Buffalo Township (part 4 of 6)

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 autotoxemia. 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 melancholia. Ill-health, business or love troubles, grief, overwork, 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 understood. Knives, scissors, cords, door-keys, anything that could be made an agent in ending one's life, should l)e care- 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 melancholia, 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 hypnotics 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 physical 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 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 practized, and the tendency to play " with the mind diseased," to make the patient express his delusions for the amusement 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 forget 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.

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 itmay follow prolonged physical or mental strain, such as may attend the vicissitudes of war or some intense fright or 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, melancholia, and mania.

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 perhaps. All of the faculties are impaired, - memory, reasoning, 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 commit serious assault or crime with no subsequent recollection.

" Circular insanity " is characterized by alternating conditions 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 institutions, to prevent suicide in a melancholic stage and extravagance 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 progressive 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, emaciation, failure of memory, emotional irritability, and exaggerated delusions. These delusions are of a most extravagant 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 untidy, 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

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 accomplish. 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 characterized 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 classification. 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 eccentricities of conduct as he grows older. He becomes suspicious 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 questioning he may explain that he refers to some secret society or some religious or political organization or some important person whom he may have known about, all of whom are working to harm him. These ideas are of vast proportions and show great system and organization. Not infrequently 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 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 ushering 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 paranoics we find the names of John Brown and Guiteau. The so-called cranks of this description really create a dangerous element in society. They are apt to make some homicidal assaults in consequence of their delusions, but if confined 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 useful 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 possible, 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 gaining in favor. It is applicable to cases both of mania, melancholia, 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 appliances, which are most complex and can be used in many ways, but will endeavor to give instead a few practical

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 irritability 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 bathtub, 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 prolonged 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 physician'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.

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 treatment 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 understanding and appreciation of their condition, I am highly gratified.*

*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.

Mrs. Chapman

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 considered 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 anyone 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 necessary 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 methodical instruction to raise the general standard of hospital nursing and attain the highest efficiency, but with the exception of the efforts made by the Medico-Psychological Association of Great Britain and Ireland and some isolated schemes at two or three asylums very little has been inaugurated 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.'^

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 encouragement 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 without 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 training 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 hospital 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 completeness of their qualifications. Can they regard themselves as 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 mistook ' 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 recognized. 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 essential 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 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 conjoined 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 requiring 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 universally recognized in the asylums of the United Kingdom. The medical stafif in every important asylum deliver lectures and give demonstrations on the subject of the nursing of the sick. The syllabus of the Medico-Psychological Association 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 institutions 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 care of the sick and the management of helpless and bedridden 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 epileptic, excited, violent and suicidal patients, and the care of those requiring diversion and companionship ; also management 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 Scotland, 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 building 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 troublesome patient was sent down to the ' Separates.' Now, the actual effect of gathering together such an explosive element as this was that each patient made the other worse.

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 arrangements, 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 without 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."

Britain give cause for some reflection. The continual changing 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 opportunities 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 nursing of the mentally afflicted, it can only be by maintaining 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 Commissioners in Lunacy, and the attention of the ruling authorities 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 guaranteed pension for service in the county asylums* of England 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 breakdown unless the motto of " tnens sana in cor pore sano" is 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 maintain 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 interests 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 employment 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 direction.

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 especially 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 instruction, 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 reasons 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.

not realized its own responsibilities, and there is no encouragement 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 feeling 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 complete appliances are of no good without the proper attendants. 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 advancement 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 conveniences 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.

The first and important object is- the recovery of the patient, as is the case in the general hospital, for these people 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 considerable 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 determination to succeed and patience to wait.

Thursday

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 discuss 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.

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 profession all over the world are considering the questions of registration, preliminary training, teachers' courses, uniformity of education, combinations of small or special hospitals, 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 question 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 reasons 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.

Private nurses have been in the past a most selfabsorbed and indifferent body of women, thinking only of their personal aims and interests, caring: little for their fellows. Those who have held hospital positions, especially hospital superintendents, being in constant touch with nursing 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 concerns 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 hanging in the balance, and that the influence of each person counts in the final turning of the scale.

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 inspiration 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 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.

Linda Richards

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.

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 reference - 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; hydrotherapy, 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.

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 demonstrations 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.

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 creating 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 different 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 narrow 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 connection 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 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 instruction 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 responsibility.

And if nurses trained under the conditions just mentioned were given such a burden of responsibility, what shall be said of the nurse who graduates with the numberless 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 responsibilities. 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 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."

Mary E. Patton

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 incorporation, 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 number 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).

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. Graduates, 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 graduating. No alarm on that score need be felt since one-third of the nurses engaged in San Francisco cannot be recognized as trained and graduated nurses, yet they are kept constantly employed and receive the same remuneration as nurses orraduated from the best schools.

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 nongraduate 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 frequently 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 difficult, 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.

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 boarding 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 accouchements, 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 highest 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 essential 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.

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 attractions, 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 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, commanding 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 profession. 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 sanguine 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 journalism - 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 Britain 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 interesting 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 sympathy and admiration.

Mrs. Margaret L. Rogers

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 dormant in our natures to develop and helps us in time to overcome 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.

fulness unknown to her sister of a few years past. However, 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 ministration. 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. Unfortunately, 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 contagious cases. In the smaller cities prices range from eighteen 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

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 registers 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 progressive, 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 obstetrical " 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 institutions 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

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 hospital, and this coming in contact with other minds who are absorbed in social, religious, political, scientific and philanthropic subjects stimulates our own intellects and, of necessity, widens our mental horizon. Of course, we occasionally 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 continuing your researches. You not only see how the other half lives, but you actually live like them.

The greatest disadvantage is the absence of home life, the never being able to make settled plans. Rooming conditions 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

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."

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 children ; she keeps the home together for the husband and the children. I should like to say more of my interest in all this work.

Ada M. Carr

Published in the Trained Nurse for the year 1895 and in the " Report of the Meeting of the Society of Superintendents in 1897," are two papers by Miss Diana Kimber, presenting- 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 suggestion 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 permission 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 twentyfive 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.

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 visiting 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 population 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 starting such work should call on all the doctors within a reasonable 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 families in this way would be educative influences as well as actual workers, reaching and teaching a portion of the community 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 Association 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 undertaken by one who has failed in other branches, or who is looking for an easy way of making profitable use of her profession. The best of the inexhaustible array of qualifications 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.

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, probably, but one peculiarly applicable here. The main difficulty 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 proportions large enough to pay expenses. Not only this, but if a nurse has painstakingly gathered together a sufficient practice 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 establishment 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 obtaming a fund sufficient to pay the necessary expenses of the

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 general 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 undertaken 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 personally 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 purposely avoided discussion of rates paid for services. This is a question upon which we ourselves have not as yet arrived at an entirely satisfactory conclusion, and we found it necessary 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 contributed 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 England. 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 outlying 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 superintendent 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.

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 nursing. 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 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 nursing, 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 Philadelphia, 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

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 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 Gymnasium and Institute of Mechanotherapy.

I believe Miss Colby is a graduate of the Posse. In both schools every subject is taught which bears on massage. 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 qualifications entitling them to claim such consideration.

There are some of the teachers who probably antedate 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 gymnastics were introduced into the public schools of fifty-two cities and towns.

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 gymnasiums mentioned obtain their practice by doing charity work in the dispensaries and hospitals under the supervision of teachers and doctors.

Friday Morning

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.

Amy Hughes

On receiving the kind invitation to read a paper on " The Origin, Growth, and Present Status of District Nursing in England " my first feeling was that it would be difficult 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 Conference 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 cannot fail to be impressed by the rapid growth of this branch of nursing and the way it has spread over the kingdom.

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 qualifications 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."

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 distributing 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»successful change was introduced by placing the nurses in district homes under fully trained superintendents, instead of allowing 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 Liverpool 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 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 quarterday." 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 follows :