lite ^4^^M-^k^■:!>•."■;- ■ '■■■■■ ■^^*^--' ^H:fcw.A^^,-:.-.-i-...-'/' ,,i NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of The New York Academy of Medicine •O* Ds. $l|e ltrin<(. By. w-^■■'■-*■* •*"**»*"v'—y»eW"vww ;«ti IS WOO. /89 Of t.UUt'JU tif I Ht AGAD£iC^L<^7' , V^-—^ No. 11 _y State Charities Aid Association, A C each had, in its town hospital, its quota of sick and wounded, to whom the supplies sent from Florence were distributed. The hospitals were dreary enough ; rambling stone buildings, with tre- mendously thick walls, small windows, narrow, wind- * ing-stairs, and great, vaulted, unventilated rooms, with stone floors ; no attempt at neatness or cheer- fulness, and not the faintest chance of fresh air. As for fresh air, a sick Italian thinks it is death, and Garibaldi, even, after he was shot in the foot at Aspromonte, set his servant at work with a pot of paste and strips of paper to close up all the cracks in the windows of his sick-room. The diet of the hospitals was about the same as the men would have had at home, a little thin broth, sour wine, and a bit of black bread. The Roman hospitals naturally received the bad cases after Garibaldi's defeat, and the mortality here was very great. There was more filth, less air, far worse wounds, and the discouraging fact that the men were prisoners after a defeat. JMo chloroform .was used by Italian physicians in operations, and no stimulants given. The suggestion of eggs and brandy, made by an American surgeon, one of the volunteers above-mentioned, was met by the answer that in a hospital where it had been tried all the cases proved fatal. One hospital, which was in 54 charge of volunteer gentlemen of Rome, was in exceptionally good condition ; there was great kind- ness shown, and the patients were better off. San Spirito is the great hospital of Rome, and is in the hands of the religious order of that name. It is devoted to the relief of sick poor, without distinc- ' tion of class or nationality, and has room for seven hundred and thirty beds. The military garrison hospital is annexed to it, and is under the same management. On the occasion of one visit to San Spirito a huge cauldron, three feet in diameter, was found boiling in the open air of the courtyard over a brazier ; attendants were pouring in bushel baskets of fresh blue violets, for the violet tea, which is a favorite tisane, or drink, in fever cases in Italy, and the air was fragrant with the delicious odor. ENGLAND. In France, as we have seen, the hospital belongs . to the State ; the almshouse, as a rule, to private charity. In England the reverse is the case. The poor-law, in theory, hitherto has provided public support only for the old and infirm, while hospitals and dispensaries are sustained by voluntary contri- butions, or by endowments received originally from individual or ecclesiastical sources. Occasionally the poor-guardians farm beds in certain hospitals__as, 55 for instance, the Jewish Board of Guardians, which farms or hires beds in the London Hospital—but the practice is very rare. In Scotland and Ireland it occurs more frequently. The grade of hospital patients in France and England differs. In very few English hospitals are there any pay wards ; treatment is gratuitous, but the rules for admission require letters of recommend- ation from subscribers, that the patient shall supply his own linen, tea, and sugar, and pay for his own washing. A large proportion of the English poor, unlike those of Paris, must be excluded from regular hospitals and find refuge in workhouse infirmaries, of which we will speak later. But one establishment, the London Hospital, at the east end, can be pointed out as the counterpart of Bellevue. Here, patients are of a low social grade, and, most of the cases of surgery being acute—the result often of wounds from violence—pyaemia abounds. English thorough- ness, in spite of old buildings, manages to keep the wards of most London hospitals free from hospital odor. All the nurses in England are women, both in male and female wards. Of eleven great London hospitals, six employ no men nurses, five employ them only occasionally ; there are a few men ser- vants, as stretcher-bearers, etc. There is a matron, 56 who is the nominal head of the nursing corps, the hospital having its own secular government. This is our fourth system of nursing, and English hospi- tals, as a rule, are illustrations of it, as are nominally many hospitals in America. Nominally—for the matron of a hospital here has commonly all she can do to look after the housekeeping work. The over- sight and discipline of the nurses, therefore, falls into the hands of the medical staff and the male ex- ecutive officer. In that case the hospital should be more properly classed as illustrating the German and Austrian systems of nursing already characterized. John Howard—an autograph copy of whose book, published in 1789, is to be found in the Astor Library—gives some interesting details of the hospi- tals of Great Britain a century ago. He constantly complains of low ceilings, bad air in the wards, floors sanded to hide dirt, and wooden bedsteads with tes- ters, and " filled with bugs." Howard says : " If the annual sum paid in several hospitals for the destruction of bugs, Westminster, for instance, were spent in airing, beating, and brush- ing beds, the end, perhaps, would be much better answered. In hospitals in Sweden the practice ex- ists of bringing a certain number of beds into the open air every fine day, for the purpose of sweeten- ing them. They are beaten and brushed on a deal ^7 frame, made for the purpose.0 But prejudices every- where in England against washing floors and open- ing windows were allowed to rule ; fixed sashes were common ; bathing was scarcely ever practiced ; medical and surgical cases were nursed in the same ward. The London Hospital, although the newest and finest then built, had not been whitewashed for years. The daily diet in this hospital was eight ounces of meat and twelve ounces of bread, and no vegetables. Tea was strictly forbidden in most hospitals, but tobacco smoking was en- couraged, probably as an antiseptic. Patients were required to pay down twenty shillings on entering, or find security for their burial. Fees to attendants were a regular exaction—one shilling to the sister, sixpence to the nurse, and sixpence to the beadle—and a door was opened to great imposi- tions. Beer was freely brought in from alehouses to all hospital patients of the period—said to be by doctors' orders. The managers of Guy's Hospital were progressive people ; we get a ray of light here. Improvements were going on, ward by ward, at the time of Howard's visit. There were contrivances for open- ing the windows easily, and the water-closets were of the best known construction ; a spring on the door as it opened and shut served to empty the pans and 58 refill them with clean water from a reservoir. This was in 1785. But the condition of some of the Irish county in- firmaries passes belief. Howard grows facetious over them. At Waterford, the surgery consisted of one pot of ointment, and eighteen old empty drawers. Castlebar Infirmary was old and ruinous ; the dirty windows were stopped with straw ; one room served for kitchen and washhouse, turf cellar and nurses' lodging. The diet was water-pottage and a pint of milk a day. Queen's County Infir- mary was one of only two hospitals in Ireland that received a large county appropriation—about three hundred pounds. It had four sick-wards. A little dirty hay in one room served for the woman nurse's lodg- ing. The ceilings were covered with cobwebs ; there were no sheets, no vault, no water. The diet was a threepenny loaf, and two pints of milk, "or rather, if my taste did not deceive me," says Howard, " of milk and water." The surgery was a closet, the furniture consisting of ten vials, some of them without corks, a little salve stuck on a board, some tow, and pieces of torn paper. There were twenty patients at the time. In County Tyrone two patients were put to bed in the bath-tub; and Howard says he does not recollect baths in proper use in any county hospital in Great Britain. " Much depends on a neat 59 and notable matron, who has humanity joined with firmness, and good sense enough to be directed by those who have more knowledge than herself. Such a woman is a treasure in a hospital or workhouse." (The italics are Howard's.) Among other valuable suggestions, he recom- mends that in every hospital one ward be kept un- furnished and vacant, so that wards may be emptied and cleaned in rotation ; an enlightened idea for one hundred years ago, but one which few managing boards have ever carried out. Reforms came slowly. Philibert Roux, a French surgeon traveling in England, in 1816, speaks of the London Hospital, " that fine institution, and one of the most recently established hospitals in London "— the one that " had not been whitewashed for years " —" where the physicians and surgeons had resolved to try every expedient in order to secure one point, the separation in different wards of medical and sur- gical cases, and did not succeed. There was no daily visiting staff. Only twice or three times a week did the chef visit the wards." District dispensaries in Ireland were established by Act of Parliament in the beginning of this cen- tury, and were supported by the " county cess," .supplemented by local charity. In i85i, by the passing of the Medical Charities' Act, the dispensa- 6o ries were placed upon the poor-rates under poor-law management, but not connected with general relief in any way. Medical relief from the poor-rates became as accessible as from any charitable dispen- sary. By Sir Robert Peel's amendment in 1862, poor persons, not destitute, but disabled from sickness, may be received into the workhouse hospitals, and by paying something may be registered separately, and not classed as paupers. In Ireland, therefore, the whole medical necessities of the poor may be de- frayed from the poor-tax—a dangerous system— since accepting medical relief is often the first downward step. The Chief Commissioner thinks there is no danger of this system pauperizing the people, as it might if it were associated with an ex- tensive system of out-door relief. Very little out- door charity is bestowed in Ireland.* As to the low character of the nursing in Eng- lish hospitals of old, and until within the last fifteen years, we have ample medical testimony. Dr. Chatto, of St. Bartholomew's hospital, writing in 1835, complains of the old, faulty system of nursing still in vogue, and instances three things : "That sisters are too ill paid—fourteen shillings to sixteen shillings a week ; and nurses, upon whom the comfort of patients mainly depends, wretchedly paid * See Reports of Health Officer of Glasgow. 1876. 6i —seven shillings a week. 2. That nurses not sisters are overworked ; they sit up alternate nights, and are called on for all sorts of household duty. 3. " Lastly," he says, "the mode of appointment and removal of nurses is faulty, being entirely independent of the medical officers, and vested in matrons or stewards," whom he thinks incompetent to judge of the capa- bilities of nurses. He condemns the apathy of doc- tors as highly discreditable, and quite inconsistent with the anxiety they so often display for the wel- fare of patients ; and adds, that large hospitals should form the best schools for instructing women, and should be able to furnish the public with good nurses on reasonable terms.* Nurses for the most part, up to fifteen years ago, were put to their work without any training, and at an age so advanced that effectual training was scarcely possible. Many could neither read nor write ; they were recruited from a low rank ; their duties included not only attendance on the sick, but cleaning and scrubbing ward floors and the stair- cases of the hospital; the women were usually widows, or those who had children depending on them, and who were attracted by the unwise but popular arrangement of board wages. Their work was complex in character, and very laborious. In *" London Medical Gazette." 1835. 62 some hospitals the night nurses received a shilling and their supper for a night's nursing; they were over-worked and destitute char-women, who went out to day's work at eighteen pence, and supple- mented these poor wages, by taking charge of hos- pital wards at night. Drunkenness was common with this class, drowsiness still more so ; the women deserved pity rather than punishment. " Now, nurse," a visiting professor would say, in the pres- ence of his students, " if this patient is not better in the morning, you will be discharged." Generally the patient was better. Of course, there were some excellent nurses, but the system was as bad as it could be. Of the manner in which woinen " nursed," of what they did, and what they left undone, what they were ready to do, and were with difficulty restrained from doing, Dr. Lionel Beale tells us the less said the better. Guy's Hospital, founded by a rich, old bookseller of that name—the managers of which were enlight- ened people, and introduced improvements, patent water-closets, etc., as we have seen—stands inter- mediate between University College, with its sister- hood, and St. Thomas Hospital, with its training- school, the three representing three distinct nursing systems. Guy's may be considered a fair illustration of the cost of nursing, and of the character and 63 amount of service required of nurses in England, under the best conditions.* It was the custom for each ward to have at its head a lay sister ; this was a title of convenience, and did not indicate any system of training, or any organization, either religious or otherwise. She ad- ministered the diet and medicine, reported symp- toms, and received the directions of the medical staff. Respectable women, who had been upper servants in families, or who had done some private nursing, were chosen. They received fifty pounds a year, and an allowance of milk and beer. The day nurses had thirty pounds a year, and beer from the hospital brewery. These were board wages, and the women all found themselves. Counting day and night service, each nurse had on an average ten patients to care for. The annual cost of nursing each bed at Guy's amounted to five pounds eight shillings. In the last fifteen years, there has been, in all English hospitals, a tendency to increase the number of nurses, to secure a better grade of women, and to separate nursing from scrub-work. Guy's Hospital, rich as it is, so rich that the difficulty of the o-overnors seems to be to know how to spend the money, now requires its nurses each to scrub, on * "Guy's Reports." Dr. John Charles Steele, 1871. 64 an average, only four hours a week ; and Dr. Steele, the resident medical superintendent, whom we must be forgiven for disliking a little, defends the practice, and thinks it would be difficult to say how a nurse's time could be fully occupied without this resource! Guy's now employs what Dr. Steele describes as " a resident staff of six scrub-women," and with occa- sional hired help and that of the nurses, pays for cleans- ing the hospital, numbering five hundred and sixty beds, about five hundred pounds a year ; and the cost of nursing each bed has run up to seven pounds ten shillings and eleven pence. Two of the largest London hospitals, St. Bartholo- mew's and the London, do their scrubbing by con- tract. The former, with six hundred beds, pays six hundred pounds ; the London, with five hundred and seventy beds, and in its condition and character re- sembling Bellevue, pays three hundred and sixty pounds a year for this purpose. There is now one nurse to every seven patients in Guy's, or one to eight if every bed were occupied. Instead of finding themselves, wages are fixed at twenty pounds a year ; the nurses are furnished with every required article of diet except butter, and a nurse's dining-room is provided. They have one day's holiday once in four weeks, and each year one week's vacation. 65 Sisters are allowed fifty-eight pounds a year, a daily ration of bread, besides beer and milk, and a suitable dress, and their rooms, which they used to furnish themselves, are now fitted up at the expense of the hospital. Sisters are compelled, however, to purchase their food out of their wages, and have it cooked in the ward kitchen, or in their own rooms, to be eaten at any convenient opportunity, not always attainable. They are enjoined to take daily exercise, and each is entitled to three weeks' holiday a year. For twenty-five years there has been a superannuation fund at Guy's, to which the Sisters are expected to subscribe quarterly, the managers doubling the sum; this takes the place of the " retired list" of the French administration. It entitles Sisters contrib- uting to a pension of thirty pounds a year, at the ao-e of sixty-five ; and in case of the death of a sister, or giving up hospital work, her quarterly pay- ments with interest are returned to her or her friends. King's College, University College, and Charing Cross Hospitals, it will be remembered, are nursed by two religious orders, and should be classed with French hospitals, under the first system of nursing described. These two communities, for a specified sum, furnish everything the hospital may require in the way of female service, including cleaning and 5 '66 i cooking. King's College Hospital, with one hundred and fifty-two beds, pays St. John's Sisterhood one thousand three hundred and forty-five pounds a year for this arrangement. University College, with one hundred and fifty beds, pays All Saints' Sisterhood one thousand five hundred pounds. Fulfilling the old proverb, we find Dr. Beale and Dr. Steele disagreeing as to the desirableness of the plan. Dr. Lionel Beale, of the Royal College of Physicians, and one of the staff of King's College Hospital, says: " I have been for years a member of the Council of St. John's House, the Mother House, and a physician of King's, and I cannot conceive a connection more natural or more likely to work well and be advantageous to both institutions, than the one that exists between King's College and St. John's Sisterhood." Dr. Steele, Superintendent of Guy's Hospital, which is nursed on the old system, while admitting that the work is well done at King's and the Uni- versity Hospitals, and not costly, considering the number of attendants, says: "The duality of the government on the sisterhood plan, and the respon- sibility of employees, not to the regular governing body, but to an outside religious agency, lead to misunderstandings, and involve the hospital in a disparity of expense scarcely warranted by the re- 67 sults,^ as far as the patients collectively are con- cerned." He thinks it would require very strong arguments to prove that a patient in the North London Hospital had double the advantages of a patient resident at Westminster, or that it was a greater charity to maintain one hundred beds at the former institution, at the same outlay as suf- ficed to nurse two hundred beds in the latter. In a paper on Hospital Expenditures, Mr. Joseph G. Wilkinson gives the annual cost of each bed in the following hospitals : University, seventy-seven pounds four shillings and tenpence ; Middlesex, sixty-two pounds six shillings and one penny; Charing Cross, fifty- nine pounds fourteen shillings and ninepence ; King's, fifty-nine pounds six shillings and fourpence ; Guy's, forty-seven pounds thirteen shillings and sevenpence ; Westminster, thirty-nine pounds nine- teen shillings and one penny. Tables have already been given, showing the number of men and women nurses employed in Paris hospitals, and the wages that are paid. On the next page will be found a table of the number and the wages of nurses in the hospitals of London ; all the nurses being women. REMUNERATION, ETC., OF NURSES AT THE FOLLOWING LONDON HOSPITALS Guy's............ Bartholomew's___ St. Thomas's...... London .......... St. George's....... Middlesex......... St. Mary's....... Westminster .. King's College.... University College .•u 0" 1 £W £ c/5 Kfc 560 20 72 650 25 81 211 7 19 57° 15 70 331 19 36 300 9 42 157 7 18 193 6 24 152 7 35 150 7 30 Annual Remuneration of Sisters. £58, Partial Board and Dresses. £58 10s., Dresses only. £50, Full Board. Pay for own Dresses. £44 7j. A,d., Partial Board and Dresses. £35, Full Board and Dresses £30, Full Board and Dresses £30, Full Board and Dresses £26 5s., Full Board. Full Board and Dresses. Full Board and Dresses. Annual Remuneration of Nurses. £20, Board and Dresses. £22 15s., Board and Dresses. £25, Board. Pay for own Dresses. £18 16s., Full Board and Dresses. £20, Full Board and Dresses ,£20, Full Board and Dresses £22, Full Board and Dresses £19 19s., Full Board. £22, Full Board, Clothing, and Washing. £16, do. do. G „ «' .2Ec £ B v 0.2 ■5 0 <^ Ph & ° ° Proportion of Nurses to Patients. 1 to 28 1 to 8 1 to 26 1 to 8 1 to 30 1 to II* 1 to 38 1 to 8 1 to 17 1 to 9 1 to 33 1 to 7 i to 22 1 to 9 1 to 32 1 to 8 I tO 22 1 to 4 I tO 21 1 to 5 Remarks, Superannuation Fund for sisters. Prizes varying from jts. 6d. to £5 are distributed among nurses. Gratuity of £5 5$. to sisters annually. Nurses have their dresses washed in hospital. p6J>345 paid for nursing am cleaning arrangements. £1,500 do. do. On 00 * Proportion of nurses to patients largely supplemented from the Nightingale Training-School. 69 We have had a glimpse of what sort of nursing there was in the large, rich, regular hospitals of Eng- land ; but what must it have been all this time in the English workhouses, to which we should fairly look for the parallel of our county poorhouses ? A cen- tury of workhouse nursing! Official reports tell us the painful story.* These buildings are not workhouses in the sense of institutions where the inmates are all able to work ; nor are they exclusively hospitals where the sick are temporarily received and treated ; but asy- lums in good part where infirm and aged poor are provided for during life, and where consumptives and persons suffering from other acute or chronic diseases, coming from regular hospitals, perhaps, and being entirely without resources, end their days. They, are institutions suigeneris. The number of sick poor requiring medical treat- ment, who enter the workhouses of London every year, is over fifty thousand. A report of the Poor- Law Board, printed for the House of Commons in 1865, showed six thousand four hundred sick in the wards of forty-one London workhouses on a given day, of whom about one-third were ill of acute dis- eases susceptible of cure. Able-bodied inmates were * See also " The Workhouse as an Hospital." Frances Power Cobbe, 1861. \ 70 estimated at thirteen per cent., and few of these could be spared from the ordinary household duties required by the presence of aged inmates and chil- dren. For nursing- the six thousand four hundred sick, there were seventy-one paid nurses ; but as thirty of these were employed at St. Pancras and Marylebone Infirmaries, where special efforts had been made in the direction of better care for the sick poor, there remained only forty-one nurses for thir ty-nine workhouses: hardly one apiece. Thirteen hospitals had no paid nurses. There were eight hundred and fifty-nine pauper helpers employed. Half these women were over fifty years of age, one quarter were above sixty, and many were seventy and even eighty years old. Pauper nurses were allowed tea or beer, and the doctor would send any feeble old body, who needed some such extra comfort, to be a nurse in the sick-wards. One workhouse hospital is mentioned where nurses were paid a penny a week. Naturally, they fleeced the patients and their friends of whatever trifle they possessed. Payment was made in extra diet, which did not amount to meat every day ; and in clothing, which was as shabby as that of ordinary- inmates. Instead of inducements being offered to the industrious, the temptation was rather to be an ordinary inmate and idle. Habits of pilfering and 7i drunkenness were common ; the latter habit culti- vated by the allowance of a pint of strong porter daily, with one or more glasses of gin for night duty or disagreeable work. In only a minority of work- houses was money payment made, and that not always dependent on good behavior. Women who had once been employed in hospitals and dismissed for cause—old age, failing health, or drunkenness—untrained, untrustworthy, ignorant, and degraded by vice of some kind came, as a last resource, to the workhouse, and were still con- sidered competent to be set in office over the pauper sick and dying. The insufficient cubic space provided, the scant outfit of utensils, etc., are matters of record. In some of the London workhouses lunatics and imbe- ciles were placed in the general wards ; in others, they were considered sick patients, and were classed separately, at the discretion of the medical officer. This officer was overworked and underpaid, some- times having the charge of three hundred patients ; and, moreover, was required by the law to furnish the medicines out of his salary. There was no system of medical inspection. * In provincial workhouses things were no better— except as regards the sites, which were generally * " Parliamentary Papers." Vol. LXL, 1866. 72 open and good. Poor-law inspectors' reports varied ; apparently in accordance with the habit of either taking official answers to official printed questions, or of the inspectors "seeing for himself." In the south-western counties—Devonshire, Dorsetshire, Cornwall—with fifty-eight workhouses, E. Gulson, esq., inspector, to the printed question, " Are the arrangements for nursing satisfactory, especially the night nursing? " returns answer, 24th January, 1867, "Nursing generally satisfactory, almost every infirm- ary having one paid nurse, and one or more helpers." But at Bath Union, in his district, where he gives to the question an unqualified yes, we find two hundred and fifty-one sick persons, including insane, and only six nurses, with nineteen pauper helpers allowed to have extra diet. Clifton Union had one hundred and fifteen sick, including lunatics, in charge of two paid nurses and fifteen pauper helpers, and there seems to have been no system of night-nursing any- where. Of sixty-five workhouses in the south-eastern counties, W. H. T. Hawley, esq., district inspector, almost all were overcrowded with sick, and without means of proper classification ; thirty-four work- houses had no paid nurses at all, the matron did the nursing with pauper help, and nursing every- where was "unsatisfactory." Separate wards for 73 children were found in only six of the sixty-five houses. Children were brought under the influence of the worst characters, and lived among diseases and scenes totally unfit to be intruded on minds so young. The Isle of Wight is in this district, and the account of its workhouse infirmary is exceptionally pleasant. It had separate wards for children and three paid nurses. There is not one black mark against it in the report of the inspector, who liberally sprinkles his official columns with crosses and ques- tion marks and exclamation points, to intensify his surprise or disgust. Only two other workhouses of the sixty-five, Southampton and Calne, could show as clean a record. The report recommends an order of the Poor-Law Board, compelling guardians to em- ploy paid nurses, and to classify inmates in work- houses. Another inspector for South Wales and the ad- joining English counties, ten in all, with sixty-three workhouses, reports one-seventh of the inmates needing the services of nurses. The medical relief books, to be sure, had the names of one-third, but these were of persons entered for beer or extra diet on account of old age, or as pay for extra housework. The paid nurses constantly acted as general ser- vants. "In no workhouse of the district does a 74 nurse habitually sit up at night. A pauper attendant is provided to sit up with a patient supposed to be dying or in childbirth.'' The eastern counties of England have seventy- four workhouses, and the government inspector reports great difficulty in obtaining competent nurses, except at salaries which the guardians are unwilling to pay. Twenty-one workhouses had only pauper nurses; and nursing was more or less un- satisfactory, accordingly. But Leeds Workhouse Infirmary; in the West Riding, has a bad pre-eminence. It was a quad- rangle of buildings, with blank walls in many of the wards. No division was made between medical and surgical cases—a common abuse, however ; itch, on the women's side, was classed with the vagrants ; the lying-in ward was in the body of the house ; the beds, as was the common custom, were of flock ; one wash-basin and one roller towel a week were allowed to wards of from eight to fourteen patients. One woman nurse had charge of seventy lunatics, of both sexes, with one male helper ; and only one nurse gave undivided attention to one hundred and fifty sick. Says Inspector Cane : " Although the medical officer is content with the existing condition of the 75 infirmary, I do not consider it in a satisfactory state." * The meat was generally boiled on meat days, in workhouse infirmaries, for soup days came next; the cooking apparatus was arranged for boiling, and the process was chosen as one requiring less care and occasioning less waste than the more healthful mode of roasting. But the insufficient diet and clothing—the patient's own clothing being removed, and workhouse, cotton garments substituted—the wretched character of the buildings, the comfortless life and bitter death of hundreds and thousands of workhouse inmates must be imagined. The mem- bers of many of our local visiting committees can fill up the outline from their own experience in our city and county poorhouses. From printed testimony we learn that the first suggestion toward organized training of nurses in England came from a medical man. Dr. Robert Gooch, an eminent English physician and reformer, traveling on the continent in 1825, was much im- pressed by the good order of the institutions in Flan- ders, under the charge of the Beguines. The singular headdresses and often beautiful faces of these nuns are familiar to all travelers in Ghent and Bruges and Brussels. The nuns are allowed to live in little * "Parliamentary Papers." Vols. LX., LXL, 1866-68. 76 families in their own houses, may take lodgers, receive visits from near male relatives for three days at a time, and occupy their leisure in raising flowers and making lace. Their lives are tranquil and pro- longed. Howard mentions seeing at Bruges, in 1785, the directress of the pharmacy, who had just celebrated the fiftieth year of her residence in the hospital. The Beguines form a corps of reserve, and in times of great public distress, like the inun- dations at Ostend, or large fires, or typhus epi- demics, give liberally their money and their service, acting as sisters of charity. In the cholera seasons of 1832, 1849, and 1853, each Beguinage volun- teered to serve one hospital. Dr. Gooch praised the Flemish system, and urged reform in the English nursing service. His letters were published in " Blackwood's Magazine," and in the " London Medical Gazette," then in its first year, and were reprinted by Robert Southey, in his Colloquies. This was ten years before Kaiser- werth. Dr. Gooch even addressed the Bishop of London, by pamphlet, deploring the state of the sick poor, especially in the country towns, and urging " all serious Christians to join in founding an order of women, selected for their good sense, industry, kindliness, and piety. Let them be placed as nurses and pupils in the hospitals of Edinburgh and Lon- 77 don ; let them be examined frequently, to see that they carry clearly in their heads what they learn ; let books be framed for them—briefly and untech- nically written ; let women thus educated be distrib- uted two together in a cottage, placed in the center of some country district, and villagers would soon have reason to bless the hour, when these women settled in their neighborhood. There are only two classes of people," Dr. Gooch adds, churchman though he was, " whom I have any hope of in- fluencing for this plan—Methodists and Quakers." He died with his wish unfulfilled, but it had in it the germ of the present English system of district nursing. Robert Southey himself theorized in his Colloquies on the need of directing the personal charity of women to hospitals, and doing for them what Mrs. Fry had done for prisons ; and several letters passed between himself and a clerical friend on the plan for educating a better order of persons as nurses for the poor. Rev. Mr. Hornby, rector of Wrinwick, in concert with Adam Hodgson, esq., of Liverpool, undertook to set on foot an institution for this pur- pose, as an experiment, and to maintain it for two years. It does not appear what good women in the parish they may have had urging them on. They hired a house and engaged a matron, received a 78 number of inmates, and sent out some few as nurses. Other persons now joined the management, but as soon as it appeared that they were educating a valuable class of women, it was sought to make them available to the upper classes as monthly nurses, and this being an entire perversion of the original plan, the two gentlemen, whose interest was for the sick poor, withdrew at the end of the two years, and the whole scheme quickly fell to the ground.* The first permanent effort in England to improve the character of nurses came from the very direction in which Dr. Gooch had set his hopes—from the Society of Friends, to whom the world owes so much. Elizabeth Fry established in London, in 1840, a small institution for training and providing sick-nurses for poor families, which is still active and useful. Pastor Fliedner had found part of his inspiration in the faith and love of the English women whom he met on a journey among English charities. The two countries interchanged philanthropic ideas ; for a few years later we find men and women in Eno-lnnd who had examined the system at Kaiserwerth, then fairly under way, trying to excite public interest at home in favor of a similar plan. They outlined a * "Life and Correspondence of Robert Southey." Edited by his son. Vol. VI., p. 71. 79 scheme and issued a circular of inquiry as to the means of raising the character of hospital nurses. The twenty-three answers—all that were elicited— from chaplains, doctors, and governors of hospitals, almost without exception testified to the evils com- plained of, and expressed despair at any remedy. The public praised the project, but gave no encour- agement. Dr. Sieveking, in 1849, had published a pamphlet on the training of workhouse women as nurses for the poor, and had urged the visiting of workhouse wards by ladies. It was good seed sown. In i852, it was stated in the " Lancet" that on recommenda- tion of the coroner for the western districts of Mid- dlesex (some catastrophe must have happened) the parish authorities of St. Pancras and Marylebone had resolved to substitute paid and efficient nurses for pauper attendants, whose age, condition, and in- firmity generally rendered them unfit for the situa- tion, and through whom the sick poor suffered very much. But the guardians had their own em- barrassments. We find them still struggling with the nursing problem in 1868, for Mr. W. H. Wyatt, then chairman of the St. Pancras Board, in his official address, says : " I would earnestly ask your thoughtful attention whether some means may not be devised for securing a better and more 8o intelligent class of persons as nurses for the sick. We have had many changes among subordinates, and our system, in this respect, is certainly open to improvement." Next, Sir Edward Parry, in the hope of procuring better nurses for the naval hospital at Haslar, near Portsmouth, drew up an appeal, signed by five medical men, soliciting the aid of all good Christians to induce even three or four respectable women to volunteer their services, and to undergo training, such as that at Kaiserwerth, then to superintend others at Haslar, and so raise the moral tone of one of the most important of the national hospitals. The appeal was extensively circulated, but this liberal offer to put a government hospital of twelve hun- dred beds in the hands of trained women did not receive a single answer. At the yearly meeting of the English Epidemio- logical Society, April, 1854, after the reading of the annual report, a paper was presented by Dr. Sieve- king, on the " Importance of Supplying the Labor- ing Classes with Nurses." He was a man well qualified to judge of the need of good nursing. He had held on to the idea he had advocated in 1849, and urged it eagerly now in the warm discussion that at once sprang up in the meeting. He stated that there were fifteen able-bodied men and twenty-three 8i able-bodied women, on an average, inmates of every union in England available for his purpose. A committee on nursing was appointed at the instance of the. society. Its last secretary, Dr. Ogle, physician to St. George's Hospital, writes about it lately to the " London Medical Gazette." The idea was to secure a better grade of nurses for the poor during epidemics, or in childbirth, and to turn to account for this purpose adult and able-bodied pauper women, of whom there were, in that same year the committee organized (1854), no less than twenty-four thousand two hundred and three in the workhouses of England. This was the number, according to returns moved for in the House of Commons. Twenty-two thousand of these were considered women of good character, and qualified, if instructed, to become useful nurses. The committee proposed that a general order of the poor-law board should make it imperative on the master and matron of each workhouse to put their able-bodied women through a course of train- ing in kitchen and infirmary. The masters of five or more large workhouses in and near London were ready to co-operate, but the poor-law board saw difficulties, as they well might, in the character of the workhouse women and in the uncertainty of their stay, which, in their view, made the plan im- 6 82 practicable. Extensive correspondence was carried on with the guardians of unions, and, though nothing definite then came of it, Dr. Ogle claims that it did service in bringing the subject of trained nursing before influential persons, and helped prepare the general mind for steps afterwards taken. The English Church, it is true, had recognized its field of duty, and the well-known St. John's Sister- hood and House had been established in 1848. But it was so difficult to interest public opinion that it was eight years later, namely, i856, before its pupils were admitted to the wards of King's College Hospital. At present St. John's manages two hos- pitals, has twenty-five sisters and one hundred and twelve nurses and pupils, and has done a great deal toward raising the standard of nursing. St. John's House furnished some of the first women who accompanied Miss Nightingale to the East in 1854. A large proportion of the workhouse sick of England are chronic and incurable cases. The Registrar-General's returns show that three diseases, dropsy, cancer and consumption, have carried off in England more than eighty thousand persons every year. The deaths from constitutional diseases in England in 1873, as shown by the abstracts for that year, published in the last report of the Registrar- General received, namely, that for 1875, numbered 83 eighty-five thousand seven hundred and twenty-six. These were chiefly from cancer and consumption, dropsy, by better diagnosis, being now generally referred to the more correct organic sources of disease. It is estimated that between thirty and forty thousand incurables are annually compelled to seek the shelter of some workhouse wherein to spend the last few feeble months of their lives ; many of them not paupers, but persons whose former industry and present anguish would give them the highest claim to compassion ; many of them, no doubt, in the earlier stages of their disease, victims simply of defective sanitary arrangements in their towns or tenements, and of the want of preventive care and nursing. It was for these poor people that the interest of Miss Louisa Twining and her friends was enlisted as early as 1853. The Workhouse Visiting Society was established in 1857, to promote " the moral and spiritual benefit of workhouse inmates," but the un- avoidable result was to open the doors of work- houses to a wider degree of visitation and interest than they had ever received. The organization, being under the auspices of the National Association for the Promotion of Social Science, encountered less official prejudice than might have been expected, and did much to call attention to and secure the 84 reform ,of abuses, especially that of pauper nursing. We find on its committee the names of Right Hon. W. Cowper, M. P., its President; Miss Twining, Secretary ; Dr. Ackland ; Charles Buxton, M. P. ; Dean Howson ; Baroness Burdett Coutts ; the Countess of Gainesborough ; Lord Houghton ; Sir Roundell Palmer; Dr. Sieveking; Mrs. Wm. E. Gladstone ; Lady Shaftesbury, and others. The suggestions made by this society were : i. That in every workhouse persons suffering from acute and distressing diseases should be placed in wards especially allotted to them, to be called the wards for male and female incurables, and that they should have the benefit of trained nursing. 2. That in these particular wards private charity be permitted to introduce whatever may tend to alleviate the sufferings of the inmates, extras from friends of patients being forbidden. On this plan, wherever guardians consented, charity penetrated where it had never ventured in England before ; grants of money to unions were made for the purchase of easy chairs, window-blinds, screens, comfortable clpthing, and the like. Ladies of the highest class visited the workhouses system- atically, and great good has been done. It is sub- stantially the same work in which the State Chari- ties' Aid Association and its local visiting committees 85 have engaged since 1872, although the scheme of our own work shaped itself in the mind of our Pre- sident some years before the war of the Rebellion. In England it has been carried on with English vigor and thoroughness against tough old English abuses, and it had, from the outset, a more pro- nounced religious element. Pamphlets and the journal of the society contain much to interest and encourage us. It was the horrors of war, at last, which produced " the peaceable fruits of righteousness," which called forth the capabilities of English women, and showed English men that their sisters and daughters could be skillful and heroic, and yet none the less ladies. One of England's chief victories in the Crimea was wrought by a woman, but men have since eagerly followed where Florence Nightingale then led. The history of the Nightingale Fund and of St. Thomas's Nursing-School—opened in June, i860— and of the Training-School and Home for Nurses, in connection with the Liverpool Royal Infirmary, opened in 1861, are familiar to you.* To these two establishments all thoughts turn when wisdom and inspiration are wanted for hospital nursing reform. The Liverpool system includes three branches, * See Dr. \V. Gill Wylie's Report, Document No. 1, State Charities' Aid Association. 86 the training-school, which nurses the hospital; dis- trict nursing of the poor, and the provision of nurses for private families. It has been in operation now fourteen years, and is the most complete organiza- tion of the kind in existence. It covers the whole town, and works in connection with the Board of Health, whose medical officer, Dr. Trench, in his report for 1874, gives three thousand three hundred and seventy-one as the number of cases attended during the year by the women, and some of them cases of extreme gravity.* The health officers are notified of every case of sickness, and a woman, if needed, is summoned. The preventive effects of prompt care and good nursing are easily calculable, and must be of the greatest importance to the general sanitary welfare of any town. May, 1865, was a marked month in the history of workhouse nursing. In May, i865, owing to the efforts of Mr. William Rathbone, the unpaid pauper nurses, who attended to the sick in the male hospital of the Liverpool Workhouse, were replaced by a staff of trained and paid nurses, under the able direc- tion of the late Agnes Elizabeth Jones. The great * National Association for Providing Trained Nurses for the Sick Poor. Report of Subcommittee of Inquiry. London, 1875. 87 success, as Dr. Barnes, Surgeon to the Workhouse, calls it, which followed this first experiment in work- house nursing, soon led to the other departments of the hospital being placed under the same conditions ; and now, for some years, the male and female medi- cal, the male and female surgical, the male and female infirm, the children, the lying-in, and the female "lock " divisions, have been carefully tended by an efficient staff of trained nurses and probation- ers, under the supervision of a lady superintendent. The Guardians of Chorlton Union made a move in the direction of better nursing about the same time that the Liverpool authorities did. They sent for two sisters of All Saints, and put the nursing of their immense new infirmary near Manchester into their hands. A circular of the Poor-Law Board, dated May, 1865, called on all metropolitan guardians to intro- duce trained nurses into London workhouses. This step was, no doubt, prompted by the death, early in that year, of two workhouse inmates under circum- stances which attracted public notice. Investigations into the state of the sick-wards in all the London workhouses were undertaken by the " Lancet Sani- tary Commission," and were reported week by week, in that journal, during i865 and 1866. The accounts disclosed serious abuses in management. The Poor- 88 Law Board were driven to make official examina- tions, and they held interviews with large and influ- ential deputations of citizens introduced by the Earl of Devon.* These deputations represented an association recently formed (and in which the Women's Workhouse Visiting Society was merged), for the improvement of workhouse infirmaries. Forty members of the House of Commons were present at the first interview, and eminent persons of all parties united in urging improved accommo- dation and treatment for the sick poor. At a pre- liminary public meeting the resolutions in favor of reform were moved by the Archbishop of York, and seconded by Thomas Hughes, M. P. An editorial in the " Lancet," speaking of the association, says: " London workhouses are the great hospitals of London ; and the one principle on which this association has" been founded is this : to declare that the sick paupers have the same right to properly organized nursing, dietaries, wards, and medical attendance as the chance inhabitants of voluntary hospitals, and to claim that those principles in which all men of all countries are agreed in treat- ing the sick should be applied to the paupers in these our state infirmaries, as well as in the volun- * Nineteenth Annual Report, Poor-Law Board. Gathorne Hardy, President. 89 tary hospitals. Thus all people agree that for the sick, when congregated, buildings of suitable con- struction are necessary ; nurses properly trained and of sufficient number ; resident medical officers ; a pharmacy within the building ; visiting officers who . are not bribed by the terms of their engagement— however generously and magnanimously they may reject the promptings of interest—to stint necessary medicines in quantity, quality, or variety, and whose work is not disproportionate to the time at their command." A document sent in to the Poor-Law Board, signed by Sir James Clark, James Paget, Dr. Wm. Jenner, Dr. George Burrows, and others, lays down concisely these principles : i. The buildings for sick poor should be specially devised, of suitable construction, and in healthy sites. The Report of Captain Douglas Galton, Royal Commission on Improving Hospitals and Barracks, may be consulted. 2. Not less than one thousand (and for particular classes of cases twelve hundred to fifteen hundred) cubic feet of air should be allowed to each patient. 3. The nursing should be conducted entirely by a paid staff, and there should be not less than one day nurse, one night nurse, and one assistant nurse for each fifty patients.* * "London Lancet," April 7, 1866. 90 Miss Nightingale's testimony and reports on the subject of cubic space in workhouses are well known. Able special committees were appointed by the Poor-Law Board, and reports were prepared on the condition of the pauper sick, on diet, etc., by Dr. Edward Smith, Dr. Markham, Mr. Farnall and others, and the work of official inspection into the condition of sick-wards, and the character of work- house nursing was extended to cover the country districts of England. The writer has already sum- marized, page 69, a number of these reports. Mr. Farnall says : " In my opinion pauper nursing should be wholly abolished, and a sufficient staff of properly trained and paid nurses should be appointed for every workhouse infirmary. I have come to this conclusion because, as a rule now, nurses are feeble old women, who know nothing about nursing, who cannot read the printed labels on medicine bottles, and whose love of drink often leads them to beg or rob the stimulants which they should give the sick, and because their treatment of the sick is not char- acterized either by judgment or gentleness. Addi- tional nurses are everywhere needed ; there are now one hundred and thirty hired ones for the London infirmaries, but these are only half enough. A system of general superintendence of the nursino- must be devised and carefully watched, with a view 9i to improvement. A money allowance for pauper helpers should be made instead of beer and gin, and a badge of honor and whatever else can excite emulation and promote self-respect should be intro- duced. Ability to read should be an essential require- ment in a nurse." Dr. Edward Smith, medical officer of the Poor-Law Board, visited, specially, forty-eight workhouses in various parts of England and Wales. In his " Report on Existing Arrangements for the Treatment of Sick Poor in Provincial Workhouses," he says : " Upon the whole, I am of opinion that in every workhouse there should be a responsible and, as far as possible, a trailed nurse to take the direct charge of the sick, and that where there are suf- ficiently good pauper nurses they should be pro- moted to the position of paid officers. "In large workhouses, where more than one nurse is employed, it is sometimes the practice to appoint a male nurse for the male patients. I think this should never be allowed. Male nurses are never employed in hospitals, and I know of no quality as nurses in which they excel women. In gentleness, patience, cleanliness, tidiness, and general devotion to their duties they are far inferior to women, and wherever there is a male nurse, the wards on his side will bear no comparison with those on the female side. At the Liverpool Infirmary the opinion 92 of the medical officers and the master was that much more dependence could be placed upon the women nurses in carrying out the instructions of the medi- cal officer." Dr. Smith's report, with all the others, was sent up to the House of Commons as pieces justificatives when fresh legislation was demanded. They were all printed in the Parliamentary Papers of 1866-68, Vols. XL. and XLI. The agitation of the subject of pauper nursing and other workhouse evils, in the highest social and official circles, secured the passage through Parlia- ment, in 1867, of a bill to carry some of the needed reforms into effect. In its annual reports since then, the Local Government Board, which is its present title, has taken pains, each year, to state the progress making under the provisions of the act toward fur- nishing separate accommodation and trained nursing for the in-door sick poor of London. The Board points out the fact, by way of explana- tion for evils, that workhouse sick-wards were origin- ally provided for cases of paupers attacked by ill- ness, and not as State hospitals for the reception of sick poor. Two-thirds of these latter in England, the Board claims, receive medical attendance in their own homes. It is also a very general practice with guardians of unions to subscribe to some medical institution in their neighborhood, so that serious 93 cases of accident or illness from the provincial work- houses may have the benefit of the best medical skill and appliances. There are two hundred workhouses in England and Wales ; forty of them in London, in the thirty parishes and unions into which London is divided. There were seventy-two thousand four hundred and forty adults in the sick-wards of English workhouses, besides thirty-one thousand four hundred and seven- ty-nine sick children on the ist July, 1873, the date of the last report that has come to hand. Of the thirty London unions or parishes, represent- ing, 1 st July, 1873, twenty-one thousand four hundred and sixty-four adult infirm, sick, and insane persons, and seven thousand nine hundred and seventy-four sick children, nine unions still retain their sick in the miserable wards of mixed workhouses ; four amal- gamated unions, which among them have thirteen workhouses, give the sick separate accommodation, but still under workhouse management ; fifteen unions have opened separate infirmaries, and two are building them. Two of the most important London infirmaries are now authorized to receive single women, or widows, between twenty-five and thirty-five years of age, as probationary nurses, to be under the control of the medical officer and ma- tron, after their year's training as assistant nurses. 94 The Board admits that the plan works satisfactorily, and we may hope that here is the entering wedge which shall break up the old abuse of pauper ser- vice, and, following in the line of Liverpool Work- house Infirmary, give the pauper hospitals of Eng- land generally a better nursing system.* Nursing institutions have sprung up in all large English cities, to the number of twenty-two in Lon- don alone. Dublin has two training-schools for nurses, both founded in 1866. Even New South Wales has its school, Miss Nightingale having sent out, in December, 1867, at the cost of the colonial government, and by its request, a corps of five trained nurses and a lady superintendent, as the nucleus of a school to take charge of Sydney In- firmary with its two hundred beds. A wing was added for the nurses' home, which is a very complete and costly building, putting St. Thomas's to the blush. Previous to the publication of Miss Nightingale's most valuable Notes on Nursing, no attempt of any importance had been made toward imparting instruction, in that shape, to women occupying the responsible position of nurses, with one exception, Dr. Connolly's Teachings for Attendants on Ltina- tic Patients, teachings said to be pervaded by the * See Third Annual Report of Local Government Board, 1874. James Stansfeld, President. 95 best principles of humanity and a clear insight into the character of the wants of the insane. Through the exertions of Doctor Maudsley and Doctor Crichton Browne, a plan has lately been set on foot in England to substitute female for male nurses in many of the lunatic wards throughout the country. It has been ascertained that the mortality of male lunatics in asylums is nearly one-third greater than that of female lunatics, and that the deaths are most numerous wherever the nursing is the poorest. The presence of women nurses in male wards is found to be much more effective in restraining outbursts of violence, abusive language, and offensive habits, than the presence of male nurses. As evidence of the increase of interest in the sub- ject of nursing, the " British and Foreign Medico- Chirurgical Review," in its current number, devotes an article to notices of various recent handbooks of instruction; while everywhere enlightened physi- cians urge that every large hospital and infirmary, and every dispensary, should take part in the busi- ness of training nurses. " A properly constructed hospital having been provided," writes Dr. John Roberton, " we are only, in a sense, at the beginning of our work. Without intelligent administration, in other words, without 96 skillful, vigilant nursing, the sanitary condition of the hospital will speedily deteriorate, and success in the medical treatment be in a measure frustrated." Dr. Henry W. Ackland, in -his preface to Miss Lees's Handbook for Hospital Sisters, claims that " Nursing is a department of the profession of med- icine and surgery; it is the medical work of women, and a fit object for the employment of great practical ability, and for the exercise of high moral qualities. It furnishes an outlet for the tender power and skill of good women of almost every class, as superintendents of hospitals, or as ward sisters or nurses. " Guy's Hospital, London, on account of the facili- ties it is able to afford', is a favorite training-ground of nursing committees. It is the most homelike and cheerful of the very sombre, not to say dingy hospi- tals of London; and the President of the Bellevue Visiting Committee, who was recently there, says it had an attraction for her which no other hospital possessed. A niece of Wilberforce is now among the ward sisters at Guy's. Three different societies have had women at work in this hospital. There are always two pupils from the Nursing Sisters' Institution, founded, as we have said, by Mrs. Fry, in 1840. The British Nursing Association sends several probationers, but has 97 latterly undertaken the nursing of the Royal Free Hospital, with special view to have the means of training its staff of sixty women, who are intended for district and private nursing. Mrs. Ranyard, also with a view to district nursing, has two or three women under probation at Guy's for two or three months. Her society, organized in 1868, is in close relations with the medical staff of the hospital, and very useful to it in the out-patients' department, being always ready to detail a nurse to any special dispensary case. The authorities of St. Bartholomew's Hospital have become dissatisfied, lately, with their old sys- tem of nursing, and Sir Sydney Waterlow, the treasurer of the hospital, lately Lord Mayor of Lon- don, and whose name is so well known in connection with " Hospital Sunday," has earnestly taken the subject in hand. The features of the new system introduced are the establishment of a nurses' home near the hospital, and the appointment of probation- ary sisters and probationary nurses, and of unat- tached probationers,, available for emergencies, acting as extra nurses, and subject to call. Arrangements are to be made for giving both sisters and nurses regular instruction in the technical knowledge of nursing, during a term of twelve months, the gratu- ity for pupils for the year being ten pounds, condi- 7 98 tional on good conduct. Special attention will be paid to the important matter of night nursing, by the appointment of one or more superintendents of night nursing, whose business it is specially to visit the wards during the night, and see that the nurses are awake and doing their duty. It is estimated that the cost of nursing the hospital of six hundred beds, on this plan, will be one thousand pounds a year; but such an outlay for such a purpose is wor- thy of the hospital, and of the excellent man who is its treasurer. Westminster Hospital is occupied by the National Association for Providing Trained Nurses for the Sick Poor; and the London Hospital, Middlesex, St. George's, Victoria, Ormund Street Hospital for Sick Children, and others, all open their wards to societies for training nurses, and in return receive the great benefit of an improved hospital service. UNITED STATES. During the years 1795-1798, the Duke de la Rochefoucauld-Liancourt, one of the best informed of the French nobility—statesman and philanthro- pist—made a journey through America. He was the pupil and friend of Arthur Young. On his estates he had established factories for the unem- ployed, and the first experiments in vaccination in 99 France were made in his chateau. He was closely attached to Louis XVI., and, proscribed and stripped for the time of his property, he fled to England and afterwards came to America. On his return to France, he found that though he himself had been suspect during the revolution, his countrymen had respected his creations ; he resumed charge of his estates, published his American travels in eight octavo volumes, a book about the Prisons of Penn- sylvania, a History of the Working Classes in Eng- land, and other works. He founded l'Ecole des Arts et des Metiers, and became a member of the Council General of Charities, and of other important public boards. It is pleasant to remember that the Frenchman's travels in America were at once translated and pub- lished in England, 1799, as containing matter of interest for English readers, the translator saying : " Although no longer a dependency of the British empire, the thirteen provinces of the American Commonwealth are not regarded by Britons as a land of strangers. The mutual animosities of the war of the American Revolution are already extin- guished." The Duke de la Rochefoucauld was an intelligent observer. We have already quoted from some of his reports about the nursing service in Paris. He IOO speaks of visiting in New York the one " public hospital which had been burnt in 17/5, during the war, almost as soon as it was erected, and rebuilt in 1791, partly by voluntary subscriptions, partly by appropriation from the State. It accommodated one hundred and fifty patients, the average number seldom exceeding sixty. Those who can afford it pay two dollars and fifty cents a week." " The poorhouse was built last year, and cost one hundred and thirty thousand dollars. It is kept remarkably neat, and the poor are well treated. A great number are infirm, decayed, and children, so that the only labor that can be expected from them is the kitchen-work, washing, sewing, and working in the garden which surrounds the building. The annual expense of each pauper is calculated at one hundred and fifty dollars. If a poorhouse be any- where proper, it is undoubtedly in a great city ; but, in my opinion, it is seldom a good institution either in a political or charitable point of view. There are eight hundred paupers in the poorhouse, besides six hundred more who receive out-door alms in winter." At the present writing, the infirm, sick, and lunatic poorhouse population of New York numbers six thousand seven hundred and thirty-one, besides over six hundred workhouse people detailed as " helpers ; " while the number of families who have IOI received out-door alms this year, in the shape of city coal, is officially stated as six thousand six hundred. The number of families who received out-door alms in both money and coal, during the year ending ist of January, 1876, was seventeen thousand one hun- dred and seventy-four, comprising sixty-two thou- sand three hundred and ninety-five persons. The number of persons who received in-door relief, dur- ing the same period, was thirty-one thousand seven hundred and seven. This makes the entire number of individuals who came under the charge of the officers of public charity in this city in 1875 over ninety-four thousand. The pauper-hospital inmates alone, including insane, on a given day,« numbered five thousand four hundred and eleven. We do not include in these figures the teeming population of the workhouse, the penitentiary, and city prisons, or of the emigrant asylums.* Says Rochefoucauld, in continuation : " According to the acknowledgments of the inspec- tors of the poor at New York, the poorhouse of New York produces paupers!' What the nursing was in American hospitals, early in the century, there is little to show. It would be safe to assert that even the word nursing is not to be found in the table of contents of any old volume or * "City Record." Official Journal, 1875,1876. 102 journal of medical science. The inaction of the medical profession and the unwise economy of hos- pital directors, resulted in the same condition of things as in England. Scrubbing the halls, wards and staircases used to be part of the duty of the nurses in the New York and other hospitals ; and very naturally the complex and menial character of the work, and the physical fatigue that followed, involved constant neglect of medical instructions. Methodical attendance on the sick, under the influence of Christian or humane sentiments, was nowhere attempted in America except by sisters of charity. Little was done outside of the Catholic Church until the formation of the Nurse Society in Philadelphia, in the year 1839, by Friends, the same class of quiet philanthropists who were moving in London at this same time, under Mrs. Fry, in behalf of better nursing. Dr. Joseph Warrington was the physician in charge of the obstetric department of the Philadelphia Dispensary, and became painfully conscious of the need of both well-trained doctors and nurses. The Nurse Society organized by him was amalgamated with the Lying-in Charity of Philadelphia in 1844, and for a third of the century now has been giving nurses special training in a quiet, effective, very practical way. Ten thousand poor women have been attended and supplied by io3 this society with doctors, nurses, comforts and nour- ishment. It has hitherto been exclusively an out- door charity, but lately has enlarged its work by building wards that will accommodate thirty patients, some of them obstetric cases, others, surgical cases sent in from the dispensary clinic — a mistaken classification, but one that will enable the society to give women the advantage of in-door training.* The sisterhood of the Holy Communion, New York, was organized in 1845, and, therefore, ante- dates St. John's, the first of the Anglican commu- nities. The sisterhood established an infirmary in 1854, the germ of St. Luke's Hospital, which was opened in i858, and which the sisters have now worked for eighteen years. St. Luke's is the most complete example among us of a hospital conducted in an elevated spirit, and combining the essential features of a great religious charity. The unity and success of its plan are due, in great measure, to its being the symmetrical growth of one organizing brain and lofty Christian soul, and to the almost un- limited confidence and furtherance accorded to this plan in its practical outworking by the board of managers ; but none the less to the labors of the devoted band of women who have had the direc- tion of all its interior economy. * " Penn Monthly." December, 1874. 104 But the venerable figure of the pastor and super- intendent of St. Luke's stands alone in this worthy office. WThy are there none who follow ? The writer once heard the exclamation, "A million of inhabitants and only one Dr. Muhlenberg! " The charitable establishments of the Lutheran Church in this country, which date from 1859, offer an opportunity for studying the German deaconess system nearer home and under American conditions. The need for hospitals and orphan houses, espe- cially among the tens of thousands of emigrants from the old world, gave character to the labors in which Rev. W. A. Passavant, of Pittsburg, Penn- sylvania, has been engaged for twenty-six years. The early purchase of land in or near growing cities, while it was still possible to secure it cheaply, was part of his wise policy. At Pittsburg there are two hospitals—one for men and women, one for children. Milwaukee and Chicago each have a hospital; one was opened last summer in Jackson- ville, Illinois, and land is held in Chicago for an emergency hospital, not yet built. Ample grounds have been secured for all coming time for these and for the establishment of other institutions of charity, as a field for the development of women's work, by women. The hospitals and homes have been always filled io5 with charity patients and charity children, and the testimony is that the success of the work is greatly due to the unselfish, laborious service of the trained sisters ; though experience has shown the necessity of considerable modifications of the European idea of deaconesses. Some of the older and more advanced orphans are now employed in nearly all the institutions. An Orphan's Farm School, near Mount Vernon, is so far the only building belonging to the Deaconess Institution, incorporated some years ago, for New York. But Rev. Dr. Krotel, one of its managers, and also an advisory member of the State Charities Aid Association, says, it is their earnest desire to train deaconesses for hospital nursing as soon as they can find proper persons, and their means and limits permit. # Hospital work has been conducted by women on a larger scale in America than in any other country. More than two thousand women are said to have been actually engaged in nursing and in superin- tending and organizing hospitals during the war of the Rebellion, some of whom received a brief special training, as the one hundred women who were in- structed and dispatched to Washington by Dr. Eliza- beth Blackwell and a committee of New York ladies acting with her. Others prepared themselves by io6 serving for short terms in the New York Hospital, in St. Luke's, and in other hospitals of the country. Some of these women, under the stress of the time, developed organizing and administrative talent of a very high order. Army nursing is emergency nursing, and is a sep- arate topic ; any full account of it would be out of place in a rapid sketch of civil hospital service. But we could not pass in silence what Miss Nightingale, in a private letter to a member of the writer's fam- ily, speaks of as "the records of a war without its parallel in history for heroic patriotism, and of organ- ized efforts of Christian philanthropy to relieve the sufferings of the heroes also without their parallel in history." The charter of the Women's Hospital, in Phila- delphia, made special provision for a training-school for nurses, which was accordingly established when the hospital opened in 1861. The first pupil entered in 1863, and others followed, until now the total number graduated is about fifty. The quality of the instruction given at this school is excellent. The Bishop Potter Memorial House was opened in 1867, in connection with the Episcopal Hospital of Philadelphia, on the same principles as the Protes- tant training-houses and sisterhoods in Germany, France, and England. So far, it is said to have io7 assumed more of the character of a sisterhood for the visitation of the sick, than a school for the prac- tical training of women in the ordinary duties of nurses. Dr. S. D. Gross, of Philadelphia, President of the American Medical Association, at its annual meeting in 1868, in his opening address, says: "I am not aware that the education of nurses has received any attention from this body—a circumstance the more surprising when we consider the great importance of the subject. It seems to me to be just as necessary to have well-trained, instructed nurses, as to have intelligent and skillful physicians. I have long been of the opinion that there ought to be, in all the prin- cipal towns and cities of the Union, institutions for the education of persons whose duty it is to take care of the sick." The committee on recommendations and sugges- tions, contained in the president's address, offered the following resolution : "That all hospitals and public institutions for the care and treatment of the sick should have educated, well-trained nurses only, and that this association would strongly recommend the establishment, in all our large cities, of nurse-training institutions," which resolution was referred by the association to a special committee, Dr. S. D. Gross, Dr. Elisha Harris, and Dr. C. A. Lee, to report at io8 the next meeting. In the transactions will be found Dr. Gross's report, read in full at New Orleans, in 1869 " In public institutions in the United States," he says, " ignorance among nurses prevails, superadded, not infrequently, to the basest moral delinquencies, as intemperance, indifference to duty, and positive disregard of the orders of the medical attendant. Male nurses are everywhere notoriously bad and incompetent. Few, even in our large towns and cities, are qualified for their business. Drunkenness and male nursing are almost synonymous terms in the experience of the American physician." Dr. Gross speaks of the long-established fact that, as a rule, women nurses are incomparably better adapted to the work than men, and goes on to say : " Another fact determined by the experience of the last ten years, is, that there is not only a marked diminution of mortality in those hospitals in which the nursing is performed by trained women, but a decided diminution in their expenditure, and a great improvement in the moral condition of the inmates. The wards are kept in a more cleanly and orderly manner, the ventilation is much more carefully attended to, the medicines, food and drink are administered with greater regularity, and a moral atmosphere prevails, the sanative and purifyino- io9 influence of which it would be difficult fully to esti- mate." The report gives the qualifications of a pupil nurse, and the branches she should be taught, and closes with the following recommendations : " i. That dis- trict schools be formed, and placed under the guard- ianship of the county medical societies in every State and Territory of the Union, the members of which should make it their business to impart, at such time and place as may be most convenient, instruction in the art and science of nursing, includ- ing elements of hygiene, and every other species of information necessary to qualify the student for the important, onerous, and responsible duties of the sick- room. 2. That nurses' homes be established, to be placed under the immediate supervision of deacon- esses or lady superintendents. 3. That a copy of this report, authenticated by the signature of the president and secretary of the association, be sent to the State medical societies of the different States of the Union, inviting their co-operation in the estab- lishment of schools for the training of nurses for hospitals and private families, in accordance with the principles therein advocated." At this point the matter seems to have rested. We do not learn that an}' State or county medical society has, so far, taken any practical step. I 10 Three training-schools for women nurses were opened in three American cities during 1873—at Bellevue Hospital, New York ; the Connecticut State Hospital, New Haven ; and the Massachusetts Gen- eral Hospital, Boston. These schools are, substan- tially, the work of women's committees ; they origin- ated with women, not with governing or medical boards, and are supported in good part by appeals to public liberality. It would occupy us too long to describe the work and organization of these schools, or to rehearse all the various societies and sisterhoods engaged in hospital work in America. Enough has been said to indicate the historic drift. District nursing can hardly be said to have been attempted among us. Nurses, as fast as trained by the schools, are taken up by the pressing necessities of hospital service; or, being freed from the schools, have sought remunerative work in private families. A wide field opens for the personal service of women in the homes of the poor, under an organized plan which might link together dispensaries, diet-kitch- ens, and nursing, and thus make more effective the good now done by detached organizations. Some such machinery, under wise, sanitary direc- tion, and controlled by good judgment—for medical charity may be overdone, and do harm as well as anv 111 other form of relief—would soon lower the death rate perceptibly in New York. It would, moreover, arrest and turn back to healthy and honest bread- winning many a poor family which sickness would plunge into pauperism. Five systems of hospital nursing, prevailing in different countries, have now been briefly sketched, and may be enumerated as follows : i. The nurses belong to a religious order, and the hospital itself has lay government; as in France and elsewhere. 2. The nurses and the hospital are both under the same relig- ious control ; as in all purely church institutions, Roman Catholic and Lutheran ; the framework of the organization being the same, but with differences in detail ; as in Italy and Germany, for in- stance. 3. The nurses are directly under the discipline of the medical staff, or of the male superintendent ; as in the majority of insti- tutions in Germany, Austria, etc. 4. A matron or housekeeper is employed as the nominal head of the nursing corps, subject to the professional or secular authorities of the hospital; as in England and America. 5. The nursing is taken in hand by a training-school, the sys- tem requiring special fitness, for her work in a nurse, and pro- viding a way for her to acquire it; the direction being generally assumed by an organization outside of, and supplementary to, the authorities of the hospital, whether lay or medical. Wherever we have followed the historic line, and have found progress in hospital reform, we have I 12 found concurrent with it an effort to devise the best means of attracting and of retaining, in the nursing service, women of good character, and with acquired fitness for their work. For, in spite of sentimental notions, women are no more born nurses than men are born chemists and engineers. Nursing is serious business ; it sig- nifies the proper use of fresh air, light, warmth, cleanliness, quiet, the proper selection and adminis- tration of food, close observation and report of symptoms, and the most scrupulous fulfillment of medical orders, and all with the greatest economy of the patient's strength. To these, in the case of a hospital nurse, must be added other special duties and qualifications. The theory that anybody will do for a nurse is as fatal to the comfort of the sick as the theory that anybody will do for a hospital superin- tendent. The thrusting of persons, without previous education for the duties, into such responsible posi- tions is trifling with human life and suffering. It has been well said, that in many cases the doc- tor can only give the word of command—it is the nurse who must fight the battle ; and what a soldier would be without drill, a nurse is without training. Your " admirable woman," no matter what are her natural gifts and goodness, must possess an equal share of practical knowledge and experience. H3 To test the fitness of a woman for a nurse's work, it is necessary that every candidate should pass a certain period of probation under competent trainers and instructors. To keep up the interest and secure the service of the women after they are trained, it is equally necessary that their position as nurses should be made as comfortable as the character of their work permits, that they should be justly paid, that their duties should be properly defined, and, above all, that they should be encouraged to feel the responsible and honorable nature of their profession. To select and prepare such a body of women nurses is the object of all nursing-schools, and the question we began with, namely : How shall we secure good hospital nursing ? is answered. What our metropolitan hospitals really need is not money—money can be had to any amount almost for the asking—but personal service of a high grade, hospital boards outside politics, super- intendents who are something more than place- holders, trained nursing and attendance, under the constant supervision of skilled women of intelligence and refinement. Mrs. Jameson's-well-known letter to Earl Russell calls attention to a hospital for sick children in London, governed by twenty-six men, with one woman in a subordinate position. Close at hand in 8 ii4 New York—to take only a few examples of richly- endowed institutions—there is a general hospital, of one hundred and fifty beds, which is governed by twenty-six men ; another, with nearly two hundred sick and wounded of both sexes, and ten male governors ; and a third, where the constituted authorities are thirty-six men, or fifty-two, including the medical board—all three institutions under ex- clusive male control. Is it not the part of such an association as ours to take the initiative of improve- ment in this matter ? Society is coming to see, • slowly, it may be, but surely, that the sick poor, the helpless, the little children, belong not to men phil- anthropists exclusively, still less to the politicians and the professional classes, but to men and women working together ; and that physicians and women standing on either hand at the bedside of the poor, ought to find, and where the right spirit prevails, will find, in each other their strongest allies. Dr. Roberton, speaking to the Manchester Sta- tistical Society, said: " I do not contemplate the formal election of females to municipal offices ; but I am persuaded that without the well-organized aid of benevolent and educated women municipal gov- ernment will ever remain limited and imperfect. The wisest, the best-devised regulations, enforced by the police alone, among the poor of large towns will 113 not succeed. But I think that a body of educated ladies for each ward of a city (or for each of our large hospitals) acting in concert with the legal authorities, would be found of wonderful service in detecting radical evils, especially the sources of preventable poverty, or, what is much the same, the various temptations which beset the laborer's family, from bad laws and defective arrangements of different kinds." ORGANIZATION OF A TRAINING-SCHOOL. Let us suppose a local committee of men and women who have taken the initiative in the matter of a nursing-school, and a board of hospital govern- ors who are ready to co-operate. The first effort of the organizers should be to make the school, if possible, an integral part of the hospital ; to secure recognition for it by the au- thorities, as having as definite rights and as per- manent a foothold in the hospital as those of the governing body ; in fact, as being the governing body, so far as the nursing service is concerned. The more homogeneous the total organization can be made, the more such a school can be identified with the hospital, the more smoothly and success- fully will it work. Otherwise; with the constantly- chano-ing committees of many of our hospital boards, and the constantly-changing character of the medical n6 authority—this unstable mode of government being characteristic of- all our charitable institutions-^a school may find itself thrown off its feet, and even struggling for existence against constant fresh relays of prejudice and inexperience. The most thorough way to secure oneness of organization and purpose would be to add to the hospital board a certain number of ladies, and to make the school, or nursing committee, one of the regular sub-committees of the board, managing its own affairs, just as do the usual sub-committees on supplies and finance. Hitherto the movement toward improving the nursing service of public hospitals, by the establish- ment of training-schools, has come from outside persons ; as a rule, it has not originated with the governing bodies. As nursing is work which pecu- liarly requires feminine supervision, the majority of the members of school committees hitherto have been women. Our hints are based on the suppo- sition of a committee outside the usual hospital authorities; but one in which the governors or managers would naturally be represented, or would hold a veto power. If hospital governors object to such extraneous authority, the remedy is in their own hands. Why should they not invite the school committee to ii7 r become members of their board, for this purpose only, if they so prefer, and of course under their own control as are their other committees ? It has been suggested, as an additional means of promoting harmony, that there might be in the medical board an advisory committee on the train- ing-school. In the case of a large, public hospital, i. e., a tax- payers' hospital, the outside committee has its advan- tages. If its members find themselves unreasonably obstructed, they have the remedy of the English ministry ; they can "go to the country." A great deal would depend upon the character of the hospital and its own form of government. Any plan of organization for the school is the best which will keep all discussions of questions of general policy and of the mutual relations that are involved above board and open, and that will leave neither oppor- tunity nor necessity for attempts on the part of any one to carry points by indirect or personal influence. Better the quintuple treaties which the Paris ad- ministration makes with the sisterhoods, than any effort to diplomatize one's way into a hospital and shuffle along there without a full, clear, written agree- ment on the points in advance, so far as they can be foreseen, between the committee of the school and the o-overning bodies of the hospital. For whatever u8 apparent kindliness may attend the first steps in organization, boards and committees change, differ- ences of opinion develop, new points come up, and new kings arise who " know not Joseph." But over and above all agreements there should be the sense of comradeship in good works. The hospital, on its part, should provide for the lodging, board, and wages of a given number of women—as many as the hospital service legitimately requires—either by furnishing quarters within the hospital grounds, or by paying the school an equiv- alent in money. Any pupils under training beyond the needs of the hospital would be at the charge of the school, and funds for this purpose would proba- bly have to be found outside. But if the general public is expected to furnish a portion of the funds, it will have a right to look for an early return in the shape of trained nurses to supply the needs of family nursing. It will become a question for the committee how to balance the rival claims of the hospital and the public. To avoid disappointment in any quarter, the plan should care- fully define in what service any surplus of trained women are to be employed ; what is to be the first aim of the school in assigning trained women to duty. Three prominent aims suggest themselves : i. To extend the school by degrees from ward to }l9 ward throughout the hospital or group of hospi- tals to which the school may be attached, and keep the ranks of the hospital nursing service fully recruited. 2. To purvey nurses for private service or for other hospitals. 3. To furnish nurses for district work among out- door poor in connection with dispensaries. All these are good and legitimate objects, but it is doubtful whether all can be pursued except by a very large, long-established school. Having defined the relations of the school with the hospital and with the public, the next important point for the committee is one of internal organiza- tion, one that is vital to the success of the school : the choice of a superintendent, and the definition of her duties and authority. Many of our charitable institutions have owed much hitherto to the intelligence and energy of women of foreign birth ; but it is time that America beo-an to train such a class of women for herself. American women will make the majority of the pupils in a nursing-school, if a high standard for the school is maintained. Therefore, provided a quali- fied woman can be found, let the superintendent be an American. Where means and time permit, a woman of the 120 right stamp might wisely be sent to England for six months or a year, to learn the routine of the Nightin- gale School. She should be thirty years old or over, with good sense, and clear, well-balanced mind, with some sympathy, tact, and a shrewd perception of char- acter, and something of the skill of a commander ; a Christian woman, of course, above all selfish aims, one .who respects herself, and whose personal digni- ty wins the respect of others. She should have some practical knowledge of bedside nursing, and a familiarity with hospital routine. On such a founda- tion, any amount of education and refinement will not come amiss, and the more the better. If she is able to give her services unsalaried, it will be an ad- vantage. But as perfect beings are not to be found, the committee will do well to keep the essential qualities in mind, and these are purity of character, technical intelligence, a just and equable temper, and the power of steady control. Whether the superintendent need be a lady, in the social sense of the word, would depend on whether there is a good governing committee which includes ladies. It is assumed that there is, and in that case a superior, practical head-nurse will be all that is at first needed. But when the school grows, and the hospital is an important one, and is one in the man- agement of which cultivated women have no repre- 121 sentation,then a qualified woman, who has social pres- tige, in charge of the school, would be very important. It is essential that the tone of the school, that is, of the whole nursing service of the hospital, should be kept at as high a pitch as possible. There are moral dangers, for both nurses and patients, inevita- bly springing from the conditions of a public hospi- tal, and no one can apprehend and avert them so effectively, and, at the same time, so unobtrusively as a quick-witted, delicate-minded woman. Given a thoroughly competent superintendent, her fitness well tested by the committee, responsibility may safely, by degrees, be put into her hands. Let the committee hold the nursing head to account for the results of her work, rather than for her methods. A committee must know almost as much about nurs- ing and the ward affairs as the superintendent does, in order to direct her in every detail, which is an obvious impossibility. The committee ought to be well chosen, composed, not of names, but of per- sons ; persons valid, not for social station alone, still less for money alone, but for intelligence and ener- gy ; persons who study the subject, and keep the current of the business ; but they should guard against over-governing. There are grave objections to any mode of govern- ing institutions, as to internal details, from the out- 122 side, by changing committees. Where there is no real continuity of government, a new set of persons never takes up the business exactly where its prede- cessors left it, and the results often bear hardly on the governed. And, as Dean Howson says : " We all know what committees are ; how frivolous the excuses for neglect or absence, how great the lack of moral courage, how heavy the burden on the one member who has a conscience." The spectacle is not infrequent of successive com- mittees treating a superintendent very much as a vicious little boy treats a bird with a string, letting it out a bit, and then jerking it abruptly back. As the object of a hospital is the nursing of the sick, the superintendent of the school becomes the most important female officer. She should, there- fore, if possible, be the matron as well as the nursing- head for the whole hospital ; in which case she would require an assistant, to whom she could delegate certain classes of housekeeping duties. It is bad organization to have one sort of nursing authority, under the name of training-school, in half the hos- pital, and a different set of nurses, under different authority, in the other half. This is not to say that the school proper need cover at first all the wards of an institution. The school might begin on a small scale with one or two wards, according as one, two, 123 or more head-nurses, who were also capable trainers, could be secured ; but to give pupils a full course of practice, it would need to include by degrees one or more wards in every division : medical, surgical, women's wards, men's wards, children's wards, and wards for diseases of women, assuming that it is a general hospital. This, of necessity, will spread a school throughout a hospital, and the superintendent and her authority must go with it. The superintendent of nursing, so far as concerns the care of the patients and the condition of the wards, would take her instructions from, and to that extent would be under the control of, the chief execu- tive officer and the visiting-staff. But she is the committee's appointee, and it is the committee^ province to support and sustain her, as well as to keep her and her nurses with a steady hand up to the mark ; to assure themselves that ^oth she and her nurses comply with the rules of the school, and with the rules and regulations of the hospital, not only in the letter but in the spirit. Complaints against any nurse by medical men should be made by them directly to the superin- tendent ; she should hear both sides, and the power of retaining or dismissing a nurse should rest with her, subject to the approval of the committee. An open, straightforward dealing all round is essential 124 to the well-being of the school. No tattling, going behind backs, or reaching over heads, should be tolerated for a moment. It is not so much the tattling as the listening that does mischief. Wherever the moderate size of the hospital ren- ders it practicable, the superintendent should make the rounds of the ward with the head-nurse and the visiting-doctor, should know what general instruc- tions are given, and keep track of individual cases, certainly of the gravest ones. In a large hospital and ^chool the regular routine work would occupy so much time that the superintendent could not pursue this plan ; but she will find it necessary to confer with the visiting-doctor often enough to ascer- tain, in' a general way, his wishes. It is bad for discipline, will surely lead to misunderstandings, and will hinder the business, if she trusts to getting, or is left to get, ||er information from subordinates. The choice of head-nurses will be a difficult point, from the present scarcity of qualified women, and from the lack of organization among them as mem- bers of a recognized calling. A school would prob- ably have to move slowly, training its own head- nurses, the first aim being to officer its own wards properly. For something besides good character and manual skill are needed in a woman : discretion, method, and ability to control a ward, both patients 125 and nurses, and to impart to her assistants what she herself knows. Not every doctor makes a good professor, as medical students well understand, and not every nurse has the knack of teaching her trade to others.' There should be strictness of discipline, gradation of authority, and a system of promotion in the school, head-nurses being held responsible for assistants. Nothing insures efficiency in business like a compact organization ; nothing is so fatal to success or to comfort as letting things go at loose ends. Too frequent changes among head-nurses are undesirable, in a disciplinary point of view. It would be an advantage to a school to be able to retain and pay adequately a certain number of skilled trainers for head-nurses of wards or of groups of wards. At first, and probably always in a small school, the superintendent would herself teach the pupils in part. In the large Nightingale School, Mrs. Ward- roper manages the business ; she does not directly teach pupils. A young, active, qualified woman- instructor is employed, and may be seen in the class-room in the nurses' pavilion, with her class assembled round a long table with their text-books. It is also part of the duty of members of the med- ical staff of St. Thomas's Hospital to instruct the 126 nurses—Dr. Bernays, for instance, chemist to the entire establishment, not apothecary, teaching them chemistry ; some of the older physicians giving them now and then an informal lecture or " talk " on some special point. The duty of technically instructing the nurses, es- pecially in surgical cases, would most naturally fall on the resident medical staff. But such young men have but one idea in getting a hospital position—" to see cases; " and where they are conscientious in their professional duties, they are generally much too busy to spare time in the training-school. At best, their term of service in any one division is very short, and there would be a constant change of in- structors. It might be well if the medical authori- ties of the hospital were to designate one or two suitable young men for assignment to duty on the house-staff, as instructors of nurses in all the techni- cal and didactic points which can be taught away from the bedside, allowing such young men extra time, and recommending them for some small com- pensation. Where the managers of a hospital are enlightened men, they will soon see that any moder- ate amount spent to improve the character of the nursing service is money well spent. Committees would do well to start with the idea that careful didactic and technical instruction must 127 be part of their plan, and that they will need a school outfit : class-room, blackboard, text-books, and manikins, the cost of which should be considered an essential, original outlay, and not left to any after chance. The subjects on which a nurse ought to be in- structed are mapped out in the prospectus of every one of our American training-schools ; but more system and thoroughness in the actual teaching are very much needed. It is one thing to have a pro- gramme, and another thing to carry it out. Nurses need not only to know how to do a thing; they need to know why it is to be done, and done in a certain way. Instruction by lectures is not enough ; a groundwork of thorough teaching and recitation should precede the lectures, and they should be followed up by regular examinations by competent medical men. Schools should always include a few women held for emergencies ; some pupils will have been in at- tendance on infectious cases, and must be isolated for a time from the other nurses as well as from the patients; for the isolation of a nurse during or after infectious cases, is quite as important as the isolation of the patient; this gives leisure, in their case, for study. By judicious planning, all the women, in turn, may receive the instruction required. 128 Advanced pupils, not actually busy at the moment of the attending doctor's visit, might profitably make the rounds of the ward or the division with him, and with the superintendent, hearing his nursing orders, and profiting by this simple, incidental instruction, just as a clinic of students might. Of course, if the visiting" gentleman is a professor, bringing his male students with him, this is out of the question. The selection of suitable pupils who will repay the trouble and cost of training, will be one of the chief functions of the ladies of the committee. They should, by advertisements, inquiry, and correspond- ence seek out and stimulate the right sort of appli- cants as probationers. One stumbling-block in all our schools is the unwillingness of American women to give the full time, and to undergo the really hard work that thoroughness in any profession requires.. Miss Nightingale says: " Three-fourths of the whole mischief in women's lives arises from their excepting themselves from the rules of training considered needful for men." The feeble constitu- tion of many American women is another serious drawback. It is unfair to the public which, either directly or indirectly, contributes the funds for the support of the school, it is time wasted, to retain women as pupils who do not show the required aptitude for 129 their work, or whose health proves infirm. Training is expensive, and it must be economized. It has been found difficult to hold women, by any contract, to a full term of two years of service, one in the school, one out of ic in remunerative' private service. The New Haven School insists on a year's training in the hospital, and only three months of service in private nursing; the wages earned during the latter period being turned into the school treasury. Short of that time it will not give a certificate. Whatever the rule may be as to length of term of training and subsequent service, it should be strictly enforced. Women who have already been nurses may seek to enter the school as pupils for short terms, for the sake of the reputation it may give them. The ex- igencies of hospital service are such that the school may sometimes be glad to take in these women, and there should be rules in advance to meet the case ; a month's probation being strictly required, as with all pupils. Rules of admission should, by all means, require pupils to wear some simple uniform dress, not as a sisterhood o-arb, but for neatness, discipline, and the convenience of medical men and visitors. If the superintendent is the right sort of woman, she will herself set an example of simplicity of manner and 9, 132 portion as governing boards see that there are women who not only possess natural fitness for, but acquired knowledge of, the business. Rules should be so modified as to permit the training, for short terms, of women of a superior social grade, who are able to pay their way. This is not intended to en- courage amateur nursing, but to enable the school to use to the utmost its opportunity. Some of the schools on the continent make this provision for boarders, as Kaiserwerth, and Berlin ; and the New Haven School offers to lodge, board, and train women at a charge of five dollars and fifty cents a week, and the price of the uniform dress. Each one of the schools now rapidly multiplying in this country—and they ought to multiply, for it is a waste not to utilize the chances that every hospi- tal furnishes—will have something to learn from the experience of others. A constant interchange of views should promote emulation until nursing shall have been rescued from the hands of ignorant, un- faithful drudges, and made, what it deserves to be, an educated and honorable profession. (Persons about to organize training schools will find valuable plans in detail, and complete sets of blank forms, in a paper by Florence Nightingale, reprinted from Blue Book : " Report on Cubic Space in Metropolitan Workhouses, 1867," with additions.) 133 In concluding this brief sketch, the writer, while heartily acknowledging the good already accom- plished, urges all women engaged in hospitals and training schools to bear in mind that their greatest success will lie in keeping the standard of their work, as to the character and tone of the direction, and the quality of the instruction given, at its highest possible point. Schools should be practically normal schools, whose graduates should feel that wherever they go, they must carry the spirit of the school with them, and that training can go on in every hospital ward where a competent head-nurse is found. Doubtless there will be obstacles to encounter, but these should only nerve to steadier effort ; for it is well to remember that any obstacle, either thought- lessly or maliciously thrust in the way of women of culture who undertake offices of charity in public % institutions, is a blow directed not so much against them as against the helpless and suffering classes of society of whom they are the natural guardians and consolers. •V/ V**' I ■ ■ ■ t-•> 'ill