Part 37

The reader may gain some insight into the life of a nurse from the conditions that prevailed until beyond the middle of the nineteenth century at a very good and well-managed English provincial hospital, the Radcliffe Infirmary at Oxford. The salary of a nurse was £5 a year. There was no distinction between a nurse and a domestic servant. One nurse only was the allowance for a ward of seventeen patients. A nurse’s day began at 6 a.m. The wards were cleaned till 7, when a bell was rung and each nurse had to bring down her ashes and sift them under the direction of the porter, who then gave her coals for the day. She took breakfast with the patients, who helped her, so far as they were able, with the ward work. At 2 p.m. she went to the servants’ hall, where she had her dinner in company with the servants on daily hire. During the dinner the ward was left in charge of a patient. After dinner she took away a plate of meat and vegetables for her supper. For the night there was normally only one nurse for the whole hospital of about 100 beds. There were no regular holidays, and the nurse was never allowed to leave the hospital before 6 p.m. The practice of nurses receiving gratuities from patients continued till 1870 and even beyond. Those patients who wished to secure a nurse’s early attention for their dressings gave tips, those who did not frequently had to wait.

What sort of woman could such a system produce? That some nurses at least were kind and skilful, even under such conditions, is a fact, and is pleasing evidence of the natural goodness and wisdom that reside in the human heart. Many, however, can have been no better than Sairey Gamp and Betsy Prig.

The first important reform in Protestant countries began in Germany, through the influence of Elizabeth Fry (p. 171). In 1822 Theodor Fliedner (1800-64), the young pastor of the church at Kaiserswerth, a little town on the Rhine near Düsseldorf, visited England and was much impressed by Elizabeth’s teaching and example. Returning to his charge, he devoted himself to the spiritual and physical care of jail-birds. In 1833 he and his devoted wife Frederica (1800-42) opened a refuge for discharged female convicts. From them the couple turned their attention to the sick poor. The conception of an organized body of specially trained women crossed their minds. In 1836 they opened a small hospital.

At this hospital six young women of the most spotless character were induced to serve as ‘deaconesses’. It was their duty to perform all the tasks of the hospital in rotation. The physicians who attended the hospital gave them instruction. The Kaiserswerth idea rapidly spread and the ‘Kaiserswerth Deaconesses’ became and remain an important order, which is still occupied in good works in many parts of the world. The conception of the order is different from that of most religious orders in that the members make no attempt to withdraw from the world, and marriage is not forbidden to them. Moreover, the duties of the Kaiserswerth deaconesses are rather different from and more varied than those of a sick-nurse. They include teaching, both secular and religious, nursing, household duties, management of children and convalescents. In 1865 a preparatory school for probationers was opened.

In England Anglican orders of a somewhat similar character were formed in the forties and fifties. In 1850 and 1851 Florence Nightingale (1820-1910), who was a lady of good social rank, visited Kaiserswerth, and went through a regular training there. She was profoundly impressed by the extremely high character of the deaconesses, most of whom were only peasant women. The next three years she spent in writing and in examining hospitals in her own country.

Florence Nightingale’s opportunity came with the outbreak of the Crimean War in 1854, and the rapid breakdown of the medical services, which contained no women nurses. The French had a number of ‘religieuses’ to nurse their sick, and a feeling of shame arose in England at the neglect and mismanagement of the British sick and wounded. The Secretary of State for War asked Florence Nightingale to go to the Crimea to organize a nursing service. She left at once with thirty-eight nurses whom she selected personally. Ten of these were Roman Catholic sisters and all the others had had nursing experience. From that event dates the Revolution in Nursing. Florence Nightingale performed marvels under conditions of great difficulty (Fig. 128) and in the face of determined opposition. She returned home in 1856 a national heroine. She had no difficulty in establishing a school and home for nurses at St. Thomas’s Hospital in London in 1860. The example was followed by the other London hospitals.

Florence Nightingale was a woman of the most powerful will and an admirable organizer and administrator. Her system of nursing contained many new features, not quite all of which have stood the test of time. That nursing rapidly and steadily improved from the moment she was in authority cannot at all be doubted. Looking back, it is apparent that the immediate success of her methods was due to two main factors. First was her capacity to secure women of high character and good social position to accept positions of responsibility. Second was her removal of the control of the nursing staff entirely from the hands of men into those of women. Her influence soon passed across the Atlantic, and she was associated with the United States Sanitary Commission and the women who took charge of army nursing during the American Civil War.

While Florence Nightingale was reforming Nursing, her contemporary, Mary Carpenter (1807-77), was applying herself to the kindred task of looking after neglected children, establishing Reformatory and Industrial Schools and improving the position of Indian women. She obtained a large measure of public support and exercised considerable influence in America, which she visited in 1873. Many other distinguished and devoted women worked on similar lines.

Among the indirect results of the activity of Florence Nightingale was the establishment at Geneva in 1864 of the International Red Cross Committee, the branches of which have done good service in many wars and have been no less useful in peace.

Florence Nightingale opposed anything in the way of State registration of nurses. Concentrating on a high ideal of competence and character for the nurse, she failed to grasp some of the secondary effects of her own scheme. A large nursing service is now a necessity in every civilized country, as a result of her efforts and example. Having regard to human imperfections, we can as little hope that every woman who nurses will be a born nurse, devoted to her task, as that every doctor or teacher will have a natural vocation for his work. In an imperfect world mankind must protect itself against the incompetent and the unfit. Registration is a way--doubtless an imperfect way--of doing this. A Nurses’ Registration Act became law in England in 1919.

There have been many improvements in the details of the training of nurses, incident on the changes in Medicine and Surgery during the last half-century. Apart from these, the main improvements in Nursing have been due firstly to an increased interest in the welfare and health of the nurse herself, and secondly to the recognition that Nursing is a profession for which, as for Medicine, some preliminary scientific knowledge should precede professional training. Thus, the very long hours of the nurse have of late been reduced, and in the best schools instruction is now given to nurses in Anatomy, Physiology, Hygiene, Bandaging, and Cookery, before the commencement of actual hospital work.

Further developments will probably be along the lines of State and Municipal Nursing Services. Since Health is a public as well as a private concern, the same must be true of the training and work of nurses.

From a painting by Jerry Barrett]

§ 18. Some Modern Physiological Concepts of Clinical Import.

The vast activity in the sciences of Physiology and Pathology during the last fifty years, and their repeated divisions into independent sciences, each prosecuted by its own specialists, have yielded many ideas which have been imported into the clinical practice of Medicine. It is impossible to say which of these are of permanent value. All previous ages have had to discard part of the practice and a large proportion of the medical ideas that have been handed down to them, and there is no reason to suppose that the age that follows us will differ from those which have gone before us. Some ideas that have entered Medicine from the physiological laboratory, pushed by interested parties or seized on in despair by physicians at a loss for a line of treatment, are already seen by men of experience and judgment to be no permanent addition to our store. Other lines of physiological thought are still under discussion by them.

There are, however, certain physiological conceptions which, apart from their general implications in the economy of the body, have received such wide application that their future, as an organic part of medical practice, seems assured. Certain of these conceptions demand discussion in even the most cursory survey of medical development.

(a) Ductless Glands and Internal Secretions.

The nature and action of the various glands of the body has been a classical physiological field. Malpighi (pp. 116-20) was the first to investigate the structure of these organs, and he was followed by many others. It became evident that many glands, such as the liver, the salivary glands, and the tear glands, are provided with ducts or tubes, which carry off the characteristic secretion of the glands. These secretions can be examined with comparative ease--as happened early with the secretion from the stomach, or ‘gastric juice’ (pp. 146-48), and later with the secretion of other glands. There remain, however, certain glands unprovided with ducts. The action of such ‘ductless glands’ long remained a mystery. Of these the type is the ‘Thyroid gland’. Much of our physiological knowledge of this organ, together with the conception of its function as indispensable to normal life, has come through Surgery.

It had long been known that certain symptoms were associated with enlarged Thyroid gland or ‘Goitre’. Attempts to remove the organ surgically were made after the introduction of antiseptic methods. Goitre is particularly common in Switzerland, and it is not remarkable that the technique of the very dangerous operation for the surgical removal of goitres was first perfected by Swiss surgeons, among whom Theodor Kocher (1841-1917) has taken the first place. The study of cases that had had their Thyroid glands removed gave a clue to the nature and action of the gland.

It was found that those surgically deprived of the Thyroid gland develop abnormal slowness in movement and response. The temperature is low, the pulse small, the muscles are torpid and sometimes rigid, and there is a failure in ordinary fine muscular movements. The patient shows a thickening and swelling of the skin and presents a dull and very characteristic appearance. When the operation was performed on one whose growth was not yet complete, development was checked. Such a patient remains infantile or childish both in body and mind.

The conditions were recognized by Swiss surgeons in the seventies as resembling those of a spontaneous disease to which the name Myxoedema was attached. Further the close relationship both of the surgical and of the spontaneous condition to the state of idiocy known as Cretinism came gradually into view. In Switzerland, as in other parts of Europe, stunted beings known as Cretins had long been known. These defectives are sometimes goitrous, sometimes without a Thyroid gland, but their general appearance and condition is an exaggerated version of what has been described for those with Thyroid glands removed (Fig. 129).

From the Collection of the Royal College of Surgeons.]

The result of these observations was to direct the attention of physiologists to the Thyroid gland. It was soon found that the symptoms of Thyroid deprivation could be experimentally produced in animals. Moreover, it was shown by Moritz Schiff of Berne (1823-1890), in 1884, that the results of the removal of the Thyroid might be avoided if the animal were fed regularly on an extract of the glands. The results were soon applied to man and have led to one of the greatest of medical triumphs. By its means sufferers from myxoedema and cretinism can be either cured or improved. A drivelling and idiotic cretinous child, adequately treated with Thyroid, enters on a normal process of development. The improvement is almost incredible, and the child rapidly passes into a healthy and happy state, so that it is literally true to say that his own parents would not recognize him (Fig. 130). Further, the gland may be given in excessive doses, and a condition produced that closely resembles a well-known pathological condition known as ‘Exophthalmic Goitre’, which is similarly susceptible of experimental investigation.

The facts here enumerated justify the deduction that the Thyroid gland secretes something which is essential to normal well-being. The organ has no duct, and the secretion is, therefore, never normally thrown out of the body. The Thyroid is, in fact, an organ of what is called ‘internal secretion’. Investigations on this secretion led to the isolation of the active principle as a pure compound known as Thyroxin in 1916. The story of the Thyroid has recently (1926) been rounded off by the preparation of Thyroxin synthetically. The synthetic product has been given with effect in cases of Myxoedema.

The observations made on the Thyroid directed further attention to other ductless organs of which a number have been shown to have their own ‘internal secretions’. Furthermore, it has been demonstrated that, among organs which throw out their products through a duct, there are those which also send an internal secretion into the blood-stream. Among these are the essential organs of sex, the testicle and ovary. The effect of castration on the general physique is well known. It may be compared with the effect of ‘spaying’ or the removal of the ovary. This operation leads to an assumption by the female, in more or less modified degree, of the secondary sexual characters of the male.

Peculiarly interesting for their practical results have been certain investigations made of late years upon the organ known as the ‘Pancreas’. The Pancreas has a duct which opens into the Intestine just below the Stomach. It has long been known that the secretion of the Pancreas is related to the amount and fate of sugar in the blood. The association of disease of the Pancreas with the symptom known as ‘Diabetes’, in which sugar appears in the urine, was also familiar. Later it became apparent that it was not the Pancreas as a whole that was related to the process but only certain isolated and peculiarly formed nests of cells. It is now possible to administer extracts of these cell-nests with very favorable results on the course of certain types of Diabetes. The extract is now in wide use under the name of Insulin.

Among the ductless glands that have been best investigated are the so-called ‘suprarenal bodies’, which lie above the kidneys. As with the thyroid gland, the attention of physiologists was directed to these bodies as a result of clinical observations. These observations date back to the middle of the nineteenth century. In the last years of that century it was observed that an extract of the suprarenal bodies, injected into the circulation, caused a rise in blood-pressure, an effect opposite to that following the extirpation of the glands. The administration of extract from suprarenal bodies has found wide clinical application. Unlike the extract of thyroid, the effect of this extract is very temporary. It is easily oxidized and rapidly disappears from the blood. It belongs to the group of substances which are known as hormones. The active element in a suprarenal extract, the ‘suprarenal hormone’, has been recently prepared by a synthetic process.

The nature of hormones has only come clearly into view of late years. The word ‘hormone’ is formed from a Greek word meaning ‘to excite’. The internal secretions have, in general, functions of considerable physiological complexity, and act, for the most part, slowly and continuously. The hormones are, however, exceptions to this rule. They act rapidly and in an excitatory manner. These substances appear to be of relatively simple chemical structure. They are easily oxidizable, so that they rapidly disappear from the body. They act, in fact, as ‘chemical messengers’, producing a state of ‘chemical correlation’ of the different parts of the body which is comparable to the better-known and more widely recognized ‘nervous correlation’.