451THE DEPARTMENTAL COMMITTEE ON POOR-LAW NURSING.

THE LANCET.

LONDON: SATURDAY, FEBRUARY 14, 1903.

The Departmental Committee on

Poor-law Nursing.IN January, 1902, the President of the Local Government

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Board appointed a committee of four gentlemen to inquire and to report-firstly, as to any difficulties experienced in

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obtaining an adequate supply of properly qualified Poor-law C

nurses and assistant nurses and how far these difficulties can (

be met; and, secondly, what regulations, if any, should be 1

made as to the qualifications and training of probationers. The minute of appointment contained two other references

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relating to nursing questions with which we do not propose (

to deal on the present occasion. Of the four gentlemen (

appointed two were the medical inspectors engaged in

inspecting the London and provincial workhouses re-

spectively, the third was an assistant secretary (formerly inspector) to the Board, and the chairman was the Parlia- Bmentary secretary to the Local Government Board. It is

a pity that the committee was not strengthened from outsidethe official circle, as its recommendations would certainlyhave carried more weight ; and perhaps the strongest fact inthis connexion is the absence of any expert on nursing,seeing that the committee was appointed to investigatequestions which gravely relate to nursing.In Part II. (e) of the report, after numerous qualifications

which occupy seven paragraphs, the committee states : "It

may reasonably be assumed that some difficulty in obtaininga proper supply of qualified nurses has been affecting abouta quarter of the workhouses and infirmaries in England andWales and that difficulty has, with a few exceptions, ex-

tended in fairly equal proportions to all classes of work-

houses " (paragraph 36). But " the point the committeewish to emphasise is that notwithstanding the difficulty of

obtaining nurses, and notwithstanding the almost certainincrease in the number of sick in recent years, there does

not appear to have been hitherto any general failure to

maintain what has been considered a fair proportion of

nurses to patients " (paragraph 40). ’’ On the other hand,a condition of affairs which involves some 171 workhouses

and infirmaries in genuine difficulty in obtaining nurses,

must indicate a considerable amount of administrative

embarrassment and if allowed to continue or to spreadmight also result in serious injury to the interests of a

large proportion of the sick poor in workhouses " (para-graph 42). It is somewhat difficult to reconcile these

paragraphs, but a perusal of the evidence appears to us

to show an overwhelming preponderance of testimony to

the existence of a very general and serious difficulty, ore

which to our knowledge has existed for many years, in

obtaining properly qualified nurses for the Poor-law service,not confined to, but chiefly affecting, the smaller institu-

tions under,, the control of the Local Government Board.

The causes of difficulty are next discussed, and while givingtoo much prominence to temporary causes, such as the Boerwar and recent epidemics, the committee hardly seems toappreciate the permanent causes.

In Part III. the committee discusses the training of

probationers and the qualifications of superintendent nurses,and after dismissing as unworkable the establishment of

central training schools for nurses it recommends thatfor the future the training of probationers should be

allowed in two classes of training schools, to be called

respectively major and minor training schools. To the

plan proposed for the major school no objection can beraised ; it is in fact that which has been successfullyin vogue for many years. The plan proposed for the

minor training schools merits the serious consideration

of the medical profe=sion and all who are interested

either in workhouse administration or general nursing.That it is receiving such consideration is shown by the

important memorial which was presented to the Presidentof the Local Government Board last week. The effect

of paragraph 90 would be that the sick wards of small

country workhouses would be recognised as minor trainingschools, provided they had a superintendent nurse and a

visiting medical officer who would engage to devote " someof his time " to instructing probationers, and provided that’’ systematic instruction were given by the superintendentnune or [the italics are ours] medical officer which compliedwith a general plan to be laid down by the Local Govern-ment Board." " At the end of 12 months’ training in such aninstitution the probationer would be eligible to receive aformal certificate of training, and the committee furtherrecommends (paragraph 91) that she "should be con-

sidered and called a Qualified Nurse’ and should be

recognised by the Board as a proper person to fill any

post in the nursing service ...... where the supervisionof a Trained Nurse is available." We have referred in

a previous issue of THE LANCET ’ 1 to the unsuitability ofsuch institutions as training schools for young women.

Surely this 12 months’ trainiog is a retrograde step and thetitle of "Qualified Nurse is here a misnomer. And since

there is nothing to restrict these persons to the Poor-law, service they (and especially those who were regarded bytheir seniors as less promising) would be launched into the;

service of the general public. Moreover, we venture to

) think that this proposition of the committee would frustrateits own ends, for the medical profession and the publicwould soon learn to recognise the worthlessness of such a

training and such a title, and the Poor-law nursing servicewould soon be brought into still further disfavour and would

e be rendered still less attractive to those who wish to earn

their living as nurses qualified in fact as well as in name.

Nothing could be more retrograde than such a course as

,- that which the committee here suggests. The real solution

e of the difficulty of obtaining an adequate supply of nurses

s consists in raising, not in lowering, the status of the Poor-o law nursing service, and this can only be done by raisinge the standard of education required, increasing the salariesnoffered to an adequate sum, and improving the conditions, of service and environment of the Poor-law nurse.

This question, from one point of view, is largely a matter

1 THE LANCET, Jan. 24th, 1903, p. 253.

452

of supply and demand. Good nurses are not forthcoming atthe wages and conditions offered. The Metropolitan AsylumsBoard was confronted with the same difficulty in its

fever hospitals. It solved the difficulty by offering higherwages and better conditions of service and the Local Govern-

ment Board would be well advised to adopt similar means.In the interests alike of the medical profession, the public,and the Poor-law nursing service we feel bound to enter

our protest at the earliest moment against a retrograde pro-posal. A large section of the public is becoming impatient,at the non-solution of this important question of workhouse

nursing. The constitution of this departmental committeewas unsatisfactory, its recommendations carry but little

weight, and the time has come for a Royal Commission tobe appointed in order thoroughly to investigate the matter.

The Treatment of Intussusception.A TRULY remarkable series of cases of intussusception

- was recently met with at the London Hospital, where withinnine days seven cases of this condition were admitted intothe wards. They were all under the care of Mr. HUGH M.RIGBY who contributed a detailed account of them to

THE LANCET of Feb. 7th (p. 364). One of the seven

patients was in a moribund condition when admitted and

died four hours later, and therefore we need hardly con-sider that case, but the remaining six patients were

submitted to operation and of these five recovered. The

one fatal case required resection of a portion of the boweland this complication of the operation for intussusceptionis universally recognised as of the gravest prognosis.Within recent years the whole question of the treatment

of intussusception has undergone a great change and

an examination of the reasons for the adoption of

the present methods should be by no means devoid of

interest.

Not long after the pathology of intussusception was

investigated the idea of forcing back the invaginated bowel

by fluid pressure arose. The earlier attempts were madewith air which was forced in by means of a syringe ; laterliquids were employed, water being chiefly used, thougholive oil has been advocated. Hydrogen and carbonic acidgas have also had their supporters, there is a very obvious

limitation to the action of both inflation and injection andthis is imposed by the ileo-cascal valve. Any intussuscep-tion limited to the small bowel cannot be affected by thedistension of the large intestine, for distension of the caecumcloses the valve firmly. It is true that it has been demon-

strated that in excessive distension of the caecum some of

the contents may escape upwards through the valve, but

this can only happen to a slight extent and when the

distending force is very great. Therefore these methods are

possible only in some forms of intussusception. The treat.

ment by inflation, and especially by injection, did certainlysucceed in reducing some intussusceptions, and this was so,not only in slight cases, but even in extensive cases, as

in one recorded by Dr. E. MANSEL SYMPSON, where severalinches of bowel protruded from the anus. In what pro-

portion of cases methods of distension succeed cannot

definitely be stated, but the statistics collected by Dr.

F. HOLME WiGGIN of New York, which give the per-

centage of successes as 25, may be considered as not under-

estimating the beneficial results of the treatment. Dis-

tension of the colon, too, is not without danger, for numerouscases are on record in which rupture of the bowel has

occurred. Mr. R. LAWFORD KNAGGS has collected seven

cases in which this accident was encountered and no

wonder need be felt at the rupture of the bowel under theconditions in which distension is usually performed, for

in most cases no attempt is made to gauge the pressureexerted by the distending fluid. A syringe is usuallyemployed and the pressure exerted by the hand on the

syringe is a very poor index to the pressure in the bowel. A

curious fact is here of great importance, and that is that thesmaller the syringe employed the greater is the distendingforce. The quantity of the liquid injected is an equallyfallacious test of the pressure in the bowel, for Mr. D’DARCYPOWER has shown that the capacity of the colon varies

greatly in different children. Indeed, in one of the fatal

cases of rupture of the bowel only nine ounces of

water had been injected. The process of distension mayalso be very exhausting to the child, especially if it

has to be repeated, as is necessary sometimes when

this is the sole method of treatment employed. In some

cases the process has been repeated four or five times.

An important objection to the treatment by distension is

that it is often very difficult for the surgeon to be certain

that the reduction is complete, for so small a portionof bowel may remain invaginated that nothing can be felt

through the abdominal wall and yet a fatal issue may

follow. On the other hand, the surgeon may feel a

small swelling after distension has been practised and

may think that reduction has not been complete, thoughthe mass felt is only cedematous bowel.For these and other reasons there has been of recent years

a growing tendency to resort to abdominal section at an

early stage of a case of intussusception. Even in the pasta laparotomy frequently followed unsuccessful attempts at

distension, but these unsuccessful attempts had been oftenso energetic and persistent that the severe exhaustion

that had been induced entirely precluded the possibilityof a successful result following the abdominal section.

Mr. JONATHAN HuTCHINSON’S case recorded in the fifty-seventh volume of the Medico-Chirargieal Transactions

appears to have been the first successful case in this

country, though one had occurred in France towards the

end of the eighteenth century. Since Mr. HUTCHINSON’S

case in 1871 many others have been recorded ; still failures

far outnumbered successes and, indeed, laparotomy for

intussusception had fallen into a certain degree of dis-

repute. With the development of abdominal surgery the con-fidence of the surgeon in the comparative harmlessness of a

laparotomy developed, and the abdomen was opened for thetreatment of this condition with less and less hesitation.

Still, however, the mortality continued high, and it was seenthat no small share of the blame was to be attributed to the

exhaustion produced by the previous attempts at reduction.Abdominal section was therefore gradually performed at anearlier stage, until it was found that the best results were

obtainable in those cases where little or no previous attemptsat distension had been made, and at the present time recourse