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Third 

International   Congress 

of  Nurses 


edited  by 
The  Committee  on  ;Pubi.ication 

isabel  hampton  robb 

I,.  L.  DOCK 
MAUD  BANFIELD 


PAN-AMERICAN   EXPOSITION 
BUFFALO 

September  i8,  19,  20,  21,  1901 


Press  of  J.  B.  Savage, 
Cleveland,  Ohio. 


joNIRMiCal' 

3 

Committees 

Executive  Gsmmittee  of  the  Congress 

THE  PRESIDENT  AND  OFFICERS 

THE  OFFICERS  OF  THE  BUFFALO  NURSES'  ASSO- 
CIATION 

THE  OFFICERS  AND  COUNCIL  OF  THE  AMERICAN 
SOCIETY  OF  SUPERINTENDENTS  OF  TRAINING 
SCHOOLS  FOR  NURSES 

THE  OFFICERS  OF  THE  NURSES'  ASSOCIA  TED  ALUMNA 
OF  THE  UNITED  STATES 

THE  AMERICAN  MEMBERS  OF  THE  INTERNATIONAL 
COUNCIL  OF  NURSES 

* 

Programme  G)mmittec 

MISS  NUTTING  MISS  BANFIELD  MISS  DOCK 

Local  Arrangements  ODmmittee 

MISS  DAMER  MRS.  CONRAD  DIEHL 

MRS.  THOS.  MORLEY  MISS  DRAKE 

MISS  M.  SIMPSON  AIISS  MILES 

MISS  SNETZINGER  MISS  OWEN 

MISS  KEATING  MISS  O.  MOORE 

MISS  McKINNON  MRS.  H.  STORCK 

* 

Finance   Committee 
MISS  RIDDLE  MISS  HEALY  MISS  ALLINE 


OFFICERS 

PRESIDENT 

MISS  McISAAC, 
Superintendent  Illinois  Training  School  for  Nurses,  Chicago. 

FIRST  VICE-PRESIDENTS 

MISS   KEATING, 

Erie   County   Hospital,   Buffalo;  President  Society   of  Superinten- 
dents of  Training  Schools  for  Nurses. 

MRS.  ROBB, 
Cleveland,  Ohio. 

President  of  the  Nurses'  Associated  Alumnae  of  the  United  States. 

SECOND  VICE-PRESIDENTS 

MISS  SNIVELY, 
Lady   Superintendent   General   Hospital,   Toronto. 

MISS  DAMER, 
Buffalo. 

Member  Board  of  Women  Managers  of  the  Exposition. 

TREASURER 

MISS  RIDDLE, 
Assistant   Superintendent   Boston    City    Hospital,    Boston. 

SECRETARY 

MISS   BANFIELD, 
Superintendent    Polyclinic    Hospital,    Philadelphia. 


HONORARY  OFFICERS 

HONORARY  PRESIDENT 

MRS.  BEDFORD  FENWICK, 
London,  England. 

HONORARY  VICE-PRESIDENTS 

MISS  ISLA  STEWART, 
Matron  St.   Bartholomew's  Hospital,  London,  England. 

MRS.   STRONG, 
MatroQ  Royal  Inflrmary,  Glasgow,  Scotland. 

MISS  HUXLEY, 
Matron  Sir  Patrick  Dun's  Hospital,   Dublin,  Ireland. 

MISS  WILSON, 
Matron  Cardiff  Infirmary,  Wales. 

FRAULEIN  GERVINUS, 
Matron   Victoria   House,    Berlin,   Germany. 

MISS   GRACE  BAXTER, 
Superintendent  of  Nurses,  Ospedale  Clinico,  Naples,  Italy. 

MBJ.  KRUYSSE. 

Matron  Wilhelmina  Hospital,  Amsterdam,  Holland. 

MISS  KEITH-PAYNE, 
Matron  Wellington  Hospital,  Wellington,  New  Zealand. 

MISS    McGAHEY, 
Matron  Prince  Alfred  Hospital,   Sydney,  Australia. 

MISS  SHIDZU   NOURSE, 
Kobe,  Japan. 


Regular  Meetings  of  Societies 

HELD  CONCURRENTLY  WITH  THE  CONGRESS 

THE     NURSES'     ASSOCIATED     ALUMNAE    OF      THE 
UNITED   STATES 

THE    AMERICAN    SOCIETY    OF    SUPERINTENDENTS 
OF  TRAINING  SCHOOLS  FOR  NURSES 

THE  INTERNATIONAL  COUNCIL  OF  NURSES 

THE  SPANISH-AMERICAN  ORDER  OF  WAR  NURSES 


The  Transactions 

of  the 

Third  International   Congress   of  Nurses 

with  the 

Reports 

of  the 

International  Council  of  Nurses 


CONTENTS 


Page. 
Address     of    Welcome — The   Hon.   Conrad   Diehl,   Mayor  of 

Buffalo    20 

Address  of  Welcome — Mrs.  George  W.  Townsend,  Presi- 
dent of  the  Women's  Educational  and  Industrial  Union 
of   Buffalo    21 

Address  of  the  President — Miss  Isabel  Mclsaac,  Superin- 
tendent of  Nursing,  Illinois  Training  School,  Chicago; 
Member  American  Society  Superintendents  of  Training 
Schools;   Honorary  Member   Matrons'   Council,   etc 22 

PAPERS 

1.  (a)  Hospital  Administration  in  Great  Britain — Miss  Isla 
Stewart,  Superintendent  of  Nursing,  St.  Bartholomew's 
Hospital,  London,  England;  President  of  Matrons'  Coun- 
cil         27 

(b)  Hospital  Administration  in  Great  Britain — Miss 
Mollett,  Superintendent  of  Nursing,  Royal  South  Hants 
and  Southampton  Hospital;  Member  of  and  Delegate  from 
the    Matrons'    Council 38 

2.  Hospital  Administration  in  America — Miss  Maud  Ban- 
field,  Superintendent  of  the  Polyclinic  Hospital,  Philadel- 
phia; Member  of  Hospital  Superintendents'  Association, 
American  Society  Superintendents  of  Training  Schools, 
Matrons'  Council;  Lecturer  in  Hospital  Economics, 
Teachers'  College,  etc 43 

3.  Hospital  Administration  in   Relation  to  Training  Schools 

— Miss  Riddle,  Assistant  Superintendent  of  Nursing,  Bos- 
ton City  Hospital;  Member  of  American  Society  Superin- 
tendents of  Training  Schools 71 

4.  Women  on  Hospital  Boards — Mrs.  Robb,  Late  Superin- 
tendent of  Nursing,  Johns  Hopkins  and  Illinois  Training 
Schools;  Member  Board  of  Women  Managers,  Lakeside 
Hospital,  Cleveland;  Member  of  American  Society  Super- 
intendents of  Training  Schools;  Lecturer  in  Hospital 
Economics,  Teachers'  College,  etc  80 


Contents  9 

WEDNESDAY,  2  TO  3 130  P.  M. 

Page. 

1.  Nurses'      Co-operative       Societies — Miss     Kimber,     Late 

Assistant  Superintendent  of  Nursing,  New  York  City  Hos- 
pital,   Blackwell's    Island    94 

The  Registered  Nurses'  Society — Miss  Cartwright,  Mem- 
ber of  St.  Bartholomew's  League;  Delegate  from  the 
Registered    Nurses'    Society    100 

2.  St.    Bartholomew's    League— Miss  Waind,  Delegate  from 

St.   Bartholomew's   League    106 

3.  Nurses'  Federation  of  Australia — Miss  S.  B.  McGahey, 
Superintendent  of  Nursing,  Prince  Alfred's  Hospital, 
Sydney;  Member  Matrons'  Council;  Delegate  from  Fed- 
eration      Ill 

THURSDAY,  0:30  A.  M.  TO  12:30  P.  M, 

1.  Preparatory  Instruction  of  Nurses — Mrs.  Strong,  Sup- 
erintendent of  Nursing,  Glasgow  Infirmary 118 

2.  What  are  we  Doing  with  the  Three  Years'  Course? — Miss 
L.  L.  Dock,  Secretary  of  the  American  Society  Superin- 
tendents  of  Training   Schools,   and   International    Council 

of  Nurses   139 

3.  Post-Graduate  Work  in  Hospitals — Miss  McMillan,  Sup- 
erintendent of  Nursing,  Lakeside  Hospital,  Cleveland; 
Member  American  Society  Superintendents  of  Training 
Schools    156 

4.  Nursingof  the  Insane— Miss  Laird,  Superintendent  of  Nurs- 
ing, State  Hospital  for  Insane,  Seneca  County,  New  York.  163 

5.  Asylum    Nursing  — Mrs.    Chapman,    Formerly    Matron    of 

Whittingham,  Leavesden,  and  Claybury  Asylums;  Honor- 
ary Treasurer  of  Association  of  Asylum  Workers,  England.  176 

THURSDAY.  3  TO  3 :3o  P.  M. 

1.  Symposium  of  15-minute  papers  on  Opportunities  and 
Responsibilities  of  the  Graduate  Nurse  of  Today — 
1.  Miss  K.  De  Witt,  Chicago,  111.;  2.  Miss  Richards, 
Taunton,  Mass.;  3.  Miss  Patton,  San  Francisco,  Cal 188-200 

2.  Private  Nursing,  Hours,  Remuneration,  etc. — Mrs. 
Rogers,  Superintendent  of  Nursing,  Bridgeport  Hospital, 
Conn 202 

3.  Hourly  Nursing —Miss  Carr,  Member  Associated 
Alumnae;  Superintendent  of  Visiting  Nurse  Association, 
Baltimore    208 


10  Contents 

FRIDAY,  9:30  A.  M.  TO  12 130  P.  M. 

DISTRICT  NURSING 

Page. 

1.  Historical  Outline  of  Origin  and  Growth  and  Present 
Status  of  District  Nursing  in  England— Miss  Amy 
Hughes,  Late  Superintendent  of  Nurses'  Co-operative 
Society ;   Delegate    -17 

2.  Tenement  House  Inspection — Mrs.  Von  Wagner,  In- 
spector of  Tenements,   Yonkers,    N.    Y 229 

3  History  of  Visiting  Nurses  in  America — .Miss  Fuhner, 
Superintendent  of  District  Nursing  Association,  Chicago; 
Delegate    237 

4.  The  Victorian  Order  in  Canada — Miss  Macleod,  Super- 
intendent of  Order ;   Delegate    '-54 

5.  Nurses'  Settlement — Miss  Wald,  Founder  of  Nurses' 
Settlement,  265  Henry  Street,  New  York  261 

6.  London  School  Board  Nurses — Miss  Honnor  Morten, 
Member  of  London  School  Board,  Nurses'  Co-operative 
Society,    €tc    272 

FRIDAY,  a  TO  3 :30  P.M. 

ARMY  NURSING 

1.  Army  Nursing  in  America — Mrs.  Kinney,  Superintendent 
Army  Nurse  Corps  of  the  United  States;  Delegate 276 

2.  Nursing  in  Cuba — Miss  Hibbard,  Superintendent  of  Nurs- 
ing in  Government  Hospital,   Matanzas,  Cuba 289 

3     Indian  Nursing   Service — Miss  Arkle,  Delegate  from  India 

Army  Nursing  Service    308 

Indian    Nursing    Service — Miss    P.    F.    Watt,    Allahabad, 
India  314 

4.  Nursing  in  South  Africa  during  the  Boer  War — Miss 
Pope,  Nurse  to  Canadian  Contingent  319 

5.  War  Nursing  in  South  Africa — Sister  Henrietta,  Kim- 
berly.   South  Africa    326 


Contents  11 

ORGANIZATION 

Page. 
6.     Organization    and    Legislation    Among    Nurses:      A.     In 

Great  Britain  and  the  Colonies,  Mrs.  Bedford  Fenwick, 
London.  B.  In  the  United  States,  Miss  Sylveen  Nye, 
President  of  New  York  State  Organization.  C.  In  Can- 
ada, Miss  Snively,  Superintendent  of  Nursing  Toronto 
General  Hospital,  Member  American  Society  Superinten- 
dents of  Training  Schools,  etc 335-351 

SATURDAY  PROGRAM  AT  THE  TEMPLE  OF  MUSIC 
Address — Mrs.  John  Miller  Horton  361 

1.  A  Plea  for  the  Higher  Education  of  Nurses — Mrs. 
Bedford  Fenwick  363 

2.  A  Retrospect  and  a  Forecast— Miss  C.  J.  Wood — Man- 
aging Director  of  Nurses'  Hostel;  late  Superintendent  of 
Nursing,  Great  Ormond  Street  Hospital,  etc.;  Delegate...  370 


12  International  Congress  of  Nurses 


REPORTS  ON  THE  STATUS  OF  NURSING  AS  TO  EDUCATION 
AND   ORGANIZATION;    SENT  TO   THE   INTER- 
NATIONAL COUNCIL  OF  NURSES 


Address  of  the  President   379 

From  By 

AFRICA   Aliss   Breay    384 

AUSTRALIA    Miss  McGahey  '. . . .  392 

BRAZIL    Miss  J.  H.  Jackson 393 

CUBA    Mrs.    Qnintard    396 

CANADA    Miss  Snively See  Part  I.  349 

DENMARK    Mrs.   Gordon  Norrie   402 

EGYPT    Miss  J.   G.  Watkins   407 

FIJI Miss  M.   C.  Anderson   410 

FRANCE    Dr.  Anna  Hamilton  417 

GREAT  BRITAIN 
AND   IRELAND   .  ..Mrs.  Bedford  Fenwick 424 

GERMANY    Miss   L.   L.   Dock   443 

GREECE    Mrs.   Bedford  Fenwick   452 

HOLLAND    Miss  C.  H.  Bastide  Baarslag  and  Miss 

Kruysse    454-461 

ITALY    Miss    Amy    Turton    and    Miss    Grace 

Baxter    464-472 

NEW    ZEALAND Mrs.   Neill    473 

SWEDEN   474 

TASMANIA    Miss   Milne    480 

UNITED    STATES.... Miss  Dock   481 


Foreign  Delegates 


13 


FOREIGN  DELEGATES 


Arkle,  Annie   

..Indian  Army  Nursing  Service,  India  Office,  Whitehall,  S.  W. 
Cartwright,   Sophia. ..  .Registered  Nurses'   Society,  London,   Eng. 

Fenwick,  Ethel  Gordon International  Council  of  Nurses. 

McGahey,  Susan  B Australasian  Nurses'  Federation. 

Mollett,   W.    J Matrons'    Council    of   England. 

Stevenson,  Louisa  

National  Union  of  Women  Workers  of  Great  Britain. 

Strong,  Rebecca Royal  Infirmary,  Glasgow,  Scotland. 

Waind,  Emilie St.  Bartholomew's  League,  London,  Eng. 

Queen  Victoria  Jubilee  Institute  for  Nurses. 

Colonial   Nursing  Association. 

Workhouse   Infirmary  Nursing  Association. 

Northern  Workhouse  Infirmary  Nursing  Asso- 
ciation. 

School  Nurses'  Society. 

Guy's  Hospital  Training  School  for  Nurses. 

Guy's  Trained  Nurses'  Institute. 

Leicester  Infirmary  (Sisters  and  Nurses). 

Maternity  and  District  Nurses'  Home,  Plaistow. 

Asylum  Workers'  Association. 

Midwives'  Institute  and  Trained  Nurses'  Club. 

Incorporated  Society  of  Trained  Masseuses. 
,  Nurses'  Hostel. 


Hughes,  Amy 
Wood,  C.  J." 


14  International  Congress  of  Nurses 


HOME  DELEGATES 


Albaugh,  R.  I Maryland  Homeopathic  Alumnae,  Baltimore. 

Allen,  Ella. .  .Trained  Nurses'  Association  of  Denver,  Denver,  Col. 

Allerton,  Eva Monroe  County  Nurses'  Association,  N.  Y. 

Austin,  C.  V Old  Dominion  Alumnae,  Richmond,  Va. 

Bailey,  Julia Rochester  Homeopathic  Alumnae,  New  York. 

Barton,  Carene  

Philadelphia   Polyclinic   Nurses'   Alumnx  Association. 

Beyers,  Minnie Kings  County  Alumnae,  N.  Y. 

Boswall,  Emily  O Boston  City  Alumnae,  Mass. 

Bradley,  Sarah  A New  York  Hospital  Alumnae. 

Brown,  M.  M Presbyterian  Alumnae,  New  York  City. 

Brown,  M.  R St.  Luke's  Alumnae,  Chicago. 

Burr,  E.  V.  .  .New  York  City  Training  School  Alumnae,  New  York. 
Burroughs,  Elizabeth.  .  .Dutchess  County  Nurses'  Club,  New  York. 

Cadmus,  Nancy  E Presbyterian  Hospital  Alumnae,  New  York. 

Carr,  A.  M Johns  Hopkins  Alumnae,  Baltimore. 

Chappelle,  Eva  E Long  Island  College  Hospital  Alumnae. 

Cheney,  Adelia  Belle. Massachusetts  Homeopathic  Alumnae,  Boston. 

Conner,  Elizabeth  B Rochester  City  Alumnae,  New  York. 

Cooke,  Genevieve St.  Barnabas  Guild,  San  Francisco. 

Cooke,  Elizabeth Old  Dominion  Alumnae,  Richmond,  Va. 

Cuthbertson,  Mrs.  William. .  .Visiting  Nurse  Association,  Chicago. 

Darner,  Annie   Bellevue  Hospital  Alumnae,  New  York  City. 

Davids,  Anna Long  Island  College  Alumnae,  Brooklyn. 

Dick,  Sarah  M Illinois  Training  School  Alumnae. 

Dock,  L.  L Bellevue  Hospital  Alumnae,  New  York  City. 

Dolliver,  Pauline Massachusetts  General  Alumnae,  Boston. 

Donahue,  Julia  M St.  Vincent's  Alumnae,  New  York. 

Drown,  Lucy Boston  City  Hospital. 

Duncan,  Jessie    Berlin   &  Waterloo   Hospital,   Canada. 

Durkee,  C.  Josephine  

Alice  Fisher  Alumnae,  Philadelphia  Hospital,  Pa. 

Evans,  Isabel  L St.  Luke's  Alumnae,  New  York. 


Home  Delegates  15 

Faj,  Margaret  G University  of  Pennsylvania  Alumnae,  Phila. 

Fulmer,  Harriet. .  .Grace  Church  Branch  Guild,  St.  Barnabas, 

Chicago;  Visiting  Nurses'  Association,  Chicago,  111. 

Gannett,    Lois    (Alternate   to   Miss   Lightbourne)    

Hospital  of  the  Good  Shepherd,  Syracuse,  N.  Y. 

Gardner,  Bertha Orange  Memorial  Alumnae,  Orange,  N.  J. 

Garrett,  Anna  C Pennsylvania  Alumnae,  Philadelphia. 

Graham,  Sarah  J Post  Graduate  Alumnje,  New  York. 

Groff,  Anna  B Pennsylvania  Alumnae,  Philadelphia. 

Hall,  E.  E Methodist  Episcopal  Alumnae,  Brooklyn. 

Hay,  Helen  S Illinois  Training  School  Alumnae. 

Hendrickson,  Plelen Allegheny  General  Alumnae,  Pittsburg,  Pa. 

Hewitt,  E.  M Columbia  and  Children's  Alumnae,  Washington. 

Hicks,  M.  R Hartford  Hospital  Alumnae. 

Hughes,  Flora  A.  C,  M.  D Boston  City  Nurses'  Club. 

Hughes,  Nellie  C St.  Mary's  Alumnae,  Brooklyn. 

Johnston,   Mary  (Alternate  to  Miss  Smythe)    

Graduate  Nurses'  Association,  Cleveland,  O. 

Keith,  Mary  L Massachusetts  General  Alumnae,  Boston. 

Kenny,  Ellen  A Rhode  Island  Alumnae,  Providence. 

Kinney,  Mrs.  Dita  H Army  Nurse  Corps,  U.  S. 

Koch,  Clara Michael  Reese  Alumnae,  Chicago,   111. 

Kritzner,  Johanna German  Hospital  Alumnae,  New  York. 

Lichtenstein,  Claribel Touro  Infirmary,  New  Orleans. 

Lightbourne,  L...  .Hospital  of  the  Good  Shepherd,  Syracuse,  N.  Y. 

Lightfoot,  Ida  M Colored  Hospital  Alumnae,  New  York. 

Lounsbury,  Harriet  Camp.  .Spanish-American  Order  War  Nurses. 
MacKenzie,  Emma  ....Michael  Reese  Hospital  Alumnae,  Chicago. 

Macleod,    Charlotte The  Victorian   Order,  Ottawa,  Canada. 

McClurg,  A.  W.  (Alternate  to  Miss  C.  V.  Austin)   

Old  Dominion  Alumnae,  Richmond,  Va. 

McFadden,   Mattie Grace  Alumnae,   Detroit,  Mich. 

McKinnon,  S.  H Erie  County  Alumnae,  Buffalo. 

Macdonald,  Isabel St.  Joseph's  Alumnae,   Paterson,  N.  J. 

Mackey,  A.  H 

Dutchess  County  Nurses'  Club  Alumnae,  Poughkeepsie. 

Mobbes,  A.  K 

New  York  City  Training  School  Alumnae,  New  York. 

Morley,  Mrs.  Thomas Buffalo  General  Hospital  Alumnae. 

Mulhorn,   Sallie    

Columbia  and  Children's  Alumnae,  Washington,  D.  C. 

Parke,  Emma  L Brooklyn  Homeopathic  Alumnae. 

Parrish,  St.  Luke's  Hospital,  Bethlehem,  Pa. 

Peters,  Anna  M Woman's   Hospital  Alumnae,   Philadelphia. 

Pettit,  Mrs.  Clara  D 


16  International  Congress  of  Nurses 

Philpotts,  M.  Gertrude St.  Luke's  Alumnse,  Chicago. 

Porteous,  Elizabeth  R Spanish-American  War  Nurses. 

Quinn,  Mrs.  M.  A Rhode  Island  Alumnse,   Providence. 

Ranney,  Alice  M M.  E.  Hospital  Alumna,  Brooklyn. 

Rice,  V Johns  Hopkins  Alumnse,  Baltimore. 

Richards,  Linda.. New  England  Hospital  for  Women  and  Children. 

Riddle,  Mary  M Boston  Nurses'  Club. 

Ridout,  Lilla  M.  E.  Hospital  Alumnse,  Philadelphia. 

Riley,  Jane  F Massachusetts   General  Alumnse,   Boston. 

Robertson,  A.  C 

Grace  Church  Guild  Branch    St.  Barnabas,  Chicago. 

Ruddem,  Sara University  of  Penn.  Alumnae,  Phila. 

Rutherford,  Anna Johns  Hopkins  Alumnse,  Baltimore. 

Schenk,  Annie Bellevue  Alumnse,  Nevir  York  City. 

Scott,  Jessie  P Michael  Reese  Alumnse,  Chicago. 

Sears,  Jessie Garfield  Alumnse,  Washington,  D.  C. 

Selden,  Gertrude  E Post  Graduate  Alumnse,  New  York. 

Sharp,  Lucy Johns  Hopkins  Alumnse,  Baltimore. 

Simmons,  Kathryn  R Roosevelt  Alumnae,  New  York. 

Smith,  Amelia Maine  General  Alumnse,  Portland,  Me. 

Smith,  Grace Graduate  Nurses'  Association,  Waltham,  Mass. 

Smythe, ....Graduate  Nurses'  Association,  Cleveland,  O. 

Stansfield,  M.  J Paterson  General  Alumnse,  Paterson,  N.  J. 

Steele,  Bessie Michael  Reese  Alumnse,  Chicago,  111. 

Stewart,  Ada  B New  York  Hospital  Alumnse. 

Stewart,  Julia  Toronto  General  Alumnse,  Canada. 

Stirk,  Anna  Presbyterian  Alumnse,  Philadelphia. 

Storck,  Mrs.  Harriet Buffalo  Nurses'  Association. 

Sweedie,  Mrs Buffalo  General  Alumnse. 

Tippett,  Alice  O St.  Barnabas'  Guild. 

Tooker,  Margaret Michael  Reese  Alumnse,  Chicago,  111. 

Turner,  Aileen   Toledo  Hospital  Alumnae. 

Underbill,  Eleanor  A S.  R.  Smith  Infirmary  Alumnse,  N.  Y. 

Walton,   Isabel  J New  York   Hospital  Alumnae. 

Weitzel,  V.  C Maryland  Univ.  Hospital  Alumnse,  Baltimore. 

Welsh,  Flora  E Boston  City  Alumnae. 

White, St.  Luke's  Alumnae,  Bethlehem,  Pa. 

Wightman,  Mary  J Visiting  Nurse  Society,  Philadelphia. 

Windsor,  Carley  Harper  Hospital  Alumnse,  Detroit. 

Wood,  Mary St.  Luke's  Alumnse,  St.  Paul,  Minn. 

Woodworth,  A.  N Henry  W.  Bishop  Alumnse,  Pittsfield,  Mass. 

Yocom,  Irene   

New  York   City  Training  School  Alumnse,    New  York. 

Young,  Sadie  C Harper  Hospital  Alumnse,  Detroit. 

Zimmerman,  Mrs.  C.  D.. .  .Buffalo  General  Alumnse,  Buffalo,  N.  Y. 


PART   I 


International  Congress  of  Nurses. 


Meetings  held  in  the  hall  of  the  Women's  Union  build- 
ing, Niagara  square,  Delaware  avenue,  in  the  Cit}'  of 
Buffalo,  Xew  York,  United  States  of  America,  on  the  18th. 
19th  and  20th  days  of  September,  1901. 

The  meeting  was  called  to  order  at  10  o'clock  in  the 
forenoon  for  the  first  session,  by  the  president,  Miss 
Mclsaac,  superintendent  of  the  Illinois  Training  School  for 
Nurses,  Chicago,  who  spoke  as  follows : 

Members  of  the  Congress  : 

We  meet  today  in  the  shadow  of  a  great  national  sor- 
row ;  a  calamity  that  has  shaken  the  foundations  of  our 
government :  it  would  seem  fitting  and  proper  that  this  Con- 
gress should  express  its  sympathy  %\"ith  Mrs.  McKinley,  and 
I  will  therefore  ask  the  secretary  to  read  a  resolution  to  that 
effect. 

Miss  Banfield : 

Resoh«ed :  That  the  International  Congress  of  Nurses 
now  assembled  in  Buffalo  expresses  its  deepest  sympathy 
with  Mrs.  McKinley,  and  heartfelt  sorrow  at  the  loss  which 
the  American  Nation  has  sustained  in  the  untoward  death  of 
its  President. 

The  President :    You  have  heard  the  resolution. 

Miss  Drown :  I  wish  to  express  for  the  members  of 
the  Congress  our  approval  of  this  resolution  presented  by 
the  secretary,  and  also  to  move  that  it  be  sent  in  the  form  of 
a  telegram  to  Mrs.  McKinley  and  that  it  be  recorded  in  the 


minutes  of  the  Congress. 


19 


20  International   Congress   of   Nurses 

The  President :  You  have  heard  the  motion.  I  would 
ask  the  Congress  to  show  an  expression  of  its  approval  by 
rising.    [All  rose.] 

The  President :  I  now  take  pleasure  in  introducing  to 
you  Mr.  Constantine,  who  has  very  kindly  offered  to  substi- 
tute for  Mr.  Diehl,  the  Mayor  of  Buffalo,  during  the  absence 
of  the  latter  in  consequence  of  the  death  of  the  President. 

Mr.  Constantine : 

Madam  President  and  Ladies: 

"It  gives  me  great  pleasure  to  welcome  the  Nurses  Con- 
gress to  Buffalo,  but  I  regret  that  His  Honor,  Mayor  Diehl, 
is  not  present  to  tender  you  the  freedom  of  the  city.  A  sad 
duty  has  called  him  elsewhere.  He  would  have  been  pleased 
to  meet  and  greet  you,  and  talk  with  you  about  the  noble 
work  in  which  you  are  engaged.  It  would  have  given  him 
great  satisfaction  to  recount  some  of  the  many  examples  of 
your  devotion  and  self-sacrifice  which  have  come  under  his 
observation  in  nearly  forty  years  of  practice. 

"To  me  is  left  the  privilege  and  honor  of  saying  a  few 
simply  homely  words  of  welcome  and  to  bid  you  God-speed 
in  your  work.  We  were  gratified  and  highly  honored  when 
you  selected  Buffalo  for  your  meeting  place,  and  your  local 
committee  had  made  plans  to  make  the  occasion  a  festive 
one.  But  you  have  come  to  a  city  saddened  by  a  terrible 
calamity  and  decked  with  the  emblems  of  mourning.  If  your 
welcome  is  not  joyous,  it  is  none  the  less  sincere  and  gener- 
ous. We  hope  you  will  see  much  of  our  beautiful  city  and 
the  Pan-American  Exposition  while  here.  You  will  find 
much  to  interest  you — much  to  help  you  in  your  work.  If 
you  make  the  most  of  your  opportunities  I  believe  in  after 
years  you  will  look  back  upon  your  visit  to  Buffalo  as  one 
of  the  pleasantest  and  most  profitable  events  in  your  life." 

The  President :  I  have  the  further  pleasure  of  introduc- 
ing Mrs.  Townsend,  who  is  the  president  of  the  Women's 
Educational  and  Industrial  Union  of  Buffalo,  an  association 
which  is  identified  with  all  of  the  most  advanced  movements 
in  woman's  work  of  all  kinds. 


OpenUig  Addresses  .      21 

Mrs.  Tovvnsend : 

Madam  President  and  Ladies: 

"We  meet  under  the  shadow  of  a  nation's  grief,  but 
there  is  a  sad  comfort  in  the  thought  that  all  good  work 
must  go  on.  I  am  reminded  of  the  beautiful  and  significant 
epitaph  to  the  great  Wesley  brothers  in  Westminister 
Abbey:  *God  takes  away  the  workers,  but  carries  on  the 
work.' 

"Organization  and  co-operation  are  watchwords  for  the 
new  century.  The  first  time  I  heard  our  world-famous 
Frances  Willard  speak  she  was  giving  her  word  of  greeting 
from  the  Christian  Temperance  Union  to  the  National 
Council  of  Women,  convened  at  Washington,  in  her  own 
marvelous  way,  and  she  spoke  with  a  charm  and  a  power 
seldom  possessed  by  woman.  She  told  a  simple  story  of 
two  children  climbing  a  steep  hill.  After  struggling  alone 
for  a  distance  the  younger  child  reached  up  her  hand  to  the 
elder  and  said :  'Let  us  take  hold  of  hands,  it  is  easier  so.' 
The  lesson  and  its  application  were  pertinent.  I  have  never 
forgotten  them.  You  are  here,  several  branches  of  the  same 
organization,  to  help  one  another.  In  the  path  of  your  ser- 
vice rise  hills  that  must  be  surmounted  as  you  press  on  to 
the  realization  of  your  best  ideals.  Here  you  will  take  hold 
of  hands  and  help  each  other  to  climb. 

"It  is  my  happy  privilege,  in  behalf  of  our  Union,  to  ex- 
tend to  you  most  cordial  greeting.  We  hope  that  while  here 
you  will  have  time  to  make  yourselves  somewhat  acquainted 
with  the  underlying  principles  of  the  Women's  Educational 
and  Industrial  Union.  Its  purpose  is  to  increase  fellowship 
among  women  in  order  to  promote  the  best  practical 
methods  for  securing  their  educational,  industrial  and  social 
advancement.  In  some  lines  our  work  is  similar  with  yours 
— we  minister  to  the  sick  and  suffering;  perhaps  we  may 
seek  to  relieve  the  trouble  of  the  heart  and  soul  more  than 
those  of  the  body,  but  the  ministry  of  the  skilled  and  faithful 
nurse  is  not  only  to  the  material.  She  cheers  the  sad  heart, 
she  strengthens  the  weak  soul  as  she  cares  for  the  diseased 
body.  Yours  is  a  beautiful  mission.   In  all  your  deliberations 


22  International  Congress  of  Nurses 

here,  and  wherever  duty  may  call  you,  to  each  and  every 
one,  I  bid  earnest  God-speed.  May  you  feel  at  home  in  this 
building,  consecrated  to  humanitarian  work. 

"You  are,  indeed,  most  heartily  and  truly  welcome." 


Address  of  the  President,  Miss  McIsaac. 
Mrs.  Townsend,  Your  Honor  the  Mayor,  Our  Foreign  Dele- 
gates, Delegates  to  the  Congress,  Ladies: 

"It  is  with  extreme  pleasure  and  appreciation  I  respond 
in  behalf  of  the  Congress  to  the  cordial  welcome  of  Buffalo 
through  Mrs.  Townsend  and  Mr.  Constantine,  who  have 
honored  us  not  only  by  the  warmth  of  their  reception,  but 
by  their  recognition  of  our  profession.  I  have  additional 
pleasure  in  extending  the  welcome  of  American  nurses  to 
the  foreign  delegates  and  representatives  whose  presence 
and  participation  in  this  Congress  will  contribute  in  so 
marked   a  degree  to  its  interest  and  success. 

"In  approaching  the  discharge  of  my  duties  as  presid- 
ing officer  of  this  third  International  Congress  of  Nurses,  I 
beg  to  express  my  appreciation  of  the  generosity  by  which  I 
have  been  called  to  such  an  honor. 

"This  appreciation  becomes  all  the  more  pronounced 
when  I  reflect  upon  the  conspicuous  achievements  of  my 
predecessors  and  colleagues  in  all  lands,  who  have  labored 
zealously  and  with  beneficent  results,  not  alone  in  nursing 
fields,  but  in  behalf  of  organization,  to  guard  which  must  be 
one  object  of  our  labors  upon  this  occasion. 

"It  requires  a  pen  and  tongue  far  more  eloquent  than 
mine  to  do  justice  to  the  feelings  which  arise  when  we  con- 
sider the  significance  of  this  gathering.  Every  meeting  of 
this  kind  is  a  record  of  our  progress,  and  by  each  one  we 
may  determine  how  far  forward  we  have  gone.  When  we 
look  back  upon  all  the  great  movements  of  the  world  we 
should  never  lose  sight  of  the  great  truth,  that  a  cause  which 
is  righteous  is  never  wholly  lost.     It  may  be  obscured  and 


Address  of  the  President  23 

neglected,  individual  effort  may  fail,  but  the  time  will  come 
when  it  is  carried  to  success. 

"If  the  phenomenal  growth  of  nursing  is  any  indication 
of  its  righteousness,  then  who  can  doubt  our  future?  Small 
wonder  that  our  pioneers,  some  of  whom  are  still  with  us, 
express  themselves  as  sometimes  awed  by  the  mighty 
impetus  of  the  ball  they  started  rolling  scarcely  more  than 
a  generation  ago.  The  story  of  our  beginning  is  so  near 
to  us  that  it  is  too  well  known  to  need  repetition — our  his- 
tory so  short  that  it  is  soon  told. 

"To  our  English  colleagues  we  of  the  United  States  owe 
more  than  we  can  repay,  and  if  in  our  swift  American  fashion 
we  have  broken  from  their  leading-strings  and  made  paths 
for  ourselves,  we  none  the  less  acknowledge  our  indebted- 
ness with  gratitude,  and  display  our  accomplishments  with 
the  same  pride,  mingled  with  a  little  doubt,  with  which  sons 
and  daughters  display  theirs  to  the  friends  at  home.  The  tie 
of  common  speech  and  common  interests  is  a  strong  one, 
even  in  the  every-day  work  of  commerce,  but  when  the 
mutual  interests  concern  life  and  death,  the  tie  grows  in 
strength  and  engenders  a  peculiar  feeling  of  sympathy  and 
kinship. 

"Our  first  International  gathering  in  Chicago  in  1893  was 
marked  very  distinctly  by  the  making  of  acquaintance, 
which  sounds  rather  insignificant,  but  on  second  thought 
assumes  its  proper  place,  and  we  realize  that  it  signified  a 
tremendous  force  in  nursing  affairs.  The  exchange  of  ex- 
periences suddenly  roused  many  women  to  the  fact  that  the 
deficiencies  and  difficulties  of  their  work  were  peculiar  to 
the  whole  nursing  profession,  and  not  to  one  school  or 
hospital.  To  that  meeting  we  owe  the  greater  part  of  the 
progress  which  has  been  made  since  then,  in  America.  The 
second  Congress,  in  London,  gave  some  of  our  members  an 
opportunity  of  studying  nursing  affairs  abroad,  and  was  the 
starting  point  of  definite  international  relations  between 
nurses ;  and  we  will  devoutly  hope  that  from  this  Congress 
may  come  as  much  that  is  good  and  stimulating. 

"The    problems    taken    up    for    discussion    on    those 


24  International  Congress  of  Nurses 

occasions  still  confront  us  in  both  continents, — the  uniform 
requirements  for  admission  to  our  schools,  the  uniform 
curriculum,  what  shall  constitute  a  trained  nurse.  State 
registration,  local  and  national  organization,  a  code  of  ethics, 
and  many  minor  questions. 

"In  America  the  extension  of  the  training  course  from 
two  to  three  years  is  nearer  an  accomplished  fact  than  any 
other  question,  and  while  the  curriculum  is  far  nearer 
uniformity  than  it  was  eight  years  ago,  there  is  still  much  to 
be  desired. 

"The  question  as  to  what  constitutes  a  trained  nurse 
seems  farther  from  settlement  in  this  country  than  at  any 
time  before.  We  Americans  have  strongly  what  the  French 
call  '  the  faults  of  our  qualities.'  In  our  nervous  energy  and 
haste  to  embrace  all  things  new  and  to  get  to  the  end  by  a 
short  cut  we  often  sacrifice  quality  and  thoroughness  to 
speed,  and  in  no  other  work  is  this  more  glaring  than  in  the 
enormous  increase  of  so-called  training-schools  which  have 
neither  educational  nor  moral  right  to  exist.  We  will  listen 
with  much  interest  and  eagerness  to  our  foreign  delegates 
upon  this  subject,  for  it  is  one  of  extreme  gravity  to  our 
profession.  The  establishment  of  a  chair  of  Hospital 
Economics  in  Columbia  University  has  been  one  of  our 
most  important  undertakings,  originating  with  the  nurse 
who  has  done  more  for  educational  standards  in  our  pro- 
fession in  America  than  any  other  one  woman ;  Isabel 
Hampton  Robb,  whose  work  is  so  well  known  to  all  of  us. 
The  Columbia  course  will  undoubtedly  be  a  most  valuable 
leaven  for  the  whole  lump,  and  I  may  say,  with  no  fear  of 
giving  offense,  that  the  superintendents  themselves  know 
better  than  any  one  else  the  great  need  of  better  teachers  of 
nursing.  We  cannot  hope  for  improvement  in  pupils  with- 
out a  greater  improvement  in  the  heads  of  our  schools.  The 
organizations  for  nurses  all  over  the  world  have  developed 
wonderfully,  and  while  we  occasionally  hear  expressions  of 
discouragement,  we  should  not  forget  that  we  have  learned 
much  by  contact,  and  should  see  our  deficiencies  now  far 
more  clearly  than  formerly,  and  if  we  continue  to  struggle 


Address  of  the  President  25 

for  better  things,  a  *  noble  discontent '  with  ourselves  will  be 
the  very  best  stimulus  we  can  have. 

"A  topic  new  to  the  nurses  of  the  United  States sinceour 
first  meeting,  although  an  old  one  in  England,  is  army  nurs- 
ing— a  huge  problem  undertaken  here  in  an  emergency,  and 
one  in  which  we  sadly  acknowledge  we  have  not  always 
done  ourselves  credit,  nor,  perhaps,  always  given  credit 
where  it  may  have  been  due.  In  this,  alas,  our  friends 
across  the  sea  share  with  us  some  of  the  same  humiliation; 
but  if  all  experience  is  good  for  us,  then  we  should  listen 
with  open  hearts  and  minds  to  those  who  can  point  out  a 
better  way  for  our  future  guidance,  and  take  the  criticism  we 
deserve  with  the  right  spirit.  For,  after  all  is  said  and  done, 
the  roots  of  our  shortcomings  existed  before  the  Spanish- 
American  or  South-African  Wars. 

"An  undertaking  of  which  we  are  justly  proud  is 
The  American  Journal  of  Nursing.  To  paraphrase 
our  great  Lincoln,  '  a  journal  of  nursing,  for  nurses  and  by 
nurses,'  the  work  of  which  has  been  entirely  done,  until 
within  a  few  weeks,  by  nurses  hard  worked  in  other  lines; 
a  monument  to  the  courage  and  devotion  of  American 
nurses,  we  recognize  it  as  a  tremendous  factor  for  good ;  and 
feel  that,  whatever  its  standards  and  influence,  it  is  and  will 
be  what  nurses  make  it. 

"  Again  I  beg  to  express  our  thanks  to  our  cordial 
hosts  of  Buffalo,  and  to  extend  the  hand  of  fellowship  to  the 
distinguished  guests  within  our  gates  who  share  with  us  this 
undertaking,  and  felicitate  them  upon  their  achievements  in 
our  profession." 

The  President :  We  would  announce  that  the  meeting 
on  Thursday  afternoon  will  convene  at  half  past  one  and 
close  at  three  o'clock.  The  day  is  to  be  a  day  of  mourning 
and  everything  will  be  closed  after  that  time  on  Thursday 
afternoon. 

Unhappily  one  of  the  foreign  delegates,  Mrs.  Strong, 
who  came  to  this  country  to  attend  the  Congress,  has  been 
delaved  and  I  would  ask  the  secretarv  to  read  her  letter. 


26  International  Congress  of  Nurses 

The  secretary  reads : 

"Episcopal  Hospital,  Philadelphia,  Sept.  i6,  igoi. 
Dear  Miss  Mclsaac: 

I  am  sorry  to  say  illness  prevents  my  being  with  you  in 
Buffalo  on  the  19th  inst.  to  read  my  paper  as  promised. 

Wishing  you  pleasant  and  profitable  meetings,  believe 
me  with  kindest  regards.  Yours  very  sincerely, 

Rebecca  Strong," 

Mrs.  Robb :  I  take  pleasure  in  moving  that  in  re- 
sponse to  Airs.  Strong's  letter  a  telegram  be  sent  to  her 
expressing  the  sense  of  regret  of  the  Congress  for  her 
absence  through  illness.    Carried. 

The  President :  We  have  this  morning  three  papers  on 
Hospital  Administration  in  Great  Britain  and  America.  It 
has  been  decided  that  all  three  papers  will  be  read  before 
we  have  any  discussion.  I  have  pleasure  in  presenting  Aliss 
Isla  Stewart  to  the  Congress. 


Hospital  Administration. 

ISLA  STEWART, 

Matron  St.  Bartholomew's  Hospital,  President  Matrons'  Council  of  Great  Britain 

and  Ireland. 

Madam  Chairman: 

The  broad  lines  of  administration  are  much  the  same 
in  a  large  majority  of  the  hospitals  of  Great  Britain  and 
Ireland,  which  are  either  endowed,  or  partially  or  wholly 
supported  by  voluntary  contribution.  Many  hospitals  have 
as  their  highest  representative,  or  figure  head,  a  Patron 
or  President,  who  in  quite  a  large  number  of  cases  is  a 
Royal  personage,  and  they  are  by  no  means  merely  orna- 
mental, as  their  patronage  implies  not  only  a  personal  con- 
tribution to  the  funds,  but  very  material  assistance  in 
attracting  the  gifts  of  the  public,  who  feel  a  certain  guarantee 
of  efficiency  and  probity  is  given  by  the  use  of  the  name 
being  allowed.  Nor  is  this  a  misplaced  belief,  as  every  care 
is  taken  in  the  way  of  enquiries  and  inspection,  to  prevent 
the  name  of  any  of  the  immediate  Royal  family  being  used 
in  connection  with  any  institution  the  general  management 
of  which  is  open  to  question.  The  subscribers  elect  the 
Governors  from  among  themselves.  These  form  a  court 
which  meets  annually,  half  yearly  or  quarterly.  They  appoint 
a  sub-committee,  frequently  known  as  the  House  Com- 
mittee, which  meets  monthly  or  fortnightly,  and  in  nearly 
all  the  large  hospitals  there  is  also  a  weekly  board,  empow- 
ered to  deal  with  any  minor  matters  that  may  arise.  The 
ex-ofificio  chairman  of  every  board  and  committee  is  the 
treasurer,  elected  by  the  governors,  in  some  hospitals  for 
life  and  in  others  annually.  There  are  also  three  or  more 
trustees  who  are  members  ex-officio  of  the  committees.  In 
a  few  hospitals  there  are  women  on  the  governing  board, 

27 


28  International  Congress  of  Nurses 

but  this  is  still  rare,  though  not  so  much  so  as  it  was  a  few 
years  ago.  I  may  instance  the  Royal  Infirmary  in  Edin- 
burgh as  the  most  important  hospital  where  this  is  the  case ; 
at  this  institution  two  women  have  been  elected  to  serve  on 
the  committees.  The  Royal  Infirmary  in  Glasgow  has  fol- 
lowed its  example,  but  they  have  not  only  placed  two  women 
on  their  conmiittee,  but  also  two  working  men.  In  many 
cases,  indeed  in  almost  all  provincial  hospitals  and  in  Scot- 
land and  Ireland,  the  medical  staff  are  represented  on  the 
board  by  two  or  more  members.  When  this  is  not  the  case 
the  medical  staff  form  themselves  into  an  advisory  com- 
mittee of  their  whole  number,  and  are  consulted  by  the  lay 
governing  body  on  all  matters  which  affect  their  interest, 
or  the  well  being  of  the  patients. 

These  are  the  unpaid  administrators,  in  whose  hands 
rests  the  enormous  responsibility  of  obtaining  money  for  the 
institution,  nursing  its  resources,  and  assuring  themselves 
that  the  funds  are  carefully,  wisely  and  honestly  spent,  and 
that  the  paid  officials  are  capable,  efficient,  and  upright. 

In  many  of  the  London,  Edinburgh  and  large  provincial 
hospitals,  the  chief  resident  authority  is  a  superintendent 
who  may  belong  to  the  medical  or  legal  professions  or  may 
be  an  army  man  or  civilian  of  tried  business  capacity.  He 
may  be  styled  the  Clerk,  House  Governor,  or  Superinten- 
dent. His  duties  are  numberless,  and  comprise  the  decision 
of  questions  chiefly  administrative  which  may  involve  con- 
siderable interest,  or  be  very  unimportant.  He  prepares  the 
business  for  the  different  committees  and  reports  to  them 
the  various  matters  which  arise  between  the  meetings  of 
the  board.  The  power  and  responsibility  of  this  official  are 
very  great,  and  are  but  rarely  abused.  Under  him  are  the 
heads  of  the  various  departments:  the  matron,  head  of  the 
nurses  and  domestic  department;  the  steward,  head  of  the 
department  which  includes  payment  of  wages,  bills,  cater- 
ing, recording  the  admission  and  discharge  of  patients,  and 
the  control  of  the  male  attendants  and  porters ;  the  clerk 
of  the  works,  wb.o  has  charge  of  the  actual  structure  of  the 
building    and    who    has    under    him    the    carpenters    and 


Hospital  Administration  29 

plumbers.  In  g-eneral  each  official  reports  personally,  in 
writing,  to  the  weekly  and  fortnightly  board,  but  this  is  not 
always  the  case,  and  in  so  important  a  hospital  as  the 
Western  Infirmary  in  Glasgow,  where  there  are  420  beds, 
the  matron  is  responsible  only  to  the  superintendent,  and 
never  sees  the  committee.  This,  of  course,  diminishes  her 
authority  and  prestige  considerably.  So  large  a  number  of 
officers  is  only  required  in  the  great  hospitals.  With  a 
decrease  in  the  size  of  the  institution,  the  number  of  these 
officials  tends  to  diminish ;  the  clerk  to  the  board  (usually 
non-resident),  and  the  matron  dividing  the  work  of  the 
steward  and  clerk  of  the  works,  and  in  a  large  number  of  the 
smaller  London  and  provincial  hospitals  the  matron  is  the 
only  permanent  resident  authority ;  though  she  is  frequently, 
even  in  her  own  immediate  department,  under  the  control  of 
the  medical  resident. 

There  is  a  very  large  number  of  important  Infirmaries 
originally  under  the  Poor  Law  Board,  the  powers  of  which 
were  transferred  to  the  Local  Government  Board  by  Act  of 
Parliament  in  1871.  These  are  entirely  supported  by  rates. 
Each  parish  when  populous,  or  group  of  parishes,  when  they 
are  smaller  or  more  scantily  populated,  supports  its  own 
institution  which  in  the  latter  case  is  known  as  a  Union 
Infirmary.  In  England  and  Ireland,  Guardians,  and  in  Scot- 
land, County  Councillors,  who  may  be  either  men  or 
women,  are  elected  by  the  rate-payers,  and  hold  office  for 
three  years.  They  deal  with  a  great  many  matters  affecting 
the  well  being  of  the  parish,  and  amongst  them  govern  the 
workhouse  and  hospital.  They  attend  a  fortnightly  board 
which  deals  with  all  the  matters  which  would  be  brought 
before  the  governors  of  the  voluntary  hospitals.  Tliey  have 
not,  however,  the  supreme  authority;  that  is  vested  in  the 
Local  Government  Board.  All  matters  of  any  importance, 
such  as  the  appointment  of  officials,  must  be  ratified  by  it, 
and  it  may  or  may  not  assent.  To  illustrate  the  extent  of 
the  authority  held  by  the  Local  Government  Board,  I  may 
mention  that  neither  the  guardians  nor  the  Metropolitan 
Asylums  Board  (which  governs  the  hospitals  for  infectious 


30  International  Congress  of  Nurses 

diseases)  can  expend  £100  without  its  consent;  and  no 
structural  alteration  can  be  made  costing-  £5  or  upwards 
without  referring  the  matter  to  it. 

The  medical  superintendent  is  in  all  cases  the  highest 
resident  authority,  and  is  directly  responsible  to  the  Local 
Government  Board  as  well  as  to  his  board  of  guardians.  The 
matron  and  steward  act  under  his  authority,  and  although 
he  may  allow  them  a  fairly  free  hand  he  can  call  them  to 
account  when  he  considers  it  necessary.  The  matron  and 
steward  report  personally  to  the  board,  but  their  written 
report  frequently  goes  through  the  medical  superintendent, 
who  in  some  institutions  is  present  when  it  is  read,  and  when 
they  see  the  committee.  The  matron  is  nominally  the  head 
of  the  nurses'  staflf,  but  as  each  nurse  can  appeal,  on  any 
matter,  to  the  medical  superintendent  her  authority  depends 
largely  on  him.  These  hospitals  are  periodically  inspected 
by  inspectors  employed  by  the  Local  Government  Board 
and  who  report  direct  to  that  board. 

The  hospitals  for  infectious  diseases  are  also  under  the 
Poor  Law,  and  are  supported  by  the  rates.  In  London  they 
are  directly  governed  by  the  Metropolitan  Asylums  Board, 
which  is  composed  of  representatives  from  the  various 
boards  of  guardians,  but  one  third  of  the  whole  number  of 
members  are  nominated  by  the  Local  Government  Board. 
The  growth  of  the  work  of  the  Asylums  Board  and  the 
increase  in  the  number  of  their  institutions  have,  during  the 
last  two  years,  led  to  a  modification  of  administration  where- 
by three  central  committees,  viz :  one  for  the  fever  hospitals, 
one  for  the  asylums,  and  one  for  the  children's  homes  have 
been  appointed,  with  power  to  appoint  sub-committees  to 
visit  the  several  institutions.  This  has  brought  about  greater 
uniformity  in  details  of  management,  but  the  powers  of  the 
sub-committees  have  been  greatly  modified,  as  they  are 
unable  to  make  regulations  upon  any  matters  which  may  be 
regarded  as  common  to  several  institutions.  Each  hospital 
has  a  sub-committee  appointed  to  it  which  meets  at  the 
hospital  fortnightly  and  reports  to  a  central  committee, 
which  in  turn  reports  to  the  general  board,  but  as  in  the 


Hospital  Administration  31 

case  of  the  guardians,  all  important  matters  such  as  those 
relating-  to  finance,  the  purchase  of  land  for  building  pur- 
poses and  the  appointment  of  the  superior  officers  must  be 
ratified  by  the  Local  Government  Board  who  may  prescribe 
regulations  for  the  government  of  their  institutions.  These 
are  also  inspected  by  Local  Government  Board  officials. 
In  the  Asylums  Board  hospitals  also,  the  medical  superin- 
tendent is  the  supreme  resident  authority.  The  matron  and 
steward  being  subject  to  his  control,  he  can  curtail*  their 
authority  and  regulate  the  internal  administration  of  the 
hospital  so  far  as  it  is  compatible  with  the  carrying  out  of 
the  board  rules.  They  report  to  the  sub-committee  on  cer- 
tain matters  connected  with  their  departments  but  in  many 
cases  the  medical  superintendent  sees  their  report  and  is 
always  present  when  they  interview  the  sub-committee  in 
order  that  his  advice  may  be  obtained  upon  any  question 
that  may  arise. 

This  condition  of  afifairs  is  inevitable  under  the  Local 
Government  Board,  who  hold  one  officer  legally  respon- 
sible for  the  good  management  of  the  whole  institution.  A 
wise  autocracy  may  constitute  the  best  form  of  institutional 
government,  and  as  in  the  case  of  the  medical  superinten- 
dents under  the  Asylums  Board  a  large  majority  are  wisely 
chosen  after  much  experience  as  assistant  medical  officers. 
The  system  works  well  and  with  marvellously  little  friction. 
The  chief  fault  lies  in  a  certain  lack  of  minute  discipline, 
which  is  not  so  apparent  now  as  it  was  in  the  past,  and  which 
may  have  been  largely  due  to  the  fact  that  the  matrons  were 
untrained  or  partially  trained  women,  often  with  little  or  no 
education,  and  who  were  given  only  partial  control  over  the 
nursing  staff,  viz.,  when  they  are  off  duty.  Now  that  both 
the  guardians  and  the  Metropolitan  Asylums  Board  are 
appointing  women  of  education,  who  are  all  fully  trained 
nurses,  the  friction  between  the  medical  superintendent  and 
the  matron  is  disappearing,  which  condition  results  in  much 
more   efficient   management  and   better   discipline,   though 

*This  is  limited  by  the  Local  Government  Board  orders. 


32  International  Congress  of  Nurses 

even  now  the  discipline  is  not  quite  so  perfect  or  strict  as 
in  the  general  hospitals.  The  control  over  the  nurse  is 
nothing  like  so  absolute.  She  signs  no  contract  on  enter- 
ing, and  has  no  training  certificate  to  look  forward  to.  The 
administration  of  hospitals  and  infirmaries  supported  out  of 
the  rates  must  always  be  much  more  difBcult  than  that  of 
the  voluntary  hospitals.  They  are  not  charitable  institu- 
tions, and  the  inmates  feel  strongly  their  right  to  be  there, 
and  never  for  a  moment  forget  that  they  have  that  right. 
In  the  infirmaries,  the  infirm  patients  are  resident  for  a  very 
long  time ;  months  indeed  may  lengthen  into  years,  and  they 
know  exactly  how  far  they  may  go  with  impunity.  In  the 
past  there  is  no  doubt  they  had  reason  to  complain,  but  this 
raises  a  class  of  difficulties,  unknown  in  general  hospitals. 
The  object  in  the  fever  hospitals  is  to  make  residence  therein 
as  attractive  as  possible  to  the  inmates  with  the  view  to 
encouraging  the  efficient  working  of  the  Public  Health  Act. 
The  hospitals  for  infectious  diseases  have  their  own  class  of 
difficulties  to  deal  with,  arising  sometimes  from  the  fact  that 
patients  who  have  had  a  slight  illness  must  remain  until  all 
fear  of  infection  has  gone,  which  is  often  long  after  they  are 
to  all  appearance  quite  well.  With  children  this  is  of  little 
consequence  and  women  bear  the  constrained  residence 
fairly  well,  but  with  men  it  often  gives  rise  to  a  certain 
amount  of  discontent.  These  little  troubles,  trivial  it  may  be 
individually,  make  it  necessary  that  they  should  be  dealt 
with  by  some  one  who  has  an  adequate  authority,  and  who 
knows  that  if  strained  it  will  go  beyond  the  weekly  board. 

The  medical  stafif  in  the  large  hospitals  in  London, 
Edinburgh,  Dublin  and  in  the  important  provincial  towns 
consists  of  a  consulting,  a  visiting,  and  a  resident  stafif.  The 
consulting  physicians  and  surgeons  are  mainly  those  who, 
having  reached  a  prescribed  limit  of  age,  have  retired  from 
the  visiting  stafif,  their  duties  being  merely  nominal.  The 
senior  visiting  stafif  are  the  physicians  and  surgeons  who 
pay  periodical  visits  to  the  hospitals  and  have  a  certain 
number  of  beds  allotted  to  their  care.  They  visit  on  certain 
days  at  regular  hours  in  London,  usually  three  or  four  days 


Hospital  Administration  33 

a  week  at  1 :30  o'clock.  In  some  of  the  provincial  hospitals 
they  make  their  visits  in  the  morning;  they  are  liable  to  be 
sent  for  at  any  hour  during  the  night  or  day,  should  a  case 
be  admitted  or  any  emergency  arise  too  critical  for  the 
resident  staff  to  deal  with.  The  junior  visiting  stafT  see  the 
out-patients  and  have  one  or  two  days  a  week  allotted  to 
each  of  them.  There  is  a  still  younger  junior  staff  who  see 
the  casualties  every  morning,  and  there  are  the  heads  of 
the  various  departments,  gynecological,  ophthalmic,  aural, 
throat,  dental,  orthopedic  and  electric.  There  are  two  or 
more  registrars,  who  superintend  the  recording  of  cases  by 
the  students,  and  a  senior  and  junior  anesthetist.  The 
resident  medical  stafif  consists  of  a  house  physician  and  sur- 
geon to  each  of  the  visiting  staff  and  to  the  heads  of  the 
gynecological  and  ophthalmic  departments.  The  junior 
visiting  stafif  and  the  heads  of  the  other  departments  have 
also  understudies,  but  they  are  usually  non-resident.  All 
these  medical  and  surgical  officers  in  the  large  hospitals 
deal  exclusively  with  matters  affecting  their  patients'  health. 
In  some  hospitals,  notably  St.  Thomas',  there  is  a  principal 
medical  and  a  principal  surgical  officer,  who  hold  their 
appointments  for  three  years,  and  who  have  authority  over 
the  more  junior  medical  stafif.  In  others,  as  in  Guy's  hospi- 
tal, the  medical  superintendent  is  the  responsible  officer  dur- 
ing the  absence  of  the  visiting  staff,  and  the  house  staff  is 
under  his  control,  but  in  the  majority  of  hospitals  the  house 
staff  is  responsible  for  the  patients  during  the  absence  of  the 
visiting  staff.  In  the  smaller  provincial  hospitals  the  respon- 
sibility of  the  management  of  the  institution  is  often  given 
to  the  senior  resident  medical  officer,  who  is  usually  quite 
a  young  man  holding  office  for  two  or  three  years  or  even 
less.  In  the  infirmaries  and  hospitals  under  the  Poor  Law 
there  is  no  visiting  staff  attached,  but  the  medical  superin- 
tendent has  under  him  resident  assistant  medical  officers 
according  to  the  number  of  beds.  In  the  infirmaries  this  is 
smaller  than  in  the  hospitals  for  infectious  diseases,  as  the 
cases  are  much  less  acute.  In  Lambeth  Infirmary  with  622 
beds  there  are  three  assistant  medical  officers.    In  Birming- 


34  International  Congress  of  Nurses 

ham  Poor  Law  Infirmary  with  1540  beds  there  are  four. 
In  the  South  Western  Fever  Hospital  with  360  beds  there 
are  three.  This  condition  of  things  works  very  well  in  the 
large  hospitals,  where  each  official  has  work  and  respon- 
sibilities enough  in  his  or  her  own  department  to  fully 
occupy  mind  and  time.  But  the  relations  are  strained  in  the 
smaller  hospitals  where  there  is  not  so  much  to  do,  and 
where  the  authority  is  frequently  placed  in  the  hands  of  the 
senior  medical  resident  physician,  who  is  usually  a  young 
man  holding  and  magnifying  his  first  authority. 

Perhaps  the  most  remarkable  change  in  the  administra- 
tion of  hospitals  of  late  years  has  been  the  enormous  increase 
in  the  number  of  nurses  and  in  the  expense  of  the 
nursing  department,  which  in  some  hospitals  seems  to  have 
reached  an  excessive  degree  and  points  to  the  necessity  for 
some  competent  authority  to  define  the  requirements  of 
hospitals  in  this  matter,  having  regard  to  the  size  of  the 
institution  and  the  chronic  or  acute  nature  of  the  cases 
received.  The  staffs  of  the  various  large  hospitals  vary  in 
proportion  to  their  patients  to  an  almost  incredible  degree. 
In  the  London  Hospital  where  there  are  776  beds  with  an 
average  of  659  patients  the  whole  nursing  staff,  including  the 
matron  and  her  assistants,  is  313 ;  or  one  nurse  to  about  2Vz 
patients  on  the  whole  number  of  beds,  and  just  over  one 
nurse  to  two  patients  on  the  number  of  beds  occupied.  In 
King's  College  Hospital  where  there  are  221  beds  and  an 
average  of  168  patients  there  is  a  nursing  staff  of  69  which 
brings  the  proportion  of  nurses  to  patients  to  very  much  the 
same  as  the  London  Hospital.  In  St.  Thomas'  Hospital  the 
beds  number  570;  the  inclusive  staff  161,  which  makes  the 
proportion  quite  one  to  3^  patients.  In  the  Edinburgh 
Infirmary  where  there  are  780  beds  with  an  average  of  711 
patients,  the  nursing  staff  is  195,  making  an  average  of  one 
nurse  to  four  beds  and  rather  less  per  patient.  The  Royal 
Infirmary,  Glasgow,  gives  almost  the  same  proportion  with 
582  beds,  an  average  of  555  patients  and  a  nursing  staff  of 
142.  The  Western  Infirmary,  Glasgow,  with  420  beds  and 
a  nursing  staff  of  128  gives  a  little  better  proportion.     The 


Hospital  Administration  35 

Mater  Misericordia  Hospital,  Dublin,  with  338  beds  and  a 
nursing  staff  of  152  gives  a  proportion  of  one  nurse  to  2^ 
patients.  The  General  Hospital,  Birmingham,  with  346  beds 
and  an  average  of  269  occupied  has  a  nursing  staff  of  102 
nurses,  giving  an  average  of  one  to  just  over  3  beds  and  one 
to  2j  patients.  Leeds  General  Infirmary  with  402  beds  has 
a  staff  of  83  nurses,  giving  an  average  of  one  nurse  to  four 
patients.  The  smaller  county  hospitals  whose  beds  are 
undef  150  seem  all  to  range  about  in  a  proportion  of  one 
nurse  to  four  patients. 

In  the  infirmaries  and  hospitals  under  the  Poor  Law 
the  proportion  of  numbers  is  curiously  different.  In 
Bethnal  Green  Infirmary  the  number  of  beds  being  669 
with  an  average  of  520  occupied,  the  number  of  the  nursing 
staff  is  80,  giving  a  proportion  of  one  nurse  to  about  6:^ 
patients.  In  the  Lewisham  Infirmary  the  number  of  beds 
being  400,  with  an  average  of  250  occupied,  the  average  is 
one  nurse  to  almost  7  patients.  Both  these  infirmaries  are 
in  the  London  district.  In  the  Poor  Law  Infirmary,  Bir- 
mingham, with  1540  beds  and  an  average  of  1131  occupied, 
the  nurses'  staff  gives  an  average  of  one  nurse  to  ten 
patients.  At  Salford,  near  Manchester,  the  Poor  Law  In- 
firmary has  800  beds  and  has  also  an  average  of  one  nurse  to 
ten  patients.  In  the  hospitals  under  the  Metropolitan 
Asylum's  Board  the  proportion  is  better,  being  about  one 
nurse  to  three  or  in  some  four  patients.  The  difference  in 
proportion  of  patients  and  nurses  in  hospital  and  Poor  Law 
infirmaries  does  not  imply  a  corresponding  lack  of  efficiency. 
Hospitals  and  infirmaries  supported  by  voluntary  contri- 
butions are  increasing.  Occupied  by  patients  suffering  from 
acute  disease,  their  aim  is  to  treat  as  large  a  number  of 
patients  as  possible  in  as  short  a  space  of  time  as  they  can, 
compatible  with  efficiency,  while  the  Poor  Law  infirmaries 
have  a  large  number  of  chronic  and  infirm  cases  whose 
condition  does  not  call  for  such  constant  attention  on  the 
part  of  the  nurse.  I  mean  that  a  larger  proportion  of 
patients  per  nurse  may  be  efficiently  attended  to  in  a  Poor 
Law  infirmary  than  in  a  hospital  in  consequence  of  the 
chronic  character  of  many  of  the  patients  in  the  former. 


36  International  Congress  of  Nurses 

It  seems  to  me  that  the  maximum  number  of  nurses 
necessary  for  ef^ciency  must  be  reached  or  overstepped 
when  the  proportion  of  nurses  is  one  to  two  patients  or  just 
under. 

This  large  number  of  nurses  connotes  a  proportionate 
number  of  wardmaids,  servants  and  cleaners,  and  brings 
the  whole  female  staff  to  a  proportion  of  one  to  1^  and  If 
patients  and  makes  the  cost  of  the  nurses  and  domestic 
department  enormous.  In  the  large  hospitals  the  average 
cost  of  the  nurses  ranges  from  £40  to  £63  per  annum ;  in 
the  smaller  general  and  special  hospitals  it  ranges  from  £33 
to  £58.  I  can  only  find  one  Scottish  hospital  quoted,  and 
that  is  the  Dumfries  Infirmary,  which  has  an  average  of  46 
beds  occupied,  a  nursing  staff  of  15,  costing  £42  per  nurse 
per  annum.  In  the  Belfast  Royal  Victoria  Hospital  with 
189  beds  and  a  nursing  staff  of  55  the  average  cost  is  £32 
for  each  nurse.  This  is  exclusive  of  service,  which  I  cannot 
find  estimated  anywhere,  but  on  a  rough  estimate  made  by 
myself  I  think  that  if  we  included  service  it  would  bring  the 
average  cost  per  nurse  somewhere  between  £63  and  £67  per 
annum.  This  amount  either  if  paid  out  of  the  rates  or  met 
by  voluntary  subscription  should  not,  I  think,  be  exceeded. 

The  average  cost  per  day  per  patient  is  almost  as  varied 
as  the  cost  and  number  of  nurses.  The  London  Hospital 
costs  5s.  2d.,  Middlesex  5s.  O^d.,  while  St.  Thomas'  costs  6s. 
O^d.  Leeds  General  Infirmary  costs  3s.  Ifd.,  and  the  Royal 
Infirmary,  Bristol,  2s.  lOd.  In  the  Metropolitan  Asylum 
Board  Hospitals  the  cost  per  patient  per  day  is  about  4s.  lOd. 
or  5s.  This  calculation  includes  not  only  the  actual  main- 
tenance of  the  patients,  but  salaries  and  maintenance  of 
officials,  furniture,  earthenware,  stationery,  insurance  and 
the  upkeep  of  the  institution.  It  must  be  borne  in  mind 
that  that  is  per  patient,  not  per  bed;  and  that  the  average 
stay  in  hospitals  of  the  patients  varies  considerably,  the 
greater  number  of  patients,  the  less  will  be  the  average  cost 
of  each.  As  for  instance,  the  average  of  the  London  is  3 
weeks  stay,  the  average  of  St.  Bartholomew's  Hospital  is  4 
weeks. 


Hospital  Administration  37 

Of  London  hospitals,  the  majority  have  an  annual 
expenditure  of  over  £10  a  bed.  The  Scottish  hospitals 
spend  about  £50  a  bed,  the  Irish  £40,  and  the  Provincial 
about  £50. 

In  London  there  are  about  six  general  hospitals  that 
have  an  annual  expenditure  of  over  £100  a  bed. 

The  administration  of  the  funds  of  the  large  hospitals 
is  becoming  more  and  more  difificult  as  the  expenses  of  each 
department  increase,  owing  to  the  much  greater  regard 
being  paid  to  the  individual  needs  of  the  patients  and  their 
more  scientific  treatment.  There  must  be  some  limit  to  the 
money  obtainable  for  charity,  and  there  should  be  some 
limit,  more  stringent  and  effective,  to  those  who  seek  for 
free  medical  aid.  There  have  sprung  up  in  late  years  admir- 
able societies  for  collecting  and  distributing  money  for  the 
use  of  hospitals.  We  have  the  Sunday  Fund,  the  Saturday 
Fund,  and  now  the  Prince  of  Wales'  Fund.  As  these 
societies  are  in  the  hands  of  business  men,  they  ha\f  no 
doubt  by  careful  selection  and  inspection  done  much  to 
bring  the  hospitals  into  line  and  to  increase  their  elBciency. 
The  governing  boards  of  hospitals  are  now  largely  com- 
posed of  business  men  who  have  experience  in  the  handling 
of  great  sums  of  money,  and  who  give  their  time  most 
ungrudgingly  to  the  service  of  the  hospitals. 


The  President :  I  now  have  the  pleasure  of  introducing 
Miss  Mollett,  who  comes  to  us  to  represent  the  Matrons' 
Council. 


County  Hospitals  in  Great  Britain. 

WILHELMINA  J.  MOLLETT, 

Matron  Royal  South  Hants  and  Southampton  Hospital,  Member  of  and  Delegate 
from  the  Matrons'  Council  of  Great  Britain  and  Ireland. 


Ladies,  I  rise  with  some  diffidence  to  speak  after  Miss 
Stewarts  able  paper,  dealing  as  it  does  with  all  the  chief 
points  of  interest  in  hospital  administration, — and  my  only 
excuse  is,  that  I  speak  as  Matron  of  a  very  different — 
though  very  important  class  of  hospital — that  is  to  say  large 
County  Hospitals  unconnected  with  medical  schools. 

It  will  not  perhaps  be  out  of  place  if  I  commence  with 
a  few  remarks  regarding  their  importance  from  a  statistical 
point  of  view  in  England, — I  am  excluding  the  hospitals  of 
Scotland,  Ireland  and  Wales,  and  all  special  hospitals. 

London  contains  twelve  general  hospitals  with  medical 
schools  attached — containing  an  aggregate  of  4,674  beds. 
The  Provinces  (or  counties)  have  tv/elve  medical  schools 
with  an  aggregate  of  3,075  beds.  Thus  the  total  number  of 
beds  in  general  hospitals  in  England  where  regular  clinical 
instruction  is  given  to  male  students  is  7,749.  But  there 
is  further  a  very  large  number  of  general  hospitals  varying 
much  in  size,  which  have  no  medical  schools  attached  to 
them,  whose  total  number  of  beds,  14,974,  is  nearly  double 
the  amount  of  those  devoted  to  clinical  instruction. 

Fifty  of  these  contain  100  beds  and  over,  and  have  a 
total  of  7,526  beds,  or  nearly  as  many  as  the  London  and 
Provincial  Medical  schools  combined. 

Sixty-four  have  from  50  to  100  beds  with  a  total  of 

3,472 — whilst  there  are  no  less  than  203  hospitals  containing 

less  than  50  beds  (of  which  66  have  less  than  ten  beds)  with 

a  total  of  3,976. 

The  figures  are  taken  from  the  Medical  Directorv. 
3S 


County  Hospitals  in  Great  Britain  39 

All  the  above  are  Voluntary  Hospitals — supported  by 
subscriptions  or  endowments.  None  of  them  are  aided  by 
the  Government  or  are  rate  supported.  A  very  few  receive 
a  small  proportion  of  paying  patients,  in  fact  they  practically 
do  not  receive  them.  Except  in  certain  primary  matters  it 
is  not  possible,  in  my  opinion,  to  compare  the  management 
of  a  County  Hospital  in  detail  with  that  of  a  hospital  having 
a  medical  school  attached.  The  essential  virtues  of  order, 
discipline,  obedience  and  the  subordination  of  the  female 
stafif  in  disciplinary  matters  to  the  female  head,  are  the  same 
in  both,  but  in  detail  they  differ. 

The  highest  authority  in  a  County  Hospital  supported 
by  voluntary  contributions  is  always  the  Governors — the 
donors  or  subscribers  in  council  assembled.  The  amount 
given  or  subscribed  to  become  a  Governor  varies,  but  the 
outcome  is  the  same,  the  formation  of  a  large  body  with 
voting  powers — meeting  about  one  or  twice  a  year  to  ap- 
point committees  and  vote  extraordinary  sums  or  changes 
in  the  By-Laws  of  the  Institution.  They  elect  the  manage- 
ment, financial  and  executive  committees  for  the  year,  the 
president,  the  chairman,  and  so  forth, — and  these  practically 
carry  on  the  business  of  the  hospital,  appointing  the 
executive  officers,  and  being  generally  responsible  to  the 
Governors  for  the  efficiency  and  economy  of  the  place.  It  is 
here  that  both  the  strength  and  weakness  of  hospital  gov- 
ernment lies, — whilst  on  the  one  hand  the  management  of 
the  hospital  is  kept  in  touch  with  public  opinion,  on  the 
other  hand  the  proper  government  of  the  hospital  is  apt 
to  be  disturbed  by  well-meaning  gentlemen  who  have  no 
knowledge  of  the  real  needs  and  requirements  of  hospital 
wards,  whilst  it  also  lays  them  open  to  the  influence  of 
popular  or  strong  executive  officers.  The  honorary  medical 
staff  have  representatives  on  the  various  committees,  the 
manner  of  their  representation  varying  slightly  in  different 
hospitals. 

The  executive  administration  in  my  hospital  containing 
130  beds,  which  I  am  following  in  this  sketch,  falls  into 
three  departments  and  I  hold  that  it  is  in  the  proper  balance 


40  International  Congress  of  Nurses 

of  power  between  these  three  departments,  the  proper  ap- 
portioning- of  their  various  responsibilities,  that  the  efficiency 
and  good  order  of  the  hospital  largely  depends.  They  are 
the  secretarial,  the  medical,  and  the  nursing  and  domestic. 

The  secretary  has  charge,  under  the  Finance  Com- 
mittee, of  the  financial  afifairs  of  the  hospital,  the  collecting 
of  subscriptions,  the  hospital  banking  business,  the  balance 
sheets,  and  so  forth.  He  attends  to  all  correspondence  that 
is  not  directly  concerned  with  medical,  nursing  or  domestic 
matters  and,  in  my  case,  overlooks  the  engineer  and  the 
engine  and  the  general  repairs  of  the  building-,  etc.  He 
acts  in  emergencies  for  the  committee  in  their  absence.  He 
is  a  non-resident  officer  and,  when  a  suitable  man,  a  very 
valuable  aid  and  counsellor.  I  am,  personally,  very  fortunate 
in  my  secretary. 

The  principal  resident  medical  officer  is  the  senior 
house  surgeon  who,  working  under  the  honorary  medical 
staff,  acts  for  them  in  their  absence  and  is  in  medical  and 
surgical  charge  of  the  patients.  But  as  he  is,  beside,  the 
resident  medical  officer  for  the  committee,  he  holds,  and 
rightly,  a  very  important  post  with  regard  to  the  patients. 
He  is,  generally  speaking,  responsible  for  the  admission  and 
discharge  of  the  patients  and  for  their  treatment  in  the 
absence  of  the  honorary  stafif,  but  he  is  not  an  administrative 
officer  as  regards  the  nursing  and  domestic  staff.  They  do 
not  fall  under  his  jurisdiction  except  in  so  far  as  he  gives  his 
orders  for  the  patients  to  the  sisters  in  charge  of  the  various 
wards. 

One  of  the  greatest  difficulties  in  a  County  Hospital 
is  in  securing  a  suitable  man  for  the  post  of  house  surgeon. 
It  is  essential  that  they  should  be  thoroughly  good  profes- 
sional men  and  men  of  common  sense,  who  work  their  way 
into  their  post  without  offending  against  all  its  conservative 
instincts.  For  they  come,  of  course,  from  various  medical 
schools ;  each  with  its  own  fads — the  Guy's  man,  the  Bart's 
man,  the  London  and  the  King's — all  think  their  own  school 
perfection  and  are  often  a  trifle  scornful  of  their  predeces- 
sor's methods.       But  the  main  point  is  that  they  should  not 


County  Hospitals  in  Great  Britain  41 

be  slack  but  keen  men  for  their  work  and,  perhaps,  from  a 
matron's  point  of  view,  that  they  should  not  be  too  sus- 
ceptible to  the  charms  of  attractive  sisters  and  probationers. 

The  matron's  department  includes  the  nursing  and 
domestic  staff,  the  food,  the  laundry  and  the  general 
management.  She  either  selects  the  various  sisters,  or 
recommends  candidates  to  the  board,  engages  probationers 
and  servants,  and  superintends  their  work,  for  which  she  is 
responsible. 

She  gives  the  orders  to  the  assistant  matron  and  to  the 
cook  and  supervises  more  or  less  the  food  supplied  to  the 
patients.  She  stations  the  sisters  and  probationers  in  their 
wards,  arranges  the  work,  the  holidays,  and  so  forth.  But 
it  really  is  not  necessary  to  enter  to  the  present  company 
into  the  details  of  her  work,  except  to  emphasize  the  fact 
that  it  is  a  combination  of  superintendent  of  nursing  with 
that  of  matron.  I  will,  however,  add  that  it  is  essential,  if 
she  is  to  carry  it  out  efificiently,  that  she  should  herself,  as 
in  my  case,  be  directly  responsible  for  it  to  the  committee 
and  not  to  any  other  official.  Perhaps  there  is  one  other 
point  I  should  mention  as  being  of  importance  and  that  is 
that  the  nursing  and  domestic  head  should  be  the  same. 
Good  nursing  depends  so  much  on  good  domestic  manage- 
ment and  is  so  intimately  connected  with  it,  that  the  two 
should  certainly  be  under  the  same  control. 

The  nursing  staff  is  divided  into  sisters  at  the  head  of 
the  wards,  a  night  superintendent,  and  probationers  who 
train  for  three  years,  and  are  stationed  on  night  or  day  duty. 
Their  average  daily  time  on  duty,  when  meal  times  and  off 
duty  time  is  deducted,  is  a  little  more  tkan  ten  hours.  I 
see  no  reason,  in  a  County  Hospital,  why  that  time  should 
be  lessened. 

Ward  maids  are  attached  to  the  wards  to  do  the 
roughest  of  the  work,  but  there  still  remains  a  fair  but  not 
undue  amount  of  ward  cleaning  to  be  done  by  the  pro- 
bationers. Ward  orderlies  are  unknown  in  English  civil 
hospitals ;  all  the  nursing  of  the  male  patients  is  done  by 
the  sisters  and  nurses. 


42  •  International  Congress  of  Nurses 

The  probationers  receive  lectures  from  the  visiting 
medical  staff  and  classes  from  the  matron. 

The  whole  scheme  of  hospital  organization  for  County 
Hospitals  resolves  itself  into  a  body  of  subscribers  appoint- 
ing committees  for  a  given  period,  who  in  their  turn  con- 
trol and  regulate  the  hospital  in  accordance  with  certain 
rules  and  by-laws,  and  the  fixed  rule  of  most  of  these 
hospitals  is  that  they  are  intended  only  for  "  fit  objects  of 
charity."  This  rule  is  carefully  guarded  by  the  medical 
profession,  amongst  whom  the  very  idea  of  pay  wards 
attached  to  a  general  hospital,  which  seems  so  usual  here,  is 
very  generally  regarded  with  great  suspicion  and  disfavor. 
It  must,  however,  be  owned  that  they  would  solve  a  most 
serious  difficulty  with  regard  to  the  poorer  middle  classes, 
who  are  of  all  people  the  worst  off  in  England  in  illness. 

In  some  towns,  especially  large  manufacturing  towns, 
the  work  people  contribute  largely  to  the  support  of  the 
hospital,  and  have  their  own  representatives  on  the  com- 
mittees. This  is  the  case,  however,  in  only  a  few  hospitals. 
It  is  not  so  in  mine. 

Further  it  is  necessary  to  remember  that  these  hospitals 
which  are  solely  intended  for  the  relief  of  the  sick  poor  and 
working  classes,  and  do  not  even  contribute  clinical  instruc- 
tion for  students,  are  built  and  maintained  entirely  by  the 
voluntary  subscriptions  of  the  more  well-to-do  classes  and 
that  they  are  beyond  and  outside  the  rate-supported  institu- 
tions such  as  Workhouse  Infirmaries  and  Asylums  for  the 
Insane.  Above  everything  else,  therefore,  these  hospitals 
are  pre-eminently  intended  for  the  sick  poor ;  for  their  com- 
fort, their  convenience,  their  medical  and  surgical  treat- 
ment ;  and  the  first  and  finest  lesson  they  have  to  teach  to 
the  nurses  trained  in  their  walls  is  that  nothing,  not  the 
nurses'  instruction,  or  convenience  or  comfort,  is  so  im- 
portant as  the  welfare  of  the  patients  confided  to  their  care. 


The   President :     Our  next  paper  will  deal   with  the 
administration  of  American  hospitals. 


Hospital  Administration  in  America. 

MAUD   BANFIELD, 

Superinteudent  of   the    Polyclinic   Hospital,    Member   of   Hospital  Superintend- 
ents" Association.  American  Society  Superintendents  of  Training  Schools, 
Matron's  Council,  Lecturer  on  Hospital  Economics,  Teachers'  College, 

[Cxpyriglited,  190».  Iit  Maud  Banfield.] 


In  considering  the  administration  of  hospitals  in  this 
country  we  are  confronted  by  the  initial  difficulty  that, 
although  an  enormous  amount  of  money  is  invested  in  these 
institutions,  there  is  no  uniform,  or  even  customary,  system 
of  administration  or  accounting.  The  State  institutions  are, 
as  a  matter  of  course,  dominated  by  politics ;  and  into  this 
matter  we  will  not  enter,  for  the  reason  that  most  of  our 
time  would  be  taken  up  in  describing  political  rather  than 
hospital  organization.  The  city  hospitals,  the  funds  for  the 
support  of  which  are  secured  by  an  appropriation  of  coun- 
cils, are  in  some  instances  free  from  jx)litics  and  ad- 
ministered satisfactorily,  notably  in  Boston  and  Cincinnati. 
But  these  institutions  are  also  in  a  class  by  themselves.  The 
average  citizen  is  more  concerned  with  the  hospital  which 
he  helps  to  support  by  voluntary  contributions  and  which, 
without  State  aid,  he  would  be  called  upon  to  support  more 
directly  than  he  does  at  present,  and  it  is  of  these  I  shall 
speak  more  particularly. 

The  business  of  running  a  hospital  is  like  any  other 
business,  inasmuch  as  it  needs  to  be  learned.  No  one 
would  take  a  man,  whatever  his  personal  attainments  in  his 
own  special  line,  and  set  him  down  at  the  head  of  a  bank, 
a  store,  a  ship,  or  an  army  corps,  and  expect  him  at  once  to 
give  a  competent  and  valuable  opinion  on  the  various  in- 
terests involved.  Like  anyone  else  he  would  just  have  to  sit 
down  and  learn.     He  would  leave  himself  entirely  in  the 

43 


44  International  Congress  of  Nurses 

hands  of  the  officers  administerino^  that  business,  and  unless 
he  had  confidence  in  them,  would  be  rash  to  lend  even  the 
support  of  his  name.  If  he  interfered  in  the  detail  working 
without  knowing  anything^  about  ft,  he  would  be  still  more 
rash.  Yet  in  a  hospital,  in  which  the  issues  of  life  and  death 
daily  concern  many  people,  such  hesitation  is  remarkably 
rare.  The  youngest  physician  or  the  most  recent  trustee 
thinks  there  must  be  something  wrong  if  he  does  not  im- 
mediately understand  all  about  it,  and  is  surprised  at  the 
strength  and  diversity  of  interests  he  finds  tugging  different 
ways.  But,  as  a  matter  of  fact,  a  hospital  is  no  less  full  of 
the  interests  of  life  and  progress  because  it  also  holds  the 
sick  and  the  dying',  who  are  unwillingly  loosening  their  grasjj 
of  these  same  interests,  to  join  those  who  sleep  soundly 
in  spite  of  it  all. 

Since  I  have  told  you  that  I  cannot  describe  any 
general  method  of  administration,  where  every  institution 
is  a  law  unto  itself;  that  I  can  give  you  no  trustworthy 
figures  of  cost  per  capita  or  other  details  which  have  proven 
so  interesting  in  the  able  papers  preceding  mine,  you  may 
wonder  what  I  have  to  say,  and  why  I  do  not  take  the  or- 
ganization of  one  or  two  hospitals  personally  known  to  me 
and  merely  say,  "and  the  others  are  rather  like  these."  I 
do  not  do  this  because  in  the  first  place  there  is  much  of 
interest  to  be  learned  regarding  the  internal  working  of 
hospitals,  and  since  we  say  in  the  announcement  of  our 
Teachers  College  Course  in  Hospital  Economics,  at  Colum- 
bia University,  that  we  "  hope  to  teach  our  students  the 
duties  of  a  superintendent  of  a  hospital,"  it  may  be  well  that 
they  should  hear  a  little  of  these  matters.  I  think  you  will 
all  admit  that  it  is  positively  remarkable  how  a  nurse  will 
go  through  her  three  or  more  years  in  a  hospital,  and  yet 
know  absolutely  nothing  of  its  administration  as  a  whole. 
She  knows  whether  she  gets  her  time  ofi  duty,  a  certain 
number  of  lectures,  good  food,  and  certain  requirements  for 
her  patients ;  but  the  machinery  which  provides  her  with  all 
these  things,  she  has  no  idea  of  .  I  think,  however,  that 
although  these  matters  have  perhaps  little  to  do  with  nursing 


Hospital  Administration  in  America  45 

per  se,  you  may  fairly  be  supposed  to  be  interested  in  them, 
for  you  also  are  citizens. 

Another  reason  why  I  have  consented  to  speak  on  this 
subject,  and  the  reason  for  my  doing  so  with  absolute 
candor,  is  that  not  only  is  much  money  admittedly  wasted 
in  the  duplication  of  charities  and  the  lax  methods  of 
administration,  but  the  first  to  suffer  from  the  maladminis- 
tration of  a  hospital  are  undoubtedly  the  patients.  This 
sounds  to  us  like  a  truism,  but  the  public  does  not  yet 
appear  to  realize  this  elementary  fact,  nor  that  it  alone  has 
power  to  mend  matters  by  the  intangible  but  very  real 
weight  of  public  opinion  and  by  ascertaining  which  are  the 
right  sort  of  charities,  rightly  and  reasonably  governed, 
before  giving  its  money  to  them.  Any  person  of  average 
intelligence  can  do  this,  if  he  is  willing  to  spend  a  little  time 
about  it  and  take  a  considerable  amount  of  trouble. 

It  seems  obvious  that  if  too  much  is  left  to  inex- 
perienced men,  if  the  food  is  badly  served,  if  the  patients  are 
subject  to  undue  interruptions,  if  a  mean  and  petty  spirit 
pervades  the  institution,  instead  of  one  of  cheerfulness  and 
peace,  if  the  visiting  staff  do  not  visit,  if  through  interest, 
jealously,  or  for  all  too  common  reasons,  incompetent  men 
are  appointed  on  the  staff,  it  is  clearly  the  patient  who  suf- 
fers primarily.  But  no  business  is  conducted  with  so  little 
real  inspection  ;  no  doll's  repair  shop  is  provided  with  so 
little  skilled  labor  in  regard  to  administrative  matters,  or 
even  when  supplied  with  skilled  labor  has  so  many  adverse 
conditions  to  struggle  against  as  the  average  hospital  in  the 
large  cities  of  America.  As  for  the  balance  sheets  and 
reports,  we  know  that  the  statistics  quoted  therein  are  often 
not  worth  the  paper  they  are  printed  on,  are  apparently  more 
often  meant  to  mislead  than  to  inform,  and  in  any  other  busi- 
ness would  land  those  responsible  therefor  in  the  bankruptcy 
courts  if  not  in  the  penitentiary.  This  is,  of  course,  the 
result  of  corporate  carelessnes  rather  than  personal  dis- 
honesty. But  it  is  wonderful  how  general  it  is,  especially 
when  it  is  remembered  that  hospital  funds  are,  or  should  be, 
practically  trust  funds,  and  liable  to  a  public  accounting. 


46  International  Congress  of  Nurses 

The  public  who  have  contributed  this  money  in  one  form 
or  another  have  at  least  a  right  to  a  plain  and  accurate 
statement,  if  one  is  issued  at  all. 

I  fear  that  a  simple-minded  inquirer  who  thinks  that  in 
order  to  ascertain  the  facts  in  regrard  to  any  institution  in 
which  he  is  interested,  he  needs  only  to  send  for  the  last 
annual  report,  will  find  that  his  task  is  by  no  means  so  easy 
as  it  looks,  either  in  regard  to  statements  of  receipts  and 
expenditures,  or  the  number  of  patients  treated.  He  will 
find  that  frequently  no  attempt  is  made  to  separate  income 
from  principal ;  that  it  is  impossible  to  ascertain  the  amount 
of  money  really  expended  for  maintenance  or  permanent 
improvements ;  that  often  the  vaguest  ideas  prevail  even  as 
to  the  total  expenditures  for  the  year,  and  the  net  profit  or 
loss.  He  will  find  that  in  the  detailed  account  for  main- 
tenance the  milk  and  the  coal,  for  instance,  are,  for  some 
inscrutable  reason,  occasionally  lumped  together.  I  call  to 
mind  one  item  entered  thus :  "  Received  for  board  of 
soldiers,  rebate  on  coal,  etc."  In  such  cases  it  is  of  course 
impossible  to  ascertain  either  the  amount  of  money  received 
from  board  of  patients,  or  the  actual  cost  of  the  lighting 
and  heating.  Nor  is  it  possible  to  ascertain  what  or  how 
much  "  etcetera "  includes.  In  some  cases  interest  on 
mortgages,  water  rent,  insurance  and  other  fixed  charges, 
sometimes  even  lighting,  heating  and  salaries  are  not 
included  in  the  estimate  of  expenses  per  capita.  This  of 
course  makes  the  expenditure  of  some  hospitals  appear 
excessive,  whilst  others  appear  abnormally  low.  In  other 
reports  the  accounts  of  the  treasurer  and  the  superintendent 
have  been  known  to  dififer  by  as  much  as  $3000,  and  the 
superintendent's  fiscal  year  may  begin  at  one  time,  and  the 
treasurer's  at  another,  whilst  convalescent  homes  and  other 
branches  of  the  same  institution  may  arrange  for  yet  a 
third.*  Where  trustees  or  managers  are  so  indififerent  in  re- 
gard to  money  matters,  it  is  hardly  to  be  wondered  at  that 

*See  editorial  in  Philadelphia  Medical  Journal  for  June  18.  1898.  This 
hospital  I  note  has  since  had  the  financial  statement  issued  in  its  annual  report 
revised  by  an  expert  accountant.  It  is  encouraging  that  drawing  attention  to 
these  matters  makes  for  better  and  more  careful  work. 


Hospital  Administration  in  America  47 

expenditures  are  oftentimes  unadvisedly  made,  and  extrav- 
agance prevails.  It  would  be  unreasonable  to  expect  other- 
wise. 

It  is  true  that  those  institutions  which  receive  State  aid 
are  required  by  the  State  to  return  an  itemized  account  of 
their  cash  payments,  divided  as  the  State  directs.  In 
Pennsylvania,  however,  the  State  will  only  accept  a  state- 
ment of  bills  actually  paid,  and  not  those  incurred.  This 
statement  obviously  does  not  represent  the  expenditures  of 
those  institutions  which  habitually  run  on  a  deficit,  and  most 
of  them  do.  The  State  Auditor  told  me  this  was  done 
because  it  was  found  that  hospital  authorities  sometimes 
made  their  deficit  appear  larger,  and  the  consequent 
necessity  for  State  aid,  therefore,  greater  than  it  actually 
was,  by  running  up  large  bills  for  maintenance,  when  these 
should  rather  be  charged  up  to  permanent  improvements. 
For  when  the  State  makes  a  grant  for  building  it  requires 
that  the  sum  allowed  should  be  employed  for  building ;  and 
if  for  maintenance  that  it  should  not  be  used  for  other  pur- 
poses.   This  of  course  is  quite  proper. 

But  the  method  pursued  to  secure  this  end  is  both 
inadequate  and  misleading.  The  economy  effected  by  the 
simple  method  of  not  paying  your  bills  is  more  apparent 
than  real. 

An  article  on  hospital  finance  as  shown  in  printed 
reports,  published  as  an  editorial  in  the  Philadelphia  Medical 
Journal  of  June  18,  1898,  written  by  an  expert  accountant 
who  has  gone  into  these  things  very  thoroughly,  would 
repay  perusal  by  any  one  interested  in  these  matters.  I 
was  somewhat  surprised  to  find  when  this  article  came 
out,  stating  substantially  what  I  have  said  above,  but  giving 
exact  references,  that  it  did  not,  so  far  as  I  am  aware,  arouse 
any  comment  whatever.  A  little  book  entitled  Municipal 
Government,  by  Bird  S.  Coler,  ex-comptroller  of  New 
York,  is  also  most  interesting,  as  showing  that  this  kind  of 
thing  is  not  confined  to  Pennsylvania.  He  commences  one 
of  his  chapters  by  saying  "  The  subsidy  system  probably 
finds  its  greatest  abuse  in  medical  charities,"  and  I  consider 
his  statements  throughout  exceedingly  conservative. 


48  International  Congress  of  Nurses 

One  of  the  reasons  (other  than  carelessness)  for  render- 
ing inaccurate  accounts  of  the  number  of  patients  treated,  is 
that  the  claims  put  forth  by  the  various  hospitals  for  State 
aid  are  ostensibly  based  on  the  amount  of  work  done,  viz : 
the  amount  of  free  treatment  given  ward  or  dispensary 
patients,  "  the  sick  poor,"  It  would  seem  hardly  worth 
while,  however,  to  do  this,  for,  as  a  matter  of  fact,  the  hospi- 
tal which  has  the  most  political  pull  usually  gets  the  largest 
grant',  and  the  quality  and  quantity  of  work  done  has  little 
to  do  with  it.  This  is  an  accepted  and  recognized  fact,  and 
has  to  be  reckoned  with  as  adding  to  the  difficulty  of  honest 
administration  of  hospitals  in  this  country.  It  has  to  be 
allowed  for  in  institutions  dependent  in  any  way  upon  State 
aid,  and  is  a  handicap  which  often  crops  out  at  unexpected 
moments. 

One  hospital,  in  order  to  add  to  the  ostensible  number 
of  cases  treated,  follows  a  simple  expedient  in  counting  the 
new  patients,  first  as  one  visit ;  then  counting  the  total  num- 
ber of  visits,  including  the  first  visit ;  and  adding  the  total 
number  of  new  cases  again  to  the  total :  thus,  if  there  were 
three  hundred  new  cases  and  a  total  number  of  nine  hundred 
visits,  it  would  be  carried  out  as  a  "  grand  "  total  of  twelve 
hundred.  These  simple  little  methods  are  by  no  means  care- 
fully hidden.  Again,  when  a  visit  of  a  legislative  committee 
is  to  occur,  whose  prerogative  it  is  to  inspect  all  hospitals 
applying  through  the  State  Board  of  Charities  for  State  aid,, 
every  possible  dispensary  service,  surgical  operation,  or 
ward  class,  is  quite  easily  arranged  to  fall  in  at  that  hour. 
Certain  hospitals  always  know  the  exact  hour  at  which  tO' 
expect  such  visitors ;  others  do  not.  However,  this  makes- 
no  difference  in  the  amount  of  money  actually  obtained, 
such  matters  being  settled  out  of  court,  as  it  were ;  and  per- 
haps may  be  considered  merely  as  a  delicate  attention  to  the 
visitors,  serving  to  make  their  stay  interesting. 

Even  a  superficial  examination  of  the  minimum  length 
of  time  and  services  rendered  constituting  a  bed-day  is  also 
full  of  surprises  and  pitfalls  for  the  unwary.  Some  hospitals 
regularly  "  admit "  any  dispensary  patient  who  needs  per- 


Hospital  Administration  in  America  49 

haps  a  slight  operation  and  a  "  whiff  of  ether,"  and  remains 
three  or  four  hours  to  recover  from  the  effects.  Others  con- 
sider that  if  a  patient  occupies  a  bed  during  the  whole  of 
a  night,  and  possibly  takes  not  only  a  "  whiff  of  ether,"  but 
a  good  breakfast  next  morning,  it  makes  one  day,  reckoning 
as  some  hotels  do.  Others  again  do  not  count  as  house 
cases  any  but  those  who  are  transferred  to  the  in-patient 
wards,  the  unit  being  twenty-four  hours.  This  last  was  the 
method  agreed  upon  by  the  hospital  authorities  in 
Philadelphia  when  rendering  their  accounts  to  the  United 
States  Government  for  the  board  of  soldiers  cared  for  during 
or  after  the  Spanish-American  War,  and  if  State  aid  were 
abolished  this  standard  would  probably  be  generally 
accepted.  The  twenty-four  hour  day  is  also  used  in  Great 
Britain,  and  I  think  you  will  find  has  been  so  reckoned  by 
Miss  Stewart  and  Miss  Mollett.  It  takes  a  little  imagina- 
tion to  consider  the  two,  three  or  four  hours  stay  necessi- 
tated by  the  removal  of  a  finger  joint  or  the  opening  of  a 
felon  a  "day,"  although  possibly  the  time  does  seem  to  the 
patient  to  go  slowly ! 

In  Philadelphia  the  supply  of  beds  is  in  excess  of  the 
demand.  This  probably  is  also  true  of  other  cities.  Never- 
theless new  hospitals  are  constantly  arising,  irrespective  of 
the  need  for  them,  and  are  given  not  only  State  charters, 
but  State  money.  State  aid  is  also  given  to  private  hospi- 
tals, which  are  used  for  special  classes  of  cases  already  amply 
provided  for,  such  as  gynecological  cases,  and  which  do 
practically  no  dispensary  or  teaching  work.  They  are  often 
closed  during  the  summer  months  while  the  physicians  con- 
nected with  them  take  their  summer  holidays.  The  reasons 
for  the  opening  of  these  hospitals  are  too  evident  to  need 
explanation,  even  to  the  casual  observer.  These  hospitals 
"  nurse  "  their  patients  cheaply  by  establishing  "  training 
schools."  They  issue  "  diplomas,"  and  it  is  often  not  until 
the  unfortunate  pupil  nurses  have  completed  two  years  ser- 
vice that  they  find  that  in  order  to  secure  any  standing  in 
their  profession,  they  have  to  begin  all  over  again ;  and  that 
even  when  they  are  willing  to  do  this,  regular  hospitals  are 


50  Internationsil  Congress  of  Nurses 

often  not  anxious  to  take  them  and  unteach  them  many  bad 
ways. 

On  the  other  hand,  State  aid  is  refused  or  very  much 
cut  down  to  hospitals  in  poor  sections  of  the  city  which 
treat  large  numbers  of  out-patients  and  which  have  existed 
for  several  years.  I  once  asked  a  member  of  the  State  Board 
of  Charities  why  this  was  done,  and  the  answer  was  a  some- 
what sweeping,  "  We  do  not  approve  of  dispensaries."  Con- 
sidering the  miscellaneous  assortment  of  things  the  board 
did  apparently  approve,  I  thought  this  was  sufficiently  inter- 
esting to  ask  "  Why  do  you  not  approve?"  and  the  answer 
was,  "Because  the  doctors  do  not  approve."  "Nor  the 
druggists,"  murmured  another  member,  "  don't  forget  the 
druggists."  I  was  not  aware  that  the  medical  profession 
or  the  drug  trade  were  "  infant  industries  "  to  stand  in  need 
of  a  protective  tariff,  as  it  were,  or  that  hospitals  were  estab- 
lished solely  for  their  benefit.  Moreover,  these  statements 
seemed  to  me  to  be  hardly  warranted  by  the  facts. 

It  is  my  belief  that  the  greater  number  of  physicians  get 
too  much  out  of  their  dispensary  practice  to  disapprove  of 
It,  and  that  they  themselves  would  readily  admit  this.  From 
the  professional  point  of  view  numbers  of  medical  men,  both 
young  and  old,  add  much  yearly  to  their  medical  lore  by  the 
study  of  dispensary  patients.  No  one  who  has  not  had  to 
buy  them  knows  the  number  of  new  drugs  used  experi- 
mentally; if  apparently  successful,  to  be  then  used  on 
in-patients  under  closer  observation ;  if  still  yielding  satis- 
factory results,  then  in  private  practice.  There  are  also  many 
classes  of  cases,  such  as  broken  arms  or  skin  diseases,  nasal 
deformities,  chronic  but  slight  orthopedic  deformities,  slight 
organic  heart  diseases,  which  it  is  cruel  and  unnecessary  to 
force  into  the  hospital  as  in-patients.  To  oblige  this  class 
of  patients  to  stop  work  entirely  and  break  up  their  homes 
for  an  affection  requiring  frequent,  although  slight  attention, 
is  forcing  pauperism  upon  them.  To  say  that  this  class  of 
patients  can  afford  to  go  to  a  doctor's  office  is  not  the  case. 
The  physician  who  has  a  fairly  good  practice  and  an  average 
experience,  cannot  afford  to  treat  them.     The  young  man 


Hospital  Administration  in  America  51 

who  is  only  busy  waitino^  for  patients  to  drop  in,  has  not 
only  a  very  limited  experience,  but  also  possesses  none  of 
the  material  resources  of  a  hospital.     He  cannot  afford  to 
give    the    patient    lint,    bandages,    splints,    ointments,    or 
medicines,  and  the  patient  cannot  afiford  to  buy  them  at 
retail  druggist  prices  and  pay  the  doctor  even  a  small  fee. 
But  most  of  all,  the  patient  whose  health  is  his  only  capital, 
as  well  as  his  income,  cannot  afford  the  loss  of  time  which 
inexpert  treatment  entails.    The  unnecessary  loss  of  skilled 
artisan  labor  is  also  a  loss  to  the  community  which  may  be 
reckoned   in   dollars   and   cents.      Moreover,   anyone   who 
knows  anything  of  hospital  work,  knows  of  many  instances 
where    patients    have    drifted    into    the    dispensaries    with 
ununited  fractures,  simple  skin  diseases  which  have  lasted 
for  years,  and  what  not,  saying  they  have  spent  all  their 
money  on  doctors,  and  now  haven't  a  cent  left.      Any  case 
which  the  physician  feels  is  imposing  on  his  tinte  and  on 
the  hospital  supplies,  he  can  easily  question  at  the  time  he 
is  taking  the  patient's  history.    By  the  manner  of  the  replies 
as  well  as  the  matter,  aided  by  his  knowledge  of  human 
nature,  he  can  frequently  tell  what  sort  of  case  it  is.     If  a 
border  line  case,  as  it  were,  the  patient  can  with  perfect 
propriety  be  made  to  take  his  turn  with  his  undoubtedly 
poorer  neighbors,  can  be  lectured  on,  or  used  for  demon- 
stration   to    students.      This    weeds    out    many.      Or    the 
physician  can  say  simply  that  he  does  not  consider  him  or 
her  a  proper  case  for  hospital  treatment.     Such  cases  can 
be  reported  at  the  hospital  ofifice,  and  investigated  either  by 
the  Charity  Organization  Society,  which  will  look  into  and 
promptly  report  upon  such  cases,  or  by  the  hospital  inquirer 
who  is  deputed  for  this  duty.       It  is  also  to  be  noted  that 
physicians     themselves     not    infrequently     encourage     the 
attendance  of  "  interesting  cases  "  quite  irrespective  of  their 
social  status.     As  I  have  lived  most  of  my  hospital  life  in 
teaching  institutions  of  one  sort  or  another,  I  must  confess 
to  a  certain  amount  of  sympathy  from  this  standpoint. 

In  any  case,  while  it  is  certain  that  many  patients  obtain 
dispensary  aid  who  are  able  to  afiford  small  fees,  the  cure  of 


52  International  Congress  of  Nnrses 

dispensary  abuse  must  necessaril}^  originate  with  the  phy- 
sician, and  be  carried  out  with  his  co-operation.  It  cannot 
be  done  without  it.  And  from  the  patient's  point  of  view 
I  must  again  repeat  that  to  force  many  patients  to  become 
hospital  in-patients,  is  to  force  pauperism  upon  them.  Few 
have  any  reserve  fund,  and  coming  into  a  hospital,  especially 
for  a  semi-chronic  condition,  means  breaking  up  their 
homes,  selling  their  bits  of  furniture,  and  boarding  the 
children  out.  I  have  not  heard  this  point  stated,  but  I  know 
it  to  be  a  fact.  The  deserving  poor  are  not  always  those  who 
have  not  a  cent  in  the  world,  nor  are  those  the  poorest.  It 
is  undoubted  that  there  are  just  as  many  abuses  from  the 
medical  side  as  there  are  from  that  of  the  patients,  only  the 
patients  have  no  one  to  write  their  briefs  for  them. 

Another  point  in  dispensary  service  which  I  mention 
merely  to  show  the  many  aspects  which  this  question  as- 
sumes, and  the  many  interests  involved,  is  brought  up  in 
an  article  by  a  physician  recently  published  in  a  well  known 
medical  journal,*  contrasting  unfavorably  the  treatment 
accorded  by  hospital  superintendents  to  physicians  working 
in  dispensary  services,  compared  to  that  accorded  phy- 
sicians of  equal  standing  in  the  wards  of  a  hospital ;  this  more 
particularly  in  neglecting  to  furnish  instruments  for  their 
use,  and  the  unreasonable  number  of  patients  they  are 
expected  to  treat  in  a  given  time;  and  recommending  per- 
sonal supervision  by  the  superintendent  as  a  remedy.  So 
far  as  I  have  been  able  to  observe,  these  statements  are 
quite  true  of  all  large  city  hospitals  from  which  I  have  been 
able  to  obtain  data.  But  neither  the  reason  or  the  remedy 
would  appear  to  be  well  taken.  The  hospital  superintendent 
does  not,  for  instance,  wilfully  assign  an  undue  number  of 
patients  to  a  certain  physician,  seeking  to  overwork  or 
incommode  him.  The  superintendent  indeed  generally  has 
nothing  whatever  to  do  with  the  assignment  of  patients, 
each  hospital  having  its  own  rules  or  customs  in  regard  to 
this.  When  one  remembers  the  "  feelings  "  which  are 
aroused  by  the  sometimes  accidental  transference  of  patients 

^Philadelphia  Medical  Journal,  Aug.   17    1901 


Hospital  Administration  m  America  53 

from  one  service. to  another,  one  wonders  at  this  particular 
complaint  being-  brought !  In  any  case,  the  remedy  would 
seem  to  lie  with  the  physician  himself,  rather  than  with 
the  superintendent  of  the  hospital.  The  patients  whom  he 
finds  himself  unable  to  treat  might  be  referred  to  another 
service,  or  even  another  hospital  which  is  not  so  crowded. 
In  the  present  overstocked  condition  of  the  medical  pro- 
fession, where  the  supply  is  greater  than  the  demand,  he 
might  secure  additional  assistants,  who,  if  they  do  not 
already  know,  might  soon  learn  to  carry  out  routine  treat- 
ment, referring  all  doubtful  cases  to  the  "  chief  of  clinic  " 
or  head  physician  for  supervision  and  direction.  Given  suf- 
ficient space  and  light,  this  difficulty  seems  capable  of  solu- 
tion in  more  ways  than  one. 

In  regard  to  the  supply  of  instruments,  it  is  only  too 
well  and  widely  known  that  hospital  superintendents  are 
not  able  to  keep  dispensary  services  supplied  with  instru- 
ments, because  they  so  speedily  disappear.  I  think  it  is 
seldom  wilful  neglect  on  the  superintendent's  part.  It  is 
merely  that  it  is  useless  to  supply  them.  In  the  recent 
report  of  the  Bellevue  Medical  Board  in  connection  with  the 
reorganization  of  that  institution,  the  recommendation  was 
made  that  an  officer  be  appointed  whose  duty  it  would  be  to 
see  that  hospital  instruments  and  supplies  were  not  removed. 
Judging  from  one's  own  experience,  however,  it  would  take 
manv  duplicates  of  Sherlock  Holmes  to  accomplish  the 
desired  result.  For  the  foregoing  reasons,  the  immediate 
supervision  of  dispensary  services  either  by  the  hospital 
superintendent  with  his  many  other  duties,  or  by  an  officer 
appointed  for  that  sole  purpose,  is,  I  fear,  impracticable.  In 
this  department  the  physician  himself  is  quite  properly 
supreme,  and  upon  him  alone  falls  the  responsibility  for  right 
treatment  of  patients,  or  in  the  last  resort  upon  the  appoint- 
ing power  which  places  him  there. 

L.A.Y   VS.    MEDICAL   CONTROL. 

Governments,  like  lesser  folks,  are  judged  by  results. 
Whether  the  government  be  called  a  limited  monarchy,  an 
autocracy,  or  a  republic,  is  of  less  importance  than  that  it 


54  International  Congress  of  Nurses 

should  be  efficient,  and  secure  to  the  people  their  just  rights 
and  privileges.  Lyman  Abbott,  in  his  Rights  of  Man,  says 
of  Government  "  Its  function  is  the  protection  of  the  inherent 
indefeasible  rights  of  person,  property,  reputation,  family 
and  liberty.  It  has  other  and  secondary  functions,  but  if  a 
government  fulfills  this  one  function  of  protection  justly  and 
adequately,  it  is  a  good  government  whatever  its  form ;  and 
whatever  its  form,  it  is  a  bad  government  if  it  fails  to  per- 
form this  function  justly  and  adequately ;  it  is  pre-eminently 
a  bad  government  if,  instead  of  protecting  rights,  it  violates 
them."  These  words  apply  to  the  administration  of  hospi- 
tals, as  well  as  of  cities  or  countries.  The  rules,  customs 
and  government  of  a  hospital  often  intimately  concern  the 
happiness,  rights  and  persons  of  from  two  to  eight  hundred 
or  more  people,  sick  and  well.  And  from  whatever  ranks 
the  governors  are  drawn,  lay,  medical,  or  both,  the  govern- 
ment is  practically  an  autocracy,  from  the  decision  of  which 
there  is  no  appeal.  Therefore  it  behooves  us,  whenever  we 
have  the  power  of  choice,  to  choose  our  autocrats  wisely. 
To  maintain  a  just  and  fair  equilibrium  between  science, 
philanthropy,  and  an  annual  deficit  is  often  the  far  from 
enviable  lot  of  the  board  of  trustees.  Indeed  finance  is  often 
the  most  urgent  of  the  three,  for  the  butcher  and  drug 
dealer  are  by  no  means  as  patient  in  the  settlement  of  their 
account  as  is  science !  Running  a  large  business  on  a  deficit 
needs  very  consistent  and  very  thorough  attention  from 
some  one  if  the  doors  are  to  be  kept  open,  patients  fed  and 
even  small  salaries  paid  regularly  to  the  necessary  employes; 
and  this  quite  without  consideration  for  the  supply  of  the 
newest  scientific  apparatus,  the  very  latest  discovery  in 
drugs,  and  the  repair  of  large  and  much  used  buildings. 
Whether  medical  men  are  generally  constituted  to  fulfill  the 
requirements  of  all  good  governments  and  also  those  of 
finance,  I  will  leave  you  to  consider.  Your  consideration 
will  no  doubt  be  aided  by  the  somewhat  acrimonious  dis- 
cussions on  this  subject  which  are  frequently  to  be  found 
in  both  the  medical  and  lay  press — particularly  the  former. 
The  medical  administration  of  the  enormous  City  Hospital 


Hospital  Administration  in  America  55 

in  Vienna  is  not  to  be  entirely  ignored.  The  conduct  of 
nurses'  registries  and  societies  by  medical  men,  where  they 
have  control,  will  doubtless  be  of  use  to  you.  There  is  also 
a  very  excellent  chapter  on  this  subject  in  Sir  Henry  Bur- 
dett's  Hospitals  and  Charities  for  1901,  page  69. 

THE   HOSPITAL   SUPERINTENDENT. 

I  have  touched  upon  a  few  of  the  varied  interests  which 
are  to  be  found  in  every  large  city  hospital,  and,  as  you 
know,  there  are  very  many  more  which  I  have  not  men- 
tioned. Now  to  reconcile  these  diverse  elements  it  would 
seem  almost  necessary  to  choose  a  man  or  woman  of  skilled 
knowledge,  with  marked  executive  ability,  with  ceaseless 
energy,  a  warm  heart,  a  wide  knowledge  of  human  nature, 
and  good  health.  Now  what  really  happens?  As  Lord 
Alelbourne  said  of  the  Order  of  the  Garter,  "There  is  no 
damned  merit  about  it." 

Amongst  the  hospital  superintendents  I  know  of,  there 
are,  besides  a  very  few  physicians,  an  ex-newspaper  re- 
porter, a  ward  boss,  a  china  factory  hand,  various  clerks,  and 
a  still  more  varied  assortment  of  clergymen.  The  clerks. 
who  have  possibly  before  occupied  the  position  of  hospital 
bookkeeper,  are  the  only  ones  who  can  be  said  to  have  had 
any  previous  knowledge  of  the  office  or  business  routine  of 
a  hospital,  and  this  after  all  is  a  point  which  is  more  easily 
acquired  than  any.  A  good  superintendent  is,  of  course, 
sometimes  evolved,  but  it  is  at  the  expense  of  the  institution 
as  well  as  of  the  individual.  Some,  taught  in  the  dear  school 
of  experience,  undoubtedly  become  first  rate  hospital  super- 
intendents ; — I  suppose  on  the  principle  that  it  is  not  advan- 
tages that  make  great  men  or  women,  but  disadvantages ; — 
and  many  certainly  work  hard  and  unselfishly.  But  surely 
if  there  was  ever  a  calling  which  needed  preliminary  train- 
ing and  skilled  administration,  it  is  that  of  hospital  superin- 
tendent. 

Teachers  are  taught  to  teach,  engineers  are  taught 
engineering,  bridge  builders  to  build  bridges,  preachers  to 
preach,  doctors  to  doctor,  but  to  reconcile  the  innumerable 


56  International  Congress  of  Nurses 

and  various  elements  in  a  large  and  busy  hospital  no 
previous  knowledge  seems  to  be  thought  necessary  !  Indeed, 
if  a  man  has  failed  in  other  walks  of  life,  or  if  a  clergyman 
has  neither  the  mental  nor  physical  calibre  to  command  suc- 
cess, he  seems  by  some  curious  process  of  reasoning  to  be 
considered  peculiarly  fitted  for  such  a  position.  In  no  busi- 
ness that  I  ever  heard  of  in  which  the  same  amount  of 
money  is  invested,  is  there  so  little  skilled  labor  employed 
as  in  hospital  administration.  This  acts  and  reacts  in  many 
ways,  and  renders  institutional  life  in  this  country  subject 
to  many  sudden  upheavals  and  much  friction.  The  patients 
complain,  the  physicians  complain,  the  employes  complain, 
in  fact  everybody  complains,  and  the  Board  puts  on  a 
worried  air — as  well  it  might — for  there  seems  to  be  a  cer- 
tain amount  of  justice  in  all  the  complaints,  and  whilst 
nobody  appears  to  be  as  much  in  the  wrong  as  asserted  by 
the  opposite  party,  still  there  is  enough  to  perplex  it  very 
thoroughly.  The  superintendent  either  fails  to  control  these 
matters  at  all,  or  else  adds  to  the  difificult3^  Then,  in  order 
that  the  domestic  complaints  may  be  removed,  a  committee 
of  ladies  is  sometimes  appointed ;  they  are  not  experts,  often 
far  from  it,  their  only  claim  to  knowledge  being  that  of  the 
"  born  housekeeper "  which  is  sometimes  supposed 
(erroneously,  I  think)  to  be  inherent  in  every  woman.  The 
organization  and  management  of  institution  households, 
however,  having  little  in  common  with  that  of  a  few  maids 
and  no  sick  people,  the  management  of  details  by  Visiting 
Committees  is  often  proved  to  be  but  an  added  discomfort. 

Having  trusted  one  superintendent  and  found  him  or 
her  wanting,  the  Board  of  Management  is  naturally  chary 
of  trusting  his  or  her  successor.  In  the  first  place  they  don't 
as  a  rule  know  where  to  look  for  a  successor.  Hospital 
superintendents  are  usually  just  men  who  happen  along. 
It  is  not  so  much  a  distinct  calling  at  present  as  a  tentative 
,  occupation,  usually  applied  for  by  a  man  who  is  "  out  of  a 
job."  If  a  large  hospital  with  plenty  of  funds  can  aft'ord  to 
pay  a  good  salary  to  a  medical  man  who  has  talent  for  detail, 
and  prefers  administrative  work  to  the  more  active  practice 


Hospital  Administration  in  America  57 

of  his  profession,  it  seems  to  be  the  best  solution.  He  has  a 
fixed  salary  and  usually  does  no  outside  practice,  and  thus 
the  difficulties  in  the  way  of  his  independence,  which  might 
apply  to  the  outside  practitioner,  have  not  to  be  reckoned 
with.  But  he  also  has  to  learn  how  to  take  care  of  build- 
ings, how  to  purchase  supplies,  obtain  estimates,  and  keep 
the  whole  intricate  machine  in  good  running  order ;  and  this 
costs  the  hospital  money,  for  all  large  department  stores  will 
tell  you  that  a  good  buyer  is  far  more  valuable  than  a  good 
seller,  and  hospital  buying  is  a  fine  art.  He  usually  has  a 
good  steward  whom,  with  the  housekeeper,  he  trusts  to  pur- 
chase the  household  supplies.  He  often  has  a  practical 
builder  to  attend  to  repairs,  and  a  good  office  force.  The 
details  of  the  various  departments,  and  the  knowledge  which 
the  superintendent  has  of  them  of  course  depends  upon  the 
individual. 

As  a  rule,  if  he  shows  himself  faithful  and  just,  no 
important  steps  are  taken  without  his  advice.  He  is  held 
responsible  for  everything  in  regard  to  the  administration 
of  the  institution,  and  for  the  employment  of  proper  persons 
to  carry  on  the  work  of  the  various  departments.  This  is 
as  it  should  be.  Unfortunately,  hospitals  so  administered 
can  be  counted  almost  on  the  fingers  of  one  hand.*  In  one 
large  hospital,  the  Johns  Hopkins,  according  to  the  by-laws, 
the  superintendent  is  a  member  of  the  executive  board,  but 
I  do  not  think  this  is  general. 

Now  the  point  which  will  be  of  special  interest  to  you 
is,  can  a  woman  who  is  a  trained  nurse  do  this  work?  There 
is  no  reason  why  she  should  not.  The  reasons  for  and 
against  lie  within  herself.  In  spite  of  the  immense  strides 
which  women  have  made  of  late  years  in  regard  to  public 
work,  it  is  even  yet,  and  even  in  this  country,  which  Max 
O'Rell  justly  calls  a  paradise  for  women,  undoubtedly  more 
dilficult  for  a  woman  to  carry  out  executive  work  concerning 
large  numbers  of  people  than  it  is  for  a  man,  and  perhaps  it 
always  will  be ;  but  to  say  that  it  is  more  difficult  is  not  by 
any  means  to  say  that  it  is  impossible.     As  there  are  com- 

[*This  statement  is  perhaps  too  sweeping. — Ed.] 


58  International    Congress    of   Nurses 

paratively  few  medical  men  who  desire  such  positions,  or  if 
they  do  desire  them,  possess  the  necessary  quaUfications,  and 
as  the  newspaper  reporter,  the  clergyman,  or  the  factory 
hand  possess  no  knowledge  at  all  of  hospital  work  or 
requirements,  it  would  seem  that  a  woman  who  had  worked 
in  the  wards  of  a  hospital,  who  had  lived  there  day  in  and 
day  out  for  at  least  six  or  more  years,  should  certainly  be 
of  more  use  than  these,  and  have  less  of  the  technical  part 
to  learn.  Florence  Nightingale  says  that  "  in  all  depart- 
ments of  life  there  is  no  apprenticeship  except  in  the  work- 
shop "  and  it  is  certainly  the  most  thorough  and  the  best,  and 
worth  whole  books  of  theory.  It  seems  to  me  that  if  women 
were  more  willing  to  take  up  this  work,  many  of  the  difficul- 
ties, and  much  of  the  friction  of  hospital  life  might  be 
avoided.  If  the  visiting  staff  see  that  the  superintendent  is 
not  only  willing  but  anxious  that  they  should  have  not  only 
the  necessaries,  but  all  the  luxuries  or  additions  which  make 
their  work  easier  that  the  hospital  can  possibly  afford,  and 
knows  exactly  what  these  requirements  are,  they  feel 
naturally  far  more  friendly  toward  the  administration  as  a 
whole.  In  many  ways  hospital  keeping  is  but  housekeeping 
on  a  larger  scale. 

It  does  not  follow,  however,  that  because  a  woman  is  a 
good  nurse,  or  even  a  good  superintendent  of  nurses,  she 
is  a  good  hospital  superintendent.  The  work  is  very  differ- 
ent. The  hospital  superintendent  represents  the  hospital, 
not  only  to  the  patients  and  their  friends,  but  to  the  trades- 
people, building  contractors,  the  city  government  in  the  mat- 
ter of  Boards  of  Health,  and  coroners'  offices,  and,  in  short, 
in  all  the  varying  phases  in  which  this  varied  business 
touches  the  public  weal.  Decisions  affecting  varied  inter- 
ests and  large  numbers  of  people  must  often  be  made 
quickly.  If  it  can  be  shown  that  a  decision  is  narrow- 
minded,  petty,  or  errs  in  any  particular,  because  unsuitable 
or  too  severe,  the  superintendent's  judgment  will  naturally 
not  be  relied  on  in  future.  It  is  absolutely  necessary  that, 
humanly  speaking,  no  mistakes  should  be  made.  More 
specially  does  this  apply  if  the  superintendent  be  a  woman, 


Hospital  Administration  in  America  59 

because  as  there  are  fewer  women  superintendents  of  busy 
hospitals,  any  errors  are  more  closely  watched  for,  any 
failure  is  a  double  failure.  If  the  same  mistake  were  made 
by  a  man,  the  public  or  the  individual  concerned  would 
merely  say  "  they  have  made  a  mistake  in  selecting  their 
superintendent,"  but  if  a  woman,  not  only  the  individual, 
but  her  sex  is  at  fault. 

There  is  one  point  especially  where  there  is  room  for  the 
right  use  of  woman's  influence  in  hospital  work  and  that 
is  the  influence  of  women  for  purity.  Unfortunately,  I  know 
of  more  than  one  hospital,  indeed,  more  than  two  or  three, 
where  this  is  still  needed.  It  is  an  unfortunate  fact  that 
men  in  teaching  institutions,  holding  the  rank  of  professors, 
wall  relate  stories  or  indulge  in  coarse  remarks,  or  even  so 
clothe  their  instruction  to  undergraduate  students,  that  their 
words  necessarily  make  a  modest  or  clean-minded  woman 
exceedingly  uncomfortable.  It  is  also  a  fact  that  this  is 
by  no  means  accidental ;  it  is  often  quite  obviously  done  for 
the  purpose  of  making  the  nurses  appear  confused,  or  rais- 
ing a  laugh  among  the  students.  It  is  no  part  of  a  nurse's 
duty  to  put  up  with  these  things ;  there  is  no  reason  why 
nurses  should  not  be  as  modest  and  delicately  minded  as  any 
other  women,  and  as  far  as  my  own  experience  goes,  I  have 
found  them  so.  But  it  is  not  fair  to  send  a  young  girl  to  a 
clinic,  to  require  her  as  a  matter  of  obedience  to  be  present 
whilst  the  professor  makes  unseemly  jokes,  or  lectures  on  a 
case  in  an  unnecessary  way.  But  whilst  I  feel  sorry  for  the 
nurse,  I  regret  it  even  more  for  the  sake  of  the  students. 
Thev  hear  the  professor,  sometimes  a  man  of  almost  world- 
wide renown,  relating  these  stories  and  making  these 
unseemly  jests.  They  think  it  is  a  manly  and  professional 
thing  to  do.  Where  teachers  offend  in  this  wav,  it  is  obvious 
that  assistants  will  often  follow  suit.  But  even  for  the  sake 
of  holding  the  student's  attention  at  lecture,  is  this  a  right 
thing  to  do?  All  young  men  have  not  good  home  influence 
to  help  them  combat  the  effect  of  this  loose  way  of  talking 
and  thinking.  Many  of  them  are  drafted  straight  from 
college  to  positions  as  resident  physicians  in  hospitals,  where 


60  Inter  national  Congress  of  Nurses 

they  make  many  mistakes  as  a  result  of  this  sort  of  teach- 
ing. That  some  "  come  out  right  in  the  end  "  is  no  argu- 
ment in  favor  of  it.  Some  do  not.  Surely  the  attitude  of  a 
teacher  of  such  a  profession — which  should  always  be  in 
fact  the  "  noble  profession  "  of  medicine — should  be  some- 
what different.  It  is  not  a  pleasant  task,  but  it  is  the  mani- 
fest duty  of  every  superintendent  of  a  hospital,  or  superin- 
tendent of  a  training  school,  to  see  that  the  nurses  at  least 
are  not  subjected  to  this  sort  of  thing.  And  the  young 
men  will  also  benefit,  and  some  day,  even  though  that  day 
may  be  far  ofif,  they  will  thank  you.  Those  of  us  who  bear 
the  burden  of  responsible  positions  have  to  face  many 
unpleasant  duties,  but  we  have  got  to  remember  that,  as 
President  Roosevelt  says,  "  Whoever  possesses  power,  is  by 
the  mere  possession  of  that  power  made  responsible  for  its 
right  employment." 

MEDICAL   SCHOOLS   FROM   THE    PATIENT'S   POINT   OF  VIEW. 

As  a  matter  of  fact  in  a  properly  administered  hospital, 
medical  schools  are  a  protection  to  the  patient  rather  than 
otherwise,  for  it  usually  means  that  the  hospital  is  a  very 
live  one,  and  thoroughly  up  with  the  times.  The  patient  is 
safe-guarded  by  public  sentiment  which  in  this  country  is 
against  overmuch  experimentation.  But  this,  as  I  have 
said,  provided  the  hospital  is  carefully  administered.  That 
is  to  say,  that  although  students  are  taught  to  work  in  the 
wards,  proper  consideration  is  had  for  the  patients.  I  have 
found  that  patients,  even  pay  patients  in  the  wards,  do  not 
resent  the  doctor's  describing  their  case  as  an  interesting 
one ;  they  are  quite  willing  as  a  general  rule  to  be  lectured 
upon  before  a  class  of  students,  and  allow  students  to 
examine  chest  or  heart  and  so  on,  in  moderation.  If  you 
have  a  capable  head  nurse  in  the  ward,  she  will  keep  her  eye 
on  any  case  which  may  be  in  process  of  examination  by  the 
students ;  and  a  kindly  word,  saying  that  she  is  afraid  the 
patient  is  tired  now,  and  had  better  rest,  I  have  never  found 
resented. 

In  properly  arranged  ward  classes  one,  two  or  three 


Hospital  Administration  in  America  61 

students  are  assig-ned  to  certain  beds,  and  the  patient  is  not 
examined  by  forty  or  fifty  young  men  one  after  another,  as 
seems  to  be  the  popular  conception.  If  the  patients  are 
women,  a  nurse  is,  of  course,  always  at  the  bedside  of  the 
patient  whilst  the  students  are  there.  In  teaching  hospitals, 
whether  under-graduate  or  post-graduate,  the  supplies  are 
much  more  liberal  than  in  non-teaching  institutions,  and  I 
think  that  on  the  whole  the  patients  are  generally  better 
nursed,  for  every  one  is  kept  up  to  the  mark,  including  the 
professors.  If  the  patients  object  to  examination,  I  have 
always  found  that  the  students  are  perfectly  willing  to  con- 
sider their  feelings. 

INSPECTION  OF  AND  PUBLIC  INTEREST  IN  HOSPITALS. 

It  would  be  a  distinct  advantage  if  frequent  official 
inspection  of  all  charities  receiving  subscriptions  from  the 
public  were  ordered  by  the  State  or  municipal  government. 
Whilst  it  is  true  that  a  hospital  must  possess  a  charter  of 
incorporation  in  order  to  hold  property  as  a  body,  this  does 
not  prevent  all  sorts  of  abuse.  Every  institution  whether  it 
be  a  hospital,  or  any  other  charity,  to  which  the  general 
public  is  invited  to  subscribe,  should  be  subject  to  this 
inspection  at  least  once  in  three  months,  and  if  the  inspectors 
are  not  satisfied  with  its  condition,  at  least  once  every  month. 
Institutions  supported  by  the  public  are  owned  by  the  public, 
if  the  people  would  only  realize  it,  and  it  is  their  duty  as  well 
as  their  privilege  at  least  to  see  that  these  institutions  do  not 
become  hot-beds  of  disease.  Of  course  when  the  millenium 
comes  no  man  or  woman  will  ever  engage  in  an  undertaking 
for  others  without  really  trusteeing  it.  But  as  matters  are 
at  present,  some  sort  of  supervision  is  certainly  necessary. 
To  prove  my  contention,  if  it  needs  proof,  I  would  again 
refer  to  the  comments  of  the  ex-comptroller  of  New  York  in 
the  book  which  I  have  already  quoted.  In  my  opinion  it 
would  be  for  the  greater  good  of  the  greater  number,  if  an 
act  of  total  prohibition,  or  at  least  high  license,  was  passed, 
regarding  so-called  private  hospitals.     By  this  is  meant  a 


62  International  Congress  of  Nurses 

house  rented  by  a  physician  as  a  personal  venture,  to  which 
he  sends  his  own  patients.  As  a  prominent  physician  said 
to  me  the  other  day,  "  the  private  hospital  is  a  star  chamber ; 
no  one  knows  what  goes  on  there  and  there  is  no  way  of 
finding-  out."  You  will  say  at  once  that  "  the  reputation  of 
the  man  who  owns  it  is  sufficient,"  but  as  a  matter  of  fact, 
this  is  not  so.  In  the  first  place  he  cannot  prevent  another 
man  with  a  lesser  reputation,  or  a  shady  one,  from  doing 
exactly  the  same  thing.  As  a  rule  the  patients  in  private 
hospitals  are  not  by  any  means  so  well  nursed  nor  so  well 
fed,  as  in  the  private  rooms  of  a  general  hospital.  The  rates 
are  often  very  high,  and  the  friends  of  the  patient  often 
make  every  effort  and  stint  themselves  for  years  in  order 
that  the  patient  may  receive  treatment  in  the  private  hospi- 
tal of  some  physician  or  surgeon,  thinking,  no  doubt,  that 
the  article  for  which  they  pay  so  highly  must  be  better  in 
quality.  It  is  true  that  there  is  greater  privacy,  but  it  must 
be  remembered  that  it  is  not  only  in  Trusts  that  publicity 
is  protection.  It  is  often  protection  for  the  patient  as  well. 
It  seems  also  rather  infra-dig.  for  physicians  who  have 
already  made  big  names  for  themselves,  to  run  this  sort 
of  a  boarding  house  for  gain.  They  may  say  that  they  can 
obtain  better  what  they  need  in  their  own  houses ;  but  any- 
one who  knows  the  running  of  a  well-equipped  hospital,  the 
attention  given  and  the  supplies  furnished  members  of  the 
staff,  will  hardly  consider  this  a  valid  reason.  The  only 
cases  to  which  exception  might  be  made  are  nervous  or 
mental  cases  which  sometimes  require  to  be  isolated  from 
their  friends,  and  kept  exceedingly  quiet  for  weeks  at  a  time. 
More  particularly  should  the  practitioner  who  is  not  con- 
nected with  any  hospital,  who  has  certain  classes  of  practice, 
such  as  gynecological  or  obstetrical,  Ije  required  to  show 
very  good  reasons  to  the  city  authorities  before  starting  a 
"  private  hospital,"  or  taking  patients  into  his  own  house. 
And  this  for  his  own  sake  as  well  as  theirs.  In  any  case, 
the  licensing  of  such  houses,  and  an  arrangement  by  which, 
although  having  the  use  of  the  house  as  required,  the  phy- 
sician would  have  no  direct  monetary  interest  except  in  the 


Hospital  Administration  in  America  63 

fees  paid  for  professional  services,  would  be  a  distinct 
advancement. 

In  conclusion,  before  any  more  definite  information  can 
be  g^iven  concerning  the  detailed  arrang^ement  and  expense  of 
hospitals  in  this  country,  it  is  necessary  that  a  uniform  sys- 
tem of  accounts  be  established  which  shall  be  regularly 
audited  by  a  certified  accountant,  and  that  a  certain  definite 
amount  of  information  derived  from  figures  resting  on  a 
definite  basis  be  forthcoming  from  all  institutions  soliciting 
money  from  the  public  and  not  only  those  receiving  State 
aid.  As  I  have  pointed  out,  a  bed-day  which  varies  in 
length  from  four  hours  to  twenty-four,  is  of  no  use.  It  is 
indeed  so  misleading  as  to  lead  to  a  rcductio  ad  ahsiirdnm 
in  some  cases. 

It  seems  as  if  there  should  be  some  check  on  the  unnec- 
essary multiplication  of  charities.  Perhaps  some  of  you  may 
have  heard  or  known  of  the  time  when  the  supply  of  orphans 
in  New  York  gave  out,  to  the  dismay  of  those  who  were 
engaged  in  founding  new  asylums  and  liked  to  see  their 
names  on  the  front  pages  of  reports?  Hospitals  in  these 
big  cities  are  nearly,  if  not  quite,  in  the  same  case.  Some 
day  an  organization  of  these  charities  will  surely  be  required. 
For  instance,  it  hardly  seems  necessary,  where  all  hospitals 
admit  their  patients  without  distinction  of  color  or  creed, 
and  allow  the  pastors  of  the  various  denominations  to  visit 
their  sick  without  let  or  hindrance,  that  each  separate 
denomination  should  multiply  machinery  and  salaries, 
simply  for  the  sake  of  calling  a  hospital  by  a  denominational 
name.  These  hospitals  are  sometimes  well  supported  by 
the  rich  members  of  the  congregation,  but  they  often  suffer 
from  many  of  the  worst  features  I  have  described,  and 
others  which  I  have  not.  It  is  diflftcult  to  advise  the  total 
abolition  of  State  aid  for  charities,  even  semi-private  ones. 
The  public,  particularly  the  working  element  which  mainly 
depends  upon  these  institutions  for  help  in  time  of  sickness, 
has  not  learnt  to  support  them ;  and  many  of  these  institu- 
tions do  a  very  useful  work.  The  knowledge  that  they 
receive  any  aid  from  the  State,  however,  takes  away  from  the 


64  International  Congress  of  Nurses 

general  masses  of  the  people  the  feeling  of  responsibility 
for  their  support.  And  perhaps  this  may  be  the  reason 
that  neither  the  working  man  or  the  large  employer  of 
labor  in  mills,  factories,  etc.,  supports  hospitals  to  the  same 
extent  as  obtains  in  Great  Britain,  where  the  hospital  system 
is  purely  voluntary  (excepting,  of  course,  poor-law 
infirmaries).  The  subscriptions  received  at  street  corners 
and  in  public  buildings,  on  Hospital  Saturday  and  Sunday 
alone,  amounted  in  1898  at  Wolverhampton,  a  comparatively 
small  manufacturing  town  in  England,  to  £36.28  per  1000 
of  the  population  and  in  Liverpool  to  £23.16.*  Contribu- 
tions from  work  people  are  often  entered  separately,  and  in 
the  Bristol  General  Hospital  where  this  is  the  custom, 
amounted  to  £1,727  for  the  year  above  mentioned.  The 
economy  of  organization  is  shown  by  the  Organized  Hebrew 
Charities  of  Philadelphia,  which  in  its  first  year  not  only 
showed  all  its  charities  in  a  flourishing  condition  (many  of 
which  had  previously  languished)  but  a  gain  of  over  $26,000 
in  subscriptions. 

Let  me  say,  finally,  that  the  foregoing  facts  and  sug- 
gested remedies  (where  it  has  been  possible  to  suggest  any) 
do  not  apply  to  country  hospitals,  nor  country  districts,  nor 
country  physicians.  These  no  doubt  have  their  own  trials, 
but  they  are  not  those  of  the  great  cities.  And  for  this  they 
may  be  duly  thankful ! 


The  President :  I  would  like  to  call  upon  Miss  Palmer,, 
the  editor  of  the  American  Journal  of  Nursing,  to  open  this 
discussion.  She  has  been  prominent  in  training  school 
work  and  hospital  work. 

Miss  Palmer :  I  feel  somewhat  embarrassed  to  be  called 
upon  to  speak  extemporaneously  upon  this  subject  of  hospi- 
tal administration  after  listening  to  the  three  papers  so  ably 
prepared.  I  am  going  to  ask  the  privilege  of  speaking  only 
from  my  own  personal  experience  in  the  administration  of 

*Burdett's  Hospitals  and  Charities,  1900.  page  204. 


Hospital  Administration  in  America  65 

hospital  work  in  this  country.  I  think  I  have  been  very 
much  happier  in  my  hospital  experience  than  our  able 
secretary. 

The  positions  which  I  have  been  fortunate  in  occupying 
as  a  hospital  superintendent,  covering-  a  period  of  nearly 
fourteen  years,  include  three  dififerent  hospitals.  My  train- 
ing was  in  a  large  hospital  in  Boston  and  I  do  not  hesitate 
to  say  that  the  administration  of  that  hospital  was  honest, 
the  physicians  were  honest,  and  the  patients  were  well 
taken  care  of. 

My  first  experience  as  a  superintendent  was  in  organiz- 
ing a  little  hospital  of  only  ten  beds  in  a  small  manufacturing 
city  in  the  southwestern  part  of  Massachussets.  I  repeat 
that  same  statement  as  to  the  administration  and  honesty  of 
that  hospital. 

yiy  next  experience  took  me  to  \\'ashington  where  our 
administration  was  very  much  influenced  by  politics.  The 
hospital  there,  and  the  administration  of  its  affairs  was  con- 
ducted by  a  board  composed  of  men  and  women  who  were 
certainly  sincerely  honest  and  uncorrupt  in  their  methods 
of  administration. 

In  the  last  hospital  which  I  have  until  recently  had  the 
honor  to  preside  over,  in  the  neighboring  city  of  Rochester, 
we  had  a  very  complete  system  of  bookkeeping.  It  was  in 
existence  before  I  went  there  and  had  been  carefully  worked 
out  by  some  very  successful  and  able  business  men.  and  I 
could  call  on  my  bookkeeper  for  a  report  for  the  detail  of 
expense  of  any  department  of  that  institution,  and  have  it 
in  five  minutes ;  what  it  was  costing  to  heat  the  building,  to 
light  the  building,  or  any  other  one  item. 

I  would  like  to  say  one  word  in  regard  to  the  point 
which  was  brought  up  in  the  last  paper  with  reference  to  the 
position  of  superintendent  being  held  by  nurses.  I  think 
the  difficulty  most  superintendents  have  to  contend  with  at 
the  present  time  in  our  hospitals,  is  the  difference  in  the 
attitude  of  the  public  towards  men  in  that  position,  and 
women  in  the  same  position.  The  public  is  not  accustomed 
to  give  to  a  woman  the  same  privileges  it  gives  to  a  man. 


66  International  Congress  of  Nurses 

It  expects  a  man  to  have  his  family  with  him  and  to  lead  a 
social  life.  It  looks  upon  him  as  a  citizen.  The  woman  is 
always  expected  to  be  there,  day  and  night. 

She  must  attend  herself  to  every  item  of  domestic  detail 
from  the  highest  to  the  lowest.  She  must  see  every  patient 
in  the  hospital  personally  and  all  of  their  friends.  She  is 
never  off  duty,  and  is  unable  to  take  the  relaxation  which 
men  are  accustomed  to  allow  themselves. 

The  President :  The  papers  are  now  open  to  general 
discussion  and  we  shall  be  very  glad  to  hear  from  anyone 
who  has  anything  to  say  upon  the  subject. 

Aliss  Davis :  I  can  only  endorse  the  secretary  in  her 
paper,  as  I  have  been  in  the  same  locality  and  I  have  met 
with  quite  the  same  difficulties  and  the  same  experiences  as 
those  she  has  met  with.  I  have  also  been  trained  with  the 
last  speaker  in  Boston  in  a  well  trained,  honest,  straight- 
forward Puritan  hospital. 

Mrs.  Kinnev :      I    feel    after    listening    to    both    Miss 

^  CD 

Banfield  and  Miss  Palmer  that,  as  Miss  Banfield  said,  there 
are  two  sides  to  the  question.  Miss  Palmer  has  been  happy. 
Any  one  who  has  had  charge  of  a  hospital  in  Massachussets 
ought  to  be  happy,  but  I  am  sure  that  any  one  who 
has  had  experiences  in  eastern  hospitals  can  hardly  be 
allowed  to  judge  of  hospitals  that  have  no  tradition.  In 
Boston  hospitals  people  enter  and  fall  into  line  and  walk 
along  with  the  procession,  so  to  speak,  without  ever  doing 
anything  out  of  line.  Take  the  hospitals  in  the  far  West; 
everybody  has  opinions  of  their  own  and  they  are  allowed  to 
express  them  and  live  up  to  them.  I  had  the  experience  of 
working  under  a  man  who  dyed  and  curled  feathers  all  his 
life ;  that  was  all  he  had  ever  done ;  after  he  was  made 
superintendent  I  was  asked  to  look  after  the  nurses,  and  I 
do  not  think  Miss  Banfield  has  touched  the  situation.  The 
superintendent  who  followed  him  after  a  certain  length  of 
time  was  a  French  officer  of  the  Franco-Prussian  War;  a 
most  admirable  gentleman  so  far  as  courtesy  was  concerned, 
but  he  had  never  been  in  a  hospital  in  his  life.     One  day 


Hospital  Administration  in  America  67 

I  was  passing-  through  the  corridor  and  he  said  to  me, 
"  Come  here,  come  here,  come  here !"  I  rushed  to  the 
window  and  looked  out  on  a  large  square  and  there  were 
three  of  my  nurses  standing  on  the  g-reen  playing  ball.  He 
said,  "  Is  that  not  scandalous?"  I  said,  "  No."  He  said, 
"  For  young  women  to  make  such  a  spectacle  of  them- 
selves," and  I  said.  "Why  ?"  I  did  not  go  further;  they 
were  recalled  and  forbidden  to  play  ball  on  the  grass. 

I  could  tell  you  things  which  you  would  not  believe. 
Visitors  were  allowed  to  enter  the  building,  no  one  to 
receive  them,  no  one  to  show  them  about  the  place.  They 
simply  entered  and  went  where  they  wished.  They  stayed 
as  long  as  they  wanted  to;  they  came  at  six  o'clock  in  the 
morning  and  stayed  until  ten  o'clock  at  night.  There  were 
as  many  as  they  pleased.  They  came  in  droves  and  went 
when  they  got  ready. 

I  had  two  large  signs  printed  in  gold  and  stood  them  at 
each  side  of  the  door  and  directed  the  nurses  to  tell  visitors 
that  the  hours  for  visiting  were  as  printed  on  that  sign.  The 
visitors  at  once  complained,  and  I  was  summoned  to  the 
office  and  reprimanded.  The  first  morning  I  was  in  power 
I  was  summoned  to  the  room  of  a  patient  whom  I  had  a 
short  time  before  seen  in  the  bed  with  his  clothes,  shoes  and 
hat  on.  I  had  directed  that  he  get  up.  A  short  time  after  I 
was  summoned  to  the  room  by  the  visiting  physician  and 
instructed  that  we  were  not  to  interfere  with  the  patients 
doing  as  they  pleased,  and  that  patient  afterwards  got  into 
bed  with  his  clothes,  shoes  and  hat  on.  I  think  I  have  said 
enough  to  substantiate  Miss  Banfield,  that  there  is  another 
side  to  the  question. 

Dr.  Hughes,  (Boston) :  I  quite  hope  that  our  foreign 
delegates  will  not  go  home  with  the  idea  that  we  are  still  in 
the  stage  of  the  American  Indian.  In  some  of  the  Western 
cities  we  still  find  hospitals  that  are  not  all  that  we  might 
wish.  We  have  in  this  country,  of  course,  more  politics  in 
one  way  than  in  England ;  in  another  way  not  any  more. 
But  all  our  politics  are  not  bad.    I  know  of  a  board  that  is 


68  International  Congress  of  Nurses 

composed  of  two  Democrats  and  two  Republicans  and  the 
fifth  one  is,  as  they  say,  the  one  who  sits  on  the  fence.  The 
medical  officer  is  appointed  by  those  poHticians  and  he  had 
remained  in  that  capacity  for  twenty  years  because  of  his 
ability. 

In  this  country  we  find  many  men  taking  a  hospital 
management  course,  and  although  there  are  a  few  boards 
who  try  to  get  a  larger  number  of  beds  and  alter  the  figures 
so  as  to  get  larger  appropriations  I  think  they  are  in  the 
main  honest  and  sincere. 

Miss  Durkee :  I  have  had  little  experience,  but  would 
like  to  speak  a  word  for  an  honest  management  under  a 
board  of  women  managers.  These  women,  who  were 
responsible  for  the  maintenance  and  efficiency  of  the  train- 
ing school,  worked  in  the  greatest  harmony  with  the  super- 
intendent of  the  hospital,  a  medical  man  appointed  by  a 
board  of  men. 

Personal  views  were  always  put  aside  for  the  good  of 
the  patients  and  the  work  generally.  They  looked  upon 
the  superintendent  of  nurses  as  a  specialist  and  expected  her 
to  supply  the  knowledge  and  experience  which  they  did  not 
possess. 

Miss  Banfield :  In  speaking  of  the  way  that  hospital 
administration  is  carried  on,  I  thought  I  had  to  speak  of 
things  as  I  found  them — not  as  I  thought  they  ought  to  be, 
or  as  it  seemed  desirable  they  should  appear  to  visitors.  I 
really  did  not  think  of  the  visitors  at  all.  I  have  no  doubt 
they  have  troubles  of  their  own.  But  as  I  told  you,  I  found 
no  uniform  system  to  dilate  upon,  statistics  so  rarely 
reliable  that  no  comparisons  could  be  made,  and  so  on. 
Nearly  every  speaker  has  used  the  words  "  honest — sin- 
cere." You  will  observe  that  I  never  once  used  these 
words,  except  where  I  specifically  stated  that  these  inac- 
curacies were  of  course  not  due  to  personal  dishonesty.  I 
added,  however,  that  such  methods  would  inevitably  land 
all  concerned  in  unpleasant  places  if  pursued  in  business  mat- 
ters ;   that   the   administration   of   public   business   and   the 


Hospital  Administration  in  America  69 

spending-  of  public  money  should  be  of  the  same  moment 
to  us  as  the  care  we  bestow  on  our  own  affairs.  This  I 
think  may  be  considered  incontrovertible.  Frankly,  I  am 
g-lad  that  you  disapprove  of  the  facts  I  have  stated.  I  would 
only  remind  you  that  I  did  not  make  these  conditions.  I 
only  related  them.  Denying^  facts  does  not  do  away  with 
them,  or  I  would  deny  them  all  most  cheerfully,  and  at  once. 
But  as  it  is,  I  cannot  take  back  one  word  I  have  said.  I 
could  add  many  more. 

I  should  like,  however,  to  mention  that,  obviously — or 
it  seems  obvious  to  me — I  was  by  no  means  calling  upon  my 
own  personal  experiences,  although  I  do  speak  from  per- 
sonal knowledge  of  every  point  I  have  touched  upon. 
Naturally  if  the  conditions  I  have  spoken  of  prevailed  in  the 
hospital  with  which  I  have  the  honor  to  be  connected,  I 
either  should  not  be  there,  or  I  should  not  say  a  word  about 
it.  I  am  happy  to  say  that  my  personal  relations  with  trus- 
tees, physicians,  and  fellow  workers  of  all  degrees,  have 
been,  and  are,  all  that  the  most  exacting  could  require ;  and 
for  this  I  feel  a  deep  sense  of  personal  gratitude  and  appre- 
ciation. But  it  never  occurred  to  me  that  my  own  personal 
experiences  would  be  of  interest  of  this  Congress,  especially 
as  I  regard  myself  as  unusually  fortunate.  It  was  hospital 
government  in  general  which,  since  we  say  we  prepare 
students  at  Teachers'  College  to  take  part  in  it  as  superin- 
tendents of  hospitals,  it  seemed  not  unreasonable  we  should 
look  into.  I  really  did  not  like  what  I  found  any  better  than 
you  do,  but  that  did  not  seem  to  me  any  reason  for  sup- 
pressing it. 

As  for  politics,  Washington  may  be  "  the  hot  bed  of 
politics  "  in  one  sense,  but  not  in  the  sense  of  the  ward  boss 
and  city  politician — politics  affecting  the  admission  of 
patients,  the  police  force,  and  city  government.  For 
Washington  is  the  one  city  in  the  States  which  has  no 
city  politics,  but  is  governed  by  direct  grant  of  Congress, 
and  independently  of  either  Democratic  or  Republican  party 
changes.  Its  citizens  have  no  vote.  It  is  often  said  to  be  the 
best  governed  city  in  the  States.    The  ordinary  wnre  pulling 


70  International  Congress  of  Nurses 

of  influential  people  I  suppose  exists  everywhere,  and 
Washington  may  perhaps  be  unduly  well  ofif  in  that  respect  ; 
but  ward  or  city  politics  it  is  spared.  Possibly  it  requires 
some  one  who  lives  in  Pennsylvania  to  appreciate  all  that 
it  escapes. 

In  conclusion,  I  may  say  that  the  reason  I  did  not  give 
instances  of  every  point  I  brought  up,  and  cite  page  and 
name  of  hospital  reports,  was  because  I  have  no  wish  to  hold 
up  any  particular  institution  or  medical  or  other  body  of 
men  as  "  bad  examples."  It  is  by  drawing  attention  to  it 
that  I  hope  to  mend  it.  I  have  given  sufificient  data  to  enable 
any  of  you  who  wish  to  look  the  matter  up  for  yourselves. 


The  President :  I  am  very  sorry  that  for  the  lack  of 
time  we  must  close  the  discussion. 

Our  next  paper,  although  on  the  same  subject,  is  on  a 
little  different  line. 


The  Relations  of  Training  Schools  to  Hospital 

Administration. 

MARY  M.  RIDDLE, 

Assistant  Superintendent  of   Nurses  in  the   Boston  City  Hospital,  Member  of 

American  Society  Superintendents  of  Training  Schools,  Delegate 

from  the  Boston  Nurses'  Club. 


As  the  interests  of  any  hospital  and  its  training  school 
are  closely  interwoven,  no  argument  is  needed  to  confirm 
the  statement  that  they  are  mutually  dependent.  That 
which  militates  for  the  advantage  of  one  reacts  for  the  good 
of  the  other  and  vice  versa  that  which  is  to  the  detriment  of 
the  one  is  also  an  evil  to  the  other. 

Since  they  are  so  closely  allied  and  participate  so  nearly 
equally  in  the  results  accruing  from  their  collaboration,  the 
proper  adjustment  of  their  relationship  seems  a  simple  mat- 
ter. But,  many  systems  are  in  vogue  and  it  is  only  by  care- 
ful consideration  of  circumstances  and  the  needs  of  the  time, 
together  with  a  just  estimate  of  the  value  of  each  to  the 
other  that  a  satisfactory  solution  is  possible. 

It  is  a  self-evident  fact  that  in  every  hospital  some  form 
of  government  is  necessary,  and  if  it  be  that  which  provides 
for  the  efficient  management  and  preservation  of  the  com- 
mon interests,  promotes  the  general  welfare,  and  establishes 
a  permanent  happy  state,  it  accomplishes  its  purpose  and  no 
individual  or  class  of  individuals  is  at  liberty  to  interfere 
with  its  administration,  lest  it  be  weakened,  and  the  end  to 
be  attained  frustrated.  Organized  training  schools  for 
nurses  are  of  comparatively  recent  date  and  their  modes  of 
growth  have  been  that  of  evolution  from  the  simpler  and  less 
complex  organizations  of  the  beginning,  on  and  on  to  the 

71 


72  International  Congress  of  Nurses 

present,  when  we  find  their  manag^ers  contemplating-  univer- 
sity education  for  the  pupil  nurse. 

When  these  schools  were  in  the  simplicity  of  the 
beginning  it  was  no  uncommon  thing  to  find  them  managed 
by  boards  in  no  way  connected  with  the  hospital.  This 
was  especially  true  of  those  hospitals  which  employed 
religious  orders  to  care  for  their  sick.  Such  nursing  bodies 
did  efficient  work,  and  paved  the  way  for  their  more  scien- 
tific, though  possibly  less  devoted  followers.  They  were, 
from  the  highest  religious  motives,  most  devoted  to  the 
relief  of  human  suffering,  and  were  responsible  only  to  the 
head  of  their  order,  regarding  the  hospital  as  the  means 
whereby  they  were  allowed  to  fulfill  their  vows  and  to 
exercise  those  functions  and  attributes  which  made  them 
indeed  "  Sisters  of  Charity." 

Other  schools  there  are,  governed  by  superintendents 
who  have  no  voice  in  the  executive  affairs  of  the  hospital, 
but  whose  interest  is  concentrated  in  furnishing  to  the  school 
clinical  advantages  for  study  and  observation.  This  relation- 
ship of  school  and  hospital  may  have  items  in  its  favor,  but 
there  are  evident  disadvantages,  prominent  among  which  is 
the  effect  upon  the  nurses  themselves.  It  is  possible  and 
altogether  probable  that  by  a  training  thus  given,  nurses 
may  be  produced  who  fail  to  consider  that  the  welfare  and 
comfort  of  the  patient  is  of  primary  importance.  His  wel- 
fare may  receive  due  consideration,  but  his  comfort  and 
happiness  are  of  secondary  value.  He  is  the  means  to  the 
end  that  they  be  educated  and  they  unconsciously  drift  into 
the  belief  that  all  patients  were  created  for  their  benefit, 
whereas  the  reverse  is  the  fact,  viz.,  that  nurses  are  created 
for  patients. 

Again  the  training  school  may  be  governed  by  a  super- 
intendent who  with  the  school  is  employed  by  the  hospital 
to  do  the  nursing  therein.  Hospitals  and  training  schools 
thus  associated  have  been  known  to  flourish  and  go  on  to 
success,  and  to  send  out  graduates  who  take  and  maintain 
positions  in  the  front  ranks  of  the  profession.  Furthermore, 
this  association  of  school  and  hospital  has  been  one  method 


Training  Schools  and  Hospital  73 

of  solving  the  problem  of  political  control  or  rather  of  keep- 
ing the  school  free  from  political  influence  when  the  hospital 
is  under  its  domination.  It  has  also  been  a  method  of 
securing  greater  freedom  for  the  school,  in  that  it  allows 
the  accomplishment  for  the  hospital  of  what  is  reasonable 
rather  than  the  exaction  of  what  is  desirable,  with  the  result 
that  the  possibilities  for  the  preservation  of  the  health  and 
strength  of  the  nursing  body  are  greatly  increased. 

Another  form  of  relationship  between  training  school 
and  hospital  is  exemplified  when  both  are  under  one  admin- 
istration. Then  do  we  have  a  form  of  government  which 
may  more  nearly  meet  the  necessity  for  any  government, 
viz.,  to  promote  the  general  welfare,  but  there  are  some 
apparent  disadvantages  to  the  school  arising  from  this  form 
of  relationship ;  first,  the  ability  of  the  board  of  trustees  to 
at  any  time  abolish  the  training  school  and  conclude  to  have 
the  nursing-  service  performed  in  some  other  way ;  second, 
it  seldom  calls  for  a  "  Ladies'  Board,"  unless  it  may  be  that 
such  a  body  constitutes  part  of  an  advisory  board. 

That  training  school  which  has  no  Ladies'  Board  doubt- 
less loses  many  of  the  influences  which  tend  to  stimulate  it 
in  the  search  for  high  ideals  and  correct  motives.  Personal 
contact  with  women  of  a  wider  and  more  varied  life  cannot 
fail  to  make  strong  impressions  upon  nurses,  and  when  the 
spoken  words  convey  the  knowledge  of  experience  they 
carry  with  them  a  conviction  that  supplements  the  teaching 
of  the  school. 

The  superintendent  of  the  hospital  is  the  nominal  head 
of  the  training  school,  under  authority  of  a  board  of  trustees. 
He,  in  turn,  delegates  his  authority  to  a  superintendent  of 
nurses,  superintendent  of  training  school,  principal  of  train- 
ing school,  or  a  directress  of  nurses ;  one  title  implies  the 
same  meaning,  suggests  the  same  routine  of  duty  and  the 
same  burden  of  responsibility  as  another,  and  is  at  the  same 
time  representative  of  some  distinctive  idea  when  given. 
Great  power  is  gained  by  this  combination  of  offices. 

The  superintendent  of  the  hospital,  whether  he  belongs 
to  the  medical  fraternity  or  to  the  laity,  wields  a  farther 


74  International  Congress  of  Nurses 

extended  influence  than  the  average  superintendent  of 
nurses,  for  by  reason  of  his  professional  and  business  rela- 
tions he  comes  in  more  immediate  contact  with  men  of 
afifairs  and  is  constantly  informed  of  the  public  pulse. 

In  matters  of  discipline  he  is  the  court  of  appeals  and 
from  his  position  as  head  of  the  training  school  on  the  out- 
side of  the  actual  work  he  should  be  able  to  form  unbiased 
opinions  and  render  judgment  without  prejudice. 

If  he  is  the  power  to  whom  appeal  may  be  made  for 
direction  and  discipline,  the  training  school  committee  of 
the  board  of  trustees  is  the  final  tribunal  or  supreme  court. 

He  is  an  adviser  not  only  in  matters  of  discipline,  but  is 
to  be  consulted  on  those  that  are  educational  or  that  other- 
wise pertain  to  the  progress  of  the  nursing  work.  The 
superintendent  of  nurses,  from  her  more  intimate  knowledge 
of  the  requirements  of  the  training  school,  gained  by  her 
experience  while  in  training,  and  her  contact  while  superin- 
tending, should  formulate  and  carry  into  execution  plans  for 
the  advancement  and  betterment  of  the  nursing  service 
within  the  hospital,  as  well  as  the  elevation  and  maintenance 
of  standards  among  pupils  who  must  soon  represent  the 
training  school  in  the  great  world  outside,  where  they  will 
be  judged  by  the  efficiency  and  spirit  which  characterize 
their  work.  In  all  this  the  superintendent  will  advise  and 
consult  and  he  will  doubtless  eventually  place  his  seal  upon 
the  results ;  but  if  he  is  wise  and  unselfish  he  will  permit  the 
superintendent  of  nurses  to  proceed  within  limitations  that 
are  not  narrowed  and  restricted  by  his  conceptions  of 
expediency,  but  by  those  which,  after  full  and  free  consulta- 
tion, they  together  conclude  will  most  surely  promote  the 
general  welfare. 

Another  element  of  power  in  this  combination  of  offices, 
subject  to  one  authority,  is  found  when  the  relationship 
between  the  training  school  and  other  departments  is 
scrutinized.  It  is  impossible  for  a  matron  or  housekeeper 
who  is  an  untrained  nurse  to  duly  appreciate  the  necessities 
of  the  hospital  from  the  standpoint  of  the  nursing  service, 
and  therefore  the  progress  of  the  work  is  frequently  impeded 


Training  Schools  mid  Hospital  75 

by  friction  which  is  the  outg^rowth  of  ignorance.  But  when 
all  departments  are  subject  to  the  one  control,  there  can  be 
no  division  of  interests,  and  consequently  no  friction  to  over- 
come. 

The  benefits  resulting  to  the  hospital  and  its  administra- 
tion in  every  department  by  this  unity  of  government  may 
be  augmented  by  placing  at  heads  of  all  departments  of  the 
domestic  service,  women  trained  and  educated  in  the  art  of 
nursing.  Success  to  the  whole  is  thus  lured  by  every  induce- 
ment of  sympathy  and  interest. 

Here,  too,  is  an  opportunity  for  the  development  of 
those  ethical  traits  in  a  nurse  which  count  for  much  in  mak- 
ing up  the  estimate  of  the  individual  as  well  as  the 
professional  body.  Here  loyalty  may  grow,  flourish  and 
bring  forth  fruit  which  shall  rebound  to  the  well-being  of  the 
training  school,  the  hospital,  and  ultimately  the  whole  pro- 
fession. 

The  matter  of  placing  trained  nurses  at  the  heads  of 
departments  has  seldom  been  carried  to  complete  success. 
Alany  existing  theories  have  thrown  their  w-eight  in  the 
scales  to  overbalance  the  success  of  the  scheme  when  tried. 
There  is  a  sentiment  noticeably  prominent  among  nurses 
that  by  taking  any  other  line  of  w^ork  than  the  actual  bed- 
side care  of  patients,  or  instruction  in  the  art,  they  forfeit 
their  place,  their  self-esteem  and  the  esteem  of  their  neigh- 
bors. 

Is  the  rejection  of  these  branches  of  work  by  our  best 
nurses  the  result  of  their  training,  or  a  deficiency  in  their 
training,  or  a  fault  of  their  earlier  education,  or  is  it  due  to 
the  influence  which  heads  of  hospitals  and  heads  of  training 
schools  have  permitted  to  surround  these  forms  of  hospital 
work ;  or,  is  it  due  to  the  fact  that  other  than  nursing  forms 
of  work  in  the  hospital  have  been  consigned  to  the  list  of 
menial  occupations?  But,  do  they  really  belong  there? 
Do  they  not  rather  represent  the  business  element  in  the 
hospital  world,  and  is  it  not  now  the  common  belief  that 
the  higher  education  best  fits  one  for  business  and  the  con- 
duct of  vast  affairs,  and  if  true,  then  does  not  the  higher 


76  International  Congress  of  Nurses 

education  in  the  hospital  best  fit  for  places  therein?  More- 
over, is  not  the  successful  management  of  vast  business 
enterprises  receiving  the  homage  of  the  world  today,  and 
are  not  these  special  lines  receiving  the  attention  of 
instructors  in  the  course  of  nurses  at  Teachers'  College? 

Then  let  not  the  training  school  despise  the  offices  of 
any  other  department,  but  rather  broaden  out  to  include 
preparation  for  them  in  its  curriculum.  Instruction  in  the 
duties  of  matron,  housekeeper  or  purveyor  might  well  form 
one  branch  of  training  for  the  third  year,  with  the  result 
that  the  trained  nurse  would  be  better  able  to  meet  the 
responsibilities  of  the  combination  of  all  ofBces  when  called 
upon  to  do  so  in  assuming  the  management  of  a  small  hospi- 
tal. Then  would  she  not  be  completely  overcome  by  the 
problems  which  demand,  for  correct  solution,  a  knowledge 
of  the  various  subsistence  supplies,  their  value  to  the  hospi- 
tal, their  cost,  their  necessity,  the  amount  required,  and  the 
manner  of  preserving  them  and  preparing  them  for  use. 
She  would  also  have  a  knowledge,  gained  by  instruction, 
observation  and  experience,  which  would  enable  her  to 
demand  the  proper  amount  of  domestic  service  within  a 
given  time  and  for  a  given  recompense. 

Whether  the  relations  between  the  hospital  and  train- 
ing school  are  those  that  naturally  arise  when  under  one 
administration  or  whether  they  are  those  due  to  the  con- 
tract which  binds  them  together,  there  are  certain  duties  and 
responsibilities  of  the  hospital  to  the  training  school  and 
vice  versa  of  the  training  school  to  the  hospital.  When  the 
relationship  is  by  contract  its  terms  doubtless  define  these 
duties  and  responsibilities  and  each  member  of  the  compact 
sees  to  it  that  the  other  renders  that  which  was  agreed  upon, 
— there  responsibilities  cease. 

But  when  hospital  and  training  sciiool  are  under  one 
administration  there  can  be  no  such  limit  of  responsibility. 

When  a  hospital  issues  to  the  world  its  prospectus 
setting  forth  the  advantages  of  its  particular  school,  and  a 
young  woman  is  induced  thereby  to  undertake  its  course  of 
training,  to  the  end  that  she  may  become  useful  and  self- 


Training  Schools  a>id  Hospital  77 

siipportinq-,  the  hospital  assumes  toward  that  young  woman 
certain  moral  responsibilities  as  well  as  those  enumerated 
in  its  agreement  with  her.  She  has  doubtless  come  from  a 
sphere  in  life  where  knowledge  of  hospitals  and  training 
schools  is  very  limited ;  she  knows  nothing  of  the  many 
phases  of  the  work  which  may  be  to  her  advantage  or  other- 
wise, therefore  she  must  be  protected,  and  this  is  one  duty 
of  the  hospital  to  the  individual  nurse, — her  interests  must 
be  preserved  and  this  cannot  be  done  if  obstacles  are  placed 
in  her  pathway  toward  success.  She  looks  forward  to  the 
time  when  she  shall  be  suf^ciently  equipped  to  take  her 
place  in  the  world  and  earn  a  competence.  The  time  arrives, 
but  she  finds  she  is  superseded,  possibly  by  undergraduates 
from  her  own  school,  who  because  they  are  undergraduates 
and  are  supported  by  the  school,  underbid  her  services  to 
such  an  extent  that  she  must  withdraw  from  the  field,  won- 
dering how  her  hospital  could  have  held  out  such  induce- 
ments to  her  when  they  evidently  do  not  exist. 

This  is  the  prevailing  condition  in  those  communities 
where  are  located  the  hospitals  having  training  schools  that 
send  their  nurses  out  to  private  duty.  In  these  days  of  pro- 
gress we  frequently  hear  the  argument  advanced  that  it  is 
only  a  part  of  the  new  plan  for  university  education  of 
nurses,  and  so  it  may  be  in  those  schools  where  the  nursing 
service  is  rendered  at  the  same  rate  as  to  the  poor  in  our 
hospitals.  Let  the  poor  and  others  be  given  the  nursing 
care  required  and  let  no  remuneration  be  exacted,  then  will 
become  perfectly  visible  the  plan  for  university  education  of 
the  nurses.  And  lest  these  patients  become  pauperized,  let 
them  be  given  to  understand  that  the  obligation  is  wholly 
on  the  part  of  the  hospital.  Possibly  a  circular  to  that  efifect 
might  be  substituted  for  or  accompany  that  which  is  now 
sent  inquiring  as  to  the  merits  of  the  nurse. 

The  idea  of  obligation  may  not  suggest  a  happy  state 
and  it  may  be  wise  to  charge  a  nominal  fee,  but  if  it  were  no 
more  than  the  actual  cost  to  the  hospital  of  the  nurse  while 
engaged  with  the  patient,  surely  all  moral  and  ethical 
requirements  would  be  met  and  the  value  to  that  training 


78  International  Congress  of  Nurses 

school  of  university  education  for  its  nurses  could  be  deter- 
mined by  the  amount  of  service  thus  given  for  which  there 
was  no  visible  increase  in  its  treasury. 

Other  responsibilities  of  the  hospital  to  its  school  under 
the  same  administration  may  be  enumerated, — as,  provision 
of  home  and  sustenance,  fulfillment  of  contracts,  provision 
of  necessary  educational  advantages,  etc.  In  return  the 
training  school  as  a  whole  and  nurses  as  individuals  will 
give  unstintedly  of  those  qualities  which  furnish  the  best 
service,  as,  loyalty,  unselfishness  and  devotion  to  principle. 
They  will  abide  by  their  contracts  and  will  guard  against  the 
purely  scientific  work,  forgetting  not  sympathy  and 
womanly  nursing  virtues  and  attributes  which  sometimes 
seem  almost  out  of  fashion  and  can  only  be  seen  in  the  dim 
distance  of  the  past,  but  will  be  ever  present  with  the 
nurse  who  heeds  the  admonition  of  one  well  fitted  to  furnish 
it,  that  "  the  ideal  nurse  must  maintain  a  strength  of 
character  upon  which  a  sick  world  may  lean." 

Notwithstanding  much  has  been  said  to  the  contrary, 
there  is  a  growing  sentiment  of  appreciation  for  training 
schools  and  their  work,  among  hospital  governors  and 
administrators.  The  school  is  no  longer  thought  an  expen- 
sive luxury  of  the  hospital  or  even  a  pecuniary  benefit,  but 
it  is  placed  where  it  belongs,  among  the  educational  institu- 
tions of  the  world.  Material  evidence  of  this  change  of 
opinion  of  the  hospital  for  its  school  is  found  in  the  pro- 
visions made  for  their  comfort,  for  their  culture  and  for 
refining  influences  which  surround  them  in  the  beautiful 
home  that  almost  every  hospital  is  ambitious  to  furnish  its 
nurses. 

An  editor  of  a  prominent  medical  journal  who  is  closely 
observant  of  the  trend  of  events  says,  "  It  is  becoming  more 
and  more  obvious  that  the  efficiency  of  a  hospital  of  any  sort 
depends  in  a  great  measure  upon  the  services  of  the  nursing 
staff.  It  would,  we  sometimes  think,  be  possible  to  get  on, 
for  a  time,  at  least,  without  physicians,  but  to  be  deprived 
of  nurses  would  mean  the  abolition  of  the  modern  hospital. 
The  external  recognition  of  this  fact  lies  in  the  ample  pro- 


Training  Schools  and  Hospital  79 

vision  now  everywhere  being  made  for  the  comfort  and 
health  of  the  nursing-  staffs  when  off  duty." 

Time  and  experience  are  the  surest  tests  by  which  the 
real  value  of  any  form  of  relationship  between  school  and 
hospital  may  be  estimated ;  but  all  departments  cannot  fail  to 
find  in  the  united  means  and  efforts,  greater  strength,  greater 
resource  and  eventually  greater  results, — unity  of  purpose  is 
the  main  prop  of  success. 


Women  on  Hospital  Boards. 

ISABEL  HAMPTON  ROBB, 

Late  Superintendent  of  Nursing   Johns  Hopkins   and    Illinois  Training  Schools, 
Member  Board  of  Women  Managers  Lakeside  Hospital,  Cleveland  ;  Mem- 
ber   of   American   Society   Superintendents  of   Training  Schools, 
Lecturer  on  Hospital  Economics,  Teachers'   College. 


So  much  has  already  been  said  about  the  advantages 
and  disadvantages  of  putting  the  administration  of  hospitals 
in  the  hands  of  boards  composed  of  women  as  well  as  men, 
that  at  first  sight  any  additional  remarks  would  hardly  seem 
to  be  required.  Nevertheless,  the  whole  subject  is  one  about 
which  nurses,  whether  they  be  superintendents  or  others 
occupied  inside  or  outside  of  hospitals,  should  take  pains 
carefully  to  inform  themselves,  for  opportunities  come  to 
many  of  us  when  the  right  kind  of  knowledge  would  be  of 
much  value  in  helping  either  the  individual  or  the  public 
to  reach  correct  conclusions  concerning  this  and  other  ques- 
tions in  which  similar  principles  are  involved.  For  these 
reasons,  this  brief  paper  that  I  have  had  the  honor  to  pre- 
pare for  the  Congress,  is  devoted  to  the  consideration  of  our 
attitude  of  mind  as  a  profession  towards  the  appointment  of 
women  on  hospital  boards,  and  an  endeavor  has  been  made 
to  place  a  true  value  upon  woman's  services  in  such  work,  to 
consider  some  of  the  ways  in  which  a  proper  selection  may 
be  made,  and  some  of  the  methods  of  organizing  her  work 
by  which  the  most  effective  service  may  be  rendered  while 
harmony  is  preserved.  In  taking  an  honest  vote  of  our 
position  towards  the  subject,  judging  from  opinions  freely 
expressed  in  private  and  from,  our  negative  attitude  in 
reference  to  it  in  public,  it  is  safe  to  say  that  in  all  probability^ 
80     . 


Women  on  Hospital  Boards  81 

superintendents  would  be  almost  unanimously  in  favor  of 
workint^  in  hospitals  where  women  are  not  represented  on 
the  managinq-  boards.  This  feeling  is  partly  due  simply  to 
the  traditional  belief  in  woman's  incompatibility  to  work 
with  women — and  we  know  how  slowly  all  fixed  traditions 
die — and  partly  to  the  fact  that  in  some  instances  this  incom- 
patibility has  been  a  matter  of  personal  experience,  which 
has  been  swiftly  carried  from  one  to  another,  and  has  not 
failed  to  leave  a  prejudice  in  the  minds  of  every  hearer.  For 
less  reason  the  feeling  is  usually  shared  in  by  the  stafif  of 
hospital  nurses,  being  founded  not  so  much  upon  any  special 
comments  they  may  have  heard  passed  upon  lady  managers, 
or  upon  any  particular  reasoning  on  their  own  part,  but 
being  the  natural  outcome  of  a  certain  unsympathetic  tone 
respecting  the  matter  that  pervades  the  hospital,  fostered,  it 
may  be,  by  the  unspoken  but  negative  attitude  on  the  part 
of  the  superintendent,  and  occasionally  by  the  thoughtless 
remarks  of  inexperienced,  unthinking  members  of  the  hospi- 
tal staff,  who  regard  with  suspicion  the  possibility  of  outside 
interference  in  their  own  particular  province.  This  con- 
ception might  be  expressed  in  words  somewhat  as  follows : 
"  Visiting  ladies  are  apt  to  be  interfering,  opinionated  in 
affairs  they  cannot  know  very  much  about,  busy-bodies  and 
stirrers  up  of  trouble.  They  are  therefore  to  be  regarded 
with  suspicion  and  treated  with  scant  or  only  forced 
courtesy."  That  some  such  feeling  pervaded  hospitals 
twenty  years  ago  I  can  testify,  and  it  seems  but  yesterday 
that  I  recall  with  what  transparent  toleration  the  ladies' 
visits  were  received  in  the  wards  by  the  nurses.  In  my  own 
particular  case  nothing  but  good  to  myself  came  from  the 
only  occasion  on  which,  as  a  pupil,  I  encountered  one  of 
the  lady  members  of  the  board.  She  came  behind  the  screen 
where  I  was  busy  in  caring  for  a  patient,  and  after  taking  in 
some  of  the  details,  abruptly  put  the  question,  "  Can  you 
comb  a  patient's  hair  so  that  it  doesn't  pull  and  hurt  the 
patient  all  the  time  ?  There  is  not  one  nurse  in  a  hundred 
Avho  knows  how  to  comb  a  patient's  hair  properly."  She 
passed  on,  leaving  with  me  the  determination  to  excel  in  at 


82  International  Congress  of  Nurses 

least  that  one  point  in  nursing  so  that  after  that  time  I  never 
arranged  a  patient's  hair  without  givine  special  thought  to 
her  comfort.  As  regards  superintendents,  the  true  source  of 
their  objection  lies  in  the  dread  that  their  own  ideas  and 
ways  may  be  interfered  with  or  hampered,  or  that  they  may 
be  disturbed  by  constant  and  untimely  visits  and  by  unneces- 
sary solicitations  for  patients  from  individual  members,  or 
by  the  board  as  a  whole.  To  always  do  our  work  in  our 
own  way  may  be  very  pleasant,  but  where  this  work  has  to 
do  so  vitally  with  so  many  people,  both  well  and  ill,  and 
where  it  is  a  public  trust,  the  surest  sign  that  we  are  broaden- 
ing out  with  growth  in  years  and  experience  is  evidenced 
by  an  ever  increasing  readiness  to  give  up  prejudices  and  to 
welcome  any  arrangement  that  will  help  the  work  on.  To 
do  the  subject  justice,  we  must  in  the  first  place  take  an 
absolutely  impartial  and  impersonal  view  of  it.  To  eliminate 
the  personal  equation  is  very  difihcult,  but  this  must  be  done, 
and  only  the  thought  of  the  benefit  that  such  boards  are 
likely  to  be  to  the  hospital  should  be  allowed  to  influence  us. 
In  nursing  as  in  any  other  work  the  more  self  is  kept  in  the 
background,  and  the  more  the  work  and  its  best  interests  are 
made  the  first  thought  and  consideration,  the  happier  the 
worker,  and  the  greater  the  success  obtained,  for  the 
reason  that  over-sensitiveness  and  friction  will  seldom  inter- 
fere. Were  I  to  allow  the  personal  sentiment  to  predominate 
I  should  take  the  side  against  the  election  of  women  to 
serve  on  hospital  boards,  as  I  did  at  a  time  in  my  hospital 
career  when  I  certainly  was  not  a  fit  judge  on  so  important 
a  matter,  since  I  had  not  yet  made  a  trial  of  both  ways  of 
working.  Increasing  experience,  however,  coupled  with  an 
unswerving  determination  to  make  the  best  interests  of  the 
hospital  my  first  consideration,  have  led  me  to  alter  my 
former  opinion,  and  I  can  hardly  express  myself  too  strongly 
in  favor  of  their  appointment.  This  decision  is  the  result 
of  personal  experience  obtained  from  various  sources.  For 
some  years  I  worked  in  two  of  the  largest  hospitals  in  the 
country,  where  the  administration  of  the  hospital  and  train- 
ing school  in  each  case  was  quite  distinct,  the  former  being 


Women  on  Hospital  Boards  83 

entirely  in  the  hands  of  men,  and  the  latter  in  those  of 
women.  In  a  third  hospital,  the  trustees  of  which  are  all 
men,  the  women  formed  an  auxiliary  board,  and  although 
giving  lavishly  of  their  time  and  means  to  procure  materials 
and  necessaries  generally  for  the  hospital,  were  not  accorded 
even  the  right  to  demand  an  account  of  the  disposition  of 
the  abundant  supplies  provided  by  them.  In  another  large 
hospital,  in  which  I  was  superintendent  of  nurses,  every- 
thing in  and  about  the  place  was  administered  and  controlled 
entirely  by  a  board  of  men  trustees.  Finally,  it  has  been 
my  privilege  to  act  as  a  member  of  a  board  of  women 
managers  in  a  hospital  administered  by  both  men  and 
women,  the  former  serving  in  the  capacity  of  trustees,  and 
the  women  as  a  board  of  managers.  In  addition  to  this 
personal  experience  after  watching  with  keen  interest  the 
administration  in  all  sorts  and  conditions  of  hospitals,  both 
in  this  country  and  abroad,  it  has  become  my  firm  convic- 
tion that  women  are  needed  in  the  administration  of  all  such 
institutions,  not  just  because  they  are  women,  or  for  any 
"  Women's  Rights  "  reasons,  but  because  unbiased  observa- 
tion has  demonstrated  their  usefulness,  and  the  influence  and 
part  they  have  taken  in  establishing  and  improving  hospi- 
tals all  over  the  world  have  become  matters  of  history. 

Msitors  to  a  modern  well  equipped  hospital  often 
express  surprise  when  they  are  told  that  there  are  still  many 
people  who  prefer  to  struggle  through  a  sickness  in  the 
squalor  of  a  tenement  house  rather  than  enter  the  wards 
where  every  attention  can  be  paid  to  them  by  trained  nurses 
and  skilful  physicians.  Nor  do  all  refuse  to  accept  these 
advantages  from  mere  blind  prejudice,  for  there  is  another 
and  a  still  stronger  reason.  Despite  all  the  care  that  is 
given  the  patients,  there  is  often  something  lacking  in  some 
of  our  most  noted  hospitals  which  the  meanest  hovel  still 
ofifers — an  atmosphere  of  home.  "  Men  may  work  from 
sun  to  sun  but  woman's  work  is  never  done."  The  former 
are  occupied  in  the  so-called  larger  fields  of  the  world,  but 
the  woman's  main  occupation  is  in  the  home,  where  she 
has  to  deal  with  men,  women  and  children,  at  their  best  and 


84  International  Congress  of  Nurses 

worst,  and  must  be  ready  to  manao^e  intelligently  a  thousand 
and  one  details,  if  she  is  to  succeed  in  making  a  happy  home 
for  herself  and  those  around  her.  As  the  bread-winner  the 
man  must  to  a  large  extent  devote  himself  to  external  mat- 
ters, and  in  the  matter  of  home  details  he  becomes 
accustomed  to  depend  upon  the  women  for  carrying  out 
successfully  the  very  many  duties  with  which  he  is  neces- 
sarily unfamiliar.  It  is  clear  that  the  same  holds  good  in 
hospital  management.  In  order  to  insure  the  greatest  suc- 
cess attainable,  the  best  work  of  men  and  women  is  essential, 
the  former  attending  to  the  financial  part,  and  to  such 
afifairs  as  come  more  strictly  within  a  man's  experience, 
the  women  looking  after  the  details  and  the  housekeeping 
part  and  those  afifairs  belonging  to  home-life  with  which 
they  are  more  conversant.  But  if  we  cannot  have  both  then 
I  should  without  hesitation  be  in  favor  of  retaining  the 
women  and  letting  the  men  go,  for  women  have  proven 
themselves  to  be  no  mean  financiers  or  planners,  where  the 
whole  responsibility  has  rested  upon  them,  and  from  the 
standpoint  of  careful  administration  and  economy  they  are 
undoubtedly  far  ahead  of  men  trustees.  One  prominent 
example  of  which  I  can  speak  with  knowledge  is  that  of  the 
Illinois  Training  School  for  Nurses,  Chicago,  organized  by 
a  few  women  for  the  purpose  of  bringing  relief  to  the  city's 
sick  poor  by  introducing  women  nurses  into  the  wards  of 
the  city  and  county  hospital.  This  organization  has  made 
for  itself  a  name  as  being  the  largest  school  in  the  country ; 
it  provides  for  the  nursing  in  two  of  the  largest  hospitals, 
and  has  steadily  increased  its  plant  as  the  need  arose.  More- 
over, it  has  not  only  kept  itself  free  from  indebtedness  and  is 
practically  self-supporting,  but  for  years  has  been  able  to 
make  to  the  public  an  annual  contribution  of  the  income 
derived  from  a  gift  of  $50,000,  which  has  been  set  apart  as  a 
special  fund  and  is  utilized  in  supplementing  the  remunera- 
tion of  competent  trained  nurses,  who  by  this  means  are 
enabled  to  take  care  of  the  patients  of  moderate  income  at 
reduced  charges. 


Women  on  Hospital  Boards  85 

The  pnpil  nurses  are  well  cared  for  and  the  school 
affords  an  object  lesson,  teachin.e^  the  people  the  duty  of 
providing  healthful  surroundings  for  those  who  care  for  the 
sick,  and  who  are  sent  out  to  teach  by  individual  example 
all  the  possibilities  of  prophylactic  hygienic  measures.  All 
this  has  been  accomplished  by  a  board  of  twenty-four 
women,  and  I  think  we  may  be  well  proud  of  the  fact  that 
the  duties  of  superintendent  have  for  years  been  efificiently 
carried  out  by  Miss  Mclsaac,  our  honorable  president. 

But  it  may  be  asked :  Do  not  the  hospital  nurses  as 
women  represent  the  home  element  in  these  institutions? 
They  undoubtedly  do,  but  it  must  be  remembered  that  their 
supervision  is  restricted  chiefly  to  the  wards,  and  the  super- 
intendent is  usually  the  only  nurse  who  has  access  to  all 
parts  of  the  hospital.  If  she  combines  the  position  of  matron 
with  that  of  superintendent  of  nurses,  she  has  undoubtedly 
greater  opportunities,  but  the  matron  is  clever  indeed  who 
in  herself  possesses  all  the  experience  and  wisdom  needed 
to  cope  with  all  the  details  of  the  various  departments  as 
thoroughly,  carefully,  economically  and  perfectly  as  they 
should  be  managed.  Besides  why  tax  and  over-work  one 
woman  when  by  a  little  management  and  system  she  ma> 
be  assisted  or  relieved  of  an  unnecessary  amount  of  detail  by 
the  willing  co-operation  of  a  number  of  other  women?  I 
have  heard  it  stated  by  superintendents  on  various  occasions 
that  these  ladies  make  more  work  and  trouble  than  they 
save.  But  when  this  is  the  case,  is  it  not  possible  that  the 
fault  lies  more  with  the  superintendent  than  with  the  board 
of  managers?  Naturally  the  latter  cannot  expect  to  know 
all  the  ins  and  outs  of  hospital  life,  but  with  proper  organiza- 
tion and  especially  with  co-operation  on  the  part  of  the 
superintendent  of  nurses  they  grasp  the  situation  in  a  sur- 
prisingly short  time,  and  hardly  ever  fail  to  contribute  many 
good  and  practical  suggestions  concerned  not  only  with  their 
own  particular  duties  but  with  the  good  of  the  whole  institu- 
tion. 

But  lor  me  accomplishment  of  the  greatest  possible 
good  there  are  three  requisites  :  (1)  a  properly  selected  board 


86  International  Congress  of  Nurses 

of  managers ;  (2)  proper  organization  and  strictly  defined 
duties ;  and  (3)  hearty  co-operation  on  the  part  of  the  super- 
intendent of  nurses.  Of  these  three  the  last  is  the  most 
essential,  since  a  house  divided  against  itself  must  inevitably 
fall,  whereas  a  united  body  of  workers,  even  though  they 
may  be  of  no  extraordinary  individual  ability,  can  accomplish 
much.  The  same  mind  should  dwell  in  all  who  have  any- 
thing to  do  with  the  hospital,  and  its  best  interest  and  great- 
est good  should  always  be  paramount  to  private  likes  and 
dislikes.  The  desire  to  have  the  opinions  of  single 
individuals  prevail  should  always  be  repressed,  and  each 
should  determine  to  take  a  broad  point  of  view,  and  accept 
cheerfully  and  carry  out  faithfully  any  well  considered 
decision  of  the  majority. 

In  the  formation  of  a  board  of  women  managers  many 
things  have  to  be  taken  into  consideration,  and  it  is  quite 
possible  that  the  superintendent  of  nurses  may  not  always 
be  able  to  appreciate  the  various  interests  to  be  consulted, 
so  that  in  some  instances  it  may  puzzle  her  to  know  why 
certain  women  are  chosen  as  members  of  such  a  board.  The 
reason  governing  the  selection  may  vary  according  to  the 
sources  from  which  the  institution  is  supported.  Some 
hospitals,  as  we  know,  are  carried  on  by  religious  denomina- 
tions; others  are  richly  endowed  by  private  bequests;  in  the 
case  of  the  municipal  hospital  the  cost  is  provided  for  out 
of  the  city  treasury,  while  others  depend  for  support  solely 
upon  public  contributions.  To  this  last  class  belong  the 
greater  number.  At  the  same  time  no  matter  how  securely 
endowed,  or  how  independent  a  hospital  may  be  of  its  public, 
it  is  always  well  to  have  a  number  of  people  in  the  com- 
munity who  take  a  personal  interest  in  it,  and  who  are 
jealous  of  its  good  name,  who  will  stand  loyally  by  it  if 
it  is  unjustly  criticized,  who  will  use  their  infiucnce  to  make 
friends  for  it,  and  who  will  see  to  it  that  it  remains  worthy 
of  the  favor  and  confidence  of  all  who  may  seek  its  shelter 
and  aid.  In  these  respects  the  assistance  of  woman  is  far- 
reaching.  Again,  the  active  co-operation  of  well-known 
women,  whose  names  stand  for  integrity  and  what  is  best 


Women  on  Hospital  Boards  87 

in  the  communily,  at  once  lifts  any  institution  with  which 
their  names  are  associated  above  reproach,  and  strengthens 
the  hands  of  the  officials  in  their  endeavors  at  every  turn. 
Moreover,  in  order  that  the  benefits  of  the  hospital  may 
be  made  as  far-reaching-  as  possible,  it  is  well  to  have  among 
its  supporters  those  who  can  serve  it  not  only  philanthro- 
pically,  but  also  financially,  and  who  can  influence  others  to 
give.  Thus  the  society  woman,  the  woman  who  is  known 
for  her  indefatigable  good  work,  the  practical  economical 
housekeper  and  the  business  woman  can  all  find  a  fitting 
place  on  hospital  boards. 

A  proper  selection  having  been  made,  thorough  organi- 
zation is  of  vital  importance.  Each  member  should  be 
chosen  for  a  definite  reason,  and  her  sphere  of  usefulness 
having  been  once  recognized,  her  duties,  privileges  and 
restrictions  should  be  defined.  Thus  a  board  divided  into 
suitable  committees,  with  an  executive  committee  composed 
of  the  heads  of  these  various  committees,  may  be  useful  in 
many  ways,  and  will  represent  and  forward  all  the  various 
interests  connected  with  the  institution,  of  which  I  need 
not  speak  in  detail  here.  Perhaps,  however,  I  may  be 
pardoned  for  pointing  out  a  few  ways  in  which  women 
members  of  the  board  can  supplement  the  work  of  caring 
for  the  sick.  For  want  of  time  and  for  absorption  in  the 
strictly  practical  part  of  their  work  nurses  are  apt  to  forget 
that  there  are  other  factors  besides  medicines  and  the  routine 
nursing  that  act  as  tonics  and  aids  to  the  restoration 
of  health,  and  that  convalescence  will  inevitably  be  retarded 
should  the  patient  fall  into  an  indifferent  listless  attitude  of 
mind.  What  brightens  up  the  sick  more  than  the  sight  of 
a  new  face,  a  few  fresh  fiowers,  a  bright  entertaining  story 
or  the  magazine  pictures,  a  quiet  game  of  some  sort,  or  per- 
haps some  light  work  for  the  fingers?  All  of  such  things 
can  be  supplied  by  the  ward  visitor  provided  the  nurses  will 
co-operate  far  enough  to  keep  her  in  touch  with  the  patient's 
needs.  Such  helps  are  sources  of  real  economy  and  great 
good,  for  they  undoubtedly  hasten  convalescence  so  that 
places  are  sooner  open  for  others  who  need  the  care  more. 


88  International  Congress  of  Nurses 

Again,  a  practical,  far-seeing  superintendent,  who  is  in 
hearty  accord  with  her  committee  on  hospital  and  household 
supplies,  can  hold  their  interest  to  such  an  extent  that  many 
items  will  be  provided,  with  a  consequent  distinct  saving  to 
the  hospital  finances.  Again,  the  individual  nurse  will  find 
it  of  great  advantage  to  her  when  she  leaves  the  hospital  to 
have  a  certain  number  of  women  in  the  community  who  are 
conversant  with  her  ability  and  her  ambitions  to  further  dis- 
trict nursing,  visiting  nursing  or  whatever  form  her  future 
work  may  take. 

In  the  brief  time  allotted  I  have  given  but  imperfectly 
a  few  of  the  many  reasons  why  women  are  in  place  on  hospi- 
tal boards,  and  I  beg  to  close  by  repeating  that  it  lies  in 
the  power  of  the  superintendent  of  nurses,  if  she  be  a 
capable,  experienced  executive  officer,  to  utilize  these 
extraneous  aids  in  order  to  develop  more  and  more  the  good 
work  done  by  such  boards.  Our  hospitals  of  today,  although 
far  ahead  of  those  of  twenty  years  ago,  in  some  respects  still 
lack  the  full  measure  of  the  home  atmosphere  that  makes 
patients  forget  they  are  within  the  walls  of  an  institution, 
and  which  can  only  exist  where  the  presence  of  woman  and 
her  aid  is  appreciated  and  utilized  to  the  utmost  extent 
possible. 

The  President :  The  chair  will  call  on  Miss  Gilmour, 
superintendent  of  nurses.  New  York  City  Hospital,  to  open 
the  discussion  on  Mrs.  Robb's  paper. 

Miss  Gilmour :  There  seems  to  be  such  a  diversity  of 
opinions  as  to  the  usefulness  or  helpfulness  of  women  on 
hospital  boards  that  it  is  a  difficult  matter  to  know  where 
to  begin. 

People  in  general  connected  with  hospitals  feel  that  as  a 
rule  these  women  are  not  practical.  They  give  too  much 
attention  to  petty  detail  and  not  enough  to  the  great  object 
for  which  the  work  is  going  on, — the  saving  of  human  life — 
so  that  a  misplaced  chair  or  rug  is  in  their  eyes  of  greater 
moment  and  will  excite  keener  criticism  than  the  cause  of 


Women  on  Hospital  Boards  89 

the  disorder,  which  may  have  been  speed  necessary  to  do 
something  of  vital  importance  to  a  patient.  And  no  amount 
of  explanation  can  convince  the  visiting  lady  that  she  is 
unjust  in  her  severe  condemnation.  As  a  nurse  was  heard 
to  remark :  "  There  is  no  use  trying  to  explain.  Her  mind 
is  already  made  up.    Appearances  are  against  me." 

On  the  other  hand,  people  outside  of  hospitals  are  of 
the  opinion  that  women  on  these  boards  are  an  absolute 
necessity,  that  they  supply  the  lack  which  is  so  apparent 
where  only  professionals  are  banded  together,  that  doctors 
and  nurses  are  so  absorbed  in  their  work  that  anything 
which  has  not  a  direct  bearing  on  the  case  in  which  they 
are  interested  is  of  little  moment  to  them.  Therefore  it 
often  happens  that  while  one  may  find  the  immediate  sur- 
roundings of  a  patient  in  immaculate  condition,  beyond  that 
things  are  quite  the  opposite  and  disorder  reigns  supreme, 
and  scant  consideration  is  shown  to  any  one  who  is  not  a 
"  case,"  or  necessary  to  the  "  case." 

To  attempt  then  to  control  these  two  such  opposite 
factions  and  dovetail  their  work  so  as  to  make  a  harmonious 
whole  of  it  is  no  easy  task  and  when  it  is  accomplished  the 
result  is  a  very  strong  combination  hard  to  break  and  ideal 
conditions  for  discipline  and  progress  are  created. 

One  such  board  working  harmoniously  wath  its  institu- 
tion is  brought  to  remembrance  today  as  an  example  of  what 
such  a  board  can  do.  This  board  was  called  into  existence 
by  one  of  our  number  since  gone  to  her  reward,  the  late 
lamented  Miss  Darche.  This  lady,  called  upon  to  undertake 
the  duties  of  a  superintendent  in  a  school  where  men, 
politicians  at  that,  held  sway,  found  there  one  woman,  a 
society  lady  of  wealth  and  culture,  whose  advice  was  often 
taken  on  important  matters  connected  with  the  school — 
indeed  who  had  been  the  means  of  securing  Miss  Darche's 
own  appointment.  This  woman  among  her  other  many 
accomplishments  was  thoroughly  practical,  thus  rendering 
her  aid  invaluable. 

Single  handed,  by  her  cleverness,  wit  and  sound  com- 
mon  sense,  she  accomplished  many   reforms  which   Miss 


90  International  Congress  of  Nurses 

Darche  originated  but  was  unable  to  carry  through  from 
lack  of  political  knowledge  and  influence. 

This  lady,  a  committee  of  one,  kept  in  very  close  touch 
with  the  school,  as  she  said,  to  find  the  superintendent's 
limitations  and  to  help  there.  In  this  way  many  of  the 
reforms  originated  by  Miss  Darche  were  talked  over  and 
where  Miss  Darche  reached  her  limit  this  lady  took  up  her 
work  and  in  every  case  put  the  reform  through. 

By  reforms  I  do  not  mean  matters  relating  to  the  inter- 
nal administration  of  the  school  which  a  superintendent 
should  be  able  to  handle  herself.  In  regard  to  nursing,  there 
Miss  Darche  was  always  supreme,  because  she  had  no 
superior  in  her  profession  and  that  fact  was  soon  recognized  ; 
but  where  money  was  needed,  where  influence  was  needed, 
or  where  people  were  needed  to  help  on  the  w^ork,  there 
the  committee  of  one  was  always  ready  and  after  suflficient 
questioning  to  understand  the  subject,  her  share  was  cheer- 
fully taken  up  in  every  case  and  nearly  always  carried 
through.  This  lady,  like  all  intelligent  women,  had  her 
political  views.  She  was  a  Democrat  and  as  long  as  Demo- 
crats were  in  power  she  was  unassailable.  The  possibility 
of  a  Republican  board  over  the  school,  the  possibility  of  any 
board  of  politicians  over  the  school  and  no  committee  of 
one  to  interview  in  its  interests  kept  looming  up  in  the 
future,  for  life  is  very  uncertain,  and  Miss  Darche  began  to 
look  to  this  possibility  wath  the  result  that  a  committee  was 
formed  chiefly  of  w^omen,  called  "  The  Advisory  Board  of 
the  New  York  Training  School  for  Nurses." 

This  board,  wide  in  its  aims,  interests  and  politics,  is 
united  in  holding  up  the  hands  of  the  superintendent,  on  all 
matters  pertaining  to  the  discipline  and  progress  of  the 
school.  The  committee  of  one  became  its  chairman  and 
nobly  has  she  fulfilled  her  oflfice.  In  describing  the  board 
not  long  ago  she  said.  "  We  are  here  to  act  as  a  buffer 
between  the  commissioner  and  the  school,  just  as  railroad 
cars  are  furnished  to  lessen  or  relieve  the  jar,  should  they 
come  together  with  unusual  violence."  Her  advice  to 
another  anxious  board   is  worth   quoting :     "  Choose  first 


Women  on  Hospital  Boards  91 

your  superintendent  on  her  merits  and  of  course  you  will 
choose  the  best  you  can  ;  then  let  her  alone.  When  she 
needs  help  she  will  let  you  know,  and  then  help  her." 

The  advisory  board  makes  monthly  visits,  goes  over 
the  hospital  and  home,  hears  the  superintendent's  monthly 
report,  talks  over  new  business,  and  gives  any  necessary 
assistance. 

Some  of  the  work  done  by  the  board  is  as  follows :  All 
recommendations  for  increase  of  numbers  on  the  staff  of 
the  Training  School,  or  increase  of  salaries  are  endorsed  by 
them;  all  special  calls  for  lecture  funds,  etc.,  are  met  by 
them,  and  in  any  emergencies  connected  with  the  nurses  of 
the  Training  School  where  financial  help  is  necessary,  it  has 
been  freely  given.  All  disputed  points  requiring  arbitration 
are  turned  over  to  them. 

Where  work  is  carried  on  in  this  way  by  a  Board  of 
Lady  Managers,  good  results  must  be  achieved  and  the 
work  of  the  superintendent  cannot  be  otherwise  than 
lightened,  while  the  moral  and  disciplinary  effect  must  be  to 
strengthen  her  hands  and  uphold  her  authority  over  her 
subordinates. 

The  President :  I  have  the  honor  of  calling  upon  IMiss 
Louisa  Stevenson,  member  of  the  Board  of  Managers,  Royal 
Infirmary,  Edinburgh,  delegate  from  the  National  Council 
of  Women  of  England. 

Miss  Stevenson  :  I  desire  that  my  first  words  to  this  Con- 
gress should  be  to  convey  to  you  an  expression  of  profound 
sympathy  from  the  president,  the  vice-president  and  all  the 
members  of  the  National  Union  of  Women  Workers  of 
Great  Britain  and  Ireland,  which  I  have  the  honor  to  repre- 
sent today,  upon  the  tragic  sorrow  which  is  now  weighing 
down  this  great  nation.  I  can  assure  you  that  these  are  no 
mere  words.  I  thank  you.  Madam  President,  for  permission 
to  give  expression  to  them. 

It  may  perhaps  be  thought  that  I  am  an  interested  sup- 
porter of  the  principle  that  hospital  boards  are  benefited  by 


92  International  Congress  of  Nurses 

the  presence  of  women  managers.  For  many  years  I  was 
of  opinion  that  there  was  a  great  deal  of  work  in  hospitals 
which  would  be  left  undone  were  there  no  women  to  attend 
to  it. 

About  six  years  ago  I  was  elected  a  member  of  the 
Board  of  Managers  of  the  Infirmary.  This  year  I  am  ofT  the 
board,  as  no  one  can  serve  more  than  five  years  in  suc- 
cession, and  so  am  able  to  attend  this  Congress,  where  I 
came  to  learn  and  not  to  teach.  I  believe  there  is  a  great 
deal  of  work  done  in  America  from  which  we  may  learn 
much.  I  think  also  there  may  be  some  things  which  you 
might  learn  from  us ;  that  must  be  left  for  you  to  decide 
when  you  visit  our  country  and  our  hospitals.  After  my 
five  years  experience  on  the  board — and  for  the  first  year  I 
was  alone  with  twenty  men  ;  the  second  year  another  woman 
was  appointed — I  have  no  hesitation  in  saying  that  our 
work  is  acceptable  to  every  one  concerned.  I  have,  at  this 
present  moment,  no  warmer  friends  in  the  world  than  the 
men  on  that  board.  We  discussed  many  subjects,  which  I 
brought  before  them,  which  would  otherwise  not  have  been 
considered  at  all.  My  experience  is  that  there  need  abso- 
lutely be  no  friction  whatever  between  men  and  women 
working  together.  I  was  on  the  most  friendly  terms  with 
the  managers,  medical  stafif,  nurses  and  every  one  connected 
with  the  hospital. 

I  confess  that  I  have  not  so  much  confidence  in  Boards 
of  Lady  Managers  working  apart  from  the  general  com- 
mittee. I  believe  that  the  best  work  can  be  done  by  the 
women  and  men  working  together,  and  I  believe  that  a  large 
amount  of  friction  is  caused  by  women  not  having  it  in  their 
power  to  carry  out  their  own  recommendations  and  reso- 
lutions. There  is  nothing  more  irritating  than  to  have  to 
make  recommendations  in  a  sub-committee  which  one 
knows  one  has  no  power  to  carry  into  effect.  I  do  not 
know  how  it  is  with  you  in  America,  but  with  us  I  have 
always  found  that  there  is  not  such  a  superabundance  of 
administrative  power  among  the  men  of  our  country  that 
we  can  afTord  to  do  without  the  perception  possessed  l)y  the 


Women  on  Hospital  Boards  93 

women.  I  do  not  think  this  question  should  be  discussed 
as  to  the  differences  between  men  and  women ;  if  a  man  or 
woman  has  the  administrative  power  and  understands  what 
good  work  is  then  that  man  and  that  woman  are  the  right 
persons  to  be  put  upon  a  board  of  managers.  I  think  for 
all  public  work  there  must  be  a  certain  amount  of  definite 
training.  No  one  can  do  efficient  work  until  they  learn  just 
how  to  do  it.  I  do  hope  from  what  I  have  seen  in  other 
countries,  from  what  I  have  seen  in  the  hospitals  under 
the  supervision  of  boards  composed  or  partly  composed  of 
women,  that  those  who  know  of  this  work  will  realize  its 
value  and  be  converted  to  having  women  on  the  boards. 
There  are  many  small  matters  which  do  not  occur  to  men, 
yet  which  are  really  important  for  the  best  interests  of  the 
institution,  and  it  is  important  to  have  women  on  the  board 
to  express  their  views  on  matters  of  which  from  experience 
they  have  a  more  intimate  knowledge  than  men. 

Now  I  really  must  not  detain  you  longer,  beyond 
assuring  you  that  I  am  fully  convinced  there  is  work  to  be 
done  on  these  boards,  which  will  be  left  undone  unless  the 
women  take  it  up. 

Miss  Dolliver:  Of  the  many  valuable  and  interesting 
points  in  the  papers  read  this  morning,  I  ask  attention  for 
a  moment  to  the  consideration  of  the  hospital  patient  as  an 
individual.  Too  often  is  the  zeal  for  the  mere  routine  w^ork 
of  the  day.  The  pupil  nurse  at  least  does  not  realize  that  she 
should  first  establish  the  right  relations  between  herself  and 
her  patient,  in  order  to  gain  his  confidence.  She  should 
make  him  feel,  though  not  necessarily  in  w^ords,  that  during 
his  stay  in  the  hospital  she  has  sincere  interest  in  him,  and 
is  constantly  mindful  of  his  needs,  both  of  mind  and  of  body. 
The  nurse  who  does  this  will  convince  him  and  all  who 
know  her  that  the  nurse  is  indeed  created  for  the  patient. 

The  meeting  adjourned. 


WEDNESDAY  AFTERNOON, 

2.00   P.   M. 


The  President:     Our  papers  this  afternoon  will  deal 
with  the  interests  of  the  private  nurse. 


The  Nurses'  Co-operation. 

DIANA  C.  KIMBER, 

Late  Assistant  Superintendent  of  Nurses,  New  York  City  Hospital. 


This  society  known  popularly  to  doctors  and  nurses  in 
London  as  the  "  Co,"  or  the  "  Co-op,"  was  formally  started 
in  1891,  and  was  registered  under  the  name  of  the  "Nurses' 
Co-operation,"  June  5th,  1894.  It  is,  in  common  with  so 
many  English  institutions  under  royal  patronage,  the 
Princess  Louise,  sister  of  the  King,  being  its  patroness ; 
whilst  a  titled  lady,  Alice,  Countess  of  Strafiford,  is  its  presi- 
dent. 

The  chief  objects  for  which  the  society  is  established 
are  as  follows : 

1.  To  establish  and  maintain  of^ces  or  agencies  where 
qualified  nurses  may  be  engaged  to  attend  patients. 

2.  To  establish  and  maintain  homes  for  nurses,  and  to 
provide  them  with  instruction,  board,  and  lodging,  and  all 
necessary  comforts. 

3.  (a)  To  purchase,  lease,  hire  or  otherwise  acquire 
real  and  personal  property ;  (b)  to  erect,  construct,  maintain 
and  alter  any  houses  necessary  for  the  purposes  of  the 
society;  (c)  to  sell,  lease,  mortgage,  or  otherwise  deal  with 

94 


The  Nurses'  Co-operation  95 

all  property  of  the  society ;  (d)  to  solicit,  collect,  accept  and 
hold  gifts,  subscriptions  and  bequests,  for  purposes  of  the 
society. 

4.  To  establish  and  hold  in  trust  funds  for  the  pro- 
vision of  sick  pay,  pensions,  or  annuities,  for  the  benefit  of 
nurses. 

The  society  consists  of  the  members  who  signed  the 
memorandum  of  association  (chartered  members)  and  of 
members  who  pay  annual  subscriptions  of  £1  Is.  (about 
$5.00)  or  of  £5  5s.  (about  $25.00)  to  the  funds  of  the  society 
— such  members  being  proposed  for  membership  by  two 
or  more  members,  and  elected  by  the  committee  of  man- 
agement. The  society  numbers  only  twenty-five  members, 
seven  of  whom  are  the  chartered  members  who  signed 
the  articles  of  association.  Of  these  twenty-five  members, 
eleven  are  men,  and  fourteen  women. 

The  management  of  the  society  is  in  the  hands  of  a 
committee,  the  committee  of  management — which  consists 
of  not  less  than  twelve,  nor  more  than  fourteen  persons,  six 
being  elected  from  the  members  of  the  association,  and  not 
more  than  eight,  nor  less  than  six,  being  elected  annually  in 
general  meeting  as  representatives  of  the  nurses.  All  the 
business  of  the  society  is  managed  by  this  committee  of 
management,  and  all  the  power  lies  in  their  hands. 

They  elect  the  members  of  the  society. 

They  appoint  the  superintendent,  the  secretary,  treas- 
urer and  other  ofBcers  and  servants  of  the  society. 

They  may  borrow  money,  and  invest  the  funds  of  the 
society. 

They  may  create  any  special  fund,  or  funds,  including 
an  annuity  fund,  a  sickness  relief  fund,  etc. 

They  formulate  and  circulate  among  the  nurses  of  the 
society  such  regulations  as  they  think  fit  for  enabling  such 
nurses  from  time  to  time  to  hold  meetings  for  the  election  of 
their  representatives  on  the  committee  of  management. 

So  much  for  the  organization  of  this  society,  and  now 
for  a  brief  outline  of  its  history. 


96  International  Congress  of  Nurses 

The  idea  of  the  Nurses'  Co-operation  originated  with 
a  trained  nurse,  a  Miss  Mary  Belcher,  who  desired  to  enable 
private  nurses  to  co-operate  for  their  mutual  advantage  and 
benefit.  Miss  Honnor  Morten  gave  assistance  in  formulat- 
ing a  workable  scheme,  and  considerable  time  and  trouble 
was  given  to  making  this  scheme  practical  in  every  detail. 
The  promised  support  of  a  suflficient  number  of  doctors  was 
secured.  A  standard  of  qualification  was  determined  so  that 
doctors  of  repute  might  feel  perfectly  secure  in  recommend- 
ing and  employing  the  nurses ;  and  rules  for  the  nurses,  for 
their  instruction,  guidance  and  protection,  were  drawn  up. 

When  the  scheme  was  ready  two  gentlemen  and  four 
nurses  came  forward  with  financial  aid  to  the  amount  of 
$2,500.00:  (of  this  sum  the  $1,500.00  advanced  by  the  two 
men  was  later  made  a  gift  to  the  institution,  while  the 
$100.00  advanced  by  the  nurses  was  repaid  in  1892).  An 
office  was  taken  at  8  New  Cavendish  St.,  London,  W.,  and 
on  February  1st,  1891,  the  Co-operation  started  with  thirty 
nurses  on  its  books. 

The  society  thus  founded  in  1891  was  registered  in  1894, 
the  memorandum  and  articles  of  association  being  signed  by 
Sir  Henry  Burdett,  editor  of  the  Hospital ;  Herbert  P. 
Hawkins,  physician ;  Mary  M.  Belcher  and  Mary  N. 
Napper,  nurses ;  P.  Michelli,  secretary,  or  as  we  should  say 
warden,  of  a  hospital  in  London ;  Chas.  Weston  and  W. 
Capel  Slaughter,  solicitors. 

The  signatures  were  witnessed  by  Miss  V.  Honnor 
Morten.  From  the  beginning  the  Nurses'  Co-operation 
seems  to  have  been  a  success,  for  we  read  that  at  the  end  of 
the  first  year,  i.  e.,  in  December,  1891,  there  were  already 
158  nurses  on  the  staflf,  and  that  1,127  calls  for  the  services 
of  the  nurses  had  been  received  by  the  association.  These 
numbers  have  steadily  increased,  and  the  report  for  the 
year  ending  December  31st,  1900,  states  that  at  that  date 
there  were  509  nurses  on  the  staflf,  and  that  during  the  year 
a  total  of  7,130  calls  had  been  received  and  filled.  During 
the   same   year  the   nurses'   gross   earnings   amounted  'to 


The  Nurses'  Co-operation  97 

£43,696  4s,  or  approximately  $218,480.00.  Again,  in  this 
report  the  nurses  are  congratulated  on  the  completion  of  a 
residential  home,  which  provides  them  with  a  restaurant, 
club  rooms,  and  many  separate  bedrooms.  And  no  charge 
is  made  for  the  use  of  a  sick  room  by  nurses  belonging  to 
the  club,  whose  admission  is  recommended  by  the  medical 
officers  of  the  society. 

Towards  the  cost  of  this  home  the  late  Lady  Howard 
de  Walden  contributed  £6,500  (or  about  $32,500.00  as  a  gift 
and  £1.500  (or  about  $7,500.00)  as  a  loan. 

Each  nurse  received  her  earnings,  less  71/3%.  She 
pays  an  annual  subscription  of  $1.20  to  the  Howard  de 
Walden  Club.     She  boards  and  lodges  herself  as  she  pleases. 

To  an  outsider,  on  reading  this  and  similar  reports  all 
seems  well,  but  recent  events  have  shown  that  for  some 
time  there  has  been  considerable  latent  discontent  among 
the  nurses  of  the  stafif,  and  with  the  resignation  of  the  late 
superintendent,  Miss  Amy  Hughes,  this  discontent  found 
expression.  It  would  appear  that  the  control  of  the  associa- 
tion has  been  drifting  further  and  further  from  the  nurses  of 
the  staflf,  and  into  the  hands  of  those  members  of  the  society 
who  are  most  constantly  present  at  the  monthly  meetings 
of  the  committee  of  management.  And  the  reason  of  this 
is  not  far  to  seek — the  nurses  finding  it  difficult  to  attend  the 
meetings  regularly  on  account  of  the  nature  of  their  work 
have  grown  careless ;  possibly  also  they  have  not  realized 
the  importance  of  their  position  on  the  committee  as  repre- 
sentatives of  the  staff,  and  those  members  of  the  society  who 
have  been  constantly  present  at  all  the  meetings,  finding  the 
power  in  their  hands,  have  grown  accustomed  to  using  it, 
and  have  possibly  unconsciously  come  to  believe  that  they 
are  the  only  persons  qualified  to  manage  the  business  of 
the  association. 

But  to  return  to  facts.  In  consequence  of  the  growth 
of  the  society,  and  consequent  increase  of  its  work,  it  became 
necessary  in  1895  for  the  committee  of  management  to 
employ  a  paid  secretary.  Up  to  this  date  the  office  had  been 
an   honorary   one,   and   had   been    held   by   Miss    Honnor 


98  International  Congress  of  Nurses 

Morten.  This  secretary  who  was  appointed  by  the  com- 
mittee of  management  is  not  a  representative  of  the  nurses 
on  the  staff. 

When  Miss  Morten  resigned  the  position  of  Honorable 
Secretary  there  were  two  rules  which  ran  as  follows : 

"  1.  There  shall  be  at  least  eight  nurses  on  the  com- 
mittee. 

"  2.  Any  surplus  remaining  shall  be  available  for  dis- 
tribution as  may  in  general  meeting  be  determined." 

The  second  rule  I  am  informed  has  been  quietly 
dropped,  and  the  first  now  reads : 

"  There  shall  be  at  least  eight  nurse  representatives  on 
the  committee." 

These  nurse  representatives  do  not  necessarily  repre- 
sent the  nurses,  and  as  a  matter  of  fact  the  present  chair- 
man, who  sits  as  one  of  the  nurse  representatives,  so  far  fails 
to  represent  their  opinions  that  95%  of  the  nurses  signed  a 
formal  protest  against  his  actions.  Four  only  of  the  nurse 
representatives  now  on  the  committee  are  nurses  on  the  staff, 
and  they  on  account  of  their  work  are  often  obliged  to  be 
absent. 

Sinte  the  general  meeting  in  June  of  this  year,  when  the 
nurses  met  to  voice  their  complaints,  the  committee  of 
management  have  issued  a  circular  letter  to  the  nurses  of  the 
Co-operation,  in  which,  to  meet  this  difiliculty  of  inadequate 
nurse  representation,  they  say : 

"  The  committee  are  quite  aware  of  the  difficulty  nurses 
find  in  attending  the  monthly  meetings  regularly,  owing  to 
their  frequent  absence  from  town  (i.  e.  London)  and  this 
makes  the  question  of  the  nurses'  representatives  a  difficult 
one.  The  committee  are  now  considering  how  the  articles 
of  association  can  be  improved,  and  due  time  and  attention 
will  be  given  thereto,  with  a  view  to  the  nurses  having, 
if  possible,  (the  italics  are  our  own)  a  larger  representation 
secured  to  them. 

"  They  also  intend  to  take  steps  to  acquaint  the  nurses 
more  fully  than  heretofore  with  such  resolutions  as  affect 
the  whole  work  of  the  Co-operation." 


The  Nurses'  Co-operation  99 

It  seems  to  us  that  the  steps  the  nurses  have  to  take 
is  to  make  the  committee  understand  that  it  must  he  made 
possible  for  them  to  have  such  representation  on  the  com- 
mittee as  will  enable  them  to  have  a  controlling  voice  in  its 
management.  Unless  the  nurses  have  this  voice  the  society 
cannot  properly  be  called  the  "  Nurses'  Co-operation ;"  hav- 
ing such  a  voice  they  can  have  no  reason  for  complaint,  if 
the  disabilities  under  which  they  may  be  suffering  are  not 
rectified. 

From  the  point  of  view  of  an  American  it  seems  some- 
what incongruous  that  a  body  of  women  seeking  to  manage 
their  own  affairs  should  accept  donations  and  patronage. 

In  England  acceptance  of  patronage  is  so  common  that 
it  does  not  occur  to  us  to  look  at  it  in  this  light,  but  we 
venture  to  think  that  the  English  nurses  who  wish  to  stand 
upon  their  own  feet,  and  manage  their  own  organizations, 
will  have  to  learn  to  face  the  fact  that  they  cannot  accept 
help  from  others  without  losing  a  certain  amount  of  inde- 
pendence. -A,/  . 


<7>y^j^. 


"«<'** 


The  Registered  Nurses'  Society. 


SOPHIA  CARTWRIGHT, 

Member  of   St.   Bartholomew's  League,   Delegate  from   the   Registered   Nurses 

Society. 


Ladies, — As  you  have  already  had  described  to  you  the 
basis  of  organization  in  the  Nurses'  Co-operation,  which  is 
identical  with  that  of  the  Registered  Nurses'  Society,  in  se- 
curing to  members  the  whole  of  their  earnings  less  a  small 
percentage  for  office  expenses,  I  do  not  propose  to  enlarge 
upon  this  point,  but  briefly  to  give  you  some  account  of  the 
distinctive  features  of  the  society  which  I  have  the  honor 
to  represent. 

It  was  in  1894,  after  the  Royal  British  Nurses'  Associa- 
tion had  been  incorporated  by  Royal  Charter,  that  Mrs.  Bed- 
ford Fenwick  felt  that  something  should  be  done  to  secure 
to  trained  and  certificated  nurses,  who  were  registered  un- 
der the  charter,  remunerative  work  as  private  nurses,  which 
work  was  largely  in  the  hands  of  uncertificated  and  ineffi- 
cient women,  or  was  manipulated  by  institutions  which  paid 
the  nurses  a  fee  and  retained  the  profits.  If  the  nurses  had 
the  management  the  margin  of  profit  would  be  theirs.  On 
the  other  hand,  Mrs.  Fenwick  urged  that  the  Chartered 
Association  had  a  professional  duty  to  the  public,  and  should 
define  a  definite  standard  of  education  and  training  for  pri- 
vate nurses. 

It  was  decided  that  the  association  could  not  initiate 
such  a  scheme,  but  eventually  some  of  the  medical  and  nurs- 
ing members  formed  a  committee,  at  Mrs.  Fenwick's  re- 
100 


The  Registered  Nurses'  Society  101 

quest,  and  inaugurated  the  Registered  Nurses'  Society,  of 
which  she  has  acted  as  Hon.  Superintendent  since  its  in- 
ception. 

Through  the  organization  of  this  society  nurse  members 
of  the  Royal  British  Nurses'  Association  were  provided  with 
a  medium  through  which  they  could  obtain  private  nursing 
work.  But  after  the  new  by-laws  were  thrust  upon  the  as- 
sociation many  of  the  early  members  felt  compelled  to  resign 
their  membership,  and  the  Registered  Nurses'  Society 
adopted  a  standard  of  its  own,  and  continued  its  work  for 
nurses  and  the  public  entirely  apart  from  the  Royal  British 
Nurses'  Association. 

The  lines  upon  which  the  society  had  worked  are  as 
follows : 

(1)  It  demands  a  three  years'  certificate  of  general 
training  from  all  applicants  for  membership. 

(2)  It  requires,  in  addition,  adequate  training  in  spe- 
cialties, such  as  maternity  nursing,  midwifery, 
mental  nursing,  massage,  fever  nursing,  etc.,  of 
members  undertaking  nursing  in  these  special 
branches. 

(3)  It  inculcates  and  encourages  in  the  members  a 
sense  of  their  direct  responsibility  for  the  well- 
being  of  the  society,  and  of  the  duty  which  they 
owe  to  the  public  in  maintaining  an  efificient  stand- 
ard of  nursing  education  for  private  nurses. 

Maintaining  as  it  does  a  standard  of  education  and  gov- 
ernment somewhat  in  advance  of  its  age,  and  being  in  no 
way  dependent  upon  social  patronage,  the  Registered 
Nurses'  Society  must  necessarily  grow  slowly  and  surely  in 
public  favor,  as  it  is  doing. 

The  society  is  not  satisfied  that  nurses  should  become 
members  merely  to  obtain  the  commercial  benefits  which  it 
confers  upon  them,  but  its  object  has  been  also  an  educa- 
tional one. 

A  large  proportion  of  the  committee,  therefore,  consists 
of  the  members  themselves,  who  participate  in  the  business 


102  International  Congress  of  Nurses 

management  of  their  society,  and  are  encouraged  to  take 
a  personal  interest  in  the  conduct  of  their  own  affairs. 

The  society  has  further  cultivated  a  broad  outlook  by 
affiliating  with  the  National  Council  of  Women,  and  also  by 
sending  delegates  to  various  congresses  and  meetings  at 
which  questions  affecting  the  interest  of  the  nursing  profes- 
sion are  discussed. 

I  believe  I  am  right  in  saying  it  is  the  only  society  of 
private  nurses  in  Great  Britain  which  has,  at  its  own  ex- 
pense, selected  and  sent  a  delegate  to  this  great  congress, 
and  I  consider  this  a  typical  instance  of  the  good  which  must 
result  from  encouraging  nurses  to  take  an  interest  in  their 
own  affairs. 

I  must  further  mention  that  members  of  the  Registered 
Nurses'  Society  are  encouraged  to  keep  themselves  ac- 
quainted with  the  contemporaneous  history  of  their  profes- 
sion at  large,  to  which  I  ascribe  the  fact  that  many  of  the 
members  of  the  society  are  keenly  interested  in  nursing 
politics  and  appreciative  of  progressive  movements. 

It  has  been  well  said  that  "we  may  divide  society  into 
those  who  are  assisting  the  progress  of  civilization,  those 
who  are  driving  it  backward  towards  barbarism,  and  those 
who,  being  inert  and  stationary,  are  an  impediment  to  the 
efforts  of  others.  We  must  choose  to  which  of  these  classes 
we  will  belong,  for  to  one  or  other  it  is  evident  we  must  be- 
long. If  we  are  vicious,  or  even  ignorant  and  prejudiced,  so 
that  in  our  intercourse  with  society  we  foster  old  errors,  and 
resist  the  improvements  of  the  age,  we  must  rank  with 
those  who  are  either  impeding  the  prosperity  of  the  country 
or  forcing  it  back  to  barbarism.  But  if  we  think,  speak,  and 
act  up  to  the  moral  lights  of  our  time,  assisting  more  or  less 
to  maintain  or  forward  improvement,  we  have  then  a  right 
to  rank  with  the  benefactors  of  mankind.  Our  positive  in- 
fluence may  be  greater  or  less,  without  either  merit  or  fault 
of  our  own,  but  we  have  joined  the  right  cause.  Each 
soldier  has  a  share  in  the  honor  of  the  victory." 

I  claim  that  in  linking  our  fortunes  with  those  of  the 
leaders  of  our  profession  who  are  working  for  professional 


The  Registered  Nurses'  Society  103 

advancement,  for  a  definite  and  efificient  standard  of  nursing 
education,  for  self-government  and  discipline,  the  Reg- 
istered Nurses'  Society  has  "joined  the  right  cause."  We 
have  proved  also  that  it  is  possible  to  combine  a  high  stand- 
ard of  profesisonal  responsibility  with  commercial  success, 
and  last,  but  not  least,  that  if  nurses  are  permitted  a  share 
in  the  management  of  their  own  afifairs,  they  appreciate  the 
dignity  and  responsibility  of  this  trust,  and  perform  their 
part  conscientiously  and  with  ability. 

The  President :  The  chair  would  like  to  call  upon  Miss 
Hughes. 

Miss  Hughes  :  I  am  asked  to  say  a  few  words  upon  the 
subject  of  Nurses'  Co-operative  Societies.  Until  last  June, 
I  had  the  privilege  of  being  in  charge  of  a  very  large  associa- 
tion of  private  nurses  working  on  the  same  lines  as  the  one 
of  which  you  have  just  heard.  The  principle  of  co-operation 
amongst  private  nurses  has  proved  so  successful  that  it  is 
becoming  very  general  with  us.  Not  only  do  the  nurses 
secure  the  full  fees  for  their  services,  but  by  each  one  con- 
tributing a  fixed  percentage  towards  working  expenses,  the 
business  of  placing  them  in  communication  with  doctors, 
helping  to  enforce  the  payment  of  their  fees  for  services 
rendered,  etc.,  is  carried  on  without  delay  and  loss  of  time  to 
the  nurse  concerned.  The  office  becomes  the  calling  place 
of  doctors  and  patients'  friends,  and  many  difficulties  can 
be  cleared  away,  and  things  made  easier  on  both  sides  by 
this  common  ground  of  meeting.  I  would  plead  that  those 
who  join  such  societies  should  try  to  eliminate  the  feeling 
that  the  work  is  only  undertaken  because  of  the  higher 
remuneration  it  secures,  and  because  of  the  greater  freedom 
of  the  life.  Private  nurses  represent  the  profession  to  the 
general  public  and  if  they  lower  the  standard  it  reacts 
unfavorably  on  us  all.  It  rests  with  each  individual 
woman  to  create  and  maintain  a  favorable  impression  or  the 
reverse  in  every  household  she  enters.  Selfishness  or  want 
of  tact  in  a  very  small  degree  create  a  wider  distrust  and 
prejudice  than  the  nurse  ever  realizes.     These  associations 


104  International  Congress  of  Nurses 

exist  for  the  benefit  of  all,  and  on  each  rests  the  respon- 
sibility of  not  only  making-  a  good  record  for  herself,  but  also 
for  her  association,  and  thus  in  a  very  direct  manner  for  her 
fellow  nurses  working  in  that  society,  and  in  addition  for  the 
nursing  world  at  large. 

The  private  nurse  of  all  others  can  least  afford  to  work 
in  an  isolated  way,  for  herself  alone — her  responsibility  to 
the  whole  community  is  too  great. 

The  President :  The  chair  would  call  upon  Miss  Rid- 
dle to  speak  for  the  American  side,  on  club  work. 

Miss  Riddle :  Madam  President,  as  the  delegate  from 
the  Boston  Nurses'  Club  to  this  Congress,  I  cannot  refuse 
your  request. 

Regarding  ways  and  means  of  keeping  up  an  interest 
in  their  work  among  the  nurses ;  a  great  deal  is  done  by  our 
Alumnae  Associations  and  the  courses  of  study  they  have 
from  time  to  time  suggested.  It  would  be  well  if  more  indi- 
vidual members  of  our  Alumnae  xA.ssociations  could  attend 
these  conventions ;  but  it  would  take  a  long  time  to  give 
them,  individually,  the  stimulus  to  be  gained  here,  since  few 
of  the  associations  are  entitled  to  more  than  four  delegates 
to  each  annual  convention. 

In  Boston  we  have  organized  the  Boston  Nurses'  Club, 
which  is  maintained  and  supported  entirely  by  its  member- 
ship composed  wholly  of  nurses.  Each  winter  a  series  of  ten 
or  twelve  lectures  is  given  upon  the  various  subjects  per- 
taining to  the  nurses'  practical  work.  In  this  way  interest 
is  maintained.  Occasionally  we  have  a  lecture  upon  some 
subject  not  wholly  within  the  nurses'  province,  but  one  upon 
which  they  should  be  informed, — such  as  some  sociological 
subject ;  we  also  have  demonstrations  in  nursing  work  from 
time  to  time,  and  by  the  courtesy  of  many  of  the  hospitals 
and  hospital  staffs  we  are,  under  certain  liberal  regulations, 
allowed  the  privilege  of  attendance  at  clinics  and  at  opera- 
tions in  the  hospitals. 

We  have  had  outlined  for  us  for  the  coming  winter  a 
course  of  study  and  a  series  of  lectures  which  we  hope  will 


The  Registered  Nurses'  Society  105 

do  for  us  just  what  has  been  mentioned  by  Miss  Hughes, 
the  last  speaker. 

We  do  not  altogether  neglect  the  social  side  of  the 
nurses'  nature,  for  we  have  set  apart  an  afternoon  of  each 
week,  when  some  of  the  nurses  are  at  home  to  all  the  other 
members  and  act  as  hostesses  at  the  afternoon  tea  served 
from  three  to  five  o'clock  on  that  day.  These  teas  are 
served  in  the  club  rooms,  are  well  attended  and  apparently 
much  enjoyed.  The  hostesses  either  offer  their  services  or 
are  appointed  by  the  committee  on  entertainment. 

We  have  established  and  maintain  a  registry*  which  is 
growing  in  favor  with  the  public  from  year  to  year.  Doubt- 
less many  nurses  become  members  of  the  club  for  the  advan- 
tages to  be  gained  from  the  registry  alone;  this  single 
motive  is,  however,  constantly  discouraged  by  the  more 
thoughtful  members  who  aim  to  have  permanently 
established  a  club  which  shall  advance  the  nursing 
profession  by  educational  and  other  means ;  which  shall 
provide  a  place  for  social  and  business  purposes  of  nurses ; 
which  shall  aid  in  all  kinds  of  charitable  work,  and  which 
shall  assist  nurses  in  securing  employment. 

As  an  organization  we  are  young,  being  in  the  third 
year  of  our  existence.  But,  we  have  met  with  such  suc- 
cess as  to  lead  us  to  conclude  that  we  are  a  necessity  to  the 
public  as  well  as  to  the  great  body  of  nurses  in  Boston. 


The  President :     We  will  now  consider  the  subject  of 
Alumnae  Associations. 


*The  "  registry  "  of  American  nurses  is  the  same  as  the  business  office  of  the 
co-operative  societies  of  the  English  nurses.  Our  word  "registry"  is  not  always 
understood  abroad.  Nur;^es  supporting  their  own  "registry"  appoint  and  pay  their 
agent,  provide  her  with  office  and  telephone,  and  make  their  own  rules.  In  America 
we  have  never  had  the  system  of  private  nurses  being  employed  on  salaries  by  insti- 
tutions.—[Ed.] 


St.  Bartholomew's  League. 

EMILIE  M.  WAIND, 

Delegate  from  St.  Bartholomew's  League. 


Madam,  the  President,  Ladies  : 

It  will,  I  think,  be  of  interest  to  you  to  know  that  our 
League  of  St.  Bartholomew's  Nurses  is  connected  with  one 
of  the  oldest  hospitals  in  England,  founded  as  it  was  in  the 
year  1123  by  a  monk  named  Rahere,  whose  tomb  may  be 
seen  in  the  beautiful  church  of  St.  Bartholomew  the  Great, 
just  outside  the  gates  of  the  present  hospital  buildings. 

Passing  through  the  many  and  varied  vicissitudes  which 
befell  the  religious  and  charitable  institutions  of  early  times 
and  receiving  royal  support  in  the  reign  of  King  Henry 
VIII,  who  refounded  the  hospital,  it  gradually  became  what 
it  is  at  the  present  time ;  one  of  the  first  schools  of  medicine 
in  the  Kingdom,  and,  what  is  of  more  importance  to  us 
today,  one  of  the  great  training  schools  for  English  nurses. 

If  imitation  be  the  sincerest  form  of  flattery,  the 
alumnse  associations  in  this  country  may  feel  duly  flattered, 
for  it  was,  I  think,  the  knowledge  of  their  existence  which, 
to  some  extent  at  least,  suggested  to  our  founder  and 
president.  Miss  Isla  Stewart,  the  possibility  of  the  formation 
of  an  association  which  would  ofler  similar  advantages  to 
its  members. 

The  need  of  such  an  association  had  made  itself  felt  for 

a   considerable   period   before   any   definite  plan   could   be 

entered  upon.     In  the  natural  course  of  events,  nurses  who 

have  enjoyed  the  security  and  protection  of  a  life  lived  in 

common,  during  the  years  of  their  training,  pass  on  to  other 

work  and  other  responsibilities. 
106 


St.  Bartholomew's  League  107 

No  definite  bond  exists  between  them  and  the  many 
friends  and  companions  of  their  old  school  with  whom 
the  difficulties  and  the  pleasures  of  hospital  life  had  been 
shared.  True,  the  bond  of  memory  was  the  possession  of 
all  who  might  desire  it,  but  it  was  neither  a  substantial  nor 
a  very  satisfactory  one. 

Letters  and  meetings  might  be  arranged  between 
individuals,  but  such  a  busy  body  of  workers  found  ever- 
increasing  difficulty  in  keeping  up  with  old  friends  and  their 
doings. 

A  visit  to  the  hospital  was  equally  unsatisfactory;  to 
be  greeted  as  a  stranger,  almost  as  an  interloper,  by  the  new 
generation  of  workers,  was  the  occasional  experience  of  any 
who  ventured  to  revisit  the  familiar  scenes. 

This  is  but  one  aspect  of  the  need  which  indicated  the 
necessity  of  an  association  to  unite  old  friends  and  new  in 
perpetuity.  In  connection  with  our  profession,  there  arise 
from  time  to  time,  many  points  of  great  and  vital  importance 
to  us  as  a  whole. 

An  opportunity  of  mutual  discussion  and  a  friendly 
interchange  of  opinion  is  an  advantage  of  no  small  moment. 
With  the  possibility  of  offering  these  and  other  advantages. 
Miss  Isla  Stewart,  with  her  usual  spirit  of  enterprise  and 
esprit  de  corps,  called  a  provisional  committee  to  discuss 
the  formation  of  an  association  similar  to  those  in  this 
country. 

Warmly  supported  by  the  members  of  this  committee, 
who  hailed  her  suggestion  wath  much  eagerness,  invitations 
were  issued  to  all  nurses  holding  the  hospital  certificate  or 
diploma,  to  join  a  league  for  their  mutual  help,  support  and 
pleasure.  With  gratifying  alacrity  applications  for  member- 
ship poured  in  from  all  parts  of  the  Kingdom  or  wherever 
St.  Bartholomew's  nurses  were  working  or  residing. 

In  due  course  an  executive  committee  was  formed ; 
by-laws  were  drawn  up  ;  a  badge  was  suggested  and  a  design 
for  the  same  prepared  and  accepted;  a  benevolent  scheme 
was   outlined,   biennial   meetings  were  arranged   providing 


108  International  Congress  of  Nurses 

opportunities  for  the  discussion  of  all  business  matters  and 
for  pleasant  social  intercourse. 

It  was  also  arranged  that  the  doings  of  league  mem- 
bers, together  with  their  names  and  addresses,  should  be 
duly  chronicled  in  a  small  half  yearly  issue  to  be  entitled  the 
League  News.  Each  number  contains  an  interesting 
editorial  touching  on  current  events  of  general  interest,  in 
addition  to  papers  on  special  subjects,  and  as  comprehensive 
a  list  as  possible  of  the  honors  achieved  by  any  members  of 
the  league.  Our  first  general  meeting  took  place  in  the 
Great  Hall  of  St.  Bartholomew's  Hospital  in  May,  1900.  It 
was  an  enthusiastic  and  representative  gathering  and  Miss 
Stewart  was  justly  proud  of  the  fulfillment  of  her  long 
cherished  scheme.  We  now  number  nearly  400  members, 
increasing  steadily  as  each  six  months  produces  more  nurses 
eligible  for  membership.  Amongst  these  we  are  proud  to 
claim  no  fewer  than  five  members  who  are  working  in  this 
country  at  the  present  moment. 


Miss  Hay :  I  am  sorry  that  I  must  speak  from  a  limited 
knowledge  only — that  of  my  own  alumnae  association.  This 
we  find  extremely  helpful  to  every  nurse  who  interests  her- 
self in  it.  We  have  monthly  meetings  at  which  we  discuss 
current  topics  and  various  questions  calculated  to  instruct 
and  entertain  ;  and  by  this  interchange  of  opinions  and  social 
intercourse  we  are  much  better  enabled  to  keep  out  of  the 
"  ruts  "  and  to  carry  to  our  work  a  fresh  interest  and  an 
increased  knowledge.  I  think  nurses  are  too  liable  to 
regard  their  organization  work  as  exceedingly  irksome.  In 
our  alumnae  association  we  hope  fo  avert  this  tendency 
so  far  as  may  be  by  making  our  meetings  attractive  and 
by  interesting  our  nurses  in  them.  Another  important  work 
of  our  alumnae  association  is  caring  for  its  sick.  A  room 
at  the  Presbyterian  Hospital,  Chicago,  endowed  by  the 
generosity  of  a  friend,  enables  us  to  provide  for  any  sick 
member  residing  in  the  city  hospital  care  and  attendance. 
For  those  outside  the  city,  or  any  unable  to  go  to  the  hospi- 


St.  Bartholomew's  League  109 

tal  for  any  reason,  a  weekly  allowance  is  made  during-  the 
nurse's  illness — a  benefit  that,  never  regarded  as  a  charity, 
is  oftentimes  the  most  opportune  and  which  for  all  of  us  is  a 
pleasing  assurance  against  the  exigencies  of  sickness  and 
misfortune. 

Miss  Stewart :  I  am  very  much  struck  with  the  amount 
of  work  you  do  in  your  alumnae  associations.  Indeed  they 
appear  to  be  forming  for  this  more  than  for  merely  giving 
pleasure  to  their  members.  The  League  of  St. 
Bartholomew's  Hospital  Nurses  was  instituted  more  on 
social  lines  than  any  of  the  associations  I  have  heard  of  in 
this  country.  We  merely  do  what  business  is  necessary 
and  give  the  social  side  as  much  prominence  as  is  possible. 
I  am  a  profound  believer  in  the  developing  efifect  of  pleasure 
in  a  busy  life.  There  is  nothing  makes  a  nurse  do  her  work 
with  such  "  snap  "  as  having  a  "  real  good  time  "  at  not  too 
frequently  recurring  intervals. 

We  have  only  one  business  meeting,  which  takes  place 
about  the  end  of  June,  and  another  meeting  in  December, 
which  is  wholly  social.  The  members  take  great  pride  in  the 
association,  and  have  much  pleasure  in  the  meetings,  indeed 
no  amusement  is  provided.  Music  is  almost  unheard,  and 
certainly  unattended  to  in  the  noise  of  many  tongues  as 
one  friend  meets  and  greets  another.  I  fear  you  would 
think  us  a  terribly  frivolous  community. 

We  issue  a  paper  twice  yearly.  It  is  entirely  devoted  to 
the  doings  of  past  and  present  nurses  of  St.  Bartholomew's 
Hospital  and  of  all  who  are  connected  with  it  in  any  way. 
There  is  an  editorial  on  some  popular  topic,  some  letters 
from  nurses  in  foreign  lands,  notices  of  the  appointments  any 
member  may  have  obtained,  notices  of  births,  marriages  and 
deaths ;  any  of  the  last  have  not  as  yet  been  recorded  we 
rejoice  to  say.  The  bi-annual  examinations  are  recorded, 
and  at  the  end  a  full  list  of  members  with  their  present 
address.     The  price  is  Is.  annually. 

The  President:  I  am  afraid  our  English  friends  will 
think  we  are  too  much  devoted  to  work,  but  I  want  to  assure 


110  International  Congress  of  Nurses 

them  that  we  are  frivolous  too,  sometimes.  I  agree  with  Miss 
Stewart  that  one  of  the  orreat  needs  of  nurses  is  more 
recreation.  Our  own  ahimnse  association  has  one  Httle 
custom  which  we  have  found  very  pleasant  and  that  is  to 
come  together  on  our  graduating  day  and  have  an  alumnae 
banquet  at  which  the  graduating  nurses  are  our  guests. 

Miss  Walton  :  May  I  ask,  is  there  a  possibility  or  prob- 
ability of  other  schools  following  the  example  of  St. 
Bartholomew's  nurses  in  organizing  in  this  way? 

Miss  Waind :  St.  John's  House,  in  London,  has 
formed  a  similar  League,  and  there  are  promises  of  others.* 


The  President :  We  now  have  the  interesting  subject  of 
organization  in  distant  countries,  and  it  is  with  much 
pleasure  I  introduce  Miss  McGahey  to  this  Congress. 

*Since  the  meeting  a  League  of  the  nur  es  of  the  Royal  South  Hants  Hospital  has 
been  formed.    Guy's  Hospital  nurses  are  also  organizing. 


Nursing  Organizations  in  the  Australasian 
Commonwealths. 

SARAH  B.  McGAHEY, 

Matron  Prince  Alfred  Hospital,  Sydney  ;    Member  Matrons'  Council ;    Delegate 
from  the  Australasian  Trained  Nurses'  Association. 


Several  months  previous  to  the  granting  of  federation 
to  the  Australian  Colonies,  an  association  of  nurses  was 
founded  in  New  South  Wales,  named  after  the  colony  in 
which  it  was  inaugurated.  The  objects  of  the  association 
are: 

"  1.  To  promote  the  interests  of  trained  nurses — male 
and  female — in  all  matters  affecting  their  work  as  a  class. 

"  2,  To  establish  a  system  of  registration  for  trained 
nurses. 

"  3.  To  afford  opportunities  for  discussing  subjects 
bearing  on  the  work  of  nursing. 

"  4.  To  initiate  and  control  schemes  that  will  afford  to 
nurses  a  means  of  providing  an  allowance  during  incapacity 
for  work,  caused  by  sickness,  accident,  age,  or  other 
necessitous  circumstances." 

A   few  months   after  its  inception   it  was  considered 

advisable  to  change  the  name  to  a  more  comprehensive 

one  in  view  of  the  fact  that  so  many  nurses  trained  in  the 

other  colonies  had  been  enrolled  as  members.     This  was 

accordingly  done  at  a  special  meeting  convened  to  deal 

with  this  and  other  important  business,  and  the  alteration 

met  with  general  approval.     Since  that  date  it  has  been 

known  as  the  Australasian  Trained  Nurses'  Association. 

Ill 


112  International  Congress  of  Nurses 

Although  the  association  was  not  established  until  1899, 
it  must  not  be  considered  that  the  Australian  nurses  were 
inactive  during  the  years  that  preceded  its  inauguration,  for 
as  early  as  1892  a  meeting  of  medical  men  and  nurses  was 
held  in  Sydney  in  order  to  consider  what  steps  could  be 
taken  to  form  an  association  of  trained  nurses  in  that  city. 
Nothing  was  accomplished  then  owing  to  a  diversity  of 
opinion  as  to  what  constituted  a  trained  nurse.  Since  then 
attempts  have  been  made  to  form  an  association  of  nurses  in 
Victoria  and  New  South  Wales  with  no  better  results  than 
on  the  previous  occasion,  but  no  doubt  all  these  efforts 
paved  the  way  to  the  culminating  point  which  was  reached 
when  the  present  association  was  formed. 

The  Australasian  Trained  Nurses'  Association  is 
managed  by  a  council  consisting  of  a  president,  a  vice- 
president,  honorable  treasurer,  two  honorable  secretaries 
and  seventeen  members  (of  whom  five  are  duly  qualified 
medical  practitioners,  five  matrons  and  superintendents  of 
nurses,  live  sisters  and  nurses,  and  two  honorable  members). 

Difficulties  arose  Avhen  registration  began,  but  these 
have  all  been  overcome  and  the  association  is  now  firmly 
established.  Early  in  its  history  the  council  realized  that  a 
grave  injustice  was  being  done  by  excluding  from  member- 
ship a  certain  section  of  the  nursing  profession  who  were 
not  fortunate  enough  to  have  received  their  training  when 
a  three  years  course  was  compulsory.  In  order  that  no  one 
should  be  excluded  who  had  a  claim  to  be  registered  a 
concessional  clause  was  drawn  up  and  passed  by  a  large 
majority,  consisting  chiefiy  of  nurses  who  held  certificates 
covering  a  period  of  three  years  training  in  hospitals.  To 
all  those  who  were  eligible  to  register  under  this  clause  a 
period  of  three  months  was  granted,  during  which  time  they 
were  at  liberty  to  make  application.  Those  desirous  of 
registering  were  required  to  produce  proof  that  they  had 
been  employed  for  not  less  than  three  years  in  the  bona 
fide  work  of  medical  and  surgical  nursing,  either  in  hospi- 
tals or  in  private  work.  Such  candidates  had  to-  furnish 
certificates  of  competency  and  good  conduct  from   three 


Nursing  Organizations  in  Australasia  113 

reputable  medical  practitioners  as  to  their  qualifications, 
etc.  The  council  retained  the  power  to  examine  applicants 
concerning  whose  qualifications  doubts  were  entertained. 
This  course  had  to  be  resorted  to  in  a  few  cases,  the  majority 
of  whom  satisfied  the  examiners. 

A  register  has  been  published  in  which  the  qualifica- 
tions of  each  nurse  appear,  except  in  the  case  of  those  who 
were  admitted  under  the  concessional  clause,  then  instead 
of  the  qualifications  the  words :  "  Admitted  by  the  council 
under  the  provisions  of  Rule  XXI  "  are  inserted.  In  the 
beginning  of  the  register  the  constitution  is  printed  and 
Rule  XXI  explains  the  conditions  under  which  such  candi- 
dates were  accepted. 

Since  the  first  of  April,  1900,  the  following  conditions 
have  had  to  be  complied  with  by  those  who  were  received  as 
members : 

Candidates  for  registration  must  produce  proof: 

"  (a)  That  they  have  been  engaged  for  three  years  in 
general  hospitals  recognized  by  the  council  and  containing 
not  less  than  40  beds ;  or 

"  (b)  That  they  have  been  engaged  for  four  years  in  a 
country,  district,  or  suburban  hospital  recognized  by  the 
council  and  containing  not  less  than  20  beds,  and  have  been 
trained  at  that  hospital  under  a  matron  or  nurse  who  holds 
a  certificate  from  a  training  school  for  nurses  recognized  by 
the  council  of  this  association ;  or 

"  (c)  That  they  have  been  engaged  for  five  years  in  a 
private,  country,  district,  or  suburban  hospital  recognized 
by  the  council  and  containing  not  less  than  10  beds,  and 
have  been  trained  at  that  hospital  under  a  matron  or  nurse 
who  holds  a  certificate  from  a  training  school  for  nurses 
recognized  by  the  council  of  this  association. 

"  Furthermore,  all  candidates  must  give  reference  as  to 
their  moral  character,  produce  certificates  of  competency 
from  the  hospitals  in  which  they  have  been  engaged,  and 
account  for  any  interval  of  time  in  their  nursing  career 
when  not  engaged  in  hospitals  or  nursing  associations." 


114  International  Congress  of  Nurses 

The  membership  of  registered  nurses  has  increased 
considerably :  at  present  406  are  enrolled,  besides  these  64 
medical  practitioners  have  joined  the  association,  amongst 
whom  are  the  leading  physicians  and  surgeons  of  Sydney. 
The  nursing  profession  in  New  South  Wales  is  deeply 
indebted  to  the  members  of  the  medical  profession  who 
have  helped  the  association  since  its  inception,  some  of 
whom  have  given  much  of  their  valuable  time  to  further  its 
interests  in  a  variety  of  ways. 

In  March,  1901,  a  circular  letter  was  sent  to  several  of 
the  leading  members  of  the  medical  profession  and  nurses 
in  the  Australian  States  and  New  Zealand,  asking  them  to 
take  steps  to  call  meetings  with  a  view  to  the  formation  of 
branches  of  the  association  throughout  Australasia.  As 
already  stated  many  nurses  residing  outside  New  South 
Wales  have  been  registered,  of  these  there  are  seventeen  in 
Victoria,  eighteen  in  Queensland,  four  in  Tasmania,  three  in 
South  Australia.  No  doubt  branches  in  several  of  the 
states  will  soon  be  formed,  as  the  nurse  members  in  many 
of  these  states  are  anxious  to  have  local  centers  established. 

An  auxiliary  of  the  midwifery  nurses  in  connection  with 
the  association  was  formed  during  the  latter  part  of  1900, 
and  up  to  the  present  date  fifty  members  have  been  enrolled. 
These  midwifery  nurses  have  a  separate  register  and  are 
entitled  to  attend  at  the  general  meeting  of  the  association 
to  elect  one  of  their  members  to  represent  them  on  the 
council  of  the  association.  In  our  country  a  large  majority 
of  midwifery  nurses  have  not  had  any  general  training 
before  taking  up  this  specialty.  During  the  past  few  years 
many  more  general  nurses  have  studied  this  branch  of  nurs- 
ing than  was  customary  previously.  The  qualification  for 
membership  is  a  certificate  proving  that  the  candidate  has 
received  six  months'  instruction  in  practical  and  systematic 
training  at  one  of  the  maternity  hospitals  in  Australia, 
recognized  by  the  council  of  the  A.  T.  N.  A.  Furthermore, 
the  candidate  is  required  to  have  passed  a  satisfactory 
examination  before  a  competent  board  of  examiners.  Can- 
didates trained  in  European  or  American  maternity  hospitals 


Nursing  Organizations  in  A  ustralasia  115 

in  which  the  course  of  training  is  equivalent  to  the  standard 
required  in  the  Austrahan  hospitals,  are  eligible  for  mem- 
bership. 

A  schedule,  setting  forth  the  minimum  amount  of  train- 
ing which  will  be  accepted  by  the  council  of  the  association, 
has  been  sent  to  each  of  the  hospitals  in  Australasia,  and 
those  not  prepared  to  adopt  it,  or  whose  number  of  beds 
does  not  fulfill  the  requirements  laid  down  by  the  associa- 
tion, cannot  be  recognized.  Moreover,  the  matrons  are 
required  to  be  qualified  nurses,  capable  of  instructing  pupils 
placed  under  them.  Matrons  registered  under  the  conces- 
sional clause  are  not  considered  sufficiently  qualified  to 
hold  such  positions  and  the  hospitals  with  which  they  are 
connected  have  not  been  recognized. 

The  council  in  its  efforts  to  protect  the  interests  of 
trained  nurses  by  refusing  to  recognize  hospitals  where 
trained  matrons  are  not  appointed  is  receiving  considerable 
support  from  the  government  medical  officer  in  Sydney, 
who  is  about  to  issue  a  circular  letter  to  each  of  the  county 
hospitals  subsidized  by  the  government,  requesting  them  to 
inform  him  when  any  change  is  to  be  made  in  their  matron 
and  before  any  appointment  to  that  position  is  effected  to 
submit  to  him  the  name  of  the  nurse  together  with  her 
qualifications.  It  is  only  fair  and  just  to  nurses  who  spend 
five  years  in  hospitals  acquiring  a  knowledge  of  their  profes- 
sion, that  vacancies  for  matrons  should  be  filled  up  from 
their  ranks,  rather  than  from  those  who  have  had  little  or 
no  training. 

In  July,  1900,  a  benevolent  fund  was  established  and 
although  the  sum  subscribed  is  small  yet  hopes  are  enter- 
tained that  it  will  be  increased.  Already  one  of  the  mem- 
bers of  the  association  has  received  a  small  amount  from 
the  fund  to  enable  her  to  take  a  holiday  after  a  protracted 
illness. 

Three  of  the  members  of  the  association  who  have 
private  hospitals  have  each  put  a  bed  at  the  disposal  of  the 
council  for  any  nurse  members  who  may  require  medical 
or  surgical  treatment. 


116  International  Congress  of  Nurses 

Soon  after  the  inauguration  of  the  A.  T.  N.  Association, 
a  society  of  nurses  was  formed  in  connection  with  the 
Prince  Alfred  Hospital  training  school,  Sydney.  This 
society  was  named  the  Prince  Alfred  Hospital  Trained 
Nurses'  Reunion,  the  greater  number  of  whose  members 
are  also  on  the  register  of  the  association.  The  certificate 
of  the  hospital  is  sufficient  qualification  for  membership. 
Several  meetings  were  held  during  the  year,  at  which  papers 
were  read  which  were  both  interesting  and  instructive. 

Tlie  list  of  members  has  now  reached  100.  As  each 
class  graduates  new  members  are  enrolled. 

Nursing  has  made  considerable  strides  during  the  past 
ten  or  twelve  years,  throughout  Australia,  and  a  great 
future  is  predicted  for  it. 

The  conditions  under  which  the  nurses  work  have 
much  improved,  modern  hospitals  have  been  erected  and 
nurses'  quarters  replete  with  all  the  necessary  comforts  are 
now  established  in  connection  with  most  of  the  leading 
hospitals.  The  daily  average  off  duty  for  pupils  and  nurses 
is  three  hours ;  in  some  hospitals  two  days'  holiday  in  the 
month  is  given  besides.  The  annual  holiday  is  two  or  three 
weeks.  An  eight  hour  day  for  nurses  has  not  yet  been 
introduced  in  any  of  the  hospitals  in  the  Australian  states, 
but  in  a  few  of  the  New  Zealand  ones  this  system  has  been 
in  force  for  some  time. 

The  course  of  training  in  the  larger  schools  is  for 
three  years ;  at  the  Prince  Alfred  Hospital  and  Sydney 
Hospital,  Sydney,  the  period  has  been  extended  to  four 
years. 

The  curricula  vary  in  the  different  schools ;  in  some  the 
course  of  instruction  has  been  considerably  increased.  At 
Prince  Alfred  Hospital  midwifery  nursing,  dispensing,  and 
housekeeping  have  been  added  and  it  is  proposed  to  deal 
with  those  subjects  during  the  fourth  year  of  training. 
Practical  and  theoretical  examinations  are  held  at  the  end  of 
each  year.  To  the  practical  examination  a  much  more 
important  place  has  been  given  than  was  customary  some 
years  ago. 


Nursing  Organizations  in  A  ustralasia  117 

The  non-payment  system  does  not  exist  to  any  extent 
in  the  AustraHan  training  schools;  in  a  few  a  premium  is 
required  to  be  paid  by  the  pupils  on  entrance,  but  the 
majority  give  some  remuneration  to  the  pupils  during  their 
period  of  training. 

It  is  hoped  soon  to  see  a  preliminary  training  school 
established  in  connection  with  one  of  the  large  hospitals. 
This  preliminary  education  would  be  a  distinct  improvement 
on  the  system  now  in  force.  According  to  existing  arrange- 
ments selected  candidates  are  taken  into  the  hospitals  on 
trial  and  their  services  are  retained  if  found  suitable  after 
a  reasonable  period  of  probation.  This  system  has  had  its 
disadvantages  but  the  preliminary  training  school  would 
rectify  many  of  these.  Some  of  the  advantages  of  such  a 
school  would  be : 

1.  Those  who  had  to  deal  with  the  raw  material  would 
be  saved  unnecessary  worry  and  trouble. 

2.  The  inefficient  and  incapable  pupils  would  be  dis- 
pensed with  before  gaining  admission  to  the  wards,  and  the 
constant  changes  amongst  pupils  of  the  first  year  would 
to  a  certain  extent  be  minimized. 

3.  The  patients  would  benefit  in  a  variety  of  ways. 
The   only   drawback   to  such   a  school   has  been  the 

expense  which  it  would  entail.  At  present  the  income  in 
many  of  the  hospitals  is  barely  sufficient  to  meet  current 
expenses,  but  no  doubt  this  great  difficulty  will  soon  be 
overcome  and  those  desirous  of  seeing  this  improvement 
in  the  training  of  nurses  will  have  their  wishes  gratified 
before  the  Australian  Commonwealth  has  celebrated  many 
of  its  anniversaries. 


The  President:  We  were  so  delayed  in  opening  this 
afternoon  that  we  will  be  obliged  to  dispense  with  the  dis- 
cussion upon  this  last  paper  which  is  regretted  by  us  all. 

There  will  be  a  meeting  of  the  Congress  committee  in 
this  room  immediately  after  this  meeting  adjourns. 

This  meeting  is  now  adjourned. 


SECOND    SESSION. 

THURSDAY,   9.30  A.    M. 

The  President :  A  telegram  from  Miss  Kindbom 
brings  her  best  wishes  for  the  success  of  the  Congress. 

The  opening  paper  is  one  written  by  Mrs.  Strong, 
Matron  of  the  Royal  Infirmary,  Glasgow,  Scotland. 


The  Preparatory  Instruction  of  Nurses. 

REBECCA  S.  STRONG, 

Matron  Glasgow  Royal  Infirmary,  Scotland. 


Ladies,  I  must  thank  you  for  the  honor  you  have 
conferred  upon  me  by  asking  me  to  read  a  paper  on  the 
"  Preparatory  Instruction  of  Nurses,"  and  presume  it  is  the 
technical  course  of  study  to  be  pursued  before  entering  the 
wards  as  probationers  for  practical  training  in  the  art  of 
nursing  which  you  desire  to  hear  about,  and  not  the  ordi- 
nary preliminary  general  education  which  is  a  sine  qua  non. 
I  ask  your  indulgence  should  I  digress  somewhat  from  the 
particular  point,  as  it  is  a  wide  subject,  with  many  side 
issues.  I  will  endeavor  to  place  before  you  something  of 
our  work  and  aims  on  the  other  side  of  the  Atlantic,  and 
the  various  events  in  the  "  chain  of  evolution  "  which  have 
led  to  the  desire  to  rescue  nursing  from  its  chaotic  condi- 
tion, placing  it  on  a  sound  basis  of  systematic  tuition,  lead- 
ing on  to  a  final  examination,  to  be  conducted  by  an  out- 
side body,  under  the  control  of  the  State. 

We  wish  to  see  ourselves  in  connection  with  the 
"  General  Medical  Council,"  to  have  a  curriculum  laid  down 
118 


The  Preparatory  Instruction  of  Nurses  119 

by  them  of  the  studies,  examinations,  and  work  to  be  done, 
before  a  woman  presents  herself  for  examination  for  her 
diploma.  We  cannot  be  a  separate  independent  body,  we 
are  the  hand-maidens  of  the  medical  profession ;  and  if  we 
educate  ourselves  beyond  what  is  required  of  us,  it  is 
valuable  time  lost,  and  is  apt  to  produce  a  spirit  of  dis- 
content with  the  subordinate  position  which  we  must  hold 
in  regard  to  the  doctor.  On  the  other  hand,  we  require  to 
keep  abreast  of  the  times,  and  if  we  do  not  educate  ourselves 
to  meet  their  needs  we  cannot  expect  their  interest  in  us. 
Diagnosing  is  not  our  province,  our  responsibility  ends  with 
a  loyalty  of  spirit  in  carrying  out  the  instructions  given, 
obeying  in  spirit  as  well  as  in  letter ;  and  it  is  only  by  being 
at  one  with  the  doctors,  supplying  their  wants,  that  we  can 
look  for  guidance  and  help  from  them  in  the  forming  of  our- 
selves into  a  recognized  body  of  people. 

I  cannot  say  that  my  ideas  are  representative  of  the 
thought  of  the  country,  they  are  merely  the  gathered  exper- 
ience of  a  thirty-five  years'  nursing  career. 

The  medical  profession  is  by  no  means  unanimous,  in 
our  country,  as  to  the  necessity  of  a  fixed  curriculum  for 
nurses,  and  what  should  constitute  a  "  Trained  Nurse  "  (I 
use  the  term  for  want  of  a  better),  but  it  must  be  borne  in 
mind  that  it  was  only  in  the  eighties  of  last  century  that 
that  profession  became  a  corporate  body.  We  can  scarcely 
expect  in  so  short  a  time  that  the  want  should  be  universally 
felt  of  a  body  of  women  specially  educated  on  fixed  lines  to 
give  assistance  to  them  in  their  work.  Physicians  and 
surgeons  will  always  have  their  individuality  to  be  con- 
sidered with  their  methods  of  treatment ;  but  a  nurse  must 
have  a  certain  amount  of  information  before  she 
is  capable  of  adapting  herself  to  their  various  requirements, 
otherwise  it  would  entail  a  great  deal  of  misunderstanding 
of  instruction  given.  We  would  like  to  do  away  with  what 
is  so  aptly  called  the  "  daring  of  inexperience."  There  are 
many  medical  men  who  are  of  opinion  that  the  time  is  not 
far  distant  when  the  term  "  Qualified  Nurse  "  will  require 
to  have  a  definite  meaning  and  not  be  left  to  the  arbitrary 


120  International  Congress  of  Nurses 

decision  of  the  various  hospitals  to  j^rant  certificates,  follow- 
ing upon  their  own  private  examinations,  which  may  or 
may  not  be  of  practical  value  in  regard  to  the  fitness  of  the 
holder  for  carrying  on  the  work  of  nursing. 

The  argument  that  there  are  many  good  nurses  who 
have  received  little  but  empirical  training  will  not  hold  good, 
any  more  than  the  same  applied  to  the  practice  of  medicine 
half  a  century  ago.  As  it  stands  today  with  us  any  woman 
who  holds  a  certificate  to  the  efifect  that  she  has  spent  three 
years  in  a  general  hospital  containing  not  less  than  forty 
beds  can  register,  provided  there  is  nothing  against  the 
moral  character. 

It  is  not  the  size  of  the  hospital  I  object  to — given  a 
good  doctor  and  a  capable  nurse  in  charge,  who  would  not 
grudge  to  devote  their  time  to  teaching,  I  believe  the  best 
results  may  be  obtained.  What  I  maintain  is,  that  resi- 
dence alone  is  an  insufficient  guarantee  of  ability,  or  fitness 
for  the  work,  without  some  test  of  the  knowledge  gained 
during  the  period  of  residence  in  hospital.  This,  I  think, 
is  where  registration  with  us  fails  to  meet  a  much-felt  want. 
The  fact  of  there  being  an  examination  by  an  outside  body 
would  be  a  valuable  stimulus  to  the  nurse  all  through  her 
term  of  residence,  and  would  do  something  towards  prevent- 
ing merely  mechanical  work,  adding  zest,  thus  causing 
happiness,  which  we  cannot  do  without. 

We  speak  of  the  old  and  new  order  of  things,  if  we 
compare  the  generations  one  with  the  other ;  it  seems  like 
constant  revolution,  but  in  reality  it  is  a  succession  of 
events  leading  to  changed  conditions.  There  is  no  break 
in  the  link ;  it  is  progress,  not  revolution ;  it  is  the  same 
with  the  so-called  "  Profession  of  Nursing." 

As  the  science  of  medicine  has  advanced,  a  more 
intelligent  assistance  has  been  called  for  by  some,  an 
instructed  intelligence,  which  can  grasp  the  meaning  of 
technical  instructions  left  for  the  guidance  of  the  nurse.  To 
prevent  repetition  of  platitudes,  you  will  find  my  ideas  on 
this  point  in  a  printed  form,  which  any  of  you  may  have 
upon  application  to  me  at  the  close  of  this  meeting. 


The  Preparatory  Instruction  of  Nurses  121 

When  I  first  entered  St.  Thomas'  Hospital,  London, 
nearly  thirty-five  years  ago,  a  year's  residence  was  con- 
sidered sufficient  length  of  time  to  prepare  one  for  the  taking 
of  responsible  positions,  even  to  that  of  matronship.  I  am 
sorry  to  say  this  custom  is  not  yet  quite  obsolete  in  some  of 
our  British  hospitals. 

The  year  mentioned  was  an  immense  improvement 
upon  what  had  been,  before  the  time  of  Miss  Nightingale 
establishing  her  school  at  St.  Thomas'  in  conjunction  with 
Mrs.  Wardroper  (matron  of  that  hospital),  after  Miss 
Nightingale's  return  from  the  Crimean  War. 

The  value  and  far-reaching  influence  of  the  work  done 
by  that  lady  requires  no  comment  from  me,  it  will  live  for 
ever.  For  Mrs.  Wardroper  I  would  like  to  say  one  word. 
The  single-handed  combat  which  she  undertook,  with  the 
general  bad  condition  and  ignorance  which  prevailed  at  that 
time  in  the  nursing  world,  was  being  nobly  fought,  when 
Miss  Nightingale,  in  search  of  a  hospital  wherein  to  establish 
a  school  for  the  training  of  nurses,  came  upon  and 
recognized  the  good  work  being  done  by  Mrs.  Wardroper, 
and  chose  St.  Thomas'  Hospital  as  the  center  for  her 
operations.  This  school  being  established  class  work  was 
gradually  introduced,  in  addition  to  the  practical  work, 
until  it  has  grown  into  an  elaborate  system,  and,  as  I  have 
remarked  elsewhere,  had  St.  Thomas'  remained  the  only 
training  school  for  nurses  we  should  have  had  uniformity, 
and  possibly  the  authorities  would  have  risen  to  the 
demands  made  upon  them ;  but,  as  there  was  perfect  free- 
dom in  the  matter,  a  legion  of  schools,  so  called,  sprang  up, 
each  establishing  according  to  their  individual  ideas  a  curri- 
culum for  the  instruction  of  their  nurses,  producing  a 
veritable  chaos  of  training.  We  require  to  know  the  method 
of  each  school  before  we  can  estimate  the  value  of  the  certi- 
ficate given. 

Looking  back  upon  my  own  early  experience,  and  the 
work  undertaken  by  me,  without  knowledge  of  the  con- 
struction of  the  human  frame,  its  functions,  and  the  hygienic 
laws  pertaining  to  the  m.aintenance  of  health,  and  my  ignor- 


122  International  Congress  of  Nurses 

ance  of  the  leading  features  of  disease,  and  inability  to  dis- 
tinguish between  healthy  and  unhealthy  excretions,  with 
the  inevitable  blunders  arising  therefrom  (in  fact  learning 
through  blunders,  which  is  not  to  be  commended  where 
risk  to  life  is  involved),  I  concluded  that  it  was  necessary  to 
be  acquainted  with  these  matters  before  entering  the  wards, 
to  be  instructed  in  the  practical  art  of  nursing,  as  there  is 
too  much  close  study  entailed  in  acquiring  the  elements  of 
these  things  to  admit  of  classes  being  carried  on  simul- 
taneously with  ward  work. 

Professor  Macewen  of  Glasgow  University  was  the  first 
to  suggest  to  me  the  possibility  of  an  organized  uniform 
method  for  the  technical  instruction  of  nurses,  before  enter- 
ing hospital  as  probationers  for  practical  work,  with  final 
examinations,  after  a  fixed  period  of  residence,  by  an  out- 
side independent  body  representing  the  State,  whose 
diploma  should  be  the  sole  guarantee  of  fitness  for  the 
office  of  "  nurse." 

It  was  on  the  New  Year's  morning  of  1891  that  Pro- 
fessor Macewen,  in  an  address  to  our  nurses,  first  made 
public  mention  of  what  he  thought  might  be  done  in  this 
respect,  and  added,  "  Will  the  Glasgow  Royal  Infirmary 
take  the  lead  ?" 

SCHEME  OF  EDUCATION  AS  ADOPTED  JANUARY  1893. 

In  consequence  of  his  representations  to  his  colleagues, 
a  scheme  was  drawn  up  by  our  staff  for  a  series  of  classes 
for  pupils  who  desired  to  become  probationers.  This 
scheme  was  placed  before  our  managers,  and  they  very 
heartily  consented  to  a  trial.  We  made  a  start  in  January, 
1893,  and  from  that  time  we  have  gone  on  with  our  pioneer 
work,  each  year  strengthening  our  confidence  in  the  sound- 
ness of  the  step  taken,  though  keenly  alive  to  the  necessity 
of  fuller  development.  The  intending  pupil  (unless  holding 
a  Leaving  Certificate  of  the  Scottish  Education  Depart- 
ment, or  one  in  connection  with  the  University)  is  required 
to  attend  a  preliminary  examination  in  Grammar,  Com- 
position, Spelling,  and  Arithmetic.     Ordinary  physique  and 


The  Preparatory  Instruction  of  Nurses  123 

good  general  health  are  indispensable.  The  first  six  weeks 
are  spent  in  attending  classes  (especially  arranged  for  nurses 
in  connection  with  St.  Mungo's  College,  Glasgow)  for  the 
acquiring  of  the  elements  of  Anatomy,  Physiology,  and 
Hygiene,  for  which  the  pupil  pays  £2  2s.,  providing  board 
and  lodging  at  her  own  expense.  It  would  take  too  long 
if  I  fully  detailed  to  you  these  classes,  but  I  will  give  you  an 
extract  from  our  syllabus. 

"  The  Anatomy  course  consists  of  not  less  than  twelve 
lectures,  embracing  the  description  of  the  bones,  joints,  and 
chief  muscles  of  the  body,  the  course  of  the  main  blood  ves- 
sels and  nerves,  and  the  broad  outlines  of  the  anatomy  of 
the  brain  and  of  the  thoracic,  abdominal,  and  pelvic  viscera, 
illustrated  by  diagrams,  casts,  and  recent  dissections.  These 
lectures  are  given  by  Professor  Henry  E.  Clark  of  St. 
Mungo's  College.  Oral  examinations  on  the  subject  matter 
are  held  throughout  the  course,  closing  with  a  written  exami- 
nation by  an  outsider.  This  method  of  examination,  I  may 
say,  is  carried  out  in  the  other  subjects,  i.  e.  Physiology  and 
Hygiene." 

Physiology  also  consists  of  twelve  lectures  given  by 
Professor  John  Barlow  of  the  same  college,  illustrated  by 
diagrams,  instruments,  and  by  microscopic  preparations — 
the  subject  matter  comprising  a  description  of  the  blood, 
muscles,  food,  digestion  of  food,  circulation  of  blood, 
respiration ;  the  skin,  kidneys,  nervous  system,  general 
arrangements  of  parts  of  the  brain  in  man,  and  the  special 
senses. 

Hygiene  is  taught  by  Professor  Hugh  Gait,  also  of  the 
same  college,  consisting  of  twelve  lectures  profusely  illus- 
trated by  models  and  diagrams,  and  including  the  general 
principles  and  fundamental  laws  of  Hygiene.  The  dwelling 
in  relation  to  health ;  air,  ventilation,  water ;  the  various 
methods  of  heating  and  lighting  are  all  very  carefully  con- 
sidered. Hygiene  for  nurses  in  regard  to  personal  cloth- 
ing and  food,  and  in  regard  to  disease  is  entered  into,  and 
the  general  principles  upon  which  buildings  constructed  for 
the  treatment  of  disease  should  be  erected. 


124  International  Congress  of  Nurses 

Upon  the  pupil  passing  successfully  the  examinations 
connected  with  this  first  course,  she  goes  on  to  a  second 
course,  for  which  the  sum  of  £3  3s.  is  paid.  This  course 
comprises  twenty  classes  or  lectures  by  Dr.  James  A. 
Adams,  surgeon  to  the  Royal  Infirmary,  on  the  nursing 
of  cases  before  and  after  operation,  according  to  modern 
ideas  of  surgery,  in  relation  to  the  germ  theory,  including 
the  operating  room  and  its  equipments. 

Fractures,  dislocations,  haemorrhage,  dressing  of 
wounds,  instruments,  the  application  of  splints,  bandaging, 
etc.,  are  all  fully  dealt  with,  several  classes  being  entirely 
given  to  practical  work. 

Lectures  and  demonstrations  on  medical  cases  are 
given  by  Dr.  Lindsay  Steven,  physician  to  the  Royal 
Infirmary,  consisting  of  lectures  and  occasional  demonstra- 
tions in  the  wards  of  the  lecturer. 

The  chief  diseases  of  the  various  organs  are  briefly 
described,  attention  being  specially  directed  to  the  training 
of  the  nurses  in  (1)  What  and  how  to  observe ;  (2)  What  is 
required  in  regard  to  nursing;  and  (3)  What  to  do  in 
emergencies. 

Instruction  is  also  given  in  the  observation  of  the 
pulse,  the  respiration  and  the  temperature,  and  the  excre- 
tions generally ;  in  the  examination  of  the  urine,  the  admin- 
istration of  medicines,  and  in  the  signs  of  poisoning  by  the 
more  common  poisons  employed  as  drugs  in  the  treatment 
of  disease. 

A  series  of  classes,  ten  in  number,  are  also  held  by 
myself,  comprising  practical  instruction  in  the  cleaning  and 
use  of  ward  appliances,  preparation  of  surgical  dressings  and 
methods  of  keeping  such,  care  of  instruments,  preparing 
and  application  of  fomentations  and  poultices,  application 
of  ointments,  blisters,  leeches,  etc. ;  special  attention  being 
given  to  the  care  of  beds  and  bedding.  Syringes  of  all 
kinds  are  explained,  and  their  uses,  with  different  methods 
of  cleaning. 

Cooking  is  confined  to  ten  lessons,  as  the  principles 
are  taught  in  the  Physiology  and  Hygienic  classes.     Par- 


The  Preparatory  Instruction  of  Nurses  125 

ticulars  of  this  work  have  been  published,  and  I  take  it  for 
granted  they  are  already  known  to  you.  This  scheme 
excludes  all  class  work  during  the  three  years  spent  in  the 
wards,  the  time  given  to  the  acquiring  of  practical  skill  in 
the  art  of  nursing.  On  looking  over  our  syllabus  you  will 
observe  that  the  three  months'  preliminary  instruction  is 
given  entirely  at  the  pupil's  own  expense. 

DISADVANTAGES  OF  THE  OIvD  SYSTEM. 

Up  to  that  time  we,  in  common  with  others,  had  gone 
on  increasing  our  class  work  until  it  came  to  be  a  serious 
hindrance  in  the  work  of  the  wards,  being  detrimental  to 
teachers,  nurses,  and  patients.  Examinations  were  a  con- 
stant "  Nemesis,"  giving  no  freedom  to  really  enjoy  work, 
and  with  insufificient  leisure  to  study  the  subject  matter 
given  in  lecture,  much  of  the  good  of  it  was  lost.  We  could 
not  see  our  way  to  less  than  a  ten  hours'  day  of  ward  work, 
and  classes  in  addition  to  this  interfered  with  both  sleep  and 
recreation. 

ADVANTAGES  OF  NEW  SCHEME- 

One  great  advantage  of  the  scheme  is  that  it  rids  us 
of  the  incubus  of  a  number  of  unsuitable  women  entering 
the  wards  upon  a  month's  trial.  I  do  not  know  which  to 
pity  most,  the  nurse  or  the  probationer,  where  the  old 
custom  still  prevails,  and  believe  some  good  pupils  are  lost 
through  the  difficulty  of  getting  accustomed  to  the 
extremely  new  environment  into  which  they  are  thrown, 
whereas,  by  being  gradually  led  into  it  through  a  prepara- 
tory course,  they  might  succeed ;  it  also  ensures  a  uniformity 
of  instruction,  and  we  know  exactly  what  to  expect  from 
each  probationer. 

FIRST  COURSE  :    ANATOMY,  PHYSIOLOGY  AND  HYGIENE. 

I  should  like  to  see  this  modified,  as  I  do  not  think 
nursing  is  sufificiently  remunerative  to  compensate  for  any 
great  outlay  in  the  gaining  of  the  knowledge  necessary  for 
the  carrying  on  of  the  work,  and  I  would  advocate  the  tak- 
ing of  the  first  course,  viz.,  Anatomy,  Physiology,  and 
Hygiene,  at  some  established  medical  school,  independent 


126  International  Congress  of  Nurses 

of  any  particular  hospital.  This  expense  to  be  borne  by  the 
pupil,  the  course  being  specially  arranged  for  pupil-nurses. 

I  have  attended  the  classes  under  the  auspices  of  the 
Royal  Infirmary,  Glasgow,  which  are  held  in  St.  ]\Iungo's 
College  of  that  city,  regularly,  and  am  of  opinion  that  the 
ground  covered  by  the  teachers  is  sufficient  to  enable  a 
woman  to  carry  on  her  work  at  the  bedside  intelligently,  and 
I  have  no  desire  to  see  these  subjects  extended.  The  fees 
for  these  classes  could  be  minimized  by  large  attendances, 
if  all  hospital  authorities  agreed  in  not  taking  pupils  for 
clinical  instruction  uptil  they  held  certificates  from  the  dif- 
ferent recognized  schools  for  the  teaching  of  these  three 
subjects.  Each  large  town  possesses  at  least  one  such  col- 
lege, and  hospitals  situated  in  smaller  towns,  where  they 
have  not  the  same  facilities,  might  combine  to  insist  upon 
their  pupils  holding  these  certificates. 

I  have  not  mentioned  Chemistry,  as  both  Physiology 
and  Hygiene  touch  upon  this  sufficiently  for  the  purpose 
of  nursing,  but  we  want  uniformity,  and  this  can  never  be 
attained  without  a  central  controlling  power  to  regulate 
these  things  for  us.  One  distinct  gain  we  should  have  in 
the  above  would  be,  freedom  from  a  preliminary  examina- 
tion, as  the  woman  who  could  pass  the  examinations  con- 
nected with  the  first  course  would  certainly  possess  suffi- 
cient general  education  for  the  second. 

SECOND  COURSE  :    CLINICAL  CLASSES. 

I  think  the  Clinical  classes  should  be  undertaken  by  the 
hospital  authorities,  each  for  themselves,  the  nature  of  these 
also  to  be  fixed,  being  confined  entirely  to  the  general,  no 
specialism.  About  two  months  should  be  sufficient  to  cover 
the  necessary  ground,  the  pupils  paying  fees  sufficient  to 
cover  the  expenses  of  lectures,  the  hospital  providing  board 
and  lodging  free  of  expense  to  the  pupil  with  suitable  class 
rooms,  and  the  matron  or  lady  superintendent,  as  she  may 
be  termed,  taking  general  supervision  of  these  classes,  and 
seeing  that  efficient  tutorial  assistance  is  given  to  the  pupils, 
in  addition  to  her  own  proper  classes. 


The  Preparatory  Instruction  of  Nurses  127 

The  nature  of  this  teaching  as  adopted  by  us,  and  the 
subjects  we  think  it  necessary  for  the  pupil  to  be  instructed 
in,  I  have  already  mentioned.  We  also  endeavor  to  impart 
some  principles  upon  which  self-education  may  be  carried 
on  during  the  three  years'  perfect  freedom  from  class  work. 

I  should  like  to  see  more  time  devoted  to  this  second 
course  of  instruction  than  we  are  at  present  able  to  give  to 
it,  and  that  is  why  I  advocate  the  lessening  of  the  expense 
to  the  pupil,  that  she  may  not  feel  it  a  hardship  in  lengthen- 
ing out  the  time.  What  we  cover  in  one  month  I  think 
requires  two.  One  hour's  class  work.  I  think,  requires 
the  whole  of  the  remainder  of  the  working  day  for  study, 
either  mentally  or  manually. 

MODUS  OPERANDI  RE  WARD  WORK  :    THREE  YEARS'  COURSE. 

The  pupil,  on  entering  upon  the  actual  work  of  nursing 
under  the  tuition  of  the  "  nurse  in  charge,"  to  make  her- 
self practically  acquainted  with  the  ward  duties  and  the 
individual  care  of  the  sick,  should  apply  herself  diligently 
to  the  understanding  and  practical  application  of  the  theory 
gained  in  class. 

Unconscious  tuition  is  constantly  going  on ;  the  Clinical 
classes,  held  for  the  benefit  of  the  medical  students,  are  of 
great  use  to  the  probationer  in  keeping  her  memory  fresh, 
and  helping  her  to  understand  the  why  and  wherefor  of 
things.  The  three  years  mentioned  is  none  too  long  for 
the  acquiring  of  the  necessary  skill  to  carry  on  so  serious  a 
work  as  nursing.  We  must  not  lose  sight  of  the  manipula- 
tive part  of  the  work,  which  largely  predominates ;  in  this, 
as  in  all  other  handicrafts,  nothing  but  actual  handling  can 
produce  skill.  We  might  hold  class  after  class,  but  all  we 
can  do  is  to  give  rules  for  guidance;  books  also  can  do  no 
more.  It  is  for  the  nurse  to  make  the  knowledge  her  own 
by  practical  application.  We  cannot  ensure  uniformity  of 
skill  in  the  carrying  out  of  nursing,  any  more  than  in  any 
other  calling.  Individualism  will  reign  here  as  elsewhere; 
general  adaptation  and  quick  intelligence  is  not  given  to  all, 
but  we  require  a  certain  amount  of  definite  knowledge. 


128  International  Congress  of  Nurses 

If  our  larger  hospitals  must  become  recog-nized  "  Train- 
ing Schools  "  for  the  supply  of  smaller  institutions  (where 
they  have  not  the  facilities  for  teaching)  and  also  for  the 
supply  of  private  nurses,  I  think  we  should  endeavor  to 
accomplish  these  objects  with  a  minimum  of  disturbance  in 
the  ward  work.  The  constant  change  of  probationers  from 
ward  to  ward,  to  give  them  an  insight  into  the  different 
methods  of  working,  was  well  enough  in  theory,  but  unwork- 
able in  practice.  We  found  they  were  not  long  enough  in 
any  one  place  to  take  a  grip  of  things,  or  for  those  about 
them  to  take  sufficient  interest  in  teaching,  feeling  they 
would  be  so  shortly  removed.  We  prefer  them  to  take 
eighteen  months  in  one  set  of  medical  wards  before  going  to 
the  surgical  to  take  the  other  eighteen  months,  but  can- 
not always  manage  this ;  sometimes  they  have  to  take  the 
surgical  first.  At  the  end  of  the  three  years  thus  spent  in 
general  medical  and  surgical  work,  we  should  like  them  to 
be  examined  by  outside  examiners  from  some  recognized 
body,  as  I  have  already  said,  whose  "  diploma  "  should  be 
the  only  legal  guarantee  for  fitness  for  the  work.  Should 
the  nurse  be  fortunate  enough  to  obtain  this,  we  should  still 
be  glad  to  retain  her  services ;  should  she  fail,  I  think  she 
should  have  the  opportunity  of  returning  to  her  "  Alma 
Mater  "  and  be  re-admitted  to  examination  later  on. 

REMUNERATION. 

At  the  present  there  is  a  great  demand  in  our  country 
for  nurses  who  have  spent  three  years  in  hospital,  and  with 
the  human  love  of  change  we  require  to  do  what  we  can 
to  make  hospital  life  agreeable  and  healthful,  and  to  give 
fair  remuneration,  otherwise  we  should  be  depleted  of  our 
best  nurses,  and  our  hospitals  would  thus  sufifer  from  the 
use  of  them  as  "  Schools  for  Nurses." 

I  think  payment  should  commence  as  soon  as  a  pro- 
bationer is  taken  into  the  service  of  the  hospital.  I  repeat,, 
nursing  is  not  a  money-making  calling.  The  day  is  past 
when  it  was  thought  to  be  noble  self-sacrifice  to  take  up 
nursing.    It  is  now  recognized  as  an  "  honorable  calling  for 


The  Preparatory  Instruction  of  Nurses  129 

honorable  women,''  and  I  think  it  ought  to  be  so  arranged 
that  women  of  moderate  means  are  enabled  to  enter  with 
the  object  of  making  a  living,  which  object  does  not  nec- 
essarily entail  a  mercenary  spirit.  I  think  it  is  a  stimulus  to 
the  overcoming  of  the  initial  difficulties  connected  with  the 
work.  We  do  not  wish  to  attract  the  dilettante  class — we 
rather  wish  to  exclude  them;  and  I  would  emphasize  what 
has  already  been  ably  said  by  Professor  Macewen  as  to  the 
desirability  of  equality  in  the  work — merit  alone  carrying 
the  day,  and  not  the  paying  of  fees  nor  purchase  of  the 
higher  positions.  We  want  women  of  earnest  purpose, 
with  no  heroics,  but  sufficient  interest  in  the  work  to  be 
happy  in  it  and  to  carry  them  through  emergencies  that 
may  arise  with  a  spirit  of  pleasure  without  feeling  ill  used. 

Free  from  the  worry  of  classes,  I  think  it  a  most 
pleasant  work,  always  varying  with  the  myriad  individuals 
and  their  myriad  interests.  I  speak  from  the  experience  of 
twelve  years  spent  directly  at  the  bedside. 

DOMESTIC  WORK. 

I  am  aware  that  some  may  raise  objection  to  the  purely 
technical  character  of  our  scheme  of  preparatory  instruction 
for  nurses,  and  think  we  altogether  lose  sight  of  the 
domestic.  This  we  can  never  escape  from ;  it  is  this 
domestic  nature  of  the  work  which  makes  it  essentially  a 
woman's  work,  and  I  would  advise  everyone  who  wishes 
to  perfect  herself  in  the  art  of  nursing  to  perfect  herself  first 
in  the  art  of  housekeeping,  including  cooking.  I  think  it 
waste  of  time  to  come  to  hospital  to  learn  these  things,  and 
they  cannot  be  done  without;  they  meet  a  nurse  at  every 
turn. 

The  whole  condition  of  a  ward  depends  on  the  nurse 
in  charge.  (Cleanliness  is  a  much  more  scientific  matter 
than  appears  at  first  sight.)  We  do  not  ask  our  nurses  to 
do  the  housemaid's  work  of  the  ward,  but  we  do  ask  for  a 
thorough  knowledge  of  the  best  methods  of  cleaning,  that 
she  may  be  able  to  direct.  We  have  no  system  for  the  tram- 
ing  of  ward-maids— I  wish  we  had— and  therefore  have  to 


1 30  International  Congress  of  Nurses 

depend  upon  the  nurse  in  charcje  for  the  g-eneral  brightness 
and  comfort  of  all  under  her.  It  is  similar  to  an  ordinary 
home,  and  we  all  know  how  much  depends  upon  the  head. 
It  is  sometimes  quite  distressing  to  hear  an  otherwise 
capable  woman  expressing  her  ignorance  of  the  most  com- 
mon household  matters,  giving  as  an  excuse  the  depending 
upon  servants. 

JOHNS  HOPKINS  CURRICULUM. 

In  looking  over  the  circular  of  information  kindly 
sent  to  me  by  Miss  Nutting  of  the  Johns  Hopkins  Hospital 
School  for  Nurses,  I  did  so  bearing  in  mind  the  characteris- 
tics of  the  two  nationalities  and  their  differing  needs.  In 
comparing  the  two  systems,  please  do  not  misunderstand 
me,  and  think  that  I  suppose  either  of  the  systems,  trans- 
planted, would  take  kindly  to  the  foreign  soil.  Each  has 
sprung  out  of  its  own  particular  need.  It  is  interesting  to 
know  what  others  are  doing,  and  we  may  be  helpful  to  each 
other  in  this  way ;  beyond  this  we  cannot  go. 

We  see  that  during  the  first  six  months  of  probation, 
before  the  pupil  enters  the  wards,  instruction  is  given  in 
household  economics,  food,  hygiene,  sanitation,  anatomy, 
physiology,  and  materia  medica.  I  must  interrupt  to  say 
one  cannot  but  feel  envious  at  the  well-arranged  school  for 
preparatory  work,  and  wish  some  generous  donor  would 
furnish  us  with  the  same  facilities  for  teaching.  Well,  after 
this  six  months  comes  eighteen  months  spent  in  practical 
work  in  medical,  surgical,  gynecological,  infectious  and 
orthopedic  wards,  not  less  than  eight  hours  daily  with  an 
hour  or  two  given  to  class  work.  This  holds  good  through 
the  two  and  a  half  years  of  ward  work.  The  last  twelve 
months  are  given  to  obstetrics,  pediatrics,  nervous  diseases, 
and  surgical  technique,  as  taught  in  the  various  operating 
rooms.  We  go  to  the  other  extreme,  giving  a  ten  hours' 
day  to  ward  work,  banishing  all  classes  during  the  three 
years  spent  in  the  wards ;  exclusion  of  class  work  while  in 
the  wards  being  our  main  object  in  adopting  a  plan  for 
the  preparatory  technical  instruction  of  nurses.     In  addi- 


The  Preparatory  Instruction  of  Nurses  131 

tion  to  this,  we  confine  ourselves  strictly  to  the  acquir- 
ing of  skill  in  general  medical  and  surgical  nursing  during 
the  three  years,  believing  this  to  be  the  best  course  for 
us.  I  do  not  think  the  average  woman  of  our  country 
could  cover  more  ground  thoroughly,  and,  as  I  have  prev- 
iously said,  we  have  the  disturbance  of  the  ward  work  in 
regard  to  the  interests  of  the  patients  to  consider. 

SPECIALISM  RE  POST-GRADUATE  WORK. 

I  also  think  all  special  subjects  should  be  taken  up 
after  a  nurse  holds  her  diploma  for  general  nursing.  I 
should  like  to  see  the  day  when  it  would  be  illegal  with  us 
for  any  woman  to  follow  specialism,  especially  midwifery, 
without  her  diploma  in  general  nursing — that  is  when  we 
arrive  at  the  "  halcyon  "  days  of  knowing  what  that  term 
indicates.  So  many  complications  arise  in  all  forms  of  ill- 
ness, that  if  a  woman  takes  up  any  special  branch  of  nurs- 
ing, without  a  general  training,  she  is  likely  to  find  herself 
in  many  difficulties. 

GENERAL. 

Any  measure  of  success  attending  our  enterprise  is 
entirely  due  to  the  enthusiasm  with  which  all  concerned 
threw  themselves  into  the  work.  The  medical  men  who 
kindly  undertook  the  various  classes  have  been  untiring  in 
their  efforts  to  make  the  two  courses  as  useful  as  possible, 
and  the  coming  in  daily  contact  with  the  pupil  through  the 
whole  term  of  residence,  viz.,  the  three  years,  is  most  help- 
ful in  keeping  up  her  interest  and  seeing  that  she  makes 
the  best  possible  use  of  her  time. 

Our  nurses  in  charge  have  almost  all  passed  through 
the  same  course  of  instruction,  and  are  most  helpful  to  me  in 
seeing  that  the  practical  nursing  is  well  taught ;  not  only  in 
this  but  in  my  own  classes  held  during  the  second  course  I 
should  be  at  a  sad  loss  if  it  were  not  for  the  ready  help  I 
receive  from  them.  Last  winter  our  charge  nurses  in  the 
medical  wards  kindly  made  arrangements  for  the  practical 
instruction   of  the  pupils   in   the   taking  of  temperatures, 


132  International  Congress  of  Nurses. 

pulses,  study  of  excretions,  and  testing.  The  resident  doc- 
tors also  kindly  assisted  in  giving  lessons  on  the  position  of 
the  organs,  etc.  T  must  thank  one  and  all ;  without  co-opera- 
tion the  matron  is  helpless.  The  intimacy  arising  from  the 
contact  with  so  many  of  her  future  fellow-workers  is  most 
beneficial  to  the  pupil,  taking  away  much  of  the  strangeness 
of  the  new  surroundings  and  cultivating  a  spirit  of  good  will. 
Thanking  you  for  your  patience  in  listening  to  me,  and 
your  interest  in  our  doings,  I  now  conclude  with  the  hope 
that  we  may  all  go  on  with  earnest  purpose,  ever  keeping 
before  us  the  highest  ideals. 


ADDENDA. 
October  15th,  1901. 

It  may  be  of  interest  to  you  to  hear  something  of  the 
history  of  the  nursing  in  the  Royal  Infirmary  during  the 
last  quarter  of  a  century.  At  the  beginning  of  that  period 
a  nurse  had  to  commence  as  a  semi-wardmaid,  under  the 
name  of  assistant  nurse,  and  work  her  way  without  any 
direct  instruction.  She  was  called  at  3  a.  m.,  commencing 
work  at  four,  which  included  the  ordinary  cleaning,  such  as 
grates,  scullery  and  bathroom,  sweeping  of  ward,  dusting, 
etc.  Carrying  of  food,  for  the  ward  supply,  and  the  wash- 
ing up  of  the  dishes  had  also  to  be  done  by  her,  and  much 
carrying  which  is  now  done  by  men.  Her  duties  ended  at 
8 :30  p.  m.,  without  any  definite  time  ofif  duty.  This  so-called 
"  assistant  "  obtained  in  the  "  surgical  houses  "  only.  In 
the  medical  the  day  and  the  night  nurses  did  all  between 
them,  nursing  and  cleaning,  with  the  exception  of  the 
ward  being  scrubbed  out  once  a  week  by  a  little  army  of 
women,  six  in  number,  who  went  the  round  of  all  the  wards 
in  turn. 

It  was  surprising  to  find  the  good  nurses  that  were 
sometimes  the  outcome  of  this  very  empirical  manner  of 
obtaining  knowledge,  but  these  were  certainly  the  excep- 


The  Preparatory  Instruction  of  Nurses  133 

tions.  We  had  better  be  silent  about  the  majority,  sit  kindly 
in  judgment,  as  the  circumstances  and  conditions  were  to 
blame,  not  the  women. 

The  most  of  these  nurses  slept  in  small  rooms  adjoining 
the  wards,  and  took  all  their  meals  (excepting  dinner)  in  the 
ward  kitchens.  Nurses  and  servants  shared  the  same  dining 
room,  and  had  to  carry  a  knife,  fork,  and  glass  with  them. 
The  nursing  staff  at  this  time  numbered  76. 

The  managers  were  desirous  of  remedying  this  state 
of  matters,  and  after  much  consideration  a  plan  was  devised 
for  the  carrying  out  of  a  building  into  the  quadrangle  to 
provide  dining  accommodation  for  the  resident  doctors,  and 
utilizing  their  old  rooms  for  the  nurses,  providing  suitable 
dining  accommodation  with  proper  table  equipments. 

An  attempt  was  also  made  to  separate  the  house  work 
from  the  nursing,  and  was  partially  brought  about  by  the 
appointing  of  a  woman  to  every  two  wards  to  do  the  rough- 
est part  of  the  work.  A  time  table  was  introduced,  which 
allowed  each  nurse  two  hours  off  duty  daily  and  shortened 
the  hours  on  duty.  A  uniform  dress  was  also  supplied  to 
the  nurses  at  the  expense  of  the  Infirmary.  Lectures  were 
instituted  to  enable  them  to  have  a  better  understanding  of 
their  duties,  but  these  were  a  questionable  boon,  as  they 
had  to  be  a,ttended  at  the  cost  of  sleep  or  recreation. 

The  remuneration  was  increased,  commencing  with 
£12  the  first  year,  £20  the  second,  increasing  £2  annually 
until  it  reached  £30,  and  three  nurses  were  placed  in  each 
ward  instead  of  only  in  some. 

In  1882,  when  the  present  dispensary  buildings  were 
reaching  completion,  a  representation  was  made  to  the 
managers  of  the  insufhciency  of  the  old  dispensary  build- 
ings to  provide  the  necessary  accommodation  for  the  nurses, 
and  suggestions  were  made  to  them  for  the  building  of  a 
"  Nurses'  Home  "  apart  from  the  main  buildings,  where 
the  nurses  might  have  suitable  sleeping  and  recreation 
rooms.  The  managers  most  readily  accepted  these  sug- 
gestions, and  the  late  Mr.  William  M'Ewen,  at  that  time 
chairman  of  the  "  house  committee,"  raised  money  for  the 


134  International  Congress  of  Nurses. 

express  purpose.  In  1887  a  Home  for  75  nurses  was  com- 
pleted and.  opened ;  this,  with  the  two  corridors  occupying 
the  site  of  the  old  dispensary,  gave  accommodation  for  105 
nurses,  and  at  that  time  it  was  arranged  for  them  to  take 
all  meals  in  the  dining  room,  with  the  exception  of  after- 
noon tea.  In  1891  the  bedside  work  had  increased  to  such 
an  extent  that  the  three  nurses  were  unable  to  accom- 
plish the  work  required  of  them  without  undue  strain. 

The  managers  were  again  approached,  and  they  granted 
permission  to  place  a  wardmaid  in  each  ward  to  relieve  the 
nurses  of  the  household  work.  They  also  granted  the 
erection  of  an  additional  flat  to  the  Home,  increasing  the 
accommodation  for  nurses  to  129.  This  enabled  four  nurses 
to  be  placed  in  each  ward,  but  left  a  very  small  reserve  for 
emergencies  (two  only),  the  probationers  in  the  wards  where 
the  work  was  lightest  being  called  upon  to  give  assistance 
in  wards  where  the  work  was  heavier,  so  that  the  four  nurses 
came  to  be  more  nominal  than  real. 

In  1892  a  scheme  was  placed  before  the  managers 
whereby  the  nurses  might  be  relieved  from  all  class  work 
during  their  three  years  spent  in  the  wards  acquiring  the 
practical  art  of  nursing,  as  this  in  itself  was  a  greater 
hindrance  to  the  practical  work  of  the  wards,  and  occupied 
much  of  the  nurses'  sleeping  or  recreation  time.  This  also 
was  acceded  to,  and  has  proved  to  be  a  right  step  by  its  very 
great  success ;  it  also  ensures  uniformity  of  teaching  in 
regard  to  the  technical  requirements  of  the  work.  It  may 
yet  be  enlarged  upon,  and  further  developed  with  advantage 
to  all.  In  the  early  part  of  1900  further  demands  arose,  in 
the  form  of  a  nurse  (for  each  surgeon)  to  prepare  dressings 
only,  and  this  being  in  accordance  with  modern  surgery,  in 
which  the  whole  aim  is  to  obtain  the  perfect  purity  of  the 
dressings  which  are  immediately  applied  to  wounds,  this 
also  was  granted  ;  and  a  few  more  beds  for  nurses  were 
obtained  by  the  giving  up  of  a  waiting  room,  and  also  our 
sick  room  for  this  purpose.  (Salaries  were  again  increased 
at  this  time,  the  maximum  reaching  £35  at  the  end  of  five 
years'  service.)     The  supplying  of  these  nurses  hampered 


The  Preparatory  Instruction  of  Nurses  135 

us  still  more  in  the  meeting  of  emergencies,  and  permission 
was  given  to  get  lodgings  for  six  additional  nurses,  which 
is  anything  but  comfortable  for  them.  The  resources  of  the 
old  Royal  in  regard  to  administration  are  now  taxed  to  the 
uttermost ;  day  by  day  the  strain  is  felt.  If  some  benevolent 
citizen  of  Glasgow  would  interest  him  or  herself  in  the' 
nursing  arrangements,  and  double  the  accommodation  pro- 
vided in  the  existing  Home,  they  would  be  providing  for 
the  future  well-being  of  the  patients. 

About  forty  nurses*  bedrooms  will  be  swept  away  in 
the  demolishing  of  the  buildings  facing  Castle  Street,  and 
accommodation  is  also  badly  needed  for  the  pupils  attending 
the  Clinical  classes  in  connection  with  our  preparatory 
course  of  instruction.  At  present  they  have  to  provide 
board  and  lodging  at  their  own  expense,  which  is  rather  too 
much  to  expect  of  them,  and  is  also  much  less  satisfactory 
to  us  than  having  them  within  the  building. 

It  is  imperative  that  the  nursing  should  be  made  attrac- 
tive and  accomplished  with  as  little  physical  strain  as  possi- 
ble, if  the  best  work  is  to  be  got.  The  arrangements  should 
be  such  as  to  cause  our  nurses  to  feel  reluctance  to  leave 
their  Alma  Mater  at  the  end  of  their  three  years'  compulsory 
residence,  and  a  voluntary  service  of  an  extra  year  or  two 
should  be  given  by  them  to  enable  us  to  build  up  an  efficient 
permanent  stafT,  so  that  both  objects  may  be  attained,  viz.,  a 
"  Training  School  for  Nurses  "  and  an  efficiently  nursed 
hospital.  The  public  themselves  will  ultimately  profit  by 
the  improved  nursing  in  our  hospitals  by  being  able  to 
obtain  for  themselves  a  more  carefully  instructed  nurse,  l)Ut 
this  cannot  be  arrived  at  without  expense;  and  a  more 
generous  support  is  needed  to  enable  us  to  carry  out  fully 
what  we  would  like  to  do  for  the  good  of  the  patients, 
which  should  be  the  primary  motive  of  all  our  movements 
in  hospital. 

No  good  nurse  of  the  past  will  resent  the  forward 
movement ;  it  is  they  who  are  most  keenly  alive  to  the  need 
of  progress.  They  are  thankful  to  those  who  have  gone 
before,  and  left  their  knowledge  and  experience  for  our 


136  International  Congress  of  Nurses. 

benefit.  The  aim  of  the  present  should  be  to  leave  a  like 
goodly  heritage.  If  we  are  not  progressing,  then  we  are 
retrograding.  Who  will  come  and  help  us  to  make  our  old 
Royal  a  household  word,  and  a  crown  of  glory  to  our  city  ? 


Miss  Dock :  I  have  lately  seen  the  working  of  the 
Johns  Hopkins  preliminary  course  and  cannot  commend  it 
too  highly.  The  whole  nurses  home  is  turned  into  a  field 
for  practical  work.  The  pupils  in  turn  learn  every  part  of 
household  work  and  management.  They  buy  supplies,  keep 
accounts,  and  learn  to  order  and  prepare  food  both  in  large 
and  small  quantities.  Their  bedrooms  are  exquisitely  kept ; 
West  Point  cannot  compare  with  them.  For  six  months  the 
pupils  do  not  go  into  the  wards.  During  this  time  they 
learn  the  management  of  a  bed  patient  in  class  by  demonstra- 
tion, become  familiar  with  all  supplies  and  appliances ;  learn 
how  to  make  the  different  surgical  supplies,  and  have 
instruction  in  hygiene,  anatomy  and  physiology,  materia 
medica,  and  the  theory  of  practical  nursing,  with  demon- 
stration. When  they  go  into  the  wards  they  know  what 
they  are  doing,  and  are  not  raw  probationers. 

Mrs.  Fenwick : 
Madam  President,  Ladies: 

The  preliminary  education  of  nurses  is  in  my  opinion 
absolutely  necessary  and  it  is  a  question  in  which  I  have 
taken  a  keen  interest  for  some  years  past.  Mrs.  Strong, 
the  able  matron  of  the  Glasgow  Royal  Infirmary,  and  whose 
absence  we  all  sincerely  deplore  today,  was  the  first  to  pro- 
pose and  organize  a  course  of  preliminary  training  for 
nurses  in  Great  Britain  in  the  year  1893.  The  pupils  are 
externes  and  pay  for  the  cost  of  the  course.  Some  years 
later  a  system  of  preliminary  education  for  probationers 
was  started  in  connection  with  the  London  Hospital  Train- 
ing School.  A  house  was  fitted  for  the  reception  of  twenty- 
eight  pupils  a  short  distance  from  the  hospital,  and  a  course 
of  seven  weeks'  instruction  is  given  in  elementary  hygiene, 


The  Preparatory  Instruction  of  Nurses  137 

physiology  and  anatomy,  together  with  practical  instruction 
in  sick  room  cookery,  bandaging,  splint  padding,  bedmak- 
ing,  how  to  take  temperatures,  the  names  and  the  care  of 
instruments  and  utensils,  and  various  other  useful  details. 

This  school  and  course  is  expensive  as  it  costs  the 
hospital  upwards  of  il,000  annually.  In  1899  I  outlined  a 
somewhat  more  extensive  course  of  preliminary  training 
for  nurses  in  a  paper  read  before  the  National  Union  of 
Women  Workers  of  England.  It  is  much  on  the  lines  now 
being  tried  at  the  Johns  Hopkins  Hospital.  A  six  months' 
course  is,  in  my  opinion,  all  too  short  a  time  in  which  to 
teach  thoroughly  all  that  a  woman  should  know  before  be- 
ing admitted  to  work  in  the  wards.  A  more  efficient  system 
might  be  defined  if  the  teaching  extended  over  a  year.  The 
cost  to  the  hospital  would  however  be  too  great.  A  sounder 
economic  policy  would  be  for  the  pupil  to  pay  for  all  pre- 
liminary teaching,  and  to  meet  her  needs  the  organization  of 
schools  for  preliminary  training  might  be  founded  in  popu- 
lous centers,  at  which  a  thoroughly  efificient  curriculum 
could  be  carried  out.  This  is  a  question  of  the  utmost  im- 
portance to  the  nursing  profession  and  will  no  doubt  at  an 
early  date  receive  the  consideration  it  deserves  from  the 
superintendents  of  training  schools  on  both  sides  of  the 
Atlantic. 

Mrs.  Robb :  It  may  be  of  interest  to  delegates  who  do 
not  know  that  a  set  of  papers  on  preliminary  courses  by 
Mrs.  Strong,  Miss  Liickes  and  Miss  Nutting  appear  in  the 
American  Journal  of  Nursing,  in  the  first  year's  numbers. 

I  think  one  of  the  general  reasons  for  establishing  this 
course  is  that  we  have  found  few  probationers  who  under- 
stand practical  housekeeping  as  they  should  understand  it. 
The  special  course  in  invalid  diet  alone  is  not  sufficient, 
because  the  women  are  so  vague  or  unpractical  in  house- 
keeping affairs  that  they  do  not  get  as  much  benefit  from 
the  diet  school  as  they  otherwise  would.  With  few  excep- 
tions, our  pupils  are  also  unpractical  in  the  general 
manag-ement  of  household  details  in  the  wards,  and  after 


138  International  Congress  of  Nurses. 

graduating  them  we  still  feel  that  they  are  deficient  in 
domestic  economy.  The  respect  in  which  private  nurses  are 
most  severely  criticized  is  that  they  are  deficient  in  house- 
hold economics.  If  pupils  understood  domestic  science 
before  entering  training  school,  such  a  course  would  not  be 
so  badly  needed. 

Miss  Macleod :  A  course  of  preliminary  training  in 
domestic  science  much  on  the  same  line  as  that  referred  to 
as  in  practice  at  the  Johns  Hopkins  Hospital  has  for  some 
years  been  carried  out  at  the  Waltham  Training  School  for 
Nurses  in  Massachusetts.  The  course  includes  the  training 
of  pupils  in  housework,  cooking  and  the  preparation  of 
supplies,  and  has  proved  of  the  utmost  value  in  the  educa- 
tion of  practical  nurses. 


What  We  are  Doing  with  the  Three  Years' 

Course. 

LAVINIA  L.  DOCK, 

Secretary  of  the  American  Society  of  Superintendents  of  Training  Schools 

for  Nurses. 


INTRODUCTORY. 

The  need  of  extending  the  two-years  course  of  train- 
ing for  nurses  in  American  hospitals  to  three  years,  and  the 
benefits  and  improved  circumstances  to  be  gained  both  by 
the  hospital  and  the  nurse  through  this  extension,  were 
first  discussed  by  the  American  Society  of  Superintendents 
of  Training  Schools  for  Nurses,  in  1895,  at  which  time  a 
paper  was  read  by  Mrs.  Hunter  Robb,  entitled  "The  Three 
Years'  Course  of  Training  in  connection  with  the  Eight 
Hour  System.''* 

*This,  however,  was  not  the  first  time  for  the  public  presentation  of  the  sub- 
ject  by  Mrs.  Robb,  as  she  had,  in  189.3,  advocated  the  adoption  of  three  years 
with  eight  hour  duty,  in  a  paper  read  before  the  International  Congress  of  Charities 
and  Correction,  and  following  this  paper,  two  hospitals— the  University  of  Penn- 
sylvania in  Philadelphia,  and  the  Johns  Hopkins  in  Baltimore— had  inaugurated 
the  three  years'  course  in  their  schools. 

This  paper  was  in  place  of  a  report  from  a  committee,  which  had  been 
appointed  the  year  before,  to  consider  the  establishment  of  the  three  years 
in  training  schools.  The  paper  was  accepted  almost  unanimously,  and  five 
years  later,  at  the  annual  meeting  of  1900,  fifty-five  schools  in  a  member- 
ship of  124  reported  a  three  years'  course  and  five  others  a  course  length- 
ened over  two  years.  Within  the  past  year,  and  up  to  the  date  of  this  paper, 
a  number  of  others  in  the  society,  now  reaching  over  70  in  all,  have  adopted 
the  three  years'  course.  [The  last  report  of  the  Commissioner  of  Education 
for  the  U.  S.,  in  a  list  of  433  hospitals  gives  137  having  a  three  years'  course. 
This  report,  however,  is  dated  1900,  and  since  then  we  know  the  number 
has   increased   greatly.] 

The  reports  made  to  the  society  of  Superintendents  in  1900,  with  the 
individual  information  gained  both  officially  and  unofficially  from  hospitals 
outside  of  the  membership  of  tie  society,  and  from  those  within  it  which 
have  recently  adopted  the  new  plan,  have  furnished  the  sources  of  informa- 
tion for  the  following  paper. 

139 


140  International  Congress  of  Nurses. 

THE   SUCCESS   OF  THE   THREE    YEARS*    COURSE. 

Both  from  the  standpoint  of  the  hospital  and  of  the 
nurses'  training  and  education,  the  success  of  the  lengthened 
course  is  unqualified.  The  hospital  service  is  benefited 
by  the  longer  stay  of  the  pupil  nurse,  and  by  her  deepened 
experience  and  better  trained  judgment.  The  medical  staff 
feels  the  advantage  in  the  less  frequent  changes  and  less 
noticeable  breaks  in  continuity,  w^hich,  as  we  all  know,  they 
disliked  in  the  short  period  of  two  years  ward  work  for  th'e 
nurses. 

The  steadiness  and  balance  of  the  training  school  are 
markedly  stronger,  and  the  nurses  realize  the  improvement 
in  the  diminished  pressure  of  study  and  the  greater  oppor- 
tunities for  observation  and  assimilation  of  knowledge.  So 
far,  inquiries  have  not  discovered  a  hospital  superintendent, 
training  school  head,  or  pupil  nurse,  who  would  prefer  to 
return  to  the  old  method. 

HOW  THE  COURSE  OF  STUDY  IS  GRADED. 

It  is  only  natural  that  in  so  short  a  period  considerable 
crudity  and  want  of  finish  should  be  found  to  exist  in  the 
curricula  of  the  various  schools.  Time  and  the  experience 
derived  from  experiment  are  needed  to  shape  a  curriculum 
completely,  so  as  to  include  the  necessary  fundamentals,  to 
cover  all  the  special  ground  made  necessary  by  the  special 
conditions  of  the  work  of  the  hospital,  and  to  include 
symmetrically  the  various  elective  courses  and  the  higher 
branches  possible  in  a  fully  developed  scheme  of  three 
years  training  with  adequate  study  time. 

But  on  the  whole,  so  far,  it  is  evident  that  advance  is 
being  made  in  two  lines  at  least :  First,  much  more  atten- 
tion is  being  paid  to  the  housekeeping  and  dietetic  basis  of 
nursing  and  of  ward  work.  The  new  gospel  of  the  elevation 
of  every  kind  of  domestic  and  manual  work  to  a  science  is 
making  its  influence  felt  in  our  training  schools,  and  is 
evidenced  by  the  greater  attention  paid  to  the  cooking 
lessons,  by  the  more  practical  and  demonstrative  teaching 


The  Three  Years'  Course  141 

of  hyg-iene  and  sanitation,  and  by  the  growing  demand  for 
preliminary  practical  training.  Second,  the  beginnings  are 
noticeable  all  over  the  country,  of  the  introduction  of  the 
elements  of  sociological  study  into  the  latter  part  of  the 
course,  and  of  a  desire  to  have  the  nurse  see  herself  and  her 
work  in  relation  to  humanitarian  and  reform  movements; 
to  open  her  mind  to  the  duty  of  the  preservation  of  the 
public  health,  the  value  of  preventive  movements,  and  the 
relation  of  health  and  disease  to  morals  and  immorality. 

These  two  tendencies  seem  the  most  encouraeine  fea- 
tures  of  our  lengthened  courses.  Theoretical  and  practical 
nursing  had  already  been  well  developed,  and  need  only  to 
be  further  improved  by  a  diminution  of  study  cramming 
and  bv   shorter  hours. 


THE   WEAKNESSES   OF   THE   THREE  YEARS'    COURSE. 

These  may  be  found  mainly  at  the  beginning  and  end 
of  the  course  in  the  absence  of  definite  entrance  qualifica- 
tions, the  lack  of  preparatory  teaching  before  entering  the 
wards,  and  indefiniteness  in  the  higher  professional  branches 
of  supervisory  and  executive  work,  such  as  will  fit  nurses  to 
take  positions  of  responsibility.  Both  weaknesses  are  well 
recognized,  but  the  difficulties  in  the  way  of  amending  them 
are  great.  The  inadequacy  of  an  educational  preparatory 
test,  based  upon  book  study  alone,  has  long  been  tacitly 
acknowledged.  The  college  graduate  who  has  never  worked 
with  her  hands,  or  learned  to  put  things  in  their  places,  or 
felt  the  pressure  of  responsibility,  has  no  advantage,  through 
her  excellent  education  alone,  over  the  intelligent  home- 
taught  girl,  who  has  always  assisted  her  mother  in  the  cares 
of  a  family,  when  the  two  enter  a  training  school  for  nurses. 
The  higher  education  is  desirable  and  excellent,  but  for 
nursing  a  special  preparatory  training  in  practical  things 
is  urgently  felt  by  superintendents  to  be  necessary,  if  the 
three  years'  course  is  to  be  relieved  of  the  burden  of  having 
to  teach  adult  women  all  sorts  of  homely  accomplishments 
which  they  should  possess  before  they  enter  a  hospital  to 


142  International  Congress  of  Nurses 

learn    nursing — and    which,    indeed,    they    cannot    always 
acquire  later. 

At  present  we  have  one  school,  *  the  Johns  Hopkins, 
which  has  worked  out  a  thorough  preparatory  course.  It 
consists  of  six  months  spent  in  household  work  of  every 
kind,  purchasing  and  inspecting  food  supplies,  preparing 
and  serving  every  kind  of  food,  both  in  large  and  in  small 
quantities,  and  in  keeping  the  financial  accounts  of  the  same. 
During  the  same  period  these  pupils  are  taught  anatomy, 
physiology,  materia  medica,  the  preparation  of  surgical  sup- 
plies, and  the  fundamentals  of  practical  nursing,  in  class,  by 
demonstration  with  a  subject.  During  this  period  the  nurses 
do  not  go  into  the  wards.  The  entire  home  of  the  training 
school  is  made  a  field  for  this  practical  work,  and  trained 
teachers  are  in  charge  of  the  different  departments  of  work. 
This  course,  the  fruit  of  Miss  Nutting's  experience  and 
reflection,  is,  to  my  mind,  the  most  important  thing  being 
done  today  in  our  training  schools.  But  few  hospitals  can 
undertake  such  a  preparatory  course,  and  favored  institu- 
tions like  the  Glasgow  Royal  Infirmary,  the  London  Hospi- 
tal, and  the  Johns  Hopkins,  are  to  be  regarded,  as  it  seems 
to  me,  as  experiment  stations,  where  object  lessons  may  be 
studied  by  the  rest  of  the  hospital  world,  to  be  adapted  to 
other  conditions,  and  carried  on  in  central  schools  such  as 
the  Dublin  Metropolitan  Technical  School  for  Nurses.  This 
latter  idea  has  been  suggested  by  several  of  our  superin- 
tendents. 

THE  DISSIMILARITIES  IN  OUR  TRAINING  SCHOOL.  CURRICULA. 

Many  dissimilarities  exist  in  the  arrangement  of  our 
curricula  of  the  different  schools.  Some  emphasize  one 
branch  and  others  different  ones  beyond  the  rest.  But  so 
far  from  looking  upon  these  dissimilarities  as  unfortunate, 
I  am  inclined  to  regard  them,  to  a  certain  extent,  as  whole- 
some and  indicative  of  vigorous  life.     They  present,  taking 


*The  Waltham  school  also  gives  excellent  training  of  the  kind  described  above 
as  preparatory  work ;  not,  however,  separated  from  the  later  work  of  ward  nurs- 
ing in  as  definite  a  way,  and  the  New  York  City  and  Metropolitan  training  schools 
now  announce  the  establishment  of  six  months  preparatory  training. 


The  Three  Years'  Course  143 

them  altogether,  a  set  of  practical  experiments  which  afford 
means  of  critical  comparison  and  enable  us  to  advance  more 
rapidly  and  intelligently  than  we  could  do,  were  all  bound 
to  one  method.  Where  uniformity  is  needed  is  in  a  certain 
minimum  quantity  of  fundamentals,  or  what  we' might  call 
primary  instruction,  and  to  this  amount  of  uniformity  we 
are  year  by  year  approaching  more  closely,  as  will  be  seen 
by  examining  our  training  school  schedules  of  work  and 
study.  But  to  require  uniformity  in  the  more  advanced 
work  would  check  experimentation,  and  indeed  would  be 
impossible,  as  our  work  follows  the  growth  and  expansion 
of  medical  science  and  hospital  development. 

THE   HOUR.S    OF  WORK. 

Less  progress  has  been  made  in  this  direction,  on  the 
whole,  than  in  any  other.  Some  half-dozen  schools  only,  so 
far  as  I  know,  have  adopted  an  eight  hours'  day,  and  while 
several  have  lightened  the  work  to  some  extent  by  longer 
hours  off  dut}-  or  by  more  extended  leaves  of  absence,  yet  as 
a  rule  the  long  hours  are  left  too  nearly  what  they  were, 
before  the  addition  of  the  third  year,  and  this  seems  dis- 
tinctly wrong,  an  evident  advantage  to  the  hospital  not  bal- 
anced by  a  corresponding  advantage  to  the  pupil ;  a  demand 
upon  her  strength  and  endurance  beyond  what  is  reasonable. 

A  moderate  increase  in  the  outlay  made  for  the  train- 
ing school  would  allow  the  enlargement  of  the  nursing 
staff  to  the  number  necessary  for  reducing  the  hours  of 
ward  work,  and  the  demands  of  medicine  and  of  the  more 
intelligent  part  of  the  public  are  making  it  daily  more 
necessary  for  the  nurse  to  have  time  allowed  her  for  the  cul- 
tivation of  her  mind  and  heart  as  well  as  for  manual  accom- 
plishment. 

The  few  schools  which  we  have  at  present  working  on 
the  eight  hour  plan  do  not  simply  reduce  working  hours  and 
leave  the  pupil  an  unsystematized  leisure,  but  provide  the 
alternatives  of  physical  and  intellectual  work,  with  reason- 
able opportunity  for  recreation,  which  make  up  the  ideal 
life. 


144  International  Congress  of  Nurses. 

THE  RETURN  OF  PRIVATE  DUTY  INTO  THE  CURRICULUM. 

With  the  extension  to  the  third  year  there  is  noticeable 
a  marked  tendency  to  re-introduce  the  practice  of  under- 
graduate pfivate  duty,  which,  in  the  two  years'  course, 
had  practically  disappeared  from  all  high-grade  schools,  but 
which  is  now  returning  to  an  alarming  extent.  '^ 

Personally  I  regard  this  as  a  serious  danger,  and  the 
Society  of  Superintendents  as  a  body  has  steadily  and 
invariably  opposed  it.  It  is  a  menace  to  the  gradu- 
ates and  a  nullification  of  the  benefits  of  the  third 
year  to  the  pupil.  It  means,  for  her,  interruption  or 
entire  loss  of  those  opportunities  which  she  can  only  have 
in  hospital,  and  which  cannot  always  be  compensated  to  her 
outside ;  she  loses  the  clinical  observation  and  teaching ; 
loses  her  class  and  lecture  work  or  her  third  year  club  work ; 
and  what  is  nearly  the  most  important  of  all,  the  daily  prac- 
tice of  order,  the  harmonious  subordination  of  self  for  a 
good  purpose,  the  discipline  of  feeling  one's  self  a  part  of  a 
symmetrical  whole,  which  does  so  much  to  mature  and 
balance  the  illy-developed  and  angular  though  excellent 
material  which  ofifers  itself  in  our  schools,  to  be  made  over 
into  the  capable  and  unselfish  woman  of  good  judgment. 
I  present  no  argument  of  injustice  to  the  patient  in  this 
custom  of  undergraduate  private  duty,  because,  as  the 
patient  must  always  specify  that  she  wants  an  under- 
graduate, and  as  the  doctor  always  knows  that  the  pupil 
is  still  in  training,  there  is  no  question  of  imposition  to  the 
patient,  who  prefers  the  pupil  nurse  because  she  costs  less. 

But  there  is  a  distinct  injustice  to  the  graduate  nurse, 
who  is  working  to  support  herself  and,  often,  others.  She 
cannot  compete  with  the  pupil  who,  receiving  maintenance 
from  the  hospital,  is  sent  out  at  from  five  to  ten  dollars  a 
week  less  than  the  graduate.  Hence  we  have  the  anomaly 
of  one  and  the  same  school  assuming  to  fit  women  to  earn 
their  livelihood  on  a  certain  plane,  and  at  the  same  time 


♦Without  attempting  a  complete  census,  I  will  mention  twelve  hospitals 
in   our   present   membership,    and    there  are  many  outside  of  it. 


The  Three  Years'  Course  145 

for  its  own  benefit  systematically  underbidding  them  in 
their  work;  an  economic  injustice  which  shows  plainly 
how  much  we  need  a  knowledsre  of  related  affairs,  throueh 
-ignorance  of  which  one-sided  specialists  can  be  a  positive 
hindrance  to  the  general  advance  of  all  workers. 

There  are  superintendents  of  nurses,  who,  looking  at 
the  question  only  from  the  standpoint  of  the  education  of 
their  pupils,  believe  that  experience  in  private  duty  is  essen- 
tial as  counteracting  the  tendency  to  institutionalism  and 
routine.  But  so  long  as  the  feature  of  financial  benefit  to 
the  hospital  is  present,  it  is  impossible  to  strip  the  question 
of  its  commercial  features  and  consider  it  as  an  educational 
factor  only.  And,  the  charge  of  institutionalism,  of  martinet 
discipline  and  routinism  being  made  against  us,  would  it 
not  be  more  sensible  not  to  send  the  pupil  forth  from  it, 
into  private  families,  but  to  bring  more  of  the  private 
patient  atmosphere  into  our  wards ;  a  reasonable  amount, 
and  so  make  the  wards  less  institutional?  If  all  the  patients 
of  a  free  ward  could  be  nursed  just  a  little  more  nearly  as 
private  patients,  the  nurse  could  learn  her  tactful  and  sym- 
pathetic ways  from  the  beginning,  and  not  have  so  much  to 
unlearn,  when  she  goes  into  private  duty. 

Two  factors  combine  today  in  our  hospitals  to  make 
nurses  mechanical.  One  is  the  almost  universal  under- 
staffing  of  wards;  the  result  being  that  the  nurse,  to  get 
through  her  day's  schedule,  can  hardly  afford  to  waste  even 
a  half  minute  in  unexpected  ways;  the  other  is  the  quite 
universally  (in  this  country)  increasing  tendency  of  hospi- 
tal internes  to  limit  and  restrict  nurses  to  the  strict  and 
literal  carrying  out  of  "  orders  "  and  to  a  technically  per- 
fect attendance  upon  themselves.  I  have  heard  instance 
after  instance  proving  this  repressive  tendency  deplored  by 
superintendents,  who  perceive  the  hedging  in  of  the  nurse's 
initiative  with  her  patient  in  nursing  ways. 

If  our  hospital  work  were  made  all  that  it  might  be 
made,  the  argument  that  pupils  need  private  duty  in 
families  would  fall  to  the  ground. 


146  International  Congress  of  Nurses 

THE   EXTENSION    OF   CO-OPERATION    IN  THE 
THREE  years'  course. 

Some  encoiiragino;-  advances  are  beinj^  made  in  this 
direction — much  more,  however,  remains  to  be  done.  Some 
of  our  most  vexations  problems  would  be  solved  if  each 
lar^S^e  school  could  make  itself  responsible  for  the  nursing 
of  one  or  two  small  and  incompletely  equipped  institutions 
which  are  now  compelled  to  conduct  their  own  training 
schools ;  or,  if  several  such  hospitals  should  agree  upon 
maintaining  co-operatively  a  central  school  which  should 
provide  the  nursing  for  all,  thus  giving  one  set  of  pupils  a 
wide  and  full  education,  instead  of  turning  out  several  sets 
each  with  a  comparatively  restricted  teaching.*  These  sug- 
gestions, made  many  times  by  others,  will  no  doubt  in  time 
be  utilized  in  practice. 


Tlie  President:     The  paper  is  open  for  discussion. 

Miss  Chappell :  I  think  graduate  nurses  all  under- 
stood, when  the  three  years'  course  was  started,  that  private 
duty  in  the  course  was  abolished.  Yet  many  schools  are 
sending  out  nurses  in  the  third  year,  and  if  the  superin- 
tendents cannot  do  away  with  it  entirely  we  must  appeal  to 
our  alumnae  societies  to  take  up  the  matter.  I  think  if 
our  associations  presented  letters  on  the  subject  to  hospital 
boards,  where  this  is  practiced,  that  w'e  could  have  some- 
thing done  to  put  an  end  to  it.  I  have  known  of  nurses 
being  out  for  as  much  as  six  months,  and  though  I  think 
private  nursing  is  good  training  I  do  not  think  pupils 
should  be  sent  to  wealthy  families  who  are  abundantly 
able  to  employ  a  graduate  nurse.  I  know^  many  nurses  feel 
strongly  on  this  matter  and  I  am  one  of  them. 

O.     But  you  think  the  private  duty  is  beneficial  ? 

A.  I  think  some  training  in  private  duty  is  very  nec- 
essary, and  ward  nursing  does  not  fit  one  for  it. 

*Such  an  arrangement  exists  in  Washington,  where  the  Children's  and 
the  Columbia  Hospitals  have  for  some  years  conducted  a  training  school 
co-operatively. 


The  Three  Years'  Course  147 

Mrs.  Robb:  So  far,  the  associated  alumnae  has 
required  two  full  years  of  training  in  the  hospital  wards, 
as  when  it  was  founded  that  was  the  course.  The  three 
years'  course  has  developed  since  then. 

Mis  Peters :  I  was  trained  under  a  two  years'  course, 
and  we  spent  our  second  year  in  private  nursing.  The 
school  now  has  three  years,  and  the  pupils  are  sent  out  in 
the  last  year.  I  think  it  is  an  injustice  to  the  nurse,  who 
should  have  the  benefit  of  her  third  year  in  training.  This 
matter  has  been  discussed  in  our  alumnae  association,  and 
we  hope  in  time  to  do  away  with  sending  out  pupils. 

Miss  Hay :  In  the  school  where  I  was  trained  the 
nurses  obtain  this  experience  in  nursing  private  patients 
which  is  so  desirable,  without  underbidding  the  graduate 
nurse.  We  call  it  "  special  duty."  The  third  year  nurse  has 
a  service  in  caring  for  one  private  patient  at  a  time,  in  the 
pay  wards.  The  head  nurse  is  not  held  responsible  for  the 
"  special's  "  work,  but  the  nurse  is  solely  in  charge  of  the 
patient  and  is  responsible  to  the  doctor,  as  she  would  be 
outside.  This  gives  her  the  confidence  and  self-reliance 
that  she  needs. 

Mrs.  Fenwick :  Miss  Dock's  suggestions  are  so  numer- 
ous that  I  shall  confine  my  remarks  to  two  points.  First 
with  regard  to  the  all  important  question,  the  term  of  train- 
ing. When  T  began  nursing  twenty-three  years  ago  the 
generally  accepted  term  was  one  year:  it  was  gradually 
extended  to  two,  and  in  England,  during  the  past  decade,  it 
has  become  almost  universal  for  nurses  to  be  given  a  three 
years'  course  of  practical  training  in  the  wards,  before  they 
are  examined  finally  and  certificated.  Now  we  are  proving 
that  three  years  is  all  too  short  a  time  for  a  nurse  to  per- 
fect herself  in  general  nursing  and  in  all  the  specialties,  such 
as  maternity  and  fever  nursing,  and  as  the  majority  of  train- 
ing schools  contain  no  facilities  for  clinical  experience  in 
obstetrics     and     infectious    fever    nursing,     these    special 


148  International  Congress  of  Nurses 

branches  must  be  learnt  after  graduation.  Several  of  the 
large  London  hospitals  have  extended  the  term  of  train- 
ing to  a  four  years'  course.  Personally  I  am  in  favor  of  a 
three  year's  course  in  a  general  hospital,  to  which  special 
departments  are  not  attached, — a  fourth  year  may  thus  be 
usefully  employed  gaining  practical  experience  in  special 
work,  and  in  the  duties  of  matron,  and  domestic  manager. 
Nothing  under  the  three  years'  course  can  suffice,  as  after 
a  probationer  has  learnt  the  elements  of  the  theory  and  prac- 
tice of  nursing  she  requires  time  to  digest  and  use  her 
knowledge,  and  become  skilled  in  its  performance. 

If  we  appreciate  the  lessons  we  have  been  taught  in 
past  ages,  we  grasp  that  no  good  work  can  be  done  in  a 
hurry.  In  the  past  a  long  and  arduous  apprenticeship  was 
compulsory  before  a  man  could  hope  to  become  a  master 
craftsman,  and  we  have  only  to  compare  the  artistic  value 
of  the  handiwork  of  the  long-time  apprentice,  with  the 
shoddy  productions  of  our  own  time,  to  realize  the  necessity 
for  perseverance  before  we  can  hope  for  perfection. 

'Secondly,  with  regard  to  the  undergraduate  nurse  being 
sent  out  to  private  duty,  I  strongly  deprecate  it — it  is  abso- 
lutely indefensible,  it  is  equally  unjust  to  pupil  nurse  and 
patient.  It  is  true  that  we  have  not  yet  defined  a  standard 
for  a  trained  nurse  and  that  we  do  not  give  a  legal  guarantee 
of  training  to  the  public,  but  whether  the  course  be  two  or 
three  years,  it  should  be  completed  by  the  pupil,  without 
interruption,  and  we  should  deal  honestly  with  a  defenceless 
public,  who  would  doubtless  object  to  pay  high  fees  for 
the  services  of  undergraduates,  if  they  knew  that  their  near- 
est and  dearest  were  placed  at  their  mercy.  The  system  of 
training  private  nurses  is  also  important.  I  am  inclined  to 
think  the  system  in  England  leaves  much  to  be  desired.  In 
Canada  and  the  States  it  is  different,  and  I  have  been 
immensely  impressed  by  the  fact  that  the  admission  of  pay 
patients  into  all  the  best  hospitals  provides  a  means  of 
educating  nurses  for  private  practice  in  the  best  possible 
manner.  In  attending  upon  the  pay  patients  in  their  single 
rooms,  nurses  have  to  perform  numerous  duties  for  the  sick 


The  Three  Years'  Course  149 

for  which  they  would  not  have  time  in  a  general  ward; 
moreover,  in  those  hospitals  where,  in  special  diet  kitchens, 
the  nurses  are  taught  to  cook  and  serve  all  the  food  for  a 
refined  class  of  patients,  they  become  conversant  with  a  sys- 
tem which  as  yet  has  not  been  attempted  at  home.  Our 
nurses  go  straight  out  of  the  general  hospital  wards,  into 
which  only  the  very  poor  are  admitted,  to  nurse  in  private 
houses,  and  to  wait  upon  patients  of  very  different  habits. 
It  is  not  surprising  that  many  fail  to  satisfy  the  medical 
officer  and  the  patients'  friends.  So  chaotic  are  private  nurs- 
ing afifairs  in  England,  that  well  educated  trained  nurses  are 
protecting  themselves  from  the  competition  of  the  unfit  by 
forming  themselves  into  co-operative  societies,  each  mem- 
ber paying  7|%  of  her  fees  to  maintain  the  organization. 
There  is  a  central  office  with  a  telephone,  secretaries  and 
other  general  expenses.  A  standard  of  training  can  thus  be 
enforced,  and  also  if  the  superintendent  is  a  well  qualified 
nurse,  as  she  ought  to  be,  good  discipline  amongst  the  mem- 
bers. Fees  are  collected  for  the  members  and  the  com- 
mittee can  carefully  consider  any  complaint  which  may  be 
made  against  them.  I  think  the  future  of  the  private  nurse 
is  largely  dependent  upon  commercial  co-operation. 

Miss  Banfield :  It  may  be  interesting  to  you  to  know 
that,  in  looking  over  the  hospital  statistics  in  connection 
with  Miss  Peter's  remarks,  I  notice  that  the  hospital  board 
took  in  between  $2,000  and  $3,000  in  a  year  for  the  services 
of  the  pupil  nurses.  This  was  turned  into  the  general  fund 
of  the  hospital. 

Miss  Peters :  I  think  that  goes  toward  supporting  the 
nurses"  school. 

Miss  Banfield :  It  is  quite  impossible  to  tell  what  it  is 
for. 

Miss  Stewart:  In  the  hospital  with  which  I  have  the 
honor  to  be  connected  the  term  of  training  for  nurses  is 
three  years,  but  we  bind  them  to  remain  four  years,  that  is, 


150  International  Congress  of  Nurses 

for  one  year  after  they  have  obtained  their  certificate.  Dur- 
ing- the  first  three  years  they  are  twice  examined,  and  if 
their  practical  and  theoretic  work  has  been  found  to  be  quite 
satisfactory,  they  are  awarded  a  certificate  of  efficiency.  In 
the  fourth  year  they  receive  payment  as  fuUy  quahfied 
nurses.  The  fourth  year  is  spent  either  in  the  hospital  or  on 
the  private  nurse's  staff.  I  attach  great  importance  to  this 
last  year ; the  nurse  has  up  till  then  had  no  real  responsibility, 
but  now  nnich  is  expected  of  her,  she  gets  some  authority, 
she  is  more  her  own  mistress,  has  more  liberty,  is  less  looked 
after,  and  learns  to  stand  by  herself  with  some  assistance 
from  those  who  have  already  learned  to  walk.  In  fact  she 
has  now  time  to  arrange  and  estimate  her  knowledge  and 
experience,  and  to  deepen  the  channel  of  her  life.  The 
enormous  benefit  of  that  year  to  the  nurse  is  the  develop- 
ment of  her  character,  which  in  many  instances  the  acute 
observer  can  see  in  her  expression.  Its  value  to  the  hospi- 
tal is  also  great,  as  it  provides  for  the  continual  presence  of 
a  fully  trained  nurse  in  the  wards,  the  care  of  the  patients  is 
therefore  never  left,  even  for  a  few  hours,  in  the  hands  of 
half  trained  unqualified  women. 

Mrs.  Robb :  Are  they  on  the  same  basis  in  the  fourth 
year  as  the  third? 

Miss  Stewart :  We  have  in  every  ward  a  "  Sister  " 
who  has  been  for  some  years  in  the  service  of  the  hospital ; 
she  is  in  full  charge  of  the  ward,  and  the  certificate  nurse  is 
immediately  under  her  in  authority.  If  the  sister  is  out, 
ill,  or  for  any  cause  absent  from  the  hospital,  the  certificated 
nurse  takes  her  place.  If  the  assistant  matron,  my  secretary, 
or  one  of  the  night  superintendents  are  ofif  duty,  I  take  the 
most  capable  of  those  qualified  nurses  to  fill  her  place,  and 
there  is  always  one  nurse  assisting  in  the  housekeeping  in 
the  nurses'  home.  In  this  way  they  gain  much  experience 
which  is  useful  to  them  later. 

Mrs.  Robb :    And  the  compensation — is  that  the  same  ? 


The  Three  Years'  Course  151 

Miss  Stewart :  They  are  paid  $12  a  month  during  the 
fourth  year,  which  is  good  pay  for  a  hospital  nurse  in  Eng- 
land. If  a  nurse  remains  longer  than  four  years  her  salary 
is  raised  to  about  $17  a  month. 

We  have  a  staff  of  private  nurses  in  connection  with 
the  hospital,  whose  headquarters  are  in  a  house  near  the 
hospital,  but  quite  apart  from  it.  No  nurse  is  sent  out  to 
do  private  nursing  until  she  has  obtained  her  certificate  of 
three  years  efficient  service  in  the  hospital.  When  she  is 
not  at  a  case  she  can  live  in  the  home,  and  is  therefore 
spared  the  expense  of  keeping  an  apartment.  She  is  paid  a 
salary  of  $12  a  month  and  in  addition  she  has  15%  rising  to 
30%  on  her  earnings. 

Miss  Hughes :  As  a  representative  of  one  of  the  large 
hospitals  and  training  schools,  Guy's  Hospital,  I  would  like 
to  say  that  the  course  of  training  there  is  on  the  same  lines 
as  St.  Bartholomew's,  as  described  by  Aliss  Stewart.  The 
nurses  are  trained  for  three  years,  and  receive  their  certi- 
ficate at  the  end  of  that  time.  The  private  nursing  institu- 
tion is  attached  to  the  hospital,  but  has  quite  distinct  prem- 
ises and  constitution.  It  maintains  forty-two  pupil  nurses  in 
training  at  the  hospital,  and  only  supplies  the  public  with 
fully  trained  graduate  nurses,  who  receive  a  fixed  salary. 
The  net  profit  earned  in  fees  by  the  institution  is  divided 
amongst  the  senior  nurses  to  be  applied  in  the  provision 
of  old  age  pensions. 

Dr.  Hughes :  How  old  are  they  when  they  begin  their 
training  ? 

Miss  Stewart:  We  receive  candidates  at  the  age  of 
21  years  on  payment  of  a  fee.  We  also  receive  free 
candidates  at  the  age  of  23  years.  They  all  have  to 
serve  three  years  before  they  obtain  their  certificate,  and  one 
year  after  that,  but  in  the  former  case  the  hours  are  shorter 
and  the  work  somewhat  lighter  during  the  first  six  months. 

Question :  All  nurses  are  obliged  to  remain  four  years 
then?     It  is  optional  with  them? 


152  International  Congress  of  Nurses 

Miss  Stewart :  It  is  not  optional.  The  candidates  sign 
an  agreement  before  entering  the  service  of  the  hospital,  in 
which  they  promise  to  remain  in  its  service  for  a  period  of 
four  years,  the  fourth  year  being  spent  as  stafT  nurse  in  the 
hospital,  or  on  the  private  stafif  of  nurses. 

Miss  Wood :  I  just  want  to  say  a  word  about  pre- 
liminary training,  going  back  to  the  beginning  of  things. 
I  have  seen  a  very  great  deal  of  physical  break-down  on  the 
part  of  the  nurses,  from  having  the  theory  and  practice 
carried  on  simultaneously ;  the  poor  nurse  with  aching  feet 
and  tired  muscles,  after  her  hard  work  in  the  day,  goes  into 
her  room,  throws  herself  on  her  bed,  and  with  her  text  book 
endeavors  to  acquaint  herself  with  the  theory.  I  am  down 
to  the  ground  in  accord  wdth  the  argument,  that  the  phy- 
siology, hygiene,  etc.,  can  be  gone  through  wdth  before  we 
go  into  the  wards,  and  if  it  was  so  planned  it  would  make  a 
very  great  difference.  Take  the  average  woman  who  comes 
into  the  hospital  and  is  turned  into  the  ward,  what  does  she 
know  of  the  language  of  the  hospital,  I  mean  of  the  use  of 
the  technical  terms  ?  She  is  told  to  go  and  bring  some- 
thing; some  appliance  of  some  kind,  and  she  rushes  off 
thinking  the  whole  time  she  only  hopes  she  may  bring  the 
right  thing.  That  means  mental,  physical  wear  and  tear. 
If  before  she  comes  into  the  hospital  wards  she  has  had 
the  various  implements  pointed  out  to  her  and  named,  when 
she  comes  into  the  ward  and  is  told  to  go  after  something, 
she  will  go  and  get  it.  I  do  think  the  present  arrange- 
ment by  which  nurses  are  taught  theory  and  practice  at  the 
same  time  is  one  of  the  great  reasons  for  their  breaking 
down. 

Speaking  from  my  own  experience,  (and  I  stand  before 
you  not  as  a  trained  nurse,  because  there  was  no  training 
in  my  da},  but  we  learned  from  practice,  without  theory,) 
I  remember  quite  well  when  I  was  first  in  the  hospital  being 
told  to  put  a  poultice  on  the  back  of  the  chest.  Where  on 
earth  was  the  back  of  the  chest  ?     I  really  did  not  know. 

I  do  hope  that  we  shall  find  out  some  means  by  which 


The  Three  Years'  Course  153 

we  can  teach  our  pupils  theory  and  practice  somewhat 
apart.  I  agree  most  thoroughly  with  these  suggestions  on 
that  matter. 

Mrs.  Robb:  The  object  in  creating  the  third  year  of 
training  in  this  country  was  intended  to  be  educational  and 
for  the  benefit  of  the  nurse,  but,  so  far  as  I  can  see,  to  the 
present  time  the  greater  benefit  has  been  to  the  hospitals. 
We  found  that  it  was  utterly  impossible  in  two  years  to 
cover  a  systematic  course  of  training.  Some  of  the  subjects 
were  too  advanced  for  the  second  year,  and  were  obviously 
third  year  subjects. 

And  in  addition  the  hours  in  the  wards  were  too  many 
and  the  work  too  hard  to  require  at  the  same  time  a  definite 
course  of  theoretical  study,  more  time  was  needed.  There- 
fore when  the  third  year  was  advocated  at  our  first  National 
Congress,  that  the  nurse  should  not  be  required  to  spend 
more  than  eight  hours  out  of  the  twenty-four  in  practical 
work  in  the  hospital,  and  that  a  certain  portion  be  devoted 
to  her  theoretical  instruction,  it  met  with  approval,  but  that 
feature  has  not  been  attained  except  in  two  or  three  in- 
stances I  am  sorry  to  say,  and  the  same  old  hours,  nine, 
ten.  eleven,  and  sometimes  twelve  or  even  more,  are  re- 
quired of  our  pupil  nurses  in  our  hospitals. 

Unannounced :  I  would  like  to  say  just  one  word  and 
that  is  that  I  represent  a  hospital  where  practically  the  idea 
that  ]Miss  Stewart  has  presented  is  upheld.  We  have  been 
able  to  do  much  in  the  way  of  shortening  nurses'  hours,  but 
I  have  been  told  repeatedly  by  the  nurses  themselves  how 
much  they  appreciated  their  third  year,  and  how  much 
they  learned  in  their  third  year. 

]\Iiss  Peters :  I  would  like  to  add  that  our  hospital  in 
connection  with  its  three  years'  course  gives  a  year's  course 
to  the  nurses  immediately  after  they  graduate,  and  there  is 
a  certificate  given  at  the  end  of  that  time,  the  fourth  year. 
It  is  not  compulsory  and  they  are  paid  $25  per  month.  I 
do  not  wish  to  be  understood  that  I  disapprove  of  the  three 


154  International  Congress  of  Nurses 

year  course,  but  I  do  disapprove  of  sending  nurses  out.  I, 
myself,  was  at  private  duty  almost  all  of  the  time  during  my 
last  year,  and  missed  all  of  the  important  lectures ;  finally 
I  requested  to  be  kept  in,  and  when  in  I  sat  up  nights,  and 
got  up  at  4  and  5  o'clock  in  the  morning  to  study  for  my 
examinations. 

Miss  Early :  After  hearing  so  much  from  so  many 
nurses  I  feel  there  is  little  for  me  to  say,  but  I  would  like 
to  advocate  the  three  years'  course.  I  did  not  have  it  myself, 
for  the  simple  reason  that  my  school  was  small — I  had  a 
two  years'  course ;  now  I  have  had  seven  months'  experience 
as  matron,  and  I  feel  that  the  two  years  is  too  crowded. 
We  try  to  get  applicants  who  have  had  a  high  school  educa- 
tion, and  to  give  them  all  we  can,  but  a  long  day's  work 
makes  one  too  tired  to  study.  If  it  were  not  for  the  nursing 
journals  we  would  fall  behind  in  many  things.  I  have  been 
much  impressed  and  benefited  by  this  Congress. 

Miss  Barnard  :  I  would  request  that  some  of  those  who 
have  had  experiences  on  the  non-payment  side  of  the  three 
year  course  would  relate  them. 

Mrs.  Robb :  There  are,  I  think,  eight  hospitals  on  the 
non-payment  system.  The  whole  idea  was  io  have  a  three 
years'  course,  eight  hours  practice  in  the  wards  and  non- 
payment. The  whole  course  was  to  be  on  the  non-payment 
basis.  In  all  our  old  circulars  of  information  we  added  a 
paragraph  saying,  that  for  the  first  year  seven  or  nine  dollars 
monthly  remuneration  would  be  allowed,  and  the  second 
year  a  little  less  was  given,  and  in  the  next  sentence  it  read 
that  this  was  not  intended  as  remuneration,  but  for  text 
books,  uniforms,  etc.  I  could  never  understand  why' 
less  was  given  the  first  year  when  everything  had  to 
be  supplied.  And  when  I  became  superintendent  it 
seemed  to  me  better  to  put  the  whole  thing  on  an 
educational  basis.  The  students  work  for  what  they  get  in 
the  way  of  an  education,  and  they  value  what  they  get,  but 


The  Three  Years'  Course  155 

it  seems  to  me  no  more  than  fair  that  the  hospital  should 
in  return  furnish  the  uniforms  and  text  books  for  their 
work.  I  think  if  we  all  look  back  we  can  recall  how  our 
money  was  spent  each  month,  how  much  of  it  went  for  uni- 
forms and  text  books.  I  do  know  from  my  own  experience 
as  a  pupil  that  much  money  was  spent  on  sweets,  as  we 
called  them,  and  on  good  times,  but  that  money  was  really 
given  to  us  in  trust  to  spend  on  uniforms  and  text  books. 

Miss  Dock :  While  it  seems  extravagant  to  spend 
much  money  on  cakes  and  candies  we  know  now  that  there 
is  a  physiological  necessity  at  the  bottom  of  the  nurse's 
craving  for  sweets.  Scientific  experiments  in  feeding  armies 
have  shown  that  soldiers  can  do  more  and  harder  work  on 
a  diet  of  sugar. 

Miss  Palmer:  In  my  experience  as  superintendent  I 
have  always  tried  to  teach  my  pupil  nurses  that  the  money 
allowed  them  by  the  hospitals  for  uniforms  and  text  books 
was  to  be  used  first  for  that  purpose.  That  they  must  pro- 
vide themselves  with  proper  uniforms  and  text  books  and 
then  if  they  could  save  anything  they  could  use  it  in  any 
way  they  chose.  The  hospital  should  provide  nurses  with 
an  ample  diet,  including  the  sweets  needed. 

The  President :  This  discussion  is  most  interesting,  but 
we  shall  be  obliged  to  go  on  to  our  next  paper,  post-graduate 
work  in  hospitals. 


Post-Graduate  Instruction   for  Nurses, 


M.  HELENA  McMILLAN,  B.  A. 

Superintendent  of  Nurses,  Lakeside  Hospital,  Cleveland; 
Member  Superintendents'  Society. 


So  busy  have  nurse  educationalists  been  in  solving-  the 
problem  of  correct  education  for  the  would-be  nurse  that,  as 
yet,  very  little  time  and  thought  have  been  devoted  to  the 
more  advanced  course  of  instruction  by  which  the  woman 
who  is  already  a  graduate  nurse  may  gain  additional 
experience  and  knowledge  in  her  chosen  work. 

Some  effort,  however,  has  been  made  in  several  of  the 
American  hospitals  to  meet  this  need.  A  few  of  the  schools, 
willing  to  be  of  further  assistance  to  the  nurses  to  whom 
they  have  already  given  the  preliminary  training,  have 
attempted  to  provide  post-graduate  work  for  the  alumnse. 
In  most  instances  this  has  resolved  itself  into  granting  such 
graduates  as  may  wish  it  the  privilege  of  returning  to  the 
hospital  for  a  short  period  during  the  school  vacation  time 
and  of  allowing  them  to  take  up  what  work  they  choose  in 
the  wards  or  operating  rooms.  Sometimes,  in  addition, 
theoretical  instruction  in  the  form  of  lectures  has  been 
attempted. 

No  claim  is  made  by  these  schools  of  giving  a  regular 
post-graduate  course;  they  are  merely  attempting  to  assist 
their  graduates  in  the  only  way  which  ofifers.  Undoubtedly 
this  opportunity  of  again  coming  into  contact  with  hospital 
methods  and  of  observing  advances  in  all  branches  of  the 
work  is  of  great  value  to  the  nurse  who  is  fortunate  enough 
to  be  a  graduate  of  a  school  sufficiently  old,  liberal  in 
thought,  and  strong  in  finances  to  allow  it  to  attempt  such 
156 


Post-Gr actuate  Instruction  for  Nurses  157 

an  undertaking-.  As  far  as  it  goes  it  is  grood,  but  it  does  not 
go  far  enough ;  is  not  a  permanent  educational  feature,  and 
reaches  only  a  very  limited  number  of  nurses.  The  schools 
which  are  able  to  undertake  even  this  most  simple  form  of 
post-graduate  work  are  few  in  number  and  fewer  still  are 
they  which  are  capable  of  keeping  up  this  effort  year  after 
year,  and  of  continuing  to  meet  the  needs  of  their  graduates. 

Schools  for  nurses  connected  with  our  modern  hospi- 
tals, if  they  carry  out  the  purposes  for  which  they  are  estab- 
lished— that  is,  of  nursing  the  sick  of  the  hospital  and  of 
educating  women  to  be  nurses — do  about  as  much  as  such 
institutions  with  their  present  limited  stafif  of  teachers  can 
successfully  accomplish.  If  the  same  teaching  force,  in  a 
spirit  of  g-enerous  self-sacrifice  for  the  good  of  the  cause, 
undertakes  in  addition  post-graduate  work,  without  ques- 
tion sooner  or  later  the  added  strain  will  be  detrimental  to 
the  teaching  staff,  and  consequently  to  the  school  and  to  the 
institution.  Should  hospital  authorities  be  willing  to  pay 
additional  salaries  and  provide  extra  teachers  to  carry  on 
this  work,  the  question  would  assume  a  different  form  ;  but 
until  such  a  time  arrives  it  is  doubtful  whether  heads  of 
schools,  in  justice  to  their  other  work,  should  attempt  post- 
graduate teaching. 

Colleges  and  universities  have  found  it  impracticable 
to  deal  with  pupil  and  graduate  at  one  time.  There  are 
instances  on  record  of  the  college  student  making  complaint 
that  material  necessary  for  the  undergraduate  had  been 
utilized  for  the  graduate.  These  complaints,  as  a  rule,  have 
been  listened  to  and  the  demands  of  the  students  met.  Post- 
graduate work  has  not  been  ignored  in  the  several  profes- 
sions, but  provision  for  it  is  made  entirely  outside  of  the 
ordinary  schools  of  instruction.  The  same  should  hold 
good  in  nurses'  schools.  In  most  hospitals,  with  propor- 
tionately large  or  small  schools  attached,  and  particularly 
since  the  three  years'  course  is  required,  not  only  the  time 
of  the  teachers  belongs  to  the  school  but  the  material  for 
study  and  opportunities  for  experience  should  be  given  to 
the  pupil,  not  to  the  graduate. 


158  International  Congress  of  A^itrses 

The  undoubted  spirit  of  unrest  which  is  sure  to  accom- 
pany the  advent  of  qraduates  into  a  nurses'  school  is 
another  reason  why  these  schools  are  not  the  right  places 
for  post-graduate  work. 

In  several  of  the  cities  of  the  United  States  there  are 
hospitals  devoted  to  specialties,  offering  post-graduate 
training  in  that  one  branch  of  the  work  to  any  nurse  who  is 
a  graduate  in  good  standing  of  an  approved  nurses'  school. 
These  hospitals  give  from  three  to  nine  months'  course  in 
practical  w'ork,  with  usually  some  theoretical  instruction. 
Most  of  them  pay  a  salary  of  from  ten  to  fifteen  dollars  per 
month,  and  require  the  nurse  to  w-ear  the  hospital  uniform. 
To  the  nurse  who,  having  completed  the  course  in  her  own 
school,  feels  that  her  training  has  been  lacking  in  certain 
branches,  these  courses  in  special  hospitals  are  of  value.  It 
is  only  a  small  class  of  nurses,  however,  to  which  these 
special  courses  appeal. 

The  average  woman  who  has  graduated  from  a  school 
giving  instruction  in  all  branches  of  nursing,  when  she 
\vishes,  for  one  reason  or  another,  for  post-graduate  instruc- 
tion, usually  feels  the  necessity  of  a  general  "  brush-up." 
The  new  methods  adopted  since  her  graduation  are  wdiat  the 
private  nurse  wants  more  particularly,  while  she  who  has 
dropped  out  of  the  field  of  actual  nursing  into  executive 
work  realizes  her  need  of  an  all-round  course  of  study. 

In  some,  if  not  most,  of  the  post-graduate  courses, 
the  graduate,  like  the  pupil,  receives  her  training  by  doing 
the  entire  nursing  of  the  institution.  She  has  practically  the 
same  working  day — usually  nine  hours — which  she  labored 
through  in  her  training  school  period.  Her  work  differs  from 
her  school  w'ork  in  being  of  a  special  nature,  but  not  other- 
wise ;  the  same  amount  of  work,  if  not  more,  is  expected  to 
be  accomplished  ;  there  being  no  probationer,  she  must  scrub 
basins,  clean  bath  rooms,  dust  and  do  other  work  wdiich 
in  a  school  the  senior  nurse  is  usually  relieved  of. 

It  is  far  from  the  intention  of  this  paper  to  criticize 
post-graduate  hospitals  and  their  methods.  If  these  institu- 
tions receive  graduates   for  instruction  and  depend  upon 


Post-Graditate  Instruction  for  Nurses  159 

them  to  nurse  their  patients,  naturally  the  first  consideration 
must  be  given  to  the  patients  and  to  the  accompHshment 
of  the  routine  duties  of  the  institution.  In  preference  to 
dirty  basins  and  bath  rooms  and  undusted  rooms,  the 
graduate  must  scrub  and  clean  and  dust.  But  the  question 
to  be  asked  is,  "  Is  the  graduate  getting  what  she  wants  and 
needs  out  of  post-graduate  work  ?  Has  she  time  and 
strength  to  devote  to  the  work  now  expected  from  her  in  a 
post-graduate  hospital  ?" 

Few  women  who  have  completed  a  two  or  three  years' 
course  in  a  nurses'  school  and  then  devoted  from  five  to 
fifteen  or  even  more  years  to  nursing  are  willing  or  able  to 
make  such  an  expenditure  of  their  strength. 

•  i\s  far  as  the  writer  could  find,  with  the  exception  of 
the  few  schools  which  are  attempting  to  provide  for  their 
own,  there  is  no  general  hospital  open  to  the  graduate  nurse, 
so  that,  even  if  she  would  spend  time  and  money  and 
strength,  no  post-graduate  work — in  other  than  the  special- 
ties, is  available. 

If  the  foregoing  statements  be  true — namely,  that 
nurses'  schools  cannot  undertake  post-graduate  work,  that 
special  post-graduate  courses  meet  the  need  of  a  very  limited 
class  of  nurses,  and  that  no  general  hospitals  are  olifering 
these  opportunities — we  must  acknowledge  that  in  reality 
there  is  no  post-graduate  instruction  for  nurses  in  the 
country.  That  there  is  necessity  for  this  instruction  and  a 
desire  for  it  felt  by  nurses  in  general  is  beyond  dispute.  Such 
being  the  case,  it  would  seem  that  something  should  be  done 
to  meet  the  demand. 

As  it  is  nurses  who  feel  this  need,  and  nurses  who  will 
be  benefited,  naturally  it  must  be  the  nurses  tliemselves  who 
will  work  out  the  problem  and  establish  such  courses  of 
instruction  as  they  wish.  The  time  for  depending  upon 
others  for  every  step  in  the  road  of  progress  is  long  past. 
Nurses  are  strongly  united  now,  and  thoroughly  capable 
of  meeting  this  demand. 

Over  two  years  ago  there  was  organized  a  course  in 
Hospital  Economics  at  Columbia  University.    The  object  is 


IGO  International  Congress  of  Nurses 

to  prepare  women  to  be  teachers  in  nurses'  schools.  The 
announcement  for  1901-1902  states  that  "  Six  students  are 
completing  the  course  for  the  year  1900-1901,  and  it  is  hoped 
that  at  least  as  large  a  class  will  be  formed  for  the  coming 
year.  Should  any  nurse  of  exceptional  ability  come  under 
your  notice,  we  trust  you  will  place  the  advantages  of  the 
course  before  her."  Further  on  the  report  says,  "  The 
expenses  for  the  past  year  were  met  in  part  by  contributions 
from  many  individual  superintendents  of  training  schools. 
Since  then  no  improvement  has  taken  place  in  the  financial 
condition,  and  for  the  coming  year  there  is  no  present  pros- 
pect of  any  other  contributions,"  and  so  on. 

The  reasoning  which  leads  up  to  the  following  con- 
clusion may  be  wrong,  but  it  seems  to  the  writer  that  if  this 
course,  instead  of  being  planned  for  only  nurses  of  "  excep- 
tional ability  "  or  for  those  who  wish  to  be  teachers,  were 
arranged  to  suit  all  graduates ;  if  the  "  hospital  economics  " 
course  could  be  made  simply  a  specialty  of  the  whole  with 
another  division  devoted  to  practical  nursing  and  new 
methods,  and  the  whole  recognized  as  post-graduate  work, 
that  the  present  object  of  training  teachers  would  not  suf- 
fer. It  does  not  seem  unreasonable  to  predict  that  large 
classes  of  nurses  taking  up  the  practical  nursing  course 
would  assist  by  their  fees  very  materially  to  meet  the 
expenses  involved. 

Should  this  come  to  pass,  the  National  Alumnae  Asso- 
ciation and  nurses  at  large  would  be  interested  and  feel 
called  upon  to  assist,  and  no  longer  would  the  financial 
burden  fall  on  training  school  superintendents  who  are 
unable  to  bear  it  indefinitely. 

It  is  beyond  the  scope  of  this  paper  and  the  ability  of 
the  writer  to  attempt  to  suggest  the  desired  schedule  of 
instruction.  Without  doubt,  there  would  be  difficulties  to 
overcome ;  hospitals  would  have  to  be  found  which  would 
open  their  doors  to  graduate  nurses  on  an  entirely  new 
basis. 

Such  questions,  as  all  others  on  this  subject,  must  be 
handed  over  for  solution  to  the  wise  decision  of  the  com- 


Post-Gradiiate  Instruction  for  Nurses  161 

mittee  on  the  Teachers'  Course.  The  object  of  this  paper 
would  be  accomplished  if  it  could  persuade  that  committee 
to  consider  this  matter  and  if  possible  enlarge  the  present 
undeniably  narrow  field  of  work  to  include  all  nurses. 

If  such  a  thing  could  be  brought  about,  an  inestimable 
boon  would  be  conferred  upon  the  graduate  nurses  of  the 
country,  and  it  would  seem  that  the  question  of  post- 
graduate work  would  be  solved  in  the  most  satisfactory 
manner  possible. 

Miss  Fuller:  It  is  with  satisfaction  as  well  as  with 
interest  I  have  noticed  that  the  necessity  for  the  develop- 
ment of  post-graduate  work  is  being  recognized  more  and 
more  each  year.  Most  large  hospitals  now  allow  their  own 
graduates  to  return  to  them  for  two  or  three  months'  ward 
work. 

Certain  opportunities  are  given  those  who  have  only 
had  the  advantages  afiforded  them  by  the  training  in  a  small 
hospital.  To  illustrate  I  will  give  a  short  outline  of  post- 
graduate work  as  it  is  conducted  at  the  Woman's  Hospital 
in  New  York.  Here  all  pupils  must  be  graduates,  and  they 
come,  as  a  rule,  from  small  hospitals.  The  nurses  are  on 
duty  from  seven  to  seven,  with  two  hours  ofif,  daily,  and  one 
afternoon  each  week.  Classes  and  lectures  are  held  weekly. 
Class  work  consists  of  systematic  instruction  in  practical 
nursing,  in  hygiene,  materia  medica,  anatomy,  physiology, 
and  gynecology.  A  course  of  lectures  is  given  by  the  dif- 
ferent surgeons ;  notes  are  taken  by  the  pupils,  written  out, 
and  handed  in  for  correction.  A  course  in  massage  is  also 
given  by  a  competent  masseuse,  and  one  in  the  diet  kitchen 
under  a  trained  teacher.  The  whole  course  is  nine 
months.  The  pupils  spend  a  definite  time  in  each 
ward,  the  treatment  room,  the  operating  room,  and  on 
night  duty.  Each  ward  has  a  different  surgeon,  with  his 
own  methods,  so  the  nurses  have  wide  experience  and  gain 
much  in  knowledge.  Each  ward  has  as  head  nurse  a 
graduate  of  some  large  general  hospital.  The  operating 
room  is  also  in  charge  of  a  permanent  head  nurse.     The 


162  International  Congress  of  Nurses 

surgical  technique  is  quite  perfect,  and  the  pupils'  course 
includes  every  detail,  including  the  after-care  of  operative 
cases,  who  are  placed,  two  each,  in  cottages  on  the  hospital 
grounds.  As  a  rule,  one  nurse  cares  for  two  patients,  by 
day,  and  another  by  night ;  serious  cases  have  a  special. 
One  head  nurse  superintends  the  cottages  and  teaches  the 
nurses. 

The  pupils  receive  $15  per  month,  with  board  and 
laundry.  At  the  end  of  their  service  they  must  pass  a  satis- 
factory examination  before  the  medical  board,  before  receiv- 
ing the  diploma  of  the  hospital.  It  was  most  interesting  to 
note  the  development  of  many  imperfectly  taught  nurses 
under  this  training.  It  is  an  excellent  experience  for  any 
graduate,  wherever  trained.  It  broadens  one,  and  I  look 
back  upon  the  months  spent  there  as  well  spent. 


The  President :  The  next  paper  we  will  take  up  is  on 
nursing  the  insane,  by  Miss  Laird,  Superintendent  of 
Nursing,  State  Hospital  for  the  Insane,  Seneca  County, 
New  York. 


The  Nursing  of  the  Insane. 

S.  LOUISE  LAIRD, 

Matron  and  Superintendent  of  Nursing,  Willard  State  Hospital. 


The  history  of  the  insane  from  earliest  times  to  the 
present  day  presents  strange  contrasts  of  ill-treatment  and 
favor.  Among-  the  Mohammedans  it  was  believed  that  they 
were  the  blessed  of  God,  and  that  their  souls  were  removed 
early  as  a  mark  of  partiality.  The  Orientals  regarded  their 
ravings  as  inspirations,  and  they  were  treated  with  marked 
respect  and  kindness ;  even  among  the  Indians  the  feeble- 
minded and  insane  received  kind  treatment.  But  through- 
out Christendom  for  long  ages  they  were  thought  to  be 
accursed  and  possessed  of  devils,  and  were  treated  accord- 
ingly. So  we  find  these  afflicted  people,  miserable  because 
of  their  mental  condition,  made  infinitely  more  wretched  by 
being  chained  for  years  to  the  walls  of  dark  and  solitary 
cells,  or  made  to  subsist  on  bread  and  water,  or  lie  on  beds 
of  straw,  tortured,  whipped,  occasionally  burned  or 
executed, — always  the  victims  of  a  fixed  belief  that  insanity 
was  an  incurable  malady. 

In  the  latter  part  of  the  eighteenth  century  Pinel  in 
France  and  William  Tuke  in  England  became,  with  others 
whose  names  are  less  known,  but  who  are  doubtless  as 
worthy  of  being  immortalized,  pioneers  in  advancing  the 
theory  that  the  insane  were  human  beings  afflicted  with 
disease,  and  gradually  the  idea  that  these  people  were  unfor- 
tunate and  not  criminal  began  to  prevail,  and  the  places 
where  they  were  confined  to  assume  the  character  of  asylums 

instead    of    prisons,    as    formerlv-      In  our    own    country 

168 


164  International  Congress  of  Nurses 

Dorothea  Dix  began  her  great  work  in  the  first  half  of  the 
nineteenth  century,  and  the  degree  of  comfort  and  care  that 
the  insane  of  America  now  experience  is  largely  the  out- 
growth of  her  zeal  and  energy.  While  our  present  methods 
are  doubtless  the  best  that  have  existed  in  this  country,  still 
they  could  be  improved  in  many  ways,  particularly  in  the 
care  given  the  indigent  insane.  The  establishment  of  train- 
ing schools  in  our  State  hospitals  is  a  great  step  in  the  right 
direction,  the  object  being  to  secure  for  these  afflicted  people 
more  intelligent  and  scientific  treatment,  and  surely  they 
need  all  the  help  that  can  be  given  them,  and  by  as  skillful 
and  enlightened  nurses  as  can  be  obtained. 

Insanity  is  defined  as  "  a  prolonged  departure  from  the 
individual's  normal  standard  of  thinking,  feeling,  and  act- 
ing," and  allows  of  many  different  classifications.  For 
practical  application  of  the  manner  of  nursing  we  will  con- 
sider it  from  three  great  divisions : 

1.  Cases  of  mental  exaltation  (mania,  acute  and 
chronic). 

2.  Cases  of  mental  depression  (melancholia,  acute  and 
chronic). 

3.  Cases  of  mental  enfeeblement  (dementia,  paranoia, 
epileptic  insanity,  circular  insanity,  general  paralysis,  idiocy, 
imbecility). 

In  this  brief  paper  we  will  give  more  time  to  the  first 
two  classes,  as  they  are  the  cases  which  you  as  graduate 
nurses  will  meet,  and  who  require  more  intelligent  and 
scientific  nursing  than  the  third  class,  as  they  need  but  little 
more  than  custodial  care  or  the  attention  given  any  feeble 
patient. 

"  Mania  is  a  form  of  insanity  characterized  by  emotional 
exaltation,  acceleration  of  the  flow  of  ideas,  and  motor  agita- 
tion.'' These  cases  are  very  interesting,  as  about  seventy 
per  cent,  of  them  are  recoverable,  which  is  always  a  source 
of  inspiration  to  the  nurse,  and  a  needed  one,  as  their  care 
is  extremely  wearisome  during  the  excited  period.  The 
pathological  cause  for  this  disorder  is  as  yet  much  obscured, 
careful  investigation  revealing  no  anatomical  basis,  though 


The  Nursing  of  the  Insane  165 

a  theory  prevails  that  it  is  due  to  a  congestion  in  the  higher 
brain-cells.  Perhaps  the  belief  in  another  theory,  that  there 
is  a  lack  of  nutrition  in  the  nerve-cells,  producing  this 
unnatural  condition,  is  the  best  for  a  nurse,  as  then  she  will 
be  stimulated  to  persevere  in  feeding  her  patient,  which  is 
regarded  as  one  of  the  chief  agents  in  bringing  about 
a  recovery. 

Usually  a  maniacal  outburst  is  preceded  by  a  period  of 
depression,  which  may  continue  for  a  few  days  or  for  a 
longer  time,  possibly  several  months,  and  when  this  gives 
way  the  true  disorder  begins  to  manifest  itself  and  the 
patient  becomes  noisy,  restless,  incoherent,  and  lacking  in 
self-control.  The  entire  system  is  disordered,  the  skin  being 
hot,  the  tongue  dry  and  coated,  sometimes  to  a  great  degree, 
the  lips  often  parched  and  bleeding,  the  bowels  irregular, 
the  urine  scanty,  the  sleep  disturbed  and  fitful. 

In  mania  the  habits  are  often  most  untidy,  due  to 
inattention  on  the  part  of  the  patient  to  bodily  wants. 

As  there  is  usually  no  distaste  for  food,  there  may  be 
no  difficulty  in  giving  it,  but  again  it  may  have  to  be  admin- 
istered forcibly,  as  the  patient's  mind  is  too  exalted  and  pre- 
occupied to  know  if  he  has  eaten  or  not.  Simple  liquid 
foods  are  recommended  to  be  given  frequently  and  in  as 
large  quantities  as  possible,  even  to  the  point  of  overfeeding. 
Rest  in  bed  with  treatment  in  massage  is  urged  if  the 
patient  is  not  too  resistive. 

Sleep  may  be  induced  by  warm  baths  or  hot  wet  packs, 
though  occasionally  a  sleep-producing  agent  will  be  neces- 
sary. In  some  cases  there  is  much  danger  from  over- 
exhaustion,  but  if  food  be  given  in  sufficient  quantities  and 
is  assimilated  this  result  may  be  averted.  As  much  care 
should  be  given  the  hair,  teeth,  and  mouth  of  the  patient  as 
if  he  were  suffering  from  a  fever  delirium,  and  this  will  add 
greatly  to  his  comfort  and  appreciation  on  recovery.  There 
is  but  little  danger  of  suicide  in  maniacal  cases. 

As  to  his  moral  treatment,  there  is  no  use  in  arguing 
with  him  in  regard  to  his  delusions,  though  these  may  be 
gently  but  firmly  contradicted  or  else  disregarded,  and  while 


166  International  Congress  of  Nurses 

it  is  best  in  the  acute  stages  never  to  discuss  these  halkicina- 
tions  and  delusions,  still  they  should  not  be  acted  upon  or 
agreed  with.  During  convalescence  brief  but  positive 
denials  of  the  imaginings  of  the  patient  may  be  beneficial, 
but  it  should  always  be  done  in  the  kindest  spirit  and  man- 
ner. As  the  patient  improves  there  will  be  a  gradual  sub- 
sidence of  this  exalted  state  towards  the  normal  condition, 
possibly  accompanied  by  a  "  tearful  irritability,"  and  gradu- 
ally the  mental  balance  will  be  restored.  There  are  instances 
where  this  restoration  takes  place  very  suddenly  upon 
awakening  from  a  normal  sleep,  but  this  is  not  usual. 

The  course  of  an  attack  of  acute  mania  usually  extends 
over  a  period  of  from  three  to  six  months,  though  some  cases 
appear  to  run  their  course  in  a  much  shorter  time.  Occas- 
ionally this  disorder  takes  the  form  of  an  inflammatory  con- 
dition of  the  brain,  in  which  all  the  before-mentioned  symp- 
toms will  be  greatly  intensified  and  death  may  result  from 
exhaustion.  More  frequently  death  is  the  result  of  some 
complication,  as  nephritis  or  pneumonia.  About  five  per 
cent,  of  these  cases  die  and  ten  per  cent,  result  in  dementia. 
Seventy-five  per  cent,  show  hereditary  taint,  which,  while 
it  is  not  considered  an  essential  factor  in  producing  mental 
disorders,  is  regarded  as  rendering  the  nervous  organism 
unstable,  and  therefore  more  liable  to  collapse  when  it  meets 
any  severe  strain,  either  physical  or  mental. 

Cases  of  chronic  mania  are  very  rare,  and  consist  of  a 
continuance  of  maniacal  disturbances,  extending  over  a  long 
period,  perhaps  for  years.  As  a  rule,  the  physical  condition 
of  the  patient  will  remain  good,  the  mental  state  one  of 
elation,  and  reason  and  judgment  will  be  much  impaired. 
There  is  no  tendency  to  suicide  and  the  habits  may  be  most 
untidy.     Recovery  from  chronic  mania  is  very  unusual. 

The  second  class  of  insane  which  we  will  consider  are 
cases  of  mental  depression  or  of  melancholia.  This  form 
of  insanity  is  characterized  by  "  constant  depression, 
retarded  flow  of  thought,  and  fixed  delusions."  These  are 
certainly  the  most  miserable  of  all  that  great  body  of  people. 
Some   sit  for  days  with   drooping  figures   and   sad  faces, 


The  Nttrsing  of  the  Insane  167 

absorbed  by  the  contemplation  of  their  own  misery,  behev- 
ing  most  firmly  that  they  have  committed  an  unpardonable 
sin,  or  that  they  are  responsible  for  the  sins  of  the  world,  or 
that  they  have  brought  want  and  trouble  upon  their 
families.  Others  constantly  walk  about,  moaning  and 
wringing  their  hands,  while  still  others  complain  they  have 
no  feeling  at  all,  seeming  unable  to  appreciate  any  sensation 
of  either  pain  or  pleasure.  When  hallucinations  are  present 
they  are  of  a  depressing  and  terrifying  nature,  and  the 
patient  is  often  troubled  by  "  hearing  voices  "  which  con- 
stantly reprove  or  threaten  him. 

The  physical  condition  is  most  uncomfortable,  the  skin 
being  pallid  and  cold,  the  circulation  slow,  digestion 
retarded,  headache  almost  constant,  urine  often  profuse 
because  of  intense  emotion,  bowels  constipated,  food  refused 
because  of  distaste  for  it  or  from  troublesome  delusions,  as 
a  belief  of  unworthiness  to  eat,  a  fear  of  poisoning,  or  dread 
of  bringing  want  upon  others — altogether  they  present  a 
most  pathetic  condition  when  in  the  acute  stage.  As  in 
mania,  there  is  no  known  anatomical  cause,  though  it  is 
supposed  to  be  the  effect  of  cerebral  ansemia  or  of  auto- 
toxemia.  It  is  not  yet  known  how^  far  the  absorption  of 
intestinal  poisonings  is  an  agent  in  producing  insanity,  but  it 
is  believed  it  is  a  more  frequent  agent  than  is  generally 
recognized,  and  it  is  certainly  a  most  important  factor  in 
retarding  the  recovery  or  in  increasing  the  intensity  of  mel- 
ancholia. Ill-health,  business  or  love  troubles,  grief,  over- 
work, shock  from  fright,  or  religious  troubles  are  among 
the  alleged  moral  causes  in  bringing  about  this  unhappy 
condition,  and,  as  in  mania,  hereditary  taint  is  found  in 
more  than  one-half  of  the  histories,  which  weakens  their 
power  of  resistance. 

From  this  picture  you  can  understand  how  true  it  is 
that  the  most  serious  danger  to  guard  against  is  that  of 
suicide,  even  in  the  mild  cases,  and  the  newspapers  furnish 
us  almost  daily  evidence  that  this  fact  is  not  generally  under- 
stood. Knives,  scissors,  cords,  door-keys,  anything  that 
could  be  made  an  agent  in  ending  one's  life,  should  l)e  care- 


168  International  Congress  of  Nurses 

fully  removed,  the  windows  arranged  to  open  but  a  little 
way,  and  constant  oversight  may  be  needed  to  prevent  the 
l^atient  from  strangling  himself  with  a  strip  of  bedding  or 
clothing.  Removal  from  his  friends  and  usual  environments 
is  often  found  of  great  benefit,  even  the  change  to  a  State 
hospital  may  be  a  relief.  With  familiar  faces  and  objects 
about  him  he  only  realizes  more  keenly  how  he  has  changed, 
and  this  adds  to  his  depression.  Moderate  travel, — always 
guarding  against  a  tendency  to  suicide, — a  short  visit  to  the 
country,  or  going  to  the  house  of  some  physician  or  to  a 
sanatorium  may  produce  very  good  results. 

As  in  cases  of  mania,  food  is  one  of  the  most  important 
remedial  agents,  but  it  must  be  selected  and  given  with  far 
more  care,  as  the  digestion  is  more  enfeebled.  It  should 
be  pushed  to  the  point  of  overfeeding,  if  necessary,  and  may 
consists  of  most  liquid  nourishments,  rare  or  raw  beef,  eggs, 
prepared  cereals,  and  sometimes  green  vegetables  or  fruit. 
That  it  be  digested  is  the  great  feature,  and  as  the  digestive 
organs  are  always  weakened,  they  should  l?e  constantly 
observed.  One  authority  recommends  washing  the  stomach 
frequently  with  salt  solution  and  giving  "  high  enemas," 
with  a  view  of  ridding  the  system  as  far  as  possible  of  masses 
of  undigested  and  unassimilated  food  and  also  stimulating 
the  lining  of  the  intestinal  tract.  Continual  rest  in  bed  with 
massage  is  strongly  recommended  in  extreme  cases  of  mel- 
ancholia, but  with  milder  degrees  part  of  the  day  in  bed, 
with  the  remainder  spent  in  some  occupation  out-of-doors, 
if  possible,  may  be  more  beneficial.  For  sleeplessness  either 
hot  wet  packs  or  prolonged  warm  baths  (from  one-half  to 
two  hours — 110°)  are  usually  successful,  though  mild  hyp- 
notics may  be  necessary. 

As  to  the  moral  treatment  during  the  acute  stage,  it  is 
best  generally  to  leave  the  patient  quite  alone.  He  cannot 
take  an  interest  in  others ;  he  is  unfit  for  labor,  either  phy- 
sical or  mental ;  amusements  are  painful  to  him,  and  his 
reason  and  judgment  are  both  impaired.  To  surround  him 
as  nearly  as  possible  with  a  neutral  atmosphere  is  the  best 
treatment,  and,  as  in  cases  of  mania,  one  should  never  argue 


The  Nursing  of  the  Insane  169 

with  him  in  regard  to  his  dehisions,  though  occasionally 
they  should  be  firmly  and  kindly  denied.  Sympathy  may  be 
given  a  melancholiac  and  will  be  greatly  appreciated,  and 
hopefulness  should  be  inspired  in  every  way  possible.  It  is 
wonderful  how  much  effect  those  about  them  may  exert 
over  the  minds  of  the  insane,  and  a  nurse  has  it  in  her 
power  to  materially  aid  or  retard  a  recovery  by  her  moral 
attitude  towards  her  patient.  All  sources  of  irritability 
should  be  removed  as  far  as  she  is  able,  and  her  whole  aim 
s4iould  be  to  govern  by  kindness,  patience,  firmness,  and 
sympathy.  This  fact  is  far  too  little  understood  and  prac- 
tized, and  the  tendency  to  play  "  with  the  mind  diseased," 
to  make  the  patient  express  his  delusions  for  the  amuse- 
ment of  herself  or  others,  cannot  be  too  severely  criticized 
and  condemned. 

When  the  recovery  of  these  patients  is  once  established, 
regular  physical  occupation,  as  walking,  bicycling,  playing 
golf,  any  out-of-door  exercise,  or  some  useful  manual  labor 
should  be  begun  and  encouraged.  "  Substitution  of 
thought  "  as  soon  as  the  patient  is  able  to  be  diverted  should 
be  sought  in  every  way,  and  to  aid  him  in  his  efforts  to  for- 
get his  own  depression  is  of  the  utmost  importance. 

In  cases  of  simple  acute  melancholia  about  ninety  per 
cent,  are  recoverable  and  five  per  cent,  result  in  death, 
usually  due  to  marasmus,  suicide,  visceral  disorders,  or 
pneumonia.  A  very  large  number  of  the  chronic  cases  die 
of  tuberculosis. 

We  will  now  consider  briefly  the  third  and  largest  class 
of  the  insane, — that  of  mental  enfeeblement. 

Dementia  is  the  general  term  given  to  the  greatest 
division  of  this  disorder,  and  one  author  speaks  of  it  as 
"  the  goal  of  all  insanities."  Being  the  result  of  so  many 
different  disturbances,  it  assumes  numerous  phases,  which 
we  will  not  have  time  to  consider  in  detail.  Rare  cases 
of  "  primary  dementia  "—that  is,  enfeeblement  of  a  mind 
once  normal  with  no  acute  form  of  insanity  preceding  it- 
may  follow  prolonged  physical  or  mental  strain,  such  as  may 
attend   the   vicissitudes   of  war  or  some   intense  fright  or 


170  International  Congress  of  Nurses 

shock,  in  which  case  the  usual  care  of  an  acute  insane 
patient  may  be  given  and  recovery  looked  for  at  any  time, 
from  a  few  months  to  a  year.  More  frequently  these  cases 
merge  into  a  condition  called  "  secondary  dementia," 
where  the  enfeeblement  is  recognized  as  the  sequel  of  some 
cerebral  disease,  as  epilepsy,  alcoholism,  syphilis,  melan- 
cholia, and  mania. 

Secondary,  or  "  terminal,"  dementia  may  be  divided  in 
two  classes,  apathetic  and  agitated. 

About  two-thirds  of  the  patients  in  our  State  hospitals 
are  demented,  many  of  whom  were  maniacal  or  demented 
when  committed,  but  have  since  lapsed  into  a  quiet  existence 
with  but  little  emotional  basis.  Their  condition  is  more 
pathetic  from  its  hopelessnes,  though  mercifully  they  are 
more  contented  with  their  lot  than  one  would  imagine  they 
could  be.  They  appreciate  any  comforts  or  favors  very 
highly,  take  an  active  pleasure  in  amusements, — a  large  part 
of  the  work  about  the  hospital  is  performed  by  them, — and 
while  they  are  not  capable  of  initiating  any  work,  they 
acquire  automatic  habits  of  employment  when  directed  and 
supervised.  They  are  very  useful  to  the  hospitals,  and  are 
deserving  of  all  that  can  be  produced  for  them  in  the  way 
of  improvements  or  diversions.  In  the  advanced  stage  of 
apathetic  dementia  the  patients  do  not  speak ;  they  crouch 
or  lie  about  on  the  floors  or  in  corners  in  the  most  negligent 
attitudes  and  cover  their  heads  with  their  clothing,  while 
those  with  agitated  dementia  are  restless  and  subject  to 
sudden  outbreaks  of  excitement  with  no  external  cause. 
With  either  of  these  classes  when  the  mind  reaches  a  certain 
plane  of  deterioration  it  remains  stationary  for  years  per- 
haps. All  of  the  faculties  are  impaired, — memory,  reason- 
ing, judgment,  and  will, — though  the  physical  condition 
may  be  quite  sound  and  only  custodial  care  is  required. 

About  ten  per  cent,  of  the  epileptics  become  insane,  and 
the  usual  form  of  their  disorder  is  dementia.  They  require 
the  care  of  an  ordinary  epileptic,  but  as  they  are  subject  to 
sudden  outbreaks  of  rage  and  fury,  when  they  may  com- 
mit serious  assault  or  crime  with  no  subsequent  recollection. 


The  Nursing  of  the  Insane  171 

their  confinement  in  an  institution  is  strongly  recommended. 
Recovery  of  a  case  of  epileptic  insanity  is  most  unusual. 

"  Circular  insanity  "  is  characterized  by  alternating  con- 
ditions of  mania  and  melancholia,  and  while  made  up  of  the 
three  most  curable  forms  of  mental  disorders,  is  still  the 
most  incurable  itself.  These  cases  are  best  cared  for  in  insti- 
tutions, to  prevent  suicide  in  a  melancholic  stage  and  extra- 
vagance in  a  maniacal  period.  By  medical  treatment  these 
cycles  may  be  retarded  or  postponed,  and  the  same  nursing 
should  be  given  these  cases  as  that  recommended  for  mania 
and  melancholia.  The  rest  cure  and  hydrotherapy  are  used 
in  both  phases. 

"  Paretic  dementia  "  is  a  disorder  characterized  by  pro- 
gressive enfeeblement  of  the  mind  combined  with  general 
paralysis  of  the  whole  body.  Intellectual  overwork  or  strain 
of  a  system  impaired  by  alcoholism  or  syphilis  is  believed  to 
be  the  chief  cause  of  paresis,  and  it  usually  runs  its  course  in 
from  three  to  five  years,  when  death  is  very  liable  to  occur. 
In  its  early  stages  it  may  be  mistaken  for  neurasthenia,  but 
gradually  more  marked  symptoms  will  be  noticed,  as  the 
paretic  articulation  and  writing,  loss  of  reflex  action,  emacia- 
tion, failure  of  memory,  emotional  irritability,  and  exag- 
gerated delusions.  These  delusions  are  of  a  most  extrava- 
gant  nature,  and  usually  grow  as  the  physical  weakness 
increases.  The  patient  may  believe  that  he  is  conducting 
large  busines  enterprises  or  that  he  is  President  or  the  Czar, 
or  he  may  have  delusions  of  great  wealth,  and 
bestow  upon  those  about  him  checks  for  large  sums, 
rule,  these  patients  are  far  from  strong,  weak  hearts 
and  degenerate  liver  and  kidneys  being  common 
among  them.  Their  bones  are  unnaturallv  fragile,  and  m 
the  latter  stages  of  the  disease  their  habits  become  very  un- 
tidy, and  they  have  a  peculiar  liability  to  bedsores  due  to  a 
disorder  of  the  nerves  which  control  the  nutrition  of  the  skin. 
As  the  final  stage  approaches  there  may  be  apoplectic 
seizures  or  convulsions,  the  patient  becomes  speechless, 
bed-ridden,  more  helpless  than  an  infant,  sometimes  hardly 
able  to  swallow  his  food,  until  finally  death  comes  to  his 


172  International  Congress  of  Nvirses 

relief.  These  are  most  distressing  cases,  and  if  possible 
should  be  taken  care  of  in  an  institution  for  the  insane. 

The  care  you  can  givje  a  patient  of  this  class  is  most 
limited.  In  the  early  stages  to  keep  him  from  squandering 
his  property  or  scandalizing  his  family  by  some  immoral 
act,  as  the  disease  progresses  to  repress  his  untidy  habits, 
to  keep  him  at  some  occupation  as  long  as  he  is  capable  of 
performing  it,  and  later  to  take  the  same  care  of  him  as 
would  be  given  any  paralytic  is  as  much  as  we  can  accom- 
plish. While  the  progress  of  this  disease  may  be  retarded  by 
different  medicines,  still  it  is  usually  fatal,  and  one  feels 
that  death  is  a  welcome  relief  from  conditions  so  degraded 
and  pitiable. 

Paranoia  is  a  form  of  chronic  mental  disease  charac- 
terized by  a  gradual  development  of  fixed  systematized  and 
elaborated  delusions  of  persecution,  conspiracy,  etc. 

These  patients  in  the  early  stages  of  their  disorder  may 
be  called  "  cranks/'  and  admit  of  a  most  elaborate  classi- 
fication. I  will  only  mention  a  few  general  symptoms,  as  it 
may  aid  you  in  being  more  tolerant  of  the  oddities  of 
"  queer  people,"  some  of  whom  are  unable  to  control  their 
idiosyncrasies,  being  in  the  first  process  of  paranoia.  In 
childhood  a  paranoic  will  be  usually  bright,  though  he 
may  be  of  a  shy  or  solitary  disposition,  showing  eccen- 
tricities of  conduct  as  he  grows  older.  He  becomes  suspi- 
cious and  depressed,  having  a  vague  idea  of  conspiracy  to 
deprive  him  of  privileges  or  property.  This  is  called  the 
persecutory  state.  He  constantly  feels  that  a  mysterious 
combination  called  "  they  "  are  against  him,  and  upon  ques- 
tioning he  may  explain  that  he  refers  to  some  secret  society 
or  some  religious  or  political  organization  or  some  import- 
ant person  whom  he  may  have  known  about,  all  of  whom 
are  working  to  harm  him.  These  ideas  are  of  vast  propor- 
tions and  show  great  system  and  organization.  Not  infre- 
quently these  patients  are  driven  to  make  appeals  to  the 
Supreme  Court,  the  President,  the  Pope,  any  power  they 
feel  can  be  reached.  This  is  followed  by  a  transition  or 
expansive  stage,  in  which  he  seeks  an  explanation  of  all 


The  Nursing  of  the  Insane  173 

these  persecutions.  He  sees  how  it  was  all  planned  out 
for  him,  perhaps  discovers  that  he  is  of  noble  or  divine 
birth.  He  may  find  much  consolation  in  the  belief  that 
he  is  beloved  by  someone  of  a  much  superior  station. 
Quite  frequently  these  people  have  distinguished  themselves 
in  literature  or  in  history.  Many  feel  that  they  are  ush- 
ering in  a  new  religion,  and  it  is  something  of  a  shock 
to  find  that  Mahomet,  Swedenborg,  and  Joan  of  Arc  are 
mentioned  with  these  cases.  Among  the  political  para- 
noics we  find  the  names  of  John  Brown  and  Guiteau.  The 
so-called  cranks  of  this  description  really  create  a  danger- 
ous element  in  society.  They  are  apt  to  make  some  homi- 
cidal assaults  in  consequence  of  their  delusions,  but  if  con- 
fined in  asylums  they  accept  that  as  a  part  of  the  scheme 
against  them,  and  believe  that  some  benefit  will  result  from 
it  either  to  the  world  or  to  themselves.  They  often  show 
a  proprietary  interest  in  the  institution,  and  are  very  use- 
ful and  interested  in  the  different  forms  of  work.  These 
patients  usually  live  to  a  good  old  age,  free  from  care, 
and  while  terminal  dementia  is  quite  sure  to  develop,  still 
the  process  is  not  rapid.  There  is  little  to  be  said  in  the  way 
of  treatment,  and  their  physical  condition  is  usually  good. 
Out-of-door  work  is  recommended  to  keep  the  mind 
diverted  from  its  delusions  and  hallucinations  as  far  as  pos- 
sible, and  through  bodily  fatigue  they  obtain  a  fair  amount 
of  repose. 

Before  closing  I  must  make  a  brief  mention  of  two 
agents — hydrotherapy  and  electricity,  which  are  used  among 
some  of  these  patients  with  marked  success.  Hydrotherapy 
is  a  form  of  treatment  among  the  insane  which  is  daily  gain- 
ing in  favor.  It  is  applicable  to  cases  both  of  mania,  mel- 
ancholia, and  some  forms  of  dementia,  but  in  order  to  be 
used  fully  it  calls  for  a  hydrotherapeutic  apparatus  which  is 
never  met  with  except  in  sanatoriums  or  hospitals,  and  its 
use  is  then  fully  directed  by  the  physicians. 

I  will  not  take  the  time  here  to  describe  these  appli- 
ances, which  are  most  complex  and  can  be  used  in  many 
ways,   but   will   endeavor  to   give  instead  a  few  practical 


174  International  Congress  of  Nurses 

therapeutic  methods,  which  you  can  use  in  any  house  with 
ordinary  phimbing-. 

It  is  known  that  water  affects  the  nerves  in  many  ways. 
Cold  baths  increase  the  irritabihty  of  the  brain  and  spinal 
cord  in  a  reflex  manner  by  stimulating-  the  nerves  of  the 
skin  and  quickening-  the  circulation,  while  warm  baths  are 
relaxing,  and  tend  to  induce  sleep  and  diminish  the  irrita- 
bility of  the  nerves.  By  keeping  in  mind  the  difference  in 
hot  and  cold  baths  one  can  devise  many  ways  of  applying 
them  with  great  benefit  to  the  patient.  Short  cold  baths, 
combined  with  sprinkling  or  rubbing,  are  stimulating  and 
tonic.  Tlie  spinal  douche  is  a  powerful  tonic  as  well  as  a 
mental  stimulus.  By  means  of  a  proper  nozzle  a  strong 
stream  is  directed  up  and  down  the  back  of  the  patient 
at  a  distance  of  ten  feet,  if  possible,  and  for  a  few  seconds 
only.  Sometimes  this  is  alternated  with  a  stream  of  hot 
water,  and  may  be  used  for  cases  of  hysteria  or  neurasthenia 
or  where  there  is  sluggish  intellect,  stupor,  or  apathy.  This 
should  be  persevered  in  daily,  and  the  temperature  of  the 
water  gradually  reduced  till  lowered  to  fifty  degrees.  In  a 
private  house  the  patient  may  stand  in  any  ordinary  bath- 
tub, and  this  process  be  imitated  by  using  the  usual  spray 
bath,  and  while  the  force  cannot  be  as  great  as  from  the 
regular  apparatus,  still  the  reaction  may  be  quite  marked 
and  beneficial.  The  portable  steam-bath  arrangements  of 
these  days  make  the  hot-air  and  vapor  baths  possible  to  all, 
and  can  always  be  used  when  the  patient  is  quiet  enough  to 
produce  general  relaxation  and  possibly  sleep.  The  pro- 
longed warm  bath  before  mentioned  and  the  hot  or  cold 
wet  packs  are  always  at  hand,  and  if  properly  used  may 
prevent  the  necessity  of  giving  hypnotics  and  aid  materially 
in  regulating  the  circulation  and  relaxing  the  nerve  tensions. 

Electricity  is  believed  to  have  much  the  same  value  as 
massage  when  used  in  connection  with  the  rest  cure.  It  also 
has  a  tonic  effect,  but  as  its  specific  use  belongs  to  the  phy- 
sician's domain,  I  will  not  take  our  limited  time  in  an 
attempt  to  describe  its  subtle  effect  and  the  manner  of  its 
application.  You  will  have  always  to  "  follow  the  doctor's 
directions"  in  anv  case. 


The  Nursing  of  the  Insane  175 

We  may  then  sum  up  the  care  of  any  acute  case  by  rest 
in  bed.  overfeeding  with  light  food,  careful  observation  of 
the  digestive  process,  massage  when  possible,  hot  wet  packs 
or  baths  for  sleeplessness,  and  electricity  when  it  is  indicated. 
The  care  of  the  chronic  insane  in  much  more  limited,  being 
an  effort  to  make  them  as  comfortable  and  happy  as  their 
mental  conditions  will  allow  and  to  keep  them  employed  as 
far  as  possible  to  delay  the  process  of  brain  decay.  These 
cases  are  so  different  there  can  be  no  general  line  of  treat- 
ment followed,  and  there  is  but  little  to  inspire  one  to  endure 
much  that  is  monotonous  and  disagreeable,  except  a  pity  for 
their  unhappy  condition  and  a  wish  to  aid  in  making  what 
remains  of  their  lives  as  attractive  to  them  as  can  be. 

If  I  have  aroused  in  your  minds  any  larger  sympathy 
for  these  afiflicted  people,  or  have  given  you  any  suggestions 
which  will  enable  you  to  care  for  them  with  a  better  under- 
standing and  appreciation  of  their  condition,  I  am  highly 
gratified.* 


Tlie  President :     The  next  paper  has  been  contributed 
by  Mrs.  Chapman,  of  England,  on  the  same  subject. 


*I  have  gathered  the  statistics  and  many  of  the  ideas  contained  in  this  paper 
from  the  writings  of  Dr.  Frederick  Peterson,  Dr.  C.  B.  Burr,  Dr.  William  D. 
Granger,  Dr.  John  B.  Chapin,  and  Dr.  P.  M.  Wise. 


Asylum  Nursing. 

MRS.  CHAPMAN, 

Formerly  Matron  of  Whittingham,  Leavesden,  and  Claybury  Asylums;  Honorary 
Treasurer  of  Association  of  Asylum  Workers,  England. 


The  increase  of  insanity  in  the  United  Kingdom  of 
Great  Britain  during  the  last  decades  of  the  nineteenth 
century  is  an  ominous  fact,  and  one  to  be  seriously  con- 
sidered by  all  those  interested  in  the  progress  of  the  nation. 

On  the  authority  of  the  Lunacy  Commissioners,  as 
expressed  in  their  report  for  1900,  it  is  stated  there  existed 
as  a  registered  lunatic  one  in  three  hundred  of  the  total 
population.  This  fact  ought  to  be  sufBcient  to  enable  any- 
one to  realize  the  gravity  of  the  situation.  Notwithstanding, 
there  is  a  great  deal  of  apathy  among  the  general  public  as 
regards  this  development  of  the  various  forms  of  mental 
disease.  It  is  not  as  yet  recognized  widely  that  cases  of 
mental  break-down  require  equal  care  and  skill  in  their 
treatment  at  the  hands  of  the  mental  nurse  as  those  which 
are  treated  in  the  ordinary  hospital.  The  efficiency  and 
ability  which  have  slowly  come  to  be  regarded  as  the  neces- 
sary qualifications  of  the  hospital  nurse  are  not  as  yet 
expected  to  the  same  degree  in  the  asylum  nurse  by  the 
public.  Much  has  been  done  by  co-operation  and  method- 
ical instruction  to  raise  the  general  standard  of  hospital 
nursing  and  attain  the  highest  efficiency,  but  with  the  excep- 
tion of  the  efforts  made  by  the  Medico-Psychological  Asso- 
ciation of  Great  Britain  and  Ireland  and  some  isolated 
schemes  at  two  or  three  asylums  very  little  has  been  inaug- 
urated by  the  authorities  responsible  for  the  maintenance 
and  for  the  efficient  working  of  the  asylums  under  their 
control.  Here  for  years  has  been  a  policy  of  "  laissez  faire.'^ 
176 


Asylum  Nursing  177 

The  stimulus  which  the  educational  movement  in  Eno-- 
land  has  experienced  the  last  few  years  is  beginning  to 
arouse  interest  in  circles  outside  that  which  is  actually 
engaged  in  asylum  work.  The  value  of  systematic  training 
in  any  profession  is  now  recognized,  and  the  great  body  of 
ratepayers,  who  support  these  institutions  for  the  care  of  the 
insane,  are  slowly  awakening  to  the  fact  that  the  highest 
economic  efficiency  is  to  be  obtained  by  the  promotion  of 
the  intellectual  efficiency  of  all  those  engaged  in  the  work  of 
asylums.  There  is  forming  a  consensus  of  opinion  that  to 
deal  adequately  with  the  problems  of  mental  disease,  and 
of  its  alarming  increase,  intelligence  must  be  allied  with 
experience,  and  that  the  perceptive  powers  of  the  nurse,  in 
order  to  meet  the  varying  psychological  manifestations  of 
mental  disease  readily  and  resourcefully,  must  be  trained 
to  a  high  degree.  Asylums  should  not  be  regarded  as  places 
where  unskilled  labor  may  find  a  congenial  outlet  for  its 
energies.  The  indifiference  of  the  past  has  been  great,  but 
the  rising  interest  in  the  question  of  efficient  mental  nursing 
in  our  asylums  now  being  manifested  is  a  source  of  encour- 
agement and  hope  to  the  advocates  of  a  better  order  of 
things. 

There  is  need  to  refute  the  opinion  that  a  nurse  may 
consider  herself  adequately  equipped  for  her  profession  with- 
out any  knowledge  of  mental  disease.  If  nursing  is  to  be 
viewed  comprehensively,  surely  all  phases  of  disease  should 
be  included  in  the  curriculum  of  studies  laid  down  for  train- 
ing the  intelligence  of  the  nurse.  Any  system  which  devotes 
its  attention  to  only  one  side  of  the  phases  of  human  disease 
lacks  comprehension.  Attention  solely  directed  to  the  care 
and  treatment  of  disease  as  manifested  in  an  ordinary  hospi- 
tal cannot  give  a  complete  view  of  the  maladies  to  which  the 
human  organism  is  subject;  rather  what  is  attained  is  a 
specialized  form  of  knowledge.  It  would  be  interesting  to 
have  the  opinions  of  those  who  have  passed  through  the 
normal  period  of  training  in  a  hospital  as  to  the  complete- 
ness of  their  qualifications.    Can  they  regard  themselves  as 


178  International  Congress  of  Nurses 

fully  trained  nurses  ?  Many  probably  have  not  viewed  the 
subject  in  this  light,  yet  if  the  term  "  trained  nurse  "  is  to 
have  a  comprehensive  connotation,  some  doubts  must  arise 
in  their  minds.  The  hospital-trained  nurse  cannot  regard 
herself  as  having  had  a  complete  training  for  her  profession 
as  a  general  nurse  unless  she  has  had  some  experience  in 
mental  nursing.  The  medical  superintendent  of  a  large 
asylum  writes  on  this  subject  to  this  effect : 

"  Looking  back  on  my  hospital  experience,  I  cannot 
help  recollecting  what  a  number  of  *  naughty '  patients  the 
nurses  in  the  hospitals  insisted  on  my  discharging.  Of 
course,  I  know  now  that  nearly  all  these  '  naughty  '  persons 
were  patients  with  mental  symptoms,  whom  the  trained 
hospital  nurse  did  not  know  how  to  manage.  They  mis- 
took '  madness '  for  '  badness.'  Medical  men  now  are 
obliged  to  take  a  course  of  lectures  on  mental  disease  before 
they  can  be  qualified  for  practice.  Why  should  hospital 
nurses  be  exempt?  " 

The  experience  here  stated,  probably,  is  not  unique.  It 
points  to  the  fact  that  there  are  diseases  whose  symptoms 
are  not  recognized  by  those  whose  training  is  restricted  to 
the  hospital  sphere  alone.  The  term  "  trained  nurse  "  has 
been  too  long  exclusively  appropriated  by  one  section  of 
the  community  of  the  nursing  world.  The  limitations  in 
the  experience  gained  in  the  hospital  wards  should  be  recog- 
nized. That  gained  by  another  section  in  the  sphere  of 
mental  nursing  equally  justifies  the  appellation  "  trained." 
On  this  ground  the  status  of  the  asylum  nurse  should 
receive  adequate  recognition.  Her  duties  are  exacting  and 
onerous  in  the  extreme,  calling  forth  all  her  powers  of 
sympathy,  tact,  resourcefulness,  with  the  power  of  infusing 
hope, — qualifications  different  in  kind  to  some  extent  from 
those  demanded  in  the  hospital  nurse,  yet  necessarily  essen- 
tial for  obtaining  succesful  results. 

The  principle  of  subdivision  of  labor  lies  at  the  base 
of  all  attainment  of  high  efficiency,  and  the  concentration 
of  effort  upon  a  certain  field  of  manifestion  of  human  disease 
is  necessary  for  attaining  that  skill  which  is  so  essential  for 


Asylum  Nursing  179 

success  in  medical  nursing.  Hospital  asylum  nurses  are 
co-operators  in  the  work  of  alleviating-  that  pain  and  misery 
which  exist  so  largely  in  the  world.  The  work  of  each 
is  correlated  with  the  other.  The  mental  is  intimately  con- 
joined to  the  physical  in  the  human  organism,  and  efficiency 
in  nursing  can  only  be  fully  attained  by  the  recognition  of 
this  relation  between  the  physical  and  mental. 

As  it  has  been  laid  down  that  knowledge  of  mental 
disease  should  be  regarded  a  necessary  qualification  in  the 
trained  nurse,  so  equally  must  it  be  insisted  that  the  mental 
nurse  should  go  through  a  course  of  training  on  the  general 
lines  of  the  hospital  nurse.  In  the  infirmary  wards  of  our 
large  asylums  there  are  always  a  number  of  cases  requir- 
ing medical  nursing,  which  can  only  be  given  with  efficiency 
by  the  asylum  nurse  after  a  period  of  training  on  the  lines 
laid  down  for  hospital  nurses.  This  has  been  almost  uni- 
versally recognized  in  the  asylums  of  the  United  Kingdom. 
The  medical  stafif  in  every  important  asylum  deliver  lec- 
tures and  give  demonstrations  on  the  subject  of  the  nursing 
of  the  sick.  The  syllabus  of  the  Medico-Psychological  Asso- 
ciation is  comprehensive,  and  if  thoroughly  worked  will 
give  a  good  elementary  knowledge  of  the  requirements  for 
efficient  nursing  in  the  infirmary  wards  of  an  asylum. 

It  is  indispensable  for  efficiency  in  an  asylum  nurse 
placed  in  charge  of  an  infirmary  ward  that  she  should  have 
this  general  insight  into  the  requirements  for  successful 
medical  and  surgical  nursing.  This  information  should  be 
gained  in  the  early  stages  of  her  experience  before  the 
study  of  the  psychological  phases  of  insanity  as  a  disease 
be  entered  upon.  It  will  enable  her  to  get  a  better  grasp  of 
the  relation  between  the  psychical  and  physical  and  of  the 
interaction  which  takes  place  between  them. 

In  most  asylums  of  the  Kingdom  there  has  been  made 
during  the  last  few  years  by  the  medical  staffs  of  these  insti- 
tutions a  sustained  efifort  to  impart  a  general  knowledge 
of  the  nursing  of  the  sick.  It  is  now  regarded  as  essential 
in  the  nurses  of  the  infirmary  wards  that  they  should  know 
something  of  elementary  anatomy  and  physiology,  of  the 


ISO  International  Congress  of  Nurses 

care  of  the  sick  and  the  management  of  helpless  and  bed- 
ridden patients ;  the  making,  moving,  and  changing  of  beds 
and  body  linen ;  the  prevention  and  treatment  of  bedsores ; 
application  of  fomentations,  poultices,  counter-irritants,  etc. ; 
the  giving  of  baths ;  administering  enemas ;  using  the 
catheter;  preparing  food  and  feeding  helpless  patients,  with 
the  observation  of  the  effects  of  diet,  stimulants,  medicine, 
etc. ;  the  laws  of  cleanliness  and  ventilation ;  the  disinfection 
of  utensils,  and  modes  of  disinfecting  in  cases  of  phthisis 
and  fevers ;  bandaging ;  first  aid  in  cases  of  accident ;  the 
observation  of  mental  symptoms,  such  as  hallucinations, 
delusions,  stupor,  etc.,  with  the  special  treatment  of  epilep- 
tic, excited,  violent  and  suicidal  patients,  and  the  care  of 
those  requiring  diversion  and  companionship ;  also  man- 
agement of  the  convalescent. 

The  following  quotations  from  a  speech  by  Dr. 
Clouston,  of  Morningside  Asylum,  Edinburgh,  on  the 
occasion  of  a  presentation  to  the  head  nurse  of  the  infirmary 
wards  of  that  institution  after  twenty-six  years'  service,  may 
be  interesting  as  showing  the  strides  made  not  only  in  Scot- 
land, but  throughout  the  Kingdom  : 

"  We  have  met  together  to  show  our  respect  and  regard 
for  Mrs.  Findlay,  head  nurse  in  the  female  hospital,  and  to 
show  our  appreciation  of  twenty-six  years  of  faithful  service 
to  the  institution  and  to  its  sick.  At  the  beginning  of  that 
time  the  sick  were  not  as  well  treated,  not  as  carefully 
nursed,  as  they  are  now.  At  that  time  all  institutions  had 
no  doubt  what  was  called  a  sick  ward,  or  a  sick  dormitory, 
but  not  a  fully  equipped  and  staffed  '  hospital.'  Shortly 
after  Mrs.  Findlay  came  here  we  were  making  great  changes 
in  this  institution,  and  we  had  under  a  separate  roof  a  build- 
ing that  used  to  be  called  '  The  Separates.'  This  building 
was  intended  for  the  very  worst  class  of  the  female  patients, 
as  it  was  thought  that  they  were  not  fit  to  mix  with  the 
others  at  all,  and  whether  curable  or  incurable,  a  trouble- 
some patient  was  sent  down  to  the  '  Separates.'  Now,  the 
actual  effect  of  gathering  together  such  an  explosive  ele- 
ment as  this  was  that  each  patient  made  the  other  worse. 


Asylum  Nursing  181 

It  was  a  veritable  pandemonium.  Following  the  general 
ideas  of  the  time,  it  occurred  to  me  that  this  building-  by  a 
thorough  alteration  could  be  made  into  a  small  hospital,  just 
like  a  pavilion  of  the  Edinburgh  Infirmary,  which  could  be 
utilized  for  the  nursing  of  the  newly  admitted  and  weak 
patients,  the  keynote  of  its  management  being  nursing  and 
cure,  and  not  detention.  This  was  carried  out,  and  for  the 
first  time  really  in  the  history  of  asylums  a  building  fully 
equipped  was  used  with  open  doors,  with  ordinary  arrange- 
ments, with  a  full  staff  of  trained  nurses  for  the  treatment  of 
the  mentally  afflicted  who  needed  nursing,  the  hospital  being 
also  used  for  the  training  of  the  new  nurses.  And  here 
comes  in  Mrs.  Findlay's  work.  She  was  alreadv  in  charge 
of  our  little  '  sick-room,'  and  I  was  firmly  convinced  by  the 
way  she  discharged  her  duties  there  that  she  would  enter 
fully  into  the  general  idea  of  the  new  hospital.  This  she 
at  once  realized  very  fully,  and  carried  out  the  medical 
intention  that  each  woman  there  was  a  patient  laboring 
under  a  disease  to  be  nursed  and  treated.  This  idea,  I  assure 
you,  was  not  then  universally  prevalent.  Mrs.  Findlay's 
success  in  her  work,  the  way  in  which  she  both  nursed 
and  superintended  the  nursing  of  poor  sick  women  and 
trained  our  own  new  nurses,  has  made  this  idea  take  pos- 
■  session  of  the  treatment  of  the  whole  of  the  insane  in  the 
country.  I  am  quite  sure  if  my  friends.  Sir  Arthur  Mitchell 
and  Sir  John  Sibbald,  were  here  they  would  back  me  up  in 
this  very  strong  statement  that  Mrs.  Findlay's  success  in  an 
ordinary  hospital  building,  her  demonstration  that  this  was 
a  possible  thing,  and  not  only  possible,  but  an  advance  on 
the  whole  treatment  of  the  mentally  aliiicted,  was  one  of  the 
reasons  why  the  Commissioners  in  Lunacy  took  up  the 
'  hospital  '  idea,  so  that  now  there  is  not  an  institution  with- 
out such  a  means  of  treatment.  .  .  .  Now  the  thorough 
success  of  Morningside  Hospital  Section  and  its  adoption 
elsewhere,  and  the  general  amelioration  that  one  feels  has 
thereby  taken  place  in  the  treatment  of  the  mentally  afflicted, 
is  a  thing  to  be  proud  of  and  grateful  for." 

The    conditions    of   the   service   in   asylums   in   Great 


182  International  Congress  of  Ahirscs 

Britain  give  cause  for  some  reflection.  The  continual  chang- 
ing of  the  staff  which  arises  from  dissatisfaction  with  the 
secluded  character  of  the  life  in  institutions,  combined  with 
the  abnormally  long  hours  of  duty,  together  with  an 
inadequate  scale  of  remuneration,  is  a  feature  in  asylum 
nursing  which  needs  careful  study.  The  restrictions 
enforced  ten  years  ago  are  now  felt  to  be  out  of  place. 
There  has  arisen  a  demand  for  greater  freedom  on  the  part 
of  the  staff,  and  the  expression  of  a  desire  for  wider  oppor- 
tunities for  recreation,  a  need  which  can  only  be  met  by  an 
extension  of  holidays  and  a  lessening  of  the  hours  of  duty. 
If  a  high  state  of  efficiency  is  ever  to  be  gained  in  the  nurs- 
ing of  the  mentally  afflicted,  it  can  only  be  by  maintain- 
ing a  state  of  permanency  among  the  staff  able  to  supply 
the  result  of  years  of  experience  to  meet  the  exigencies 
which  so  often  arise  in  the  wards  in  a  manifold  variety. 

This  perpetual  ebb  and  flow  among  the  personnel  of 
the  staffs  of  our  asylums  has  been  noted  by  the  Commis- 
sioners in  Lunacy,  and  the  attention  of  the  ruling  authori- 
ties of  our  asylums  has  been  drawn  to  the  fact,  and  it  has 
been  suggested  that  some  determined  effort  should  be  made 
to  render  the  service  in  our  asylums  more  attractive,  both 
financially  and  socially.  At  present  there  is  no  guaran- 
teed pension  for  service  in  the  county  asylums*  of  Eng- 
land and  Wales,  but  there  is  being  made  a  representative 
effort  to  promote  legislation  to  attain  this  end,  and  so  place 
the  asylum  nurse  upon  the  same  basis  as  other  branches  of 
the  civil  service  in  the  Kingdom. 

In  this  respect  there  is  a  difference  between  hospital  and 
asylum  nursing.  There  exists  a  greater  need  for  recreation 
in  the  latter.  Companionship  with  invalids  has  a  most 
depressing  effect  and  requires  vigorous  counteraction  to 
ward  off  injurious  results,  while  the  nervous  strain  entailed 
in  the  care  of  acute  cases  of  insanity  ultimately  in  a  few 
years  reacts  upon  the  nurse  and  causes  a  general  break- 
down unless  the  motto  of  "  tnens  sana  in  cor  pore  sano"  is 

*Asyluins  under  the  management  of  the  various  county  councils. 


Asylum  Nursing  183 

carefully  regarded.  A  true  appreciation  of  this  statement 
can  only  be  gained  by  those  who  have  had  actual  experience 
of  the  inner  life  of  our  asylums  and  the  excessively  trying 
conditions  which  often  exist  therein.  The  efifort  to  main- 
tain a  healthy  physical  tone  among  the  staff  of  our  asylums 
should  meet  with  every  encouragement  from  the  managers 
of  these  institutions.  A  low  state  of  health  diminishes  the 
efficiency  of  the  nurse,  and  the  work  consequently  suffers. 
However  we  may  regard  it,  due  consideration  of  the  needs 
of  the  staff  promotes  both  the  medical  and  economic  inter- 
ests of  our  asylums.  There  is  expressed  a  general  desire  to 
raise  the  status  and  qualifications  of  the  asylum  nurse,  and 
some  progress  in  this  respect  has  been  made.  This  can  be 
further  advanced  by  careful  selection  of  candidates.  On 
the  whole,  it  is  probable  there  is  better  material  from  which 
to  select  female  nurses  than  male.  Wider  spheres  of  work 
for  men  have  a  great  deal  to  do  with  this  condition  of  things, 
but  for  those  who  elect  to  remain  in  the  service  the  same 
course  of  instruction  and  training  is  open  as  is  available  to 
the  female  nurse,  and  a  man  of  good  character  holding  the 
medico-psychological  certificate  will  readily  find  employ- 
ment either  in  an  asylum  or  with  a  private  case.  A  good 
moral  character  is  the  foundation  upon  which  the  successful 
training  of  the  nurse  rests.  Asylum  nursing  makes  severe 
demands  on  moral  qualities  of  character.  Tact,  power  of 
self-control,  sympathy,  and  quick  perceptive  powers  are  all 
needed. 

On  the  authority  of  Dr.  Spence,  writing  in  the  Journal 
of  Mental  Science  in  1899,  it  may  be  stated  that  there  is  no 
wide  difference  existing  between  the  conditions  of  asylum 
nursing  in  England  and  in  America.  The  development  in 
recent  years  in  America  has  acted  as  a  stimulus  upon  the 
asylums  of  England,  and  the  facilities  for  the  interchange  of 
ideas  which  now  exist  will  promote  progress  in  every  direc- 
tion. 


The  President:    The  chair  would  ask  Miss  Wood,  of 
England,  to  open  this  discussion. 


184  International  Congress  of  Nurses 

Miss  Wood :  I  am  a  delegate  from  the  Asylum 
Workers'  Association.  This  association  is  one  of  modern 
growth.  It  is  an  association  of  medical  men,  specialists  in 
the  medical  profession,  and  of  the  more  intelligent  and 
advanced  superintendents  and  nurses  in  the  asylums.  The 
object  of  the  association  is  to  improve  the  condition  of  the 
patient,  by  improving  the  education  and  equipment  of  the 
attendant.  Our  asylums  have  been  a  byword  in  times  past 
for  the  very  low  standard  of  the  attendants  employed  in 
them ;  women  of  no  character,  or  of  shady  character,  who 
could  not  get  employment  elsewhere,  have  obtained 
employment  as  attendants  to  the  insane.  The  means  by 
which  the  society  hopes  to  bring  about  a  different  state  of 
things  is  by  the  education  of  the  attendants.  They  require 
that  members  of  the  Asylum  Workers'  Association  shall 
pass  the  examination  of  the  Medico-Psychological  Society, 
which  is  one  of  the  medical  associations  of  England  especi- 
ally devoted  in  its  attention  to  this  branch  of  medical 
science,  which  will  improve  the  standard  of  those  who 
hold  its  certificate.  All  asylums,  whether  in  touch  with 
the  Medico-Psychological  Society  or  not,  are  educating 
their  nurses  by  giving  them  lectures,  and  practical  instruc- 
tion, teaching  them  the  various  phases  of  insanity,  which 
Miss  Laird  has  described  to  you.  Another  step  has  been 
taken  in  giving  the  asylums  the  hospital  equipment.  This 
was  not  always  so,  but  the  attendants  now,  to  a  limited 
extent,  get  training  in  medical  and  surgical  nursing.  It 
is  also  much  hoped  by  the  Asylum  Workers'  Association 
that  the  head  nurses  and  attendants  may  also  be  trained 
nurses,  with  the  special  training  for  the  insane  as  well.  You 
see  that  this  is  a  distinct  attempt  at  raising  the  standard. 

But  then  of  course  must  come  improved  conditions. 
The  women  of  questionable  character  were  for  obvious  rea- 
sons much  controlled  by  regulations  which  women  of  a 
better  class  will  not  submit  to,  and  one  of  the  objects  of  the 
association  is  to  secure  shorter  hours,  longer  vacations,  and 
considerate  treatment  for  the  workers. 

The  work  is  arduous,  because  the  English  public  has 


Asylum  Nursing  185 

not  realized  its  own  responsibilities,  and  there  is  no  encour- 
agement for  people  to  make  themselves  acquainted  with  the 
machinery  of  the  asylum. 

In  the  old  days  the  "  mad  house  "  attendants,  as  they 
were  called,  were  rather  looked  upon  as  persons  to  be  cast 
aside  and  not  received  into  society  of  any  kind.  Now  if 
we  can  only  bring  about  a  feeling  upon  the  part  of  every 
one  engaged  in  the  care  of  the  insane,  and  the  public,  a  feel- 
ing that  we  are  all  banded  together  only  for  good,  the  work 
of  the  Asylum  Workers'  Association  will  be  a  grand  one, 
and  will  mark  a  great  step  forward  in  our  profession. 

The  best  buildings  in  the  world,  and  the  most  com- 
plete appliances  are  of  no  good  without  the  proper  atten- 
dants. It  is  now  the  aim  of  the  training  that  the  individual 
nurse  should  not  only  understand  the  character  of  the 
patient  with  whom  she  has  to  deal,  but  that  she  should 
have  a  sense  of  individual  responsibility,  and  should  take 
some  pride  in  her  calling. 

Miss  Richards :  I  am  glad  to  speak  upon  this  subject. 
It  is  one  in  which  I  am  deeply  interested.  My  experience 
in  this  branch  of  nursing  has  been  short,  covering  only  two 
and  one-half  years.  I  am  glad  to  welcome  any  advance- 
ment which  tends  to  the  better  care  of  the  insane.  The 
school  of  which  I  have  charge  is  connected  with  one  of 
the  State  Hospitals  in  Massachusetts.  The  hospital  has 
buildings  set  apart  for  the  care  of  the  physically  sick.  These 
buildings  are  very  modern  in  structure  and  have  all  con- 
veniences for  caring  for  medical  and  surgical  cases.  The 
male  patients  are  cared  for  by  male  nurses  who,  like  the 
women  nurses,  are  members  of  the  training  school. 

In  these  wards  the  nurses  are  taught  much  as  their 
sisters  are  in  the  general  hospital.  She  has  always  to  bear 
in  mind  the  fact  that  she  is  not  only  caring  for  a  patient  with 
a  diseased  bodv,  but  one  who  is  both  mentally  and  physically 
ill. 

Many  times  orders  given  are  executed  with  difficulty 
and  occasionally  there  will  be  utter  failure  on  the  part  of  the 


186  International  Congress  of  Nurses 

nurse  to  do  just  what  the  doctor  orders.  This  of  course  is 
always  reported  and  the  responsibiHty  taken  from  the  nurse. 

The  first  and  important  object  is-  the  recovery  of  the 
patient,  as  is  the  case  in  the  general  hospital,  for  these  peo- 
ple do  get  well  occasionally,  and  the  nurse  is  not  to  look 
upon  them  as  hopeless. 

In  the  hospital  with  which  I  am  connected  the  patients 
are  classified.  The  excited  in  wards  for  such  patients.  The 
suicidals  by  themselves,  and  the  quiet  patients  in  wards 
apart  from  the  above  named.  Then  convalescent  wards  are 
provided  and  always  well  filled. 

Every  little  restraint  is  hard,  though  the  very  excited 
patients  are  frequently  put  to  bed  and  confined  there  by 
humanely  devised  restraining  sheets  which  allow  of  con- 
siderable movement  and  yet  keep  the  patient  from  wearing 
herself  out  as  she  would  do  were  she  allowed  to  be  about 
the  ward.  These  patients  are  fed  regularly  and  it  is  most 
gratifying  to  see  often  after  a  few  days  of  rest  in  bed  the 
patient  become  more  quiet  and  as  days  go  on  the  mind 
gradually  becomes  clear  till  reason  is  restored.  Training 
school  work  in  these  hospitals  moves  very  slowly.  But  we 
who  have  been  years  in  the  work  can  look  backward  to  the 
organizations  of  training  schools  in  the  general  hospitals 
and  can  remember  how  very  slowly  was  advancement  made. 
History  is  repeating  itself,  and  better  days  are  surely  in 
store  for  these  special  schools.  The  great  want  and  need  is 
for  conscientious  women  as  superintendents  of  these  schools, 
women  with  very  warm  hearts  and  sound  judgment,  a  deter- 
mination to  succeed  and  patience  to  wait. 

The  meeting  then  adjourned. 


THURSDAY. 

1.45    P.   M. 

Thursday  p.  m.,  meeting^  called  to  order  at  1.45. 

Miss  Darner:  The  Women's  Union  have  asked  me  to 
make  an  announcement  that  the  whole  building-  is  open  to 
your  inspection  and  that  they  would  like  the  nurses  who 
have  time  to  look  over  the  building.  A  number  of  nurses 
doing  private  duty  have  requested  that  an  informal  gathering 
be  held  here  at  5  o'clock  for  private  duty  nurses  only,  to  dis- 
cuss anything  they  feel  interested  in. 

The  President :  The  chair  would  request  the  secretary 
to  read  a  draft  of  the  program  for  Saturday,  as  it  may  be  of 
interest  to  some  of  the  members  present  in  making  their 
plans.  We  would  like  to  assure  you  that  if  any  of  you  have 
planned  to  go  home  on  Friday,  you  will  miss  a  great  deal  of 
pleasure  on  Saturday.  There  will  be,  first,  an  address  of 
welcome  by  Mrs.  John  W.  Horton.  Mrs.  Fenwick  will 
speak  to  us  on  the  subject  of  the  better  education  of  nurses. 
Miss  Louisa  Stevenson  will  then  say  a  few  words  to  us  upon 
some  educational  subject.  Miss  Wood,  of  England,  will  give 
an  address,  "  A  Retrospect  and  Forecast."  A  hospital 
drill  at  4  p.  m.  is  especially  arranged  for  the  Congress  of 
Nurses.  The  Women's  Building  will  be  placed  entirely  at 
the  disposal  of  the  Congress  during  the  day. 


We  will  now  consider  the  papers  on  the  work  of  the 
graduate  nurse. 


187 


The  Opportunity  and  Responsibility  of  the 
Graduate  Nurse  of  Today. 

(first  paper.) 


KATHERINE  DeWITT, 

Illinois  Training  School,  Chicago. 


The  question  of  opportunity  is  not  a  difficult  one.  The 
problems  which  are  facing  the  nursing  world  are  of  such 
importance,  are  so  much  in  evidence,  and  are  so  insistent 
that  a  nurse  must  be  blind  and  deaf  who  is  ignorant  of  their 
existence.  The  thinkers  and  workers  in  the  nursing  pro- 
fession all  over  the  world  are  considering  the  questions  of 
registration,  preliminary  training,  teachers'  courses,  uni- 
formity of  education,  combinations  of  small  or  special  hospi- 
tals, post-graduate  work,  and  the  maintenance  of  alumnae 
associations.  These  and  similar  themes  press  closely  upon 
us  and  demand  attention.  The  difficulty  lies  in  the  ques- 
tion of  responsibility.     Who  should  bear  it? 

Graduate  nurses  may  be  divided  into  three  classes — 
those  who  hold  hospital  positions,  those  who  do  private 
nursing,  and  those  who  have  married  or  have  for  other  rea- 
sons retired  into  private  life.  Their  interest  in  nursing 
affairs  dwindles  as  they  get  farther  away  in  space  or  time 
from  their  place  of  training.  Very  few  who  have  given  up 
nursing  work  retain  more  than  a  vague  interest  in  our 
doings.  Those  who  do,  those  who  hold  the  motto,  "  Once 
a  nurse,  always  a  nurse,"  are  the  most  valuable  of  workers. 
They  often  have  more  leisure  for  thinking,  more  time  to 
devote  to  ofiticial  responsibilities,  and  a  broader  view  of 
affairs  than  those  who  are  still  in  the  ranks. 
188 


opportunity  and  Responsibility  189 

Private  nurses  have  been  in  the  past  a  most  self- 
absorbed  and  indifferent  body  of  women,  thinking  only  of 
their  personal  aims  and  interests,  caring:  little  for  their  fel- 
lows. Those  who  have  held  hospital  positions,  especially 
hospital  superintendents,  being  in  constant  touch  with  nurs- 
ing affairs  and  seeing  the  abuses  which  need  reform,  have 
been  the  pioneers  in  all  progressive  movements  and  have 
labored  almost  alone.  The  alumnae  asociations,  growing 
in  all  directions,  are  beginning  to  get  hold  of  the  scattered 
private  nurses  and  to  arouse  their  interest,  but  all  graduate 
nurses,  in  whatever  walk  of  life,  have  opportunities  which 
should  appeal  to  them — responsibilities  which  they  should 
not  shirk. 

We  are  said  to  be  heirs  of  the  ages.  Trained  nurses  of 
today  are  heirs  of  very  difficult  pioneer  work,  done  by  a  band 
of  energetic  efficient  workers  whose  toil  has  been  so 
effective  that  what  would  seem  to  require  a  century  to  bring 
about  has  been  done  in  a  third  of  that  time.  We  come  into 
line  and  find  modern  hospitals,  well  equipped,  with  training 
schools  attached,  where  nurses  are  taught  in  both  theoretical 
and  practical  work.  Are  we  to  drink  in  all  the  knowledge 
offered  us  and  devote  the  strength  derived  therefrom  to  con- 
cerns which  affect  ourselves  alone  ?  To  do  this  is  to  miss 
the  opportunity  of  doing  our  share  of  the  world's  work  and 
results  in  narrowness  and  in  imperfect  development.  It  is 
most  exasperating  to  the  leaders  in  any  line  of  work  to  see 
about  them  those  who  could  be  their  helpers  but  who  will 
not  exert  themselves.  These  are  they  who  sit  back  and 
criticize  the  often  faulty  work  done  by  others.  Perhaps  the 
work  is  faulty  through  lack  of  help  which  they  could  have 
given.  Perhaps  they  think  that  if  their  own  personal  work  is 
well  done  they  have  fulfilled  their  duty.  They  fail  to  realize 
that  those  who  are  not  helping  are  hindering;  that  affairs  of 
moment  which  will  affect  them  personally  in  time  are  hang- 
ing in  the  balance,  and  that  the  influence  of  each  person 
counts  in  the  final  turning  of  the  scale. 

Emerson  says :  "  If  you  act,  you  show  character ;  if 
you  sit  still,  you  show  it.     You  think  because  you  have 


190  International  Congress  of  Nurses 

spoken  nothing  when  others  spoke,  and  have  given  no 
opinion  on  the  times,  that  your  verdict  is  still  expected  with 
curiosity  as  a  reserved  wisdom.  Far  otherwise ;  your  silence 
answers  very  loud.  You  have  no  oracle  to  utter,  and  your 
fellow  men  have  learned  that  you  cannot  help  them." 

There  is  a  class  of  beings,  not  intentionally  lazy  or 
selfish,  but  of  a  timid,  retiring  disposition,  who  think  they 
are  unfitted  by  nature  to  "  speak  in  meeting  "  or  to  write 
papers,  and  that  therefore  they  are  of  no  value  and  must  be 
counted  out. 

Yet  these  services,  though  conspicuous,  are  not  the 
most  useful.  The  nurse  who  thinks  and  reads  and  gains 
a  clear  idea  of  the  standards  for  w'hich  we  are  striving  is  a 
help.  She  who  in  her  daily  life  improves  the  opportunities 
of  talking  with  and  interesting  other  nurses  is  a  help.  To 
one  who  is  alert  many  occasions  will  arise  in  which  she 
may  be  of  service,  and  she  may,  by  her  presence  and  interest, 
be  of  aid  in  meetings  in  which  she  takes  no  active  part. 

I  wish  I  could  tell  at  length  the  story  of  a  member  of 
my  own  alumnae  association,  one  of  the  "  quiet  sort."  She 
is  married,  she  is  in  ill-health,  she  is  an  exile  from  home — 
excellent  excuses  for  dropping  out  of  sight ;  yet  ev;ery 
alumnae  oliticer,  every  nurse-acquaintance,  feels  the  inspira- 
tion which  comes  from  her  eager  interest  and  unswerving 
loyalty.  She  is  the  kind  of  person  who  never  forgets  when 
her  dues  should  be  paid,  who  does  not  neglect  to  send  in 
any  change  in  her  address,  who  responds  promptly  to  any 
appeal  made  to  our  members  in  general.  When  our  new 
nursing  journal  was  contemplated,  and  we  realized  that  it 
must  have  a  goodly  number  of  subscribers  to  make  a  start, 
she,  in  a  land  of  strangers,  secured  five  subscriptions.  Do 
these  things  seem  trifles  ?  They  are  the  trifles  which  count. 
An  alumnae  asociation  whose  members  were  all  animated  by 
her  spirit  could  work  wonders. 

I  once  heard  an  enthusiastic  young  minister,  speaking 
of  missions  to  some  college  students,  say :  "  When  we  get 
to  the  Heavenly  Jerusalem  and  hang  our  battered  armor  on 
the  jasper  walls  and  look  back  on  the  conflicts  we  have  been 


opportunity  and  Responsibility  191 

waging,  we  shall  say,  '  I'm  glad  I  was  in  that  battle.'  "  How 
is  it  with  us  ?  When  the  first  number  of  our  nursing 
journal  appeared,  those  who  had  wrestled  with  the  problem 
of  getting  it  started,  those  who  had  given  what  they  could  to 
help  establish  it,  those  who  had  written  for  it,  those  who 
had  skirmished  for  subscribers  for  it,  could  look  upon  it 
with  joy  and  pride  and  say :  "  I  am  glad  I  was  in  that 
battle,"  When  the  army  nursing  bill  had  been  passed  by 
Congress,  those  who  had  seen  ills  in  the  nursing  service 
and  had  striven  to  remedy  them,  those  who  had  borne 
unpleasant  testimony  for  conscience's  sake,  those  who  had 
worked  early  and  late  to  rouse  interest  in  the  measure,  could 
give  a  sigh  of  relief  and  say :  "  I  am  glad  I  was  in  that 
battle." 

Shall  we  fold  our  hands  while  others  do  the  fighting  ? 
No!  The  battle  is  still  on.  Let  us  be  thankful  that  the 
interesting  part  of  the  struggle  is  not  over  and  that  we  may 
have  a  hand  in  it.  Let  us  try  to  earn  the  right  to  enjoy  the 
glow  of  pleasure  which  comes,  when  the  battle  is  over,  to 
those  who  have  helped  win  the  victory. 


The  Opportunities  and  Responsibilities  of  the 
Graduate  Nurses  of  Today. 

(second  paper.) 


LINDA    RICHARDS, 

Taunton,  Mass. 


If  it  is  true  that  the  responsibihty  of  a  community,  a 
body,  or  an  individual  is  measured  by  its  opportunity,  the 
graduate  nurse  of  today  carries  a  burden  which  no  one  can 
call  light, — a  burden  much  heavier,  I  fear,  than  is  realized 
by  the  majority  of  nurses. 

Were  we  to  ask  the  average  graduate  if  she  considers 
her  advantages  while  in  the  training  school  great  or  even 
fairly  good  we  might  be  surprised  to  hear  in  reply  that  she 
felt  her  opportunities  to  have  been  few,  and  not  at  all  what 
she  had  expected  or  thought  hers  by  right,  and  that  she, 
as  a  matter  of  fact,  considered  her  advantages  as  having 
been  inferior  to  what  they  should  have  been,  so  prone  is  the 
human  mind  to  fail  to  recognize  present  blessings  in  the 
attempt  to  catch  sight  of  some  fancied  advantage  not  within 
reach. 

To  enable  us  to  fully  realize  the  opportunities  of  nurses 
recently  graduated  and  of  those  still  in  training,  let  us 
enumerate  a  few  of  the  more  prominent : 

In  any  well  regulated  training  school  of  the  present 
time  we  will  find  as  a  first  requisite  a  superintendent  of  the 
school  who  is  a  graduate  nurse,  a  woman  having  graduated 
from  a  school  well  known  and  of  good  report,  and  who  has 
been  chosen  because  of  her  fitness  for  the  position. 
192 


opportunities  and  Responsibility  193 

If  the  school  is  connected  with  a  large  hospital,  or  if  it 
is  a  school  giving-  a  three  years'  course,  graduate  nurses  will 
be  found  in  charge  of  wards,  thus  giving  the  pupil  nurses  the 
advantage  of  excellent  instruction  in  their  practical  work, 
as  well  as  superior  teaching  in  the  class  and  lecture  room. 

Text-books,  many  and  varied,  for  class  work  and  refer- 
ence— books  especially  adapted  to  the  needs  of  nurses  in 
training — are  at  her  command.  Many  of  these  have  been 
compiled  by  graduate  nurses  and  superintendents  of  training 
schools.  A  well-defined  course  of  study,  which  (thanks  to 
the  Superintendents'  Association)  is  now  fairly  uniform,  will 
be  found  in  all  large  and  in  many  of  the  small  training 
schools.  Added  to  this  instruction  is  given  in  special 
branches,  as  some  knowledge  of  dietetics,  with  practical 
instruction  in  the  preparation  of  foods  for  the  sick;  hydro- 
therapy, limited  largely  to  the  giving  of  the  various  kinds 
of  baths,  care  and  use  of  the  electric  battery,  massage  and 
physical  culture,  the  application  of  heat  by  the  latest  and 
most  approved  methods,  and  a  knowledge  of  bacteriology, 
with  the  different  methods  employed  in  destroying  germs. 
These  are  a  few  of  the  many  subjects  which  are  taught  in 
the  training  schools  of  the  present  day,  and  upon  which 
nurses  are  requied  to  pass  a  satisfactory  examination  before 
graduating. 

Each  branch  is  taught  by  an  expert,  thus  giying  pupils 
the  surety  of  being  well  and  uniformly  instructed. 

Demonstrations  in  modern  methods  of  medical  and 
surgical  nursing,  which  are  free  to  all  nurses,  are  given  by 
some  of  the  larger  hospitals,  and  these  public  demonstra- 
tions are  of  great  value  to  nurses  who  have  graduated  and 
are  doing  private  nursing  and  in  danger  of  growing  rusty, 
and  also  to  those  who  are  still  pupils  in  schools  connected 
with  the  smaller  hospitals  giving  a  more  limited  course  of 
instruction. 

Lecture  courses  for  the  benefit  of  graduate  nurses  are 
often  provided  by  the  alumnae  of  the  school  or  by  graduate 
nurses'  associations  which  are  open  to  all  graduates  for 
membership  and  consequent  advantages. 


194  International  Congress  of  Ntirses 

Nurses'  clubs  have  been  organized  by  many  schools. 
Connecting'-links  they  are  between  the  pupil-nurses  and 
j^raduates,  and  productive  of  g-ood  in  giving  help  and  creat- 
ing a  feeling  of  unity. 

The  school  alumnae,  of  which  nearly  every  school  of  any 
standing  boasts,  and  of  which  the  national  alumnae  is  an 
outgrowth,  which  may  be  likened  to  the  powerful  oak 
grown  from  the  tiny  acorn. 

The  Nurses'  Home,  where  nurses  tired  with  the  trying 
duties  of  the  ward  can  go  for  rest  and  quiet.  Nor  would 
we  forget  that  it  was  through  the  generosity  of  one  noble 
woman  that  the  first  home  for  nurses  in  America  was  built, 
and  so  well  has  her  example  been  followed  that  few  indeed 
are  the  hospitals  which  have  not  a  "  Nurses'  Home." 

The  Society  of  Superintendents  of  Training  Schools, 
which  has  during  its  few  years  of  existence  accomplished 
so  much  for  the  nursing  profession  and,  through  the  dif- 
ferent schools,  for  under-graduates  as  well.  It  is  because  of 
the  existence  of  this  society  that  we  have  an  approach  to 
a  universal  curriculum,  which  will  in  time  be  uniform  and 
will  be  found  in  use  in  all  schools,  and  by  reason  of  which 
all  graduates  will  stand  upon  common  ground. 

It  is  through  the  influence  of  this  society  that  the  nar- 
row school  feeling  is  giving  place  to  the  broader  interest  in 
nursing  as  a  profession.  All  these  advantages  have  been 
instrumental  in  placing  the  nursing  profession  in  America 
upon  a  higher  level,  thus  adding  to  its  strength  and  power. 

It  is  also  through  the  efforts  of  this  society  that  we 
have  today  the  special  course  in  hospital  economics  in  con- 
nection with  Columbia  College,  from  which  two  classes  have 
been  graduated.  Already  are  the  benefits  derived  from  the 
course  so  apparent  that  one  feels  like  prophesying  that  the 
time  is  not  far  distant  when  to  be  able  to  secure  a  position 
as  superintendent  of  a  training  school  a  diploma  from  this 
special  course  will  be  a  necessity. 

For  a  long  time  the  need  of  a  periodical  especially 
adapted  to  the  wants  of  nurses  had  been  recognized,  and  the 
sentiment  that  only  nurses  who  were  thoroughly  conversant 


opportunities  and  Responsibility  195 

with  the  needs  of  nurses  could  meet  the  demand  grew  daily 
stronger,  and  today  we  have  The  American  Journal  of 
Nursing,  and  this  long-felt  need  has  been  satisfactorily  met. 

Each  year  has  given  added  opportunities,  and  so  quietly 
have  they  come  that  those  not  concerned  in  bringing  them 
about  often  fail  to  detect  them. 

Opportunities  of  which  the  most  optimistic  nurse  of 
twenty-five  years  ago  would  not  have  dreamed  are  now  open 
to  the  pupil-nurse,  and  this  without  her  effort  or  thought.  ^ 

To  prove  that  these  advantages  are  real  and  great,  let 
us  compare  the  advantages  just  enumerated  with  those  of 
the  earliest  pupils,  who,  when  they  entered  the  training 
school,  found  there  no  graduate  superintendent  to  guide  or 
counsel  them,  no  trained  nurses  in  charge  of  wards  to 
instruct  them  in  practical  duties,  no  class  instruction  was 
given,  and  in  most  things  they  were  their  own  teachers. 
Lectures  were  given  irregularly,  no  notes  upon  them  being 
required.  The  nurses  were  required  to  know  but  little,  and 
walked  by  faith,  not  by  sight.  But  meagre  as  the  instruc- 
tion was,  the  pupils  were  taught  that  from  the  time  they 
entered  the  training  school  to  the  end  of  their  lives  they 
would  be  considered  as  persons  of  great  and  grave  respon- 
sibility. 

And  if  nurses  trained  under  the  conditions  just  men- 
tioned were  given  such  a  burden  of  responsibility,  what 
shall  be  said  of  the  nurse  who  graduates  with  the  number- 
less advantages  of  the  present  day  ? 

Is  it  not  just  that  more  and  better  results  be  expected 
of  her  than  of  her  less  favored  sister  ?  Surely  yes.  The 
nurse  of  the  present  time  is  to  be  congratulated  because  of 
her  many  and  varied  privileges.  But  she  is  to  constantly 
remember  that  hand  in  hand  with  these  come  heavy  respon- 
sibilities. The  first  she  will  joyfully  welcome.  The  last 
must  be  conscientiously  borne. 

Does  some  one  ask,  What  are  these  responsibihties  ? 
The  reply  must  be,  Their  name  is  legion.  Two  or  three 
stand  out  so  prominently  that  they  almost  name  themselves: 
Let  the  nurse  of  todav  consider  it  her  solemn  duty  to  raise 


196  International  Congress  of  Nurses 

the  standard  even  higher.  Let  her  keep  in  touch  with  every 
advanced  movement.  Let  each  year's  work  exceed  in 
excellence  that  of  the  preceding  year.  Let  her  show  to  the 
world  that  her  profession  is  one  of  the  grandest,  and  that 
she  is  an  honor  to  it.  She  is  to  enter  new  fields — let  it  be  to 
conquer,  and  let  her  prove  a  help  and  blessing  wherever  she 
is  found. 

The  eyes  of  the  world  are  upon  her,  and  great  things 
are  expected  of  her.  Let  her  always  carry  this  thought, 
"  To  whom  much  is  given,  of  her  much  is  required." 


■, » 


Private  Nursing  on  the  Pacific  Coast. 

MARY  E.  PATTON, 

Superintendent  of  Nurses,  City  and  County  Hospital,  San  Francisco. 


San  Francisco  has  a  population  of  342,182  and  is  recog- 
nized as  the  medical  center  for  the  Pacific  slope. 

There  are  twenty-one  private  hospitals  in  the  City  of 
San  Francisco,  eleven  of  which  conduct  training  schools  for 
nurses.  The  city  directory  registers  370  trained  nurses. 
Sixty  per  cent  of  this  number  are  probably  graduates.  Two 
hundred  and  twenty-five  graduated  nurses  seems  but  a 
small  showing,  when  the  many  schools  and  date  of  incor- 
poration, sixteen  years  ago,  of  the  first  school  *  is  taken  into 
consideration.  But  two  of  the  eleven  schools  enumerated 
are  connected  with  hospitals  containing  as  many  as  two 
hundred  beds,  consequently  the  number  of  nurses  in  training 
and  graduating  is  necessarily  small.  The  maximum  num- 
ber of  graduates  from  all  schools  may  be  placed  at  forty 
yearly.  ■^'^'^ 

In  illustration  of  how  the  ranks  are  diminished  I  iristy 
cite  the  San  Francisco  training  school  whose  graduates 
reach  a  total  of  eighty-nine,  (school  organized  in  1891). 

tIt- 

Engaged  in  private  nursing,  San  Francisco 28  •' 

Filling  hospital  positions 2$''A^' '  ■ 

Married    ISji-n; 

Returned  to  their  homes  after  graduating "^ 

Librarian,  public  library,  San  Francisco rl'r  B   ■ 

U.  S.  Army  Nursing  Corps '5 

Private  nursing  in  other  coast  cities .^J'9-'-'^>: 

Private  nursing  in  New  York  City ;;;ri^T'r' 

♦Hospital  for  Children  and  Training  School  for  Nurses.  November  8.  1885. 


198  International  Congress  of  Nurses 

I  believe  similar  conditions  reduce  the  number  of 
graduates  of  the  other  San  Francisco  schools.  Our  leading 
practitioners  tell  us  we  have  need  of  more  nurses.  Gradu- 
ates, experienced  and  skilful,  are  always  in  demand.  Yet, 
one  hears  the  stock  phrase,  "  Where  will  all  the  nurses  find 
work  "  when  announcements  are  made  of  classes  graduat- 
ing. No  alarm  on  that  score  need  be  felt  since  one-third 
of  the  nurses  engaged  in  San  Francisco  cannot  be  recog- 
nized as  trained  and  graduated  nurses,  yet  they  are  kept  con- 
stantly employed  and  receive  the  same  remuneration  as 
nurses  orraduated  from  the  best  schools. 

This  being  the  case  nurses  have  not  felt  the  necessity 
of  organizing, — and  may  in  part  account  for  the  lack  of 
nurses'  clubs  and  alumnae. 

No  general  movement  toward  organizing  a  directory  for 
nurses  of  all  schools  has  yet  been  made.  A  directory  *  is 
conducted  in  San  Francisco,  where  graduate  and  non- 
graduate  nurses  register.  The  charge  is  made  by  deducting 
a  certain  per  cent  of  the  wages,  thus  nurses  who  are  greatly 
in  demand  and  constantly  employed  pay  to  this  agency  3% 
of  all  earnings.  From  the  less  fortunate  ones  who  are  fre- 
quently disengaged,  6%  of  their  salaries  is  collected  by  the 
proprietor  of  this  directory. 

The  San  Francisco  training  school,  Children's  Hospital 
and  St.  Luke's  Hospital  graduates  have  established  homes, 
share  expenses  and  receive  only  nurses  from  their  respective 
schools.  These  homes  constitute  "  headquarters  "  for  nurses 
engaged  in  private  work. 

Exact  statistics  from  other  coast  cities  have  been  diffi- 
cult, in  fact,  impossible  to  obtain.  Portland,  Seattle  and  Los 
Angeles  have  each  tw^o  or  more  training  schools  and  their 
quota  of  graduates. 

Many  Eastern  nurses  attracted  by  the  climate  of 
California  and  others  who  have  crossed  the  Continent  with 
patients  elect  to  remain  and  continue  the  work  of  private 
nursing,  mainly  in  Southern  California. 


♦Nurse  Agency,  Mr.  F.  E.  Goodban,  Prop.,  1117  VanNess  Ave.,  San  Francisco. 


Private  Nursing  on  the  Pacific  Coast  199 

As  nearly  as  can  he  learned,  the  standard  rate  of  wages, 
twenty-five  dollars  weekly,  as  maintained  in  San  Francisco, 
is  not  averaged  elsewhere  on  the  Coast. 

The  percentage  of  people  living  in  hotels  and  board- 
ing houses  is  larger  in  San  Francisco  than  that  of  any  other 
city  of  its  size  in  the  Union.  In  consequence  of  this,  in  time 
of  illness  the  private  hospitals  are  chosen;  indeed,  many 
having  comfortable  homes  prefer  the  hospital  for  accouche- 
ments,  operations  or  a  long  siege  of  fever.  Patients  coming 
to  San  Francisco  for  treatment,  accidents  and  illness 
occurring  amongst  the  floating  population  must  needs  also 
be  taken  to  a  private  hospital.  In  this  way  many  graduated 
nurses  are  employed  in  hospitals — engaged  by  the  patient  or 
physician  of  patient  independent  of  the  hospital  authorities. 

Practically  there  are  no  slums  in  San  Francisco,  nor 
have  we  many  real  cases  of  poverty.  The  clerk  and 
mechanic  can  afiford  to  pay,  when  sickness  comes,  the  high- 
est wage  paid  the  graduate  nurse. 

San  Francisco  is  rated  one  of  the  healthiest  cities  in 
the  United  States.  Our  Health  Boards  are  most  vigilant  in 
stamping  out  specific  infectious  diseases — many  of  the  latter 
are  consequent  to  the  great  shipping  traiBc  between  San 
Francisco  and  the  Orient.    (We  have  no  epidemics). 

San  Francisco  is  in  itself  a  park  when  one  reckons  on 
fresh  air.  We  have  no  summer,  no  cellars  and  very  fev/ 
refrigerators.  In  winter  we  have  no  furnaces,  furs  nor 
frost,  and  instead  there  are  flowers,  green  fields  and  a  mean 
temperature  of  60°  F. 

The  cost  of  living  may  be  placed  at  a  very  moderate 
figure;  board  and  room  can  be  obtained  at  a  good  family 
hotel  or  boarding  house  from  twenty-five  dollars  per  month 
and  upwards.  A  sunny  furnished  room  (the  sun  is  an  essen- 
tial in  San  Francisco),  location  central,  may  be  secured  from 
ten  to  twenty  dollars  per  month.  Meals,  breakfast  and 
lunch,  twenty-five  cents  and  even  less,  and  an  excellent  full 
course  dinner  for  fifty  cents.  San  Francisco  is  noted  the 
world  over  for  the  excellence,  variety  and  reasonable  charge 
of  its  restaurants.  Its  cuisine  includes  the  Italian,  French, 
German,  Mexican  and  Spanish. 


200  International  Congress  of  Nurses 

An  eastern  nurse,  a  stranger  on  the  coast,  would  do 
well  to  apply  at  one  of  the  private  hospitals,  presenting  at 
the  same  time  her  credentials  and  in  this  way  she  will  meet 
the  physicians  who  will  be  quick  to  recognize  her  work. 

The  smaller  towns  on  the  coast  do  not  boast  of  even  one 
trained  nurse  as  a  rule.  It  is  the  custom  to  telegraph  to 
San  Francisco  wdien  one  is  required. 

While  Sacramento,  the  State  Capitol,  is  a  good  field  for 
trained  nurses  there  is  but  one  training  school  of  recent 
organization,  and  but  few  graduate  nurses. 

The  Pacific  slope  is  most  bountiful  in  its  productions, — 
from  the  wealth  of  minerals,  orchards,  fields  of  grain,  its 
flocks  grazing  on  the  hills,  to  the  natural  physical  attrac- 
tions, mountains,  rivers,  lakes,  ocean  and  sapphire  skies, 
and  over  all  an  enchantment  indescribable,  made  vivid  by 
the  ruins — momuments  of  a  vanished  race.  A  sweet  leisure 
still  rests  with  its  children — an  inheritance  from  the  Spanish 
hidalgo,  and  a  marked  contrast  to  the  energetic  business 
world  of  San  Francisco ;  the  mart  of  all  nations. 


DISCUSSION. 

Mrs.  Fenwick :  I  think  it  was  Mrs.  Robb  who  said 
''  Once  a  nurse,  always  a  nurse,"  and  both  she  and  I  have 
proved  that  we  feel  the  principle  of  that  very  strongly.  It  is 
not  given  to  every  woman  who  leaves  her  school  and  active 
practice,  to  do  public  work.  It  takes  both  time  and  money, 
and  women  who  elect  to  marry  have  many  other  duties, 
especially  those  who  are  the  mothers  of  families.  It  is  not 
always  possible  for  them  to  take  an  active  part  in  nursing 
afifairs,  although  none  need  be  too  busy  to  have  a  heartfelt 
interest  in  professional  matters. 

After  listening  to  Miss  Richards'  most  excellent  paper, 
it  seems  almost  incredible  that,  since  my  first  visit  to  the 
United  States  in  1892,  such  wonderful  changes  can  have 
taken  place.  I  had  the  pleasure  of  visiting  the  Johns 
Hopkins  Hospital  at  that  time,  and  there  meeting  Mrs. 
Robb — then  Miss  Hampton.  In  1892  there  was  practically 
no  organization  of  American  nurses — today  Miss  Richards 


Private  Nursing  on  the  Pacific  Coast  201 

has  shown  us  what  marvellous  progress  has  been  made  by 
the  formation  of  the  alumnae  societies  and  the  National 
Associated  Alumnae  of  Trained  Nurses.  It  is  indeed  a  most 
hopeful  and  encouraging-  report  that  has  been  placed  before 
us,  but  we  notice  all  the  same  that  these  splendid  results 
would  not  have  been  accomplished,  if  a  few  of  the  old  war 
horses  had  not  thrown  themselves  into  the  fray,  and,  com- 
manding the  respect  of  the  nursing  legions,  led  them  to 
victory.  It  appears  to  me  that  today  you  American  nurses 
are  so  advanced  in  organization  that  every  graduate  can  take 
her  part  if  she  so  chooses  in  the  government  of  her  profes- 
sion. In  Great  Britain  we  are  going  very  slowly  along  the 
same  lines,  but  it  takes  us  longer  to  organize  because  we 
have  more  prejudices  to  uproot  and  overthrow. 

I  have  no  doubt  that  international  communication  will 
be  immensely  helpful  to  European  nurses,  and  I  am  san- 
guine that  in  the  near  future  international  organization 
amongst  nurses  will  take  place,  and  thus  what  of  good  is 
accomplished  in  one  country  will  benefit  nurses  all  over 
the  world.  As  a  nurse  who  has  taken  up  professional  jour- 
nalism— not  from  any  superabundance  of  literary  talent  or 
personal  preference  for  the  work,  but  as  a  means  to  an  end 
— to  give  the  nurses  of  my  country  a  voice  in  the  press  and 
thus  make  them  articulate,  I  may  perhaps  be  permitted 
to  say  a  few  words  of  congratulation  to  those  amongst  you 
who  have  organized  and  instituted  the  American  Journal 
of  Nursing,  a  publication  which  is  bound  to  do  an  immense 
amount  of  good  for  the  nursing  profession  in  all  the  English 
speaking  countries  of  the  world.  I  hope  that  after  this 
Congress  its  circulation  will  greatly  increase  in  Great  Brit- 
ain and  our  Colonies,  and  that  we  shall  reap  the  benefits  of 
the  works  of  your  able  editor.  Miss  Sophia  Palmer.  I  speak 
very  feelingly  upon  this  subject  of  professional  journalism, 
because  I  know  the  arduous  and  increasing  labor  of  inter- 
esting people  in  class  journals ;  it  takes  great  courage  to  edit 
such  a  journal,  and  infinite  patience  to  wait  the  necessary 
time  to  see  it  a  success.  The  American  Journal  of  Nursing 
and  those  who  are  working  for  it  have  my  warmest  sym- 
pathy and  admiration. 


Private    Nursing. 

MRS.  MARGARET  L.  ROGERS, 

Superintendent  of  Nursing,  Bridgeport  Hospital,  Conn. 


Of  all  the  professions  now  open  to  women  there  is  none 
possessing  the  possibilities  of  nursing.  The  deeper  our 
medical  men  penetrate  into  the  science  of  medicine,  the  wider 
grows  the  horizon  of  the  trained  nurse. 

Scarcely  a  quarter  of  a  century  ago  the  physician 
regarded  her  advent  with  a  feeling  of  distrust,  fearful  that 
as  soon  as  her  training  was  completed  she  would  proceed 
to  the  practice  of  medicine  and  in  time  share,  if  not  entirely 
absorb,  his  circle  of  patients.  Time  has  proved  the  fallacy 
of  that  idea,  until  today  the  reputable  physician  refuses  to 
take  a  serious  case  unless  the  responsibility  is  shared  by  a 
competent  nurse. 

As  a  character-builder  the  training  school  has  no  equal ; 
I  think  it  is  its  prevailing  atmosphere  of  unselfishness  which 
causes  all  the  tiny  germs  of  good  that  have  long  lain  dor- 
mant in  our  natures  to  develop  and  helps  us  in  time  to  over- 
come our  most  glaring  errors.  The  regular  routine,  the 
unity  of  purpose,  the  absolute  rule  of  willing  subjects,  leave 
their  mark  for  all  time  upon  the  character  and  disposition  of 
its  pupils ;  and  they  must,  because  of  this  discipline,  go  forth 
better  women,  better  equipped  for  the  battle  of  life,  whether 
to  grace  homes  of  their  own  or  to  become  the  temporary 
members  of  the  homes  of  the  suffering. 

In  the  present  day  there  are  many  fields  in  which  the 

nurse  may  find  an  outlet  for  her  activities.     The  need  of 

hospitals,    the    demand    in    the    army,    and  the    increasing 

growth  of  district  and  settlement  work  give  a  choice  to  use- 
202 


Private  Nursing  203 

fulness  unknown  to  her  sister  of  a  few  years  past.  How- 
ever, it  is  in  private  nursing  that  the  large  majority  find 
an  opening  most  suited  to  their  capabilities.  The  reason 
for  this  is  because  of  the  great  pleasure  in  personal  min- 
istration. In  other  branches  of  the  work,  owing  to  lack 
of  time  or  the  inability  to  be  in  many  places  at  the  same 
time,  one's  work  is  apt  to  become  largely  that  of  the  teacher 
and  the  guide,  and  the  joy  of  personally  making  "a  little 
comfortable  the  uncomfortable  way  "  is  seldom  tasted. 

From  the  financial  standpoint  the  private  nurse  is  paid 
better  than  any  other;  she  is  an  active  worker,  she  can 
be  busy  from  nine  to  ten  months  in  the  year.  She  has  the 
advantage  of  being  absolutely  free  when  she  is  free.  Unfor- 
tunately, she  cannot  ever  hope  to  increase  her  salary ;  she  is 
worth  as  much  when  she  takes  her  first  case  as  when  she 
takes  one  ten  years  hence.  While  experience  adds  greatly 
to  her  worth,  it  does  not  add  to  her  financial  value.  The 
most  she  can  ever  hope  to  do  it  to  "  become  established," — 
to  have  her  own  little  coterie  of  patients  and  physicians  to 
whom  she  is  absolutely  indispensable. 

In  the  larger  cities  in  this  country  the  remuneration  for 
private  nursing  is  almost  uniform,  twenty-five  dollars  per 
week,  or  four  dollars  per  day,  being  the  average  salary. 
Some  nurses,  and,  indeed,  some  hospitals,  ask  thirty  dollars 
per  week,  or  five  dollars  per  day,  for  nursing  male  patients, 
still  others  make  a  distinction  in  obstetrical  work,  and  I 
think  all  nurses  in  all  places  make  an  extra  charge  for  con- 
tagious cases.  In  the  smaller  cities  prices  range  from  eight- 
een dollars  to  twenty-one  dollars  per  week,  but  as  living 
expenses  are  comparatively  lower  the  difference  is  not  so 
great  as  it  appears  at  first  thought.  The  question  of  hours 
is  still  worth  considering.  The  nurse  in  the  large  cities  does 
not  feel  this  to  any  great  extent,  as  in  almost  all  cases 
requiring  care  at  night  twelve-hour  duty  is  an  established 
custom. 

But  in  the  smaller  cities  even  people  who  can  alTord 
all  sorts  of  luxuries  feel  that  unless  a  nurse's  training  has 
done  away  with  the  necessity  for  sleep  it  has  failed  in  its 


204  International  Congress  of  Nurses 

purpose.      Indeed,   a   few   days   ago    I    heard    a   physician 

remark  that  Miss  B was  an  excellent  nurse,  as  she 

had  gone  seventy-two  hours  without  sleep.  Of  course,  he 
was  a  very  young  physician. 

Nurses,  no  matter  where  their  homes  may  be,  usually 
locate  in  the  city  where  they  have  taken  their  training.  It 
would  almost  seem,  when  we  consider  the  large  classes 
which  are  graduated  annually  in  hospital  centers,  that  the 
supply  would  be  greater  than  the  demand.  But  this  is  not 
the  case,  the  demand  is  constantly  on  the  increase. 

The  family  of  moderate  income,  which  a  few  years 
ago  did  its  own  nursing,  now  finds  it  impossible  to  get  along 
without  trained  assistance.  The  family  of  afifluence,  which 
formerly  employed  one  nurse,  now  finds  it  necessary  to 
«mploy  two  or  three.  So  that  while  hospital  and  club  regis- 
ters show  an  increased  number  of  graduates  on  their'  lists, 
they  show  a  corresponding  increase  in  the  number  of  calls. 

The  larger  cities  possess  the  attraction  of  affording  a 
greater  choice  of  work.  Indeed,  it  is  becoming  popular  to 
take  up  special  lines  of  work.  The  movement  has  thus  far 
met  with  the  hearty  approval  of  physicians  and  patients. 
It  could  hardly  be  otherwise,  as  the  concentration  of  mind 
and  effort  in  a  given  direction,  if  a  nurse  is  at  all  progress- 
ive, must  result  in  an  added  usefulness,  and  at  the  same  time 
these  special  cases  would  require  suf^cient  regular  care  to 
prevent  her  from  growing  rusty  in  general  work.  "  Nervous 
cases,"  "children's  diseases,"  "gynecological  and  obstet- 
rical "  work  all  afford  opportunities  for  the  "  specialist." 

Many  young  nurses  from  the  smaller  hospitals  in  the 
United  States  and  Canada,  ambitious  to  enlarge  their  views 
and  come  in  contact  with  the  "  great  in  medicine,"  gravitate 
towards  the  larger  cities  and  in  time  become  members  of  the 
great  army  of  workers.  For  such  the  private  hospital  and 
sanatorium  afford  the  needed  stepping-stone.  These  insti- 
tutions employ  only  graduate  nurses,  and  pay  them  a  salary 
of  about  twenty-five  dollars  a  month  and,  of  course,  living. 
This  seems  very  small  compensation  for  very  hard  work, 
but  it  supplies  the  means  of  present  support  and  brings  a 


Private  Nursing  205 

nurse  in  contact  with  prominent  physicians,  who  in  turn 
become  the  medium  through  which  she  reaches  her  sick 
public. 

The  private  nurse  enjoys  many  advantages  over  other 
wage-earners.  She  is  protected,  and  she  is  ahnost  ahvays 
brought  in  contact  with  refined  intellectual  people,  and  is 
forced  to  talk  of  other  things  than  nursing.  We  all  have  a 
tendency  to  get  into  the  "  professional  rut,"  or,  perhaps,  it 
would  be  truer  to  say  we  are  very  deep  in  the  "  professional 
rut  "  when  we  leave  the  training  school,  the  world  having 
narrowed  down  for  most  of  us  to  the  four  walls  of  the  hos- 
pital, and  this  coming  in  contact  with  other  minds  who  are 
absorbed  in  social,  religious,  political,  scientific  and  phil- 
anthropic subjects  stimulates  our  own  intellects  and,  of 
necessity,  widens  our  mental  horizon.  Of  course,  we  occas- 
ionally come  in  contact  with  very  unlovely  people,  for  the 
snob  and  the  parvenu  are  not  exempt  from  bodily  ailments. 
We  should  take  this  as  a  well-needed  discipline  to  reduce 
us  to  a  proper  state  of  humility,  for  I  think  with  continuous 
prosperous  and  pleasant  cases  most  of  us  are  apt  to  grow 
critical  and  exacting  and  "  refuse  to  see  the  sun." 

If  you  are  a  student  of  human  nature  or  interested  in 
"  class  problems,"  what  a  glorious  opportunity  for  con- 
tinuing your  researches.  You  not  only  see  how  the  other 
half  lives,  but  you  actually  live  like  them. 

The  experience  under  doctors  of  different  schools  is 

pleasant  and  instructive.    To  our  physicians  we  are  simply 

,an   individual   nurse.     To   outside  men  we   represent  our 

school,  and  it  is  judged  for  or  against  according  to  our 

merits,  so  that  there  is  a  double  incentive  for  well-doing. 

The  greatest  disadvantage  is  the  absence  of  home  life, 
the  never  being  able  to  make  settled  plans.  Rooming  con- 
ditions in  this  country,  with  the  spasmodic  boarding  nurses 
are  obliged  to  indulge  in,  are,  indeed,  not  pleasant  subjects 
for  contemplation.  The  club  will  in  time  fill  this  most 
pressing  need.  I  have  been  fortunate  enough  to  enjoy  the 
privileges  of  one  for  a  short  time,  and  the  refined,  cultured 
home  atmosphere  with  which  the  nurses  had  succeeded  in 


206  International  Congress  of  Nurses 

surrounding  themselves  was  most  agreeable  and  made 
home-coming  a  distinct  pleasure. 

Of  its  financial  advantages  I  need  not  speak,  as  in  this 
day  of  "  combines  "'  and  "  trusts  "'  they  are  too  apparent  to 
need  mention. 

The  question  is  often  asked,  What  are  the  requisites  to 
make  the  ideal  private  nurse  ?    I  do  not  know. 

To  my  mind  there  can  be  no  fixed  standard  to  which 
we  can  appeal,  as  the  vagaries  of  taste  are  infinite  and  often 
quite  inexplicable.  Convention,  education,  accident,  and 
idiosyncracy  all  play  an  important  part.  I  do  think  it  is 
an  absolute  necessity  to  love  and  believe  in  your  work  in 
order  to  attain  any  degree  of  success  in  it.  And  why  not 
believe  in  it  ?  Surely  outside  of  the  home  it  is  the  noblest 
work  left  to  women  and  requires  a  many-sided  culture. 
"  The  heights  and  depths  of  human  nature  must  be  within 
the  range  of  your  vision ;  you  must  have  a  knowledge  not 
learned  of  books  ;  a  wide  sympathy  ;  the  strength  that  springs 
from  sympathy  and  the  magnanimity  of  strength."  You 
must  be  a  doer  of  deeds,  preferably  not  a  speaker  of  words. 
You  may  not  attain  what  the  world  calls  success,  but  you 
will  attain  a  truer  success.  It  is  not  only  what  we  have 
done,  but  what  we  have  made  of  ourselves.  If  we  have 
repressed  our  individuality,  cultivated  much  selfishness, 
criticism,  and  gossip,  and  closed  our  eyes  and  our  hearts 
to  all  altruism,  then  our  lives  have  been  failures,  and  our 
influence,  like  all  things  false,  will  be  suicidal  and  transitory, 
less  than  "'  the  snow  upon  the  desert's  dusty  face  which, 
lighting  a  little  hour  or  two,  is  gone."  To  attain  the  truest 
success  we  must  soak  in  the  waters  of  unselfishness,  be 
vitalized  from  within  with  a  true  love  for  our  profession,  and 
realize  in  ourselves  the  best  we  are  capable  of,  and  of  her 
"  to  whom  much  has  been  given,  much  will  be  required." 


The  President :  We  have  with  us  a  nurse  from  Hol- 
land. I  have  great  pleasure  in  introducing  Miss  Von 
Vollenhogen. 


Private  Ntirsing  207 

Miss  Von  Vollenhogen :  I  am  glad  to  have  the  honor 
to  speak  to  this  Congress,  Madam  President. 

We  are  a  small  country  and  have  much  to  learn  from 
the  large  ones.  We  work  very  hard,  and  our  training  is 
very  good.  There  is  not  so  much  private  nursing  with  us 
as  with  you,  because  our  sick  people  mostly  go  to  hospitals, 
and  so  many  private  nurses  are  not  needed. 

Besides  the  hospital  nurse  and  the  private  nurse,  there 
is  the  district  nurse.  I  think,  and  I  hope,  that  in  time  the 
district  nurses  will  be  of  greater  importance,  and  that  there 
will  be  more  of  them.  For  it  is  such  a  help  in  the  homes  of 
the  poor  families  to  have  the  nurse  come  in.  She  makes  it 
possible  for  the  sick  mother  to  stay  at  home  with  her  child- 
ren ;  she  keeps  the  home  together  for  the  husband  and  the 
children.  I  should  like  to  say  more  of  my  interest  in  all  this 
work. 


The  Progress  of  Hourly  Nursing. 

ADA  M.  CARR, 

Superintendent  District  Nursing  Association,  Baltimore ;  Delegate  Johns  Hopkins 

Alumna?  Association. 


Published  in  the  Trained  Nurse  for  the  year  1895  and 
in  the  "  Report  of  the  Meeting  of  the  Society  of  Superinten- 
dents in  1897,"  are  two  papers  by  Miss  Diana  Kimber,  pre- 
senting- so  clearly  and  forcibly  the  need  and  the  possibiHties 
of  a  different  class  of  nursing  work  to  those  already  existing, 
that  today  there  seems  nothing  to  add  in  the  way  of  sug- 
gestion along  the  broad  lines  of  the  idea  itself.  Taking  heed 
to  the  ancient  admonition  of  the  making  of  many  books, 
and  the  consequent  weariness  of  the  flesh,  I  would  ask  per- 
mission to  quote  from  Miss  Kimber's  papers,  and  merely 
add  something  of  what  has  been  accomplished  in  the  years 
during  which  the  practical  working  out  of  her  ideas  has  been 
carried  on  in  different  cities. 

The  need  for  visiting  or  hourly  nursing  has,  I  am  very 
sure,  been  brought  home  to  us  all,  as  it  was  to  Miss  Kimber, 
by  instances  coming  under  our  personal  observation, — not 
one,  but  many :  self-supporting  women  in  boarding-houses, 
homes  where  trained  care  and  trained  advice  is  sorely 
needed,  but  where  the  family  resources,  already  strained  to 
their  utmost,  do  not  permit  of  an  outlay  of  twenty  to  twenty- 
five  dollars  a  week :  treatments,  dressings,  where  all  the 
actual  nursing  necessary  could  be  compressed  into  one  or 
two  hours  out  of  twenty-four.  There  is  no  need  to  cite 
a  typical  case ;  anyone  with  experience  can  supply  her  own. 

In  London  some  years  ago,  talking  to  an  old  lady  of 

nearly  eighty,  who  knew  Florence  Nightingale,  and  who 
208 


The  Progress  of  Hourly  Nursing  209 

during  her  whole  Hfe  had  been  associated  in  the  manv  and 
varied  forms  of  philanthropy,  and  kept  careful  watch  over 
the  rise  of  the  newer  methods,  I  mentioned  the  plan  of  visit- 
ing nursing,  which  our  own  alumnae  had  taken  up  at  that 
time  with  much  interest.  She  told  me  that  in  her  opinion 
it  was  one  of  the  most  hopeful  signs  in  a  profession  over 
whose  developments  she  was  inclined  to  shake  her  head. 
Miss  Kimber  writes  in  the  papers  to  which  I  have  referred : 
"  It  would  seem  we  are  confronted  with  two  problems — (1) 
How  shall  we  provide  more  work  for  our  graduate  nurses  ? 
and  (2)  How  shall  we  provide  skilled  nursing  for  people 
who  cannot  afiford  to  pay  the  usual  price  of  the  trained 
nurse? 

When  we  consider  that  the  larger  mass  of  the  popula- 
tion is  composed  of  workers  earning  a  fair  competence, 
which  separates  them  from  the  really  poor  on  the  one  hand 
and  the  wealthy  on  the  other,  it  is  evident  that  we  may 
expect  to  answer  the  first  problem  satisfactorily  if  we  can 
solve  the  second. 

The  plan  I  suggest  is  in  substance  this :  That  individual 
nurses  or  groups  of  nurses  of  sufficient  enterprise  for  start- 
ing such  work  should  call  on  all  the  doctors  within  a  reason- 
able radius  of  their  headquarters  and  state  that  they  would 
take  care  of  patients  by  the  hour,  by  the  night,  and  by  the 
half-day,  assist  at  operations  and  prepare  for  the  same, 
attend  confmement  cases,  and  take  after-care  of  such 
by  paying  one  or  more  calls  a  day.  They  would  thus  create 
a  demand  for  their  services  among  the  class  of  people  we 
most  desire  to  reach. 

They  should,  in  fact,  become  visiting  nurses,  not 
employed  by  a  society  paying  them  a  salary  to  nurse  the 
poor,  but  visiting  nurses  employed  by  the  doctor  to  take 
care  of  patients  able  to  pay  the  nurse  for  the  services 
rendered. 

And  now  let  me  say  a  few  words  as  to  what  seems  to  me 
to  be  some  of  the  advantages  of  this  method  of  nursing. 
First,  I  have  thought  that  nurses  introduced  into  the  fami- 
lies in  this  way  would  be  educative  influences  as  well  as 


210  International  Congress  of  Nurses 

actual  workers,  reaching  and  teaching  a  portion  of  the  com- 
munity very  susceptible  of  profiting  by  such  instruction. 
The  care  of  the  sick  would  not  be  taken  entirely  out  of  the 
hands  of  their  friends,  for  whenever  necessary  or  practicable 
it  would  be  shared  by  them. 

But  the  chief  argument  in  favor  of  the  adoption  of  this 
kind  of  nursing  is  that  it  brings  the  services  of  the  trained 
nurse  within  the  range  of  nearly  all  wage-earners,  and  is  a 
fair  arrangement  for  supplying  non-charitable  help,  the  basis 
of  the  system  being  adequate  remuneration  for  services 
rendered.  It  is  in  itself  a  healthier,  wholesomer  life ;  it 
leaves  a  possibility  for  some  kind  of  home  life ;  it  allows  play 
for  more  individuality ;  and,  better  than  all,  it  gives  greater 
opportunities  for  usefulness  and  help."  It  will  be  seen  that 
in  theory  and  suggestion  there  is  little  to  add  to  Miss 
Kimber's  comprehensive  view. 

I  think,  although  this  is  delicate  ground  on  which  to 
tread,  it  will  be  generally  admitted  that  private  nursing  is 
often  very  demoralizing  in  its  effects,  and  the  outline  of 
advantages  possessed  by  the  visiting  nursing  as  given  by 
Miss  Kimber  must  appeal  to  all  who  have  reason  to  deplore 
the  dangers  and  difficulties  peculiar  to  the  exigencies  of 
private  duty. 

In  papers  read  before  the  National  Alumnae  Associa- 
tion last  year  by  nurses  who  had  ventured  into  this  new 
field,  the  benefits  to  the  nurse  as  well  as  to  the  patient  were 
strongly  dwelt  upon. 

It  may  be  well  here,  however,  to  consider  the  relation  of 
the  nurse  to  the  work.  It  is  not  an  occupation  to  be  under- 
taken by  one  who  has  failed  in  other  branches,  or  who  is 
looking  for  an  easy  way  of  making  profitable  use  of  her  pro- 
fession. The  best  of  the  inexhaustible  array  of  qualifi- 
cations needed  for  the  make-up  of  the  modern  nurse  are 
required  to  insure  genuine  success  in  this  special  branch, 
experience  and  executive  ability  among  them, — the  first 
not  least,  it  is  well  to  remember. 

The  public  and  the  doctors  are  quick  to  feel  the  under- 
lying spirit,  and  in  this  work,  depending  for  the  present  on 


The  Progress  of  Hourly  Nursing  211 

the  recognition  by  them  of  its  real  usefulness,  if  the  right 
spirit  as  well  as  the  faithful  work  be  not  present,  the  result 
is  fatal. 

In  our  own  city  during  the  past  four  years  we  have 
watched  over  our  prospects,  successes,  and  failures,  and 
have  arrived  at  a  very  definite  conclusion  that  the  work 
cannot  stand  without  the  workers — a  trite  conclusion,  prob- 
ably, but  one  peculiarly  applicable  here.  The  main  diffi- 
culty seems  to  lie  in  the  establishment  of  visiting  nursing 
on  a  secure  and  permanent  basis.  It  has  been  shown 
wherever  it  has  been  tried  that  the  work  is  slow  to  grow. 
It  does  not  spring  full-armed  into  prosperous  existence  in 
a  single  night,  nor,  valuable  and  essential  as  we  feel  it  to  be, 
does  it  follow  that  physicians  and  the  public  generally  will 
impulsively  adopt  this  same  view.  It  must  be  demonstrated 
point  by  point,  case  by  case,  that  it  is  a  good  and  desirable 
thing  to  win  slow  recognition  from  those  on  whom  it 
depends  for  success.  Patient  pioneering  is  needed,  and 
there  are  few  nurses  who  can  afford  to  spend  months  in 
waiting  while  their  practice  slowly  develops  into  propor- 
tions large  enough  to  pay  expenses.  Not  only  this,  but  if  a 
nurse  has  painstakingly  gathered  together  a  sufficient  prac- 
tice and  should  be  called  away  by  any  of  those  emergencies 
which  nurses  as  well  as  all  mankind  are  heir  to,  it  is  most 
difficult  to  find  someone  ready  and  competent  to  take  her 
place.  Doctors  and  patients  must  become  familiarized  all 
over  again  with  a  new  personality  and  a  new  address,  and 
hard-won  interest  is  all  too  easily  lost. 

It  is  for  these  reasons  that  I  would  like  to  call  the 
attention  of  alumnse  associations  interested  in  the  establish- 
ment of  new  branches  of  work  to  the  plan  adopted  by  the 
Johns  Hopkins  Alumnse  Association  some  years  ago  to 
establish  visiting  nursing. 

Being  assured  that  it  was  a  good  and  necessary  thing, 
but  also  being  convinced  that  desultory  and  imperfectly 
planned  efforts  would  in  all  probability  result  in  failure, 
the  association  bent  its  energies  primarily  towards  obtam- 
ing  a  fund  sufficient  to  pay  the  necessary  expenses  of  the 


212  International  Congress  of  Nurses 

work  durinc^  the  time  that  mig^ht  elapse  before  it  should 
become  self-supporting. 

After  some  deliberation  it  was  decided  that  the  work 
should  be  conducted  under  the  auspices  of  the  association, 
that  the  nurse  be  appointed  by  it,  and  that  the  association 
hold  itself  responsible  for  the  quality  of  work  and  the  gen- 
eral arrangements  that  should  be  made  in  the  interests  of  the 
public  and  the  nurses.  All  money  collected  to  be  paid  to  the 
association,  while  the  nurse  was  to  be  assured  a  sufificient 
monthly  remuneration  independently  of  the  amount  earned. 
This  arrangement  has  never  been  altered,  and  has  given 
general  satisfaction,  the  sense  of  security  to  the  nurse 
counterbalancing  the  greater  independence  of  work  under- 
taken by  individuals,  and  the  interest  of  an  influential  body 
providing  the  continuity  so  essential.  Fortunately  a  nurse 
volunteered  for  the  Avork  with  the  understanding  that  out 
of  the  fund  collected  her  actual  living  expenses  be  paid. 
The  plan  suggested  by  Miss  Kimber  of  communicating  per- 
sonally and  by  printed  notices  with  doctors  was  followed, 
adding  druggists,  clergymen,  charity  workers,  heads  of 
departments  in  schools  and  colleges. 

The  work,  uncertain  and  spasmodic  at  first,  grew  by 
slow  degrees,  until  it  is  now  self-supporting.  During  the 
past  winter  two  nurses  have  been  kept  well  occupied,  and 
we  have  the  reasonable  expectation  that  the  work  is  here  to 
stay.  Monthly  reports  are  made  to  the  association  of  visits 
made,  new  calls,  and  fees  collected,  thus  keeping  up  the 
general  interest,  while  the  association  treasurer  is  responsible 
for  the  accounts.  We  ourselves  are  mainly  indebted  to  the 
creative  energy  and  wise  guidance  of  one  of  our  members, 
but  underlying  everything  is  the  foundation  on  which  it  is 
built. 

The  main  object  in  writing  this  paper  is  to  emphasize 
this  point — that  the  success  of  the  work  in  Baltimore  is  due 
to  the  fact  that  its  foundation  is  permanent,  depending  on 
an  influential  body,  not  upon  the  accident  of  circumstances 
affecting  the  life  and  work  of  an  individual.  I  have  pur- 
posely avoided  discussion  of  rates  paid  for  services.    This  is 


The  Progress  of  Hourly  Nursing  213 

a  question  upon  which  we  ourselves  have  not  as  yet  arrived 
at  an  entirely  satisfactory  conclusion,  and  we  found  it  neces- 
sary to  depart  from  those  originally  agreed  upon.  Each 
city,  from  what  I  can  learn,  has  its  own  conditions,  and 
nurses  undertaking  the  work  have  a  fluctuating  scale. 

I  might  add  that  much  interest  has  been  shown  in  this 
work  by  prominent  women  in  Baltimore.  They  contri- 
buted in  the  beginning  towards  its  establishment. 


Miss  Wood :  I  am  very  much  interested  in  this  subject 
of  hourly  nursing,  or  "  daily  nursing  "  as  we  call  it  in  Eng- 
land. In  1890,  I  interviewed  a  large  number  of  our  medical 
men  to  find  out  from  them  if  there  was  any  opening  for 
nurses  who,  by  making  several  visits,  would  be  able  to  meet 
the  difficulty  of  providing  trained  nurses  for  the  poorer 
middle  classes.  They  thought  there  was  such  an  opening, 
and  assisted  by  the  nurses  in  the  hospital,  I  tried  it.  We 
found  that  for  nurses  who  tried  to  work  alone  it  was  not 
remunerative,  but  by  living  together  in  the  principal  out- 
lying districts  of  London  they  have  to  a  certain  extent  made 
it  successful.  There  are  several  living  at  the  Nurses'  Hostel 
who  are  making  it  a  success. 

I  quite  agree  with  Miss  Carr.  It  should  be  taken  up 
by  an  association.  We  are  confronted  with  some  difficulties 
in  dealing  with  this  question — the  difficulty  of  the  patient, 
forgetting  that  the  nurse  has  several  other  patients  to  visit ; 
— that  every  one  wants  the  nurse  at  about  the  same  time ; — 
and  that  the  homes  of  the  patients  may  be  several  miles 
apart.  All  these  difficulties  could  be  met  and  a  solution 
arrived  at  if  there  was  a  corps  of  nurses,  with  a  superinten- 
dent arranging  the  calls  for  them,  and  planning  the  whole 
work  on  an  organized  basis. 

There  is  no  doubt  whatever  that  it  is  the  work  of  the 
future.  But  the  nurses  who  undertake  it  will  have  to  give 
up  somewhat  of  their  independence. 

I  am  sure  that,  if  we  undertake  this  work  on  some 
such  lines  as  these,  in  a  business-like  way,  it  will  be  a  great 


214  International  Congress  of  Nurses 

help  to  those  people  who  have  small  means,  and  to  those 
who  do  not  require  the  services  of  a  nurse  all  day  long. 
For  these  the  hourly  nurse  will  fill  a  great  need. 

Miss  Hicks:  I  wish  in  a  very  few  words  to  tell  of 
the  work  which  is  being  done  in  Hartford,  in  hourly  nurs- 
ing. The  results  so  far  have  been  very  satisfactory.  The 
nurse  is  located  at  a  nurses'  club  in  the  city,  and  is  there 
three  times  a  day,  at  fixed  hours,  for  one-half  an  hour  each 
time,  to  receive  calls  from  the  doctors  and  the  charitable 
organizations  of  the  city.  Her  salary,  so  far,  has  been 
entirely  paid  by  the  Guild,  but  they  hope  that  the  work 
will  become  self-supporting  ultimately.  In  July  the  nurse 
made  200  visits. 

Miss  Williams :  I  do  not  understand  how  a  nurse  can 
make  200  nursing  visits  in  a  month.  What  was  the  nature 
of  the  work  ? 

Miss  Hicks :  I  cannot  answer  specifically  as  I  did  not 
do  it  myself.  The  nurse  used  a  bicycle  and  sometimes  made 
12  or  13  visits  in  a  day. 

Miss  McKinnon :  I  made  185  such  visits  in  a  month — 
much  of  the  work  was  in  the  evening,  giving  baths,  etc.  It 
can  be  done,  but  it  is  very  hard  work. 

Miss  Dock :  Miss  Rutherford,  of  the  Johns  Hopkins 
Alumnae,  who  made  an  exceptional  record  in  hourly  nurs- 
ing, often  made  12  or  13  visits  in  a  day.  The  nursing  visits 
were  baths,  or  carrying  out  some  special  treatment.  A 
large  service  of  evening  visits  was  worked  up.  The  doctors 
ordered  cold  packs  and  such  treatment  for  nervous  and 
sleepless  patients  and  this  often  kept  her  busy  until  11  p.  m. 
But  such  work  is  too  hard  to  keep  up  indefinitely. 

Unannounced :  I  know  two  trained  nurses  in  Phila- 
delphia, who,  needing  to  remain  in  their  own  homes,  have 
worked  up  a  practice  of  hourly  work,  in  massage,  Swedish 
movements,  or  general  nursing.    They  work  very  hard,  but 


The  Progress  of  Hourly  Nursing  215 

make  about  three  times  as  much  in  a  year  as  the  private 
duty  nurse. 

Unannounced:  I  would  like  to  say  that  I  have  done 
this  kind  of  work;  had  a  ^^ood  practice,  and  gave  it  a 
thorough  trial,  w'orking  harder  than  my  strength  would 
permit — I  did  not,  however  find  it  as  remunerative  as  private 
duty,  for  the  nurse  who  is  reasonably  busy. 

Miss  Hughes:  I  would  like  to  ask  for  some  informa- 
tion regarding  the  practice  of  massage  in  this  country. 

Miss  Boswall :  In  answer  to  Miss  Hughes'  question  I 
shall  speak  for  Boston  only,  as  I  am  altogether  ignorant 
of  methods  and  customs  prevailing  in  other  cities. 

There  are  two  large  schools  where  massage  is  taught, 
one  is  the  Posse  Gymnasium,  founded  by  the  late  Baron 
Posse,  who  died  in  1895.  This  school  is  carried  on  by  the 
Baroness  Posse.  The  other  large  school  is  the  Colby  Gym- 
nasium and  Institute  of  Mechanotherapy. 

I  believe  Miss  Colby  is  a  graduate  of  the  Posse.  In 
both  schools  every  subject  is  taught  which  bears  on  mas- 
sage. Indeed  the  term  massage  covers  depths  and  breadths 
of  instruction  and  the  course  covers  two  and  three  years  of 
hard  work. 

I  think  very  few  of  the  students  are  graduate  nurses. 
The  Colby  Gymnasium  offers  special  privileges  for  graduate 
nurses,  established  teachers,  and  others  possessing  qualifi- 
cations entitling  them  to  claim  such  consideration. 

There  are  various  other  instructors  in  Boston,  nearly 
all  of  whom  are  graduates  of  either  the  Posse  or  the  Colby. 

There  are  some  of  the  teachers  who  probably  ante- 
date the  arrival  of  Baron  Posse  in  1885,  but  it  was  he  who 
raised  the  practice  of  medical  gymnastics  and  massage  to 
the  dignity  of  a  profession  ;  and  through  his  efforts  gym- 
nastics were  introduced  into  the  public  schools  of  fifty-two 
cities  and  towns. 

Many  trained  nurses  combine  massage  of  parts  or  joints 
with  the  other  care  of  their  patients,  but  as  a  rule  very  few 


216  International  Congress  of  Nurses 

trained  nurses  regularly  engaged  in  the  practice  of  their 
profession  undertake  to  give  general  massage. 

The  lessons  given  in  the  various  hospitals,  as  part  of 
the  nurses'  training,  may  develop  the  gifts  of  a  "  born 
rubber,"  but  do  not  fit  one  without  special  gifts  to  engage 
in  massage  with  much  success.  Graduate  nurses  who 
wish,  from  various  reasons,  to  make  a  specialty  of  massage, 
find  it  necessary  to  take  a  course  of  lessons  from  some 
instructor,  usually  prefering  a  short  course  with  a  class  to  a 
longer,  broader  one  in  a  school.  The  students  in  the  gym- 
nasiums mentioned  obtain  their  practice  by  doing  charity 
work  in  the  dispensaries  and  hospitals  under  the  super- 
vision of  teachers  and  doctors. 


FRIDAY   MORNING. 

9.40   A.   M. 


The  President :  The  meeting-  will  please  come  to  order. 
We  have  an  important  programme  on  district  nursing  and 
allied  subjects,  and  we  will  listen  to  all  our  papers  before 
beginning  discussion. 


The  Origin,  Growth  and  Present  Status  of 
District  Nursing  in  England. 

AMY  HUGHES, 

Late  Superintendent  Nurses'  Co-operation ;  Delegate  from  Fourteen  Nursing 

Societies  in  England. 


On  receiving  the  kind  invitation  to  read  a  paper  on 
"  The  Origin,  Growth,  and  Present  Status  of  District  Nurs- 
ing in  England  "  my  first  feeling  was  that  it  would  be  diffi- 
cult to  avoid  repeating  much  of  what  had  already  been  said 
when  I  had  the  honor  of  speaking  on  the  work  of  the  Queen 
Victoria's  Jubilee  Institute  for  Nurses  and  Nursing  Con- 
ference held  in  Chicago  in  1893.  I  trust  you  will  forgive 
some  inevitable  repetition,  as  the  work  of  the  Queen's 
Institute,  of  which  I  am  again  the  representative  today,  is 
closely  interwoven  with  the  history  of  district  nursing. 

In  collecting  statistics  of  the  work  since  then,  one  can- 
not fail  to  be  impressed  by  the  rapid  growth  of  this  branch 
of  nursing  and  the  way  it  has  spread  over  the  kingdom. 

If  this  increase  is  remarkable  in  eight  years,  it  is  much 

more  so  since  the  first  effort  to  bring  skilled  nursing  within 

217 


218  International  Congress  oj  Nurses 

reach  of  the  poor  in  their  own  homes  was  made  b}'  Mrs. 
Fry  in  1845,  who  estabHshed  the  Nursing  Sisters  of 
Devonshire  Square,  Bishopsgate,  for  that  purpose.  This 
effort  was  followed  by  the  Society  of  St.  John's  House, 
founded  in  1848  with  the  design  '*  of  improving  the  quali- 
fications and  raising  the  character  of  nurses  for  the  sick  in 
hospitals,  among  the  poor  in  their  own  homes  and  in  private 
families,  by  providing  for  them  professional  training, 
together  with  moral  and  religious  discipline  under  the  care 
of  a  sister  superior  aided  by  a  chaplain." 

District  nursing  was  first  definitely  formulated  in  Liver- 
pool in  1859,  a  trained  nurse  being  sent  to  work  in  a  small 
district. 

Such  good  results  were  obtained  that  its  promoter,  Mr. 
W.  Rathbone,  was  encouraged  to  extend  the  work,  and 
within  four  years  the  whole  of  Liverpool  was  divided  into 
eighteen  districts,  each  supplied  with  a  trained  nurse.  To 
avoid  any  risk  of  the  work  becoming  a  new  system  of  distri- 
buting relief,  the  nurses  were  not  allowed  to  give  any  sick 
comforts  themselves.  A  band  of  ladies  undertook  to  be 
responsible  for  the  cost  of  such  necessaries  for  the  poor  of 
their  own  neighborhood,  and  this  system  is  continued  at  the 
present  day  in  Liverpool.  As  the  work  increased,  a»success- 
ful  change  was  introduced  by  placing  the  nurses  in  district 
homes  under  fully  trained  superintendents,  instead  of  allow- 
ing each  one  to  live  in  separate  lodgings.  The  value  of 
this  change  made  itself  immediately  manifest  in  the 
improved  standard  of  work  and  discipline  among  the  nurses, 
as  well  as  in  increased  zeal  and  esprit  de  corps.  There 
are  now  four  homes  established  in  Liverpool  and  forty-one 
nurses,  the  Central  Home,  newly  opened,  being  a  model  of 
convenience  for  the  work. 

The  success  of  the  system  of  district  nursing  in  Liver- 
pool stimulated  the  work  in  other  places,  and  in  several 
large  towns  nurses  were  provided  for  the  sick  poor. 

It  appears  strange  to  us  that  at  that  comparatively 
recent  date  the  greatest  obstacle  lay,  not,  as  might  have 
been  expected,  in  the  want  of  supporters  for  such  a  novel 


District  Nursing  in  England  219 

scheme,  and,  in  consequence,  want  of  funds,  but  in  the 
extreme  diflficuhy  of  obtaining  the  necessary  nurses.  It 
seems  almost  incredible  that  sober,  trustworthy  women,  with 
nursinor  experience,  were  hardly  to  be  found  for  this  work. 
I  may  quote  on  this  point  from  Mr.  W.  Rathbone's  ''  Sketch 
of  the  History  and  Progress  of  District  Nursing,"  to  which 
this  paper  is  already  greatly  indebted :  "  As  a  step  towards 
the  improvement  of  the  nursing  standard,  the  matron  of  the 
Royal  Infirmary  in  Liverpool  had  been  empowered  to  pay 
a  salary  of  sixteen  pounds  to  any  nurse  who  deserved  it. 
This  salary  was  certainly  not  an  exorbitant  one,  and  yet 
no  more  than  four  nurses  could  be  found  worthy  to  receive 
it.  Any  ordinary  nurse  of  that  time,  if  paid  more  than  the 
usual  salary  of  ten  pounds,  would  most  probably  have 
incurred  dismissal  for  drunkenness  after  the  first  quarter- 
day."  In  thus  tracing  this  work  from  its  origin  we  realize 
the  enormous  strides  made  by  the  nursing  profession  since 
Miss  Nightingale  founded  the  training  school  for  nurses  at 
St.  Thomas'  Hospital  in  1860. 

The  first  of  the  societies  organized  for  the  sole  benefit 
of  the  poor  in  London  was  the  "  East  London  Nursing 
Society,"  founded  in  1868.  It  attains  its  object  by  placing  a 
trained  nurse  in  each  parish  and  supplying  fully  trained 
nursing  superintendence ;  there  is  also  an  efificient  plan  for 
the  supply  of  necessary  diet  and  comforts  for  the  patients. 
There  are  now  three  homes  in  East  London,  accommodating 
most  of  the  thirty-three  nurses  who  work  there ;  the  rest 
still  live  in  lodgings.  The  society  is  affiliated  with  the 
Queen's  Institute. 

A  new  development  which  led  to  the  foundation  of  the 
Metropolitan  and  National  Nursing  Association  in  1874 
gave  a  fresh  impetus  to  district  nursing.  The  movement 
was  initiated  by  the  Council  of  the  Order  of  St.  John  of 
Jerusalem,  and  the  objects  of  the  association  were  as  fol- 
lows : 

1.  To  train  and  provide  a  body  of  skilled  nurses  to 
nurse  the  sick  poor  in  their  homes. 


220  International  Congress  of  Nurses 

2.  To  establish  in  the  metropolis  and  to  assist  in  estab- 
lishing' in  the  country  district  organizations  for  this  pur- 
pose. 

3.  To  establish  a  training  school  for  district  nurses  in 
connection  with  one  of  the  London  hospitals. 

4.  To  raise  by  all  means  in  its  power  the  standard  of 
nursing  and  the  social  position  of  nurses. 

The  g-reat  departure  in  this  scheme  was  the  employ- 
ment of  nurses  drawn  from  the  ranks  of  educated  women, 
due  to  the  suggestion  of  the  first  superintendent,  Miss 
Florence  Lees,  now  Mrs.  Dacre  Craven. 

In  her  own  words:  ''There  were  several  grovmds  for 
this  decision,  and  these  were  chiefly  that,  in  nursing  the  poor 
in  their  own  homes,  nurses  were  placed  in  positions  of 
greater  responsibility  in  carrying  out  doctors'  orders  than  in 
hospitals ;  that  women  of  education  would  be  more  capable 
of  exercising  such  responsibility ;  that  the  vocation  would 
attract  women  anxious  for  independent  employment,  and  a 
corps  of  nurses  recruited  altogether  among  educated  women 
would  have  a  greater  influence  over  the  patients,  and  by 
their  higher  social  position  would  tend  to  raise  the  whole 
body  of  professional  nurses  in  the  consideration  of  the 
public."' 

Such  an  innovation  was  not  considered  practical  by 
those  most  interested  in  the  movement,  even  Miss  Night- 
ingale saying,  ''  I  don't  believe  you  will  find  it  answer, 
but  try  it,  try  it  for  a  year."  Tlie  result,  however,  fully 
justified  the  experiment,  and  the  high  standard  thus  estab- 
lished has  exercised  its  influence  over  the  whole  develop- 
ment of  the  work. 

It  was  resolved  to  adopt  the  principle  that  the  nurses 
should  live  together  in  homes  under  trained  district  super- 
intendents, and  a  central  home  was  established.  From  this 
center  several  homes  were  rapidly  started,  and  by  1887  there 
were  nine  established  in  London  on  these  lines,  besides 
several  in  the  country. 

It  remained,  however,  for  Queen  Victoria,  by  the  insti- 
tution   of    "  The    Queen    Victoria's    Jubilee    Institute    for 


District  Nursing  in  England  221 

Nurses,"  to  consolidate  the  wofk  of  district  nursing  and  to 
raise  it  from  the  sphere  of  individual  efifort  to  become  a  great 
national  institution.  Queen  Victoria  realized  the  great  bene- 
fits arising  from  this  work,  which  had  been  quietly  making 
its  way  among  the  humblest  of  her  subjects.  With  that 
keen  insight  into  the  merits  of  a  debated  question  which 
was  one  of  her  attributes,  she  decided  to  devote  the  bulk 
of  the  subscription  raised  by  the  women  of  England  as  a 
gift  to  her  Majesty  on  the  occasion  of  the  celebration  of  the 
fiftieth  year  of  her  reign,  some  seventy  thousand  pounds, 
to  this  comparatively  unknown  object,  rather  than  to  bestow 
it  on  some  already  established  charity. 

In  1888  her  Majesty  approved  a  scheme  for  connecting 
the  Jubilee  Institute  with  the  ancient  charity  of  St. 
Katharine's  Hospital. 

In  order  to  obtain  the  interest  and  support  of  local 
institutions,  of  which  there  were  many  already  existing  in 
the  large  towns,  conditions  of  affiliation  with  the  Queen's 
Institute  were  drawn  up.  These  were  at  once  accepted  by 
the  Liverpool  association,  with  others,  and  now  there  are 
comparatively  few  nursing  organizations  which  are  not  in 
touch  with  the  institute.  A  trained  nurse  was  also  appointed 
as  general  inspector  of  nursing. 

In  1889  the  institute  was  incorporated  by  royal  charter, 
and  a  president  and  council  were  appointed  by  her  late 
Majesty. 

Mention  must  be  made  of  what  was  done  in  Scotland, 
Wales,  and  Ireland,  as  well  as  in  England,  to  estimate 
rightly  the  growth  of  district  nursing. 

In  Scotland  an  energetic  council  at  once  started  a  cen- 
tral home  in  Edinburgh,  and  the  system  extended  rapidly 
to  Glasgow,  Dundee,  Aberdeen,  and  other  places. 

In  Wales  a  Central  Home  was  established  in  Cardiff, 
and  the  work  has  spread  slowly  but  steadily  over  the  prin- 
cipality. It  is  found  necessary  to  employ  Welsh-speaking 
nurses  in  the  rural  districts,  as  that  language  is  still  spoken 
far  more  generally  than  is  supposed,  especially  among  the 
older  people.  However,  in  spite  of  this  difficulty,  the  work 
is  spreading  from  one  district  to  another. 


222  International  Congress  of  Nurses 

In  Ireland  the  initiation  of  district  nursing  was  slower, 
and  it  was  necessary  to  establish  two  training  homes  in 
Dublin,  one  for  Roman  Catholic,  the  other  for  Protestant 
nurses.  But  its  progress  has  been  uninterrupted,  and  the 
Queen's  nurses  are  in  every  part  of  the  country,  even  in  the 
desolate  island  of  Achil,  where,  to  quote  the  words  of  the 
superintendent :  ''  The  people  are  nursed  under  conditions 
inconceivable  except  to  those  who  have  seen  them.  There 
is  only  one  nurse  to  the  eight  thousand  inhabitants,  and 
Achil  is  twenty-five  miles  long  and  fifteen  miles  broad." 

In  1888,  almost  at  the  same  time  as  the  Queen's  Insti- 
tute was  taking  form  and  beginning  its  great  work  in 
the  towns  and  large  centers  of  the  United  Kingdom,  the 
Rural  Nursing  Association  was  started  very  quietly  in  a 
corner  of  the  Western  Midlands,  by  a  small  association  of 
ladies  and  gentlemen,  to  provide  nurses  and  midwives  for 
the  sick  poor,  with  whose  homes  and  needs  they  were  per- 
sonally familiar.  From  the  first  the  Rural  Nursing  Associa- 
tion determined  against  the  system  of  sending  nurses  to 
live  in  their  patient's  homes,  the  committee  believing  the 
poor  have  neither  accommodation  nor  means  sufficient  to 
enable  them  to  lodge  and  feed,  as  well  as  partially  to  pay  for 
the  services  of  a  competent  nurse.  A  high  standard  of  train- 
ing was  required,  and  the  nurse's  services  were  extended 
over  as  large  an  area  as  possible  by  means  of  a  pony  or 
donkey  cart,  and  later  by  the  ubiquitous  bicycle.  This  asso- 
ciation was  soon  afifiliated  to  the  Queen's  Institute,  in  1891, 
and  in  1897  was  amalgamated  entirely  with  it. 

The  question  of  providing  nurses  for  the  scattered 
villages  and  hamlets  in  thinly  populated  areas  where  work 
is  intermittent  and  distances  great  is  a  difficult  one. 

This  special  branch  of  district  nursing  is  as  yet  in  its 
very  infancy,  and  much  has  to  be  done  in  the  future  to  find 
a  practical  and  satisfactory  way  of  working  the  rural 
districts. 

The  system  of  county  associations  is  an  efifort  to  meet 
the  special  difficulties  in  these  districts.  Trustworthy, 
responsible  women  are  selected  for  training,  especially  as 


District  Nursing  in  England  223 

midwives  and  maternity  nurses,  and  return  to  work  in  their 
own  neighborhood  under  the  supervision  of  superintend- 
ents who  are  fully  qualified  Queen's  nurses.  Valuable  help 
in  the  training  of  these  village  nurses  is  given  by  the 
Plaistow  "  Maternity  and  District  Nursing  Association," 
whose  work  lies  in  the  densely  populated  region  of  "  London 
over  the  border." 

There  are  now  five  of  these  county  associations  in 
England,  employing  over  one  hundred  and  ten  village 
nurses,  three  in  Scotland,  and  one  in  Wales. 

The  history  of  the  growth  of  district  nursing  would  be 
incomplete  without  mentioning  the  work  done  by  other 
institutions  whose  methods  are  different  from  those  of  the 
Queen's  Institute.  Among  these  are  the  "  Biblewomen 
Nurses,"  founded  by  Mr.  Ranyard,  whose  work  lies  in 
several  districts  of  London. 

The  Mildmay  deaconesses  also  send  nurses  into  the 
homes  of  the  poor. 

In  the  country  the  system  of  the  Ockley  Nursing 
Association  was  formed  to  provide  women  with  some 
knowledge  of  nursing  to  live  in  the  home  where  there  is  ill- 
ness, and  perform  the  household  duties  as  well  as  attend  to 
the  patient.  The  promoters  claim  this  method  answers  the 
question  of  cottage  nursing,  especially  in  cases  where  the 
wife  and  mother  is  laid  aside,  but  it  has  opened  up  other 
difficulties,  some  of  them  unforeseen,  which  show  the  true 
solution  of  this  problem  has  yet  to  be  found. 

I  now  pass  on  to  speak  of  the  present  status  of  district 
nursing. 

It  is  interesting  to  notice  how  the  standard  of  train- 
ing has  risen  with  the  growth  of  the  work.  Much  still 
remains  to  be  done  in  this  direction,  especially  in  the  case  of 
village  nurses,  but  every  year  finds  public  opinion  more 
enlightened  on  this  point. 

The  great  difficulty  lies  in  the  necessity  of  providing 
inexpensive  nurses  in  poor  districts  in  the  country,  especially 
in  agricultural  parts,  and  also  in  the  ignorance  still  linger- 
ing among  those  who  supply  the  nurses  that  good  and  suffi- 
cient training  is  a  necessity. 


224  International  Congress  of  Nurses 

When  a  patient  and  room  are  clean  and  tidy  and  food 
and  medicine  regularly  administered,  there  is  a  tendency  to 
think  all  that  is  necessary  has  been  accomplished. 

It  requires  special  knowledge  to  discriminate,  on  the 
one  hand,  between  the  woman  who  is  disciplined  to  absolute 
obedience  in  carrying  out  orders,  who  is  trained  in  the  best 
possible  way  of  performing  the  details  of  nursing  service, 
each  apparently  trivial,  yet  so  important  in  their  sum  total, 
and  the  woman  who,  however  capable  and  w-illing,  yet  lacks 
the  knowledge  that  in  unreserved  obedience  to  orders  lies 
her  raison  d'etre,  who  is  prone  to  suggest  remedies  of  her 
own,  and  is  full  of  prejudices  and  superstitions  which  her 
short  experience  of  training  has  failed  to  eradicate. 

The  Queen's  Institute  has  formulated  the  highest 
standard  of  training  and  experience  hitherto  attained.  Its 
nurses  must  have  a  minimum  of  two  years'  training  in  an 
approved  hospital  or  infirmary,  followed  by  practical 
experience  of  district  work  under  trained  supervision.  In 
many  cases  special  training  in  a  maternity  hospital  is  also 
required.  Nurses  who  wish  to  join  the  institute,  having 
already  been  trained,  are  required  to  fulfil  these  conditions. 

The  institute  aims  at  securing  the  services  of  educated 
women,  believing  them  to  exercise  a  beneficial  influence  over 
the  patients  and  their  friends.  Tact,  courtesy,  and  refine- 
ment are  necessary  to  deal  successfully  with  the  ignorance 
and  prejudices  of  the  poor,  whether  in  town  or  country. 

I  would  lay  special  stress  on  the  necessity  of  some  prac- 
tical experience  of  the  work  under  trained  supervision.  It 
is  not  to  supplement  deficiencies  in  previous  training,  but  to 
enable  the  nurse  to  apply  her  nursing  knowledge  to  the 
best  possible  advantage  under  such  altered  conditions.  She 
is  saved  the  necessity  of  buying  her  own  experience  at  the 
expense  of  her  patients  and  herself  if  she  profits  by  that 
already  gained  by  others.  Training  is  found  desirable  for 
those  who  engage  in  philanthropic  works,  such  as  settle- 
ments, etc.,  and  it  is  equally  necessary  in  this  branch  of 
nursing. 

The  Queen's  Institute  has  added  yet  another  develop- 


District  Nursing  in  England  225 

ment  to  its  "  Counsels  of  Perfection  "  by  its  adequate  sys- 
tem of  inspection  by  trained  nurses.  There  is  no  suspicion 
of  interference  with  local  effort,  no  curtailing  of  personal 
energy,  but  simply  a  regular  visitation  of  every  affiliated 
association  from  the  city  with  its  forty  to  fifty  nurses  and 
their  superintendents  in  various  homes,  to  the  solitary  nurse 
in  the  remoteness  of  the  country.  Each  association  keeps 
its  reports,  etc.,  on  the  same  lines,  and  from  each  the  same 
standard  of  work  is  required. 

The  inspector  comes  as  a  friend  alike  to  the  nurse  and 
the  committee,  visiting  the  cases,  seeing  the  books,  and  help- 
ing by  her  experience  and  advice  to  smooth  over  any  little 
difficulties  that  may  arise.  It  is  the  evenness  of  the  work 
thus  obtained  that  is  making  it  a  success  by  securing  a  uni- 
form standard  throughout  the  land. 

Two  other  fundamental  principles  of  the  institute  are : 

1.  That  the  nurses  shall  not  be  almoners.  Their  work 
is  nursing,  and  nursing  only,  though  they  are  encouraged 
to  bring  deserving  cases  to  the  notice  of  the  proper  local 
authorities,  and  in  every  way  thus  to  secure  necessary  sick- 
comforts  for  their  patients. 

2.  That  the  nurses  shall  never  interfere  with  the  relig- 
ious views  of  their  patients. 

These  two  rules  lift  the  work  of  Queen's  nurses  above 
suspicion  of  almsgiving  and  proselytizing.  At  the  same 
time  the  nurses  are  left  free  to  bring  their  patients  in  touch 
with  the  local  agencies  that  make  for  good. 

Nor  must  the  indirect  benefits  of  the  work  of  the 
Queen's  Institute  (and  of  other  nursing  associations  based 

upon  right  principles)  be  overlooked.    They  foster  the  spirit 
of  independence  and  help  the  people  to  help  themselves. 

That  this  spirit  does  obtain  in  many  localities  is  proved 
by  the  fact  that  in  a  quarry  district  in  Wales  two  nurses 
are  supported,  and  there  is  a  balance  of  over  three  hundred 
pounds  in  the  bank,  which,  with  the  exception  of  about  fifty 
pounds,  is  contributed  annually  by  the  workmen,  and  in 
another  district  the  nurse  is  practically  supported  by  half- 
crown  yearly  subscriptions. 


226  International  Congress  of  Nurses 

Nor  is  this  all.  By  interestins;-  the  well-to-do  of  a  dis- 
trict in  their  poorer  neighbors,  the  Queen's  nurses  form  a 
valuable  link  in  the  chain  of  union  between  capital  and 
labor. 

There  are  excellent  systems  by  which  sick  and  con- 
valescent diets,  warm  garments,  and  convalescent  aid  in 
giving  change  of  air,  etc.,  are  brought  to  those  who  by  no 
fault  of  their  own  are  unable  to  obtain  these  extra  neces- 
saries when  sickness  is  among  them.  Among  these  may  be 
mentioned  the  Scottish  Needlework  Guild,  the  Bedford  Sick 
Dinners  Society,  the  London  Convalescent  Dinners  Aid 
Society,  and  many  others. 

Then  also  the  nurses  can  bring  the  homes  of  the  patients 
to  the  notice  of  the  local  sanitary  authorities,  thus  insuring 
cleanliness,  a  proper  water  supply,  and  other  simple  but 
essential  necessities  for  healthy  surroundings.  Tliough  for- 
bidden to  proselytize,  their  influence  is  the  open  door  by 
which  those  who  seek  the  moral  welfare  of  their  poorer 
brethren  may  obtain  an  entrance  where  other  means  have 
proved  unavailing. 

The  personal  interest  of  her  late  Majesty  in  this  work 
has  invested  it  with  universal  interest.  This  interest  showed 
itself  in  many  ways.  The  Council  of  the  Queen's  Institute 
was  appointed  by  her,  the  names  of  all  nurses  were  sub- 
mitted to  her  before  they  were  placed  on  the  roll  of  "Queen's 
Nurses,"  and  even  the  details  of  the  nurses'  uniforms  were 
chosen  by  her.  Those  present  at  the  gathering  of  "  Queen's 
Nurses  "  at  Windsor  Castle  on  July  2,  1896,  will  not  easily 
forget  the  enthusiasm  kindled  by  the  gracious,  kindly  words 
addressed  to  them  by  one  who  ever  proved  herself  a  woman 
full  of  sympathy  with  those  in  trouble  and  distress.  "I  am 
very  much  pleased  to  see  my  nurses  here  today,  and  to  hear 
of  the  good  work  they  are  doing.  I  am  sure  they  will 
continue  to  do  it."  Her  Majesty's  special  recognition  of  the 
"  Queen's  Nurses  "  in  Ireland,  on  the  occasion  of  her  visit 
there,  was  deeply  appreciated  and  gave  a  direct  stimulus  to 
the  work  in  that  country.  Her  last  message  to  the  council 
was  given  on  February  24,  1900,  and  runs  thus : 


District  Nursing  in  England  227 

"  Her  Majesty  desires  me  to  express  the  sincere  satis- 
faction with  which  she  learns  that  the  institute  continues  to 
prosper  and  is  so  much  appreciated."  This  interest  is  con- 
tinued by  the  present  Queen.  In  July  this  year  some  hun- 
dreds of  Queen's  nurses  received  their  badges  from  the 
hands  of  Queen  Alexandra,  thus  establishing  her  identity 
with  the  institute  as  its  present  head. 

Queen  Alexandra's  first  address  to  the  Jubilee  nurses 
at  Marlborough  House,  July  3,  1901,  his  Majesty  the  King 
being  present,  with  her  Royal  Highness  Princess  Victoria, 
her  Royal  Highness  Princess  Louise  (Duchess  of  Argyll), 
and  Prince  Albert  and  Princess  Victoria  of  Cornwall  and 
York,  was  as  follows  : 

"  It  gives  me  the  greatest  pleasure  to  receive  you  all 
here  today,  and  it  is  most  gratifying  to  me  to  be  able  to 
carry  on  the  noble  work  founded  by  our  dearly  beloved  and 
never-to-be-forgotten  Queen  Victoria.  I  have  always  taken 
the  most  sincere  interest  in  nurses  and  nursing,  a^nd  it  affords 
me  heartfelt  satisfaction  to  be  associated  in  your  labors  of 
love  and  charity. 

"  I  can,  indeed,  imagine  no  better  or  holier  calling  than 
that  in  which  you  are  engaged  of  tending  the  poor  and 
suffering  in  their  own  homes  in  the  hour  of  their  greatest 
need.  I  shall  follow  with  interest  the  reports  of  the  institute, 
and  shall  anxiously  note  the  progress  which  you  are  making 
from  year  to  year. 

"  I  pray  that  God's  blessing  may  rest  upon  your  devoted 
and  unselfish  work,  and  that  He  will  have  you  all  in  His 
holy  keeping." 

A  special  effort  is  being  made  by  means  of  the  "  Queen's 
Commemoration  Fund  "  to  raise  sufficient  funds  to  endow 
the  "  Queen's  Institute  "  in  perpetuity,  so  that  it  may  keep 
pace  with  the  ever-growing  demands  on  its  resources. 

Having  thus  outlined  the  history  of  district  nursing 
from  one  nurse  in  1859  to  the  great  work  of  mercy  which 
has  spread  over  the  whole  land,  I  would  only  add  that  it  is 
not  systems  alone,  admirable  as  they  can  be,  which  bring 
success,  it  is  the  work  of  each  individual  nurse  which  makes 


228  International  Congress  of  Nurses. 

the  work  what  it  is ;  it  is  not  nursing  alone,  though  that 
should  be  as  perfect  and  well-disciplined  as  training  and 
experience  can  insure,  but  moral  influence,  to  which  there 
is  practically  no  limit. 

The  influence  of  a  good  nurse  remains  after  her  nursing 
services  are  ended.  It  is  the  opportunities  given  by  dis- 
trict nursing  that  make  it  so  important  and  so  responsible. 
Nurses  who  grasp  the  inner  meaning  of  their  work  have 
few  limits  to  their  powers  of  usefulness.  They  nurse  the 
homes  as  well  as  the  patients;  they  give  valuable  object- 
lessons  in  the  practical  details  of  nursing,  simple  sick- 
cookery,  cleanliness,  etc.,  thus  helping  their  fellow-women 
to  be  less  helpless  and  hopeless  when  sickness  invades  the 
home. 

They  can  advocate  self-restraint,  thrift,  and  household 
economics ;  they  can  give  valuable  advice  in  the  dieting 
and  management  of  infants  and  young  children,  so  helping 
to  strengthen  the  sinews  of  the  nation — "  As  the  child  is,  so 
the  man  is  " — and  the  simple  hygiene  of  proper  feeding 
taught  in  language  "  understanded  by  the  people  "  means 
the  future  welfare  of  its  sons. 

Thus  every  earnest  district  nurse  who  sows  the  seeds 
of  thrift,  self-help,  self-restraint,  self-respect  in  the  round  of 
daily  work  is  a  helper,  however  obscure  her  path  of  duty,  in 
solving  the  social  problems  of  the  day. 

I  will  conclude  with  the  message  entrusted  to  me  on 
June  15  by  Miss  Florence  Nightingale  to  give  to  the  dis- 
trict nurses  at  the  Congress: 

"  I  do  not  think  that  there  is  any  human  being  who 
may  be  as  useful  as  a  district  nurse  if  she  is  helpful  without 
being  interfering.  May  God  bless  and  keep  the  district 
nurses  here  in  a  body  is  the  fervent  prayer  of  Florence 
Nightingale." 


Tenement  House  Inspection. 

JOHANNA  VON  WAGNER, 

Sanitary  Inspector  of  Tenements,  Yonkers,  N,  Y. 


Because  so  little  is  done  to  teach  people  in  their  homes 
how  to  better  their  condition,  I  am  grateful  for  the  oppor- 
tunity to  speak  to  you  about  my  work  in  the  tenement 
.houses  as  Sanitary  Inspector. 

While  not  every  city  has  a  tenement  house  problem, 
every  city  has  a  housing  problem,  and  it  is  the  duty  of  the 
Board  of  Health  to  see  that  the  homes  of  the  working-classes 
are  made  at  least  healthful. 

Organizations  of  public-spirited  citizens  should  be 
formed,  which,  after  acquainting  themselves  with  local  con- 
ditions, would  revise  building  and  sanitary  codes  and  see  to 
the  enforcement  of  laws.  Already  this  is  done  in  New  York, 
too  late,  to  be  sure,  to  eradicate  the  evil  which  a  tenement 
house  is, — it  is  here  to  stay, — but  an  organization  of  men 
and  women  can  do  much  to  improve  the  homes  of  the  poor. 
To  be  able  to  cope  with  such  a  problem,  a  thorough  knowl- 
edge of  existing  conditions  is  essential.  A  house-to-house 
inspection  will  reveal,  aside  from  existing  facts,  the  wants 
and  needs  of  the  people. 

Having  been  a  tenement  house  inspector  for  over  four 

years,  I  am  able  to  speak  of  the  need  and  benefit  of  such 

work.     It  touches  the  people  in  their  homes,  and  their 

lives  can  often  be  made  brighter  by  helpful  sympathy.    From 

year  to  year  it  is  harder  for  the  poor  man  to  live,  and  the 

dailv  complaint  is  that  he  cannot  find  rooms. 

229 


230  International  Congress  of  Nurses 

Twenty-five  years  ago  the  Chief  of  the  Department  of 
Health  in  Glasgow  realized  the  need  of  women  inspectors 
in  connection  with  the  Health  Department,  as  only  women 
could  deal  with  women  efifectively,  and  ever  since  that  time 
the  work  has  been  done  there  by  women  health  visitors,  as 
they  are  called. 

The  larger  cities  in  England  have  followed  the  example 
of  Glasgow,  and  there  are  several  sanitary  institutes  in 
England,  where  men  and  women  are  graduated  to  do  the 
work  of  sanitary  inspectors. 

Several  years  ago  in  Chicago  the  Board  of  Health 
appointed  women  to  inspect  factories,  sweat-shops,  and 
tenement  houses,  and  five  years  ago  Yonkers  first  had  a 
woman  tenement  house  inspector,  and  it  is  almost  two  years 
since  I  was  regularly  appointed  by  the  Board  of  Health,  and 
I  can  say  without  vanity  that  in  no  city  is  the  work  done 
so  effectively  as  in  Yonkers,  because  the  qualifications  which 
a  nurse  has  enable  her  to  do  better  than  the  average  woman. 

It  would  take  too  long  to  detail  the  combat  gone 
through  to  get  the  appointment. 

Landlords,  politicians  (members),  and  employes  of  the 
Board  of  Health  all  fought  against  the  woman  inspector, 
and  but  for  the  members  of  the  board  and  one  brave  woman, 
Miss  Mary  Marshal  Butler,  president  of  the  Civic  League 
and  Woman's  Institute,  who  overcame  all  opposition,  the 
appointment  would  not  have  been  successful.  After  passing 
civil-service  examination  the  appointment  was  made,  and 
in  February,  1900,  I  commenced  my  duties  as  an  employe 
of  the  Board  of  Health,  as  formerly  I  had  done  the  work 
of  the  Civic  League. 

I  will  pass  over  the  difficult  task  of  working  with  the 
same  people  that  fought  so  hard  not  to  have  me,  and  will 
only  say  that  those  same  men  are  my  best  friends  at  present, 
and  agree  with  the  secretary,  who  said :  "  How  did  we  ever 
get  along  without  our  woman  inspector  ?" 

The  Health  Officer  said  that  he  would  like  to  have  one 
woman  inspector  to  every  twenty-five  thousand  inhabitants. 
The  president  of  the  board  said  that  the  moral  influence  of 


Tenement  House  Inspection  231 

a  woman  inspector  in  the  department  had  been  very  bene- 
ficial. All  this  I  say  to  show  that  the  work  has  been  appre- 
ciated by  friend  and  foe  and  the  need  demonstrated. 

In  onr  beautiful  Terrace  City  such  bad  conditions  were 
revealed  as  to  shock  the  whole  community.  Tenement 
houses  in  Yonkers  compare  favorably  with  those  elsewhere ; 
we  have  all  the  evils  of  New  York  slums,  only  on  a  smaller 
scale.  As  a  large  proportion  of  our  population  lives  in 
tenement  houses,  the  need  for  improvement  was  great. 

The  average  tenement  house  has  deprived  the  people 
of  light,  air,  and  privacy ;  it  has  dark  bedrooms,  with  some- 
times the  worse  than  useless  air-shaft  opening  into  a  com- 
mon hall, — a  hall  which,  on  entering,  sends  a  chill  through 
one's  bones ;  as  a  rule  it  is  not  ventilated,  is  very  dark, 
unventilated  toilets  open  into  it,  and  damp  cellar  air  and 
odors  from  cooking  and  toilets  which  greet  one  on  entering 
are  over-powering. 

I  begin  my  work  in  the  cellar,  much  to  the  surprise  of 
the  people,  who  have  neglected  to  clean  it  and  stored  all 
sorts  of  rubbish  away  in  it.  As  a  rule,  that  most  important 
part  of  the  house  has  also  been  neglected  by  the  builder, 
light  and  air  have  not  been  provided  for,  and  after  a  rain- 
storm it  is  very  often  flooded. 

Right  here  I  begin  to  inspect  the  plumbing,  and  unless 
the  house  is  new  the  pipes  or  construction  are  generally 
defective.  I  have  to  get  a  light  to  do  this.  When  I  go  to 
the  upper  floors  the  living  rooms  over  the  cellar  are  damp 
also  and  very  unhealthy.  The  tenants  have  malaria,  rheu- 
matism, and  tuberculosis,  children  have  bronchitis  and  do 
not  thrive,  and  even  up  to  the  top  floor  all  complain  of 
ill-health. 

I  go  through  the  rooms,  seeing  to  proper  ventilation, 
cleanliness,  need  of  repair,  and  over-crowding;  follow  the 
plumbing  up  to  the  roof ;  see  to  the  condition  of  the  roof, 
fire-escape,  hall,  toilets,  and  then  inspect  the  yard,  recep- 
tacles for  garbage,  pulley-line  poles,  cleanliness,  and  drain- 
age. 

I  have  witnessed  scenes  which  cannot  be  described,  and 


232  International  Congress  of  Nurses 

every  day  reveals  new  misery :  the  poor  little  children  locked 
up  in  basements  while  both  parents  work  in  the  mill ;  the 
household  of  the  habitual  drinking-woman,  the  neglected, 
vermin-covered  children,  six  in  one  bed,  poorly  covered, 
looking  like  little  skeletons ;  the  consumptive's  room,  where 
bedding,  floor,  and  furniture  are  covered  with  expectoration, 
where  the  children  play  on  the  floor,  and  wife  and  baby 
share  the  same  bed ;  where  out  of  fear  a  contagious  patient 
is  hidden  in  a  closet,  and  out  of  kindness  a  paralytic  or  any 
other  bedridden  patient  is  left  alone  for  a  month  or  two, 
never  bathed  on  body  or  bed-linen  changed  so  as  to  cause 
no  pain,  and  where  bed-sores  from  shoulders  to  heels  have 
become  gangrenous. 

It  was  in  a  small  rear  house  where  I  knocked,  per- 
ceiving the  odor  far  ofT.  "  No  admittance  "  was  on  the 
face  of  the  woman  who  was  supposed  to  care  for  the  patient, 
but  I  managed  to  gain  entrance,  and  only  by  the  exercise 
of  the  greatest  tact  was  I  allowed  to  see  the  poor,  sick 
woman  and  care  for  her — until  death.  The  horrors  of  that 
sick-room  I  shall  never  forget,  and  I  hope  and  pray  there 
may  never  be  another  case  like  it. 

The  poor,  the  hungry,  and  the  needy, — but  it  would 
take  too  long  to  speak  of  all  the  different  phases. 

The  teachings  of  Christ  are  forgotten.  We  do  not  know 
how  our  neighbors  live,  and  we  would  rather  not  know. 
Not  charity,  but  justice  is  needed. 

The  greedy  landlord  who  looks  for  twelve  per  cent, 
has  to  be  dealt  with.  Model  tenement  houses  can  be 
erected  on  a  paying  financial  basis.  They  have  proved  a 
success  wherever  they  have  been  built,  and  aside  from  the 
fact  that  they  returned  between  five  and  six  per  cent.,  they 
have  provided  healthy  homes  for  people  of  small  means. 

While  they  are  a  great  blessing,  the  greater  need  is  to 
put  existing  houses  in  sanitary  condition  and  prevent  badly 
constructed  houses  from  being  erected,  and  here  it  is  where 
a  woman  inspector  does  the  most  good. 

Everything  dangerous  to  public  health  is  reported, — 
dark  rooms  and  halls,  closed  skylights  and  air-shafts,  defec- 


Tenement  House  Inspection  233 

tive  and  boxed-in  plumbing,  filth  and  disease,  damp  cellars, 
over-crowding, — all  these  things  are  nuisances  and  reported, 
and  in  a  given  time  remedied,  which  may  be  from  a  day  to  a 
month.  If  the  owner  is  not  willing  or  able  to  do  it,  the 
Board  of  Health  has  the  work  done.  The  law  is  that  one 
toilet  shall  be  provided  for  every  two  families,  but  I  think 
that  each  family  should  have  its  own  water-closet,  and  to 
have  it  not  in  a  dark  corner,  but  open  to  the  external  air, 
is  just  as  important. 

Fire-escapes  should  receive  better  attention;  the 
straight,  narrow  ladders  without  the  platform  will  hardly 
answer  for  most  people — not  to  speak  of  the  absence  of 
fire-escapes  in  so  many  houses. 

The  house-to-house  instruction,  aside  from  reporting 
nuisances,  is  an  important  part  of  the  work. 

"  Thank  God !  some  one  is  going  around  that  knows 
something,"  an  old  Irishwoman  said.  They  have  had  mis- 
sionaries to  look  after  their  spiritual  welfare,  but  no  one 
to  help  them  bear  their  burden  and  improve  their  lot  in 
life. 

After  explaining  to  them  how  to  care  for  and  feed 
babies,  the  women  will  say,  "  Why  did  we  not  know  this 
before  ?"  A  birth  and  a  death  every  year  and  sickness  and 
undertakers'  bills  in  many  cases  cause  the  poor  man's 
poverty.  Ignorance  of  the  common  laws  of  health  and 
unhealthy  homes  and  food  are  undoubtedly  causes  of  the 
prevalence  of  the  drink  habit. 

Much  can  be  done  towards  the  prevention  of  the  spread 
of  contagious  diseases,  and  especially  tuberculosis,  not  only 
by  reporting  the  fumigation  of  rooms  and  enforcing  strict 
cleanliness  and  isolation,  but  by  providing  sputum-cups  for 
the  poor  which  may  be  burned  after  use,  and  after  death 
from  this  disease  fumigation  and  thorough  cleaning  before 
another  family  moves  in. 

With  the  teachings  given  to  the  people  how  to  protect 
themselves  and  how  to  improve  their  ways  of  living  there 
should  go  the  enforcement  of  laws  governing  landlords  and 
agents  and  an  awakening  of  the  social  conscience  at  large, 


234  International  Congress  of  Nurses 

and  I  confess  that  is  the  hardest  part  of  my  work.  Being 
a  woman  and  having  no  vote,  poHtics  do  not  influence  my 
reports.  Cellars  have  to  be  cleaned  and  whitewashed, 
carpets  removed  from  stairs,  halls  ventilated  and  cleaned, 
rooms  whitewashed  or  painted,  papers  removed  where  pos- 
sible, air-shafts  and  skylights  have  to  be  made  to  open  to 
admit  air,  roofs  repaired,  and  plumbing  looked  after.  The 
characteristics  of  the  dififerent  nationalities  have  to  be  dealt 
with,  and  each  watched  acordingly. 

When  commencing  to  inspect  a  street  the  children 
carry  the  news  that  the  Health  Board  is  around,  which  is 
the  signal  for  general  house-cleaning. 

When  I  try  to  have  people  move  out  of  unhealthy 
houses,  I  hear  always  the  same  remark,  "  We  can't  find 
good  rooms,"  and  the  requests  for  me  to  find  rooms  are 
numerous  indeed  and  difficult  to  comply  with. 

After  revealing  conditions  in  Yonkers,  some  good  citi- 
zens remodelled  old  houses  and  put  them  in  sanitary  condi- 
tion, and  it  has  proved  a  financial  success.  There  is  a 
woman  rent-collector  who  collects  weekly,  which  is  safer 
for  the  landlord  and  easier  for  the  tenant,  and  with  it  goes 
a  supervision  which  is  of  great  value  to  both.  With 
improved  homes  we  have  better  health  and  better  citizen- 
ship, which  is  all-important  to  a  nation. 

While  far  from  being  good,  conditions  are  greatly 
improved  in  Yonkers.  Better  school  attendance  in  winter, 
decreased  immorality  rate,  especially  among  children,  and 
greater  cleanliness  are  among  the  visible  results  from  the 
work  done  so  far. 

Prevention  is  my  motto,  and  when  we  can  prevent 
disease  we  have  touched  the  foundations  of  most  evils. 

What  larger  field  of  usefulness  could  we  wish  for  than 
to  go  from  house  to  house  and  give  the  people  the  benefit 
of  our  knowledge  of  sanitation,  hygiene,  and  domestic 
science  ? 

A  great  English  statesman  has  said,  "  Of  what  use 
is  sanitary  legislation  unless  it  is  practically  applied  ?"  and 


Tenement  House  Inspection  235 

only  by  obtaining  the  co-operation  of  every  hotisekeper  with 
the  Board  of  Health  can  rules  and  laws  be  enforced. 

Let  there  be  well-trained  women  to  do  this  work.  As 
Dr.  Benjamin  Lee,  president  of  the  State  Board  of  Health, 
said:  "Women  are  born  sanitarians,  and  make  better 
teachers;  besides,  they  attend  to  detail  work,  and  I  would 
say  the  work  is  essentially  one  for  women.  No  matter  what 
the  condition  of  the  house,  a  woman  is  admitted  because 
she  will  understand,  when  a  man  cannot  enter,  and  very 
often  the  remark  is  made,  '  I  am  so  glad  it  is  a  woman  this 
time.'  " 

After  inspecting  rooms,  closets,  and  bedding,  I  am 
made  acquainted  with  the  sorrows,  the  wants,  and  some- 
times the  joys  of  the  family,  and  I  seldom  leave  without 
having  given  advice  or  help,  or  put  them  in  the  way  to  help 
themselves.  The  invitation  to  call  again  soon  or  spend 
Sunday  with  the  family  shows  that  the  visit  has  been 
appreciated. 

The  field  for  usefulness  is  large,  and  the  work  fills  one's 
life  to  the  utmost.  While  it  is  hard  to  bear  so  many  peo- 
ple's burdens,  the  thought  that  this  work  is  a  step  in  the 
right  direction  gives  new  courage  and  hope. 

I  hope  to  live  long  enough  to  see  more  cities  take  up 
this  work.  Only  those  women  who  love  the  people  and  will 
work  for  public  service  and  not  personal  gain  should  take  it 
up.  It  is  the  hardest  work  I  have  ever  done,  and  it  requires 
courage  and  a  good  deal  of  faith  to  enter  into  all  places. 

May  more  nurses  prepare  for  this  work,  and  indeed  be 
the  friends  of  the  people. 

It  is  the  true  mission  of  the  Board  of  Health  to  take 
up  this  work,  and  may  there  be  enough  public-spirited  men 
and  women  in  every  city  to  see  to  it  that  the  large  class  of 
working-people  at  least  have  healthy  homes. 

The  President :  The  chair  has  been  requested  to  have 
a  letter  read  from  Mrs.  Butler,  showing  how  well  Mrs.  \'on 
Wagner  has  done  her  work. 


^36  International  Congress  of  Nurses 

My  Dear  Miss  Mclsaac:  In  view  of  Mrs.  Von 
Wagner's  attendance  at  the  International  Council  of  Nurses, 
I  would  like  to  give  my  testimony  to  the  efficiency  of  her 
work  in  Yonkers,  and  emphasize  the  desirability  of  inducing 
nurses  to  consider  the  official  inspection  of  tenement  houses 
as  a  field  for  their  professional  ability. 

In  visiting  Health  Departments  here  and  abroad  with 
reference  to  the  work  of  women  Sanitary  Inspectors,  it  has 
impressed  me  that,  other  qualifications  being  equal,  the 
knowledge  possessed  by  a  trained  nurse  who  had  the  ability 
to  impart  it  would  be  of  great  additional  benefit  in  accom- 
plishing permanent  good  results,  and  I  am  hoping  that  as 
the  work  is  taken  up  in  this  country  more  nurses  may  be 
found  who  will  fit  themselves  for  the  position. 

In  Chicago,  where  six  women  Tenement  and  Factory 
Inspectors  are  employed  by  the  Health  Department,  the 
duties  of  the  women  are  about  the  same  as  those  prescribed 
for  men.  I  believe  the  duties  of  the  woman  inspector  should 
include  the  instructive  work,  and  that  to  her  should  be 
given  certain  duties  differentiating  her  work  from  that  of  a 
general  Sanitary  Inspector. 

There  are  comparatively  few  places  in  this  country 
where  women  are  employed  in  connection  with  Health 
Boards,  but  it  is  our  earnest  hope  that  an  impetus  may  be 
given  to  the  idea  through  this  Nurses'  Council,  and  that 
a  great  and  practical  purpose  may  be  reached  through  the 
paper  to  be  read  and  discussed  at  your  meeting. 

Wishing  you  all  progress  in  the  various  departments 
•of  helpfulness  you  are  considering, 

I  am  very  cordially  yours, 

Mary  Marshali,  Butler. 


History  of  Visiting  Nurses  in  America. 

HARRIET  FULMER, 

Superintendent  of  the  Visiting  Nurse  Association  of  Chicago. 


In  the  characteristics  and  aim  of  district  or  visiting- 
nurse  work  there  may  be  said  to  be  "  nothing  new."  It  is  a 
branch  of  nursing  so  well  known  to  our  profession  that  it 
is  needless  to  dwell  upon  the  purpose  of  the  work. 

At  the  Congress  of  Nurses,  held  in  Chicago  in  1893,  the 

subject  of  this  paper  was  given  such  complete  and  detailed 
description  by  women  of  years  of  experience  in  the  work 
that  it  would  be  time  misspent  to  take  up  that  which  was  so 
well  covered  then. 

The  facts  and  data  of  the  present  paper  are  largely 
statistical,  and  intended  only  as  historical  of  the  subject, 
and  simply  to  show  the  growth  of  the  work  in  various  parts 
of  the  country  in  the  last  ten  years.  This  philanthropy  has 
now  taken  its  place  among  the  organized  charities  of 
modern  times.  Only  a  few  years  ago  quite  unknown,  it  is 
now  operated  successfully  in  almost  every  section  of  the 
country.  It  is  a  charity  of  which  its  promoters  never  tire ; 
and  noting  its  success  and  present  steady  growth,  one  often 
wonders  why  its  initiatory  stages  had  such  uphill  work. 

District  or  visiting  nurse  work  covers  that  branch  of 

nursing  which  cares  for  the  sick  poor  in  their  own  homes, 

when  by  reason  of  surrounding  circumstances  the  patient 

may  not  be  sent  to  a  hospital.    The  work  is  likened  to  a  large 

out-door  hospital,  the  various  towns  and  localities  being 

divided  into  wards  or  districts,  the  whole  being  responsible 

to  the  head  or  superintending  nurse. 

237 


238  International  Congress  of  Nurses 

From  the  first  year  of  its  existence,  when  Fliedner  at 
Kaiserswerth  sent  trained  women  into  the  homes  of  the 
poor,  and  WilHam  Rathbone,  M.P.,  saw  the  need  of  it  in 
England,  the  character  of  this  work  has  not  changed ;  it 
still  carries  out  the  first  param^ount  principles  of  giving 
skilled  nursing  to  the  poor  and  the  small  wage  earner  in 
their  own  homes,  and  to  use  such  methods  of  instruction  as 
teach  them  to  care  for  their  own  sick  and  to  carry  out  the 
right  observance  of  sanitary  laws. 

The  pioneers  of  this  work  had  untold  dif^culties  to 
overcome,  for  by  no  means  did  their  efforts  meet  with  warm 
support.  Medical  men  were  suspicious  that  these  organi- 
zations sending  out  skilled  nursing  help  would  interfere 
with  their  practice,  and  many  of  the  laity  felt  it  an  innova- 
tion not  practical,  and  that  the  poor  could  get  on  the  same 
as  they  always  had  done. 

It  is  needless  to  say  that  the  newer  and  younger  associa- 
tions have  none  of  these  difficulties,  for  physicians  every- 
where now  are  not  only  the  instigators  in  new  localities,  but 
are  always  the  staunchest  supporters  of  the  scheme.  The 
development  of  the  work  in  America  has  not  been  a  bed  of 
roses,  and  with  all  its  seeming  success  in  this  country  we 
are  years  behind  Germany  and  England — where  140  trained 
women  are  employed  in  America  800  are  employed  in 
England. 

A  woman  prominent  in  philanthropic  work  says, 
"  There  is  no  form  of  organized  philanthropy  that  demon- 
strates more  clearly  the  present  progressive  ideas  of  social 
and  economic  work  among  the  less  fortunate,"  and  a  student 
of  social  problems  has  well  said,  "  It  is  the  safest  and 
most  practical  means  of  bridging  the  gulf  which  lies  between 
the  classes  and  the  masses." 

This  principle  is  largely  illustrated  in  the  successful 
social  settlement  made  up  of  nurses  at  265  Henry  street. 
New  York  City. 

In  continuance  I  should  like  to  put  in  short  form  a  few 
general  suggestions  to  those  who  are  contemplating  form- 
ing this  work  in  new  localities.    I  shall  give  below  a  combi- 


Visiting  Nurses  in  America  239 

nation  of  the  various  methods  carried  out  in  many  of  the 
organizations  now  operated. 

First  comes  the  need,  then  the  presentation  of  the 
project  at  a  general  meeting  of  the  pubhc,  to  which  should 
be  asked  prominent  physicians  of  the  locality  to  give  it 
endorsement.  Then  comes  the  mode  of  support,  usually 
best  by  voluntary  contributions  in  small  sums  from  the 
public  rather  than  by  individuals,  as  then  one  may  feel 
that  they  have  a  special  claim  upon  the  service.  If  operated 
upon  the  nonsectarian  principle,  you  then  have  the  support 
of  all  the  religious  elements,  but  are  confined  to  no  particular 
one.    Cases  should  be  taken  and  received  from  all  sources. 

An  ideal  system  may  have  many  adjuncts  operating  in 
connection  with  it.  First  is  the  Flower  Mission,  or  the 
Diet  Kitchen,  or  the  Convalescent  Home  in  some  near-by 
country  place,  to  which  patients  may  be  sent.  Then  in  the 
district  must  be  the  ever-ready  and  well-filled  loan  press, 
containing  every  known  article  that  may  be  used  for  the 
comfort  and  well-being  of  the  sick.  The  most  successful 
organizations  go  upon  the  principle  that  the  best  results  are 
shown  to  the  people  when  the  professional  nurse  gives  the 
service  assisted  by  the  most  modern  sick-room  appliances 
rather  than  by  make-shifts,  and  yet  always  giving  informa- 
tion as  to  what  articles  may  be  used  in  the  place  of  the 
modern  ones. 

In  adopting  a  name  for  any  new  society  doing  this 
work  we  would  advise  the  use  of  the  term  "  Visiting 
Nursing "  as  being  more  comprehensive  than  "  District 
Nursing,"  and  as  less  cumbersome  than  "  Instructive  Visit- 
ing Nursing." 

The  woman  employed  to  do  this  work  should  be  a 
graduate  of  a  large  general  training  school,  for  she  may 
care  for  many  cases  without  meeting  the  doctor  in  attend- 
ance, and  she  should  know  how  to  meet  every  emergency. 

In  starting  the  work  in  a  new  locality  preference  should 
he  given  a  nurse  who  has  had  experience  in  district  nursnig 
work,  and  the  rules  for  the  admission  of  additional  nurses  to 
the  society  should  be  most  severe.    She  should  be  required 


240  International  Congress  of  Nurses 

at  the  end  of  a  certain  time  to  give  a  complete  sketch  of 
how  she  would  meet  all  the  various  emergencies  that  might 
arise  in  the  work ;  how  she  would  send  a  case  to  the  hospi- 
tal, secure  ambulance  service,  report  cases  for  relief  sent  to 
various  institutions,  to  summer  homes,  etc. 

The  next  step  in  the  right  direction  in  the  work  in  this 
country  will  be  to  establish  a  special  post-graduate  course 
for  all  nurses  desiring  to  take  up  visiting  nurse  work,  for 
too  many  nurses  come  into  the  work  having  little  idea  as 
to  the  requirements  and  demands ;  and  during  the  period  of 
perhaps  their  first  year,  the  organizations  suffer  by  their 
lack  of  knowledge. 

In  the  near  future  the  Chicago  association  will  establish 
a  course  of  this  kind  where  graduates  from  general  training 
schools  may  take  up  and  learn  the  work  in  a  systematic 
way. 

I  may  go  on  now  with  some  of  the  general  require- 
ments and  rules  for  nurses.  She  is  employed  actively  from 
eight  to  ten  hours  per  day,  and  if  she  is  doing  the  work  in 
the  right  spirit  any  additional  service  required  is  done  with- 
out comment.  The  salaries  throughout  the  country  paid 
to  these  workers  seem  to  be  about  uniform,  forty-five 
dollars,  fifty  dollars,  and  sixty  dollars  per  month,  according 
to  the  time  they  remain  in  the  work. 

Not  all  organizations  wear  a  regulation  uniform,  but 
those  who  do  are  to  be  commended.  For  in  many  instances 
its  moral  effect  upon  the  patient  is  constantly  apparent,  and 
there  is  nothing  that  can  take  the  place  of  the  plain  ging- 
ham dress  and  the  neat  coat  and  hat  of  subdued  color. 

In  most  organizations  the  visits  of  the  nurse  average 
from  eight  to  twelve  in  one  day,  varying  from  a  half  hour  to 
two  hours  each.  A  typical  day  in  a  large  society  is  as  fol- 
lows :  The  first  visit  was  to  a  dying  consumptive,  where  a 
bath  and  clean  linen  were  given ;  the  second,  a  bath  and 
alcohol  sponge  to  a  man  with  typhoid ;  third,  dressing  a 
varicose  ulcer  on  the  leg  of  a  woman  who  makes  wrappers 
all  day  long  at  forty  cents  per  dozen ;  fifth,  baths  and  clean 
linen  to  a  family  of  five,  all  ill  with  typhoid ;  reported  case 


Visiting  AUtrses  in  America  241 

to  Board  of  Health,  arranged  to  send  patients  to  hospital; 
two-hours'  work  required;  sixth,  maternity  case:  bathed 
mother  and  babe;  received  ten  cents  for  service;  seventh, 
took  temperature  and  pulse  of  convalescing  typhoid; 
arranged  to  send  patient  to  country ;  eighth,  bath  to  mother 
and  daughter,  both  ill  with  consumption ;  new  case,  reported 
to  Health  Board  ;  ninth,  very  sick  babe;  gave  bath,  furnished 
milk,  and  instructed  mother;  sent  free  doctor;  tenth,  man 
with  locomotor  ataxia ;  gave  bath,  made  application  to  send 
patient  to  Home  for  Incurables. 

Who,  in  hearing  this,  will  say  that  it  was  not  a  day 
full  of  satisfaction  to  the  nurse,  of  practical  benefit  to  the 
patients,  and  of  infinite  credit  to  the  supporters  of  the  work 
who  make  it  possible  that  the  relief  may  be  given? 

In  the  regular  systematizing  of  the  work  we  do  not  find 
it  an  easy  matter,  the  very  character  of  the  work  itself 
bringing  about  rather  a  hap-hazard  way  of  doing  it,  for  the 
very  reason  that  no  day's  work  can  be  arranged  prior  to  its 
beginning. 

The  records  kept  and  the  reports  made  for  filing  require 
much  skill  and  patience,  and  take  a  large  part  of  the  nurse's 
time  and  labor.  Most  of  the  women  employed  find  their 
greatest  hardship  in  the  exposure  to  the  elements,  rain,  cold, 
and  snow  in  winter,  and  the  beating  rays  of  the  sun  in  sum- 
mer, for  the  visiting  nurse  goes  on  her  rounds,  rain  or  shine, 
heat  or  cold,  and  often  the  nurse  herself,  after  a  very  hard 
day's  labor,  wonders  why  she  is  willing  to  give  up  a  lucrative 
and  half-comfortable  private  practice  for  this  life  of  exposure 
and  self-denial.  But  nearly  every  woman  now  doing  the 
work  finds  that  indescribable  something  which  is  akin  to 
fascination  in  being  the  instrument  that  brings  so  much 
comfort  to  those  who,  without  her,  would  have  naught,  and 
at  the  same  time  combining  with  her  labor  self-support  and 
independence. 

Miss  Brent,  of  Brooklyn,  N.  Y.,  in  a  clever  paper  on 
district  nursing  read  before  the  Congress  of  Charities  in 
1894,  sums  up  the  work  of  the  nurse  as  follows :  "  It  is  a 
hand-to-hand  struggle   against   disease,   poverty,  and   dirt. 


242  International  Congress  of  Nurses 

against  the  most  pitiful  ignorance  and  inherited  prejudice. 
The  nurse  finds  her  routine  work  widely  different  from  hos- 
pital or  private  duty.  .  .  .  Beginning  each  morning  her  daily 
rovmd  of  visits,  carrying  with  her  in  as  small  a  compass  as 
possible  all  the  necessary  appliances  for  her  work,  she  goes 
from  house  to  house,  from  one  patient  to  another,  mounting 
flight  after  flight  of  stairs, — for  it  is  a  curious  but  true  fact 
that  tenement  house  patients  always  live  on  the  top  floor 
of  a  very  tall  house, — here  making  beds,  preparing  nourish- 
ment, giving  sponge-baths,  there  bandaging  a  leg  or  apply- 
ing a  dressing,  but  in  all  cases  carrying  out  the  doctor's 
orders,  leaving  notes  of  temperature  and  general  condition, 
being  certain  the  medicine  will  be  properly  administered, 
and  seeing  that  proper  nourishment  is  provided  whether  by 
direct  orders  or  otherwise, — in  short,  doing  everything  in 
her  power  for  her  patient's  comfort." 

The  following  is  an  extract  from  a  letter  from  Florence 
Nightingale  to  Lady  Aberdeen  in  commendation  of  district 
nursing  work : 

"  Let  me  gladly  add  myself  as  a  witness  of  experience 
here  to  the  great  blessings  which  the  trained  district  nurse 
has  brought  to  the  sick  poor. 

"  If  you  are  able  to  maintain  the  high  standard  for 
your  nurses  which  you  have  done,  and  succeed  in  attracting 
good  young  women  to  enter  upon  the  work,  there  can  be 
no  doubt  that  it  will  get  on  and  prosper.  DifBculties  and 
trials  there  must  be,  but  with  so  noble  an  object,  it  is  worthy 
the  expenditure  of  much  labor  and  patience." 

From  the  hospital  training  school  the  area  of  the 
trained  nurse's  work  has  become  extended  to  private  nurs- 
ing (nursing  the  well-to-do)  and  latterly  to  that  far  more 
numerous  class  of  patients  who  are  either  entirely  destitute, 
or  able  to  make  a  small  contribution  for  the  services  of  a 
nurse,  and  yet  who  are  not  fit  subjects  for  hospital  treat- 
ment. 

It  is  especially  and  above  all  to  this  last  class  that  the 
trained  district  nurse  has  proved  so  great  a  benefit.  For 
the  duties  of  the  district  nurse  more  experience,  more  self- 


Visiting  Nurses  in  America  243 

denial,  are  wanted  than  for  those  of  a  hospital  nurse  or 
private  practice,  who  have  the  doctors  ahvavs  at  hand  to 
refer  to,  and  have  all  the  appliances  of  hospital  or  home  at 
the  service  of  the  patient. 

The  success  of  district  nursing  depends,  more  than  in 

hospital   and  private   practice,   upon   the  character  of  the 

nurse,  and  the  character  of  the  nurse  depends  much  more 

upon  the  nature  of  her  training  and  the  continuance  of  those 

helps,  physical  and  moral,  which  that  training  has  supplied 
to  her.  ^^ 

The  total  number  of  associations  doing  this  work  in 
America  is  fifty-three ;  the  number  of  nurses  employed  one 
hundred  and  thirty. 


SOCIETIES  AT   PRESENT  OPERATING   IN    AMERICA, 
IN    ALPHABETICAI,  ORDER. 

Albany,  N.  Y. — The  work  in  Albany  is  done  by  the 
Albany  Guild  for  the  Care  of  the  Sick  Poor,  and  is  the  out- 
growth of  the  Fruit  and  Flower  Mission,  which  was  organ- 
ized in  1880.  It  employs  four  nurses  and  does  much  work 
among  the  class  which  pays  small  fees  for  the  nurse's 
care.  The  nurse  here  may  not  respond  to  any  calls  except- 
ing those  sent  to  her  from  the  physicians  and  by  the  presi- 
dent of  the  association.  This  method  necessarily  limits  the 
field. 

Bufifalo,  N.  Y. — The  District  Nursing  Association  of 
Bufifalo  was  organized  in  1892,  to  provide  free  nursing 
among  the  sick  poor  and  to  carry  on  a  diet  kitchen  and 
flower  mission  in  connection  therewith.  The  association 
is  strictly  non-sectarian,  receiving  its  support  from  the  vol- 
untary contributions  of  all  denominations.  There  are  now 
four  nurses  doing  duty  for  the  association.* 

*  The  Board  of  Health  of  BufiEalo   has  now  authorized  these  nurses  to  act  as 
Sanitary  Inspectors. 


244  International  Congress  of  Nurses 

Boston,  Mass. — Boston  has  the  oldest  of  the  Visiting 
Nurse  societies  estabHshed  in  America;  it  was  organized  in 
1886.  The  fourteen  nurses  work  in  connection  with  the 
dispensary  physicians  connected  with  the  Boston  Dispen- 
sary, estabHshed  in  1796.  This  association  is  known  as  the 
Instructive  District  Nursing  Association  of  Boston. 

Baltimore,  Md. — The  work  in  Baltimore  is  known 
under  the  name  of  the  Instructive  Visiting  Nurse  Associa- 
tion. It  began  in  January,  1896,  with  one  nurse.  At  the 
beginning  of  the  present  year  it  has  five.  The  association 
is  partially  self-supporting,  the  deficit  is  made  up  by  volun- 
tary contributions.  It  is  non-sectarian  and  neutral.  Coop- 
erates with  the  other  charities  of  the  city.  From  the  first 
it  has  been  a  most  successful  organized  society. 

Brooklyn,  N.  Y. — The  visiting  nurse  work  is  estab- 
lished in  this  city  and  is  known  as  the  Red  Cross  Instructive 
and  District  Nursing  Society,  and  is  now  a  department  of 
the  Bureau  of  Associated  Charities.  Three  nurses  are  em- 
ployed who  do  the  usual  nursing  work.  In  addition  to  the 
work  done  under  the  auspices  of  the  Bureau  of  Charities 
there  is  also  a  graduate  nurse  at  the  Pratt  College  Settle- 
ment, supported  by  a  private  individual. 

Colorado  Springs,  Col. — The  work  here  is  compara- 
tively new,  and  the  one  nurse  employed  is  under  the  super- 
vision of  the  Associated  Charities  and  paid  by  them. 

Columbus,  O  . — The  organization  is  known  here  as 
the  Instructive  District  Nursing  Association.  It  was 
organized  in  1898,  through  the  efforts  of  philanthropic 
citizens,  and  is  now  supported  by  voluntary  contributions. 
Three  nurses  are  now  employed.  This  organization  secured 
its  first  nurses  from  the  organization  in  Chicago.  It  has 
been  most  successful. 

Chicago,  111. — The  Visiting  Nurse  Association  of  Chi- 
cago was  organized  in  1890.  Fifteen  nurses  are  employed. 
It  has  also  a  staff  of  untrained  women  who  are  sent  to 
remain  in  the  home.  It  is  non-sectarian,  neutral,  and  exclu- 
sively a  public  charity,  supported  by  voluntary  contribu- 
tions, fees,  and  legacies.     Managed  by  a  board  of  directors 


Visiting  Nurses  in  America  245 

of  thirty-two  women.  Cooperates  with  all  the  organized 
charities  of  the  city.  Gives  only  nursing  and  medical  caie 
and  only  such  relief  as  pertains  to  the  sick.  Paramount 
object,  instruction  to  the  people  in  sanitary  laws  and 
hygiene  and  the  care  of  their  own  families  in  time  of  illness. 

Cambridge,  Mass. — The  district  nursing  in  this  locality 
is  under  the  direct  supervision  of  the  District  Nursing 
Association  of  Boston.  It  is  really  a  branch  of  that  city's 
work. 

Concord,  Mass. — The  work  at  Concord  was  established 
in  1900,  and  employs  one  nurse.  The  largest  part  of  the 
work  is  done  in  the  families  of  those  who  can  pay  small 
sums  for  the  service,  though  the  association  was  started 
for  the  benefit  of  the  destitute  poor. 

Charleston,  S.  C. — In  this  city  is  an  organization  known 
as  the  Ladies'  Benevolent  Society,  whose  constitution  says  it 
"is  formed  for  the  relief  of  the  sick  only."  It  is  probably 
the  oldest  of  its  kind  in  America,  having  just  had  its  eighty- 
eighth  anniversaiy.  It  is  supported  by  voluntary  contribu- 
tions, fees  and  legacies.    It  is  undenominational. 

Cleveland,  O. — A  club  of  young  women  support  a 
nurse  here,  A  regularly  organized  society  is  now  in  process 
of  forming. 

Davenport,  la. — In  connection  with  St.  Luke's  Hos- 
pital of  this  city  is  organized  a  department  of  district  nurs- 
ing. The  pupils  in  the  second  year  are  sent  out  to  care  for 
the  sick  in  their  own  homes  under  the  supervision  of  the 
superintendent  of  nurses. 

Denver,  Col.— In  1892  the  Denver  Flower  Mission 
employed  a  visiting  nurse  to  care  for  the  sick  poor.  In 
1900  this  association  merged  into  what  is  known  as  the 
Visitinp-  Nurse  Association  and  Flower  Mission  of  Denver. 
It  is  supported  by  voluntary  contributions,  fees,  and  lega- 
cies. Two  nurses  are  employed.  They  also  have  in  con- 
nection a  complete  medical  and  surgical  staff.  The  chanty 
organization  of  Denver  contributes  towards  the  fund. 

Detroit,  Mich.— The  Visiting  Nurse  Association  of 
Detroit  was  organized  in  1896.     It  is  supported  by  the 


246  International  Congress  of  Nurses 

various  guilds  and  church  societies  and  voluntary  contri- 
butions. It  has  in  its  employ  at  present  three  trained 
nurses.  It  has  the  hearty  support  of  all  the  institutions  of 
the  city. 

Fall  River,  Mass. — In  Fall  River,  Mass.,  the  work  is 
done  under  the  auspices  of  the  Union  Hospital,  which  sends 
out  one  nurse  who  cares  for  as  many  cases  as  possible  dur- 
ing the  day. 

Fort  Wayne,  Ind. — The  work  is  known  in  this  city 
as  the  Visiting  Nurse  League.  It  is  supported  by  various 
church  circles  and  the  contributions  of  the  pubHc.  It 
employs  two  nurses  and  works  in  connection  with  the  asso- 
ciated charities. 

Fitchburg,  Mass. — In  Fitchburg,  Mass.,  the  work  is 
known  as  the  Instructive  Home  Nurse  Association,  and 
is  a  department  of  the  charity  organization  known  as  the 
Fitchburg  Benevolent  Union.  Employs  two  nurses  and 
makes  a  specialty  of  its  loan  closets,  the  system  of  which 
could  be  profitably  copied  in  all  other  district  nursing  work. 

Grand  Rapids,  Mich. — The  District  Nurse  Association 
in  Grand  Rapids  is  operated  in  connection  with  the  charity 
organization  of  that  city.  Two  nurses  are  employed  who 
work  entirely  in  connection  with  the  associated  charities. 
The  fund  is  supplied  by  private  individuals. 

Harrisburg,  Pa. — The  Visiting  Nurse  Society  of  Har- 
risburg  is  neutral  and  non-sectarian ;  employs  two  nurses 
and  is  supported  by  a  private  individual.  It  was  formed 
in  1899  and  has  been  most  successful.  The  work  is  done 
by  nurses  formerly  employed  by  the  Chicago  Association. 

Hartford,  Conn. — Hartford  is  perhaps  the  newest  of  the 
organized  associations.  It  was  started  in  February,  1901, 
under  the  auspices  of  the  local  branch  of  St.  Barnabas 
Guild  for  Nurses,  and  has  one  nurse. 

Hampton,  Va. — A  very  successful  organization,  organ- 
ized since  1899,  is  the  district  work  done  in  connection 
with  the  Hampton  Training  School  for  Nurses  connected 
with  the  Dixie  Hospital.  This  is  the  oldest  training  school 
.for  colored  women  in  America,  and  the  pupil  nurses  are 
sent  to  furnish  nursing  care  to  the  sick  poor  in  the  town. 


Visiting  Nurses  in  America  247 

Kansas  City,  Mo. — The  work  in  Kansas  City  was 
begun  in  1891,  and  is  known  as  the  Visiting  Nurse  Asso- 
ciation of  Kansas  City.  Two  nurses  do  the  work  in  this 
organization.  It  is  supported  by  voluntary  contributions 
of  the  pubHc. 

Keene,  N.  H. — In  Keene,  N.  H.,  the  work  is  done  by 
student  nurses  sent  out  from  the  city  hospital. 

Los  Angeles,  Cal. — The  work  was  started  in  Los 
Angeles  in  1899.  One  nurse  is  employed  by  the  city — the 
only  place  in  America  where  it  is  done  in  this  way.  The 
plan  might  well  be  adopted  elsewhere. 

Lynn,  Mass. — The  district  work  in  the  homes  of  the 
poor  was  organized  here  in  1896  through  an  agreement 
between  the  Lynn  Hospital  and  the  Associated  Charities, 
whereby  the  Associated  Charities  was  to  pay  the  Lynn 
Hospital  for  the  service  of  a  nurse  in  training.  The  nurse 
is  changed  once  in  two  months.  She  reports  at  the  ofifice 
of  the  Associated  Charities  for  all  her  cases. 

Lawrence,  Mass. — The  work  of  the  visiting  nurse  in 
this  locality  is  supplied  by  the  pupil  nurses  from  the  Law- 
rence Training  School  for  Nurses. 

Maiden,  Mass. — One  nurse  has  been  employed  here 
since  1899.  She  works  in  connection  with  the  Industrial 
Aid  Society.     The  salary  is  paid  by  this  society. 

Melrose,  Mass. — In  Melrose  the  work  is  done  by  the 
pupil  nurses  of  the  Melrose  Hospital. 

Middletown,  Conn. — The  work  was  organized  here  in 
1901,  and  has  one  nurse  employed.  The  work  is  going 
on  most  successfully. 

Milwaukee,  Wis. — The  work  here  is  done  by  two 
nurses  employed  by  the  Associated  Charities.  There  is  no 
distinct  organization  of  the  kind. 

Mt.  Kisco,  N.  Y. — The  work  here  is  done  by  the  \'is- 
iting  Nurse  Association  known  as  the  Ellen  Wood  Memor- 
ial District  Nurse  Association.  Was  named  in  memory  of 
Miss  Wood,  a  Johns  Hopkins  nurse,  the  alumnae  association 
of  that  school  contributing  towards  the  support.  One 
nurse  is  employed. 


248  International  Congress  of  Nurses 

Newton,  Mass. — This  association  was  organized  in 
1898.  It  acts  under  tiie  direction  of  the  physicians  of  the 
city  of  Newton,  and  is  supported  by  voluntary  contribu- 
tions.    Two  nurses  do  the  work. 

New  York  City.— The  ground  is  fairly  well  covered  in 
New  York  City,  although  the  work  is  not  done  by  any  one 
organized  society  for  this  work.  The  field  is  a  large  one, 
and  really  should  be  covered  by  an  organized  society  operat- 
ing on  a  separate  and  distinct  basis.  The  Bureau  of  Asso- 
ciated Charities  has  six  nurses  working  in  connection  with 
it.  Nurses  are  engaged  in  the  various  parishes  of  Grace, 
Trinity,  St.  Thomas,  and  others.  Tlie  City  Missionary 
Society,  one  of  the  oldest  organizations  in  New  York  City 
for  caring  for  the  sick  poor,  has  employed  a  band  of  trained 
women  for  manv  vears.  The  work  at  the  Nurses'  Set- 
tlement  265  Henry  street,  is  most  complete  in  every  detail, 
consisting  of  visiting  nursing  carried  on  in  three  different 
localities  where  the  settlement  has  houses  or  flats ;  first  aid, 
or  dressing  rooms,  where  minor  surgical  cases  are  treated, 
of  which  there  are  three,  also  situated  in  different  localities ; 
a  country  home  where  convalescent  patients  are  taken  all 
through  the  year,  and  social  and  teaching  work  which  has 
grown  up  as  a  secondary  development.  The  entire  number 
of  nurses  connected  with  the  settlement  is  now  seventeen, 
of  whom  a  monthly  average  of  ten  is  engaged  in  the  work 
of  visiting  nursing  in  the  homes,  both  of  non-pay  patients 
and  of  those  who  can  pay  small  sums. 

Newburg,  N.  Y. — The  work  here  was  started  in  1897 
by  the  clergymen  of  the  city,  and  is  known  as  the  Visiting 
Nurse  Society  of  Newburg.  The  expenses  are  met  by  con- 
tributions from  the  various  churches,  by  fees,  and  legacies. 
They  have  one  nurse,  and  she  may  only  take  cases  sent  to 
her  by  physicians  of  the  city.  The  work  is  now  on  a  perma- 
nent basis. 

Newport,  R.  I. — The  work  in  Newport  is  carried  on 
under  the  auspices  of  the  Newport  Hospital,  the  pupil 
nurses  in  training  in  the  second  year  being  sent  out  to  care 
for  patients  in  their  own  homes  who  are  unable  to  pay  for 


Visiting  Nurses  in  America  249 

the  service.    The  plan  has  been  operated  successfully  for  a 
number  of  years. 

Norfolk,  Va.— The  work  here  is  under  the  direction  of 
the  Norfolk  Union  of  the  King's  Daughters.  Two  nurses 
are  employed,  part  of  one  nurse's  time  being  used  as  a 
friendly  visitor  for  the  united  charities.  There  is  great  need 
for  this  work  in  that  locality. 

Oakland,  Cal. — The  work  is  done  by  the  pupil  nurses 
sent  out  from  the  Oakland  Hospital.  There  is  not  the  great 
need  in  this  locality  as  found  in  many  others.  It  was  estab- 
lished in  1894. 

Omaha,  Neb. — The  work  was  organized  in  Omaha  in 
1897  with  one  nurse  in  charge.  It  is  supported  by  volun- 
tary contributions,  and  is  indorsed  by  leading  physicians 
of  the  city.  It  is  modelled,  both  in  constitution  and  the 
detail  work,  upon  the  Chicago  plan. 

Orange,  N.  J. — The  work  in  Orange,  N.  J.,  is  carried 
on  by  the  nurses  of  the  Orange  Hospital  Training  School, 
who  live  at  the  Nurses'  Settlement  in  the  district  occupied 
largely  by  the  mill  hands.  It  is  supported  by  voluntary 
contributions. 

Plainfield,  N.  J. — The  work  was  established  here  sev- 
eral years  since  under  the  auspices  of  the  City  Union  of 
the  King's  Daughters.  The  fund  is  supplied  entirely  by 
this  organization.  The  nurse  co-operates  with  the  Asso- 
ciated Charities. 

Philadelphia,  Pa. — The  Visiting  Nurses'  Society  was 
organized  here  in  1875,  almost  simultaneously  with  that  of 
Boston.  It  employs  eight  graduate  nurses  and  several 
undergraduates.  It  is  supported  entirely  by  voluntary 
contributions.  It  is  non-sectarian,  and  its  constitution 
says  that  "the  object  of  this  society  is  to  give  to  the  poor 
and  to  those  of  moderate  means  the  best  home  nursing 
possible  under  existing  circumstances." 

Proctor,  Vt. — Tlie  Proctor  Hospital  Training  School 
takes  care  of  the  poor  in  their  own  homes  by  sending  out 
a  pupil  nurse  when  in  her  second  year  training. 


250  International  Congress  of  Nurses 

Rochester,  N.  Y. — The  Rochester  City  Hospital  fur- 
nishes through  its  out-door-rehef  department  a  district 
nurse  who  cares  for  cases  who  are  poor  and  who 
are  unable  to  leave  their  families  to  go  to  the  hospital.  The 
ground  is  well  covered  in  Rochester,  though  there  is  a  field 
for  a  regular  organization. 

Salem,  Mass. — The  work  is  done  here  in  connection 
with  the  Associated  Charities,  but  is  supported  by  private 
individuals.     One  nurse  is  employed. 

St.  Louis,  Mo. — The  sick  poor  in  their  own  homes  are 
cared  for  here  by  the  nurse  employed  in  connection  with 
the  Visiting  Nurse  Department  of  the  St.  Louis  Provident 
Association.  It  was  formed  in  1895  and  is  supported  by  the 
regular  Associated  Charities. 

St.  Paul,  Minn. — One  visiting  nurse  is  employed  here 
by  the  Bethel  Settlement.  The  field  in  St.  Paul  is  covered 
very  much  in  the  same  way  as  that  in  New  York.  There  is 
no  regularly  authorized  system  under  one  head,  but  the 
sick  poor  are  well  cared  for. 

Scranton,  Pa. — The  Associated  Charities  in  this  city 
employs  a  nurse  in  connection  with  their  work.  The 
expenses  are  met  by  that  organization. 

San  Francisco,  Cal. — In  1897  the  Fruit  and  Flower 
Mission  of  San  Francisco  employed  a  visiting  nurse  to 
care  for  the  sick  poor.  In  the  following  year,  in  1898,  she 
was  transferred  to  the  Associated  Charities  and  a  second 
nurse  was  added  to  the  work.  The  support  comes  from 
private  individuals,  who  furnish  the  money  for  this  purpose. 
Calls  are  received  from  the  Associated  Charities.  In  addi- 
tion to  these  nurses  there  are  several  others  working  in 
connection  with  the  various  parishes.  The  sick  poor  are 
well  cared  for  in  San  Francisco. 

Syracuse,  N.  Y. — The  society  here  is  an  organized  one, 
known  as  the  Visiting  Nurse  Association  of  Syracuse.  It 
was  organized  m  1896,  and  is  supported  by  private  indi- 
viduals and  public  contributions.  Two  nurses  cover  the 
field. 


Visiting  Nurses  in  America  251 

Washington,  D.  C— The  Instructive  Visiting  Nurse 
Society  was  organized  in  Washington  in  1900.  It  now 
employs  five  nurses  and  is  supported  by  the  voluntary  con- 
tributions of  the  public. 

Waltham,  Mass.— The  District  visiting  nursing  is 
done  here  by  the  pupil  nurses  of  the  Waltham  Training 
School.  This  system,  now  in  operation  in  many  localities,  is 
indebted  to  Dr.  A.  Worcester  for  its  origin.  It  was  the  first 
time  in  this  country  that  the  sick  poor  had  been  cared  for 
in  their  own  homes.  The  work  is  most  successfully  carried 
on  and  serves  two  purposes,  that  of  giving  care  to  the  peo- 
ple who  cannot  alTord  to  pay  for  the  service,  and  also  giving 
experience  to  young  women  in  training  which  they  perhaps 
could  not  get  under  the  roof  of  the  hospital. 

Winchester,  Mass. — The  work  was  organized  here  in 
1899.  Two  nurses  are  employed  who  do  much  charity 
work,  but  are  especially  serviceable  to  the  small  wage 
earner,  who  pays  a  fee  for  care  received.  The  support  is 
from  voluntary  contributions. 

Worcester,  Mass. — The  work  is  done  here  by  two 
nurses,  supported  by  voluntary  contributions,  and  who 
work  in  connection  with  the  Associated  Charities. 

This  paper  would  not  be  complete  without  a  mention 
of  the  Victoria  Order  of  Nurses,  founded  in  Canada  by 
the  Countess  of  Aberdeen.  The  order  is  for  the  benefit  of 
the  sick  poor,  the  same  as  all  other  district  nursing  societies, 
and  is  supported  by  voluntary  contributions.  Its  work  is 
larger  and  covers  a  greater  field  than  any  of  the  organiza- 
tions of  its  kind  in  the  States.  In  Montreal  there  is  also 
a  district  nurse  sent  out  in  connection  with  the  Diet  Dis- 
pensary. 

In  Toronto  the  Nursing  at  Home  Mission  does  the 
same  sort  of  work  as  is  covered  by  the  organized  societies 
in  the  States ;  it  also  is  supported  by  the  voluntary  contribu- 
tions of  the  public. 


252  International  Congress  of  Nurses 

SUMMARY. 

After  laying  before  you  all  the  plans  and  operations 
of  the  various  organizations  of  this  character  now  under 
way,  we  leave  it  to  you  to  choose  the  best  means  of  opera- 
tion. With  the  active  professional  worker  the  neutral  lines 
seem  the  best  lines.  Whether  the  work  can  be  carried  on 
with  or  without  the  religious  element  depends  upon  the 
locality.  The  demand  for  this  work  is  usually  spontaneous, 
and  not  always  will  the  same  people  recognize  its  necessity. 
In  one  instance  it  may  be  the  physicians  of  the  locality,  in 
another  the  clergy,  in  another  the  philanthropic  and  ben- 
evolent wealthy  citizens.  The  question  is  :  shall  the  work  be 
non-sectarian  and  neutral,  or  shall  it  be  a  specified  charity  by 
itself,  or  operated  in  connection  with  churches  or  dispen- 
saries, or  with  the  city  physicians?  Or  shall  it  be  a  depart- 
ment of  the  organized  charities  which  already  exist  in  every 
state  of  the  Union?  No  one  can  advise  any  special  plan, 
but  we  can  all  urge  communities  to  provide  for  the  care 
for  the  sick  poor  in  their  homes,  where  the  well  members 
of  the  family  may  be  taught  a  responsibility  towards  their 
own  sick  that  they  would  not  otherwise  have.  Not  more 
than  one-third  of  the  cases  usually  helped  can  enter  hospi- 
tals, and  many  do  go  who  should  not,  for  in  these  instances 
a  home  may  be  broken  up  and  the  responsibility  that  should 
be  borne  by  the  individual  shifted  to  an  institution. 

Many  contend  that  the  work  comes  very  near  being  a 
luxury  to  the  poor.  If  it  is,  then  every  asylum  founded 
for  charity  is  a  luxury,  and  a  luxury,  too,  that  relieves  the 
individual  of  any  dependence  upon  his  own  exertions  and 
has  no  results  to  show  save  that  of  pauperization. 

Before  closing,  just  a  word  as  to  the  woman  detailed 
for  such  work  as  this.  Only  can  she  be  successful  when  she 
has  passed  through  a  broad  general  training  in  the  best 
nurses'  schools  that  can  be  found.  With  this  must  be 
refinement  and  culture  which  give  the  courage  and  patience 
to  overcome  the  overwhelming  difficulties  to  be  encoun- 
tered. 


Visiting  Nurses  in  America  255 

Armed  with  these  weapons,  she  goes  forth  as  no  other 
philanthropic  worker,  with  a  profession  so  valuable  and  at 
once  so  practical  that  there  is  no  mistaking  the  need  she  fills. 

For  the  past  ten  years  it  has  been  clearly  shown  "that 
the  district  visiting  nurse  work  is  the  best  means  at  the 
smallest  cost  of  helping  the  conditions  of  the  poor,  sick  or 
well."  Hospitals  do  much  good,  but,  after  all,  they  ofifer 
but  outside  methods  of  education.  It  is  by  reaching  the 
people  in  their  own  homes  and  teaching  them  to  utilize 
and  make  the  best  of  what  they  have  that  lasting  good  may 
be  accomplished. 

To  the  following  we  are  gratefully  indebted  for  data 
and  information  pertaining  to  the  subject  of  this  paper :  To 
the  secretaries  and  superintendents  of  the  various  Visiting 
Nurse  Societies  and  to  the  secretaries  of  the  charity  organ- 
izations in  all  parts  of  the  country. 

For  articles  on  the  subject  of  district  nursing  you  are 
referred  to  the  following:  The  "Report  of  the  Conference 
of  Charities  in  1894,"  Nursing  Section ;  paper  by  Edith  S. 
Brent,  Brooklyn,  N.  Y.,  on  "District  Nursing;"  a  pamphlet 
published  by  the  Victorian  Order  of  Nurses,  by  Lady 
Aberdeen  on  "District  Nursing;"  "The  History  of  District 
Nursing,"  by  Dr.  A.  Worcester,  M.  D. ;  a  small  volume  on 
"District  Nursing"  by  William  Rathbone,  M.  P. ;  a  work 
on  "District  Nursing"  by  Mrs.  Dacre-Craven,  and  one  by 
Miss  Amy  Hughes. 


The  Victorian  Order  in  Canada. 

CHARLOTTE  MACLEOD, 

Chief  Lady  Superintendent  Victorian  Order  of  Nurses,  Canada. 


The  pioneers  in  district  nursing-  in  Canada  were  the 
Sisters  of  Charity,  who  also  led  the  way  in  hospital  nursing. 
The  well-known  Sisters  of  Providence  have  been  long 
engaged  in  this  work,  especially  in  the  cities  of  the  Province 
of  Quebec.  They  go  their  rounds  in  pairs,  taking  with 
them  whatever  material  is  necessary  for  the  services  they 
may  be  called  upon  to  perform,  and  they  frequently  remain 
hours,  or  even  days,  with  patients  who  are  too  ill  to  be  left 
in  the  care  of  inexperienced  hands. 

Several  of  the  hospitals  also  send  their  nurses  out  as 
district  nurses,  notably  the  Maternity  and  Western  Hos- 
pitals in  Montreal.  The  Winnepeg  General  Hospital  has 
boarded  and  lodged  one  of  its  graduates  for  this  purpose 
for  the  last  three  years.  Nor  has  the  field  been  left  entirely 
to  the  hospitals  and  orders  mentioned.  Various  philan- 
thropic societies  have  taken  up  the  work  of  district  nursing 
and  are  doing  all  in  their  power  to  thus  lessen  the  sufferings 
of  humanity.  Perhaps  the  one  of  longest  standing  is  the 
Nursing-at-Home  Mission  in  Toronto,  which  began  opera- 
tions about  fourteen  years  ago  in  this  lovely  way : 

A  nurse,  who  was  taking  a  post-graduate  course  at  the 
Children's  Hospital  in  Toronto,  was  so  impressed  with 
the  sad  condition  in  which  many  of  the  children  were 
brought  to  the  hospital  that  she  determined  to  see  what 
could  be  done  by  carrying  the  skill  and  tenderness  of  a 
trained  nurse  into  the  homes  of  the  poor.  She  therefore 
left  the  hospital,  rented  a  room,  and  began  work  in  the  dis- 
254 


District  Ntirsing  in  Canada  255 

trict.  Her  example  of  devotion  was  soon  followed  by 
another  nurse,  and  shortly  afterwards  this  work  came  under 
the  auspices  of  the  Mission  Union.  Finally  a  home  was 
provided  where  three  women  were  taken  in  for  training. 
The  superintendent,  who  is  herself  a  thoroughly  qualified 
nurse,  visits  the  patients  with  the  probationers  and  gives 
them  practical  lessons  at  the  bedside.  Experience  is  also 
gained  in  a  free  dispensary  with  which  the  home  has  been 
connected  for  the  last  seven  years.  Courses  of  lectures 
too  are  given  to  the  nurses  by  many  of  the  physicians  who 
employ  their  services.  The  period  of  probation  is  two 
years,  after  which  time  a  diploma  is  granted.  The  rate  of 
remuneration  received  by  these  nurses  depends  entirely 
upon  the  amount  of  charity  support  accorded  the  mission 
from  year  to  year,  the  work  itself  being  the  first  consid- 
eration.    In  the  report  for  1900  it  was  stated: 

"Gratuities  to  nurses  (eight  in  number),  four  hundred 
and  twenty-one  dollars  and  twenty-five  cents.  In  addition 
to  the  home  being  rent  free,  there  is  a  city  grant  of  two 
hundred  and  fifty  dollars,  but  the  remainder  of  the  support 
is  from  voluntary  subscriptions,  no  charge  being  made  to 
the  patients." 

Two  sets  of  deaconesses,  the  Anglican  and  the  Meth- 
odist, do  district  nursing  also  in  the  city  of  Toronto.  Some 
of  these  women  are  admitted  to  Grace  Hospital  and  West- 
ern Hospital  for  three-months'  training,  and  afterwards,  in 
connection  with  their  course  in  church  and  Bible  history, 
they  go  out  in  district  nursing  work  during  the  remainder 
of  their  two  years. 

In  Montreal  district  nursing  started  in  connection  with 
a  diet  dispensary  which  was  established  in  1879,  but  it  was 
not  until  six  years  later  that  the  necessity  for  a  visiting 
nurse  became  apparent  to  the  managers  of  the  institution. 
The  success  of  this  nurse's  work  was  so  marked  that  very 
soon  an  assistant  was  appointed.  Neither  of  these  women 
was  trained,  but  the  pioneer  in  the  work  served  for  thirteen 
years  before  her  retirement. 

Early  in  the  year  1897,  the  year  of  the  celebration  of 


256  International  Congress  of  Nurses 

our  late  beloved  Queen's  Diamond  Jubilee,  the  women  of 
Western  or  Newer  Canada  recommended  that  an  organiza- 
tion be  formed  as  a  Jubilee  ofTferin^  to  her  Majesty,  which 
would  provide  nursing  service  in  the  more  remote  districts 
of  the  dominion.  The  Countess  of  Aberdeen,  wife  of  the 
then  Governor-General  of  Canada,  responded  in  a  most 
enthusiastic  m.anner  to  this  proposal.  But  to  carry  such 
a  scheme  to  a  successful  issue  in  so  varied  and  extensive  a 
country  as  Canada  proved  to  be  a  difficult  task.  When  the 
project  known  as  the  Victorian  Order  of  Nurses  for  Can- 
ada was  finally  launched,  owing  to  the  false  rumors  as  to 
the  aims  of  the  order,  it  met  with  little  or  no  favorable 
response  from  either  doctors  or  nurses.  Dr.  Alfred  Wor- 
cester, of  Waltham,  Mass.,  who  was  invited  by  the  Countess 
of  Aberdeen  for  this  purpose,  aided  very  materially  in  over- 
coming the  prejudices  of  many  by  giving  addresses  in  some, 
of  the  larger  cities  on  district  nursing,  and  by  showing 
how  the  Victorian  Order  might  be  managed  on  more 
economical  lines  than  were  at  first  thought  possible. 
Finally  a  fund  was  started  and  organization  began.  The 
constitution,  by-laws,  and  regulations  were  drawn  up  and 
a  royal  charter  procured.  The  royal  charter  authorized  the 
formation  of  a  Board  of  Governors  which  should  have  the 
management  and  control  of  the  order  and  of  its  affairs,  and 
it  also  appointed  his  Excellency  the  Governor-General  of 
Canada  as  patron. 

Five  members  of  the  Board  of  Governors  are  selected  / 
by  the  patron,  and  the  others  by  the  Canadian  Medical  i 
Association,  by  each  Provincial  Medical  Association,  and 
by  each  local  association  according  to  the  amount  of  its  \ 
yearly  income.  There  is  an  Executive  Council,  made  up-  \ 
from  the  members  of  the  board,  whose  numbers  and  powers  ' 
are  defined  by  the  governors. 

The  chief  lady  superintendent  is  appointed  by  the 
Board  of  Governors,  and  the  most  prominent  among  her 
duties  are  the  organizing  of  new  branches,  recommending 
suitable  district  lady  superintendents  and  nurses,  overseeing 


District  Nursing  in  Canada  257 

their  work,  and  reporting  on  the  same.  The  order  under- 
takes to  teach  district  nursing. 

Only  nurses  holding  diplomas  from  some  recognized 
hospital  training  school  and  who  come  highly  recom- 
mended are  considered  eligible  for  the  course  of  training  in 
district  nursing.  A  period  of  four  months'  probation  is 
given  at  the  training  home  either  at  Montreal  or  Toronto 
to  test  the  adaptability,  tact,  and  previous  training  of  these 
nurses.  During  that  time  they  are  provided  with  board, 
lodging,  laundry,  and  an  allowance  of  twenty  dollars  a 
month.  At  the  expiration  of  this  course  the  nurse,  if  she 
is  desirous,  and  has  proved  herself  acceptable,  is  recom- 
mended to  the  Board  of  Governors  as  a  candidate  for  the 
order.  She  is  then  presented  with  her  diploma  and  badge, 
either  by  his  Excellency,  the  wife  of  the  Governor-General, 
or  by  one  of  the  governors,  who  admits  her  to  tlie  order 
in  the  following  words: 

"By  the  authority  of  the  Board  of  Governors,  I  have 
the  honor  of  admitting  you  formally  into  the  ranks  of  the 
Victorian  Order  of  Nurses.  You  have  been  recommended 
to  the  Board  of  Governors  by  the  chief  lady  superintendent 
as  a  nurse  possessing  the  qualifications  and  training  which 
our  order  requires,  and  have  proved  through  your  training 
in  district  nursing  your  efficiency  in  all  your  nursing  work 
and  your  willingness  to  observe  all  the  regulations  of  the 
order.  We  therefore  welcome  you  very  heartily  to  the 
order,  and  we  enlist  you  for  active  service  for  two  years. 
May  you  be  enabled  to  carry  into  action  the  true  spirit  of 
the  order,  and  may  God's  blessing  rest  upon  you." 

The  nurse  thus  admitted  and  pledged  for  two  years' 
service  in  the  order  must  be  prepared  to  go  anywhere  in 
the  dominion,  either  for  district  nursing  or  to  serve  in  one 
of  the  cottage  hospitals.  She  is  provided  with  her  outfit 
(uniform  and  nursing  bag)  and  receives  a  salary  of  not  less 
than  three  hundred  dollars  a  year,  with  maintenance  and 
laundry.  She  is  also  entitled  to  one  month's  holiday  each 
year.  Should  she  remain  in  the  order  for  three  or  more 
years,  she  will  have  a  miniature  badge  presented  to  her. 


258  Internatioiial  Congress  of  Nurses 

like  the  one  worn  by  her  during  her  term  of  service,  with 
the  dates  of  entrance  and  retirement  engraved  on  it,  as  a 
souvenir  of  her  work. 

The  trustees  of  the  Waltham  Training  School  for 
Nurses  at  the  inception  of  the  Victorian  Order  of  Nurses 
for  Canada  sent  over  their  superintendent  for  three  months, 
and  afterwards  released  her  from  her  duties  at  Waltham 
that  she  might  accept  permanently  the  position  of  chief 
lady  superintendent  of  the  order.  She,  with  five  nurses 
who  had  graduated  at  Waltham,  and  three  from  other 
schools,  began  work  early  in  February  of  1898.  During 
the  three  months  branches  were  established  in  four  of  the 
larger  cities  and  four  nurses  were  equipped  and  sent  with 
the  militia  to  the  Yukon,  where  they  performed  most  heroic 
services. 

The  work  of  the  order  has  slowly  but  steadily  pro- 
gressed, and  has  been  extended  from  coast  to  coast.  Out 
of  the  twentv-six  branches  which  have  been  established  in 
a  little  over  three  years,  twenty-four  are  carrying  on  the 
work  successfully.  In  all  there  are  fifty  nurses  engaged  in 
the  work. 

This  year  a  greater  efifort  than  ever  is  being  made  to 
provide  suitable  buildings  for  cottage  hospitals.  Her  Excel- 
lency the  Countess  of  Minto  is  doing  much  to  create  a  spe- 
cial fund  for  this  purpose.  It  will  be  known  as  the  "  Lady 
Minto  Fund  for  Erecting  Queen  Victoria  Cottage  Hospi- 
tals'' in  memory  of  our  late  beloved  sovereign.  Model  plans 
have  already  been  drawn  for  cottage  hospitals  to  accommo- 
date either  six  or  ten  patients,  two  nurses  and  a  maid.  Since 
the  inauguration  of  the  order  seven  cottage  hospitals  have 
been  established,  and,  although  several  of  these  buildings 
may  be  regarded  as  mere  apologies  for  hospitals,  most 
excellent  work  has  been  done  within  their  walls.  As  an 
illustration  of  the  assistance  afforded  by  the  order  in  estab- 
lishing cottage  hospitals,  which,  after  all,  are  really  district 
nursing  stations,  the  following  account  is  given : 

In  a  small  town  in  the  Northwest  Territories  the 
women  who  are  members  of  the  National  Council  had  put 


District  Nursing  in  Canada  259 

by  a  small  sum  of  money  towards  a  building  fund  for  a 
hospital ;  but  as  they  met  with  no  encouragement  from  the 
men  of  the  town,  they  felt  their  project  must  be  postponed 
indefinitely.  Just  then  the  Victorian  Order  came  to  their 
assistance  and  advised  them  to  rent  a  cottage  and  make  it 
habitable  for  patients.  A  nurse  from  the  order  was  sent  to 
take  charge.  Within  a  few  months  a  request  was  made  by 
the  local  committee  for  a  second  nurse.  In  the  following 
year  patients  were  refused  admittance,  owing  to  the  over- 
crowded condition  of  the  building.  Enteric  fever,  maternity, 
surgical,  and  chronic  cases  have  all  been  cared  for  there, 
and  several  major  operations  have  been  performed  in  the 
small  room  which  the  nurses  occupy  as  their  dining  and 
sitting  room.  Great  inconveniences  have  been  overcome 
by  these  devoted  nurses  in  their  desire  to  serve  these 
patients,  who  otherwise  in  many  cases  would  have  been  left 
to  take  shelter  in  a  third-rate  boarding  house  with  only  such 
care  as  the  slatternly  servants  might  give  them.  However, 
the  nurses  have  now  been  rewarded,  having  just  moved  into 
a  fine  brick  building  erected  for  this  purpose.  As  the 
expense  of  keeping  a  stafif  of  four  Victorian  Order  nurses 
in  this  little  hospital  would  be  too  great,  a  training  school 
consisting  of  four  probationers  under  a  highly  qualified 
superintendent  is  now  in  progress.  There  are  only  twenty 
beds,  but  as  the  cases  are  varied,  and  a  thoroughly  well 
planned  curriculum  enforced  during  a  term  of  three  years, 
including  three  months  of  district  nursing,  there  is  no 
apprehension  of  their  not  being  well  fitted  for  district  or 
cottage  hospital  nursing  in  the  West. 

These  Victorian  Cottage  Hospitals  will  be  open  to  give 
a  training  in  nursing  to  the  Doukhobour,  and  to  the 
educated  Indian  girl,  that  she  may  be  of  special  service  to 
her  own  people. 

Innumerable  instances  might  be  related  of  the  blessing 
the  Victorian  Order  nurse  has  been  in  the  cottage  hospital 
to  the  homeless  sufTerer,  in  the  humble  room  of  the  crowded 
tenement  house  during  her  daily  visits  in  the  city  districts, 
or  in  the  rural  districts,  where  she  may  have  to  drive  ten 


260  International  Congress  of  Nurses 

or  fifteen  miles  and  even  canoe  up  a  river  in  order  to  reach 
her  patient.  In  the  latter  case  the  nurse  may  have  to  remain 
a  few  da3's  if  her  services  are  not  required  in  the  village 
and  the  patient  requires  special  care. 

One  of  the  chief  dif^culties  has  been  an  inadequate 
supply  of  good  nurses.  This  is  pioneer  work,  and  it  does 
not  appeal  to  those  who  like  a  city  life  with  its  brightness 
and  comfort,  though  it  should  be  said  that  even  in  remote 
districts  the  Victorian  Order  nurse  is  not  by  any  means 
forgotten  or  neglected.  No  nurse  practicing  her  calling, 
even  in  most  luxurious  homes,  can  receive  such  honor  and 
hearty  gratitude  as  is  accorded  to  our  nurses  amid  their 
rude  surroundings.  In  one  of  the  most  outlying  districts, 
where  every  effort  to  procure  suitable  board  and  lodging 
for  the  nurse  had  failed,  her  committee  had  a  small  shack 
built  and  furnished  for  her  use. 

The  Victorian  Order  of  Nurses  for  Canada  needs 
women  in  it  for  country  as  well  as  for  city  districts, — women 
who  are  capable  of  performing  the  highest  duty  on  earth, 
namely,  in  helping  their  fellow-beings  back  to  health,  also 
helping  them  to  lead  noble,  clean,  and  wholesome  lives, 
inwardly  as  well  as  outwardly. 

The  Victorian  Order,  in  common  with  the  whole 
empire,  mourns  deeply  the  loss  of  her  after  whom  it  was 
named ;  but  the  Queen's  nurses  will  undoubtedly  respond 
more  quickly  than  ever  to  the  inspiration  of  her  life — as 
noble  woman  and  as  noble  Oueen. 


The  Nurses'  Settlement. 

LILLIAN  D.  WALD, 

Founder  of  the  Nurses'  Settlement,  New  York ;  Graduate  of  the  New  York 

Hospital. 


About  eight  years  ago  tenement  house  Hfe  in  its  most 
pitiable  aspect  was  presented  to  me.  I  had  been  giving  a 
course  of  lessons  in  home  nursing  to  a  group  of  proletariats 
from  the  older  world — people  who  find  a  renewal  of  hope 
in  New  York,  if  not  realized  for  themselves,  at  least  but 
deferred  and  as  ardently  felt  for  their  children. 

One  morning  one  of  the  women  of  the  class  was  not 
present,  and  her  little  daughter  came  to  ask  me  to  call  upon 
her  mother  as  she  was  ill.  Despite  the  experience  in  a 
large  metropolitan  hospital,  and  the  subsequent  knowledge 
gained  through  a  year's  residence  in  a  reformatory  and 
asylum  for  the  waifs  of  New  York,  the  exposure  of  that 
rear  tenement  on  the  lower  East  Side  was  a  terrible  shock, 
a  shock  that  was  at  first  benumbing — a  picture  had  been 
presented  of  human  creatures,  moral,  and  in  so  far  as  their 
opportunities  allowed  them,  decent  members  of  society, 
living  in  rooms  reached  through  a  court  that  held  open 
closets  to  be  used  by  men  and  women,  from  some  of  which 
the  doors  had  been  torn  away;  up  dirty  steps  into  a  sick 
room  where  there  was  no  window,  the  one  opening,  leading 
into  a  small  crowded  room  where  husband,  children  and 
boarders  were  crowded  together — impossible  conditions 
under  which  to  attempt  to  establish  a  home  and  bring  up 
children. 

Upon  further  acquaintance  with  the  house  and  neigh- 
borhood I  learned  that  kindly  attention  from  the  outside 

261 


262  International  Congress  of  Nurses 

had  not  been  wholly  absent.  The  visitor  from  a  medical 
dispensary  had  called,  and,  touched  by  the  poverty  of  the 
place,  had  sent  a  bottle  of  beef  extract  with  directions  for 
use  printed  upon  it,  but  there  was  no  one  in  the  house  who 
could  read  English.  Other  charitable  persons  had  sent 
coal,  but  my  nurse's  instinct  revolted  at  the  knowledge  that 
nobody  had  washed  the  woman,  made  her  bed,  t)r  performed 
any  of  the  offices  that  every  human  creature  should  feel 
entitled  to  in  like  condition. 

I  will  not  take  time  now  to  describe  all  of  the  circum- 
stances and  the  responsibilities  of  the  community,  as  they 
appeared  to  me,  toward  this  one  family ;  to  me  personally 
it  was  a  call  to  live  near  such  conditions,  to  use  what 
power  an  individual  may  possess  as  a  citizen  to  help  them 
and  to  give  to  all  of  my  world,  wherever  it  might  be,  such 
information  as  I  could  regarding  conditions  that  seemed  to 
be  generally  unknown. 

To  a  friend  the  plan  was  revealed  :  "Let  us,  two  nurses, 
move  into  that  neighborhood ;  let  us  give  our  services  as 
nurses,  and  let  us  contribute  our  sense  of  citizenship  to 
what  seems  an  alien  group  in  a  so-called  democratic 
community." 

Having  formulated  some  necessary  details  of  the  plan, 
we  proceeded  to  look  for  suitable  quarters,  and  in  the 
search  discovered  the  "Settlement."  In  the  stress  of  hos- 
pital training,  neither  of  us  had  learned  that  men  and 
women,  moved  by  some  personal  experience  or  by  theo- 
retical training,  had  arrived  at  the  same  impulse  to  action 
and  had  established  themselves  in  the  crowded  quarters 
of  cities  and  called  themselves  ''Settlement  Workers." 
The  idea  was  identical  with  our  own,  and  though  many 
activities  have  grown  from  that  idea,  the  fundamental  prin- 
ciple remains — that  people  shall  take  up  their  residence 
in  industrial  communities,  giving  what  they  may  have  of 
public  spirit,  and,  partaking  of  the  life  about  them,  preserv- 
ing their  identity  as  individuals,  and  endeavoring  to  keep 
the  settlement  free  from  the  institutional  form  of  philan- 
thropic work. 


The  Nurses'  Settlement  263 

For  the  first  two  months  of  our  experiment  we  two 
nurses  lived  at  the  College  Settlement.  After  that  the  top 
floor  of  a  tenement  house  that  gave  reasonable  comfort 
was  our  home  for  two  years,  and  that  was  practically  the 
beginning  of  the  present  association  of  workers  known  as 
the  "Nurses'  Settlement."  The  life  possible  through  mak- 
ing our  home  among  the  people  in  a  simple  informal  way 
led  us  easily  and  naturally  into  all  the  questions  that  afifected 
them. 

Through  our  visits  to  the  children  and  our  interest  in 
their  general  welfare  we  learned  of  the  unsatisfactory  school 
conditions  and  of  the  absurdity  of  a  compulsory  school  law 
when  there  was  not  adequate  school  accommodation  for 
the  children.  Such  knowledge  as  came  to  our  notice,  such 
effective  protest  as  would  illustrate  the  conditions  of  our 
neighborhood,  was  brought  before  a  suitable  public,  indi- 
viduals or  societies  especially  concerned,  whenever  occasion 
could  be  found  or  be  made. 

The  women  on  the  lower  floors  in  the  tenement  where 
we  lived  were  employed  in  the  needle  trades,  and  unbearable 
treatment  at  the  hands  of  a  foreman  had  moved  them  and 
their  fellow  workers  to  agitate  for  trade  organization.  In 
the  search  for  some  one  of  their  own  sex  who  could  speak 
for  them  in  what  they  called  "better  English"  they  came  to 
us,  and  that  was  our  first  introduction  to  the  protest  of  the 
workers  which  is  expressed  in  trades  unionism. 

A  semi-ofttcial  recognition  by  the  Board  of  Health 
gave  us  the  privilege  of  inspection  of  the  tenements,  and 
valuable  information  was  thus  stored  up  on  the  housing 
problem.  The  experience  thus  gained  had  its  share  of 
influence  in  the  general  education  of  the  public,  which  later 
led  to  the  Tenement  House  Exhibit;  to  the  appointment 
of  a  tenement  house  conimissioner  under  Governor  Roose- 
velt, and  the  final  creation  of  a  separate  department  for 
the  city  of  New  York.  One  of  the  members  of  the  settle- 
ment took  active  part  in  the  movement  and  was  one  of  the 
two  women  on  the  jury  of  awards  for  plans  for  mcKlel  tene- 
ment houses. 


264  International  Congress  of  Nurses 

Through  her  efforts  to  obtain  a  legacy  that  had  been 
bequeathed  "  for  a  fountain  somewhere  in  the  city,"  the 
Schiff  fountain  was  erected  in  the  neighborhood  of  the  set- 
tlement and  was  the  strong  influence  in  having  an  adjacent 
site  selected  for  a  park  and  public  playground,  to  make 
place  for  which  no  more  congested  and  unsightly  rookeries 
could  have  been  demolished. 

The  movement  for  public  playgrounds  is  now  well 
known.  They  have  been  valiently  fought  for,  and  their  need 
wonderfully  told  by  Mr.  Jacob  A.  Riis,  that  best  friend  and 
most  lovable  fighter  for  the  children  of  the  poor.  His  efforts 
have  been  assisted  by  the  Nurses'  Settlement  for  years, 
according  to  our  ability.  To  meet  the  rightful  demand  of 
the  children  for  play,  we  conducted  in  our  back  yards  one 
of  the  first  playgrounds  in  the  city.  It  was  an  experimental 
station  in  a  way,  as  well  as  an  enlightenment  of  the  general 
public,  and  was  instrumental  in  helping  to  develop  public 
feeling  in  the  matter.  After  a  time  the  interests  of  the  resi- 
dents of  the  settlement  were  directed  to  the  "Outdoor  Rec- 
reation League,"  share  being  taken  in  its  executive  work, 
and  co-operation  given  to  Mr.  Charles  B.  Stover,  the  apostle 
for  New  York  of  outdoor  play-places  for  the  children  of 
crowded  districts. 

The  workers  of  the  settlement  can  look  with  gratification 
upon  the  increasing  interest  in  public  school  matters  affect- 
ing their  neighborhood  as  in  some  part  the  result  of  their 
efforts  to  bring  public  attention  to  the  lack  of  room  for  the 
children  in  the  schools,  and  in  other  ways  to  bring  the 
interests  of  their  localities  directly  to  the  school  boards. 
One  of  the  household  was  for  a  time  school  inspector,  but 
whether  in  ofHcial  relationship  or  not,  the  members  have 
been  frequently  consulted  by  those  in  authority  on  the  Board 
of  Education. 

I  have  passed  over  the  steps  of  growth  of  the  settle- 
ment, and  to  understand  how  it  has  attained  its  present 
status  I  should  go  back  to  that  first  beginning  in  the  tene- 
ment, when  it  was  apparent  that  not  only  were  the  nurses' 
services  needed  for  the  sick,  but  that  likewise  their  friendly 


The  Nurses'  Settlement  265 

offices  were  needed  as  interpreters  for  bringing  to  the  proper 
sources  the  larger  and  more  general  matters  that  affected 
the  life  of  the  people  they  were  in  contact  with. 

Mr.  Jacob  H.  Schiff,  who,  from  the  very  beginning, 
had  made  us  feel  his  support,  encouragement,  and  confi- 
dence, suggested  the  change  from  the  tenement  quarters 
to  a  house,  arguing  that  a  more  permanent  basis  would  be 
established  for  these  personal  services  if  it  were  made  possi- 
ble for  others  to  join  us.  The  desire  of  others  to  co-operate 
with  us  had  been  for  some  time  apparent,  and  therefore  this 
most  generous  and  public-spirited  citizen's  offer  was 
accepted.  A  house  near  the  tenements,  once  the  property 
of  the  fashionable  and  well-to-do,  who  had  inhabited  Henry 
street  half  a  century  before,  was  purchased  by  him.  Neces- 
sary changes  were  made  in  it,  and  almost  immediately  the 
house  was  filled  with  residents,  and  the  nursing  was 
extended.  The  clubs  and  social  features  of  the  house  then 
began  to  assume  organized  form. 

The  next  year  another  house  was  given  for  the  use  of 
the  settlement  by  a  new  member,  Miss  Helen  McDowell,  a 
lay-woman,  who  came  into  residence,  fitted  it  up  and 
contributed  the  means  to  carry  it  on,  and  who  has  taken 
charge  of  much  of  the  social  work  among  the  young  people. 
Not  long  after  that,  offers  of  money  and  suitable  workers 
came  to  the  settlement,  and  fresh  opportunities  to  extend 
presented  themselves.  The  needs  of  an  uptown  district 
having  been  urged,  a  house  was  selected  there,  purchased 
by  Mrs.  Butler  Duncan  for  extension  of  the  settlement,  and 
workers  placed  in  it  who  had  served  an  apprenticeship  in 
the  down-town  house.  A  little  later  also  a  part  of  a  house 
in  still  another  locality  was  given  to  the  settlement  by  Mr. 
John  Crosby  Brown,  father  of  one  of  the  residents,  who  with 
the  other  members  of  that  family  has  done  much  to 
strengthen  the  settlement,  and  several  nurses  are  accom- 
modated there. 

Finally  a  dream  of  the  nursing  staff  was  realized  in 
the  gift  from  a  young  married  woman,  Mrs.  Sylvan  Bier,  of 


266  International  Congress  of  Nurses 

a  charming  home  in  the  coimtry,  where,  all  the  year  round, 
and  without  restriction  or  conditions  save  those  imposed  by 
the  circumstances  of  the  patients,  the  convalescents  and  tired 
out  people  who  need  rest  are  entertained,  and  where,  in  the 
summer,  many  delightful  outings  for  the  young  people  are 
planned. 

From  the  needs  of  the  neighborhood  has  sprung  the 
service  that  we  call  the  "First  Aid  Rooms"  in  three  very 
crowded  quarters.  In  each  one  a  nurse  is  in  attendance  at 
certain  hours  of  the  day,  and  cases  that  require  small  dress- 
ings, fresh  cuts,  old  w^ounds,  simple  eye  cases,  eczemas,  etc., 
are  treated.  These  are  such  nursing  cases  as  might  be 
attended  to  by  the  members  of  the  families  if  the  mothers 
had  sufficient  intelligence  or  sufficient  leisure.  Many  of 
them  are  sent  by  the  physicians  of  the  large  dispensaries  who 
have  not  the  confidence  that  the  parents  will  apply  oint- 
ments, dress  wounds  or  syringe  ears  daily  and  in  a  cleanly 
way.  These  are  often  school  children,  and  the  nurse  is  thus 
able  to  care  for  a  far  greater  number  than  would  be  possible 
if  she  went  to  them. 

This  work  has  also  a  direct  bearing  on  the  school 
attendance  of  the  children,  and  though  many  of  the  cases 
are  not  important  from  a  medical  point  of  view,  they  are 
of  the  utmost  importance  from  the  educational  standpoint, 
as  the  children  are  sent  home  by  the  medical  inspectors, 
and,  not  being  allowed  to  re-enter  while  the  trouble  con- 
tinues, often  miss  much  precious  school  time,  for  it  must 
be  remembered  that  few  of  these  children  can  attend  school 
after  fourteen — at  that  age  they  all  begin  wage-earning. 

As  an  illustration,  I  knew  of  a  lad  of  twelve  years  who 
had  never  been  in  school  because  of  eczema  of  the  scalp. 
True,  the  mother  had  gone  to  the  dispensaries  and  obtained 
ointments,  but  the  over  driven,  worn  out  woman  said  they 
did  no  good.  Careful  epilation,  systematic  disinfection  and 
application  of  the  medicament  were  so  successful  that  when 
school  opened  in  the  fall  I  had  the  pleasure  of  placing  the 
boy  there  for  the  first  time  in  his  life. 

The  settlement,  in  co-operation  with  the   New  York 


The  Nurses'  Settlement  267 

Kindergarten  Association,  maintains  a  kindergarten.  The 
children,  upon  graduating  from  the  kindergarten  and  enter- 
ing the  public  schools,  are  invited  to  come  back  as  members 
of  clubs.  They  are  the  youngest  club  members,  and  when 
the  first  one  was  called  "The  Alumnse  Association  of  the 
Nurses'  Settlement  Kindergarten,"  the  name  seemed  longer 
than  some  of  the  members. 

Probably  the  boys'  clubs  connected  with  the  settlement 
hold  the  most  intimate  place.  The  first  one  organized,  of 
which  I  have  the  honor  of  being  a  member,  undertook  the 
study  of  the  lives  of  American  heroes.  We  took  the  term 
"hero"  broadly,  and  men  or  women  who  by  fearless  living 
had  made  the  world  a  better  place  to  live  in  were  counted  as 
such.  Thus  we  had  the  biographies  of  those  who  had  con- 
tributed as  statesmen,  soldiers,  philanthropists  and  writers  to 
the  realization  of  the  highest  hopes  of  the  country,  and  living 
members  of  the  family  under  discussion  often  came  to  con- 
tribute personal  reminiscences  or  family  history.  Since 
then,  as  this  club  matured,  it  has  taken  up  the  study  of 
civil  government  and  other  similar  study,  and  is  but  a  type 
of  what  all  the  clubs  are  doing.  Some  of  the  girls'  clubs 
combine  study  with  the  boys  and  young  men,  and  inter- 
esting debates  on  important  topics  of  the  day  are  held  in 
their  meeting  rooms. 

In  the  interests  of  a  considerable  number  of  boys  not 
responsive  to  the  more  intellectual  stimulus  of  study,  rooms 
have  been  set  apart  for  manual  work,  and  with  the  co-opera- 
tion of  the  "Children's  Aid  Society,"  carpentry,  wood  carv- 
ing and  basket  work  are  carried  on.  The  large  dancing- 
school  classes,  gymnasium  work,  etc.,  are  possible  through 
the  courtesy  of  this  society.  It  gives  us  the  privilege  of 
using  their  large  and  roomy  floors  after  school  hours  and  in 
the  evenings.  Our  dancing  school  has  led  us  to  the  same 
conclusion  that  experience  with  young  people  anywhere 
would  bring — that  the  desire  to  dance  and  to  meet  their  kind 
socially  is  a  wholesome  and  healthy  one,  and  that  it  is  a 
dangerous  thing  not  to  recognize  and  meet  the  want  whole- 
somely, lest  innocent  desires  be  diverted  wrongly. 


268  International  Congress  of  Nurses 

The  dancing-  classes  are  refined  gatherings,  properly 
chaperoned,  and  with  no  other  restrictions  than  the  ordinary 
ones  of  good  manners.  They  are  successful  rivals  to  the 
public  dances  that  are  over  or  back  of  the  saloons,  and  also 
provide  opportunities  for  those  young  people  whose  careful 
parents  would  not  allow  them  to  go  elsewhere. 

We  have  a  penny  provident  bank,  and  habits  of  thrift 
are  inculcated  by  making  it  easy  to  save  the  pennies.  When 
the  deposit  reaches  the  sum  of  one  dollar,  an  account  may 
be  opened  in  the  savings  bank  in  the  locality. 

All  of  such  work  is  not  done  by  the  nurses,  for  beside 
our  valued  lay  members,  who  share  in  the  social  and  educa- 
tional work,  a  large  stafif  of  non-residents  takes  part  in  the 
classes  and  clubs. 

The  kindergarten  teachers  are,  of  course,  trained  for 
that  purpose.  Leaders  for  clubs  and  teachers  for  the  vari- 
ous classes  are  recruited  from  the  outside,  and  among  them 
are  distinguished  lecturers  who  find  their  students  respon- 
sive and  their  audiences  sympathetic.  Musicales,  private 
theatricals,  and  the  varied  undertakings  that  bring  gayety 
and  zest  into  the  social  life  are  successful  with  us.  We  are 
fond  of  saying  that  next  to  nursing  typhoid  fever  we  love 
to  give  a  ball. 

Our  nursing  work  is  the  "raison  d'etre"  of  our  exist- 
ence, from  which  all  our  other  activities  have  had  their 
natural  and  unforced  growth,  but  the  papers  at  this  confer- 
ence have  dwelt  upon  the  detail  and  method  of  district 
nursing,  and  our  methods  do  not  differ  sufificiently  to  war- 
rant my  taking-  up  time  and  space  to  enlarge  upon  it.  We 
conceive  the  underlying  thought  of  the  district  nurse  to  be 
that  of  neighborliness,  and  plan  to  have  each  nurse  work  in 
a  small  district  in  close  touch  with  the  settlement  house 
that  she  belongs  to,  that  recourse  may  be  had  to  it  in  emer- 
gency as  quickly  as  possible. 

We  hope  that  the  nurse  with  her  knowledge  of  hygiene 
and  sanitation  and  the  care  of  the  body  in  health  and  illness 
will  be  an  educator,  and  we  lay  much  stress  upon  this,  that 
she  should  not  have  too  large  a  district  or  too  many  patients 


The  Nurses'  Settlement  269- 

to  look  after.  We  believe  that  the  nurse  should  have  time 
to  give  the  bath,  and,  if  necessary,  to  make  the  second  or 
even  the  third  visit  in  the  day,  and  not  be  adviser  and 
instructor  only;  not  forgetting-  her  charity  organization 
tenets  of  the  dangers  of  doing  for  people  what  they  ought 
to  do  for  themselves,  yet  holding  to  the  ideals  of  the  nurse 
in  her  work. 

With  this  in  mind,  though  we  do  not  undertake  night 
nursing  as  a  rule,  yet  we  would  have  a  night  nurse  obtained 
through  a  registry  if,  in  our  opinion,  this  was  the  only 
thing  to  be  done  for  the  patient.  We  also  send  women  to 
scrub  and  clean  in  the  homes  that  the  nurses  go  to,  if  there 
is  no  one  who  should  rightfully  perform  these  services,  as 
we  consider  it  a  part  of  good  nursing  to  have  the  rooms 
kept  clean. 

The  various  needs  of  the  patient  are  kept  vividly  in 
mind.  From  what  we  call  the  settlement  point  of  view  we 
believe  that  the  patients  should  know  their  nurse  as  a  social 
being  rather  than  as  an  official  visitor,  and  that  all  legitimate 
relationships  which  may  follow  from  her  introduction  as  a 
nurse  shall  be  allowed  to  take  place. 

It  is  good  from  this  point  of  view  that  the  patient 
should  know  the  home  of  the  nurse,  and  that  the  nurse 
should  be  intelligent  about  the  housing  conditions,  the 
educational  provisions,  and  the  social  life  of  the  neighbor- 
hood in  which  she  works  and  lives. 

From  this  motive  has  come  the  opportunity  for  the 
settlement  to  show  where  the  neighborhood  has  been 
neglected,  and  to  bring  into  communication  the  different 
elements  of  society  that  go  to  make  up  a  great  city.  We 
think  and  feel  sincerely  that  the  relationship  is  reciprocal, 
that  we  are  partaking  of  the  larger  life,  that  society  has  in 
general  closed  the  avenues  that  lead  to  this  knowledge,  and 
that  the  different  elements  of  society  need  each  other.  The 
well-meaning  employer  needs  his  interpreter  and  the  people 
of  such  neighborhoods  as  our  own  should  have  their  point 
of  view  considered  and  given  dignified  place  in  the  councils 
of  the  public-spirited.     This  is  the  ideal  of  democracy,  the 


270  International  Congress  of  Nurses 

best  "  spirit  of  the  times,"  and  in  its  accomplishment  we 
have  responsibihty  and  privilege — our  share  in  speeding 
the  realization  of  the  unity  of  society,  the  brotherhood  of 
man. 

The  numerical  record  of  work  of  the  settlement  for  one 
year  was : 

Nursing  work — 3,991  patients  in  their  homes ;  26,600 
visits  to  their  homes;  12,694  cases  treated  in  (three)  first 
aid  rooms ;  225  convalescents  entertained  in  the  country 
house. 

Social  work — Thirty-five  clubs,  from  kindergarten  age, 
to  clubs  of  married  women ;  classes  in  dancing  school ;  four 
classes  singing  school,  private  theatricals,  concerts,  gym- 
nasium, fresh  air  work. 

Educational  work — Kindergarten,  reference  library, 
sewing,  crocheting,  etc. ;  basketry,  carpentry,  carving, 
housekeeping  (including  cooking,  laundry,  etc.) ;  home 
nursing ;  classes  in  civics,  municipal  and  national  govern- 
ment, history,  literature,  current  topics,  with  papers  and 
debates. 

[Between  the  dates  of  reading  this  paper  and  its  publi- 
cation the  settlement  has  been  extended  in  the  following 
ways :  Under  the  special  supervision  of  Miss  Mabel  Kit- 
tridge  an  apartment  in  an  ordinary  tenement  has  been 
rented  and  suitably  furnished  with  such  accommodations 
as  the  people  may  have  in  their  homes.  Here  all  the 
lessons  are  given  in  house  cleaning,  home-making,  laundry 
and  domestic  science  in  general.  These  rooms,  attractive 
in  their  simple  inexpensive  furnishings,  make  also  a  whole- 
some resort  for  the  members  of  the  classes. 

A  large  house,  at  299  Henry  street,  had  been  pur- 
chased by  the  late  Mr.  Leonard  Lewisohn  for  the  use  of 
the  settlement,  and  the  members  of  his  family  continue  his 
generous  relationship  to  the  work.  One  of  the  houses 
formerly  used  for  residents  and  for  the  kindergarten  is  by 


The  Nurses'  Settlement  271 

this  provision  freed  for  the  use  of  the  young  men  and 
women  who  are  members  of  the  senior  clubs. 

A  house  overhanging-  the  Hudson  river-bank  has  been 
built  for  the  children's  and  young  girls'  use  during  summer 
vacation  time,  and  plans  are  under  consideration  for  a 
better  equipped  convalescents'  home. 

A  camp  for  the  boys  at  one  of  the  outlying  parks  has 
been  made  possible  through  a  friend  of  the  boys  and  the 
granting  of  a  site  by  the  Park  Commissioner.  The  nurs- 
ing staff  has  been  enlarged  by  the  College  and  University 
Settlements,  each  having  a  nurse  in  residence  who  is 
responsible  for  the  calls  in  her  vicinity.] 

Note. — As  the  work  of  the  settlement  lias  become  known 
among  nurses,  two  similar  groups  have  been  established;  one  in 
Orange,  N.  J.,  and  the  other  in  Richmond,  Va.  Both  are  centers 
of  district  nursing  and  social  work  and  of  an  interest  in  civic 
improvement  which  gives  them  much  influence. — [Ed.] 


The  School  Nurse. 

HONNOR  MORTEN, 

Member  of  the  London  School  Board. 


There  is  no  daily  medical  inspection  of  primary  schools 
in  England,  though  the  spread  of  both  major  and  minor 
infections  amongst  school  children  is  fully  recognized.  So, 
while  the  state  and  municipal  authorities  are  deciding  what 
they  shall  do  with  regard  to  arresting  this  spread  of  disease, 
private  individuals  have  been  sending  nurses  to  some  of  the 
schools  in  London,  Liverpool,  and  elsewhere  and  doing  the 
work  quietly  as  a  charity.  It  was  on  this  line  that  the  Lon- 
don School  Nurses'  Society  was  founded  in  1898  with  the 
vice-chairman  of  the  London  School  Board  as  its  chairman 
of  committee.  The  staff  of  nurses  has  always  been  small, 
never  more  than  five,  though  the  elementary  schools  of 
London  numbers  over  500,  and  the  nurses  have  only  been 
able  to  visit  the  very  poorest  schools  and  touch  the  mere 
finger  of  the  evil.  But  they  are  getting  a  slow  recognition 
by  the  authorities,  a  rapid  regard  from  scholars,  teachers 
and  parents. 

On  February  27,  1900,  the  following  notice  appeared 
in  the  School  Board  of  The  London  Gazette : 

"  The  School  Management  Committee  give  their  con- 
sent to  a  nurse  from  the  London  School  Nurses'  Society 
attending  each  morning  for  one  hour  and  a  half  to  dress 
the  eyes  and  sores  of  the  children  in  those  schools  where 
the  divisional  members  consider  it  desirable,  and  make  'the 
necessary  arrangements,  provided  that  the  board  shall  not 
be  liable  for  any  of  the  cost  thereof ;  and  in  any  case  where 
272 


The  School  Nurse  275 

a  school  is  visited  by  a  nurse  of  the  society  the  board  pro- 
vide a  basin  and  kettle  for  the  use  of  a  nurse  at  a  cost  of  3s. 
for  the  two  articles." 

Her  Majesty's  Inspector,  in  his  report  of  April  19, 
1900,  on  Laxon  Street  School,  says :  "  The  visits  of  a  nurse 
to  this  very  large  infants'  school  have  proved  most  beneficial 
to  the  health  of  the  children,  so  much  so  that  it  could  be 
wished  that  the  School  Board  might  make  such  visits  uni- 
versal in  their  schools  in  poor  localities." 

Then  in  June  of  this  year  (1900)  the  School  Board 
cautiously  appointed  one  nurse  of  its  own  as  an  experiment, 
especially  to  deal  with  a  virulent  form  of  ringworm  that  is 
very  prevalent.  This  nurse  is  not  now  at  work,  but  the  fact 
remains  that  for  the  first  time  the  public  school  authority 
in  England  has  made  such  an  appointment. 

The  work  done  by  the  voluntary  nurses  consists  in 
weekly  or,  if  necessary,  daily  visitation  of  the  schools,  seeing 
the  children  sent  to  her  by  the  teachers,  dressing  small  sores, 
cleaning  dirty  heads,  and  bathing  sore  eyes.  Where  neces- 
sary the  teacher  is  advised  to  exclude  a  child,  or  a  bad  case 
is  followed  to  its  home,  or  the  mother  sent  for  to  be  seen 
at  the  school.  It  is  found  that  pediculi  and  mild  ophthalmia 
form  the  large  majority  of  the  cases ;  in  some  girls'  schools 
as  many  as  90  per  cent,  of  the  scholars  were  found  to  be 
suffering  from  pediculi.  After  six  months'  regular  visiting 
these  "  head  and  eye  chronics  "  become  cured  and  a  higher 
standard  of  cleanliness  reigns  in  the  school  and  the  nurse's 
visits  are  less  frequent  and  often  very  brief. 

The  ideal  would  be  for  some  six  school  nurses  in  a 
district  to  visit  daily,  under  a  doctor,  reporting  to  him  where 
major  infections — such  as  diphtheria — were  found  and 
medical  help  wanted,  while  they  attended  to  the  enormous 
number  of  cases  of  minor  infections.  Towards  such  an 
ideal  we  are  slowly  but  surely  tending  and  then  the  School 
Nurses'  Society  will  gladly  dissolve  and  hand  over  its 
charitable  voluntary  work  into  the  hands  of  the  school 
authorities. 


274  International  Congress  of  Nurses 

DISCUSSION. 

i\Hss  Mclsaac :  I  like  to  tell  of  the  Crerar  Fund  of 
Chicago  on  every  opportunity,  that  possibly  the  idea  may 
be  taken  up  by  others.  Several  years  ago  a  philanthropist 
of  Chicago,  Mr.  John  Crerar,  left  $50,000  to  the  Illinois 
Training  School.  Tlie  women  managers  of  the  school 
decided  that  as  this  money  was  not  actually  needed  for  the 
support  of  the  school,  it  should  be  devoted  to  providing 
trained  nurses  for  the  middle  classes. 

The  income  of  the  fund  is  used  in  the  following  man- 
ner: The  nurse  receives  $20  per  week  for  her  services, 
$25  being  the  average  rate  for  private  duty  in  Chicago. 
The  patient  pays  from  $7  to  $10  a  week  for  the  nurse's 
services,  according  to  his  income.  These  receipts  are 
added  to  the  yearly  income  from  the  fund.  We  send  nurses 
only  within  the  city  limits,  and  only  to  acute  cases,  and 
maternity  cases.  There  is  no  work  in  Chicago  more  appre- 
ciated or  that  has  done  more  good  than  this,  which  we  call 
the  "  Crerar  Nursing."  I  have  repeatedly  heard  nurses  say 
that  if  they  had  money  to  give  to  anything  it  should  be  to 
the  Crerar  Fund. 

Miss  Walker:  I  would  like  to  thank  Miss  Wald  for 
the  suggestion  that  in  district  nursing  we  not  only  help  the 
people  but  that  the  people  help  us.  There  was  so  much  to 
me  in  those  few  words  that  I  think  she  ought  to  be  thanked 
for  them. 

Question :  As  to  the  nurses  of  the  Victorian  order ; 
do  they  work  entirely  as  visiting  nurses  or  do  they  ever  stay 
with  the  patient? 

Miss  Macleod :  They  work  as  visiting  nurses  as  a 
rule ;  but  in  the  rural  districts  they  sometimes  stay  with  a 
patient  for  several  days. 

Unannounced :  W"e  find  that  our  poor  patients  are 
often  able  to  pay  ten  or  twenty-five  cents  a  visit,  and  that 


The  School  Nurse  275 

they  prefer  doing  so.     While  we  do  much  free  work  we  are 
always  glad  to  encourage  this  feeling  of  independence. 

Unannounced :  I  think  nurses  as  inspectors  of  schools 
would  do  better  work  than  the  doctors,  for  the  doctor  does 
not  treat  the  school  child.  He  simply  sends  it  home. 
We  are  trained  to  recognize  symptoms,  although  we  are  not 
to  make  diagnoses.  But  the  nurse  can  take  the  child  to  a 
dispensary  or  show  the  mother  what  to  do,  and  thus  have  a 
more  practical  influence  on  lessening  the  spread  of  con- 
tagion. 

[The  complete  system  would  undoubtedly  be  for  the 
doctor  and  nurse  to  work  together  in  school  inspection — 
the  doctor  to  examine  and  give  directions,  the  nurse  to  visit 
the  mothers,  instruct  them,  and  apply  dressings  and  treat- 
ment.— Ed.] 

The  President :  It  is  a  matter  of  constant  regret  that 
we  have  so  little  time  for  discussion.  The  time  has  now 
come  for  us  to  adjourn. 


FRIDAY    AFTERNOON. 

2.00   P.   M. 

The  President :  If  there  are  any  resolutions  to  come 
from  the  body  of  the  house  the  chair  would  request  that  they 
be  sent  up  at  once  in  writing. 

Our  next  paper  is  on  an  entirely  new  subject.  I  have 
the  very  great  pleasure  of  introducing  Mrs.  Kinney,  who  is 
at  the  head  of  the  United  States  Army  Nursing  Corps. 


Army  Nursing. 

DITA  H.  KINNEY, 

Superintendent  Army  Nurse  Corps,  D.  S.  A. 


The  origin  and  subsequent  history  of  army  nursing  is 
so  well  known  that  in  view  of  the  limited  time  alloted  for 
the  presentation  of  the  subject  such  a  retrospect  may  be 
omitted. 

No  occasion,  however,  should  be  allowed  to  pass 
unnoticed  which  offers  an  opportunity  for  a  tribute  to  her 
who  is  the  professional  mother  of  us  all,  or  to  him  to  whom 
the  United  States  Army  Nurse  Corps  owes  its  existence. 
Just  as  soldiers,  be  they  officers  or  privates,  salute  in  passing 
their  superiors,  do  we  army  nurses  metaphorically  rise  to 
our  feet  and  stand  at  attention  as  we  recall  for  a  moment 
276 


Army  Nursing  27'Z_ 

all  that  we  owe  to  the  wisdom  and  philanthropy  of  this  man 
and  this  woman — 

Florence  Nightingale,  the  first  army  nurs^. ; 

George  M.  Sternberg,  Surgeon-General  United  States 
Army; 

We  salute  you. 

Ever  since  the  days  of  the  Revolution,  Congress  has 
from  time  to  time  authorized  the  employment  of  women  in 
army  hospitals.  An  act  dated  July  27,  1775,  provides  for  a 
matron  "  to  superintend  the  nurses,  [query — were  these 
too  women?]  the  bedding,  etc."  A  similar  act,  April  7, 
1777,  provides  for  a  matron  "  who  shall  take  care  that  the 
provisions  are  properly  prepared,  that  the  utensils  are  kept 
in  order,  and  that  the  utmost  economy  be  observed  in  her 
department." 

In  1814  provision  was  made  for  female  attendants 
known  as  "  matrons."  At  the  present  day  one  of  these  is 
allowed  at  each  post,  but  she  is  simply  and  solely  a  laun- 
dress, and  never  by  any  chance  has  anything  to  do  with  the 
care  of  the  sick. 

The  incidents  of  the  war  of  the  Crimea  demonstrated 
to  the  medical  department  of  the  English  army  the  value  of 
female  nurses  in  army  hospitals,  and  since  that  time  they 
have  formed  a  part  of  the  military  establishment  of  that 
country.  The  Lancet  in  its  issue  of  April  27,  1901,  says: 
"Without  skilled  female  nurses,  the  proper  care  of  the  sick 
cannot  be  accomplished,  and  it  will  probably  be  necessary, 
even  under  ordinary  conditions,  to  increase  the  existing 
establishment.  It  will  certainly  be  so  in  the  event  of  war  on 
any  large  scale." 

There  is  in  England  a  finely  organized  school  where 
graduate  nurses  who  desire  to  enter  the  army  must  take  a 
course  before  being  permanently  assigned  to  that  work. 
English  army  nurses  have  in  addition  to  their  pay  an  allow- 
ance for  clothing  and  servant  hire,  and  after  retirement  are 
pensioned. 


278  International  Congress  of  Nurses 

In  France  and  Germany,  by  arrangement  with  certain 
religious  and  secular  nursing  orders,  a  limited  number  of 
women  are  employed  to  care  for  the  sick  of  the  respective 
armies  in  time  of  peace,  with  a  provision  for  a  suitable 
increase  in  event  of  war,  but  neither  country  has  an 
organized  nursing  service  such  as  exists  in  our  own  land 
and  in  Great  Britain. 

Previous  to  the  year  1887  the  nursing  of  the  sick  of  the 
United  States  Army  was  done  by  soldiers  specially  detailed 
for  that  duty.  They  were  selected  with  no  special  regard 
for  their  qualifications,  and  were  entitled  to  twenty  cents 
extra  duty  pay,  as  this  sum  was  called.  Eventually  this  was 
discontinued,  and  in  that  same  year  Congress  authorized 
the  establishing  of  a  body  of  well-qualified  men  who  should 
be  permanently  attached  to  the  hospital  in  the  various 
capacities  demanded  by  such  service.  The  authority  thus 
given  resulted  in  the  organization  of  the  hospital  corps  as 
it  now  stands. 

Up  to  the  time  of  the  Spanish-American  war,  the  navy 
had  no  such  body.  Today  its  hospital  corps  is  a  vigorous 
organization,  giving  large  promise  of  efficiency  and  offering 
special  inducements  to  young  men  for  advancement.  Its 
highest  rank  is  not  open  to  civilians,  but  is  to  be  filled  by 
promotions  from  the  lower  grades.  These  pharmacists,  as 
they  are  called,  are  not  enlisted  men,  but  '*  warrant  officers." 
Their  positions  are  tenable  up  to  the  retiring  age,  after 
which  they  receive  a  pension  and  such  other  benefits  as 
belong  to  their  rank. 

During  the  happy  and  uneventful  period  in  our  coun- 
try's history  between  1887  and  the  Spanish-American  war, 
the  hospital  corps  proved  itself  amply  sufficient  for  the  care 
of  the  sick  of  a  small  army  of  twenty-five  thousand  men. 
At  this  time  the  corps  numbered  about  six  hundred,  and 
after  the  addition  of  what  was  deemed  a  sufficient  number 
to  meet  the  emergency,  it  was  thought  to  be  unlikely  that 
the  services  of  female  nurses  would  be  required. 

It  took  but  a  short  time,  however,  to  make  evident  the 
great  desirability  of  skilled  women  over  the  raw  material 


Army  Nursing  27^ 

which  had  been  recently  added  to  the  corps,  and  at  the 
request  of  the  Surgeon-General  of  the  Army  Congress,  in 
April,  1898,  authorized  the  employment  of  female  nurses. 

Even  before  the  call  to  arms  had  sounded  through  our 
land  hundreds  of  patriotic  women,  trained  and  untrained, 
had  offered  their  services  as  nurses  in  the  event  of  war. 
The  tremendous  rush  of  work  thrown  upon  the  War  Depart- 
ment made  it  impossible  to  investigate  the  qualifications  of 
these,  and  so  all  such  communications  had,  with  the 
courtesy  which  distinguishes  all  official  procedure,  been 
replied  to,  filed,  and  buried. 

The  genius  of  Dr.  Anita  Newcomb  McGee  at  this  point 
saw  the  opportunity  and  seized  it.  She  formulated  a  plan 
whereby  the  Society  of  the  Daughters  of  the  American 
Revolution  were  to  become  an  Examining  Board  for  all 
nurses  who  wished  to  enter  the  service  of  the  government. 
The  Daughters  promised  their  hearty  cooperation,  and  she 
at  once  called  upon  the  Surgeons-General  of  the  Army  and 
Navy,  and  submitted  her  project  for  their  approval,  with  the 
result  that  they  gladly  availed  themselves  of  the  proffered 
services. 

What  followed — her  achievements — her  untiring  devo- 
tion to  the  work — is  too  w-ell  known  to  need  more  than 
passing  mention.  It  may,  however,  be  stated  that  she  took 
in  bulk  from  the  War  Department  all  the  accumulated  appli- 
cations, and  so  far  as  was  possible  investigated  the  references 
and  qualifications  of  each  one,  and  from  these  made  a  list  of 
those  who  could  be  available  at  a  moment's  notice.  Neither 
she  nor  they  had  long  to  wait. 

It  may  be  both  interesting  and  profitable  just  here  to 
pause  for  a  moment  to  compare  conditions  at  this  time  with 
those  which  existed  at  the  outbreak  of  the  Civil  War.  We 
find  that  trained  nursing  as  we  know  it  today  had  no  exist- 
ence then,  and  though  Congress  in  August,  1861.  authorized 
the  employment  of  women  as  nurses,  these  were  chosen 
more  on  account  of  their  matronly  age  and  manners  than 
because  of  any  special  qualification  for  their  work.  Miss 
Dorothea  Lynde  Dix  held  the  position  of  superintendent  of 


280  International  Congress  of  Nurses 

these  nurses,  althoug-h  that  appointment  carried  with  it  no 
definite  official  status.  Indeed,  a  notable  proportion  of  the 
nursing  during  the  Civil  War  was  done  by  women  who  were 
never  officially  appointed  or  paid. 

On  May  10  (nineteen  days  after  the  formal  declaration 
of  war)  the  Surgeon-General  of  the  Army  ordered  four 
nurses  to  Key  West,  Fla.,  and  by  July  15  forty-seven  nurses 
had  entered  into  contract  with  the  government  and  had  been 
assigned  to  different  general  hospitals. 

About  this  time  an  epidemic  of  yellow  fever  offered  an 
opportunity  for  the  employment  of  immune  nurses.  The 
Surgeon-General  detailed  Mrs.  Curtis,  the  wife  of  the  super- 
intendent of  the  Freedman's  Hospital  of  Washington,  D.  C, 
to  go  South  to  secure  these.  No  distinction  of  color  or  sex 
was  made,  and  most  of  those  selected  were  untrained. 

Following  close  upon  this  epidemic  of  yellow  fever 
came  one  of  typhoid  in  the  large  camp  hospitals  where  the 
recruits  were  in  training,  and  Dr.  McGee  thus  describes  the 
existing  conditions  at  that  time :  "  It  became  evident  that 
these  camp  hospitals  had  lost  their  transitory  character  and 
become  stationary,  consequently  the  objection  to  the 
employment  of  women  as  nurses  in  them  had  practically 
ceased,  and  the  demand  for  trained  female  nurses  grew  to 
an  entirely  unexpected  proportion." 

The  roll  of  army  nurses  numbered  at  this  time  about 
one  thousand  names.  Not  only  did  they  go  to  general  and 
field  hospitals,  but  wherever  the  surgeon  in  charge  of  a 
division  or  post  hospital  so  requested  nurses  were  assigned 
to  duty  under  him.  During  the  fall  it  was  not  uncommon 
for  regiments  or  larger  divisions  of  troops,  when  they  moved 
to  southern  camps  or  to  Cuba,  to  take  with  them  the  nurses 
attached  to  their  hospitals,  and  no  inconvenience  or  diffi- 
culty has  been  reported  as  having  ensued. 

It  is  needless  to  refer  to  the  great  value  of  the  work 
done  by  these  trained  assistants  to  the  medical  department 
of  the  army,  since  surgeons,  patients,  and  the  public  at  large 
have  been  most  enthusiastic  in  their  expressions  of  appre- 
ciation.    There  was  scarcely  a  training  school  in  the  United 


Army  Nursing  281 

States  which  did  not  send  some  of  its  best  representatives 
for  this  work,  and  the  women  adapted  themselves  to  camp 
conditions  in  a  manner  which  quite  altered  many  a  precon- 
ceived opinion. 

The  Sisters  of  Charity  merit  prominent  mention  in  this 
connection,  as  they  furnished  from  their  order  two  hundred 
sisters,  many  of  whom  had  had  a  large  hospital  experience. 
A  few  of  the  sisters  from  four  other  Roman  Catholic  orders 
and  from  one  Protestant  Episcopal  sisterhood  served  for  a 
time. 

Auxiliary  No.  3  to  the  American  National  Red  Cross 
Society  Relief  Committee  of  New  York  was  unique  in  the 
work  of  furnishing  money  for  the  transportation  of  many 
nurses,  also  for  their  comfort  while  awaiting  orders  in  New 
York  and  while  serving  at  certain  army  hospitals. 

There  was  much  difficulty  in  the  time  of  the  greatest 
stress  in  securing  enough  suitable  applicants  to  meet  the 
demands.  At  some  of  the  more  important  points  the  chief 
surgeons  were  authorized  to  secure  help  without  regard  to 
training,  and  thus  a  few  undesirable  appointees  were 
enrolled.  Temporary  assistance  was  also  accepted  from 
women  not  connected  with  the  medical  department.  Such 
irregular  nurses  were  not  subject  to  the  same  control  and 
discipline  as  those  on  regular  duty,  and  here  again  was  an 
opening  through  which  some  who  proved  to  be  undesirable 
gained  admission  to  the  corps. 

The  beginning  of  the  year  1899  found  the  work  of  sub- 
stituting trained  for  untrained  immune  nurses  well  begun. 
From  this  point  the  evolution  of  the  Army  Nurse  Corps, 
from  an  experiment  to  an  effective  working  organization, 
was  a  matter  of  steady  and  uninterrupted  development,  and 
while  it  is  at  the  present  time  on  a  comparatively  satisfactory 
basis  there  are  yet  many  points  which  must  be  readjusted 
before  it  can  be  said  to  have  attained  to  its  greatest  possibili- 
ties. It  must  also  be  remembered  that  there  is  naturally  a 
wide  divergence  of  opinion  as  to  what  is  really  to  be  desired 
for  it — between  the  point  of  view  of  the  lawmakers  on  the 
one  hand  and  others  most  deeply  interested  on  the  other. 


282  International  Congress  of  Nurses 

When  Section  19  of  the  Army  Reorganization  Bill  was 
first  drawn  up,  though  its  details  were  most  carefully  con- 
sidered, the  most  vitally  important  was  to  secure  for  it  a 
place  upon  the  statute ;  the  finer  work  of  fitting  and  adjust- 
ing it  to  meet  existing  conditions  could  well  be  left  for  the 
future.  With  the  signing  of  the  bill  by  the  President 
(February  2,  1901),  this  great  achievement  was  accom- 
plished, and  the  Nurse  Corps  became  a  part  of  the  medical 
department  of  the  United  States  Army.  While  this  new 
dignity  involves  the  corps  in  some  temporary  complications, 
it  will  eventually  result  to  its  great  advantage. 

The  new  law  inaugurated  some  important  changes,  i.  e. : 

1.  The  Judge  Advocate  General  has  recently  rendered 
a  decision  that  the  members  of  the  Nurse  Corps  must  be 
regarded  as  a  component  part  of  the  army  of  the  United 
States,  and  he  adds:  "There  is  considerable  ground  for 
belief  that  they  are  subject  to  the  articles  of  war  and  are 
triable  by  courts-martial." 

2.  Provision  was  made  for  the  appointment  of  a 
trained  nurse  as  superintendent,  who  under  the  Surgeon- 
General  should  have  charge  of  the  administrative  work  of 
the  corps.  Mrs.  Dita  H.  Kinney  was  appointed  by  the 
Secretary  of  War  to  fill  this  position  March  15,  1901. 

3.  The  nurses  were  no  longer  under  contract,  but  were 
appointed  by  the  Surgeon-General  with  the  approval  of  the 
Secretary  of  War. 

4.  Their  pay  passed  from  the  medical  to  the  pay 
department  of  the  arm3^ 

The  important  work  of  drafting  the  new  regulations 
has  been  a  matter  of  many  months.  As  these  stand,  pro- 
vision is  made  for  certain  examinations  to  test  the  mental, 
moral,  physical,  and  professional  qualifications  of  each 
applicant.  And  just  here  I  beg  to  make  a  most  heartfelt  and 
sincere  acknowledgment  to  the  superintendents  of  the 
various  training  schools  for  their  valuable  and  valued  assist- 
ance in  this  regard.  Had  it  not  been  for  this  cooperation 
it  is  not  too  much  to  say  that  the  most  important  and 
difficult  work  of  selecting  suitable  and  proper  nurses  from 


Army  Nursing  283 

among  the  large  number  of  applicants  could  not  have  been 
accomplished.  Each  of  these  has  been  and  is  today 
accepted  or  rejected  in  accordance  with  the  recommendation 
of  the  superintendent  of  nurses  under  whom  she  was  trained. 

After  appointment  a  nurse  is  required  to  give  a  term  of 
service  of  at  least  four  months  in  the  United  States  before 
being  assigned  to  foreign  duty.  The  term  of  service  has 
been  increased  from  one  year  to  three,  the  tour  of  foreign 
duty  from  one  year  to  two. 

The  records  of  the  corps  are  most  accurate  and  com- 
plete. Those  referring  to  the  efficiency  of  the  nurses  with 
their  papers  of  application  and  recommendation  are  filed  in 
the  office  of  the  corps.  Other  documents  which  bear  upon 
their  places  of  service,  change  of  status,  and  official  orders 
are  carded  and  filed  with  other  official  papers  in  the  record 
room  of  the  Surgeon-General's  office,  where  they  are  easily 
accessible  when  needed. 

Efficiency  reports  are  prepared  quarterly  by  each  chief 
nurse  and  forwarded  by  the  commanding  officer  of  each 
hospital,  who  endorses  thereon  his  approval  or  disapproval 
of  the  ratings.  In  the  same  way  (by  endorsement)  he 
reports  upon  the  efficiency  of  the  chief  nurse.  Special 
efficiency  reports  are  required  whenever  a  nurse  changes 
her  station  or  upon  her  discharge  from  the  service.  In  all 
cases  the  text  of  these  reports,  by  whom  made,  with  the 
dates  of  leaves,  illness,  payments,  and  all  other  data  con- 
cerning each  nurse,  are  noted  upon  a  card  and  alphabetically 
filed.  By  this  arrangement  it  is  possible  to  have  at  a 
moment's  notice  all  information  connected  with  every  case. 
Monthly  returns  are  prepared  by  the  commanding  officer. 
On  these  appear  all  changes,  i.  e.,  gains  or  losses  by  transfer, 
with  the  date  of  the  last  payment  of  each  nurse.  All  papers 
are  forwarded  through  the  chief  surgeon  of  the  division  or 
department,  and  endorsed  by  him  as  approved  or  otherwise. 

During  the  present  year  the  medical  department  has 
deemed  it  advisable  to  abandon  the  use  of  the  Red  Cross, 
and  has  adopted  in  place  of  it  the  cross  of  the  department 
in  its  own  color,— i.  e.,  green.     The  white  brassard  worn 


284  International  Congress  of  Nurses 

by  the  privates  of  the  hospital  corps  is  replaced  by  this,  and 
the  badge  of  the  Army  Nurse  Corps  will  hereafter  be  in 
green  instead  of  red  enamel.  The  red  Greek  cross  on  a 
white  field  will  still  be  used  on  hospital  flags,  hospital  ships, 
and  ambulances  authorized  and  required  by  the  Geneva 
treaty. 

There  have  been  approximately  eight  thousand  applica- 
tions since  the  first  one  was  made  to  the  War  Department. 
Of  these  sixteen  hundred  and  eighty  have  been  employed 
by  the  government.    The  largest  number  serving  at  any  one 

time  was  twelve  hundred  in  September,  1898. 

The  number  of  nurses  on  duty  at  the  present  time  is 

somewhat  less  than  at  this  time  last  year.  In  1900  there 
were  two  hundred  and  ten  against  one  hundred  and  seventy- 
six  in  1901.  Twenty-eight  appointments  were  made  in  the 
latter  year.  Of  these  thirteen  had  given  previous  satisfac- 
tory service,  fifteen  were  new.  Sixty-two  have  been  dis- 
charged ;  of  these  ten  are  doing  private  work  in  the 
Philippines,  one  has  accepted  a  teacher's  position  in  the 
same  place,  four  have  requested  discharge  to  be  married. 
The  rest  have  left  the  service  for  various  reasons,  such  as 
long  term  of  service,  family  conditions,  and  impaired  health. 

There  have  been  but  fifteen  deaths  among  the  members 
of  the  corps  since  the  beginning  of  the  Spanish-American 
war.  Most  of  these  were  from  typhoid  fever  and  some  from 
■disabilities  which  existed  .  before  the  nurse  entered  the 
service. 

On  September  1,  the  distribution  of  nurses  was  as 
follows :  United  States — San  Francisco,  thirty-six ;  Fort 
Bayard,  nine ;  Cuba,  six ;  Philippines,  ninety-three ;  trans- 
ports, eleven;  awaiting  discharge,  seven. 

Under  ordinary  conditions  the  Surgeon-General  does 
not  approve  the  placing  of  nurses  at  small  post  hospitals, 
chiefiy  because  of  the  difficulty  of  securing  suitable  accom- 
modations for  them.  A  commanding  officer  is  at  liberty, 
however,  to  request  the  temporary  assignment  of  female 
nurses  in  any  emergency.  Under  this  provision  nurses 
were  recently  sent  to  Fort  Sam  Houston,  Texas,  and  to 
Eenicia  Barracks,  California. 


Army  Nursing  ^85 

For  a  time  there  were  nurses  in  both  China  and  Japan, 
but  the  need  for  hospitals  in  those  places  no  longer  exists, 
and  they  have  been  closed. 

The  employment  of  nurses  in  the  schools  of  instruction  • 
for  the  hospital  corps  has  been  a  most  gratifying  success. 
Beginning  as  dietists,  their  work  was  at  first  confined  to 
teaching  the  preparation  of  food  for  the  sick  and  the  adap- 
tation of  the  rather  unpromising  "  ration  "  to  this  use.  In 
some  places  the  work  has  been  extended  to  include  a  course 
in  general  nursing,  bed-making,  the  changing  of  bed  and 
body-clothing  of  a  patient  in  bed,  the  preparation  of  the 
ordinary  antiseptics  and  disinfectants,  with  a  glimpse  into 
the  germ  theory  and  the  rigorous  requirements  of  aseptic 
surgery.  These  subjects  are  fully  and  most  carefully  covered 
by  the  lectures  of  the  doctors  in  charge,  the  practical  demon- 
strations being  given  by  these  nurse  teachers. 

The  question  of  the  rank  of  the  nurses  is  an  interesting 
one,  but  by  no  means  of  as  great  importance  as  may  at  first 
appear.  One  who  is  a  lady  will  never  be  denied  that  which 
belongs  to  a  lady  and  what  is  due  her  as  such.  Indeed,  if 
all  nurses  had  always  been  ladies  and  had  always  conducted 
themselves  as  such,  the  question  would  never  have  been 
brought  up  at  all !  This  is  only  one  more  exemplification  of 
the  truth  so  often  observed,  that  the  many  must  often  sufifer 
for  the  mistakes  of  the  few.  It  is  a  noteworthy  fact,  how- 
ever, that  in  the  examinations  of  candidates  for  admission 
to  the  nursing  service  of  the  English  army  one  of  the  ques- 
tions asked  of  a  referee  is,  "  Has  the  applicant  the  birth, 
breeding,  and,  education  to  make  her  an  acceptable  member 
of  a  profession  which  is  made  up  of  ladies?"  The  regard  in 
which  our  English  army  nurse  sisters  are  held  was  finely 
exemplified  by  the  attentions  paid  a  party  of  American 
nurses  at  Malta.  The  transport  on  which  they  were  on 
duty  was  temporarily  detained  in  that  harbor.  During  this 
time,  a  ball  was  given  by  the  English  officers  and  their 
wives  to  which  the  officers  on  board  ship  and  the  nurses 
were  invited.  Nothing  could  have  exceeded  the  charming 
cordiality  and  hospitality  of  this  occasion.     I  am  sure  the 


286  International  Congress  of  Nurses 

solution  of  this  whole  matter,  as  well  as  of  many  others  of 
far  greater  importance,  lies  in  the  hands  of  the  nurses  them- 
selves. As  they  sow,  so  shall  they  reap.  If  they  have  this 
fact  ever  before  their  minds,  it  must  only  be  a  question  of 
time  when  they  will  be  unquestioningly  accorded  the 
position  which  cultivation  and  good  breeding  may  always 
claim,  and  to  which  as  members  of  a  high  and  noble  pro- 
fession they  are  entitled. 

But  there  is  yet  another  aspect  to  the  situation  which 
must  not  be  forgotten.  The  Nurse  Corps  is  yet  in  its 
infancy,  and  the  present  nurses  are  in  reality  pioneers  in  the 
work.  They  must  decide  whether  as  such  they  are  willing 
to  put  up  with  temporarily  unpleasant  things  for  the  sake  of 
the  work  itself  and  for  the  sake  of  those  who  will  follow  and 
reap  the  rewards  of  their  forbearance.  Few  of  those  whose 
feet  are  breaking  new  paths  find  the  walking  pleasant  or 
easy,  and  the  recognition  of  such  service  is  more  often 
delayed  than  promptly  accorded.  But  the  "  patient  waiter 
is  no  loser,"  and  the  reward  will  surely  come  to  the  Army 
Nurse  Corps  even  if  those  who  made  sacrifices  are  no  longer 
members  of  it. 

A  recommendation  looking  towards  an  amelioration  of 
many  misatisfactor)^  conditions  is  now  before  the  Surgeon- 
General,  who  never  turns  a  deaf  ear  where  the  interests  of 
his  nurses  are  concerned. 

Besides  these  open  questions  we  dream  of  the  time 

1.  When  there  shall  be  a  regularly  established  post- 
graduate course  for  army  nurses,  such  as  now  exists  at 
Netley,  England. 

2.  When  frequent  visits  of  inspection  of  the  nursing 
service  will  be  possible,  thus  keeping  headquarters  in  close 
touch  with  the  nursing  staff  of  each  and  every  hospital. 

3.  When  the  Quartermaster's  Department  will  carry 
the  materials  for  the  nurses'  uniforms,  so  that  these  may  be 
tmiform  in  fact  as  well  as  in  name.     And,  best  of  all, 

4.  When^  after  faithful  service,  old  and  otherwise  inca- 
pacitated nurses  will  be  "  retired  "  with  suitable  provision 
for  their  declining  years.     This  is  not  too  much,  we  think, 


Army  Nursing  287 

to  ask  of  the  country  to  whose  service  they  have  given  them- 
selves, their  work,  and  their  Hves. 

Perhaps  the  most  important  detail  connected  with  the 
administration  of  the  Nurse  Corps  remains  yet  to  be  men- 
tioned. I  refer  to  the  reserve  list.  Only  those  who  have 
given  at  least  six  months  of  entirely  satisfactory  service  are 
eligible  for  a  place  on  this  roll  of  honor.  When  a  nurse  is 
offered  a  place  on  this  list  she  is  allowed  to  indicate  whether 
she  is  willing  to  re-enter  the  service  at  any  time  when  she 
may  be  needed,  or  only  in  case  of  war  or  national  calamity. 

A  nurse  is  dropped  from  the  reserve  on  attaining  the 
age  of  forty-five,  or  if  she  ceases  to  practice  her  profession 
for  a  continuous  period  of  five  years,  or  for  cause :  though 
in  the  latter  case  she  is  always  given  a  hearing. 

A  place  on  this  list  is  the  highest  distinction  an  army 
nurse  can  achieve,  and  we  look  forward  to  the  time  when  to 
know  a  nurse  is  an  "  army  reserve  "  will  be  considered  a 
sufficient  recommendation  without  further  endorsement. 

The  objections  which  were  at  first  offered  to  the  admis- 
sion of  women  as  nurses  in  army  hospitals  have  been 
gradually  overcome.  They  have  been  found  to  meet  priva- 
tion cheerfully,  and  to  adapt  themselves  readily  to  the  vary- 
ing conditions  incident  to  army  service,  particularly  in  new 
fields. 

In  a  report  to  the  Surgeon-General  a  chief-surgeon 
says :  "  The  female  nurses  have  done  excellent  service  here. 
Their  influence  on  both  the  sick  and  the  well  has  been  a 
good  one,  and  they  have,  as  a  rule,  been  discreet  in  conduct, 
amenable  to  discipline,  and  possessed  of  professional  attain- 
ments of  a  high  order." 

On  the  other  hand  it  is  most  gratifying  to  note  the 
unmistakable  evidences  given  by  the  nurses  of  their  love 
for  and  their  deep  interest  in  their  work.  One  who  was  a 
veritable  pioneer  writes :  "  It  is  very  hard  for  me  to  see  the 
others  starting  for  foreign  duty  and  be  obliged  to  stay 
behind.  But  I  know  I  have  had  more  interesting  work  than 
any  who  go  now  can  ever  have.  I  can  never  forget  some 
of  my  army  hospital  experiences.     The  memory  of  the  old 


288  International  Congress  of  Nurses 

dirty  wards,  with  their  filthy  corners  and  the  half-fed 
patients,  will  always  remain  with  me.  When  I  think  that 
it  has  been  my  privilege  to  lend  a  hand  in  improving-  all  this, 
I  feel  very  sure  that  there  is  no  profession  on  earth  which 
so  fully  repays  all  labors  as  our  own.  Then  too  a  woman's 
influence  means  so  much  in  the  strange  foreign  lands — it 
may  be  for  good,  or  it  may  be  for  evil.  Do  let  us  try  to  send 
nothing  but  the  best." 

And  so  she  goes  on  through  a  long  letter.  That  there 
have  been  a  few  in  the  corps  whose  influence  has  not  been 
for  all  that  was  highest  and  best  we  recall  with  all  humilia- 
tion and  regret,  because  there  is  no  getting  away  from  the 
fact  that  the  disgrace  of  one  of  our  members  is  the  disgrace 
of  all.  All  things  considered,  however,  it  seems  little  less 
than  miraculous  that  such  records  have  been  so  exceptional. 
As  a  profession  we  have  good  reason  to  be  proud  of  the 
achievements  of  the  Army  Nurse  Corps  as  a  body,  and  of 
the  work  of  its  members  as  individuals. 

I  beg  in  closing  to  bespeak  for  it  in  future  the  interest 
and  the  cooperation  of  all  trained  nurses.  Its  work  con- 
cerns deeply  every  training  school  in  the  country,  and  its 
efficiency  and  fair  name  must  in  the  very  nature  of  things 
be  a  source  of  solicitude,  just  as  its  successes  must  be  a 
matter  of  pride  to  every  individual  representative  of  these. 

And,  finally,  all  will  agree  that  the  very  best  service 
which  her  loyal  daughters  can  furnish  is  not  too  much  for 
us,  as  a  profession,  to  place  at  the  disposal  of  our  beloved 
country. 


The  Establishment  of  Schools  for  Nurses  in 

Cuba. 

M.  EUGENIE  HIBBARD, 

Member  of  the  American  Society  of  Superintendents  of  Training  Schools  for 
Nurses,  and  Superintendent  of  the  Santa  Isabel  Hospital,  Matanzas,  Cuba. 


With  the  United  States  mihtary  occupation  of  the 
island  of  Cuba,  a  countr}'  so  crossed  and  barred  by  events 
in  its  previous  history,  began  a  new  regime,  difificult  for  the 
people  of  tropical  climes  to  appreciate,  and  possibly  more 
difficult  for  them  to  imitate  and  sustain. 

The  conditions  were  such  in  1898  that  vigorous  efforts 
were  imperative  to  make  the  island  habitable  for  those  who 
were  forced  or  chose  to  remain  in  Cuba,  aside  from  the 
population  whose  heritage  it  is. 

At  once  energetic  minds  set  to  work  to  evolve  order 
out  of  chaos,  and  enforce  a  sanitary  administration  that 
would  eventually  and  effectually  relieve  the  country  of  filth, 
disease  and  the  dread  scourge  yellow  fever,  which  limited 
the  ingress  of  foreigners,  enforcing  quarantine  laws 
extremely  trying  to  travelers  and  proving  a  serious  menace 
to  the  business  interests  and  development  of  the  island. 

It  was  also  essential  to  arouse  the  inhabitants  from  their 

apathy  to  a  sense  of  their  personal  national  responsibilities, 

substituting  the  practical  for  the  sentimental  in  actual  work, 

which  only    could  be  accomplished    by    enlisting  them  as 

co-workers  with  those  whose  knowledge  had  been  secured 

through  experience,  and  to  whom  today  the  greatest  credit 

should  be  generously  given  for  the  excellent  results. 

289 


'200  International  Congress  of  Ahirses 

-According-  to  the  latest  record,  Havana,  the  city  of  the 
island,  has  only  one  rival  in  the  United  States,  in  producing 
a  lower  death  rate. 

In  Cuba,  as  in  most  countries  that  have  been  dominated 
by  strong  religious  views  and  where  the  government  has 
been  practically  led  b}-  the  Church,  a  condition  existed  that 
prevented  women  from  taking  an  active  part  in  philan- 
thropic work,  outside  the  religious  orders  of  Sisters  of 
Charity  or  members  of  the  various  communities  recognized 
by  the  Church.  These  Sisters,  among  whom  there  are 
always  some  excellent  women,  had  charge  of  the  nursing 
and  domestic  departments  to  the  various  state  institutions, 
such  as  hospitals,  orphan  asylums  and  asylums  for  the  poor 
and  destitute,  and  were  considered  the  legitimate  persons  to 
carry  on  such  work. 

Unfortunately  their  vows  restricted  them  in  the  per- 
formance of  duties  that  are  considered  an  important 
essential  in  the  care  of  hospital  patients,  and  which  duties 
were  delegated  to  persons  of  inferior  position  and  ability  to 
perform. 

The  strides  that  the  medical  profession  has  made  in  the 
line  of  progress  during  the  last  twenty-five  years  has 
demanded  an  evolution  in  the  ranks  of  the  so-called  nurse, 
and  in  countries  where  the  religious  orders  do  not  rule  the 
graduate  nurse  is  the  result. 

A  similar  one  we  hope  shortly  to  produce  here — edu- 
cated and  trained  on  lines  that  will  command  the  respect 
of  the  older  sisters  in  the  service  of  nursing. 

As  inheritors  of  customs  and  prejudices,  founded  on 
Moorish  habits,  we  find  the  women  of  Cuba  an  affectionate, 
emotional  and  irresponsible  people,  without  much  moral, 
mental  or  physical  force,  incapable  of  sustained  effort,  and 
most  to  be  deplored,  without  ideals  or  standards  that  excel, 
but  with  an  innate  sense  of  refinement  and  a  disposition  to 
be  led  through  their  affections  which  is  most  gratifying  if 
properly  directed. 

The  lack  of  education  among  the  larger  class  of  women 


Schools  for  Nurses  in  Cuba  291 

in  the  ordinary  brandies,  or  even  the  rudiments  of  Spanish. 
is  an  obstacle  which  is  difficult  to  overcome  or  overlook. 

Out  of  this  material  (with  the  optimistic  view  predomi- 
nating) we  hope  to  evolve  the  traditional  calm,  self-poised, 
intelligent,  industrious  and  ambitious  graduate  nurse  of  the 
twentieth  century. 

Therefore  upon  whosoever  the  duty  falls  of  introducing 
new  ways,  imperceptibly  though  radically  changing  social 
customs,  facing  the  traditions  of  the  country,  and  to  a  cer- 
tain extent  the  opposition  of  the  Church,  an  exquisite  tact 
is  required,  which  should  be  controlled  by  common  sense, 
good  judgment  and  a  strong  desire,  for  the  moment,  to 
work  in  harmony  with  existing  conditions,  with  the  end  in 
view  of  creating  a  picture  of  life  and  its  possibilities,  for 
women,  that  will  both  entice  and  charm,  and  be  a  factor 
strong  enough  to  overcome  scruples  that  at  present  prevent 
women  of  education  and  refinement  from  taking  an  active 
part  in  a  life  savoring  of  publicity. 

With  the  passing  of  the  religious  to  the  secular  regime, 
and  the  subsequent  v\athdrawal  of  the  "Sisters''  from  the 
various  hospitals,  the  establishment  of  schools  for  nurses 
became  an  absolute  necessity  to  provide  for  the  inmiediate 
care  of  the  sick. 

The  first  school  for  nurses  in  Cuba  was  started  by  Dr. 
Raimundo  Menocal  in  connection  with  the  Sanitarium 
"  Havana."  in  the  city  of  Havana.  It  was  opened  in 
January.  1899.  with  twenty-two  pupils,  under  the  charge 
and  theoretical  instruction  of  Dr.  \'idal  Sotolongo.  The 
sanitarium  was  closed  in  the  month  of  May,  the  same  year. 
The  permanent  establishment  of  the  schools  for  nurses, 
however,  is  due  to  the  interest  and  influence  of  Dr.  C.  L. 
Furbush  and  General  Ludlow,  assisted  ably  by  Drs.  Emilano 
Nuney  and  Raimundo  Menocal.  The  first  school  for 
nurses  was  officially  established  and  opened  August.  1899. 
:\Iiss  Mary  O'Donnell,  graduate  of  Bellevue  Hospital.  New 
York  City,  was  appointed  superintendent. 

Later,  and  under  the  direction  of  Major  E.  St.  j. 
Greble,    Superintendent   of  the    Department    of    Charities 


292  International  Congress  of  Nurses 

(which  is  under  the  general  supervision  of  the  Department 
of  State  and  Government),  schools  for  nurses  were  estab- 
lished in  connection  with  the  following-  hospitals  named  in 
chronological  order: 

Hospital  Civil,  Cienfuegos,  March,  1900;  Aliss  Jeanette 
Byers,  superintendent. 

Hospital  No.  1,  Havana,  September,  1900;  Miss  Ger- 
trude W.  Moore,  superintendent. 

Hospital  Santa  Isabel,  Matanzas,  October,  1900;  Miss 
M.  E.  Hibbard,  superintendent. 

Hospital  General,  Puerto  Principe,  November,  1900; 
Miss  Mitchell,  superintendent. 

Hospital  General,  Remedios,  November,  1900 ;  Miss 
Samson,  superintendent. 

Hospital  Civil,  Santiago  de  Cuba,  January,  1901;  Miss 
G.  W.  Moore,  superintendent. 

Making  a  total  of  seven.  Changes  have  taken  place  in 
the  supervision  of  some  of  the  schools,  but  the  names  given 
were  the  first  superintendents  appointed. 

On  the  retirement  of  Major  E.  St.  J.  Greble  from  the 
position  of  Superintendent  of  the  Department  of  Charities, 
Major  J.  R.  Kean  received  the  appointment  and  the  subse- 
quent success  of  the  schools  is  due  largely  to  his  personal 
interest  and  keen  appreciation  of  the  actual  requirements  at 
this  stage  of  the  schools'  existence.  Shortly  after  assuming 
office,  in  July,  1901,  the  following  order  was  issued : 

Office  Superintendent  Dept.  Charities. 
Circular  No.  14. 

Havana,  Cuba,  July  i6,  igoi. 

By  authority  of  the  Military  Governor,  a  Board  will  be 
convened  to  meet  in  the  office  of  the  Superintendent  of 
Charities,  Havana,  Cuba,  at  twelve  o'clock,  July  22,  1901,  or 
as  soon  thereafter  as  practicable,  to  draw  up  a  system  of 
regulations  for  the  Training  Schools  for  Nurses  in  Cuba. 
They  will  also  fix  the  course  and  duration  of  instruction,  the 


Schools  for  Nurses  in  Cuba  293 

requirements  for  admission,  the  standard  to  be  required  be- 
fore graduation,  and  make  recommendations  with  regard  to 
salaries  and  allowances.  The  Board  will  also  recommend 
a  suitable  manual  for  use  in  the  nurses'  schools  and  in  the 
hospitals  under  state  control. 

The  Board  will  be  composed  as  follows : 

Dr.    Manuel    Demn,    Vice-President    of   the    Central 
Board  of  Charities,  of  Cuba,  Havana. 

Dr.    Emeliano    Nufio,    Medico-Director   of    Mercedes 
Hospital,  Havana. 

Dr.  Enrique  Diago,  Medico-Director,  Hospital  No.  1, 
Havana. 

Airs.  L.  W.  Quintard,  Inspector,  Department  of  Chari- 


ties. 


Miss  M,  Eugenie  flibbard,  Superintendente,  "  Escuela 
de  Enfermeras,"  Matanzas. 

The  Superintendent  of  Charities  will  issue  the  necessary 
transportation. 

J.  R.  Kean, 

]\Iajor  and  Surgeon,  U.  S.  Army,  Superintendent  Depart- 
ment of  Charities. 


The  meetings,  several  in  number,  were  well  attended, 
and  at  the  end  of  the  month  of  August,  1901,  a  "  Plan  of 
General  Regulations  for  the  Schools  for  Nurses  of  the 
Island  of  Cuba  was  submitted  for  the  approbation  of  the 
Central  Board  of  Charities  of  the  Island  of  Cuba." 

Later  in  the  month  of  October,  1901.  these  were  made 
more  comprehensive,  and  somewhat  modified,  and  again 
submitted  for  approval.  Eventually  on  January  3,  1902, 
the  plan  was  approved  of  in  its  entirety  by  the  Military 
Governor  of  the  Island  of  Cuba,  General  Wood. 


294  International  Congress  of  Nurses 

REGULATIONS  FOR  THE  SCHOOLS  FOR  NURSES  IN  CUBA. 

The  aim  and  fixed  intention  of  those  interested  in 
organizing-  Schools  for  Nurses  in  Cuba  was  to  put  them  at 
once  on  the  highest  plane  attainable,  giving  the  result  of 
similar  work  in  other  countries  as  sufficient  reason  to 
establish  a  standard  tliat  would  at  once  command  the 
respect  of  the  people  and  the  self-respect  of  the  accepted 
student,  defining  emphatically  a  position  for  the  nurse  in 
a  country,  until  recently,  ignorant  of  her  existence.  To  start 
with  a  high  standard  is  a  more  effectual  way  of  securing 
success  than  in  placidly  allowing  conditions  to  evolve. 

The  science  of  nursing  has  passed  the  pioneer  stage  and 
has  now  a  foundation  firm  as  a  rock.  Hand  in  hand  with 
the  medical  profession  (as  hand  maiden  of  it)  it  claims 
respect  for  the  assistance  it  gives  to  suiifering  humanity  and 
to  the  advance  of  medical  research.  To  those  who  have  so 
earnestly  and  so  wisely  encouraged  the  work  of  nursing  in 
Cuba,  the  profession  owes  a  heavy  debt  of  gratitude,  for 
without  the  assistance,  interest  and  concentrated  effort  of 
men  of  influence  and  prestige  and  the  hearty  support  of  the 
Cuban  doctors  of  reputation  and  influence,  the  work  that 
has  been  accomplished  in  Cuba  could  never  have  given  to 
the  world  the  history  of  its  existence.  Today  the  number 
of  pupils  in  training  exceeds  150,  with  at  least  37  instruct- 
ors— American  graduates. 


No.  3. 

Headquarters  Department  of  Cuba. 

Havana,  Cuba,  January  ■^,  igo2. 

The  Military  Governor  of  Cuba,  upon  the  recommenda- 
tion of  the  Superintendent,  Department  of  Charities, 
directs  the  publication  of  the  following  Regulations  for  the 
Schools  for  Nurses  of  the  Island  of  Cuba : 


Schools  for  Nurses  in  Cuba  295 

I.  The  Schools  for  Nurses  are  created  in  the  Island  of 
Cuba  with  power  to  issue  diplomas  to  the  crraduate,  showing- 
their  fitness  to  practice  their  profession. 

II.  The  Schools  for  Nurses  will  be  classified  as  State 
institutions  and  will  be  under  the  immediate  supervision  of 
the  Department  of  Charities. 

III.  The  rules  and  regulations  published  herewith 
will  govern  the  establishment  and  management  of  the 
Schools  for  Nurses,  and  all  special  regulations  enacted  by 
the  Boards  of  Alanagers  for  the  interior  administration  of 
hospitals  to  which  such  schools  may  be  annexed  will  con- 
form to  these  rules. 

H.  L.  Scott, 
Adjutant  General. 


Preamble. 

The  object  of  these  schools  shall  be,  first,  to  further  the 
best  interests  of  the  nursing  profession  by  establishing  and 
maintaining  a  universal  standard  for  instruction  and  provid- 
ing students  with  the  proper  means  of  education  in  the 
practical  care  of  the  sick ;  second,  to  secure  for  the  students 
upon  graduation  a  degree  or  title  which  will  be  a  protection 
in  practicing  their  profession  and  be  a  recognized  means  of 
securing  employment ;  third,  to  provide  hospitals  and  insti- 
tutions in  the  island  with  skilled  service  in  the  nursing- 
department  and  proper  number  of  graded  assistants,  thus 
conferring  a  benefit  to  the  mass  of  sufifering  humanity. 

Tlie  Schools  for  Nurses  are  State  institutions,  attached 
to  hospitals  for  mutual  benefit,  but  under  the  direct  control 
of  the  Department  of  Charities.  The  director  of  the 
hospital  shall  be  the  immediate  representative  of  the  Depart- 
ment in  the  school,  and  the  treasurer  of  the  hospital  shall 
be  also  the  treasurer  of  the  school.  Separate  estimates  for 
the  schools  shall  be  prepared  and  signed  by  the  director  and 
the  treasurer. 


296  International  Congress  of  Nurses 

General  Regulations  for  the  Schools  for  Nurses 
OF  THE  Island  of  Cuba. 


Chapter  I. 

ESTABLISHMENT   OF  SCHOOLS. 

Article  1.  Schools  for  Nurses  may  be  established  in 
all  cities  of  the  island  where  there  are  public  hospitals  con- 
taining more  than  one  hundred  beds,  whatever  their 
classification  may  be,  subject  to  the  provisions  established 
in  this  g-eneral  plan  of  regulations,  after  previous  approval 
by  the  Department  of  Charities,  and  inscription  in  the 
School  of  Medicine  of  the  University  of  Havana. 

Article  2.  The  schools  will  be  governed  by  the  internal 
regulations  of  the  institution,  except  where  said  regulations 
are  contrary  to  the  rules  established  in  this  plan.  The 
schools  shall  not  comprise  less  than  twenty  students. 

Article  3.  The  heads  of  the  schools  will  be :  First,  the 
medical  director ;  second,  the  superintendent ;  and,  next, 
the  graduate  nurses  who  may  be  designated  to  act  as  assist- 
ants to  the  superintendent. 

Article  4.  A  committee  consisting  of  three  members 
of  the  Central  Board  of  Charities,  appointed  by  the  same ; 
a  professor  of  the  School  of  Medicine,  appointed  by  the 
dean ;  and  a  graduate  nurse  holding  no  position  in  any 
school,  but  having  previously  filled  the  position  of  superih- 
tendent,  designated  by  the  Department  of  Charities,  will 
deal  with  all  affairs  of  a  general  character  affecting  the 
schools.  All  correspondence  will  be  transmitted  through 
the  Department  of  Charities.  This  committee  will  meet 
regularly  once  a  month,  and  will  hold  special  meetings  as 
often  as  necessary. 

Article  5.  The  director  of  the  school  shall  designate 
the  professors  that  may  be  required  to  deliver  the  lectures 
referred  to  in  the  curriculum,  employing  the  doctors  in 
attendance  on  the  hospital,  and  all  those  who  may  be  willing 


Schools  for  Nurses  in  Ctiba  297 

to  do  so  without  receiving  any  remuneration  whatsoever  for 
such  work. 

Article  6.  The  course  of  instruction  in  each  school 
will  cover  a  period  of  three '  courses,  of  a  year  each,  in 
accordance  with  the  provisions  established  in  the  official 
plan  of  the  School  of  Medicine.  Nevertheless,  any  student 
may  be  admitted  to  examination  for  the  first  year,  provided 
she  has  previously  completed  a  course  of  five  months'  study. 

Article  7.  At  the  expiration  of  the  first  and  second 
courses,  the  examinations  will  take  place  before  a  board 
consisting-  of  two  professors  belonging  to  the  hospital, 
designated  by  the  director,  and  presided  over  by  him  or  his 
delegate.  Said  board  will  make  the  students  acquainted 
with  the  list  of  subjects  of  the  examination  fifteen  days  in 
advance. 

Article  8.  The  qualifying  degrees  on  the  capacity  and 
knowledge  of  the  students  will  be:  Good,  very  good, 
rejected.  They  will  be  awarded  by  a  majority  of  votes.  The 
director  will  issue  to  each  student  a  certificate  of  the  results 
obtained  from  her  examination,  filing  with  it  her  personal 
documents. 

Article  9.  At  the  expiration  of  the  third  course,  the 
examination  will  take  place  before  a  board  consisting  of 
three  professors  of  the  School  of  Medicine  and  Pharmacy, 
appointed  by  the  dean  of  the  faculty.  The  oldest  professor 
will  preside.  The  degrees  in  this  examination  will  be  those 
established  in  the  regulations  of  the  School  of  Medicine  and 
will  be  noted  in  the  documents  of  the  student,  to  be  kept  on 
file  in  the  Department  of  Charities. 

Article  10.  The  examinations  corresponding  to  the 
third  year,  will  take  place  in  the  capital  of  each  province,  or 
in  those  cities  where  a  large  number  of  students  exist,  on 
the  dates  fixed  by  the  dean  of  the  faculty  of  medicine,  who 
will  notify  the  directors  of  the  schools  and  the  members  of 
the  board  designated  by  them  in  advance,  in  order  that  they 
may  take  the  necessary  measures.  The  expenses  incurred 
by  the  members  of  the  board  shall  be  paid  by  the  Depart- 
ment of  Charities  and  Hospitals.    The  amount  assigned  to 


298  International  Congress  of  Nurses 

cover  said  expenses  will  be  $8  g'old  daily  and  free  transpor- 
tation. 

Article  11.  The  examinations  will  be  public  and  the 
Department  of  Charities  will  provide  the  building. 

Article  12.  After  the  examination  of  the  third  course, 
the  dean  of  the  faculty  will  issue  a  diploma  to  each  student, 
whose  exercises  have  been  approved,  which  diploma  shall 
state  that  said  student  is  admitted  to  the  practice  of  the 
profession  of  nursing.  Said  diploma  will  merit  all  authori- 
ties, as  well  from  the  courts,  the  respect  and  consideration 
due  all  professional  titles.  Without  this  diploma,  the  prac- 
tice of  the  profession  of  nursing  is  not  allowed.  Each 
school  will  award  a  silver  medal  to  every  student  who 
obtains  the  diploma  of  nurse. 

Article  13.  The  students  who  may  not  pass  the  first 
examination  shall  have  a  right  to  request  a  repetition,  but 
on  a  second  failure  they  shall  be  dismissed  from  the  school. 

Article  14.  The  students  whose  perseverance  and  con- 
tinued good  conduct  has  distinguished  them  from  their 
companions  during  the  three  years,  will  be  awarded  a  special 
gold  medal,  if  so  accorded  by  two-thirds  of  the  number  of 
professors  belonging  to  the  institution  assembled  for  the 
purpose  by  the  director  of  the  same,  provided  he  and  the 
superintendent,  who  will  be  present  at  the  meeting,  deem 
any  student  worthy  of  said  prize.  The  design  of  the  medal 
will  be  determined  by  the  Department  of  Charities,  and  will 
be  paid  for  with  funds  of  the  same. 


Chapter  II. 


ADMISSION    TO   THE   SCHOOL. 


Article  15.  AH  applicants  for  admission  as  students  to 
the  Schools  for  Nurses  shall  apply  by  writing  to  the  director 
of  the  hospital  to  which  the  school  is  annexed,  filling  the 
form  of  application  adjoined,  enclosing  with  it  a  letter  from 
a  respectable  person  certifying  as  to  her  moral-  character, 


Schools  for  Xitrscs  in  Cuba 


299 


and  antecedents,  and  another  letter  from  a  doctor  certifying 
as  to  her  good  heaUh.  If  she  is  a  minor  she  must  also 
enclose  written  permission  from  her  parents  or  guardians. 
If  the  applicant's  certificate  meets  the  approval  of  the 
director,  he  will  endorse  it  with  his  recommendation  to  the 
superintendent,  who  will  admit  her  definitely  after  a  month 
of  probation,  during  which  she  shall  receive  nothing  else  at 
the  expense  of  the  schools  but  board,  lodging  and  Taundry. 
This  admission  will  be  notified  to  the  Department  of  Chari- 
ties. 

Article  16.  The  age  for  admission  shall  be  from  18 
to  36  years.  The  applicant  may  be  admitted  when  there 
is  only  a  difference  of  a  few  months  before  she  attains  the 
eighteen  years,  provided  she  has  a  strong  constitution.  A 
moderate  education  is  indispensable  for  admittance  into  the 
schools.  To  ascertain  this,  the  superintendent  will  examine 
the  students  whenever  she  may  deem  it  convenient. 

Article  17.  Applicants  may  be  admitted  any  time 
during  the  year,  but  the  course  of  instruction  will  not  be 
considered  complete  until  the  three  years  of  practical  course 
have  expired,  counting  from  the  date  of  admission  and 
taking  into  account  the  month  of  probation. 

Article  18.  The  students  can  be  suspended  for  misde- 
meanor or  incapacity  whenever  the  director  and  superin- 
tendent may  deem  that  they  deserve  it,  notifying  the 
Department  of  Charities  of  such  action  and  motives  thereof. 

Article  19.  The  students  will  receive  as  remuneration 
for  their  services  eight  dollars  per  month  during  the  first 
year,  twelve  dollars  during  the  second,  and  twenty-five 
dollars  gold  during  the  third.  Each  student  will  provide 
all  her  necessary  uniforms.  For  the  acquisition  of  these, 
the  school  will  assign  for  each  student  of  the  first  and  second 
years  thirty-six  dollars  yearly,  which  will  remain  in  the 
charge  of  the  treasurer  to  be  spent  when  the  superintendent 
may  deem  it  convenient.  Should  a  balance  remain  at  the 
end  of  the  year,  it  will  be  given  over  in  cash  to  the  nurse  to 
whom  the  amount  is  credited.  The  nurses  who  abandon 
the  school  lose  all  right  to  their  uniforms.     They  cannot  be 


300  International  Congress  of  Nurses 

worn  on  the  streets,  unless  when  rendering  service.  Laun- 
dry of  uniforms  shall  be  provided  for  all  the  students  at  the 
expense  of  the  school. 


Chapter  III. 

DUTIES   OF    THE   STUDENTS. 

Article  20.  All  students  are  obliged  to  reside  in  the 
schools.  The  hours  of  duty  for  students  will  be  divided 
between  day  and  night.  They  will  render  their  services 
eight  hours  during  the  day,  devoting  the  remaining  four 
hours  to  meals,  study,  recreation  and  rest,  and  twelve  hours, 
during  the  night,  taking  turns  in  such  a  manner  that  each 
student  may  be  able  to  render  her  services  approximately 
one  consecutive  month. 

Article  21.  During  the  first  two  years  the  students  will 
not  render  their  services  out  of  the  school.  During  the 
third  year,  they  will  be  able  to  do  so  during  a  period  which 
will  not  exceed  three  months,  whenever  the  director,  in 
accordance  with  the  superintendent,  may  deem  it  con- 
venient. When  the  services  are  rendered  to  the  sick  poor, 
a  special  agreement  will  be  made  with  the  municipal  authori- 
ties. If  attendance  is  rendered  to  private  individuals, 
outside,  three  dollars  daily  and  cost  of  transportation  will 
be  charged.  This  amount  will  be  paid  over  to  the  treasurer, 
and  after  deducting  a  certain  sum  which  the  school  may 
deem  wise  to  give  to  the  nurse  as  gratification,  the  balance 
remaining  will  be  kept  with  the  object  of  accumulating  a 
fund  destined  to  be  used  as  a  prize,  which,  in  accordance 
with  the  Department  of  Charities,  will  be  awarded  to  the 
student  who  may  be  deemed  worthy  of  such  a  distinction. 

Article  22.  Hospitals  having  no  school  for  nurses  in 
cases  of  emergency  can  apply  for  nurses  to  the  schools 
established  in  the  locality,  provided  they  pay  the  school 
annexed  to  the  hospital  in  which  they  render  their  services 
the  amount  decided  upon  as  gratification  and  the  cost  of 


Schools  for  Nurses  in  Cuba  301 

transportation.  The  students  who  are  employed  in  that 
capacity  will  figure  in  the  pay  roll  of  the  hospital  to  which 
the  school  is  annexed. 

Article  23.  Each  student  will  have  three  weeks'  vaca- 
tion every  year,  which  will  be  granted  to  them  by  turns  by 
the  superintendent  in  accordance  with  the  director. 

Article  24.  In  sickness,  all  students  shall  have  gratui- 
tous care;  but  the  time  lost  in  such  manner  shall  be  made 
up,  provided  said  time  exceeds  one  month  in  each  year. 

Article  25.  The  students  will  have  no  intercourse  with 
the  employees  other  than  a  strictly  professional  one.  Any 
infraction  of  this  order  will  be  severely  reprimanded,  and 
the  director  of  the  school  shall  be  held  responsible  for  such 
infringement. 


Chapter  IV, 

DUTIES   OF  THE   SUPERINTENDENT   AND    HER    ASSISTANTS. 

Article  26.  The  superintendent  shall  be  a  graduate 
nurse  of  a  school  of  established  reputation,  and  must  pre- 
sent her  credentials  and  satisfactory  references  from  the 
school  from  which  she  proceeds.  She  will  be  appointed  by 
the  Department  of  Charities,  in  accordance  with  the 
director. 

Article  27.  The  superintendent  shall  have  the  super- 
vision and  direct  control  of  the  school.  She  shall  be  author- 
ized to  accept  the  applicants  after  the  month  of  probation, 
notifying  their  admission  to  the  Department  of  Charities, 
through  the  director.  She  shall  in  like  manner  send  a  writ- 
ten report  of  the  motives  which  prompted  her  to  reject  any 
applicant  whom  she  may  not  deem  desirable.  She  shall 
keep  a  record  book  of  admissions  and  rejections,  which  will 
be  always  at  the  disposal  of  the  director. 

Article  28.  She  shall  be  authorized  to  suspend  any 
student  for  misdemeanor,  notifying  the  director  so  that  he 


302  International  Congress  of  Nurses 

may,  after  considerino^  the  necessary  information,  approve 
or  disapprove  her  action. 

Article  29.  She  shall  send  to  the  Department  of  Char- 
ities every  three  months  a  written  statement  of  the  assiduity, 
attendance  and  conduct  of  each  student,  and  forward  to  the 
School  of  Medicine  and  Pharmacy  a  statement  of  the  num- 
Ijer  of  students  inscribed  in  each  course.  Before  the  final 
examination  she  must  send  in  a  complete  report,  contain- 
ino-  all  necessary  information  with  rci^ard  to  the  documents 
and  practical  work  of  each  student. 

Article  30.  The  superintendent  shall  be  authorized  to 
purchase  all  articles  necessary  for  the  requirements  of  the 
school  when  it  is  independent  of  the  hospital.  Payments 
will  be  made  by  the  treasurer  on  approval  of  the  director. 
The  purchase  of  wearino-  apparel  for  the  nurses  will  be 
always  made  by  the  superintendent. 

Article  31.  She  shall  have  the  "general  supervision  of 
all  the  patients  in  the  hospital  in  accordance  with  the 
director.  She  shall  see  that  the  students  serve  in  turn  in 
the  dififerent  departments,  and  determine  those  who  are  to 
render  their  services  by  nij^ht  and  shall  be  responsible  to 
tiie  director  of  the  hospital  for  condition  of  cleanliness  of 
doors,  walls,  windows,  roofs  and  furniture  of  both  medical 
and  surgical  wards  and  operating  rooms,  as  well  as  the 
laundry  and  kitchen. 

Article  32.  She  will  receive  every  morning  the  report 
of  the  graduate  nurses  and  obtain  the  reciuisitions  for  the 
daily  reciuirements  transferring  the  report  and  recjuests  to 
tlie  medical  director  an  hour  in  advance. 

Article  33.  She  shall  every  night  before  retiring  give 
the  necessary  instructions  to  the  assistant  wdio  is  to  act  as 
night  superintendent,  and  obtain  from  her  in  the  morning 
a  written  report  of  all  the  night  occurrences.  She  shall 
refer  all  information  dealing  with  the  patients  to  the  doctor 
in  attendance  on  the  ward,  and  those  dealing  with  affairs 
in  general  to  the  director. 

Article  34.     She  shall  not  absent  herself  from  the  hos- 


Schools  for  Nurses  in  Cuba  303 

pital    during-   the   day   without   notifying  the   director  and 
designating  an  assistant  to  take  her  place. 

Article  35.  She  shall  attend  the  lectures  delivered  by 
the  professors  to  the  students  and  review  and  correct  the 
notes  taken. 

Article  36.  She  shall  give  weekly  lectures  to  the  stu- 
dents, on  the  practical  knowledge  they  must  possess  for  the 
proper  discharge  of  their  duties  and  practice  of  their  pro- 
fession. 

Article  37.  She  shall  supervise  all  the  assistant  nurses 
in  their  departments,  and  will  notify  the  director  of  any 
fault  committed.  She  will  inspect  the  distribution  of  food  to 
the  nurses  and  patients  of  the  hospital,  seeing  that  the 
instructions  of  the  director  are  complied  with. 

Article  38.  Whenever  a  case  of  contagious  disease 
occurs,  she  shall  take  all  proper  precaution  to  isolate  it  and 
disinfect  all  the  linen;  soliciting  from  the  director  anv 
order  which  may  be  necessary. 

Article  39.  To  assist  her  in  the  proper  discharge  of 
all  the  duties  mentioned,  she  will  have  under  her  orders  at 
least  four  assistants,  graduate  nurses,  one  to  have  com- 
plete charge  of  the  operating  room,  one  to  act  as  night 
superintendent  and  the  remainder  to  render  their  services 
in  the  medical  and  surgical  wards.  The  night  superinten- 
dent shall  receive  more  salary  than  the  others,  considering 
the  kind  of  service  which  she  renders.  The  assistants  shall 
have  charge  of  the  instruction  of,  the  students  in  their 
respective  sections  and  comply  with  all  the  instructions 
received  from  the  superintendent.  They  shall  not  leave 
the  building  without  first  obtaining  permission  from  the 
superintendent,  nor  pass  the  night  out  of  the  institution. 
They  shall  enjoy  a  day  vacation  every  week  by  turns.  If 
sick  for  more  than  a  month,  the  amount  exceeding  it  will 
be  discounted  from  their  services. 

The  assistants  will  be  appointed  in  the  same  manner 
as  the  superintendent. 


304  International  Congress  of  Nurses 

Chapter  V. 

THEORETICAL  INSTRUCTION. 

Article  40.  The  theoretical  instruction  will  cover  three 
terms :  the  school  term  will  be  from  the  first  of  October 
to  the  first  of  June,  and  the  examinations  will  be  held  dur- 
ing the  latter  part  of  the  last  month. 


Official  Curriculum  Schools  for  Nurses. 


THEORETICAL  INSTRUCTION  FROM  OCTOBER  TO  JUNE. 

FIRST  YEAR. 

Professional  discipline. 

Anatomy :    Skeleton,  Bones,  Articulation  and  Muscles. 

Hygiene  and  Bacteriology:  Action  of  the  Bacteria. 
Disinfection  and  Isolation. 

Outlines  of  Physiology. 

Materia  Medica:  Metric  System,  Medicines  and  their 
administration ;  Drugs  and  classification. 

Surgical  Practice :  Asepsis  and  Antisepsis,  Cicatriza- 
tion, Accidents  of  penetrating  and  general  wounds. 

Preparation  of  nourishment  for  the  sick. 

Services  to  Children ;  State  at  birth.  Physiological 
changes  ;  Growth  and  development ;  Morbid  predisposition  ; 
Infant  Mortality ;  Care  of  a  Healthy  Child ;  Nourishment 
for  a  Healthy  Child,  and  for  a  Sick  Child. 

SECOND   YEAR. 

Anatomy:  Digestive  Apparatus,  Circulatory,  Respira- 
tory, Glandular  System,  Excretory  and  Nervous  Apparatus. 

Outlines  of  Physiology. 

Hygiene  and  Bacteriology :  Air,  Water,  Hygiene^ 
Materia  Medica,  Poisons,  Antidotes,  Hypodermic  In- 
jections, Hydrotherapies;  Medical  Practice,  instruction  in 


Schools  for  Nurses  in  Cuba  305 — 

general  observations  (elementary  clinics)  of  the  patients' 
symptoms,  temperature,  pulse  and  respirations,  etc.,  chart 
keeping,  etc. 

Surgical  Practice:  Care  before,  during,  and  after  the 
operation  ;  Care  in  special  operations. 

THIRD   YEAR. 

Gynecology. 

Obstetrics :  Care  of  the  woman  during  pregnancy, 
confinement,  and  afterwards ;  care  of  the  new-born  child. 

Surgical  Practice:  Anesthesia,  dressings  and  band- 
ages; services  rendered  in  surgical  wards. 

Medical  Practice:  Analysis  of  the  urine,  care  of  dis- 
eases of  the  digestive,  circulatory,  respiratory,  ner\^ous,  and 
urinary  organs,  and  contagious  diseases. 

Eyes,  Skin,  Ears,  Throat,  and  Xose :  Anatomy,  care 
in  health  and  sickness,  post-operative  care,  special  cases. 

Practice  of  Massage. 

Article  41.  The  superintendent  will  issue  to  each 
student  a  tri-monthly  statement  of  her  services  in  accord- 
ance with  the  following  form  : 

Name    

Date  of  admission  to  School 

Wards  in  which  they  have  served  during  the 

three    months 

Behavior    i 

Interest   Manifested    

Aptness  for  observation 

Punctuality 

Application    

Disposition    

Cleanliness 

Order    

Amiability    

Peculiarities   

Distinction  in  Character 

Distinction  in  Work   


306                International  Congress  of  Nurses 
Faults  Committed  in  Work 

Faults  in  Character 

Improvement    

Remarks 

Date 

(Signature) 


FORM    OF  APPLICATION. 

The  answers  to  the  questions  shall  be  written  in  the 
applicants'  own  handwriting. 

Name,  surname,  and  address  of  applicant.  .  .  . 

Civil   condition    

What  has  been  your  occupation 

Height Weight 

I  What  education  have  you  received,  and 
where? 

r 

1 

Age Date,  and  place  of  birth 

i  Have  you  been  in  any  other  school  for 
nurses?    

Are  you  strong  and  healthy? 

Is  your  sight  and  hearing  perfect? 

I  Have  you  any  physical  imperfections  or  de- 
fects?    

Have  you  a  vaccination  certificate? 

W'hat  acute  diseases  or  surgical  operations 
have  you  suffered,  and  on  what  date? 

Have  you  read  and  clearly  understood  the 
regulations  of  the  school?    


Date 

(Signature) 


Indian  Army  Nursing  307 

The  President :  Our  next  paper  is  on  the  Indian  Army 
Nursing  Service,  by  Miss  Arkle,  delegate  from  and  Nurs- 
ing Sister  in  that  Service,  who  has  been  sent  to  this  country 
by  the  EngHsh  government.  She  has  very  kindly  loaned  us 
some  photographs,  showing  Army  nurses  in  their  uniforms. 
They  are  to  be  handed  out  to  the  audience  if  they  will 
promise  to  bring  them  back. 


The  Indian  Army  Nursing  Service. 

ANNIE  ARKLE, 
Delegate  Indian  Army  Nursing  Service. 


The  Indian  Army  Nursing  Service  was  initiated  by  that 
good  friend  of  the  British  soldier,  Lord  Roberts,  in  1888, 
and  although  it  has  only  been  .in  existence  14  years,  there 
has  been  a  great  advance  in  the  understanding  of  nurses, 
and  nursing  in  India,  and  of  the  necessity  for  nursing  and 
in  the  care  given  to  sick  soldiers,  now  acknowledged  to  be 
necessary  for  them. 

Candidates  for  the  service  apply  to  the  Under  Secretary 
of  State  for  India,  and  must  have  had  at  least  three  years' 
training  in  a  Civil  General  Hospital.  The  service  is  com- 
posed of:  1st,  lady  superintendents,  of  whom  there  are 
four  (one  in  each  command),  and  nursing  sisters,  of  whom 
there  are  between  50  and  60.  We  are  an  integral  part  of 
the  military  medical  department,  and  are  subject  to  court 
martial  in  the  usual  way.  Promotion  of  nursing  sister  to 
lady  superintendent  is  made  by  the  principal  medical 
officer  of  bis  Majesty's  forces  in  India  on  .the  grounds  of 
experience,  administrative  capacity,  and  personal  fitness. 
Last  year  six  (I  think)  of  our  sisters  were  sent  to  China 
when  the  war  broke  out. 

The  duration  of  a  term  of  service  is  five  years,  after 
which  time  the  sister  is  entitled  to  one  year's  furlough  out 
308 


Indian  Army  Nursing  309 

V  of  India  on  two-thirds  pay  with  free  passage  from  and  to 
her  station.  At  the  end  of  five  years  she  can  leave  the  ser- 
vice or  sign  an  agreement  to  return  for  another  term.  In 
the  event  of  her  leaving  after  the  first  term  she  will  receive 
a  gratuity  of  500  rupees  (about  $150).  After  the  second 
term  the  bonus  is  increased  to  1,500  rupees  (about  $450). 
The  gratuity  given  to  the  lady  superintendent  is  propor- 
tionately higher.  If  she  agrees  to  return  she  receives  two- 
thirds  pay  while  on  furlough.  Should  she  leave  before  her 
first  term  of  service  is  completed  (for  any  cause  save  sick- 
ness) she  will  be  obliged  to  pay  the  sum  of  £25  ($120)  or 
give  six  months'  notice  and  pay  £20  ($100). 

After  15  years'  service  the  sister  receives  a  pension  of 
about  $250  per  annum.  After  20  years'  service  this  pension 
is  increased  to  about  $300,  with  an  addition  for  every  year's 
service  as  lady  superintendent. 

In  addition  to  free  quarters,  fuel,  light  and  punkah 
pullers,  the  lady  superintendent  receives  300  rupees  a 
month ;  the  nursing  sister,  175  rupees.  When  she  becomes 
"senior  sister"  in  a  station  where  there  is  no  lady  superin- 
tendent, she  receives  200  rupees.  There  is  always  a  small 
compensation  allowance  varying  with  the  rate  of  exchange ; 
pony  allow-ance  of  30  rupees  a  month  is  allowed  on  field 
service,  provided  a  pony  be  kept. 

The  lady  superintendent  has  control  over  all  the  sisters 
in  her  command.  Once  every  year  she  visits  the  nursing  staff 
of  all  hospitals  in  her  command  for  the  purpose  of  inspec- 
tion, and  afterwards  submits  a  full  report  on  the  manner  in 
which  each  sister  has  done  her  duty,  which  reaches  the  prin- 
cipal medical  officer  of  his  Majesty's  forces  in  India  through 
the  prescribed  channel.  Should  the  report  not  be  favorable 
it  must  be  shown  to  the  sister  concerned,  who  has  the 
opportunity  of  making  an  appeal,  and  has  the  right  to  have 
the  matter'enquired  into  by  a  board  of  officers  in  the  usual 
way.  The  senior  nursing  sister  does  the  housekeeping  and 
is  responsible  that  order  and  regularity  be  carried  out  in 
the  quarters  and  in  the  w^ards. 


310  International  Congress  of  Nurses. 

When  a  new  sister  arrives  at  a  station  she  usually  pays 
an  entrance  fee  for  the  use  of  crockery,  cutlery,  glass,  etc., 
in  fact  for  all  those  things  we  require  in  the  quarters  not 
provided  by  the  government.  This  is  very  hard  on  a  sister 
who  is  moved  often  from  station  to  station,  and  much 
expense  would  be  spared  the  sisters  if  the  government 
would  grant  a  small  amount  yearly  to  cover  these  expenses. 

The  hours  of  the  sisters  on  duty  vary  in  some  stations. 
As  a  rule,  there  are  three  sisters  in  one  station.  No.  1  sis- 
ter comes  on  duty  at  7  a.  m.  and  remains  till  2  p.  m.  No.  2 
comes  on  at  2  and  stays  till  8  p.  m.  or  9  when  there  is  anyone 
very  seriously  ill  in  the  ward.  No.  2  again  comes  on  the 
next  morning  at  7  a.  m.,  while  No.  3  is  doing  night  duty 
from  9  p.  m.  to  7  a.  m.  Night  duty  we  take  for  a  week  in 
turn. 

During  the  term  of  five  years  the  sister  is  allowed  two 
months'  privilege  leave  on  full  pay.  She  can  also  occas- 
ionally get  (if  convenient)  10  days'  station  leave,  and  some- 
times even  three  days'  district  leave  is  given.  Sick  leave, 
up  to  a  maximum  of  six  months,  is  allowed  during  the  term 
of  five  years.    This  leave  must  be  taken  in  India. 

For  each  ward  with  an  average  of  25  beds  there  are 
two  orderlies.  The  orderly's  relief  is  changed  every  six 
hours,  and  in  most  stations  there  are  four  reliefs.  Some- 
times, when  special  orderlies  are  required,  there  are  as  many 
as  18  or  20  doing  duty  in  the  wards  where  the  sisters  work. 
Before  the  orderly  gets  his  certificate  he  is  put  through  a 
course  of  stretcher  drill  by  the  medical  officer,  after  which 
(if  he  passes  his  examination)  his  nursing  certificate  is 
given,  signed  by  the  medical  officer  and  the  sister  in  charge. 
One  great  difficulty  in  training  orderlies  is  the  little  time 
one  sometimes  has  in  which  to  do  it. 

Frequently  from  stations  where  there  are  no  sisters, 
men  are  sent  from  the  regiments,  and  are  expected  to  be 
efficient  nurses  at  the  end  of  three  months.  This  clearly  is 
impossible,  and  the  certificates  are  not  worth  much.  Now, 
in  stations  where  there  are  sisters,  the  orderlies  are  gen- 
erally allowed  to  remain  for  quite  twelve  months,  only  being 


Indian  Army  Nursing  314 

called  into  the  regiment  once  for  about  a  fortnight  for  his 
musketry  training.  At  the  end  of  the  year,  if  the  man  is 
intelligent,  conscientious,  and  fond  of  his  work,  it  is  sur- 
prising how  capable  a  nurse  he  makes.  I  have  seen  some 
men  most  excellent.  If  he  is  not  a  suitable  man  in  every 
way  he  can  always  be  returned  to  the  regiment  and  another 
man  sent  in  his  place. 

In  addition  to  the  practical  training  given  in  the  wards 
the  senior  sister  holds  a  class  about  once  a  week  on  the 
general  principles  of  nursing.  Very  often  orderlies  remain 
three  and  even  four  years  in  the  wards  at  their  own  request. 

Native  servants  do  the  roughest  of  the  work  in  the 
wards. 

I  think  it  is  quite  impossible  to  point  out  the  great 
good  done  by  the  influence  of  women  in  the  wards  (they 
must  be  first-class  women,  both  technically  as  nurses,  and 
as  ladies),  and  the  good  tone  introduced  by  nurses  fresh 
from  the  perfection  of  management  of  a  civil  hospital  at 
home. 

From  my  own  experience  I  find  the  orderlies  much 
better  and  more  willing  to  learn  than  I  ever  expected.  I 
have  seen  them  infinitely  gentle  when  handling  a  sick  com- 
rade, and  soldiers,  when  sick,  behave  most  splendidly; 
always  grateful  and  cheerful.  In  our  wards  all  the  cases 
are  acute — when  convalescent  they  go  to  the  other  wards; 
when  chronic,  they  come  home  to  Netley. 

When  there  are  many  cases  and  the  work  is  heavy 
(which,  by  the  way,  is  almost  always  in  most  stations)  the 
sister,  in  addition  to  her  ordinary  duties,  has  just  got  to 
help  the  orderlies,  and  sponging  patients  with  the  ther- 
mometer 112°  in  the  shade  is  not  easy  work,  and  you  can 
imagine  how  persistently  one  has  to  sponge  or  ice-pack 
in  a  hot  climate,  and  how  imperative  it  is  in  cases  of  heat- 
stroke and  fever.  Yes.  after  some  months  of  this  work  one 
does  so  long  for  the  delights  of  the  cool  Himalayas,  and 
with  what  a  sigh  of  relief  one  wakes  up  the  first  morning 
of  the  60  days'  privilege  leave.  It  is  astonishing  how  many 
of  the  ordedies  prefer  remaining  in  the  furnace  below  to 


o 


12  International  Congress  of  Nurses 


what  they  describe  as  "  climbinq^  them  khiuls  "  (khud  means 
a  mountain  side). 

The  sugg-estions  I  would  make  are : 

1.  That  a  messing  allowance  be  granted. 

2.  That  the  number  of  sisters  be  increased,  so  that 
no  military  station  be  without  them. 

3.  That  the  sick  leave  might  be  extended  to  leave  in 
England,  or  a  sea  voyage  if  the  medical  officer  considers 
it  essential,  the  government  to  provide  the  passage  both 
ways.  At  the  present  time  our  sick  leave  must  be  taken 
in  the  countrx*.  and  I  think  we  all  agree  that  India  is  not 
generally  chosen  as  a  health  resort. 

At  the  same  time,  our  service  is  young,  and  already 
the  government  has  made  many  reforms,  and  scarcely  a 
year  passes  that  one  does  not  find  some  alteration  for  the 
better,  and  I  am  sure  in  time  it  will  be  almost  perfect.  Our 
quarters  are  always  large  and  comfortable,  the  pay  is  good, 
the  amount  of  leave  is  most  generous,  and  there  is  a  pen- 
sion at  the  end  of  our  service,  and  there  is  that  home-feeling 
one  has  in  one's  quarters  surrounded  by  one's  little  gods. 
One  can  keep  a  pony,  trap,  or  bicycle,  and  one  can  have 
one's  live  pets  about  one.  This  to  an  English  woman  who 
is  an  animal  lover  means  a  great  deal,  and  I  think  a  real 
change  is  so  good  for  one.  When  off  duty  we  can  putter 
around  in  the  garden  or  go  down  to  the  club  and  play  ten- 
nis, or  to  the  links  and  play  golf :  and  I  think  a  good  canter 
across  the  country  is  about  the  best  medicine  I  know  of  for 
a  weary  nurse.  After  it  one  goes  on  duty  so  fresh.  I  take 
it — to  remember  the  men,  and  give  them  of  our  very  best 
when  on  duty,  we  must  try  to  forget  them  when  off  duty. 

Now,  I  fear  you  will  be  disappointed  with  my  paper, 
but  I  have  not  the  power  to  show  you,  unless  you  come 
to  India,  how  the  temperature  can  drop  30°  in  30  minutes, 
neither  can  I  explain  to  you  how  good  a  patient  the  British 
soldier  is  under  the  most  trying  conditions.  We  do  our 
best  to  keep  him  comfortable  in  the  hot  weather,  and  it  is 


Indian  Army  Xiirsing  313 

sometimes  impossible  with  the  heat,  the  flies,  and  the 
mosquitoes.  I  cannot  take  you  up  to  the  hills  and  ask  you 
away  up  to  the  favorite  spot,  to  watch  the  gflory  of  the 
sunrise,  nor  stand  spellbound  at  the  grandeur  of  the  sunset 
when  all  the  hosts  of  Heaven  surely  must  be  down  there 
over  the  plains  where  are  the  most  gorgeous  billows  of 
clouds  as  far  as  one  can  see.  One  just  expects  to  hear  the 
trumpet  call,  when  we  awake  and — "  'tis  gone  and  all  is 
Gjav.'' 


The  Work  of  the  Indian  Army  Nursing  Service. 


MISS  WATT, 
Allahabad,  India. 


In  attempting-  to  give  a  brief  account  of  the  Indian 
Army  Nursing  Service,  its  advantages  and  disadvantages, 
in  a  way  which  may  possibly  be  helpful  to  some  intending 
candidate,  two  difficulties  present  themselves :  first,  it 
is  almost  impossible  to  give  an  accurate  picture  of  Anglo- 
Indian  life  to  those  who  are  strangers  to  it ;  in  the  second 
place,  it  must  never  be  forgotten  that  fifteen  years  have  to 
be  spent  in  anv  part  of  India,  and  no  one  can  foretell  the 
effects  of  climate  on  the  health. 

Fifteen  years'  hard  labor  in  a  trying  climate  ought  only 
to  be  attempted  by  the  vigorous  and  strong.  A  weakly, 
delicate  woman  is  not  only  a  burden  to  herself,  but  a  source 
of  never-ending  anxiety  to  her  superiors,  while  her  work 
must  necessarily  be  less  well  done,  however  excellent  her 
intentions. 

All  the  rules  and  conditions  of  the  service  are  clearly 
laid  down  in  a  small  blue-book  issued  half  yearly.  This  in 
itself  is  no  small  advantage,  as  before  engagement  all  the 
rules  can  be  studied  and  each  candidate  can  be  sure  of  the 
nature  of  her  agreement. 

Application  for  admission  is  made  in  the  first  instance 
to  the  Under  Secretary  of  State  for  India,  Indian  Office,  S. 
W.,  and  a  form  is  received  which  must  be  accurately  filled  up 
and  returned  with  the  numerous  necessary  certificates 
attached. 

If  the  candidate  be  accepted,  she  receives  fifteen  pounds 
outfit  allowance  (which  is  quite  insufficient),  and  she  will 
314 


Indian  Army  Nursing  3X5 

probably  be  ordered  to  embark  on  a  transport  about  a 
month  after  appointment. 

Pay  begins  from  date  of  embarkation,  with  the  addition 
of  exchange  compensation  allowance,  and  the  deduction  of 
income  tax  (which  always  seems  an  unnecessary  hardship). 
The  pay  averages  one  hundred  and  eighty  rupees  per  month, 
about  eleven  and  a  half  pounds  English  money.  This  sounds 
high,  but  it  must  be  remembered  that  board  is  not  included. 
The  sisters  receive  from  government  free  "  furnished  "  quar- 
ters, fuel,  lights  and  punkah  coolies,  but  no  allowance  for 
messing. 

The  quarters  allotted  are,  as  a  rule,  convenient  and 
comfortable.  Each  sister  has  a  bedroom,  dressing-room, 
and  bath-room,  in  some  cases  a  private  sitting  room, 
besides  a  general  drawing-room  and  dining-room  for  com- 
mon use.  "  Furnished  "  quarters  means  that  the  heavier 
articles  of  furniture,  beds,  tables,  wardrobes,  chairs,  etc., 
are  supplied  by  government  in  each  station.  All  cooking 
utensils,  crockery,  table  and  bed  linen,  cutlery,  plate,  and 
glass  have  to  be  found  by  the  sisters,  and  this  is  a  somewhat 
serious  tax  on  the  pay. 

It  is  usual  for  the  senior  sister  to  do  all  the  housekeep- 
ing, and  either  make  a  monthly  charge  for  supplying  all 
household  necessaries  or  charge  each  newcomer  an 
entrance  fee,  the  money  being  devoted  to  replacing  worn- 
out  things  and  breakages.  The  messing  bills  may  be  taken 
to  amount  to  fifty  rupees  per  month  as  an  average.  If  gov- 
ernment could  be  induced  to  grant  one  hundred  rupees 
yearlv  to  each  establishment  of  nursing  sisters  much  trou- 
ble  would  be  saved. 

We  will  now  suppose  that  the  new  sister  has  arrived 
in  India,  and  (to  take  an  ordinary  case)  that  she  forms  one 
of  three  sisters  working  in  a  station  hospital.  One  sister 
will  be  on  night  duty  for  a  week,  her  hours  being  from  9 
p.  m.  to  7  a.  m.  Sister  No.  1  will  be  on  duty  from  7  a.  m. 
till  2  p.  m,  and  Sister  No  2  from  2  p.  m.  until  8  p.  m.,  unless 
there  are  very  acute  cases,  when  she  will  remain  until 
relieved  by  the  night  sister. 


316  International  Congress  of  Nurses 

These  hours  are  sHghtly  varied  in  dififerent  stations, 
but  the  above  is  a  very  usual  arrangement.  In  comparison 
with  a  London  hospital  nurse's  day  these  hours  seem  short, 
but  in  a  bad  climate  and  with  the  endless  worries  entailed 
b}^  working  with  orderlies  and  native  servants  the  work 
will  be  found  quite  sufficiently  fatiguing. 

Each  sister  is  entitled  to  two  months'  privilege  leave 
every  year  on  full  pay.  Three  days'  hospital  leave  and  ten 
days'  station  leave  can  often  be  obtained.  After  serving 
without  privilege  leave  for  two  years  and  nine  months, 
three  months'  leave  may  be  granted  to  allow  of  a  short  visit 
to  England.  After  five  years'  service  the  sisters  have  one 
year's  furlough  on  two-thirds  pay,  with  free  passage  out  and 
home. 

At  the  end  of  her  five  years  a  sister  may  retire  from  the 
service  with  a  gratuity  of  five  hundred  rupees ;  after  ten 
years'  service  fifteen  hundred  rupees  are  given,  and  after 
fifteen  years  a  pension  of  fifteen  pounds  may  be  hoped  for. 
After  twenty  years'  ser\'ice  a  pension  of  sixty  pounds  a  year 
is  promised,  but  it  seems  improbable  that  many  sisters  will 
serve  so  many  years. 

For  lady  superintendents  the  gratuities  and  pensions 
are  proportionately  higher,  but  as  there  are  only  four  lady 
superintendents,  a  sister's  chances  of  supplying  this  proud 
position  are  but  slender. 

The  senior  sister  in  each  station  receives  twenty-five 
rupees  per  month  extra,  a  small  enough  compensation  for 
the  worries  of  housekeeping. 

Once  a  year  the  lady  superintendent  inspects  each  sta- 
tion in  her  presidency,  and  writes  a  "  confidential  report " 
on  each  sister  as  to  the  manner  in  which  she  has  performed 
her  work,  whether  she  has  "  maintained  pleasant  relations  " 
with  the  other  sisters,  her  aptitude  for  training  orderlies, 
and  her  conduct  as  a  whole.  The  lady  superintendent  must, 
of  course,  be  guided  by  the  reports  of  the  medical  officer 
in  charge  and  of  the  senior  sister.  However,  one  golden 
rule  enjoins  that  if  the  report  be  unfavorable,  it  must  be 
communicated  to  the  sister  concerned,  so  if  she  thinks  that 


Indian  Army  Nursing  .'517 

any  injustice  has  been  done,  she  has  an  opportunity  for  rep- 
resenting her  side  of  the  case. 

The  sisters'  intercourse  with  the  medical  oflficers  will 
almost  invariably  be  pleasant;  as  a  rule  they  thoroughly 
appreciate  good  work,  and  the  prejudice  against  "  women 
in  military  hospitals"  is  almost  non-existent  in  India.  The 
person  with  whom  it  is  sometimes  difficult  to  work  har- 
moniously is  the  Eurasian  "  assistant  surgeon."  He  com- 
bines the  functions  of  a  dresser  and  a  dispenser,  and  is  sup- 
posed to  maintain  discipline  in  the  wards. 

But  while  all  the  above  conditions  of  service  are  fair, 
and  although  the  sisters'  Indian  life  may  be  in  every  way  a 
pleasant  and  useful  one,  there  are  at  present  some  grave 
drawbacks  in  the  Indian  military  hospital  system  which  are 
a  hindrance  to  successful  nursing  work. 

The  principal  changes  which,  in  the  writer's  opinion, 
ought  to  be  introduced  are :  (a)  in  the  training  of  orderlies  : 
(b)  in  the  army  native  hospital  corps. 

(a)  At  present,  a  rough,  uneducated  private  is  intro- 
duced into  a  ward  full  of  enterics.  At  the  end  of  three 
months  a  miraculous  change  is  supposed  to  have  boon 
effected,  whereby  the  man  is  fully  qualified  to  work  by  him- 
self in  charge  of  a  ward  in  some  hospital  where  there  are  no 
sisters. 

Why  should  an  uneducated  man  be  thought  capable  of 
learning  the  whole  art  of  nursing  in  three  months,  when  a 
well-educated  woman  cannot  be  trained  in  less  than  three 
years?  In  three  months  the  orderly  can  be  taught  to  fetch 
and  carry,  to  do  as  he  is  told,  and  to  be  a  fairly  useful  pair 
of  hands  while  working  under  a  trained  head.  But  tlu- 
training  of  orderlies  to  fit  them  for  independent  posts  should 
surely  be  prolonged  for  at  least  twelve  months.  Then  only 
the  exceptional  men,  possessing  the  moral  qualifications  of 
sobriety  and  intelligence,  should  be  given  certificates.  At 
present  the  orderly's  certificate  is  not  worth  the  paper  on 
which  it  is  written. 

(b)  The  army  hospital  native  corps  is  at  present  com- 
posed of  the  scum  of  the  bazaars,  insufificicntlv  paid,  work- 


318  International  Congress  of  Nurses 

ing^  under  impossible  conditions  (e.  g..  a  fine  of  two  annas 
per  month  can  be  deducted  once  only  during-  the  month  for 
grave  misconduct  among  the  lowest  grade).  Until  some 
radical  reform  takes  place  whereby  respectable  natives, 
properly  paid  and  severely  disciplined,  can  be  obtained,  the 
native  service  of  the  hospital  will  always  be  a  bar  to  really 
eflficient  work. 

The  chief  reforms  suggested  in  the  present  conditions 
of  the  working  of  the  service  are : 

(a)  That  a  messing  allowance  of  one  hundred  rupees  per 
annum  be  granted ; 

(b)  That  the  time  of  the  orderlies'  training  be  increased 
to  twelve  months  ; 

(c)  That  the  army  hospital  native  corps  be  remodelled 
so  as  to  secure  a  certain  measure  of  efficiency. 

In  conclusion,  the  Indian  army  nursing  service  ofTers 
every  prospect  of  happiness  and  congenial  work  to  a  well- 
trained,  strong,  and  healthy  woman.  The  drawbacks  which 
can  be  removed  are  minor  ones,  and  the  chief  drawback — 
that  of  hard  work  in  a  bad  climate — must  be  taken  into 
account  by  each  individual  candidate  before  entering  the 
service. 


Nursing  in  South  Africa  During  the  Boer  War, 

1899 — 1900. 


GEORGINA  FANE  POPE, 
Canadian  Nursing  Reserve. 


Reading  as  a  young-  girl  a  most  interesting  account  of 
Miss  Florence  Nightingale's  noble  work  during  the  Cri- 
mean war,  I  became  filled  with  the  desire  to  become  an 
*'  army  nursing  sister  "  and  go  to  the  front.  England  being 
happily  at  peace,  and  I  much  under  age,  I  was  obliged  to 
moderate  my  ardor ;  but  with  the  main  hope  still  uppermost. 
a  few  years  afterwards  I  entered  the  training  school  for 
nurses  attached  to  Bellevue  Hospital,  New  York.  Fourteen 
years  later,  viz. :  October  14,  1899,  I  received  my  appoint- 
ment, with  three  other  nurses,  to  go  out  with  the  Canadian 
contingent  then  called  to  active  service  in  South  Africa — 
thus  realizing  my  early  aspirations. 

Upon  our  arrival  at  Cape  Town  we  found  our  troops 
had  orders  to  proceed  up  country  immediately.  We  reported 
to  the  principal  medical  ofBcer,  making  every  effort  to  be 
allowed  to  accompany  them  to  the  front,  but  this  we  were 
told  was  impossible,  as  no  nursing  sisters  could  be  accom- 
modated in  the  field  hospitals.  So  with  very  disconsolate 
feelings  we  saw  our  countrymen  en  train  without  us.  and 
came  to  realize  at  that  early  date  what  served  us  in  good 
stead  later,  viz.:  that  we,  too,  were  soldiers,  to  do  as  we 
were  told  and  go  where  we  were  sent.  Later  in  the  day  we 
received  orders  to  proceed  to  Wynberg  for  duty  in  the  large 
base  hospital  there,  called  No.  1  General.  These  general 
hospitals,  of  which  there  were  thirteen  or  more,  were  most 
complete.  They  were,  as  a  rule,  under  canvas,  and  con- 
tained from  six  hundred  to  one  thousand  beds.  They  left 
England  with  a  staiT  of  surgeons,  sisters,  trained  orderlies, 
etc.,  and  a  full  equipment  of  everything  needful,  including 
the  comfortable  blue  flannel  hospital  kit  that  "Tommy  At- 
kins" wears  during  convalescence. 


320  International  Congress  of  Xnrses 

No.  1  (icncral  was  placed  at  Wynbcrp  liarracks  and 
miinbcred  about  one  thousand  beds.  No.  2  was  pitched 
under  canvas,  also  at  Wynberg,  and  No.  3  at  Rondebosch. 
about  six  miles  away,  close  to  Mr.  Cecil  Rhodes'  beautiful 
place,  "  Groot  Schnur."  Pitched  beside  No.  3  was  the  pri- 
vate hospitiil  sent  out  by  the  Duke  of  Portland,  and  the 
two  numbered  over  seven  hundred  beds.  The  private  hos- 
pitals were  almost  ideal  in  their  equipment,  havinrj  every 
comfort  for  the  patients,  beautifully  appointed  operatmii" 
tents.  X-ray  api)aratus.  etc.  There  were  four  larjj^e  jjeneral 
ho.spitals  at  the  Cape,  besides  the  Portland,  a  convalescent 
hospitals  for  officers  at  Claremont,  two  larije  rest  camps, 
and  two  hospitals  for  the  Pioer  prisoners  at  (irecnpoint  and 
Simon's  Town,  for  many  months  all  these  places  beinc^  full. 
At  Wynberg  we  found  our  services  jjjreatly  needed,  the 
wounded  from  Graspan  and  P>elmont  havinq;  recently  been 
broui^ht  down  in  lar.^e  numbers.  A  few  days  after  our 
arrival  a  larj^e  convoy  brouf^^ht  in  the  wounded  from 
Maj^ersfontein  and  Modder  river,  when  all  my  empty  beds 
were  filled  with  the  men  of  the  Hig^hland  P)rijTade,  which 
sufifered  so  severely  in  these  en<:^ag^ements.  (The  arrival 
of  this  convoy  was  a  most  pitiful  sic^ht,  many  of  the  men 
being  stretcher  cases,  shot  through  thigh,  foot,  or  spine. 
What  struck  one  most  was  the  wonderful  pluck  of  these 
l)Oor  fellows,  who  had  jolted  over  the  rough  veldt  in  ambu- 
lances and  then  endured  the  long  train  journey,  also  the 
utter  self-forgetfulness  of  everyone  else,  surgeons,  sisters, 
and  orderlies,  all  of  whom  worked  on  regardless  of  time  or 
hunger  until  everyone  was  as  comfortable  as  they  could 
be  made. 

Tommy  made  the  least  of  all  his  woes.  A  tlrink  first, 
then,  after  his  wounds  had  been  attended  to,  "A  bit  of 
tobacco  "  for  a  smoke,  and  a  piece  of  paper  to  "  Send  a  line 
so  that  they  won't  be  scared  at  home  ''  were  invariably  the 
first  requirements. 

During  this  early  period,  with  the  exception  of  sun- 
stroke and  rheumatism,  almost  all  the  cases  were  surgical, 
and  operations  would  continue  all  day  long  after  the  arrival 


Nursing  in  South  Africa  321 

of  a  fresh  convoy.  'Hie  X-rays  were,  of  course,  very  val- 
uable in  locatin^£^  bullets,  and  saved  Tommy  many  a  probe. 
I  have  not  yet  heard  the  statistics  of  the  wounded,  but  from 
my  own  experience  should  judge  that  the  percentage  of 
successful  surgical  results  was  very  high.  I  have  seen 
ghastly  shell  and  explosive  -bullet  wounds,  which  one  would 
think  must  surely  end  in  septicaemia,  make  perfect  recov- 
eries, while  head  cases,  spine  cases,  etc.,  sometimes  made 
seemingly  miraculous  cures.  One  saw  oftentimes  such 
wonderful  escapes!  I  had  a  patient — a  corporal  of  the 
West  Yorks,  mentioned  for  a  distinguished  service  medal 
— who  had  been  shot  through  the  jaw,  the  bullet  glancing 
up  sideways,  passing  through  the  eye  without  the  slightest 
injury  to  the  sight,  and  coming  out  of  the  rim  of  his  helmet ; 
another,  shot  like  Achilles,  in  the  heel,  the  bullet  lodging 
in  the  heel  of  the  boot,  making  a  unique  souvenir;  one 
which  passed  through  both  legs,  escaping  the  bone,  and 
hanging,  a  prisoner,  under  the  skin  of  the  left  leg;  while 
another  passed  through  a  man's  arm  and  found  a  resting 
place  in  the  purse  inside  his  haversack ;  others  flattened 
against  blessed  medals  worn  round  the  neck  and  watches 
in  the  tunic  pocket,  by  this  means  escaping  the  lungs  or 
heart.  After  a  month  spent  in  the  huts  at  Wynberg,  we 
went  under  canvas  at  Rondebosch,  experiencing  the  adven- 
tures of  camp  life  and  the  power  of  an  African  midsummer 
sun,  together  with  sand  storms,  rain  storms,  and  some- 
times a  too  intimate  acquaintance  of  scorpions  and  snakes. 
In  February  enteric  fever  cases  began  to  come  down. 
The  fever  was  generally  of  a  very  malignant  type,  being 
often  complicated  with  pneumonia  and  early  severe  head 
symptoms,  while  I  have  seen  the  body  so  covered  with 
spots  one  couldn't  put  the  proverbial  "  pin  "  between  them. 
The  treatment  was  generally  ice  caps,  sponge  baths,  and 
cold  packs  for  temperature,  poultices  for  pneumonia,  and 
ergotine  for  hemorrhages.  The  diet  was  fresh  milk,  Ben- 
ger's  food,  beef  tea — where  there  was  no  diarrhoea— and 
egg  switches,  while  some  doctors  included  rice,  biscuits,  soft 
boiled  eggs,  etc.,  from  the  start  with  very  favorable  results. 


322  International  Congress  of  Nurses 

We  had  many  inoculated  cases,  which  generally  ran  a  mild 
and  irregular  course  of  fever.  In  my  service  I  did  not  lose 
any  of  these  cases,  except  in  one  instance  where  there  had 
been  no  reaction  from  the  inoculation. 

We  were  singularly  fortunate  at  Rondebosch  in  our 
results.  During  the  six  months'  service  there,  including 
medical  and  surgical  cases  of  our  own  and  the  Portland 
hospital,  we  had  but  thirty  deaths.  But  here  at  the  base 
we  always  had  good  air,  plenty  of  good  water,  with  an 
abundance  of  fresh  milk,  eggs  and  ice.  The  general  hos- 
pital fare  was  excellent,  and  added  to  this  we  received  daily 
quantities  of  fruit  and  dainties  sent  by  the  Red  Cross  Com- 
mittee of  the  Colony,  besides  many  medical  comforts  from 
England. 

In  May  we  were  ordered  up  country,  and  were  the  first 
sisters  to  reach  Kroonstadt,  O.  R.  C,  stopping  en  route 
at  Springfontein  and  Bloemfontein.  At  the  latter  place 
enteric  fever  and  dysentery  were  raging,  the  hospitals,  of 
which  there  were  three  general  and  many  smaller  ones, 
being  all  crowded.  No.  9  having,  we  were  told,  eighteen 
hundred  patients.  All  persons  and  supplies  were  being 
taxed  to  the  utmost.  In  Kroonstadt  we  had  our  hardest 
taste  of  active  service.  Lord  Roberts  and  Lord  Methuen's 
forces  had  just  passed  through,  leaving  sick  and  wounded 
in  large  numbers. 

Owing  to  the  congested  state  of  the  lines  of  communi- 
cation, our  hospital  equipment  was  delayed  a  few  days  in 
reaching  Kroonstadt.  The  Dutch  church,  hotels,  Staat 
Huis,  etc.,  were  quickly  converted  into  hospitals,  where  we 
made  the  patients  as  comfortable  as  possible.  Fresh  milk 
was  very  hard  to  get,  an  of^cer's  servant  having  been  shot 
dead  by  the  Boers  in  his  effort  to  get  some  at  a  farm  near 
by,  but  of  condensed  milk,  beef  tea,  champagne,  and  jelly 
we  had  plenty. 

When  our  hospital  arrived  it  .was  pitched  on  the  out- 
skirts of  the  town,  and  close  beside  it  the  Scottish  National, 
a  beautifuly  equipped  hospital  just  sent  out.  The  weather 
was  now  very  cold  at  night,  the  frost  being  thick  both  inside 


Nursing  in  South  Africa  323 

and  out  of  our  single  bell  tents— the  patients,  being  in  dou- 
ble marquees,  did  not  feel  the  cold  so  much.  We  were  scarce 
of  water,  and  lived  on  rations  which  an  orderly  cooked 
for  us  on  a  fire  on  the  veldt,  dinner  being  a  movable  and 
uncertain  feast  on  a  rainy  day.  Around  our  camp,  within 
fifty  yards,  were  several  six-inch  guns,  while  we  had  pre- 
pared in  a  donga  a  place  of  safety  for  helpless  patients  and  a 
bomb-proof  shelter  for  all  the  hospital  staff  in  case  of  attack, 
which  had  for  some  time  threatened  us  dailv.  Haneinsr 
m  our  mess  was  a  copy  of  orders  to  be  observed  when 
attacked,  etc.  Several  mornings  we  wakened  to  hear  the 
boom  of  guns,  which,  however,  were  never  near  enough  to 
necessitate  our  using  the  shelter. 

Here  the  mortality  was  much  greater  than  at  the  Cape. 
The  men,  being  greatly  undermined  by  the  hard  campaign, 
after  drinking  the  waters  of  the  Modder,  contaminated  with 
the  Boer  dead,  fell  easy  victims  to  disease,  and  were  in  a 
poor  state  to  stand  the  ravages  of  South  African  enteric 
fever. 

Sad  indeed  was  the  now  familiar  sight  of  fatigue  parties 
bearing  aloft  the  stretcher  containing  its  silent  burden  cov- 
ered by  the  Union  Jack,  and  still  more  sad  the  ever-increas- 
ing number  of  little  mounds  on  the  veldt.  After  two  months 
in  Kroonstadt  we  received  orders  for  Pretoria,  where  we 
were  attached  to  the  stafT  of  the  Irish  hospital  sent  out  by 
Lord  Iveagh.  Here  the  service  became  much  lighter, 
enteric  fever  being  greatly  on  the  wane. 

After  completing  a  year's  service,  we  Canadian  sisters 
received  ten  days'  leave  of  absence,  which  was  spent  going 
through  Natal,  stopping  at  all  places  of  interest.  We  met 
officers,  civil  surgeons,  and  sisters  who  had  been  through 
the  siege  of  Ladysmith  whose  account  of  their  hardships, 
including  diet  and  danger,  made  me  feel  as  though  we  had 
had  little  to  bear  in  comparison. 

In  November  we  left  for  the  Cape,  spending  our  last 
month  at  Wynberg  pending  embarkation  for  Canada,  which 
we  reached  on  January  8,  1901,  after  nearly  fifteen  months' 
absence. 


'324  International  Congress  of  Nurses 

I  cannot  close  this  paper  without  speakin^  of  the  great 
kindness  with  which  we  were  received  on  all  sides.  We 
had,  with  our  troops,  a  most  enthusiastic  reception  at  the 
Cape  upon  our  arrival.  By  the  Royal  Army  Medical  Corps 
from  the  surgeon  general  down  to  the  humblest  orderly 
we  were  invariably  treated  with  the  greatest  courtesy  and 
respect,  by  the  "  army  nursing  sisters  "  with  great  con- 
sideration and  kindness.  While  among  the  nursing  reserve, 
of  whom  there  were  about  eight  hundred  in  South  Africa, 
we  made  many  friends,  meeting  sisters  <^rained  at  the 
London,  St.  Bartholomew's,  St.  Thomas',  and  many  other 
well-known  standard  hospitals,  whose  reputations  are  well 
maintained  by  the  work  of  their  nurses  in  South  Africa. 
We  had  the  privilege  of  meeting  many  distinguished  physi- 
cians and  surgeons  of  the  old  country,  under  whom  it  was 
a  pleasure  to  serve.  The  work  of  the  Red  Cross  w^as  excel- 
lent, and  great  was  the  timely  aid  so  often  received  from  it. 
While  the  kindly  gift  or  word  sent  or  given  by  the  private 
individual  often  made  one  think  of  the  "  touch  of  nature 
that  makes  the  whole  world  kin."  We  found  Tommy 
Atkins  a  very  good  patient  and  a  fine  fellow :  always  grate- 
ful, generally  cheerful,  bearing  loss  of  limb,  loss  of  health, 
and  many  other  minor  discomforts,  with  a  fortitude  that 
realized  our  best  ideal  of  British  pluck,  while  his  considera- 
tion for  the  presence  of  the  sister  was  at  times  quite  touch- 
ing. He  is  very  entertaining  during  convalescence,  often 
writing  verses,  sometimes  in  eulogy  of  the  sisters  and  again 
in  descriptions  of  battles,  etc.,  and  making  all  kinds  of  curi- 
osities, those  having  had  service  in  India  doing  beautiful 
work.  I  am  the  proud  possessor  of  several  specimens  both 
of  verse  and  handicraft  which  I  value  greatly.  Above  all, 
he  loves  tobacco  and  cigarettes,  but  enjoys  any  attention. 
A  lady  while  at  Rondebosch  gave  me  one  day  in  the  ward 
a  bundle  of  handkerchiefs  and  a  pint  bottle  of  white-rose 
scent.  A  few  minutes  later  I  heard,  "  Sister,  I'd  thank  you 
for  a  clean  handkerchief,  please,  and  a  drop  of  that  scent 
on  it,  sister,  please,"  until  all  with  energy  to  notice  anything 
Vv'ere  supplied,  and  even  after  the  fancy  handkerchiefs  had 


Nursing  in  SotttJi  Africa  326 

to  be  replaced  by  the  regulation  kit  article  a  liberal  dose 
of  the  "  ripping  scent  "  would  be  daily  called  for. 

In  conclusion,  I  would  say  that  I  ever  deemed  it  a 
great  privilege  to  aid  in  caring  for  the  sick  and  wounded, 
and  while  the  hardships  necessarily  endured  in  such  a  cam- 
paign have  faded  from  my  mind,  I  still  often  seem  to  hear 
the  "  Thank  you,  sister,''  of  the  grateful  soldier ;  while 
together  with  pleasant  memories  of  large  convoys  of  happy 
convalescents  sent  home  comes  the  vision  of  the  many  sad 
graves  left  on  the  far-off  veldt  of  South  Africa.  ''  Requiem 
aeternam  dona  eis,  Domine;  et  lux  perpetua  luceat  eis." 
("  Grant  to  them  Thine  eternal  rest,  O  God,  and  in  the 
light  everlasting  may  they  dwell.") 


War  Nursing  in  South  Africa,  1900. 

SISTER  HENRIETTA, 

St.  Michael's  Home,  Kimberley,  South  Africa. 


In  writing  of  war  nursing  I  mean  to  keep  to  personal 
experience  and  to  the  work  of  our  own  nurses.  I  am  sister 
in  charge  of  a  Nurses'  Home  in  Kimberley,  South  Africa, 
and  was  in  Kimberley  during  the  siege  and  for  fourteen 
months  after  we  were  relieved. 

One  of  our  great  trials  during  the  early  part  of  the 
siege  was  that  our  nurses  had  so  little  to  do.  The  people 
who  usually  employ  us  had  nearly  all  left  town  before  war 
was  declared,  our  country  cases  we  could  not  reach  except 
through  three  nurses  who  were  shut  out,  and  the  absence 
of  evening  amusements,  the  scarcity  of  aerated  waters  and 
wine,  etc.,  the  small  quantity  of  meat  during  the  hot 
weather,  and  the  early  going  to  bed,  all  made  the  town 
unusually  healthy,  until  the  food  became  so  small  in  quan- 
tity and  bad  in  quality  that  all  felt  more  or  less  the  worse 
for  it.  After  Christmas  there  was  a  great  strain  upon  all 
our  resources.  Every  moment  of  my  time  was  taken  up  in 
trying  to  spin  out  our  wretched  scraps  of  horse  flesh  and 
our  few  ounces  of  milk  in  our  own  household,  and  I  often 
had  to  send  nurses  to  houses  where  food  was  so  scarce  I 
was  terrified  for  them.  If  I  gave  them  food  when  they  came 
to  the  home  they  would  pocket  it  to  take  to  the  starving 
children  where  they  were  nursing,  and  the  hospital  was  so 
full  that  many  came  to  us  who  would  not  otherwise  have 
thought  of  engaging  a  private  nurse.  At  last,  too,  so  many 
of  the  hospital  nurses  were  ill  that  we  had  to  send  all  we 
326 


War  Nursing  in  South  Africa  327 

could  possibly  spare  to  help  there.  Our  brave  district 
nurses  went  about  their  work  through  all  the  bombard- 
ment as  if  nothing  were  going  on.  I  cannot  say  how  mis- 
erable I  felt  at  seeing  them  go  out  in  the  morning  while 
the  awful  roar,  shriek  overhead,  and  crash,  like  the  crack 
of  doom,  were  raging  outside.  By  God's  mercy  none  of 
them  were  injured,  but  their  escapes  were  marvelous.  Sev- 
eral of  them  were  covered  with  the  dust  and  debris  of 
the  explosions,  and  all  narrowly  missed  death  by  the 
awful  hundred-pounders.  It  was  a  matter  of  deep  thank- 
fulness to  see  each  one  come  in  safely  from  her  round, 
although  it  was  only  to  start  off  again  in  a  few  hours. 
That  was  true  war  nursing, — through  the  shot  and  shell 
of  the  siege,  half-starved  themselves,  ministering  in  the 
most  hidden  way  among  the  wretched,  starving  people  of 
the  town  with  the  greatest  patience  and  simplest  courage. 

However,  Feburary  15  came  at  last,  and  the  army 
entered  in  triumph,  and  our  brave  commander.  General 
Kekewich,  was  able  to  send  his  famous  telegram  to  the 
Queen,  "By  the  help  of  God  we  have  kept  the  flag  flying." 

But  the  triumphant  march  of  the  great  army  was  fol- 
lowed by  another  march.  In  a  few  days  over  a  thousand 
sick  and  wounded  soldiers  had  been  brought  into  the  town. 
Lord  Methuen  sent  to  me  asking  us  to  undertake  the  nurs- 
ing of  one  big  hall  or  school  room  after  another,  turned 
hastily  into  a  field  hospital,  until  we  had  over  five  hundred 
under  our  care.  First  were  the  Christian  Brothers'  Schools. 
I  was  asked  to  send  one  nurse  there  and  one  to  Nazareth 
House,  close  by,  on  February  17.  The  sisters,  however, 
objected  to  more  outside  help  in  their  own  house  than  they 
got  from  orderlies,  so  they  took  in  for  weeks  and  weeks, 
greatly  at  their  own  expense  and  in  the  most  generous  way, 
from  thirty  to  forty  of  the  slightly  wounded, — the  worst 
wounds  going,  of  course,  very  properly  to  the  civil  hospital, 
where  every  appliance  was  at  hand. 

Our  two  soon  found  enough  to  do  at  the  Christian 
Brothers'.  Imagine  two  handsome  new  school-rooms  and 
one  little  class  room,  with  desks  and  school  books  all  lying 


328  International  Congress  of  Nurses 

about,  and  ambulances  with  forty  wounded  men  in  them 
at  the  door,  bedsteads,  stores,  Red  Cross  comforts,  mat- 
tresses, blankets,  etc.,  etc.,  all  arriving^  at  the  same  time, 
with  only  a  tiny  kitchen  and  no  arrangements  whatever  for 
cooking  for  more  than  half  a  dozen  lay  brothers.  Our  peo- 
ple worked  like  galley  slaves,  and  got  the  bedsteads  up,  the 
men  to  bed,  and  the  wounds  dressed  and  seen  to  by  about 
2  a.  m.  of  the  next  day.  In  a  few  days  all  was  order  and 
peace.  The  little  class  room  was  the  nurses'  room,  with 
two  small  beds  and  a  little  table  for  meals,  their  two  boxes, 
two  chairs,  and  near  the  farther  wall  piles  of  opened  stores 
— cases  of  wine,  brandy,  cigars,  bovril,  bandages,  and  all 
sorts  of  things.  The  wards  were  quite  pretty,  as  neat  and 
smart  as  they  could  be  in  the  rush  of  work  and  incessant 
changing  of  patients,  all  being  sent  to  the  general  hospitals 
at  Wynberg  from  these  field  hospitals  as  soon  as  they  could 
be  moved.  There  were  capital  results,  even  when  the 
wounded  were  replaced  by  typhoid  and  dysentery  cases 
in  a  very  bad  condition. 

The  next  place  we  undertook  was  the  drill  hall.  Here 
three  of  our  nurses,  two  of  whom  had  been  at  work  all  the 
previous  night  with  a  little  outside  help,  came  in  to  find  a 
fine  hall,  two  or  three  side  rooms,  and  dusty  desolation. 
It  was  2:30  p.  m.  before  they  got  a  thing  in.  At  8:30  p.  m. 
they  sent  and  asked  me  to  come  and  see  if  all  was  right. 
There  was  room  for  one  hundred  and  twenty,  and  the  shops 
were  still  able  to  supply  good  bedsteads  and  mattresses, 
so  the  long  rows  of  beds  were  all  beautifully  made,  each 
one  turned  down  ready  to  be  occupied,  with  a  clean  shirt 
on  the  pillow,  a  clean  towel  at  the  head,  and  a  gay-colored 
blanket  for  a  quilt.  The  De  Beers  Company  had  sent  down 
a  wire,  so  it  was  brilliantly  lighted  with  electric  light,  and 
the  flags  and  trophies  of  its  proper  use  made  the  hall  bright 
and  gay.  In  one  of  the  smaller  rooms  four  beds  were  made 
up  for  nurses,  but  there,  too,  was  the  operating  table,  and 
the  dressing  tables  at  the  side  with  all  the  beautiful  and 
costly  dressings  supplied  by  the  army.  Another  of  the 
smaller  halls  had  to  be  the  guard  room  for  orderlies,  but  it 


War  Nursing  in  South  Africa  329 

was  a  long-  room,  and  the  upper  half  had  tables  with  rows 
and  rows  of  clean  white  enamel  mugs,  each  with  a  new 
spoon  in  it,  and  rows  and  rows,  too,  of  bottles  of  bovril. 
jars  of  Liebig,  tins  of  condensed  milk,  all  opened  ready  for 
use,  and  loaves  of  bread.  Lord  Lock  said  to  me:  "  At  2:30 
there  was  absolute  chaos !  It  seemed  impossible  that  a  sick 
man  could  be  put  in  for  weeks;  by  8  p.  m.  it  was  a  most 
beautiful  hospital."  As  I  was  looking  the  ambulances  began 
to  arrive,  and  I  leave  you  to  guess  how  long  it  was  before 
those  nurses  thought  of  bed. 

In  the  same  way  we  undertook  the  public  schools  with 
one  hundred  and  thirty  beds;  and  a  few  days  later  in  St. 
Mary's  Hall  and  the  skating  rink  we  received  the  wounded 
Boers  from  Cronje's  laager  at  Paardeberg.  There  indeed 
was  a  scramble,  one  hundred  and  thirty-seven  men  with 
awful  wounds,  dirty,  draggled,  wretched  and  beaten.  The 
shops  had  no  more  bedsteads,  the  line  of  railway  was 
blocked  with  wounded  soldiers,  military  stores,  horses  and 
food  for  the  starving  town  of  forty-three  thousand  souls, 
as  well  as  with  the  military  arms,  ammunition,  and  huge 
guns  with  all  their  timber.  It  was  far  too  hot  for  the  nurses 
to  take  the  half-mile  walk  there  and  back  to  come  home 
for  their  meals,  and  there  was  absolutely  no  accommoda- 
tion for  them  except  one  miserable  little  room,  half  of  which 
was  broken  down  by  a  shell,  where  the  corporal  took  his 
meals.  In  some  way  or  other,  through  the  kindness  of 
friends,  they  were  provided  for.  But  here  was  nursing 
indeed.  There  was  not  one  bedstead,  only  three  mattresses 
and  three  pillows;  sheets  and  pillow  cases  were  entirely 
lacking;  there  were  only  two  or  three  chairs  and  a  few 
little  tables;  but  in  both  rooms  there  was  a  thoroughly 
good  floor,  and  I  don't  think  the  men  suffered  lying  on  it 
on  folded  blankets;  of  course,  there  could  be  no  comfortable 
undressing,  but  Boers  are  not  accustomed  to  that. 

But  the  nurses!  Through  the  whole  day  standing  in 
the  furiously  hot  little  operating  rooms,  or  dressing  ghastly 
wounds,  almost  standing  on  their  heads,  for  the  men  were 
all  on  the  floor.     Indeed,  the  heat  of  the  whole  place  was 


330  International  Congress  of  Nurses 

indescribable.  Kimberley  was  burning  with  heat.  The 
rink  was  crowded  in  another  week,  when  the  whole  one 
hundred  and  thirty-five  Boers  were  put  there  and  St.  Mary's 
filled  with  our  own  men.  In  about  three  weeks'  time  the 
Boers  were  well  enough  to  be  moved  to  Simon's  Town, 
except  three,  who  went  into  the  civil  hospital.  They  wrote 
a  letter  of  thanks  for  the  treatment  they  had  received 
before  they  left.  I  looked  upon  that  as  one  of  the  best  and 
most  difficult  pieces  of  work  we  ever  did.  We  had  one  of 
the  hospital  nurses  to  help  us.  Meanwhile  the  workshops 
of  the  De  Beers  Company  were  pouring  out  stretchers, 
and  in  a  few  days  after  we  took  it  over,  pillows,  sheets, 
towels,  and  pillow  cases  made  St.  Mary's  quite  handsome. 

Our  work  in  these  halls  came  to  an  end  when  the  Elev- 
enth General  Hospital  came  up  country,  the  twenty  army 
sisters  and  six  Canadian  nurses  taking  them  over,  until  the 
fourteen  hundred  beds  of  the  Eleventh  Hospital  made  a 
city  of  canvas  on  a  fine,  healthy  brow,  with  a  most  com- 
plete equipment  of  thirty-four  nursing  sisters  and  an  army 
of  doctors  and  orderlies. 

Of  course,  all  I  have  told  you  sounds  very  rough  and 
unprepared,  and  the  work  was  much  unlike  the  order  and 
discipline  and  finish  of  a  well-worked  civil  hospital.  But 
in  a  town  crushed  by  an  awful  time  of  tension,  with  the 
great  strain  on  the  railways,  the  rush  of  patients,  the  dif- 
ficulty of  providing  suddenly  for  some  twelve  to  fifteen 
hundred  more  patients  than  we  usually  have  to  provide  for, 
the  impossibility  of  knowing  beforehand  whether  one  man 
will  be  sent  in  after  a  battle  or  a  thousand,  and  the  general 
distress  and  misery  that  war  brings,  the  difficulties  were 
very  great ;  but  all  the  men  I  saw  spoke  most  gratefully, 
and,  far  from  complaining,  seemed  to  think  that  everything 
they  could  possibly  want  was  provided  in  Kimberley.  The 
ladies  in  the  town  were  most  good  in  sending  milk,  fruit, 
jelly,  and  all  kinds  of  nice  things  to  the  soldiers, — often, 
I  am  sure,  at  the  cost  of  much  self-denial  in  their  own  house- 
holds. 

In  such  a  vast  organization  as  our  army  medical  corps, 


War  Nursing  in  South  Africa  331 

in  the  multitude  of  calls  of  all  kinds  and  the  huge  press  of 
work,  and  the  strain  that  war  brings  on  every  department, 
it  appears  to  me  inevitable  that  there  must  be  some  incom- 
petent, some  dishonest,  some  mistakes  and  blunders- 
much  work  which  might  be  better  done.  I  hear  of  army 
sisters  and  reserves  who  behave  badly,  neglect  patients, 
and  care  for  nothing  but  amusing  themselves,  but  I  have 
not  met  them.  All  I  have  seen,  and  I  have  seen  many, 
have  appeared  to  me  to  be,  each  in  her  own  degree,  quiet, 
earnest,  painstaking  women,  saying  little  or  nothing  of 
their  own  discomforts,  and  most  anxious  to  do  all  they 
possibly  can  for  the  sick  under  great  drawbacks,  not  the 
least  of  which  is  that  they  are  strangers  to  one  another, 
in  a  strange  land,  seven  thousand  miles  away  from  home 
and  hospital.  I  do  not  believe  that,  given  all  the  circum- 
stances, the  numbers,  the  heat,  the  freedom,  the  poor  food 
bringing  its  sensation  of  lethargy  and  weariness,  the  con- 
stant illness,  the  many  deaths, — I  do  not  believe,  I  say, 
that  any  other  profession  could  have  borne  it  as  we  have 
done.  A  few  weeks  ago  I  was  in  company  with  some  half 
dozen  army  reserves  who  were  traveling  with  convalescent 
patients.  They  seemed  to  me  to  eat  most  ravenously 
and  in  enormous  quantities,  yet  they  looked  thin  and  worn. 
I  wondered  if  the  open-air  life  produced  these  appetites. 
But  one  day  one  of  them  said  quite  simply  that  they  had 
all,  up  country,  had  such  very  poor  and  monotonous  food 
that  when  they  saw  a  good  table  with  plenty  and  variety 
they  felt  they  could  hardly  satisfy  their  hunger.  That  was 
all  they  ever  said,  and  in  about  a  week  their  appetites 
became  normal. 

I  think  a  flaw  in  the  system  has  been  the  want  of  super- 
intendence. Each  general  hospital,  of  which  there  are 
something  under  thirty,  has  a  Netley  sister  at  the  head, 
and  she  is  undoubted  mistress  of  all  she  surveys,  within  the 
Hmits  of  army  regulations,  but  most  mixed  parties  have 
been  sent  to  the  field  and  stationary  hospitals.  Perhaps  a 
London  hospital  sister,  two  co-operatives,  a  nurse  from 
some   provincial   hospital,   a   nurse   from   some  little  civil 


332  International  Congress  of  Nurses 

hospital  in  the  wilds  of  Africa,  a  nurse  who  has  done  private 
nursing  for  herself  in  her  own  home,  have  all  been  sent 
tog'ether  to  some  outlyingf  station  hospital  entirely  on  an 
equality.  If  even  two  are  sent,  to  my  mind  it  is  productive 
of  peace  and  prudence  if  one  is  over  the  other ;  where  there 
are  more,  I  am  sure  it  is  better.  The  best  nurses  should,  I 
think,  have  been  selected  by  the  doctors  as  superintendents, 
and  should  have  been  called  nursinj^  sisters;  the  rest  should 
have  taken  subordinate  positions  and  been  called  army 
nurses,  addressed  as  nurse,  and  expected  to  do  nurses' 
work.  Many  women,  even  with  the  best  intentions,  are 
not  fit  to  be  set  down,  away  from  all  previous  influences, 
and  left  to  order  their  lives  as  seems  good  to  themselves. 
From  the  system  as  it  is  at  present  have  arisen  the  few 
scandals  and  the  many  failures  in  nursing  in  this  great  war, 
and  it  has,  I  am  certain,  destroyed  the  after  career  of  hun- 
dreds of  good  nurses.  Another  weak  point,  if  I  am  to  say 
honestly  what  I  think,  is  with  the  orderlies ;  they  do  not 
appear  to  me  to  be  the  right  class  of  man.  They  are  above 
half  the  work,  and  not  up  to  the  other  half.  The  regular 
scrubber,  who,  under  the  ward  sister,  does  the  rough  work 
in  a  civil  hospital,  as  a  matter  of  course  is  lacking,  and 
the  men  are  not  up  to  the  work  of  a  good  male  nurse.  They 
are  too  often  rough  to  the  patients,  greedy,  lazy,  and,  I  fear, 
dishonest.  One  of  our  great  troubles  was  caused  by  this. 
We  took  over  halls  with  beautiful  new  white  floors,  and  we 
gave  them  back  stained  from  end  to  end  from  want  of 
proper  scrubbing.  A  wipe-up  was  all  the  orderlies  ever 
gave  to  any  accident  on  the  floor,  and  to  get  the  ward  well 
cleaned  was  an  impossibility.  No  one  attached  to  the  mil- 
itary was  willing  to  give  the  thorough  cleaning  a  ward  in 
a  civil  hospital  gets  daily  as  a  matter  of  course,  and  there 
were  great  and  serious  sanitary  faults  from  the  same  reason. 
The  men  were  all  too  superior  to  do  it;  the  nurses,  of 
course,  had  neither  strength  nor  time,  until  in  one  large 
hall  the  superintending  nurse,  with  a  small  watering  can 
of  mercurial  lotion  and  a  big  mop,  mopped  out  the  ward 
herself  for  two  or   three   days,  after  which   the   orderlies 


War  Nursing  in  So7ith  Africa  333 

slowly  took  to  mopping  it  out  themselves.  They  were  all 
too  superior  for  scrubbers'  work,  and  a  sick  or  wounded 
man  can't  be  left  with  any  peace  of  mind  to  their  care  for, 
as  I  say,  they  are  not  up  to  the  work  of  a  well-trained 
nurse.  I  should  have  thought  that  the  best  soldiers  and 
best  educated  men  would  have  been  chosen  for  the  army 
corps  and  thoroughly  trained,  like  a  probationer  in  a  hos- 
pital, and  made  to  do  their  real  nursing  properly  or 
degraded.  The  larger  number  should  be  from  a  lower  class 
of  men,  and  be  bearers,  scrubbers,  and  regular  cleaners  and 
washers.  The  difficulty  we  had  in  getting  washing  done 
for  a  thousand  sick  in  our  worn-out  town,  with  scarcely  a 
bar  of  soap  within  five  hundred  miles,  was  unspeakable, 
yet  the  orderlies  spent  nearly  all  their  time  in  idling  about 
the  guard  room.  I  heard  one  surgeon-major  say  that  his 
sergeant  was  "  no  more  good  than  a  sick  headache,"  and 
others  must  often  have  thought  as  much. 

It  seems  to  me  that  in  the  African  campaign  infinite 
care  has  been  taken  of  the  sick.  The  hospitals  themselves, 
excepting  always  the  camp  hospitals,  have  really  shown 
how  much  can  be  done  with  few  appliances  and  in 
the  roughest  surroundings,  the  hospital  trains  have  been 
marvels  of  ingenuity  in  the  way  of  saving  pain,  and  the 
greatest  care  has  been  taken  on  the  hospital  ships.  The 
generals,  when  in  town,  have  visited  both  the  general  and 
field  hospitals  daily ;  ladies  have  been  ready  at  all  hours  and 
times  to  cook,  to  sew,  to  fetch  and  carry,  to  write  letters, 
to  read,  to  help  in  every  way.  Of  the  doctors  it  does  not 
become  me  to  speak,  but  their  part  on  the  field  and  in  the 
hospital  alike  has  been  noble.  One  doctor  told  me  of 
another  who  went  on  calmly  dressing  a  wound,  scarcely 
looking  up  until  it  was  done,  although  forty  bullets  fell 
either  close  to  him  or  through  parts  of  his  clothing  or  dress- 
ings while  he  was  doing  it.  And  in  criticising  sanitary 
measures  it  should  not  be  forgotten  how  the  microbes  of 
disease  are  continually  carried  in  the  proboscis  of  a 
mosquito,  or  what  a  plague  of  mosquitoes  we  had  all 
through  Africa  in  the  year  1900. 


334  International  Congress  of  Nurses 

The  President :  Our  next  paper  is  one  of  the  greatest 
importance  and  interest,  and  is  to  be  presented  to  us  by  one 
who  speaks  with  authority  on  this  subject.  I  have  the 
great  honor  and  pleasure  of  presenting  one  who  needs  no 
introduction  to  this  audience,  Mrs.  Bedford  Fenwick. 


The  Organization  and  Registration  of  Nurses. 

ETHEL  GORDON  FENWICK, 

President  of  the  International  Council  of  Nurses. 


"Wouldst  thou  plant  for  eternity,  then  plant  into  the  deep  in- 
^nite  faculties  of  man,  his  fantasy  and  heart." 

Such  it  seems  to  me  must  be  the  aim  of  any  worthy 
scheme  of  organization  for  nurses,  the  inspiration  of  whose 
work  is  divine,  and  the  dutiful  performance  of  which  inevit- 
ably ennobles  the  worker. 

This  question  of  the  organization  and  registration  of 
trained  nurses  has  occupied  my  mind  for  many  years,  and, 
indeed,  there  are  few  subjects  which  can  be  of  greater 
importance  to  any  profession  than  those  which  relate  to 
its  organization,  and  to  the  basis  upon  which  its  recognized 
membership  is  founded.  In  the  case  of  nursing  it  will  be 
generally  admitted  that  these  matters  are  still  in  an  inchoate 
condition,  although  our  pioneers  have  dug  and  delved, 
and  loosened  the  roots  of  many  prejudices. 

As  most  trained  nurses  know,  there  is  at  present  no 

general  standard  of  training  and  certification  adopted  for 

the  nursing  profession.     Some  hold  that  nursing  is  still 

so  infantile  in  its  growth  that  it  would  be  impossible  to 

define   a   general   and   universal   curriculum   of  education. 

Others,  however,  have  argued  strongly  that  until  inirsing 

education  is  systematized,  and  not  only  its  period  but  its 

various  details  are  accurately  defined,  there  can  be  no  hope 

for  any  general  improvement  of  the  nursing  profession,  for 

the  simple  reason  that  education  must  form  the  foundation 

335 


336  International  Congress  of  Nurses 

on  which  the  whole  structure  of  professional  organization 
is  built. 

But  all  nurses  who  have  considered  the  question  intel- 
ligently have  grasped  the  fundamental  principle  that  our 
profession,  like  every  other,  needs  regulation  and  control, 
and  we  claim  that  this  power  of  control  should  rest  in  our 
own  hands.  That  in  our  corporate  capacity  we  must  have 
the  right  to  live,  and  move,  and  have  our  being,  and  that 
it  is  from  our  own  ranks  that  the  women  must  step  out  to 
whom  the  responsibility  of  guiding  our  destinies  must  be 
entrusted.  Women,  strong  and  faithful,  able  and  willing 
to  maintain  intact  the  trust  imposed  upon  them. 

Where  are  these  women  to  come  from?  Surely  from 
our  training  schools.  The  undergraduate  of  today  is  the 
superintendent  of  tomorrow,  and  it  is  to  our  training  schools 
that  we  must  turn  wath  hope  for  the  future.  In  the  hands 
of  the  superintendents  of  today  there  rests  an  enormous 
responsibility.  In  their  wise  selection  of  probationers,  and 
in  the  example  and  precept  they  set  before  their  pupils 
they  can  sound  the  keynote  of  the  tone  of  the  nursing  pro- 
fession of  the  future.  Now  is  the  time  to  assure  proba- 
tioners that  it  is  not  enough  that  they  attain  technical  pro- 
ficiency. Unwearied  devotion  to  the  sick — obedience  to 
medical  directions — these  lessons  have  been  taught  and 
well  assimilated  in  the  past,  and  have  resulted  in  prodigious 
self-sacrifice,  and  the  crowning  of  many  martyrs  in  the 
battalions  of  the  great  army  of  nurses  all  over  the  world. 
This  fine  devotion  to  duty  is  mainly  the  result  of  the  lessons 
received  by  nurses  during  their  training  from  high-minded 
women  placed  in  authority  over  them.  It  is  magnificent, 
but  it  is  not  enough.  In  addition  to  a  fine  example  in  all  / 
the  domestic  virtues,  and  in  selfless  devotion  in  the  practical  I 
care  of  the  sick,  our  young  nurses  must  be  inspired  also 
with  a  keen  sense  of  citizenship  so  that  when  they  leave 
the  training  school  they  will  be  fully  alive  to  the  importance 
of  their  public  and  professional  duties,  and  be  ready  to 
enter  their  corporate  life  in  the  right  spirit,  the  spirit  which 
asks  not  what  it  is  to  receive,  but  what  it  can  give.     For 


Organization  and  Registration  337^ 

this,  after  all,  is  the  essence  of  professional  as  opposed  to 
commercial  existence ;  they  must  be  taught  that  their  prede- 
cessors have  won  for  them  privileges  and  liberties  which 
are  a  sacred  trust,  which  are  not  theirs  to  hold  or  renounce 
at  will,  but  which  it  is  their  duty  to  jealously  guard.  Fur- 
ther they  must  be  fired  with  ambition  not  only  to  maintain 
the  standard  attained  by  their  predecessors,  but  also,  in  their 
day  and  generation,  to  guide  their  profession  onward  and 
upward.  There  are  heroic  qualities  in  the  modern  woman 
which  will  respond  to  such  teaching. 

Perhaps  at  the  present  time  the  practical  is  in  advance 
of  the  ethical  side  of  our  work,  just  because  in  a  great 
measure  we  have  been  so  occupied  in  raising  our  standard 
of  practical  proficiency  that  we  have  had  little  time,  and 
given  too  little  thought  to  the  preparation  of  the  pupil  for 
the  wider  obligations  which  lie  before  her  when  she  emerges 
from  the  state  of  tutelage  and  becomes  an  independent  grad- 
uate. 

PRACTICAL   ORGANIZATION. 

Experience  has  shown  that  both  amongst  men  and 
women  the  best  and  strongest  bond  of  union  is  to  be  found 
in  the  close  ties  of  friendship  formed  by  those  who  have 
been  educated  together,  or  have  passed  through  the  same 
course  of  training,  and  who  are  naturally  drawn  together 
by  sympathy  with,  and  admiration  for,  their  common  Alma 
Mater.  And  thus  the  system  so  wisely  inaugurated  in  the 
United  States,  now  being  also  successfully  followed  in  the 
United  Kingdom,  the  union  of  nurses  belonging  to  the 
same  training  schools  for  mutual  help  and  protection,  offers 
in  many  respects  the  strongest  bond,  as  well  as  the  greatest 
incitement  to  nurses  to  associate  together. 

We  may  take  it  then  that  the  units  of  organization  in 
the  nursing  profession  should  be  societies  of  nurses  who 
hold  the  certificate  of  the  same  training  school,  and  who 
are  therefore  graduates  of  their  profession.  The  exercise 
of  the  graduate  vote  would  thus  enfranchise  professionally 
each  certificated  nurse,  and  it  would  become  the  aim  of 


388  International  Congress  of  Nurses 

every  probationer  not  only  to  obtain  the  certificate  of  her 
school,  but  admission  to  membership  of  its  leag'ue. 

Whilst  realizing^  that  combination  is  the  best  means  of 
efifecting  organization  and  reform,  the  weight  of  our  nurs- 
ing societies  does  not  depend  upon  their  numerical  strength, 
but  on  the  vital  force  and  courage  of  their  individual  mem- 
bers. Spirit  is  an  intangible  thing.  Anatomists  tell  us  they 
dissect  a  body  and  do  not  find  it.  But  it  is  indisputable 
that  the  great  movements  which  stir  society  from  its  very 
foundations  are  invariably  produced  by  the  workings  of 
the  living  spirit  of  man.  Such  great  movements  usually 
owe  their  impetus  to  one  of  those  master  spirits  endowed 
with  the  genius,  energy,  and  confidence  which  fit  a  man 
to  wield  these  moral  forces;  to  reveal  to  his  age  the  wants 
of  which  it  had  but  a  dim  and  perplexed  consciousness ;  to 
interpret  to  it  its  own  confused  and  half-formed  opinions, 
and  to  give  them  shape,  compactness,  and  strength. 

For  some  time  to  come  there  will  remain  a  large  body 
of  nurses,  working  in  various  branches  of  nursing,  who 
are  not  eligible  for  association  in  connection  with  the  large 
training  schools.  In  England,  hundreds  of  those  practical 
workers  are  engaged  in  private  and  district  nursing,  and  in 
organizing  our  profession  some  means  must  be  found  to 
associate  together  this  large  number  of  workers.  How  is 
this  to  be  done?  Why  not  by  forming  a  National  League 
of  Nurses,  composed  of  delegates  representing  each  train- 
ing school  society,  and  also  of  delegates  from  professional 
associations  of  nurses,  formed  for  the  benefit  of  nurses  who 
hold  the  approved  qualifications  of  training? 

A  NATIONAL  COUNCIL  OF  NURSES. 

Having  by  delegation  formed  a  National  Society  or 
League  of  Nurses,  it  would  appear  to  me  to  be  desirable 
to  advance  organization  still  further  by  affiliating  together 
in  a  Federation  of  Nurses,  preferably  called  a  National 
Council,  representatives  of  the  Matrons'  and  Nurses' 
National  Societies  in  equal  proportions.  Thus  a  Council 
of  Nurses  might  be  formed  in  each  country  representative 


Organization  and  Registration  339 

of  every  nursin-  interest,  which  would  be  eligible  for  affilia- 
tion with  the  International  Council  of  Nurses,  so  that  in 
a  very  simple  manner  every  graduate  nurse  would  have 
voting  power  direct  or  through  the  chosen  delegate  of  her 
Training  School  League,  in  the  National  League,  and  also 
in  conjunction  with  the  superintendents  in  the  National 
Council,  and  yet  still  further  in  the  International  Council 
of  Nurses. 

The  National  Council  would  act  as  the  supreme  repre- 
sentative of  the  nursing  profession  in  its  own  countr>'; 
would  be  able  with  united  power  to  make  representations 
to  the  government  of  the  country  on  all  nursing  questions ; 
it  should  organize  a  parliamentary  department,  and  so  focus 
and  co-ordinate  the  local  influence  of  every  one  of  its  com- 
ponent societies,  and  through  them  the  personal  influence  of 
every  individual  nurse,  with  members  of  the  legislature,  that 
in  any  act  dealing  with  or  relating  to  nursing  matters  the 
interests  of  the  nursing  profession  should  be  completely  pro- 
tected and  safeguarded.  Finally,  through  its  representatives 
upon  the  International  Council,  it  would  obtain  and  dissem- 
inate throughout  its  own  country  for  the  information  and 
instruction  of  its  component  societies  and  their  members, 
news  of  what  is  transpiring  in  the  nursing  profession  and  of 
all  that  tends  to  the  improvement  of  nursing  in  every  coun- 
try in  the  world.  And  so  we  arrive  at  the  crown  and  apex 
of  the  organization  as  I  have  sketched  it  out. 

THK  INTERNATIONAL  COUNCIL  OF   NURSES. 

The  objects  which  it  is  hoped  this  new  body  will  be 
able  to  attain  in  the  future  will  be  to  draw  together  the 
Nursing  Councils  of  the  different  nations;  to  diffuse 
amongst  them  professional  information  from  each  country 
which  will  be  useful  to  all;  to  unite  together  and  thus 
strengthen  the  efforts  for  professional  improvement  which 
may  be  made  in  any  country,  by  the  assistance  and  advice 
of  the  nurses  in  other  lands.  And  above  all,  to  arrange  for 
the  holding  of  International  Congresses  in  different  coun- 
tries, on  the  same  grounds  as  those  which  have  made  such 


340  International  Congress  of  Nurses 

meetingfs  so  valuable  in  the  past,  for  the  general  considera- 
tion of  important  nursins^  matters,  and  for  the  determination 
of  questions  which  are  of  common  interest  and  importance 
to  the  nurses  in  every  country.  Such  then,  in  brief,  are 
the  sug-g-estions  which  I  would  make  for  the  organization 
of  nurses ;  each  country,  of  course,  carrying  out  the  prin- 
ciples by  its  own  methods,  and  by  details  which  seem  to 
each  to  be  most  appropriate. 

Passing  on  now  to  the  second  branch  of  my  subject, 

THB    REGISTRATION   OF   NURSES. 

I  would  suggest  a  measure  in  broad  outline,  which 
would,  I  imagine,  be  easily  adaptable,  and  with  variation  of 
details  equally  applicable  to  every  country.  It  being  admit- 
ted that  the  nursing  of  the  sick  is  a  matter  which  closely 
affects  every  class  of  the  community,  and  that  it  is  therefore 
of  extreme  importance  to  the  public  welfare  that  those  who 
undertake  the  responsible  duties  of  sick  nursing  should 
be  not  only  absolutely  trustworthy  from  a  personal  point  of 
view,  but  skilled  also  in  their  technical  duties,  it  follows  that 
it  is  the  duty  of  the  state  to  provide  public  safeguards  in  this 
matter.  It  is,  therefore,  suggested  that  the  legislature  in 
each  country  should  pass  an  act^ forming        "  - 

A   GENERAL   NURSING   COUNCIL. 

This  body  should  be  empowered  to  deal  with  all  educa- 
tional matters  affecting  nurses,  that  is  to  say,  to  define  the 
precise  curriculum  through  which  every  woman  must  pass 
before  she  can  be  certificated  as  a  trained  nurse.  It  must 
define  the  period  of  her  training,  and  the  subjects  of  her 
education ;  and  no  nurse  would  then  be  permitted  to  offer 
herself  for  examination  until  she  produced  a  schedule  duly 
signed  by  the  matron  of  her  training  school  testifying  as  to 
her  general  good  conduct  and  practical  proficiency,  and  by 
the  lecturers  upon  the  different  subjects  in  the  curriculum, 
testifying  that  she  had  attended  the  regulation  number 
of  lectures  and  demonstrations  on  each  subject.  It  would 
be  the  duty  of  the   General   Nursing  Council  to  appoint 


Organization  and  Registration  JiT 

examiners  and  hold  examinations,  and  to  grant  to  candi- 
dates who  passed  those  examinations  a  state  diploma  in 
nursing.  It  would  be  the  duty  of  the  Nursing  Council  to 
register  nursing  qualifications.  It  is  probable  that  it  would 
call  into  existence  nursing  colleges  to  facilitate  its  educa- 
tional work.  The  first  result,  therefore,  of  the  appointment 
of  such  a  council  would  be  that  a  uniform  system  of  nurs- 
ing education  and  a  uniform  standard  of  qualification  would 
be  established  throughout  the  country  in  question.  Because, 
it  is  almost  needless  to  add,  that  the  nursing  act  would  make 
registration  essential  as  a  qualification  to  practice ;  and  that 
no  one  would  be  permitted  under  heavy  penalties  to  term 
herself  a  trained  nurse,  or  to  take  any  fee  or  reward  as  such 
unless  she  were  duly  registered.  Then  again,  it  would  be 
the  duty  of  the  General  Nursing  Council  to  strike  off  from 
their  list  the  name  of  any  registered  nurse  who  proved  her- 
self to  be  unworthy  of  trust  and  professional  confidence. 
So,  on  the  other  hand,  the  public  would  be  protected  against 
the  ignorant  and  inei^cient  persons  who  now  can  term 
themselves  trained  nurses,  can  obtain  the  most  responsible 
work  in  that  capacity,  and  so  bring  danger  to  the  sick. 
And  the  nursing  profession  would  be  protected  against 
those  members  of  the  calling  who  bring  discredit  on  its 
fair  name  and  on  all  their  fellow  workers.  It  would  be  the 
duty  of  the  Nursing  Council  to  publish  each  year  a  com- 
plete list  of  its  registered  nurses,  showing  the  names  and 
addresses,  the  date  of  registration,  and  the  nursing  qualifi- 
cations possessed  by  each  nurse,  in  parallel  colunms  against 
her  name ;  so  that  in  future  any  person  desiring  information 
on  the  subject,  could,  by  reference  to  the  register  of  trained 
nurses,  ascertain  at  once  with  certainty  whether  any  given 
person  were  or  were  not  a  trained  nurse ;  and,  in  the  latter 
event,  precisely  what  nursing  qualifications  she  possessed. 

:;  Then  we  come  to  the  constitution  of  the  Nursing  Coun- 
cil. Without  going  into  arguments  which  would  be  out  of 
place  on  this  occasion,  I  would  briefly  say  that  the  council 
should  be  constituted  so  as  to  represent  the.  different  inter- 
ests involved.     First,  the  goyernmerit  of  tlie  country  by 


342  International  Congress  of  Nurses 

established  custom  demands  its  own  representatives  on  such 
a  council.  The  traininpf  schools  of  the  country  should  pos- 
sess representatives  who  would  he  of  the  greatest  possible 
practical  assistance  in  the  determination  of  the  great  educa- 
tional questions  with  which  the  council  would  be  called 
upon  to  deal,  and  the  regfistered  nurses  themselves,  whose 
interests  would  be  those  most  involved,  should,  I  consider, 
be  given  an  ample  representation,  and  should  be  entitled 
to  elect  by  ballot  a  certain  number  to  represent  them  on  the 
General  Nursings  Council  of  their  country. 

With  reg^ard  to  its  finances,  I  consider  that  every  nurse 
should  pay  a  substantial  fee  for  registration,  and  a  small 
annual  payment  each  year.  The  object  of  this  latter  pay- 
ment deserves  perhaps  to  be  explained.  It  would  not  only 
provide  the  council  with  a  large  permanent  income  for  its 
working  expenses,  but  it  would  compel  the  nurse  each  year 
to  give  her  present  address,  a  matter  the  importance  of 
which,  in  the  case  of  such  a  profession  as  nursing,  and  for 
the  correct  keeping  of  the  register,  need  scarcely  be  insisted 
upon.  Indeed,  I  fear  that  if  this  measure  were  not  adopted 
so  many  nurses  would  neglect  to  give  their  changes  of 
address,  and  so  many  would  die,  or  marry,  or  disappear, 
without  the  knowledge  of  the  registrar,  that  the  register 
would  speedily  become  hopelessly  incorrect  and  therefore 
utterly  unreliable.  But  a  further  object  and  advantage  of 
the  annual  fee  would,  to  my  mind,  be  that  the  Nursing 
Council  would  thereby  be  provided  with  funds  to  enable 
it  suf^ciently  to  protect  the  public  against  nursing  quacks, 
and  to  protect  the  registered  nurses  against  oppression  and 
injustice ;  by  means  of  a  legal  prosecution  in  the  first  place, 
and  of  legal  defense  in  the  second. 

I  must  trespass  no  longer  on  your  attention.  I  thank 
you  for  the  courteous  hearing  you  have  given  me.  I  have 
endeavored  to  deal  with  general  principles  on  which  a  com- 
mon ground  of  agreement  may  be  found  rather  than  with 
details  on  which  difTerences  of  opinion  are  certain  to  exist. 
I  only  hope,  and  that  most  earnestly,  that  the  deliberations 
of  this  congress  on  this  vitally  important  question  to  our 


Organization  and  Registration  343 

profession  may  result  in  the  determination  of  some  common 
ground  of  action,  on  which  we  shall  be  agreed,  for  which  we 
can  all  cordially  work  together,  and  which  shall  in  the  future 
bring  about  the  best  possible  system,  whatever  that  may 
prove  to  be,  of  organization  for  the  nursing  profession  and 
of  state  registration  of  trained  nurses. 


The  President :  Our  next  paper  under  the  same  head- 
ing is  by  Miss  Sylveen  Nye,  President  of  the  New  York- 
State  organization. 

Madam  Chairman,  Ladies— I  am  somewhat  like 
the  Irishman  who  wanted  to  say  a  few  words 
before  he  began.  I  feel  that  I  owe  an  apology  to  all  New 
York  State  nurses  that  I  have  not  a  better  paper  prepared 
to  present  in  their  behalf  today.  My  only  apology  is  that 
it  has  been  Pan-American  year,  and  I,  with  other  Buf- 
falo women,  have  been  rushed.  One  of  the  most  satisfac- 
tory features  of  this  congress  is  this,  that  we  are  all  united 
in  what  we  want  to  do.  That  we  should  differ  as  to  methods 
is  natural.  We  represent  different  states  and  different  coun- 
tries, where  dififerent  conditions  must  exist  and  where  dif- 
ferent methods  must  be  pursued  to  obtain  our  desired 
results.  I  have  been  a  nurse  for  ten  years.  During  the 
last  five  years  my  work  has  taken  me  among  nurses,  and 
I  have  met  them  in  more  dififerent  ways  than  ever  before. 
When  I  first  left  my  alma  mater  I  shared  the  opinion  of 
so  many  nurses  that  mine  was  the  only  hospital,  my  train- 
ing school  the  only  school,  and  our  staff  the  greatest 
physicians.  I  went  from  there  to  the  University  Hospital 
in  Philadelphia,  where  as  head  nurse,  later  as  night  super- 
intendent, I  learned  that  mine  was  not  the  greatest  hospital 
in  the  world  and  our  staff  not  the  wost  wonderful  physi- 
cians. My  next  work  brought  me  to  Buffalo,  where  I  was 
connected  with  a  small  private  hospital,  and  I  have  learned 
to  have  great  sympathy  with  the  small  hospitals.  During 
the  last  five  years  I  have  visited  and  met  graduates  from 


344  International  Congress  of  Nurses 

most  of  the  hospitals  in  New  York  State.  My  heart  goes 
out  with  sympathy  and  affection  to  every  woman  who  is 
entitled  to  wear  a  cap  and  gown  regardless  of  the  school 
from  which  she  is  a  graduate.  Last  year  I  became  chair- 
men of  the  committee  for  New  York  State  organization  of 
nurses. 

I  was  asked  to  write  a  paper  on  State  Organization  for 
Trained  Nurses  in  the  Hospital  Review,  setting  forth  what 
we  wanted  to  accomplish  in  New  York.  Those  who  have 
read  my  paper  will  notice  that  I  then  advocated  many  of  the 
things  set  forth  in  Mrs.  Fenwick's  paper  today.  We  desire 
and  expect  to  accomplish  four  things :  Uniform  qualifica- 
tions, uniform  curriculum,  uniform  final  examination  con- 
ducted by  the  regents,  and  the  legalization  of  the  title  of 
nurse.  I  cannot  agree  with  the  lady  of  the  foreign  delega- 
tion upon  how  to  obtain  these  desired  results.  You  peo- 
ple who  are  familiar  with  legislation  and  the  methods  used 
to  obtain  it  in  the  State  of  New  York  must  know  that  these 
things  cannot  be  accomplished  in  the  manner  suggested 
by.  the  paper  which  has  just  been  read. 

I  honestly  and  truly  believe  that  in  any  steps  we  take 
we  must  have  the  support  and  the  co-operation  of  the  phy- 
sician, the  patient,  and  the  hospital  authorities.  I  have  no 
sympathy  with  the  movement  that  ignores  the  advice  and 
the  wish  of  the  medical  profession  and  hospital  authorities, 
and  the  people  under  whom  we  are  compelled  to  act,  and 
who  control  to  a  very  large  extent  our  patronage,  nor  with 
any  organization  of  nurses  that  does  not  include  all  nurses. 

One  of  the  most  encouraging  features  of  this  wonder- 
ful new  century  is  the  demand  for  the  betterment  of  condi- 
tions affecting  human  life.  Among  all  classes,  from  the 
humblest  laborer  to  the  most  profound  scientist,  we  see  a 
spirit  of  progression.  The  various  movements  for  organi- 
zation, for  the  benefit  of  the  many,  demonstrating,  as  they 
do,  the  desire  for  better  living  and  for  the  elimination  of 
evil,  have  never  been  equaled. 

The  need  for  improvement  in  the  nursing  profession  is 
loo  well  known  to  admit  of  discussion.    The  nurses  of  today 


Organization  and  Registration 


345 


are  not  satisfied  with  their  standards,  and  to  me  the  most 
hopeful  feature  of  this  is  the  fact  that  the  dissatisfaction  has 
come,  not  from  patients,  physicians  or  hospital  authorities, 
but  from  the  nurses  themselves.  The  many  or^nizations 
of  nurses  have  been  diagnosing;  they  have  been  holding 
consultations,  if  you  please,  and  there  is  an  unanimous  decis- 
ion that  something  for  improvement  should  be  done. 

The  universal  and  spontaneous  formation  of  nurses' 
organizations,  under  different  names  and  different  forms, 
indicates  a  current  of  feeling  not  plainly  visible,  but  which 
will  be  felt;  the  general  demand  for  improvement  and  pro- 
tection of  our  profession  is  not  to  be  temporary,  but  it  must 
be  granted  if  proper  methods  are  employed  ;  a  mistake,  even 
though  slight,  in  our  course  will  be  fatal.  It  must  be  con- 
ceded that  an  organization  of  nurses  which  includes  all 
nurses  is  our  strongest  possible  formation.  Once  united 
we  can  make  ourself  felt  and  cause  the  enactment  of  laws 
for  our  protection.  Protection  to  ourselves  from  the 
entrance  to  our  ranks  of  unfit  and  improper  persons ;  pro- 
tection to  ourselves  from  the  quacks  and  frauds  invading 
our  ranks,  claiming  that  which  we  have  struggled  so  hard  to 
acquire;  protection  to  ourselves  against  the  institutions 
unfit  and  incapable  of  giving  a  training  suitable  to  prepare 
one  for  the  work,  but  which  now  turn  out  graduates  with 
the  title  of  "nurse,"  but  before  we  can  effect  the  enact- 
ment of  such  laws  we  must  be  united — united  in  its  full- 
est meaning,  and  create  a  public  sentiment  which  demands 
all  we  so  much  desire ;  cause  the  public  to  feel  that  which  we 
so  keenly  feel ;  make  our  cause  that  of  the  public.  The  best 
and  most  stable  laws  are  only  answers  to  the  demand  of  the 
people.  We  can  never  expect  it  from  any  other  source,  and 
if,  by  chance,  we  should  succeed  it  would  be  only  with  diffi- 
culty that  we  could  cause  the  enforcement  of  such  statutes. 
If  we  make  ourselves  felt,  if  we  are  strong  enough  to  impress 
the  necessity  upon  the  public,  it  will  of  itself  attain  our  de- 
sired end.  While  the  course  we  have  to  pursue  may  not  be  a 
new  one  it  must  necessarily  be  original.  It  is  dangerous  to 
imitate.    Facts  and  circumstances  diflfv^r,  and  the  most  it  is 


346  International  Congress  of  Nurses 

safe  to  do  by  way  of  acceptinc^  criterions  is  to  profit  by  the 
errors.  Do  not  let  us  attempt  imitation,  lest  we  fail.  Orij^i- 
nality  is  admirable,  satisfactory  and  usually  successful. 
Imitation  is  not  the  genuine — it  is  cheaper.  It  is  not  a  suc- 
cess— no  matter  how  perfect  the  imitation.  Our  training- 
should  have  taught  us  to  use  discretion ;  to  shun  petty  and 
trivial  matters ;  to  hold  ourselves  above  any  and  all  things 
that  in  the  slightest  degree  retard  the  progression  of  our 
profession,  even  though  it  be  to  the  individual's  displeasure; 
to  ignore  all  except  that  which  brings  the  goal  nearer ;  to 
grasp  every  opportunity  to  advance  the  profession  and  very 
soon  the  desired  legislation  will  come  without  serious 
hindrance. 

The  question  with  which  we  have  to  deal  is  "How  to 
Organize  "  The  first  step  is  to  let  go  the  non-essentials ; 
let  go  all  selfishness  and  self-seeking,  all  bitterness  and 
unkindly  feeling.  We  cannot  accomplish  what  we  wish 
without  a  true  sisterhood.  The  nurses  of  today  are,  in  the 
main,  earnest,  sincere,  practical  women,  ready  to  do  that 
"something;"  ready  to  take  hold  and  help  lift  if  they  are 
only  shown  how^  Just  think  what  we  might  accomplish 
if  we  could  reach  nurses  in  a  way  to  divert  all  energy  wasted 
in  vain  worry,  criticisms,  foolish  bickerings,  fretting  over 
non-essentials,  into  success  capital.  Governor  Russell,  of 
Massachusetts,  once  said :  "  Make  a  living,  but  remember 
that  there  is  another  thing  better  than  making  a  living, — 
making  a  life." 

In  all  sincerity,  all  candor  and  honesty  of  purpose  I 
want  to  say  that  I  believe  that  a  State  society  organized  on 
alumnae  lines  would  be  a  failure.  The  very  nature  of  such 
an  organization  is  too  narrow.  Nurses  need  to  broaden,  to 
mingle  with  those  of  other  schools,  and  to  get  out  of  the 
ruts.  The  nurse  whose  first  interest  is  "  our  alumnse"  is 
apt  to  be  narrow  or  to  become  so.  A  membership  in  a  well 
organized,  well  conducted,  general  club  is  uplifting.  It 
inspires  a  person  with  a  wholesome  self  respect,  and — "  It 
is  the  first  blow  at  the  petty  prejudices  which  the  old  man- 
ner of  living  apart  from  the  world  has  fostered.     In  it  a 


Organization  and  Registraticvi  347 

woman  quickly  learns  that  hers  is  not  the  only  true  religious 
creed,  that  her  doctor  is  not  the  only  worthy  M.  D.,  that 
her  way  is  not  the  only  infallible  way.  She  is  soon  ashamed 
of  her  own  narrowness."  It  would  be  a  mistake  to  make 
the  State  associations  dependent  upon  the  success  of  the 
local  organizations,  which  are  too  often  failures,  and  kept 
in  existence  only  through  the  indefatigable  efforts  of  a 
few  women.  We  would  give  all  honor  to  the  alumnae  socie- 
ties. They  have  done  much  toward  agitating  and  bringing 
to  notice  and  thought  the  need  for  improvement,  but  we 
believe  they  should  be  subordinate  to  the  general  club, 
otherwise,  they  disseminate  the  forces  and  weaken  all  finan- 
cially. Their  continued  existence,  except  as  a  means  of 
maintaining  an  esprit  de  corps  among  the  graduates,  and  a 
love  and  loyalty  for  the  Alma  Mater,  is  a  step  backward  and 
jeopardizes  progression.  Within  the  next  few  months  three 
States.  New^  York,  Illinois  and  Virginia,  will  perfect  a  State 
organization.  I  cannot  dwell  too  strongly  upon  the  need  of 
organizing  in  such  a  way  that  we  may  be  able  to  command 
the  assistance  of  every  nurse  in  the  State;  and  that  we  can 
rely  upon  the  co-operation  of  physicians  and  not  antagonize 
hospitals  and  through  them  politicians. 

The  New  York  State  Society  w-as  organized  last  April 
with  sixty-five  charter  members.  The  plan  of  what  shall 
constitute  membership  is  to  be  settled  at  the  second  meeting. 
I  believe  that  we  should  organize  in  such  a  way  that  we  may 
ask  any  woman  in  the  State  who  is  a  graduate  of  a  recog- 
nized school  to  become  a  member;  we  reaHze  all  that  that 
implies ;  it  would  mean  the  admission  of  many  whose  stand- 
ards are  not  what  we  might  wish,  but  the  fault  is  not  theirs ; 
we  must  look  farther  back ;  the  wrong  is  with  our  laws  that 
have  allowed  all  sorts  of  hospitals  to  maintain  training 
schools  regardless  of  the  product.  My  plan  would  be  to 
have  all  such  help  us  to  help  themselves.  Ability  means  to 
take  conditions  as  they  are,  and  make  of  them  what  we  wish. 
I  would  have  meetings  held  as  often  as  every  three  months, 
giving  all  members  an  opportunity  to  attend. 


348  International   Congress   of   Nurses 

A  business  corporation  in  which  I  am  interested  lately 
issued  a  bulletin  in  which  was  quoted  these  old  Greek  lines : 

"Who  art  thou?" 

"  I  am  Opportunity,  the  master  of  all  things." 

"  Why  on  tiptoe  standings?" 

"  I  run  forever  forward." 

"  Why  is  thy  hair  all  in  front?" 

"  For  him  who  meets  me  to  seize." 

It  seems  to  me  that  there  never  was  a  time  in  the  history 
of  the  nursing  profession  when  an  opportunity — oppor- 
tunity worth  while — 'was  so  easily  within  the  grasp  of  each 
individual  nurse,  as  at  this  particular  moment. 


The  President:     Our  next  paper  is  also  on  the  same 
subject  as  it  relates  to  Canada. 


Organization  and  Legislation  in  Canada. 

MARY  AGNES  SNIVELY, 

Lady  Superintendent  General  Hospital,  Toronto,  Canada  ;  Member  of  the  Ameri- 
can Society  of  Superintendents ;  Treasurer  of  the  International 
Council  of  Nurses. 


It  is  my  privileg-e  and  pleasure  to  present  to  this  con- 
gress a  brief  statement  regarding-  the  present  status  of 
nursing  in  Canada,  and,  in  order  that  I  may  not  needlessly 
occupy  valuable  time,  I  will  simply  state  that  all  of  oiu-  rep- 
resentative schools  are  conducted  on  the  same  general  lines 
as  those  which  obtain  in  well-regulated  schools  in  this 
country.  We  employ  the  same  methods,  we  are  animated  by 
the  same  aspirations,  and  we  endeavor  to  keep  before  us  the 
same  high  ideals  as  our  fellow-workers  in  the  United  States, 
to  whom  we  unhesitatingly  and  gratefully  acknowledge  our 
indebtedness.  True  it  is  that,  at  present,  such  schools  are 
few  in  number  in  Canada;  nevertheless,  these  undoubtedly 
constitute  the  leaven  which,  while  working  more  slowly  in 
our  more  conservative  country,  is  none  the  less  surely  and 
steadily  asserting  itself  along  the  line  of  progress.  We  have 
our  school  organizations,  and  these  are  undoubtedly  multi- 
plying, and  we  have  attempted  a  national  organization. 

In  1900  a  bill  to  incorporate  the  Canadian  Nurses' 
Association  was  introduced  into  the  Dominion  Parliament, 
but  on  account  of  certain  clauses  which  were  considered 
detrimental  to  the  interests  of  nurses  it  was  withdrawn  after 
the  second  reading  with  the  promise  that  a  second  bill 
should  be  introduced  within  a  year.  ^^^ 


350  International  Congress  of  Nurses 

In  1901,  when  the  second  bill  was  introduced,  it  was 
evident  that  a  progressive  association  could  not  prosper 
under  the  conditions  with  which  the  bill  was  likely  to  be 
freighted,  and,  further,  that  in  Canada  there  remained  much 
yet  to  be  accomplished  in  the  way  of  alumnae  and  provincial 
associations  before  a  national  organization  would  prove 
beneficial.    The  bill  for  these  reasons  was  withdrawn. 

An  important  feature  in  connection  with  many  of  our 
large  training  schools  is  the  decided  advance  in  respect  to 
the  conditions  which  surround  the  nurse  in  the  home  or 
residence  where  her  "  off  duty  "  hours  are  spent.  In  many 
instances  these  are  commodious  buildings  adjacent  to  the 
hospital,  with  well-lighted  and  heated  sleeping  apartments, 
parlors  where  they  may  spend  their  leisure  time  or  entertain 
their  friends,  libraries  containing  both  general  arid  medical 
literature  to  which  they  have  access,  lecture  and  class-rooms 
containing  suitable  charts  and  appliances  where  they  receive 
theoretical  and  practical  instruction. 

It  must  be  remembered  that  the  evolution  of  the 
Canadian  trained  nurse  has  taken  place  in  a  country  where 
wealth  is  to  a  large  extent  limited.  With  the  exception  of 
Montreal,  this  may  truly  be  said  of  all  Canadian  hospitals. 

But  difficulty  and  struggle  do  not  necessarily  imply 
failure;  indeed,  we  all  know  that  the  contrary  is  generally 
the  case,  for  effort  is  usually  the  price  paid  for  development. 

Sterling  worth,  strength  of  character,  and  fertility  of 
resource  are  the  characteristics  so  eminently  conspicuous  in 
our  ancestors  who  in  the  early  part  of  the  last  century  were 
pioneers  in  our  vast  dominion.  And  no  less  is  this  true  of 
nurses  who  have  gained  their  experience  in  the  less  wealthy 
hospitals  which  are  found  in  the  Dominion  of  Canada.  Yet 
Canada  has  truly  made  rapid  strides  in  nursing  during  the 
last  fifteen  years.  She  has  learned  to  value  skilled  nursing 
to  such  an  extent  as  to  be  willing  to  make  almost  any  sacri- 
fice in  order  to  secure  it.  Her  physicians  and  surgeons  are 
now  loyal  friends  and  allies,  when  once  they  were  inclined 
to  be  conservative  or  critical. 

The    larger    schools    are    yearly    making    noticeable 


Organization  and  Legislation  35^ 

advance  in  educational  methods,  and  the  smaller  ones  are 
rapidly  multiplying  in  the  newer  parts  of  the  country,  these 
in  their  turn  becoming  centers  radiating  in  lesser'  degree 
their  benign  influence.  Still,  we  realize  that  we  have  not 
yet  attained— far  from  it— but  of  Canadian  nurses  it  may 
truly  be  said,  "  we  are  reaching  forward  to  those  things 
which  are  before,  and  ever  pressing  forward  towards  the 
^oal  of  our  high  calling." 

The  President :  The  subject  of  the  papers  to  which  we 
have  just  listened  must  appeal  to  every  member  of  this  audi- 
ence. It  is  one  of  vital  importance  to  every  one  interested 
in  the  nursing  profession;  therefore  the  chair  would  of!er 
this  resolution,  which  has  received  the  endorsement  of  the 
executive  committee: 

Whereas,  The  nursing  of  the  sick  is  a  matter  closely 
affecting  all  classes  of  the  community  in  every  land  ;  and, 

Whereas,  To  be  efficient  workers  nurses  should  be 
carefully  educated  in  the  important  duties  which  are  now 
allotted  to  them ;  and, 

Whereas,  At  the  present  time  there  is  no  generally 
accepted  term  or  standard  of  training,  nor  of  system  of  edu- 
cation, nor  of  examinations  for  nurses  in  this  or  in  conti- 
nental countries ;  and, 

Whereas,  There  is  no  method,  except  in  South  .\frica.* 
of  enabling  the  public  to  discriminate  easily  between  trained 
nurses  and  ignorant  persons  who  assume  that  title  ;  and, 

Whereas,  This  is  a  fruitful  source  of  injury  to  the  sick 
and  of  discredit  to  the  nursing  profession, 

T^solved;  That  it  is  the  opinion  of  this  International 
Congress  in  general  meeting  assembled,  that  it  is  the  duty 
of  the  nursing  profession  of  every  country  to  work  for  suita- 
ble legislative  enactments  regulating  the  education  of  nurses, 
and  protecting  the  interests  of  the  public,  by  securing  State 
examinations  and  public  registration,  with  the  proper  penal- 
ties for  enforcing  the  same. 

[*And  now  inNew  Zealand.— Ed.] 


352  International  Congress  of  Nurses 

Miss  Stewart:  I  have  much  pleasure  in  seconding-  this 
resolution,  but  first  I  want  to  say  that  I  am  not  a  delegate 
from  any  association,  and  what  I  say  is  for  myself  alone. 
I  think  that  State  registration  is  a  cure  for  many  of  the  evils 
we  see  every  day.  It  will,  to  a  large  extent,  prevent  the 
partially  trained  or  untrained  nurse  taking  what  properly 
belongs  to  the  trained  nurse,  her  work  and  her  title  to 
which  she  has  gained  the  right  by  three  years'  work  and 
study  in  a  g-eneral  hospital.  In  England  we  use  very  gener- 
ally, what  I  see  but  rarely  in  America,  the  outdoor  uniform 
of  cloak  and  bonnet.  It  can  be  worn  by  anyone  and  is  some- 
times the  only  qualification  its  wearer  has  to  the  name  of 
nurse,  and  it  serves  to  cover  such  a  multitude  of  sins.  Reg- 
istration cannot  altogether  alter  this  condition,  for  the  public 
will  at  all  times  choose  for  itself ;  but,  at  least,  it  will  give  the 
public  an  opportunity  of  knowing  what  it  is  choosing  and 
paying  for. 

State  registration  for  nurses  means  a  uniform  standard 
of  ef^ciency.  This  is  one  little  point  upon  which  Mrs.  Fen- 
wick  and  I  disagree.  She  advocates  a  uniform  curriculum, 
which  I  do  not.  I  always  deprecate  anything  that  takes 
away  the  individuality  of  the  schools.  Let  there  be  a  uni- 
form standard  of  ef^ciency,  which  each  school  must  reach  in 
any  way  it  finds  best  suited  to  it.  I  think  we  must  hold  to 
the  uniform  standard  and  leave  the  curriculum  to  the  indi- 
vidual schools. 

There  are  many  difficulties  to  be  faced  when  the  details 
of  this  scheme  come  to  be  considered,  and  not  the  least  of 
them  will  be  the  small  hospitals  of  thirty  and  forty  beds  and 
under.  It  is  impossible  for  nurses  to  be  adequately  trained 
in  them,  partly  from  want  of  sufficient  variety  of  cases  and 
partly  from  the  almost  insuperable  difficulty  of  enforcing 
the  discipline  of  the  larger  schools,  and,  to  a  large  extent,  it 
is  discipline  which  trains  the  woman  into  the  nurse. 

Although,  as  I  have  pointed  out,  I  see  the  difficulties 
which  lie  before  us,  when  we  come  to  the  details  of  this 
scheme,  I  am,  and  always  have  been  strongly  in  favor  of 
State  registration  and  examination.  Therefore,  I  have 
much  pleasure  in  seconding  the  resolution  now  before  us. 


Organization  and  Legislation  353  - 

Miss  Snively:  Madam  President,  ladies.  As  a  Cana- 
dian representative  I  would  like  to  say  that  Canada  has 
shown  her  appreciation  of  the  resolution  which  has  been 
moved  by  the  chairman  regarding  the  legislation  which 
should  come  in  behalf  of  the  nursing  profession.  Many  of 
those  present  remember  we  have  lately  made  an  attempt  at 
legislation,  and  although  we  have  failed.  I  may  say  that  one 
cause  of  the  failure,  perhaps  one  of  the  very  prominent 
cause  of  failure,  was  just  on  the  line  we  have  been  speaking 
about,  because  some  of  the  members  of  parliament  feared 
for  the  nurses  with  whom  they  were  personally  acciuainted, 
who  had  done  good  work  in  their  families,  although  they 
were  not  trained  nurses,  absolutely  trained  nurses,  they 
feared  that  future  promised  ill  for  them.  We  hope  to  make 
another  trial  on  a  better  line  and  that  Canada  will  have  legis- 
lation for  her  trained  nurses. 

Miss  McGahey :  I  endeavored  to  tell  you  on  Wednes- 
day about  our  association  in  Australia.  Our  association 
there  is  well  established.  We  have  much  more  to  do  and 
hope  to  do  it,  and  no  doubt  will  do  it  in  our  own  way.  We 
hope  at  no  distant  day  to  have  introduced  in  parliament  a 
bill  to  save  our  nurses,  to  safeguard  ourselves.  Many  years 
ago  we  realized  the  great  necessity,  realized  that  a  great 
injustice  was  being  done  our  nurses  who  had  taken  the 
training  school  work  for  four  or  five  years,  and  when  they 
went  out  as  private  nurses  they  had  no  better  position  than 
those  who  had  spent  only  six  or  eight  months  and  who  were 
able  to  give  satisfaction  to  the  doctor,  or  the  head  of  the 
training  schools  who  had  been  perhaps  asked  to  resign 
because  unsatisfactory,  and  still  stood  on  the  same  platform 
as  those  who  had  spent  years  in  training.  In  one  way  the 
Australasian  Trained  Nurse  Association  has  done  a  .great 
deal  of  good,  and  we  now  have  a  register.  Now  many  of 
the  public  who  employ  nurses  refer  to  our  register,  and  if  the 
nurse's  name  is  not  in  the  register  no  doubt  she  is  asked  why 
she  is  not  there.  The  leading  nurses  are  all  registered.  It 
is  very  gratifying  to  learn  that  New  Zealand,  a  couniry 


354  International  Congress  of  Nurses 

always  well  to  the  front,  has  had  a  bill  introduced  in  their 
parliament  to  protect  the  nurses.  It  is  already  now  in  the 
first  reading-  and  may  have  passed  the  upper  house,  and  we 
hope  before  the  next  meeting-  of  the  International  Council 
of  Nurses  you  will  hear  that  Australia  has  got  its  State  reg- 
istration for  nurses. 

Mrs.  Robb:  Madam  Chairman,  ladies — I  warmly 
endorse  Mrs.  Fenwick's  paper. 

American  nurses  may  not  be  aware  that  we  are  indebted 
in  part  for  our  education  in  organization  to  British  nurses, 
and  British  nurses  may  not  be  aware,  in  their  turn,  that  they 
have  been  silently  teaching  their  younger  American  sisters ; 
I  think  this,  therefore,  a  very  fitting  moment  to  express  our 
appreciation  of  the  advantages  they  have  so  generously 
given  us  through  their  pioneer  efforts.  That  we  have  tried 
to  improve  by  them  the  work  that  we  have  accomplished 
during  the  last  seven  years  testifies,  and  in  order  that  you 
may  know  where  our  education  began,  I  will  briefly  speak 
of  the  organization  of  the  Royal  British  Nurses'  Association. 
This  organization,  as  you  perhaps  know,  was  the  first  asso- 
ciation among  British  nurses  that  came  to  our  notice.  It 
was  indeed  most  interesting  to  read  of  its  inception ;  it  at 
first  seemed  to  American  nurses  who  read  about  it  that  the 
organization  was  all  that  could  be  desired,  as  the  association 
stood  partly  for  the  registration  of  trained  nurses.  But  on 
further  reading  its  transactions,  and  following  its  workings, 
we  found  that  something  was  wrong,  and  after  a  little  closer 
study  the  following  criticisms  seemed  warranted :  First,  it 
was  evident  that  the  nurses  of  the  Royal  British  Nurses' 
Association  were  not  really  acquainted  with  each  other,  or 
at  least  not  sufficiently  well  enough,  to  have  organized  for 
the  purpose  of  legislation ;  consequently  how  could  they  ask 
the  public  to  know  them  and  think  well  of  them?  second, 
that  the  Royal  British  Nurses'  Association  was  being  too 
much  looked  after  by  the  medical  profession ;  and,  third, 
that  it  was  being  too  heavily  patronized.  Therefore,  when 
it  came  to  the  question  of  organizing  in  America,  for  pro- 


Organization  and  Legislation  355 

fessional  advancement  and  for  the  purpose  of  obtaining 
legislation  for  nurses,  we  had  learned,  first,  that  it  would  be 
wiser  to  organize  nurses  in  such  a  way  as  to  enable  them  to 
become  thoroughly  acquainted  with  each  other,  and  thus  to 
know  our  own  minds  before  we  could  seek  recognition  as  a 
profession  of  intelligent  women  by  the  public. 

Second  :  That  we  should  have  something  like  a  uniform 
basis  of  general  education.  We  should  know  better  what 
our  training  schools  were  teaching,  as  there  seemed  to  be  no 
uniformity  in  the  system  employed  in  the  different  schools. 
We  had  really  no  general  idea  of  what  was  being  done,  and 
all  that  had  to  be  worked  out;  and,  third,  we  clearly  saw 
that  we  should  look  after  our  own  affairs,  and  do  our  own 
work,  and  create  our  own  profession.  We  do  not  mean  by 
this,  however,  that  we  are  not  aware  of  our  constant  obliga- 
tion to  a  kindly  public,  and  also  that  we  should  be  and  are 
loyal  to  the  medical  profession,  but  if  we  wish  to  be  a  suc- 
cessful body  of  workers,  we  must  take  care  of  our  owm  affairs 
from  beginning  to  end.  On  this  basis,  then,  the  American 
nurses  began  to  organize — first  the  school  alumnae,  for 
we  could  not  ask  you  to  be  interested  in  a  large  organi- 
zation of  nurses,  until  you  knew  your  own  colleagues,  or  to 
grasp  the  broader  professional  problems  until  you  were 
interested  in  home  affairs.  For  educational  purposes  also 
the  Society  of  Superintendents  of  Nurses  was  formed,  and 
next  arose  the  question  of  the  organization  of  the  profession 
as  a  whole,  and  only  last  year  did  we  finally  reach,  in  that 
process  of  organization,  the  point  at  which  we  could  begin 
to  consider  legislation,  and  I  am  happy  to  say  that  the  ques- 
tion was  at  once  taken  up  by  the  State  organization  of 
nurses  of  New  York,  and  we  are  hoping  for  very  favorable 
results. 

The  privilege  of  meeting  with  the  foreign  delegates  to 
this  Congress  makes  it  very  clear  to  us  what  the  next  step 
in  our  organization  should  be,  and,  as  Mrs.  Fenwick  so 
forcibly  put  it  before  us,  the  necessity  for  further  organiza- 
tion in  order  that  we  may  become  better  acquainted  with 
the  nurses  of  other  countries  and  their  work.     Many  of  you, 


356  International  Conc^ress  of  Nurses 

no  doubt,  were  present  at  the  meetingf  of  the  International 
Council  of  Nurses  held  in  this  room  last  Tuesday.  At  that 
time  we  were  told  that  the  United  States  is  the  only  country 
at  present  in  which  the  nurses  are  ready  to  afifiliate  with  the 
International  Council  of  Nurses,  so  we  have  not  worked  in 
vain  up  to  this  point. 

So  far  as  a  uniform  curriculum  is  concerned  I  quite 
agree  with  Mrs.  Fenwick. 

It  was  with  great  pleasure  that,  only  the  other  day  in 
an  educational  journal,  I  read  that  the  president  of  one  of 
our  large  universities  advocates  the  advisability  of  a  uni- 
form standard  education  for  the  universities  of  the  country, 
and  it  seemed  to  me  that  unknowingly  we  had  worked  along 
the  right  lines  in  this  respect. 

The  President :  You  have  heard  the  resolution  ;  all  in 
favor  of  adopting  it  will  manifest  it  by  rising.    All  rose. 

The  President :  The  chair  understands  there  are  to  be 
some  further  resolutions  presented.  I  will  call  upon  the 
secretary  to  read  the  first  resolution. 

The  secretary  reads : 

Resolved,  That  the  third  International  Congress  of 
Nurses  strenuously  protests  against  the  sending  out  of  pupil 
nurses  to  private  duty  during  their  period  of  training  in  the 
hospitals. 

[Proposed  by  Miss  Nevins,  superintendent  of  the  Gar- 
field Hospital  in  Washington,  D.  C] 

Miss  Dock  :     I  second  the  motion. 

The  President :  This  resolution  has  been  presented  by 
Miss  Nevins,  of  Washington,  D.  C,  and  seconded  by  Miss 
Dock.  All  of  those  in  favor,  signify  it  by  saying  aye.  It 
seems  to  be  unanimously  carried. 

Delegate  from  Maryland  General  Hospital :  I  desire 
to  second  that  resolution  because  our  society  is  so  very 
anxious  about  this  point. 


Organization  and  Legislatioti  357^ 

Miss  Dock :  I  willingly  yield  my  second  to  the  dele- 
gate from  Maryland. 

The  President :     \\q  will  now  have  the  third  resolution. 
Resolution  read  by  secretary : 

Resolved,  Tliat  the  delegates  and  visitors  to  this  Con- 
gress, having  a  deep  appreciation  of  the  benefit  and  pleasure 
they  have  derived  from  these  meetings,  desire  to  express 
their  gratitude  to  all  officers  and  committees  for  the  excel- 
lent arrangements  made  for  the  meetings  of  this  Congress ; 
also  to  all  \n\\o  have  given  of  their  time  in  the  preparation  of 
the  papers  and  addresses  which  have  been  of  such  great 
interest  and  instruction.  They  also  desire  to  express  the 
pleasure  this  assemblage  has  had  in  welcoming  the  foreign 
delegates.  They  feel  that  this  coming  together  of  the  most 
distinguished  members  of  our  profession  in  Great  Britain 
and  her  colonies  and  in  this  country,  with  the  good  will  of 
those  in  Europe,  has  been  productive  of  most  unusual  stimu- 
lation, w^hich  we  trust  will  result  in  good  and  effectual  work. 

The  President :  This  resolution  has  been  offered  by 
Miss  Hay  of  the  Illinois  Training  School,  and  has  been 
seconded  by  Dr.  Hughes  of  Boston. 

I  think  I  voice  the  sentiments  of  the  Congress,  and 
especially  of  the  American  members,  when  I  say  that  we  are 
greatly  indebted  to  the  foreign  delegates  for  their  papers  and 
for  their  very  helpful  ideas.  We  are  indebted  to  them  for 
the  formation  of  many  of  our  training  schools,  and  1  wish 
to  express  our  appreciation  to  the  English  nurses  for  com- 
ing here  and  giving  us  so  generously  of  their  time. 

You  have  heard  the  resolution.  The  chair  would 
request  that  the  Congress  express  its  approval  by  rising. 

The  audience  arose. 

Mrs.  Fenwick:  Madam  President,  colleagues— I  just 
arise  to  respond  a  few  words  to  this  most  kind  resolution 
which  has  been  passed  by  the  Congress.  I  feel  sure  that 
every  delegate  who  has  attended  this  Congress,  either  from 
England,  the  colonies  or  elsewhere,  has  enjoyed  it  as  a  pnv- 


358  International  Congress  of  Nurses 

ileg-e.  We  thank  you  for  the  kind  way  you  have  listened  to 
the  papers  we  have  been  privileged  to  read.  I  must  express 
my  appreciation  for  the  honor  of  being  your  honorary 
president.  It  is  the  highest  honor  that  has  ever  been  con- 
ferred upon  me.    I  thank  you. 

Miss  Stewart :  Mrs.  Fenwick  has  said  everything  that 
ought  to  be  said. 

It  has  been  the  ambition  of  my  life  to  come  to  America, 
l)ut  I  doubt  if  I  should  ever  have  come  if  this  Congress  had 
not  given  me  the  opportunity.  I  assure  you  that  it  is  not 
often  one  has  the  pleasure  and  privilege  of  preparing  a  paper 
to  be  read  before  so  many  whose  names  have  been  house- 
liold  words  for  so  many  years. 

I  thank  you  very  much  for  your  kindness  since  I  have 
been  here,  and  for  all  the  pleasure  I  have  had. 

Miss  Amy  Hughes :  I  can  only  join  with  those  who 
have  already  spoken  in  thanking  you  all  most  warmly  for 
vour  kindness  to  us.  It  has  been  a  great  privilege  to  be 
present  at  such  a  Congress  as  this,  and  I  personally  appre- 
ciate it  even  more  because  I  had  the  happines  of  attending 
the  one  in  1893.  If  I  may  say  so,  I  am  deeply  impressed 
bv  the  sense  of  growth  and  increased  unity  and  strength 
presented  at  this  meeting.  The  feelings  of  devotion  to  our 
work  and  the  desire  of  attaining  a  high  standard  profession- 
ally have  developed  so  quickly  that  I  am  tempted  to 
compare  the  movement  to  the  Indian  juggler's  artifice  of 
planting  a  seed  before  his  audience  which  in  a  few  moments 
is  shown  as  having  become  a  little  tree.  I  would  say  our 
strength  and  hope  for  the  future  lies  in  the  efforts  of  each 
individual  nurse  to  honestly  maintain  in  herself  the  high 
standard  we  are  aiming  at.  We  must  not  forget  we  are 
soldiers  and  must  therefore  loyally  obey  the  orders  of  our 
officers,  the  medical  profession,  in  our  work ;  but  in  our  own 
hands  alone  lies  the  position  we  as  a  profession  will  take  in 
the  eyes  of  the  world.  Such  a  gathering  as  this,  with  its 
unity  of  purpose  manifested  in  so  many  countries,  under 
varying  conditions,  shows  what  can  be  done  and  what  lies 
before  us.     I  thank  you  all  most  warmly. 


r  '^  Organization  and  Legislation  359 

Miss  McGahey:  I  have  appreciated  being  present  at 
these  meetings.  For  many  years  I  have  looked  forward  to 
a  visit  to  America,  and  now  my  hopes  have  been  reahzed. 
I  think  that  I  have  traveled  farther  to  attend  this  Congress 
than  any  of  the  other  delegates.  I  have  come  15,000  miles. 
I  assure  you  that  the  reception  I  have  met  with  will  not 
soon  pass  from  my  mind,  and  the  meetings  which  I  have 
been  privileged  to  attend  have  been  most  edifying  and 
instructive.     I  thank  you  all. 

■  MissMollett:  I  want  to  speak  personally.  They  have 
all  mentioned  the  privilege  of  meeting  you  here,  but  I  want 
to  emphasize  my  personal  enjoyment.  It  has  been  to  me  a 
great  pleasure  and  happiness,  and  I  carry  away  with  me  the 
recollection  of  American  nurses  that  is  most  pleasing.  I 
have  met  with  universal  kindness,  courtesy,  and  considera- 
tion, for  which  I  thank  you  very  sincerely. 

Miss  Stevenson:  Madam  President,  ladies — Although 
I  have  not  the  honor  to  be  a  nurse,  I  have  for  many  years 
been  connected  with  nurses  in  various  conditions.  In  the 
first  place,  as  one  of  the  guardians  of  the  poor,  I  have  had 
to  do  with  the  workhouse  hospital.  I  have  also  had  to  do 
with  the  Queen  Victoria  Nursing  Association.  I  also  have 
for  many  years  been  a  member  of  the  Royal  Infirmary,  so 
I  have  some  excuse  for  saying  a  few  words  to  you.  and  I 
thank  the  committee  who  organized  this  Congress,  from 
which  I  have  learned  much.  I  am  perfectly  certain  that 
after  having  been  here  I  shall  be  much  better  fitted  for  any 
duty  that  I  am  called  upon  to  perform  in  connection  with 
nursing. 

I  thank  you  most  cordially  for  the  kindness  1  have 
received,  and  I  shall  never  regret  the  day  when  I  made  up 
my  mind  to  cross  the  Atlantic  and  come  in  contact  with  tiu- 
American  nurses. 

Miss  Wood:  My  co-delegate  has  said  all  that  could 
be  said,  I  think,  but  I  would  like  to  make  one  point,  and 
that  is  that  we  owe  a  very  great  debt  to  the  organizing  bexly 
of  this  Congress.     It  has  been  a  great  piece  of  work  to  get 


360  International  Congress  of  Nurses 

it  up.  There  has  been  no  detail  omitted.  Nothinj^  has  been 
foff^otten  for  our  pleasure  and  hap]:)iness.  I  really  have  to 
thank  our  American  sisters  for  havinj^  given  us  a  very  good 
time.  I  think  everything  I  ought  to  say  has  already  been 
said,  but  I  would  like  to  add  that  I  think  I  return  to  Eng- 
land a  more  intelligent  and  a  broader-minded  woman. 

Miss  Cartwright :  Madam  President,  ladies — In 
behalf  of  the  Registered  Xurses'  Society,  which  I  have  the 
honor  to  represent,  I  very  cordially  thank  you  for  your 
kindness  to  me  as  one  of  the  British  delegates. 


-j-i' 


Miss  Arkle :  I  claim  the  distinction  of  having  come 
the  farthest.  One  delegate  says  she  has  come  15,000  miles, 
but  I  have  come  from  India  to  England  ;  that  is  8,000  miles ; 
from  England  to  New  York,  3,000  miles ;  from  New  York 
to  San  Francisco,  3,000  miles ;  from  San  Francisco 
here ;  and  I  think  that  makes  more  than  15,000  miles.  So  I 
have  really  beaten  her.  I  should  not  have  come  had  I  not 
known  I  would  enjoy  myself  most  thoroughly,  and  I  have 
enjoyed  myself  more  than  I  expected. 

The  President :  The  chair  feels  quite  unequal  to  say- 
ing what  is  the  proper  thing,  only  to  echo  the  kind 
expressions  which  we  have  heard  from  our  foreign  visitors, 
and  which  we  have  heard  from  our  own  home  delegates,  and 
echo  the  feeling  that  is  in  the  hearts  of  us  all.  It  has  been 
worth  all  the  work  it  has  given  to  bring  it  about,  and  it  is 
going  to  be  a  red  letter  day  in  the  nursing  profession  all  over 
the  world — this  third  International  Congress  of  Nurses. 
The  improvement  in  all  lines,  in  all  departments  of  nursing 
will  go  on  with  new  vigor.  Those  of  us  who  are  here 
today  who  know  anything  of  the  work  of  the  International 
Congress  of  Nurses  in  Chicago,  know  how  much  grew  out 
•of  that,  and,  as  Miss  Hughes  has  said,  if  from  that  we  have 
grown  so  much,  surely  from  this  there  should  be  greater  and 
fuller  growth  than  ever  before. 

The  meeting  will  be  adjourned  now  until  tomorrow 
.afternoon  at  the  Exposition  grounds. 


SATURDAY,    P.   M. 


Mayor  Diehl,  the  first  speaker,  extended  a  welcome  to 
the  visitors  more  in  the  capacity,  as  he  expressed  it,  "of  a 
medical  man  than  as  a  mayor."  In  the  course  of  his 
remarks  he  said  that  no  physician  on  earth  holds  such  a 
responsible  position  as  does  the  nurse. 

Mrs.  John  Miller  Horton,  in  her  usually  gracious  man- 
ner, extended  a  welcome  in  behalf  of  the  board  of  women 
managers  of  the  exposition. 

"  The  request  to  say  a  few  words  of  welcome  to  you 
comes  to  me  as  a  pleasant  means  of  expressing  the  deep 
interest  I  feel  in  your  organization,"  she  said,  "and  my 
appreciation  of  the  noble  work  in  which  you  are  engaged. 
Some  of  you  have  come  to  us  from  over  the  sea.  To  you 
r  extend  a  double  welcome.  It  must  be  remembered  that 
only  a  few  short  years  ago  you  were  obliged  to  fight  the 
prejudices  that  new  methods  are  apt  to  encounter  in  the 
Old  World,  and  those  of  us  who  were  traveling  on  the  con- 
tinent were  obliged  to  telegraph  to  London  for  help  in  times 
of  illness.  It  will  be  recalled  that  the  uniform  you  wear  then 
sent  terror  to  the  hearts  of  many  of  the  gay  revellers  at 
Mediterranean  resorts,  who  thought  only  of  themselves  and 
did  not  wish  to  have  any  reminder  of  the  grim  presence  of 
disease.  To  me  that  uniform  is  a  badge  of  honor  worthy  to 
rank  with  the  cross  of  St.  Louis  or  Victoria.  Your  pro- 
fession calls  for  not  only  great  technical  skill,  but  a  rare 
patience  and  courage. 

"  In    this    connection  I  will    relate  an  incident    which 

occurred  a  few  years  ago  in  one  of  the  cities  in  the  south  of 

361 


362  International  Congress  of  Nurses 

France.  Through  the  long,  lonely  watches  of  the  night  a 
mother  sat  by  the  bedside  of  her  child,  ill  unto  death,  unable 
to  find  anyone  to  aid  her  in  the  care  of  the  little  one.  But 
when,  with  the  dawn,  the  English  trained  nurse  arrived  from 
London,  it  seemed  as  if  the  brightness  of  the  sunshine  had 
entered  the  sick  room,  and  the  heavy  burden  of  a  dread 
responsibility  had  been  lifted  from  the  mother  to  the  willing 
shoulders  of  one  whose  tender  hand  brought  healing  in 
its  touch  to  the  sick  child  and  comfort  to  the  anxious  heart 
of  that  mother,  whose  gratitude  found  expression  in  a  wish 
to  save  others  the  anxiety  she  had  suffered,  and  thus  was 
founded  the  Holland  Home  for  Nurses  on  the  Riviera, 
where,  in  a  comfortable  home,  the  young  nurses  who  leave 
London  for  their  work  among  the  winter  resorts  in  the 
south  of  France  can  stay  while  not  employed,  and  those 
desiring  their  services  have  but  to  ap])ly  there  to  secure  at 
once  the  help  needed. 

"  No  words  of  mine  can  express  the  gratitude  we  feel 
toward  these  noble,  self-sacrificing  women  who  come  to  us 
in  our  sorrow  and  anxiety  for  loved  ones.  They  are,  indeed, 
like  unto  the  ministering  angels  of  God,  bringing  healing  in 
their  wrings. 

"  Most  cordially,  then,  I  bid  you  welcome,  thrice  wel- 
come. May  your  coming  here  be  fraught  with  as  many 
blessings  to  you  as  has  the  coming  of  your  sisters  been  to 
those  of  us  who  in  our  need  have  had  the  comfort  of  having 
you  abide  with  us,  in  our  homes  and  in  our  hearts." 


A  Plea  for  the  Higher  Education  of  Trained 

Nurses. 

ETHEL  GORDON  FENWICK, 

President  of  the  International  Council  of  Nurses. 


Ladies  and  Gentlemen :  1  am  deeply  sensible  of  the 
honor  of  addressing  this  great  assembly  in  the  interests  of 
nursing.  Trained  nurses  and  the  public  are  so  closely 
united  by  the  ties  of  friendship  and  mutual  obligation  that 
this  seems  an  opportune  moment  to  consider  how  best  they 
can  discharge  the  duties  they  owe  to  each  other. 

I  trust  you  will  not  misunderstand  me  when  I  say  that 
the  public  generally  are  not  acquainted  with  the  vital  needs 
of  trained  nurses,  and  have  not  fully  realized  the  very  rapid 
process  of  evolution  which  nursing  is  passing  through  in 
order  to  keep  pace  with  the  demands  made  upon  it  by  scien- 
tific medicine  and  surgery.  Let  me  prove  my  point  by 
reference  to  Florence  Nightingale.  I  doubt  very  much  if 
the  large  majority  of  persons  who  honor  her  name  realize 
the  significance  of  her  unique  work,  which  is  the  heritage  of 
humanity.  The  world  is  apt  to  associate  her  name  primarily 
with  army  nursing  reform,  but  it  is  not  the  Red  Cross  which 
will  symbolize  her  life's  work  and  immortalize  her  name 
when  she  goes  hence,  but  the  fact  that  she  laid  down  the 
laws  and  principles  of  nursing  on  a  scientific  basis,  and  it  is 

because  she  realized  and  enforced  the  truth  that  nursing  is 

363 


364  International  Congress  of  Nurses 

not  only  a  technical  handicraft,  but  a  scientific  profession, 
that  the  nurses  of  all  nations  owe  her  an  inestimable  debt. 

The  modern  nurse,  so  fit  and  trim,  is  now  indispensable 
in  every  sick  room.  She  is  known  to  and  honored  by  all. 
Nurses  have  qualified  themselves  for  the  duties  demanded 
from  them — their  expert  knowledge,  their  skill,  and 
resourcefulness  have  only  been  acquired  by  years  of  prac- 
tical work  in  the  hospital  wards  and  by  many  hours  of 
theoretical  study.  This  severe  training  successfully  passed 
through,  they  are  ready  and  willing  to  pour  out  a  treasure  of 
skilled  and  tender  care  for  the  benefit  of  the  sick  and  suffer- 
ing amongst  rich  and  poor,  and  their  only  demand  is  that 
the  educational  curriculum — l)e  it  never  so  severe — shall  fit 
them  to  perform  their  duties  in  the  most  thorough,  and  in 
the  most  acceptable,  manner. 

With  a  few  notable  exceptions  modern  training  schools 
do  not  provide  a  complete  system  of  nursing  education,  and 
I  doubt  if  it  is  possible  for  them  to  do  so. 

It  may  be  urged  that  the  old  order  has  passed  and  a 
new  era  dawned — that  we  have  now  good  training  schools 
connected  with  our  great  hospitals  where  the  best  clinical 
material  is  at  hand,  that  to  these  hospitals  are  attached  well 
regulated  nurses'  homes,  under  the  direction  of  trained 
superintendents,  provided  with  every  comfort  and  even 
luxury ;  that  theoretical  teaching  is  organized,  and  practical 
details  systematically  taught ;  that  hours  on  and  off  duty 
have  been  carefuly  regulated.  All  this  being  admitted,  the 
question  may  be  asked — What  more  is  required? 

I  own  gratefully  that  much  has  been  accomplished,  and 
notably  in  the  United  States,  but  I  would  also  urge  that 
much  remains  to  be  done.  Few  who  have  studied  the  ques- 
tion will  be  prepared  to  admit  that  the  nursing  education 
afforded  by  the  majority  of  our  training  schools  is  the  best 
which  it  is  possible  to  give,  and  until  this  is  unanimously 
conceded  nurses  must  earnestly  plead  for  increased  facilities 
for  acquiring  knowledge  in  order  to  qualify  themselves  for 
their  onerous  vocation  in  the  best  possible  manner. 

Moreover,  when  our  training  schools  have  thoroughly 


Higher  Education  365 

systematized  their  teachinjr  there  will  still  remain  functions 
in  relation  to  the  education,  discipline,  and  status  of  the 
trained  nurse  which  will  not  come  within  their  jurisdiction. 
Science  and  hospital  economics  are  daily  makinj:^  such 
increased  demands  upon  the  intelligence  and  vitalitv  of 
trained  nurses,  that  with  the  best  the  training  schools  have 
to  give  them  they  cannot  go  the  pace. 

To  enumerate  our  most  pressing  needs,  we  require  pre- 
liminary education  before  entering  the  hospital  wards;  we 
need  post-graduate  teaching  to  keep  in  the  running;  we 
need  special  instruction  as  teachers  to  fit  us  for  the  respon- 
sible positions  of  sisters  and  superintendents ;  we  need  a 
State-constituted  board  to  examine  and  maintain  discipline 
in  our  ranks,  and  we  must  have  legal  status  to  protect  our 
professional  rights  and  to  insure  to  us  ample  professional 
autonomy. 

We  stand  now  at  the  Rubicon,  and  to  cross  it  we  need 
a  gilded  galley.  We  must  either  go  forward  or  go  back ; 
beyond,  we  see  plainly  the  flowery  promised  land ;  before 
us  lies  the  organized  and  scientific  profession  of  our  dreams, 
in  which  every  duly  qualified  nurse  is  registered  as  a  skilled 
nursing  practitioner.  Behind  us  is  that  dreary  downhill 
path,  descending  to  a  disorganized  vocation  of  obsolete 
methods,  in  the  ranks  of  which  all  kinds  and  conditions  of 
workers — good,  bad,  and  indififerent — struggle  and  compete. 

Justice  and  self-respect  demand  that  we  shall  go  for- 
ward, and  it  is  greatly  to  the  honor  of  nurses  that  the  cost 
of  professional  organization  and  progressive  educational 
methods  has  been  financed  by  some  of  their  members 
inspired  by  a  high  sense  of  professional  duty. 

Here  in  the  United  States  I  have  only  to  allude  to  the 
splendid  work  accomplished  by  the  Society  of  Superintend- 
ents of  Training  Schools.  Having  associated  themselves 
together  to  effect  professional  reform,  they  brought  into 
existence  the  Alumnae  Associations  of  graduate  nurses, 
which  are  grouped  into  a  national  society  known  as  the 
Associated  Alumna  of  Trained  Nurses  of  the  United  States. 
Together  the  Superintendents'  and  Nurses'  Societies  form 


366  International  Congress  of  Niirses 

the  Federation  of  American  Nurses,  a  body  which  repre- 
sents the  profession  in  the  National  Council  of  Women,  and 
which  will  at  an  early  date  also  affiliate  with  the  Interna- 
tional Council  of  Nurses,  which  has  called  together  this 
great  Congress. 

Again,  when  it  was  realized  that  American  nurses  must 
have  a  voice  in  the  press,  those  same  women  came  forward 
and  undertook  the  entire  financial  responsibility  of  produc- 
ing the  American  Journal  of  Nursing,  to  which  they  have 
also  given  generous  unpaid  services. 

Through  the  influence  of  the  Society  of  Superintend- 
*  ents  a  post-graduate  educational  course  for  nurses  desiring 
to  qualify  for  the  higher  professional  posts  has  been 
organized  at  Teachers'  College,  Columbia  University,  and 
members  of  the  society  have  ungrudgingly  given  time  and 
labor  to  make  the  course  a  success.  We  realize,  therefore, 
that  nurses  have  not  been  unmindful  of  their  professional 
obligations. 

But  educational  advantages  for  nurses  mean  a  direct 
gain  to  the  public,  and  I  think  you  will  agree  with  me  that 
it  is  not  just  that  the  whole  financial  burden  of  the  further 
advance  of  nursing  should  be  entirely  borne  by  nurses  them- 
selves. In  other  and  richer  professions  the  public  take  their 
share  in  financial  support.  Witness  the  magnificent  univer- 
sities, the  endowed  professional  chairs,  the  medical  colleges, 
public  libraries,  and  numerous  organizations  which  afiford 
opportunities  of  study  to  different  sections  of  workers, 
resulting  in  the  ultimate  benefit  of  the  community  at  large, 
but  owing  their  existence  to  the  munificence  of  a  compara- 
tively few  public-spirited  persons. 

I  claim  that  the  time  has  come  when  nurses  need  their 
educational  centers,  their  endowed  colleges,  their  chairs  of 
nursing,  their  university  degrees,  and  State  registration,  and 
the  present  seems  the  psychological  moment  to  come  to  the 
public,  not  as  strangers,  but  as  professional  workers  known 
and  trusted  through  the  length  and  breadth  of  the  land,  and 
to  urge   that,  as  nurses    pour  out  on  its  behalf  a  skill  and 


Higher  Education  3(57 

devotion  for  which  gold  is  no  real  recompense,  the  public 
shall  now  prove  its  appreciation  and  interest  in  the  noble 
work  of  .nursing  by  giving  something  of  its  wealth  to  place 
nursing  education  and  the  status  of  the  trained  nurse  on  a 
strong  financial  basis. 

Is  it  too  much  to  hope  that  the  wealthy  will  come  for- 
ward and  found  colleges  of  nursing — colleges  in  which  the 
teaching  power  of  the  profession  would  be  focussed  and 
centered,  which  would  put  the  apex  on  our  training  course, 
and  by  improving  the  standard  of  nursing  the  sick  confer  a 
real  and  lasting  benefit  on  humanity  at  large? 

To  pass  from  the  consideration  of  the  theoretical  and 
technical  curriculum  of  nursing  education :  A  nurse  cannot 
live  by  learning  alone.  We  must  consider  also  her  fantasy 
and  heart.  The  heart  must  be  cultivated  with  as  much 
assiduity  as  the  understanding.  True  excellence  of  charac- 
ter is  usually  acquired  by  self-cultivation,  by  patient  and 
unwearied  endeavor,  and  it  is  founded  on  the  conviction  that 
intellectual  attainments  alone  are  those  which  can  exalt  the 
mind,  that  pure  and  virtuous  feelings  alone  are  those  which 
can  adorn  it.  To  this  end  we  would  have  nurses  come  into 
touch  with  all  that  is  purest,  wisest,  and  most  potent  for  good 
in  this  beautiful  world,  to  do  which  they  must  take  their  part 
in  the  civil  and  social  movements  of  the  time,  realize  the 
obligations  of  citizenship,  and  appreciate  at  their  true  value 
national  and  international  events.  They  must  live  with 
others,  not  altogether  for  them. 

During  this  last  decade  there  has  grown  up  the  great 
International  Council  of  Women,  initiated.  I  need  hardly 
say,  by  an  American  woman,  to  which  the  women  workers 
of  the  world  gathered  into  National  Councils  are  affiliated. 
Listen  to  the  preamble  of  the  constitution:  "Sincerely 
believing  that  the  best  good  of  humanity  will  be  advanced 
by  greater  unity  of  thought,  sympathy,  and  puri>oso.  we 
hereby  bind  ourselves  together  in  a  confederation  of  workers 
committed  to  the  overthrow  of  all  forms  of  ignorance  and 
injustice,  and  to  the  application  of  the  Golden  Rule  of 
society,  law,  and  custom." 


368  International  Congress  of  Nurses 

Would  it  not  be  well  that  this  mother  Council  should 
attach  to  itself  by  the  silken  strin^^s  of  sympathy  interna- 
tional societies  of  experts,  such  as  the  nurses  have  founded 
in  their  International  Council  of  Nurses,  and  thus  encourage 
them  in  their  social  and  moral  development?  And  would 
it  not  also  be  well  that  it  should  gather  from  us,  for  its  own 
intellectual  expansion,  all  the  expert  information  we  have 
to  impart?  In  conclusion,  may  I  recapitulate  the  three 
points  which  I  wish  to  impress  upon  your  kind  attention^ 
and  throug-h  the  good  offices  of  the  press  on  others  also. 

1.  The  need  for  a  more  thorough  and  better  organized 
educational  curriculum  for  trained  nurses,  and  the  founda- 
tion and  endowment  of  colleges  in  which  such  education  can 
be  centered. 

2.  Tlie  advantages  of  an  International  Council  of 
Nurses  for  the  furtherance  of  the  social  and  professional 
progress  of  nurses,  and  for  the  maintenance  of  a  high  stand- 
ard of  nursing  ethics  and  esprit  de  corps. 

3.  The  advantages  of  the  al^liation  of  international 
societies  of  experts  with  the  International  Council  of 
Women  for  mutual  intellectual  expansion  and  organization. 

Miss  Louisa  Stevenson,  of  Edinburgh,  Scotland,  dele- 
gate from  the  National  Union  of  Women  Workers  of  Great 
Britain  and  Ireland,  indorsed  the  suggestions  made  by 
Mrs.  Fenwick  as  to  what  was  necessary  in  order  to  raise 
the  standard  of  training  so  as  to  fit  nurses  to  render  such 
service  as  would  ensure  to  their  patients  the  full  benefit  of 
the  progressive  skill  of  physicians  and  surgeons.  She  said 
the  public  required  enlightenment  on  this  question,  as  few 
understood  what  efificient  nursing  meant  and  might  be 
made.  Much  responsibility  lay  with  the  nurses  themselves, 
and  each  one  should  realize  that  she  is  either  helping  or 
hindering  this  work.  To  hinder  it  one  had  simply  to  do 
nothing.  A  very  little  efTort  on  the  part  of  each  would 
accomplish  wonders. 


Higher  Education  369 

Miss  Isla  Stewart,  of  London,  president  of  the  Matron's 
Council  of  Great  Britan,  presented  to  Miss  Mclsaac  the 
decoration  of  the  Matron's  Council,  as  an  honorary  distinc- 
tion and  as  a  token  of  the  appreciation  with  which  she  and 
her  work  are  held  by  the  members  of  the  Matrons'  Council 
of  Great  Britain  and  Ireland. 

Miss  Mclsaac,  in  accepting  the  honor,  declared  it  a 
tribute  from  the  Eng-lish  nurse  to  the  American  nurse, 
and  not  to  herself  personally. 


A   Retrospect  and  a  Forecast. 

CATHERINE  J.  WOOD, 

Superintendent  of  the  Nurses' Hostel,  London;   Delctrate  frum  Fourteen  Nursea' 

Associations  of  England. 


The  sick  man  has  been  with  us  from  all  time,  there- 
fore the  nursing-  of  the  sick  is  not  an  invention  of  the  pres- 
ent day,  but  has  chained  effectiveness,  in  common  with  all 
cognate  subjects  relating  to  life  and  health,  by  the  light 
which  has  been  shed  upon  it  in  modern  times.  The  nun 
by  the  bedside  in  the  convent  infirmarium  was  none  the  less 
a  sick-nurse,  though  she  was  groping  her  way  among  the 
perplexities  and  complexities  of  human  disorders  without 
the  aid  of  scientific  knowledge,  and  that  she  did  her  work 
well  we,  who  stand  in  the  full  light  of  scientific  nursing, 
must  own.  When  sick-nursing  was  undertaken  apart  from 
the  religious  life  of  the  convent,  it  entered  on  a  new  phase, 
and  a  phase  in  which  it  touched  its  lowest  point.  From  being 
the  occupation  of  the  well-born  and  religious-minded 
woman,  it  became  the  employment  of  the  outcast  and  the 
iiimioral. 

It  was  at  this  point  that  several  philanthropists.  Pastor 
Fliedner  in  Germany,  Mrs.  Elizabeth  Fry  in  England,  and 
others  whose  sympathies  had  been  aroused  by  the  ghastly 
suffering  and  neglect  of  the  sick,  initiated  the  deaconesses 
of  Kaiserswerth  and  the  Nursing  Sisters  of  Bishopsgate 
street.  The  system  of  training  for  both  orders  w^as  the 
same :  They  learnt  the  technical  work  in  the  hospital,  and 
were  taught  general  domestic  service  in  the  institution. 
370 


Retrospect  and  Forecast  371 

The  whole  of  their  Hfe,  being  ruled  and  directed  as  in  a 
religious  house,  was  supposed  to  be  devoted  to  the  service 
of  the  sick,  though  they  were  without  the  life  vows  of  the 
nun.  It  was  an  essentially  Protestant  revival;  it  sprang 
out  of  the  heart  of  Protestant  nations.  Tlie  Roman  Cath- 
olic nun  was  still  nursing  in  the  infirmarium,  but  her  meth- 
ods were  the  same;  she  had  not  improved  her  training. 
The  great  hospitals  up  to  this  date  (I  am  speaking  of  the 
first  quarter  of  the  nineteenth  century)  were  unaffected  by 
the  movement;  the  masters  of  the  art  of  healing  had  not 
yet  grasped  the  fact  that  medicine  practiced  without  nursing 
must  be  one-sided  in  action;  that  until  the  intelligent  min 
istrant  took  her  place  as  the  eyes  and  hands  of  the  doctor, 
the  best  possible  was  not  done  for  the  patient.  At  this 
time  the  skilled  nursing  of  the  patient  was  of  necessity  left 
in  the  hands  of  the  medical  students,  who  were  inclined  to 
look  on  the  patient  as  so  much  material  provided  for  their 
instruction.  The  "  nurses  "  were  drawn  from  the  lowest 
denizens  of  the  surrounding  neighborhood,  such  as  pre- 
ferred sick-nursing  to  street-walking,  and  perhaps  they 
were  able  to  combine  the  two  trades.  This  was  the  state 
of  nursing  as  recently  as  in  the  sixties.  I  am  now  speaking 
of  matters  within  my  own  knowledge.  The  charwoman  still 
reigned  supreme  in  the  great  hospitals  in  London  as  the 
night  nurse,  and  was  in  request  when  a  "  special  "  was 
wanted ;  strange  though  it  may  sound,  this  system  was  one 
of  the  hardest  to  kill.  As  a  variant  on  this  method  of  night 
nursing  the  nights  were  shared  out  among  the  day  nurses, 
the  turn  coming  every  third  or  fourth  night,  with  the  result 
that  the  most  convalescent  patient  sat  up,  the  night  nurse 
taking  the  vacated  bed. 

With  the  Crimean  war  and  Miss  Nightingale,  a  better 
prospect  opened  out  before  the  sick.  Miss  Nightingale's 
work  is  known  to  all,  it  is  written  in  the  pages  of  history, 
it  lives  in  the  heart  of  every  true  nurse.  To  her  is  due  the 
credit  of  placing  before  the  world  the  need  of  efficient  tram- 
ing  for  sick-nurses.  Herself  a  student  of  Kaiserswerth,  she 
contended  that  no  intention,  however  good,  no  enthusiasm, 


372  International  Congress  of  Nurses 

however  fervid,  could  supply  the  lack  of  technical  knowl- 
edg-e  or  practical  skill  in  handlinj^  the  patient.  This  sounded 
the  death  knell  of  Sairy  Gamp  and  all  her  sisters,  and  since 
1870  every  hospital  has  become  in  a  more  or  less  degree  a 
training  school  for  nurses.  At  first  the  training  of  the 
nurses  was  in  the  hands  of  the  doctors ;  now  it  has  become 
a  specialized  department  of  hospital  work  and  is  in  the 
hands  of  the  matron  and  ward  sisters ;  clinical  lectures  fol- 
lowed, and  now  there  is  very  complete  theoretical  instruc- 
tion with  its  corollary,  examination  and  certificate.  This  is 
the  point  where  we  now  stand.  With  the  levelling  up  of 
the  teaching  there  ensued,  as  a  matter  of  course,  the  level- 
ling up  of  the  pupils,  so  that  the  ranks  of  the  profession 
include  the  higb.ly  educated  gentlewoman  as  well  as  the 
w^oman  of  the  artisan  class:  it  offers  scope  for  both,  and 
both  alike  are  acceptable  in  its  varied  departments. 

From  looking  back  we  must  now  cast  a  glance  for- 
ward, and  by  a  survey  of  the  whole  field  endeavor  to  arrive 
at  the  future  which  lies  before  us.  It  is  perhaps  needless 
to  emphasize  the  fact,  so  evident  to  us  all,  that  we  have 
reached  the  parting  of  the  ways,  and  depending  upon  our 
choice  will  be  the  future  of  one  of  the  most  noble  of  all 
women's  occupations.  We  are  probably  all  agreed  that 
theory  must  go  hand  in  hand  with  practice  of  the  proba- 
tioner's course,  that  the  three  years'  hospital  training  is 
the  shortest  period  in  which  the  pupil  can  secure  a  full 
knowledge  of  her  work,  that  the  results  must  be  tested  by 
examination  and  receive  some  form  of  certification.  This 
is  our  English  system,  and  so  far  as  I  have  been  able  to 
acquaint  myself  with  your  methods  we  agree  in  principle. 
Armed  with  the  certificate  of  her  training  school,  the  trained 
nurse  steps  forth  on  her  career  to  find  her  place  in  one  of 
the  many  branches  of  the  profession  open  to  her  as  a  pri- 
vate, district  or  hospital  nurse,  under  the  State  in  army 
or  navy  nursing  service,  in  municipal  infirmaries  for  desti- 
tute or  infectious  patients,  or  in  these  various  departments 
of  the  service  in  the  colonies  and  dependencies  of  our 
Empire. 


Retrospect  and  Forecast  378 

Now  we  come  to  the  weak  point  of  the  profession:  the 
nurse  becomes  a  unit,  irresponsible  and  uncontrolled.  As 
the  ties  which  bound  her  to  her  trainincr  school  relax,  the 
allegiance  to  its  unwritten  code  changes  with  time  into  a 
sentimental  recollection ;  she  finds  nothing  to  take  its  place, 
she  sees  no  corporation  or  official  body  which  represents 
to  her  mind  the  mind  of  the  profession,  nothing  which  may 
rise  up  before  her  as  armed  with  disciplinary  or  judicial 
authority,  no  concrete  body  of  tradition  placing  before  her 
all  the  best  and  noblest  of  the  past :  if  she  has  an  ideal,  it 
is  her  own  creation;  if  she  has  a  code  of  ethics,  she  has 
formed  it  for  herself;  if  she  has  a  standard  of  work,  it  is 
the  lingering  memory  of  the  old  hospital  which  has  sur- 
vived in  her  mind.  I  think  that  I  am  right  in  saying  that 
in  America,  as  in  England,  we  are  no  farther  on  the  road 
that  leads  to  organization. 

This  state  of  things  can  satisfy  no  one  who  has  the 
best  interests  of  the  profession  at  heart,  but  it  is  more  easy  to 
lament  it  than  to  find  the  remedy.  There  is  no  doubt  that, 
being  a  profession  of  women,  we  inherit  the  disadvantage 
common  to  the  whole  sex,  the  difficulty  of  combination,  ol 
concerted  action.  A  man  when  he  begins  his  career  knows 
that  he  has  to  become  a  part  of  a  whole ;  that  he  has  to 
combine  with  others ;  that  he  has  to  work  for  the  general 
prosperity  of  his  trade ;  that  if  success  is  to  attend  his  efforts, 
it  is  best  secured  by  availing  himself  of  the  various  organi- 
zations which  will  improve  his  standing  professionally  or 
intellectually.  He  learned  this  unconsciously  at  his  public 
school;  it  is  the  atmosphere  he  breathes;  his  creed  is  to 
play  up  for  his  side.  We  women  learn  this  lesson  hardly, 
some  never  learn  it  at  all ;  it  may  be  that  we  miss  the  dis- 
cipline of  the  public  school,  but,  from  whatever  cause,  wo 
rarely  learn  to  work  together  for  the  good  of  the  whole 
body.  The  heads  of  the  training  schools,  looking  no  farther 
than  their  own  four  walls ;  the  teachers  of  the  schools,  only 
thinking  of  the  examination  that  is  to  follow ;  the  employers 
of  nurses,,  keen  to  get  all  they  can  for  their  money;  the 
theorists,  or  so-called  philanthropists,  using  the  nurse  as 


374  International  Congress  of  Nurses 

a  buffer,  or  exploiting  her  to  serve  their  own  ambitious  pur- 
poses ;  the  nurse  herself,  immersed  in  the  hard  stress  of 
competition, — all  these  have  no  thoughts  to  spare  for  pro- 
fessional organization.  From  whence,  then,  is  succor  to 
come?  It  may  be  forced  upon  us  from  the  outside,  but  it 
is  better  far  that  it  should  come  from  within. 

So  long  as  we  are  without  organization  nothing  can  be 
done.  We  want  professional  agreement  on  questions  of 
training,  practice,  ethics,  conduct,  remuneration.  Xo  legis- 
lation can  settle  these  points  justly  without  us.  and  woe 
be  to  us  if  legislation  attempts  to  do  so  before  there  is  a 
consensus  of  professional  opinion.  In  England  we  have 
tried  the  experiment  of  organizing  the  profession  in  con- 
junction with  the  medical  profession,  but  with  disastrous 
results ;  it  is  a  failure,  and,  moreover,  it  has  had  the  evil 
effect  of  setting  the  clock  of  reform  back  for  many  years. 
It  cannot  be  done ;  we  must  be  free  to  organize  ourselves ; 
the  relation  of  man  to  woman  complicates  the  situation ; 
the  relative  position  of  doctor  atid  nurse  makes  it  impos- 
sible. Though  our  work  is  in  common,  the  details  differ, 
and  though  we  do  not  claim  independence  of  the  medical 
profession,  we  claim  freedom  to  discuss  our  own  affairs, 
to  make  our  own  laws,  to  decide  on  common  principles  of 
work. 

It  may  be  well  to  recall  the  object  of  our  work,  the 
relation  in  which  we  stand  to  the  patient  on  the  one  hand 
and  to  the  doctor  on  the  other,  and  then  to  ask  ourselves : 
Is  the  system  of  training  as  at  present  carried  out  the  one 
that  is  followed  by  the  best  results?  Is  there  not  a  danger 
that  theory  is  overshadowing  practice?  Is  not  too  much 
time  and  mental  energy  bestowed  on  the  study  of  obscure 
questions  of  anatomy  and  physiology  to  the  detriment  of 
securing  that  expert  knowledge  of  ministering  to  the  neces- 
sities of  the  patient  which  is  the  characteristic  of  a  good 
nurse?  Is  there  not  a  danger  that  the  great  and  important 
place  given  to  theory  in  the  curriculum  and  the  examina- 
tion may  lead  to  a  want  of  balance  in  the  mind  of  the  aver- 
age student,  leading  her,  when  free  from  the  etiquette  of 


Retrospect  and  Forecast  375" 

the  hospital  ward,  to  mix  up  treatment  with  nursin<;.  to 
forget  the  dignity  of  her  own  profession  in  criticising  the 
methods  of  the  medical  attendant?  These  are  very  grave 
considerations,  which  require  to  be  looked  full  in  the  face 
and  considered.  We  do  not  want  to  make  a  race  of  spoiled 
medical  students,  but  capable  nurses,  and  for  those  who  are 
drawn  to  seek  the  higher  mysteries  of  the  healer's  art  there 
should  be  opportunities  found  in  a  post-graduate  course  or 
in  entering  the  ranks  of  the  medical  profession.  Out  of  this 
branch  of  the  subject  spring  many  others,  such  as  the  need 
of  a  central  examining  body  independent  of  and  above  the 
training  schools,  a  record  ofifice  for  the  registration  and 
filing  of  the  certificates,  all  controlled  by  some  form  of  gov- 
erning body  chosen  by  and  forming  a  part  of  the  profession. 
Would  it  not  somewhat  clear  the  path  from  difficulties  if 
some  minimum  curriculum  were  agreed  on,  representing 
the  least  possible  for  the  efficient  training  of  a  sick-nurse, 
suited  to  average  intellects  and  average  physique?  We  need 
ask  for  no  legal  authority  to  initiate  these  reforms,  and  when 
the  time  comes  when  we  seek  a  legal  recognition  and  pro- 
tection of  our  status,  we  have  a  much  stronger  claim 
because  we  have  made  up  our  minds  as  to  what  wc  want, 
we  go  with  a  united  front. 

As  a  means  to  this  end  we  might  seek  to  raise  our 
ideals,  to  get  out  of  the  spirit  of  money-grubbing  and  nuick- 
raking  for  excitement.  We  want  to  awaken  tiie  spirit  of 
self-sacrifice  and  self-discipline;  the  giving  of  one's  best 
for  another,  which  is  the  highest  of  all  woman's  privileges; 
to  emphasize  the  fact  that  sick-nursing  is  one  of  the  grand 
ministries  of  the  world;  to  show  the  beauty  of  service.  .\n 
ideal  like  this  will  enlarge  the  range  of  our  vision,  ennoble 
our  methods,  place  us  in  a  right  attitude  towards  our 
patients,  and  shed  a  new  light  on  our  work  and  life. 

End  of  Part  I 


REPORTS 

OP  THE 

International   Council   of   Nurses. 


PART   II. 


MONDAY.  SEPT.  16,  1901. 


Address  of  the  President. 

ETHEL  GORDON. 


'■  Ladies :  In  opening-  this,  the  first  session  of  the  Inter- 
national Council  of  Nurses,  it  is  my  first  duty  to  express 
how  deeply  I  appreciate  the  honor  of  having  been  elected 
as  your  first  president,  to  convey  to  its  members  my  pro- 
found sense  of  the  responsibility  attached  to  the  office,  and 
to  assure  them  that  it  is  my  earnest  determination  to  uphold 
the  dignity  of  the  distinguished  professional  position  which 
has  been  conferred  upon  me. 

WORK. 

"  The  text  of  the  few  words  which  I  would  say  to  you 
is  comprised  in  the  one  word— Work.  We  take  our  stand 
in  the  Preamble  of  this  International  Council  of  Nurses  as 
a  confederation  of  workers.  '  We,  nurses  of  all  nations.'  it 
runs,  '  sincerely  believing  that  the  best  good  of  our  pro- 
fession will  be  advanced  by  greater  unity  of  thought,  sym- 
pathy, and  purpose,  do  hereby  band  ourselves  in  a  confetl- 
eration  of  workers  to  further  the  efficient  care  of  the  sick 
and  to  secure  the  honor  and  interests  of  the  nursing  pro- 
fession.' 


379 


380  International  Congress  of  Xitrscs 

"  The  work  which  hes  before  us  in  the  orj^anization 
of  an  International  Council  of  Nurses  may  well  impress  us 
with  its  magnitude.  We  have  written  down  its  constitution, 
— a  constitution  preg;nant  with  and  powerful  for  good, — 
but  we  have  to  make  that  constitution  live,  and  to  do  this 
we  must  inspire  it  with  the  vital  force  of  a  fine,  purposeful 
spirit.    Hence  'work'  must  be  our  watchword. 

"  It  has  been  written  that  no  man  is  happier  than  he 
who  loves  and  fulfils  the  particular  work  for  the  world  which 
falls  to  his  share.  To  man  is  entrusted  the  nature  of  his 
actions,  not  the  result  of  them,  and  therefore  does  it  behoove 
us  to  be  diligent  in  our  several  spheres,  although  the  law 
of  evolution  wills  it  that  the  good  which  our  exertions  ellfect 
may  rarely  become  visible.  Between  the  result  of  single 
efforts  and  the  end  we  have  in  view  and  the  magnitude  of 
the  obstacles  to  be  overcome  there  may  often  appear  a  large 
and  painful  disproportion.  Inn  we  must  not  allow  ourselves 
to  be  discouraged  by  seemings ;  warm  and  hearty  endeavor 
will  certainly  meet  its  reward.  Good  uses  are  never  with- 
out result.  Once  enacted,  they  become  a  part  of  the  moral 
world ;  they  give  to  it  new  enrichment  and  beauty,  and 
the  whole  universe  partakes  of  their  influence.  They  may 
not  return  in  the  shape  wherein  played  forth,  but  likelier 
after  the  manner  of  seeds,  which  never  forget  to  turn  to 
flowers.  Philosophers  tell  us  that  since  the  creation  of  the 
world  not  one  particle  of  matter  has  been  lost ;  it  may  have 
passed  into  new  shapes,  it  may  have  combined  with  other 
elements,  it  may  have  floated  away  in  vapor,  but  it  comes 
back  even  then  in  the  dewdrop  and  rain,  helping  the  leaf 
to  grow  and  the  fruit  to  swell ;  through  all  its  wanderings 
and  transformations  Omniscience  watches  over  and  directs 
it.  So  it  is  with  every  generous  and  self-denying  efifort, 
it  may  escape  our  observation  and  be  utterly  forgotten,  it 
may  seem  to  have  been  all  in  vain,  but  it  has  painted  itself 
on  the  eternal  world  and  is  never  elTaced.  Nothing  that  has 
the  ideas  and  principles  of  good  in  it  can  die  or  be  fruitless. 
That  which  the  fountain  sends  forth  returns  again  to  the 
fountain.     *  Every  man,  '  says  Fichte,  '  should  go  on  work- 


Council  Reports  381 

ing,  never  debating  within  himself,  nor  wavering  in  doubt 
whether  it  may  succeed,  but  labor  as  if  of  necessity  it  must 
succeed;    In  work,  then,  consists  the  true  pride  of  Hfe. 

"  Thus  we  have  inspiration  and  effort,  but  we  also  need 
order.  See  what  order  there  is  in  nature  along  with  sublim- 
est  activity,  what  smoothness,  what  ease!  How  still  the 
growth  of  the  plant,  yet  how  rapid !  How  peacefully  the 
stars  of  midnight  seem  encamped,  yet  before  morning  whole 
armies  have  disappeared!  So  much  is  achieved  because 
everything  is  done  in  order  at  the  right  time,  intently  yet 
deliberately.  So  in  the  formation  of  the  International  Coun- 
cil of  Nurses  its  founders  have  looked  well  to  its  organiza- 
tion. The  vote  covers  all.  They  have,  therefore,  chosen 
graduate  suffrage  as  the  foundation  on  which  to  erect  their 
stately  pillar  of  international  professional  cooperation,  and 
have  thus  based  the  constitution  on  the  fundamental  prin- 
ciple that  a  free,  and  therefore  a  progressive,  community 
must  be  self-governing.  The  organization  of  the  Interna- 
tional Council  is  as  simple  as  it  is  sure.  The  graduate 
nurses  combine  to  form  Alumnse  Associations :  by  delega- 
tion these  societies  cooperate  to  form  a  National  Associ- 
ation. The  National  Associated  Alumnse,  in  conjunction 
with  the  Superintendents'  Society,  federate  to  make  a 
National  Council,  and  the  National  Councils  are  eligible  for 
affiliation  with  the  International  Council  of  Nurses.  Thus, 
through  gradual  delegation  we  provide  that  every  graduate 
nurse  becomes  articulate  in  this  International  Council  of 
Nurses.  We  have,  in  short,  secured  to  our  members  pro- 
fessional suffrage,  and  order  will  thus  be  evolved  out  of 
chaos. 

"And  yet  in  making  our  council  mechanically  perfect, 
let  us  remember  that  the  vital  force  is  of  the  spirit,  and  not 
of  the  letter  of  the  law.  In  a  society  which  would  be  world- 
wide, which  would  include  members  of  every  race  and  creed, 
we  must,  while  maintaining  inviolate  certain  broad  general 
principles  which  form  our  common  bond  of  union,  permit 
— nay,  foster — individuality  in  detail,  authorizing  each  coun- 
try to  apply  these  principles  in  a  manner  best  suited  to  its 


382  International  Co)ti^rcss  of  Xurscs 

own  needs.  In  like  manner  every  Xational  Council  will  do 
well  to  encourage  and  develop  the  individuality  of  its  mem- 
bers, for  only  so  shall  we  utilize  to  the  full  the  correlation 
of  our  forces  and  make  our  council  a  progressive  power 
for  good.  Diversity  of  opinion  is  the  very  salt  of  life,  and 
we  shall  do  well  to  encourage  rather  than  deprecate  its 
expression. 

"  The  task  to  which  we  must  first  devote  all  our  ener- 
gies is  the  building  up  of  Xational  Councils  of  Nurses  in 
every  land.  Let  it  be  a  labor  of  love.  Ruskin  says:  '  It  is 
useless  to  put  your  heads  together  if  you  can't  put  your 
hearts  together.  Shoulder  to  shoulder,  right  hand  to  right 
hand,  among  yourselves  with  no  wrong  hand  to  anybody 
else,  and  you'll  win  the  world  yet.' 

"  Into  these  councils  should  be  gathered,  through  vari- 
ous associations  for  mutual  help  and  professional  progress, 
every  individual  graduate  nurse,  and  the  chief  work  in  Euro- 
pean countries  for  many  years  to  come  will  be  the  educa- 
tion of  these  graduates  in  the  immensity  of  human  responsi- 
bility, which  includes  their  duty  towards  their  neighbor, 
other  than  their  patient,  and  their  duty  to  the  Stated  All 
worthy  progress  of  women  and  their  work  must  spring  from 
this  sense  of  corporate  existence  and  reverence  for  political 
rights ;  associations  of  women  to  be  of  any  real  value  in  the 
body  politic  must  comprise  mind  as  w-ell  as  matter.  We 
have  experience  that  associated  masses  of  women  devoid 
of  the  innate  vigor  of  conscience  fall  an  easy  prey  to  the 
unscrupulous,  and  retard  rather  than  promote  the  intellec- 
tual advancement  of  their  sex.  Realize  then  the  patience, 
the  singleness  of  purpose,  and  the  fine  courage  required  by 
those  who  would  sow  the  seed  of  high  endeavor  in  the 
fallow  fields  of  the  nursing  world.  Indeed,  it  is  a  stupendous 
project,  and  will  need  the  aid  of  hope,  faith,  and  charity  un- 
bounded. 

"  The  inspiration  is  ours ;  let  the  effort  be  forthcoming, 
and  order  must  result.  '  What  the  child  admired,  the  youth 
endeavored  and  the  man  acquired.' 


Council  Reports  383 

"  National  Councils  of  sentient  beings  alone  can  form 
an  International  Council  of  any  worth.  Awaken  and  culti- 
vate the  senses  of  each  individual  graduate  nurse,  and  let 
the  result  be  never  so  slow,  it  will  be  sure,  a  weighty  Inter- 
national Council  of  Nurses  must  be. 

"  'Hope  is  of  the  valley;  Effort  stands 

Upon  the  mountain  top,  facing  the  sun; 

Hope  dreams  of  dreams  made  true  and  great  deeds  done; 
Effort  goes  forth,  with  toiling  feet  and  hands, 
To  attain  the  far-off  sky-touched  table-lands 

Of  great  desire;  and,  till  the  end  is  won. 

Looks  not  belo\ii,  where  the  long  strife  begun 
In  pleasant  fields,  piet  torrents,  rocks  and  sands. 
Hope;  but  when  Hope  bids  look  within  her  glass, 

And  shows  the  wondrous  things  which  may  befall. 

Wait  not  for  destiny,  wait  not  at  all; 
This  leads  to  failure's  dark  and  dim  morass; 

Sound  thou  to  all  thy  powers  a  trumpet  call. 
And,  staff  in  hand,  strive  up  the  mountain  pass.'  " 


Nursing  in  Africa. 


MARGARET   BREAY, 

Formerly  Matron  English  Hospital.  Zanzibar;  Councillor  International 

Council  of  Nurses. 


Africa  is  known  as  the  *'  Dark  Continent,"  but  dark- 
ness is  giving-  place  to  dawn,  and  dawn  with  tropical  rapidity 
to  broad  daylight.  A  powerful  factor  in  this  development 
is  the  trained  nurse,  who,  following  the  flag,  has  found  her 
way  to  the  heart  of  the  Continent,  until  in  Uganda,  on  the 
shores  of  the  Victoria  Nyanza,  there  is  now  a  hospital  hav- 
ing a  three  years'  certificate  nurse  as  a  matron,  and  on  the 
island  of  Likoma,  on  Lake  Nyara.  there  is  a  well-appointed 
hospital  nursed  by  certificated  British  nurses.  The  same 
may  be  said  of  Zomba,  the  headquarters  of  the  British 
administration  in  British  Central  Africa. 

On  the  northern  seaboard  British  nurses  are  doing 
excellent  work  in  hospitals  at  Port  Said,  Alexandria,  and 
Algiers,  while  further  inland  at  Cairo  there  is  a  large  hos- 
pital, the  Kaiser-el-Aini,  with  an  English  matron  and  nurs- 
ing staff,  in  which  native  nurses  are  trained.  On  the  west 
coast  many  lives  have  been  saved  by  the  good  offices  of 
members  of  our  profession  in  the  hospitals  at  Sierra  Leone 
and  Lagos,  and  trained  nurses  have  also  gone  inland  to 
nurse  members  of  the  West  Frontier  Force  on  expeditions 
into  the  interior.  On  the  east  coast  there  is  at  Mombasa  a 
government  hospital,  founded  originally  by  the  Imperial 
British  East  African  Company,  which  is  nursed  by  religious 
sisters,  at  Tanga  is  another  under  the  care  of  German  dea- 
384 


Council  Reports  385 

conesses,  while  the  island  of  Zanzibar,  the  metropolis  of  the 
east  coast,  has  English,  French  and  native  hospitals.  The 
former  is  interesting,  inasmuch  as  in  it  some  progress  has 
been  made  in  giving  systematic  instruction  to  native  men 
and  women  in  nursing.  The  hospital  is  maintained  by  the 
Universities'  Mission  to  Central  Africa,  and  has  a  nursing 
staflf  of  a  matron  and  five  or  six  British  certificated  nurses, 
who  take  considerable  pains  to  train  the  natives  who  work 
under  them.  The  value  of  this  work  is  great,  as  the  African 
thus  receives  instruction  in  habits  of  order,  method,  and 
discipline,  and  in  an  appreciation  of  the  value  of  time,  which 
are  foreign  to  him  naturally.  So  far  the  men  have,  on  the 
whole,  made  better  nurses  than  the  women,  partly  because 
African  women  marry  so  early  that  few  of  them  stay  in  the 
hospital  long  enough  to  pass  through  a  full  training,  partly 
because  in  Zanzibar,  as  in  other  Oriental  countries,  the  men 
are  in  advance  of  the  women  in  educational  development, 
partly  again  because  the  male  wards  are  more  used,  and 
consequently  afford  a  better  training  ground  than  the  female 
ones,  and  it  would  outrage  national  feelings  to  place  an 
unmarried  woman  in  charge  of  male  wards.  Nevertheless 
some  of  the  girls  have  proved  themselves  apt  and  trust- 
worthy pupils,  and  given  equal  advantages,  would  no  doubt 
become  as  proficient  as  the  men.  Tliey  have  many  of  the 
characteristics  essential  in  a  good  nurse,  being  gentle,  kind, 
and  sympathetic,  dexterous  with  their  hands  and  quiet  in 
their  movements.  They  are  also  as  a  rule  devoted  to  chil- 
dren. On  the  other  hand,  they  do  not  like  performing 
those  parts  of  their  work  which  they  consider  menial,  and 
they  have  not  much  sense  of  responsibility,  neither  have 
they  much  stamina. 

So  far  as  practical  work  goes,  both  native  men  and 
women  in  Zanzibar  have  learnt  enough  to  make  them  very 
useful.  For  instance,  they  can  polish  instruments  and  pre- 
pare for  an  operation  in  a  way  which  would  be  creditable 
in  an  up-to-date  London  hospital.  Their  theoretical  work 
has  so  far  lagged  behind  the  practical,  and  there  are  at  pres- 
ent no  nursing  text-books  in  the  Swahili  language. 


386  International  Congress  of  Nurses 

The  influence  of  the  training  given  in  this  hospital  is 
far  reaching,  because  many  of  those  who  received  it  ulti- 
matelv  return  to  their  tribes  up  country^  and  thus  carry 
their  nursing  knowledge  to  villages  where  no  European  is 

stationed. 

Mention  must  also  be  made  of  a  midwife  who  is  at  work 
in  the  town  of  Zanzibar,  under  the  auspices  of  the  Lady 
Dufferin  fund. 

We  must,  however,  turn  to  South  Africa  to  find  nursing 
organizations  in  an  advanced  condition.  Nurses  in  South 
Africa  are  so  far  the  only  ones  who  have  legal  status  and 
registration,  a  privilege  granted  to  them  largely  by  the 
efforts  of  Sister  Henrietta  of  Kimberley.  This  registration 
is  carried  out  by  the  Cape  Medical  Council. 

In  1891,  when  the  new  medical  bill  was  brought  before 
the  Cape  parliament,  the  trained  nurses  of  the  country 
almost  unanimously — a  little  band  of  some  66  women  then, 
now  quite  an  army — petitioned  for  a  place  on  the  register 
and  State  control.  With  much  care  and  forethought  an 
admirable  act  was  drawn  up  and  passed,  providing  for  the 
registration  of  foreign  trained  nurses,  and  the  State  exam- 
ination and  then  registration  of  the  colonial  trained.  The 
bill  was  in  two  parts,  the  first  referring  to  midwives,  and  the 
second  to  trained  nurses. 

After  ten  years'  trial,  on  the  whole  it  has  worked  well. 
Nursing  is  a  recognized  profession,  and  trained  nurses 
legally  stand  in  the  same  position  as  doctors  and  lawyers, 
the  certificate  granted  by  the  council  being  practically  a 
license  to  practice. 

Miss  M.  H.  Watkins,  in  her  paper  read  in  the  Nursing 
Section  at  the  International  Congress  of  Women  held  in 
London,  gave  the  following  information  as  to  the  working 
of  the  act. 

"  After  the  act  was  passed  a  year  of  grace  was  given, 
during  which  all  nurses  holding  hospital  certificates  could 
register.  When  this  year  of  grace  was  over,  the  medical 
council  formed  a  syllabus  of  subjects  in  which  nurses  must 
be  trained,  which  is  much  the  same  as  in  the  best  hospitals 


Council  Reports  387 

in  Enj^lancl.  They  also  suggested  books  to  be  studied  by 
nurses.  They  have  also  appointed  the  following  centers 
at  which  examinations  shall  be  held:  Cape  Town,  Kim- 
berley,  Port  Elizabeth,  Grahamstown,  and  King  William's 
Town. 

"The  house  surgeons  generally,  and  in  Kimberley  some 
of  the  visiting  surgeons,  give  courses  of  lectures  on  anti- 
septics, anatomy,  physiology,  etc.  Examinations  are  held 
half-yearly,  in  June  and  December.  Now  the  council  will 
not  examine  any  who  have  not  had  three  years'  hospital 
training  in  a  hospital  of  not  less  than  forty  beds. 

"The  written  questions  are  uniform  for  each  center,  and 
are  entrusted  to  two  medical  men,  who  sit  as  local  commis- 
sioners during  the  time  in  which  the  answers  are  being 
written,  and  by  whom  they  are  returned  to  the  medical 
council.  These  same  two  doctors  conduct  the  viva-voce 
examination,  which  is  generally  held  on  the  day  following 
the  written.  The  marks  for  the  viva-voce  are  given  by 
these  doctors  and  reported  to  the  medical  council,  who 
themselves  examine  the  written  papers,  and  in  some  two  or 
three  weeks'  time  send  certificates  to  nurses  who  have 
passed  their  examinations  successfully.  The  medical  coun- 
cil publishes  yearly  a  register  of  certificated  nurses,  which 
can  be  had  for  half  a  crown, 

"Hitherto  registration  has  had  a  markedly tgood  effect 
in  the  colony — 1st,  by  raising  the  standard  of  education 
for  nurses :  2d,  in  raising  the  status  of  nurses ;  3d,  in  awak- 
ening ambition  in  nurses ;  and  4th,  in  affording  by  their 
published  register  an  opportunity  to  the  public  of  know- 
ing that  the  nurse  they  engage  is  duly  qualified,  an  oppor- 
tunity of  which,  I  am  glad  to  say,  many  avail  themselves. 

"Of  course,  education  and  registration  do  not  always 
ensure  a  nurse  being  an  acceptable  one.  There  are  and 
always  will  be  nurses  and  nurses,  but  I  think  registration 
has  done  as  much  as  we  might  have  expected  in  the  time." 

A  leading  superintendent  of  nursing  in  South  Africa 
writes  in  the  Nursing  Record :     "  The  main  advantage  of 


388  International  Congress  of  Xnrses 

the  register  to  nurses  is  that  in  any  case  of  difficuhy  they 
can  appeal  to  the  council,  such  as  testimonials  withheld, 
wrongful  dismissal,  or  unjust  accusation.  The  council 
goes  thoroughly  into  the  matter,  and  in  the  few  cases  which 
have  been  brought  before  it,  it  has  shown  itself  much 
inclined  to  take  the  part  of  the  nurse.  Nurses  can  register 
as  midwives  do,  either  by  producing  approved  certificates 
of  some  foreign  country,  and  proof  of  three  years'  training 
and  successful  examinations,  or,  in  the  case  of  colonial 
nurses,  proof  of  training  and  character,  and  passing  of  the 
council's  examination  for  nurses. 

REPRESENTATION  ON    COUNCIL- 

But  nurses  have  one  great  difficulty.  There  are  on  the 
council  a  representative  dentist  and  chemist,  elected  by  the 
dentists  and  chemists,  and  approved  by  the  governor,  to 
advise  the  council  on  subjects  pertaining  to  dentistry  and 
pharmacy  respectively,  and  to  lay  before  the  council  the 
claims  of  dentists  and  chemists.  There  should  also  be  a 
representative  nurse-midwife,  who  should  be  able,  not  to 
vote  in  the  council,  but  to  speak  on  midwifery  and  nursing 
questions.  There  have  been  various  cases  which  show  the 
need  of  this.  A  magistrate  wrote  to  the  council  saying  a 
case  had  come  before  him  in  which  he  could  only  commit 
the  midwife  for  trial  for  manslaughter,  but  he  believed  there 
were  extenuating  circumstances  into  which,  as  a  layman, 
he  could  not  enter. 

He  begged  the  council  to  appoint  a  commission  of 
inquiry,  and  if  the  woman  was  acquitted  on  the  graver 
charge  to  take  such  steps  in  dealing  with  her  that  another 
woman  should  not  lose  her  life  through  her  ignorance  and 
carelessness.  After  a  long  time  the  council  replied  that  as 
she  was  an  amateur  midwife,  untrained  and  unregistered, 
they  had  no  machinery  in  their  hands  to  deal  with  her. 
Again,  five  licensed  midwives  in  one  town  addressed  the 
council  about  a  quack  (also  licensed).  They  said  it  was  a 
fact  that  in  this  place  several  women  had  died  shortly  after 
childbirth,  that  they  had  all  been  attended  by  this  midwife, 


Council  Reports  389 

that  various  charges  were  being  continually  made  against 
her  competency  and  professional  conduct.  They  urged  the 
council  for  the  sake  of  other  midwives'  professional  status 
to  grant  an  inquiry  which  would  either  clear  the  midwife 
in  question  or  suspend  her  license  for  a  period.  After  a 
fortnight  the  council  answered  by  a  facetious  inquiry  as  to 
whether  the  midwives  were  prepared  to  write  the  death  cer- 
tificates themselves  for  the  women  who  they  stated  died 
shortly  after  childbirth ;  and  after  a  lapse  of  several  weeks 
came  another  letter  saying  that  the  council  could  not  listen 
to  any  request  of  the  kind  from  midwives.  Yet  if  a  doctor 
reports  a  midwife  to  the  council  she  is  at  once  suspended 
without  any  inquiry  for  three,  six,  or  nine  months.  What  is 
wanted  is  representation  on  the  council.  Again,  on  nursing 
questions :  A  clause  in  the  act  provides  that  the  council's 
certificate  may  be  given  to  any  foreign  nurse  who  has  been 
trained  for  three  years  by  any  training  school  which  the 
council  may  consider  competent  to  train,  and  who  holds 
the  certificate  of  that  body.  But  this  "  competence  "  in 
the  eyes  of  the  council  appears  to  me  to  be  absolutely  capri- 
cious. Now  an  Edinburgh  Royal  Infirmary  nurse  is  refused 
her  license  and  registration,  now  a  Leicester  nurse,  a  Bir- 
mingham General  Hospital  nurse,  a  Ryde  Infirmary  nurse, 
while  again,  nurses  from  obscure  and  petty  training  schools 
are  passed.  A  nurse  on  the  council  could  lay  the  different 
training  in  different  schools  before  the  council  and  advise 
them  on  the  subject. 

Again,  nurses  have  petitioned  parliament,  and  written 
privately  to  the  council,  asking  that  three  years'  training 
may  be  the  standard — even  royalty  has  addressed  the  coun- 
cil on  the  subject  on  behalf  of  the  South  African  nurses — 
but,  for  a  year,  one  year's  training  was  all  they  required; 
then  for  seven  years,  only  two.  The  wishes  oi  nurses  and 
matrons  were  wholly  disregarded,  but  in  1899  a  doctor  in 
the  council  brought  the  subject  forward.  It  was  passed  at 
once,  approved  by  the  governor,  and  forthwith  became  law. 
A  representative  nurse  on  the  council  could  have  done  it 
from  the  first.     No  doubt  the  tendency  of  the  council  is 


390  International  Congress  of  Nurses 

to  make  all  persons  pass  the  Cape  examinations,  whatever 
their  previous  history  has  been ;  as  an  M.  A.  of  Oxford  has 
to  pass  certain  Cape  examinations  before  he  can  enter  the 
civil  service,  and  it  would  cause  less  friction  to  say  so  fairly 
than  to  reject  nurse  after  nurse,  who  have  held  ^ood  posi- 
tions in  England,  on  some  trivial  point  or  other. 

The  great  aim  of  nurses  should  be  that  no  private 
nursing-  institution  should  be  allowed  to  send  out  an  unreg- 
istered  nurse,  and  no  hospital  receiving  a  government  grant 
should  be  allowed  to  employ  any  woman  as  matron  or  sister 
who  is  unregistered.  But  this  cannot  be  while  registration 
is  made  so  difficult  and  worrying  to  nurses,  and  until  they 
are  represented  by  a  trained  nurse  holding  a  midwifery  qual- 
ification on  the  council. 

The  larger  hospitals,  such  as  the  Kimberley  Hospital, 
the  Provincial  Hospital,  Buluwayo,  Rhodesia,  prepare  pupils 
for  the  Cape  government  examination  of  nurses,  for  which 
those  may  enter  who  have  received  three  years'  training  in 
the  wards  of  the  hospital.  Certificates  are  no  longer  granted 
by  individual  schools,  as  the  medical  council  has  received 
the  authority  to  issue  certificates  formerly  permitted  to  hos- 
pital authorities. 

Some  of  the  South  African  hospitals  are  fine  buildings, 
such  as  the  New  Somerset  Hospital,  Cape  Town,  where 
there  is  a  training  school  for  nurses  in  charge  of  the  All 
Saints  Sisters,  and  the  Johannesburg  Hospital,  which  has 
300  beds.  The  Memorial  Hospital,  Buluwayo,  has,  I  am  in- 
formed, an  excellent  up-to-date  theatre,  adjoining  which  are 
an  anaesthetic  room,  and  a  small  room  in  which  a  Rontgen 
ray  apparatus  is  fitted.  This  has  been  much  used  recently, 
as  many  patients  have  been  admitted  with  gun-shot  wounds. 
As  a  rule  the  bulk  of  the  cases  are  medical,  including  enteric, 
malaria,  and  hsemoglobinuria. 

Besides  the  hospitals  which  are  able  to  give  nurses  a 
training  which  will  qualify  them  for  registration  there  are 
also  smaller  ones.  The  Chartered  Company  maintains  sev- 
eral, one  being  at  Gwels.  The  nurses  are  paid  a  good  salary, 
and  if  they  stay  for  three  years  they  are  entitled  to  six 


Council  Reports  391 

months'  holiday,  the  company  paying-  all  expenses  of  the 
passage  home. 

In  addition  to  the  general  hospitals  there  are  various 
private  nursing  homes  and  institutions  which  send  out  pri- 
vate nurses  in  South  Africa.  I  am  informed  on  reliable 
authority  that  the  work  both  in  hospitals  and  in  private 
homes  is  nmch  harder  than  at  home.  The  only  service  avail- 
able is  that  of  native  untrained  servants,  who  usually  pre- 
fer basking  in  the  sun  and  living  on  a  few  herbs  and  mealies 
to  working  hard  for  the  white  people,  who,  after  all.  only 
feed  them. 

It  will  be  seen  that  while  beyond  Cape  Colony  little  or 
no  progress  has  been  made  in  the  organization  of  nurses, 
yet  that  north,  south,  east  and  west  nurses  are  doing  excel- 
lent work  at  isolated  stations,  and  the  development  of  the 
Continent  during-  the  last  quarter  of  a  century  has  been  so 
rapid  that  there  is  g-round  for  hoping  that  before  the  dawn 
of  the  next  century  National  Councils  of  African  Nurses 
may  apply  for  membership  of  the  International  Council. 


Nursing  in  Australia. 

SARAH  B.  McGAHEY, 

Matron  Prince  Alfred  Hospital,  Sidney;  Honorary  Vice  President  International 

Council  of  Nurses. 


INSTRUCTION    IN    NURSING. 

1.  In  all  the  principal  hospitals  systematic  instruction 
is  given  to  the  members  of  the  nursing  staff  in  Elementary 
Nursing,  Elementary  Anatomy  and  Physiology,  Hygiene, 
Medical  and  Surgical  Nursing  and  Invalid  Cookery. 

(a)     Length  of  Course:     Three  years  in  almost  every 
recognized  training  school. 
Prince  Alfred  Hospital  and  Sydney  Hospital,  Syd- 
ney, have  a  four  (4)  years'  course. 

2.  Practical  Work :  Practical  instruction  is  being 
given  in  the  majority  of  training  schools. 

(a)  Organization  of  Nurses :  The  only  organizations 
are  the  Australasian  Trained  Nurses'  Associa- 
tion, and  the  Prince  Alfred  Hospital  Trained 
Nurses'  Reunion. 


392 


Nursing  in  Brazil. 

JAIfE  A.  JACKSON, 

Matron  and  Superintendent  Strangers'  Hospital,  Brazil. 


There  is  no  training  school  for  nursing  in  the  whole 
of  Brazil,  but  every  now  and  then  there  is  a  great  talk  about 
one,  and  then  it  dies  out  again.  In  the  native  hospi- 
tals here  there  are  not  any  nurses  at  all,  the  work  of 
the  wards  being  undertaken  by  Sisters  of  Mercy  and  the 
Order  of  St.  Vincent  de  Paul,  and  under  them  in  the  male 
wards  they  have  men  who  wear  a  linen  uniform,  no  collar 
or  tie,  slippers  without  socks,  and  smoke  cigarettes.  They 
call  them  "serventes." 

In  the  large  hospital  here,  the  Santa  Casa  da  Miseri- 
cordia,  which  has  two  thousand  beds,  it  is  the  same,  the 
sisters  getting  up  at  midnight  and  4  a.  m.  to  give  the  medi- 
cines, and  the  ward  is  then  left  in  charge  of  one  of  these 
men.  It  is  a  beautiful  building,  but  the  patients  and  bedding 
are  filthy.  In  the  Hospital  for  the  Insane,  which  is  just 
below  us,  the  work  is  now,  on  the  female  side,  under  the 
care  of  Frenchwomen  who  have  had  some  little  training 
before  coming  out,  but  they  are  not  certificated.  That  now 
being  the  hospital  of  the  state,  the  sisters  are  not  employed 
there. 

In  the  S.  Sabastano  Hospital  for  yellow  fever  they  have 
boys  who  have  been  trained  there  under  the  superintendent, 
Dr.  Seidel,  and  two  years  ago  I  had  one  from  him,  and  he 
is  still  with  me.  He  is  very  clean,  but  I  had  to  teach  him 
how  to  sponge  patients,  wash  them,  make  beds,  etc.  Now 
he  is  most  valuable,  as  he  knows  a  great  deal  about  yellow 
fever  with  all  its  sequelae,  and  I  can  leave  him  alone  at  night 

393 


394  International  Con!j;rcss  of  Xurscs 

with  patients.  He  can  take  temperature,  pulse  and  respira- 
tion, and  also,  if  the  patient  should  have  failure  of  the  heart, 
which  is  a  very  common  thing-  in  yellow  fever,  he  knows 
just  when  to  give  caffeine,  and  I  consider  that  a  great  deal 
in  a  Brazilian. 

Patients  are  never  washed,  or,  I  might  say,  very  rarely, 
in  the  native  hospitals,  and  very  often  fresh  patients  are  put 
into  the  beds  without  change  of  bedding. 

In  S.  Paulo,  at  the  Hospital  Samaritano,  they  train  pro- 
bationers, and  I  have  written  to  the  medical  superintendent 
and  asked  him  to  kindly  give  me  all  the  information  he  can. 
His  reply  I  append  here : 

"  In  reply  to  your  letter  of  inquiry,  I  can  only  state 
that  as  far  as  S.  Paula  goes  there  is  absolutely  nothing 
done  as  to  organization  for  training  of  nurses.  In  the  Sama- 
ritano all  our  stafT  nurses  arc  home-trained,  and  we  have 
only  two  probationers'  places.  We  require  three  years  of 
service,  including  medical  and  surgical  work.  If  they  finish 
the  term  that  is  proof  that  their  work  has  been  satisfactory, 
and  a  certificate  to  that  effect  is  given.  In  the  national 
hospitals  the  trained  nurse  is  an  unknown  quantity.  Roman 
Catholic  sisterhoods  are  nominally  the  source  of  supply  of 
nurses,  but  what  is  done  is  done  by  uninstructed  persons, 
male  and  female,  who  frequently  have  been  patients  them- 
selves, and,  showing  some  interest  in  their  fellow-patients, 
have  been  asked  to  remain  as  nurses ! 

"  So  far  as  I  know  Brazil  and  its  hospitals,  you  may 
state  that,  with  the  exception  of  one  or  two  hospitals,  such 
as  the  Strangers'  and  the  Samambano,  which  have  English 
trained  nurses,  there  is  no  such  thing  known  in  the  native 
hospitals  as  the  trained  nurse  in  our  acceptance  of  the  term. 
They  are  in  this  respect  at  least  one  hundred  years  behind 
the  times." 

Buenos  Ayres  is  very  much  more  progressive.  The 
matron  who  was  there  for  eleven  years,  Miss  Eames,  left 
last  November,  and  is  now  in  London.  I  think  she  was 
from  St.  Thomas'  Hospital. 


Council  Reports  395 

The  head  nurses  have  mostly  been  trained  at  home^ 
and  yet  they  have  selected  as  matron  one  of  their  proba- 
tioners, with  only  the  training  possible  there,  which  Miss 
Eames  did  not  think  quite  sufficient. 

South  America  has  still  to  be  roused  up,  for  it  is  twenty- 
five  years  behind  every  country.  Every  Brazilian  doctor 
or  visitor  who  comes  up  here  exclaims  at  the  cleanliness 
of  the  place  and  at  ourselves  in  our  white  uniform,  and  one 
great  compliment  they  pay  us  is  that  we  are  most  punctual 
and  better  able  to  adapt  ourselves  to  sick-nursing  than  the 
Brazilians. 

I  am  only  sorry  that  I  cannot  give  you  a  better  account 
of  the  condition  of  things  in  hospital  work  in  the  capital  of 
Brazil,  and  you  will  find  my  letter  of  very  little  use.  I 
w^ish  I  could  say  that  we  are  going  with  the  times.  All  we 
can  do  is  to  try  and  keep  up  to  the  standard  as  far  as  we 
can  that  we  were  taught  at  home,  and  that  is  difficult  in  a 
country  like  this,  where  everything  is  lax. 


Nursing  in  Cuba. 


LUCY  W.  QUINTARD, 

Inspector  of  Hospitals,  Department  of  Charities,  Havana ;  Councillor 
International  Council  of  Nurses. 


One  of  the  greatest  problems  presented  to  the  govern- 
ment at  the  beginning-  of  the  American  occupation  of  the 
island  of  Cuba  was  how  to  deal  with  the  appalling  condition 
of  her  hospitals.  A  visit  to  some  of  these  places  would 
remind  one  of  the  Dark  Ages.  They  were  dens  of  immor- 
ality and  uncleanness  in  every  form. 

Their  unsanitary  condition  was  responsible  for  much 
of  the  sickness  in  the  cities  and  surrounding  country.  No 
precautions  were  taken  to  prevent  the  spread  of  disease.  In 
many  instances  where  expensive  apparatus  had  been  pro- 
vided for  the  disinfection  of  clothes,  it  had  never  been  used 
for  this  purpose. 

Dirty  water  from  the  baths  and  laundries  was  often 
disposed  of  by  turning  it  into  the  streets.  In  some  places 
clothes  were  washed  in  the  rivers  without  a  previous  disin- 
fection, to  breed  disease  wherever  their  waters  were  used. 
Those  employed  in  the  care  of  the  sick  were  of  the  lowest 
type  of  humanity.  The  very  name  of  "enfermero,"  or  nurse, 
was  a  term  of  degradation. 

Recognizing  the  herculean  task  before  them  of  cleaning 
up  these  hospitals,  and  realizing  their  helplessness  to  accom- 
plish it  singlehanded,  the  men  to  whom  this  work  was 
intrusted  turned  to  the  nursing  profession  for  assistance, 
and  they  met  with  a  hearty  response. 

396 


Council  Reports  397 

Good  women  answered  the  call  and  went  to  work  with 
a  will,  working^  early  and  late  to  cooperate  with  the  heads  of 
departments  in  every  possible  way. 

Preparations  were  made  for  establishing  schools  in  the 
large  hospitals  for  the  education  of  Cuban  girls  in  the  prac- 
tical care  of  the  sick.  In  August  of  1899  the  first  school 
was  opened  in  the  Hospital  Mercedes,  Havana.  The  first 
class  was  composed  of  seven  pupils. 

It  was  proposed  at  first  to  limit  the  course  of  instruc- 
tion to  two  years,  but  it  was  soon  found  impossible  to  bring 
these  girls  up  to  a  proper  standard  in  that  time,  and  the 
course  was  extended  to  three  years.  In  March  of  1900 
plans  were  formed  for  starting  a  school  at  Puerto  Principi, 
in  the  center  of  the  Island. 

This  was  to  be  a  model  hospital  and  school,  and  no 
expense  was  spared  in  renovating  and  furnishing  the  large 
Spanish  military  hospital,  a  building  capable  of  accommo- 
dating from  250  to  300  patients,  for  this  purpose.  The  work 
was  however  so  delayed  on  the  building  that  it  was  not 
ready  for  the  reception  of  patients  until  the  first  week  in 
November.  This  school  was  opened  with  twenty-five  pupils,, 
which  number  has  since  been  increased  to  thirty. 

In  the  summer  of  1900  another  school  was  opened  in 
Hospital  No.  1,  in  Havana,  and  one  in  the  hospital  in  Cien- 
fuegos.  In  the  autunm  of  the  same  year  still  another  was 
started  in  connection  with  Hospital  San  Isabel,  Matanzas. 

In  January  of  1901  plans  were  formulated  for  a  school 
in  connection  with  the  Hospital  Civil,  Santiago  de  Cuba,  but 
owing  to  delays  in  getting  the  estimates  passed  by  the  mil- 
itary governor  this  hospital  was  not  opened  until  the  begin- 
ning of  April.  This  lattqr  school  has  been  one  of  the  most 
difficult  to  establish,  owing  to  the  fact  that  the  population  of 
Santiago  de  Cuba  is  fully  two-thirds  negro. 

These  six  schools  are  all  in  a  healthy  flourishing  con- 
dition. They  have  been  established  on  a  good  firm  founda- 
tion, and  if  the  present  status  can  be  maintained,  and  good 
American  graduates  can  be  kept  at  the  head  of  them  until 
their  own  graduates  have   had  sufficient  experience  after 


398  International  Congress  uf  Xurscs 

their  training  to  occupy  positions  as  superintendents  and 
head  nurses,  there  is  no  reason  why  Cuba  should  not  in 
a  few  years  be  able  to  boast  of  a  fine  nursing  service  in  her 
hospitals  as  well  as  a  thoroughly  trained  corps  of  women  to 
meet  the  demands  of  private  individuals.  These  schools 
are  organized  as  state  institutions  under  the  control  of  a 
central  board  which  will  govern  them  independently  of 
the  hospitals  to  which  they  are  attached.  The  standard 
will  thus  be  uniform.  The  course  of  training  will  be  three 
years.  The  curriculum  will  cover  much  the  same  ground, 
simplified,  as  in  our  schools  in  the  United  States.  The 
practical  instruction  will  be  given  by  American  graduates, 
and  will  of  course  be  adapted  to  the  difference  in  climate 
and  the  nature  of  the  diseases,  many  of  which  are  much 
modified  in  Cuba. 

The  examinations  at  the  close  of  the  first  and  second 
years  will  be  held  by  the  physicians  of  the  hospital.  The 
third  year's  examinations  will  be  conducted  before  a  board 
appointed  from  the  School  of  Medicine  and  Pharmacy  which 
will  meet  for  this  purpose  in  each  of  the  cities  where  there 
is  a  school. 

The  diplomas  will  be  given  by  this  board.  This  diploma 
will  be  recognized  as  giving  the  nurse  a  professional  status, 
and  without  such  diploma  no  person  will  be  permitted  to 
follow  the  practice  of  nursing.  The  director  of  the  hos- 
pital will  be  the  representative  of  the  central  board.  The 
superintendent  and  her  graduate  assistants  will  receive  their 
appointments  from  the  board  with  the  approval  of  the 
director. 

So  far  no  schools  have  been  organized  in  the  small 
hospitals,  as  it  has  been  impossible  in  so  short  a  time  to 
provide  for  all.  It  has  been  considered  best  to  train  the 
pupils  in  the  larger  hospitals  where  they  could  have  the 
greater  experience  and  send  them  for  a  few  months  in  their 
third  year  to  the  smaller  hospitals,  thus  giving  them  the 
benefit  of  skilled  nursing. 

During  the  third  year  the  pupils  will  also  be  sent  to 
private  cases  for  a  period  not  exceeding  three  months.    The 


Coiincil  Reports  399 

money  received  from  this  source  is  to  be  placed  with  the 
treasurer  of  the  hospital  and  allowed  to  accumulate  with 
the  object  of  being  used  for  the  benefit  of  the  nurses  in  some 
way  not  yet  determined. 

This  outside  work  may  also  be  of  some  service  to  the 
pupil  insomuch  as  it  will  try  her  in  positions  where  she  will 
be  called  upon  for  the  first  time  in  her  life  to  act  for  herself, 
and  yet  where  she  will  be  in  a  certain  measure  under  the 
supervision  of  her  hospital. 

In  organizing  these  schools  much  has  had  to  be  taken 
into  account.  The  ill  repute  of  the  hospitals  and  their 
employees ;  the  habits  and  temperament  of  the  people ;  the 
rigid  rules  governing  the  lives  of  the  women  who  have 
never  known  what  freedom  or  independence  meant;  the 
strong  prejudices  against  a  woman  occupying  positions 
which  would  take  her  from  the  shelter  of  her  own  home, 
especially  when  it  meant  that  she  must  live  entirely  away 
from  her  home  for  three  years.  This  latter  is  not  confined 
to  Cuba.  How  many  of  us  can  remember  the  difficulties 
•experienced  in  the  early  history  of  our  own  schools  on  this 
line! 

In  the  eastern  end  of  the  Island,  where  nearly  80  per 
■cent,  of  the  population  is  negro,  we  are  confronted  with  the 
race  difficulty.  It  is  almost  impossible  to  draw  the  color 
line  here  where  it  can  only  be  recognized  by  the  educated 
€ye. 

Under  such  circumstances  as  these  we  have  had  to 
of¥er  inducements  to  girls  to  enter,  which,  I  am  sorry  to 
say,  have  taken  the  form  of  money  compensation,  and  we 
are  paying  our  pupils  eight  dollars  a  month  for  the  first 
year,  twelve  dollars  the  second  year,  and  twenty-five  dollars 
the  third  year.  Besides  this  an  allowance  of  three  dollars 
a  month  is  made  for  uniforms  during  the  first  two  years. 

This  to  me  is  the  one  weak  point  in  organization,  and 
yet  I  recognize  the  fact  that  it  was  necessary  in  order  to  get 
the  better  class  of  girls  to  enter  our  schools. 

This  is  contrary  to  conditions  existing  in  the  United 
States,  but  it  can  be  explained  and  excused  to  a  certain 


400  International  Congress  of  Xurscs 

extent  by  the  fact  that  many  of  these  girls  have  been  obHged 
to  contribute  to  the  support  of  their  famiHes  by  sewing, 
and  cannot  afford  to  devote  three  years  to  a  work  which 
will  not  enable  them  to  continue  this. 

Other  conditions  we  have  to  contend  with  are  a  lack 
of  education,  stability,  and  truthfulness. 

The  girls  are  intelligent,  quick  to  pick  up  new  ideas 
and  adapt  them,  but  they  have  no  stability  of  character; 
one  is  never  sure  of  them,  and  a  Cuban  girl  thinks  no  more 
of  telling  a  falsehood  than  the  truth.  This  lack  of  truth- 
fulness arises  no  doubt  from  the  conditions  existing  for  so 
many  years  of  intrigue  and  deception.  In  time  of  Spanish 
rule  the  Cubans  never  knew  whether  they  were  surrounded 
by  friends  or  foes,  even  the  members  of  their  own  house- 
holds might  betray  them.  Time  and  training  are  the  only 
remedies,  and  on  these  two  factors  we  must  depend  for 
improvement. 

When  one  realizes  the  many  perplexing  problems  to 
be  solved  in  the  training  of  these  women  is  it  any  wonder 
that  we  feel  the  need  of  assistance  from  the  graduates  of 
our  northern  schools?  Never  could  one  undertake  better 
missionary  work  than  in  devoting  a  couple  of  years  to  one 
of  our  Cuban  schools.  But  we  want  women  of  strong  char- 
acter, patient  and  painstaking,  tactful  and  cheerful. 

These  Cuban  girls  can  be  won  by  a  smile  and  a  kind 
word,  but  can  never  be  driven.  There  is  much  that  is 
lovely  in  their  character ;  there  is  also  much  to  be  eradicated. 

With  all  my  disappointments  and  discouragements  in 
regard  to  our  work  here,  I  still  feel  hopeful.  My  two  years' 
work  among  this  people  has  taught  me  that  by  educating 
these  girls  as  nurses  we  are  doing  much  to  help  the  women 
of  Cuba  generally. 

There  is  a  lack  of  nurses  in  Cuba,  in  fact  there  are 
none.  When  a  mem_ber  of  the  family  is  ill  he  or  she  is 
nursed  by  all  the  near  relatives  and  many  of  the  friends. 
It  would  be  considered  a  want  of  feeling  on  the  part  of 
these  if  they  did  not  attend  in  full  force.  These  people  are 
very  helpless  in  time  of  sickness.     Their  sole  idea  of  nurs- 


Council  Reports  401 

ingf  is  to  g-ive  all  the  medicine  and  food  they  can  get  the 
patient  to  swallow,  to  keep  every  door  and  window  closed, 
and  avoid  all  external  use  of  water. 

There  are  many  rocks  ahead,  one  of  the  most  danger- 
ous being  the  temptations  which  await  our  girls  when  they 
emerge  from  their  school  ready  to  take  up  their  career  in 
a  world  of  which  they  have  had  so  little  knowledge.  This 
is  a  matter  which  must  be  discussed,  and  some  means  must 
be  provided  for  their  protection  as  far  as  is  possible. 

Our  nursing  organization  in  Cuba  is  still  in  its  infancy, 
and  while  it  appears  a  strong  healthy  infant,  there  remains 
the  dang-er  that  all  the  changes  which  the  new  repubUc  will 
bring  may  tend  to  crush  out  its  young  life,  and  our  work 
of  the  past  two  years  and  a  half  will  be  destroyed.  The 
next  year  will  decide  this  question. 

This  work  has  wrought  such  wonderful  changes  in  our 
hospitals  that  the  doctors  of  Cuba  have  learned  the  value 
of  the  service  and  will,  I  am  sure,  do  all  in  their  power  to 
promote  its  interest. 


Nursing  in  Denmark. 

CHARLOTTE  NORRIE, 

Secretary  Danish  Council  of  Women,  Copenhagen;  Councillor  International 

Council  of  Nurses. 


fCommunehospital  i  Kobenhavn  is  our  largest  hos- 
pital. It  contains  more  than  950  beds  in  six  male  and  six 
female  divisionts,  viz:  two  surg-ical,  two  medical,  one  for 
nervous  and  mental  patients  (the  latter  are  removed  as  soon 
as  the  diagnosis  is  certain),  and  one  for  diseases  of  the  skin, 
etc.  I  have  before  me  a  printed  communication  from  this 
hospital,  signed  July  30,  1898. 

Pupils  desiring  to  enter  the  hospital  career  are  received 
for  a  term  of  fifteen  months,  and  they  receive  both  practical 
and  theoretical  training;  their  work  in  the  sick  room  is 
taken  as  equivalent  for  their  training;  they  receive  no  sal- 
ary, but  they  have  full  board,  lodging,  uniform  and  laundry. 

The  theoretical  training,  given  by  a  house-surgeon,  is 
suspended  for  the  summer  months. 

After  this  course  of  fifteen  months,  an  examination 
takes  place,  and  the  successful  candidates  may  be  accepted 
as  assistant  nurses  and  receive  the  usual  salary. 

Pupils  who  wisb  to  do  private  nursing,  or  to  work  in 
county  hospitals,  may  take  part  in  this  training,  but  they 
receive  neither  lodging,  dress  nor  laundry,  and  they  have 
to  pay  thirty  kroner  (one  krone  is  about  Is.  Id.)  monthly  for 
board.  These  extra  pupils  may,  after  having  passed  their 
examinations,  continue  their  work  at  the  hospital  for  six 
months  without  paying  for  their  board,  after  which  term 
they  may  have  a  certificate  on  leaving  the  hospital. 
402 


Council  Reports  403 

The  age  required  for  admission  is  generally  between 
22  and  30  years. 

Next  to  the  Kommunehospital  comes  the  Kongelige 
Frederiks  Hospital.  I  have  no  information  regarding  the 
training  of  nurses  at  this  hospital. 

Dronning  Louises  Bornehospital  contains  sixty  to  six- 
ty-five beds,  surgical  and  medical  cases,  boys  and  girls, 
while  they  are  small. 

The  printed  communication  before  me  is  dated  January 
1,  1900. 

Pupils  are  received  for  two  years'  practical  and  theo- 
retical training  on  the  same  terms  as  above.  Besides  the 
general  training  they  will  be  taught  to  work  at  the  theater 
and  at  out-patient  department,  to  sterilize  milk,  etc. 

Theoretical  training  as  above. 

During  the  second  year  thev  may  be  looked  upon  as 
assistant  nurses,  if  such  a  place  is  vacant ;  they  then  receive 
the  usual  salary. 

Age  of  admission  about  20  to  30  years. 

Day  pupils  are  received  for  a  term  of  three  months ; 
they  pay  thirty  kroner  monthly  for  board. 

Froken  Lovenhielm  has  given  information  to  the  effect 
that  her  nursing  school  is  now  a  deaconesses'  home,  with  a 
three  years'  training  for  deaconesses.  Its  name  is  now  St. 
Lucas  Stiftilse. 

Den  Danske  Diako7iissestiftilse  has  a  hospital  contain- 
ing about  ninety  beds  for  men  and  women,  medical  and 
surgical  cases  together.  The  lady  superintendent  writes  me 
one  week  ago  that  the  sisters  going  in  for  training  at  this 
institution  will  not  all  be  sick-nurses.  They  always  begin 
with  thorough  training  in  cleaning  a  house  and  keeping  it 
so ;  if  possible,  they  also  learn  laundry  work  and  house- 
keeping. Then  they  generally  go  to  a  home  for  incurables, 
and  after  this  to  the  sick  wards. 

Here  they  usually  commence  in  the  children's  wards, 
and  after  a  few  months  they  go  to  the  adult  male  and  female 
wards.  The  pupil  now  works  under  the  supervision  of  the 
elder  sisters  in  the  different  wards  for  at  least  one  year,  if 


404  International  Congress  of  Xurses 

she  is  deemed  fit  for  sick  nursino:  and  is  expected  to  work 
afterwards  at  county  hospitals.  The  sisters  who  are  to  do 
district  nursing  are  very  often  only  eight  months  at  the 
hospital,  but  generally  they  work  for  three  months  more  at 
a  maternity  home.  All  the  sisters,  even  if  they  enter  for 
teaching  or  housekeeping,  have  at  least  six  months'  train- 
ing in  the  sick  wards.  Only  those  sisters  who  seem  to  be 
especially  fit  for  it  are  admitted  to  do  theater  [operating 
room]  work. 

The  Qverloge  (head  physician)  teaches  pathology  in 
one  weekly  lesson  for  nine  months ;  a  sister  gives  one  weekly 
hour  instruction  in  anatomy,  bandaging,  etc. 

Such  is  the  plan,  which  is  not  always  strictly  followed, 
as  the  individual  necessities  may  require  other  measures, — 
but  the  tendency  is  towards  prolongation. 

Kbbenhavns  Garnisonssygelius  is  our  metropolitan 
military  hospital,  and  contains  about  500  beds,  medical  and 
surgical  cases  together,  in  different  divisions  and  clinics: 
three  for  medical  and  surgical  cases,  one  for  epidemic  fevers, 
one  for  women  and  children  [of  the  soldiers'  families],  for 
eyes,  ears,  etc. 

The  nursing  in  this  hospital  is  based  on  the  same  prin- 
ciples as  in  our  best  civil  hospitals. 

I  have  my  information  partly  from  an  article  by  the 
Danish  surgeon-general,  Dr.  Hon.  Johan  Moller.  in  the 
April,  1898,  number  of  a  military  medical  quarterly  paper, 
Melitorlogen,  and  partly  from  a  written  statement  from  one 
of  the  overplejersker  (head  nurses,  superintendents  of  nurs- 
ing) received  a  week  ago. 

Pupils  are  received  for  a  term  of  six  months,  and  are 
placed  under  the  supervision  of  one  of  the  elder  nurses  or 
assistant  nurses  for  their  practical  training.  During  the 
three  summer  months  one  of  the  house  surgeons  lectures 
two  hours  weekly,  teaching  anatomy  and  military  nursing. 
This  training  is  finished  by  an  examination,  generally  held 
before  the  stabsloge  ag  sygehuschef  (medical  superinten- 
dent).   They  receive  no  certificate. 

They  have  lodging,  full  board  and  laundry,  and  after 


Council  Reports  405 

two  months  of  probation  they  receive  a  salary  of  12  kroner 
monthly,  and  after  the  six  months  they  may  enter  the  hos- 
pital as  assistant  nurses. 

Besides  the  female  nurses,  each  of  whom  has  about  ten 
patients,  there  are  sygepassere  (orderlies)  taken  amongst  the 
best  conscripts — we  have  compulsory  conscription  in  Den- 
mark. Many  of  them  have  passed  their  final  examinations 
at  the  university  to  become  lawyers,  ministers,  etc.,  others 
are  teachers,  clerks,  etc.,  besides  a  few  artisans,  as  cabinet 
makers,  saddlers,  etc.  They  first  go  through  a  drill  for 
two  and  one-half  months,  and  then  they  go  for  six  months 
to  one  of  the  military  hospitals.  During  the  first  two  and 
one-half  months  they  are  taught  military  deportment,  dis- 
cipline, etc.,  besides  elementary  anatomy,  physiology,  and 
first  aid  to  the  injured.  In  the  hospitals  they  take  part  in 
the  nursing  under  the  supervision  of  the  nurses,  from  whom 
they  take  orders  as  far  as  nursing  is  concerned. 

The  training  at  all  our  hospitals  may  be  said  to  be  based 
on  the  principle  of  training  nurses  for  the  use  of  the  hospital. 
Outsiders  may  take  part  in  this  training,  e.  g.,  the  Red  Cross 
sisters  are  admitted  on  favorable  terms  to  profit  from  this 
training. 

The  Royal  Lying-in  Hospital  liberally  permits  nurses, 
who  have  been  trained  elsewhere,  to  work  there  for  about 
a  month  that  they  may  learn  to  take  care  of  women  and 
children  after  confinement. 

As  to  the  relatively  excellent  training  of  our  midwives, 
I  shall  another  day  send  you  information.  They  pass  an 
examination  after  training,  and  they  are  certificated  and 
registered,  and  nobody  else,  save  a  medical  man  or  woman, 
is  permitted  to  assist  at  childbirth.  The  midwife  very  often 
leaves  as  soon  as  mother  and  baby  are  well  at  rest,  and  then 
the  nurse  takes  her  place. 

Danish  nurses  are  associated  in  the  Danish  Council  of 
Nurses,  whose  president  is  Mrs.  Tschnerning,  of  the  Kom- 
mune  Hospital. 


■^^\^ 


Nursing  in  Egypt. 

JANE  G.WATKINS, 
Matron  Government  Hospital,  Cairo. 


I. 

The  only  authorized  training  chool  for  nurses  in  Egypt 
is  the  government  hospital,  Kasr  el  Aini,  Cairo.  Here  the 
patients,  mostly  Egyptians,  are  nursed  by  Egyptian  nurses 
of  their  own  sex,  under  the  supervision  of  an  English  stafif 
consisting  of  a  matron  and  seven  sisters. 

The  hospital,  which  contains  420  beds,  is  divided  into 
two  wings,  one  for  male  patients  and  the  other  for  the 
hareem,  or  female  patients. 

On  the  male  side  the  nurses  are  men  of  the  lower  class, 
sufificiently  educated  to  be  able  to  read  and  write,  who  work- 
in  the  wards  for  a  long  or  short  period  according  to  their 
capabilities.  They  receive  no  special  training  and,  of  course, 
no  certificate. 

L" Ecole  Medicate  des  Filles  provides  the  nurses  for  the 
female  patients.  These  pupils  are  under  the  superintendence 
of  the  matron  of  the  hospital.  They  are  chosen  from  the 
Sanich  school,  a  government  secular  institution  under  the 
care  of  an  English  head  mistress,  and  are  obliged  to  bring 
with  them  a  certificate  of  proficiency  in  reading  and  writing. 

The  term  of  training  is  for  three  years.     During  the 
whole  of  this  period  the  pupils  work  in  the  wards,  medical, 
surgical,  ophthalmic,  midwifery,  and  gy-naecological,  under 
406 


Council  Reports  407 

the  supennsion  of  English  sisters,  who  train  them  in  prac- 
tical nursing.  For  theoretical  work,  during  the  first  year, 
lectures  are  given  by  the  physiologist  (a  native)  of  the  med- 
ical school  on  elementary  physiology  and  anatomy,  and  by 
the  matron  on  nursing.  At  the  end  of  this  term  an  exam- 
ination is  held  on  these  subjects. 

During  the  second  year  the  principal  subjects  taught 
are  pharmacology  by  the  professor  of  chemistry  (a  Ger- 
man), and  theoretical  nursing  by  the  matron.  The  pupils 
are  examined  in  these  subjects  at  the  end  of  twelve  months. 

For  the  third  year  the  lectures  are  on  midwifery,  nor- 
mal and  abnormal  labors,  which  are  given  by  a  native 
doctor,  on  anatomy  of  the  pelvis  and  gynaecology  by  another 
native  doctor,  and  on  legal  medicine  by  the  director  of  the 
medical  schools. 

The  practical  training  in  the  wards  in  midwifery  is 
given  by  the  surgeons  attending  the  cases.  There  is  no 
English  midwife  in  the  hospital,  and  the  pupils  receive  no 
special  training  in  obstetrical  nursing.  The  pupils  have 
lessons  in  English  and  are  instructed  in  physical  exercises. 

At  the  end  of  her  three  years,  if  a  pupil  passes  her  final 
examination,  and  her  conduct  has  been  satisfactory,  she 
receives  a  diploma  from  the  sanitary  department  and  is  reg- 
istered by  the  state  as  a  "hakeema."  A  "hakeema"  has  the 
following  choice  of  work :  She  may  practice  as  a  midwife 
on  her  own  account,  or  she  may  remain  in  the  government 
employment  in  either  of  the  following  capacities :  She  may 
stay  on  in  the  hospital  as  a  sort  of  staff  nurse ;  there  are  two 
of  these  posts  at  Kasr  el  Aini.  She  may  be  attached  to  one 
of  the  police  divisions  of  Cairo  or  Alexandria,  or  she  may 
go  to  a  moodarieh  (province),  working  with  the  doctor 
attached  to  the  police  station  or  province.  Under  these 
conditions  a  "hakeema"  may  legally  certify  cause  of  deaths 
write  a  simple  prescription,  attend  cases  of  normal  labor, 
treat  gynaecological  patients,  and  in  case  of  an  outbreak  of 
an  epidemic  inspect  females.  A  few  Mohammedan  families 
who  object  to  a  male  doctor  employ  a  certificated 
"hakeema"  for  sick  female  relatives. 


408  International  Congress  of  Nurses 

In  addition  to  and  quite  distinct  from  the  hakeemas  are 
the  "diahs."  These  are  completely  uneducated  women,  who 
receive  theoretical  instruction  by  a  course  of  lectures  on 
simple  midwifery  given  by  a  doctor  or  midwife  at  Kasr  el 
Aini  or  other  government  hospitals.  The  course  of  lectures 
usually  occupies  about  fifteen  days.  At  the  end  of  this  time 
they  are  examined  by  a  doctor,  and  if  passed  by  him  are 
licensed  by  the  state  to  attend  cases  of  the  simplest  kind. 
The  law  is  very  strict  with  regard  to  the  limitations  of  the 
"  diah's  "  work.  She  may  use  no  instrument  of  any  kind, 
not  even  for  rupturing  the  membranes. 

The  cases  of  normal  labor  at  Kasr  el  Aini  Hospital  are 
very  few  indeed,  and  are  chiefly  women  undergoing  a  term 
of  imprisonment  at  one  of  the  state  prisons.  The  abnormal 
cases  are  usually  very  difficult  ones,  as  the  patient  has  prob- 
ably been  attended  in  her  own  home  by  a  "  diah,"  who  has 
not  recognized  the  difficulty  of  the  case  until  the  patient  has 
been  several  days  in  labor  and  is  in  danger  of  death. 

There  is  very  little  demand  for  Egyptian  women  as 
nurses  among  Egyptians. 

The  "hakeema"  as  a  midwife  has  a  recognized  position, 
and  so  has  the  "  diah."  The  great  majority  of  women  in 
Egypt  are  still  veiled,  and  they  have  no  authority  in  any 
household  but  their  own.  They  are,  therefore,  simply  use- 
less as  nurses.  The  German  hospitals,  of  which  there  are 
two  in  Egypt,  one  in  Cairo,  and  one  in  Alexandria,  are 
nursed  by  German  deaconesses  trained  at  Kaiserswerth.  The 
French  hospitals,  three  in  number,  one  at  Cairo,  one  at  Suez, 
and  one  at  Alexandria,  are  nursed  by  the  sisters  of  St.  Vin- 
cent de  Paul. 

The  British  hospital  at  Port  Said  has  an  English  super- 
intendent, who  has  four  fully  trained  nurses  under  her,  three 
for  the  hospital  and  one  for  private  cases.  They  are  all 
engaged  from  England  for  three  years. 

The  government  hospital  at  Port  Said  is  nursed  by  sis- 
ters of  the  Bon  Pasteur  order. 

The  Greek  hospital  in  Alexandria  also  employs  English 
.sisters. 


Council  Reports  409 

II. 

ORGANIZATIONS   OF   CERTIFICATED   NURSES. 

Of  these  there  are  three  in  Cairo : 

The  English  hospital  and  Victoria  Nursing  Home,  the 
staff  of  which  consists  of  a  matron  and  seven  nurses,  all 
English.  The-  nurses  are  employed  in  the  hospital  and  for 
outside  work. 

The  English  Nursing  Home,  which  has  a  superinten- 
dent and  four  nurses. 

The  Marianne  Hughes  Nursing  Fund,  which  employs 
two  nurses.  The  nurses  employed  by  it  are  engaged  by  the 
matron  of  Kasr  el  Aini  Hospital  and  are  under  her  super- 
vision. They  nurse  for  any  doctor  in  Cairo,  and  may  be 
sent  to  other  parts  of  Egypt  by  special  permission  from  the 
committee  of  the  fund.  They  are  engaged  for  six  to  eighteen 
months,  and  when  not  nursing  private  patients  they  are 
employed  in  the  government  hospital. 

In  Alexandria  the  Victoria  Home,  which  is  a  home  for 
governesses  and  a  registry  ol^ce  for  servants,  keeps  three 
nurses,  whom  it  sends  out  to  cases  as  they  are  required. 


Nursing    in    Fiji. 


MAY  C.  ANDERSON, 

Sister  Superintendent. 
(Sent  by  courtesy  of  B.  (Jlanville  Corney,  Chief  Medical  Officer,  Fiji.) 


Away  in  the  distant  Pacific,  far  from  the  centers  of 
civihzed  hfe,  one  scarcely  expects  to  meet  with  all  the  com- 
forts so  easily  obtainable  in  laro^e  cities.  Nevertheless,  in 
one  group  of  islands,  one  of  the  many  in  southern  seas, 
we  have  our  little  hospital,  which,  thousfh  not  an  imposing 
edifice  of  stone,  tiles,  etc..  still  carries  on  its  work  from  year 
to  year,  and  achieves  the  primary  end  for  which  hospitals 
exist. 

Many  things  have  a  humble  beginning,  and  this  insti- 
tution is  not  an  exception.  The  beginning  was  made  in 
1883,  by  erecting  a  few  native  houses  of  unsawn  timber, 
reeds  and  thatch  ;  not  aseptic,  perhaps,  many  nurses  may 
think,  and  quite  correctly  so,  yet  for  a  time  they  served 
their  purpose  in  sheltering  patients  who  came  from  neigh- 
boring or  distant  islands.  Situated  on  rising  ground,  over- 
looking a  beautiful  harbor  within  coral  reefs,  and  sur- 
rounded by  tropical  foliage,  the  spot  was  happily  chosen 
for  its  future  development.  In  course  of  time  properly 
equipped  wooden  buildings  superseded  the  primitive  struc- 
tures of  thatch,  and  accommodation  was  provided  for  a 
much  greater  number  of  patients. 

Until  1888  the  hospital  was  in  charge  of  a  non-resident 
medical  officer,  and  its  domestic  administration  was  presided 
410 


Council  Reports  411 

over  by  an  untrained  matron  who  was  kind,  indeed,  to  the 
patients,  but  lacked  the  knowledge  so  essential  in  nursing- 
the  sick.  The  work  of  the  wards  was  carried  on  by  native 
and  Melanesian  laborers.  The  need  for  further  improve- 
ment soon  became  very  apparent,  and  the  government 
decided  to  obtain  the  services  of  a  trained  nurse.  Our  pio- 
neer sister  was  a  lady  from  St.  Thomas'  Hospital,  London, 
who  bravely  set  to  work  to  surmount  the  difificulties  inci- 
dental to  life  in  a  new  country,  previous  lack  of  nursing 
organization,  and  an  imfamiliar  vernacular.  During  the 
early  years  Europeans  rarely  sought  admission  to  the  wards, 
for  it  was  regarded  as  a  native  hospital  only,  and  many 
necessary  comforts  were  wanting.  The  sister  soon  found 
that  it  was  impossible  to  work  on  alone,  and  accordingly 
made  arrangements  to  train  probationers,  one  of  whom 
remained  to  complete  her  training  (three  years),  and  for 
some  time  worked  under  a  sister  who  was  trained  in  the 
London  hospital  and  succeeded  the  one  previously  men- 
tioned. Subsequently  the  appointment  became  again  vacant, 
and  was  next  filled  by  an  old-time  probationer,  who  con- 
tinues in  charge  at  the  present  time.  From  1888  forwards, 
a  resident  medical  superintendent  has  been  installed.  The 
wards  are  nine  in  number,  detached,  and  contain  in  all 
107  beds.  The  operating  theater,  dispensary,  offtce.  and 
eye  room  are  included  in  the  block  which  contains  the 
European  wards,  but  there  are  also  two  separate  private 
wards  for  the  latter  class.  Our  patients  include  a  very 
mixed  variety,  Europeans.  Fijians,  Indian  coolies,  repre- 
sentatives from  almost  every  island  in  the  South  Pacific,  and 
a  few  stray  Japs  and  Chinese.  Owing  to  the  natural  forma- 
tion of  the  land,  it  was  impossible  to  build  the  wards  in 
regular  pavilions,  and  perhaps,  in  a  climate  like  ours,  this 
is  no  disadvantage,  on  account  of  race  prejudices.  In  fair 
weather  the  walk  from  ward  to  ward  is  pleasant  enough, 
and  nurses  and  patients  almost  live  in  the  open  air ;  but  in 
the  rainy  season,  which  is  a  long  one,  the  task  is  not  quite 
so  easy,  for  the  distances  to  be  traversed  are  too  great  to 
permit  of  covered  ways.     This,  however,  is  a  detail — the 


412  International  Congress  of  Nurses 

roughs  of  life  are  ever  mixed  with  the  smooth,  and  the 
pretty  surroundings,  in  fine  weather,  compensate  for  the 
disagreeables  of  the  heat  and  rain.     The  buildings  are  all 
timber,  surrounded  by  spacious  verandas,  roofed  with  shin- 
gles; the  floors  stained  and  polished,  and  all  kept  spick 
and  span.     The  Europeans'  wards  are  fitted  with  all  the 
ordinary  ward  furniture,  and  are  very  bright  and  cheerful. 
The  native  wards  are  not  supplied  with  more  than  is  really 
necessary,  as  native  habits  are  usually  somewhat  grimy  and 
disagreeable,  and  nurses  must  ever  be  on  the  alert  to  keep 
everything  clean.      Though  the  actual  scrubbing,  sweeping 
and  polishing  is  done  by  native  ward  servants,  they  are  so 
untrustworthy  that  an  untiring  supervision  has  to  be  main- 
tained over  their  work.     Iron  bedsteads  are  used  through- 
out, and  the  Fijians  use  mats,  blankets,  and  native  pillows 
(a  piece  of  wood  or  bamboo  on  two  short  legs,  which  sup- 
ports the  nape  of  the  neck),  not  our.  idea  of  comfort,  but  suf- 
ficiently cherished  by  them.    Very  few  indulge  in  the  luxury 
of  a  soft  pillow.     Of  course  patients  who  are  very  ill  are 
provided  with  all  that  is  necessary,  but  unless  there  is  any 
reason  why  a  change  should  be  made  we  allow  them  to  fol- 
low their  own  customs  in  so  far  as  is  consistent  with  good 
sanitation  and  discipline.    Attached  to  each  ward  is  a  lava- 
tory and  shower  bath  with  an  abundance  of  excellent  water ; 
for  a  daily  bath  is  a  necessity  here,  and  often  has  to  be 
insisted  on.     Not  one  of  the  least  amusing  of  my  duties 
is  the  early  round  and  questionings  to  learn  if  each  patient 
has  had  his  "  morning  tub,"  and  some  of  the  evasive  replies 
and   frequently  direct  and  unblushing  falsehoods   I   meet 
with  are  very  ingenious.    The  patient's  delight  is  unbounded 
when  he  can  show  you  some  wet  hair,  and  the  laugh  of  sat- 
isfaction that  passes  around  is  infectious  when  a  less  fortu- 
nate perverter  of  the  truth  is  promptly  sent  to  have  his  bath. 
As  with  all  uncultured  people,  the  Fijians  have  curious 
ideas  about  soap  and  water,  and  when  not  under  European 
supervision  they  allow  their  sick  tO'  lie  for  weeks  and  even 
months  and  never  dream  of  washing  or  sponging  them,  or 
even  combing  their  thick  hair.     Imagine  our  feelings  when 


Council  Reports  413 

such  cases  arc  brought  to  the  hospital, — and  those  of  the 
friends  (who  often  stay  a  few  hours),  when  they  see  the 
bath  given.  There  is  much,  apart  from  actual  nursing,  that 
is  interesting  in  the  customs,  ideas  and  languages  of  the 
people  with  whom  we  have  to  deal. 

Diets  are  sometimes  a  difficulty  with  native  patients, 
and  as  we  try  to  give  to  each  according  to  their  religious 
and  caste  prejudices,  the  diet  list  often  presents  a  very  com- 
plicated bill  of  fare.  Rice  enters  largely  into  all  their  meals, 
with  bread,  yams,  taro,  breadfruit,  tea,. all  ordinary  invalid 
delicacies,  and  some  meat  or  fish.  Smoking  is  habitual  with 
all  native  races  here,  and  is  generally  allowed  outside  or 
in  the  verandas,  but  patients  sometimes  steal  a  smoke  in  the 
wards,  and  pipe  and  tobacco  are  confiscated  from  a  man 
who  is  not  smart  enough  to  hide  them  before  a  nurse 
appears.  They  love  to  secrete  their  little  treasures  under 
their  mats,  so,  to  keep  the  beds  fresh,  everything  is  sunned 
and  aired  each  fine  morning,  and  when  the  doctor  comes 
round,  the  wards  really  look  very  quaint  with  the  rows  of 
beds,  bright  fringed  mats,  with  brown,  black  and  yellow 
patients. 

The  nursing  of  some  of  our  patients  is  often  difficult,  for 
they  cannot  understand  our  reasons  for  much  that  is  done, 
but  on  the  whole  they  are  amenable  and,  if  persuaded  and 
firmly  treated,  are  fairly  submissive.  Everj^  year  adds  some 
improvement  to  our  wards  or  buildings,  but,  like  Oliver 
Twist,  we  are  always  wanting  more,  though  by  patient  wait- 
ing and  steadfast  adherence  to  purpose  we  usually  get  what 
we  want  in  the  end. 

Our  admissions  last  year  amounted  to  1,472,  but  the 
number  of  out-patients  treated  is  only  about  550  annually. 
The  diseases  met  with  are,  among  others,  dysentery,  yaws, 
ankylostomiasis,  tuberculosis,  internal  and  external  parasites 
of  all  sorts,  and  many  others  with  which  most  nurses  have  to 
deal. 

Enteric  fever  is  not  prevalent  in  Fiji,  but  isolated  cases 
sometimes  occur  and  run  a  more  or  less  irregular  course. 


414  International  Congress  of  Xurses 

Your  newly  acquired  territory-  in  Samoa,  or,  at  any  rate, 
the  German  portion  of  those  islands,  whose  people  we  con- 
sider our  neighbors,  has,  however,  cjuite  an  evil  reputation 
with  regard  to  that  disease,  and  almost  all  the  worst  cases 
of  enteric  fever  we  have  nursed  in  our  hospital  have  been 
brought  to  us  from  the  warships  on  that  station. 

Our  operations  are  conducted  on  aseptic  principles,  and 
our  death  rate  for  all  admissions  only  averaged  3.56  per  cent, 
in  the  last  five  years.  The  European  staff  consists  of  a 
resident  medical  superintendent,  visiting  surgeons  and  phy- 
sicians, sister-in-charge,  three  nurses  and  a  steward.  The 
dispenser  is  a  native  Fijian,  who  is  clever  and  competent. 
Native  students  are  trained  here  and  receive  a  three  years' 
course  of  instruction  in  technical  and  practical  work,  after 
which,  if  successful  in  their  examinations,  they  are  sent  out 
among  the  sick  in  the  provinces.  They  sometimes  work 
alone,  but  are  for  the  most  part  under  the  supervision  of  a 
district  medical  officer.  The  cooks  and  other  servants  are 
Indian  coolies. 

The  training  for  the  nurses  extends  over  three  years. 
Lectures  are  given  by  the  medical  staff,  and  they  receive 
instruction  in  practical  ward  work  and  invalid  cooking  from 
the  sister.  A  certificate  is  given  if  the  examinations  are 
passed  creditably.  As  w^ell  as  our  own  work  in  connection 
with  our  wards,  much  is  done  to  help  the  district  medical 
officers  and  the  native  practitioners  who  requisition  all  their 
supplies  from  this,  the  parent  hospital  as  it  were.  The 
Fijian  group  comprises  over  200  islands,  about  80  of  which 
are  inhabited,  and  some  of  these  are  very  isolated.  The 
total  population  is  about  122,673.  It  is  thus  a  difficult  mat- 
ter to  reach  all  the  sick,  but,  during  the  last  three  years, 
provincial  hospitals  in  charge  of  English  medical  men  have 
been  established  and  sanitary  inspectors  appointed  to  visit 
the  more  populated  districts,  so  that,  at  the  present  time, 
the  wants  of  the  Fijian  are  being  well  cared  for.  In  time 
we  shall  train  more  nurses,  and  some  may  like  provincial 
work;  just  now  the  only  trained  nurses  here  are  our  own. 
Infant  mortality  in  the  villages  is  great.    It  is  pitiful  to  see 


Council  Reports  415 

the  condition  of  some  babies  broug^ht  into  hospital,  and  to 
note  the  apathetic,  ignorant  helplessness  of  the  mothers.  It 
is  almost  useless  to  try  and  teach  the  present  generation 
of  mothers  very  much.  On  one  occasion,  after  talking  to  a 
number  of  women  for  some  time,  and  demonstrating  how 
children  should  be  treated  from  birth  onward,  they  listened 
most  attentively,  ag-reed  ostensibly  with  all  I  said,  and 
admired  our  methods ;  but  they  finally  remarked :  "  Yes, 
that  is  all  very  good  and  true  for  white  people,  but  we  are 
Fijians."  As  a  rule  they  are  pleased  when  anything  is  done 
for  the  children,  and  the  mothers,  who  often  come  in  with 
them,  severely  scold  the  little  things  if  they  cry  or  show  any 
fear  of  us. 

In  the  native  wards  prayers  are  said  every  night  and 
morning  by  one  or  another  of  the  patients,  who  acts  as  a  lay- 
reader;  and  a  hymn  is  sung  in  which  every  one  joins. 
Native  games  are  played  on  the  veranda,  but  nothing  gives 
so  much  pleasure  as  a  pack  of  cards  for  euchre,  and  the 
boys'  delight  is  unlimited  when  presented  with  a  few  mar- 
bles. Story  telling  is  a  favorite  pastime,  and  most  natives 
are  fluent  speakers.  One  evening  I  listened  to  a  man  relat- 
ing the  story  of  "Dick  Whittington  and  his  cat"  to  a  most 
interested  audience.  So  prolonged  was  the  tale  with  addi- 
tions from  his  own  inventive  brain  that  i<t  was  some  time 
before  I  realized  what  he  was  talking  of;  unfortunately 
my  interest  flagged  early,  and  I  bade  them  good  night  and 
retired.  The  Fijian  is  very  patient  when  ill  and  nothing 
worries  him,  except  a  milk  diet,  for  which  he  has  an  intense 
dislike ;  but  they  are  not  hard  to  manage,  and  they  never 
fear  the  approach  of  death. 

If  a  nurse  so  wishes  it,  her  life  may  be  made  very 
happy  if  she  takes  a  genuine  interest  in  her  work  and  the 
people.  The  "  off  duty  "  hours  and  holidays  are  liberal, 
and  uniform  is  provided.  People  here  are  somewhat  cut 
off  from  the  world  at  large,  Australia  being  eight  days  and 
New  Zealand  four  days  distant,  but  there  is  pleasure  in 
looking  forward  to  the  arrival  of  the  fortnightly  mails ; 
and,  if  we  cannot  visit  historical  places  or  have  the  advan- 


416  International  Congress  of  Nurses 

tages  of  more  civilized  lands  and  institutions,  nature,  at 
least,  comes  forward  and  offers  a  great  deal  that  is  beautiful 
and  instructive  to  supply  their  place.  Bright  foliaged 
crotons  and  coleuses  grow  in  luxuriant  profusion,  and  many 
other  gay  shrubs  and  flowers  are  used  to  adorn  the  many 
hills,  slopes,  and  nooks  provided  by  the  natural  formation 
of  the  land.  The  large  crimson  hibiscus  grows  exceptionally 
well  and  makes  effective  hedges  to  line  the  paths  from  ward 
to  ward,  so  that  the  hospital  is  like  a  very  picturesque  rural 
village,  and  fulfils  all  the  needs  of  a  tropical  climate. 


Nursing  in  France. 

ANNA  HAMILTON,  M.  D, 
Medicin  Resident  Maison  de  Sante  Protestante,  Bordeaux. 


For  the  last  forty  years  the  French  hospitals  have  been, 
as  a  rule,  conducted  by  religious  orders  devoid  of  all  train- 
ing, and  also  generally  of  instruction  and  education. 

Gradually  the  rules  of  narrow-minded  modesty  and 
strict  church  attendance  obliged  these  orders  to  engage 
rough  male  and  female  servants  to  do  what  nursing  work 
the  nuns  were  prevented  from  doing  in  the  wards. 

Even  as  early  as  1788  we  see  in  a  report  drawn  up 
for  the  king  of  France  by  the  great  Dr.  Cenon  on  the  state 
of  the  big  Hotel-Dieu  of  Paris  that  there  were  102  nuns  in 
that  hospital  and  307  ward-helpers,  besides  228  other  hos- 
pital employees ! 

The  want  of  proper  training  rendered  nursing  a  most 
unpleasant  work,  the  absence  of  education  developed  coarse- 

» 

ness  in  it,  and  ignorance  stopped  its  progress ;  thus  nursing, 
left  in  the  hands  of  those  common,  ignorant  helpers,  could 
not  be  otherwise  than  looked  down  upon  by  all  in  France. 
It  was  supposed,  and  ever  since  believed,  that  nuns  only, 
beings  of  a  special  nature,  could  possibly  live  in  the  hos- 
pitals without  losing  their  morals. 

When  reform  sprung  up  in  Protestant  countries  it  was 
not  taken  into  consideration  by  the  religious  bodies,  who 
ruled  the  hospitals  through  the  nuns,  and  these  last,  kept 

417 


418  International  Congress  of  Xurses 

aloof  from  all  that  goes  on  in  the  world,  went  on  exactly 
in  their  work  as  they  were  wont  to  do  ages  ago. 

Private  hospitals  are  very  rare  in  France ;  they  are  all 
civil  hospitals,  ruled  over  by  the  (a)  commission  adminis- 
trative des  hopitaux,  whose  members  are  elected  half  by 
the  municipal  council  and  the  other  half  named  by  the 
prefect.  As  chance  and  politics  will  have  it,  they  may  be 
a  most  ignorant  set  of  men.  (b)  The  municipal  council, 
which  allows  the  necessary  money  from  the  town  taxes,  the 
mayor  of  the  town  being  always  president  of  the  hospitals. 
(c)  The  assistance  publique  of  France,  which  sends 
inspectors,  and  whose  approval  must  be  asked  for  heavy 
loans  or  purchases  or  plans  of  new  hospitals.  This  last 
depends  on  the  ministry  of  interior. 

In  the  hospitals  we  have  a  director  (man),  who  lives 
in  the  hospital  and  is  responsible  for  everything  (except  the 
nuns).  He  usually  is  a  man  without  much  education,  and 
with  very  little  method  or  hospital  experience.  I  knew  a 
former  naval  captain  take  that  place,  and  in  another  instance 
a  former  gendarme  was  entrusted  with  that  post !  He 
usually  is  a  fonctionnaire  who  has  friends  at  court  and  is 
eager  to  secure  a  post  where  he  may  make  money  in  many 
ways. 

In  hospitals  worked  by  nuns  we  find  two  masters,  the 
director  and  the  superior  (head  of  the  nuns),  who  usually 
are  at  daggers  drawn  all  the  year  round.  She  alone  has 
authority  over  the  nuns,  she  alone  can  reprove  them,  change 
them  from  one  ward  to  another,  or  can  exact  obedience  from 
them  on  any  point  whatever.  He  rules  over  the  lay 
employees,  who  work  under  the  nuns'  orders  in  the  wards, 
engages  and  dismisses  them,  and  this  very  awkward  state 
of  things  brings  on  constant  friction  in  the  hospital  staff. 

Doctors  form  a  third  party,  with  no  authority,  though 
they  are  supposed  to  be  sole  masters  of  their  wards.  Obnox- 
ious nuns,  who  disobeyed  their  orders,  neglected  the 
patients,  and  scoffed  at  them,  have  been  known  to  remain 
more  than  seven  years  in  the  same  wards  in  spite  of  all  the 
doctors'  demand  for  their  removal. 


Council  Reports  419 

I.  (a)  The  curriculum  of  training  for  nuns  consists  of 
religious  instruction  during  the  novitiate,  which  lasts  from 
six  to  twelve  months,  the  probationer  remaining  in  a  con- 
vent. She  is  then  sent  to  a  school,  asylum,  charitable  work 
of  any  kind,  or  to  a  hospital,  just  as  the  superior  of  the  order 
may  wish,  the  opinion  or  desire  of  the  novice  not  being 
taken  into  consideration.  If  she  is  sent  to  a  hospital,  she 
works  with  the  older  nuns,  and  after  some  time  will  be 
given  a  ward  to  superintend.  I  have  known  cases  where 
nuns  being  short,  a  new  one  with  no  experience  at  all  was 
immediately  turned  into  ward-sister  with  thirty  patients  to 
be  responsible  for,  and  not  the  smallest  hospital  experience. 

(b)  There  is  no  technical  instruction  on  the  subject. 

II.  (a)  There  exist  339  orders  of  nuns  who  take  up 
nursing,  and  may  also  be  contemplative  or  instructive  orders 
besides.  Of  these  eighty-one  only  restrict  themselves  to 
nursing,  and  forty-eight  of  them  ought  to  work  solely  in 
hospitals,  but  actually  there  are  only  five  of  them  still  in 
attendance  in  hospitals. 

(b)  The  constitution  and  regulation  of  monastic  orders 
vary  from  one  to  another,  but  we  find  that  hospital  nuns, 
as  a  rule,  are  not  allowed  to  do  night  work,  to  give  any 
nursing  help  to  male  patients  or  little  boys,  to  attend  women 
in  child  labor,  or  to  nurse  syphilitic  women. 

They  must  all  take  their  meals  at  the  same  time  and 
also  attend  prayer  together. 

They  wear  woolen  dresses  and  long  and  wide  sleeves, 
which  they  are  not  allowed  to  tuck  up,  as  showing  their 
arms  bare  would  be  immodest. 

They  are  not  allowed  to  give  vaginal  douches  or 
enemas,  or  to  be  present  at  men's  operations  or  gynaeco- 
logical ones. 

Their  lay-helpers,  ignorant  and  worse,  and  the  medical 
students  do  what  proper  nurses  would  accomplish  ever  so 
much  better,  being  refined  and  womanly. 

We  have  in  France  two  other  religious  communities, 


420  International  Congress  of  Nurses 

who  do  not  consent  to  be  called  monastic,  but  are  very 
near  to  it. 

1.  The  Hospital  Sisters  of  Lyons  (founded  in  the  sev- 
enth century)  are  unique  in  France.  They  were  formerly 
women  of  loose  morals,  who  repented  and  remained  in  the 
hospitals  for  the  rest  of  their  life. 

It  was  only  in  1690  that  they  began  to  be  called  sisters 
instead  of  servants  of  the  hospitals.  They  have  never  been 
allowed  to  take  vows  of  any  kiml  by  the  hospital  authori- 
ties and  proprietors,  for  the  general  rule  of  hospital  organ- 
ization has  an  exception  in  Lyons,  where  it  is  quite  peculiar 
to  the  town.  The  hospitals  are  very  wealthy,  but  dreadfully 
old-fashioned. 

These  sisters  have  no  superiors,  only  a  chaplain  and 
confessor  in  each  hospital.  They  are  taken  mostly  from  the 
peasant  class,  and  are  taught  elementary  knowledge  at  the 
hospital.  Some  of  them  are  allowed  to  work  for  the  mid- 
wife certificate,  a  most  remarkable  fact. 

The  novitiate  lasts  one  year ;  then  for  ten  or  fifteen  years 
the  nun  becomes  a  prete^idant  sister,  earning  eighty  francs 
a  year  and  providing  her  own  clothes.  Afterwards  she  gets 
only  forty  francs,  but  is  adopted  by  the  hospital  council, 
which  promises  to  clothe  and  feed  and  take  care  of  her  to 
the  end  of  her  life.  But  at  any  time  one  of  these  peculiar 
nuns  can  leave  and  marry  if  she  likes  to  do  so. 

However  liberal  these  nuns  may  be,  the  hospital  wards 
show  the  want  of  training  and  common  knowledge  in  these 
women,  for  dirt,  neglect,  and  disobedience  to  the  doctor's 
orders  abound  there,  as  in  other  hospitals  nursed  by  relig- 
ious communities. 

2.  The  Institution  of  Deaconesses  of  Paris  (founded 
1841)  possessed  only  eighty-five  sisters  in  1878.  These 
sisters  aim  at  all  kinds  of  good  work,  doing  nursing  as  well, 
but  without  any  special  training  towards  it.  Novices  learn 
cooking,  washing,  *etc.  They  do  not  take  up  night  work 
in  hospitals,  and  take  in  lay  helps  (quite  ignorant)  for  that. 
If  they  are  called  upon  to  do  night  work  they  do  not  expect 


Council  Reports  421 

to  be  allowed  to  rest  next  day.  No  examinations  are  passed, 
and  these  sisters  mostly  come  from  the  servant  class. 

In  1877  the  municipal  council  of  Paris,  wishing-  the 
hospitals  to  be  properly  attended  and  the  patients  cleverly 
nursed,  decided  to  open  schools  for  nurses  (of  both  sexes), 
and  to  gradually  replace  the  nuns  by  lay-nurses  in  the  civil 
hospitals  of  the  towns. 

But  this  assembly  of  men,  though  clever  enough  and 
lovers  of  progress,  did  not  understand  at  all  the  requisites 
for  securing  proper  training  for  nurses.  Lectures  were 
begun,  given  by  clever  doctors,  who  spoke  on  medical  sub- 
jects, not  nursing,  and  anyone,  even  devoid  of  elementary 
instruction,  was  allowed  to  attend.  A  class  for  learning 
reading  and  writing  was  opened  for  those  who  wanted  to 
learn  just  enough  to  be  able  to  write  the  examination  papers  ! 
They  mostly  were  men  and  women  working  all  day  in  the 
hospitals,  not  only  in  the  wards,  but  even  in  the  post-mortem 
rooms  or  stables,  linenry,  washhouse,  etc.,  etc. 

There  was  no  link  between  the  hospital  ward  work  and 
the  school.  The  diploma  of  nursing  might  be  obtained  after 
eight  months'  attendance  at  the  lectures  and  successful 
examination  papes,  which  might  be  tried  for  over  and  over 
again.  In  one  case  a  male  nurse  attempted  the  examina- 
tions every  year  for  nine  years  before  getting  the  diploma, 
though  these  papers  were  written  at  any  time  the  candidate 
wished  to  and  without  much  guarantee  of  honest  personal 
work. 

The  hospitals  did  not  make  a  rule  of  engaging  only 
nurses  who  had  the  diploma  or  wished  to  work  for  it,  and 
the  diploma  holders,  being  mostly  devoid  of  education,  did 
not  get  the  best  posts.  No  practical  training  was  given  in 
the  wards,  and  the  actual  state  of  Paris  hospitals  proves  it  at 
one  glance. 

The  personnel  is  so  very  unsteady  that  we  find  in  the 
year  1898  that  there  were  fourteen  dismissals  in  the  hos- 
pitals of  Salpetriere,  Bicetre,  Pitie,  and  Lariboisiere  of  male 
and  female  nurses  for  drunkenness,  disobedience,  neglect, 
idleness,  misconduct,  etc.,  etc.     This  shows  what  a  poor 


422  International  Congress  of  Xurses 

result  the  nursing  schools  opened  more  than  twenty  years 
before  had  given. 

The  nurses  are  allowed  to  marry  and  we  find  cases  of 
man  and  wife,  both  nurses,  sleeping  in  dormitories !  When 
there  are  children  the  case  is  still  worse,  and  ward  work  is 
more  than  ever  neglected.* 

This  attempt  made  in  Paris  in  the  hope  of  getting  a 
properly  trained  staff  led  to  two  results:  (a)  a  few  other 
French  towns  (eight  to  ten  at  most)  followed  the  same  plan 
with  unsatisfactory  results ;  (b)  the  others  decided  to  uphold 
the  nun  system  rather  than  have  those  lay-nurses  whose 
loose  morals  are  too  well  known. 

A  nursing  school  for  girls  only  exists  since  1889  at  the 
Protestant  House  of  Health  at  Bordeaux.  But  the  proba- 
tioners were  not  provided  with  proper  accommodation,  did 
not  care  to  stay  on,  and  the  nursing  staff  was  more  like  a 
set  of  servants,  and  there  was  no  training  given  besides 
the  theoretical  lectures. 

In  May,  1901,  the  management  of  this  school  of  nurses 
was  given  over  to  me,  and  it  is  being  set  on  a  proper  footing 
for  lady  probationers,  and  has  properly  trained  nurses  to 
instruct  them. 

Free  and   paying  probationers   are   received   for   two 
years'  training.     Lectures  are  given  by  doctors  and  exam- 
inations passed  before  professors  of  the  medical  faculty.  The 
hospital  holds  sixty-eight  beds  for  men,  women  and  chil 
dren,  and  an  important  out-patient  and    accident    depart 
ment. 

In  Paris  a  nursing  school  was  opened  in  1899  for  girls 
of  good  education.  It  is  under  the  care  of  the  Society  for 
Helping  the  Sick.  The  probationers  are  sent  to  the  Paris 
hospitals  at  the  time  the  visiting  doctors  go  round.  That 
is  all  the  hospital  training  they  get !     Girls  have  to  engage 

*0n  entering  the  Paris  hospitals  a  would-be  nurse  has  to  work  three 
years  as  probationer,  five  years  as  nurse,  two  years  as  staff  nurse,  two 
years  as  under-ward  surveyor,  two  years  as  ward  surveyor.  If  numerous 
punishments  have  been  inflicted,  more  years  are  added  to  the  above.  But 
it  is  not  a  rule  even  for  those  who  have  been  more  than  fourteen  years  in 
service   to   hold   the   good   posts!    They  are  given  to  outsiders! 


Council  Reports  423 

themselves  for  eight  years,  of  which  two  are  spent  in  train- 
ing (?)  and  the  other  six  in  attending  paying  patients  in 
private  houses. 

There  are  in  France  a  great  many  so-called  nursing 
lectures  organized  by  Red  Cross  Societies,  which  are 
attended  by  fashionable  ladies  who  never  go  in  for  any  kind 
of  practical  training,  and  only  attend  hospitals  at  the  time 
the  visiting  doctors  go  their  round. 

They  very  often  go  through  theoretical  examinations, 
hold  diplomas  and  medals,  notwithstanding  their  want  of 
experience  in  real  nurses'  work,  and,  moreover,  all  expect 
to  hold  the  most  important  posts  in  future  ambulancies ! 

The  Superior  Council  of  Assistance  Publique  of  France 
took  into  consideration  the  want  of  proper  nursing  stafifs  in 
all  French  hospitals  in  1898.  Several  men  doctors  were 
asked  to  draw  up  a  program  of  studies  for  nurses.  This 
lengthy  program  has  been  published,  and  shows  the  utter 
ignorance  of  these  medical  men  of  what  the  training  of  a 
nurse  should  be. 

Notwithstanding,  the  council,  with  its  high  authority, 
published  a  paper  asking  all  the  hospitals  of  France  to 
instruct  their  nursing  staff  after  the  program.  Until  now 
(August,  1901)  only  one  town  has  responded  to  this  appeal. 
A  great  many  town  authorities  have  taken  up  the  subject, 
for  everywhere  dissatisfaction  is  felt  at  the  actually  deplora- 
ble state  of  French  hospitals. 


Nursing  in  Great  Britain  and  Ireland. 

ETHEL  GORDON  FENWICK, 
President  International  Council  of  Nursee. 


THE  DEVELOPMENT  OF  THE  SCIENCE  OF  NURSING. 

From  the  earliest  ages  of  which  we  have  any  historical 
record  the  sick  have  been  tended,  and  the  art  of  healing  has 
been  practiced,  but  the  development  of  nursing-  on  scientific 
principles  has  only  been  attempted  during  the  last  half 
century. 

In  the  evolution  of  our  profession  we  note  three  stages : 

1.  The  period  of  untrained  aid — developing  in  many 
instances  by  constant  practice  into  a  considerable  ajnount 
of  skill. 

2.  The  time  when,  in  order  to  qualify  as  a  trained 
nurse,  a  woman  was  required  to  undergo  a  short  period  of 
hospital  training,  varying  in  length  from  three  months  to  a 
year. 

At  this  stage  a  general  willingness  to  obey  orders,  with- 
out any  knowledge  of  the  reasons  for  the  duties  required, 
was  considered  adequate. 

3.  The  higher  standard  of  skill  which  is  required  at 
the  present  time,  and  which  is  attainable  only  by  prolonged 
practical  work,  combined  with  an  intelligent  comprehen- 
sion of  underlying  principles. 

Thus  nursing  has  developed  on  the  same  lines  as  those 

adopted  by  the  science  of  medicine,  and  can  only  hope  to 

make  true  progress  along  the  same  lines  as  this  associated 

profession,   by   procuring  adequate   educational   privileges 

and  powers  of  self  government. 
421 


Council  Reports  425 

THE   CURRICULUM   OF  TRAINING. 

In  the  principal  general  hospitals,  with  a  few  notable 
exceptions,  three  years'  training  in  the  wards  of  the  institu- 
tion is  now  required.  Here  any  semblance  of  uniformity 
ceases.  Some  require  preliminary  evidence  of  general 
knowledge.  Some  give  a  certificate  at  the  end  of  the  course 
only  after  the  pupils  have  passed  a  satisfactory  examination, 
others  do  not  impose  this  test.  Yet  other  hospitals  with- 
hold the  certificate  until  the  nurse  severs  her  connection 
with  the  institution.  In  some  few  hospitals,  notably  at  St. 
Bartholomew's,  the  Royal  Free  Hospital,  St.  George's,  and 
St.  Mary's,  in  London,  a  fourth  year^of  service,  not  neces- 
sarily spent  in  the  wards,  is  now  required.  The  quality  of 
training  given  also  varies  considerably.  In  a  very  limited 
number  of  hospitals  systematical  clinical  instruction  is  given 
by  the  ward  sisters,  in  the  rest  the  amount  of  instruction 
depends  largely  upon  the  individual  inclination  of  the  sister 
to  impart  instruction.  In  the  large  majority  of  hospitals, 
nurses  who  have  passed  through  an  irregular  training  for 
three  years  in  the  wards  are  considered  competent  to  act  as 
sisters  of  wards  and  nurse  trainers,  without  any  further 
qualification  than  that  of  the  general  training  of  a  nurse. 
Sufficient  emphasis  has  not  yet  been  laid  on  the  necessity  of 
their  possessing  ability  to  impart  instruction  as  well  as  pro- 
ficiency in  the  actual  performance  of  nursing  duties  and, 
so  far,  no  special  training  in  the  best  methods  of  teaching  is 
provided  for  future  ward  sisters. 

In  Ireland  the  three  years'  standard  of  training  has  not 
been  so  uniformly  adopted  as  in  the  rest  of  the  United  King- 
dom. Upon  inquiry  I  find  that  the  reason  is  mainly  a 
financial  one.  The  country  is  not  a  rich  one,  and  the  cost 
of  the  up-keep  of  the  nursing  schools  at  the  present  day  is 
so  considerable  that  the  schools  in  many  instances  are 
tempted  to  deprive  the  nurse  of  the  third  year's  practical 
experience  so  that  some  return  for  money  expended  may 
be  quickly  obtained  through  the  fees  paid  for  her  services 
as  a  private  nurse. 


426  International  Congress  of  Xurses 

PRELIMINARY  AND  TECHNICAL  TRAINING  SCHOOLS. 

In  England  the  London  Hospital  has  instituted  a 
course  of  technical  training  which  pupils  pass  through 
before  entering  the  wards  of  the  hospital.  The  training  is 
o-iven  in  a  special  home,  and  those  who  show  no  aptitude 
for  nursing  work  are  not  accepted  as  general  probationers. 

In  Scotland,  at  the  Royal  Infirmary,  Glasgow,  a  course 
of  preliminary  education,  which  all  probationers  are  required 
to  pass  through,  is  given  at  their  own  expense.  These 
schemes  are  a  distinct  advance,  and  a  step  in  the  right  direc- 
tion, towards  a  thoroughly  efficient  course  of  preliminary 
education  for  probationers,  before  they  are  permitted  to 
enter  the  wards  of  a  hospital  for  their  practical  work. 

In  Dublin  a  school  has  been  established,  called  the 
Dublin  Metropolitan  Technical  School,  with  which  many  of 
the  training  schools  are  connected,  the  object  being  "  to 
instruct  probationer  nurses  in  anatomy,  physiology,  hy- 
giene, invalid  cookery,  and  such  other  objects  outside 
hospital  training,  as  may  be  deemed  necessary  for  the  effi- 
cient training  of  nurses."  At  the  conclusion  of  each  term 
an  examination  is  held  in  the  subject  lectured  upon,  and 
nurses  who  pass  these  examinations  are  awarded  diplomas, 
but  in  no  case  are  these  diplomas  delivered  to  the  nurses 
until  they  have  received  their  nursing  certificates  after  due 
training. 

CONDITIONS  OF  TRAINING. 

Candidates  may  enter  the  service  of  hospitals  as  reg- 
ular, or  paying  probationers.  In  the  first  instance  they  are 
bound  for  a  definite  period  of  service  and  receive  salaries 
ranging  from  about  £10  to  £20  per  annum.  Paying  proba- 
tioners are  admitted  by  payment  of  a  guinea  a  \\eek  for 
short  terms  of  service,  from  three  months  to  a  year,  in  return 
for  which  payment  they  are  often  exempted  from  much  of 
the  routine  ward  work. 

In  a  limited  number  of  schools  regular  probationers  pay 
a  varying  sum  for  their  three  years'  training.     The  cost  of 


Council  Reports  427 

maiiitainino^  an  efificient  nursing  school  in  connection  with  a 
large  hospital  is  becoming  year  by  year  so  expensive  a  mat- 
ter that  it  is  not  improbable  that  in  the  near  future  nurses^ 
like  other  professional  women,  will  be  called  upon  to  pay 
part  of  the  cost  of  their  professional  education  and  the 
up-keep  of  their  colleges. 

THEORETICAI,  COURSE   OF  TRAINING 

The  steps  taught  in  most  nurse-training  schools  are 
elementary  anatomy  and  physiology,  and  the  theory  of 
medical,  surgical,  and,  in  some  instances,  of  gynaecological 
nursing.  Obstetric  nursing  is  rarely  included.  In  some 
instances  hygiene,  dispensing  and  invalid  cookery  are  added 
to  the  list  of  subjects  taught. 

HOURS    ON    DUTY. 

A  nurse's  hours  on  duty  are  from  nine  to  twelve  hours 
on  day  duty,  and  usually  twelve  hours  on  night  duty.  In 
many  of  the  leading  hospitals  an  effort  has  been  made  to 
reduce  them  still  further  by  increased  half-days  and  whole 
days  ofif  duty,  and  undoubtedly  a  great  improvement  has 
taken  place  in  this  connection  during  the  past  decade.  Class 
work  and  study  which  formerly  had  to  be  done  in  the 
meagre  ofif-duty  hours  are  now  arranged  as  part  of  the  work 
to  be  accomplished  in  on-duty  hours. 

AN  IMPARTIAL  EXAMINATION. 

In  the  large  majority  of  schools  the  examinations  of 
nurses  are  conducted  by  the  medical  lecturers  to  nurses, 
and,  in  very  rare  instances,  by  the  matron  of  the  school. 

A  few  have  enlisted  the  services  of  medical  men 
attached  to  other  institutions,  who  conduct  the  final  exam- 
inations of  probationers  before  they  are  awarded  their  cer- 
tificates. In  no  instance,  so  far  as  I  am  aware,  does  any 
institution  invite  a  thoroughly  efificient  superintendent  of 
nursing  to  conduct  the  examination  in  practical  nursing  as 
apart  from  that  in  theory,  which,  in  this  country,  is  almost 
without  exception  conducted  by  medical  men.    This  cannot 


428  International  Congress  of  Xurses 

be  considered  a  satisfactory  condition  of  things.  Examina- 
tions should,  in  my  opinion,  be  conducted  by  a  state 
appointed  body,  and  to  prove  that  it  is  not  improbable  that 
in  the  near  future  a  more  efificient  examination  of  nurse 
probationers  will  be  enforced,  the  action  taken  by  a  con- 
ference composed  of  representatives  of  poor  law  unions 
in  Yorkshire  may  be  noted.  The  feeling  was  general  that 
there  should  be  a  uniform  standard  of  training  and  examina- 
tion for  nurses  in  workhouse  infirmaries,  and  ultimately  it 
was  agreed  to  form  a  board,  to  be  known  as  the  Yorkshire 
Poor  Law  Nursing  Board,  composed  of  guardians,  medical 
men,  and  trained  superintendents  of  nursing,  and  that  the 
examinations  of  candidates  should  be  conducted  as  to  theory 
by  the  medical  officers,  and  in  practical  nursing  by  the 
superintendents  of  nursing.  This  nursing  board  will  exam- 
ine only  duly  accredited  candidates  and  award  certificates. 
This  is  a  step  forward  towards  a  satisfactory  method  of 
examination.  An  examination  by  a  state  appointed  body 
is  the  only  method  by  which  an  impartial  judgment  can  be 
pronounced,  and  upon  which  a  registrable  diploma  of  nurs- 
ing can  be  awarded. 

WHAT  BECOMES  OF  THE  GRADUATE  NURSE? 

In  most  institutions  in  the  United  Kingdom  the  engage- 
ment of  the  probationary  nurse  ends  with  the  completion 
of  her  term  of  training.  It  may  be  renewed  by  the  commit- 
tee under  a  different  contract,  or  the  certificated  nurse  may 
elect  to  work  in  one  of  the  various  branches  of  nursing, 
either  in  a  special  hospital,  in  connection  with  the  govern- 
ment departments,  or  in  district  or  private  service. 

NURSING  SOCIETIES. 

As  the  value  of  skilled  nursing  became  apparent,  the 
services  of  the  trained  nurse  were  requisitioned  in  a  variety 
of  directions,  but  in  the  large  majority  of  societies  with 
which  nurses  are  connected  their  position  is  that  of  indus- 
trial workers  who  are  paid  definite  salaries  for  the  work  per- 


Council  Reports  429 

formed.  The  relations  of  the  society  to  the  nurse  are  those 
of  employer  and  employed,  and  she  has  in  it  no  degree  of 
self-government  or  legal  status. 

EMPLOYERS   OF   NURSES. 
GOVERNMENT   DEPARTMENTS. 

Amongst  the  agencies  which  employ  nurses  in  various 
capacities  must  first  be  mentioned  the  government  depart- 
ments, 

1.  A  Navy  Nursing  Service.  Employed  by  the  Admir- 
alty to  superintend  the  nursing  of  sick  and  wounded  sailors. 

2.  An  Army  Nursing  Service,  with  which  is  connected 
a  Reserve.  Employed  by  the  war  office  to  superintend  the 
nursing  of — and  in  some  degree  to  nurse — sick  and  wounded 
soldiers. 

3.  An  Indian  Army  Nursing  Service.  Employed  by 
the  Indian  office  to  superintend  the  nursing  of  British  sick 
and  wounded  soldiers  in  India. 

4.  A  Poor  Law  Nursing  Department.  In  this  nurses 
are  employed  by  the  local  government  board,  which  pro- 
vides for  the  nursing  of  destitute  persons  in  poor  law  infirm- 
aries. 

5.  The  Metropolitan  Asylums  Board.  Nurses  are 
employed  by  this  board  to  nurse  persons  suffering  from 
infectious  diseases  in  London  and  the  suburbs,  in  hospitals 
provided  for  the  purpose. 

6.  There  is  also  a  Colonial  Nursing  Association, 
which  aims  at  supplying  nurses  to  British  crown  colonies. 
This  society  was  founded  by  private  enterprise,  but  it  is 
utilized  by  the  colonial  office. 

In  none  of  these  government  offices  is  there  a  nursing 
department  comprised  of  experts  empowered  to  deal  with 
nursing  matters. 

DISTRICT   NURSING. 
THE  QUEEN  VICTORIA'S  JUBILEE  INSTITUTE. 

Foremost  among  district  nursing  societies  is  the  Queen 


430  International  Congress  of  Nurses 

Victoria's  Jubilee  Institute,  which  was  founded  by  her  late 
Majesty  out  of  part  of  the  women's  jubilee  offering  in  1887. 
Its  object  is  to  supply  nurses  to  the  poor  in  their  own  homes. 
When  first  formed  the  standard  of  training  required  was  one 
year  in  a  hospital  and  six  months  in  the  district  home. 

Last  year  the  hospital  training  was  raised  to  two  years. 
As  Queen's  nurses  hold  a  very  honorable  position  in  the 
body  politic,  it  is  very  desirable  that  the  standard  should  be 
raised  to  the  full  term  of  three  years'  hospital  training  now 
enforced  in  the  leading  training  schools,  and  demanded  by 
government  departments  for  their  employees. 

There  are  four  branches  of  the  Queen's  Jubilee  Insti- 
tute, namely,  those  for  England,  Scotland,  Ireland,  and 
Wales,  which  are  largely  self-governing.  It  is  to  the  credit 
of  Scotland  that  for  many  years  a  two  years',  and  now,  I 
believe,  a  three  years'  course  of  instruction  for  its  nurses 
has  been  enforced. 

The  work  of  district  nurses  amongst  the  poor,  both  in 
urban  and  rural  districts,  is  one  of  the  utmost  value,  as  a 
really  efficient  and  well-trained  nurse  acts  as  a  health 
missioner  in  the  homes  of  the  poor.  The  professional  status 
of  district  nurses  should,  therefore,  be  such  as  to  encourage 
women  of  the  highest  type  and  of  sound  education  to  under- 
take this  particular  branch  of  work. 

RURAL    NURSING    ASSOCIATIONS. 

There  are  also  County  Nursing  Associations  having  the 
same  object.  These,  in  many  instances,  are  founded  on  the 
model  of  what  is  known  as  the  Holt-Ockley  system,  under 
which  women  of  the  artisan  class  are  given  a  few  months' 
instruction  in  nursing  and  midwdfery,  and  then  employed  to 
nurse  the  poor  in  their  own  homes.  The  most  rudimentary 
of  these  rural  workers  may  be  called  upon  to  nurse  one  case 
at  a  time,  live  in  the  home  of  the  patient,  and  undertake,  in 
addition  to  the  nursing,  the  household  duties  of  a  laboring 
woman. 

Thus  we  have  employed  in  district  nursing  all  classes 
of  women  from  the  highly  educated  gentlewoman  to  the 


Council  Reports  431 

illiterate  cottage  help.  I  consider  that  a  nurse  supplied  by 
the  rich  to  care  for  the  poor  should  be  of  the  most  efficient 
and  educated  type.  It  is  no  charity  to  provide  for  the  poor 
a  quality  of  nursing  which  is  inferior  to  that  which  is  utilized 
by  those  who  can  afiord  to  pay.  Grades  of  helpers  who  take 
part  in  the  care  of  the  rural  poor,  who  have  merely  a  smat- 
tering of  practical  nursing  knowledge,  have  no  right  to  the 
title  of  "  trained  nurse,"  and  should  not  be  so  nominated. 
As  cottage  helps  to  clean  and  cook  and  wash  no  doubt  the 
work  of  these  women  is  very  useful  when  under  the  direc- 
tion of  a  trained  nurse,  but  they  have  no  more  right  to  the 
title  of  trained  nurse,  which  is  bestowed  upon  them,  than 
have  wardmaids,  and  it  appears  to  me  a  mistake  that  rural 
training  societies,  recognizing  these  cottage  helps  as 
^'  nurses,"  should  be  affiliated  with  the  Queen's  Jubilee 
Institute. 

PRIVATE   NURSING. 

The  branch  of  nursing  which  suffers  most  from  the  lack 
of  professional  organization  and  control  is  that  of  private 
nursing,  for  here,  truly,  chaos,  written  with  a  big  C,  alone 
describes  its  condition  in  the  United  Kingdom,  and  it  is 
here  in  the  open  market,  where  all  sorts  and  conditions  of 
nurses  meet  and  compete  without  any  standard  of  either 
education  or  efficiency. 

Private  nurses  may  be  considered  under  five  aspects : 

1.  Those  working  in  co-operations.  A  well  conducted 
co-operation  has  a  trained  and  experienced  superintendent 
at  its  head,  and  the  nurses  who  are  members  take  part  in 
its  management.  The  nurses  receive  their  own  fees,  less 
a  certain  percentage,  usually  7^  per  cent.  (Is.  7d.  in  £1  Is.), 
which  is  deducted  for  secretarial  and  office  expenses.  The 
nurse  boards  and  lodges  herself  when  not  at  a  case.  This 
is  a  just  and  self-respecting  arrangement  of  private  nursing 
work.  The  Nurses'  Co-operation  of  London  and  the  Reg- 
istered Nurses'  Society  exemplify  this  class  of  society. 

2.  Well  regulated  private  nursing  institutions,  attached 


432  International  Congress  of  Nurses 

to  hospitals,  to  which  nurses  trained  in  the  school  attach 
themselves.  They  receive  a  regular  increasing  salary,  and 
in  some  cases  a  bonus  on  their  earnings.  The  nurses  are 
housed  and  boarded  when  off  duty,  the  institution,  not  the 
nurse,  taking  the  surplus  profits,  or  risk  of  deficit. 

3,  Well  regulated  nursing  institutions  other  than  those 
attached  to  hospitals.  There  are  a  certain  number  of  pri- 
vate nursing  institutions,  such  as  St.  John's  House,  organ- 
ized entirely  in  the  interests  of  the  nurses,  but  the  majority 
of  these  private  nursing  institutions  are  conducted  on  com- 
mercial principles,  and  like  the  institutions  attached  to  hos- 
pitals make  a  profit  from  the  work  of  the  nurses. 

4.  Nurse  Farms. — Untrained  lay  persons  have  not 
been  slow  to  realize  that  there  is  money  to  be  sweated  out 
of  nursing  labor,  and  we  have  flourishing  in  our  midst 
"  nurse  farms,"  organized  by  professional  or  semi-profes- 
sional middlemen.  Nurses  of  good  standing  do  not  connect 
themselves  with  these  institutions,  but  the  middleman  is 
not  particular  as  to  the  type  of  person  engaged.  He  conse- 
quently finds  a  use  for  those  who  will  accept  a  lower  salary 
than  the  well  certificated  nurse,  for  the  women  with  a  few 
months'  training,  for  those  who  have,  for  various  reasons, 
been  rejected  by  the  training  schools,  and  for  those  who, 
after  a  few  months'  training  in  a  special  (such  as  maternity) 
hospital,  are  quite  prepared  to  nurse  cases  of  general  dis- 
ease. The  middleman  charges  fees  commanded  by  thor- 
oughly qualified  nurses,  and  pays  his  motley  crew  as  low  a 
salary  as  they  can  be  induced  to  accept,  and  finds  this  fraud- 
ulent business  highly  profitable. 

UNDESIRABLE   UNITS. 

A  few  nurses  of  good  standing  work  entirely  on  their 
own  account  for  medical  men,  who  keep  them  supplied  with 
work,  but  the  private  nursing  question  cannot  be  disposed 
of  without  reference  to  the  undesirable  units,  attached  to 
no  institution,  and  subject  to  no  control,  who  swell  the  ranks 
of  private  nurses  and  bring  discredit  upon  them.     In  most 


Council  Reports  433 

instances  the  isolated  worker  is  one  whom  no  institution  of 
repute  would  admit  to  its  staff. 

Nurse  farms  and  nurse  frauds  will  continue  to  exist 
until  medical  men  and  the  public  realize  the  importance  of 
nurses  being  subjected  to  a  definite  educational  curriculum, 
preparatory  to  registration  and  control  by  a  state  appointed 
body. 

PRIVATE    HOSPITALS. 

Private  hospitals  for  paying  patients  have  largely  in- 
creased of  recent  years.  They  vary  very  much  in  their 
organization  and  management.  A  limited  number  are 
efficiently  conducted  and  officered  by  trained  nurses,  but 
too  often  these  home  hospitals  are  controlled  by  unpro- 
fessional persons,  and  in  consequence  women  with  little 
or  no  training  are  employed  as  nurses.  Further,  the  average 
house,  by  reason  of  its  many  stories,  is  most  unsuitable  for 
the  purpose.  It  is  desirable  that  in  the  future  some  munici- 
pal control  should  be  exercised  over  home  hospitals,  and 
that  they  should  be  built  for  the  purpose  on  hygienic  prin- 
ciples and  licensed  and  inspected. 

NURSING    IN   POOR   LAW   INFIRMARIES. 

This  sketch  of  nursing  in  Great  Britain  would  not  be 
complete  without  reference  to  nursing  the  sick  in  Poor 
Law  Infirmaries,  where  provision  for  the  indigent  sick, 
other  than  those  received  in  hospitals,  is  made  by  the  rate- 
payers. The  nursing  in  these  institutions  is  still  a  very 
uncertain  quantity.  In  some  instances  magnificent  hos- 
pitals, with  a  training  school  attached,  are  organized  sep- 
arately from  the  workhouse ;  but,  again,  the  pauper  sick 
may  have  no  other  provision  than  the  most  primitive  wards 
attached  to  the  workhouse,  where  the  system  of  nursing 
is  entirely  obsolete. 

The  Workhouse  Infirmary  Nursing  Association  has, 
during  the  last  twenty  years,  done  much  to  arouse  the  con- 


434  International  Congress  of  Nurses 

science  of  the  community  on  the  necessity  for  the  efficient 
nursing  of  the  indigent  class.  I  am  of  opinion  that  no 
adequate  reform  is  possible  until  a  Nursing  Department  has 
been  inaugurated  by  the  local  government  board. 

MENTAL   NURSING. 

To  no  very  great  extent  have  the  asylums  for  the  insane 
been  utilized  to  the  best  advantage  for  the  training  of  mental 
nurses,  the  system  at  present  largely  employed  being  to  edu- 
cate attendants  rather  than  highly  skilled  mental  nurses. 

I  would  here  emphasize  the  principle  that  a  general 
training  is  necessary  before  it  is  possible  properly  to  profit 
by  a  special  one,  and  that  it  is  impossible  to  produce  the 
most  efficient  type  of  nurse  except  by  clinical  and  practical 
experience,  which  is  not  available  for  those  trained  in 
asylums  for  the  insane.  General  principles  absorbed  from 
text-books  are  of  very  little  practical  value.  An  impetus, 
however,  to  better  education  for  asylum  attendants  has  been 
given  by  the  Medico-Psychological  Society,  which  has  insti- 
tuted a  rudimentary  examination  for  male  and  female  asylum 
attendants,  and  the  fact  that  some  of  the  more  progressive 
asylum  managers  are  appointing  trained  nurses  to  the 
position  of  matrons  and  sisters  of  wards  points  to  the  con- 
clusion that  they  realize  the  necessity  of  providing  more 
highly  skilled  nursing  for  the  care  of  the  insane. 

THE   MIDWIFE   QUESTION. 

Some  reference  is  necessary  to  the  midwife  question, 
inasmuch  as  it  afifects  the  interests  of  trained  nurses.  There 
are  in  Great  Britain  and  Ireland  a  large  number  of  women 
who  practice  midwifery  after  a  few  months'  special  training, 
and  who  seek  to  obtain  legal  status  by  registration. 

Professional  opinion  on  this  question  is  divided.  Some 
medical  practitioners  and  trained  nurses  hold  that  the  train- 
ing given  is  insufficient,  and  that  it  is  a  fundamental  error 
to  give  legal  status  to  specialists.  Others  believe  that  in  the 
interests  of  the  poor  such  legislation  is  desirable. 


Council  Reports  435 

It  must  be  noted  that  when  midwives  began  to  ask  for 
registration  the  medical  act  of  1886,  including  midwifery  in 
the  curriculum  of  the  registered  medical  practitioner,  had  not 
been  passed,  and  the  education  of  trained  nurses  was  in  its 
infancy.  At  the  present  day  we  have  medical  practitioners, 
qualified  in  midwifery,  of  bo'th  sexes,  and  a  large  body  of 
trained  nurses.  It  appears  to  me  that  the  practice  of  mid- 
wifery falls  naturally  into  the  hands  of  the  registered  med- 
ical practitioner,  and  the  trained  nurse,  holding  an  obstetric 
qualification,  who  works  under  medical  direction,  and  that, 
at  our  present  stage  of  evolution,  it  would  be  a  mistake  to 
legislate  for  midwives  as  such.  I  may  add  that  the  legisla- 
tion proposed  for  the  regulation  of  midwives,  by  medical 
practitioners,  has  been  of  so  penal  a  nature  that  it  would 
be  dangerous  to  the  liberty  of  the  subject.  I  may  point 
out  to  superintendents  of  training  schools  the  importance 
of  including  education  in  obstetric  nursing  in  the  training 
school  curriculum,  for  we  cannot,  as  nurses,  take  exception 
to  the  specialist  midwife  if  we  do  not  provide  in  her  stead 
a  better  qualified  woman. 

SOCIETIES  OP   NURSES. 

There  are  in  Great  Britain  a  limited  number  of  societies 
of  nurses,  founded  for  professional,  as  apart  from  commer- 
cial and  philanthropic  purposes.  Of  these  must  be  men- 
tioned 

THE   ROYAL   BRITISH    NURSES*    ASSOCIATION 

which  was  founded  in  1887,  as  the  British  Nurses'  Associa- 
tion, by  nurses  for  the  benefit  of  nurses.    Its  objects  were : 

1.  To  unite  all  qualified  British  nurses  in  membership 
of  a  recognized  profession. 

2.  To  provide  for  their  registration  on  terms  satis- 
factory to  physicians  and  surgeons  as  evidence  of  their  hav- 
ing received  systematic  training. 

3.  To  associate  them  for  their  mutual  help  and  pro- 


436  International  Congress  of  Nurses 

tection,  and  for  the  advancement  in  every  way  of  their  pro- 
fessional work. 

Membership  was  open  to  medical  men  and  to  trained 
nurses  of  three  years'  standing. 

The  association  was  incorporated  by  royal  charter  in 
1893.  From  this  time  onwards,  owing  to  the  ungenerous 
attitude  assumed  by  a  section  of  the  medical  members,  the 
entire  control  has  drifted  into  the  hands  of  a  small  bureau- 
cracy of  honorable  officials.  The  principle  of  state  regis- 
tration, which  it  was  founded  to  obtain,  has  been  publicly 
voted  against  by  its  medical  secretary,  and  the  association 
is  now  actively  opposed  to  professional  progress  and  self- 
government  for  its  nurse  members,  and  is  chiefly  used  as  a 
philanthropic  agency.  When  the  majority  of  the  nurse 
members  of  the  society  are  alive  to  their  professional  inter- 
ests, no  doubt  they  will  make  some  use  of  their  royal 
charter. 

THE   matrons'    council. 

The  Matrons'  Council  of  Great  Britain  and  Ireland  is 
an  association  of  superintendents  of  trained  nurses,  formed 
on  lines  analogous  to  those  of  the  American  Society  of 
Superintendents  of  Training  Schools.  Membership  is  open 
to  women  who  are,  or  have  been,  matrons  of  hospitals  and 
superintendents  of  nursing  institutions  who  are  trained 
nurses.    Its  objects  are  : 

1.  To  enable  members  to  take  counsel  together  upon 
matt-ers  affecting  their  profession. 

2.  To  bring  about  a  uniform  system  of  education, 
examination,  certification  and  state  registration  for  nurses 
in  British  hospitals. 

3.  To  hold  conferences  to  discuss  subjects  of  profes- 
sional and  also  of  general  interest. 

THE  LEAGUE   OF   ST.    BARTHOLOMEW'S    NURSES. 

The  League  of  St.  Bartholomew's  Nurses  is  an  associ- 
ation of  certified  nurses  who  have  passed  through  the  train- 


Council  Reports  437 

ing  school  of  the  hospital.  The  qualification  for  member- 
ship is  the  certificate  of  the  hospital.  St.  Bartholomew's 
is  notable  as  being  the  first  nurse  training  school  in  the 
United  Kingdom  to  afifiliate  its  members  for  professional 
and  social  purposes  upon  the  same  principles  upon  which 
the  alumnae  associations  are  already  founded  in  the  United 
States  and  Canada.     Its  objects  are : 

(a)  By  union  to  encourage  the  members  to  maintain 
a  high  standard  of  work  and  conduct. 

(b)  For  mutual  help  and  pleasure. 

(c)  To  promote  the  establishment  of  a  fund  for  the 
relief  of  former  nurses  of  the  hospital  who  are  in  distressed 
circumstances  and  need  temporary  or  permanent  help. 

THE   LEAGUE   OF   ST.    JOHN'S   HOUSE   NURSES. 

Within  the  last  few  months  a  League  of  the  Nurses  of 
St.  John's  House  has  also  been  formed.  The  objects  of  the 
league  are : 

(a)  By  union  to  elevate  and  strengthen  our  profession 
by  endeavoring  to  maintain  a  high  standard  of  work  and 
conduct. 

(b)  To  bring  about  a  uniform  system  of  education, 
examination,  certification,  and  state  registration  for  British 
nurses. 

(c)  To  promote  the  usefulness  and  honor,  the  financial 
and  other  interests,  of  the  nursing  profession. 

(d)  For  mutual  help,  sympathy,  and  pleasure. 

The  qualification  for  membership  is  a  certificate  of  three 
years'  training,  after  examination,  in  a  general  hospital  of 
not  less  than  fifty  beds. 

THE  NURSING   SECTIONAI,   COMMITTEE   OF   THE 
MIDWIVES'    INSTITUTE. 

A  nursing  sectional  committee,  composed  of  trained 
nurses  and  others,  has  been  formed  in  connection  with  the 
Midwives'  Institute  to  consider  questions  that  concern 
nurses,  as  apart  from  midwives. 


438  International  Congress  of  Nurses 

THE   DUBLIN   NURSES'    CLUB. 

A  nurses'  club  for  professional  and  social  purposes  was 
most  hopefully  inaugurated  in  Dublin  last  year,  and  already 
numbers  nearly  500  members.  The  members  have  much 
appreciated  both  the  professional  lectures  and  the  social 
gatherings  they  have  enjoyed  through  its  medium,  and  their 
hope  is  that  through  it  they  may  have  an  opportunity  of 
elevating  and  ennobling,  by  every  means  in  their  power, 
the  useful  and  honorable  profession  to  which  they  belong. 

THE  NATIONAL  LEAGUE  OF  CERTIFICATED  NURSES   OF 
GREAT  BRITAIN  AND  IRELAND. 

The  constitution  of  a  National  League  of  Certificated 
Nurses  has  also  been  defined  by  the  Matrons'  Council, 
which  is  analogous  to  that  of  the  National  Associated 
Alumnae  in  the  United  States.  The  league  has  reserved 
to  itself  the  right  to  supersede  the  word  certificated  by  regis- 
tered when  nurses  are  thus  distinguished  by  act  of  parlia- 
ment. 

CONSTITUTION. 

Article  I. — Name. — The  name  of  the  association  shall 
be  "  The  National  League  of  Certificated  Nurses  of  Great 
Britain  and  Ireland." 

Article  IL — Objects. — The  objects  of  the  national 
league  shall  be:  (1)  To  establish  and  maintain  a  code  of 
ethics.  (2)  To  elevate  the  standard  of  nursing  education. 
(3)  To  promote  the  usefulness  and  honor,  the  financial  and 
other  interests,  of  the  nursing  profession. 

Article  IIL — Eligibility. — Associations  of  nurses  hav- 
ing the  following  qualifications  shall  be  eligible  for  affilia- 
tion with  the  National  League  :  (1)  Associations  composed 
of  graduates  of  schools  of  nursing  connected  with  general 
hospitals  of  not  less  than  fifty  beds,  giving  three  years'  full 
training  in  the  wards,  and  certification  after  examination. 


Council  Reports  439 

(2)  Associations  composed  of  graduates  of  schools  of  nurs- 
ing connected  with  poor  law  infirmaries  of  not  less  than  200 
beds,  giving  three  years'  full  training  in  the  wards  of  the 
infirmary,  and  certification  after  examination,  and  whose 
training  schools  are  recognized  by  the  local  government 
board.  (3)  Professional  associations  of  nurses,  formed  for 
the  benefit  of  nurses,  the  members  of  which  hold  the  qualifi- 
cations of  training  as  defined  above. 

Article  IV. — Membership. — Membership  of  the  National 
League  shall  be  confined  to  trained  nurses  as  defined  above, 
and  divided  into  members,  active  members,  and  honorary 
members.  Members  shall  consist  of  all  members  of  the 
affiliated  associations.  Active  members  shall  consist  of  del- 
egates duly  elected  to  represent  these  associations  on  the 
grand  council  of  the  National  League,  and  shall  include  all 
honorary  officers  of  the  National  League.  Honorary  mem- 
bers shall  consist  only  of  nurses  who  have  rendered  dis- 
tinguished service  to  the  nursing  profession. 

Article  V. — Officers. — The  Hon.  officers  of  the  National 
League  shall  be  a  president,  first  and  second  vice-presidents, 
secretary  and  treasurer,  who  shall  be  ex-officio  members  of 
all  committees. 

Article  VL — Government :  Grand  Council. — (1)  The 
National  League  shall  be  governed  by  a  grand  council  com- 
posed of  duly  appointed  delegates  from  affiliated  associa- 
tions and  the  Hon.  officers.  (2)  Societies  affiliated  in  the 
National  League  shall  have  the  right  to  representation  by 
delegation  on  the  grand  council  as  follows :  Each  associa- 
tion of  under  a  hundred  members  shall  have  the  right  to 
depute  one  delegate ;  over  one  hundred,  and  up  to  three 
hundred  members,  two  delegates;  and  over  three  hundred 
members,  three  delegates,  after  which  there  shall  be 
no  increase  of  representation.  (3)  The  grand  council 
shall  meet  annually  for  the  transaction  of  business,  when 
the  honorary  officers,  who  shall  form  the  executive  commit- 
tee, shall  be  elected.     Executive  Committee. — The  execu- 


440  International  Congress  of  Xurses 

tive  committee  shall  be  composed  of  the  honorary  officers. 
It  shall  meet  from  time  to  time  for  the  transaction  of  busi- 
ness, and  shall  report  annually  to  the  grand  council. 

Article  VII. — Code  of  Ethics. — The  code  of  ethics  of 
the  National  League  shall  be  binding  upon  all  members. 

Article  VIII. — Amendments. — No  addition  or  amend- 
ment shall  be  made  to  the  constitution  at  an  annual  meeting 
unless  such  addition  or  amendment  shall  be  formally  pro- 
posed and  seconded  by  members  of  the  National  League 
at  the  said  meeting,  nor  unless  notice  shall  have  been  given 
in  writing  to  the  secretary  of  the  full  text  of  the  proposed 
resolution,  by  registered  letter,  at  least  three  weeks  previ- 
ously, for  insertion  upon  the  agenda  of  the  said  meeting. 
Such  addition  or  amendment  must  be  carried  by  a  majority 
vote  of  two-thirds  of  those  present  at  the  meeting. 

THE    NATIONAL   COUNCIL   OF   NURSES. 

At  the  time  of  the  formation  of  the  National  League  of 
Certificated  Nurses,  it  was  felt  that  in  the  near  future  the 
federation  of  the  matrons'  and  nurses'  national  societies, 
that  is  to  say,  of  the  Matrons'  Council  and  the  National 
League,  was  advisable  under  a  few  articles  of  association. 

Quite  recently  it  has  been  agreed  "that  the  National 
Council  of  Nurses  be  formed  of  the  honorable  officers  of  the 
Matrons'  Council,  and  of  the  National  League  of  Certificated 
Nurses  in  equal  proportions  of  at  least  twelve  representa- 
tives of  each  body."  This  society  will  answer  to  the  Amer- 
ican Federation  of  Nurses,  and  a  means  is  thus  provided 
for  nurses  of  the  United  Kingdom  to  take  their  place  in  the 
International  Council  of  Nurses. 

Important  functions  of  the  National  Council  in  each 
country  would  be  to  develop  an  interest  in  professional  mat- 
ters, and  to  disseminate  information  with  regard  to  them, 
to  organize  and  guide  nursing  movements,  to  obtain  nurs- 
ing legislation,  to  act  as  the  mouthpiece  of  the  nursing  pro- 
fession in  its  relations  with  medical  bodies,  and  lastly  to 


Council  Reports  441 

be  the  recognized  medium  for  the  conduct  of  business  with 
the  International  Council  of  Nurses. 

SOCIETIES   OF   ASSOCIATED   WORKERS. 

The  Midwives'  Institute  of  London  associates  mid- 
wives  for  their  professional  benefit.  The  Incorporated 
Society  of  Trained  Masseuses  provides  for  the  training, 
examination,  and  co-operation  of  masseuses,  and  is  doing 
most  useful  work. 

The  Association  of  Asylum  Workers  is  formed  of  the 
medical  superintendents  and  matrons,  and  the  male  and 
female  attendants  working  in  asylums  for  the  insane. 

NURSING  LITERATURE. 

Professional  literature  is  a  powerful  influence  in  the 
formation  of  a  profession,  and  an  interesting  phase  in  nurs- 
ing progress  has  been  the  development  of  a  nursing  press. 
It  is  an  undeniable  fact  that  the  only  nursing  papers  which 
are  of  any  real  value  to  nurses  are  those  which  are  edited 
by  members  of  their  own  profession.  Of  this  class  is  the 
Nursing  Record,  and  it  is  significant  that  it  is  the  only  paper 
which  professes  to  deal  with  professional  matters  which  has 
consistently  placed  before  the  English  nursing  world  the 
necessity  for  a  defined  educational  curriculum,  and  for  state 
registration  of  nurses  by  act  of  parliament,  thus  inspiring 
nurses  with  a  sense  of  their  responsibilities  both  to  the  pub- 
lic and  to  each  other. 

The  League  of  St.  Bartholomew's  Nurses  has  an  official 
organ,  League  News,  which  is  published  twice  a  year. 

These  are  at  present  our  only  publications  which  are 
edited  by  trained  nurses.* 

Nursing  Notes,  the  organ  of  the  Midwives'  Institute, 
is  also  the  official  organ  of  various  nursing  societies,  the 
members  of  which  contribute  largely  to  its  columns, 
although  it  has  a  lay-editor. 

♦Since  this  article  was  written  "St.  John's  House  News"  and  the  "Journal  of 
the  Royal  South  Hants  Nurses'  League"  have  been  established. 


442  International  Congress  of  Nurses 

Incredible  as  it  may  appear,  the  official  organ  of  the 
Royal  British  Nurses'  Association  is  edited  by  the  secretary, 
who  is  a  lay-woman. 

Asylum  News  is  the  oro^an  of  the  Association  of  Asylum 
Workers,  and  is  edited  by  a  medical  man. 

SUMMARY. 

It  will  be  seen  that  while  in  individual  hospitals  the 
standard  of  nursing  is  progressive  and  maintained  at  a  high 
level,  there  is  need  for  greater  cohesion  between  the  various 
schools,  the  members  of  which  are  largely  unknown  to  one 
another.  The  problem  to  be  solved  in  the  future  is  how 
best  our  scattered  forces  may  be  brought  into  line,  and  side 
by  side,  in  the  strength  which  comes  only  from  union,  may 
work  for  the  public  good  and  for  their  professional  well 
being. 


Nursing  Organization  in   Germany. 

LAVINIA  L.  DOCK. 

Secretary,  International  Council  of  Nurses. 


It  is  from  the  German  forms  that  the  EngHsh  and  our 
own  nursing  systems  have  developed.  While  it  is  true  that 
the  great  English  philanthropist  and  reformer,  Elizabeth 
Fry,  was  the  first  to  arouse  that  spirit  of  reform  in  hospital 
management  and  the  care  of  the  sick  in  institutions  which 
finally  culminated  in  the  work  of  Florence  Nightingale,  yet 
the  training  of  the  latter  at  Kaiserswerth,  and  her  establish- 
ment of  the  first  training  school  at  St.  Thomas,  which 
became  to  a  certain  extent  the  model  for  all  others,  gave 
the  English  schools,  and,  subsequently,  through  them  the 
American  ones,  in  modified  forms,  something  of  the  organ- 
ization and  discipline  of  the  great  Fliedner. 

It  is  most  interesting  to  see,  in  full  working  order,  a 
system  as  far  removed  as  the  poles  from  ours  in  the  one 
principle  of  individual  freedom,  but  like  it  in  outer  con- 
formation, and  containing  all  the  germs  of  those  changes 
which  we  have  made.  Then,  too,  there  are  to  be  found  in 
Germany  so  many  degrees,  shading  from  their  strictest 
orders  down  to  organizations  which  are  nearly  free,  that 
one  can  find  there  examples  of  nearly  every  stage  passed 
through,  in  the  development  from  the  old  religious  orders 
of  the  middle  ages  to  our  modern  profession  of  trained 
nursing.  The  very  last  stages  of  all  are  not  found  in  Ger- 
many;  I   mean  the  organization  and   co-ordinated  life  of 

443 


444  International  Congress  of  Nurses 

the  graduate  nurse,  upon  which  we  in  our  post-graduate 
associations  and  national  union  are  now  beginning  to  enter  * 

It  is  to  be  remembered  that  we  nurses  are  descended  in 
a  straight  Hne  from  the  old  conventual  orders.  In  times  not 
so  very  remote,  no  hospital  nursing  was  done  except  by 
religious  sisterhoods  and  brotherhoods.  The  hospitals  were 
closely  connected  with  the  churches  and  were  always  built 
near  them. 

When  Germany  became  Protestant,  although  ideas  and 
beliefs  were  altered,  forms  were  but  slightly  so,  for  forms 
simply  represent  custom,  which  we  all  know  changes  slowly. 

So  in  Germany  today  may  be  found  religious  orders, 
Evangelical  or  Lutheran,  which  are  almost  as  strict  as  the 
Roman  Catholic  sisterhoods.  The  obedience  required  is 
as  absolute,  the  members  or  deaconesses  give  up  their  whole 
Hfe  and  enjoyment  of  personal  property,  and  are  not 
expected  to  marry.  Others  again,  still  religious  and  wear- 
ing the  same  conventional  dress,  are  less  rigid ;  the  nurses 
are  not  bound  for  life,  but  may  leave  and  marry.  Still  the 
rules  while  in  service  are  very  strict,  and  the  daily  life  could 
hardly  be  distinguished  from  that  of  the  others.  Tlie  dea- 
conesses never  lay  ofT  their  uniform,  do  not  go  to  places  of 
amusement,  and  have  no  choice  as  to  their  work,  but  go 
where  they  are  sent  and  do  what  they  are  told.  They  work 
in  hospitals,  do  district  nursing,  or  are  sent  to  private  duty. 
Though  there  is  always  at  their  head  a  head  sister,  or  Oberin, 
yet  the  real  control  of  these  orders  is  in  the  hands  of  the 
clergy  or  "  pastors." 

On  the  street,  whatever  the  uniform  may  be  (often 
brown  or  gray,  sometimes  black),  the  deaconesses  may 
always  be  distinguished  by  the  form  of  their  white  starched 
linen  cap,  or  more  properly  hood,  which  comes  down  over 
the  ears  and  ties  under  the  chin.  All  nurses  in  Germany 
wear  street  uniforms,  but  the  little  hoods  or  bonnets  of  the 
lay  nurses  or  "  sisters,"  do  not  cover  the  ears. 

♦When  this  volume  appears  it  is  possible  that  this  statement  may  no  longer 
hold  true,  as  we  hear  of  a  new  movement  to  organize  nurses  on  a  self-governing 
basis,  directed  by  Frl.  von  Schliehting, 


Council  Reports-  445 

As  the  deaconesses  grow  old  they  are  cared  for  by 
the  mother-house,  and  as  they  have  no  future  to  worry  over, 
one  usually  sees  on  the  faces  of  these  women  the  sweet, 
serene,  placid  expression  typical  of  conventual  life.  One 
finds,  too,  in  talkino^  with  them  that  the  problems  of  today, 
as  we  nurses  feel  them,  are  as  totally  unknown  to  them  as 
life  in  another  planet.  All  things  are  very  clear  and  simple 
to  them.  People  are  divided  into  "  good  "  and  "  bad  ;"^ 
those  who  will  work  and  those  who  will  not,  and  all  that 
goes  wrong  is  ascribed  to  Providence. 

We  can  understand  them,  but  they  could  not  under- 
stand us.  To  them  our  modes  of  life  would  seem  quite  law- 
less, even  revolutionary. 

Then  there  are  in  Germany  next,  in  point  of  freedom, 
the  organizations  of  lay  nurses  connected  with  large  gen- 
eral hospitals.  The  finest  and  most  noteworthy  of  this 
class  are  the  Hamburg  Nursing  Sisters,  at  the  great  hospital 
in  Eppendorf,  and  the  Victoria  House  Sisters,  in  Berlin. 

Of  these  two  the  Victoria  House  is  the  most  "free" 
in  this  respect;  that  no  religious  test  is  made ;  whereas  the 
Hamburg-  Sisters  are  required  to  be  Lutherans,  though 
exceptions  may  sometimes  be  made.  As  these  two  great 
schools  are  much  alike  in  their  organization,  I  will  describe 
them  together,  and  it  will  be  seen  that,  though  not  under 
the  control  of  the  clergy,  they  are  still  close  corporations, 
thoroughly  organized  for  work  and  mutual  benefit,  but 
allowing  little  latitude  for  individual  freedom,  the  control 
all  being  from  above,  and  the  benefits  compulsory.  The 
Eppendorf  nurses  belong  to  the  nursing  association 
{Schwestern  Verein)  of  the  Hamburg  State  hospitals.  The 
objects  of  the  association  are  stated  to  be :  (a)  To  provide 
a  school  for  training  nurses,  in  order  that  the  sick  and 
wounded  in  peace  and  war  may  have  skilled  care ;  in  time 
of  peace  the  association  undertakes  the  care  of  the  hospitals 
of  the  State  of  Hamburg,  primarily  the  New  General  Hos- 
pital at  Eppendorf.  (b)  To  bind  the  graduates  (ScW^5/^rw) 
together  in  a  close  union.  To  this  association  money  was 
given  by  a  wealthy  citizen  of  Hamburg  to  endow  the 
"Erica"  House  or  Nurses'  Home, 


446  International  Congress  of  Nurses 

The  officers  of  the  association  comprise  various  physi- 
cians connected  with  the  medical  schools,  an  administrator 
of  the  fund  donated  toward  the  Nurses'  Home,  the  director 
of  the  New  General  Hospital,  and  the  Frau  Oberin  or  super- 
intendent of  nurses,  in  an  advisory  or  consulting-  capacity. 
At  the  end  of  her  time  of  training  the  pupil  receives  the 
badge  of  the  association,  a  red  cross  on  a  wdiite  ground, 
and  signs  an  agreement  to  give  not  less  than  two  years  of 
service  to  the  hospital.  As  a  matter  of  fact,  however,  it  is 
assumed  that  she  will  remain  during  her  lifetime  a  member 
of  the  association,  that  is,  subject  to  the  control  of  its 
officers,  and  while  this  is  not  obligatory,  most  of  the  nurses 
do  so,  as  they  are  thus  provided  with  work  and  otherwise 
cared  for,  whereas,  to  do  otherwise,  i.  e.,  to  go  forth  and 
work  independently,  means  that  they  cease  to  belong  to 
the  association  and  thereby  lose  all  its  benefits. 

The  graduates  or  sisters  are  now  sent  to  the  various 
institutions  belonging  to  the  State  of  Hamburg,  and  to  cer- 
tain hospitals  and  other  institutions  in  the  German  colonies, 
in  Jerusalem  and  elsewhere,  all  of  which  branches  are  super- 
vised by  the  Fratt  Oberin,  a  woman  of  g-reat  ability  and 
energy.  These  positions  are  not  open  to  nurses  w'ho  leave 
the  association. 

The  Hamburg  association  does  not  send  nurses  to  pri- 
vate duty,  so  that  question  does  not  enter  here,  but  in  time 
of  war  or  during  epidemics  the  association  is  prepared  to 
supply  nurses  for  work  under  the  Red  Cross,  the  Frau 
Oberin  holding  a  prominent  and  responsible  position  among 
the  officers  of  the  Red  Cross  Society  of  Hamburg. 

The  Victoria  House,  in  Berlin,  is  quite  similar  in  its 
general  plan.  However,  in  the  time  of  service  to  which 
the  nurses  bind  themselves  they  may  be  sent  to  private  duty 
among  the  rich  or  poor.  This  interesting  school  (founded 
by  the  Empress  Frederick,  and  having  a  very  beautiful 
nurses'  home,  with  single  bed  rooms),  has  now  a  member- 
ship of  240  graduates,  and  nurses  several  of  the  city,  uni- 
versity and  private  hospitals  in  Berlin ;  does  private  duty 
and  district  nursing,  provides  for  certain  colonies  and  under- 


Council  Reports  447 

takes  to  be  ready  for  war  and  pestilence.  In  these  two 
schools,  then,  we  find  the  form  of  organization  which,  by 
simply  dividing-  or  specializing  its  functions  and  transferring 
a  part  of  the  control  into  the  nurses'  hands,  is  ready  to 
develop  into  our  system  of  training  school  and  independent 
alumnae  associations. 

The  state  pays  so  much  for  the  work  of  each  sister 
employed  in  its  hospitals ;  private  institutions  and  private 
duty  of  course  also  pay,  and  from  the  income  thus  received 
the  associations  pay  the  allowances  and  salaries  of  the 
nurses  (very  small  they  seem  to  us,  ranging  from  $75  to 
$125  yearly),  and  contribute  to  the  old  age  pensions  and 
sick  funds.  The  arrangements  concerning  pensions  will 
require  a  little  explanation  for  x\merican  nurses  to  under- 
stand. Germany  has  a  compulsory  system  of  old  age  pen- 
sions and  insurance  for  times  of  illness,  which  has  been 
established  by  law  within  the  last  decade,  and  includes  in 
its  provisions  nearly  all  wage  earners  and  recipients  of  small 
salaries,  among  whom  are  naturally  nurses.  The  distinctive 
feature  of  this  state  law  is  that  the  employee  and  the 
employer  both  contribute  to  the  provision  made  for  the 
future  of  the  worker,  the  proportion  of  the  payments  made 
by  the  employer  being  in  the  ratio  of  about  one  to  three, 
speaking  roughly. 

The  payments  are  very  small,  are  made  weekly,  and  are 
taken  charge  of  by  the  government,  a  careful  scrutiny  being 
maintained  by  government  officials  over  the  accounts  of 
each  individual.  Thus  one  finds  that  domestic  servants,  as 
an  example,  all  have  their  little  books  in  which,  so  long  as 
they  have  employment,  the  weekly  payments  are  recorded 
by  stamps.  When  they  change  positions  or  lose  employ- 
ment, the  records  are  submitted  to  the  proper  authorities. 
Such  nurses  as  the  deaconesses  of  religious  orders,  I  was 
told,  do  not  come  under  the  state  pension  law,  as  their 
mother-houses  undertake  to  care  for  them  during  life  and 
give  them  a  home.  But  others  do,  and  one  great  advantage 
to  the  nurse  belonging  to  a  secular  institution  over  inde- 
pendent life  is  that  these  institutions,  as  the  Hamburg  and 


448  International  Congress  of  Xiirses 

Berlin  associations,  which  we  are  considering,  take  the 
whole  charge  of  the  pension  arrangements  for  their  mem- 
bers, and,  by  paying  the  premiums  and  adding  to  the  contri- 
butions, are  enabled  to  secure  for  their  nurses  better  and 
more  'liberal  arrangements  than  they  icould  individually 
obtain.  In  the  case  of  the  Hamburg  sisters,  the  state,  being 
the  employer,  pays  the  employer's  share  toward  the  pen- 
sion fund,  and  the  nursing  association,  acting  for  all  of  its 
members,  pays  the  employee's  share. 

Then,  further,  these  associations  have  elaborate  pro- 
visions intended  to  meet  the  varying  needs  of  nurses  who 
may  leave  or  become  invalided  before  their  time,  as  is 
quite  necessary  when  these  hard-working  women  are  kept 
in  an  entirely  dependent  position  financially. 

Is  there,  then,  no  further  development  to  be  found  in 
Germany?  Though  I  did  not  personally  encounter  them, 
I  learned  of  organizations  which  advocate  the  entire  freedom 
of  the  trained  nurse  after  her  hospital  course  is  completed, 
and  obtained  the  circulars  and  explanatory  leaflets  of  one, 
the  "Evangelischen  Diakoniez'erein,"  established  within  a 
few  years,  which  considers  the  subject  more  from  an  indus- 
trial standpoint  than  the  older  ones,  and  insists  that  the  nurse 
shall  choose  her  own  employment  and  receive  her  own  earn- 
ings. In  such  a  system  we  would  find  the  stage  of  develop- 
ment next  before  our  own.  The  final  step  into  organization 
of  graduate  nurses  as  a  means  of  raising  the  profession  of 
nursing  to  a  higher  plane,  and  of  educating  the  nurses  to  a 
larger  view  of  their  duties  and  responsibilities,  is  yet  to  be 
taken.  Even  these  movements  for  "free"  or  independent 
nurses  are  initiated  by  "pastors"  of  liberal  views,  and  all  text- 
books, lectures  to  nurses,  histories  of  nursing,  theories  of 
nursing  and  rules  of  conduct  for  nurses,  are  written  by  men. 
An  American  is  astonished  at  the  silence  among  these  women 
of  the  Old  World.  The  superintendents  of  nurses  in  these 
vast  establishments,  women  of  immense  ability  and  possess- 
ing authority  in  certain  directions  more  extensive  than  any 
of  our  superintendents  possess,  have  no  associate  life.  They 
do  not  unite,  write  papers,  or  speak  in  public. 


Council  Reports  449 

Still  there  is  an  undercurrent  goings  on  among  women 
in  Germany  and  among  the  nurses,  of  desire  for  greater 
freedom.  Many  graduates  have  separated  themselves  from 
the  nursing  associations  and  are  to  be  found  working  at  pri- 
vate duty  in  the  large  cities.  Their  lives  are  rather  forlorn ; 
the  patients  and  doctors  do  not  like  them  as  well  as  the  dea- 
conesses, (or  pretend  they  do  not) :  they  are  meagerly  paid 
and  have  not  learned  to  strengthen  one  another.  One  longs 
to  help  them  but  does  not  know  how.  Their  help  must 
come  from  themselves  and  will  be  the  result  of  a  long,  slow 
process. 

Then  there  are  the  Red  Cross  associations,  whose  work 
is  marvelously  perfected  in  Germany. 

I  have  often  heard  nurses  at  home  say :  "  What  does 
it  mean  to  be  a  Red  Cross  nurse,  and  how  can  one  join  the 
Red  Cross?"  I  will  try  to  give  some  idea  of  what  it  means 
on  the  continent,  and  it  will  then  be  easy  to  compare  our 
system  in  America. 

Germany  being  a  nation  of  warriors,  understands  what 
it  seems  peaceful  nations  do  not  always  know,  viz:  that  no 
government  can  do  all  that  is  needed  for  soldiers  in  time 
of  war,  but  that  the  nation  must  help.  So  after  the  Geneva 
conference,  patriotic  societies  were  formed  all  over  Ger- 
many, under  the  patronage  of  the  Kaiserin,  to  carry  out  the 
provisions  ,of  the  International  Red  Cross.  They  have 
various  names,  such  as  "  Women's  Aid  Society,"  "  Society 
of  the  Fatherland,"  etc.,  and  are  to  be  found  in  every  large 
city  and  division  of  the  empire.  They  are  all  associated 
together  in  the  most  thorough  way,  so  that  wheels  move 
within  wheels  with  perfect  smoothness.  They  have  certain 
representation  in  a  central  committee,  and  at  the  head  of  all 
stands  an  official  appointed  by  the  Kaiser.  They  do  not 
disband  in  times  of  peace,  but  remain  thoroughly  organized, 
make  yearly  reports  of  their  finances,  resources  and  gen- 
eral condition,  and  their  outfits,  appliances  and  general 
stores  are  subject  to  regular  inspection  by  a  royal  inspector. 
Complete  regulations  are  made  for  the  various  departments 
of  aid  needed  for  the  army,  and  in  time  of  war  each  society 


450  International  Congress  of  Xnrses 

knows  exactly  where  it  has  to  go  and  what  it  has  to  do. 
Their  army  regulations  are  not,  like  ours,  meant  apparently 
to  make  it  impossible  to  find  out  where  authority  lies,  but 
there  is  a  direct  chain  of  authority  and  responsibility  from 
the  Kaiser  down,  one  might  say,  to  the  floor  washer.  The 
Red  Cross  societies  build  and  maintain,  in  the  different 
towns,  civil  hospitals  where  they  receive  the  poor  and  where 
they  train  their  nurses.  The  women  who  enter  to  train  as 
Red  Cross  sisters  do  so  on  the  same  general  plan  which  I 
have  described  as  being  characteristic  of  Germany,  viz :  the 
modified  sisterhood  plan.  They  do  not  look  forward  to 
independent  work,  but  give  themselves  over  to  the  control 
and  uses  of  the  societies.  They  receive  their  living,  cloth- 
ing and  small — very  small — salaries.  In  time  of  war  th^ey 
are  sent  to  the  military  hospitals,  and  in  time  of  peace  they 
are  kept  employed  in  the  civil  hospitals,  or  are  sent  out  to 
private  duty,  the  society  receiving  their  earnings.  When 
they  get  old  they  are  tucked  into  some  easy  berth  or  live 
on  their  little  pensions  as  best  they  may.  They  are  not 
bound  to  remain  with  the  Red  Cross  societies,  but  they  are 
not  eligible  for  war  service  if  they  leave.  There  is  no  staff 
of  women  nurses  attached  to  the  army  in  time  of  peace, 
but  should  a  soldier  be  seriously  ill  and  need  skilled  care, 
the  military  authorities  simply  send  for  a  Red  Cross  nurse. 
The  goverment  pays  nothing  for  the  services  of  these  nurses. 
As  the  secretary  of  the  central  committee  said :  "  We  exist 
to  help  the  government ;  not  to  have  the  government  help 
us."  Many  women  living  in  their  own  homes  and  possess- 
ing means  take  a  partial  training  in  the  Red  Cross  hospitals 
that  they  may  take  a  helpful  part  in  time  of  need,  and  I 
have  been  told  that  in  time  of  epidemics,  when  the  trained 
"  sisters  "  were  all  needed  for  emergency  work,  these  women 
have  taken  their  places  in  the  routine  hospital  work. 

It  is  now  easy  to  see  why  one  cannot  readily  become  a 
"  Red  Cross  Nurse  "  at  home.  We  have  no  such  system 
as  this  on  the  continent,  and  thorough  and  admirable  as  it 
is,  it  would  be  both  impossible  and  undesirable  to  introduce 
it  in  our  country,  for  it  is  based  upon  an  autocracy  which 


Council  Reports  451 

we  hope  to  leave  behind  us.  It  would  take  from  our  nurses 
all  that  freedom  which  they  have  attained,  and  return  them 
to  the  conditions  of  the  Middle  ages.  We  can  nurse  our 
army  either  by  a  purely  volunteer  service,  or  by  a  paid 
skilled  service  based  on  voluntary  agreement  and  contract, 
but  not  by  women  who  are  simply  a  part  of  the  properties 
and  the  outfits  of  the  relief  associations. 


Nursing  in  Greece, 

ETHEL  GORDON  FENWICK, 


The  hospitals  in  Greece,  where  trained  nurses  are 
employed,  are  mostly  to  be  found  in  the  city  of  Athens, 
where  much  stimulus  has  been  given  to  the  eflficient  nurs- 
ing of  the  sick  by  the  personal  interest  taken  in  the  ques- 
tion by  her  Majesty  the  Queen  of  the  Hellenes,  and  her 
Royal  Highness  the  Duchess  of  Sparta,  crown  princess  of 
Greece. 

The  Evangelismos  Hospital,  which  has  a  Danish  lady 
superintendent,  owes  its  origin  to  the  energy  of  Queen  Olga, 
who  visits  it  almost  daily  and  takes  a  personal  interest  in  the 
nursing  of  the  patients.  It  must,  however,  be  remembered 
that  Greece,  being  in  the  far  east  of  Europe,  has  only  quite 
recently  begun  to  discard  oriental  ideas  as  to  women,  and 
that  nursing  as  a  profession  for  women  does  not  exist  in 
the  country.  When  war  was  declared  between  Greece  and 
Turkey  in  1897  the  only  trained  nurses  available  were  those 
who  were  sent  from  England,  Germany,  Denmark  and 
Sweden.  The  outcome  of  the  help  then  rendered  has  been 
most  gratifying  for,  on  the  initiative  of  the  crown  princess, 
the  old  military  hospital  has  been  razed  to  the  ground  and 
has  been  replaced  by  a  fine  and  convenient  modern  build- 
ing. This  hospital  is  nursed  by  English  sisters  with  Greek 
orderlies  to  assist  them.  The  sisters  go  on  rounds  with  the 
doctors,  and  are  responsible  for  receiving  and  carrying  out 
orders. 
452 


Council  Reports  453 

At  the  instance  of  the  crown  princess  a  children's  hos- 
pital has  also  been  built.  This  is  supervised  and  nursed 
by  English  ladies,  and  Greek  probationers  are  taken  for 
two  years'  training  in  medical  and  surgical  work.  Lec- 
tures are  given  by  the  resident  medical  officer.  It  is  hoped 
that  in  time  this  hospital  will  form  a  training  school,  but  at 
present  it  only  contains  twenty-two  beds. 

Up  to  the  present  little  progress  has  been  made  in 
Greece  with  regard  to  the  training  of  women  as  nurses.  The 
"  material  "  is  not  forthcoming,  as  at  present  well  educated 
and  middle  class  women  consider  nursing  a  derogatory 
occupation.  There  is  hope  for  the  future,  however,  as  in 
the  last  quarter  of  a  century  women  of  the  higher  class  have 
been  greatly  emancipated.  Some  of  these  ladies  were  of 
the  very  greatest  assistance  to  the  English  nurses  who 
worked  during  the  war.  Conspicuous  amongst  them  were 
Mme.  Baltazzi  and  Mme.  Soutzo,  who  accompanied  the 
medical  staff  daily  on  their  rounds  and  acted  as  interpreters 
between  them  and  the  nurses,  besides  contributing  greatly  to 
the  harmonious  and  smooth  working  of  the  domestic 
arrangements  generally. 

The  tact,  graciousness,  and  ability  of  these  ladies  was 
of  so  high  an  order  that  when  once  Greek  women  generally 
realize  the  dignity  of  labor  there  is  every  prospect  that  they 
will  be  able  to  furnish  from  amongst  their  number  women 
whom  after  training  will  make  a  very  high  type  of  nurse. 
A  word  must  be  said  as  to  the  Greek  orderlies  who  worked 
under  the  English  sisters  throughout  the  war.  They  have 
not  much  idea  of  personal  cleanliness  and  the  practical 
details  of  asepticism  and  antisepticism  are  hard  to  impress 
upon  them.  But  they  have  their  good  qualities.  Owing 
probably  to  the  fact  that  their  staple  food  is  bread,  coffee, 
and  a  little  light  wine,  they  are  gentle  and  amenable.  They 
are  also  sober.  Given  a  thorough  education  they  would 
probably  make  better  orderlies  than  the  average  British  man 
of  similar  standing. 


[Nursing  in  Holland. 

MEJ.  C.  A.  LA  BASTIDE  BAARSLAG, 
Amsterdam. 


The  editorial  staff  of  "  Het  Maandblad  voor  Ziekenver- 
pleging,"  a  Dutch  monthly  nursing  magazine,  has  charged 
me  with  the  most  agreeable  task  of  writing  a  short  essay  on 
the  development  of  sick  nursing  in  Holland  during  the  last 
fifty  years.  The  warm  sympathy  and  interest,  of  which 
we  are  assured  on  the  part  of  our  transatlantic  sisters,  give 
me  courage  to  hope  that  this  paper  may  find  a  cordial  wel- 
come at  the  Congress  of  Nurses  at  Buffalo. 

About  fifty  years  ago  sick  nursing  was  in  our  country 
chiefly  the  task  of  religious  corporations,  especially  of 
Roman  Catholic  orders.  The  brothers  of  St.  Johannes  de 
Deo  have  for  more  than  four  centuries  devoted  themselves 
to  the  care  of  their  suffering  fellow-creatures,  and  a  great 
number  of  sisterhoods  are  also  of  a  very  ancient  date. 

Not  until  the  year  1830  there  arose  in  Protestant  hearts 
the  ardent  desire  to  bring  aid  and  comfort  to  their  sick 
fellow-men,  and  the  Protestant  deaconesses  took  up  this 
work  of  charity.  In  1843  the  first  house  of  deaconesses  in 
Holland,  that  at  Utrecht,  was  opened,  in  the  course  of  time 
followed  by  many  other  institutions  of  that  kind  throughout 
our  whole  country.  Some  of  these  houses  of  deaconesses 
are  joined  to  the  "  Deutsche  Diakonissen-Verein,"  the  Bond 
of  Kaiserswerth,  such  as  the  Arnhem  Home,  founded  in 
1884,  and  at  present  supervised  by  our  well  known  Mother 
454 


Council  Reports  455 

von  Ness.  In  all  these  institutions  patients  are  nursed,  pay- 
ing different  fees  according  to  their  financial  condition. 
Besides  the  care  for  those  indoor  patients,  the  sisters  devote 
themselves  to  district  nursing.  Of  recent  years  we  have 
also  several  private  societies  for  district  nursing,  free  from 
any  religious  bias,  but  founded  on  the  broad  principle  of 
human  solidarity.  It  would  be  an  impossibility  to  mention 
them  all  with  their  names  in  this  short  paper,  I  only  wish 
to  direct  your  special  attention  first  tO'  the  society  for  district 
nursing  at  Rotterdam  (Matron :  Miss  M.  des  Amorie  van 
der  Hoeven),  originally  issuing  from  the  Dutch  bond  of 
Protestants,  but  at  present  on  a  distinct  basis,  since  the 
branch  of  social  work  has  been  eliminated  from  the  pro- 
gram of  the  above  named  bond,  and  secondly  to  the 
"  Amsterdam  Society  for  District  Nursing,"  and  that  at  the 
Hague,  both  institutions  sending  out  visiting  nurses.  The 
patients,  who  are  divided  in  different  classes  according  to 
their  social  state,  pay  for  every  visit  at  a  fixed  rate.  The 
poor  are  aided  and  comforted  by  the  sisters  free  from  any 
expenses  at  all.    The  nurses  have  a  fixed  salary. 

There  are  still  a  great  number  of  institutions  sending 
out  nurses  for  outdoor  nursing,  such  as  the  section  for  sick 
nursing  of  the  Association  of  the  White  Cross,  the  Associa- 
tion for  Sick  Nursing  at  Harlem,  etc.,  etc. 

To  give  you  an  idea  of  the  fees  that  are  paid  I  will  tell 
you  the  rate  fixed  by  "  The  White  Cross :" 

Night  nursing  f.3 ;  f.2.50,  and  f.1.50. 
Day  nursing  f.2.50;  f.2,  and  f.l.  .J 

Night  and  day  nursing  f.4 ;  f.3,  and  f.2.  '  ' 

The  poor  have  not  to  pay  anything. 

So,  you  see,  there  are  three  classes.  Our  Dutch  florin 
f.  equals  40  American  cents ;  f.2.50  equals  $1.  Now  you 
may  further  cipher  for  your  own.  The  private  nurses  who 
are  not  joined  to  any  association  at  all  fix  their  rate  them- 
selves. 

I  feel  very  happy  to  be  able  to  state  the  fact  that  nearly 
every  town  in  our  country  has  its  own  communal  hospital. 


456  International  Congress  of  Ntirses 

at  least,  every  town  of  any  significance,  and  that  sick  nurs- 
ing in  the  country  grows  more  and  more  a  matter  of  gen- 
eral interest.  Next  to  these  city  hospitals,  where  the  poor 
are  nursed,  we  find  a  great  many  other  private  hospitals 
as  well  for  the  treatment  of  general  cases,  as  for  that  of 
some  special  diseases.  So  there  are  children's  hospitals, 
ophthalmic  and  gynaecological  hospitals,  homes  for  neuro- 
logical patients,  several  private  institutions  for  sick  nursing 
and  clinics,  etc.,  etc. 

Devotion  and  love  are  indispensable  qualities  with  a 
nurse,  but  they  are  not  all.  A  really  good  nurse  cannot 
do  without  knowledge;  she  must  be  trained  in  the  art  of 
sick  nursing.  And  in  this  regard  we  have  made  in  Holland 
great  progress  during  the  last  twenty  years.  The  standard 
of  nursing  has  been  raised,  and  the  nurse  of  now-a-days  is 
quite  another  being  from  the  one  of  a  quarter  of  a  century 
ago.  The  nurse  of  that  time — if  we  may  entitle  her  as  such, 
for  it  is  too  noble  a  name  for  so  unworthy  a  being — was  a 
splendid  specimen  of  the  Sairey  Gamp  type,  so  wonderfully 
immortalized  by  Dickens.  To  Miss  Reynvaan,  late  matron 
of  the  Wilhelmina  hospital  at  Amsterdam  and  honorary 
member  of  the  British  Matrons'  Council,  belongs  the  honor 
of  having  brought  about  a  thorough  reorganization  in  the 
nursing  world.  It  was  she  who  felt  the  urgent  need  of  effi- 
cient nursing  by  well-bred  women,  and  she  herself  set  the 
example.  Belonging  to  a  patrician  Amsterdam  family,  she 
devoted  herself  to  nursing  work.  Her  task  of  matron  in 
the  Buiten-Gasthuis,  (now  transformed  into  the  Wilhelmina 
hospital),  one  of  the  two  city  hospitals  at  Amsterdam,  was 
a  difficult  one,  but  yet  she  did  not  despair,  and  with  the  aid 
of  Dr.  van  Deventer,  at  that  time  medical  superintendent 
of  the  Buiten-Gasthuis,  she  attained  her  noble  aim.  The 
male  and  female  Sairey  Gamps  were  superseded  by  a  more 
competent  nursing  stalT,  Inspired  by  her  words  and  deeds 
a  great  number  of  well-bred  and  intellectually  developed 
women  took  up  nursing  work  and  gradually  there  came  a 
blessed  change  in  the  condition  of  things.  She  has  been  a 
noble  pioneer  on  the  path,  leading  to  the  raising  of  the 


Council  Reports  457 

standard  of  nursing,  and  a  word  of  praise  and  honor  must 
be  spoken  to  her  at  this  time. 

The  need  of  a  special  training  in  sick  nursing-  was  more 
and  more  feU,  and  also  the  truth,  that  theoretical  knowledge 
without  practical  experience  was  not  enough.  For  this 
reason  some  hospitals  offered  an  opportunity  for  a  thorough 
training,  the  passing  of  an  examination,  and  the  getting  of 
a  certificate.  In  the  year  1879  the  first  certificate  for  sick 
nursing  was  given  by  the  society  of  the  White  Cross.  The 
number  of  hospitals  and  societies  that  are  granting  certifi- 
cates for  sick  nursing,  has  largely  increased  since  that  time. 
We  urgently  want  state  registration  and  fervently  hope 
that  this  new  century  will  fulfil  this  righteous  desire  in 
a  not  too  far-off  future.  In  the  meantime  the  Dutch  associa- 
tion for  sick  nursing  (de  Nederla^idsche  Bond  voor  Ziek- 
enverplegitig)  whost  rules  and  by-laws  have  recently  been 
revised,  proposes  to  evolve  some  order  out  of  the  present 
chaos,  and  to  introduce  more  uniformity  and  co-operation 
with  regard  to  training  and  examinations. 

The  different  hospitals  and  societies  for  sick  nursing 
make  different  demands  of  the  candidates  who  are  desirous 
to  pass  the  examination ;  a  three  years'  training  in  one  of 
our  larger  hospitals  is  a  general  demand,  although  there  are 
still  some  institutions  that  think  a  two  years'  training  suf- 
ficient. 

The  curriculum,  though  not  quite  the  same  everywhere, 
contains  generally  the  following  branches  of  science: 

Some  knowledge  of  anatomy  and  physiology. 

The  nursing  of  internal,  infectious,  and  neurological 
diseases. 

The  nursing  of  surgical  cases;  some  knowledge  of  the 
treatment  of  wounds  and  the  needed  aid  in  sudden  accidents. 

The  nursing  of  lying-in  women  and  new-born  children. 

Some  knowledge  of  hygiene,  ventilation,  feeding,  dis- 
infection, bathing,  sick  room  comfort,  etc.,  etc. 

Special  certificates  are  given  by  some  associations  for 
obstetric  nursing  and  the  nursing  of  the  insane,  the  latter 


458  International  Congress  of  Xiirses 

by  the  Dutch  Association  for  Psychiatry  and  Xeiirology 
and  the  Society  of  the  White  Cross. 

The  probationers  in  the  hospitals  do  not  pay  for  their 
theoretical  and  practical  training.  As  a  reward  for  the 
different  duties  rendered  by  them  in  the  wards,  they  receive 
a  small  salary,  besides  free  boarding;  f.lOO,  to  f.200  a  year 
($40  to  $80). 

In  most  hospitals  we  find  next  to  the  medical  superin- 
tendent a  matron,  especially  charged  with  the  control  of  the 
sisters.  In  smaller  institutions  the  functions  of  matron  and 
head  of  the  household  are  united  in  one  person,  but  in 
larger  hospitals  there  are  two  dignitaries  for  those  separate 
branches  of  the  work.  Although  each  hospital  for  itself 
is  dependent  upon  local  conditions  and  its  own  pecuniary 
means,  the  following  conclusions  have  been  accepted  at  a 
meeting,  held  in  1898,  by  the  medical  superintendents  and 
matrons  of  our  principal  hospitals,  in  consequence  of  an 
inquiry  made  by  the  Dutch  Association  for  Sick  Nursing : 

1.  The  patients  ought  never  to  be  confided  to  the  care 
of  untrained  nurses,  either  by  day  or  by  night. 

2.  The  day  duty  of  the  head  nurses  and  the  other  sis- 
ters shall  not  last  more  than  twelve  hours  after  deducting 
the  time  needed  for  the  different  meals. 

3.  To  the  head  nurses  and  the  other  sisters,  who  are 
on  duty  by  day,  an  undisturbed  night's  rest  of  at  least  seven 
hours  ought  to  be  secured. 

4.  The  nurses  who  are  on  duty  by  night  ought  to  have 
before  the  beginning  of  their  period  of  night  watching  an 
extra  time  for  sleeping  of  over  six  hours,  and  one  of  over 
four  hours  immediately  after  the  close  of  that  period. 

5.  The  night  nurses  shall  not  perform  any  duties  by 
day. 

6.  Each  nurse  shall  have  every  fortnight  one  holiday 
and  one  evening  ofif  duty. 

It  i^  thought  most  desirable  to  give  to  the  nurses  on 
their  working  days  an  opportunity  of  passing  their  leisure 
hours  outside  the  hospital. 


Council  Reports  459 

7.  Half  an  hour  at  least  should  be  granted  to  the 
nurses  for  breakfast  and  supper  and  one  hour  for  dinner. 

8.  The  hospital  ought  to  pay  for  each  sister  who  is 
working  there  an  insurance  fee  for  invalidity  and  accidents. 

9.  To  the  nurses  a  holiday  time  of  at  least  two  weeks 
a  year  should  be  granted,  to  the  head  nurses  one  of  at  least 
three  weeks. 

As  a  matter  of  course  a  short  paper  like  this  cannot 
enter  into  details.  I  will  not  end,  however,  before  having 
mentioned  very  briefly  three  associations  which  are  striv- 
ing, each  in  its  own  way,  to  further  the  cause  of  sick  nursing 
in  Holland.    And  then  I  name,  in  the  first  place : 

L  De  Nederla7idsche  Bond  voor  Ziekenverpleging ^ 
the  Dutch  association  for  sick  nursing,  with  its  official 
organ :  "  Het  Maandblad  voor  Ziekenverpleging." 

The  bond — for  the  sake  of  brevity  I  shall  call  it  so — 
desires  to  further  the  cause  of  sick  nursing  in  the  broadest 
sense  of  the  word  in  Holland  and  its  colonies. 

It  is  striving  to  attain  this  aim : 

(a)  By  taking  care  of  the  moral,  intellectual,  and 
material  interests  of  all  those  who  are  devoting  their  lives 
to  the  nursing  of  the  sick. 

(b)  By  the  holding  of  meetings  at  which  all  matters 
concerning  sick  nursing  are  to  be  discussed. 

II,  De  Wilhdmina-  Vereeniging ,  the  Wilhelmina  asso- 
ciation, formed  for  the  purpose  of  improving  and  raising 
mental  nursing.  It  extends  its  care  to  all  male  and  female 
nurses,  who  are  giving  themselves  to  that  branch  of  nursing 
in  Holland  and  its  colonies,  and  especially  to  those  who  are 
working  in  lunatic  asylums. 

The  Wilhelmina  association  tries  to  attain  its  purpose : 

(a)  By  the  finding  and  helping  of  persons  fit  to  be 
trained  as  mental  nurses. 

(b)  By  furthering  and  facilitating  the  thorough  train- 
ing of  these  persons. 

(c)  By  the  founding  of  homes,  in  which  male  and. 


460  International  Congress  of  Nurses 

female  nurses  who  are  needing  rest  or  who  have  no  employ- 
ment for  the  time  being  may  be  boarded. 

(d)  By  supporting  male  and  female  nurses  in  cases 
of  chronic  diseases,  invalidity,  or  old  age. 

The  Wilhelmina  association  has  recently  founded  at 
Amsterdam  the  Wilhelmina-home,  a  training  school  for  the 
examination  and  preparation  of  young  women,  who  wish 
to  be  accepted  as  probationers  in  some  hospital  for  the 
insane.  One  of  our  most  eminent  medical  men  has  there- 
fore very  truly  called  the  Wilhelmina-home  a  "  sieve." 

The  home  has  a  four-fold  purpose;  it  intends  to  be: 

1.  A  training  school  in  which  young  women  who  are 
wishing  to  devote  themselves  to  mental  nursing  may  be 
trained  as  probationers  free  from  all  expenses. 

2.  A  center  for  sisters,  who  are  out  of  service  or  weak- 
ened, where  they  may  find  the  rest  so  urgently  needed  by 
them. 

3.  The  matron  is  bound  to  register  the  names  of  the 
sisters  in  order  to  be  able  to  give  the  wished-for  information 
to  all  those  who  are  wanting  their  services. 

4.  The  home  is  to  be  the  place,  where  everyone, 
throughout  our  whole  country  may  find  mental  nurses  fit 
for  their  task. 

III.  De  Nederlandsche  Vereeniging  tot  bevorderiyig 
der  belangen  van  Verpleegsters  en  Verpiegers,  the  Dutch 
association  for  furthering  the  interests  of  female  and  male 
nurses,  with  its  oflficial  organ,  "  Nosokomos,"  a  monthly. 

This  association,  founded  in  May,  1900,  must  still  prove 
its  vital  and  active  power. 

And  so  I  have  come  to  the  end  of  my  task,  deeply  con- 
vinced of  the  incompleteness  of  my  work,  but  also  hoping 
that  I  may  have  given  you  at  least  some  idea  of  the  present 
state  of  things  in  our  Dutch  nursing  world. 


The  Training  of  Nurses  in  the  Wilhelmina 
Hospital,  Amsterdam,  Holland. 

MEJ.  L.  KRUYSSE, 
Matron ;  Hon.  Vice  President  International  Council  of  Nurses. 


The  training  of  probationers  and  nurses  consists  of  a 
three  years'  course. 

The  following  course  of  lectures  is  given : 

First  Year — Anatomy,  surgical  nursing,  bandaging, 
first  help  in  emergency  cases  and  transport  of  patients.  Lec- 
tures on  general  nursing  and  nursing  ethics. 

Second  Year. — Elementary  physiology,  medical  and 
fever  nursing.  Continuation  of  lectures  on  general  nursing 
and  nursing  ethics. 

Third  Year. — Lectures  on  foods  and  principles  of 
hygiene.    Repetition  classes  for  examination. 

At  the  completion  of  the  three  years'  course,  after  the 
certificate  for  general  nursing  has  been  earned,  the  nurses 
get  a  course  of  sick  room  cookery,  and  they  can  also  obtain 
certificates  for  monthly  and  mental  nursing,  as  lectures  on 
those  subjects  are  given  afterwards. 

The  probationers  have  no  preliminary  training,  but 
everything  is  taught  them  in  the  wards  without  having  any 
responsibility.    They  enter  the  hospital  on  a  month's  trial. 

Women  of  every  class  and  denomination  are  accepted 

461 


462  International  Congress  of  Nurses 

as  probationers  when  they  prove  to  be  of  g-ood  character 
and  devoted  to  the  sick,  and  if  they  are  sufificiently  educated. 

HOURS   AND    MEALS. 

Nurses  and  probationers  come  on  duty  at  6:30  a.  m. 
and  remain  till  7  or  8  p.  m.  Breakfast  is  served  from  7:45 
to  8 :15  and  from  8 :30  to  9.  Nurses  have  a  preliminary 
breakfast  in  the  ward  kitchens.  Fifteen  minutes  are  given 
for  lunch  from  11  to  11 :30.  Dinner  from  1  to  2,  and  from 
2:15  to  4:15.  Supper  at  7  p.  m.  and  at  8:15.  Nurses  and 
probationers  are  on  duty  together  eleven  hours  per  day. 
Every  three  months  they  are  one  month  on  night  duty. 
Every  week  alternately  they  have  the  evening  ofif,  or  the 
whole  day. 

They  are  allowed  to  sleep  out,  and  they  have  late  leave 
occasionally  to  attend  the  theatre  or  some  concert.  They 
have  three  weeks'  holiday.  The  head  nurses  come  on  duty 
at  8 :30  a.  m.  and  remain  till  8  p.  m.  Between  8  and  10  p.  m. 
they  must  be  on  call  and  superintend  their  wards  occasion- 
ally. They  have  the  evening  and  whole  day  off  every  week 
alternately  and  four  weeks'  holiday. 

SALARIES. 

Probationers  receive  during  the  first  one  and  a  half 
years  £8,  and  afterwards  £16  2-3,  besides  board  and  washing. 
Certificated  nurses  receive  £20  5-6  and  assistant  head  nurses 
£25.  Head  nurses  begin  with  £33^  and  go  up  to  £50  in 
time. 

HOSPITAL   ECONOMY. 

Special  attention  is  paid  to  this  most  important  ques- 
tion. Not  only  is  quality  and  quantity  of  food  seen  to,  but 
also  linen,  dressings,  instruments,  nursing  articles,  etc.,  in 
order  to  have  as  little  waste  as  possible. 

Different  articles  are  purchased  by  contract,  but  the 
contracts  are  not  always  granted  to  the  lowest  bidders. 


Council  Reports  463 

THE    WILHELMINA   HOSPITAL 

is  comparatively  new.  It  replaced  the  old  "Biiiten  Gast- 
huis,"  which  was  no  longer  fit  for  use.  Tlie  foundation 
stone  was  laid  May  28,  1891,  by  Queen  Wilhelmina,  when 
she  was  eleven  years  of  age.  The  hospital  has  been  in  use 
since  1893.  It  is  a  municipal  hospital,  supported  by  the 
rents  of  the  municipality.  ' 

The  patients  did  not  pay  as  a  rule,  but  since  January, 
1901,  they  pay,  if  possible,  a  small  fee,  according  to  their 
income. 

The  board  is  chosen  out  of  the  municipal  Poor  Law 
Board  and  is  subject  to  that  body. 

THE   NURSING    STAFF, 

Each  ward  is  in  charge,  if  possible,  of  a  certificated 
nurse  and  an  assistant  charge  nurse.  The  number  of  nurses 
and  probationers  varies  on  account  of  the  number  of 
patients  and  the  amount  of  work  to  be  done. 

In  the  medical  wards  are  nine  nurses,  two  on  night  duty 
included  (for  42  patients).  For  the  children's  wards  we  have 
eleven  nurses,  also  two  on  night  duty  included. 

Besides  the  general  wards,  the  mental  department  and 
the  fever  hospital,  there  is  also  the  lying-in  hospital  and 
gynaecological  department,  where  the  nurses  get  a  special 
training  for  private  nursing  in  this  branch. 

The  dispensary  is  in  charge  of  a  lady  dispenser  and  four 
assistants. 


Nursing  in  Italy. 

AMY    TURTON, 

Directress  of  Nurses.  Villa  Natalia  Regina.  Florence ;  Honorary  Vice  President 
International  Council  of  Nuri-es. 


I  regret  that  my  paper  must  be  necessarily  far  from 
satisfactory,  owing  to  the  diflficuhy  in  obtaining  concise 
information.  I  have  been  unable  to  find  out  if  any  training 
school  existed  in  Italy  before  one  started  by  Professor 
Durante  and  Signora  Prandi  Ribeghini  in  Rome  in  1892  or 
1893. 

Professor  Durante  instituted  a  set  of  lectures  in  his 
surgical  clinic,  and  Signora  Prandi  conducted  from  six  to 
ten  young  girls  from  her  "Scuola  Professionale,"  who  first 
listened  to  the  lectures,  then  were  taken  to  the  dressings, 
and  finally  admitted  to  operations,  and  entrusted  (I  think, 
after  six  months)  with  the  nursing  of  his  operative  cases. 
Italians  have  great  facility  for  grasping  most  things,  and 
these  girls  learned  well  everything  that  was  taught. 

The  misfortune  was  that  so  many  things  were  not 
taught  at  all,  and  others  were  mistaught.  No  matron  being 
obtainable  (trained  nurses  not  yet  existing  in  Italy),  every- 
thing had  to  be  taught  by  the  surgeon  and  his  assistants. 
The  ethics  of  nursing  thus  became  falsified,  and  the  girls 
refused  to  do  the  humbler  offices  for  the  sick,  calling  them 
"  bassi  servizi,"  and  ringing  for  servants  to  do  them,  or 
leaving  them  undone  (the  emptying  of  utensils)  for  a  whole 
464 


Council  Reports  465 

night.  The  surgeons  were  also,  of  course,  unable  to  teach 
bed  bathing  and  bed  making,  poultice  making,  etc.,  except 
theoretically. 

In  consequence,  an  Italian  friend,  who  called  in  Duran- 
te's  two  best  nurses,  and  who  had  seen  English  trained 
nurses  at  work,  defined  Durante's  as  "  excellent  young 
women,  but  ignorant  of  the  most  rudimentary  parts  of  their 
profession." 

In  1896  (a  sequence,  we  think,  of  the  propaganda  we 
were  beginning  to  spread)  an  attempt  was  made  to  give 
theoretical  teaching  to  the  stafif  of  the  big  women's  hospital 
in  Rome,  San  Giovanni.  Both  the  nuns  and  the  servant 
nurses  (infermiere  inservienti)  were  ordered  by  the  adminis- 
tration to  attend  a  set  of  lectures  given  by  one  of  the  physi- 
cians, which  comprised  the  elements  of  anatomy  and  physi- 
ology, and  went  fairly  thoroughly  into  the  theory  of  nursing, 
of  disinfection  and  ventilation,  and  ended  with  demonstra- 
tion of  bandaging. 

These  lectures  lasted  during  one  winter,  and  were  fol- 
lowed by  an  examination,  conducted  by  a  medical  and  sur- 
gical chief  (the  former  being  also  superintendent  of  the  hos- 
pital), and  by  the  lecturer.  The  nuns  were  examined  sepa- 
rately, and  were  more  severely  interrogated  than  the  ser- 
vants, but  the  same  set  of  lectures  served  for  the  instruction 
of  all. 

Since  this  first  attempt  there  have  been  two  other  sets 
of  lectures  on  the  same  lines,  followed  by  examination ;  the 
nun-novices  and  the  new  servant  nurses  (with  those  who 
failed  to  pass  the  first  year's  exam.)  were  the  audience. 

In  Florence,  two  years  later,  the  same  attempt  at 
educating  the  staff  technically  was  made  at  the  general 
hospital,  Santa  Maria  Nuova.  The  lectures  were  excellent, 
and  the  servant  nurses,  male  and  female,  were  obliged  to 
attend ;  but  the  nuns  declined  to  be  present,  with  the  excep- 
tion of  the  superintending  sister  and  one  companion  sister, 
who  assisted  at  the  lectures  to  see  that  the  servant  nurses 
conducted  themselves  with  propriety.     These  lectures  have 


466  International  Congress  of  Nurses 

not  been  repeated,  probably  because  the  superintendent  saw 
the  uselessness  of  ^iving^  instruction  to  nuns  who  refused  to 
receive  it,  and  to  nurses  who  were  unable  to  remember 
what  they  heard,  havingf  no  text-books  sufficiently  elemen- 
tary for  their  comprehension,  and  being  too  illiterate  to  take 
any  sort  of  notes.  I  have  not  been  able  to  ascertain  what 
curriculum  is  adopted  in  the  convents  of  nursing  orders. 
It  certainly  varies  greatly.  In  that  of  the  Roman  hospital 
above  mentioned,  I  heard  that  it  was  originally  very  com- 
prehensive but  has  not  kept  pace  with  the  times.  The  sis- 
ters of  this  order  (founded  by  the  Princess  Doria,  grand- 
mother to  the  present  prince)  are  unusually  proficient  in 
everything  that  is  not  prohibited.  They  make  beds,  change 
linen,  make  poultices,  wash  (to  a  certain  extent),  and  comb 
their  patients,  as  well  as  give  hypodermics  and  medicines, 
prepare  surgical  dressings,  instruments,  etc.  The  elder  sis- 
ters are  even  proficient  at  bleeding,  but  they  are  not  allowed 
to  give  vaginal  douches,  pass  the  catheter,  or  be  present 
at  childbirth. 

But  few  religious  orders  receive  as  thorough  a  training 
as  this.  The  majority  of  nuns  confine  themselves  (by  the 
rules  of  their  order)  to  receiving  doctors'  orders,  adminis- 
tering food  and  medicine,  and  maintaining  order  and  disci- 
phne  in  the  wards.  All  bed  making,  moving  of  patients, 
bathing,  poulticing,  care  of  skin,  etc.,  etc.,  is  left  for  the 
servant  nurses. 

To  resume,  an  attempt  has  been  made  in  the  last  six  or 
seven  years  by  some  hospital  directors  to  improve  the  exist- 
ing staffs  of  nurses,  nuns,  and  servants.  Their  success  has 
been  small ;  first,  because  the  nuns  (with  the  exception  of 
the  Doria  Order  in  Rome)  refuse  the  instruction  offered, 
and  secondly,  because  the  servant  nurses  are  really  only  fit 
to  be  servants,  too  ignorant  to  remember  or  comprehend 
what  is  taught. 

Nuns  and  servant  nurses  have  no  term  of  service. 
Religious  novices  and  new  servants  learn  by  working  with 
their  respective  seniors  in  the  wards.    The  nuns  remain  at 


Council  Reports  467 

work  so  long  as  the  Mother  Superior  orders,  unless  the 
doctors  are  dissatisfied,  when  the  Mother  Superior  removes 
them. 

The  servant  nurses  remain  as  long  as  they  like,  if  they 
give  satisfaction  to  doctors  and  nuns.  Some  remain  only  a 
few  months,  others  many  years ;  but  the  pay  is  always  the 
same ;  there  are  no  higher  posts  to  be  obtained  (male  nurses 
excepted ;  they  may  become  corporals  at  higher  wages), 

NAMES^OF  ORGANIZATIONS  OF  CERTIFICATED  NURSES. 

The  first  successful  attempt  at  organizing  a  training 
school  for  nurses  was  made  in  Rome  in  1896.  Marchesa 
Olga  Guiccioli,  whose  husband  was  then  prefetto,  consented 
to  act  as  president  of  a  small  committee  composed  of  Italian 
ladies  and  three  professors.  One  of  the  latter  was  superin- 
tendent of  the  hospital  for  women  and  in  favor  of  progress. 
He  gave  permission  for  pupil  nurses  to  work  in  the  wards 
of  his  hospital,  under  my  guidance  and  instruction.  Six 
pupils  were  found,  and  the  nuns  were  asked  by  the  president 
to  co-operate  with  me  in  training  them  for  private  nurses, 
the  superintendent  at  the  same  time  informing  them  that 
he  had  given  his  consent.  The  pupils  attended  the  same  set 
of  lectures  as  were  given  to  nuns  and  servants,  but  received 
repetition  lessons  from  me.  They  passed  satisfactorily,  and 
the  second  year  received  lectures  by  themselves  from  a 
house  doctor  on  medical  and  surgical  pathology,  and  a  set 
on  gynaecology,  and  one  on  nursing,  from  myself.  The 
pupils  were  examined  by  the  professor  and  the  lecturers, 
before  the  members  of  the  committee,  and  received  certifi- 
cates with  a  higher  or  lower  number  of  marks,  according  to 
their  merits. 

A  similar  school  was  started  in  Naples  the  following 
year,  January,  1897,  and  has  continued  under  the  presidency 
of  the  Principessa  Strongoli,  and  the  superintendence  of 
Miss  Grace  Baxter,  graduate  of  the  Johns  Hopkins  Hos- 
pital, Baltimore. 


468  International  Congress  of  Nurses 

In  the  autumn  of  1897,  I  started  a  school  in  Florence 
(the  committee  findino:  it  desirable  that  I  should  leave  the 
Roman  pupils  from  time  to  time  with  the  nuns,  to  enlist 
their  sympathy  with  the  work).  For  two  years  I  continued 
to  train  pupils  in  Rome  and  Florence,  dividing  the  year 
between  the  two  schools,  the  nuns  and  the  doctors  directing 
and  instructing  the  pupils  during  my  absence  from  one  or 
other  hospital. 

In  the  winter  of  1899  the  direction  of  the  Roman  school 
was  confided  to  an  Italian  nurse,  one  of  Miss  Baxter's  first 
graduates.    She  continues  on  exactly  the  same  lines. 

In  1900  I  handed  over  the  teachings  of  the  Florentine 
pupils  to  another  of  Miss  Baxter's  graduates,  and  we  hope 
that  a  third  of  her  nurses  will  be  called  to  Milan  to  direct 
a  school  which  a  purely  Italian  committee  is  attempting  to 
found. 

So  far,  these  "  Scuole  per  Infirmiere  "  are  quite  efforts 
of  philanthropy,  and  the  funds  are  provided  by  the  com- 
mittees, the  certificate  not  legalized,  no  official  post  given 
by  the  administration  to  either  "  Direttrice  "  or  pupils ;  but 
an  official  permission  for  the  existence  of  the  school,  and  for 
partial  provision  of  the  pupils'  meals  is  voted  by  the  admin- 
istration. 

The  regulations  of  all  three  schools,  Roman,  Neapol- 
itan, and  Florentine  are  the  same.  Two  years'  training  in 
hospital  wards,  medical  and  surgical ;  the  usual  subjects 
taught  theoretically  by  doctors,  and  both  theoretically  and 
practically  by  the  direttrice.  Examinations  each  year  by 
doctors  and  direttrice. 

On  receiving  certificates  the  nurses  either  live  in  their 
own  homes  and  are  sent  by  the  direttrice  to  private  cases, 
or  (in  Naples)  put  by  her  in  the  hospital  wards,  and  paid 
by  the  committee,  the  hospital  giving  them  only  food. 

Our  nurses  are  sent  to  private  cases  with  a  printed  reg- 
ulation, claiming  the  usual  consideration  for  them  (not  to 
eat  with  servants,  seven  hours  for  sleep,  two  for  recreation), 
and  a  fee  of  five  francs  for  non-infectious  cases,  seven  or 


Council  Reports  469 

eight  for  infectious  ones.  The  committee  reserves  the  right 
to  make  special  terms  for  long  cases,  etc.  Tlie  certificated 
nurses  of  Rome,  Naples,  and  Florence  have  slowly  gained 
the  confidence  of  the  doctors  and  the  public,  and  the  demand 
for  their  services  steadily  increases. 

N.  B.  The  Villa  Regina  Natalia  is  a  cosmopolitan 
nursing  home  recently  started  in  Florence  with  the  approval 
and  co-operation  of  the  Florentine  clinical  professors.  It 
has  an  English  superintendent  (Miss  Turton),  and  the  pa- 
tients have  the  option  of  being  nursed  by  English  or  Italian 
nurses. 


The  Blue  Cross  Society. 

GRACE  BAXTER, 

Directress  of  Nurses,  Ospedalo  Clinico,  Na|)les. 


The  Bine  Cross  (Croce  Azzurra)  Society  for  the  Pro- 
motion of  Nnrsing  in  Naples  was  founded  in  1895  under  the 
patronage  of  Her  Excellency  the  Princess  of  Strongoli,  one 
of  the  court  ladies  of  H.  M.  Queen  Margaret  of  Italy,  and 
a  woman  of  progressive  views,  wide  culture  and  untiring 
activity  where  the  well-being  and  improvement  of  her 
country  are  concerned.  The  princess  became  interested  in 
the  nursing  question  through  Miss  Amy  Turton,  an  English 
woman,  who  is  perhaps  the  chief  advocate  in  favor  of  the 
nursing  movement  in  Italy,  and  who  has  made  this  form  of 
pioneer  work  her  life  object. 

These  two  able  allies  had  the  good  fortune  to  find  in 
Naples  a  hospital  director  who  realized  that  "all  the  good 
qualities  of  the  heart  cannot  compensate  for  professional  in- 
efficiency." But  in  spite  of  Professor  Paolucci's  approval 
a  hard  fight  was  sustained  before  leave  could  be  got  from 
the  administration  of  the  clinical  hospital  in  Naples  to  allow 
the  pupil  nurses  to  work  in  the  wards,  and  about  six  months 
elapsed  before  the  princess  was  successful  in  her  efforts, 
and  I  was  invited  to  take  charge  of  the  training  school  about 
to  be  opened. 

It  was  at  first  difficult  to  find  the  right  type  of  woman 

as  probationer.    No  nice  young  girl  had  ever  been  allowed 

to  be  in  such  constant  contact  with  doctors,  unless  assum- 
470 


Council  Reports  471 

ing-  the  nun's  habit,  and  in  fact,  the  first  elements  who  served 
merely  to  open  a  way  for  the  others  were  all  subsequently 
eliminated.  It  is  significant  of  the  difficulties  we  encoun- 
tered that  out  of  eighty,  between  applicants  and  probationers 
I  have  been  able  to  retain  only  twenty,  nine  of  whom  are 
still  in  training. 

The  first  set  of  girls  being  collected,  the  president 
arranged  with  our  house  doctors  (five  out  of  six  of  whom 
are  professors  of  the  university)  for  the  several  sets  of  lec- 
tures, which  were  anatomy,  physiology,  hygiene  for  the  first 
year,  gynaecology  and  obstetrics,  surgical  and  medical  nurs- 
ing, and  materia  medica  for  the  second  year.  These  lectures 
are  excellent  in  every  way. 

The  nurses  began  to  work  in  the  wards  under  protest 
from  all,  at  first,  but  we  made  progress  steadily  if  slowly.  I 
hardly  know  myself,  when  we  began  to  be  the  recognized 
factor  that  we  are  now,  in  spite  of  many  difficulties  still 
existing.  In  the  surgical  clinic  of  Prof.  d'Antona  (the  most 
prominent  surgeon  of  the  south)  the  nurses  have  entire 
charge  of  the  female  patients  night  and  day,  prepare  for 
rounds,  do  all  the  sterilizing  and  most  of  the  preparation  of 
patients  for  operation.  In  Prof.  Salvia's  clinic  my  senior 
nurse  does  all  the  operating  room  work,  but  of  course  this 
is  exceptional  in  a  country  where  the  doctors  are  accus- 
tomed to  do  all  such  things  themselves. 

In  the  medical  wards,  whereas  I  had  formerly  to  fight 
for  any  little  bit  of  practice,  it  has  become  a  recognized  fact 
that  the  nurse  in  charge  receives  the  doctors'  orders,  and 
executes  them,  being  responsible  for  all  that  concerns  the 
nursing  of  the  patients,  except  of  course  at  night,  for  there 
being  no  nurses'  home,  and  no  food  to  be  had  on  the  prem- 
ises, one  has  to  make  many  concessions. 

Two  of  the  pupil  nurses  besides  their  work  in  the  wards 
are  taking  a  special  course  in  massage. 

With  regard  to  the  graduates,  except  for  two  or  three 
months  during  the  slack  season,  they  have  been  continually 
in  demand,  and  in  fact  the  calls  for  private  nurses  have  been 
in  excess  of  the  supply. 


472  International  Congress  of  Nurses 

Four  of  our  graduates  have  had  permanent  positions 
offered  them :  one  to  start  a  training  school  on  our  own 
lines  in  Rome,  where  she  is  g-etting  on  well,  though  labor- 
ing under  the  same  difficulties  as  myself;  two  more  are  in  a 
sanitorium  in  Florence,  a  fourth  is  chief  masseuse  in  the 
medical  polyclinic  under  Prof.  Castellino.  Italians  are  very 
quick  to  learn,  very  deft-handed,  good-mannered,  patient, 
capable  of  long  hours  and  needing  comparatively  rarely 
nourishment.  In  fact  they  require  training  in  care  of  their 
own  health,  being  apt  to  neglect  exercise  and  defer  taking 
food,  so  that  the  quality  of  their  w'ork  consequently  suffers. 

In  September,  1900,  the  Blue  Cross  obtained  the  silver 
medal  at  the  exhibition  of  hygiene  held  in  this  city,  together 
with  a  "  Diploma  d'onore." 


Nursing  in  New  Zealand. 

GRACE  NEILL, 

Assistant  Inspector  Hospitals  and  Asylums,  Wellington;  Councillor  International 

Council  of  Nurses. 


In  reply  to  your  circular  of  February  28,  asking  for 
information  as  to  the  curriculum  of  training  adopted  in  our 
principal  hospitals :  We  have  four  hospitals  with  beds 
between  one  and  two  hundred,  Wellington,  Christchurch, 
Auckland  and  Dunedin,  and  these  are  our  principal  training 
schools.  Each  has  a  staflf  of  from  forty  to  sixty  nurses. 
Three  have  a  strict  eight  hour  duty  alike  for  night  and  day 
nurses,  the  fourth  nine  for  day  and  ten  for  night  nurses. 

1.  The  course  is  three  years. 

The  subjects  taught  are :  Anatomy,  physiology,  case- 
taking,  urine  testing,  all  that  pertains  to  operating  room, 
names  of  instruments,  care  of  them,  aseptic  theories,  prac- 
tical nursing  and  ward  work. 

2.  There  is  no  organization  of  certificated  nurses. 
Steps  are  being  taken  in  the  direction  of  state  registration 
for  hospital  trained  nurses.* 


*Since  this  report  was  sent  New  Zealand  has  passed  a  law  requiring  state 
examination  and  registration. 


473 


Nursing  in  Sweden, 


THE  CURRICULUM  OF  TRAINING  ADOPTED  AT  THE 
PRINCIPAL  HOSPITALS, 

SopHiAHKMMKT,  Stockholm,  Sweden. 


(a)  term  of  nurses'  service. 

The  probationer  comes  to  Sophiahemmet  [Sophia  Hos- 
pital] for  one  month  on  trial.  If  necessary  the  month  may 
be  prolonged  to  two  months. 

The  probationer  is  trained  for  a  year  and  a  half  at 
Sophiahemmet  or  some  other  nursing  institution.  At  the 
end  of  this  time  the  probationer  is  either  approved  and  pro- 
moted staff  of  a  ward  on  trial,  or  her  time  of  training  is  pro- 
longed, or  she  is  considered  unsuitable  as  a  nurse  at  Sophia- 
hemmet. 

Half  a  year  as  staff  nurse  on  trial  completes  the  train- 
ing, and,  if  approved  by  the  authorities,  the  probationer  is 
then  received  as  a  trained  nurse. 

During  the  third  year  the  nurse  remains  in  the  service 
of  Sophiahemmet,  to  which  she  has  bound  herself  by  sign- 
ing: a  formal  agreement. 
474 


Council  Reports  475 

This  agreement  may  be  renewed  after  the  third  year  if 
the  nurse  desires  to  remain  in  the  service  of  Sophiahemmet. 

(b)  subjects  taught  theoretically  and 

practically. 

The  theoretical  instruction  is  carried  on  by  lectures 
during  the  whole  of  the  first  year,  -with  the  exception  of  a 
month  or  six  weeks  in  summer,  at,  the  rate  of  twO'  lectures  a 
week.  They  are  given  by  medical  men,  and  comprise  anat- 
omy, surgery,  hygiene  and  materia  medica.  A  nurse  also 
gives  classes  on  the  theory  of  nursing,  and  a  pastor  a  bible- 
reading  once  a  week  during  the  first  six  months  of  training. 

The  practical  training  comprises  general  domestic  work 
as  well  as  cooking  for  those  who  are  able  to  do  it  or  have 
not  learned  it  already.  It  also  consists  of  training  in  a  gen- 
eral hospital,  as  well  as  an  ophthalmic,  gynaecological, 
lying-in  and  contagioys  hospital.  Bandaging  is  also  prac- 
ticed, and  in  the  theater  the  nurse  learns  how  to  give  an 
anesthetic. 


THE  NURSING  INSTITUTION  OF  THE  RED  CROSS 

SOCIETY, 

Kammakargatan  66,  Stockholm, 
(a)  term   of   nurses'    SERVICE. 

A  training  of  twelve  months  is  given  to  the  probationer, 
of  which  the  first  is  considered  as  a  month  of  trial.  If  the 
probationer  has  had  no  preparatory  experience  of  regular 
hospital  work  the  lady  superintendent  may  require  of  her 
an  extra  month  on  trial. 

During  the  first  six  months  the  probationer  is  trained 
at  some  general  hospital,  and  during  the  remaining  six 
months  at  some  nursing  institution  indicated  by  the  com- 
mittee of  the  Red  Cross  Society.  The  probationer  who  has 
completed  her  training  is  received  as  staf¥  nurse  on  trial  on 


476  International  Congress  of  Nurses 

the  understanding  that  she  is  to  work  for  the  society  at 
the  private  hospital  of  the  Red  Cross  Society,  or  in  some 
other  way.  for  six  months,  after  which  time,  if  she  is  con- 
sidered suitable,  the  lady  superintendent  notifies  this  to  the 
committee,  and  she  is  received  as  a  trained  nurse  by  the 
Swedish  Society  of  the  Red  Cross. 

The  nurse  who  is  thus  received  must  agree  to  serve, 
if  the  Red  Cross  Society's  nursing  institution  should 
demand  it,  during  the  two  years  following  either  in  some 
nursing  institution  or  on  the  private  stafY  of  the  Red  Cross. 

At  the  same  time  it  is  expected  of  every  nurse  in  the 
service  of  the  Red  Cross  Society  that  she  shall  be  on  duty 
if  the  country  should  become  engaged  in  war  or  be  threat- 
ened with  war,  wherever  and  whenever  the  committee 
requires  her  to  go. 

(b)  subjects  taught  theoretically  and 

practically. 

Lectures  are  given  twice  a  week  during  the  first  six 
months  of  training  by  a  medical  man.  These  lectures  com- 
prise medical  and  surgical  nursing,  anatomy,  physiology, 
and  pathology,  as  well  as  general  nursing. 

The  practical  work  consists  of  general  medical  and 
surgical  ward  work,  theater  work,  and  the  giving  of  anaes- 
thetics, as  well  as  out-patient  work  and  the  preparation  of 
bandages.  No  practical  work,  such  as  the  sweeping  of  the 
wards,  cooking  or  washing  up,  is  expected  of  the  proba- 
tioners, who  give  the  whole  of  their  time  to  the  nursing. 


THE  GENERAL  HOSPITAL  OF  SABBATSBERG, 
Stockholm. 

(a)  the  period  of  training  for  nurses. 

Consists  of  six  months'  work  as  probationers,  properly 
speaking,  and  six  months'  work  as  assistant  nurses  of  the 
hospital. 


Council  Reports  477 

(b)  subjects  taught   theoretically  and 

practically. 

These  are  exactly  the  same  as  those  of  the  Red  Cross 
nurses. 

THE  DEACO>rESS  INSTITUTION  AT  ERSTA, 
Stockholm. 

(a)  time    of    TRAINING    FOR    THE    DEACONESSES. 

The  deaconess  is  trained  during  twelve  months  at  the 
hospital  of  the  institution.  The  deaconess  works  eight 
months  as  probationer,  four  of  which  are  spent  in  the  vari- 
ous wards  and  three  in  the  theater,  the  out-patient  depart- 
ment and  the  dispensary,  and  one  month  on  night  duty. 
The  last  four  months  she  returns  to  the  wards  as  staflE  nurse, 
and  helps  to  train  the  new  probationers. 

(b)  subjects  taught  theoretically  and 

practically. 

The  chief  part  of  the  instruction  is  practical,  and 
includes  dispensing  and  the  giving  of  anaesthetics.  The 
medical  man  of  the  hospital  of  the  institution  on  his  daily 
rounds  also  points  out  to  the  deaconess  all  points  worthy 
of  notice,  explains  the  different  symptoms  of  disease  and 
the  reason  why  the  nurse  is  expected  to  do  a  cenain  thing 
to  the  patient. 

The  theoretical  instruction,  properlv  speaking,  is  given 
in  regular  courses  of  lectures  during  six  months  of  the  year 
by  the  medical  man  at  the  head  of  the  hospital,  who  lec- 
tures an  hour  a  week  on  medical  and  surgical  nursing,  and 
gives  extra  lectures  as  well  on  special  subjects  such  as 
tubercular  diseases,  epidemics,  etc..  or  on  any  subject 
requested  by  the  nurses  themselves.  The  resident  doctor 
also  lectures  an  hour  a  week  on  anatomy  and  physiology-, 
and  gives  some  notions  of  patholog>-  as  well.  He  also 
makes  a  post-mortem  examination  for  the  benefit  of  the 


478  International  Congress  of  Nurses 

deaconess  probationers,  and  exhibits  to  them  the  principal 

organs  of  the  body. 

The  deaconess  at  the  head  of  the  hospital  also  lectures 
to  the  probationers  on  general  nursing  and  other  kindred 
subjects,  and  superintends  the  practice  of  bandaging. 

On  entering  the  hospital  for  her  year  of  training  the 
deaconess  has  already  learned  housework,  cooking,  baking 
and  sewing,  so  that  she  only  needs  to  apply  herself  to  nurs- 
ing, properly  speaking. 


11. 

(a)  names  and  organizations  of  certificated  nurses. 

(a)  Though,  properly  speaking,  not  organizations  of 
certified  nurses,  the  above  mentioned  institutions — Sophia- 
hemmet,  the  Red  Cross  Society,  Sabbatsberg  and  Ersta— 
act  as  such  by  providing  nursing  work,  each  for  its  own 
nurses,  the  Red  Cross  Society,  in  addition  to  this,  when 
short  of  their  own  workers,  giving  cases  to  others  as  well, 
at  the  rate  of  a  fee  of  one  crown  for  each  separate  case. 


THE  FREDRIKA  BREMER  SOCIETY, 
Drottninggatan  54,  Stockholm. 

(b)    the  constitution  and  regulations  of  such 

societies. 

Every  Swedish  woman  of  unblameable  conduct,  and 
under  the  age  of  42,  who  has  made  nursing  her  profession, 
and  has  had  a  course  of  theoretical  and  practical  training  at 
a  hospital  during  a  period  of  at  least  six  months,  and  has 
done  good  duty  as  ward  nurse  in  a  general  hospital  as  well 
during  a  period  of  at  least  six  months,  is  entitled  to  be 
entered  on  the  lists  of  the  Fredrika  Bremer  Society. 


Council  Reports  479 

Upon  special  approval  by  the  committee  of  the  society 
in  every  special  case  such  nurses  as  well  may  be  entered, 
who  have  had  no  regular  theoretical  and  practical  training, 
but  are  able  to  prove  by  certificate  from  a  medical  man  that 
they  have  served  as  ward  nurses  at  a  general  hospital  for 
the  period  of  at  least  two  years,  as  well  as  by  such  who  can 
prove  by  certificate  from  a  medical  man  that  they  have  been 
engaged  in  private  nursing  to  his  satisfaction  during  a 
period  of  at  least  six  months. 

Nurses  pay  a  fee  of  one  crown  on  being  entered  on  the 
lists  of  the  society. 

If  permanent  work  is  procured  through  the  society  the 
fee  of  one  per  cent,  of  the  salary  of  the  first  year  is  paid. 


Nursing  in  Tasmania 

J.   D.   MILNE, 
Lady  Superintendent  General  Hospital,  Launceston. 


There  are  training  schools  in  the  general  hospitals  at 
Hobart  and  Launceston. 

The  Hobart  Hospital  gives  a  three  years'  course  with 
certificate  of  training  in  medical  and  surgical  nursing.  No 
test  examinations  are  held.  The  Launceston  Hospital  gives 
a  three  years'  course,  with  nursing  of  the  insane,  medical^ 
surgical,  and  infectious  training. 

There  are  courses  of  lectures,  twenty  each  year,  given 
by  physicians  and  by  the  matron,  on  the  theory  of  the  above 
subjects. 

There  is  no  organization  among  nurses.  We  are  pre- 
paring to  form  a  branch  of  the  Australasian  Nurses'  Asso- 
ciation. 


480 


Nursing  in  the  United  States. 

LAVmiA  L.  DOCK, 

Secretary  Internationa,!  Council  of  Nur.ses. 


The  plan  of  nursing  organization  of  the  old  world  under 
which  nurses  may  remain  an  integral  part  of  their  hospital 
schools,  was  not  continued  in  the  United  States  when  the 
first  training  schools  for  nurses  were  founded  at  the  Belle- 
vue,  Massachusetts  General,  and  New  Haven  hospitals, 
although  the  general  plan  of  ward  work  and  teaching  fol- 
lowed the  English  plan  to  a  certain  extent,  as  the  first  super- 
intendent of  the  Bellevue  school,  who  inaugurated  the 
reforms  there,  was  an  English  nurse.  Sister  Helen. 

The  managers  no  doubt  felt  that  this  system,  with  its 
old  age  pensions  and  provisions  for  sickness,  would  not 
work  well  in  a  democracy,  and  it  was  not  attempted,  the  only 
approach  to  it  being  the  "  school  registry."  This  meant,  sim- 
ply, that  patients  and  doctors  sent  to  the  school  to  call  for 
private  duty  nurses,  and  that  the  school  sent  such  graduates 
as  it  could  guarantee.  In  some  schools  this  work  was  car- 
ried on  solely  as  a  service  to  the  public,  no  charge  being 
made  to  the  patient  or  to  the  nurse  for  the  accommoda- 
tion ;  in  other  schools  a  yearly  fee  was  paid  by  the  nurse 
for  the  benefit  to  herself,  and  in  such  cases  as  the  number 
of  nurses  increased  the  registry  work  became  a  definite 
business,  with  some  profit  accruing  to  the  school  which 
managed  thus.  As  this  financial  profit  may,  in  a  large  reg- 
istry, be  considerable,  it  has  proved  that  the  "  registry  " 

481 


482  International  Congress  of  Nurses 

question  has  become  one  of  the  troublesome  ones  in  the 
progress  of  American  nurses.     Lay  people  of  unfit  quali- 
fications have  attempted  to  make  money  in  this  way,  and 
have  often  succeeded,  owing  to  the  professional  pre-occu- 
pation  of  the  nurse,  and  also  to  her  indolence  in  dealinji 
with  such  affairs.     It  is  still  the  case  that  in  some  places 
nurses  pay  not  only  a  fee,  but  also  a  percentage  of  their 
earnings,  to  these  registries,  which  are  really  only  intelli- 
gence offices.     Such  conditions  are  obviously  worse  than 
the  "  Sisterhood  "  out  of  which  the  nurses  developed,  their 
redeeming  feature  being  their  transitoriness.     Most  firmly 
fixed  of  these  commercially  managed  registries  are  certain 
ones  controlled  by  the  medical  societies  of  the  towns  in 
which  they  belong;  they  are  known  to  be  very  profitable, 
but  no  nurse  has  a  voice,  and  all  information  is  refused,  even 
the  addresses  of  nurses  belonging  to  them  being,  in  one  well 
known  instance,  refused  to  any  one  for  any  purpose.     The 
management  is  entirely  that  of  a  private  monopoly,  and 
intimidation  is  used  in  the  control  of  the  nurses,  as  they  are 
told  that  if  they  register  elsewhere  the  physicians  will  not 
employ  them.    Such  registries  are  evidently  a  distinct  draw- 
back to  the  social  and  civic  development  of  the  nurse,  and 
are  quite  indefensible  from  the  standpoint  of  medical  pro- 
fessional ethics,  being  only  explainable  from  the  point  of 
view  of  pure  commercialism.     Organization  among  nurses 
is  definitely  discouraged  by  the  policy  of  such  registries, 
as  is  shown  by  the  actual  facts,  and  on  the  other  hand,  the 
only  attempts  made  at  national  pension  funds,  supported  by 
charity,  for  nurses,  are  in  places  dominated  by  these  med- 
ical registries. 

The  most  advanced  and  best  organized  nurses  in  the 
United  States  either  belong  to  their  school  registries,  or 
conduct  their  own,  and  the  latter  on  the  whole  are  the 
most  numerous. 

The  first  registries  attempted  no  further  control  of  the 
nurse  personally  than  to  make  a  few  rules  as  to  her  business 
obligations.  They,  however,  fixed  a  price  for  her  services, 
which  should  have  been  accepted  as  a  minimum  or  average, 


Council  Reports  483 

leaving  a  fair  amount  of  flexibility  for  the  maximum,  but 
which  has  instead  unfortunately  become  established  as  a 
definite  quantity,  so  that  now,  when  from  various  causes 
there  is  a  tendency  to  lower  the  rates  of  payment,  the  whole 
force  of  custom  is  against  the  nurse  raising  them  under 
proper  circumstances,  as  the  doctors  do. 

It  will  be  seen  that  in  their  early  history  American 
nurses  retained  certain  disadvantages  from  an  old  system, 
and  lost  its  advantages.  Their  lives  at  this  period  were 
isolated,  their  modes  of  living  dreary,  and  their  outlook  lim- 
ited. However,  they  were  at  least  free  to  strike  out  for 
themselves,  and  the  first  associations  were  of  graduates  of 
one  school  banded  together  in  "  alumnae  societies,"  Bellevue 
the  first  in  1889,  and  the  Illinois  Training  School  next  in 
1890.  As  a  rule,  in  this  stage,  the  graduates  of  one  school 
only  knew  one  another,  and  were  not  acquainted  with  those 
of  other  schools. 

In  1895  the  first  statistical  report  of  such  associations 
was  made  (Training  School  Alumnae  Associations;  paper 
read  by  Miss  S.  F.  Palmer,  before  the  American  Society 
of  Supermtendents  of  Training  Schools  for  Nurses,  1895). 

Among  164  schools  in  the  United  States,  thirty-one 
societies  were  reported,  of  which  two  were  religious  guilds, 
four  were  general  clubs,  admitting  graduates  from  all  good 
schools,  and  twenty-five  were  alumnae  associations.  These 
societies  were  quite  small,  not  by  any  means  including  all 
the  graduates  who  were  eligible,  the  majority  of  whom 
seemed  indifferent  anc'  preferred  their  isolation,  so  that  the 
work  of  the  comparatively  few  public  spirited  ones  was 
most  arduous  and  often  discouraging. 

Objects  were:  the  elevation  of  the  profession  (in  a 
vague  and  general  way),  social  meetings,  and  sick  benefit 
funds,  and  the  latter  have  been  well  managed  and  successful. 

In  1893  the  Society  of  Superintendents  of  Training 
Schools  for  Nurses  was  formed  at  the  World's  Fair,  a  con- 
gress of  nurses  having  been  assembled  at  the  suggestion 
of  Mrs.  Fenwick,  the  present  head  of  our  International 
Council.     Mrs.  Robb,  then  Miss  Hampton,  was  chairman 


484  International  Congress  of  Nurses 

of  the  congress,  and  she,  with  other  leading  spirits  of  the 
nursing  world,  already  had  plans  for  a  national  association 
of  graduate  nurses,  which  was  later  organized  under  the 
name  "  Associated  Alumna?  of  the  United  States  and  Can- 
ada." (Third  Annual  Report  of  the  Society  of  Superintend- 
ents of  Training  Schools  for  Nurses.  Annual  Reports  of 
the  Nurses'  Associated  Alumnae.)  With  the  necessity  of 
incorporating  this  association,  the  name  was  altered  later, 
leaving  out  Canada,  and  the  Canadian  nurses  were  asked  to 
organize  separately. 

The  Canadian  members  remain  in  the  superintendents' 
society,  as  this  is  not  incorporated. 

Since  then  organization  has  taken  on  fresh  energy, 
and  has  advanced  rapidly,  so  that  we  may  consider  we  are 
but  just  noting  our  earliest  stages  and  are  developing  along 
the  Hnes  of  a  vast,  comprehensive,  and  closely  related  yet 
individually  free  group  of  associations. 

State  associations  are  now  arising,  New  York,  Vir- 
ginia, and  Illinois  having  formed  their  outlines.  Such  soci- 
eties will  necessarily  be  more  liberal  and  inclusive  in  their 
membership  qualifications  than  any  we  have  yet  had,  and 
their  peculiar  work  will  be  to  influence  the  future  status  of 
nursing  education  by  suitable  legislation,  restrictive  on  some 
lines  and  constructive  on  others.* 

In  this  task  the  magazine  established  in  October,  1900, 
under  the  control  of  the  National  Alumnae  is  expected  to 
prove  a  potent  factor.  The  last  step  in  organization  was  the 
affiliation  of  the  National  Alumnae  and  the  society  of 
superintendents  under  the  name  "  American  Federation  of 
Nurses,"  in  April,  1901.  Under  this  form  and  title  we  have 
joined  the  National  Council  of  Women,  and  this  is  the  body 
which  is  ready  to  enter  the  International  Council  of  Nurses. 
We  have  left  this  federation  free  to  develop  as  the  state 
societies  come  into  membership  with  the  national,  or  as 
other  groups  of  nurses  may  desire  to  enter  it. 


♦This  work  is  now  definitely  beginning  in  New  York  StatP  where  a  registra 
tion  bill  is  in  preparation  for  the  Legislature  of  1902-3. 


Council  Reports  485 

NURSING   EDUCATION    IN    THE   UNITED  STATES. 

Nursing  education  stands  thus : — Preliminary  require- 
ments :  No  fixed  uniformity  of  preliminary  examination  or 
definite  requirements  has  been  reached,  further  than  by  gen- 
eral opinion.  While  a  good  common  education  is  agreed 
upon,  we  have  not  put  upon  paper  what  this  should  be, 
exactly.*  Refinement  and  accustomedness  to  nice  ways  of 
living  are  sought;  ultimately,  the  personal  character  and 
capability  of  the  pupil  nurse  are  put  ahead  of  technical 
attainments. 

PERIOD  OF  TRAINING. 

Two  years  was  the  almost  universal  course  of  our 
schools  at  first ;  yet  our  school  boards  tacitly  assumed  that 
the  training  was  finished  in  the  first  year,  as  in  the  second 
the  pupils  were  made  head  nurses,  and  also  sent  out  to  pri- 
vate cases. 

As  time  went  on  the  latter  custom  died  away,  so  that 
two  years'  work  in  the  hospital  wards  has  been  the  rule 
throughout  the  country  for  the  past  ten  years;  since  1894 
some  seventy  odd  hospitals  have  adopted  the  three  years' 
course  ;f  this  will  no  doubt  extend  to  all  hospitals  as  the 
advantages  are  great.  In  the  third  year  there  is  now  a 
tendency  to  return  to  undergraduate  private  duty,  which 
must  be  looked  upon,  on  the  whole,  as  an  injurious  ten- 
dency, which  we  must  hope  will  prove  temporary,  as  in  the 
two  years'  course. 

COURSE   OF   THEORETICAL   STUDY. 

The  generally  accepted  course  of  study  covers  hygiene, 
anatomy,  physiology,  materia  medica,  principles  of  bacteri- 
ology, asepsis  and  antisepsis,  and  medical,  surgical,  gynaeco- 
logical and  obstetrical  nursing.  Lectures  on  massage,  spe- 
cialties   (such   as   eye,   ear,   etc.)   are   included,   and   some 


*Some  of  our  best  schools  require  a  High  School  education,  but  this  is  by  no 
means  universal. 

tSince  the  preparation  of  this  article  the  number  has  risen  to  over  a  hundred 


486  International  Congress  of  Nurses 

attempt  at  teaching  cooking  for  the  sick  is  quite  general, 
though  not  always  as  well  worked  out  as  might  be. 

While  lectures  are  universally  of  excellent  quality,  the 
criticism  may  be  made  that  we  have  too  many.  From  the 
practical  standpoint  this  is  the  least  useful  form  of  study  for 

the  pupil. 

Teaching  by  demonstration,  and  the  laboratory  method, 
or  having  the  pupil  carefully  watched  in  the  performance 
of  each  duty,  is  less  well  developed,  though  this  method  is 
constantly  extending. 

PRACTICAL    WORK. 

Practical  work  follows  the  theoretical,  as  far  as  material 
allows.  Besides  the  medical,  surgical,  gynaecological,  and 
operation  room  ser^'ices,  all  schools  of  good  grade  provide 
obstetrical  training  for  their  pupils,  either  in  their  own 
wards  or  in  some  special  hospital.  Such  training  includes 
examination  of  patient,  and  delivery  of  uncomplicated  cases, 
only  in  order  that  the  nurse  may  be  prepared  to  meet  emer- 
gencies. The  nurse  never  takes  up  midwifery  work,  and 
in  private  practice  or  district  nursing  goes  only  to  obstetric 
cases  where  a  doctor  is  in  attendance.  The  midwife  ques- 
tion, so  distracting  in  other  countries,  does  not  exist  here 
as  a  complication  to  nurses,  and  is  consequently  a  question 
that  we  may  leave  to  the  medical  profession  to  settle.  Mid- 
wives  are  only  in  practice  among  the  foreign  population  of 
our  large  cities,  and  the  rising  generation  learns  to  call  foi 
a  doctor,  either  man  or  woman. 

The  largest  hospitals  usually  give  their  pupils  training 
in  contagious  diseases,  but  the  smaller  ones  seldom ;  we 
mean  scarlet  fever,  diphtheria,  erysipelas,  measles,  etc. 
Typhoid  fever  is  received  in  all  general  hospitals. 

Few  hospitals  give  nervous  or  insane  training.  Com- 
paratively few  yet  give  a  really  thorough-going  practical 
training  in  cooking  and  housewifery,  though  almost  all 
make  some  eflfort  in  this  direction,  and  so  far  we  have  but 
one  definite  preliminary  course,  where  a  six  months'  train- 
ing is  given  in  these  two  branches,  and  where  the  whole 


Council  Reports  487 

foundation  of  practical  work  is  laid  before  the  pupil  is  sent 
into  the  wards.* 

Examinations  are  held  at  the  end  of  each  year  and  are 
mostly  written,  conducted  by  the  medical  and  surgical  staflf. 

POST-GRADUATE    WORK. 

There  are  several  good  post-graduate  courses  available 
in  special  hospitals,  but  no  general  hospital  has  yet  planned 
out  a  systematic  post-graduate  course. 

STATE   EXAMINATIONS    AND   REGISTRATION. 

As  yet  we  have  nothing  of  the  kind ;  but  the  state  soci- 
eties will  begin  work  in  this  direction  within  the  next  year 
or  two.  There  are  at  present  various  quack  schools  in 
existence,  which  are  managed  by  doctors,  who,  presumably, 
do  not  realize  what  they  are  doing;  one  is  in  Philadelphia, 
one  in  Chicago,  the  third  and  least  pretentious  in  New  York 
City.  In  the  far  West  a  number  of  imitators  are  arising. 
To  attack  these  and  bring  about  a  complete  general  standard 
of  training,  by  dint  of  urging  co-operation  instead  of  the 
extreme  individualism  now  practiced  by  hospitals,  will  be 
the  work  of  the  future  for  our  organizations,  and  will  fully 
occupy  their  time  for  the  rest  of  the  twentieth  century. 


♦The  Johns  Hopkins  Hospital.  Since  writing  this  article  excellent  prepara- 
tory courses  on  this  plan  have  been  established  in  the  New  York  City  and  Metro- 
politan Hospitals,  New  York. 


End  of  Part  II. 


APPENDIX 


Nursing  in  Norway. 

DR.  L.  GVAM. 

(Sent  thruuKh  courtesy  uf  Mi»i)  (iina  Krug.) 


Norwegian  nurses  are  trained  by  different  societies,  as: 

The  Deaconess  organizations, 

The  Norwegian  Woman's  Sanitary  Society, 

The  Society  of  the  Red  Cross, 

The  Sister  House  of  Bethania. 

While  in  training  the  nurses  reside  at  the  hospital 
home.  They  have  courses  in  Anatomy  and  Physiology, 
with  lectures  by  the  physicians.  Practical  training  is  given 
in  the  wards  of  the  different  hospitals.  Special  training  is 
given  in  Surgery  and  bandaging  in  private  clinics  ami 
classes.  The  time  of  training  is  never  less  than  one  year. 
The  hours  of  duty  are  from  7  a.  m.  to  8  p.  m.,  with  ample 
time  off  for  meals  and  rest. 

When  a  nurse  is  on  night  duty  she  has  as  a  rule  the 
next  day  to  sleep. 

After  being  in  the  hospital  for  some  time  nurses  are 
paid  for  their  services.  Upon  graduation  they  usually 
receive  their  calls  from  the  hospital,  looking  upon  it  as  a 
home.  As  a  rule  they  remain  in  the  service  of  the  hospital 
for  at  least  five  years. 

488 


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