Buffalo Township (part 5 of 6)

The g-reat departure in this scheme was the employment of nurses drawn from the ranks of educated women, due to the suggestion of the first superintendent, Miss Florence Lees, now Mrs. Dacre Craven.

In her own words: ''There were several grovmds for this decision, and these were chiefly that, in nursing the poor in their own homes, nurses were placed in positions of greater responsibility in carrying out doctors' orders than in hospitals ; that women of education would be more capable of exercising such responsibility ; that the vocation would attract women anxious for independent employment, and a corps of nurses recruited altogether among educated women would have a greater influence over the patients, and by their higher social position would tend to raise the whole body of professional nurses in the consideration of the public."'

Such an innovation was not considered practical by those most interested in the movement, even Miss Nightingale saying, '' I don't believe you will find it answer, but try it, try it for a year." Tlie result, however, fully justified the experiment, and the high standard thus established has exercised its influence over the whole development of the work.

It was resolved to adopt the principle that the nurses should live together in homes under trained district superintendents, and a central home was established. From this center several homes were rapidly started, and by 1887 there were nine established in London on these lines, besides several in the country.

Nurses," to consolidate the wofk of district nursing and to raise it from the sphere of individual efifort to become a great national institution. Queen Victoria realized the great benefits arising from this work, which had been quietly making its way among the humblest of her subjects. With that keen insight into the merits of a debated question which was one of her attributes, she decided to devote the bulk of the subscription raised by the women of England as a gift to her Majesty on the occasion of the celebration of the fiftieth year of her reign, some seventy thousand pounds, to this comparatively unknown object, rather than to bestow it on some already established charity.

In order to obtain the interest and support of local institutions, of which there were many already existing in the large towns, conditions of affiliation with the Queen's Institute were drawn up. These were at once accepted by the Liverpool association, with others, and now there are comparatively few nursing organizations which are not in touch with the institute. A trained nurse was also appointed as general inspector of nursing.

Mention must be made of what was done in Scotland, Wales, and Ireland, as well as in England, to estimate rightly the growth of district nursing.

In Scotland an energetic council at once started a central home in Edinburgh, and the system extended rapidly to Glasgow, Dundee, Aberdeen, and other places.

In Wales a Central Home was established in Cardiff, and the work has spread slowly but steadily over the principality. It is found necessary to employ Welsh-speaking nurses in the rural districts, as that language is still spoken far more generally than is supposed, especially among the older people. However, in spite of this difficulty, the work is spreading from one district to another.

In Ireland the initiation of district nursing was slower, and it was necessary to establish two training homes in Dublin, one for Roman Catholic, the other for Protestant nurses. But its progress has been uninterrupted, and the Queen's nurses are in every part of the country, even in the desolate island of Achil, where, to quote the words of the superintendent : '' The people are nursed under conditions inconceivable except to those who have seen them. There is only one nurse to the eight thousand inhabitants, and Achil is twenty-five miles long and fifteen miles broad."

In 1888, almost at the same time as the Queen's Institute was taking form and beginning its great work in the towns and large centers of the United Kingdom, the Rural Nursing Association was started very quietly in a corner of the Western Midlands, by a small association of ladies and gentlemen, to provide nurses and midwives for the sick poor, with whose homes and needs they were personally familiar. From the first the Rural Nursing Association determined against the system of sending nurses to live in their patient's homes, the committee believing the poor have neither accommodation nor means sufficient to enable them to lodge and feed, as well as partially to pay for the services of a competent nurse. A high standard of training was required, and the nurse's services were extended over as large an area as possible by means of a pony or donkey cart, and later by the ubiquitous bicycle. This association was soon afifiliated to the Queen's Institute, in 1891, and in 1897 was amalgamated entirely with it.

The question of providing nurses for the scattered villages and hamlets in thinly populated areas where work is intermittent and distances great is a difficult one.

This special branch of district nursing is as yet in its very infancy, and much has to be done in the future to find a practical and satisfactory way of working the rural districts.

The system of county associations is an efifort to meet the special difficulties in these districts. Trustworthy, responsible women are selected for training, especially as midwives and maternity nurses, and return to work in their own neighborhood under the supervision of superintendents who are fully qualified Queen's nurses. Valuable help in the training of these village nurses is given by the Plaistow " Maternity and District Nursing Association," whose work lies in the densely populated region of " London over the border."

There are now five of these county associations in England, employing over one hundred and ten village nurses, three in Scotland, and one in Wales.

The history of the growth of district nursing would be incomplete without mentioning the work done by other institutions whose methods are different from those of the Queen's Institute. Among these are the " Biblewomen Nurses," founded by Mr. Ranyard, whose work lies in several districts of London.

In the country the system of the Ockley Nursing Association was formed to provide women with some knowledge of nursing to live in the home where there is illness, and perform the household duties as well as attend to the patient. The promoters claim this method answers the question of cottage nursing, especially in cases where the wife and mother is laid aside, but it has opened up other difficulties, some of them unforeseen, which show the true solution of this problem has yet to be found.

It is interesting to notice how the standard of training has risen with the growth of the work. Much still remains to be done in this direction, especially in the case of village nurses, but every year finds public opinion more enlightened on this point.

The great difficulty lies in the necessity of providing inexpensive nurses in poor districts in the country, especially in agricultural parts, and also in the ignorance still lingering among those who supply the nurses that good and sufficient training is a necessity.

When a patient and room are clean and tidy and food and medicine regularly administered, there is a tendency to think all that is necessary has been accomplished.

It requires special knowledge to discriminate, on the one hand, between the woman who is disciplined to absolute obedience in carrying out orders, who is trained in the best possible way of performing the details of nursing service, each apparently trivial, yet so important in their sum total, and the woman who, however capable and w-illing, yet lacks the knowledge that in unreserved obedience to orders lies her raison d'etre, who is prone to suggest remedies of her own, and is full of prejudices and superstitions which her short experience of training has failed to eradicate.

The Queen's Institute has formulated the highest standard of training and experience hitherto attained. Its nurses must have a minimum of two years' training in an approved hospital or infirmary, followed by practical experience of district work under trained supervision. In many cases special training in a maternity hospital is also required. Nurses who wish to join the institute, having already been trained, are required to fulfil these conditions.

The institute aims at securing the services of educated women, believing them to exercise a beneficial influence over the patients and their friends. Tact, courtesy, and refinement are necessary to deal successfully with the ignorance and prejudices of the poor, whether in town or country.

I would lay special stress on the necessity of some practical experience of the work under trained supervision. It is not to supplement deficiencies in previous training, but to enable the nurse to apply her nursing knowledge to the best possible advantage under such altered conditions. She is saved the necessity of buying her own experience at the expense of her patients and herself if she profits by that already gained by others. Training is found desirable for those who engage in philanthropic works, such as settlements, etc., and it is equally necessary in this branch of nursing.

ment to its " Counsels of Perfection " by its adequate system of inspection by trained nurses. There is no suspicion of interference with local effort, no curtailing of personal energy, but simply a regular visitation of every affiliated association from the city with its forty to fifty nurses and their superintendents in various homes, to the solitary nurse in the remoteness of the country. Each association keeps its reports, etc., on the same lines, and from each the same standard of work is required.

The inspector comes as a friend alike to the nurse and the committee, visiting the cases, seeing the books, and helping by her experience and advice to smooth over any little difficulties that may arise. It is the evenness of the work thus obtained that is making it a success by securing a uniform standard throughout the land.

1. That the nurses shall not be almoners. Their work is nursing, and nursing only, though they are encouraged to bring deserving cases to the notice of the proper local authorities, and in every way thus to secure necessary sickcomforts for their patients.

These two rules lift the work of Queen's nurses above suspicion of almsgiving and proselytizing. At the same time the nurses are left free to bring their patients in touch with the local agencies that make for good.

That this spirit does obtain in many localities is proved by the fact that in a quarry district in Wales two nurses are supported, and there is a balance of over three hundred pounds in the bank, which, with the exception of about fifty pounds, is contributed annually by the workmen, and in another district the nurse is practically supported by halfcrown yearly subscriptions.

Nor is this all. By interestins;- the well-to-do of a district in their poorer neighbors, the Queen's nurses form a valuable link in the chain of union between capital and labor.

There are excellent systems by which sick and convalescent diets, warm garments, and convalescent aid in giving change of air, etc., are brought to those who by no fault of their own are unable to obtain these extra necessaries when sickness is among them. Among these may be mentioned the Scottish Needlework Guild, the Bedford Sick Dinners Society, the London Convalescent Dinners Aid Society, and many others.

Then also the nurses can bring the homes of the patients to the notice of the local sanitary authorities, thus insuring cleanliness, a proper water supply, and other simple but essential necessities for healthy surroundings. Tliough forbidden to proselytize, their influence is the open door by which those who seek the moral welfare of their poorer brethren may obtain an entrance where other means have proved unavailing.

The personal interest of her late Majesty in this work has invested it with universal interest. This interest showed itself in many ways. The Council of the Queen's Institute was appointed by her, the names of all nurses were submitted to her before they were placed on the roll of "Queen's Nurses," and even the details of the nurses' uniforms were chosen by her. Those present at the gathering of " Queen's Nurses " at Windsor Castle on July 2, 1896, will not easily forget the enthusiasm kindled by the gracious, kindly words addressed to them by one who ever proved herself a woman full of sympathy with those in trouble and distress. "I am very much pleased to see my nurses here today, and to hear of the good work they are doing. I am sure they will continue to do it." Her Majesty's special recognition of the " Queen's Nurses " in Ireland, on the occasion of her visit there, was deeply appreciated and gave a direct stimulus to the work in that country. Her last message to the council was given on February 24, 1900, and runs thus :

" Her Majesty desires me to express the sincere satisfaction with which she learns that the institute continues to prosper and is so much appreciated." This interest is continued by the present Queen. In July this year some hundreds of Queen's nurses received their badges from the hands of Queen Alexandra, thus establishing her identity with the institute as its present head.

Queen Alexandra's first address to the Jubilee nurses at Marlborough House, July 3, 1901, his Majesty the King being present, with her Royal Highness Princess Victoria, her Royal Highness Princess Louise (Duchess of Argyll), and Prince Albert and Princess Victoria of Cornwall and York, was as follows :

" It gives me the greatest pleasure to receive you all here today, and it is most gratifying to me to be able to carry on the noble work founded by our dearly beloved and never-to-be-forgotten Queen Victoria. I have always taken the most sincere interest in nurses and nursing, a^nd it affords me heartfelt satisfaction to be associated in your labors of love and charity.

" I can, indeed, imagine no better or holier calling than that in which you are engaged of tending the poor and suffering in their own homes in the hour of their greatest need. I shall follow with interest the reports of the institute, and shall anxiously note the progress which you are making from year to year.

A special effort is being made by means of the " Queen's Commemoration Fund " to raise sufficient funds to endow the " Queen's Institute " in perpetuity, so that it may keep pace with the ever-growing demands on its resources.

Having thus outlined the history of district nursing from one nurse in 1859 to the great work of mercy which has spread over the whole land, I would only add that it is not systems alone, admirable as they can be, which bring success, it is the work of each individual nurse which makes the work what it is ; it is not nursing alone, though that should be as perfect and well-disciplined as training and experience can insure, but moral influence, to which there is practically no limit.

The influence of a good nurse remains after her nursing services are ended. It is the opportunities given by district nursing that make it so important and so responsible. Nurses who grasp the inner meaning of their work have few limits to their powers of usefulness. They nurse the homes as well as the patients; they give valuable objectlessons in the practical details of nursing, simple sickcookery, cleanliness, etc., thus helping their fellow-women to be less helpless and hopeless when sickness invades the home.

They can advocate self-restraint, thrift, and household economics ; they can give valuable advice in the dieting and management of infants and young children, so helping to strengthen the sinews of the nation - " As the child is, so the man is " - and the simple hygiene of proper feeding taught in language " understanded by the people " means the future welfare of its sons.

Thus every earnest district nurse who sows the seeds of thrift, self-help, self-restraint, self-respect in the round of daily work is a helper, however obscure her path of duty, in solving the social problems of the day.

" I do not think that there is any human being who may be as useful as a district nurse if she is helpful without being interfering. May God bless and keep the district nurses here in a body is the fervent prayer of Florence Nightingale."

Johanna Von Wagner

Because so little is done to teach people in their homes how to better their condition, I am grateful for the opportunity to speak to you about my work in the tenement .houses as Sanitary Inspector.

While not every city has a tenement house problem, every city has a housing problem, and it is the duty of the Board of Health to see that the homes of the working-classes are made at least healthful.

Organizations of public-spirited citizens should be formed, which, after acquainting themselves with local conditions, would revise building and sanitary codes and see to the enforcement of laws. Already this is done in New York, too late, to be sure, to eradicate the evil which a tenement house is, - it is here to stay, - but an organization of men and women can do much to improve the homes of the poor. To be able to cope with such a problem, a thorough knowledge of existing conditions is essential. A house-to-house inspection will reveal, aside from existing facts, the wants and needs of the people.

Twenty-five years ago the Chief of the Department of Health in Glasgow realized the need of women inspectors in connection with the Health Department, as only women could deal with women efifectively, and ever since that time the work has been done there by women health visitors, as they are called.

The larger cities in England have followed the example of Glasgow, and there are several sanitary institutes in England, where men and women are graduated to do the work of sanitary inspectors.

Several years ago in Chicago the Board of Health appointed women to inspect factories, sweat-shops, and tenement houses, and five years ago Yonkers first had a woman tenement house inspector, and it is almost two years since I was regularly appointed by the Board of Health, and I can say without vanity that in no city is the work done so effectively as in Yonkers, because the qualifications which a nurse has enable her to do better than the average woman.

Landlords, politicians (members), and employes of the Board of Health all fought against the woman inspector, and but for the members of the board and one brave woman, Miss Mary Marshal Butler, president of the Civic League and Woman's Institute, who overcame all opposition, the appointment would not have been successful. After passing civil-service examination the appointment was made, and in February, 1900, I commenced my duties as an employe of the Board of Health, as formerly I had done the work of the Civic League.

I will pass over the difficult task of working with the same people that fought so hard not to have me, and will only say that those same men are my best friends at present, and agree with the secretary, who said : " How did we ever get along without our woman inspector ?"

The Health Officer said that he would like to have one woman inspector to every twenty-five thousand inhabitants. The president of the board said that the moral influence of a woman inspector in the department had been very beneficial. All this I say to show that the work has been appreciated by friend and foe and the need demonstrated.

In onr beautiful Terrace City such bad conditions were revealed as to shock the whole community. Tenement houses in Yonkers compare favorably with those elsewhere ; we have all the evils of New York slums, only on a smaller scale. As a large proportion of our population lives in tenement houses, the need for improvement was great.

The average tenement house has deprived the people of light, air, and privacy ; it has dark bedrooms, with sometimes the worse than useless air-shaft opening into a common hall, - a hall which, on entering, sends a chill through one's bones ; as a rule it is not ventilated, is very dark, unventilated toilets open into it, and damp cellar air and odors from cooking and toilets which greet one on entering are over-powering.

I begin my work in the cellar, much to the surprise of the people, who have neglected to clean it and stored all sorts of rubbish away in it. As a rule, that most important part of the house has also been neglected by the builder, light and air have not been provided for, and after a rainstorm it is very often flooded.

Right here I begin to inspect the plumbing, and unless the house is new the pipes or construction are generally defective. I have to get a light to do this. When I go to the upper floors the living rooms over the cellar are damp also and very unhealthy. The tenants have malaria, rheumatism, and tuberculosis, children have bronchitis and do not thrive, and even up to the top floor all complain of ill-health.

I go through the rooms, seeing to proper ventilation, cleanliness, need of repair, and over-crowding; follow the plumbing up to the roof ; see to the condition of the roof, fire-escape, hall, toilets, and then inspect the yard, receptacles for garbage, pulley-line poles, cleanliness, and drainage.

every day reveals new misery : the poor little children locked up in basements while both parents work in the mill ; the household of the habitual drinking-woman, the neglected, vermin-covered children, six in one bed, poorly covered, looking like little skeletons ; the consumptive's room, where bedding, floor, and furniture are covered with expectoration, where the children play on the floor, and wife and baby share the same bed ; where out of fear a contagious patient is hidden in a closet, and out of kindness a paralytic or any other bedridden patient is left alone for a month or two, never bathed on body or bed-linen changed so as to cause no pain, and where bed-sores from shoulders to heels have become gangrenous.

It was in a small rear house where I knocked, perceiving the odor far ofT. " No admittance " was on the face of the woman who was supposed to care for the patient, but I managed to gain entrance, and only by the exercise of the greatest tact was I allowed to see the poor, sick woman and care for her - until death. The horrors of that sick-room I shall never forget, and I hope and pray there may never be another case like it.

The teachings of Christ are forgotten. We do not know how our neighbors live, and we would rather not know. Not charity, but justice is needed.

The greedy landlord who looks for twelve per cent, has to be dealt with. Model tenement houses can be erected on a paying financial basis. They have proved a success wherever they have been built, and aside from the fact that they returned between five and six per cent., they have provided healthy homes for people of small means.

While they are a great blessing, the greater need is to put existing houses in sanitary condition and prevent badly constructed houses from being erected, and here it is where a woman inspector does the most good.

tive and boxed-in plumbing, filth and disease, damp cellars, over-crowding, - all these things are nuisances and reported, and in a given time remedied, which may be from a day to a month. If the owner is not willing or able to do it, the Board of Health has the work done. The law is that one toilet shall be provided for every two families, but I think that each family should have its own water-closet, and to have it not in a dark corner, but open to the external air, is just as important.

Fire-escapes should receive better attention; the straight, narrow ladders without the platform will hardly answer for most people - not to speak of the absence of fire-escapes in so many houses.

" Thank God ! some one is going around that knows something," an old Irishwoman said. They have had missionaries to look after their spiritual welfare, but no one to help them bear their burden and improve their lot in life.

After explaining to them how to care for and feed babies, the women will say, " Why did we not know this before ?" A birth and a death every year and sickness and undertakers' bills in many cases cause the poor man's poverty. Ignorance of the common laws of health and unhealthy homes and food are undoubtedly causes of the prevalence of the drink habit.

Much can be done towards the prevention of the spread of contagious diseases, and especially tuberculosis, not only by reporting the fumigation of rooms and enforcing strict cleanliness and isolation, but by providing sputum-cups for the poor which may be burned after use, and after death from this disease fumigation and thorough cleaning before another family moves in.

With the teachings given to the people how to protect themselves and how to improve their ways of living there should go the enforcement of laws governing landlords and agents and an awakening of the social conscience at large, and I confess that is the hardest part of my work. Being a woman and having no vote, poHtics do not influence my reports. Cellars have to be cleaned and whitewashed, carpets removed from stairs, halls ventilated and cleaned, rooms whitewashed or painted, papers removed where possible, air-shafts and skylights have to be made to open to admit air, roofs repaired, and plumbing looked after. The characteristics of the dififerent nationalities have to be dealt with, and each watched acordingly.

When commencing to inspect a street the children carry the news that the Health Board is around, which is the signal for general house-cleaning.

When I try to have people move out of unhealthy houses, I hear always the same remark, " We can't find good rooms," and the requests for me to find rooms are numerous indeed and difficult to comply with.

After revealing conditions in Yonkers, some good citizens remodelled old houses and put them in sanitary condition, and it has proved a financial success. There is a woman rent-collector who collects weekly, which is safer for the landlord and easier for the tenant, and with it goes a supervision which is of great value to both. With improved homes we have better health and better citizenship, which is all-important to a nation.

While far from being good, conditions are greatly improved in Yonkers. Better school attendance in winter, decreased immorality rate, especially among children, and greater cleanliness are among the visible results from the work done so far.

What larger field of usefulness could we wish for than to go from house to house and give the people the benefit of our knowledge of sanitation, hygiene, and domestic science ?

Let there be well-trained women to do this work. As Dr. Benjamin Lee, president of the State Board of Health, said: "Women are born sanitarians, and make better teachers; besides, they attend to detail work, and I would say the work is essentially one for women. No matter what the condition of the house, a woman is admitted because she will understand, when a man cannot enter, and very often the remark is made, ' I am so glad it is a woman this time.' "

After inspecting rooms, closets, and bedding, I am made acquainted with the sorrows, the wants, and sometimes the joys of the family, and I seldom leave without having given advice or help, or put them in the way to help themselves. The invitation to call again soon or spend Sunday with the family shows that the visit has been appreciated.

The field for usefulness is large, and the work fills one's life to the utmost. While it is hard to bear so many people's burdens, the thought that this work is a step in the right direction gives new courage and hope.

I hope to live long enough to see more cities take up this work. Only those women who love the people and will work for public service and not personal gain should take it up. It is the hardest work I have ever done, and it requires courage and a good deal of faith to enter into all places.

It is the true mission of the Board of Health to take up this work, and may there be enough public-spirited men and women in every city to see to it that the large class of working-people at least have healthy homes.

My Dear Miss Mclsaac: In view of Mrs. Von Wagner's attendance at the International Council of Nurses, I would like to give my testimony to the efficiency of her work in Yonkers, and emphasize the desirability of inducing nurses to consider the official inspection of tenement houses as a field for their professional ability.

In visiting Health Departments here and abroad with reference to the work of women Sanitary Inspectors, it has impressed me that, other qualifications being equal, the knowledge possessed by a trained nurse who had the ability to impart it would be of great additional benefit in accomplishing permanent good results, and I am hoping that as the work is taken up in this country more nurses may be found who will fit themselves for the position.

In Chicago, where six women Tenement and Factory Inspectors are employed by the Health Department, the duties of the women are about the same as those prescribed for men. I believe the duties of the woman inspector should include the instructive work, and that to her should be given certain duties differentiating her work from that of a general Sanitary Inspector.

There are comparatively few places in this country where women are employed in connection with Health Boards, but it is our earnest hope that an impetus may be given to the idea through this Nurses' Council, and that a great and practical purpose may be reached through the paper to be read and discussed at your meeting.

Harriet Fulmer

In the characteristics and aim of district or visitingnurse work there may be said to be " nothing new." It is a branch of nursing so well known to our profession that it is needless to dwell upon the purpose of the work.

subject of this paper was given such complete and detailed description by women of years of experience in the work that it would be time misspent to take up that which was so well covered then.

The facts and data of the present paper are largely statistical, and intended only as historical of the subject, and simply to show the growth of the work in various parts of the country in the last ten years. This philanthropy has now taken its place among the organized charities of modern times. Only a few years ago quite unknown, it is now operated successfully in almost every section of the country. It is a charity of which its promoters never tire ; and noting its success and present steady growth, one often wonders why its initiatory stages had such uphill work.

From the first year of its existence, when Fliedner at Kaiserswerth sent trained women into the homes of the poor, and WilHam Rathbone, M.P., saw the need of it in England, the character of this work has not changed ; it still carries out the first param^ount principles of giving skilled nursing to the poor and the small wage earner in their own homes, and to use such methods of instruction as teach them to care for their own sick and to carry out the right observance of sanitary laws.

The pioneers of this work had untold dif^culties to overcome, for by no means did their efforts meet with warm support. Medical men were suspicious that these organizations sending out skilled nursing help would interfere with their practice, and many of the laity felt it an innovation not practical, and that the poor could get on the same as they always had done.

It is needless to say that the newer and younger associations have none of these difficulties, for physicians everywhere now are not only the instigators in new localities, but are always the staunchest supporters of the scheme. The development of the work in America has not been a bed of roses, and with all its seeming success in this country we are years behind Germany and England - where 140 trained women are employed in America 800 are employed in England.

A woman prominent in philanthropic work says, " There is no form of organized philanthropy that demonstrates more clearly the present progressive ideas of social and economic work among the less fortunate," and a student of social problems has well said, " It is the safest and most practical means of bridging the gulf which lies between the classes and the masses."

In continuance I should like to put in short form a few general suggestions to those who are contemplating forming this work in new localities. I shall give below a combi-

First comes the need, then the presentation of the project at a general meeting of the pubhc, to which should be asked prominent physicians of the locality to give it endorsement. Then comes the mode of support, usually best by voluntary contributions in small sums from the public rather than by individuals, as then one may feel that they have a special claim upon the service. If operated upon the nonsectarian principle, you then have the support of all the religious elements, but are confined to no particular one. Cases should be taken and received from all sources.

An ideal system may have many adjuncts operating in connection with it. First is the Flower Mission, or the Diet Kitchen, or the Convalescent Home in some near-by country place, to which patients may be sent. Then in the district must be the ever-ready and well-filled loan press, containing every known article that may be used for the comfort and well-being of the sick. The most successful organizations go upon the principle that the best results are shown to the people when the professional nurse gives the service assisted by the most modern sick-room appliances rather than by make-shifts, and yet always giving information as to what articles may be used in the place of the modern ones.

In adopting a name for any new society doing this work we would advise the use of the term " Visiting Nursing " as being more comprehensive than " District Nursing," and as less cumbersome than " Instructive Visiting Nursing."

The woman employed to do this work should be a graduate of a large general training school, for she may care for many cases without meeting the doctor in attendance, and she should know how to meet every emergency.

In starting the work in a new locality preference should he given a nurse who has had experience in district nursnig work, and the rules for the admission of additional nurses to the society should be most severe. She should be required at the end of a certain time to give a complete sketch of how she would meet all the various emergencies that might arise in the work ; how she would send a case to the hospital, secure ambulance service, report cases for relief sent to various institutions, to summer homes, etc.

The next step in the right direction in the work in this country will be to establish a special post-graduate course for all nurses desiring to take up visiting nurse work, for too many nurses come into the work having little idea as to the requirements and demands ; and during the period of perhaps their first year, the organizations suffer by their lack of knowledge.

In the near future the Chicago association will establish a course of this kind where graduates from general training schools may take up and learn the work in a systematic way.

I may go on now with some of the general requirements and rules for nurses. She is employed actively from eight to ten hours per day, and if she is doing the work in the right spirit any additional service required is done without comment. The salaries throughout the country paid to these workers seem to be about uniform, forty-five dollars, fifty dollars, and sixty dollars per month, according to the time they remain in the work.

Not all organizations wear a regulation uniform, but those who do are to be commended. For in many instances its moral effect upon the patient is constantly apparent, and there is nothing that can take the place of the plain gingham dress and the neat coat and hat of subdued color.

In most organizations the visits of the nurse average from eight to twelve in one day, varying from a half hour to two hours each. A typical day in a large society is as follows : The first visit was to a dying consumptive, where a bath and clean linen were given ; the second, a bath and alcohol sponge to a man with typhoid ; third, dressing a varicose ulcer on the leg of a woman who makes wrappers all day long at forty cents per dozen ; fifth, baths and clean linen to a family of five, all ill with typhoid ; reported case to Board of Health, arranged to send patients to hospital; two-hours' work required; sixth, maternity case: bathed mother and babe; received ten cents for service; seventh, took temperature and pulse of convalescing typhoid; arranged to send patient to country ; eighth, bath to mother and daughter, both ill with consumption ; new case, reported to Health Board ; ninth, very sick babe; gave bath, furnished milk, and instructed mother; sent free doctor; tenth, man with locomotor ataxia ; gave bath, made application to send patient to Home for Incurables.

Who, in hearing this, will say that it was not a day full of satisfaction to the nurse, of practical benefit to the patients, and of infinite credit to the supporters of the work who make it possible that the relief may be given?

In the regular systematizing of the work we do not find it an easy matter, the very character of the work itself bringing about rather a hap-hazard way of doing it, for the very reason that no day's work can be arranged prior to its beginning.

The records kept and the reports made for filing require much skill and patience, and take a large part of the nurse's time and labor. Most of the women employed find their greatest hardship in the exposure to the elements, rain, cold, and snow in winter, and the beating rays of the sun in summer, for the visiting nurse goes on her rounds, rain or shine, heat or cold, and often the nurse herself, after a very hard day's labor, wonders why she is willing to give up a lucrative and half-comfortable private practice for this life of exposure and self-denial. But nearly every woman now doing the work finds that indescribable something which is akin to fascination in being the instrument that brings so much comfort to those who, without her, would have naught, and at the same time combining with her labor self-support and independence.

Miss Brent, of Brooklyn, N. Y., in a clever paper on district nursing read before the Congress of Charities in 1894, sums up the work of the nurse as follows : " It is a hand-to-hand struggle against disease, poverty, and dirt.

against the most pitiful ignorance and inherited prejudice. The nurse finds her routine work widely different from hospital or private duty. . . . Beginning each morning her daily rovmd of visits, carrying with her in as small a compass as possible all the necessary appliances for her work, she goes from house to house, from one patient to another, mounting flight after flight of stairs, - for it is a curious but true fact that tenement house patients always live on the top floor of a very tall house, - here making beds, preparing nourishment, giving sponge-baths, there bandaging a leg or applying a dressing, but in all cases carrying out the doctor's orders, leaving notes of temperature and general condition, being certain the medicine will be properly administered, and seeing that proper nourishment is provided whether by direct orders or otherwise, - in short, doing everything in her power for her patient's comfort."

" Let me gladly add myself as a witness of experience here to the great blessings which the trained district nurse has brought to the sick poor.

" If you are able to maintain the high standard for your nurses which you have done, and succeed in attracting good young women to enter upon the work, there can be no doubt that it will get on and prosper. DifBculties and trials there must be, but with so noble an object, it is worthy the expenditure of much labor and patience."

From the hospital training school the area of the trained nurse's work has become extended to private nursing (nursing the well-to-do) and latterly to that far more numerous class of patients who are either entirely destitute, or able to make a small contribution for the services of a nurse, and yet who are not fit subjects for hospital treatment.

It is especially and above all to this last class that the trained district nurse has proved so great a benefit. For the duties of the district nurse more experience, more self- denial, are wanted than for those of a hospital nurse or private practice, who have the doctors ahvavs at hand to refer to, and have all the appliances of hospital or home at the service of the patient.

Societies At Present Operating In America In Alphabeticai, Order

Albany, N. Y. - The work in Albany is done by the Albany Guild for the Care of the Sick Poor, and is the outgrowth of the Fruit and Flower Mission, which was organized in 1880. It employs four nurses and does much work among the class which pays small fees for the nurse's care. The nurse here may not respond to any calls excepting those sent to her from the physicians and by the president of the association. This method necessarily limits the field.

Bufifalo, N. Y. - The District Nursing Association of Bufifalo was organized in 1892, to provide free nursing among the sick poor and to carry on a diet kitchen and flower mission in connection therewith. The association is strictly non-sectarian, receiving its support from the voluntary contributions of all denominations. There are now four nurses doing duty for the association.*

Boston, Mass. - Boston has the oldest of the Visiting Nurse societies estabHshed in America; it was organized in 1886. The fourteen nurses work in connection with the dispensary physicians connected with the Boston Dispensary, estabHshed in 1796. This association is known as the Instructive District Nursing Association of Boston.

Baltimore, Md. - The work in Baltimore is known under the name of the Instructive Visiting Nurse Association. It began in January, 1896, with one nurse. At the beginning of the present year it has five. The association is partially self-supporting, the deficit is made up by voluntary contributions. It is non-sectarian and neutral. Cooperates with the other charities of the city. From the first it has been a most successful organized society.

Brooklyn, N. Y. - The visiting nurse work is established in this city and is known as the Red Cross Instructive and District Nursing Society, and is now a department of the Bureau of Associated Charities. Three nurses are employed who do the usual nursing work. In addition to the work done under the auspices of the Bureau of Charities there is also a graduate nurse at the Pratt College Settlement, supported by a private individual.

Colorado Springs, Col. - The work here is comparatively new, and the one nurse employed is under the supervision of the Associated Charities and paid by them.

Columbus, O . - The organization is known here as the Instructive District Nursing Association. It was organized in 1898, through the efforts of philanthropic citizens, and is now supported by voluntary contributions. Three nurses are now employed. This organization secured its first nurses from the organization in Chicago. It has been most successful.

Chicago, 111. - The Visiting Nurse Association of Chicago was organized in 1890. Fifteen nurses are employed. It has also a staff of untrained women who are sent to remain in the home. It is non-sectarian, neutral, and exclusively a public charity, supported by voluntary contributions, fees, and legacies. Managed by a board of directors of thirty-two women. Cooperates with all the organized charities of the city. Gives only nursing and medical caie and only such relief as pertains to the sick. Paramount object, instruction to the people in sanitary laws and hygiene and the care of their own families in time of illness.

Cambridge, Mass. - The district nursing in this locality is under the direct supervision of the District Nursing Association of Boston. It is really a branch of that city's work.

Concord, Mass. - The work at Concord was established in 1900, and employs one nurse. The largest part of the work is done in the families of those who can pay small sums for the service, though the association was started for the benefit of the destitute poor.

Charleston, S. C. - In this city is an organization known as the Ladies' Benevolent Society, whose constitution says it "is formed for the relief of the sick only." It is probably the oldest of its kind in America, having just had its eightyeighth anniversaiy. It is supported by voluntary contributions, fees and legacies. It is undenominational.

Davenport, la. - In connection with St. Luke's Hospital of this city is organized a department of district nursing. The pupils in the second year are sent out to care for the sick in their own homes under the supervision of the superintendent of nurses.

Denver, Col. - In 1892 the Denver Flower Mission employed a visiting nurse to care for the sick poor. In 1900 this association merged into what is known as the Visitinp- Nurse Association and Flower Mission of Denver. It is supported by voluntary contributions, fees, and legacies. Two nurses are employed. They also have in connection a complete medical and surgical staff. The chanty organization of Denver contributes towards the fund.

various guilds and church societies and voluntary contributions. It has in its employ at present three trained nurses. It has the hearty support of all the institutions of the city.

Fall River, Mass. - In Fall River, Mass., the work is done under the auspices of the Union Hospital, which sends out one nurse who cares for as many cases as possible during the day.

Fort Wayne, Ind. - The work is known in this city as the Visiting Nurse League. It is supported by various church circles and the contributions of the pubHc. It employs two nurses and works in connection with the associated charities.

Fitchburg, Mass. - In Fitchburg, Mass., the work is known as the Instructive Home Nurse Association, and is a department of the charity organization known as the Fitchburg Benevolent Union. Employs two nurses and makes a specialty of its loan closets, the system of which could be profitably copied in all other district nursing work.

Grand Rapids, Mich. - The District Nurse Association in Grand Rapids is operated in connection with the charity organization of that city. Two nurses are employed who work entirely in connection with the associated charities. The fund is supplied by private individuals.

Harrisburg, Pa. - The Visiting Nurse Society of Harrisburg is neutral and non-sectarian ; employs two nurses and is supported by a private individual. It was formed in 1899 and has been most successful. The work is done by nurses formerly employed by the Chicago Association.

Hartford, Conn. - Hartford is perhaps the newest of the organized associations. It was started in February, 1901, under the auspices of the local branch of St. Barnabas Guild for Nurses, and has one nurse.

Hampton, Va. - A very successful organization, organized since 1899, is the district work done in connection with the Hampton Training School for Nurses connected with the Dixie Hospital. This is the oldest training school .for colored women in America, and the pupil nurses are sent to furnish nursing care to the sick poor in the town.

Kansas City, Mo. - The work in Kansas City was begun in 1891, and is known as the Visiting Nurse Association of Kansas City. Two nurses do the work in this organization. It is supported by voluntary contributions of the pubHc.

Los Angeles, Cal. - The work was started in Los Angeles in 1899. One nurse is employed by the city - the only place in America where it is done in this way. The plan might well be adopted elsewhere.

Lynn, Mass. - The district work in the homes of the poor was organized here in 1896 through an agreement between the Lynn Hospital and the Associated Charities, whereby the Associated Charities was to pay the Lynn Hospital for the service of a nurse in training. The nurse is changed once in two months. She reports at the ofifice of the Associated Charities for all her cases.

Lawrence, Mass. - The work of the visiting nurse in this locality is supplied by the pupil nurses from the Lawrence Training School for Nurses.

Maiden, Mass. - One nurse has been employed here since 1899. She works in connection with the Industrial Aid Society. The salary is paid by this society.

Mt. Kisco, N. Y. - The work here is done by the \'isiting Nurse Association known as the Ellen Wood Memorial District Nurse Association. Was named in memory of Miss Wood, a Johns Hopkins nurse, the alumnae association of that school contributing towards the support. One nurse is employed.

Newton, Mass. - This association was organized in 1898. It acts under tiie direction of the physicians of the city of Newton, and is supported by voluntary contributions. Two nurses do the work.

New York City. - The ground is fairly well covered in New York City, although the work is not done by any one organized society for this work. The field is a large one, and really should be covered by an organized society operating on a separate and distinct basis. The Bureau of Associated Charities has six nurses working in connection with it. Nurses are engaged in the various parishes of Grace, Trinity, St. Thomas, and others. Tlie City Missionary Society, one of the oldest organizations in New York City for caring for the sick poor, has employed a band of trained women for manv vears. The work at the Nurses' Settlement 265 Henry street, is most complete in every detail, consisting of visiting nursing carried on in three different localities where the settlement has houses or flats ; first aid, or dressing rooms, where minor surgical cases are treated, of which there are three, also situated in different localities ; a country home where convalescent patients are taken all through the year, and social and teaching work which has grown up as a secondary development. The entire number of nurses connected with the settlement is now seventeen, of whom a monthly average of ten is engaged in the work of visiting nursing in the homes, both of non-pay patients and of those who can pay small sums.

Newburg, N. Y. - The work here was started in 1897 by the clergymen of the city, and is known as the Visiting Nurse Society of Newburg. The expenses are met by contributions from the various churches, by fees, and legacies. They have one nurse, and she may only take cases sent to her by physicians of the city. The work is now on a permanent basis.

Newport, R. I. - The work in Newport is carried on under the auspices of the Newport Hospital, the pupil nurses in training in the second year being sent out to care for patients in their own homes who are unable to pay for

Norfolk, Va. - The work here is under the direction of the Norfolk Union of the King's Daughters. Two nurses are employed, part of one nurse's time being used as a friendly visitor for the united charities. There is great need for this work in that locality.

Oakland, Cal. - The work is done by the pupil nurses sent out from the Oakland Hospital. There is not the great need in this locality as found in many others. It was established in 1894.

Omaha, Neb. - The work was organized in Omaha in 1897 with one nurse in charge. It is supported by voluntary contributions, and is indorsed by leading physicians of the city. It is modelled, both in constitution and the detail work, upon the Chicago plan.

Orange, N. J. - The work in Orange, N. J., is carried on by the nurses of the Orange Hospital Training School, who live at the Nurses' Settlement in the district occupied largely by the mill hands. It is supported by voluntary contributions.

Plainfield, N. J. - The work was established here several years since under the auspices of the City Union of the King's Daughters. The fund is supplied entirely by this organization. The nurse co-operates with the Associated Charities.

Philadelphia, Pa. - The Visiting Nurses' Society was organized here in 1875, almost simultaneously with that of Boston. It employs eight graduate nurses and several undergraduates. It is supported entirely by voluntary contributions. It is non-sectarian, and its constitution says that "the object of this society is to give to the poor and to those of moderate means the best home nursing possible under existing circumstances."

Proctor, Vt. - Tlie Proctor Hospital Training School takes care of the poor in their own homes by sending out a pupil nurse when in her second year training.

Rochester, N. Y. - The Rochester City Hospital furnishes through its out-door-rehef department a district nurse who cares for cases who are poor and who are unable to leave their families to go to the hospital. The ground is well covered in Rochester, though there is a field for a regular organization.

Salem, Mass. - The work is done here in connection with the Associated Charities, but is supported by private individuals. One nurse is employed.

St. Louis, Mo. - The sick poor in their own homes are cared for here by the nurse employed in connection with the Visiting Nurse Department of the St. Louis Provident Association. It was formed in 1895 and is supported by the regular Associated Charities.

St. Paul, Minn. - One visiting nurse is employed here by the Bethel Settlement. The field in St. Paul is covered very much in the same way as that in New York. There is no regularly authorized system under one head, but the sick poor are well cared for.

Scranton, Pa. - The Associated Charities in this city employs a nurse in connection with their work. The expenses are met by that organization.

San Francisco, Cal. - In 1897 the Fruit and Flower Mission of San Francisco employed a visiting nurse to care for the sick poor. In the following year, in 1898, she was transferred to the Associated Charities and a second nurse was added to the work. The support comes from private individuals, who furnish the money for this purpose. Calls are received from the Associated Charities. In addition to these nurses there are several others working in connection with the various parishes. The sick poor are well cared for in San Francisco.

Syracuse, N. Y. - The society here is an organized one, known as the Visiting Nurse Association of Syracuse. It was organized m 1896, and is supported by private individuals and public contributions. Two nurses cover the field.

Washington, D. C - The Instructive Visiting Nurse Society was organized in Washington in 1900. It now employs five nurses and is supported by the voluntary contributions of the public.

Waltham, Mass. - The District visiting nursing is done here by the pupil nurses of the Waltham Training School. This system, now in operation in many localities, is indebted to Dr. A. Worcester for its origin. It was the first time in this country that the sick poor had been cared for in their own homes. The work is most successfully carried on and serves two purposes, that of giving care to the people who cannot alTord to pay for the service, and also giving experience to young women in training which they perhaps could not get under the roof of the hospital.

Winchester, Mass. - The work was organized here in 1899. Two nurses are employed who do much charity work, but are especially serviceable to the small wage earner, who pays a fee for care received. The support is from voluntary contributions.

Worcester, Mass. - The work is done here by two nurses, supported by voluntary contributions, and who work in connection with the Associated Charities.

This paper would not be complete without a mention of the Victoria Order of Nurses, founded in Canada by the Countess of Aberdeen. The order is for the benefit of the sick poor, the same as all other district nursing societies, and is supported by voluntary contributions. Its work is larger and covers a greater field than any of the organizations of its kind in the States. In Montreal there is also a district nurse sent out in connection with the Diet Dispensary.

In Toronto the Nursing at Home Mission does the same sort of work as is covered by the organized societies in the States ; it also is supported by the voluntary contributions of the public.

Summary

After laying before you all the plans and operations of the various organizations of this character now under way, we leave it to you to choose the best means of operation. With the active professional worker the neutral lines seem the best lines. Whether the work can be carried on with or without the religious element depends upon the locality. The demand for this work is usually spontaneous, and not always will the same people recognize its necessity. In one instance it may be the physicians of the locality, in another the clergy, in another the philanthropic and benevolent wealthy citizens. The question is : shall the work be non-sectarian and neutral, or shall it be a specified charity by itself, or operated in connection with churches or dispensaries, or with the city physicians? Or shall it be a department of the organized charities which already exist in every state of the Union? No one can advise any special plan, but we can all urge communities to provide for the care for the sick poor in their homes, where the well members of the family may be taught a responsibility towards their own sick that they would not otherwise have. Not more than one-third of the cases usually helped can enter hospitals, and many do go who should not, for in these instances a home may be broken up and the responsibility that should be borne by the individual shifted to an institution.

Many contend that the work comes very near being a luxury to the poor. If it is, then every asylum founded for charity is a luxury, and a luxury, too, that relieves the individual of any dependence upon his own exertions and has no results to show save that of pauperization.

Before closing, just a word as to the woman detailed for such work as this. Only can she be successful when she has passed through a broad general training in the best nurses' schools that can be found. With this must be refinement and culture which give the courage and patience to overcome the overwhelming difficulties to be encountered.

Armed with these weapons, she goes forth as no other philanthropic worker, with a profession so valuable and at once so practical that there is no mistaking the need she fills.

For the past ten years it has been clearly shown "that the district visiting nurse work is the best means at the smallest cost of helping the conditions of the poor, sick or well." Hospitals do much good, but, after all, they ofifer but outside methods of education. It is by reaching the people in their own homes and teaching them to utilize and make the best of what they have that lasting good may be accomplished.

To the following we are gratefully indebted for data and information pertaining to the subject of this paper : To the secretaries and superintendents of the various Visiting Nurse Societies and to the secretaries of the charity organizations in all parts of the country.

For articles on the subject of district nursing you are referred to the following: The "Report of the Conference of Charities in 1894," Nursing Section ; paper by Edith S. Brent, Brooklyn, N. Y., on "District Nursing;" a pamphlet published by the Victorian Order of Nurses, by Lady Aberdeen on "District Nursing;" "The History of District Nursing," by Dr. A. Worcester, M. D. ; a small volume on "District Nursing" by William Rathbone, M. P. ; a work on "District Nursing" by Mrs. Dacre-Craven, and one by Miss Amy Hughes.

Charlotte Macleod

The pioneers in district nursing- in Canada were the Sisters of Charity, who also led the way in hospital nursing. The well-known Sisters of Providence have been long engaged in this work, especially in the cities of the Province of Quebec. They go their rounds in pairs, taking with them whatever material is necessary for the services they may be called upon to perform, and they frequently remain hours, or even days, with patients who are too ill to be left in the care of inexperienced hands.

Several of the hospitals also send their nurses out as district nurses, notably the Maternity and Western Hospitals in Montreal. The Winnepeg General Hospital has boarded and lodged one of its graduates for this purpose for the last three years. Nor has the field been left entirely to the hospitals and orders mentioned. Various philanthropic societies have taken up the work of district nursing and are doing all in their power to thus lessen the sufferings of humanity. Perhaps the one of longest standing is the Nursing-at-Home Mission in Toronto, which began operations about fourteen years ago in this lovely way :

A nurse, who was taking a post-graduate course at the Children's Hospital in Toronto, was so impressed with the sad condition in which many of the children were brought to the hospital that she determined to see what could be done by carrying the skill and tenderness of a trained nurse into the homes of the poor. She therefore left the hospital, rented a room, and began work in the dis- trict. Her example of devotion was soon followed by another nurse, and shortly afterwards this work came under the auspices of the Mission Union. Finally a home was provided where three women were taken in for training. The superintendent, who is herself a thoroughly qualified nurse, visits the patients with the probationers and gives them practical lessons at the bedside. Experience is also gained in a free dispensary with which the home has been connected for the last seven years. Courses of lectures too are given to the nurses by many of the physicians who employ their services. The period of probation is two years, after which time a diploma is granted. The rate of remuneration received by these nurses depends entirely upon the amount of charity support accorded the mission from year to year, the work itself being the first consideration. In the report for 1900 it was stated:

"Gratuities to nurses (eight in number), four hundred and twenty-one dollars and twenty-five cents. In addition to the home being rent free, there is a city grant of two hundred and fifty dollars, but the remainder of the support is from voluntary subscriptions, no charge being made to the patients."

Two sets of deaconesses, the Anglican and the Methodist, do district nursing also in the city of Toronto. Some of these women are admitted to Grace Hospital and Western Hospital for three-months' training, and afterwards, in connection with their course in church and Bible history, they go out in district nursing work during the remainder of their two years.

In Montreal district nursing started in connection with a diet dispensary which was established in 1879, but it was not until six years later that the necessity for a visiting nurse became apparent to the managers of the institution. The success of this nurse's work was so marked that very soon an assistant was appointed. Neither of these women was trained, but the pioneer in the work served for thirteen years before her retirement.

our late beloved Queen's Diamond Jubilee, the women of Western or Newer Canada recommended that an organization be formed as a Jubilee ofTferin^ to her Majesty, which would provide nursing service in the more remote districts of the dominion. The Countess of Aberdeen, wife of the then Governor-General of Canada, responded in a most enthusiastic m.anner to this proposal. But to carry such a scheme to a successful issue in so varied and extensive a country as Canada proved to be a difficult task. When the project known as the Victorian Order of Nurses for Canada was finally launched, owing to the false rumors as to the aims of the order, it met with little or no favorable response from either doctors or nurses. Dr. Alfred Worcester, of Waltham, Mass., who was invited by the Countess of Aberdeen for this purpose, aided very materially in overcoming the prejudices of many by giving addresses in some, of the larger cities on district nursing, and by showing how the Victorian Order might be managed on more economical lines than were at first thought possible. Finally a fund was started and organization began. The constitution, by-laws, and regulations were drawn up and a royal charter procured. The royal charter authorized the formation of a Board of Governors which should have the management and control of the order and of its affairs, and it also appointed his Excellency the Governor-General of Canada as patron.

Five members of the Board of Governors are selected / by the patron, and the others by the Canadian Medical i Association, by each Provincial Medical Association, and by each local association according to the amount of its \ yearly income. There is an Executive Council, made up- \ from the members of the board, whose numbers and powers ' are defined by the governors.

The chief lady superintendent is appointed by the Board of Governors, and the most prominent among her duties are the organizing of new branches, recommending suitable district lady superintendents and nurses, overseeing

Only nurses holding diplomas from some recognized hospital training school and who come highly recommended are considered eligible for the course of training in district nursing. A period of four months' probation is given at the training home either at Montreal or Toronto to test the adaptability, tact, and previous training of these nurses. During that time they are provided with board, lodging, laundry, and an allowance of twenty dollars a month. At the expiration of this course the nurse, if she is desirous, and has proved herself acceptable, is recommended to the Board of Governors as a candidate for the order. She is then presented with her diploma and badge, either by his Excellency, the wife of the Governor-General, or by one of the governors, who admits her to tlie order in the following words:

"By the authority of the Board of Governors, I have the honor of admitting you formally into the ranks of the Victorian Order of Nurses. You have been recommended to the Board of Governors by the chief lady superintendent as a nurse possessing the qualifications and training which our order requires, and have proved through your training in district nursing your efficiency in all your nursing work and your willingness to observe all the regulations of the order. We therefore welcome you very heartily to the order, and we enlist you for active service for two years. May you be enabled to carry into action the true spirit of the order, and may God's blessing rest upon you."

The nurse thus admitted and pledged for two years' service in the order must be prepared to go anywhere in the dominion, either for district nursing or to serve in one of the cottage hospitals. She is provided with her outfit (uniform and nursing bag) and receives a salary of not less than three hundred dollars a year, with maintenance and laundry. She is also entitled to one month's holiday each year. Should she remain in the order for three or more years, she will have a miniature badge presented to her.

The trustees of the Waltham Training School for Nurses at the inception of the Victorian Order of Nurses for Canada sent over their superintendent for three months, and afterwards released her from her duties at Waltham that she might accept permanently the position of chief lady superintendent of the order. She, with five nurses who had graduated at Waltham, and three from other schools, began work early in February of 1898. During the three months branches were established in four of the larger cities and four nurses were equipped and sent with the militia to the Yukon, where they performed most heroic services.

The work of the order has slowly but steadily progressed, and has been extended from coast to coast. Out of the twentv-six branches which have been established in a little over three years, twenty-four are carrying on the work successfully. In all there are fifty nurses engaged in the work.

This year a greater efifort than ever is being made to provide suitable buildings for cottage hospitals. Her Excellency the Countess of Minto is doing much to create a special fund for this purpose. It will be known as the " Lady Minto Fund for Erecting Queen Victoria Cottage Hospitals'' in memory of our late beloved sovereign. Model plans have already been drawn for cottage hospitals to accommodate either six or ten patients, two nurses and a maid. Since the inauguration of the order seven cottage hospitals have been established, and, although several of these buildings may be regarded as mere apologies for hospitals, most excellent work has been done within their walls. As an illustration of the assistance afforded by the order in establishing cottage hospitals, which, after all, are really district nursing stations, the following account is given : by a small sum of money towards a building fund for a hospital ; but as they met with no encouragement from the men of the town, they felt their project must be postponed indefinitely. Just then the Victorian Order came to their assistance and advised them to rent a cottage and make it habitable for patients. A nurse from the order was sent to take charge. Within a few months a request was made by the local committee for a second nurse. In the following year patients were refused admittance, owing to the overcrowded condition of the building. Enteric fever, maternity, surgical, and chronic cases have all been cared for there, and several major operations have been performed in the small room which the nurses occupy as their dining and sitting room. Great inconveniences have been overcome by these devoted nurses in their desire to serve these patients, who otherwise in many cases would have been left to take shelter in a third-rate boarding house with only such care as the slatternly servants might give them. However, the nurses have now been rewarded, having just moved into a fine brick building erected for this purpose. As the expense of keeping a stafif of four Victorian Order nurses in this little hospital would be too great, a training school consisting of four probationers under a highly qualified superintendent is now in progress. There are only twenty beds, but as the cases are varied, and a thoroughly well planned curriculum enforced during a term of three years, including three months of district nursing, there is no apprehension of their not being well fitted for district or cottage hospital nursing in the West.

These Victorian Cottage Hospitals will be open to give a training in nursing to the Doukhobour, and to the educated Indian girl, that she may be of special service to her own people.

Innumerable instances might be related of the blessing the Victorian Order nurse has been in the cottage hospital to the homeless sufTerer, in the humble room of the crowded tenement house during her daily visits in the city districts, or in the rural districts, where she may have to drive ten or fifteen miles and even canoe up a river in order to reach her patient. In the latter case the nurse may have to remain a few da3's if her services are not required in the village and the patient requires special care.

One of the chief dif^culties has been an inadequate supply of good nurses. This is pioneer work, and it does not appeal to those who like a city life with its brightness and comfort, though it should be said that even in remote districts the Victorian Order nurse is not by any means forgotten or neglected. No nurse practicing her calling, even in most luxurious homes, can receive such honor and hearty gratitude as is accorded to our nurses amid their rude surroundings. In one of the most outlying districts, where every effort to procure suitable board and lodging for the nurse had failed, her committee had a small shack built and furnished for her use.

The Victorian Order of Nurses for Canada needs women in it for country as well as for city districts, - women who are capable of performing the highest duty on earth, namely, in helping their fellow-beings back to health, also helping them to lead noble, clean, and wholesome lives, inwardly as well as outwardly.

The Victorian Order, in common with the whole empire, mourns deeply the loss of her after whom it was named ; but the Queen's nurses will undoubtedly respond more quickly than ever to the inspiration of her life - as noble woman and as noble Oueen.

Lillian D. Wald

About eight years ago tenement house Hfe in its most pitiable aspect was presented to me. I had been giving a course of lessons in home nursing to a group of proletariats from the older world - people who find a renewal of hope in New York, if not realized for themselves, at least but deferred and as ardently felt for their children.

One morning one of the women of the class was not present, and her little daughter came to ask me to call upon her mother as she was ill. Despite the experience in a large metropolitan hospital, and the subsequent knowledge gained through a year's residence in a reformatory and asylum for the waifs of New York, the exposure of that rear tenement on the lower East Side was a terrible shock, a shock that was at first benumbing - a picture had been presented of human creatures, moral, and in so far as their opportunities allowed them, decent members of society, living in rooms reached through a court that held open closets to be used by men and women, from some of which the doors had been torn away; up dirty steps into a sick room where there was no window, the one opening, leading into a small crowded room where husband, children and boarders were crowded together - impossible conditions under which to attempt to establish a home and bring up children.

had not been wholly absent. The visitor from a medical dispensary had called, and, touched by the poverty of the place, had sent a bottle of beef extract with directions for use printed upon it, but there was no one in the house who could read English. Other charitable persons had sent coal, but my nurse's instinct revolted at the knowledge that nobody had washed the woman, made her bed, t)r performed any of the offices that every human creature should feel entitled to in like condition.

I will not take time now to describe all of the circumstances and the responsibilities of the community, as they appeared to me, toward this one family ; to me personally it was a call to live near such conditions, to use what power an individual may possess as a citizen to help them and to give to all of my world, wherever it might be, such information as I could regarding conditions that seemed to be generally unknown.

To a friend the plan was revealed : "Let us, two nurses, move into that neighborhood ; let us give our services as nurses, and let us contribute our sense of citizenship to what seems an alien group in a so-called democratic community."

Having formulated some necessary details of the plan, we proceeded to look for suitable quarters, and in the search discovered the "Settlement." In the stress of hospital training, neither of us had learned that men and women, moved by some personal experience or by theoretical training, had arrived at the same impulse to action and had established themselves in the crowded quarters of cities and called themselves ''Settlement Workers." The idea was identical with our own, and though many activities have grown from that idea, the fundamental principle remains - that people shall take up their residence in industrial communities, giving what they may have of public spirit, and, partaking of the life about them, preserving their identity as individuals, and endeavoring to keep the settlement free from the institutional form of philanthropic work.

For the first two months of our experiment we two nurses lived at the College Settlement. After that the top floor of a tenement house that gave reasonable comfort was our home for two years, and that was practically the beginning of the present association of workers known as the "Nurses' Settlement." The life possible through making our home among the people in a simple informal way led us easily and naturally into all the questions that afifected them.

Through our visits to the children and our interest in their general welfare we learned of the unsatisfactory school conditions and of the absurdity of a compulsory school law when there was not adequate school accommodation for the children. Such knowledge as came to our notice, such effective protest as would illustrate the conditions of our neighborhood, was brought before a suitable public, individuals or societies especially concerned, whenever occasion could be found or be made.

The women on the lower floors in the tenement where we lived were employed in the needle trades, and unbearable treatment at the hands of a foreman had moved them and their fellow workers to agitate for trade organization. In the search for some one of their own sex who could speak for them in what they called "better English" they came to us, and that was our first introduction to the protest of the workers which is expressed in trades unionism.

A semi-ofttcial recognition by the Board of Health gave us the privilege of inspection of the tenements, and valuable information was thus stored up on the housing problem. The experience thus gained had its share of influence in the general education of the public, which later led to the Tenement House Exhibit; to the appointment of a tenement house conimissioner under Governor Roosevelt, and the final creation of a separate department for the city of New York. One of the members of the settlement took active part in the movement and was one of the two women on the jury of awards for plans for mcKlel tenement houses.

Through her efforts to obtain a legacy that had been bequeathed " for a fountain somewhere in the city," the Schiff fountain was erected in the neighborhood of the settlement and was the strong influence in having an adjacent site selected for a park and public playground, to make place for which no more congested and unsightly rookeries could have been demolished.

The movement for public playgrounds is now well known. They have been valiently fought for, and their need wonderfully told by Mr. Jacob A. Riis, that best friend and most lovable fighter for the children of the poor. His efforts have been assisted by the Nurses' Settlement for years, according to our ability. To meet the rightful demand of the children for play, we conducted in our back yards one of the first playgrounds in the city. It was an experimental station in a way, as well as an enlightenment of the general public, and was instrumental in helping to develop public feeling in the matter. After a time the interests of the residents of the settlement were directed to the "Outdoor Recreation League," share being taken in its executive work, and co-operation given to Mr. Charles B. Stover, the apostle for New York of outdoor play-places for the children of crowded districts.

The workers of the settlement can look with gratification upon the increasing interest in public school matters affecting their neighborhood as in some part the result of their efforts to bring public attention to the lack of room for the children in the schools, and in other ways to bring the interests of their localities directly to the school boards. One of the household was for a time school inspector, but whether in ofHcial relationship or not, the members have been frequently consulted by those in authority on the Board of Education.

I have passed over the steps of growth of the settlement, and to understand how it has attained its present status I should go back to that first beginning in the tenement, when it was apparent that not only were the nurses' services needed for the sick, but that likewise their friendly offices were needed as interpreters for bringing to the proper sources the larger and more general matters that affected the life of the people they were in contact with.

Mr. Jacob H. Schiff, who, from the very beginning, had made us feel his support, encouragement, and confidence, suggested the change from the tenement quarters to a house, arguing that a more permanent basis would be established for these personal services if it were made possible for others to join us. The desire of others to co-operate with us had been for some time apparent, and therefore this most generous and public-spirited citizen's offer was accepted. A house near the tenements, once the property of the fashionable and well-to-do, who had inhabited Henry street half a century before, was purchased by him. Necessary changes were made in it, and almost immediately the house was filled with residents, and the nursing was extended. The clubs and social features of the house then began to assume organized form.

The next year another house was given for the use of the settlement by a new member, Miss Helen McDowell, a lay-woman, who came into residence, fitted it up and contributed the means to carry it on, and who has taken charge of much of the social work among the young people. Not long after that, offers of money and suitable workers came to the settlement, and fresh opportunities to extend presented themselves. The needs of an uptown district having been urged, a house was selected there, purchased by Mrs. Butler Duncan for extension of the settlement, and workers placed in it who had served an apprenticeship in the down-town house. A little later also a part of a house in still another locality was given to the settlement by Mr. John Crosby Brown, father of one of the residents, who with the other members of that family has done much to strengthen the settlement, and several nurses are accommodated there.

a charming home in the coimtry, where, all the year round, and without restriction or conditions save those imposed by the circumstances of the patients, the convalescents and tired out people who need rest are entertained, and where, in the summer, many delightful outings for the young people are planned.

From the needs of the neighborhood has sprung the service that we call the "First Aid Rooms" in three very crowded quarters. In each one a nurse is in attendance at certain hours of the day, and cases that require small dressings, fresh cuts, old w^ounds, simple eye cases, eczemas, etc., are treated. These are such nursing cases as might be attended to by the members of the families if the mothers had sufficient intelligence or sufficient leisure. Many of them are sent by the physicians of the large dispensaries who have not the confidence that the parents will apply ointments, dress wounds or syringe ears daily and in a cleanly way. These are often school children, and the nurse is thus able to care for a far greater number than would be possible if she went to them.

This work has also a direct bearing on the school attendance of the children, and though many of the cases are not important from a medical point of view, they are of the utmost importance from the educational standpoint, as the children are sent home by the medical inspectors, and, not being allowed to re-enter while the trouble continues, often miss much precious school time, for it must be remembered that few of these children can attend school after fourteen - at that age they all begin wage-earning.

As an illustration, I knew of a lad of twelve years who had never been in school because of eczema of the scalp. True, the mother had gone to the dispensaries and obtained ointments, but the over driven, worn out woman said they did no good. Careful epilation, systematic disinfection and application of the medicament were so successful that when school opened in the fall I had the pleasure of placing the boy there for the first time in his life.

Kindergarten Association, maintains a kindergarten. The children, upon graduating from the kindergarten and entering the public schools, are invited to come back as members of clubs. They are the youngest club members, and when the first one was called "The Alumnse Association of the Nurses' Settlement Kindergarten," the name seemed longer than some of the members.

Probably the boys' clubs connected with the settlement hold the most intimate place. The first one organized, of which I have the honor of being a member, undertook the study of the lives of American heroes. We took the term "hero" broadly, and men or women who by fearless living had made the world a better place to live in were counted as such. Thus we had the biographies of those who had contributed as statesmen, soldiers, philanthropists and writers to the realization of the highest hopes of the country, and living members of the family under discussion often came to contribute personal reminiscences or family history. Since then, as this club matured, it has taken up the study of civil government and other similar study, and is but a type of what all the clubs are doing. Some of the girls' clubs combine study with the boys and young men, and interesting debates on important topics of the day are held in their meeting rooms.

In the interests of a considerable number of boys not responsive to the more intellectual stimulus of study, rooms have been set apart for manual work, and with the co-operation of the "Children's Aid Society," carpentry, wood carving and basket work are carried on. The large dancingschool classes, gymnasium work, etc., are possible through the courtesy of this society. It gives us the privilege of using their large and roomy floors after school hours and in the evenings. Our dancing school has led us to the same conclusion that experience with young people anywhere would bring - that the desire to dance and to meet their kind socially is a wholesome and healthy one, and that it is a dangerous thing not to recognize and meet the want wholesomely, lest innocent desires be diverted wrongly.

The dancing- classes are refined gatherings, properly chaperoned, and with no other restrictions than the ordinary ones of good manners. They are successful rivals to the public dances that are over or back of the saloons, and also provide opportunities for those young people whose careful parents would not allow them to go elsewhere.

We have a penny provident bank, and habits of thrift are inculcated by making it easy to save the pennies. When the deposit reaches the sum of one dollar, an account may be opened in the savings bank in the locality.

All of such work is not done by the nurses, for beside our valued lay members, who share in the social and educational work, a large stafif of non-residents takes part in the classes and clubs.

The kindergarten teachers are, of course, trained for that purpose. Leaders for clubs and teachers for the various classes are recruited from the outside, and among them are distinguished lecturers who find their students responsive and their audiences sympathetic. Musicales, private theatricals, and the varied undertakings that bring gayety and zest into the social life are successful with us. We are fond of saying that next to nursing typhoid fever we love to give a ball.

Our nursing work is the "raison d'etre" of our existence, from which all our other activities have had their natural and unforced growth, but the papers at this conference have dwelt upon the detail and method of district nursing, and our methods do not differ sufificiently to warrant my taking- up time and space to enlarge upon it. We conceive the underlying thought of the district nurse to be that of neighborliness, and plan to have each nurse work in a small district in close touch with the settlement house that she belongs to, that recourse may be had to it in emergency as quickly as possible.

We hope that the nurse with her knowledge of hygiene and sanitation and the care of the body in health and illness will be an educator, and we lay much stress upon this, that she should not have too large a district or too many patients to look after. We believe that the nurse should have time to give the bath, and, if necessary, to make the second or even the third visit in the day, and not be adviser and instructor only; not forgetting- her charity organization tenets of the dangers of doing for people what they ought to do for themselves, yet holding to the ideals of the nurse in her work.

With this in mind, though we do not undertake night nursing as a rule, yet we would have a night nurse obtained through a registry if, in our opinion, this was the only thing to be done for the patient. We also send women to scrub and clean in the homes that the nurses go to, if there is no one who should rightfully perform these services, as we consider it a part of good nursing to have the rooms kept clean.

The various needs of the patient are kept vividly in mind. From what we call the settlement point of view we believe that the patients should know their nurse as a social being rather than as an official visitor, and that all legitimate relationships which may follow from her introduction as a nurse shall be allowed to take place.

It is good from this point of view that the patient should know the home of the nurse, and that the nurse should be intelligent about the housing conditions, the educational provisions, and the social life of the neighborhood in which she works and lives.

From this motive has come the opportunity for the settlement to show where the neighborhood has been neglected, and to bring into communication the different elements of society that go to make up a great city. We think and feel sincerely that the relationship is reciprocal, that we are partaking of the larger life, that society has in general closed the avenues that lead to this knowledge, and that the different elements of society need each other. The well-meaning employer needs his interpreter and the people of such neighborhoods as our own should have their point of view considered and given dignified place in the councils of the public-spirited. This is the ideal of democracy, the best " spirit of the times," and in its accomplishment we have responsibihty and privilege - our share in speeding the realization of the unity of society, the brotherhood of man.

Nursing work - 3,991 patients in their homes ; 26,600 visits to their homes; 12,694 cases treated in (three) first aid rooms ; 225 convalescents entertained in the country house.

Social work - Thirty-five clubs, from kindergarten age, to clubs of married women ; classes in dancing school ; four classes singing school, private theatricals, concerts, gymnasium, fresh air work.

Educational work - Kindergarten, reference library, sewing, crocheting, etc. ; basketry, carpentry, carving, housekeeping (including cooking, laundry, etc.) ; home nursing ; classes in civics, municipal and national government, history, literature, current topics, with papers and debates.

[Between the dates of reading this paper and its publication the settlement has been extended in the following ways : Under the special supervision of Miss Mabel Kittridge an apartment in an ordinary tenement has been rented and suitably furnished with such accommodations as the people may have in their homes. Here all the lessons are given in house cleaning, home-making, laundry and domestic science in general. These rooms, attractive in their simple inexpensive furnishings, make also a wholesome resort for the members of the classes.

A large house, at 299 Henry street, had been purchased by the late Mr. Leonard Lewisohn for the use of the settlement, and the members of his family continue his generous relationship to the work. One of the houses formerly used for residents and for the kindergarten is by

A house overhanging- the Hudson river-bank has been built for the children's and young girls' use during summer vacation time, and plans are under consideration for a better equipped convalescents' home.

A camp for the boys at one of the outlying parks has been made possible through a friend of the boys and the granting of a site by the Park Commissioner. The nursing staff has been enlarged by the College and University Settlements, each having a nurse in residence who is responsible for the calls in her vicinity.]