkish I camp. He repeats this, on the 1st February, in reply to a ; letter from the Assistant Quartermaster- General, stating that 1 the camps were clean. I Dr. Anderson reports to Dr. Hall two or three cases of Smallpox, among drafts on board ship. Has employed separa- j tion, disinfecting fluids, &c. Staff" Surgeon Roberts writes to Assistant- Adjutant General, I 4th Division, about the dirty state of the ground near 4th Divi- sion Hospitals and the latrines. Fatigue parties were applied January 23. Dr. Hume. January 23. Dr. Anderson. January 24. Dr. Anderson. January 25. January 26. Dr. Hume. January 27. Dr. Linton. January 28. Dr. Anderson, February 3. Dr. Roberts. XLIV BOARD OF HEALTH CALLED FOR February 9. Dr. Hanbury. February 10. Dr. Hume. February IL Dr. Hanbury. February 12. Dr. Hume. Same date. February 12. Dr. Alexander. February 13. Dr. Hall. February 16. Dr. Anderson. February 17. Dr. Hanlmry. for, with little elFect. No method of makiug latrines or ensuring cleanliness, except by desultory action. A sanitary camp police wanted. Gives reply from Assistant-Adjutant- General that the pro- posals were good but could not be carried out. StafF-Surgeon Hanbury writes to Dr. Hall on the influence of diet on the diseases of the army. Also, same date, about Hospital latrines. Dr. Hume to Lieutenant-Colonel Colborne. — Reports tents of 28th Regiment worn out and admitting water. About 100 sick are disposed in some such tents. Recommends other accommodation. Dr. Hanbury reports to Dr. Hall that fever is prevalent in Balaclava Hospital, and that Dr. Hall's suggestion for ventilating the wards had not been carried out. This was done after- wards. Dr. Hume, writing to Lieutenant-Colonel Colborne, objects to a proposal which had been made to use the best tents for sick. Advises a sijip being sent to Constantinople for tents and transport. If this is not done, the whole Division will be placed in danger. Same date, Dr. Hume receives reply about the salt provi- sions. Commissariat had been directed to supply lime-juice and live cattle expected daily. Dr. Hume reports to Dr. Hall that the sick of the 3rd Divi- sion, 1,503 in number, had been on salt provisions for five days. Only eleven bottles of lime-juice. Dr. Alexander applies to General Codrington, for a daily issue of fresh meat, for hospitals. After the sufferings of the winter were well nigh ended. Dr. Hall writes to Lord Raglan, informing his Lordship that Diet is a question of so much importance to the welfare of an army'* that he recommends the appointment of a Committee, " to take into consideration the present mode of rationing the troops in the Crimea, to see if any and what changes can be eff'ected in improving it." Dr. Anderson reports to Lieutenant-Colonel Harding twenty dead bullocks in the Harbour : carrion lying along the beach, near the entrance. Suggests tugging dead animals out to sea. Staft-Surgeon Hanbury states to Dr. Anderson that Pur- IN MARCH 1855. XLV eyor had reported that there was no fresh meat obtainable for ick in Balaclava Hospital, and protests against it. Staff-Surgeon Eoberts reports graves want covering with rash earth. Dr. Anderson writes to Dr. Hall about fresh latrines for jjtlospital. li Eeports crowded state of "Timandra," with Croats on 'joard. Dr. Hume to Lieutenant-Colonel Colborne. — Recommends a |iaily police to collect, burn, or bury filth and rags round the tiospitals. Mr. Mouat reports to Major of Brigade, Cavalry Division, iiraperfect burial of horses, near the Camp. Strongly repre- isents danger to health ; advises covering carcases with pow- dered charcoal, lime, and earth. I States result to have been that camps were inspected. Four jdirty camps cleaned and suggestions carried out. t Dr. Anderson again reports the case of the " Timandra :'* [eleven cases of fever on board. I Dr. Alexander calls the attention of General Airey to un- buried horses, near his Division ; advises latrines to be covered up, and very great attention paid, daily, to the cleansing of the Camp. i Staff- Surgeon Hanbury suggests whitewash for roofs of hos- pital huts, to protect them against the sun. Dr. Linton. — Memorandum to Medical Officers, to see to removal of camp nuisances. Dr. Hall recommends Lord Raglan to appoint a Board of Health, to consider " the sanitary state of the Army," as to " diet and water, accommodation for sick and well, clothing, duty, and locality." It is worthy of remark that this is the first Board of Health called for by Dr. Hall. By this date the whole mischief which such a Board might have prevented had long been done. By this date, also, the Commission of Inquiry into the sup- plies of the Army, and the Sanitary Commission for removing sanitary defects, were both at work at Scutari. Of what possible use could therefore this Board of Health be at such a time ? A more perfect illustration of ex-post facto proceeding can hardly be conceived. February 17. Dr. Roberts. February 19. Dr. Anderson. February 23. February 24. Dr. Hume. February 25. Mr. Mouat. February 27. Dr. Anderson. February 28. Dr. Alexander. March 6. Dr. Hanbury. March 8. Dr. Linton. March 8. Board of Health. XLVI CONCLUDING March 6. Staff-Surgeon Roberts proposes sinking wells for water. Dr. Eoberts. March 7. Staff-Surgeon Roberts proposes raising sides of tents and emptying tliem, for ventilation. March 10. Anderson recommends to Dr. Hall whitewashing the Dr. Anderson. j-Qofs of hospital huts. March 11. He advises the " Severn" to be cleared out. March 13. Reports Greneral Hospital crowded with sick, sent down without warning. March 13. Represents to Lieutenant- Colonel Harding the filthy state of the beach and the encampment behind the cattle wharf. March 17. Requests hospital sentries. March 17. Dr. Hanbury reports to Dr. Hall fever in Balaclava General Dr. Hanbury. Hospital from overcrowding and among the Orderlies. Encloses letter from Mr. Archer on the subject. March 27. Staff-Surgeon Eoberts reports to Adjutant- General, 4th Dr. Roberts. Division, that graves want fresh covering ; Regimental tents unequally occupied ; want of tent ventilation — advises raising the sides. In reply, attention was ordered to be given to ven- tilation, but General Campbell states Mr. Roberts took the hint as to the measures he recommends from what he had seen done in the Division. March 31. In his Quarterly report, Staff-Surgeon Roberts states tha during the previous winter, he many times found meat n eaten, for want of water to cook it, the men not being able fetch it: also from want of fuel. Eound three days' ratio in one tent uncooked, for want of fuel. Both fresh and s meat were so found. On the 27th January Private Gallagh had not eaten his rations for a month. A number of simil instances of uncooked rations. Meat buried that was n cooked. Want of water. Men's persons had been covered with vermin. Of what possible use could it be to poor " Private Gallagher,'' and to " a number of similar instances," to report, so long afterwards, that they had not been able to eat their rations two months ago ? July, 1857. "Writing in July, 1857, referring to his reports. Dr. Robertf Dr. Roberts, says, " The reader of these pages will see that there was n( sanitary discipline observed in our Army in the Crimea, at th( time referred to." REMARK. XLVII These abstracts, continued up to the end of the first winter Ind the arrival of the Civil Commissions, show the operation f the existing Army Regulations in Divisions and Regiments, ^he representations made by the Divisional Medical Officers, IS to the deplorable condition of the Army, and the causes jrom which it was perishing, are urgent enough. The practice I allowed by the Principal Medical Officer in this matter appears \o have been that of representing the miserable state of the irmy mainly by sending other people's letters to the Mili- ary Authorities. The entire want of system and of uniformity nd efficiency in practice which the whole correspondence dis- loses is very striking. Under such a sanitary regime what hope j^as there for the Array ? The only use which can be made of the [vidence is as a warning. It shows clearly that any future Army, lituated as the Army of the East was situated, would perish as : perished, unless a sweeping alteration be made in the whole tdministrative arrangements bearing on the health and effi- iency of the troops. [ With proper administrative arrangements^ such representa- lions should have been almost, if not altogether, unnecessary, find, wherever it is necessary to make them, such necessity ught to be taken as indicating neglect of duty on the part of ome one. But, to trust to such representations as a means f preserving the health and efficiency of an Army is simply to facrifice the Army. The amended Regulations should clearly X the responsibility as regards the nature and amount of Nations and clothing, shelter, sanitary arrangements, and lospital equipments. 'I PREFACE TO SECTION II. It is now well-known that a large element in the mortality i|Lring the winter of 1854-55 was the loss of life on board •\e Sick Transports between Balaclava and Scutari. ' The sick, from the landing in the Crimea, September 15, 1854, ii the end of January, 1855, were brought to Scutari in 56 'I'ansports, some of which were sailing vessels and others samers. The sick were received on board, and sometimes detained for iveral days before the vessel sailed. The voyage for sailing iiips was usually six days, and for steam ships nnder two days: iit the average time the sick were detained on board was eight 'jys and a-half from the time of their embarkation at Bala- «iva till they were disembarked at Scutari. The numbers I those who died on board are variously stated, but they are obably, in every instance, understated. It appears, that about 13,093 sick were embarked during the ^ur and a-half months, of whom about 976 died. This is a mor- ility of no less than seventy-four and a-half per 1,000 in the I ort space of eight and a-half days. When we reduce this pro- ] rtion to the proportion of deaths per annum, we find that, lid the embarkation of sick gone on for twelve months at the Sine rate of mortality, no less than 3,182 men would have died (t of every 1,000 embarked; in other words, the whole ipulation of the Sick Transports would have perished on the Jiack Sea upwards of three times. The following Table gives the monthly details of this catas- i»phe. I 74i per 1,000 Mortality of Sick on board Transports for 4^ Months. MORTALITY ON BOARD Arrived at Scutari. Sick Deaths Deaths per embarked ncp 1 finn 1,000 per anil. 1854. arriving Died on per 1,000 on cases on hoard Sick at Scutari Passage. 1 rfiMsport. during the Scutari. Sept. ] f), 1854, Months. month. to Jan. ol, lo55 (Sept. 10 — o(J. . ovo t 7S 567 15 26-4 2981 162 54-3 ZDOO 00 1855. 2902 262 90 321 13,093 976 74-5 198* 3182 Feb 2178 41 19 427 Feb. 25 to Mar. 17 1067 5 4-7 315 Mar. 18 to April 7 860 4 4-6 144 Upon a voyage no longer than from Tynemouth to Londoi there died 74 out of every 1.000 sick embarked, during a perio of months. The loss in individual Transports was much greater thj this average. The " Caduceus" embarked 430 sick on Sept. * 1854, and disembarked them at Scutari on Sept. 29. Durii the six days the sick were on board, there died no fewer ths 114 men, being 26J per cent, of the total number embarke or in the incredible ratio of 16,160 per 1,000 per annum. 1. Either 1- In considering what possible causes could have led i Transports guch a calami tv, we can but come to one of two conclusions. ■ untit tor Sick -n- ^ ^ " a- ^ m or Sick unfit l^ither these Sick Transports were m a condition utter for Voyage, unfit for sick as regards their Sanitary state, or sick wei shipped in a condition utterly unfit for such a voyage. Froi the imputation of one neglect or the other we cannot escap We have positive evidence that the Transports were, many j them, unfit for the purpose. They were overcrowded, badi ventilated, not clean, and not fitted up for the reception sick. The attendance on board was also deficient. The supe* ficial space, allowed in these Transports, was fixed by a Boa of Inspection formed at Balaclava, December 12, 1854, C ft. by 21 ft. for sick and 6 ft. by 3 ft. for wounded men. T] * Viz., from October 1, 1854, to January 31, 1855. SICK TRANSPORT SHIPS. Ill eight between decks varied from 6 ft. to 8 ft. In one instance lone was it 8^ feet, and in one other 9 feet in some parts. We now, on the other hand, that many cases of Choleraic Disease 'ere put on board, and, as might have been expected, great :'as tlie mortality in consequence. Those who were brought bhore alive often arrived in a state of collapse, only to die. It has been usual to refer the terrible episode of these ''ransport Ships to the condition of the sick in camp as the lause. The cases, it is said, were bad cases, therefore they lied in large numbers on board the Transports and in the lospitals at Scutari whan they arrived there : therefore the ccurrence of the catastrophe at Scutari and on the voyage was navoidable. It is, however, too late, and men know too much for such an ipology to be accepted now for this sacrifice of the soldier, jf the cases were so severe, the worst that could be done with jhem was to ship them in unwholesome Transports for the 1 polluted" Hospitals at Scutari. To have begun by putting i»hips and Hospitals into a Sanitary state fit to receive the sick Ipto have kept the cases which it was unsafe to move at palaclava — this, it would seem, would have been the more ^tractical conclusion to be drawn from the above as to what •ught to have been done. The sick could but have died at Balaclava. But the Prin- ipal Medical Ofilcer himself has shown that cases which were ortunately so bad as to be unfit for removal, in February 1855, uffered only a fifteenth part of the mortality which, had they ')een sent to Scutari, would have been their fate. We do not allude, of course, to those times of which the ailing of the Caduceus may have been one, when, an Army cing on the march, it is imperative to remove the sick, how- > ( r perilous to them such removal may be ; but, at such linos, how much more imperative is it to have good Sanitary onditions on board the Transports! 2. During February it will be seen that the character of 2. Mortality at cases from the Crimea improved. The per centage of Scutari did not itality upon those embarked onboard the Transports fell on bS Sick 1 0111 90 to 19 per 1,000 ; but the mortality at Scutari rose, viz. Transports, roin 821 to 427. And even, during the three weeks ending Uarch 17, when the mortality on board the Transports, which IV SICK TRANSPORT. had been above 74 per 1000 from Sept. 15, 1854, to Jan. 31, 1855, fell to under five per 1,000, the mortality at Scutari still main- tained its fatal pre-eminence, and continued at 315 per 1,000, a far higher rate, indeed, than it had been for the four months ending Jan. 31, 1855, which was 198 per 1000. 3. If we take the Sick whom we received alive at Scutari, the dead being deducted, a still more fatal per centage presents itself, being of Deaths to 1,000 living disembarked, as follows: Months. Sick disembarked at Scutari. Died on voyage of those embai'ked from the Crimea. Deaths to ',000 living landed. 1854. Sept. 15-30.. .. 3676 311 84-6 Oct 552 15 27 2819 162 57-4 J Dee 2430 226 93 m 1855. 2640 262 99-2 % 12,117 976 80-5 , 3. Mortality on board Sick Transports per 1,000 of living landed. In the month of January we actually lost ten to every 100 who arrived alive. 1 5iNCE the landing of the British Troops at Old Fort, in September 1854, the state of the Army has been con- tahtly before the public, detailed in Despatches, Private I jetters, the Public J ournals. Speeches in Parliament, and lleports of Commissions, Boards, and Parliamentary inquiries. Yet nevertheless the main and real issue for the Queen ,nd the people has never yet been tried, viz., were the lules and Regulations of the Service adequate to their bject, — the preservation in health and life of the British irmy ? I It is not denied that a large part* of the British force ierished from causes not the unavoidable or necessary jesults of war — a number which must be called large eyond all proportion, when we remember that the Army hich thus suffered was for the most part confined in its perations to an area of occupation of six miles by four, to i period of seven months, when there was neither march or retreat, in a country where the climate was nearly as lood as that of England, although more variable, j The question arises, must what has here occurred occur No tribunal has ever yet tried this question. It hardly perns to have occurred to the national mind. I* 10,053 men, or 60 per cent, per annum, perished in seven months, ,pm disease alone, upon an average strength of 28,939. This mortality jceeds that of the Great Plague. B 2 Yet this is tlie great issue to be tried — how an Army is to be preserved in its ordinary Campaigns, if indeed it be presumed that troops are kept up for actual service. The public mind is gorged with the details of the case, without the real question at issue ever being seen, viz., upon what rules and principles did the Army Authorities act, as far as regards the prevention of that loss which did not occur before the enemy, or as the immediate and inevitable results of the strategy of the siege ? what are the rules and principles now ? what will they be for the future ? It is upon the answer to these two last questions that depends the preservation of the future British Army, amidst those wants inherent in the nature of any serious campaign. The remarks which follow refer mainly to that part of the subject which is concerned with the treatment of the sick and wounded ; but they have been extended also tc those general sanitary arrangements by which the soldiei is preserved in health and strength. 3 I. FoTEs ON THE Sufferings And Privations of the Army FROM April, 1854, to the Beginning of 1855. The Army of 25,000 men, intended to land in Turkey, Precautions 1 April, 1854, at some spot to be determined by the posi- Apin^"i854 on of the Russian Army, was preceded, owing to the ')resight of the British Government, by an Engineer, [iree Medical and one Commissariat Officers, to report pon the facilities of the country for their several objects. I It does not appear, however, that the Medical Officers ver placed themselves in communication with the resident ractitioners of the country, with the view of making nown to the Army Medical Staff the peculiarities of the IfFects of the climate in regard to the treatment of disease, hree or four of these resident practitioners, nevertheless, eld degrees of British Universities, and two of them had •cm 14 to 20 years' experience, being officially attached ither to the Sultan or the British Embassy, while a third was native Armenian, educated for ten years in England, who [as well-known in Constantinople, Broussa, and the neigh- ourhood. At least we cannot trace that any suggestions {r instructions were issued to the Medical Officers of the rmy in the summer of 1854, as to the nature of the di- late, clothing required, or any remarks as to the caution 3quired in prescribing remedies, such as calomel, &c., for isease in Turkey.^ Valuable information was afterwards iven (too late) by these to Army Medical Officers, chiefly * The Director-General states that he " did not make any definite commendations to the Government," in consequence of the Reports of e three Doctors, because a copy of that Report was left with the Army, r the guidance of the Inspector-General of Hospitals, Dr. Hall." B 2 4 LORD RAGLAN's ORDERS OF MAY. as to the kinds of clothing and of medicine necessary foi the troops in that climate. Lord Raglan's The Army landed at Gallipoli, proceeded to Scutari fnTay,^l854! ^^^^^^d to Varna, after Lord Raglan had (in May for a System of niadc such preparations for the Campaign as he judgec Nfcessarief to best. By referring to Lord Raglan's General Orders ii the Soldier. -^^^^ ^^.^^ ^^^^ ^^^^ j^^^ anticipated those e^dl which were the principal cause of the after sufferings o the troops, viz., the leaving to the discretion of the Com missariat, or even of the soldier himself, the supply o proper food, i Neglect of That a man must be kept alive to fight, and cannot if in Hospital, be in the trenches, would seem to be ; truth, though a truth not recognised, in general, b; military authorities, though certainly Napoleon considerei that the principal qualities required to make a grea Military Commander were Civil ones. Yet, in a countr where the soldier was necessarily dependent upon th Commissariat for every kind of supply, it appears to hav been in a very short time left, contrary to Lord Raglan orders, to the sanitary knowledge of a Commissar General, whether the soldier was to live on sa meat^ rum, and biscuit, and on these alone, or noi and to the sanitary knowledge of the soldier himsel whether he were to purchase vegetables or not; and, ? far as appears, no remonstrances or representations wei made, at the time they ought to have been made, viz., i the summer of 1854, by the Head of the Medical Depar ment, who does not appear to have remembered h sanitary functions. By Lord Raglan's General Orders (at Scutari), in Ma 1854, founded upon a Treasury Minute, the Commissarij was ordered to provide, to be paid for monthly out of tl messing, 1 NEGLECT OF J'HE ORDERS OF MAY. 5 Preserved Potatoes, Sugar, Chocolate, Rice, Coffee, Barley. Tea, Porter, Ale, and Tobacco were also to be provided, and ere to be paid for daily out of the pocket money of the )ldier, if he chose to have them. None of these articles |»ccept Coffee, Sugar, and, for a short time. Rice, formed art of the regular Ration. It was left to the soldier him- 3lf to determine whether he would have them or not Fuel was to be provided as a Ration : — I lb. Charcoal, or 3 lbs. Wood. The absence of this Ration in the Crimea was for some me almost tantamount to ordering the soldier to eat his leat raw, or not at all. Lord Raglan also laid down the number of Tents and mount of Transport. In about three v/eeks the above system of supply ceased, 1 consequence of various irregularities, and was, in short, failm'C. The sufferings of the Army in Bulgaria and in the Jrimea from want of blankets and of proper food are well 'nown. The bread in Bulgaria was sour and unwhole- jme, supplied by contract, and this, though there were he ovens of the country, and others might have been uilt, and bakers existed in the Army, and others might ave been obtained. If the Army were too weak to give lakers, or the country could not supply them in sufficient lumbers, especial representations ought to have been for them. Lord Raglan and his After about Three Weeks the System of Supply is abandoned. Consequent Privations and Sufferings of the Army in Bulgaria. Bad Bread and Meat. aade to England 6 NEGLECT OF THE ORDERS OF MAY. Staff occasionally ate the Frciicli bread, the French Array having baked for themselves the whole time. In the Crimea, the men had only biscuit, till bread was brought from Constantinople. The meat, supplied to the Army as mutton, all over Turkey, was generally bad, and was sometimes goats^ flesh; salt beef or pork were supplied in the Crimea ; in both instances, the men were unable to cat their whole Ration, and large quantities of it were thrown away. Yet, upon these things depends the health of a man; and in the Army, above all other trades, the physical state of the employed is the force of the employer. The health of the men is the main engine of the Commander. Contract The system of cgntract for many articles, especially for System. ]\/[eat and Bread, is extravagant, insecure, and inefficient. Bread can be provided for an Army cheaper and better by its own bakers than by any contract system. The sour bread in Bulgaria, and the constant use of biscuit in the Crimea, have been alleged by most of the Medical Officers as a powerful cause of disease. According to the contracts, the fresh Meat was delivered killed to the Troops. Goats were thus constantly substi- tuted, without possibility of detection, for Sheep. The Sheep and Cattle should always be delivered alive. Drill. At Scutari and in Bulgaria, six hours' drill, under a burning sun, greatly impaired the health of the troops ; but we find, in these same General Orders, Lord Raglan's precautions for the health of his Army, as to length ol drills, time of day of drills, fatigue duties, &c. These precautions extend even to orders about Latrines. In general the causes of our suffering in Bulgaria were the unhealthy nature of the ground, want of proper food of proper clothing, of shelter from the sun, and of medic supplies. NEGLECT OF THE ORDERS OF MAY. 7 All the Surgeons are unanimous in saying, that even 1 Bulgaria the food was bad, the tents were bad, the •ansport bad. tThe remedy for the food is to have the Ration laid wn, to have the Bread baked and the Meat killed not y contract, but in the Army. Other changes in the lommissariat will be suggested. The remedy for bad 3nts is to have good ones and carriage for them. With regard to all these deficiences, the questions of nportance to solve seem to be — Were Lord Eaglan's General Orders disregarded or WhjAvere Lord Raglan's iscontmued ? If so, why so ? W^as it brought to his GeneralOrders Otice? disregarded? The Duke of Wellington, we know, wrote to the Pre- lier in England for shoes, saying, "If you don^t send hoes, the Army can^t march/^ He corresponded himself with Admiral Berkeley at Lis- on, in order to arrange for sending, during a whole win- 3r, sailing transports for fresh meat to Yigo and Oporto. He ordered marches to be made in directions where ullocks would be found. He ordered men to march considerable distances, in rder to fetch their own clothing when it arrived, and eturn with it on their backs. He writes on one occasion to one of his Generals : — I wish I had it in my power to give you well-clothed [Voops, or to hang those who ought to have given them heir clothing.^^ He is known to have paid particular attention to the anitary position of his encampments. He appears to have been his own Quarter Master eneral. Commissary General, Adjutant General, and 'rincipal Medical Officer. The question arises, — Is it safe to have a system which 8 THE PRINXIPAL MEDICAL OFFICER'S FOSITION. consists of a man ? — in short, where the Commander of the Forces does every tiling himself, even to ordering his Army^s shoes? (which seems nearly as inexpedient as Miss Nightingale ordering the men shirts) . Lord Raglan appears to have trodden close in the steps of his Master and Fnend, ^dth this difference that his General Orders were disregarded, after a time, withont his knowledge. TVith regard to the famous move to the Crimea, without pretending for one instant to enter into the military ques- tion, it may safely be said that, in a sanitary point of view, it appeared the only salvation for the Aitqv, wliich was so reduced in health that, another month in Varna, (so it is thought by many high ^Medical Authorities) and nothing would have been left of the British Army but its graves. As it was, the men were so weak that it Avas found neces- sary, as is well known, to give an Order that they should abandon theii' kits on landing in the Crimea. Also, the Army could not have advanced towards the Danube, even had it been necessary, for the Commissariat had neither transport nor supplies. To retreat upon Constantinople would have fatall} injured the morale of the Army. That the sufferings and mortality of the men were fi'ightfiilly increased by the expedition to the Crimea is alas ! too tnie. Could they have been prevented? "Why was no It is, we presume, the business of the Principal Medica Sufferinc^^ot^ Officer ^ith the Army to report to its Commander tht the Army state of its health, and both what he iudo:es to be necessary made bv the ' j ^ Principal to secure that health and to be likely to impair it, as wel Officer. ^^^^ ^^^P^ ^0 cure disease ; and that measures in thi; department must be taken beforehand is as obvious as tha the Artillery or Transport must be prepared beforehand. But, when the Army landed, where was the Principa THE PRINCIPAL MEDICAL OFFICER S POSITION. Medical Officer? In India. He did not leave England ■ th the Army, as did the Commander of the Forces, aarter Master General, Adjutant General, Commissaiy 3neral. Instead of accompanyius: the Forces, his pre- •LTations ha\'ing been all made in England, or. what would "ive been better still, preceding them, the fii'st Principal "cdical Officer was appointed at [Malta. He joined the rmy at Scutari, after having been superseded, and Aving, in consequence, resigned before he left Malta, hus although he continued with the AiTay till the arrival <* the next Piincipal !Medical Officer from India, he could 'ive httle interest in originating suggestions which he Duld not see carried out. : There were three Principal ^Medical Officers in the airse of one month; and on June 17, 1854, Dr. Hall ;:iued from India. Too late — as will presently be seen. '. Dr. Smith admits that " there was faidt in the system,'^ ad that '* that system has not been changed.'" I Dr. Hall wi-ites a letter to Lord Eaglan, fi'om Vaima, aigust 3, 1S54, and again August 11, stating his requii'e- euts in the way of Transport, the only effect of which ould have been to reUeve himself fi'om responsibi- -T; for he must have known that, as to asking Lord •aglan for spn'ng waggons in Bidgaida, and at that time, might as well have asked for a roc's egg. The letter 5 ould have been written in [March, or eaidy in April : when r. Hall was in India. This was no faidt of his. I The Ambulance Waggons sent out, being too hea^■y, i^re all broken to pieces : the Ambulance Corps had fallen ft' their animals, and were almost extinct — the Army was itually without Transpoit. To return fi*om the appointment of the Principal -edicid Officer to his duties. I These arc, as we have already s;iid, to detail all his Date of the appointment of the Principal Medical Officer. Vide Stafford" Committee, p. 29, Q. 401-2 Cummina: Maiwelf Eepon, Pu-.ies of a Principal Medical Officer. Vidf Queen V Kcfiralaiions. 10 EVIDENCE OF SUFFElilNGS. recommendations to tlie Commander of the Forces, as to matters affecting the health of the Troops ; Clothing, Drilling, Rationing, Sick transport. Tenting, Was this done ? To acknowledge the receipt, to the Director- General in England, of Medical Stores, &c. ; to detail the anticipated wants to him, from time to time, together with what there is in store, in order to be able to meet the demands likely to be made. Was this done in July or August, 1854- ? That all these wants existed will presently be shown. That the Principal Medical Officer could not detail them, while in India, and that, therefore, till his arrival, it was no fault of his, has also been shown ; but it has been denied that they existed. Evidence from It therefore becomes necessarv to quote evidence ; and Official . . . 1 n -, P 1 Documents, as it IS generally considered, and some of the quotations which follow, tend to imply that civilian judgment upor the wants of Military Hospitals is not of so much value aj that of Army Medical Officers, the evidence of these last and of Commanding Officers upon the spot will be almost invariably quoted. We will begin with Lord Cardigan^ evidence, as follows : — " I found the supply of medicines very inadequate, from thi first moment that we landed at Varna. I was constantly spoker to by the Surgeons themselves, and also by the Brigade Major who said that there was great difiiculty from the want of medi cine. This was in the month of July 1854, when there was J great deal of sickness. The Surgeons were in such a situatioi with regard to medicines, and there was such a total want o medicines .that I wrote to Lord Raglan a most pressing letter Lord Cardigan on the Fears felt by Medical Officers. LORD Cardigan's evidence. 11 questing that he would send for the Chief of the Medical apartment at Varna, and that he would represent to him that e Medical Officers of the Brigade under my Command were ry ill supplied with medicines, and had no medical comforts any description. I got an immediate answer from Lord iglan, to say, that he had sent to the Chief of the Medical epartment, and that a large stock of medicines and medi- 1 comforts had been immediately sent out on mules to the :igade. I think I might also state that I had great difficulties contend with in this matter ; for, although the Surgeons of e Eegiments constantly came to me, and freely communicated th me as to the deficiency of the medicines, yet when they jund that I was going to take this thing up, and communicate th the Commander-in-Chief of the Army, a totally different 3W of the case seemed to come over them, and they appeared 1 me to be very much alarmed at the probable or possible spleasure of the Head of the Medical Department, and I was irticularly requested not to name any one of these Surgeons, to represent, in any strong language, that they had made ese representations to me. In short, it appeared to me that ere was a great terror of the Head of the Medical Hepart- nt. The consequence was that I had to manage this matter writing a private letter to Lord Eaglan, and I requested rd Raglan to send for the Head of the Medical Department, lid to say, that there was a deficiency of medicine, but I did ft attach blame to anybody ; and I so managed it that we got 6 medicines, and the thing passed off, without anything else ing said. Certainly, when I was about to make that repre- lutation to Lord E-aglan, there seemed to me to be a great al of apprehension amongst the Medical Officers, that they m\d get themselves into difficulties by making a representa- >n, which might reflect upon the Head of the Medical Depart- hnt. One or two of them said that they had forwarded emorials to their own superior Medical Officers, and the hers said that it had not been done generally. However, the and object was that no blame was to be thrown upon the ead of the Medical Department, and therefore I made no 'servation which could reflect upon him, and the matter was ttled quietly by the medicines being sent out. I had a very 'eat diflleultv about it. T was at first requested by the 12 LORD cardigan's EVIDENCE. Medical Officers not to make any representation at all. I sa that was impossible; that they had represented to me tli; they had not got medicines ; that there was great unhealthine in the Camp ; that the men were dying ; and, ' do you mean say,' I added, ' that, on account of any feeling with respect the Medical Department, or anything else, I am to refrain fro letting Lord Eaglan know that there is not a sufficient qua tity of medicines for the cure of the men ?' " Accuracy of this Picture. Absence of Official Repre- sentations to tlie Commander of the Forces, and to the Director- General, as late as the end of 1S54. This is an accurate picture of the state of the Am Medical Department generally. It will be denied : but is true for all that. I stand upon my personal observati( and upon much evidence which, though one thing may 1 said to me and another to their Chief, is also true. The history of our sufferings, for the latter part of tl year 1854, is well known. I am not going to recall thei I am simply going into the question of the causes whit produced them, and the remedies which are to obvia these causes of suffering. Was Lord Kaglan made aware of the improper quaU of the bread and meat furnished to the troops, and if ^ at what date ? Was the General Order of May 1854 cancelled, and not, why did not the Commissariat continue the syste; thereby established, and write to England for a continu( supply of such articles as could not be furnished in Turkc among those detailed in Lord Raglan^s Orders? Was the Fuel provided when the troops could no long obtain it for themselves ? — and if not, why not ? Tl General Order of the Commander of the Forces was sufi cient authority. 1/ But July, August, September, October, Kovembe 1854, have passed, and wbere are the official remoi strances and representations from the Principal Medic Officer to the Commander of the Forces, and to tl EVIDENCE OF SURGEONS. 13 irector- General in England, as to the Diet, including reen CoflPee, and not including Lime J uice, &c., as to the lothing, or rather nakedness, of the Troops,— as to the ant of Medicines and Medical Comforts, — as to the state ■ the Hospitals ? Did he wait for December until the mischief was pne? I A ad did the course of events wait until these tardy [^monstrances were forthcoming? Let the Medical Offi- ps who did not wait to make theirs, tell. I Dr. Alexander, now Inspector- General, says : — " Camp, Heights, Sevastopol, " January 15, 1855. " We have been much worse off here for medicines, comforts, c, than we were in Bulgaria." [Was this possible ?] " The liisery and wretchedness the troops have suffered here, but lore particularly the sick, are scarcely credible, and require to e seen to be believed — poor sick wretches lying on the ground, |ith some miserable blankets, in tents that let in rain as if they ere sieves, and with no fuel save the miserable roots and rushwood that could be gathered for cooking, &c." Evidence of Medical Officers, as to the actual state of things. Dr. Alexander's Evidence, He further states tbat — ! " At Monastir he was informed ' that the demand for Essence f Beef (in his Division, the Light) amounted to almost the hole of the supply originally sent from England.' " I When it is seen what that supply was, this will be |hought very little to be wondered at. Farther he says, still speaking of Monastir : — j " I received an express from a 1st Class Staff Surgeon, in |harge of a Cavalry Brigade, requesting me to send him some (ledicines, as ' he was completely run out of everything,' and is men were dying from Cholera." 14 EVIDENCE OF State of things To continue— Siirgeou Cooper, 4th Dragoon Guards as represented ^^^S • — on the Spot. Surgeon Cooper. Surgeon Nicoll. ''Ever since I joined the Eegiment, 1 have experienced the utmost difficulty in procuring sufficient medicines for tlie treat ment of the cases in Hospital. I have, over and over again applied for some of the most useful, commonest, and mos familiar drugs, without being able to procure them. My re quisitions have never been responded to, in full. It is a fals- position for a medical officer to be placed in, when obliged t supplicate, in place of receiving without any difficulty bein; raised. " The Hospital has not been supplied with fresh meat for tli last three weeks. Cavalry Camp, Crimea, " Dec. 24, 1854." Surgeon NicoU, Grenadier Guards^ says : — " Camp before Sevastopol, " Dec. 20, 1854. " Up to a late period no beds or bedding were available 1 the men. Our requisitions for certain quantities of medicin( are nearly always cut down. Medical comforts are totally i sufficient. The means of carriage supplied for the sick ai wounded, in the field, are lamentably deficient. Lately, tl French have taken our sick into Balaclava." Surgeon Wyatt. Surgeon Wyatt^ Coldstream Guards, says : — " Camp hefore Sevastopol, ''Jan. 10, 1854.1 " The sick, most of whom were afflicted with Cholera, Dyse tery, and Fever, were compelled to lie on the wet ground, wi no other shelter than a bell tent, which often was pervious the rain. It is of little use for the Regimental Surgeon know that abundance of Medical stores and comforts have be< «ent from England, if, through mismanagement or neglect, t MEDICAL OFFICERS. 15 3st required and essential articles cannot be procured through ose channels through which the custom of the Service directs tn to apply for them, and at a time when their failure is of e most vital importance." Let us now see what was the " abundance of Medical ores and comforts'^ wbicli had " been sent from Eng- ad." Dr. Smith writes_, Sept. 23, 1854, that he is "quite lable to apprehend what has become of all that have :en already forwarded, viz., of medicines, medical com- jrts, and Hospital stores.^^ He furnishes a List of the " ample supply^' which he bas sent out." Let us now examine it, in order to see what and where is this " ample supply.^^ The "Return [furnished by Dr. Smith] of the Medical (')mforts supplied for the Army in the East,^^ shows that, i)m the beginning of the War, up to November 14, 1854, 1[e following quantities of Articles were sent out, so as to j^rive, and the ships they were sent in did arrive, prior to ]|3cember 1, 1854: — Port Wine 1,200 doz. Brandy 500 galls. Sugar 11,680 lbs. Tea 2,600 lbs. Barley 1,680 lbs. Preserved Potatoes .... 85 cwt. Arrowroot 2,464 lbs. Preserved Mutton 1,792 lbs. Essence of Beef 2,240 lbs. Oatmeal 7 cwt. Sago 2,688 lbs. Cocoa and Milk . . . . . 560 pts. Concentrated Milk . . . . 560 pts. State of things as represented at home. The "Ample Supply." Dr. Smith's Return of Stores sent out, up to Nov. 14, 1854, calculated for the Supply, say, of 2,000 Sick, eight per cent, of 25,000. Sebastopol Committee, 3rd Report, p. 462, pp. 508—10. 16 WHAT WAS TIIK SUPPOSED of 1854. Vide 2nd These quantities were calculated as for the wants of ar| CWittee- Army of 25,000 men. Dr. Smith states that he cal' Dr. Smith's ^ulated " then on " ten to twelve per cent, of sick, at th( Evidence, i -i i Q. 8073. outside,""^ though, afterwards, he says that he "shouk double it^' for an Army in the field. The Army was onb 25,000 strong when it landed at Scutari, and, if we pu the sick, not at ten or twelve, but at eight per cent, only the number of men for whom hospital stores should hav been supplied, would be 2,000. The actual In actual fact, the sick must have increased to 10, 15 ^^^^rose^ eyen 50 per cent., in July, August, Septembei gradually to October, November, December, and J anuary. nearly 20,000, . -, i -r. i • ^ i i before the end For these are the " Keturns showing the total numbe of men of Lord Kaglan^s Army, sick or wounded, durin each month, from the landing in Turkey .^^ 1854. Sick or Wounded. April 503 May 1,835 June 3,498 July 6,937 August 11,236 September .. .. 11,693 October 11,988 November . . . . 16,846 December . . . , 19,479 And, alas ! in January, 1855, though this does not conce us now, 23,076. An abstract is annexed, prepared from the Adjutar * This extraordinary estimate, of what the sickness should be (whai never, under Dr. Smith's predecessors, has been) in war, leads us to a Did not Dr. Smith know what the sickness was, in the Peninsular W or did he hold that his sanitary arrangements were so perfect that t afforded no just analogy for his guidance } AMPLE SUPPLY V 17 eneraPs returns, showing tlie sick present, i. e., in the rimea, and tlie sick absent, i. e., at Scutari, &c., in every eek from October 1, 1854, to April 30, 1855. RETURN OF SICK/^ 54 O.'tober 15 22 November 1 8 15 22 December 1 Present. 56 January 15 22 February 1 March April 15 22 1 8 15 22 1 8 15 22 119 506 494 667 977 1,895 1,451 1,936 2,272 2,657 2,181 2,504 3,009 3,858 3,374 4,498 4,246 4,262 4,167 4,186 3,938 3,712 3,327 3,073 2,770 2,818 2,511 2,130 Absent. 4,273 4,804 3,620 3,549 4,453 4,874 5,649 5,741 5,440 5,224 6,334 6,755 7,559 7,082 7,995 7,907 8,776 8,995 9,427 9,454 9,670 9.259 9,216 8,896 8,199 7,685 7,270 6,553 Total Nunibei-. 4,392 5,310 4,114 4,216 5,430 6.769 7.100 7,677 7,712 7,881 8,515 9,259 10,568 10,940 11,369 12,405 13,022 13.257 13,594 13,640 13,608 12,971 12,543 11,969 10,969 10,503 9,781 8,683 Yet it appears, by the above-mentioned " Return of edical Comforts,'^ that none were supplied from England ^ftween 27 May, 1854, and 20 Sept., 1854, although, in iig. and Sept. the " total number " of sick had increased i 11,000. rhe Return, p. 16, gives, it appears, the Sick, ''Remaining and initted" for each month. This Return, the actual number of those in pital on each of the days mentioned. C 18 THE ACTUAL SUPPLY, Taking, Let US, however, see what, supposing there had been 2,000 sick only, according to the calculation at eight per cent, would have been the allowance of Medical however, 2,000, the lowest estimate of probable Sick. Comforts per Sick Man, during six months, viz., June E^turnrshows Julv, August, September, October, November. If w( a great defici ^ j Smith's return of supplies forwarded by him, th ency. ^ ^ j ^ simple calculation of numbers, shown by figures, give the allowance per Sick Man, for six months : — Port Wine bottles. Brandy ■ li bottles. c lbs. Tea . U lbs. Sago or Arrowroot. . lbs. Preserved Mutton . . 3 4 lb. Essence of Beef • H lb. Concentrated Milk. . I ■I pint. Ol lbs. Preserved Potatoes. . . 5 lbs. Barley 3 lb. It is to be remarked here, that Bread and Meat ai furnished to the sick man in Hospital by the Commissari; Contractors ; and Tea and Sugar are also supposed to 1 supplied ; but Wine, Sago, Arrowroot, &c., &c., are sei out from England, unless the Purveyors can procure the on the spot. Absence of any In order to see whether there was a sufficient supp between May Medical Comforts to last from May to Septembe SepLmber, '^^^^ months) during which time the Army did not recei 1854. any, it is necessary to take the three supplies, of whi< Three i. i ^ Shipments, the total has been given, separately. L By the Sailed, per ^^Bride,'' 15 April; and per "Balbec "Bride and ^ t.«- , , " Balbec;- - May; both arrivmg .27 May, 1854, at Scutari. UP TO DE(^EMBEH, ]8r)4. 19 1st Supply. Port Wine . . 600 doz. Brandy 300 galls. Barley 1,626 lbs. Su.2^ar 4,680 lbs. Tea 2,200 lbs. Arrowroot 672 lbs. Preserved Potatoes 45 cwt. Preserved Mutton 1,120 lbs. Essence of Beef 1,120 lbs. Sago 672 lbs. Sailed, per Mauritius,^^ 17 Aug.; arriving 20 Sept., ; Scutari. 2nd Supply. Arrowroot 560 lbs. Sago 1,120 lbs. Oatmeal 5 cwt. Sailed, per "Vifredo,'' 20 Sept.; and per Briton,^' ^ Sept. : arriving 1 Oct., and 9 Nov., at Scutari. 3rd and last Supply up to 14 November, 1854: — Port Wine 600 doz. Brandy 200 galls. Sugar 7,000 lbs. Tea 400 lbs. Arrowroot 1,132 lbs. Preserved Potatoes 40 cwt. Preserved Mutton 672 lbs. Essence of Beef 1,120 lbs. Oatmeal 2 cwt. Sago . . 896 lbs. Concentrated Milk 560 pints Cocoa and Milk 560 pints c 2 arriving m Mav. 2. By the Mauritius,' arriving in September. 3. By the " Vifredo," and " Briton," arriving in October and November. 20 THE ACTUAL Sl ^TM/r krown to tlie Dircetor- (Irneral '. Wan the Date In every case^ the Date of Delivery^' of the articles to of Delivery known or not " Consignee/' is stated as " not known at this Office'' (namely the Director GeneraPs), even at the date of April 27, 1855, a year after the sailing of the first supply. Nevertheless Dr. Smith also states that, "reports refer- ring to general matters connected with the health of the Army and the supplies arc sent to him every mail/' that " he gets the receipts of medicines and medical comforts that have arrived at Scutari, from Scutari, on the medicines arriving there ; tliat is the depot from which all our sta- tions sii])plied;" that he gets an acknowledgment in letters;" that ho has these documents;" that " he is getting them printed now, to show when the medicines were sent out, and wlien they arrived ; by what ship, and at what date;" that, " as a matter of course, there is only one officer to receive them. If they are medicines, it is the apothecary; if liospital stores or medical comforts, the Purveyor receives them ;" that " having acknowledgments, in letters, of the arrival of them, of course, whoever writes the letter, signs it." This is March 26, 1855.— Yet on April 27th, one month later, the date of delivery is not known to Dr. Smith. In his Evidence on March 26, he states that, " Varna/' not Scutari, " was likely to be the Head Medical Quarters of the Army." Yet elsewhere he says, that he ''sent enormous quantities" (of quinine) "to the Medical Depot at Scutari;" that he "has been going on sending there from the time the Army went out."^ Vide * Dr. Smith says, in answer to the question "Have you any Returns of CommTu'4 <'lie stores that have been sent to the East, and can you put them in?" U.mT-^ m7. '■'^^^^y ^^^e all put in before the Sebastopol Committee. They are all printed in the Report of that Committee." Q. " Are you aware of the dates when the first ships Avith stores and medical comforts arrived in the East?" No, I cannot charge my memory with that." UP TO DECEMBER, 1854. 21 Let us now compare the dates of Dr. Smith's requisition Was the Delay in the Ordnance, of the Orders of that Board for the Admiralty' 'upply of such requisition, and of the period at which the Lrticles ordered were reported ready for embarkation, or i,t which they were actually shipped. I Perhaps the blame of dilatoriness rests with the Adnii- alty or the Ordnance. 1 The requisition for the first supply was made by Dr. bmith in February, and on March 24th ; the supply was i»rdered by the Board, on February 20 and April 3, espectively ; the articles were shipped in the '' Bride" :nd BaJbec," which sailed, the first, on April 15, tlie day he articles were actually shipped, and tlie second. May 2. I^^or. the next supply, per "Mauritius," Dr. Smith made |he requisition on August 8 ; it was granted August 8, md the ship sailed August 17. For the third supply, per j' Briton," the requisition was made by Dr. Smith Sep- lember 2, granted September 4 ; articles shipped Septem- |)er 21 ; vessel sailed September 28. There does not seem to have been much delay here on he part of the Admiralty or Ordnance. The " Army and Navy" was granted by the Board, NTovember 17, on requisition made by Dr. Smith, Novem- ier 17 (this vessel was taken up by the Army Medical I t Q. Are you aware that none arrived between May and September, iu be year 1854?" "They must have arrived in the East between these eriods, because I was sending out constantly medicines and medical com- brt-s." I Q. " Let me call your attention to Appendix, No. 8, of the Report of the ^'Ommittee on the Army before Sevastopol, p. 462, where it states that the |wo first ships arrived May 27, at Scutari, and that no other ships with ledical stores and comforts arrived till Sept. 20, iu the same yearl" Probably they went to Yarna.'' ' Here ^tr. Peel very seasonably interrupts, and steps in to the rescac of >r. Smith, by changing the subject. 22 THE AcrrUAL SUPPLY. Suppl les. Department) ; Hrti(;les shipped December 12 ; vessel sailed same day. The Director- But what follows now will probably appear tlie most con^ider'ed the curious of all tlie facts stated. It appears from Dr. SmitVs Supplies evidence, Sebastopol Committee, 2nd Report, Qu. 8,117, sumcient ror ^ re • < Six Months, that he considered that " there were stores suthcient sent anticipite'any out" to "have lasted them for six months;- that he purchases on ^^-^ ^-^^ requisitions.^^ Yet he says, Qu. 8,128, the spot. He ^ says he that the Officers under the Medical Department" had ^ wait for^^ power to purchase," but that there was " a doubt as to bSinding what is the position of the Purveyor." He reiterates, further howcvcr, Qu. 8,130, that he " did not calculate that the Hospitals would require anything from^' the markets of the East; " the intention was,'' he says, ''that the Hos- pitals should be supplied from this country with all that was requisite," and not on the spot. He again repeats, Qus. 8,182-3, that on November 5, 1854, he " was aware that he had dispatched from this country ample provision for every want;" '^'and, in the next place, it was con- sidered by the Medical Authorities out there that they had what was wanted;" that he ''had no reports to have justified him in saying anything else." He tells us, Qu. 8,902, '' always to keep in view that, the moment the Principal Medical Officer joined the Army, he would he aware what he possessed, and if he saw that anything was getting low, he would immediately make a requisition foi whatever he wanted, and continue doing so periodically," All this makes confusion worse confounded — especially as, according to Dr. Smith, Qu. 8,943, " Inspector Gene- ral" Hall did "report to the effect that everything was amply provided," on his arriving at Constantinople. Having, now, stated what was actually sent out, the He otates, however, Q. 8,903, that he " never waited for the Kequisi tions, for he thought his safe course was to continue sending out stores." EVIDENCE RESUMED. 23 esult will the less surprise us. W e resume the evidence s given on the spot. Surgeon Bostock^ Scots Fusilier Guards, says : — " Before Sevastopol, Jan. \, 1855. " In reviewing the events of the last six months, every lurgeon in charge of a Eegiment must have heeu painfully onvinced of tlie inefficiency of the means to siipplj/ the xigencies of the Service in the field. The Army has been without transport for the Sick and Wounded, without proper helter and accommodation for men sulfering under acute dia- ase, and without an adequate supply of medicines, appliances, nd comforts, essential to their treatjuent. With regard to ledical comforts I regret to say, that the most necessary arti- les for the diet of the sick w^re supplied in such limited uantities as to excite the surprise of every officer present." Evidence (from Official Documents) of the Sufleringii of the Army, Resumed. Evidence of Medical Officers. Surgeon BoBtock. Surgeon Hearn^ 1st Royals, says: — Before Sevastopol, " Bee. 1854. "The chief cause of the great sufferiogs of the sick and ounded of the British Army may, I fully believe, be traced 0 tlie general and, indeed, almost incredible apathy evinced y the authorities, from the very outset of the Expedition, with egard to everything connected with the Medical Department. Vhen we sailed for the Crimea, we were obliged to leave ehind us a new Hegimental Medicine Chest, which had been sued at home, expressly on account of our embarkation for ctive service, and, in fact, everything exce])t two small pan- iers, containing surgical instruments and a supply of medi- ne, which, as regarded quantity and variety, was most liserably scanty, with Hospital Canteens A and B, the sets of bedding which accompanied them, and the Hospital Marquee. ambulance nor vehicles of any description were allowed to 6 embarked, wov was any provision made for the conveyance of he wearied, sick, or wounded soldier, who iiad to endure a long Surgeon Hearii. 24 EVIDENCE AS TO THE march and fight his way through an euemy'a country, unless the ten stretchers given over to the band, who were also en- cumbered with their own packs and accoutrements, could be considered as sucli. Before we commenced our march, from the lauding at Old Tort, the Hospital Marquee, canteens, and bedding were ordered to be re-embarked, and there were but four water mules for the whole Battalion. The sick or wounded were, in short, to all appearance, thrown entirely overboard, one small circular tent only being allowed for a whole Kegi- ment. The consequences soon became apparent: when men fell out of the ranks from exhaustion, or were seized with sudden disease, of which Cholera was the most frequent, the medical officers could render no effectual aid. The regiment moved on, and the victims were compelled either to drag them- selves miserably along or to perish where they lay. In short they were left to their fate. The history of Alma, I regret to say, is but too painfully true. There were no means of carry- ing the wounded off the field, except the few Bearers already alluded to ; and whilst, on the day following the battle, there was not a wounded Frenchman on the ground, it was disgrace- ful to the British nation to see, even on the second day, many of its brave defenders suffering, without any human aid, where they fell. The present ambulance, I need hardly say, has proved a complete failure. The carriages are heavy lumbering machines, which, on good Macadamised roads and with stout English horses might answer their purpose well, but which are all but useless in field practice. The class of men also sent out in this Department was probably the very worst that could have been selected, being composed chiefly of worn out, drunken, and useless old soldiers, most of whom perished at Yarna, shortly after their arrival. | "But little, comparatively speaking, has been done for the sick. During the late severe affliction of Cholera, when the Admission and Discharge Book was converted almost exclu- sively into a Eegistry of Deaths, it was most melancholy to see the men wet, wearied, and half naked, borne by their comrades, or dragging themselves slowly and painfully along to an hospital tent wholly unprovided with anything for their comfort. Destitute of bedding, of blankets, and of fuel, it was impossible to [iroduee or maintain even that degree of PRIVATIONS OF THE ARMY. 25 ere animal heat that was requisite for their recovery. Of hat avail, I would ask, were Doctors and Physic in this ?plorable state of things ? " Upon my personal experience I stands and I declare tliat^ idging from the condition of the men I saw, these statc- I'lents are the literal truth, and no more than the literal •uth. I would also, as far as my personal observation goes, j-echo the statement of Dr. Alexander that — " It is due to the Medical Officers, as well as to those in large of medicines and purveyor's stores, to state that no men Duld have worked harder or performed more zealously their Irduous and onerous duties (botli in Bulgaria, during the |ivages of Cholera, as well as in the Crimea) and that none of lem have spared eitlier trouble or inconvenience in doing all ley could to obtain whatever would tend to the comforts of tieir sick." i The following letter was circulated for the information circular from I " Sir — With reference to your requisition of the 2nd for Uumbreck. ledical comforts, I beg to inform you that there is no arrow oot, brandy, essence of beef, sago, or candles in store, and that round rice will be substituted for arrow root and sago. The round rice, however, has not yet been procured from on board hip, although two requisitions have been made for its being mded. The above has been made known to Dr. Dumbreck, lie Principal Medical Officer in the Crimea, who proposes hat rum should be procured from the Commissariat, in lieu of he brandy required. the Purveyor of the Forces to the Medical " Balahlava^ " October 3, 1854. Officers, referring to a representation made to Dr. I have, &c.. " (Signed) K. Jennee, " Purveyor to the Forces. 26 EVIDENCE AS TO THE Dr. After this letter the evidence from this very Dr. Dum- Dumbreck's ]^j.Qc[r which we iiow insert, is the more unaccountable, representation. ' - n i> Dr. Dumbreck states that he "left the camp m tront ot Sevastopol, i. e., Lord Raglan's Head-Quarters Camp, on the 13th of November, the evening before the great storm; up to that time there were no wants that he " saw that were not supplied. He says that " there was a prospective scarcity of fuel f that he "was told that in some regiments they managed to roast their coffee that he " was told that certain Commanding Officers managed better than others, and that in some regiments they managed to roast their coffee, but that in others they left it undone ; but that is mere hearsay. '' That he "never had any direct evidence that green coffee was used that " green coffee was issued to the troops, certainly ; but he supposed an attempt was made to roast it, in many instances.^' He states that " the Army never suflfered, while he was in Medical Command, for the want of surgical appliances that " during his stay at Varna, there was not the slightest vestige of the want of medical comforts ; they had a very abundant supply;" that "he saw no want of medical comforts in any of those instances, viz., the battle of the Alma, Balaclava and Tnkermann, at all of which he was present.^^ He states that "before he left the Crimea, some articles of medicine were consumed at such a rate as to render their probable want to be feared; opium, for instance.'^ That he himself " made a requisition to Scutari for the articles that were wanted ; at least the Dispenser that was under his orders did.'' We will now resume the evidence of the real state of things, as represented on the spot. Surgeon Surgeon Davies, 49th Regiment, says : — Davics. PRIVATIONS OF THE ARMY. 27 " Camp, before Sevastopol, " Dec. 12, 1854. " No beds have been supplied until the last week, when 24 )ts were received, without any bedding whatever." " JDec. 21, 1854. " The supply of medical comforts has improved, but no fresh leat has been supplied for the sick for the last ten days or fortnight, and not for many weeks to the Eegiment. In bnsequence, scurvy is shewing itself, and there have been no l3getables for the last two months." ' Surgeon Blake, 55th Regiment, addresses his Divisional SurgeonBlake. taff Surgeon thus : — " Oaiiip before Sevastopol, " Mv. 26, 1854. " Sir — I have the honor to remonstrate most respectfully gainst the very inadequate supply of medicines and medical Dmforts for the sick issued to the Hospital under my charge, lOugh, I believe, I am in the same position as others. At lis moment, witli a large number of cases of Dysentery and diarrhoea, I can obtain no castor oil, no preparation of opium, ive a small quantity of morphine, no preparation of chalk, or anything for a gargle, should I place a patient imder the ifluence of mercur3^ " The only medical comforts issued are arrow root and port fine, and these in quite inadequate quantities ; tea can hardly !c procured. Under these circumstances, and without any iifficient protection from the inclemency of the weather, it is ^npossible to treat Patients with any hope of success, or with psticeto themselves or the service." December 21, 1854. " The number of tents in use is four ordinary bell tents for lie sick, and one for stores, hospital serjeant, and orderlies, "he number is quite inadequate, and the tents themselves are 1 calculated for the accommodation of sick. 28 EVIDENCE AS TO THE *'T\veiitv blankets it^siiod in October is the only bedding; have received since landing in the Crimea, and many of thes<' were lost when the Hospital was vacated on the morning o jS'ovember 5. About a week ago 24 beds were issued, withou beddinj;. Thev are. however, of little use, as it is impossibl to place more than live in a tent ; and to do that it is necessar to ti-eat two-thirds of the men in their own tents, a most uu satisfactory mode of proceeding. I need hardly state that th whole of the articles mentioned under this head are totall inadequate for the number of sick. " At the present time, when fresh meat, even for the sick, i a rarity, about 3 lbs. tea, 2 — 3 lbs. arrow root or sago, witl latterly, brandy and port wine, as required, is the whole amour of medical comforts issued, and this is a far more liberi supply than at any previous period. For upwards of a wee no fresh meat has been issued, and I have been obliged t boil rice and biscuit together, for the greater portion of tb Patients in Hospital. The above-named articles, with rice i times, forms the whole list of extras I have been able to obtaii *' The only means of cooking consists in one camp kettL issued in October. Of course this is quite insufficient. " "With respect to the conveyance of sick and wounded i the field, I think it would be far better, were an Ambulam Cai't attached to each Eegiment. or what would be still mo) useful, a proper line of mules, with litters, such as those usf in the French service, and from which we have of late deriv£ so much benefit, and which have the advantage of being usefi anywhere, whilst the Ambulance Cart requires a good road. " I would suggest that one pack-horse is not sufficient f( the conveyance of Hospital stores. In fact, the want of fu ther means prevented any stores, even cooking utensils, beii carrif'd on the march. Whilst the Eation issued to the troops consists of sa meat, almost constantly, I think it would be highly advant geous, were a larger proportion of rice issued, or a proporri( of preserved potatoes. Preserved meat or soup for the sit would be a very acceptable addition to the list of medical cot forts. For a considerable period, green coffee has been is5U( to the men, which they can neither roast nor grind properl 1 I TMUVATIOXS OF THE ARMY. 29 al which is consequently of little use. Were tea or cocoa B,)stituted, it would, I think, be of great service." Surgeon Graves, 68tli Light Infantry, writes : — Surgeon Graves. I " Camp before Sevastopol, i " Dec. 26, 1854. " Fuel for cooking Hospital Eations has never been sup- ped, the Orderlies having procured wood whenever it was to b cut in the neighbourhood of the camp. This has of late b^oine scarce and difficult to obtain, and which difficulty must iirease as the season advances, the thermometer standing n'v at freezing point. This want of fuel has been productive Diiuch disease, because the Eations were used in an uncooked 5-te, than which nothing is more conducive to affections of the s raach and bowels. •' I feel bound to state, that neither medicines, medical r nforts, hospital furniture and conveniences, were sufficiently > • lied for a length of time, and our very last requisition for [J nforts, viz., Arrow Eoot, Sago, and Prepared Cocoa, was n; complied with. In lately requiring for medicine, neither licture or Powdered Opium were supplied. Fresh meat has b n supplied whenever the Commissariat were able to procure it:uul that has been tolerably regular to the Sick in Hospital." ■^nrgeon Macartney, 77tli Regiment, writes: — Surgeon Macartney. I" Lines hefore Sevastopol, " Dec. 22, 1854. In the Crimea the sick and wounded in the field are b ught in by the band on the Hospital stretchers in the first n^cance, and they are afterwards periodically conveyed to Bala- cya, en route to Scutari, &c. This was done at first by the Iiglish ambulance, but latterly by the French ; the latter, Cisisting of strong mules, with chairs, for the sitting and r lining posture on either side of the animal, seems admirably p 1(^(1 for the purpose ; but the waggons of the former are too h vy for the state of the roads of the country, and tlic men 30 EVIDENCE AS TO THE too old and drunken. After the battle of Alma, the wounded of my regiment were carried to the Ships from the Field Hos- pital, in hammocks slung from poles, by the sailors. " I have been frequently unable, for a considerable time, tc; procure supplies of Pulv. Opii. Emp. Lytta?. ^ Pulv. Cretje c. Opio. Arrow Eoot. Tinct. Catechu. B-iee. Hydrarg. c. Creta. Preserved Soup 01. Terebintli. Wine, Brandy, &e." Surgeon Scott. Surgeon Scott, 79tli Highlanders, writes :~ " Another source of difficulty in obtaining medicines am medical comforts, &c., is the number of signatures required t( be attached to each requisition, as well as the difficulty and los of time in finding the proper persons to authorize the issue It would be very desirable that this should be, in future simplified. " With regard to the means and modes of carrying sick an^ wounded, I am of opinion that a well organized Ambulanc Corps, similar to that used by the Prench, would be a grea improvement, and should be adopted without delay. Pror what I have seen of the ambulance w^aggons now in use wit the army, I have come to the conclusion that they are on! adapted for the conveyance of sick and wounded in a lev( country with good roads. They are so heavy that, under mo^ favourable circumstances, they require six mules to draw then and on bad roads from eight to ten. They can only carry te men, and from the nature of the springs, are very rough an uneasy. The system in use by the French has many advai tages, as has been obvious from the extraordinary amount ( assistance it has afibrded us at a time when we were perfect] helpless, from our ambulance establishment being complete! knocked up. Their system consists of an iron frame chair fixe on each side of a mule by means of a pack saddle, in whic a patient, if slightly wounded, sits on each side ; if bad! wounded, however, he lies on an iron frame litter, covere with a waterproof sheet. This litter can be removed with tl PRIVATIONS OF THE ARMY. 31 itient in it, and forms a bed or stretelior. By this means ck or wounded men are easily transported up or down very ;eep hills and along the worst possible roads, with ease and ifety. In this way, every single mule is made available, and ot one more tlian necessary is employed. One muleteer is pie to drive and take care of three mules and six patients, and most as many when in litters. In addition to the above, it mnot be denied that a certain number of light spring waggons ill, under certain circumstances, be very useful ; at all events, |ae waggon should be attached to each regiment for the con- >yance of an Hospital tent, medical comforts, stores, &c., ) indispensable in our Field Hospitals." Surgeon Anderson, 90th Light Infantr}^, writes : — Surgeon Anderson. " The sick in camp receive the same ration as the efficient )ldier. The only means of cooking the extremely limited pro- sion of extras is at a miserable fire of green boughs and roots i a hole in the ground. Firewood is extremely scarce, and otained with the greatest difficulty. " I beg leave to state, for your information, that the sick of 16 regiment under my medical charge, are sufiering much from pe very inadequate supply of medicines, medical comforts, and le necessary transport for these latter articles, which might obtained from Balaclava, were the transport available ; and irther, that I have no doubt but that the sickness has been 'reatly augmented in consequence of the men not being sup- lied with occasional fresh meat, rice, &c., &c. The men of the bth Eegiment have now been on salt provisions for three ^eeks, consisting of pork or beef, biscuit, coffee in its raw ate, and sugar of the worst description, and in very small kantities. A great proportion of the sickness is attributable |) the imperfect preparation of the coffee ; and very frequently, 'tiring the very inclement weather, the men have no possible eans of cooking even their salt provisions, leaving them ill-fed id overworked." Surgeon Munro, 93rd Highlanders, writes : — Surgeon Munro. 32 EVIDENCE AS TO THE 8urgeon Fraser. Prediction of Zymotic Disease. " Camp, Balaklava, " Jan. 7, 1855, " The different medicines contained in the panniers war' good, but too small in quantity, suited only for field service, and not, in my opinion, sufhcient for the expenditure of temporary Hospital. Since the investment of Sevastopol an the formation of Greneral and Field Eegimental Hospitals, have found it difficult to obtain supplies of medicines an medical comforts ; not that transport was not attainable, for fatigue party of a few men could always be got, but frequentl such medicines as were asked for were not in store at Bale klava; and during nearly two months, to the best of my reco] lection, my requisitions for Arrow E-oot, Ground liice, an Essence of Beef, were not complied with. Surgeon Eraser, 2nd Battalion Rifle Brigade whites :— : " I have no especial remark or suggestion to make to th above [viz., his answers to queries], but simply and earnestl to state that the continued deficiency of a due and regula supply of medicines and medical comforts and convenience for the sick, often made my duties most painful and irksome and rendered medical aid comparatively useless. " However, I may add that, though so much lias bee neglected in remedying diseases when they have develope themselves, on the other hand, much has been omitted in th way of preventing disease, especially Dysentery, occasioned, n doubt, very much by the vicissitudes of the weather, withou due protection from them, and the continued hardships f duty, combined with the rations which, though of sufficlen quantity, have not been daily mixed vvith farinaceous or vegf table food. And since the early part of November, the ratio of meat being almost continuously salt, without rice or potatoe (save for a few days with some onions), or lime juice with th rum, the Dysentery becomes now necessarily Scorbutic, an Scurvy itself has made its appearance in its usual form c spongy gums, swollen and discoloured extremities ; and if th above causes are allowed to operate (I mean those over whic we have control), the efficiency of our Army must be mor affected by it than by the sword and artillery of the enemy." PRIVATIONS OF THE ARMY. 33 [n order to test the truth of this remark, let us examine Preponderance " Retui'n showing the specific Diseases by which the Diseasrin^the jmissions into Hospital and Deaths have been occasioned Crimea, aiong the troops serving in the Crimea, from October 1, li!)4, to March 31, 1855, exclusive of those under treat- ii[nt at Scutari; prepared from a Return furnished by Ij. Hall." The total of Admissions is 52,548 3,806 only are Wounded 48,742 Sick. □ut of this total of sickness the cases of Zymotic pre- itible Disease, namely Scurvy .. .. 1,678 Cholera 2,167 Diarrhoea 18,708 Dysentery 4,441 Fevers 9,185 amount to no less than . . 36,179 ^0 that if these be deducted from 48,742, one-fourth, 012,563, is all that remains. That is to say, that Pre- Titible Disease, that which is, or may be, prevented at 1) le, made 75 per cent, of all the Diseases of the Army. The total of Deaths is . . . . 5,359 from Wounds . . . . 373 from Disease 4,986 I'Vom Zymotic Disease, consisting of 34 EVIDENCE AS TO THE Scurvy Cholera 92 Diarrlieea Dysentery Fevers 1,237 1,303 696 1,137 the total of Deaths is . . . . 4,465 ! J which being deducted from 4,986, only 521 remain, bei^ little more than one-tenth of the whole; so that neair 90 per cent, died from preventible causes alone. It is here to be noticed that the term " Scurvy'^ meaj only the scurvy which shews itself by sores; as eigl. tenths of all the disease in our Army was scorbuti, occasioned chiefly by improper diet. The average stren^i of the army for this period was 28,623. j For various reasons, which will be given hereafter, t|; Returns of Disease and of the Causes of Death at Scut|i are so incorrect that they will be of little use for cf present purpose, and are therefore not quoted here. T ) probability is that Scutari would shew even a larger p:{- portion of Zymotic Disease than the Crimea. The m m- tality, also, from diseases of the stomach and bowels 25 per cent, higher. ; But, almost all the admissions at Scutari having bfji re-admissions from the Crimea, to give these here woii only be repeating the same information; and, althom indubitably much Hospital Fever and Choleraic Disc 3 were generated within the Hospital walls of Scutari, ;[t as the deaths which resulted were entered under the nab of the disease assigned at admission, it will be of as lit^ avail for our purpose to give the Returns of deaths s those of admissions. Inspector-General Dr. Alexander, Light Divisi' , further says : — PRIVATIONS OF THE ARMY. 35 " Jan. 15, 1855. " About the same period, December, although the troops were on sufficient rations, few or no medical comforts could be had, there being at the time neither sago or arrowroot when applied for, &c. JVow, I must acknowledge, with the ample Isupplies sent out by the Director General for any contingency, land command of the Constantinople market, I cannot conceive why anything tending to the comfort of the sick and wounded hvere not always at hand when required, both in Bulgaria, as well as here in the Crimea ; more particularly as we had com- jmand of the sea, and steamers continually plying, both when 'we were in Bulgaria, between Scutari and Varna, and now between the former and Balaklava." Dr. Smith states that he communicated to Dr. Hall hat there was an ample supply of medicines and medical [stores prepared at Scutari,"^ from which he might draw any Supplies for the Army." Farther, he quotes a letter re- beived by him from the Acting Apothecary in Chief at Scutarij dated November 14, 1854, saying, "I beg to give vou au unqualified contradiction that any want has been ifelt since I arrived in the Command, for either medicines br surgical appliances and he adds, I am bound to consider it as a distinct refutation of any statement to the contrary, being official, and from an Officer whom I am bound to trust \ Surgeon De Lisle, 4th Regiment, writes : — Surgeon I De Lisle. " Oamp near Sevastopol, J " Dec. 26, 1854. I " It is impossible to state how often I have fruitlessly made pquisitions for medicines and medical comforts. With regard ::o the former, I have not often been refused altogether, but phe quantities issued have been often ridiculously small. I bomplain, however, less of this than of the want of medical * Compare Note to page 21^ together witb pp. 20, 23. n 2 36 EVIDENCE AS TO THE comforts. My sick ask me for soup and sago, and I musi soothe them with a dose of medicine in lieu of these. Now few of my sick would have been patients at all, if they hac; enjoyed warm clothing, less fatigue, less exposure, and movt regular and more extensive meals. I cannot go on heaping uf medicine after medicine in the stomachs of those who requin, nourishment more substantial. The Purveyor's store is th( only dispensary from which 1 wish to draw my supplies. M3I cook, had he something to cook, would be my most efficienii orderly. I cannot state how often, or for how long a period, 1, have been refused these supplies on requisition ; but I car state that I have scarcely ever known my Eequisitions com' plied with, without such a severe curtailing as left me bui little to boast of " On October 3, the Purveyor of the Forces informed us. that he had in store neither ' Arrowroot, Brandy, Essence 0 Beef, Sago or Candles.' He reminded us, however, thai, ' Grround Eice made a capital substitute for Arrowroot anc Sago.' But, unfortunately, he had also to remind us in the next paragraph of his letter, that the said Ground Eice was not forthcoming. It was on board ship, though two Eequisi tions had been made for it." Surgeon Surgeon Marlow, 28th Eegiment, gives the following Marlow. general view : , Camp before Sevastopol, " December 18, 1854. "I am therefore inclined to enumerate amongst the ehie causes of diseases : — 1st. Inadequate shelter when oif duty. 2nd. Irregularity in the rationing. 3rd. Want of sufficient clothing. 4th. Almost incessant duty and consequent exposure. " The last of the causes assigned is, as a matter of course unavoidable, and may be at once dismissed. But with regarc, to the first a few words may be said. The tents at present ii possession of the regiment have nearly all been in use sinc( April, and many of them are quite worn out, decayed, full 0 j PRIVATIONS OF TUE ARMY. 37 loles, and as pervious to water as a sieve. The men return Prora a fatiguing day's duty in the trenches, cold and wet [ihrough, and find the floor of the tent in which they have to [;leep, a mere puddle ; until very lately, their single wet blanket mswering for bed and bedding ; they have now two. Second, irregularity in the rationing. There have been days, both in ihis month and the preceding, and not a few, on which a short lUowance of biscuit and meat has been issued ; occasionally 'here has been no sugar, and latterly no rice at all. "With re- jipect to the coffee, it is given out in a green state. The fuel is lext to be looked for by the men themselves, however tired they nay be; means for roasting the coffee have then to be found, jind the result is generally a compound resembling so much ;harcoal and hot water, and about as nutritious. A few in- ;tances of undoubted scurvy have occurred, but the scorbutic jliathesis is apparent in many of the men; and it is much to be [vished that lime juice could be issued as a preservative mea- liure, as on long sea voyages, before the disease has time to develop itself, not to mention the prejudicial influence such a Itate of the constitution would be likely to have in all cases of |vounds and accidents. Third, want of clothing. Until very ately the men were literally in rags, swarming with vermin, .he boots in many instances useless, and the so-called great ^oat threadbare. After the chief burst of the sickness had )ccurred, a supply of warm clothing was distributed. But the- ield hospital soon became so crowded (our own means of trans- |)ort being a mere cipher), that the assistance of the I'rench pnbulance was solicited, by the aid of which this great accumu- ation of disease, filth, and misery was handed over to the nedical department at Balaklava in hundreds. It would thus !eem, that while the causes of disease would appear to have re- 'eived scarcely sufiicient attention, the efforts of the Medical Officers to remedy the evil have neither been supported, nor at 41 times justly appreciated. " I have, &c., " (Signed) B. W. Maelow, M.D., " Surgeon 2Sth Regiment.'' The above extracts have beeu taken at hazard from 38 EVIDENCE OF Gumming Maxwell Report, Evidence of Commanding Officers. Col. Hodge. Commanding 4th Drag. Gds. the correspondence of the Medical Officers, and while the most distressing and disgusting details have been, in each! letter, purposely omitted, these letters are by no means chosen as being the strongest evidence of the state, now admitted, of the sick and wounded at that time, as to absence of medical comforts, of sick transport, of proper tents, &c. If it be thought that they have been purposely; selected as being the strongest in description, we would refer to the evidence of Surgeon Lockwood, 7th Roya"; Fusiliers, December 21, 1854; Surgeon Longmore, IQtl Regiment, December 24, 1854; Surgeon Watt, 23rc Fusiliers ; Colonel Yea, Commanding 7th Fusiliers, anc others. Surgeons Howard, 20th Regiment, Mackinnon 21st Fusiliers, Marlow, 28th Regiment, Grier, 92nd High- landers, in Charge of Medicines for the Division (Light) give "Returns of their Requisitions for Medicines," ai also for " Medical Comforts,^' shewing the quantities re quired and those received, side by side. A few extracts from the letters of Commanding Officer; will here be added. Colonel Hodge, Commanding 4th Dragoon Guards, says " Camp, Kadilcoi, December 25, 1854. " The comforts of the sick soldiers, belonging to the Eegi ment under my command, have been, in my opinion, but littl cared for ever since we landed at Varna in July last. " No beds or bedding have been given to the Hospital. " Four stretchers, borne by men, is all we have to carry ou wounded from the field ; an absurd mode of conveyance fo cavalry, whose wounded are frequently miles from the rear c the Army. It is a pity that we do not copy our allies, th French, whose admirable mule chairs have been so freely mad use of by our sick and wounded during this Campaign. " I can answer for the Surgeon having asked for very simpl medicines, and not having been able to procure them." COMMANDING OFFICERS. 39 Colonel Newton, Commanding ist Battalion Coldstream (|iards, says ; — "Many medicines have been applied for in vain, also medical nforts, and Hospital necessaries ; and the allowance of fresh 'at for the Hospital has also been in many instances defi- nt. Opium at one time was not to be procured, and some was ^ren for the use of the Hospital by Lieut. -Colonel Carlton of lis Battalion. Brandy also has not been obtained, nor is it i|vv; but it has been given by Lieutenant- Colonel Wood, of ti's Battalion, and myself. Tea has also been given by the dicers." hiiiuary 11, 1855. Col. Newton, Commanding 1st Batt. Coldstream Guards. 'olonel Walker, Commandini? Scots Fusilier Guards, ^ ' Commanding \|ites :— S. F. Gds. " Scutari, ^'"December 11, 1854. ' No bedding beyond blankets has been provided, the sick a l wounded faring alike. I endeavoured ineffectually to pro- ( • ' some straw for the Hospital tents, but my application was Lj attended to. I consider men in sickness, or suffering from vunds, do require a softer bed than the bare ground, and that t[' addition of hay or straw would greatly add to their comfort, n,l even perhaps save life." 'Lieutenant-Colonel Unett, Commanding 29th Regiment, ^t.-Col. Unett, j J D o J Commandmg elites : — 29th Kegt. " Camp hefore Sevastopol, A ''Dec. 20, l^M. ■ (' So small has been the supply issued at the various times (te., of medicines and medical comforts), that it has been used u generally in two days, consequently it has been impossible ti keep any store of medicines; the same applied to the ndical comforts, and it has been my painful position to hear 40 EVIDENCE AS TO THE repeatedly from sick Officers and Orderlies attending the Hog- pital, the impossibility there was of obtaining from the Eegi- mental Hospital either the medicines they required, or the comforts they needed. I reported this want personally to the Officer Commanding the Division a few days after our batteries; had opened. The General contradicted the report I made in- such a strong manner, and with such strong expression, that discretion thenceforth kept me silent on this matter. I imme- diately returned and corroborated my statement by a persona] investigation in the regiment. " There can be no doubt that, had the regiment been pro- vided with proper means of transport for the men who fell sict on the line of march, as well as transport for the medicines anc requisites for the sick men's proper treatment, with better pro tection against the weather, and better provisions for the car( of the sick when the Field Hospitals were established, tha: very many valuable lives, in all human probability, might have been saved." Col Horn Colonel Horn, Commanding 20tli Regiment, says ^20t?^Eegt.^ " Camp before Sevastopol, " Dec. 30, 1854. " I cannot but deplore the sad want of better arrangement for the restoration of the sick and wounded of the regimer> under my command, and the lamentable results therefrom. I " The Surgeon reports to me the want of one of the moii useful of medicines, where the prevailing sickness is bowel con' plaint, viz., opium. " Since writing the above, I have been required to send party of 150 men of the regiment to Balaclava, for the purpot of bringing a small portion (only) of the planking and timb( required for the construction of their huts. On the return ■ these men, they will almost to a man be required to proceed ' the trenches for the night, after their twelve mile trip ai labour to and from Balaclava. These and other hard duti (for our soldiers sometimes go four days out of the seven in tl trenches), coupled with the fact of their being frequently ( short rations, imperfectly cooked from want of time and go( weather, cannot, I apprehend, at the present inclement seaso PRIVATIONS OF THE ARMY. 41 ut seriously affect the sanitary state of the troops serving in le Crimea." Lieut. -Colonel Lord West, Commanding 21st Fusiliers, ^^ '^^■.^^^^^ jTites : — Commanding 21st Fus. " Dec. 25, 1854. " The miseries endured by our sick on the march from the mding-place in the Crimea to the Alma, after the action, and luring the march thence to the heights above Sevastopol, I onsider to be the usual concomitants of any great enterprise, jjuch as that we undertook. "It was probably found impossible to provide and embark a iLifficiency of bat animals to convey the stores, the material and |aggage of a numerous army, hastily thrown upon a hostile [liore. 1 " When such an effort is to be made, a calculated sacrifice of len must, in general, be decided upon. I " Such a sacrifice, unfortunately, did occur. In my Eegiment lone, in addition to the deaths recorded and known, I have icurred a loss of forty-seven men unaccounted for, being those rho fell out in the march and could not be brought along ; or Hio, being embarked from the Alma to Scutari, died on the assage, having never been heard of since. "I pass over such incidents as these, which must be classed mongst the usual calamities attendant upon long marches and ther rapid operations, which mark the commencement f a campaign. " I come now to what has occurred in our own standing fiamp, which occurrences have been so fully described by Dr. flackinnon. I " The utter helplessness of our Medical Department, their lotal inability to meet the pressing emergencies, as they trose, became most conspicuously manifest. This may be attributed partly to their dependence upon the Commissariat and to their want of stores, medicines. Purveyors, nd Clerks, upon the spot in the field. Each division ought to have a Purveyor and an Apothecary )epartmeut. 42 SYSTEM OF " The sick in Hospital should not be dependent, for their Eations, upon the Eegiment to which they belong ; they should receive their Eations from the Purveyors, as well as theii medical comforts and other extras. " In visiting my Hospital, I have constant complaints, from the Patients, that they have not received their biscuit and coffee from the companies. " The Commissariat of the Division will not now issue fresh' meat to the Surgeon on his Eequisition, and deduct it from the Eation Eeturn of the Eegiment ; but they require it to be issued to the different companies, who are then supposed to send it to their sick, in Hospital, and this is very often most irregularly done. " The Deputy Inspectors and Staff Surgeons of Divisions appear to possess no powers whatever. " If, for instance, they send in an Indent to the Commis- sariat, for straw for the Patients to lie upon, or for carriage, it is most probably refused ; the Surgeon must then try to' obtain these and similar things through another channel, through the Commanding Officer of the Eegiment, who refers it to the Assistant Quarter-master- General of the Division,' who forwards it to the Qaarter-master-General of the Army. Kequisition " It is this perpetual bandying to and fro of Eequisitions. Exemplified ^^^^^ one Department to another ; the furnishing of some portion of Hospital diet by the Commissariat, and another, including medical comforts, by the Purveyor, that creates thi[ delay and embarrassment that prevails at present. | " In conclusion, it appears to me, that unless the Medical' Board is reconstructed on a basis of greater authority and inde- pendence, as regards the procuring of carriage, of Hospital accommodation, furniture and utensils ; and unless it is provided with an efficient staff of purveyors, clerks and apothecaries, present, on the spot, where the Army is encamped, or in quarters in the field, the unfortunate scenes of misery and destitution, and consequent loss of life, such as I have wit- nessed amongst the sick in the camp, during the inclement weather of the last six weeks, will inevitably, under similar circumstances, again occur." The system of Requisitions is wonderfully fallacious. REQUISITIONS. 43 I is generally defended^ on the ground of a Requi- jion being necessary as a Voucher, but it is no check in tit way, because, if an article be not in store and not ued, that article may not be, and frequently is not, ? uck off : it is obvious therefore that nothing but a lliceipt from the recipient can be a voucher. The Duke of Newcastle's Commission, two of w^hom pire Medical Officers, make the following recommcnda- ;ns : — ' That every Eegiment should always be supplied at once ?;h its due allowance of Hospital acconunodation and furni- ; 'e, without requisition. ' That the store of medicines and medical comforts kept w ith Eegiment should always be sufficient for at least a fort- ]j;ht's probable consmnptiou, and should be repleDished iKodically, from the Principal Store, without requisition. ' That, when tiie regimental stores fail before their periodical •ijilenishment, the requisition of the Regimental Surgeon should ijCompHed with, without needing the approval of the Medical [jlBcer of the Division ; and, to prevent fraud, that the whole ithe Requisition should be in the handwriting of the Sur- 2[3n." i' According to the ordinary practice" (we quote again from k) same Eeportj) " when a Eegimental Surgeon is in want of r-dicines and medical comforts, he applies to the Principal Ipdical Officer of his Division for a supply. This Officer, if h approves of the Eequisition, countersigns it, and the r'(uired articles are issued, by the Apothecary or the Pur- yor's Clerk in charge of the Stores attached to the Division. men the stock of medicines and medical comforts in these Ares began to fail, the Eegimental Surgeons endeavoured to Bp their wants supplied by the Apothecary aud Purveyor at Maclava, where the principal stores in the Crimea are kept. ][is practice entailed upon these latter gentlemen a great addi- tin to their ordinary labours, and, upon the Surgeons, the iu- c'lvenience of sending several miles for their supplies. This i'ouvenience became gradually aggravated, in proportion as it Kume frequent, aiul its frequency became more and more 44 REQUISITION-SYSTEM. necessary, as the quantities that were dealt out at a time t them, in answer to their Eequisitions, became smaller. Tt practice, under such circumstances, of requiring the counte: signature of the Medical Oflficer in charge of Divisions, Gp(i rated very vexatiously. " We learnt that the issue to Eegiments of huts, and ma quees, and other articles, was made only upon Eequisitio: We think that the consequence of this practice may be observ( in the Hospital accommodation which our table exhibits. Tl condition of the sick varies in every Eegiment, and it varies, . great measure, with the energy and zeal of the Commandir and Medical Officers, and with the means of transport at the disposal. We think that the state of the men should not } left dependent on such circumstances. " The diet-roll is, as we have already observed [that is, : General Hospitals], submitted to the Staff Surgeon of tl: Division, who revises it." y .i Dr. Alexander states, being in charge of the Light Biv sion : — " Eequisitions for medicines, comforts, &c.,were at first se: direct to the Apothecary and Purveyor, until Dr. Hall desin their being sent in direct to him, for his approval," &c. Dr. Alexander, being in medical charge of 1st Brigad^^ Light Division, says : — " On arriving at Scutari from Gallipoli, I set about at on preparing for the field, and called upon all the Surgeons of r Brigade to furnish me with a list of what they conceived nect sary for the field, and that we would arrange together. Su was done, and communicated to the Principal Medical Offic of the Division, whose answer was that he would not * bre. bulk and on repeatedly reasoning with him and urging hi to have some supplies, save the paltry pannier one, the sar answer as above was given, with ' I am responsible.' I belie) however, some small supplies of tea and arrowroot were issu( prior to our embarking for Varna." EVIDENCE. 45 jt.-Coloncl Patullo, Commanding 30tli Regiment, JanuarT/ 15, 1S55. ' The state of tlie Hospital, since bad weather has set in, has bji-n deplorable, and it is not to be wondered at that few return titheir duty who enter it. ■' The regiment, as far as I can judge, has been invariably in w i'l of proper medicines and hospital comforts. I have always, ii :iscs of Cholera, which were very frequent, heard the Medical C.lcers say that they could do nothing for the men ; they had n means of treating the Patients. Even in cases of officers men of the Eegiment who were taken into Balaclava, b ring from Cholera, the Medical Officers who accompanied tlim were unable to obtain, at the Greneral Hospital, a grain of n Heine suitable to the disease. 1 n conclusion, I am of opinion that the Department has 1) 11 conducted during the Campaign with too rigid economy b-the Superintending Officers, and that many of the subordi- Ti are deterred from making the necessary Eequisitions i^'h fear of its bringing on them the censure of their b icriors, and affi[}cting their future prospects. ' The ^ledical Officers of the Eegiment have exerted them- - to the utmost with the means at their disposal." oloncl Spencer, Commanding 44th Regiment, Commanding Officers' Evidence Kesumed. Lt.-Col. Patullo, 30th Regt. R" December 1, 1854. The quantity of medicines and medical comforts has been TrA' Hmitud ; not long since there was no Brandy or Opium f' f'holora Patients. Supply of fuel bad." oloncl Haly, Commanding 47tli Regiment, writes; — Col. Haly, Commanding 47th Kegt. " January 4, 1855. I will not attempt to disguise from you that it was most 46 EVIDENCE AS TO THE depressing and discouraging to see the very meagre allowanc'i of comforts and appliances for the accommodation of the sicl especially in Bulgaria, where there was no difficulty, had prope arrangements existed, in providing any amount of nourishiDi diet, prepared in a palatable form, with any medicines or com forts that might be necessary for them. " The nature of the bedding was, in my opinion, totally unfi for the use of the sick, in the manner in which it was theret; applied ; it consisted of a piece of double canvass laid on the bar earth, without the slightest intermediate substance, the soldier' great coat, and an ordinary blanket. Sick men who were oblige to lie in a state of suffering on the hard ground for days an even weeks, had much to endure, which could not tend toward the patient's convalescence. Having, during the period w were in Bulgaria, discovered that the canvass spread under th patients was, in reality, the ticking of a palliasse, I mad application, through the regular channel, for a supply of stra^ for the sick ; pointing out that, if the Authorities at home ha supplied palliasse tickings, it must have been intended thattli sick should be furnished with straw to fill them. I regret i say that my application was returned to me, with a remai signed by the Staff Surgeon of the 2nd Division, that tl supply of straw for the sick was deemed unnecessary. Howeve not satisfied at seeing my sick men lying on the ground, succeeded in the course of some days in making some ha which I gave over to stuff the beds in the Hospital, having pr viously given one small hair mattrass for the use of su( patient as might be most in need of it. " Being informed that the supply of wine to the Eegiment Hospital was so very limited, I constantly gave such contribi tion as I could from a small stock purchased by myself for tl purpose, and only regret that my very limited means prevent* my being able to afford a better supply." Illustration from the Evidence of Purvrvor's Clerk, Harrington. Purveyor's Clerk Harrington^ in charge of Light Di\ sion, writes, enclosing the following Eequisitions, answen and unanswered : — I " Invoice of Medical Comforts supplied for the use of tii PRIVATIONS OF THE ARMY. 47 ght Division, after repeated applications, August 1, 1854, at onastir : "48 bottles Port Wine. " 36 „ Brandy. "50 lbs. Sago. "3 „ Arrowroot. *' The above were supplied at the time the Cholera was at its ight. " Eequisition made November 11, 1854, for " 150 Mats .. .. 90 received. " 1,000 Gruernsey frocks not received. "800 Cholera belts. " 1 2 Tarpaulins . . 11 received. K. Jenner, Esq., Purveyor. I" No reason assigned; but I understood that the articles not pplied were still on board ship. " JSTovemler 11, 1854. " 200 Blankets . . . . not received. " 4 Hospital Marquees . . not received. " 1,000 Guernsey frocks. " This requisition was approved by the Inspector Greneral of Qspitals, Dr. Hall, and also by General Airey, and forwarded li-ee times to the Officer in Charge of the Quarter-Master 3nerar8 Department, at Balaklava, who returned it because had not noticed the approval of General Airey. " November 16, 1854. " 4 boxes Essence of Beef 2 received. H 20 lbs. Arrow root . . received. " 20 „ Tea . . . . not received. "12 „ Candles .. .. not received.* Purveyor's Clerk, Head Quarters. Eeasou assigned — none in store. r It is impossible to overstate the liorror expressed by Itegimental ] dical Officers, at the suffering entailed upon Cholera Patients, by being ''.ed in the night, and there being no candles to light the attendants in ti.ing the nccessarj measures. See also the next page. 48 EVIDENCE AS TO THE " 1 chest Tea " 2o lbs. Ground Hice 25 „ Sago "20 Arrow root " 12 „ Candles . . K. Jenner, Esq,, Purveyor. " Eeason assigned — none in store. " 4 boxes Essence of Beef " 20 tins Chocolate " 2 dozen Brandy . . " 4 doz. Port Wine " 50 lbs. Sago " 20 tins Chocolate " 100 cases Essence of Beef " K. Jenner, Esq., Purveyor. ''November 18, 1854. 13 lbs. received, not received, received, not received. 6 lbs. received. JSTovemher 22, 1854. received, received, not received. November 29, 1854. received. 30 received, received, received. "12 lbs- Candles .. " K. Jenner, Esq., Purveyor. " 4 cases Preserved Potatoes " K. J enner, Esq., Purveyor. ' November 30, 1854. received. " December 2, 1854. received. " December 4, 1854. not received, not received. " 2 cases Lime Juice " 12 lbs. Candles . . " K. Jenner, Esq., Purveyor. " Eeason assigned, I believe to have been, that the Purveyo had but a small supply in store, as he afterwards sent out hot Arrow root and Sago without requisitions being sent for then TRIVATIONS OF THE ARMY. 49 " Decemher 13, 1854. " 2 doz. Port "Wine . . 3 doz. received. " 12 lbs. Candles . . received. " Decemher 14, 1854. " 24 lbs. Arrow root . . not received. " 30 „ Sago . . . . nob received. " 10 boxes Essence of Beef not received. 12 lbs. Candles . . received. Eeason assigned, tbat there vs^ere none in store, but they e daily expected ; and the Purveyor at the same time in- fcjned me that as soon as they arrived he would supply them, W ch he did as soon as they were landed, which was not until B^ember 30, since when the Eequisitions have been always C([iplied with. At the same time I consider it my duty to state tl|b, from Purveyor Jenner, I have invariably met with every d(|lre to furnish the supplies required, and that in the cases in w eh he has not been able to meet fully, he has done so as far asiy in his power, and has repeatedly advised me of the arrival ol!:'esh stores at Balaclava, in order that I might obtain them." I tiajor Davis, Commanding 95tli Begiment, writes : — Major Davis, Commanding " Camp before Sevastopol, " Jan. 12, 1855. Medical comforts are so few as to be almost unknown, and supply of medicines has been so inadequate that a similar rey to this part of the question might be given, with little 63 '•geration. There is little use in making suggestions, as there has been m h difficulty lately, even in subsisting the men on salt pro- viuns. The want of fresh meat and vegetables, or some kind ofiiixed diet, together with fatigue and exposure, insufficiency of (othing, (which latter is now being corrected) I believe to be he chief cause of sickness. It would be beneficial if rice I'getables (if fresh cannot be had, preserved potatoes) and bread occasionally, which our allies find no difficulty in lb ;niug constantly, in lieu of biscuit, could be issued by the E 95th Regt. I 50 EVIDENCE. Commissariat, and fresh meat at least twice a-week. Also.i if the men could have three nights uninterruptedly off duty ;i and, if tents could be given them in the redoubts, and on alii pickets, where it would not be dangerous to have them. Men.; after twenty -four hours' continuous exposure to rain and snow.i and having no change, lie in their tents, rolled in wet blankets.; till dried by their ovvn heat, or till they are carried to the Hospital." ! Col. Shirley, Colonel Shirley, Commanding 88tli Regiment Commanding 8Sih Rcgt. writes : — " Camp before Sevastopol, " Dec. 28, 1854. " The hospital tents now used are five common round be] tents, and one of these is used to contain the Medicines, &c There are not nearly sufficient to contain half the sick (havin; by this morning's state — Sick Sergeants 3 Eank and File 107 110 28 only in hospital tents) and are, moreover, perfectly unsuited to the purpose, especial! in such weather as we have had for this last month or mor as they are not weather-proof, being simple, without any so: of lining to make them warm or water-proof. " The means of cooking are the same as those for the rest ' the regiment, viz., camp kettles of a very defective constru tion ; no stoves or fire places of any description, except a he^ of stones piled up to raise the pot, and placed against a wall loose stones. Within the last few days, three pots wi handles, and placed on iron stands, were issued to the Eegimei and I sent them to the Hospital. These are an improveme on the common camp kettles, inasmuch as they have handk but I am not aware that any saucepans or utensils for cookie different from those in use in the Eegiment, are even issu SCUTARI. 51 ti the Hospital. In short, I consider the means of cooking a thing which requires more than common boiling, most i 1 1 equate. • i conceive that, if the control of the Medical Staff was peed more immediately under the General Officers, com- r|uding Brigades and Divisions, than it is at present, the B!)ply of necessary comforts for the men would be much g 'ater, and earlier obtained, than at present ; and, at all events, ( leers commanding E/Cgiments, as the reports to the General ( leers would then go through them, would know what the 11)1 received in the way of comforts, which, in consequence of t excessive jealousy of the Medical Department, reg£irding 1 slightest interference with their practice, they cannot a irtain with any degree of accuracy at present." We have now to say a few words about Scutari. Lord Hardinge stated that "the Hospital at Scutari vs under Lord Raglan^s command; but that^ at the same t iC; the reports made to him (Lord R.) did not give such a rue account of the extent of the misfortunes as, perhaps, 0 ^lit to have been given that " Lord Raglan did not r ;cive, at an early period, sufficient information of the e;ent of the distress ; he did not know that the case was Si bad f that " Lord Raglan sent down Dr. Hall to make .i]f[uiries into that matter that " Dr. HalPs report was t'the effect that everything was in capital order that *' jord Raglan was therefore not to be blamed ; but that 1 Hall was to be blamed that he (Lord Hardinge) ^' as not aware that any inquiry had been made into the c iduct of Dr. Hall for giving that incorrect report a hough he admits that " it was Lord Raglan^ s duty to c I Dr. Hall to account f but that he considers " it is s rcely fair for him (Lord Hardinge) to express an opinion 1 )n these points." ''If Dr. Hall," he adds, "made a I 'ort which was not justified by the state of the Hos- 1 uls, and that report went to Lord Raglan, the Honour- E 2 State of things in the Hospital at Scutari. Lord Hardinge's Statement. I 52 OFFICIAL VIEWS AS TO able Chairman is too keen not to know tliat the blame attaches to the person who made the untrue report." Lord Hardinge farther stated, in answer to a question : — " Was it not Lord Raglan^s duty to see to the state of! the Hospital But an Officer in the Field, a long dis- tance from the place, in the state in which the lines at Balaklava were, could not be absent from his post for a moment/^ Question : — But he could have made enquiries in a much shorter time than we could — Lord Hardinge^s answer : " Yes, but his suspicions of anything going wrong had been corrected by Dr. HalPs report ; one hardly sees why he should have sent another person down.-*^ Question : — "But the newspapers and the same means ; that were open to you for exploring into the mischief, were open to Lord Baglan?^^ — Lord Hardinge's answer " I suspect that we heard earlier from the newspapers thai Lord Baglan did ; it came here first, and then went back to the Camp." x.)^ Statements Dr. Hall thus reports (20 Oct., 1854) home, to Dr| Dr. (now Sir Smith, that he has "much satisfaction in being able t(| John) Hall, inform him that the whole Hosspital establishment her-i (at Scutari) has now been put on a very creditable footing and that the sick and wounded are all doing as well a could possibly be expected." "I am also happy to inforni you that, by the strenuous exertions and unceasing labour of First Class Staff Surgeon Menzies and the Medical Officers under him, all cur difficulties have been in j great measure surmounted, and in a short time, I flatte myself, we shall have an Hospital Establishment that wilj bear a comparison with any one of the same magnitud! formed under similar disadvantages; or, indeed, I mah almost venture to say, under any circumstances." , In his letter to the Times, July 9, 1855, he says, tha| THE HOSPITALS AT SCUTARI. 53 ^le "reiterates and adheres to every syllable he then vrote/^ viz., when he left Scutari, Oct. 21, 1854. He 1^ considers he is quite as good a judge of the subject, and [uite as worthy of credit, as the Duke of Newcastle's nformants, whose reports may, perhaps, refer to an earlier j.^r a later period than his.'' ^ Mr. Herbert, in his evidence, says that " Lord Raglan ent Dr. Hall to inspect the Hospitals, and Dr. Hall went |)ack giving a very flourishing account of the state of them, |nd that report was sent home to us," that " Lord Raglan lad reason to believe that all was going on well," that [ all the information which he (Lord Raglan) had was erfectly satisfactory to him, which was the information liven by the Inspector- General of Hospitals, in whose itatement he of course placed confidence ;" that "Dr. lalFs statement was founded upon what he had himself pen. But I apprehend," adds Mr. Herbert, "that people ISLve looked upon the state of things at Scutari with very jifferent eyes. I have received throughout extremely |ontradictory evidence from Scutari. Officers who were iliere even quite at the beginning, wrote and said that •bey had never seen an Army Hospital more effective ; there have been great improvements of late years in fospitals, especially Civil Hospitals. I think originally [)0 much was expected. At the same time I am bound to iy that I think that too little was done ; but men who ave been accustomed to see Hospitals in the field, would 8 bottles 207 „ 82 lbs. 6 „ 1,2454 lbs. 424 1 pints iOo IDS. 192 „ 250 „ None 93 tins. 3 casks These articles were always read! procurable from the Commisf riat Alydos, \Uh December, 1854. W. J. A. Tucker, Purveyor to the Forces. Return of Medical Comforts received at Varna from the 1st Septeml to the 17th November, 1854, showing from what Quarter they w< obtained. 1854. Port Wine. Brandy. Bottles. Bottles. September 6 By Purchase . . 12 7 Do 10 16 Do 36 19 Do 16 21 Do 36 27 Do 36 October 21 Do 72 8 November 15 Do Ahydos, IQth December, 1854. W. J. A. Tucker, Purveyor to the Forces * Probably a misprint for September. AT SCUTARI, IN NOVEMBER, 1854. 57 SDICAL Comforts, &c., issued for the Use of the Sick (other than those in 'the General Hospital) at Varna, from 1st September to 17th November, 1854. c o Date. rrow 1 '? C3 W ?* 5 c "S c. round H c3 o o lbs. btts. lbs. lbs. botts. ^pnts. lbs. lbs. lbs. .854 Total . . 20 29 462 121 259 30 197 98 518 Ahydos, 16th December, 1854. W. J. A. Tucker, Purveyor to the Forces. I Lord Raglan, the Duke of Newcastle, and Mr. Herbert ere bound to believe the official information of their leads of Departments. How far this official information as correct, how far they were well used by the officials fider them, who gave them that evidence to which they 3re compelled, officially and technically, to trust, is now 16 question. Dr. Hall left Scutari, Oct. 21, 1854. On that day, by le official returns, there were, in hospital at Scutari; arrack Hospital, 1267; General Hospital, 658. The Superintendent of Nurses arrived on Nov. 4, 1854. '^iicre were then in Hospital at Scutari; Barrack Hospital, 500 ; General Hospital, 800 ; also by official return. There were therefore only 375 patients more in the ospitals than when Dr. Hall pronounced them in a ; tisfactory condition. No other change had taken place, ^hat the wants were will be seen by the Requisitions, il^ned by Medical Officers, which began to flow in upon e Superintendent of Nurses, — an abstract of wdiich is inexed, p. 59 — and which came to her, because they 'uld not be satisfied elsewhere. 58 SUPPLY OF STORES AT It is painful^ but necessary, to mention^ that the Pri:' cipal Medical Officer in charge of the Barrack Hospit made his first Requisition, stating that there were b twenty utensils in a Hospital, of which 1,000 cases, thr under treatment, were Diarrhoea and Dysentery ; that t ; inhabitants of the hospital were living over a cesspool, evil which was not remedied till April, 1855, by t; Sanitary Commission ; that the drains were first clean i out by this Commission ; that, as to the Latrines, which, i Turkish buildings, are merely holes surmounting carthe- ware pipes, some of these pipes had burst and saturated t ; building, — which nuisance necessarily continued up to t; time the British left the East ; that one side and a h f of the building, partly occupied by patients, were expose, from want of repair, to the weather ; that the washing almost nil, and the cooking abominably bad. The grear FitZe Stafford's part of these nuisances had been reported on by and o Q^°699^1^7o^o then Principal Medical Officer so early as May 18; and Seb. Com., That they were all considered as nuisances and evils s 4th lieport, *^ _ _ Q. 20,936. proved by their having been officially remedied, wl i remonstrated against in earnest. More will be said of this elsewhere. Let us, howev , still keeping to official documents, now look at a reti a of what was in store even on January 1, 1855, of Hospi l Furniture. On that day, (the number of patients who had arri^d in the Hospitals of the Bosphorus during the last fortnij t amounting to 2532, followed by 1044 more in the n t six days) the Superintendent of Nurses, according to r invariable custom of ascertaining first, whether the a - cles, for which requisition was made upon her by Mediil Officers, were or were not in the Purveyor's Stores,- n order that no ostentatious display or unnecessary is e might be made by her, received the following return, fr Q SCUTAKI IN JANUARY, 1855. 59 e General Hospital at Scutari, where the Central Store en was. January 1, 1855. Plates (tin) . . . . . . . . none Candlesticks none Tin drinking cups none Urinals (metal) plenty- Bed pans some Close stools plenty but frames wanted Tin Pails for Tea none jl at present Bolsters none Night caps a few Slippers none Knives and forks none 1 Spoons none 1 Flannel Shirts . . . . . . none Socks, pairs none ^ Drawers, pairs none Some tea pots and coffee pots. On January 18, 1855, — 2,438 more patients having ?Hved since January 1, — and half one wing of the Barrack iDspital having been occupied (on that day), though entirely bare of every one of the above articles, the Pur- l|H^or- in- Chief reiterated the same negative in the presence <: the Inspector-General to Miss Nightingale, who then SippHed the articles. \ iTo sum up : I iThe propositions which flow from the foregoing facts, -ffi three. It is proved, not by the vague reports of newspaper fci'respondents, nor from the cursory views of benevo- Summaiy. A real Deficiency existed. 60 CONCLUSIONS FROM THE lent dilettanti^ but from the written evidence of almo; every Commanding Officer and Regimental Surgeon in tb Crimea, that the troops did suffer, in the winter of 185^^ from a greater or less deficiency of medical comfort' medicines, &c. It could not 2. This deficiency is not only shown by testimony to hav ex^sfect^wHh been the actual fact, but it may be proved that it could n< the amount of heen otherwise, by reference to the list of supplies • supplies sent, ' ^ ^ medical comforts sent out, furnished by the Director-Genei ' himself, who states that he had, according to his judgmen provided medical men, medicines, and medical stores abundance. In other words there is no occasion for " su prise'^ as to ^' where these enormous supplies could ha^ gone.'^ These ample stores" were sufficient to ha' lasted an army in which were 2,000 sick (the rate of sid ness, it is supposed, allowed by the Director-General) period of from 3—4 weeks. It must, therefore, have be( anticipated that they could not last an Army, in whi( were 11,000 sick, a period of six months, but that Requij tions would be made by the Principal Medical Officers ( the spot, for further supplies, when they were require No such requisitions appear, in any Documents publishe to have been made in any part of 1854, excepting o for medicines. On the contrary, the Army ajipears have been left six months upon these supplies, if mo were not furnished on the spot; it being always a swered by the Principal Medical Officers, that " the war of the Army were fully supplied/^ With regard to the deficiencies and sufferings, it is therefore proved not on that the fact was so, but that it could not have been otht wise. It will be so 3. Having proved it to have been so, and that it cov again, unless the system be not have been otherwise, it may also be proved that it e\ altered. ^-jj unless a different system be adopted. FOREGOING EVIDENCE. 61 /Vas the very simple expedient of sending out a printed ular form, to be filled up so as to state (under heads) "wjit arc the medicines and medical comforts now in store, wkt the receipts of the same from home, since the date o; last Report, and what the present wants, employed in )r. A. Smith states, March 26, ]855, in answer to the qistion "Do they (the Reports sent you) contain the roipts of medicines and medical comforts that have aijived there since the date of their last Report?" Absence of all official information, given to the authoritie , at home, of the wants of the men, and of the means for supplying them. ,)r. Smith writes, "Sept. 23, 1854,'' to the " Principal ]V|dical Officer, Turkey, I The supply of medicines you hav6 demanded, and also a si|ply of medical comforts, will leave in a few days in the * J'ince,' a large steamer, which is being loaded with stores for ir(nediate dispatch." »Yas this the first " demand" for " Medicines were tl; " Medical Comforts" on Requisition or not ? what was til supply on board the Prince^ which does not appear in tl Return" furnished by Dr. Smith, and, when she was 1( , Nov. 14, 1854, what measures were taken to replace 1^ supply? [ (Phe questions we would ask are four. . How is it that the food of the soldier was bad ? that (h| had in Bulgaria sour bread, in the Crimea, biscuit ? ti t he had in Bulgaria bad meat, sometimes goat's flesh, ii tlie Crimea salt meat? Vas Lord Raglan made aware of it, by the Principal N dical Officer, and at what date ? 5. Was the General Order of May 1854 cancelled, and luvhat date? If not, was Lord Raglan made aware of tl virtual cessation of the supplies (ordered in it to the Four Questions on this subject. 62 CONCLUSIONS FROM men) by the Commissary-General, and at what date ? Or ' did the Commissary -General write to England for a con- tinued supply of such articles as Turkey did not furnish, in order to enable him to meet Lord Raglan's Order? | 3. How was it that the Fuel was not provided ? The General Order of the Commander of the Forces was sufficient authority for the Commissary-General. 4. Did the Principal Medical Officer remonstrate officially, with Lord Raglan, in July, August, September October, November, 1854, as to the Clothing, Salt Meat Biscuit, Green Coffee, want of Lime Juice, &c., &c., fo: the troops ? In December the mischief was done, as i shown by the frightful increase of Disease, — j (viz., 19,500 Sick and Wounded). I Did he also remonstrate officially with his Chief, h England ? With regard to the Green Coffee, a letter appears froa Dr. Smith, dated not earlier than Jan. 24, 1855, remo: strating against its use. And this, when we know that it had been said, for t previous four months, that the Soldier would ma somehow (without any means) to roast and to grini or rather to mash it — and this with a Capital of 300, inhabitants, within thirty-six hours' passage, the whole whom drink coffee (of course roasted and ground, ( pounded) every day of their lives. Three 1- The Duke of Newcastle, Lord Hardinge, and D Smith, we have seen, question the existence of any wanti upon the ground of no official evidence of such havi reached them, or, rather, upon the ground of the offi reports of the Principal Medical Officer and others, up February, 1855, as to the ample supply'' of everything It would appear as if Dr. Hall not only made no Rcqi| Conclusions. THE FOREGOING EVIDENCE. 63 ition for more stores (except of medicines) before the iitumn or winter, but even denied that he wanted any. 2. It appears hazardous, to use the mildest term, for )r. Smith to assert, upon the ground that he had received .0 Requisition from Dr. Hall, that, therefore, there were !► wants, when, by looking over the List of his own pplies sent, he would have seen that there could be no )res of medical comforts left, and that the supply fpr- ^arded in April and May could not possibly have lasted [11 September, when the next supply arrived, nor that, ain, even with the third supply, till December, unless ore was purchased on the spot. 3. The Commission, sent out by the Duke of Newcastle, 0 of the three Members of which were Army Surgeons, z., an Inspector- General and a Staff Surgeon, state, in eir Report, p. II, that the Hospital accommodation^^ as " very inadequate," the tents being wholly unsuit- ble,^' that there was a " general want of bedsteads and 'very other means of raising the men above the ground,**^ supply of " Hospital utensils far too limited,^^ and " of tiedicines and medical comforts, in some important parti- alars, very insufficient. Upon this point,^^ they add, "we ave the almost unanimous testimony of Regimental Sur- eons. Surgeons of Divisions, and of the Principal Medical )fficer of the British Army in the East.^-* Dr. Hall states, 1 his Evidence, January 16, 1855, that these wants were 'fficially reported to him. The Report of the Commissioners is dated February 23, ^y^{ ||855, and, at this very time, Dr. Smith was denying these ^ Iji ants, on the authority of his officials on the spot. He also says, in answer to the question ^^Did Dr. [all ever go to Scutari to examine the state of the rytli lospitals?'' 10 1« gg CONCLUSIONS. a soldier enlist, viz., being out of work, in a state of into ication, or jilted by bis sweetheart. Yet the incentives 1 enlistment, which we desire to multiply, can hardly be pi by Englishmen of the nineteenth century, in this fern viz., more poverty, more drink, more faithless sweetheart And, in England, Conscription will ever be impossible 67 II. li Notes on the Deficiencies of Sick Transport. When a Naval and Military Force act together, for ope- Facilities ijiions on shore, it has been customary for the Military ^^^gick 1 tree to borrow assistance from the Navy. And, in the ^•■ansport by the presence of 1 e War, application was made to the Navy for transport a Naval Force. ( the troops and also for that of the Sick and Wounded. Assuming that Hospitals existed at the base of opera- t»ns and also at a distance from the base, there seems no (Hculty in a member of the Quarter-Master GeneraPs Dc- } ftment being appointed to meet a member of the Medical ]!partment, who should receive, at Head Quarters, Eeturns csuch Sick and Wounded as were deemed capable of being i')ved, and for whom it was desirable that they should be Dved to the General Hospital at the base, or to the har- lur, with a view to embarkation. The portion designed f ' embarkation would be divided into two sections, those "vio are to be invalided home and those for the General bspitals, at a distance from the base. A.S this service became of greater importance, it would I] almost a consequence that some ships should be fitted fl the especial use of the sick, being retained for that prpose — some for the shorter and some for the longer Tfage. Surely the necessary detail of military and naval returns, o[ provisioning the ships, and the Statistics of embarkation a|i of disembarkation, ought not to be very embarrassing t« those accustomed to them ; and, in the case of ships fijed in England, it must be supposed that little could be ^jnting for the comfort of the Sick, either in dietary or fi|ings. 68 WANT OF COMBTNATIOX Extreme want, Yet, in the last war, the ample Hospitals of Scutar "war/of Koulali, &c., being successively provided for the Sick, an arrangements supplemented bv Smyrna and Rcnkioi, not to speak of tV for using these " , ^ i ^ • i - 1 t> • i. i facilities. large Hut Hospitals of the Crimea, both liegimental an General, these preparations were neither made in tlj Crimea nor carried out on board ship, to perfection, eve at the end of the war. E. g., after the It is notorious, although a large portion of the Battle < Battle of Alma. ^^^^ ^^^^ ^^^^ ^j^^ men-of-war, attended, as the w^ere, by transports, that no assistance was asked from tl Navy at first. Individuals only landed from the ships, 1 offer help. When the Sick were taken to the beach, the most insu ficient and contradictory orders existed for putting the on board, and many ships were over-crowded. Inadequa surgical assistance was afforded, and the first four or fi^ ships brought the Wounded down in a lamentable cond tion. After Things were amended before the Battle of Inkerman Inkerraann. ° The Wounded were brought down in less numbers and f better provided for. But a difficulty in receiving the took place, and ships were detained much longer at anch at Scutari than they had been performing their voyag About Christmas 1854 four ships were gradually fitte solely for the transport of the Sick. And, through the energy of the Transport Agent, th( were provided with every comfort, although the ships we not, perhaps, the best adapted for the purpose. On the Return About this time, the British Naval Commander-in-Chi of Admiral i • i i ' Dundas. went home, with three Ime-of-battle ships, anchoring, f forty-eight hours, at the Seraglio Point, at Constantinop As he only offered to take 100 Invalids home, ai desired that they should be put on board, at a few hou: notice, none, it is believed, were sent, although it wou FOR SICK TRANSPORT BY THE NAVY. 69 and in the Crimea. Ive been the greatest boon to Scutari, because it was the l|ae of almost the greatest over-crowding. So faulty was the combination between the Naval and General want lilitary authorities that the Sick came down without any Combination tice, so that the Hospital could not be got ready for Scutari, em. And ships were reported ready also without tice, so that the numerous forms to be passed through, I fore Sick and Invalids could be embarked, could not perfected, and they sailed without their complete c|!nplement. This relates to Scutari. In the Crimea the same description may be repeated, afnost word for word, as applicable. One ship, in the a'tumn of 1855, when no especial hurry existed, and after t ^ taking of Sevastopol, sailed with less than twenty I| valid s, another without any. There appeared to be no system of arrangement between t ; Quarter- Master GeneraFs Department, the Agent of ^Ixnsports, and the Medical Department. And, although 4lwas the intention of the Quarter-Master General to apoint a Deputy Inspector- General of the Army Medical ' I'partment, for this particular duty, viz., the collecting t ; sick and allotting them to ships about to sail, the ijention was never carried out. [n the meantime, after Christmas 1854, some of the Sst ships were appointed to this service, for each of ^\ ch the hire amounted to from £2,000 to £3,000 per ni,nth — Government paying the coals, '■f to the fittings, although they were tolerably good, no \?i pin was adopted for changing the atmosphere between ^d|^ks. And, in consequence, the "Great Tasmania,^' ^ I'l I'd in England for 500 sick, was sent away with 80 less H iu her complement, it not being thought safe to crowd ' nk-e upon her lower deck. The fittings were re-arranged Fittings, 70 SICK TRANSPORT. Failure of the Ambulance Waggons. Those Deficiencies were not the Fault of the Medical Department. Evidence for the foregoing Statements. on her arrival in England, and a kind of blower" adde( to change the air on the deck, in which there were n port holes. Whatever was arranged in England, and assembled i, Varna, as to Ambulance, was either broken up when th Army moved or remained behind when the Battle of Aim was fought. I Two or three of the Ambulance waggons, the spring' and construction of which gave little satisfaction, we]' used in the Crimea after the mud had ceased to be a obstruction. It is said that the Ambulance Corps Pensioners enrolled was completely broken up. Daring the mud, the Ambulance service was perfornK by Dragoon horses, pack horses and mules, and Fren( cacolets and mules, lent to the British. The few Ambulance waggons remaining were aga organized for the trenches during the spring and sumir of 1855 ; after June 1855, the cacolets were attached the Land Transport, to whom the service of the Ambular ; was made over. During the two assaults of June a. September 1855, a General Hospital having been est}- lished in the front, the wounded had not to be carr i above a mile. As, according to the rules of the Army, the Medil Department is supplied by other Departments with Ami • lance and with Transport for the Sick and Wounded, tl ^ were the victims and not tlie promoters of the confus i in the Land and Sea Transport. ' In the autumn of 1855, a Regimental Medical Offi r applied for Transport, to take his Sick down to Balacls ; but before it came, a period of a fortnight, the men w e dead. The following evidence, taken from official documei will sustain the above representations. i EVIDENCE, 71 r*The question is, whether sufficient space was allotted to Gumming le sick and wounded soldiers on board the vessels in which Slaxwell iiey were transported. Although we are, from the want of the Report. 3cessary data, unable to pronounce a confident opinion upon lis point with respect to every ship, there are many as to hich we do not hesitate to express our conviction that they ere much overcrowded. J udgiug from the size of the ' Kan- jiroo,' and from the scanty information which we obtained om the junior Medical Officer on board, — the senior beiug ;ad, — we do not think that she was large enough to carry 400 ck men, besides 24 officers, sufieriug from cholera. We can- bt doubt, also, that the ' Andes' and ' Colombo,' on their first yage, and the ' Orient' and the ' Caduceus, were greatly ercrowded. Having come from Balaklava to this place in the pieopatra' on her voyage in January, we think that she had at last 40 men too many on board on that occasion, and, conse- lently, that she was much overcrowded on her former voyage so. With respect to the vessels which have been represented us by the Medical Officers in charge of them as too crowded, though we are not in a position to confirm their opinion with nfidence, we have no reason to doubt the truth of their re- esentations. We think, further, that whenever the men have len in fact limited to the space mentioned by Dr. Anderson that which is allowed by the Board of Inspection* at Bala- ava in its calculation of the number of patients which a vessel in properly carry, they have been overcrowded ; aud if that has been strictly observed by the Board ever since its for- ation on the 12th December, we must declare that every ssel which brought down sick and wounded men from the fimea to Scutari subsequent to that date was overcrowded, ae superficial space of six feet by two and a half or three feet '•pears to us too small even in the loftiest decks, and we think at the height between decks ought to be made an element in j e calculation, even when the ventilation is most perfect. We ust add, however, tliat in estimating the number of patients ich a vessel can accommodate, mere measurements, whether ^ " These gentlemen, according to tlie evidence of Dr. Anderson, the esent Principal Medical Officer at Balaklava, in estimating the number of tients which a vessel can properly carry, allow 6 feet by 2^ feet for sick^ '1 6 feet by 3 feet for wounded men." 72 EVIDENCE AS TO superficial or cubic, are not the only legitimate elements computation. The character and gravity of the maladies uud which the patients are suffering, or the injuries which th have sustained, the length of time that they are to remain board, the state of the ventilation, and the season of the year which the voyage is performed — all these circumstances shoi be taken into consideration. " The supply of medical attendance on board has not alw; , been sufficient. It is impossible, indeed, to determine exact . a priori, what number of patients may be properly attended • one surgeon. This number must depend upon the characte the cases to be treated : severe wounds, for instance, obvioi; , exacting more time and care than trifling indispositions. C ■ siderins:, however, the general nature of the cases, both med and surgical, that arrived at Scutari during our residence t that place, we think that a surgeon could not give to more t 2 100 patients daily, even for a short voyage of two or three d.j, that degree of attendance which a patient should obtain fro 3 medical man. When a larger number was entrusted to ^ care, we think that the supply of medical attendance was i- sufficient." "Although we think it probable that men have occasio- had reason to complain both of the quantity supplied aii.i manner in which their food was cooked, we are dispose :: attribute these faults to the want of order, rather than to le want of a due supply of provisions or medical comforts. " The Table which we have set forth shows that a considei ile space of time has on some occasions elapsed between theii- barkation of the sick and the commencement of the vo} ^. It will be observed that many days elapsed between the rst embarkation of sick and wounded on board the ' Echu a,' the 'Tynemouth,' the 'Shooting Star,' the 'Arabia,' he ' Edendale,' the ' Medway,' the • Avon,' the ' Timandra,' nd the 'Australian,' and the sailing of those vessels for €ir destination. This was owing partly to boisterous weather DUt more generally to the fact that the sick were brought do\ to the harbour in small numbers daily, and the vessels wer .de- tained until they had received theii- complements. The ' us- tralian' appears to have been detained in discharging her c go, which she was doing while the sick were being sent on be d. SICK TRANSPORT. 73 (M . 00 lO CN . r-H T-H 0 CO J:jco-*cocococooo oj-t^ <=> CO rH rH c CM rH 0 CO ^ )JBoa no sl^d . CO ICS CO CO . . . 0 CO 0 . • . rH TJI • • P< Ph o a CO GO • Ph m Ph p. p^ " • *^ ^ • > 02 ccco 0(2; ^ tH nH f-H to (N * OS 05 OS m -f^ -t.3 -1.3 p4 Ph P4 p4 0 0 a> 0 CO CO — Sept Sept. Sept. Oct. Oct. Oct. Oct. Oct. a ei 00 rH 00 00 gq CO CO CO rH CO CO CO xnmO OOOO o • rH rH rH (M . . . 00 \ T-{ r->. T-K T-<. <>X .7-1 l-H . . rH rH . rH . . rH . . , T-{ 1-^ . 00 • rH 0 . rH . . . 0 . . . . . . (M . . Men. 2 0 0 CO 0 _ 0 0 0 CO ^ g 'iT* ^ 0 Ir- .Or-li>.rHCO (M '*(MG<>(MOSr-i(MrH m e . 00 . . rH (M rHlOCO'rJHOOOJr^O rH ! o Height between Deeks. Ft. In. Lofty CO 0 * CO 00 9 & 7 ft. About 6 ft. 7 0 8 0 6 to 7 ft. 6" 7 8*0 Tonnage. 1800 1775 180G 2000 About 1000 1106 1090 800 1400 1800 1 o n 1 Kangaroo . . Dunbar Cambria Vulcan Andes Colombo Arthur the Great . . Orient Caduceus . . Courier Cornwall Negociator . . Lady M'Naughten . . Australian . . Cambria Echunga • EVIDENCE AS TO rHr-HCN I— 1 r-i COCN O.CO .COi— li-t rH r-t i-t r-i • . ooooooooO(U(i)c:)Oi>o(i)■ >^ > > >^ > > >' I Id id '.6 ^{yOOOOOOOOO -l .O r-l '"'•^ .r-((MCO (M 1 ^k d OOOCN^ .COCO00*000(M»0 Ot-cOlr^G^t^cOCOG^OCOt^l:^ .-^1^0i»0-^(M - 00 . . ^ ^ CO Oi Tonnage. OOCOOOOCMOO OOO coo O 05 oocooooG— lG^COOCOQOOOr-i(MC-OiOOi>-CO C35 r-l(Ni— lCMT-tCN(MCO-li-Hl:^rH(MOOO CO>OOOi^-* CO r-(CMi— 'I— (i—lOQCNCO t— (r-li— (i— I ^^^^^^^^ § o fa S ?0 00 ^ o o r-lCqrH>-l7-!G-IOlOOO-*-^OOt^CO GMOCOO• O CO O I— I CM 7—1 1—1 rH =i o o J3 O O O pO O <1 Commission ^^^^^^^ ^^^^ ^'^^e of the Barrack Hospital. From the b^le of the Alma to that of Inkermann, it afforded room for only »1 patients ; but the average number in the building during it time was 1,276. From the last-mentioned date until the .' of December there was room for only 1,220, while the ave: ?e number in Hospital during the same period exceeded 2; 0. From the 19th of December to the 27th day of January, le accommodation was sufficient for 1,643 patients, but the ac al average number, according to the weekly state, was 2,228. le iiddition of the eastern half of C. corridor made the total ac( n- IN THE HOSPITALS. 85 nidation fit for only 1,704^ ; but we regret to state tliat tlie liispital has continued down to within the last few days over- wded by about 400 patients." February 23, 1855. 'Upon comparing the maximum number which the General spital can in our opinion accommodate, viz., 968 patients, Wh the numbers appearing in the WT^ekly states of that Hos- pil, and which will be found below, we think that it w^as not O T-crowded until the last week in December, and that, with ti exception of one week in January, it has been over-crowded iipe that date. UMBER OF Patients in the several HosprrALS at Scutari at the end of the Weeks ending on the hereunder-mentioned Days. Datk. General Hospital. Barrack Hospital. Haidar Pasha. Stables. Kuleli Total Numlier of Sick, not including Hospital Ships. 1854. jtober 7 724 1,198 1,922 14 694 1,174 1,868 21 658 1,267 1,925 28 620 1,242 1,862 pvember 4 800 1,500 2,300 11 734 2,062 2,796 18 907 1,958 2,865 25 856 2,183 3,039 Lembcr 2 829 2,202 no 3,141 9 746 2,176 179 3,101 16 710 1,900 240 3,750 23 957 2,434 240 3,721 30 1,034 2,401 234 3,669 1855. ^Jiuary 6 1,008 2,387 386 234 4,341 1 13 875 2,249 307 60 508 3,999 20 1,006 2,179 304 60 508 3,545 27 1,007 2,221 350 63 495 4,016 'I 86 OVERCROWDING. Date. neral )spital. Barrack Hospital. 3 ^ Is %t o Total Num of Sick. OuPh Sol Average Daily No. February 969 2,043 488 707 908 5,115 )} Up to 1 March 15) 828 1,650 434 312 878 4,102 When we re- consider that the space allotted by the gulations of the Service is only two feet between the ha, that the filling both wards and corridors with patients, under the most favourable circumstances^ like buildii* two Hospitals "back to hack/' and that it is without i;- puting such regulations and admitting such circumstar !S that the Hospital Commissioners are still compelled o declare the space actually given to have been not evenu accordance with such regulations, but far below them— e think we may reiterate the term " frightful over-crow dii " with, alas ! no hope of contradiction. ^ . " "We have allowed in the wards five feet per man, accorc ^ Uumming . , . Maxwell to the Hospital regulations of the service, except where jie Report. height of the rooms does not give, with that superficial meas 3- ment, the cubic space of 800 feet per man. In that case e have determined the number which can be accommodated y allowing that amount of cubic space to each person. " The corridors of the Barrack and Greneral Hospitals ar it present occupied by sick and wounded. Those of the Barr k contain two rows of beds, and those of the General Hosp il have a single row. "We think it much to be regretted that t y should be so occupied, for such occupation is not only injuriis to the ventilation of the wards, but deprives the patients of le place in which they can most conveniently take exercise dui;g Sanitary Report. * The wards and corridors being both occupied by sick, they couk in fact, be considered only as two Hospitals built back to back, with the il air in each intermingling by the doors." BAD VENT1LA.T10N. 87 recovery. Making all due allowance, however, for the piit deuiand for hospital accommodation which has existed ire during this winter, and for future contingencies, we think it not more than a single row of beds should, under any cir- i-mstances, be placed ia the corridors ; and our calculation Ijceeds on the supposition that each man in that single row^ 8 five feet in width allowed to him." Hoping that never again may be seen " allowed in the ^pvice five feet in wddth to each man/' or about two feet rkween the l)eds, and especially not in war time,, especially :iit in war epidemics, w^hen it would be far better for the im, \^ ere they treated in the open fields than in such lispital space, we take leave of this part of the subject. With regard to the ventilation, scarcely anything l|d been done, up to the arrival of the Sanitary Commis- fij>iiers, ^larch 6, 1855, to improve its state in the Barrack J jspital, not even as much as breaking a pane of glass in jtp privies. What they did shows its defects; and what the atmo- B ierewas at night in that Hospital, especially in Corridor iid Wards D, it is impossible to describe, or to remember, 3vthout wondering that every patient in them was not sept ofi" by fever or cholera. 2. Bad Ventilation. Eeport of Sanitaky Commission. On entering the Hospital, the first thing that attracted our •I It ion was the defective state of the ventilation. !'xcepting a few small openings here and there, there were ■ans of renewing the atmosphere within the Hospital. Ji' large cubic space above the top of the ward windows always r Miied a considerable amount of hot and foul air for which was no escape. There was not even an open tire-place < ted witli the building, and the wards were heated by . the pipes of which passed through a small hole at the ; one of the w indows. feauitary Commission Report. 38 BAD VENTILATION. || " There was no communicatiou between the wards and con dors in the majority of instances, except by the doors, and hen. that free circulation and perflation of the atmosphere, so nece sary in military hospitals was impossible." i " The upper parts of the windows in the privies and in t] galleries connecting them with tlie corridors were at once i moved, so as to allow the emanations to escape into the exte' nal atmosphere." "The rooms are large and lofty, and have generally thr windows, much too small for their cubic contents, and the hea of these windows do not reach to within five or six feet of t ceiling. The window space in the corridors is considerable, a • the heads of the windows come up much closer to the ceilir The different flats of the building communicate by large rooi stone staircases. " To remedy the defective ventilation, the Commission : commended that the upper portion of the windows should in . cases be opened, and the current of air modified by the inserti: of perforated zinc plates, louvre boarding, or otherwise, tl adequate space for the escape of foul air should be provided near as possible to the ceiling of each ward, and that the stg - cases should be used for ventilating shafts by openings bei' made through their ceilings to the roof." The ventilation in the General Hospital was much 1 ; objectionable. " Both wards and corridors were used for the sick, but i ; disposable means of ventilation were such that the Hospil could hardly be said to be over-crowded." j Viz., March 6, 1855. P " Permanent and independent ventilating arrangements, ' perforated zinc panes in the windows and ventilating opemi ' at the ceilings, were directed to be introduced for the wai , the same as those for the Barrack Hospital. " The upper window sashes in the privies and galleries w ) directed to be removed, so as to prevent, as far as practical, efiluvia from entering the corridors. " The General Hospital, like the Barrack Hospital, is divii l longitudinally all round into wards and corridors; the wai BAD DRAINAGE. 89 f ing outwards, and the corridors facing towards the court-yard, lit it differs from the Barrack Hospital in one important par- tjular — namely, that the wards and corridors communicate not cly by the doors but by numerous large lofty windows in the cfision wall, so that by proper management of the windows, by introduction of perforated zinc panes, and by suitable ven- t^ting openings at the ceiling of each ward, a thorough venti- I ion could be at all times secured." 3. With regard to want of drainage^ so much has been Drainage gid, that a few extracts from the diary of the Sanitary (pmmission are all that is necessary, " "We found the whole of the Turkish sewerage belonging to ii Barrack Hospital in a defective condition. The sewers and (iins were badly formed, badly constructed, badly laid, and I I trapped. It may be here stated generally, that all the buildings used jj Hospitals were sewered. Turkish sewers are made of rubble- ipne, or coarse brickwork. The bottoms are flat, rough, and lieven ; there are no means of external ventilation, no means ir cleansing or flushing, and the ends or mouths of the sewers i| Scutari opened above the level of the sea, and were exposed 1 the action of the winds, which, in certain directions, blew |o the sewer- end, and carried the foul emanations from the <|posits within them through the pipe drains to the privies, J d thence into the corridors and wards where the sick were ]kced. It was stated to us that a change of wind had been 'iserved to be attended by an accession of fever cases from nong the sick, and that existing fever cases put on a more :igravated form. We found that the winds to which these -lilts were attributed blew in the direction of the open mouths the sewers. These sewers were, in fact, cesspools of the 1st dangerous description, through which, and through the livies, the wind forced sewer gases directly into the wards of ^0 Hospital. ■ The exhalations escaping through the defective walls and I vers of sewers, where they happened to pass close to or under- I'ath occupied rooms, could in some instances be distinctly '.served within the rooms, and there is reason to believe that 90 DRAINAGE AND SEWERAGE. fatal cases both of fever and cholera arose from this circu) stance among the inmates." " In order to diminish, as far as practicable, the injurio emanations proceeding from the sewers and privies, it w directed that the outfall sewers of the Hospital should be (, tended, and a canvas cover placed over their mouths to preve the wind driving the effluvia into the Hospital ; that thi openings for ventilation should be made in each main sew, between the Hospital and the outfall, w^ith a water-trap at ea, ventilator, and a man-hole for cleansing : water-tanks for flus ing the sewers were also directed to be placed immediat( outside the w^alls of tlie building. These tanks consisted hogsheads, each having a large wooden valve, covering a pi communicating with the head of each sewer. The insped was directed to see that these flushing tanks were filled wi water three times a day, and the valves opened by himself " All the privies, sewers, and drains, were directed to thoroughly cleansed, and their contents deodorized and remove It was further directed that peat charcoal should be freely us as a deodorizer for these purposes." " The privies of this large building (the General Hospit are situated in four square towers, built on the outside of i Hospital, instead of being within the square, as in the Barra Hospital. One of the towers is situated at each angle of i main building, and communicates with the interior by means ' a gallery opening into each corridor. The windows of tbi galleries were all closed at the time of our examination, and» the structure of the privies and the arrangement of the drains were essentially the same as in the Barrack Hospital, t effluvia entered the corridors, and could be easily detect within them at some distance from the doors. " This constituted the main sanitary defect of the Gene Hospital, but it was a very dangerous one, and neutralized, a great extent, the advantages possessed by the building." " On several occasions, both in the Barrack and other Hos tals, we saw the excreta of patients in utensils under the bei instead of having been at once removed." " The effluvia from the privies had free access to the corrido and added materially to the impurity of the air." | DRAINAGE AND SEWERAGE. 91 • The first step taken by the Commissiouers was to examine efully the outskirts of the Barrack Hospital, to ascertain \^|ether there were any external causes likely to affect the ppity of the surrounding atmosphere. 'The si;e of the Hospital, as already stated, is open and airy, rlooking the sea on two sides, and on a third side facing the oin country ; on the fourth side it is contiguous to one extremity Scutari, which, like all Turkish towns, we found to be in a bl sanitary condition. The paving was rough and badly laid, ;i I the channelling very defective. The surface in many places \^|s filthy, and had putrefying mud lying in hollows, and there wtre nuisances among the houses. The ravine to the south-east 0 1 lie Hospital, contained offensive deposit, which tainted the :i on that side of the building. There was some refuse, and ^ cral dead dogs lying close to the Hospital walls. • The surface of the inner square was uneven, badly formed, ii )erfectly drained, and very dirty. ' Four detached buildings within the court-yard, one at each al^le of the square, and communicating with the corridors, con- t ii the privies. These buildings open into each line of corri- (! s by two large doors, one on either side of the angle. By tis arrangement each corridor in the circuit of the building cinraunicates with the privies by eight doors. The privies ' isist merely of a marble slab with an opening communicating \ h a vertical pipe of red tile carried down into a drain at the 1 -craent of the building. The privies, and the galleries I ween them and the corridors, are lighted by a number of ^|fZed windows, which we found were all closed, so that there is a direct com.munication between the sewers, which were 1 tied with filth, and the corridors and wards of the Hospital." ■ The Turks, as it is known to those who have travelled in 1 East, are remarkably decorous in their habits, and the I ossaries on the side of these long Corridors were separated t 111 the Corridor by an ante-room ; the door leading into the I -room was not opposite to that which led to the neces- .s, so that it was impossible, even if the door had been ned, for anyone to obtain a view of those places. The i ks never use any paper, and therefore the soil-pipes were \ \ small ; but there were, as it is a part of their religion to House of Commons Committee Evidence. 92 DRAINAGE AND SEWERAGE. perform ablutions after using tliese necessaries, small taps the left-hand side. When the army was at the Barracks the summer, these taps were by the soldiers broken off, and consequence the supply of water was stopped. When t Barrack was re-opened as an Hospital, no sufficient pains Wd taken to repair those pipes, or secure a flow of water; and h pipes soon choked up; and the liquid fseces, the evacuatici from those afflicted with diarrhoea, filled up the pipes, floai. up over the floor, and came into the room in which the nec. saries were, extended and flowed into the ante-room, and wn more than an inch deep when I got there in the mornir; men suffering from diarrhoea, who liad no slippers at the ti i and no shoes on, as this flood of filth advanced, came less a. less near to the necessary, and nearer and nearer to the do , till at last I found them within a yard of the ante-roi performing the necessary functions of nature; and in €(■ sequence the smell from this place was such that I can use epithet to describe its horror." The hideous state of the privies too truly described this last extract^ which refers to the Barrack Hospit, continued there, more or less, up to March, 1855, which month it was still occasionally at once our crin and our punishment. A farther misery, and the cause of much disease, w in the autumn of 1854, the placing of tubs in those wai. farthest from the privies (in the absence of utensils), hold the excreta of from thirty to fifty patients, afflict with diarrhoea and dysentery; it is easy to imagine t consequence of this frightful nuisance, and it often becai Miss Nightingale^s duty to see these tubs removed a emptied by a couple of orderlies, who carried one on a p( between them. These tubs were, however, discontinued at a late peri of the winter of 1854-55. Sanitary " ^® directed the immediate removal of the excreta of t Report. sick out of the Hospital." DRAINAGE AND SEWERAGE. 93 This was, however, not done, not even to the last. \nd, again, we wish to allude to the fact, that in no ispital is there less discipline than in a military one. It inquestionable that there can be no safety for the sick, eliecially for cases of typhus and bowel disease, if their el'-reta are allowed to stand for twenty-four, nay^ even 1 Ive hours in the wards, excepting in the most perfectly cfistructed close stools, — perhaps not even then ; they o',dit to be carried immediately and instantly away and c [)ticd. V et it was found impossible, from first to last, to induce tl orderlies to do this more than once, as a practice, in tviity-four hours; should they have accomplished it t^ ce, they thought they had done wonders. I have seen a zealous Orderly Medical Officer when gpg his rounds, open every close-stool (when we had lf-c|se-stools) and, finding every one full, call up the jiollerly, and make him empty them. [ have heard the rule made over and over again, always t( empty them immediately ; but if Medical Officers, Siiitary Commissioners, Hospital Officers, think that it f "wls done, i. e. with any regularity or as a rule, they are n^taken. il, ||ind is it fair to ask Medical Officers, to see to these ifdiails of drudgery? My own belief, founded on much ji e verience, is, that it can only be effectually done by a ^\ nan ; it is done in the Civil Hospitals by her ; it has !) II done in Military ones by her. J |\.nd here, homely and sickening as is the subject, I n st pay my tribute to the instinctive delicacy, the ready ;i ution of orderlies and patients during all tjiat dreadful ')d; for my sake, they performed offices of this kind ich they neither would for the sake of discipline, nor f( that of the importance to their own health, which they 94 DRAINAGE AND SEWERAGE. did not know), and never one word nor one look which gentleman wonld not have used ; and, while paying tl humble tribute to humble courtesy, the tears come in my eyes as I think how, amidst scenes of horrible filth, loathsome disease and death, there rose above it all t] innate dignity, gentleness, and chivalry of the men (f never, surely, was chivalry so strikingly exemplified) shi ing in the midst of what must be considered as the lowt sinks of human misery, and preventing instinctively t use of one expression which could distress a gentlewoms I return to the point, viz, that if it is thought that d cipline in such matters as these is best enforced by Medi( Officers and Ward Masters, it is a mistake. The Medi( Officers should be strictly professional; the Ward Mast( should enforce every rule except what pertains to the he side of the patient; this last can only be done by wom(, not with their own hands, but by directing and traini; orderlies ; it is an humble prerogative which no one y I grudge them. And now I take leave of this disgusting subject, oi' adding that, if it sickens us to read it, it was far mo sickening to see it and go through with it, involving, asji did, disease and death to an unknown number of hva men. ^ Sanitary "Connected with this question of over-crowding, we ni Report. state, that we found a considerable portion of the Barr t Hospital in use as a Depot. We considered that the prase 3 of so many soldiers and other persons not necessary for 3 treatment of the sick, was a source of danger, from occupy ? cubic space within the building, and increasing the impuif of the air, from the defective privy drainage, of the tn of which opinion we had subsequently two striking confiri ■ tions. " All the Hospitals had a water supply. That for the Barr i Hospital was found to be hardly sufficient in amount for 3^ DRAINAGE AND SEWERAGE. 95 J'ge a number of sick. The water was not so pure as could 78 been desired, and it was received into tanks within the Irrack squure. • Speaking generally, we were of opinion that the walls of the jards and Corridors were not so clean as they might have kn. ■ There were false floors in the Wards, which had been used It sleeping berths for the Turkish soldiers, and wdiich had the llrlsteads of the sick placed on them. There were also box Hts along the walls of the Wards, for the use of the soldiers. (' were of opinion that there ought to have been no such I 1 ised spaces capable of collecting dirt and foul air within I • walls, and that it would have been advisable to have I iioved the whole of this useless woodwork before the sick ^ 10 put into the Wards, had there been time and means for (|ing so. ' We directed the frequent use of quicklime-wash for the p-pose of cleansing the walls and improving the atmosphere iithe Wards and Corridors. This we considered one of the l ist important sanitary precautions which could be adopted. perience has shown that all porous substances, such as the lister of walls and ceilings, and even woodwork, absorb the (Kinations proceeding from the bodies and breath of the sick. 'i(>r a time, the plaster becomes saturated with organic ijitter, and is a fresh source of impurity to the air of the Tard. It hence follows that unless the walls and ceilings ( Hospitals be constructed of absolutely non-absorbent nterials, it is necessary, at short intervals, to use some {plication capable of neutralizing or destroying the absorbed (j^anic matter. Of all known materials, quicklime wash is 1' > best and cheapest for this purpose. Its effect in freshen- i : the air in crowded wards and rooms is immediate, and it is ( 0 of the most efficacious agents for mitigating the virulence (i epidemic disease. ■ The following is a summary of the work done during the I iod of Mr. Wilson's inspectorship : — Hand-carts or large basketsful of filth removed 5,114 i Sewers and latrines flushed (times) . . . . 466 Carcases of animals buried . . . . . . 35 96 DRAINAGE AND SRWERAGE. Weekly Abstra^ct of Mii. Wilson's Diaries. Week ending March 24. *' Thirteen men, on an average, employed in cleansing tl surface of the ground in the vicinity of the Barrack Hospit and at Kulali, in removing the refuse, burying animals, Sl During the week there were collected and removed from t] vicinity of the Barrack Hospital 202 hand-carts or baskets fi, of filth, rubbish, and offensive matter. Two tons of filth we removed at Kulali. The carcases of 15 dogs and 2 hors were buried, and the sewers of the Barrack Hospital we flushed three times. WeeTc ending March 31. " The cleansing operations were extended to the Glenei Hospital and Palace Hospital this week. The number of dk employed was 20 on the average. The ground about bo Hospitals, and that portion of the village nearest the Barra Hospital was swept clean. A large sewer within the barra square was opened, by order of the Commissioners, ai 42 hand-carts of filth removed from it. The sewers connect with the privies were opened and cleansed, and 26 hand-cai of filth removed from them. A sewer at the Greneral Hospi was also opened and cleansed, and 14 hand-carts of filth W6 removed from it. Water was carried to the flushing tan] and the sewers at the Barrack Hospital were flushed ninete times in the course of the week. The total filth and reft removed from the vicinity of Barrack, General, and Pala Hospitals during this week, was 354 hand-carts or baskets fi and the carcases of 7 dead animals were buried. Peat charc( was used in the cleansing operations. Week ending April 7. " The ground about the Barrack, General, and Pala Hospitals was swept as usual, also part of the village Scutari ; an offensive sewer at the Barrack Hospital cleansed. The average number of men employed during t week was 25. There were 297 hand-carts or baskets f of filth removed. Water was carried to the flushing tan and the sew^ers and privies at the Barrack Hospital w( WANT or CLEANLINESS. 97 lu|o(l twcntv-one times. The Hospital at Kukli wnn n5 3ctcd. Peat charcoal was used for deodorizing the privies, rh ground round the Hospital was cleansed and the privies luJed. Week ending April 14. 'iPhe average number of men employed this week was 20. ["hi ground about the Hospitals was swept as usual, and il^lhand-carts or baskets full of filth were removed. Water ra carried to the flushing tanks, and the sewers at the ack Hospital were flushed nineteen times during the . The carcases of 2 horses, a cow, and 4 dogs were Mild. Week ending April 21. ' H)veral large foul sewers were opened at the Barrack lo )ital by order of the Commissioners ; peat charcoal was pf ed to deodorize their contents, and above 100 hand-carts f th were removed from them. The ground around all the lol)itals was cleansed. The filth and refuse collected and ^nved during the week, amounted to 417 hand-carts or IS Is full. Water was carried to the flushing tanks, and the u s and privies at the Barrack Hospital were flushed out V( Ly-four times. Peat charcoal was applied to the privies (' (lay. A dead horse was buried. The average number II employed during the week was 26. iinilar cleansing works were carried out during the two I* I t ling weeks." i We come now to the fourth cause of our disaster at 4. Want of Cleanliness. I ri — want OI cleanliness. Deficiency in ( The Washing: 1 . SmitVs evidence upon the subject is as follows, in V< r to the question — 1. "Then the state of things which has been described, A.Smith, Esq., sence of washing and so on, occurred while Mr. Wreford 26^1ai-ch ere? — I must say that there was not an absence of 1855. ig. Not long ago I called upon him to show me what Ls no- had been done, and he sent me home a return, show- 98 EXTREME DEFICIEXCY ing the washing that had been done for three months by n- tract, and the number of articles washed was very large ; ut I must say it was not what I considered sufficient for so Ue a hospital. 8854 "Did you observe whether that return included he early part of November? — I will ask permission to put he return in as evidence. I feel convinced that it did applto that time ; but it was done by contract, not in the hospita"i . . . I was perfectly aware that females can see nny things, in which there might be a deficiency of cleanliness Qd comfort, that men do not see, and even that men have ot time to see; because the medical officers w^ere overwheled with work — there might be a spot upon a sheet that a me ^al officer would not notice, and a woman would at once. 9504. "You thought that the hospitals were in that ^sat state of cleanliness, that it would require the delicacy a woman to find out the least dirt in the hospital ? — I do nol ay that. 9505. You spoke of a spot on a sheet ? — I put that fan example. I spoke figuratively, and that a female would n ce that when a man would not. 9506. You thought that there was no dirt or filth in be hospitals that would be readily noticed by men, and that 1 ire would on that account be an advantage in women going > t ? — I had no reason, from any communications that I ad received, to believe that there was that state of filth ir he hospital that it would be readily noticed." In order now to form an idea of what Dr. Smith n- siders as a " very large number of articles washed/^ is, of course, necessary to compare them with the numb< of men washed for. A Return is annexed. " Returns showing the total number of sick and wou ed treated in the hospital at Scutari : Months. Total treai During November, 1854 16,846 „ December, 1854 19,479 „ January, 1855 23,076 A. Smith, M.D. D,-Gener " 13, St. James's-place, 29th March, 1855." ! J IN WASHING. 99 The number of sick treated, although manilestly iilorrect, is taken from Dr. Smithes return, Sevastopol (Jmmittee, 2nd Report, p. 705, where it accompanies til number of articles washed, in the same return, alarently for the purpose of comparison, and the result iJis follows, viz., that, in the month of January, when 2000 men were treated in hospital at Scutari, I 11,600 shirts, I 10,600 sheets, I 9,200 blankets. e considered to be a " very large number of articles hed" for them, or 1 shirt to each 2 men, and less than leet and 1 blanket to each 2 men. Phe total number of pieces washed is 51,000, or rather than 2i articles per man. et this is the month in which the washing reaches the dmum of the three months under consideration. it the same time, it is necessary to mention that the limjithly " numbers of sick returned as treated in the pitals at Scutari," are the same as the monthly numbers he return representing not the sick treated in the pitals at Scutari," but the " total sick of Lord lan^s Army." et us now take the evidence of the Cumming-Maxwell iiiH % •h !i eiRJort :— iimediately connected with the subject of hospital fur- Gumming ■ and clothing is the provision which has been made for "Report^ wishing, both of bedding and personal clothing. This, we irijof opinion, has not been satisfactory. At the General j^5jpital, indeed, eight or ten Armenians are employed for Hit purpose, and we have heard no complaints from the men , except that they frequently get the shirt of another id of their own from the wash ; and this we may observe es a greater evil than the mere loss of property. The H 2 100 EXTREME DEFICIENCY washing is effected without boiling, and without this proco it is impossible to get rid of animal matter. Under m circumstances the exchange complained of is peculiarly obji. tionable. The washing of the bed linen is very badly dci there, the sheets which return from the wash being frequent found in a more filthy condition than those which they n intended to replace. " From the following table, which has been furnished tos by the purveyor, it will be seen that 7,824 shirts were wasli at that hospital during the month of January, which gives o every man about two shirts per week. The number washect the Barrack Hospital during the same period was only 8,81 ; and as the average number of patients in that build ^ exceeded in January 2,200, all the men did not even get (e shirt in a fortnight from the public washing establishment.' I I IN WASHING. 101 lI'UBN of Articles of Bedding, &c., belonging to the Genekal and Barrack Hospitals, washed by the Contractors, &c., during the Month of January. Scutari, February 8, 1855. I Palliasses Bolsters Blankets Rugs Sheets Turkish Beds Turkish Pillows .... Turkish Coverlets . . . Turkish Sheets . . . . . Great Coats Gowns, H. P Waistcoats, H. P. . . . Trowsers, H. P Shirts Drawers Coatees Bandages Hair Beds , Hair Pillows , Flock Beds Flock Pillows Haversacks Towels Regimental Trowsers Pairs of Stockings. . , Pairs of Socks . . . . Nightcaps , Fine Sheets Turkish Gowns Pads Ship Mattresses , . . . , Turkish Curtains . . . Handkerchiefs Total Pieces . . . General Hospital. 1,324 215 3,254 266 4,844 172 397 7,824 1,-47 7, 24 28,033 Barrack Hospital. 1,417 1,068 5,984 1,371 5,797 11 2 26 23 367 329 189 322 3,837 193 685 811 86 28 40 44 121 85 182 261 97 4 2 7 7 2 2 23,402 Total. 2,741 1,238 9,238 1,637 10,641 11 2 26 195 367 644 440 719 11,661 193 685 811 86 28 40 44 121 1,432 182 7,824 261 97 4 2 7 7 2 2 51,435 (Signed) Selkirk Stuart, Purveyor to the Forces. t is thus to be deduced from the above, that the defici- y of washing in the Barrack Hospital was much more allrming than at first appears. Because the articles Wihed for the Barrack Hospital were 23,400, for the G leral Hospital, 28,000, w^hereas the average of Patients ii^he General Hospital was under 1,000, in the Barrack I^ispital over 2,200. 104 EXTREME J)EFICIENCY Cumminj; " The washing at the Barrack is done by contract, and noi' ^^^^^^oH^ only is the quantity washed in general insufficient, but th( ^^^^ * washing is very inadequately performed; Miss NightingaL states, in her evidence in February, that she had seei ' blankets come back from the wash torn and covered witl stains.' She added, that she had herself ' sorted these blanket when taking in sick, and been compelled to throw away thi so-called clean blankets till they could be carried away an destroyed.' Mr. Stuart gave us a similar description of th washing at an earlier period. We must add, that we hear of some shirts having been brought into the wards on or occasion as clean, which were found on examination with li( upon them ; and Dr. Calder states in his evidence the san thing with respect to blankets. " With the view of meeting to some extent the want proper washing. Miss Nightingale established a wash-house ( the 30th TsTovember, which was provided w^ith boilers, part from the engineer office, partly from her own resources. T average number of articles washed weekly at that estabhs ment during the month of January was 500 shirts and 1 other articles ; but these figures, like the other returns whi we obtained from the same quarter, do not indicate the who extent of the evil sought to be remedied. We are glad state, however, that washing, wringing, and drying machiii have arrived from England, for the purpose of doing all i s washing of these establishments." Il Yet, after all this reporting, the Chief Commissioi ' being himself Inspector- General at Scutari, the estabhs- ment here promised, with its machines , did not come ii) operation till May 1, 1855. Dr. Caldcr's " • • - In the first instance — indeed, till a comparati^'f Evidence. recent date, I had no sheets ; even blankets were scarce. I had frequently difficulty in procuring them, the men of a requiring a change — such as were bleeding, or with profe discharge. When I asked for blankets, I was told none v^e to be had, in consequence of difficulty of getting them wasH- !Kugs were in want also, but not to the same extent. If e IN WASHING. 105 s Evidence. hi blankets we did not care so much for rugs. In more than 0 ' instance I had to send them back because they were filled h lice. These were isolated cases, and by no means general. 1 ngs were generally clean. ' For a few days I had considerable difficulty in getting pital utensils, especially bed-pans. This was especially felt he case of men with stumps or fractures." 13104. In going through the Hospital, did you notice the Commissioner dition of the linen of the patients ? — Yes. Maxwel L3105. AVhat state was it in ? — When I first arrived there, I ound the men constantly without linen at all. I found tini constantly without sheets, and I found them constantly A\ !i shirts of the very filthiest description ; and I thought it SI niportant a matter to look into, that one of the very first |) its to which we addressed ourselves was to ascertain what hi been done for the washing of the hospital. ' 13106. What did you find had been done in that respect ? iV e found that in the Greneral Hospital the washing was le by a party of Armenians, eight or ten in number. There 'i a wash-house there, supplied with troughs, and the wash- ii , as far as quantity was concerned, I never heard a corn- pant of. The men got their two shirts a week, but I fiQuently heard them complain that they did not get their Ola shirts. There was great confusion, and a man who sent h\ shirt to the wash was never sure of getting it sent back ; iJurally, therefore, those who had shirts were very often mely reluctant to part with them. I have been told of r cated instances (though I never found it myself), of four oliive shirts having been found under the pillow of a patient, ' luse he was afraid that if they went to the wash, they 1 iT would come back, or that he would get others. In r )ect to the Barrack Hospital, I found that the purveyor, 8!)rtly after that establishment was set on foot, had entered i !o a contract with an Italian, or Levantine, of the name of (itone ; in that respect, I think, following the regulations wit have been referred to : but that contract was broken r)eatedly. ■ 13107. How was it broken ? — The man did not wash the iiugs, so the purveyor assured me. When I first examined 106 EXTREME DEFICIENCY the purveyor, he told me that he was then about to enter inj a contract with another contractor ; and when I left, the was ing of the Barrack Hospital, so far as it is done (I do not s;. that it is well done, very far from it), is done by those t\ contractors, Ottone, and a gentleman of the name of Parry. "13109. A\^hat was about the average number (viz., ' Patients in Hospital) ?— In the Barrack Hospital, in the we ending the 4th of November, there were 1,500 patients ; the week ending the 11th, there were 2,062. On Novemh the 18th, there were 1,958; and on the 25th of Novemk there were 2,183. I think that shows the average sufficient! " 13112. Speaking generally, wdiat should you say was t condition of the men with regard to their linen in the t^ Hospitals ? — G-enerally speaking, I should say that they wt in a very unsatisfactory condition. "13113. Including linen sheets as well as their shirts? Yes. The washing has been very badly done throughc, simply for this reason, that they do not understand boili- clothes out there, and in order to get rid of animal matter,, is indispensable, so I am assured, that the clothes should : boiled. In the next place, the men came down sometiir. with vermin, and the vermin could not be got rid of unless t) clothes were boiled. There have been cases in which shi i have been brought back from the wash with vermin ; one v; mentioned to me in conversation, of about a dozen shii, I think, that were brought back into the wards of the Hospi ': with vermin upon them, although they professed to be clean Mr. Stafford's ''7590. In what state were the clothes of those men?- Evidence. rpj^g clothes of those men were swarming with lice, as thicks the letters on a page of print ; and when I have been undre • ing the men, to put them to bed, when they had not streng. to undress themselves, they have asked me not to come nr them, knowing the state in which they w^ere. My own cloth were never free wlien I was in the Hospital." IN WASHING. 107 JSTRACT of Weekly States of Sick and Wounded from October 1 to January 31. Officers. Date. 'a itted. r6 pn M ained. 1 ained. itted. tc 2 r2 CJ "~ s a H ci ■<. 1854 — — 1 7 October 70 3 1 72 61 403 67 1,868 8 14 „ 72 23 9 2 84 1,868 307 295 46 1,834 11 o21 „ 84 12 20 76 1,834 386 151 29 2,040 2i D 28 „ 76 8 47 37 2,040 350 370 56 1,964 2i 'ct. to4 Nov. 37 11 2 1 45 1,964 952 384 52 2,480 5 11 45 34 10 69 2,480 850 469 36 2,825 r. 0 18 69 49 4 3 111 2,825 1,045 557 94 3,219 11 0 25 111 9 102 3,219 438 144 67 3,446 2( 0 2 Dec. . . 102 10 5 107 3,446 436 315 70 3.497 3 9 „ 107 12 95 3,497 263 388 70 3,302 11 0 16 „ 95 8 1 86 3,302 299 521 85 2,995 i: 0 23 „ 86 2 1 83 2,995 1,321 402 130 3,784 2' 0 30 „ 83 1 35 1 48 3,784 ],091 770 108 3,997 1855 3 )ec. to 6 Jan. 48 16 6 1 55 3,997 1,044 367 249 4,425 7 m. to 13 „ 55 18 13 60 4,425 727 444 277 4,431 1' o20 60 16 8 ' 1 67 4,431 667 346 270 4,482 2: 0 27 67 29 30 1 65 4,482 1,243 984 274 4,467 21 0 31 65 29 16 78 4,467 619 127 165 4,794 Men. R. W. Lawson, Dy. I. Gen., P. M. O. rincipal Medical Ofiicer's Office, Scutari, February 1, 1855. > pon all this evidence, it is to be observed that, whereas tt; great deficiency in washing chiefly relates to the Bar- r k Hospital, the total admissions are not given with ij.ard to that Hospital separately. It is obvious, upon a fl ment's reflection, that the " average weekly number^' of plients, although a fair way of judging in matters which r cr to consumption, cubic feet of space, &c., does not g e a fair statement with regard to washing ; since a man d 3S not eat or breathe in hospital after he is dead or dis- cirged, but his dirty shirt or sheet, it is to be presumed, is act to be worn or used by his successor. And when the 108 STATE OF FLOORS, II state of the blankets and shirts, if any there were, of I3 men entering Scutari Hospitals from the Crimea, s remembered, too filthy for description, it is not to be si- posed that the men were intended to be left in these. " Two shirts per week'' is a fair average per bed, if t t bed be occupied by one inmate, but how, if it should e successively occupied by three or four in one week ? Yet the number of shirts washed for the Barru Hospital in November, 1854, was 6 per month, for 13 whole of the Patients ; of total pieces of all kinds, 4,8c ; the average number of patients being 2,000 afr November 9. Miss Nightingale never succeeded in washing more th 2,000 shirts per month in her small subsidiary washi^ establishment, a miserable number, even as a subsidia , for so many. But it was intended to supplement e Barrack Hospital washing only, that of the General H- pital being, as has been stated, tolerably sufficient. Filthy state of (2) Another evil, less apparent, but no less deadly, is Floors,Walls, ^j^^ ^^^^^ ^ ^^^1^^ ceilings of the Wards d ana (Jeilmgs. ' '^^ Corridors. The former were, in many cases, so much 1 1 of repair, that it was impossible to keep them clean, 'je wooden divans raised round some of the Wards in e Barack Hospitals, on which the men were laid on thr mattresses, were receptacles of filth underneath, and we a hiding place for rats, the smell of which was abominab. The walls were saturated with organic matter, from 13 long continuance of patients with Hospital gangre , typhus fever, and every worst kind of Hospital dise3 within them; and lime-washing was very imperfecj^ practised till the spring of 1855, at first not at . Bugs, lice, and fleas, were inexterminable. The menw 3 allowed to bring in their blankets with them from 13 Crimea till February, 1855, which were unavoida/ WALLS, AND CEILINGS. 109 co'|red with vermin^ as there was no possibility of washing in jie camp. 3t Dr. Smith says in evidence : ] have no proof, beyond Mr. Stafford's opinion, that disease wail3aused by any thing in the Hospitals." ud Mr. Wreford, Purveyor- General, writes to Dr. SDj:h, February 12, 1855 :— ' L^he necessity for a subsidiary washing establishment has ne r been made apparent to me." ad not the matter been too destructive of life, health, HKxlity, and discipline, to be fit subject for a joke, one we d be tempted to think that one authority at least had L in jest when he said that the use of the Female ses going out was to see a spot upon a sheet." At th; time, sheets were not, at least such as could be used. ) With regard to the personal cleanliness of the men. Personal It IS been said elsewhere both how eager they were for it, an how impossible it was for them to attain it. may be added here, in confirmation, that the sum of towels washed by the Purveyor during the three ths of November, December, 1854, and January, ), for the Barrack Hospital, containing in those ths 2,000-2,400 patients, was 132 ! and that no basins or )ap were provided officially. Nor are either towels or bajis to this day provided sufficiently in the British Mjtary Hospitals, the men and Doctors being still ex,!cted to bring in their own, except one basin and one ia( -towel to each ward. The stone-floored lavatories on tti ; round floor are still all that exists in our Military H|pitals.^ u Barracks, till lately, the pump and the urine tubs were all that 401 rs had to wash in ; some insufficient lavatories have been now, I tieve, provided for the men in some Barracks. 110 DEFICIENCY OF MEANS One of the first purchases made by Miss Nightingale, a her arrival, was 200 Turkish towels at Constantino];!. These were accidentally delivered at the Purveyor's Of e at the General Hospital, and put into use by him am(g the patients there. She was of course too glad that t.s should be done among the patients anywhere, as the sll greater want in the Barrack Hospital could be suppliedu the same manner. She therefore never reclaimed thd, and they were incorporated as Purveyor's stores. But it might be as well to notice what, so late as F). ruary 1855, was the Return of Purveyor's Stores in usdt the Barrack Hospital, a time when the patients avera:d 2,043. 194 towels. No basins. 14 baths. Eetden of Pueveyor's Stores in use at the Barrack Hospita Scutari. Articles. Palliasses Bolsters Blankets Sheets Eugs. Boards Tressels Gowns Trowsers Waistcoats Towels , Stockings , Tin plates Knives and forks Spoons Chamber-pots . . Close stools .... Bed-pans Urinals Tubs Baths No. of each. 2,894 3,338 4,956 4,490 4,300 7,18.5 4,551 2,120 1,958 1,540 194 1,072 1,110 674 233 992 276 204 36 19 14 Remarks. A certain number of art e8 of bedding, dresses, towels c. at the wash, are not i3iclud( in the numbers stated in this e- turn, although it may be id they are in use at this hosf tl, being required to keep the t ig working, and supplying cm linen, &c. Barrack Hospital, Scutari, February 12, 1855. Selkirk Stuart, Purveyor to the Fo s. FOR PERSONAL CLEANLINESS. Ill . Wc have only one thing more to notice, as the fifth Want of cahe of the mortality at Scutari ; and that is the want of Comforts. Hjpital comforts. 'his has been denied, will be denied again; a few official r( )rds are therefore annexed. I .) Bad cookery. The evidence annexed is that of Bad Cooking. ,C|imissioner Maxwell : — 'lYith respect to the kitchen, I may state, that in the lowest P. B.Maxwell, fl( ' of the Barrack Hospital there is a kitchen which is only "^j^^^j^ u?l for a depot ; the Hospital has nothing to do with it. In 1855. th quadrangle there are two kitchens of considerable dimen- ,si( S, one of which is used, and the other has never been fitted Uf owing to some difficulty in getting coppers. 13092. Chairman.] Was there any difficulty in getting coers in Constantinople ? — I do not say there was any diflQ- icuiy ; I inquired why it was not so employed, and the answer 1 the engineer's department was that there was some diffi- Y in getting coppers. 13093. Mr. Layard.] Did you ever go into the bazaars at stantinople ? — Yes, often. 13094. Did 3^ou never see any large coppers there? — I lot say that I did ; I may have seen them. 13095. Do you not know that in every Turkish house there large coppers ? — They all cook in them. The other kitchen , wi fitted up as a Turkish kitchen, and was supplied with IB 'Ccber boilers, containing about 56 gallons each. 18096. AVas that enough for the wants of that large Hos- For cooking the ordinary diets it was, but for cooking < it was not enough. It was not at all adapted for cooking To do that there were, I think, three or four supple- ii! tary kitchens attached to the Hospital; four supplementary ki hens have been constructed since we arrived there. 13097. Chairman.] Had you any evidence while you were tb e of irregularity in cooking the food of the patients ? — rj, I noticed that myself. \ 13098. What did the irregularity arise from ? — I think it IT 1^ from a radically wrong system in the issuing and distribu- if the food. 112 WANT OF HOSPITAL COiMFORTS. " J 3099. You thought that the system was wrong ? — Uttcy wrong, as it seemed to me. " 13100. In what respect ? — In issuing the provisions for 3 different meals to the orderlies, and giving it to them to 3 carried out. The meat was taken, for example, raw to the ],. chen by the orderlies, and there it was cooked ; then the ore lies came back for it, and they had to carry it back to the wa s and cut it up ; all depended upon those orderlies. If the C(.. mittee will allow me, I will give a full account of it. "13101. Did you observe that the food was not sufficieiy dressed ? — Sometimes it w^as done to rags, and sometimeut was insufficiently dressed. " 13102. Then do you attribute that to the system ?"— Is. "13103. How? — I had better explain what the systems. The diets, ordinary and extra, are issued and distributed! the Barrack Hospital in the following manner, according to le evidence of Clifford, the steward ; Hill, the cook ; and Jenni s, an orderly, whom we examined upon the subject. The Medal Officer prescribes daily in his morning visit the diet and arti is of medical comfort which he thinks suitable for each pat it for the following day. This diet-roll is, as we have already b- served, submitted to the Surgeon of the division, who re\3s and returns it to the ward-master, in w^hose custody ifc rem is until the following morning. At 61 a. m. an orderly from mess, which consists of about 25 men, attends at the purvej 's store with his diet-roll, and produces it to the steward, 10 delivers the quantity of bread required for breakfast, and ahe same time makes a memorandum in his book of the numb(of full, half, low, spoon, and milk diets on the diet-roll.' .at takes up a considerable time, and it is an inconvenient mount for the steward to make those returns when he is actualljn- gaged in dealing out the bread. ' This is done because the 1 3k containing the diet-roll is not available after breakfast, heir in use for marking the diets for the next day. As the numb iof orderlies thus engaged is necessarily considerable, an hor;Or an hour and a half is employed in this manner. The brea is delivered, not in portions, but in loaves. The tea is obtaed by another, or sometimes the same, orderly from the kitc^- As soon as breakfast is concluded, that is, between 9 and 10 ; a., BAD COOKERY. 113 th(j»rderlj returns to tlie store, and obtains from the steward jroper quantity of meat (which is weighed and delivered to raw, and in bulk), bread and salt for dinner. This process ^esthe time of the steward till 12|^ p. m., or even later. The 'ly carries the meat to the kitchen, ties it up, puts a skewer igh it, and marks it with a tally, for the purpose of distin- ling it from the numerous other messes to be boiled in the copper. The men arrive at the kitchen for this purpose, ow succession, from about 10^ to 1^ p. m.' How can )ne expect regularity, or that the dinner can be properly 3d ? * While the ordinary diets are in process of cooking, the rderly goes to his ward, and as soon as the Medical Officer haf inished his round, and no longer needs the book in which th6|iiet-rolls are bound up, takes that document, and returns I to the steward, from whom he now obtains the due allow- of porter, which he forthwith distributes ; he then returns more, and obtains the other articles of extra diet, such as :ens, wme, lemons, eggs, arrowroot, sago, brandy, &c. By itime the dinner is cooked; and notwithstanding the tallies, anchebest efforts of the cook to see that the messes are issued fai]|', mistakes occur, and the diets of one ward are sometimes fcakli to another. According to the evidence of John Hill, the 80c|. the distribution of this meal, including soup, occupies an hoi and a half. The orderly carries up the dinner on a round *V0 en tray, which he places on the floor, and then divides the me into as many portions, assigning to each its due allow- iiM of bone, as there are patients. To eat this meat the men iirejut imperfectly supplied with plates, knives, and forks ; as Joc as it is concluded the orderly goes for the extras which ia\ been prescribed for the more weakly patients. They are aovprepared by the cooks attached to the extra-diet kitchens; :)u1i'efbre these were opened they used to be cooked by the )r(l lies themselves, sometimes m the kitchen coppers, but no commonly in their own tin canteens, and either in the 1"! , or in some of the sheds in the barrack square, and not ml ([uently in the stoves of the wards,' where I have found " constantly cooking. ' When the articles in question oked the orderly delivers to each patient all the extras >iv ribed for him for the day, without regard as to whether 1 114 BAD ARRANGEMENTS the food is to be administered at one or several times; li tlien cooks his own dinner, and afterwards gets the tea of h mess' This is the account which I have to give." In speaking of the distribution of food, it is necessary t make one last remark on the want of discipline in Mihtai Hospitals. At Scutari^ the food came up in messes to each wan there to be divided either by the Orderly, or more often 1 the patients themselves. The practice was various. Som«i times the Orderly divided it upon his own bed, and tl patients all ate it on theirs. The table in the ward, whf i one had begun to exist there, was generally covered, ar the patients therefore rarely, if ever, dined there. In the Barrack Hospital, it was at last attained, th'j convalescents should dine at a table in the corridors. In one of the other General Hospitals, the Orderlies ai Wardmasters, after they had brought up the patieni' dinners, retired to eat their own. Many zealous Orderi Medical Officers always made a point of being present i the patients' meals, and seeing them properly distribute ' and properly eaten at the table, if the patient were able > leave his bed, instead of on his bed. But this vv^as nev done as a rule even at that Hospital, without the inte vention of the Medical Officer. , The meat is and always must be cold, before it is servi'r to the Patients, both at the War Hospitals and at tho Army Hospitals at home, which I have seen. For the •are no means of keeping it warm. I would suggest the following : — vt That it should be always divided in the kitchen, wbi Is. Every man is examiucd before he goes to tlie Crimea 'J' nie, but not when he comes out of hospital. We endeavour 118 EVIDENCE AS TO to complete the outfits as mucli as we cau. This is done par ' out of commissariat stores and dead men's effects. In the saiis way we give the red coatees of dead men. We want a quartermaster's establishment, — a large st(» with necessaries of all kinds. The complication of accouii with so many soldiers of different regiments requires a lai) staff. In a regiment, a soldier who wants anything is suppM by his captain, who inspects him and draws the article wan1;l from the quartermaster's stores. Here we have no oificer discharges the duty of a captain." The want of shirts, and indeed of almost all clothing, i the part of the men^ being here proved beyond the pes- bility of dispute by the statement of almost every offici, — in General Airey^s short and pithy words, " the Ari^ was almost without clothes/^ — let us see what was I3 "enormous supply'^ which, ?tS Commissioner Max\\l truly states, " co-existed with constant complaints of 13 want of the articles in question." According to Dr. Lawson, the number of Admissio , Oct. 28, 1854, to Jan. 31, 1855, was 10,995. The number of shirts issued from the Quartermast- General's store was, up to 15th February, 4,387, a num r equal to the men discharged from Hospital betwci December 5, the period when these issues commenced, ) to January 31, viz., 4,349, The Purveyor states that he issued from October 1 ) February 15, 11,234 shirts, of which he says 2,500 w 3 dcUvered to Miss Nightingale. Now, 800 only were d(- vered to her, as appears by the Extract from the Cummii'- Maxwell Kepori, p. 356. The 2,500 she indeed mr. requisition for, but 800 only were received, because e rest were not forthcoming. Another example of the fallif of requisitions as vouchers for receipt, although thercs not the shadow of a suspicion of any dishonesty. WANT OF SHIllTS. 119 I he H()0 appear again in Miss Nightingale's schedule ; 1 i cfore deducting from 11,234 2,500 8,734 remain. Miss Nightingale issued from November 10, 1851, up I February 15, 1855, — 10,537 cotton shirts G,823 flannel shirts 17,360 (' which 400 and 400 respectively were, as just stated, |ini Purveyor's store, deducting which, the issue from llr own stores was 10,500. ■Therefore, to 11,000 men admitted into Hospital were 1 ued — SniKTS. 4,387 from Quartermaster-General 8,73 i from Purveyor 800 ditto, through Miss Nightingale 13,1)*21, or little more tlian \\ shirt to each man. I p to December 4, it appears that the nundjcr found in 1 u'uts' knapsacks was 22 ! Purely, in Miss Nightingale's issues of 16,560 shirts iioual, there can be found nothing extravagant or 1 iiueessary, but, on the contrary, they must be thought t5.;u insulficicnt. For no mention is here made of the * MO men in Hospital on Oct. 28, 1854, or of the Admis- ^ after Jan. 31, 1855, or of the great want of washing, li, of course, made a gi-eater sujjply of linen ncces- 120 EVIDENCE AS TO Gumming Maxwell Report, p. 273. CumminjET Maxwell Keport, p. 273. Number of Shirts found in Patients' Knapsacks that a deposited in the Pack Store of the Barrack Hospital \ Scutari. , Twenty-two. Selkirk Stuart, 4!th December, 1854. Purveyor to the Fore Return of the Kumber of Shirts issued from the Purveyor's Stores the General Hospital and Barrack Hospital at Scutari, from , October, 1854 to 16th February, 1855. ack lai. iss gale. Issued. To Gene Hospit; To Barr Hospi To Kulu To Haidar P To M Nightin; Total. Remarks. From Store at General 4,203 512 1,000 5,715 From Store at Barrack Hospital 3,019 558 442 1,500 5,519 Totals issued 4,203 3,019 558 954 2,500 11,234 Barrack Hospital, Scutari, 22nd February, 1855. Selkirk Stuart, Purveyor to the For Gumming Maxwell Report, p. 274, Account of Clothing received into Quartermaster's Stores at Scut. Date. 1854 Dec. 5 16 1855, Jan. 14 Feb Total 589 3,588 3,092 2,000 9.269 1,173 1,817 1,000 4,000 7.990 4,628 4,597 2,081 11,306 4,086 4,086 600 600 1,600 360 1,960 Received from Consi- tinople, purchased y Captain Wetherall. From Quartermaster > neral. Purchased by order|)f Lord William Paul From Constantin( e, purchased by Cap " Wetherall. Purchased by orde )f Lord William Paul From Quarterraaste General. r WANT OF SHIRTS. 121 the above clothing there has been served out to the men of the General DepOt, and to invalids proceeding to England, since the 5th December, as follows : — [•hirts Drawers. Socks. Mitts. Trowscrs. Boots. Blankets. 4,887 3,088 6,703 1,500 300 1,930 1,530 Uari, I5th February, 1855. Jasper Hall, Captain 4th K.O. Refjiment, Qr. Mr. The Store was established when the first articles of clothing Tu received, viz., on tlie 5th December, 185-1;, as above. Jasper Hall, Captain, 4:th Refjiment^ Qr. Mr. With regard to all kinds of utensils, that there was a eat want of these cannot now be denied, for it is proved I' the Requisitions of the Medical Officers, an abstract of [lich is given, p. 149. A very insufficient Requisition for ch was made upon the Ambassador, which was very sufficiently replied to. Some further extracts are given, to establish not only ^e want of stores, but the great defect of system in issuing id receiving them, at Scutari. It will be proved — 1. That the system of Requisitions is a vicious one. f |2. That there was a great want of store-room, and of all Invenience for landing stores. 1. Tliat the system of Requisitions is a vicious one . The Cumming ^Maxwell Report says — I" In support of the practice of ist;uing upon requisition, it is lid that thosc^ documents are necessary, or at h^ast convenient, * vouchers to prove that the articles mentioned in them have t*en supplied ; but we think that in this respect their value is lorthless, because it must constantly be optional with the pur- ?yor or clei-k ivceiviujj; the rr(jui>ition whether he shall or uol Bad Effects of the System of llo(|uisitions. Cumming Maxwell Keport. ] 22 BAD EFFECTS OF THE draw his peD or pencil through those articles which he is una 5 to supplv. In this respect a receipt by the recipient after article has been furnished is of far superior value and We think it right, after making this observation, to add, t we have not the slightest ground for suspecting that any sib fraud as we have alluded to as of possible occurrence, has e i been attempted ; but, in pointing out the evils of the systv. we do not think it right to omit all notice of such a defect s this. For the reasons above set forth, we think that e practice of issuing on requisition is ^'icious, and should e limited as much as possible." It is vicious both ways, for that which it has nott pretends to supply, and that which it has, it does t supply. Cnmming " From the neglect to file those requisitions which e Eepon!^ altogether rejected, coupled with the practice of never issu? articles except upon written demands, it sometimes happ<5, that while wards are in want of articles, a quantity of thesi 8 Iving in store, and might be had upon application. We fo d this to be the case on more than one occasion in the cours »f our inquiry. The following instance may be mentioned. It 1 v be seen, upon reference to the hst of furniture in the purvey 8 store on 31st January, wliich will be found below, that tl e were on that day a number of boards and trestles in store, and t, upon iDquiring, a few days later, we ascertained that there still wanting in the Barrack Hospital alone 2S9 bedsteads, ' 142 in the first division, 87 in the second, and 60 in the thirc 0 complete its furniture ; while in Haidar Pasha a consid number of patients was still unsupplied. " It is not to be inferred that the surgeons neglect to the wants of their wards kno':vn. This state of things i result of the omission to make a note or memorandum, wh requisition is not answered, of the article demanded, and of person demanding it — an omission which leaves the p" without the means of furnishing the goods when his s replenished, but compels him to wait for a fresh requi We have been assured that steps ar^ taken to give due of the arrival of goods which have been in demand ; but SYSTEM OF REQUISITION. 123 \n 've that those steps have been very ineffectual. We have lb.id that surgeons whose requisitions were not complied with wi u they were made, have remained long in ignorance that thr demands might be supplied if repeated. On the other k l, the refusal which they have met becomes generally kivvn, and requisitions for the article in question cease to be mte. We believe that many deficiences which have been at di^rent times observed in the furniture of the wards is to be at ibuted to the practice of issuing only upon requisition, and tone neglect to supply at a subsequent time those requisitions wl.'h were not immediately answered. :. That there was a great want of store-room, and of Want of Store- tk necessary conveniences for landing stores, owing to the d( 3ndence of Purveyor upon Commissariat. Decemher 25th. Me. Weefobd. Dr. Menzies showed me a letter from the Ambassador i six weeks ago, and in consequence conferred with me as to he expediency of accepting the offer which it contained. A t deliberation, as we expected hourly stores from Varna, \\ thought it best to decline the offer. We had not then bed of the disaster that had happened to the " Courier," the vc el which had been sent to that place for the purpose of bi'.ging them down. On about the 16th or 17th November, I as given to understand, the offer was repeated ; and then wngreed to ask for certain utensils and 200 sets of bedding. T'- bedding was sent, but unfortunately in the wet weather. ^ had asked for the bedding, from having received a commu- n tion from Dr. Hall, to be provided for the reception of at It . 1,000 wounded, who were already on their way to Scutari. -00 sets of bedding would, I think, have sufficed, or, at . would have aided us. We did not like to ask for more, ise I thought it would have sufficed. The wet did not •-jil the bedding, and it came in very useful. AVe got a few ctirs and tables, also, for the officers' quarters. All these ^^s were applied for by Dr. Menzies to the Ambassador. I 1 oeeu to the Pacha of this place, and asked him to get me Mr. Wreford's Evidence. — Cumming Maxwell Eeport. 124 WANT OF STORE ROOM, the bedding, but they were obtained from the Ambassad. The oiFer of the Ambassador was not accepted for anythir except these things mentioned — bedding, chairs, tables, al other things, of which I will furnish a list. Several of I3 articles have not yet been sent. " As assisting Mr. Ward, I went to the bazaar to h slippers. I passed several hours there, and could only get ) pairs on that occasion. I have purchased altogether about () pairs. From an apprehension of running short, and to m t every possible contingency of non-arrival of ships, I purchail nearly 350 dozen of port wine from several houses in Const - tinople. Nothing could be more timely, however, than ^ arrival of the supplies sent from England, both as to the ti3 and the quantities sent. I have had great difficulty in gett j stores landed here — not owing to the neglect of the Comn- sariat, but to the state of the elements. The Commissait land for us. I know that our stores have sometimes gone 3 Balaclava, in consequence, I suppose, of improper stowage, t is the duty of the Commissariat to store for us, but they h e not the means of storing. We are, to a certain extent, limi 1 for storage in the Barrack hospital, but heavy bales are I think, safe in the passage. There is a sentry there. It wo i be a great security if they were under lock and key. " In England, the patient brings with him inventories 1 duplicate of his necessaries ; one is signed by the pack stc - keeper, and the other by the non-commissioned officer \'3 brings the necessaries, and is attached to the man's kit. t the G-eneral hospital Mr. Ward has established the old practe of having a book with the man's name, and the articles writ 3 opposite. " When I came out matters were in arrear. They are working gradually, but slowly. We have by no means a si - cient supply of clerks. Our great work has been with 3 hospital stoppages. That involves an account with every ii - vidual soldier. The stoppage is 4^c?. a day. The Prmcil Medical Officer gets a daily return of the number of " patients admitted, discharged, and died, and names of e. 1 patient. He adds up the whole, and forwards it to the p - veyor. AND MEANS FOR LANDING. 125 Dr. Menzies. . . . Did you give him that list 1 — I did. j^^. T^jg^^jg OS 19. "When was that 1 — I think it must have been on or Evidence. ;il it the lltli of November. 1)820. Have you got it there? — Yes, I have; this is the list, w I a note from Mr. Wreford, explanatory of the articles still ling. This was sent in in November; but many of the aijL'ies were not supplied up to the 5th of January, when Mr. A^ eford writes to me on tlie subject ; I wanted to have some ill rination as to the reason why those things had not been lied. »2l. Are the Committee to understand, that in the begin- II : of January you inquired why things that ought to have provided in November had not been supplied? — I wanted i>\v what things he had got upon the requisition that was in about the 14th of November, and this is Mr. Wreford's nation : — ' Dear Sir,— I herewith enclose a copy of the list icles which accompanied my letter to you of the 19tli No- cr, wliicli was prepared in compliance with a letter which ad consulted me upon, then recently received from Lord lord de Redclilfe, offering his kind assistance to procure use of the hospitals here any articles of which we might 1 in immediate need. I beg to add, that having occasion to L Messrs. Black's a few days afterwards, in search of port I was shown the original list, and my opinion asked as to scription of articles we required, which I gave, and further ! upon them the necessity of their being procured with as 1 delay as possible. Now I may mention that the mercan- ' stabhahment of Messrs. Black is one of the oldest and one • most respectable in Constantinople, and consequently 'j; large and extensive ramifications, and yet even they ''oen unable to complete this list, the articles having been in in tiie quantities and at the intervals stated, the whole as yet far from completion ; and I have been more than nformed at the house that they cannot get the people to and to find all the articles ready made is impossible. I ion tliis to sliow the difliculties that surround us here; for 126 WANT OF MEANS if a merchant like Mr. Black cannot procure these things, !w much less practicable is it for strangers to do so.' "* [The following list was handed in.] Statement of Articles Received, in accordance with a List to the ijAs- SADOR, about the 20th or 21st November, 1854, from Mr. Black, iof those yet to be supplied.— 2nd January, 1855. Desckiption OF Articles. Quantities Ordered. Supplied 28 Nov. 1854. Supplied 5 Dec. 1854. 1854. 6 ^.^^ Total Supplied. Hair brooms, &c 200 Turkish brooms, &c. 196 196 Tin cans, 2 gallons. . 100 200 15 1 K 10 30 Close-stool frames . . 150 zo 26 Spitting-boxes 300 "45 '58 103 500 100 Hand scrubbing brushes 100 1,000 i'90 794 984 Drinking cups, pint : 1 Goblets .. .. \- 1,000 283 419 702 Tin cup . . . . J Buckets (2 gallons). . 100 Washhand-basins . . 200 1*97 197 Door-mats 36 '35 35 700 200 204 204 40 39 39 12 12 12 1,000 341 341 Woollen socks . 2,000 2,000 2,000 B. Selkirk Stuart, Purveyor to the Fl Dr. Smith's representation of the case. The representations as to the satisfactory state of tari Hospitals_, given below^ were exactly the same as t made to me when I left England for Scutari, Oct 1854, (including the singular and misleading express that "the Medical Officers would not object to^^ * How then were "these things" procured, in Constantinople, by otls,' although also strangers'? FOR RECEIVING AND ISSUING STORES. 127 ving the men a nice drink of Capillaire Syrup,") vide [). .'^1 ; but, nevertheless, they seem to have been altogether at ariance with even that evidence which had been already jithis date, October 1854, received at home, and which i( led even then to throw light upon the real state of the s785. Have you ever had any reports from Dr. Hall as to Dr. Smith's :: tli| iusufficiency of the clothing of the men ?— Not of the Evidence. - in fTiciency of the clothing of the men after the winter *•! ling was issued. n78G. Have you any such reports at all? — In a letter I ly received from liim, when I called upon him to explain I I causes of the great sickness, he stated that the causes ot ho sickness had been very various that the men had been o\ -wrought and over-fatigued in the trenches, sometimes for and 14j hoiu-s a day, often up to nearly their knees in III L and wanting any covering when they were away from (li . , trying to get rest in the mere tents. '^787. Have you had any reports either in those letters, or "1 rw-ise, of the insufficiency of the clothing of the men? — -N specific reports. ^788. Up to what date have you any reports? — Dr. Hall mod me that the want of sufficient clothing was one of 1 1 i ;iuses of the sickness. - s789. When did Dr. Hall's reports cease stating that the were suffering from the want of sufficient clothing ? — have only ceased very lately ; that is to say, he used to .ilain that the abundance of warm clothing which was at t'> klava, would have saved many men from sickness, if they liave got it up to the camp. 790. Has the Principal Medical Officer, Dr. Hall, been ii'utly consulted as to the state of the health of the army, t s fitness for the duties required of it ? — I cannot exactly ^•r that question. I think that, looking at it as a medical "i - he would probably have advised some little modification ; hi uhetlier he was consulted or not, I cannot positively say. ^71)1. lias he sent you any of the reports that he made to 'ii ' "inmaiuk'r-in-chiof as to the state of tlio men? — I think 128 PR. smith's that the only report he wrote to me was in answer to a letr in which I asked whether he had taken sufficient precauti s to endeavour to get a proper place in which the men mijt sleep and rest in winter ; — he stated, in the first place, thatie liad no knowledge till a very late period, that there was ly probability of the men remaining in the front of Sebastcol during the winter, but when he did get that knowledge, e suggested that they should endeavour to imitate the prac :e of the Eussians by digging places in the ground, and throw g spars over them, so that they might put earth upon them, d in that way gain a mode of shelter better than tents, it then the question came to be, would they be able to do it ?. . " 8182. ... It has been represented to this Commi se by competent witnesses, who have themselves seen the fiss upon the spot, that nothing could be so horrible or so disg t- ing, or in every way so calamitous, as the state of the Hospitals from the time of the arrival of the sick from ie battle of the Alma, and for a considerable time afterwards. It has also been stated by Mr. Macdonald, the witness who is sent to distribute the charitable fund collected by le "Times" newspaper, that he applied to you upon the 5t3f November, for a letter of introduction, and for informa l with respect to the state of the Hospitals in the East, id that you at that time told him that his mission was a vy supererogatory one, and not required at all, inasmuch as aule means had been provided, and every precaution taken supply everything that was necessary for the comforts andie care of the sick in the Hospitals at Scutari ; what reports id you at that time from Constantinople, to justify that repreia- tation? — I had no reports to have justified me in saying i)'- thing else. " 8183. What reason had you to believe that the statof things at that time known to the public, or published to le world, was false ? — In the first place, I was aware that I id despatched from this country ample provision for every wa;; and in the next place, it was considered by the mecal authorities out there, that they had what was wanted. "8181. Chairman: What evidence have you got of it last proposition ? — I ought, to a certain extent to comn it VI FW OF niF CASE. 129 ojin the last part of what I yaid ; wlicn the medical autho- Tpa wrote to me to that eficct, they were daily in expectation d! receiving from Varna, all that had been left at Varna. \\\en the army moved from Varna they left the entire equip- n it of their General Hospital behind them, and the Inspector- Ciiieral of IIos])ital5j gave positive directions to the authorities ti.t remained, to forward everything directly to Scutari, where k , sick and woumlcd would be sent. Those authorities made iiry eftbrt that they could to do so, but they failed. The i horities at Constantinople, who were communicating with Q were also exerting themselves to the utmost of their Pi.-er, to induce the transport department to send vessels to V^na to bring away the stores ; and day after day were those & irts repeated, but without success ; the supply had not lived on the 10th of November; but I was not aware >that. r8l85. -Mr. Ellice : What letters or reports had you from k 86 medical authorities at the time ? — I had regularly letters bfeach mail, reporting what had happened. |.' 818G. Will you state to the Committee upon what grounds fjji formed that opinion, whicli you expressed to Mr. Mac- diuild, that there was an ample supply of everything required r« the sick and wounded in the Hospitals at Scutari ? — AV^hat Ijxpressed to Mr. Macdonald was this: he brought a letter [^introduction, asking for an introduction to the Principal E'dical Officer at Scutari ; and I said I should be happy to |e him one; his reply was, that as he was going on a special f^'pose of this kind, be would like to consult with me. I,aid, ']f you will state to me on what principle this fund t,; been raised, and in what way it is intended to distribute 1 means, I will give you what information I can.' He did ^. immediately reply to that, and I said, ' Perhaps you may I- yet have established a principle, therefore I will volunteer Igive you what information I can.' I said, ' The Medical ^icere of the army are held by myself and the Government rponsible that every man in the hospital is supplied with • atever he requires for his welfare, irrelevant of expense; it ^'s not matter wliat it is, if he requires it, the Medical jfieer has the power of ordering it ; on tlie other hand, the 130 DR. smith's Medical Officer is equally bound not to allow anything to 1 administered to a man in the hospital that can in any m conduce to his injury. Those two points are to guide til Medical Officers.' Then I said, ' Under those circumstancd and assuming as I do, that the Medical Officers are suppliii with what is necessary for the first, and that they do not wai to be supplied with what is necessary for the second, anythii' that you will have to distribute will be of a neutral descriptici that neither do good nor harm, but may please the palate the men. For instance, a medical man knows best what useful for the sick, and he will probably give barley water, ir, case of fever, in preference to giving capillaire syrup (v. p. 12' I do not know that the Medical Officer would object to yo giving the man a nice drink of capillaire syrup ; such thin|;, I think, you may give out advantageously, without being int(i fered with ; but I think your main object will be to distribii this fund to the poor men who may have been discharged frd the Hospital, and who may have many wants to be supphi which the Government are not in the habit of providing f . Let me give you one piece of advice, not to give them monc; or else you will give them the means of obtaining drink, al only send them back to the Hospital.' " 8187. The department of the Government must have bei under the same impression; the Duke of Newcastle stated U same thing to Mr. Macdonald, but that impression, or tit opinion, must have been founded upon some report you ill received ; that what you have stated to be the duty of 13 Medical Officers had been performed efficiently, and that ev»/ comfort and every necessary had been supplied to the Patien ? — I certainly understood that from the correspondence. l3 Medical Officer in correspondence with me, was every mom(fc expecting arrivals from Varna, which would make thi independent of everything. " 8188. The facts of the case have been represented to 13 Committee by two witnesses, Mr. StaffiDrd and Mr. Macdon^ , to be these : that there were very few beds ; that the plo lieport. 134 ])U. MENZIES' REPORT. iu the form of diarrhoea, which merged into a chronic fori although not of a fatal character. Notwithstanding that tl climate of Scutari had been generally speaking healthy durii the above period, the weather had been very changeab' stormy, wet, and cold, which conditions must no doubt ha tended to aggravate the affections to which I have alluded, a} which have chiefly come from the Crimea. "I have to report favourably of the buildings now der- minated the General and Supplementary Hospitals, the foriD' liaviug been built for the purposes for which it was intend*, but the latter as a barrack for troops, but which has lato small, and without conveniences for a separate cooking esli)- lishment, without which their efficiency must necessarily )e impaired. " Some parts of the General Hospital require repairs, stie of the rooms being very leaky. The quarters for Medal Officers are also inadequate for the present number doing ciy there. The drainage and privies are at times greatly ouof order, and when the south wind blows there is a very oflfeuire odour wafted up through the building from these reserves. It is my opinion also that the close proximity of the bu J- ground whicli lies between the sea and the Hospital, iy prove hereafter a source of unhcalthiness in this locality I beg to recommend that the site of the burial-ground be tb*©- tore changed, and no more bodies be placed in the immec^te vicinity of the Hospital. " Diet.— I liave very little to say on this subject. "O- 1>R. MENZIES* Ui:i'(»nT. 13.'', viiions are supplied by contract. At one time the supplieH 'or the HoMj)ital were by no means of the best qualitv, but jiuch iinprovt'ment has of late taken place in this respect. *rhe articles of diet are those pointed out in the Hospital T^^lations, and which are in my opinion quite suflicient. "The extras and medical comforts arc allowed to any extent •onaidered necessary for th-j j)articular cases by the Medical 'Jfficen*. ^ ** With respect to the hospital bcildin*^, we have been ' ted to the Turkish authorities i'or a lar*^e supply for the . . ral Hospital, durint^ the time that our own beddiiiLj was leticient in consequence of its being detained at Varna, and • was left with us here being insuflieient lor the large mT of sick and wounded carried at dillerent times from he Criniea. The boards and tressels sent Irom England are small a portion of our miseries. I OPIC OF A LktTKII from J)l{. Cl MMlNtJ, P. H. >rAXWKI,L, KsQ., , AND P. S. Lainc;, Ks(^, to Loud W. Pai let. IMy Lord, Scufuri, Januari/ ^Cttli. f** Having recently received instructions from his (ira»'e the of .Newcastle to report lo your Lorilshij) all practical ilions which we n comuK nd with a view to the better 136 LETTERS OF THE I organizatiou and working of the Hospital here, we hasten !> submit for your consideration some points which have occuriil to us in the course of our inquiry, and upon which we are jl agreed. j "1. It appears to us that the first step towards the due ganization of the Barrack Hospital would be the total remo;l of the depot* from its precincts. As long as the building, wh i is now chiefly devoted to the accommodation of the sick,b partially occupied by duty men, convalescents, and a \m number of soldiers' wives, and is consequently frequented bjji variety of other persons, either connected with the cantei which is established in the place, or otherwise, we are of opinii that great difficulty will continue to exist in establishing orcr and regularity in the hospital. " 2. It appears to us that one of the most obvious defectsii the organization of our hospital establishments, is the utjr absence of a trained body of orderlies. The task which devol-s on these men requires that persons of intelligence and respe> able character, good constitution, and active habits, shdcl alone be employed ; and, further, that they should have undi'- gone some training in their duties before they are placed ints responsible situation. Your Lordship is probably aware tit our hospital orderlies seldom fulfil these conditions. In orir to form gradually such a corps as we suggest, we would begp recommend that the Medical Officers in charge of wards sho |(l be requested to report at once, and from time to time in futi^, to the Commandant, such of their orderlies as may be, eitir from ill-health, inaptitude, habits, or character, unsuited ir their situation ; that these men should be removed ; that tl]|r places should be filled only by men, who upon due iuquy should appear to possess, as far as possible, the qualificatio which we have mentioned ; and that those vrho prove tht - selves duly qualified should not be removed except for misC'|- duct or incapacity, but should be retained in their situationis long as their services were needed and useful. • This was not effected till May, 1855. Consequently, this fruitful soi e of disease was left festering in the Barrack Hospital during the whole te of our jrreatcst overcrowding. 1 Hospital commissioners. i"8. We would offor a wimilar recoinineiidatiou respecting the election of hosj)ilal aerjeantrf, wardiiiasters?, and cooks. "4. It appears to uh extremely desirable that the clothin«; of Ijvery patient should, on the eve of his leaving the hospital, be riispected by a Medical Officer, and that every article of dress taaential to his health should be supplied before he be dis- charged. This recommendation, if adopted, would necessitate he establishment of a clothing store in the hospital; but any Inconvenience arising from the introduction of an additional jl'lement into the already complicated organization of our hospi- tals would be more than compensated by the beneficial effect ,,vhich it would have on the well-being cf our soldiers. Owing |:o the want of such a store, men have either been exposed to a recurrence of sickness from insufficient clothing, or have been iipermitted to carry away shirts, flannel waistcoats, drawers, and .)ther articles of hospital clothing. This practice has, we learn, •been carried to an extent seriously detritneiital to the comfort |of the sick in hospital, as it has been found practically inipos- isible to supj)ly the constant drain thus kept up on the pur- ivuyor's store. "We have, &c., " (Signed) "A. Cu^nriNG, l.G.U. "Lord William Paulet, "P. Benson Maxwell. I " Commandant J Scutari. " P. Sinclair Laing." Fehruarij dth. IcoPY OF A Letteii riioM Cl'mmino, p. B. Maxwell, Esij., A>u P. S. Lainc;, Esq., to Loiin W. Paulet. I " My Lord, " Scutari, February dth. In pursuance of our instructions from the Duke of New- ui-'^ilc, to report to your Lordship all practical alterations which we recommend with a view to the better organization and working of the hospital, we beg to recommend that further hospital accommodation should be at once provided for the sick and wuunded of the army. " We aiv of opinion that the Barrack ILispital is at present much overcrowded. From calculations which wi; have made, 138 LETTEKS OF THE based upon the superficial measurement of the wards and coi- dors at present occupied by the patients, we think that lit more than 1,913 men should be admitted into this hospil The number of men, exclusive of orderlies, in the wards ail corridors devoted to the sick is, this day, 2,107, and amountu,. within the last month, to 2,400. "The over-crowding is altogether in the corridors. Its much to be regretted that any patients should be placed i them, but we think that under no circumstances ought they ) contain more than one row of beds. If the second row wo- removed, the corridors might still afford accommodation ;r 725 men. The wards may contain 1,188 more, making a to I of 1,913, from which, if 192 orderlies — taking their number b the rate allowed by the regulations of the service — be deduct» ^ it will appear that the wards and corridors now occupied as i hospital ought not to contain more than 1,721 patients, — abe t 400 less than the number actually in the building on this d{.. Our estimate is perhaps larger than it ought to be, when itjj considered that many of the patients are suffering from feverf a very dangerous character. " The General Hospital, the stables adjoining the Barra: Hospital, and the buildings at Haidar Pasha in our possessi( , are full. The hospitals at Kululi are already more crowd! than they ought to be, and the huts in course of erection i the Barrack Square will not, we believe, suffice, when co - pleted, to accommodate the number of men at present in excd in the Barrack Hospital. " Under these circumstances, we deem it our duty to sugg(; . to your Lordship the expediency of providing further hospr|ki« accommodation for the reception of any sick or wounded m i who may be sent hither from the Crimea, and also of the lar > number who at the present time over-crowd the Barrack H( • pital. " We must add, that the crowded state of the barrack roon4 in which the soldiers of the depot and soldiers' wives are qmi^ tered is extremely injurious, not only to their inmates, but al ^^ to the sanitary condition of the hospital. "The prevalence of fever at the present time renders necessary tliat we should also earnestly recommend that yo ' HOSPITAL COMMISSIONERS. 130 JIxtfdBhip should provide the Medical Officers employed in the hoHpital with (juartera out of the building. Four Surgeons have died within the last month of fever caught in tlie hospital, Ijand three more have narrowly etscaped the same fate from the some cause. " We have, &c., " (Signed) " A. Camming, I.G.ll . » " P. Benson Maxwell. (• "Lord Wm. Paulet, " P. Sinclaie Lai.ng." " Commandant, ISculari. 140 IV. Resume of the Evidence as to (1) the Crimea, I) THE Sick Transport, (3) the Scutari Hospital THE Winter of 1854-5. The Excessive jj^^g heen too sadly proved by the above evid( e. Mortality was • ■ ' owing, 1, to that the excessive mortality in the winter of 1854-5 ajK? Privations not be attributed to any one single cause, but to the rlQ- m the Crimea ; ^j^g^j action of three distinct and successive condition 2, to the Wretched 1. The Army was ill-provided in the Crimea, and dii Condition of .1^1 the Sick was generated there. ''"toTr utVer^' ^' '^^^ ^^^^ Transports were in a state fatal to the I k, UnheaUhiness and absolutely unhealthy for all ; and the Sick were m Hospitals at 6 — 27 days on board. Up to February 13, only one vclge Scutari. appears to have been not longer than 3 days — or I 5 not longer than 4 — only 1 of 5 days. Up to this |te, eight per cent, of all the sick embarked from the Criea perished on board between Balaclava and Scutari. 3. The sanitary state of the Hospitals at Scutari was ich that the sick had not a chance. It appears vain to eap evidence upon evidence that this was so : if the evicoce already given is not enough to make people belieV it, " neither would they believe if one rose from the dea( " The per- The Mortality per cent, rose as rose the numbi of MortaUtVin Patients — a sure proof always of sanitary defects iitlie the Hospitals construction of the buildings. Mortality may be i^h rose with the ° j j Number of from the state of the Patients admitted; but, if the Patients, but . i 1 • i i i ^ ^ • • did not fall centage be higher as the number of those Patient in- ^™with H^^^ creases, then it proves that there is something destrusive decrease. in the building itself. Now every admission of Patiei i at Scutari not only made every sanitary evil worse for RESUME OF THE PRECEDING SECTIONS. 141 I'atients themselves, hut for those who came after them. 'Ilic consequence was that there was always an excess of Increane. mortality a little after each in-road of Patients, tlicn a (li<4|)roportionate rise. Statistics tell nothin*^ without conditions. ]5iit the • whole history of Scutari may be read at a glance in our Statistical Records, an analysis of which T here annex, if we romj)are them with our conditions, which I have cnu- I merated : — ! AVALTBis of Weekly States of Siok and Wounded, from October 1, 1854, to June 30, 1855, in the Hospitals of the Bosphonis. Date 1854. Oct. 1— Oct. 14 Oct. 15— Xov. 11 Nov. 12— Dec. 9 Dec. 10— Jan. 6, 1855 1S55. Jan. 7 -Jan. 31 Feb. 1— Fel). 28* Feb. 25— Mar. 17 Mar. 18— Apr. 7 Apr. 8 -Apr. 28 Apr. 29— May 10 May 20 — hinc 9 June 1(»— June 30 • Koalali. 1865. Feb. 1— Feb. 28 28 648 581 302 608 520 Compare ' 1S51. 1855. 1 ' . omitting the Oct. 1— Jan. 31 123 3,140 10,843 2,145 203 19-8 wornt time, vlz.,"^ 1855. 1855. 1 Febniary j Feb. 25 -June 30 126 2.501 1 8.073 1,020 118 12 6 - 3 . 14 1,993 28 2 229 28 3^258 28 3,701 25 4,520 28 4,178 3.779 3,306 2.803 2,018 1,504 1,442 590 2,043 1,944 3,194 3,072 3.112 1,621 1,650 1.190 1,350 996 1,266 113 173 301 572 986 1,329 510 237 127 70 48 28 Mortality. 148 101 121 202 319 415 235 125 79 60 56 34 19-2 8-5 15-5 17-9 321 42-7 31-5 14-4 10-7 5-2 4-8 2-2 142 RESUME OF THE ;^ote. After consulting the best Statistical authoril^s, I find that the mortality of Hospitals can be compare(in two ways, which mutually check and confirm each oth: (1), by dividing the deaths by the mean "strength' of the sick in Hospital, and reducing the mortality to ija which would obtain, were the time of observation a yir By this method, it will be seen in the Table I give, the mortality in the Bosphorus Hospitals fell from 415 per cent, per annum in February \ in the three weeks enc ^' I March 17, 1855, to 125 „ 79 „ 3) in five successive periods 60 „ J J r three weeks each. 56 „ and 34 „ By the second method the deaths are divided by tie number of cases treated. Where the number of sic is stationary, the numbers (1) admitted and (2) dischaied (including deaths) must be equal in a given time, he number of cases treated will be represented by the n li- bers either admitted or discharged, as they are ecal. When the number of sick increases or decreases, the nn- bers admitted and discharged will differ; but the numer of cases treated will, in all ordinary cases, be nearly re'C- sented by taking the mean of the numbers admitted ad discharged. Thus, 6^751 Patients were admitted miohe Bosphorus Hospitals in the 126 days, February 2^ June 30, 1855, and in the same period 9,392 patients i^re discharged. The cases treated are represented by 0,751 + 9,392 = 16,143 = 8,072. PRECEDING SECTIONS. 143 A.S the deaths were 1,020, the mortality on the cases ated was 12-6 per cent. By this method the mortality of the cases was at the 31 e of 31 '5 in the first three weeks, and fell progressively to 14-4 per cent, of cases treated. A.S 2,501 were under treatment 126 days, the days of kness were 2,501 X 126 = 315,126 days That is 315,126 = 39 days 8,073 the treatment of each case on an average. In the first period, the cases were under treatment ut 49 days ; in the last 24 days. [While the mortality fell from 31*5 to 2'2, the duration the cases fell from 49 to 24 days. At Koulali, the worst of all the hospitals, in February 55, the mortality was 52 per cent, on all the cases 3ated in Hospital during that month ! At Scutari and iDulali, it was nearly 43 per cent, during February on the •!ses treated ! sin other words, had the rale of mortality at Koulali ntinued, — in two months, the troops in Hospital there )uld have been swept away. Had that at Scutari and fOulali continued at what it was in February, in three onths its Hospital population would have been annihila- d; that is, the mortality there was 415 per cent annually, I the sick population, — at Koulali, it was 608 per cent, nually. 144 RESUME OF THE On comparing tlie cases treated with tlie rate of mc tality, by the aid of the Table, it will be seen that the p( . centage of deaths rose at the rate of more than twice 1 1 increase of Patients : that is to say that_, when the Patien increased in number by one half, the mortality per cei. was double what it was before. We reiterate the wore. It was not the absolute number of deaths which doubled. It was the per-centage of deaths among t; Patients, which became about 32 per cent, from 15 J p • cent. But, in February, when the number of Patients stol still, the mortality still continued rising by one-third f the per-centage ! Decrease after Again, when the number of cases treated was diminis the Sanitary "[^y onc-fourth, the per-centaffe of mortality fell to ab improvements ^ r o ./ and with the one-fiftccnth. This was after the improvement of *crowding° sanitary conditions of Scutari, effected by the Sanita; Commission. We attribute one-half of the decrease f mortality to this improvement — the other half to t) cessation of the over- crowding, and to the improvemf t in the condition of the Patients admitted. | It must not be forgotten that the evils arising £r(!i over-crowding, together with bad sanitary conditions, jj an ever accumulating ratio. If nothing is done to the drainage, every excess f Patients leaves it in a worse state for the next, f nothing is done to the walls of wards, the respiration al exhalations from Patients contaminate them with a si greater impregnation of organic matter for the next ser5 of inhabitants. If nothing is done for the ventilation, Hospital atmosphere becomes more and more fatal. This is what took place at Scutari. 1 Now mark the decrease in terms of three weeks. W tlio three weeks ending March 1 7, the ratio of Deaths to cailli }m;K(:i:i>in'(; section^. 14.') ated had fullciijiit Kouhili and Scutari^ to o I per cent, the three weeks ending April 7, at Koulali and Scutai i, 14i per cent. In tlie three weeks ending April 28, at I the Hospitals, to 10*7 per cent. By May 19, to rr.2 ])t r nt. By June 'M), to 2 2 })er cent. The Sick Population of the Hospitals, i. c, the mean I the numbers remaining at the beginning and end, fell that time from 3,800 to 1,100 — the number of cases ated from 1, GOO to 1,200. That is to say, tliat, while e mortality fell from 31*5 to 2'2 per cent, of cases treated, c duration of the cases fell from 19 to 24 days. It lias been continually stated, and lately in evidence, The Docroase the Principal Medical Officer of tlie Army in the East, w^as^norolvin'^ at the reduction of mortality at Scutari, after those to one but to . . several causes, ospitals were put under good sanitary conditions, was lie, not to these, but solely to the improved state of the |lrmy in the Crimea. \ Has it not been sufficiently proved that the condition of •iC Army in the Crimea, the condition of the Sick Trans- i)rt8, the condition of the Hospitals on the Bosphorus ere all concerned in producing our fearful mortality ? hat more could we have of proof? I Put healthy men, sick men with good constitutions, ck men with ruined constitutions into buildings in the late of those at Scutari, during the winter of 1851—55, d tluTc will be seen a certain amount of mortality laong the healthy men, as was illustrated by that among IT Orderlies and troops in Depot, a greater amount of |lortality among the sick with good constitutions, an icceasive anu)unt among those with ruined constitutions. But what is it that we wish to prove? That it was no l^e trying to do anything for these poor disabled men, I ready condennied to death'.' Rather prove how much 146 RESUME. more they ought to have been cared for and placed und tlie best conditions for recovery. There was nothing new to history in the sanitary resulj, of our campaign. j There was nothing diflPerent from the Irish famine feV|' in that among the starved Crimeans^ except the stroi'j scorbutic cliaracter impressed by the use of salt ratioiL Tliere was nothing different from the old Gaol fevij, familiar to us from Howard^s researches, in the Hospil fever of Scutari, except that it was in a somewhat mikir form. Beautiful and convenient as were the buildings jf Scutari to an unpractised eye, to one accustomed to let at gaols, hospitals, poor-houses, with a view to their saj- tary condition, these Scutari buildings were, in thjr unimproved state, like the Gaols of old, pest-housesif Typhus Fever. The five conditions generating this plajje have been enumerated above. Let us not deny them, but let us set to work to ascr- tain what is the education, what the organization, w|it the system of Medical and other Departments, which Hll pi-event the recurrence of such a fearful loss of life? r Note as to After a narrative of the privations of the sickm IIliirts (llannel and cotton) Pairs of Socks and Stockings Pairs of Drawers Towels Handkerchiefs Comforters Flannel Pairs of Slippers Knives and forks Spoons yards 50,000 23,713 G,813 5,826 10.044 9,638 1,384 3,626 856 2,630 List of Articles Supi)lied Privately, upon the Requisition of Medical Oflicers. 150 PRIVATE SUPPLIES. 4,524 4,545 5,477 2,086 1 232 74 168 253 14 2^ 55 68 Inference. Night caps . . Gloves and Mits . . • • • • P^s- Drinking cups Tin plates Basins, zinc, &c. Dressing gowns Air Beds and Pillows Thread and Tape .. packages Lanterns, Candle Lamps, and Lamps Preserved Meats cases Meat Biscuits barrels Isinglass and Gelatine . . . • Ihs. India-rubber sheeting pieces, 325 yds. Camp Kitchen Cooking Stoves and Canteens Boilers and Stewpans Tables and Forms, Baths, Soap, Games, Brooms and Scrubbers, Bedpans, Tin pails. Combs, Scissors, &c., &c.. were supplied with and without Requisition. The above is independent of the Extra Diets, includh: Wine, and of the innumerable minor Surgical appliance, such as Arm-Slings, Bandages, Eye-shades, Old Line supplied as they were wanted. Both descriptions of thini ought to be, and it is trusted always will be, in futui under the charge of women. These do not, therefoi strictly belong to our example. The conclusion which must necessarily be drawn fro tliis unhappily large example is, that the soldier ought I'ACK-STORE AT SCU'I Alii. 1.31 13 supplied with Hospital clothing and necessaries, and |iat his own kit should be placed under charge in a regu- ;ted Pack -store, there to await his recovery or death, f In the last event it would be, as now, sold, and the pro- jcds dehvered to the Purveyor or Gox crnor, lor transmis- |on to the Regiment, and from thenee to the War l)e- lirtment, which answers the application of relatives, l' Among the unhai)pily neglected Departments, the I'ack sLoio at fack-store at Scutari showed a greater confusion, perhaps, i;in any otlier. Hundreds of raen^s knapsacks were irown into it, promiscuously, and lay for months un- tirted — were, indeed, not unfrequently plundered. These juapsacks belonged partly to the Sick who came into Hospital, partly to those w ho died on the passage. Con- S-quently those wlio could claim the knapsacks, whether ;ie soldier who recovered, or the widow of him who died, ad no means of discovering them in the confused heap, ludit was not till April 1855, when thousands of men had one away, that the Pack-store was reduced to order. I I 152 V. Further Hospital History. — Notice of the Fib? EiMPLOYMENT OF FeMALE NuRSES, OF THE EMPLOYME;r OF A Corps of Male Nurses, and of the Arrival f THE Sanitary Commission. | ! Commence- Miss Nightingale and her Nurses were sent oii, E^iployme^nt October, 1854, by the War Office, and arrived ^ of Female yember 4, the eve of the Battle of Inkermann. Quart(s Nurses. ^ _ ^ ! Arrival of the and Rations were assigned to them within the Barra: Nurses in Hospital, Scutari, in pursuance of letters from t; ^Tss?''' Secretary at War, and Miss Nightingale was fiirnishl with Instructions. It was not till March, 1856, that Miss Nightingale wIj pwt individually into General Orders. But no Gene]| Order has ever existed defining the duties of the Nursil in the various Hospitals to which they were respectivcf attached. ■ Subordinatioa In the Civil Hospitals of Smyrna and Renkioi t; to the Medical . r^iipi-i*^ i -li^i Officers. number was fixed beiore leaving home, together with tt ; of those serving in other Departments. With regard } Miss Nightingale^s first party, the number admitted in\ the Barrack and General Hospitals, Scutari, was fixed ^ arrangement with the respective Principal Medical Office; of those Hospitals. But, nevertheless, the number a mitted into each Division depended upon the Medic 1 Officer of that Division, who sometimes accepted thei. sometimes refused them, sometimes accepted them aftj thoy had been refused ; while the duties they were pe mitted to perform varied according to the will of ea< individual ^Medical Officer, and each Medical Officer su ccssi\ cly, and according to the amount of occupation i i:.mi'L()V.mi:nt or nurses. 163 Iidifjil Olliccfs and Orderlies, and accordiii";- to the tiniatiou in which each individual Nurse was hehl hv ich iiuhvidual Medical Officer. With regard to Kxtra Diets, Medical Comforts, and free gifts," notliinjj;- was given by the Nurses, except V the order of the Superintendent, which order was con- jquent ui)on the Requisition of a Medical Officer and hat only, — with some few exceptions. Tlic different reinforcements of Nurses sent to the 1 i from 60 to 100 Patients, and was in fact, though not i name, the treating Surgeon. Again, there is scarcely any one of the Purveyor's duti( which we have not seen the Surgeon performing; am though fortunately the converse cannot be asserted, vi2 that the Purveyor sometimes performed all the Surgeon duties, we have known him to appropriate one, at least, • these, in exercising a veto, practically, though not nora nally, upon Articles of Diet. E. g.^ for months, at one General Hospital in tl Crimea, the Deputy Purveyor-in-Chief supplied neitht AND rURVKYING DEPARTMENTS. 169 f(tls nor eggs to the requisition of the Medical Officer in ( i';^e, although these articles were to be had and were aiually procured in the market; and_, on one occasion, t ' necessary brushes, &c., for cleaning and whitewashing I Wards, were refused to the Medical Officer in charge (^ing a considerable time, although these articles were in Vgain, there was no uniformity of system in the General Diversities of litspitals. It was impossible to tell what the system was. "^^'vjj^ioug ^ one, the Purveyor was nobody — in anotlier he was ji'ospiuis rybody. Ie. g., in one of the largest General Hospitals, the Prin- Medical Officer, if about to receive a couple of hun- ( (I Patients, communicated in no way with the Pur- ^jV'or : he communicated wdth the Orderly Medical Officer i|d with the AVardmaster. He did not say to the Pur- er " 200 Patients are to be bedded and fed ; when this done, we will visit and prescribe for them." He sent a '. edical Officer down to the wharf, to receive the Patients, e ordered the Orderly Officer and Wardmaster to have eparations made for them ; and the first official infor- jation received by the Purveyor might be when the jominal Roll was sent in to him the next morning. I Again, we have seen a zealous Medical Officer in charge j" Wards get up at six o'clock in the morning, direct his rderlies how to sweep, clean, air the Wards, &c. If he lid not do this, the order (or rather the disorder) of things 'ight bo as follows : — I There might be four Orderlies to the AVard : not one as senior ; the Assistant Wardmaster might not come Ho his Wards till eight o'clock, and these Wardraasters ere so frequently changed that they hardly knew their wn duties. Each Orderly set to work in a diticrent jorner of his Ward, according to his own fancy, opened or 170 WANT OF DISCIPLINE. | I did not open the windows, as he thought best. T3 Convalescents, who ought to have got up and breakfasll at the table in the Ward, when there were tables (at fi't there were none) breakfasted in bed, renewing all the ef- fusion in the Ward, and got up when everything was do];. It had then to be done all over again. It was no ons fault, for these Orderlies were wholly unacquainted w 1 their business. Their only idea of cleaning was raisings much dust as possible. In some Hospitals a Purveyor's Clerk was sent round ) inspect" the cleanHness of the Wards; in others n. But he was only laughed at, if he came ; for it was a kil of supererogatory work of merit, not duty. And this brings us to the mention of an error whii we think very generally prevails as to the discipline i Military Hospitals. State of How our brave fellows distinguished themselves, ' ^^^Mmtary" ^ unflinching regard to discipline, in the Crimean W;, Hospital. is too well known now to require a comment. We canr: feel respect and admiration for it greater than what : deserves; but the discipline among the Patients mail tained by the Ward ^' Sister" of a London Civil Hospiri is far stricter than any to be seen in the wards of a Mi- tary Hospital. Although she has to do with ruffias (often) over whom she has no power but that afforded 1' their temporary stay under her care, every man is in b who is ordered to be in bed, and every man gets up at t time he is ordered to get up. We have yet to see ti Military Ward where the Medical Officer invariably fin the Patients remaining in bed or getting up, the mec; cines taken, &c., as he has directed. In one instance, shrewd Artillery Wardmaster hit upon the plan of writii a Nominal List, which was hung up daily, of the men wl were to remain in bed and the men who were to get up, XOTE TO P. 170, ON THE ADMINISTRATION OF ^NFeDICINES. In speaking of Ilospitiil Discipline the extreme negligence in ilitary Hospitals, as to the administration of medicine, has '1 mentioned. The Patient really takes it or not, at his own rction, unless given by the Medical Oflicer himself. This deems almost to be intended, for, in tho Military Hospi- ^' Eegulations," it is positively one of the Articles that L'Jiciues shall be administered twice a-day, as though this • re a condition or quality of all medicines, to be taken twice In Civil Hospitals a Table of the Hours at which Medicines to be given is hung up in every ward, wliich is the only ,!iod of enforcing discipline in this respect. The cxaii4)le annexed is that used at Guy's Hospital, London. The Hours at which Medicines are to be given. When " 'nlered Kvcr\- Kour 1 lours. Wlicu Ordered Four Times Daily. When Ordered Three Times Daily. When Ordered Twice Daily. When Ordered Morning and Evening. When Ordered Daily. 1 2 o'clock Morning oClofk M'lroiug G o'clock Morning oClock 1 Tonoon 10 o'clock Forenoon 10 o'clock Forenoon 10 o'clock Forenoon 10 o'clock Forenoon 10 o'clock Forenoon .Clock '■moon 6 o'clock Evening 2 o'clock Afternoon 2 o'clock Afternoon 6 o'clock Evening 6 o'clock Evening or at 1" o'clock at Night f IJed Time Bed Time Bed Time fiiaters are requested to see that the Medicines are regularly administered, •'id to adhere to the above periods, unless specially ordered otherwise. apothecary's department. 171 ; tliat any officer entering the Ward might be able to \- their obedience. Perhaps there wouki ])e tliree lilies ordered to be up, twelve to be in bed; and tlirec ' 'lid be found in bed and the other twelve nobody knows re. On the other hand, many Convalescents will lie in 1 1 all day wlio wouhl l)e niiieli better for being up. .'. Ill the Apotlu'cary^s Department, although loaded Apothecan-'s h checks and counter-cheeks, the only thing at which ^^'Partmcnt. never arrive thereby is the knowledge how a grain of (licine is really expended. 1 1 can be traced, it is true, fiom the Apothccary^s Store i!ie Surgery, but no farther. \fter this, the Medical Registry is supposed to be the . k, /, e., the voucher for the expenditure of drugs, but 11 reality, none. Is it possible for a Medical Inspector ist up the quantities in, perhaps, 1,000 prescriptions, -ec whether the sum thereof tallies with the amount mil lias disappeared from the Surgery? This is sup- ,)!iiug that the Medical Register is kept in such a way as " Regulations direct, which it is not. The Regulations t that the quantities shall all be written down to the 1 •escriptions. l?ut, when a Patient is taking some medi- ne continuously, his bottle" is ordered to be sent to the ir<7cr}' ; perhaps, e. y., instead of an 8 oz. bottle, one ir times the size will be sent to be filled, and what then ' omes of the check ? In the Oeneral Hospitals of the East, the Dispenser tended in the morning from nine till one and in the evcn- l^ir from eight till nine at the Surgery : in the intermc- liours, the Surgery was left in charge of an Orderly, |Uo was sometimes present and sometimes absent : whih^ • Surgery was sometimes locked and sometimes not. idreds of pounds worth of drugs might have been jiwtracted and sold, without any one ))eing the wiser. 172 MEDICAL STAFF CORPS. except in the knowledge that they were gone. It is tie that, in some Hospitals, the Principal Medical Offi'ir required the Dispenser to take stock every fortnight, id report to him. But this only informed the Princiil Medical Officer that the medicines were gone somewhdi. The Dispenser could not say whether a Medical Offi r had made up his own medicines in the Dispenser's i- sence, which, of course, frequently happened ; whether e Orderly had drunk them, or whether they had been tala for other than Hospital purposes. When a man has the responsibility of stores, he muste in charge, i, e., there must be no power of taking anythg out of his stores without his knowledge. Careful Mediil Officers would leave the Prescription they had made up, s a voucher for the poor Dispenser, of what they had taki. It would be easy to remedy this defect in our system if checks, at the same time saving trouble. A Dispenser might be continually in charge in the S - gery, so that nothing could be taken or made up, withit his knowledge. And Medical Officers might, as they have sometir s been known to do, out of their own sense of integri , make up monthly, in their Medical Register, an Abstr t of the quantities of medicines used by them. It would e then but small trouble for the Medical Inspector to co - pare the sum of these Abstracts with the quantity i- pended in the Surgery. In the llegimental Hospitals, under ordinary circu- stances, the Regimental Chest of Medicines is replenislil every six months. There cannot be much difference in U demand; the calculation of what ought to be used 3 easily made; and no change or criticism seems to ' here necessary, CVp8^^^^ The Medical Staff Corps has been formed and organiz ! I purveyor's department. 173 f(t the service of General Hospitals; but the training of 1 1 (3 men has been so defective that the material remains 11 ; almost as raw as it was at the beginning. Numbers h (' remained idle, at the Depot at Chatham ; numbers li (' been distributed in the Regimental Service, where ; higher grades must remain ignorant of and unpractised ii he duties of large General establishments. ^Phe Purveyor's Department has been provided with a I'urveyor's ^ . Department. \ \ numerous staflp ; but nearly, if not all, were Purveyor's 0 War Office Clerks, from the highest to the lowest rank, n'li well skilled in book-keeping, accounts, and copying 1(' ors, but entirely and necessarily deficient in the follow- 1 indispensable specialities : — The knowledge of buying and selling and of the markets f the world. The Chemistry of food and its adulterations. Cooking. U'ashing. "Mechanics. Building. Engineering. Sanitary science. 'These things are insufficiently or not at all represented i the Purveying Department. Its functions are, besides, so inaccurately defined that ' y varied in every one of the War Hospitals ; and it was i aost impossible to discover then, as it is now, at home, tiat they really were and are. ' This Staff, also, is serving now almost entirely in the \ ^imcntal Hospitals of Garrisons and Camps, j Again, a few illustrations may be necessary. iA whitish liquid used to be issued to the Patients, at •atari, under the name of milk, in which there was not a p t)f milk. There would have been two ways of meeting 174 purveyor's this : — either the Principal Medical Officer might have . formed his Medical Officers that there was no milk d that they must order the Patients some other kind of dii ; or a Purveyor's Clerk^ if such there had been, who km anything about the testing and adulteration of food, mi^t have been appointed to test the milk and procure r] milk. Real milk was provided for the Patients, in some of Is Hospitals, by Miss Nightingale, upon Medical requisitic ; and the Purvey or-in- Chief authorized her to obtain s much real milk as she could, which she did, in varies ways. If articles of food are to be provided by the Purveyor Department, surely they ought to have the necessr/- knowledge to provide them good. Again, we see daily, in the London Civil Hospitals, U most valuable practical improvements contributed by t; Stewards, in the domestic and mechanical construction f their Hospitals, including the ventilation, sinks, wati- closets, &c. We have seen, in the East, a Principal Medical Offic his own Engineer, directing the Sappers and Miners. Again, the Purveyor's Department is a kind of ^"'pai- site" upon all other Departments (as has been well sa , by the Director- General, of his own Medical Depa- ment). . -M The Commissariat furnishes it with bread, meat, al^ fuel, for the Patients ; the Barrack Department with evef article of Hospital furniture ; the soldier's kit furnis" its own contents. The consequence of this is, that if, as constantly ha pens, the Barrack Department declines furnishing t article, although printed on its list, as not being in its pc session, the Purveying Department has discharged its i DEPARTMENT. 175 -|, isibility, by asking for it, and makes no farther exer- 1 1, s to procure it. he Soldier, having no place to put his little articles in, u 1 11 in Hospital, excepting under his pillow, brings in \vi itiiry reasons, to confiscate them for the time being, hand them to the Hospital Serjeant, desiring him take them away,^^ well knowing that neither he nor tl Patient has anywhere else to put them. )uc jack towel is provided for a Ward, upon which the Patients wipe themselves, the Medical Officer ; unless he is " friends^' with the Orderly, who then i i lishes him with a clean one out of his own kit. t is difficult, as has been said, to define what are the \ oyer's functions, in Regimental Hospitals at home : ;i few Contractors do easily the work for all England, I the Purveyor's Clerk does not even take the trouble >ue Extras daily to the Hospital Serjeant. The latter I. US, e. g., a dozen bottles of port wine at a time. This 1 liowever, very carefully looked after. No peculation ; possible. Vmong the Purveyor's chief attributes in Regimental 1 ^pitals at home, are the keeping the accounts of the I >j)ital stoppages, the cooking, all the Kitchen Atten- ( its being under him (the washing is generally done by t,' Hospital Serjeant's wife), &c. { Wliy not make him, like the Steward of a Civil Ji)spital, find all supplies? The supplies when issued ^ nild be under the charge of a Superintendent of ^pital Attendants, such an Officer being far more neces- ily responsible for the care of them. 176 DISPENSERS. ( Dispensers were provided during the War for the Ary, and employed in General Hospitals and with some H i. ments. These are nearly all now either employed as Stig. keepers^ or discontinued ; and Regimental Hospitals ce i again without regular Dispensers. In cases where three or four Regimental Hospitals re I under one roof, they have each their separate Surgiy, i where the Hospital Serjeant^ in most cases, makes up le i Medicines. How great would be the saving, if there ^^e one Surgery and one Dispenser to all ! ''■■i 177 VII. D ACHED Memoranda on the Operation of the Regimental System of Hospital Treatment. u el !\ erybody who has a living remembrance of the great Ct.inity of 1854 must ask, what w^ere the operative c;^cs, wliat has been done, and what remains to be done event the recurrence of such a calamity, to provide, • all and any circumstances (for this is the question) U ;i sufficient Hospital organization ? ):ie of the operative causes undoubtedly was the exclu- >i ly Regimental organization of the Medical Depart- II it; and, while it remains such, there is every proba- bly of a recurrence of the scenes of 1854, under similar ci'umstances.^ here are two or three men who devised and practically The system of medical treatment for the Army, previous to the "War ai again since the restoration of peace, has been entirely Regimental ints organization. There was, and as yet still is, only one Hospital "Wj-h claims to be called General, namely, that at Fort Pitt : the Artillery Hi ital, at Woolwich, which might be thought a second exception, is the ill Hospital, for the Regiment of Artillery. It should be added, li there is also at Dublin an establishment similar to that at Fort Pitt. E ry other existing Hospital is strictly a Regimental Hospital. Uniformly w this system a Medical Officer, as soon as he enters the Army, is at «t appointed to a Regiment, continues to serve as a Regimental Officer, as in the one case above mentioned, of Fort Pitt, until he is (1 altogether from direct practice and is transferred to the charge of liting or other military district, with the duty of inspecting recruits "I cyiraental Hospitals; his functions being now almost entirely those of II accountant and registrar. he attendance on the patients, according to the practice hitherto, has b»i given merely by orderlies, told off, at the rate of one for every ten ■i . to serve this duty in the Regimental Hospital, in addition to one R''ital Serjeant per regiment, of whose duties more will be said herc- Exclusively Regimental character of the English Medical System. •n an expedition is sent out, the organization, in like manner, con- N 178 KEGIMENTAL CHARACTER set forth a good working plan of General Hospital orgaL zation ; and, while these men are living, there would be ) danger of a similar breakdown to that of 1854. But tl^r did not instruct the Surgeons immediately below them^i their plans of working ; and the latter remained in aim t perfect ignorance of them. The history of this is as follows : — This character When the usual Regimental Hospitals and small Mediil ^hrOentrS Staff proved utterly insufficient during the late War, f d Hospitals larare General Hospitals were established at vari(^ established ^ ^ during the late tinues to be regimental. A Principal Medical Officer (of the rank o| Inspector or Deputy-Inspector) is appointed, with Staff Surgeons, at j rate of one to each Division or Brigade, who act as Inspecting OflS' over the Regimental Hospitals attached to the regiments of the Divi or Brigade ; every single regiment retaining, as in time of peace, its special Regimental Hospital, which it is supposed to carry about wi and to establish as it can, wherever it goes. Preparations were indeed made for the establishment of a Hospita larger numbers in the neighbourhood of Constantinople, and a bull at Scutari was handed over to the British authorities for this pu' The General Hospital, however, thus established at Scutari, retained i| of the features of the Regimental Hospital familiar to the military mel man. Dr. Menzies, the officer in charge of it, declares in his evidl " I have followed the general rules for Regimental Hospitals so could." Sick and wounded men were certainly received indiserimin from different regiments : in the place of the Regimental Surgeon, we fid the 2nd class Staff Surgeon, or to serve in his place, the Assistar Acting Assistant-Surgeon ; and to inspect the whole Hospital there 1st class Staff Surgeon; just as in the army in the field there 1st class Surgeon to inspect the various Regimental Hospitals Division. With the medical treatment of the Patients in the Ge Hospital, this Officer had little more to do than he would have if attached to a Division in the field, as Inspector of its Reginn Hospitals. In theory to the very last, the General Hospital, or Go Hospitals, at Scutari, continued to be a congeries of Regimental Hosp and, at one period, it was actually such in practice. In fact, towards end of the War, in the General Hospital (that which was first estab and to which the others were superadded) the regimental arrangew were distinctly and purposely resumed, and this Hospital simply admjed under its roof the several Regimental Hospitals of the cavalry, whichM then been put into winter quarters at Scutari. 1^1 i OF THE HOSPITAL SYSTEM. 179 rs, Medical Staff Officers were sent out to the East, \' . succeeded in bringing these establishments into a • or less creditable state; but they failed^ as far as strictly professional duties were concerned, in estab- 1 ling a system or, at least, an improved and well-regu- I (1 system. The functions of the different ranks were I strictly defined^ the individual liberty of officers was, ■jirndly, too carefully preserved, and the interests of s nee were disregarded. these three statements we may give a few illustrations. )i' the most interesting period of the Campaign there \ 1 be no ]\Iedical history whatever, i. e., none of 'any \ lie. The Medical Registers were not kept, nor w^ouldit 1 ^ c been possible to keep them, owing to their voluminous ciracter ; nor, had they been kept, would they have been ( any use for Medical science ; for the general routine I U eping the Registers is scarcely of any scientific value. About the beginning of the summer of 1855, a form of (^cstions was prepared for the Surgeons to answer, and tese answers will afibrd, when an Abstract is made of Ipni, very valuable information. But no rule for practice come to during the War. The principle which we ,iud constantly asserted, by more than one Principal ''Mlical Officer, was that of making his General Hospital much like a congeries of Regimental Hospitals as Mblc. And though this theory neither was nor could systematically carried out into practice, it remained III does still remain their theory, and prevents, as it pre- ^nted, any attempt to devise a better and more ]n'ac- bable scheme. f Each Surgeon in charge of Wards was as independent i. though he had been a Regimental Surgeon. He seldom Sent into any one else's Wards. Enormous as were the inil)ers of cases of the same kind treated, viz., of Dysen- N 2 Three defects of the System. Absence of all Registration of Treatment. Entire Independence of the Surgeons in charge of ditierent Wards, as regards Practice and Rules of Treatment. 180 THKEE DEFECTS OF tery. Fever, Scurvy, &c._, there was no comparison different treatments, in order to determine, from expe'. ence, the most successful kind of treatment, with a viewio its adoption generally, \ Medical Officers were frequently changed ; but the s :- i cessor was not enabled to profit by the experience of is predecessor. Each had to learn his own lesson, if he could ; and ;e results were often curious. I Contrast, in It is well known that, in the French Military andja > *\he French^ our own Naval Hospitals,* the highest Medical ranks e System. ^hos^ who actually treat the Patients, as they ought lop- ally to be. In both these Services, they are in chai3, themselves, of a certain number of Patients. In ;.e French Service, the " treating'^ Medical Officer [medetf- major) is accompanied by his Assistant Surgeon (aifi^e-majH) and dictates to him the dietetic and medical treatment, i d the observations on each case. These are written downiy the Assistant, at the bedside, on the same cahier," and )- pear on the same sheet. For alternate days there i a different sheet, so that the Surgeon holds his sheet of preceding day, with its treatment recorded, in his hc l, while dictating to his Assistant the treatment of to-da} From this sheet are extracted the Diet Roll, the I3- scriptions, fee, but not by the treating Surgeon. * We beg not to be understood to mean that the French Army Me sal System is perfect; on the contrary, the collision of interests betweeihe French Intendance and Medical Department is obviously and acti.ly hurtful to the Patients. The interest of the first is economy — the int jst of the second is efficiency: yet the former are allowed occasional! to recommend the latter for promotion ; and a Medical Officer troublei ne to the Intendance from his care of his Patients, may thus be puni ed for his very zeal and humanity. It is reversing the order of things ?r, as a very high Functionary of the French Army said to me, "pu Qg the * materiel ' first ; the ' body ' over the soul.' " THE REGIMENTAL SYSTEM. 181 III our Regimental Hospitals at home, the Surgeon has t make six different records of the Diet Roll himself. :To give some idea of the multifarious duties, non-pro- MuUifarioua i sionalj devolving upon the Surgeon, we may state that, professional i one of the General Hospitals, during the War, the ^s^rgel^ ( (Irrly Medical Officer, told off for duty each twenty-four lurs, had to give a written Report to the Principal rdical Officer, that he had inspected the Kitchen, the ( Ills, the Steward's Store, the Wards, the Water-closets^ 1 short, every conceivable appurtenance of a Hospital, ;out most of which he could know nothing, if he did in- ject them, and complained bitterly that he had to do so. |iThe natural result of loading a man with a greater |riety of duties than he can possibly attend to, or than he possibly be properly acquainted with, is that none arc tended to, and the Report becomes merely nominal. One more illustration. We are now on the point of Illustration of nding out an Expedition to China. The sufferings and ^^^'^MedicaT •eat mortality of the troops, in the Expedition of 1840, Records, om Dysentery and from salt meat, especially of the ')th Regiment (the mortality of which was upwards i' 10 per cent.) arc fresh in the English memory, aluable medical records are said to exist of this, in the rchivcs of the Army Medical Board; yet they were not iblicly communicated to all the Medical Officers accom- I lying tliis Expedition, nor could they be to those who -•re ordered to China, from a station distant from Eng- I' Why are not abstracts of or selections from our Medical f^cords published half-yearly and a copy sent to every ledical Officer in the Service ? f To sum up. J Three things which it is here endeavoured to establish ire:-~ 182 FAILURE OF THE 1. The want of definition of the functions of U different ranks. 2. The too great care of the individual liberty f Medical Officers. 3. The disregard of the interests of science. We cannot^ at the same time^ repeat too often how al; some of the Medical Officers organized their Genel Hospitals. But these General Hospitals have been d- continued^ some of these officers are on half-pay, some r- sorbed in the Regimental and Depot Service, and few,f any, will ever have an opportunity of again acting out r handing down their experience. Recurrence It appears that the Army Medical Department, wii since the War ^ ^ . , t t i i ^ . to the very lew exceptions, has now slipped back to tJ Regimental g^xng state, in which it was before the War: and t Hospital ^ ' System; may, therefore, be concluded that, the system being U same, it will work again in the same manner in any futi a War, if the personal experience of a few individuals, whi^ acted so leading a part in the last, is no longer at or command. We find now the Regimental System kept up as excl- sively as before the War — Regiments and Detachmeu establishing Hospitals wherever they go, independent : each other, according to the system detailed in the He, pital Regulations. j whicli in the It is, however, an acknowledged fact that the Re|; ^ent1rel>'^"^ mental organization of the British Army — the necessa' inadequate, consequence of the nature of our Service, as it was f( mcrly, proved insufficient for the purposes of a large For; REGIMENTAL SYSTEM. 183 rield — iicnce tiic demand for Staff cducatioi IK c the brij^adinj? tof^ether of Troops at liomo, &e. it, althon*;-!! in the Military Medical Service, the evils { exclusively Regimental organization are, if possible, ) >ro evident than in any other branch of the Military ice, in this alone nothing has yet been done to change System. W ithout actual experience, indeed, which the late War ^ al)undantly and sadly furnishes, it is logically evident 1 it to divide a small number of sick into half-a-dozen nitals, which have all to be kept up as complete and rate establishments_, instead of uniting them into one, ^sarily involves considerable waste of labour and ex- :i>iC. hut this is not the greatest disadvantage of the System. Nine \s long as the System of Regimental and Detachment itals is exclusively kept up, no great improvement Particulars in whicii Small Military Hospitals niusL )()ssible, in any of the following particulars : — coutinue to be I . The management and internal economy of Hospitals, 'l^^^c'<^°*- "king, washing, supply and issue of extras, &c. -. The financial part of the Service. 1. The professional and economical Superintendence, j 4. The organization of the Attendance Department and * Superintendence. .'j. The Dispensing and supply of Medicines and other [pplianccs. The introduction of proper baths, lavatories, &c. See n. 187 7. The classification and treatment of particular l)is- ^ riu- iuiixM'ativcly needed organization of Hospitals >r tlu' Soldiers' Wives and Children, when sick, the want f which is most demoralizing. ' 9. The arrangcnuMits for the treatment of sick Prisoners lid others, not bclou'-iuir to l\(>iriuH'uts on the Station. 184 ITS NUMEROUS NECESSARY In large permanent Establishments only, could the: things be properly regulated. In Malta, Corfu, Gibraltar, London, Portsmoul, Aldershott, &c., there is a sufficient body of Troops i' such Establishments to be made. Regiments even now leave their sick behind, them — o; consequence of which is, that no system of Sick Transpc is devised. But, above all and before all this, under the prese: But the exclusively Regimental System, no great improvement ci Dib?dvantage made in a professional point of view, i. e., in raising U is the want of standard of professional qualification among Army Medi Professional , • i . i t ^ Training to be Officers which IS SO much needed. ^^*^them However justly they now claim improvement in tb status and position (which can hardly, we trust, fail to '? granted them), how much more justly would they claf this, which alone will not bring about the necessary ij-5 provement in scientific matters, if a change in the Systd had raised their professional claims ? The desiderata are : — 1. Sufficient professional occupation for Medical Offic 5 to keep up their knowledge, and sufficient material to ai - ment it by experience. 2. Opportunity for improving and furthering the prr- tice of Surgery and Medicine, by command over lai3 numbers of cases of the same affections. 3. Opportunity for comparing results of different mo( 5 of treatment. These things cannot, ordinarily, be found in a Regime • tal or Detachment Hospital. No great improvement can be made, because — 1 . No practice can ever be established as the best in t ) Army for the treatment of certain diseases, if the sick treated in so many hundred Hospitals by as many hundi i DISADVANTAGES. 185 ^ t ircons, scarcely one of whom ever becomes acquainted V li the result of the practice of all the rest. 2. No system of mutual information and clinical in- s iiction can ever be established under a System where i lividual experience remains individual property, or is 1 ried in Official Reports. '). No professional specialities, and this is a most impor- 1 it point, will ever be educated in the Army, as long as I one can have an opportunity for collecting the neces- \ material for study, practice, and experiment, in special iscs. Twenty legs may be broken in the same Garri- . m one year; but, under the present system, no Sur- on in the Garrison sees more than the one or two under > care, and therefore has very little chance indeed of iirning anything by it ; whereas a man who treated the •dole twenty would be master of the subject, and all the lii;rs (for this is the main point) ^would share the benefit his experience. I. The introduction of publicity is one of the most im- rtant agents for the improvement of the Department, ' aiise it would bring Individuals and Establishments ito competition with their rivals in Civil Life and other nnies; but this is almost impossible under the present -tern. The same thing may be said, both as to the impor- iicc and as to the impossibility, (under the present tern), of introducing prizes, distinctions, and promo- 11 for scientific and professional labours. Vrom all these reasons, it would appear that the deduc- Establish m is as follows:— Divisional or Brigade It is desirable to establish on Stations, where larger Hospitals, mhcrs of Troops than one Regiment are collected, at no and al)roa(l, permanent Divisional or Brigade Hos- lials; together with a permanent Staff of Medical and 186 DIRTINESS IN Administrative Officers aud subordinates, for the tre- ment of the sick of the Station, and of Detachmei's within reasonable distance. ! At this moment, the Artillery at Portsmouth alone hrj six Hospitals, of which four are within five miles distari of each other. One advantage to be derived from the above arran^. ment would be the necessity of transporting sick. This would lead to an organization of such transpo', which at present does not exist ; and did not exist, evi during the War, at home. Another advantage would be, that the efficient Hospi StafP, trained under such an organization, would supj Regiments going on Colonial Service for the period such Service, after which it would return to the Gene Staff. The technical difficulties of transforming the prese Regimental Medical Officers into Staff Officers may appe| greater than they really are. In the British Army, where one Regiment, or hal: Regiment, is stationed by itself at a Colonial Post, it essential to keep up the main features of the Regimeni Medical system ; but, whereas now there are, besides i Regimental Surgeon, two Assistant Surgeons to e Regiment in time of peace, three in time of war, o: Regimental Surgeon and one Assistant Surgeon would enough to do the duty, if there were Divisional Hospital where more than one Regiment are stationed togethe The Senior Assistant Surgeon, who is expecting his pr motion, might be appointed to the Divisional Hospital. Tiaths and It is not necessary to prove the great importance personal cleanliness, and of opportunity for bathing, Hospitals. Neither is it difficult to make the English Soldier ke( REGIMENTAL HOSPITALS. 187 h iself clean. In the Crimea, nothing depressed him and |) him to shame so much as the impossibility he was II Icr of obtaining the means to do so. Nothing pleased t Patient so much as being washed when he came into 1 .|)ital. There are, of course, dirty and brutal characters in our A iiy ; but anybody who has seen the pursuit of cleanli- Ti s under difficulties of the British Soldier, heard his ( i (!aties to the Orderly to bring him soap and water in t Hospital, seen him sitting up in bed scrubbing himself, v,l allow that it is the least difficult task in a British ?litary Hospital to inculcate cleanliness among the men. \ ct in most, if not all. Regimental and Garrison Hospi- t is still to be seen the Lavatory on the ground floor, V h sink and stone flooring, of the same construction for t sick as for the well; and in the Wards little or no 1 )vision of basins, towels, soap, &c., which the man is - 1 supposed to find for himself from his kit. The Medical Officer has still the same difficulty in ^^scribing baths for his Patients. They may be pre- S'ibed, but the thing is not done; and, we fear, never \11 be done, till there are General and Di^dsional Hospi- ts, with proper arrangements for bathing and personal ' filing. In 1818 a circular was issued from the Director- ' iicraFs Office, stating that baths were not necessary in iitary Hospitals. I The cooking is now provided for, by recent order. Cooking. Regimental Hospitals, an Orderly being told off", for [)urpose, from the ranks; hitherto it has been done. Regulation, by the Orderly attending upon the sick. 188 THE HOSPITAL SEEJEANT. Practicable The Regimental System, as laid down in the Hospil ^^\nthT^^^ Regulations, is so defective in its organization that, if pi, Kegimental ggrved, it needs to be improved. System, ' ^ _ The Medical According to those Regulations, the entire manageme; ^^HospUal* ^ of the Hospital rests with the Medical Officer and a H(. the whde St^ P^*^^ Serjeant under the Military Authorities. in charge of a The duties of the Hospital Serjeant, by Regulation, llcgimental i- • t . Hospital, as at SO multifarious that it may sately be said to amount to i constUuted physical impossibility for one man, however active a I intelligent, to perform them all. In addition to whi(, the natural dislike of almost every Surgeon for non-p]|. fessional and book-keeping duties throws many more thji Regulation duties on the Hospital Serjeant. Summed up, they are as follow : — 1 . To superintend the Wards ; the attendance on Patients ; the administration of Medicine, &c., &c., &c 2. To keep up Military discipline. 3. To assist the Surgeon in keeping the Admissi books; in making States, Returns, Accounts, and otb Documents. , 4. To take charge of the Dieting, Issue of Extras, w4 half-a-dozen Diet Rolls and Provision Returns. i 5. To take charge of the Washing, Hospital Stor , Furniture, Medical and Surgical Stores, Surgery, &c. The Hospital Serjeant, in short, is to act as Ward-Master, Serjeant, Steward, Clerk, Dispenser, till very lately, and, where there is no Purveyor, as Purveyor's Clerk Under the most ordinary circumstances, it is uttei' impossible for one man to perform all these duties ; b what becomes of them when the number of sick increast under extraordinary circumstances ? till SUGGESTIONS. 189 lit is indeed the chief fault of the Regimental Hospitals, \ ., this want of expansibility. |,What really happens is the construction of a different s'tcm in every Regimental Hospital. In one, the Hos- I al Serjeant is always in his Wards, where indeed he 1 s need always to be, and leaves all the writing to an (iderly. In another, he has never time to enter his Proper Staff of ^ards, which are left to the charsre of Patients and Order- Officcre ^ required in a 1 and devotes himself to the book- keeping. Keirimental 1)111 a Regimental Hospital really requires, to do its ^^^^P^^^'- 1 -iiicss properly : — 1 . A Serjeant, to take Military charge of the Hospital ; I its Inhabitants, to take the general superintendence, :(l to be the Office Clerk. ' An Assistant Ward-Master ; to be the Head Nurse, ^lurinteud the Orderlies, attend on the sick, administer T^dicines, &c. ; for the Orderlies are only the sweeps and ii-carricrs under the present system. • A Dispenser (Non-Commissioned), to compound, kc charge of Medical and Surgical Stores, of Returns il Accounts connected with these. (The same man may fill Offices 2 and 3 ; but not Offices iiiid 2, which, to be well done, must essentially be dis- lurged by two different persons. No. 3 must be an 'ucated Dispenser.) I. An Assistant Steward, as Purveyor's Clerk ; to take .re of Purveyor's and Barrack stores, provisions, cook- washing, diets, and extras; including Returns and < units connected with these. Orderlies in the Regulation-proportion to the sick. 1 (No. 1 should always be a Soldier ; No. 2 of the Medical 'taff Corps.) 190 INCAPACITY TO DEAL Need of the How^ then, must these General Hospitals be organize? OrgSizliuon Fcrmoy, &c., &c., there are Depot Battalions, t of General Aldershot there is a Camp ; yet there is but one Gene] ti^?of Peace. Hospital, viz., at Chatham, and Surgeons might be ma/ years there and learn nothing of the organization oj;i General Hospital. It is of the first importance to make use of this ti s when there are congregations of Eegiments (as at Ald- shot) grouped together, to form a system of Divisioil Hospitals, in which alone Army Surgeons can be propey trained. The Regimental System was proved completely iUus(7 in the Crimea, not affording accommodation for one-ten of the sick, although the Regimental Surgeons are adi- rable and the Regimental Hospitals, during the latr part of the time, were in admirable order. It might never happen again that we should be twen ■ one months in the field on the same spot, and on I3 march the Regiment cannot carry its Hospitals with ; there must be General Hospitals in the rear, as in 1 3 beginning of the Crimean War. Yet our whole system at home, and in time of pea, having been a Regimental one, it naturally happen 1 during the War, that Staff Surgeons, never having sei more than 50 — 100 sick together before, had no ideaf organizing an Hospital where there were to be 1,000- 2,500 sick. The Regimental Hospital System is, at once, the m Evils of the expensive and the least conducive to Science that could Regimental 1 - i System. devised. It requires a larger body of Medical Officers, a lar^i' body of Attendants and Officers of every description th anv other svstem. I WITH LARGE NUMBERS. 191 t tlie same time, it is the least conducive to Science ; to how can a man learn much when he has one or two and not more, of each disease to practise upon? I no of the main objects of a Regimental Surgeon is to lie no death in his Regiment during the year; and this I en accomplished ; because when a Regiment moA^es, >ick can be transferred to another Regimental Hospi- or a l)atcli of weakly men may be sent to Chatham to il or be invalided. Provided a man dies out of his Regi- 11 it, or is invalided, the object is gained."^ )uriiig the War, 13,000 sick and wounded passed Ignorance ami ' 'Ui,di Portsmouth. Those who were able to move were the means of on to Chatliam or to Chichester, the rest detained Transport. II ieueral Hospital at Portsmouth up to November 24, t will scarcely be credited, yet so entirely unac- c tomed were the authorities to deal with large numbers, I t there were no sick carriages, or other means pro- \ ( d, to convey the wounded men to Chatham. A ( lain number of second-class tickets were bought, equal t the number of invalids, and the men put into the lid-class carriages, without even a pillow, when they t iiLT went to Chichester or to London Bridge, as the might be ; from which latter Station they were -fcrred by another train to Chatham. I he confusion and distress when the W ounded first ■ ivcd at Portsmouth was almost equal to that suffered at ' iclava, or after Alma at Scutari. There was no prepa- •n, and hundi-eds of wounded men were laid in their |i* Th's is but another proof of how little our Returns of Mortality ■'ly tell. In order to give us any actual insight into the sanitary state r army, we must know how many days a Regiment spends in Hospital ' year ; that \n, how many days it is more or loss ineffective, and how men are invalided as unfit for service. 192 PRESENT DEFICIENCY blankets on the floor^ as appears by the account of le indignant Surgeons. The worst cases were taken into lie Hospital, as fast as there was room for them, under ie care of a very able 2nd Class Staff Surgeon, who p . formed many amputations upon these wounded arrivji, but had not one death among them. Fallacy of the It is repeatedly said that the Regimental System s knolwedgeof Perfect, because the Regimental Surgeon knows all s their men by nien. The fact of the frequent changes of Regimen l Regimental . • i -n • Surgeons. Surgeons is not noticed. One Regiment has been knoi to have no less than six Regimental Surgeons successivijr during the War : and one Surgeon to have been Rei- mental Surgeon to seven Regiments successively, in 1 West Indies. I Fallacy of the It is true that the Regimental Service is infiniti r drawn from preferred by Medical Officers to the Staff Service, becaib onhe^MSal Regimental Surgeon is more independent, and li Men for inspected. n Regimental . i n i j I Service ; It IS also said, not without some truth, that the Soldr p^^ftrence^of ^^^^^ Regimental Hospital better than the Gene-l the Soldier for Hospital as now conducted. Regimental , | Hospitals. The good ones do, but why ? Because there is, no , much less discipline in a General than a Regimeni Hospital ; the utmost that a Medical Officer can do wi; a refractory Patient or Orderly who " commits himseli is, to place him under arrest, and report him to the Coi mandant, or Commanding Officer, and the utmost punis ment which usually follows is to order the man, if ii orderly, to rejoin his Regiment. I have more than on seen cases where an orderly, if anxious for some reason rejoin his Corps, offended on purpose. Actual On this and many other accounts, the Corps called tl Deficiency at t i of the Medical Medical Staff Corps is an excellent institution, althoug! statr Corps ^j^jg moment, its Members are generally inferior to tl| OF THE MEDICAL STAFF CORPS. a Orderlies of tlic Line, having been selected by merely wl>i< li wa.i Mvin^' at them ; ])ut the impossibility of having pcrma- Ui'e General lyt good Orderlies is obvious — not in the Reginioiits J^ospitals. V TO, if th(^ Re^nnicntal Surgeon is on good terms with his I Handing Oflicer, he ean obtain whiehever one or two he likes; but in General Hospitals it is impossible vpcct the Adjutant (or whoever the OfHeer may be) to r tiie 100 best men for the Hospital service. He tells ic worst. \ pcnnancnt Corps of Hospital Attendants, with l intcndcnts of its own, is therefore an obvious im- inent ; but it has not been made in the best way. :id of their having Medical Officers or skilled Nurses lilted expressly to instruct them theoretically and '(•ally in dressing a blister, putting on a water-dress- iidallthe minor dressings they will have to perform, have been left to learn, or not to learn, by their <) I intuition. A Medical Staff Orderly has been seen i Iravouring to make a Patient eat his })oulticc — in all / i faith. is C(jrps is also understood to be enlisted to serve ■ 1 Hospital i. e., not to be employed under fire, or in tl tield. Yet it would seem as if one of its main duties 1(1 have been to carry wounded to the rear : whence it I also have followed that the Medical Staff Orderlies t to be instructed in such duties as having at hand he use of the Surgeon what is necessary for an itation, for putting up a compound fracture, for mg the tourni(piet in case of hemorrhage. A II amount of Anatomical Instruction from a Medical •r would ap})ear to be highly necessary, so that they d at least know where the principal arteries are. :i:ivc seen a Medical Officer cooking starch himself in Y.xtra Dmies .itchen in a Hospital, because the Medical Staff ^^^^^Je^o^^^e ^ ' Medical 194 BAD ATTENDANCE. Officers, in Orderlies did not know how to make starch for stare ;d consequence of ijandasfcs : and it was not the business of anv one to si w the Ignorance » ^ of the them. I have seen a Medical Officer (doing duty as Assisiit Surgeon, at Scutari), spreading simple dressing himdf on lint, spending a couple of hours in making his en petty arrangements, which were obviously the duty ojm Orderly or Nurse, and which, had they been made for Ijti, would have given him time to attend far more clo to far more Patients. The cause of all this is in the Medical Officer b understood to perform duties which he never does perf and which he ouglit not to perform, if he does his dutj^y his Patients. He is understood to dispense, adminiier medicine himself, and attend to all those minor Surgal details which, in all Civil Hospitals, are the recogn duty of the Nurse. It is true, that the Hospital Serjeant does dispense it is true, that the Orderlies do dress blisters, &c. ; but le absurd practice is still followed out, viz., of winkin their doing so, and not recognizing the necessity o being so ; and therefore it is not made a regular pa their education to learn how to do it properly; ind they are supposed to require no education at all. The washing is done as follows : — the Diets^' counted up, which means the Patients ; the Hospital jeant probably has a wife, and she receives the dirty lii washes it, the Purveyor reckons up the pence, and her so much per " Diet.^^ This again does very well there are ten Patients j where there were 10,000, we the failure. But is this a preparation for organizing a General pital in time of war ? Is it to be wondered at, that Me Officers brought up in this School to look after a d FOREIGN HOSPITALS. 195 Pi cuts, should have lost their heads in time of pressure, anjl been incapable of coping with it ? hese minute details are given, in order to shew how !i( ssary it is to have model General Hospitals at home. 'r< my one who has seen a Regimental Hospital at work 111 ine of peace at home, and a General Hospital abroad in| me of war, it would seem as if the Surgeons who made th|latter march at all, must have been gifted with real inntive genius, and resource, so wholly unprepared were rh with any example, any training, any experience. So faji'om blaming them for what they did not, we must "'1 ire what they did. I sketch may be added of the organic difference \('cn the Hospital Service of the several nations l^^ed in the War. lie essential characteristic of the French is, the im- aiice given to the Divisional Hospital Service in the over the Regimental. The Regimental Medical ice treats only those ephemeral cases wdiich are to be iipted from duty for a day or two. 11 those whose wound or disease, such as Bronchitis, s supposed likely to last for a term of weeks, are to the Divisional Ambulance, established in the Those, again, whose disease may possibly last for lis, — chronic cases, which yet may rejoin the Army, do not therefore require to be sent home, are sent to I leneral Hospital at the base of operations (in the late , Constantinople). lie Sardinian Medical Service closclv resembles the Sketch of the Hospital Service of the French and Sardinians. 196 FRENCH AND SARDINIAN above in its formation. In tlie late War, the Geneil Ambulances were in the Crimea, on the heights above o- own Castle Hospital, at the mouth of Balaklai Harbour. The General Hospitals were at Jeni Koi, i the Bosphorus. " There are 1,276 Medical Officers in the French Army, f this number about 600 are employed in the different E( - ments. Each Eegiment has a complement of 3 Medil Officers, viz., 1 Medecin Major, 2 Aides. "The remaining 676 are attached to the ambulances id Hospitals— they can be detached for service in the Eegime:s, according to the exigencies of the Service, or vice versa. " Of the 676, about 400 perform the duties of Assistants d Dressers; the remaining 276 only are the actual respons.e officers. "Those Medical Officers who are attached to Eegime.s cannot treat their sick, but only slight cases of indisposit i, such as may be liable to incapacitate the men from the -r- formance of their duties for a few days only: all those lO are really sick are sent to the Ambulances," (Eivisiona )r General) " where they are at once removed from all fur 3r control or care of the Eegimental Medical Officers, who are Dt permitted even to visit them after their removal. " The duties of the Eegimental Medical Officers are to a- mine, each morning, all those soldiers who report tbemsees sick and to send them to the Divisional Ambulance, or exept them from duty for a da) or two, according as the gravit of their case may demand either expedient ; to make siiggestQS to the officer commanding the Eegiment, on all matters n- nected with the Sanitary arrangements of the Camp or :r- racks, and also to report on all Medical matters to the Mecal Board in Paris. " This Board is composed of — "1 Pharmacien Inspecteur-General, " 6 Inspecteurs-Generaux des Hopitaux." * * This extract is translated from a French document. MILITARY HOSPITALS. 197 (The French Ucj^mental Medical Officer corresponds jiactly to tlie Sanitary Officer we would wisli to see • tablishcd, as our Rej^imental Surgeon. I The grand fault of tlie French Medical System is its Ispendencc upon and sul)ordination to the Intcndance, |bich defect branches out into every ramification. It is ipossibh^ to describe the deplorable consequences of this .bordination, nor the feeling entertained by the French l^edical Service about it^ which, for obvious reasons, they f-e obliged to dissemble. .In our Army, as is well known, the Regiment esta- of the Euu'Utih. ishes its Regimental Hospital, wherever it goes, f Theoretically, it is exclusively a Regimental system of Lospitals; but, practically, as has been seen, it entirely ^•caks down. , When an army is advancing, for instance, as was our kfle at the Alma, the sick and wounded must obviously be ♦ansferred as quickly as possible to the General Hospitals : the base of operations. During the whole winter of '•1-55, even when we were stationary, the Regimental flospitals were found incapable of holding one-tenth of [le sick and wounded, and it will be seen by the return . 17, how large was the proportion sent to the same •oneral Hospitals. \ (ieiKTul Hospital was also established early in the immer of '55, in the front, three others in the rear. . Great as are the theoretical advantages of Regimental lospitals, practically, in operations of any magnitude, |3ey must always be found inadequate. For what cir- imstances could have hvcn found so favourable to them * the late War, wIhtc we remained on the spot after ■'daklava, Inkermann, and all the winter? How luany battles are recorded in history, where the 'Hiiy remained whe re the Ijattle was fought, after it was 198 RUSSIAN MILITARY over, and was able to accommodate its sick and wound I on the spot ? This can only be the case in sieges, iri standing camp or winter quarters. The question will be immediately asked, as to injury likely to be inflicted on the sick by moving ther^ This may very shortly be answered. There cannot i a doubt as to the fatal consequences of transport]^ Cholera or Choleraic Diarrhoea. It was little less tlii manslaughter sending these cases down to Scut£. Cholera can best be treated where the man is attacb. Lay the man down, if possible, then and there in blanke , and treat him there. Move him in a horizontal positi(, when he can be moved, to the nearest Hospital. As for fever, change of air is the best thing for the en in the incipient stage, or when convalescence has begi. In the collapse stage of Typhoid Fever, it is nearly sure ) be fatal. In wounds, there are always 24 hours^ respite, bef(3 inflammatory symptoms set in, when it does the wound I no harm to be moved. It is true, on the other hand, that there is a time wL i wounded are moved with difficulty, especially compoul fractures. Great must have been the suff'ering, and fatal t; consequences, of the 7 miles' land journey after Inkerma i to the wounded. But, again, after how many battles has it not bei compulsory to move the wounded off" the ground ? It remains to say, is it safe to depend upon an excl sively Regimental system, when in all emergencies, t: General Hospitals must be what we must fall back upoi The Russian system can scarcely bear a comparis' with ours ; because their Regiments are Divisions. TIi had a regular system of transporting the sick and wound HOSPITALS. 19!) the North side of Sevastopol, then upon Mackenzie's Iligbts, then upon Bakschi-Serai, and lastly upon Sim- |jTopol. This system seems to have been excellent. And the p|(iderful efi'ects of change of air upon the sick in in- Aing recovery, si)ite of the inconvenience of transport, 4 well known, and have been seen in the Peninsula, even ( ;i retreat. I 200 VIII. Notes on the Existing Organization for Geneil Hospitals. Government of General Hospitals. Hitherto there have been Nine Departments concerned in their Management. 1. The Medical Department. The primary necessity of Hospital management i; he reduction of Departments to their smallest pos)le number^ and the definition of their functions. Mil jt General Hospitals should be compared with Ci^il Hosp Js, Gaols, Lunatic Asylums, and Workhouses — institu containing from 1,000 to 1,500 persons. In our present Military General Hospitals there ire nine Departments, a system which seems to have -en adopted for the sake of checks and counter-checks ihe object of which is rather to save money than to sav.he lives of the sick. It is a system inconsistent with pr ipt and efficient action. The nine Departments are as follow : — First, the Medical Department, named by :lie Director-General, and appointed by the Command of the Forces. In the case of Scutari, the position was one : er- mediate between the Home and the Military auth .tr. In other cases, also, General Hospitals at the ba d operations must always be at some distance fronthe army. The first and second Commandants at Scutaii ere named by the Commander of the Forces ; the third, ter having been made Commandant of a Civil Hospit at Smyrna, by the sole authority of the T\'ar Depart *nt, was appointed Major- General Commanding in the os- phorus, by the Commander of the Forces. The Principal Medical Officer was appointed b} r-^ THE NINE DErAKTMENTS. 201 ommander of the Forces, and was inspected and reported [)on by the Inspector-General in the Crimea — {vide eport of the House of Commons Committee and the eneral Orders). The War Department, dissatisfied with this Report, and ^ceiving extraneous information, sent out to Scutari an Iditional staff, to reinforce the Medical Department, »ctober 1854, unappointed, though possibly confirmed, by ic Commander of the Forces. Secondly, the Commissariat, who are the carriers, o. The ore-keepers, and bankers of the army. Commissari The ^Medical Department, therefore, can send its stores irough them only, and it was, at Scutari, dependent for •16 removal of its stores to and from Varna on the -ommissariat, using a portion of that Transport which .as under the command of the Admiralty. Upon the dme principle the transport of even wood, charcoal, and ?e, meat, and bread, rested with the Commissariat, as did be conveyance to the Purveyor's Department of whatever I'as landed from England. In the Contracting Department of the Commissariat, the 'urveyors and Medical OfiScers received from the Com- lissariat commodities in the choice of which they had no (oice and o\er the quality of which they had no power, xcept that of reporting.* The questions to be asked, in order to elucidate this all -important iceiioQ of supply, would seem to be the following : — 1. What are the inconveniences from mixing the duties of the Purveyor .ith those of the Commissariat ] Had the Purveyor, in the late War, any "cto on the Commissariat contracts, on the choice of kinds, I qualities, prices 1 2. Did any remarks or remonstrances induce the Commissary ever to I 3. Was not the Purveyor in the hands of the Commissary, and wa.s there 202 THE NINE DEPARTMENTS. In the Banking Department of the Commissariat, le officers of all grades in the Hospitals, Medical, Civil, id any appeal to the Commander-in-Chief, except in extreme cases, arj if used, did it bring on dispute ] ! 4. As to coal, wood, charcoal, did not the Commissary provide these lid not the supply run low, and was not the quality bad, on account of |jre being no store on the Asiatic side and of the difficulty in the pag,ge, without any immediate remedy ? i 5. In these matters would the service have profited, as to supplybd rapidity, certainty and quality, had the Purveyor made his own contra is? 6. Does the same apply as to bread 1 7. Was not the bread at Koulali better than at Scutari, under siilar circumstances 1 8. In landing goods, stores, and provisions, was the Purveyor depeEimt on the means of carriage the Commissary had collected, and could he Commissary know the wants of the Purveyor, while collecting that car: ge from day to day ? j 9. Was mutton always given to the British and beef to the French, [th few exceptions 1 Could the Purveyor, had the Eegulations allowed, have provided be( Was he ever told that quantities of cattle existed round Olympi in sight of Scutari? Was the question ever debated between the Medical Officers and she Purveyor, and any demand made on the Commissariat, at Head Qua sra at Pera 1 10. Had the Purveyor supplied his own Hospitals, by Agents and |tt- tractors, would any practical difficulty have arisen, by conflicting wit! be Commissariat, which mutual understanding and information would not to prevented or removed ? ! 11. In this point of view, were not the Hospitals on the Bosphorusikd Dardanelles Avholly detached in principle, as well as geographically, Im the Army Hospitals at the base and centre of operations in the Crime? ! ' 12. If the Commissariat can alone supply the Army and Army Hosp Is, does it follow that the Purveyor may not purvey provisions, carriage, c, as well as other supplies, for Hospitals in England, in the Colonies, id detached from Armies, e., drawing their supplies from other districts an those used for the Army's supplies 1 \ 13. As the Commissariat had the carriage department, i. e., the brin ig goods from the quays to the Hospitals, and as the Quartermaster-Ge)>l had the care of the quays, was there any good combined action or jay mechanical contrivance for diminishing the labour, in bringing the ma! of goods up the steep ascent, from the landing-place to Scutari 1 In bh eases, would advantage be derived from the Commissariat not being alh jjd to intervene ? MANAGING GENERAL HOSPITALS. 203 iclesiastical, were taken from their duties in the Ilospi- to be paid at Pera, the Central Counting-house of u Coramissariat, on the opposite side of the Bosphonis. ■Third, the Purveyor's DepartmexNt. — A great part 3. The ( the food supplied to the Hospital consists of the Department ^(ulated rations of the soldiers who arc inmates. These contracted for and provided by the Commissariat, and Food. l*urveyor is obliged to receive them, whatever may (his judgment as to the price, or even as to the quality, they should be so bad as to be altogether unfit i use. As to the periods of supply (which is of the jj^atest importance to his office) he is subject to the jjjvisions of tlie Contract drawn as above. I As to other commodities, not contracted for by the 1 immissariat, however great may be the wants of the 6 dicrs, the Purveyor is restricted to the existing AVar- [ iits of the War Department (which are wholly inade- date to the requirements of the soldiers in hospital, in J he of war). If he exceeds them, he is liable to be jUctcd to the pecuniary value of the excess. 'But, where the Purveyor has the signature of a Medical ] (flicer for a medical requirement, as wine or spirits, he is Molly reckless of the quantity suppHed, not considering ■ hiself responsible, and exercises no judgment in the i, |iThe first Purveyor-General, e. g., even while holding in Knives, Forks, t. Is the Purveyor held bound to see that the kitchens are perfectly i pted to the service ? ^ ^re any kitchens so adapted ] ^. |6. Arc requirements as to food, its preparation, its distribution, sci-ving, ^ ^,ander the Purveyor or under the ^Medical Officer? Vhat simplification of action could be suggested ? Would variety of Diet be more expensive '. If potatoes or other food, not to be had on the spot, were ordered, by I departmental steps were they obtained ? 204 THE NINE DEPARTMENTS. and Spoons, his hand the Secretary at War's general authorization 5 to issues^ in November 1854, and while admitting that he |ew as a fact that a portion of the soldiers then in Hospitaiad been ordered to abandon their knapsacks_, refused to siply knife, fork, spoon, kc. &c., upon the ground that the 'Ur Department Warrant required each soldier to brin^the knife, fork, and spoon of his kit into Hospital for use The refusal, on the same ground of Warrants, applsto utensils, benches and tables, lamps, &c., whic^h ougli to be furnished by the Barrack Department, accordii to War Office Regulation. The principle of supplying some articles under Warints and others not under Warrant, although under cirim- stances of paramount necessity, did affect the Purveor^s mind and would affect any other Purveyor's mind, fith. the idea that he was showing great liberality, unde the first; while exercising great economy, or absolute re;sal, in regard to the second. > This refusal was, however, foreseen by the War Dflart- ment, and, consequently, a peculiar and exceptional j wer was given to the Ambassador at Constantinople, sji it was on finding that the Ambassador did not exercijjthe power nor use the credits thus given to him, that fiss Nightingale issued, for a length of time, a great vjiety of stores and extra diets (on the requisitions of M(ical Officers) as follow : — i THE PURVEYOR. 205 ;|;rage Daily Issue of Extra Diets supplied from F. Nightingale's Ij Kitchens to the Extra Diet Rolls of the Medical Officers, Barrack I Hoapital, Scutari, from 13th January, 1855, to 13th February. Vide ( p. 41 of " Report upon the Scutari and Crimean Hospitals," by the Cumming-Maxwell Commission. No. BUpp 5 gallons . 6 „ ... 0 „ ... |5 „ ... fO quarts... in :: ::: b „ ... 5 portions 5 bottles... ^8 ,. ... '.5 lbs. ... . 4 dozen ... \0 Beef tea Chicken broth Arrow-root Sago ... Barley water Rice water Lemonade Milk ... Rice puddings Port wine Marsala Brandy Jelly ... Eggs ... Chickens From Public Stores. 80 lbs. beef 28 chickens Barley Rice Rice 28 chickens From Private Sources. 12 chickens Arrow -root Sago Lemons Milk Port wine Marsala Brandy Isinglass Eggs 12 chickens SCHEDULE A. In of the Principal Articles of Hospital Furniture, &c., supplied by Miss Nightingale, on the requisitions of the Medical Officers to the Hospitals at Scutari, from November 10, 1854, to July 1, 1856. 't; -3 rs •~ ^ c u 15| i lippli beiii sour r— O dJ './J Obtain I'liblic Obtain Private ill Numbe from July July 1, 18 from privi Total N .\rtirlcs from Ko\ to July iton Shirts . . . . 400 10,137 10,537 1,436 1,385 13,358 inncl ditto . . . . 400 6,423 ,6,823 1,013 1,324 9,160 awers 4,607 4,607 460 105 5,172 irs of Hocks and 1 stockings. . . . J 50 6,123 6,173 791 865 7,829 >,'ht caps 270 1,238 1,508 1,046 270 2,824 ire of elipper.s . . 300 1,050 1,350 410 443 2,203 raforters 2,674 2,674 594 157 3,425 »re of mittens . . 427 427 15 442 wpital suits ofl I'lothing . . . . 1 150 293 443 29 12 484 indkcrchicfs 615 615 1,460 1,310 3,385 206 THE NINE DEPARTMENTS. i List of Principal Articles of Hospital Furniture, &c. — continued. | 1 is p p plied 855. 1 ^ 3 ^ 2 - in ? . „ S s^: § m'- ! ARTICLES. <= • So M ^ ii3 CO ^'50 ^ 3 g 1-5 ^" Ph OP-t from July from Q A1 OVi oUi A 1 116 1 Sheets (pairs) . . 379 o79 12 27 li 150 639 '7QQ 269 319 l,3i Hair mattresses 20 4 247 OA *7 70 "'2 3! Straw pillows . . 150 T Kr\ loU 152 3| Knives and forks . . 70 d40 710 '7'7 64 8 100 1,017 1,11 / I'l ll 136 1,3 Tin drinking cups. . 300 4,026 44 300 4,6 Earthenware ditto . . 57 500 667 250 8 Tin plates OOU l,4oD 1,786 300 2,0 75 76 Basins (zinc) . . 155 155 9 1 Basins (earthenware 80 200 80 3 Basins (wooden) . . 100 lUU 1 W^ooden spoons . . 1,300 1,300 28 Zo Bed pans, &c oio 613 DO 6 Tin pails for soup . . 192 192 16 2 86 00 Hair brooms . . 30 45 75 20 Hand scrubbers 136 136 23 1 Long scrubbers 78 78 48 93 40 23 Shoe brushes (sets) 93 2 Blacking (dozen) .. 224 224 16 \ AAA 444 0 A 528 130 7. Lamps and lanterns 106 106 1 6 1 Scissors (pairs) 51 51 24 Mats (cocoa nut) . . 39 39 25 Saucepans 10 17 97 2 1 1 3*6 36 3' OA 24 9 3; Expectorating cups 20 20 3*4 5' Tables 84 84 2 13 9! 144 144 5 22 17: 19 19 2 2: Baths 16 16 6 2 2- Operating tables . . 2 2 THE PURVEYOR. 207 V Purveyor, under siieli circumstances and for such les as hospital shirts, knives, and forks, would natu- ; i\ consider no requisition upon him as vaUd, inasmucli , ilu'v are theoretically provided for by the War Depart- riit. And the fact of the articles not being otherwise ided would not defend him against pecuniary loss for lying wliat was not included in the War Department . ilation, as was stated in words and truly. Tlie Purveyor's Department, having first issued the pro- Cooking. us, was held to cook them ; but it was not responsible J - extra-diet kitchens, and none existed previous to Miss ightiugale's. The only approach to extra diets was the )king of fowls, arrow-root, &c., in one of the common )per8 at the same time as the other food, and with the le method. The Kitchen illustrates the conflicting powers of Depart- The Kitchen, lilts: the Commandant assigns the orderlies to the ifjuat^ration is, who fetch the diets, and the cook, who cooks cm ; tlie •Medical Officer determines the diet ; the Engi- "(T maintains the kitchen in a sufficient state of repair ; Purveyor supplies the food, part of which he obtains 1 the Contractor, as he does the fuel. The Commissa- ■ lirough the Contractor supplies fuel, bread, and meat ; soldier himself supplies some of the utensils necessary eating. In the case of Scutari, the Commissariat ilii'd the carriage of the fuel, through the local subor- te stationed there. 1 one case of fuel running short, an extra-diet kitchen >up plied by Miss Nightingale buying four caique loads tiu'l. The Commissariat Officer, not having a supply i Scutari from the Contractor, offered her orderly .tl, to ny what he could at the l^azaar. Tlic local Commissariat Officer thus depended entirely I lie Contractor, and, in a gale of wind, which prevented 208 THE NINE DEPARTMENTS. the commissariat supply coming from Constantinople he had no mode of reproducing his supply; although to ihe market of Scutari town, a mile distant, a numbe|of " arabas" brought in fuel daily. j The Purveyor, therefore, bound to supply the dinrrs, had no means to supply the fuel, but depended onjhe soundness of the Contract, the fidelity of the Contrabr (the servant of the Commissariat), and the state of he weather. | Washing. The washing is also in the Purveyor's Department ; |it, not being responsible for the care and cleanliness of he patients, he had no sufficient incitement either to prode liberally and punctually for its execution, or to pro Be the machines, appliances, and labour necessary — cons'e- rations which guide the mind of the Steward of a (HI Hospital in England and even of the Committee, in'he construction of the building. A large wash-house, admirably fitted by the Tur sh authorities who built the Hospital, was seized by the C'n- missariat, and used as a depot for chopped straw, he Purveyor contented himself with contracting for he washing. The contract was very soon broken, in coje- quence of the evident want of means for fulfilling it. After November 4, 1854, Miss Nightingale having ap- plied 2,000 shirts on the refusal of the Purveyor so tdo (upon the principle above stated that the soldier as bound to have them in his kit), it was found that the ]3ii were not supplied with clean shirts, all efficient mean of washing having been neglected. Miss Nightingale fori 3d a washing establishment, by which a portion of waslig was effected ; another portion was given out to indivic al soldiers' wives by the Purveyor: the sheeting and beddg continued to be washed by the Contractor. Even after the order from England was obtained to THi; riTRVKYOU, vnii out till' wash-house, the Commissariat liaviug no ; ('st in llie matter, allowed two inontlis to elapse before 11 was eftected; the straw being carried away on panniers. The wash-house, as fitted by the Turks, with additional achines sent out by the Medical Department, on require- [ent, and a (lryin<^ closet supplied by private benevolence, °d all that was required with peculiar efficiency. It was pt, liowcver, opened till May 1, 1855. The Purveyor has charge of every soldier^s kit, arms Kit. f^r. 1(1 accoutrements, money, &c. If the soldier dies, the ifects arc sold, and the proceeds forwarded through the aymaster to the War Department to the credit of the latives. These duties would devolve upon a Governor, •lould such an officer be appointed, who would, in addi- pn, cause an inventory to be taken of tlie man's effects, pon his entry into Hospital ; this to be read to him, 'ceive his signature, and be forwarded to his relatives case of deatli. Fourtli, the Engineer's Department. — To the Engi- 4. The ser Officer belong the fittings, drainage, and repairs DepfJ.^'^^er Hospitals. He can act on requisition only of Com- landant, Quarter-Master General, Chief Medical Officer, • Purveyor — the last tvvo indirectly. He is dependent T the snj){)ly of money to purchase labour and material I the Commandant. I He is not constituted a judge of sanitary matters ; as to iitilation, for instance, he can take no measures witliout 10 authority of one of the above Officers, with whom the requisitions" to promote it must officially originate, f And, as to water-supply, the same principle applies, however much he may be convinced of the necessity of ^ch mca.sures from his professional experience, he has to •t under the instructions of those who may have no faowledge of what may be necessary for protecting health p 210 THE NINE DEPARTMENTS. nor official responsibility as to proceedings even obvio ly necessary. As to the kitchens^ lie is bound to see to their efficie ly, but only upon requisition of the Chief Medical Officeibr Purveyor, countersigned by the Commandant. To illustrate this again, it must here be stated at the Engineer Officer at Scutari, although directed oy the Commandant to raise buildings for stores, was uii)le to do so for want of a supply of money ; for the sne reason the Commandant was unable to effect the repa of a large portion of the Scutari Barracks. These tligs were afterwards provided for by an order from Engli, received October 1854, which gave the Ambassador po'^r. This power, however, he did not use, vainly endeavouag to obtain such repairs from the Turks. After the rejirs w^ere begun, and some 80 workmen employed, at a mocint of great urgency, the money for the payment was advaied to the Engineer Officer from a private source. The necessary improvements in drainage, and clean Qg the Hospital yard and adjacent ground and roads, re not effected till the Sanitary Commission directed t!se operations under the powers of their Commission. \t\\ regard to the water supply, whatever investigations ay have been made before the arrival of the Commissm, nothing was done, though imminent danger of its dim u- tion or interruption existed. If any representation as made to superior powers, it was to the Ambassador, Iio may have referred to the Turkish authorities, as in 'he parallel case of repairs of the Hospital buildings. About the year 1806, an aqueduct of four miles as constructed by Sultan Selim, for the supply of his ne y- built mosque and village of Selimineh, to which the '. )s- pital is adjacent. This aqueduct was formed of pipe ies, laid close under the surface of the ground, and was f( THE ENGINEER. 211 trtoe cxcocdine^ly defoctivc, and likely, upon evidence ic Turkisli employes, as well as from obvious defects, , threes-fourths of its supply in the summer. was not till April 1855, howe\jr, tliat the Kuf^ineer r was empowered, by a sufficieutly authoritative r, to take the necessary measures. He began the r of the acjueduet May 1, 1855, and the operations iiated towards the end of July. In the beginning, :ind afterwards eighty, Turks and Greeks were .yed under Saj)per and Miner non-commissioned rs. , ii>i)dy, the intelligence and experien(;e of the Clreek \\ kiiien in this peculiar kind of work supplied the want iierpreters in great measure, and the Sappers (of u Mu three or four only could be spared) were enabled to . lin the excellent })lan marked out for the work, in cases varying from the old line of the conduit, u one spot, where the ground had broken away with t. conduit, the chasm was filled up with the body of 'f'.ul horse, through which the water ran for several I l oiu this history it may be inferred that, without these , it is very doubtful whether means would liave existed intain a supply of water to the Hospital and troops, inting to from 5,000 to 7,000 men. I was stated to the Sanitary Commission, that the J litional water supply was contingent on the Turks ' iii'^ authority, and that this matter was in course when ! > the Engineers' Department belonged the duty of ijUntaining the (piays, which, after great delay, was I'ected under an order from the Quarter-Master General's :irrived. 212 THE NINE DEPARTMENTS. assistance of oflficers, non-commissioned officers, or inr. praters, and effected his objects, only after unnecessj-y delay in authorization, by the employment of great niii- bers of the Greek population. In regard to the improvements introduced by le Sanitary Commissioners, he was assisted by their infcDr officers, by the advice of their Engineer, and by jie carpenters sent out from England in the summer of l^i5. It may here be observed, in justice to the Offir, Captain, now Major Gordon, who commanded the Eri. neers, from September 1854 up to the evacuation of Turkey by the British, that not only had he neilsr distinct authority to whom to apply, upon points evideily requiring his interference, nor definite power in execulig what was to be done; but, while responsible for large si is of money expended in contracts and for labour, ski id and unskilled, (chiefly Greek,) he had often difficultieiin getting cash in time and even in trusting his messeng s. For his inferior officers, commissioned and non-comijs- sioned, were perpetually sick ; no efficient assistance as rendered to him in answer to his constant applicatics; he was also harassed by contradictory orders, and by le results of attempts to escape responsibility in those ab^e and below him. It is therefore as surprising as i is creditable to him tliat so much was effected in his Dep t- ment. But the fortunate efficiency of this Officer in le midst of difficulties by no means excuses the sys m which leaves the Engineer of a Hospital or Depot in tie of war, to be commanded by several Departments, a:e incapable and unwilling to direct him in any speal duties. 0. Adjutant- Fifth, the Adjutant - General^s Department d General s , Dcpartinont. Charge, besides keeping up the military discipline, of le burials, the cleansing of the barrack-yard, incidoritall; n k THE QUARTEK-MASTER-GENERAL 213 id case the liospital-yard also^ and of supplying fatigue p;i ICS for landing the sick, and every imaginable purpose; s executed ironi the occupation of the Barrack IIos- 111 Octob(;r 185 to its close in August 185G, with alacrity and unwearied perseverance by Lieutenant, (.'aptain Finnerty, 47tli Regiment. \tli, the Quaktek-Master General's Department. - duties consist of obtaining quarters and distributing I to troo})s, Officers, Chaplains, Medical Officers, aus, women — within and without the Hospital; it has rge the Quarter-^VIaster's stores, also finding store . and the transport of the sick, with the Quarter- -r General's duties belonging to tlie Depot, rtrst, the landing of the sick at Scutari was effected -t by hap-huzard. The larger Hospital was filled till M hold no more ; the excess went on to the other tal, either on stretchers or otherwise. Afterwards, a 1 of vacant beds from each Hospital was made to the (T-Master (icnerars Office by the Inspector-General, ;he boats containing sick being ordered to the wharf inunicating with the Barrack Hospital or with the a! and Palace Hospitals, as the case might be, the v Assistant Quarter-^VIaster General stood at the 1 directing the course of the sick transport. Occa- iy, however, he lost his reckoning, did not remember iinbcr of sick lie had sent to occupy the number of ; l)eds, ;ind sent another boat-load at random *'to >li — " the Medical Officer in charge. 'It \vli:it really was "astonishing" was the non- • ruction of a pier between the Barrack and General or feeble carrying by unwilling Turks, stretcher cases" during the greater tals. Th( icscents, of the t the winter will long be remembered. 11 tlic case of a remodelled Hospital, with Governor, G. The Quarter- Master General'H Department. 214 THE NINE DEPARTMENTS. i Steward, &c., all the Quarter-Master General's du ;s which apply to the interior of a Hospital would cease. Seventh, the Contractor, who enters into contrjts with the Commissariat. — Thus the Commissariat make te contracts for bread, meat, fuel, and sometimes wine, )r the Purveyors, upon whom, therefore, the Contractors :e not immediately dependent, as they ought to be, andas actually is the case with corresponding department^in Naval and Civil Hospitals. Thus the Purveyors havem immediate interest in enforcing the terms of the Contr t, but not the power to do so. The Commissariat have le power, but not the interest. Eighth, the Paymaster, who keeps the accounts of le soldier in Hospital, and receives from the Purvey or jis report of their stoppages. — The stoppages are nowiof thirteen kinds; viz., two on board ship, two in the fid, two for sick and wounded in the field, three for sicijin Hospital, one for troops at home, three for troops ser\^g abroad, — which is very unsatisfactory to the men. iji- formity of stoppages would reduce a great expense fn keeping accounts, now taking many soldiers from tlir duty — it would be a great satisfaction to the mei- and an uniform stoppage might be fixed so as not to tat anything to the country. It is impossible to desciie to one who has not seen it the distrust engendered in le men and the expense occasioned to Government by le cumbrous machinery of " stoppages.'^ The ration stoppage in the Crimea was — j 4<^d. doing duty on shore ; S^d. in hospital ; i 4^^?. in hospital at Scutari ; 5d. on board ship ; 6d. ditto, if receiving spirits. Tin: COMMANDANT. 2 I r each man it is necessary, to the settlemont of liis Crimean iiit, that the precise amount of stoppaj^e to wliicli he HilmcJ^' i»|ect on each day should be ascertained. This, how- Kepurt. , III a vast number of cases, is impossible; and tlierc- the soldier cannot get a settlement of liis account ; rr can the Ii(>;^im(^ntal Paymaster, nor th(.' Commis- Mcil, nor the Purveyor. At length, after an amount of Jioiir and correspondence which is almost incredible, the i'xtricable knot has prol)ably to be cut by an arbitrary incnt, as being tlie only one practica])le. liven when the whole details of the various stoppages M' traced and established, the amount of labour and \tent of the accounts is enormous." \n(l ninthly, the Commandant. — His present duties are rpj^^ t military command of Depot and Hospital, including Commandant. ■ of Medical and Civil Oilicers, and of camp followers ihourers employed. But the duties of a Governor, if wrnor were appointed, would supersede those of the i iiiuiandant in the interior discipline of the Hospital, ■ 1 would include countersigning orders and .'inditing ints, to which would be added the carrying out the nommendations of the Sanitary OfHcer, the collecting, ffanging, and forwarding reports of Admissions, Deaths, ' Discharges, the disbursement of incidental expendi- vVC. jfhc duties of the Commandant, by the present system, 1 v)lve absolute comnumd over two Departments, concern- 1 which his military education and career leave him 'oily uninstructed, viz., the Medical and Purveying Ipartnicnts. He must necessarily, therefore, interfere nitly, and occasionally olhciously, or he must allow Departments to be carried on without any of those C'cks or supervisions apparently intended to exist, except extraordinai'y exigencies, as in the late war. 216 THE NINE DEPARTMENTS. occasion various exceptional orders, he has no meanspf obtaining money or credit with the Commissariat, beydd his current official expenses. The 1st and 2nd Commandants, at Scutari, wiji- drew as much as possible from all interference %h the Medical Officers. With regard to the Purvej^g Officers, these Commandants accepted those officers' en views of their respective duties : a principle of actm which, it is evident, would be most readily adopted)y military men, who must be averse to involve themselvem the difficulties of directing officers as to duties with wbh they themselves must be necessarily unacquainted. In discussing the question of the Government (j a General Hospital, hereafter, it will be proposed thsj a " Governor'^ shall absorb the duties of Commandaniof Adjutant and Quarter- Master General, that there shalbe no depot at or in any future hospital, or within the spire of the " Governor's" duties, and that all patients njst cease to be soldiers in Hospital, as in the Sardhm army. It is desirable, vrherever it may be found practicale, that the Depot should be not less than a mile distant f m the Hospital. Great practical inconvenience results f m its proximity. In what follows it is assumed — i Summary of 1st. That there will be two or more General Hosp ils Changes which • -rr^ i may be England. assumed as 2nd. That there will be a Medical Staff Corps. already proved ^ to be 3rd. That there will be a Female Nursing EstaWh- necessary. ment, with restricted and defined powers. NECESSARY CHANGES. 217 4th. That there will be ;ui Army Works Corps, or a Woneers' Corps, the praetical operations of which would c directed by Eii^niiecrs. \ 5th. That a Sanitary element in the army, as stationed Ijt home and abroad, will exist, as has been proved in |ie late campaign to Ije necessary. p 6th. That Ilegimcntal Hospitals w^ill remain as they ffc; subject to the formation of temporary Central Hospi- lils in the front, in case of siege or during w inter quarters. I 7th. That there will be a General Hospital at the base 'f operations. 8th. That there will be a Depot (near the General lospital, at the base of operations), with a Quarter-Mas- 1 (ieneral's store, (independent of the divisional stores |f regiments,) from which the deficiency of the soldier^s lit, arms, and accoutrements can be made up. 'I 9th. That the Depot will not be under the same com- land, or in the same building as the Hospital, although would furnish guards to the Hospital. I 218 IX. Propositions as to General Hospitals. Propositions 1. That the Hospital shall not be dependent ii]'n ^^HospiTafr^ the Commissariat for any supplies, but that the Coranij- sariat shall honour the drafts of the Treasurer, counlr- signed by the Governor, for the expenses of the Hospijl, including the pay of the officers, attendants, and otl]b attached to it, and that the Governor shall be held respji- sible for the due and proper disbursement and applicat n of the funds. 2. That the duties of the Purveyor shall be equivaliit to those of the Steward in a Civil Hospital. 3. That all transport by sea or land required by e Steward for the purposes of the Hospital, be obtainec)r provided by the Governor, as also the transport requild by the Principal Medical Officer for stores strictly medijl. 4. No contracts for supplies to the Hospital which je Steward may propose to make, shall be concluded u jl approved and countersigned by the Governor, unless w];ii made at a distance from the Hospital by written instrl- tions from the Governor, by whom, in that case, tljy must subsequently be countersigned. ! 5. All Contracts for supplies shall contain a clause aut)|- rizing the Steward to purchase in the market, at the c;t of the Contractor, any supplies which the Contractor uy fail to deliver in terms of his Contract — if they |e immediately required. 6. The government and control of the Hospital sill be vested in the Governor, except so far as relates to e medical and surgical treatment of the patients by e Medical Officers. I'ltoi'osri'KjNS. 219 1 7. The Governor of a General Hospital, whether lie he Military or Medical Officer or a Civilian, shall con- k-reci, and shall assume the functions, and be vested ith the powers, of a Civil Governor. 8. That there be attached to the Hospital one or more I ilitary Officers of the Adjutant-General's Department, ibject to the authority of the Governor, to conduct the sciplinc of convalescents, when necessary, and to see I at they are properly equipped when they proceed to join e Depot. 9. Tliat all orders or requisitions of the Principal [cdical Officer, or of the Steward, for supplies for the ospital, sliall be ineffective unless countersigned by the lovenior. 10. That the Governor be selected and named by the .•crctary of State for War, by whom the other Officers, .eads of Departments in the Hospital, should also be lined. In the event of a vacancy occurring on service, ,e Commander of the Forces to make a provisional ^|)ointment, subject to the approval of the Secretary of .ate. fll. All Officers of Engineers, Sanitary Officers, or hers employed on the application of the Governor to rry on duties connected with the Hospital, to be under 0 authority of the Governor while so employed. 12. All the labour required to carry out plans approved the Governor, under the directions of any Depart- ent, to be obtained or hired by the Governor or by his rittcu directions, and not otherwise. 220 GENERAL HOSPITALS. ! Propositions In establishing a General Hospital for an Army in .e ^iio?p^taS field, the first principle is to have the heads of Hospd furtSierdetui^ Departments named before leaving home, and to mfe them conjointly and severally responsible for providig what is really necessary to enable them to do their diy in an efficient manner. i Governor or The Govemor of a General Hospital, whether he')e Commandant, -^-j-^^j.^^ Medical or Civil, ought to be selected by le War Department for his fitness alone ; i. e., his capaicy for administration, and not upon grounds of professical eminence. U He ought to be responsible for the whole managemk of the Hospital; to have authority in it similar to thaof the Governor of a Fortress, and over every one in t^ whatever be his professional rank, unless over Spejil Commissions of Inspection; to correspond directly ^^ih the War Department or the Commander of the Torls, whose representative he is ; subject to the orders of |o one else; and not subject to the Head of the Medkl Department with the Army. He ought to reside within the Hospital, and visit e\|y part of it at least once a week — to work the Medi l, Attendance, Steward^ s, and Treasurer's Departments UIl^^ him as wheels of one machine ; with power to remove 11 impediments, and with commensurate responsibility. Each Department would acquit itself of responsibiy only after reporting to him the impediments it found o the performance of its duties, and any neglect of order - it being his business to find the remedy. His written order would be sufficient authority, exo> rating those subject to him from all responsibility t obeying it. i It would be his duty to require from time to tie returns of all stores ; of all probable wants; to take ce rnK r;()VKiiN()K. 221 Jit stores arc provided in time to meet these wants; tihave a reserve at commaiid. kll questions as to the limits of the different Depart- pnts should he deeidcd hy liim, without appeal, exeopt tihe Commander of the Forces, or the War Department ijhome. iFhe Governor should sec to the combination of the li^hest efticieucy with the j^reatest economy in the IIos- kvv\)'uv^ in view tluit the most economical Hospital t which, ra'fcris jjari/jus, restores the greatest number (j men in tlie shortest time to the ranks, and not tliat vicli is conducted at the smallest monthly expenditure ]\' head. lie must have tlie fullest discretion, in order to secure ti complete efficiency of the Hospital at all times, and ider all circumstances. Tlie P riucij)al Medical Officer, selected for the charge Principal t liis tituess alone, to have, 1, the control of everything 'officer' ad every one properly belonging to the Medical Depart- tmt, including Apothecary, Dispensers, Dressers, &c. 2. To prepare, in communication witli the Apothecary, |3 lists of Medicines, Medical and Surgical appliances, ijttruments, ice, — in communication with the Head of the jtendance Department, the list of Medical Comforts to I provided by the Steward — both lists being submitted I the Governor. To point out, from time to time, all defects in the • iLiU'V arrangements, and to report, when required by <• Governor, upon such as arc pointed out by the junior ledical Officers or others. To direct and control the treatment of the Patients, i>nly in regard to medicines and ap[>lianees, but also > rr«^rard to diet, clothing, bedding, position of bed, and 222 THE PRINCIPAL MEDICAL OFFICER. choice of w^rd, i e., everything afiPecting health or tre - ment in the hospital. Every Medical Officer, in charge of Patients, should n e at least once a day, in a Book kept for the purpose, to whh | the Ward Masters and Officers of the Attendance Dep;;. \ ment have free access, under the name and number of e Patient, not only the prescriptions and distinct directiis for administering or applying them, but also the Diet \i h the hours at which it is to be given, and a note under e head of Attendance, e. g., " very good,^^ " good,^^ " in f- ferent,^' not good,^' '^bad,^^ specifying, in the lai;r case, the nature of the defect, e. g., " want of punctua y in administering medicine,^' or food,^^ or " wine,^^ & The Ward Master should at once communicate tl e notes to the Head of the Attendance Department : a re > || tition of the offence to be reported by the Medical Off immediately to the Governor, who will investigate iln communication with the Head of the Attendance Dep i- ment. I By this arrangement. Medical Officers would be lef it liberty to devote themselves to their proper professic il duties. It is absurd to suppose that, if required to mac.e a large establishment of attendants engaged in multi- |; rious occupations, cooking, &c.. Medical Officers can :iO give to their professional duties the time and thou it necessary to ensure fair play, either to their Patients o o 4 themselves. The ablest will often find, in the conscii- & tious performance of these duties, more to do than he n well accomplish. Steward. The Steward (1) to provide and to issue — the writn order of the Governor being sufficient authority — evti- |j thing required for the use of the Hospital ; in such maD as he may be directed by the Governor, 11 IK STKWAKI). 22:^ To report immcdifitcly to the Governor any iii;il)ility to roc'iiri^ tlio articles so ordered ; to propose any tem})0- >ubstitutes; and to point out the manner in which ; .irtieh:s ordered could most readily be obtained. To make himself acquainted witli the prices of com- lii itics, tlie wages of labour, and the resources of tlie ry where the Hospital is placed, in as far as regards (|uirements. Want of information ought never to be ;se of delay in obtaining articles, the order having ^^iveu, or the emergency having arisen, lie Steward is not to be, like the Purveyor, a part of v-^ponsible to the Medical Department, but to be iisiblc to the Governor, whether he be a Civilian, a lilitary or a Medical Olhcer. i<' is to liave no power to determine what is to be (led, and conse(pu;ntly no responsilulity for the wiicy of the provision made, either of stores sent from ill le or ordered on the spot. > duty is to ex(^cute the orders he receives from tlie rnor, and to store and issue the supplies according to orders. he Heads of tlu^ ]\Iedical and Attendance Department iiiine beforehand, subject to the Governor's approval, stores and suj)plies of every kind are to be provided, r from home or where the Hospital is to l)e estal)lished. ho Steward lays before the Governor monthly, or 0 iicr if recpiired, accurate Returns shewing the quantity cry article in store at the date of the last Return, the lities since received and issued, and the quantities ming in store. ; is the duty of the Governor, in connnunication with Heads of the Medical and Attendance Departments, < rcise the necessary foresight in securing adequate I 224 THE HEAD OF THE | Superintend- There should be, in all Hospitals, a Superintende'; of Attendance Hospital Attendants, selected according to fitness, uH- Department. tary. Civil, or Medical, with entire control over all atind- ants, ! Male nurses, \ Cooks, I Washers, ' Linen storekeepers, in short all not belonging to the Steward's Departme; or to the Medical Department. He should have the entire distribution of the duti! of the Hospital attendants and be responsible for the wr in which those duties are performed, as a Commaring Officer is responsible for the discipline and drill o his Regiment. ] The Ward Master of a certain number of wards vbld be responsible to his Superintendent, for seeing the d:ies performed by the attendants in his Wards. He 'wlild keep the Books and Accounts, see the instructions c the Medical Officers carried out, make up from those insuc- tions the Diet-Roll of the Patients, transmit it tclthe Cook, and be responsible that the food was properly ind punctually served to the Patients, reporting any faiire, being held responsible if he does not report it. Unless the failure to report is practically madi an offence, entailing certain punishment, the disinclinati( to bring an acquaintance into trouble will certainly lead ^en a good Ward Master to conceal the shortcomings o his friend. A man ought to be relieved from the odiur of being a tale-bearer, by making it a breach of duty an an offence against discipline not to report any deviation )in instructions. A Hospital attendant is a sentry on cty, within sight of the enemy^s lines, and no relaxation of is- ciphne can be excused. \ ATTENDANrr: DErAlITMEN 1. 'J'J.J I All luirscs, male and lbnial(3, should bo ahlc to read ircctions. The Head of the Attendance Department is to furnish, , lists of tlie various furniture, including utensils of iL'ery description, bed and body- clothing, bedding, bcd- llcads, &c., re(juired for the number of patients to be pro- (I for, as well as, 2, a report of the size and arrange- of the cooking api)aratus ; 3, of the washing and lU'-honses, the laundry, stores, &c. ; as, also, !•, the iicr and classes of attendants; and, in short, every- : necessary to the etficiency of the Department. To submit the Lists to the Principal Medical OfHcer looted for the Hospital, aud, finally, to the Governor ■ed, these ollicers making any addition they may deem >>ary, and ultimatel}' countersigning the Lists and [>nrt. I Subsccpient complanits of the iusutliciency of that pro- [sion would thus be precluded, and the responsibility for jfects would be brought home to individuals. I To prevent needless extravagance and capricious de- nnds, a scale, in proportion to the number of patients to •connuodated, should be fixed upon sound data, on (Inch these supplies should be provided ; and a strict ac- •iint of those issued should be exacted. , Every (juarter, a Committee of Lispection might " take fjck" and giv(» in a written Report, it being for the Head , the Attendance Department to account for any defi- cncy and to ])roduce for condemnntion all worn-out tirlcs, and have them replaced, if not abeady done. "Ml ('i\il and Naval Hospitals valuabh; information, I to what this scale should be, may be obtained. I But articles ])rocurable in England may be unattainable . the rountrv when^ the Cieneral Hospital is to be. IVo- Q 226 COMMISSARY OFFICER. vision must be made accordingly. Our late experience a the Crimean War is a valuable guide. The length of time that each article may be supposedio last must be determined by experience. I But it is quite certain that the worst, the least dural;, and, therefore, ultimately the most costly articles of eviy description will be those procured on contracts conce<'d to the lowest tender. Treasury or Attached to every General Hospital of an Army in e Conimissarv Officer. ' field, should be an Officer who performs the duties )f Treasurer and is the only Public Accountant. It is his duty — 1. To provide the requisite funds and to make all p/. ments as determined by the Governor, whose written orijr is liis sufficient authority. 2. To keep the accounts of receipt and expenditure ;)f funds. 3. To subject the accounts of the Steward to preliminy audit : to see that they are accompanied by the necessy vouchers for the purchase and payment, and to ask for le explanations likely to be required by the Auditors it home. The funds being, in all cases, provided by the Treasu r, the payment of the Attendance Department should bf n the hands of the Head of that Department and should )e conducted as the payment of wages in a commercial es1> lishment, or of a company by the captain. Men naturally look with more deference to a cef tlirough whose hands they receive their pay ; and 11 means of influence should be concentrated in the heacof a Department, in which the mere force of coercive di i- pline cannot secure the services of most value to the Sk. M^here so much depends upon the tone of feeling, u 'D Loral inHucnce, and tlic impulse «^iv('u by the Head ol" the )epartment, it is of great consequence that the persons Ijomposin*? it should not be exposed to any disturl)inj^ in- uenecs and should not look beyond their own Depart- -lent for anythin*;. I It might he well to introduce a system of punisliment Jy moderate fines. Looking at our })ast experience of Scutari Hospitals, as Xf<'eHsit\ o''a , r Sanitarv i 8tartmg-i)onit, what were the evils f otllrer or Not in the climate, not in the situation. orinspc.^ion^ The operative causes of our great mortality w(*re — 1. Over-crowding of the Patients in the buildini^s, so . *'^°„, ^ ^ ' helow, p. 235. hat it may safely be said that, treated under a hedge, iiey would have had more chance of recovery. I 2. Extremely defective drainage. The Barrack Hos- ital contained, in reality, under its foundations a cess- ool exposing a large exhaling surface ; the wind, when- Brer it blew up the drains, brought on outbreaks of fever, holera, &c. ; the saturation of the walls, in various parts r both Hos])itals, by the bursting of the earthenware ipcs of Turkish latrines, occasioned also disease; the alls of Wards and Corridors, from neglect of lime- sashiug, were impregnated with organic matter. ' 3. Want of ventilation and means of warming ; the ispector-General of Hospitals frankly saying that he kept • the foul air in order to keep out the cold. 1. Inconvenience and confusion, regarding store-room id distribution of food, fuel, medical stores, clothing, pen, packs, and squadbags. [ 6. L'nsuitable and unwholesome accommodation for I'fficers of all classes, whereby the ratio of mortality nong Medical Ofheers was raised to an extent nnpa- .dleled in history, and far higher than what it was in the rimea, among the hardships of the field. 228 NECESSITY OF 6. Wholly deficient means for washing and insufficien for cooking. | 7. Want of regard to the supply and quality of thj water ; dirty clothes were once discovered in a tank and | dead horse in the aqueduct. It has never been denied that the mortality at Scutar necessarily high, from the state of the patients, when ac mitted, was considerably raised by these causes. The me could hardly have been placed under worse conditions, f( recovery. i The remedy is a simple one. i Let some Medical Officer, or (better) some specially qu: lified Sanitary Officer, medical or otherwise, thorough conversant with sanitary details, and with him an Eng neer, be employed, to choose the situation of any Generj Hospital in rear of an army in the field. Let these report, where full power to act is not giv( them, upon 1. The character of the situation, j Its defects. The means of remedy. The character of the buildings, — above all the maximul of Patients which ought to be contained in them, i The defects of the buildings and the means of remedy; In these days when, by scientific analysis and by practic statistics, it has been ascertained that the three essentij for health, without which medical treatment can be of : avail, are — I, Light, | 2. Air, i 3. The congregating a given number of human beiiii only upon a given space, it is just as criminal to put m, to death by the agencies, which are as certain, of bad and insufficient room, as by highway murder or by puttir men to sea in a vessel not seaworthy. , i A SAM I AliY OFFICKli The exact amount of cxlialcd carbonic acid^ in a given |ij)acc, where a given number of human Ijeings are |reathiiig, has been measured. The injurious eflects on lie system of an atmosphere, containing a certain })ei-- eiitage of carbonic acid, can be estimated. I Can we say that it is manslaughter to put a man to jeath by poison or by the knife, and not manslaughter to lilt him to di^ath ])y the slov.er j)oison of bad ventilation uid bad drainage I n. These oflicers should report upon, The drainage: — its condition, I Its defects, j The remedies, including, where [)racticable, the provi- fon of such an outfaL ^o the sea, river, or some other Dint, as will ensure no nuisance remaining behind. III. The ventilation: — its condition, ; Us defects, The remedies, together with the means of warming and )oling the building, or hutting. TV. The water supply, with its resources, at all seasons: Its defects, " Their remedies. V. The condition of the walls and ceilings of AVards, '1(1 the means of cleansing and disinfecting them. VI. The means of storing and distributing Food, Fuel, Medical Stores, Clothing, Linen, Arms of Patients, Packs and s([mulbags. I VII. The means of cooking and washing : how to t)vidc them. 230 HOSPITAL KIT — I VIII. The accommodation for attendants of all kindsj and especially for Medical Officers. j The building or hutting should be then at once put int' order, upon the report of the Medical Officer and the spe! cification of the Engineer Officer. Reproach to th authorities and destruction to the Patients would thus l avoided. ! But at this moment how many Medical Officers ai' there capable of making such a sanitary report? Ho' many are there to do the work here described efficiently Our experience in the Crimea and at Scutari, as we IIS the Barracks and Hospitals planned since our retur home, do not enable us to answer this question satisfat torily. Hospital Kit. How is the General Hospital to be furnished? j Hitherto it has been furnished by the Patients then selves with what they brought in with them. And it has not been supposed that a Hospital wantt more or better appliances than a Barrack or tent. What is, however, the end of aU the arrangements mai for the army ? Its efficiency : and whatever provid 1 best for its efficiency is most economical. If a HospitI establishment restores fewer men more slowly to t] ranks, it is more expensive, however cheap, than oi which restores more men more quickly. To say nothh of a man^s pension, it costs the country from .^100 £120 to replace a made soldier on foreign service. T] real value of a soldier to the service is very much mo than this. It cannot be stated in money. That Hospit system, therefore, is the cheapest, which restores mc men in the shortest time. Our Military Hospital system almost ignores the cur tive means used by every medical man of reputation home, viz., the economy of the patient's vital powers || WHO IS ru IMLOVIDE IT? 231 I his bed, his coveriiij;^, his food, liis attendance, his imtal state. A Military Hospital cannot rival a Civil hspital in these thin;j;s^ l)ut may command them to a lu'h greater degree than it (h)cs, especially with the ad- vitages afforded us by (lisci[)linc. jWe are constantly told, by those whose idee Jbct is Sfalingering,'' that the Hospital must not be made too infortablc, just as we are told that the workhouse must \ be too comfortable. But the comforts of the l|ter, which generally exceed those of the poor in their rn dwellings, are found to be consistent with a strin;^cnt It of destitution and with driving paupers from the poor- Iaisc, as soon as they can exist beyond its w^alls. So a ^ lilar discipline may drive .Malingerers from the Hos- I al. Frequent in the l\Miinsular AVar, they were rare in tf* Crimean Campaign. Exceptional cases there will always be. But public ciuion among their comrades is wow generally sufficient t drive even bad soldiers out of Hospital, as soon as they tit for duty. .The Hospital, th(>refore, should furnish everything to tjs soldier, irrespective of his ordinary military equip- r;nt. For the experience of the late AVar has shown that V accidents of war will deprive the sick or wounded sol- C^r of his kit, and prevent him from bringing into Hos- Ijal that which he wants w hen there, even if he possessed i which he does not. It is positively incredible that we should, nominally, ^Ive Hospitals, and expect the sick to supply any part of t^) furniture. A sick soldier is, in fact, treated as a kind < hardy exotic, able to bear what would kill a civilian. -On his arrival in Hospital, the Military Patient ought to ^ divested, as the Naval Patient is, of his pack, his arms, ^^muuition, clothing, blanket, &c., which ought to l)r 232 NOT THE SOLDIER HIMSELF. \ washed or baked, in order to kill the vermin, and placd in the pack-store, with name, No., Regiment of the owner. He receives them on going out of Hospital, aij thus becomes immediately effective. j The amount of transport necessary for Hospital storci upon the above system, will be adduced, as an objectioii but the base of operations for the British Army h' always been and always will be the sea. So it was in Spain, though the Army traversed t]! Peninsula, in quasi friendly countries. jl So it was with Marlborough; though the Army was v the Danube, the base of operations was in Holland or tl Netherlands, in friendly countries. It is, therefore, safe to calcujate, in most instancfi upon the General Hospitals of a British Army in the fie being either upon the coast or in a country whose resourc! are at the command of the Army. One thing should never be forgotten. Our Army a volunteers, not conscripts, and never will be. It therefore, worth while to make our service popular, ai to attract a better class into it, by improving the p£: occupations, education, and comfort of the soldier. A General Officer, of acknowledged distinction, has i marked that, after the experience of the Crimean War, might be hard to recruit such a class for another war. I speak from experience of two things, viz., that, u murmuring as the soldier is, a more forlorn being does n exist than he, separated from his comrades, in a Genei Hospital, nor one who feels more the thought and care Ids country, if, in such a situation, he is provided for ' her, in Hospital, with the comforts of home. And tl will always be the case with the Anglo-Saxon. Hospital furniture. Hospital utensils. MEDICAL STAFF (OKI'S. 2'.]'.) (I and body clotliiiii^, H)kiui^ by trained cooks, liL'ient kitchen battery, < ipcr serving of the food, ishing and drying apparatus, Acsc are important parts of the treatment. 1(1 it never can be pretended that what is supplied to I pauper, in every poor-liouse in the country, is too ; a hixury for sick sokliers, to give whom a fair chance •ovcry is to give the country a fair chance of success, economical terms, in time of war. rec things the late AVar has obtained for us, wliich lould not have had witliout it. AVhethcr we can name Medical Stafl' : <• than three is doubtful. torps. . We have an Ordnance full, which was empty. . \Vc have a ^lilitary Train. . \Vc have a Medical Staff Corps. But whetlier this \s; trained body or not is now to be shown. hat a body of trained attendants is necessary to attend u|ii sick men in Hospital docs not appear to require much f"c to prove. Yet until the late War it was never :lit of. n who, at considerable cost, had been taught one were told olf to practise another, which they had V been taught, and were changed just when they were ining to learn. Commanding Officers, of course, did ;kc to part with good soldiers, and told off the least at for Hospital Orderlies. illed labour, the result of training and practice, is as :i)le to the Medical Officer, in his attendants, as to other master of a trade. No Medical Officer would the most kind-hearted soldier as an auxiliary, if he 1 get a trained nurse; nor would he dream of bring- 234 MEDICAL STAFF CORPS. ing the former into his own sick room, if he could hav the latter. There must be a certain number of attendants in Hospital, skilled or unskilled. The question is, which shs they be ? We have decided the question against Orderlies fro the ranks, as withdrawing too many men from the disc plined strength of the army. We have very wisely organised a Corps, on purpose f Hospital Attendants. — I But have we trained them ? A man trained to any kind of work will not only do better but do more of it, in a given time, than an unskilfi workman. The rate of pay is justly higher than in the Army, b( cause the Medical Staff Orderlies are supposed to gi^ more skilled labour than the Orderlies from the ranks. But, to have trained attendants, there must be an o; ganised and established system of instruction, in suitab^ schools and under competent teachers. During peace th can be done. But it has not been done. Every Militai Hospital might become a training school. And nov while the memory of the late War is fresh, it must t done or it never will be done. A small trained body nov in time of peace, would serve as a nucleus ready in th event of a war. The Medical Staff Orderlies ought to be enlisted fc different periods, in order to avoid the expiry of th periods of service of too many at once. P R E F i?^ C E TO SECTION X. PART I. UTHOEITIES FOE THE STATISTICS USED IN THE SECTION, WITH AN Enquiry as to their Sufeiciency. [ Sources of The whole of the figures in the ensuing Section have been the^Statisti^s ' ken from official and authentic sources. Those, from p. 247 to p. 251, have been taken from Sir A. ''lUoch's invaluable " Statistical Eeport on the Sickness, Mor- iity, and Invaliding among the Troops in the United King- m, 1853," p. 3 to p. 75. [The strengths given, at p. 247, are the aggregate strengths : ? the 10 years, 1837-1846, and the whole of the data refer to jo same period, which is the last given in the Beport. The Civil Mortality, p. 247, is taken upon the Deaths in uen years, 1838 — 44, in twenty-four large towns, Eegistrar- 3nerars 8th and 9th Eeports, quoted by Sir A. TuUoch, in e same Eeport, p. 31. It is gratifying to learn that, during the nine years, 1845-53, -1|b troops serving at home have experienced a slight reduction the excessive mortality from which they suffer. Although I shght an improvement, it shows that the time is at hand ' len much greater sanitary advance will be made, and corre- ending results enjoyed. I The improvement stands thus : — B II Comparison of Rates of Mortality in Army serving at home, 1837—46 and 1845-53. 1837 PEINCIPLE FOR CORRECTING Annual Mortality per 1,000 of Mean Strength. 46 (ten years) 1845—53 {nine Household Cavalry. Dragoon Guards and Dragoons, Foot Guards. n -1 10-5 13-5 13-2 20-4 19 2 Inf try of me. 18 17 Corrected Mortality for each Arm of the Service at Home. The Table of Pensioners, p. 255, was furnished by Dr. Balur, the able coadjutor of Sir A. Tulloch, and the materials fobhe Table at p. 259 by the Adjutant- General's Office. The Statistics of the Metropolitan Police Porce (p. 252), ive been taken from M'Culloch's Statistics of the British Empe. Those of the City Police were furnished by Mr. Boise Childs, Surgeon to that Porce. Those of the Comparison of the Army serving at home ith the Civil Population (pp, 253, 254) were afforded by;he Eegistrar- General, as well as the Corrected Rate of Mortity for the Army at home (Note, p. 253). A full Table will now be given, also furnished by the Geiral Register Office, correcting the mortality for each arm oishe Service at home. The explanation of the difference which will be seenbet^;en this Table and that given in Sir A. Tulloch's Report, a)ve mentioned, p. 31, is as follows ■— In instituting a comparison between the mortality of diffejnt arms of the service, at different ages, it is necessary to ke into account the number of men in each arm at those ages,nd for very obvious reasons : Each period of 5 years (or any other period) in human ife has an average mortality belonging to it, and the nu ^er of men in the Army at any such period must obvicsly influence the sum total of life for the period. The mortality over (say) 5 such periods is made up of the or- tality of each period, the whole being added together. If there be a preponderance in any Arm of numbers a\ he ages at which the mortality is high, the whole mortality wi be high. [E MORTALITY FOR EACH ARM OF THE SERVICE. Ill If there be a preponderance of numbers of low mortality ■es, the aggregate mortality will be low. iThe problem is, in fact, a fractional one of this kind : — Mortality ^^^^ reduce all the fractions of this class to Numbers. common denominator, before we can either add, subtract, ide or compare them. I Ii2 IV CORRECTED TABLE OF MORTALITY Table of the Mortality of the British Army, if the rates had been the ne as those in— 1. The Household Cavalry ; 2. Dragoon Guards and ra- goons ; 3. Infantry of the Line ; 4. Foot Guards— serving at homi Ages. Under 20 20—25 25-30 30—35 35—40 40 and upwards . Total 11,911 50,387 38,242 22,099 10,005 3,633 130,277 Deaths, if the Mortality had been, the San as in the 90 588 394 293 84 49 1,498 2« 626 547 326 153 67 1,818 157 896 758 438 211 85 2,545 133 1,087 806 431 224 95 2,776 I ■I 1^' 4 2,38^^ Rate of Mortality per 1,000. in .« Total.. .. Under 20 . . . . 20—25 .. .. 25—30 .. .. 30-35 .. .. 35—40 .. . . 40 and upwards 11-0 7- 5 11-7 10-3 13-3 8- 4 13-4 6I/a 2 S 13-3 18-7 8-3 12-4 14-3 14- 8 15- 3 18-3 13-1 17-8 19-8 19-8 21-0 23-4 20-4 11-2 21-6 21- 1 19-5 22- 4 26-2 o <3 u t • 17' 12- IT- IS- 18- 19-; 2r( I IN THE BRITISH ARMY AT HOME. V Che annual deaths among the 136,277 effectives of the litish Armj, if the mortality were the same as in the House- l"d Cavalry, would be 1,498 ; in the Dragoon Guards, 1,818 ; i the Infanl^-y of the Line, 2,545 ; in the Foot Gruards, 2,776 ; i the men of all arms in the British Service at home, ceulated on the same proportion of ages, it is 2,381. Che annual rate of mortality to 1,000 of the Household (valry is ll'O ; of the Dragoon Guards, 13'3 ; of the Infantry dthe Line, 18-7 ; of the Foot Guards, 20*4 ; and of the men li dall arms in the British Service at home, calculated in the s'le way, it is 17*5. -f the 136,277 soldiers had been subject to the rate of mor- t .ty which prevails in the healthiest districts of England, the amal deaths would have been 1,051 ; in one of the un- hlthiest cities (Manchester) 1,688; and in all England, 148. r !^ote. — The numbers of the men living in the British Army, i|l851, are obtained from the Census Eeport of 1851, Vol. I (ccupations), p. cccxlvi. I full Table will now be given, showing the mortality of the vole Army, both at home and abroad, during fifteen years, fim 1889 to 1853, and calculating the annual mortality upon thse data, for both Officers and Men, with the annual mor- tiity in healthy districts in England, annexed for the sake of 1 cpparison. [t will be seen that the soldier suffers a mortality of 33 f • 1,000.; the Englishman in healthy districts of 77 per 1,000 ; - hat is to say, that one Englishman under these circumstances ds where die rather more than four soldiers. [[t thus appears that, during a period of 15 years, termina- tjg before the Crimean Expedition, 58,000 of Her Majesty's tops have perished. Comparing these Deaths with those Oiurring among the healthy part of Her civil subjects, we see t!,t more than three-fourths, or 44,550, would have been saved, ' hi they remained among that civil population, from which Dist, if not all, of them have come. It may be truly said tit by far the larger portion of these 44,550 have been lost f|ni ignorance and want of sanitary foresight. But fatalism isjiot confined to the Mahometan races — it may still be found, a|l very largely, among the Christians. I Table of Mortality of the Army at Home ami Abroad, 1839-1853. I FROM 1839 TO 1853. VII 58,000 then have perished in 15 years. These are figures on the page — but, to us, these figures are men. The following Table, a deduction from the last, will make the excess of Mortality existing in the Army over that in Civil Life still more evident. N'uMBER of Deaths of Xox-Commissioned Officers and Men, showing also tlie Number of Deaths that would have occurred if the Mortality were 7'7 per 1,000, such as it was among Englishmen of the Soldiers Age in : Healthy Districts, in the years 1849-53, which fairly represent the average mortality. f- Years Deatlvi that would hciv6 occurred in Healthy Districts among ]\Iales of the Soldier's Ages.* Actual Deaths of Non- commissioned Officers and Men. Excess of Deaths among Non- commissioned Officers and Men. ji 1839 763 2,914 2,151 1 1840 829 3,300 2,471 1841 857 4,167 3,310 1842 888 5,052 4.164 1843 914 5,270 4,356 1 1844 920 3,867 2,947 f 1845 911 4,587 3,676 1846 930 5,125 4,195 1847 9-^1 4,232 3,251 1848 987 3,213 2,226 1849 954 4,052 3,098 1850 919 3,119 2,200 1851 901 2,729 1,828 1852 915 3,120 2,205 1853 920 3,392 2,472 Total .. 13,589 58,139 44,550 Excess of Deaths in the Army over those in Civil Life in Healthy Districts. The Table may be read thus : in the year 1839 the numiber f Deaths among non-commissioned officers and men was 2,914 ut of the strength (98,912, see preceding Table) — whereas lie deaths among the same number of men of the same ages in le healthy districts of England would have been only 763 ; ! * The exact mortality in the healthy districts is -0077122, the logarithm I which (3-8871801) has been used in making this calculation. VITI TABLE OF MORTALITY IN THE ARMY consequently the excess of deaths in the army amounted o 2,151. After so frightful a table it is necessary to remind ourse'is that matters have been much worse, viz., in the Army abro;. Comparison of If we compare the rates of Mortality of the Army at e Rates of various stations abroad, prior and subsequent to 1837, ,s ^thf \myf Sir A. Tulloch gives us the means of doing, the proof of ]w at the various much has been done, and how much still remains to be do, abroatjrior even more convincing, and subsequent to 1837. Ratio of Deaths* per 1,000 Agqreg e OF Mean Strength. Streng[. ( 1818—1836 21-4 60 ;9 1 1837—1856 11-7 66 2 1817—1836 16-3 40 6 1837—1856 16'5t 47 11 ^, , f 1817—1836 25-2 70)3 ^^"^^"^^^^"^^ i 1837-1856 1 6-4 55:3 1817—1836 28-8 11:1 1837—1856 32-3J 22 8 ( 1817—1836 1 6-1 64 iC I 1837-1856 14-1 133 1^ ^ . f 1817—1836 14-7 i 1837-1856 11-9 . , f 1825-1836 37-7 Newfoundland < Malta I Bermudas | Bengal Presidency .... | Madras Presidency .... | Bombay Presidency .... | 1837— 1856 9-3 1817—1836 75-5 1838— 1856 69-5 1817—1836 76 1838—1856 38-5 1817—1836 62-7 1838-1856 58-7 * These Deaths do not include those occurring out of Hospital, e suddenly from disease, or from accident. Nor are the killed in ai|)a included. t The Deaths from Cholera were, prior to 1837, "8 per 1,000. after „ 4'3 X This was the consequence of Fevers, the Mortality from which 11 per 1,000 of Mean Strength, before 1837. 20-7 „ after 1837. ABROAD, 1817 TO 1836, AND 1837 TO 1856. IX Vji Diemen's N(j Zealand Wit Indies Land Ja aica (White I ^ Black I ^ White I Black of Good ope Mliritius Stielena Ratio OF 1839- 1844- 1817- 1837- 1817- 1837- 1817- 1837- J 1817- i 1838- 1817- 1837- 1837- 1818 1838 Black 1838 f 1818- I 1838- 1818, 19, 29, 21, 1837- OF Deaths per 1,000 Mean Strength. j White I (Black White ( 1818- l 1838— { -1856 ■1856 1836 1853 1836 ■1853 1836 ■1855 1836 1855 1836 1856 1856 1836 1856 -1856 -1836 -1855 36, 37 -1856 7-8 9-1 78-5 60 40 28-4 121-3 58-5 30 35- 3* 69-8 36- 8 21- 1 13-7 12 10-9 13-9t 27-4 22- 4 25-4 10-6 Aggregate Strength. 17,600 15,128 86,661 51,115 40,934 19,967 51,567 22,100 5,729 13,645 42,978 29,908 35,305 22,714 73.508 4,136 10,066 30,515 29,178 5,908 8,258 |t will be seen from these statements that our home troops h{|e actually suiFered more in their own country than the tr)ps do now, who are serving at some of our foreign and Gonial Stations, such as Cape of Good Hope, St. Helena, Zealand, Yan Diemen's Land, Newfoundland, Nova Sco- ti Canada, and Gribraltar. Why should this be ? jt will also be seen how frightful is the mortality, even now, olthe troops in some of Her Majesty's possessions, as the \ st and East Indies, &e. )nly one-third of the Statistical case has, however, here been statistics of g 3n. The other two-thirds, viz., the Eecruiting and the Recruiting and I aliding, remain still to be considered. nVceLlry make the case iThe Deaths from Cholera were, after 1837, 11'7 per 1,000 of Mean complete. S ngth ; prior to 1837, none. The Deaths from Diseases of the Lungs increased from 3*9 per 1,000, b'lre 1837, to 67 per 1,000, after 1837. X CONSIDERATIONS OF RECEUITING AND INVALIDING Difficulty of The exact relative mortality of the Army to the morta|;y ascertaining amono- the same acres in civil life is far more difficult to asr- Mortality of tain than would at first sight appear. Among the Civil popa- the Army and ^ion the elements of the problem are sufficiently constant, at ^^with^an/^ it is not so in the Army. The first difi'erence between le precision. Civil population and the Army comes into play at the perio of recruiting. There is a process of selection out of the Civil populatn, whereby about a third of all men of the army ages who pre; it themselves is rejected, as unfit for military service, very o m from diseases which will eventually shorten life; but the 3- cise number rejected cannot be ascertained exactlj^ There is besides a previous process of selection, so to spik, from the circumstance that a certain proportion of the ( il population is unable from sickness to present itself for recr't- ment, and this part remains to furnish deaths which raise le mortality of the Civil population. ]S[ext, the Army is subject to reduction, and there is evy probability that the strongest and most healthy men -e retained at such times, and the weakest sent back into le civil population. Additions to the Army also infuse into it younger and be ;r lives than those already there, a circumstance which likeve interferes with the accuracy of the comparison. Another disturbing element is invaliding, by which mern bad health are discharged altogether from the Army, an a large number invalided die within the first year, while m y others die shortly afterwards from diseases contracted in e service. The ratio of mortality among men serving canit, therefore, be taken as a ground of comparison with the n'- tality of the same classes in Civil life. If we had the meih which is certainly not the case at present, of calculating e value of all the elements affecting the life of tlie soldier, e should find the absolute mortality in the Army greatly hig r than the statistics represent, and the comparison with e mortality in Civil life much more unfavourable to the Armj It would be most desirable in the constitution of the sta ■ tical department, which is now contemplated, to provide 3 means of accurate comparison between the Army and Civil 1 > which do not now exist. STATISTICS OF UECIIUITING. XI It is extremely important to make tlie statistical case as )mplete as possible. AVe have the Army Mortality among • en serving complete as the middle part of our problem, but it , absolutely deficient, 1st, in the recruiting, i. e., the inlet . the Army, and, 2nd, the invaliding, i. e., the outlet from the rmy. These two extremes ought to be furnished, in order to )mplete the case, and to obtain for us (as they would do) the ost perfect body of Army statistics in existence, although Dt the most perfect possible. I. With regard to Recruiting, the extremely imperfect man- Statistics of 3r, in which our recruiting statistics are kept, prevents us from Kocruiting. •riving at any general or accurate conclusion. There are three methods of examining recruits j and of le results of two of these no record whatever is kept. • The methods are as follow : 1. When a man enlists for the regiment in which he wishes ) serve, he is examiiied by the liegimental Medical Officer, and f him rejected or approved. Of the numbers thus examined 0 return is made. 2. When a man enlists at the Head Quarters of a Eecruiting 'istrict, he is examined by the Staff Surgeon, and by him ;jected or approved. Inspections by this process are called iPrimary" ones, and of these returns are made. 3. When a man enlists at any of the out-stations of these recruiting Districts, he is first examined by the nearest Army iedical Officer, or by a Civil Medical man. If approved, 3 is then examined a second time, at Head Quarters, by the Xaff Surgeon. Of the first examinations no return is made. the last examinations are called " Secondary " ones, and are 'turned, but mixed up with the Primary examinations, made > Head Quarters as described in process JS'o. 2. 1 The only returns made, therefore, are those of the Primary id Secondary Inspections, at Head Quarters, made by the itaff Surgeons. In three districts only, viz., those of London, dinburgh and Dublin, and for five years only, are the Primary listinguished from the Secondary Inspections. Therefore, as we have no means of ascertaining what rejections ave taken place to sift the number which actually arrives at fead Quarters for "Secondary" examination, no comparison : the difference as to numbers of the " Secondary " rejections, Xrr REJECTION OF UNHEALTHY which take place at the different Head Quarters of Eecruit g Districts, can give any accurate result at all, as to the absol;e ratio of rejections. Yet when we consider the incalculable importance of e contribution to our knowledge as to the health of our Cil population, which would be afforded by accurate recruit g statistics, did we possess them, we must the more regret e exceedingly imperfect nature and limited extent of the in]'- mation which they actually contain. Such as they are, the only fact to be derived from them if any conclusive nature is the following: Erom 1832—1842, at Head Quarters of the 10 Eecruitg Districts of England, Scotland, and Ireland, nearly 30 per ce:. of all the recruits examined were rejected, and, from 184'- 1852, 331^ per cent., or one-third of the whole. Of the rejections one-fourth, at least, may be safely said to have b(i for causes which would shorten life. In 1831, the ''^ Primary rejections" at Dublin were neajr 72 per cent! What important consequences might be drai from the comparison of facts like these as to the health f a district, if only the statistics were kept as they might be. When we see the amount of care thus given in sifting t3 good lives from the bad for military service, well may we £7 that the Army are picked lives. The inferior lives are thrown back into the mass of t) population. The Civil population has had all the loss— 1 3 Army has had all the gain. Yet, with all this, the Army, frd which the injured lives are subtracted, dies at twice the rate f mortality of the general population, to which the injured li^^i are added. It is useless to go into the recruiting statistics at great' length. Because, owing to the entire absence of Eeturns . Recruiting Processes (1) and (3), owing to the mixing up " " Primary " and " Secondary " rejections in the Eeturns whi do exist, and which are thereby rendered almost valueless, it impossible to say how much below the truth this " one-third and "one-fourth" are. They are to be depended on as ben correct as far as they go. But the real truth would give us far higher ratio. They are then much below the truth. Bi how much there are no means of knowing. LIVES IN KECRUITING. XIIT Three very interesting tables, therefore, are all that will now given. Table I, shewing the causes of rejection, and ratio of rejec- ms at these Head Quarters of Eecruiting Districts. And upon this it must be remarked, of what great importance I would be to have and to use the same nomenclature and fe same classification throughout the three subjects for statis- i!s in our Army, viz. — for the Statistics of Kecruiting, for ose of Death and Disease during Service, and for tliose of vahding, as also to let this Nomenclature and this Classifica- m be the same as that used by the Civil Registrar-General England. Our system of Registration of Deaths in the civil population now complete. Our knowledge of what it suffers from dis- se is extremely incomplete. "Were the recruiting statistics pt upon the same system of nomenclature as that used by e Registrar- General, they would form a most important idition to his means of information. (Tables II and III, shewing the native countries and the cupations of the recruits examined, are given only for ,eir general interest, and do not afiect, strictly speaking, our ■bject. These tables are taken from the Appendix to the Report the Commission of Enquiry into the Regulations affecting e Sanitary Condition of the Army, &c., No. LXYI. XIV TABLES OF REJECTION OF EECRUITS. O O C0Ot0'»O(MT-tC0-tOOS (2 00 ?0 !>> CO CJ»OOOt-l>.iX>»000(M(MOO'>!jiCOOO»01>.l>.COkOt^ (NO S3 a ^, 2 ^ 'p o 2 a a O M ^ o a d O (D a « . O 1^ M a;2 . fe: « 3 o « o o o -d •— ' O t3 .2 ^ d _d i^i ° i ° s 8 §^-Jsao-|i d ® CO d .a O , c3 P. "^^ >H 3 O) 3 e3 ^ O) d rd Q 02 o ^ O 000 in -►^ - .0 d -'l) c3 o a; « d o O -IJ y — c3 cs o) CO O I.: 0 PLACES OF BIRTH AND OCCUPATION. XV Ratio per ^ ^ • I d i o -:i i i 1 181S-«J. 1 r s- i 1-5 2 I CO i i 5 CM Natives of England Wales Scotland Ireland ... Foreign Countries Not stated Total E-1 { 1= r Z 1 1 IIP- I 10.031 3,750 34 i OS i i § i i- 17,685 1,022 74 24 i t 11,156 5,208 1,054 62 2 3 I Husbandmen, labourers, ) and servants ...j Mechanical Trades Shopmen and clerks ... Protessioual occupations Boys Not stated Total XVI STATISTICS OF INVALIDING. Statistics of II. We now come to the invaliding and the apparent redition i Invaliding, -^^i^j^,]^ jg thereby effected in the real mortality of the Arm Apparent Por instance, the aggregate strength, 44,343, of the i'oot effec^tedln G^uards, from 1845 to 1853, yields its own proper mortalyof Mortality of 851. But, besides the mortality on effectives, tliere is ajtto^ i l^^In^Uding t^^^i^g P^^^^ non-efi^ctives invalided, who irtly become ' pensioners, partly are invalided without peiions. These invalids are discharged at any time after the rmy strength is made up for the year. They are included i the strength up to the day the annual return is made, but;hey i begin to disappear and their mortality together with the, as soon as the day of making up the strength has passed. Gere- after they form a distinct class, with a special mortality Of those who receive no pension, no further trace can boh- tained : of the pensioners alone any distinctive statical results can be established. It is considered that one year's mortality among lese invalids of both classes might be fairly added to the moility of the effectives, because the diseases of which they die ^:hin the year maybe fairly attributed to causes connected with heir service. But it can be ascertained only for the pensione] We therefore add together the effective strength and lor- tality for 1845 — 53, to the invalid (pensioners') mortalit and strength, 1845 — 53. (The invalid strength must be fled, because it does not exist in the effective strength.) Thus- 1845—53. Died. Aggregate Strength . . 44,343 851 Invalided with pension 1,565 210 45,908 1,061= P3-1 per 130 ' ' ( per annu being an increase of 3-9 upon the Mortality of the Effecres, which was, during that period, 19*2 per 1,000 per annum. By the kindness of Dr. Balfour, so often mentioned, a ble will now be supplied, showing how far the Mortality c the Troops serving at home is increased, by adding the Mor lity of the Pensioners, during the first year of Pension — or, r; ler, how far below the real rate of Mortality of the troops hat represented as their Mortality actually is, because men ely TABLES OF THE MORTALITY OF PENSIONERS. XVII • die are invalided to die out of the Army. Aud, again, it :,ist be observed that many are invalided witliout pension, and lis cease to be under observation. The table includes the ! )usehold Brigade, the Kegiments of the Line, Cavalry and ^fantry, serving at home, and the Horse Artillery at home, '^e Poot Artillery and the Sappers and Miners are not iiluded, because it was found impossible to distinguish bween the Pensioners from liomc service and those from i eign service : — Table Xo. I.* roops serving at Home. 1815—53. Nine Years. t s Total Dcatlis. 1 Ratio of Deaths per 1,000. Total placed on Pension List. 1 Died witliin | [ Tw elve Months, j c u <= s s Sf-S s 6 S Died among these. Ratio of Deaths per 1,000. 1 Increase. | I.asehold Cavalry 10,819 114 10 5 360 45 11,179 159 14-2 3-7 C airy (Line) .. 55,004 1 ' 724 13-2 ],757 140 56,761 864 15-2 2-0 1 1 Guards 44,343 851 19-21,565 1 210 45,908 1,061 23 1 3U I mtry (Line) . . 204,650 3,425 16 7 6,767 536 211,417 3,961 18-7 2-0 E3orse Artillery' 6,031 70 11 -6 273 12 6,304 82 13-0 1-4 Table showinc: the apjtartnt Ecdiictiou of Eatc of Mortality of Troops serving at home, by luvalidiiiit?. iV similar Table is now added, derived from the same source, 8 wing the apparent reduction of Mortality in the whoiti ^iiy, at home and abroad, effected by the invaliding. In this and the following Table the numbers pensioned and the deaths amgthem are obtained from Sir Alexander Tulloch's Department— the s'ngth from the Returns made annually by each Ec-imcnt to the War Cce. c p 10 The same for the whole Array at home and abroad. XVIII KATIO OF INVALrOED TO STRENGTH Table No. II. Army and Ordnance Corps. Nine Years, 1845—53. Cavalry, Guards, and Infantry, ex- clusive of West India and Colo- nial Corps Koyal Artillery . . Royal Engineers. . Aggregate Strength. 1,091,389 86,600 16,469 Total Deaths. 33,569 1,520 275 30 -7 17-5 16-7 Total No. placed on Pension List. 29,057 2,214 402 .5 a 2,255 133 25 Total Strength of Men serving and Pensioned. 1,120,446 88,814 16,871 Total i . Deaths ^ £ among these, i ii 5 P. 35,824,2- 1,6538 611 3007 ■811 1-8 A third Table is now annexed, of whicli the materials are ;iO derived from Dr. Balfour, showing the Aggregate Strengtlbf each Arm of the Service at home, at periods of service of se n years, and the ratio of Invaliding at each such period of service : — Table No. III.* Table showing the rate of Invalided to Sti-ength on Home-Service. 1839—53. Fifteen Years. Household Cavalry. Strength Invalided Ratio Invalided \ per 1,000 serving J Cavalry (Line.) Strength Invalided Ratio Invalided "1 per 1,000 serving J Foot Guards. Strength Invalided Ratio Invalided "I per 1,000 serving / Infantry (Line.) Strength Invalided Ratio Invalided "1 per 1,000 serving j 1. Under 7 Years' Service. 2 7-14 Years' Service. 3. 14-21 Infantry. 14—24 Cavalry. 4. Total under 21 or 24. At 2: f e r 8,332 4,988 4,188 17,508 6 52 68 147 267 2 6 2 13 -6 351 15-2 6 •3 48,541 21,721 15,453 85,715 1, 4 713 510 568 1,791 1, 5 14-7 23 -5 36 7 20-9 7 36,761 20,731 12,707 70,199 3, 1 526 335 254 1,115 1, 7 , 14-3 16 1 20- 15-9 3 •i 195,628 70,549 39,097 305,274 3, 5 3,105 1,485 2,174 6,765 3,4 15-9 21 -1 55-6 20-8 9 * These data are obtained from the Returns made annually by^h Ivegiment to the War Department. IN THE RESPECTIVE ARMS. XIX It would, however, be unsafe to reason upon the fourth Defect in )lumn. The three first and the fifth are the important ^'"^11''^ ^les. The comparison ought to be drawn, year by year, if [)ssible, or at least period by period, as is there done, and not 1 the Total. This would lead to inaccurate inference, as to le actual loss of efficiency from invaliding ; the shorter the jiriod taken, the more it diminishes the error. But it would ,) still better to take 1,000 men and follow them up to the end ' their service, till they are all dead or invalided, than to take 1 en a year, or, as has here been done, an aggregate of years ; icause fresh lives, of course, continually supplement the ,lumn "under seven years' service." And the elements of e calculation are thus perpetually changing. The man may tually appear on the Strength twenty-four times — on the jinvahded" he will appear only once. It would also be very desirable, if possible, to give in a sepa- te column, after each period of invaliding, the per-centage of 3n invalided, who died within the year, in order that we ■ight see where the highest mortality lay. Por the ratio of vahding of men under seven years' service, which varies from 2 per 1,000 in the Household Cavalry to 15-9 per 1,000 in e Infantry of the Line, bears no proportion to the Mortality .long the Invalids, which raises the Mortality among the ousehold Cavalry by 3*7, among the Infantry of the Line by jdy 2-0 per 1,000. The following Table is from the Appendix to the Evidence ken before the Commission appointed to inquire into the •gulations affecting the Sanitary condition of the Army, &c. |o. LVI, and shews in one summing-up the Strength, ieaths and Invaliding of the whole Army, taken (1) generally, ;) abroad, and (3) at home. c 2 p 10 XX STKENGTH, DEATHS, AND INVALIDING. Strength, Deaths, aad Invaliding in the Army at Home and Abroad. Table No. IV, 1839—1853. Among the Tkoops generally. Cavalry, Guards, and Infantry. Aggregate of 15 years... Annual Average Ratio per 1,000 mean strength Royal Artillery. Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Royal Sappers and IMiners. Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Royal Mai'ines. Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Among the Troops serving Abroad. Royal Artillery (Foot). Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Royal Sappers and Miners. Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Royal Marines, Afloat. Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Troops serving at Home. Household Cavalry. Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Cavalry, (Line). Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Royal Horse Artillery. Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Royal Artillery (Foot). Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Royal Sappers and Miners. Aggi-egate of 15 yeai's Annual Average Ratio per 1,000 mean strength Foot Guards. Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Infantry (Line). Aggregate of 15 years Annual Average Ratio per 1,000 mean strength Royal Marines, Ashore. Aggregate of 15 years Annual Average " Ratio per 1,000 mean strength" ... Officers Non-Com. Officers & Privls Strength Deaths Strength Deaths Invaing 82,093 5,473 1.373 91 16-72 1,762,037 117,469 58,139 3.876 32-99 i 7,549 503 71 9-40 134.286 8,952 2,482 165,7^ 18-48 37 23,779 1,585 432 28if 1817 \i A 156,519 10,435 2,720 17-38 2,478 165 40 1614 47,066 3,138 11,156 741 91,174 6,078 1,224 siv-V 26 01 291 ISA 26-08 1,867 124rV 20-48 18,114 1,208 194 13 10 7 89 87,129 5,809 1,161 13-3 ^6 t 646 43 9,457 'CoO 120 8 12-7 539 •94 4 403 '293 31 "it 77,763 5,184 1,138 75i| 14-6 12,623 841 141 * 67,105 4,474 1,306 87iV 19-5 * 308,409 20,560 5,197 346^ 16-y 859 f 65, .34 5 4,356 853 56H 13- t The Invalids from the Tr oops serving abroad and at home cannot be separate DEFECT OF SYSTEM OF AVERAGES. XXI The preceding tables, however, do not give the absolute alue of the loss to the service from invaliding, nor the mor- alitj among men invalided. They present the same defect ■rhich runs through all systems of averages, where absolute esults are expected from them. For instance, the men who scape invaliding during the first period of seven years, are assed on to the next septennial period, and are again counted gainst the number invalided, and, although the same men, bey are made to represent, so to speak, a dilferent force. Yere the tables given year by year, the error would be dimi- ished, but still the total loss in effective service from invalid- lo; hardly admits of being expressed in figures, for figures 3present all classes of soldiers, good and bad, healthy and nhealthy. The same remarks apply to the statistics of lortality generally. The defect of the system of averages applied to sucli pro- lems is that it fails to give the absolute facts of the case. le wish to know how much the mortality of the Army during ly year or scries of years is increased by the mortality among valids. This can only be done by adding tlie whole mortality, ?ar by year, to that of the Army. But, when we say that, aring a term of years, such a per centage of men was invalided, 6 count over and over again tlio men who escaped invaliding, hile we also take advantage of the additions of new lives, ade year by year, and take the per centage of loss, not on the imaged constitutions alone, but on a body of men made up of lose who have been exposed to the causes which influence the nount of invaliding, and of those who have not been exposed these causes. The problems, to which the system of averages in vital sta- ptics is applicable, or non-applicable, may be described as I Hows : — 1. If we want to compare, irrespective of all conditions, the iaths among corresponding populations, we may use the sys- m of averages, but it only tells us the fact that the mortality similar, or different, hut absolutely nothing more. 2. If we are desirous of knowing the mortality at different Tiods of time among the very same individuals, we may use e same system, but it tells us nothing more than the rates at Oferent periods. Defect of the System of Averages as applied to such Problems. Problems to which the System of Averages in Vital Statistics is or is not applicable. XXII PROBLEMS TO WHICH SYSTEM OF The figures given at pp. 254, 314, illustrate this aud all th it is worth. ! 3. As soon as we introduce conditions into vital statistic! and require to know something about the circumstances ; reasons of the mortality, the system of averages fails. Illustrations of This may be illustrated as follows : — i Svr^ein^of Lord Eaglan lost 90 men from Scorbutic Dysentery (sas Averages in out of a regiment 1,000 strong, in the month of January aloi Vital Statistics ^ ^ ^^^^ l^ other diseases out of the same Eeffiment, , does not show. ° ' the 12 months. The way of stating this by averages would be to say thatt Eegiment had lost in 12 months 100 men, or at the rate of per cent, per annum. Not a very heavy death rate, it wou appear, under the circumstances. Out of the 100 deaths 90 occurred in a month, 10 in ; months. The ordinary mortality would be — say 10 + 1=' per 1,000 per annum. But, during the Scorbutic Dysente' month, it was 90 X 12=1080 per 1,000 per annum. Again, ■ out of the 100 deaths occurred (say) in a fortnight. The practical conclusion of the first method is that the ye was rather an unhealthy one ; the practical conclusion of t' second, that measures for saving life ought instantly to ha been carried out. Again. — Take the case of the force in India during ; epidemic of Cholera. 100 Eegiments, 1,000 strong, yield (say) usually 40 deat per 1,000 per annum, and the rate next year is suddenly rais to 200 per 1,000 per annum. The fact, as stated by averages, proves that, some how other, the mortality had risen over India by 160 per 1,000 abo the usual average. The conclusion is, that the special year is unfortunately : unhealthy one, nothing more. The fact being examined in detail, it is, however, found, th some regiments have lost 20 per 1,000, and some 40, while t half of other regiments has entirely disappeared at carta stations. The real conclusion is, that Sanitary improvement, or enti removal of troops, is necessary at certain stations, and not others. AVERAGES IS NOT APPLICABLE. XXIII The system of averages, applied to questions which it cannot I ve, becomes thus practically injurious. The Public Health Act can only be applied, by Government, i towns with a mortality not less than 23 per 1,000 ; but the ^3rage thus taken conceals the most important fact ; viz., that i a fourth part of the town the mortality may be as high as per 1,000. ,The practical result is, that the minority may be suffering {,3ve five times the mortality suffered by the majority. The 1 ention of the Act, as regards the only real sufferers in the c;e, may thus be nullified. Again, when an average mortality is struck over the entire l|> of a population, at (say) 32 per 1,000 per annum, the important fact does not appear at all, that half of all the ( Idren born may die under five years of age. Hence, the causes of this great infantine mortality may be Cjjrlooked and never touched, although thousands of pounds r\yhe spent in works for reducing the average mortality below 2 per 1,000, For the question, at what age was this excess c, mortality ? — is practically very important. On the answer t|bhe question, whether the mortality occurs among adults or a Dng children, depends very much the nature of the causes of n rtality to be removed. Che same remarks apply to averages for septennial and all 0 er periods of life, AVe cannot average a calamity. If I lose 1 3,000 to day, it is no practical benefit to me to learn from a^alculation that my average loss during 20 years is £1,000 a iar, ^he system of counting the same men over and over again in a i-aging mortality, in a stream of life passing through years, IS ust as absurd. Every year, nay, every month in vital sta- t.ics has its own problem, in itself complete, and the ground 0 in eternal fact, incapable of being averaged with any other fjLi— true in itself and by itself, but ceasing to be true as soon a|t is mixed up with another similar fact — admitting of com- prison, but not of combination, 'he fact, that the mortality of our Army in the East in Hos- p|il was, during 2} years, at the average rate of 22 '8 per cent, isi ot a very suggestive one. But the fact that, during eight ^ iths of that time, it was losing men from disease alone, at Mortality of the Army in the East in Hospital, at the Average Kate. XXIV AVEKAGE MORTALITY OF ARMY IN THE EAST. the rate of GO per cent., per annum — during other five month at the rate of 1'2 per cent., per annum, is a very suggesti^ one — as also that, during one month, its rate of mortality i Hospital was 117 per cent, per annum, during another mont; under one per cent., per annum. None of the numbers hei given include the killed in action. Mortality in the Army of the East, in Hospital, during 2^ Years, from April 1, 1854, to June 30, 1856. Period. Years of Life or Aggregate Strength Average Strength of the Army. Deaths. Annual ^lortality per Cent. April 1, 1854, to 1 June 30, 1856 V 79,273 34,526 18,058 22-78 (2i years) J KoTE. — The years of life and the average strength of the Army ha' been derived from the weekly return of the strength, from April 1855 1 May 1856 (inclusive) and for the previous period, April 1854 to Marc 1855 inchisive, from the return of the Deaths during each month, and froi a return of the rate of Mortality during the same periods. The following Table gives the Classes of Disease from whic this mortality arose. Class of Diseases. Number of Deaths from specified causes. Of the Total Deaths the Proportion per cent, from each class. Of the Total Deaths (e.xclusive of Violent Deaths) the Proportion per cent, from each class. Death.'* Annually t 100 living. 1. Zymotic 14,507 81 -9 94 3 18-7 2. Constitutional 204 1 1 1 3 3 3. Local 668 3 8 4 -3 9 4. Developmental 19 •1 •1 5. Violent 2,314 13 1 3 0 SYSTEM OF AVERAGES. XXV in engineer, for a river of unequal velocity, takes the sec- tiis at different points ; but lie does not strike the average of t] se sections ; for there is no fict obtained in taking the a^rage velocity of a river, of which he can make use in con- siicting engineering works, requiring the absolute velocity a I given point to be taken into account. n constructing a Table of Mortality we take 100 men, e ht die the first year, there are left 92 — two die the second y r, there are left 90. The usual metliod of stating this mor- t; ty would be to talce the Jiundrcd over again and strike tlie d 'erence, thus — 100 + 100—200 8 + 2 = 10 System of Averages destroys the value of absolute facts in certain cases. 2)10(5 Isrefore, it is a mortality of 5 per cent., per annum. Now, tli is manifestly wrong, and gives the Secretary of State no i(a of his accumulated loss. vVhat we want to know is, where the conditions vary, what t. result is of each successive condition, not what is the a rage of the whole. Che only arithmetical problems where averages can be justly u.d are those where they diminish the error, as they would, e.'., in a series of chemical experiments or astronomical obser- vaous. In vital statistics, they only increase the error. Dr. Farr has constructed a " Stream,^^ in accordance with t idea above expressed, viz., that it would be better to follow u a given number of men, through a certain number of years' s vice, showing the number annually lost to the service by iialiding and by death out of the same body, not supple- nnted by fresh lives. The result is — ' XXVI ACCUMULATED LOSS BY DEATH Numbers remaining of 10,000 Recruits at each successive year, serving at Home. Table L i j Table showing, of 10,000 Eecruits, at the Age 20, the numbers remain^ at each successive year of Age, up to 40, and also the Numbers annuj'/ eliminated by Invaliding or by Death, — It has been constructed fi i the facts supplied, by the Army Eeports and by the Tables of Dr. Balfc , on Invaliding. The principle of construction is the same as tt employed at the General Register Office, in constructing Life Tab ,. It is assumed that the soldiers enter the Service at the age of twel? years. Age. English Soldiers. Complet Years c Service Living. Dying and Invalided. Dying. Invalided. 20 10,000 350 169 181 0 21 9,650 325 168 157 1 22 9,325 305 166 139 2 23 9,020 289 164 125 3 8,731 278 162 116 4 25 8,453 270 160 110 5 2G 8,183 265 159 106 6 27 7,918 264 158 106 7 28 7,654 263 157 106 8 29 7,391 266 155 111 9 30 7,125 271 153 118 10 31 6,854 275 150 125 11 32 6,579 282 147 135 12 33 6,297 288 145 143 13 34 6,009 296 144 152 14 85 5,713 302 144 158 15 36 5,411 307 143 164 16 37 5,104 313 141 172 17 38 4,791 315 138 177 18 39 4,476 318 135 183 19 40 4,158 20 AND INVALIDING. XXVII Table II. Summary of Table No; III, •RENGTH and Invaliding in the Army serving at Home during the Years P. xviii. 1839-1853. (See Dr. Balfour's Table No. Ill, p. xviii..) Strength. Years' Service. l« > .9 <=> 5 03 All periods of service . . 18,114 87,129 73,720 308,409 487,372 JARS. - 7 -14 —24 Cavalry :■ and upwards Infantry. . ; and upwards Cavalry . . 8,332 4,988 4,188 606 48,541 21,721 15,453 1,414 36,761 20,731 12,707 3,521 195,628 70,549 39,097 3,136 289,262 117,989 51,804 19,641 6,656 2,020 1 Invalided. ^11 periods of service . . 589 2,836 2,282 9,859 15,566 lARS. - 7 -14 i— 21 Infantry .—24 Cavalry !i and upwards Infantry. . 1^ and upwards Cavalry . . 52 68 147 *322 713 510 568 1,045 526 335 254 1,167 3,105 1,486 2,174 3,094 4,396 2,399 2,428 715 4,261 1,367 Propoetion of Teoops Invalided to 1,000 serving at each period of service, at home. All periods of service . . 31*93 0—7 15-19 7-14 20-34 14—21 ) 24/ •• 43-98 21 and upwards ) 24 „ / • • . . 648-46 XXVIII LOSS OF VETERANS TO THE AHMY AS IT IS Accumulated Table III. j Loss by Death pj^Qp^^j^^j^jj Troops, serving at Home, who Died or were Invalidetijut anuluvaliamg. . , , ^ ^ >^ , i t ^ of 1,000 serving in the Household Cavalry, Cavalry, and Infant i lu three septennial periods of Service. Ajres. 20-27 27—34 34-41 Years of Service. 0— 7 7-14 14—21 or 24 Deatlis at Home Invalided at Home Invalided ;l Deaths I to 1,000 Serving. 17- 41 18- 31 19- 15 15-19 20-34 43-98 32 •6( 38 -eij 63 -IJ The Table may be read thus:~To 1,000 Troops who have served l ier 7 Years, of the Ages 20 and under 27, 17'41 Die, 15-19 are iNVALiDEind 32-60 Die or are Invalided Annually. Note.— Table I was constructed from the facts in Tables II and III. Comparison of the Loss of Veterans to the Army as it is now and as it might be. Table IY. Table showing the Number of Effectives (distinguishing Young Sol ire from Veterans) remaining (1) in the Army as it is : (2) in the Am in an Improved State— if the number of Annual Recruits were 10,000, nd the Army served only at Home in a time of Peace. Effectives .... Young Soldiers Veterans .... Years of Service. 0—20 0—10 10-20 A";es. 20-40 20-30 30-40 To 10,000 Annual Eecruits Army in its present Sanitary State. Army in an Improved State. Upon the above hypothesis. 141,764 84,888 56,876 166,910 92,305 74,605 25,1 7,4 17,7 AND AS IT OUGHT TO BE. XXIX The Table is intended to show more particularly the large . imber of Veterans lost to the Army as it is at present consti- ited : — Thus in the Army as it is, the number of "Young )ldiers at the Ages 20—30 is 84,888, and of Veterans of the ■ges 30 — 40 56,876, while in an improved state the numbers ^ould be respectively 92,305 and 74,605, showing an addition ) the strength of the Army of 7,417 Young Soldiers and 7,729 Veterans. The number of Veterans actually in the Army, owing to lervice in unhealthy stations abroad, is much less tlian in ther of the above estimates ; in 1851, of 120,733 men, 88,620 ere of the Age 20—30, and only 32,104 were 30—40. Loss of Veterans to the Army in its present State. Two very interesting Tables are added, furnished by Deputy nspector- General Taylor to the Commission of Enquiry into le Eegulations affecting the Sanitary Condition of the Army, c; givmg- XXX CLASSES OF DISEASE FOR WHICH in O O C r-H r-l O t-CM 00 r to CO O < C< r-t C5 O I I •<}< 00 CI c- 05 ?0 CO O Oi i-ieo I (NO eo O r-H I— I I— I TP lO O rH (M i-l <— I I— I • r-l «5 30 OOCO (-HI 040 CCCO Oi a c^tn t- -H Ci I Ctr-iCOf-Hi«r-((>»r- o o C5 o OS CO oc 00 CO "SI e« CO 00 to o 00 o ^ coco t-m coco o CO i-H cc o ci oi CI Ct f >0 t^O t^Cn C- ) rH (M •- Q0©» COOS lO «0 ifi CO OS t^r ^■^ Si ?.St 1^* OOO O 050 '^irs l> CO CO eo a r-^ Oi t-< OS O O CO CM I 00 GO «c o « eo 1-1 CO h tCpH K 4, t>D « o S o '=3 S MEN ARE INVALIDED. XXXI Total. 264 200 5,093 4,048 3,418 2,627 1,614 1,000 202 174 205 226 3,240 3,615 ' 255 34 1 O d \ r.i m CO 00 S d" ^ 1857. CO ^ 00 >0 lO r— 1 O OSO OOO CDiO \a ^iS 2S'~' t^'-' "'^ 4,053 1,854 5,907 1 185G. mo 00 OS Ci 35 1— 1 o «o CO to en r-) 0» t^>n OO rl r-H 0<0 I t r— 1 13 1—1 CI II 00 d ■x o o Co" 1855. f— IrH -^r-H OD'fl t^d C» OCO 1— <30 00 rH 1— 1 r-l 1 r-H O 1 j o C! o in 1,198 1854. 05 CO ci CO O 00 o cq_ 1853. ' r-Hr-H CCi— 1 rJ. O-— < 0»n OOf^ os-^ C030 t — < OC OS OS CO 00 CO o CO cs cs r--. CO o o in o i^ i o f ^ rH CS^CSOOOt- 1 r-l^ll r-tr-> r-ir-t C» rH 1 1 I— m OC OS o t-; vi CD COO inos cjos ocr> com tJio oo-^< CI rH rHrH pHrH 1 1 O d OSI- GO o_^ ci CO ■>*co OrH 00 CI in>n OO -^cs coco rH rH M C CO rH CO C» O CO C» rH rH rH d 1 1 719 1,020 OS CO 18«. rHO. Om OCl rHI— CSrH COl-O C rHCO c»t}< It US CO CM rH d Ci 1 1 t^o CO t~ c» co_ CO o o d" s CO OSO com t^eO OOrH rHin rnrn 'fC^ rHCOClOrHOOd OOd 1 CO ■<}< rH rH rH Ti< 1 1 CO ^ ID 00 00 CO co_ d" S 2 Li 11 ^ 23 o 'a 'si 'a aj to o t) ^2 3 o o ® o cs a a. 3 a ^ _u_a 3? 6C 15 B-^ a a |In the Statistical Section, XI, p. 324, will be found some :)re minute questions, asked upon these data, which a Statis- al Department, if formed at the War Office, ought to be ,lo to answer. D P 10 I PART II. Abstract of Sanitaey Eecommendatioks contained Appendix LXXIX to the Eepout of the Eoy Commission, on the Sanitaet State of the Aemy. Sanitary knowledge compreliends — 1. Drainage, ventilation, cleansing, &c., of buildings, suchi the General Hospitals. 2. The sanitary state of occupied towns, such as Balaclavi 3. The sanitary state of camps, such as that before Seb- topol. 4. The question of water-supply. The abstracts of the sanitary recommendations which be found elsewhere, will give a fair idea of the amount of pr- tical information at the command of the Army on such subjei , and the whole result may be summed up shortly as follows : February 21, On February 21st, 1854, the Director- Greneral proposed) i8o4. Horse Guards to send out three senior medical officers) Director- General, the prospective seat of w^ar, to make topographical enquir. . He was authorized to do so the same day. February 27. C)n the 27th he sent his instructions to Drs. Lint, Dumbreck, and Mitchell, the officers selected for the purpos This was a very proper and a very prudent step, but 3 instructions were meagre and not concise enough. He trusi evidently to the men themselves. There are no reports among the papers from Drs. Linton rl Mitchell. There are reports from Dr. Dumbreck, contain,' 1 r BULGARIAN SANITARY RECOMMENDATIONS. XXXV sjgestions for improvements in the clothing oi troops and c tain sanitary suggestions for occupied towns. Che suggestions about clothing were urged by Dr. Smith on t ) Horse Guards, but declined, and Dr. Smith issues no i tructions on the sanitary part, so that the Commission was a ead failure and led to no result. Che troops went to the East without any sanitary mstruc- ti as from the Army Medical Department. [irhere is no paper to show that the Camp at Devna was t;en up, after asking the opinion of the Principal Medical ( icer, or that any advice was tendered by him about the site. Cjere are representations of Dr. Hall's, but apres coupf about r ving camps affected with Cholera, made very properly and ^ ;h success. J Dr. Smith sends one solitary sanitary recommendation about t[) Army, and that is to filter the water for the Hospitals. fOn the subject of Hospitals at Yarna there is a report, with commendations from Dr. Dumbreck to General Tylden, for i proving the Hospital at Varna. They are good, so far as iij go. He used every effort, apparently, to get them carried ( b ; but, even at this early part of the War, he could get no < ectual aid and the improvements were not carried out. This (jie affords a striking instance of the utter want of any sani- iy organization at the very opening of the campaign. So far as the campaign in Bulgaria is concerned sanitary 1 iasures, in their preventive aspect, appear never to have im entertained, except by Dr. Linton, of the 1st Division, io, on the 7th July, appointed Mr. Cooper, Surgeon, to the ♦[iiitary charge of the 1st Division Camp> Mr. Cooper is an jfle, energetic man, and proceeded vigorously with his work, 6orting and representing personally nuisances, &c. ; but it is ♦[^y to see, from his letters, that he made little or no progress i his work. There is no record of any inspector having been appointed f any other division. [The sanitary procedure, with regard to Scutari, may be Scutari, mmed up as follows : — There was no intelligent sanitary inspection of the buildings tfore occupation. I What was done afterwards was good but never touched the D 2 p 10 XXXVI REVIEW OF THE SANITARY RECOMMENDATION Crimea. Januarv 12, ISof). Director- General. October 12, Dr Linton. T)o survey, no topographical report, no sanitary report, no cautkj to military authorities, no sanitary memoranda to medil officers of divisions. In short, so far as the papers are c(- cerned, the sanitary question appears never to have been C(- sidered in its preventive aspect, for there is no record of a- preliminary measures having been recommended, either by h Director Greneral or the Principal Medical Officer. There , of course, no reference to any opinion having been asked, : sanitary matters, by the military authorities. This coufidi; inaction is rather singular, as even very popular books, some them very well known, had indicated the ground occupied the British troops as unhealthy. This same fact had a' been adverted to in the public press, before the Army went ' the Crimea. No sanitary measures were organized for securing the heal of Balaclava, the very basis of the operations. The Director- General makes no sign on the subject 1. January 12th, 1855, when he writes a general instruction Dr. Hall, to represent defects of every kind, without specific tion of any sanitary defects, to Lord Eaglan in writing. Dr. Linton, Inspector- General 1st Division, on the 12 October, 1854, appointed Surgeon E. Smith to superintend t sanitary state of the 1st Division Camp and to report, writing, to the Principal Medical Officer. This is tlie only instance of sanitary prescience recorded the correspondence. The example does not appear to ha been followed. The earliest indication of a recorded sanitary opinion is in letter from 1st Class Staff-Surgeon Anderson to Major Woo 3rd Division, on the 7th December, 1854, in which sickness the 9th Eegiment is attributed entirely to exposure and dam Tlie next reference to sanitary matters is on the 22i OF THE ARMY MEDICAL OFFICERS. XXXVII Jcember. Bj that time the water-supply, from neglect, had bome impure, and Mr. Aspinall, a civilian who was there, rommeuded alum to purify the water. The matter was r OTed to Dr. Hall, who says, in reply, " the experiment can dno harm and, as it may do good, I will call the attention of Bdical officers to it." jJSToTE. — Dr. Alexander had already represented want of h^s as a cause of disease, and this letter was sent to the (lartermaster-Greneral by Dr. Hall on 26th November.] ■[hese entries indicate the whole sanitary" procedure in the ( up before Sebastopol, so far us can be learned from the cor- rjipondence, during the period of greatest suffering and loss in t^i British Army. There is no further notice of any kind on the subject till the 2;h January, 1855, when Staff-Surgeon Hume, 3rd Division, cnplains to Dr. Hall of nuisance from drink sold and ponies l,)t near the Hospital. This Dr. Hall represents to the Jjutant- General, on the 24th January, and goes on to say, as ijvere incidentally, " "When on the subject of camp nuisances I'aay mention," &c., and he proceeds to recommend the fol- l i'mg sanitary precautions : — Latrines to be dug for all the cops and the soil covered over with earth daily. Dead alimals to be buried, " instead of being allowed to decay and tnt the air above ground." [This appears to have been the fit notice of the abomination.] " It would also be highly f ira&Ze"— mark the expression ! — to direct pioneers to clear i^md the hospital marquees and tents daily, to collect all offal, c ty and condemned clothes, " which are now merely thrown (Lside the tents and there allowed to rot." Trenches round t hospitals should be deepened. Says that medical officers, Ten spoken to about it, state they cannot get labour, 'arnsthe Adjutant- General that if these measures are not t:en graver diseases will appear and carry off thousands, [[his is all very proper, but why was it not done and the Smce organized, before this date ?] |Dr. Hall, in reply to a query about using quick-lime, to ((isume dead animals, very properly expresses his opinion, on i|e 28th January, that the carcases ought to be buried. He li terates the sanitary advice given in his former letter, and November 26. Mr. Alexander. Camp. January 24, 1855. Dr. Hume. January 24, 1855. Dr. Hall. This was also complained of by Dr. Linton, on the 27th and 1st February. January 28. Dr. Hall. I XXXVIII REVIEW OF THE SANITARY RECOMMENDATIO February 5, 1855. Dr. Eoberts. February 17. February 24. Dr. Hume. February 25. Mr. Mouat. Marcli 8. Board of Health. objects to the site for certain barrack-huts, at the head f Balaclava harbour. The site was selected without any consultation with U medical authorities. The huts were erected. They still wi) occupied, notwithstanding Dr. Hall's protest, and were of vacated after fever had ravaged the Guards who were i them. On the 5th February, 1855, Surgeon Eoberts recommen the formation of a camp police, for cleansing the 4th Divisi , to the Assistant Adjutant- General, and, on the 17th, he advis graves to be better covered. A daily sanitary police for the Camp Hospitals was si- gested, by Dr. Hume, on the 24th February, to Lieutena- Colonel Colborne, for the hospitals of the 3rd Division, ) collect and burn or bury filth and rags. On the 25th February Surgeon Mouat, 6th Inniskili Dragoons, calls the attention of his Brigade Major to ca- lessly-buried dead horses, within the Cavalry Camp, v\ predicts fever, &c., if not attended to. The complaint led) inspection. Four camps were cleaned and the dead hora properly buried. This is a very proper letter, under the ( - cumstances, but the necessity for it proves the want of sanit y system. The next indication of vitality is on the 8th March, 18 , two days after Sir JohnMc Neill's Commission and the Sanit f Commission arrived at Constantinople, and the day the n 1 would arrive in the Crimea. On the date given Dr. Hall recc ■ mended Lord Eaglan to appoint a Board of Health, "to tis into consideration the sanitary condition of the Army," as t Diet and water, Accommodation for sick and well. Clothing, Duty, and Locality, " the Board to report on the best means of remedying, removi or abating whatever may appear to be prejudicial to healt" The Board to consist of Drs. Hall, Linton, Alexander, M!' donell, Hume, Wood, Mouat, Anderson, OF THE AIIMY MEDICAL OFFICERS. XXXIX Were it not for the astouDdiiig fact that such a Board was ;t called together at the beginning of the campaign, it would ] positively ludicrous to think of its being summoned after 1)3 Army was lost. :It is called together after it could render no effective service id after the Home Government had taken the matter into its lads, apparently simply to save the Department. What other good it could do is invisible. On the same day, March 8th, Dr. Linton issued a memo- :iidum to the medical officers of 1st Division, calling attention camp nuisances. ,0n the 14th Dr. Hall recommends boring holes in the ards, to ventilate the hospitals. And, on the same date, . vises the site of a Land Transport Corps Cam]) to be moved ;pther from the Hospitals of the 4th Division. . On the 19th March Dr. Hall reports, apparently for the first ,ue, on his weekly state, that the men of the 79th and 93nd .ighlanders were affected by the locality of their camps, " but at strategic reasons prevented their removal." [By this ne the whole strength of the 79th had passed through hos- tal, from fevers and other zymotic diseases, but this is not ited by Dr. Hall.] [JS'either is any remedy even then sug- sted.] On the 24th March Dr. Hall recurs, in his weekly state, to e Camp of the 79th and 93rd, pointing out " that it was ring to the localities of their camps, which it would be desir- jile to change." On the 27th Dr. Hall calls attention of General Airey to a Iter of Staff-Surgeon Eoberts, Principal Medical Officer 4th vision, advising ventilation of tents and diminution of over- owding, which Dr. Hall backs. On the 25th the Board of Health Ecport was transmitted, by r. Hall, to Lord Eaglan. The following are its recommenda- 3ns, of a sanitary kind, regarding the Camp. Water runs to aste, for want of tanks or means of collecting. Water to 5 husbanded and wells dug. Tanks to be cleansed; a atermg trough constructed. Huts to be ventilated, by three juare turrets (Dr. Alexander) through the roof, and holes in [le doors. Inmates of huts to be limited. Site of many |i.mps objectionable, from vicinity of ravines with animal March 8. Dr. Linton. March 14. Dr. Hall. March 19. Dr. Hall. March 24. March 27. March 25. Board of Health. XL KEVIEW OF THE SANITARY RECOMMENDATIONS remains. Such remains to be covered with additional eajh and lime, and recurrence of nuisances to be prevented. \. most cleanliness should be observed in camps and their vicin f. Great attention to latrines, to be dug sufficiently deep, f .r feet at least; to be covered daily with earth and refe charcoal. Tents to be boarded and not overcrowded. Out walls to be raised daily, as also in marquees: tents to-e struck once a week. Duties considered a principal causof disease. (Cavalry, who performed no such duties, suffe.d most from zymotics at this date.) Grraves should be four H deep and lime used. Camp of Coldstream Guards unhealt,\ Spotted Typhus has appeared. " Huts should not be occup d by troops." Suggests a deep trench from Kadikoi to the 1> bour, about a mile, to drain the ground, to secure the heth of the 71st (who did not suffer from this ground) and a :w Eoyal Artillery, who might have been removed. [Thewk was a good one, but good for other sanitary purposes than th e indicated, and it was done towards the end of the year y the Army Works Corps for the road.] Eccommends the?- moval of filth from the General Hospital, and burial of d.d animals. I The most obvious matters omitted in this report are — 1st. The Camp of the 79th. 2nd. Drainage of huts ! 3rd. Eemoving earth from huts. From these causes a very large part of the zymotic diseie then in camp took its origin. Unremoved damp was the main local cause and it is noiit all recognized by the Board. Their recommendations otherwise are good. April 5. April Dr. Hall transmits letter of Dr. ]VJ> Dr.Macdonell. donell, to the Quartermaster- General, about a nuisance fm bat animals, in the Cavalry Camp. April 16. 16ih April Dr. Hall transmits to Quartermasl> Drs. Linton General letters of Dr. Linton and Dr. Scott, about removal )f and Scott, ^jc)^]^ Regiment, and objects to their being placed on the sitof the Zouave Camp. April 30. the 30th April Dr. Hall represents nuisances in e Dr. Hall. trenches and advises latrines properly managed. May i. 1st Ma V encloses to Quarterai aster- General Dr. Anderses Dr. Anderson. * OF THE ARMY MEDICAL OFFICERS. XLT May 2. Dr. Hall. 'commendations about cleansing in the vicinity of Croat .ospital. There are sanitarj- suggestions made subsequently by rious persons and of the following nature : — ;May 2nd — Dr. Hall, about removal of filth of Balaclava ospital. May 12 — Dr. Hall, about covering dead animals. May 12. May 15 — Dr. Taylor, about camp being too close during May 15 lolera. Dr. Taylor. Dr. Hall, May 12th — Eemoval of certain camps during Cho- May 12. a. Dr. Hall. May 27 — Not in favour of white-washing roofs. -^^^ 27 June 2nd— Nuisance and Cholera in trenches. j^^g 2 June 4 — Charcoal powder for latrines in trenches. j^ne 4 July 2nd and 6th — Recommends removal of aflfected camps. July 2 and 6. th — Eemoval of dead animals from vicinity of hospitals. ,Tuly 11. 18th July — Dr. Hall, for improving drainage in hospital huts July 18. ( 3rd Division. 3rd August — Dr. Hall, suggests means of remedying defects August 3. i hospital huts, for winter. May 20, 1855 — Dr. Alexander recommends French latrine. May 20, 1855. IHth February, 1856. Dr. Alexander —Unburied horses near j'ebruary28 1 Division. Latrines should be covered and Camp kept clean. 1856. Dr. Alexander, in his March monthly report, states the Camp ^^r. Alexander, cjiis Division to have been in good order. With a few exceptions the sanitary recommendations made 1 the very few medical officers who made such were good in f iiciple. ^r. Linton's proceeding of appointing a sanitary inspector f the 1st Division, who only did his work for a very short t e, for he died of Fever apparently in consequence, was by f the best and most judicious sanitary proceeding adopted d ing the whole siege, by the Army Medical Department. I did the same at Varna. It indicates what the Principal Wical Officer of the Army ought to have done. Vith this single exception the whole sanitary procedure, as n xrds the Camp, was most defective at first, and there can b'lo doubt caused much sickness. There was an entire want o^istimating tlie importance of sanitary precautions, and no Siitary organization was ever advised or attempted. E p 10 XLIl REVIEW OF THE SANITARY RECOMMENDATIONS The statement of StafF-Surgeon Eoberts, 4th Division, thi " there was no sanitary discipline observed in our Army in t j Crimea" has been already given. And there could be nori under the system or, rather, no-system which prevailed. While making these remarks on the absence of sanita' system in the Army, it is necessary to repeat that they rei; exclusively to the defects usually classed under that desigi; tion (sanitary defects) in Civil life ; those defects which st local and not personal. Balaclava. The town of Balaclava was selected as the base of operatic i during the Siege of Sebastopol. Any one at all conversa; with sanitary work would have detected, at a glance, the sa- tary peculiarities and possibilities of the place. A small narr • plot of ground, not more than sufficient for its 500 inhabitan, had to receive 20,000 or 25,000 men per diem, with numerc? horses, in addition to the whole population required for c(- ducting the business at the basis : Guards, ships, and a const? 1; harbour population of above 2,000 men. A place altogetlr very likely to become most unhealthy. Difficult of access p sanitary purposes and requiring more than ordinary cs. Crowds of Turkish soldiers were also in the town and vicini , shortly after it was occupied. Here was a case then of all others requiring a vigilant sa - tary police. There is no document to show that Balaclava was er inspected : any one recommendation made when it was oc- pied or any one step taken to preserve it in a sanitary cori- tion, fit for being a basis for such an Army. Of course the place got unhealthy, and when matters be|U to look serious, representations were made by any body to ij body, without order or system, in the vain hope of remedy g the evil. Dr. Anderson. I^he first of these recommendations was made by Dr. Anc- December 29, gon, on the 29th December, 1854, nearly two months after e occupation. The Commandant having intended to bring e Land Transport Camp and Bazaar too close to the Gendl Hospital, Dr. Anderson very properly protests and the eviis prevented. December 30. Next day, the 30th December, 1854, Dr. Anderson calls e attention of the Commandant to the mortality among ^' OF THE ARMY MEDICAL OFFICERS. XLIII January 15, 1855. rkish troops, probably from Typhus, which will degenerate ho Plague. The filthy state of that part of the town occupied 1i the Turkish troops ; also the foetid mud, at the place where t) sick were embarked, in front of the Hospital. " This emits {faalaria highly prejudicial to the health of the town, extremely ^i^eterious to the sick who may have to wait there for embark - jon." On the 15th January Dr. Anderson again calls attention to 1 ) subject of his last letter. Asks for enquiry as to the deaths J ong the Turks, also that the Turkish Burial-ground be bught under observation, and repeats his warning. ||0n the 24th January Dr. Anderson requests a sentry, to January 24 pvent Turks and others committing nuisances near the Hos- ]:aL On the 16th February he calls the attention of the Com- liudant to twenty dead bullocks floating in the harbour, and ^0 to carrion lying along the beach nearer the entrance to ^3 harbour. He suggests that the dead animals be towed out 1: sea. The hospital latrines having become offensive, he suggests t3 formation of others, on the 19th February. On tlie 10th 'arch Dr. Anderson suggests whiting the roofs of huts, to ];ep them cool. (Dr. Hall, at a subsequent period, apparently J m want of knowledge, denies the efficacy of this precau- t:a.) |0n the 13th March Dr. Anderson calls the attention of the '^immandant " to the filthy state of the encampment behind id beside the Cattle Wharf," " in my opinion one of the few : mining abominations of Balaclava." Che Board of Health, already mentioned, which was called Dr. Hall's recommendation, on March 8th, 1855, met at ilaclava, in the very heart of the evil. The report was sent ' Lord Eaglan, on the 28th March. Let us see what it says :.out Balaclava. iNot one word ! It accepts the present state, with all its nominations, while Cholera was imminent, recommends thing, and sends this report to Head Quarters, after Dr. ivin and the Engineer and Inspectors of the Sanitary Com- ssion had arrived in the Crimea, and saw with their eyes the lOiYiinations reported in the Sanitary Commission Keport. February 16. February 19. March 10. March 13. March 28. XLTV ORrMEAN SANITAEY RECOMMENDATIONS. The Commission found that it would have then taken 300 mi for many weeks to remove sanitary evils which a Sanits- Board, convened in the heart of these evils, overlooked the ver existence of. The proceedings of the Medical Board, at Balaclava, cleai- show that the Principal Medical Officer had formed no estimfi as to the bad sanitary state of the town and its probable effi on health, for he did not include the subject in the instructic; issued to the Board, and the subject was consequently i; mentioned at all in its Eeport. After the arrival of the Sanitary Commission recommem- tions on sanitary subjects appear to have been more frequen- made, all good in themselves, but the general result which striti. one, after readiug all the documents, is that the amount ' sanitary knowledge shown is very different in different office "With one exception there is no exhibition of sanitary pi science. Some knew more, some less, but the Army has sanitary method and very little sanitary intelligence, for protection. The Balaclava Board of Health, comprising t sanitary knowledge of the Army in the East, entirely ov( looked the most important local causes of disease then prevai ing and took no cognizance of them whatever. Even where representations were made there appears to hn been no necessary connexion between such representation a the execution of improvements. In the case of the Hospital at Varna, already adverted ' even after Lord Eaglan had directed the works to be carri out, nothing effisctual was done. In short the British Army w witliout any sanitary system whatever, and the Army Medic Department has shown no symptom, in these papers, of havii kept pace with sanitary improvement in Civil life. 235 X. '^tES ON THE Necessity of special Sanitary Func- lONARIES IN CONNECTION WITH MILITARY HOSPITALS, ND WITH THE ArMY IN GENERAL, BOTH AbROAD ND AT Home. s the sanitary or the sanatory element of most inortance to the health of an Army? Let recent expe- ri ice shew : — We have seen in the Crimean Army 12,025 imjk in Hospital, while 11,367 only were effective for duty. Ifnen are not kept in health, an Army may be rendered infective by disease, though every sick man may be Cl3d. anitary measures include : — '. The choice of localities, or (in those which for mili- ta reasons must be occupied), the removal of the causes of hsease. To this branch belongs especially the selec- 3ti|i and construction, the repair and adaptation of hidings, and the sanitary charge and management of j owns. The choice of Diet, with regard to climate, fatigue, exposure, ar the counteracting of the influence of Diets, unavoid- ab defective. . The choice of clothing with regard to climate, &c. arious Acts of Parliament having lately passed in j^ggessity of E:;land, and Sanitary Commissions having been ap- Sanitary pcited, as weU as sanitary powers given to Boards of Ojirdians and local Boards of Health, now governing the W]tle area of England, it cannot but be admitted that 3rvi8ion, 236 WHAT WAS DONE BY Sanitary Science is accepted by the country and by ,e Government, as necessary to the well-being of the inha't- ants — and practical action derived from it is estabHshec'n law and in fact. There should Therefore to establish a community of 500 to 1,(0 ^ '^omcerin^ EngHshmen, densely congregated together^ without a General sanitary element of government, would not only be wng Hospital, in itself, but contrary to the principle distinctly establisld in this country. It is therefore proposed that a sanity Officer be added to the Officers of every General Hospil Powers and He should have distinct powers to demand, in cariy^ Responsibility j^'g yi^igcts, the assistance of the Enorineer Officer, e of this Officer, . . Medical Officer, and the Steward. In case of conflict'^ opinions, the Governor should decide upon each case'f sanitary requirement, after hearing the full explanation f these Officers. In cases of importance, the opinions of each Offi^r would be recorded. Under this plan, immediate action's obtained, an amount of independence as great as possi ? secured to the Sanitary Officer, and the honour and cl- racter of each Departmental Officer secured by reco , where desirable. Improvements It is notorious that neither the knowledoje nor t; eflcetcd at . . ^ Scutari, by the means necessary to effect sanitary improvements, : Commission Scutari, existed before the arrival of the Sanitary Coi- mission. The non-cleansing of the Hospital and i appurtenances, the neglect of the ill-constructed and no acting drains of the place, and the accumulating : indefinite number of sick, as well as of Medical Office: Orderlies, and Nurses, and soldiers in depot, within narrow area, in the interior of the Hospital, placed i inhabitants in circumstances far more adverse to cure ai to health than are afforded by even the most crowded ai uuwliolcsomc alleys of tlie worst towns. No appliances f THE SANITARY COMMISSION. 237 ve:iilation were resorted to, and, had they been so, they wci d have brought in a foetid (although cokl) atmosphere, frc! the state of the yards and external drains. may safel}^ be affirmed that even a magnificent stone mtpital, under the above-mentioned circumstances, leaves th- soldier in a sanitary condition far inferior to that of thpommonest hut. The French Surgeons, long accus- tofed to Hut Hospitals, in Algeria, distinctly affirmed th| they preferred the separate huts in the Seraglio Gar- de;, at Constantinople, to the splendid Hospital on the heihts of the Campo di Pera;^^ and they were right. Icithis building, as at Scutari, the corridors, however wi and commodious, with their staircases and the wjils opening into the corridors, acted as a series of tii|iels towards the establishment of an uniform Hospital atfosphere, less salubrious than the external air. he evils of Scutari have been fully described. The List of the Measures ifljisures taken by the Sanitary Commission were as carried out by P the Sanitary (-^^^ • Commissioners . As to over-crowding. at Scutari. "hey removed one row of beds from the Corridors of til Barrack Hospital ; they fixed the distance of the beds at lot less than six feet from head to head ; they allowed n less than 1,0(]0 cubic feet of space for each bed. . As to ventilation. hey introduced everywhere in the Hospitals plates of Pjforated zinc or wire gauze ; and ventilating shafts for tl escape of foul air in the ceiling of each ward. >. As to drainage. fhey drained the site of Haida Pacha, called the iace Hospital ; they closed fifty open privies under the vjrds at Kuiuli, removed 200 cavalry horses in one he basements there, and closed the wards and quarters Qt them. 238 SANITARY MEASURES IN They closed the Stable Hospital at Scutari, and th(two 'f Convalescent Ships in the Golden Horn at Constantirple. ;> They constructed a large flushing tank at the ead ■ of every drain, which was flushed several times a dMni order to sweep out the contents of the sewers intjthei sea. I [■ The latrines, sewers, and drains, were cleansed and deodorized with peat charcoal. The sewers were tr^ped and ventilated, so as to prevent the wind bio win up i through them into the Hospitals. The outskirts of the Hospitals were daily cleansed 4. As to cleanliness. They ordered constant lime-washing for the wallsmd ceilings of all the Wards and Corridors, in order to cLnse and disinfect their saturated surfaces. i All this ought to have been done and finished b ore |f the Hospitals were occupied. It matters not wheth'or not these evils had been reported on. It is evidentihati the present system does not ensure the putting iichii buildings as those of the Scutari Hospitals into fit der \, for the admission of sick, before such sick are adm ;ed. i This is what is necessary, if the many lives are i be spared, which were sacrificed here. All these saraiy ; measures ought to have been taken from the first. Che i disgrace to our service is, not so much that they ere 1 not more speedily executed, as that they should ven have been required. But then, as now, no adequate estimate of theiiim- portance had ever been formed, nor does it now ist Much is thought of the importance of keeping a posion \ against the enemy — little of that of keeping it ag nst disease. Even now, sanitary measures are still (led '^humbug,'' although we have lost half an arm, by disease. I t THE OENEKAL HOSPITALS. 239 « it is quite evident tliat, at the present time^ considering Tlie Sanitary tl great advance during the last ten years of Sanitary ^General^ Sence and practical sanitary improvements in England gho^{^£f ((forced bylaw, under appeals to the tribunals), no Army an Army ;^ dical Officer, having been on service during that period, Officer. Cihave acquired a competent knowledge of the subject. I:^ sphere of observation, confined to a single regiment, oeven to a detachment, is far too limited to give him a p ctical command of the subject. [t is therefore evident that, for the immediate purpose, D Medical Officer should be allowed to undertake the cirge of a Sanitary Department in a Hospital, unless he gone through the practical study of the science in civil 1 ; in England. In order, then, to prove that the sanitary element is Necessity of r^essary to an army on active service, we have, first, the SanUarv ccumstances which led to the appointment of the Sanitary ^^fficer ^ ^ * attached to the (mmission of the Army in the East; secondly, a large army, ption of the details which form its evidence. And in ^aeral, antecedent to the events of the War, we have at lime a mass of facts such as those at the Serpent's Nest, £ York, at Newcastle and Gateshead, and in Soho, Indon, which justify the proceedings of Sanitary Com- I ssions and Boards, and of Cholera Investigations, &c., ( ring the last ten years, in Great Britain. The military i)de, probably, of representing this sanitary element ^»uld be a sanitary Officer, of superior attainments, ] iced not merely in every General Hospital, but in every harter-Master General's office, at Head Quarters. This Sanitary Officer ought not only to have power to Hesbouldhave „ the })0\ver of ];3ord his observations and make his reports to the Com- reportino- under of the Forces, like any other Officer, as well as to I'^Xp^^^^ent *,3nerals of Brigades and Divisions, Commandants, or and , responsible for )wn Majors, Naval Officers commanding ports used tor the execution 240 WANT OF A SANITARY OFFICER 1 of all necessary military purposes, but the independent power of report g operations, home. In the meantime he would also have the powof demanding the means for enforcing such executive opci- tions as would not interfere with the military tactics )r the military safety of the troops. (Dr. Jackson's That the above is neither drawn from partial observatn Statement, in „ i • -n i ii , 1799.) nor from hasty conclusion will at once appear by the 1- lowing quotation. Dr. Eobert Jackson, in 1799, a r recording the state of things'^ which he considers 'S- jurious to the character of the officer and the welfare )f the soldier/' prophesies (in the following words) thal.t will continue until physicians have the place in Coun s of Military Commanders that is due to science. The heah history of the late wars in Europe is demonstrative n proof of the important fact that military life has b(n sacrificed in an enormous proportion to ignorance, i. e., o the unwillingness of Commanders to be advised on subjes which they could not themselves be supposed to know.'" After half a century of progress in the division f labour, and what may be called the recognition of Sanit;y Science in the last ten years, and after its progresse development up to this hour, the "Physician'' of Dr. Ja(- son must be taken in the double sense of Sanitf? philosopher and Medical Officer, a position occupi , indeed, by himself alone. This Officer Enough has been said, it is hoped, to show that t s ^ be an" Army ^ Officer also sliould not be an Army Medical Officer: t3 office of the Sanitary Officer and of the Medical Offi(r cannot be filled by the same person, however much it mr be necessary for the latter to have Sanitary acquirement We are speaking of the Superior Sanitary Offic, attached to the Quarter-Master General's Departmer; the Medical Officer or Assistant w^ould be the local advi^' and enforcer of Sanitary measures, under the Sanita Medical Officer. WITH EVERY ARMY. 241 c' cer: for the representatives of the Sanitary Officer, in c|perent stations, would probably be, most conveniently, ?;dical Officers, specially instructed. The want of sanitary care in the hai'bour of Balaclava, gierally, is well known, and how late it was before any 3mpt was made for the formation of quays, or for ing the surface of the water, as it may be called, and tc'ing the results to sea. Even after much had been djie in the way of improvement, some of the dead Cijcasses were, nevertheless, allowed to collect, when dv'en by the eddy, immediately under the Castle Hospital b^^hts. Dead horses were buried in the Sick Wharf at Eaclava, and the salt water filtering through, this nlsance became intolerable every evening after sunset in ]\^jy, 1855, and most conducive to bowel complaints. fn short, the following may be taken as a fair account ol:he condition of Balaclava, a town of from 500 to 600 inibitants, in the spring of 1855, six months after we hjf occupied it, and at the time of the arrival of the :S|itary Commission. ■he east side of the harbour was, from end to end, a ms of putrefying animal and vegetable matter; dead ar aals were floating in the harbour ; the village was fil*y — there were no slaughter-houses and few latrines. Tl whole town was smelling of sulphuretted hydrogen. Tl horrible condition of the graveyard at the head of th;harbour will be elsewhere spoken of. |ihe question is not, here, had recommendations been mle to remove these evils? his was the state the town was in — of this there is no q^|tion. The Commandant and Admiral were, it is tri, using their best exertions, but the case appeared ^li')st hopeless. It is far easier to prevent than to ^'ei ;dy such a state of things. The necessity of an Instances showing the necessity of such a functionary. Balaclava. Its condition in the Spring of 1855. 242 SANITARY MEASURES Improvements effected after the arrival of the Sanitary Commission. The Camp. Inrtlanccs of the Officer of Health, or his equivalent, was made appant. Sanitary measures ought to have been taken immediacy on the occupation of the town, and a sanitary polic(at once organized. From May till September, 1855, tire were outbreaks of cholera and fever both in the shipjQg and the town. Admiral Boxer himself died of chofera early in June. A few words will here be said on the course takeiby the Sanitary Commission, in order to illustrate the sjps necessary in such a case. The graveyard, and all filth that could not be biiit, were covered over with lime, charcoal, and earth. Latiies were erected ; a cleansing staflp was organized ; a Rus an barge, which had been blown out of the harbou of Sevastopol, was employed at Balaclava in carrying iich refuse out to sea as could not be burnt on shore a slaughtering place was provided ; houses were lime-waied inside and out; the shoal water at the head of the har)ur filled up ; the decaying matter along the east side oithe harbour deodorized, and covered in with temporary qi.ys. Drains were made ; one of the sources of water suppl3vas covered over. ThreeNaval Surgeons daily made an inspedon of the ships ; cleansed, lime-washed, fumigated, ventil ed, or removed the ships out of harbour. Dead animals ere towed to sea. The worst houses were pulled down, lese works advanced slowly, from the deficiency of lalur; but, by the end of July, they w^ere so far advanced hat the Commandant could carry them on alone — and ]da- clava became, what it might have been from the begin ng, as healthy a little seaport as can be seen. A very few words will suffice, in like manne]|to describe the sanitary condition of the Camp. f Comparatively little had here to be done by the Sanitary Comniij^sion, and that chiefly in the constru ion i IN THE CRIMEA. 243 I of huts. Many were un ventilated, many were partially advantageous [buried, or had earth heaped up asrainst them. There was operation of ... . Sanitary fever in consequence. Kidge ventilation was introduced, functionaries. [the earth cut away, the sites drained, the huts lime-washed [outside. 1 The camps of the Guards before Sevastopol, and of the Highland Brigade beyond Kamara, became sanitary - models. Little fault can be found with the arrangements , of the second winter. The large drains along the roads had a most beneficial effect. The following is an instance which shows the usefulness Case of the of a Sanitary Commission, when its powers can obtain [nHu^sNoHh- |any promptness of remedial action. About April, 1855, a I great number of the 79th Regiment, part of Sir Colin CampbelFs Brigade, v/ere ill with fever, having been hutted lOn the heights to the north-east of Balaclava. The t Sanitary Commissioners, having inspected the ground in consequence of Sir C. CampbelPs representation, called (his attention to the topographical defects of the spot. I The huts were indeed placed on the sloping base of a steep acclivity, and stood upon clay and shale, one-fourth |0f each hut being " inserted'^ into the cutting of the hill. The result was, that the whole of the rain and moisture fiom the heights (the case being similar to that of Gates- (head) was deposited beneath the huts, and even what would have in time oozed through towards the lower ) ground, was attracted by the heat of the men^s bodies I lying in the huts, the floors of which were not more than [two inches above the surface. Sir C. Campbell was told that the cause must be local, and that the fever was I generated by warm damp, in proof of which, when he ordered a board to be taken up, the GeneraFs cane pierced jthrough the oozy ground beneath, and was drawn up in ||a stinking state. In consequence of this, the sick were R 2 244 SANITARY MEASURES taken out and placed under canvass on the hill-side higer up, and recovered. The men were also removed higer up, and the fever immediately abated. I Mortality of The 79th embarked for Kertch, but on Mav 25, l^i5, the 31st and of , • t p r-. p t i • , four the 31st arrived irom Coriu and were quartered m he th^Sry empty huts. They were almost immediately attacfed in these huts, ^ith Cholera, of which thirty-four died. The 31st Tre marched to the front, but they carried the Cholera ith. them, and seventeen more deaths occurred. The lits remained empty from June till November, when ur companies of the Eoyal Artillery were landed and marced to these heights. Three were quartered in these tts, and one in the immediate vicinity. Seven men die* of Cholera in the huts, none in the company not in the Its. Upon all being moved out, and the same huts remoid, and re- erected for their reception on higher ground imie- diately above, only one more case of Cholera died. '^*^®^"PP^y ^"^e of the first charges naturally given to a Sani ry Officer, would be that of the water supply, as to its quantity and quality. In all times, camps have len chosen with great regard to the supply of water, od always must be so; and the selection of the best spri^, and economy in the use of them, will obviously con(.ce to the maintaining a position. During the occupatio of the Crimea, no wells were at first sunk, except by the N/al Brigade. A great want of economy was observed in he use of water, by the horses being allowed to drink in he pools which had been formed, instead of the water b ng baled or raised with hand-pumps into casks. One poion of the British Cavalry was, however, supplied by a strim conducted into wooden troughs, viz., the Light Cavry Brigade. The water down several ravines of limes ne was allowed to trickle away and form marshy swai wlion it might have been arrested by short and low d: IN THE CRIMEA. 245 jid a little side walling, as used universally all over the last. The Sanitary Commission, it is known, reported )on this subject; and also, as required, gave in some linions on the spot. The fears which the progress of the hot weather, wards the middle of May, 1855, naturally created, were, twever, cut short by tlie advance of the Allied Force, on |e arrival of the Sardinians, Avhich gave us possession a considerable part of the Tchernaya. The fears at jime on the same subject, arising out of the obvious : jduction of water in a limestone country in the summer, jiy he judged of by the fact that not only a distilling li |ssel was sent out, but an expedition was talked of, with 'I |e object of pumping water out of the Tchernaya to the : "iiteau, where the chief part of the army was encamped. : '|iis, however, was not carried out ; the water-supply ling, in fact, sufficient for an Army of ten times the I fength ; but large portions of the cavalry and other Irses were habitually watered at the river during the rest (j the year. It may appear as if the question of the Medical Officers Medical men ,{ . ^-111 1 r hsive not in Ijvmg an amount or sanitary knowledge, ready tor general given V i|mediate appUcation, had been passed over. But when ^^{^^fy ^Jf^ ; ijis considered what is the multitude of sanitary facts Sanitary ; bught to light in every town in England, and what the ; ejiensive action resulting from them, and also that every l^ie town in England has several medical men, and yet ij| discovery or abatement of nuisances took place before J f inquiries referred to ; it is no discredit to the Army ^ Itjidical Officers to suppose them not to be informed of \ tji mahgn influences of causes, more or less difficult to f ect, in a country which they have never seen before, and ' I place where they are almost momentary sojourners. farther than tliis. Medical education, as well Civil as Science. 246 EXCESSIVE MORTALITY OF THE ARMY Military, which includes the study of the organs of lie human body in their normal state, that of their attrilites or powers, that of these organs in their abnorma or diseased state, that of the art of healing, does not incide the preservation of the human body from noxioujjn- fluences, any more than it does from mechanical violepe; in other words, the removing the human body fron]:lie causes of disease, or vice versa removing the causes. In general terms, these causes are removed by draining nd : ventilation, and the supply of wholesome aliment, his t latter, which is called Sanitary Science, forms no pai of the education of the medical man, nor is his observaon exercised thereon in after life. The individual or;he nation has been willing to pay for a restorative pro;ss, feeling the inconvenience of want of health, annou;ed by pain or local inability. But the individual or mm ; has not hitherto been willing to pay for " prevent e^^ f action, securing the person from evils which, thoug he i does not feel, the forewarnings of Science can indicate ith certainty. From this false security the nation has ;eii already awakened. It is only reasonable to recire that the Army should be so also. These are the arguments which, maturely considced, i should lead, it is presumed, to the establishment ? a i Sanitary element, in addition to the Curative element ng ; attached to the British Forces. Whether the preceding conclusions should be limite to ' Armies in the field, and Hospitals at the base of oj ra- tions; whether or not there is any similar want of sani iiy improvement and sanitary supervision, in our miliiry arrangements at home and in time of peace, may ap ;ar from considering the simple question : — ^lonTlitv thcro excess in the mortality of Military over f the Pensioners, we must take — j Strength, Deaths. j Army 597,508 16,412 j Pensioners. . , . 15,614 1,285 I 613,122 17,697 | Then 17,697 x 1,000 Mortality = 28*8 per 1,000 per annum, 613,122 , The Pensioners, therefore, raise the Mortality of be Army from 27*4 to 28-8, or 1-4 per 1,000. | It is important to remember the difference between lis calculation and that referring to the Foot Guards. The effective strength, in Table No. 4, refers to le ivhole Army, in all climates, and the Deaths also indie those abroad. The Pensioners, also, are those of the whole Armjjin all climates. ' The Mortality among the Pensioners is therefore ac 3d to the Mortality of the whole Army at home and abr d, in order to ascertain the total Mortality of the Aiy. This must not, therefore, be compared with the Death in our Civil Population, as may fjiirly be done with refercce to that among the Household Troops, j In the calculation referring to the Foot Guards pe average strength has been obtained, by adding their In- sioners, and also the Mortality in the same way. ^ The total Mortality thus obtained may be fairly c n- pared with the Mortality in Civil Life at home. j This ought to be done, also, with the other HouseiW Troops. j IN riMK OF PEACE. 261 But, to make it more fair^ the number of men pur- lasing their discharges should be taken into account. To sum up, we have, then, the Statistics of Mortality in le Army, but they are incomplete for the comparison ith Civil Life, which may be made as far as the House- aid Troops are concerned. We want, for complete Statistics, — I 1. The number of men who have purchased their dis- large for the same years for which the Returns are iven. 2. For the same years the number of men invalided, id the Deaths among them during the first year of their ischarge or pension. 3. The number of men wlio die of diseases for which iiey have been invalided, up to the completion of their 3riod of service. In 1851, a few months only before the great disaster of Comparison „ . , 111*^ I 11-11 with Ilicratc8 le Lrimea, these remarkable words were published; oi' Mortality and Sickness in the Duke of " Durhig the 3 years and 5 months ending i^lay 25, 1814, ^'^^^jj^S^^^'" le Enghsh Army had 22| per cent, constantly sick, and the isii— 1814. ckness from wounds did not amount to more than li per mt. It is probable that if some of the subjects discussed in 'lis paper, if the causes of disease and the meaus of their 'moval had been as well understood as the use of tlie amputai- ig knife and the Materia Medica, the Duke of Wellington odd have had 8,000 more men at his command, and the )uutry would have had to pay and su])port less tlian 5,815 efficient men constantly sick in Hospitals. In that case >,999 years of sickness might have been saved." The writer of these lines would apparently have found difficult to believe that an Army was then leaving the lores of England which, even before tliat year was out, I I ' I 262 UNHEALTHINESS AND INSUFFICIENCY would be losing men at tlie rate of 60 per cent, per anrm, would lose, in the short space of seven months, 39 per (tit. of its whole number from disease alone, and that ''he country would have to pay and support^' more than halfiiat Force as " inefficient men sick in Hospital/' Apparetly he found it impossible to believe that, with our premt ^ advance in sanitary knowledge, which he here conla- cently records, we should keep an Army in the eid under the sanitary conditions of 500 years ago, tha we should see again the same state of the Soldiery repe ed which Shakspeare and Froissart describe as existin in the British Army before the battle of Agincourt, ind before those of Cressy and Poitiers — see, too, the me courage and unflinching endurance, but the same suer- ings, the same famine, greater mortality, and far gnter ^ disease. Apparently he would not have credited his senses, had he heard the Principal Medical Office' of such an Army doubting whether the ration of raw alt beef was not enough to preserve in health men underg ng the severest duty, day and night, in the trends.* Requiescat in Pace. But let not the British Army ''est in peace'' at home in the sanitary state of fifty years ^o, when all around is making progress — let it not a monument to the disgrace of our Regimental Syster in which money is held to be worth more than men. k * It could have been " foretold, as a certain consequence, sooner or ter, of their dietary, that the British troops would fall into the calamitous ^ite of health which befell them last winter, in the Crimea." -Dr. Christ »n. OF BARRACKS AND HOSPITALS AT HOME. 263 If we were to look into the construction of Military state of 3spitals and Barracks, this, if fully appreciated, would be H^ogpitals^ai ; nost sufficient, of itself, to account for the ill-health of Home. ('r Army. I We have not one Barrack which can be compared, in ] int of construction, to the Caserne Napoleon, at Paris, ( to the Petit Chateau, at Brussels. Over-crowding is the fault in both of these. Yet they 1 th give 800 cubic feet of space per man. Our Regulations allow only 450 — 500 cubic feet per Barracks, im; but a Return will show that 300 feet even of cubic s ice is more than is actually given in some Barracks in ]. gland, at this moment. The cubic space allowed per man at this very day, is as h as — Cubic Feet. At Chatham— Infantry 350—219 „ St. Mary's Casemates 375—243 I Hull Citadel 315—273 Brompton 450—243 Gravesend 294 Portsmouth 550—219 Dover Castle 412—147 London — Wellington and St. George's 390 Tower 397 „ Portman Street 331 St. John's Wood 370 Woolwich—Artillery 583—369 „ Engineers 576 — 433 Windsor — Cavalry 475 „ Infantry 332 Parkhurst 520—333 Winchester 467—344 264 UNHEALTHmESS AND INSUFFICIENCY In eight instances only in England and Wales doc the maximum of cubic space allowed in barracks reac 600 feet per man. The Barrack rooms are still the day and sleeping roon of our soldiers, and are still without partitions, which ; equally destructive to health, morality, and discipline. partition might be given to each man to sleep in, coi structed, with little additional expense, of corrugated iroi. about 5 feet 9 inches high, and 6 inches from the floo the space thus divided off being 5 feet wide and 7 feet loii; with curtain at the end, something after the fashion ' Colonel Jebb^s Asylum for Female Convicts, at Fulhar where two tiers of cells are thus seen, with a hangir balcony for communication for the upper tier, in one larji well-ventilated dormitory. ' Till we do this, we shall never see our soldiers respe themselves; and till we see them with good, airy, we lighted and well warmed day-rooms, we shall never S( them temperate, healthy, or long-lived. | Hospitals. ^iti^ regard to our Hospitals, it would be difficult institute a comparison between those of Portsmout Chatham, and Brompton, and the Military French Ho pitals of Val de Grace and that (not yet occupied) at Vi; cennes ; they bear about the same relation to each oth that the Gaols of the last century did to those of oi day. In the Hospital at Portsmouth, which is simply ai expressly a building containing four Regimental Hospita' the cubic space is about half what it should be, the mea' of ventilation are wholly inadequate, the length of wards • placed in the width instead of in the length of the buildin so that they have only windows at each end; the stai (!ascs, which arc of wood, arc dirtv ; the wards are dirt; OP BARRACKS AND HOSPITALS AT HOME. 265 r lavatory, which is on the ground-floor, is ill-lighted ; re are no conveniences for baths, the Hospital is ill- led. et the Director- General says, in his evidence before a ise of Commons' Committee, that " it is a new and pindid Hospital." ;8792. With regard to the men coming to this country, had elisions been made here for the rereption of them?— Eull r ision. 8793. Have you heard any complaints of the state of the ['pital at Portsmouth ? — Xone. ^8794. How were the men transported from the ship to the [[pital? — Those that were seriously ill were supported in •i les fitted up specially for the purpose, to be carried by four Li ; those who were not so ill were transported in omnibuses f'jpriug waggons, and those who required neither conveyance, esume marched to the barracks. 8795. You have seen, have you not, various statements in papers as to the bad treatment of those persons who ' ^ed, and as to the neglect existing ; have you made any i.dries upon that subject ? — Yes. ,8796. Were they founded or unfounded? — They were I ed by the medical officers. .8797. Have you heard no complaint whatever as to the ['pital at Southsea? — None whatever. I do not think it is a lly possible to make a complaint against it ; it is a new and 3.tidid Hospital." !i !>ur Regulations give from 700 — 800 cubic feet of space 33ach Patient, about half of what is given in Civil I;pitals, less than half what is given in the Military I^ipitals of France. jl et even this meagre space is reduced at Chatham ; and iave seen there patients with only 350 cubic feet of ^e. Casemates are altogether inadmissible as wards for [ospital; yet they arc thus used at Chatham. In the II 256 UNHEALTHINESS AND INSUFFICIENCY Garrison Hospital, at Brompton, the wards, long md narrow, with ten beds in each, with only one windor at one end and a door opposite at the other end, with me window over it, are so ill-contrived that, if the roof are taken off, proper ventilation would not be secured, ^'he cubic space for each Patient is under 500 feet. The \^^s are intolerably close at night, both here and at Fort itt* In the wards of Fort Pitt, the Patients have 713-157 cubic feet each. But the minimum in the five caseiate wards, is only 236 feet. In the Fever Female Ward Mih Patient has only 735 cubic feet. Now the minimum granted by all Civil Me cal authorities is from 1,200 — 2,000 cubic feet. Our Regulations give 2 feet from bed to bed. In ort Pitt it is only IJ foot, in the Casemates less, ml Medical authorities give 4 — 6 feet as the minimum^s- tance between the beds. The cubic space allowed per Patient in this year (ll<7), is — Cubic Feet. Tower of London 575 Croydon 437 Woolwich 883—248 Plymouth 575—524 Portsmouth 513—213 Windsor 748—599 Winchester 591—526 In nine instances only, in England and Wales, oes the maximum of cubic space allowed in Hospitals i ich 1000 feet per Patient. There are probably no Barracks either by original on- struction, well-selected locality, or improvements, i a good sanitary state in these islands ; probably even no or- OP BAKRACKS AND HOSPITALS AT HOME. 267 itory^ in which the most simple processes of ventilation lYG been adopted and preserved. We have heard of oops in the West Indies moved to positions, deemed to 3 safe, in Yellow Fever. We have even seen a portion of town population moved under tents in England on an ;tack of Cholera. Some improvements have taken place L Hospital Architecture in England — greater still in ranee and Belgium. Improved normal rules have been id down and acted upon for the vast number of Lunatic sylums and Prisons which have been erected during the st ten years. Yet nevertheless the plan of the building the new Royal Victoria Hospital, near Netley, the undation -stone of which was laid by the Queen herself May, 1856, contains within itself most of the Sanitary ifects which accurate observation and judicious criticism ive condemned in existing structures of this kind. Surely no trouble can be thought too great in collecting le reasonings of eminent men, and in examining the :amples of buildings on sound principles, when we con- dor that this noble Building, wliich will contain 1,000 itients, is intended to become a monument of the War, id a testimony of the beneficence of the Queen and ition towards the British Army. But, if still further imulus were wanting, it would be found in the awful aggeration of the bad principles of this kind of building dmitting of so easy a misuse) which was seen at Scu- ri.-^ * If it be objected against condemning the plan of Scutari buildings, as bad system of Hospital construction, that the Sanitary arrangements opted there brought the mortality, in the Hospitals, down to 2-2 per Qt. (which was actually the case in June, 1855, instead of being 42-7 per nt., as it was in Feb., 1855) it may be answered, or rather asked, upon lat condition? Upon that of not allowing above 800—1,000 Patients in Argument against the Construction of Scutari Hospitals. 268 FOUR PROPOSITIONS FOR Propositions for carrying out immediate SANiTAlf Improvements in the Army. j First. I. Re- constitution of the Army Medical Board^ rh ^oTtTe Arm^ elements, Medical, Statistical, and Sanitary. : Medical Board. ^lie Sanitary element, though to be acknowledged^ the re-constitution, must not be introduced until oppon- nity has been afforded of finding the best man for le purpose at present in the Army Medical Department. ■ This is all-important, for upon the success of the appo t- ment will depend the whole future progress of the Sanii.'y cause in the Army. For this purpose the records of the Medical Departmttt, on sanitary matters, must be carefully examined, id suitable enquiries made into the capacity of the men. | Second. II. The sanitary improvements in Barracks, Hospijls Improvements ^-nd Garrisons need not be delayed, but might be at o[;e m Barracks proceeded with, and special provision should be madebr practicable and ^ ^ r r , necessary. a building such as the Barrack Hospital, upwards of 700 feet square ad three flats in height. Had this building been differently distributed ijits construction, it might easily have accommodated 3,000 Patients, with jod recovering conditions. It is ruinous to build after this fashion. The les- lion, both sanitary and economical, is to find that construction whichili accommodate the greatest number of Patients upon a given area, witl he greatest facilities for recovery. However good the construction and ventilation of any Corridors, if cy are filled up with Patients, it is tantamount to having two Hospitals " ck to back," it is tantamount to building up a street. In all our experice, whether of healthy or of sick men, such a construction generates diseg. If it be objected that the condition of the men (sent down fronlhe Crimea during the first winter) was such that they could not, by possibity, have lived, under any circumstances, I answer, as I have done before, lat the Land Transport Corps sent us down men in exactly the samecondion, the second winter, and that, under different circumstances, theylid recover— witness our low rate of mortality. But, as has been said, it was at the expense of limiting a building ip- wards of 700 feet square to an extravagantly small numl)er of Patient; And, again, had there been an Epidemic, no Sanitary precautions uld have prevented it from spreading, in a building so constructed. SANITARY IMPROVEMENTS. 269 lis work. So for as is known^ certain improvements could I carried out, with little difficulty and small cost, but iiers would require the execution of more permanent yrks. Every BaiTack^ Hospital and Garrison should be |imined, with reference to its sanitary condition ; and all (.perience has shown that it is essentially necessary that 1,3 examinations should be made, the nature of the sani- 1y works and their extent determined, and the works temselves executed, under the direction of persons com- f ent to deal with special sanitary defects ; otherwise the 1 !ommendations and suggestions made will be so unwise, i\ the cost so extravagant, that the whole thing will be limght into discredit. The War Department should issue a Sanitary Commis- Svn for this special purpose, as it did for the East, con- s ting of a Sanitary authority and an Engineer Officer, ti which might be added such consultative Military men, s ' the Barrack Master and Regimental Surgeon at each lirrack, as might be deemed advisable. Thus the sani- ty education of the Army Medical Men might be going c^; but the Civil Sanitaiy authority should be held respon- s|le for the specialities. III. School of Militarj^ Hygiene, with models. Third. Sanitary i| School. |[V. The complete revision of all Regulations, referring Fourth. t sanitary matters, whether contained in the Queen^s, of Sanitary ( arter-Master General's, Hospital, Barrack, or Purveyor's Eeguiations, Insulations, and the re-casting such portion as may r uire alteration. DETAIL. 270 RECONSTITUTION OF THE Propositions for carrying out immediate Sanj Improvements in the Army considered in FuitttER First. I. Supposing the Army Medical Board to be re-cjisti- ^oTthrArmy^ tuted as proposed, with three Departments, Medical J MedicalBoard. tary, and Statistical : The Medical Department would attend to pro ding Medical attendance, Medicines, Instruments, &c. | The Sanitary Department would attend to questiisof Clothing, Diet, Drink, Sanitary state of Quarters, Coaps, Transports, Garrisons, &c. The Statistical Department would attend to every hing relating to Medical Reports, so far as figures are concned. The question will be presently considered whether . will not be necessary to separate, in the Sanitary Depar lent, the duties relating to Personal and Camp Hygiene from those which relate to the Hygiene of Towns and Bui mgs. Five plans of ^^Tq subjoin five plans for introducing the Satarv introducing j tr o . the Sanitary Department. Department, 1. Let the Army Medical Department remain as i pre- sent constituted. Let a Sanitary Officer be attacjd to the Department, subordinate to the Director- Gener; , who would be the executive head. For obvious reasons, this arrangement would altc ether negative itself in the present state of things. 2. Let the governing authority of the Army Medic i De- partment be re-constituted as a deliberative Boar with executive power. Let one member be a Sanitary Cicer. This arrangement is obviously inadmissible, bee ise it ARMY MEDICAL ROARD. 271 rtually constitutes the majority of the Board the Sani- ty Administrators of the Army. 3. Let the Army Medical Department be re-constituted. It the Board be a Consultative Board, communicating ith all the Departments of the Army which have any [inaction with matters relating to Army Hygiene. Let all questions coming from any Department on such :Djects to the Board be referred to the Sanitary Officer, V ose opinion should be forwarded to the executive head : the Department from which tlie question emanated : : information and advice on sanitary subjects, which t3 Sanitary Officer feels it his duty to volunteer to any l ecutive Department, to be sent through the Board to (i head of that Department in like manner. The Sanitary Officer to be held solely responsible for I ; advice. 4. Let the Army Medical Department be re-constituted, \:h a General Officer, Medical Officer, or Civilian selected f his fitness as its executive head. Let him have under la consultative officers, heads of the various sub-depart- I nts. Let one be the Sanitary Head ; to him let all c istions be referred, from him all information and recom- r ndations be received, — the Director-General, or what- f 3r he be called, being solely responsible for the execu- tn. 5. Proposition 4 being carried into effect, let also a Sani- ly Officer be attached (not to the Army Medical Depart- Viit, but) to the War Department or Horse Guards^ as a ^ tinct and independent officer. 272 PROVISIONAL ARRANGEMENTS Advantage^ — that he would thus ensure the previis adoption of the best arrangements and best original ci- struction for sanitary purposes, instead of, as in the ]i- vious propositions^, being only able at the best to reii\y evils which had occurred. Most of the sanitary evils affecting Camps, Hospils, and Barracks, proceed from defective original construc m or arrangements as to sanitary points. According to this last proposition, the Sanitary Ofisr would be general sanitary adviser to the Quarter-Ma^r General's and Engineer's Department. i action. Transition It is very easy to plan a Sanitary Department for le provided fo?. future, but it will be very difficult to put one in aon during the transition time which must elapse before iir { Army Medical Officers are sufficiently educated in sani ry matters. Provisional If the Sanitary Officer had to carry his measies arrangements for Sanitary through the Director-GencraPs Office, as at present (i- stituted, they would be, as has been said, simply negati d. Now the Quarter-Master GeneraFs Department is le executive in any case under our present army organ a- tion. It therefore appears the most practical, if not le best conceivable plan, to attach a Sanitary Officer to le War Department or Horse Guards at home, with Saniiry Officers under him and corresponding with him at station, whose executive will be, as above stated, le Quarter-Master General's Department at each station. It will be immediately objected that there willjB collision between the Sanitary and Medical Departme-sk' There need not be. FOR SANITARY SUPERVrSTOX. 273 1. To the Regimental and Staff Surgeons would belong Distribution of that concerns the personal hygiene of the soldier ; ^i)uUe7 Inis Clothing, Bedding, Diets, Personal cleanliness, &c. Treatment in Hospital. I. To the Sanitary Officers would belong all that con- QDS the hygiene of the building and locality, number of i |.abitants to cubic space, ventilation, drainage, cleanli- rfis of site, of building, &c. S^ow most of this does belong already to the Quarter- ly star GeneraFs Department, therefore we are only giving a rofessional adviser to hira who must be the executive. sanitary Officers might be attached as follow: — 1 to Canada. 3 „ India. 1 „ Mediterraneai). 1 „ West Indica. 3 „ England. 2 „ Ireland. 1 „ Scotland. nd in the event of war, to General Hospitals at the base of operations, subject e Governor, as, on stations, to the Quarter-Master eral. to the Camp, &c. e Sanitary Officers would naturally report, not only eir chief at home, but also to the Governor, Com- idant, or General Officer on the Station, '.s Staff Surgeons become more educated in sanitary miters, they will naturally become the Sanitary Officers, 'he general argument used to prove that Army Medical g^g^^^'^J'^^^gt T 274 PERSONAL HYGIENE TO BE LEFT be left to Regimental Sursreons. Officers must look after the hygiene, as well as the curof their own men, is conclusive. A double set of offi(rs could not act. The conditions are so various in which armies id detachments are placed, that those only who attend le sick can protect the health of the troops. A whole regiment might be laid low with fever i a week, if the Regimental Surgeon did not understand tlse questions called by the name of personal hygiene , wlili include Clothing, Duties, |t| Diet, Positions, &c. ] Cleanliness. _ 1^ Hygiene of Towns, Barracks, Hospitals, a distinctly different question. Examples. 1. Scutari Hospitals. Such a thing has actually happened. If a choice were to be made of any one class of offi^rs exclusively, to have sole charge of all that concerns he health of troops, undoubtedly it would be better to eduite all Army Medical Officers as officers of health, ley would treat disease all the better, and have less of : to treat. The difficulty is with Barracks, Garrisons, HospitalsiC. with existing buildings and future ones to be construi^d, and with towns and villages to be occupied by troops. The highest order of intelligence, of education, an of l)ractical experience is required in an officer of health ho has to deal with these. Need instances be multiplied ? 1. Scutari Hospitals. The most hideous sanitary als were festering there, evils which raised the mortalibper (;ent. to 415 annually on the sick population. Fo six months nothing at all was done to remedy these evils Yet these Hospitals were seen by all (and reporte- ou by most) of the Senior Medical Officers out in the Er . I TO THE ARMY MEDICAL OFFICERS. 275 These Hospitals liad within their walls, at various times, |e men best informed on sanitary subjects in the army; id every one of them missed the evils and failed to ggest the remedies. More than this, these Hospitals were reported on as 3atisfactory,^^ as " flourishing,^^ as " convenient for the caption of the sick and wounded/^ and this when the ortality at Scutari w^as rising to 415 per cent, per num, at Kululi to 608 per cent, per annum. 2. Balaclava. No effort was made to establish a sani- ry police in this little village, w^hich came into our hands clean and beautiful as any village in Holland. What it became after our occupation may be inferred )m the following facts : 1,1. Large numbers of beasts of burthen were daily fssing in and out, and no means were taken to remove !e manure. |2. Large numbers of cattle were slaughtered when "ttle were obtained, and no slaughter-houses were i ranged. 3. 20,000 or 30,000 men passed in and out daily, and :j> arrangements were made for them. 4. A burying-ground existed at the head of the har- ur, where our men were buried almost in the water, [lere decomposition was going on immediately below the iirface, and remains and portions of red coats were even ' casionally to be seen protruding above the surface. Yet no representations appear to have been made by Army Medical Department as to the necessity of a iiitary police. The evil, when done, was, it is said, ported on; but no precautions had been previously i ngested in time to avert it. [3. Netley Hospital. The plans of this building had ilJeived the fullest consideration from the Army Medical T 2 2. Occupation of Balaclava, 3. Plan of Netley Hospital. 276 HYGIENE OF BUILDINGS Department and its officers, and been sanctioned by |e best men among them, yet it never can be, what it ount to be, an honourable monument of the War to commei)- rate which it was planned, of the country whose sick iris to receive, and of the Sovereign whose personal regard :)r Her troops it so royally represents. 4. Drainage in 4. Supposing that a street in London were to )e a Town. f]j.ained, and a large sum to be laid out in draining t, should we consult the Physician attending us on the 1st method of doing so ? Conclusions. To one who, with some sanitary experience, has seer Scutari, Balaclava, Netley, ! the following conclusions appear inevitable. 1. Unavoidable !• A few of the most competent sanitary officers in le ^^on^these Army may, eventually, be set apart for such duties as re subjects of involved by the above considerations. But the occupa m Army . . . ^ Medical Men. of towns and of large buildings presents insurmountle problems to ordinary observers. Such problems are le- cialities, like those in our Barracks and Military HospiJs throughout Great Britain and her Colonies, at is moment. 2. Necessary 2. Nothing but a very large experience could have e- Experience _ . . , i • i exists only vcnteo the opmions which were given from having L'n Tf HealthT S^^^^ ^^"^y Medical Department in any of le Towns. above instances. And these men neither had nor cc Id they have had such experience in the Army. If the question be asked, Do men with the experioe necessary to cope with such matters exist in Civil Mecal Life? it may be answered, no, not as medical men; bius Civil Officers of Health they do. Such experience i ly be found in Dr. Duncan, Officer of Health at Liverp >1, A SPECIAL FUNCTION. 277 i Dr. Thomson, at Marylebone, in Mr. Simon, in London -above all, in Dr. Sutherland, late Sanitary Commis- i>ner in the East. These men have had constantly Ifore their eyes the effects of over-crowding, of bad Tiitilation, bad drainage, bad water, of organic matter jAirating the walls of buildings, of soils and sub-soils, i., &c. Any one of these men could have laid his hand at once ( the causes of disease and death at Scutari and Bala- (iva, and, what is more, have shown the practicable ].iiedy (Dr. Sutherland did do this). For the question, len the evil has arisen, is not " What is the best jssible remedy for this?" but "What are the means at nd to improve immediately the conditions thus pro- f.cing disease and death?" Without the practical lowledge necessary to answer this last question, there lay be such a delay that there is no one left to kill. 3. There must be special men for special work. No 3. This work a :edical man that ever lived makes a good sanitary officer, ^^essentially erely because he is a medical man, for the above pur- Medical, •se — it is a speciality. As to towns, especially, we find this practically in civil e, viz., that other qualifications than that of medical lowledge, go to make good Officers of Health. These salifications being present, medical knowledge becomes use. 4. It would be cheaper, in every respect, to the country, 4. Distinction have competent men to advise the Departments on between ch subjects as the Hygiene of H^gTenTand I that of Buildings, Buildings. Towns, &c., saving that of soldiers and camps to the Army Medical en under a special Officer of Health of their own. 278 THREE BRANCHES OF 5. Distinction exists in Civil Life. 6. Neither Army nor Civil Medical Men have the competent knowledg-e, as Medical Men, for the latter branch of Hygiene. 7. Which branch of Hygiene comes most under the notice of the Civil Profession, which of the Army ] Summarv of the Three Branches of Military Hygiene. 5. The distinction is clear, and it is a practical oi. In civil life, the Physician is, or ought to be, the fam^ adviser in the Hygiene, which corresponds to that of 1? soldier on duty. But no one would trust his Physiciji to do the work of an Officer of Health in executing r advising sanitary repairs or improvements in the house r town he lives in. 6. This is simply matter of fact and of experien Neither the Army nor the Civil Medical Profession (i furnish competent men for such purposes. We m that neither Army nor Civil Medical Men in Engld have special qualifications for such work, unless hrou, buildings, and districts. Are there men competent, both by scientific knowle(« and practical experience, to undertake the new sanit y administration in all these three branches ? Is there a single individual, either in the Army or a Civil life, competent to do the duty of all three ? To give the Army a sanitary head over all these th e branches would be to ensure a failure, a semblance inst»d of a rcalitv. MILITARY HYGIENE. 279 l^oth theory and experience show that the two first, Distribution of 1. Personal Hygiene; 2. Camping and positions, ^^tie^. a; better understood, and will be better administered by 4iiy Medical Men— even with their present imperfect elication — than by Civilians. 3ut to seek in the Army for a knowledge of the third b nch is hopeless, including, as it does, an acquaintance wh the principles of li linage, \,iter supply, Ij/ing, cleansing, Siitary police of towns, Cpstruction and sanitary improvement of Barracks, Hospitals, and ' Other buildings, \V(3ther in towns or garrisons, j^xamples more than sufficient have occurred to prove ih assertion. 5ome Army Medical Officers may, in time, acquire siicient scientific and practical knowledge to deal with sih matters. during the transition period, it appears essentially n essary that, while . The Army Medical Department shall be allowed to r^i^Q two aiainister that which it is competent to perform, under ^J^JheXrmy a mitary head of its own, there should Surgeons. !. Be a special arrangement for the sanitary improve- 2 The last to B^at or construction of buildings, for the removal of the Quarter sjiitary defects in garrisons and occupied towns, and for General's a|)rding sanitary advice to the department specially uJiderSani^tary 4rged with these things. 280 HOW THEY SHOULD It seems necessary to add three observations : — Distinction 1- It ^^^s been objected that the great sanitary imprb- ^^anTNavy^*^ ments efi'ected in the Navy during the last few jm, Hygiene. prove that the same may be made by the Army for iti-lf. But it is impossible to institute a comparison which fall be just throughout between the two services. For, whereas the Navy Medical Officer is always iihis barrack, with the causes of disease constantly undeihis very eyes, so that his whole experience and daily obs(/a- tions must accumulate for him lessons in Naval Saniiry Science, — with the Army Medical Officer, on the cier hand, conditions, new to him, continually arise, as I is moved from place to place, in which he may be wl,lly inexperienced and uneducated. He may have to preare a building or town for the occupation of troops, ha ng been all his life entirely out of the way of any knowl Ige of such matters. 2. Important 2. An important practical lesson may be learnt om L^sonTo be experience of Netiey. j derived from The Engineer Officer who made the plans, disti ?tly the experience ^ ^ ^ _ of Netiey. stated in evidence that he considered himself respor ble only for constructing a building which would not ill; that he assumed the existence of a sanitary adviser tthe Engineer's Department. Now it is vain to say that icli an one already exists. The best opinions and advice the best information were taken from the Head of the I my Medical Department and his Officers — and we seethe result. Nevertheless, the 70,000/. already spent at N< ey, will have been well spent for the country, in s ing soldiers' lives, if two principles are thereby established iz., (1). That the Quarter-Master General's Depart ent assumes the necessity and existence of a compent Sanitary adviser, just as a town does that of an O cer of Health. BE DISTRIBUTED. 281 (2) . That tins Sanitary adviser must have the special |ualification united to his office ; such qualifications laving been sought and not found in the Army Medical Department, supposed to possess them, but whose educa- ;ion does not necessarily afford them. 3. It has been said that the Statistical Officer might Distinction ilso be the Sanitary Officer of the Army ; but the distinc- statistTcaUnd ':ion between these two Departments is an important and Sanitary W ork. I practical one, as much so as the distinction between a Cookery-book and articles of food. Registering is essentially a different work from search- ing out operative causes and tlic means of remedy. Nay, more, to be employed in the first is almost a disquali- ification for the second. Witness the mistakes made by ithe ablest Actuaries, as to causes of mortality. Witness ^Sir Alexander TullocVs invaluable Ueports, in which scarcely a word occurs capable of practical application by :a Sanitary Officer. The Registrar is not an officer of bealth. The contemplation of figures tends rather to fatalism ; while a practical combativeness against operative causes is what we seek in the officer of health. I And, although the latter must be furnished with Sta- tistics, the former will not necessarily acquire sanitary experience, at least of an applicable nature. II. Should the Sanitary Commission proposed for Bar- racks and Hospitals be issued, the manner of working such a Commission would be as follows : I 1. To examine into the prevailing diseases in Barracks and the mortality in Hospitals. i 2. To examine into all the conditions affecting the health of the buildings and their vicinity. Second. Immediate Sanitary Commission and its Functions. 282 IMMEDIATE COMMISSION 3. To draw up a brief statement of the remec required, witli sketch plans, where necessary. j 4. The Commission should either have power to du|;t the works to be proceeded with, as was the case in le East, or if that could not be done, consistently with e present money arrangements, the Keports should be s it to the War Department, and the estimates laid bef e Parliament in the usual way, but separately for Barra .s and Hospitals. Eesponsibility As the Sanitary part of the Commission must e Commission, responsible for the results, all works or portions of wo s influencing the health of troops must be executed to :s satisfaction. Sanitary During the preliminary inspections, many sanitary s,^- possiWe^*^ gestions of importance could be made and carried out on je without gpQ|- without cost, and as it would be advisable to compl e waiting for the ^ \ ^ ^ Estimates, a number of enquiries, for the purpose of obtaining cci- parative sanitary information, before any works of imf > tance were decided on, no time would be lost, although le cost of the improvements might have to go into the usil estimates. Possible The Army Mortality can be and ought to be brou|.t Army''''^ down to 8^ per 1,000. Of this there is no doubt; .e Mortality. Model Lodging-houses, where 300 — 700 persons are c i- gregated in a close space under good sanitary conditics, afibrd a convincing proof of it, if any such we wanted."^ i * The Model Lodging-houses were built for health and show a rat if mortality little more than one-half of that of London. The Comi'n Lodging-houses were built for disease, but, under inspection, showed n 1854, onc-sixih of the rate of Cholera Mortality in the whole metrop a. The Barracks are built for disease and show twice the rate of mortr'y from Consumption, more than twice that from Cholera and Fever, d nearly twice that from all Diseases, which is shown by the Civil Pop v- tion. FOR BARRACKS AND HOSPITALS. 283 It will be found that the repair of men is more expen- se than the repair of buildings ; and that these buildings nght be put to rights at a cost equal to that of the treat- fant of the men who come out of them sick. III. With regard to a School of Military Hygiene, a fort sketch of the subjects which should be taught in it, ny here be given; and valuable information may be (rived from our sister-country, France, as to the best ] m of giving practical instruction in these subjects. The nitary education of the Army Medical Officer in France, { en at the " Val de Grace,^^ is as complete as ours is de- 1 tive. Full instruction is given to the Student in the iench Service on every question of Military Hygiene, none ilthe British. Every practical point likely to arise in the ( irse of his service is practically presented to the French ^ident, — and no one acquainted with our sad Crimean e'ierience will say that any one point could safely be c itted. It is essential that the Army Medical Officer should be jLctically acquainted with the following subjects : L. All the articles of food, with their relative value, and Ijty to detect deficiencies or adulterations.* \ The effects of particular articles of diet on healthy u 1; in different climates and under different conditions a to labour, exposure, and fatigue. 5. The diseased constitutional states, likely to arise f m the continued use of the same articles of diet.f Third. Instruction in Military Hygiene. Sanitary Education at the Val de Grace. Sanitary Subjects with which the Army Medical Officer should be acquainted. i The Milk supplied to the Hospitals at Scutari was adulterated to an arming extent. "Milk and the appreciation of its qualities by taste" is lir e one of the subjects, at the Val de Grace, of the " course of instruction o|kIilitary Hygiene." I It is only necessary to refer to the repeated destruction of large bodies 284 SCHOOL OF MILITARY HYGIENE 4. The changes which are required under these circun stances, | 5. The means of testing the purity of water and othi drinks, and also the best methods of purifying water f(! troops. 6. The characters and qualities of drinks which tli soldier is likely to meet with in different countries.^ 7. The question of clothing and accoutrements, regards materials, qualities, adaptation to climates. 8. The science of medical topography, of physic geography, the climate, waters,t and local diseases of i. countries where the soldier is likely to be stationed. 9. The conditions as to soils, sub-soils, geological stru ture, natural drainage, marshes, lakes, banks of rivers, ai the conditions connected with these, likely to affect t] health of troops. 10. The means of detecting, in the sick, indications the presence of organic matter in the air or water of t" district, by its effect in modifying disease. 11. The special effects of particular kinds of shelter tents, huts, bivouacs, damp soils, as influencing the air these, and the results to the health of troops. 12. The effects of crowding and defective ventilatio and the best means of remedy. { of British troops, chiefly owing to the continued use of salt meat, and the unaccountable apathy on this subject in the late Expedition to i Crimea. * The alcoholic drinks sold by the Greeks, at Scutari and in the Crim were of the most pernicious quality, + We Avill only refer to the fact that the suspected cause of Yell Fever, on the West Coast of Africa, was discovered not by an Ar Medical Officer, but by a London chemist. It was this, viz., that, wli. the rivers pass through the mangrove swamps, decomposition takes place the sulphates of the water by the presence of organic matter, and sulp retted liydrogcn gas is produced. t It is only necessary to refer to the disaster at Scutari. i AS PROVIDED IN FRANCE. 285 3. The best metliods of improving the surface and SI -soil drainage^ — the external characters of military posi- ti:is likely to affect the health of troops^ with the means 0''emedying these, if remediable. 4. The local conditions affecting the health of towns, v:iages, and buildings to be occupied for military purposes, \v h a view of pointing out the sanitary defects, and the ffQner of remedying these.'^ 5. All the sanitary questions connected with perma- nnt Barracks, Hospitals, Garrisons, &c., including d:inage, water supply, cleansing, ventilation, &c., and the b t means of rendering all military buildmgs healthy, as r^ards these things.t 6. Military gymnastics, exercises, duties, and their .e:^;cts upon health. 7. The whole subject of camp diseases and epidemics, tlir nature, origin, causes, management, and prevention. 8. Chemical and microscopic analysis for sanitary Pii poses. 19. The subject of cooking, especially as regards the piparation of hospital diets and comforts. ;0. The effects of different kinds of baths in the Bgienic treatment of disease. 'he Army Medical Officer should be so thoroughly and p ctically conversant with all these subjects, that the ^ itary Officer should be able to apply to him for advice a: . assistance with perfect confidence. He must, however, bi instructed in these various subjects, as the French ^ dical Officer is already, practically and scientifically. Our occupation of Balaclava is a disastrous example of the neglect of th ) remedies. » Every Barrack and Militar}^ Hospital, in the United Kingdom, will :f af|d examples of the neglect of these sanitary questions. The Buildings ai; Camps planned quite lately, Aldershot, Netley Hospital, &c., are, P( aps, among the most glaring. 286 REVISION OF EXISTING I The benefits to be derived by the Service would anjjr compensate for the cost to the country. And^ in a pic- tical race like the Anglo-Saxon, were the Army Medal Officer, once really educated in Sanitary Science, lie Military Officer would readily avail himself of it for ne good of the Service. \ Fourth. IV. It has frequently been stated that ample sanii;y of Sanitary instructions are already to be found in the exisltg Kegulations. a Regulations," and that ample sanitary recommendatas were actually made during the war in the East, in resjct to all the evils which affected the health of the troop so fatally. However this may be, it is a fact, beyond dispie, that, with regard to the execution of recommendatids, there are no means provided, whereby any recommeia- tion, however good and appropriate, for securing the he::li of the troops, can be brought into practical operata. There is an abyss between the evil and the remedy, le only bridge across which is the sending a copy of ly reports to the Director General. With regard to the problems at Scutari and BalacLa, there is nothing in the Regulations" that would he led any ordinary Medical man either to have discov( the evils (at least in the Hospitals and in the occupai»n of the town), or to have suggested the remedies : and, e'n if suggested, there are no means provided of removing le defects. With regard to the Regulations for Army Hospita ,'^ the sanitary heads in these Regulations are not spei ic enough nor numerous enough, — and, such as they e, they presuppose a much larger amount of sanitary > SANITARY REGULATIONS. 287 / il knowledge than is usually possessed by most Medical i^n, either in or out of the Army. The remedies for this are : 1. A better Sanitary education, till every Medical Cicer is a Sanitary Officer. I. A Regulation specially appointing him as such, and r uiring that he be consulted on all matters affecting the kith of the troops, and that he be also required to report a/ defects to his Commanding Officer in writing. 3. A Regulation that Commanding Officers should con- s er such recommendations and give effect to them, so far aithe interests of the Service will permit ; and that they r ord their reasons for rejecting them, if rejected. i. That copies of such recommendations, and replies, ai reports of the steps taken, be sent to the Secretary of kite for War and Commander in Chief. 5. That, in disputed cases, the Sanitary Head at the \ar Department be consulted by the Secretary of State f ■ War. 6. That there should be Sanitary inspections by Army Kiiitary Inspectors. 7. That, for special service, an Inspector be detached f Sanitary Officer (as, e.^., at Scutari or in the Crimea). S. That, for present purposes, and until the improve- 1 ats in education, &c., are introduced into the Army i dical Department, all Barracks must be carefully exa- lined by another machinery, such as has been indicated, }op. II., and the sanitary defects corrected, which will i once reduce the sickness and mortality in the Army. 288 XI. Notes on the Inaccuracy of Hospital Statistics THE Necessity of a Statistical Department. Want in General Military Hospitals, of a Statistical Department separately en raged in llegistration. The Nomenclature of Disease should, for uniformity's sake, be that used by the Civil Registrar- General. The present Military Nomenclature of Disease is, moreover, quite inadequate and obsolete. General Inaccuracy of The acknowledged importance of Statistical Sciencin England, proved by the elaborate system of the Regist r- GeneraFs Office, founded about twenty years since, seas to show the absolute necessity of a Statistical Departmit. In the General Standing Hospitals, it would seem at the Officer charged with this duty should not be le charged with the treatment of the sick, Otherwiseie would be reporting to himself, which is contrary toie action of the National Registration under the late stat;e. If the Army Registration is to be analogous to le National Registration, which, in all reason, it would s m should be the case, it appears to follow that the non q- clature of disease should be that used by the Regist r- General ; the more so, as the latter is fixed so as to r- respond with the technical words in French and in German, determined by the Statistical Congresses at Brussels and at Paris, held in the years 1853 and 185.' Nomenclature identical with that of the Regist r- General cannot be obtained, unless that used by le Medical Officers in their Reports and Returns, and on le bed-ticket of each patient is made also to correspond. Another reason for this change will appear from le consideration that the present terms, which are inadeqi te to their purpose, are no others than those used in Cull 's Nosology of 1785, with a few additions. The Army Statistics have never been incorporated ^ INACCURACY OF THE STATISTICS OP DEATH. 289 tl Civil statistics of England, producing a very unjust Army , ,1 1 P 1 , Statistics, even iDnvenience to the relatives oi ttie aeacl, the more so as as regards the 0 soldiers are volunteers. This, however, would be a T^^x^ ' Registration of BGior grievance, if the Array Statistics themselves could Deaths. b( relied upon. Of the soldiers who are no longer pjaded with their regiments, one portion is returned k:ed, one portion missing, and the rest in Hospital or irihded. In the late war, the second class will be fcad, from special circumstances, unusually small. It is irthe last two classes that large discrepancies arose. T)se in Hospital must be considered to include those oi'the passage from the Crimea to the Bosphorus, and frn the Bosphorus to England. The discrepancy, bcveen the truth and the returns, was supposed to be giiter than in the Peninsula War, and may be accounted foas follows. Great numbers of men were embarked, not 017 after Alma, but during the succeeding autumn and w ter on board transports, and even on board the after- w ds-appointcd sick ships, without any nominal list. Of the it appears, by comparing the numbers of those who eDarked with those who landed, that about 919 died and w e thrown overboard on the passage. For the reason alVe stated, many of these were not reported nominally. Awe have no security for the accuracy of the Military or ^ iical Officers in charge, sometimes invalids themselves, th figure (949) may or may not represent the actual nviber lost. In one instance, the Captain of a transport hi asserted that seventy bodies were thrown overboard fr a his ship in one voyage, without their names, regi- DQits, or ranks being entered into any report on board th ship. 'n entering the gates of the Hospitals on the Bos- porus, many men were unable to give their names to the seeant stationed to require them, and consequently were u 290 INACCURACY OP THE STATISTICS OF DEATH. entered by a simple number ; in other cases, the na e of the regiment was added, which could not be ascertheda except when the accoutrements were sufficient!}- com ete; Of these men, unable to account for themselves, a proportion died. Each was entered simply as " a im"' in the death books ; but, as the returns show^ thajtiie^ excess of burials over deaths numerically reported (iltlieil " Orderly E-oom^^) during the six months after the ])ttlei of Alma, amounts, in the Hospitals of the Bosphor tot 530, it follows that that number, which actually enjredi the Hospitals, died without the Death being rep(ted, nominally or numerically. In some cases, the ;ard remained after the occupant of the bed which it nre4 sented had been removed by death ; the first real \m\ thus representing its proper owner and his success' ori successors, who followed him rapidly to the grave ird-i But, till about February 1855 we had no bed-tickets aallpt nor, till about that month, was a Nominal E/Cturn of dithsr made by Surgeons in charge of the Wards. The na3of|; the man who died was, up to this time, simply scrahedr oflP the Diet Roll. Another source of inaccuracy was that, althoug) allt who left the Hospitals of the Bosphorus for home, ereit:; recorded with nominal lists on embarkation, yet thos(t^ho; died during the voyage were not reported to their respcivei regiments. Many cases of this kind have occurred iiis-i putably, as appears from correspondence, ultiirtelyi proving that the man never was again present eith' atJi; his Depot or with his Regiment on service, and wanoti discharged from Hospital at home. This great amount of inaccuracy is the more surpr^ng^fl because, in this War, there were no such causes as ave occurred in almost every other, viz., desertion, ital accidents occurring to troops dispersed over a poputed, ACCURATE STANDARD OF COMPARISON. 293 " (Inclosure.) " Dr. Hall to Lord Eaglan. •*'It LoJiD, Before Sehastopol, April 3, 1855. 'In transmitting the weekly state of sick to the Slst March, Iiave the honour to state, that I am sure it will be pleasing tiyour lordship to learn, that the general health of the Army Citinues steadily to improve ; and altliough fevers and bowel caplaints continue to prevail, they are both assuming a milder ciracter, and the latter are of much less frequent occurrence. ' During the present week the admissions to strength have b* n in the ratio of 3'93 per cent., aud the deaths to strength 08 per cent. • Last week, the admissions to strength were 4-35 per cent., a I the deatlis 0 -52 per cent. ; which makes a decrease of 139 'u'X\Q admissions, and 43 in the deaths during the week." The facts which the Commander of the Forces and the Vir Department want to know, and ought to know, con- c ning the health of an Army in the field, arc not, as is tiis shown, supplied them. iWhat they want to know is — i. How long the army will last at the tlien rate of mor- tity. I. Whether the diseases arc preventible from which the nrtality arises. What proportion of the army is inefficient from s.;ness. the mere information that " the admissions to strength b e been in the ratio of 3-93 per cent.'^ during " the pisent week,'' and ''the deaths to strength 0-38 per c.t." is simply misleading to the authorities, unless ii eed, which is hardly likely, they are thoroughly au fait o^tatistical inquiries. )'52, 3*93 per cent, look nothing. 3ut multiply 3-9 by 52 = 2,028, in order to find the a^ual admissions per 1,000; and it will be seen that the 294 FALSE IMPRESSIONS GIVEN whole force will go twice througli hospital in a year, aii that rate. And multiply 14-3 by 52 = 7,436 per 1,000 pei annum ; and the whole force will go seven times througl hospital in a year. This "sickness'^ of "14-31 per cent.^^ must, however include the admissions and the remaining in hospital Some remarks will be offered, further on, upon thi method of calculating the mortality. But is this a stat of things to congratulate a Commander of the Force upon, as being " pleasing'^ to him " to learn Multiply 0*52 by 52 in the same way, and it will b found that the mortality is 270 per 1,000 per annum ;— i], other words, that more than one-fourth of the whol, population of the army will perish in a year. 2. At a time when every one in the Crimea was expect ing cholera, which actually did come, which is short! after recorded by the Inspector-General himself, th Commander of the Forces is congratulated on the ste? dily improving^^ state of the " health of the army.^^ During the ten weeks intervening between May 5 an July 14, 1855, 96 per cent, of all the deaths from diseas were of the classes usually considered mitigable an zymotic. That is to say that, granting that the remainiD four per cent, were not preventible, there might have bee saved to the Commander of the Forces a large part of tl 96 out of every hundred men he lost from disease. Is not this important to him to know from his retun at a glance ? 3. For a Commander in the Field, the number ( deaths among his men is, after all, not so necessary f( , him to know as the rate of inefficiency from sickness i his army, granting that a large amount of that sickne: may be mitigated or prevented. In January 1855 more than half the Infantry of tl BY MEDICAL STATISTICAL RETURNS. 295 A ny before Sebastopol* was sick in hospital^ and three- fcrths of all that sickness zymotic, and so it continued frin October 185 i till July 1855. Nay, even in that diidful week which included the attack on the lledan, Jne 18th, 1855, even in that week nearly 65 per cent, of althe deaths in hospital were zymotic. )f what vital importance is it not to a Commander and a overnmcnt to know this ? 'Tow take the unit of 1,CK)0 per annum, include the dcths in the General Hospitals at the base of operations, w: lOut which it is obvious that no correct result as to the m tality of an army can be obtained, and let us compare th mortality at dillcrent periods of our history in the C: nea. Per I, ()()() PER Annum. . ri855 ....l,173i '^^^"^^'•3^ ilH-oG .... 211 r 1855 .... 203 ^^^y 11856 .... 8 January 1 to May 31 |^|^r^^J ■) 628 856 .... 11^ ' Crimea, May 1856 8 Line at home 18 7 Guards at home 20'4 lius we were losing in the Crimea, in May 1856, less th half of what we lose in the Line at home, and two- fif -s of what we lose in the Guards at home. 't is obvious that what is wanted is for the Commander Wliat Statistics arc of he Forces and the Secretary of State for War to be requisite for a mle instantly and continuously acquainted, (both as to ^theTorces.^^ acVrmy at home and in the field,) with not only (1) the re proportion of mortality ; (2) the real proportion of tliiase; but also (3) the kind of disease and mortality. *\^ide p. 17, where is given the Adjutant- General's Return of Sick (Picnt and Absent) for the Infantry Divisions before Sebastopol. 296 STATISTICS REQUIRED Therefore — 1. Present strength, 2. Sick in hospital at a given date, 3. Total admissions since last report, j 4. Total deaths since last report, i 5. Percentage of sick to present force, j 6. Percentage of deaths to present force, per annum, 7. Percentage of admissions from zymotic disease to l';al admissions, 8. Percentage of zymotic cases in Hospital to total sic 9. Percentage of deaths from zymotic disease to Hal deaths from disease, 10. Admissions and deaths from wounds, — ^ at short periods, both Departments should be furniijed with a statement of these 10 points, in such a form as iat they shall be able to appreciate them at a glance. It may easily be ascertained what the weekly stat( of an Army in the field are now, as furnished to the ( ai- mander of the Forces by his Principal Medical Of! i\\ and the daily states furnished by his Adjutant- Genenj. The following is a specimen of what we rememhe to have seen furnished by the Principal Medical Officer : - Weekly Medical Sta.te. 1. Strength in field, as given by Adjutant-General, iis morning. i * The States, furnished by the Adjutant-General, include,— ' 1. Present under arms ; 3. Missing ; i and the numbers employed on various duties. ■ For military' purposes these States are, of course, adapted ; and fc is unquestionably not intended here to offer any impertinent suggestior a a purely military question. It is only mentioned now to show th{ the information required for the above purpose is not here, either, to be iM; since these States show neither the Reinforcements nor the Deaths. CASES WHOLLY OMITTED. 291 )untry, or falliug out during long marches, especially 3treats. Another obvious defect in the Statistics of Disease of ir Army (whicli are not published, even at any subsequent 3riod, when military reasons no longer exist for their )ncealment) is, that the Returns are only made up on one ly of the week, of the men then in Hospital. Conse- lently a man, entering the Hospital on the following ly and dying, or being discharged, previous to the subse- lent Report, will not appear in the column of Total Sick, lich shows those at the end of the week. In cholera id diseases which run their course in a few hours, the 3turns may actually only show one-seventh of the cases. 16 other six-sevenths will, however, appear in the Death 'id Admission Returns for the week. But, in the Reyu mtal Return, a man admitted and discharged to duty iring the week would not appear. Statistical Returns, whether of the Hospital or of the .^my, can be, comparatively, of little use, till extended, th a sufficient nomenclature, over periods adequately ntinguished, and over portions of the force, under different jographical or sanitary circumstances. For example, the l:al loss in the last war, over the period of two years, ' less classified into monthly Returns, will not indicate 1 i fact that we were losing men at the annual rate of 73 per 1,000, in January 1855, and in January 1856 Uhe rate of 21 per 1,000, which shows that, the weather ling similar at both periods, the influences of climate 1 re not to be looked to as the grand causes of disaster.^ For the purposes of accurate comparison, it is absolutely Requisites for accurate i'3essary to reduce all our facts to comparison. |i This is very much wanted for comparison. Every man, whatever his e^erience, wants an unit of comparison. u 2 292 REQUISITES FOR AN 1 , Unity of time. i 2. Unity of strength, or numbers under observation. Now the standard of comparison, as to mortality, 11 over the civilized world is the per-centage of deaths ;r annum ; as to sickness, the per-centage of admissions i;o hospital, in the same time, together with the number 3f days^ sickness in the same time. And, without reference to the same standard, it is i- possible for the most intelligent" to judge. By dividing the iveekly deaths by the force in le Crimea, as was done in the published Returns, the l;h mortality of the Crimea appeared to be exceedingly ],?. For people naturally took the mortality per cent, per?/?^' for the mortality per cent, per annum. False From the Extracts given below, which are taken f m ^created by letters of the Principal Medical Officer to the Commarer Medical Statistical of the Forces, in the published Dispatches, the meai \% Returns in the of what is here suggested will at once be seen. Crimea. " (Enclosure.) ' " Dr. Hall to Lord Ragla?^. " My Loed, Before Sehastopol, March 19, 185 " In transmitting the weekly state of sick of the Army to 'ie 17th instant, I have the honour to state, that though the ik- ness still amounts to 14'31 per cent., the mortality does ot exceed 0*51 per cent., which is a proof that the diseases re milder in character ; and I think I may safely say the gei "al health and appearance of the men is greatly improved ; and ad not the duty, by the unavoidable operations of the siege gig on, been increased of late, I think the sick Hst would have en still more diminished, as the men's condition is in every c er way so mucli improved, both in diet, dress, and acconin la- tion. V'AY IN WniCn RETURNS WERE MADE AT SCUTARI. 301 was interrogated: "What is I liavc Diarrhoea/' vil Hospitals, this decision, exacted in Military Estab- hraents within twelve liours, is frequently deferred for a ^riod of several days or even weeks. The way the Returns of the Army INIedical Depart- i3nt were made at Scutai'i was as follows : — At first, no ominal List was sent with the Patients. Afterwards, len such was regularly received at the Principal Medical • Beer's Office, stating also the men's diseases, these ^;re not communicated for the guidance of the treating lirgeon. The Patient te matter with you?'' "Oh, Sir, (, "Fever," or "Dysentery." Some Assistant Surgeons ]t down what was thus said as the Diagnosis, and after- nrds it was entered in the Returns as the Cause of -;ath, in the event of a fatal termination to the case. fOr the Patient said, " Oh, Sir, I have pains in my back Jjd my legs." This was entered as Chronic Rheu- utism. Thirty-three deaths from "Chronic Rheu- utism" have been seen in one Quarterly Return from one JDspital. These cases, so returned as Chronic Rheu- utism, were generally Scurvy, and frequently ended in (ath; but a great number of Medical Officers were so Itle in favour of the idea that Scurvy prevailed in the ^ my, that they would not acknowledge the cases as such -.even when the post mortem appearances demonstrated t3 natm'e of the disease. The great number of cases ^dch appear as Fevers, which were not Fevers, will also 1 remarked. Very few who came down from the Crimea t Scutari, during the first part of the first winter, came Vth Fever. It w^as contracted afterwards in Hospital, ul was that called Hospital or Camp Fever, and by the iench, Typhus. With us it was called Febris c. c, ^'mmon Continuous Fever (which means — what?) It was not till the spring of 1855 that there appeared Way in which the Medical Returns were made at Scutari. 302 WAY IN WHICH RETURNS WERE MADE AT SCUTA in the British Army, araong the cases sent down from he Crimea to Scutari, what the French call '^Fievre |y- phoide/' The French and Russian camps were decima d, in the spring of 1856, with the same Fever which he British had the preceding spring, and from some of he same causes, viz., an inadequate supply of fuel, food, ad clothing, combined with want of sanitary pre u- tions. But, in the British Hospitals, if a man came in 'th feverish symptoms, it was very common to return m under F. c. c, though afterwards it might prove tcbe Pneumonia, &c., and therefore the numbers of Feb. ( c. must appear unduly increased. In the first winter, a great number of those returncias Fever died not in the acute stage, but afterwards in he secondary stage of Consumption, or something else. What was called Frost-bite was almost always the ■ elific Treasury of the Nation all that large field of obser- 306 ABSENCE OF RECORDS OF TREATMENT. vation which official advantages place at the command ' the Army Surgeon. j Analogous to this system^ by which the world is deprivi of valuable results^ is that by which the visible Materi. of self-recorded facts has been allowed to perish. Few . no preparations can have been made of bones and amp tated limbs, since few or none have been sent hon^ How can it be expected, when the only encouragement.; tiie probable interment of a preparation in the micl(- ground Museum at Fort Pitt, by order of the Direct* General, that Army Surgeons, in the midst of th * labours, should select specimens and send them home, ) be afterwards prepared and deposited, if thought worthy f Fort Pitt? This Museum is one of the first in the worl; and it is not here meant that to enrich it ought not to 3 tlie legitimate object of ambition to the Army Surgeon - but that it ought to be placed in a locale worthy of it a 1 accessible to Students. From what is above stated, it becomes evident th , notwithstanding the treatment of gun-shot wounds is 1 ? known than any other branch of Surgery, after twe^ months of actual campaign and two years of Hospil treatment, no classification will be obtained of the fa( , recorded in the manner they have been, w^hich can be f any public utility. Even were they published as tl.' have been sent home, no Pathologist could collect fr- 1 them arranged data from which he could draw valua3 conclusions, for the use of those who may make futi3 researches in this branch of Surgery. Necessity for a For the Completeness of a Military General Hospital a - Pathological .-ri. . -r /v: Department in separate Pathological element is required. Its omc'j OonS ^^I'ing the time of his investigations, in order that s i Hospitals. Reports may be above suspicion, must be independent those who treat the patients. IIEGISTRATION AT SCUTAKT. 307 lis du-ty would be to demonstrate in the Solioolj to ti ulate such criticisms and illustrations as he might make u n the Statistics of Disease, and to act as Curator of the j\'|seum, unless in the very large Hospitals, wliere this w ild be a separate office. t may be thought necessary to give a short resume of rccsume of the wit has been said of the method in use at Scutari, ontlie ^^^^^^^^ "-^^ oj iiing of the Crimean campaign, for receiving sick and rc stering their admissions and diseases — this having b( 1, as it were, an improvised scheme of General Hos- pi ls — as well as for recording the results, deaths and biilals. I shall be obliged to use some repetition. 'ip to the middle of February 1855, the method said to e> t was the following : — The Adjutant or his Serjeant st d at the landing-place or hospital gate and took the n; les of those who were able to speak, receiving a verbal rort, from the Officer in charge, of the number who had (111 during the voyage. At first, there was no ari-ange- m it for registering the sick when they were received into H'lpital; and the erasure of the man's name from the diet rO|'was long the only record of his death, excepting the A'utant^s head-roll of burials. believe that the Medical Officer in charge always er -avoured to make a nominal roll on the voyage from B; klava to Scutari ; more than one has stated that it to him half a day from his professional duties about the to do so. But, whatever this nominal roll was, it went in the Principal Medical Officer's office, and not into the wds; one copy was given, I have been told, to the I>''uty Assistant Quartermaster- General on landing; bi at what period this was first done I am not aware. It babeen stated to me by several Medical Officers that, t'v'i as late as March 1855, the Inspecting Medical Officer lansports, upon going on board, frequently found this X 2 at Scutari for receiving; 8ick, and registeriii!^ their Admissions, Diseases, and Deaths. 308 REGISTRATION AS list imperfect, owing to the illness of the Medical Offic in charge, or other unavoidable cause, and had to compl(: it then and there. Till the middle of Februarj^, or later, ^\e had no be- tickets, and no regular death returns. It is well knon that the sick were put on board at Balaclava withcfc nominal or numerical lists up to February 1855. Upi their admission at Scutari, an Assistant- Surgeon vfi charged, sometimes late in the evening, to take the nam , regiments, regimental number, &c., and to make the dif- nosis of perhaps 100 patients before nine the u(t morning. One-twentieth have been known to die befc they could give their names. After the end of March all this confusion ceased. It it was not till the end of April that a census of the Hos - tals was taken, and returns " squared" with the Adjuta - General in the Crimea. Returns probably existed of which I knew^ nothing. I am speaking only, first, of what I saw ; secondly, of w t I was informed of by witnesses on the spot and at the tii The Director-General may have other witnesses and ot r returns. The conclusion I draw from all this is, not that any ( e was to blame, for all were burdened with work beydl their strength, but that there was no system ready cr - uized of registration for General Hospitals, and tlia a Registrar is an essentially necessary Officer for such u institution. In consequence of the great confusion of the Hospi from the battle of the Alma till a late period of the wii r of 1851-55, a number of men were buried from the pitals, exceeding in six months the deaths reported in e "orderly room" by 530; but the deaths reported in ic orderly room exceed those rci)ortcd in the Hospital 1)0. s PRACTISED AT SCUTARI. 309 In November by 12 December „ 143 „ January 125 280 hile, as if to make up the lost ground, the medical re- lirns, which had exceeded the orderly room returns ' by 12 deaths in October, exceed again by 253 „ „ February, 265 E aging the sum of deaths very nearly equal. The Adju- t having buried 280 men more than the total number ^ orted by the Inspector-General as dead, the account ad to be balanced at a subsequent period. ! A census was taken of the Hospitals, April 30, 1855, by Ihich it appeared that 517 non-commissioned officers and (Idiers had been buried whose deaths were unrecorded, n official report was then seni up to the Adjutant-General 1 the Crimea, and they were struck off the strength of le army. The names and regiments of 28 others re- tiained unknown. j I have carefully compared the statistics from six different statistics from ^ficial sources and none of them a^ree. six different ' ° Sources, I It is possible that, in some of these cases, the numbers all different. * deaths may be the numbers occurring in the several onths, — in other cases, the numbers recorded in those onths. At the same time, the great discrepancies in the |(veral numbers shake confidence in their accuracy, and nder it difficult to make use of them for statistical pur- )ses. From details inserted in the Appendix, it will be seen 310 CONFLICTING UETURNS OF DEATHS. 1. That there are four different returns of the deaths on board the transports bringing Sick from Balaclava to Scutari, and that the number reported is different in each separate return. Nay, there is scarcely a single ship for which the three returns agree, which report the ships separately. 2. The Adjutant's head -roll of burials, the most trust- worthy record of deaths, exceeded in six months by up- wards of 500 the number reported as having died in the Hospitals ; and the Adjutant states that this list of burials does not include civilians. 3. The Director-General himself represents the very numbers in the return of total sick treated in Lord Raglan's army^'^ as having been treated at Scutari alone in November, December 1854, and January 1855. 4. The returns of dead at Scutari from October 1 to December 31, 1854, vary as follows : . , Crimean Adjutant s ^ Principal ^ ItEPORTED KeTURN liETURN OF Medical ,^ T> Deaths. ^ , ^ (Iniantry J3URIALS. Officer s Heturn. ^ ^ ALONE.) 1,301 1,046 910 795t Smyrna Hospital did not then exist : and Koulali Hos- pital did not exist till December, and contained then, as a maximum, but 240 patients. These sources of discrepancy are therefore eliminated. The result of my examination of these statistics is simply * Appendix, Third Keport Committee before Sebastopol, p. 470; Second Keport, p. 705. + The deaths of the Cavalry, Artillery, and Engineers, averaged toge- ther about one-ninth of those of the Infantry at Scutari, according to the Inspector-General's return for seven months, viz., October 1, 1854 to April 30, 1855. This Avould not have equalized the numbers, for 9) 795(88, 795 + 88 = 883. APRIL 185.5 TO MARCH 1856 ■ IN THE ARMY IN THE EAST. APRIL IH54 TO MARCH 1855 cU rrprpjsenbs vrhal T/A^ Mor^ialMy would Tvcwe, ic€rh,ht(jd " /i(>(Jnisirii r\liil'il.< lli< rd^djMe/ Moriitldy vn ttw j4rm,if / hi- III I' n-i/Ji I I'ny ofJtrr ived^e,und iifi .iiirw.-; Hi<: MiirlMbty ferWOO /)er ct CompaTi > i ■ '•r Circle, , mid la. Month. "I' tU Mfinchrslij t il , /, rJiihi9 thy excfss of Mor^alih/ in Viv •"."'I'- r\n 111,,! ,.l rii. J f/,r iiiosI^AmJJ^j Tnwm^^ ErifjfUnd. I' Mi'iiiililil i„, IK (J III I .In II imi. fe ■ / \ " V / — -^a' HASTY DIxiGNOSIS OF DISEASE. 311 liis^ that, however satisfactory they may be to the depart- lents who have put them forth, and whichever of them lay be correct, exbibitiDg as they do such palpable diver- [tj, still, to any one not in tlie secret as to how things /hich apparently differ so widely are nevertheless identi- ally the same, they convey no trustworthy idea as to the ckness and mortality of the army in the East, and that, )r any practical purpose, they are as put forth to the ublic, who are most interested in the matter, not absolute :uths, but only approximations. The calculations which give, I believe, understate the mortality actually experi- Qced. The superficial mode of entering Disease, according to Fatal I i. • 1 • J.1 r i. i. 1 1, Consequences ae symptoms appearmg during the nrst twelve hours of the hasty fter entrance into Hospital, led to the followino; result : and imperfect ^ " Diagnosis, hat, notwithstanding subsequent symptoms displayed illustrated by bemselves and treatment was altered to meet them, the notice of the icorbutic character of disease, although prevailing, it is ^^^s^Q^butk aid, to the extent of 80 per cent., was never recorded, character of the . . ^ T T Men's Diseases /Onsequently, so striking a characteristic ot disease, spread inthelate War. ver so large a number of Patients, never led to the inves- igation of the common causes of so general an effect, /hich it otherwise w^ould have peremptorily commanded. Had the search been made after the cause which pro- aced 80 per cent, of the disease among our Troops, this eing Scorbutic Dysentery and Diarrhcea, &c., no other onclusion could by any possibility have been arrived at ban the following : that the disease was caused by salt •revisions, cooked in mess-tins capable of containing so mall a quantity of water thg^ the salt remained undis- harged in that large proportion which is got rid of by coking as performed in the Navy ; the addition to which ation was rum and biscuit. This was the food of the soldier day after day, while exposed to cold and wet, and 312 IGNORANCE AS TO THE PREVALENCE undergoing extreme labour. The compensations of diet usually afforded to the Sailor were nevertheless in store at Balaclava, viz. : rice and lime-juice ; and soft bread might have been provided, partly by baking at Balaclavs in the existing Russian ovens, and partly by importatior from Constantinople, as was subsequently done. Vege- tables might have been obtained, potatoes supplying tht want of green vegetables during the dead of the winter. It may fairly, then, be anticipated that, had the Scor- butic taint been reported to have existed to the extent t( which it really did, it would have been seen that the deatl of the British Soldier should rather have been ascribed t( his diet (which might have been modified or changed) than to the climate (which at all events was not wors( than that of his own country), or even to the over-worl in the trenches (which, however excessive, had he beei supported by nourishing and well-cooked food, he coulc have better borne till reinforcements arrived to reduc( it.) * Vital For an example of the vital importance of accurate '™ accurate Statistics of Disease to a Commander of the Forces and i ^^Disease^^ War Department, the following may be taken : We derive from Official Returns for January 1855, thai there were in that month Total Admissions 1 , , Total Deaths in o i^c into Hospital | Al,i90 Hospital .. J ^^^^^ (Primary) Per 1,000 per ann. \ , , , Per 1,000 per ann. "1 . -, ^o.t to strength . . J to strength j * This will be considered in greater detail in the Notes on Diet. Hen it is enough to say that the food was at once uncooked and insufficient Even had it all been eaten, which it was not, it would have contained onl} 23 oz. nutritive value, instead of 28 oz., the quantity necessary- for health Tiie fact of the food being thus disproportioned to the labour, would hav( been in itself sufficient to account for a large part of the destruction of th( liritish Army. The want of shelter and of warm clothing did the rest. OF SCURVY IN THE ARMY. 313 )f these^ the Admissions and Deaths from Diseases of tl' Scorbutic type are returned as follows : Admissions Deaths Scurvy 542 31 Scorbutic Dysentery . . . . 181 44 723 75 0 75 deaths from Scorbutic disease in that months when frn two-thirds to three-fourths of all the Disease in the A^ny were due to the Scorbutic type. The larger part, ifj.ot all_, of the Admissions and Deaths, recorded below, w'ich are for the same month of January, 1855, may be r(d " Scorbutic type^' or " Bad food/^ which is the same tllig. Admissions Deaths ^ Acute Dysentery * 8651 2101 Chronic „ . . . 143 J 578J 1-5 Scorbutic „ 181 44 Diarrhoea 4,191 1,199 p Acute Rheumatism 342 58 o Chronic „ 84 9 Q 1,413 124 542 31 7,761 2,253 ;^et instead of 7,761 admissions, and 2,553 deaths from S)rbutic disease, or bad food, are returned admissions 7 ), deaths 75. n the case of Armies in the Field, where half an Army ny melt away from such a cause, or be rendered inefh- C iit, just when its services are most wanted, not by ' Acute and Chronic Dysentery furnished a mortality ot 78 per centr- al was by far the most fatal disease in this fatal category. 314 IGNORANCE OF THE PREVALENCE Comparison ■with the amount of Zymotic Disease in a Civil Population, wounds but by disease — as was actually tlie fact with oiu in the Criniea_, in January 1855_, — of what vital importaiK is it, then, in such a case^ for the authorities to be fui nished with such information as the above, leading, as :; does, directly to the discovery of the true cause — tbj remedy for which, in our instance, was close at hand.* But what shall we say when we see the proportion i V. Inch the Army in the East suffered from Zymotic disease compared to that in which the Civil Population suffers £i home? and the utter insignificance into which sink tli Deaths from Wounds of an Army in the field, even whe engaged in constant warfare, compared with the Death from Zymotic disease ? The two Tables annexed give thi information ; and, when we consider that Zymotic deati is as much a " Violent death^^ as that which has usual! been called such, we may indeed say that the one ha killed its thousands,^^ but the other its " tens o' thousands ! TABLE No. L Annual Rate of Mortality per cent, in the Army of the East and in the English Male Population of the Ages 15 — 45. Deaths Annually to 100 living. Class of Diseases. In the Army in the East. English Male Popu- lation, 15—45. 1. Zymotic Diseases . . 18-7 •2 2. Constitutional Diseases •3 •4 3. Local Diseases '9 •3 4. Violent Deaths 3-0 •1 All Causes 22-9 1-0 * The whole of General Sir W. Codringtou's admirable Evidence, in the Report of the Crimean Commissioners, will corroborate the above, in its CHscutial features. OF SCURVY IN THE ARMY. 315 TABLE No. 2. Tab; showing the Estimated Average Monthly Strength of the Army ; a the Deaths and Annual Rate of Mortality per 1,000 in each month, fi 1 April 1854 to March 1856 (inclusive), in the Hospitals of the Army ii he East. I Estimated Average : Monthly j Stren;rtli I of tlie Arniv. 18 185 April . . May June July . . August . . September October . . November December January . . February March . . April May June July . . August . . September October . . November December 1 January . . February March . . 18. 8,571 23.333 28,333 28,722 30,246 30,290 30,643 29,736 32,779 32,393 30,919 30,107 32,252 35,473 38,863 42,647 44,614 47,751 46,852 37,853 43,217 44,212 43,485 46,140 Deaths. Zymotic Diseajius. 1 12 11 359 828 788 503 844 1,725 2,761 2,120 1,205 477 508 802 382 483 189 128 178 91 42 24 15 1 81 132 287 114 83 42 32 48 49 209 134 164 276 53 33 18 2 .\nnualrate of Mortality perlOOO. All other Zymotic Diseases. Wounds and Xn ju.rics All other Causes. 5 1-4 7-0 9 6-2 4-6 6 4-7 2-5 23 150-0 9-6 30 328-5 •4 11-9 70 312-2 32*1 27-7 128 197-0 51-7 50-1 106 340-6 115-8 42-8 131 631-5 41-7 48-0 324 1022-8 30-7 120-0 361 822-8 16-3 140-1 172 4S0-3 12-8 68-6 57 177-5 17-9 21-2 37 171-8 16-6 12-5 31 247-6 64-5 9-6 33 107-5 37-7 9-3 25 129-9 44-1 6-7 20 47-5 69-4 5-0 18 32-8 13-6 4-6 32 56-4 10-5 10-1 28 25-3 5-0 7-8 48 11-4 •5 13-0 19 6-6 5-2 35 3-9 9-1 Comparison between Deaths from Abounds luiil Zymotic Deaths, in an Army in time of AVar. Th Deaths under the head of Wounds and Injuries " comprise the : lowing Causes :— Luxatio, Sub-Luxatio, Vulnus Sclopitorum, Vulnus cisum, Contusio, Fractura, Ambustio, and Concussio-Cerebri, 11 eight Uegiments, viz., tlie 4Qth, 95th, 63rd, 33rd, 2cid, 50tli, 28th, and 41th, the mortality from disease al ie, in seven months, was 73 per cent. ; a fact unparal- le 3d in English history, except in the short Burmese war ol[.826. Walcheren, so often referred to, gives only the 316 THE SCURVY IN THE ARMY, statistic of lOi per cent, from disease in seven montb and the Peninsula 12 per cent, in a year. The 46th pi esents the apparent anomaly of losing mo than its average strength. That part of the Infantry, actually engaged in the siq throughout these seven months, lost 45 per cent, fro' ^ disease alone, in these seven months. i The average of the whole force gives a mortality of I per cent., including the Highland Brigade, never employd k in the trenches, but encamped near Balaclava, the avera; loss in which was only 24 per cent.; the Cavalry, partial dismounted and therefore not performing picket dut: which therefore lost only 15 per cent.; four Begimeni arriving about Christmas, which were sent immediately j ^ the front, and lost 27 per cent.; and four Regimer arriving in January, and remaining three weeks witho; taking any part of the duty in the front, which lost on: 7 per cent. The Naval Brigade shews the astonishing difference per centage of mortality from disease of 3^ per cen! instead of 73 per cent, for the eight Regiments abo , specified. * The mortality from disease among Military Officei i who suffered in action a loss greater in proportion th the men, was about 6 per cent, only, including the deatl from wounds at Scutari, which are not included among tl men. i Account of The account of one day of a soldier's life in the trench^ Soldiers' Day, , • i . /. when (lurmg the winter oi 1854 — 55 wall remove any surpri employed in ^yi^j^h the abovc statistics may have created. the irenchcB. Mustered with great coat and blanket, half an hov before dusk, the soldier marched, through the mud, in' the trenches, whicli, owing to the nature of the grouii irOW IT WAS CONTRACTED. 317 we full of deep holes, out of which the boulders had been dii filled with \a ater, into which he could not but fall in the darkness : he took his seat with his back to the bank, in cramped position, to allow of others passing before hii along the bottom of the trench, only four feet wide. Tb'e he remained, if no alarm occurred, whatever tht^ we her might be, till morning, when he was relieved and ari ed again at his quarters. I the early part of the winter, he was thus on duty in thiitrenches two nights out of three; later, one night out of wo; but the average of duty was, till the termination of he winter, excessive. The 4Cth Kegiment actually seied in the trenches six nights out of seven, then ceasing to e able to furnish parties for trench-duties. he soldier, on his return, liad to collect fuel to roast hiii^reen coffee, without tools, although the chief part of th fuel consisted of roots. He next ground his coffee bereeu a fragment of shell and a stone, and then boiled it i)r use. But the majority of the men were too much exausted to go through this process. They breakfasted orheirrum and biscuit, and then lay down on the muddy grind of the tent, without other covering, either above oroelow, but the great coat and blanket, brought wet fr a the trenches. In the afternoon, "the soldier might be.irdered to go from five to seven miles, on fatigue duty, tc 3alaelava, to fetch the rations of his regiment. On his reirn, he had again to gather fuel, to boil the salt rations in he mess cans, which did not hold water enough to ab- stict the salt. A portion only of the salt beef was, there- fc^, consumed, and it became the duty, every week, of tl Quarter Master Generars Department to bury what was tbwn away, to the amount of hundreds of lbs. per regi- TrtQt. The salt pork, issued two days out of the seven, E^.taining less salt, was eaten often wholly or partially 318 DUTY OF THE SOLDIER ON SERVICE. hj raw. Towards dusk, the soldier was either marched aga to the trenches or retired to his tent, if not on sentry picket duty. He had on either a shirt, which he had worn for s' weeks, with swarms of vermin on his person and hair, i was ^vithout linen altogether. His kit having been left board, by order, when he landed at Old Fort, was in vei few cases recovered, and that after a period of from six r ten weeks. He wore, during the winter, a single pair of laced boot which, being wet through, he was afraid to unlace, lest tl heat of the tent should dry them, so that they could n( be put on again. Thus, even when asked by the Reg' mental Surgeon, he denied that he felt numbness in h' feet, lest he should be ordered to unlace his boots. (The French soldier, with his shoes and gaiters, and tli sailor with his shoes, obtained warmth to his feet.) ^^J^aUvJ^s (lone A man who has reported himself fit for duty, over nigh Sick. h^^s not unfrequently been carried back sick l^y his con rades from trenches in the morning, and has died on h: way or a few hours afterwards, so little inclination wa there to shirk duty. This does not refer to cases of chc Icra, which are essentially sudden. The soldier, if reported sick, was removed from his owi tent to the Hospital tent, in most instances precisely simi lar, for very few Hospital IMarquees had been brought t( tlic front. Here tlie men lay, often in the mud, generalb with only salt provisions and biscuit, sometimes withou medicine or medical comforts, and with so little room tha* the Medical Officer could hardly pass between the patients The Medical Officer, unable thus often to procure medica comforts, medicine, or marquees, sent down his patient, aJ the most humane means of dealing with him, on a mule oi cavalry horse, sometimes led and somefinu^s not, tin'ough TREATMENT WHEN SICK. 319 thtain and storm, to Balaclava. Both deaths and frost- bit! occasionally occurred on the way, and falls were ne«ssarily frequent. On arriving at Balaclava (the small Ge^sral Hospital there, formed out of the school-house, aining only 300 — 400) the large majority of the sick wounded were laid upon the beach for several hours, or fair, awaiting their turn of distribution into trans- pO|5. (The Sick Ships^^ were not organised before Jafiary 1855.) uring the voyage the sick man may have been on the de s, in a hammock, or in a bunk. He seldom received an|hing but water, or tea and biscuit, for the first tw ve hours, at least until after the organization of the Sii Ships. e was detained, previous to sailing from the Crimea, aBj after arriving in the Bosphorus, on board ship for a peiod greatly exceeding (as an average) the length of the vpjige, which was from 36 — 60 hours. n landing, he was carried, if unable to walk, up to the pitals, suffering a still further delay, sometimes of tl hep, the final order for his reception into a particular H pital or ward not having been issued. he universal impression is, nevertheless, that, among thi men, there never was heard a m^urmur, and that, fr< i first to last, they continued as eager " to get into S(pastopol" and "to go back to their comrades,^^ as if tliy never had suffered. Wen when in Hospital, they were never heard to refer io -ast hardships, otherwise than as a simple matter of n( essity " in war-time." ^ On those who saw the simple courage, the enduring patience, the good m), the strength to suffer without words, of this handful of men defend- inij.he position, like the Greeks at Thermopylae, who drew their blankets 0T| their heads and died without a word, like the Greeks of old, it has mile an impression never to be forgotten. Their devotion to one another, w} 1 scovnini? to report themselves sick, for fear of throwing more labour Unfailing endurance of the Men under hardships. 320 DEATHS AND ADMISSIONS IN THE ARMY. Deaths and Admissions in the British Army in the East. After this short account of a soldier's day, iir the winter of the Campaign, the following statistics of Sickness and Mortality of the Army, month by moi during the whole Campaign, will be in no way unaccoul able. It will be observed that, in January 1855, Annual Rate of Mortality per 1,000 was 1,174: a higl rate than that which prevailed during the month (Se tember) when the mortality was highest in the year of 1 Great Plague, 1665. Deaths and Admissions into Hospital in the British Ai in the East : 1854. Deaths in Hospital, Deaths to Force including Crimea, per 1,000 per Scutari, Transports. Annum. Admissions inw Hospital (Primary Strength per 1,01 per Annum. April . . 6 8-4 468 May 21 10-8 1,224 June 17 7-2 1,116 July . . . . 382 159-6 2,100 August . . 859 340-8 3,384 September .. 939 372 2,676 October. . . . 763 298-8 2,832 November .. 1,237 499-2 3,336 December . 1,970 721-2 3,888 1855. January February March . . April May . . 3,168 2,523 1,409 582 594 1,173-6 ^- 979-2 561-6 223-2 202-8 4,176 2,760 2,316 1,716 1,944 on their comrades, has made a still deeper impression. There is scarce! any example in history to compare with it. More will be said of this hen after. But surely the blood of such men calls to us from the ground, no for vengeance, but for mercy on their survivors ! * The health of the Army before Sevastopol was then improving. Bn this enormous per-centage was kept up by the bad state of the Scntar Hospitals, which was growing worse. THE NAVAL RRir.ADE. 321 Deaths and Admissions — continued. Deaths in Hospital, Deaths to Force, iueluding Crimea, per 1,000 per Admissions into Hospital (Primary) to Strength per 1,000 per Annum. June 3,396 2,832 2,760 2,004 1,380 1,176 1,332 July August . . September October. . November December 1856.t January February March . . A-pril . . May . . Tune 92 11 29 6 50 13 21-6 9-6 10-6 8-4 7-2 2-4 1,116 924 972 840 720 432 * If it be asked how it was that the Mortality in November 1855, being >3 per 1,000, should still be so high, it may be answered there were causes enough. 1. With regard to the Crimea, the whole Array was not hutted till the nd of January 1856 : half, at least, was still unhutted in December 1855. And the whole of the excess of Mortality in November was produced by -'holera, arising from the men being crowded together in the old huts (un- entilated), from the dampness of the ground, and from the ground being sed up, which it soon becomes with a careless army. 2. With regard to Scutari, it was the month of the fatal outbreak of holera, which began with the German Legion ; these troops are not, how- !ver, of course, included. 110 out of the Total Deaths, 243, in November 1855 were produced by 'holera. It might be important to bring out yet more strongly the difference etween the cause of the Mortality in the winter of 1854-55, which was hiefly bad food and bad clothing, and that of the summer of 1855, which as neglect of Sanitary measures t The total Admissions into Hospital, during the last six months of the ccupation, from January to June, 1856, were 21,659, and the Deaths 261, eing at the rate of 24 Deaths per 1,000 Admissions per annum. The Y 322 THE NAVAL BRIGADE. Contrast The Naval Brigade, in which the mortality from disease **^*^^Navy shows so remarkable a difference as that above referred to were placed under the following circumstances, largel; differing from those of the troops. They obtained far better shelter tlian the common bell tent, by burrowing into the sides of the hill, by keepin; sheltered ground, hy erecting loose stone walls, by coverin, themselves in with tarpaulin, slate, board, and portions c condemned sails, by making tubular chimneys of piercel canister, &c. I They formed boilers of the empty powder-cans, about twj feet cube, with a large orifice on the top, which are usej for the great guns. They were served with fuel, chiefli from the ships. Their water was near ; indeed, their Conrj mander sunk a well, with well-sinkers obtained from til i army. ! As a corps attached to the army, they obtained issues t\ certain necessaries, on application of their active Conl manders, irrespective of the long-established forms f« issues to the troops. 1 In the morning, coffee or cocoa was prepared for a sailo' as it would have been on board ship. In the evening, hi. soup was served out to him, on his return from tl' trenches, made for him from salt meat with ample tin to soak out the salt, by processes used on board shii or from ox-heads, which, if not thrown away at tl neighbouring Commissariat Divisional Slaugliter-hous were at least not issued to the troops. The sailor, having theoretically the same advantages ' the soldier, as to extra issues, having his own warm cloti ing, and the purser's stores at hand, enjoyed a still great; i Deaths to Strertffth in the Household Troops at home arc 26 per 1,000, j* annum, according to the calculation jjiven in the Sanitary Secti'i inchulins: Invalids. COMMON CONTINUOUS FEVER. 323 benefit in the care with which his officers exacted that his wet clothes should be taken from him on his return from :he trenches^ and dried in a hut at a stove prepared for the purpose ; that he should have a pair of dry blankets ready :o receive him, and a change of shoes and stockings, till he Invent on duty again. Oranges were also served out, in Dursuance of the custom of the Navy, which classifies acids :is additional rations, and not as medical comforts, issuable )u the Surgeon's order. An exception to the above statement is to be made, lowever, with regard to that small portion of the Naval brigade, separated and brigaded with the Light Division, vhich suffered in like manner, being under like circum- stances. The importance of using a more elaborate and specific illustration of lomenclature of disease is shown, from the consideration ^JomTnckture ;liat the Febris c. c.^' (Common Continuous Fever) of of Disease. ;he British Military Hospital, a term including Typhus, Typhoid Fever, Relapsing Fever, and Febricula, indicates leither the origin of the disease nor the kind of treat- nent, inasmuch as it is made to include every kind of ever, together with drunkenness. We want a new head- ing, " Drunken Fever,'' to separate these casualties from evers arising from other causes. All apoplexies, almost vithout exception, in our Army might be styled " Drunken \poplexy." A formal posting of the drunken statistics night exercise a salutary inflence. In the proposed iiosology of Dr. Farr, we find the disease termed 'Alcoholismus," which includes Delirium Tremens." This last is made to appear in Army Statistics under 'Diseases of the Brain." But the terms which are used, ^.g., in the Sardinian army, and copied from our own 3ivil Registrar- General's Office (with the addition of y2 324 NECESSITY OF A STATISTICAL DEPARTMENT, some diseases, incidental to camps), do indicate both [e origin of the disease and the mode of cure, and the m«ie of prevention. General La Marmora was visited, in c-7 16-7 motic Diseases li) 4-9 est and Tubercular Diseases 4 5 9-2 3-3 2-6 Comparison of the Mortality of the Line with that of the Civil Population, e Deaths in England and Wales (1848-54) arc taken from the Registrar General's 18th Annual Report, p. 150 ; and the Deaths in the Infantry of Ae Line, from Colonel Tulloch's Report of 1853, p. 62. Now, recurring to the latest date of Colonel Sir A. lUocVs valuable Reports, which is, we believe, 1853, and e last date in which, referred to, is 1846,~recurring to e non-arrangement for their regular publication, we )uld ask, is there any annual medical and sanitary port whatever pubhshed, containing summaries and iialyses of the reports of the Medical Officers of the Army ? If the causes of death among 2,600,000 people in Why cannot, . what is done ondon can be printed iveekly, on the 1 uesday lollowmg ^i^jj apparent e week, and if the births and deaths for the whole of ^j^fi^^/g'^,, igland and Wales can be printed quarterkj, within a done for 328 NECESSITY OF A STATISTICAL DEPARTMENT, Soldiers, in month of the end of every quarter, could not clas5|ied facilities of returns of the attacks of sickness, and of the mortalij' of fr?8? much Army be published periodically, with equal punctuflty? greater ? Does not the organization of the Army offer the greiest facilities known for statistical registration ? Could not the mean strength of each regiment be d;er mined by monthly musters? Coukl not the mean nu\her of from fever, consumption, and other causes be d er- mined by the same method ? Were the strength thus determined compared witlthe deaths by the various causes, and with the attacks of ck- ness, a complete view would thus be obtained of the jain results of the sanitary or fatal influences to whiclithe regiment had been exposed. i If these results could be collected for one regiment, hey could be collected for every regiment. This follows n;es- sarily from the x\rmy organization. The practical utility of such information woul be greatly increased by its embracing the whole Armyind above all, by its being collected and analysed immediaily: the object being for the Secretary of State for the far Department to be able to see the movements of the h Jth of the Army, as clearly as the movements of time or the face of a clock. The great utility of partial returns, published iiny years after the events have happened, after the me to which they relate are dead or have been discharged bas been shewn by Sir A. Tulloch^s Blue Books. Woulcaot complete returns of the whole facts for every portic; of the Army be still more useful than these partial retuis? Would not recent information, punctually supjed, be practically of greater use than the retarded, almost os- thumous returns which have hitherto been publishe in England ? j FOR THE AKMY IN GENERAL. 329 The difference in the efficiency of a healthy and an un- althy Army has been practically illustrated in the most rrible manner by our late Crimean campaign; where ore than half the Infantry was sick in Hospital at once, ^rt of the remaining half was told off to attend upon eni; and the remainder only was capable of trench and tigue duty, and of keeping the position. It is unquestionable, — and our experience of the way in hich, in Civil life, mortality can be, and has been, reduced, 3ed hardly be referred to, — it is unquestionable that the ortality and sickness of the Army in peace may be !duced to one-half, at most, of its present excessive nount. It is a thing beyond all doubt to be done. The 3gree to which this would affect our system of recruiting, ar system of pensioning, the well-being of our men can jarcely be calculated. One question remains; Are Vital Statistics made a ranch of Medical education ? Are the Medical Officers xamined on this subject? To what extent have pub- shed works of Army Medical Officers assisted Sir A. Tul- och in his Statistical researches ? Twenty years hence it will scarcely be credited that a ime has been, so late as the year 1857, when there was othing analogous to our Civil General Register Office in lilitary organization. , The main end of Statistics should not be to inform Main end of Statistics. cihe Government as to how many men have diea, out to pnable immediate steps to be taken to prevent the exteu- \mn of disease and mortality. 330 PRINCIPLES FOR THE MILITARY It is therefore of paramount importance to have sp ial reporting for special occasions : e. g., the Yellow F/er breaks out in consequence of the locality or overcrow img of a Barrack, or Dysentery in consequence of mono ny of diet. If the Government had known, week by week, ;iat Scorbutus was ravaging the Army in the Crimea, the ry first appearance of the disease in the weekly states, vth a reason why the disease had appeared at all, would I ve led the Government immediately to have sought for hib requisite supplies to arrest it. If the Medical Ofi&cer waits till the time of repor jg comes round, all that is accomplished is that the Gov(ti- ment know that they have lost a certain immber of Lq- dreds of men in a way which might have been j'e- vented. ^| In France, in the event of an epidemic breaking ou'in any part of the Army, the facts are noted, day by day bo the " Conseil de Sante,^^ at Paris, who notify them, ly by day, to the Minister of War. |§ It is therefore to be concluded, from the above ci» siderations, that 1. Whatever Statistical system be adopted should »e uniform ; and in every case where there is likely to be { y doubt as to the precise meaning of a nosological term it ought to be defined. 2. Whatever period is laid down for sending in the S.- tistical Reports, these periods should be departed from^t the first appearance of any epidemic in the Army. A\i the progress of the disease, with its causes, the meit adopted to arrest it, and the success of these means, shoi|l^ 1)0 reported, day by day, to the War Department, where p practicabk\ STATISTICAL DEPARTMENT. 331 3. Au Officer should be attached to the Army Medical epartment, with suitable assistance, to enable him to ake up the Army Statistics with due accuracy.* 4. There being already an authorized and official form ' registration for the Mortality in Great Britain, it is .1 the highest degree important that the form used in the rmy should be the same. 5. The Registration of Disease and Mortality would )me under the Statistical Department of the Army Medi- al Department, for all medical and sanitary purposes; hile the mortality might be very well transmitted to the [Registrar General's Office, and published quarterly.f 6. The forms required for such a system of Army Medi- al Statistics as are here proposed, are I. Weekly Regimental State,"! shewing Strength : 1. Zymotic Diseases under their various heads. 2. Mortality from these. 3. More prominent Diseases of other classes and mor- ahty from these. 4. All other Diseases. 5. Total Admissions during the week. 6. Total Deaths during the week. 7. Per-centage of Admissions from Zymotic Disease to ffotal Admissions. ! 8. Per-centage of Deaths from Zymotic Disease to Total Deaths from Disease. ' * One Form, made up at home, should be the same as the Registrar- .General's Form. L t It appears to follow, from the proposal to transfer the Statistics of Death from the War Department to the Eegistrar-General's Department, that the same form of Ilegistration should be used. I t The Regimental Medical Statistics should be kept on the same Form as that used by the Registrar-General of England. 332 MILITARY STATISTICS. 9. Admissions and Deaths from Wounds. [This Return to shew the causes of Zymotic Disc e and Mortality in connection with 1 and 2.] II. Return, as already proposed, to be made up by e Principal Medical Officer, and sent home, week by we:, to the War Department, and also to the Command g Officer. APPENDIX I TO SECTION XI. iiuAL AND Proposed Forms for Medical Statistics in THE Army. I need hardly be stated that a correct set of Statistics is the Medical baj3 of all Army hygiene. sho ^IdT/^ays lierefore, whateyer forms are adopted should haye reference be drawn so as no only to numerical data, but to causation. to indicate the Preyentible disease, and especially the whole zymotic Disease. c\i i, should be clearly distinguished from othoi- types. We should haye an account of all zymotic cases, whence th arise, their nature and causation in Climates, Soils, IDefectiye drainage, Marshes, Position of Stations or Garrisons, Diet, Duties, Water, Barracks, tents, &c. State of Hospitals, Ventilation of Barracks and Hospitals, Oyercrowding, Temperature, Intemperance. v^ery local or personal cause should therefore enter as an II ACTUAL AND PROPOSED FORMS Present form of Classification of Diseases. element into the returns, and by due classification of iiese afterwards, the Grovernment would be kept fully informal not only of the health of the Army, but of all the conditions iflu- encing it at a particular time and place, as well as of thtjare with which the Medical and Commanding Officers lookfter the men. The weekly State — the weekly State sent to the Comm ider of the !Forees — the weekly State transmitted, as it ought ) be regularly, to the Army Medical Department at home, shoii be so framed as to group together all zymotic and mit ible diseases, in order that, at a glance, the Government at me should be able to tell, to what extent sanitary measures are qui- site and to what extent they have been neglected. Any g(eral summary of army disease and mortality should be drawn ) on the same principles. All our existing weekly forms and um- maries are practically useless, except for simple nuDcical purposes. Her Majesty's Ministers want to know, in act, what they are to do to preserve the numerical efilciency ( the force, rather than what the force has suffered from sickne and death. The classification annexed below, which is that at pres t in use, is of scarcely any value as pointing out the causes rom which our mortality springs ; almost as well might the 'ord witchcraft be assigned as a cause. ' Fevers Eruptive Tevers Diseases of the Lungs „ „ Liver „ „ Stomach and Bowels Epidemic Cholera Diseases of the Brain Dropsies j Rheumatic Affections Venereal „ ; Abscesses and Ulcers i Wounds and Injuries Corporal Punishment Diseases of the Eyes „ „ Skin All »)ther Diseases. FOR MEDICAL STATES. Ill ompare with this the following proposed Details for Eegi- meutal, Divisional, or Army Weekly Medical State, and for any general summary to be used for immediate practical purposes. Proposed Form. Strength Officers, Men. o 0) r— 4 ■i Fevers : Intermittent „ Remittent Yellow „ Continued „ Typhoid „ Typhus Plague „ Eruptive (Small Pox, Varioloid, Chicken Pox, Miliaria, Scarlet Fever, Measles, Quinsy, Diphtheria) » Erysipelas Erythema Pyoemia Hospital Gangrene Cholera Diarrhoea Dysentery : Acute „ Chronic „ Scorbutic „ Avith Liver diseases Scorbutus Ophthalmia Scrofula Phthisis pulmonalis Catarrh 1 nfluenza Intemperance Rheumatism Carbuncle Farunculus Syphilis Gonorrhoea Sun-stroke Frost-bite \ Foot lameness I Wounds and Injuries Other Diseases of Brain of Chest „ „ of Abdomen of Eye Diseases of Liver „ of Skin Abscesses and Ulcers Corporal Punishment This form is merely given as a rough illustration of what is 'ere meant. As an equally rough explanation of the suggestion, B 2 IV SUGGESTIONS FOR A SANITAKY | it may be stated that the name "Intermittent Fever," coj-eys the idea, as to its causation, of marshy ground in low tentera- tures; "Remittent," of marsh}^ ground in high temperatujs. The names of some of the Fevers suggest defective drajiage as a cause ; but over-crowding, where ail other conditiomf-ere good in a Crimean hut, would produce Continued Fe^j*; a little more would produce Typhoid Fever ; and a little aore Typhus. The three Dysenteries have frequently dietetic ci ses. Phthisis is again mainly owing to over-crowding and bad ;nti- lation. Were the Sanitary element represented, as it ought i be, in the Army Medical Department, a form like this )uld immediately suggest causes, to be enquired into, as prodiing the kind of mortality indicated as predominant at the resp' tive Stations. It is not often, it may be as well to say, tha-Jany one cause is to be found operating alone, in separate acti , as might sometimes be seen in the Crimea. Considerations The following considerations are suggested as thos' on Construction such a Sanitary nomenclature, as is here indicated, ] gbt of a Sanitary be founded. '^^^J^?-^^^^'^^'^^^ 1. Nosological arrangements have generally been basi on of Disease. . . ° ° ^ some scientificground. — Fevers have been classed together Jso, Cachectic diseases, and constitutional diseases generally, in- dicating some common origin or a common constitutional d ect. Again, Diseases of Cavities (head, chest, abdomen) ave been classified together, mainly for pathological purposes. 2. Why should there not be an arrangement of diases according to their causes, and with a special view to the rej)val of such causes, and the prevention of such disease ? Why s uld the attention of the Medical man be always directed to hat disease has caused, and not to what has caused the diseas to what it has done, and not to its prevention ? A Sanitar no- menclature is thus of importance. It recognizes prevei on. It recognizes preventible causation. 3. In tlie present state of Sanitary knowledge, it won bo impossible to arrange all known diseases according to leir causation ; but many of the n.ost important may be so groed, and experience will, in time, add greatly to the numbers. For example, we have diseases of Malarial origin, su(, as intermittent and remittent fevers, — i i NOMENCLATURE OF DISEASE. V Diseases from animal exhalations, siicli as plague, typhus, ( itinued fevers, — Diseases proceeding partly from the one, partly i'rom the ( er class of causes, such as cholera, diarrhoea, dysentery, — Diseases arising from bad food, such as scorbutus, and ( er blood diseases, — Diseases, in which several causes co-operate, as, for ex- jple, in phthisis, Tvhich arises from foul air, want of exercise 1,1 food — in ophthalmia, where foul air alternates with dry- ijs, hght, dust, &c. t. Speaking generally, the whole Zymotic class may be con- jered mitigable and several of its divisions of disease pre- vitible. ;[t would be a great means of directing the attention of j?dical Offiers to the causation, if, in all cases of prevailing imotic disease, they were required to state distinctly the cause. Itwo or three consecutive cases of any such disease happened t appear in a regiment, the cause should be at once searched 1, reported, and removed. 5. It would be unsafe at present to lay down precisely the (.eases and their causes : — the one as being an invariable con- 5;[uence of the other ; because disease is the result of the oration of many causes, and perhaps the determining cause is (3, which, by itself, and, in the absence of others, would pro- (ce no effect. It may be the last straw which breaks the (nel's back. It will be enough at present to indicate the im- ]:'tance of the matter. The Diseases of the Crimean Army, which caused the Deaths Classification ( imerated at pp. 320, 321, are given here, re-classed, according of Diseases of f'l T> • ^ u 1 . Crimean Army, I tne ±tegistrar-(jrenerai s nomenclature. according to hmAL Eeturn showing the Primary Admissions into the Hospitals of j)r^5'arr he Army in the East, from the 10th April, 1854, to the 30th June, H56 ; also the Deaths from Primary as well as Secondary Admissions, ogether with those occurring on board Transports, conveying Sick and iVounded, during the same period. — Arranged according to the Classifi- ;:ation of Causes of Death proposed by Dr. Farr, in the 16th Annual Report of the Registrar-General, pp. 82-96. Class. Causes of Death. Admissions. Deaths. 162,123 18,057 Specified Causes 161/297 17,712 VI DISEASES OF THE CRIMEAN ARMY ACCORDING Class. Causes of Death. Admissions. r ths. I II III IV V Diseases. Violent 112,651 828 25,043 214 22,561 507 204 668 19 I (Orders) 3. Dietetic (included in Order 1) . . 108,577 3^748 326 — 0\J0 4 0 II 458 370 - 84 120 III Diseases of the — 1. Nervous System 2. Organs of Circulation 3. Respiratory Organs 4. Digestive Organs 6. Organs of Generation 7. Organs of Locomotion 8. Integumentary System . . 4,051 263 2,607 4,592 239 129 13,162 117 41 384 84 6 1 35 IV 1—3. Not occurring in the Army . . 4. Diseases of Nutrition 214 - — 19 V 1. Accident 5. Punishment and Execution 2,484 i o,Zoo 20 1,774 532 7fil 20 1 826 345 I Order 1. 21 5 4 2 Phlebitis Typhus (and continued) Fever Influenza Remittent Fever Rheumatism (acute and chronic) . . 3 924 78 3 25,841 « 9,506 8,278 44,164 6,970 2,406 2,957 I 5,044 0 9 21 0 075 _* 144 259 651 512 60 311 283 * No admissions or deaths were returned under this head. ; TO THE registrar-general's FORMS. VII Causes of Death. Admissions. Deaths. 3,748 4 * 1* 2,096 178 * * ZoL A A 44 257 0 68 0 1 0 • * 294 63 62 1 79 20 23 0 90 3 279 116 1 1 11 7 87 70 42 10 44 4 261 17 10 8 128 0 28 0 3,307 0 133 1 24 4 8 9 127 29 58 0 45 0 10 0 * _ * 1,688 199 Order 2. Syphilis . . Hydrophobia Order 3. Privation Purpura and Scurvy (see above, under Dysentery) Alchoholism " (includes only Delirium Tremens other cases not returned.) Order 4. Scabies Worms Dracunculus Order 1. Gout Dropsy Cancer et Tumores . . Mortification . . Cachexia Order 2. Scrofula Phthisis Hydrocephalus . . Order 1. Cephalitis Apoplexy Paralysis Insanity (Dementia) Epilepsy Tetanus Cephalalgia Neuralgia Ophthalmitis . . Otitis Order 2. Pericarditis Aneurism Heart Disease . . Varix Palpitatio Epistaxis . Laryngitis. Bronchitis , Order 3. * No admissions or deaths were returned under this head. VIII DISEASES OF THE CRIMEAN AKMY ACCORDING Class. Causes of Death. Admissions. Order 3 {continued). Pleurisy Pneumonia Asthma and Dyspnoea . . Other Lung Diseases Order 4. Gastritis Enteritis Peritonitis Ascites Ulceration of Intestines . . Hernia Ileus et Constipatio Intussusception Stricture of Intestines Fistula Dyspepsia Haemorrhois Hsematemesis Singultus Pancreas Hepatitis Jaundice Other Liver Diseases Spleen Disease Order 5. Xephritis (and Nephria) . . Ischuria Nephria (see above) Diabetes Stone Haematuria Cystitis Stricture of Urethra Hydrocele Varicocele Order 6. (Not applicable to the Army.) Order 7. Arthritis Ostitis and Periostitis Joint Disease Exostosis Necrosif, Caries, &c Order 8. Phlegmon Ulcer Skin Diseases 264 590 55 29 30 16 101 1,862 1 * 129 906 358 15 1 * 251 878 * 9 26 39 * 1 9 139 15 2 25 2 10 8,323 4,090 749 No admistiions or deaths were returned under thi."? head. TO THE registrar-general's FORMS. IX 1 ■ plass. Causes of Death. Admissions, Deaths. Iiv Orders 1—3. (Not applicable to the Army.) Order 4. 214 9 It Order 1. 2,389 9 13 2 6 65 463 0 2 2 0 65 1 Order 2. (It is not stated that all these wounds and injuries were incurred in fighting, but, there being no means of distinction, they have all been referred to this order.) 80 1,453 10,691 1,270 4,006 380 399 4 1 1 1,706 18 21 14 0 0 Order 3. + — + Order 4. 20 20 Order 5. 1§ 1,773 1§ 0 826 345 \ * These are not properly returned, but appear under the collective f "Accidental, Sudden, Ebrietas, and Cold, &c." i t Unsuccessful attempts at suicide were, apparently, not recorded. $ No admissions or deaths were returned under this head. § This case was returned simply as hanging. Note.— The names of certain Orders as well as those of certain specific Diseases are omitted, as not applicable to the Army. X DISEASES OF THE INFANTRY AT HOME ACCORDINC' Classification of Diseases of Infantry of Line serving at Home, according to that of Dr. Farr. If this Classification of Causes of Deatli, as proposedby Dr. Farr, be adopted, then the classes of mortality from dise es most prevalent in the Infantry on Home Stations, as compbd with the extent of the same types of disease in Civil life, at he same ages, may be shewn by the following Table. The differences between this Table and that given at p. 27 will be explained by the two facts: — 1. That the diseases re there classified according to the imperfect system of nomenclaxe in use. 2. That the deaths from accident and " unaccomail for" in the Infantry are there not given, which raise the i-r- tality 1-1 per 1,000. Deaths and Annual Rate of Moetality per 1,000, from all CAiiss, Zymotic Diseases, Chest and Tubercular Diseases, and all OG|tt Diseases amongst the English Male Population, aged (1848-54) and amongst the Infantry of the Line serving at F.« (1837-46). Deaths Annual Rate of Mortality per 1,000 b'g Causes of Death. Of Males aged 15 to 45, in England & Wales during the 7 Years 1848-54. Of Infantry or THE Line (serving at Home) durinsi the 10 Years'" 1837-46. Of Males aged 15—45, in England & Wales during the 7 Years 1848-54. Of Infai.t or the ] E (servin< Home) d ig the 10 Y 3 1837-J All Causes 283,167 2,865^ 9-8 17 'i Zymotic Diseases . . 56,347 659 2-0 4-1 Chest and Tubercular) 130,753 1,612 4-5 10-1 All other Diseases (in-) eluding Violent Deaths f 96,067 594 3-3 3 7 Males, aged ] 5 — 45, living in England and Wales, | , ^ „^ c^o-, in the middle of 1851 / -^'^^^'^^^ Aggregate Strength of Infantry of the Line (serving "I i rn i at Home) in 10 years 1837—46 J ^^^^^"^ Note.— Tiic Deaths in England and AValks (1848 — 54) are taken fi i the 18th Annual Report of the Registrar-General, p. 150^ and the Pop tiou (1851) from the Census Report, Occupations, Vol. 1, p. clix. '.'3 TO THE REGISTRAE-GENERAL's FORMS. XI Deaths and aggregate strength of the Infantry^ of the Line (1837 — 46) are ftaken from Sir A. Tulloch's Eeport on the Health of the Army for 1853, jp, 62 and p. 9, At p. 9, in addition to the 2,683 deaths from Disease (p. 62) [%re returned the particulars of 127 deaths by Violence, leaving, however, 55 deaths unaccounted for — 2,683 + 127 + 55 make the above 2,865 deaths. i Bronchitis and Influenza have no place in the Army nomenclature. The Chronic Catarrh" of the Army Eetums is believed to be really " Phthisis" |in the great majority of cases; "Acute Catarrh" comprehends, probably, both Epidemic Catarrh" or Influenza, and Bronchitis. The 55 deaths from "Acute Catarrh" have been treated as Influenza and referred to Zymotic Diseases. The Deaths from Tubercular and Chest Diseases comprise Scrofula, 24 (including Apostema Lumbare, 10, Hydrarthrus, 1) ; [Phthisis, ],241 ; Haemoptysis, 36 ; Chronic Catarrh, 135; Hydrocephalus, 2; Asthma, 2; Dyspnoea, 7 ; Pleurisy, 10; Pneumonia, 155. The Zymotic Diseases are, as far as the nomenclature allows, the same as those enume- rated in the Registrar- General's 16th Annual Report, pp. 83-5 of the Appendix. APPENDIX II. TO SECTION XI. Sources of the Statistics used in the Sectiott. Sources of the I have carefully collated all the statistics from six differit Statistics. official sources. ' j Inaccuracies The sick appear to have been sent from the front to Balacl a T^. . without any accurate account of their numbers — to have b^n Discrepancies. *' put on board without any steps having been taken to kee]a proper register. The number of deaths on board during e passage is reported different in each separate return. WIq the sick arrived at Scutari, there was, at first, no prc- sion for registering them on landing, or when they we received into Hospital. And, even after death, the only trit- worthy record of the fact was the Adjutant's Head Eoll?f Burials, which exceeded in six months by upwards of 500 ve number reported in the Orderly Eoom as having died in ie Hospitals. While, to complete the chain of defects, the reti i of total sick treated in Lord Eaglan's Army, including in it 1 who were sick both in the Crimea and at Scutari, is used / the Director- Greneral himself as the number treated at Scutil. The Eeturns of Dead at Scutari from Oct. 1 to Dec, I, 1854, vary as follows: — i 1. 2. 3. 4. \ Principal -p Inspector- Medical -REPORTED Burials. General's. Officer's. -L^eaths. Infantry aloni = 910 1,046 1,301 795 The sum of these three months has been taken, in order • cover any unavoidable discrepancies arising from Burials e; taking place on the same day as the Deaths. t Yet the Eetu of Burials exceeds in three months that of Deaths reported ' the Hospital Books by nearly 400. Another reason for taking these three months was, in ord to eliminate the unavoidable delays in reporting from Smyrcj wliere the British Army Hospital did not exist till the middle 1 February, and from Koulali, which was opened December i * Plus one-ninth, roughly speaking, for Cavalry, Artiller}-, and Eni! necrs, vide statement, p. xii, of the Mortality of these Arms at Scuta' These figures are quoted from Sir A. Tulloch. ' + The burials generally took place within twenty-four hours of til deaths. AUTHORITIES USED FOR THE STATISTICS. XIII 854, but contained during tliat month a maximum only of 240 atients. The result of my examination of these Statistics is simply lis — that, however satisfactory they may be to the Depart- leiits who have put them forth, and however correct they lay be, although exhibiting such palpable diversity,— still, to ny one not in the secret as to how things w^hich apparently iffer so widely are nevertheless identically the sairie, they onvey no trustworthy idea as to the sickness and mortality of 'he Army in the East — and that, for any practical purpose, hey are, as put forth to the public, who are most interested in -he matter, but approximations to the truth. I will here put in four sets of returns. Return No. I. Deaths on board Sick Transports, l)etween the Crimea and Scutari. Name of Ship.* Kangaroo Ounbar i^ambria Vulcan A.ndes Colombo Arthur the Great . . Orient Oaduceus Courier Cornwall I'fegotiator .Lady McNaughten 'Australia : Cambria Echunga Palmerston &c. &c. &c. Deaths according to Cumming- Maxwell Return. House of Commons Return. Adjutant' Return. 22 22 10 30 21 18 10 25 15 4 30 30 57 24 50 30 32 or 33 26 45 114 104 16 33 16 6 6 8 6 6 3 g 3 8 3 12 None 7 6 1 11 7 5 I In the Adjutant-General's Eeturn from the Crimea, it will be [seen that the total number of " deaths in the Infantry, from I October 1, 1854, to May 1, 1855," "on board ship or else- I where" (meaning not on the Bosphorus or in the Crimea) is 715. I Returns from the Medical Officer of each Corps serving in * The above comparison is made, taking the first seventeen ships in order as their names stand in the return. The results can only be regarded as approxima- tions. XIV AUTHORITIES USED the Crimea, and from the Inspector- Greneral of Hospitals b Scutari, show that, during the same period, the number f deaths in Cavalry, Artillery, and Eoyal Engineers, was, co- pared with those in the Infantry, thus,* Crimea. Scutaei. Infantry .. 4,963 4,052 Cavalry ) Artillery .. 378 470 Engineers j in other words, the deaths of the Cavalry, Artillery, and En - neers were one-thirteenth of those of the Infantry in t; Crimea, and rather more than one-ninth of those at Scuta, Now the mortality on board ship, including all arms of t^ service, is, according to Gumming Maxwell Eeport. Sept. 15, 1854, to Feb. 11, 1855. House of Commons Report. Same period. ScutariAdjutant's Report. Same period. Crimean Adjut£ General's Eepo Oct. 1, 1854, t May 1, 1855. 923 915 888 716 + T3 or Return Xo. II. From Returns of Adjutant's Office at Scutari.— Recapitulation. Months. No of Burials in each Month. No. of Deaths re- ported in each Month. Excess of Burials over Deaths in each Month. Remarks. Sept. 1854 Oct. „ Kov. „ Dec. Jan. 1855 Feb. „ March „ April „ May 165 266 368 667 1,473 1.151 418 165 76 78 219 291 536 1,360 1,076 416 152 76 87 47 77 131 113 75 2 13 517 of the 545 ha- been struck off tl strength of the Gener Depot, the other 28 we men brought asho: either deader insensibl with no marks to asce tain their names < regiments. 4,749 4,204 545 * 190 Deaths took place in the General Hospital at Balaclava, in tl record of which no distinction is made as to the Arm of the Service < wliich the dead belonged. t The Deaths from September 1 6 to October 1 are reported as about 27! from February 1 1 to May 1 about 27. II FOR THE STATISTICS. XV Eetijrn No. III. /PENDIX TO EePORT mOM THE SeBASTOPOL COMMITTEE, 2kd Eepoet, p. 705. irtjek showing the total numbeu of sick and Wounded treated in Hospital at Scutari : Months, Total treated. 1 ring November 1 854 . . . . 1 6,846 „ December 1854 .. .. 19,479 „ January 1855 .. .. 23,076 A. Smith, M.D., Director-General. 13, St. James' s-j)! ace, 2Sth March, 1855. Appendix to Report from the Sebastopol Committee, p. 470. . 1.— Retukn showing the Total Number of Men of Lord Raglans Army Sick during each Month, from the Landing in Turkey. MONTHS. Total Sick or Wounded of all Arms during each Month. [54, April May June July August . . September October November December '5, January ... 503 1,835 3,498 6,937 11,936 11,693 11,988 16,846] Compare numbers 19^479 1 for same months at 23,076 J Scutari, above. To 17 Feb. ... Crimea ... To 25 „ ... Scutari ... To 17 „ ... Abydos ... To 25 „ ... Gallipoli .. To 20 „ ... Smyrna .. 9,284 6,725 385 70 500 ToTALto latest dates in Feb. 16,964 A. Smith, Director-General. irm-y and Ordnance Medical Department, 14 March, 1855. XVI AUTHORITIES USKI) Return No. IV. Deaths at Scutari and Koulali Hospitals. October 1, 1854, to April 30, 1855. 1. Com- mandant at Scutari 2.* Medical Returns. 3. Head Roll Burials. 4. Reported Deaths. 5. Depot Returns, 6.. Inspe )r- Gen<;.l (Infanr.)t ! November . December . .Tnnnnrv February . . March .... 1,480 1,254 424 250 267 393 1,235 1,329 555 200 266 368 667 1,473 1,151 418 165 219 291 536 1,360 1,076 416 152 213 244 493 1,079 1,254 324 213 \ I! 4,(IJ JRem. 4,229 4,508 4,050 3,820 4,r! At Scutari and Koulali. At Scutari. J The above are the returns from six difterent official sou]?s. * For the first four months of Return 2, read : — October 1 to November 4 250 November 5 to December 2 267 December 3 to December 30 . . 393 December 31 to January 31 1,235 Another Principal Medical Officer's Return shows from — October 1 to November 4 258 being a trifling difference between the two Principal Medical Officers, ut one easily explainable. According to the latter, the Return of deaths - October, 231. November, 279. This Return, however, could not be taken, because there were no meac of ascertaining the mortality, separately, of December 1 and 2. The " Medical Return" (2) for April is only up to April 28, yet exc Is by 35 the Head Roll of Burials, which is till April 30. All other figures are copied absolutely as they were found in the diffe it Returns. t As given by Sir A. TuUoch. X Being Cavalry, Artillery, and Royal Engineers. j ! I FOR THE STATISTICS. XVII le discrepancies in them will no doubt be explained to us at me future time. Smyrna is not included. The Smyrna ospital was opened to sick February 15, and from that day ,1 March 31, 127 deaths occurred, by the Inspector-General's 'turn. Eeturns 1 and 2 purport expressly to be for Scutari ■ d Koulali — Eeturns 3, 4, 5 to be for Scutari alone. Eeturn I'nai/ include Smyrna. Otherwise, being for the " Infantiy " I me, it would prove that a part is greater than the whole. '. r the deaths in the month of March of Infantry alone are pater than those recorded by the other Eeturns in March j all Arms of the Service. However, the Smyrna supposition OS not account for the difference to those unacquainted with i3se matters — as Eeturn 6 is something less than Eeturn 2 ( e Medical Eeturn) for February, although something more !■ March . Some light may be thrown upon the discrepancies in the ]?dical Eeturns, when it is mentioned that, up to a period v'iously stated as sooner or later than Febmary, 1855, the lidical Eeturns of Deaths were made up from the Pur- vor's Diet Eolls, upon which the name of the dead man neared as scratched out, and from verbal or imperfect Iports made by the Medical Officers in charge ; that no ll-tickets existed up to this somewhat obscure period ; and t.t it appears uncertain at what period the ^Medical Officers required to fill up regular Eeturns of deaths. I am 1 to believe this from evidence collected on the spot, Returns 1 and 2 purport, as has been said, to be for both htari and Koulali ; nevertheless the numbers are sometimes ^ ater, sometimes less than Eeturns 3, 4, 5, which purport to I for Scutari alone. Eeturns 1 and 5 show the same for Ibruary, 1855, although purporting to include difterent \ ces. C A li NOTE TO PAGES 315, 316. The AMorNT of the Soldier's Duties as a Cause of ti Mortality in the Crimea. The severe The awful mortality, recorded in those pages, will appe SoldTer^n^the ^^^^ extraordinary when it is seen what the duties of these m(, Crimea. were. The 95th Eegiment, belonging to the Second Division ; tl 50th, 28th, 44th, belonging to the Third ; the 46th and 63i belonging to the Fourth ; the 23rd and 33rd, belonging to t Light Division ; — these ill-fated Eegiments all lost 73 out every 100 men, from disease alone, in seven months. Th. could not, however, have been other than thus swept away for the excessive labour which, in addition to their privatioi they underwent will be seen from the following Extracts :— Extracts. " This will be seen better by referring to a summary of the Return for some of the months, say January, which gives the followi result : — Rank and File. Brigade of Guards. 2nd Division. 3rd Division. 4th Division, Light Division. Total. 1 Effective and present under 1 arms . . . . . . J 948 2,469 2,668 2,332 2,770 11;' Detailed for duty of various 1 kinds daily . . . . J 408 827 1,170 1,431 1,490 5,( * Returns showing the Rank and File in each of the Infantry Divisi* of the Army before Sevastopol. THE SOLDI ER^S DUTIES. XIX ' he results for December and February were much the same as in Jai iry ; indeed, it was not till the termination of the winter, when the lick began to return to duty, when considerable drafts and oth reinforcements arrived, and when a new division of the ground bet !en the British and French armies was made, that any material reh ition took place. ' ne obvious cause of this extreme pressure may be traced to the cir( tnstance, that at this time the number of sick in Hospital and at Sci .ri, considerably exceeded the force fit for duty, as may be seen by e following summary for the month of January : — e4-i O d d d d Brigad 1 Guan t 2nd Divi8i( 3rd Divisi( 4th Divisic Lighi Divisic o Sic) -Present 403 534 1,023 1,004 1,194 4,158 Sic) -Absent 1,063 1,708 1,373 1,802 1,821 7,867 Total Sick. . 1,466 2,242 2,396 2,806 3,115 12,025 ' 0 that the 11,367 effectives shown on the preceding page, had to perrm not only their own duty but that of the 12,025 who were sicl and this, too, under the most adverse circumstances. So large a 1 tnber of sick also involved the necessity for many men being witjlrawn from duty to attend upon them, and increased the pres- sur Dn the remainder. ' he routine of duty in particular regiments is thus described by var us officers : — ' )rd West, commanding the 21st Regiment, states that : — 21st Regiment. ' Those for the day covering party are roused out of their tents at 4 ( lock in the morning' have about a mile and a-half to march doT through snow and mud, and get back to their camp about 7 o'c. ;kinthe evening, being thus exposed in open trenches for 15 toi I to such inclement weather as now prevails. Most of them will go I the following evening at 5 o'clock, and remain out all night till 6 0 ock the following morning ; this routine has been kept up inces- san f for the last six weeks.' ' ieutenant-Colonel Maxwell, coinnianding the 46th Regiment, a .{(jth which was nearly annihilated by sickness in the months of Regiment. (; 2 A 11 XX GREATER MORTALITY OF THE November and December, states that the number of hours his n • were in the trenches in every 24, was 12 in the first of these mon*, and 10| in the second ; and it was stated by the Surgeon and verii by the Lieutenant-Colonel, that at one time the men were in e trenches for six successive nights, and had only one night in bedh the course of a week, but that afterwards the duty was better re - lated. LightDivision. "The duties in the Light Division are thus described by Depy Inspector-General Alexander, in a letter dated 10th Decern -, ]85 i :— " ' In the 7th Fusiliers, men were in the trenches 24 hours, with t relief, up to or about the 17th November : on the 14th two com,- nies were kept on piquet for 36 hours, when, of course, no cook? took place. " ' In the 19th Regiment, taking the total number of hours r November, viz. 720 — 304 have been passed by the men either on djr in the trenches or on piquet, which is 10 hours daily for each n., the remaining 14 being passed in bringing water, seeking for f I, cooking, and other duties, i3 575 587 155 146 161 268 150 193 138 254 189 433 ^ o 600 517 137 121 418 885 169 447 239 331 317 1.136 3,249 4,817 2,144 190 Total. a2m 275 582 258 35 293 379 42 421 I 'i Number constantly Sick. Ifc may, from the data here presented, be probably infei d J that to the excessive mortality (described above) of cer n ^ corps, the condition of the Hospitals at Scutari contribid quite as largely as the amount of military labour. In e extracts presented in the last note too large a share iu e ^ calamitous result has most likely been assigned to the seve pressure of the soldier's duties. „^ A third table, which may here follow, gives a view of e ii amount of men constantly sick, the number of soldiers atil :\ times to be deducted, as ineffective by reason of sickness, fifl the Strength of the Army. ^ There has been no attempt made in any of the elaboie Eeports of Commission, or Comniittee, which have been plai before the public, to arrive at this fact, to obtain an estini.''> •• for the seven months of disaster in the Crimea, of the nunir a " constantly sick." Yet this must, on all occasions, be oncf ABOUT THIRTY-EIGHT PER CENT. XXVII t" most important questions as regards the welfare of an Iny. Che fact is, with our imperfect statistics, it is next to impos- iB|le to estimate the sickness correctly. The only perfectly c rect deduction which can be made with regard to them is 1 1 of a well-known statistical authority : " I do not profess t make anything tally which depends on Crimean informa- tQ." Statistically, the figures given in Table C are certain to be i orrect, although deduced from Adjutant-General's and iidical Eeturns. But, for sanitary purposes they give a ;iijigh idea of the disabled state of our Army d uring the seven 1 nths in question. Table C. Strength.* Sick.t Per-Centage of Sick. Effectives. ) w^ould be also allowed to visit the Dispensary patients t their own homes when it was necessary; the whole unc supervision, as at Edinburgh, of the Tutor. Examiners for 2. To give the Army and Public proper confidence i the Hospital Course as a School, it is obvious that examining body should exist, placed beyond suspicion to capacity and impartiality towards individuals. Tl would be easily formed upon the principle of the grf Endowed Schools of England, viz., the adding to t * Two Chairs of Military Surgeiy already exist, viz., at Edinburgh a Dublin. It is only proposed, therefore, to increase the number of i Chairs bv two. the Annual Examination FOR MEDICAL OFFICEKS. 351 Heil Masters and Tutors of the School a Professor from onfof tlie Universities for the periodical examination. Wli a moderate honorarium, it would not be difficult to obi.n from the great London Schools of Medicine, Pressors of each of the four subjects to assist in the exaination, forming a Board with the Tutors of the Sclol. ^le best men should be taken, and only, if Military aiK Civilian Medical men be equal in merit, should the pre renco then l)e given to the Military. Besides these annual examinations, it is assumed ihi there would be a weekly examination, which would coiist of a critical analysis of the cases of the week with th( Clinical Tutor, with instructional and interlocutory reiirks, drawing out the knowledge of the individual pul, thus affording means for a Book of Remarks to be ke by the Tutor, which, at a future period, would afford thtet of the pupiPs progress ; the existence of the book be g of course known to the pupil, although he would ha; no access to its contents. The same, ccetcris pco'ibuSj weld take place in the Dissecting and Pathological Deartments. The usual certificates of attendance upon L( Lures, given alike in Medical Schools and in the Theo- lo(:al Depart! ucnt of the Universities, afford no other in -mation than that the Student has been present at ce ain courses given by the respective Professors, whereas th register referred to would be an appeal to almost day facts, recorded on the responsibility of the Tutor. The independence of this new Army School of M'licine and Surgery is one of the chief objects to be cc tended for by those interested in its utility, perma- mce and public estimation. Its practical independence wdd involve immediate dependence upon the War Weekly Examination. The whole Institution should be immediately under the control of the War Department. 352 PREPARATORY COURSE. Department, which, in creating the School, would sim. taneously lay down rules for its guidance as well as ' the means of its maintenance and for its influence up\ the Service. In the latter would be involved due att(. tion to the just pretensions of the Pupils, in giving th'il a legitimate share in the turn of appointment on pi. ^ motion, especially during the period w-hich would elap before all the Medical Officers appointed have pass through the Army Medical School. A Senate should ; formed of the Tutors. I The Director- General who makes the appointment to the Army Medical Department, should not interfc' in the Army Medical School, except in so far as havii a voice in the appointment of the Tutors of the Schoc as well as in its primary regulations fixed by the W Department. If it were otherwise, not only the honou and practical usefulness of the Tutors would be interfere with, and the dignity of the Institution, representing tl scientific dictum of the War Department, lowered, bi the power which distributes appointments to vacancie' would take a prejudiced view, owing to its partialities an' partial information of the attainments of the Probationer} the result being that the appointment to a vacancy woul not emanate solely from the testimony given by th Tutors and Examiners on all those points which fori the data for the recommendation of the Probationer t Her Majesty^s Service. ' The present tendency of action seems to be that certaii' things in the War Department can be done independentl;' * The first appointments must be opened to public competition, and thi best men selected. So should the Professorships of Militarj' Surgery, t< which men are now being appointed, be open to all candidates, and no given to favourites. SUBSEQUENT CAREEK. 353 of :s high officers, viz., the Schools at Sandhurst and at W^lwich, the Staff Education (involving a fixed rule) an. the Sanitary Coramisibion in the East ; the above ob rvations are, therefore, not travelling beyond pre- ccynt; and it is hoped that they are supported upon grands of sufficient reason. It will be sufficient to quote the precedent of the Distinctions U] versity of London, to insist upon Honorary Distinc- stud\^^^"^ tics, such as Gold Medals and Fellowships; to the lat r of which, however, may be added Paid Fellowships. Si,pose two a year, up to the number of ten or twenty, pa 25/. to 50/. each, for the junior and senior respec- ti\,y, involving an outlay for the first year of 75/., and aniltimate maximum of outlay of 750/. iter obtaining his first rank upon leaving the Medical Proposed Scpol, the young Officer would become Assistant Regi- '^^"carcen^"^^^ m< tal Surgeon, and in due course. Regimental Surgeon, or,:s equivalent in rank, 2nd Class Staff Surgeon. On Duties of the beig promoted to 1st Class Staff Surgeon, he would find o^^/^ri th the duties, now performed bv that grade, have been Regimental ^ ^ ^ cj Surgeon, al )st entirely undertaken by the Steward of the Hospital as 1st Clas an the Governor. He would still have the power of ^ ^.^^ Staff Surgeon, ■r in a rorting and making requisitions, and his duties would ^^^^^ be. hose of really superintending the medical treatment of lie sick ; he would treat a certain number of Patients, wii an Assistant Surgeon attached to him; he would also be Consulting Surgeon ; he would assist on Boards, for di'harge or inv aliding, if he himself be the treatmg 0 cer, with another ; or if he is not the treating Officer, inonjunction with that Officer ; and the Governor being, 2 A 354 TTTE FIRST CLASS STAFF SURGEONS ex officio, tlic reporting Officer, in cases of discharge, 1', as recording Officer would be, in these cases, the thit Member on the Board, or as Inspector If Called to administer the superior duties of seve j Re<^hnental I^cgimental Hospitals of a Division, instead of those f Hospitals of a one General Hospital, he would assume the title, pro tei, of Inspector, and be at the same time Consulting Surge* of the Division. As Inspector- There would, of course, be an Inspector General for t) Exp'dltZr whole Expeditionary Force. When the Army was disbanded, these two last bei; only temporary ranks, the holder of them would remr 1st Class Staff Surgeon, with his actual services recorde the advantage of which would be that, in future appoii ments, the whole of the 1st Class Staff Surgeons woi; be open to the choice of the Director General, witho his being bound by the trammels of rank or seniority. As Pathologist The office of Pathologist would be discharged by 1st Class Staff Surgeon, the Medical School excepted. There would be one in each General Hospital, wl, while acting as Pathologist, would cease to treat t Patients. This would be necessary, in order to keep 1 Pathological Reports above suspicion. It is understood that in the Medical School, and in ai of the General Hospitals, there would be an Apotheca with his Dispensers, as by the regulation of the la war. With all Regiments, too, there ought to be some one '\ dispense, not however having the rank of a Commissionc; Officer. Comment on Upon all this it is to be remarked, that the object the proposed . j. ^ Plan. ^ot to have one name or another lor any rank, but to r duce the Superintending Ranks and increase the Executi^ ones. SHOULD ACTUALLY PTIACTISE. 355 ] t the 1st Class Staff Surgeon be an execntive Officer — i matters not then what he is called — let him prescribe for atients, in the same manner as Surgeons and Phy- siciis do in Civil Hospitals. Let there be Assistant Sufsons, in charge of a certain number of Patients^ who acc apany the 1st Class Staff Surgeon in his visits, take iov his prescriptions, diets, &c., for the Patients, and see tlie carried out ; who also register cases of importance, not as at present, any case that comes in ; this occupies mu valuable time, and is of no reai use. The Admis- sioiind Discharge Book is all that is necessary for the ^re er number of cases. * I the 1st Class Staff Surgeon is made an Executive Offibr, then there will be only two superintending ranks, whii is all that is necessary, and the numbers in each of the would thereby be increased. Too few boons already The 1st Class should be Executive Officers. Leaving only the Deputy Inspector- (Jcneral as Superintend- ing Officer. • A. FoRTEATH, Esq., Surgeon, Royal Dragoons. Camp near Kadehoi, Crimea, January 15, 1855. S] —In answering the queries of the Commission, I find by the copy that have retained, that I omitted to offer a suggestion, which I humbly conci/e would be of some importance; viz., — T fc every soldier should be furnished with a book, similar to his ac- cour book, in which each time he was admitted to, or discharged from hoapil, should be entered along with columns for disease, when and whei contracted, exciting cause, symptoms on admission, peculiar symp- tomi reatment, result, duration. This book to be in place of medical regi rs, which might be reserved for uncommon cases and for deatli repo5. The book to be kept either in the possession of the hospital serg at, or troop or company Serjeant, and to be produced each time the man jports himself sick. B ,his means the man's previous medical history would be soen at a glan —a great help to a medical officer, who has frequently great diffi- cult; ,t arriving at the truth, especially on being newly appointed to the regii'int, and with men sent to general hospitals, or in invaliding. I have, &c., (Signed) A. Foeteath, M.D., Surgeon, Royal Dragoons. 2a2 356 SCALE OF PAY. exist in the Service, to induce the best men to enter or j remain in it. Let good selections for promotion be mac and there is no danger of men being unfitted. In tl case, it would be ungracious to replace a man in inferior position. It would also prevent men from acti independently. They would be too much under the pow of the Authorities, and too many now, it is to be fean would act so as to please them and thus to obtain otli; good appointments. In proof of which, how few m spoke out in the Crimean war, and how are these ni treated ! | Thus, should the government and direction of the Art . Medical Departm^ent remain as it now is, but the 1st Ch Staff Surgeon be made, as he ought to be, an Executi Officer, the Deputy Inspectors General and Inspectc General should be continued, as they now are, as p( manent superintending ranks, should be increased I numbers, and the choice of a Principal Medical Officer i : any Expeditionary Force be unlimited among them. Consequent It follows upon this arrangement that a different m J^ew Scale of . ^ ^ Payment. and principle of pay should be adopted."^ Assuming that an Acting Assistant Surgeon coutinm upon this rank during his stay in the Army Medid School, he would receive 5^. per day and his quarters ai rations ; and 7s. per day, with quarters and mess-mom for the first three years as Assistant Surgeon. After 3 years 10^. * The suggestions made by the Army Medical Officers themselves < this subject are annexed. It will only be remarked, upon these, that tb have strong grounds of justice : for, no comparison can fairly be instituU between Medical and Military Officers as to pay. The expensive educ tion of the former, their comparative age,— the Ensign often entering . SCALE OF PAY. 357 igimeiital or 2nd Class Staff Surgeon : Under 10 years 13^. After „ „ 155. 15 „ 195. „ 20 „ 22s, „ 25 „ 24s. .'ter 15 years' service, the Regimental Surgeon should ha^ the relative rank of, and the 2nd Class Staff Surgeon be fomoted to, I'st Class Staff Surgeon. hile serving in tlie office of Inspectors of Division, or Inspector General of an Expeditionary Force, such pafand allowances should be granted as should be con- sid ed proper during the service. ' le half-pay should be two-thirds of the full pay of the rai and time of service. ?e of 16, the Medical Officer at the age of 23,— entitle the Medical Be]rtment to a higher rate of pay. Su( stions for the Improvements required in the Pay and Status of Officers of the A rmy Medical Department. 1 Chat the following changes be made in the Titles of Army Medical Off rs:— Agf t. Staff Surgeon Ass t. Surgeon .... Regt, . . Sui;on Regt. . . S*aj Surgeon 2nd Class. . Sta[ Surgeon 1st Class . . Berty inspector-General i Insiictor-General to remain unaltered. to be styled Staff Surgeon. Brigade Surgeon, or Sur- geon of Brigade. Division Surgeon, or Sur- geon of Division. Surgeon General. 358 STANDING COMMISSION. Sunding As it is necessary; both for the good of the Service a| of Ii^pection, the protection of the Soldier, that absolute uniform" 2. That the following be the relative Rank and Pay of different grades • Assistant Surgeons. Relative Rank. Daily rate of Pay. On first appointment. After 5 yrs. service in rank. On first appoint- ment. After a full pay servi in the rank 5 years. 10 yean Lieutenant Captain. {a) 10s. (&) ll5. 6d 13.?. (a) This ammmt of p'ay is considered but a fair remuneration in con quence of age on entrance, speciality of Education, and inability ' sell. {h) As corresponding to the pay of a Captain, which rank they are reco: mended to receive after 5 years. 3. Regimental Surgeons, and Staff Surgeons 2nd Class, or, according proposed Title for the latter, Staff Surgeons : — Relative Rank. Daily rate of Pay. On first ap- pointment. After a full pay service in the ran 3 years. 6 years. 9 years. lis. Qd. 205. 225. Qd. 245. 4. 1st Class Staff Surgecms, or Brigade Surgeons: — Daily Rate of Pay. Relative Rank. On first ap- pointment. After a full pay servic in the rank. 3 years. 6 years^ Lieutenant-Colonel, with a step of rank after 3 years' service under the same conditions as the more purely Military Officer. 255. 285. 30*. STANDING COMMISSION. 359 ii lie Military Medical Service should be kept throu"-li- oii, and the talents^ acquirements (by service or otherwise) ai assiduity of the various Officers should be perfectly wl known and reported by fitting authority, it may be ill rred that a Standing Commission of Inspection is the b( if not the only, way of securing these advantages, at le t under present arrangements. ts duties would be pretty well defined by saying that Duties, tlv^ should be compounded of those pointed out in the Iitructions of tlie three Commissions of J^lnquiry into S - tari Hospitals, into Supplies of the Army, and of Sani- taV Enquiry, minus the Executive Powers which were eilrusted to those Commissioners, with a view to remedy Li isastrous and urgent state of afi'airs ; if such strong Deputy Inspector-General, or Division-Surgeon : — Daily Eate of Pay. H Relative Rank. On first ap- pointment. After a full pay service in the rank. 3 years, 6 years. 5J»nel 32s. 35s. 37s. 6d. Inspector-General, or Surgeon-General : — 1 Relative Rank. Daily Kate of Pay. On first ap pointment. Without further increase. Wor-General 50s. . Half Pay.— Medical Officers of all Ranks to have the unqualified ri'it to retire after 20 years' full pay service ; on pay according to the si joined scale. After 35 years' full pay service, retirement to be compul- 3<, for all Ranks. 360 STANDING COMMISSION. 1 and additional powers were wanted, they could always je added by the Executive, for the special occasion. i Scale of Half Pay after Full Pay Service in all Ranks I RANK. Under 5 years. Between 5 and 10. 1 Between 1 10 & 20. Between 20 & 25. Assistant Surgeon— Regi- T on retirement mental and Staff 1 on reduction s. d. 4 0 5 6 s. d. 4 9 6 6 5. d. 5 6 7 6 s. d. 6 6 8 0 i Surgeon — Regimental and f on retirement 9 0 11 6 11 6 13 0 15 0 18 0 11 U Staff Surgeon, 1st Class, J on retirement or Brigade Surgeon . . . [ on reduction 14 0 16 0 20 0 22 0 25 27 Deputy Inspector-General, / on retirement or Division Surgeon . . [ on reduction 19 0 21 0 25 0 26 0 30 32 Inspector-General, or Sur- / on retirement 35 0 37 0 40 42 8. Relative Rank. — To have effect in choice of Quarters— In Lodg: j — Servants— Forage and Field Allowances — Honorary Distinctioni i- Brevet Rank — Funeral Honours— Good Service Money — Full Pay Ret: ^ ment — In mixed Boards — Courts Martial and Courts of Enquiry. Medij Officers have no desire to sit on Courts Martial, or Military Courts f Enquiry, but if required by Military Authority so to do, to assume i) position, and take place according to relative rank. ; 9. On Courts Martial for trial of a Medical Officer, and on Coul of Enquiry concerning the conduct of Medical Officers, and the natii of Hospital and Medical occurrences, a portion of such Courts to Medical Officers. 10. That a medical charge allowance, equivalent to a command allc ance as given to the more purely Military Officers, should be granted I Medical Officers under similar circumstances both at home and abroad, j 11. That Medical Officers should not be called upon to perform exf I duties without receiving additional pay; when other Officers in the An; in similar cases receive extra allowances. j 12. That there should be a defined and limited period for holding i stations both at home and abroad. 13. Any Officer who on his turn for Foreign Service arriving, shall 1 found unfit and never likely to be fit for Foreign Service, to be placed ( Half Pay until sufficiently recovered to take his service abroad. 14. That the leave of Medical Officers should be the same as that PERIODICAL AND SPECIAL INSPECTIONS. 361 I 'WL the British Forces extend over every part of the Periodical wild, it should be so arranged that every Force should beisited by a Commission once a year, the Commissions ^be g perfectly similar as to the Instructions given them, ar their own rules of conduct, and taking different Divi- s of Inspection in successive years. ; may be doubted whether, in the Australian Colonies ar New Zealand, where the Garrisons have been so gi tly reduced, and are likely to be still more so, as the C( )nies become progressively self-protective, a Commis- si( with identical duties could not be formed by the G ernors and Chief Military Authority. India would, of cc'se, form one District, including all its Presidencies — €i ada and the West Indies would form another — Great B ;ain and the Mediterranean Commands might be in- nlled in another. Much time would be saved by for- m'ding a set of preliminary questions, so that the answers OtJ Officers in the Army, and that a certain proportion of Medical Ofers be allowed to study in some of the larger schools at home or abid, on the same principle that Officers are permitted to complete their edation at Sandhurst. . That Medical Officers be relieved from the duties of Dispenser and Clk, and that competent persons be appointed to discharge those fu ions. . That on War Service, the Transport for the conveyance of Medical St s and the Ambulance for the carriage of the Sick and Wounded, be a di ict branch of the General Transport Service, at the immediate di ^sal of the Chief Medical Officer of the Expedition in communication w the General Commanding ; and that also the Provisioning the Sick Ijt ntrusted to a distinct branch of the Commissariat under the super- in idance of the Chief Medical Officer of the Army. . The principle adopted in these recommendations is, that Medical 0 ;ers, without assuming the power of military command, should receive thsubstantive advantages and privileges corresponding with their relative n . These suggestions arc further based upon the resolutions laid before P lament by the Select Committee of the House of Commons, on the J iical Department of the Army, dated the 3rd July, 1856, of which A usTus Stafford, Esq., M.P., was Chairman. 362 PERIODICAL AND SPECIAL INSPECTIONS. I should be ready on the arrival of the Commissioiien:and every available means should be taken to shortejthe periods of enquiry; so that what would become an amal duty should be effected within a reasonable time jund > without unjustifiable expense. i Speeial Besides the periodical Inspections, it should be ^iftin . Inspections, the power of the Commissioners, either in consequeni' of: an order, or on sufficient evidence of the desirablem* of a visit, or mei^o motu, to make any special InspecMi; in the last two cases, of course, specifying afterwardsAyt such expense was incurred — for an Inspection, unexp ted and without notice, is far more valuable than any Reports." the Military and Medical Officers : but its efiPects arevy FtcZe Stafford's . Committee, difi'crent. Among Military Officers, if a '^Confidenl Sir G Wethcrall, p. K.eport is made to the Commander-in-Chief, by a "^Qo^Q^ Qo?-^^^' manding Officer against a Subaltern, the matter, if ct 3272-3. sidered sufficiently important, is referred back to the Cc-fi manding Officer. He is instructed to inform the Subaltn of the charge brought against him — a Court of Enquires held, and the Subaltern has the means of explanation. > 1^ On the other hand, if a "Confidential Report'^ is mji to the Director-General, by the Principal Medical Offic,# against a Medical Officer, the latter may see for years promotion deferred, but will never know to what this^ ? due, nor of what he is accused. He has no means of j • Dr. A. Smith's * Dr. Smith admits that " the Principal Medical Officers varj-, like Opinion. other persons, in integrity as well as in capacity/' that " there might ; charges brought against medical officers who are perfectly guiltless, which may stand as bars to their promotion, and which charges they n never hear of." He admits that " Confidential Reports" are made only ' to general conduct and general efficiency of a medical officer ; not aa ^ stance does he recollect^ in his time, as to any extraordinary manner | treating the sick." He says " they do not descend into particulars minute as the treatment of diseases"— the very particulars, one would hi thought, which Avould have been the most useful ones in the " Confident i Report" of a medical officer to his medical chief, upon his subordinates. He says that the " established rule, with regard to promotion in t higher ranks, is selection," that he " has occasionally taken seniority of ra' as his guide, but that he is not justified in doing so, because he is told tl the filling up of the superior vacancies is to be by selection ;" that "in t case of appointing Dr. Hall," he made use "partly of selection but prin of seniority of rank." ' SYSTEM OF CONFIDENTIAL REPORTS. 379 tifug himself. It is a complete " Inquisition" affair, and hes wholly au secret.'' And these ^'Confidential Re )rts," as well as other reports, examinations, inspec- tio &c., are by no means so framed as to determine wh a candid ignoramus would think the inspections of thePrincipal Medical Officer should determine, viz., the FwZeStafford's prissional capacity of the Medical Subaltern, his treat- 23!^Q?^32T-8^ me: of disease, surgical skill, medical knowledge, &c. The inspections and reports refer to his conduct, of whh it would appear that the Commanding Officer would be le better judge, and even to such matters as neatness in laking out Returns, Diet Rolls, &c. without blots, thciorder of the beds, the arrangement of the medicine bol es, &c. '1 the other hand, the Commander-in-CIiief, according r/^Ze Stafford's AT Ti Committee, p. to le evidence oi the Adjutant-Cjreneral, exerts but little 193^ q. 326O- autority over Medical Officers, as the Director-General carsave a Medical Officer, who has committed an offence tht) might be followed by a Court Martial in a Military Ofi:er, by transferring the offender to another Regiment, if , Regimental Surgeon, to the great scandal of the reebctable members of the profession. And, while, on ac(ant of the few unfortunate instances which have occrred, a Medical Officer is not allowed to have more thi a bottle of wine in his possession, for his sick, for feathat he should drink it, a Staff Surgeon 1st Class has her|L knowuj after eight months^ drinking, to cut his thi at in a fit of Delirium Tremens. ere the responsibility of the Director-General full and opi , these things could not happen. But it is a system of ' Confidential Report/' a system where one man tle nds upon the personal judgment (not to call it fancy) of ne man, and where there is neither the control ot 380 SUMMARY OF OBJECTIONS TO public opinion, of the rule of seniority, of private comjti- tion nor of public examination. It is impossible that science can prosper under sm a system. Again, the Regimental Surgeon is much more inde dent, much less looked after (necessarily) than the Class Staff Surgeon in a Hospital. Yet, instead of tr ferring the peccant member to the Staff, where he wdji be inspected, it is to be feared that he is often transfej to another Regiment. And here we are speakingii deference, not in opposition, to the feelings of the n respectable and far larger portion of the Med Department. Summary of ^P^ ^^^^ summary I am expressing Objections felt views of nilie-tenths of the most honourable and ab. to the present -n/r t i -r^ System of men of the Army Medical Department. dence asTt ^^^^ objcct and glory of the medical profession would be obviously, medical skill and practice. If a good Mei exercised in . . . . General Officer be appointed to do something else, his services ki^which^' which he has spent his life in acquiring, however, a) one, There is, doubtlcss, a portion of the Army Medi the Medical . i Officer could Department who like to keep the housekeeping and bo( Professional^ keeping in their own hands. They think that it multipl Sphere. ^]^q number and the powers of the department. Thisii: very small portion. But they do not consider how imp siblc it is to raise the true dignity of the department, » attract the best men into it, as long as this is the case. To make high-priced labour do what low-priced labor can do, to make men at 7s. 6d. a-day do what men - Is. 6d. a-day could just as well perform, is the true w to degrade a scientific department. But I do not see how it is possible, without the orj zation of large permanent establishments, in which THE PRESENT SYSTEM OF SUPERINTENDENCE. 381 per administrative staff could be trained, to make army surgeon other than a sort of maid of all-work, e real objection to General Hospitals in the minds f'Army Medical Officers, is a most legitimate and HI tiswerable one under the present system. . Regimental Surgeon is master, as he ought to be, ofjhis own practice in his Regimental Hospital. The pr';tising Surgeon in the General Hospital is not. With, the slightest knowledge of human nature, with th commonest sense, it is obvious that the inspections, as ii( conducted in General Hospitals, the system of super- inindence and subordination of scientific acquirement to rac, must destroy in a man his sense of responsibility, ar (the most important quality, the latest acquired, in a mi of action, which a medical man must be) his self- re mce. therefore, do Surgeons under the present regime most reonably and justly object to be anything but Regi- m|ital Surgeons. inspections ought to be merely for the purpose of corseting facts, with the view of enabling the authorities toct upon them. he sole purpose in educating and examining the Mlical Officer is to fit him for medical practice. If he is j3t fit to practise, he is not fit to be a Medical Officer : m yet, he is to be subjected to weekly interference in hi;)ractice and in petty details much better left to himself. !he only rationale of superintendence is, when it comes frd a superintendent better qualified than the super- ininded, which the treating Surgeon, in the Army Mlical Department, does not feel to be the case in most infances. For the superintendent has, in most instances, ce ed to practise, he evil inflicted bv the "confidential reports'' is not I 382 GRIEVANCES IN RESPECT Promotion. SO much the injury to individuals, severely as this is soi . times felt, as the lowering of the whole moral tone of j| department, the danger of depriving a man of his scientiousness, his sense of responsibility, his true dign: For Army Medical Men are like all other medical m And such interference with their practice and their rej tation would be fatal to all. No increase of pay will ra the department while these things are suffered to ex; It is a working in the dark,^' an undermining injurious to the essential honour of this or any ot department.^ Pay and The grievances of which all Army Medical Offid complain, are The system of administration at the War Departm© including as it does Uncertainty, Apparent injustice. An offensive system of inspection, t Promotion to the Inspecting Ranks of men who ha not the confidence of the profession. Insufficiency of pay. The apparently unfair length of time before retiremei Insufficiency of rank. The Director-GeneraPs proposal of an improved sea of pay, the annual cost to the country of which would 1 £217,763, or j850,000 more than the present rates, presumed to be the salve to all the wounds. * Throu£!:hout the evidence taken by the late Committee on the Am Aledical Department, it appears assumed that Confidential Reports a made solely by superior Medical Officers on their juniors. It would co duce to Her Majesty's Service to ascertain Avhethcr or not Confident!. Reports are made generally by Medical Officers on each other; and i ascertain to what extent confidential reports are made by Members « local Heads of other Departments, on Medical Officers and other serran of Her Majesty, stationed or not stationed in the same Hospital as tl: makers of the Confidential Report. OF PAY AND PROMOTION. 383 cei is remedy would, however, have no effect upon the coititutions of honourable men ; for his panacea is mtily more pay and vanity. I any future re-arrangement of the pay and promotion, pears to be necessary, Changes, That the Medical Officer should have a reasonable linty as to his rise in his profession. That the principle of seniority should be strictly adjired to, except in the Inspecting Ranks. That the present anomalies, so much complained of, of uniors in rank receiving the same pay as their sujriors — of seniors being inspected as to their medical trenment by juniors, should be avoided, and that, as far aspcticable, every step in the progress of the Medical Ofier, from his entering the Service until the period of is being selected for the rank of Deputy Inspector- G^eral, should be fixed by regulation, known to the wile service, and adhered to. That in every instance of selection, and in every insLUce of recommendation for honours, the reasons sh(|ld be stated fully in writing, and made known to the Splice ; and that, in any case where any charge is made agjjast any Medical Officer, likely to interfere with his int ests, such charge should be made in writing, and coimunicated immediately to the officer against whom it lia: )een made, and that, in any record of the charge, the an^ er to it should be given verbatim. 'le Army Medical Department is not the only one, 111 hich discontents prevail from similar causes. The Ditrict Poor Law Medical Officers have constantly com- plajied, for many years past, of the small amount of reijineration allowed for their services, and of the treat- loA they have received from guardians and vestries. ' le evils, resulting from such differences, have been so 384 GRIEVANCES IN RESPECT great that nothing short of the poverty of the Me cal » Officers, or a humane desire to be a martyr in the jbseiil of the poor, would have ensured the continuance o jtheyo services of these men. i One of the most common objections, stated by the oor | Law Medical Officers, is that their opinions in majere 1 with which they are most conversant, are disregarded) their recommendations treated with contempt. There is thus a close resemblance between the a of discontent in both professions. It unfortunately happens, however, in the Army, much of the discontent is occasioned by the admii tion of the department itself. And the result is that esprit (le corps, A\hich it is desirable to uphold, is large extent wanting. It has been stated before a Committee of the Hi of Commons, that the interest of the service reqi a departure from rules. It must appear, to all who j well considered the subject, that the interest of the sej can only be guarded by laying down rules and by adhe to them. The true principle upon which promotion should ' appears to be the following : — When young men enter the Service, they have t| experience mostly to gain ; and it is not until after years' service that the true capabilities of a man ca: ascertained. The highest capability of a Medical Offi the capability of treating the Sick and Wounded, no man should be selected into the inspectorial rankw this account. The inspectorial talent, which is the (|j talent that ought to form the basis of selection into rank, is one which, in tlie vast majority of instan,i8>( requires age for its development. It would be perfectly safe, therefore, to give the p i- OF PAY AND PROMOTION. 385 pie of seniority free course, until a man, by length of rvice alone, arrives at the highest executive rank. Selection to inspectorial offices should rest upon this inciple, that the Director- General, being himself person- y responsible for the administration of his Department, ould have the power of selecting his representatives, it, at the same time, the Army Medical Service should '•Id that its interests, in the executive ranks, are tho- ?ughly protected against what it might consider an invi- ( ms interference with its rights of progress by seniority. Confidential Reports must be utterly abolished. No Urease of pay will compensate a man for a stab in the (■rk ; and every statement to his prejudice should be sent i ^rbatim to him directly for a reply. It may be expected, under an improved system, that a Itter educated, more intelligent and honourable set of Bn will enter the Service. But we must not expect to (tain such a class solely by increase of pay. The class ^; are most desirous of obtaining consists of those men HO, while they look for a fair remuneration for their r rvices, look at least as much to fair, honourable, and ■ ^ntlemanly treatment, and a proper recognition of their 5 -vices, as amongst the most prominent reasons for (siring to enter the public service. As to Substantive Rank, would it not be much better Substantive Kank. i every sense for the service that the Medical Department sbuld be quite separate and distinct from the Army? tlit it should devote its whole time to the prevention and Cre of disease, and not be called upon to perform any cities which are now discharged by Officers in regi- Ants? fThe principle of substantive rank infers a greater or less c regard of the specialties of the medical profession, and 2 c 386 RELATIVE RANK. ( IS treat r eman, l,r it, shoi] h a greater or less participation in military duties, for wliii f the Medical Officer is not competent. Would it not be better to limit the ^Medical Office: duties in regard to all courts and boards, simply to appef ing before them and giving advice and information wh required ? Relative Rank. With respect to Relative E-ank, the true princij appears to be this that, while the Medical Officer is treat as becomes his education and position as a gentleman relative rank, and the advantages following from be at least one grade lower than that of the Commandii f Officer to whom he is attached. It would not answer in practice for the Commandii^ Officer to be a Brigadier General, and the Chief Medici r Officer to be a Major- General. • - If the Army Medical Department were, as it oug' ^ to be, totally separated from the combatant part of t.l Army, its true position, in the Army List, would be o of the Army hierarchy and apart by itself. i Addenda as to the Organization of General ft Hospitals. I s A» there must It docs not appear to be necessary to raise again an o' ^ Ho?pitaK discussion whether there ought or ought not to 1 ^ ^^thcir Greneral Hospitals, because there must be General Ilospitai Goveinmcnt Experience has established their necessity in every wa If they arc an evil, let the evil be made as Hght ■ possil)le by good organization. ^ But this has not evrn ])ecn attempted. And in whs' I war have not our General Hospitals been signal failures' " Take tlie early part of George II.^s reign, take Cuiinbr . take the last and most fatal instance — Scutari. IB ncecbsary. GENERAL HOSPITALS. 387 this has been the case, and as this always will be the ca ; until some scheme for their government be formed, ; not advisable at least to go into the question of the IS oijmization of General Hospitals. reneral Hospitals at the base of operations, where this is i a distance from the Army, must necessarily fall th|)ugh, between the two authorities, the Commander ofithe Forces engaged in active operations, and the Dtartments at home, unless there be a Governing Head wii commensurate responsibility on the spot. ' it is said that the General Officer commanding in th district is the governing power, it is obvious that the Cdimander of the Forces will give the man least wanted in [he front for the purpose. A Governor sent from h0^.e for the Hospital (and that alone), known for his poiers of administration, might have a chance of being ap,)inted on account of efficiency, and not of inefficiency. 1 all similar institutions we seek for an executive a single he I, to be on the spot in order to answer for failure, ^^^f/ttr^"^ to lave the unquestioned responsibility of governing — Governor, a jsponsibility which shall be his and no one's else. ' the experience of the failure of the Scutari Hospitals wiinot teach us this lesson, no stronger argument can be US( £|Hch an Officer should have full power to obtain — His Duties. Labour, Transport, Supplies, t labour and land transport by hire when not obtain- from the Military Train. The sea transport he must oiin by application to the Admiral on the station. His •lies must not be dependent on the irresponsible imissariat. But whether his steward be a Commis- 2 c 2 388 ADDENDA AS sariat Officer detached for the duty, or a Purveyor, is n, --^ the place here to discuss. If it is feared that there will be clashing in the mark ^' with the Commissariat, it need only be mentioned th\ ■ the articles of supply for a Hospital are different frc i" those for an army. The French bake a different bre for their Hospitals ; and we are allowed, as it is, to gi^ Id. per lb. more for our Hospital meat. s That the responsibility for all supplies should rest up( ^ one person and not upon two, as at present (viz. t Purveyor and the Commissariat), seems to be an axic in Government. At least we may leave the onus of di ' proving it to be so to others. i! Care of Civil A Civil Hospital has one treasurer, who administers t] Hospitals, fiiiance of all the wards. It has one Committee, wl manages the supply of all the wards. It has or is Secretary, who manages the correspondence for all tl wards. It has one House Governor or Superintendei i for all the wards; one kitchen which cooks for all tl 1« wards; one laundry which washes for all the wards; oi' ) surgery; one apothecary; one pharmacy and laboratoi i for all the wards ; one set of attendants, under one head « ene set of accounts ; one system of supply. It has on set of officers; one operating theatre ; one dissecting roon i There is not a bad case in the Hospital which may nc 1 have the advantage of the advice of all the best officei 3; in the institution; there is not a surgeon or physicia:' -i who may not be called into consultation by all the rest f I have never known an instance where the interests of \ patient were sacrificed to the interests of an individual \ officer. So strong is the professional spirit in Civil medical i life, that the experience of each man becomes the commoi i\ property of all the rest. There is nothing like this in th( ^ Military Hospital. ■I TO GENERAL HOSPITALS. 389 ,^he Director- General has admitted that Scutari was a ^'I'owded and polluted Hospital/^ but the remedy sug- gtlted is sending the sick home, and this on March 16, li5. t would have seemed as though the remedy would have b|n that of some scheme for governing the Hospitals, iijuding that of sanitary reform. [Vere such a scheme established, and were also a com- f^;e sanitary element organized at home, the necessity ola standing Commission of Inspection, as hereafter acjocated, would be greatly diminished. !'he duties of the Governor have been fully discussed in mother place, as also those of the Sanitary Officer. Adenda in Illustration of the Utility of a Standing Commission op Enquiry. ^he utility of a " Standing Commission of Enquiry" in} Military Hospitals, or of some similar authority, be advocated on the grounds of the example afforded b Scutari ; and, so far from this being a bad one, it can sc|:cely be hoped (even if a campaign were to take place aiong the towns of Belgium, so thickly scattered over the cCfUtry), that any buildings could be found approaching incapacity and good arrangement to the Barrack and Gaeral Hospital erected by Sultan Abdul Medjid, the foner being calculated to hold 10,000 troops. It fell to tl lot of our Army as a Hospital, after the breaking-up of our adjacent Camp, and the moving of our base of 0{irations, successively to Varna, Old Fort, and Balaclava. t1 General Hospital was full before the battle of the Ajia, with the exception of about 300 beds. (The Sitan's Quarters, in both Hospitals, were reserved). A A Standing Commission of Enquiry would have been of the greatest service at Scutari. 390 ADDENDA AS TO THE USE portion of the Barrack was required for stores ; and neaij W a third was in such bad repair as to be unfit for t accommodation of sick. In this state of things, ti wounded from Alma arrived in such a condition that was absohitely necessary to land them, and sick ai i^^ wounded continued to arrive till the end of Septembd 0^ and all through October, till a mass of wounded agaiJO arrived from Inkermann, November 9th. Yet, di this period, the Commandant and Medical Officer h no means whatever of practically enlarging the bui by repairs ; and, amidst their doubts and difficulties^ they issued no peremptory orders to the Purveyor fBif the cleaning out of the portion fit for the reception 1 the sick and wounded. The doubts, indeed, were sufij^if ciently serious to have justified the (then) Purveyor iic refusing such an order, unless either of the above-name Officers would make himself personally responsible. 1 Had a Commission or Governor existed, not only woiii ti the requirements of the sick have been clearly foreseei i but, at any rate, upon the embarcation at Varna, tl ;i authority and funds would have been present to carry 01 'ii all the necessary preparations for receiving the sick an -\ wounded, with the ample means which existed close to : ^ capital of G50,000 inhabitants, by which very means whi was afcrwards done was actually eff'ected. Even before the Battle of lukermaim had been fough the British Ambassador had received orders, which m i only enabled but exhorted him to provide for the wants c t the British Hospitals promptly and Hbcrally. Nothing : however, was practically done ; farther than a diplomatii i invitation to the Seraskier's Department to repair tb' Barracks, to which the Seraskier replied by that deman' • for time and consideration, wliich is the first form c Turkish etiquette. A few days after the wounded arrivedi OP A STANDING COMMISSION. 391 question of repairs was urged upon the Ambassador ; neither by Commandant^ Medical Officer, nor Fur- or. After another delay, the hopes of negotiation were ai ndoned, and the repairs ordered. In the meantime, sick had greatly suffered from over-crowding, in Lip and ruinous quarters. By the energy of the Engi- nr Officer, the repairs were eftected with 100 Greek kmen, and six or seven Sappers and Miners. The r{|irved Sultan's Quarters were then obtained, by the irprference of the Ambassador, on application, but not mjie by the Authorities above cited. As to the furnishing oil the necessaries for the Sick and for the Extra-diet Kchens, formed by the Nursing Establishment, which w e refused by the Purveyor, the Ambassador sent articles to the value of £S3, according to a list furnished him. Viien the enormous wants of the wounded from Inkermann a] eared, a second and larger catalogue of requirements was fcirt^arded to him ; of which the Ambassador, after a fort- n|ht's delay, with great civility, acknowledged the receii)t — t was the only answer received. is it was already ascertained what the Purveyor would ai| what he would not provide, the wants of the sick and wimded, proved by the Requisitions of the Medical Oicers, were supplied from sources not official. — Vide " fospitals Commission'^ Report, 1855. rom this short abstract of events at Scutari, from July tCj^SFovember, 1854, it will be seen that every one of these gilat evils, the weight of which was partially prevented ftjn falling upon the sufferers, would have been entirely a]Bsted, had a Standing Commission, such as has been bibre described, existed ; or a Governor, with commen- 81 ate power and responsibility, on the spot. The want o:/igour would have been supphed by a normal authority, ejjanating from the proper source— in other words, from 392 WANT OF A STANDING COMMISSION the War Department, — and forming in fact a compomt part of its machinery. Correspond- The letters of Lord Stratford de Redcliffe and Dr. M{. Sfordand ^^^^>^ ^^^^ October 24, 1854, the Ambassacr Dr. Menzies. at Constantinople had announced to the Chief of Hospitals at Scutari the power he had of supplying th wants. But this officer (34 days after the Alma 27 days after the occupation of Balaclava and the co mencement of the siege) denied that they had pressi wants. These letters shew that the Ambassador's letter November 2, partially replied to on November 5, receiv a further (still inadequate) reply on November 20, after order from Head Quarters, dated November 12 ; co sequently, the Principal Medical Officer practically refu to acknowledge the Ambassador's supreme authority supply. The Principal Medical Officer, after stating the " want means for heating the Wards and Corridors," November makes no application for Stoves in the List, p. 2 nor does he " require " Bedsteads, though he had p viously stated that they were not supplied by the Turk He even contents himself with "200 sets of beddin while in daily expectation of another Action, in certai anticipation of frightful sickness, and after receiving, onl ten days before, 1,100 wounded from Inkermann. 0 November 19, just two months after the base of operation at Varna was broken up, he complains of the non-arrival c Hospital stores from Varna, and still expects them — whic stores at Varna were 36 hours distant only — nay, even Greek boat (in September) could have conveyed a message * Vide Report upon the state of the Hoipitals of the British Army i) the Crimea and Scutari, pp. 261, 262, 263. AT SCUTARI. 393 hi the Admiral refused to send one for the pressing mis of the sick.* ' t might be as well to mention, that the non-reception 0':he stores from Varna has been made, like the loss of tl Prince, the scape-goat of all our deficiencies. These slices arrived December 4, and proved a mere drop in the 01 an. jChe Ambassador writes that the particular wants, e: ressed by the Principal Medical Officer, in his letter of C ober 26, — viz., Turkish bedding and articles, such as i'iles and chairs, stoves, &c., " have been mentioned to t] Seraskier in general terms,^^ he (the Ambassador) "resuming that bedsteads, stoves, tables and chairs are tl objects immediately wanting/' i^ut the fact is that the British merchants of Pera, h iring deplorable accounts from Scutari, did, after having tlir offered contributions rejected at Scutari, apply to tl Ambassador to ascertain the truth of the wants of the si\i. Between the Alma and Inkermann, when sick first 0 upied the Barrack Hospital, Dr .M'Grigor, who was ii! charge there, was allowed to engage three Civil Sur- gi)ns from Pera, one of whom shortly after died. Yet, tiiugh Dr. M^Grigor and his assistants were labouring 2 hours per diem, and though the Barrack Hospital was iu most filthy state, the services of Dr. Hamlin and ten o|the Armenian Students, who offered themselves to aist the sick, were refused, as also those of a German Brgeon. Dr. Hamlin was the head of the American A fortnight before, he reports to Kear-Admiral Boxer, dated " Scutari, ^^ember 5, 1854," (the very day of Inkermann,) that he has received Plimptory orders to provide for a large number of sick and wounded; he riLiests that a steamer may be sent to Varna for the bedding and stores 1 there, and asks for boards and trestles. 394 WANT OF A STANDING COMMISSION Mission at Bebec, on the Bosphorus ; he made the offi )K by the unanimous wish of the American Board of Mi:| 'd sions; he himself had studied medicine, and was practi 'i cally experienced in the diseases and resources of tlj J country. j | From the foregoing it may be gathered that, after orl ti great battle and the commencement of operations, viz :l October 20, when it was deemed necessary in London tj f send out a Commission, 17 Medical Officers, and a Corfijffl of Female Nurses, the Authorities of the Army Medic?) f Department (theoretically dependent upon the Commandeil 'i of-the-Forces), had no means of supplying their own wants and virtually refused the extrinsic and extraordinar l A assistance of the Ambassador, specially authorized. Th lo few wants of the Hospital which were absolutely definedi i and which were not one-twentieth part of those whicl i really existed, were, as these documents prove, left to bt| i supplied "immediately^^ by the intelligence, liberalityit and humanity of the Seraskier (the Turkish Minister oi ^ War) . Nor was this all : he w as only generally^' in j } formed of what these wants were. I i Yet it appears that, even for this small and partia j admission to the Ambassador of what tlic deficienciCvM ji were which then existed in our Hospitals, the Principal 5 Medical Officer of Scutari was called to account by hie i chief at home, for he writes : — " Scutari, 5th December, 1854,'' that he " distinctly] stated to Lord Stratford that the sick and wounded had received every care and attention/' and he "begs to rcj)ort that there has been no wantJ' He again states, " I liope you will clearly understand tliat it was not an absolute want of those articles that made me ask for tliem, but perhaps an excessive degree of anxiety regard- ing the charge whicli 1 liad, and which led me to deter- , 1 AT SCUTARI. 395 h^e, whatever might occur, that, did I err, it should at teft be on the safe side/^ 'hese words sound almost like a jest to one who reiembers the condition of the Barrack Hospital at that ti e. On December 4, the Engineer Officer reports that . about a fortnight the whole nnmber of stoves required w be erected, but to speak with any certainty about em the probable time of completion of a work, for the eicution of which I am dependent on Turks, is out of Ik^ question." Yet, at this time, the Inspector- General, wiitever may be thought of the propriety of the alterna- ti !, candidly admitted that he was obliged to keep in tl foul air, in order to keep out the cold. 'o end this singular and " sad eventful ^' history, which h: only been given to show the necessity of some sceme of organization for General Hospitals, or, in default oithis, for some standing Commission of Inspection; B Menzies reports to Major Sillery, dated " Scutari, A'gust 21, 1854," that he has received instructions fru the Inspector- General to prepare additional accom- irdatiou in barracks for the sick and wounded from the Any in the field, and requests that the range of build - ir s facing Constantinople and half the range facing the Si of Marmora (both stories) be purified and lime- w hed, with the passages. t thus appears that he had ample time for preparation^ a: pie notice having been given. Two months afterwards, he reports to Lord Stratford dfRedcliffe, dated " Scutari, October 26, 1854," in that u brtunate letter, (of which the partial report has already cited, but for which partial report, such as it was, 0 ug too great an admission, he had to make so abject an a dogy,) that the Hospitals are satisfactorily supplied, up uthe present time, with all that is required for the com- 396 WANT OF A STANDING COMMISSION AT SCUTARI fort and sustenance of the sick, and that more is expectf daily from England ; that there has been no deficiency i I the Hospital supplies, and that the quality has improve i He asks the loan of Turkish bedding, utensils, and stov( and states that there is no want of surgical appliances. Dr. Menzies therefore confessed that he made t i| application, although there was no need of it — apparent, i for the double purpose of satisfyinghis own Department th no blame could be attached to it ; while, at the same tim the deficiency really existing was made up by the Turkic Government. Dr. Menzies tells Dr. Smith that there w; no need of anything, and yet he applies to Lord Stratfoi for bedding ; and, in proof that there was no need of an; thing, he adduces a letter from Mr. Wreford which prov( that the beds were wanted. At the same time that Lor Stratford was empowered by the British Government t provide liberally everything that was requisite, the bent volent intention of the Government was frustrated by th fear which the Principal Medical Officer had of the censur ' of his Department. ^ The months of September, October, and Novembe 1 were wasted for almost all purposes of preparation for th* army of sick and wounded, which had begun to pour in. And the fatal effects of this delay were never recovere( till the winter was over. 397 XIIL Notes as to Pay and Stoppages. Stoppages are deductions of pay to meet the different aibunts of expense to which the soldier puts the Gvernment. ?hose for his Ration at this present time are,— 1. 4ld. for troops at home. 2. Sid, J, serving abroad. 3. 4id. ,j at Hong Kong.* 4. ^d. at an out-post,* Cape of Good Hope. 5. 5c?. on board ship. 6» ^d. „ with spirits, or an equivalent in tea and sugar. 7. S^d. for troops in the field. 8. 4^^d. „ in the Crimea.* . 3Jd in Hospital for wounds received in action [abroad] . . 4|g?. in Hospital for wounds received in action [at home] . . 9d. in Hospital for sickness on Foreign service. . \0d. „ for sickness at Home. . Qd. „ on board ship. le stoppages for sickness were lowered to the amount o:the stoppages for wounds, by an Order given about Qristmas, 1854, in the late War, which was made to tile effect from the battle of Alma. The higher charge iij Hospital had evidently been made with a view to d|j3ourage malingering. I * The Ration marked * receives an addition of coffee, sugar, &c. Stoppages. 398 STOPPAGES. As the man's accounts in the Regiment are madej) during his absence, subject to stoppages, before e nature of them can be ascertained from the Returnjjjf the Paymaster in Hospital and others, the highest amoiit is entered against him. When his accounts are recei^pl from Hospital and otherwise, the balance, if any, |s placed to his credit, and the next settlement will app r in his "little book/^ This system engenders a want'if confidence in the soldier, who, not being able to comp - hend the details, always thinks himself, in some way r other, defrauded. It would be a far greater satisfaction to the soldier, ai no loss would accrue to the Government, if one unifo i rate of stoppage were determined ; in other words, if, % diet being "found^^ for him, whether in or out ofHospit , whether on ship-board or in the field, he were to rece ? a net pay. By the above means, a great amount of labour a I expense to the Paymaster's Ofiice, either with the Re,'- ment or in Hospital, would be saved. Remittances. "^^^ remarked that, as a great object in armies, i foreign service, ought to be to prevent drunkenness, and ) enable the soldier to remit money home, the same facilif should be afforded to the soldier which has lately be . given to the sailor, for placing his money in the Saving' Bank of his Regiment, when he receives his pay. A) the experiment, tried in the last campaign by dire private means, and afterwards by a Money Order Offi( sufficiently proves how highly advantageous to the Arm as a point of discipline, and to the country, as a poi of economy, this facility given to the soldier must ha been. i By private means, about 1,000Z. per month was tran mitted home in small sums of 20^. and 30^. each. REMITTANCES. 399 The amount transmitted home by the Money Order (ices was £71,000 in six months, i.e. from January, l')6, when they were established, till the Army went hue. E URN of the Number and Amount of Money Orders issued to the Army I the East, at Balaclava, Constantinople, Head Quarters, and Scutari, iiring the late War. OflBces. Period. Money Orders issued. N amber. Amount. 1856. January 30 to July 9 inclusive 5,195 £ s. d. 16,942 4 10 January 18 to Aug. 13 „ 6,333 30,019 11 4 January 28 to June 30 „ 4,458 12,901 11 3 January 18 to July 26 „ 3,402 11,372 3 1 Total 19,388 £71,235 10 6 E iklava . . . Cistantinople I I:?.d Quarters . S-tari (Signed) Money Order Office, November 21, 1856. J. R. JACKSON, Controller. ^he ordinary way of remitting money home is difficult t'the soldier, inasmuch as he must first get leave of his (mmanding Officer, or, if in Hospital, of his Medical ( leer, to send at all. He must next sign a form at the 1 master^s Office ; a delay then occurs, in the case of I )spital, of five or six weeks, for the comparison of regi- r ntal books ; forms and certificates are then to be sent 1 the person receiving the money. But, not unfre- clgntly, if a change of residence has occurred, from the 1 Lgth of delay, the money is lost altogether. On the other hand, a man, having money, and no safe 1 ans of keeping it about his person or knapsack, or 1 iig apprehensive of being killed in action or sent sick 400 FIXED RATION AND UNIFORM STOPPAGE. to Hospital, has been known, by his own statement, eitlr to have drunk or gambled as much as £\0 or <£20, on 1^ f eve of going into action or to the trenches., because, '3 ? would add, *^ he had no means of sending it to his 3 ^ or mother/^ Others would place the money in the hai 5 ' ' of some accidental private friend. The 6d. per day additional field-pay in the Crimea but an additional incentive to drunkenness. The soldier ought to have, on going abroad, the pri ■ lege of the sailor, to leave his standing order for pay » his family. = |» Connection of The question of an uniform stoppage is now under CC ' r ^ and an^^^^ sideration, by the War Department; that of the Rati ^ Uniform ^^^j Hospital Diet for the Army is inseparable from '™ Stoppage. ^ J c For, hitherto, it has been considered that the Soldier bu' certain articles from the Commissariat, who sells them him at a certain price, and certain other articles he hu' r in the market. The sanitary arrangement or compositir of the Soldier^s diet has been nearly or altogether 1( ^ to himself; and, although the soldier is almost entire h dependent for his circumstances upon superior authorit Government has not appeared to consider itself respoi sible. Now, if an uniform Stoppage be adopted, the new prii ^ ciple would be virtually established, viz., that the soldit should receive a net pay, and the country find him wit whatever is necessary for him, whether in or out of Hoi' } pital, whether in the field, in barracks, or on boar ^ ship. It is essential, therefore, to fix what is the Ration fitter • to preserve the man in the highest state of phj^sical effici ency, and also what is the Hospital diet most likely t restore him. A Commission, formed of such men as Drs. Christison FIXED RATION AND UNIFORM STOPPAGE. 401 ^iD. Thomson, Lyon Playfair, (a military man being a» ed to the number) would settle the question at once, ai,. carry the public opinion of the country with them ; for t\ names of these men stand highest in Europe in I^tetic Science. Lny examination as to the facts of the immense con- fuon of the present system of Stoppages, would show ill the doing away with this, by economising the nmber and time of the Office Clerks employed in adjust- iB| the Balance of Pay due to the men, would go far to ccipensate to the country the (undoubtedly) greater ejense of Hospital Diet over Ration. ust as on the other hand the facts of our present cijabrous machinery of Hospital Extra Diets would show tb advantages of forming a scheme of Hospital Diets. T|S need not be \ery complicated in a Military Hospital, irvhich females, children, and old people are excluded. Lt the Edinburgh Infirmary there are nine Diets, of w ch the respective costs are 2^d., 4|c?., 4^^/., 5|6?., S^d., 4n, 3^6?., 4'd., and 4d. per diem."^ They were composed by Dr. Christison). 'he modifications required by a Military Hospital w dd be regulated by . The efiects of climate upon constitution in men on € onial service. . The fact of all the patients being male adults, which si plifies the number of diets required. The cost mentioned above would be different in England, Scotland, an the Colonies. It does not, of course, include that of stimulants. It is (ml given to shew that an uniform stoppage of (say) 7d. would not be so filibelow the actual cost as is generally supposed. 402 Cookin,£^ of the Army. Hospital Kitchens and Camp Kitchens. I XIV. Notes on the Dieting and Cooking of the Arj^ The cooking for the Army has not advanced with he requirements of the times, in the art of preparing greatest variety and best combination of the most nour ing food with rapidity and simplicity. In the Hospitals, kitchens consist of nothing more t simple boilers, with sometimes a small oven, but scart,^ any other appliances for Extra Diets; in camps, ^ soldier is restricted to two utensils, his mess-can, wlih should be used only for holding his food when prepa] but which has been used to a very great extent also ^ cooking it, and his camp-kettle (in the late Campaiij, of tin), for cooking the mess of five men, though ait holding sufficient water for the purpose. It is admitted that, in the using of these utensils, ^ in constructing a fireplace for cooking in the open air, !^ Oriental is superior to either the French or the British | While the uninstructed British Soldier frequently djjl not even raise a w^all, but lights a gipsy fire upon the s "f face, the Sapper and Miner, taught upon a principle, c 'f nicks in the sod, like the French, to a transverse notch ; life the Turkish Soldier cuts a trench, six inches deep and c inches wide, in a curve against a bank, natural or artifici, not less than two feet high. He cuts a few trenches li like size in the earth, radiating inwards from the curvii| near trench ; he places his kettles upon the intersectiiJ of these trenches, and the result is a steady draugl,!- leading upwards against the bank : no blast of air bio »' through any one trench so as to disturb the fire. Turkish Soldiers Kitclien . At P. 402, the same is iesorilpe4, as curved. It varies accordir^Ho tlie nature of ike ground . HOSPITAL AND CAMP KITCHENS. 403 Sardinian Regimental Kitchens were extremely French Field Hospital Kitcliens, In the French Divisional Field Hospitals, the kitchen is urge hut, with a huge brick or stone chimney arched over { learth below, two feet from the ground, on which roast- i I with small spits, grilling with gridirons, and boiling \h pots-au-feu suspended, are performed. In an exten- se Hospital they have, besides, large boilers set in brick- uk. In the French Hospitals, at Constantinople, besides the Itra Diet Kitchens, and the Tisanerie, which belonged to t ; Pharmacie, there was the General Kitchen, which was f ed with large coppers only, in which the meat, beef, \s slowly boiled from four to five hours. Being, also, c; up, not into messes skewered together, as in the litish Hospitals, but into individual portions, — it was rich more thoroughly boiled. [n the British Field Hospital in the front, when it was British F eld ppared for wounded, in the beginning of June 1855, the Kil*chelfs. Judical Officer had no other kitchen for his patients than t ) or three camp-kettles at the angle of two low walls, I hout any protection ; and he afterwards obtained, with g at difficulty, an order for a hut and a small cast-iron s ve. )n September 8, 1855, whatever the kitchens may have I n, they were not capable of cooking beef-tea for the vunded, lemonade, &c., which were supplied by M. Soyer f m his kitchens. \s for the Regimental Hospital Kitchens, they con- s ed of nothing more than a few camp-kettles, placed m t air over a fire, screened by one or possibly two walls, al in a few cases covered with a bit of board, or fragment 0 racking case, or tarpaulin l^he General Kitchen of the Monastery Hospital of 2 D 2 r 404 HOSPITAL AND CAMP KITCHENS. Regimental Kitchens in the Camp at Aldershot. Cooking Service in the Crimea. St. George was highly creditable and efficient ; that othe General Hospital at Balaclava passable ; that of the CMJe Hospital on the Heights of Balaclava inefficient, tilre- formed by M. Soyer; those of the two General Hosj:als ' of the Land Transport Corps produced partially uneaWe '™ food, till three of M. Soyer's Portable Boilers were op- • ■ plied to each. All these five Hospitals had, how|i|r, Extra Diet Kitchens, under charge of the Nurses, aied to them by Miss Nightingale, in most cases under dec- tion of M. Soyer.* In the Camp at Aldershot, the Regimental Kitcb. is a large corrugated iron hut, having in its centre a ifty brick chimney, on the base of which two wide brick ttfis its extend along the floor ; each pierced in its upper sufeDe-W for three or four small moveable cauldrons. The entof -o the flues, where the fires are fed, afl'ord a small roaingi kitchen for Officers, being provided with a front gite.^fi The advantage of this scheme is its simplicity and cMi-®i liness; its disadvantage, that it involves a large heavyflln ijil hut, of which the chimney bricks must be left OD^ij ground, if the troops move, and that the draught iillic lj flues is so fierce that the boiling is too rapidly perfor«d. Much of the nutritive value of the food is thus lost. ■ ^itti There is, at Aldershot, a small counterpart, for the )eii;:tc air, which, however, is made of square tiles, with a|*f^.!tio f :.rl chimney which has an iron flue in the centre. A cooking plan, similar to this, was adopted irthe'i Crimea for one half the Regiment of the 17th LaDfefc»iT( while for the otiicr half M. Soyer's Portable Boilers provided. The French in the Crimea, according to their cui * She used, in all, the admirable small stoves of Little, or of Si Glasjf^ow. The latter are perhaps preferable. COOKING SERVICE. 405 Id off 10 men per Company to cook for the rest ; but, the English -4rmy, this could not at first be done. It appears that the Guards, for the first month or more ter going to the Crimea, cooked and fetched water and el individually; but afterwards some combined plan was rmed. It appears also that it was thought unadviseable, I withdrawing too many men from the ranks, that men ;ould be told oft' by General Order for cooking.* I The practice of men cooking individually was pursued the Regiments of the Line from the landing in the (rimea up to about the beginning of January 1855, or ben the camp-ketties, thrown away, had been replaced. ;fter that period, it seems to have been the practice to II off two men per company to cook. I It is obvious that, in the British Army, neither the ;ess-cans, which were provisionally used, nor the camp- ittles, calculated for five, could boil a sufficient quantity of ,od together, in the manner most advantageous for the pro- ]:ss; and that, although cooks were told off for the Army ;nerally by January 1855, the cooking was a rude and pid affair, generally carried on behind a wall in the open ;r. Had even a roofless room of stone and mud been instructed, it would have been an improvement. The cooks appear to have been without the sHghtest ^truction, and their only principle of action was to tsten through the work as quickly as possible, and [tbe out of the wind and rain, — or at another season \ the year, out of the burning sun. They had no in- inictions as to soaking salt meat. There was no emula- on, nor were any orders or superintendence given with a ew to cause the imitation of any adroit contrivance. Cooking seems to have been generally considered the Fair of the men entirely, though there were some • The Officers are cooked for by the servants allowed them. 406 COOKING SEKVICE. I exceptions : and it appears to have been erroneously su posed that self-preservation would be motive enough \ induce them to learn and practise an Art essential to th( life and health. The Medical Department, as it appea:, neither obtained General Orders to convey their advi. . to the Army as to the management of their Kations, njlj made any Reports with a view of obtaining useful proofs of neglect and ignorance, although some zealo, and conscientious members of that Department nev ceased to send in their remonstrances. Supposing it to be conceded, that a process of cooki Soyer's ^^r more than five produces more palatable and nutritic BoUers^ food with greater economy than that used at present, and Little s considering the great number of camp-kettles which pra^ j Stoves. . n 111^ tically were thrown away, even when men had no kna' | sacks, and the weight, inconvenience, and amount ji breakage which they incur, it seems that M. Soye], Portable Boilers are preferable for the use of an Arn. . even in the field. k One of these weighs only 80-90 lbs., made of mallealjt iron, which will last in good repair for a great length , time. ; » Two of these, with one of Little^s Stoves, can be carri(, 'jj on one mule ; i. e., arc together less than 240 lbs. weigh They require very little fuel, and will cook meat, veg _^ tables and tea, for 120 men — Little^s Stove cooks Extrs, . for Sick or for Officers.— And, if Little's Stove be carri£| by other means, 60 lbs. of fuel may be carried with tlj two boilers. Allowing the mule and its load for oi Company alone, ten mules will be required for the who. ^ llegiment. Two men, which is the number now told oi . are sufficient to conduct the mules and carry on the cool iug. One of these men would be the permanent Cool ^ and the other wouhl be exchanged, so as to let all the me soyer's boilers. 407 lira a certain amount of cooking. (The French, who 1 1 off 10 men per cent, to cook, waste a great amount of .yength.) The additional transport necessary is compen- si':ed by the decrease of labour for the men, and the great ^ ;urity for their having a nourishing diet. It is said that there is risk of kilUng, laming, or losing ijs mule — but the risk of losing the camp-kettle has been {bved ; and the men will, at all events, only have to fall \?k on their mess-cans as before, or apply to the next ( mpany for a " turn " at their Boilers. This particular I lie would not run more risk than the horses of Superior (ficers, or of the Artillery. It is only in case of forced iirches that any danger would exist; and in these the r;n carry their own cooked Rations, The gain of this kind of kitchen is enormous in point of f since it does not consume one-fourth part of what is c^linarily used ; where Government pays for fuel, there- f e, as in the last War, the pecuniary saving is great. Lord Raglan^s " General Order^^ allowed a ration of 3bs. wood or | lb. charcoal per man. And it would abear from the General Order dated December 16, 1854, tit li rations of fuel were then allowed per man. One E al cooked for a whole Company in two of Soyer's Stoves c isumes only about 25 lbs. wood. Even estimating the t 36 meals per diem as expending 75 lbs fuel, which t y do not, one-fourth only would be consumed of t ; 300 lbs. allowed per Company. The saving may t refore be calculated, especially in summer, when the 8»'dier lights his fire only to cook and not to warm him- :.frhe construction of these Boilers is such, that their tinsmission and renewal by the Commissariat is no nlre difficult than that of the camp-kettles replaced in tlj: Crimea. 408 soyer's diet. Soyer's Stoves will boil, stew, bake and steam, in sho; do everything but grill ; ensuring that variety in cookin which is proved essential to health. A few of his Reeeipi arc here annexed, which were found most useful in tli Crimea. I Soyer's (No. 1.) SoYEE s FooD FOE THE Teoops. — To Cook fob a Receipts. Eegiment of 1,000 Men : — Head Quarters, 20th June, 1855. Place 20 Stoves in a row, in the open air or under cover. Put 30 quarts of Water in each Boiler, 50 lbs. of Eatio " Meat, 4 squares from a cake of dried Vegetables — or, if fres ''^ mixed Vegetables are issued, 12 lbs. weight — 10 small tabJ; l spoonfuls of salt, 1 ditto of pepper, light the fire, simmer gentljjtaj from two hours to two hours and a half, skim the fat from th top, and serve. (] It will require only two cooks per regiment, the provisio and water being carried to the kitchen by fatigue-parties. (No. 2.) Sotek's Bivouac Cookeet foe the Aemt. - * Stewed Salt Beef and Poek. — Poe a Company of 10 W Men oe a Eegiment of 1,000 Men : — \ Head Quarters, 12th June, 1855. Put in a Boiler, of well-soaked Beef 30 lbs., cut in piece ^ of a quarter-of-a-pound each. 20 lbs. of Pork. 1^ lb. of Sugar. 8 lbs. of Onions sliced. 25 quarts of Water. 4 lbs. of Eice. \ ' in Simmer gently for tliree hours, skim the fat off the top' ^ti and serve. Note. — TTow to soak the Meat. — Put 50 lbs. of Meat in each Boiler, having filled them witli Water, and let soak all night and ])rior to using it, wash it and squeeze it with your hands,, to extract the Salt. < 4( SOYER^S DIET AND RECEIPTS. 409 case the Meat is still too salt, boil it for two minutes, thi y away the Water, and put fresh to your Stew. > closely following the above receipt you will have an ex( lent dish. No. 3.) Soter's Eeceipt to Cook Salt Meat fok 50 Men:— Head Quarters, Crimea, 12th May, 1856. Put 50 lbs. of Meat in the Boiler. : Fill with Water, and let soak all night, i Next Morning wash the Meat well. rill with fresh Water, and Boil gently Three Hours. S. — Skim off the fat, which, when cold, is an excellent sul titute for Butter. (No. 4.) Soyeb's Army Soup for 50 Men: — ^1 Head Quarters, 12th May, 1856. Put in the boiler 30 quarts, 7^ gallons, or 5| camp kettles o£(ater. Add to it 50 lbs. of Meat, either Beef or Mutton, The rations of preserved or fresh Vegetables. Ten small table spoonfuls of Salt. Simmer Three Hours, and serve. S.— When Eice is issued, put it in when boiling. Three pounds will be suflBcient. About 8 pounds of fresh Vegetables. Or 4 squares from a cake of preserved ditto. A table spoonful of Pepper, if handy. jnm off the fat, which, when cold, is an excellent substitute foi3utter. ( 0. 5.) SoYER's Bivouac Cookery.— Soyer's Pood fob 100 Men, USIN& Two Stoves:— Faris, 2&h April, 1857. ut or chop 50 lbs. of fresh Beef in pieces of about a quarter- 410 DR. CHRISTISON'S PRINCIPLES of-a-pound each ; put in the Boiler, with Ten Table spooj of Salt, two ditto of Pepper, four ditto of Sugar, Onions m f cut in slices : light the fire now, and then stir the Meat th' a spatula, let it stew from 20 to 30 minutes, or till it fori a^l thick gravy, then add a pound and a half of Elour ; mix .^11 f together, put in the Boiler 18 quarts of Water, stir well f j a y minute or two, regulate the Stove to a moderate heat, ani^et i simmer for about Two Hours. Mutton, Pork, or Yeal, ca 36 Stewed in a similar manner, but will take half-an-hour Isi ] Cooking. j Note. — A pound of Eice may be added with great advant^ ditto plain Dumplings, ditto Potatoes, as well as m^i Vegetables. ^ For a Eegiment of 1,000 Men use 20 Stoves. |l {No. 6.) The Bivouac Stoye : — ■ Paris, 2m April, 18f)M Each Stove will consume not more than from 12 to 15 j.i, of fuel, and allowing 20 Stoves to a Regiment, the consumpti|j would be 300 lbs. per thousand men. , The allowance per Man is, I believe, 3^ lbs. each, wli i gives a total of 3,500 lbs. per thousand men. , The economy of fuel would consequently be 3,200 lbs. r E-egiment daily. Coal will burn with the same advantage. Salt Beef, Pork, Irish Stew, Stewed Beef, Tea, Coffee, c^,, can be prepared in these Stoves, and with the same economy^ They can also be fitted with an Apparatus for Bakii, Koastiug, and Steaming. Philosopliy of Since Liebig and his followers, the nutritive properti Ditt. ^^^^1^ hoi\i for men and animals, have been large studied ; and almost every Article of Diet has be( reduced to a scale of nutrition, with this object. Dr. Dr. Christison has laid down eight principles, for testii Christiisonb FOR TESTING NUTRIMENT. 4l 1 th((autritive value of any dietary, which are so important Eigi^^ th." they will be here given in his own words : — Principles. "All articles of food used by man consist of one or more, ant'^enerally several nutritive principles ; and most of them conin water and an indigestible cellular tissue. The two latir must, of course, be deducted in estimating nutritive " The nutritive principles consist of two sets — one of whh maintains respiration, and the other repairs the waste coitantly incurred by the animal textures in the exercise of the functions. As the respiratory principles commonly abmd in carbon, they are sometimes called carboniferous, wb3 the reparative principles, because they all contain nitigen, are termed nitrogenous. " Experience has shown that the most successful dietaries foi'odies of men, deduced from practical observation, contain caianiferous and nitrogenous food in the proportion of about th]3 of the former to one of the latter, by weight. During twaud-twenty years that my attention has been turned to the priant subject, not a single exception has occurred to me. " Hence it is obvious that the least weight of food in the ro ;h state will be required, first, when there is least moisture anjcellular tissue in it ; and secondly when the carboniferous an;nitrogenous principles are nearest the proportion of three to Lie. " Of the various nutritive principles belonging to each ser some may replace one another ; some are better than of cs ; some are probably essential. This branch of the sci ice of the subject is unfortunately still imperfect. " Two things however are certain — that nitrogenous may re .ice carboniferous food, for supporting respiration, though at' great loss ; but that carboniferous food (without nitrogen) (^jiot replace nitrogenous food, for repairing textural waste, t "The daily amount of nutritive principles of both sets mlt increase with exercise and exposure, otherwise the body qi^kly loses weight, and ere long becomes diseased. If the abj e proportion between the two sets be maintained, the w< ;ht of real nutriment per day varies, for adults at an active 1 412 DR. christison's tests of food. age, between seventeen and thirty-six ounces ; the forrr ( being enough for prisoners confined for short terms, the lutr being required for keeping up the athletic constitution, or 1 1 which is capable of great continuous muscular efforts, as i prize-running and other similar feats. 8. "Dietaries ought never to be estimated by the roii weight of their constituents, without distinct reference to -.j real nutriment in these, as determined by physiological at chemical inquiry. " Keeping these principles in view, and with the help o; simple table, it is not difficult to fix the dietary advisable any body of men, according to their occupation. It is i general, easy to detect the source of error in unsuccessj dietaries. For example : any scientific person conversant the present subject could have foretold, as a certain sequence, sooner or later, of their dietary, that the Bril troops would fall into the calamitous state of health w befell them last winter in the Crimea." The whole of Dr. Christison's paper, from which thei extracts are taken, will be given in the Appendix, as beiii too valuable for a word to be omitted. One of his Tabl only will be added here. DR. CHRISTISON'S TABLE. Table referred to in Dr. Christison's Observations on Diet. STANDARD TABLE OF NUTRIMENT, 1849. 413 Per centage of Nutriment. Carboniferous. Nitrogenous. Totals. Wiat-flour .. Bud 0;neal Bi,ey (Pearl) Pie P(! toes Ciiots Tuips L( i of Beef and Mutton Pj'ofMeat .. A rage Beef and Mutton B!)n SI timed Milk Cheese ^teFish .. N'Milk .. Slnmed Milk B :ermilk . . BT Tea (strong) . . B r Tea, and meat decoc on of Broth 71-25 51-5 65-75 67-0 55-5 24-5 8-5 6-7 6-7 0-0 100-0 15-0 62-5 0-4 0- 0 8-0 5-5 1- 0 0-0 00 16-25 10-5 16-25 15-0 24-5 2-5 1-5 0-3 0-3 27-0 0-0 20- 25 8-36 64-6 21- 0 4-5 4-5 6-0 1.44 0-72 87-5 62-0 82-0 82-0 80-0 27-0 10-0 6- 0 7- 0 27-0 100-0 35-25 70-86 65-0 21-0 12-5 10-0 7-0 1-44 0-72 Doubtless for the soldier, there is a question of bulk as w\ as of nutritive power ; this, however, has been tested h our Northern expeditions. Our preserved meat, pamican and meat biscuit, preserved and compressed V etables, the same with gelatine, have been invented in C'lsequence, and largely used in our Naval expedi- tilQS. But, besides this, in salt provisions there are many gidations between the salt junk of the Navy, guaranteed f( three years, the delicate Hamburg beef, and the West- pdian ham. There is the pickling used for domestic prposes, and largely in the United States ; there is t ■ pickled beef, with dried crystallization of salt upon it ; i 414 AS TO SALT MEAT. ||| both sufficing for the conservation of food for mm months. A process analogous to the old Tartar plan ' compressing thin laminae of beef, dried in the sun^ betwe(' hot plates of metal_, would probably produce preservdi meat extremely compact and capable of being restordf by boiling, in great measure, to its nutritive state. Ar of these are obviously preferable to the present salt b? and salt pork, prepared for a time which, with Stea Navigation, is wholly unnecessary as far as the soldier concerned. It is also most important to remember, with regard • salt provisions (and for this statement we have D ; Christison^s authority), that the danger of this kir- ' of food is not only that, already mentioned, of the sa ' not being sufficiently discharged by the process of cool: ' ing, but of its nutritive value being lost by the ver process necessary to make it eatable in any sufficier I quantity. Dr. Christison states, " neither by physiologicj • experiment, nor by chemical analysis, is the nutritiviif value of salt meat scientifically known.^' He also sayij "Meat highly salted must be so thoroughly steeped i cold water, to remove the salt, before it is eatable inlargjim quantities, that much of its most nutritive constituent ; must be washed out, viz., its albumen and sapid extrac i called osmazome." And again, he says, " salt meat i assumed to equal fresh meat in nutritiveness — an extremel; dubious assumption ; but there is no authority by whicl to fix its true value. My persuasion is that, apart fron! the tendency of the protracted use of such food to favoui the development of disease, its nutritive value has beer much over-rated. The Philosophy of Food has proved that not onh quality, nutritive power, but also variety in diet must,!, be consulted to preserve the man in health ; so that here'^i PROPOSED ARMY RATION. 415 I je Ifve a further poiut in which the present army diet is efeiive. T re is also the consideration of supplying vegetables 1 'c certain ratio to meat, and in a much greater rofirtion to salt meat ; and again, though bread, rice, ndii meal, oatmeal and biscuit may all be considered iriT|ceous, biscuit is an improper food for troops with mpnt scurvy, as they are unable to eat it from the ain t occasions the gums. Biscuit, also, being a kind of nle^ened bread, composed merely of flour and water, lak a greater call upon enfeebled digestions, under any irci istances, than bread. E ht-and-twenty ounces of real nutriment have been lid )wn as the full ration by Dr. Christison ; the articles ein well chosen, this should consist of — 21 oz. carboniferous 7 oz. nitrogenous former maintains respiration, the latter repairs the ^^y^^^^^^^^n incurred by the animal textures, proposed Dietary, given in the Crimean Com- iii^ners'" Report, is — Soft Bread 34 oz. Fresh Vegetables 8 Rice or Barley 2 Fresh Meat IC) ^ Coffee, roasted and ground . . 1 Sugar 2 3 lb. 5 oz. , is difficult to over-value the proposed addition of tea and coffee to le m 's rations. They possess a renovating power, in circumstances of uusu fatigue, which is constantly experienced in Civil Life, and which 416 PROPOSED ARMY RATION. Spirits I pint Weekly Mustard i oz. Pepper i Salt I This contains 20 oz. Carboniferous 6 oz. Nitrogenous or Reparative 26 oz. total real nutriment * Substitutions for — foi jeat n 24 oz. Soft Bread, 16 oz. Biscuit. 8 jy Tresh Vegetables, 2 „ Preserved Vegeta 1 J, Coffee, ^ „ Tea. This contains the difference of about A oz. less Carle „ iferous, more nitrogenous, and a trifle less total si^m nutriment than the former. |[J " In both of these scales," however, writes Dr. Christi D " the total quantity falls a little short of what appears most advisable. In all other respects, the Dietary sej^y' unexceptionably good. It cannot be said that the c|"^ I have often heard Officers, who served in the Spanish Campaigns, as d as in the late Burmese War, describe in the strongest terms. This, j;| tonous and insufficient Diet, would be corrected by omUi equally monotonous. The instinctive craving of the mer " in Hospital for butter, cheese, milk, for the fat of bacon., , ^ for fruit, pickles, jam, and such like articles of food, will-t be remembered by many ; and, under requisition fro'^^lj the jMcdica) Officers, we always sought to satisfy it. SYSTEM OF EXTRAS. 421 ut here again is an instance of the non-definition of th respective duties of the several Medical ranks; arequi- sili'nfor butter, signed by the Assistant Surgeon in charge of he Ward, countersigned by the Deputy Inspector- G eral in charge of the Hospital, having been thus aiiveredj — the 1st Class Staff Surgeon, in charge of the nision of the Hospital, and the Inspector- General in ch'.^ge of the Station, when going their rounds, threw th butter out of the window of the ward, unaware, it is tr !, that it had been obtained upon Requisition of the otir two Officers."^' t is not necessary to say more, in order to prove the Necessity of a inlortance of Dieting and Cooking as sanitary and "^TableSor^*" th.-apeutic agents, as well as the necessity of philosophic- ^o^die^s ia _ . , xiospitai, so as ali determining the principles upon which these are to to dispense beoractically worked out, in order that never again may ^^^Vxtras!^ be heard that confusion of ideas about " spoiling^^ the m 1, or " too much indulgence" of the soldier, but that it I would here add a criticism which, being strictly unprofessional, will, ifc hoped, disarm censure. It is this. The inspections appeared to be m; 3 more with regard to the appearance of the wards than to the health or ives of the Patients. A singular bustle always took place among Oi rlies and Patients when it was known that the Inspector-General was go :5 round. " Extras, " although ordered upon diet rolls by Medical 01 3rs, were hidden under the Patients' mattresses, books were thrust aw , &c., &c. If these extras were seen, they might be perhaps thrown m; by order of the Inspecting Officers. Had this been done after con- su ng the tongue or pulse of the Patient, or otherwise looking at him pr 3ssionally, and finding the diet unsuitable— however rough the man- ne the intention would have been above criticism. To discuss professional tnment is certainly not my province ; but the consideration of profes- su il treatment seemed rarely to enter into the question. It was because th " extra" made " the ward untidy," and ought to have been eaten "at th Proper time," that it was condemned. did not appear to be the question, what was desirable for the Patient, nc how, by means of shelf or receptacle in the ward, or store-closet, or ex a kitchen at hand, to make neatness, which is indispensable in a H pital, compatible with the Patients' wants, which are equally important. 422 HOSPITAL DIET TABLE. may practically be known what is and what is not essen*!!}^' for his preservation in, or restoration to_, the utir^tj'^'' vigour. A seven-days^ Diet-Table should be laid down for tary Hospitals, making use of all the various meth roasting, boiling, baking, mincing, hashing, &c., and all the various materials of food considered essent: and the cumbrous and awkward, but now necessi machinery of extras may be dispensed with, except rare and special cases. I^"stlce^of One word more about Hospital Stoppages. These w Stoppages, instituted on the principle that, when a man was sick, was off work. But the soldier belongs to the Governmei he is not a labourer in the employment of the mastt he is not allowed to take his labour into the market wl off duty ; he cannot be compared in any way, when sii to the labourer off work : and yet the man is to be fii for getting sick in the performance of his duty. The ration and messing now is not to exceed S^d. inl Infantry, and 10c?. in the Cavalry ; this includes 1 bread, | lb. meat, beef or mutton (that is, two-thirds beef, one-third mutton) vegetables, 1 pint coffee, breakfast, 1 pint for tea; salt, pepper, &c. The ch: for Hospital Stoppages, which is lOd. at home, mig' fairly be reduced, even if an uniform stoppage be nij^ adopted, as we trust it may. But, if an uniform stoppa: be adopted, shall the Hospital stoppage be kept up, f f the sake of " catching" the dissipated and the " mali gerer?" You are not to punish a man who has incurrt. his illness on duty," says Sir John McNeill, " in ordi' to catch a man who has incurred his illness by his fault." Ordinary Diet For the ordinary diet of a soldier out of Hospital tl out of . Hospital. dietaries of the Navy and of Emigrant ships, acknov PROPOSED ARMY DIET TABLE. 423 ged to be so much better than the Military Ration, afford valuable hints. t should not be forgotten that different circumstances ^^^^^^^^^J" ^ exposure, exertion, climate, &c., render essential, in in a different" r to preserve health or even life, modifications of Diet. food of the Esquimaux and of the Hindoo contains rcely a grain in common. No allowance was, however, made for this in the ( imea ; and, had the troops been restricted six months 1 iger to the Diet with which they began the campaign, t) Army must have been annihilated. A. Memorandum is annexed, proposing a Diet for the Diet Table for kldier, suggested by Sir R. Tulloch. H^ospita]! I Memorandum regarding Proposed Diet for the Soldier. iFor Breakfast, Coffee, Cocoa, and Tea on successive (jys, with Bread and Butter. The quantity of Coffee or Cocoa to be an ounce, or of ''.a i of an ounce. Bread 6 ounces. In Scotch Corps, Oatmeal Porridge and Milk, or Oat- i^ial and Butter, if preferred, for breakfast. Dinner to vary as follows, on each day of the week : — 1st. day. — Irish Stew of Mutton with Potatoes, and Rice Pudding. 2nd day. — Salt, or Corned Pork, with Pease Soup and Potatoes, mashed with Greens or Cabbage, and a little fat, termed Col-cannon. 3rd day. — Eoast or baked Mutton, with Potatoes and Yorkshire Puddings. 4th day .—Boiled Beef, with Soup and Vegetables, thickened with Bice, Pearl Barley, or Sago, and Boiled Potatoes. 424 PROPOSED ARMY DIET TABLE. I tfS 4 5th day. — Roast Beef or Baked Beef, with Potati under, and Plum Pudding. 6th day. — Boiled Mutton, with Soup and Vegetah and Boiled Potatoes. 7th day. — Stewed Beef, with Vegetables, and PI a Pudding. 8th day. — Soup made from head, shanks, and feet )f animals not otherwise issuable ; Ro;t Heart, fried Liver, Tripe, and other pais not at present made available ; Bread Pi - ding, with Baisins, &c., made from End not used during previous days, and at pH ^ sent generally wasted. On each day, 4 ounces of bread to be used with ifi Dinner. Half-pint of Beer on each day at Dinner. Por Supper, Half- pint of Beer, with 2 ounces of Chee , and 6 ounces of Bread, or Bread with Butter, and T , Coffee, or Cocoa, as at Breakfast, or Porridge and 0 - cakes, in lieu of Bread, in Scotch Regiments . ilj The quantity of meat for each day is, according to tp present regulation, | of a pound, uncooked, which, \ eluding bone, averages about 7 or 8 ounces of cookl Meat. This, with 1 lb. of Bread, the soldier is entitlj to have for 4^d. per day, whatever may be the cost, home, or S^d. if abroad. The expense of the rest of the messing would n exceed about 4^d. per day more, leaving the soldier, o of his Is, Id. per day, about 4d. over. Of this, 2d. a d would about cover his necessaries, barrack damages, ai small stoppages, leaving about 2d. a day for pocket moni after all his other wants are amply supplied, and he h had a pint of beer provided for him. I PROPOSED ARMY DIET TABLE 425 If this diet were found too expensive, the Beer and ( eese for the Supper could be struck off, and the Tea j'i Bread substituted, which would make a saving of nut Id. per day, or the former diet might be confined t the men who had more than Is. Id. a day, and who ^ uld be better able to afford the expense. (Married men, who could not afford these rates, might eher be allowed to live out of mess, or the Beer and 5 )per meal made optional. The different companies of a Regiment would com- i;nce with different days' diet, so that all might not be listing, boiling, and baking on the same days. Note. — An exact estimate of the cost, nutritive value, I ., of the Diet here proposed, together with observations von it, will be found in the Appendix. 426 XV. M Notes on the Functions of the Commissariat CONNECTION WITH THE SuPPLY OF FoOD FOR T]l Army. The The Commissariat of the British Army is endowed wil ? ^^rc^thT^^ many of the functions of the French IntendancC; ar' Bankers, ^j^g same time, with some of those of the Treasui storekeepers, ' ,i and Carriers with which many of its appointments originate. In otLl r of t e Army, j^^gp^^^g^ -^g name shows, it is a servant of the Coi! mander of the Forces. j Upon the management of the Military Chest, i, e., til ; " paying Department of the Army, connected with Ij'' species of banking, it is not the intention of this pap' ^ to touch. ^ The Commissariat are also the storekeepers and carrie! ^ of the Army : all Purveyor's stores pass through thd i hands. It is not proposed to treat of either of thei^ ^< topics, except in so far as carrying provisions forms component part of feeding the Army Their dulies in It is with the supply of food only and with sanitai'^e provisions, that this paper has to do. ' }^ supplyin: Food The feeding of the Army involves a supply of ' ^ Bread or biscuit, i i Meat or salt Meat, i Its carriage, i Its distribution, \\t^ Its cooking. ^Ki \k It ought, also, as has been shown, to involve the suppl^y IE COMMISSARIAT SUPPLIES THE ARMY'S FOOD. 427 of iveral other articles of food, necessary to make a pei!Ct Ration. is the business of the Commissariat to procure, tra sport to the field, and distribute, bread or biscuit and ' le duty of the Commissariat, in the late War, after laning the cattle destined for provisioning the troops, wa to preserve them in the country, and to take the recisite number to its own divisional slaughter places. Fna these, the meat was delivered to the regiments, who ser, their own parties for it. It may be observed, by the wa that, as the delivery took place on exactly the same pri^iples as in England, the "fifth quarter" of the animal wa retained by the Commissariat. Finding no sale for thi," fifth quarter'^ in the Crimea, which is the perqui- sit of the butcher and Commissariat all over the world, it eing practically so valuable that the butcher's price fomeat is about the same as that at which he buys it, W€,;ht for weight; this "fifth quarter,'^ consisting of he I, tongue, feet and entrails, hide and horns, was Off red to be buried as a nuisance by the Quartermaster- G( era?s Department. The French and the sailors fre- qu itly procured and made use of the fresh heads, nay, ha - even been known to dig them up. le duties of the Commissariat, as regards feeding ^j^e th Army, it must be observed, were arrested by the non- ^^^^^poi^^^^^^ extence of roads to the front, the decision as to which, for the _ . , , „ , Formation of as ell as their actual formation, rested with the Quarter- i^oads. miter- Generars Department. The reason given for not ra; ing the road, before that operation became impracti- ca e, was the necessity of employing every man in the siee operations, or in guarding the position; but the sta- tic cs of sick show, on examination, that more men were \viidrawn from these primary objects by the neglect of 428 EXCESSIVE AND UNNECESSARY the road than would have been withdrawn by the makg J of it. This diflPerence is also to be added, that_, in the (je*" case, they would have been restored to the ranks as ei-i" cient soldiers, and, in the other, they were either invahdl, dead, or debilitated, j if Origin of It has been shown that the Scorbutic type of diseb.^ excessive use predominated in a very large majority of cases in leif of Salt ^ March, 1855. Provisions, as J f r y furnished by In tracing the origin of this, by far the most prominf January, 1855. For not only was a great weight of 3ab Lges, sent from Varna on the deck of a ship, thrown intc the Harbour,* no Commissary being willing to receive the:!, on the ground that they were not consigned to any one but potatoes were not bought for the use of the An/, though they could have been supplied to a con- side ible extent from Trieste. Ispared potatoes were offered on sale to the men, wliii they, however, not knowing the importance of vege- tcJx , to their health, did not make use of, on account of tlie: high price, and from not knowing how to cook them. Ater May, 1855, it may be said generally that the Arry had an ample supply of fresh meat, fresh bread, veg ables, and lime-juice. 5 me of the most remarkable dates are here annexed, for he purpose both of illustrating our sanitary and aielitic history, and of confirming the principles to be laidjlown. jThis is an event that appears to have happened more than once. A Supply of Kice and of A^egetables could have been got. Dates of the variations in the issue of Fresh Meat, Vegetables, &c. 432 ACTUAL ISSUE OF 1. — Fresh Meat. 1. Fresh meat issued to men for duty. Per Month per M/ lbs. In December * 1854 . . . . . . 3 W In January^ 1855 . . .. .. 5 In February, . . . . . . 4 2. Average quantity of fresh meat issued to each mlfi of the Five Divisions composing the Army, includiM the sick in camp. i Per Month. ^ lbs. oz. In December, 1854 6 4 ^ In January, 1855 9 0 ^ In February, „ . . , . ..82 i II. — Vegetable Food. f ■] 1. Rice. i| Issue of 2 oz. Rice to each man daily — discontinue ! ^ November 15, 1854. General order to resume December 27, 1854. Issue became general in the cour of January. Quantity of Rice in store, November 1 1854:— At Balaklava, 74,000 lbs. At Scutari, 296,000 „ N.B. — The men always declared that they would rathi; liave lost their rum than their rice. fj 2. Lime Juice. 20,000 lbs. arrived for the troops, December 10, 1854 * 8,000 head of cattle were then in our possession. VEGETABLES, FRESH BREAD, &C. 433 no 5 issued to the troops till the first week in February, 18 The fact of its existence in store was first dis- co^ red by Lord Raglan himself (from a return called for by im) on January 24, 1855, and on January 29 appeared his reneral Order, making it a part of the ration, only five da; afterwards. 3. Preserved and Dried Potatoes. one issued to the troops except at a high price, which the declined, till about the latter part of January, when the were issued gratis, although at first chiefly to the Hoitals, and eagerly received. Quantity in store : — I At Balaclava, November 1, 1854, . . 32,400 lbs. At Scutari, October 1, 1854 .c 6,000 „ 4. Peas.^ |j hole Peas were issued, but the men would not take thfi, from not knowing how to cook them ; they were ne^r told to use soda. Quantity in store at Balaclava, 51 00 lbs., December 16, 1854. 5. Barley. aantity in store at Balaclava and Scutari, 65,000 lbs. y\z part from October 1, 1854, part from December 1, l^t, part from January 1, 1855. Issue of Vegetables. Lly five or six regiments received any at all m |ember, 1854. _ Peas," says Dr. Christison, " should be supplied, if possible, in the stiof flour, when intended for part of the Rations of troops on active ser» :e in the field. They are then much more easily cooked, as well as 1 compactly packed and more easily served out." 2 F 434 ACTUAL ISSUE OF Still fewer acknowledge any in December, 1854. Tli f issues this month amounted to — j il for 2 potatoes-i • on i iib. < , . > per man m 31 days, ' L 1 onion J ^ ' ! I including sick. t i lb. per man per week, including sick, in Januaiiii 1855. Vegetables began to be issued regularly about tllIJa 20th or 24th of this month. ; 1 In some regiments, supply irregular up to the middle the month, in February, 1855. ' i In five regiments only insufficient in March, 1855. il 6. Fresh Bread. jl^^ Nothing but biscuit issued to the troops till Api'i 1855 ; nor to the sick in camp till April 9, 1855. I N.B.— The sick bought the 2 lb. loaf at 2.9., 3^. \\i 7. Green Coffee. November and December, 1854, January, 1855, jjj 173,000 rations of Tea at this time at Balaclava; and mo ili, could have been procured from Constantinople or tlits Navy.* nil III.— Porter. 147,000 gallons were in store at Scutari from December jr, 1854, till April or May, 1855. The exhaustion product by the men being sometimes all day on fatigue duty to ai from Balaclava without food was such that, had this porti'fi been brousrht to Balaclava and served out to them ther * There does not appear to have been any Ecport made, recoramendii the issue of Tea, by the Principal Medical Oflicer, till March 22, 181 although, on January 24, it was advised by the Director Gcnenl H ^ home. FUEL, BLANKETS, &C. 435 i s unquestionable that much suffering would have been s ed."^ 1\.—Fuel^ he issue of Wood to the troops near Balaclava began cember 29, 1854, but not to the front, excepting a small mtity to the Hospitals, and that not till the middle J anuar J. The issue of charcoal began on December 8, but only :he troops in front. V. — Camp Kettles. •Tot replaced till January, 1855. VI. — Blankets. Lt the end of December, 1854, there were blankets eiiugh in store to have given a third blanket to every iffi. In December, when the weather was severe, the , and even the sick, lay on the muddy ground of their tj|;s, with nothing under or over them but the great coat blanket, these too often wet from the trenches. The sierings of the men from cold w ere at their height during aary. he dates of distribution of blankets are — ' When practicable, half-a-pint of porter (ten ounces) would form a desirable substitute for the ration of spirits. The nutriment is much tl ame, viz., one ounce, but the alcohol is only one-half; and neverthe- Ic its renovating power is greater. All Officers engaged in active service ii .dia, especially during the occasional privations in the late Burmese W have borne strong testimony to the superior advantages of malt liquor spirit."— Dk. Chrtstison. The whole of the Southern Coast of the Black Sea is wooded for hun- of miles. 2 F 2 Faultiness of the whole Dietetic System. 436 GENERAL BAD DIET, &C. First week, December, 1854, 1 to every 2 men. Ditto, January, 1855, 1 to every complete. man madioit These entries show, as far as they regard Food, that thjtci whole dietetic system pursued in the Army was bad. Iij^iiii fact, it was nothing but the merest haphazard. The resulip was inevitable after these conditions had been permitted tiuei exist. lurli It is not to be assumed that the whole of our disaste^nie in the Crimea was due to salt provisions. On thirisl contrary, it is most dangerous to the attainment oiai practical truth, to ascribe the disease of 1854-55 to an;itapi one defect alone. It is unquestionable that no amount ojcoi fresh provisions would have saved that Army from sciuT(|ij and death under such circumstances as those from whicliisi it suffered. Scurvy has been seen in armies which neveiiBo had a day's salt rations. It is unquestionable also tha^jl no army ever died of salt rations alone. But, under sudjL circumstances as those which existed in the Crimea, ijb was imperative to make an entire and immediate changdln from salt to fresh provisions, as soon as scurvy appeared ,,f; this would have saved many lives. The scorbutic diathesL'infi depends, however, on many other personal and local condi-i|i|i tions, and it is a superstition to suppose it only arises froncii^ salt meat. Had fresh rations been issued every day, anCute cooked (or rather left uncooked) after the maimer of thcifie] salt rations, the men would still have suffered froiD|L disease ; hence the stress that has been laid in thescljjj Notes on the subject of Cooking. Did we but know itsiiji extreme importance, and how any food imperfectly cooked»iti, is at least as great a provocative of disease as salt)!]. })rovisions arc, we should have paid a little more attention to Cooking in the case of Armies. MR. Alexander's letter. 437 Che fact is, that when men are exposed to unaccustomed c iditions of climate, dress, shelter, fatigue, damp, foul a &c., it is of imperative importance to give them a n ;ritive, well-cooked, and varied diet, in order to enable t] constitution to select and appropriate the elements ri uired for making up the waste. It is safer not to e: »ose men to such conditions, than to trust to being able t( neutralize them when they have arisen ; hence winter qirters have always been the safeguard of ancient a: lies. But, as there were none in the Crimea, the army p ished through neglect of these preservative conditions. ^ army either, be it ever so well fed, or cared for, will eape zymotic diseases under defective sanitary con- dions. These diseases pay little respect to good living, lis is also shown by the Crimean experience. Hence tl' supreme importance of sanitary measures. But they dcnot render the other measures unnecessary. /Vhat were the causes, besides Salt Meat, of the disease Mr. iE:he Army Mr. Alexander has admirably summed up in Lttter^onThe a litter to the Principal Medical Officer, dated December causes of ^ Disease, K 1854. ^Vant of rest, exposure to cold and wet, harassing duties, iiufficiently nutritious food, no fuel for cooking, want of cl thing (the men being almost bootless, and in rags, with 0: 7 one miserable worn-out blanket), tents not affording p: cection, for several days full of mud. Rations have, gierally speaking, been 1 lb. fresh or salt meat, 1 lb. b;3uit, 1 oz. (raw) coffee, 1| oz. sugar, with rice, or b ley, 1 gill rum. Bice only issued 4 days, barley 1 day d -ing the month. Vegetables were in use for the former p tion of the month, as well as meat, alternately fresh a:l salt, for the later portion salt, not always full ration. VIr Alexander recommends " huts for men with cooking pees, fuel, cooking utensils, clothing, blankets.^' 438 CONCLUSIONS AS TO SOLDIERS DIET. Eemedies and Preventives of Scurvy. Conclusion. The letter is remarkably interesting from showing th{ uncooked fresh meat appears to have had as prejudicial i eflPect as uncooked salt meat on the men^s health. | } When scurvy has appeared, an instant change of di(' ^ an issue of lime-juice and vegetables are the remedii : which, in our case in the Crimea, were not supplied, ^ has been shown. But, in order to prevent scurvy, ^ must trust exclusively neither to fresh meat* nor , | vegetables. A nutritive and varied diet, as has been sai \ varied to meet the conditions of climate, season, fatigu i and the other circumstances to which troops may ^\ exposed, is the essential. For variety is a main thou^' indirect preservative against disease. But in the Crimea, during a winter siege, warm clothin, blankets, good shelter, supply of fuel, cooking places ai- '! vessels sufficiently large to hold water enough to cook tl' ^ rations well, good arrangements in the trenches, a hi-, meal before going in, and after returning, as well as meai"' to dry the men after their return ; these things were f j necessary, besides a generous diet, to save the Army fro Disease and from Death. From the above, the following considerations natural arise, which have already been touched upon, viz. : — That it should not be left to the discretion of tl private soldier to provide himself, or not, with articles • diet essential to his health, but of which, in his ignoranci he cannot be supposed to estimate the importance; b.|| that the dietary of the soldier should be fixed after evei necessary scientific inquiry, such variations being allowe and designated as the period of the year, climate of tl district in whicli he is serving, and the nature of his servk * Salt is not a direct cause of Scurvy. Perhaps the only direct caui known is Ammonia. On board Guano Shijjs it has been produced, whci every other rouditiou was good. FRENCH INTENDANCE. 439 Kjie desirable ; the selection to be made by the Com- BCiader of the Forces, advised by the Sanitary Officer, ai;r hearing the practical observations of the Principal Cnmissariat Officer. Phe known anomalies and difficulties of the Comrais- French sj at and Purveying Service, no doubt, led Government ^and EasT t( the inquiry into the French Intendance which has ^ Indian Commissariat. b n carried out by three well-qualified officers.^ Sir John McNeill and Colonel Tulloch do not appear to have been sent 01; to inquire into the mode of supply of the Army — but into the Com- m ^ariat — nor into the way in which the duties of finding the Army with fcl and clothing ought to be performed — but into the way in which the Q'.rtermaster-General performs his duties. t is impossible not to come to some very strong conclusions, upon com- p; :ng the Report on the French Intendance and that by the Crimean C imissioners, together with Colonel Tulloch's Pamphlet. They are these. B . as it is a Military question, and these conclusions could only come with a: value from a Military opinion, nothing but the intense interest of the siject of our Crimean sufferings, to one who has witnessed them, could e use the placing these remarks here at all, even in a note. volonel Tulloch says " The Quartermaster-General admits that this was Let there be a h duty," the Commissary-General that " that was his," and somebody else ^^g^^^^y^^^ tit the other was his. But is there no Department whose duty it is to brin«- b ig the clothing, and not to leave it till it is on the men's backs, nor the Food and f( 1 till it is down the men's throats % Clothing :^ the question is not whose fault it is or is not, that the men were not ^^^^g^j^j^^^ c iicd, but how the men are to be clothed and fed, then surely it is D aiingless to say the Government had discharged its duty, when it had b Light the clothes to Balaclava, the Quartermaster-General when he had iiicd the Requisitions, that the responsibility of some other Department t n l)egan. >jt the same Department which brings the clothes to Balaclava be r ponsible for carrying them on to the Army, whether it be seven miles or s enty miles from the Port. Mr John McNeill carried the country with him by those few words, \,ch give the whole case : ' The most anxious wish of the country, from the Queen to the humblest c ler subjects, was to provide the Army of the East with all that was I essary to its welfare, and even to its comfort ; there was no time, from t commencement to the termination of the war, at which the people of country were not ready to furnish any amount of funds that might be 440 FRENCH INTENDANCE A modification^ however, of the Commissariat dutidtsp exists in the Indian service, which, though much neardii^i considered necessary for that purpose. The resources of the country well '^'^ greater than at any former time ; its power to produce every manufactun"''^' article that the Army could require was such as the world had never befo '*" seen ; its mercantile marine provided fleets of transports, including ilf^^ magnificent ocean steam-ships, such as no other army ever commanded) f^''' the resources of the Turkish Provinces were found sufficient to suppllF nearly three times the number of men with abundance of wholesome foS' for another year, without being exhausted ; the Army occupied the saniP ground throughout the whole time, and was as stationary as the populatic't*' of a town ; no part of it was ever more than seven miles distant from secure harbour, and a considerable part was encamped within a mile or t^jj"! of the port ; the Allied Navies had undisputed command of the sea, sotlu vessels of all classes navigated it with the same security as in a time ( profound peace. Yet the country is expected to believe that, with all almost boundless resources and these means and facilities, it was impossiblijf^ by any exercise of talent, energy, and foresight, to provide either sufficierlF' food or sufficient clothing for twenty or thirty thousand men during thei'f''' first winter in the Crimea." But there is a still farther question. If the Army had been seventr miles from the harbour, there ought to have been a Department who8|'* duty it was to bring food and clothing to the Army wherever it was- upon whom the Commander of the Forces could have laid his hand anc said, It was your business and no one's else to clothe and feed these men and they are not clothed and fed." 'f Let us never need again to bandy the question about (like a parcel o unruly servants) as to whose " place " it was. We know now that, in January, 1855, we were losing men at the annual rate of 1,174 per 1,000.: we know that, in that month, there were 12,000 Infantry in Hospital, and only 11,000 in the trenches. Either this is true or it is not. There is no excuse ; for the thing has happened. If a Eegiment has starved, it is no excuse to say that its food was on the Black Sea. To organize a system by which an Army should always have its roasted and ground, and its clothes carried seven miles, might be an answer sufficient to the questions asked by the Committees, the Commissions and Boards which have hitherto considered the subject. It would be no answer to the Queen and the people, requiring to know how another Army is to be governed, so as to save it from a fate similar to that of the last. It has, farther, been said that the Quartermaster-General's Department, the Adjutant-General's Department, and the Commissariat Department are the organization to preserve the Army in health and efficiency, and are amply sufficient for the purpose. It is difficult to define the respective duties of the two first DcpartmeiitB. as they themselves admit. But the following is an approach : AND INDIAN COMMISSARIAT. 441 :o We principles of the British Army than the French Midance, supplies those wants and removes those Til Quartermaster-General is to provide the Soldier with shelter, water md ads, to take up the ground, and to " authorize the issue" of blankets, ,'reailoats, and all that is comprehended under "warm clothing." T;, Adjutant-General provides the uniform, or regimental clothing ; telU:f the men to their duties, and has authority over all appertaining to iisdine. I4 ly, the Commissariat supplies food, transport, and stowage for stores; bein in this last office, the Store-keepers and Carriers of the Army. Tl ;e are the Definitions of their duties. Here follows the Problem, jpor he solution of which the lives of 30,000 men did depend, and those 3f n ly more will depend again. G;,;n, upon Sir E. Airey's evidence, that the Army was not clothed — ^iye^ upon the evidence of almost every Commanding Officer and Regi- aien i Surgeon in the Serivce, that the food was bad and insufficient for meiLa active service — that the shelter was equally bad — that the transport Ud ft exiat, — Is lere a Department, or, if not, can one be organized, whose business it ^hal le to see that the clothes are on the men's backs, and the food in the men, mouths 1 B^comparing all the curious evidence of Regimental Surgeons and Commanding Officers, now in our possession, we can see that there was no imifioaity of system, that some Regiments suffered more and some less, acco ing to the measures adopted (of their own accord) by their Com- man ng Officers. B„ let there be a Department, whose duty it is to go to the Commanding Otfu of a Regiment, and say, " Sir, it is my business to see that your men re clothed and fed, and they are not; to see that their food is pro- perl cooked, and it is not." Let this Department, in its turn, be amenable to ti Commander of the Forces, who can, if it breaks down in that duty, kao apon whom to visit it. ^ >v, the food and transport are in the Commissariat's hands ; the water, w.. clothing, tents, and road-making in the Quartermaster-General's, &c.,:c. L us have a Department which has the responsibility of providing food and ransport, tents, and clothing ; in short, all the organization to support life 1 an army, and about which there is no question— if the clothing IS D on the men's backs, whether it is seven miles off or 3,000 miles off; it ii lot there, and they are responsible. Conel TuUoch dwells much upon the fact, that Lords Lucan and Caigan did not know how to cover in the horses, to give them shelter, to n>ie mvas or pits, or this, that, or the other. Colonel Tulloch is a man of invtive mind, who would have known how to devise all these things; Let there be a Department to provide Food, Transport, Tents, and Clothing. 442 FRENCH IN TENDANCE anomalies by which so much suffering has been ocif.i, sioned in the late Campaign. j {i The second Burmese War, in some degree analogous bjii the Crimean Campaign, was a severe test of this specsiite of Commissariat. The many stupendous expeditions if|[ the British Army since that period, besides the ordim^tl marches of British troops in India, which are in thehisi selves the most searching trials of Commissariat proi-iri sion, prove that the modification of the Commissariat i'g the East India Company's Service deserves respect ain imitation. Ii] The primary difference between this and the Frenlfff Intendance is, that the Indian Commissariat is, in ^Ik respects, under the orders of the Commander of t but it is in vain to expect every Cavalry OflBcer, good or bad, to hV^^^ builder, or every trooper to get off his horse, and set to work to shelter] ;j) and a Military Secondly, let there be a Military Train, from which a number of men i^. Train, to be brought, Avho know, as their trade, how to run up buildings to shel furnish Men both horses and men. It is but an extension of our ovm. Sappers and Mind IS foi Building, -j^^^ these men, as well as many other trades, be at the disposal of tjjii Department whose business it is to find shelter, food, and clothing for t j , troops. ' The French heen constantly reiterated, " VVe were not prepared for a campaijl have already in the Crimea; — we did not expect to winter there." But neither we | this the French prepared ; neither did they expect to winter there. They h i organization, j^^j.^ jj^ouths to feed, less transport to feed them with, than we had. Yet the first winter, it is now beyond a doubt, their clothing, food, w Ij transport were far better than ours, and their Hospitals better appointed. , They have but two Departments— that which regulates the discipluiF and duties of the Army, and that which provides it with the materilli necessary for its existence. ij The War Minister is the one head over both. The entire separation of the Civil administration from the Military, tl, ' making the soldier an instrument to fight, while all his wants are to provided for by civilians, is the bane of our Service. C In the French Army, the first " pick " of the Conscription is for ii'j Military' Train. The whole of the Officers for the Intendance go through ; Court< (V Administration, those who pass their examination are appointed 1 ! the Intcudauce, the rest curry their improved education into the Army. AND INDIAN COMMISSARIAT. 443 fo.es, whereas the French Intendance is dependent upi its centre in Paris; that the Indian Commissariat kevs its own accounts, with an independent audit office, a'$istem precisely similar to that of the national accounts in 'England, whereas the French Intendance is charged wi the separate administration and control of the Army, ex'usive of all that belongs to military discipline and op ations. lie Commissariat in India, instead of embracing the m! agement of the military chest, i. e., the banking of th Army, is, as before stated, a distinct department uEier the Commander of the Forces, having, nevertheless, its centre of supply and regulation at the Presidency, wii its central officer for the whole Presidency, Its fu ;tions are confined to the providing subsistence and mi ns of transport for all troops either in the field or in ca:onments, thereby appearing to involve the Purveyor's di^es. 11 cantonments, which are equivalent to Barracks, th " Public Works^ Department " has duties equivalent to hose of the Barrack Master. ■he Officers for the Commissariat carrying on the class ofluties, technically called "subsistence'^ and "trans- pc are drawn from the Army and have at their head a ieutenant-Colonel or Major -General. Their import- ar 13 is so great that their appointments are confirmed to thca by the Governor- General. The Officer is subjected toi primary examination and to two half-years' proba- ti(i, one in the Central Commissariat Office of the P sidency, and one in the Military Auditor-GeneraFs 0 ce ; finally, he passes through an examination before a >oard, and then only becomes permanently attached to tfc Commissariat Department. If, however, he should 444 LORD Raglan's specla^l intervention fail in this final examination, he returns to his form; regimental service. | (i' The result is, as may be supposed, that no Officers higher attainments are found in the Indian Army th those of the Commissariat. I ( Cases of Orders were given by Lord Raglan to collect mules ;| g^ven by LoTd ^licant, and also (together with oranges) , in Sicily, Cretj Eaglanfor Mai or Fellowes was sent, in this latter case, as for supplying special wants, special service, with a Commissariat Officer, who reprt sented the Paying Department, inasmuch as he drew an negotiated Government Bills. The above are two distind instances of the interference of the Commander of ih Forces, as such, with the duties of the Commissary j General, in cases which combined distant action, larg expenditure, and a pressing want. j Here it would appear that the Commander of the Force:; promptitude arose from knowing that a common order t the Commissary, such as would have been given in SpaiH) to collect the mules from the surrounding districts, pay ing a fair value to the owners, would have proved of m effect, because there were no mules. In this particulai* the Commander of the Forces seems to have been well informed, — and, had he had a Sanitary Officer or Boai'c attached to the Army, with power to make reports, markec, " Urgent,^^ we may fairly infer that he would have takcB- measures, equally prompt and efficient, for procuring and bringing to the troops such provisions as would have pre-, vented them from starving upon salt meat and biscuit,' as soon as he was made aware that these articles of diet IN PARTICULAR EXIGENCIES. 445 acially do not give sufficient nutriment to enable a mi to resist exposure and severe labour, but engender di ase in the strongest constitutions. We are the more ccdnced that such would have been Lord Raglan's m sures, when we see him actually taking the initiative in he matter of the lime-juice ; when we see him, within U days of his detecting its existence in store, from a rem furnished him, at his own desire, by the Com- m^ary, January 24, 1855, putting his Adjutant-General ill' communication with his Principal Medical Officer ujn the subject, and within three days more, publishing hi General Order, making it a part of the Ration, thus a(ng Principal Medical Officer himself; and, when we se him, too, urging and almost forcing upon his un- w ing Commissary the supply of fuel. 'here exists evidence that the Medical Department, ne soldiers and not for the Canteens, they had very little ect. No uniform system appears to have been adopted. Mdiers on leave in great numbers, and officers' servants, well as soldiers going down to the port for their regi- 3nts, frequented the market at Kadikoi, which was a -ecies of German fair, in which every kind of thing was ICS 456 CANTEENS. sold, the articles of largest consumption being sp ts porter, and wine. Kadikoi was apparently under no r ^. lation, after some kind of permission had been grante t( build the respective huts, except that the Provost-Mai !ia from time to time appeared by his policemen for the re rention of riot and taking up of thieves. The regula1i)n! thus regarded the after effects, not the preventioijirJ?'! drunkenness. : ' ^ Spirits were procurable with great facility in Balacjvs^^o! also; some of the Medical Staff Orderlies in the Gerlriliiel Hospital were constantly intoxicated, and some die(;oi,P! delirium tremens. One of them, who was employee |tr?!' carry milk daily from the General to the Castle Hosp having been found repeatedly drunk, was excused punishment on the ground that to pass through a s; portion of the town was a greater temptation than a could be expected to resist. With the deepest regret I record, upon my pers authority, the fact that our own soldier-patients have seen, stealing past the sentry, in blue Hospital gown slippers, on their way to the nearest canteen, in a Gen Hospital in the Crimea; and that British soldiers tj been seen exchanging clothing for drink at a Sard canteen. 457 XVII. Soldiers' Wives. ^OR many years, women have been " allowed to be Women IfDgnized as belonging to regiments, and consequently, Barracks" Cnmanding Officers have been allowed to give leave to c^ain soldiers to marry. n the few garrisons of England, such as Dover, Ports- nuth, Plymouth, barracks were added to the ports; and ii other places, barracks have gradually arisen, so that t]3ps are almost always in Barracks, except on a march. kYomen, then, being " alio wed,'' and barrack -room Nature of the . ,T ••IP, 1 Accommoda- te stmg, eitner m the original fortresses or more modern tionin /ibrracks, these women are lodged with their husbands, as Barracks. cmce may assign them, at the rate of six per 100 men, a will hereafter be shown. rhe only refinement beyond this, up to this time, is, rtiit the whole of the married men and the whole of their T/es, with their families, have been placed together in C3 or more barrack-rooms; i.e., the available space of carters has been allotted in a different manner, but i : increased, on account of the women. This is called living in " married rooms,'' and no par- tions are allowed, except at night, when temporary ones usually put up with blankets, &c. In other regiments, the Commanding Officers direct lit every room shall have one married couple, with their < ildren, if they have any. The woman is allowed a bed ^ 5 d bedding, but not the children. Where, however, in such quarters as the Tower of )ndon and Dover Castle, spare room necessarily existed, e having been used for political prisoners, the other 458 ACCOMMODATION FOK SOLDIERS' WIVES. having extensive casemates, Serjeants' wives have bei allowed separate quarters, each with her husband, am this practice obtaining, was then in some cases, extend' to barracks. Indeed, they are now ordered to have sep rate rooms. i In common Barracks, it may be presumed, therefoi that Commanding Officers managed to assign odd corn(, wherever they could, by forcing the troops to close up their quarters ; for, by the fortress system, Serjeants h: gradually obtained a quasi prescriptive right to i\ indulgence. Women out of The Government allow the Commanding Officer to gi Barracks. three women, besides the six per 100 who are allowed i dulgences in Barracks,* 2d. per day to live out of Barrac if they wish it; but they lose their fuel, &c., and in li town that I am acquainted with in England, Ireland, Scotland, could an unfurnished room be had in the neig bourhood of the Barracks for less than 2^. a week. — He' is the furniture then to be had ? The Soldier's pay is 13g?. a day. The wife, if allowed be married, is employed in washing either for the Office or men, which at the outside will enable her to earn 6c?. i day. i The women married without leave have no siu means of living, and depend entirely upon their husban( being allowed by the Captain of the Troop, or Commant ing Officer, to be out of mess ; by this means tl family has the 13c?. a day to spend ; but, if the men arem allowed out of mess, they have their f lb. of meat and 1 1 of bread for 4^^d, ; the contract price for which may 1 1] * It appears, from a Return of the Barracks and Encampments occupi on January 1, 1857, lately presented to Parliament, that, out of 251 si tions, at 20 only is there any separate accommodation provided for marri' soldiers. ACCOMMODATION FOR SOLDIERS' WIVES. 459 h lier, but the Government charges the Soldier the same aliome and everywhere. f a woman is to be confined^ or is ill, she has frequently toe treated in a Barrack Room. A fatal case under SI circumstances has recently occured. ^his is the nineteenth century, and England is supposed toe a Christian country ! f married women are allowed by the Regulations, as a What ought to cciponent part of a Regiment, they ought to have provi- ^WomeTin^ si I made for them. Barracks. Ivery couple should have a room to themselves, with fu and Barrack furniture also.* 'he allowance granted for tlic carriage of Baggage (viz., scuuch a mile), since the opening of railways, is sufficient to onvey also the regulated number of women, and perhaps m^e. L ward should be told off in all Hospitals (or wards), fo the accommodation of women and children, and a in Tied orderly of steady habits in charge of it. 'he wives of the Staff Serjeants should not be carried oil a march, unless the Baggage Fund was more than eiugh to carry the privates' wives. 'he state of things above described remains to this State of things -, T T . Sit this day at d{, and is illustrated now at Aldershot — where huts Aldershot. ej't, in which married men and their wives are con- gi'^ated — without any classification or separation. Canvas sevens separate the famihes in those regiments where C amanding Officers are most considerate of the morality of heir men. ince the disbanding of the Militia, the Camp at Alder- sU may be considered henceforth as standing quarters Might not, also, more discretion be allowed to the Surgeon in taking a)t,rried man into Hospital, if he had a separate room, as it entails star- va^u on hie family ? 460 ACCOMMODATION FOR SOLDIERS' WIVES. I of Regiments of the Guards, Line, &c. The normal staj^i^" then, being arrived at, is nearly the same, without muii^'^' improvement, as that of the ordinary Barracks and Garl*'' sons of Great Britain. j i'' It is said that, in the new Infantry Barracks, there to be separate quarters for married women, at the rate If t^'- six per cent. Leave to As to these " allowed'^ women, the present Regulatioi, ^ Marry. . . . which are annexed, practically authorize Commandi;, Officers to grant "leave to marry'' to a certain number i:': soldiers.* * Queen's Kegulations.— Page 353. Paragraph 1. " When a Eegiment embarks for Garrison Duty on Forei Service;, the lawful wives of soldiers are permitted to embark in the ^ portion of 6 to 100 men, including Non-Commissioned Officers." j'*' 2. " When Regiments embark for India or New South Wales, the wi" of soldiers are permitted to embark with their husbands in the proporti^ - of 12 to 100 men." j ^' 3. "When a Regiment is embarked for Active Field Service, embarkation of soldiers' wives is altogether forbidden." ^ 5. " In making the selection of women to proceed, care is always to '\ y taken that those of the best character and most likely to be useful are fiii il chosen. And no greater proportion of Serjeants' wives is to be select than the Serjeants' wives bear to the Corporals, Drummers and Privates the Battalion." 6. " Officers commanding Regiments on Foreign Stations are to speci in the Returns which they transmit to the Depot Companies at home, tl vacancies which may from time to time occur in the regulated number ' ^ soldiers' wives, and the names of those proposed by them to be sent oi' with detachments, to fill such vacancies." 7. " It is to be considered a rule, in no ease to be departed from, tha " women who have joined the Regiment without authority, who may fin their way out to the Regiment, who have been taken out, or, who may, b' ' the permission of the Commander-in-Chief (obtained through the Quartc « master General), accompany Officers as servants in their families, an'^i afterwards quit such service, should they refuse to be sent home at th' ^ expense of the officer, in conformity to his engagement when such pe; , ' mission was granted, are not to benefit by being allowed at any fatui( ^ time to fill the vacancies which may arise in the regulated number fo' f whom rations are allowed, and which must be reserved for those who hav^i waited at home for their turn to go out." * ' 1 ■ LEAVE TO MAURY. 461 l!e Commandmg Officer is restricted to no other rules aud;o no qualifications of the women. These depend, tliesfore, on the temper of that officer, or his amount of howledge of the future fortunes of the regiment. le soldier^s selection may be restricted, at the time he.* tains leave to marry, to Canada or to the county of Gal ay. In the one case, the woman practically has no 8. To such wives of Soldiers as are not permitted to embark with theit usbands, the rates of allowance authorized by Act of Parliament are gran I, under the Orders of the Secretary-at-War, to enable them to pro- ceed ' their homes, or other places at which they intend to reside during thej^ence of their husbands on Foreign Service." .JIWar Office Regulations. — Page 59, (1st Part of the Book). flligraph 5. " Such lawful wives of Non-Commissioned Officers and Prives, embarking for Foreign Stations, as may be permitted to accom- panjhcir huKsbands, not exceeding in number 6 for every 100 men, — (exerting regiments going to India or Kew South Wales, — on which ocoatns 12 for every 100 men are allowed), shall, if the Officer command- ing; 13 Station judge fit, be allowed for themselves and legitimate children, iHOvions according to the following rules; namely, — • -cry wife one-half the soldier's ration (liquor excepted), and every child le-fourth of such ration, if under seven years of age, and one-third, if oyond that." Addenda to War Office Regulations, 1855.— Page 56. (Relating to Camps.) Pagraph 8. "In these accounts the rations authorized to be supplied t'> <''cers' Servants, not being soldiers, and to women, are not to be inch ed, although these parties receive the benefit of the Public Con- tract.' Queen's Regulations.— Page 237. 1 ttmmanding Officers of Regiments are to take care that the number of sol rs' wives permitted to reside with their husbands in Barracks do not ex( \ the proportion allowed by the Royal Warrant, viz.,— four women pel ^oop, or Company of 60, Rank and File, and six per Troop, or com- pai >f 100, Rank and File,— exclusive of Serjeants. i^ldiers who have m rried without the consent of their Commanding OflK>s are, under no circumstances, to be allowed to iiave their wives m Bar,3ks, or to participate in any of the advantages allowed by the Regu- lati(3 of the Service to married soldiers." 462 soldiers' wives in BULGARIA. home or friends to return to; in the other, she wild and illiterate as scarcely to know even the Ian agr spoken at her new quarters. Agjain, native Indian vlnei returning with their husbands from India, suffer mi h ii England. On an order for foreign service, the Comma iinc Officer takes the number allowed, viz., six per ccn tin individuals generally being fixed by lot. In the last Campaign, regiments have been kno a t( bring out from eight to twenty ; and, of the regi ent: which arrived later, some brought none. In peace, women are allowed to take their ch Irer with them — of course, not in war. Nevertheless, ken were more than 100 children born with the Army, bwlef: those which stationary Serjeants had sent out to lj and, although the mortality among infants was very about fifty went home with the Army. Soldiers'Wives it is difficult, and perhaps not necessary, to descrili m Bulgaria, gj-g^^ suffering of the women in Bulgaria, not o| whom had any information as to what her wants wou or how to provide for them ; nor could she, on her aiwal. obtain any advice as to the present or future. She mid receive little from her natural protector, who was empgred f) on other duty. Her only theory of protection was, thiiiei-tj regiment would never desert her, unless by general (Jer.;.,, By the " privileges of the regiment,'' a half rati | isij, allowed the soldier's wife. She also obtains ter%e, • equivalent to the quarters before described, and amon her private gains the washing for the Officers is what she i^ks , upon as a certainty. She is not allowed any bajige., (except the bundle which she carries), sea-chest, b(4or.. bedding. She is allowed the use of ordnance beddinB With these exceptions, she has nothing which amAs,^ to status in the Army, or approaches that of the Fifth soldiers' wives in the CRIMEA. 463 I mtiniere, the only woman allowed in the French Army, ! le Cantiniere is the wife of a soldier who is told off to 1 :end upon her in the discharge of her defined duties, i iich are to supply the French soldier with wine, spirits, d whatever else he may require under regulations. From Varna, the women of the British Army were Soldiers' ibarked, after more or less delay; some even went with tlie WaHn'tlfe eir regiments to the Crimea ; they were not, however, Crimea, rowed to land, but sooner or later all were collected at ;utari, except a few who had gone up with their giments to the Crimea after the first occupation, and me individuals who had found their way there from the ass with the baggage and stores at Varna. During the distress, a few in the Crimea returned to mtari j a few even remained on board the transports for onths. In the spring and summer of 1855 and subse- lently, a great many women were collected in the irimea ; many having gone up, surreptitiously, passengers . the French paquehots, and made their way through le French camp ; some having gone concealed onboard ir own vessels, and some with late-arriving regiments, hey were allowed, by the Commanding Officers of regi- ents, to remain till the end of the Campaign, when the igiments which sailed in transports took their women ith them. But no such privilege could be granted to ose who sailed in a man-of-war, as Naval Officers only !ceived on board the exact number of men ordered. The unacknowledged position of the women in the rimea gave rise to irregularities and to hardships too lainful to describe, because to do so is needless. Their :ate was not the result of any order or recognized custom. Suffice it to say that there was actual danger of about nxty women being left behind, and all protection having eased for these women on the embarkation of the yi 464 soldiers' wives at scutari. j Commanding Officers of their regiments, they eiier individually reported themselves to Miss Nightingal or were reported en masse by the Commanding Officers ho left them. The case, being unprecedented, fell undeno regulation, and could only be finally disposed of, ;ter'' applications in several quarters, by the Commander o: ;he Forces, or rather by his ^' alter ego the newly-cre ;ed Chief of the StaiF, who exercises supreme authoritlin his stead. His disposal of the matter was an ordei for the transport "Thames,^' to take the whole of the wo en to England, calling at Scutari for the other regimdtalji wives, whom the Commandant at Scutari was ordere to - send home in the same ship. The state of the women at the base of operation or General Depot, including Scutari, Koulali, and oier places on the Bosphorus, has now to be particular] :;d. It was perfectly analogous to that of any common Br; sh Barrack, with two differences. Firstly, they were in a Mahometan country, with rj few means of communicating with the population arc ad j them, and none of deriving any assistance from them, tn ' the second place, their quarters at Scutari, with he exception of those of two or three Serjeants' wijs, who had possessed themselves of odd corners in le Towers of the large Barracks, were of the worst descp- tion the place afforded, — dirty, out of repair, with ca- gerous holes in the floors, some of them dark and da p, ^ and one or two with broken drains, admitting effliia which produced fever. To add to this, the quarters were filled up with ] W comers, till the space left for walking between the ri s, . which they attempted to hang up between the paillas s, ^ was filled with bundles, broken boxes, and their w plates and cups, and daily provisions. Most lay on e ^ soldiers' ^VIVES at SCUTARI. 465 jor, which was sometimes brick and sometimes earth; me had boards and trestles. The sick and the lying-in omen were mingled with the rest ; and, among this mass, le husbands took up their regular quarters. A very small Drtion of lamp-light was allowed, and what with the igs hung round the beds, the place was nearly dark, he meals, such as they were, were eaten in winter-time i the light of a rush-light which each had contrived to )rrow or to buy. This state of things is by no means better than the )odes of the lowest Irish in Dublin. But it had one convenience which these have not. The lodger remains hilc he pays ; but the soldier's wife was often moved four • five times, as the quarters were gradually repaired, till ) room remained which had not fallen under the hands ■ the Sappers and Miners for repair. As soon as the iiarters were repaired, they were allotted either to sick — 1 being reported good enough — or to troops. ' The women who came down from the Crimea were in a iate of filth, and nearly destitute of clothing. A Medical OflRcer was told off to attend the women ; it whether they could find him or not, in case of need, as, at first, another matter — depending upon the Serjeant charge of the room, who was every day necessarily )sent, or upon any other person being found to go for m. I The Serjeant in charge was merely the senior Non-Com- issioned Officer who happened to be in the room, and ho might be, of course, changed from day to day. Between the time that the army left the camp at Scutari id the Battle of Inkerman, the women were compara- ively few. The only employment they could obtain was le little washing of the officers of the General Hospital, liich was performed in any vessels they could manage to 2 H 466 get togetlier_, and with any fuel they might be able to Soon after Inkerman, it was found that the Washigt'i Contract for the Hospitals had broken down, and a Wai-- ing Establishment was set up by Miss Nightingale, whh employed a considerable number. Tlie Purveyor ao made an attempt to employ women, on seeing what Id been established, which occupied eighteen more. The oif.j apparatus these had were a few crocks and a little chare I ■ ' which they bought, hot water being obtained by bribi» the orderlies with porter. About this time, many begilf to be employed in making the clothes which were gii to them, and in other work for which they were nji to a considerable extent. This was continued for a loji'isi period. ||i They were also employed by private interposition i nursing sick officers_, sick medical officers, civilians, ali, women, and paid by private funds, as the Governmc,b,] nurses could not be allowed to go out of Hospital. | They were also recommended to private service amo^r^, the officers' wives and British residents at Pera, by tf\^ same means, after having been tested by the employmei ? heretofore mentioned, to the number of 20-25. , ^ After Christmas 1854, when numbers had arrived frcj;j Varna and the Crimea, every effort was made to persua|ij. women who were able, to go home ; and an order wr^^ procured from the Commandant that all widows shou, be sent home. Those of very disorderly character, up(j ^ being reported by the Provost-Marshal and the Adjutaij ^ were also ordered home. Each woman who went hoD | had an outfit, provided by private funds. ; '-^ Children. During January 1855, there were twenty-two infants j | the depot, and many were subsequently born. ^ ,| Sickness. The sick and lying-in women, and infants, were reHev(. ^, by private funds wdth food and clothing, and a sma ^ soldiers' wives at SCUTARI. 467 Improvements Jing-in Hospital was properly fitted up by the same rans over the wash-house, in December 1854, with paid r '.'ses. The fever which had broken out among the women in t depot, produced an alarm which, after much solicita- t i, induced the Commandant to grant a house in the t( ^u, obtained by requisition from the Pacha, on payment 0 1 rent. This was partially repaired by the Engineers, a I cleaned, fitted up, and furnished by private funds. It V, ; of considerable size, and at one time held about forty w nen, the sick and their attendants, and some few who l(ged there, and did the work provided for them. Chey were very well superintended and the plan was p fectly successful. In 1855, a small school was added, inThecom-se" a lumber of children of civilians and stationary Serjeants h ing collected at Scutari. n June 1855, the depot having been moved into huts n May, three huts were appropriated to the married T^nen and their husbands. These were divided with ci' tains and fitted up by private interposition. They were d ent, more healthy, and far more comfortable than the ^nen^s quarters had previously been. A washing hut also provided, which was a great boon to the women, riy Alicia Blackwood's efficient and systematic efforts p duced great reforms. Finally, the women went home a he breaking up of the depot in the vessel obtained for tl se of the Crimea, which was ordered to take them up. TSy are passed home on landing in England, according tcthe general order, by the Quartermaster-GeneraPs Gice at the port of arrival. The first amelioration of the condition of Soldiers' wives Obvious ^ild naturally begin by an uniform order, fixing the ^ ^^brmade.*^^ n'nber of women which should be allowed to each Regi- Number, ttat, in proportion to its strength, both with regard to 2 H 2 468 IMPROVEMENTS SUGGESTED. the companies of the Regiment on service and those in thej ^ depot. The statement given before sufficiently shows tht! j accident which rules the present allowance of women jjl A register is kept in every regiment^ in which th\^ names of the women married_, with and without leave, artjjj recorded. In some regiments, when a vacancy occur[j|j, among the six women per cent, allowed indulgences iij^^ Barracks, the Commanding Officer fills it up from th(j|jj women who have married without leave. In othe]^^ regiments, the Commanding Officer will, on no accountjjj] do this. Selection. Secondly, the choosing by lot should be abolished and a mode of selecting the women most proper.jj, according to their seniority and other qualifications, shoulc| be adopted. The female volunteers might be selected bjj]| a Board, formed of the Colonel, Adjutant, and Chaplain,! and passed by the Surgeon. But the security would, L however, chiefly consist in the report of that Board, sentjj to the War Department, so that the women of a Regimenlij should be personally known, as well as its men, to thatL Department. Quarters. Thirdly, it is obvious that the brutalizing state of the quarters, not only as described at Scutari, but in ordi-, nary barracks in England, must be abolished. The pro- vision for married soldiers in barracks, need not on thatj account be very large, as quarters might be hired for them in the town where the barracks are, where a few of the husbands might be allowed to reside, the others being allowed at stated times out of barracks. By this means, a great economy might be effected, while the different degrees of indulgence would tend to discipline and regu- 1, larity. ^^ Employments. Fourthly, to this improvement in quarters must be added, ^ privileged employments in Regiments, such as Canteen- j STATISTICS AS TO SOLDIEES' WIVES. 469 k€ )ing, a portion of the tailoring, washing, mending, &c. It s not at all beyond fair expectation that a certain nr'iber of women should be accepted to fulfil certain us ul offices in each regiment, and be so highly rewarded th. not only respectable women may be tempted to marry sdiers with a view to them, but that they will have the hifiest incentive to good conduct in avoiding the risk of Dsing them. If these offices and duties are found of se, and it is important to give encouragement, pre- mims in the way of pensions might be offered for a ce:ain number of years' service. ■ the whole number of women who may be permitted to larry into the regiment cannot be so employed, still bi|i remuneration might be secured for a few, which weld encourage the rest ; and these few might even ha} some honorary distinction, approaching the uniform, lik the French Cantiniere. ft appears from the records of the Royal Commission of statistics as to thtPatriotic Fund, that about one in seven and-a-half of "^wfves! tb soldiers of the Line is the proportion of married men to ingle. 1 1851, by the Census Report, one in 6^^ of the men, inmding Non-Commissioned Officers, was married. ut of 6,593 Officers of the Army 1,675 had wives. „ 136,277 Men „ „ 20,755 Total 22,430 wives. 29,782 children. ; should be remarked upon this last return, that the ssive mortality among soldiers^ childr(in reduces the iber. : does not seem, therefore, that the discouragements ^^\'^"g^f 470 STATISTICS AS TO SOLDIERS' WIVES. Marriage do not appear to be successful, except in demoralizing the condition of Marriage. Condition of the Sick Wives. to marry in the British Service have been successful. G| men are not prevented from marrying, but only marrying respectable women. A report by Dr. Letheby, on the state of unhealthii and indecency which he found in an Alley in London, recently excited universal attention. Those who have b«| the most sliocked by its frightful details appear to be h.\ aware that the state of the wives and children of soldi! "allowed'^ to marry is at this moment, and at hoi worse than that of the London alley recorded by Letheby. I have seen lately in a casemate at Brompton, n! men, nine women and twenty-three children, living a sleeping together, where there was only one door am small window on either side, the ceiling being coved a| bomb-proof ; and where the atmosphere was such that would be impossible for each family to be prope screened off from another without risk of suffocation. How is it possible for the morality of the soldier to raised while the immorality of his domestic relations] thus made inevitable ? Marriage with the soldier is, more or less, a licensj concubinage. The number of Pensioners who have mJ than one wife living is two per cent. ; and it has bel known to exist as a supposition among the soldiers, th^ if they marry three women, they cannot be tried bigamy. The condition of the sick wives is another considei tion. The Medical Officer is almost uniformly kind to the poor creatures. He attends them whether married wj leave or not ; but his position, under these circumstam is one demoralizing to himself and productive of sm good to those be is thus assisting. NUMBER OF SICK WOMEN. 471 He finds the sick woman or child in such a dwelKng, id in such an atmosphere, that he can really do hardly jything for them. The husband or father frequently jsfers applying for assistance to a common Dispensary, 'le Medical Officer has no means of ordering anything ]t medicine (which he ma}^ order from the Medical lores), unless he puts his hand in his own pocket, which liny have not, of course, the means to do. Extras or Hic he may not order from the Hospital Kitchen. What reall}^ happens when the Medical Officer is ; lions or humane is, that he does order wine or extras, id accounts for them to some other name in his Extra et Roll. It is true that there is a regulation enabling Medical tficers, with the sanction of their Commanding Officer, 1 take sick women into Hospital, but it is rarely, if ever, :idc use of, for the sanction of Commanding Officers )u]d be with difficulty obtained; in very rare cases, )uld indeed the accommodation admit of it ; and the ospital Serjeant does not like the trouble. It might be as well to add the number of women and ildren treated at Chatham during the year ending ,;arch 31, 1857, in order to give some idea of the number < cases. Two casemates at Fort Pitt are all the accom- odation appropriated for them. Lying-in women Sick women . . Infectious Sick children . . Infectious 30 26 7 12 31 Number of Sick Women at Chatham. Total . . . . 106 As, therefore, it appears that the regulations do not What can be ' ^ IF c done to 472 SUGGESTIONS. promote a better Morality. As to leave to Marry. Sleeping Rooms. Sick Wards. deter the soldier from marrying, and tliat the worn obliged to submit to what utterly demoralizes her, i/t can be done to promote morality in marriage ? 1. Commanding Officers might be limited as has b said, as to the number of those to whom leave is grai to marry. Leave might not be granted before the sol has had ten years' service, or at least one good cone badge, which involves a service of five years ; it mighi made a reward to the best men ; and the character of woman might be carefully and personally inquired i by the Commanding Officer, who might refuse unless it proved to be perfectly good. 2. A portion of the Barracks in which the regim or battalion is quartered, might be fitted up, after fashion of Greenwich Hospital, with wooden partitic not extending the whole width of the room, for the m ried men ; two iron bedsteads, where there are childi might stand in one of these partitions. With regii inspection, such Barrack rooms, it has been proved, i be kept in the most perfect state of cleanliness, ud pain of turning out the disorderly or uncleanly worn a female Non-Commissioned Officer, who would proba be the wife of a Non-Commissioned Officer, should put in charge, whose duty it should be to report : noisy, quarrelsome, or improper conduct, or any of decency or cleanliness. Separate rooms would, course, be better still. 3. A lying-in ward, a sick ward, and a ward for inii tious diseases, should be set apart for tlie sick wo and children of the regiment; and the Medical O should be able to place these upon the Diet Roll of Hospital, in the same way as the women would, w well, receive rations. A nurse should be provided the lying-in ward at the expense of the Government, SUGGESTIONS. 473 mther for the ward for infectious diseases ; Government d(5 already provide for the latter class, but for this only ; ai, in consequence of this, the same nurse sometimes at nds, as at Chatham, the lying-in women and the fever :[:s; a lying-in woman took fever in consequence and lil. Jo mis-appropriation of the sick diets to healthy wives 11 children need take place with proper care. . practical exemplification of the good of some of the i]ve arrangements for the soldiers' wives was given, as 3['ied out by General Lawrence, when in command of a 3i;alion of the Rifle Brigade at St. Louis^ Barracks, in ] ada. He also, it may be mentioned by the way, pro- r\)(l hot coSee and a bun for the men, at a halfpenny )] three-farthings per cup, which they could have before r(ig on duty or on returning from duty; the conse- }mce of which was, that all but two inveterate drinkers ;(5ed to take their morning dram. 'here will be an apparent inconsistency in the above )l3rvations, arising from the inconsistency of the Regu- 8ons themselves and the actual usages, — and also from ;] confusion of ideas between soldiers^ wives " allowed to I Ty" and " allowed indulgences in Barracks," a con- 'i on which exists in the minds of officers themselves. ^he Regulations are not enforced, which prevent those i|) have married without leave from receiving indul- ces. Virtually it is left, in a great measure, to the ;retion of the Commanding Officer. Great evil results hn this, because, in consequence of a man who has fiirried without leave being taken upon the list of those T\o are allowed accommodation and advantages for their « es in Barracks, the Commanding Officer has not the pver of limiting the indulgence of marrying to men of ^)d character. This is the result of carelessness and Some of these arrangements have actually been effected in Canada. The Regulations as to the Non- Recognition of Women Married without Leave are not strictly enforced. Mischievous results of this. 474 LODGING-HOUSES want of attention to the importance of the subject, 'ae practical eflfect is, that^the worst of women come eventu ly upon the strength of the Regiment, and misery am ig^ the married people is the consequence. ! LODGTNG-HOUSES FOR MaRRIED MeN OF THE LiNE. | . Lodging- The experiment has been tried for the Guards, the fu U Married Men. ^^r the erection of the building having been chiefly s S-W scribed by the Oflficers. A statement of the particulars of Receipt and Exp - diture is annexed, which was kindly furnished by e " Architect and Treasurer, who would give valuable inf - ^ matiou, as to the possibility of similar buildings payi ^ their own expenses. ■ " Particulars relating to the Victoria Lodging-House, VauxhalUBridge Road, London. The building contains fifty tenements of two roon i and four tenements of three rooms. It is six stories Li height, and each story contains nine tenements. j 1 The total cost of the building was ,£6,400 ; therefo ; 1 the cost of each tenement was cir. j6118 10^. Od. Tl ' excessive outlay was occasioned by the expensive natu 1 of the foundations, the high price of building materia ' the scarcity and high price of labour, and the stringe regulations of the M. Building Act. j The cost of the site was £1,800 ; therefore the cost superficial area, occupied by each tenement, was ci £33 Qs. Sd, The total expense connected with the building, previoi to its occupation, was £8,200. The following statements indicate the quarterly revenu i ! FOR MARRIED SOLDIERS. 475 am expenditure during the year^ which terminated on the 271 of July, 1857. Quarter No. 1. Quarter No. 2. Quarter No. 3. Quarter No. 4. gnp ntendence .. Cre ' Accounts . . Eat £ 8. d. U 14 6 1 12 0 6 4 3 24 3 4 £ 8. d. 13 13 0 3 5 1 14 17 3 5 16 8 £ s. d. 14 7 6 1 17 6 4 1 3 0 16 8 £ 8. d. 14 11 0 5 16 2 13 17 3 13 6 8 Tot Expenditure . . 46 14 1 46 6 0 37 12 0 17 16 6 21 2 11 63 16 3 47 11 1 41 13 9 Grc^ Revenue 93 0 1 65 8 6 84 19 2 89 4 10 ^om the above statements the following conclusions an Irawn, viz : — That the approximate annual revenue amounts to thisum of £332 12*. 7d, That the approximate annual expenditure amounts to le sum of £153 Os. Id. That the approximate annual return upon the capital of:e8,200 amounts to £2 2s. per cent." H. A. Darbishire, I "~[ Wk is to be observed that the low rate of dividend is m'nly caused by the large sum expended originally in tb purchase of the land, and the very low rents asked for tl tenements. 'he maximum paid for a tenement with three rooms is 3.' 66?. per week, with two rooms 3*. But most of the U -roomed tenements are let for only 2*. 6d. per week. n suggesting, however, the foundation of similar eiibhshments by Government in all the large garrison t(' ns of England and Ireland, it is to be considered that 476 LODGINGS FOR MARRIED MEN. Government already pays lodging money for the ma le men; that under no circumstances could the o(l^ required be so great as in the case of the Guards' Lo(!iii House; and that, although it is not asserted that'hi could ever be made a good building speculation ifc Government, yet, in the 19th century, an age of civizs tion and humanity, it is not possible to suppose that i'ja be intended to leave Soldiers^ wives in the condition now are, worse than perhaps that of any part of the j population. It is to be observed that the Model Lodging H(j in London, which are built on very expensive ground cost far more in superintendence than a Military Lod| House could do, pay a dividend of 4 per cent, toi shareholders. 477 XVIII. CoirRUCTioN OF Hospitals, especially for the Army. 1 e true principle of Hospital construction is that of P\^^ of [ e distance between the blocks should not be less than administration ioile the height. 'lere should not be more than two or, at most, three flalto the block, nor more than one ward to each flat. >r the purposes of administration, the building ought to ; in a square ; the basement story connected all round by a arched corridor, with an open terrace above. ' le whole Hospital should be erected upon an arched baiQQent. Hospital formed of separate pavilions might be built m ae, provided large, roomy, well-ventilated, and well- lig ed staircases intervened between each two pavilions. iiis is the plan of the new Military Hospital at Vin- ce es, which, however, forms three sides of a square. lis principle would have been illustrated in Netley, h it been made so thin as only to have admitted two ro . of beds between the windows, in the breadth of the wds, had there been no corridors, and had the pavilions bei separated by staircases. It would then have been peectly healthy; but administration would have been n ' difficult in so long a line. s it is, there are to be two complete and different ad- m istrations, with two kitchens, two sets of offices com- ple; it is the most expensive and least administrable ate pavilions, placed side by side, or in line. The , r is the best. It diminishes the distance to traverse to block to block. Hospital construction ; requisites, good sanitary conditions, and facility of fc Q. ^here is only one kitchen to Vincennes. 478 BEST FORM OF HOSPITAL. That not more than 100 patients can with safety a facility of administration be massed under one roof, 1 come to be an acknowledged principle of Hospital co struction. Buildings of two flats are most compatible with perf( sanitary conditions and facility of administration. Even emigrant ships the occupation is limited now to one dec Eeasons for In all town statistics, it has been found that, ccete'i above Plan, paribus, the third floor is the most unhealthy, the groii floor the next, the first and second floor the most healtt This does not refer to houses where a prince lives on t] first story, and a cobbler at the top, but where the venl lation, size of rooms, character of inhabitants, &c., is tl same on all the floors ; indeed, where the first floor ^ usually the most crowded. | The same statistics hold good in Hospitals. There invariably the highest mortality in the third tier of be( (except where the ventilation of the third floor is decided superior), because, when all other circumstances are alik the third tier has the disadvantages of the first an I second, in addition to its own. All these considerations point to the conclusion tha for the successful treatment of the sick, there should nc be more than two flats in a Hospital. Probably the bes construction, for sanitary purposes, is a ground floor fo stores, and two tiers of wards above. At the same time, i the number of patients never exceed 100 in any block three flats might be admitted for the sake of economy. Objection to '^^^ least administrable form of Hospital is the \on{ Hospital with corridor with wards of from eisht to ten patients, opening long Corridor . . . and small off" one side. Attendance, meaning of course due attentioi Wards. patients, becomes almost impossible. The abovt plan contemplates wards of 20 patients, where one orderly sitting up, each for a watch of four hours during the night, is amply sufficient. But how to provide attendance smt- 1 PARIS Mosp i t al__ de Laribois terey 612 Lits. SIZE OF THE WARDS. 479 \j superintended, especially at night, for wards of eight ten patients, is difficult to divine. The French break up their General Hospitals into parate blocks, while we sometimes agglomerate our 3gimental Hospitals into one building, thus reversing the aitary law. The Lariboisiere Hospital at Paris has accommodation r 600 patients under six roofs ; and we had in the Crimea 10—600 patients at the Castle Hospital in from 20 — 30 rge and small huts. One administration, in both cases, for all. This is the true principle. All that has to be manufac- red, as the cooking, washing, &c., should be, as much as )ssible, concentrated into one ; while human beings, sick well, should be distributed as much as possible. In London, one wash-house will do for a number of mihes, and is as good : s giving an additional room to Lch ; but this does not break up our house system and mvert London into a gigantic public institution. The best size of wards for ensuring the two conditions ' health and facility of discipline, is from 20 to 25 sick. Wards smaller than these are more difficult to ventilate f natural means alone. A certain amount of space is iquisite for diffusion, in order to secure perfect natural ^ntilation. The mode of construction in Hospitals is, it is presumed, ) be determined by that which is best for the recovery of 16 sick. If any other consideration is taken, such or ich a percentage of mortality is to be sacrificed to that ther consideration. But it so happens that the safest for the sick is the most conomical mode of construction. Take the example of Portsmouth Hospital, or Netley, tee the windows are at each end of the ward. There hould not properly be more than four beds in each of Evident danger of collecting a great number of Sick Men, labouring under Diseases of every kind, into one large Building, where they breathe a common Atmosphere. !N"umber of Sick which a Ward should contain, for Health, Discipline, and Administra- tion. 480 SIZE O^^ WARDS REQUIRED those wards. For it is undesirable ever to allow moretfe^ two beds between each two windows ; otherwise, when e windows are opened, the effluvia blow over all the int^. vening row of beds before escaping, j j Discipline. Wards of a smaller size than those indicated above, of 20 — 25, are decidedly objectionable, because unfavoyi) able to discipline, inasmuch as a small number of mj when placed together in the same ward, more reat associate together for any breach of discipline thai larger number. It has been proved by experience that the presencejp, female nurses in large wards renders discipline extremf ii easy, and that a sufficient number of female nurses cani^; be allotted in smaller wards. J, In the event of a death taking place in the ward, 13;, survivors, when they are few in number, are far n)(,3 likely to be affected by it than a larger number. It is very desirable, for the purposes of discipline, tit men of the same regiment should not be placed togetl^ in the same small wards of General Hospitals. There needs only a comparison between the discipb of Civil and Military Hospitals to substantiate the abc; assertions. If discipline mean the enforcing obedience » orders by teaching how they are to be obeyed, there ; little or none in a Military Hospital. In the administration of food, of medicine, in the clea liness of the patient's person, bedding, and utensils, in tf patient^s personal obedience to medical orders, as torisi; or remaining in bed — all of these being matters abc; which there is no question or demur in a Civil Hospit the discipline in a MiHtary Hospital is far inferior. How can it be otherwise? Unless the Medical Officei; converted into nurse, cook, and house-maid, he cannot s to all these things. The ward-master or hospital-serjea is necessarily absent from his ward a great deal, on accou FOR HEALTH AND DISCIPLINE. 481 of eturns and accounts. The orderly cannot enforce oliience. There is no one in charge to enforce the m lical orders, i, e., without whose knowledge no disobe- diice can take place, as there is in a Civil Hospital, w; re one ward sister" is daily seen in absolute control (rflO — 40 men, as far as obtaining absolute obedience tonedical orders; there is no rebellion, tacit or open. Th is the answer, if it be asked, how then was there not di ipline, although the wards did contain 20 — 40 patients dung the war ? wo other considerations are involved in that of the size Two n J :j T • 1 • J. i.' considerations or ards, economy and cimical mstr action. fc may be asked, why should not all the sick be placed ^determining ill ne ward, provided there be cubic space enough ? The ar>ver is, with from 20 — 25 sick the height of 15-16 feet is nough, but it would not be enough for more, and height aiays involves expense. 'he greatest economy and the greatest safety to patients is|i the above number. Jso without the most perfect ventilation, there is alays more danger of effluvia being driven by a draught ti they accumulate in osie part of a very large ward, as w the case in the long corridors of Scutari, f ards of a moderate size, like those indicated, are better & the purposes of ventilation than wards half the size ; ai are less subject to a hospital atmosphere than wards oliouble the size. But a ward of this latter size may be rc dered perfectly healthy by having a height in propor- ti'i to its width. Vhere clinical instruction is intended, to admit even a :es, Extra : is perhaps hardly necessary to add tliat there should (^1^^]^^,!^' and be I few small wards for operation cases, and for noisy dean Linen, fe r cases. he baths should be separated from the pavihons, but Baths* CO lected by the corridor, he walls and ceilings should be of Parian cement, the "he Turkish bath in the General Hospital, Scutari, with its boilers, y chambers, and exterior cooling-room, with about a dozen hot- i ips, was in perfect order, on the occupation of the British, aad its li attendant known. Yet, although this was shown to the Pr ipal Medical Ofhcers, and the Chief Commissioner, it was not tilhbout February 1855 that Dr. Forrest, just before leaving his cor land, caused this bath to be cleansed from its most filthy con- dit 1, produced by the British. Till that period, the interior chamber wa receptacle of filth, and the exterior was given up to the individual cocng of the servants of Ofhcers, chiefly of Medical Officers. It was aft vards used by the excellent Principal Medical Officer, of the latter peid, as a remedial measure for cholera, and also formed into a regular baing establishment for the sick, under regulation. An analogous, th(;h inferior bathing establishment, was constructed in the Barrack Hf ital, by the late Dr. McGrigor, then in medical charge there, about irv, 1855. I 486 BATHS, KITCHEN, TvAUNDRY. I floors of tile. They should be suitably ventilated a [ warmed. They should contain hot and cold water batli, sulphureous water, hot air, medicated and vapour batl, shower baths, and douche. There should be a portal^ bath to each ward. j Best form of The kitchen should be placed away from the ware Kit3*icn^ Its walls and ceilings should be of Parian cement or soi ; similar material; for plaster has a tendency to fall off, frc the vapour and effluvia of the kitchen. The cooking apparatus, boilers, &c., if placed in 1 centre of the kitchen, instead of against the walls, w afford twice the amount of fire space. In the Paris kitchens, there is a brick erection in t] middle of the floor, with iron doors and brass mountin^^ coppers with covers, places for baking and for roasting, & The dressers are against the walls. The floors are flagg( with square flags. This appears to be the most conveniei mode of erection. Be&t form of The excellent new washing, drying, and wringing m; ^^H^os^pitlr ^ chines lately invented are so numerous that it would tal, too long to enumerate them. On the whole, the laundi, at the Wellington Barracks, which also washes for all tl Guards^ Hospitals and barracks, and the new laundry { Haslar Naval Hospital, are the best I have seen. Bi every day brings in fresh inventions, and a reformer always adopting the good ones. It is a further question in army matters, whether body of men should be trained to do as much as possibl by hand, so as to be serviceable in the field, wher machines cannot be had, or whether all the inventions fo saving labour which are now so good, and daily improving should be made use of. Probably both must be done. || How should If orderlies are to sleep among their patients, the per ; OrderHes'be centage of mortality will be of course raised among them ACCOMMODATION FOR NURSES. 487 T s was the case at Scutari, where it was frightfully high, accom- t) ugh it was never ascertained how high. Statistics are, h rever, not necessary to establish such an obvious fact. l 3 orderlies should sleep at a distance from the wards, a I not take their meals in them. ^ ^Vith regard to the female nurses, there is the further q;stion as to what class of nurses should be employed in nitary hospitals. My own opinion is humbly but e irely against employing any but women of the effi- CQCy, responsibility, and character of head nurses in C'il Hospitals. For such a Nurse, a small airy room off h' ward, but so that she can always have it under com- Dnd, is the best for her efficiency, and need not be inju- ras to her health. LTnlcss, however, there are facile means of access to a)ther nurse's room, in case of illness, there must be o'y a day room for each head nurse adjacent to her ward, ^e must sleep at a distance from her ward, but con- tuous to the other nurses. If assistant female nurses a; employed, it must be considered that association in lige dormitories tends to corrupt the good and make the tl worse. And separate accommodation, or accom- B'ldation for two or three together, should be provided citiguous to the ward, if possible — if not, to one a ther. So bedding but the hair mattress has yet been dis- Bedstead and cVered that is fit for hospitals. Hair is indestructible. ^ I'does not readily retain miasma. And, if it does, heat e-ily disinfects it. It may be washed. It is not hard to t ) patient. It saves the objectionable use of a blanket ' IDER the patient. 'Straw palliasses are absolutely objectionable. They a; cold; and, in some cases, the abstraction of heat from ti spine lowers the patient's vital energy to a degree 488 BEDDING AND FURNITURE. which does not leave him a chance. The loss of life mi; have been great during the war from laying our patieri on palliasses, which were either placed on wooden divai, or on flagged corridors, with only a mat underneath. Th^ bedsteads should be iron; and there are gre differences in the way the sacking is put in. The: should always be a shelf at the head. The French ha; one at the feet too. The Naval and Civil Hospitals have all kinds of drop and surgical bedsteads for raising a patient when cannot be moved, for inclining him at a certain angle, & There is no reason, but a general objection to comfort, prevent us using these bedsteads in Military He pitals. Ward The furniture should be of oak. White window cu Furniture, tains are used in some French Hospitals, not to exclui the light, but to look cheerful. They are desirable, b not necessary. The less ward furniture, speaking generally, tl better. But hitherto, as is well known, a military patia; has been expected almost to furnish his own ward. Water-supply The water must either be drawn from a tank at ■< and Drainage, distance from the Hospital, or from a main under pre sure; but never from a cistern within the Hospital. The fault of the water supply in Parisian hospitals i that the water is either carried up by porteurs d^eau or pumped up and remains standing. i There is no question that this is wrong. There should be convenient means in or close to tl wards for obtaining pure drinking water for the sick. No drain should ever pass under a Hospital ; all sink water-closets, lavatories, and baths, should be so place that the drainage should be conveyed directly away, witl. out passing under any part of the Hospital, in impc] i DRAINAGE AND VENTILATION. 489 \ us glazed earthen pipes, the larger of them egg-shaped, rll cemented. All drains or pipes for the purpose of conveying away T ter from any part of the Hospital should be carefully t pped between the outer wall of the building and the srer, and should be provided with the means of flushing : 8 drains should be ventilated. The water-closets should be placed at the end of the Best position Trd, opposite the entrance, and separated by a hghted Wate^-closets id ventilated lobby. There should be a bath-room and and ^, . . Lavatories, hatory adjoining, but, ol course, separate. The water- with regard to ( )sets should be of the best construction, self-acting. Wards. The doors, windows, and fire-places should be the means Best system of ( ventilation for such wards as those described ; nothinoj ventilation for ^ o a Hospital. (jC is wanted. If a Hospital must be ventilated artifi- lally, it betrays a defect of original construction which ) artificial ventilation can compensate ; it is an expensive id inefficient means of doing that which can be done leaply and efficiently by constructing the building so as ! admit the open air around. But there are buildings of original defective con- jruction which it is undoubtedly necessary to ventilate 'tificially; and in countries where fuel is dear and cold vere, the problem complicates itself, because it is a less nsumption of fuel to warm the fresh air as it is admitted. In the case supposed, warming is a necessary part of mtilation, and heating the air required heats the wards, ithout extra cost of fire-places, which always burn many mes the quantity of fuel expended for warming. I In England, where fuel is cheap, there can be no such tcuse. If attendants cannot be trained to keep the rooms ven- [lated without draughts, there is a defect of intelligence in lie particular individuals, and attendance on the sick is ot their calling. 490 VENTILATION AND WAKMING. j Occasionally, ventilating shafts carried up from thi "^^^ ceiling of the ward to the roof will be found an advantsj ^ ^ geous means of renewing the air. I There should be one or more open fire-places in thj '^''^ ward, but lofty, so that the throat of the chimney shall bj above the patient's head and bed. I *i The chimney is the best ventilating shaft; and one disl advantage of artificial ventilation is, that the fire musi -^^^ then be supplied with its own consumption of air by a shall w to itself. Otherwise, it will take the air from the artificial ventilation and cause it to cease to act. Whereas, witll 3^1 natural ventilation, the fire sets it acting, takes the air iron the room, and is the most valuable means of changing th( J^i atmosphere. Our grandfathers' lofty fire-places are the greatest los! in modern house architecture. The little low fire-place.' of this date bring the best current of air below the stratuir in which we are breathing. With our system, to breath( the best air, we must not be more than six years old, oi we must lie down. Warming. The best system of warming for a Hospital is radiation, open fire-places. Heated air from metal surfaces should never be used for warming. It has a tendency to produce disease of the lungs. The hot-house system of warming with a brick floor and brick flues is perfectly safe ; but an earthenware floor in Hospitals, unless glazed, is inadmis- sible, because of the great absorption of water. In a ward of the size mentioned, 80 feet by 25, two fire-places Avould probably be necessary. Laboi-aiory. A convenient position for the Laboratory will, of course, not escape notice. (JasApparatus. Also for Gas Apparatus, if it be determined to light the building in that way. Clinical School Should a School of Clinical Medicine and Surgery be connected with the Hospital, provision would have to be CLINICAL SCHOOL, &C. 491 11^3 for a Museum, Library, and suitable rooms for con- duang Post mortem inquiries, examinations, and opera- tic i, in proximity to each other, but at a sufficient dis- taifB from the Sick. ]|| small Cemetery would also be required, at as great a d«^.nce as practicable from the walls of the building. V a " Lift'^ be designed, which, for purposes of disci- Lift, pli'i as well as economy of labour, is essentially necessary, wlj'ever practicable, the great advantage of working it ' a Hydraulic Press, where the position admits of it, ra1er than by an Engine or any other means, is obvious. lining Rooms or Day Rooms for the Convalescents are Diuiiig lioom. ve; desirable. I 492 I I have tried, in obedience to command, to give wh idea I could of the Sanitarj^ state of the Army. It w necessary, in order to ilhistrate its Medical or Sanitai organization, to show the results which exist as tests of i efficiency, both in peace and in war. The tests which exist under the former condition ar the Barrack and the Military Hospital at home and in tl colonies, together with the rate of mortality, and that < inefficiency from sickness of the troops. In the state < war, the histories of the Duke of Wellington's campaign of Walcheren, and of the late expedition to the East, exi as tests of our sanitary condition. But, with regard to the last War, it has been here dwe upon with greater detail, not only because we have muc more information on the sanitary history of the Crimea campaign than we have upon any other, but because it is complete example (history does not afford its equal) of a army, after falling to the lowest ebb of disease and disastc from neglects committed, rising again to the highest stat of health and efficiency from remedies applied. It is tli whole experiment on a colossal scale. In all other example the last step has been wanting to complete the solutio of the problem. We had, in the first seven months of the Crimean cam paign, a mortality among the troops at the rate of sixt; per cent, per annum from disease alone — a rate of morta lity which exceeds that of the Great Plague of 1665 t* the population of the metropolis, and a higher ratio thai, the mortality in Cholera bears to the attacks ; that is to say. CONCLUDING REMARKS. 493 I..,. r e greater than ordinarily dies in time of pestilence out o^ick. We had, during the last six months of the war, a mor- t ty among our sick little more than that among our hilthy Guards at home, and a mortality among the tlops two-thirds only of what it is among the troops at Lne. The mortality among troops of the Line at home has I n, on an average of ten years,* 18*7 per 1,000 per aaum, and among the Guards, 20"4 per 1,000 per annum, (raparing this with the Crimean mortality for the last s months of the war, we find that the deaths to sick were 1 more than 2 i per 1,000 per annum, and the mortality aong the troops in the Crimea did not exceed 11*5 per ])00 per annum.f Is not this the most complete experiment in army Ijgiene? |But we cannot try this experiment over again for the Inefit of inquirers at home, like a chemical example ; it 1 ist be brought forward as a historical instance. An experiment, however, equally (perhaps more) impor- lat is annually tried at home. The Recruiting Keturns, showing the number of rejec- 1 ns and their causes, are the first step in this important joblem. They show the excessive care taken to obtani ebest possible men for the Service. The Mortality and validing Returns show the excessive ingenuity displayed i getting rid of them afterwards. From an examination of these Recruiting Returns may ' 1837—1846. .f In taking this average, the last month, June 1856, which would havc- jluced it much lower, has been purposely excluded, because troops were ibarking. This would have made it unfair. The Deaths to Strength in Inewere under 2^ per 1,000 per annum. But troops left their sick liiud them, which has made us comprise the mortality of sick. 494 CONCLUDING REMARKS. be gathered how perfect is the system for excluding all wl i are not only likely to yield a high rate of mortality, b who are, in any way, physically weak or inefficient ; hen- the British army consists of only the finest specimens the finest physical race in the world, with the exceptio perhaps, of some part of our aristocracy. The ingenui i which, among this selection of first-rate physical frame; i made for health and for long life, produces scrofula, coit i sumption, and premature mortality, far surpasses any ingn ^ j nuity with which we are acquainted. Majendie and othe have produced scrofula among rabbits and other anima by the same causes; but they did their work far le extensively and quickly. The comparative health of men of the army-ages ii England, and of soldiers in barracks on home stations, the proof. It is, when carefully examined, a more striking exper, ment in army hygiene than that of the Crimea. But th. ^ difference is this — in the Crimea, the remedies applied an the results obtained in health and efficiency formed thi last step of the problem which is wanting here. i V 254. I have tried to show, therefore (p. 254), the relativ mortality of the army at home and of the English mal population, at corresponding ages. I have tried to show (p. iv. Preface to Sanitary Section; the same comparison for the whole army at home an( abroad. : A complete picture is thus given of the chances of lif of the soldier compared with those of the civilian at tht, same ages in time of peace. ; Pp. 315, 327. I have shown (pp. 315, 327) the chief classes of disease by which these awful results are brought about, in ordeii to sec how far it is within the powers of preventive science to diminish the risks to wliicli ihc soldier is exposed, whe- ther at home or in tlic field. CONCLUDING REMARKS. 495 'he comparison between the chances of life of the so'ier in the field and those of the civilian at home is th ; given (p. 314) ; and it will there be found how insig- P. 314. ni ;ant^ comparatively, to the former are, in his estimated da^ers, the results from wounds. : is, however, now, with the results of our sanitary ex3riment at home that we have to do. he relative mortality of the Foot Guards and of the Ei;lish male population in large towns, at the correspond- in! ^J-g^s, given at p. 247, is the strongest illustration. P. 247. 'he Guards are, physically, the select lives out of the sect. They are chosen by practised Medical Officers 01 of the strongest and best looking recruits, how well leiour Recruiting Returns show. Any weakness or dis- ef i is enough to prevent a man being chosen for Service. T ! young Guardsman is, in every sense, a " picked" life, ai would be selected as a first-class life in any Insurance O.ce. is soon as the recruit enters the Service, he is placed u'ler the entire control of educated Officers. His diet, clmliness, personal habits are strictly attended to. He isfiodged in Barracks which have cost the country many ti es the price of the house in which he was born. He n er leaves the country in time of peace, but passes from h Town Quarters in London to his Country Quarters at \^ndsor or at Winchester; and, whenever he suff'ers fim the slightest ailment, his Medical Adviser is instantly b ide him ; he has Hospital accommodation, medicine, a'l attendance immediately. )f all men, a soldier in Her Majest/s Household T)ops is the most likely, it would seem, to enjoy perfect h dth and long life. |rhe men rejected, when the Guardsman was chosen, hj/e passed back into Civil life. The Civil population has l(b a certain proportion of its good life, which has gone 496 CONCLUDING REMARKS. into the Army. It has received back those lives whti were not good enough for the Army. The Civil popi.. tion has had all the loss^ the Army all the gain. P. 247. We have seen, p. 247, how the Guards die oflp uni^ circumstances, so very favourable to life, apparently, Is those we have mentioned. i Pp. 257, 258. ^^^^ ^^^^^ 257, 258, that the mortality in 'e Guards, great as it appears, appears less than it really i; The rate of mortality exhibits all the deaths in Civil population which take place between the ages 20 and 40, but does not exhibit all the deaths which place among the men selected for the Guards. Evt year, between the ages of 20 and 40, men are rendeil unfit for service by organic disease, and are discharged ) die among the Civil population and to raise its ratef mortality; and these are included in that of the Cil population, and are consequently not shown in that of t ; Army. These deaths are, in fact, deducted from those ' the Guards, and added to those of the Civil populatic , so that in the comparison the Guards have a doul: advantage from their not receiving bad lives and frc tiieir invaliding bad lives. The Guards, though the most unhealthy corps in Service, are not the only corps which suffers a great ex( of mortality. All the Line, even on home service, suflPc although at a somewhat lower rate. P. 253. It has been shown, p. 253, what is the excess of mor among the Line on home Stations over the mor among the general English population, and p. 247, ov the mortality in large towns, subject to the same correcti as to invaliding, which has been already mentioned necessary to be made for the Guards. The whole Army, vide p. 254, like the Guards, com of carefully "picked^^ lives, and the lives rejected a thrown back into the general population. But, notwitl; CONCLUDING REMARKS. 497 ding this process of selection, and the apparently orable circumstances under which the troops are placed, \ have, from some cause or other, the extraordinary r ults summed up, p. 254. To show the full bearing, too, of this process of section in any comparison between the health of the i my and that of Civilians, it is necessary to state that, of t ) Civil population at the recruiting age, a certain part i mablc, from illness, to present itself to the recruiting ccer; that deaths among that part go to raise the ( ilian mortality ; that of those who do present them- sves for recruits, a third part at least, though probably aiQuch larger proportion, is rejected as unfit for service; tit of those rejected, at least a fourth part is suffering f m diseases which shorten life. The wide extent of the British Empire, and the great T 'iety of climates which it presents, as well as thetopogra- {ical peculiarities of our Sovereign's various colonies and pssessions scattered over the whole earth, would lead us to e'pect a higher rate of mortality among soldiers born in British Islands, when these soldiers are sent on service a road, than would exist among the home population at t ! same ages. \ccordingly, in some years, it will be found that the i rtaHty in the Troops is from five to six times greater t .n it is in Civil life. The mortality of the whole Army at home and abroad, cnpared with that among Englishmen of the Army ages, i healthy districts, is given, p. iv, Preface to Sanitary ^■ction, p. 235. If we can imagine the total sum of life among 10,000 jn, between 20 and 40 years of age, entering the Army, ad remaining on home-service, and among the same mber of Englishmen, taken (1) all over the town and P. 254. Mortality of the whole Army, at Home and Abroad. Sum of I ife among 10,000 Men in Army on Home- service, in general 498 CONCLUDING REMARKS. Population country districts, and (2) m the healthy districts, at honL and in " n • ti i country at the same ages — all starting alike, we shall see a ver ^^^bDme^' different rate in the progress of death among the varicj classes. The proportion of death increases and that f life diminishes in a very different ratio and to a vc different extent in each. The mortality is greater and progresses more rapic among the English male population generally than amo ; that in healthy districts. The general population has 1( a third more by the time it arrives at the age of 40 th the healthy population, while the soldiers have lost al a third more of their numbers than the general populati and more than twice as many as the healthy population. Loss of Life, of If we can also imagine the total money value of 10, Money-value ^^n between the ages of 20 and 40, as well as the loss entailed on y^lue from loss of life at each succeeding year between t country m case ^ of Army, taken two ages ; and, further, the relative value of the amo" service only, of life ill the Army, as contrasted with that of two cl of civil population, passing on from 40 years to the s ceeding periods of life, we shall see that the Nation 1 the money value of the excess of mortality existing in general population over that of the population in healt" districts — we shall also see that while, among healthy ci populations, about 8,500 lives, out of 10,000, survive t wear and tear of the ages between 20 and 40, and the after add their quota to the wealth of the community, or 6,900 of the Arm}/ lives are available for the same p' pose. In the case of the Army, the country incurs great e pense in educating the soldier for his duties, and it difficult to over-estimate the value of a good soldier, for can hardly be replaced. In the present state of sani knowledge, it may be fairly stated that the whole excess money-loss between that in healthy districts and that ^ CONCLUDING REMARKS. 499 H Army, might be saved to the tax-payers of the country. wHe general community incurs a still further loss of pro- d3tive labor, because it will be at once seen that the rmber of lives at 40 years of age, passed back iato the gieral population (supposing that the average age of dis- cirge from service is 40 years), is much smaller in the imy than the proportion which survives in the healthy C il population ; and the productive power of the country i: lu'thcr taxed for the support, by Poor Rates and other- V c, of a large proportion of men, temporarily or perma- i;itly disabled by diseases contracted in the Service. The loss from invaliding has been already referred to as aerious cause of inefficiency in the Army in its present ste. The tables at pp. xxvi — \dii, Preface to Section X, he been constructed to bring under one view the whole g';at loss sustained. In Table IV is shown the number of ejctives, young soldiers and veterans, (1) who remain in t ; Army as it is, (2) w^ho would remain, if the Army vre as healthy as the Civil population. The Army serving ahome, in time of peace only, between the ages of 20 ?1 40, has been taken as the example. Under the pre- sit system, 10,000 annual recruits would be required to s.tain a force of 141,764 men; while, under the improved ciditions as to health, 10,000 annual Recruits would s tain an Army of 166,910 men. The great experiment, then, which is annually going on uder our very eyes, proves what is the loss of life, service, ai money-value entailed on the country by the neglect c sanitary measures in the Army, taken in time of peace, c home- service only. It is, in the highest degree, important to know the ^^Clas^^^^^^^/^ c sses of disease from which the great losses in the Army ^hich this i time of peace arise ; for it is in this way alone that we f^-^^^^'^l c I ascertain whether, and to what extent, we can mitigate Home- service. 2 K 2 500 CONCLUDING REMARKS. or prevent these diseases by known sanitary preca tions. ' The classes of mortality from disease most prevalent !. the Infantry on home stations, as compared with ti p. X, extent of the same types of disease in Civil life at thesau ^SecSon 1/^ ^^^^ shewn, p. x, Appendix I to Section XI. Two Classes of once struck by the remarkable fact, that mc : Disease, viz., than seven-ninths of the mortality in the Infantry are d : 1, Zymotics, 2, . . ' Consumption, to two classcs of disease alone — viz., to Zymotic Diseasii *the^Army^at^ ^^^^^ Fevers, Cholera, Diarrhoea, and to Chest a: Home. Tubercular Diseases, such as Consumption, &c. In fat the mortality from Chest and Tubercular Diseases alor' in the Infantry on home service, exceeds the total mort' lity from all causes among the Civil population at t same ages; while the deaths from Zymotic Disease a' above double what they are in Civil Hfe. Again, Che and Tubercular affections are the scourge of the Ci^ population, and yet the Civil population suffers less th; one-half the mortality from these diseases which occurs the Infantry, while the deaths from Zymotic Disease in t i Infantry nearly equal the total deaths from Chest affectioJ in the Civil population. It is necessary here also to repe that, while the mortality of the English male populatic exhibits all the deaths occurring from each class diseases, that of the Infantry does not. It takes i account of men discharged on account of Chronic Tube cular and Chest Diseases, whose deaths, taking place aft discharge, go to swell the mortality, from these disease' among the Civil population. I have now exhibited the frightful mortality, continual and year by year going on, in the British Army at horn and the classes of disease to which this mortality is 1' be attributed. Causes of this The first question which arises is — What can be tl CONCLUDING REMARKS. 501 ciseofalltliis? By what possible procedure can it be tit the first-rate lives selected out of the British working ppulation can be so deteriorated as that such a terrible r,.ult should follow ? Is there anything in the food^ cloth- duties, habits of the men, to which such a loss can be a ributed ? Are the Army medical men less skilful than t)se in Civil life ? To these two last queries we must reply gaerally in the negative. There is, on the contrary, every- t ng in the soldier^s favor in these particulars, except that J 'haps he is not sufficiently worked. His barrack accom- Ddation too has cost the country enough of money. ],iere has been no expense spared in this either. Can t3re be anything here to occasion such a fearful annual Is of life? iLet us see what sanitary experience teaches as to the (;usation of the diseases from Avhich soldiers suffer : — 1. Consumption, and diseases of this class, are the ^5ult of breathing foul air, contaminated by the breath ( other persons. It is air polluted in this way which jpears to be the special agent which predisposes people to (nsumptive diseases. How is such a state of the air ([iefly produced ? Simply by crowding too many people i'co unventilated rooms, especially to sleep. If barrack- ] oras are crowded and unventilated, and if the atmosphere i close or foul during the hours of sleep, when the system more peculiarly predisposed to its effects, the elements id seeds of Consumption and Tubercular Disease are iere. To develop these seeds into activity, all that has be done is to take the men out of such an atmos-phere fiich they have been breathing night after night, and to pose them on guard to wet and cold. The disease will on show itself. But exposure to wet and cold alone will )t do it. This the Crimean experience has proved, as it is excessive Mortality in the Army at Home. 1. Causes of Consumption. 502 CONCLUDING REMARKS. proved daily and nightly in night trades and' occupatioi, always excepting the case of the soldier at home. To know whether the conditions requisite to prodiij Consumption and Tubercular Disease exist in Barracks, ilj only necessary to read the disgusting evidence given hef( ; the Barrack Committee, and to consult the tables gin Pp. 263, 6. at pp. 263, 6, shewing the amount of cubic space allowed^ the men in Barracks and to the sick in Military Hospita. It would be difficult to frame conditions more likely i generate such diseases than those to which soldiers [: exposed in barrack-rooms. They are, in fact, the sc same conditions as those which have been determined direct experiment to be necessary for the production ' Tubercular Disease in animals. When a sufficient cai3 is found, it is not necessary to look for another. 2. Causes of 2. Zymotic Diseases, Fevers, Diarrhoea, Cholei; Diseases. Dysentery, &c., are known in Civil life to be mc intense in their activity where certain local conditions a present. First in prominence amongst these conditions are aga, overcrowding and defective ventilation — the repeat breathing, in fact, of air already breathed, such air heii further contaminated by moisture and exhalations fro the skin. Next in importance are emanations proceeding froi animal excretions or from decaying vegetable matt{ together with moisture. The want of drainage and tli foul state of the latrines and urinals in Barracks ' described in various reports, are sufficient illustrations this class of causes. i There are others of minor importance which need n- be mentioned. Those enumerated are quite sufficient account for the excess of zymotic mortality from wliichtli I CONCLUDING REMARKS. 503 ajiy on home stations suffers. If men, returning from f(3ign service, happen occasionally to be more susceptible t(;he operation of such causes, they will, of course, suffer nre severely. But allowance is made in the " Statistical Ejorts on the Sickness and Mortality of the Troops s(/ing at home,^' for even this contingency, as they do 11' exhibit any deaths occmTing for the first six months aj!r men have returned from foreign service. lie next query is one which it is almost superfluous to Can this pi,. It is, whether there be any known means of prevent- Mortality^e iii this excessive mortality, and whether there be any prevented? h ie of reducing the disease and mortality among the T{iops to the same amount as appears among the Civil pnulation ? L^he reply, if one were wanted, is, that the soldier's ndrtality on home service should, to say the least of it, n er have been greater than that of the Civil population, ai that it might be less. Che mortality and disease among the Civil population a], the very evils, towards the reduction of which to Wilier dimensions, the whole sanitary procedure under e^ry sanitary Act of Parliament is directed. It was the la',^eness of those very evils which led to the sanitary a|i:ation which ended in the Legislature giving a sanitary C( 8 to England ; and, to say the least of it, it is hardly ciJible that it should be necessary, at the present day, to a/ocate similar measures for the Army. bhere is no reason why, with proper sanitary measures, tl general health of the population should not be raised tf|the standard of the most healthy districts of the a .ntry, as indeed it has been in certain marked instances ; ail why should the health of the Army on home service b( any exception, seeing that the personal conditions of 504 CONCLUDING REMARKS. the soldier are so much more favourable ? If this wei done, and if our Home Army consisted of 100,000 Guard i we should save nearly 1,500 good soldiers yearly, wIk; from all experience in other cases, are as certainly killei by the neglects specified as if they were drawn up oi Salisbury Plain and shot. Loss of Life referring to pp. vi, vii. Preface to Sanitary Sectioi. GXCCSSIVG in the whole p. 235, where is found the Army mortality at home an: Ho^me and abroad, as compared with that of an English populatio; Abroad, ^it the same asres, we cannot fail to be struck with th although less ^ . than it was. immense loss of life entailed on the Army, and th Prefece^to corresponding cost to the country from foreign service Sanitary rpj^jg j^gg jg niuch less than it was in former times, as wli Section, p. 235. ^ ^ be seen by referring to pp. ii, viii, ix. Preface to Sanitari Section, p. 235. It has been diminished by various sanii tary means, and there is no reason whatever why, ii intelligent enquiry were instituted, and proper sanitari precautions taken, all the Army mortality on that melan choly table might not be very materially lowered. It is to be regretted that, with the materials existinji in the Army Medical recesses, from which the valuabL returns of Sir A. TuUoch have actually been drawn, v. report should not have been published at least twice t year. This, it is hoped, will now be done, by the ne^i Statistical Branch, the formation of which is at present under consideration at the War Department. From these returns has been gathered what is set forth at pp. viii, ix, of the Preface to the Sanitary Section, X; viz., which Stations have stood still in sanitary progress, which have advanced, which will still want a "Barrack Commission.'^ There is here to be found — 1, satisfactory evidence how much has already been done, by the good sense of Com- CONCLUDING REMARKS. 505 H; troops has been exemplified in so many touching opporu '''' inf.ances, who has been to them indeed so truly a royal ^^^^'^^^^e miding Officers, to reduce, with sanitary means, the mitality of the troops ; and— 2, convincing proof how m ^h may still be done, [ow, if ever, is the time. irst. We have a Sovereign whose personal regard for Reasons for ? on thi unity to •oduce Remedies mther, that the loyalty which, with the Enghsh soldier, W always been a duty, is now become an enthusiasm. iiecondly. We have an Army in whose memory is still fr h the greatest example of heroic endurance in modern, 0] ndeed in any times — fresh, not as that which it may h e read in history, but that which it has seen, shewn in \Uf, and accomplished. They have a pride in the power tly have proved in themselves to ''endure hardness" T^hout complaint — our soldiers — and well they have eiined their right to it. rhirdly. We have Officers, of whom, in the late War, nny instances could be cited, known only to God and ttitheir men, of willingness to ''endure hardness" with tto, and to do whatever could be done, at their own pri- vi;e cost, to alleviate those hardships to their men. 'Fourthly. We have, at this moment, a Royal Commission s ting, composed of some of the best men of the country f information in Army matters, and with a President adieir head who is, perhaps, the man who has shown r )st knowledge and feeling as to the wants and constitu- t n, physical and moral, of an Army, in this day. They have si'eady elicited a mass of evidence regarding the Sanitary siite of the Army, such as we have never had before — tey have brought together a treasure of information and sggestions, which will be a manual for Army sanitary ifatters in all future times— they will have the privilege ( working out practically their own suggestions. 506 CONCLUDING REMARKS. 1 Fifthly. We have a War in India^ which will require 1 large addition to our forces, and which will, without sail tary foresight, prove a most unhealthy and destructil war, destructive solely from disease. And, lastly, with regard to the men who are gone, w] need our words no more, what shall we say ? The fitte; tribute to them is to be silent — as they were. For the courage and their griefs were too big for our wore' although they seemed to them too little for theirs — buj for the sake of the survivors, not for theirs, let the remarl able lines be here quoted of one who best knew the dee( he was writing about : 1 "The sufferings of the army in the course of the winter, ar, especially during the months of December and January, mu have been intense. It has been only by slow degrees, and aft( the frequent repetition of similar details, as one witness aft( another revealed the facts that had come under his own obse vation, that we have been able to form any adequate conceptic , of the distress and misery undergone by the troops, or fully i appreciate the uaparalleled courage and constancy with whic they have endured their sufferings. Great Britain has often ha reason to be proud of her army, but it is doubtful whether tt whole range of military history furnishes an example of an arm exhibiting, throughout a long campaign, qualities as high a have distinguished the forces under Lord E-aglan's commanc The strength of the men gave way under excessive laboui watchiug, exposure, and privation ; but they never murmurec their spirit never failed, and the enemy, though far outnumber ing them, never detected in those whom he encountered an; signs of weakness. Their numbers were reduced by disease aii( by casualties to a handful of men, compared with the great exten of the lines which they constructed and defended, yet the arm; never abated its confidence in itself, and never descended fron its acknowledged military pre-eminence. " Both men and officers, when so reduced that they wen hardly fit for the lighter duties of the camp, scorned to bt excused the severe and perilous work of the trenches, lest the\ CONCLUDING REMARKS. 507 i)M throw an undue amount of duty upon their comrades ; yet t!y maintained every foot of ground against all the efforts of t! enemy, and with numbers so small that, perhaps, no other t ops would even have made the attempt. 'Suffering and privation have frequently led to crime, in itiies as in other communities, but offences of a serious cha- rier have been unknown in the British Army in the Crimea. ])t one capital offence has been committed, or even alleged to l^e been committed, by a soldier, and intemperance has been ]'e. Every one who knows anything of the constitution of the .my must feel that, when troops so conduct themselves l .'oughout a long campaign, the officers must have done their ( ty and set the example. The conduct of the men, therefore, i plies the highest encomium that can be passed upon their cicers. They have not only shared all the danger and expo- /re, and most of the privations which the men had to undergo, t we everywhere found indications of their solicitude for the lilfare of those who were under their command, and of their Instant readiness to employ their private means in promoting e comfort of their men. Doubtless there has been, as there svays must be, better management in some regiments than in hers, but amongst much that was painful in the evidence that 3 have heard, it was always gratifying to observe the commu- ty of feelings and of interests that appeared everywhere to bsist between the men and their officers, and which the gimental system of the British Army seems almost always produce." Among these men there never was heard a murmur — jiere never was seen one moment^s unwillingness to go ck to their hardships, until their country's cause was [on. i Upon those who watched, week after week and month rter month, this enduring courage, this unalterable atience, simplicity, and good sense, this voiceless strength ) suffer and " be still,'' it has made an impression never ) be forgotten. 508 CONCLUDING REMARKS, The Anglo-Saxon on the Crimean heights has won fi himself a greater name than the Spartan at Thermopylj as the six months^ struggle to endure was a greater pro of what man can do, than the six hours' struggle to figh The traces of the name and sacrifice of Iphigenia mi\ still be seen in Tauris ; but a greater sacrifice has befi there accomplished by a" handful of brave men wl' defended that fatal position, even to the death. And, Inkermann now bears a name like that of Thermopylae, is the story of those terrible trenches, through which th men patiently and deliberately, and week after wee went, till they returned no more, greater than that Inkermann. Truly were the Sevastopol trenches, to o men, like the gate of the Infernal Regions. "Lasciali ogni speranza, voi cVentrate.'^ And yet these men woul refuse to report themselves sick, lest they should thro more labour on their comrades. They would draw thei blankets over their heads and die without a word. Well may it be said that there is hardly an example i, history to compare with this long and silent fortitude. But surely the blood of such men is calling to us froi the ground, not to avenge them, but to have mercy o:j their survivors ! We can do no more for those who have thus sufferei and died in their country's service. They need our hel]: no longer. Their spirits are with God, who gave them It remains for us to strive that their sufferings may no have been endured in vain for us — to endeavour so to lean from experience as to lessen such sufferings in future b forethought and wise management. \ For the mere If we really desire to draw into the ranks of our Arm] Recniitfngifis ^^st and strongest men of the working classes, w( imperative to must hold out positive inducements to them quite othei put forth ^ ^ ^ . inducements than thosc negative ones which have been so much in use CONCLUDING REMARKS. 509 V , drink, want of work, disappointment in love. It must to Enlist, n, be forgotten that the intelligence of these working prestn't state of closes has undergone a great advance of late years, and cSry^^ tit the details of the Crimean catastrophe as well as the njclects from which it arose are perfectly well known ajong them. All over the three kingdoms there are tlise who mourn the loss of friends and kindred, not be- ciise they died in battle against their country's enemies, b . because they perished from neglect of the conditions aiolutaly necessary for their health and lives. The eints of that war have made an impression, never to be \i)ed away, on the soldier-classes of the country. And, iiwe would make them more ready than they at present ai! to flock to the ranks, it must be by looking to their Mth and comfort, by reforming their Barracks, by intro- dcing a better system for securing their physical and Eiral well-being, whether in peace or in war — not for- g:ting their domestic relations. It must be, in short, b sweeping away those abuses which have hitherto led to soh serious losses from sickness and premature mortality ijall times, seasons, and countries. It must be by mak- i ,^ the Service as attractive to the soldier-spirits of the cmtry as it ought to be made, when dealing with a brave fd intelligent people. And no moral and intellectual \ )gress can be, by any means of ours, eff'ected, without Unitary progress. iThis is a short summary of our Sanitary condition in Mortality from L . . 1 o -i. cj Disease of IfQe of peace. Unfavourable as it is to the sanitary feys- Armies in time tn, or rather want of System, in the British Army, it (hibits results which might be considered as, in the %hest degree, favourable, when contrasted with the ]S3rtality from disease among the British Troops in i|ae of war. It is at such times that the excessively defective state 510 CONCLUDING REMARKS. French Invasion of Russia. Walcheren. P. 314. Comparison of Mortality from Disease in the CrimeanArmy and in the Civil Population. of Sanitary Science and practice in the Army becoi pre-eminently remarkable, and leads to the most dis{l trous results. It is riglit_, however, to remind ourseht that such defects are not confined to the British Arm| ^' all Armies, during war, have sufi'ered from the neglect very ordinary hygienic precautions, and some Armies ha- ^ been all but destroyed in consequence. Nearly si'^^' sevenths of the vast Army, with which Napoleon I. i| vaded Hussia, had perished before the setting in of f fierce cold which destroyed the remainder, and to wM it was convenient to that gigantic vanity to ascribe tl destruction of the whole. Of this we have statistii proof ; and of this our own great Duke was well aware, The actual losses in battle form a very small part the calamities of a war — so small indeed that, if the exce* of mortality caused by disease could be cut ofi", the loi from wounds would be hardly deemed worthy of tl'ij^^ familiar phrase, the " Horrors of War/^ How just th*w expression is now, those only who have seen the Crimea 1^ Expedition can well appreciate ! ' - The facts connected with the disastrous Walchere 1^ Expedition, as well as the ignorance and neglect of themoj'i ordinary precautions which led to so great a loss of life, arj matters of history. But, up to the present time, the expc rience of that expedition seems to have led to nobenefici^i result, so far at least as can be gathered from the sti ^ more disastrous Crimean War. ! At p. 314 are given the comparative results of thi ' mortality among the English male population of th Army ages and among the British Army in the East. Fo' every Englishman of the Army ages who died at home nearly 23 died in the East. The proportion of death • from wounds, exclusive of those killed on the field, during the War, was 30 times greater among the soldier ; CONCLUDING REMARKS. 511 t Manchester. thi among the Civil population. But, even at that rate, th< mortality in Hospital from Avounds did not exceed 3 )Y cent, of the strength, while the deaths from all ca es were nearly 23 per cent, of the force in the field. ^hen we examine the cause of this great mortality, we,earn that, for every man of the ages and numbers wB died at home from Zymotic Disease, 93 died in the Any in the East ! The remaining diseases shewn are not w(;h notice. If they were all expunged, and the deaths frci wounds, taking place in Hospital, with them, the fa() would remain that the Army in the Crimea almost peshed from Zymotic Disease. he awful Mortality in that noble Army is shown still At ni'e strikingly when compared with that of the town of Michester, one of the most unhealthy in England, and OB very subject to Zymotic Diseases. [ad the Crimean Army been as healthy as Manchester, it:^ould have lost 1^ per cent, per annum. It did lose, difing eight months, 60 per cent, per annum ; or 58| per ce:. more than one of the most unhealthy towns in E-land. \^e have seen (p. 320) how healthy the Army was when p. 320. , . , , . T X 1 1- Vital statistics it mded m the East ; how, immediately on its reaching Crimean V na, sickness and death began to increase, shewing the SI den exposure of the Troops to some very unusual CEses of mortality. We have seen that, the whole time tl Army was in Bulgaria, it suffered severely — that the Bairtahty declined when it left that pestiferous region for tl Crimea— that, from the moment it broke ground bijpre Sevastopol, in a comparatively healthy district of C(|.ntry, the mortality began to rise during October— % it increased with frightful rapidity during November ai|l December, attaining during January 1855, a higher War. 512 CONCLUDING REMARKS. fatality tlian tlie maximum mortality of the Great Pla^'i of London in September 1665. P. 320. Page 320 gives a representation of that great calai during the first year of the War. Excepting^ perhaps,! one or two of the mediaeval epidemics, no pestilence, which we have any record, would form such a picture eight consecutive months. P. 321. Page 321 gives the mortality of the second year of War. It was great in the beginning, as compared the most unhealthy cities in England; but when coi! pared with the first year's mortality it is insignificai It will be seen that, for the last six months, January June 1856, inclusive, the mortality retires within Manchester rate and all but disappears. We have h at a glance the vital statistics of the Crimean War. Zymotic The immense preponderance of Zymotic Diseases cause of the been already referred to, and a glance at p. 315 will sh whole these diseases were the cause of the whole cati Catastrophe m j Crimea. trophe. The total mortality from wounds at Alma, Ink mann, and during five months in the trenches, excli of the killed in action, is insignificant ; so is the to mortality from diseases not Zymotic. While the Zymo Diseases are shewn to be the pests and scourges of cain_ and armies now, as they were of cities and towns in tl middle ages before the dawn of Sanitary knowledge. The analysis of the second year's mortality exhibi. an immense reduction in the deaths from all cause except from wounds, the legitimate result of war, bi even to nearly the end the Zymotic mortality retains i preponderance, and disappears only when the Army b arrived at its most healthy condition. P. 320. On comparing the total mortality, as shown at p. 32( P. 315. with the Zymotic mortality, as shewn at p. 315, it wi CONCLUDING REMARKS. 513 ] seen that the very first diseases from which the Army {ffered (as shewn by the dates) in Bulgaria, were Zy- ])tic Diseases. They were chiefly Fever and Cholera, bught on by neglect of sanitary precautions, principally i the first bad selection of Camp sites. The first outbreak Igan to subside in September only and continued to (cline until the Army sat down before Sevastopol, iiother and far more terrible invasion of Zymotic Disease flowed that event. The men were hard worked. But hard work of itself iver induced Zymotic Disease. Other causes must be l)ked for : and these causes once existing, fatigue would (•operate powerfully with them. The men had no suffi- ( nt shelter. They were in want of clothing suitable to t3 weather. They suffered from wet and damp. They \ re exposed to the elements at all times and seasons, ^eir food was not sufficiently nutritive nor varied. They Id no proper means of cooking, little or no fuel, and t3y could not eat their rations. What wonder, then, if sirvy and scorbutic disease appeared at a very early {Hod, if Fever, Cholera, Diarrhoea, Dysentery followed, so f to threaten the total destruction of the Force ! Every issible neglect of hygiene had been committed, and t^se figures show the natural results. During the snmer of 1855, Zymotic Diseases still prevailed, though t a comparatively insignificant degree. Sanitary defects i draining, cleansing, ventilation and overcrowding were tm the prevailing causes. During the winter of 1855-56, s the previous causes of disease had been removed. The r^n were well clothed, fed, and sheltered. Their huts ^re properly drained and ventilated, and nuisances had hn removed. The hard work had also ceased. Compare t3 two periods of September to May 1854-55 and 1855^6, si no more instructive lesson on army hygiene could be 2 L 514 CONCLUDING REMARKS. given. The men were the same, the conditions only been altered. Could an ^schylus or a Sophocles appear agai what a subject would he here find for his delineation • Fatality ! How much grander is the Christian fate th? that of the Greeks ! How much greater a conception f(t a Tragedy ! Do this, says the Greek fate, and a famil shall be extinguished or an individual hunted down I: the Furies. Do this, says the Christian fate, and 18,0Ci men shall die ; and Providence would not be good, if were otherwise. Do the other, and 18,000 men shall liv The requirements of Health had been disobeyed in evei particular during the first winter in the Crimea; and si' has left on those figures an everlasting vindication of h( broken commands. During the second winter she ha, been more perfectly obeyed, and the sign of her displeji sure has almost ceased to appear. ! Sanitary In discussing the causes of the terrible mortality of thjj ^^SlkTn fearful winter, another important point must not be ovei Hospital, in looked, viz. — what chances a sick man had of proper cai Crimean War. and treatment. ■ It is well known that the Medical vStafF exerted itself ti the very utmost, and incurred a large proportionate moi; tality among its members in consequence ; but the accom modation for the sick in camp was for several montli most defective. There were no proper Hospitals and n suitable beds or other appliances. The sufi'ering fror, exposure among the sick was perhaps greater, considerin;| their diseased state, than even among the Army generallji On board Sick '^^^ tra-usport ships were, for many months, defectiv, Transports. i\^q highest degree, overcrowded, badly ventilated ; and moreover, many cases were shipped in a state wholly unfi for removal, particularly those of Choleraic Disease. Ther vwas a great rtiortality on board the ships in consequence |||| CONCLUDING REMARKS. 515 J;iring the period of four months and a half from the l .ding in the Crimea to the end of January 1855, out of i.093 sick shipped for Scutari, nearly 75 per 1,000 died 0 a passage of only 300 miles. Had the embarkation of gone on for 12 months and the same high rate of nrtahty prevailed among them, no less than 3,182 per 100 would have died. In other words, the population of t ; Sick Transports would have perished on the Black Si upwards of three times. In the month of January, \^ lost 10 on the passage to every 100 we received alive, le terrible episode of these Transport Ships is given, pp. i' i|iv, Preface to Section II., p. 67, and pp. 73-5. pf these sick who thus arrived in the Bosphorus, there in Hospitals of did, in the month of February 1855, 415 per cent, per the Bosphorus. aaum, and in one Hospital, that of Koulali, actually 608 p cent. For when the sick were landed, they were crowded in buildings which had undergone no sufficient sanitary p paration for their reception. The drainage, ventilation, lite- washing, &c., were so defective that the buildings we little better than pest-houses; and the result was a; enormous and needless mortality among the sick, wich went to swell the losses of the Army, and to raise itiproportionate rate of mortality. ^he Scutari mortality was, in fact, a separate problem, ai must be considered by itself. It was the case of thou- s? ds of sick removed 300 miles from the causes which h; occasioned their disease, and exposed to another class oldsks in the buildings into which they were received. T ; buildings were spacious and magnificent in external aj earance; far more so, indeed, than any military build- int in Great Britain, and several of them were apparently b(!:er suited for Hospitals than any Military Hospitals at *^he mere external appearance was, however, fatally 2 I. 2 516 CONCLUDING REMARKS. deceptive. Underneath these great structures were seweii of the worst possible construction, loaded with filth, meij cesspools, in fact, through which the wind blew sewer ai up the pipes of numerous open privies into the corridoi and wards where the sick were lying. The wards had no means of ventilation, the walls n quired constant lime-washing, and the number of sic placed in the Hospitals during the first winter was disprc portionately large, especially when the bad sanitary staii of the buildings is taken into consideration. The Hospit population was increased, not only without any sanitai precautions having been taken, but while the sanitai conditions were becoming daily worse, for the sewers wei getting more and more dangerous, and the walls mo] and more saturated with organic matter. Some sligl improvements were made in the beginning of March 185. but it was not till the 17th that eflPectual means wei put into operation for removing the causes of disease in tl buildings, viz., by the Sanitary Commissioners. By tli month of June the improvements were nearly complete and the proportion of sick had fallen off. i P. 141, Page 141 shews the whole history of that frightful Scuta xxviii^Preface calamity. It exhibits the annual rate of mortality pt to Section III, cent, on the sick population of the Hospitals. It wii be seen that, even from the very beginning of the occi pation of these buildings in October 1854, and befoi the sufferings of the winter had begun, the mortalil was very high, although the number of sick was small indicating the unhealthy state of the buildings at tlj very beginning. Nothing was done to improve tliei even then — only fresh ship-loads of sick were passed inl them. Tlie mortality, of course, continued to rise- still nothing was done. Then came the great Crimea catastroplie, and ship after ship arrived with sick in ^ CONCLUDING REMARKS. 517 isceptible a condition, that the foul air of these Hospi- lis was almost certain death to them ; and, acecordingly, 1 ey died, in the month of February, at the rate of 41 5 per (iat. per annum. So that in twelve months, at such a ]te, the whole sick population of the Hospitals would ],ve perished four times. In the month of February, 55, we actually lost two out of every five men treated in te Hospitals of the Bosphorus, and one out of every two i Koulali, the worst of all the Hospitals. Well might ^! learn from our incredible mortality a terrible Sanitary ];son ! The reduction in the mortality, after the sanitary \)Yks had been begun, is most striking, and it falls eventu- iy, in June, 1855, to less than a sixth part of what it ns when the Barrack and General Hospitals were occupied %ether in October 1854, and to a nineteenth part of uat it was in February 1855. Our General Hospitals ] ve been so deplorably mismanaged in all our wars Iat men have come to ask the question, whether it \)uld not be better to do without them altogether ? The (iperience of Scutari has proved that General Hospitals ]iy become pest-houses from neglect, or may be made J healthy as any other buildings. (The question of these Zymotic Diseases is of infinitely Zymotic . . , . 11' 4" Disease the I eater importance during war than during peace ; tor no ^^^^ destroyer j^apons are so destructive of Armies in the field as they ^^^{^j.^^^'' i 3. The slaughter of battles and of sieges is cast into re shade by that of pestilence, which, during long wai's, |the real arbiter of the destinies of Nations, for it exhausts leir resources more completely thau all other losses in e field. In a country like ours, with a hmited population, an Valuoofthe ^!.tirely voluntary system of recruitment, and colonies and ]'ssessions in all climates and latitudes, the question ol litary hygiene is rapidly becoming a question of vital 518 CONCLUDING REMARKS. ! importance to the interests of the Empire. The tiii| appears to have arrived, when by the British race aloii f must the integrity of that Empire be upheld. The coi! ^ quering race must retain possession. And experience h:j shown that, without special information and skilful appll cation of the resources of science in preserving health, tl' ^ drain upon our home population must exhaust our mean A competent authority states, that " It is calculated thi^ ^ we shall require something like 25,000 to 40,000 men no ^ in a year to keep up the strength of our army every wher f These must all be for a considerable time in barracV ^ at home, if we can find the requisite number. Bu while it is doubtful whether we can find men enough t meet the necessary expenditure of soldiers abroad, w are squandering our means at home, and needlessly 65 pending men in barracks here, who might be preserved t' maintain our strength and our dominion elsewhere. Wha would be thought of a brewer who treated his dray-horse' in like manner — or a huntsman who so dealt with hi' horses or his hounds ? A dairyman would be ruined in twelvemonth who suffered his cows to be so fatally crowdeo' Independently of all moral and political considerations, i is the most wretched mismanagement on the part of thi nation. It is doubtful whether our Military Statesmei are yet alive to the truth of sanitary science — they admi it, but they do not feel it — their minds, in some instances still run in the old rut. While the Board of Health ii' warning us all to put our houses in order, to attend to ouii sewerage, ventilation, &c., the dwellings of our soldiers; under the special care and superintendence of the Govern-' ment, are the most neglected, in these respects, of the habitations of our fellow- subjects. Public attention is now concentrated upon India, and thinks little of what is being done or left undone at home; but men are not in a mood CONCLUDING REMARKS. 519 t^pe trifled with. They are in that sort of savage frame 0 nind which would delight in tearing somebody to pieces - hey would prefer a Brahmin, or a Mussulman, but as t]y cannot get that, they would take what they could get. 1 Cholera should break out badly in our Barracks, and s^;uld be traced to the neglect of timely and repeated \^:'nings, it would fare ill with the responsible/^ Chat we shall have another epidemic of Cholera soon is, s aking as men speak, certain. The signs are already h'e. We have put our house in order (in a certain B asure, at least,) as far as regards the civil population. Tion them it will bear less hardly than it did in 1849 and l!54. Shall the Queen's troops, and troops which have d served so well of us, be the only portion of Her subjects \'ich shall not escape, whose chance of life shall not be Iked to? It has been shown that they have suffered more than tice as much in past years, even when the rest of the {ipulation was at its worst, from Cholera and other epi- ctaics, as their civil fellow-subjects have done. This f al preponderance will be seen, as still more glaring, iw that the Sanitary state of CiviUans has somewhat ii proved. The Queen's Household Troops in London have suffered ii their Barracks a yet higher proportion of mortahty hm Cholera, in comparison with the civil population, lore than five times the proportion of Royal Horse <^ards actually died, in 1849, from Cholera, in Knights- Hdge, compared with Civilians, although including all Jies, and both sexes, in the same parish*. Shall this pro- Deaths per 1,000, from Cholera, in 1849, of Troops and Civilians, in same Parishes. Pee 1,000. ( ilians— St. Pancras . . . . • • • • ■ ' ^'^ ' >ops— 2nd Life Guards, Regent's Park . . •• 10-4 520 CONCLUDING REMARKS. portion be raised yet higher by the mortality of th | metropolis falling, while that of the Household Troo]- j does not, and thus be made still more fearfully striking i Such_, however, will, in all probability, be the case, unles ; the Barracks are improved, before the next epidemi comes. To introduce, therefore, a proper sanitary system int i the British Army is, especially at this juncture, of essen tial importance to the Queea and the Public Service. The principal defects pointed out and the principal sug gestions for their remedy offered, in the preceding notes will now be subjoined. Civilians — Kensington . . . . . . . . . . 3-3 Troops — Eoyal Horse Guards, Knightsbridge . . . . 17'5 Civilians— Marylebone and St. Martin's in the Fields . . 2 7 Troops— 1st Batt. Gren, Guards, Barracks, Portman Street 1 3 2 1st Batt. Coldstream Guards, Barracks, Trafalgar Sq. J Civilians — St. John's and St. Margaret's, Westminster . . 6-8 Troops— 2nd and 3rd Batt. Gren. Guards, Wellington Barracks* 2*0 Civilians— East London and Whitechapel . . . . . . 5'i Troops— 2nd Batt. Coldstreams, 2nd Batt. Scots Fus. Guards, Tower .. .. .. .. lO'O Civilians — Marylebone.. .. .. .. .. 1"7 Troops— 1st Batt. Scots Fus. Guards, St. John's Wood and Portman Barracks . . . . . . . • 2*0 The Deaths of the Civilians are taken on the whole population, without ' distinction of age or sex„ ' * The Wellington Barracks are in St. James's Park, the most healthy spot in the district. 521 UMMARY OF DEFECTS AND SUGGESTIONS. 1. Field Service. 1. There appear to have been no preliminary sani- I. Defects in ry instructions sent to the Army in Bulgaria, even after Sanitary e receipt of the Reports of an Army Medical Commission, ■epared as these Reports were by the Director- Generars !sire. 2. No instruction sent, to examine and prepare the ospitals on the Bosphorus, before they were occupied. 3. No sanitary instruction issued for the guidance of [edical Officers going to the Crimea, on any one subject, ther regarding town or country. I Note. — After sanitary neglects had become matter of kblic notoriety, inquiry was made about individual cases, e. g., the drainage and graveyard at Scutari, but all .lis was after the evil was done and the penalty incurred. : II. The recommendations from the Director- General's jj j^^^^^^^ )ffice affecting the personal hygiene of the soldiers evince as to Supply, lore information and practical insight. They are often jtiforced with vigour, as, e.g., in the case of Lime Juice, fentilated Tents, and, to a certain degree. Clothing. But the Army could not live on Lime Juice. There is ittle mention made of Vegetables, or of ground Coffee, till 522 SUMMARY OF DEFECTS AND SUGGESTIONS. 1. Field the mischief was done. There is no mention at all of Fresi Meat^ Breads Fuel, Roasted Coffee, or Cooking, until tli winter of 1854-55 was over, and the Civil Commissioii were come. The very essentials to life are neglected, an even the remedies are posthumous to the death of th i Army in many cases, in others tardy and ill-timed. With regard to Hospital supplies, which were undenig bly within the jurisdiction of the Department, no coi - respondence about them, so far as hitherto has appeared took place, although the Director- General must hav known that they were exhausted, during a considerabli period of 1854. III. General HI. The very obvious defects of the procedure of th DcfcctiS of Procedure. Army Medical Department, in reference to the Hygiend of the Army in the East during the first year of tli( campaign, may be summed up as follows : — 1. The Department appears never to have been consultec about Rations, Clothing, or Sanitary measures. 2. With the exception of advice as to Clothing and ventilated Tents, which was not followed, and as to Peati Charcoal, which was, the Army Medical Department appears to have tendered no advice on Sanitary measures nor on Hygiene to the Horse Guards or War Depart- ment, before or during the first winter. 3. The Director- General appears to have sent no Sani- tary instructions, nor any instructions as to the compo- sition of Rations, to the Principal Medical Ofiicer of the Army. i The narrative given shows that the whole Dietetic sys- tem pursued in the Army is wrong ; that, in fact, the feed- ing of the Troops was nothing but the merest hap-hazard, and that the result which did follow was inevitable after these conditions had been permitted to exist. SUMMARY OF DEFECTS AND SUGGESTIONS. 523 The Director-General appears never to have made any I. Field g iitary suggestions with respect to the state of Scutari ])spitals, until after their condition had become matter ( public complaint in England, and the Government had t :en other means of remedying the evils. k The Principal Medical Officer appears never to have cisulted the Director-General on any Sanitary subject, iron the composition of Rations. He only recommended ^i;getables and Lime J nice after Scurvy had appeared. He ( ly stated that the Ration contained too much salt meat, { the time when the issue of fresh meat was 3 lbs. per ] m per month, and this six weeks or two months after sirvy had appeared. 5. The Principal Medical Officer does not appear to I've been consulted by the Commander of the Forces on le composition of Rations, or on any Sanitary subject. 6. The Principal Medical Officer appears not to have len consulted as to Clothing or shelter. 7. The Principal Medical Officer appears to have given advice to the Commander of the Forces on any of these f'bjects, until the Army was suffering and exhausted, ; d when it was too late to obtain what was necessary.* '8. The Principal Medical Officer issued no Sanitary emorandiim for the guidance of his Medical Officers, i the army taking up ground before Sevastopol. 9. The Medical Officers were not consulted about I* The contrast between the Diet correspondence during the first winter [the Crimean War and that of the remainder of the campaign, is striking, "ter Sir John McNeill's Commission went out, the Principal Medical ;ficer appears to have received new light on the subject of Diet, and, [ring the remaining part of the occupation, he writes and applies con- liually on all subjects, meat, bread, vegetables, lime-juice, porter. A jiscription of the Disease produced by want, and a prescription of Lime |iice and vegetables as the remedy, were the mode of action of the first Inter, replaced by abundant writing about diet and a lively sense of its iportance, during the after period. 524 SUMMARY OF DEFECTS AND SUGGESTIONS. « Sanitary or Hygienic points by tlieir Commandin Officers. We are left to conclude^ on the one hand, either tha the Army was so well provided that no written represei] tations on the subject were necessary : on the other, tha it was no part of the duty of the Medical Department t make such representations. Yet, when we consider that it is not by wounds or ii action that Armies have been cut off in the field, but h Epidemic Disease — that it is not on battles, but on epide mics that the fate of nations at war has depended, shouk it not be considered that the Sanitary care of an Army i; an essential part of strategy ? ' I II. Field Hospitals. ' II. Field According to the present system, serious deficiencies in Hospitals. stores and equipments of Field Hospitals, and their means of transport, may, at any time, take place. * To prevent this in future — A fixed scale of Field Equipments, and of Medicines,: according to a specified List and Formulse, should be laidi down. Let there be a Military Pharmacopoeia, fixed upon by the most distinguished men of the Medical profession in Great Britain and Ireland, Civil and Military. Such names cannot fail to conciliate confidence in the Army Medical Profession. Let them decide what medicines and appliances are really essential to the health of an Army and compatible with reasonable means of transport. Their dictum will be accepted. Whereas now it is true that an unreasonable bulk is sometimes required in the supplies of medicines demanded. I. Field Service. SUMMARY OF DEFECTS AND SUGGESTIONS. 525 III. General Hospitals. A great amount of mismanagement, failure and suffer- iii. General g resulted in the late war, from the want of some DEFEcig"^^^' ipreme Officer, who should be held responsible for the lalth and efficiency of the Hospitals at the base of opera- tms. The only way to prevent similar occurrences is to de- Suggestions, rmine : — 1. That a Governor be selected and named by the ;cretary of State for War, by whom the other Officers, reads of Departments in the Hospital, should also be imed. In the event of a vacancy occurring on service, lC Commander of the Forces to make a provisional )pointment, subject to the approval of the Secretary of tate. 2. That all Officers of Engineers, Sanitary Officers, or thers employed on the application of the Governor to lirry on duties connected with the Hospital, be under le authority of the Governor while so employed. 3. That all the labour required to carry out plans pproved by the Governor, under the directions of any department, be obtained or hired by the Governor or by is written directions, and not otherwise. 4. That the government and control of the Hospital 3 vested in the Governor, except so far as relates to the ledical and surgical treatment of the patients by the ledical Officers. 5. That the Governor of a General Hospital, whether le be a Military or Medical Officer or a Civilian, be onsidered, and assume the functions, and be vested fdth the powers of, a Civil Governor. i 6. That tliere be attached to the Hospital one or more Ivlilitary Officers of the Adjutant- GeneraFs Department, 526 SUMMARY OF DEFECTS AND SUGGESTIONS. III. General subject to the authority of the Governor, to conduct tti; discipline of convalescents, when necessary, and to se that they are properly equipped when they proceed t join the Depot. 7. That all orders or requisitions of the Principj! Medical Officer, or of the Steward, for supplies for thi Hospital, shall be ineffective unless countersigned by th Governor. 8. That the Hospital be not dependent upon th: Commissariat for any supplies, but that the Commissaria honour the drafts of a Treasurer, countersigned b the Governor, for the expenses of the Hospital, includ ing the pay of the officers, attendants, and others attachei to it, and that the Governor be held responsible fo the due and proper disbursement and application of th( funds. 9. That the duties of the Purveyor be equivalen to those of the Steward in a Civil Hospital. 10. That no contracts for supplies to the Hospital whicl' the Steward may propose to make, be concluded until approved and countersigned by the Governor, unless wher made at a distance from the Hospital by written instruc-| tions from the Governor, by whom, in that case, they must subsequently be countersigned. 11. That all Contracts for supplies contain a clause authorizing the Steward to purchase in the market, at the cost of the Contractor, any supplies which the Contractor may fail to deliver in terms of his Contract — if they are immediately required. 12. That all transport by sea or land required by the : Steward, for the purposes of the Hospital, be obtained or provided by the Governor, as also the transport required by the Principal Medical Officer for stores strictly medical. SUMMARY OF DEFECTS AND SUGGESTIONS, 527 N:e as to proposed Office of Treasurer in General m. Geneeal Hospitals, p. 226. Hospitals. he grounds upon which it is considered important to seirate the office of Treasurer or Paymaster from that of P veyor or Steward, are as follow: — . If the Purveyor of a General Hospital is to be a Tasurer also, he must do one or other duty by deputy; h( cannot do both in person as they ought to be done. T;y must practically be done by different men. And tb only question really to be considered is whether the diies shall be divided, and each man be held responsible foi what he does ; or whether the Purveyor shall be mle to account to his own deputy, and his own deputy tciim. . If the Purveyor is Treasurer and Paymaster, no one w venture to be very troublesome about defects in the P'veying, for he can retaliate most effectually by being tiiblesome about accounts and payments. This is really tl most important consideration. There can, in that case, be no preliminary audit on tl spot, and no subsequent audit at home can be both ji: and effectual, especially where local difficulties are to b'sncountered. . No one in private life would dream of putting the w )le of his funds into the hands of the man whose biiness it was to supply his establishment with food, and k,e him to make out an account of the manner in Tv.ch they had been disposed of. A prudent man would p 36 his funds with a banker, and give orders from time t( time, as funds were required for the supply of pro- v:ons. The principle appears the same in both cases. A/iiy should the line of action in the Army be contrary tchat adopted by the most business like country in the 528 SUMMARY OF DEFECTS AND SUGGESTIONS. General world ? If a Paymaster- General were to be appointed ^ 3PJTA.XiS an Army in the fields ought he to be made dependent ontg Commissariat for funds ? The Governor of a Hospital f he had the means, would do better to pay a Treasurer ct of his own pocket, than have the duties of banking a I of supply jumbled up together in the hands of the saij man, however good a man he might be. 5. But independently of these considerations, t; object of every system is to have the work well a:l thoroughly done; and no arrangement can really i\ economical which is incapable of effecting this objed The plan, whatever it may be, which makes our Hospitji most efficient for the care of sick and wounded soldiei and their restoration to efficiency, must ultimately be t. best and the most economical. An efficient soldier is n a low-priced article. And if the Purveyor has, besid the duty of supplying every required article, the labou anxiety, and responsibility of providing, disbursing, ai accounting for all the funds required for all purposes : the Hospital, it is made virtually impossible for one mi in a thousand to do both as they ought to be done; an if they are not so done, the ultimate loss falls upon tl public. Even the difference in the first cost is not so great as may at first sight appear. There must be hands enoug to do the work, and they must all be paid for, in whai ever form it is put. The person, whatever his designatioi to whom the Purveyor entrusts the banking part of th: work, must be a person competent to conduct it, an must be paid accordingly. The additional first cost c having a Treasurer or Paymaster could only be tli difference between his salary when employed under th Purveyor and his salary when employed under th* Governor. It is a fallacy to suppose that the work cai SUMMARY OF DEFECTS AND SUGGESTIONS. 529 bnad without paying for it ; or that good work can be HI. General h; without paying an adequate price for it. Hospitals. 'o sum up. There can be no question tliat to have a Remedies. S svard to buy, and a Treasurer to supply him with the rf lisite funds on sufficient cheques or orders, is a safer, m '6 efficient, and at the same time a more economical s}em in the end, than to combine the duties of Pur- vfor and Banker in the hands of one person. Till the frictions of banking and of supply are separated, no ac pate remedy can be brought to the evils experienced fr i the present system, whether of Commissariat or of P veying. TV. Sick Transport. 'he Sick Transports, during the late War, up to the mdle of February, 1855, were in a condition utterly unfit fo sick as regards their Sanitary state, and sick were sbiped in a condition utterly unfit for the voyage. The Tmsports were, many of them, unfit for the purpose. Tly were overcrowded, badly ventilated, not clean, and n( fitted up for the reception of sick. The attendance on bed was also deficient. The superficial space, allowed in the Transports, was fixed by a Board of Inspection fo led at Balaclava, December 12, 1854, at 6 ft. by 2i ft. fo sick and 6 ft. by 3 ft. for wounded men. The height hiveen decks varied from 6 ft. to 8 ft., only in one instance w; it 8i ft., and in one other 9 ft. in some parts. Many cas of Choleraic Disease were put on board. As might h£3 been expected, great was the mortality, in conse- qiice of all these causes. : is necessary in future : — hat properly-fitted transport ships be provided, for the co/eyance of the sick and wounded, who may be equal 2 M IV. Sick Transport. Defects. Eemedies. 530 SUMMARY OF DEFECTS AND SUGGESTIONS. TrLspobt voyage, with a suitable staff of Medical Officers ar of attendants. , And that other properly-fitted Transport Ships be pr. vided, for the conveyance home of invalids, not sick. V. Hospital Management. MaSTement ^* ^^^^ delay, inefficiency, and uncertainty have aris( Defects. * from the present mode of supplying Hospitals by requis tion ; the requisition being also made upon an Officer wJ is only partly responsible for the supplies "requirec being in store. 2. The existing Diet-tables are defective, and necesf tate the use of a large number of Extras which might I avoided. 3. A large proportion of the time of the Medical Of cers is taken up in matters of household detail, and cons quently lost to them for their proper professional duties. The forms of Admission Books, Medical Registers, Di( Rolls, &c., now in use, absorb a considerable amount time, without any corresponding advantage to the Sick. 4. The present Hospital administration, from the a sence of any organized system of Hospital governme . and attendance, is not such as to afford experience in ti, \ management of General Hospitals, in the event of the! i being called for in an emergency. 5. The present system of frequent inspection is obje tionable, on account of its interference with the treatme of the sick, and with details of Hospital managemer.. which would be better left to the responsibility of tli ^ treating Surgeon, upon whom, rather than upon tl Inspector, such responsibility should rest. It is proposed, Avith a view of remedying these evils . SUMMAK'Y OF l^EFECTS AND SUGGESTIONS. 531 . That, in future, all the duties of supply shall be p formed by one Officer, according to a list to be laid d /n ill his Instructions ; subject to the orders of the g erning Head of the Hospital. 5. That revised Diet Tables be adopted, after consulta- til with the best Dietetic Authorities of the day. ;. That the Medical Officers be relieved from all duties, e ept those strictly concerned with the treatment of the Sk, in order to enable them to devote as much time as p siblc to these. That simplified forms of Admission Books, Medical F^istcrs, and Diet Rolls be adopted. L That, with a view to habituate the Medical and iministrativo Officers to the conduct of large General I-spitals, as weU as to secure the superior advantages e oyed in such by the patients. General Hospitals, with a s table scheme of government and attendance, be substi- ted for agglomerated Regimental Hospitals, in such Doibers, and at such Stations, as the Secretary of State s'dl select. That a Commissioned Officer for the management of I>spital attendants be appointed, with certain specified dties. ). That the duties of Inspectors and Deputy Inspectors 0 Hospitals shall not extend to interference with the t atment of the sick, or to interference with such details 0 Hospital management as the treating Officer should be 1 d directly responsible for. That the duties of all Inspectors and Deputy Inspectoi s s)uld be fixed by the Director-General, and the regula- tns for such duties should be pubhshed for the informa^ t n of the Service. That Female Nurses be introduced into all General and 1 ge Garrison Hospitals. 2 M 2 V, Hospital Management. Alterations Suggested. ! ( 532 SUMMARY OF DEFECTS AND SUGGESTIONS. VI. Sanitary Officer for Hospitals, Encampments! ' &c. VI. Sanitary 1 • There is no standing order or regulation to makefc )§ CcTnsultation inoperative on the Commanding Officer to consult t'; \t AS TO Medical Officer on any matter affecting the health of t ; Hospitals, -1/211 Encampments, troops m the neld^ or lor entrusting to any compete; 1 Present Want ^^^^^^^7 Officer the sanitary improvement of occupi i of any towns, villages, districts, or buildings, or for obtaini: in Sanitary Re- . i • • i - n j sponsibility. Competent sanitary advice, with respect to sites for camj |j: erection, draining, and ventilation of huts, water-supp] and other similar matters. The regulation that Medic h Officers are to report their opinion on certain matte ? affecting the health of the troops is defective, and is n necessarily followed by any practical steps for removii i causes of the disease reported on. In the case of armi ^ in the field, no competent Sanitary Officer is attached Head Quarters, whose special duty it is to attend 0013 stantly to all external conditions affecting the health the Army. 2. There cannot be a moment's doubt as to the essentii nullity of the whole sanitary procedure with regard to tl General Hospitals at the base of operations, in the lai War. No measure that was recommended was unnece: sary, but, even if the measures had been all carried ou the Hospitals would still have been unfit for the sick. After all was done, the murderous Sanitary defects ( these Hospitals remained untouched ; and Death did hij work well. ' The defects and their bearing on the health of th Hospitals required sanitary knowledge to discover ani estimate, and practical knowledge to remove. Th recommendations made by certain Medical Officers wer' superficial, elementary, obvious to any one with a nose SUMMARY OF DEFECTS AND SUGGESTIONS. 533 a,l such as any person would have made; but the VI. Sanitary dects so discovered were not those which had converted ^osktals^ t! Hospitals into pest-houses. ENCAm'MENTs, 'Even if they had been all discovered, was it the time to h/e set about the remedies, as the Sanitary Commission v5 sent out to do, when the sick had perished? iFhe evil lay in not having such a sanitary organization i: the Army as would have caused every source of danger the removed J before a single sick man was placed in any 03 of the buildings. There is 1, nothing in the education of the Medical (icer — 2, nothing in the organization or powers of the /my Medical Department — 3, nothing in the whole Hos- pal procedure — 4, nothing in the Army regulations which vuld have met the case of these Hospitals. And were a s iilar necessity to arise again, especially after the lapse oia few years of peace, the whole thing would occur over a^iin. This is the frightful consideration which ought to B'ke us recall over and over again this experience; oierwise, let bygones be bygones. Dur General Hospitals have always been shambles for t i sick. And men have come to recommend that none b ever formed again at the base of operations. The Scutari buildings were spacious and magnificent in e ernal appearance ; far more so, indeed, than any miH- t y buildings in Great Britain ; and several of them were, a')arently, better suited for Hospitals than any Mihtary I)spitals at home. This merely external appearance was, however, fatally dieptive. Underneath these great structures were sewers 0 the worst possible construction, loaded with filth, mere c spools, in fact, through which the wind blew sewer air u the pipes of numerous open privies into the corridors al wards where the sick were lying. 534 SUMMARY OF DEFECTS AND SUGGESTIONS. VI. Sanitary The wards had no means of ventilation_, the walls rel I OFnCERFOR . . 1 Hospitals, quired constant lime-washing, and the number of sicl [ ^^^^ Ta'^'''^''' crowded into the Hospitals, during the winter of 54-55 was disproportionately large, especially when the bac I Sanitary state of the buildings is taken into consideration The population of the Hospitals was increased not onh without any Sanitary precautions having been taken, bu while the Sanitary conditions were becoming daily worse for the sewers were getting more and more dangerous anc the walls more and more saturated with organic matter. 3. Almost every word of this, which applies to Fiek Service, may be repeated, mutatis mutandis, for home There are Barracks and Military Hospitals in England at this moment, in nearly as bad a sanitary state as th( buildings at Scutari. The plans of Netley Hospital sho\\ an amount of sanitary knowledge quite behind that of the age. Remedy. The necessity of appointing some competent Sanitarj officer, for consultation, seems to be apparent, from what has been said. i VII. Barracks. \ VII. The amount of disease and mortality among the troops, P^ient ^vils time of peace, greatly exceeds that among the classes and ages in Civil Life, from which the Army is recruited. There is nothing in the occupation of a Soldier which can account for this. The mortality from Pulmonary and Zymotic Diseases, which together make up a large propor- ! tion of the excess, is double in the Army what it is at the j same ages in Civil Life. \ The state of the atmosphere in Barracks is most impure and offensive, arising from over-crowding, insufficient ven- i tilation, and defective drainage. To this state of the . SUM3IARY OF DEFECTS AND SUGGESTIONS. 535 f nosphere is to be attributed much of the liability of VII. Jldiers to Zymotic Disease, and, together with imperfect ( 3rcise, the same conditions predispose the men to pul- imary disease. In all Barracks, the provision for married soldiers is l^hly defective. A minimum space, sufficient for health, should always Suggestii 1 allotted to each man in his Barrack-room and in the (lard-room, with suitable Sanitary arrangements. —Day- ]Dms should be constructed for the use of the men. — .lid all Barracks should be provided with kitchens, admit- iiig of variety in cooking. It is also necessary : — That separate sleeping accommodation, either by cor- gated iron partitions, as used at Col. Jebb^s Asylum, Fulham, or by other equally easy, simple, and eco- )mical means, be provided for Privates in their Barrack Doms. That suitable accommodation be provided for married Idiers, and that Model Lodging-houses, in certain cases, ; erected for their use. That all Barrack-rooms, Guard-rooms, and Day-rooms ; properly lighted and warmed. — That every Barrack lOuld contain ablution-rooms and baths, a laundry and ying-room, and workshops. VIII. Statistics. ' There is no Statistical Department connected with the VIII. ^ -r» 1 • Statistics, rmy Medical Department, the existmg Keports having present 3en, at first, voluntarily prepared by gentlemen who take Deficiencies. 1 interest in the matter. Owing to this defect, the eturns of Sickness and Mortality, in the late War, ^came involved in inextricable confusion. 1 536 SUMMAEY OF DEFECTS AND SUGGESTTOKS. j j vni. The Mortality in the Field was returned week by week Statistics. . ^ , ^ , . , *^ instead ot the proportion to strength per annum. The mitigable forms of disease and mortality are no returned, as they ought to be, separately. The classification of Diseases adopted differs from tha of the Registrar- General. The deaths in the Army are not registered in th( Registrar- GeneraPs Office. - The rates of mortality are only published at long inter- vals. And there are no means of frequent comparisor 5 between the Mortality in the Army with that in Civi Life, or with its own previous rates. Improvements It is necessary that an efficient Statistical Staff hi Suggested. appQi^^ed, in connection with the Army Medical De- ^ partment ; — that, in future, the Mortality in the Field should be reduced to the received unit of time, viz., a year ; and that it should be stated at so many pei I* 1,000 per annum; — that the Weekly Medical States should exhibit, in a separate group, the Disease and' f Mortality from Zymotics, and that each State should ' have noted on it the causes of the predisposition to such diseases. ' That the same nomenclature and forms should be used for Army diseases and mortality as have been adopted by the Registrar- General. That the Statistics should be kept so as to enable the | Government to judge of the comparative healthiness of every Station and Barrack ; and so as to admit of the sick- ^ ness and mortality being traced to their causes, and the remedies being applied. That the Statistics of Mortality be communicated to' the Registrar- General, for comparison and publication, — also those of births and marriages in the Army. The form of the Schedules appended to the Registration Acts to be 1-^ SUMMARY OF DEFECTS AND SUGGESTIONS. ' 537 a)pted, so as to admit of an accurate and ready compa- VIII. r )n with the National returns. Statistics. 3ne great object of Army Statistical Returns is to show t men of science and to the pubhc the peculiar diseases f m which the Army suffers. And this will be accom- pshed most effectually by adopting the same form of ossification as is employed in returning the causes of dith in the civil population. IX. Pay and Promotion of Medical Officers. L. The present system of promotion by seniority (reckoned, B,: from the date of first appointment but from seniority i^.hin the limits of the station or group of stations) neces- S|ites, as the Director-General informs us, (Report of the (mmittee on the Army Medical Department, Q. 4,552), t; introduction of very complicated rules, which have ij/er even been reduced to writing, in any systematic f m, — which are known only to the Director- General and a; scattered over a correspondence of forty years. In order to prevent the rules from operating harshly on i hviduals, a fresh enactment is made, he says, to meet € !h special case, as it arises. I. Further, he stated before the same Committee of the l)use of Commons, that the interest of the Service ri^uires a departure from rules. 3. There are two purely administrative ranks, one of a rxed character, and two executive ranks, in the Army ledical Department. The principle of appointment to the administrative iliks is not sufficiently well defined. f4. Confidential Reports, affecting the character and pro- iption of a Medical Officer, may be used to his disadvan- IX. Pay and Promotion op Medical Officers Present system. Uncertainty. Departure from Rules. Want of Rule. Confidential Reports, 538 SUMMARY OF DEFECTS AND SUGGESTIONS. IX. Pay and tage, without his having any opportunity of explanatioi Promotion of ^ ^ Medical or defence. GeneraHy ^' '^^^ grievances of which all Army Medical Officers complain^ are the following, which they consider to b( caused by the system of administration at the Arm} Medical Department : — i Uncertainty, Apparent injustice, ! An offensive system of inspection, Promotion to the Inspecting Ranks of men who have not the confidence of the profession, Insufficiency of pay. The apparently unfair length of time before retirement, Insufficiency of rank. The Director-GeneraPs proposal of an improved scale of pay, the annual cost to the country of which would be £217,763, or £50,000 more than the present rates, is presumed to be the salve to all the wounds. It unfortunately happens, however, among Army Medical Officers, that much of the discontent is occasioned by the administration of the Department itself. And the result is that the esprit de corps, which it is desirable to uphold, is to a large extent wanting. Relative Rank. 6. It is complained that the Relative Rank conferred upon Medical Officers is not, in all grades, so high as the value and importance of the Department would seem to justify. That the relative rank and the practical advantages which it is meant to confer are undefined, and vary, according to the interpretation which Commanding Officers may put upon this rank. That there are no regulations in the Queen's Service, either one way or other, upon the subject. SU3IMAKY OF DEFECTS AND SUGGESTIONS. 539 :'hat Medical Officers are subjected to humiliation, in c sequence. That they are not considered entitled to the same hiours and distinctions as Combatant Officers, and that i] y do not receive them in the same proportion. That the Military honours, at funerals, are not propor- t aed to the relative rank of the Medical Officer. That, in the Army List, the Medical Officers are not iierted according to their relative rank. \jid that, in the General Army List, the Department is p ced after others before which it ought to have prece- dice, as a scientific profession. The pajT^ given, the honours bestowed, and the position aarded to the Army Medical Officers are not such as to a ract to the ranks of the Army Medical Department a f r share of the best men who devote themselves to the ladical profession. Still more will this be the case, when t3 higher standard of attainments, now proposed by a byal Commission, is exacted. 7. There is no Roster, at present, according to which (iery Officer of the Staff would go abroad, in his turn, and I ve an equal share of foreign service. In the lower ranks, a Roster might be estabUshed, i d in time of peace be maintained with convenience to 1e Department. In any future re-arrangement of the pay and promotion, i appears to be necessary, 1. That the Medical Officer should have a reasonable rrtainty as to his rise in his profession. That the principle of seniority should be strictly ;.hered to, except in the Inspecting Ranks. That the present anomalies, so much complained , of juniors in rank receiving the same pay as their IX. Pay an Promotion of Medical Officers. Eoster for turn of Service. Alterations apparently required. Certainty and fixity of Rule. I 540 SUMMARY OF DEFECTS AND SUGGESTIONS. IX. Pay and superiors — of seniors being inspected as to their medicE Promotion of , . . i i i i • i i ■, Medical treatment by juniors, should be avoided, and that, as fa Officers. practicable, every step in the progress of the Medicp Officer, from his entering the Service until the perid of his being selected for the rank of Deputy Inspector General, should be fixed by Regulation, known to th whole Service, and adhered to. Adherence to 2. It must appear, to all who have well considered thi. subject, that the interest of the Service can only bi guarded by laying down rules and by adhering td them. Openness. 3. 4. In every instance of selection for the adminis trative ranks, and in every instance of recommendatioi for honours, the reasons should be fully stated in writ- ing, and made known to the Service; and, in any cas(: where any charge is made against any Medical Officer likely to interfere with his interests, such charge shoulc be made in writing, and communicated immediately tc the Officer against whom it has been made, and, in any record of the charge, the answer to it should be given! verbatim. True principle 5. The true principle upon which promotion should rest of Promotion, , , ^ Seniority in appears to be the following :— S^elecUon^in When young men enter the Service, they have their the higher experience mostly to gain ; and it is not until after many Appointments, ^^^j^g^ service that the true capabilities of a man can be ascertained. The highest capability of a Medical Officer is the capability of treating the Sick and Wounded. And no man should be selected into the inspectorial rank on ; that account. The inspectorial talent, which is the only | talent that ought to form the basis of selection into that J rank, is one which, in the vast majority of instances, requires age for its development. ; SUMMARY OF DEFECTS AND SUGGESTIONS. 541 [t would be perfectly safe, therefore, to give the prin- and c le of seniority free course, until a man, by length of Medical s vice alone, arrives at the highest executive rank. Officers. Selection to inspectorial offices should rest upon this pnciple, that the Director-General, being himself person- am responsible for the administration of his Department, s)uld have the power of selecting his representatives. It, at the same time, the Army Medical Service should f 1 that its interests, in the executive ranks, are thoroughly p)tected against what it might consider an invidious ijcrference with its rights of progress by seniority. Confidential Reports must be utterly abolished. No iirease of pay will compensate a man for a stab in the d"k; and every statement to his prejudice should be sent V batim to him directly for a reply. [t may be expected, under an improved system, that d b ter educated, more intelligent and honourable set of nn will enter the Service. But we must not expect to Oiain such a class solely by, increase of pay. The class are most desirous of obtaining consists of those men T\o, while they look for a fair remuneration for their si'vices, look at least as much to fair, honourable, and gitlemanly treatment, and a proper recognition of their st'vices, as amongst the most prominent reasons for d iring to enter the public service. •. With respect to Relative Rank, the true principle ap- Relative Rank, p .rs to be this, that, while the Medical Officer is treated a becomes his education and position as a gentleman, his idtive rank, and the advantages following from it, should b at least one grade lower than that of the Commanding Cicer to whom he is attached. ■ t would not answer in practice for the Commanding Cicer to be a Brigadier- General, and the Chief Medical Cicer to be a Major-General. 542 SUMMARY OF DEFECTS AND SUGGESTIONS. IX. Pay AND If Army Medical Department were, as it ougl ^MedicaI^^ to be, totally separated from the combatant part of tl Officers. Army, its true position, in the Army List, would be m of the Army hierarchy and apart by itself. As to Substantive Rank, would it not be much bettt in every sense for the Service that the Medical Depar ment should be quite separate and distinct from th Army? that it should devote its whole time to the pn vention and cure of disease, and not be called upon t perform any duties which are now discharged by Officei in Regiments? The principle of substantive rank infers a greater or le^ disregard of the specialities of the medical profession, an a greater or less participation in military duties, for whic the Medical Officer is not competent. Would it not be better to limit the Medical Officer duties in regard to all courts and boards, simply to appeal ing before them and giving advice and information whe required ? Pay. The pay of Army Surgeons and Assistant Surgeon should be increased. X, Medical Education. X. Medical Education. Defects. 1. Under the present system, the preliminary require ^ ments of candidates, for entrance into the Army Medica ^ Service, are defective. 2. The examination which candidates have to undergo ^ on their entrance, is insufficient. ' 3. The professional training, after a candidate has beei ^ accepted and before he joins his Regiment, is inadequate ^ and, in all Sanitary matters, wholly wanting. ^ 4. The means of subsequent professional informatioi and improvement are inadequate. 1. It appears to be desirable that Candidates shouh ^ SUMMARY OF DEFECTS AND SUGGESTIONS. 543 he legal qualifications in Medicine, as well as in Sur- X. gy; and should give evidence of having had a liberal ^MEmcir^ gieral education. Officers. I. Their examination should be entrusted to a special bly of practised Examiners. 3. Provision should be made by the State for instruct- i; candidates in the specialties of the Army Medical lofession, before appointment to the Office of Assistant- ^ rgeon, and promotion to that of Surgeon. And more e)ecially for a complete course of instruction by tho- nghly competent Professors, in Military Hygiene, Sani- ty Science, and the Physical education of troops. iLet leave of absence be granted to Medical Officers to f able them to extend their knowledge and experience at ])spitals and Medical Schools. XI. Rations. The present Rations are not settled on any principle xi. (tablished with a view to producing the highest physical I^-^tioi (iciency of the men. The manner of cooking is defective ; 1e Stoppages are so various, and the accounts so com- } cated and cumbrous, that the whole system, in time of ] ace, involves an enormous waste of labour, while it is i mediately abandoned in time of war. There is no pro- ^>ion, moreover, for varying the quality and amount of 1e Ration, according to the varying conditions of the Mdier's life, in peace and war. Let one uniform rate of Stoppage be adopted, both at '•me and abroad, in Hospital, on board ship, in peace :id in war, including Ration and Regimental Messing; : d, in consideration of that consolidated stoppage, that ere be issued to the soldier, by the Commissariat, a 544 SUMMARY OF DEFECTS AND SUGGESTIONS. XI. sufficient Ration for three daily meals, including ve2 Rations. . , ^ , \ . , . ^ tables, tea, coiiee, and sugar, also occasional flour an raisins for puddings, and extra bread, with such variatio: abroad as the climate, period of the year, nature of tl service, or the markets may render necessary. XII. Cooking. XII. Cooking. At present, in Barrack as in Hospital, but one mode ( dressing food is recognised or provided for, viz., boilmj But, except in a few Barracks, no meat can be bakec roasted, or fried, with the existing means — a defect in tli cooking likely to co-operate with other defects, in bein injurious to the health of the men. It is suggested that, in every Barrack and Hospital means should be provided for cooking Rations and Diets in the various methods indicated. XIII. Hospital Construction. XIII. 1. Neither the plans adopted nor the sanitary arrange Construction, ments, generally, have been such as to ensure a health). Defects. state of the Hospitals. 2. The amount of cubic space allowed for the sick has been too small, and the ventilation has been defective. 3. The kitchen arrangements have been defective. Necessary It is very necessary, as proved by existing Military Improvements Hospitals:— 1. That all plans for the original construction of Hospi- tals be submitted to competent Sanitary authorities,, before such plans are finally approved. 2. That the amount of cubic space per patient be not less than 1,400 feet in Hospitals at home, nor less than 2,000 feet in tropical climates. SUMMARY OF DEFECTS AND SUGGESTIONS. 545 'hat the beds be placed at a minimum distance of 4 feet fr Q the nearest sides, and 12 feet from foot to foot. i'hat water-closets of the best construction be attached tc'the wards, and tlie whole drainage of the Hospital ccs^eyed away by impervious drains, without passing uier the building; and that all water-closets and sinks b( separated from the wards by a ventilated and lighted lo)y. hat all Hospitals be provided with suitable Baths and L atories ; be well lighted, by gas if possible, and tho- ro^hly warmed on the requisition of the Medical Officer of ach ward, hat, in all new Hospitals, the windows be placed near eai other, on opposite sides of the ward, and that the b€s be placed in pairs between the windows. hat all new Hospitals be constructed in separate Palions, in order to prevent a large number of sick from be g agglomerated under one roof. hat the walls and ceilings of Hospitals be constructed of 'arian cement, instead of bare brick or plaister, and the flcrs rendered impervious to moisture, by saturating the wed with bees'-wax. " hat the ventilation be by natural means, viz., by doors, wi'iows, and lofty fire-places, aided by ventilating shafts in he walls. lat wards be of a size to hold from 20 — 25 sick, as a miimum, with the addition of a few smaller wards for sgial cases. ^1 That such improvements be introduced into the sticture of kitchens as to enable the sick to have a suit- ab variety of diet. he sanitary improvements in Barracks, Hospitals, and Gbrisons need not be delayed, but might be at once pro- oei ed with, and special provision should be made for this 2 N 546 SUMMARY OF DEFECTS AND SUGGESTIONS. work. So far as is known, certain improvements could 1 carried out, with little difficulty and small cost, but othe would require the execution of more permanent work Every Barrack, Hospital and Garrison should be examine with reference to its sanitary condition ; and all experieiii has shown that it is essentially necessary that the exam nations should be made, the nature of the sanitary worl and their extent determined, and the works themselv executed, under the direction of persons competent to de with special sanitary defects ; otherwise the recommendi tions and suggestions made will be so unwise, and the co so extravagant, that the whole thing will be brought inl discredit. The Army Mortality can be and ought to be brougl down to 8| per 1^000, Of this there is no doubt ; th Model Lodging-houses, where 300 — 700 persons are coi gregated in a close space under good sanitary condition; afford a convincing proof of it, if any such were wanted.^ It will be found that the repair of men is more exper sive than the repair of buildings, and that these building may be put to rights at a cost equal to that of the treat ment of the sick who come out of them. * The Model Lodging-houses were built for health and show a rate < mortality little more than one-half of that of London. The Commo Lodging-houses were built for disease, but, under sanitary inspectioi showed, in 1854, one-sixth of the rate of Cholera Mortality in the whol metropolis. The Barracks are built for disease and show twice the rati of mortality from Consumption, more than twice that from Cholera an' Fever, and nearly twice that from all Diseases, which is shown b; the Civil Population^ -;. WALCHEREN EXPEDITION \^ ILE we are occupied with the subject of Army Hygiene, w should not forget the lessons of past experience, upon tl evils of defective knowledge and of defective adminis- * trive arrangements. It may be of advantage, for the sfie of comparison with the Crimean Campaign, to intro- die some account of the disaster at Walcheren. The rcimblance between the two cases throughout is very remarkable, showing a similar want of foresight in arrang- ir the details of both expeditions, and the disastrous C( sequences which clearly followed from that want. The Auy Medical Department of that day appears to have 0(upied a similar administrative position, with reference t(the Government, which the present department did d ing the Crimean war, and it was equally helpless in nesting emergencies. The result in both cases was tit the armies all but perished, while it was never clearly aiijrtained who was to blame. The following account of the Walcheren expedition is tien from Clarke's History of the War, Vol. II, pp. 168 t(l74:— ^The supplies of South Beveland and the other islands (August, p sessed by the troops were now exhausted, and the navy a I army equally anticipated the approach of famine. A nre tremendous evil, at the same time, afflicted the 2n2 I 548 EXTRACT DESCRIBING troops. About the middle of August, the effects of the baneful atmosphere began to appear and 3,000 men wen already on the sick list/^ ''^ Eight thousand men were on the sick list when Lorci (September Chatham embarked for England/^ (September 14th.)i c< rpj^jg calamity was not anticipated, by those who planneci the expedition, though nothing could be more certain thar its occurrence. It was notorious to every intelligent indi-' vidual, unconnected with the British Government, that the marshes of Walcheren were not less injurious, or less fatal. s than the stagnant waters of Batavia, and the reports oi' eminent physicians had many years before recorded and described the symptoms of the Walcheren fever. Sir Johni Pringle, Surgeon- General to the English Army, employed^ in Zealand, during the campaign of 1747, published a| treatise on the diseases of the Army, from which the fol- i lowing is an extract : — ^ In Zealand the sickness was great among the four battalions which had continued there since the beginning i of the campaign. These men, partly in camp and partly \ in cantonments, lay in South Beveland and in the Island \ of Walcheren, two districts of that province, and both in , the field and quarters were so very sickly that, at the j height of the epidemic, some of these corps had but 100 { men fit for duty, which was less than the seventh part of a ' complete battalion. The Royals, in particular, at the end i ^ of the campaign, had but four men that had never been ill. At the end of the campaign we had in hospitals, exclusive of the wounded, 4,000 British, which was something more than a fifth part of our whole number. But it is to be remarked that the four Zealand battalions furnished nearly the half, so that, when those corps went into winter quarters, their sick, in proportion to their men fit for duty, were nearly as four to one.' THE WALCHERFN EX:PEDITION. 549 Sir John then adverts to the known qualities of the a, which he describes as most unwholesome. He says ao that the epidemics of the country generally appear at end of July or the beginning of August, under the ciicular heats, and end when the frost begins. The work G Dr. Pringle had been extensively circulated, and might Ive been purchased at any of the book stalls for a trivial fice. The expedition sailed on the 28th July, and no medical jrson was consulted on the nature of the climate. " Sir Lucas Pepys, President of the Medical Board, was it consulted till six weeks after the sailing of the expedi- t'U. No preparations were made for the cure or preven- t'ln of the fever. Sir Lucas knew that the disorders of 'lalcheren prevailed in the months of July, August, and {;ptember, and that the marsh fever is greater in Wal- ( eren than in any part of the world, except Batavia. " The disease of the troops is just what he should have i pected, and, had the plan of their destination been con- led to him, he should have recommended extraordinary ■■ecautions. " Neither the Inspector- General, Mr. Knight, nor the irgeon-General, Mr. Keate, nor the Deputy-Inspector, Y. Webb, were asked for their advice. '^The expedition was sent out just as the season of fever jgan, and every provision of physicians and medicmes las neglected. The return of the sick was as follows : — On the 13th September, rank and file only, 7,626 „ 19th „ ^^1^^ „ 21st „ 8^684 „ 22nd „ 8^^^^ „ 23rd . 9,046 550 EXTRACT DESCRIBING On the 12th July, when the expedition was about tJ f sail, Mr. Keate wrote very earnestly to the War Depart ^ ment, imploring that two more hospital ships should b' furnished with the necessary equipments, to receive tin sick of the troops, about to sail from Portsmouth. Lon Castlereagh's Secretary answered that one hospital shi] had already been provided and refused the request. Oi the 17th Mr. Keate renewed his application, stating tlu great inconvenience and distress the Service must inevit- • ably suffer, from this arrangement. The request was agair refused, and the fleet, already provided with one pilot sailed with one hospital ship. All these arrangements fell under the official manage- ment of Lord Castlereagh, the Secretary for the Wai Department. All the Dutch provinces are subject to marsh dis- tempers, but Zealand, in particular, is not only low and damp, like the rest, but surrounded by the mouths of the Scheldt, whose oozy beaches unite with the marshy lands, so that, except the sea-breeze from the westward, every wind comes laden with pestilential vapours. The bottom of every canal that communicates with the sea is thickly covered with ooze, which, when the tide is ebbed, disperses a most offensive and noxious effluvia. ^' The whole island is intersected with ditches ; they are filled with water, in which masses of animal and vegetable matter are always putrefying ; and, numerous as these ditches are, they do not suffice to drain the swampy soil. The effects of such a country are visible in the natives, though counteracted by the Dutch habit of high feeding, by the use of ardent spirits, and by the practice of smoking. It is computed that nearly a third of the inha- , bitants are attacked with fever every sickly season. TUE WALCHEHEN EXPEDITION. 551 (,:ildren are very subject to glandular swellings, to (structions in the viscera, and to dropsies. They are ]le, their circulation languid, aud their fibres lax. Scrofula is a very general complaint and deformed jrsons are numerous. "As they grow up, the complexion is sallow^, the body l)ated, and premature old age inevitable. "The sickly season begins with June and ends with (;tober, continuing as long as the sun has power sufficient 1 draw up marsh miasmata. Our armament went at the Mrst time, but, as the first effects of this poisonous atmo- jliere are slow and as activity and excitement are more ricacious than all other counteracting causes, the troops, J long as they w ere in active service, resisted its influence. '.ot a single man had died of the disease when Flushing jrrendered, and, when it first began to appear, it was jtributed more to accidental and temporary causes than ■ the permanent and irremoveable nature of the country, 'le stench proceeding from the half-extinguished fires in ■e town, the inundation which had spread widely through e British lines, and the exhalations from the dead bodies < the enemy, which had been laid in heaps and just ■ vered over with sand, more for the purpose of conceal- lent than burial, were assigned as the immediate causes sickness, and the reason why the men did not recover is easily found, in the want not only of needful accom- odation but of common comforts for the sick. The men ;id been exposed to wet and to the night-air, they often 3pt upon the damp ground, and some thousands of them 3re up to the middle in w^ater during one whole night, tie water also which they drank was said to contain imerous insects; sickness and vomiting were in many ises attributed to this cause, and the prevalence of worms emed to authorize the conjecture. 552 EXTRACT DESCRIBING The opinion had so much weight in England tha water was sent over to the garrison, and the requisit quantity was estimated at 500 tons a week. Filtering, distillation, or simple boiling would have beei easier than the expedient ; but the men themselves neve complained of the water, and, when the first importatioi arrived, it seemed to be so little wanted that Sir Eyr( Coote asked the army physicians what he should do witl it, and, by their advice, it was distributed to the fleet. " The want of comforts was a more apparent cause. A: the army, being intended for active service, was noi encumbered with heavy baggage, there was a want o: bedding for the sick. General Picton had 800 men inva- lided, among those who were under his detached com- mand, and for these only 200 beds. He applied to the navy and received some, but insufficient assistance, and many of the sick had, therefore, to lie on the floor, with knapsacks for pillows and great coats for blankets. Several of the Flushing hospitals, having had their roofs destroyed, from the violent bombardment which the town had undergone, the patients were exposed to the incle- mency of the weather. On this account workmen were sent from England, but repairs went slowly on, and the workmen themselves presently augmented the sick lists. In Middleburgh, where they were better accommodated, there was no circulation of air, and two shared a bed, so much were they crowded. Middleburgh is a spacious city, containing 16,000 inhabitants, and the best and most comfortable accommodations might surely have been pro- cured, yet the soldiers were quartered in cold and damp churches, and the hospitals were established in ware- houses, into which light and air had no other entrance than iron grates. It coidd hardly be deemed oppressive, to call upon the Dutch for suitable quarters — a people THE WALCITEKEN EXPEDITION. 553 10 sleep, at least, ))ct\vceii two beds, might have spared dding for the sick. The necessity of the case might ve made them acknowledge the propriety of such a easure, and the fair compensation which would after- irds be given to them must have impressed as strong an 3a of British justice on their minds as they could pos- :)ly receive at seeing the health of the army sacrificed to in scruples and ill-timed formality. "On no former occasion did disease rage so banefully ; long troops (except, perhaps, when the small-pox made i first appearance in Europe) and never was disease more leadful, in all its forms and circumstances. "The ministers, alarmed and astonished at the evil and ] w aware of their own culpable inadvertence, called upon ie principal officers of the Army Medical Department to ipair to Walcheren. To this summons the Surgeon- •meral to the Army replied that the duty in question ns entirely medical. The Physician-General represented lat the Inspector-General of Army Hospitals was the ]rson to whom this duty properly belonged, and the inspector- General replied that the duties required were jrely medical and belonged to the Physician-General. ' lis gentleman, however, learning that both the Surgeon { d Physician-General declined going, declared that he ready at the shortest notice. When this correspond- (ce was laid before the Commander-in-Chief and the 1 cretary at War, they concurred in opinion that the Phy- 5'ian-General, Sir Lucas Pepys, was the most proper ]rson to be employed on this service, and they therefore clered him to proceed immediately to Walcheren, with 1o other physicians. This determination seems to have frprised Sir Lucas and he returned an incautious answer, ^pressing his concern that a man nearly seventy years of le, with his infirmities, should be thought capable of 2 o 554 EXTRACT DESCKIBING j undertaking snch a duty, solemnly declaring himself unfit to perform it, and mentioning two physicians in his stead :i they, he said, would see the business well performed;! whereas, if he himself were able to go, it would merely be' a 'pro forma and no possible good would arise from it,i i)ecause he knew^ nothing of the investigation of camp andj contagious diseases. In consequence of this conduct the Physician- General and the Surgeon- General were justly; dismissed from their situations, and a new Army Medical; Department was established. \ " The sick, however, did not suflPer so much as mighty have been expected in consequence of the petty squabbles: of the Medical Board and the misconduct of its members, j There were able men upon the spot, and both there and^ in English hospitals all means were employed, within thei power of medical skill, to check or alleviate the calamity, j The British Government endeavoured to ascertain by ; what means the eflPect of the Walcheren climate might bei counteracted or avoided; and these were so easy that, hadf they been perceived in time, much of the evil might cer- j tainly have been prevented. So local were the causes of disease that vessels stationed only a few yards from the land continued perfectly healthy. The air about the sand hills is much purer than in the other parts of the island; and betw een Domburgh and West Capelle there were huts in good repair, which the French constantly occupied, during the sickly months, and where 2,000 men might have been stationed. " At this time (September 9th) the English army was receiving the infection at the rate of about 800 men in four days. On the 23rd of September Sir Eyre Coote stated the progress of the disease to be such that, if it should continue three weeks longer, our possession of the island would be most precarious. THE WALCTTEREN EXPEDITION. 555 " On the 6tli October lie again wrote that his force, ;)m sickness, had ])ccorae so trivial as to make the I, fence of the island extremely difficult and uncertain, four lordship must excuse me/ he adds, 'for adverting I frequently to this subject, for I cannot be supposed ■sensible to the critical situation in which I am placed." " On the 22nd October he stated the effective, at Wal- ( eren, to be diminished to 4,000 men. On the 23rd of Octol)er, 1809. t^tober he called the serious attention of Government to • e critical situation of the island, and, on the 27th, he :!inounced that the sick must be abandoned, in the event ^hich have been found very suitable. The diets of the first and eventh days alone are materially less. It would require an ddition of four ounces of meat and four ounces of bread to * Note. —The peas for this dinner 1 assume to be split peas, which i-eigh 7,100 grains, or almost exactly a pound per pint. X DR. CHRISTISON's OBSERVATIONS. t make them equal to the Navy allowances. This addition woul raise their nutritive value as follows : — I oz. oz. oz. First day .. 21 75 6-70 28-45 Seventh do. 20-74 6*56 27-30 ' The relative proportion of the carboniferous to the nitro genous nutriment of the seven diets approaches nearly to tha' which scientific analysis has shown to be very exactly the pro' portion in the dietaries hitherto examined, which have bee] practically found satisfactory, viz., the ratio of three to one' Every day's allowance, however, appears appreciably short o' this proportion, except the second ; and the closer approach o that day's diet depends on the nutritive value which I hav( assumed for salt meat, and which I have admitted to be over estimated. The diet of the first, fifth, and seventh dayr deviates the greatest from the general rule. Each of thes(: ought to present about one ounce more of real nitrogenous' nutriment, to bring it under the rule. In every way Nos. 1 and 7 therefore appear rather defective. I will not say positively that in practice these occasiona deficiencies would tell on the actual nourishment of the men But equally from scientific analysis and from past practica' observations, it is probable that they would do so. It is easy ! however, to test the fact by experiment, viz., by weighing th(" men of a company in each of several regiments at the end o1. the fourth and eighth weeks. And, indeed, if I may be per-' mitted to advise in this matter, I would recommend that this' test should be applied, whatever scheme of diet maybe ulti- mately adopted. I apprehend I am to assume that the proposed diets are intended for soldiers in ordinary circumstances. "When they! have to encounter prolonged fatigue, exposure, and defective, sleep, a larger allowance is necessary. Nothing can be more! certain, at least, than that, in civil life, the nutriment must rise- materially with the bodily expense, exposure, and night watching, otherwise w^ork cannot be done so well, and the seeds] of disease are ultimately sown. j s Edinburgh, : 1 Itli November, 1857. ! SIR JOHN M'NEILL's REPORT. XI {From tlie Report of the Crimean Commissioners.) Obsekyations on a Keport by Sir John M'Neill, RELATIVE TO THE EaTIONS FOR SOLDIERS. By Dr. Ciiristison. In consequeuce of the advaaces made in physiology and hemistry, the nutritive value of any dietary, deduced from ractical experience, may be tested with care and certainty by Bference to its chemical composition. As this fact is little nown to practical men, it may be well to explain the princi- les on which the method is founded. 1. All articles of food used by man consist of one or more, nd generally several nutritive principles ; and most of them ontain water and an indigestible cellular tissue. The two itter must, of course, be deducted in estimating nutritive alue. 2. The nutritive principles consist of two sets — one of which maintains respiration, and the other repairs the waste con- tantly incurred by the animal textures in the exercise of their unctions. As the respiratory principles commonly abound in . arbon, they are sometimes called carboniferous, while the eparative principles, because they all contain nitrogen, are ermed nitrogenous. 3. Experience has shown tliat the most successful dietaries < or bodies of men, deduced from practical observation, contain arboniferous and nitrogenous food in the proportion of about hree of the former to one of the latter, by weight. During wo-and-twenty years that my attention has been turned to the resent subject, not a single exception has occurred to me. 4. Hence it is obvious that the least weight of food in the ough state will be required, first, when there is least moisture -nd cellular tissue in it ; and secondly when the carboniferous .nd nitrogenous principles are nearest the proportion of three 0 one. 1 5. Of the various nutritive principles belonging to each set, ome may replace one another ; some are better than others : ome are probably essential. This branch of the science of the ubject is unfortunately still imperfect. 6. Two things, however, are certain— that nitrogenous may XII DK. CHRISTISON's OBSERVATIONS replace carboniferous food, for supporting respiration, thoug at a great loss ; but that carboniferous food (without nitrogei! cannot replace nitrogenous food, for repairing textural waste, j 7. The daily amount of nutritive principles of both set} must increase with exercise and exposure, otherwise the bodj quickly loses weight, and ere long becomes diseased. If th above proportion between the two seta be maintained, th weight of real nutriment per day varies, for adults at an activ age, between seventeen and thirty-six ounces ; the former beinj enough for prisoners confined for short terms, the latter bein,| required for keeping up the athletic constitution, or that whic , is capable of great continuous muscular efforts, as in prizti running and other similar feats. 8. Dietaries ought never to be estimated by the rough weigh! of their constituents, wdthout distinct reference to the reaj nutriment in these, as determined by physiological and chetnij cal inquiry. Keeping these principles in view, and with the help of : simple table, it is not difficult to fix the dietary advisable foj any body of men, according to their occupation. It is, alscl in general, easy to detect the source of error in unsuccessful dietaries. For example, any scientific person conversant witlj the present subject could have foretold, as a certain conse i quence, sooner or later, of their dietary, that the British troop; j would fall into the calamitous state of health which befel thenj last winter in the Crimea. j Soldiers in the field will be the more efficient the nearer the} are brought to the athletic constitution. But as the demancj for protracted, unusual exertion occurs only at intervals, thej highly nutritive athletic dietary is not absolutely necessary. Or j the whole, from experience in the case of other bodies of mcEj somewhat similarly circumstanced, 28 ounces of real nutriment.l of which 7 are nitrogenous or reparative, will probably prove j the most suitable. Any material reduction below 28 ounces] will certainly not answer ; and under unusual exertion kept upj for days continuously, as in forced marches, or forced siege j labour, the quantity should for the time be greater, if possible, j One dietary proposed, in the report put before me, corres-J ponds very closely, in all respects, with the pi'inciples now laidf down. ON SIR jonN :m'neill's proposals. XITI The articles are well chosen. The standard ration contains I ounces of carboniferous, Q\ of nitrogenous, and therefore 1 of total real nutriment. When biscuit and compressed getables are substituted for soft bread and fresh vegetables, 3 day's ration consists of lOf carboniferous food, 6| nitro- nous, and 264- total. In both of these scales, tbe proportion of the two sets of inciples is nearly as three to one. In both, the total quan- y falls a little sliort of what appears the most advisable. In other respects the dietary seems unexceptionably good. It QDot be said that the deficiency will certainly occasion ill altb ; but there is too little to keep up the strength and ergy of the men in circumstances of unusual exertion. The [lowing is an apt illustration : — In the general prison at jrth, the dietary for long terms of imprisonment consists of ' ounces of carboniferous, and 6 ounces of nitrogenous food ; all, 25 ounces. Xow, in the first place, it has been found isafe to reduce this amount for ordinary sedentary occupa- ms; but, secondly, prisoners under vigorous exercise are und to require a material increase. Some j^ears ago, when I as appointed to inquire into certain points relative to the anagement of the prison, there were several men employed at \e pumps for raising water daily from the Tay, for prison use -an occupation requiring much expenditure of muscular rength. These men were, without exception, compelled to jsist when fed on 25 ources a-day. An addition of 8 ounces meat and 6 ounces of bread was found necessary, and then ey all worked vigorously and cheerfully. This raised their lowances to 23| ounces of carboniferous, and 8^ of nitroge- )us food, or 32 ounces in all. The standard difficulty in regulating the dietary of soldiers 'i tbe field is tlie present necessity of substituting salt meat fresh, when it becomes necessary to use only store provi- ons. The difficulty arises -from the known tendency of salt leat to engender disease, or at least to favour its development, Lid the supposed impossibility of storing effectual substitutes ')r it. A third difficulty must be here admitted :— Neither by hysiological experiment, nor by chemical analysis, is the utritive value of salt meat scientifically known. If soldiers could be supplied with what people in civil life XIV DR CHRISTIS0N\S OBSERVATIONS | know as salt meat, there would be less difficulty ; but mihtar^j i authorities ought to disabuse their minds of this very natura l i comparison. The salt meat for soldiers in the field has alway^; 1 been highly salted, in order to keep for two years or more ir; I every climate. Now, my persuasion is that, apart from thei i tendency of the protracted use of such food to favour the deve-i ^ lopment of disease, its nutritive value has been much overrated. i i This may appear evident from the fact stated in the Eeport,i i that of a body of men, fed even on rations by no means liberal,! i few continued to eat a pound of salt meat daily for any length: i of time. And the science of the question has been sufficiently looked into for an explanation ; because meat highly salted must be so thoroughly steeped in cold water, to remove the salt, before it is eatable in large quantity, that much of its most nutritive constituents must be washed out, viz. its albumen, and sapid extract called osmazome. Therefore it appears a good suggestion in the Eeport puti before me to deduct four ounces from the ration of salt pork i i and salt beef, and to substitute half a pint (eight ounces) ofi peas instead of the four ounces of pork; and, for the four; ounces of beef, six ounces of flour, an ounce of currants orj raisins, and half-an-ounce of lard, for making a pudding, i Besides qualifying the irksomeness and probable injurious] effects of the daily salt meat, this substitution — which will bej made chiefly during protracted marches, or other active opera- ( tions at a distance from head stores, and when more food is i needed to meet greater muscular efforts — raises the daily ( allowances to 23| ounces of carboniferous, 7i nitrogenous, audi 31 total nutriment, under the peas ration j and to 24 J, 6, i and SO^ ounces under the flour- pudding ration. In these esti- 1 mates, however, the salt meat is assumed to equal fresh meat in | nutritiveness — an extremely dubious assumption ; but there is no authority by which to fix its true value. It is much to be desired that a more material reduction of the salt meat could be effected. Nor does this seem impossible, j Three substitutes have been proposed : preserved meat, pem- j mican, and meat-biscuit. | The first of these consists of fresh meat, cooked and preserved j hermetically in vacuo in tin cases. Ac present, a prejudice j against it has arisen from the late discovery of abominable jj ON SIR JOHN McNeill's proposals. finds in our navy contracts. But this is unreasonable. Such feds could not have been practised, except under a system of ve lax examination on delivery. It is not to be doubted that mit may be preserved in vacuo certainly and securely, and the pr ess is not now very costly. The men would probably obct to the frequent use of it, because it palls on the taste ; bu it would be taken once a-week readily, when fresh provi- si(S are scarce, and even twice a week when no other fresh anial food can be had. icmmican is meat thoroughly dried up by a cooking heat, EE generally beat up with a proportion of fat. I understand it said to be objected to on account of manufacturing diffi- cu ies, and its tendency to deteriorate in a temperate, and still m e in a warm climate. But in these days of manufacturing in inuity, one ought to be very slow to admit such an obstacle ; n{ can I see where any unconquerable difficulty can lie. Pbably it would not be relished continuously by the men, but it ould be taken readily as an occasional ration, at all events 013 a-week ; and I am persuaded that, were the skill of the cct united with the art of the manufacturer, a more palatable arcle than common pemmican might be produced. It is of mnent to consider that, were it found practicable to introduce tl as an article of meat rations, a great saving would be efcted over fresh meat, salt meat, or preserved meat, in W'ght, and consequently in transport, for pemmican contains tb nutriment of at least three times its weight of fresh meat. Teat-biscuit — consisting, I believe, generally of the ordinary hi uit materials baked with extract of meat — was tried, as I fa aware, by some of our officers in the Crimea, but found to b( .ften spoiled in store or transport. There must have been 8C e palpable error, however, in either its composition or pre- S€'ation ; at least, a similar article was used successfully by sc e in the Burmese war. I see no difficulty on the part of a sHed manufacturer in preparing a meat-biscuit with biscuit- fl< r, dried meat instead of meat-extract (as being both more mritive and cheaper), fat, salt, and pepper, which, on being thoughly dried, might be perfectly preserved in tins, and w ch would constitute a highly nutritive and not unpalatable aide of food. It could be easily converted into soup, either al\e or with the help of compressed vegetables. It would also XVI T)R. CHRISTISON's OBSERVATIONS be, in its biscuit state — the meat being cooked in the manufaci ture — a good resource for the men when turned out suddenl i in the early morning, and without the opportunity of cookin;i their breakfast. And, like pemmican, it could be easily trans ported, as it consists almost entirely of nutriment, wit! extremely little moisture. Probably the men might not Hke t use it continously ; but in urgent circumstances, as on force' marches, it ought to prove of great service ; and in circum' stances less urgent it might be made the meat-ration of one da ' in the week, or possibly even two days. On the whole, it is very desirable that careful experiment were made as to the preparation and preservation of pemmicai and meat-biscuit. Such experiments ought not to be lef entirely to practical men ; scientific knowledge and practica skill should be combined ; otherwise, serious errors may b( committed. In the proposed dietary, no mention is made of cheese amon^ the substitutions for the standard articles. It is excellent however, theoretically as an occasional substitute for meat, t( qualify an otherwise too farinaceous food, because it consists, ii a great measure, of an important nitrogenous principle. Then it has well-ascertained practical advantages. It is not costly it is easily preserved for a time ; it is all nutriment, and there fore cheap to transport; it is relished by all hard-workicj people ; and there is reason to suppose that it constitutes ai effective article of some successful dietaries in civil life. Peas should be supplied, if possible, in the state of flour when intended for part of the rations of troops on active servict in the field. They are then much more easily cooked, as wel as more compactly packed and more easily served out. When practicable, half a pint of porter (ten ounces) would form a most desirable substitute for the ration of spirits. The nutriment is much the same, viz., one ounce, but the alcohol is only one-half; and nevertheless, its renovating power is greater. All officers engaged in active service in India, especi- ally during the occasional privations in the late Burmese war. have borne strong testimony to the superior advantages of malt liquor over spirit. It is difficult to over- value the proposed addition of tea and coffee to the men's rations. They possess a renovating power. ON SIR JOHN m'NEILL^S PROPOSALS. XVII i circumstances of unusual fatigue, which is constantly expe- laced in civil life, and which I have often heard officers, who sved in the Spanish campaigns, as well as in the late Burmese ^,v, describe in the strongest terms. This, however, is not all, f it has been recently shown by a very curious physiological L uiry, that both of them, and especially coffee, possess the sgular property of diminishing materially the wear and tear C3he soft textures of the body in the exercise of its functions i:in active occupation. \dth Decemler, 1855. C A 14 XVIII DIET IN EMIGRANT SHIPS. | The Dietary Scale of Emigrant Ships, an excellent one up ^ most accounts, is here annexed as a good example. ! DiETAEY Scale for Emigrant Ships Sailing under Government I Superintendence. ' This is the Scale for each Adult. AYomen to receive the same Eations I5 Men. Children between 1 and 14 to receive one-half. Infants unde year to be allowed one quart of water daily, but no Eations. All if Issues are to continue on the same days as below. f i Sunday. Tuesday. i za a Thursday. Friday. Saturday. Weeki; Biscuit* oz. 8 8 8 8 8 8 8 m Beeft . . oz. 6 s. Pork+ 6 Q 6 S S -5 "3 g n:, g .S -3 CO • bC -2^ N C .3 QJ _( cTo ='.3 ^ c .2 bc bc- ^ _ bcfl S3 %^ o s =S1 •s.g is r^: , I . , (NO. II.) NAVAL HOSPITAL DIETS. XXIII ■5 > M S - = "rt ^ a P -5 2 a* — si's O 5; o I CTJ H O .1 - ^ fcj) d . . s 6 •2 p2 s>c.3 ^ c» S H O ° - * g.Si * HP sals 1^^^ .22222 a 3 g (3 rs r- r-3 r3 p,'p,p< CC cft^ OC O "^"rH ''''' : : : : « • ■ fc. ' ' ■ 'Hfi • 1 1 1 S I 1^^ • ••22S222SS.SS .9 I— (00 00^-r0GO'<#'O HinrH r-.'c>r-( rH t; a :: to :;::::: : : : a o so •5c:52 "^ss ^ Si = = = ^ -'I = |2 i ^illl'il:!?!^ 1° IP cntntnmmco co ^JSS" s s s a s a^^-js-g , ^ -S ;S ^ a :::::::^::::'or: ' ' ^ , '• ^ ° i-Sa i : : : : : ^S^eu^l i g | J 15 =^ §.1 1 2 s'oisl-^- s s.'^i^-— ^'-^^ — ' 11-2 11^ bo o a Ph =t; '-5 J ' o " a? XXIV (no. III.) DIET TABLE IN GUY's HOSPITAL. s ris CO 510 pq o c3 d 43 Sh S e3 o -2 ^1 ^ g^ r ft I a ^ o •'^ o o P5 o 3 4^ d O o o ^1 O 1^ d ^ O M o o.§ .5 d *o ■Sc^-S d 13 HPQ ^ -l-J I 1 d o S- PH CJ o <^ d +=> H-3 'O d g ^ CJ -1-3 O O o s c d 13I d 52| d'^'s d d d .-tf ■3 d O 5*5 O '"3 Sh ^ > P5 'O fco r! d .2 o o o d 3 , Tea 1 „ Potatoes... 8 Salt 3 4 » ilk ., 6 „ Tea i 4 » Sugar ... 1^ „ Salt 4 » Tea i 4 »> 1 » Sugar li » Milk ... 6 „ Tea i „ Sugar l-i» Milk ... 6 „ Butter ... 2 Sugar ... U » Milk 6 „ Vegetables 3 „ Milk ... 6 „ Vegetables 4 » Butter ... 1 » Vegetables 3 „ Butter ... 1 » Flour 1 » Butter ... 1 » Flour 1 4 JI When meat, roasted, baked, or stewed — Bread 19 oz. (beino; 3 oz. extra) in lieu of barley and flour. To be marked " va- ried " on Roll. BREAKFxVST. a ... ead itter .1 pint 3 oz. \„ Tea 1 pint Bread ... 6 oz. Butter ... \ „ Tea 1 pint Bread ... 6 oz. Butter ... A „ Tea 1 pint Bread ... 6 oz. Butter ... i „ Tea 1 pint Bread ... 6 oz. Butter ... 1 „ DINNER. tl... itlier « deiuts ead . 8 oz. >.ed or icken 2 oz. 3 „ Soup 15 oz. Meat ... 8 „ Bread ... 4 „ Potatoes ... 8 „ Fish 8 oz. Bread 6 „ Potatoes ... 8 „ Butter ... 1 „ Roast Chop or Steak. Meat 8 oz. Bread 6 „ Potatoes ... 8 „ Vegetables... 3 „ Soup ... 1 pint Meat ... 12 oz. Bread ... 4 „ Potatoes ... 16 „ When meat, roasted, baked, or stewed- Meat ... 12 oz. Bread ... 7 „ Potatoes ... 16 „ Vegetables 4 „ SUPPER. » ... ead . tter . pint 1 oz. i„ Tea 1 pint Bread ... 6 oz. Butter ... i „ Tea 1 pint Bread ... 6 oz. Butter ... i „ Tea 1 pint Bread ... 6 oz. Butter ... \ „ Tea Ipint Bread ... 6 oz. Butter ... ^ „ lie mad !ar,2o ?ar,2o idsngar nd chc for ev for ev \ oz. tc rged according to th ery five pints, ery five pints, two pints. e following proporti 3US :— D Al4 XXXIV NUTRITIVE VALUES. NtJTEiTiYE Value of the above Diets. 1.— Tea. Carbon. Nitrogen. Total. j 4-12 0-84 4-96 3-' 0-0 3- 0-48 0-27 0-75 7-60 1-11 8-71 4.— Milk. Carbon. Nitrogen. Total. 7-21 1-44 8-68 1-60 0-20 1-80 4-80 2-70 7-50 0-50 0-50 14-11 4-37 18-48 One pint of milk with 6 oz. of bread for breakfast ; 1 pint of milk with 2 oz. of rice and 4 oz. of bread for dinner; 1 pint of milk with 4 oz. of bread for supper. 5. — Low. Carbon. Nitrogen. Total. Meat, 8 oz. exclusive of bone. . 1-20 1-61 2-81 7-21 r47 8-68 1-50 1-50 0-48 0-27 0-75 1-60 0-20 1-80 1 1 Milk, 15 oz 1-20 0-67 1-87 0-50 0-50 0-30 0-40 0-70 13-99 4-62 18-61 A pint of tea with 5 oz. of bread for breakfast ; the same for supper ; three quarters of a pint of beef tea with 4 oz. oi bread for dinner, also a pudding, consisting of 2 oz. of rice ] with half an ounce of sugar, three quarters of a pint of milk, , one egg, ginger, or cinnamon a few grains. nutritive values. 7.— Half. XXXV J it, 8 oz. exclusive of bone. I ad, 16 oz latoes, 8 oz I ley. If oz S ar, If oz ik, 6 oz \.jetables, 3 oz. Iter, 1 oz I ur, I oz Carbon. Nitrogen. Total. 1-20 1-62 2-82 8-24 1-68 9-92 1-96 0-20 2-16 1-17 0-28 1-45 1-75 1-75 0-48 0-27 0 75 0-06 0-01 0-07 1-00 1-00 0-18 0-04 0-22 16-04 4-10 20-14 iDne pint of tea with G oz. of bread for breakfast ; the same f supper ; 1 pint of soup, also the meat, 4 oz. of bread, and 8z. of potatoes for dinner. 10. — Entire. Alt, 12 oz. . . . Ead, 16 oz. .. . Fatoes, 16 oz. . Eley, 24 oz.. . . S ar, 1^ oz. . . . i:,k, 6 oz \;e tables, 4 oz. E ter, 1 oz. . . . F ar, oz Carbon. 1-80 8-24 3-92 1-77 1-75 0- 48 008 1- 00 0-18 19-22 Nitrogen. 2-43 1-68 0-40 0-37 0-27 0-02 0-04 5-21 Total. 4-23 9-92 4-32 2-14 1-75 0-75 0-10 TOO 0-22 24-43 i. pint of tea with 6oz. of bread for breakfast; the same f( supper ; 1 pint of soup with the meat, 4 oz. of bread, and Idz. potatoes for dinner; the meat to be roasted, boiled, or sUYed, on alternate days. When meat roasted, or stewed, 3 z. bread extra, instead of the barley and flour for soup. 6. — Fowl. iearly the same as half diet, with half a fowl or chicken, ^^ghing 8 oz. exclusive of bone, either to be roasted or made ii) soup, in lieu of the 8 oz. of meat. ^ 1)2 XXXVI NUTKITIVE VALUES. 8. — Fish. j Nearly the same as half diet ; but 8 oz. of white fish in lie of the 8 oz. of meat. I 9. — EOAST. ! Nearly the same as half diet ; but 8 oz. of mutton chops o' steak in lieu of the 8 oz. of meat. The foregoing diets are composed of nearly the same ingre dients as the present Hospital diets, with the exception o the "Low," where pudding and some extra meat are markei in lieu of potatoes. 1 oz. of butter is also added on all abov' milk diet. Being ten in number in place of five, they alloY a greater variety to be given to the patients, without issuing! extras, thereby saving a good deal of writing as well as time. "Were the above ten diets or other such laid down, extra could be dispensed with (with the exception of spirits, wine' or malt liquor, and perhaps occasionally some article for certau' patients on tea diet). During war, in General Hospitals, the above, or a simila; dietary could be carried out, but in Eegimental Field Hospitals' the Medical Officer must make the most of the usual rations preserved vegetables being issued in certain proportions n lieu of fresh, when these cannot be obtained. Generally speaking, no serious cases (if possible) should be treated ii' Eegimental Field Hospitals. All other diet tables, and the writing they entail, should be dispensed with in Eegimenta' Field Hospitals, It is presumed that fresh or preserved' vegetables will in future be issued as a daily portion of the soldier's ration, Instructions as to the aboye Diets. By Mr. Alexander. ( The diets to be marked by the prescribing Medical Officer on the rolls by their initials. The bread and tea in the tea diet are to be apportioned! according to the instructions of the Medical Officer. INSTRUCTIONS FOR USE. XXX VII On tea, spoon and beef tea diets, drinks of barley water, ;e water, and lemonade, may be given when deemed necessary the Medical Officer, and the quantities so given must be irked daily on the abstract of diets. The meat for the various diets, as also the fowls, are to be good quality, and must weigh in the raw state, exclusive bone, the weights specified in the diet table. The bread is also to be of the best household kind. The meat on low diet is to be used for beef tea, so as to ike three quarters of a pint of good beef tea for each patient such diet. The meat on half and whole diets is to be boiled with the getables, barley, and flour, and a quarter of an ounce of sugar p each diet may be charged in addition to that on the dietary, irking "for soup" (also pepper for seasoning), so as to allow each patient the quantity specified in the diet table. The sat on full diet when not made into soup, is to be roasted, ked, or stewed, and 3 oz. of extra bread will be given in lieu the barley and flour. In the diets, when no soup is given, the vegetables are to be loked in bulk, and served up to each patient in the propor- ms specified. When potatoes cannot be procured of a sufficiently good ality, either 3 oz. of rice, 3 oz. of flour, or 8 oz. of bread ij be issued in lieu of 16 oz. of potatoes. Preserved potatoes, when issued, will be in the proportion 1 oz. of the preserved to 5 oz. of fresh and 1 oz. of mixed eserved vegetables in lieu of 10 oz. of fresh. Half an ounce of coSee may be substituted for one-eighth • an ounce of tea at breakfast and supper. Milk is to be calculated at 20 oz. to the imperial pint. As the above scale of diet allows of considerable variety, !d supplies sufficient nourishment. Medical Officers are quested to avoid all deviations from the same, as far as then- . ty towards their patients may permit. In cases of emer- incy, or when patients are brought into Hospital, and before Lg placed on the diet roll, the Medical Officer may draw iiat he deems necessary from the reserve kept by the Nurse < by the Assistant Wardmaster in General Hospitals, and by lB Assistant Steward in Eegimental Hospitals. XXXVIII INSTRUCTIONS FOR USE. ] Wine, spirits, and malt liquors will be considered as extras and, when ordered, will be marked as such on the diet rol opposite the names of the patients receiving them. During war, the above scale of diets niay be used in Grenera and other Hospitals, but should any deviations from the same be necessary, it will be the duty of the Principal Medica Officer in the field to decide what those deviations may be and to lay down a scale adapted to the position, climate, an( the supplies obtainable. In Regimental Field Hospitals, during war, in the evem of the diets on the table not being obtainable, the usual ratioi being drawn from the Commissariat, the Medical Officer of th( corps will order the same to be cooked and distributed to th( patients according to the manner he thinks best suited foi them, and should extras, such as arrowroot, sago, sugar, tea essence of beef, Gillon's preserved meat juice, or other articlef for soup, also wine, spirits, &c., be deemed necessary by tk prescribing Medical Officer, they are to be given and marked on the diet roll, against the names of the patients receivino them. i RECEIPTS FOR MILITARY HOSPITALS. XXXIX Receipts for Hospital Diets akd Drixks, most of WHICH WEEE USED IN THE WaE HOSPITALS OF THE East. The following receipts for Hospital diets and drinks, pre- ared by M. Soyer, and composed mainly of the ingredients f the diiferent diets in the proposed diet table, were what e found most useful in the War Hospitals of the East, as ir as our means and materials allowed us to use them. Bill of Faee foe Militaet Hospitals. PAGE lutton soup . . xl Jeef soup . . . . xli ieef tea . . . . xli ^hick ditto . . . . xli .^hick white beef tea . . xlii PAGE Mutton tea . . xlii Yeal ditto . . xlii Lamb ditto . . xlii Chicken tea . . xlii Chicken broth . . xlii Fish. ole water souchet . . xliii Broiled whiting . xlv }rill ditto . . . xliii Fried fish . xlv lounder ditto xliii Fried sole . xlv Vhiting ditto . xliv Whiting . xlvi kate ditto . . . xliv Smelts . xlvi ;od fish ditto . xliv Flounders. . xlvi irel6e ditto . . . xliv Skate . xlvi aute and baked fish . . xliv Brill . xlvii )itto whiting . xliv Boiled fish . xlvii iroiled sole . . . xlv teaks . . . . xlvii /hops . . . . xlvii )itto, broiled . . xlviii lutton, roast . v xlviii Beef, roast . . xlviii Eoast fowls . . xlviii Grilled ditto . . xlviii RECEIPTS FOR T lidding s. PAGE , PAG3 Kice, plain, boiled xlix Panada arrowroot lii ' Eice pudding. . xlix Eice, pulp, ground lii Sago . . 1 Bread and milk . . lii Arrowroot 1 Thick milk liii Eice . . 1 Kice milk Ini Tapioca Bread pudding . . liii J.»jLcH>tll KJLxl • • • • |j Bread and butter Batter pudding li pudding liii Sago jelly li Observations on Custard . . . . li pudding liii Plain arrowroot lii Stewed French Pulp ditto . . Hi plums,. liii Wine ditto lii Beverages. Semi-citric lemonade. . liv Prencb Beverages : — Soyer's plain lemonade liv Tea of violet Tartaric lemonade liv flowers. Ivii Lime juice lemonade . . Iv Elder flower water Ivii Toast and water Iv Lime ditto Ivii Apple toast and water Iv Pren clip I um water Ivii Barley water . . Iv Eflfervescent Bever- Apple barley water . . Iv ages : — Arrowroot water Ivi Easpberry water Ivii Eice water Ivi Pine-apple syrup Ivii Citronade Ivi Currant ditto . . Ivii Spring drink . . Ivi Orgeat syrup Ivii Summer ditto Ivi Camomile water Iviii Mulberry Ivi Dandelion tea . . Iviii Eeceipts roR Cooking in Military Hospitals. Semi'Steived Mutton and Soup. \ Full Diet. — Put into a stewpan 12 oz. of mutton, 1 tea- j spoonful of barley, half one of salt, 2 oz. of vegetables, com- ^ posed of a little onion, celery, turnip, and carrot, mixed | COOKING IN MILITARY HOSPITALS. XLI i:iue proportion ; add 2 pints of water. If diets for twentj- fi) are boiled in one mess, pints of water will suffice to e h ration, put all on the fire, simmer gently one hour and a qirter ; skim off the fat ; mix a teaspoonful of flour with a He water, so that it may form a thin batter, pouring it over t; soup one quarter of an hour before serving; add a quarter t spoonful of sugar ; skim if required, and serve. This will rke a good soup, and will serve for full diet. The meat ry be put back into the stewpan, warmed up, and served siarately. For half diet, 8 oz. of meat, use the same proportions. Variation for seasoning. i little pepper, cloves, thyme, bayleaf, parsley, celeryleaf, <^,, may be introduced. Semi- Stewed Beef and Soup. Proceed as for mutton soup. Eice may be used instead c barley, adding a gill more water, as beef takes longer to ok. If, to each diet a teaspoonful of browning be added, it \ 1 give it an inviting colour. Beef Tea. Cut 1 lb. of stock beef into large dice, put ^ oz. of butter i a stewpan, place in your beef, set on a slow fire, stirring (jasionally, until a brownish colour comes at the bottom, and U meat gets set, then place in 2 pints of boiling water, with 1 f a teaspoonful of salt, a pinch of sugar, a clove, and one- i irth part of a middle-sized onion, cut into slices ; simmer [ atly thirty minutes ; skim and serve. N.B.— If the beef tea is wanted plain, omit the seasoning, (3epting the salt. Tliich Beef Tea. Put in your mixture half a teaspoonful of arrowroot, mixed ^th 2 tablespoonfuls of water. This will be found a delicate ot for weak cases. Yeal, lamb, and even fowls may be done the same, the meat ivery palatable, and may be served in the broth when done convalescent patients. XLIl RECEIPTS FOR I Thick White Beef Tea. i i Proceed as for beef tea, only prevent its browning, it shou be removed from the fire when the stock at the bottom begii to get thick and white, w^hich it does just before brownin then add in your water as for brown beef tea, simmer ditt(, skim and serve. This beef tea will be found very suitable for weak stomach Mutton Tea. Take l^lbs. weight of mutton, bone included, the scrag wi do. Proceed as for beef tea ; skim and serve. Veal Tea. Cut 1 lb. of solid veal stock meat in dice, put it into a ste\^, pan, with a little butter, as for beef tea ; stew gently till glaze is formed at the bottom, stirring now and then; ad^^ 2 pints of water, half a teaspoonful of salt, and a little pine: of sugar. When boiling, add a small slice of onion, and a fev sprays of fresh parsley. Skim off the fat, pass through a siev and serve. Lamb Tea. j Take some of the scrag or inferior trimmings of lamb, horn and all ; proceed as for veal tea, and only put in 1^ pints o water ; a little less salt. Skim off and serve. j IST.B. — If the meat is to be eaten, the meat of the chump o!, lamb is preferable. If made in quantities, lambs' heads maj, be introduced with great advantage, the meat and brains being very delicate. Chicken Tea. Take half a chicken, cut into six neat pieces, put it into stewpan with butter, proceed as for veal tea; skim, and serve the fowl in the tea. Either of the teas may be made thick by the addition of a little arrowroot, as in thick beef tea. Chicken Broth. Properly trim, and place half a small chicken, cut in two,: lengthways in a stewpan, also 1 tablespoonful of rice, I small COOKING IN MILITARY HOSPITALS. XLIII tfipoonful of salt, 2 oz. of mixed vegetables cut in dice, add a nch of sugar, and 2 pints of water ; boil half an hour ; skim ai serve. |if a large fowl, cut it into four, and proceed as with the clSken, allowing half a pint more water for evaporation, as l£je fowls require longer doing. A few herbs may be added, if iUowed by the medical attendant. pwo tablespoonfuls of sago in lieu of rice is a good variation. Rule for Fish, either hoiled, hroiled, haTced or fried. Fou may always ascertain when fish is done, as then the fjjh separates from the bone easily with the aid of a fork i: tried in the thickest part. Take care that it does not C3rdo, which takes all the nutriment from the fish. || Sole Water Souchet. Trim a sole by cutting oflf the fins, let it weigh 8 oz. before oking, cut crossways in four pieces, put them in a stewpan, £i half a pint of water, a quarter of a teaspoonful of salt, half tit quantity of sugar, about twenty leaves of fresh parsley; } t on a sharp fire, cover over, boil from five to eight minutes, {d turn out the contents of the pan into a soup plate and rve. The liquor is of course the best part of the water f ichet for weak digestions. Brill Water Souchet. I Take half a pound of brill, cut into four slices, add seasoning, '«(;., as for sole, with the addition of another gill of water, boil :inutes, or till done, and serve. Flounders Water Souchet. Take two middling-sized flounders, weighing together 8 oz., it oif the fins, cut each flounder in two, crossways, season, 3., as for sole, putting in only one gill and a half of water; bil fast five minutes, and serve. XLIV RECEIPTS FOR Whiting Water SoucJiet. ] Have a nice firm whiting, or two small ones, with the skii- on, cut them each in three pieces, season as for sole; boi quickly five minutes, and serve. Take care not to break the pieces, this fish being very delicate Skate Water Souchet. j Take a nice piece of skate weighing half a pound, divide ii into four, add seasoning as for sole; boil slowly ten minutes according to the thickness, and serve. , For a variation a little pepper, a slice of onion, a small sprig; of thyme, or winter savory may be introduced. i i Cod Fish Water Souchet. ! Cut 8 oz, in four pieces, proceed as with brill, and serve. i Gelee Water Souchet. To any of the above souchets add half a teaspoonful of! arrowroot, mixed with 2 tablespoonfuls of water, pour over the* fish five minutes before serving. ! JST.B. — In special cases, if lemon or lime juice is suitable, ? a few drops will be found relishing. { Saute and JBaJced Fish. Fish, such as used for water souchet, may be sauted as follows : — Put in a saute or fryingpan 1 oz. of butter, place the sole or other fish over the butter, season with a quarter teaspoonful of salt and a little pepper, put in a slow oven or on the stove for five minutes, then turn it the other side, put it back for ten minutes longer and serve. If fish cooked thus is done in large quantities, half an ounce of butter for each diet will suffice. A little light melted butter may be served with any of the above fish. A little pepper and lime or lemon-juice, where allowed, is very relishing. Saute and Baked Whiting. Por whiting proceed as for sole ; whiting with the skin on is preferable to those already prepared by the fishmonger, which COOKING IN MILITARY HOSPITALS. dressed round. The fish being very delicate must be turned cefuUy. For any baked fish, egg and bread crumb over lightly id do not turn your fish as it should have a little brownish (.our. Broiled Fish. Sole. — Trim as for frying and dip in flour ; butter very lightly (8r with a paste brush, put on a gridiron previously well pased (to prevent sticking) over a very slow fire, turn once; ('ht minutes will do a sole of as many ounces weight, and (lier fish in proportion. Whiting. — Proceed in the same manner. Note. — This is the lightest and most difficult way fish can 1 dressed. Conger eels are now daily dressed in French Hospitals, hali- -ts might replace this fish in England. Fried Fish. Any kind of fish, though fried in fat, when properly done, •es not retain the slightest particle of fat, which would be ejudicial to the patient. This is avoided by having the fat a proper degree of heat, which can be ascertained when it !gins to smoke, and when all boiling has ceased. If you then p your finger in water, and let a drop fall into the fat, it will ss loudly, if properly heated. Eat overheated is equally unfit 'r use, which fact can also be ascertained by the quantity of ack smoke emitted by the fat, and making a very disagreeable aell. 'A quarter of a teaspoonful of salt, or half that quantity as Tmitted, must be sprinkled over all kinds of fried fish, when shing up. I Fried Sole. Trim and dry a sole in a clean cloth, dip lightly in )ur, break an egg, which beat up well, egg the sole lightly ^er with a paste brush, roll it in bread crumbs, make the •umbs adhere with the flat of a knife, then have ready placed I a flat fryingpan 21bs. of either lard or clarified dripping, set 1 the fire, and when the fat emits a light smoke, then is the Ime to place in the sole as it proves that all moisture is I i XLVI RECEIPTS FOR i exhausted ; another test is, when the white smoke appears, to throw in a few bread crumbs and if thej hiss and frizzle it is ready for the sole ; let the flattest part of the sole be at the bottom of the pan, and when that side is of a nice colour, turn it with a slice to the other. It will take from four to fivei minutes ; take it up with a fish slice, thereby draining off the' fat, and serve. N.B. — All fried fish which are taken from the fryingpan should be drained on a clean cloth, or sieve, laying the best side of the fish next the cloth. The above quantity of lard or dripping will cook diets for , about twenty-five patients ; but care must be taken that the fish is always thoroughly emerged in the fat ; the remains to be saved, as it will keep good several days. Fried WJiiting. Take one large or two small whitings, dry in a cloth, flour, and bread-crumb them as sole, and when the fat is hot, place the back down in the pan till it takes a nice colour, then turn the other side ; three minutes will do the small, and five minutes the large whitings. They may be fried with the skin on, and fixed lengthways, instead of trussing them round. Fried Smelts. IFlour, egg, and bread-crumb as whiting, have your pan moderately hot, then place in the smelt, turn once ; two or three minutes will do them yellowish. They are extremely delicate. Fried Flounders. Proceed as for sole, only the fat should be hotter than for sole. This fish being of a watery nature, is unpalatable if not done nice and crisp. Skate Fried. Use eggs, flour, and bread-crumb for the curly part of skate, and fry as for whiting. It will take six minutes doing ; and serve. COOKING IN MILITARY HOSPITALS. Brill Fried. put half a pound of this fish into three or four pieces, egg and b ad-crumb, and fry as skate. vod fish and halibut may be fried the same. lalmon, if obtainable, cheap and allowable, may be fried the sue. Flain Boiled Sole, Skate, or Brill. ?>ut 1| pints of water to boil. When boiling, put in either othe above fish, whole or in pieces, with half a teaspoonful osalt, takino^ care that the fish is well under the water. Boil fib from five to six minutes, or rather more, and serve plain, i'httle butter, melted with lemon-juice, makes either very a )etizing ; or pour over a little plain melted butter, or a little p sley butter. All the above mentioned may be boiled and s ved up the same. ' Steaks. Out 8 oz. of steak, or rump steak, flatten either to the thick- 138 of three-fourths of an inch, taking care that each piece ciitains a little fat. Put a clean fryingpan on the fire, with I f an ounce of butter, which, when browned a Httle, is ready t receive the steak; keep it on a rather quick fire, turning it sreral times, and while cooking, season each side with one- firth of a teaspoonful of salt and a pinch of pepper (if rowed). Six minutes will do the steak; and, by pressing it Xih. SL fork, or with your fiuger, you can ascertain if the steak i equally done through. When done, suspend the steak over the pan, to allow the ulted fat, if any, which clings to the meat to fall back into 1f3 pan. Chops. Have a fine chop weighing 8 oz., and three-fourths of an iijh in thickness, or rather more, having not too much bone or k Saute the same as steak, turning the chop two or three Ijues while doing ; and after becoming well browned on either lile, it is done. XLVIII RECEIPTS FOR Six minutes will cook it on a good sharp fire, as it thereb' becomes carbonized, and retains its gravy. This remark als' applies to steaks. Lamb chops, half small chickens, and veal cutlets, may b done the same. Note. — Veal is much used in French Hospitals, dressed ii many ways, such as broth, stews, broiled, &c. ! Broiled Chops and SteaJcs. j w \ k Tor broiling chops and steaks, place them on a gridiron, or' a sharp fire ; turn either three or four times. Pive or sis ''^ minutes will do either. Season as for fried steak. More is lost in weight by broiling than by sauteing, but it improves the flavour, and is more succulent. J i Boasting Mutton or Beef. ,^ A joint not weighiug less than 6 lbs. should be done at one f« time, and afterwards divided into diets. I ^ How to Boast. — Hang up the meat, light the gas, one hour il to seventy-five minutes will do a joint of 6 lbs. Two or threef joints of the same size might be roasted at once, giving them^ m one and a half hours ; and for a large leg of mutton one houri and three quarters. Lamb and veal require less time doing.j i The meat does not require basting. I If To Maine Gravg. — Pull out the dripping-pan, extract all tbe i fat which floats on the top, add a teaspoonful of salt to the il gravy, also half a pint of hot water, and 1 tablespoonful of 1 browning, set back into the oven a few minutes to get hot, and i to each diet put a tablespoonful, the quantity of gravy in i proportion to the meat. 1 Boast and Grilled Fowls. ' Fowls should be roasted whole and divided into diets, accord- ing to size. They should also be grilled whole, being divided up the back, and trussed as usual for grilling ; rub over a little butter, and grill on a moderate fire, turning several times, keeping a light i yellow colour. When partly done, season with a small tea- n COOKING IN MILITARY HOSPITALS. poonful of salt and a little pepper. When done, rub over a ttle fresh butter, serve whole or in portions. A slow fire is preferable to a sharp one. Por a change, the )wl prior to cooking might be egged and bread crumbed. Flain Boiled Bice. Set a pint of water to boil in a stewpan, add 2 oz. of rice, reviously washed; boil ten minutes, or until the grains become ather soft ; drain into a colander, then slightly grease a stew- an with butter, and place the rice in again ; let it now steam 3n or twelve minutes slowly, near the fire, or in a slow oven ; ach grain of rice will then swell up, and become well separated, t is then ready for use, plain or in various ways. The addition of ^ ounce of butter, ditto of sugar, a pinch f salt, mixed lightly together with a fork, will make it very sub- tantial, although light, and it may then be eaten as solid food. For a variation, a drop of milk or cream may'be added, or a ittle sweetmeat, such as jam, may be introduced. Also with 1 lb. of plain rice, half a pint of thinnish arrowroot iT milk will form a delicate food ; ditto flavoured with a little emon or powdered cinnamon. Sago milk or water sago may be added to the rice. Half a lint of prepared calves' foot jelly, partly dissolved, may be dded, and used when required. , If required savoury, a teaspoonful of essence of beef, or strong >eef tea, a pinch of salt and butter may be introduced. This rice may be used in puddings, by laying it lightly in a lish, and pouring over custard, seasoning rather highly to com- .ensate for the plain rice. When large quantities of rice pudding are required, this ■eceipt will be found excellent, as it saves a great deal of trouble n making, always observing that the rice must be thoroughly )oiled before going into the oven. Cheap Blain Bice Budding for Campaigning In this no eggs or milk are required. Put on the fire in a moderate sized saucepan, 12 pints of " vater, when boiling add to it 1 lb. of rice, or 16 tablespoonfuls, i oz. of brown sugar, 1 large tablespoonful of salt, and the rind E A 14 L RECEIPTS FOR COOKING IN of a lemon thinly peeled ; boil gently for half an hour, tl i strain all the water from the rice, keeping it as dry as possil . The rice water is then ready for drinking, either warm or cc ^. Lemon or lime juice may be introduced, which will makej, palatable and refreshing. ^ The Pudding. \ Add to the rice 3 oz. of sugar, 4 tablespoonfuls of flour, h ' a teaspoonful of pounded cinnamon ; stir it on the fire c( tinually for five to ten minutes, put it in a tin or pie dish a bake. By boiling the rice fifteen minutes more it will be ve good to eat without baking. Cinnamon may be omitted. i Sago Pudding and Pulf. \ Put in a stewpan 1\ oz. of sago, two-thirds of a pint of mil : stir it till it boils, then stir in half an ounce of sugar, a pin( of cinnamon, add an egg, and bake in a moderately heated ov( ten minutes. Arrowroot Pudding and Pulp. Take oz. of arrowroot, which put into a stewpan wit three-fourths of a pint of milk, half an ounce of sugar, of cinn; mon and salt each a pinch ; set on the fire, and stir continual] until it boils. When done, turn out, butter and put it in you mould, bake as above. Delicate Pice Pudding and Pulp. Take 2 oz. of rice, let it boil in a stewpan till tender, aboui ten minutes, dry it, and put it back again into the stewpan adding quarter of an ounce of sugar, half a pint of milk, a pincl of salt, and cinnamon, set it on the fire, and boil a few minutes break an egg, beat it well, then take the pan ofi" the fire, mb your egg in quick ; butter your tin or pie dish, pour in, anc bake until set, and serve. Tapioca Pudding and Pulp. Put 2 ozs. of tapioca in a stewpan, with half-a-pint of milk, i Icq add in half an ounce of sugar, a pinch of cinnamon, boil a few I lit minutes, stir in an egg, and bake as usual. \ Isi i MILITARY HOSPITALS. LI Macaroni Pudding and Pulp. 2 pints of water to boil, then put in 2 oz. of broken ni, and let it boil till tender ; throw the water away ; 1(1 half a teaspoonful of flour, and mix well, then put in half a pi; of milk, a little butter, a pinch of cinnamon, and salt, with a ';tle lemon peel or juice, boil gently for five minutes, beat ai;gg, which put in, mix well, butter the mould, and bake aa Sago Jelly. *ut into a pan an oz. of sago, half an oz. of sugar, a little pi'e of lemon peel or cinnamon, add to it a pint of water, a sn 11 pinch of salt ; boil gently five minutes, stirring continually U1.1 rather thick; then add a tablespoonful of either port, sLj'ry, or Marsala wine; mix well. Serve hot or cold. j Batter Pudding. reak an egg in a small basin, add a small tablespoonful of flc r, a pinch of salt, a quarter of a pinch of sugar, a pinch of ctpped lemon peel or pounded cinnamon, beat all well toge- thi' till it forms a smooth batter ; then add five tablespoonfuls of |iilk (if wanted very delicate, six) ; butter well a small basin, pc^ in your mixture. Pour some water in a stewpan, enough tonmerse half way the basin, and when boiling put in your pi ding ; boil twenty minutes ; pass the knife round the basin, tui out and serve plain, or with a teaspoonful of pounded suir, the juice of a quarter of a lemon, or a little port or shjTy. A little melted butter with sherry may be poured over. Custard Pudding. ut into a pan to warm 1 gill of milk, add to it a quarter of artunce of sugar, a little cinnamon, break and beat an egg well, per the milk over, mixing very quickly ; butter a small cup, ps j the custard in it through a fine colander, put the pudding tojteam in boiling water, boil fast, and in about ten minutes it W! be quite set ; pass a knife between the cup and the pudding, tuii out on a plate and serve. i'he same may be baked. j e2 Lll RECEIPTS FOR COOKING IN i Flain Arrowroot. Put half a pint of milk to boil, or rather less, moisten 1 oz,' of arrowroot in a basin with cold milk, then pour it into the boiling milk, add a quarter of an ounce of sugar, a pinch of salt' and serve. A nut of butter may be introduced. 1 j Fulp Arrowroot. ' Put 2 oz. of arrowroot into a stewpan, moisten with a pint ol milk, add a pinch of salt, half an ounce of sugar, and a pincb of cinnamon, put on the fire, stir the whole, and when thick leave it two minutes to set, put in a basin and serve. Wine Arrowroot. Place on the fire two-thirds of half a pint of water, with hali an ounce of sugar, and when the water boils, have ready mixed up in a basin, 1 oz. of arrowroot, a nip of cinnamon, a sprinkle ol salt, and two tablespoonfuls of water; mix till this form a batter, and place it in the boiling water, stirring the while ; lei simmer another minute, pour in half a wine glass of wine, eithei port, sherry, or Marsala, and serve. i Arrowroot Canada. \ The addition of the yolk of an egg, well beaten, if put in the above pulp, when cooked, will form panada, and keep good twc days. Ground Bice Pulp. Put 2 oz. of ground rice in a stewpan, with three quarters oi a pint of milk, and three-quarters of an ounce of sugar, and a little cinnamon; set on the fire, boil a few minutes and serve. Por panada add the yolk of an egg ; serve hot or cold. Bread and Milk. ; Boil 1 pint of milk, add to it a quarter of an ounce of sugar, cut a quarter of a pound of bread into slices, put the same into a basin, put on the bread two small nuts of fresh butter (il allowed), pour your milk over, cover over to soak, and serve. Tops and bottoms or rusks may be used instead of bread. MILITARY HOSPITALS. LIU Thich MOk. Put into a basin 1 tablespoonful of flour, with 3 of water, ix well to form a batter ; then set a pint of milk to boil, and hen boiling pour it over the pulp ; then place all in a stewpan, ve it a few minutes boil, add in a little salt, half an ounce of igar, a nut of butter ; mix well and serve. Bice 3Iilh. Put 2 oz. of rice in a stewpan, add half an ounce of sugar, with ilf a pint of water, and a little lemon peel; let the rice simmer 11 all the water has evaporated, then work in by degrees one int of milk, let it simmer gently till the rice is in pulp, and irve. (Bread Budding. !Boil half a pint of milk, add in the milk 1 oz. of bread umbs, half an ounce of sugar, and a piece of lemon peel ; eat up an egg well , add it in, pour your pudding in a tart dish, ake or steam for fifteen or twenty minutes, and serve. ^1 Bread and Butter Budding. Butter well a tart dish, lay in a few slices of bread and butter, )oil half a pint of milk, pour the milk over a welhbeaten egg, itirring the while, then pour all over the pudding ; bake in a lot oven from ten to fifteen minutes till nicely coloured. A ew raisins or currants laid on the top when put in the oven ire a good variation. I have tried the precediug puddings both steamed and )aked, and though both are indispensable to diet, I consider :hat the pulp of each of the puddings is more palatable, md contains more nutriment than either a baked or steamed pudding, which is submitted to greater evaporation, especially !bhe baked pudding, which is often partly destroyed through being overdone. When any of the above puddings are not to Ibe baked or steamed, a boil should be given to the pudding to pt the egg. Stewed French Blums. Soak 12 large or 18 small-sized plums for half an hour. Put I them into a stewpan, with a spoonful of brown sugar, a gill of LIV RECEIPTS FOR COOKING IN water, a little cinnamon, and some thin rind of lemon, let then stew gently twenty minutes, then put them into a basin with f little of the juice till cold. A small glass of either port, sherry or claret, is a very good addition. The syrup is excellent; These plums are freely given in the Trench Hospitals. Soyer^s Plain Lemonade for 2 pints of water. Thinly peel the outside of a lemon, which put into a basin, with two teaspoonfuls of sugar, roll the lemon on a table with your hand so as to soften it, then cut the lemon in two, length- ways, squeeze the juice over the peel, stir all round with a spoon for a minute or two, pour two pints of water, mix well, pass through a colander or sieve, it is then ready. , Semi- Citric Lemonade , for 12 patients. ] Put a quarter of an ounce of citric acid to dissolve in half a i pint of water ; peel 5 lemons thinly, and put the peel in a large vessel, with three-quarters of a pound of white sugar, broken up ; roll each lemon on the table to soften it ; cut each in two, and press out the juice in a colander or sieve, over the peel and sugar : then well macerate the same with a spoon ; then I pour half a pint of water through the colander, so as to extract ! all the juice ; triturate the sugar, peel and juice for a minute ' with the spoon, so as to form a syrup, and extract the aroma ! from the peel and the dissolved acid, and mix all well together ; I pour on 12 pints of water, stir well : it is then ready. A little ' ice in summer is a great addition. Note. — If made in smaller quantities, reduce the proportions : by one-half or one-fourth. It will keep good for several days I in a cool place. i Tartaric Lemonade. Dissolve a quarter of an ounce of crystallized tartaric acid in half a pint of water, which put into a large vessel; when dis- solved, add 7 oz. of pounded white sugar; mix well to form a white syrup ; add to it 6 pints of cold water, mixing slowly. It is then ready. Note. — This lemonade, which has been submitted to eminent Medical officers at Scutari, has been approved of, when other MILITARY HOSPITALS. LV honades are not obtainable. It can be made for either the ;)spitals or camps, and will be found to answer equally ill for domestic consumption, if lemons are not to be (tained. Lime Juice Lemonade. Take 1 tablespoonful of lime juice, ditto of sugar, mix well \ form a syrup, then pour over 2 pints of water and it is l3n ready. Toast and Water. Cut a piece of crusty bread about a quarter of a pound in ^%ht; place it upon a toasting-fork, and hold it about six i3hes from the fire ; turn it often, and keep moving it gently I . til it is of a light yellow colour, then place it nearer the fire, <• d, when of a good brown chocolate colour, put it into a jug, i d pour over it 3 pints of boiling water ; cover the jug until lid, then strain it into a clean jug, and it is ready for use. Apple Toast and Water. I Bake a middle-sized apple, over which you have put a tea- )|oonful of brown sugar ; when well done, and nice and brown, if.d in the toast and water. In an hour after it is ready for inking. The apple is good to eat, by the addition of a little more igar. Barley Water. Put into a stewpan 7 pints of water and 2 oz. of barley, -lich stir occasionally while boiling ; add 2 oz. of white sugar, ,e rind of half a lemon, thinly peeled ; let all boil gently for |)0ut two hours, without covering ; pass through a colander to a jug. It is then ready. The barley may be left in. * Note.—li the process of boiling is carried on too slowly, the firley water will turn reddish, which must be avoided, as it ^ould be white. Apple Barley Water. Add to barley water half a pound of apples, cut in slices, ith the skin on, removing only the pips; cut a lemon in LVI RECEIPTS FOR COOKING IN slices; boil gently till the apples are done; pass througli colander. This is a very refreshing beverage. | Arrowroot Water, Put into a pan 3 oz. of arrowroot, 2 oz. of white sugar, tl peel of half a lemon, one-fourth of a teaspoonful of salt, 4 pinlj of water ; mix well ; set on the fire ; boil a few minutes. It : then ready for use either cold or warm. Rice Water. Put 7 pints of water to boil, add to it 2 oz. of washed ric< 2 oz. of sugar, the peel of two-thirds of a lemon, boil geutl three-quarters of an hour, by which time it will be reduced t 5 pints ; strain through a colander, it is then ready. Note. — The rice may be left in the beverage," or made into \ pudding ; or by the addition of a little jam, or sugar, it will b found very good. Citronade. ' J Put a gallon of water on to boil, cut up 1 lb. of apples, eac;; into quarters, two lemons in thin slices, put them in boilinj water, and boil until they can be pulped ; pass the hquo through a colander ; boil it up for a few minutes with half . pound of brown sugar ; skim and bottle off, taking care not t( cork the bottles, and keep it in a cool place. j For Spring Drink. Ehubarb in the same quantities, and done in the same wa} as apples, adding more sugar. | For Summer Drink. ! One pound of red currants, bruised with some raspberries, half a pound of sugar, added to a gallon of cold water, wel) stirred and allowed to settle, adding the juice of a lemon. Mulberry. The same, adding a little lemon peel. MILITARY HOSPITALS. LVII Feench Bevebages. The following are some of the principal Trench tisannes and eet beverages : Tea of Violet Flowers. Put into a teapot two teaspoonfuls of dry violet flowers, pour er them a pint of boiling water, let it stand a few minutes, lur into a cup, and sweeten with half a teaspoonful of honey. Elder Floiver Water. Proceed as above, using elder flowers. Lime Flower Water. Put two pinches of lime flowers in a teapot, proceed and !reeten as above. French Flum Water. Boil 3 pints of water, add in 6 or 8 dried plums, previously •lit, 2 or 3 slices of lemon, a teaspoonful of honey or sugar, oiled half an hour. \ Tor fig, date, and raisin water, proceed as above. Por fig 'ater, use 6 figs. Effeevescent Bevebages. Baspherry Water. Put 2 tablespoonfuls of vinegar into a large glass ; pour in ilf a pint of water, mix well. j Fine Apple Syrup. ' Three tablespoonfuls to one pint. Currant Syrup. The same proportions. Syrup of Orgeat. Proceed the same. The orgeat to be obtained at a French 3nfectioner, as well as the other syrups ; this beverage, made r A 14 LVIII MILITARY HOSPITALS, of almonds, is in daily consumption in the cafes of Paris, and is considered very cooling. j i Camomile Water May be made in the same way. Add a double quantity ol sugar or honey.* i I Dandelion Tea. i ! Put 1|- pints of water to boil, place one-eighth part of anj i ounce of the dandelion root in a teapot, give it a boil, sweeteni 1 as above, it is then ready. \ t Note. — For the above French beverages, sugar may be \ used instead of honey. j % * This drink is seldom used in France. ! ' ; I ; I i ! ! 557 ►Sanitiry Notes on Encampments. ' e have not yet spoken of one operative cause of such para- Dunt importance in its effects on life and health that it is i possible to omit it in treating of Sanitary matters at all ; id jet, because it involves a question purely military, it is (ficult to approach it without impertinence. The providential law may be stated thus : mortality, all other ( cumstances being the same, bears a proportion, within cer- 1 n limits, to the number of persons placed together upon the me ground. To illustrate : The ratios of density of population are in — Liverpool (I'arisl Manchester London Birmingham . . 138 100 50 40 lese figures representing the number of inhabitants dwelHng ( equal spaces of ground. Mortality increases in a corresponding ratio — Deaths in the whole population annually. Teom Consumption. Fbom Fevee- Liverpool (Parish) . . 1 in 166 1 in 407 Manchester .. .. 1 in 172 1 in 498 London 1 in 246 1 in 690 Birmingham .. .. 1 in 207 1 in 917 Inhabitants to the Square Mile. Built and Unbuilt Aeea. London (Metropolis) 27,423 Birmingham . . . . 33,669 Manchester (Township) 83,224 Liverpool (Parish) . . 100,899 Built Aeea. 138,224 r2 558 ENCAMPMENTS. | AvEEAGE Age AisNUAL Deaths. at Death. Teaes. i London . . . . 1 in 37 26^ Birmingham . . 1 in 36 Manchester (Union) 1 in 29 20 Liverpool (Parish) . . 1 in 28 17 , The Quartermaster-G-eneral's regulations for Camping are ' purely of a military nature ; and as a camp is nothing more nor ! less than a town without paving, they may be considered, for' all practical purposes connected with the health of the inhabi- ' tants, about on a par with the instructions (if there were any) delivered by the Anglo-Saxon Quartermaster to his men when they took possession of England, and constructed those aggre- gations of villages and farm steadings which they dignified with the name of "Towns," and which for 1,000 years afterwards' were the nurseries of plague, black death, sweating sickness, j typhus, and lastly cholera. The Saxon rule of castrametation was a very simple one. It consisted of one instruction, namely, " put as many huts on a given space as you can." ' The modern Quartermaster repeats this very simple maxim, and adds a second, make as good a front as you can." And, ' as there are troublesome laws of nature, called sanitary laws, ■ he throws a sop to them, and having laid down certain condi- tions, which are essentially unhealthy, he recommends atten- tion to salubrity. Let us now see what he advises in the way of crowding. He gives three methods for encamping a Battalion, 850 strong, in 60 tents. No 1. j The ground occupied by these 60 tents is 210 yards long and ^ 86 yards wide, or 7,560 square yards — so that the occupied! and unoccupied area, appropriated to the tents of these 850 men, gives a density of population equal to 348,000 per square mile. But this is not the worst. The tents are arranged in' two single lines and four double lines, each tent touching the other in tlie length. By this ai-rangemcnt 170 men sleep on' quartermaster-general's methods. 559 in area of 504 square yards, so that the crowding on the inha- bited area of the camp so arranged is in the ratio of 1,044,820 )er square mile. It may be stated, as an illustration of the extent of this crowding, that Loudon, if equally crowded, would lold on its built inhabited area 127,000,000 of people, or about bur times the population of the three Kingdoms. If we com- pare the population placed on the whole 7,560 square yards namely, the tent spaces and the ground between) with the Dopulation of London, on the built and unbuilt area, we find ihat, if London were equally crowded as is the camp of these ^50 rank and file^ it would hold^42,000,000 of people. No. 2. The title bestowed on this plan of castrametation is an jmphatic one. It is called " compressed," and so it is. The 60 tents with their 850 occupants are arranged in ten louble rows, tliree in a row. The density of population in the )ccupied area is in tlie ratio of 1,290,000 souls per square mile. Che density on the whole area occupied and intervening is enor- iious. There are 850 men on 3,960 square yards (220 x 18), „vhich gives 064,000 to the square mile. A similar density )ver the built and unbuilt area of the metropolis would enable jt to hold 81,000,000 of people. No. 3. In this plan the 60 tents are arranged in ten parallel rows, dx tents in a row, with about 18 yards between the rows. The space actually occupied is about 210x36 yards= 7,560 quare yards, on which 850 men are located. This gives a lensity of 347,000 to the square mile. The density in each row )f tents is nearly the same as in No. 1. H the built md unbuilt area of London were similarly occupied, it would jontain 42,000,000 of people.* * The number of square miles within the area of the metropolis is 21-92. Squaee Mile. Persons. Squaee Miles. P^^^^^^' Then as 1 .: 347,000 :: 121-92 : 42,000,000 560 COMPARATIVE DENSITY The densities in all the Cavalry plans given are very much less, because the tents are spread to suit the picketted horses, which are placed among the tents, between the lines ; a very bad arrangement, if it could be avoided. The following are the populations of some Districts of great density, in comparison with the Infantry Camp plans : Inhabitants per Square Mile. Occupied and UlfOCCUPIED Aeea. The most dense district in England, viz., East London London generally Quartermaster- General's Plans for Encampments.* No. 3 ^. .. No. 1 . . . . No. 2 847,000 ) 348,000 j 664,000 Occupied Area and Streets. 175,816 17,678 1,044,820 1,290,000 Density, Square Yards to a Person. Quarterm aster- G-eneral' a Plans for Encampments. ^0.3 Occupied and unoccupied area 8 9 No. 2 ditto 4-7 Nos. 1, 2, 3. Occupied area . . 3*0 The most dense district in Eng- land, viz.. East London, built area and streets 17-6 London 1600 Proximity or Mean Distance from Person to Person, including the space occupied by the body. Yards. 3-2 2-3 1-9 4-5 14-2 N.B. — There were densities in Camps in the Crimea greater than any of these. Two Kegiments, belonging to our German Legion, have been * Vide Quartermaster-General's Regulations for Encampments, Horse Guards, 11 May, 1853. IN CAMPS AND TOWNS. 561 een encamped, side by side, on the Bospliorus, (in a friendly lountry;,— the one, in close order, suffered from Zymotic Dis- ease—the other, encamped in open order, had only three cases )f disease at the same time. A Eegiment in the Crimea, encamped on the finest ground we had, suffered severely from iholera— the operative cause being the density upon the ground. It is also to be observed that, with the tents placed in double ines, back to back, as in the Quartermaster- Greneral's plan So. 1, it is absolutely impossible, in cleaning out the tents, for ;he men of one tent to avoid quarrelling with those of another )ecause they can hardly help throwing the dirt out of one tent nto another. This plan is therefore unfavourable to discipline. I It is hoped that, in offering these remarks, one shall hardly ')e suspected of such a preposterous thing as that of presuming ;o interfere with Military necessities ; or of not knowing that ;here are circumstances, nature of ground, &c., where all other langers must yield in importance to danger from the enemy. The only object sought for here has been to point out a ^reat and invariable law of nature, in the most unpretending md practical manner. It would appear as if the following conclusions might flow Tom the above. But, in order to give all the details necessary, I short Manual on the subject of Encampment would have to 3e drawn up, by competent persons. The well-known fact, referred to, that, other things being 3qual, towns or parts of towns are unhealthy in the ratio of the lumber of inhabitants upon a given area, cannot be put aside. The more crowded the area, the higher is the ratio of sick- less and mortality. The diseases incident to overcrowding are Zymotics, espe- •ially Fever ; also Consumption. The Quartermaster-General's plans are defective, because :he tents touch each other ; and those of the Infantry Eegi- nents give a degree of overcrowding in the Companies greater :han exists in the most overcrowded parts of towns. A double Company, arranged according to the plan for iCnfantry Encampment, viz., 12 tents on two rows, with 15 men to a tent, gives a population of 1,044,820 to the square mile. The population of London is less than a twentieth part of :his density. 562 SANITARY SUGGESTIONS. The existing " Quartermaster- General's Regulations" do not admit of improvement. The Sanitary points, requiring discussion,, would be muchj better treated in detail, as has been said, in a Manual. ; SlJGaESTIONS. ! 1. When an Army takes the field, a Sanitary Officer should ' be attached to the Quartermaster- Greneral's Department, who ■ shall give advice on all subjects connected with the health of i the Camp, and who for this purpose shall be consulted by the Quartermaster- Greneral. 2. Before a Eegiment or Detachment is encamped, the Medical Officer in charge shall be consulted as to the selection of the ground. 3. The following are among the chief Sanitary points requi- ring attention : — j (a). Sufficient labour should be set apart for the daily cleans- ing of the camp, and. for removing the refuse to a distance. (5). Latrines should be placed at a sufficient distance from the nearest tent or hut, and always to leeward of the prevalent wind. (c). Slaughtering-places should be established in a similar position. {(1) . Suitable Kitchens should be constructed in a convenient | position. (e). The ground should be always surface-drained, and, if on j a slope, the drainage from the high ground behind should be ■ cut offi ' (/). Tents should never be placed close together; but should ; always have a space between them, to allow of a free circulation of air ; the larger the space over which a camp can be spread, the more healthy it will be. (ff). All towns and buildings occupied during war, either for Quarters or Hospitals, should be carefully inspected by the Sanitary Officer, and measures taken for placing them in a good sanitary condition, before they are occupied. Precautions should also be taken, by cleansing, draining, sewering, &c., to preserve occupied towns, after occupation, in a healthy condi- tion. (h). In erecting huts, in camp, the ground should be levelled SANITARY SUGGESTIONS. 563 id drained, to the depth of at least a foot, round the site to js occupied. No earth should ever be heaped against the sides the hut. (i). Large ventilators should be placed in the ridge of each jit. 565 1e subjects discussed in the preceding pages have been dilt with, as required by Lord Panmure's instructions, ^.h special reference to the experience obtained during t J Crimean war. While the sheets were passing through t ) press, those lamentable occurrences took place in India vich luivc led to an universal conviction that this vast e pire must henceforth be held by British troops. If we T re to be led by past experience of the presumed effect c Indian climates on European constitutions, our country ight almost despair of being able to supply men enough f ' the military occupation of so vast a region. The art ( preserving healtli has hitherto made but small progress i our Eastern possessions. The British race has carried Uh it into those regions of the sun its habits, its customs, id its vices, without considering that there are penalties e acted by nature in her tropical dominions from those no neglect or transgress her laws far more severe than i the more temperate climates of our own country. ^ rider a low temperature man may do with impunity what i.der a higher one is death. Our vast Eastern empire (nsists of many zones, of many regions, of many climates. -5 plains, rivers, deltas, table lands, its sub-alpine dis- Icts, and regions of eternal snow present, perhaps, all le climates of the earth; and on the mere question of rmate it is surely within human possibihty so to select : d arrange military stations and service that at all ordi- : .ry times our troops may have the opportunity of recruit- :g their health and strength, to a considerable degree at ast, without interfering materially with military service, ight it not be possible, even in the great majority of stances, so to arrange the stations, and so to connect em, by railroads and telegraphs, that the troops would 566 hardly be required to occupy unhealthy districts ? Eve: with regard to such districts the question arises t what extent the unhealthiness is inevitable, and t what extent it would be remediable. There have bee: and there are eminent men in the Indian service wh' entertain no doubt as to the practicability of introducin | sanitary reform into almost every barrack and cantonmen i in the East. Considerable progress has indeed been mad , in this very matter within the last half century; and ther- can be little doubt but that, aided by the clearer light c j modern discovery and especially by the complete experi ; ence of the Crimean war, a great deal may be done t< diminish the disease and mortality in a large army oj occupation by which we must hereafter hold our Indiai Empire. ] The subject is one which, it cannot be doubted, wilj receive the immediate attention of Her Majesty^ s Govern ment. As an illustration of the necessity of Government inter ' ference in the matter, it may be stated, on the very firs authority, that, after a campaign, perhaps one of the mos : arduous and successful on record, and when the smallnes of the British force, and the season of the year require( i every sanitary precaution to be taken for the preservatioi of the force, a certain earnest, energetic Officer appointee a Sanitary Inspector to attend to the cleansing of a capture( city, and to the burial of some thousand dead bodies of men i horses, asses, bullocks, camels and elephants, which wen | poisoning the air. The Bombay Government, to whicl the appointment was referred, ^' would not sanction it,^ because there was no precedent for it.'' In future, it ought to be the duty of the Indian Govern ment to require no precedents^' for such procedure The observance of sanitary laws should be as much part o 567 13 future regime of India as the holding of Military jsitions or as Civil government itself. It would be a ible beginning of the new order of things to use hygiene ; the handmaid of civilization. w SUBSIBIAEY NOTES AS TO THE INTRODUCTION OF FEMALE NURSING INTO MILITARY HOSPITALS IN PKACK AND IN WAR. Jlresentcb bn request to t^e ^etretarg of ^late for Mnt. L 0 N D 0 : I'RINTF.D BY HARRISON AND SONS, ST. MARTIN'S LANE, 1858. CONTENTS. PAGES Digest v— x Thoughts submitted by Order, concerning— I. Hospital Nurses 1 — 9 II. Nurses in Civil Hospitals 9 — 14 III. Nurses in Her Majesty's Hospitals 15—19 Systems of Female Nursing in the War Hospitals of the different Nations engaged in the Crimean War .... 19—26 Note in regard to the Russian Nurses employed in the War Hospitals of the Crimea 26—28 Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and in War 1" 63 Addenda with regard to Female Nursing in a Military Hospital on the Pavilion or Lariboisiere Plan .... 63—90 Addenda as to Mixed Nursing, by Nurses and Orderlies, in Military Hospitals, on the Double Pavilion or Vincennes Plan Additional Hints as to Ventilation, Hospital Floors, and Cautions in Ward-buildiug suggested by the Lari- boisiere Hospital 118—127 Note on Contagion and Infection 128—132 b iv CONTENTS. PAGES. Note on Observations by the Principal Medical Officer o the Army in the East 132, 133 Thoughts submitted as to an Eventual Nurses' Provident Fund 1—1 Note as to the Number of Women employed as Nurses in Great Britain 20, 21 Note as to Teaching Nursing 22, 23 DIGEST. PAGES THOUGHTS SUBMITTED BY ORDER 1.28 CONCERNING I. Hospital Nurses, TI. Nurses in Civil Hospitals. III. Nurses in Her Majesty's Hospitals. I. Hospital Nurses .. .. .. .. i_9 Twenty Observations on how to improve Hospital Nursing, II. Nurses in Civil Hospitals .. .. 9-14 Twenty-three Heads for Regulations as to Nursing in Civil Hospitals. III. Nurses in Her Majesty's Hospitals .. .. 15-19 Twenty-two suggestions in the event of the introduc- tion of Female Nursing into Military Hospitals. Various systems of Female Nursing during the Crimean War in the Military Hospitals 19-28 Of the French and Sardinians .. .. .. .. 19-22 Russians 22, 23, 26-28 English . . . . . . . . . . . . 23 Proposed Duties of Female Nurses in Military General Hospitals 23,24 The Hospital Serjeant, or Ward Master will not be super- seded— he will still have too much to do for any one man properly to perform, and part of his duties must be given to another officer 24-26 Note in regard to the Russian Nurses employed in THE War-Hospitals of the Crimea 26-28 vi DIGEST. PAGES SUBSIDIARY NOTES AS TO THE INTRODUCTION OF FEMALE NURSING INTO MILITARY HOSPITALS IN PEACE AND IN WAR 1-133 I. Five Conditions essential to this service .. . . 1-3 II. Our Nurses were of four kinds. . . . . . . . 3 Absolute subordination to the Medical Officer as to Medical Orders essential and practised by us . . 4 IlL 1. Qualified subordination essential of Superintendent- General to Director- General and Principal Medical Officer 4-6 2. Also of Matron and Nurses to Principal Medical Officer and Staff- Surgeons . . . . . . 6, 7 3. Female service can only be introduced gradually, and introduction regulated by Director-General . . 7-9 V. 1. Shall Roman Catholic Sisters be introduced? .. 9, 10 2. Or Anglican Sisters ? . . . . . . . . 10 3. Power of Police in Civil Hospitals . . . . . . 11 „ „ Military 12-15 4. Pay and Rations of Nurses . . . . . . . . 1 5-20 On the whole it would seem best, where practicable, to board the Nurses, not to "ration" them, nor to let them "find themselves." Community of cooking implies economy of nourishment . . 1 7-20 5. Washing to be " put out" 20, 21 G. Cleaning their own Rooms . . . . . . . . 21-23 7. Nurses to keep keys of closet in Wards . . . . 23 8. Pay, dress, and duties of Matrons . . . . . . 24-28 More properly named Superintendents . . . . 27 Lady Volunteers had better begin by being Nurses, not Superintendents ex-officio . . . . . . 28 9. Sundry Regulations as to Nurses . . . . . . 29-31 10. Have the Patients' Diets sent hot, and ready divided, from kitchen . . . . . . . . . . 31 11. What Ward duties the Nurses should do themselves 31 And why 32, 33 Patients should not be made quasi Orderlies . . . . 34 Visitors in Military Hospitals .. . .. .. 35 12. Regulation-Number of Orderlies — depends on the size of wards whether sufficient . . . . . . 35-41 What is the regulation -attendance in Naval Hospitals 37 What in Civil Hospitals . . . . . . . . 38 Comparative Cost of Nursing in larger and smaller wards . . . . . . . . . . . . 39-41 DIGEST. 13. Hospital floors Sanitary necessities . , Trial of Hospital floors, oiled and polished with "laqne," as in Berlin Hospitals, recommended on sanitary grounds and for ease of cleaning 14. Ventilation of Wards 15. Special Wards, whether desirable or not , . 1 6. Opinion as to Superintendent-General paying Nurses' wages, and as to Governor's jurisdiction over Nurses 17. Wages and Pensions of Nurses Three rules in raising Wages Five general principles as to Wages and Pensions . . Six applications of the foregoing principles. . Seven heads for Regulations as to Nurses' Wages and Pensions 18. Proportion of Nurses to Patients .. 19. Precautions in sending Nurses on Foreign Service.. Hospital Laundries . . Addenda, with regard to Female Nursing in a Mili- tary Hospital on the Pavilion, or Lariboisiere Plan I. Four conditions to be considered in adopting the Pavilion Plan 1. Economy of attendance 2. Facility of supervision 3. Desirableness of doubling the Pavilion, in a Military Hospital, in order to give to each Nurse but one floor to serve . . . • 4. Nurse to sleep near her Ward Importar.rp of lighting by gas II. 1. One Nurse must serve the whole Pavilion, in a Military Hospital, if single Pavilions be adopted . . 2. Nurses' day in such a Pavilion 3. What the responsibility of Nurses is for discipline of Ward or Pavilion . . 4. Importance of Lifts III. 1. - Casualty" Cases should be in a completely appointed set of Wards, apart And why 2. Restraint or non-restraint in Violent Cases viii DIGEST. PAGES IV. Simplicity of Construction essential to Discipline . . 75 Polished impervious Walls. Covered Exercising Place. Reserve Wards . . . . . . . . . . . . 76 V. Nurses' Meals to be sent them Cooked . . . . 76 VI. Arrangements for a Pavilion and its Wards . . . . 77-90 2. Where should Wardmaster sleep ? .. .. .. 77 3. And Orderlies sleep ? . . . . . . . . 77 4. And dine? .. .. .. .. 78 7, 8, Scullery to each Ward, and what to be done in it. . 79 Poultice-making . . . . . . . . . . 79 9. Presses in Ward . . . . . . . . . . 80, 81 10. Nurses' Room . . . . . . . . . • 82 Lavatory, Water-Closet, Sink . . . , . . 83 Baths 84 11. Summary of arrangements .. .. .. .. 85 Scullery Appurtenances . . . . . . . . 86 12. Nurses' Sleeping Quarters . . . . . . . . 86 Ward for Sick Nurses . . . . . . . . 87 13. Classification of Patients .. .. .. .. 88 14. Nurses to be called by their Wards . . 88 15. Foul Linen 88 16. Washing Bandages .. .. .. .. .. 89 17. Splints, &c., where to be kept .. .. .. 89 Cotton Lint never to be used . . . . . . 89 18. Classification of Nurses .. .. .. .. 90 Superintendent's Store Room . . . . . . 90 Addenda as to Mixed Nursing by Nurses and Order- lies IN Military Hospitals on the Double Pavi- lion Plan .. .. .. .. .. .. .. 91-117 I. Orderlies' Duties .. .. .. .. .. 91-108 Proportion of Nurses, Ward Masters, and Orderlies to Sick 91-93 Wine to be always administered by Nurse . . . . 93 Orderlies — their Duties vary according to appurte- nances of Ward . . . . . • . . . . 94 If Hot and Cold Water are laid on, and there are Lifts, one Orderly's Service saved to each 30 Sick . . 94, 95 Night-Duty of Orderlies 95-108 Scheme of Night- Service for three Orderlies watching by turns 96, 97 DIGEST. IX Exercise for Orderlies . . Night Refreshment for Orderlies Where are the Night Orderlies to sleep ? Comparative Merits of different Systems of Night Nursing in Home and in Foreign Hospitals An Assistant Ward Master should go round the Wards at Night Extraordinary System of Night-Nursing in the Army at present PAGES 97 98, 99 100 101-3 104 105-8 II. Twelve Sundries in organizing a Military HosPiTAi 108-lU 1. Nurses' Room .. .. .. .. .. 108 2. Medical Officer's Room 108 3. Water- Closets 109 4. Warm and Cold Water Supply 109 5. Corridors 109 6. Lobby 110 7. Material of Ward Utensils HO 8. Reserve Wards 111-112 Necessity of Annual Cleansing of the whole of a Hospital 9. Occasional Revision of Rules .. .. •• 10. Defect in German Organization of Nursing .. US 11. Nurses' Exercise 12. Number of Ward Masters 114 III. Regulations .. 1 . Deprivation of Visitors salutary in certain Wards. . 2. Numbering Patients saves time 3. Prohibition of Swearing Conclusion . . 114-117 114-16 117 117 117 Additional Hints as to Pavilion Hospitals suggested BY the Construction of the Lariboisiere Hospi- tal at Paris I. Ventilation Artificial Ventilation never freshens a Ward II. Oiled Boards versus Parquets .. Cleaning polished and oiled Boards much less laborious, and freshens the Ward much more than ih^Jrottaue of Parquets. Mode of Cleaning them at Berlin 118-127 118-120 120-124 122-124 X DIGEST. PAGES III. Ten Cautions in Building Hospital Pavilions . . . . 124-127 Size of Wards. Our own Regimental Hospitals extra- ordinary for their many holes and corners . . . . 125 Casualty Wards 126 ''Contagion" and "Infection" Defined .. 128-132 Idea of ** Contagion " invented by Men to excuse themselves for the neglect of all Sanitary arrange- ments . . . . . . . . . . . . . . 128 In the ordinary sense of the worJ, no such thing as ''Contagion" 129 "Nor as inevitable '' Infection" .. .. .. 130 "Infection" and Incapable Management, or Bad Construction, convertible terms . . . . . . 131 *' Epidemics " do not spread — they develop themselves in Constitutions made ripe for them by Sanitary neglects . . . . . . . . . . . . 131 Note on certain " Observations " by Sir John Hall . 132, 133 Thoughts Submitted as to an Eventual Nurses' Provident Fund .. .. .. .. .. .. 1-19 Actual Wages and Prospects of Nurses . . . . 1-3 Some further Provision desirable . . . . . , 4-6 Of what Nature ? 6-15 With regard to Kind ? 6-8 With regard to Persons ? . . , . . . . . 8 With regard to Objects ? \ . . 9-15 Material Objects ? 9-12 Children, in the case of Nurses, a Temptation to Petty Dishonesty and taking Bribes .. .. .. 11,12 Sanitary Objects ? . . . . . . . . . . 13 Moral Objects ? 13-15 Hospitals not places for Penitents . . . . . . 14, 15 Rules to be followed in giving Assistance . . . . 15-17 Prospects of Eventual Support .. .. .. 18,19 Note as to the Number of Women employed as Nurses in Great Britain 20, 21 Tables of Ages, &c 21 Note as to Teaching Nursing — Institution at Madras. . 22, 23 I L L U S T I{ A T I 0 N. Plan of tlie Lariboisibre Hospital at, Paris UVATE AND CONFIDENTIAL. Thoughts submitted by order concerning I. Hospital-Nurses. II. Nurses in Civil Hospitals. III. Nurses in Her Majesty's Hospitals, I. Hospital-Nurses. 1. It would appear desirable to consider that definite Definite Diects arc to be attained ; and that the road leading to Objects : road to them to be lem is to a larjre extent to be found out — therefore to is to a large extent to be found out- jmsider all plans ar I rules, for some time to come, as in great measure tentative and experimental. 2. The main object I conceive to be, to improve i jspitals, by improving hospital-nursing ; and to do this Y improving, or contributing towards the improvement, f the class of hospital-nurses, whether nurses or head- urses. 3. This I propose doing, not by founding a Religious |>rder ; but by training, systematizing, and morally im- roving as far as may be permitted, that section of the irge class of women supporting themselves by labour, who jike to hospital-nursing for a livelihood,— by inducing, 1 the long run, some such women to contemplate useful- found out. Presumed Main Object. Presumed Intentions. 2 HOSPITAL NURSES IN GENERAL. Reli.i^ious Orders. Their Advantages. Advantages of Hired Labour. ness_, and the service of God in the relief of man, as well as maintenance, and by incorporating with both these i classes a certain proportion of gentlewomen who may think fit to adopt this occupation without pay, but under the: same rules, and on the same strict footing of duty per-! formed under definite superiors. These two lattei elements, if efficient (if not, they would be mischievous! rather than useless), I consider would elevate and leaven the mass. 4. It may or may not be desirable to incorporate intoi the work, either temporarily or permanently, members of Religious Orders, whether English or Eoman Catholic,; or both, who may, with the consent of their Superiors,! enter hospitals nursed under the above system, upon the: definite understanding of entire obedience to secular- authorities in secular matters, and of abstinence from proselytism. 5. Great and undoubted advantages as to character, t decorum, order, absence of scandal, protection against i calumny, together with, generally speaking, security; for some amount of religious fear, love, and self-sacrifice,' are found in the system of female Eeligious Orders. ! 6. On the other hand, the majority of women in all European countries are, by God^s providence, compelled; to work for their bread, and are without vocation fori Orders. In England the channels of female labour are few, i narrow, and over-crowded. In London and in all large j towns, there are accordingly a large number of women ; who avowedly live by their shame; a larger number whoi occupy a hideous border-land, working by day and sinning by night ; and a large number, whether larger or smaller j than the latter class is a doubtful problem, who preserve j their chastit}^, and struggle through their lives as they; HOSPITAL NUKSES IN GENERAL. 3 an, on precarious work and insufficient wages. Vicious ropensities are in many cases the cause, remediless by- he efforts of others, of the two first classes : want of work lasufficient wages, the absence of protection and restraint, re the cause in many more. ' Perhaps the work most needed now is rather to aim at Ueviating the misery, and lessening the opportunities and he temptations to gross sin, of the many ; than at pro- aoting the spiritual elevation of the few, always supposing [hat this latter object is best effected in an Order. ! At any rate, to promote the honest employment, the kcent maintenance and provision, to protect and to lestrain, to elevate in purifying, so far as may be permit- ed, a number, more or less, of poor and virtuous women, -s a definite and large object of useful aim, whether success )e granted to it or not. The Orders remain for the reception of those women fvho either are or believe themselves drawn to enter them, b who experience their need of them. 1 7. The care of the sick is the main object of hospitals. Main Object of the care of their souls is the great province of the clergy oTstkTct ' >f hospitals. The care of their bodies is the duty of the ^""^^^^^'^ mrses. Possibly this duty might be better fulfilled by Cier^ and .•eligious nurses than by Sisters of any Order; because j^^^ses. !he careful, skilful, and frequent performance of certain coarse, servile, personal offices is of momentous conse- luence in many forms of severe illness and severe injury, md prudery, a thing which appears incidental, though Hot necessarily so, to Female Orders, is adverse to or ncompatible with this. 8. Grave and peculiar difficulties attend the incorpora- objections to don of members of Orders, especially of Roman Cathohc A-^^^^^^^^^^^^^ Drders, into the work. And, both with reference to the [Queen's hospitals, and still more to the civil hospitals, I I B 2 Orders with SecularNurses, 4 HOSPITAL NURSES IN GENERAL. humbly submit that much thought^ and some consul ta tion with a few impartial and judicious men_, should pre cede the experiment of their introduction. This appear:; i to me one of the most important questions for decision! i Should it be decided in favor of their introduction, I trus i k\ it may be resolved to do so only tentatively and experi ltis mentally. ! f 1 confess that, subject to correction or modificatior' i from further experience or information, my belief, th( J result of much anxious thought and actual experience, isj that their introduction is certain to effect far more harm iri J some ways than it can effect good in others; that a greal! 3 part of the advantages of the system of Orders is lost, when their members are partially incorporated in a secu-i i lar, and therefore, as they consider, an inferior system and that their incorporation, especially as regards thei i Roman Catholic Sisters, will be a constant source oli ! confusion, of weakness, of disunion, and of mischief. Saint Vincent de Paule well knew mankind, when hel ! imposed, amongst other things, the rule on the Sisters! ! of his Order never to join in any work of charity with the. Sisters of any other Order. This rule was mentioned to : me on an occasion which gave it weight, by the Superior of the Sisters of Charity of one of the two Sardinian Hospitals on the Heights of Balaklava, in the spring of 1856, and by the Mere Generale at Paris, October 1854, when she was solicited by me, with the assent and sanction, ! both of the English and of the French Governments, to ; grant some of her Sisters to us at Scutari. i 9. As regards ladies, not members of Orders, pecuHar difficulties attend their admission : yet their eventual admixture to a certain extent in the work is an impor- tant feature of it. Obedience, discipline, self-control, work understood as work, hospital service as implying HOSPITAL NURSES IN GENERAL. 5 -nasters, civil and medical, and a mistress, what service aeans, and abnegation of self, are things not always easy 0 be learnt, understood, and faithfully acted upon, by =adies. Yet they cannot fail in efficiency of service or tropriety of conduct — propriety is a large word — without lamaging the work, and degrading their element. Their iismissal (like that of Sisters) must always be more roublesome, if not more difficult than that of the other lurses, It miffht be better not to invite this element ; to let it tjome if it will learn, understand, and do what has to be learnt, understood, and done : if not, it is better away. It appears to me, but I may be quite mistaken, that, n the beginning, many such persons will offer themselves, :)ut few persevere ; that in time a sufficient number will brm an important element of the work; more is not lesirable. It seems to me important that ladies, as such, should lave no separate status; but should be merged among .:he head-nurses, by whatever name these are called. Thus efficiency would be promoted, sundry things would DC checked, and the leaven would circulate. There are many women, daughters and widows of the middle classes, who would become valuable acquisitions to the work, but whose circumstances would compel them to find their maintenance in it. These persons would be far more useful, less troublesome, would blend better and more truly with women of the higher orders, who were m the work, and would influence better and more easily the other nurses, as head-nurses, than as ladies. Whether or not the better judgment of others agrees with mme, my meaning will be understood. In truth the only lady in a hospital should be the chef of the women, whether called Matron or Superintendent. 6 HOSPITAL NURSES IN GENERAL. The efficiency of her office requires that she should rantj as a lady and an officer of the hospital. At the same time, I think it important that every Matron and Superinten-i dent, (unless during war-service, when the rough-and-ready i life and work required will probably be best undergone by women of a higher class) should be a person of the mid die i classes, and if she requires and receives a salary, so much the better. She will thus disarm one source of opposition and jealousy, and enough will remain, inseparable from her office. The quasi-spiritual dignity of Sisters of Mercy is a thing siii generis. But the real and faithful discharge of the duties of the wards of a General Hospital, whether with reference to superiors, companions, or patients, is incompatible with the status, as such, of ladies. The reali dignity of a gentlewoman is a very high and unassailable ■ thing, which silently encompasses her from her birth to her grave. Therefore, I can conceive no woman who knows, either from information or from experience, what i hospital duties are, not feeling as strongly as I do, that either the assertion or the reception of the status as such of a lady, is against every rule and feeling of common sense, of the propriety of things, and of her own dignity . Religion. 10. The question of the mode of Religion is an aU- important one, and the choice of a mode bears far more directly upon this work than may, at first sight, appear. To give up the common ground of membership of the National Church is to give up a great source of strength. St. John's St. John's House, if it steers clear of the rock of prudery, undoubtedly possesses great advantages over a system of hospital nursing by promiscuous instruments. Not because it includes a Sisterhood, a system, in which I, for one, humbly but entirely disbelieve ; but because the HOSPITAL NURSES IN GENERAL. borious, servile, anxious, trying drudgery of real hospi- I work (and to be anything but a nuisance it must ever main a very humble and very laborious drudgery), quires, like every duty, if it is to be done aright, the fear id love of God. And in practice, apart from theory, no lal union can ever be formed between sects. The work ')w proposed, however, must essentially forbear to avail self of the bond of union of the National Church. 11. None but women of unblemished character should ^ suffered to enter the work, and any departure from lastity should be visited with instant final dismission. II applications on behalf of late inmates of penitentiaries, jformatories, of all kinds and descriptions, should be jfiised. The first offence of dishonesty, and, at the very 'irthest, the third offence of drunkenness, should ensure ^reversible dismissal. No nurse dismissed, from whatever mse, should be suffered to return. 12. It is very important, if possible, to make provision )r the disabled age of deserving nurses. It does not seem me, I speak very diffidently, desirable to concentrate icm in one or more large buildings. I believe half the imates of half the alms-houses, &c., are not on speaking 3rms with each other. John Bull is of a pecuhar idio- vncrasy : nowhere are there such homes as in England, at life in community does not seem congenial here. A ension and the option of ending their days in solitary uiet, or with some friend or relation, would probably e the most comfortable arrangement for nurses. 13. Many women are valuable as nurses, who are yet imfit for promotion to head-nurses. It appears to me that ft would be very desirable to have an intermediate recom- -ense : say, after ten years' good service, to raise nurses' rages; after a second ten years, to raise them further. If 14. There should be an age for the reception and for Only Women of Unblemished Character should be employed. Provision for Old Age. Progressive Increase of Wages. Fixed Age for 8 HOSPITAL NURSES IN GENERAL. Admission and Retirement. Simplicity of Rules, Definition of Authorities. Economy. Commence- ment : Training. Limits. Encumbrance of Public Support or Patronaffe. the retirement both of nurses and head-nurses. I think mi head-nurse should be under thirty. 15. Simplicity of rules^ placing the nurses^ in souk' respects^ absolutely under the Medical man, and, in others: absolutely under the Female Superintendent, is very im; portant ; also, at the outset^ to have a clear and recordec definition of these respective limits. 16. Economy is very important, with regard to tht eventual extension of the work. 17. In the event of the nurses not being trained in Hei Majesty^s service, advantage, it seems to me, would attenc their beginning in a great established hospital; unless indeed it should be judged best to select and train a stafi of nurses first in a smaller and quieter one. Yet much that would be unpleasant in the larger place would pro- bably be beneficial. The restraint, control, contact with the masters, work, and order of things of a great and settled place, would materially help with reference to the^ nurses. 18. Common sense will assuredly make the fixed resolve ; both to fulfil one's duty, and to keep within it. It is as essential to do the latter as the former, and often more difficult, especially for women ; most especially for hospital-nurses. 19. It appears to me most important to be free, once and for ever, from the injurious, untrue, and derogatory appendage of public patronage: what is called support in these days always ends in patronage. This work, truly understood, never has been, never will be, never can be, a popular work ; for many reasons, one of which is that the public, of all orders, never can know anything of the real nature of hospital- work. With the best intentions, it Av ill therefore make perpetual and impeding mistakes in supporting"' or patronizing it. Its support and patronage NURSES IN CIVIL HOSPITALS. 9 re equally injurious in different ways as regards our Caution, Non- lasters the medical men, ourselves the nurses, and people ^anTTrust"' Irho are neither medical men nor nurses. 20. I end as I began. Let nothing be done rashly, jet us not be fettered with many rules at first. Let us ake time to see how things work; what is found to answer )est ; how the work proceeds ; how far it pleases God to iccept and bless it. Let us be prepared, as I know well ve must be, for disappointments of every sort and kind. What can any of us do in anything, what are any of us ncant to do in anything, but our duty, leaving the event to God? His Will be done in earth, as it is in fHeaven. II. Nurses in Civil Hospitals. 1. The isolation of each head-nurse and her nurses isolation of .appears to me very important. The head-nurse should ^^Jgc and'her 'be within reach and view of her ward both day and night. Nurses. Associating the nurses in large dormitories tends to cor- rupt the good, and make the bad worse. Small airy rooms contiguous to the ward are best. The ward should have but one entrance, and the head-nurse^s room should be close to it, so that neither nurse nor patient can leave, nor iany one enter the ward, without her knowledge. I 2. All the nurses should rank and be paid alike, with All to^Rank ^progressive increase of wages after each ten years^ good ,u,e, .uh service, or a slow annual rise, which is better. Increase of ■* Wages. I 3. The night-nurses should be on duty 13 hours, with Kight Nurse. 1 instant dismissal if found asleep; 8 hours should beaUowed for sleep, and 4 hours for daily exercise, private occupation, or recreation. If they have no time to themselves for their mending, making, &c., they do it at night, sometimes 10 NURSES IN CIVIL HOSPITALS. innocently, sometimes to the injury of the patients', would not however prohibit occupation at night ; as some times the ward-duty is slight; and doing something iM far better and more awakening than doing nothing. Thiji is one of the matters the head-nurse should constantly i look to. I do not fancy, but at present am not positive about, cleaning or scrubbing at night. The night-nurse should have a reversible lamp, or something that without disturbing the patient, gives her light, brighter than the dim fire or gas-light properly maintained in the wards at night. She should have a room to herself. Day Nurses. 4. The day-nurses should have eight hours^ sleep, and if it be possible, 4 hours daily for exercise, private occupa- tion or recreation. They may have one room. Nurses to 5. All provisions, &c., &c., should be as much as fetch no Jung. pQggji^j^g brought into the wards, or to the ward-doors, by lifts. Nothing should be fetched by the nurses. This would save much time ; would enable the nurses to do more work, and yet have more leisure; and above all, would obviate the great demoralization consequent on the nurses, patients, and men-servants congregating in num- bers several times daily. Patients to 6. The patients should be made as useful as possible, fetch nothing, consistently with their capacities, inside the ward ; but should be permitted to fetch nothing to it. Scrubbing. 7. I strongly incline to have the scrubbing done in each ward, by a nurse assigned for that purpose, and for general attendance when the scrubbing is done. There should be hours for the scrubbing, before and after which it should not be done. This whole matter is one on which I am not positive at present. Distribution of ^- At present, I incline to something of the following Ward Work, scale. Two wards, single are best, but it might be one double ward, with 40 beds, served by 1 head-nurse and 3 NURSES IN CIVIL HOSPITALS. U 1 rses. The head-nurse to superintend all things, and to ( the dressings not done by the surgeons and dressers, :usted mainly ])y one nurse, whom she thus instructs in ] rsing. Another nurse to do the scrubbing, and mainly u cleaning, and when these are over to mind the ward ( ring the remaining hours in turn or in conjunction li the first nurse. The third to be night-nurse. In morning, before dressing begins, and before the night- rse goes off duty, all three nurses to clean the ward, ike the beds, wash the helpless patients, &c. 9. Hours of morning and evening poulticing and Hours of CSsing to be fixed. Dressing and ^ roulticnig, 10. Hours of administration of medicine, always except and of night given by head-nurse, to be fixed. Medicine. 11. Hours of exercise of head-nurse and nurses to be Hours of :cd, and arranged with reference to the ward-duties. '^Holidayr^ fixed occasional holiday given in turn to the nurses is ood. An annual longer holiday for them and for the i 3ad-nurses is good ; a fortnight is, I think, a good limit, Ihe hoHdays cause inconvenience, no doubt, but on the fhole do, I think, far more good than harm. The hohdays lould be distributed in rotation during a fixed time of ar, and comprehended in two or three months, or four the very outside ; and no woman declining her hohday : the proper time should be allowed it at any other. ' 12. No head-nurse or nurse should be out of the hospital Permission of . . Matron for efore or after the limit of her dady exercise time, two extra time out. ours, without wTitten permission of the Matron. The latron, I think, should put the cause and amount of the ixtension in writing, and report the same to the Treasurer j-r Chief Officer, at the next general meeting, whenever it is called, of the Officers of the Hospital. She wdl find his a great protection against petitions. There is not a •loubt that the fewer extraordinary absences, the better. 1! 12 NURSES IN CIVIL HOSPITALS. Place of Exercise. Caution. Dress. Wages. 13. Were it possible to have a small garden (in collegl >l gardens much effect and much refreshment is produced b a green sward, a few trees, some shrubs, a fountain, an some seats) , in this, at strictly separated hours, the mei ' patients, the women patients, the head-nurses and nurse; ^ the men-servants, if they choose, which perhaps is nc(|i5'" likely, could walk or sit down. This arrangement wouli little interfere with its enjoyment by the dignitaries an their children, who require it quite as much, and would b i ' found in its results practically and not poetically usefuH d Hospitals are, and perhaps must be, in or near crowdc :o thoroughfares. Streets are miserable places to walk ij jci, during great part of the year. Nurses want and unconi ie i sciously crave for fresh air, and often half-an-hour is bettei irj than more,given them close to their work — and away froni the streets, it would be often a great preservative. li] 14. I should, however, be very cautious as to intro \i ducing music or anything of that sort. Hospitals are noiij^oii tea-gardens, nor homes, nor meant to be either. Greaii ii quiet and some severity of discipline are necessary, anci it ought to be exacted. i w 15. I think the head-nurses should wear a regulationj i dress, and the nurses another; if we adopt the honest so word livery, in use in the hospitals, it will perhaps do no i harm. Caps, dresses, aprons, should be prescribed r ^ whether or not out-of-door dress should be prescribed isi i to be considered apart. Each should have three dressesi yearly. Better, I think, avoid washing stuffs ; they re-j i quire endless change to look decent. Head-nurses and t nurses might wear the same dress, and some difference m > | the cap would be quite distinction enough. i j 16. I incline towards giving the head-nurses £^0\\ a-year, one or two rooms (one room with an alcove and j ; curtain would be best), fuel and light. The nurses j NURSES IN CIVIL HOSriTALS. I3 Irging; tlic night-nurse a room to herself, the others tretlior; entire board, fuel, light, and good wages to be d'idcd upon. L 7. The nurses' rooms should be suppHed witli plain com- Furniture. f.tal)le furniture. In tlie large Hospitals the head-nurse f nishes her own room or rooms, which doubtless promotes ] ' comfort and her care of the furniture, both desirable t ngs; yet the tendency of many to accumulate decora- S which take time to clean, &c., is a drawback. I s nild be inclined, as an experiment, to try the furnishing jan, or at least to have some scale as to furniture allowed. J bed, arm-chair, and sofii; a chest of drawers, wash-hand <)le or slielf; book-case or shelves; a little table, and ; arger one, a couple of chairs, a footstool, and a cup- lard with broad shelves, are tlie utmost that can be 1 quired. IS. A difficult and important point to settle is the Visitors, lint of liberty allowed as to receiving visits. It is liable on all accounts to make head-nurses and nurses 1 comfortable, and, as it were, at home : it is also better ry should not be unnecessarily out; also London dis- iiccs are great, and even omnibus-fare is a consideration; 0 it is important to remember that these women are t: to feel and say: "We are not in a nunnery,^' nor ould they be. Still upon the whole, considering the usance of ordinary visitors, and the greater nuisance of traordinary {e.g., visitors to some head-nurses, kind lends come to see how we are getting on, &c., &c., &c.), tliink if it were possible to make the rule that no -itors are allowed, it would be a great gain. I am not irc, at present, whether it is possible or not— still less bother it is possible to keep such a rule, if made. But, all events, nurses and head-nurses should only be per- litted to receive visitors on certain days and hours of the 14 NUKSES IN HER MAJESTY^S HOSPITALS. Discharged Patients. Graduated scale of Pensions. No occasional Wards. Head-Nurse to each Ward. Religious Influence. week ; and those hours and days should be strictly kept tc In Military Hospitals a still more rigid rule will be neces sary. , 19. No discharged patients, however previously well' | conducted_, should be allowed to visit the wards. j 20. Apart from raising the wages of good nurses afte ! every ten years^ service, I think it would well answer t( establish a graduated scale of pensions, for both head nurses and nurses ; beginning with a small pension aftei ten years' good service, increasing every five years after ' wards. Many women are quickly worn out in this hfe;^ and it is equally undesirable to turn faithful worn-out servants adrift without any provision, or to retain them ic' duties for which they are become unfit. It is a question^ whether there should not be a compulsory stoppage from wages, in order to entitle the nurses to pension under conditions. 21. Have no occasional wards, or wards for accidental' and peculiar patients. 22. Every ward, or set of wards, should be under a head-nurse. Discipline is always defective under other arrangements. 23. This turns greatly upon a previous question. Every' endeavour should be used to bring the women under the influence of religion, God's instrument for saving, strengthening, and comforting souls. So far as this work i depends on rule, system, and superintendence, great things may be done at any rate — so far as moral influence is concerned, it can only be hoped for in the channels appointed by Him who turneth all hearts whithersoever' He will. 15 III. Nurses in Her Majesty's Hospitals. 1. If their introduction is eventually commanded by Two kinds of 13 Queen's Government, it will be ad^dsable to consider fir tit their service admits of two distinct kinds. Females. 2. " Their chief duties'' may be " taking charge of the The one: its l.en and superintending the issue of extras," Advantages; They will thus contribute materially to the comfort and ll-being of the sick; the real difficulties which un- l ubtedly beset the introduction of women into ward irvice will be avoided ; and, an important consideration, )t lightly to be discarded, their exclusion from the ward rvice will materially diminish the opposition of adverse asters, some of whom are also unscrupulous masters. 3. On the other hand, I suppose, the experience of every The other : its , . ..I'll Advantages, jman, admitted to ward service m hospitals where women die not before, is that many lives are actually saved by ,Lch admission, which would otherwise, humanly speaking, ) lost. In time of war some ciphers may be safely added » the many. Any other great emergency, I suppose, it do not speakfrom experience, would give the same result. That the experience of many surgeons is identical, their )nduct has proved; no other testimony, under present rcumstances, can rationally be expected from them. 1. It is often right to begin with the smaller and less- Both to be pposed good, and to introduce gradually, and, as it pleases Weighed, rod, the remainder. It may be our duty to do this, as to lis matter. 5. Practically, it is of little avail to superintend, ever Practical ^ D carefully, the issue of extras to the sick, unless there ^^Ifc SeJond!" 5 permission and opportunity to pour the nourishment, erhaps in continual drops, down the throat of reluctant gony, or delirium, or stupor. And it is of httle avad to lave this permission, unless there be also that of raismg 16 NURSES IN HER MAJESTY'S HOSPITALS. Its real and great Difficulties. Condense numbers as much as possible. Only Head Nurses. Classify the Patients. the decent covering under which cholera, erysipelas, oii '0 the oppression of long recumbency, or the discharging 0 wound, or the recent operation lie, and seeing to matterij ;is within. It is a further question, whether the painftLj cr? cleansing of painful wounds, and the important minoi ; dressings, as poulticing, which things, generally speaking! fed never have been done, and never will be done by surgeons| are best left to nurses, orderlies, or the patients thai selves. 6. At the same time, nothing is more pernicious than^U to under-rate the objections of opponents. There is nc ml doubt that the admission of women to ward service is beset- m with difficulties. These Naval and Military Hospitals are.; Is and must ever be, peculiar Hospitals, essentially different 11, in important details from the Civil Hospitals. 1 ^ Sisters of Mercy, as regards the ward service, are deco-' i] rous and kind, and sometimes inefficient and prudish. | Nurses are careful, efficient, often decorous, and alwaysjie kind, sometimes drunken, sometimes unchaste. Misconduct of women is far more pernicious in a Mili-i ^ tary or Naval Hospital than in any other, as regards thei 1 result of things — the crime is, of course, equally crime u everywhere. 7. It appears to me desirable to simplify and condense, \ j as much as possible, female service in these Hospitals. Let there be as few women, and these few as efficient and , as respectable as can be. Let all that can really be done ] by men be so done. 1 : 8. Head-nurses are alone, I think, desirable to be , employed ; I mean persons of the character, responsi- 1 bility, and efficiency, of head-nurses in other Hospitals. 9. The patients should be distinctly classed, though, of course, this is not the Female Superintendent's busi- , ness. NUKSKS IN IIK.U >[A.7I<:sTY's HOSPITALS. 17 There are many pros and cons to the formation of oon- vescent wards. It is a question whether convalescent or chronic patients i piirc female nurses at all. Of such chronic cases, probably 100 would be efficiently svcd by one nurse, having orderlies under her. Of »ite cases, probably, one nurse shovild take charge of not f)re than fifty, possibly not more than forty. 10. The nurses should be strong, active women, of not I s til an thirty, nor, I think, more than sixty years of age, ( unblemished character, and should be irreversibly dis- i ssed for the first oftence of unchastity, drunkenness, ( dishonesty, or proved impropriety of any kind. i 1 . Their wages, I think, the same as those of head- irses in Civil Hospitals — certainly, not more. 12. Their pension on the same graduated scale. 1.'). Their rules should be simple, very definite, should \i\v them at the absolute disposal of the surgeon as to ^.rd matters, and at the absolute disposal of the Female {.perintendent in all other matters. Their dress should 1 uniform. 1 !. Their duties should be strictly defined, and be ( iMstent with the Code of Army Hospital Regulations, 1 ; revision of which has been announced. 15. Give them plenty to do, and great responsibiHty— 1 ) effectual means of steadying women. 16. The nurse's lodging in view of her ward renders Ir far more efficient; but this requires some special Jcangement. It would not do to have the chance of the i .rse's being suddenly taken ill, with only patients and ulerlies within immediate reach. AVere the nurses^ rooms : arranged that two or more were on one floor (as is the ( in all Hospitals), and so arranged as to be entirely rate, and yet, when so desired, easily accessible to each Qualitication of Nurses. Wages. Pensions. Duties. Means of Steadying them. Lodging. 18 NURSES IN HER MAJESTY^S HOSPITALS. other, which might easily be contrived, this would pro- ^ bably answer all purposes. Food. 17. Their food should be sent them cooked with some '■: slight variety. With the plainest intentions nature ofteni revolts from the perpetual joint of excellent meat in Hos-I pital air and life. The occasional " potage/' fish, &c., ol' other systems, are in fact, a refreshing and palatable ^ change. If, however, avoiding names that shock and frighten, some slight change of diet could be contrived, the effect would be good. This is practical and not at all ^ romantic, though it may look the latter, ^ 18. Could the honest opinions be had of a few good f> Military and Surgical Authorities before beginning, it * would be good. 19. The Female Superintendent- General^s own powers and responsibilities must be absolutely fixed, and so as not . to clash with those of the Officer (should such an Officer ^ be appointed, as has been elsewhere recommended), who . shall superintend the Hospital attendants. ; 20. Confidential reports must be so modified, as far as i women are concerned, that the humble boon granted to pickpockets, of being informed of accusations laid to their charge, must be extended to Her Majesty^s nurses. 21. In framing the system and the Superintendent's own office, let it be attempted to secure the permanent efficient working, please God, in ordinary hands. To aim at the best conceivable may lead to failure. Genius works with ordinary materials, but never constructs an edifice which it alone can inhabit. Quietness. 22. " In quietness and in confidence shall be your strength." Quietness has been from the beginning of its publicity the one thing wanting in this work. I know the fuss, which from its beginning surrounded it, was abhorrent to us and was the act of others : but the work, which is all ; Opinion of honest Military Authority desirable. Female Super- intendent- General. Confidential Reports. Permanency of the System. FRENCH AND SARDINIAN HOSPITAL SERVICE. 19 3 care for, has througliout suffered from it. It is equally jurious and impeding as regards surgeons, nurses, and 'ople, who are neither. External help in this coarse, pulsive, servile, noble work, for it is all these things, is uly the reed which pierced the hand that leant upon it. lie hospital, naval, military, or civil, nursed well, and ■adually training a few nurses, would do more good to ic cause than an endless amount of meetings, testimo- als, pounds, and speeches, to say nothing of newspaper iffings, which to-morrow might turn into revilings. This >\ er will, never can be a popular work. Few good ones V, for few are Avitliout the stern fructifying element of Loral restraint and influence ; and though the streams of lis are many, its source is one. Hearts are not touched ithout Religion. Religion was not given us from above in iipressions and generalities, but in habits of thought and J:tion, in love of God and of mankind, carried into action. A vcrv short comparison will here be made between the Various . Svstems of lethods of Female Nursing in the Military Hospitals of Female Nursing Russia, France, and ^'^^P^^^^* England, Sardinia, exemplified in the last War. To do this, a sketch must be partly repeated, which has ^^^^^^^^^^.^^^ (een already given, of the organic difference between the Hospital . Service, lospital Service of each nation. . The essential characteristic of the French is, the im- ortance given in the field to the Divisional Hospital ►lervice over the Regimental. The Regimental INIedical Service treats only those phemeral cases which are to be exempted from duty for \ day or two. Cases of wounds or disease likely to last or a term of weeks are sent to the Divisional Ambulance 20 FRENCH AND SARDINIAN FEMALE NURSES. English. Russian, Female Nurses. Sardinian and French Female Nurses. in the field; those^ where disease may possibly last for months^ to the General Hospitals at the base of opera- J tions. I J The Medical Service of the Sardinians closely resembles' the above in its formation. In the late War^ their General Ambulances were at Balaklava; their General Hospitals at Jeni Koi on the Bosphorus. They had no Divisional or Regimental Hospitals. In our Army, as is well known, the Regiment esta- blishes its Regimental Hospital wherever it goes. Theo- retically, it is exclusively a Regimental system of Plospitals ; how'ever much, practically, it breaks down. The Russian system can scarcely bear a comparison with ! ^ ours ; because their Regiments are Divisions. They had a regular system of transporting the sick and wounded ij upon the North side of Sebastopol, then upon ^lackenzie's ' Heights, then upon Bakschi- Serai, and lastly upon Sim-:: pheropol. i ] The adaptation of Female Nursing to the different ^ ^ systems in the French, ^ Sardinian, ii Russian, and ^ 'i English Armies has now to be noticed. The Sardinians had Sisters of Charity, both in the General Ambulances in the Crimea, and in the General Hospitals on the Bosphorus. i The principal duties of these admirable women appear ' to have been the care of the linen and small stores, and the cooking, much of which they did with their own hands, ? for sick officers and men. These duties were admirably , performed. They appeared, besides, to have a certain ; charge in the wards, the power of giving " douceurs/' the { administration of extras, the seeing to the cleanliness of FRENCH AND SARDINIAN FEMALE NURSES. 21 ids and patients, and something more precise with j^ard to sick Officers; but their duties seemed to be imewhat undefined in their relation to the Infirmiers. li ether the Soeur or the Infirmier Major were in charge, see the duties about the patient properly executed, IS rather a problem. This was still more the case in the French Hospitals, here the " Soeur" in the wards appeared more of a consolatrice'^ and an administratrix of extras : althousrh, it of the wards, her admirable housekeeping, both in the tchen and the linen- store, was predominant. The French ^' Soeurs" were not admitted to the Divi- onal Ambulances in the front : it was whispered, because ' the corruption of the French Intendance, upon whom icy tacitly exercised a very inconvenient " surveillance."'^ hry served in all the General Hospitals at Constan- inoplc; and to their admirable services, M. Baudens, lispecteur-General en Crimee, has rendered an eclatant wioignage^' in his " Mission Medicale en Orient," pub- slied in the numbers of the " Revue des Deux Mondes," f February 15, April 1, and June 1, 1857. In these French Hospitals of Constantinople, the Soeurs" appeared to do all the cooking for the sick Officers and that of the extras for the men. I I do not think that, in either French or Sardinian hospitals, the care of bed-sores and such like, which can '»nly be done by women, was sufficiently given to the Sceurs." I have heard complaints made of this kind both by Officers and men; and " Soeurs," both French and Sardi- lian, have been to me to look at the way in which we reated bed-sores, and to borrow air-pillows and water- 3eds. There is such a difference however in different Hospi- 22 RUSSIAN FEMALE NURSES. talsj in time of war and of peace, &c., that I would not bej . understood to mean that any of these remarks applyj irl absolutely or generally, but only to Hospitals I havei n seen. i jli It may be as well to mention that, talking of " FrencVl ilc and Sardinian" Sisters, they all come from one *• Maisonl I Mere,'' that of the Filles de la Charite de S. Vincentjiile de Paule,'' at Paris. There is a " Maison Succursale,"| t at Turin. But all are of the same Order, and under the* 11 same head. j]la Let me mention Soeur Cordero, the excellent Superioress I of all the Sisters employed in the Sardinian Hospitals U of the war, with the warmest affection and respect. She i ]e was a woman of high rank, of the most captivating Ii manners, but of the utmost simplicity of character, and i it of unfailing devotion to right and to God. ! j Russian. It remains to mention the Eussian system, which, as i i regards the organization of the duties of the " Sisters," ] i appeared to me by far the best I have known. I am at a l i] loss to conceive what is meant by the following sentence ' ( in the Report by two of our Army Medical Officers on \ ^ the "Russian Medical Department,'' presented to the House of Commons. Speaking of the Sisters of Mercy, ' ; who are generally widows of officers, it is said " their chief ] duties appeared to be in taking charge of the linen and , j superintending the issue of extras." This is founded on error of observation — as the Russian system seems to be the only perfectly organized system of female attendance in Military Hospitals, which was developed in the Crimean War. In it, the Sister has charge of all that relates to the bed-side of the patient ; she receives the orders from the Medical Officer, attends him in his rounds ; he confers with her afterwards ; she even reports the " felchers" or dressers, as also the orderlies, as far as regards their , ruorosED arrangements. 23 (!;charge of duties at the bed-side of the patient. The (tlerlies are, of course, under the control of a Non- (mmissioned Officer, in all that pertains to discipline, ( >thing, meals, &c. The felchers'^ are under a superior ' clcher,'^ and under the Medical Officers. There are female nurses, wives and widows of soldiers, 1 dcr the " Sisters," who are generally, as has been iitcd, widows of Officers. This appears the nearest approach to good organization 'liave met with. But again I say there may be much difference among c Russian Military Hospitals. I would not be con- krcd as laying down an absolute experience. ' It has been said elsewhere what was the system or no stem pursued in the English Military Hospitals, as to -iiiale Nursing. It was a new thing, and no General rdcr or Warrant was ever issued as to the duties of the u ses. Many duties clearly devolved upon the Female iiperintendent-General, as she was afterwards called in General Orders,'' which never should devolve upon her rain. But it mav be now clearly enunciated what the duties ^ Female Nurses should be, and many reasons will subse- loutly be given why there never will be discipline in ilitary Hospitals till they are as follow : Women only of the character, efficiency, and responsi- ihty of Head Nurses in other Hospitals should be admit- 3d into Military ones. They should have charge and be 3sponsible for all that pertains to the bed-side of the atient ; for his cleanliness, and that of his Hnen, bed, and tensils; for all the minor dressings, not performed by urgeons or Dressers; for the administration of medi> mes, and of the meals; for the obedience of the patient nd orderlies to the orders of the Medical Officer. They English. Proposed Duties of Female Nurses in Military Hospitals. I 24 PROPOSED DISTRIBUTION should be left to men. should receive the orders of the latter, and always attendl « him in his visits. 1 Till the above is done by women, the same want of dis-j | cipline, now to be observed in Military Hospitals, and] often already noticed, will continue, — such is my firmi belief, the result of much experience. i Duties which There will be abundance left for the Ward Master on Serjeant to do in taking Military charge of the Hospital and its inhabitants, in being Office Clerk, &c., i. e., keeping the Admission books, making States, Returns,' Accounts, and other documents, without his being Head- : Nurse, without his superintending the Orderlies at the - bed-side, his administering medicines, &c., which can only i be satisfactorily done by a woman. And, when done by her, there will still be ample work for two men, where one does now the work of three. i The first should do the Military part, the second should i compound, take charge of Medical and Surgical stores, of , Returns and Accounts connected with these ; and, where i there is no Purveyor, of Purveyor's and Barrack stores, provisions, cooking, washing, diets, and extras, inciuding Returns and Accounts connected with these. As it is, there is one Hospital Serjeant, who is Ward- Master, Serjeant, Steward, Clerk, Dispenser, Parvcyor's Clerk, and Head -Nurse — a kind of ^' Maitre Jacques," as in Moliere's Avare.^' One man cannot do all these things. A Pemale should be the Head-Nurse — a Serjeant should be the Serjeant and Clerk — a Ward-Master the Steward, Dispenser, Ward-Master, and Purveyor's Clerk. And here I must deplore the confusion unavoidable in these definitions of proposed duties, while we have no separate system for Regimental and General Hospitals. What Dr. Menzies declared, in his evidence as to the OF DUTIES. 25 cneral Hospitals at Scutari, is strictly true, and one -eat cause of our failure at Scutari " I have followed le general rules for Regimental Hospitals, so far as I )uld." While Regimental Hospitals are what they are, females ver can be admitted there. On the other hand, if cneral Hospitals be established, one liappy consequence ill be that the cooking and washing will be taken out of le hands of the Hospital Serjeant, and regularly orga- zcd, it is hoped under a Captain- Superintendent of 'rdcrlies. All Purveyor's and Barrack stores, that is, Tospital stores and furniture will, it is hoped, fall under 'le charge of a Steward; Medical and Surgical stores nder that of an Apothecary. It will only remain to place a female Head-Nurse in I large of all that concerns the bed-side of a patient, and le duties of the Orderlies about the bed-side, and a \ ard-Master in charge of everything else belonging to he Orderlies and Patients. (> But, if it should be determined to retain everywhere fate old Regimental system, it is only just to add this ^ ery strong testimony and appeal in favour of the old slospital Sergeant, who indeed deserves it: — - " I may take this opportunity of stating my conviction that, I 'om the very arduous, constant, and responsible duties of the ■'^ lospital Sergeant, and his influence for good or ill among the J on-commissioned officers and men of the regiment, it is parti- I'ularly required for the good of the service that he should be "i'ut at least on the same footing in rank and pay as a first-class BtafF sergeant. He ought to pass an examination by a Board of il'/Iedical Officers as to his fitness for compounding medicines on he same footing as a druggist in England. My Hospital Ser- I'.eant, who has been eight years a sergeant, three of which as 5 lospital Sergeant, receives at present Is. lOd. pay per diem, a^id .n allowance of 4^^. per diem as Hospital Orderly; at the same 26 RUSSIAN WAR-NURSES time that there are sergeants in the ranks of the regiment four years junior to him as a non-commissioned officer who are receiving 2s. lOd. pay per diem. " My experience leads me to consider that the regimental bandsmen are not, as a body, likely to be sufficiently strong or able men for the duty of carrying the wounded to be consigned to them. " Signed) Thomas Longmoee, " Surgeon Idth Begiment,^^ Note in Regard to the Russian Nurses Employed IN THE War-Hospitals of the Crimea. i The Russian nurses^ in the opinion of their Master, the i famous surgeon, Pirogoff, did other things besides what the Army Medical Director- General told the House of; Commons they did. But it is to be observed — In the first place, that much allowance is to be made for the confusion incident to Scotch and Russian surgeons talking French together, and going over many subjects in a very short time. And in the second, that very likely some extra confa- sion arose in the minds of our Army Medical Officers from the fact of two entirely different sets of women having served in the Russian War Hospitals, viz. : (1.) The Sisters of the Elevation of the Cross. (2.) The " Frauen des Barmherzigen Wittwen Instituts," (mentioned in a very cold manner in pages 4, 26, and implicitly, 27, of Professor Pirogoff^s pamphlet, Die Gemeinschaft der Schwestern zur Kreuz-erhohung. Ber- lin : 1856'^) ; who are those spoken of at pp. 22, 23, above. IN THE CRIMEA. 27 The Widows were so instituted, about forty years or ore ago, by IVIary of AVirtemberg, during so many years le venerated Eniprcss-:\Iotlier. It is quite possible tbat in le war-prcs^ure their serviees proved rather nondescript, ley being neither sisters nor nurses, strictly speaking ; or erhaps the sole reason why Professor PirogofF has not ne good word for them is, that they were not under his rders. The Sisters of the Elevation of the Cross were a body f secular women, witli a few Sisters of Mercy, formed by lie Grand Duchess Helena, and placed by her under the rders of the famous civilian Surgeon Pirogoff, to whom lie supreme surgical command in Sevastopol was virtually iven. Several things are incidentally mentioned con- eruing them in his pamphlet, quite inconsistent with the onstitution of an ordinary religious order. One or two things in the pamphlet are incongruous ;nough to English ideas : — the narrative given, however imply and succinctly, of the performances of the sisters by lamc, the publication of the Professor's evident disagree- nent with the first " Obcrin," or Superior, who served ten nonths, (the second, whom he so highly praises, had only ;erved two when he Avrote) ; the improvement, by which the Sisters' concerns were "sat upon" by the Comite of Iberin, Chaplain, Doctor, and elder Sisters, &c., &c. But the division of Professor Pirogojefs war-nurses into :hree categories is a pregnant hint for future service, please God we yield it. These three categories consisted of (1) the "Yerband-Schwestern," or those who assisted the Surgeon in the dressings, and the Eeld-scherer'' '(Dresser) in preparing them. (2) The " Apothekerinnen,'' or those who were in charge of all medical appliances for immediate use, and who superintended the " Feld-scherer'' (Dresser) in the administration of medicines. (3) The 28 RUSSIAN WAR NURSES. Wirthinnen/' who looked after the diets^ clean linen, &c., of the patients, and the order of the hospital. Each category" was responsible for carrying out the orders of the medical officers. To every Hospital-jBaroicA-e (hut) was attached one sister of each of the above descriptions. In ordinary service the less nurses know of each other's' wards the better — in war service it is essential that as few | women should serve as many sick as possible ; and it is ' impossible to attempt assigning to each nurse the entire I supervision of a ward. I think the categories, modified, of course, and adapted to the Queen's service, might be' most useful. Another point usefully proved by Professor Piiogoff's pamphlet is the extreme importance, if it be possible, of placing the nurses clearly under the orders of the Principal Medical Officer, though a further point is, if possible, toi be secured, viz., that of the Principal Medical Officer being favourable to their service. As women they should be entirely under the control of their female superior, yet the Principal Medical Officer should have a certain clear amount of power in ordering that Superior as to their, employment at particular stations and on particular ser- vices. The Transport Abtheilung of the Russian sisters seems to have been an admirable, though very unpretending service. We might take a useful hint from it. Three Sisters accompanied the more numerous* convoys of Sick Transport from Simpheropol to Perekop, and provided the sick with tea, sugar, clean linen, medical and surgical appliances, &c., on the way. * According to Professor PirogofF sick were almost daily sent from Sim- pheropol to Perekop. They could not, therefore, be always accompanied by Sisters. jE3ii)iARY Notes as to the Introduction of Female ! Nursing into Military Hospitals in Peace and in War. It is, perliaps, advisable first to speak of some of those ■ fficultics met witli in the War Hospitals of the East, in 'der tliat such may be prevented for others who may in iture be Superintendents- General of Nurses in Military hospitals whether in peace or in war. I. No one ought to undertake a matter of duty of this lind without first obtaining the consent of the AVar OfBce to ye conditions. 1. That every month, each of her sub-Superintendents shall irnisli her with an abstract of the requisitions made by her 1 11 le Purveyor, whetlier for Nurses' consumption, or for that Patients, and that she furnish the War Office with an )stract of these. It is then the part of the Purveyor to ■sprove her accounts, instead of its being, as before, her part I disprove his. 2. That it be made a point of honour, not of grace, with the /ar Department, to submit to her any Eeport, confidential* or 'herwise, made concerning the Female Nursing Staff; a con- tion, without which it would be impossible to have respect- )le women in the ]\Iilitary Service. I * As little reference as possible, no reference at all, if it can be avoided, ou]d be made, on our pai-t, to the Confidential Report, which, in 1855, IS presented against the War-Nurses. The less scandal about women is verted to the better -a truth all slanderers have always appreciated : iCalomnicz, calomnlez toujours : il en rcste toujours quelque chose." It mid be far preferable if Nurses could enter the Army Hospitals quietly, d let by gones be by-goncd (the useful expai'ience always excepted, which ^ been gained). 2 FIVE CONDITIONS ESSENTIAL TO THIS SERVICE. 3. That the powers of the Superintendent- General shall be strictly defined, and put in " G-eneral Orders" in the first place, I and not in the last, in order that there may not be the useless . and endless correspondence which there was in the first Super- intendent-G-eneral' s case (and for what ?). 4. That the Superintendent- General have the power of com- municating directly with the "War Department ; and that her Money- Accounts be sent in by her directly to that Depart- ment. 5. That it be made a point of honour that the Medical Officers communicate to the Superintendent- General, or Local Superintendent, any complaint they may have against the Nurses for disobedience. In March 1856 the following appeared in " General Orders." Had it but been seventeen months earlier how much it might have saved !* The definition of the Superintendent-General's powers and duties, therein contained, is all that is wanted to prev^ent irregularities disastrous to the Service. Geneeal Oedees. Ma/rch 1856. " It is notified, by order of the Secretary of State for War, that Miss Nightingale is recognized by Her Majesty's Government as the General Superintendent of the Female Nursing Establishment of the Military Hospitals of the Army. No lady, sister, or nurse is to be transmitted from one Hospital to another, or into any Hospital, without previous consultation with her. Her instructions, however, require her to have the approval of the Principal Medical Officer, in her exercise of the responsibility thus vested in her. * The work was done under many diflSculties, some inevitable, some which should have been spared. Things happened among us deeply to be regretted. Rebellion among some ladies and some nuns, and drunkenness among some nurses unhappily disgraced our body ; minor faults justified pro tanto the common opinion that the vanity, the gossip, and the insub- ordination (which none more despise than those who trade upon them) of women make them unfit for, and mischievous in the Service, however mate- rially useful they may be in it. Of all this, the material consequences might have been spared by some such " General Order " as the above, which, at least, prevents others from taking advantage and making capital of such faults. NURSES OP FOUR SORTS. 3 " The Principal IMedical Officer will communicate witli Miss iglitingale upon all subjects connectedwith the Female Nursing itablishment, and will give his directions through that lady." II. Nurses. 1. Our Nurses were of four sorts. Nuns. Ladies. Sisters (Anglican). Nurses. The Nuns were received not as Nuns, but as Nurses. Their (so called) training told sometimes against us ; some- mes for us. The same with the " Sisters" (Anglican). ; The Ladies were useful, exactly in proportion as they ap- mched the professional, and not the dilettante, mode of thought. A larger proportion of paid Nurses than of Ladies did ell, ajid this under circumstances of peculiar temptation. Paid urses are always the most useful. 2. There should always be a proportion of Nurses in Army (ospitals To preside in Extra Diet Kitchens,* „ in Linen Stores. To teach the Orderlies to nurse in the Wards. The proportion of Eoman Catholic " Soeurs," in French [ilitary Hospitals, is as small as this would be ; they under- ike even less duty than this : in Military Hospitals they do luch less than in Civil Hospitals. Women in Military Hospitals should all be contracted ser- pts, whether Nuns, Ladies, or professional Nurses. There should be a retiring pension to each woman. * The Extra Diet Kitchens must, it is necessary to state, be under a jparate roof from the General Kitchens, as long as the Present jstem (or 0-system) of cooking exists. But the sooner it is a tered the better. IL should be one kitchen only. But the T^urse should al-ys^^^^^^^^^^^ \d the administering of the Diets. She is ^^^^^^^f ^^^^o^^^ ^erson, also, to administer the medicines, &c. The Orderhes 0 be of any se, m^st act under the direction of the Head-Kurse and not -^^^^^^^^^^^ ently. It ^.'ould seem hardly necessary to enunciate such a self-evident ■roposition. ^ 2 4 QUALIFIED SUBORDINATION OF 3. Miss Nightingale took service on the ground of being |^ under the Principal Medical Officer, and, consequently, of not |j interfering with him. | There was no imperium in imperio in her case. This exists in the case of the Trench " Soeurs de Charite," , and existed in individual instances among the " Sisters" under Miss Nightingale ; i. e., they gave articles of diet, &c., as from j Sisters, not in obedience to Medical orders. This was imme- ■ diately put a stop to by her. That the Medical Officer is sole - master of diets, is an axiom of medicine, and of common sense. 1 This involved our only answering the Extra Diet Eolls in | our kitchens ; not originating either in quantity or quality. Afterwards, although frequent were the insinuations that we transgressed the above maxim, no evidence of the fact was ever obtained, except the following, which is given verbatim and literatim, as "put into Court" by a First Class Staff- Surgeon, in charge of one of the divisions of the Barrack Hospital, Scutari. He alleged " that the Nurses were in the habit of giving diets without leave and when pressed for the facts, produced the annexed statement in " W. J. North- cott's " handwriting. "2447. Pte. John M'Cormick, L. T. Corps, age twenty, 11 Com- pany, admitted into 6 Ward, F. Corridor. Admitted with Febris C. C, April 30th, 1856. On or about the 10th of May I was con- fined in the Garrison Cells, Scutari, for allowing food and drink to be brought to this Patient, by one of Miss Nightingale's Nurses ; and at the time it was brought I were on duty at the Vic- toria Barracks, Scutari, three-quarters of a mile from the Hospital, and never saw the Nurse, food, or drink that was administerd to the above-named Patient, and I never saw the doctor that ordered me to be confind. I was confind by order of ist Class Staff-Surgeon Preudergast. About two and a half hours after I were aquanted with the case. " (Signed) 173. W. J. Northcott, " A.W.M., M SC." III. 1. Lay cloA\Ti 1. In defining the office and duties of the Superintendent- distinctly the Qeiieral of Nurses, her direct communication with, and qualified communica- ' tit r i tion which is subordination to, the Director- General of the Army Medical to take place Department, and, abroad and in war, with and to the Principal UPERINTENDENT-GENERAL TO DIRECTOR-GENERAL. 5 ]^ dical Officer of the district, or equivalent, must be very between e: ctly defined. If the formation and government of a body of Q^^raf and ^ lien to serve in the Hospitals of the Army Medical Depart- Superin- D nt, and in these alone, is contemplated, the less the Director- GeneraTand tneral and the Superintendent- G-eneral have to do with each (in war 'and 0 er, in matters of detail, the better, and the less chance of abroad) . . • 1 J 11 .1 1 Principal 0 Usion. For very weighty moral and practical reasons, the Medical Officer 8^3 2:overnment of the women must belonsr to the Superinten- Supcrin- tendentr d it- General, and to the Matrons, whom she delegates, and General, and vo are themselves responsible and amenable to her. But it the qualified ?1 never ivorJc to introduce female service into the Army of the latter. Lspitals, and to leave the Director- Greneral of the Army 1 )dical Department, which, like everything else in the Army, is a I must be a hierarchy, no other power in connection with it, tm to write and encourage confidential reports against it. 1 ere ought to be a definition of the Superintendent-General's pition as regards him, and also, as regards the Principal Medi- c Officer of the district, abroad and in war. It is useless, and vuld be dangerous to evade this; it ought to be deliberately fi:tled, and distinctly stated. In the " General Orders" of larch 185G, the Superintendent-General's complete power or the women, and qualified subordination to the Principal "cdical Officer, are well and definitively expressed. It is impossible to appoint the w^ork of the Nurses without 1e concurrence of the Director- General. It does not do to ] t a woman into a great ward, or several smaller wards, of ion, with several orderlies, without clearly defining her posi- 1)n there. To put her under the orderlies would be to make ] r being there at all much worse than useless ;.but she cannot ] ^■e assigned to her the responsibility of the ward or wards, J d consequently, authority over both orderlies and patients, r.elf being responsible to the Surgeon and Matron, without •e concurrence of the Chief of the Army Medical Depart- ' Nor, without such concurrence, can the duties of the Nurses . assigned. At this moment there are extant two sets oi egulations-the old Army Hospital Regulations, and those 1855 made for the late Medical Staff Corps. In these .oulutions, both the former and the latter, every duty a urse can discharge is assigned to difterent men. Iho 5 QUALIFIED SUBORDINATION OF MATRON TO j responsibility of the ward, the administration of diets and! medicines, the application of poultices, fomentations, leeches,! enemas, and minor dressings, are all in so many words assigned ' as the duties of Assistant-Surgeons, of Hospital- Serjeants, and I Orderlies ; and of Assistant-Surgeons, of Ward-Masters and | Orderlies of the Medical Staff Corps. The Regulations ini general are being revised ; — so much the better. But the new i body of Orderlies, announced in the " Grazette" as the Hospital i Corps, will, of course, receive rules from the Director- Greneral ; i and if these things are not settled with him, there will be con- • tradictory rules in operation, which will most materially thwart j the working of the Female Service. j "We have ourselves experienced this, as to the administration of i medicines, which one Principal Medical Officer took away from i the Nurses, saying that it was the duty of the Assistant- i Surgeons, in which he was borne out by an existing Eegulation. ! And it would really seem as if this were the intention of the | said Begulation, for it is there laid down that the medicines are I to be administered twice-a-day, as if this were a property of ' medicine. j The existence of these Regulations proved also a great < stumbliug-block in the Castle Hospital, after the war-pressure i was over. \ IJnless the Director- General, and in war and abroad, the . Principal Medical Officer, are brought into regular communica- ' tion with the Superintendent- Greneral of Nurses, by the Rules, they will, at every inspection of Hospitals, revert to the pro- cedure of giving orders and makiug alterations, which in fact amount to reprimands on the Superintendent- General, and on her Matrons, through the medium of some Clerk or Orderly. There should be, therefore, a distinct channel of communication laid down between the Director- General, and in war and abroad, the Principal Medical Officer and the Superintendent- General of Nurses. 2 ^^^^ 2. Also, and in the same way, there should be distinct rules between for direct communication between the Principal Medical Officer M r^^T()fficer ^^^^ Hospital, and the Matron, and between the Staff (or and Matron, equivalent) Surgeons of the Hospital, and the Matron ; if not Staff-Surgcona also between these latter and the Nurses. Staff-Surgeons The constitution of a General Hospital is about to be orga- PRINCIPAL MEDICAL OFFICER. 7 lized in England. In tlie large War Hospitals there was he Principal Medical Officer, a Staff-Surgeon in charge of each division, then the Assistant-Surgeon, who answered to what, IS is now proposed, is called the Prescribing Medical Officer of he Wards. As regards the Matrons and Nurses, it must not )e proposed to ignore all but these Prescribing Medical Officers. Jertainly, it would never do to give the Superior Surgeons of be Hospital no say as to the nursing. In 999 cases out of 1,000, the Superior and older Surgeon is the one who under- stands and cares mucb the most about the men, and who, there- ore, in tbe long run, would more appreciate and be fairer to \Iatrons and Nurses who did their duty by them. The Supe- ior and older Surgeons too, in general, have far more correct ■deas of the importance of discipline in a ward, and of the ways )f maintaining it, than tbe Assistant-Surgeons. Moreover, as kr as one can judge on a mysterious subject, generally speaking, ;he older and Superior Surgeon is the bonester man. He must )e brought into direct communication with the Matron ; this jpill effect good, and prevent mischief. So also let the Staff- Surgeon of the Division, or equivalent, be placed in direct com- aiunication witli tbe Nurses of the wards of his Division ; this ^svill effect good and prevent mischief. If the Nurse is to trust jto receiving the orders of the Staff-Surgeon, through the medium bf the Assistant-Surgeon, she will often find herself in a false position. 3. Now, as to the introduction of Nurses into all G-eneral Hospitals — this gets rid of many difficulties, but at a fearful cost. For years to come, the difficulty will be not to extend the and Nurses, and the qualified subordination of the Matron and Nurses. 3. All the General Hospitals cannot be undertaken at tvork, but to serve sucb Hospitals as must be undertaken, with ^^ateriaUf The material has, in a great Head-nurses to be created.) Secretary of State should be made a-ware that the FemaleServico can only be introduced gradually. Director- General must have a voice in the respectable and efficient women. degree, to be created ; abundance of applications will be re- ceived— the prospect of a pension alone will do that — but the real choice will be very limited. In these MiUtary Hospitals sach Nurse must be a Head Nurse, and a trustworthy woman. Many a woman who will make a respectable and efficient Assistant-Nurse under tbe eye of a vigilant Head-Nurse, will not do at all when put in a military ward or wards, herself the only woman, and Head-Nurse over the Orderlies. As a body, itbe mass of Assistant-Nurses are too low in moral principle. 8 MATERIAL OF NURSES FOR MILITARY HOSPITALS introduction. Director- General and Superin- tendent- General differing, Secretary of State to decide. and too flighty in manner, to make any use of here. Supposing all the Head-Nurses of the great Civil Hospitals* offered them- selves, there are perhaps not many who could be recommended for a Military Hospital. Some, who are very highly to be thought of, would never bear transplanting into the res dv/ra et servitii novitas of the Army Hospitals. The class from which the Head-Nurses are mainly drawn, tradesmen's and servants* widows, &c., will volunteer in numbers, but, in the majority of cases, intending only to lead the idle life of many a London Head-Nurse — "mental, not manual labour" — "Superinten- dence"— i. e., standing by while the Orderlies do her work and their own. The material has to be created. The rarest powers can do nothing effective in this, in 3, 6, or 12 months. To lay a solid foundation will take the patient, anxious labour of years. To begin with one Hospital would have great advantages. Netley, if it is proceeded with, might be the one, though, in most respects, a Hospital in an ordinary vulgar seaport woidd be far preferable. Then let the work gradually be extended. It is much more to be feared that the line will be taken of forcing prematurely than of opposing its extension. If it is attempted to occupy all the General Hospitals at once, how is the gratuitous repetition to be avoided of the inevitable misfortune of Scutari, viz., that of beginning on a large scale, with a number of strangers ? It certainly should be left to the Director- G-eneral to regulate the introduction of Nurses into the G-eneral Hospitals — and there is far more reason to fear that * To all references which may here be made to Civil Hospitals I should wish to say, by way of preface : — 1. That I have always believed and I believe it more and more every day I live, that what is wrong in hospitals is to be patiently, laboriously, and, above all, quietly mended by efforts made from within them, if it pleases God to grant that blessing upon them without which all human efforts are vain, and not by accusations, investigations, and noise from without. 2. Also I have always believed, since I knew Hospitals at all, and I believe it more and more every day I live, that, with all their faults and shortcomings, which are easily learnt and more easily declaimed against, our great English hospitals are places in which more is done for the relief and cure of human misery, or, rather, of that large branch of it arising from disease, than in any other places in the world. Also that their faults are not essential to them, but that they may, by God's blessing on the patient endeavours of many years, be very much modified. HAS TO BE CREATED. 9 le, if unf^ivoiirablo to the change, will hurry, than obstruct such utroduction ; indeed it might be better to settle that matter )eforehand with the Secretary of State, letting the Director- 3reneral be apprised of it, viz., that time is required to effect he gradual introduction of the Female Service with which the Superintendent- General has been charged. To sum up. A rule must be introduced by which the Director-G-eneral is brought into communication with the Superintendent- General, and her qualified subordination to him listinctly expressed. Let the Principal Medical Officer in war ilso communicate directly with the Superintendent- General or :hc person performing her functions in the War-Hospitals, and her qualified subordination to him be distinctly expressed, Jhe same with each Principal Medical Officer of a Hospital, rind the Matron of that Hospital. No alteration in these Regulations can, of course, be made without the consent of the Secretary of State. In case the Director-General and Super- intendent-General finally differ as to any new arrangements, the matter should be referred to the Secretary of State. The Superintendent- General should issue special regulations for nurses, after conference with the Director- General, and under the sanction of the Secretary of State ; also, local regu- lations for the JMatrons with the consent of the Principal Medical Oflicer and sanction of the Governor of any General Hospital. If the ]\Iatron difier with the Principal Medical Officer, the decision should rest with the Governor of the Hospital. IV. As to some miscellaneous considerations, of no small import- ance— 1 1. It is necessary for a Superintendent- General to have l^Koman^ counted the cost, and to be prepared or not prepared to include Eoman Catholic Sisters among the Nurses. This will deprive her of some valuable women; of one (speaking for the pre- sent time,) who is invaluable ; of many decorous, not very useful women. The question is perhaps settled by the fact, that where you have the Eoman Catholic Sister, you cannot be secure from the Eoman Catholic Direction, with all its many strings, and machinery of opposition. Abroad the cause ot the 10 SISTERS — ROMAN-CATHOLIC AND ANGLICAN. Eoman Catholic Churcli is often the cause of religion ; and the i Eomish Priest serves both zealously at the same time, and with i a pure heart. In England, and in matters of England, the first ! aim of the Direction is too often to damage what is not Eoman, ! and the second to promote what is Christian. Upon the whole I must think Eoman- Catholic Sisters are better out of, than in, the Army Hospitals. It would be right to think well over how fer they could be entirely dispensed with, in the event of having soon to undertake a "War Service. In the event of a decision being made to dispense alto- gether with Eoman Sisters, it would be as well to be pre- pared (though we never can speculate on the tactics of the Eoman faction, and after what occurred during the Crimean war, it may think it better to take things quietly) for a battle, {not confined to the Army Medical Department,) for the pro- duction of an Inspector- General's letter assigning " reasons" for preferring Nuns to secular Nurses, and for the delivery of sundry opinions of similar purport, ranging from that line to the one taken in the paper emanating from the Army Medical Department, extolling the Eussian Nurses, "who were all Sisters of Mercy, and mostly widows of officers." 2. Anglican 2. The nature of the Service and Eules would, unless in war Sisters? service, perhaps exclude English "Sisters" from the Nurses. They supplied us with some valuable women in the last war, and their Lady-Superior behaved ever generously, loyally, and well towards us. The principle and detail of most sisterhoods render them unsuited for admixture with the secular element ; and the comfortable belief into which the good women (of both branches) practically, if not theoretically, settle, that secular women are too bad to be mended or influenced, unfortunately makes their usefulness among Nurses nearly null. It would never do to unsettle any of the Sisters ; but if it so happened that any voluntarily ofiered to serve as bona fide Nurses, some valuable individuals might thus be acquired ; but this should not at all be pressed. It would certainly remove a difficulty in declining Eoman Catholic Sisters, if the rule should be to decline also English Catholic Sisters, forming the Staft' entirely of secular women. 3. Whom is 3. In Civil Hospitals there are three distinct elements of POWER OF POLICE IN CIVIL HOSPITALS. 11 government. Pirst, the Civil Authority ; the chief being the the Nurse to treasurer, or the equivalent civilian, whose subordinate is called summon in liversely Steward, Superintendent, House Governor; second, disoTderliness he Physicians and Surgeons (duly represented, in case of Ward 1 Holidays or illness, by the Assistant Physicians or Surgeons), Apothecary and House Surgeon ; and third, the chief of the N'urses — the Matron. ; It requires of course temper, discretion, forbearance, and ■ortunate circumstances w^hich do not always happen, for these .luthorities not to spend a portion of their time in quarrelling with each other ; but the ruts are old and deep, and the wheels nove on, though they often stick. The Civil Authority is a 'veTj important element, especially when the chief is a man of tiudgment and firmness, who keeps himself paramount over all, imd does not delegate all to his suborduiate the Steward. The Steward and the Matron generally find their duties disposed to clash. In some Hospitals the rules are inexplicit in assigning power to the Matron over all the women. But this apart. The Steward represents and wields the police of the Hospital. He progresses through the wards, he perceives, or the Head Nurse reports to him, something disorderly. He rectifies it (or not, as the case and the man may be). She thus, over and above her [relation to the Matron, has to appeal to, and to account to, the Steward. This power of police and discipline, wielded by the Civil Authority of the Hospital, is of immense moment in regulating the good order of the Hospital; it acts in sundry important ways which need not be particularized. Now, in the case of Military Hospitals, there is one impor- tant simplification of the business, which need not be enlarged upon. All the patients are men. Put there are two thmgs which do not simplify the machinery of the Military Hospital The attendants, in the plan proposed, are not (and cannot be) all i Nurses, under the Matron ; nor all Orderlies, under an Officer ; there are Nurses under a Matron, and Orderlies under some Ofiicer; and there is no Civil element. The Doctors both pre- scribe, and hitherto have governed. An Officer orders flogging, &c.; but the Doctors practically both prescribe, and hitherto I have governed. And a Military Hospital must, and should ever 12 POWER OF POLICE AND DISCIPLINE remain, essentially different from a Civil Hospital ; both '■ different in discipline and detail, and altogether a rougher and | ruder place. It should never for a moment be forgotten that i the soldier is a very peculiar individual, old and stern as is his ' trade. A regiment, if one thinks into it, is a curious thing. I The Hospital which receives these men when ill and wounded, whether regimental or general, is, and ought to be, a place essentially different in many things from the great Civil Hospital. The moral standard of the patients of the | Military Hospital, their readiness to obey, their good feeling ! to each other, are strikingly higher than in the Civil Hospital ; j but the soldier is what, amidst all his faults, he has been made j by the habit and spirit of discipline, which has become an j instinct and a second nature, and which ennobles his own. Eel ax discipline, and in proportion as you do so, there remains j of the soldier a being with as much or more of the brute than ' the man. ' Discipline then being the pivot upon which the good order of all military things, Military Hospitals included, turns, it follows, that if you set down a few women (they should not be many) in a great Military Hospital, unless they can become effectually incorporated into the general spirit of discipline of the place, they will only injure themselves and the whole. As women, the more entirely they are under the government of the Matron, herself under the government of the Superin- tendent-Greneral, the better. As Ward Nurses, the more entirely they are under the orders of their Surgeons, the better; but they have not only to obey the Surgeons, they have to enforce the Surgeons' orders among the patients, and both for so doing, and for the cleanliness, &c., of the ward, they have to give orders to the Orderlies. In the case where a rule will work, by which, if the Nurse has to complain of an Orderly, she reports the same to the Matron, who lays the complaint before the chief of the Orderlies (whatever may be fixed upon as his name) ; well and good; but a more direct procedure will also be found necessary. Every firm and discreet woman (none other is fit for a male ward, least of all for a military ward), will avoid collisions, reports, and violent outbreaks in the ward as much as possible. IN MILITARY HOSPITALS. 13 But still, every now and then these things will happen, and though by all means to be avoided if possible, when tliey do come, they clear the ward-atmosphere like a storm, provided ithe discii)line be strict. Every now and then — and every ; experienced Head Nurse will tell the same story — some diso- bedience, slovenliness, truculence, or sly impudence, will arise in the ward, and she will find she cannot put it down alone. ; If she remain helplessly deprecating or scolding the men, her [ position becomes at once an unseemly and a dangerous one, as that of all contemned authority is. In such a case, in the Civil Hospital, the Head Nurse goes straight, according to the nature of the case, to the House Surgeon or to the Steward, unless the visiting hour be at hand, and she judges it best to refer to the Surgeon. Discretion is again here required, as in everything in Hospitals ; but between the Surgeon and the Steward, a firm, discreet Head Nurse will generally get the ringleader expelled, and two or three others, named or unnamed, .warned of a similar fiite. After this sort of explosion, the ward is quiet and orderly for months. The thing is seldom done, but the patients know it can be done at any time, and ' that it will be done, in such or such a contingency. } Now the soldier cannot be turned out of Hospital, and he i knows he cannot. It becomes the more important not to suffer i an hour's relaxation of discipline there. If, therefore, such an ; outbreak, either on the part of patients or orderlies, should I happen in a Military Hospital, the Nurse ought to be able to ' summon at once the proper authority and afterwards to report the whole to the Matron, but first to bring direct the proper authority into the ward. Whether it be the Captain of Order- lies or the Orderly Medical Officer, or, as in case of emergen- cies, is generally preferable, the Staff-Surgeon himself, she ought to have power at once to bring the proper authority nito the ' ward, to put down confusion and restore discipline at once, and . then afterwards to report to the Matron what has passed. It must never be forgotten, that in every Eegiment we must calculate upon there being two or three thorough scoundrels, five or six men who are not far off from being so, and an mde- : terminate number whom discipline saves from rankmg after i them. One year with another, characters no doubt as vile as 14 TO WHAT WARDS FEMALE SERVICE APPLICABLE. the worst that disgrace our gaols pass through the General \ Hospitals. j Another thing to be remembered is, that whatever classifica- i tion may be carried out, we may be certain beforehand that ' numbers of patients from a vile cause will be in the ordinary j surgical wards of every General Hospital in time of peace, i Very severe cases of this sort give heavy work, and little ; trouble. They suffer much generally, alike from disease and ! treatment ; are frightened, if not ashamed, about themselves ; I and are generally extra- submissive and quiet. These cases, ! however, generally would belong to the separated wards ; which i latter contain usually a large admixture of patients who suffer ! comparatively little, and who require to be dealt with with i unswerving firmness. For reasons somewhat too technical to \ write, it is to be hoped, upon the whole, that female service will | not be, at Jirst, at all events, extended to these wards. The I disgusting and comparatively painless secondary condition will, I fear, find its way into the ordinary surgical wards, as it does into the equivalent wards of every Civil Hospital. ! All these things would increase the mistake of laying any i bar between the Staff Surgeon and the Nurse. In all matters of discipline, generally speaking, the Staff Surgeon will give much more support than the Assistant Surgeon. A short definite rule should therefore be made, saying whom the Nurse is to summon in the event of disorderliness in the ward. \ One thing more. There is nothing more dangerous than to undervalue the objections of opponents. Let us give them their full weight, and while firmly holding our course, and trusting to God to guide it, draw useful cautions from the objections which we quietly and steadily confront. In the great Military Hospitals, of Eoman- Catholic countries, intelligent, well-behaved, Army Surgeons, while explaining everything with thorough business-like precision, if spoken to of the Paris Army Hospitals, before the recently introduced Soeurs de St. Vincent served there, and asked what they think upon the whole of the service of women in Array Hospitals — after a little hesitation, and being urged to speak plainly, will generally say that they prefer in Civil Hospitals the service PAY AND RATIONS. 15 )f ScDurs to those of hired nurses— but they deprecate dther Sisters or any women in Military Hospitals. 1. Because the presence of women, however virtuous and guarded, Tould excite passions and produce unfavourable results in many ■jases. 2. Because they were unnecessary, the Orderhes being efficient, faithful, kind, and sufficient. Of the second reason one can judge nothing by a walk ;hrough a hospital, as it does not always follow that what the naster says is enough is so — though this is one of the Hysterics it is good to know and not good to reveal. Of the irst there is no doubt. The question remains, striking ;he balance of good and evil — Do chaste, guarded, and 3fficient nurses on the whole contribute more to the economy )f human life, the order, cleanliness, and decency of a Military Hospital than they do harm ? Possibly the former effects are asual and general ; the latter exceptional and rare : after all, most soldiers are men and not beasts. But it is well and neces- sary to bear in mind both the existence of this danger, and the exaggerated fears many Army Surgeons conscientiously as well as unconscientiously have of it. I therefore very earnestly hope that the work will not be (encumbered, at first at all events, with the charge of the vene- real wards. And it is most important, for the favourable result of the anxious and difficult experiment about to be made, of (permanently introducing female service into Army Hospitals, that we should be quite clear of the convalescent patients, and should only attend patients severely HI or severely injured. , 4. Pat and Eations.— In the great Civil Hospitals the 4. lay ana Head-Nurses have, on an average, 50/. a-year, no board, an aUowance of fuel and light, and the use of one or two, generally unfurnished, rooms. The Assistant-Nurses, on an average, receive about 125. a-week, [£31 per annum] no board, lodging, with the use of some furniture, sometimes an allowance of fuel and light, apart from, the use of both in the wards. Both Guy's and St. Bartholomew's Hospitals now give par- tial board to the Assistant-Nurses, and St. Thomas's is about to adopt the same plan. . * • . 4. St. Mary's Hospital gives board to both Head and Assistant- Nurses. Rations. 16 KATIONS TO BE COMxMUTABLE In the last war Her Majesty's Nurses received, on an average, ISs. a-week, lodging and board, fuel, light, and partial! clothing — 18s. a-week is 46Z. 16s. yearly. Incorporated intoi a permanent Service, and with a pension, they ought not to receive the latter amount until after approved years of Service. It is certainly a different thing to undertake service in a Hospital in Smithfield or the Borough, and to undertake to go, at a moment's notice, to any part of the world. But the Army Service involves this ; and the pension it involves makes a reasonable equivalent for the additional wear and tear of climate, travel, &c. Going abroad is a regular part of the Service undertaken. Any artificial inducements should be avoided ; at the same time their condition should be made a comfortable one. Wages, say 20Z., rising to 501. a-year, rations, an allowance of fuel and light, and a small furnished room, would be enough, and not too much. To this should be added a fixed annual gift of a few strong articles of regulation dress ;* avoiding multipli- city, and securing the things being all good of their kind. Id the last war they had too many things, and some were rubbish. They ought to be well able to supply themselves with linen, shoes, &c., whether at home or when ordered abroad. The articles to be given annually should be three strong dark gowns, six strong aprons, six caps, six collars, one bonnet — and let the things be good — biennially or triennially, one summer and one winter cloak. In India, &c., this might be modified. Their r^oom should be furnished, because, in removing to and fro, it is better to release them from the cares and the pre- tences of furniture; also, because, instead of many gimcracks, you can thus furnish their rooms with a few comfortable, strong, plain things, presenting a certain military simplicity, which ought to pervade a Military Hospital. Their wages abroad should not be increased. Whether they serve at home or abroad concerns the Superintendent- General alone, and is no merit or title for additional advantages on their part. * In their regulation dress they should always appear, except when they go on holidays. But let the Queen pay for the transport of one box and one bag only, for each Nurse on duty ; and if she takes more let her pay for it herself. FOR MESS-MONEY. 17 If the principle of rations is considered preferable by the Shall Rations War Department, it is important to give no extra trouble that ^<^^ommutabIe can be helped. If not, it is to be considered whether or not moaey in the it would be well to get rid of the rations, in the three king- United doms at all events, for these reasons : Kingdom ? (1.) Tliese women are Head-^^uraes. They will think (i.^ Because themselves more comfortable "finding themselves" than such managing on the substantial and somewhat unvarying provi- allov^'greater sions of the rations. Some take coffee rather than tea ; some variety, tea rather than coffee ; many would rather pay for white sugar than not pay for brown. Considering the nature of nursing- vs-ork, when faitlifully done, it is better they should enjoy and be refreshed by simple meals to their taste than by unpalatable larger portions ; especially if tlie former can he done at no addi- 'ional cost or trouble to tlic Queen. (2.) You thus relieve the Superintendent and Matrons of (2.) Because it all communication with the department of the Purveyor- ^^^^'^^V General ; of all the mistakes, accidental or otherwise, which might occur ; of all complaints of quantity or quality of pro- \ isions ; of amenities such as those experienced at Balaclava General Hospital, &c., &c., &c. Of five London Hospitals, the three endowed Hospitals pay all their Head-Nurses in money, and give no board. (This is strictly correct, although, to avoid a long unimportant detail, I have simplified things in this paragraph, and in the two concern- ing the pay of Head- Nurses and Nurses.) The London Hospital gives its Ilead-Nurses wages, and a fixed quarterly payment vice the rations of bread, meat, and vegetables, to which they are .V the rules entitled. This change was made not very long igo, to end the frequent complaints of quantity, quality, and price, made, perhaps with foundation, by the Nurses. The Westminster Hospital paid its Head-Nurses partly m money partly in rations of cooked provisions, and there were repeated and general complaints of the quality, quantity, and cookmg of the provisions issued to them. It is therefore to be considered whether the simpler and better plan be not to give the Nurses a fixed money payment and let them " find themselves," unless rte War Department obiect to rations not being issued in part payment. Abroad in many cases, in war in all cases, rations would be 18 THREE WAYS OF MANAGING COOKING. desirable. A fixed calculation as to expense should be made. Experience and consideration will probably give rise to the i following conclusion — except in war and in retired stations : abroad, not to have Eations ; still less to let the Nurses i " find themselves, " for the following reasons : — (1.) It j is important that the Nurses should not have this excuse for | being absent from their duties — " that they have been to get j provisions." (When absent, it should be in pursuit of health j and exercise.) (2.) If the Nurse is to cook for herself, greater , accommodation will be required than the one room recom- mended, otherwise the necessary cleanliness cannot be observed. To commute the Hations for mess -money, to put this mess- money in charge of the Matron, wherever there is a market ; wherever there is none, to let her " draw^^ for such provisions on her own indent, as she thinks best, upon the Purveyor, ap- pears to me the safest course. Eor with regard to this question of dieting the Nurses it should never be forgotten that, in all cases (how much more in those where great physical fatigue and mental anxiety are involved) that principle is the best, if such can be established, which settles diet with a view to pro- ducing the highest physical efficiency. Yariety and mode of cooking are two essential elements in this. And there can be no doubt that, if a Matron will take the trouble to consult the tastes of her Nurses, together with the above conditions, a better diet might be laid down than could be secured by leav- ing them solely to their unassisted vagaries and ignorance of what is really the best diet. Community of cooking also im- plies economy. Also the Nurse ought not to be permitted to starve herself, to save money. Her time is too valuable to allow of her cooking her own dinner ; but she should always prepare her own breakfast and tea, when and of what she pre- fers herself, if she feels inclined to do so. Knot Where, however, the system of rations must be adopted, commutable, three ways remain of working it : — (1.) Shall the (1.) Let each Nurse receive, and cook her own rations. Nurse cook her own Rations 1 (2.) Shall the (2.) Let the rations be delivered en masse to the Matron, ^and send^ who has them cooked, sending her proportion to each Nurse, them? R/VTIONS TO BE DRAWN " EN MASSE." 19 (3.) Let the Matron, requiring a small payment to cover (3.) Shall the 3xpenses, arrange that each Nurse can receive her dinner ^^^^^^ 30oked as she wishes it. There is something of this sort at the Dinner cYoked London Hospital; where the Nurses (and Assistant Nurses) fo^; ber, as she have the right of sending their joint to be boiled or baked in ^ ' one of the kitchen stoves. Of these different waj^s, the first would be hked best by the svomen — a thing to be considered, in subordination, and as a 'belp to their respectability and their efficiency — still it is, :br some reasons stated above, objectionable. However, n this, as in far more important things, it is essential to consider everything as tentative and experimental for some years to come. Do not be fettered by too many rules at first : l;ry different things, and see which answers best. With regard to rations, it is as well to explain that there were two ways of drawing them for the nurses during the war. In some of the Crimean Hospitals, it was arranged that the same ration should be drawn for a Nurse as that appointed by Regulation for a Medical Staff Orderly. This answered, as may be supposed, exceedingly ill. There was considerably more of some articles, such as bread and meat, than the women could eat ; and the surplus had to be wasted or returned to the Pur- veyor a serious complication. Of some articles, such as tea and sugar, there was as much too little ; and these had to ^be drawn as extras, except such as the Superintendent-General found it easier and more simple, as she generally did, to provide herself. The other method was for the Local Superintendent to draw daily on the Purveyor for such articles as she judged necessary ; and by thus drawing en masse, a considerable saving was, ot course, eftected for the Queen, the tastes and health of women were consulted, and there was no complication of accounts. Where rations are to be drawn at all the latter method should be always followed ; and as the former might be understood by the word " rations," it would be better to call them by some other name, as it must be obvious that such a method could never answer for women. The experiment which I should wish to try, by which greater variety eould be secured, but which could only be practised where there was a market at hand, would be for a commu- B 2 20 NURSE TO CLEAN BUT NOT SCOUR tation to be made of rations for money. Each nurse to supply her quota of " mess money," the " mess money" to be alli expended on the " mess," and the Matron to manage the " mess" day by day, and arrange for the cooking to be done in common. If each nurse's dinner is to be cooked separately, it necessarily, entails great waste of nourishment. The Nurses would not like this so well as " finding themselves," but it would ensure them a far better diet.* Wages and It would be a question whether the Queen should pay the > ^^^m 'ithe^ Superintendent- General so much for each Nurse's wages, andi ■ distinct. SO much for board, the latter to be retained by the Super- intendent-General, or whether the Superintendent-General or each Matron, with the Superintendent - General's consent, should arrange with the Nurses. This is important, as which , ever way it is settled, there must not be disputes between Matron, Nurses, or still less Superintendent- General, as to what amount of wages is to be allotted to the board, or what savings can be effected in the coals, &c. i On the whole it would seem best for the Nurse's pay to j be so much in money for herself, and so much in money for food into the Superintendent-General's hands. But the ques- , tion of how much is a serious business. 5. Washing, 5. Washii^g. — Except in war-emergencies, this must not be donr^^^Rule ^^^"^^^^ ^^^^ V Nurses, they must be compelled to to compel the put it out. I would not trouble the Authorities about this ; "^"7«^oM? Nurses can afford it, and the more things are simplified the better. In out-of-the-way districts, the Matron might arrange with a laundress, the Nurses making a fair payment. In war-emergencies, if possible, provide a strong washerwoman, but this woiild have to be settled each case on its merits. Except in emergencies they must not wash ; it takes up far too much time ; it takes up strength which is wanted for other * I would allow each Nurse 1^ pint of porter or ale 2^er diem, or, instead of the half-pint of porter, 1 oz. of brandy or a wineglass-full of wine, as she likes best. Most Nurses crave, and rightly, for a luncheon about 9 or 10 A.M., and drink some beer then. I would let them take their own time as to when they drink their day's allowance. But, while trying to suit each Nurse's varying tastes (and in Hospital duty the taste does vary) each Nurse must keep to one thing, say for a week or month. HER OWN ROOM. 21 things ; and washing and drying either in wards or nurses' rooms is unhealthy and objectionable. There must be a rule as to this : some worthy souls would scrub at every rag, rather than pay a few pence weekly. The Nurse ought, however, to be compelled to have certain changes of linen weekly, which some will not, if they pay for it themselves. 6. Cleaning their own rooms.— I well foresee sundry difficulties in the little rooms at the entrance of their wards, where I hope it will be managed to quarter the Nurses. But there is no other way of fairly and really working a ward ; and I trust this plan will receive a fair trial. For efficiency, also for comfort, it is most objectionable to make the Nurse sleep at a distance from the patients. This is one of the points on which theories, and the practical working of things, are very divergent. It is an excellent thing when the Head-Nurse's room opens into the ward and when part of the upper part is of glass, with a thick curtain, so that she can see into the ward, without being seen. Let each Ilead-Nurse have a small room, with a window opening into external air, with a curtain making an alcove, belli nd which there should be a small iron bedstead, with good bedding, and a washing table ; and in the foreground a table, a small one for meals, a chest of drawers, and a comfortable arm-chair, two chairs, and I should add a sofa. Each room should have a few shelves on the wall, and a large cupboard or small, closet with broad shelves, and space at the bottom to stowaway the Nurse's box. Simplification and avoiding all trouble which can be spared to the Departments are very important. I would not therefore insist upon a little kitchen for the Nurses, nor upon a very capital arrangement in some of the Sisters rooms in Guy's Hospital, where, behind a decent little door in the sitting-room, there is a sink, with water laid on, a little safe for meat, &c., at top, and a complete little apparatus of the very few utensils required for cooking one woman's meals ; so that a Nurse can cook and wash-up, in her own room, without carrying things out of it. This is much better than a kitchen, if the Nurse is to cook her own meals ; but, as above stated, I would rather she did not. One room, with a curtain making an alcove, is much better than two. The Queen is saved fuel; the Nurse is saved cleaning two rooms ; and if fuel is only issued for one, she sleeps in a warm room, instead of one where there never is a hre, 6. Cleaning their own Eooms. No Orderly, on any pretence, must enter a Nurse's Room Scrubbing the only thing the Matron may arrange for a Soldier's Wife to do. Nurse must do nothing of her own in "Ward, or Ward- kitchen, or Orderlies' Kitchen. 112 NURSE TO KEEP KEYS OF CLOSET and where her things get damp and spoiled. Often, where Head-i nurses have two rooms, one is built without a fire-place. Con- dense and simplify all things — one great object is to form a body of useful hard-working women, of simple self-helping habits. Two Nurses' rooms should be together, but separate. Sudden illness might occur, and the two women should be at each other's summons. The Quartermaster- General wws^ grant a cabinet between the two : this is must, not mai/. The Super- intendent-General must see to this herself, at first at all events:' there is a singular obtuseness in the small officials, by whom these things are managed : if not overlooked, they will be sure to put the construction in a particularly awkward, exposed place. These things do enter into an Englishwoman's daily comfort or misery — it is worth arranging them decently in the first instance. Now as to the cleaning of these rooms. Head Nurses; generally are far too much disposed to make servants of their nurses ; put orderlies for nurses, and this objectionable ten- dency would be a hundred-fold more objectionable. The Matron must make it an absolute rule, that the only thing an orderly ; does for a nurse is to carry her box in and out on the two grand i occasions of her entering and leaving the Hospital. The one thing which in a Civil Hospital, an Assistant Nurse should be allowed to do for the Head Nurse, is the cleaning her fire-place, : a thing done in a few minutes, and with satisfaction, by women who have done it all their lives ; but a dirty tedious messing business to those who have not. But never mind : the orderly ' must never enter the Nurse's room : she must do it, and learn to do it. The prosaic little business of black-lead, ashes, and mess lying on the threshold of the work will do good rather than harm. And even black-lead is unnecessary, as a varnish now obtainable looks better. The orderly must never enter the j Nurse's room — a sine qua non. The Nurses should have, at their choice, a carpet, not nailed down, or none. In either case the room will require scrubbing, once a week if no carpet, (which is best and cleanest in Hospital life), seldomer, if carpet. Now the Nurses should not be required to scrub their own rooms • — it is useless waste of strength — it makes their hands coarse and hard, and less able to attend to the delicate manipulation which they may be called upon to execute — and with all the IN WARDS. 23 ming proper which ought to fall upon them, and not upon le orderlies, their time can be better occupied than in clean- their own rooms. Also, while trying to keep clear, on the le hand, of the tribe of "fine ladies," it will be possible, on le other, if such menial offices are to be performed, to fall into iie opposite mistake and to fail in obtaining the class of women desirable to fill such important trusts. Let the Matron consent to a cliarwoman, soldier's wife, or some one person named and defined, and found, to be paid by the Head Nurse, to come for the two hours, whicli, at furthest, this business will take. It would be well worth while for the Matron to look out and provide two or three strong women to do this, by fixed rotation — each Nurse making a fair payment — and to ascertain that they are in and out of the Hospital by a particular hour, so as to prevent these external persons doing other things than scrubbing. But do not trouble the Departments as to this — the more things are simplified, aiul the fewer expenses are in connection with the Nurses, by far the better. Take the trouble to see that a tidy useful fire-place is in each Nurse's one room. Some fire-places will consume thrice the fuel of one which can do ten times more work. A compact useful little fire-place, to burn as little fuel, and do as much business (in a very small way) as possible, is a thing of daily use, economy, and comfort. The nurse should not do anything of her own in the ward, or the ward or orderlies' scullery, if there is such a place. This is a matter requiring some decision. 7. Let there be in each ward a closet, or, better still, a 7. in each dresser,* with broad shelves, and a large table with large drawers, of which closet or dresser, and drawers, the shelves,' Table nurse has the sole keys. Let the articles of linen which wUh D^rawe^r^^ are kept in the ward be there; also the bandages, lint, \gyg old linen, oilsilk, ointments, &c., &c., which should always be, Nothing to be 1 ji • ^ -u A kept in -Nurses some at hand, some in reserve; also the wme and brandy ^^^^ ^j^^^^ ordered for the men. Let the nurse never be allowed to deposit Dressings Stimulants to * Better than a closet is a moveable dresser, only table-height, under ^^^^^^'(^losets. which cleaning can be carried on. There Bhould be no projections in a ward or recess, which are only lodgments for Hue and dust. The walls of a ward should be even, polished, impcrvioufl. 24 PAY AND DRESS Hospital property in her room, which, if there is no place for it, she must do, and it is much better she should not. ' I ^20or*^er^ 8. "With regard to the Matrons, though as Locke says of annum^ tutors, there are all kinds of persons to be found, it is certain Quarters, and the right persons are not always found ; and these officers will ; A woman for outset especially. Let them be (if it the Linen, be possible) of the middle class ; if it be possible, middle aged, ^^paid^as^a^ active women, widows of officers or army surgeons. A vast ' Kurse, but deal of struggle is ever going on in professional life ; a vast ; never entering silent, decorous misery ever follows on the premature i the wards. j i i n i i • i deaths, the compelled early retirements, the sundry chances and changes which ever abound m the army of England. So far as it goes, and cceteris paribus, it would be right, just, i and expedient to give a preference for these matronships to widows of officers and army surgeons. Try to secure thorough principle, sense, activity, and steady discreet ways ; never mind a little vulgarity of manner ; that the different orders should have their indefinable perpetual distinctions of manner as of other things, is perhaps for a long time to come in the essence of things. Two or three women of the stamp of the Matrons of a few of our Civil Hospitals would be very valuable. If the Matron do not get tired of what, unless one keeps one's i secret thoughts fixed on the meaning and the end of all things, I is coarse, thankless, up-hill work enough — she will in the course of years accomplish great good. But she must have principle, sense, heart, and a firm cheerful mind. She must be not under thirty and, if possible, not over forty, on appoint- ment. Should her being without children be made a sine qua non? Children — poor little things — are wanted no- where in the way of business, but do not be too strict about this : they are sometimes pledges to other things than fortune — thoughts, anxieties, and labours for them, concentrate and steady a mothers heart — there will be fewer adventurers. Maternal nurses must upon the whole be discouraged, because upon the whole the disadvantages seem to overweigh the advantages.* But the Matron's office and duties are dif- * With regard to children we might look forward to a time when a school might be formed for the children, if any, of such of Her Majesty's Nurses as are widows. This would be an additional bond to the Service OF MATRONS. 25 fereut; she is not fixed to a great ward of patients; and her having children should not be a bar, especially if they did not live with her. Young and grown-up daughters are much in a INIatron's way ; sons matter much less. The greatest Civil Hospital gives its Matron 200?. and a louse, the other great Hospitals, 150Z., and a liouse. The London Hospital jiives 150/., and a couple of good well-furnished rooms, and a servant. A house is an impediment to a Matron's duty. She is seen arriving in the wards, and she is more or less liindcred in entering them. From her rooms she issues and re-issues, unexpectedly, and much more efficiently. 2001. and quarters is not at all too much. Tlio ^Fatron must be responsible for the storing, mending, and distribution of the linen, and for returning to the laundry any linen not properly washed or dried. Linen ought never to be dried in the wards, a process both inconvenient and unwholesome. The Matron ought to liave a stead} , respectable woman, certainly not belov,' the rank and pay of a nurse, to be responsible to, and under her, for the linen, otiierwisethe propercare of the linen will take up far too much of her time. This is important. If, however, a Nurse should be thus set aside for the Laundry, she must not be allowed to enter the wards ; otherwise she will uncon- sciously become a gossip and mischief-maker. I Avould term her " Linen Nurse," not Assistant. The Matron should also have a steady, ])roperly paid servant. A Matron of the proper sort has quite other things to do at a leisure moment, than to keep her wardrobe in order. She must have a servant ; but it seems to be advisable to simplify things, and condense payments as much as possible ; and I would ratlier consider this in the salary, and let the Matron find and pay her own servant. Try to have the servant's room near the Matron's. These minutiae, once provided for, enter much into tlie daily working and comfort of things. The dress of tlie Matrons is a difficult thing to settle. Some- times a Matron is afflicted with a taste for either gorgeous or for the mothers. The children, of course, are not to be admitted into Hospital; and strict rules must be made (and kept to) as to when the mother should visit them. I do not anticipate that it would be possible ever to have married women in the Service. And it is hardly necessary to add, that no women but of unblemished character can ever be admitted. 26 PAY AND DRESS OF MATRONS. i elegant apparel, which the Nurses are invariably proud of, admire i and humbly emulate. This sort of thing would be really out of | place in a Military Hospital, and would moreover sadly discom- i pose the Nurses with their plain caps and gowns. How would it be to allow the Matrons the choice between a Eegulation i dress and a plain black or brown silk gown ? j It will take much thought to decide whether the Matrons ! should all be paid alike, or whether climate and size of Hospital • enter into this. On the one hand they undertake a service, i of which almost the first regulation very properly is, that they undertake to go to all parts of the world as soon as sent ; on ' the other hand, certainly some climates wear health and life ■ much quicker than at home. The Matrons out of the three kingdoms have increased | responsibility, and can do more mischief, if incompetent or ; untrustworthy. If the Matron has increased pay abroad, it would not do not to augment that of the Nurses. This is an important matter ; and as it is on aU accounts necessary that Matrons ' and Nurses should on their engagement thoroughly understand j the nature of the service they undertake and, of course, a ' serious part of the service is that it involves sudden and long removals, it would be necessary to define upon what terms they go abroad. Tet it never would do, for reasons which will readily be perceived, to make the foreign stations objects of desire to Matrons and Nurses. These stations will always be so far the most anxious, that they will always be the most removed from the Superintendent- General's inspection and immediate rectification of anything that goes wrong. They will also be, in various ways, the most trying to Nurses. The rules once settled, every Matron and Nurse refusing to go abroad when ordered, ought at once to be discharged, and to forfeit all re-admittance into the service and all pensions. On the whole, I think the Matrons should all be paid alike. But inasmuch as foreign service necessitates more wear and tear to the constitution, one year should count as equal to two years of service for pension, in case of disability. The same should be made applicable to the Nurses. As the advantage is distant, it would, in a great measure, do away with any desire for foreign service. VOLUNTEERING FOR FOREIGN SERVICE. 27 Volunteering for foreign or war-service must be the ex ption-careful selection the rule. The "adventurers" will be generally ready to volunteer, and it would be too much to hope that we shall always, perhaps ever, be entirely free from that tribe; the most we can hope is soon to discover and get rid oi them. Foreign stations will never do for an untried .Matron or Nurse. At the same time it is most desirable not ito change the Executive officers of any Hospital more than can be avoided. ( But let there not be too many rules at first ; see how things work, and take one step at a time. The selection of exclusively middle-class Matrons seems to be important.* Their order will disarm one source of oppo- • sitioii and jealousy ; plenty more w^ill remain, inseparable from the work ; but it is good to get this out of the way. The name of Matron is the same as in Civil Hospitals. In many respects the office and duties are different: e.g., the Matron in Military Hospitals must exercise afar more constant supervision in the wards. But this will require great discretion on her part. It is the practice of most Civil Hospitals - for the Matron never to enter the wards till the Nurse's dressings are over. It would be advantageous to modify this. • But, at the same time, the Matron must understand Hospital J Nursing, or she may make very serious mistakes in either : reprimanding or directing the Nurse as to technical matters. ' She must be a person who knows herself what she has to see that others know; or she will get herself, with or without the Nurse, into very injurious errors. There is much in a name ; and, in some respects, that of Superintendent would better denote her office, as regards the Nurses, would add to her authority, which is desirable, and would point her out as acting under the Superintendent-G-eneral. Incorporate among the Nurses whatever women of the higher orders may be admitted into the Service at first. If inefficient and unfit they are far better altogether eliminated. If thoroughly efficient as Ward Nurses, if thoroughly obedient and respectful to the Matron, if they have sense and heart to * Should a woman, however, out of the higher orders, be found as effi- cient a.s one of the mid.lle classes, as Matron, this should be no reason for excludins: her. 28 UNPAID NURSES. gradually leaven, not coldly withdraw from occasional compa- ' nionship with the other Nurses, they will, in the course ofi'^ time, effect quietly a great deal of good. 1' There should be some "Rule of this kind — I ^ Any Matron or Nurse who may receive permission to serve' Her Majesty without pay shall be, in all respects, bound by and ^ amenable to the Regulations on pain of dismissal from the ser-i ^ vice, without permission of re-entering it. ' If this cannot be done, money can easily be returned in one > ^ shape or other; but it would have a good moral effect on the Nurses to allow of the admixture of unpaid Nurses, pro- i ' vided they are strictly bound by the same Regulations, and distinguished by no sort of peculiar designation. The Surgeons will dislike these unpaid Nurses ; but, in the long run a firm, discreet woman, wJio is an efficient Nurse, can get on i with any Surgeon ivJio has his sick at heart. The Matron also will not at all like them, at first, but will find that she can rely upon ; them and that they quietly and effectually help her with the other i Nurses : and, if she has her heart in her work, she will end by f being just, though, perhaps, always a little extra strict with and jealous of them. The other Nurses will have, at the first, i a strong little touch of republicanism towards them, which -will J gradually wear off, and, with God's help, a higher and truer i moral tone, and a simpler and more useful kind of habits among them will prevail, than would otherwise be the case. ; As for the patients, with all their faults, trust them — trust the English soldier, and the peasantry from which he springs. What these poor fellows are we know, and need not discuss. They are worth suffering a good deal for ; please God in the long run good will be done. If only we can keep clear of the false, pernicious, and derogatory system of puffery and fuss which others, for their own purposes, and from vague, silly good-feel- ing have wound around this work — a work essentially unpo- pular the moment we come to details ! We have learnt what reality is and what its presence or absence in this business imports. As for the many and great other difficulties of the work, they must be appreciated, they need not be dreaded. The purpose is a good and noble one, and God grant it success ! All we have to do is, to do our utmost, and leave the event to Him. VARIOUS RULES AS TO NURSES. 29 9. As for the Nurses the material must be formed. If 9. Nurses- few respectable soldiers' widows, including, and all the hegin with few etter, non-coniniissioned officers' widows, could be found it' ris paribus, a preference should be given to widows if the Service. Except in emergencies Nurses should not be taken under lirty, or above forty* years of age. These women are Head uirses. Most of the Civil Hospitals take no Head Nurse fter forty. < h\e caution in engaging Nurses is perhaps not sufficiently llriided to. Certificates, without personal inquiry and answers ) distinct questions, are not worth the paper on which they i\' written. As to engaging any Nurses out of the great Hospitals, for umlry reasons, this should be done as little as may be. Lot us begin, for the sake of God and this His work, with • A women. Extension is easy — to occupy too much ground 1 lirst would be, I do in my conscience believe, an irretrievable li-lake. \t) unnecessary Nurses should be suffered in Hospital; and Xurse in charge of wards should be required to do needle- , i l k for the Hospital. There should be no superfluous hands ; imI the less a Nurse enters another's ward the better, hi case of suspension of a Nurse for misconduct, temporary : stance must, however, be obtained; and this might be either , .inting anotlier Nurse, to do, for the time, such duty in the uspended ward as she could do in addition to her own, or lit ting in a temporary substitute. All such di8h)cati()n of the Service, necessary and useful for mergencies and holidays, should, nevertheless, be made to ilvo place as seldom as may be. No Nurse, during her suspension, should be aUowed to enter nv ward of the hospital. Any Nurse asking or accepting a present, whether in money * If it be desired to include some War-Nurses after 40 it would be etter for the Superintendent-General, with the sanction of the Secretary Nate, to take, at first starting, a few past the age. than on their .unt, to alter the age. It stands to reason that., on the formation of he approved Nurses of the War-Service should be included in it, for ike of the Service, I 30 PRAYERS TO BE READ BY NURSE. or in kind, from any patient, or friend of any patient, whetlier | during his illness or after his death, recovery, or departure,! must be at once suspended from duty, her pay immediately ! cease, and the Superintendent-General be apprised of it, who, I if satisfied of the truth of the charge, should immediately' dismiss her. j Two hours daily for exercise or recreation should be allotted | to the Nurses, during which two hours they are to be consi- j dered relieved of the responsibility of their wards. But I would ; not be too absolute in requiring them to go out : sometimes to lie down or sit still for an hour or two will do more good than ' a walk. Give them two hours for optional exercise. Head- ' Nurses cannot have more of fixed leisure. They must get time for private occupation as they can : very often not at all ; ] and no Nurse fit for her place will, of course, in emergent | states of her ward, leave it. Also the Matron must not worry herself or them, if an anxious Nurse sits up part of a night or a whole night with bad cases. ' To a certain degree the Matron will find it better to allow a * little liberty and choice, in the matter of times and hours, j (always excepting after proper hours, i. e., after dark) to ' the Nurses, who are Head-Nurses, than to attempt making ' them mere machines. An uniform system, as far as possible, and a little range to each, will answ^er best. But do not hurry the uniform system too much ; take time : this is very i important. j The Nurse should, every morning, at an hour to be fixed by ' the Chaplain or Matron, read aloud in the ward, the Confes- sion, the Lord's Prayer, the Collect for the Week, the Collect for Grace, and the Benediction ; and every evening, at an hour to be fixed by the Chaplain or Matron, she should read aloud in. the ward the Confession, the Lord's Prayer, the Thanks- giving, the Collect for Aid, and the Benediction.* This would Christianize things, instead of heathenizing them ; and I believe not a soldier would dream that his con- science was injured by it. The Roman Catholics and Presbyterians might be allowed quite to refrain, if they chose, which they would not. It would be necessary for the * It is better to omit the Belief, Singularly enough it is the one thing objected to by Dissenters and Roman Catholics. WHAT THE NURSES ARE TO DO THEMSELVES, 31 Jhaplain- General to approve of and direct in this, and best to rt-ait a year or two before beginning it. The prayers shoiikl be very short, the whole not more than five or six minutes eacli time, and the Nurse should read them, the men joining at the proper times. In some Civil Hospitals the prayers are far too long and are gabbled over by some patient, perhaps the worst character and the best scholar in the ward, or are stumbled through by some little boy, upon wliom the others cast the distasteful office, with circumstances of irreverence, partly unintentional and partly shocking. At St. Bartholomew's Hospital the very short morning and the very short evening prayers are printed clearly on each side of a card, which is affixed to each bed ; and each morning and evening the Head-Nurse reads them aloud : the difference is very great. 10. The Colney- Hatch Lunatic Asylum has a diet system worth inquiring into ; nothing is fetched by the Nurse, the Medical Ollicer writes the diets on a large slate which is ready for liini outside the ward. The great advantage of this seems to be, that the Nurse's time is set free from a good deal of arithmetic and some writing; also that each man's portion is served him from the kitchen, not cut up laboriously by the Nurse. In most Hospitals the .Nurse cuts and divides the diets ; in the London Hospital she moreover weighs them. All this takes a great deal of time. If the patients can get the divided portions liot from the kitchen, it is far preferable. At St. George's Hospital tlie portions are sent hot and divided from the kitchen. 11. It should be distinctly settled by whom poulticing, fomenting, and all minor dressings, applying leeches and > blisters, and giving enemas,* are to be done. ' * If the Surgeons are for the men doing it, I would not overpress this point. But, in the case of weak patients, it requires extra care and it would be much better to leave it as the duty of the Nurse. At all events it will not answer to leave the enema and its administrator unspecified. The Medical Staff Regulations assign it to the Ward-Masters. It is a ' simple thing enough, but one by the careless or ignorant admimstration of ' which manv a man (and woman) has been injured for life ; and either the Ward-Master, the Assistant Ward-Master, or the Nurse shou d be respon- sible for it. I should prefer, as above stated, charging the Nurse with it ; 10. Have the Diets sent hot and ready- divided from the Kitchen. 11. The less any Patient is made into an Orderly by the Surgeon the better. The Nurse should have Regulations to invoke to allow her to do her duty. 1 32 WHAT THE NURSES ARE TO DO THEMSELVES It would be advisable to consider whether the Nurse ought not to instruct the Orderlies in some things. This, if it did not clash with Orderlies' Eules, would make these men, especially i those ordered for foreign service, much more useful than they are now, without such teaching. It will, however, be essential that there should be no clashing . between the Nurses' Eegulations and those already or to be issued to the Orderlies. And for this, among other reasons, it is essential to establish a direct channel of communication ' between the Director -Greneral and Superintendent-General of Nurses. Ward Medical I think, upon the whole and with reference to preventing, ; Officer to give as far as rules can do it, the obstruction of the Nurse's duty. Directions to, , . . t t ^ ^rr^ l^urse. "^y adverse or inexperienced Medical Omcers giving orders to "Ward or Assistant AVard-Master, Orderlies, or patients, instead ■ of to her, that it is better to charge him to give the Nurse his orders as to the sick. [ All the above-mentioned things should be done by the i Nurse, i. e., by her habitually and as a rule ; occasionally i letting an orderly do them, under her own eye, in order that he ; may learn, as well by doing them sometimes himself as by often i seeing her. j The reasons why all these things must be clearly settled i beforehand are these : — I I. Adverse Medical Officers will make all use of counter- ' regulations. j II. Medical Officers who give fair play will find it impossible ; to settle the matter, if, on ordering, e.y., leeches, the Orderly i shows Rule so and so by which he does it, and the Nurse Eule j so and so by which she does it. The existence of the old regu- i lations and the arrival of the new ones, about the Medical Staff Orderlies, were made great use of against our work, by some of the Medical Officers, after the heavy pressure of the war was over. So, at Scutari, a Principal Medical Officer took away > and would not restore the practice of the nurses giving medi- j cines, in which he was borne out by an existing rule. Contra- , dictory rules are miserable things. but if objected to by the Surgeons, I should at once let them assign it to whichever Non-commissioned Officer they chose. AND WHY. 33 Unless the Matron's authority is supported by the Principal Medical Officer the Patients always suffer. The Nurse is the only proper person to be responsible for the directions of the Medical Officers being carried out in a General Hospital. III. It will enable the Matron to stop all nonsensical pru- dery, on the part of the nurses, and to require that they should do what they undertake to do, and not pass off to an Orderly, ^still less to a patient, the duties they should discharge them- selves. As a general rule there is a good deal of this false modesty on the part of Nurses, especially of Head Nurses. In individual cases it is a serious thing to shake even false ideas of decorum : in la} ing down general Rules it is the more important to lay down as duties what are such. Suppose an application of what the French call " la petite chirurgie" ordered. The Head Nurse • never dreams of doing such things." The Nurse, following her superior's false shame of duty, transfers the business to an ignorant patient. In some cases great harm has arisen thereby 'to the Patient. In other cases, but not the majority, after such an order given, the Head Nurse goes quietly to the bed, draws the curtain round it, and makes the application herself — saying " she always did that herself, as it was a business requiring care, as the patient was often disposed to resist, and as she was thus certain that it was properly and effectively done." I have always admired and respected such women ; but they are not the majority. Very often patients ire allowed or left to do things for themselves, which they annot do properly, or when they ought not to be trusted to iiflict the pain on themselves which doing things properly often auses. The practice of allowing some particular patient to become a ^ort of half orderly in the ward, letting him always attend some articular case, or give general help in severe cases, is most ■eprehensible. It is never allowed, whether in Civil or n Military Hospitals, without very bad consequences to the liscipline of the ward. Where extra help, in lifting, &c., is •equired, let the Nurse require the most convalescent of the )atients to help, but let her carefully refrain from selecting any )atient or allowing any patient to put himself forward, as a egular help or quasi-O'rderly. As an almost invariable rule it 34 REGULATION NUMBER OF ORDERLIES, 1 will be found that the less patients do for each other the better ! for themselves, and for the discipline and the good feeling of \ the ward. Let them be made useful in the wards, as far as i possible, in such lighter cleaning, &c., as a patient can pro- perly do (here, again, discretion is required, or a lazy Orderly ! will lay undue burdens on a willing patient) ; but the less they do for each other undoubtedly the better for all parties. I would not, however, expressly exempt the patients from being i made useful in nursing the sick. A lazy or ill-conditioned ' patient might make it a handle to refuse to do or grumble at doing things which he ought to do, such as (a thing frequently i required) giviog and emptying a bed-pan to an ordinary patient who cannot leave his bed, while the Nurse and Order- i lies are doing other things in the ward; assisting to move a i helpless patient, if all the Orderlies are not at hand; sometimes : watching or attending for an hour or so a critical case, &c., &c., i &c. What the Superintendent-General and all Superin- tendents must be especiaUy vigilant against is selecting any ; particular patient or allowing a willing patient constantly or | often to do these things, and to become a quasi-Orderly to the i ward or to any patient in it. \ Assistant-Surgeons, partly from inexperience and partly from ; spite, sometimes make this sort of quasi-Orderly of a patient, j The Nurse should have the power of respectfully saying, in * such a case, " The Regulations order me to do so and so, sir : I beg you to let me do my duty." j It is an important and should be, if possible, an invariable rule | that no discharged patient is ever to enter any ward. Soldiers ! are, in many respects, on a different footing, as to each other, | from Civil patients. The above provision is perhaps rendered thereby (not the less, but) the more important for the good order of the ward. Still this, desirable in (and the rule in several) Civil Hospitals, might be considered by Military as well as Medical Officers to interfere too much with the feeling of j comradeship which, in its measure, is so essential a part of the | soldier's very peculiar condition. The following rules however might, at all events, be carried out. Some of them are actually | in the " Hospital Eegulations." I As quietness is indispensable in Hospitals, every duty should j be performed with the least possible noise, more especially at | now FAR APPLICABLE. 35 night. Every patient must be in bed by 8 o'clock in winter, and 9 in summer; and no conversation must be permitted after that time. Patients sliould be made useful in the wards, as far as possible ; but should fetch nothing into them. And no dis- charged patient should be permitted to enter any ward, except in the fixed visiting hours. The Governor, where there is a G-overnor, or the Principal Medical Officer, will fix the visiting hours ; which shall not be more than two hours during each of three days of the week. [Take proper advice as to whether this maximum is too short. It is fully enough for Civil Hospitals, but Military Hospitals are in sundry respects essentially diflerent.] In the discipline of all Military Hospitals, besides the pro- hibition of all swearing and foul language included in the Articles of War, is included the non-admission, or if by over- t sight admitted among visitors, the immediate expulsion of all disorderly persons. (Query — whether notto specify prostitutes.) I very much wish that Hospital Sentries in General Hospi- tals might keep out all visitors, except in the fixed visiting hours. And I very much wish that a stringent rule were made as to 'female visitors, botli in llegimental and in General Hospitals. Proper Military as well as Medical advice should be taken on this point. It might not do to exclude them altogether ; and, 'if soldiers' wives come, it might be better to admit also all respectable-looking women, for it would be useless attempting defining as to sisters, aunts, friends, &c., &c. ; though, except in the case of dying patients, all women, except their wives and mothers, are better away. I do not know what amount of strictness in ])ractice is shown in enforcing the Eegulations in English Army Hospitals ; but if, at present, equivocal women, as well as ascertained prostitutes, are not excluded (which very possibly they are) they should be. At the same time, a sentry may often be honestly puzzled as to equivocal or non-equivocal appearance, in these days of over-dressing. And some mistake, made by a stupid or brutal sentry, might lead to endangering the rule. This whole matter must be referred to men. 12. With regard to the question of the " Eegulation" num- ^g. Orderlies' ber of Orderlies, viz., 1 to every 10 patients, it is to be Attendance, observed, — (1.) A ward of 40 patients might be efficiently served (but (l-HO-Bed it would be hard work) with Minimum Size 0 2 36 NUMBER OP ATTENDANTS TO RE MAINLY for Regulation Number of 1 Attendant to 10 Patients. (2.) 20-Bed 1 Head Nurse — Female. 3 Orderlies. With no number under 40 of patients to a ward, can th( Regulation proportion of 1 attendant to 10 patienta be adherec to. (2.) AVith a ward of 20 patients (cut, scheme, and arrange (3.) 10-Bed Ward cannot be served by 1 Orderly + ^ Nurse. Ward requires ^^ic hours and duties as you will), you cannot efficiently serve 02 Attendants. . • i -i 1 it With less than | 3 Ilead-Nurse — Female. 8 Orderlies. And the other ward of this Head Nurse ought to be on the same floor. N- B. — The same number would quite as efficiently serve a ward of 25 or even 30 patients. (3.) The Army system of 1 Orderly to 10 patients, with a number not exceeding 10 ])atients to a ward, is upset as imme- diately by one bad case among the 10, as by 9 to tlie 10. For, is the same Orderly to be on duty for the 21 hours ? The difficulty is practically got over by the Army, with a permission that any " bad case" may select any one he likes of his comrades (out of the Depot) to be *' told off," to attend upon him. This extraordinary regulation is e([uivalent to (and affords little other practical result, than) granting opportunity for any quantity of spirits, and illicit food, to be smuggled into Hospital, and it is clear that it would be totally inadmissible in a Greneral Hospital, where the whole system of nursing would be under the most stringent discipline and supervision. (4.) The iutroduction of Female Nurses into Military Hos- pitals is not intended to supply the place of Orderlies, but to perform a class of duties which never has been performed at all in the Army. Few other Hospital duties of those generally called such have been hitherto fulfilled, in Military Hospitals, except diet-earrying, sweeping, and writing. (4.) Female Nurses not to be Substitutes for Orderlies. (5.) Naval (5.) In all Naval Hospitals, the Kegulation number of DETERMINED BY SIZE OF WARDS. 37 ifcendants is 1 to every 7 patients, or 2 attendants for each Hospitals ird containing more than 7 patients and up to 14. These Nun^ber^of ttendants or Nurses, in sailor's language, have charge of the Attendants 1 to len, bedding, and ward furniturQ, under the Ward Matron, ^ Patients, id they are responsible for the proper care of the sick, and e due administration of the medicine, wine, and other medical mforts. They are on duty all day and watch at night in their irn, which is regulated by the Medical Officer in charge of the ard, in this or similar fashion : — a group of three contiguous ards is allotted during the night to two nurses, one begins her ity at 9 and ends at 1 o'clock, when she is relieved by another, ho watches till G. She patrols the three wards, resting in lat one where there may be a case requiring more than ordinary ;tention. If there should be a case of fever, delirium, or other larp seizure, extra Nurses, both men and women, are assigned ^> the charge of that special case, according to the urgency of s wants. The great majority of Naval patients are either )nvalescent, or suffering Irom trivial complaints, which do not npair their activity. They can therefore take care of them- 3lves, and assist the Nurse during the day in cleaning the "ards, &c.— and we know what good housemaids seamen make. 'he Nurses are paid one shilling a night for night watching, "hey have under the most severe circumstances two-and-a-half ights in bed for half a night out of bed. At Haslar Naval Hospital the system of Orderlies, as under- ' tood from the Principal Medical Officer, is as follows: — 2 Orderlies are on a floor, to look after, say, 90 patients, ^heseare divided for night duty into three divisions of 4 each ; f these 4 — 2 are on from 9 to 2, a. m. 2 „ „ 2to8. The Head-Quarter room or ward is the one which has the lost severe cases ; this ward, then, the Watcher at night sits in, nd makes the rounds of the others every now and then to see f anything is required. This system will of course be modified, ccording to the nature of the cases in Hospital. The other ttendants do not sleep in the wards. The Nurses are male or emale according to the discretion of the Principal Medical )fficer. In Civil Hospitals the number is as great of attendants to Civil Hospitals •atients, and is mainly determined by the size of the ward : ^'^^^ '-^ Attendants to 44 Patients. 38 COMPARATIVE COST OF NURSING i I g., in one Hospital, where there are quadruple wards of | 44 patients, 11 in each compartment, though the average | number of patients is 48, the number of attendants is 7. 1 In exceptional cases ex^fa Night-Nurses, sometimes extra Day-Nurses serye particular patients. The labour, both of cleaning and of night-nursing, is much increased by the wards being four, separated by a large lobby. In another of the large London Hospitals, where there are to each ward, Patients. 22 ) 24 J 30 34 40 Attendants. there are Sister. Nurses. Sister. Nurses. Scrubber. Sister. Nurses. Sister. 3 Nurses. 1 Helper. (6.) Same Number of Men will not do same amount of Work as an equal Number of Women would. (7.) Hospital Attendance an entirely new subject in the Army. In the Lariboisiere Hospital at Paris, where the wards hold 32 beds, 1 Sister, L Nurse, and 2 Orderlies on the Men's side, 1 Sister, 2 Nurses, and 1 Orderly on the Pemale side, serve the ward efficiently. (6.) One woman does the work of more than a man in a Hospital, speaking of the duties discharged by Under Nurses in Civil Hospitals ; for men are not accustomed to these duties in England, as women are from their childhood. Prom this it is by no means to be inferred that women of the class of Under Nurses in Civil Hospitals should be employed in Military Hospitals, which unquestionably they should not. But it is to be inferred that the work will not be done efficiently, with a smaller number of men than would be employed of women. (7.) The question of attendance has scarcely been intelli- gently considered in the Army at all. And hardly any prac- tical answer has yet been given to such questions as the above. I conceive it to be practically impossible to serve 4 wards, as proposed at Netley, viz., of 9 beds each, with IN LARGER AND SMALLER WARDS. 39 1 Head Nurse, 4 Orderlies. For, as has been said, one bad case in each ward, makes this economy as unmanageable as nine. (8.) A ward in a Military Hospital now may often be little (8.) Hospital else than a barrack-room, with an Inspection by a Medical ^^""^^ Oflieer twice a day. It is designed to make it by the new ^LTSct' Regulations into a place where the sick must be and always ^^^oms at will be suitably attended. But this cannot be done by such a, 'P'^^^''^' scheme as — 1 Female Head Nurse ) / 50 Patients, in (sav) 0 Orderlies . ) ^ ( 6 Net ley Wards f thougli this attendance would be more than sufficient for 50 cases in one ward ; but such a ward is considered in a sanitary sense too large. Two wards of 30 beds each on the same floor would be efficiently served by such a Staff, however ; and there would be no sanitary objection. (0.) The Regulation number of one Orderly to ten patients (^O Regulation therefore requires modifying. Practically it is broken every day ^o'lVlSients and in the extra(jrdinary manner above mentioned, which gives requires the moat critical cases to be attended by the rawest hands. modifying. , (10.) The question of Hospital floors will be fully discussed (10.) One farther on. An Orderly should be trained to be the frotfeur ^^'^^iJtte^^^ to each ward. He should also be tlie porter to fetch and carry Frotteur. very thing to and from the ward. (11.) The plan of Xetley, with its wards for 9 sick, is by far (U.) the costliest for administration, as the foUowing facts will ^''XsfoT orove : Nursing with larger and II. It is proposed to provide the Hospital with Orderlies smaller Wards. ■ and Nurses to conduct the nursing in wards of 9 sick, ' as nuuitioned. * ' II. On sanitary grounds wards may safely be large enough i 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 Or- derly, and a-third of a Nurse (that is, a Nurse could ||; superintend three sucli wards.) 40 COMPARATIVE COST OF NURSING A ward of 30 eick 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, in- cluding lodging, rations, wages, at less than £50 a year, which when capitalized at 3 per cent. (33 years' pur- chase), would amount to £1,650 for each. V. A ward of 9 sick would cost in nursing £1,650 X2\=: £3,850, or £427 15*. 6d. per bed. VI. A ward of 30 sick would cost for nursing, in perpetuity, £1,650 X 4 = £6,600 = £220 per bed. ,i [One Nurse to each ward is here allowed.] 1 VII. The cost of the two plans relatively for a Hospital of 1,000 sick would stand thus : t Wards with 9 beds = £427,775 j! Wards with 30 beds = 220,000 i I Capitalized difference of cost in | £207 775 ' favour of large wards j ' ^ Netley has cost already Land = £30,000 Works 89,000 £119,000 J It hence appears that, if works and site were both sacrificed, and fresh land purchased, and wards for 30 sick built on it, the I 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 eco- nomy of administration, the cost would stand thus : Tor each ward of 25 sick, 3 Orderlies, at £1,650=^4,950 If 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 ward 825 5,775 IX LARGER AND SMALLER WARDS. 41 (^r cost for each bed = £231 The comparative cost of wards with 9 beds and 25 beds, would stand thus for 1000 sick: Wards with 9 beds . . . , £427 775 Wards with 25 beds . . . 231 000 Saving £196,775 Deduct cost of Netley, already incurred 1 19,000 Saving from abandoning Netley = .. £77,775 The cost of the administration per 1000 beds at Netley and Aldershot would stand as follows : Netley £427,775 Aldershot, pavilions, with 3 superimposed wards and 25 sick in each, would require 3 Orderlies and 1 Nurse* to each ward, and would cost £264 per bed in perpetuity, or per 1000 sick . . . . 264,000 Difference of cost in favour of iVldershot £163,775 iSome abatement would have to be made, as regards the cost cf 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 £50 per annum ; money at 4 per cent., per 1000 sick ^324,000 Wards of 30. 3 Orderlies and a Nurse, money at 4 per cent., per 1000 sick . . • • 166,000 Extra cost of small wards . . . . 158,000 Cost of Netley 11^,000 Saving in giving it up .£39,000 * One Nurse might possibly be able to serve the whole Pavilion. The highest estimate is here taken. 42 SANITARY NECESSITIES AS TO HOSPITAL FLOORS 13. Hospital 13. Flooes. — In building a new Hospital or laying a new Floors. 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 consi- dered. 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 absorb iug 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 sur- face. 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 ofiensive 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 furni- ture, effectually obviate risk of slipping. It would hardly be possible, however, to make deal floors as slippery as oak parquet, 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 sand- stone, 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 AND THEIR CLEANING. 43 •erccptible, quite different from that of soap and water. It is he exhalation from the organic matter which has entered the ioor Irom the feet and breath of the inhabitants. How much nore dangerous this in Hospital AVards need hardly be said. There is at Bethanien Hospital, at Berlin, a very admirable looring, which would be worth trying in England. The floors hroughout are wood, prepared in the following manner :— The loor id first oiled with linseed oil, and then rubbed over with a )eculiar " laque" varnish, the technical process of which will )e found in the note,* and polished, so as to resemble French )olish. Every there years or so the rooms and wards are suc- ;e8sively emptied for a fortnight, when a new flooring is laid, •e-oiled, varnished with the laque varnish, and thoroughly Iried. Every day the floors are wet-rubbed by means )f a piece of sacking or coarse webbing at the end of I long, hard broom, the performer stands for the per- formance, also while immediately afterwards, having wrung the sacking completely dry, she goes over the ground again with tlie 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 * The floors are of deal ; the length and breadth of the boards depending 'on circumstances. Wood skirtings run round the walls, following the recesses of the window and doors, 2iin. in height and l|in. in thickness. ,The skirtings should have no indents in them, which form convenient lodgments for dust and take time to clean. A little rim must run round the top of the skirting, edging the wall. The skirtmg should thence descend, unindented, upon the floor. The boards are coloured and prepared, as follows : A new floor is rubbed over two or three times, with warm linseed- oil varnish, having some fine yellow-ochre, powdered, in it ; then a coat of *' laque-lustre," a species of French polish, is laid over it, the result being a reddish-yellow colour, in which the grain and veining of the wood is shown. If, after being used some time, it begins to look worn, it is rubbed over with oil and a new coat of polish laid on it ; but, as this takes a long time to dry, it is usual to fill uj) the worst parts with thin oil-colour, and then to take the yellow polish and lay it on, in two successive coats, leaving it to dry, if possible, for twenty-four hours, as it wears the better the firmer and drier it is. For old boards, that have been much used, considerably more laque- lustre is required than for new ones. After laying on the laque-lustre it is desirable that the floor should not be trodden upon for six weeks, and it is also well occasionally, say about once a week, to poUsh it, which conduces much to make it serviceable. 44 " lackering" used at BERLIN 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 scrub- bing. (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 purifica- tion 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 FOR HOSPITAL FLOORS. 45 lat the flooring, which is tlie same as at Bethanien, is less 3ed. (2.) St. Hed wig's Hospital, where 250 male and female ledical and surgical patients are nursed by Roman Catholic isters of St. Charles Borromaeus (head quarters at Nancy), ith female servants and male nurses. The house is new ; the ooring the same as at Bethanien. The Superior, an intelligent l-erman, speaks much of its excellence for hospital purposes ; is being introduced, though as yet very partially, into Vance. f:^.) The great Charite Hospital, the town-hospital for 1,200 itients, spite its French name. It consists of two buildings ; le old one, used in winter ; and a splendid new one, into hich all tlie patients, except the lunatics and the small-pox ad the venereal cases, are moved for the six summer months, he flooring throughout is of the same wood (deal) as at Betha- ien, but has much more laque. The more laque is used, the Tighter the floor shines, but the sooner it requires re-oiling Qd laque varnishing. The Charite floors are re-oiled with ique every year ; ihey are cleaned in the same way as at Beth- aien, only with more* dry rubbing. On bad days, when the umerous students have passed through, the ward floors occa- onally require to be cleaned ; but, in general, even on these Occasions, it is enough to sweep them, and to clean the next lorning as usual. (4.) The principal Military Hospital, the Garnison Lazareth 1 the Hirsch AUee, for 800 patients, usually not filled. The ooring is the same as at Bethanien, except that no laque is sed. °It is oiled generallv, not always, yearly. The Ober Inspector, a Landwehr civilian, who is supreme ver the Hospital, and an Ober-Stabs-Arzt, both .peak very trongly as to the superiority of this flooring over all others for losintal use, and m particular over flooring which requires onsi ear .bbing. It has only been introduced of late years. Tkey dor it equal to any amount of hospital wear and .r. The n,ilitary patients, like those of the Chante Betha. ien, and St. Hedwig's, wear hospital shppers, with soles hick enough to admit of their walkmg :n the garden, when ,ne; when not fine, they are not ^U°-V"f ' ,i el' shoe oor ng would not stand the constant tread of naded shoes. 46 SANITARY NECESSITY FOR But often, on bad days as on fine ones, great numbers of ! soldiers come to visit their sick comrades, and leave | the floor very dirty ; generally it is enough to sweep the I floor after the visitors are gone, and to clean it as usual ! next morning; sometimes it is necessary to clean it the i 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, i 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 exceed- ': ingly satisfactory. I (5.) Two years ago the greater part of the boards in the • Kaiserswerth Institution, 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 the Kaiserswerth floorings would not answer tlie English require- \ ment of extreme cleanliness. They are substantially clean, but, like those of the Military Hospital of Berlin, it takes examina- ' tion 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 the Bethanien colour. 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 ABOLISHING SCRUBBING. 47 reading incident to all ward floors ; it ia also more expensive. .iOt us consider it wholly unsuitable for wards. (ii.) Oiled boards, with more or less laque. , The Charite boards have a great deal of laque. 1 The Betl\anien and St. Hedwig's boards much less. (ill.) Oiled boards without any laque — As in the ^lilitary Hospital. II. Much laque makes the floors shine brighter; requires lore time to clean them ; and earlier re-preparation than yhere less laque is used. The Charite boards would be unmeaningly splendid for an lilnglish Hospital, and quite out of place in a Military one ; ■esides entailing some unnecessary annual expense, and some aily finicking care. nr. A small quantity of laque, as at Bethanien, gives an mount of polish to the floors, which enables the eye at once 0 ascertain whether they are clean or not ; considerably m proves the appearance of the floor ; and, according to all ligh authority, adds both to the durability of the floor, and the lealthiness of the Hospital. It renders the whole flooring less ubject to cracks, to dirt and dust getting into holes and corners ; and, above all, by filling up the grain of the floor, it <)revents the saturation, by organic matter, which otherwise alvos place and which scrubbing only makes more mischievous. IV. Where no laque is used, the absence of all polish on lu" dark-brown floors makes examination necessary, to see .vhether they are thoroughly clean or not. This flooring would lever satisfy the eye or the mind of an English Inspector- Jeiieral or Surgeon. But the main objection to the absence .f laque certainly consists in the sanitary one above stated. V. All the various authorities agree in estimating very .lighly the superiority of this flooring to flooring requirmg ^erubbing. They all agree in their reasons for this preference, The dampness which remains in a ward more or less .ime after it has been scrubbed, is completely avoided. (II.) The tendency to miasma is greatly counteracted, both n- getting rid of the damp, which encourages and spreads he exhalation of the organic saturations; and by ^^^king Je door impervious, preventing dirt, and with dirt miasma, findmg its way into holes, chinks, and corners of the floor. 48 BERLIN lackering" PROCESS MAY BE FURTHER (ill.) 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. (yi.) 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. YI. 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. (in.) The tread sounds a little more, little, but more, than on white boards. (lY.) 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.) (y.) 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 furni- ture most used, bed, tables, soflis, &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 Ofilcers, Military and Medical (I do not mean patients), in possession of scrubbed rooms and carpets. The Superinten- deut 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 Charite and at Bethanieu, long broad corridors run along the back of the wards which open into them. The corridors are floored like the wards. In those IMPROVED FOR HOSPITAL FLOORS. 49 of tlie Charite 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 I'piece of matting is laid along the middle of the floors. Tii. This flooring is unsuited for stairs, though so used in some Hospitals, ■ as, in case of fire, oiled wood would burn I rather quicker than common wood. Hospital stairs should bg of stone. VIII. It is also unsuitable f©r 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 floor- ing, admitting of scrubbing, because these oiled boards do not . well stand sand or bran, and our Surgeons might be discom- posed at missing one or other of these things. Sand or bran I mixed with blood would make a mess, the traces of which ' would show a little on this flooring. For the rest, it is par- ticularly 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 5 or if there has been a very great mess, five minutes, a wet tcloth to lap up the blood, &c., another wet cloth^ a pail, and a broom, do all: after the operations are ov-er, a few minutes* whole or partial cleaning, as the ease 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. Eed floorcloth, of sufii- eient size, round the operating-table, might answer every purpose. IX. On laying down the oiled boards for the first time, sir 1 weeks should pass after the oiling and laquering before th© ! 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. 50 PRACTICAL SUGGESTIONS AS TO FLOORS. XI. The flooring, so prepared, or re-prepared, ouglit, 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, un- less 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 atmo- sphere, 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 difier- ence. 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 hos- pitals, 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 comple- ment of English workmen, to prepare the boards. The mode of cleaning is extremely simple, thougli of course VENTILATION. 51 of Wards. 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 tliese 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. li. Ventilatio??. — The amount of fresh air required for 14. Veutilatiou 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 ofl\ ^ Tlie 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 15| cubic feet per hour. This large quantity if not speedily carried away would un- doubtedly 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 15^ cubic feet of carbonic acid in the atmo- sphere 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 I to undisrstand 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 I produce disease. i This will be still more the case in sick wards overcrowded I with sick, the exhalations from whom are always highly morbid 1 and dangerous, as they are nature's method of eliminating matter from the body,in orderthat it mayrecover health. A much larger mass of air is required to dilute and carrj 3) 2 noxious 52 NIGHT VENTILATION. 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 sufiBciently, 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 ex- perience 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 pyoemia and Hospital gan- grene had appeared among the sick in consequence. These diseases disappeared on the introduction of ventilating arraDge- ments, whereby 2 ,000 cubic feet of fresh air per bed per hour were supplied to the wards. Notwithstanding this large quan- tity, 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 At one of our largest London Hospitals it wiU be per- >ntilation. reived 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 gene- rated, in quiet. SPECIAL WARDS. 53 • 15. Special Wards. — It may be laid down as an axiom in Special Wards, the management of sick affected with certain zymotic diseases, delh-abiror such as fevers, cholera, dysentery, &c., that Lhey should be dis- not. tributed over a wide superficial area, and have a large allowance of cubic space. Agglomeration of such cases in small ill-venti- lated wards is quite sufficient of itself to occasion a high pro- portionate 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 ot these diseases in Hospitals. Medical Men generally are satisfied that these ends cannot be safely arrived at by agglomerating sick in fever wards in Hos- pitals. And hence has arisen a practice, which experience appears to have approved, of intermingling a smaU 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 avail- able 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 w^indows, 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 precau- tions, under the same roof. Without discussing the validity 54 WAGES, HOW TO BE PAID. of the opinions held in Southern Europe as ix> 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 started; 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 16. All salaries and wages of Matrons and Nurses should be ^o^Pay^m^ntr P^^^^ Superintendent- General's order, from the Hospital by Superin- chest, to the Matron, who should pay the wages and other Gene^raL expenses of the Nurses, and account for all monies received by her on such orders. All outfits and travelling expenses, in eases of transfer, &c., should be provided on the order of the Superintendent-General. Opinion as to There would be considerable difficulty in the way of making t ^^d^"t- payments at a distance to Nurses, direct from the Superin- General paying tendent- General, otherwise than by orders on the Hospital Wages and 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 w^ould draw from the Hospital Treasury, on the orders of the Superin- tendent-General, and would account to her. As a matter of dis- cipline, it would make no material difference whether the orders of the Superintendent- General, in favour of the Salaries. GOVERNOR TO BE SUPREME. 55 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 tliose orders, as any other banker would. 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. The Matron should be able to draw from the Purveyor, on her own indent, with the sanction of the Governor of the Hos- pital, 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 Superin- tendent-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. 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 com- posing 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 respon- sibility, by directing the Matron to remove theoffendiug Nurse from the Hospital. The conduct of the Nurse would become the subject of investigation afterwards, in terms of the esta- blished regulations. But practically such a case could hardly occur, unless by the fault of the Matron, who would, of her Matrons abroad may dismiss Nurses under appeal. Matron to draw Rations and Extras. Opinion as to Governor's jurisdiction over Nurses. 56 THREE PRINCIPLES IN RAISING WAGES. 17. Nurses' Wages. Efficiency of Nurses does not increase by springs and starts, like Grasshoppers. The first five years a constant improvement. Afterwards if there has not been improvement made before, no hope at all. Three principles in Wages. By rate of Wages to own accord, desire to remove a Nurse, on being satisfied tliat such a measure was necessary or expedient. It would be proper, too, both for her own justification and for the mainte- nance of the Grovernor'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 Superin- tendent- Greneral . "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. 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 does not go by starts and springs, like grass- hoppers, but makes " a small annual increase," like the wage* 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. Tor 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. The reasonable principle I believe to be, 1, to begin improv- ing 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. Because the object is to induce the young and efficient RATE OF PENSION. 57 women to stay, not the old ones. They will stay long enough, because the old ones nobody else will take. Tlie rate of pension ought, on the other hand, to increase with the number of years' seryice, and continue increasing till the end. The principle of pensioning is different from that of wages. After the woman has reached her maximum of eflBci- ency, 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. 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 Hos- pitals 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. 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 Depart- inents, there is only one year of such probation before increase begins, though the persons are much younger w^hen 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 allow- ance 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 aff'ord facility for enforcing retirement without injustice. This would be eco- nomy. 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 retain those who are efficient. By rate of Pension to reward those who have been efficient. Civil Service an Example. Opinion as to Wages and Pensions. 58 GENERAL PRINCIPLES AS TO 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 provRion. Persons who can hardly be said to be disabled but who have become less efficient are retamed, because, if dismissed, they have no means of liveli- hood. I have consulted the best authorities upon these points ; and I find the following general principles admitted : — GrENEEAL PRINCIPLES AS TO WaGES AND PENSIONS. (1.) Same Salary at first. (2.) Same Annual rate of increase. (3.) Maximum Salary fixed, (4.) Pension for Service after Ten Years. (5.) Amount of Pension a certain Per- centage on mean Salary of preceding year. (1.) At whatever age a Nurse enters the Service she shall begin with the same salary. (2.) The annual rate of increase shall be the same for all ages of entrance. (3.) The maximum salary shall not exceed £ . (4.) The pension for service shall not begin until ten years of completed service. (5.) The amount of pension shall be a certain percentage on the salary during the year preceding that on which she is pen- sioned. Applications or the foeegoing Peinciples. (1.) Annual rise of Wages till the maximum of efficiency. (2.) After five years' Service Pension for Disability. (3.) Pension on a Scale graduated on the Wages. (1.) That the wages of Nurses shall rise annually, for a defi- nite number of years, attaining their maximum, on an average, at the age forty-five, when the JSTurses are found to be most efficient. (2.) That, after five years' service, the Nurse shall, in the case of absolute disability, become entitled to a pension during the period of her disability. (3.) The pension will be on a scale graduated on the wages. It will be twenty per cent, of the annual wages in the year of service, 5 — 6, and the rate to be granted will rise progressively two per cent, per annum, until the rate on the wages becomes seventy per cent. WAGES AND PENSIONS. 59 (4.) All Nurses will be placed on the Eetired List at the age ,f sixty.* (5.) Those Nurses who are pensioned at an earlier age, for inability, will, if called upon, be liable to serve when that tisability ceases, or to forfeit their pension. They must herefore bring an annual medical certificate of disability to the Superintendent- General, in order to receive their pension. (6.) Nurses who are partially disabled will only be entitled to a certain proportion of the pension allowed in the icale, to be determined, on representation made by the Super- ntendent- G eneral. Exampla Completed Yeaks OF {Service. 30 0 31 1 32 2 33 3 34 4 Age. "Wages. £20? 22 24 26 28 Pension. (4.) All Nurses to retire at Sixty. {5.) Nurses to serve again who are Pensioned for Disability, when Disability ceases before Sixty. (6.) Nurses partially Disabled to receive partial Pension. Example. 03 U d5 35 40 45 50 55 60 5 10 15 20 25 30 SOX -2 40 -3 50 .4 50 -5 50 -6 50 -7 12 20 25 30 35 These principles, if admitted, would suggest the following heads for regulations as to Nurses' wages and pensions (1.) At whatever age a Nurse enters the service, the amount of wages paid to her during her first year of service, will be £20. (2.) There will be an annual rate of increase of wages equal to 10 per cent, of the first year's wages, until the yearly wages amount to £50, beyond which there will be no further increase. (3.) A pension will be awarded for service to any Nurse, who jiiay retire, on account of age, at the expiry of ten full years' • And this should be adhered to, the rare though extant cases of effici- ency for Hospital nursing, past this age, notwithstanding. (1.) Amount of Wages, first year, £20. (2.) Annual rate of increase up to £50, when it ceases. (3.) No Pension till Ten Years' Service completed, nor for Disability 60 RATE OF PENSION. till Five Years. (4.) Rate of Peusion. (6.) Knrses, Pensioned for Disability, whose Disability ceases, may be called on for Service. 18. Number of Nurses to Patients. service, but in case of disability, a Nurse shall receive a pension after five years' service, or a gratuity, according to circum- stances, if discharged for disability, before she has completed five years of service. (4,) Rate of Pension. The pension will be on a scale gradu- ated on the wages. It will be 30 per cent, of the wages re- ceived by the Nurse in her tenth year of service, and the pension granted to Nurses who have served more than ten years, will rise at the rate of 2 per cent, of the wages for every additional year of service, until the pension amounts to 70 per cent, of the wages received during the year preceding its grant, beyond which no higher pension will be granted, except in cases of special devotedness to the public service, when an addition to the regulated rate of any pension may be granted on special recommendation, made by the Superintendent- General of Nurses, setting forth the nature of the service for which such augmented pension is to be granted.* But no such pension shall exceed the amount of £50. (5.) Any Nurse pensioned for disability, may be called on for service in the event of such disability ceasing before the age of sixty, in which case her wages will be the same as they would have been, had she not been disabled. (6.) Every Nurse who has completed her sixtieth year, must retire from the service on her rate of pension. (7.) Any Nurse, temporarily or permanently disabled in the service, who has served more than five and under ten years, will be entitled to a lower rate of pension, according to the circum- stances of each case, as represented by the Superintendent- General. 18. Nurses should be selected and appointed by the Super- * Great caution must be used in acting upon this. The Superin- tendent-General, or the Superintendents who are responsible to her, order the service of each Nurse. How far is it just to consider extra dangerous duties or stations meritorious in the Nurse who does or suffers from them ? Others might have done the same, if so ordered. Others might have wished for such an order. Or a strong efficient Nurse who, in other respects, gives anxiety, may render extra useful service on an emergency, and suff'er for it in health : and yet, during her whole service, have given more anxiety and less satisfaction than others who did not, perhaps had not the opportunity to, distinguish themselves by any extra useful service. i PROPOKTION OF NURSES TO PATIENTS. 61 ntendent-General of Nurses for each General Hospital, iu a oroportion not exceeding one nurse for every twenty-five 3ases. There is nothing so fatal to discipline as to require by regula- tions what it is known and admitted cannot be performed. Such rules are made to be broken. Therefore, is it not better, instead of fixing a number to fix a limit, and say not exceed- ing one to every 25 or 30 patients," leaving it to the Super- intendent-General to economize Nurses, and not appoint the full number permitted, unless when really necessary ? In one case she might consider one nurse for fifty or even sixty suffi- cient ; in another, one for every twenty-five might be few enough. Why tie up her hands against economy as well as against extravagance ? At the same time it is necessary to state — (1.) That, by all accounts, at home and abroad, in the English and in foreign armies, the proportion of severe cases ia very considerably less, in time of peace, in a Military Hospital than in a Civil one, especially in the surgical wards. (2.) That the Nurse's time, being relieved of the waste incurred by fetching and waiting for things, the cleaning of the ward being done by Orderlies, and, an important item, the Ward-Master being responsible for the serving the patients' food, twenty-five sick are not enough, on an average, to occupy, properly, her time. ' (3.) That idleness, always pernicious, is never more so than to Hospital-Nurses. (4.) That petting the patients, by way of filling up time, would be, of the two, more pernicious than idleness. (5.) That it is most important, apart from these reasons, to train and accustom these Nurses to serve efficiently large numbers of patients, so as to make them useful in war-service, where every woman who can be spared is better away; and where a small efficient staff" would, please God, do excellent service. (6.) That it is not in human nature, taking its average, sup- ' posing the Eegulations lay down that the proportion is not to ! exceed 25, for many Nurses not to murmur at having more ; whereas they ought from the first to understand, that the ser- vice is a very laborious one, and that none but women able and 62 MINIMUM or TWENTY-FIVE PATIENTS TO ONE NURSE. willing to undergo and render laborious service, ought to enter it, or be suffered to remain in it. (7.) Care must be taken therefore that in fixing this mini- mum, no use may be made of it dangerous to the service, either in the Hospital work itself, or in provoking adverse criticisms upon these Eegulations in quite different places. Twenty-five cases are not generally enough. 19. 19, It would be expedient to take the advice of an able and ^rsending^ honest man of business as to whether the Superintendent- Nurses abroad. General should, on engaging a Matron or Nurse, have her signature to a bond or not. On the one hand, we know what bonds are to loose consciences, and if the promulgation of the Eegulations give undoubted power to the Superintendent- General and to her Matrons on foreign stations, I should prefer having no bond. But this is for a man of business to answer. It is important to remember that the power of instant dis- missal for misconduct, and of sending the Nurse home must be retained, which renders the service different from ordinary female service. A discharged governess or servant, if she insisted on remaining at her own expense at the foreign station, could not be sent home forcibly by her late mistress ; now it is essential that an offending Nurse be forthwith passed on board the first returning ship. Also performances similar to those of one or two of the women in the War-Hospitals who, on hearing of good situations, misbehaved in order to be dis- charged, ought to be effectually prevented. A lawyer must advise, first, if it can be ; secondly, how it can be done. The Superintendent- General, on sending abroad Nurses, ought to have some security either that they remain there and do their duty, or that they be sent home for her judgment if they fail in duty. To have them either going abroad as Nurses by way of securing a free passage, and then looking out for lucrative situations, or accepting the offers which might, and, occasionally, undoubtedly would, be made to them, would be most injurious to the Service. Can it be prevented by any stronger measure than the instant forfeiture of all claim to the eventual pension ? If so, it should. Could this power be extended to the washer- women who would probably be sent with the Nurses ordered to War or out-of-the-way foreign stations ? Perhaps it will simplify things not to include them in the Eegulations. FEMALE NURSING IN PAVILION HOSPITALS. 63 The persons provided by tlie Officer, whoever he may be, Hospital ;o attend to the hospital linen under the orders of the Matron, I^aundries. vill be pretty sure to give the Matron trouble. But it is much 3etter to begin very modestly, and to avoid alarming the ittondance Department ; and so to be content with the people provided in the linen store, and not at all to invade the regions Df the kitchen. By degrees, please God the work prospers, it may be extended. I fear a laundry of men, except in war- service, will be a costly and inefficient concern. Yet a laundry of women, exempt from the control of the Matron, would be probably the worse evil of the two. And it is both right and expedient to move very slowly, and to begin with the nursing service alone. Ultimately, if we invade both laundry and kitchen, I should still wish, in both, to have as few women as possible. The fewer women are about an Army Hospital the better. Addenda with eegaed to Eemale Nursing in a Militaby Hospital on tke Pavilion or Lariboisiere Plan. 1. In considering the Pavilion Plan to be in future received as the sanitary necessity for Hospital construction, we must i look upon it as susceptible of many modifications. And, particularly in adapting it for a Military Hospital, we must ask by what modification can it be made, 1. Most econo- mical as to attendance, a greater amount of which is rendered necessary than by other plans of construction. 2. Easy as to supervision ; and, of course, a Hospital spread over the extent of space now proved to be essential by sanitary knowledge, whether built on the Pavilion plan or not, must multiply the amount of supervision over that required in the ! concentrated over-crowding of the old Hospital system (over- ^ : crowding not with regard to cubic space in the wards, but to i the superficial area on the ground). 3. Economical as to the number of sick to be accommodated on the same floor, so as to save unnecessary waste of time and strength on the stairs to both Ward-Masters and Nurses. Each Nurse should have, in time of peace, not less than from 50—60 patients under her charge, i 64 FOUR PRINCIPLES TO MODIFY APPLICATION 1. Pavilion Plan indispensable on Sanitary grounds. Its Difficulties, on the score of Discipline in Military Hospitals, to hs openly met and guarded against. 4. Efficient as to convenient accommodation for Nurses and Ward-Masters, near to the wards of which they are in charge. 1. The Pavilion Plan, while it is incontestably superior, on sanitary grounds, to any other, while it perhaps may be made equally economical, with regard to building, is more expensive than the older crowded and badly-constructed Hos- pitals, not only as to ground, but because each separate entrance, staircase, set of appurtenances, represents an addi- tional cost of materials, and of hands to keep them clean and in order. Human life is, however, a more expensive article than any other. If human beings, and especially sick human beings, are to be spread over as much space as possible, which is now known to be an essential to health and more especially to recovery, this must be done under any system and can be best done under the Pavilion system. It of course necessarily entails a greater amount and cost of attendance and of super- vision. Pure air and light are the prime necessities of a hos- pital. These are best secured by the Pavilion Plan, and there- fore it is the cheapest in the end. As to the hands, there never ought, never will, never can, be a superfluity of hands in a well- regulated Hospital. The duty of the hands consists of two parts — to keep the Hospital clean; to attend the sick. I had rather not enumerate the instances where I have seen that, often from the most various causes, one result arises — that more time and care is given to floors, stairs, &e., &c., &c., than to the sick. Extreme cleanliness is of vital importance; this should be combined with extreme simplicity of detail, and with providing for considerable numbers at once. You can efiectually clean a large ward in much less time than two small ones ; a long stair than two short ones, &c. Extreme, not jiniclcing, cleanliness, thorough ventilation, for which an ample supply of opposite windows will certainly in the long run prove infinitely the best plan, and careful nursing, are probably the main conditions, humanly speaking, of a large proportion of cures — subsidiary to the medical or surgical treatment. Sanitary necessities are never to be rejected, on account of the trouble they give or of the means of clranliness which they render necessary. Because the saving of life, not the saving of trouble, is the object of all sanitary appliances. Hospitals amon^ the number. And the saving of life is the only real economy. OF PAVILION PLAN. 65 f you have saved " hands" and trouble, and lost life, you 'lave been extravagant. The object is not to banish appliances vhich will cost trouble in keeping them clean, but to discover hose appliances which can be kept clean, at least cost of abour. And this is perfectly possible. 2. The Vincennes modification of the Pavilion plan has been ulopted, among other reasons, for the greater facility of super- nsion it affords. The Military Superior, the Surgeon, the Matron, can at any instant pop in upon any ward of a Hospital which has one roof. Each pavilion may, unless the natter be specially considered with a view to providing this effectual supervision, perceive the approach of any inspec- tor. The system of scouts, watch, alarm, is well understood in many hundred wards, whose patients would be puzzled to give the things names. Military patients will know both things and names. Bemember that Ward-Masters, Orderlies, and Nurses require inspection as well as patients. Whatever system of Hospital construction is adopted should provide for easy supervision, at unexpected times. 3. The more we see of different systems, the more we see the great mistake of giving a Nurse too little to do. Twenty-four ordinary sick or surgical cases are too few for a Head Nurse. In a Military Hospital, the proportion of heavy cases is in ordinary times considerably below the average pro- portion of such cases in a Civil Hospital, open, as the latter 'is, to accidents, and to the cases of dangerous disease always 'more or less rife in low and crowded neighbourhoods. Upon an average, a third or a fourth of the cases in the ordinary surgical wards of a Military Hospital will be ulcers from causes honest and dishonest. What these men will re- quire is rest (the cleanliness which is often so irksome a novelty to the corresponding Civilian patient is routine to the soldier), and very simple treatment. It is* most important, if possible, to form a staff of active, laborious, useful women, who, if ordered on war-service, can at once cope with numbers, and serve efficiently a considerable number of heavy cases. Eelieved of all cleaning, and relieved of the great loss of time incurred by fetching, waiting, &c., &c., none of these 2. Kasy Supervision to be provided for. 3. If from 24—30 Patients be the right Number, Sanitarily speaking, for a Ward, the Pavilion Plan should, in a Military Hospital, be so arranged that more than one such Ward should be on the same floor, for faciHty of Supervision. 66 NURSE^S LODGING NEAR HER WARD IMPORTANT. Nurses, who are, in fact, Head Nurses, should serve less than forty men. And, as I before submitted, I had rather she served fifty or sixty than forty. Give them twenty-four patients, and either they will become idle, finicking women, or they will take to petting the patients, a thing to be sedulously avoided everywhere, most of all in Military Hospitals. 4. Importance 4. The more we see of different systems, the more apparent of the Head becomes the importance of the Head Nurse (all these are Head Nurse , ^ ^ sleeping close Nurses) sleeping close to the ward : — to her W ard. regards the efficiency of her service : — As regards the saving her own time, strength, and securing her a modicum of comfort in a work where, if she does her duty, she will never have a superfluity of comfort. Time, strength, and this modicum of comfort, enter much into a Nurse's health — and health is essential both for efficiency and economy. Where the Nurse sleeps at a distance from her ward, her efficiency, both as to superintendence and work, especially at night, in dangerous cases, is seriously impaired. If she sleeps at a distance from her ward, her comfort, also, such as it is, is destroyed. "Whatever a Nurse does for herself, she must do by fits and starts. A really efficient Head Nurse is never able to make anything for herself, though she often would far rather save the money it costs to " put it out." The most simple mendings, even the feat of stowing away the laundress' supply of a Saturday evening, become, when a ward is heavy, or when there are two or three of those cases of urgent danger, so many of which, by God's blessing, the assiduous care of these women saves, year by year, in our Hospitals, a procedure done in several acts. The misery of dividing her small eff'ects (the smaller the better) between a day 'room and a distant sleeping-room, the unseemliness and inconvenience of carrying things backwards and forwards, cannot be described. If it be possible, the Nurses must sleep adjoining their wards; and it will not do to give each only 24 patients. It would be considerably better, if feasible, to have two Nurses in contiguous rooms ; but in the Pavilion Plan this would involve bringing one Nurse away from her ward ; and 1 GAS IN HOSPITAL WARDS. 67 'ather than this, the next best, though inferior plan is to put .me Nurse immediately above and below the other, with a dis- }inct bell which she can in a moment ring from her bed into :he other Nurse's room, to summon her if needed. Some years ago gas was laid on in the Sisters' rooms in Importance of Gruy's Hospital. In the other Hospitals there is an allow- Lighting ince of candle to each Sister. The disadvantages of gas are Ward?by Gas, i.ts alleged unhealthiness and its certainly being disagree- "^i^h Sanitary iible to some eyes. Its advantage is its cheapness. Liberty ^^^^^^^^i^^^- bo buy a candle and not use the gas is allowed at Gruy's. A-S it will be a very important thing to conduct the Nursing Service as economically as possible, and as there must not be any wretched false economy as to essential matters, which in the end always proves waste, it will be well to save as much as can be in matters not essential. It would be worth while to ascertain the average amount of 3aving which the substitution of gas for an allowance of candle has effected at Guy's. Gas is used in the wards of St. Bartholomew's, St. Thomas's, and Guy's, day and night. It appears, when ventilation is properly attended to, to answer well, and to do no harm. At night the gas is lowered so as to leave the ward just light enough to see all that is done in it: if bleeding, &c. occurs, it can in an instant be raised, and the ward lighted up. London Hospital burns gas in the evening, and throughout the passages at night ; but when the night watch begins at nine, the wards are dark, except the Nurse's candle. A spare candle, un-lighted, is always at hand. It is very important for the order of a ward that the attendant in charge, and also any inspector suddenly entering, should see at once all that is going on in the ward. Where -there are dangerous cases, this is of great moment ; and where there are not, it is equally necessary for the police of the ward. A candle or a rushlight give insufficient light. Properly lowered, gas at night does not disturb the patients. After a night or two, those who are accustomed to sleep in the dark get used to it. If the Nurse sleeps adjoining the ward, there must be sufficient light in the ward at night. If the gas-fittings are properly tight and if every gas-burner has a ventilator, so that the products of combustion are effectually . conveyed away, for each gas-jet consumes as much air as eleven E 2 68 HOW ONE NURSE COULD MANAGE II.— 1. Should it be necessary to serve one Pavilion with one Nurse means by which this could be effected. 2 Head Nurse's Day in a Pavilion Hospital. men, it would ba greatly preferable that there should be a low gas light in the wards at night. II. — 1. Suppose the Lariboisiere plan retained, as proposed at Aldershot, for a Military Hospital, with wards of twenty- four beds each — then, with fear and trembling, but with the firm conviction that it is better for human nature, most of all, for nursing human nature, to have somewhat too much than a great deal too little to do, I respectfully recommend that one Nurse serve the three wards of each Pavilion. One woman cannot sleep alone in the Pavilion. The Nurses must sleep together near the Matron's quarters. If the Nurses sleep away from the wards there should be some way by which a Nurse can at once be summoned, in case of any urgency in her ward, and it would be well to consider this in the distribution of quarters. Either the Matron should lock the Nurses' quarters at night, and any summons should be brought to her and by her referred to the Nurse ; or the summons should go straight to the Nurse's door. There are difficulties both ways, even supposing these summons should be unfrequent. The Nurse of each Pavilion should inhabit the room on the ground-floor ward, where the heaviest surgical cases will be probably placed, whence she can better command the movements of the Pavilion, and attend the entrance of the Surgeon. 2. Her day might be something like this (in time, perhaps, God will bless us with some Army Chaplain who will get up early and give us a very short service morning and evening) : — She should be effective, and enter the Pavilion about 6 a.m., go through the wards, read prayers in one by turns at the appointed hour, and give out the linen wanted. (Six is the nominal hour when the Head Nurses of one great London Hospital enter on their duty.) Here must be no nominal hours, all must be real, though not overstrained. Then the dressings, &c., attendance on Surgeons, &c. With 72 patients on different floors, she must train the Orderlies to do the lighter dressings (by training I mean real teaching, not leaving the Orderly to find them out himself) ; she must see all the wounds of all her wards which she does not dress herself at least every other day (which she can do by seeing some in the morning and some in the evening), and she must dress the ONE PAVILION. 69 heavy cases of all the wards herself. All this, with method, and not losing time by fetching and waiting, an efficient Head Nurse can do. She must be responsible for the linen of the wards ; but this must be simplified as much as can be, so as to secure respon- sibility, yet relieve the Nurse of unnecessary time spent over it. The Nurse should be relieved of all writing and counting, on the score of loss of time incurred. It will not do to charge a Nm*se, with seventy-two patients on three different ifloors, with serving each man his portion of diet; the diets of two wards would get cold while she was serving the first. It will be better to make the Ward-Master of Pavilion wards responsible for the serving the diets. There must, of course, bo a card at each bed, or some other record, showing the diet the man is ordered. The Nurse must know at a moment's I glance what each patient is ordered. The largest London wards are the two male accident wards in the London Hospital. Each Head Nurse has charge of five wards of 12 beds, separated (and in some respects impeded) by two lobbies. Very often there are fifteen beds in each ward (not by over crowding), and these Head Nurses are • often to be seen in charge of seventy-five patients each, includ- : ing many serious, and some urgent cases. The two lobbies, the small wards, and the duty of some daily writing and arith- metic in settling the diets, with some daily loss of time in fetching and waiting for medicine, render a Head-Nurse's service, as regards "manual" labour, less efficient than it might be ; even where she is most efficient. Eelieve the Nurses as much as possible of all writing and arithmetic. If it could be possible to relieve them altogether of the "settling" the diets, so much, by a great deal, the better. In the Lariboisiere system, with one Nurse to each Pavilion, it is utterly impossible to prevent the Nurse losing daily time and strength on the stairs. But, relieved of writing, of arithmetic, of losing time by "settling" and fetching, such women as it will be our aim to procure can get through the duty of seventy-two patients, although with the serious draw-, back of their being in separate wards and on separate floors. If, however, the Pavilion plan were so modified as to have two pavilions end to end, with an intervening staircase, so 70 NURSE S RESPONSIBILITY FOR DISCIPLINE, 3. Responsibility of Nurse for Discipline of her Ward or Wards —how Modified in Milicai-y Hospitals. spacious and well ventilated as to cut off the ventilation of the two wards on the same plane, then all the conditions as to health, and facility of nursing and supervision, would be much more easily obtained. Of this more hereafter. 3. As to the Nurse's responsibility for the good order of the three wards in a pavilion, supposing the three wards are served by one Nurse, there must always be a clear differ- ence between this responsibility in the Head Nurse of a Civil and a Military Hospital. The Civil Head Nurse, whose assistants are all Nurses, who with herself are under the Matron, is charged with, and responsible for, the good order of the ward, and it becomes her duty, the moment she finds herself unable to do this alone, at once to call in the Steward, or equivalent Officer, in whose hands is the police of the Hospital. The Military Head-Nurse's Assistants are Orderlies, i.e. men and soldiers, who, with the patients, are under military discipline. Of this military discipline, the military power from the Commandant down to the Non-Commissioned Officers acting as Ward-Masters, &c., is in charge ; the duty of the Military Nurse is, I apprehend, in case of any insubordination which she cannot put down at once, to call in the Ward-Master or equivalent, before calling in the superior Military or the Surgical Ofiicer ; it being, however, well understood on all sides, that she has the right of direct appeal to the superior Military or the Surgical Officer, if the Ward-Master does not do his duty, or in the event of a grave irregularity, if he is not at hand, besides its being her duty to report such to the Matron, if the case admits of being deferred till that can be done. It is impossible to settle details until the regulations as to the new Hospital Corps are fixed; and whatever regulations, whether for Nurses or for Orderlies are made, some difficulty, and much discretion will be inevitable and necessary in working them. But it is necessary to bear in mind that whereas in the Civil Hospital the Head Nurse, under the control of, and responsible to, the Ofiicers, including the Matron of the Hospital, is solely in charge of both the nursing and the discipline of her ward, both as to patients and as to Assistant Nurses; in the Military Hospital, she is in charge of the nursing, and the Ward-Master of the discipline, both of HOW MODIFIED IN MILITARY HOSPITALS. 71 atients and Orderlies. To be in charge of the nursing, oplies to have power to enforce discipline, but this is rather, 1 ordinary cases, to call in the military power, beginning 'om the lowest or Ward-Master's grade and reporting this 3 the Matron, than to invoke herself the military superiors, 'herefore it would be well worth while trying how far it rould answer to serve the three wards by one Nurse, who, in ach ward where she successively is, is bound, on perceiving ny irregularity, to call in the Ward-Master, and, in contiu- encies, to appeal directly to the Surgeon and the Captain of )rderlies, and to make the discipline of the three wards the fharge of the Ward- Master, who is bound to go through the rards when the Nurse is not in them. The Ward-Master, in >rder to fulfil his charge, must enter all the wards, while the ^urse is in one of them ; so that the patients of one ward, who aay know that they are safe from the Nurse for half an hour ►r more, as she is in another ward, know that they are not afe from the Ward-Master. In a military Hospital we must bear in mind that it is essential ;hat the discipline over patients and orderlies should be exer- jised by men, and that the Ward-Masters must be the lowest md immediate deposits of this power of discipline. All these things must be settled with the concurrence of the Director- General . It is a great comfort that the Hospital staff returns to joldiers. We shall get on infinitely better with them than we 30uld have done with the late Medical Staff Corps, though, . ifter all, in the long run, we should manage with them too. If snly God helps us with the sort of women required, thoroughly efficient Nurses, laborious active women, discreet as well as jwell-condacted, and aware (a little) of the sort of work and place, they are in ! — let us trust this to Him, when the time comes, and depend upon it, to give each Nurse plenty to do • will become one great means of forming such women — pro- vided, which must be strenuously kept in view, they are made to do it. -1. It is very important to have the system of lifts through- 4. Importance I! out the Hospital, although here, as throughout, the plan of of Lifts. Pavilions renders them much more requisite, and makes them work less efficiently than the block plan. Lifts, to carry meals 72 CASUALTY WARDS SHOULD BE SEPARATE IIL— L CasualtyWards for noisy and offensive cases should be separate from the ordinary Wards, and under a completely- appointed Staff of their own — both for Sanitary and administrative reasons. and medicine, linen, coals, &c., &c., to and from the first and second floor wards, are very preferable to the Orderlies carrying them up and down. One sort of load ought certainly not to be brought up and down by lifts, but to be carried up and down by men, viz., coffins and the dead. Using the lift for this purpose (as is done in one Civil Hospital) is on all and every account thoroughly objectionable. The system of lifts is the more important, because although there is no objection to the washing of tea cups, drinking cups, and medicine vessels at the sink in the scullery, it is certainly neither necessary nor safe to wash the dinner dishes close to the sick wards. By a little arrangement, the whole of these could be removed by lifts to a scullery beside the kitchen, and there cleansed and set aside for next day's use. III. — 1. Sanitary necessities can never be interfered with. The concentrating offensive and noisy cases together, while entirely separating them from each other, in a completely appointed set of wards, is a far more efficient working thing than appending a small ward to each ward. St. Thomas's (a very admirable Hospital in very many things) has a casualty ward (for such cases) for men and one, adjoining but separate, for women, under the charge of one Sister. Baths are in the wards. Gruy's had the same provision with, however, the drawback that there was not a Sister in charge, but a Nurse over other Nurses, with higher pay, but not a Sister or Head Nurse. •However excellent such a Nurse may be, every ward must be under the same regular government as is general in the Hos- pital, if discipline and order are not to suffer. Every ward or set of wards should be under a completely appointed staff. St. Bartholomew's had a set of casualty wards, including two of about ten beds each, several small wards of two and one bed each, including two with gratings and other melancholy necessary appliances to prevent extremely violent delirious patients from becoming suicides. These wards were often partially empty, never quite so. They were long served like the casualty wards of Guy's ; but some years ago they were placed under the charge of the Sister of the male operation ward immediately above, who received in consequence a small annual increase ol' wages. AND COMPLETE IN THEMSELVES. 73 London Hospital sent its noisome, offensive, and extra- iinfectious eases to its other wards — small wards for one patient eneh, and, like Guy's, not under the regular management of a regular Head Nurse. It most certainly appears that the plan of concentrating these cases together, but with (as at St. Bartholomew's) small wards where extra-violent patients can be put sejia- ratcly, tlie whole under one staff of Nurses, is far the best working plan. And for this reason. Occasionally, a very offensive case requires little nursing beyond the fixed daily dressings, and can lie quietly enough in his bed or ward. But noisy cases almost always, and offensive cases generally, require close watching. Now the moment we have a patient in a little room at the end of the ward, it is our duty to go in and out and see after him, and supposing him to be a violent, delirious case, he is, unless under strong restraint, unsafe alone ; and even then the restraint requires looking to. In very many cases the frequent inspection of Nurse and Orderlies would not be enough, and the man ought to have a watcher. We can never send one of the Orderlies of the ward, wanted for its regular duty, to sit down in one of these little rooms ; and we can never keep a fixed extra Orderly idling about, unless the little ward is inhabited. We must then fall back upon extra Orderlies, put in when the case wants close watching — of course not otherwise. At night, also, the watching which suffices for the ward will often not suffice for the extra case — and he must have a watcher apart. The plan of extra Orderlies or extra Nurses is a very bad one, to be avoided as much and as long as possible ; it very seriously interferes with the disci])line of wards. Recollect that each oft'ensive or extra-infectious case, put into the little ward, ought to represent a great amount of separa- tion and care, which it will be difficult to secure. His mug, utensils of all descriptions, bandages, &c., ought to be washed separately from those of the patients of the large ward. Is this easily secured ? In the two Borough Hospitals they at once remove a case of erysipelas or gangrene, occurring in any ward, erysipelas from 74 RESTRAINT IN VIOLENT CASES. venereal wards included, into the casualty ward. In the two other great Hospitals it is only when the erysipelas or gangrene becomes severe that the removal is made. JS'ow at once to remove these cases from the ordinary wards is very advan- tageous. St. Bartholomew's larger wards for male and female casualty cases, two small wards for two patients each, and two grated wards for one each, are very efficient. The wards are all con- tiguous, and, as has been said, under the charge of a remarkably efficient Sister, who has charge also of the male operation ward immediately above. The little casualty wards, of course, add to the work, and greatly to the anxiety of watching ; but cer- tainly violent delirium tremens' cases, alone and in a secure ward which can be darkened, appear often to quiet much sooner than where several of these wretches lie shouting to and at each other. Delirium tremens will never be a thing unknown in a Military Hospital. One such case in the little ward adjoining the Pavilion Ward would be a heavy infliction on the severe cases in the latter ; the noise would be heard throughout it. And unless the ward were properly secured, or unless the man were under strong restraint — and then that would require constant looking to— he would not be safe a moment alone; while the Orderly was emptying slops or bringing in his dinner, something might occur. 2. Restraint or 2. Eestraint is again a thing which must be left to our mas- Non-restraint ters, and to them solely — but an ugly, sorrowful, little truth may ^^remens!^ here be told. Eestraining and non-restraining processes, and- their results may be seen, both where, in the same Hospital, one or more of the Surgeons orders restraint never to be used to his patients, however violent, and others order it to be used in violent cases : and where the rule of the Hospital is to restrain violent cases, removing the restraint so soon as the paroxysm is over, or as soon as amelioration renders the sudden return of paroxysms less likely. I am not speaking of lunatic asylums, but of delirium, particularly delirium tremens, in hospitals. Lunatics occasionally enter the Civil Hospitals, but, of course, as soon as that supreme earthly misery is ascer- tained, they are removed to the proper refuge. It is my humble opinion and firm belief that mechanical restraint excites a |: SIMPLICITY OF CONSTRUCTION. 75 patient much less, and quiets him much sooner, than the prolonged struggle with his attendant's arms and hands, which must otherwise be resorted to. The coercion apparatus ought also to be good, not cheap, and always in perfect order. The least thing out of order either 'causes pain, which when it can be avoided is cruel, or it endan- igers the efficiency of the whole. The strength and cunning of these patients resembles those of madmen, which for the time behig they are. Eestraiut renders the usual complement of ward servants able to manage many cases. Xon-restraint means that some person must stand or sit by or upon the patient's bed, and hold ; and struggle with him often for hours — also that generally this person must be a stranger to the ward. Extra attendants are most injurious to discipline. Could there be a set of casualty or e(|uivalent wards, with its own Head-Xurse, the sick would gain much. But if necessary to adopt the little ward with every ward — in that case the Nurse must manage the three addi- tional patients — twenty-four or twenty-five are, indeed, too few. IV. In all Hospitals, let the construction be as simple as it IV. Simplicity ^ . T -i.! 1 i p of Construction can be. Let its splendour be its lotty airy wards, with plenty ot essential to windows ; water in all due abundance on each floor ; an ample, Discipline, not excessive, supply of linen, polished impervious walls and ceilings, well-laid and bees-waxed oak floors, and a thorough not excessive, supply of good apparatus of the various neces- sary kinds. But every unneeded closet, scullery, sink, lobby, represents botli a place which must be cleaned, and which must take hands and time to clean, and a hiding or skulking place for patients or servants disposed to do wrong; and of such no Hospital will ever be free. And every cornice, every brass lock or handle, which could be replaced by a plain china or ebony one ; every decoration, or flourish, or ledge, on doors, windows, tables, beds, presses, &c., represents either a collection of dust or a great waste of hands, time, and strength in un- necessary cleaning and dusting. These are not crotchets, but the result of close observation of the practical workmg ot these matters. Every five minutes wasted upon cleaning what had better not have been there to be cleaned, is something taken 76 NURSES^ MEALS. Polished Walls. Covered Exercising Place. Reserve Wards. V. Nurses' Meals. from and lost by the sick. Let the appurtenances of the wards be simple and complete, but as plain and as undecorated as it is possible to be. Polished impervious walls and ceilings are of the first con- sequence in Hospitals. It is perhaps hardly necessary tp state that, if Parian cement be used, it must not and need not be of the kind lining the wards and corridors at Gruy's Hospital, which is as rough as the rougliest plaster, of a dark and dirty colour, and which nothing could improve but being lime-washed twice a-year ; it should be polished like that used at the Lari- boisiere Hospital at Paris, and of a pure white. In building a new Hospital, some covered arcade or some place where the patients might take exercise in wet weather, and where inspection could be exercised over them, without fuss, is worth contriving In St. Thomas's, the patients walk under the covered arcades of the court. Both in Betlianien and in the Charite Hospitals at Berlin there are reserve wards, — or rather in the Charite there is a reserve Hospital, into which most of the sick are moved for six months in the year, to change the air alternately of all the wards, which during the time receive a thorough cleaning. Great stress is laid at Berlin on thus providing, when building a new Hos- pital, a certain reserve space, which obviates the necessity of less efficient and far more costly steps afterwards. V. Let us, by all means, consider as settled, that the Nurses' food is sent them cooked. Possibly, in the long run, the undoubted advautages of this plan will be found to be over-balanced by its disadvantages ; but let us begin by trying it. I submit that their dinners, and possibly suppers, should alone be sent them cooked, and that each Nurse should receive a fixed weekly quantity of groceries, and a daily or two days' allowance of bread. For packing up the Nurse's meals sent her from the kitchen, a Vienna custom might be useful. Each Nurse to have a long, strong, straw basket, properly named or numbered. Some contain five dishes and covers, but two or three would here be sufficient for every purpose, including an occasional slice of pudding. The dishes strong tin, with a tin cover, and if the Nurse prefers eating her dinner out of it rather than the dignity of plates, and the trouble of washing them up, the QUARTERS FOR ORDERLIES. 77 [atroii should let her take hers her own way. If taken \y hand, two baskets of this sort can be carried with ease, iut if the Matron, as a general procedure, sends each Nurse I hot little dinner, of a good well-cooked portion of meat and ggetables, one such dish and cover will do for one Nurse, and iree, five, or six can be accommodated out of the same asket, or one large basket, carried by two men, would serve II the Nurses round. The dishes should, in either case, be ^umbered or named, not the Nurse's name, but the ward. A dish and cover of strong, coarse earthenware is used in Ihe Vienna Hospital, as a grander edition of dinner, &c. The jin ones keep warm without fire for a long time. If the meal rrives when the Nurse cannot eat it, put by on the hob, or 3me provision for warming in the scullery, it will keep warm [.nd good till she can eat it. YL Supposing that we serve each Pavilion by one Nurse, f. submit that — 1. The Nurse's day-room should be on the ground floor. 2. The Ward-Master should sleep in his room on the second )r highest floor ; should tlie Nurses sleep' in the Pavilion, the ^ard-Master sliould still sleep in it. In the event of the Pavilions being arranged end to end, as Iready suggested, the difiiculty in regard to Nurses' and Ward- [Masters' rooms would be materially diminished. 3. I think, but am not sure, that the Orderlies had better sleep away from their wards, but I would leave this to be jettled by the Doctors. In cases of sudden outbursts of [danger, delirium, or drunkenness, from the results of concealed 'spirits, and of the Surgeon being sent for, it is useful to have, at once, other than the Night Orderly at hand. And a part of (what has been said as to the importance of the Head Nurse [sleeping near her ward, applies to the Orderlies. Yet there are important reasons why the Orderlies should not be or feel ■too much at home in their wards; and if the authorities are disposed to try the plan of lodging the Orderlies together, away from their wards, they are probably right, though I should not be surprised if, after a fair trial, it were found better to fevert to the having them near the ward. The Pavilion Plan, VI. Arrangements for a Pavilion served by one Nurse. 1. Nurse's Day-room. 2. Ward- Master's Sleeping-room. 3. Where should Orderlies Sleep ? 78 WARD SCULLERY. 4. Where should Orderlies Dine ? 5. Should Orderlies be brought together ? 6. Should Orderlies have a Day-room in Pavilion ? 7. Scullery to each Ward. 8. What should be done in the Scullery ? which, on the oue hand, gives all concerned more liberty of doing wrong than the block plan, and which, on the other, renders it more difficult to call in help, whether of supervisor or of Orderlies, if help is suddenly wanted in the night, makes it the more desirable to let the authorities take quite their own way, as to this. 4. I think the Orderlies had better have their cooked meals sent them into the wards. Of course, they can only eat toge- ther in detachments ; but in many cases, the absence of even one of the Orderlies would be very inconvenient. Perhaps just as the bell rings to summon to the common meal, something is going on which requires all the ward service ; the man either goes late to a cold dinner, or goes away just when he is wanted. If his dinner is brought to him in one of these emergencies, it is put by to keep warm till it is over. Eegularity as to meals, as far as possible, should be strictly attended to ; and is, in all well-regulated wards : and it is well, where, as in some Hospi- tals, there is a fixed hour for meals ; but it would seem better that the meals should come to the ward servants than the ward servants go to their meals. 5. In the case of Civil Hospitals served by women, it is very important that each Head-Nurse, and each set of Assis- tant-Nurses, should sleep, eat, and live in the ward and its appertaining rooms, and not assemble together more than can be avoided. With Orderlies the case is partly different. Still I would not unnecessarily bring them all together, any more than allow them to be too much at home in their wards. 6. If the Orderlies do not sleep in the Pavilion they should not have a day-room. 7. To each ward should be attached a scullery, small, but not too small, which only muddles things and work, well provided with cold, and, if possible, with warm water ; and it should be law that no patient enters the scullery unless sent there by the Nurse to help in washing up, &c. ; and, as a rule, they ought not to be sent there. Make them useful in the ward ; keep the scullery for the Nurse and Orderlies. 8. Prom this scullery let the Nurse get the water she re- quires— Orderlies ditto. Let the Orderlies eat their meals in it, if they do not eat POULTICE-MAKING. 79 ,hem away from the ward. The food of the Orderlies is gene- •ally dilFerent from that of most of the patients, and it inswers better for them to eat their meals not under the noses )f the patients. In emergencies, of no rare occurrence, the 3rderly must watch a patient and eat his dinner at the same :ime, and so must tlie Nurse ; but, as a rule, it is undoubtedly Detter that ward-servants should not eat under the observation 3f the patients. In the scullery all the cleaning must take place, whicli is not done in the lavatory. In the scullery extras are to be warmed, drinks ditto, hot- bricks heated, water- bottles filled, &c., &c., &c., and none of these things are to be done at the ward-fire. On the other hand, there is no way so good of making poul- Poultice- tices, a thing humble but important, as for the Nurse to stand "lakmg. at a small table in front of the ward-fire, to make the poultices there, spread them, and forthwith apply them. Sometimes in a large ward, where the Surgeon orders them extensively, a large iron pot is filled with poultice, and then quickly spread and applied. Sometimes the pot is filled and the poultices spread in the scullery or kitchen, to avoid the mess in the ward. AVhen a number of poultices are thus spread away from the sight of the patients, even by very clever N arses, some arrive too large, or too small, or too broad, or too narrow ; and either the poultice has to be returned, or, as of course usually takes place, to be put on the wound it does not fit. I would not trust any Nurse, including myself, to make a number of poultices of the right size, unless within sight of the patients. Kather than do this it is better to make the poultice-pot (wood does not hold heat, this must be of iron), in the scullery, to take it into the ward, and there spread and apply the poultices. But a large iron pot of linseed poultice seldom contains the article ncarlv so weU made, as when made in smaller consecutive quantities in a wooden bowl. The bowl does not keep warm above a certain time. Where the poultice is made in a mass, even by very clever Nurses, it never is so well made as when the Nurse makes the poultices in the wooden bowl. These 80 WARD PRESSES. must be forthwith spread, applied, and the bowl re-filled, if more are wanted. This is another reason why the person who washes the wound should also make the poultice, as also why the Orderlies should clean the ward, whythe Nurse should as far as possible be relieved of all "mental labour," and why kept as much as possible to "manual labour." All severe wounds she should wash and dress herself, and many a wound becomes severe, when the patient is allowed to fiddle over it himself Some wounds will not bear being left uncovered, and of course in some cases the Nurse will wash the wound, and immediately afterwards apply the poultice. In general, the Surgeon will consider the vvounds take no harm from being washed all round, and then poulticed all round. This requires not to be over-hurried, and not to lose a moment's time. A careful Nurse will never apply a poultice without having first seen the wound : carelessness, haste, idleness, over-work, and prudery, each and all produce very sorry results as to this. I think, therefore, poultices should be made in the ward, and immediately after the table cleared away, and the slight mess also. In some Hospitals they place a straw carpet just round , the table, and also carry it to any bed which requires an extra mess in dressing or cleaning. 9. Presses in ^- ^ regular store closet is hardly desirable. A good Ward. arrangement is this : — At the end of the ward, nearest the Nurse's room, or the ward-door, a large press for linen. By it or opposite it another press, for stimulants, dangerous medicines, stock medicines, such as castor oil and one or two others which are always to be at hand, though not ordered for any particular case, stock lotions (as few as possible), lint, old soft linen, stronger but not coarse ditto for pads, &c., cotton wool, tow, oilskin, splints and pads, &c., &c. Of all these things, the Nurse should always have a certain reserve on hand. It will be well worth while to see that these presses are made commodiously for their purpose. The linen press should have broad deep shelves, and the difi'erent kinds of things should be sorted apart ; the other press should have broad deep shelves VIENNA APPARAT." 81 for the heavier things, and separate slielves for the bottles ; the stimulants by themselves in one row, the stock medicines in another, unless these and the stock laudanum were toge- ther, but they are better apart, and the dangerous things upon the topmost shelf ; another row for sweet oil, mustard, stock lotions, &c., another row for ointments. Each bottle and pot to be distinctly labelled in whatever is reckoned the most lasting manner; opinions differ as to labels and letters cut in the glass. The latter are boring by night, if something is suddenly wanted, and it is just then that mistakes are to be guarded against. A strong clear printed label, securely fastened to the bottle, is preferable, to be renewed when neces- sary, as Orderlies' thumbs even while holding a bottle, if the Nurse's hands are on the bed, wear labels out. There is a great saving of time and of chance of mistakes effected by clearly printing the directions for the administration of medi- cine, "once," "twice a day," "every three hours," &c.j and affixing them to each medicine bottle. Of both these presses the Nurse should have the key or keys. One key might do for both, but it may be best to have two keys. It is a very good plan where the shape of all medicine bottles and of those for liniments is distinctly different ; and where, e.g., square bottles are used for poisons, or blue bottles for poisons, and square for lotions. A small narrow shelf over each patient's bed, or over his locker, solely for his medicines and wine. "When these are on the locker it is less convenient. AVhere the medicines are not dangerous, it is better to have them thus at each bed, than concentrated away from the beds. Dangerous medicines should never be. left at a patient's bed. The two presses will answer all demands. As, however, it does not do not to have a supply of everything that may be * wanted always in readiness, a stand or table in the ward should have upon it a small supply of whatever may be suddenly wanted — a little lint, linen, tow, and two or three vessels. The supply of lint, &c., to be small enough for the Nurse to keep account of it, and for the patients to know that account is kept of it. In constant daily use in the surgical wards of the great " Apparat" in 82 WARD APPURTENANCES. German Vienna Hospital is a thing called in Teutonic style " Apparat." Hospitals. rpi^g Nurse carries it round for herself, when preparing and dressing the patients, and carries it after the Surgeon when he makes his rounds. The system of both dressing and washing is in some respects so different from the English one, that the fittings would vary. This concentration of what is wanted for dressing and washing wounds, and for attending the Surgeon in his inspection of them, and of what is at once wanted on any- bleeding, fit, &c., is very useful ; all the more from its being in a compact portable form, which can be thus successively carried to each bed. An English carpenter would make a lighter and handier thing. Brass basins, which are there used, are not desirable. Of course, one must be most especially anxious not to introduce any novelty, particularly any foreign novelty, flister than can be avoided, and we may consider it better either to leave the general system unaltered of rushing on some emergency to the dressing table drawer, or closet, and thence bringing successively the things wanted, or at all events not to extend concentration further than the excellent plan, so far as it goes, of the London Hospital, where each Head Nurse attends the Surgeons with a large basket in her hand, containing most of the dressings required, spunges, and one or two little matters also usefully at liand. The apparat has the advantage of carry- ing wdth itself the basins used for washing. In the Military Hospital of Vienna a tray attends each Surgeon, without basins. 10. Nurse's 10. It is important to have the Nurse's room opening Room. Qj^gg -j^^.^ ^Yie ward, and, upon the whole, I should incline to its having but one door, although it may be thought better there should be a second, so that she caji leave her room without being seen to do so by the patients. Also, by all means, let the scullery be opposite the Nurse's room, and not between the ward and the room. As an invariable Hospital rule, rather more than elsewhere in Military Hospitals, publicity may be considered to be a very great police, and a still greater protection. It is far better that twenty-four patients should see the Nurse's door than one or none ; and that her room should open full upon the ward than into an intervening scullery. SINKS AND BATHS. 83 In contemplating a Military Hospital, we contemplate a )lace tbrougli wliich, one year with another, all characters, ncluding a few of the vilest, pass. These are not theoretical natters. The more repulsive the subject, the more prevention better than cure. Guard against too many closets, sinks, fee, &c., &c. At the end of the ward there should be a lavatory, Lavatory, kith a row, or two opposite rows, of white earthenware oasins fixed in a stand, with outlet tubes and plugs : each basin should have a hot and cold water-pipe : and there should be not I jess than one to each four beds. There should also be in the lavatory a hot and cold water-pipe, from which a portable aath can be filled. At the furthest end of the ward should be a water- Water-closet, closet, with not less than one soil-pan to each eight beds : and khite earthen or porcelain urinals in the same proportion, fn the London Civil Hospitals water-closets are now in general use throughout the wards, but not in all of the 2:reat Hospitals. In all the Civil Hospitals, it is usual that she patients' water-closets have no inside bolt or lock, and that ;here is only accommodation for one inside. In some London Civil Hospitals the male patients, able to take exercise, are expected to make use of urinals out of doors. These matters bne, two, or three experienced army surgeons had better pronounce upon ; other things are to be considered than the recommendations of architect, plumber, or even sanitarian. There is in a Berlin Hospital a very useful piece of prosaic Sink, apparatus — adjoining the water-closet, a sink, with a high, large, deep, round, pierced basin of stone, above a large hole, into which the contents of a bed-pan can be at once emptied, and from which the bed-pan is at once effectually cleansed. lAdjoining this is a sink into which all other slops are emptied. In mentioning this pierced basin or sink solely for emptying and cleansing bed-pans, &c., which is used at the Bethanien Hospital at Berlin, and is far better than emptying the said vessels into the often-occupied water-closet, and then cleansing them in an awkward fashion between the water-closet and the sink, it is necessary to add that the cock ought to extend far enough over the sink for the bed-pan, &c., to be thoroughly cleansed by a stream of water f2 84 BATHS. falling directly into it. The Nurse stands at the sink, empties the pail, &c., in it, without fear of splashing, and rinses and fills it, without stirring from the place. 'Now this absence of splashing water and of moving about from sink to pump, or cock, saves mess and time. The oblong sink, usual in England, has by no means the same advantages. (The partition containing the sink vrould be an appropriate receptacle for the bed-pans to hang by hooks or nails on the wall pending their use.) B<)ths. In Civil Hospitals, two baths, in an airy closet at the end of the ward, to be locked at all times when not in actual use, are a very great advantage. Bringing a bath into a ward, which in many urgent cases must be done when the baths are distant, is a messing discomfort. Still it had better be left to surgeons to say whether, in Military Hos- pitals, it would not be preferable to have, in each ward, only a portable bath, on wheels, covered with india-rubber, to be brought into the ward for any urgent case ; and to take all the men able to walk,- or safely to be carried, to the Hospital baths. Of these, some trustworthy, or intended and supposed to be trustworthy, man, who ought to rank as a non- commissioned officer, should have charge. An intelligent and respectable-looking man, a serjeant, has charge of the baths in the Grarrison Hospital at Vienna. In a great London Civil Hospital, St. Thomas's, it is the very admirable practice for each patient (of course with neces- sary exceptions) to be bathed on his or her admission. The Sisters are responsible for examining each woman in the bath, which is within the female wards, and for at once reporting before suffering them to go to bed, any case of suspected pregnancy, syphilis, or contagious disease. A man does the same for the men, who are bathed apart from the wards. This arrangement is an excellent one. On the other hand, severe cases, just able to be carried to baths, get no good by going through the air, and being jolted up and down stairs. In planning a Military Hospital, in which the service of women is to be introduced, it is important to obtain the advice of experienced Army Surgeons as to the arrangement of appurtenances of the wards to be used by the patients alone. Endeavour to prevent the system of holes and corners. It is SUMMARY OF WARD ARRANGEMENTS. 85 best that the Nurse's door should command the view of those Avho come in or out of the Lavatory, and in or out of the water- closet. This whole section is both ugly and important. 11. To sum up. I think it would work the best to have no store-closet, only two well-appointed presses, by which a certain amount of cleaning is saved, and a corner avoided. Could two cupboards or presses in the wall be arranged for the ward linen and the ward stores, it would be preferable to presses placed against the walls. Take care, however, that the wall is suflBciently thick, so that the presses are not damp, and if this cannot be provided against, keep to presses separate from the wall. Believe that all this is neither theory nor fidget — but practice. The furthest end of the ward should contain a lavatory, a water-closet, and the pierced basiii for emptying and clean- ing bed-pans is a very useful thing. At the other end of the ward, the Nurse's little room, her door opening full upon the ward. If the upper half were of glass, with a curtain before it, allowing the Nurse to see the ward without hems seen, it would be all the more useful. At St. Thomas's, a window opens into the ward, the Sister drawing a blind when she chooses, and a door opens into the passage, just within the ward doors, opposite the scullery, so that the Sister enters the scullery, in which there is a water-closet, for the accommodation of herself and Nurses, without traversing her ward. Whether door or window, the Nurse should see at once all that is going on in her ward. I prefer a door; yet, if there is to be a ward for one, it may be best and most central to have the Nurse's window on the large ward, and her door open on the passage. Opposite the Nurse's room should be a scullery, not too small. The scullery should be well provided with cold, and, if possible, warm water. If a supply of hot water can be obtained by turning a cock, this is best. Provision should be made in the ward scuUery for keeping poultices warm which is every now and then wanted. It is not ricrht to wash eating-vessels and poultice pans, &c., m the same sink; and this should be considered in arrangmg the scullery. If each ward washes its own bandages, which it oucht not to do, the second sink will come in usefully for 11. Summary. 86 POSITION OF NURSE^S DAY -ROOM this. It is worth while, in enforcing extreme simplicity, to prevent jumbling together eating-vessels and things for wounds and sores. Sinks are infinitely most handy when made deep, somewhat in the shape of broad round basins, with hole at bottom ; it saves much splashing and mess ; the cock to overhang full the middle of the sink. The wall against the sink should have some protection. Such a scullery, with complete efficient simple, apparatus for its various purposes, places for washing up and cleaning, and for ward purposes and cookery, so that the Nurse can warm the drinks, prepare fomentations, &c., without jostling the Orderlies, who are washing up or cleaning, will be a very great comfort, simplification, and promoter of order, cleanliness, efficiency, and -work. At one corner a decent little table for Orderlies' meals, above it their separate safes for their bread, cold rations, &c., &c. ; each to have and keep his key; each to have his locker. Each floor and ward will require a scullery. It is far better for each ward to contain its own appointments — and all the other stores to be together, apart. On the second floor might be the "Ward-Master's room ; vice the JN'urse's room. Il e^^iTf^^ c[uarters, if we are driven to their not sleeping Quarters. ^^^^ their wards, should be adjoining" the Matron's two rooms, and separate water-closet, in a part of the Hospital as central as can be managed without trespassing on our betters. I would simplify these quarters as much as possible — either a series of very smaU rooms, or one great space partitioned ofi" each into a little cell, with a window, bed, washing table, chest of drawers, and a very small wardrobe, with space to hang up three or four gowns, deep enough for another row for shawl, &c., at top a shelf for bonnet and caps, at bottom a deep drawer for boots and shoes. These things will be a convenient riddance to the chest of drawers, and comfort to the women. In each cell very strong hooks to hang up and air a little gowns taken off at night, and one or two chairs. The nurses must wash their hands, &c., in the rooms off their wards, and I think it must be understood as a rule that they leave their quarters in the morning and return to them at night. Optional carpet. Each cell to be numbered either with number or with name of Pavilion. Opposite this space a small lumber room, wherein AND SLEEPING-ROOM. 87 each nurse may deposit her box, thereby hindering dissemination of bugs. Opposite also a running open cupboard, with par- titions numbered or named as rooms, containing each Nurse's broom, dustpan, &c., each with a key. Also pump, sink, water closet. When furnishing begins, it will be well worth while to see Furnishing, that all articles of furniture, whether for wards or Nurse's quarters, admit of being easily swept and scrubbed underneath, and swept and dusted at top. Chests of drawers, &c., with too narrow space between bottom and ground, harbour dust, or sadly waste a few precious minutes in the most busy part of every day. As few high pieces of furniture as possible, to gather dust and be out of easy reach ; as few as possible of cumbrous articles difficult to move from the wall, to sweep and dust behind, &c. There ought to be, near the Superintendent's quarters, one or two small rooms, where, necessity occurring, sick Nurses might be lodged. We cannot hope always to escape having sick Nurses ; and there would be serious objection in a Military Hospital, where only one Nurse sleeps on each floor, to having the Nurse ill in her room for more than 2 or 3 days at the outside. Or there might be one good-sized airy room, with two or three dark washable curtains dividing it into little dormitories, so that one Nurse, whom the Superintendent must engage and watch, could attend them all. And as Her Majesty's Nurses must have allowed them such decent comfort as can be, but no fastidiousness, I think the cubicles in one room would be best. Not to be called so, however, by any means, as it would sound Latin and " Puseyitical." The Nurse's ward to be locked and key kept by Superintendent, except when tenanted. I should hope three beds would answer thoroughly, as well as that the ward would be empty eleven months out of the twelve. Considering the awkwardness of illness among Nurses, when it did occur in a Military Hospital, it would be worth while that, adjoining the little ward, there should be a little room for any one infectious case which might occur; e.g., supposing one Nurse ill in the ward with bronchitis, it would not do to put another with small-pox into the ward,— at least it would be very impolitic. The ward should have a water-closet and a little sink of its own, and a little cell, but with window and 88 CLASSIFICATION OF CASES. fireplace, for the attending Nurse to lie down in. When not used, once a month's, or week's at the most, cleaning bj a char- woman would be enough. It should be always clean and ready for use. In the Ci\T.l Hospitals, few years pass without sundry Head-Nurses and Nurses dying, not a few Nurses being warded, and sundry Head-Nurses ill in their rooms. The peculiarity of Military Hospitals makes this little preparation for what is certain every now and then to occur seem desirable and economical ; to hire lodgings in the neighbouring town would be in all ways a worse plan. 13. 13. Endeavour, if possible, to obtain a classification of the ^^S^Case^"^°" severe and non-severe cases, and let tlie Nurses be only appointed to the wards of severe cases. The convalescent cases to be successively removed to the convalescent pavilions, whether they bear or not that name. No convalescent ward in any of the floors of the Pavilions to be served by Nurses. 14. Niu-ses to 1^- ^^'i^l found excellent in many respects not to allow be called by the the Nurses' names to be used in the ward of the Hospital, or ^^"ward«^^^^' ^^ong each other, so far as the Matron takes cognizance of. In the great London Hospitals the name of a Nurse is never heard, except occasionally to each other as a solace, partly very natural, partly harmless vanity. She is Sister or Nurse of such and such a ward. In hasty parlance she is distinguished from the otliers by the name of the ward only. In it she is always addressed as Sister or Nurse. Thus a Sister of St. Thomas's Hospital, whose services in the War Hospitals of the East I can never forget, was always at St. Thomas's spoken of out of her ward as Sister of George, or, more commonly, Sister George ; and spoken to quickly or called to in a hurry as George. All this, the only course of all the great and, I belie v^e, of the smaller London Hospitals, works excellently, in many ways. 1.5. Foul Linen 15. Arrangements should be made that foul linen remains —how to be for the least possible time out of the laundry. As regards the Dispust d of. j^^^j^^j.^ deposits, the best plan is that of the London Hospital, where each ward has a bin of its own marked accordingly. To similar bins all the foul linen should be, at least, daily carried, unless it is judged best to receive and wash all the linen in a heap, returning numbers only to each ward. The former plan CAUTION ABOUT LINT. 89 16. Washiug is preferable. In any case the linen of the " foul wards" should be received and washed apart. During the time, which ought to be as short as possible, between dirty linen leaving the patients and reaching the bin or bins, a large box in the scullery \ is making the best of a bad business— the presence of foul i Hospital linen always is that— and is preferable to a closet. : 16. Washing bandages, a very important thing. Shall a I washerwoman be told off for that*particular purpose ? or shall tlie Orderlies of each ward do it alia meglio ? The former is ' the better plan ; if not adopted, the Nurse must see well to the matter. 3 7. It would depend upon what sort of work is usually 17. Splints- going on in the Surgical Wards of a Military Hospital in peace Eandages,Lint whether it will be worth either a press with glass front, in ^be\ept! which splints, pads, &c., &c., are excellently arranged, as at St. Bartholomew's ; or the pad-basket and splint-rack, which are also excellent, provided in London Hospital. The splint- rack, enabling the Surgeon at once to see and choose of all shapes and sizes, is perhaps only suited for an accident ward, and would be out of place in a military ward in peace. It may be better to have these stores entirely in some dispenser's or store- keeper's jurisdiction, and to let the Nurse confine herself to padding, &c., any sphnt sent by the Surgeon into the ward. Let our masters take exactly their own way about this. Bandages, lint, &c., &c., &c. should perhaps rest entirely with the Dispenser, otherwise it would be useful in the greater Hospitals, to have under the Matron a Nurse charged with preparing them and giving them out, writing in a book the date, amount of each, and the ward they are given to. In a small Hospital the Matron could do this herself While speaking of lint, it seems a duty to state that, in some Cotton Lint of the Military Hospitals, in certain County and even London ^^^^Jl Hospitals, and also in Workhouses, and in the practice of private Surgeons, a preparation of cotton has been recently substituted in the dressing of wounds for charpie or Surgeons' lint, pro- perly so called. So miserable an economy at the expense of the sick is not adopted in several, at least, of the London endowed Hospitals, probably in none. For all purposes for which lint is necessary cotton fibre should be totally disused, in the army and everywhere else. It is irritating and injurious to wounds. 90 STORE-ROOM. 18. Classification of Women. Superin- tendent'sStore It increases human suffering ; it delays patients in Hospital, and, in doing so, of course, increases the cost which such a substitution has been intended to reduce. Nurses should be particularly careful never to use this material, which is easily distinguished, even by the touch. Any Surgeon may tell the best of it from lint by submitting it to microscopic examina- tion, and on doing so he will readily discover that characteristic of cotton fibre which rendors it so ill adapted for surgical dressings. It does not absorb the discharges from wounds, as linen lint does. The fibre is ragged instead of being smooth, and it is apt to become matted together, and to adhere to the surface and edges. 18. It is essential to have as few women as can efficiently do their work. Supposing the Hospital were for one thousand patients, not taking into account that some wards would pro- bably be foul wards, where I earnestly hope female service will not be, at present at all events, introduced, and that some wards would be for slight or convalescent cases, where I hope it never will be — supposing each ^^'urse served seventy-five patients, supposing one Nurse, at the very least, was told oft' for the linen, fourteen or fifteen Nurses would serve the Hospital. I conclude the Matron to have no cognizance of the laundry. The Superintendent* will require a store room, or at least a store closet, and hers should be well appointed. It would depend upon the other arrangements of the quarters, whether the world in general, when sent for to fetch what it wanted, enter from the same side as the door of the Superintendent's bed-room, or from the other side. And it would depend upon the nature and amount of stores of which she had charge, in the larger Military Hospitals, whether or not she should have a Nurse told off for this also. Economy is essential ; but useless fiddling over every duster or scrubbing-flannel given out, &c., &c., &c., sadly hinders the Matron's time from more important things. Housekeepers must be avoided, and every woman must * The " Superintendent" and "Matron" are here used throughout as synonymous terms ; because " Matron" is the shorter aud more familiar name ; although, for reasons before given, " Superintendent" would be the better word for Military Hospitals. DOUBLE PAVILION PLAN. 91 have a distinct and sufficient share of work, and each be dis- tinctly and equally under the Matron. Still it would be ad- vantageous if we could from the first include in the staff of Nurses for the larger Hospitals, one or two places which could be filled by efficient persons who yet were unfitted for the ward work, which calling will be, and ought to be, laborious and wearing enough. Many a woman would never do to look after a Pavilion and seventy-five men ; who yet, in charge of linen or stores, would be most valuable, and influence most beneficially the Nurses, whom yet she might be unfit to govern. The system of the SoDurs de St. Vincent, who, in theory and fact, subject entirely to the will of the Superiors in general practice, are yet selected and trained for specialites, who remain long in these specialites, which specialites include such requiring more or less of physical strength, seems to be one giving many useful hints for us. Addenda as to Mixed Nuksing by Nueses and Oederlies IN Military Hospitals on the Double Pavilion Plan. I. After much anxious thought, re-consideration of all things, and pondering, I submit — 1. That three Orderlies will efficiently serve a ward of from 28 to 30 patients, including night-duty. 2. That each of two wards of 30 each, should there be two such under the same Head Nurse, on the same flat, ought to be entirely separate in all other respects. 3. That if night-duty be required, each such ward should have an Orderly on night-duty. 4. That each such ward should have a scullery. With regard to these questions, I further submit — 1. Economy of hands, combined with efficiency of service, is an urgent thing in all Hospitals ; most of all in Military Hospitals, Od the score of expense ; On that of efficiency of inspection ; 92 PROPORTION OF NURSES rrom the nature of Military Hospitals, where the aim should be throughout to combine great simplicity with thorough efficiency ; From the importance of training the staff, male and female, of Military Hospitals, for service in War Hospitals, where every man or woman who can be spared is better away. 2. Yet economy of hands, carried too far, becomes, like all other such economies, penny wise and pound foolish. 3. Without doubt, large wards can be efficiently served by fewer hands than small or moderate wards. But, as sanitary considerations limit the size of wards to from 24 to 30 patients, let us make this the basis of all calculation. 4. The more it is considered, the more essential it appears, to train ]N"urses, from the first, to do efficiently a great deal of work. A small staff of respectable, laborious, and thoroughly efficient women seems the thing to be aimed at ; whether con- sidering Military Hospitals by themselves, or as a training- school for Hospital war-service. 5. It would be better to give each Nurse one great ward ; but wards above a certain size are inadmissible for sanitary reasons. 6. The care of 24 to 30 patients is not sufficient duty, by a great deal, for a Nurse. 7. Therefore, upon the whole, and as decidedly the lesser of two evils, I recommend assigning to each Nurse two wards. 8. It is less difficult, and less objectionable, that she should have charge of two wards on one floor, than of two wards on two floors. 9. As regards the Nurse, I recommend therefore, upon the whole, to give each Nurse the charge of two wards of 30 men each ; the wards to be on the same floor ; but, except as being under the same Head Nurse, entirely separate. 10. It is important to repeat that the Nurse (who is Head Nurse), will be set free of two things, which consume much of a Civil Head Nurse's time. (1) . "Settling the diets," and fetching, besides waiting for, portions of those diets {e.g. wine) and medicine. (2) . Distribution of Diets. — It is quite possible that, in no long time, it may be found desirable to assign this duty to the Nurse. But it would be better to try to have it efficiently, AND ORDERLIES TO SICK. 93 which implies honestly, discharged by the Ward-Master. It will relieve the Nurse daily of considerable time ; and it charges the Ward-Master with a definite duty which he can perform. The more he has defined duties, the less he will be inclined to fidget and disturb the Nurse. He is pretty cer- tain to do this ; but definite duties will diminish the tendency. I should avoid giving the Ward-Masters too few wards. Otherwise they will make themselves insufferable obstructions, one way or another, to the Nurses. I should say that each Ward-Master, in charge of a Pavilion of six wards of 30 each, besides the small wards for one, would not have at all too mucli to do. Where tliere are no Nurses, the Ward-Master should have Assistant Ward-Masters in their place. N.B. Wine might be treated as medicine, and, as such, deli- vered by the Nurse. Wine and medicine are usually, in the Civil Hospitals, given from the Apothecary's shop at the same time. Or it might be considered desirable to leave this duty to the Ward-Master. In either case, it will never do to serve a bad case at once with all his wine, and either to let him stupify himself by swallowing it at once to make sure that he has it ; or to set it by his bed-side for the flies to spoil it, or for a dishonest comrade, or here and there an Orderly, to drink it. The Nurse should receive, whether directly or from the Ward-Master, the wine of such patients, and should administer it in successive small fresh portions. The intelligent adminis- tration of wine ordered to bad cases is one of those momentous minuticB by which, I do believe, and beheve more and more, many lives are, by God's blessing, annually saved in English Hospitals which would be lost elsewhere. Of course the only E-egulation about wine should be to specify whether the Ward- Master or the Nurse should administer it. 11. Eelieved of the loss of time incurred by fetching and waiting, and relieved at starting, at all events, and we will hope permanently, of the time consumed in distributing the diets, I certainly consider that a Nurse of the class of which, please God, Her Majesty's must all be, (strong, laborious, active, and conscientious women,) can efficiently serve two wards of 30 men each. 94 DUTIES Orderlies. 12. I should prefer wards of 30 each to wards of 25 each. 13. In forming rules for the proportion of Orderlies to sick, it is important to Consider that the duty varies extremely according to the appurtenances of the ward. 14. I consider extreme plainness and simplicity to be proper and indispensable to a Military Hospital. Let us take for granted (and may it prove correct to do so), that in none of Her Majesty's Hospitals Orderlies' time will be wasted in cleaning any ornamental things, whether unnecessary furniture, flourishes, or cornices, &c., &c., on necessary furniture ; super- numerary shelves, nooks and corners, &c., &c. Once provided, all these things must be carefully and constantly cleaned, or they become receptacles of dust and breeders of fleas ; and to clean them involves enormous waste of time. A few minutes daily wasted on each of many things, make an enormous sura. 15. But it is very true economy to supply, if possible — which in old buildings it often is not — every ward of every hospital with a constant supply of water, (taking care that it is not wasted by mischievous or childish patients) ; and to give every ward of every Hospital the use, under proper con- trol, of a lift by which, at fixed hours, food, medicine, linen and fuel are brought into the wards. Believe that this is not theory, but the result of practical observation, much extended. 16. Now, these two things — supply of water (if hot and cold so much the better, and supply of water imports, of course, the appliance for getting rid of it, and of the contents of bed- pans, &c., &c., by one or more sinks) and the use of lifts can be applied to a new Hospital ; can possibly, not certainly, be applied to some of the old Hospitals within the Kingdom, — can certainly not be applied to many of the Army Hospitals abroad. 17. Upon an average, these two things make the difierence of one Orderly's duty to a ward of 30 men, 18. And a ward of 30 men, so supplied, would be efficiently served by half a nurse and three Orderlies, including night- duty. 19. Without these two things (it is a mere comparative OF ORDERLIES. 95 question as to loss of time and absence of thorough cleanli- ness, wliether the ^Yater is brought from a pump in the court, or a stream some hundred yards off, above or below), andmanj^, if not most, Army Hospitals abroad, must always remain without these two tilings, I consider that one Orderly to every seven patients will not be too much ; while it is certain that, other things being equal, the ward with the appliances and the three Orderlies will be better served than the ward without the ap])liance3 and with the four Orderlies. Where there is no Nurse, one Orderly for 7 patients will always be advisable. In these memoranda as to Orderlies' work, &c., no notice whatever has been taken of the possible abolition of scrub- ing, because it does not do to count unhatched chickens. If, however, that formidable weekly business could be got rid of, as well as the bi-weekly or daily washings of bed-head- floors, &c. the labour of the Orderlies would be, without underrating that required for keeping oiled floors cleaned, very materially lightened. Nifflit-duty of Orderlies. 20. Convalescent wards, which will be of great use in many ways, will be of use here. With them Nurses will have nothing to do. It is possible enough that, in course of time, the Medical Ofiicers will desire to have Nurses there, and that it may be useful to place there elderly, still efficient Nurses ; but let this come or not as it will, and let us keep quite clear of them, at all events, till the Nursing-service be tried and established in Army Hospitals. In these wards, night-duty will probably be quite unnecessary, though in that case either an Orderly or Assistant Ward-Master ought to sleep at hand ; and night-duty is a service which must be spared wherever it can be spared, and rendered as efficient as possible wherever it is really wanted. I have before submitted that in Paris, Vienna and Berlin, the average of severe cases in Army Hospitals, in time of peace, is very considerably lower than in Civil Hospitals. This quite as much applies to English Army Hospitals. Whether the ordinary wards would require night-duty I do not know If thev often did, I should prefer havmg a regular 96 NIGHT DUTY Scheme of Night-Sri'vice for Three Orderlies watching l»y turns. night-duty in them. If they seldom required it, I would not have it. 21. In Civil Hospitals, served by women, I should undoubt- edly prefer assigning the night-duty to one Assistant Nurse. 22. But Orderlies are in sundry respects different, and, upon the whole, I recommend not to have night Orderlies, but to let each Orderly in turn do the night-duty. 23. It is important to remember — the more so as it is often forgotten — that to lay more upon human nature than its Maker has made it to bear, is to do a foolish, let alone a wicked thing. Upon an average, all men and women can dis- pense with, or abridge sleep for more or less time. Upon an average, all men and women, after a laborious day, require a good night, in the long run. "When they do not have it, either health, eflBciency, or sobriety, or all go. Believe, again, that this is not theory, but the result of practical observation, much extended. A strong soldier is no exception to the general rule. In the long run, if made to do night- duty after a laborious day, he will either go to sleep, or drink to keep awake, or he will get knocked up before his time. And this it is part of his business to be in time of war ; therefore, in peace-service, it is economical to let him last his time. It is then sound economy to give watchers sufficient sleep. 24. Supposing regular night duty required, in a ward of 30 men, supplied as above, and served by half a Nurse and three Orderlies, it might be worked thus : the Principal Medical Officer would decide whether the same Orderly should do the night duty for a week, or the three on successive nights : pro- bably the latter. The Orderly might come on night duty at 9 P.M., and remain on duty until 9 a.m., thus taking his share in the heavy morning work of cleaning the ward, &c. In all well- ordered Hospitals it is required that this should be done by 10 A.M., in some by 9 a.m. Earlier is undesirable in the English latitude (in other climates it is different), unless either the patients are to be disturbed earlier than English Surgeons consider right ; or the ward, &c. cleaning is hurried through. A large ward, got into thorough order by 9 a.m., is in very good time. Of course it may happen occasionally to be got ready somewhat earlier, but this refers to the average. OF ORDERLIES. 97 Scheme eoe Three Oedeeltes A. E. C. Seeyixg AYaed X. Monday, 3 p. m. A. goes to bed, after taking his share of the morning work, eating his dinner, and helping to clear away ward dinner, (fee. 9. p.m. A comes on night duty, after 5 hours' sleep, and allowing 1 hour for undressing, dressing, and eating his supper, Tuesday, 9 a.m. A goes off duty, having watched until 6 a.m., having breakfasted, having taken his share of the morning work, and leaving the ward clean. Let him have the option of one or two hours' fresh air, either now, or before 3 p.m. ; let him sleep full three hours ; let him have his hot portion of dinner taken to him at the usual hour, unless all the Orderlies on night duty are served together at a different hour ; and let him, 3 P.M., return on duty, washed and shaved. B goes to bed, (fee. ; 9 p.m. B comes on night duty. "Wednesday, 9 a.m. B goes off duty; 3 p.m., C goes to bed, &c. ; 9 p.m., C comes on night duty, :3 and for his meals, some little time must be given, I think you will get more, and get it longer, out of the man by giving him 12 hours on night duty and ] 2 hours off. Still it will not do to interfere too much with analogies, and the proper authorities must decide whether this is too much. 25. Again, leaving the question for decision to the proper Exercise for authorities, I had rather each Orderly had one hour or two hours Orderlies, for exercise each afternoon or each alternate afternoon, care of course being taken that he did not exercise himself in some tap. He should report himself to the Nurse, or to the Ward-Master, or Assistant Ward-Master on going and on his return. So should the Night-Orderly when coming on and going off duty. Also in many emergencies of no very unfrequent occurrence at home, and constantly abroad, the Orderly must dispense with G 98 NIGHT DUTY Night Eefreshment for Orderlies necessary. recreation time. Eut as a rule, it is certain that fresh air is necessary to preserve health in Hospital duty. Doctors of all kinds know and act on this as regards themselves. The waste of time and strength, at present too often incurred by the endless fetching, heavy carrying, &c., of many Hospitals is in a considerable degree counteracted by its forcing the Nurses into other than ward air ; the air of a Hospital Court is better than that of the best ventilated wards as it is, not as it might be. The same applies, in its degree, to Orderlies. But it is better, and far more economical, to avoid the fetching and carrying as much as possible ; to keep the ward attendants in the ward to their duty under the supervision of the chief and responsible ward-servant ; and to give each in turn a short daily recreation, if possible. 26. Now comes a thing I am very anxious about concerning night duty, the more anxious because it is important, and because I am afraid it is an innovation. I have watched the night duty with particularly anxious interest, in each Hospital I have entered, feeling at once its importance and its difficulties, and of the following principle I am thoroughly certain. The Orderly doing night duty should either be allowed refreshment during the night, or the recurrence of this night refreshment should be considered in allotting the rations. In none of the Civil Hospitals, so far as I know, is night refreshment given. The Nurses usually on board wages, apportion, when they can, some from their food. In one Hospital there exists a rule that no Night Nurse is to take refreshment during her watch, the intention being to keep her more vigilantly to her duty. This is one instance among many of the serious and cruel mistakes which men of business or bene- volence, or both, make, when legislating on matters which they do not understand. It is, fortunately for the fine Hospital where it is the rule, practically disregarded ; the Head Nurses knowing well that a Nurse watching and fasting in award from 9 to 9, or even from 9 till the breakfast hour of 6, would cither soon be unfit for duty, or put drams in her pocket, or doze through the night. A strong soldier, required to watch in a ward and fast from 9 P.M. till 9 A.M., or 6 a.m., or shortly before, would stand the trial quite as ill as a Nurse. There is an admirable rule at OF OKDERLIES. 99 two foreign Hospitals where I have served. Sisters watch in some wards, Men Nurses in others ; and each watcher receives from the house, on going on night duty, a bottle of beer, a can with about six or eight cups of coffee, milk and sugar in propor- tion, and three slices of bread and butter. The Sister s bottle of beer is about one pint; the Man-Nurse's double; his coffee can is also a good deal larger. The rule of allowing sufficient for three solid refreshments (which of course can if desired be made by the watcher two or three) during the night, is an excellent one. I think it would be very sound economy to allow each Orderly on night duty, a proportion of beer or porter, of coffee or tea, and of bread and butter, or bread and cheese, to take at his own time during his watch, besides his supper before going on duty, and his breakfast just before 6, (both Nurse and Orderlies ought to have breakfasted by 6, and to begin the day duty at 6, and I wish it began by opening the windows and repeating the short prayers for 5 or 6 reverent minutes). Of course it may be considered preferable to reckon this night-ration in the Orderly's rations. Or suppose the bread and beer or porter to be reckoned in the rations, and a can of coffee given him for the night watch. Settle details as is best, and of course analogies must be considered ; but in truth hospital watching is a very peculiar business ; important, unobtrusive, most peculiarly trying, and the bright side of very few Hospitals. Each watcher should undoubtedly have refreshment forthe night. The Nurse should have her groceries in the lump, and refresh herself as she likes out of them. Her watching, if she does her duty, will be, w^hen she has bad cases, severe enough; but I would not provide her with extra refreshment ; as the watch- ing is not prescribed and regular duty. There should be as little extra watching on the part of Orderlies as is possible; when it is indispensable the extra watcher should have the same night-ration. I submit my strong impressions on the subject of this night refreshment now, because, small as it may seem, it very largely enters mto the working of a night watch. I have suggested the division of the Night Orderly's sleep, because, if A. comes on duty at 6 a.m., and is sent to bed at noon or 1 to get ready for his night watch at 9 p.m., he is 100 NIGHT-DUTY scarcely fit for a long sleep, and supposing the patients dine at noon (an excellent liour) he has not, or scarcely, taken his share of the clearing away which, got over in time, enables the other Orderlies, one or both, to have a short recreation in the afternoon. Also if sent to bed at one he has not eight hours' sleep, as out of that he has to undress, dress, and sup. Also he has to remain on duty from 9 p.m. to 9 p.m. next night, which is much too long as a rule. If he does not go to bed before his watch, and goes off duty at 9 a.m. next morning, whatever time may be then allowed him for sleep, he cannot, as a rule, be depended upon for performing his watch duty efi&ciently. Where are the 27. If the Ward Orderlies watch by turns, it should be arranged Night that the men who sleep before and after the watch can do so Sleep by Day 1 quietly. This is by no means always attended to, as to Nurses in Civil Hospitals. Upon the whole, I cannot think it would answer to have always the same watchers, as regards Orderhes. The other Orderlies, supposing them lodged apart from the wards, will certainlj^ go seldom enough to their quarters during day, except during their exercise time. It may be thought essential to retain soldiers under very primitive notions as to quarters. So though in a dormitory of women, I think little cells, parted either with a partition or a curtain, the whole thoroughly airy, are in all respects preferable to unparted rooms, it may be, by some, thought better that the Orderlies shall sleep in large airy wards, not parted by curtains or parti- tions. I know, however, one high Military authority, at least; who considers the same reasons apply to men as to women in this. Soldiers are generally able to go to sleep whenever ordered. Indeed their general capacity of doing whatever they are bid is one of their many fine points. The Orderlies' wards must be under some sort of inspection, and noise must not be suffered in them. Non-Commissioned Officers, either "Ward or Assistant Ward-Masters, or some special functionary (but such I would not multiply) must sleep near, and have general charge of the order and quiet of such wards. I conclude that one or more Assistant Ward-Masters, at all events, must watch, and as they must sleep by day, this will fit in well enough. I should avoid putting the Orderlies in a too much out of the way pare of the Hospital ; they should know themselves liable to inspecting visits any time, I am not sure that Ward or OF ORDERLIES. 101 Assistant Ward-Masters would not be much better guardians of the Orderlies' wards than any special functionary. Drink is the vice of these men, noble fellows as, as a body, they are, and I should avoid quartering any man too comfortably and solely in one particular post. Cases have been where the duenna of the Nurses' dormitory was herself a determined, disguised drunk- ard, and reported others accordingly as she was bribed or not witli drink for herself. The whole question of Orderlies sleeping near or away from their wards should be well considered by the proper authority, two or three experienced Army-Surgeons. Upon the whole, I think it would be well to try the quartering them separately : there is much to be said on both sides as usual. 28. In several foreign Hospitals a certain number of Night Watchers, both Sisters, and Men-Nurses, are told off for night- duty for four weeks, during which they are exempted from all labour by day, and receive better food than the usual diet. They also receive good night-refreshment. In one Hospital the following is the arrangement. The wards usually contain from 10 to 13 beds, and there are many small wards for three, two, or one, bad cases or operation cases. All tlie wards open upon a corridor. The Sisters do not watch in the men's wards. Comparative Merits of Different Systems of Night Nursinor. A Sister watches in the female medical wards „ surgical „ „ children's wards and girls' ward A Man-Nurse „ male medical wards surgical wards and boys' ward An operation-case, or an extra bad or anxious case, or a case requiring special attendance and put in a single ward, has an Extra- Watcher. Often there are no Extra- Watchers : sometimes there are several at once. The Extra- Watcher is either a Sister or a Man-Nurse, taken from among the other Sisters or Men-Nurses, who, after his or her day's duty, does the extra watch. As regards all English hospitals, civil or military, the advantages of this system are these : — 1. It severs certain persons for night-duty, who have full time for sleep and refreshment in the air during day, and who are allowed to do no other work. 102 NIGHT-DUTY 2. It secures these persons good food aud refreshment at night. 8. These persons know their sick, and, being told on coming on duty, of any change, &c., are as much at home in their posts by night as others are by day. 4. When it is found that a Sister cannot sleep by day, and, therefore, that her health breaks, she is not allowed to finish the four weeks and become ill, but is put to another duty and another Sister appointed to the watch. (Many a strong Nurse cannot sleep at day.) 5. The persons so appointed get into the way of it, if they stand it at all, and the system is found a great relief to the whole house and a great gain to the sick, in the place of another system of dividing the night between two Sisters and two Men-Nurses, who each watch half of the watch. JPer contra. I. The great London hospitals are places very far from perfect : some things may, please God, be, with time, patience, and extreme quietness, very much improved ; but some things wall never be perfect and never can be. But they are places where I do believe, and so far as I know, the sick are cared for in a way that is done nowhere else. The proportion of heavy cases in every London ward, cannot, I think, be met except by having a watcher in each. An English physician or surgeon would not consider that his cases could otherwise receive the attendance and the watching, the observation of possible change and prevention of possible mischief, which they ought to receive. It is right to bear in mind, — 1. That small wards multiply exceedingly the demand for Watchers : four wards, of 10 patients each, taking the average of patients as in London, would not be attended, according to the English notion, by one Watcher; 40 patients in one ward would be fully attended by one Watcher. The London Hospital has two Night-Nurses for its quadruple wards. An extra Night- Nurse has frequently to be put on, on account of the difficulty the subdivision of tha ward gives to the watching. 2. That the average of severe cases in each ward of London hospitals is very considerably more than the propor- tionate average of severe cases in each ward of the foreign hos- OF ORDERLIES. 103 pitals in question. In all foreign hospitals with which I am acquainted the proportion of accidents is comparatively small to those of the London hospitals. The docks, the manufac- tures, the crowded and dangerous works, &c., &c., with us, account for this. 3. That, striking the balance for and against, it is neces- sary that each London ward should be watched by a Nurse ; at the same time, that without doubt a certain number of troublesome, ill-conditioned patients (no ward of any Hospital is without such) sleep soundly and let their neighbours sleep soundly when the Watcher only looks into the ward at frequent intervals, who would, if the Watcher sate in the ward the whole night, make it their business to require attendance from the Watcher during the whole night, or at least much oftener than by the otlier plan. 11. The second flaw of the above system, as it applies to London Hospitals, is, that it renders Extra- Watchers so often indispensable. The employment of Extra Watchers can never be wholly prevented, but it should be the endeavour of every Hospital to employ such as seldom as can possibly be. Extra watch- ing is most injurious to the health of all ward-servants, and to the sobriety, and therefore morality, of many paid ward servants. This is a very important reason, I humbly consider, for avoiding as much as possible small wards. I do consider small wards very objectionable in working a Hospital. But it is right to remember that we have been told of England, of Austria and of Prussia that the proportion of severe cases in Military Hospitals in time of peace is considerably smaller than in Civil Hospitals. Night watching is not done in the Military Hospitals either of Vienna or Berlin. Orderlies, or an Orderly, sleep in each ward, and watching is only done to bad cases. How far English Army Surgeons consider night watching desirable in the Army Hospitals I will presently tell. I should think the convalescent wards, among many impor- tant advantages, would receive a number of patients who require no night watching. An Orderly ought to be at hand here, but not watching. 104 NIGHT DUTY If niglit duty is considered requisite in the ordinary wards, I do not see how the English standard of things could be met, excepting by having one Watcher in each ward where there is regular night watching. I think, however, that the foreign system of night watching above detailed might give very useful hints for women in war service, and for emergencies of cholera, &c., &c., in home service ; and with regard to supervision in the latter. I think, with submission to the proper authorities (the two or three experienced Army Surgeons I have so often adverted to) feeling strongly that awkward mistakes might occur in several of these matters without them, as civilians and women cannot and ought not to trust their own judgments respecting such, that in a large Military Hospital, an Assistant "Ward- Master ought to go round the wards at night. Not with any idea of his rendering assistance to the Watchers over bad cases. The Nurses must do their duty of Head-Nurses, and see to this themselves. Perambulation through a large Hospital at night in point of fact excludes the possibility of doing anything in any one ward, unless in some exceptional occurrence which only proves the rule. The object is the important one of seeing that the Orderlies are awake, sober, alert, and at their duty, and that the patients are quiet and in bed. The Nurse would hear any noise, but there is such a thing as quiet drinking, as well as noisy drinking. In St. G-eorge's there is a Night-Matron, chief over the Night-Nurses, who goes through the Hospital every hour during the night-watch. I have heard this spoken of by experienced Authorities of other Hospitals with approbation and envy, and some idea was entertained of introducing it into another great Hospital. In Civil Hospitals, I think, but I do not know, that the benefits of this Night-Matron may be perhaps more imaginary than real. The Head-Nurses at St. George's sleep away from their wards ; a great mistake, I humbly consider. But Military Hospitals are entirely different in sundry essen- tial respects. I think a ntfn-commissioned officer. Assistant Ward-Master for instance, ought to make his rounds every night. When once such a service takes place, every hour is better than three or four times a night. He must be "up to" OF ORDEKLIES. 105 sundry things— taking the wards in uncertain rotation, some- times returning suddenly on his steps, &c., &c., &c. It will be worth securing, if possible (this parenthesis will be understood), that the Nurse's water-closet should be within her room, if not, as close to it as may be. 29. Tlie following extraordinary system of Night Nursing is Present State tliat which prevails in the Army at present : Night- The " nursing is managed" either by means of patients " told "^MiiUary^ off in watches" tlirougli the niglit for the purpose of attending Hospitals, to other patients, or by means of soldiers sent in from the ranks to attend specially upon each bad case; or by Orderlies " arranging it among themselves," without any exemption meanwhile from day duty. Upon each and all of these systems or no-systems it is hardly necessary to make any comment. It is dilEcult to tell which is the worst. In the principal, indeed the only General Hospital in Eng- land, " Nursing is managed by comrade-patients told off in three watches of two hours each for the night." \_sic.'] " Orderlies are likewise warned and often sit up for the pur- pose." These passages are given vcrhatim et literatim^ because they are so remarkable. And it is necessary to add that these patients being the relapses among the " Invalids" are nearly the worst cases we have. AVcre it the report of a Head-Nurse in a Civil Hospital to her Ecsident Medical Officer, it would undoubtedly cost her her place. One scarcely knows whether to pity more the sick patient or the orderly patient. One scarcely knows how to estimate the amount of medical comforts intended to be consumed by the sick patient which will actually be consumed by the sitting-up patient, and necessarily so. And the expe- dient which turns over the man who is too ill to be left at all to the care of men who ought to be recovering themselves, but who are pulled out of their beds for two hours to nurse (for the first time perhaps in their lives,) and a very "serious" case too, is to say the least of it a singular one. At Wooiwich Artillery Hospital the cases which require constant attention are about 2 per cent. There are now^ 545 patients in Hospital, and 11 cases consequently, each requiring 106 NIGHT NURSING IN one Orderly to itself. The Orderlies, according to Eegulation, are 55, so that one-fifth part of the Orderly service is required for these cases. Yet there is no system or arrangement for such. The Orderlies arrange (or do not arrange) among them- selves to do the reliefs day and night. Of the 11 cases at this time in Woolwich Hospital with 11 Orderlies sitting up with them, it so happens, as I am informed, that only one would require, if such were together in wards where regular night nursing was established, an attendant specially to itself. It is needless to enlarge upon the cruelty of the above prac- tice. The one serious case is disturbed in the day by the goings to and fro, the noise and bustle of the light cases — while these are disturbed at night by the sitting-up necessary for the one bad case, which may be besides, and too often is, a noisy or ofiensive one. The bad economy is as obvious. It often hap- pens that 11 cases who might all, if in one ward, be attended and as efficiently attended, by one .Night Orderly, require each an Orderly to itself in as many different wards. In the " G-arrison Hospital" at Chatham, "when any case assumes such a character as to require more than the usual care and watching, a Kequisition is immediately sent to the Com- manding Officer of the Corps to which the man belongs for a steady well-conducted soldier and who generally is the man's own comrade" [so much the worse] " to nurse him, and to at- tend upon him throughout his illness, but who is relieved by another as often as the Medical Officer in charge of the case considers necessary." The following is the average number of sick in Army Gene- ral Hospitals in time of peace at home, for whom night-nursing is considered necessary by the Medical Officers. But it is im- portant to add that this number would be probably estimated as very much higher if proper means of night-nursing were at their disposal. Of constantly sick mean proportion per cent, requiring night nursing : 1 TT -J- 1 i- -D'i.1. \ Medical Division 5 General Hospital, Fort Pitt | g^j.g^g^^ ^ G-arrison Hospital 2 These cases are usually scattered through the wards. MILITAPvY HOSPITALS. 107 It is but fair to add that the best Medical OfiBcers themselves desire another system, or rather are aware tliat there is at pre- sent no system at all, and would gladly accept one. " With means for good night-nursing," they say, " arrangements in accordance might be introduced. At present we like to have a case requiring much attendance amongst cases that require little, in order that the patients or comrades may assist." AVhat are the consequences of such "assistance" to the cases in question has already been fully stated throughout these notes. " Witli respect to the use of [the inmates as] servants, they Poor-Law require tlic strictest superintendence on the part of the * * Regulation oflicers. The employment of [the inmates] in offices of trust u^SoTwoi^ is inexpedient, inasmuch as it tends to impair the discipline of houses, the house. In offices of mere labour, which can be performed under trustworthy superintendence, [the inmates] may be useful. Where responsibility is involved, paid servants should be engaged." The above is one of the regulations of what?— not of a Cljaritable Institution but of the Poor Law; and the house of which it treats so tenderly and wisely is— a Workhouse!* If paupers are to be thus cared for, how should it be with our soldiers ? If any " office " can be called one " of trust," surely it is that of carrying out the orders of the Medical man in a critical case, a case of life or death ! Can any "responsibility " be "involved," greater than this? Tet these are just the cases left to the " Comrade Patients." For ordinary cases the ordinarv attendance is given ; for serious cases, the untrained and unskilled attendance. Yet, if the Hospitals are not for these serious cases, what are they for ? Tor these alone how- ever is no systematic provision made. One would thmk that every bad case took the Hospital by surprise. Imagme the orders of the Medical Officers carried out by nurses (?) changed "every two hours," and who are, m fact, sleepy ^'"^Thnvstem of Military nursing and management, as described by Army^Medical Officers themselves in the above quotations, . If it be said that the Workhouse sick are .11-nursed, it is in proportiorx as this rule is broken, not as it is kept, that they are so. 103 TWELVE SUNDRIES IN PLANNING and which is, we are expressly told, to be re-enacted at the Eoyal Victoria Netley Hospital, is precisely the one which led, as a matter of course, to the calamities, as far as nursing was con- cerned, in the Hospitals in the East, and which will lead to them again so long as it is continued. Even in the case of invalids, who may not require such careful attendance as sick, the system of nursing by comrades is most objectionable; and if the atten- dance at Netley can only be carried out on such a plan, it is doubtful whether Netley should be used even for an Invalid Hospital. The question has been asked the Netley Committee, By whom are your Invalids to be nursed, when sick ? And it has been answered, that they are to nurse each other! IT. Nurse's Eoom, &c. Nurse's Room. It is essential that between every two wards, in a hospital where the blocks are built end to end, there should be, as at the new Military Hospital of Yincennes, a lobby with a thorough supply of pure fresh air. If it were possible, where the Head Nurse, or rather in a Military Hospital the Nurse, has charge of two such wards on the same floor, to let her have a long, narrow room, with screened windows, opening into both wards, the door opening into the passage in the midst, it is worth contriving. Medical 2. The Medical Officer's room should be on the ground floor Officers Room. ^^^^ entrance and apart from everything else. The servant or whoever cleans the room, should not be a "Ward- Orderly, (ward-attendance cannot be kept too entirely separate from all other concerns). Water-Closets. 3_ The ward water-closet should have a pane of glass at top, so that a faint gas-light in the lavatory at night can light sufficiently the closet, and the (bed-pan) sink. The water-closet should be constructed, as is done often in those of English railway stations, so that each visitor involuntarily, on rising or on opening the door, purifies the concern. Besides the ward water-closet, there should be general A NEW MILITARY HOSPITAL. 109 water-closets, aDcl urinals separate from the wards, for the use, during tlie day, of those patients who can leave the wards. The latrines at the Lariboisiere Hospital are a good example, both for what should be avoided in construction, and what should be imitated in position. The sort of latrine used there would never do for England. The men able to go out are expected to use by day an urinal in a corner of tiie little garden belonging to each pavilion. At night no sick men are allowed to leave the ward on that or any other pretence ; they must use the latrines. Tlic latrines are at the furthest end of the ward. Opposite the one door is a partially glazed door, beyond this is a large window, grated in network as well as with panes and frame. On one side opens a space where the men, able to get up, are expected to wash, and which, moreover, contains two latrines, each separated by a partition and secured by a door. The same arrangement prevails on the female side. The rule of having the water-closet on the furthest side of the ward, removing all pretence of leaving the ward by night, is excellent. 4. The importance, immense addition of efficiency, and Warm and ultimate economy of carrying warm and cold water into every Cold-Water ward, and the necessity of intending and contriving this in the ^^PP^J- first construction of a Hospital, — subsequent additions and alterations being generally less effectual, and always more expensive — cannot too frequently be repeated. 5. Corridors as proposed at Xetley are useful and objection- Corridors, able. They lie between one side of the wards and air. They make oversight of the patients more difficult; and when a number of patients are walking up and down them, the serious cases in the wards are disturbed. On the other hand, it is desirable to have some place of exercise and yet shelter for patients, capable of being heated and of being overlooked. There ought to be no accumulation of patients at the same time sutfered. AVith regard, however, to corridors inside the building, if there are none it is all th.e better for tl.'e sick ; that each ward should have two rows of large windows opening direct into the outer air is indispensable, as has often been said already. 110 TWELVE SUNDRIES IN PLANNING Lobby. 6. Provided this double range of windows be secured, double wards of thirty on the same floor would cause no disadvantage to the sick. But, if such be determined on, let especial care be taken to separate the two, not by a showy hall, but by a lobby and an ample staircase, extending from top to bottom of the building, and communicating freely with the open air at the roof, as well as by the stair-windo\\ s : admitting a thorough current of external air, so that, of a morning especially, the two wards do not mutually send the close air into each other. The lobby should not be turned into a vestibule. Thorough air is all that is wanted. Patients should not be suffered to remain in it. Material of 7. The material of the different utensils required for ward U^n'n^ service should be settled. In the use of glass or earthenware for all eating, drinking, and washing vessels there is great su- periority as to cleanliness, and the saving of time and labour in cleaning these materials, to those of tin or other metal. Still two things have to be weighed against these great advan- tages. First, if these vessels are cleaned by Ward- Orderlies, the amount of breakage would be much greater in proportion than as done by Nurses, and it is imperative to have as few women as possible in the service of Military Hospitals. Secondly, it is very important to avoid even the appearance, especially at first, of anything like introducing luxury into Army Hospitals ; and I can quite understand this appearing like luxury. The material of one description of ward- vessels should in par- ticular be left to the Surgeons. In sending to distant foreign or war-stations, urinals of tin have one material advantage over those of glass or china, that they do not break so easily ; but, as to home-service, these tin urinals cannot, by any amount of cleaning, be freed from an unclean smell. In Vienna General Hospital, where economy is exceedingly attended to, all the urinals are of glass, as the superior cleanliness is considered well worth the additional expense. A damaged or broken glass or earthenware urinal is dangerous ; and if there is difficulty in obtaining the immediate issue of a new for a damaged one, it is better to have tin. In Vienna General Hospitals the patients' eating vessels A NEW MILITAUY HOSPITAL. HI were formerly of tiu ; but v^ eve some time ago furnished of ea^then^Yare, for tlie same reasons as those given above ; also because tlic hot tin vessels were found awkward to the patients. (I do not think much of this latter reason ; in hospitals, there is little fear of food reaching the patients too hot). In Vienna and Berlin ^Military Hospitals the eating vessels are all of tin. 8. In building a large new Hospital, the question of whether ReserveWards. or not reserve wards, or Pavilions, should be provided is an important question, to be referred to the proper Authorities In one German Hospital is a Sommer-Lazareth, or separate Hospital, which most of the sick occupy during the six summer months. This is considered the best plan ; but so expensive that well-considered arrangements in designing the building may render its adoption unnecessary. In another Grerman Hospital is a group of wards on eacli of two floors, into which tlie male and female patients, especially the surgical cases, are successively moved ; both in order that during this time the other wards may be thoroughly cleaned; also to change the air; also in case of some sudden epidemic, &c. In every Hospital a thorough cleaning of the wards is essen- tial. In three of the great London Hospitals this is done every year, in one every three years. Nuisance as it is, for the time being, it is such a complete purification of places which want purifying, that having it done every year is preferable to every three years. For the same reasons bare white walls, 'white- washed every year, and oftener if there has been some sudden outburst of any zymotic disease or Hospital gangrene are pre- ferable to all colour. But polished impervious cement is, it is necdh^ss Uj repeat, the only really safe Hospital wall. When the cleaning time of a great London Hospital draws near, the num- ber of patients is gradually reduced, and none but urgent cases taken in. The cleaning usually begins with the topmost ward of one part of the building, or of several parts of the building » at once. The patients are usually moved to the ward immedi- ately beneath. The ward goes through a complete purification, also reparation of whatever wants repair. All its furniture ditto ; the bedsteads in particular. Afterwards windows and doors are left wide open for two or three days, and nights so far as feasible. In about a week from its commencement the 112 TWELVE SUNDRIES IN PLANNING cleaning is over ; the patients moved back ; and the ward or wards so cleaned recommence their usual taking-in — and so on. The cleaning of a great London Hospital usually takes two full months ; and a great nuisance it is for the time, but the place benefits by it the whole remaining ten. It is excellent economy to have plenty of bands, so as to have the cleaning part, in distinction to the airing part, done as quickly as thorough cleaning admits of. It is very bad economy to put too much of this great extra cleaning upon the Nurses. This would of course not apply to a Military Hospital, where it is important the Orderlies should become as thoroughly qualified as may be for foreign and war service. It is necessary that whatever exterior help is called in, should be closely overlooked; contractors and contractors' servants being seldom overmuch troubled with conscience. Now it might be exceedingly worth while to have one or more reserve Pavilions, with a view to this annual cleaning. If the flooring of polished oiled boards should be found to answer (that it should receive a fair trial is very desirable, as it might result in a material benefit to our Hospitals), it would be doubly useful, when, every third year or so, the oiling and polishing required renewal, to leave the newly-oiled wards empty for a fortnight. An additional week or two would additionally harden and improve the flooring ; but a fortnight would suffice. It might also be right to have reserve wards for what must occur every now and then in a Military Hospital, an influx of patients beyond the usual number, or an outbreak of cholera, or some malignant epidemic, which it might be desirable to isolate from the other patients. It may now be confidently expected that, under the new regime, the progress in improvement of Military Hospitals will proceed rapidly ; that it will be quietly done is almost as certain — real improvement and noisy philanthropy being fear- fully inconsistent with each other, especially in that momen- tous machine called the Army of England, which is no safe plaything. Dr. Helm, the Director of the Vienna Greneral Hospital, in a little pamphlet published some time ago, insists on the impor- tance, in designing a new Hospital, of providing Eeserve wards, A NEW MILITARY HOSPITAL. 113 especially with a view to dangerous epidemics. They should admit, he urges, of easy and complete isolation from all the re- maining parts of the building. 9. Dr. Esse, Director of tlie Charite, at Berlin, in a practical and systematic, but pedantic and pudding -headed, little book on Hospitals, published in 1857, strongly urges the importance of occasionally revising and altering the rules of Hospital Ofiicers and servants, and all the Charite instructions end with this proviso of alteration. It is one of our many unavoidable difficulties that it is necessary to begin our work under definite rules, while it is also necessary to consider the service, for some years to come, as tentative and experimental. It is well to bear in mind what cannot be expressed. 10. In admiring much, very much about the Grerman Hospi- tals, it becomes necessary not to omit a warning. A number of women, all equal among themselves, with no female Superior or Superiors whatever, under the sole control of men, in an ascending scale from the Abtheilungs-Inspectoren or Oberkran- kenpfleger, through Doctors of sundry ranks, to the Director himself, such is the system followed, as in the great Charite Hospital at Berlin, so in the great General Hospital at Vienna ; and this cardinal mistake leads to many others. 11. It is desirable that the Eules should give daily exercise to the Nurses, or rather that the Eules should give them the right of daily exercise; that the Superintendent should encourage and exhort them to take fresh air daily when feasible, leaving them sometimes to take a little quiet in their rooms. But in war service, and sundry foreign stations in time of peace, not merely exigencies of service (which at home will and ought often enough to curtail or abrogate exercise time), but various other reasons might render it very undesu-able to give the Nurses right to two hours' daily exercise. It must be impressed upon all Superintendents, that it is essential in the long run to the health of Nurses to have fresh air; but in many foreign sta- tions it might be far better for the Superintendent to take, or rather send, them out for one vice two hours, &c. In war and foreign service, the exercise time must be at the discretion of the Superintendent. There may be awkwardness enough on sundry home stations in allowini? each Nurse two hours at her own discretion out- Occasional Revision of Eules. Defect in some Systems of i^"ursing. Nurses' Exercise. 114 REGULATIONS AS TO side of the Hospital every day. Still it is right to look things in the face. The Itules do not contemplate a Sisterhood, but a staff of secular women, bound by strict rules in all that concerns the duty they undertake, left to themselves as to sundry things which in Sisterhoods are ruled. (How and by what measures in process of time strong and quiet religious influence may be brought to bear upon this staff, is the question of vital impor- tance as to the whole ; without it, I doubt whether the service of women would, in the long run, answer in Military Hospitals, which are and must remain very peculiar places ; with it, it might please God to suffer good service to be done Him). Nurses trusted to do their duty in wards must be trusted to walk out alone if they choose, and I would not attempt to re- strict it, though the Superintendent must see to this, so far as she can without doing or encouraging spy-work, a thing which has many advantages, and is often done in various, very various ways, but which in the long run brings no blessing, and fro tanto, degrades all who are concerned with it. Number of 12. In Vienna Military Hospital each set of five or six wards, ^ard- Masters, ^-^i^ gQ patients, sometimes 20, in each, had a Sergeant and a Corporal over the Orderlies. (Berlin Military Hospital is served by Civil male Nurses). I think a "Ward-Master would be enough for each Pavilion of six wards of 30 patients each, in three stories, each couple of wards being in charge of a Nurse, and each ward served by three Orderlies. III. Eegulations. 1. Proper military and medical advice should be taken as to whether it would be advisable to draw a distinction between the venereal and the other patients. In the Vienna Military Hospital they are locked up by themselves in particular wards, but are allowed to see their comrades at visiting hours. In the Berlin Military Hospital they are locked up in wards, and allowed to receive no visits whatever, excepting, of course, from the Chaplain and the proper Military and Medical Officers ; and in the case of dying patients from their nearest friends. Query as to depriving certain Patients of Visitors. VISITORS. 115 Nor are they allowed exercise in the grounds. This excellent regulation makes them heartily tired of the venereal wards, and even this is a very salutary thing. In the Vienna and Berlin Civil Hospitals, the venereal patients of both sexes are also placed in locked wards, and allowed no visitors. Nor are they allowed exercise in the grounds or garden. In the two Paris Venereal Hospitals no visitors are allowed. Now, as the more disagreeable the subject, the more necessary it is to be explicit upon it when entered upon, this wholesome discipline exists in a very faint degree in our great Civil Hospitals, — a thing not to be lost sight of in introducing any change in the Army Hospitals. The three greatest London Hospitals have venereal wards. The female patients never leave the ward. The male patients take exercise in the court. In one case the rule is, that this should be at different hours from the other patients ; the rule is not strictly adhered to. The exercise question should, in Military Hospitals, be left entirely to the Surgeons ; they may fairly consider it enters into the question of treatment, which is different from the Continental treatment. The enforcement of different hours of exercise from those of the other patients is good, as is every brand whicli can, quietly and effectually, afiix disgrace to these wards. Deprivation of visitors, if it could be done, would be very salutary. In the great London Civil Hospitals, men and women visit the male venereal wards ; women alone the female wards (and melancholy things are the visiting hours there; here and there a heart-broken mother, abundance of prostitutes, and no lack of procuresses. A firm and vigilant Head Nurse will sometimes refuse admitting one of the two latter sorts to some patient, whom she knows they are endeavouring to make sure of again ; but as the rules admit female visitors, and she is by rights only entitled to eject a visitor whose behaviour is disorderly in the ward, the Head Nurse can only do this in point of fact by straining the rules, and cannot do it often). The female visitors of the male venereal wards are usually, on the average, much less disreputable than those to the equi- 116 llEGULATIONS. valent female wards; and are generally wives, mothers, and sisters, seldom prostitutes. There can be no doubt, however, that it would be much better if the patients of neither male nor female foul wards were allowed visitors, unless in the comparatively very rare cases of extreme danger ; it would, in that case, be necessary that the Hospital should supply them with linen, and either supply them with groceries or forbid their receiving them from without. In various essential respects the patients of a Military Hospital are different from those of a Civil Hospital. Were it possible to prevent all female visitors to the wards, except in dangerous cases, this would be best. If the existing rules or practice do not compel the sentries to refuse entrance to all disorderly women, however orderly their behaviour, such a rule, at any rate, should be enforced. And if all visitors, male and female, including, of course, soldiers, could be refused admittance to the venereal wards, always excepting cases of great danger, it would be very desirable. At all events, it would be very desirable to have all female visitors, without exception, excluded from these wards. These things are, I do consider, very important. But I would not press them, if refused. Let the female service obtain, please G-od (I do not write these words pro formd^ — if possible, I feel every day more intensely how solely it is to Him we must trust in this difiRcult work, — the more so that, if possible, I feel every day more intensely the importance of, if He grants it success, improving secular Hospital nursing, leaving the English Sisterhoods, which will always have great advantages, and, I believe, great disad- vantages, with reference to Hospital nursing, to take their share in this great field, which has plenty of room for both), let, I say, the female service obtain a firm footing in the Army Hos- pitals, and with it, and by cautious degrees, sundry ameliora- tions will creep in insensibly as to decorum among other things. Those solemn beautiful words I have always felt so full of meaning to us, " In quietness and in confidence shall be your strength." Query as to 2. Military as well as Medical advice should also be taken ^Patiente ^ upon the following point : In most, not all, the great London Hospitals the patients. S^'EARING. — CONCLUSION. 117 whose names are on their bed-tickets, are called by the numbers 1, 2, 3, &c., suspended over each bed; sometimes a patient's name is never heard in the ward. Now, very possibly, this would not at all do in a Military Hospital, and, if so, there is not another word to be said about it. Otherwise, very few things so effectually save time, as the numbering plan. (In Civil Hospitals it is also excellent in other ways, of much less consequence in a Military Hospital, which will never, I conclude, be afflicted with "gentlemen," Mr. So-and-So, and Master So-and-So, which latter inscription is frequently to be read on the letters of little boys in Hospitals, wliose friends, on visiting days, also enquire for them by that title). But few things, I repeat, so etfectually save time as nuuibering instead of naming the patients (names, of course, to be on bed-tickets). If, however, the officers consider it " unsoldierly," give it up at once. 3. The regulations lately in force contained in plain strong Regulations as language proliibition of swearing and indecent language in Swearing. Hospitals; tliey are quoted irom the Articles of War. It would be well to retain this in any new Eegulations ; and the retention of this Eule is not the less important when women are put in charge of INIilitary wards, since, though it is not their business to maintain discipline, it is their duty to call in those whose duty it is when discipline is infringed. And it is important that this prohibition of swearing and foul language should not be looked upon as an individual or collective crotchet, or female innovation, but remain the rule of the Service. Such language would never be used in the Nurse's presence unless by her own fault. But it should be unheard in the ward, whether she is in it or not. The old definite words should be transcribed. I do not like writing any part of the above, not because it Conclusion, can, in any sense, be said to strain the necessary principle of reserve, save for strictly business purposes, as to all which is, strictly speaking. Hospital business, but because of the extreme caution necessary as to this sort of topics. Still life is so un- certain that the possible iutroduction of permanent "Female Service into Army Hospitals has determined me on writing what I had rather not have written. 118 VENTILATION AT THE Additional Hints as to Pavilion Hospitals suggested BY THE construction OF THE LaEIBOISIEEE HosPITAL AT Paris, I. — Ventilation. The question of ventilation is so all-important, so much doubt still seems to exist as to the comparative merits of natural and artificial ventilation, so much has been said in favour of the latter, because it is seen adopted in the finest hospital in the world, the Lariboisiere, that I have added a few practical remarks upon this system. The conclusion is, that even at the Lariboisiere, without opening the windows occa- sionally, and especially in the morning, real freshness is never obtained in the wards, and that, therefore, if there must be artificial ventilation, that is the best which allows the most of the windows being opened. On the men's side, Thomas' system, or that of injecting air at given points, by means of two high-pressure steam engines, each working a large fan, is adopted. On the female side, Duvoir's system aff'ords ventilation by extracting air at given points. In both, a number of shafts and openings provide for the exit of the air. Persons at the Lariboisiere Hospital, who ought to be good judges, including foremost the Director, an experienced and able administrator, consider the ventilation on the male side the most expensive and the best, both for day and night, being the coolest in summer and the warmest in winter. In winter two great advantages are assigned to this side : first, the heating being provided by the Hospital, the wards are warm- able at pleasure ; whereas that of the female side is provided by the contractor at a fixed degree of heat, which, in extra cold weather, is augmented : from 15° to 18° C are the usual limits of the winter temperature on the female side, while that on the male side is usually several degrees higher. Secondly, the system of heating on the male side permits the windows to be opened : while on the female side objections are often made to opening the windows in winter, which it is alleged interferes with the heating. Per contra. How difficult it is to learn any facts by hear- say we know. Other persons who ought to be good judges LARIBOISIERE HOSPITAL. 119 think the male side apt to be too warm in winter, especially at night, and consider tlie temperature on the female side quite sufficient. Both sides are ventilated both by the windows and by the machinery by day in summer. Both sides are ventilated, each by its own different machiuerv, by night in summer, except that, exceptionally on hot summer nights, a window is opened two or three times in the night, or five minutes every hour. Both sides are considered to be ventilated in winter mainly by the machinery by day ; and both sides are entirely venti- lated in winter by the machinery by night. As far as can be made out from conflicting accounts, (conflict- ing from the very simple reason that one person will consider a ward, or drawing room, for that matter, airy which another will consider close ; one, pleasantly warm, another too hot or too cold), it is practically found impossible to freshen the ward of a morning without opening some windows, and to keep it fresh during the day without now and then doing the same ; and it is easier to open the windows on the male side in winter than on the female side. The ventilation on both sides is considered to work with equal efficiency during the whole of the day. Of the eighteen wards, the ventilation on entering the wards at five a.m., wlien the ward nightwatch has generally not opened a single window, is certainly surprisingly good ; i.e. the air is surprisingly little bad. But neither here, any more than anywhere else, are the icards efectually freshened, until the ivindows are, of course tcith proper caution, opened. In both these particulars, no difference is to be observed between the male and female side. In repeating that the Director, and other persons who ought to be good judges, consider the machinery of the male side the most expensive and the best, I add these things : First. Since this machinery was erected, so far as concerns the steam engine, it is said that equally efficient and much less expensive engines have been erected in other Hospitals, among others, Necker and Beaujon. In both Hospitals, the plans of Duvoir and Van Heecke are in use, one on either side. But certainly, the system of outlets at Beaujon for the foul air is by no means so good as at the Lariboisiere. 120 VENTILATION AT THE Secondly. If an accident happened to the machinery of the male side, which is in communication with the steam engine, the results might be very serious. Twice a stove has burst on that side, happily without damaging anything else than furniture near it ; had patients been near it, they must have been hurt or killed ; and an accident on a large scale might blow up not a small part of the Hospital. More or less danger is inseparable from powerful steam machinery, or powerful machinery of any kind : the question is one of degree. Thirdly. Both sides of the Hospital have one thing in common. Except the sculleries of the 3 ground floor wards on the male side, which have each a stove or fire place, the kitchens or sculleries attached to all the other wards are warmed by hot water. Undoubtedly this saves much mess, much cleaning of stoves &c., and much bringing of fuel and conse- quent dirt. But the absence of fire is always a loss to the service of a ward. Sundry things, some one or other, often all of which are constantly wanted in a large ward, e.g. warm- ing broth or drink, cooking for an extra bad case, warming poultices, warming (not airing) linen for ditto, &c., &c., &c., are much more slowly done by water than fire heat, and it is a question, variously answered, whether some of these things are as well done by the slow water method, as by the quick fire heat. Occasionally the hot water is not forthcomiug, a nuisance alike to the ward attendants of the ward whose scullery is thus heated, and to those of the wards supplied with stoves, which have then to do, in driblets, considerable ex- tra duty. During the hot months the smell of the latrines is very little perceptible in the wards, generally not at all: but the test of this, as of the ventilation, is in winter, when the large window close to the latrines is generally closed, and the smell is very ofi"ensive- II. — Oiled Boards versus Parquets. 1. They have in common the superiority over common floor- ings— that they are not scrubbed, and the damp thus arising is avoided. LARIBOISIERE HOSPITAL. 121 2. As regards labour, so far as Civil Hospitals are concerned, where tlie ward service is done by women, parquets would be more laborious than scrubbing ; a large ward, to be kept in a proper state, requires a certain amount oifrottage (the peculiar il>6W^\m\^ parquets) every day; and this/ro^%e is held to be unfit, from the fatigue it causes and the strength it requires, to be done by women, and is always done by men. Certainly Ward Nurses could never be required to frotter ; it is altogether a man's business. 3. As regards labour, so far as Military or Naval Hospitals are concerned, where men preponderate in the ward service, it is my impression (for of course I cannot pretend any certainty as to tliis), tliat sailors who are proverbially handy (a different quality from cither laboriousness or endurance, though they have these too) would, with instruction and painstaking, accomplish in time frottage ; that civilians would under the same conditions; that soldier orderlies (infinitely, I humbly think, the best material for the staple of military ward service), would generally make bad frotteurs. 4. As regards labour, cleaning oiled boards, though a laborious business, is much less so than either scrubbing or frotteing ; and is fully within the power of average strong women : none otlier should nurse. (What subdivision of clean- ing the ward, and of nursing properly so-called, might both improve the work done and relieve the Nurses, is another thing ; my impression remains, that it is better to consider these things to a certain extent as distinct duties, discharged by women ranking alike ; and that in a ward of forty, served by a Head Nurse and three Nurses, to charge one with the main ward cleaning, is better economy of strength and time than to divide it among the three). 5. As regards labour, any Orderly giving his mind to it for a day at the shortest, or a week at the longest, ought to learn thoroughly how to clean polished oiled boards well, always supposing him to be properly taught a very simple thing, which, like everything else, can be done well, ill, or indifferently. 6. Apart from the question of labour augmented or spared, the advantages of oiled and polished boards I believe to be these : — (1.) Prevention of dust. 122 OILED BOARDS (2.) More easy purification of the air of tlie ward in the morning. The air of every ward becomes more or less impure during the night, and the floor and furniture more or less dusty. Making the beds in the morning adds to the dust the night has accumulated. The dust is more thoroughly destroyed by the cleaning necessary to oiled and polished boards oftlie BetJianien variety, than by any other cleaning I have seen. It is fairly destroyed ; whereas both parquets and boards generally retain a little. Also, the water, with which the oiled boards after being swept are cleaned, freshens the ward and purifies it of the close- ness remaining of the night air, in a very speedy and remark- able manner, which is even more evident as well as more useful in winter than in summer — as in winter it is not possible to admit as much air from the windows as in summer, especially when it is most wanted, in the cold, close, early mornings. The advantages of oiled and polished boards as counteracting the spread of miasma, which is strongly dwelt on at Berlin by competent authorities, I have not alluded to, as probably parquets are considered equal in these respects to them. Stains, mess, and dirt falling on polished oiled boards are much more easily cleaned than on parquets. Note. Mode of Gleaning Ward and Room Floors at BetJianien, Berlin. I. Daily. 1. Take a common hair broom, a broom with a hard brush, a cloth of coarse flax, and one or two pails of cold water. 2. Sweep the floor and skirtings with the hair broom. 3. Dip the cloth in a pail, wring it gently between the hands, so as to have the whole equally wet, not running. Throw it on the ground, reverse the hard broom, and placing the reversed handle upon the cloth, clean the floor close to the skirtings, not the skirtings themselves, and the corners. When the cloth becomes dry, rinse it and re-wet it in the same pail. 4. Then wet the cloth somewhat more, wringing it as before, throw it on the floor at the end furthest from the door, VERSUS PARQUETS. 123 and placing the brush of the hard broom upon it, brush, firmly ^nd quickly, each board in the direction that the boarding runs, about as far as the arms can reach, standing, not kneel- ing. A small ward can be at once brushed wet, a large one •must be divided into parts, and each part be successively brushed wet and brushed dry. When the cloth becomes dry, rinse it and re-wet it. 5. To brush dry, rinse and well wring the cloth, brush as i before. The firmer you can press, the better and quicker the floor will be dried. When the cloth becomes wet, rinse it and wring it as before. I 6. Change the water when dirty. More or less water must be used, according as the floor is trod by dirty boots and shoes. 7. Aim at drying the floor by one dry brushing ; if not, it must be dry brushed a second time. Once should suffice. 8. Ten minutes, at the furthest, after the dry rubbing is over, the floor ought to be thoroughly dry. When it is quite dry, sweep quickly over it with the hair broom. I 9. On putting by the cleaning materials, rinse well the cloth in clean water. ' II. Weekly. 1. Brush the skirtings with a small hard brush, and wipe them dry with a rag, as the cloth would be too large, and wet the walls. 2. Use more water to clean the floor, which will probably require two dry brushings. 3. Clean the brooms and pails. III. Annually. 1. Throw warm, not hot, water on the floor, and brush firmly and quickly, wet and dry. A very little soda in each pailful will be an improvement. More than very little will injure the flooring. [A new cloth, which it is economical to cut from a great 124 A FEW CAUTIONS piece which makes into some or many dozens, should be steeped for a night in a pail once filled with boiling water, and in the morning rinsed and wrung several times in clean cold water, then used at once. Two or three new cloths can be steeped in the same pail.] III. — Cautions in IIospital-Bidl cling . — Often repeated, hut oftener neylected. 1. Wherever practicable build the hospital on arches ; but, for the sake of discipline, they should be locked up. 2. If practicable, let the laundry, if served by women, be removed from sight of the place where the patients take exercise, and of the ward windows. 3. In a Civil Hospital it is objectionable to give the female patients right to take exercise in corridors which the officers and servants have constantly to traverse to go to and from the wards. In a Military Hospital ii is of little comparative dis- advantage that the patients should do this, although, 4. In building a hospital it might be well worth while to contrive that the covered space, essential to give the patients power of taking exercise, should be used solely for that purpose. 5. In Germany, the general opinion is in favour of small wards, twenty beds are considered the desirable maximum ; twelve, 2^er se, better than twenty. Ditto in Belgium, under the same restriction, although, in practice, there are wards containing larger numbers. In the old Hospitals at Paris, the number of patients is too large. The Charite has long great wards of 100 and 120 patients. At St. Louis (which is mostly for cutaneous, not venereal, diseases, where the patients usually are long under treatment and able to go about, and where there is little acute illness,) wards of eighty and seventy beds are the rule, smaller wards the exception. This may be considered an ex- ceptional class of patients. The Charity, somewhat densely pressed upon by neighbourhood, is also not considered a favourably circumstanced Hospital as to air. Putting aside for a moment the sanitary question, which we have fully discussed elsewhere, and which appears to be IN PAVILION-BUILDING. 125 .decided in favour of wards of from twenty to thirty patients, .we will look upon the question of administration. The moment we consider that a great public Hospital has to pro- vide efficient attendance for all the sick it receives, that it must be economical of attendance, both because the expense of attendance, as well as the other requirements of the sick, commands all practicable economy; and because efficient attendance in sufficient numbers is difiicult to obtain ; it becomes evident that it is far better for the sick to have larger wards, efficiently served by as few attendants as is compatible with efficiency. This, which is the fair statement of the case, strikes those who have watched the working of the system of small wards in North Germany as more true than ever. Such persons consider that the size and numbers of the wards at the Lariboisiere Hospital, viz., thirty-four beds, in- cluding the two in the little ward, are good: that preserving the existing considerable space between the beds, and supposing the same ratio of conditions as to windows, &c., and the small ward for two at the end, wards of forty or fifty would be equally healthy for tlie sick, but that the number fifty should not be surpassed. Assuming, however, that thirty patients in a ward, or thirty- two, are the maximum number, sanitary and administrative necessities being conciliated, let us see what we do in our Military Hospitals at home. In most of our Eegimental Hospitals the number of wards and of holes and corners, in comparison with the number of sick, is quite extraordinary. In a hospital for a battalion 500 or 600 strong, we shall find eight or ten wards of sm.all size, a small kitchen, everything, in fact, on a small scale, just as if a large French Hospital had suddenly collapsed. How much more sensible would it not be to have one or, at most, two large wards for thirty sick each, with a small casualty ward and an itch ward ! How much less expensive such a structure would be in erecting and administering, and how much more easy would be the discipline and oversight, not to mention the greater facility of ventilation ! 126 A FEW CAUTIONS 6. There is nothing at the Lariboisiere Hospital answering to casualty wards. Besides the eighteen wards of thirty-four each, the Hospital contains two little (and inconveniently placed), wards of ten beds each, which, when medical cases overflow, are made medical wards ; and which are closed when the ordinary wards suffice. But of casualty wards, for offensive, or noisy cases, there are none, and the double- bedded little ward at the end of each large ward is intended to answer this purpose ; also, but subsidiary to this, to allow now and then a patient of the better class to have the comparative privacy. This latter consideration does not apply to a Military Hospital. As to allowing Non-Commissioned Officers for instance to be in the little wards, discipline would, I think, very soon suffer. But if casualty wards are provided for extra offensive, and noisy cases, it seems to me that any Hospital would be much better without these small wards attached to each larger one. Apart from tlie purposes which the casualty wards ansiver, they are a nuisance. If convalescent patients are put into them, they are comparatively removed from inspection, and often play tricks there. Patients requiring much attention can seldom be put there, however their condition otherwise fits them for the little ward, because the ward attendants, and especially the Sister (as in secularly served Hospitals the Head Nurse), find it impossible to serve the inmates of the little ward properly, if there are also many serious cases in the large ward. I submit therefore that the small ward is only an incubus, if casualty wards are provided. One thing is certain : a patient requiring much attendance, put into a little ward, ought to have an extra attendant to himself, by day and by night ; otherwise, either he is more or less neglected, or he unduly monopolises the service of the ward attendants. It remains a question for far others than women to settle, whether off'ensive and delirious cases are under more favour- able conditions of cure when scattered in little wards, than when assembled in a large, or in several small wards. On this subject, I can only add my confirmed belief that a large IN PAVILION-BUILDING. 127 airy ward, provided with a few small wards, and with complete ward attendance, is a much better place for the care and attendance of such cases, than small wards attached to the i ordinary wards. ! 7. Avoid many holes and corners. I could ?zo^ recommend . a dining room for patients attached to each ward, or floor, or ; pavilion. If there is any dining room, let all the convalescent ; patients of the wards not being convalescent wards, dine ■ together in a room apart from the wards, and let the rest dine each at his bed side. If not, let each patient dine at his bed side. At the Lariboisiere Hospital, each ward has a vestiary, a doubtful arrangement. The nature of a Military Hospital renders it proper to have but one vestiary under charge of some man. 8. If possible, let all foul linen be delivered daily, twice 1 perhaps better than once daily, into the laundry, so as to ' remain the shortest possible time in the neighbourhood of the ward ; otherwise, do what you will, foul Hospital linen will \ fairly, to say the ugly truth — stink, and its temporary recept- , acle will stink also. I would not make this temporary receptacle a room. A large chest in the scullery, a region ; under constant purification by fire and air, would be, as i already hinted, p. 88, the least bad place for an accumulation inevitable to all Hospitals, but which should accumulate for as little time as possible. 9. Provide from the first room for storing and issuing dried , clean linen, as well as laundry room. j 10. In badly-planned Hospitals artificial ventilation is an ' excellent auxiliary for expelling the foul air, engendered in the ward, especially at night ; but windows only can be relied upon for introducing good air. Let Hospitals, therefore, be so con- structed as to admit of opening one or more windows as much as possible all the year round, with as little chance of draught as may be to individual patients, which can be done by provid- ing double windows, opening above and below, or by some similar expedient. 128 "contagion" and " infection" defined. Note on Contagion and Infection. There are no words in regard to which there is more mis- conception, or more nonsense talked and written, than the two words "contagion" and " infection;" and as the word "infec- tious" has been used in these Notes, it is necessary to say what it does mean, and what it does not mean. The word " contagion" appears to have been first used by certain classical writers to signify the spread of scab among sheep ; and it would have been well for humanity if the word had been restricted to this very primitive bucolic signification. It was not till centuries after "Virgil's death that the common sense of men had descended so low as to iutroduce it into the Medical vocabulary. This took place at a period when, from the neglect of sanitary arrangements, pestilence attacked whole masses of people, and when no one appears to have considered that nature had an}^ laws for her guidance whatever. It was not until human intelligence had descended to this depth that men seem to have bethought themselves of Virgil's term as affording them an adequate explanation for pestilence, and sufficient reason for not exerting themselves to prevent its recurrence. So it has continued ever since. The little word used in all innocence by the poet for poetic purposes has become the ground-work of every manner of false observation, false reason- ing, neglect of sanitary laws, lazarettos, quarantine, and con- tinually-threatened interruption to the commercial intercourse of mankind. No single word has ever done so much harm to the human race, or given such a proof of what a mighty thing a word is ! One would have thought that, after the sanitary experience of the last fifteen years, the word " contagion" would have disappeared from our language ; but, even in the last document issued by the expiring Board of Health, written by their Medical Officer, Mr. Simon, and based on erroneous statistical evidence (Papers relating to the Sanitary state of the People of England, 1858), it is stated that " a further — practically speaking, unavoidable — cause of premature death in every civi- lized country is the risk of its current contagions T [The italics are not mine.] And this refers to small pox, hooping cough. " CONTAGION" AND INI^^ECTION" DEFINED. 129 measels, iiud scarlatina, tlic mortality from which wc are to presume, is " unavoidable." If this be Board of Health doctrine, it is certainly not sanitary doctrine. It would have astonished tlie Health of Towns Commission, and the first Board of Health. "Contagion," as its etymology implies, means the commu- nication of disease from person to person by contact. It is often confused with "infection;" but it has quite a different meaning. Contagion presupposes the existence of certain germs, like the sporules of fungi, which can be bottled up and conveyed any distance, attached to clothing, merchandize, especially to woollen stuffs, for which it is supposed to have a particular affection, and to feathers, which of all articles it especially loves, so much so that, according to Quarantine laws, a live goose may be safely introduced from a plague country ; but, if it happens to be eaten on the voyage, its feathers cannot be introduced withotit danger to the entire community. The absurdities connected with the doctrine are numberless. Suffice it to say that in the ordinary sense of the term tliere is no such thing as "contagion." There are two or three diseases in which there is a specific virus which can be seen, tasted, smelt, and analysed, and which, in certain constitutions, propagates the original disease by inoculation, such as small-pox, cow-pox, and syphilis, but these are not " contagions" in the sense sup- posted. AVith regard to the mysterious, imponderable, indivisible nonentities, which nudvc up our " ciirrcnt contagions," they may safely be dismissed into the limbo of extinct superstitions. The word "contagion" therefore is altogether objectionable. The word " infection" expresses a fact, without involving a hypothesis. It is most necessary, however, that the meaning should be guarded ; for, just as there is no such thing as " contagion," there is no such thing as inevitable " infection." Infection acts througli the air Poison the air breathed by individuals and we have infection. Shut up 150 healthy people in a Black Hole of Calcutta, and in twenty-four hours you have an infection produced, so powerful that it will in that time have destroyed nearly tlu; whole of the inmates. Sick people are more sus- ceptible than healthy people ; and it' you shut up sick people I 130 " contagion'^ and infection" defined. together, without a sufficient space and sufficient fresh air, you will have not only fever, but erysipelas, pyaemia, and the usual tribe of Hospital-generated epidemic diseases produced. Again, if we have a Fever Hospital with over-crowded badly- ventilated wards, or with the air stagnant in them, we are quite certain to have the air become so infected as to poison the blood not only of the sick, so as to augment their mortality, but also of the medical attendants and nurses, so that they shall also become subjects of fever. It will be seen at a glance that, in every such case and in every such example, the infection is not inevitable, but the simple result of gross carelessness and ignorance. In certain Hospitals it has been the custom to set apart wards for what are called "infectious" diseases; but, in reality, there ought to be no diseases considered such. It follows from what has been stated that, with proper sanitary precautions, diseases reputed to be peculiarly " infectious" may be treated in wards among other sick without any danger ; just in the same way as, with proper sanitary precautions, a number of healthy people may be congregated together without becoming subject to the horrors of the Black Hole of Calcutta. It is in the highest degree probable that we should never have heard of " infectious" wards, if the other wards of a Hospital had been supplied with sufficient space and air for the sick ; and in too many cases it is to be feared that the pre- sumed " infectious" cases are huddled away into small, ill- lighted, ill- ventilated rooms, a kind of Lazaretto, in fact, where, if they die, they have at least been kept from doing harm to the other sick in Hospital ! It is high time that common sense should deal with the question ; for there does not seem to be much hope for a deh- verance from these superstitions from any other quarter. The "infectious" wards in Military Hospitals correspond, in some sense, to the "casualty" wards in Civil Hospitals, into which accidents, noisy, and erysipelatous cases are trans- ferred, when necessary. The advantages of a separate set of wards for this class of cases have been already insisted upon in these Notes ; not certainly because the cases are inevitably " infectious," but because the segregation of such facilitates greatly administration and nursing, while it removes oftensive contagion" and infection" defined. 131 and noisy patients out of the Hospital wards, whose inmates they would annoy. The question of infection or non-infection has nothing to do with the arrangement. No stronger con- demnation of any Hospital or ward could be pronounced than the simple fact that any disease has attacked other patients than those first affected by it. " Infection" and incapable management, or bad construction, are, in Hospitals, conyertible terms. It may be useful to mention what the meaning is of the words "epidemic," "endemic," "sporadic," and "zymotic." When a large number of people are attacked simultaneously with the same form of disease it is said to be epidemic. When a small number, as, e. g., the inhabitants of a single court or alley, are so attacked, it is said to be endemic. When scattered cases of the same disease happen, one here, one there, over a large surface, the disease is said to be sporadic. The term zymotic, wliich includes all diseases of the preceding categories and some others, implies the existence of certain changes in the constitution or in the blood, rendering persons so affected liable to the diseases in question. It is a vulgar error to suppose that epidemics are occasioned by the spread of disease, from person to person, by infection or contagion ; for it is an ascertained fact that, before any people is attacked epidemically, the disease attacks individuals in a milder form, one at a time, at distant intervals, for weeks or months before the epidemic appears. Before an epidemic of cholera, these cases consist gene- rally of diarrhoea of more or less intensity, followed by a rapidly fatal case or two, very much resembhng cholera. Even plague itself, as in the recent epidemic at Bengazi, begins with cases which cannot be distinguished from ordinary typhus- fever, the succeeding cases getting more and more intense, until the epidemic seizure takes place. Experience appears to show that without this antecedent preparatory stage, affecting more or less the entire population of a town or district, the occurrence of an epidemic is impossible-the epidemic being, in fact the last or, so to speak, the retributive stage of a succes= sion of antecedent phenomena extending over months or years, and all traceable to the culpable neglect of natural laws. It is simply worse than folly, after the penalty has been incurred, ' ' ■ I 2 132 NOTE. to cry out " contagion/' and call for the establislimont of sanitary cordons and quarantine, instead of relying on measures of hygiene. Epidemics are lessons to be profited by : they teach, not that "current contagions" are "inevitable" but that, unless nature's laws be studied and obeyed, she will infallibly step in and vindicate them, sooner or later. In the words of the Eegistrar- General, which are as appli- cable to Armies as to States, " Sanitary measures and not qua- rantines are the real safe-guards of nations." Note . I have just seen a paper by Sir John Hall, entitled " Observations on the Difficulties experienced by the Medical Department of the Army during the late War in Turkey." In this somewhat singular document, which appears to be a defence of Sir John Hall's own conduct, there are certain statements made about the female nursing establishment in the East which require a word of comment. It will be observed that throughout the paper, the weapon which Sir John Hall uses against all civil interference in re- pairing the sufferings which proceeded from the defects of his own department is simply detraction. As for Civil Commissions, they were useless, as for Civil Hospitals, they were costly, and their officers lived magnifi- cently and were extravagantly paid. As for the nurses, they were benevolent, pious, well-intentioned persons, but what could they do? How could one woman nurse eighty sick? The medical men thought they could not. Why had M iss Nightingale stores of port wine placed at her disposal, which she could give to the French Hospitals, while he, the principal Medical Officer of tlie Army, had no such stores at his disposal ? Sir John Hall must have already discovered that this old weapon is no longer of use in defending his position. It would have been more to the purpose had he produced his reqaisitions for food, clothing, comforts, &c., and shown how they were refused or not complied with. At the very time I gave over part of our own private stores of port wine, &c., to NOTE. 133 tlie Frrncli Hospitals (for ])nrt only of what was given were Government stores at all), Sir John Hall might have ob- tained, out of the large wine store at Balaklava, any amount of wine lie required, by merely asking for it. The simple statement of this fact would have been a better answer to M. Baudens* than assuming that I could obtain from Grovernment stores and wine for the French Hospitals which he could not obtain for his own. As to his statement about the Nurses, it simply shows ignorance of tlie whole matter. Nobody ever contemplated giving to a Nurse the entire charge of a number of sick in a Military General Hospital. It is no part of good Hospital nursing to do so. With proper Orderlies, a Nurse can very well attend to sixty or seventy sick. "VYe were prevented, indeed, by the authorities, and by circumstances, from organ- izing a proper system of nursing, and were obliged to do all the good possible in the best possible way. But Sir John Hall's method of estimating the efficiency of nursing, by dividing the Qumber of sick by the number of Nurses, is simply absurd. * To M. Baudens, whose recent death is so much to be lamented, I cannot here but add a tribute of admiration for his wise and enlightened sanitary views, during the year of his superintendence over the Medical Department of the French army in the East, and of gratitude for his ready and magnanimous acceptance of our stores, when the French sick were really in want of them, after these had been refused by other French authorities. LONDON : PRINTED BY HARRISON AND SONS, ST. martin's lane, W.C. PRIVATE AND CONFIDENTIAL. THOUGHTS SUBMITTED AS TO AN EVENTUAL NURSES' PROVIDENT FUND. I. Wages and Prospects of Nurses. II. Desirability of some further Provision. III. Of what Nature? 1 . With regard to kind ? 2. „ persons ? 3. „ objects ? IV. Suggestions as to the Rules to be followed. V. Prospects of Eventual Support. I. Wages and Prospects of Nurses. 1. The nurses of the great London hospitals are divided Thejwo^ into two classes : head-nurses or sisters, and nurses or Hospital assistant-nurses. These latter are, generaUy, subdivided into day and night-nurses. 2. The head-nurses, on an average, receive about £50 ^^^^^^f^ . 1 T I or oistora. a-year and no board, or lower wages and partial board; the use of one or two rooms, generally unfurnished, and an allowance of fuel and light. Sometimes uniform outer- 2 ACTUAL WAGES clothing is included. Sometimes two pints of l)ccr daily are added to the above. Nurses or 3. The day-nurses^ on an average/receive about 12^. a- .A-Ssist £1X1 1 " Nurses. week and no boards or lower wages and partial board; Day Nurses, lodging, with the use of some furniture ; sometimes an allowance of fuel and light apart from the use of both in the wards. Sometimes uniform outer-clothing is added to the above ; sometimes they have also an allowance of one pint of beer daily. Night Nurses. 4. The night-nurses, on an average, receive about 105. a- week and no board ; lodging, with the use of some furni- ture ; sometimes an allowance of fuel and light apart from the use of both in the wards. Sometimes they live in their own lodgings, near the hospital, receiving the same wages. Retiring 5. I am informed that St. Bartholomew's Hospital has Raym^entlatst fixed scale of pensions, nor is the term of service de- Bartholomew's fined. But pensions have been granted to worn-out sisters of from £15 to £25; as also pensions of smaller amount to some worn-out nurses. 6. St. Thomas's Hospital, in like manner, has given, St. Thomas's, ^yithout any fixed rule, pensions to worn-out sisters, of from c€30 to £50. A gift in money has been granted on the retirement of a sister; and the same has been done in the case of nurses who may have received injuries in the discharge of their duties ; and in a very few in- stances of long and faithful service they have been pen- sioned. At Guy's 7. Guy's Hospital for a long time generously provided Hospital. ^^^^ .^^ superannuated sisters, but the plan in practice being found very objectionable, was a few years since given up, and the authorities established a Superannuation Fund for the Servants of the Hospital. It is compulsory on sisters, optional to nurses, to belong to it. Each subscriber receives a book containing printed AND PROSPECTS OF NURSES. 3 rules, with tables of rates of ages, payments, and pensions, and also blank leaves. The subscriber selects the amount of pension for which she wishes to subscribe. At each quarterly payment of wages, a proportion is paid into the fund; entered in the subscriber's book, and pro- perly attested; the hospital makes a payment of equal amount into the fund on the subscriber's account. If the subscriber die before attaining the age when the pension begins, the amount paid by the subscriber is dis- posable by w^ill, and in case of intestacy reverts to the next of kin. The pensions, one-half of which are thus pur- chased by the subscriber, and one-half presented by the hospital, vary, if I remember rightly, from £15 to £50. In February 1857, no nurse subscribed; to which three remarks apply : — first, that every good work takes time to grow^ ; secondly, that not a few of the sisters, having looked foi'ward to benefiting by the old system of superannua- tion, rather grudged their own payments than sought to induce their nurses to subscribe; thirdly, that many of the nurses w^ere really unable to make the payment. 8. The non-endowed hospitals, I believe, but write from very imperfect information, grant few pensions. Sometimes they grant a gift of £25 or less to a retiring head-nurse. Sometimes they employ a head-nurse, become too old for her work, as an extra and inferior nurse. Sometimes they grant a worn-out head-nurse an asylum in the incurable ward of the hospital. I believe the pensions to old nurses are still fewer than the few to head-nurses. Definite information could easily be procured. Their funds do not permit such a diversion from their main and primary object, for which they are often, as it is, inadequate. 9. Of the wages and prospects of eventual provision of the nurses of the county hospitals I know nothing; but understand that the former are lower than, and the latter A 2 At the Non- Endowed Hospitals. At County Hospitals. 4 DESIRABILITY OF as entirely blank as those of the nurses of the non-endowed London hospitals. II. Desirability of some further Provision. Unfitness of Nurses for any other work. Shortness of their time of capacity for Service. Character of Nurses as a Class. 1 . It may be safely taken for granted as a rule, with few exceptions, that a thorough hospital nurse can seldom turn herself to any other business. Her life and work are alto- gether peculiar ; she acquires a knowledge and habits which incapacitate her from aU ordinary occupations, grows into fitness for them, and out of fitness for all others. 2. No less so, that the time during which a hospital nurse can work and lay by, is short, compared with the average duration of other kinds of service. Apart from all excess of their own, their Avork and its concomitants wear out hospital nurses fast. In every large hospital you will see many women of 40, whom you would suppose 60, and strength often decays as prematurely as appearance. Well- ventilated bed-rooms, more sleep, and better food, would be materially in their favour ; but the work can never be other than one which wears out most constitutions fast. 3. In the London hospitals there are some women of ex- cellent character and of great efficiency; many the reverse, in one or both respects ; many between the two classes, who generally end by ranking in the second. 4. To augment the number of the first class, to reduce the number of the second, to induce the intermediate eventually to rank with the first, and not with the second, is the desire of every hospital. 5. It is most important, in all things, in none more than in hospital matters, to moderate expectations, not to hope too much from any measure, or set of measures, and to keep well in view the stern prosaic realities of things. The hospitals of great towns are not asylums where a few SOME FURTPIER PROVISION. 5 or many selected patients can be received and petted ; but great receptacles of all sick comers. Their foundations lie down and deep in tlie Imman sin and misery for wliicli they in part provide^, and the traces of their purpose and nature must ever remain impressed upon them. They are also schools for the practical education of a great profession, important to mankind and dangerous to its members. Hospital nurses are not women attempting or following " counsels of perfection," (whatever incorporation of other elements may be eventually effected), but some of those many women whom God has ordained to earn their bread by toil, (and in the large towns of England honest ways of earning that bread are for women but too scarce and too overcrowded), and upon whom He has laid the same condi- tion as on all the souls He has made, to keep the command- ments to enter into life. A very mixed class they must ever remain: to improve the class, by God's blessings would be to effect a great benefit both to the hospitals and to these immortal souls. 6. Among several things which might be done or tried, with the view, if it please God to prosper the endeavour, of eventually improving the class of hospital nurses, the establishment of some definite prospect of eventual provi- sion, dependent upon good character, appears very im- portant. 7. It would tend to augment the number of steady respectable women, who are anxious to keep a good moral and require a good business character, whose aim it is to do their duty, to give satisfaction to their superiors, to keep their places in the same hospital, and eventually to end their days out of the workhouse. 8. It would tend to diminish-the number of ill-conducted women, who wander from hospital to hospital; whose wages go in drink or finery, or both ; who would be dis= Probable. beneficial results of a prospect of eventual provision, depending on character. 6 THREE KINDS OF Kinds of possible assistance, three. Pensions. Facilities for Saving. Additions to Savings. gusted at the idea of regularly laying by for their future support, and who would resent strict investigation into character. 9. It would tend to induce the intermediate class of women_, who hesitate between good and bad companions, to incline to the former, and to break off from the latter, by the favourable result of provident and economical habits on their actual conduct ; and by the effect which the prospect of a decent support in their age, dependent upon these habits, would produce. III. Of what Nature ? 1 . With regard to kind ? 2. „ persons? 3. „ objects? 1. With regard to kind. There are three kinds of possible assistance. First. Granting free pensions to efficient and well-con- ducted sisters and nurses, under fixed regulations. Second. Providing sisters and nurses with a secure channel of investing their savings ; giving them thus the important assistance of saving their time, trouble, and expense, in obtaining information as to such secure invest- ment. Third. Combining, with the second, a certain propor- tion of pecuniary aid. As to the first. It would be wise economy if the endowed hospitals, who alone could do it, were to grant such pensions ; but whether they are likely to do more than they do now I am quite ignorant. Whether our labours in this field should take the direction of the second or third, is one of the most diffi- cult questions with reference to a thing which is rife with ditliculties. Towards solving it, I submit that it would POSSIBLE ASSISTANCE. t be expedient to employ an able and honest man of business to procure — I. The rules, working, and results so far of the Ifo^ma^i^ii " and Advice to Servants' Provident Society. be procured on II. Of several of the various partly self-supporting and Subject, partly assisted provident societies of the different trades' and city unions. III. Of some dozen benefit societies in large towns. IV. Of Guy's Hospital Superannuation Fund. V. To take the practical opinion of two experienced actuaries. VI. Also of the Treasurer and Matron of St. Bartholo- mew's ; Of the Treasurer, Resident Medical Officer, and jMatron of St. Thomas's ; Of the Treasurer and Matron of Guy's Hospital; Of the Chairman of the House-Committee, House- Governor, and Matron of the London Hospital ; Of the equivalent authorities of St. George's, and of two or three other hospitals (including King's College). My impression is that it is not possible, in the majority pj^^^j^^^.^^ of cases, for either head-nurses or nurses to purchase Nurses to purchase annuities out of their savings. Annuities out I. Their work wears them out comparatively soon. savings. II. During its continuance they require to live well i. e., to have a sufficiency of good plain food. HI. They are obliged to put out and pay for either the whole or nearly the whole of their washing, making, and mending (and most properly obliged) . Thus apart altogether from the consideration that many nurses are widows with families, and many others bur- dened with helpless or infirm relations, and that, in many of these cases, the smallest saving out of their wages is 8 TO WHOM IT SHOULD BE EXTENDED. impossible, I doubt whether it can be reasonably expected that, as a class, hospital nurses should lay by out of their unassisted savings a provision for their age.^ Persons to be 2. With regard to persons, assisted. Shall the Fund be open exclusively to nurses belonging to the proposed Institution under Miss Nightingale ? Or extended to those of the London hospitals ? Or extended to all Hospitals in England ? Or in the three kingdoms ? Or in Her Majesty's dominions in general ? Shall the Fund be extended to private and monthly nurses, including midwives, as well as to hospital-nurses ? I submit that we should consult, on these points, the authorities of the principal hospitals and a few men of experience in business besides. (Philanthropists by trade are, as is well known, the worst possible authorities on subjects of this kind.) My impression is that the Fund should certainly be extended to the three kingdoms. Whether it should be extended to the empire would depend entirely, in ray judgment, upon the check and scrutiny it would be pos- sible to exert, on accounts, monies, and certificates, in distant parts. Upon this men of business should advise. I think the Fund might eventually be open to private nurses, midwives, and monthly nurses.f * If the sisters and nurses, as a rule, were fed as well as lodged at all the Hospitals, &c., the class of women would, in a very short time, be entirely changed ; this kind of employment would not then, with the reduced money payment, be so much an object of desire to widows with families, particularly if compelled to subscribe to a pension fund, which should be compulsory. t At first it would be unwise to attempt too much. If extended to Her Majesty's dominions or private nurses, it would be almost impos- sible to control abuses. OBJECTS TO BE SOUGHT TN GIVING IT. 9 I think it perhaps might be open to the St. John's House nurses and to those of any institution which does not provide its servants with a pension. The Nursing Sisters' Society, I believe, have recently decided on granting their sisters ^20 a-year, after twelve years' service, a wise, generous, and, if properly worked, economical measure. We must avoid the very appearance of disfavour to other nursing institutions. 3. With regard to objects. ^^iou^^^ Shall the objects be Material ? Sanitary ? Moral? Or shall they be restricted cither to the first only or the first and second ? Here, again, I submit that we should consult hospital authorities and a few men of business and of experience, as to the feasibility, often a distinct thing from desirability, of these things. Upon the whole, and weighing many opposite difficulties, my impression is strongly in favour of attempting to com- bine the three. Material objects. The benefit and provident societies embrace many Material ^ Objects to be objects : annuities, payments on illness, payments at sought. burial, provision for children's apprenticeships, provision for childi-en at death, and other things. I. It appears to me that the main if not the only object Provision after ^ ^ . . Superannua- of the Fund should be to provide annuities. tion. II. It would be a question whether or not to arrange Durmg for payments during illness.^ Every now and then ward * Every institution ought to provide lor its nurees during illness, but in fact it is not done. 10 PROVISION OF ANNUITIES. Burial Payments. Payments for Children. Reasons against the last Form of Aid. air gets down the throat of almost every nurse, and every few years or so there is an illness. In many cases a nurse^s pay stops either when or soon after she becomes a patient. Some check upon malingering, a thing well known where the name is not, is essential to every hos- pital. Of course it presses heaviest upon those who do not require it. After an illness, before returning into the wards, the best thing is a short thorough change of air. Often a severe illness is, and oftener still would be prevented by a week's change of air, when the peculiar hospital- languor, so well known in hospitals, and so indescribable outside of them, first fairly sets in. The means of change of air, either before or after illness, are often deficient. Still, useful as some such provision would be, in many cases every year, it appears to me so subordinate to the great object of furnishing these women with some provision on their superannuation, that if it in the least impeded or rendered the latter less secure, I should unhesitatingly give it up. III. With burial payments I think the Fund should have nothing to do. IV. As to payments for children, whether on apprentice- ship or at death : — Upon the whole, after much anxious thought, I think it undesirable to encourage mothers, as such. This is one of the many points, as to hospitals, where theories and experience diflPer much from each other. A very large proportion of nurses are mothers, often widows, with large families, whom they support and put to service out of their wages, too often eked out by improper means, i. bribes and petty dishonesty. Many of these women are moral, sober, industrious, and doubly anxious to retain their places, on account of their children ; still there are serious embarrassments in employing them. PAYMENTS FOR CHILDREN UNDESIRABLE. U The wages of hospital nurses are not and never can be enough to supply a proper support for children, in addition to the support the mothers ought themselves to have. Con- sequently when children are in whole or in part lodged, fed, clothed, " educated," and put to service out of the £50 a- year of the head-nurse, or out of the 128. a-week of the nurse, the mother either stints herself of proper food, proper strong drink (we deal with practice not with theory), proper warm clothing, for the children's sake, or she supplies the deficiency by improper means. If the nurse cannot afford to live well and abstains from disho- nesty, one of two things infallibly happens— either she takes to drink, as the fallacious support of an exhausted frame, or her strength fails and she breaks down, after a few months', sometimes a few years' struggle. When once she has taken to drink, one of two things invariably follows (dishonesty may be presumed to ensue upon, though it often does not precede habits of drink) ; she is or be- comes unguarded, and is soon found out, and sinks into the miserable second and far too numerous class of cha- racterless hospital nurses, unless drink shortly finishes her ; or, in the other case, she is cautious and guarded — she then becomes sly, dishonest, and thoroughly venal ; she extorts gifts and takes bribes from her patients and their friends — and the friends of hospital patients, like others, are of various kinds ; she commits constant acts of petty but often most dangerous dishonesty, possibly remaining an efficient and clever nurse, sometimes a favourite nurse ; and, so far as regards the crime which has taken the name of immorality, a moral woman. A certain proportion of nurses are all the above, excepting drink ; for though, almost without exception, every nurse who drinks takes bribes, some take bribes and do not drink. 12 nurses' children. Of course widows and unmarried women who are not mothers do the ahove things ; but there cannot he a doubt of the additional and terrible temptation to women burdened with children^ to make money in various ways out of their patients. Even in the most favourable cases (and it is to be feared they are few) where the real good principle of the mother restrains her from venality, there are still serious objections. The time when a nurse can go out must necessarily be comparatively very limited. The time that is enough for the moderate demands of friendship or acquaintance is miserably insuffi- cient for the natural yearnings of the mother, especially if the children are young and helpless. The consequence is that, either openly or by stealth, she goes to them or has them brought to her at unallowed times ; or, if the rules of the hospital are lax as to visitors, the children are perpetually with her : and let it be remembered, that the head-nurse^s room or rooms are usually at the entrance of the ward, that being infinitely the best place. It is difficult to say w^hether such a practice is most objection- able as regards the children, or the patients, or the hos- pital j and whether it is most objectionable when the children are young, or adolescent, or grown up. It is objectionable in aU and every one of these cases. And no less objectionable is it in the case of the assistant-nurse, who where the rules are lax will receive her children either in the ward or in the nurses' kitchen ; or where they are strict, wiU have the children come about the hospital and will meet them on the sly. These things enter immensely, minute as they seem, into the discipline of wards and of the hospital ; and dis- cipline means a great deal. SANITARY AND MORAL OBJECTS. 13 Sanitary objects. A good many nurses enter hospital service who are quite unfit for it. Often consumptive and ruptured women, those suffering from piles or prolapsus, &c., present them- selves, are admitted, struggle on for a time, and break down with or without taking to drink. Undoubtedly, none but strong healthy women should enter hospital service; tlie work will wear them out quite soon enough, and some of the above complaints are particularly liable to follow the work. Here again men of business must advise : the fund ought to liave some efficient though not infallible security as to the average good healtli on joining of its members. Life Insurance ruk^s as to this would be to the point. BeHevc mc, all these things are important. Sanitary Objects. To discourage admission of women physically unfit. Moral objects. The most difficult part of a difficult tiling, only perhaps Moral Objects •.-,21 X- 1. ' i_ i_ attainable, it IS at tiie same time the most important. I. 1 think that every nurse, before joining the Fund, Need of should produce a certificate from her matron, stating her ^^^^1^^^^^^' to be a respectable woman. In plain words, for the word respectable is certainly capable of most wondrous exten- sion, the certificate should state her to be, in the matron^s belief, and to the best of her knowledge, a chaste woman, and should specify whether she be spinster, wife, or widow. In either of the latter cases, the marriage certificate, and in the last that of the husband's death, should accompany the matron's. The matron's certificate should, I consider, also state her to be sober ; and it would be a question whether it should not also state her to have served for not less than 14 CERTIFICATES OF a year in the hospital. The vagabond class arc a terrible drag upon the whole order ; and some of these might, from the novelty of the thing, be disposed to join it at first. II. An important question would be : Should the matron's certificate be renewed every year, and should the continuance of the nurse's membership depend on its pro- duction? Men of business must advise as to this : I am quite unversed as to the details of Provident Societies. So far as regards the contributor's own money, the contract once entered into, must certainly be open to no further question ; unless there has been fraud in the pre- liminary statement on which it was based. With regard to any assistance that may be given the question is different. III. The preliminary certificate I do consider very important, and the subsequent ones, if they can be re- quired. Hospitals are Until the hospitals are swept of the many mothers who '^Penitents!*^^ are not wiA^es, now unhappily to be found in them, no real good can be done. Hospitals are not, and never can be, places for penitents and they are about the most dan- gerous places where sham penitents can be. This is precisely what so many people of verj^ different kinds cannot or will not see ; some from ignorance, some from knowledge, some from the vague, silly, kind feeling which does such mischief when exerted on practical matters. Suffer me to submit, without wearying patience by urging proof, — i. That real penitents are wrongly placed in hospital service, because their admission breaks down the standard which respectable women who are hospital nurses feel (quite as keenly as their superiors do in their own concerns) ought at once to restrain and to protect those engaged in this very peculiar, very trying, and very exposed work and GOOD CHARACTER. 15 life. (I have invariably observed that real penitents are extra-prudish, and comparatively inefficient, in their hos- pital duty. It will at once be perceived how inevitable this result is.) ii. That sincere but unconfirmed penitents, in addition to the above, are most dangerously and improperly placed in a situation, to them, of very peculiar trial. iii. That sham penitents, who unhappily abound, are dangerous everywhere, extra-dangerous in hospitals, whether to superiors, companions, or patients. iv. That although the class must ever be a very mixed one, it is most important to have a standard. Let it be necessary for every nurse to enter hospital with a good character, and to leave it on losing it. Deception, hypo- crisy, and successful guilt will be found in hospitals, as elsewhere ; but the class nuist be raised, and therefore improved, by requiring the condition of good character; though guilt may occasionally mask itself behind it. V. That although, for various and very differing reasons, the certificates will be not unscldom untrustworthy, still the same reasoning will apply. Upon the whole the ten- dency will be, by requiring the condition of good cha- racter, to improve a class which, containing, as it does, many well-conducted women, is sadly degraded and con- taminated by many vile ones. vi. I do not overlook the fact that honest certificates, especially if annually renewed, might give the matrons some perplexity, from reasons which need not be enlarged upon. Still, it seems to me, it would be well worth trying. IV. Rules to be followed in giving Assistance. Lastly. With regard to rules to be followed in giving assistance of whatever kind. 16 SUGGESTIONS IN DETAIL Need of Advice It seems to me most important that we should with a view i.-i iini - i i-- n above all to obtam the opinions both oi hospital authorities and oi a Security. ^-^^^ business, before laying down rules. The whole matter is so essentially mixed up with the tangible point of securing that the savings of these poor women should avail them in their age, that it is urgent to have sound practical advice as to letting nothing else imperil this. Security seems the cardinal point of the whole, and that is a question for men of business to answer. Suggestions in The following suggestions toward obtaining it are offered. 1. Security of invested savings to be the first and main thing to be secured. Every other object should be subor- dinate to this. 2. If we decide upon aiding their savings, let the security of this aid be the main point. Invest all donations, annual or not; unless, should any hospitals contribute annually, it might be fairly considered that those contri- butions should be annually used. 3. The aim should be to enable all hospital nurses, of good character, to provide annuities for themselves, whether with or without assistance. I think assistance will be necessary. 4. Also to enable private and monthly nurses, and mid- wives, to do the same, but without requiring the certificate of character, which, not to be a mockery, ought to be an effectual one ; and these persons are not under a fixed superior. 5. The pensions should, if it be possible, range from £IS or £15 a-year to £60 a-year : say £13, £20, £30, £40, £50, 6. Each hospital nurse to produce, before being allowed to join the Eund, a certificate from her matron of chastity, general good conduct, and a statement as to her being unmarried, married, or a widow, also of her having served FOR REGULATIONS. 17 in one hospital not less than a year. Also her marriage certificate, if a wife, and, if a widow, that and the certifi- cate of her husband's death. In the event of her marriage or re-marriage afterwards, the marriage-certificate to be produced, and her altered name and the fact of her marriage duly recorded in the Fund-book. (All this is important : aliases and fictitious marriages are sadly common, in this class). 7. If possible the certificate to be produced once a-year, and, on its failure, the contributor to cease to have a title to assistance. Assistance in the form of an addition to the annuity may be made contingent ; the annuity which the premiums provide must be absolute : most of the vices tend to shorten life, that is, to diminish the number of annual payments, so that the fund would not be likely to incur losses through them. 8. Private and monthly nurses, and midwives, to produce, before being allowed to join the Fund, a certi- ficate from the Clergyman of the parish, stating his belief that the subscriber is a respectable woman, unmarried, married, or a widow ; and in the latter cases, marriage and death certificates. On any after-marriage or re-marriage, certificate to be produced and altered name registered, on pain of expulsion from the Fund. I should not attempt an annual certificate for this migratory and independent'' class. 9. Each nurse, before being allowed to join the Fund, to undergo whatever examination is undergone by women before they are allowed to eff'ect Life Insurances, as to her being, at the date of joining, a healthy woman. (Physicians ought to advise here as to inserting provi- sions technical enough to be efi'ective). 10. Payments to be made weekly, monthly, quarterly, or annually, as shall be advised. Amounts to run from B 18 PROBABILITY OF 6d. or Is. a week upwards. For the plan to work, it ought to allow small payments on an ascending scale. Many will only be able to make very small payments. Few will be able to make other than small payments. 11. Payments made by a subscriber dying before attain- ing pension to be devisable by will, and in case of intes- tacy, divided among next of kin. 12. All possible safe curtailment of office expenses. 13. Treasurers, or equivalent civil chiefs, of all hospitals that subscribe, to be on the committee or council, or by whatever name the equivalent may be termed. V. Prospects of eventual Support. Support by the Nurses themselves. Support from the Hospitals. Support from the Public in general. 1. I believe that many head-nurses would thoroughly appreciate and thankfully avail themselves of such a Fund. 2. I think that many nurses would do the same, and, in time, many more. Many cannot contribute to it ; many will not. 3. What aid the hospitals might be disposed to give I do not know. I rather think none at first. If the thing works and works well, I think they would probably contri- bute. But it must never be forgotten that, excepting the endowed hospitals (the financial position of St. George^s I do not know) the London hospitals find their income scarcely sufficient, often not sufficient, to meet their expenditure. They cannot be expected, nor would they perhaps be justified, to curtail the number of the sick they relieve, in order to provide for the superannuated nurses of those sick. It is true, however, that it might enable them to get better nurses, which is surely economy. 4. I do not think that much lasting public interest is likely to attend the Fund. The interest the public has. EVENTUAL SUPPORT AND SUCCESS. 19 for the last few years, taken in hospitals has been fictitious and almost mischievous. The public can never really know what hospitals are, nor is it feasible or desirable that it should. What eventual good may be done in them must be done quietly and with great patience. What good may be done among the nurses must be done by infusing, if it may be, a higher and truer spirit of duty, by increased discipline and protection, and by ameliorating, in some material points, among which the aim contem- plated by the Fund ranks very high, a condition which, to the end of time, must remain severe, rough, dan- gerous, and in all senses trying. In the details of all these things, most especially in all that concerns disciphne, which involves protection, the public, with the best inten- tions, will only be an obstacle, and John Bull is sadly prone to pull up anything he plants or anything he waters, to see how it grows. I think anything like appeals to or solicited support from the public might, in various ways, seriously embarrass the Superintendent of a very difficult and a very important though, at the same time, a very humble branch of Her Majesty's Service. I should be very anxious to avoid this : it would be perpetuating the evils of publicity, and sacri- ficing the greater good for the lesser. 5. In conclusion I again submit that it would be desirable Necessity of to ascertain from the hospital authorities above men- -^^^i^^e. tioned, and if possible from three or four able and honest men accustomed to business, their opinion as to the scope and details of this plan. In matters of spirit and of disci- pline we should probably rely on other judgment ; but these are matters of business; and in which, without binding ourselves to follow, it seems most important to obtain and to weigh, the opinions of men long conversant with business. January 23, 1858. » ^ 20 Note as to the Number of Women employed as Nurses in Great Britain. To show the importance of an Institute for Nurses^ it must be stated that 25^466 were returned, at the census of 1851, as nurses by profession, exclusive of 39,139 nurses in domestic service,* and 2,882 midwives. The numbers of different ages are shown in table A, and in table B their distribution over Great Britain. To increase the efficiency of this class, and to make as many of them as possible the disciples of the true doctrines of health, would be a great national work. * A curious fact will be shown by Table A, viz., that 18,122 out of 39,139, or nearly one-half of all the Nurses, in domestic service, are between 5 and 20 years of age. TABLES OF AGE AND DISTRIBUTION. 21 85 and Upwards 2 - 1 o 1 ^ o I— 1 i i o 1 O 2542 369 1 o 3825 712 1 3456 833 1 o 3982 1196 1 CO o -X o CI C» 1— 1 i 2223 1468 1359 1681 1118 2495 1 CI 817 4174 1 o 1 1-5 10,855 7259 1 CO o 1 Under 5 Years. 25,460 89,139 NUKSES. Nurse (not Domestic Servant) Nurse (Domestic Servant) ... •saiBjVL puB q;norauoj\[ •uoisiaiq; q;xi CO O 'sgijunoo nj9q;jo>i •nO]SlAT(£ll^0I CI O O P-H •9JTqSJlJ0X • uoisiaiq; q^^g o o •saijunoQ q^.i0|^ 'uoisiaiq; q-jg 970 2135 •S9^imo3 pneipiiv •noisiAi(i q;/, 1303 957 puBipiiii •noisiAiQ q^9 1225 2283 saijunoj UJ3}sa vv •UOISIAIQ- qig 3055 1737 •S9Huno3 uig^sny^ •uoisiAig \\'\f c^ •pnBipij\[ qinos •uoisuiq; p.i8 2286 1252 "u.i9iSBg; q^nos •UOISIAIQ png 2878 2514 •uopuoi *UOIST-\IQ 7807 50G1 •SB9S TlSI^I-ia 9qi in" 8pUB{s'x « o •pUB^^OOS 1543 1922 •B91BAi pUB puB^sua 23,751 18,945 •SB9S qsnna 9q; ui SpUB^SI pUB UIB^Tig 1B9I9 25,466 21,017 Kurse (not Domestic Servant) Nurse (Domestic Servant) ... 22 Note as to teaching Nursing. There is^ at Madras, an Institution called the Military Female Orphan Asylum_, which trains 200 orphan girls, daughters of European soldiers. They enter in infancy, and, as they attain a proper age, they are married to soldiers or others. There is always an abundance of appli- cants for them, and every endeavour is made to train them to be useful soldiers' wives. Dr. MacPherson, the excel- lent Principal Medical Officer of the Turkish Contingent, when at Kertch, who is now in charge of this Asylum, was the person, I believe, who introduced amongst the senior girls, a system of training, to enable them to officiate as nurses, an all-important element in their education. Below is a syllabus of the theoretical branches taught, a practical knowledge being acquired in the Hospital attached to the Institution. It would be well if all women underwent a similar training. Course of Instruction for the Class of Sick Nurses^ at the Military Female Orphan Asylum, Popular and Regional Anatomy and Physiology. A general knowledge of the human body, its various organs, and their uses. Sanitation. To be made acquainted with every subject relating to health, viz. : Food — Exercise — Clothing — Cleanliness — Ventilation, &c. Sick-room Management. Administration of Medicines, Application of Leeches, Lotions, Fomentations, &c. Cleanliness, Darkening of INSTRUCTION IN NURSING. 23 the Apartment, Quietness, &c. Cooking for the Sick. Diet for Infants. Household Medicine and Surgery. To be taught how to act in emergencies, viz. : in cases of Fainting — Hysterics — Convulsions of Children — Burns — Stings of Insects — Wounds^ &c.; and the simplest mode of treating the diseases most commonly met with in India, viz. : External Inflammation, Cholera, Fever, Dysentery, Sore Eyes, Bowel Complaints, Cutaneous Eruptions. How to prepare Poultices, Fomentations, and Lotions. „ dress Wounds, Sores, and Blisters. „ apply Bandages.