^"O.iuvyci i! \{YOa ■ aWei 1 1 ^ i mi ai 713DNV ■ ^lOS/\lN'uLUJys /^aiAJNomv ,s^tiiBK/\r. 1 (y/ %ojr ^ .0^■lAili■0%. ^Aa3AINfl3WV ^^AHVHan ^^l•LIBRARYa^ hm]i\fj.j^- ^w^vwiL,. ninKnf.cr u-±\m4^ }Nmu vLao/,^ ijr^v-SO^ ^lOSA AlLlBH Third International Congress of Nurses edited by The Committee on ;Pubi.ication isabel hampton robb I,. L. DOCK MAUD BANFIELD PAN-AMERICAN EXPOSITION BUFFALO September i8, 19, 20, 21, 1901 Press of J. B. Savage, Cleveland, Ohio. joNIRMiCal' 3 Committees Executive Gsmmittee of the Congress THE PRESIDENT AND OFFICERS THE OFFICERS OF THE BUFFALO NURSES' ASSO- CIATION THE OFFICERS AND COUNCIL OF THE AMERICAN SOCIETY OF SUPERINTENDENTS OF TRAINING SCHOOLS FOR NURSES THE OFFICERS OF THE NURSES' ASSOCIA TED ALUMNA OF THE UNITED STATES THE AMERICAN MEMBERS OF THE INTERNATIONAL COUNCIL OF NURSES * Programme G)mmittec MISS NUTTING MISS BANFIELD MISS DOCK Local Arrangements ODmmittee MISS DAMER MRS. CONRAD DIEHL MRS. THOS. MORLEY MISS DRAKE MISS M. SIMPSON AIISS MILES MISS SNETZINGER MISS OWEN MISS KEATING MISS O. MOORE MISS McKINNON MRS. H. STORCK * Finance Committee MISS RIDDLE MISS HEALY MISS ALLINE OFFICERS PRESIDENT MISS McISAAC, Superintendent Illinois Training School for Nurses, Chicago. FIRST VICE-PRESIDENTS MISS KEATING, Erie County Hospital, Buffalo; President Society of Superinten- dents of Training Schools for Nurses. MRS. ROBB, Cleveland, Ohio. President of the Nurses' Associated Alumnae of the United States. SECOND VICE-PRESIDENTS MISS SNIVELY, Lady Superintendent General Hospital, Toronto. MISS DAMER, Buffalo. Member Board of Women Managers of the Exposition. TREASURER MISS RIDDLE, Assistant Superintendent Boston City Hospital, Boston. SECRETARY MISS BANFIELD, Superintendent Polyclinic Hospital, Philadelphia. HONORARY OFFICERS HONORARY PRESIDENT MRS. BEDFORD FENWICK, London, England. HONORARY VICE-PRESIDENTS MISS ISLA STEWART, Matron St. Bartholomew's Hospital, London, England. MRS. STRONG, MatroQ Royal Inflrmary, Glasgow, Scotland. MISS HUXLEY, Matron Sir Patrick Dun's Hospital, Dublin, Ireland. MISS WILSON, Matron Cardiff Infirmary, Wales. FRAULEIN GERVINUS, Matron Victoria House, Berlin, Germany. MISS GRACE BAXTER, Superintendent of Nurses, Ospedale Clinico, Naples, Italy. MBJ. KRUYSSE. Matron Wilhelmina Hospital, Amsterdam, Holland. MISS KEITH-PAYNE, Matron Wellington Hospital, Wellington, New Zealand. MISS McGAHEY, Matron Prince Alfred Hospital, Sydney, Australia. MISS SHIDZU NOURSE, Kobe, Japan. Regular Meetings of Societies HELD CONCURRENTLY WITH THE CONGRESS THE NURSES' ASSOCIATED ALUMNAE OF THE UNITED STATES THE AMERICAN SOCIETY OF SUPERINTENDENTS OF TRAINING SCHOOLS FOR NURSES THE INTERNATIONAL COUNCIL OF NURSES THE SPANISH-AMERICAN ORDER OF WAR NURSES The Transactions of the Third International Congress of Nurses with the Reports of the International Council of Nurses CONTENTS Page. Address of Welcome — The Hon. Conrad Diehl, Mayor of Buffalo 20 Address of Welcome — Mrs. George W. Townsend, Presi- dent of the Women's Educational and Industrial Union of Buffalo 21 Address of the President — Miss Isabel Mclsaac, Superin- tendent of Nursing, Illinois Training School, Chicago; Member American Society Superintendents of Training Schools; Honorary Member Matrons' Council, etc 22 PAPERS 1. (a) Hospital Administration in Great Britain — Miss Isla Stewart, Superintendent of Nursing, St. Bartholomew's Hospital, London, England; President of Matrons' Coun- cil 27 (b) Hospital Administration in Great Britain — Miss Mollett, Superintendent of Nursing, Royal South Hants and Southampton Hospital; Member of and Delegate from the Matrons' Council 38 2. Hospital Administration in America — Miss Maud Ban- field, Superintendent of the Polyclinic Hospital, Philadel- phia; Member of Hospital Superintendents' Association, American Society Superintendents of Training Schools, Matrons' Council; Lecturer in Hospital Economics, Teachers' College, etc 43 3. Hospital Administration in Relation to Training Schools — Miss Riddle, Assistant Superintendent of Nursing, Bos- ton City Hospital; Member of American Society Superin- tendents of Training Schools 71 4. Women on Hospital Boards — Mrs. Robb, Late Superin- tendent of Nursing, Johns Hopkins and Illinois Training Schools; Member Board of Women Managers, Lakeside Hospital, Cleveland; Member of American Society Super- intendents of Training Schools; Lecturer in Hospital Economics, Teachers' College, etc 80 Contents 9 WEDNESDAY, 2 TO 3 130 P. M. Page. 1. Nurses' Co-operative Societies — Miss Kimber, Late Assistant Superintendent of Nursing, New York City Hos- pital, Blackwell's Island 94 The Registered Nurses' Society — Miss Cartwright, Mem- ber of St. Bartholomew's League; Delegate from the Registered Nurses' Society 100 2. St. Bartholomew's League— Miss Waind, Delegate from St. Bartholomew's League 106 3. Nurses' Federation of Australia — Miss S. B. McGahey, Superintendent of Nursing, Prince Alfred's Hospital, Sydney; Member Matrons' Council; Delegate from Fed- eration Ill THURSDAY, 0:30 A. M. TO 12:30 P. M, 1. Preparatory Instruction of Nurses — Mrs. Strong, Sup- erintendent of Nursing, Glasgow Infirmary 118 2. What are we Doing with the Three Years' Course? — Miss L. L. Dock, Secretary of the American Society Superin- tendents of Training Schools, and International Council of Nurses 139 3. Post-Graduate Work in Hospitals — Miss McMillan, Sup- erintendent of Nursing, Lakeside Hospital, Cleveland; Member American Society Superintendents of Training Schools 156 4. Nursingof the Insane— Miss Laird, Superintendent of Nurs- ing, State Hospital for Insane, Seneca County, New York. 163 5. Asylum Nursing — Mrs. Chapman, Formerly Matron of Whittingham, Leavesden, and Claybury Asylums; Honor- ary Treasurer of Association of Asylum Workers, England. 176 THURSDAY. 3 TO 3 :3o P. M. 1. Symposium of 15-minute papers on Opportunities and Responsibilities of the Graduate Nurse of Today — 1. Miss K. De Witt, Chicago, 111.; 2. Miss Richards, Taunton, Mass.; 3. Miss Patton, San Francisco, Cal 188-200 2. Private Nursing, Hours, Remuneration, etc. — Mrs. Rogers, Superintendent of Nursing, Bridgeport Hospital, Conn 202 3. Hourly Nursing —Miss Carr, Member Associated Alumnae; Superintendent of Visiting Nurse Association, Baltimore 208 10 Contents FRIDAY, 9:30 A. M. TO 12 130 P. M. DISTRICT NURSING Page. 1. Historical Outline of Origin and Growth and Present Status of District Nursing in England— Miss Amy Hughes, Late Superintendent of Nurses' Co-operative Society ; Delegate -17 2. Tenement House Inspection — Mrs. Von Wagner, In- spector of Tenements, Yonkers, N. Y 229 3 History of Visiting Nurses in America — .Miss Fuhner, Superintendent of District Nursing Association, Chicago; Delegate 237 4. The Victorian Order in Canada — Miss Macleod, Super- intendent of Order ; Delegate '-54 5. Nurses' Settlement — Miss Wald, Founder of Nurses' Settlement, 265 Henry Street, New York 261 6. London School Board Nurses — Miss Honnor Morten, Member of London School Board, Nurses' Co-operative Society, €tc 272 FRIDAY, a TO 3 :30 P.M. ARMY NURSING 1. Army Nursing in America — Mrs. Kinney, Superintendent Army Nurse Corps of the United States; Delegate 276 2. Nursing in Cuba — Miss Hibbard, Superintendent of Nurs- ing in Government Hospital, Matanzas, Cuba 289 3 Indian Nursing Service — Miss Arkle, Delegate from India Army Nursing Service 308 Indian Nursing Service — Miss P. F. Watt, Allahabad, India 314 4. Nursing in South Africa during the Boer War — Miss Pope, Nurse to Canadian Contingent 319 5. War Nursing in South Africa — Sister Henrietta, Kim- berly. South Africa 326 Contents 11 ORGANIZATION Page. 6. Organization and Legislation Among Nurses: A. In Great Britain and the Colonies, Mrs. Bedford Fenwick, London. B. In the United States, Miss Sylveen Nye, President of New York State Organization. C. In Can- ada, Miss Snively, Superintendent of Nursing Toronto General Hospital, Member American Society Superinten- dents of Training Schools, etc 335-351 SATURDAY PROGRAM AT THE TEMPLE OF MUSIC Address — Mrs. John Miller Horton 361 1. A Plea for the Higher Education of Nurses — Mrs. Bedford Fenwick 363 2. A Retrospect and a Forecast— Miss C. J. Wood — Man- aging Director of Nurses' Hostel; late Superintendent of Nursing, Great Ormond Street Hospital, etc.; Delegate... 370 12 International Congress of Nurses REPORTS ON THE STATUS OF NURSING AS TO EDUCATION AND ORGANIZATION; SENT TO THE INTER- NATIONAL COUNCIL OF NURSES Address of the President 379 From By AFRICA Aliss Breay 384 AUSTRALIA Miss McGahey '. . . . 392 BRAZIL Miss J. H. Jackson 393 CUBA Mrs. Qnintard 396 CANADA Miss Snively See Part I. 349 DENMARK Mrs. Gordon Norrie 402 EGYPT Miss J. G. Watkins 407 FIJI Miss M. C. Anderson 410 FRANCE Dr. Anna Hamilton 417 GREAT BRITAIN AND IRELAND . ..Mrs. Bedford Fenwick 424 GERMANY Miss L. L. Dock 443 GREECE Mrs. Bedford Fenwick 452 HOLLAND Miss C. H. Bastide Baarslag and Miss Kruysse 454-461 ITALY Miss Amy Turton and Miss Grace Baxter 464-472 NEW ZEALAND Mrs. Neill 473 SWEDEN 474 TASMANIA Miss Milne 480 UNITED STATES.... Miss Dock 481 Foreign Delegates 13 FOREIGN DELEGATES Arkle, Annie ..Indian Army Nursing Service, India Office, Whitehall, S. W. Cartwright, Sophia. .. .Registered Nurses' Society, London, Eng. Fenwick, Ethel Gordon International Council of Nurses. McGahey, Susan B Australasian Nurses' Federation. Mollett, W. J Matrons' Council of England. Stevenson, Louisa National Union of Women Workers of Great Britain. Strong, Rebecca Royal Infirmary, Glasgow, Scotland. Waind, Emilie St. Bartholomew's League, London, Eng. Queen Victoria Jubilee Institute for Nurses. Colonial Nursing Association. Workhouse Infirmary Nursing Association. Northern Workhouse Infirmary Nursing Asso- ciation. School Nurses' Society. Guy's Hospital Training School for Nurses. Guy's Trained Nurses' Institute. Leicester Infirmary (Sisters and Nurses). Maternity and District Nurses' Home, Plaistow. Asylum Workers' Association. Midwives' Institute and Trained Nurses' Club. Incorporated Society of Trained Masseuses. , Nurses' Hostel. Hughes, Amy Wood, C. J." 14 International Congress of Nurses HOME DELEGATES Albaugh, R. I Maryland Homeopathic Alumnae, Baltimore. Allen, Ella. . .Trained Nurses' Association of Denver, Denver, Col. Allerton, Eva Monroe County Nurses' Association, N. Y. Austin, C. V Old Dominion Alumnae, Richmond, Va. Bailey, Julia Rochester Homeopathic Alumnae, New York. Barton, Carene Philadelphia Polyclinic Nurses' Alumnx Association. Beyers, Minnie Kings County Alumnae, N. Y. Boswall, Emily O Boston City Alumnae, Mass. Bradley, Sarah A New York Hospital Alumnae. Brown, M. M Presbyterian Alumnae, New York City. Brown, M. R St. Luke's Alumnae, Chicago. Burr, E. V. . .New York City Training School Alumnae, New York. Burroughs, Elizabeth. . .Dutchess County Nurses' Club, New York. Cadmus, Nancy E Presbyterian Hospital Alumnae, New York. Carr, A. M Johns Hopkins Alumnae, Baltimore. Chappelle, Eva E Long Island College Hospital Alumnae. Cheney, Adelia Belle. Massachusetts Homeopathic Alumnae, Boston. Conner, Elizabeth B Rochester City Alumnae, New York. Cooke, Genevieve St. Barnabas Guild, San Francisco. Cooke, Elizabeth Old Dominion Alumnae, Richmond, Va. Cuthbertson, Mrs. William. . .Visiting Nurse Association, Chicago. Darner, Annie Bellevue Hospital Alumnae, New York City. Davids, Anna Long Island College Alumnae, Brooklyn. Dick, Sarah M Illinois Training School Alumnae. Dock, L. L Bellevue Hospital Alumnae, New York City. Dolliver, Pauline Massachusetts General Alumnae, Boston. Donahue, Julia M St. Vincent's Alumnae, New York. Drown, Lucy Boston City Hospital. Duncan, Jessie Berlin & Waterloo Hospital, Canada. Durkee, C. Josephine Alice Fisher Alumnae, Philadelphia Hospital, Pa. Evans, Isabel L St. Luke's Alumnae, New York. Home Delegates 15 Faj, Margaret G University of Pennsylvania Alumnae, Phila. Fulmer, Harriet. . .Grace Church Branch Guild, St. Barnabas, Chicago; Visiting Nurses' Association, Chicago, 111. Gannett, Lois (Alternate to Miss Lightbourne) Hospital of the Good Shepherd, Syracuse, N. Y. Gardner, Bertha Orange Memorial Alumnae, Orange, N. J. Garrett, Anna C Pennsylvania Alumnae, Philadelphia. Graham, Sarah J Post Graduate Alumnje, New York. Groff, Anna B Pennsylvania Alumnae, Philadelphia. Hall, E. E Methodist Episcopal Alumnae, Brooklyn. Hay, Helen S Illinois Training School Alumnae. Hendrickson, Plelen Allegheny General Alumnae, Pittsburg, Pa. Hewitt, E. M Columbia and Children's Alumnae, Washington. Hicks, M. R Hartford Hospital Alumnae. Hughes, Flora A. C, M. D Boston City Nurses' Club. Hughes, Nellie C St. Mary's Alumnae, Brooklyn. Johnston, Mary (Alternate to Miss Smythe) Graduate Nurses' Association, Cleveland, O. Keith, Mary L Massachusetts General Alumnae, Boston. Kenny, Ellen A Rhode Island Alumnae, Providence. Kinney, Mrs. Dita H Army Nurse Corps, U. S. Koch, Clara Michael Reese Alumnae, Chicago, 111. Kritzner, Johanna German Hospital Alumnae, New York. Lichtenstein, Claribel Touro Infirmary, New Orleans. Lightbourne, L... .Hospital of the Good Shepherd, Syracuse, N. Y. Lightfoot, Ida M Colored Hospital Alumnae, New York. Lounsbury, Harriet Camp. .Spanish-American Order War Nurses. MacKenzie, Emma ....Michael Reese Hospital Alumnae, Chicago. Macleod, Charlotte The Victorian Order, Ottawa, Canada. McClurg, A. W. (Alternate to Miss C. V. Austin) Old Dominion Alumnae, Richmond, Va. McFadden, Mattie Grace Alumnae, Detroit, Mich. McKinnon, S. H Erie County Alumnae, Buffalo. Macdonald, Isabel St. Joseph's Alumnae, Paterson, N. J. Mackey, A. H Dutchess County Nurses' Club Alumnae, Poughkeepsie. Mobbes, A. K New York City Training School Alumnae, New York. Morley, Mrs. Thomas Buffalo General Hospital Alumnae. Mulhorn, Sallie Columbia and Children's Alumnae, Washington, D. C. Parke, Emma L Brooklyn Homeopathic Alumnae. Parrish, St. Luke's Hospital, Bethlehem, Pa. Peters, Anna M Woman's Hospital Alumnae, Philadelphia. Pettit, Mrs. Clara D 16 International Congress of Nurses Philpotts, M. Gertrude St. Luke's Alumnse, Chicago. Porteous, Elizabeth R Spanish-American War Nurses. Quinn, Mrs. M. A Rhode Island Alumnse, Providence. Ranney, Alice M M. E. Hospital Alumna, Brooklyn. Rice, V Johns Hopkins Alumnse, Baltimore. Richards, Linda.. New England Hospital for Women and Children. Riddle, Mary M Boston Nurses' Club. Ridout, Lilla M. E. Hospital Alumnse, Philadelphia. Riley, Jane F Massachusetts General Alumnse, Boston. Robertson, A. C Grace Church Guild Branch St. Barnabas, Chicago. Ruddem, Sara University of Penn. Alumnae, Phila. Rutherford, Anna Johns Hopkins Alumnse, Baltimore. Schenk, Annie Bellevue Alumnse, Nevir York City. Scott, Jessie P Michael Reese Alumnse, Chicago. Sears, Jessie Garfield Alumnse, Washington, D. C. Selden, Gertrude E Post Graduate Alumnse, New York. Sharp, Lucy Johns Hopkins Alumnse, Baltimore. Simmons, Kathryn R Roosevelt Alumnae, New York. Smith, Amelia Maine General Alumnse, Portland, Me. Smith, Grace Graduate Nurses' Association, Waltham, Mass. Smythe, ....Graduate Nurses' Association, Cleveland, O. Stansfield, M. J Paterson General Alumnse, Paterson, N. J. Steele, Bessie Michael Reese Alumnse, Chicago, 111. Stewart, Ada B New York Hospital Alumnse. Stewart, Julia Toronto General Alumnse, Canada. Stirk, Anna Presbyterian Alumnse, Philadelphia. Storck, Mrs. Harriet Buffalo Nurses' Association. Sweedie, Mrs Buffalo General Alumnse. Tippett, Alice O St. Barnabas' Guild. Tooker, Margaret Michael Reese Alumnse, Chicago, 111. Turner, Aileen Toledo Hospital Alumnae. Underbill, Eleanor A S. R. Smith Infirmary Alumnse, N. Y. Walton, Isabel J New York Hospital Alumnae. Weitzel, V. C Maryland Univ. Hospital Alumnse, Baltimore. Welsh, Flora E Boston City Alumnae. White, St. Luke's Alumnae, Bethlehem, Pa. Wightman, Mary J Visiting Nurse Society, Philadelphia. Windsor, Carley Harper Hospital Alumnse, Detroit. Wood, Mary St. Luke's Alumnse, St. Paul, Minn. Woodworth, A. N Henry W. Bishop Alumnse, Pittsfield, Mass. Yocom, Irene New York City Training School Alumnse, New York. Young, Sadie C Harper Hospital Alumnse, Detroit. Zimmerman, Mrs. C. D.. . .Buffalo General Alumnse, Buffalo, N. Y. PART I International Congress of Nurses. Meetings held in the hall of the Women's Union build- ing, Niagara square, Delaware avenue, in the Cit}' of Buffalo, Xew York, United States of America, on the 18th. 19th and 20th days of September, 1901. The meeting was called to order at 10 o'clock in the forenoon for the first session, by the president, Miss Mclsaac, superintendent of the Illinois Training School for Nurses, Chicago, who spoke as follows : Members of the Congress : We meet today in the shadow of a great national sor- row ; a calamity that has shaken the foundations of our government : it would seem fitting and proper that this Con- gress should express its sympathy %\"ith Mrs. McKinley, and I will therefore ask the secretary to read a resolution to that effect. Miss Banfield : Resoh«ed : That the International Congress of Nurses now assembled in Buffalo expresses its deepest sympathy with Mrs. McKinley, and heartfelt sorrow at the loss which the American Nation has sustained in the untoward death of its President. The President : You have heard the resolution. Miss Drown : I wish to express for the members of the Congress our approval of this resolution presented by the secretary, and also to move that it be sent in the form of a telegram to Mrs. McKinley and that it be recorded in the minutes of the Congress. 19 20 International Congress of Nurses The President : You have heard the motion. I would ask the Congress to show an expression of its approval by rising. [All rose.] The President : I now take pleasure in introducing to you Mr. Constantine, who has very kindly offered to substi- tute for Mr. Diehl, the Mayor of Buffalo, during the absence of the latter in consequence of the death of the President. Mr. Constantine : Madam President and Ladies: "It gives me great pleasure to welcome the Nurses Con- gress to Buffalo, but I regret that His Honor, Mayor Diehl, is not present to tender you the freedom of the city. A sad duty has called him elsewhere. He would have been pleased to meet and greet you, and talk with you about the noble work in which you are engaged. It would have given him great satisfaction to recount some of the many examples of your devotion and self-sacrifice which have come under his observation in nearly forty years of practice. "To me is left the privilege and honor of saying a few simply homely words of welcome and to bid you God-speed in your work. We were gratified and highly honored when you selected Buffalo for your meeting place, and your local committee had made plans to make the occasion a festive one. But you have come to a city saddened by a terrible calamity and decked with the emblems of mourning. If your welcome is not joyous, it is none the less sincere and gener- ous. We hope you will see much of our beautiful city and the Pan-American Exposition while here. You will find much to interest you — much to help you in your work. If you make the most of your opportunities I believe in after years you will look back upon your visit to Buffalo as one of the pleasantest and most profitable events in your life." The President : I have the further pleasure of introduc- ing Mrs. Townsend, who is the president of the Women's Educational and Industrial Union of Buffalo, an association which is identified with all of the most advanced movements in woman's work of all kinds. OpenUig Addresses . 21 Mrs. Tovvnsend : Madam President and Ladies: "We meet under the shadow of a nation's grief, but there is a sad comfort in the thought that all good work must go on. I am reminded of the beautiful and significant epitaph to the great Wesley brothers in Westminister Abbey: *God takes away the workers, but carries on the work.' "Organization and co-operation are watchwords for the new century. The first time I heard our world-famous Frances Willard speak she was giving her word of greeting from the Christian Temperance Union to the National Council of Women, convened at Washington, in her own marvelous way, and she spoke with a charm and a power seldom possessed by woman. She told a simple story of two children climbing a steep hill. After struggling alone for a distance the younger child reached up her hand to the elder and said : 'Let us take hold of hands, it is easier so.' The lesson and its application were pertinent. I have never forgotten them. You are here, several branches of the same organization, to help one another. In the path of your ser- vice rise hills that must be surmounted as you press on to the realization of your best ideals. Here you will take hold of hands and help each other to climb. "It is my happy privilege, in behalf of our Union, to ex- tend to you most cordial greeting. We hope that while here you will have time to make yourselves somewhat acquainted with the underlying principles of the Women's Educational and Industrial Union. Its purpose is to increase fellowship among women in order to promote the best practical methods for securing their educational, industrial and social advancement. In some lines our work is similar with yours — we minister to the sick and suffering; perhaps we may seek to relieve the trouble of the heart and soul more than those of the body, but the ministry of the skilled and faithful nurse is not only to the material. She cheers the sad heart, she strengthens the weak soul as she cares for the diseased body. Yours is a beautiful mission. In all your deliberations 22 International Congress of Nurses here, and wherever duty may call you, to each and every one, I bid earnest God-speed. May you feel at home in this building, consecrated to humanitarian work. "You are, indeed, most heartily and truly welcome." Address of the President, Miss McIsaac. Mrs. Townsend, Your Honor the Mayor, Our Foreign Dele- gates, Delegates to the Congress, Ladies: "It is with extreme pleasure and appreciation I respond in behalf of the Congress to the cordial welcome of Buffalo through Mrs. Townsend and Mr. Constantine, who have honored us not only by the warmth of their reception, but by their recognition of our profession. I have additional pleasure in extending the welcome of American nurses to the foreign delegates and representatives whose presence and participation in this Congress will contribute in so marked a degree to its interest and success. "In approaching the discharge of my duties as presid- ing officer of this third International Congress of Nurses, I beg to express my appreciation of the generosity by which I have been called to such an honor. "This appreciation becomes all the more pronounced when I reflect upon the conspicuous achievements of my predecessors and colleagues in all lands, who have labored zealously and with beneficent results, not alone in nursing fields, but in behalf of organization, to guard which must be one object of our labors upon this occasion. "It requires a pen and tongue far more eloquent than mine to do justice to the feelings which arise when we con- sider the significance of this gathering. Every meeting of this kind is a record of our progress, and by each one we may determine how far forward we have gone. When we look back upon all the great movements of the world we should never lose sight of the great truth, that a cause which is righteous is never wholly lost. It may be obscured and Address of the President 23 neglected, individual effort may fail, but the time will come when it is carried to success. "If the phenomenal growth of nursing is any indication of its righteousness, then who can doubt our future? Small wonder that our pioneers, some of whom are still with us, express themselves as sometimes awed by the mighty impetus of the ball they started rolling scarcely more than a generation ago. The story of our beginning is so near to us that it is too well known to need repetition — our his- tory so short that it is soon told. "To our English colleagues we of the United States owe more than we can repay, and if in our swift American fashion we have broken from their leading-strings and made paths for ourselves, we none the less acknowledge our indebted- ness with gratitude, and display our accomplishments with the same pride, mingled with a little doubt, with which sons and daughters display theirs to the friends at home. The tie of common speech and common interests is a strong one, even in the every-day work of commerce, but when the mutual interests concern life and death, the tie grows in strength and engenders a peculiar feeling of sympathy and kinship. "Our first International gathering in Chicago in 1893 was marked very distinctly by the making of acquaintance, which sounds rather insignificant, but on second thought assumes its proper place, and we realize that it signified a tremendous force in nursing affairs. The exchange of ex- periences suddenly roused many women to the fact that the deficiencies and difficulties of their work were peculiar to the whole nursing profession, and not to one school or hospital. To that meeting we owe the greater part of the progress which has been made since then, in America. The second Congress, in London, gave some of our members an opportunity of studying nursing affairs abroad, and was the starting point of definite international relations between nurses ; and we will devoutly hope that from this Congress may come as much that is good and stimulating. "The problems taken up for discussion on those 24 International Congress of Nurses occasions still confront us in both continents, — the uniform requirements for admission to our schools, the uniform curriculum, what shall constitute a trained nurse. State registration, local and national organization, a code of ethics, and many minor questions. "In America the extension of the training course from two to three years is nearer an accomplished fact than any other question, and while the curriculum is far nearer uniformity than it was eight years ago, there is still much to be desired. "The question as to what constitutes a trained nurse seems farther from settlement in this country than at any time before. We Americans have strongly what the French call ' the faults of our qualities.' In our nervous energy and haste to embrace all things new and to get to the end by a short cut we often sacrifice quality and thoroughness to speed, and in no other work is this more glaring than in the enormous increase of so-called training-schools which have neither educational nor moral right to exist. We will listen with much interest and eagerness to our foreign delegates upon this subject, for it is one of extreme gravity to our profession. The establishment of a chair of Hospital Economics in Columbia University has been one of our most important undertakings, originating with the nurse who has done more for educational standards in our pro- fession in America than any other one woman ; Isabel Hampton Robb, whose work is so well known to all of us. The Columbia course will undoubtedly be a most valuable leaven for the whole lump, and I may say, with no fear of giving offense, that the superintendents themselves know better than any one else the great need of better teachers of nursing. We cannot hope for improvement in pupils with- out a greater improvement in the heads of our schools. The organizations for nurses all over the world have developed wonderfully, and while we occasionally hear expressions of discouragement, we should not forget that we have learned much by contact, and should see our deficiencies now far more clearly than formerly, and if we continue to struggle Address of the President 25 for better things, a * noble discontent ' with ourselves will be the very best stimulus we can have. "A topic new to the nurses of the United States sinceour first meeting, although an old one in England, is army nurs- ing — a huge problem undertaken here in an emergency, and one in which we sadly acknowledge we have not always done ourselves credit, nor, perhaps, always given credit where it may have been due. In this, alas, our friends across the sea share with us some of the same humiliation; but if all experience is good for us, then we should listen with open hearts and minds to those who can point out a better way for our future guidance, and take the criticism we deserve with the right spirit. For, after all is said and done, the roots of our shortcomings existed before the Spanish- American or South-African Wars. "An undertaking of which we are justly proud is The American Journal of Nursing. To paraphrase our great Lincoln, ' a journal of nursing, for nurses and by nurses,' the work of which has been entirely done, until within a few weeks, by nurses hard worked in other lines; a monument to the courage and devotion of American nurses, we recognize it as a tremendous factor for good ; and feel that, whatever its standards and influence, it is and will be what nurses make it. " Again I beg to express our thanks to our cordial hosts of Buffalo, and to extend the hand of fellowship to the distinguished guests within our gates who share with us this undertaking, and felicitate them upon their achievements in our profession." The President : We would announce that the meeting on Thursday afternoon will convene at half past one and close at three o'clock. The day is to be a day of mourning and everything will be closed after that time on Thursday afternoon. Unhappily one of the foreign delegates, Mrs. Strong, who came to this country to attend the Congress, has been delaved and I would ask the secretarv to read her letter. 26 International Congress of Nurses The secretary reads : "Episcopal Hospital, Philadelphia, Sept. i6, igoi. Dear Miss Mclsaac: I am sorry to say illness prevents my being with you in Buffalo on the 19th inst. to read my paper as promised. Wishing you pleasant and profitable meetings, believe me with kindest regards. Yours very sincerely, Rebecca Strong," Mrs. Robb : I take pleasure in moving that in re- sponse to Airs. Strong's letter a telegram be sent to her expressing the sense of regret of the Congress for her absence through illness. Carried. The President : We have this morning three papers on Hospital Administration in Great Britain and America. It has been decided that all three papers will be read before we have any discussion. I have pleasure in presenting Aliss Isla Stewart to the Congress. Hospital Administration. ISLA STEWART, Matron St. Bartholomew's Hospital, President Matrons' Council of Great Britain and Ireland. Madam Chairman: The broad lines of administration are much the same in a large majority of the hospitals of Great Britain and Ireland, which are either endowed, or partially or wholly supported by voluntary contribution. Many hospitals have as their highest representative, or figure head, a Patron or President, who in quite a large number of cases is a Royal personage, and they are by no means merely orna- mental, as their patronage implies not only a personal con- tribution to the funds, but very material assistance in attracting the gifts of the public, who feel a certain guarantee of efficiency and probity is given by the use of the name being allowed. Nor is this a misplaced belief, as every care is taken in the way of enquiries and inspection, to prevent the name of any of the immediate Royal family being used in connection with any institution the general management of which is open to question. The subscribers elect the Governors from among themselves. These form a court which meets annually, half yearly or quarterly. They appoint a sub-committee, frequently known as the House Com- mittee, which meets monthly or fortnightly, and in nearly all the large hospitals there is also a weekly board, empow- ered to deal with any minor matters that may arise. The ex-ofificio chairman of every board and committee is the treasurer, elected by the governors, in some hospitals for life and in others annually. There are also three or more trustees who are members ex-officio of the committees. In a few hospitals there are women on the governing board, 27 28 International Congress of Nurses but this is still rare, though not so much so as it was a few years ago. I may instance the Royal Infirmary in Edin- burgh as the most important hospital where this is the case ; at this institution two women have been elected to serve on the committees. The Royal Infirmary in Glasgow has fol- lowed its example, but they have not only placed two women on their conmiittee, but also two working men. In many cases, indeed in almost all provincial hospitals and in Scot- land and Ireland, the medical staff are represented on the board by two or more members. When this is not the case the medical staff form themselves into an advisory com- mittee of their whole number, and are consulted by the lay governing body on all matters which affect their interest, or the well being of the patients. These are the unpaid administrators, in whose hands rests the enormous responsibility of obtaining money for the institution, nursing its resources, and assuring themselves that the funds are carefully, wisely and honestly spent, and that the paid officials are capable, efficient, and upright. In many of the London, Edinburgh and large provincial hospitals, the chief resident authority is a superintendent who may belong to the medical or legal professions or may be an army man or civilian of tried business capacity. He may be styled the Clerk, House Governor, or Superinten- dent. His duties are numberless, and comprise the decision of questions chiefly administrative which may involve con- siderable interest, or be very unimportant. He prepares the business for the different committees and reports to them the various matters which arise between the meetings of the board. The power and responsibility of this official are very great, and are but rarely abused. Under him are the heads of the various departments: the matron, head of the nurses and domestic department; the steward, head of the department which includes payment of wages, bills, cater- ing, recording the admission and discharge of patients, and the control of the male attendants and porters ; the clerk of the works, wb.o has charge of the actual structure of the building and who has under him the carpenters and Hospital Administration 29 plumbers. In g-eneral each official reports personally, in writing, to the weekly and fortnightly board, but this is not always the case, and in so important a hospital as the Western Infirmary in Glasgow, where there are 420 beds, the matron is responsible only to the superintendent, and never sees the committee. This, of course, diminishes her authority and prestige considerably. So large a number of officers is only required in the great hospitals. With a decrease in the size of the institution, the number of these officials tends to diminish ; the clerk to the board (usually non-resident), and the matron dividing the work of the steward and clerk of the works, and in a large number of the smaller London and provincial hospitals the matron is the only permanent resident authority ; though she is frequently, even in her own immediate department, under the control of the medical resident. There is a very large number of important Infirmaries originally under the Poor Law Board, the powers of which were transferred to the Local Government Board by Act of Parliament in 1871. These are entirely supported by rates. Each parish when populous, or group of parishes, when they are smaller or more scantily populated, supports its own institution which in the latter case is known as a Union Infirmary. In England and Ireland, Guardians, and in Scot- land, County Councillors, who may be either men or women, are elected by the rate-payers, and hold office for three years. They deal with a great many matters affecting the well being of the parish, and amongst them govern the workhouse and hospital. They attend a fortnightly board which deals with all the matters which would be brought before the governors of the voluntary hospitals. Tliey have not, however, the supreme authority; that is vested in the Local Government Board. All matters of any importance, such as the appointment of officials, must be ratified by it, and it may or may not assent. To illustrate the extent of the authority held by the Local Government Board, I may mention that neither the guardians nor the Metropolitan Asylums Board (which governs the hospitals for infectious 30 International Congress of Nurses diseases) can expend £100 without its consent; and no structural alteration can be made costing- £5 or upwards without referring the matter to it. The medical superintendent is in all cases the highest resident authority, and is directly responsible to the Local Government Board as well as to his board of guardians. The matron and steward act under his authority, and although he may allow them a fairly free hand he can call them to account when he considers it necessary. The matron and steward report personally to the board, but their written report frequently goes through the medical superintendent, who in some institutions is present when it is read, and when they see the committee. The matron is nominally the head of the nurses' staflf, but as each nurse can appeal, on any matter, to the medical superintendent her authority depends largely on him. These hospitals are periodically inspected by inspectors employed by the Local Government Board and who report direct to that board. The hospitals for infectious diseases are also under the Poor Law, and are supported by the rates. In London they are directly governed by the Metropolitan Asylums Board, which is composed of representatives from the various boards of guardians, but one third of the whole number of members are nominated by the Local Government Board. The growth of the work of the Asylums Board and the increase in the number of their institutions have, during the last two years, led to a modification of administration where- by three central committees, viz : one for the fever hospitals, one for the asylums, and one for the children's homes have been appointed, with power to appoint sub-committees to visit the several institutions. This has brought about greater uniformity in details of management, but the powers of the sub-committees have been greatly modified, as they are unable to make regulations upon any matters which may be regarded as common to several institutions. Each hospital has a sub-committee appointed to it which meets at the hospital fortnightly and reports to a central committee, which in turn reports to the general board, but as in the Hospital Administration 31 case of the guardians, all important matters such as those relating- to finance, the purchase of land for building pur- poses and the appointment of the superior officers must be ratified by the Local Government Board who may prescribe regulations for the government of their institutions. These are also inspected by Local Government Board officials. In the Asylums Board hospitals also, the medical superin- tendent is the supreme resident authority. The matron and steward being subject to his control, he can curtail* their authority and regulate the internal administration of the hospital so far as it is compatible with the carrying out of the board rules. They report to the sub-committee on cer- tain matters connected with their departments but in many cases the medical superintendent sees their report and is always present when they interview the sub-committee in order that his advice may be obtained upon any question that may arise. This condition of afifairs is inevitable under the Local Government Board, who hold one officer legally respon- sible for the good management of the whole institution. A wise autocracy may constitute the best form of institutional government, and as in the case of the medical superinten- dents under the Asylums Board a large majority are wisely chosen after much experience as assistant medical officers. The system works well and with marvellously little friction. The chief fault lies in a certain lack of minute discipline, which is not so apparent now as it was in the past, and which may have been largely due to the fact that the matrons were untrained or partially trained women, often with little or no education, and who were given only partial control over the nursing staff, viz., when they are off duty. Now that both the guardians and the Metropolitan Asylums Board are appointing women of education, who are all fully trained nurses, the friction between the medical superintendent and the matron is disappearing, which condition results in much more efficient management and better discipline, though *This is limited by the Local Government Board orders. 32 International Congress of Nurses even now the discipline is not quite so perfect or strict as in the general hospitals. The control over the nurse is nothing like so absolute. She signs no contract on enter- ing, and has no training certificate to look forward to. The administration of hospitals and infirmaries supported out of the rates must always be much more difBcult than that of the voluntary hospitals. They are not charitable institu- tions, and the inmates feel strongly their right to be there, and never for a moment forget that they have that right. In the infirmaries, the infirm patients are resident for a very long time ; months indeed may lengthen into years, and they know exactly how far they may go with impunity. In the past there is no doubt they had reason to complain, but this raises a class of difficulties, unknown in general hospitals. The object in the fever hospitals is to make residence therein as attractive as possible to the inmates with the view to encouraging the efficient working of the Public Health Act. The hospitals for infectious diseases have their own class of difficulties to deal with, arising sometimes from the fact that patients who have had a slight illness must remain until all fear of infection has gone, which is often long after they are to all appearance quite well. With children this is of little consequence and women bear the constrained residence fairly well, but with men it often gives rise to a certain amount of discontent. These little troubles, trivial it may be individually, make it necessary that they should be dealt with by some one who has an adequate authority, and who knows that if strained it will go beyond the weekly board. The medical stafif in the large hospitals in London, Edinburgh, Dublin and in the important provincial towns consists of a consulting, a visiting, and a resident stafif. The consulting physicians and surgeons are mainly those who, having reached a prescribed limit of age, have retired from the visiting stafif, their duties being merely nominal. The senior visiting stafif are the physicians and surgeons who pay periodical visits to the hospitals and have a certain number of beds allotted to their care. They visit on certain days at regular hours in London, usually three or four days Hospital Administration 33 a week at 1 :30 o'clock. In some of the provincial hospitals they make their visits in the morning; they are liable to be sent for at any hour during the night or day, should a case be admitted or any emergency arise too critical for the resident staff to deal with. The junior visiting stafT see the out-patients and have one or two days a week allotted to each of them. There is a still younger junior staff who see the casualties every morning, and there are the heads of the various departments, gynecological, ophthalmic, aural, throat, dental, orthopedic and electric. There are two or more registrars, who superintend the recording of cases by the students, and a senior and junior anesthetist. The resident medical stafif consists of a house physician and sur- geon to each of the visiting staff and to the heads of the gynecological and ophthalmic departments. The junior visiting stafif and the heads of the other departments have also understudies, but they are usually non-resident. All these medical and surgical officers in the large hospitals deal exclusively with matters affecting their patients' health. In some hospitals, notably St. Thomas', there is a principal medical and a principal surgical officer, who hold their appointments for three years, and who have authority over the more junior medical stafif. In others, as in Guy's hospi- tal, the medical superintendent is the responsible officer dur- ing the absence of the visiting staff, and the house staff is under his control, but in the majority of hospitals the house staff is responsible for the patients during the absence of the visiting staff. In the smaller provincial hospitals the respon- sibility of the management of the institution is often given to the senior resident medical officer, who is usually quite a young man holding office for two or three years or even less. In the infirmaries and hospitals under the Poor Law there is no visiting staff attached, but the medical superin- tendent has under him resident assistant medical officers according to the number of beds. In the infirmaries this is smaller than in the hospitals for infectious diseases, as the cases are much less acute. In Lambeth Infirmary with 622 beds there are three assistant medical officers. In Birming- 34 International Congress of Nurses ham Poor Law Infirmary with 1540 beds there are four. In the South Western Fever Hospital with 360 beds there are three. This condition of things works very well in the large hospitals, where each official has work and respon- sibilities enough in his or her own department to fully occupy mind and time. But the relations are strained in the smaller hospitals where there is not so much to do, and where the authority is frequently placed in the hands of the senior medical resident physician, who is usually a young man holding and magnifying his first authority. Perhaps the most remarkable change in the administra- tion of hospitals of late years has been the enormous increase in the number of nurses and in the expense of the nursing department, which in some hospitals seems to have reached an excessive degree and points to the necessity for some competent authority to define the requirements of hospitals in this matter, having regard to the size of the institution and the chronic or acute nature of the cases received. The staffs of the various large hospitals vary in proportion to their patients to an almost incredible degree. In the London Hospital where there are 776 beds with an average of 659 patients the whole nursing staff, including the matron and her assistants, is 313 ; or one nurse to about 2Vz patients on the whole number of beds, and just over one nurse to two patients on the number of beds occupied. In King's College Hospital where there are 221 beds and an average of 168 patients there is a nursing staff of 69 which brings the proportion of nurses to patients to very much the same as the London Hospital. In St. Thomas' Hospital the beds number 570; the inclusive staff 161, which makes the proportion quite one to 3^ patients. In the Edinburgh Infirmary where there are 780 beds with an average of 711 patients, the nursing staff is 195, making an average of one nurse to four beds and rather less per patient. The Royal Infirmary, Glasgow, gives almost the same proportion with 582 beds, an average of 555 patients and a nursing staff of 142. The Western Infirmary, Glasgow, with 420 beds and a nursing staff of 128 gives a little better proportion. The Hospital Administration 35 Mater Misericordia Hospital, Dublin, with 338 beds and a nursing staff of 152 gives a proportion of one nurse to 2^ patients. The General Hospital, Birmingham, with 346 beds and an average of 269 occupied has a nursing staff of 102 nurses, giving an average of one to just over 3 beds and one to 2j patients. Leeds General Infirmary with 402 beds has a staff of 83 nurses, giving an average of one nurse to four patients. The smaller county hospitals whose beds are undef 150 seem all to range about in a proportion of one nurse to four patients. In the infirmaries and hospitals under the Poor Law the proportion of numbers is curiously different. In Bethnal Green Infirmary the number of beds being 669 with an average of 520 occupied, the number of the nursing staff is 80, giving a proportion of one nurse to about 6:^ patients. In the Lewisham Infirmary the number of beds being 400, with an average of 250 occupied, the average is one nurse to almost 7 patients. Both these infirmaries are in the London district. In the Poor Law Infirmary, Bir- mingham, with 1540 beds and an average of 1131 occupied, the nurses' staff gives an average of one nurse to ten patients. At Salford, near Manchester, the Poor Law In- firmary has 800 beds and has also an average of one nurse to ten patients. In the hospitals under the Metropolitan Asylum's Board the proportion is better, being about one nurse to three or in some four patients. The difference in proportion of patients and nurses in hospital and Poor Law infirmaries does not imply a corresponding lack of efficiency. Hospitals and infirmaries supported by voluntary contri- butions are increasing. Occupied by patients suffering from acute disease, their aim is to treat as large a number of patients as possible in as short a space of time as they can, compatible with efficiency, while the Poor Law infirmaries have a large number of chronic and infirm cases whose condition does not call for such constant attention on the part of the nurse. I mean that a larger proportion of patients per nurse may be efficiently attended to in a Poor Law infirmary than in a hospital in consequence of the chronic character of many of the patients in the former. 36 International Congress of Nurses It seems to me that the maximum number of nurses necessary for ef^ciency must be reached or overstepped when the proportion of nurses is one to two patients or just under. This large number of nurses connotes a proportionate number of wardmaids, servants and cleaners, and brings the whole female staff to a proportion of one to 1^ and If patients and makes the cost of the nurses and domestic department enormous. In the large hospitals the average cost of the nurses ranges from £40 to £63 per annum ; in the smaller general and special hospitals it ranges from £33 to £58. I can only find one Scottish hospital quoted, and that is the Dumfries Infirmary, which has an average of 46 beds occupied, a nursing staff of 15, costing £42 per nurse per annum. In the Belfast Royal Victoria Hospital with 189 beds and a nursing staff of 55 the average cost is £32 for each nurse. This is exclusive of service, which I cannot find estimated anywhere, but on a rough estimate made by myself I think that if we included service it would bring the average cost per nurse somewhere between £63 and £67 per annum. This amount either if paid out of the rates or met by voluntary subscription should not, I think, be exceeded. The average cost per day per patient is almost as varied as the cost and number of nurses. The London Hospital costs 5s. 2d., Middlesex 5s. O^d., while St. Thomas' costs 6s. O^d. Leeds General Infirmary costs 3s. Ifd., and the Royal Infirmary, Bristol, 2s. lOd. In the Metropolitan Asylum Board Hospitals the cost per patient per day is about 4s. lOd. or 5s. This calculation includes not only the actual main- tenance of the patients, but salaries and maintenance of officials, furniture, earthenware, stationery, insurance and the upkeep of the institution. It must be borne in mind that that is per patient, not per bed; and that the average stay in hospitals of the patients varies considerably, the greater number of patients, the less will be the average cost of each. As for instance, the average of the London is 3 weeks stay, the average of St. Bartholomew's Hospital is 4 weeks. Hospital Administration 37 Of London hospitals, the majority have an annual expenditure of over £10 a bed. The Scottish hospitals spend about £50 a bed, the Irish £40, and the Provincial about £50. In London there are about six general hospitals that have an annual expenditure of over £100 a bed. The administration of the funds of the large hospitals is becoming more and more difificult as the expenses of each department increase, owing to the much greater regard being paid to the individual needs of the patients and their more scientific treatment. There must be some limit to the money obtainable for charity, and there should be some limit, more stringent and effective, to those who seek for free medical aid. There have sprung up in late years admir- able societies for collecting and distributing money for the use of hospitals. We have the Sunday Fund, the Saturday Fund, and now the Prince of Wales' Fund. As these societies are in the hands of business men, they ha\f no doubt by careful selection and inspection done much to bring the hospitals into line and to increase their elBciency. The governing boards of hospitals are now largely com- posed of business men who have experience in the handling of great sums of money, and who give their time most ungrudgingly to the service of the hospitals. The President : I now have the pleasure of introducing Miss Mollett, who comes to us to represent the Matrons' Council. County Hospitals in Great Britain. WILHELMINA J. MOLLETT, Matron Royal South Hants and Southampton Hospital, Member of and Delegate from the Matrons' Council of Great Britain and Ireland. Ladies, I rise with some diffidence to speak after Miss Stewarts able paper, dealing as it does with all the chief points of interest in hospital administration, — and my only excuse is, that I speak as Matron of a very different — though very important class of hospital — that is to say large County Hospitals unconnected with medical schools. It will not perhaps be out of place if I commence with a few remarks regarding their importance from a statistical point of view in England, — I am excluding the hospitals of Scotland, Ireland and Wales, and all special hospitals. London contains twelve general hospitals with medical schools attached — containing an aggregate of 4,674 beds. The Provinces (or counties) have tv/elve medical schools with an aggregate of 3,075 beds. Thus the total number of beds in general hospitals in England where regular clinical instruction is given to male students is 7,749. But there is further a very large number of general hospitals varying much in size, which have no medical schools attached to them, whose total number of beds, 14,974, is nearly double the amount of those devoted to clinical instruction. Fifty of these contain 100 beds and over, and have a total of 7,526 beds, or nearly as many as the London and Provincial Medical schools combined. Sixty-four have from 50 to 100 beds with a total of 3,472 — whilst there are no less than 203 hospitals containing less than 50 beds (of which 66 have less than ten beds) with a total of 3,976. The figures are taken from the Medical Directorv. 3S County Hospitals in Great Britain 39 All the above are Voluntary Hospitals — supported by subscriptions or endowments. None of them are aided by the Government or are rate supported. A very few receive a small proportion of paying patients, in fact they practically do not receive them. Except in certain primary matters it is not possible, in my opinion, to compare the management of a County Hospital in detail with that of a hospital having a medical school attached. The essential virtues of order, discipline, obedience and the subordination of the female stafif in disciplinary matters to the female head, are the same in both, but in detail they differ. The highest authority in a County Hospital supported by voluntary contributions is always the Governors — the donors or subscribers in council assembled. The amount given or subscribed to become a Governor varies, but the outcome is the same, the formation of a large body with voting powers — meeting about one or twice a year to ap- point committees and vote extraordinary sums or changes in the By-Laws of the Institution. They elect the manage- ment, financial and executive committees for the year, the president, the chairman, and so forth, — and these practically carry on the business of the hospital, appointing the executive officers, and being generally responsible to the Governors for the efficiency and economy of the place. It is here that both the strength and weakness of hospital gov- ernment lies, — whilst on the one hand the management of the hospital is kept in touch with public opinion, on the other hand the proper government of the hospital is apt to be disturbed by well-meaning gentlemen who have no knowledge of the real needs and requirements of hospital wards, whilst it also lays them open to the influence of popular or strong executive officers. The honorary medical staff have representatives on the various committees, the manner of their representation varying slightly in different hospitals. The executive administration in my hospital containing 130 beds, which I am following in this sketch, falls into three departments and I hold that it is in the proper balance 40 International Congress of Nurses of power between these three departments, the proper ap- portioning- of their various responsibilities, that the efficiency and good order of the hospital largely depends. They are the secretarial, the medical, and the nursing and domestic. The secretary has charge, under the Finance Com- mittee, of the financial afifairs of the hospital, the collecting of subscriptions, the hospital banking business, the balance sheets, and so forth. He attends to all correspondence that is not directly concerned with medical, nursing or domestic matters and, in my case, overlooks the engineer and the engine and the general repairs of the building-, etc. He acts in emergencies for the committee in their absence. He is a non-resident officer and, when a suitable man, a very valuable aid and counsellor. I am, personally, very fortunate in my secretary. The principal resident medical officer is the senior house surgeon who, working under the honorary medical staff, acts for them in their absence and is in medical and surgical charge of the patients. But as he is, beside, the resident medical officer for the committee, he holds, and rightly, a very important post with regard to the patients. He is, generally speaking, responsible for the admission and discharge of the patients and for their treatment in the absence of the honorary stafif, but he is not an administrative officer as regards the nursing and domestic staff. They do not fall under his jurisdiction except in so far as he gives his orders for the patients to the sisters in charge of the various wards. One of the greatest difficulties in a County Hospital is in securing a suitable man for the post of house surgeon. It is essential that they should be thoroughly good profes- sional men and men of common sense, who work their way into their post without offending against all its conservative instincts. For they come, of course, from various medical schools ; each with its own fads — the Guy's man, the Bart's man, the London and the King's — all think their own school perfection and are often a trifle scornful of their predeces- sor's methods. But the main point is that they should not County Hospitals in Great Britain 41 be slack but keen men for their work and, perhaps, from a matron's point of view, that they should not be too sus- ceptible to the charms of attractive sisters and probationers. The matron's department includes the nursing and domestic staff, the food, the laundry and the general management. She either selects the various sisters, or recommends candidates to the board, engages probationers and servants, and superintends their work, for which she is responsible. She gives the orders to the assistant matron and to the cook and supervises more or less the food supplied to the patients. She stations the sisters and probationers in their wards, arranges the work, the holidays, and so forth. But it really is not necessary to enter to the present company into the details of her work, except to emphasize the fact that it is a combination of superintendent of nursing with that of matron. I will, however, add that it is essential, if she is to carry it out efificiently, that she should herself, as in my case, be directly responsible for it to the committee and not to any other official. Perhaps there is one other point I should mention as being of importance and that is that the nursing and domestic head should be the same. Good nursing depends so much on good domestic manage- ment and is so intimately connected with it, that the two should certainly be under the same control. The nursing staff is divided into sisters at the head of the wards, a night superintendent, and probationers who train for three years, and are stationed on night or day duty. Their average daily time on duty, when meal times and off duty time is deducted, is a little more tkan ten hours. I see no reason, in a County Hospital, why that time should be lessened. Ward maids are attached to the wards to do the roughest of the work, but there still remains a fair but not undue amount of ward cleaning to be done by the pro- bationers. Ward orderlies are unknown in English civil hospitals ; all the nursing of the male patients is done by the sisters and nurses. 42 • International Congress of Nurses The probationers receive lectures from the visiting medical staff and classes from the matron. The whole scheme of hospital organization for County Hospitals resolves itself into a body of subscribers appoint- ing committees for a given period, who in their turn con- trol and regulate the hospital in accordance with certain rules and by-laws, and the fixed rule of most of these hospitals is that they are intended only for " fit objects of charity." This rule is carefully guarded by the medical profession, amongst whom the very idea of pay wards attached to a general hospital, which seems so usual here, is very generally regarded with great suspicion and disfavor. It must, however, be owned that they would solve a most serious difficulty with regard to the poorer middle classes, who are of all people the worst off in England in illness. In some towns, especially large manufacturing towns, the work people contribute largely to the support of the hospital, and have their own representatives on the com- mittees. This is the case, however, in only a few hospitals. It is not so in mine. Further it is necessary to remember that these hospitals which are solely intended for the relief of the sick poor and working classes, and do not even contribute clinical instruc- tion for students, are built and maintained entirely by the voluntary subscriptions of the more well-to-do classes and that they are beyond and outside the rate-supported institu- tions such as Workhouse Infirmaries and Asylums for the Insane. Above everything else, therefore, these hospitals are pre-eminently intended for the sick poor ; for their com- fort, their convenience, their medical and surgical treat- ment ; and the first and finest lesson they have to teach to the nurses trained in their walls is that nothing, not the nurses' instruction, or convenience or comfort, is so im- portant as the welfare of the patients confided to their care. The President : Our next paper will deal with the administration of American hospitals. Hospital Administration in America. MAUD BANFIELD, Superinteudent of the Polyclinic Hospital, Member of Hospital Superintend- ents" Association. American Society Superintendents of Training Schools, Matron's Council, Lecturer on Hospital Economics, Teachers' College, [Cxpyriglited, 190». Iit Maud Banfield.] In considering the administration of hospitals in this country we are confronted by the initial difficulty that, although an enormous amount of money is invested in these institutions, there is no uniform, or even customary, system of administration or accounting. The State institutions are, as a matter of course, dominated by politics ; and into this matter we will not enter, for the reason that most of our time would be taken up in describing political rather than hospital organization. The city hospitals, the funds for the support of which are secured by an appropriation of coun- cils, are in some instances free from jx)litics and ad- ministered satisfactorily, notably in Boston and Cincinnati. But these institutions are also in a class by themselves. The average citizen is more concerned with the hospital which he helps to support by voluntary contributions and which, without State aid, he would be called upon to support more directly than he does at present, and it is of these I shall speak more particularly. The business of running a hospital is like any other business, inasmuch as it needs to be learned. No one would take a man, whatever his personal attainments in his own special line, and set him down at the head of a bank, a store, a ship, or an army corps, and expect him at once to give a competent and valuable opinion on the various in- terests involved. Like anyone else he would just have to sit down and learn. He would leave himself entirely in the 43 44 International Congress of Nurses hands of the officers administerino^ that business, and unless he had confidence in them, would be rash to lend even the support of his name. If he interfered in the detail working without knowing anything^ about ft, he would be still more rash. Yet in a hospital, in which the issues of life and death daily concern many people, such hesitation is remarkably rare. The youngest physician or the most recent trustee thinks there must be something wrong if he does not im- mediately understand all about it, and is surprised at the strength and diversity of interests he finds tugging different ways. But, as a matter of fact, a hospital is no less full of the interests of life and progress because it also holds the sick and the dying', who are unwillingly loosening their grasjj of these same interests, to join those who sleep soundly in spite of it all. Since I have told you that I cannot describe any general method of administration, where every institution is a law unto itself; that I can give you no trustworthy figures of cost per capita or other details which have proven so interesting in the able papers preceding mine, you may wonder what I have to say, and why I do not take the or- ganization of one or two hospitals personally known to me and merely say, "and the others are rather like these." I do not do this because in the first place there is much of interest to be learned regarding the internal working of hospitals, and since we say in the announcement of our Teachers College Course in Hospital Economics, at Colum- bia University, that we " hope to teach our students the duties of a superintendent of a hospital," it may be well that they should hear a little of these matters. I think you will all admit that it is positively remarkable how a nurse will go through her three or more years in a hospital, and yet know absolutely nothing of its administration as a whole. She knows whether she gets her time ofi duty, a certain number of lectures, good food, and certain requirements for her patients ; but the machinery which provides her with all these things, she has no idea of . I think, however, that although these matters have perhaps little to do with nursing Hospital Administration in America 45 per se, you may fairly be supposed to be interested in them, for you also are citizens. Another reason why I have consented to speak on this subject, and the reason for my doing so with absolute candor, is that not only is much money admittedly wasted in the duplication of charities and the lax methods of administration, but the first to suffer from the maladminis- tration of a hospital are undoubtedly the patients. This sounds to us like a truism, but the public does not yet appear to realize this elementary fact, nor that it alone has power to mend matters by the intangible but very real weight of public opinion and by ascertaining which are the right sort of charities, rightly and reasonably governed, before giving its money to them. Any person of average intelligence can do this, if he is willing to spend a little time about it and take a considerable amount of trouble. It seems obvious that if too much is left to inex- perienced men, if the food is badly served, if the patients are subject to undue interruptions, if a mean and petty spirit pervades the institution, instead of one of cheerfulness and peace, if the visiting staff do not visit, if through interest, jealously, or for all too common reasons, incompetent men are appointed on the staff, it is clearly the patient who suf- fers primarily. But no business is conducted with so little real inspection ; no doll's repair shop is provided with so little skilled labor in regard to administrative matters, or even when supplied with skilled labor has so many adverse conditions to struggle against as the average hospital in the large cities of America. As for the balance sheets and reports, we know that the statistics quoted therein are often not worth the paper they are printed on, are apparently more often meant to mislead than to inform, and in any other busi- ness would land those responsible therefor in the bankruptcy courts if not in the penitentiary. This is, of course, the result of corporate carelessnes rather than personal dis- honesty. But it is wonderful how general it is, especially when it is remembered that hospital funds are, or should be, practically trust funds, and liable to a public accounting. 46 International Congress of Nurses The public who have contributed this money in one form or another have at least a right to a plain and accurate statement, if one is issued at all. I fear that a simple-minded inquirer who thinks that in order to ascertain the facts in regrard to any institution in which he is interested, he needs only to send for the last annual report, will find that his task is by no means so easy as it looks, either in regard to statements of receipts and expenditures, or the number of patients treated. He will find that frequently no attempt is made to separate income from principal ; that it is impossible to ascertain the amount of money really expended for maintenance or permanent improvements ; that often the vaguest ideas prevail even as to the total expenditures for the year, and the net profit or loss. He will find that in the detailed account for main- tenance the milk and the coal, for instance, are, for some inscrutable reason, occasionally lumped together. I call to mind one item entered thus : " Received for board of soldiers, rebate on coal, etc." In such cases it is of course impossible to ascertain either the amount of money received from board of patients, or the actual cost of the lighting and heating. Nor is it possible to ascertain what or how much " etcetera " includes. In some cases interest on mortgages, water rent, insurance and other fixed charges, sometimes even lighting, heating and salaries are not included in the estimate of expenses per capita. This of course makes the expenditure of some hospitals appear excessive, whilst others appear abnormally low. In other reports the accounts of the treasurer and the superintendent have been known to dififer by as much as $3000, and the superintendent's fiscal year may begin at one time, and the treasurer's at another, whilst convalescent homes and other branches of the same institution may arrange for yet a third.* Where trustees or managers are so indififerent in re- gard to money matters, it is hardly to be wondered at that *See editorial in Philadelphia Medical Journal for June 18. 1898. This hospital I note has since had the financial statement issued in its annual report revised by an expert accountant. It is encouraging that drawing attention to these matters makes for better and more careful work. Hospital Administration in America 47 expenditures are oftentimes unadvisedly made, and extrav- agance prevails. It would be unreasonable to expect other- wise. It is true that those institutions which receive State aid are required by the State to return an itemized account of their cash payments, divided as the State directs. In Pennsylvania, however, the State will only accept a state- ment of bills actually paid, and not those incurred. This statement obviously does not represent the expenditures of those institutions which habitually run on a deficit, and most of them do. The State Auditor told me this was done because it was found that hospital authorities sometimes made their deficit appear larger, and the consequent necessity for State aid, therefore, greater than it actually was, by running up large bills for maintenance, when these should rather be charged up to permanent improvements. For when the State makes a grant for building it requires that the sum allowed should be employed for building ; and if for maintenance that it should not be used for other pur- poses. This of course is quite proper. But the method pursued to secure this end is both inadequate and misleading. The economy effected by the simple method of not paying your bills is more apparent than real. An article on hospital finance as shown in printed reports, published as an editorial in the Philadelphia Medical Journal of June 18, 1898, written by an expert accountant who has gone into these things very thoroughly, would repay perusal by any one interested in these matters. I was somewhat surprised to find when this article came out, stating substantially what I have said above, but giving exact references, that it did not, so far as I am aware, arouse any comment whatever. A little book entitled Municipal Government, by Bird S. Coler, ex-comptroller of New York, is also most interesting, as showing that this kind of thing is not confined to Pennsylvania. He commences one of his chapters by saying " The subsidy system probably finds its greatest abuse in medical charities," and I consider his statements throughout exceedingly conservative. 48 International Congress of Nurses One of the reasons (other than carelessness) for render- ing inaccurate accounts of the number of patients treated, is that the claims put forth by the various hospitals for State aid are ostensibly based on the amount of work done, viz : the amount of free treatment given ward or dispensary patients, " the sick poor," It would seem hardly worth while, however, to do this, for, as a matter of fact, the hospi- tal which has the most political pull usually gets the largest grant', and the quality and quantity of work done has little to do with it. This is an accepted and recognized fact, and has to be reckoned with as adding to the difficulty of honest administration of hospitals in this country. It has to be allowed for in institutions dependent in any way upon State aid, and is a handicap which often crops out at unexpected moments. One hospital, in order to add to the ostensible number of cases treated, follows a simple expedient in counting the new patients, first as one visit ; then counting the total num- ber of visits, including the first visit ; and adding the total number of new cases again to the total : thus, if there were three hundred new cases and a total number of nine hundred visits, it would be carried out as a " grand " total of twelve hundred. These simple little methods are by no means care- fully hidden. Again, when a visit of a legislative committee is to occur, whose prerogative it is to inspect all hospitals applying through the State Board of Charities for State aid,, every possible dispensary service, surgical operation, or ward class, is quite easily arranged to fall in at that hour. Certain hospitals always know the exact hour at which tO' expect such visitors ; others do not. However, this makes- no difference in the amount of money actually obtained, such matters being settled out of court, as it were ; and per- haps may be considered merely as a delicate attention to the visitors, serving to make their stay interesting. Even a superficial examination of the minimum length of time and services rendered constituting a bed-day is also full of surprises and pitfalls for the unwary. Some hospitals regularly " admit " any dispensary patient who needs per- Hospital Administration in America 49 haps a slight operation and a " whiff of ether," and remains three or four hours to recover from the effects. Others con- sider that if a patient occupies a bed during the whole of a night, and possibly takes not only a " whiff of ether," but a good breakfast next morning, it makes one day, reckoning as some hotels do. Others again do not count as house cases any but those who are transferred to the in-patient wards, the unit being twenty-four hours. This last was the method agreed upon by the hospital authorities in Philadelphia when rendering their accounts to the United States Government for the board of soldiers cared for during or after the Spanish-American War, and if State aid were abolished this standard would probably be generally accepted. The twenty-four hour day is also used in Great Britain, and I think you will find has been so reckoned by Miss Stewart and Miss Mollett. It takes a little imagina- tion to consider the two, three or four hours stay necessi- tated by the removal of a finger joint or the opening of a felon a "day," although possibly the time does seem to the patient to go slowly ! In Philadelphia the supply of beds is in excess of the demand. This probably is also true of other cities. Never- theless new hospitals are constantly arising, irrespective of the need for them, and are given not only State charters, but State money. State aid is also given to private hospi- tals, which are used for special classes of cases already amply provided for, such as gynecological cases, and which do practically no dispensary or teaching work. They are often closed during the summer months while the physicians con- nected with them take their summer holidays. The reasons for the opening of these hospitals are too evident to need explanation, even to the casual observer. These hospitals " nurse " their patients cheaply by establishing " training schools." They issue " diplomas," and it is often not until the unfortunate pupil nurses have completed two years ser- vice that they find that in order to secure any standing in their profession, they have to begin all over again ; and that even when they are willing to do this, regular hospitals are 50 Internationsil Congress of Nurses often not anxious to take them and unteach them many bad ways. On the other hand, State aid is refused or very much cut down to hospitals in poor sections of the city which treat large numbers of out-patients and which have existed for several years. I once asked a member of the State Board of Charities why this was done, and the answer was a some- what sweeping, " We do not approve of dispensaries." Con- sidering the miscellaneous assortment of things the board did apparently approve, I thought this was sufficiently inter- esting to ask " Why do you not approve?" and the answer was, "Because the doctors do not approve." "Nor the druggists," murmured another member, " don't forget the druggists." I was not aware that the medical profession or the drug trade were " infant industries " to stand in need of a protective tariff, as it were, or that hospitals were estab- lished solely for their benefit. Moreover, these statements seemed to me to be hardly warranted by the facts. It is my belief that the greater number of physicians get too much out of their dispensary practice to disapprove of It, and that they themselves would readily admit this. From the professional point of view numbers of medical men, both young and old, add much yearly to their medical lore by the study of dispensary patients. No one who has not had to buy them knows the number of new drugs used experi- mentally; if apparently successful, to be then used on in-patients under closer observation ; if still yielding satis- factory results, then in private practice. There are also many classes of cases, such as broken arms or skin diseases, nasal deformities, chronic but slight orthopedic deformities, slight organic heart diseases, which it is cruel and unnecessary to force into the hospital as in-patients. To oblige this class of patients to stop work entirely and break up their homes for an affection requiring frequent, although slight attention, is forcing pauperism upon them. To say that this class of patients can afford to go to a doctor's office is not the case. The physician who has a fairly good practice and an average experience, cannot afford to treat them. The young man Hospital Administration in America 51 who is only busy waitino^ for patients to drop in, has not only a very limited experience, but also possesses none of the material resources of a hospital. He cannot afford to give the patient lint, bandages, splints, ointments, or medicines, and the patient cannot afiford to buy them at retail druggist prices and pay the doctor even a small fee. But most of all, the patient whose health is his only capital, as well as his income, cannot afford the loss of time which inexpert treatment entails. The unnecessary loss of skilled artisan labor is also a loss to the community which may be reckoned in dollars and cents. Moreover, anyone who knows anything of hospital work, knows of many instances where patients have drifted into the dispensaries with ununited fractures, simple skin diseases which have lasted for years, and what not, saying they have spent all their money on doctors, and now haven't a cent left. Any case which the physician feels is imposing on his tinte and on the hospital supplies, he can easily question at the time he is taking the patient's history. By the manner of the replies as well as the matter, aided by his knowledge of human nature, he can frequently tell what sort of case it is. If a border line case, as it were, the patient can with perfect propriety be made to take his turn with his undoubtedly poorer neighbors, can be lectured on, or used for demon- stration to students. This weeds out many. Or the physician can say simply that he does not consider him or her a proper case for hospital treatment. Such cases can be reported at the hospital ofifice, and investigated either by the Charity Organization Society, which will look into and promptly report upon such cases, or by the hospital inquirer who is deputed for this duty. It is also to be noted that physicians themselves not infrequently encourage the attendance of " interesting cases " quite irrespective of their social status. As I have lived most of my hospital life in teaching institutions of one sort or another, I must confess to a certain amount of sympathy from this standpoint. In any case, while it is certain that many patients obtain dispensary aid who are able to afiford small fees, the cure of 52 International Congress of Nnrses dispensary abuse must necessaril}^ originate with the phy- sician, and be carried out with his co-operation. It cannot be done without it. And from the patient's point of view I must again repeat that to force many patients to become hospital in-patients, is to force pauperism upon them. Few have any reserve fund, and coming into a hospital, especially for a semi-chronic condition, means breaking up their homes, selling their bits of furniture, and boarding the children out. I have not heard this point stated, but I know it to be a fact. The deserving poor are not always those who have not a cent in the world, nor are those the poorest. It is undoubted that there are just as many abuses from the medical side as there are from that of the patients, only the patients have no one to write their briefs for them. Another point in dispensary service which I mention merely to show the many aspects which this question as- sumes, and the many interests involved, is brought up in an article by a physician recently published in a well known medical journal,* contrasting unfavorably the treatment accorded by hospital superintendents to physicians working in dispensary services, compared to that accorded phy- sicians of equal standing in the wards of a hospital ; this more particularly in neglecting to furnish instruments for their use, and the unreasonable number of patients they are expected to treat in a given time; and recommending per- sonal supervision by the superintendent as a remedy. So far as I have been able to observe, these statements are quite true of all large city hospitals from which I have been able to obtain data. But neither the reason or the remedy would appear to be well taken. The hospital superintendent does not, for instance, wilfully assign an undue number of patients to a certain physician, seeking to overwork or incommode him. The superintendent indeed generally has nothing whatever to do with the assignment of patients, each hospital having its own rules or customs in regard to this. When one remembers the " feelings " which are aroused by the sometimes accidental transference of patients ^Philadelphia Medical Journal, Aug. 17 1901 Hospital Administration m America 53 from one service. to another, one wonders at this particular complaint being- brought ! In any case, the remedy would seem to lie with the physician himself, rather than with the superintendent of the hospital. The patients whom he finds himself unable to treat might be referred to another service, or even another hospital which is not so crowded. In the present overstocked condition of the medical pro- fession, where the supply is greater than the demand, he might secure additional assistants, who, if they do not already know, might soon learn to carry out routine treat- ment, referring all doubtful cases to the " chief of clinic " or head physician for supervision and direction. Given suf- ficient space and light, this difficulty seems capable of solu- tion in more ways than one. In regard to the supply of instruments, it is only too well and widely known that hospital superintendents are not able to keep dispensary services supplied with instru- ments, because they so speedily disappear. I think it is seldom wilful neglect on the superintendent's part. It is merely that it is useless to supply them. In the recent report of the Bellevue Medical Board in connection with the reorganization of that institution, the recommendation was made that an officer be appointed whose duty it would be to see that hospital instruments and supplies were not removed. Judging from one's own experience, however, it would take manv duplicates of Sherlock Holmes to accomplish the desired result. For the foregoing reasons, the immediate supervision of dispensary services either by the hospital superintendent with his many other duties, or by an officer appointed for that sole purpose, is, I fear, impracticable. In this department the physician himself is quite properly supreme, and upon him alone falls the responsibility for right treatment of patients, or in the last resort upon the appoint- ing power which places him there. L.A.Y VS. MEDICAL CONTROL. Governments, like lesser folks, are judged by results. Whether the government be called a limited monarchy, an autocracy, or a republic, is of less importance than that it 54 International Congress of Nurses should be efficient, and secure to the people their just rights and privileges. Lyman Abbott, in his Rights of Man, says of Government " Its function is the protection of the inherent indefeasible rights of person, property, reputation, family and liberty. It has other and secondary functions, but if a government fulfills this one function of protection justly and adequately, it is a good government whatever its form ; and whatever its form, it is a bad government if it fails to per- form this function justly and adequately ; it is pre-eminently a bad government if, instead of protecting rights, it violates them." These words apply to the administration of hospi- tals, as well as of cities or countries. The rules, customs and government of a hospital often intimately concern the happiness, rights and persons of from two to eight hundred or more people, sick and well. And from whatever ranks the governors are drawn, lay, medical, or both, the govern- ment is practically an autocracy, from the decision of which there is no appeal. Therefore it behooves us, whenever we have the power of choice, to choose our autocrats wisely. To maintain a just and fair equilibrium between science, philanthropy, and an annual deficit is often the far from enviable lot of the board of trustees. Indeed finance is often the most urgent of the three, for the butcher and drug dealer are by no means as patient in the settlement of their account as is science ! Running a large business on a deficit needs very consistent and very thorough attention from some one if the doors are to be kept open, patients fed and even small salaries paid regularly to the necessary employes; and this quite without consideration for the supply of the newest scientific apparatus, the very latest discovery in drugs, and the repair of large and much used buildings. Whether medical men are generally constituted to fulfill the requirements of all good governments and also those of finance, I will leave you to consider. Your consideration will no doubt be aided by the somewhat acrimonious dis- cussions on this subject which are frequently to be found in both the medical and lay press — particularly the former. The medical administration of the enormous City Hospital Hospital Administration in America 55 in Vienna is not to be entirely ignored. The conduct of nurses' registries and societies by medical men, where they have control, will doubtless be of use to you. There is also a very excellent chapter on this subject in Sir Henry Bur- dett's Hospitals and Charities for 1901, page 69. THE HOSPITAL SUPERINTENDENT. I have touched upon a few of the varied interests which are to be found in every large city hospital, and, as you know, there are very many more which I have not men- tioned. Now to reconcile these diverse elements it would seem almost necessary to choose a man or woman of skilled knowledge, with marked executive ability, with ceaseless energy, a warm heart, a wide knowledge of human nature, and good health. Now what really happens? As Lord Alelbourne said of the Order of the Garter, "There is no damned merit about it." Amongst the hospital superintendents I know of, there are, besides a very few physicians, an ex-newspaper re- porter, a ward boss, a china factory hand, various clerks, and a still more varied assortment of clergymen. The clerks. who have possibly before occupied the position of hospital bookkeeper, are the only ones who can be said to have had any previous knowledge of the office or business routine of a hospital, and this after all is a point which is more easily acquired than any. A good superintendent is, of course, sometimes evolved, but it is at the expense of the institution as well as of the individual. Some, taught in the dear school of experience, undoubtedly become first rate hospital super- intendents ; — I suppose on the principle that it is not advan- tages that make great men or women, but disadvantages ; — and many certainly work hard and unselfishly. But surely if there was ever a calling which needed preliminary train- ing and skilled administration, it is that of hospital superin- tendent. Teachers are taught to teach, engineers are taught engineering, bridge builders to build bridges, preachers to preach, doctors to doctor, but to reconcile the innumerable 56 International Congress of Nurses and various elements in a large and busy hospital no previous knowledge seems to be thought necessary ! Indeed, if a man has failed in other walks of life, or if a clergyman has neither the mental nor physical calibre to command suc- cess, he seems by some curious process of reasoning to be considered peculiarly fitted for such a position. In no busi- ness that I ever heard of in which the same amount of money is invested, is there so little skilled labor employed as in hospital administration. This acts and reacts in many ways, and renders institutional life in this country subject to many sudden upheavals and much friction. The patients complain, the physicians complain, the employes complain, in fact everybody complains, and the Board puts on a worried air — as well it might — for there seems to be a cer- tain amount of justice in all the complaints, and whilst nobody appears to be as much in the wrong as asserted by the opposite party, still there is enough to perplex it very thoroughly. The superintendent either fails to control these matters at all, or else adds to the difificult3^ Then, in order that the domestic complaints may be removed, a committee of ladies is sometimes appointed ; they are not experts, often far from it, their only claim to knowledge being that of the " born housekeeper " which is sometimes supposed (erroneously, I think) to be inherent in every woman. The organization and management of institution households, however, having little in common with that of a few maids and no sick people, the management of details by Visiting Committees is often proved to be but an added discomfort. Having trusted one superintendent and found him or her wanting, the Board of Management is naturally chary of trusting his or her successor. In the first place they don't as a rule know where to look for a successor. Hospital superintendents are usually just men who happen along. It is not so much a distinct calling at present as a tentative , occupation, usually applied for by a man who is " out of a job." If a large hospital with plenty of funds can aft'ord to pay a good salary to a medical man who has talent for detail, and prefers administrative work to the more active practice Hospital Administration in America 57 of his profession, it seems to be the best solution. He has a fixed salary and usually does no outside practice, and thus the difficulties in the way of his independence, which might apply to the outside practitioner, have not to be reckoned with. But he also has to learn how to take care of build- ings, how to purchase supplies, obtain estimates, and keep the whole intricate machine in good running order ; and this costs the hospital money, for all large department stores will tell you that a good buyer is far more valuable than a good seller, and hospital buying is a fine art. He usually has a good steward whom, with the housekeeper, he trusts to pur- chase the household supplies. He often has a practical builder to attend to repairs, and a good office force. The details of the various departments, and the knowledge which the superintendent has of them of course depends upon the individual. As a rule, if he shows himself faithful and just, no important steps are taken without his advice. He is held responsible for everything in regard to the administration of the institution, and for the employment of proper persons to carry on the work of the various departments. This is as it should be. Unfortunately, hospitals so administered can be counted almost on the fingers of one hand.* In one large hospital, the Johns Hopkins, according to the by-laws, the superintendent is a member of the executive board, but I do not think this is general. Now the point which will be of special interest to you is, can a woman who is a trained nurse do this work? There is no reason why she should not. The reasons for and against lie within herself. In spite of the immense strides which women have made of late years in regard to public work, it is even yet, and even in this country, which Max O'Rell justly calls a paradise for women, undoubtedly more dilficult for a woman to carry out executive work concerning large numbers of people than it is for a man, and perhaps it always will be ; but to say that it is more difficult is not by any means to say that it is impossible. As there are com- [*This statement is perhaps too sweeping. — Ed.] 58 International Congress of Nurses paratively few medical men who desire such positions, or if they do desire them, possess the necessary quaUfications, and as the newspaper reporter, the clergyman, or the factory hand possess no knowledge at all of hospital work or requirements, it would seem that a woman who had worked in the wards of a hospital, who had lived there day in and day out for at least six or more years, should certainly be of more use than these, and have less of the technical part to learn. Florence Nightingale says that " in all depart- ments of life there is no apprenticeship except in the work- shop " and it is certainly the most thorough and the best, and worth whole books of theory. It seems to me that if women were more willing to take up this work, many of the difficul- ties, and much of the friction of hospital life might be avoided. If the visiting staff see that the superintendent is not only willing but anxious that they should have not only the necessaries, but all the luxuries or additions which make their work easier that the hospital can possibly afford, and knows exactly what these requirements are, they feel naturally far more friendly toward the administration as a whole. In many ways hospital keeping is but housekeeping on a larger scale. It does not follow, however, that because a woman is a good nurse, or even a good superintendent of nurses, she is a good hospital superintendent. The work is very differ- ent. The hospital superintendent represents the hospital, not only to the patients and their friends, but to the trades- people, building contractors, the city government in the mat- ter of Boards of Health, and coroners' offices, and, in short, in all the varying phases in which this varied business touches the public weal. Decisions affecting varied inter- ests and large numbers of people must often be made quickly. If it can be shown that a decision is narrow- minded, petty, or errs in any particular, because unsuitable or too severe, the superintendent's judgment will naturally not be relied on in future. It is absolutely necessary that, humanly speaking, no mistakes should be made. More specially does this apply if the superintendent be a woman, Hospital Administration in America 59 because as there are fewer women superintendents of busy hospitals, any errors are more closely watched for, any failure is a double failure. If the same mistake were made by a man, the public or the individual concerned would merely say " they have made a mistake in selecting their superintendent," but if a woman, not only the individual, but her sex is at fault. There is one point especially where there is room for the right use of woman's influence in hospital work and that is the influence of women for purity. Unfortunately, I know of more than one hospital, indeed, more than two or three, where this is still needed. It is an unfortunate fact that men in teaching institutions, holding the rank of professors, wall relate stories or indulge in coarse remarks, or even so clothe their instruction to undergraduate students, that their words necessarily make a modest or clean-minded woman exceedingly uncomfortable. It is also a fact that this is by no means accidental ; it is often quite obviously done for the purpose of making the nurses appear confused, or rais- ing a laugh among the students. It is no part of a nurse's duty to put up with these things ; there is no reason why nurses should not be as modest and delicately minded as any other women, and as far as my own experience goes, I have found them so. But it is not fair to send a young girl to a clinic, to require her as a matter of obedience to be present whilst the professor makes unseemly jokes, or lectures on a case in an unnecessary way. But whilst I feel sorry for the nurse, I regret it even more for the sake of the students. Thev hear the professor, sometimes a man of almost world- wide renown, relating these stories and making these unseemly jests. They think it is a manly and professional thing to do. Where teachers offend in this wav, it is obvious that assistants will often follow suit. But even for the sake of holding the student's attention at lecture, is this a right thing to do? All young men have not good home influence to help them combat the effect of this loose way of talking and thinking. Many of them are drafted straight from college to positions as resident physicians in hospitals, where 60 Inter national Congress of Nurses they make many mistakes as a result of this sort of teach- ing. That some " come out right in the end " is no argu- ment in favor of it. Some do not. Surely the attitude of a teacher of such a profession — which should always be in fact the " noble profession " of medicine — should be some- what different. It is not a pleasant task, but it is the mani- fest duty of every superintendent of a hospital, or superin- tendent of a training school, to see that the nurses at least are not subjected to this sort of thing. And the young men will also benefit, and some day, even though that day may be far ofif, they will thank you. Those of us who bear the burden of responsible positions have to face many unpleasant duties, but we have got to remember that, as President Roosevelt says, " Whoever possesses power, is by the mere possession of that power made responsible for its right employment." MEDICAL SCHOOLS FROM THE PATIENT'S POINT OF VIEW. As a matter of fact in a properly administered hospital, medical schools are a protection to the patient rather than otherwise, for it usually means that the hospital is a very live one, and thoroughly up with the times. The patient is safe-guarded by public sentiment which in this country is against overmuch experimentation. But this, as I have said, provided the hospital is carefully administered. That is to say, that although students are taught to work in the wards, proper consideration is had for the patients. I have found that patients, even pay patients in the wards, do not resent the doctor's describing their case as an interesting one ; they are quite willing as a general rule to be lectured upon before a class of students, and allow students to examine chest or heart and so on, in moderation. If you have a capable head nurse in the ward, she will keep her eye on any case which may be in process of examination by the students ; and a kindly word, saying that she is afraid the patient is tired now, and had better rest, I have never found resented. In properly arranged ward classes one, two or three Hospital Administration in America 61 students are assig-ned to certain beds, and the patient is not examined by forty or fifty young men one after another, as seems to be the popular conception. If the patients are women, a nurse is, of course, always at the bedside of the patient whilst the students are there. In teaching hospitals, whether under-graduate or post-graduate, the supplies are much more liberal than in non-teaching institutions, and I think that on the whole the patients are generally better nursed, for every one is kept up to the mark, including the professors. If the patients object to examination, I have always found that the students are perfectly willing to con- sider their feelings. INSPECTION OF AND PUBLIC INTEREST IN HOSPITALS. It would be a distinct advantage if frequent official inspection of all charities receiving subscriptions from the public were ordered by the State or municipal government. Whilst it is true that a hospital must possess a charter of incorporation in order to hold property as a body, this does not prevent all sorts of abuse. Every institution whether it be a hospital, or any other charity, to which the general public is invited to subscribe, should be subject to this inspection at least once in three months, and if the inspectors are not satisfied with its condition, at least once every month. Institutions supported by the public are owned by the public, if the people would only realize it, and it is their duty as well as their privilege at least to see that these institutions do not become hot-beds of disease. Of course when the millenium comes no man or woman will ever engage in an undertaking for others without really trusteeing it. But as matters are at present, some sort of supervision is certainly necessary. To prove my contention, if it needs proof, I would again refer to the comments of the ex-comptroller of New York in the book which I have already quoted. In my opinion it would be for the greater good of the greater number, if an act of total prohibition, or at least high license, was passed, regarding so-called private hospitals. By this is meant a 62 International Congress of Nurses house rented by a physician as a personal venture, to which he sends his own patients. As a prominent physician said to me the other day, " the private hospital is a star chamber ; no one knows what goes on there and there is no way of finding- out." You will say at once that " the reputation of the man who owns it is sufficient," but as a matter of fact, this is not so. In the first place he cannot prevent another man with a lesser reputation, or a shady one, from doing exactly the same thing. As a rule the patients in private hospitals are not by any means so well nursed nor so well fed, as in the private rooms of a general hospital. The rates are often very high, and the friends of the patient often make every effort and stint themselves for years in order that the patient may receive treatment in the private hospi- tal of some physician or surgeon, thinking, no doubt, that the article for which they pay so highly must be better in quality. It is true that there is greater privacy, but it must be remembered that it is not only in Trusts that publicity is protection. It is often protection for the patient as well. It seems also rather infra-dig. for physicians who have already made big names for themselves, to run this sort of a boarding house for gain. They may say that they can obtain better what they need in their own houses ; but any- one who knows the running of a well-equipped hospital, the attention given and the supplies furnished members of the staff, will hardly consider this a valid reason. The only cases to which exception might be made are nervous or mental cases which sometimes require to be isolated from their friends, and kept exceedingly quiet for weeks at a time. More particularly should the practitioner who is not con- nected with any hospital, who has certain classes of practice, such as gynecological or obstetrical, Ije required to show very good reasons to the city authorities before starting a " private hospital," or taking patients into his own house. And this for his own sake as well as theirs. In any case, the licensing of such houses, and an arrangement by which, although having the use of the house as required, the phy- sician would have no direct monetary interest except in the Hospital Administration in America 63 fees paid for professional services, would be a distinct advancement. In conclusion, before any more definite information can be g^iven concerning the detailed arrang^ement and expense of hospitals in this country, it is necessary that a uniform sys- tem of accounts be established which shall be regularly audited by a certified accountant, and that a certain definite amount of information derived from figures resting on a definite basis be forthcoming from all institutions soliciting money from the public and not only those receiving State aid. As I have pointed out, a bed-day which varies in length from four hours to twenty-four, is of no use. It is indeed so misleading as to lead to a rcductio ad ahsiirdnm in some cases. It seems as if there should be some check on the unnec- essary multiplication of charities. Perhaps some of you may have heard or known of the time when the supply of orphans in New York gave out, to the dismay of those who were engaged in founding new asylums and liked to see their names on the front pages of reports? Hospitals in these big cities are nearly, if not quite, in the same case. Some day an organization of these charities will surely be required. For instance, it hardly seems necessary, where all hospitals admit their patients without distinction of color or creed, and allow the pastors of the various denominations to visit their sick without let or hindrance, that each separate denomination should multiply machinery and salaries, simply for the sake of calling a hospital by a denominational name. These hospitals are sometimes well supported by the rich members of the congregation, but they often suffer from many of the worst features I have described, and others which I have not. It is diflftcult to advise the total abolition of State aid for charities, even semi-private ones. The public, particularly the working element which mainly depends upon these institutions for help in time of sickness, has not learnt to support them ; and many of these institu- tions do a very useful work. The knowledge that they receive any aid from the State, however, takes away from the 64 International Congress of Nurses general masses of the people the feeling of responsibility for their support. And perhaps this may be the reason that neither the working man or the large employer of labor in mills, factories, etc., supports hospitals to the same extent as obtains in Great Britain, where the hospital system is purely voluntary (excepting, of course, poor-law infirmaries). The subscriptions received at street corners and in public buildings, on Hospital Saturday and Sunday alone, amounted in 1898 at Wolverhampton, a comparatively small manufacturing town in England, to £36.28 per 1000 of the population and in Liverpool to £23.16.* Contribu- tions from work people are often entered separately, and in the Bristol General Hospital where this is the custom, amounted to £1,727 for the year above mentioned. The economy of organization is shown by the Organized Hebrew Charities of Philadelphia, which in its first year not only showed all its charities in a flourishing condition (many of which had previously languished) but a gain of over $26,000 in subscriptions. Let me say, finally, that the foregoing facts and sug- gested remedies (where it has been possible to suggest any) do not apply to country hospitals, nor country districts, nor country physicians. These no doubt have their own trials, but they are not those of the great cities. And for this they may be duly thankful ! The President : I would like to call upon Miss Palmer,, the editor of the American Journal of Nursing, to open this discussion. She has been prominent in training school work and hospital work. Miss Palmer : I feel somewhat embarrassed to be called upon to speak extemporaneously upon this subject of hospi- tal administration after listening to the three papers so ably prepared. I am going to ask the privilege of speaking only from my own personal experience in the administration of *Burdett's Hospitals and Charities, 1900. page 204. Hospital Administration in America 65 hospital work in this country. I think I have been very much happier in my hospital experience than our able secretary. The positions which I have been fortunate in occupying as a hospital superintendent, covering- a period of nearly fourteen years, include three dififerent hospitals. My train- ing was in a large hospital in Boston and I do not hesitate to say that the administration of that hospital was honest, the physicians were honest, and the patients were well taken care of. My first experience as a superintendent was in organiz- ing a little hospital of only ten beds in a small manufacturing city in the southwestern part of Massachussets. I repeat that same statement as to the administration and honesty of that hospital. yiy next experience took me to \\'ashington where our administration was very much influenced by politics. The hospital there, and the administration of its affairs was con- ducted by a board composed of men and women who were certainly sincerely honest and uncorrupt in their methods of administration. In the last hospital which I have until recently had the honor to preside over, in the neighboring city of Rochester, we had a very complete system of bookkeeping. It was in existence before I went there and had been carefully worked out by some very successful and able business men. and I could call on my bookkeeper for a report for the detail of expense of any department of that institution, and have it in five minutes ; what it was costing to heat the building, to light the building, or any other one item. I would like to say one word in regard to the point which was brought up in the last paper with reference to the position of superintendent being held by nurses. I think the difficulty most superintendents have to contend with at the present time in our hospitals, is the difference in the attitude of the public towards men in that position, and women in the same position. The public is not accustomed to give to a woman the same privileges it gives to a man. 66 International Congress of Nurses It expects a man to have his family with him and to lead a social life. It looks upon him as a citizen. The woman is always expected to be there, day and night. She must attend herself to every item of domestic detail from the highest to the lowest. She must see every patient in the hospital personally and all of their friends. She is never off duty, and is unable to take the relaxation which men are accustomed to allow themselves. The President : The papers are now open to general discussion and we shall be very glad to hear from anyone who has anything to say upon the subject. Aliss Davis : I can only endorse the secretary in her paper, as I have been in the same locality and I have met with quite the same difficulties and the same experiences as those she has met with. I have also been trained with the last speaker in Boston in a well trained, honest, straight- forward Puritan hospital. Mrs. Kinnev : I feel after listening to both Miss ^ CD Banfield and Miss Palmer that, as Miss Banfield said, there are two sides to the question. Miss Palmer has been happy. Any one who has had charge of a hospital in Massachussets ought to be happy, but I am sure that any one who has had experiences in eastern hospitals can hardly be allowed to judge of hospitals that have no tradition. In Boston hospitals people enter and fall into line and walk along with the procession, so to speak, without ever doing anything out of line. Take the hospitals in the far West; everybody has opinions of their own and they are allowed to express them and live up to them. I had the experience of working under a man who dyed and curled feathers all his life ; that was all he had ever done ; after he was made superintendent I was asked to look after the nurses, and I do not think Miss Banfield has touched the situation. The superintendent who followed him after a certain length of time was a French officer of the Franco-Prussian War; a most admirable gentleman so far as courtesy was concerned, but he had never been in a hospital in his life. One day Hospital Administration in America 67 I was passing- through the corridor and he said to me, " Come here, come here, come here !" I rushed to the window and looked out on a large square and there were three of my nurses standing on the g-reen playing ball. He said, " Is that not scandalous?" I said, " No." He said, " For young women to make such a spectacle of them- selves," and I said. "Why ?" I did not go further; they were recalled and forbidden to play ball on the grass. I could tell you things which you would not believe. Visitors were allowed to enter the building, no one to receive them, no one to show them about the place. They simply entered and went where they wished. They stayed as long as they wanted to; they came at six o'clock in the morning and stayed until ten o'clock at night. There were as many as they pleased. They came in droves and went when they got ready. I had two large signs printed in gold and stood them at each side of the door and directed the nurses to tell visitors that the hours for visiting were as printed on that sign. The visitors at once complained, and I was summoned to the office and reprimanded. The first morning I was in power I was summoned to the room of a patient whom I had a short time before seen in the bed with his clothes, shoes and hat on. I had directed that he get up. A short time after I was summoned to the room by the visiting physician and instructed that we were not to interfere with the patients doing as they pleased, and that patient afterwards got into bed with his clothes, shoes and hat on. I think I have said enough to substantiate Miss Banfield, that there is another side to the question. Dr. Hughes, (Boston) : I quite hope that our foreign delegates will not go home with the idea that we are still in the stage of the American Indian. In some of the Western cities we still find hospitals that are not all that we might wish. We have in this country, of course, more politics in one way than in England ; in another way not any more. But all our politics are not bad. I know of a board that is 68 International Congress of Nurses composed of two Democrats and two Republicans and the fifth one is, as they say, the one who sits on the fence. The medical officer is appointed by those poHticians and he had remained in that capacity for twenty years because of his ability. In this country we find many men taking a hospital management course, and although there are a few boards who try to get a larger number of beds and alter the figures so as to get larger appropriations I think they are in the main honest and sincere. Miss Durkee : I have had little experience, but would like to speak a word for an honest management under a board of women managers. These women, who were responsible for the maintenance and efficiency of the train- ing school, worked in the greatest harmony with the super- intendent of the hospital, a medical man appointed by a board of men. Personal views were always put aside for the good of the patients and the work generally. They looked upon the superintendent of nurses as a specialist and expected her to supply the knowledge and experience which they did not possess. Miss Banfield : In speaking of the way that hospital administration is carried on, I thought I had to speak of things as I found them — not as I thought they ought to be, or as it seemed desirable they should appear to visitors. I really did not think of the visitors at all. I have no doubt they have troubles of their own. But as I told you, I found no uniform system to dilate upon, statistics so rarely reliable that no comparisons could be made, and so on. Nearly every speaker has used the words " honest — sin- cere." You will observe that I never once used these words, except where I specifically stated that these inac- curacies were of course not due to personal dishonesty. I added, however, that such methods would inevitably land all concerned in unpleasant places if pursued in business mat- ters ; that the administration of public business and the Hospital Administration in America 69 spending- of public money should be of the same moment to us as the care we bestow on our own affairs. This I think may be considered incontrovertible. Frankly, I am g-lad that you disapprove of the facts I have stated. I would only remind you that I did not make these conditions. I only related them. Denying^ facts does not do away with them, or I would deny them all most cheerfully, and at once. But as it is, I cannot take back one word I have said. I could add many more. I should like, however, to mention that, obviously — or it seems obvious to me — I was by no means calling upon my own personal experiences, although I do speak from per- sonal knowledge of every point I have touched upon. Naturally if the conditions I have spoken of prevailed in the hospital with which I have the honor to be connected, I either should not be there, or I should not say a word about it. I am happy to say that my personal relations with trus- tees, physicians, and fellow workers of all degrees, have been, and are, all that the most exacting could require ; and for this I feel a deep sense of personal gratitude and appre- ciation. But it never occurred to me that my own personal experiences would be of interest of this Congress, especially as I regard myself as unusually fortunate. It was hospital government in general which, since we say we prepare students at Teachers' College to take part in it as superin- tendents of hospitals, it seemed not unreasonable we should look into. I really did not like what I found any better than you do, but that did not seem to me any reason for sup- pressing it. As for politics, Washington may be " the hot bed of politics " in one sense, but not in the sense of the ward boss and city politician — politics affecting the admission of patients, the police force, and city government. For Washington is the one city in the States which has no city politics, but is governed by direct grant of Congress, and independently of either Democratic or Republican party changes. Its citizens have no vote. It is often said to be the best governed city in the States. The ordinary wnre pulling 70 International Congress of Nurses of influential people I suppose exists everywhere, and Washington may perhaps be unduly well ofif in that respect ; but ward or city politics it is spared. Possibly it requires some one who lives in Pennsylvania to appreciate all that it escapes. In conclusion, I may say that the reason I did not give instances of every point I brought up, and cite page and name of hospital reports, was because I have no wish to hold up any particular institution or medical or other body of men as " bad examples." It is by drawing attention to it that I hope to mend it. I have given sufificient data to enable any of you who wish to look the matter up for yourselves. The President : I am very sorry that for the lack of time we must close the discussion. Our next paper, although on the same subject, is on a little different line. The Relations of Training Schools to Hospital Administration. MARY M. RIDDLE, Assistant Superintendent of Nurses in the Boston City Hospital, Member of American Society Superintendents of Training Schools, Delegate from the Boston Nurses' Club. As the interests of any hospital and its training school are closely interwoven, no argument is needed to confirm the statement that they are mutually dependent. That which militates for the advantage of one reacts for the good of the other and vice versa that which is to the detriment of the one is also an evil to the other. Since they are so closely allied and participate so nearly equally in the results accruing from their collaboration, the proper adjustment of their relationship seems a simple mat- ter. But, many systems are in vogue and it is only by care- ful consideration of circumstances and the needs of the time, together with a just estimate of the value of each to the other that a satisfactory solution is possible. It is a self-evident fact that in every hospital some form of government is necessary, and if it be that which provides for the efficient management and preservation of the com- mon interests, promotes the general welfare, and establishes a permanent happy state, it accomplishes its purpose and no individual or class of individuals is at liberty to interfere with its administration, lest it be weakened, and the end to be attained frustrated. Organized training schools for nurses are of comparatively recent date and their modes of growth have been that of evolution from the simpler and less complex organizations of the beginning, on and on to the 71 72 International Congress of Nurses present, when we find their manag^ers contemplating- univer- sity education for the pupil nurse. When these schools were in the simplicity of the beginning it was no uncommon thing to find them managed by boards in no way connected with the hospital. This was especially true of those hospitals which employed religious orders to care for their sick. Such nursing bodies did efficient work, and paved the way for their more scien- tific, though possibly less devoted followers. They were, from the highest religious motives, most devoted to the relief of human suffering, and were responsible only to the head of their order, regarding the hospital as the means whereby they were allowed to fulfill their vows and to exercise those functions and attributes which made them indeed " Sisters of Charity." Other schools there are, governed by superintendents who have no voice in the executive affairs of the hospital, but whose interest is concentrated in furnishing to the school clinical advantages for study and observation. This relation- ship of school and hospital may have items in its favor, but there are evident disadvantages, prominent among which is the effect upon the nurses themselves. It is possible and altogether probable that by a training thus given, nurses may be produced who fail to consider that the welfare and comfort of the patient is of primary importance. His wel- fare may receive due consideration, but his comfort and happiness are of secondary value. He is the means to the end that they be educated and they unconsciously drift into the belief that all patients were created for their benefit, whereas the reverse is the fact, viz., that nurses are created for patients. Again the training school may be governed by a super- intendent who with the school is employed by the hospital to do the nursing therein. Hospitals and training schools thus associated have been known to flourish and go on to success, and to send out graduates who take and maintain positions in the front ranks of the profession. Furthermore, this association of school and hospital has been one method Training Schools and Hospital 73 of solving the problem of political control or rather of keep- ing the school free from political influence when the hospital is under its domination. It has also been a method of securing greater freedom for the school, in that it allows the accomplishment for the hospital of what is reasonable rather than the exaction of what is desirable, with the result that the possibilities for the preservation of the health and strength of the nursing body are greatly increased. Another form of relationship between training school and hospital is exemplified when both are under one admin- istration. Then do we have a form of government which may more nearly meet the necessity for any government, viz., to promote the general welfare, but there are some apparent disadvantages to the school arising from this form of relationship ; first, the ability of the board of trustees to at any time abolish the training school and conclude to have the nursing- service performed in some other way ; second, it seldom calls for a " Ladies' Board," unless it may be that such a body constitutes part of an advisory board. That training school which has no Ladies' Board doubt- less loses many of the influences which tend to stimulate it in the search for high ideals and correct motives. Personal contact with women of a wider and more varied life cannot fail to make strong impressions upon nurses, and when the spoken words convey the knowledge of experience they carry with them a conviction that supplements the teaching of the school. The superintendent of the hospital is the nominal head of the training school, under authority of a board of trustees. He, in turn, delegates his authority to a superintendent of nurses, superintendent of training school, principal of train- ing school, or a directress of nurses ; one title implies the same meaning, suggests the same routine of duty and the same burden of responsibility as another, and is at the same time representative of some distinctive idea when given. Great power is gained by this combination of offices. The superintendent of the hospital, whether he belongs to the medical fraternity or to the laity, wields a farther 74 International Congress of Nurses extended influence than the average superintendent of nurses, for by reason of his professional and business rela- tions he comes in more immediate contact with men of afifairs and is constantly informed of the public pulse. In matters of discipline he is the court of appeals and from his position as head of the training school on the out- side of the actual work he should be able to form unbiased opinions and render judgment without prejudice. If he is the power to whom appeal may be made for direction and discipline, the training school committee of the board of trustees is the final tribunal or supreme court. He is an adviser not only in matters of discipline, but is to be consulted on those that are educational or that other- wise pertain to the progress of the nursing work. The superintendent of nurses, from her more intimate knowledge of the requirements of the training school, gained by her experience while in training, and her contact while superin- tending, should formulate and carry into execution plans for the advancement and betterment of the nursing service within the hospital, as well as the elevation and maintenance of standards among pupils who must soon represent the training school in the great world outside, where they will be judged by the efficiency and spirit which characterize their work. In all this the superintendent will advise and consult and he will doubtless eventually place his seal upon the results ; but if he is wise and unselfish he will permit the superintendent of nurses to proceed within limitations that are not narrowed and restricted by his conceptions of expediency, but by those which, after full and free consulta- tion, they together conclude will most surely promote the general welfare. Another element of power in this combination of offices, subject to one authority, is found when the relationship between the training school and other departments is scrutinized. It is impossible for a matron or housekeeper who is an untrained nurse to duly appreciate the necessities of the hospital from the standpoint of the nursing service, and therefore the progress of the work is frequently impeded Training Schools mid Hospital 75 by friction which is the outg^rowth of ignorance. But when all departments are subject to the one control, there can be no division of interests, and consequently no friction to over- come. The benefits resulting to the hospital and its administra- tion in every department by this unity of government may be augmented by placing at heads of all departments of the domestic service, women trained and educated in the art of nursing. Success to the whole is thus lured by every induce- ment of sympathy and interest. Here, too, is an opportunity for the development of those ethical traits in a nurse which count for much in mak- ing up the estimate of the individual as well as the professional body. Here loyalty may grow, flourish and bring forth fruit which shall rebound to the well-being of the training school, the hospital, and ultimately the whole pro- fession. The matter of placing trained nurses at the heads of departments has seldom been carried to complete success. Alany existing theories have thrown their w-eight in the scales to overbalance the success of the scheme when tried. There is a sentiment noticeably prominent among nurses that by taking any other line of w^ork than the actual bed- side care of patients, or instruction in the art, they forfeit their place, their self-esteem and the esteem of their neigh- bors. Is the rejection of these branches of work by our best nurses the result of their training, or a deficiency in their training, or a fault of their earlier education, or is it due to the influence which heads of hospitals and heads of training schools have permitted to surround these forms of hospital work ; or, is it due to the fact that other than nursing forms of work in the hospital have been consigned to the list of menial occupations? But, do they really belong there? Do they not rather represent the business element in the hospital world, and is it not now the common belief that the higher education best fits one for business and the con- duct of vast affairs, and if true, then does not the higher 76 International Congress of Nurses education in the hospital best fit for places therein? More- over, is not the successful management of vast business enterprises receiving the homage of the world today, and are not these special lines receiving the attention of instructors in the course of nurses at Teachers' College? Then let not the training school despise the offices of any other department, but rather broaden out to include preparation for them in its curriculum. Instruction in the duties of matron, housekeeper or purveyor might well form one branch of training for the third year, with the result that the trained nurse would be better able to meet the responsibilities of the combination of all ofBces when called upon to do so in assuming the management of a small hospi- tal. Then would she not be completely overcome by the problems which demand, for correct solution, a knowledge of the various subsistence supplies, their value to the hospi- tal, their cost, their necessity, the amount required, and the manner of preserving them and preparing them for use. She would also have a knowledge, gained by instruction, observation and experience, which would enable her to demand the proper amount of domestic service within a given time and for a given recompense. Whether the relations between the hospital and train- ing school are those that naturally arise when under one administration or whether they are those due to the con- tract which binds them together, there are certain duties and responsibilities of the hospital to the training school and vice versa of the training school to the hospital. When the relationship is by contract its terms doubtless define these duties and responsibilities and each member of the compact sees to it that the other renders that which was agreed upon, — there responsibilities cease. But when hospital and training sciiool are under one administration there can be no such limit of responsibility. When a hospital issues to the world its prospectus setting forth the advantages of its particular school, and a young woman is induced thereby to undertake its course of training, to the end that she may become useful and self- Training Schools a>id Hospital 77 siipportinq-, the hospital assumes toward that young woman certain moral responsibilities as well as those enumerated in its agreement with her. She has doubtless come from a sphere in life where knowledge of hospitals and training schools is very limited ; she knows nothing of the many phases of the work which may be to her advantage or other- wise, therefore she must be protected, and this is one duty of the hospital to the individual nurse, — her interests must be preserved and this cannot be done if obstacles are placed in her pathway toward success. She looks forward to the time when she shall be suf^ciently equipped to take her place in the world and earn a competence. The time arrives, but she finds she is superseded, possibly by undergraduates from her own school, who because they are undergraduates and are supported by the school, underbid her services to such an extent that she must withdraw from the field, won- dering how her hospital could have held out such induce- ments to her when they evidently do not exist. This is the prevailing condition in those communities where are located the hospitals having training schools that send their nurses out to private duty. In these days of pro- gress we frequently hear the argument advanced that it is only a part of the new plan for university education of nurses, and so it may be in those schools where the nursing service is rendered at the same rate as to the poor in our hospitals. Let the poor and others be given the nursing care required and let no remuneration be exacted, then will become perfectly visible the plan for university education of the nurses. And lest these patients become pauperized, let them be given to understand that the obligation is wholly on the part of the hospital. Possibly a circular to that efifect might be substituted for or accompany that which is now sent inquiring as to the merits of the nurse. The idea of obligation may not suggest a happy state and it may be wise to charge a nominal fee, but if it were no more than the actual cost to the hospital of the nurse while engaged with the patient, surely all moral and ethical requirements would be met and the value to that training 78 International Congress of Nurses school of university education for its nurses could be deter- mined by the amount of service thus given for which there was no visible increase in its treasury. Other responsibilities of the hospital to its school under the same administration may be enumerated, — as, provision of home and sustenance, fulfillment of contracts, provision of necessary educational advantages, etc. In return the training school as a whole and nurses as individuals will give unstintedly of those qualities which furnish the best service, as, loyalty, unselfishness and devotion to principle. They will abide by their contracts and will guard against the purely scientific work, forgetting not sympathy and womanly nursing virtues and attributes which sometimes seem almost out of fashion and can only be seen in the dim distance of the past, but will be ever present with the nurse who heeds the admonition of one well fitted to furnish it, that " the ideal nurse must maintain a strength of character upon which a sick world may lean." Notwithstanding much has been said to the contrary, there is a growing sentiment of appreciation for training schools and their work, among hospital governors and administrators. The school is no longer thought an expen- sive luxury of the hospital or even a pecuniary benefit, but it is placed where it belongs, among the educational institu- tions of the world. Material evidence of this change of opinion of the hospital for its school is found in the pro- visions made for their comfort, for their culture and for refining influences which surround them in the beautiful home that almost every hospital is ambitious to furnish its nurses. An editor of a prominent medical journal who is closely observant of the trend of events says, " It is becoming more and more obvious that the efficiency of a hospital of any sort depends in a great measure upon the services of the nursing staff. It would, we sometimes think, be possible to get on, for a time, at least, without physicians, but to be deprived of nurses would mean the abolition of the modern hospital. The external recognition of this fact lies in the ample pro- Training Schools and Hospital 79 vision now everywhere being made for the comfort and health of the nursing- staffs when off duty." Time and experience are the surest tests by which the real value of any form of relationship between school and hospital may be estimated ; but all departments cannot fail to find in the united means and efforts, greater strength, greater resource and eventually greater results, — unity of purpose is the main prop of success. Women on Hospital Boards. ISABEL HAMPTON ROBB, Late Superintendent of Nursing Johns Hopkins and Illinois Training Schools, Member Board of Women Managers Lakeside Hospital, Cleveland ; Mem- ber of American Society Superintendents of Training Schools, Lecturer on Hospital Economics, Teachers' College. So much has already been said about the advantages and disadvantages of putting the administration of hospitals in the hands of boards composed of women as well as men, that at first sight any additional remarks would hardly seem to be required. Nevertheless, the whole subject is one about which nurses, whether they be superintendents or others occupied inside or outside of hospitals, should take pains carefully to inform themselves, for opportunities come to many of us when the right kind of knowledge would be of much value in helping either the individual or the public to reach correct conclusions concerning this and other ques- tions in which similar principles are involved. For these reasons, this brief paper that I have had the honor to pre- pare for the Congress, is devoted to the consideration of our attitude of mind as a profession towards the appointment of women on hospital boards, and an endeavor has been made to place a true value upon woman's services in such work, to consider some of the ways in which a proper selection may be made, and some of the methods of organizing her work by which the most effective service may be rendered while harmony is preserved. In taking an honest vote of our position towards the subject, judging from opinions freely expressed in private and from, our negative attitude in reference to it in public, it is safe to say that in all probability^ 80 . Women on Hospital Boards 81 superintendents would be almost unanimously in favor of workint^ in hospitals where women are not represented on the managinq- boards. This feeling is partly due simply to the traditional belief in woman's incompatibility to work with women — and we know how slowly all fixed traditions die — and partly to the fact that in some instances this incom- patibility has been a matter of personal experience, which has been swiftly carried from one to another, and has not failed to leave a prejudice in the minds of every hearer. For less reason the feeling is usually shared in by the stafif of hospital nurses, being founded not so much upon any special comments they may have heard passed upon lady managers, or upon any particular reasoning on their own part, but being the natural outcome of a certain unsympathetic tone respecting the matter that pervades the hospital, fostered, it may be, by the unspoken but negative attitude on the part of the superintendent, and occasionally by the thoughtless remarks of inexperienced, unthinking members of the hospi- tal staff, who regard with suspicion the possibility of outside interference in their own particular province. This con- ception might be expressed in words somewhat as follows : " Visiting ladies are apt to be interfering, opinionated in affairs they cannot know very much about, busy-bodies and stirrers up of trouble. They are therefore to be regarded with suspicion and treated with scant or only forced courtesy." That some such feeling pervaded hospitals twenty years ago I can testify, and it seems but yesterday that I recall with what transparent toleration the ladies' visits were received in the wards by the nurses. In my own particular case nothing but good to myself came from the only occasion on which, as a pupil, I encountered one of the lady members of the board. She came behind the screen where I was busy in caring for a patient, and after taking in some of the details, abruptly put the question, " Can you comb a patient's hair so that it doesn't pull and hurt the patient all the time ? There is not one nurse in a hundred Avho knows how to comb a patient's hair properly." She passed on, leaving with me the determination to excel in at 82 International Congress of Nurses least that one point in nursing so that after that time I never arranged a patient's hair without givine special thought to her comfort. As regards superintendents, the true source of their objection lies in the dread that their own ideas and ways may be interfered with or hampered, or that they may be disturbed by constant and untimely visits and by unneces- sary solicitations for patients from individual members, or by the board as a whole. To always do our work in our own way may be very pleasant, but where this work has to do so vitally with so many people, both well and ill, and where it is a public trust, the surest sign that we are broaden- ing out with growth in years and experience is evidenced by an ever increasing readiness to give up prejudices and to welcome any arrangement that will help the work on. To do the subject justice, we must in the first place take an absolutely impartial and impersonal view of it. To eliminate the personal equation is very difihcult, but this must be done, and only the thought of the benefit that such boards are likely to be to the hospital should be allowed to influence us. In nursing as in any other work the more self is kept in the background, and the more the work and its best interests are made the first thought and consideration, the happier the worker, and the greater the success obtained, for the reason that over-sensitiveness and friction will seldom inter- fere. Were I to allow the personal sentiment to predominate I should take the side against the election of women to serve on hospital boards, as I did at a time in my hospital career when I certainly was not a fit judge on so important a matter, since I had not yet made a trial of both ways of working. Increasing experience, however, coupled with an unswerving determination to make the best interests of the hospital my first consideration, have led me to alter my former opinion, and I can hardly express myself too strongly in favor of their appointment. This decision is the result of personal experience obtained from various sources. For some years I worked in two of the largest hospitals in the country, where the administration of the hospital and train- ing school in each case was quite distinct, the former being Women on Hospital Boards 83 entirely in the hands of men, and the latter in those of women. In a third hospital, the trustees of which are all men, the women formed an auxiliary board, and although giving lavishly of their time and means to procure materials and necessaries generally for the hospital, were not accorded even the right to demand an account of the disposition of the abundant supplies provided by them. In another large hospital, in which I was superintendent of nurses, every- thing in and about the place was administered and controlled entirely by a board of men trustees. Finally, it has been my privilege to act as a member of a board of women managers in a hospital administered by both men and women, the former serving in the capacity of trustees, and the women as a board of managers. In addition to this personal experience after watching with keen interest the administration in all sorts and conditions of hospitals, both in this country and abroad, it has become my firm convic- tion that women are needed in the administration of all such institutions, not just because they are women, or for any " Women's Rights " reasons, but because unbiased observa- tion has demonstrated their usefulness, and the influence and part they have taken in establishing and improving hospi- tals all over the world have become matters of history. Msitors to a modern well equipped hospital often express surprise when they are told that there are still many people who prefer to struggle through a sickness in the squalor of a tenement house rather than enter the wards where every attention can be paid to them by trained nurses and skilful physicians. Nor do all refuse to accept these advantages from mere blind prejudice, for there is another and a still stronger reason. Despite all the care that is given the patients, there is often something lacking in some of our most noted hospitals which the meanest hovel still ofifers — an atmosphere of home. " Men may work from sun to sun but woman's work is never done." The former are occupied in the so-called larger fields of the world, but the woman's main occupation is in the home, where she has to deal with men, women and children, at their best and 84 International Congress of Nurses worst, and must be ready to manao^e intelligently a thousand and one details, if she is to succeed in making a happy home for herself and those around her. As the bread-winner the man must to a large extent devote himself to external mat- ters, and in the matter of home details he becomes accustomed to depend upon the women for carrying out successfully the very many duties with which he is neces- sarily unfamiliar. It is clear that the same holds good in hospital management. In order to insure the greatest suc- cess attainable, the best work of men and women is essential, the former attending to the financial part, and to such afifairs as come more strictly within a man's experience, the women looking after the details and the housekeeping part and those afifairs belonging to home-life with which they are more conversant. But if we cannot have both then I should without hesitation be in favor of retaining the women and letting the men go, for women have proven themselves to be no mean financiers or planners, where the whole responsibility has rested upon them, and from the standpoint of careful administration and economy they are undoubtedly far ahead of men trustees. One prominent example of which I can speak with knowledge is that of the Illinois Training School for Nurses, Chicago, organized by a few women for the purpose of bringing relief to the city's sick poor by introducing women nurses into the wards of the city and county hospital. This organization has made for itself a name as being the largest school in the country ; it provides for the nursing in two of the largest hospitals, and has steadily increased its plant as the need arose. More- over, it has not only kept itself free from indebtedness and is practically self-supporting, but for years has been able to make to the public an annual contribution of the income derived from a gift of $50,000, which has been set apart as a special fund and is utilized in supplementing the remunera- tion of competent trained nurses, who by this means are enabled to take care of the patients of moderate income at reduced charges. Women on Hospital Boards 85 The pnpil nurses are well cared for and the school affords an object lesson, teachin.e^ the people the duty of providing healthful surroundings for those who care for the sick, and who are sent out to teach by individual example all the possibilities of prophylactic hygienic measures. All this has been accomplished by a board of twenty-four women, and I think we may be well proud of the fact that the duties of superintendent have for years been efificiently carried out by Miss Mclsaac, our honorable president. But it may be asked : Do not the hospital nurses as women represent the home element in these institutions? They undoubtedly do, but it must be remembered that their supervision is restricted chiefly to the wards, and the super- intendent is usually the only nurse who has access to all parts of the hospital. If she combines the position of matron with that of superintendent of nurses, she has undoubtedly greater opportunities, but the matron is clever indeed who in herself possesses all the experience and wisdom needed to cope with all the details of the various departments as thoroughly, carefully, economically and perfectly as they should be managed. Besides why tax and over-work one woman when by a little management and system she ma> be assisted or relieved of an unnecessary amount of detail by the willing co-operation of a number of other women? I have heard it stated by superintendents on various occasions that these ladies make more work and trouble than they save. But when this is the case, is it not possible that the fault lies more with the superintendent than with the board of managers? Naturally the latter cannot expect to know all the ins and outs of hospital life, but with proper organiza- tion and especially with co-operation on the part of the superintendent of nurses they grasp the situation in a sur- prisingly short time, and hardly ever fail to contribute many good and practical suggestions concerned not only with their own particular duties but with the good of the whole institu- tion. But lor me accomplishment of the greatest possible good there are three requisites : (1) a properly selected board 86 International Congress of Nurses of managers ; (2) proper organization and strictly defined duties ; and (3) hearty co-operation on the part of the super- intendent of nurses. Of these three the last is the most essential, since a house divided against itself must inevitably fall, whereas a united body of workers, even though they may be of no extraordinary individual ability, can accomplish much. The same mind should dwell in all who have any- thing to do with the hospital, and its best interest and great- est good should always be paramount to private likes and dislikes. The desire to have the opinions of single individuals prevail should always be repressed, and each should determine to take a broad point of view, and accept cheerfully and carry out faithfully any well considered decision of the majority. In the formation of a board of women managers many things have to be taken into consideration, and it is quite possible that the superintendent of nurses may not always be able to appreciate the various interests to be consulted, so that in some instances it may puzzle her to know why certain women are chosen as members of such a board. The reason governing the selection may vary according to the sources from which the institution is supported. Some hospitals, as we know, are carried on by religious denomina- tions; others are richly endowed by private bequests; in the case of the municipal hospital the cost is provided for out of the city treasury, while others depend for support solely upon public contributions. To this last class belong the greater number. At the same time no matter how securely endowed, or how independent a hospital may be of its public, it is always well to have a number of people in the com- munity who take a personal interest in it, and who are jealous of its good name, who will stand loyally by it if it is unjustly criticized, who will use their infiucnce to make friends for it, and who will see to it that it remains worthy of the favor and confidence of all who may seek its shelter and aid. In these respects the assistance of woman is far- reaching. Again, the active co-operation of well-known women, whose names stand for integrity and what is best Women on Hospital Boards 87 in the communily, at once lifts any institution with which their names are associated above reproach, and strengthens the hands of the officials in their endeavors at every turn. Moreover, in order that the benefits of the hospital may be made as far-reaching- as possible, it is well to have among its supporters those who can serve it not only philanthro- pically, but also financially, and who can influence others to give. Thus the society woman, the woman who is known for her indefatigable good work, the practical economical housekeper and the business woman can all find a fitting place on hospital boards. A proper selection having been made, thorough organi- zation is of vital importance. Each member should be chosen for a definite reason, and her sphere of usefulness having been once recognized, her duties, privileges and restrictions should be defined. Thus a board divided into suitable committees, with an executive committee composed of the heads of these various committees, may be useful in many ways, and will represent and forward all the various interests connected with the institution, of which I need not speak in detail here. Perhaps, however, I may be pardoned for pointing out a few ways in which women members of the board can supplement the work of caring for the sick. For want of time and for absorption in the strictly practical part of their work nurses are apt to forget that there are other factors besides medicines and the routine nursing that act as tonics and aids to the restoration of health, and that convalescence will inevitably be retarded should the patient fall into an indifferent listless attitude of mind. What brightens up the sick more than the sight of a new face, a few fresh fiowers, a bright entertaining story or the magazine pictures, a quiet game of some sort, or per- haps some light work for the fingers? All of such things can be supplied by the ward visitor provided the nurses will co-operate far enough to keep her in touch with the patient's needs. Such helps are sources of real economy and great good, for they undoubtedly hasten convalescence so that places are sooner open for others who need the care more. 88 International Congress of Nurses Again, a practical, far-seeing superintendent, who is in hearty accord with her committee on hospital and household supplies, can hold their interest to such an extent that many items will be provided, with a consequent distinct saving to the hospital finances. Again, the individual nurse will find it of great advantage to her when she leaves the hospital to have a certain number of women in the community who are conversant with her ability and her ambitions to further dis- trict nursing, visiting nursing or whatever form her future work may take. In the brief time allotted I have given but imperfectly a few of the many reasons why women are in place on hospi- tal boards, and I beg to close by repeating that it lies in the power of the superintendent of nurses, if she be a capable, experienced executive officer, to utilize these extraneous aids in order to develop more and more the good work done by such boards. Our hospitals of today, although far ahead of those of twenty years ago, in some respects still lack the full measure of the home atmosphere that makes patients forget they are within the walls of an institution, and which can only exist where the presence of woman and her aid is appreciated and utilized to the utmost extent possible. The President : The chair will call on Miss Gilmour, superintendent of nurses. New York City Hospital, to open the discussion on Mrs. Robb's paper. Miss Gilmour : There seems to be such a diversity of opinions as to the usefulness or helpfulness of women on hospital boards that it is a difficult matter to know where to begin. People in general connected with hospitals feel that as a rule these women are not practical. They give too much attention to petty detail and not enough to the great object for which the work is going on, — the saving of human life — so that a misplaced chair or rug is in their eyes of greater moment and will excite keener criticism than the cause of Women on Hospital Boards 89 the disorder, which may have been speed necessary to do something of vital importance to a patient. And no amount of explanation can convince the visiting lady that she is unjust in her severe condemnation. As a nurse was heard to remark : " There is no use trying to explain. Her mind is already made up. Appearances are against me." On the other hand, people outside of hospitals are of the opinion that women on these boards are an absolute necessity, that they supply the lack which is so apparent where only professionals are banded together, that doctors and nurses are so absorbed in their work that anything which has not a direct bearing on the case in which they are interested is of little moment to them. Therefore it often happens that while one may find the immediate sur- roundings of a patient in immaculate condition, beyond that things are quite the opposite and disorder reigns supreme, and scant consideration is shown to any one who is not a " case," or necessary to the " case." To attempt then to control these two such opposite factions and dovetail their work so as to make a harmonious whole of it is no easy task and when it is accomplished the result is a very strong combination hard to break and ideal conditions for discipline and progress are created. One such board working harmoniously wath its institu- tion is brought to remembrance today as an example of what such a board can do. This board was called into existence by one of our number since gone to her reward, the late lamented Miss Darche. This lady, called upon to undertake the duties of a superintendent in a school where men, politicians at that, held sway, found there one woman, a society lady of wealth and culture, whose advice was often taken on important matters connected with the school — indeed who had been the means of securing Miss Darche's own appointment. This woman among her other many accomplishments was thoroughly practical, thus rendering her aid invaluable. Single handed, by her cleverness, wit and sound com- mon sense, she accomplished many reforms which Miss 90 International Congress of Nurses Darche originated but was unable to carry through from lack of political knowledge and influence. This lady, a committee of one, kept in very close touch with the school, as she said, to find the superintendent's limitations and to help there. In this way many of the reforms originated by Miss Darche were talked over and where Miss Darche reached her limit this lady took up her work and in every case put the reform through. By reforms I do not mean matters relating to the inter- nal administration of the school which a superintendent should be able to handle herself. In regard to nursing, there Miss Darche was always supreme, because she had no superior in her profession and that fact was soon recognized ; but where money was needed, where influence was needed, or where people were needed to help on the w^ork, there the committee of one was always ready and after suflficient questioning to understand the subject, her share was cheer- fully taken up in every case and nearly always carried through. This lady, like all intelligent women, had her political views. She was a Democrat and as long as Demo- crats were in power she was unassailable. The possibility of a Republican board over the school, the possibility of any board of politicians over the school and no committee of one to interview in its interests kept looming up in the future, for life is very uncertain, and Miss Darche began to look to this possibility wath the result that a committee was formed chiefly of w^omen, called " The Advisory Board of the New York Training School for Nurses." This board, wide in its aims, interests and politics, is united in holding up the hands of the superintendent, on all matters pertaining to the discipline and progress of the school. The committee of one became its chairman and nobly has she fulfilled her oflfice. In describing the board not long ago she said. " We are here to act as a buffer between the commissioner and the school, just as railroad cars are furnished to lessen or relieve the jar, should they come together with unusual violence." Her advice to another anxious board is worth quoting : " Choose first Women on Hospital Boards 91 your superintendent on her merits and of course you will choose the best you can ; then let her alone. When she needs help she will let you know, and then help her." The advisory board makes monthly visits, goes over the hospital and home, hears the superintendent's monthly report, talks over new business, and gives any necessary assistance. Some of the work done by the board is as follows : All recommendations for increase of numbers on the staff of the Training School, or increase of salaries are endorsed by them; all special calls for lecture funds, etc., are met by them, and in any emergencies connected with the nurses of the Training School where financial help is necessary, it has been freely given. All disputed points requiring arbitration are turned over to them. Where work is carried on in this way by a Board of Lady Managers, good results must be achieved and the work of the superintendent cannot be otherwise than lightened, while the moral and disciplinary effect must be to strengthen her hands and uphold her authority over her subordinates. The President : I have the honor of calling upon IMiss Louisa Stevenson, member of the Board of Managers, Royal Infirmary, Edinburgh, delegate from the National Council of Women of England. Miss Stevenson : I desire that my first words to this Con- gress should be to convey to you an expression of profound sympathy from the president, the vice-president and all the members of the National Union of Women Workers of Great Britain and Ireland, which I have the honor to repre- sent today, upon the tragic sorrow which is now weighing down this great nation. I can assure you that these are no mere words. I thank you. Madam President, for permission to give expression to them. It may perhaps be thought that I am an interested sup- porter of the principle that hospital boards are benefited by 92 International Congress of Nurses the presence of women managers. For many years I was of opinion that there was a great deal of work in hospitals which would be left undone were there no women to attend to it. About six years ago I was elected a member of the Board of Managers of the Infirmary. This year I am ofT the board, as no one can serve more than five years in suc- cession, and so am able to attend this Congress, where I came to learn and not to teach. I believe there is a great deal of work done in America from which we may learn much. I think also there may be some things which you might learn from us ; that must be left for you to decide when you visit our country and our hospitals. After my five years experience on the board — and for the first year I was alone with twenty men ; the second year another woman was appointed — I have no hesitation in saying that our work is acceptable to every one concerned. I have, at this present moment, no warmer friends in the world than the men on that board. We discussed many subjects, which I brought before them, which would otherwise not have been considered at all. My experience is that there need abso- lutely be no friction whatever between men and women working together. I was on the most friendly terms with the managers, medical stafif, nurses and every one connected with the hospital. I confess that I have not so much confidence in Boards of Lady Managers working apart from the general com- mittee. I believe that the best work can be done by the women and men working together, and I believe that a large amount of friction is caused by women not having it in their power to carry out their own recommendations and reso- lutions. There is nothing more irritating than to have to make recommendations in a sub-committee which one knows one has no power to carry into effect. I do not know how it is with you in America, but with us I have always found that there is not such a superabundance of administrative power among the men of our country that we can afTord to do without the perception possessed l)y the Women on Hospital Boards 93 women. I do not think this question should be discussed as to the differences between men and women ; if a man or woman has the administrative power and understands what good work is then that man and that woman are the right persons to be put upon a board of managers. I think for all public work there must be a certain amount of definite training. No one can do efficient work until they learn just how to do it. I do hope from what I have seen in other countries, from what I have seen in the hospitals under the supervision of boards composed or partly composed of women, that those who know of this work will realize its value and be converted to having women on the boards. There are many small matters which do not occur to men, yet which are really important for the best interests of the institution, and it is important to have women on the board to express their views on matters of which from experience they have a more intimate knowledge than men. Now I really must not detain you longer, beyond assuring you that I am fully convinced there is work to be done on these boards, which will be left undone unless the women take it up. Miss Dolliver: Of the many valuable and interesting points in the papers read this morning, I ask attention for a moment to the consideration of the hospital patient as an individual. Too often is the zeal for the mere routine w^ork of the day. The pupil nurse at least does not realize that she should first establish the right relations between herself and her patient, in order to gain his confidence. She should make him feel, though not necessarily in w^ords, that during his stay in the hospital she has sincere interest in him, and is constantly mindful of his needs, both of mind and of body. The nurse who does this will convince him and all who know her that the nurse is indeed created for the patient. The meeting adjourned. WEDNESDAY AFTERNOON, 2.00 P. M. The President: Our papers this afternoon will deal with the interests of the private nurse. The Nurses' Co-operation. DIANA C. KIMBER, Late Assistant Superintendent of Nurses, New York City Hospital. This society known popularly to doctors and nurses in London as the " Co," or the " Co-op," was formally started in 1891, and was registered under the name of the "Nurses' Co-operation," June 5th, 1894. It is, in common with so many English institutions under royal patronage, the Princess Louise, sister of the King, being its patroness ; whilst a titled lady, Alice, Countess of Strafiford, is its presi- dent. The chief objects for which the society is established are as follows : 1. To establish and maintain of^ces or agencies where qualified nurses may be engaged to attend patients. 2. To establish and maintain homes for nurses, and to provide them with instruction, board, and lodging, and all necessary comforts. 3. (a) To purchase, lease, hire or otherwise acquire real and personal property ; (b) to erect, construct, maintain and alter any houses necessary for the purposes of the society; (c) to sell, lease, mortgage, or otherwise deal with 94 The Nurses' Co-operation 95 all property of the society ; (d) to solicit, collect, accept and hold gifts, subscriptions and bequests, for purposes of the society. 4. To establish and hold in trust funds for the pro- vision of sick pay, pensions, or annuities, for the benefit of nurses. The society consists of the members who signed the memorandum of association (chartered members) and of members who pay annual subscriptions of £1 Is. (about $5.00) or of £5 5s. (about $25.00) to the funds of the society — such members being proposed for membership by two or more members, and elected by the committee of man- agement. The society numbers only twenty-five members, seven of whom are the chartered members who signed the articles of association. Of these twenty-five members, eleven are men, and fourteen women. The management of the society is in the hands of a committee, the committee of management — which consists of not less than twelve, nor more than fourteen persons, six being elected from the members of the association, and not more than eight, nor less than six, being elected annually in general meeting as representatives of the nurses. All the business of the society is managed by this committee of management, and all the power lies in their hands. They elect the members of the society. They appoint the superintendent, the secretary, treas- urer and other ofBcers and servants of the society. They may borrow money, and invest the funds of the society. They may create any special fund, or funds, including an annuity fund, a sickness relief fund, etc. They formulate and circulate among the nurses of the society such regulations as they think fit for enabling such nurses from time to time to hold meetings for the election of their representatives on the committee of management. So much for the organization of this society, and now for a brief outline of its history. 96 International Congress of Nurses The idea of the Nurses' Co-operation originated with a trained nurse, a Miss Mary Belcher, who desired to enable private nurses to co-operate for their mutual advantage and benefit. Miss Honnor Morten gave assistance in formulat- ing a workable scheme, and considerable time and trouble was given to making this scheme practical in every detail. The promised support of a suflficient number of doctors was secured. A standard of qualification was determined so that doctors of repute might feel perfectly secure in recommend- ing and employing the nurses ; and rules for the nurses, for their instruction, guidance and protection, were drawn up. When the scheme was ready two gentlemen and four nurses came forward with financial aid to the amount of $2,500.00: (of this sum the $1,500.00 advanced by the two men was later made a gift to the institution, while the $100.00 advanced by the nurses was repaid in 1892). An office was taken at 8 New Cavendish St., London, W., and on February 1st, 1891, the Co-operation started with thirty nurses on its books. The society thus founded in 1891 was registered in 1894, the memorandum and articles of association being signed by Sir Henry Burdett, editor of the Hospital ; Herbert P. Hawkins, physician ; Mary M. Belcher and Mary N. Napper, nurses ; P. Michelli, secretary, or as we should say warden, of a hospital in London ; Chas. Weston and W. Capel Slaughter, solicitors. The signatures were witnessed by Miss V. Honnor Morten. From the beginning the Nurses' Co-operation seems to have been a success, for we read that at the end of the first year, i. e., in December, 1891, there were already 158 nurses on the staflf, and that 1,127 calls for the services of the nurses had been received by the association. These numbers have steadily increased, and the report for the year ending December 31st, 1900, states that at that date there were 509 nurses on the staflf, and that during the year a total of 7,130 calls had been received and filled. During the same year the nurses' gross earnings amounted 'to The Nurses' Co-operation 97 £43,696 4s, or approximately $218,480.00. Again, in this report the nurses are congratulated on the completion of a residential home, which provides them with a restaurant, club rooms, and many separate bedrooms. And no charge is made for the use of a sick room by nurses belonging to the club, whose admission is recommended by the medical officers of the society. Towards the cost of this home the late Lady Howard de Walden contributed £6,500 (or about $32,500.00 as a gift and £1.500 (or about $7,500.00) as a loan. Each nurse received her earnings, less 71/3%. She pays an annual subscription of $1.20 to the Howard de Walden Club. She boards and lodges herself as she pleases. To an outsider, on reading this and similar reports all seems well, but recent events have shown that for some time there has been considerable latent discontent among the nurses of the stafif, and with the resignation of the late superintendent, Miss Amy Hughes, this discontent found expression. It would appear that the control of the associa- tion has been drifting further and further from the nurses of the staflf, and into the hands of those members of the society who are most constantly present at the monthly meetings of the committee of management. And the reason of this is not far to seek — the nurses finding it difficult to attend the meetings regularly on account of the nature of their work have grown careless ; possibly also they have not realized the importance of their position on the committee as repre- sentatives of the staff, and those members of the society who have been constantly present at all the meetings, finding the power in their hands, have grown accustomed to using it, and have possibly unconsciously come to believe that they are the only persons qualified to manage the business of the association. But to return to facts. In consequence of the growth of the society, and consequent increase of its work, it became necessary in 1895 for the committee of management to employ a paid secretary. Up to this date the office had been an honorary one, and had been held by Miss Honnor 98 International Congress of Nurses Morten. This secretary who was appointed by the com- mittee of management is not a representative of the nurses on the staff. When Miss Morten resigned the position of Honorable Secretary there were two rules which ran as follows : " 1. There shall be at least eight nurses on the com- mittee. " 2. Any surplus remaining shall be available for dis- tribution as may in general meeting be determined." The second rule I am informed has been quietly dropped, and the first now reads : " There shall be at least eight nurse representatives on the committee." These nurse representatives do not necessarily repre- sent the nurses, and as a matter of fact the present chair- man, who sits as one of the nurse representatives, so far fails to represent their opinions that 95% of the nurses signed a formal protest against his actions. Four only of the nurse representatives now on the committee are nurses on the staff, and they on account of their work are often obliged to be absent. Sinte the general meeting in June of this year, when the nurses met to voice their complaints, the committee of management have issued a circular letter to the nurses of the Co-operation, in which, to meet this difiliculty of inadequate nurse representation, they say : " The committee are quite aware of the difficulty nurses find in attending the monthly meetings regularly, owing to their frequent absence from town (i. e. London) and this makes the question of the nurses' representatives a difficult one. The committee are now considering how the articles of association can be improved, and due time and attention will be given thereto, with a view to the nurses having, if possible, (the italics are our own) a larger representation secured to them. " They also intend to take steps to acquaint the nurses more fully than heretofore with such resolutions as affect the whole work of the Co-operation." The Nurses' Co-operation 99 It seems to us that the steps the nurses have to take is to make the committee understand that it must he made possible for them to have such representation on the com- mittee as will enable them to have a controlling voice in its management. Unless the nurses have this voice the society cannot properly be called the " Nurses' Co-operation ;" hav- ing such a voice they can have no reason for complaint, if the disabilities under which they may be suffering are not rectified. From the point of view of an American it seems some- what incongruous that a body of women seeking to manage their own affairs should accept donations and patronage. In England acceptance of patronage is so common that it does not occur to us to look at it in this light, but we venture to think that the English nurses who wish to stand upon their own feet, and manage their own organizations, will have to learn to face the fact that they cannot accept help from others without losing a certain amount of inde- pendence. -A,/ . <7>y^j^. "«<'** The Registered Nurses' Society. SOPHIA CARTWRIGHT, Member of St. Bartholomew's League, Delegate from the Registered Nurses Society. Ladies, — As you have already had described to you the basis of organization in the Nurses' Co-operation, which is identical with that of the Registered Nurses' Society, in se- curing to members the whole of their earnings less a small percentage for office expenses, I do not propose to enlarge upon this point, but briefly to give you some account of the distinctive features of the society which I have the honor to represent. It was in 1894, after the Royal British Nurses' Associa- tion had been incorporated by Royal Charter, that Mrs. Bed- ford Fenwick felt that something should be done to secure to trained and certificated nurses, who were registered un- der the charter, remunerative work as private nurses, which work was largely in the hands of uncertificated and ineffi- cient women, or was manipulated by institutions which paid the nurses a fee and retained the profits. If the nurses had the management the margin of profit would be theirs. On the other hand, Mrs. Fenwick urged that the Chartered Association had a professional duty to the public, and should define a definite standard of education and training for pri- vate nurses. It was decided that the association could not initiate such a scheme, but eventually some of the medical and nurs- ing members formed a committee, at Mrs. Fenwick's re- 100 The Registered Nurses' Society 101 quest, and inaugurated the Registered Nurses' Society, of which she has acted as Hon. Superintendent since its in- ception. Through the organization of this society nurse members of the Royal British Nurses' Association were provided with a medium through which they could obtain private nursing work. But after the new by-laws were thrust upon the as- sociation many of the early members felt compelled to resign their membership, and the Registered Nurses' Society adopted a standard of its own, and continued its work for nurses and the public entirely apart from the Royal British Nurses' Association. The lines upon which the society had worked are as follows : (1) It demands a three years' certificate of general training from all applicants for membership. (2) It requires, in addition, adequate training in spe- cialties, such as maternity nursing, midwifery, mental nursing, massage, fever nursing, etc., of members undertaking nursing in these special branches. (3) It inculcates and encourages in the members a sense of their direct responsibility for the well- being of the society, and of the duty which they owe to the public in maintaining an efificient stand- ard of nursing education for private nurses. Maintaining as it does a standard of education and gov- ernment somewhat in advance of its age, and being in no way dependent upon social patronage, the Registered Nurses' Society must necessarily grow slowly and surely in public favor, as it is doing. The society is not satisfied that nurses should become members merely to obtain the commercial benefits which it confers upon them, but its object has been also an educa- tional one. A large proportion of the committee, therefore, consists of the members themselves, who participate in the business 102 International Congress of Nurses management of their society, and are encouraged to take a personal interest in the conduct of their own affairs. The society has further cultivated a broad outlook by affiliating with the National Council of Women, and also by sending delegates to various congresses and meetings at which questions affecting the interest of the nursing profes- sion are discussed. I believe I am right in saying it is the only society of private nurses in Great Britain which has, at its own ex- pense, selected and sent a delegate to this great congress, and I consider this a typical instance of the good which must result from encouraging nurses to take an interest in their own affairs. I must further mention that members of the Registered Nurses' Society are encouraged to keep themselves ac- quainted with the contemporaneous history of their profes- sion at large, to which I ascribe the fact that many of the members of the society are keenly interested in nursing politics and appreciative of progressive movements. It has been well said that "we may divide society into those who are assisting the progress of civilization, those who are driving it backward towards barbarism, and those who, being inert and stationary, are an impediment to the efforts of others. We must choose to which of these classes we will belong, for to one or other it is evident we must be- long. If we are vicious, or even ignorant and prejudiced, so that in our intercourse with society we foster old errors, and resist the improvements of the age, we must rank with those who are either impeding the prosperity of the country or forcing it back to barbarism. But if we think, speak, and act up to the moral lights of our time, assisting more or less to maintain or forward improvement, we have then a right to rank with the benefactors of mankind. Our positive in- fluence may be greater or less, without either merit or fault of our own, but we have joined the right cause. Each soldier has a share in the honor of the victory." I claim that in linking our fortunes with those of the leaders of our profession who are working for professional The Registered Nurses' Society 103 advancement, for a definite and efificient standard of nursing education, for self-government and discipline, the Reg- istered Nurses' Society has "joined the right cause." We have proved also that it is possible to combine a high stand- ard of profesisonal responsibility with commercial success, and last, but not least, that if nurses are permitted a share in the management of their own afifairs, they appreciate the dignity and responsibility of this trust, and perform their part conscientiously and with ability. The President : The chair would like to call upon Miss Hughes. Miss Hughes : I am asked to say a few words upon the subject of Nurses' Co-operative Societies. Until last June, I had the privilege of being in charge of a very large associa- tion of private nurses working on the same lines as the one of which you have just heard. The principle of co-operation amongst private nurses has proved so successful that it is becoming very general with us. Not only do the nurses secure the full fees for their services, but by each one con- tributing a fixed percentage towards working expenses, the business of placing them in communication with doctors, helping to enforce the payment of their fees for services rendered, etc., is carried on without delay and loss of time to the nurse concerned. The office becomes the calling place of doctors and patients' friends, and many difficulties can be cleared away, and things made easier on both sides by this common ground of meeting. I would plead that those who join such societies should try to eliminate the feeling that the work is only undertaken because of the higher remuneration it secures, and because of the greater freedom of the life. Private nurses represent the profession to the general public and if they lower the standard it reacts unfavorably on us all. It rests with each individual woman to create and maintain a favorable impression or the reverse in every household she enters. Selfishness or want of tact in a very small degree create a wider distrust and prejudice than the nurse ever realizes. These associations 104 International Congress of Nurses exist for the benefit of all, and on each rests the respon- sibility of not only making- a good record for herself, but also for her association, and thus in a very direct manner for her fellow nurses working in that society, and in addition for the nursing world at large. The private nurse of all others can least afford to work in an isolated way, for herself alone — her responsibility to the whole community is too great. The President : The chair would call upon Miss Rid- dle to speak for the American side, on club work. Miss Riddle : Madam President, as the delegate from the Boston Nurses' Club to this Congress, I cannot refuse your request. Regarding ways and means of keeping up an interest in their work among the nurses ; a great deal is done by our Alumnae Associations and the courses of study they have from time to time suggested. It would be well if more indi- vidual members of our Alumnae xA.ssociations could attend these conventions ; but it would take a long time to give them, individually, the stimulus to be gained here, since few of the associations are entitled to more than four delegates to each annual convention. In Boston we have organized the Boston Nurses' Club, which is maintained and supported entirely by its member- ship composed wholly of nurses. Each winter a series of ten or twelve lectures is given upon the various subjects per- taining to the nurses' practical work. In this way interest is maintained. Occasionally we have a lecture upon some subject not wholly within the nurses' province, but one upon which they should be informed, — such as some sociological subject ; we also have demonstrations in nursing work from time to time, and by the courtesy of many of the hospitals and hospital staffs we are, under certain liberal regulations, allowed the privilege of attendance at clinics and at opera- tions in the hospitals. We have had outlined for us for the coming winter a course of study and a series of lectures which we hope will The Registered Nurses' Society 105 do for us just what has been mentioned by Miss Hughes, the last speaker. We do not altogether neglect the social side of the nurses' nature, for we have set apart an afternoon of each week, when some of the nurses are at home to all the other members and act as hostesses at the afternoon tea served from three to five o'clock on that day. These teas are served in the club rooms, are well attended and apparently much enjoyed. The hostesses either offer their services or are appointed by the committee on entertainment. We have established and maintain a registry* which is growing in favor with the public from year to year. Doubt- less many nurses become members of the club for the advan- tages to be gained from the registry alone; this single motive is, however, constantly discouraged by the more thoughtful members who aim to have permanently established a club which shall advance the nursing profession by educational and other means ; which shall provide a place for social and business purposes of nurses ; which shall aid in all kinds of charitable work, and which shall assist nurses in securing employment. As an organization we are young, being in the third year of our existence. But, we have met with such suc- cess as to lead us to conclude that we are a necessity to the public as well as to the great body of nurses in Boston. The President : We will now consider the subject of Alumnae Associations. *The " registry " of American nurses is the same as the business office of the co-operative societies of the English nurses. Our word "registry" is not always understood abroad. Nur;^es supporting their own "registry" appoint and pay their agent, provide her with office and telephone, and make their own rules. In America we have never had the system of private nurses being employed on salaries by insti- tutions.— [Ed.] St. Bartholomew's League. EMILIE M. WAIND, Delegate from St. Bartholomew's League. Madam, the President, Ladies : It will, I think, be of interest to you to know that our League of St. Bartholomew's Nurses is connected with one of the oldest hospitals in England, founded as it was in the year 1123 by a monk named Rahere, whose tomb may be seen in the beautiful church of St. Bartholomew the Great, just outside the gates of the present hospital buildings. Passing through the many and varied vicissitudes which befell the religious and charitable institutions of early times and receiving royal support in the reign of King Henry VIII, who refounded the hospital, it gradually became what it is at the present time ; one of the first schools of medicine in the Kingdom, and, what is of more importance to us today, one of the great training schools for English nurses. If imitation be the sincerest form of flattery, the alumnse associations in this country may feel duly flattered, for it was, I think, the knowledge of their existence which, to some extent at least, suggested to our founder and president. Miss Isla Stewart, the possibility of the formation of an association which would ofler similar advantages to its members. The need of such an association had made itself felt for a considerable period before any definite plan could be entered upon. In the natural course of events, nurses who have enjoyed the security and protection of a life lived in common, during the years of their training, pass on to other work and other responsibilities. 106 St. Bartholomew's League 107 No definite bond exists between them and the many friends and companions of their old school with whom the difficulties and the pleasures of hospital life had been shared. True, the bond of memory was the possession of all who might desire it, but it was neither a substantial nor a very satisfactory one. Letters and meetings might be arranged between individuals, but such a busy body of workers found ever- increasing difficulty in keeping up with old friends and their doings. A visit to the hospital was equally unsatisfactory; to be greeted as a stranger, almost as an interloper, by the new generation of workers, was the occasional experience of any who ventured to revisit the familiar scenes. This is but one aspect of the need which indicated the necessity of an association to unite old friends and new in perpetuity. In connection with our profession, there arise from time to time, many points of great and vital importance to us as a whole. An opportunity of mutual discussion and a friendly interchange of opinion is an advantage of no small moment. With the possibility of offering these and other advantages. Miss Isla Stewart, with her usual spirit of enterprise and esprit de corps, called a provisional committee to discuss the formation of an association similar to those in this country. Warmly supported by the members of this committee, who hailed her suggestion wath much eagerness, invitations were issued to all nurses holding the hospital certificate or diploma, to join a league for their mutual help, support and pleasure. With gratifying alacrity applications for member- ship poured in from all parts of the Kingdom or wherever St. Bartholomew's nurses were working or residing. In due course an executive committee was formed ; by-laws were drawn up ; a badge was suggested and a design for the same prepared and accepted; a benevolent scheme was outlined, biennial meetings were arranged providing 108 International Congress of Nurses opportunities for the discussion of all business matters and for pleasant social intercourse. It was also arranged that the doings of league mem- bers, together with their names and addresses, should be duly chronicled in a small half yearly issue to be entitled the League News. Each number contains an interesting editorial touching on current events of general interest, in addition to papers on special subjects, and as comprehensive a list as possible of the honors achieved by any members of the league. Our first general meeting took place in the Great Hall of St. Bartholomew's Hospital in May, 1900. It was an enthusiastic and representative gathering and Miss Stewart was justly proud of the fulfillment of her long cherished scheme. We now number nearly 400 members, increasing steadily as each six months produces more nurses eligible for membership. Amongst these we are proud to claim no fewer than five members who are working in this country at the present moment. Miss Hay : I am sorry that I must speak from a limited knowledge only — that of my own alumnae association. This we find extremely helpful to every nurse who interests her- self in it. We have monthly meetings at which we discuss current topics and various questions calculated to instruct and entertain ; and by this interchange of opinions and social intercourse we are much better enabled to keep out of the " ruts " and to carry to our work a fresh interest and an increased knowledge. I think nurses are too liable to regard their organization work as exceedingly irksome. In our alumnae association we hope fo avert this tendency so far as may be by making our meetings attractive and by interesting our nurses in them. Another important work of our alumnae association is caring for its sick. A room at the Presbyterian Hospital, Chicago, endowed by the generosity of a friend, enables us to provide for any sick member residing in the city hospital care and attendance. For those outside the city, or any unable to go to the hospi- St. Bartholomew's League 109 tal for any reason, a weekly allowance is made during- the nurse's illness — a benefit that, never regarded as a charity, is oftentimes the most opportune and which for all of us is a pleasing assurance against the exigencies of sickness and misfortune. Miss Stewart : I am very much struck with the amount of work you do in your alumnae associations. Indeed they appear to be forming for this more than for merely giving pleasure to their members. The League of St. Bartholomew's Hospital Nurses was instituted more on social lines than any of the associations I have heard of in this country. We merely do what business is necessary and give the social side as much prominence as is possible. I am a profound believer in the developing efifect of pleasure in a busy life. There is nothing makes a nurse do her work with such " snap " as having a " real good time " at not too frequently recurring intervals. We have only one business meeting, which takes place about the end of June, and another meeting in December, which is wholly social. The members take great pride in the association, and have much pleasure in the meetings, indeed no amusement is provided. Music is almost unheard, and certainly unattended to in the noise of many tongues as one friend meets and greets another. I fear you would think us a terribly frivolous community. We issue a paper twice yearly. It is entirely devoted to the doings of past and present nurses of St. Bartholomew's Hospital and of all who are connected with it in any way. There is an editorial on some popular topic, some letters from nurses in foreign lands, notices of the appointments any member may have obtained, notices of births, marriages and deaths ; any of the last have not as yet been recorded we rejoice to say. The bi-annual examinations are recorded, and at the end a full list of members with their present address. The price is Is. annually. The President: I am afraid our English friends will think we are too much devoted to work, but I want to assure 110 International Congress of Nurses them that we are frivolous too, sometimes. I agree with Miss Stewart that one of the orreat needs of nurses is more recreation. Our own ahimnse association has one Httle custom which we have found very pleasant and that is to come together on our graduating day and have an alumnae banquet at which the graduating nurses are our guests. Miss Walton : May I ask, is there a possibility or prob- ability of other schools following the example of St. Bartholomew's nurses in organizing in this way? Miss Waind : St. John's House, in London, has formed a similar League, and there are promises of others.* The President : We now have the interesting subject of organization in distant countries, and it is with much pleasure I introduce Miss McGahey to this Congress. *Since the meeting a League of the nur es of the Royal South Hants Hospital has been formed. Guy's Hospital nurses are also organizing. Nursing Organizations in the Australasian Commonwealths. SARAH B. McGAHEY, Matron Prince Alfred Hospital, Sydney ; Member Matrons' Council ; Delegate from the Australasian Trained Nurses' Association. Several months previous to the granting of federation to the Australian Colonies, an association of nurses was founded in New South Wales, named after the colony in which it was inaugurated. The objects of the association are: " 1. To promote the interests of trained nurses — male and female — in all matters affecting their work as a class. " 2, To establish a system of registration for trained nurses. " 3. To afford opportunities for discussing subjects bearing on the work of nursing. " 4. To initiate and control schemes that will afford to nurses a means of providing an allowance during incapacity for work, caused by sickness, accident, age, or other necessitous circumstances." A few months after its inception it was considered advisable to change the name to a more comprehensive one in view of the fact that so many nurses trained in the other colonies had been enrolled as members. This was accordingly done at a special meeting convened to deal with this and other important business, and the alteration met with general approval. Since that date it has been known as the Australasian Trained Nurses' Association. Ill 112 International Congress of Nurses Although the association was not established until 1899, it must not be considered that the Australian nurses were inactive during the years that preceded its inauguration, for as early as 1892 a meeting of medical men and nurses was held in Sydney in order to consider what steps could be taken to form an association of trained nurses in that city. Nothing was accomplished then owing to a diversity of opinion as to what constituted a trained nurse. Since then attempts have been made to form an association of nurses in Victoria and New South Wales with no better results than on the previous occasion, but no doubt all these efforts paved the way to the culminating point which was reached when the present association was formed. The Australasian Trained Nurses' Association is managed by a council consisting of a president, a vice- president, honorable treasurer, two honorable secretaries and seventeen members (of whom five are duly qualified medical practitioners, five matrons and superintendents of nurses, live sisters and nurses, and two honorable members). Difficulties arose Avhen registration began, but these have all been overcome and the association is now firmly established. Early in its history the council realized that a grave injustice was being done by excluding from member- ship a certain section of the nursing profession who were not fortunate enough to have received their training when a three years course was compulsory. In order that no one should be excluded who had a claim to be registered a concessional clause was drawn up and passed by a large majority, consisting chiefiy of nurses who held certificates covering a period of three years training in hospitals. To all those who were eligible to register under this clause a period of three months was granted, during which time they were at liberty to make application. Those desirous of registering were required to produce proof that they had been employed for not less than three years in the bona fide work of medical and surgical nursing, either in hospi- tals or in private work. Such candidates had to- furnish certificates of competency and good conduct from three Nursing Organizations in Australasia 113 reputable medical practitioners as to their qualifications, etc. The council retained the power to examine applicants concerning whose qualifications doubts were entertained. This course had to be resorted to in a few cases, the majority of whom satisfied the examiners. A register has been published in which the qualifica- tions of each nurse appear, except in the case of those who were admitted under the concessional clause, then instead of the qualifications the words : " Admitted by the council under the provisions of Rule XXI " are inserted. In the beginning of the register the constitution is printed and Rule XXI explains the conditions under which such candi- dates were accepted. Since the first of April, 1900, the following conditions have had to be complied with by those who were received as members : Candidates for registration must produce proof: " (a) That they have been engaged for three years in general hospitals recognized by the council and containing not less than 40 beds ; or " (b) That they have been engaged for four years in a country, district, or suburban hospital recognized by the council and containing not less than 20 beds, and have been trained at that hospital under a matron or nurse who holds a certificate from a training school for nurses recognized by the council of this association ; or " (c) That they have been engaged for five years in a private, country, district, or suburban hospital recognized by the council and containing not less than 10 beds, and have been trained at that hospital under a matron or nurse who holds a certificate from a training school for nurses recognized by the council of this association. " Furthermore, all candidates must give reference as to their moral character, produce certificates of competency from the hospitals in which they have been engaged, and account for any interval of time in their nursing career when not engaged in hospitals or nursing associations." 114 International Congress of Nurses The membership of registered nurses has increased considerably : at present 406 are enrolled, besides these 64 medical practitioners have joined the association, amongst whom are the leading physicians and surgeons of Sydney. The nursing profession in New South Wales is deeply indebted to the members of the medical profession who have helped the association since its inception, some of whom have given much of their valuable time to further its interests in a variety of ways. In March, 1901, a circular letter was sent to several of the leading members of the medical profession and nurses in the Australian States and New Zealand, asking them to take steps to call meetings with a view to the formation of branches of the association throughout Australasia. As already stated many nurses residing outside New South Wales have been registered, of these there are seventeen in Victoria, eighteen in Queensland, four in Tasmania, three in South Australia. No doubt branches in several of the states will soon be formed, as the nurse members in many of these states are anxious to have local centers established. An auxiliary of the midwifery nurses in connection with the association was formed during the latter part of 1900, and up to the present date fifty members have been enrolled. These midwifery nurses have a separate register and are entitled to attend at the general meeting of the association to elect one of their members to represent them on the council of the association. In our country a large majority of midwifery nurses have not had any general training before taking up this specialty. During the past few years many more general nurses have studied this branch of nurs- ing than was customary previously. The qualification for membership is a certificate proving that the candidate has received six months' instruction in practical and systematic training at one of the maternity hospitals in Australia, recognized by the council of the A. T. N. A. Furthermore, the candidate is required to have passed a satisfactory examination before a competent board of examiners. Can- didates trained in European or American maternity hospitals Nursing Organizations in A ustralasia 115 in which the course of training is equivalent to the standard required in the Austrahan hospitals, are eligible for mem- bership. A schedule, setting forth the minimum amount of train- ing which will be accepted by the council of the association, has been sent to each of the hospitals in Australasia, and those not prepared to adopt it, or whose number of beds does not fulfill the requirements laid down by the associa- tion, cannot be recognized. Moreover, the matrons are required to be qualified nurses, capable of instructing pupils placed under them. Matrons registered under the conces- sional clause are not considered sufficiently qualified to hold such positions and the hospitals with which they are connected have not been recognized. The council in its efforts to protect the interests of trained nurses by refusing to recognize hospitals where trained matrons are not appointed is receiving considerable support from the government medical officer in Sydney, who is about to issue a circular letter to each of the county hospitals subsidized by the government, requesting them to inform him when any change is to be made in their matron and before any appointment to that position is effected to submit to him the name of the nurse together with her qualifications. It is only fair and just to nurses who spend five years in hospitals acquiring a knowledge of their profes- sion, that vacancies for matrons should be filled up from their ranks, rather than from those who have had little or no training. In July, 1900, a benevolent fund was established and although the sum subscribed is small yet hopes are enter- tained that it will be increased. Already one of the mem- bers of the association has received a small amount from the fund to enable her to take a holiday after a protracted illness. Three of the members of the association who have private hospitals have each put a bed at the disposal of the council for any nurse members who may require medical or surgical treatment. 116 International Congress of Nurses Soon after the inauguration of the A. T. N. Association, a society of nurses was formed in connection with the Prince Alfred Hospital training school, Sydney. This society was named the Prince Alfred Hospital Trained Nurses' Reunion, the greater number of whose members are also on the register of the association. The certificate of the hospital is sufficient qualification for membership. Several meetings were held during the year, at which papers were read which were both interesting and instructive. Tlie list of members has now reached 100. As each class graduates new members are enrolled. Nursing has made considerable strides during the past ten or twelve years, throughout Australia, and a great future is predicted for it. The conditions under which the nurses work have much improved, modern hospitals have been erected and nurses' quarters replete with all the necessary comforts are now established in connection with most of the leading hospitals. The daily average off duty for pupils and nurses is three hours ; in some hospitals two days' holiday in the month is given besides. The annual holiday is two or three weeks. An eight hour day for nurses has not yet been introduced in any of the hospitals in the Australian states, but in a few of the New Zealand ones this system has been in force for some time. The course of training in the larger schools is for three years ; at the Prince Alfred Hospital and Sydney Hospital, Sydney, the period has been extended to four years. The curricula vary in the different schools ; in some the course of instruction has been considerably increased. At Prince Alfred Hospital midwifery nursing, dispensing, and housekeeping have been added and it is proposed to deal with those subjects during the fourth year of training. Practical and theoretical examinations are held at the end of each year. To the practical examination a much more important place has been given than was customary some years ago. Nursing Organizations in A ustralasia 117 The non-payment system does not exist to any extent in the AustraHan training schools; in a few a premium is required to be paid by the pupils on entrance, but the majority give some remuneration to the pupils during their period of training. It is hoped soon to see a preliminary training school established in connection with one of the large hospitals. This preliminary education would be a distinct improvement on the system now in force. According to existing arrange- ments selected candidates are taken into the hospitals on trial and their services are retained if found suitable after a reasonable period of probation. This system has had its disadvantages but the preliminary training school would rectify many of these. Some of the advantages of such a school would be : 1. Those who had to deal with the raw material would be saved unnecessary worry and trouble. 2. The inefficient and incapable pupils would be dis- pensed with before gaining admission to the wards, and the constant changes amongst pupils of the first year would to a certain extent be minimized. 3. The patients would benefit in a variety of ways. The only drawback to such a school has been the expense which it would entail. At present the income in many of the hospitals is barely sufficient to meet current expenses, but no doubt this great difficulty will soon be overcome and those desirous of seeing this improvement in the training of nurses will have their wishes gratified before the Australian Commonwealth has celebrated many of its anniversaries. The President: We were so delayed in opening this afternoon that we will be obliged to dispense with the dis- cussion upon this last paper which is regretted by us all. There will be a meeting of the Congress committee in this room immediately after this meeting adjourns. This meeting is now adjourned. SECOND SESSION. THURSDAY, 9.30 A. M. The President : A telegram from Miss Kindbom brings her best wishes for the success of the Congress. The opening paper is one written by Mrs. Strong, Matron of the Royal Infirmary, Glasgow, Scotland. The Preparatory Instruction of Nurses. REBECCA S. STRONG, Matron Glasgow Royal Infirmary, Scotland. Ladies, I must thank you for the honor you have conferred upon me by asking me to read a paper on the " Preparatory Instruction of Nurses," and presume it is the technical course of study to be pursued before entering the wards as probationers for practical training in the art of nursing which you desire to hear about, and not the ordi- nary preliminary general education which is a sine qua non. I ask your indulgence should I digress somewhat from the particular point, as it is a wide subject, with many side issues. I will endeavor to place before you something of our work and aims on the other side of the Atlantic, and the various events in the " chain of evolution " which have led to the desire to rescue nursing from its chaotic condi- tion, placing it on a sound basis of systematic tuition, lead- ing on to a final examination, to be conducted by an out- side body, under the control of the State. We wish to see ourselves in connection with the " General Medical Council," to have a curriculum laid down 118 The Preparatory Instruction of Nurses 119 by them of the studies, examinations, and work to be done, before a woman presents herself for examination for her diploma. We cannot be a separate independent body, we are the hand-maidens of the medical profession ; and if we educate ourselves beyond what is required of us, it is valuable time lost, and is apt to produce a spirit of dis- content with the subordinate position which we must hold in regard to the doctor. On the other hand, we require to keep abreast of the times, and if we do not educate ourselves to meet their needs we cannot expect their interest in us. Diagnosing is not our province, our responsibility ends with a loyalty of spirit in carrying out the instructions given, obeying in spirit as well as in letter ; and it is only by being at one with the doctors, supplying their wants, that we can look for guidance and help from them in the forming of our- selves into a recognized body of people. I cannot say that my ideas are representative of the thought of the country, they are merely the gathered exper- ience of a thirty-five years' nursing career. The medical profession is by no means unanimous, in our country, as to the necessity of a fixed curriculum for nurses, and what should constitute a " Trained Nurse " (I use the term for want of a better), but it must be borne in mind that it was only in the eighties of last century that that profession became a corporate body. We can scarcely expect in so short a time that the want should be universally felt of a body of women specially educated on fixed lines to give assistance to them in their work. Physicians and surgeons will always have their individuality to be con- sidered with their methods of treatment ; but a nurse must have a certain amount of information before she is capable of adapting herself to their various requirements, otherwise it would entail a great deal of misunderstanding of instruction given. We would like to do away with what is so aptly called the " daring of inexperience." There are many medical men who are of opinion that the time is not far distant when the term " Qualified Nurse " will require to have a definite meaning and not be left to the arbitrary 120 International Congress of Nurses decision of the various hospitals to j^rant certificates, follow- ing upon their own private examinations, which may or may not be of practical value in regard to the fitness of the holder for carrying on the work of nursing. The argument that there are many good nurses who have received little but empirical training will not hold good, any more than the same applied to the practice of medicine half a century ago. As it stands today with us any woman who holds a certificate to the efifect that she has spent three years in a general hospital containing not less than forty beds can register, provided there is nothing against the moral character. It is not the size of the hospital I object to — given a good doctor and a capable nurse in charge, who would not grudge to devote their time to teaching, I believe the best results may be obtained. What I maintain is, that resi- dence alone is an insufficient guarantee of ability, or fitness for the work, without some test of the knowledge gained during the period of residence in hospital. This, I think, is where registration with us fails to meet a much-felt want. The fact of there being an examination by an outside body would be a valuable stimulus to the nurse all through her term of residence, and would do something towards prevent- ing merely mechanical work, adding zest, thus causing happiness, which we cannot do without. We speak of the old and new order of things, if we compare the generations one with the other ; it seems like constant revolution, but in reality it is a succession of events leading to changed conditions. There is no break in the link ; it is progress, not revolution ; it is the same with the so-called " Profession of Nursing." As the science of medicine has advanced, a more intelligent assistance has been called for by some, an instructed intelligence, which can grasp the meaning of technical instructions left for the guidance of the nurse. To prevent repetition of platitudes, you will find my ideas on this point in a printed form, which any of you may have upon application to me at the close of this meeting. The Preparatory Instruction of Nurses 121 When I first entered St. Thomas' Hospital, London, nearly thirty-five years ago, a year's residence was con- sidered sufficient length of time to prepare one for the taking of responsible positions, even to that of matronship. I am sorry to say this custom is not yet quite obsolete in some of our British hospitals. The year mentioned was an immense improvement upon what had been, before the time of Miss Nightingale establishing her school at St. Thomas' in conjunction with Mrs. Wardroper (matron of that hospital), after Miss Nightingale's return from the Crimean War. The value and far-reaching influence of the work done by that lady requires no comment from me, it will live for ever. For Mrs. Wardroper I would like to say one word. The single-handed combat which she undertook, with the general bad condition and ignorance which prevailed at that time in the nursing world, was being nobly fought, when Miss Nightingale, in search of a hospital wherein to establish a school for the training of nurses, came upon and recognized the good work being done by Mrs. Wardroper, and chose St. Thomas' Hospital as the center for her operations. This school being established class work was gradually introduced, in addition to the practical work, until it has grown into an elaborate system, and, as I have remarked elsewhere, had St. Thomas' remained the only training school for nurses we should have had uniformity, and possibly the authorities would have risen to the demands made upon them ; but, as there was perfect free- dom in the matter, a legion of schools, so called, sprang up, each establishing according to their individual ideas a curri- culum for the instruction of their nurses, producing a veritable chaos of training. We require to know the method of each school before we can estimate the value of the certi- ficate given. Looking back upon my own early experience, and the work undertaken by me, without knowledge of the con- struction of the human frame, its functions, and the hygienic laws pertaining to the m.aintenance of health, and my ignor- 122 International Congress of Nurses ance of the leading features of disease, and inability to dis- tinguish between healthy and unhealthy excretions, with the inevitable blunders arising therefrom (in fact learning through blunders, which is not to be commended where risk to life is involved), I concluded that it was necessary to be acquainted with these matters before entering the wards, to be instructed in the practical art of nursing, as there is too much close study entailed in acquiring the elements of these things to admit of classes being carried on simul- taneously with ward work. Professor Macewen of Glasgow University was the first to suggest to me the possibility of an organized uniform method for the technical instruction of nurses, before enter- ing hospital as probationers for practical work, with final examinations, after a fixed period of residence, by an out- side independent body representing the State, whose diploma should be the sole guarantee of fitness for the office of " nurse." It was on the New Year's morning of 1891 that Pro- fessor Macewen, in an address to our nurses, first made public mention of what he thought might be done in this respect, and added, " Will the Glasgow Royal Infirmary take the lead ?" SCHEME OF EDUCATION AS ADOPTED JANUARY 1893. In consequence of his representations to his colleagues, a scheme was drawn up by our staff for a series of classes for pupils who desired to become probationers. This scheme was placed before our managers, and they very heartily consented to a trial. We made a start in January, 1893, and from that time we have gone on with our pioneer work, each year strengthening our confidence in the sound- ness of the step taken, though keenly alive to the necessity of fuller development. The intending pupil (unless holding a Leaving Certificate of the Scottish Education Depart- ment, or one in connection with the University) is required to attend a preliminary examination in Grammar, Com- position, Spelling, and Arithmetic. Ordinary physique and The Preparatory Instruction of Nurses 123 good general health are indispensable. The first six weeks are spent in attending classes (especially arranged for nurses in connection with St. Mungo's College, Glasgow) for the acquiring of the elements of Anatomy, Physiology, and Hygiene, for which the pupil pays £2 2s., providing board and lodging at her own expense. It would take too long if I fully detailed to you these classes, but I will give you an extract from our syllabus. " The Anatomy course consists of not less than twelve lectures, embracing the description of the bones, joints, and chief muscles of the body, the course of the main blood ves- sels and nerves, and the broad outlines of the anatomy of the brain and of the thoracic, abdominal, and pelvic viscera, illustrated by diagrams, casts, and recent dissections. These lectures are given by Professor Henry E. Clark of St. Mungo's College. Oral examinations on the subject matter are held throughout the course, closing with a written exami- nation by an outsider. This method of examination, I may say, is carried out in the other subjects, i. e. Physiology and Hygiene." Physiology also consists of twelve lectures given by Professor John Barlow of the same college, illustrated by diagrams, instruments, and by microscopic preparations — the subject matter comprising a description of the blood, muscles, food, digestion of food, circulation of blood, respiration ; the skin, kidneys, nervous system, general arrangements of parts of the brain in man, and the special senses. Hygiene is taught by Professor Hugh Gait, also of the same college, consisting of twelve lectures profusely illus- trated by models and diagrams, and including the general principles and fundamental laws of Hygiene. The dwelling in relation to health ; air, ventilation, water ; the various methods of heating and lighting are all very carefully con- sidered. Hygiene for nurses in regard to personal cloth- ing and food, and in regard to disease is entered into, and the general principles upon which buildings constructed for the treatment of disease should be erected. 124 International Congress of Nurses Upon the pupil passing successfully the examinations connected with this first course, she goes on to a second course, for which the sum of £3 3s. is paid. This course comprises twenty classes or lectures by Dr. James A. Adams, surgeon to the Royal Infirmary, on the nursing of cases before and after operation, according to modern ideas of surgery, in relation to the germ theory, including the operating room and its equipments. Fractures, dislocations, haemorrhage, dressing of wounds, instruments, the application of splints, bandaging, etc., are all fully dealt with, several classes being entirely given to practical work. Lectures and demonstrations on medical cases are given by Dr. Lindsay Steven, physician to the Royal Infirmary, consisting of lectures and occasional demonstra- tions in the wards of the lecturer. The chief diseases of the various organs are briefly described, attention being specially directed to the training of the nurses in (1) What and how to observe ; (2) What is required in regard to nursing; and (3) What to do in emergencies. Instruction is also given in the observation of the pulse, the respiration and the temperature, and the excre- tions generally ; in the examination of the urine, the admin- istration of medicines, and in the signs of poisoning by the more common poisons employed as drugs in the treatment of disease. A series of classes, ten in number, are also held by myself, comprising practical instruction in the cleaning and use of ward appliances, preparation of surgical dressings and methods of keeping such, care of instruments, preparing and application of fomentations and poultices, application of ointments, blisters, leeches, etc. ; special attention being given to the care of beds and bedding. Syringes of all kinds are explained, and their uses, with different methods of cleaning. Cooking is confined to ten lessons, as the principles are taught in the Physiology and Hygienic classes. Par- The Preparatory Instruction of Nurses 125 ticulars of this work have been published, and I take it for granted they are already known to you. This scheme excludes all class work during the three years spent in the wards, the time given to the acquiring of practical skill in the art of nursing. On looking over our syllabus you will observe that the three months' preliminary instruction is given entirely at the pupil's own expense. DISADVANTAGES OF THE OIvD SYSTEM. Up to that time we, in common with others, had gone on increasing our class work until it came to be a serious hindrance in the work of the wards, being detrimental to teachers, nurses, and patients. Examinations were a con- stant " Nemesis," giving no freedom to really enjoy work, and with insufificient leisure to study the subject matter given in lecture, much of the good of it was lost. We could not see our way to less than a ten hours' day of ward work, and classes in addition to this interfered with both sleep and recreation. ADVANTAGES OF NEW SCHEME- One great advantage of the scheme is that it rids us of the incubus of a number of unsuitable women entering the wards upon a month's trial. I do not know which to pity most, the nurse or the probationer, where the old custom still prevails, and believe some good pupils are lost through the difficulty of getting accustomed to the extremely new environment into which they are thrown, whereas, by being gradually led into it through a prepara- tory course, they might succeed ; it also ensures a uniformity of instruction, and we know exactly what to expect from each probationer. FIRST COURSE : ANATOMY, PHYSIOLOGY AND HYGIENE. I should like to see this modified, as I do not think nursing is sufificiently remunerative to compensate for any great outlay in the gaining of the knowledge necessary for the carrying on of the work, and I would advocate the tak- ing of the first course, viz., Anatomy, Physiology, and Hygiene, at some established medical school, independent 126 International Congress of Nurses of any particular hospital. This expense to be borne by the pupil, the course being specially arranged for pupil-nurses. I have attended the classes under the auspices of the Royal Infirmary, Glasgow, which are held in St. ]\Iungo's College of that city, regularly, and am of opinion that the ground covered by the teachers is sufficient to enable a woman to carry on her work at the bedside intelligently, and I have no desire to see these subjects extended. The fees for these classes could be minimized by large attendances, if all hospital authorities agreed in not taking pupils for clinical instruction uptil they held certificates from the dif- ferent recognized schools for the teaching of these three subjects. Each large town possesses at least one such col- lege, and hospitals situated in smaller towns, where they have not the same facilities, might combine to insist upon their pupils holding these certificates. I have not mentioned Chemistry, as both Physiology and Hygiene touch upon this sufficiently for the purpose of nursing, but we want uniformity, and this can never be attained without a central controlling power to regulate these things for us. One distinct gain we should have in the above would be, freedom from a preliminary examina- tion, as the woman who could pass the examinations con- nected with the first course would certainly possess suffi- cient general education for the second. SECOND COURSE : CLINICAL CLASSES. I think the Clinical classes should be undertaken by the hospital authorities, each for themselves, the nature of these also to be fixed, being confined entirely to the general, no specialism. About two months should be sufficient to cover the necessary ground, the pupils paying fees sufficient to cover the expenses of lectures, the hospital providing board and lodging free of expense to the pupil with suitable class rooms, and the matron or lady superintendent, as she may be termed, taking general supervision of these classes, and seeing that efficient tutorial assistance is given to the pupils, in addition to her own proper classes. The Preparatory Instruction of Nurses 127 The nature of this teaching as adopted by us, and the subjects we think it necessary for the pupil to be instructed in, I have already mentioned. We also endeavor to impart some principles upon which self-education may be carried on during the three years' perfect freedom from class work. I should like to see more time devoted to this second course of instruction than we are at present able to give to it, and that is why I advocate the lessening of the expense to the pupil, that she may not feel it a hardship in lengthen- ing out the time. What we cover in one month I think requires two. One hour's class work. I think, requires the whole of the remainder of the working day for study, either mentally or manually. MODUS OPERANDI RE WARD WORK : THREE YEARS' COURSE. The pupil, on entering upon the actual work of nursing under the tuition of the " nurse in charge," to make her- self practically acquainted with the ward duties and the individual care of the sick, should apply herself diligently to the understanding and practical application of the theory gained in class. Unconscious tuition is constantly going on ; the Clinical classes, held for the benefit of the medical students, are of great use to the probationer in keeping her memory fresh, and helping her to understand the why and wherefor of things. The three years mentioned is none too long for the acquiring of the necessary skill to carry on so serious a work as nursing. We must not lose sight of the manipula- tive part of the work, which largely predominates ; in this, as in all other handicrafts, nothing but actual handling can produce skill. We might hold class after class, but all we can do is to give rules for guidance; books also can do no more. It is for the nurse to make the knowledge her own by practical application. We cannot ensure uniformity of skill in the carrying out of nursing, any more than in any other calling. Individualism will reign here as elsewhere; general adaptation and quick intelligence is not given to all, but we require a certain amount of definite knowledge. 128 International Congress of Nurses If our larger hospitals must become recog-nized " Train- ing Schools " for the supply of smaller institutions (where they have not the facilities for teaching) and also for the supply of private nurses, I think we should endeavor to accomplish these objects with a minimum of disturbance in the ward work. The constant change of probationers from ward to ward, to give them an insight into the different methods of working, was well enough in theory, but unwork- able in practice. We found they were not long enough in any one place to take a grip of things, or for those about them to take sufficient interest in teaching, feeling they would be so shortly removed. We prefer them to take eighteen months in one set of medical wards before going to the surgical to take the other eighteen months, but can- not always manage this ; sometimes they have to take the surgical first. At the end of the three years thus spent in general medical and surgical work, we should like them to be examined by outside examiners from some recognized body, as I have already said, whose " diploma " should be the only legal guarantee for fitness for the work. Should the nurse be fortunate enough to obtain this, we should still be glad to retain her services ; should she fail, I think she should have the opportunity of returning to her " Alma Mater " and be re-admitted to examination later on. REMUNERATION. At the present there is a great demand in our country for nurses who have spent three years in hospital, and with the human love of change we require to do what we can to make hospital life agreeable and healthful, and to give fair remuneration, otherwise we should be depleted of our best nurses, and our hospitals would thus sufifer from the use of them as " Schools for Nurses." I think payment should commence as soon as a pro- bationer is taken into the service of the hospital. I repeat,, nursing is not a money-making calling. The day is past when it was thought to be noble self-sacrifice to take up nursing. It is now recognized as an " honorable calling for The Preparatory Instruction of Nurses 129 honorable women,'' and I think it ought to be so arranged that women of moderate means are enabled to enter with the object of making a living, which object does not nec- essarily entail a mercenary spirit. I think it is a stimulus to the overcoming of the initial difficulties connected with the work. We do not wish to attract the dilettante class — we rather wish to exclude them; and I would emphasize what has already been ably said by Professor Macewen as to the desirability of equality in the work — merit alone carrying the day, and not the paying of fees nor purchase of the higher positions. We want women of earnest purpose, with no heroics, but sufficient interest in the work to be happy in it and to carry them through emergencies that may arise with a spirit of pleasure without feeling ill used. Free from the worry of classes, I think it a most pleasant work, always varying with the myriad individuals and their myriad interests. I speak from the experience of twelve years spent directly at the bedside. DOMESTIC WORK. I am aware that some may raise objection to the purely technical character of our scheme of preparatory instruction for nurses, and think we altogether lose sight of the domestic. This we can never escape from ; it is this domestic nature of the work which makes it essentially a woman's work, and I would advise everyone who wishes to perfect herself in the art of nursing to perfect herself first in the art of housekeeping, including cooking. I think it waste of time to come to hospital to learn these things, and they cannot be done without; they meet a nurse at every turn. The whole condition of a ward depends on the nurse in charge. (Cleanliness is a much more scientific matter than appears at first sight.) We do not ask our nurses to do the housemaid's work of the ward, but we do ask for a thorough knowledge of the best methods of cleaning, that she may be able to direct. We have no system for the tram- ing of ward-maids— I wish we had— and therefore have to 1 30 International Congress of Nurses depend upon the nurse in charcje for the g-eneral brightness and comfort of all under her. It is similar to an ordinary home, and we all know how much depends upon the head. It is sometimes quite distressing to hear an otherwise capable woman expressing her ignorance of the most com- mon household matters, giving as an excuse the depending upon servants. JOHNS HOPKINS CURRICULUM. In looking over the circular of information kindly sent to me by Miss Nutting of the Johns Hopkins Hospital School for Nurses, I did so bearing in mind the characteris- tics of the two nationalities and their differing needs. In comparing the two systems, please do not misunderstand me, and think that I suppose either of the systems, trans- planted, would take kindly to the foreign soil. Each has sprung out of its own particular need. It is interesting to know what others are doing, and we may be helpful to each other in this way ; beyond this we cannot go. We see that during the first six months of probation, before the pupil enters the wards, instruction is given in household economics, food, hygiene, sanitation, anatomy, physiology, and materia medica. I must interrupt to say one cannot but feel envious at the well-arranged school for preparatory work, and wish some generous donor would furnish us with the same facilities for teaching. Well, after this six months comes eighteen months spent in practical work in medical, surgical, gynecological, infectious and orthopedic wards, not less than eight hours daily with an hour or two given to class work. This holds good through the two and a half years of ward work. The last twelve months are given to obstetrics, pediatrics, nervous diseases, and surgical technique, as taught in the various operating rooms. We go to the other extreme, giving a ten hours' day to ward work, banishing all classes during the three years spent in the wards ; exclusion of class work while in the wards being our main object in adopting a plan for the preparatory technical instruction of nurses. In addi- The Preparatory Instruction of Nurses 131 tion to this, we confine ourselves strictly to the acquir- ing of skill in general medical and surgical nursing during the three years, believing this to be the best course for us. I do not think the average woman of our country could cover more ground thoroughly, and, as I have prev- iously said, we have the disturbance of the ward work in regard to the interests of the patients to consider. SPECIALISM RE POST-GRADUATE WORK. I also think all special subjects should be taken up after a nurse holds her diploma for general nursing. I should like to see the day when it would be illegal with us for any woman to follow specialism, especially midwifery, without her diploma in general nursing — that is when we arrive at the " halcyon " days of knowing what that term indicates. So many complications arise in all forms of ill- ness, that if a woman takes up any special branch of nurs- ing, without a general training, she is likely to find herself in many difficulties. GENERAL. Any measure of success attending our enterprise is entirely due to the enthusiasm with which all concerned threw themselves into the work. The medical men who kindly undertook the various classes have been untiring in their efforts to make the two courses as useful as possible, and the coming in daily contact with the pupil through the whole term of residence, viz., the three years, is most help- ful in keeping up her interest and seeing that she makes the best possible use of her time. Our nurses in charge have almost all passed through the same course of instruction, and are most helpful to me in seeing that the practical nursing is well taught ; not only in this but in my own classes held during the second course I should be at a sad loss if it were not for the ready help I receive from them. Last winter our charge nurses in the medical wards kindly made arrangements for the practical instruction of the pupils in the taking of temperatures, 132 International Congress of Nurses. pulses, study of excretions, and testing. The resident doc- tors also kindly assisted in giving lessons on the position of the organs, etc. T must thank one and all ; without co-opera- tion the matron is helpless. The intimacy arising from the contact with so many of her future fellow-workers is most beneficial to the pupil, taking away much of the strangeness of the new surroundings and cultivating a spirit of good will. Thanking you for your patience in listening to me, and your interest in our doings, I now conclude with the hope that we may all go on with earnest purpose, ever keeping before us the highest ideals. ADDENDA. October 15th, 1901. It may be of interest to you to hear something of the history of the nursing in the Royal Infirmary during the last quarter of a century. At the beginning of that period a nurse had to commence as a semi-wardmaid, under the name of assistant nurse, and work her way without any direct instruction. She was called at 3 a. m., commencing work at four, which included the ordinary cleaning, such as grates, scullery and bathroom, sweeping of ward, dusting, etc. Carrying of food, for the ward supply, and the wash- ing up of the dishes had also to be done by her, and much carrying which is now done by men. Her duties ended at 8 :30 p. m., without any definite time ofif duty. This so-called " assistant " obtained in the " surgical houses " only. In the medical the day and the night nurses did all between them, nursing and cleaning, with the exception of the ward being scrubbed out once a week by a little army of women, six in number, who went the round of all the wards in turn. It was surprising to find the good nurses that were sometimes the outcome of this very empirical manner of obtaining knowledge, but these were certainly the excep- The Preparatory Instruction of Nurses 133 tions. We had better be silent about the majority, sit kindly in judgment, as the circumstances and conditions were to blame, not the women. The most of these nurses slept in small rooms adjoining the wards, and took all their meals (excepting dinner) in the ward kitchens. Nurses and servants shared the same dining room, and had to carry a knife, fork, and glass with them. The nursing staff at this time numbered 76. The managers were desirous of remedying this state of matters, and after much consideration a plan was devised for the carrying out of a building into the quadrangle to provide dining accommodation for the resident doctors, and utilizing their old rooms for the nurses, providing suitable dining accommodation with proper table equipments. An attempt was also made to separate the house work from the nursing, and was partially brought about by the appointing of a woman to every two wards to do the rough- est part of the work. A time table was introduced, which allowed each nurse two hours off duty daily and shortened the hours on duty. A uniform dress was also supplied to the nurses at the expense of the Infirmary. Lectures were instituted to enable them to have a better understanding of their duties, but these were a questionable boon, as they had to be a,ttended at the cost of sleep or recreation. The remuneration was increased, commencing with £12 the first year, £20 the second, increasing £2 annually until it reached £30, and three nurses were placed in each ward instead of only in some. In 1882, when the present dispensary buildings were reaching completion, a representation was made to the managers of the insufhciency of the old dispensary build- ings to provide the necessary accommodation for the nurses, and suggestions were made to them for the building of a " Nurses' Home " apart from the main buildings, where the nurses might have suitable sleeping and recreation rooms. The managers most readily accepted these sug- gestions, and the late Mr. William M'Ewen, at that time chairman of the " house committee," raised money for the 134 International Congress of Nurses. express purpose. In 1887 a Home for 75 nurses was com- pleted and. opened ; this, with the two corridors occupying the site of the old dispensary, gave accommodation for 105 nurses, and at that time it was arranged for them to take all meals in the dining room, with the exception of after- noon tea. In 1891 the bedside work had increased to such an extent that the three nurses were unable to accom- plish the work required of them without undue strain. The managers were again approached, and they granted permission to place a wardmaid in each ward to relieve the nurses of the household work. They also granted the erection of an additional flat to the Home, increasing the accommodation for nurses to 129. This enabled four nurses to be placed in each ward, but left a very small reserve for emergencies (two only), the probationers in the wards where the work was lightest being called upon to give assistance in wards where the work was heavier, so that the four nurses came to be more nominal than real. In 1892 a scheme was placed before the managers whereby the nurses might be relieved from all class work during their three years spent in the wards acquiring the practical art of nursing, as this in itself was a greater hindrance to the practical work of the wards, and occupied much of the nurses' sleeping or recreation time. This also was acceded to, and has proved to be a right step by its very great success ; it also ensures uniformity of teaching in regard to the technical requirements of the work. It may yet be enlarged upon, and further developed with advantage to all. In the early part of 1900 further demands arose, in the form of a nurse (for each surgeon) to prepare dressings only, and this being in accordance with modern surgery, in which the whole aim is to obtain the perfect purity of the dressings which are immediately applied to wounds, this also was granted ; and a few more beds for nurses were obtained by the giving up of a waiting room, and also our sick room for this purpose. (Salaries were again increased at this time, the maximum reaching £35 at the end of five years' service.) The supplying of these nurses hampered The Preparatory Instruction of Nurses 135 us still more in the meeting of emergencies, and permission was given to get lodgings for six additional nurses, which is anything but comfortable for them. The resources of the old Royal in regard to administration are now taxed to the uttermost ; day by day the strain is felt. If some benevolent citizen of Glasgow would interest him or herself in the' nursing arrangements, and double the accommodation pro- vided in the existing Home, they would be providing for the future well-being of the patients. About forty nurses* bedrooms will be swept away in the demolishing of the buildings facing Castle Street, and accommodation is also badly needed for the pupils attending the Clinical classes in connection with our preparatory course of instruction. At present they have to provide board and lodging at their own expense, which is rather too much to expect of them, and is also much less satisfactory to us than having them within the building. It is imperative that the nursing should be made attrac- tive and accomplished with as little physical strain as possi- ble, if the best work is to be got. The arrangements should be such as to cause our nurses to feel reluctance to leave their Alma Mater at the end of their three years' compulsory residence, and a voluntary service of an extra year or two should be given by them to enable us to build up an efficient permanent stafT, so that both objects may be attained, viz., a " Training School for Nurses " and an efficiently nursed hospital. The public themselves will ultimately profit by the improved nursing in our hospitals by being able to obtain for themselves a more carefully instructed nurse, l)Ut this cannot be arrived at without expense; and a more generous support is needed to enable us to carry out fully what we would like to do for the good of the patients, which should be the primary motive of all our movements in hospital. No good nurse of the past will resent the forward movement ; it is they who are most keenly alive to the need of progress. They are thankful to those who have gone before, and left their knowledge and experience for our 136 International Congress of Nurses. benefit. The aim of the present should be to leave a like goodly heritage. If we are not progressing, then we are retrograding. Who will come and help us to make our old Royal a household word, and a crown of glory to our city ? Miss Dock : I have lately seen the working of the Johns Hopkins preliminary course and cannot commend it too highly. The whole nurses home is turned into a field for practical work. The pupils in turn learn every part of household work and management. They buy supplies, keep accounts, and learn to order and prepare food both in large and small quantities. Their bedrooms are exquisitely kept ; West Point cannot compare with them. For six months the pupils do not go into the wards. During this time they learn the management of a bed patient in class by demonstra- tion, become familiar with all supplies and appliances ; learn how to make the different surgical supplies, and have instruction in hygiene, anatomy and physiology, materia medica, and the theory of practical nursing, with demon- stration. When they go into the wards they know what they are doing, and are not raw probationers. Mrs. Fenwick : Madam President, Ladies: The preliminary education of nurses is in my opinion absolutely necessary and it is a question in which I have taken a keen interest for some years past. Mrs. Strong, the able matron of the Glasgow Royal Infirmary, and whose absence we all sincerely deplore today, was the first to pro- pose and organize a course of preliminary training for nurses in Great Britain in the year 1893. The pupils are externes and pay for the cost of the course. Some years later a system of preliminary education for probationers was started in connection with the London Hospital Train- ing School. A house was fitted for the reception of twenty- eight pupils a short distance from the hospital, and a course of seven weeks' instruction is given in elementary hygiene, The Preparatory Instruction of Nurses 137 physiology and anatomy, together with practical instruction in sick room cookery, bandaging, splint padding, bedmak- ing, how to take temperatures, the names and the care of instruments and utensils, and various other useful details. This school and course is expensive as it costs the hospital upwards of il,000 annually. In 1899 I outlined a somewhat more extensive course of preliminary training for nurses in a paper read before the National Union of Women Workers of England. It is much on the lines now being tried at the Johns Hopkins Hospital. A six months' course is, in my opinion, all too short a time in which to teach thoroughly all that a woman should know before be- ing admitted to work in the wards. A more efficient system might be defined if the teaching extended over a year. The cost to the hospital would however be too great. A sounder economic policy would be for the pupil to pay for all pre- liminary teaching, and to meet her needs the organization of schools for preliminary training might be founded in popu- lous centers, at which a thoroughly efificient curriculum could be carried out. This is a question of the utmost im- portance to the nursing profession and will no doubt at an early date receive the consideration it deserves from the superintendents of training schools on both sides of the Atlantic. Mrs. Robb : It may be of interest to delegates who do not know that a set of papers on preliminary courses by Mrs. Strong, Miss Liickes and Miss Nutting appear in the American Journal of Nursing, in the first year's numbers. I think one of the general reasons for establishing this course is that we have found few probationers who under- stand practical housekeeping as they should understand it. The special course in invalid diet alone is not sufficient, because the women are so vague or unpractical in house- keeping affairs that they do not get as much benefit from the diet school as they otherwise would. With few excep- tions, our pupils are also unpractical in the general manag-ement of household details in the wards, and after 138 International Congress of Nurses. graduating them we still feel that they are deficient in domestic economy. The respect in which private nurses are most severely criticized is that they are deficient in house- hold economics. If pupils understood domestic science before entering training school, such a course would not be so badly needed. Miss Macleod : A course of preliminary training in domestic science much on the same line as that referred to as in practice at the Johns Hopkins Hospital has for some years been carried out at the Waltham Training School for Nurses in Massachusetts. The course includes the training of pupils in housework, cooking and the preparation of supplies, and has proved of the utmost value in the educa- tion of practical nurses. What We are Doing with the Three Years' Course. LAVINIA L. DOCK, Secretary of the American Society of Superintendents of Training Schools for Nurses. INTRODUCTORY. The need of extending the two-years course of train- ing for nurses in American hospitals to three years, and the benefits and improved circumstances to be gained both by the hospital and the nurse through this extension, were first discussed by the American Society of Superintendents of Training Schools for Nurses, in 1895, at which time a paper was read by Mrs. Hunter Robb, entitled "The Three Years' Course of Training in connection with the Eight Hour System.''* *This, however, was not the first time for the public presentation of the sub- ject by Mrs. Robb, as she had, in 189.3, advocated the adoption of three years with eight hour duty, in a paper read before the International Congress of Charities and Correction, and following this paper, two hospitals— the University of Penn- sylvania in Philadelphia, and the Johns Hopkins in Baltimore— had inaugurated the three years' course in their schools. This paper was in place of a report from a committee, which had been appointed the year before, to consider the establishment of the three years in training schools. The paper was accepted almost unanimously, and five years later, at the annual meeting of 1900, fifty-five schools in a member- ship of 124 reported a three years' course and five others a course length- ened over two years. Within the past year, and up to the date of this paper, a number of others in the society, now reaching over 70 in all, have adopted the three years' course. [The last report of the Commissioner of Education for the U. S., in a list of 433 hospitals gives 137 having a three years' course. This report, however, is dated 1900, and since then we know the number has increased greatly.] The reports made to the society of Superintendents in 1900, with the individual information gained both officially and unofficially from hospitals outside of the membership of tie society, and from those within it which have recently adopted the new plan, have furnished the sources of informa- tion for the following paper. 139 140 International Congress of Nurses. THE SUCCESS OF THE THREE YEARS* COURSE. Both from the standpoint of the hospital and of the nurses' training and education, the success of the lengthened course is unqualified. The hospital service is benefited by the longer stay of the pupil nurse, and by her deepened experience and better trained judgment. The medical staff feels the advantage in the less frequent changes and less noticeable breaks in continuity, w^hich, as we all know, they disliked in the short period of two years ward work for th'e nurses. The steadiness and balance of the training school are markedly stronger, and the nurses realize the improvement in the diminished pressure of study and the greater oppor- tunities for observation and assimilation of knowledge. So far, inquiries have not discovered a hospital superintendent, training school head, or pupil nurse, who would prefer to return to the old method. HOW THE COURSE OF STUDY IS GRADED. It is only natural that in so short a period considerable crudity and want of finish should be found to exist in the curricula of the various schools. Time and the experience derived from experiment are needed to shape a curriculum completely, so as to include the necessary fundamentals, to cover all the special ground made necessary by the special conditions of the work of the hospital, and to include symmetrically the various elective courses and the higher branches possible in a fully developed scheme of three years training with adequate study time. But on the whole, so far, it is evident that advance is being made in two lines at least : First, much more atten- tion is being paid to the housekeeping and dietetic basis of nursing and of ward work. The new gospel of the elevation of every kind of domestic and manual work to a science is making its influence felt in our training schools, and is evidenced by the greater attention paid to the cooking lessons, by the more practical and demonstrative teaching The Three Years' Course 141 of hyg-iene and sanitation, and by the growing demand for preliminary practical training. Second, the beginnings are noticeable all over the country, of the introduction of the elements of sociological study into the latter part of the course, and of a desire to have the nurse see herself and her work in relation to humanitarian and reform movements; to open her mind to the duty of the preservation of the public health, the value of preventive movements, and the relation of health and disease to morals and immorality. These two tendencies seem the most encouraeine fea- tures of our lengthened courses. Theoretical and practical nursing had already been well developed, and need only to be further improved by a diminution of study cramming and bv shorter hours. THE WEAKNESSES OF THE THREE YEARS' COURSE. These may be found mainly at the beginning and end of the course in the absence of definite entrance qualifica- tions, the lack of preparatory teaching before entering the wards, and indefiniteness in the higher professional branches of supervisory and executive work, such as will fit nurses to take positions of responsibility. Both weaknesses are well recognized, but the difficulties in the way of amending them are great. The inadequacy of an educational preparatory test, based upon book study alone, has long been tacitly acknowledged. The college graduate who has never worked with her hands, or learned to put things in their places, or felt the pressure of responsibility, has no advantage, through her excellent education alone, over the intelligent home- taught girl, who has always assisted her mother in the cares of a family, when the two enter a training school for nurses. The higher education is desirable and excellent, but for nursing a special preparatory training in practical things is urgently felt by superintendents to be necessary, if the three years' course is to be relieved of the burden of having to teach adult women all sorts of homely accomplishments which they should possess before they enter a hospital to 142 International Congress of Nurses learn nursing — and which, indeed, they cannot always acquire later. At present we have one school, * the Johns Hopkins, which has worked out a thorough preparatory course. It consists of six months spent in household work of every kind, purchasing and inspecting food supplies, preparing and serving every kind of food, both in large and in small quantities, and in keeping the financial accounts of the same. During the same period these pupils are taught anatomy, physiology, materia medica, the preparation of surgical sup- plies, and the fundamentals of practical nursing, in class, by demonstration with a subject. During this period the nurses do not go into the wards. The entire home of the training school is made a field for this practical work, and trained teachers are in charge of the different departments of work. This course, the fruit of Miss Nutting's experience and reflection, is, to my mind, the most important thing being done today in our training schools. But few hospitals can undertake such a preparatory course, and favored institu- tions like the Glasgow Royal Infirmary, the London Hospi- tal, and the Johns Hopkins, are to be regarded, as it seems to me, as experiment stations, where object lessons may be studied by the rest of the hospital world, to be adapted to other conditions, and carried on in central schools such as the Dublin Metropolitan Technical School for Nurses. This latter idea has been suggested by several of our superin- tendents. THE DISSIMILARITIES IN OUR TRAINING SCHOOL. CURRICULA. Many dissimilarities exist in the arrangement of our curricula of the different schools. Some emphasize one branch and others different ones beyond the rest. But so far from looking upon these dissimilarities as unfortunate, I am inclined to regard them, to a certain extent, as whole- some and indicative of vigorous life. They present, taking *The Waltham school also gives excellent training of the kind described above as preparatory work ; not, however, separated from the later work of ward nurs- ing in as definite a way, and the New York City and Metropolitan training schools now announce the establishment of six months preparatory training. The Three Years' Course 143 them altogether, a set of practical experiments which afford means of critical comparison and enable us to advance more rapidly and intelligently than we could do, were all bound to one method. Where uniformity is needed is in a certain minimum quantity of fundamentals, or what we' might call primary instruction, and to this amount of uniformity we are year by year approaching more closely, as will be seen by examining our training school schedules of work and study. But to require uniformity in the more advanced work would check experimentation, and indeed would be impossible, as our work follows the growth and expansion of medical science and hospital development. THE HOUR.S OF WORK. Less progress has been made in this direction, on the whole, than in any other. Some half-dozen schools only, so far as I know, have adopted an eight hours' day, and while several have lightened the work to some extent by longer hours off dut}- or by more extended leaves of absence, yet as a rule the long hours are left too nearly what they were, before the addition of the third year, and this seems dis- tinctly wrong, an evident advantage to the hospital not bal- anced by a corresponding advantage to the pupil ; a demand upon her strength and endurance beyond what is reasonable. A moderate increase in the outlay made for the train- ing school would allow the enlargement of the nursing staff to the number necessary for reducing the hours of ward work, and the demands of medicine and of the more intelligent part of the public are making it daily more necessary for the nurse to have time allowed her for the cul- tivation of her mind and heart as well as for manual accom- plishment. The few schools which we have at present working on the eight hour plan do not simply reduce working hours and leave the pupil an unsystematized leisure, but provide the alternatives of physical and intellectual work, with reason- able opportunity for recreation, which make up the ideal life. 144 International Congress of Nurses. THE RETURN OF PRIVATE DUTY INTO THE CURRICULUM. With the extension to the third year there is noticeable a marked tendency to re-introduce the practice of under- graduate pfivate duty, which, in the two years' course, had practically disappeared from all high-grade schools, but which is now returning to an alarming extent. '^ Personally I regard this as a serious danger, and the Society of Superintendents as a body has steadily and invariably opposed it. It is a menace to the gradu- ates and a nullification of the benefits of the third year to the pupil. It means, for her, interruption or entire loss of those opportunities which she can only have in hospital, and which cannot always be compensated to her outside ; she loses the clinical observation and teaching ; loses her class and lecture work or her third year club work ; and what is nearly the most important of all, the daily prac- tice of order, the harmonious subordination of self for a good purpose, the discipline of feeling one's self a part of a symmetrical whole, which does so much to mature and balance the illy-developed and angular though excellent material which ofifers itself in our schools, to be made over into the capable and unselfish woman of good judgment. I present no argument of injustice to the patient in this custom of undergraduate private duty, because, as the patient must always specify that she wants an under- graduate, and as the doctor always knows that the pupil is still in training, there is no question of imposition to the patient, who prefers the pupil nurse because she costs less. But there is a distinct injustice to the graduate nurse, who is working to support herself and, often, others. She cannot compete with the pupil who, receiving maintenance from the hospital, is sent out at from five to ten dollars a week less than the graduate. Hence we have the anomaly of one and the same school assuming to fit women to earn their livelihood on a certain plane, and at the same time ♦Without attempting a complete census, I will mention twelve hospitals in our present membership, and there are many outside of it. The Three Years' Course 145 for its own benefit systematically underbidding them in their work; an economic injustice which shows plainly how much we need a knowledsre of related affairs, throueh -ignorance of which one-sided specialists can be a positive hindrance to the general advance of all workers. There are superintendents of nurses, who, looking at the question only from the standpoint of the education of their pupils, believe that experience in private duty is essen- tial as counteracting the tendency to institutionalism and routine. But so long as the feature of financial benefit to the hospital is present, it is impossible to strip the question of its commercial features and consider it as an educational factor only. And, the charge of institutionalism, of martinet discipline and routinism being made against us, would it not be more sensible not to send the pupil forth from it, into private families, but to bring more of the private patient atmosphere into our wards ; a reasonable amount, and so make the wards less institutional? If all the patients of a free ward could be nursed just a little more nearly as private patients, the nurse could learn her tactful and sym- pathetic ways from the beginning, and not have so much to unlearn, when she goes into private duty. Two factors combine today in our hospitals to make nurses mechanical. One is the almost universal under- staffing of wards; the result being that the nurse, to get through her day's schedule, can hardly afford to waste even a half minute in unexpected ways; the other is the quite universally (in this country) increasing tendency of hospi- tal internes to limit and restrict nurses to the strict and literal carrying out of " orders " and to a technically per- fect attendance upon themselves. I have heard instance after instance proving this repressive tendency deplored by superintendents, who perceive the hedging in of the nurse's initiative with her patient in nursing ways. If our hospital work were made all that it might be made, the argument that pupils need private duty in families would fall to the ground. 146 International Congress of Nurses THE EXTENSION OF CO-OPERATION IN THE THREE years' course. Some encoiiragino;- advances are beinj^ made in this direction — much more, however, remains to be done. Some of our most vexations problems would be solved if each lar^S^e school could make itself responsible for the nursing of one or two small and incompletely equipped institutions which are now compelled to conduct their own training schools ; or, if several such hospitals should agree upon maintaining co-operatively a central school which should provide the nursing for all, thus giving one set of pupils a wide and full education, instead of turning out several sets each with a comparatively restricted teaching.* These sug- gestions, made many times by others, will no doubt in time be utilized in practice. Tlie President: The paper is open for discussion. Miss Chappell : I think graduate nurses all under- stood, when the three years' course was started, that private duty in the course was abolished. Yet many schools are sending out nurses in the third year, and if the superin- tendents cannot do away with it entirely we must appeal to our alumnae societies to take up the matter. I think if our associations presented letters on the subject to hospital boards, where this is practiced, that w'e could have some- thing done to put an end to it. I have known of nurses being out for as much as six months, and though I think private nursing is good training I do not think pupils should be sent to wealthy families who are abundantly able to employ a graduate nurse. I know^ many nurses feel strongly on this matter and I am one of them. O. But you think the private duty is beneficial ? A. I think some training in private duty is very nec- essary, and ward nursing does not fit one for it. *Such an arrangement exists in Washington, where the Children's and the Columbia Hospitals have for some years conducted a training school co-operatively. The Three Years' Course 147 Mrs. Robb: So far, the associated alumnae has required two full years of training in the hospital wards, as when it was founded that was the course. The three years' course has developed since then. Mis Peters : I was trained under a two years' course, and we spent our second year in private nursing. The school now has three years, and the pupils are sent out in the last year. I think it is an injustice to the nurse, who should have the benefit of her third year in training. This matter has been discussed in our alumnae association, and we hope in time to do away with sending out pupils. Miss Hay : In the school where I was trained the nurses obtain this experience in nursing private patients which is so desirable, without underbidding the graduate nurse. We call it " special duty." The third year nurse has a service in caring for one private patient at a time, in the pay wards. The head nurse is not held responsible for the " special's " work, but the nurse is solely in charge of the patient and is responsible to the doctor, as she would be outside. This gives her the confidence and self-reliance that she needs. Mrs. Fenwick : Miss Dock's suggestions are so numer- ous that I shall confine my remarks to two points. First with regard to the all important question, the term of train- ing. When T began nursing twenty-three years ago the generally accepted term was one year: it was gradually extended to two, and in England, during the past decade, it has become almost universal for nurses to be given a three years' course of practical training in the wards, before they are examined finally and certificated. Now we are proving that three years is all too short a time for a nurse to per- fect herself in general nursing and in all the specialties, such as maternity and fever nursing, and as the majority of train- ing schools contain no facilities for clinical experience in obstetrics and infectious fever nursing, these special 148 International Congress of Nurses branches must be learnt after graduation. Several of the large London hospitals have extended the term of train- ing to a four years' course. Personally I am in favor of a three year's course in a general hospital, to which special departments are not attached, — a fourth year may thus be usefully employed gaining practical experience in special work, and in the duties of matron, and domestic manager. Nothing under the three years' course can suffice, as after a probationer has learnt the elements of the theory and prac- tice of nursing she requires time to digest and use her knowledge, and become skilled in its performance. If we appreciate the lessons we have been taught in past ages, we grasp that no good work can be done in a hurry. In the past a long and arduous apprenticeship was compulsory before a man could hope to become a master craftsman, and we have only to compare the artistic value of the handiwork of the long-time apprentice, with the shoddy productions of our own time, to realize the necessity for perseverance before we can hope for perfection. 'Secondly, with regard to the undergraduate nurse being sent out to private duty, I strongly deprecate it — it is abso- lutely indefensible, it is equally unjust to pupil nurse and patient. It is true that we have not yet defined a standard for a trained nurse and that we do not give a legal guarantee of training to the public, but whether the course be two or three years, it should be completed by the pupil, without interruption, and we should deal honestly with a defenceless public, who would doubtless object to pay high fees for the services of undergraduates, if they knew that their near- est and dearest were placed at their mercy. The system of training private nurses is also important. I am inclined to think the system in England leaves much to be desired. In Canada and the States it is different, and I have been immensely impressed by the fact that the admission of pay patients into all the best hospitals provides a means of educating nurses for private practice in the best possible manner. In attending upon the pay patients in their single rooms, nurses have to perform numerous duties for the sick The Three Years' Course 149 for which they would not have time in a general ward; moreover, in those hospitals where, in special diet kitchens, the nurses are taught to cook and serve all the food for a refined class of patients, they become conversant with a sys- tem which as yet has not been attempted at home. Our nurses go straight out of the general hospital wards, into which only the very poor are admitted, to nurse in private houses, and to wait upon patients of very different habits. It is not surprising that many fail to satisfy the medical officer and the patients' friends. So chaotic are private nurs- ing afifairs in England, that well educated trained nurses are protecting themselves from the competition of the unfit by forming themselves into co-operative societies, each mem- ber paying 7|% of her fees to maintain the organization. There is a central office with a telephone, secretaries and other general expenses. A standard of training can thus be enforced, and also if the superintendent is a well qualified nurse, as she ought to be, good discipline amongst the mem- bers. Fees are collected for the members and the com- mittee can carefully consider any complaint which may be made against them. I think the future of the private nurse is largely dependent upon commercial co-operation. Miss Banfield : It may be interesting to you to know that, in looking over the hospital statistics in connection with Miss Peter's remarks, I notice that the hospital board took in between $2,000 and $3,000 in a year for the services of the pupil nurses. This was turned into the general fund of the hospital. Miss Peters : I think that goes toward supporting the nurses" school. Miss Banfield : It is quite impossible to tell what it is for. Miss Stewart: In the hospital with which I have the honor to be connected the term of training for nurses is three years, but we bind them to remain four years, that is, 150 International Congress of Nurses for one year after they have obtained their certificate. Dur- ing- the first three years they are twice examined, and if their practical and theoretic work has been found to be quite satisfactory, they are awarded a certificate of efficiency. In the fourth year they receive payment as fuUy quahfied nurses. The fourth year is spent either in the hospital or on the private nurse's staff. I attach great importance to this last year ; the nurse has up till then had no real responsibility, but now nnich is expected of her, she gets some authority, she is more her own mistress, has more liberty, is less looked after, and learns to stand by herself with some assistance from those who have already learned to walk. In fact she has now time to arrange and estimate her knowledge and experience, and to deepen the channel of her life. The enormous benefit of that year to the nurse is the develop- ment of her character, which in many instances the acute observer can see in her expression. Its value to the hospi- tal is also great, as it provides for the continual presence of a fully trained nurse in the wards, the care of the patients is therefore never left, even for a few hours, in the hands of half trained unqualified women. Mrs. Robb : Are they on the same basis in the fourth year as the third? Miss Stewart : We have in every ward a " Sister " who has been for some years in the service of the hospital ; she is in full charge of the ward, and the certificate nurse is immediately under her in authority. If the sister is out, ill, or for any cause absent from the hospital, the certificated nurse takes her place. If the assistant matron, my secretary, or one of the night superintendents are ofif duty, I take the most capable of those qualified nurses to fill her place, and there is always one nurse assisting in the housekeeping in the nurses' home. In this way they gain much experience which is useful to them later. Mrs. Robb : And the compensation — is that the same ? The Three Years' Course 151 Miss Stewart : They are paid $12 a month during the fourth year, which is good pay for a hospital nurse in Eng- land. If a nurse remains longer than four years her salary is raised to about $17 a month. We have a staff of private nurses in connection with the hospital, whose headquarters are in a house near the hospital, but quite apart from it. No nurse is sent out to do private nursing until she has obtained her certificate of three years efficient service in the hospital. When she is not at a case she can live in the home, and is therefore spared the expense of keeping an apartment. She is paid a salary of $12 a month and in addition she has 15% rising to 30% on her earnings. Miss Hughes : As a representative of one of the large hospitals and training schools, Guy's Hospital, I would like to say that the course of training there is on the same lines as St. Bartholomew's, as described by Aliss Stewart. The nurses are trained for three years, and receive their certi- ficate at the end of that time. The private nursing institu- tion is attached to the hospital, but has quite distinct prem- ises and constitution. It maintains forty-two pupil nurses in training at the hospital, and only supplies the public with fully trained graduate nurses, who receive a fixed salary. The net profit earned in fees by the institution is divided amongst the senior nurses to be applied in the provision of old age pensions. Dr. Hughes : How old are they when they begin their training ? Miss Stewart: We receive candidates at the age of 21 years on payment of a fee. We also receive free candidates at the age of 23 years. They all have to serve three years before they obtain their certificate, and one year after that, but in the former case the hours are shorter and the work somewhat lighter during the first six months. Question : All nurses are obliged to remain four years then? It is optional with them? 152 International Congress of Nurses Miss Stewart : It is not optional. The candidates sign an agreement before entering the service of the hospital, in which they promise to remain in its service for a period of four years, the fourth year being spent as stafT nurse in the hospital, or on the private stafif of nurses. Miss Wood : I just want to say a word about pre- liminary training, going back to the beginning of things. I have seen a very great deal of physical break-down on the part of the nurses, from having the theory and practice carried on simultaneously ; the poor nurse with aching feet and tired muscles, after her hard work in the day, goes into her room, throws herself on her bed, and with her text book endeavors to acquaint herself with the theory. I am down to the ground in accord wdth the argument, that the phy- siology, hygiene, etc., can be gone through wdth before we go into the wards, and if it was so planned it would make a very great difference. Take the average woman who comes into the hospital and is turned into the ward, what does she know of the language of the hospital, I mean of the use of the technical terms ? She is told to go and bring some- thing; some appliance of some kind, and she rushes off thinking the whole time she only hopes she may bring the right thing. That means mental, physical wear and tear. If before she comes into the hospital wards she has had the various implements pointed out to her and named, when she comes into the ward and is told to go after something, she will go and get it. I do think the present arrange- ment by which nurses are taught theory and practice at the same time is one of the great reasons for their breaking down. Speaking from my own experience, (and I stand before you not as a trained nurse, because there was no training in my da}, but we learned from practice, without theory,) I remember quite well when I was first in the hospital being told to put a poultice on the back of the chest. Where on earth was the back of the chest ? I really did not know. I do hope that we shall find out some means by which The Three Years' Course 153 we can teach our pupils theory and practice somewhat apart. I agree most thoroughly with these suggestions on that matter. Mrs. Robb: The object in creating the third year of training in this country was intended to be educational and for the benefit of the nurse, but, so far as I can see, to the present time the greater benefit has been to the hospitals. We found that it was utterly impossible in two years to cover a systematic course of training. Some of the subjects were too advanced for the second year, and were obviously third year subjects. And in addition the hours in the wards were too many and the work too hard to require at the same time a definite course of theoretical study, more time was needed. There- fore when the third year was advocated at our first National Congress, that the nurse should not be required to spend more than eight hours out of the twenty-four in practical work in the hospital, and that a certain portion be devoted to her theoretical instruction, it met with approval, but that feature has not been attained except in two or three in- stances I am sorry to say, and the same old hours, nine, ten. eleven, and sometimes twelve or even more, are re- quired of our pupil nurses in our hospitals. Unannounced : I would like to say just one word and that is that I represent a hospital where practically the idea that ]Miss Stewart has presented is upheld. We have been able to do much in the way of shortening nurses' hours, but I have been told repeatedly by the nurses themselves how much they appreciated their third year, and how much they learned in their third year. ]\Iiss Peters : I would like to add that our hospital in connection with its three years' course gives a year's course to the nurses immediately after they graduate, and there is a certificate given at the end of that time, the fourth year. It is not compulsory and they are paid $25 per month. I do not wish to be understood that I disapprove of the three 154 International Congress of Nurses year course, but I do disapprove of sending nurses out. I, myself, was at private duty almost all of the time during my last year, and missed all of the important lectures ; finally I requested to be kept in, and when in I sat up nights, and got up at 4 and 5 o'clock in the morning to study for my examinations. Miss Early : After hearing so much from so many nurses I feel there is little for me to say, but I would like to advocate the three years' course. I did not have it myself, for the simple reason that my school was small — I had a two years' course ; now I have had seven months' experience as matron, and I feel that the two years is too crowded. We try to get applicants who have had a high school educa- tion, and to give them all we can, but a long day's work makes one too tired to study. If it were not for the nursing journals we would fall behind in many things. I have been much impressed and benefited by this Congress. Miss Barnard : I would request that some of those who have had experiences on the non-payment side of the three year course would relate them. Mrs. Robb : There are, I think, eight hospitals on the non-payment system. The whole idea was io have a three years' course, eight hours practice in the wards and non- payment. The whole course was to be on the non-payment basis. In all our old circulars of information we added a paragraph saying, that for the first year seven or nine dollars monthly remuneration would be allowed, and the second year a little less was given, and in the next sentence it read that this was not intended as remuneration, but for text books, uniforms, etc. I could never understand why' less was given the first year when everything had to be supplied. And when I became superintendent it seemed to me better to put the whole thing on an educational basis. The students work for what they get in the way of an education, and they value what they get, but The Three Years' Course 155 it seems to me no more than fair that the hospital should in return furnish the uniforms and text books for their work. I think if we all look back we can recall how our money was spent each month, how much of it went for uni- forms and text books. I do know from my own experience as a pupil that much money was spent on sweets, as we called them, and on good times, but that money was really given to us in trust to spend on uniforms and text books. Miss Dock : While it seems extravagant to spend much money on cakes and candies we know now that there is a physiological necessity at the bottom of the nurse's craving for sweets. Scientific experiments in feeding armies have shown that soldiers can do more and harder work on a diet of sugar. Miss Palmer: In my experience as superintendent I have always tried to teach my pupil nurses that the money allowed them by the hospitals for uniforms and text books was to be used first for that purpose. That they must pro- vide themselves with proper uniforms and text books and then if they could save anything they could use it in any way they chose. The hospital should provide nurses with an ample diet, including the sweets needed. The President : This discussion is most interesting, but we shall be obliged to go on to our next paper, post-graduate work in hospitals. Post-Graduate Instruction for Nurses, M. HELENA McMILLAN, B. A. Superintendent of Nurses, Lakeside Hospital, Cleveland; Member Superintendents' Society. So busy have nurse educationalists been in solving- the problem of correct education for the would-be nurse that, as yet, very little time and thought have been devoted to the more advanced course of instruction by which the woman who is already a graduate nurse may gain additional experience and knowledge in her chosen work. Some effort, however, has been made in several of the American hospitals to meet this need. A few of the schools, willing to be of further assistance to the nurses to whom they have already given the preliminary training, have attempted to provide post-graduate work for the alumnse. In most instances this has resolved itself into granting such graduates as may wish it the privilege of returning to the hospital for a short period during the school vacation time and of allowing them to take up what work they choose in the wards or operating rooms. Sometimes, in addition, theoretical instruction in the form of lectures has been attempted. No claim is made by these schools of giving a regular post-graduate course; they are merely attempting to assist their graduates in the only way which ofifers. Undoubtedly this opportunity of again coming into contact with hospital methods and of observing advances in all branches of the work is of great value to the nurse who is fortunate enough to be a graduate of a school sufficiently old, liberal in thought, and strong in finances to allow it to attempt such 156 Post-Gr actuate Instruction for Nurses 157 an undertaking-. As far as it goes it is grood, but it does not go far enough ; is not a permanent educational feature, and reaches only a very limited number of nurses. The schools which are able to undertake even this most simple form of post-graduate work are few in number and fewer still are they which are capable of keeping up this effort year after year, and of continuing to meet the needs of their graduates. Schools for nurses connected with our modern hospi- tals, if they carry out the purposes for which they are estab- lished — that is, of nursing the sick of the hospital and of educating women to be nurses — do about as much as such institutions with their present limited stafif of teachers can successfully accomplish. If the same teaching force, in a spirit of g-enerous self-sacrifice for the good of the cause, undertakes in addition post-graduate work, without ques- tion sooner or later the added strain will be detrimental to the teaching staff, and consequently to the school and to the institution. Should hospital authorities be willing to pay additional salaries and provide extra teachers to carry on this work, the question would assume a different form ; but until such a time arrives it is doubtful whether heads of schools, in justice to their other work, should attempt post- graduate teaching. Colleges and universities have found it impracticable to deal with pupil and graduate at one time. There are instances on record of the college student making complaint that material necessary for the undergraduate had been utilized for the graduate. These complaints, as a rule, have been listened to and the demands of the students met. Post- graduate work has not been ignored in the several profes- sions, but provision for it is made entirely outside of the ordinary schools of instruction. The same should hold good in nurses' schools. In most hospitals, with propor- tionately large or small schools attached, and particularly since the three years' course is required, not only the time of the teachers belongs to the school but the material for study and opportunities for experience should be given to the pupil, not to the graduate. 158 International Congress of A^itrses The undoubted spirit of unrest which is sure to accom- pany the advent of qraduates into a nurses' school is another reason why these schools are not the right places for post-graduate work. In several of the cities of the United States there are hospitals devoted to specialties, offering post-graduate training in that one branch of the work to any nurse who is a graduate in good standing of an approved nurses' school. These hospitals give from three to nine months' course in practical w'ork, with usually some theoretical instruction. Most of them pay a salary of from ten to fifteen dollars per month, and require the nurse to w-ear the hospital uniform. To the nurse who, having completed the course in her own school, feels that her training has been lacking in certain branches, these courses in special hospitals are of value. It is only a small class of nurses, however, to which these special courses appeal. The average woman who has graduated from a school giving instruction in all branches of nursing, when she \vishes, for one reason or another, for post-graduate instruc- tion, usually feels the necessity of a general " brush-up." The new methods adopted since her graduation are wdiat the private nurse wants more particularly, while she who has dropped out of the field of actual nursing into executive work realizes her need of an all-round course of study. In some, if not most, of the post-graduate courses, the graduate, like the pupil, receives her training by doing the entire nursing of the institution. She has practically the same working day — usually nine hours — which she labored through in her training school period. Her work differs from her school w'ork in being of a special nature, but not other- wise ; the same amount of work, if not more, is expected to be accomplished ; there being no probationer, she must scrub basins, clean bath rooms, dust and do other work wdiich in a school the senior nurse is usually relieved of. It is far from the intention of this paper to criticize post-graduate hospitals and their methods. If these institu- tions receive graduates for instruction and depend upon Post-Graditate Instruction for Nurses 159 them to nurse their patients, naturally the first consideration must be given to the patients and to the accompHshment of the routine duties of the institution. In preference to dirty basins and bath rooms and undusted rooms, the graduate must scrub and clean and dust. But the question to be asked is, " Is the graduate getting what she wants and needs out of post-graduate work ? Has she time and strength to devote to the work now expected from her in a post-graduate hospital ?" Few women who have completed a two or three years' course in a nurses' school and then devoted from five to fifteen or even more years to nursing are willing or able to make such an expenditure of their strength. • i\s far as the writer could find, with the exception of the few schools which are attempting to provide for their own, there is no general hospital open to the graduate nurse, so that, even if she would spend time and money and strength, no post-graduate work — in other than the special- ties, is available. If the foregoing statements be true — namely, that nurses' schools cannot undertake post-graduate work, that special post-graduate courses meet the need of a very limited class of nurses, and that no general hospitals are olifering these opportunities — we must acknowledge that in reality there is no post-graduate instruction for nurses in the country. That there is necessity for this instruction and a desire for it felt by nurses in general is beyond dispute. Such being the case, it would seem that something should be done to meet the demand. As it is nurses who feel this need, and nurses who will be benefited, naturally it must be the nurses tliemselves who will work out the problem and establish such courses of instruction as they wish. The time for depending upon others for every step in the road of progress is long past. Nurses are strongly united now, and thoroughly capable of meeting this demand. Over two years ago there was organized a course in Hospital Economics at Columbia University. The object is IGO International Congress of Nurses to prepare women to be teachers in nurses' schools. The announcement for 1901-1902 states that " Six students are completing the course for the year 1900-1901, and it is hoped that at least as large a class will be formed for the coming year. Should any nurse of exceptional ability come under your notice, we trust you will place the advantages of the course before her." Further on the report says, " The expenses for the past year were met in part by contributions from many individual superintendents of training schools. Since then no improvement has taken place in the financial condition, and for the coming year there is no present pros- pect of any other contributions," and so on. The reasoning which leads up to the following con- clusion may be wrong, but it seems to the writer that if this course, instead of being planned for only nurses of " excep- tional ability " or for those who wish to be teachers, were arranged to suit all graduates ; if the " hospital economics " course could be made simply a specialty of the whole with another division devoted to practical nursing and new methods, and the whole recognized as post-graduate work, that the present object of training teachers would not suf- fer. It does not seem unreasonable to predict that large classes of nurses taking up the practical nursing course would assist by their fees very materially to meet the expenses involved. Should this come to pass, the National Alumnae Asso- ciation and nurses at large would be interested and feel called upon to assist, and no longer would the financial burden fall on training school superintendents who are unable to bear it indefinitely. It is beyond the scope of this paper and the ability of the writer to attempt to suggest the desired schedule of instruction. Without doubt, there would be difficulties to overcome ; hospitals would have to be found which would open their doors to graduate nurses on an entirely new basis. Such questions, as all others on this subject, must be handed over for solution to the wise decision of the com- Post-Gradiiate Instruction for Nurses 161 mittee on the Teachers' Course. The object of this paper would be accomplished if it could persuade that committee to consider this matter and if possible enlarge the present undeniably narrow field of work to include all nurses. If such a thing could be brought about, an inestimable boon would be conferred upon the graduate nurses of the country, and it would seem that the question of post- graduate work would be solved in the most satisfactory manner possible. Miss Fuller: It is with satisfaction as well as with interest I have noticed that the necessity for the develop- ment of post-graduate work is being recognized more and more each year. Most large hospitals now allow their own graduates to return to them for two or three months' ward work. Certain opportunities are given those who have only had the advantages afiforded them by the training in a small hospital. To illustrate I will give a short outline of post- graduate work as it is conducted at the Woman's Hospital in New York. Here all pupils must be graduates, and they come, as a rule, from small hospitals. The nurses are on duty from seven to seven, with two hours ofif, daily, and one afternoon each week. Classes and lectures are held weekly. Class work consists of systematic instruction in practical nursing, in hygiene, materia medica, anatomy, physiology, and gynecology. A course of lectures is given by the dif- ferent surgeons ; notes are taken by the pupils, written out, and handed in for correction. A course in massage is also given by a competent masseuse, and one in the diet kitchen under a trained teacher. The whole course is nine months. The pupils spend a definite time in each ward, the treatment room, the operating room, and on night duty. Each ward has a different surgeon, with his own methods, so the nurses have wide experience and gain much in knowledge. Each ward has as head nurse a graduate of some large general hospital. The operating room is also in charge of a permanent head nurse. The 162 International Congress of Nurses surgical technique is quite perfect, and the pupils' course includes every detail, including the after-care of operative cases, who are placed, two each, in cottages on the hospital grounds. As a rule, one nurse cares for two patients, by day, and another by night ; serious cases have a special. One head nurse superintends the cottages and teaches the nurses. The pupils receive $15 per month, with board and laundry. At the end of their service they must pass a satis- factory examination before the medical board, before receiv- ing the diploma of the hospital. It was most interesting to note the development of many imperfectly taught nurses under this training. It is an excellent experience for any graduate, wherever trained. It broadens one, and I look back upon the months spent there as well spent. The President : The next paper we will take up is on nursing the insane, by Miss Laird, Superintendent of Nursing, State Hospital for the Insane, Seneca County, New York. The Nursing of the Insane. S. LOUISE LAIRD, Matron and Superintendent of Nursing, Willard State Hospital. The history of the insane from earliest times to the present day presents strange contrasts of ill-treatment and favor. Among- the Mohammedans it was believed that they were the blessed of God, and that their souls were removed early as a mark of partiality. The Orientals regarded their ravings as inspirations, and they were treated with marked respect and kindness ; even among the Indians the feeble- minded and insane received kind treatment. But through- out Christendom for long ages they were thought to be accursed and possessed of devils, and were treated accord- ingly. So we find these afflicted people, miserable because of their mental condition, made infinitely more wretched by being chained for years to the walls of dark and solitary cells, or made to subsist on bread and water, or lie on beds of straw, tortured, whipped, occasionally burned or executed, — always the victims of a fixed belief that insanity was an incurable malady. In the latter part of the eighteenth century Pinel in France and William Tuke in England became, with others whose names are less known, but who are doubtless as worthy of being immortalized, pioneers in advancing the theory that the insane were human beings afflicted with disease, and gradually the idea that these people were unfor- tunate and not criminal began to prevail, and the places where they were confined to assume the character of asylums instead of prisons, as formerlv- In our own country 168 164 International Congress of Nurses Dorothea Dix began her great work in the first half of the nineteenth century, and the degree of comfort and care that the insane of America now experience is largely the out- growth of her zeal and energy. While our present methods are doubtless the best that have existed in this country, still they could be improved in many ways, particularly in the care given the indigent insane. The establishment of train- ing schools in our State hospitals is a great step in the right direction, the object being to secure for these afflicted people more intelligent and scientific treatment, and surely they need all the help that can be given them, and by as skillful and enlightened nurses as can be obtained. Insanity is defined as " a prolonged departure from the individual's normal standard of thinking, feeling, and act- ing," and allows of many different classifications. For practical application of the manner of nursing we will con- sider it from three great divisions : 1. Cases of mental exaltation (mania, acute and chronic). 2. Cases of mental depression (melancholia, acute and chronic). 3. Cases of mental enfeeblement (dementia, paranoia, epileptic insanity, circular insanity, general paralysis, idiocy, imbecility). In this brief paper we will give more time to the first two classes, as they are the cases which you as graduate nurses will meet, and who require more intelligent and scientific nursing than the third class, as they need but little more than custodial care or the attention given any feeble patient. " Mania is a form of insanity characterized by emotional exaltation, acceleration of the flow of ideas, and motor agita- tion.'' These cases are very interesting, as about seventy per cent, of them are recoverable, which is always a source of inspiration to the nurse, and a needed one, as their care is extremely wearisome during the excited period. The pathological cause for this disorder is as yet much obscured, careful investigation revealing no anatomical basis, though The Nursing of the Insane 165 a theory prevails that it is due to a congestion in the higher brain-cells. Perhaps the belief in another theory, that there is a lack of nutrition in the nerve-cells, producing this unnatural condition, is the best for a nurse, as then she will be stimulated to persevere in feeding her patient, which is regarded as one of the chief agents in bringing about a recovery. Usually a maniacal outburst is preceded by a period of depression, which may continue for a few days or for a longer time, possibly several months, and when this gives way the true disorder begins to manifest itself and the patient becomes noisy, restless, incoherent, and lacking in self-control. The entire system is disordered, the skin being hot, the tongue dry and coated, sometimes to a great degree, the lips often parched and bleeding, the bowels irregular, the urine scanty, the sleep disturbed and fitful. In mania the habits are often most untidy, due to inattention on the part of the patient to bodily wants. As there is usually no distaste for food, there may be no difficulty in giving it, but again it may have to be admin- istered forcibly, as the patient's mind is too exalted and pre- occupied to know if he has eaten or not. Simple liquid foods are recommended to be given frequently and in as large quantities as possible, even to the point of overfeeding. Rest in bed with treatment in massage is urged if the patient is not too resistive. Sleep may be induced by warm baths or hot wet packs, though occasionally a sleep-producing agent will be neces- sary. In some cases there is much danger from over- exhaustion, but if food be given in sufficient quantities and is assimilated this result may be averted. As much care should be given the hair, teeth, and mouth of the patient as if he were suffering from a fever delirium, and this will add greatly to his comfort and appreciation on recovery. There is but little danger of suicide in maniacal cases. As to his moral treatment, there is no use in arguing with him in regard to his delusions, though these may be gently but firmly contradicted or else disregarded, and while 166 International Congress of Nurses it is best in the acute stages never to discuss these halkicina- tions and delusions, still they should not be acted upon or agreed with. During convalescence brief but positive denials of the imaginings of the patient may be beneficial, but it should always be done in the kindest spirit and man- ner. As the patient improves there will be a gradual sub- sidence of this exalted state towards the normal condition, possibly accompanied by a " tearful irritability," and gradu- ally the mental balance will be restored. There are instances where this restoration takes place very suddenly upon awakening from a normal sleep, but this is not usual. The course of an attack of acute mania usually extends over a period of from three to six months, though some cases appear to run their course in a much shorter time. Occas- ionally this disorder takes the form of an inflammatory con- dition of the brain, in which all the before-mentioned symp- toms will be greatly intensified and death may result from exhaustion. More frequently death is the result of some complication, as nephritis or pneumonia. About five per cent, of these cases die and ten per cent, result in dementia. Seventy-five per cent, show hereditary taint, which, while it is not considered an essential factor in producing mental disorders, is regarded as rendering the nervous organism unstable, and therefore more liable to collapse when it meets any severe strain, either physical or mental. Cases of chronic mania are very rare, and consist of a continuance of maniacal disturbances, extending over a long period, perhaps for years. As a rule, the physical condition of the patient will remain good, the mental state one of elation, and reason and judgment will be much impaired. There is no tendency to suicide and the habits may be most untidy. Recovery from chronic mania is very unusual. The second class of insane which we will consider are cases of mental depression or of melancholia. This form of insanity is characterized by " constant depression, retarded flow of thought, and fixed delusions." These are certainly the most miserable of all that great body of people. Some sit for days with drooping figures and sad faces, The Nttrsing of the Insane 167 absorbed by the contemplation of their own misery, behev- ing most firmly that they have committed an unpardonable sin, or that they are responsible for the sins of the world, or that they have brought want and trouble upon their families. Others constantly walk about, moaning and wringing their hands, while still others complain they have no feeling at all, seeming unable to appreciate any sensation of either pain or pleasure. When hallucinations are present they are of a depressing and terrifying nature, and the patient is often troubled by " hearing voices " which con- stantly reprove or threaten him. The physical condition is most uncomfortable, the skin being pallid and cold, the circulation slow, digestion retarded, headache almost constant, urine often profuse because of intense emotion, bowels constipated, food refused because of distaste for it or from troublesome delusions, as a belief of unworthiness to eat, a fear of poisoning, or dread of bringing want upon others — altogether they present a most pathetic condition when in the acute stage. As in mania, there is no known anatomical cause, though it is supposed to be the effect of cerebral ansemia or of auto- toxemia. It is not yet known how^ far the absorption of intestinal poisonings is an agent in producing insanity, but it is believed it is a more frequent agent than is generally recognized, and it is certainly a most important factor in retarding the recovery or in increasing the intensity of mel- ancholia. Ill-health, business or love troubles, grief, over- work, shock from fright, or religious troubles are among the alleged moral causes in bringing about this unhappy condition, and, as in mania, hereditary taint is found in more than one-half of the histories, which weakens their power of resistance. From this picture you can understand how true it is that the most serious danger to guard against is that of suicide, even in the mild cases, and the newspapers furnish us almost daily evidence that this fact is not generally under- stood. Knives, scissors, cords, door-keys, anything that could be made an agent in ending one's life, should l)e care- 168 International Congress of Nurses fully removed, the windows arranged to open but a little way, and constant oversight may be needed to prevent the l^atient from strangling himself with a strip of bedding or clothing. Removal from his friends and usual environments is often found of great benefit, even the change to a State hospital may be a relief. With familiar faces and objects about him he only realizes more keenly how he has changed, and this adds to his depression. Moderate travel, — always guarding against a tendency to suicide, — a short visit to the country, or going to the house of some physician or to a sanatorium may produce very good results. As in cases of mania, food is one of the most important remedial agents, but it must be selected and given with far more care, as the digestion is more enfeebled. It should be pushed to the point of overfeeding, if necessary, and may consists of most liquid nourishments, rare or raw beef, eggs, prepared cereals, and sometimes green vegetables or fruit. That it be digested is the great feature, and as the digestive organs are always weakened, they should l?e constantly observed. One authority recommends washing the stomach frequently with salt solution and giving " high enemas," with a view of ridding the system as far as possible of masses of undigested and unassimilated food and also stimulating the lining of the intestinal tract. Continual rest in bed with massage is strongly recommended in extreme cases of mel- ancholia, but with milder degrees part of the day in bed, with the remainder spent in some occupation out-of-doors, if possible, may be more beneficial. For sleeplessness either hot wet packs or prolonged warm baths (from one-half to two hours — 110°) are usually successful, though mild hyp- notics may be necessary. As to the moral treatment during the acute stage, it is best generally to leave the patient quite alone. He cannot take an interest in others ; he is unfit for labor, either phy- sical or mental ; amusements are painful to him, and his reason and judgment are both impaired. To surround him as nearly as possible with a neutral atmosphere is the best treatment, and, as in cases of mania, one should never argue The Nursing of the Insane 169 with him in regard to his dehisions, though occasionally they should be firmly and kindly denied. Sympathy may be given a melancholiac and will be greatly appreciated, and hopefulness should be inspired in every way possible. It is wonderful how much effect those about them may exert over the minds of the insane, and a nurse has it in her power to materially aid or retard a recovery by her moral attitude towards her patient. All sources of irritability should be removed as far as she is able, and her whole aim s4iould be to govern by kindness, patience, firmness, and sympathy. This fact is far too little understood and prac- tized, and the tendency to play " with the mind diseased," to make the patient express his delusions for the amuse- ment of herself or others, cannot be too severely criticized and condemned. When the recovery of these patients is once established, regular physical occupation, as walking, bicycling, playing golf, any out-of-door exercise, or some useful manual labor should be begun and encouraged. " Substitution of thought " as soon as the patient is able to be diverted should be sought in every way, and to aid him in his efforts to for- get his own depression is of the utmost importance. In cases of simple acute melancholia about ninety per cent, are recoverable and five per cent, result in death, usually due to marasmus, suicide, visceral disorders, or pneumonia. A very large number of the chronic cases die of tuberculosis. We will now consider briefly the third and largest class of the insane, — that of mental enfeeblement. Dementia is the general term given to the greatest division of this disorder, and one author speaks of it as " the goal of all insanities." Being the result of so many different disturbances, it assumes numerous phases, which we will not have time to consider in detail. Rare cases of " primary dementia "—that is, enfeeblement of a mind once normal with no acute form of insanity preceding it- may follow prolonged physical or mental strain, such as may attend the vicissitudes of war or some intense fright or 170 International Congress of Nurses shock, in which case the usual care of an acute insane patient may be given and recovery looked for at any time, from a few months to a year. More frequently these cases merge into a condition called " secondary dementia," where the enfeeblement is recognized as the sequel of some cerebral disease, as epilepsy, alcoholism, syphilis, melan- cholia, and mania. Secondary, or " terminal," dementia may be divided in two classes, apathetic and agitated. About two-thirds of the patients in our State hospitals are demented, many of whom were maniacal or demented when committed, but have since lapsed into a quiet existence with but little emotional basis. Their condition is more pathetic from its hopelessnes, though mercifully they are more contented with their lot than one would imagine they could be. They appreciate any comforts or favors very highly, take an active pleasure in amusements, — a large part of the work about the hospital is performed by them, — and while they are not capable of initiating any work, they acquire automatic habits of employment when directed and supervised. They are very useful to the hospitals, and are deserving of all that can be produced for them in the way of improvements or diversions. In the advanced stage of apathetic dementia the patients do not speak ; they crouch or lie about on the floors or in corners in the most negligent attitudes and cover their heads with their clothing, while those with agitated dementia are restless and subject to sudden outbreaks of excitement with no external cause. With either of these classes when the mind reaches a certain plane of deterioration it remains stationary for years per- haps. All of the faculties are impaired, — memory, reason- ing, judgment, and will, — though the physical condition may be quite sound and only custodial care is required. About ten per cent, of the epileptics become insane, and the usual form of their disorder is dementia. They require the care of an ordinary epileptic, but as they are subject to sudden outbreaks of rage and fury, when they may com- mit serious assault or crime with no subsequent recollection. The Nursing of the Insane 171 their confinement in an institution is strongly recommended. Recovery of a case of epileptic insanity is most unusual. " Circular insanity " is characterized by alternating con- ditions of mania and melancholia, and while made up of the three most curable forms of mental disorders, is still the most incurable itself. These cases are best cared for in insti- tutions, to prevent suicide in a melancholic stage and extra- vagance in a maniacal period. By medical treatment these cycles may be retarded or postponed, and the same nursing should be given these cases as that recommended for mania and melancholia. The rest cure and hydrotherapy are used in both phases. " Paretic dementia " is a disorder characterized by pro- gressive enfeeblement of the mind combined with general paralysis of the whole body. Intellectual overwork or strain of a system impaired by alcoholism or syphilis is believed to be the chief cause of paresis, and it usually runs its course in from three to five years, when death is very liable to occur. In its early stages it may be mistaken for neurasthenia, but gradually more marked symptoms will be noticed, as the paretic articulation and writing, loss of reflex action, emacia- tion, failure of memory, emotional irritability, and exag- gerated delusions. These delusions are of a most extrava- gant nature, and usually grow as the physical weakness increases. The patient may believe that he is conducting large busines enterprises or that he is President or the Czar, or he may have delusions of great wealth, and bestow upon those about him checks for large sums, rule, these patients are far from strong, weak hearts and degenerate liver and kidneys being common among them. Their bones are unnaturallv fragile, and m the latter stages of the disease their habits become very un- tidy, and they have a peculiar liability to bedsores due to a disorder of the nerves which control the nutrition of the skin. As the final stage approaches there may be apoplectic seizures or convulsions, the patient becomes speechless, bed-ridden, more helpless than an infant, sometimes hardly able to swallow his food, until finally death comes to his 172 International Congress of Nvirses relief. These are most distressing cases, and if possible should be taken care of in an institution for the insane. The care you can givje a patient of this class is most limited. In the early stages to keep him from squandering his property or scandalizing his family by some immoral act, as the disease progresses to repress his untidy habits, to keep him at some occupation as long as he is capable of performing it, and later to take the same care of him as would be given any paralytic is as much as we can accom- plish. While the progress of this disease may be retarded by different medicines, still it is usually fatal, and one feels that death is a welcome relief from conditions so degraded and pitiable. Paranoia is a form of chronic mental disease charac- terized by a gradual development of fixed systematized and elaborated delusions of persecution, conspiracy, etc. These patients in the early stages of their disorder may be called " cranks/' and admit of a most elaborate classi- fication. I will only mention a few general symptoms, as it may aid you in being more tolerant of the oddities of " queer people," some of whom are unable to control their idiosyncrasies, being in the first process of paranoia. In childhood a paranoic will be usually bright, though he may be of a shy or solitary disposition, showing eccen- tricities of conduct as he grows older. He becomes suspi- cious and depressed, having a vague idea of conspiracy to deprive him of privileges or property. This is called the persecutory state. He constantly feels that a mysterious combination called " they " are against him, and upon ques- tioning he may explain that he refers to some secret society or some religious or political organization or some import- ant person whom he may have known about, all of whom are working to harm him. These ideas are of vast propor- tions and show great system and organization. Not infre- quently these patients are driven to make appeals to the Supreme Court, the President, the Pope, any power they feel can be reached. This is followed by a transition or expansive stage, in which he seeks an explanation of all The Nursing of the Insane 173 these persecutions. He sees how it was all planned out for him, perhaps discovers that he is of noble or divine birth. He may find much consolation in the belief that he is beloved by someone of a much superior station. Quite frequently these people have distinguished themselves in literature or in history. Many feel that they are ush- ering in a new religion, and it is something of a shock to find that Mahomet, Swedenborg, and Joan of Arc are mentioned with these cases. Among the political para- noics we find the names of John Brown and Guiteau. The so-called cranks of this description really create a danger- ous element in society. They are apt to make some homi- cidal assaults in consequence of their delusions, but if con- fined in asylums they accept that as a part of the scheme against them, and believe that some benefit will result from it either to the world or to themselves. They often show a proprietary interest in the institution, and are very use- ful and interested in the different forms of work. These patients usually live to a good old age, free from care, and while terminal dementia is quite sure to develop, still the process is not rapid. There is little to be said in the way of treatment, and their physical condition is usually good. Out-of-door work is recommended to keep the mind diverted from its delusions and hallucinations as far as pos- sible, and through bodily fatigue they obtain a fair amount of repose. Before closing I must make a brief mention of two agents — hydrotherapy and electricity, which are used among some of these patients with marked success. Hydrotherapy is a form of treatment among the insane which is daily gain- ing in favor. It is applicable to cases both of mania, mel- ancholia, and some forms of dementia, but in order to be used fully it calls for a hydrotherapeutic apparatus which is never met with except in sanatoriums or hospitals, and its use is then fully directed by the physicians. I will not take the time here to describe these appli- ances, which are most complex and can be used in many ways, but will endeavor to give instead a few practical 174 International Congress of Nurses therapeutic methods, which you can use in any house with ordinary phimbing-. It is known that water affects the nerves in many ways. Cold baths increase the irritabihty of the brain and spinal cord in a reflex manner by stimulating- the nerves of the skin and quickening- the circulation, while warm baths are relaxing, and tend to induce sleep and diminish the irrita- bility of the nerves. By keeping in mind the difference in hot and cold baths one can devise many ways of applying them with great benefit to the patient. Short cold baths, combined with sprinkling or rubbing, are stimulating and tonic. Tlie spinal douche is a powerful tonic as well as a mental stimulus. By means of a proper nozzle a strong stream is directed up and down the back of the patient at a distance of ten feet, if possible, and for a few seconds only. Sometimes this is alternated with a stream of hot water, and may be used for cases of hysteria or neurasthenia or where there is sluggish intellect, stupor, or apathy. This should be persevered in daily, and the temperature of the water gradually reduced till lowered to fifty degrees. In a private house the patient may stand in any ordinary bath- tub, and this process be imitated by using the usual spray bath, and while the force cannot be as great as from the regular apparatus, still the reaction may be quite marked and beneficial. The portable steam-bath arrangements of these days make the hot-air and vapor baths possible to all, and can always be used when the patient is quiet enough to produce general relaxation and possibly sleep. The pro- longed warm bath before mentioned and the hot or cold wet packs are always at hand, and if properly used may prevent the necessity of giving hypnotics and aid materially in regulating the circulation and relaxing the nerve tensions. Electricity is believed to have much the same value as massage when used in connection with the rest cure. It also has a tonic effect, but as its specific use belongs to the phy- sician's domain, I will not take our limited time in an attempt to describe its subtle effect and the manner of its application. You will have always to " follow the doctor's directions" in anv case. The Nursing of the Insane 175 We may then sum up the care of any acute case by rest in bed. overfeeding with light food, careful observation of the digestive process, massage when possible, hot wet packs or baths for sleeplessness, and electricity when it is indicated. The care of the chronic insane in much more limited, being an effort to make them as comfortable and happy as their mental conditions will allow and to keep them employed as far as possible to delay the process of brain decay. These cases are so different there can be no general line of treat- ment followed, and there is but little to inspire one to endure much that is monotonous and disagreeable, except a pity for their unhappy condition and a wish to aid in making what remains of their lives as attractive to them as can be. If I have aroused in your minds any larger sympathy for these afiflicted people, or have given you any suggestions which will enable you to care for them with a better under- standing and appreciation of their condition, I am highly gratified.* Tlie President : The next paper has been contributed by Mrs. Chapman, of England, on the same subject. *I have gathered the statistics and many of the ideas contained in this paper from the writings of Dr. Frederick Peterson, Dr. C. B. Burr, Dr. William D. Granger, Dr. John B. Chapin, and Dr. P. M. Wise. Asylum Nursing. MRS. CHAPMAN, Formerly Matron of Whittingham, Leavesden, and Claybury Asylums; Honorary Treasurer of Association of Asylum Workers, England. The increase of insanity in the United Kingdom of Great Britain during the last decades of the nineteenth century is an ominous fact, and one to be seriously con- sidered by all those interested in the progress of the nation. On the authority of the Lunacy Commissioners, as expressed in their report for 1900, it is stated there existed as a registered lunatic one in three hundred of the total population. This fact ought to be sufBcient to enable any- one to realize the gravity of the situation. Notwithstanding, there is a great deal of apathy among the general public as regards this development of the various forms of mental disease. It is not as yet recognized widely that cases of mental break-down require equal care and skill in their treatment at the hands of the mental nurse as those which are treated in the ordinary hospital. The efficiency and ability which have slowly come to be regarded as the neces- sary qualifications of the hospital nurse are not as yet expected to the same degree in the asylum nurse by the public. Much has been done by co-operation and method- ical instruction to raise the general standard of hospital nursing and attain the highest efficiency, but with the excep- tion of the efforts made by the Medico-Psychological Asso- ciation of Great Britain and Ireland and some isolated schemes at two or three asylums very little has been inaug- urated by the authorities responsible for the maintenance and for the efficient working of the asylums under their control. Here for years has been a policy of " laissez faire.'^ 176 Asylum Nursing 177 The stimulus which the educational movement in Eno-- land has experienced the last few years is beginning to arouse interest in circles outside that which is actually engaged in asylum work. The value of systematic training in any profession is now recognized, and the great body of ratepayers, who support these institutions for the care of the insane, are slowly awakening to the fact that the highest economic efficiency is to be obtained by the promotion of the intellectual efficiency of all those engaged in the work of asylums. There is forming a consensus of opinion that to deal adequately with the problems of mental disease, and of its alarming increase, intelligence must be allied with experience, and that the perceptive powers of the nurse, in order to meet the varying psychological manifestations of mental disease readily and resourcefully, must be trained to a high degree. Asylums should not be regarded as places where unskilled labor may find a congenial outlet for its energies. The indifiference of the past has been great, but the rising interest in the question of efficient mental nursing in our asylums now being manifested is a source of encour- agement and hope to the advocates of a better order of things. There is need to refute the opinion that a nurse may consider herself adequately equipped for her profession with- out any knowledge of mental disease. If nursing is to be viewed comprehensively, surely all phases of disease should be included in the curriculum of studies laid down for train- ing the intelligence of the nurse. Any system which devotes its attention to only one side of the phases of human disease lacks comprehension. Attention solely directed to the care and treatment of disease as manifested in an ordinary hospi- tal cannot give a complete view of the maladies to which the human organism is subject; rather what is attained is a specialized form of knowledge. It would be interesting to have the opinions of those who have passed through the normal period of training in a hospital as to the complete- ness of their qualifications. Can they regard themselves as 178 International Congress of Nurses fully trained nurses ? Many probably have not viewed the subject in this light, yet if the term " trained nurse " is to have a comprehensive connotation, some doubts must arise in their minds. The hospital-trained nurse cannot regard herself as having had a complete training for her profession as a general nurse unless she has had some experience in mental nursing. The medical superintendent of a large asylum writes on this subject to this effect : " Looking back on my hospital experience, I cannot help recollecting what a number of * naughty ' patients the nurses in the hospitals insisted on my discharging. Of course, I know now that nearly all these ' naughty ' persons were patients with mental symptoms, whom the trained hospital nurse did not know how to manage. They mis- took ' madness ' for ' badness.' Medical men now are obliged to take a course of lectures on mental disease before they can be qualified for practice. Why should hospital nurses be exempt? " The experience here stated, probably, is not unique. It points to the fact that there are diseases whose symptoms are not recognized by those whose training is restricted to the hospital sphere alone. The term " trained nurse " has been too long exclusively appropriated by one section of the community of the nursing world. The limitations in the experience gained in the hospital wards should be recog- nized. That gained by another section in the sphere of mental nursing equally justifies the appellation " trained." On this ground the status of the asylum nurse should receive adequate recognition. Her duties are exacting and onerous in the extreme, calling forth all her powers of sympathy, tact, resourcefulness, with the power of infusing hope, — qualifications different in kind to some extent from those demanded in the hospital nurse, yet necessarily essen- tial for obtaining succesful results. The principle of subdivision of labor lies at the base of all attainment of high efficiency, and the concentration of effort upon a certain field of manifestion of human disease is necessary for attaining that skill which is so essential for Asylum Nursing 179 success in medical nursing. Hospital asylum nurses are co-operators in the work of alleviating- that pain and misery which exist so largely in the world. The work of each is correlated with the other. The mental is intimately con- joined to the physical in the human organism, and efficiency in nursing can only be fully attained by the recognition of this relation between the physical and mental. As it has been laid down that knowledge of mental disease should be regarded a necessary qualification in the trained nurse, so equally must it be insisted that the mental nurse should go through a course of training on the general lines of the hospital nurse. In the infirmary wards of our large asylums there are always a number of cases requir- ing medical nursing, which can only be given with efficiency by the asylum nurse after a period of training on the lines laid down for hospital nurses. This has been almost uni- versally recognized in the asylums of the United Kingdom. The medical stafif in every important asylum deliver lec- tures and give demonstrations on the subject of the nursing of the sick. The syllabus of the Medico-Psychological Asso- ciation is comprehensive, and if thoroughly worked will give a good elementary knowledge of the requirements for efficient nursing in the infirmary wards of an asylum. It is indispensable for efficiency in an asylum nurse placed in charge of an infirmary ward that she should have this general insight into the requirements for successful medical and surgical nursing. This information should be gained in the early stages of her experience before the study of the psychological phases of insanity as a disease be entered upon. It will enable her to get a better grasp of the relation between the psychical and physical and of the interaction which takes place between them. In most asylums of the Kingdom there has been made during the last few years by the medical staffs of these insti- tutions a sustained efifort to impart a general knowledge of the nursing of the sick. It is now regarded as essential in the nurses of the infirmary wards that they should know something of elementary anatomy and physiology, of the ISO International Congress of Nurses care of the sick and the management of helpless and bed- ridden patients ; the making, moving, and changing of beds and body linen ; the prevention and treatment of bedsores ; application of fomentations, poultices, counter-irritants, etc. ; the giving of baths ; administering enemas ; using the catheter; preparing food and feeding helpless patients, with the observation of the effects of diet, stimulants, medicine, etc. ; the laws of cleanliness and ventilation ; the disinfection of utensils, and modes of disinfecting in cases of phthisis and fevers ; bandaging ; first aid in cases of accident ; the observation of mental symptoms, such as hallucinations, delusions, stupor, etc., with the special treatment of epilep- tic, excited, violent and suicidal patients, and the care of those requiring diversion and companionship ; also man- agement of the convalescent. The following quotations from a speech by Dr. Clouston, of Morningside Asylum, Edinburgh, on the occasion of a presentation to the head nurse of the infirmary wards of that institution after twenty-six years' service, may be interesting as showing the strides made not only in Scot- land, but throughout the Kingdom : " We have met together to show our respect and regard for Mrs. Findlay, head nurse in the female hospital, and to show our appreciation of twenty-six years of faithful service to the institution and to its sick. At the beginning of that time the sick were not as well treated, not as carefully nursed, as they are now. At that time all institutions had no doubt what was called a sick ward, or a sick dormitory, but not a fully equipped and staffed ' hospital.' Shortly after Mrs. Findlay came here we were making great changes in this institution, and we had under a separate roof a build- ing that used to be called ' The Separates.' This building was intended for the very worst class of the female patients, as it was thought that they were not fit to mix with the others at all, and whether curable or incurable, a trouble- some patient was sent down to the ' Separates.' Now, the actual effect of gathering together such an explosive ele- ment as this was that each patient made the other worse. Asylum Nursing 181 It was a veritable pandemonium. Following the general ideas of the time, it occurred to me that this building- by a thorough alteration could be made into a small hospital, just like a pavilion of the Edinburgh Infirmary, which could be utilized for the nursing of the newly admitted and weak patients, the keynote of its management being nursing and cure, and not detention. This was carried out, and for the first time really in the history of asylums a building fully equipped was used with open doors, with ordinary arrange- ments, with a full staff of trained nurses for the treatment of the mentally afflicted who needed nursing, the hospital being also used for the training of the new nurses. And here comes in Mrs. Findlay's work. She was alreadv in charge of our little ' sick-room,' and I was firmly convinced by the way she discharged her duties there that she would enter fully into the general idea of the new hospital. This she at once realized very fully, and carried out the medical intention that each woman there was a patient laboring under a disease to be nursed and treated. This idea, I assure you, was not then universally prevalent. Mrs. Findlay's success in her work, the way in which she both nursed and superintended the nursing of poor sick women and trained our own new nurses, has made this idea take pos- ■ session of the treatment of the whole of the insane in the country. I am quite sure if my friends. Sir Arthur Mitchell and Sir John Sibbald, were here they would back me up in this very strong statement that Mrs. Findlay's success in an ordinary hospital building, her demonstration that this was a possible thing, and not only possible, but an advance on the whole treatment of the mentally aliiicted, was one of the reasons why the Commissioners in Lunacy took up the ' hospital ' idea, so that now there is not an institution with- out such a means of treatment. . . . Now the thorough success of Morningside Hospital Section and its adoption elsewhere, and the general amelioration that one feels has thereby taken place in the treatment of the mentally afflicted, is a thing to be proud of and grateful for." The conditions of the service in asylums in Great 182 International Congress of Ahirscs Britain give cause for some reflection. The continual chang- ing of the staff which arises from dissatisfaction with the secluded character of the life in institutions, combined with the abnormally long hours of duty, together with an inadequate scale of remuneration, is a feature in asylum nursing which needs careful study. The restrictions enforced ten years ago are now felt to be out of place. There has arisen a demand for greater freedom on the part of the staff, and the expression of a desire for wider oppor- tunities for recreation, a need which can only be met by an extension of holidays and a lessening of the hours of duty. If a high state of efficiency is ever to be gained in the nurs- ing of the mentally afflicted, it can only be by maintain- ing a state of permanency among the staff able to supply the result of years of experience to meet the exigencies which so often arise in the wards in a manifold variety. This perpetual ebb and flow among the personnel of the staffs of our asylums has been noted by the Commis- sioners in Lunacy, and the attention of the ruling authori- ties of our asylums has been drawn to the fact, and it has been suggested that some determined effort should be made to render the service in our asylums more attractive, both financially and socially. At present there is no guaran- teed pension for service in the county asylums* of Eng- land and Wales, but there is being made a representative effort to promote legislation to attain this end, and so place the asylum nurse upon the same basis as other branches of the civil service in the Kingdom. In this respect there is a difference between hospital and asylum nursing. There exists a greater need for recreation in the latter. Companionship with invalids has a most depressing effect and requires vigorous counteraction to ward off injurious results, while the nervous strain entailed in the care of acute cases of insanity ultimately in a few years reacts upon the nurse and causes a general break- down unless the motto of " tnens sana in cor pore sano" is *Asyluins under the management of the various county councils. Asylum Nursing 183 carefully regarded. A true appreciation of this statement can only be gained by those who have had actual experience of the inner life of our asylums and the excessively trying conditions which often exist therein. The efifort to main- tain a healthy physical tone among the staff of our asylums should meet with every encouragement from the managers of these institutions. A low state of health diminishes the efficiency of the nurse, and the work consequently suffers. However we may regard it, due consideration of the needs of the staff promotes both the medical and economic inter- ests of our asylums. There is expressed a general desire to raise the status and qualifications of the asylum nurse, and some progress in this respect has been made. This can be further advanced by careful selection of candidates. On the whole, it is probable there is better material from which to select female nurses than male. Wider spheres of work for men have a great deal to do with this condition of things, but for those who elect to remain in the service the same course of instruction and training is open as is available to the female nurse, and a man of good character holding the medico-psychological certificate will readily find employ- ment either in an asylum or with a private case. A good moral character is the foundation upon which the successful training of the nurse rests. Asylum nursing makes severe demands on moral qualities of character. Tact, power of self-control, sympathy, and quick perceptive powers are all needed. On the authority of Dr. Spence, writing in the Journal of Mental Science in 1899, it may be stated that there is no wide difference existing between the conditions of asylum nursing in England and in America. The development in recent years in America has acted as a stimulus upon the asylums of England, and the facilities for the interchange of ideas which now exist will promote progress in every direc- tion. The President: The chair would ask Miss Wood, of England, to open this discussion. 184 International Congress of Nurses Miss Wood : I am a delegate from the Asylum Workers' Association. This association is one of modern growth. It is an association of medical men, specialists in the medical profession, and of the more intelligent and advanced superintendents and nurses in the asylums. The object of the association is to improve the condition of the patient, by improving the education and equipment of the attendant. Our asylums have been a byword in times past for the very low standard of the attendants employed in them ; women of no character, or of shady character, who could not get employment elsewhere, have obtained employment as attendants to the insane. The means by which the society hopes to bring about a different state of things is by the education of the attendants. They require that members of the Asylum Workers' Association shall pass the examination of the Medico-Psychological Society, which is one of the medical associations of England especi- ally devoted in its attention to this branch of medical science, which will improve the standard of those who hold its certificate. All asylums, whether in touch with the Medico-Psychological Society or not, are educating their nurses by giving them lectures, and practical instruc- tion, teaching them the various phases of insanity, which Miss Laird has described to you. Another step has been taken in giving the asylums the hospital equipment. This was not always so, but the attendants now, to a limited extent, get training in medical and surgical nursing. It is also much hoped by the Asylum Workers' Association that the head nurses and attendants may also be trained nurses, with the special training for the insane as well. You see that this is a distinct attempt at raising the standard. But then of course must come improved conditions. The women of questionable character were for obvious rea- sons much controlled by regulations which women of a better class will not submit to, and one of the objects of the association is to secure shorter hours, longer vacations, and considerate treatment for the workers. The work is arduous, because the English public has Asylum Nursing 185 not realized its own responsibilities, and there is no encour- agement for people to make themselves acquainted with the machinery of the asylum. In the old days the " mad house " attendants, as they were called, were rather looked upon as persons to be cast aside and not received into society of any kind. Now if we can only bring about a feeling upon the part of every one engaged in the care of the insane, and the public, a feel- ing that we are all banded together only for good, the work of the Asylum Workers' Association will be a grand one, and will mark a great step forward in our profession. The best buildings in the world, and the most com- plete appliances are of no good without the proper atten- dants. It is now the aim of the training that the individual nurse should not only understand the character of the patient with whom she has to deal, but that she should have a sense of individual responsibility, and should take some pride in her calling. Miss Richards : I am glad to speak upon this subject. It is one in which I am deeply interested. My experience in this branch of nursing has been short, covering only two and one-half years. I am glad to welcome any advance- ment which tends to the better care of the insane. The school of which I have charge is connected with one of the State Hospitals in Massachusetts. The hospital has buildings set apart for the care of the physically sick. These buildings are very modern in structure and have all con- veniences for caring for medical and surgical cases. The male patients are cared for by male nurses who, like the women nurses, are members of the training school. In these wards the nurses are taught much as their sisters are in the general hospital. She has always to bear in mind the fact that she is not only caring for a patient with a diseased bodv, but one who is both mentally and physically ill. Many times orders given are executed with difficulty and occasionally there will be utter failure on the part of the 186 International Congress of Nurses nurse to do just what the doctor orders. This of course is always reported and the responsibiHty taken from the nurse. The first and important object is- the recovery of the patient, as is the case in the general hospital, for these peo- ple do get well occasionally, and the nurse is not to look upon them as hopeless. In the hospital with which I am connected the patients are classified. The excited in wards for such patients. The suicidals by themselves, and the quiet patients in wards apart from the above named. Then convalescent wards are provided and always well filled. Every little restraint is hard, though the very excited patients are frequently put to bed and confined there by humanely devised restraining sheets which allow of con- siderable movement and yet keep the patient from wearing herself out as she would do were she allowed to be about the ward. These patients are fed regularly and it is most gratifying to see often after a few days of rest in bed the patient become more quiet and as days go on the mind gradually becomes clear till reason is restored. Training school work in these hospitals moves very slowly. But we who have been years in the work can look backward to the organizations of training schools in the general hospitals and can remember how very slowly was advancement made. History is repeating itself, and better days are surely in store for these special schools. The great want and need is for conscientious women as superintendents of these schools, women with very warm hearts and sound judgment, a deter- mination to succeed and patience to wait. The meeting then adjourned. THURSDAY. 1.45 P. M. Thursday p. m., meeting^ called to order at 1.45. Miss Darner: The Women's Union have asked me to make an announcement that the whole building- is open to your inspection and that they would like the nurses who have time to look over the building. A number of nurses doing private duty have requested that an informal gathering be held here at 5 o'clock for private duty nurses only, to dis- cuss anything they feel interested in. The President : The chair would request the secretary to read a draft of the program for Saturday, as it may be of interest to some of the members present in making their plans. We would like to assure you that if any of you have planned to go home on Friday, you will miss a great deal of pleasure on Saturday. There will be, first, an address of welcome by Mrs. John W. Horton. Mrs. Fenwick will speak to us on the subject of the better education of nurses. Miss Louisa Stevenson will then say a few words to us upon some educational subject. Miss Wood, of England, will give an address, " A Retrospect and Forecast." A hospital drill at 4 p. m. is especially arranged for the Congress of Nurses. The Women's Building will be placed entirely at the disposal of the Congress during the day. We will now consider the papers on the work of the graduate nurse. 187 The Opportunity and Responsibility of the Graduate Nurse of Today. (first paper.) KATHERINE DeWITT, Illinois Training School, Chicago. The question of opportunity is not a difficult one. The problems which are facing the nursing world are of such importance, are so much in evidence, and are so insistent that a nurse must be blind and deaf who is ignorant of their existence. The thinkers and workers in the nursing pro- fession all over the world are considering the questions of registration, preliminary training, teachers' courses, uni- formity of education, combinations of small or special hospi- tals, post-graduate work, and the maintenance of alumnae associations. These and similar themes press closely upon us and demand attention. The difficulty lies in the ques- tion of responsibility. Who should bear it? Graduate nurses may be divided into three classes — those who hold hospital positions, those who do private nursing, and those who have married or have for other rea- sons retired into private life. Their interest in nursing affairs dwindles as they get farther away in space or time from their place of training. Very few who have given up nursing work retain more than a vague interest in our doings. Those who do, those who hold the motto, " Once a nurse, always a nurse," are the most valuable of workers. They often have more leisure for thinking, more time to devote to ofiticial responsibilities, and a broader view of affairs than those who are still in the ranks. 188 opportunity and Responsibility 189 Private nurses have been in the past a most self- absorbed and indifferent body of women, thinking only of their personal aims and interests, caring: little for their fel- lows. Those who have held hospital positions, especially hospital superintendents, being in constant touch with nurs- ing affairs and seeing the abuses which need reform, have been the pioneers in all progressive movements and have labored almost alone. The alumnae asociations, growing in all directions, are beginning to get hold of the scattered private nurses and to arouse their interest, but all graduate nurses, in whatever walk of life, have opportunities which should appeal to them — responsibilities which they should not shirk. We are said to be heirs of the ages. Trained nurses of today are heirs of very difficult pioneer work, done by a band of energetic efficient workers whose toil has been so effective that what would seem to require a century to bring about has been done in a third of that time. We come into line and find modern hospitals, well equipped, with training schools attached, where nurses are taught in both theoretical and practical work. Are we to drink in all the knowledge offered us and devote the strength derived therefrom to con- cerns which affect ourselves alone ? To do this is to miss the opportunity of doing our share of the world's work and results in narrowness and in imperfect development. It is most exasperating to the leaders in any line of work to see about them those who could be their helpers but who will not exert themselves. These are they who sit back and criticize the often faulty work done by others. Perhaps the work is faulty through lack of help which they could have given. Perhaps they think that if their own personal work is well done they have fulfilled their duty. They fail to realize that those who are not helping are hindering; that affairs of moment which will affect them personally in time are hang- ing in the balance, and that the influence of each person counts in the final turning of the scale. Emerson says : " If you act, you show character ; if you sit still, you show it. You think because you have 190 International Congress of Nurses spoken nothing when others spoke, and have given no opinion on the times, that your verdict is still expected with curiosity as a reserved wisdom. Far otherwise ; your silence answers very loud. You have no oracle to utter, and your fellow men have learned that you cannot help them." There is a class of beings, not intentionally lazy or selfish, but of a timid, retiring disposition, who think they are unfitted by nature to " speak in meeting " or to write papers, and that therefore they are of no value and must be counted out. Yet these services, though conspicuous, are not the most useful. The nurse who thinks and reads and gains a clear idea of the standards for w'hich we are striving is a help. She who in her daily life improves the opportunities of talking with and interesting other nurses is a help. To one who is alert many occasions will arise in which she may be of service, and she may, by her presence and interest, be of aid in meetings in which she takes no active part. I wish I could tell at length the story of a member of my own alumnae association, one of the " quiet sort." She is married, she is in ill-health, she is an exile from home — excellent excuses for dropping out of sight ; yet ev;ery alumnae oliticer, every nurse-acquaintance, feels the inspira- tion which comes from her eager interest and unswerving loyalty. She is the kind of person who never forgets when her dues should be paid, who does not neglect to send in any change in her address, who responds promptly to any appeal made to our members in general. When our new nursing journal was contemplated, and we realized that it must have a goodly number of subscribers to make a start, she, in a land of strangers, secured five subscriptions. Do these things seem trifles ? They are the trifles which count. An alumnae asociation whose members were all animated by her spirit could work wonders. I once heard an enthusiastic young minister, speaking of missions to some college students, say : " When we get to the Heavenly Jerusalem and hang our battered armor on the jasper walls and look back on the conflicts we have been opportunity and Responsibility 191 waging, we shall say, ' I'm glad I was in that battle.' " How is it with us ? When the first number of our nursing journal appeared, those who had wrestled with the problem of getting it started, those who had given what they could to help establish it, those who had written for it, those who had skirmished for subscribers for it, could look upon it with joy and pride and say : " I am glad I was in that battle," When the army nursing bill had been passed by Congress, those who had seen ills in the nursing service and had striven to remedy them, those who had borne unpleasant testimony for conscience's sake, those who had worked early and late to rouse interest in the measure, could give a sigh of relief and say : " I am glad I was in that battle." Shall we fold our hands while others do the fighting ? No! The battle is still on. Let us be thankful that the interesting part of the struggle is not over and that we may have a hand in it. Let us try to earn the right to enjoy the glow of pleasure which comes, when the battle is over, to those who have helped win the victory. The Opportunities and Responsibilities of the Graduate Nurses of Today. (second paper.) LINDA RICHARDS, Taunton, Mass. If it is true that the responsibihty of a community, a body, or an individual is measured by its opportunity, the graduate nurse of today carries a burden which no one can call light, — a burden much heavier, I fear, than is realized by the majority of nurses. Were we to ask the average graduate if she considers her advantages while in the training school great or even fairly good we might be surprised to hear in reply that she felt her opportunities to have been few, and not at all what she had expected or thought hers by right, and that she, as a matter of fact, considered her advantages as having been inferior to what they should have been, so prone is the human mind to fail to recognize present blessings in the attempt to catch sight of some fancied advantage not within reach. To enable us to fully realize the opportunities of nurses recently graduated and of those still in training, let us enumerate a few of the more prominent : In any well regulated training school of the present time we will find as a first requisite a superintendent of the school who is a graduate nurse, a woman having graduated from a school well known and of good report, and who has been chosen because of her fitness for the position. 192 opportunities and Responsibility 193 If the school is connected with a large hospital, or if it is a school giving- a three years' course, graduate nurses will be found in charge of wards, thus giving the pupil nurses the advantage of excellent instruction in their practical work, as well as superior teaching in the class and lecture room. Text-books, many and varied, for class work and refer- ence — books especially adapted to the needs of nurses in training — are at her command. Many of these have been compiled by graduate nurses and superintendents of training schools. A well-defined course of study, which (thanks to the Superintendents' Association) is now fairly uniform, will be found in all large and in many of the small training schools. Added to this instruction is given in special branches, as some knowledge of dietetics, with practical instruction in the preparation of foods for the sick; hydro- therapy, limited largely to the giving of the various kinds of baths, care and use of the electric battery, massage and physical culture, the application of heat by the latest and most approved methods, and a knowledge of bacteriology, with the different methods employed in destroying germs. These are a few of the many subjects which are taught in the training schools of the present day, and upon which nurses are requied to pass a satisfactory examination before graduating. Each branch is taught by an expert, thus giying pupils the surety of being well and uniformly instructed. Demonstrations in modern methods of medical and surgical nursing, which are free to all nurses, are given by some of the larger hospitals, and these public demonstra- tions are of great value to nurses who have graduated and are doing private nursing and in danger of growing rusty, and also to those who are still pupils in schools connected with the smaller hospitals giving a more limited course of instruction. Lecture courses for the benefit of graduate nurses are often provided by the alumnae of the school or by graduate nurses' associations which are open to all graduates for membership and consequent advantages. 194 International Congress of Ntirses Nurses' clubs have been organized by many schools. Connecting'-links they are between the pupil-nurses and j^raduates, and productive of g-ood in giving help and creat- ing a feeling of unity. The school alumnae, of which nearly every school of any standing boasts, and of which the national alumnae is an outgrowth, which may be likened to the powerful oak grown from the tiny acorn. The Nurses' Home, where nurses tired with the trying duties of the ward can go for rest and quiet. Nor would we forget that it was through the generosity of one noble woman that the first home for nurses in America was built, and so well has her example been followed that few indeed are the hospitals which have not a " Nurses' Home." The Society of Superintendents of Training Schools, which has during its few years of existence accomplished so much for the nursing profession and, through the dif- ferent schools, for under-graduates as well. It is because of the existence of this society that we have an approach to a universal curriculum, which will in time be uniform and will be found in use in all schools, and by reason of which all graduates will stand upon common ground. It is through the influence of this society that the nar- row school feeling is giving place to the broader interest in nursing as a profession. All these advantages have been instrumental in placing the nursing profession in America upon a higher level, thus adding to its strength and power. It is also through the efforts of this society that we have today the special course in hospital economics in con- nection with Columbia College, from which two classes have been graduated. Already are the benefits derived from the course so apparent that one feels like prophesying that the time is not far distant when to be able to secure a position as superintendent of a training school a diploma from this special course will be a necessity. For a long time the need of a periodical especially adapted to the wants of nurses had been recognized, and the sentiment that only nurses who were thoroughly conversant opportunities and Responsibility 195 with the needs of nurses could meet the demand grew daily stronger, and today we have The American Journal of Nursing, and this long-felt need has been satisfactorily met. Each year has given added opportunities, and so quietly have they come that those not concerned in bringing them about often fail to detect them. Opportunities of which the most optimistic nurse of twenty-five years ago would not have dreamed are now open to the pupil-nurse, and this without her effort or thought. ^ To prove that these advantages are real and great, let us compare the advantages just enumerated with those of the earliest pupils, who, when they entered the training school, found there no graduate superintendent to guide or counsel them, no trained nurses in charge of wards to instruct them in practical duties, no class instruction was given, and in most things they were their own teachers. Lectures were given irregularly, no notes upon them being required. The nurses were required to know but little, and walked by faith, not by sight. But meagre as the instruc- tion was, the pupils were taught that from the time they entered the training school to the end of their lives they would be considered as persons of great and grave respon- sibility. And if nurses trained under the conditions just men- tioned were given such a burden of responsibility, what shall be said of the nurse who graduates with the number- less advantages of the present day ? Is it not just that more and better results be expected of her than of her less favored sister ? Surely yes. The nurse of the present time is to be congratulated because of her many and varied privileges. But she is to constantly remember that hand in hand with these come heavy respon- sibilities. The first she will joyfully welcome. The last must be conscientiously borne. Does some one ask, What are these responsibihties ? The reply must be, Their name is legion. Two or three stand out so prominently that they almost name themselves: Let the nurse of todav consider it her solemn duty to raise 196 International Congress of Nurses the standard even higher. Let her keep in touch with every advanced movement. Let each year's work exceed in excellence that of the preceding year. Let her show to the world that her profession is one of the grandest, and that she is an honor to it. She is to enter new fields — let it be to conquer, and let her prove a help and blessing wherever she is found. The eyes of the world are upon her, and great things are expected of her. Let her always carry this thought, " To whom much is given, of her much is required." ■, » Private Nursing on the Pacific Coast. MARY E. PATTON, Superintendent of Nurses, City and County Hospital, San Francisco. San Francisco has a population of 342,182 and is recog- nized as the medical center for the Pacific slope. There are twenty-one private hospitals in the City of San Francisco, eleven of which conduct training schools for nurses. The city directory registers 370 trained nurses. Sixty per cent of this number are probably graduates. Two hundred and twenty-five graduated nurses seems but a small showing, when the many schools and date of incor- poration, sixteen years ago, of the first school * is taken into consideration. But two of the eleven schools enumerated are connected with hospitals containing as many as two hundred beds, consequently the number of nurses in training and graduating is necessarily small. The maximum num- ber of graduates from all schools may be placed at forty yearly. ■^'^'^ In illustration of how the ranks are diminished I iristy cite the San Francisco training school whose graduates reach a total of eighty-nine, (school organized in 1891). tIt- Engaged in private nursing, San Francisco 28 •' Filling hospital positions 2$''A^' ' ■ Married ISji-n; Returned to their homes after graduating "^ Librarian, public library, San Francisco rl'r B ■ U. S. Army Nursing Corps '5 Private nursing in other coast cities .^J'9-'-'^>: Private nursing in New York City ;;;ri^T'r' ♦Hospital for Children and Training School for Nurses. November 8. 1885. 198 International Congress of Nurses I believe similar conditions reduce the number of graduates of the other San Francisco schools. Our leading practitioners tell us we have need of more nurses. Gradu- ates, experienced and skilful, are always in demand. Yet, one hears the stock phrase, " Where will all the nurses find work " when announcements are made of classes graduat- ing. No alarm on that score need be felt since one-third of the nurses engaged in San Francisco cannot be recog- nized as trained and graduated nurses, yet they are kept con- stantly employed and receive the same remuneration as nurses orraduated from the best schools. This being the case nurses have not felt the necessity of organizing, — and may in part account for the lack of nurses' clubs and alumnae. No general movement toward organizing a directory for nurses of all schools has yet been made. A directory * is conducted in San Francisco, where graduate and non- graduate nurses register. The charge is made by deducting a certain per cent of the wages, thus nurses who are greatly in demand and constantly employed pay to this agency 3% of all earnings. From the less fortunate ones who are fre- quently disengaged, 6% of their salaries is collected by the proprietor of this directory. The San Francisco training school, Children's Hospital and St. Luke's Hospital graduates have established homes, share expenses and receive only nurses from their respective schools. These homes constitute " headquarters " for nurses engaged in private work. Exact statistics from other coast cities have been diffi- cult, in fact, impossible to obtain. Portland, Seattle and Los Angeles have each tw^o or more training schools and their quota of graduates. Many Eastern nurses attracted by the climate of California and others who have crossed the Continent with patients elect to remain and continue the work of private nursing, mainly in Southern California. ♦Nurse Agency, Mr. F. E. Goodban, Prop., 1117 VanNess Ave., San Francisco. Private Nursing on the Pacific Coast 199 As nearly as can he learned, the standard rate of wages, twenty-five dollars weekly, as maintained in San Francisco, is not averaged elsewhere on the Coast. The percentage of people living in hotels and board- ing houses is larger in San Francisco than that of any other city of its size in the Union. In consequence of this, in time of illness the private hospitals are chosen; indeed, many having comfortable homes prefer the hospital for accouche- ments, operations or a long siege of fever. Patients coming to San Francisco for treatment, accidents and illness occurring amongst the floating population must needs also be taken to a private hospital. In this way many graduated nurses are employed in hospitals — engaged by the patient or physician of patient independent of the hospital authorities. Practically there are no slums in San Francisco, nor have we many real cases of poverty. The clerk and mechanic can afiford to pay, when sickness comes, the high- est wage paid the graduate nurse. San Francisco is rated one of the healthiest cities in the United States. Our Health Boards are most vigilant in stamping out specific infectious diseases — many of the latter are consequent to the great shipping traiBc between San Francisco and the Orient. (We have no epidemics). San Francisco is in itself a park when one reckons on fresh air. We have no summer, no cellars and very fev/ refrigerators. In winter we have no furnaces, furs nor frost, and instead there are flowers, green fields and a mean temperature of 60° F. The cost of living may be placed at a very moderate figure; board and room can be obtained at a good family hotel or boarding house from twenty-five dollars per month and upwards. A sunny furnished room (the sun is an essen- tial in San Francisco), location central, may be secured from ten to twenty dollars per month. Meals, breakfast and lunch, twenty-five cents and even less, and an excellent full course dinner for fifty cents. San Francisco is noted the world over for the excellence, variety and reasonable charge of its restaurants. Its cuisine includes the Italian, French, German, Mexican and Spanish. 200 International Congress of Nurses An eastern nurse, a stranger on the coast, would do well to apply at one of the private hospitals, presenting at the same time her credentials and in this way she will meet the physicians who will be quick to recognize her work. The smaller towns on the coast do not boast of even one trained nurse as a rule. It is the custom to telegraph to San Francisco wdien one is required. While Sacramento, the State Capitol, is a good field for trained nurses there is but one training school of recent organization, and but few graduate nurses. The Pacific slope is most bountiful in its productions, — from the wealth of minerals, orchards, fields of grain, its flocks grazing on the hills, to the natural physical attrac- tions, mountains, rivers, lakes, ocean and sapphire skies, and over all an enchantment indescribable, made vivid by the ruins — momuments of a vanished race. A sweet leisure still rests with its children — an inheritance from the Spanish hidalgo, and a marked contrast to the energetic business world of San Francisco ; the mart of all nations. DISCUSSION. Mrs. Fenwick : I think it was Mrs. Robb who said '' Once a nurse, always a nurse," and both she and I have proved that we feel the principle of that very strongly. It is not given to every woman who leaves her school and active practice, to do public work. It takes both time and money, and women who elect to marry have many other duties, especially those who are the mothers of families. It is not always possible for them to take an active part in nursing afifairs, although none need be too busy to have a heartfelt interest in professional matters. After listening to Miss Richards' most excellent paper, it seems almost incredible that, since my first visit to the United States in 1892, such wonderful changes can have taken place. I had the pleasure of visiting the Johns Hopkins Hospital at that time, and there meeting Mrs. Robb — then Miss Hampton. In 1892 there was practically no organization of American nurses — today Miss Richards Private Nursing on the Pacific Coast 201 has shown us what marvellous progress has been made by the formation of the alumnae societies and the National Associated Alumnae of Trained Nurses. It is indeed a most hopeful and encouraging- report that has been placed before us, but we notice all the same that these splendid results would not have been accomplished, if a few of the old war horses had not thrown themselves into the fray, and, com- manding the respect of the nursing legions, led them to victory. It appears to me that today you American nurses are so advanced in organization that every graduate can take her part if she so chooses in the government of her profes- sion. In Great Britain we are going very slowly along the same lines, but it takes us longer to organize because we have more prejudices to uproot and overthrow. I have no doubt that international communication will be immensely helpful to European nurses, and I am san- guine that in the near future international organization amongst nurses will take place, and thus what of good is accomplished in one country will benefit nurses all over the world. As a nurse who has taken up professional jour- nalism — not from any superabundance of literary talent or personal preference for the work, but as a means to an end — to give the nurses of my country a voice in the press and thus make them articulate, I may perhaps be permitted to say a few words of congratulation to those amongst you who have organized and instituted the American Journal of Nursing, a publication which is bound to do an immense amount of good for the nursing profession in all the English speaking countries of the world. I hope that after this Congress its circulation will greatly increase in Great Brit- ain and our Colonies, and that we shall reap the benefits of the works of your able editor. Miss Sophia Palmer. I speak very feelingly upon this subject of professional journalism, because I know the arduous and increasing labor of inter- esting people in class journals ; it takes great courage to edit such a journal, and infinite patience to wait the necessary time to see it a success. The American Journal of Nursing and those who are working for it have my warmest sym- pathy and admiration. Private Nursing. MRS. MARGARET L. ROGERS, Superintendent of Nursing, Bridgeport Hospital, Conn. Of all the professions now open to women there is none possessing the possibilities of nursing. The deeper our medical men penetrate into the science of medicine, the wider grows the horizon of the trained nurse. Scarcely a quarter of a century ago the physician regarded her advent with a feeling of distrust, fearful that as soon as her training was completed she would proceed to the practice of medicine and in time share, if not entirely absorb, his circle of patients. Time has proved the fallacy of that idea, until today the reputable physician refuses to take a serious case unless the responsibility is shared by a competent nurse. As a character-builder the training school has no equal ; I think it is its prevailing atmosphere of unselfishness which causes all the tiny germs of good that have long lain dor- mant in our natures to develop and helps us in time to over- come our most glaring errors. The regular routine, the unity of purpose, the absolute rule of willing subjects, leave their mark for all time upon the character and disposition of its pupils ; and they must, because of this discipline, go forth better women, better equipped for the battle of life, whether to grace homes of their own or to become the temporary members of the homes of the suffering. In the present day there are many fields in which the nurse may find an outlet for her activities. The need of hospitals, the demand in the army, and the increasing growth of district and settlement work give a choice to use- 202 Private Nursing 203 fulness unknown to her sister of a few years past. How- ever, it is in private nursing that the large majority find an opening most suited to their capabilities. The reason for this is because of the great pleasure in personal min- istration. In other branches of the work, owing to lack of time or the inability to be in many places at the same time, one's work is apt to become largely that of the teacher and the guide, and the joy of personally making "a little comfortable the uncomfortable way " is seldom tasted. From the financial standpoint the private nurse is paid better than any other; she is an active worker, she can be busy from nine to ten months in the year. She has the advantage of being absolutely free when she is free. Unfor- tunately, she cannot ever hope to increase her salary ; she is worth as much when she takes her first case as when she takes one ten years hence. While experience adds greatly to her worth, it does not add to her financial value. The most she can ever hope to do it to " become established," — to have her own little coterie of patients and physicians to whom she is absolutely indispensable. In the larger cities in this country the remuneration for private nursing is almost uniform, twenty-five dollars per week, or four dollars per day, being the average salary. Some nurses, and, indeed, some hospitals, ask thirty dollars per week, or five dollars per day, for nursing male patients, still others make a distinction in obstetrical work, and I think all nurses in all places make an extra charge for con- tagious cases. In the smaller cities prices range from eight- een dollars to twenty-one dollars per week, but as living expenses are comparatively lower the difference is not so great as it appears at first thought. The question of hours is still worth considering. The nurse in the large cities does not feel this to any great extent, as in almost all cases requiring care at night twelve-hour duty is an established custom. But in the smaller cities even people who can alTord all sorts of luxuries feel that unless a nurse's training has done away with the necessity for sleep it has failed in its 204 International Congress of Nurses purpose. Indeed, a few days ago I heard a physician remark that Miss B was an excellent nurse, as she had gone seventy-two hours without sleep. Of course, he was a very young physician. Nurses, no matter where their homes may be, usually locate in the city where they have taken their training. It would almost seem, when we consider the large classes which are graduated annually in hospital centers, that the supply would be greater than the demand. But this is not the case, the demand is constantly on the increase. The family of moderate income, which a few years ago did its own nursing, now finds it impossible to get along without trained assistance. The family of afifluence, which formerly employed one nurse, now finds it necessary to «mploy two or three. So that while hospital and club regis- ters show an increased number of graduates on their' lists, they show a corresponding increase in the number of calls. The larger cities possess the attraction of affording a greater choice of work. Indeed, it is becoming popular to take up special lines of work. The movement has thus far met with the hearty approval of physicians and patients. It could hardly be otherwise, as the concentration of mind and effort in a given direction, if a nurse is at all progress- ive, must result in an added usefulness, and at the same time these special cases would require suf^cient regular care to prevent her from growing rusty in general work. " Nervous cases," "children's diseases," "gynecological and obstet- rical " work all afford opportunities for the " specialist." Many young nurses from the smaller hospitals in the United States and Canada, ambitious to enlarge their views and come in contact with the " great in medicine," gravitate towards the larger cities and in time become members of the great army of workers. For such the private hospital and sanatorium afford the needed stepping-stone. These insti- tutions employ only graduate nurses, and pay them a salary of about twenty-five dollars a month and, of course, living. This seems very small compensation for very hard work, but it supplies the means of present support and brings a Private Nursing 205 nurse in contact with prominent physicians, who in turn become the medium through which she reaches her sick public. The private nurse enjoys many advantages over other wage-earners. She is protected, and she is ahnost ahvays brought in contact with refined intellectual people, and is forced to talk of other things than nursing. We all have a tendency to get into the " professional rut," or, perhaps, it would be truer to say we are very deep in the " professional rut " when we leave the training school, the world having narrowed down for most of us to the four walls of the hos- pital, and this coming in contact with other minds who are absorbed in social, religious, political, scientific and phil- anthropic subjects stimulates our own intellects and, of necessity, widens our mental horizon. Of course, we occas- ionally come in contact with very unlovely people, for the snob and the parvenu are not exempt from bodily ailments. We should take this as a well-needed discipline to reduce us to a proper state of humility, for I think with continuous prosperous and pleasant cases most of us are apt to grow critical and exacting and " refuse to see the sun." If you are a student of human nature or interested in " class problems," what a glorious opportunity for con- tinuing your researches. You not only see how the other half lives, but you actually live like them. The experience under doctors of different schools is pleasant and instructive. To our physicians we are simply ,an individual nurse. To outside men we represent our school, and it is judged for or against according to our merits, so that there is a double incentive for well-doing. The greatest disadvantage is the absence of home life, the never being able to make settled plans. Rooming con- ditions in this country, with the spasmodic boarding nurses are obliged to indulge in, are, indeed, not pleasant subjects for contemplation. The club will in time fill this most pressing need. I have been fortunate enough to enjoy the privileges of one for a short time, and the refined, cultured home atmosphere with which the nurses had succeeded in 206 International Congress of Nurses surrounding themselves was most agreeable and made home-coming a distinct pleasure. Of its financial advantages I need not speak, as in this day of " combines "' and " trusts "' they are too apparent to need mention. The question is often asked, What are the requisites to make the ideal private nurse ? I do not know. To my mind there can be no fixed standard to which we can appeal, as the vagaries of taste are infinite and often quite inexplicable. Convention, education, accident, and idiosyncracy all play an important part. I do think it is an absolute necessity to love and believe in your work in order to attain any degree of success in it. And why not believe in it ? Surely outside of the home it is the noblest work left to women and requires a many-sided culture. " The heights and depths of human nature must be within the range of your vision ; you must have a knowledge not learned of books ; a wide sympathy ; the strength that springs from sympathy and the magnanimity of strength." You must be a doer of deeds, preferably not a speaker of words. You may not attain what the world calls success, but you will attain a truer success. It is not only what we have done, but what we have made of ourselves. If we have repressed our individuality, cultivated much selfishness, criticism, and gossip, and closed our eyes and our hearts to all altruism, then our lives have been failures, and our influence, like all things false, will be suicidal and transitory, less than "' the snow upon the desert's dusty face which, lighting a little hour or two, is gone." To attain the truest success we must soak in the waters of unselfishness, be vitalized from within with a true love for our profession, and realize in ourselves the best we are capable of, and of her " to whom much has been given, much will be required." The President : We have with us a nurse from Hol- land. I have great pleasure in introducing Miss Von Vollenhogen. Private Ntirsing 207 Miss Von Vollenhogen : I am glad to have the honor to speak to this Congress, Madam President. We are a small country and have much to learn from the large ones. We work very hard, and our training is very good. There is not so much private nursing with us as with you, because our sick people mostly go to hospitals, and so many private nurses are not needed. Besides the hospital nurse and the private nurse, there is the district nurse. I think, and I hope, that in time the district nurses will be of greater importance, and that there will be more of them. For it is such a help in the homes of the poor families to have the nurse come in. She makes it possible for the sick mother to stay at home with her child- ren ; she keeps the home together for the husband and the children. I should like to say more of my interest in all this work. The Progress of Hourly Nursing. ADA M. CARR, Superintendent District Nursing Association, Baltimore ; Delegate Johns Hopkins Alumna? Association. Published in the Trained Nurse for the year 1895 and in the " Report of the Meeting of the Society of Superinten- dents in 1897," are two papers by Miss Diana Kimber, pre- senting- so clearly and forcibly the need and the possibiHties of a different class of nursing work to those already existing, that today there seems nothing to add in the way of sug- gestion along the broad lines of the idea itself. Taking heed to the ancient admonition of the making of many books, and the consequent weariness of the flesh, I would ask per- mission to quote from Miss Kimber's papers, and merely add something of what has been accomplished in the years during which the practical working out of her ideas has been carried on in different cities. The need for visiting or hourly nursing has, I am very sure, been brought home to us all, as it was to Miss Kimber, by instances coming under our personal observation, — not one, but many : self-supporting women in boarding-houses, homes where trained care and trained advice is sorely needed, but where the family resources, already strained to their utmost, do not permit of an outlay of twenty to twenty- five dollars a week : treatments, dressings, where all the actual nursing necessary could be compressed into one or two hours out of twenty-four. There is no need to cite a typical case ; anyone with experience can supply her own. In London some years ago, talking to an old lady of nearly eighty, who knew Florence Nightingale, and who 208 The Progress of Hourly Nursing 209 during her whole Hfe had been associated in the manv and varied forms of philanthropy, and kept careful watch over the rise of the newer methods, I mentioned the plan of visit- ing nursing, which our own alumnae had taken up at that time with much interest. She told me that in her opinion it was one of the most hopeful signs in a profession over whose developments she was inclined to shake her head. Miss Kimber writes in the papers to which I have referred : " It would seem we are confronted with two problems — (1) How shall we provide more work for our graduate nurses ? and (2) How shall we provide skilled nursing for people who cannot afiford to pay the usual price of the trained nurse? When we consider that the larger mass of the popula- tion is composed of workers earning a fair competence, which separates them from the really poor on the one hand and the wealthy on the other, it is evident that we may expect to answer the first problem satisfactorily if we can solve the second. The plan I suggest is in substance this : That individual nurses or groups of nurses of sufficient enterprise for start- ing such work should call on all the doctors within a reason- able radius of their headquarters and state that they would take care of patients by the hour, by the night, and by the half-day, assist at operations and prepare for the same, attend confmement cases, and take after-care of such by paying one or more calls a day. They would thus create a demand for their services among the class of people we most desire to reach. They should, in fact, become visiting nurses, not employed by a society paying them a salary to nurse the poor, but visiting nurses employed by the doctor to take care of patients able to pay the nurse for the services rendered. And now let me say a few words as to what seems to me to be some of the advantages of this method of nursing. First, I have thought that nurses introduced into the fami- lies in this way would be educative influences as well as 210 International Congress of Nurses actual workers, reaching and teaching a portion of the com- munity very susceptible of profiting by such instruction. The care of the sick would not be taken entirely out of the hands of their friends, for whenever necessary or practicable it would be shared by them. But the chief argument in favor of the adoption of this kind of nursing is that it brings the services of the trained nurse within the range of nearly all wage-earners, and is a fair arrangement for supplying non-charitable help, the basis of the system being adequate remuneration for services rendered. It is in itself a healthier, wholesomer life ; it leaves a possibility for some kind of home life ; it allows play for more individuality ; and, better than all, it gives greater opportunities for usefulness and help." It will be seen that in theory and suggestion there is little to add to Miss Kimber's comprehensive view. I think, although this is delicate ground on which to tread, it will be generally admitted that private nursing is often very demoralizing in its effects, and the outline of advantages possessed by the visiting nursing as given by Miss Kimber must appeal to all who have reason to deplore the dangers and difficulties peculiar to the exigencies of private duty. In papers read before the National Alumnae Associa- tion last year by nurses who had ventured into this new field, the benefits to the nurse as well as to the patient were strongly dwelt upon. It may be well here, however, to consider the relation of the nurse to the work. It is not an occupation to be under- taken by one who has failed in other branches, or who is looking for an easy way of making profitable use of her pro- fession. The best of the inexhaustible array of qualifi- cations needed for the make-up of the modern nurse are required to insure genuine success in this special branch, experience and executive ability among them, — the first not least, it is well to remember. The public and the doctors are quick to feel the under- lying spirit, and in this work, depending for the present on The Progress of Hourly Nursing 211 the recognition by them of its real usefulness, if the right spirit as well as the faithful work be not present, the result is fatal. In our own city during the past four years we have watched over our prospects, successes, and failures, and have arrived at a very definite conclusion that the work cannot stand without the workers — a trite conclusion, prob- ably, but one peculiarly applicable here. The main diffi- culty seems to lie in the establishment of visiting nursing on a secure and permanent basis. It has been shown wherever it has been tried that the work is slow to grow. It does not spring full-armed into prosperous existence in a single night, nor, valuable and essential as we feel it to be, does it follow that physicians and the public generally will impulsively adopt this same view. It must be demonstrated point by point, case by case, that it is a good and desirable thing to win slow recognition from those on whom it depends for success. Patient pioneering is needed, and there are few nurses who can afford to spend months in waiting while their practice slowly develops into propor- tions large enough to pay expenses. Not only this, but if a nurse has painstakingly gathered together a sufficient prac- tice and should be called away by any of those emergencies which nurses as well as all mankind are heir to, it is most difficult to find someone ready and competent to take her place. Doctors and patients must become familiarized all over again with a new personality and a new address, and hard-won interest is all too easily lost. It is for these reasons that I would like to call the attention of alumnse associations interested in the establish- ment of new branches of work to the plan adopted by the Johns Hopkins Alumnse Association some years ago to establish visiting nursing. Being assured that it was a good and necessary thing, but also being convinced that desultory and imperfectly planned efforts would in all probability result in failure, the association bent its energies primarily towards obtam- ing a fund sufficient to pay the necessary expenses of the 212 International Congress of Nurses work durinc^ the time that mig^ht elapse before it should become self-supporting. After some deliberation it was decided that the work should be conducted under the auspices of the association, that the nurse be appointed by it, and that the association hold itself responsible for the quality of work and the gen- eral arrangements that should be made in the interests of the public and the nurses. All money collected to be paid to the association, while the nurse was to be assured a sufificient monthly remuneration independently of the amount earned. This arrangement has never been altered, and has given general satisfaction, the sense of security to the nurse counterbalancing the greater independence of work under- taken by individuals, and the interest of an influential body providing the continuity so essential. Fortunately a nurse volunteered for the Avork with the understanding that out of the fund collected her actual living expenses be paid. The plan suggested by Miss Kimber of communicating per- sonally and by printed notices with doctors was followed, adding druggists, clergymen, charity workers, heads of departments in schools and colleges. The work, uncertain and spasmodic at first, grew by slow degrees, until it is now self-supporting. During the past winter two nurses have been kept well occupied, and we have the reasonable expectation that the work is here to stay. Monthly reports are made to the association of visits made, new calls, and fees collected, thus keeping up the general interest, while the association treasurer is responsible for the accounts. We ourselves are mainly indebted to the creative energy and wise guidance of one of our members, but underlying everything is the foundation on which it is built. The main object in writing this paper is to emphasize this point — that the success of the work in Baltimore is due to the fact that its foundation is permanent, depending on an influential body, not upon the accident of circumstances affecting the life and work of an individual. I have pur- posely avoided discussion of rates paid for services. This is The Progress of Hourly Nursing 213 a question upon which we ourselves have not as yet arrived at an entirely satisfactory conclusion, and we found it neces- sary to depart from those originally agreed upon. Each city, from what I can learn, has its own conditions, and nurses undertaking the work have a fluctuating scale. I might add that much interest has been shown in this work by prominent women in Baltimore. They contri- buted in the beginning towards its establishment. Miss Wood : I am very much interested in this subject of hourly nursing, or " daily nursing " as we call it in Eng- land. In 1890, I interviewed a large number of our medical men to find out from them if there was any opening for nurses who, by making several visits, would be able to meet the difficulty of providing trained nurses for the poorer middle classes. They thought there was such an opening, and assisted by the nurses in the hospital, I tried it. We found that for nurses who tried to work alone it was not remunerative, but by living together in the principal out- lying districts of London they have to a certain extent made it successful. There are several living at the Nurses' Hostel who are making it a success. I quite agree with Miss Carr. It should be taken up by an association. We are confronted with some difficulties in dealing with this question — the difficulty of the patient, forgetting that the nurse has several other patients to visit ; — that every one wants the nurse at about the same time ; — and that the homes of the patients may be several miles apart. All these difficulties could be met and a solution arrived at if there was a corps of nurses, with a superinten- dent arranging the calls for them, and planning the whole work on an organized basis. There is no doubt whatever that it is the work of the future. But the nurses who undertake it will have to give up somewhat of their independence. I am sure that, if we undertake this work on some such lines as these, in a business-like way, it will be a great 214 International Congress of Nurses help to those people who have small means, and to those who do not require the services of a nurse all day long. For these the hourly nurse will fill a great need. Miss Hicks: I wish in a very few words to tell of the work which is being done in Hartford, in hourly nurs- ing. The results so far have been very satisfactory. The nurse is located at a nurses' club in the city, and is there three times a day, at fixed hours, for one-half an hour each time, to receive calls from the doctors and the charitable organizations of the city. Her salary, so far, has been entirely paid by the Guild, but they hope that the work will become self-supporting ultimately. In July the nurse made 200 visits. Miss Williams : I do not understand how a nurse can make 200 nursing visits in a month. What was the nature of the work ? Miss Hicks : I cannot answer specifically as I did not do it myself. The nurse used a bicycle and sometimes made 12 or 13 visits in a day. Miss McKinnon : I made 185 such visits in a month — much of the work was in the evening, giving baths, etc. It can be done, but it is very hard work. Miss Dock : Miss Rutherford, of the Johns Hopkins Alumnae, who made an exceptional record in hourly nurs- ing, often made 12 or 13 visits in a day. The nursing visits were baths, or carrying out some special treatment. A large service of evening visits was worked up. The doctors ordered cold packs and such treatment for nervous and sleepless patients and this often kept her busy until 11 p. m. But such work is too hard to keep up indefinitely. Unannounced : I know two trained nurses in Phila- delphia, who, needing to remain in their own homes, have worked up a practice of hourly work, in massage, Swedish movements, or general nursing. They work very hard, but The Progress of Hourly Nursing 215 make about three times as much in a year as the private duty nurse. Unannounced: I would like to say that I have done this kind of work; had a ^^ood practice, and gave it a thorough trial, w'orking harder than my strength would permit — I did not, however find it as remunerative as private duty, for the nurse who is reasonably busy. Miss Hughes: I would like to ask for some informa- tion regarding the practice of massage in this country. Miss Boswall : In answer to Miss Hughes' question I shall speak for Boston only, as I am altogether ignorant of methods and customs prevailing in other cities. There are two large schools where massage is taught, one is the Posse Gymnasium, founded by the late Baron Posse, who died in 1895. This school is carried on by the Baroness Posse. The other large school is the Colby Gym- nasium and Institute of Mechanotherapy. I believe Miss Colby is a graduate of the Posse. In both schools every subject is taught which bears on mas- sage. Indeed the term massage covers depths and breadths of instruction and the course covers two and three years of hard work. I think very few of the students are graduate nurses. The Colby Gymnasium offers special privileges for graduate nurses, established teachers, and others possessing qualifi- cations entitling them to claim such consideration. There are various other instructors in Boston, nearly all of whom are graduates of either the Posse or the Colby. There are some of the teachers who probably ante- date the arrival of Baron Posse in 1885, but it was he who raised the practice of medical gymnastics and massage to the dignity of a profession ; and through his efforts gym- nastics were introduced into the public schools of fifty-two cities and towns. Many trained nurses combine massage of parts or joints with the other care of their patients, but as a rule very few 216 International Congress of Nurses trained nurses regularly engaged in the practice of their profession undertake to give general massage. The lessons given in the various hospitals, as part of the nurses' training, may develop the gifts of a " born rubber," but do not fit one without special gifts to engage in massage with much success. Graduate nurses who wish, from various reasons, to make a specialty of massage, find it necessary to take a course of lessons from some instructor, usually prefering a short course with a class to a longer, broader one in a school. The students in the gym- nasiums mentioned obtain their practice by doing charity work in the dispensaries and hospitals under the super- vision of teachers and doctors. FRIDAY MORNING. 9.40 A. M. The President : The meeting- will please come to order. We have an important programme on district nursing and allied subjects, and we will listen to all our papers before beginning discussion. The Origin, Growth and Present Status of District Nursing in England. AMY HUGHES, Late Superintendent Nurses' Co-operation ; Delegate from Fourteen Nursing Societies in England. On receiving the kind invitation to read a paper on " The Origin, Growth, and Present Status of District Nurs- ing in England " my first feeling was that it would be diffi- cult to avoid repeating much of what had already been said when I had the honor of speaking on the work of the Queen Victoria's Jubilee Institute for Nurses and Nursing Con- ference held in Chicago in 1893. I trust you will forgive some inevitable repetition, as the work of the Queen's Institute, of which I am again the representative today, is closely interwoven with the history of district nursing. In collecting statistics of the work since then, one can- not fail to be impressed by the rapid growth of this branch of nursing and the way it has spread over the kingdom. If this increase is remarkable in eight years, it is much more so since the first effort to bring skilled nursing within 217 218 International Congress oj Nurses reach of the poor in their own homes was made b}' Mrs. Fry in 1845, who estabHshed the Nursing Sisters of Devonshire Square, Bishopsgate, for that purpose. This effort was followed by the Society of St. John's House, founded in 1848 with the design '* of improving the quali- fications and raising the character of nurses for the sick in hospitals, among the poor in their own homes and in private families, by providing for them professional training, together with moral and religious discipline under the care of a sister superior aided by a chaplain." District nursing was first definitely formulated in Liver- pool in 1859, a trained nurse being sent to work in a small district. Such good results were obtained that its promoter, Mr. W. Rathbone, was encouraged to extend the work, and within four years the whole of Liverpool was divided into eighteen districts, each supplied with a trained nurse. To avoid any risk of the work becoming a new system of distri- buting relief, the nurses were not allowed to give any sick comforts themselves. A band of ladies undertook to be responsible for the cost of such necessaries for the poor of their own neighborhood, and this system is continued at the present day in Liverpool. As the work increased, a»success- ful change was introduced by placing the nurses in district homes under fully trained superintendents, instead of allow- ing each one to live in separate lodgings. The value of this change made itself immediately manifest in the improved standard of work and discipline among the nurses, as well as in increased zeal and esprit de corps. There are now four homes established in Liverpool and forty-one nurses, the Central Home, newly opened, being a model of convenience for the work. The success of the system of district nursing in Liver- pool stimulated the work in other places, and in several large towns nurses were provided for the sick poor. It appears strange to us that at that comparatively recent date the greatest obstacle lay, not, as might have been expected, in the want of supporters for such a novel District Nursing in England 219 scheme, and, in consequence, want of funds, but in the extreme diflficuhy of obtaining the necessary nurses. It seems almost incredible that sober, trustworthy women, with nursinor experience, were hardly to be found for this work. I may quote on this point from Mr. W. Rathbone's '' Sketch of the History and Progress of District Nursing," to which this paper is already greatly indebted : " As a step towards the improvement of the nursing standard, the matron of the Royal Infirmary in Liverpool had been empowered to pay a salary of sixteen pounds to any nurse who deserved it. This salary was certainly not an exorbitant one, and yet no more than four nurses could be found worthy to receive it. Any ordinary nurse of that time, if paid more than the usual salary of ten pounds, would most probably have incurred dismissal for drunkenness after the first quarter- day." In thus tracing this work from its origin we realize the enormous strides made by the nursing profession since Miss Nightingale founded the training school for nurses at St. Thomas' Hospital in 1860. The first of the societies organized for the sole benefit of the poor in London was the " East London Nursing Society," founded in 1868. It attains its object by placing a trained nurse in each parish and supplying fully trained nursing superintendence ; there is also an efificient plan for the supply of necessary diet and comforts for the patients. There are now three homes in East London, accommodating most of the thirty-three nurses who work there ; the rest still live in lodgings. The society is affiliated with the Queen's Institute. A new development which led to the foundation of the Metropolitan and National Nursing Association in 1874 gave a fresh impetus to district nursing. The movement was initiated by the Council of the Order of St. John of Jerusalem, and the objects of the association were as fol- lows : 1. To train and provide a body of skilled nurses to nurse the sick poor in their homes. 220 International Congress of Nurses 2. To establish in the metropolis and to assist in estab- lishing' in the country district organizations for this pur- pose. 3. To establish a training school for district nurses in connection with one of the London hospitals. 4. To raise by all means in its power the standard of nursing and the social position of nurses. The g-reat departure in this scheme was the employ- ment of nurses drawn from the ranks of educated women, due to the suggestion of the first superintendent, Miss Florence Lees, now Mrs. Dacre Craven. In her own words: ''There were several grovmds for this decision, and these were chiefly that, in nursing the poor in their own homes, nurses were placed in positions of greater responsibility in carrying out doctors' orders than in hospitals ; that women of education would be more capable of exercising such responsibility ; that the vocation would attract women anxious for independent employment, and a corps of nurses recruited altogether among educated women would have a greater influence over the patients, and by their higher social position would tend to raise the whole body of professional nurses in the consideration of the public."' Such an innovation was not considered practical by those most interested in the movement, even Miss Night- ingale saying, '' I don't believe you will find it answer, but try it, try it for a year." Tlie result, however, fully justified the experiment, and the high standard thus estab- lished has exercised its influence over the whole develop- ment of the work. It was resolved to adopt the principle that the nurses should live together in homes under trained district super- intendents, and a central home was established. From this center several homes were rapidly started, and by 1887 there were nine established in London on these lines, besides several in the country. It remained, however, for Queen Victoria, by the insti- tution of " The Queen Victoria's Jubilee Institute for District Nursing in England 221 Nurses," to consolidate the wofk of district nursing and to raise it from the sphere of individual efifort to become a great national institution. Queen Victoria realized the great bene- fits arising from this work, which had been quietly making its way among the humblest of her subjects. With that keen insight into the merits of a debated question which was one of her attributes, she decided to devote the bulk of the subscription raised by the women of England as a gift to her Majesty on the occasion of the celebration of the fiftieth year of her reign, some seventy thousand pounds, to this comparatively unknown object, rather than to bestow it on some already established charity. In 1888 her Majesty approved a scheme for connecting the Jubilee Institute with the ancient charity of St. Katharine's Hospital. In order to obtain the interest and support of local institutions, of which there were many already existing in the large towns, conditions of affiliation with the Queen's Institute were drawn up. These were at once accepted by the Liverpool association, with others, and now there are comparatively few nursing organizations which are not in touch with the institute. A trained nurse was also appointed as general inspector of nursing. In 1889 the institute was incorporated by royal charter, and a president and council were appointed by her late Majesty. Mention must be made of what was done in Scotland, Wales, and Ireland, as well as in England, to estimate rightly the growth of district nursing. In Scotland an energetic council at once started a cen- tral home in Edinburgh, and the system extended rapidly to Glasgow, Dundee, Aberdeen, and other places. In Wales a Central Home was established in Cardiff, and the work has spread slowly but steadily over the prin- cipality. It is found necessary to employ Welsh-speaking nurses in the rural districts, as that language is still spoken far more generally than is supposed, especially among the older people. However, in spite of this difficulty, the work is spreading from one district to another. 222 International Congress of Nurses In Ireland the initiation of district nursing was slower, and it was necessary to establish two training homes in Dublin, one for Roman Catholic, the other for Protestant nurses. But its progress has been uninterrupted, and the Queen's nurses are in every part of the country, even in the desolate island of Achil, where, to quote the words of the superintendent : '' The people are nursed under conditions inconceivable except to those who have seen them. There is only one nurse to the eight thousand inhabitants, and Achil is twenty-five miles long and fifteen miles broad." In 1888, almost at the same time as the Queen's Insti- tute was taking form and beginning its great work in the towns and large centers of the United Kingdom, the Rural Nursing Association was started very quietly in a corner of the Western Midlands, by a small association of ladies and gentlemen, to provide nurses and midwives for the sick poor, with whose homes and needs they were per- sonally familiar. From the first the Rural Nursing Associa- tion determined against the system of sending nurses to live in their patient's homes, the committee believing the poor have neither accommodation nor means sufficient to enable them to lodge and feed, as well as partially to pay for the services of a competent nurse. A high standard of train- ing was required, and the nurse's services were extended over as large an area as possible by means of a pony or donkey cart, and later by the ubiquitous bicycle. This asso- ciation was soon afifiliated to the Queen's Institute, in 1891, and in 1897 was amalgamated entirely with it. The question of providing nurses for the scattered villages and hamlets in thinly populated areas where work is intermittent and distances great is a difficult one. This special branch of district nursing is as yet in its very infancy, and much has to be done in the future to find a practical and satisfactory way of working the rural districts. The system of county associations is an efifort to meet the special difficulties in these districts. Trustworthy, responsible women are selected for training, especially as District Nursing in England 223 midwives and maternity nurses, and return to work in their own neighborhood under the supervision of superintend- ents who are fully qualified Queen's nurses. Valuable help in the training of these village nurses is given by the Plaistow " Maternity and District Nursing Association," whose work lies in the densely populated region of " London over the border." There are now five of these county associations in England, employing over one hundred and ten village nurses, three in Scotland, and one in Wales. The history of the growth of district nursing would be incomplete without mentioning the work done by other institutions whose methods are different from those of the Queen's Institute. Among these are the " Biblewomen Nurses," founded by Mr. Ranyard, whose work lies in several districts of London. The Mildmay deaconesses also send nurses into the homes of the poor. In the country the system of the Ockley Nursing Association was formed to provide women with some knowledge of nursing to live in the home where there is ill- ness, and perform the household duties as well as attend to the patient. The promoters claim this method answers the question of cottage nursing, especially in cases where the wife and mother is laid aside, but it has opened up other difficulties, some of them unforeseen, which show the true solution of this problem has yet to be found. I now pass on to speak of the present status of district nursing. It is interesting to notice how the standard of train- ing has risen with the growth of the work. Much still remains to be done in this direction, especially in the case of village nurses, but every year finds public opinion more enlightened on this point. The great difficulty lies in the necessity of providing inexpensive nurses in poor districts in the country, especially in agricultural parts, and also in the ignorance still linger- ing among those who supply the nurses that good and suffi- cient training is a necessity. 224 International Congress of Nurses When a patient and room are clean and tidy and food and medicine regularly administered, there is a tendency to think all that is necessary has been accomplished. It requires special knowledge to discriminate, on the one hand, between the woman who is disciplined to absolute obedience in carrying out orders, who is trained in the best possible way of performing the details of nursing service, each apparently trivial, yet so important in their sum total, and the woman who, however capable and w-illing, yet lacks the knowledge that in unreserved obedience to orders lies her raison d'etre, who is prone to suggest remedies of her own, and is full of prejudices and superstitions which her short experience of training has failed to eradicate. The Queen's Institute has formulated the highest standard of training and experience hitherto attained. Its nurses must have a minimum of two years' training in an approved hospital or infirmary, followed by practical experience of district work under trained supervision. In many cases special training in a maternity hospital is also required. Nurses who wish to join the institute, having already been trained, are required to fulfil these conditions. The institute aims at securing the services of educated women, believing them to exercise a beneficial influence over the patients and their friends. Tact, courtesy, and refine- ment are necessary to deal successfully with the ignorance and prejudices of the poor, whether in town or country. I would lay special stress on the necessity of some prac- tical experience of the work under trained supervision. It is not to supplement deficiencies in previous training, but to enable the nurse to apply her nursing knowledge to the best possible advantage under such altered conditions. She is saved the necessity of buying her own experience at the expense of her patients and herself if she profits by that already gained by others. Training is found desirable for those who engage in philanthropic works, such as settle- ments, etc., and it is equally necessary in this branch of nursing. The Queen's Institute has added yet another develop- District Nursing in England 225 ment to its " Counsels of Perfection " by its adequate sys- tem of inspection by trained nurses. There is no suspicion of interference with local effort, no curtailing of personal energy, but simply a regular visitation of every affiliated association from the city with its forty to fifty nurses and their superintendents in various homes, to the solitary nurse in the remoteness of the country. Each association keeps its reports, etc., on the same lines, and from each the same standard of work is required. The inspector comes as a friend alike to the nurse and the committee, visiting the cases, seeing the books, and help- ing by her experience and advice to smooth over any little difficulties that may arise. It is the evenness of the work thus obtained that is making it a success by securing a uni- form standard throughout the land. Two other fundamental principles of the institute are : 1. That the nurses shall not be almoners. Their work is nursing, and nursing only, though they are encouraged to bring deserving cases to the notice of the proper local authorities, and in every way thus to secure necessary sick- comforts for their patients. 2. That the nurses shall never interfere with the relig- ious views of their patients. These two rules lift the work of Queen's nurses above suspicion of almsgiving and proselytizing. At the same time the nurses are left free to bring their patients in touch with the local agencies that make for good. Nor must the indirect benefits of the work of the Queen's Institute (and of other nursing associations based upon right principles) be overlooked. They foster the spirit of independence and help the people to help themselves. That this spirit does obtain in many localities is proved by the fact that in a quarry district in Wales two nurses are supported, and there is a balance of over three hundred pounds in the bank, which, with the exception of about fifty pounds, is contributed annually by the workmen, and in another district the nurse is practically supported by half- crown yearly subscriptions. 226 International Congress of Nurses Nor is this all. By interestins;- the well-to-do of a dis- trict in their poorer neighbors, the Queen's nurses form a valuable link in the chain of union between capital and labor. There are excellent systems by which sick and con- valescent diets, warm garments, and convalescent aid in giving change of air, etc., are brought to those who by no fault of their own are unable to obtain these extra neces- saries when sickness is among them. Among these may be mentioned the Scottish Needlework Guild, the Bedford Sick Dinners Society, the London Convalescent Dinners Aid Society, and many others. Then also the nurses can bring the homes of the patients to the notice of the local sanitary authorities, thus insuring cleanliness, a proper water supply, and other simple but essential necessities for healthy surroundings. Tliough for- bidden to proselytize, their influence is the open door by which those who seek the moral welfare of their poorer brethren may obtain an entrance where other means have proved unavailing. The personal interest of her late Majesty in this work has invested it with universal interest. This interest showed itself in many ways. The Council of the Queen's Institute was appointed by her, the names of all nurses were sub- mitted to her before they were placed on the roll of "Queen's Nurses," and even the details of the nurses' uniforms were chosen by her. Those present at the gathering of " Queen's Nurses " at Windsor Castle on July 2, 1896, will not easily forget the enthusiasm kindled by the gracious, kindly words addressed to them by one who ever proved herself a woman full of sympathy with those in trouble and distress. "I am very much pleased to see my nurses here today, and to hear of the good work they are doing. I am sure they will continue to do it." Her Majesty's special recognition of the " Queen's Nurses " in Ireland, on the occasion of her visit there, was deeply appreciated and gave a direct stimulus to the work in that country. Her last message to the council was given on February 24, 1900, and runs thus : District Nursing in England 227 " Her Majesty desires me to express the sincere satis- faction with which she learns that the institute continues to prosper and is so much appreciated." This interest is con- tinued by the present Queen. In July this year some hun- dreds of Queen's nurses received their badges from the hands of Queen Alexandra, thus establishing her identity with the institute as its present head. Queen Alexandra's first address to the Jubilee nurses at Marlborough House, July 3, 1901, his Majesty the King being present, with her Royal Highness Princess Victoria, her Royal Highness Princess Louise (Duchess of Argyll), and Prince Albert and Princess Victoria of Cornwall and York, was as follows : " It gives me the greatest pleasure to receive you all here today, and it is most gratifying to me to be able to carry on the noble work founded by our dearly beloved and never-to-be-forgotten Queen Victoria. I have always taken the most sincere interest in nurses and nursing, a^nd it affords me heartfelt satisfaction to be associated in your labors of love and charity. " I can, indeed, imagine no better or holier calling than that in which you are engaged of tending the poor and suffering in their own homes in the hour of their greatest need. I shall follow with interest the reports of the institute, and shall anxiously note the progress which you are making from year to year. " I pray that God's blessing may rest upon your devoted and unselfish work, and that He will have you all in His holy keeping." A special effort is being made by means of the " Queen's Commemoration Fund " to raise sufficient funds to endow the " Queen's Institute " in perpetuity, so that it may keep pace with the ever-growing demands on its resources. Having thus outlined the history of district nursing from one nurse in 1859 to the great work of mercy which has spread over the whole land, I would only add that it is not systems alone, admirable as they can be, which bring success, it is the work of each individual nurse which makes 228 International Congress of Nurses. the work what it is ; it is not nursing alone, though that should be as perfect and well-disciplined as training and experience can insure, but moral influence, to which there is practically no limit. The influence of a good nurse remains after her nursing services are ended. It is the opportunities given by dis- trict nursing that make it so important and so responsible. Nurses who grasp the inner meaning of their work have few limits to their powers of usefulness. They nurse the homes as well as the patients; they give valuable object- lessons in the practical details of nursing, simple sick- cookery, cleanliness, etc., thus helping their fellow-women to be less helpless and hopeless when sickness invades the home. They can advocate self-restraint, thrift, and household economics ; they can give valuable advice in the dieting and management of infants and young children, so helping to strengthen the sinews of the nation — " As the child is, so the man is " — and the simple hygiene of proper feeding taught in language " understanded by the people " means the future welfare of its sons. Thus every earnest district nurse who sows the seeds of thrift, self-help, self-restraint, self-respect in the round of daily work is a helper, however obscure her path of duty, in solving the social problems of the day. I will conclude with the message entrusted to me on June 15 by Miss Florence Nightingale to give to the dis- trict nurses at the Congress: " I do not think that there is any human being who may be as useful as a district nurse if she is helpful without being interfering. May God bless and keep the district nurses here in a body is the fervent prayer of Florence Nightingale." Tenement House Inspection. JOHANNA VON WAGNER, Sanitary Inspector of Tenements, Yonkers, N, Y. Because so little is done to teach people in their homes how to better their condition, I am grateful for the oppor- tunity to speak to you about my work in the tenement .houses as Sanitary Inspector. While not every city has a tenement house problem, every city has a housing problem, and it is the duty of the Board of Health to see that the homes of the working-classes are made at least healthful. Organizations of public-spirited citizens should be formed, which, after acquainting themselves with local con- ditions, would revise building and sanitary codes and see to the enforcement of laws. Already this is done in New York, too late, to be sure, to eradicate the evil which a tenement house is, — it is here to stay, — but an organization of men and women can do much to improve the homes of the poor. To be able to cope with such a problem, a thorough knowl- edge of existing conditions is essential. A house-to-house inspection will reveal, aside from existing facts, the wants and needs of the people. Having been a tenement house inspector for over four years, I am able to speak of the need and benefit of such work. It touches the people in their homes, and their lives can often be made brighter by helpful sympathy. From year to year it is harder for the poor man to live, and the dailv complaint is that he cannot find rooms. 229 230 International Congress of Nurses Twenty-five years ago the Chief of the Department of Health in Glasgow realized the need of women inspectors in connection with the Health Department, as only women could deal with women efifectively, and ever since that time the work has been done there by women health visitors, as they are called. The larger cities in England have followed the example of Glasgow, and there are several sanitary institutes in England, where men and women are graduated to do the work of sanitary inspectors. Several years ago in Chicago the Board of Health appointed women to inspect factories, sweat-shops, and tenement houses, and five years ago Yonkers first had a woman tenement house inspector, and it is almost two years since I was regularly appointed by the Board of Health, and I can say without vanity that in no city is the work done so effectively as in Yonkers, because the qualifications which a nurse has enable her to do better than the average woman. It would take too long to detail the combat gone through to get the appointment. Landlords, politicians (members), and employes of the Board of Health all fought against the woman inspector, and but for the members of the board and one brave woman, Miss Mary Marshal Butler, president of the Civic League and Woman's Institute, who overcame all opposition, the appointment would not have been successful. After passing civil-service examination the appointment was made, and in February, 1900, I commenced my duties as an employe of the Board of Health, as formerly I had done the work of the Civic League. I will pass over the difficult task of working with the same people that fought so hard not to have me, and will only say that those same men are my best friends at present, and agree with the secretary, who said : " How did we ever get along without our woman inspector ?" The Health Officer said that he would like to have one woman inspector to every twenty-five thousand inhabitants. The president of the board said that the moral influence of Tenement House Inspection 231 a woman inspector in the department had been very bene- ficial. All this I say to show that the work has been appre- ciated by friend and foe and the need demonstrated. In onr beautiful Terrace City such bad conditions were revealed as to shock the whole community. Tenement houses in Yonkers compare favorably with those elsewhere ; we have all the evils of New York slums, only on a smaller scale. As a large proportion of our population lives in tenement houses, the need for improvement was great. The average tenement house has deprived the people of light, air, and privacy ; it has dark bedrooms, with some- times the worse than useless air-shaft opening into a com- mon hall, — a hall which, on entering, sends a chill through one's bones ; as a rule it is not ventilated, is very dark, unventilated toilets open into it, and damp cellar air and odors from cooking and toilets which greet one on entering are over-powering. I begin my work in the cellar, much to the surprise of the people, who have neglected to clean it and stored all sorts of rubbish away in it. As a rule, that most important part of the house has also been neglected by the builder, light and air have not been provided for, and after a rain- storm it is very often flooded. Right here I begin to inspect the plumbing, and unless the house is new the pipes or construction are generally defective. I have to get a light to do this. When I go to the upper floors the living rooms over the cellar are damp also and very unhealthy. The tenants have malaria, rheu- matism, and tuberculosis, children have bronchitis and do not thrive, and even up to the top floor all complain of ill-health. I go through the rooms, seeing to proper ventilation, cleanliness, need of repair, and over-crowding; follow the plumbing up to the roof ; see to the condition of the roof, fire-escape, hall, toilets, and then inspect the yard, recep- tacles for garbage, pulley-line poles, cleanliness, and drain- age. I have witnessed scenes which cannot be described, and 232 International Congress of Nurses every day reveals new misery : the poor little children locked up in basements while both parents work in the mill ; the household of the habitual drinking-woman, the neglected, vermin-covered children, six in one bed, poorly covered, looking like little skeletons ; the consumptive's room, where bedding, floor, and furniture are covered with expectoration, where the children play on the floor, and wife and baby share the same bed ; where out of fear a contagious patient is hidden in a closet, and out of kindness a paralytic or any other bedridden patient is left alone for a month or two, never bathed on body or bed-linen changed so as to cause no pain, and where bed-sores from shoulders to heels have become gangrenous. It was in a small rear house where I knocked, per- ceiving the odor far ofT. " No admittance " was on the face of the woman who was supposed to care for the patient, but I managed to gain entrance, and only by the exercise of the greatest tact was I allowed to see the poor, sick woman and care for her — until death. The horrors of that sick-room I shall never forget, and I hope and pray there may never be another case like it. The poor, the hungry, and the needy, — but it would take too long to speak of all the different phases. The teachings of Christ are forgotten. We do not know how our neighbors live, and we would rather not know. Not charity, but justice is needed. The greedy landlord who looks for twelve per cent, has to be dealt with. Model tenement houses can be erected on a paying financial basis. They have proved a success wherever they have been built, and aside from the fact that they returned between five and six per cent., they have provided healthy homes for people of small means. While they are a great blessing, the greater need is to put existing houses in sanitary condition and prevent badly constructed houses from being erected, and here it is where a woman inspector does the most good. Everything dangerous to public health is reported, — dark rooms and halls, closed skylights and air-shafts, defec- Tenement House Inspection 233 tive and boxed-in plumbing, filth and disease, damp cellars, over-crowding, — all these things are nuisances and reported, and in a given time remedied, which may be from a day to a month. If the owner is not willing or able to do it, the Board of Health has the work done. The law is that one toilet shall be provided for every two families, but I think that each family should have its own water-closet, and to have it not in a dark corner, but open to the external air, is just as important. Fire-escapes should receive better attention; the straight, narrow ladders without the platform will hardly answer for most people — not to speak of the absence of fire-escapes in so many houses. The house-to-house instruction, aside from reporting nuisances, is an important part of the work. " Thank God ! some one is going around that knows something," an old Irishwoman said. They have had mis- sionaries to look after their spiritual welfare, but no one to help them bear their burden and improve their lot in life. After explaining to them how to care for and feed babies, the women will say, " Why did we not know this before ?" A birth and a death every year and sickness and undertakers' bills in many cases cause the poor man's poverty. Ignorance of the common laws of health and unhealthy homes and food are undoubtedly causes of the prevalence of the drink habit. Much can be done towards the prevention of the spread of contagious diseases, and especially tuberculosis, not only by reporting the fumigation of rooms and enforcing strict cleanliness and isolation, but by providing sputum-cups for the poor which may be burned after use, and after death from this disease fumigation and thorough cleaning before another family moves in. With the teachings given to the people how to protect themselves and how to improve their ways of living there should go the enforcement of laws governing landlords and agents and an awakening of the social conscience at large, 234 International Congress of Nurses and I confess that is the hardest part of my work. Being a woman and having no vote, poHtics do not influence my reports. Cellars have to be cleaned and whitewashed, carpets removed from stairs, halls ventilated and cleaned, rooms whitewashed or painted, papers removed where pos- sible, air-shafts and skylights have to be made to open to admit air, roofs repaired, and plumbing looked after. The characteristics of the dififerent nationalities have to be dealt with, and each watched acordingly. When commencing to inspect a street the children carry the news that the Health Board is around, which is the signal for general house-cleaning. When I try to have people move out of unhealthy houses, I hear always the same remark, " We can't find good rooms," and the requests for me to find rooms are numerous indeed and difficult to comply with. After revealing conditions in Yonkers, some good citi- zens remodelled old houses and put them in sanitary condi- tion, and it has proved a financial success. There is a woman rent-collector who collects weekly, which is safer for the landlord and easier for the tenant, and with it goes a supervision which is of great value to both. With improved homes we have better health and better citizen- ship, which is all-important to a nation. While far from being good, conditions are greatly improved in Yonkers. Better school attendance in winter, decreased immorality rate, especially among children, and greater cleanliness are among the visible results from the work done so far. Prevention is my motto, and when we can prevent disease we have touched the foundations of most evils. What larger field of usefulness could we wish for than to go from house to house and give the people the benefit of our knowledge of sanitation, hygiene, and domestic science ? A great English statesman has said, " Of what use is sanitary legislation unless it is practically applied ?" and Tenement House Inspection 235 only by obtaining the co-operation of every hotisekeper with the Board of Health can rules and laws be enforced. Let there be well-trained women to do this work. As Dr. Benjamin Lee, president of the State Board of Health, said: "Women are born sanitarians, and make better teachers; besides, they attend to detail work, and I would say the work is essentially one for women. No matter what the condition of the house, a woman is admitted because she will understand, when a man cannot enter, and very often the remark is made, ' I am so glad it is a woman this time.' " After inspecting rooms, closets, and bedding, I am made acquainted with the sorrows, the wants, and some- times the joys of the family, and I seldom leave without having given advice or help, or put them in the way to help themselves. The invitation to call again soon or spend Sunday with the family shows that the visit has been appreciated. The field for usefulness is large, and the work fills one's life to the utmost. While it is hard to bear so many peo- ple's burdens, the thought that this work is a step in the right direction gives new courage and hope. I hope to live long enough to see more cities take up this work. Only those women who love the people and will work for public service and not personal gain should take it up. It is the hardest work I have ever done, and it requires courage and a good deal of faith to enter into all places. May more nurses prepare for this work, and indeed be the friends of the people. It is the true mission of the Board of Health to take up this work, and may there be enough public-spirited men and women in every city to see to it that the large class of working-people at least have healthy homes. The President : The chair has been requested to have a letter read from Mrs. Butler, showing how well Mrs. \'on Wagner has done her work. ^36 International Congress of Nurses My Dear Miss Mclsaac: In view of Mrs. Von Wagner's attendance at the International Council of Nurses, I would like to give my testimony to the efficiency of her work in Yonkers, and emphasize the desirability of inducing nurses to consider the official inspection of tenement houses as a field for their professional ability. In visiting Health Departments here and abroad with reference to the work of women Sanitary Inspectors, it has impressed me that, other qualifications being equal, the knowledge possessed by a trained nurse who had the ability to impart it would be of great additional benefit in accom- plishing permanent good results, and I am hoping that as the work is taken up in this country more nurses may be found who will fit themselves for the position. In Chicago, where six women Tenement and Factory Inspectors are employed by the Health Department, the duties of the women are about the same as those prescribed for men. I believe the duties of the woman inspector should include the instructive work, and that to her should be given certain duties differentiating her work from that of a general Sanitary Inspector. There are comparatively few places in this country where women are employed in connection with Health Boards, but it is our earnest hope that an impetus may be given to the idea through this Nurses' Council, and that a great and practical purpose may be reached through the paper to be read and discussed at your meeting. Wishing you all progress in the various departments •of helpfulness you are considering, I am very cordially yours, Mary Marshali, Butler. History of Visiting Nurses in America. HARRIET FULMER, Superintendent of the Visiting Nurse Association of Chicago. In the characteristics and aim of district or visiting- nurse work there may be said to be " nothing new." It is a branch of nursing so well known to our profession that it is needless to dwell upon the purpose of the work. At the Congress of Nurses, held in Chicago in 1893, the subject of this paper was given such complete and detailed description by women of years of experience in the work that it would be time misspent to take up that which was so well covered then. The facts and data of the present paper are largely statistical, and intended only as historical of the subject, and simply to show the growth of the work in various parts of the country in the last ten years. This philanthropy has now taken its place among the organized charities of modern times. Only a few years ago quite unknown, it is now operated successfully in almost every section of the country. It is a charity of which its promoters never tire ; and noting its success and present steady growth, one often wonders why its initiatory stages had such uphill work. District or visiting nurse work covers that branch of nursing which cares for the sick poor in their own homes, when by reason of surrounding circumstances the patient may not be sent to a hospital. The work is likened to a large out-door hospital, the various towns and localities being divided into wards or districts, the whole being responsible to the head or superintending nurse. 237 238 International Congress of Nurses From the first year of its existence, when Fliedner at Kaiserswerth sent trained women into the homes of the poor, and WilHam Rathbone, M.P., saw the need of it in England, the character of this work has not changed ; it still carries out the first param^ount principles of giving skilled nursing to the poor and the small wage earner in their own homes, and to use such methods of instruction as teach them to care for their own sick and to carry out the right observance of sanitary laws. The pioneers of this work had untold dif^culties to overcome, for by no means did their efforts meet with warm support. Medical men were suspicious that these organi- zations sending out skilled nursing help would interfere with their practice, and many of the laity felt it an innova- tion not practical, and that the poor could get on the same as they always had done. It is needless to say that the newer and younger associa- tions have none of these difficulties, for physicians every- where now are not only the instigators in new localities, but are always the staunchest supporters of the scheme. The development of the work in America has not been a bed of roses, and with all its seeming success in this country we are years behind Germany and England — where 140 trained women are employed in America 800 are employed in England. A woman prominent in philanthropic work says, " There is no form of organized philanthropy that demon- strates more clearly the present progressive ideas of social and economic work among the less fortunate," and a student of social problems has well said, " It is the safest and most practical means of bridging the gulf which lies between the classes and the masses." This principle is largely illustrated in the successful social settlement made up of nurses at 265 Henry street. New York City. In continuance I should like to put in short form a few general suggestions to those who are contemplating form- ing this work in new localities. I shall give below a combi- Visiting Nurses in America 239 nation of the various methods carried out in many of the organizations now operated. First comes the need, then the presentation of the project at a general meeting of the pubhc, to which should be asked prominent physicians of the locality to give it endorsement. Then comes the mode of support, usually best by voluntary contributions in small sums from the public rather than by individuals, as then one may feel that they have a special claim upon the service. If operated upon the nonsectarian principle, you then have the support of all the religious elements, but are confined to no particular one. Cases should be taken and received from all sources. An ideal system may have many adjuncts operating in connection with it. First is the Flower Mission, or the Diet Kitchen, or the Convalescent Home in some near-by country place, to which patients may be sent. Then in the district must be the ever-ready and well-filled loan press, containing every known article that may be used for the comfort and well-being of the sick. The most successful organizations go upon the principle that the best results are shown to the people when the professional nurse gives the service assisted by the most modern sick-room appliances rather than by make-shifts, and yet always giving informa- tion as to what articles may be used in the place of the modern ones. In adopting a name for any new society doing this work we would advise the use of the term " Visiting Nursing " as being more comprehensive than " District Nursing," and as less cumbersome than " Instructive Visit- ing Nursing." The woman employed to do this work should be a graduate of a large general training school, for she may care for many cases without meeting the doctor in attend- ance, and she should know how to meet every emergency. In starting the work in a new locality preference should he given a nurse who has had experience in district nursnig work, and the rules for the admission of additional nurses to the society should be most severe. She should be required 240 International Congress of Nurses at the end of a certain time to give a complete sketch of how she would meet all the various emergencies that might arise in the work ; how she would send a case to the hospi- tal, secure ambulance service, report cases for relief sent to various institutions, to summer homes, etc. The next step in the right direction in the work in this country will be to establish a special post-graduate course for all nurses desiring to take up visiting nurse work, for too many nurses come into the work having little idea as to the requirements and demands ; and during the period of perhaps their first year, the organizations suffer by their lack of knowledge. In the near future the Chicago association will establish a course of this kind where graduates from general training schools may take up and learn the work in a systematic way. I may go on now with some of the general require- ments and rules for nurses. She is employed actively from eight to ten hours per day, and if she is doing the work in the right spirit any additional service required is done with- out comment. The salaries throughout the country paid to these workers seem to be about uniform, forty-five dollars, fifty dollars, and sixty dollars per month, according to the time they remain in the work. Not all organizations wear a regulation uniform, but those who do are to be commended. For in many instances its moral effect upon the patient is constantly apparent, and there is nothing that can take the place of the plain ging- ham dress and the neat coat and hat of subdued color. In most organizations the visits of the nurse average from eight to twelve in one day, varying from a half hour to two hours each. A typical day in a large society is as fol- lows : The first visit was to a dying consumptive, where a bath and clean linen were given ; the second, a bath and alcohol sponge to a man with typhoid ; third, dressing a varicose ulcer on the leg of a woman who makes wrappers all day long at forty cents per dozen ; fifth, baths and clean linen to a family of five, all ill with typhoid ; reported case Visiting AUtrses in America 241 to Board of Health, arranged to send patients to hospital; two-hours' work required; sixth, maternity case: bathed mother and babe; received ten cents for service; seventh, took temperature and pulse of convalescing typhoid; arranged to send patient to country ; eighth, bath to mother and daughter, both ill with consumption ; new case, reported to Health Board ; ninth, very sick babe; gave bath, furnished milk, and instructed mother; sent free doctor; tenth, man with locomotor ataxia ; gave bath, made application to send patient to Home for Incurables. Who, in hearing this, will say that it was not a day full of satisfaction to the nurse, of practical benefit to the patients, and of infinite credit to the supporters of the work who make it possible that the relief may be given? In the regular systematizing of the work we do not find it an easy matter, the very character of the work itself bringing about rather a hap-hazard way of doing it, for the very reason that no day's work can be arranged prior to its beginning. The records kept and the reports made for filing require much skill and patience, and take a large part of the nurse's time and labor. Most of the women employed find their greatest hardship in the exposure to the elements, rain, cold, and snow in winter, and the beating rays of the sun in sum- mer, for the visiting nurse goes on her rounds, rain or shine, heat or cold, and often the nurse herself, after a very hard day's labor, wonders why she is willing to give up a lucrative and half-comfortable private practice for this life of exposure and self-denial. But nearly every woman now doing the work finds that indescribable something which is akin to fascination in being the instrument that brings so much comfort to those who, without her, would have naught, and at the same time combining with her labor self-support and independence. Miss Brent, of Brooklyn, N. Y., in a clever paper on district nursing read before the Congress of Charities in 1894, sums up the work of the nurse as follows : " It is a hand-to-hand struggle against disease, poverty, and dirt. 242 International Congress of Nurses against the most pitiful ignorance and inherited prejudice. The nurse finds her routine work widely different from hos- pital or private duty. . . . Beginning each morning her daily rovmd of visits, carrying with her in as small a compass as possible all the necessary appliances for her work, she goes from house to house, from one patient to another, mounting flight after flight of stairs, — for it is a curious but true fact that tenement house patients always live on the top floor of a very tall house, — here making beds, preparing nourish- ment, giving sponge-baths, there bandaging a leg or apply- ing a dressing, but in all cases carrying out the doctor's orders, leaving notes of temperature and general condition, being certain the medicine will be properly administered, and seeing that proper nourishment is provided whether by direct orders or otherwise, — in short, doing everything in her power for her patient's comfort." The following is an extract from a letter from Florence Nightingale to Lady Aberdeen in commendation of district nursing work : " Let me gladly add myself as a witness of experience here to the great blessings which the trained district nurse has brought to the sick poor. " If you are able to maintain the high standard for your nurses which you have done, and succeed in attracting good young women to enter upon the work, there can be no doubt that it will get on and prosper. DifBculties and trials there must be, but with so noble an object, it is worthy the expenditure of much labor and patience." From the hospital training school the area of the trained nurse's work has become extended to private nurs- ing (nursing the well-to-do) and latterly to that far more numerous class of patients who are either entirely destitute, or able to make a small contribution for the services of a nurse, and yet who are not fit subjects for hospital treat- ment. It is especially and above all to this last class that the trained district nurse has proved so great a benefit. For the duties of the district nurse more experience, more self- Visiting Nurses in America 243 denial, are wanted than for those of a hospital nurse or private practice, who have the doctors ahvavs at hand to refer to, and have all the appliances of hospital or home at the service of the patient. The success of district nursing depends, more than in hospital and private practice, upon the character of the nurse, and the character of the nurse depends much more upon the nature of her training and the continuance of those helps, physical and moral, which that training has supplied to her. ^^ The total number of associations doing this work in America is fifty-three ; the number of nurses employed one hundred and thirty. SOCIETIES AT PRESENT OPERATING IN AMERICA, IN ALPHABETICAI, ORDER. Albany, N. Y. — The work in Albany is done by the Albany Guild for the Care of the Sick Poor, and is the out- growth of the Fruit and Flower Mission, which was organ- ized in 1880. It employs four nurses and does much work among the class which pays small fees for the nurse's care. The nurse here may not respond to any calls except- ing those sent to her from the physicians and by the presi- dent of the association. This method necessarily limits the field. Bufifalo, N. Y. — The District Nursing Association of Bufifalo was organized in 1892, to provide free nursing among the sick poor and to carry on a diet kitchen and flower mission in connection therewith. The association is strictly non-sectarian, receiving its support from the vol- untary contributions of all denominations. There are now four nurses doing duty for the association.* * The Board of Health of BufiEalo has now authorized these nurses to act as Sanitary Inspectors. 244 International Congress of Nurses Boston, Mass. — Boston has the oldest of the Visiting Nurse societies estabHshed in America; it was organized in 1886. The fourteen nurses work in connection with the dispensary physicians connected with the Boston Dispen- sary, estabHshed in 1796. This association is known as the Instructive District Nursing Association of Boston. Baltimore, Md. — The work in Baltimore is known under the name of the Instructive Visiting Nurse Associa- tion. It began in January, 1896, with one nurse. At the beginning of the present year it has five. The association is partially self-supporting, the deficit is made up by volun- tary contributions. It is non-sectarian and neutral. Coop- erates with the other charities of the city. From the first it has been a most successful organized society. Brooklyn, N. Y. — The visiting nurse work is estab- lished in this city and is known as the Red Cross Instructive and District Nursing Society, and is now a department of the Bureau of Associated Charities. Three nurses are em- ployed who do the usual nursing work. In addition to the work done under the auspices of the Bureau of Charities there is also a graduate nurse at the Pratt College Settle- ment, supported by a private individual. Colorado Springs, Col. — The work here is compara- tively new, and the one nurse employed is under the super- vision of the Associated Charities and paid by them. Columbus, O . — The organization is known here as the Instructive District Nursing Association. It was organized in 1898, through the efforts of philanthropic citizens, and is now supported by voluntary contributions. Three nurses are now employed. This organization secured its first nurses from the organization in Chicago. It has been most successful. Chicago, 111. — The Visiting Nurse Association of Chi- cago was organized in 1890. Fifteen nurses are employed. It has also a staff of untrained women who are sent to remain in the home. It is non-sectarian, neutral, and exclu- sively a public charity, supported by voluntary contribu- tions, fees, and legacies. Managed by a board of directors Visiting Nurses in America 245 of thirty-two women. Cooperates with all the organized charities of the city. Gives only nursing and medical caie and only such relief as pertains to the sick. Paramount object, instruction to the people in sanitary laws and hygiene and the care of their own families in time of illness. Cambridge, Mass. — The district nursing in this locality is under the direct supervision of the District Nursing Association of Boston. It is really a branch of that city's work. Concord, Mass. — The work at Concord was established in 1900, and employs one nurse. The largest part of the work is done in the families of those who can pay small sums for the service, though the association was started for the benefit of the destitute poor. Charleston, S. C. — In this city is an organization known as the Ladies' Benevolent Society, whose constitution says it "is formed for the relief of the sick only." It is probably the oldest of its kind in America, having just had its eighty- eighth anniversaiy. It is supported by voluntary contribu- tions, fees and legacies. It is undenominational. Cleveland, O. — A club of young women support a nurse here, A regularly organized society is now in process of forming. Davenport, la. — In connection with St. Luke's Hos- pital of this city is organized a department of district nurs- ing. The pupils in the second year are sent out to care for the sick in their own homes under the supervision of the superintendent of nurses. Denver, Col.— In 1892 the Denver Flower Mission employed a visiting nurse to care for the sick poor. In 1900 this association merged into what is known as the Visitinp- Nurse Association and Flower Mission of Denver. It is supported by voluntary contributions, fees, and lega- cies. Two nurses are employed. They also have in con- nection a complete medical and surgical staff. The chanty organization of Denver contributes towards the fund. Detroit, Mich.— The Visiting Nurse Association of Detroit was organized in 1896. It is supported by the 246 International Congress of Nurses various guilds and church societies and voluntary contri- butions. It has in its employ at present three trained nurses. It has the hearty support of all the institutions of the city. Fall River, Mass. — In Fall River, Mass., the work is done under the auspices of the Union Hospital, which sends out one nurse who cares for as many cases as possible dur- ing the day. Fort Wayne, Ind. — The work is known in this city as the Visiting Nurse League. It is supported by various church circles and the contributions of the pubHc. It employs two nurses and works in connection with the asso- ciated charities. Fitchburg, Mass. — In Fitchburg, Mass., the work is known as the Instructive Home Nurse Association, and is a department of the charity organization known as the Fitchburg Benevolent Union. Employs two nurses and makes a specialty of its loan closets, the system of which could be profitably copied in all other district nursing work. Grand Rapids, Mich. — The District Nurse Association in Grand Rapids is operated in connection with the charity organization of that city. Two nurses are employed who work entirely in connection with the associated charities. The fund is supplied by private individuals. Harrisburg, Pa. — The Visiting Nurse Society of Har- risburg is neutral and non-sectarian ; employs two nurses and is supported by a private individual. It was formed in 1899 and has been most successful. The work is done by nurses formerly employed by the Chicago Association. Hartford, Conn. — Hartford is perhaps the newest of the organized associations. It was started in February, 1901, under the auspices of the local branch of St. Barnabas Guild for Nurses, and has one nurse. Hampton, Va. — A very successful organization, organ- ized since 1899, is the district work done in connection with the Hampton Training School for Nurses connected with the Dixie Hospital. This is the oldest training school .for colored women in America, and the pupil nurses are sent to furnish nursing care to the sick poor in the town. Visiting Nurses in America 247 Kansas City, Mo. — The work in Kansas City was begun in 1891, and is known as the Visiting Nurse Asso- ciation of Kansas City. Two nurses do the work in this organization. It is supported by voluntary contributions of the pubHc. Keene, N. H. — In Keene, N. H., the work is done by student nurses sent out from the city hospital. Los Angeles, Cal. — The work was started in Los Angeles in 1899. One nurse is employed by the city — the only place in America where it is done in this way. The plan might well be adopted elsewhere. Lynn, Mass. — The district work in the homes of the poor was organized here in 1896 through an agreement between the Lynn Hospital and the Associated Charities, whereby the Associated Charities was to pay the Lynn Hospital for the service of a nurse in training. The nurse is changed once in two months. She reports at the ofifice of the Associated Charities for all her cases. Lawrence, Mass. — The work of the visiting nurse in this locality is supplied by the pupil nurses from the Law- rence Training School for Nurses. Maiden, Mass. — One nurse has been employed here since 1899. She works in connection with the Industrial Aid Society. The salary is paid by this society. Melrose, Mass. — In Melrose the work is done by the pupil nurses of the Melrose Hospital. Middletown, Conn. — The work was organized here in 1901, and has one nurse employed. The work is going on most successfully. Milwaukee, Wis. — The work here is done by two nurses employed by the Associated Charities. There is no distinct organization of the kind. Mt. Kisco, N. Y. — The work here is done by the \'is- iting Nurse Association known as the Ellen Wood Memor- ial District Nurse Association. Was named in memory of Miss Wood, a Johns Hopkins nurse, the alumnae association of that school contributing towards the support. One nurse is employed. 248 International Congress of Nurses Newton, Mass. — This association was organized in 1898. It acts under tiie direction of the physicians of the city of Newton, and is supported by voluntary contribu- tions. Two nurses do the work. New York City.— The ground is fairly well covered in New York City, although the work is not done by any one organized society for this work. The field is a large one, and really should be covered by an organized society operat- ing on a separate and distinct basis. The Bureau of Asso- ciated Charities has six nurses working in connection with it. Nurses are engaged in the various parishes of Grace, Trinity, St. Thomas, and others. Tlie City Missionary Society, one of the oldest organizations in New York City for caring for the sick poor, has employed a band of trained women for manv vears. The work at the Nurses' Set- tlement 265 Henry street, is most complete in every detail, consisting of visiting nursing carried on in three different localities where the settlement has houses or flats ; first aid, or dressing rooms, where minor surgical cases are treated, of which there are three, also situated in different localities ; a country home where convalescent patients are taken all through the year, and social and teaching work which has grown up as a secondary development. The entire number of nurses connected with the settlement is now seventeen, of whom a monthly average of ten is engaged in the work of visiting nursing in the homes, both of non-pay patients and of those who can pay small sums. Newburg, N. Y. — The work here was started in 1897 by the clergymen of the city, and is known as the Visiting Nurse Society of Newburg. The expenses are met by con- tributions from the various churches, by fees, and legacies. They have one nurse, and she may only take cases sent to her by physicians of the city. The work is now on a perma- nent basis. Newport, R. I. — The work in Newport is carried on under the auspices of the Newport Hospital, the pupil nurses in training in the second year being sent out to care for patients in their own homes who are unable to pay for Visiting Nurses in America 249 the service. The plan has been operated successfully for a number of years. Norfolk, Va.— The work here is under the direction of the Norfolk Union of the King's Daughters. Two nurses are employed, part of one nurse's time being used as a friendly visitor for the united charities. There is great need for this work in that locality. Oakland, Cal. — The work is done by the pupil nurses sent out from the Oakland Hospital. There is not the great need in this locality as found in many others. It was estab- lished in 1894. Omaha, Neb. — The work was organized in Omaha in 1897 with one nurse in charge. It is supported by volun- tary contributions, and is indorsed by leading physicians of the city. It is modelled, both in constitution and the detail work, upon the Chicago plan. Orange, N. J. — The work in Orange, N. J., is carried on by the nurses of the Orange Hospital Training School, who live at the Nurses' Settlement in the district occupied largely by the mill hands. It is supported by voluntary contributions. Plainfield, N. J. — The work was established here sev- eral years since under the auspices of the City Union of the King's Daughters. The fund is supplied entirely by this organization. The nurse co-operates with the Asso- ciated Charities. Philadelphia, Pa. — The Visiting Nurses' Society was organized here in 1875, almost simultaneously with that of Boston. It employs eight graduate nurses and several undergraduates. It is supported entirely by voluntary contributions. It is non-sectarian, and its constitution says that "the object of this society is to give to the poor and to those of moderate means the best home nursing possible under existing circumstances." Proctor, Vt. — Tlie Proctor Hospital Training School takes care of the poor in their own homes by sending out a pupil nurse when in her second year training. 250 International Congress of Nurses Rochester, N. Y. — The Rochester City Hospital fur- nishes through its out-door-rehef department a district nurse who cares for cases who are poor and who are unable to leave their families to go to the hospital. The ground is well covered in Rochester, though there is a field for a regular organization. Salem, Mass. — The work is done here in connection with the Associated Charities, but is supported by private individuals. One nurse is employed. St. Louis, Mo. — The sick poor in their own homes are cared for here by the nurse employed in connection with the Visiting Nurse Department of the St. Louis Provident Association. It was formed in 1895 and is supported by the regular Associated Charities. St. Paul, Minn. — One visiting nurse is employed here by the Bethel Settlement. The field in St. Paul is covered very much in the same way as that in New York. There is no regularly authorized system under one head, but the sick poor are well cared for. Scranton, Pa. — The Associated Charities in this city employs a nurse in connection with their work. The expenses are met by that organization. San Francisco, Cal. — In 1897 the Fruit and Flower Mission of San Francisco employed a visiting nurse to care for the sick poor. In the following year, in 1898, she was transferred to the Associated Charities and a second nurse was added to the work. The support comes from private individuals, who furnish the money for this purpose. Calls are received from the Associated Charities. In addi- tion to these nurses there are several others working in connection with the various parishes. The sick poor are well cared for in San Francisco. Syracuse, N. Y. — The society here is an organized one, known as the Visiting Nurse Association of Syracuse. It was organized m 1896, and is supported by private indi- viduals and public contributions. Two nurses cover the field. Visiting Nurses in America 251 Washington, D. C— The Instructive Visiting Nurse Society was organized in Washington in 1900. It now employs five nurses and is supported by the voluntary con- tributions of the public. Waltham, Mass.— The District visiting nursing is done here by the pupil nurses of the Waltham Training School. This system, now in operation in many localities, is indebted to Dr. A. Worcester for its origin. It was the first time in this country that the sick poor had been cared for in their own homes. The work is most successfully carried on and serves two purposes, that of giving care to the peo- ple who cannot alTord to pay for the service, and also giving experience to young women in training which they perhaps could not get under the roof of the hospital. Winchester, Mass. — The work was organized here in 1899. Two nurses are employed who do much charity work, but are especially serviceable to the small wage earner, who pays a fee for care received. The support is from voluntary contributions. Worcester, Mass. — The work is done here by two nurses, supported by voluntary contributions, and who work in connection with the Associated Charities. This paper would not be complete without a mention of the Victoria Order of Nurses, founded in Canada by the Countess of Aberdeen. The order is for the benefit of the sick poor, the same as all other district nursing societies, and is supported by voluntary contributions. Its work is larger and covers a greater field than any of the organiza- tions of its kind in the States. In Montreal there is also a district nurse sent out in connection with the Diet Dis- pensary. In Toronto the Nursing at Home Mission does the same sort of work as is covered by the organized societies in the States ; it also is supported by the voluntary contribu- tions of the public. 252 International Congress of Nurses SUMMARY. After laying before you all the plans and operations of the various organizations of this character now under way, we leave it to you to choose the best means of opera- tion. With the active professional worker the neutral lines seem the best lines. Whether the work can be carried on with or without the religious element depends upon the locality. The demand for this work is usually spontaneous, and not always will the same people recognize its necessity. In one instance it may be the physicians of the locality, in another the clergy, in another the philanthropic and ben- evolent wealthy citizens. The question is : shall the work be non-sectarian and neutral, or shall it be a specified charity by itself, or operated in connection with churches or dispen- saries, or with the city physicians? Or shall it be a depart- ment of the organized charities which already exist in every state of the Union? No one can advise any special plan, but we can all urge communities to provide for the care for the sick poor in their homes, where the well members of the family may be taught a responsibility towards their own sick that they would not otherwise have. Not more than one-third of the cases usually helped can enter hospi- tals, and many do go who should not, for in these instances a home may be broken up and the responsibility that should be borne by the individual shifted to an institution. Many contend that the work comes very near being a luxury to the poor. If it is, then every asylum founded for charity is a luxury, and a luxury, too, that relieves the individual of any dependence upon his own exertions and has no results to show save that of pauperization. Before closing, just a word as to the woman detailed for such work as this. Only can she be successful when she has passed through a broad general training in the best nurses' schools that can be found. With this must be refinement and culture which give the courage and patience to overcome the overwhelming difficulties to be encoun- tered. Visiting Nurses in America 255 Armed with these weapons, she goes forth as no other philanthropic worker, with a profession so valuable and at once so practical that there is no mistaking the need she fills. For the past ten years it has been clearly shown "that the district visiting nurse work is the best means at the smallest cost of helping the conditions of the poor, sick or well." Hospitals do much good, but, after all, they ofifer but outside methods of education. It is by reaching the people in their own homes and teaching them to utilize and make the best of what they have that lasting good may be accomplished. To the following we are gratefully indebted for data and information pertaining to the subject of this paper : To the secretaries and superintendents of the various Visiting Nurse Societies and to the secretaries of the charity organ- izations in all parts of the country. For articles on the subject of district nursing you are referred to the following: The "Report of the Conference of Charities in 1894," Nursing Section ; paper by Edith S. Brent, Brooklyn, N. Y., on "District Nursing;" a pamphlet published by the Victorian Order of Nurses, by Lady Aberdeen on "District Nursing;" "The History of District Nursing," by Dr. A. Worcester, M. D. ; a small volume on "District Nursing" by William Rathbone, M. P. ; a work on "District Nursing" by Mrs. Dacre-Craven, and one by Miss Amy Hughes. The Victorian Order in Canada. CHARLOTTE MACLEOD, Chief Lady Superintendent Victorian Order of Nurses, Canada. The pioneers in district nursing- in Canada were the Sisters of Charity, who also led the way in hospital nursing. The well-known Sisters of Providence have been long engaged in this work, especially in the cities of the Province of Quebec. They go their rounds in pairs, taking with them whatever material is necessary for the services they may be called upon to perform, and they frequently remain hours, or even days, with patients who are too ill to be left in the care of inexperienced hands. Several of the hospitals also send their nurses out as district nurses, notably the Maternity and Western Hos- pitals in Montreal. The Winnepeg General Hospital has boarded and lodged one of its graduates for this purpose for the last three years. Nor has the field been left entirely to the hospitals and orders mentioned. Various philan- thropic societies have taken up the work of district nursing and are doing all in their power to thus lessen the sufferings of humanity. Perhaps the one of longest standing is the Nursing-at-Home Mission in Toronto, which began opera- tions about fourteen years ago in this lovely way : A nurse, who was taking a post-graduate course at the Children's Hospital in Toronto, was so impressed with the sad condition in which many of the children were brought to the hospital that she determined to see what could be done by carrying the skill and tenderness of a trained nurse into the homes of the poor. She therefore left the hospital, rented a room, and began work in the dis- 254 District Ntirsing in Canada 255 trict. Her example of devotion was soon followed by another nurse, and shortly afterwards this work came under the auspices of the Mission Union. Finally a home was provided where three women were taken in for training. The superintendent, who is herself a thoroughly qualified nurse, visits the patients with the probationers and gives them practical lessons at the bedside. Experience is also gained in a free dispensary with which the home has been connected for the last seven years. Courses of lectures too are given to the nurses by many of the physicians who employ their services. The period of probation is two years, after which time a diploma is granted. The rate of remuneration received by these nurses depends entirely upon the amount of charity support accorded the mission from year to year, the work itself being the first consid- eration. In the report for 1900 it was stated: "Gratuities to nurses (eight in number), four hundred and twenty-one dollars and twenty-five cents. In addition to the home being rent free, there is a city grant of two hundred and fifty dollars, but the remainder of the support is from voluntary subscriptions, no charge being made to the patients." Two sets of deaconesses, the Anglican and the Meth- odist, do district nursing also in the city of Toronto. Some of these women are admitted to Grace Hospital and West- ern Hospital for three-months' training, and afterwards, in connection with their course in church and Bible history, they go out in district nursing work during the remainder of their two years. In Montreal district nursing started in connection with a diet dispensary which was established in 1879, but it was not until six years later that the necessity for a visiting nurse became apparent to the managers of the institution. The success of this nurse's work was so marked that very soon an assistant was appointed. Neither of these women was trained, but the pioneer in the work served for thirteen years before her retirement. Early in the year 1897, the year of the celebration of 256 International Congress of Nurses our late beloved Queen's Diamond Jubilee, the women of Western or Newer Canada recommended that an organiza- tion be formed as a Jubilee ofTferin^ to her Majesty, which would provide nursing service in the more remote districts of the dominion. The Countess of Aberdeen, wife of the then Governor-General of Canada, responded in a most enthusiastic m.anner to this proposal. But to carry such a scheme to a successful issue in so varied and extensive a country as Canada proved to be a difficult task. When the project known as the Victorian Order of Nurses for Can- ada was finally launched, owing to the false rumors as to the aims of the order, it met with little or no favorable response from either doctors or nurses. Dr. Alfred Wor- cester, of Waltham, Mass., who was invited by the Countess of Aberdeen for this purpose, aided very materially in over- coming the prejudices of many by giving addresses in some, of the larger cities on district nursing, and by showing how the Victorian Order might be managed on more economical lines than were at first thought possible. Finally a fund was started and organization began. The constitution, by-laws, and regulations were drawn up and a royal charter procured. The royal charter authorized the formation of a Board of Governors which should have the management and control of the order and of its affairs, and it also appointed his Excellency the Governor-General of Canada as patron. Five members of the Board of Governors are selected / by the patron, and the others by the Canadian Medical i Association, by each Provincial Medical Association, and by each local association according to the amount of its \ yearly income. There is an Executive Council, made up- \ from the members of the board, whose numbers and powers ' are defined by the governors. The chief lady superintendent is appointed by the Board of Governors, and the most prominent among her duties are the organizing of new branches, recommending suitable district lady superintendents and nurses, overseeing District Nursing in Canada 257 their work, and reporting on the same. The order under- takes to teach district nursing. Only nurses holding diplomas from some recognized hospital training school and who come highly recom- mended are considered eligible for the course of training in district nursing. A period of four months' probation is given at the training home either at Montreal or Toronto to test the adaptability, tact, and previous training of these nurses. During that time they are provided with board, lodging, laundry, and an allowance of twenty dollars a month. At the expiration of this course the nurse, if she is desirous, and has proved herself acceptable, is recom- mended to the Board of Governors as a candidate for the order. She is then presented with her diploma and badge, either by his Excellency, the wife of the Governor-General, or by one of the governors, who admits her to tlie order in the following words: "By the authority of the Board of Governors, I have the honor of admitting you formally into the ranks of the Victorian Order of Nurses. You have been recommended to the Board of Governors by the chief lady superintendent as a nurse possessing the qualifications and training which our order requires, and have proved through your training in district nursing your efficiency in all your nursing work and your willingness to observe all the regulations of the order. We therefore welcome you very heartily to the order, and we enlist you for active service for two years. May you be enabled to carry into action the true spirit of the order, and may God's blessing rest upon you." The nurse thus admitted and pledged for two years' service in the order must be prepared to go anywhere in the dominion, either for district nursing or to serve in one of the cottage hospitals. She is provided with her outfit (uniform and nursing bag) and receives a salary of not less than three hundred dollars a year, with maintenance and laundry. She is also entitled to one month's holiday each year. Should she remain in the order for three or more years, she will have a miniature badge presented to her. 258 Internatioiial Congress of Nurses like the one worn by her during her term of service, with the dates of entrance and retirement engraved on it, as a souvenir of her work. The trustees of the Waltham Training School for Nurses at the inception of the Victorian Order of Nurses for Canada sent over their superintendent for three months, and afterwards released her from her duties at Waltham that she might accept permanently the position of chief lady superintendent of the order. She, with five nurses who had graduated at Waltham, and three from other schools, began work early in February of 1898. During the three months branches were established in four of the larger cities and four nurses were equipped and sent with the militia to the Yukon, where they performed most heroic services. The work of the order has slowly but steadily pro- gressed, and has been extended from coast to coast. Out of the twentv-six branches which have been established in a little over three years, twenty-four are carrying on the work successfully. In all there are fifty nurses engaged in the work. This year a greater efifort than ever is being made to provide suitable buildings for cottage hospitals. Her Excel- lency the Countess of Minto is doing much to create a spe- cial fund for this purpose. It will be known as the " Lady Minto Fund for Erecting Queen Victoria Cottage Hospi- tals'' in memory of our late beloved sovereign. Model plans have already been drawn for cottage hospitals to accommo- date either six or ten patients, two nurses and a maid. Since the inauguration of the order seven cottage hospitals have been established, and, although several of these buildings may be regarded as mere apologies for hospitals, most excellent work has been done within their walls. As an illustration of the assistance afforded by the order in estab- lishing cottage hospitals, which, after all, are really district nursing stations, the following account is given : In a small town in the Northwest Territories the women who are members of the National Council had put District Nursing in Canada 259 by a small sum of money towards a building fund for a hospital ; but as they met with no encouragement from the men of the town, they felt their project must be postponed indefinitely. Just then the Victorian Order came to their assistance and advised them to rent a cottage and make it habitable for patients. A nurse from the order was sent to take charge. Within a few months a request was made by the local committee for a second nurse. In the following year patients were refused admittance, owing to the over- crowded condition of the building. Enteric fever, maternity, surgical, and chronic cases have all been cared for there, and several major operations have been performed in the small room which the nurses occupy as their dining and sitting room. Great inconveniences have been overcome by these devoted nurses in their desire to serve these patients, who otherwise in many cases would have been left to take shelter in a third-rate boarding house with only such care as the slatternly servants might give them. However, the nurses have now been rewarded, having just moved into a fine brick building erected for this purpose. As the expense of keeping a stafif of four Victorian Order nurses in this little hospital would be too great, a training school consisting of four probationers under a highly qualified superintendent is now in progress. There are only twenty beds, but as the cases are varied, and a thoroughly well planned curriculum enforced during a term of three years, including three months of district nursing, there is no apprehension of their not being well fitted for district or cottage hospital nursing in the West. These Victorian Cottage Hospitals will be open to give a training in nursing to the Doukhobour, and to the educated Indian girl, that she may be of special service to her own people. Innumerable instances might be related of the blessing the Victorian Order nurse has been in the cottage hospital to the homeless sufTerer, in the humble room of the crowded tenement house during her daily visits in the city districts, or in the rural districts, where she may have to drive ten 260 International Congress of Nurses or fifteen miles and even canoe up a river in order to reach her patient. In the latter case the nurse may have to remain a few da3's if her services are not required in the village and the patient requires special care. One of the chief dif^culties has been an inadequate supply of good nurses. This is pioneer work, and it does not appeal to those who like a city life with its brightness and comfort, though it should be said that even in remote districts the Victorian Order nurse is not by any means forgotten or neglected. No nurse practicing her calling, even in most luxurious homes, can receive such honor and hearty gratitude as is accorded to our nurses amid their rude surroundings. In one of the most outlying districts, where every effort to procure suitable board and lodging for the nurse had failed, her committee had a small shack built and furnished for her use. The Victorian Order of Nurses for Canada needs women in it for country as well as for city districts, — women who are capable of performing the highest duty on earth, namely, in helping their fellow-beings back to health, also helping them to lead noble, clean, and wholesome lives, inwardly as well as outwardly. The Victorian Order, in common with the whole empire, mourns deeply the loss of her after whom it was named ; but the Queen's nurses will undoubtedly respond more quickly than ever to the inspiration of her life — as noble woman and as noble Oueen. The Nurses' Settlement. LILLIAN D. WALD, Founder of the Nurses' Settlement, New York ; Graduate of the New York Hospital. About eight years ago tenement house Hfe in its most pitiable aspect was presented to me. I had been giving a course of lessons in home nursing to a group of proletariats from the older world — people who find a renewal of hope in New York, if not realized for themselves, at least but deferred and as ardently felt for their children. One morning one of the women of the class was not present, and her little daughter came to ask me to call upon her mother as she was ill. Despite the experience in a large metropolitan hospital, and the subsequent knowledge gained through a year's residence in a reformatory and asylum for the waifs of New York, the exposure of that rear tenement on the lower East Side was a terrible shock, a shock that was at first benumbing — a picture had been presented of human creatures, moral, and in so far as their opportunities allowed them, decent members of society, living in rooms reached through a court that held open closets to be used by men and women, from some of which the doors had been torn away; up dirty steps into a sick room where there was no window, the one opening, leading into a small crowded room where husband, children and boarders were crowded together — impossible conditions under which to attempt to establish a home and bring up children. Upon further acquaintance with the house and neigh- borhood I learned that kindly attention from the outside 261 262 International Congress of Nurses had not been wholly absent. The visitor from a medical dispensary had called, and, touched by the poverty of the place, had sent a bottle of beef extract with directions for use printed upon it, but there was no one in the house who could read English. Other charitable persons had sent coal, but my nurse's instinct revolted at the knowledge that nobody had washed the woman, made her bed, t)r performed any of the offices that every human creature should feel entitled to in like condition. I will not take time now to describe all of the circum- stances and the responsibilities of the community, as they appeared to me, toward this one family ; to me personally it was a call to live near such conditions, to use what power an individual may possess as a citizen to help them and to give to all of my world, wherever it might be, such information as I could regarding conditions that seemed to be generally unknown. To a friend the plan was revealed : "Let us, two nurses, move into that neighborhood ; let us give our services as nurses, and let us contribute our sense of citizenship to what seems an alien group in a so-called democratic community." Having formulated some necessary details of the plan, we proceeded to look for suitable quarters, and in the search discovered the "Settlement." In the stress of hos- pital training, neither of us had learned that men and women, moved by some personal experience or by theo- retical training, had arrived at the same impulse to action and had established themselves in the crowded quarters of cities and called themselves ''Settlement Workers." The idea was identical with our own, and though many activities have grown from that idea, the fundamental prin- ciple remains — that people shall take up their residence in industrial communities, giving what they may have of public spirit, and, partaking of the life about them, preserv- ing their identity as individuals, and endeavoring to keep the settlement free from the institutional form of philan- thropic work. The Nurses' Settlement 263 For the first two months of our experiment we two nurses lived at the College Settlement. After that the top floor of a tenement house that gave reasonable comfort was our home for two years, and that was practically the beginning of the present association of workers known as the "Nurses' Settlement." The life possible through mak- ing our home among the people in a simple informal way led us easily and naturally into all the questions that afifected them. Through our visits to the children and our interest in their general welfare we learned of the unsatisfactory school conditions and of the absurdity of a compulsory school law when there was not adequate school accommodation for the children. Such knowledge as came to our notice, such effective protest as would illustrate the conditions of our neighborhood, was brought before a suitable public, indi- viduals or societies especially concerned, whenever occasion could be found or be made. The women on the lower floors in the tenement where we lived were employed in the needle trades, and unbearable treatment at the hands of a foreman had moved them and their fellow workers to agitate for trade organization. In the search for some one of their own sex who could speak for them in what they called "better English" they came to us, and that was our first introduction to the protest of the workers which is expressed in trades unionism. A semi-ofttcial recognition by the Board of Health gave us the privilege of inspection of the tenements, and valuable information was thus stored up on the housing problem. The experience thus gained had its share of influence in the general education of the public, which later led to the Tenement House Exhibit; to the appointment of a tenement house conimissioner under Governor Roose- velt, and the final creation of a separate department for the city of New York. One of the members of the settle- ment took active part in the movement and was one of the two women on the jury of awards for plans for mcKlel tene- ment houses. 264 International Congress of Nurses Through her efforts to obtain a legacy that had been bequeathed " for a fountain somewhere in the city," the Schiff fountain was erected in the neighborhood of the set- tlement and was the strong influence in having an adjacent site selected for a park and public playground, to make place for which no more congested and unsightly rookeries could have been demolished. The movement for public playgrounds is now well known. They have been valiently fought for, and their need wonderfully told by Mr. Jacob A. Riis, that best friend and most lovable fighter for the children of the poor. His efforts have been assisted by the Nurses' Settlement for years, according to our ability. To meet the rightful demand of the children for play, we conducted in our back yards one of the first playgrounds in the city. It was an experimental station in a way, as well as an enlightenment of the general public, and was instrumental in helping to develop public feeling in the matter. After a time the interests of the resi- dents of the settlement were directed to the "Outdoor Rec- reation League," share being taken in its executive work, and co-operation given to Mr. Charles B. Stover, the apostle for New York of outdoor play-places for the children of crowded districts. The workers of the settlement can look with gratification upon the increasing interest in public school matters affect- ing their neighborhood as in some part the result of their efforts to bring public attention to the lack of room for the children in the schools, and in other ways to bring the interests of their localities directly to the school boards. One of the household was for a time school inspector, but whether in ofHcial relationship or not, the members have been frequently consulted by those in authority on the Board of Education. I have passed over the steps of growth of the settle- ment, and to understand how it has attained its present status I should go back to that first beginning in the tene- ment, when it was apparent that not only were the nurses' services needed for the sick, but that likewise their friendly The Nurses' Settlement 265 offices were needed as interpreters for bringing to the proper sources the larger and more general matters that affected the life of the people they were in contact with. Mr. Jacob H. Schiff, who, from the very beginning, had made us feel his support, encouragement, and confi- dence, suggested the change from the tenement quarters to a house, arguing that a more permanent basis would be established for these personal services if it were made possi- ble for others to join us. The desire of others to co-operate with us had been for some time apparent, and therefore this most generous and public-spirited citizen's offer was accepted. A house near the tenements, once the property of the fashionable and well-to-do, who had inhabited Henry street half a century before, was purchased by him. Neces- sary changes were made in it, and almost immediately the house was filled with residents, and the nursing was extended. The clubs and social features of the house then began to assume organized form. The next year another house was given for the use of the settlement by a new member, Miss Helen McDowell, a lay-woman, who came into residence, fitted it up and contributed the means to carry it on, and who has taken charge of much of the social work among the young people. Not long after that, offers of money and suitable workers came to the settlement, and fresh opportunities to extend presented themselves. The needs of an uptown district having been urged, a house was selected there, purchased by Mrs. Butler Duncan for extension of the settlement, and workers placed in it who had served an apprenticeship in the down-town house. A little later also a part of a house in still another locality was given to the settlement by Mr. John Crosby Brown, father of one of the residents, who with the other members of that family has done much to strengthen the settlement, and several nurses are accom- modated there. Finally a dream of the nursing staff was realized in the gift from a young married woman, Mrs. Sylvan Bier, of 266 International Congress of Nurses a charming home in the coimtry, where, all the year round, and without restriction or conditions save those imposed by the circumstances of the patients, the convalescents and tired out people who need rest are entertained, and where, in the summer, many delightful outings for the young people are planned. From the needs of the neighborhood has sprung the service that we call the "First Aid Rooms" in three very crowded quarters. In each one a nurse is in attendance at certain hours of the day, and cases that require small dress- ings, fresh cuts, old w^ounds, simple eye cases, eczemas, etc., are treated. These are such nursing cases as might be attended to by the members of the families if the mothers had sufficient intelligence or sufficient leisure. Many of them are sent by the physicians of the large dispensaries who have not the confidence that the parents will apply oint- ments, dress wounds or syringe ears daily and in a cleanly way. These are often school children, and the nurse is thus able to care for a far greater number than would be possible if she went to them. This work has also a direct bearing on the school attendance of the children, and though many of the cases are not important from a medical point of view, they are of the utmost importance from the educational standpoint, as the children are sent home by the medical inspectors, and, not being allowed to re-enter while the trouble con- tinues, often miss much precious school time, for it must be remembered that few of these children can attend school after fourteen — at that age they all begin wage-earning. As an illustration, I knew of a lad of twelve years who had never been in school because of eczema of the scalp. True, the mother had gone to the dispensaries and obtained ointments, but the over driven, worn out woman said they did no good. Careful epilation, systematic disinfection and application of the medicament were so successful that when school opened in the fall I had the pleasure of placing the boy there for the first time in his life. The settlement, in co-operation with the New York The Nurses' Settlement 267 Kindergarten Association, maintains a kindergarten. The children, upon graduating from the kindergarten and enter- ing the public schools, are invited to come back as members of clubs. They are the youngest club members, and when the first one was called "The Alumnse Association of the Nurses' Settlement Kindergarten," the name seemed longer than some of the members. Probably the boys' clubs connected with the settlement hold the most intimate place. The first one organized, of which I have the honor of being a member, undertook the study of the lives of American heroes. We took the term "hero" broadly, and men or women who by fearless living had made the world a better place to live in were counted as such. Thus we had the biographies of those who had con- tributed as statesmen, soldiers, philanthropists and writers to the realization of the highest hopes of the country, and living members of the family under discussion often came to con- tribute personal reminiscences or family history. Since then, as this club matured, it has taken up the study of civil government and other similar study, and is but a type of what all the clubs are doing. Some of the girls' clubs combine study with the boys and young men, and inter- esting debates on important topics of the day are held in their meeting rooms. In the interests of a considerable number of boys not responsive to the more intellectual stimulus of study, rooms have been set apart for manual work, and with the co-opera- tion of the "Children's Aid Society," carpentry, wood carv- ing and basket work are carried on. The large dancing- school classes, gymnasium work, etc., are possible through the courtesy of this society. It gives us the privilege of using their large and roomy floors after school hours and in the evenings. Our dancing school has led us to the same conclusion that experience with young people anywhere would bring — that the desire to dance and to meet their kind socially is a wholesome and healthy one, and that it is a dangerous thing not to recognize and meet the want whole- somely, lest innocent desires be diverted wrongly. 268 International Congress of Nurses The dancing- classes are refined gatherings, properly chaperoned, and with no other restrictions than the ordinary ones of good manners. They are successful rivals to the public dances that are over or back of the saloons, and also provide opportunities for those young people whose careful parents would not allow them to go elsewhere. We have a penny provident bank, and habits of thrift are inculcated by making it easy to save the pennies. When the deposit reaches the sum of one dollar, an account may be opened in the savings bank in the locality. All of such work is not done by the nurses, for beside our valued lay members, who share in the social and educa- tional work, a large stafif of non-residents takes part in the classes and clubs. The kindergarten teachers are, of course, trained for that purpose. Leaders for clubs and teachers for the vari- ous classes are recruited from the outside, and among them are distinguished lecturers who find their students respon- sive and their audiences sympathetic. Musicales, private theatricals, and the varied undertakings that bring gayety and zest into the social life are successful with us. We are fond of saying that next to nursing typhoid fever we love to give a ball. Our nursing work is the "raison d'etre" of our exist- ence, from which all our other activities have had their natural and unforced growth, but the papers at this confer- ence have dwelt upon the detail and method of district nursing, and our methods do not differ sufificiently to war- rant my taking- up time and space to enlarge upon it. We conceive the underlying thought of the district nurse to be that of neighborliness, and plan to have each nurse work in a small district in close touch with the settlement house that she belongs to, that recourse may be had to it in emer- gency as quickly as possible. We hope that the nurse with her knowledge of hygiene and sanitation and the care of the body in health and illness will be an educator, and we lay much stress upon this, that she should not have too large a district or too many patients The Nurses' Settlement 269- to look after. We believe that the nurse should have time to give the bath, and, if necessary, to make the second or even the third visit in the day, and not be adviser and instructor only; not forgetting- her charity organization tenets of the dangers of doing for people what they ought to do for themselves, yet holding to the ideals of the nurse in her work. With this in mind, though we do not undertake night nursing as a rule, yet we would have a night nurse obtained through a registry if, in our opinion, this was the only thing to be done for the patient. We also send women to scrub and clean in the homes that the nurses go to, if there is no one who should rightfully perform these services, as we consider it a part of good nursing to have the rooms kept clean. The various needs of the patient are kept vividly in mind. From what we call the settlement point of view we believe that the patients should know their nurse as a social being rather than as an official visitor, and that all legitimate relationships which may follow from her introduction as a nurse shall be allowed to take place. It is good from this point of view that the patient should know the home of the nurse, and that the nurse should be intelligent about the housing conditions, the educational provisions, and the social life of the neighbor- hood in which she works and lives. From this motive has come the opportunity for the settlement to show where the neighborhood has been neglected, and to bring into communication the different elements of society that go to make up a great city. We think and feel sincerely that the relationship is reciprocal, that we are partaking of the larger life, that society has in general closed the avenues that lead to this knowledge, and that the different elements of society need each other. The well-meaning employer needs his interpreter and the people of such neighborhoods as our own should have their point of view considered and given dignified place in the councils of the public-spirited. This is the ideal of democracy, the 270 International Congress of Nurses best " spirit of the times," and in its accomplishment we have responsibihty and privilege — our share in speeding the realization of the unity of society, the brotherhood of man. The numerical record of work of the settlement for one year was : Nursing work — 3,991 patients in their homes ; 26,600 visits to their homes; 12,694 cases treated in (three) first aid rooms ; 225 convalescents entertained in the country house. Social work — Thirty-five clubs, from kindergarten age, to clubs of married women ; classes in dancing school ; four classes singing school, private theatricals, concerts, gym- nasium, fresh air work. Educational work — Kindergarten, reference library, sewing, crocheting, etc. ; basketry, carpentry, carving, housekeeping (including cooking, laundry, etc.) ; home nursing ; classes in civics, municipal and national govern- ment, history, literature, current topics, with papers and debates. [Between the dates of reading this paper and its publi- cation the settlement has been extended in the following ways : Under the special supervision of Miss Mabel Kit- tridge an apartment in an ordinary tenement has been rented and suitably furnished with such accommodations as the people may have in their homes. Here all the lessons are given in house cleaning, home-making, laundry and domestic science in general. These rooms, attractive in their simple inexpensive furnishings, make also a whole- some resort for the members of the classes. A large house, at 299 Henry street, had been pur- chased by the late Mr. Leonard Lewisohn for the use of the settlement, and the members of his family continue his generous relationship to the work. One of the houses formerly used for residents and for the kindergarten is by The Nurses' Settlement 271 this provision freed for the use of the young men and women who are members of the senior clubs. A house overhanging- the Hudson river-bank has been built for the children's and young girls' use during summer vacation time, and plans are under consideration for a better equipped convalescents' home. A camp for the boys at one of the outlying parks has been made possible through a friend of the boys and the granting of a site by the Park Commissioner. The nurs- ing staff has been enlarged by the College and University Settlements, each having a nurse in residence who is responsible for the calls in her vicinity.] Note. — As the work of the settlement lias become known among nurses, two similar groups have been established; one in Orange, N. J., and the other in Richmond, Va. Both are centers of district nursing and social work and of an interest in civic improvement which gives them much influence. — [Ed.] The School Nurse. HONNOR MORTEN, Member of the London School Board. There is no daily medical inspection of primary schools in England, though the spread of both major and minor infections amongst school children is fully recognized. So, while the state and municipal authorities are deciding what they shall do with regard to arresting this spread of disease, private individuals have been sending nurses to some of the schools in London, Liverpool, and elsewhere and doing the work quietly as a charity. It was on this line that the Lon- don School Nurses' Society was founded in 1898 with the vice-chairman of the London School Board as its chairman of committee. The staff of nurses has always been small, never more than five, though the elementary schools of London numbers over 500, and the nurses have only been able to visit the very poorest schools and touch the mere finger of the evil. But they are getting a slow recognition by the authorities, a rapid regard from scholars, teachers and parents. On February 27, 1900, the following notice appeared in the School Board of The London Gazette : " The School Management Committee give their con- sent to a nurse from the London School Nurses' Society attending each morning for one hour and a half to dress the eyes and sores of the children in those schools where the divisional members consider it desirable, and make 'the necessary arrangements, provided that the board shall not be liable for any of the cost thereof ; and in any case where 272 The School Nurse 275 a school is visited by a nurse of the society the board pro- vide a basin and kettle for the use of a nurse at a cost of 3s. for the two articles." Her Majesty's Inspector, in his report of April 19, 1900, on Laxon Street School, says : " The visits of a nurse to this very large infants' school have proved most beneficial to the health of the children, so much so that it could be wished that the School Board might make such visits uni- versal in their schools in poor localities." Then in June of this year (1900) the School Board cautiously appointed one nurse of its own as an experiment, especially to deal with a virulent form of ringworm that is very prevalent. This nurse is not now at work, but the fact remains that for the first time the public school authority in England has made such an appointment. The work done by the voluntary nurses consists in weekly or, if necessary, daily visitation of the schools, seeing the children sent to her by the teachers, dressing small sores, cleaning dirty heads, and bathing sore eyes. Where neces- sary the teacher is advised to exclude a child, or a bad case is followed to its home, or the mother sent for to be seen at the school. It is found that pediculi and mild ophthalmia form the large majority of the cases ; in some girls' schools as many as 90 per cent, of the scholars were found to be suffering from pediculi. After six months' regular visiting these " head and eye chronics " become cured and a higher standard of cleanliness reigns in the school and the nurse's visits are less frequent and often very brief. The ideal would be for some six school nurses in a district to visit daily, under a doctor, reporting to him where major infections — such as diphtheria — were found and medical help wanted, while they attended to the enormous number of cases of minor infections. Towards such an ideal we are slowly but surely tending and then the School Nurses' Society will gladly dissolve and hand over its charitable voluntary work into the hands of the school authorities. 274 International Congress of Nurses DISCUSSION. i\Hss Mclsaac : I like to tell of the Crerar Fund of Chicago on every opportunity, that possibly the idea may be taken up by others. Several years ago a philanthropist of Chicago, Mr. John Crerar, left $50,000 to the Illinois Training School. Tlie women managers of the school decided that as this money was not actually needed for the support of the school, it should be devoted to providing trained nurses for the middle classes. The income of the fund is used in the following man- ner: The nurse receives $20 per week for her services, $25 being the average rate for private duty in Chicago. The patient pays from $7 to $10 a week for the nurse's services, according to his income. These receipts are added to the yearly income from the fund. We send nurses only within the city limits, and only to acute cases, and maternity cases. There is no work in Chicago more appre- ciated or that has done more good than this, which we call the " Crerar Nursing." I have repeatedly heard nurses say that if they had money to give to anything it should be to the Crerar Fund. Miss Walker: I would like to thank Miss Wald for the suggestion that in district nursing we not only help the people but that the people help us. There was so much to me in those few words that I think she ought to be thanked for them. Question : As to the nurses of the Victorian order ; do they work entirely as visiting nurses or do they ever stay with the patient? Miss Macleod : They work as visiting nurses as a rule ; but in the rural districts they sometimes stay with a patient for several days. Unannounced : W"e find that our poor patients are often able to pay ten or twenty-five cents a visit, and that The School Nurse 275 they prefer doing so. While we do much free work we are always glad to encourage this feeling of independence. Unannounced : I think nurses as inspectors of schools would do better work than the doctors, for the doctor does not treat the school child. He simply sends it home. We are trained to recognize symptoms, although we are not to make diagnoses. But the nurse can take the child to a dispensary or show the mother what to do, and thus have a more practical influence on lessening the spread of con- tagion. [The complete system would undoubtedly be for the doctor and nurse to work together in school inspection — the doctor to examine and give directions, the nurse to visit the mothers, instruct them, and apply dressings and treat- ment. — Ed.] The President : It is a matter of constant regret that we have so little time for discussion. The time has now come for us to adjourn. FRIDAY AFTERNOON. 2.00 P. M. The President : If there are any resolutions to come from the body of the house the chair would request that they be sent up at once in writing. Our next paper is on an entirely new subject. I have the very great pleasure of introducing Mrs. Kinney, who is at the head of the United States Army Nursing Corps. Army Nursing. DITA H. KINNEY, Superintendent Army Nurse Corps, D. S. A. The origin and subsequent history of army nursing is so well known that in view of the limited time alloted for the presentation of the subject such a retrospect may be omitted. No occasion, however, should be allowed to pass unnoticed which offers an opportunity for a tribute to her who is the professional mother of us all, or to him to whom the United States Army Nurse Corps owes its existence. Just as soldiers, be they officers or privates, salute in passing their superiors, do we army nurses metaphorically rise to our feet and stand at attention as we recall for a moment 276 Army Nursing 27'Z_ all that we owe to the wisdom and philanthropy of this man and this woman — Florence Nightingale, the first army nurs^. ; George M. Sternberg, Surgeon-General United States Army; We salute you. Ever since the days of the Revolution, Congress has from time to time authorized the employment of women in army hospitals. An act dated July 27, 1775, provides for a matron " to superintend the nurses, [query — were these too women?] the bedding, etc." A similar act, April 7, 1777, provides for a matron " who shall take care that the provisions are properly prepared, that the utensils are kept in order, and that the utmost economy be observed in her department." In 1814 provision was made for female attendants known as " matrons." At the present day one of these is allowed at each post, but she is simply and solely a laun- dress, and never by any chance has anything to do with the care of the sick. The incidents of the war of the Crimea demonstrated to the medical department of the English army the value of female nurses in army hospitals, and since that time they have formed a part of the military establishment of that country. The Lancet in its issue of April 27, 1901, says: "Without skilled female nurses, the proper care of the sick cannot be accomplished, and it will probably be necessary, even under ordinary conditions, to increase the existing establishment. It will certainly be so in the event of war on any large scale." There is in England a finely organized school where graduate nurses who desire to enter the army must take a course before being permanently assigned to that work. English army nurses have in addition to their pay an allow- ance for clothing and servant hire, and after retirement are pensioned. 278 International Congress of Nurses In France and Germany, by arrangement with certain religious and secular nursing orders, a limited number of women are employed to care for the sick of the respective armies in time of peace, with a provision for a suitable increase in event of war, but neither country has an organized nursing service such as exists in our own land and in Great Britain. Previous to the year 1887 the nursing of the sick of the United States Army was done by soldiers specially detailed for that duty. They were selected with no special regard for their qualifications, and were entitled to twenty cents extra duty pay, as this sum was called. Eventually this was discontinued, and in that same year Congress authorized the establishing of a body of well-qualified men who should be permanently attached to the hospital in the various capacities demanded by such service. The authority thus given resulted in the organization of the hospital corps as it now stands. Up to the time of the Spanish-American war, the navy had no such body. Today its hospital corps is a vigorous organization, giving large promise of efficiency and offering special inducements to young men for advancement. Its highest rank is not open to civilians, but is to be filled by promotions from the lower grades. These pharmacists, as they are called, are not enlisted men, but '* warrant officers." Their positions are tenable up to the retiring age, after which they receive a pension and such other benefits as belong to their rank. During the happy and uneventful period in our coun- try's history between 1887 and the Spanish-American war, the hospital corps proved itself amply sufficient for the care of the sick of a small army of twenty-five thousand men. At this time the corps numbered about six hundred, and after the addition of what was deemed a sufficient number to meet the emergency, it was thought to be unlikely that the services of female nurses would be required. It took but a short time, however, to make evident the great desirability of skilled women over the raw material Army Nursing 27^ which had been recently added to the corps, and at the request of the Surgeon-General of the Army Congress, in April, 1898, authorized the employment of female nurses. Even before the call to arms had sounded through our land hundreds of patriotic women, trained and untrained, had offered their services as nurses in the event of war. The tremendous rush of work thrown upon the War Depart- ment made it impossible to investigate the qualifications of these, and so all such communications had, with the courtesy which distinguishes all official procedure, been replied to, filed, and buried. The genius of Dr. Anita Newcomb McGee at this point saw the opportunity and seized it. She formulated a plan whereby the Society of the Daughters of the American Revolution were to become an Examining Board for all nurses who wished to enter the service of the government. The Daughters promised their hearty cooperation, and she at once called upon the Surgeons-General of the Army and Navy, and submitted her project for their approval, with the result that they gladly availed themselves of the proffered services. What followed — her achievements — her untiring devo- tion to the work — is too w-ell known to need more than passing mention. It may, however, be stated that she took in bulk from the War Department all the accumulated appli- cations, and so far as was possible investigated the references and qualifications of each one, and from these made a list of those who could be available at a moment's notice. Neither she nor they had long to wait. It may be both interesting and profitable just here to pause for a moment to compare conditions at this time with those which existed at the outbreak of the Civil War. We find that trained nursing as we know it today had no exist- ence then, and though Congress in August, 1861. authorized the employment of women as nurses, these were chosen more on account of their matronly age and manners than because of any special qualification for their work. Miss Dorothea Lynde Dix held the position of superintendent of 280 International Congress of Nurses these nurses, althoug-h that appointment carried with it no definite official status. Indeed, a notable proportion of the nursing during the Civil War was done by women who were never officially appointed or paid. On May 10 (nineteen days after the formal declaration of war) the Surgeon-General of the Army ordered four nurses to Key West, Fla., and by July 15 forty-seven nurses had entered into contract with the government and had been assigned to different general hospitals. About this time an epidemic of yellow fever offered an opportunity for the employment of immune nurses. The Surgeon-General detailed Mrs. Curtis, the wife of the super- intendent of the Freedman's Hospital of Washington, D. C, to go South to secure these. No distinction of color or sex was made, and most of those selected were untrained. Following close upon this epidemic of yellow fever came one of typhoid in the large camp hospitals where the recruits were in training, and Dr. McGee thus describes the existing conditions at that time : " It became evident that these camp hospitals had lost their transitory character and become stationary, consequently the objection to the employment of women as nurses in them had practically ceased, and the demand for trained female nurses grew to an entirely unexpected proportion." The roll of army nurses numbered at this time about one thousand names. Not only did they go to general and field hospitals, but wherever the surgeon in charge of a division or post hospital so requested nurses were assigned to duty under him. During the fall it was not uncommon for regiments or larger divisions of troops, when they moved to southern camps or to Cuba, to take with them the nurses attached to their hospitals, and no inconvenience or diffi- culty has been reported as having ensued. It is needless to refer to the great value of the work done by these trained assistants to the medical department of the army, since surgeons, patients, and the public at large have been most enthusiastic in their expressions of appre- ciation. There was scarcely a training school in the United Army Nursing 281 States which did not send some of its best representatives for this work, and the women adapted themselves to camp conditions in a manner which quite altered many a precon- ceived opinion. The Sisters of Charity merit prominent mention in this connection, as they furnished from their order two hundred sisters, many of whom had had a large hospital experience. A few of the sisters from four other Roman Catholic orders and from one Protestant Episcopal sisterhood served for a time. Auxiliary No. 3 to the American National Red Cross Society Relief Committee of New York was unique in the work of furnishing money for the transportation of many nurses, also for their comfort while awaiting orders in New York and while serving at certain army hospitals. There was much difficulty in the time of the greatest stress in securing enough suitable applicants to meet the demands. At some of the more important points the chief surgeons were authorized to secure help without regard to training, and thus a few undesirable appointees were enrolled. Temporary assistance was also accepted from women not connected with the medical department. Such irregular nurses were not subject to the same control and discipline as those on regular duty, and here again was an opening through which some who proved to be undesirable gained admission to the corps. The beginning of the year 1899 found the work of sub- stituting trained for untrained immune nurses well begun. From this point the evolution of the Army Nurse Corps, from an experiment to an effective working organization, was a matter of steady and uninterrupted development, and while it is at the present time on a comparatively satisfactory basis there are yet many points which must be readjusted before it can be said to have attained to its greatest possibili- ties. It must also be remembered that there is naturally a wide divergence of opinion as to what is really to be desired for it — between the point of view of the lawmakers on the one hand and others most deeply interested on the other. 282 International Congress of Nurses When Section 19 of the Army Reorganization Bill was first drawn up, though its details were most carefully con- sidered, the most vitally important was to secure for it a place upon the statute ; the finer work of fitting and adjust- ing it to meet existing conditions could well be left for the future. With the signing of the bill by the President (February 2, 1901), this great achievement was accom- plished, and the Nurse Corps became a part of the medical department of the United States Army. While this new dignity involves the corps in some temporary complications, it will eventually result to its great advantage. The new law inaugurated some important changes, i. e. : 1. The Judge Advocate General has recently rendered a decision that the members of the Nurse Corps must be regarded as a component part of the army of the United States, and he adds: "There is considerable ground for belief that they are subject to the articles of war and are triable by courts-martial." 2. Provision was made for the appointment of a trained nurse as superintendent, who under the Surgeon- General should have charge of the administrative work of the corps. Mrs. Dita H. Kinney was appointed by the Secretary of War to fill this position March 15, 1901. 3. The nurses were no longer under contract, but were appointed by the Surgeon-General with the approval of the Secretary of War. 4. Their pay passed from the medical to the pay department of the arm3^ The important work of drafting the new regulations has been a matter of many months. As these stand, pro- vision is made for certain examinations to test the mental, moral, physical, and professional qualifications of each applicant. And just here I beg to make a most heartfelt and sincere acknowledgment to the superintendents of the various training schools for their valuable and valued assist- ance in this regard. Had it not been for this cooperation it is not too much to say that the most important and difficult work of selecting suitable and proper nurses from Army Nursing 283 among the large number of applicants could not have been accomplished. Each of these has been and is today accepted or rejected in accordance with the recommendation of the superintendent of nurses under whom she was trained. After appointment a nurse is required to give a term of service of at least four months in the United States before being assigned to foreign duty. The term of service has been increased from one year to three, the tour of foreign duty from one year to two. The records of the corps are most accurate and com- plete. Those referring to the efficiency of the nurses with their papers of application and recommendation are filed in the office of the corps. Other documents which bear upon their places of service, change of status, and official orders are carded and filed with other official papers in the record room of the Surgeon-General's office, where they are easily accessible when needed. Efficiency reports are prepared quarterly by each chief nurse and forwarded by the commanding officer of each hospital, who endorses thereon his approval or disapproval of the ratings. In the same way (by endorsement) he reports upon the efficiency of the chief nurse. Special efficiency reports are required whenever a nurse changes her station or upon her discharge from the service. In all cases the text of these reports, by whom made, with the dates of leaves, illness, payments, and all other data con- cerning each nurse, are noted upon a card and alphabetically filed. By this arrangement it is possible to have at a moment's notice all information connected with every case. Monthly returns are prepared by the commanding officer. On these appear all changes, i. e., gains or losses by transfer, with the date of the last payment of each nurse. All papers are forwarded through the chief surgeon of the division or department, and endorsed by him as approved or otherwise. During the present year the medical department has deemed it advisable to abandon the use of the Red Cross, and has adopted in place of it the cross of the department in its own color,— i. e., green. The white brassard worn 284 International Congress of Nurses by the privates of the hospital corps is replaced by this, and the badge of the Army Nurse Corps will hereafter be in green instead of red enamel. The red Greek cross on a white field will still be used on hospital flags, hospital ships, and ambulances authorized and required by the Geneva treaty. There have been approximately eight thousand applica- tions since the first one was made to the War Department. Of these sixteen hundred and eighty have been employed by the government. The largest number serving at any one time was twelve hundred in September, 1898. The number of nurses on duty at the present time is somewhat less than at this time last year. In 1900 there were two hundred and ten against one hundred and seventy- six in 1901. Twenty-eight appointments were made in the latter year. Of these thirteen had given previous satisfac- tory service, fifteen were new. Sixty-two have been dis- charged ; of these ten are doing private work in the Philippines, one has accepted a teacher's position in the same place, four have requested discharge to be married. The rest have left the service for various reasons, such as long term of service, family conditions, and impaired health. There have been but fifteen deaths among the members of the corps since the beginning of the Spanish-American war. Most of these were from typhoid fever and some from ■disabilities which existed . before the nurse entered the service. On September 1, the distribution of nurses was as follows : United States — San Francisco, thirty-six ; Fort Bayard, nine ; Cuba, six ; Philippines, ninety-three ; trans- ports, eleven; awaiting discharge, seven. Under ordinary conditions the Surgeon-General does not approve the placing of nurses at small post hospitals, chiefiy because of the difficulty of securing suitable accom- modations for them. A commanding officer is at liberty, however, to request the temporary assignment of female nurses in any emergency. Under this provision nurses were recently sent to Fort Sam Houston, Texas, and to Eenicia Barracks, California. Army Nursing ^85 For a time there were nurses in both China and Japan, but the need for hospitals in those places no longer exists, and they have been closed. The employment of nurses in the schools of instruction • for the hospital corps has been a most gratifying success. Beginning as dietists, their work was at first confined to teaching the preparation of food for the sick and the adap- tation of the rather unpromising " ration " to this use. In some places the work has been extended to include a course in general nursing, bed-making, the changing of bed and body-clothing of a patient in bed, the preparation of the ordinary antiseptics and disinfectants, with a glimpse into the germ theory and the rigorous requirements of aseptic surgery. These subjects are fully and most carefully covered by the lectures of the doctors in charge, the practical demon- strations being given by these nurse teachers. The question of the rank of the nurses is an interesting one, but by no means of as great importance as may at first appear. One who is a lady will never be denied that which belongs to a lady and what is due her as such. Indeed, if all nurses had always been ladies and had always conducted themselves as such, the question would never have been brought up at all ! This is only one more exemplification of the truth so often observed, that the many must often sufifer for the mistakes of the few. It is a noteworthy fact, how- ever, that in the examinations of candidates for admission to the nursing service of the English army one of the ques- tions asked of a referee is, " Has the applicant the birth, breeding, and, education to make her an acceptable member of a profession which is made up of ladies?" The regard in which our English army nurse sisters are held was finely exemplified by the attentions paid a party of American nurses at Malta. The transport on which they were on duty was temporarily detained in that harbor. During this time, a ball was given by the English officers and their wives to which the officers on board ship and the nurses were invited. Nothing could have exceeded the charming cordiality and hospitality of this occasion. I am sure the 286 International Congress of Nurses solution of this whole matter, as well as of many others of far greater importance, lies in the hands of the nurses them- selves. As they sow, so shall they reap. If they have this fact ever before their minds, it must only be a question of time when they will be unquestioningly accorded the position which cultivation and good breeding may always claim, and to which as members of a high and noble pro- fession they are entitled. But there is yet another aspect to the situation which must not be forgotten. The Nurse Corps is yet in its infancy, and the present nurses are in reality pioneers in the work. They must decide whether as such they are willing to put up with temporarily unpleasant things for the sake of the work itself and for the sake of those who will follow and reap the rewards of their forbearance. Few of those whose feet are breaking new paths find the walking pleasant or easy, and the recognition of such service is more often delayed than promptly accorded. But the " patient waiter is no loser," and the reward will surely come to the Army Nurse Corps even if those who made sacrifices are no longer members of it. A recommendation looking towards an amelioration of many misatisfactor)^ conditions is now before the Surgeon- General, who never turns a deaf ear where the interests of his nurses are concerned. Besides these open questions we dream of the time 1. When there shall be a regularly established post- graduate course for army nurses, such as now exists at Netley, England. 2. When frequent visits of inspection of the nursing service will be possible, thus keeping headquarters in close touch with the nursing staff of each and every hospital. 3. When the Quartermaster's Department will carry the materials for the nurses' uniforms, so that these may be tmiform in fact as well as in name. And, best of all, 4. When^ after faithful service, old and otherwise inca- pacitated nurses will be " retired " with suitable provision for their declining years. This is not too much, we think, Army Nursing 287 to ask of the country to whose service they have given them- selves, their work, and their Hves. Perhaps the most important detail connected with the administration of the Nurse Corps remains yet to be men- tioned. I refer to the reserve list. Only those who have given at least six months of entirely satisfactory service are eligible for a place on this roll of honor. When a nurse is offered a place on this list she is allowed to indicate whether she is willing to re-enter the service at any time when she may be needed, or only in case of war or national calamity. A nurse is dropped from the reserve on attaining the age of forty-five, or if she ceases to practice her profession for a continuous period of five years, or for cause : though in the latter case she is always given a hearing. A place on this list is the highest distinction an army nurse can achieve, and we look forward to the time when to know a nurse is an " army reserve " will be considered a sufficient recommendation without further endorsement. The objections which were at first offered to the admis- sion of women as nurses in army hospitals have been gradually overcome. They have been found to meet priva- tion cheerfully, and to adapt themselves readily to the vary- ing conditions incident to army service, particularly in new fields. In a report to the Surgeon-General a chief-surgeon says : " The female nurses have done excellent service here. Their influence on both the sick and the well has been a good one, and they have, as a rule, been discreet in conduct, amenable to discipline, and possessed of professional attain- ments of a high order." On the other hand it is most gratifying to note the unmistakable evidences given by the nurses of their love for and their deep interest in their work. One who was a veritable pioneer writes : " It is very hard for me to see the others starting for foreign duty and be obliged to stay behind. But I know I have had more interesting work than any who go now can ever have. I can never forget some of my army hospital experiences. The memory of the old 288 International Congress of Nurses dirty wards, with their filthy corners and the half-fed patients, will always remain with me. When I think that it has been my privilege to lend a hand in improving- all this, I feel very sure that there is no profession on earth which so fully repays all labors as our own. Then too a woman's influence means so much in the strange foreign lands — it may be for good, or it may be for evil. Do let us try to send nothing but the best." And so she goes on through a long letter. That there have been a few in the corps whose influence has not been for all that was highest and best we recall with all humilia- tion and regret, because there is no getting away from the fact that the disgrace of one of our members is the disgrace of all. All things considered, however, it seems little less than miraculous that such records have been so exceptional. As a profession we have good reason to be proud of the achievements of the Army Nurse Corps as a body, and of the work of its members as individuals. I beg in closing to bespeak for it in future the interest and the cooperation of all trained nurses. Its work con- cerns deeply every training school in the country, and its efficiency and fair name must in the very nature of things be a source of solicitude, just as its successes must be a matter of pride to every individual representative of these. And, finally, all will agree that the very best service which her loyal daughters can furnish is not too much for us, as a profession, to place at the disposal of our beloved country. The Establishment of Schools for Nurses in Cuba. M. EUGENIE HIBBARD, Member of the American Society of Superintendents of Training Schools for Nurses, and Superintendent of the Santa Isabel Hospital, Matanzas, Cuba. With the United States mihtary occupation of the island of Cuba, a countr}' so crossed and barred by events in its previous history, began a new regime, difificult for the people of tropical climes to appreciate, and possibly more difficult for them to imitate and sustain. The conditions were such in 1898 that vigorous efforts were imperative to make the island habitable for those who were forced or chose to remain in Cuba, aside from the population whose heritage it is. At once energetic minds set to work to evolve order out of chaos, and enforce a sanitary administration that would eventually and effectually relieve the country of filth, disease and the dread scourge yellow fever, which limited the ingress of foreigners, enforcing quarantine laws extremely trying to travelers and proving a serious menace to the business interests and development of the island. It was also essential to arouse the inhabitants from their apathy to a sense of their personal national responsibilities, substituting the practical for the sentimental in actual work, which only could be accomplished by enlisting them as co-workers with those whose knowledge had been secured through experience, and to whom today the greatest credit should be generously given for the excellent results. 289 '200 International Congress of Ahirses -According- to the latest record, Havana, the city of the island, has only one rival in the United States, in producing a lower death rate. In Cuba, as in most countries that have been dominated by strong religious views and where the government has been practically led b}- the Church, a condition existed that prevented women from taking an active part in philan- thropic work, outside the religious orders of Sisters of Charity or members of the various communities recognized by the Church. These Sisters, among whom there are always some excellent women, had charge of the nursing and domestic departments to the various state institutions, such as hospitals, orphan asylums and asylums for the poor and destitute, and were considered the legitimate persons to carry on such work. Unfortunately their vows restricted them in the per- formance of duties that are considered an important essential in the care of hospital patients, and which duties were delegated to persons of inferior position and ability to perform. The strides that the medical profession has made in the line of progress during the last twenty-five years has demanded an evolution in the ranks of the so-called nurse, and in countries where the religious orders do not rule the graduate nurse is the result. A similar one we hope shortly to produce here — edu- cated and trained on lines that will command the respect of the older sisters in the service of nursing. As inheritors of customs and prejudices, founded on Moorish habits, we find the women of Cuba an affectionate, emotional and irresponsible people, without much moral, mental or physical force, incapable of sustained effort, and most to be deplored, without ideals or standards that excel, but with an innate sense of refinement and a disposition to be led through their affections which is most gratifying if properly directed. The lack of education among the larger class of women Schools for Nurses in Cuba 291 in the ordinary brandies, or even the rudiments of Spanish. is an obstacle which is difficult to overcome or overlook. Out of this material (with the optimistic view predomi- nating) we hope to evolve the traditional calm, self-poised, intelligent, industrious and ambitious graduate nurse of the twentieth century. Therefore upon whosoever the duty falls of introducing new ways, imperceptibly though radically changing social customs, facing the traditions of the country, and to a cer- tain extent the opposition of the Church, an exquisite tact is required, which should be controlled by common sense, good judgment and a strong desire, for the moment, to work in harmony with existing conditions, with the end in view of creating a picture of life and its possibilities, for women, that will both entice and charm, and be a factor strong enough to overcome scruples that at present prevent women of education and refinement from taking an active part in a life savoring of publicity. With the passing of the religious to the secular regime, and the subsequent v\athdrawal of the "Sisters'' from the various hospitals, the establishment of schools for nurses became an absolute necessity to provide for the inmiediate care of the sick. The first school for nurses in Cuba was started by Dr. Raimundo Menocal in connection with the Sanitarium " Havana." in the city of Havana. It was opened in January. 1899. with twenty-two pupils, under the charge and theoretical instruction of Dr. \'idal Sotolongo. The sanitarium was closed in the month of May, the same year. The permanent establishment of the schools for nurses, however, is due to the interest and influence of Dr. C. L. Furbush and General Ludlow, assisted ably by Drs. Emilano Nuney and Raimundo Menocal. The first school for nurses was officially established and opened August. 1899. :\Iiss Mary O'Donnell, graduate of Bellevue Hospital. New York City, was appointed superintendent. Later, and under the direction of Major E. St. j. Greble, Superintendent of the Department of Charities 292 International Congress of Nurses (which is under the general supervision of the Department of State and Government), schools for nurses were estab- lished in connection with the following- hospitals named in chronological order: Hospital Civil, Cienfuegos, March, 1900; Aliss Jeanette Byers, superintendent. Hospital No. 1, Havana, September, 1900; Miss Ger- trude W. Moore, superintendent. Hospital Santa Isabel, Matanzas, October, 1900; Miss M. E. Hibbard, superintendent. Hospital General, Puerto Principe, November, 1900; Miss Mitchell, superintendent. Hospital General, Remedios, November, 1900 ; Miss Samson, superintendent. Hospital Civil, Santiago de Cuba, January, 1901; Miss G. W. Moore, superintendent. Making a total of seven. Changes have taken place in the supervision of some of the schools, but the names given were the first superintendents appointed. On the retirement of Major E. St. J. Greble from the position of Superintendent of the Department of Charities, Major J. R. Kean received the appointment and the subse- quent success of the schools is due largely to his personal interest and keen appreciation of the actual requirements at this stage of the schools' existence. Shortly after assuming office, in July, 1901, the following order was issued : Office Superintendent Dept. Charities. Circular No. 14. Havana, Cuba, July i6, igoi. By authority of the Military Governor, a Board will be convened to meet in the office of the Superintendent of Charities, Havana, Cuba, at twelve o'clock, July 22, 1901, or as soon thereafter as practicable, to draw up a system of regulations for the Training Schools for Nurses in Cuba. They will also fix the course and duration of instruction, the Schools for Nurses in Cuba 293 requirements for admission, the standard to be required be- fore graduation, and make recommendations with regard to salaries and allowances. The Board will also recommend a suitable manual for use in the nurses' schools and in the hospitals under state control. The Board will be composed as follows : Dr. Manuel Demn, Vice-President of the Central Board of Charities, of Cuba, Havana. Dr. Emeliano Nufio, Medico-Director of Mercedes Hospital, Havana. Dr. Enrique Diago, Medico-Director, Hospital No. 1, Havana. Airs. L. W. Quintard, Inspector, Department of Chari- ties. Miss M, Eugenie flibbard, Superintendente, " Escuela de Enfermeras," Matanzas. The Superintendent of Charities will issue the necessary transportation. J. R. Kean, ]\Iajor and Surgeon, U. S. Army, Superintendent Depart- ment of Charities. The meetings, several in number, were well attended, and at the end of the month of August, 1901, a " Plan of General Regulations for the Schools for Nurses of the Island of Cuba was submitted for the approbation of the Central Board of Charities of the Island of Cuba." Later in the month of October, 1901. these were made more comprehensive, and somewhat modified, and again submitted for approval. Eventually on January 3, 1902, the plan was approved of in its entirety by the Military Governor of the Island of Cuba, General Wood. 294 International Congress of Nurses REGULATIONS FOR THE SCHOOLS FOR NURSES IN CUBA. The aim and fixed intention of those interested in organizing- Schools for Nurses in Cuba was to put them at once on the highest plane attainable, giving the result of similar work in other countries as sufficient reason to establish a standard tliat would at once command the respect of the people and the self-respect of the accepted student, defining emphatically a position for the nurse in a country, until recently, ignorant of her existence. To start with a high standard is a more effectual way of securing success than in placidly allowing conditions to evolve. The science of nursing has passed the pioneer stage and has now a foundation firm as a rock. Hand in hand with the medical profession (as hand maiden of it) it claims respect for the assistance it gives to suiifering humanity and to the advance of medical research. To those who have so earnestly and so wisely encouraged the work of nursing in Cuba, the profession owes a heavy debt of gratitude, for without the assistance, interest and concentrated effort of men of influence and prestige and the hearty support of the Cuban doctors of reputation and influence, the work that has been accomplished in Cuba could never have given to the world the history of its existence. Today the number of pupils in training exceeds 150, with at least 37 instruct- ors — American graduates. No. 3. Headquarters Department of Cuba. Havana, Cuba, January ■^, igo2. The Military Governor of Cuba, upon the recommenda- tion of the Superintendent, Department of Charities, directs the publication of the following Regulations for the Schools for Nurses of the Island of Cuba : Schools for Nurses in Cuba 295 I. The Schools for Nurses are created in the Island of Cuba with power to issue diplomas to the crraduate, showing- their fitness to practice their profession. II. The Schools for Nurses will be classified as State institutions and will be under the immediate supervision of the Department of Charities. III. The rules and regulations published herewith will govern the establishment and management of the Schools for Nurses, and all special regulations enacted by the Boards of Alanagers for the interior administration of hospitals to which such schools may be annexed will con- form to these rules. H. L. Scott, Adjutant General. Preamble. The object of these schools shall be, first, to further the best interests of the nursing profession by establishing and maintaining a universal standard for instruction and provid- ing students with the proper means of education in the practical care of the sick ; second, to secure for the students upon graduation a degree or title which will be a protection in practicing their profession and be a recognized means of securing employment ; third, to provide hospitals and insti- tutions in the island with skilled service in the nursing- department and proper number of graded assistants, thus conferring a benefit to the mass of sufifering humanity. Tlie Schools for Nurses are State institutions, attached to hospitals for mutual benefit, but under the direct control of the Department of Charities. The director of the hospital shall be the immediate representative of the Depart- ment in the school, and the treasurer of the hospital shall be also the treasurer of the school. Separate estimates for the schools shall be prepared and signed by the director and the treasurer. 296 International Congress of Nurses General Regulations for the Schools for Nurses OF THE Island of Cuba. Chapter I. ESTABLISHMENT OF SCHOOLS. Article 1. Schools for Nurses may be established in all cities of the island where there are public hospitals con- taining more than one hundred beds, whatever their classification may be, subject to the provisions established in this g-eneral plan of regulations, after previous approval by the Department of Charities, and inscription in the School of Medicine of the University of Havana. Article 2. The schools will be governed by the internal regulations of the institution, except where said regulations are contrary to the rules established in this plan. The schools shall not comprise less than twenty students. Article 3. The heads of the schools will be : First, the medical director ; second, the superintendent ; and, next, the graduate nurses who may be designated to act as assist- ants to the superintendent. Article 4. A committee consisting of three members of the Central Board of Charities, appointed by the same ; a professor of the School of Medicine, appointed by the dean ; and a graduate nurse holding no position in any school, but having previously filled the position of superih- tendent, designated by the Department of Charities, will deal with all affairs of a general character affecting the schools. All correspondence will be transmitted through the Department of Charities. This committee will meet regularly once a month, and will hold special meetings as often as necessary. Article 5. The director of the school shall designate the professors that may be required to deliver the lectures referred to in the curriculum, employing the doctors in attendance on the hospital, and all those who may be willing Schools for Nurses in Ctiba 297 to do so without receiving any remuneration whatsoever for such work. Article 6. The course of instruction in each school will cover a period of three ' courses, of a year each, in accordance with the provisions established in the official plan of the School of Medicine. Nevertheless, any student may be admitted to examination for the first year, provided she has previously completed a course of five months' study. Article 7. At the expiration of the first and second courses, the examinations will take place before a board consisting- of two professors belonging to the hospital, designated by the director, and presided over by him or his delegate. Said board will make the students acquainted with the list of subjects of the examination fifteen days in advance. Article 8. The qualifying degrees on the capacity and knowledge of the students will be: Good, very good, rejected. They will be awarded by a majority of votes. The director will issue to each student a certificate of the results obtained from her examination, filing with it her personal documents. Article 9. At the expiration of the third course, the examination will take place before a board consisting of three professors of the School of Medicine and Pharmacy, appointed by the dean of the faculty. The oldest professor will preside. The degrees in this examination will be those established in the regulations of the School of Medicine and will be noted in the documents of the student, to be kept on file in the Department of Charities. Article 10. The examinations corresponding to the third year, will take place in the capital of each province, or in those cities where a large number of students exist, on the dates fixed by the dean of the faculty of medicine, who will notify the directors of the schools and the members of the board designated by them in advance, in order that they may take the necessary measures. The expenses incurred by the members of the board shall be paid by the Depart- ment of Charities and Hospitals. The amount assigned to 298 International Congress of Nurses cover said expenses will be $8 g'old daily and free transpor- tation. Article 11. The examinations will be public and the Department of Charities will provide the building. Article 12. After the examination of the third course, the dean of the faculty will issue a diploma to each student, whose exercises have been approved, which diploma shall state that said student is admitted to the practice of the profession of nursing. Said diploma will merit all authori- ties, as well from the courts, the respect and consideration due all professional titles. Without this diploma, the prac- tice of the profession of nursing is not allowed. Each school will award a silver medal to every student who obtains the diploma of nurse. Article 13. The students who may not pass the first examination shall have a right to request a repetition, but on a second failure they shall be dismissed from the school. Article 14. The students whose perseverance and con- tinued good conduct has distinguished them from their companions during the three years, will be awarded a special gold medal, if so accorded by two-thirds of the number of professors belonging to the institution assembled for the purpose by the director of the same, provided he and the superintendent, who will be present at the meeting, deem any student worthy of said prize. The design of the medal will be determined by the Department of Charities, and will be paid for with funds of the same. Chapter II. ADMISSION TO THE SCHOOL. Article 15. AH applicants for admission as students to the Schools for Nurses shall apply by writing to the director of the hospital to which the school is annexed, filling the form of application adjoined, enclosing with it a letter from a respectable person certifying as to her moral- character, Schools for Xitrscs in Cuba 299 and antecedents, and another letter from a doctor certifying as to her good heaUh. If she is a minor she must also enclose written permission from her parents or guardians. If the applicant's certificate meets the approval of the director, he will endorse it with his recommendation to the superintendent, who will admit her definitely after a month of probation, during which she shall receive nothing else at the expense of the schools but board, lodging and Taundry. This admission will be notified to the Department of Chari- ties. Article 16. The age for admission shall be from 18 to 36 years. The applicant may be admitted when there is only a difference of a few months before she attains the eighteen years, provided she has a strong constitution. A moderate education is indispensable for admittance into the schools. To ascertain this, the superintendent will examine the students whenever she may deem it convenient. Article 17. Applicants may be admitted any time during the year, but the course of instruction will not be considered complete until the three years of practical course have expired, counting from the date of admission and taking into account the month of probation. Article 18. The students can be suspended for misde- meanor or incapacity whenever the director and superin- tendent may deem that they deserve it, notifying the Department of Charities of such action and motives thereof. Article 19. The students will receive as remuneration for their services eight dollars per month during the first year, twelve dollars during the second, and twenty-five dollars gold during the third. Each student will provide all her necessary uniforms. For the acquisition of these, the school will assign for each student of the first and second years thirty-six dollars yearly, which will remain in the charge of the treasurer to be spent when the superintendent may deem it convenient. Should a balance remain at the end of the year, it will be given over in cash to the nurse to whom the amount is credited. The nurses who abandon the school lose all right to their uniforms. They cannot be 300 International Congress of Nurses worn on the streets, unless when rendering service. Laun- dry of uniforms shall be provided for all the students at the expense of the school. Chapter III. DUTIES OF THE STUDENTS. Article 20. All students are obliged to reside in the schools. The hours of duty for students will be divided between day and night. They will render their services eight hours during the day, devoting the remaining four hours to meals, study, recreation and rest, and twelve hours, during the night, taking turns in such a manner that each student may be able to render her services approximately one consecutive month. Article 21. During the first two years the students will not render their services out of the school. During the third year, they will be able to do so during a period which will not exceed three months, whenever the director, in accordance with the superintendent, may deem it con- venient. When the services are rendered to the sick poor, a special agreement will be made with the municipal authori- ties. If attendance is rendered to private individuals, outside, three dollars daily and cost of transportation will be charged. This amount will be paid over to the treasurer, and after deducting a certain sum which the school may deem wise to give to the nurse as gratification, the balance remaining will be kept with the object of accumulating a fund destined to be used as a prize, which, in accordance with the Department of Charities, will be awarded to the student who may be deemed worthy of such a distinction. Article 22. Hospitals having no school for nurses in cases of emergency can apply for nurses to the schools established in the locality, provided they pay the school annexed to the hospital in which they render their services the amount decided upon as gratification and the cost of Schools for Nurses in Cuba 301 transportation. The students who are employed in that capacity will figure in the pay roll of the hospital to which the school is annexed. Article 23. Each student will have three weeks' vaca- tion every year, which will be granted to them by turns by the superintendent in accordance with the director. Article 24. In sickness, all students shall have gratui- tous care; but the time lost in such manner shall be made up, provided said time exceeds one month in each year. Article 25. The students will have no intercourse with the employees other than a strictly professional one. Any infraction of this order will be severely reprimanded, and the director of the school shall be held responsible for such infringement. Chapter IV, DUTIES OF THE SUPERINTENDENT AND HER ASSISTANTS. Article 26. The superintendent shall be a graduate nurse of a school of established reputation, and must pre- sent her credentials and satisfactory references from the school from which she proceeds. She will be appointed by the Department of Charities, in accordance with the director. Article 27. The superintendent shall have the super- vision and direct control of the school. She shall be author- ized to accept the applicants after the month of probation, notifying their admission to the Department of Charities, through the director. She shall in like manner send a writ- ten report of the motives which prompted her to reject any applicant whom she may not deem desirable. She shall keep a record book of admissions and rejections, which will be always at the disposal of the director. Article 28. She shall be authorized to suspend any student for misdemeanor, notifying the director so that he 302 International Congress of Nurses may, after considerino^ the necessary information, approve or disapprove her action. Article 29. She shall send to the Department of Char- ities every three months a written statement of the assiduity, attendance and conduct of each student, and forward to the School of Medicine and Pharmacy a statement of the num- Ijer of students inscribed in each course. Before the final examination she must send in a complete report, contain- ino- all necessary information with rci^ard to the documents and practical work of each student. Article 30. The superintendent shall be authorized to purchase all articles necessary for the requirements of the school when it is independent of the hospital. Payments will be made by the treasurer on approval of the director. The purchase of wearino- apparel for the nurses will be always made by the superintendent. Article 31. She shall have the "general supervision of all the patients in the hospital in accordance with the director. She shall see that the students serve in turn in the dififerent departments, and determine those who are to render their services by nij^ht and shall be responsible to tiie director of the hospital for condition of cleanliness of doors, walls, windows, roofs and furniture of both medical and surgical wards and operating rooms, as well as the laundry and kitchen. Article 32. She will receive every morning the report of the graduate nurses and obtain the reciuisitions for the daily reciuirements transferring the report and recjuests to tlie medical director an hour in advance. Article 33. She shall every night before retiring give the necessary instructions to the assistant wdio is to act as night superintendent, and obtain from her in the morning a written report of all the night occurrences. She shall refer all information dealing with the patients to the doctor in attendance on the ward, and those dealing with affairs in general to the director. Article 34. She shall not absent herself from the hos- Schools for Nurses in Cuba 303 pital during- the day without notifying the director and designating an assistant to take her place. Article 35. She shall attend the lectures delivered by the professors to the students and review and correct the notes taken. Article 36. She shall give weekly lectures to the stu- dents, on the practical knowledge they must possess for the proper discharge of their duties and practice of their pro- fession. Article 37. She shall supervise all the assistant nurses in their departments, and will notify the director of any fault committed. She will inspect the distribution of food to the nurses and patients of the hospital, seeing that the instructions of the director are complied with. Article 38. Whenever a case of contagious disease occurs, she shall take all proper precaution to isolate it and disinfect all the linen; soliciting from the director anv order which may be necessary. Article 39. To assist her in the proper discharge of all the duties mentioned, she will have under her orders at least four assistants, graduate nurses, one to have com- plete charge of the operating room, one to act as night superintendent and the remainder to render their services in the medical and surgical wards. The night superinten- dent shall receive more salary than the others, considering the kind of service which she renders. The assistants shall have charge of the instruction of, the students in their respective sections and comply with all the instructions received from the superintendent. They shall not leave the building without first obtaining permission from the superintendent, nor pass the night out of the institution. They shall enjoy a day vacation every week by turns. If sick for more than a month, the amount exceeding it will be discounted from their services. The assistants will be appointed in the same manner as the superintendent. 304 International Congress of Nurses Chapter V. THEORETICAL INSTRUCTION. Article 40. The theoretical instruction will cover three terms : the school term will be from the first of October to the first of June, and the examinations will be held dur- ing the latter part of the last month. Official Curriculum Schools for Nurses. THEORETICAL INSTRUCTION FROM OCTOBER TO JUNE. FIRST YEAR. Professional discipline. Anatomy : Skeleton, Bones, Articulation and Muscles. Hygiene and Bacteriology: Action of the Bacteria. Disinfection and Isolation. Outlines of Physiology. Materia Medica: Metric System, Medicines and their administration ; Drugs and classification. Surgical Practice : Asepsis and Antisepsis, Cicatriza- tion, Accidents of penetrating and general wounds. Preparation of nourishment for the sick. Services to Children ; State at birth. Physiological changes ; Growth and development ; Morbid predisposition ; Infant Mortality ; Care of a Healthy Child ; Nourishment for a Healthy Child, and for a Sick Child. SECOND YEAR. Anatomy: Digestive Apparatus, Circulatory, Respira- tory, Glandular System, Excretory and Nervous Apparatus. Outlines of Physiology. Hygiene and Bacteriology : Air, Water, Hygiene^ Materia Medica, Poisons, Antidotes, Hypodermic In- jections, Hydrotherapies; Medical Practice, instruction in Schools for Nurses in Cuba 305 — general observations (elementary clinics) of the patients' symptoms, temperature, pulse and respirations, etc., chart keeping, etc. Surgical Practice: Care before, during, and after the operation ; Care in special operations. THIRD YEAR. Gynecology. Obstetrics : Care of the woman during pregnancy, confinement, and afterwards ; care of the new-born child. Surgical Practice: Anesthesia, dressings and band- ages; services rendered in surgical wards. Medical Practice: Analysis of the urine, care of dis- eases of the digestive, circulatory, respiratory, ner\^ous, and urinary organs, and contagious diseases. Eyes, Skin, Ears, Throat, and Xose : Anatomy, care in health and sickness, post-operative care, special cases. Practice of Massage. Article 41. The superintendent will issue to each student a tri-monthly statement of her services in accord- ance with the following form : Name Date of admission to School Wards in which they have served during the three months Behavior i Interest Manifested Aptness for observation Punctuality Application Disposition Cleanliness Order Amiability Peculiarities Distinction in Character Distinction in Work 306 International Congress of Nurses Faults Committed in Work Faults in Character Improvement Remarks Date (Signature) FORM OF APPLICATION. The answers to the questions shall be written in the applicants' own handwriting. Name, surname, and address of applicant. . . . Civil condition What has been your occupation Height Weight I What education have you received, and where? r 1 Age Date, and place of birth i Have you been in any other school for nurses? Are you strong and healthy? Is your sight and hearing perfect? I Have you any physical imperfections or de- fects? Have you a vaccination certificate? W'hat acute diseases or surgical operations have you suffered, and on what date? Have you read and clearly understood the regulations of the school? Date (Signature) Indian Army Nursing 307 The President : Our next paper is on the Indian Army Nursing Service, by Miss Arkle, delegate from and Nurs- ing Sister in that Service, who has been sent to this country by the EngHsh government. She has very kindly loaned us some photographs, showing Army nurses in their uniforms. They are to be handed out to the audience if they will promise to bring them back. The Indian Army Nursing Service. ANNIE ARKLE, Delegate Indian Army Nursing Service. The Indian Army Nursing Service was initiated by that good friend of the British soldier, Lord Roberts, in 1888, and although it has only been .in existence 14 years, there has been a great advance in the understanding of nurses, and nursing in India, and of the necessity for nursing and in the care given to sick soldiers, now acknowledged to be necessary for them. Candidates for the service apply to the Under Secretary of State for India, and must have had at least three years' training in a Civil General Hospital. The service is com- posed of: 1st, lady superintendents, of whom there are four (one in each command), and nursing sisters, of whom there are between 50 and 60. We are an integral part of the military medical department, and are subject to court martial in the usual way. Promotion of nursing sister to lady superintendent is made by the principal medical officer of bis Majesty's forces in India on .the grounds of experience, administrative capacity, and personal fitness. Last year six (I think) of our sisters were sent to China when the war broke out. The duration of a term of service is five years, after which time the sister is entitled to one year's furlough out 308 Indian Army Nursing 309 V of India on two-thirds pay with free passage from and to her station. At the end of five years she can leave the ser- vice or sign an agreement to return for another term. In the event of her leaving after the first term she will receive a gratuity of 500 rupees (about $150). After the second term the bonus is increased to 1,500 rupees (about $450). The gratuity given to the lady superintendent is propor- tionately higher. If she agrees to return she receives two- thirds pay while on furlough. Should she leave before her first term of service is completed (for any cause save sick- ness) she will be obliged to pay the sum of £25 ($120) or give six months' notice and pay £20 ($100). After 15 years' service the sister receives a pension of about $250 per annum. After 20 years' service this pension is increased to about $300, with an addition for every year's service as lady superintendent. In addition to free quarters, fuel, light and punkah pullers, the lady superintendent receives 300 rupees a month ; the nursing sister, 175 rupees. When she becomes "senior sister" in a station where there is no lady superin- tendent, she receives 200 rupees. There is always a small compensation allowance varying with the rate of exchange ; pony allow-ance of 30 rupees a month is allowed on field service, provided a pony be kept. The lady superintendent has control over all the sisters in her command. Once every year she visits the nursing staff of all hospitals in her command for the purpose of inspec- tion, and afterwards submits a full report on the manner in which each sister has done her duty, which reaches the prin- cipal medical officer of his Majesty's forces in India through the prescribed channel. Should the report not be favorable it must be shown to the sister concerned, who has the opportunity of making an appeal, and has the right to have the matter'enquired into by a board of officers in the usual way. The senior nursing sister does the housekeeping and is responsible that order and regularity be carried out in the quarters and in the w^ards. 310 International Congress of Nurses. When a new sister arrives at a station she usually pays an entrance fee for the use of crockery, cutlery, glass, etc., in fact for all those things we require in the quarters not provided by the government. This is very hard on a sister who is moved often from station to station, and much expense would be spared the sisters if the government would grant a small amount yearly to cover these expenses. The hours of the sisters on duty vary in some stations. As a rule, there are three sisters in one station. No. 1 sis- ter comes on duty at 7 a. m. and remains till 2 p. m. No. 2 comes on at 2 and stays till 8 p. m. or 9 when there is anyone very seriously ill in the ward. No. 2 again comes on the next morning at 7 a. m., while No. 3 is doing night duty from 9 p. m. to 7 a. m. Night duty we take for a week in turn. During the term of five years the sister is allowed two months' privilege leave on full pay. She can also occas- ionally get (if convenient) 10 days' station leave, and some- times even three days' district leave is given. Sick leave, up to a maximum of six months, is allowed during the term of five years. This leave must be taken in India. For each ward with an average of 25 beds there are two orderlies. The orderly's relief is changed every six hours, and in most stations there are four reliefs. Some- times, when special orderlies are required, there are as many as 18 or 20 doing duty in the wards where the sisters work. Before the orderly gets his certificate he is put through a course of stretcher drill by the medical officer, after which (if he passes his examination) his nursing certificate is given, signed by the medical officer and the sister in charge. One great difficulty in training orderlies is the little time one sometimes has in which to do it. Frequently from stations where there are no sisters, men are sent from the regiments, and are expected to be efficient nurses at the end of three months. This clearly is impossible, and the certificates are not worth much. Now, in stations where there are sisters, the orderlies are gen- erally allowed to remain for quite twelve months, only being Indian Army Nursing 314 called into the regiment once for about a fortnight for his musketry training. At the end of the year, if the man is intelligent, conscientious, and fond of his work, it is sur- prising how capable a nurse he makes. I have seen some men most excellent. If he is not a suitable man in every way he can always be returned to the regiment and another man sent in his place. In addition to the practical training given in the wards the senior sister holds a class about once a week on the general principles of nursing. Very often orderlies remain three and even four years in the wards at their own request. Native servants do the roughest of the work in the wards. I think it is quite impossible to point out the great good done by the influence of women in the wards (they must be first-class women, both technically as nurses, and as ladies), and the good tone introduced by nurses fresh from the perfection of management of a civil hospital at home. From my own experience I find the orderlies much better and more willing to learn than I ever expected. I have seen them infinitely gentle when handling a sick com- rade, and soldiers, when sick, behave most splendidly; always grateful and cheerful. In our wards all the cases are acute — when convalescent they go to the other wards; when chronic, they come home to Netley. When there are many cases and the work is heavy (which, by the way, is almost always in most stations) the sister, in addition to her ordinary duties, has just got to help the orderlies, and sponging patients with the ther- mometer 112° in the shade is not easy work, and you can imagine how persistently one has to sponge or ice-pack in a hot climate, and how imperative it is in cases of heat- stroke and fever. Yes. after some months of this work one does so long for the delights of the cool Himalayas, and with what a sigh of relief one wakes up the first morning of the 60 days' privilege leave. It is astonishing how many of the ordedies prefer remaining in the furnace below to o 12 International Congress of Nurses what they describe as " climbinq^ them khiuls " (khud means a mountain side). The sugg-estions I would make are : 1. That a messing allowance be granted. 2. That the number of sisters be increased, so that no military station be without them. 3. That the sick leave might be extended to leave in England, or a sea voyage if the medical officer considers it essential, the government to provide the passage both ways. At the present time our sick leave must be taken in the countrx*. and I think we all agree that India is not generally chosen as a health resort. At the same time, our service is young, and already the government has made many reforms, and scarcely a year passes that one does not find some alteration for the better, and I am sure in time it will be almost perfect. Our quarters are always large and comfortable, the pay is good, the amount of leave is most generous, and there is a pen- sion at the end of our service, and there is that home-feeling one has in one's quarters surrounded by one's little gods. One can keep a pony, trap, or bicycle, and one can have one's live pets about one. This to an English woman who is an animal lover means a great deal, and I think a real change is so good for one. When off duty we can putter around in the garden or go down to the club and play ten- nis, or to the links and play golf : and I think a good canter across the country is about the best medicine I know of for a weary nurse. After it one goes on duty so fresh. I take it — to remember the men, and give them of our very best when on duty, we must try to forget them when off duty. Now, I fear you will be disappointed with my paper, but I have not the power to show you, unless you come to India, how the temperature can drop 30° in 30 minutes, neither can I explain to you how good a patient the British soldier is under the most trying conditions. We do our best to keep him comfortable in the hot weather, and it is Indian Army Xiirsing 313 sometimes impossible with the heat, the flies, and the mosquitoes. I cannot take you up to the hills and ask you away up to the favorite spot, to watch the gflory of the sunrise, nor stand spellbound at the grandeur of the sunset when all the hosts of Heaven surely must be down there over the plains where are the most gorgeous billows of clouds as far as one can see. One just expects to hear the trumpet call, when we awake and — " 'tis gone and all is Gjav.'' The Work of the Indian Army Nursing Service. MISS WATT, Allahabad, India. In attempting- to give a brief account of the Indian Army Nursing Service, its advantages and disadvantages, in a way which may possibly be helpful to some intending candidate, two difficulties present themselves : first, it is almost impossible to give an accurate picture of Anglo- Indian life to those who are strangers to it ; in the second place, it must never be forgotten that fifteen years have to be spent in anv part of India, and no one can foretell the effects of climate on the health. Fifteen years' hard labor in a trying climate ought only to be attempted by the vigorous and strong. A weakly, delicate woman is not only a burden to herself, but a source of never-ending anxiety to her superiors, while her work must necessarily be less well done, however excellent her intentions. All the rules and conditions of the service are clearly laid down in a small blue-book issued half yearly. This in itself is no small advantage, as before engagement all the rules can be studied and each candidate can be sure of the nature of her agreement. Application for admission is made in the first instance to the Under Secretary of State for India, Indian Office, S. W., and a form is received which must be accurately filled up and returned with the numerous necessary certificates attached. If the candidate be accepted, she receives fifteen pounds outfit allowance (which is quite insufficient), and she will 314 Indian Army Nursing 3X5 probably be ordered to embark on a transport about a month after appointment. Pay begins from date of embarkation, with the addition of exchange compensation allowance, and the deduction of income tax (which always seems an unnecessary hardship). The pay averages one hundred and eighty rupees per month, about eleven and a half pounds English money. This sounds high, but it must be remembered that board is not included. The sisters receive from government free " furnished " quar- ters, fuel, lights and punkah coolies, but no allowance for messing. The quarters allotted are, as a rule, convenient and comfortable. Each sister has a bedroom, dressing-room, and bath-room, in some cases a private sitting room, besides a general drawing-room and dining-room for com- mon use. " Furnished " quarters means that the heavier articles of furniture, beds, tables, wardrobes, chairs, etc., are supplied by government in each station. All cooking utensils, crockery, table and bed linen, cutlery, plate, and glass have to be found by the sisters, and this is a somewhat serious tax on the pay. It is usual for the senior sister to do all the housekeep- ing, and either make a monthly charge for supplying all household necessaries or charge each newcomer an entrance fee, the money being devoted to replacing worn- out things and breakages. The messing bills may be taken to amount to fifty rupees per month as an average. If gov- ernment could be induced to grant one hundred rupees yearlv to each establishment of nursing sisters much trou- ble would be saved. We will now suppose that the new sister has arrived in India, and (to take an ordinary case) that she forms one of three sisters working in a station hospital. One sister will be on night duty for a week, her hours being from 9 p. m. to 7 a. m. Sister No. 1 will be on duty from 7 a. m. till 2 p. m, and Sister No 2 from 2 p. m. until 8 p. m., unless there are very acute cases, when she will remain until relieved by the night sister. 316 International Congress of Nurses These hours are sHghtly varied in dififerent stations, but the above is a very usual arrangement. In comparison with a London hospital nurse's day these hours seem short, but in a bad climate and with the endless worries entailed b}^ working with orderlies and native servants the work will be found quite sufficiently fatiguing. Each sister is entitled to two months' privilege leave every year on full pay. Three days' hospital leave and ten days' station leave can often be obtained. After serving without privilege leave for two years and nine months, three months' leave may be granted to allow of a short visit to England. After five years' service the sisters have one year's furlough on two-thirds pay, with free passage out and home. At the end of her five years a sister may retire from the service with a gratuity of five hundred rupees ; after ten years' service fifteen hundred rupees are given, and after fifteen years a pension of fifteen pounds may be hoped for. After twenty years' ser\'ice a pension of sixty pounds a year is promised, but it seems improbable that many sisters will serve so many years. For lady superintendents the gratuities and pensions are proportionately higher, but as there are only four lady superintendents, a sister's chances of supplying this proud position are but slender. The senior sister in each station receives twenty-five rupees per month extra, a small enough compensation for the worries of housekeeping. Once a year the lady superintendent inspects each sta- tion in her presidency, and writes a " confidential report " on each sister as to the manner in which she has performed her work, whether she has " maintained pleasant relations " with the other sisters, her aptitude for training orderlies, and her conduct as a whole. The lady superintendent must, of course, be guided by the reports of the medical officer in charge and of the senior sister. However, one golden rule enjoins that if the report be unfavorable, it must be communicated to the sister concerned, so if she thinks that Indian Army Nursing .'517 any injustice has been done, she has an opportunity for rep- resenting her side of the case. The sisters' intercourse with the medical oflficers will almost invariably be pleasant; as a rule they thoroughly appreciate good work, and the prejudice against " women in military hospitals" is almost non-existent in India. The person with whom it is sometimes difficult to work har- moniously is the Eurasian " assistant surgeon." He com- bines the functions of a dresser and a dispenser, and is sup- posed to maintain discipline in the wards. But while all the above conditions of service are fair, and although the sisters' Indian life may be in every way a pleasant and useful one, there are at present some grave drawbacks in the Indian military hospital system which are a hindrance to successful nursing work. The principal changes which, in the writer's opinion, ought to be introduced are : (a) in the training of orderlies : (b) in the army native hospital corps. (a) At present, a rough, uneducated private is intro- duced into a ward full of enterics. At the end of three months a miraculous change is supposed to have boon effected, whereby the man is fully qualified to work by him- self in charge of a ward in some hospital where there are no sisters. Why should an uneducated man be thought capable of learning the whole art of nursing in three months, when a well-educated woman cannot be trained in less than three years? In three months the orderly can be taught to fetch and carry, to do as he is told, and to be a fairly useful pair of hands while working under a trained head. But tlu- training of orderlies to fit them for independent posts should surely be prolonged for at least twelve months. Then only the exceptional men, possessing the moral qualifications of sobriety and intelligence, should be given certificates. At present the orderly's certificate is not worth the paper on which it is written. (b) The army hospital native corps is at present com- posed of the scum of the bazaars, insufificicntlv paid, work- 318 International Congress of Nurses ing^ under impossible conditions (e. g.. a fine of two annas per month can be deducted once only during- the month for grave misconduct among the lowest grade). Until some radical reform takes place whereby respectable natives, properly paid and severely disciplined, can be obtained, the native service of the hospital will always be a bar to really eflficient work. The chief reforms suggested in the present conditions of the working of the service are : (a) That a messing allowance of one hundred rupees per annum be granted ; (b) That the time of the orderlies' training be increased to twelve months ; (c) That the army hospital native corps be remodelled so as to secure a certain measure of efficiency. In conclusion, the Indian army nursing service ofTers every prospect of happiness and congenial work to a well- trained, strong, and healthy woman. The drawbacks which can be removed are minor ones, and the chief drawback — that of hard work in a bad climate — must be taken into account by each individual candidate before entering the service. Nursing in South Africa During the Boer War, 1899 — 1900. GEORGINA FANE POPE, Canadian Nursing Reserve. Reading as a young- girl a most interesting account of Miss Florence Nightingale's noble work during the Cri- mean war, I became filled with the desire to become an *' army nursing sister " and go to the front. England being happily at peace, and I much under age, I was obliged to moderate my ardor ; but with the main hope still uppermost. a few years afterwards I entered the training school for nurses attached to Bellevue Hospital, New York. Fourteen years later, viz. : October 14, 1899, I received my appoint- ment, with three other nurses, to go out with the Canadian contingent then called to active service in South Africa — thus realizing my early aspirations. Upon our arrival at Cape Town we found our troops had orders to proceed up country immediately. We reported to the principal medical ofBcer, making every effort to be allowed to accompany them to the front, but this we were told was impossible, as no nursing sisters could be accom- modated in the field hospitals. So with very disconsolate feelings we saw our countrymen en train without us. and came to realize at that early date what served us in good stead later, viz.: that we, too, were soldiers, to do as we were told and go where we were sent. Later in the day we received orders to proceed to Wynberg for duty in the large base hospital there, called No. 1 General. These general hospitals, of which there were thirteen or more, were most complete. They were, as a rule, under canvas, and con- tained from six hundred to one thousand beds. They left England with a staiT of surgeons, sisters, trained orderlies, etc., and a full equipment of everything needful, including the comfortable blue flannel hospital kit that "Tommy At- kins" wears during convalescence. 320 International Congress of Xnrses No. 1 (icncral was placed at Wynbcrp liarracks and miinbcred about one thousand beds. No. 2 was pitched under canvas, also at Wynberg, and No. 3 at Rondebosch. about six miles away, close to Mr. Cecil Rhodes' beautiful place, " Groot Schnur." Pitched beside No. 3 was the pri- vate hospitiil sent out by the Duke of Portland, and the two numbered over seven hundred beds. The private hos- pitals were almost ideal in their equipment, havinrj every comfort for the patients, beautifully appointed operatmii" tents. X-ray api)aratus. etc. There were four larjj^e jjeneral ho.spitals at the Cape, besides the Portland, a convalescent hospitals for officers at Claremont, two larije rest camps, and two hospitals for the Pioer prisoners at (irecnpoint and Simon's Town, for many months all these places beinc^ full. At Wynberg we found our services jjjreatly needed, the wounded from Graspan and P>elmont havinq; recently been broui^ht down in lar.^e numbers. A few days after our arrival a larj^e convoy brouf^^ht in the wounded from Maj^ersfontein and Modder river, when all my empty beds were filled with the men of the Hig^hland P)rijTade, which sufifered so severely in these en<:^ag^ements. (The arrival of this convoy was a most pitiful sic^ht, many of the men being stretcher cases, shot through thigh, foot, or spine. What struck one most was the wonderful pluck of these l)Oor fellows, who had jolted over the rough veldt in ambu- lances and then endured the long train journey, also the utter self-forgetfulness of everyone else, surgeons, sisters, and orderlies, all of whom worked on regardless of time or hunger until everyone was as comfortable as they could be made. Tommy made the least of all his woes. A tlrink first, then, after his wounds had been attended to, "A bit of tobacco " for a smoke, and a piece of paper to " Send a line so that they won't be scared at home '' were invariably the first requirements. During this early period, with the exception of sun- stroke and rheumatism, almost all the cases were surgical, and operations would continue all day long after the arrival Nursing in South Africa 321 of a fresh convoy. 'Hie X-rays were, of course, very val- uable in locatin^£^ bullets, and saved Tommy many a probe. I have not yet heard the statistics of the wounded, but from my own experience should judge that the percentage of successful surgical results was very high. I have seen ghastly shell and explosive -bullet wounds, which one would think must surely end in septicaemia, make perfect recov- eries, while head cases, spine cases, etc., sometimes made seemingly miraculous cures. One saw oftentimes such wonderful escapes! I had a patient — a corporal of the West Yorks, mentioned for a distinguished service medal — who had been shot through the jaw, the bullet glancing up sideways, passing through the eye without the slightest injury to the sight, and coming out of the rim of his helmet ; another, shot like Achilles, in the heel, the bullet lodging in the heel of the boot, making a unique souvenir; one which passed through both legs, escaping the bone, and hanging, a prisoner, under the skin of the left leg; while another passed through a man's arm and found a resting place in the purse inside his haversack ; others flattened against blessed medals worn round the neck and watches in the tunic pocket, by this means escaping the lungs or heart. After a month spent in the huts at Wynberg, we went under canvas at Rondebosch, experiencing the adven- tures of camp life and the power of an African midsummer sun, together with sand storms, rain storms, and some- times a too intimate acquaintance of scorpions and snakes. In February enteric fever cases began to come down. The fever was generally of a very malignant type, being often complicated with pneumonia and early severe head symptoms, while I have seen the body so covered with spots one couldn't put the proverbial " pin " between them. The treatment was generally ice caps, sponge baths, and cold packs for temperature, poultices for pneumonia, and ergotine for hemorrhages. The diet was fresh milk, Ben- ger's food, beef tea — where there was no diarrhoea— and egg switches, while some doctors included rice, biscuits, soft boiled eggs, etc., from the start with very favorable results. 322 International Congress of Nurses We had many inoculated cases, which generally ran a mild and irregular course of fever. In my service I did not lose any of these cases, except in one instance where there had been no reaction from the inoculation. We were singularly fortunate at Rondebosch in our results. During the six months' service there, including medical and surgical cases of our own and the Portland hospital, we had but thirty deaths. But here at the base we always had good air, plenty of good water, with an abundance of fresh milk, eggs and ice. The general hos- pital fare was excellent, and added to this we received daily quantities of fruit and dainties sent by the Red Cross Com- mittee of the Colony, besides many medical comforts from England. In May we were ordered up country, and were the first sisters to reach Kroonstadt, O. R. C, stopping en route at Springfontein and Bloemfontein. At the latter place enteric fever and dysentery were raging, the hospitals, of which there were three general and many smaller ones, being all crowded. No. 9 having, we were told, eighteen hundred patients. All persons and supplies were being taxed to the utmost. In Kroonstadt we had our hardest taste of active service. Lord Roberts and Lord Methuen's forces had just passed through, leaving sick and wounded in large numbers. Owing to the congested state of the lines of communi- cation, our hospital equipment was delayed a few days in reaching Kroonstadt. The Dutch church, hotels, Staat Huis, etc., were quickly converted into hospitals, where we made the patients as comfortable as possible. Fresh milk was very hard to get, an of^cer's servant having been shot dead by the Boers in his effort to get some at a farm near by, but of condensed milk, beef tea, champagne, and jelly we had plenty. When our hospital arrived it .was pitched on the out- skirts of the town, and close beside it the Scottish National, a beautifuly equipped hospital just sent out. The weather was now very cold at night, the frost being thick both inside Nursing in South Africa 323 and out of our single bell tents— the patients, being in dou- ble marquees, did not feel the cold so much. We were scarce of water, and lived on rations which an orderly cooked for us on a fire on the veldt, dinner being a movable and uncertain feast on a rainy day. Around our camp, within fifty yards, were several six-inch guns, while we had pre- pared in a donga a place of safety for helpless patients and a bomb-proof shelter for all the hospital staff in case of attack, which had for some time threatened us dailv. Haneinsr m our mess was a copy of orders to be observed when attacked, etc. Several mornings we wakened to hear the boom of guns, which, however, were never near enough to necessitate our using the shelter. Here the mortality was much greater than at the Cape. The men, being greatly undermined by the hard campaign, after drinking the waters of the Modder, contaminated with the Boer dead, fell easy victims to disease, and were in a poor state to stand the ravages of South African enteric fever. Sad indeed was the now familiar sight of fatigue parties bearing aloft the stretcher containing its silent burden cov- ered by the Union Jack, and still more sad the ever-increas- ing number of little mounds on the veldt. After two months in Kroonstadt we received orders for Pretoria, where we were attached to the stafT of the Irish hospital sent out by Lord Iveagh. Here the service became much lighter, enteric fever being greatly on the wane. After completing a year's service, we Canadian sisters received ten days' leave of absence, which was spent going through Natal, stopping at all places of interest. We met officers, civil surgeons, and sisters who had been through the siege of Ladysmith whose account of their hardships, including diet and danger, made me feel as though we had had little to bear in comparison. In November we left for the Cape, spending our last month at Wynberg pending embarkation for Canada, which we reached on January 8, 1901, after nearly fifteen months' absence. '324 International Congress of Nurses I cannot close this paper without speakin^ of the great kindness with which we were received on all sides. We had, with our troops, a most enthusiastic reception at the Cape upon our arrival. By the Royal Army Medical Corps from the surgeon general down to the humblest orderly we were invariably treated with the greatest courtesy and respect, by the " army nursing sisters " with great con- sideration and kindness. While among the nursing reserve, of whom there were about eight hundred in South Africa, we made many friends, meeting sisters <^rained at the London, St. Bartholomew's, St. Thomas', and many other well-known standard hospitals, whose reputations are well maintained by the work of their nurses in South Africa. We had the privilege of meeting many distinguished physi- cians and surgeons of the old country, under whom it was a pleasure to serve. The work of the Red Cross w^as excel- lent, and great was the timely aid so often received from it. While the kindly gift or word sent or given by the private individual often made one think of the " touch of nature that makes the whole world kin." We found Tommy Atkins a very good patient and a fine fellow : always grate- ful, generally cheerful, bearing loss of limb, loss of health, and many other minor discomforts, with a fortitude that realized our best ideal of British pluck, while his considera- tion for the presence of the sister was at times quite touch- ing. He is very entertaining during convalescence, often writing verses, sometimes in eulogy of the sisters and again in descriptions of battles, etc., and making all kinds of curi- osities, those having had service in India doing beautiful work. I am the proud possessor of several specimens both of verse and handicraft which I value greatly. Above all, he loves tobacco and cigarettes, but enjoys any attention. A lady while at Rondebosch gave me one day in the ward a bundle of handkerchiefs and a pint bottle of white-rose scent. A few minutes later I heard, " Sister, I'd thank you for a clean handkerchief, please, and a drop of that scent on it, sister, please," until all with energy to notice anything Vv'ere supplied, and even after the fancy handkerchiefs had Nursing in SotttJi Africa 326 to be replaced by the regulation kit article a liberal dose of the " ripping scent " would be daily called for. In conclusion, I would say that I ever deemed it a great privilege to aid in caring for the sick and wounded, and while the hardships necessarily endured in such a cam- paign have faded from my mind, I still often seem to hear the " Thank you, sister,'' of the grateful soldier ; while together with pleasant memories of large convoys of happy convalescents sent home comes the vision of the many sad graves left on the far-off veldt of South Africa. '' Requiem aeternam dona eis, Domine; et lux perpetua luceat eis." (" Grant to them Thine eternal rest, O God, and in the light everlasting may they dwell.") War Nursing in South Africa, 1900. SISTER HENRIETTA, St. Michael's Home, Kimberley, South Africa. In writing of war nursing I mean to keep to personal experience and to the work of our own nurses. I am sister in charge of a Nurses' Home in Kimberley, South Africa, and was in Kimberley during the siege and for fourteen months after we were relieved. One of our great trials during the early part of the siege was that our nurses had so little to do. The people who usually employ us had nearly all left town before war was declared, our country cases we could not reach except through three nurses who were shut out, and the absence of evening amusements, the scarcity of aerated waters and wine, etc., the small quantity of meat during the hot weather, and the early going to bed, all made the town unusually healthy, until the food became so small in quan- tity and bad in quality that all felt more or less the worse for it. After Christmas there was a great strain upon all our resources. Every moment of my time was taken up in trying to spin out our wretched scraps of horse flesh and our few ounces of milk in our own household, and I often had to send nurses to houses where food was so scarce I was terrified for them. If I gave them food when they came to the home they would pocket it to take to the starving children where they were nursing, and the hospital was so full that many came to us who would not otherwise have thought of engaging a private nurse. At last, too, so many of the hospital nurses were ill that we had to send all we 326 War Nursing in South Africa 327 could possibly spare to help there. Our brave district nurses went about their work through all the bombard- ment as if nothing were going on. I cannot say how mis- erable I felt at seeing them go out in the morning while the awful roar, shriek overhead, and crash, like the crack of doom, were raging outside. By God's mercy none of them were injured, but their escapes were marvelous. Sev- eral of them were covered with the dust and debris of the explosions, and all narrowly missed death by the awful hundred-pounders. It was a matter of deep thank- fulness to see each one come in safely from her round, although it was only to start off again in a few hours. That was true war nursing, — through the shot and shell of the siege, half-starved themselves, ministering in the most hidden way among the wretched, starving people of the town with the greatest patience and simplest courage. However, Feburary 15 came at last, and the army entered in triumph, and our brave commander. General Kekewich, was able to send his famous telegram to the Queen, "By the help of God we have kept the flag flying." But the triumphant march of the great army was fol- lowed by another march. In a few days over a thousand sick and wounded soldiers had been brought into the town. Lord Methuen sent to me asking us to undertake the nurs- ing of one big hall or school room after another, turned hastily into a field hospital, until we had over five hundred under our care. First were the Christian Brothers' Schools. I was asked to send one nurse there and one to Nazareth House, close by, on February 17. The sisters, however, objected to more outside help in their own house than they got from orderlies, so they took in for weeks and weeks, greatly at their own expense and in the most generous way, from thirty to forty of the slightly wounded, — the worst wounds going, of course, very properly to the civil hospital, where every appliance was at hand. Our two soon found enough to do at the Christian Brothers'. Imagine two handsome new school-rooms and one little class room, with desks and school books all lying 328 International Congress of Nurses about, and ambulances with forty wounded men in them at the door, bedsteads, stores, Red Cross comforts, mat- tresses, blankets, etc., etc., all arriving^ at the same time, with only a tiny kitchen and no arrangements whatever for cooking for more than half a dozen lay brothers. Our peo- ple worked like galley slaves, and got the bedsteads up, the men to bed, and the wounds dressed and seen to by about 2 a. m. of the next day. In a few days all was order and peace. The little class room was the nurses' room, with two small beds and a little table for meals, their two boxes, two chairs, and near the farther wall piles of opened stores — cases of wine, brandy, cigars, bovril, bandages, and all sorts of things. The wards were quite pretty, as neat and smart as they could be in the rush of work and incessant changing of patients, all being sent to the general hospitals at Wynberg from these field hospitals as soon as they could be moved. There were capital results, even when the wounded were replaced by typhoid and dysentery cases in a very bad condition. The next place we undertook was the drill hall. Here three of our nurses, two of whom had been at work all the previous night with a little outside help, came in to find a fine hall, two or three side rooms, and dusty desolation. It was 2:30 p. m. before they got a thing in. At 8:30 p. m. they sent and asked me to come and see if all was right. There was room for one hundred and twenty, and the shops were still able to supply good bedsteads and mattresses, so the long rows of beds were all beautifully made, each one turned down ready to be occupied, with a clean shirt on the pillow, a clean towel at the head, and a gay-colored blanket for a quilt. The De Beers Company had sent down a wire, so it was brilliantly lighted with electric light, and the flags and trophies of its proper use made the hall bright and gay. In one of the smaller rooms four beds were made up for nurses, but there, too, was the operating table, and the dressing tables at the side with all the beautiful and costly dressings supplied by the army. Another of the smaller halls had to be the guard room for orderlies, but it War Nursing in South Africa 329 was a long- room, and the upper half had tables with rows and rows of clean white enamel mugs, each with a new spoon in it, and rows and rows, too, of bottles of bovril. jars of Liebig, tins of condensed milk, all opened ready for use, and loaves of bread. Lord Lock said to me: " At 2:30 there was absolute chaos ! It seemed impossible that a sick man could be put in for weeks; by 8 p. m. it was a most beautiful hospital." As I was looking the ambulances began to arrive, and I leave you to guess how long it was before those nurses thought of bed. In the same way we undertook the public schools with one hundred and thirty beds; and a few days later in St. Mary's Hall and the skating rink we received the wounded Boers from Cronje's laager at Paardeberg. There indeed was a scramble, one hundred and thirty-seven men with awful wounds, dirty, draggled, wretched and beaten. The shops had no more bedsteads, the line of railway was blocked with wounded soldiers, military stores, horses and food for the starving town of forty-three thousand souls, as well as with the military arms, ammunition, and huge guns with all their timber. It was far too hot for the nurses to take the half-mile walk there and back to come home for their meals, and there was absolutely no accommoda- tion for them except one miserable little room, half of which was broken down by a shell, where the corporal took his meals. In some way or other, through the kindness of friends, they were provided for. But here was nursing indeed. There was not one bedstead, only three mattresses and three pillows; sheets and pillow cases were entirely lacking; there were only two or three chairs and a few little tables; but in both rooms there was a thoroughly good floor, and I don't think the men suffered lying on it on folded blankets; of course, there could be no comfortable undressing, but Boers are not accustomed to that. But the nurses! Through the whole day standing in the furiously hot little operating rooms, or dressing ghastly wounds, almost standing on their heads, for the men were all on the floor. Indeed, the heat of the whole place was 330 International Congress of Nurses indescribable. Kimberley was burning with heat. The rink was crowded in another week, when the whole one hundred and thirty-five Boers were put there and St. Mary's filled with our own men. In about three weeks' time the Boers were well enough to be moved to Simon's Town, except three, who went into the civil hospital. They wrote a letter of thanks for the treatment they had received before they left. I looked upon that as one of the best and most difficult pieces of work we ever did. We had one of the hospital nurses to help us. Meanwhile the workshops of the De Beers Company were pouring out stretchers, and in a few days after we took it over, pillows, sheets, towels, and pillow cases made St. Mary's quite handsome. Our work in these halls came to an end when the Elev- enth General Hospital came up country, the twenty army sisters and six Canadian nurses taking them over, until the fourteen hundred beds of the Eleventh Hospital made a city of canvas on a fine, healthy brow, with a most com- plete equipment of thirty-four nursing sisters and an army of doctors and orderlies. Of course, all I have told you sounds very rough and unprepared, and the work was much unlike the order and discipline and finish of a well-worked civil hospital. But in a town crushed by an awful time of tension, with the great strain on the railways, the rush of patients, the dif- ficulty of providing suddenly for some twelve to fifteen hundred more patients than we usually have to provide for, the impossibility of knowing beforehand whether one man will be sent in after a battle or a thousand, and the general distress and misery that war brings, the difficulties were very great ; but all the men I saw spoke most gratefully, and, far from complaining, seemed to think that everything they could possibly want was provided in Kimberley. The ladies in the town were most good in sending milk, fruit, jelly, and all kinds of nice things to the soldiers, — often, I am sure, at the cost of much self-denial in their own house- holds. In such a vast organization as our army medical corps, War Nursing in South Africa 331 in the multitude of calls of all kinds and the huge press of work, and the strain that war brings on every department, it appears to me inevitable that there must be some incom- petent, some dishonest, some mistakes and blunders- much work which might be better done. I hear of army sisters and reserves who behave badly, neglect patients, and care for nothing but amusing themselves, but I have not met them. All I have seen, and I have seen many, have appeared to me to be, each in her own degree, quiet, earnest, painstaking women, saying little or nothing of their own discomforts, and most anxious to do all they possibly can for the sick under great drawbacks, not the least of which is that they are strangers to one another, in a strange land, seven thousand miles away from home and hospital. I do not believe that, given all the circum- stances, the numbers, the heat, the freedom, the poor food bringing its sensation of lethargy and weariness, the con- stant illness, the many deaths, — I do not believe, I say, that any other profession could have borne it as we have done. A few weeks ago I was in company with some half dozen army reserves who were traveling with convalescent patients. They seemed to me to eat most ravenously and in enormous quantities, yet they looked thin and worn. I wondered if the open-air life produced these appetites. But one day one of them said quite simply that they had all, up country, had such very poor and monotonous food that when they saw a good table with plenty and variety they felt they could hardly satisfy their hunger. That was all they ever said, and in about a week their appetites became normal. I think a flaw in the system has been the want of super- intendence. Each general hospital, of which there are something under thirty, has a Netley sister at the head, and she is undoubted mistress of all she surveys, within the Hmits of army regulations, but most mixed parties have been sent to the field and stationary hospitals. Perhaps a London hospital sister, two co-operatives, a nurse from some provincial hospital, a nurse from some little civil 332 International Congress of Nurses hospital in the wilds of Africa, a nurse who has done private nursing for herself in her own home, have all been sent tog'ether to some outlyingf station hospital entirely on an equality. If even two are sent, to my mind it is productive of peace and prudence if one is over the other ; where there are more, I am sure it is better. The best nurses should, I think, have been selected by the doctors as superintendents, and should have been called nursinj^ sisters; the rest should have taken subordinate positions and been called army nurses, addressed as nurse, and expected to do nurses' work. Many women, even with the best intentions, are not fit to be set down, away from all previous influences, and left to order their lives as seems good to themselves. From the system as it is at present have arisen the few scandals and the many failures in nursing in this great war, and it has, I am certain, destroyed the after career of hun- dreds of good nurses. Another weak point, if I am to say honestly what I think, is with the orderlies ; they do not appear to me to be the right class of man. They are above half the work, and not up to the other half. The regular scrubber, who, under the ward sister, does the rough work in a civil hospital, as a matter of course is lacking, and the men are not up to the work of a good male nurse. They are too often rough to the patients, greedy, lazy, and, I fear, dishonest. One of our great troubles was caused by this. We took over halls with beautiful new white floors, and we gave them back stained from end to end from want of proper scrubbing. A wipe-up was all the orderlies ever gave to any accident on the floor, and to get the ward well cleaned was an impossibility. No one attached to the mil- itary was willing to give the thorough cleaning a ward in a civil hospital gets daily as a matter of course, and there were great and serious sanitary faults from the same reason. The men were all too superior to do it; the nurses, of course, had neither strength nor time, until in one large hall the superintending nurse, with a small watering can of mercurial lotion and a big mop, mopped out the ward herself for two or three days, after which the orderlies War Nursing in So7ith Africa 333 slowly took to mopping it out themselves. They were all too superior for scrubbers' work, and a sick or wounded man can't be left with any peace of mind to their care for, as I say, they are not up to the work of a well-trained nurse. I should have thought that the best soldiers and best educated men would have been chosen for the army corps and thoroughly trained, like a probationer in a hos- pital, and made to do their real nursing properly or degraded. The larger number should be from a lower class of men, and be bearers, scrubbers, and regular cleaners and washers. The difficulty we had in getting washing done for a thousand sick in our worn-out town, with scarcely a bar of soap within five hundred miles, was unspeakable, yet the orderlies spent nearly all their time in idling about the guard room. I heard one surgeon-major say that his sergeant was " no more good than a sick headache," and others must often have thought as much. It seems to me that in the African campaign infinite care has been taken of the sick. The hospitals themselves, excepting always the camp hospitals, have really shown how much can be done with few appliances and in the roughest surroundings, the hospital trains have been marvels of ingenuity in the way of saving pain, and the greatest care has been taken on the hospital ships. The generals, when in town, have visited both the general and field hospitals daily ; ladies have been ready at all hours and times to cook, to sew, to fetch and carry, to write letters, to read, to help in every way. Of the doctors it does not become me to speak, but their part on the field and in the hospital alike has been noble. One doctor told me of another who went on calmly dressing a wound, scarcely looking up until it was done, although forty bullets fell either close to him or through parts of his clothing or dress- ings while he was doing it. And in criticising sanitary measures it should not be forgotten how the microbes of disease are continually carried in the proboscis of a mosquito, or what a plague of mosquitoes we had all through Africa in the year 1900. 334 International Congress of Nurses The President : Our next paper is one of the greatest importance and interest, and is to be presented to us by one who speaks with authority on this subject. I have the great honor and pleasure of presenting one who needs no introduction to this audience, Mrs. Bedford Fenwick. The Organization and Registration of Nurses. ETHEL GORDON FENWICK, President of the International Council of Nurses. "Wouldst thou plant for eternity, then plant into the deep in- ^nite faculties of man, his fantasy and heart." Such it seems to me must be the aim of any worthy scheme of organization for nurses, the inspiration of whose work is divine, and the dutiful performance of which inevit- ably ennobles the worker. This question of the organization and registration of trained nurses has occupied my mind for many years, and, indeed, there are few subjects which can be of greater importance to any profession than those which relate to its organization, and to the basis upon which its recognized membership is founded. In the case of nursing it will be generally admitted that these matters are still in an inchoate condition, although our pioneers have dug and delved, and loosened the roots of many prejudices. As most trained nurses know, there is at present no general standard of training and certification adopted for the nursing profession. Some hold that nursing is still so infantile in its growth that it would be impossible to define a general and universal curriculum of education. Others, however, have argued strongly that until inirsing education is systematized, and not only its period but its various details are accurately defined, there can be no hope for any general improvement of the nursing profession, for the simple reason that education must form the foundation 335 336 International Congress of Nurses on which the whole structure of professional organization is built. But all nurses who have considered the question intel- ligently have grasped the fundamental principle that our profession, like every other, needs regulation and control, and we claim that this power of control should rest in our own hands. That in our corporate capacity we must have the right to live, and move, and have our being, and that it is from our own ranks that the women must step out to whom the responsibility of guiding our destinies must be entrusted. Women, strong and faithful, able and willing to maintain intact the trust imposed upon them. Where are these women to come from? Surely from our training schools. The undergraduate of today is the superintendent of tomorrow, and it is to our training schools that we must turn wath hope for the future. In the hands of the superintendents of today there rests an enormous responsibility. In their wise selection of probationers, and in the example and precept they set before their pupils they can sound the keynote of the tone of the nursing pro- fession of the future. Now is the time to assure proba- tioners that it is not enough that they attain technical pro- ficiency. Unwearied devotion to the sick — obedience to medical directions — these lessons have been taught and well assimilated in the past, and have resulted in prodigious self-sacrifice, and the crowning of many martyrs in the battalions of the great army of nurses all over the world. This fine devotion to duty is mainly the result of the lessons received by nurses during their training from high-minded women placed in authority over them. It is magnificent, but it is not enough. In addition to a fine example in all / the domestic virtues, and in selfless devotion in the practical I care of the sick, our young nurses must be inspired also with a keen sense of citizenship so that when they leave the training school they will be fully alive to the importance of their public and professional duties, and be ready to enter their corporate life in the right spirit, the spirit which asks not what it is to receive, but what it can give. For Organization and Registration 337^ this, after all, is the essence of professional as opposed to commercial existence ; they must be taught that their prede- cessors have won for them privileges and liberties which are a sacred trust, which are not theirs to hold or renounce at will, but which it is their duty to jealously guard. Fur- ther they must be fired with ambition not only to maintain the standard attained by their predecessors, but also, in their day and generation, to guide their profession onward and upward. There are heroic qualities in the modern woman which will respond to such teaching. Perhaps at the present time the practical is in advance of the ethical side of our work, just because in a great measure we have been so occupied in raising our standard of practical proficiency that we have had little time, and given too little thought to the preparation of the pupil for the wider obligations which lie before her when she emerges from the state of tutelage and becomes an independent grad- uate. PRACTICAL ORGANIZATION. Experience has shown that both amongst men and women the best and strongest bond of union is to be found in the close ties of friendship formed by those who have been educated together, or have passed through the same course of training, and who are naturally drawn together by sympathy with, and admiration for, their common Alma Mater. And thus the system so wisely inaugurated in the United States, now being also successfully followed in the United Kingdom, the union of nurses belonging to the same training schools for mutual help and protection, offers in many respects the strongest bond, as well as the greatest incitement to nurses to associate together. We may take it then that the units of organization in the nursing profession should be societies of nurses who hold the certificate of the same training school, and who are therefore graduates of their profession. The exercise of the graduate vote would thus enfranchise professionally each certificated nurse, and it would become the aim of 388 International Congress of Nurses every probationer not only to obtain the certificate of her school, but admission to membership of its leag'ue. Whilst realizing^ that combination is the best means of efifecting organization and reform, the weight of our nurs- ing societies does not depend upon their numerical strength, but on the vital force and courage of their individual mem- bers. Spirit is an intangible thing. Anatomists tell us they dissect a body and do not find it. But it is indisputable that the great movements which stir society from its very foundations are invariably produced by the workings of the living spirit of man. Such great movements usually owe their impetus to one of those master spirits endowed with the genius, energy, and confidence which fit a man to wield these moral forces; to reveal to his age the wants of which it had but a dim and perplexed consciousness ; to interpret to it its own confused and half-formed opinions, and to give them shape, compactness, and strength. For some time to come there will remain a large body of nurses, working in various branches of nursing, who are not eligible for association in connection with the large training schools. In England, hundreds of those practical workers are engaged in private and district nursing, and in organizing our profession some means must be found to associate together this large number of workers. How is this to be done? Why not by forming a National League of Nurses, composed of delegates representing each train- ing school society, and also of delegates from professional associations of nurses, formed for the benefit of nurses who hold the approved qualifications of training? A NATIONAL COUNCIL OF NURSES. Having by delegation formed a National Society or League of Nurses, it would appear to me to be desirable to advance organization still further by affiliating together in a Federation of Nurses, preferably called a National Council, representatives of the Matrons' and Nurses' National Societies in equal proportions. Thus a Council of Nurses might be formed in each country representative Organization and Registration 339 of every nursin- interest, which would be eligible for affilia- tion with the International Council of Nurses, so that in a very simple manner every graduate nurse would have voting power direct or through the chosen delegate of her Training School League, in the National League, and also in conjunction with the superintendents in the National Council, and yet still further in the International Council of Nurses. The National Council would act as the supreme repre- sentative of the nursing profession in its own countr>'; would be able with united power to make representations to the government of the country on all nursing questions ; it should organize a parliamentary department, and so focus and co-ordinate the local influence of every one of its com- ponent societies, and through them the personal influence of every individual nurse, with members of the legislature, that in any act dealing with or relating to nursing matters the interests of the nursing profession should be completely pro- tected and safeguarded. Finally, through its representatives upon the International Council, it would obtain and dissem- inate throughout its own country for the information and instruction of its component societies and their members, news of what is transpiring in the nursing profession and of all that tends to the improvement of nursing in every coun- try in the world. And so we arrive at the crown and apex of the organization as I have sketched it out. THK INTERNATIONAL COUNCIL OF NURSES. The objects which it is hoped this new body will be able to attain in the future will be to draw together the Nursing Councils of the different nations; to diffuse amongst them professional information from each country which will be useful to all; to unite together and thus strengthen the efforts for professional improvement which may be made in any country, by the assistance and advice of the nurses in other lands. And above all, to arrange for the holding of International Congresses in different coun- tries, on the same grounds as those which have made such 340 International Congress of Nurses meetingfs so valuable in the past, for the general considera- tion of important nursins^ matters, and for the determination of questions which are of common interest and importance to the nurses in every country. Such then, in brief, are the sug-g-estions which I would make for the organization of nurses ; each country, of course, carrying out the prin- ciples by its own methods, and by details which seem to each to be most appropriate. Passing on now to the second branch of my subject, THB REGISTRATION OF NURSES. I would suggest a measure in broad outline, which would, I imagine, be easily adaptable, and with variation of details equally applicable to every country. It being admit- ted that the nursing of the sick is a matter which closely affects every class of the community, and that it is therefore of extreme importance to the public welfare that those who undertake the responsible duties of sick nursing should be not only absolutely trustworthy from a personal point of view, but skilled also in their technical duties, it follows that it is the duty of the state to provide public safeguards in this matter. It is, therefore, suggested that the legislature in each country should pass an act^ forming " - A GENERAL NURSING COUNCIL. This body should be empowered to deal with all educa- tional matters affecting nurses, that is to say, to define the precise curriculum through which every woman must pass before she can be certificated as a trained nurse. It must define the period of her training, and the subjects of her education ; and no nurse would then be permitted to offer herself for examination until she produced a schedule duly signed by the matron of her training school testifying as to her general good conduct and practical proficiency, and by the lecturers upon the different subjects in the curriculum, testifying that she had attended the regulation number of lectures and demonstrations on each subject. It would be the duty of the General Nursing Council to appoint Organization and Registration JiT examiners and hold examinations, and to grant to candi- dates who passed those examinations a state diploma in nursing. It would be the duty of the Nursing Council to register nursing qualifications. It is probable that it would call into existence nursing colleges to facilitate its educa- tional work. The first result, therefore, of the appointment of such a council would be that a uniform system of nurs- ing education and a uniform standard of qualification would be established throughout the country in question. Because, it is almost needless to add, that the nursing act would make registration essential as a qualification to practice ; and that no one would be permitted under heavy penalties to term herself a trained nurse, or to take any fee or reward as such unless she were duly registered. Then again, it would be the duty of the General Nursing Council to strike off from their list the name of any registered nurse who proved her- self to be unworthy of trust and professional confidence. So, on the other hand, the public would be protected against the ignorant and inei^cient persons who now can term themselves trained nurses, can obtain the most responsible work in that capacity, and so bring danger to the sick. And the nursing profession would be protected against those members of the calling who bring discredit on its fair name and on all their fellow workers. It would be the duty of the Nursing Council to publish each year a com- plete list of its registered nurses, showing the names and addresses, the date of registration, and the nursing qualifi- cations possessed by each nurse, in parallel colunms against her name ; so that in future any person desiring information on the subject, could, by reference to the register of trained nurses, ascertain at once with certainty whether any given person were or were not a trained nurse ; and, in the latter event, precisely what nursing qualifications she possessed. :; Then we come to the constitution of the Nursing Coun- cil. Without going into arguments which would be out of place on this occasion, I would briefly say that the council should be constituted so as to represent the. different inter- ests involved. First, the goyernmerit of tlie country by 342 International Congress of Nurses established custom demands its own representatives on such a council. The traininpf schools of the country should pos- sess representatives who would he of the greatest possible practical assistance in the determination of the great educa- tional questions with which the council would be called upon to deal, and the regfistered nurses themselves, whose interests would be those most involved, should, I consider, be given an ample representation, and should be entitled to elect by ballot a certain number to represent them on the General Nursings Council of their country. With reg^ard to its finances, I consider that every nurse should pay a substantial fee for registration, and a small annual payment each year. The object of this latter pay- ment deserves perhaps to be explained. It would not only provide the council with a large permanent income for its working expenses, but it would compel the nurse each year to give her present address, a matter the importance of which, in the case of such a profession as nursing, and for the correct keeping of the register, need scarcely be insisted upon. Indeed, I fear that if this measure were not adopted so many nurses would neglect to give their changes of address, and so many would die, or marry, or disappear, without the knowledge of the registrar, that the register would speedily become hopelessly incorrect and therefore utterly unreliable. But a further object and advantage of the annual fee would, to my mind, be that the Nursing Council would thereby be provided with funds to enable it suf^ciently to protect the public against nursing quacks, and to protect the registered nurses against oppression and injustice ; by means of a legal prosecution in the first place, and of legal defense in the second. I must trespass no longer on your attention. I thank you for the courteous hearing you have given me. I have endeavored to deal with general principles on which a com- mon ground of agreement may be found rather than with details on which difTerences of opinion are certain to exist. I only hope, and that most earnestly, that the deliberations of this congress on this vitally important question to our Organization and Registration 343 profession may result in the determination of some common ground of action, on which we shall be agreed, for which we can all cordially work together, and which shall in the future bring about the best possible system, whatever that may prove to be, of organization for the nursing profession and of state registration of trained nurses. The President : Our next paper under the same head- ing is by Miss Sylveen Nye, President of the New York- State organization. Madam Chairman, Ladies— I am somewhat like the Irishman who wanted to say a few words before he began. I feel that I owe an apology to all New York State nurses that I have not a better paper prepared to present in their behalf today. My only apology is that it has been Pan-American year, and I, with other Buf- falo women, have been rushed. One of the most satisfac- tory features of this congress is this, that we are all united in what we want to do. That we should differ as to methods is natural. We represent different states and different coun- tries, where dififerent conditions must exist and where dif- ferent methods must be pursued to obtain our desired results. I have been a nurse for ten years. During the last five years my work has taken me among nurses, and I have met them in more dififerent ways than ever before. When I first left my alma mater I shared the opinion of so many nurses that mine was the only hospital, my train- ing school the only school, and our staff the greatest physicians. I went from there to the University Hospital in Philadelphia, where as head nurse, later as night super- intendent, I learned that mine was not the greatest hospital in the world and our staff not the wost wonderful physi- cians. My next work brought me to Buffalo, where I was connected with a small private hospital, and I have learned to have great sympathy with the small hospitals. During the last five years I have visited and met graduates from 344 International Congress of Nurses most of the hospitals in New York State. My heart goes out with sympathy and affection to every woman who is entitled to wear a cap and gown regardless of the school from which she is a graduate. Last year I became chair- men of the committee for New York State organization of nurses. I was asked to write a paper on State Organization for Trained Nurses in the Hospital Review, setting forth what we wanted to accomplish in New York. Those who have read my paper will notice that I then advocated many of the things set forth in Mrs. Fenwick's paper today. We desire and expect to accomplish four things : Uniform qualifica- tions, uniform curriculum, uniform final examination con- ducted by the regents, and the legalization of the title of nurse. I cannot agree with the lady of the foreign delega- tion upon how to obtain these desired results. You peo- ple who are familiar with legislation and the methods used to obtain it in the State of New York must know that these things cannot be accomplished in the manner suggested by. the paper which has just been read. I honestly and truly believe that in any steps we take we must have the support and the co-operation of the phy- sician, the patient, and the hospital authorities. I have no sympathy with the movement that ignores the advice and the wish of the medical profession and hospital authorities, and the people under whom we are compelled to act, and who control to a very large extent our patronage, nor with any organization of nurses that does not include all nurses. One of the most encouraging features of this wonder- ful new century is the demand for the betterment of condi- tions affecting human life. Among all classes, from the humblest laborer to the most profound scientist, we see a spirit of progression. The various movements for organi- zation, for the benefit of the many, demonstrating, as they do, the desire for better living and for the elimination of evil, have never been equaled. The need for improvement in the nursing profession is loo well known to admit of discussion. The nurses of today Organization and Registration 345 are not satisfied with their standards, and to me the most hopeful feature of this is the fact that the dissatisfaction has come, not from patients, physicians or hospital authorities, but from the nurses themselves. The many or^nizations of nurses have been diagnosing; they have been holding consultations, if you please, and there is an unanimous decis- ion that something for improvement should be done. The universal and spontaneous formation of nurses' organizations, under different names and different forms, indicates a current of feeling not plainly visible, but which will be felt; the general demand for improvement and pro- tection of our profession is not to be temporary, but it must be granted if proper methods are employed ; a mistake, even though slight, in our course will be fatal. It must be con- ceded that an organization of nurses which includes all nurses is our strongest possible formation. Once united we can make ourself felt and cause the enactment of laws for our protection. Protection to ourselves from the entrance to our ranks of unfit and improper persons ; pro- tection to ourselves from the quacks and frauds invading our ranks, claiming that which we have struggled so hard to acquire; protection to ourselves against the institutions unfit and incapable of giving a training suitable to prepare one for the work, but which now turn out graduates with the title of "nurse," but before we can effect the enact- ment of such laws we must be united — united in its full- est meaning, and create a public sentiment which demands all we so much desire ; cause the public to feel that which we so keenly feel ; make our cause that of the public. The best and most stable laws are only answers to the demand of the people. We can never expect it from any other source, and if, by chance, we should succeed it would be only with diffi- culty that we could cause the enforcement of such statutes. If we make ourselves felt, if we are strong enough to impress the necessity upon the public, it will of itself attain our de- sired end. While the course we have to pursue may not be a new one it must necessarily be original. It is dangerous to imitate. Facts and circumstances diflfv^r, and the most it is 346 International Congress of Nurses safe to do by way of acceptinc^ criterions is to profit by the errors. Do not let us attempt imitation, lest we fail. Orij^i- nality is admirable, satisfactory and usually successful. Imitation is not the genuine — it is cheaper. It is not a suc- cess — no matter how perfect the imitation. Our training- should have taught us to use discretion ; to shun petty and trivial matters ; to hold ourselves above any and all things that in the slightest degree retard the progression of our profession, even though it be to the individual's displeasure; to ignore all except that which brings the goal nearer ; to grasp every opportunity to advance the profession and very soon the desired legislation will come without serious hindrance. The question with which we have to deal is "How to Organize " The first step is to let go the non-essentials ; let go all selfishness and self-seeking, all bitterness and unkindly feeling. We cannot accomplish what we wish without a true sisterhood. The nurses of today are, in the main, earnest, sincere, practical women, ready to do that "something;" ready to take hold and help lift if they are only shown how^ Just think what we might accomplish if we could reach nurses in a way to divert all energy wasted in vain worry, criticisms, foolish bickerings, fretting over non-essentials, into success capital. Governor Russell, of Massachusetts, once said : " Make a living, but remember that there is another thing better than making a living, — making a life." In all sincerity, all candor and honesty of purpose I want to say that I believe that a State society organized on alumnae lines would be a failure. The very nature of such an organization is too narrow. Nurses need to broaden, to mingle with those of other schools, and to get out of the ruts. The nurse whose first interest is " our alumnse" is apt to be narrow or to become so. A membership in a well organized, well conducted, general club is uplifting. It inspires a person with a wholesome self respect, and — " It is the first blow at the petty prejudices which the old man- ner of living apart from the world has fostered. In it a Organization and Registraticvi 347 woman quickly learns that hers is not the only true religious creed, that her doctor is not the only worthy M. D., that her way is not the only infallible way. She is soon ashamed of her own narrowness." It would be a mistake to make the State associations dependent upon the success of the local organizations, which are too often failures, and kept in existence only through the indefatigable efforts of a few women. We would give all honor to the alumnae socie- ties. They have done much toward agitating and bringing to notice and thought the need for improvement, but we believe they should be subordinate to the general club, otherwise, they disseminate the forces and weaken all finan- cially. Their continued existence, except as a means of maintaining an esprit de corps among the graduates, and a love and loyalty for the Alma Mater, is a step backward and jeopardizes progression. Within the next few months three States. New^ York, Illinois and Virginia, will perfect a State organization. I cannot dwell too strongly upon the need of organizing in such a way that we may be able to command the assistance of every nurse in the State; and that we can rely upon the co-operation of physicians and not antagonize hospitals and through them politicians. The New York State Society w-as organized last April with sixty-five charter members. The plan of what shall constitute membership is to be settled at the second meeting. I believe that we should organize in such a way that we may ask any woman in the State who is a graduate of a recog- nized school to become a member; we reaHze all that that implies ; it would mean the admission of many whose stand- ards are not what we might wish, but the fault is not theirs ; we must look farther back ; the wrong is with our laws that have allowed all sorts of hospitals to maintain training schools regardless of the product. My plan would be to have all such help us to help themselves. Ability means to take conditions as they are, and make of them what we wish. I would have meetings held as often as every three months, giving all members an opportunity to attend. 348 International Congress of Nurses A business corporation in which I am interested lately issued a bulletin in which was quoted these old Greek lines : "Who art thou?" " I am Opportunity, the master of all things." " Why on tiptoe standings?" " I run forever forward." " Why is thy hair all in front?" " For him who meets me to seize." It seems to me that there never was a time in the history of the nursing profession when an opportunity — oppor- tunity worth while — 'was so easily within the grasp of each individual nurse, as at this particular moment. The President: Our next paper is also on the same subject as it relates to Canada. Organization and Legislation in Canada. MARY AGNES SNIVELY, Lady Superintendent General Hospital, Toronto, Canada ; Member of the Ameri- can Society of Superintendents ; Treasurer of the International Council of Nurses. It is my privileg-e and pleasure to present to this con- gress a brief statement regarding- the present status of nursing in Canada, and, in order that I may not needlessly occupy valuable time, I will simply state that all of oiu- rep- resentative schools are conducted on the same general lines as those which obtain in well-regulated schools in this country. We employ the same methods, we are animated by the same aspirations, and we endeavor to keep before us the same high ideals as our fellow-workers in the United States, to whom we unhesitatingly and gratefully acknowledge our indebtedness. True it is that, at present, such schools are few in number in Canada; nevertheless, these undoubtedly constitute the leaven which, while working more slowly in our more conservative country, is none the less surely and steadily asserting itself along the line of progress. We have our school organizations, and these are undoubtedly multi- plying, and we have attempted a national organization. In 1900 a bill to incorporate the Canadian Nurses' Association was introduced into the Dominion Parliament, but on account of certain clauses which were considered detrimental to the interests of nurses it was withdrawn after the second reading with the promise that a second bill should be introduced within a year. ^^^ 350 International Congress of Nurses In 1901, when the second bill was introduced, it was evident that a progressive association could not prosper under the conditions with which the bill was likely to be freighted, and, further, that in Canada there remained much yet to be accomplished in the way of alumnae and provincial associations before a national organization would prove beneficial. The bill for these reasons was withdrawn. An important feature in connection with many of our large training schools is the decided advance in respect to the conditions which surround the nurse in the home or residence where her " off duty " hours are spent. In many instances these are commodious buildings adjacent to the hospital, with well-lighted and heated sleeping apartments, parlors where they may spend their leisure time or entertain their friends, libraries containing both general arid medical literature to which they have access, lecture and class-rooms containing suitable charts and appliances where they receive theoretical and practical instruction. It must be remembered that the evolution of the Canadian trained nurse has taken place in a country where wealth is to a large extent limited. With the exception of Montreal, this may truly be said of all Canadian hospitals. But difficulty and struggle do not necessarily imply failure; indeed, we all know that the contrary is generally the case, for effort is usually the price paid for development. Sterling worth, strength of character, and fertility of resource are the characteristics so eminently conspicuous in our ancestors who in the early part of the last century were pioneers in our vast dominion. And no less is this true of nurses who have gained their experience in the less wealthy hospitals which are found in the Dominion of Canada. Yet Canada has truly made rapid strides in nursing during the last fifteen years. She has learned to value skilled nursing to such an extent as to be willing to make almost any sacri- fice in order to secure it. Her physicians and surgeons are now loyal friends and allies, when once they were inclined to be conservative or critical. The larger schools are yearly making noticeable Organization and Legislation 35^ advance in educational methods, and the smaller ones are rapidly multiplying in the newer parts of the country, these in their turn becoming centers radiating in lesser' degree their benign influence. Still, we realize that we have not yet attained— far from it— but of Canadian nurses it may truly be said, " we are reaching forward to those things which are before, and ever pressing forward towards the ^oal of our high calling." The President : The subject of the papers to which we have just listened must appeal to every member of this audi- ence. It is one of vital importance to every one interested in the nursing profession; therefore the chair would of!er this resolution, which has received the endorsement of the executive committee: Whereas, The nursing of the sick is a matter closely affecting all classes of the community in every land ; and, Whereas, To be efficient workers nurses should be carefully educated in the important duties which are now allotted to them ; and, Whereas, At the present time there is no generally accepted term or standard of training, nor of system of edu- cation, nor of examinations for nurses in this or in conti- nental countries ; and, Whereas, There is no method, except in South .\frica.* of enabling the public to discriminate easily between trained nurses and ignorant persons who assume that title ; and, Whereas, This is a fruitful source of injury to the sick and of discredit to the nursing profession, T^solved; That it is the opinion of this International Congress in general meeting assembled, that it is the duty of the nursing profession of every country to work for suita- ble legislative enactments regulating the education of nurses, and protecting the interests of the public, by securing State examinations and public registration, with the proper penal- ties for enforcing the same. [*And now inNew Zealand.— Ed.] 352 International Congress of Nurses Miss Stewart: I have much pleasure in seconding- this resolution, but first I want to say that I am not a delegate from any association, and what I say is for myself alone. I think that State registration is a cure for many of the evils we see every day. It will, to a large extent, prevent the partially trained or untrained nurse taking what properly belongs to the trained nurse, her work and her title to which she has gained the right by three years' work and study in a g-eneral hospital. In England we use very gener- ally, what I see but rarely in America, the outdoor uniform of cloak and bonnet. It can be worn by anyone and is some- times the only qualification its wearer has to the name of nurse, and it serves to cover such a multitude of sins. Reg- istration cannot altogether alter this condition, for the public will at all times choose for itself ; but, at least, it will give the public an opportunity of knowing what it is choosing and paying for. State registration for nurses means a uniform standard of ef^ciency. This is one little point upon which Mrs. Fen- wick and I disagree. She advocates a uniform curriculum, which I do not. I always deprecate anything that takes away the individuality of the schools. Let there be a uni- form standard of ef^ciency, which each school must reach in any way it finds best suited to it. I think we must hold to the uniform standard and leave the curriculum to the indi- vidual schools. There are many difficulties to be faced when the details of this scheme come to be considered, and not the least of them will be the small hospitals of thirty and forty beds and under. It is impossible for nurses to be adequately trained in them, partly from want of sufficient variety of cases and partly from the almost insuperable difficulty of enforcing the discipline of the larger schools, and, to a large extent, it is discipline which trains the woman into the nurse. Although, as I have pointed out, I see the difficulties which lie before us, when we come to the details of this scheme, I am, and always have been strongly in favor of State registration and examination. Therefore, I have much pleasure in seconding the resolution now before us. Organization and Legislation 353 - Miss Snively: Madam President, ladies. As a Cana- dian representative I would like to say that Canada has shown her appreciation of the resolution which has been moved by the chairman regarding the legislation which should come in behalf of the nursing profession. Many of those present remember we have lately made an attempt at legislation, and although we have failed. I may say that one cause of the failure, perhaps one of the very prominent cause of failure, was just on the line we have been speaking about, because some of the members of parliament feared for the nurses with whom they were personally acciuainted, who had done good work in their families, although they were not trained nurses, absolutely trained nurses, they feared that future promised ill for them. We hope to make another trial on a better line and that Canada will have legis- lation for her trained nurses. Miss McGahey : I endeavored to tell you on Wednes- day about our association in Australia. Our association there is well established. We have much more to do and hope to do it, and no doubt will do it in our own way. We hope at no distant day to have introduced in parliament a bill to save our nurses, to safeguard ourselves. Many years ago we realized the great necessity, realized that a great injustice was being done our nurses who had taken the training school work for four or five years, and when they went out as private nurses they had no better position than those who had spent only six or eight months and who were able to give satisfaction to the doctor, or the head of the training schools who had been perhaps asked to resign because unsatisfactory, and still stood on the same platform as those who had spent years in training. In one way the Australasian Trained Nurse Association has done a .great deal of good, and we now have a register. Now many of the public who employ nurses refer to our register, and if the nurse's name is not in the register no doubt she is asked why she is not there. The leading nurses are all registered. It is very gratifying to learn that New Zealand, a couniry 354 International Congress of Nurses always well to the front, has had a bill introduced in their parliament to protect the nurses. It is already now in the first reading- and may have passed the upper house, and we hope before the next meeting- of the International Council of Nurses you will hear that Australia has got its State reg- istration for nurses. Mrs. Robb: Madam Chairman, ladies — I warmly endorse Mrs. Fenwick's paper. American nurses may not be aware that we are indebted in part for our education in organization to British nurses, and British nurses may not be aware, in their turn, that they have been silently teaching their younger American sisters ; I think this, therefore, a very fitting moment to express our appreciation of the advantages they have so generously given us through their pioneer efforts. That we have tried to improve by them the work that we have accomplished during the last seven years testifies, and in order that you may know where our education began, I will briefly speak of the organization of the Royal British Nurses' Association. This organization, as you perhaps know, was the first asso- ciation among British nurses that came to our notice. It was indeed most interesting to read of its inception ; it at first seemed to American nurses who read about it that the organization was all that could be desired, as the association stood partly for the registration of trained nurses. But on further reading its transactions, and following its workings, we found that something was wrong, and after a little closer study the following criticisms seemed warranted : First, it was evident that the nurses of the Royal British Nurses' Association were not really acquainted with each other, or at least not sufficiently well enough, to have organized for the purpose of legislation ; consequently how could they ask the public to know them and think well of them? second, that the Royal British Nurses' Association was being too much looked after by the medical profession ; and, third, that it was being too heavily patronized. Therefore, when it came to the question of organizing in America, for pro- Organization and Legislation 355 fessional advancement and for the purpose of obtaining legislation for nurses, we had learned, first, that it would be wiser to organize nurses in such a way as to enable them to become thoroughly acquainted with each other, and thus to know our own minds before we could seek recognition as a profession of intelligent women by the public. Second : That we should have something like a uniform basis of general education. We should know better what our training schools were teaching, as there seemed to be no uniformity in the system employed in the different schools. We had really no general idea of what was being done, and all that had to be worked out; and, third, we clearly saw that we should look after our own affairs, and do our own work, and create our own profession. We do not mean by this, however, that we are not aware of our constant obliga- tion to a kindly public, and also that we should be and are loyal to the medical profession, but if we wish to be a suc- cessful body of workers, we must take care of our owm affairs from beginning to end. On this basis, then, the American nurses began to organize — first the school alumnae, for we could not ask you to be interested in a large organi- zation of nurses, until you knew your own colleagues, or to grasp the broader professional problems until you were interested in home affairs. For educational purposes also the Society of Superintendents of Nurses was formed, and next arose the question of the organization of the profession as a whole, and only last year did we finally reach, in that process of organization, the point at which we could begin to consider legislation, and I am happy to say that the ques- tion was at once taken up by the State organization of nurses of New York, and we are hoping for very favorable results. The privilege of meeting with the foreign delegates to this Congress makes it very clear to us what the next step in our organization should be, and, as Mrs. Fenwick so forcibly put it before us, the necessity for further organiza- tion in order that we may become better acquainted with the nurses of other countries and their work. Many of you, 356 International Conc^ress of Nurses no doubt, were present at the meetingf of the International Council of Nurses held in this room last Tuesday. At that time we were told that the United States is the only country at present in which the nurses are ready to afifiliate with the International Council of Nurses, so we have not worked in vain up to this point. So far as a uniform curriculum is concerned I quite agree with Mrs. Fenwick. It was with great pleasure that, only the other day in an educational journal, I read that the president of one of our large universities advocates the advisability of a uni- form standard education for the universities of the country, and it seemed to me that unknowingly we had worked along the right lines in this respect. The President : You have heard the resolution ; all in favor of adopting it will manifest it by rising. All rose. The President : The chair understands there are to be some further resolutions presented. I will call upon the secretary to read the first resolution. The secretary reads : Resolved, That the third International Congress of Nurses strenuously protests against the sending out of pupil nurses to private duty during their period of training in the hospitals. [Proposed by Miss Nevins, superintendent of the Gar- field Hospital in Washington, D. C] Miss Dock : I second the motion. The President : This resolution has been presented by Miss Nevins, of Washington, D. C, and seconded by Miss Dock. All of those in favor, signify it by saying aye. It seems to be unanimously carried. Delegate from Maryland General Hospital : I desire to second that resolution because our society is so very anxious about this point. Organization and Legislatioti 357^ Miss Dock : I willingly yield my second to the dele- gate from Maryland. The President : \\q will now have the third resolution. Resolution read by secretary : Resolved, Tliat the delegates and visitors to this Con- gress, having a deep appreciation of the benefit and pleasure they have derived from these meetings, desire to express their gratitude to all officers and committees for the excel- lent arrangements made for the meetings of this Congress ; also to all \n\\o have given of their time in the preparation of the papers and addresses which have been of such great interest and instruction. They also desire to express the pleasure this assemblage has had in welcoming the foreign delegates. They feel that this coming together of the most distinguished members of our profession in Great Britain and her colonies and in this country, with the good will of those in Europe, has been productive of most unusual stimu- lation, w^hich we trust will result in good and effectual work. The President : This resolution has been offered by Miss Hay of the Illinois Training School, and has been seconded by Dr. Hughes of Boston. I think I voice the sentiments of the Congress, and especially of the American members, when I say that we are greatly indebted to the foreign delegates for their papers and for their very helpful ideas. We are indebted to them for the formation of many of our training schools, and 1 wish to express our appreciation to the English nurses for com- ing here and giving us so generously of their time. You have heard the resolution. The chair would request that the Congress express its approval by rising. The audience arose. Mrs. Fenwick: Madam President, colleagues— I just arise to respond a few words to this most kind resolution which has been passed by the Congress. I feel sure that every delegate who has attended this Congress, either from England, the colonies or elsewhere, has enjoyed it as a pnv- 358 International Congress of Nurses ileg-e. We thank you for the kind way you have listened to the papers we have been privileged to read. I must express my appreciation for the honor of being your honorary president. It is the highest honor that has ever been con- ferred upon me. I thank you. Miss Stewart : Mrs. Fenwick has said everything that ought to be said. It has been the ambition of my life to come to America, l)ut I doubt if I should ever have come if this Congress had not given me the opportunity. I assure you that it is not often one has the pleasure and privilege of preparing a paper to be read before so many whose names have been house- liold words for so many years. I thank you very much for your kindness since I have been here, and for all the pleasure I have had. Miss Amy Hughes : I can only join with those who have already spoken in thanking you all most warmly for vour kindness to us. It has been a great privilege to be present at such a Congress as this, and I personally appre- ciate it even more because I had the happines of attending the one in 1893. If I may say so, I am deeply impressed bv the sense of growth and increased unity and strength presented at this meeting. The feelings of devotion to our work and the desire of attaining a high standard profession- ally have developed so quickly that I am tempted to compare the movement to the Indian juggler's artifice of planting a seed before his audience which in a few moments is shown as having become a little tree. I would say our strength and hope for the future lies in the efforts of each individual nurse to honestly maintain in herself the high standard we are aiming at. We must not forget we are soldiers and must therefore loyally obey the orders of our officers, the medical profession, in our work ; but in our own hands alone lies the position we as a profession will take in the eyes of the world. Such a gathering as this, with its unity of purpose manifested in so many countries, under varying conditions, shows what can be done and what lies before us. I thank you all most warmly. r '^ Organization and Legislation 359 Miss McGahey: I have appreciated being present at these meetings. For many years I have looked forward to a visit to America, and now my hopes have been reahzed. I think that I have traveled farther to attend this Congress than any of the other delegates. I have come 15,000 miles. I assure you that the reception I have met with will not soon pass from my mind, and the meetings which I have been privileged to attend have been most edifying and instructive. I thank you all. ■ MissMollett: I want to speak personally. They have all mentioned the privilege of meeting you here, but I want to emphasize my personal enjoyment. It has been to me a great pleasure and happiness, and I carry away with me the recollection of American nurses that is most pleasing. I have met with universal kindness, courtesy, and considera- tion, for which I thank you very sincerely. Miss Stevenson: Madam President, ladies — Although I have not the honor to be a nurse, I have for many years been connected with nurses in various conditions. In the first place, as one of the guardians of the poor, I have had to do with the workhouse hospital. I have also had to do with the Queen Victoria Nursing Association. I also have for many years been a member of the Royal Infirmary, so I have some excuse for saying a few words to you. and I thank the committee who organized this Congress, from which I have learned much. I am perfectly certain that after having been here I shall be much better fitted for any duty that I am called upon to perform in connection with nursing. I thank you most cordially for the kindness 1 have received, and I shall never regret the day when I made up my mind to cross the Atlantic and come in contact with tiu- American nurses. Miss Wood: My co-delegate has said all that could be said, I think, but I would like to make one point, and that is that we owe a very great debt to the organizing bexly of this Congress. It has been a great piece of work to get 360 International Congress of Nurses it up. There has been no detail omitted. Nothinj^ has been foff^otten for our pleasure and hap]:)iness. I really have to thank our American sisters for havinj^ given us a very good time. I think everything I ought to say has already been said, but I would like to add that I think I return to Eng- land a more intelligent and a broader-minded woman. Miss Cartwright : Madam President, ladies — In behalf of the Registered Xurses' Society, which I have the honor to represent, I very cordially thank you for your kindness to me as one of the British delegates. -j-i' Miss Arkle : I claim the distinction of having come the farthest. One delegate says she has come 15,000 miles, but I have come from India to England ; that is 8,000 miles ; from England to New York, 3,000 miles ; from New York to San Francisco, 3,000 miles ; from San Francisco here ; and I think that makes more than 15,000 miles. So I have really beaten her. I should not have come had I not known I would enjoy myself most thoroughly, and I have enjoyed myself more than I expected. The President : The chair feels quite unequal to say- ing what is the proper thing, only to echo the kind expressions which we have heard from our foreign visitors, and which we have heard from our own home delegates, and echo the feeling that is in the hearts of us all. It has been worth all the work it has given to bring it about, and it is going to be a red letter day in the nursing profession all over the world — this third International Congress of Nurses. The improvement in all lines, in all departments of nursing will go on with new vigor. Those of us who are here today who know anything of the work of the International Congress of Nurses in Chicago, know how much grew out •of that, and, as Miss Hughes has said, if from that we have grown so much, surely from this there should be greater and fuller growth than ever before. The meeting will be adjourned now until tomorrow .afternoon at the Exposition grounds. SATURDAY, P. M. Mayor Diehl, the first speaker, extended a welcome to the visitors more in the capacity, as he expressed it, "of a medical man than as a mayor." In the course of his remarks he said that no physician on earth holds such a responsible position as does the nurse. Mrs. John Miller Horton, in her usually gracious man- ner, extended a welcome in behalf of the board of women managers of the exposition. " The request to say a few words of welcome to you comes to me as a pleasant means of expressing the deep interest I feel in your organization," she said, "and my appreciation of the noble work in which you are engaged. Some of you have come to us from over the sea. To you r extend a double welcome. It must be remembered that only a few short years ago you were obliged to fight the prejudices that new methods are apt to encounter in the Old World, and those of us who were traveling on the con- tinent were obliged to telegraph to London for help in times of illness. It will be recalled that the uniform you wear then sent terror to the hearts of many of the gay revellers at Mediterranean resorts, who thought only of themselves and did not wish to have any reminder of the grim presence of disease. To me that uniform is a badge of honor worthy to rank with the cross of St. Louis or Victoria. Your pro- fession calls for not only great technical skill, but a rare patience and courage. " In this connection I will relate an incident which occurred a few years ago in one of the cities in the south of 361 362 International Congress of Nurses France. Through the long, lonely watches of the night a mother sat by the bedside of her child, ill unto death, unable to find anyone to aid her in the care of the little one. But when, with the dawn, the English trained nurse arrived from London, it seemed as if the brightness of the sunshine had entered the sick room, and the heavy burden of a dread responsibility had been lifted from the mother to the willing shoulders of one whose tender hand brought healing in its touch to the sick child and comfort to the anxious heart of that mother, whose gratitude found expression in a wish to save others the anxiety she had suffered, and thus was founded the Holland Home for Nurses on the Riviera, where, in a comfortable home, the young nurses who leave London for their work among the winter resorts in the south of France can stay while not employed, and those desiring their services have but to ap])ly there to secure at once the help needed. " No words of mine can express the gratitude we feel toward these noble, self-sacrificing women who come to us in our sorrow and anxiety for loved ones. They are, indeed, like unto the ministering angels of God, bringing healing in their wrings. " Most cordially, then, I bid you welcome, thrice wel- come. May your coming here be fraught with as many blessings to you as has the coming of your sisters been to those of us who in our need have had the comfort of having you abide with us, in our homes and in our hearts." A Plea for the Higher Education of Trained Nurses. ETHEL GORDON FENWICK, President of the International Council of Nurses. Ladies and Gentlemen : 1 am deeply sensible of the honor of addressing this great assembly in the interests of nursing. Trained nurses and the public are so closely united by the ties of friendship and mutual obligation that this seems an opportune moment to consider how best they can discharge the duties they owe to each other. I trust you will not misunderstand me when I say that the public generally are not acquainted with the vital needs of trained nurses, and have not fully realized the very rapid process of evolution which nursing is passing through in order to keep pace with the demands made upon it by scien- tific medicine and surgery. Let me prove my point by reference to Florence Nightingale. I doubt very much if the large majority of persons who honor her name realize the significance of her unique work, which is the heritage of humanity. The world is apt to associate her name primarily with army nursing reform, but it is not the Red Cross which will symbolize her life's work and immortalize her name when she goes hence, but the fact that she laid down the laws and principles of nursing on a scientific basis, and it is because she realized and enforced the truth that nursing is 363 364 International Congress of Nurses not only a technical handicraft, but a scientific profession, that the nurses of all nations owe her an inestimable debt. The modern nurse, so fit and trim, is now indispensable in every sick room. She is known to and honored by all. Nurses have qualified themselves for the duties demanded from them — their expert knowledge, their skill, and resourcefulness have only been acquired by years of prac- tical work in the hospital wards and by many hours of theoretical study. This severe training successfully passed through, they are ready and willing to pour out a treasure of skilled and tender care for the benefit of the sick and suffer- ing amongst rich and poor, and their only demand is that the educational curriculum — l)e it never so severe — shall fit them to perform their duties in the most thorough, and in the most acceptable, manner. With a few notable exceptions modern training schools do not provide a complete system of nursing education, and I doubt if it is possible for them to do so. It may be urged that the old order has passed and a new era dawned — that we have now good training schools connected with our great hospitals where the best clinical material is at hand, that to these hospitals are attached well regulated nurses' homes, under the direction of trained superintendents, provided with every comfort and even luxury ; that theoretical teaching is organized, and practical details systematically taught ; that hours on and off duty have been carefuly regulated. All this being admitted, the question may be asked — What more is required? I own gratefully that much has been accomplished, and notably in the United States, but I would also urge that much remains to be done. Few who have studied the ques- tion will be prepared to admit that the nursing education afforded by the majority of our training schools is the best which it is possible to give, and until this is unanimously conceded nurses must earnestly plead for increased facilities for acquiring knowledge in order to qualify themselves for their onerous vocation in the best possible manner. Moreover, when our training schools have thoroughly Higher Education 365 systematized their teachinjr there will still remain functions in relation to the education, discipline, and status of the trained nurse which will not come within their jurisdiction. Science and hospital economics are daily makinj:^ such increased demands upon the intelligence and vitalitv of trained nurses, that with the best the training schools have to give them they cannot go the pace. To enumerate our most pressing needs, we require pre- liminary education before entering the hospital wards; we need post-graduate teaching to keep in the running; we need special instruction as teachers to fit us for the respon- sible positions of sisters and superintendents ; we need a State-constituted board to examine and maintain discipline in our ranks, and we must have legal status to protect our professional rights and to insure to us ample professional autonomy. We stand now at the Rubicon, and to cross it we need a gilded galley. We must either go forward or go back ; beyond, we see plainly the flowery promised land ; before us lies the organized and scientific profession of our dreams, in which every duly qualified nurse is registered as a skilled nursing practitioner. Behind us is that dreary downhill path, descending to a disorganized vocation of obsolete methods, in the ranks of which all kinds and conditions of workers — good, bad, and indififerent — struggle and compete. Justice and self-respect demand that we shall go for- ward, and it is greatly to the honor of nurses that the cost of professional organization and progressive educational methods has been financed by some of their members inspired by a high sense of professional duty. Here in the United States I have only to allude to the splendid work accomplished by the Society of Superintend- ents of Training Schools. Having associated themselves together to effect professional reform, they brought into existence the Alumnae Associations of graduate nurses, which are grouped into a national society known as the Associated Alumna of Trained Nurses of the United States. Together the Superintendents' and Nurses' Societies form 366 International Congress of Niirses the Federation of American Nurses, a body which repre- sents the profession in the National Council of Women, and which will at an early date also affiliate with the Interna- tional Council of Nurses, which has called together this great Congress. Again, when it was realized that American nurses must have a voice in the press, those same women came forward and undertook the entire financial responsibility of produc- ing the American Journal of Nursing, to which they have also given generous unpaid services. Through the influence of the Society of Superintend- * ents a post-graduate educational course for nurses desiring to qualify for the higher professional posts has been organized at Teachers' College, Columbia University, and members of the society have ungrudgingly given time and labor to make the course a success. We realize, therefore, that nurses have not been unmindful of their professional obligations. But educational advantages for nurses mean a direct gain to the public, and I think you will agree with me that it is not just that the whole financial burden of the further advance of nursing should be entirely borne by nurses them- selves. In other and richer professions the public take their share in financial support. Witness the magnificent univer- sities, the endowed professional chairs, the medical colleges, public libraries, and numerous organizations which afiford opportunities of study to different sections of workers, resulting in the ultimate benefit of the community at large, but owing their existence to the munificence of a compara- tively few public-spirited persons. I claim that the time has come when nurses need their educational centers, their endowed colleges, their chairs of nursing, their university degrees, and State registration, and the present seems the psychological moment to come to the public, not as strangers, but as professional workers known and trusted through the length and breadth of the land, and to urge that, as nurses pour out on its behalf a skill and Higher Education 3(57 devotion for which gold is no real recompense, the public shall now prove its appreciation and interest in the noble work of .nursing by giving something of its wealth to place nursing education and the status of the trained nurse on a strong financial basis. Is it too much to hope that the wealthy will come for- ward and found colleges of nursing — colleges in which the teaching power of the profession would be focussed and centered, which would put the apex on our training course, and by improving the standard of nursing the sick confer a real and lasting benefit on humanity at large? To pass from the consideration of the theoretical and technical curriculum of nursing education : A nurse cannot live by learning alone. We must consider also her fantasy and heart. The heart must be cultivated with as much assiduity as the understanding. True excellence of charac- ter is usually acquired by self-cultivation, by patient and unwearied endeavor, and it is founded on the conviction that intellectual attainments alone are those which can exalt the mind, that pure and virtuous feelings alone are those which can adorn it. To this end we would have nurses come into touch with all that is purest, wisest, and most potent for good in this beautiful world, to do which they must take their part in the civil and social movements of the time, realize the obligations of citizenship, and appreciate at their true value national and international events. They must live with others, not altogether for them. During this last decade there has grown up the great International Council of Women, initiated. I need hardly say, by an American woman, to which the women workers of the world gathered into National Councils are affiliated. Listen to the preamble of the constitution: "Sincerely believing that the best good of humanity will be advanced by greater unity of thought, sympathy, and puri>oso. we hereby bind ourselves together in a confederation of workers committed to the overthrow of all forms of ignorance and injustice, and to the application of the Golden Rule of society, law, and custom." 368 International Congress of Nurses Would it not be well that this mother Council should attach to itself by the silken strin^^s of sympathy interna- tional societies of experts, such as the nurses have founded in their International Council of Nurses, and thus encourage them in their social and moral development? And would it not also be well that it should gather from us, for its own intellectual expansion, all the expert information we have to impart? In conclusion, may I recapitulate the three points which I wish to impress upon your kind attention^ and throug-h the good offices of the press on others also. 1. The need for a more thorough and better organized educational curriculum for trained nurses, and the founda- tion and endowment of colleges in which such education can be centered. 2. Tlie advantages of an International Council of Nurses for the furtherance of the social and professional progress of nurses, and for the maintenance of a high stand- ard of nursing ethics and esprit de corps. 3. The advantages of the al^liation of international societies of experts with the International Council of Women for mutual intellectual expansion and organization. Miss Louisa Stevenson, of Edinburgh, Scotland, dele- gate from the National Union of Women Workers of Great Britain and Ireland, indorsed the suggestions made by Mrs. Fenwick as to what was necessary in order to raise the standard of training so as to fit nurses to render such service as would ensure to their patients the full benefit of the progressive skill of physicians and surgeons. She said the public required enlightenment on this question, as few understood what efificient nursing meant and might be made. Much responsibility lay with the nurses themselves, and each one should realize that she is either helping or hindering this work. To hinder it one had simply to do nothing. A very little efTort on the part of each would accomplish wonders. Higher Education 369 Miss Isla Stewart, of London, president of the Matron's Council of Great Britan, presented to Miss Mclsaac the decoration of the Matron's Council, as an honorary distinc- tion and as a token of the appreciation with which she and her work are held by the members of the Matrons' Council of Great Britain and Ireland. Miss Mclsaac, in accepting the honor, declared it a tribute from the Eng-lish nurse to the American nurse, and not to herself personally. A Retrospect and a Forecast. CATHERINE J. WOOD, Superintendent of the Nurses' Hostel, London; Delctrate frum Fourteen Nursea' Associations of England. The sick man has been with us from all time, there- fore the nursing- of the sick is not an invention of the pres- ent day, but has chained effectiveness, in common with all cognate subjects relating to life and health, by the light which has been shed upon it in modern times. The nun by the bedside in the convent infirmarium was none the less a sick-nurse, though she was groping her way among the perplexities and complexities of human disorders without the aid of scientific knowledge, and that she did her work well we, who stand in the full light of scientific nursing, must own. When sick-nursing was undertaken apart from the religious life of the convent, it entered on a new phase, and a phase in which it touched its lowest point. From being the occupation of the well-born and religious-minded woman, it became the employment of the outcast and the iiimioral. It was at this point that several philanthropists. Pastor Fliedner in Germany, Mrs. Elizabeth Fry in England, and others whose sympathies had been aroused by the ghastly suffering and neglect of the sick, initiated the deaconesses of Kaiserswerth and the Nursing Sisters of Bishopsgate street. The system of training for both orders w^as the same : They learnt the technical work in the hospital, and were taught general domestic service in the institution. 370 Retrospect and Forecast 371 The whole of their Hfe, being ruled and directed as in a religious house, was supposed to be devoted to the service of the sick, though they were without the life vows of the nun. It was an essentially Protestant revival; it sprang out of the heart of Protestant nations. Tlie Roman Cath- olic nun was still nursing in the infirmarium, but her meth- ods were the same; she had not improved her training. The great hospitals up to this date (I am speaking of the first quarter of the nineteenth century) were unaffected by the movement; the masters of the art of healing had not yet grasped the fact that medicine practiced without nursing must be one-sided in action; that until the intelligent min istrant took her place as the eyes and hands of the doctor, the best possible was not done for the patient. At this time the skilled nursing of the patient was of necessity left in the hands of the medical students, who were inclined to look on the patient as so much material provided for their instruction. The " nurses " were drawn from the lowest denizens of the surrounding neighborhood, such as pre- ferred sick-nursing to street-walking, and perhaps they were able to combine the two trades. This was the state of nursing as recently as in the sixties. I am now speaking of matters within my own knowledge. The charwoman still reigned supreme in the great hospitals in London as the night nurse, and was in request when a " special " was wanted ; strange though it may sound, this system was one of the hardest to kill. As a variant on this method of night nursing the nights were shared out among the day nurses, the turn coming every third or fourth night, with the result that the most convalescent patient sat up, the night nurse taking the vacated bed. With the Crimean war and Miss Nightingale, a better prospect opened out before the sick. Miss Nightingale's work is known to all, it is written in the pages of history, it lives in the heart of every true nurse. To her is due the credit of placing before the world the need of efficient tram- ing for sick-nurses. Herself a student of Kaiserswerth, she contended that no intention, however good, no enthusiasm, 372 International Congress of Nurses however fervid, could supply the lack of technical knowl- edg-e or practical skill in handlinj^ the patient. This sounded the death knell of Sairy Gamp and all her sisters, and since 1870 every hospital has become in a more or less degree a training school for nurses. At first the training of the nurses was in the hands of the doctors ; now it has become a specialized department of hospital work and is in the hands of the matron and ward sisters ; clinical lectures fol- lowed, and now there is very complete theoretical instruc- tion with its corollary, examination and certificate. This is the point where we now stand. With the levelling up of the teaching there ensued, as a matter of course, the level- ling up of the pupils, so that the ranks of the profession include the higb.ly educated gentlewoman as well as the w^oman of the artisan class: it offers scope for both, and both alike are acceptable in its varied departments. From looking back we must now cast a glance for- ward, and by a survey of the whole field endeavor to arrive at the future which lies before us. It is perhaps needless to emphasize the fact, so evident to us all, that we have reached the parting of the ways, and depending upon our choice will be the future of one of the most noble of all women's occupations. We are probably all agreed that theory must go hand in hand with practice of the proba- tioner's course, that the three years' hospital training is the shortest period in which the pupil can secure a full knowledge of her work, that the results must be tested by examination and receive some form of certification. This is our English system, and so far as I have been able to acquaint myself with your methods we agree in principle. Armed with the certificate of her training school, the trained nurse steps forth on her career to find her place in one of the many branches of the profession open to her as a pri- vate, district or hospital nurse, under the State in army or navy nursing service, in municipal infirmaries for desti- tute or infectious patients, or in these various departments of the service in the colonies and dependencies of our Empire. Retrospect and Forecast 378 Now we come to the weak point of the profession: the nurse becomes a unit, irresponsible and uncontrolled. As the ties which bound her to her trainincr school relax, the allegiance to its unwritten code changes with time into a sentimental recollection ; she finds nothing to take its place, she sees no corporation or official body which represents to her mind the mind of the profession, nothing which may rise up before her as armed with disciplinary or judicial authority, no concrete body of tradition placing before her all the best and noblest of the past : if she has an ideal, it is her own creation; if she has a code of ethics, she has formed it for herself; if she has a standard of work, it is the lingering memory of the old hospital which has sur- vived in her mind. I think that I am right in saying that in America, as in England, we are no farther on the road that leads to organization. This state of things can satisfy no one who has the best interests of the profession at heart, but it is more easy to lament it than to find the remedy. There is no doubt that, being a profession of women, we inherit the disadvantage common to the whole sex, the difficulty of combination, ol concerted action. A man when he begins his career knows that he has to become a part of a whole ; that he has to combine with others ; that he has to work for the general prosperity of his trade ; that if success is to attend his efforts, it is best secured by availing himself of the various organi- zations which will improve his standing professionally or intellectually. He learned this unconsciously at his public school; it is the atmosphere he breathes; his creed is to play up for his side. We women learn this lesson hardly, some never learn it at all ; it may be that we miss the dis- cipline of the public school, but, from whatever cause, wo rarely learn to work together for the good of the whole body. The heads of the training schools, looking no farther than their own four walls ; the teachers of the schools, only thinking of the examination that is to follow ; the employers of nurses,, keen to get all they can for their money; the theorists, or so-called philanthropists, using the nurse as 374 International Congress of Nurses a buffer, or exploiting her to serve their own ambitious pur- poses ; the nurse herself, immersed in the hard stress of competition, — all these have no thoughts to spare for pro- fessional organization. From whence, then, is succor to come? It may be forced upon us from the outside, but it is better far that it should come from within. So long as we are without organization nothing can be done. We want professional agreement on questions of training, practice, ethics, conduct, remuneration. Xo legis- lation can settle these points justly without us. and woe be to us if legislation attempts to do so before there is a consensus of professional opinion. In England we have tried the experiment of organizing the profession in con- junction with the medical profession, but with disastrous results ; it is a failure, and, moreover, it has had the evil effect of setting the clock of reform back for many years. It cannot be done ; we must be free to organize ourselves ; the relation of man to woman complicates the situation ; the relative position of doctor atid nurse makes it impos- sible. Though our work is in common, the details differ, and though we do not claim independence of the medical profession, we claim freedom to discuss our own affairs, to make our own laws, to decide on common principles of work. It may be well to recall the object of our work, the relation in which we stand to the patient on the one hand and to the doctor on the other, and then to ask ourselves : Is the system of training as at present carried out the one that is followed by the best results? Is there not a danger that theory is overshadowing practice? Is not too much time and mental energy bestowed on the study of obscure questions of anatomy and physiology to the detriment of securing that expert knowledge of ministering to the neces- sities of the patient which is the characteristic of a good nurse? Is there not a danger that the great and important place given to theory in the curriculum and the examina- tion may lead to a want of balance in the mind of the aver- age student, leading her, when free from the etiquette of Retrospect and Forecast 375" the hospital ward, to mix up treatment with nursin<;. to forget the dignity of her own profession in criticising the methods of the medical attendant? These are very grave considerations, which require to be looked full in the face and considered. We do not want to make a race of spoiled medical students, but capable nurses, and for those who are drawn to seek the higher mysteries of the healer's art there should be opportunities found in a post-graduate course or in entering the ranks of the medical profession. Out of this branch of the subject spring many others, such as the need of a central examining body independent of and above the training schools, a record ofifice for the registration and filing of the certificates, all controlled by some form of gov- erning body chosen by and forming a part of the profession. Would it not somewhat clear the path from difficulties if some minimum curriculum were agreed on, representing the least possible for the efficient training of a sick-nurse, suited to average intellects and average physique? We need ask for no legal authority to initiate these reforms, and when the time comes when we seek a legal recognition and pro- tection of our status, we have a much stronger claim because we have made up our minds as to what wc want, we go with a united front. As a means to this end we might seek to raise our ideals, to get out of the spirit of money-grubbing and nuick- raking for excitement. We want to awaken tiie spirit of self-sacrifice and self-discipline; the giving of one's best for another, which is the highest of all woman's privileges; to emphasize the fact that sick-nursing is one of the grand ministries of the world; to show the beauty of service. .\n ideal like this will enlarge the range of our vision, ennoble our methods, place us in a right attitude towards our patients, and shed a new light on our work and life. End of Part I REPORTS OP THE International Council of Nurses. PART II. MONDAY. SEPT. 16, 1901. Address of the President. ETHEL GORDON. '■ Ladies : In opening- this, the first session of the Inter- national Council of Nurses, it is my first duty to express how deeply I appreciate the honor of having been elected as your first president, to convey to its members my pro- found sense of the responsibility attached to the office, and to assure them that it is my earnest determination to uphold the dignity of the distinguished professional position which has been conferred upon me. WORK. " The text of the few words which I would say to you is comprised in the one word— Work. We take our stand in the Preamble of this International Council of Nurses as a confederation of workers. ' We, nurses of all nations.' it runs, ' sincerely believing that the best good of our pro- fession will be advanced by greater unity of thought, sym- pathy, and purpose, do hereby band ourselves in a confetl- eration of workers to further the efficient care of the sick and to secure the honor and interests of the nursing pro- fession.' 379 380 International Congress of Xitrscs " The work which hes before us in the orj^anization of an International Council of Nurses may well impress us with its magnitude. We have written down its constitution, — a constitution preg;nant with and powerful for good, — but we have to make that constitution live, and to do this we must inspire it with the vital force of a fine, purposeful spirit. Hence 'work' must be our watchword. " It has been written that no man is happier than he who loves and fulfils the particular work for the world which falls to his share. To man is entrusted the nature of his actions, not the result of them, and therefore does it behoove us to be diligent in our several spheres, although the law of evolution wills it that the good which our exertions ellfect may rarely become visible. Between the result of single efforts and the end we have in view and the magnitude of the obstacles to be overcome there may often appear a large and painful disproportion. Inn we must not allow ourselves to be discouraged by seemings ; warm and hearty endeavor will certainly meet its reward. Good uses are never with- out result. Once enacted, they become a part of the moral world ; they give to it new enrichment and beauty, and the whole universe partakes of their influence. They may not return in the shape wherein played forth, but likelier after the manner of seeds, which never forget to turn to flowers. Philosophers tell us that since the creation of the world not one particle of matter has been lost ; it may have passed into new shapes, it may have combined with other elements, it may have floated away in vapor, but it comes back even then in the dewdrop and rain, helping the leaf to grow and the fruit to swell ; through all its wanderings and transformations Omniscience watches over and directs it. So it is with every generous and self-denying efifort, it may escape our observation and be utterly forgotten, it may seem to have been all in vain, but it has painted itself on the eternal world and is never elTaced. Nothing that has the ideas and principles of good in it can die or be fruitless. That which the fountain sends forth returns again to the fountain. * Every man, ' says Fichte, ' should go on work- Council Reports 381 ing, never debating within himself, nor wavering in doubt whether it may succeed, but labor as if of necessity it must succeed; In work, then, consists the true pride of Hfe. " Thus we have inspiration and effort, but we also need order. See what order there is in nature along with sublim- est activity, what smoothness, what ease! How still the growth of the plant, yet how rapid ! How peacefully the stars of midnight seem encamped, yet before morning whole armies have disappeared! So much is achieved because everything is done in order at the right time, intently yet deliberately. So in the formation of the International Coun- cil of Nurses its founders have looked well to its organiza- tion. The vote covers all. They have, therefore, chosen graduate suffrage as the foundation on which to erect their stately pillar of international professional cooperation, and have thus based the constitution on the fundamental prin- ciple that a free, and therefore a progressive, community must be self-governing. The organization of the Interna- tional Council is as simple as it is sure. The graduate nurses combine to form Alumnse Associations : by delega- tion these societies cooperate to form a National Associ- ation. The National Associated Alumnse, in conjunction with the Superintendents' Society, federate to make a National Council, and the National Councils are eligible for affiliation with the International Council of Nurses. Thus, through gradual delegation we provide that every graduate nurse becomes articulate in this International Council of Nurses. We have, in short, secured to our members pro- fessional suffrage, and order will thus be evolved out of chaos. "And yet in making our council mechanically perfect, let us remember that the vital force is of the spirit, and not of the letter of the law. In a society which would be world- wide, which would include members of every race and creed, we must, while maintaining inviolate certain broad general principles which form our common bond of union, permit — nay, foster — individuality in detail, authorizing each coun- try to apply these principles in a manner best suited to its 382 International Co)ti^rcss of Xurscs own needs. In like manner every Xational Council will do well to encourage and develop the individuality of its mem- bers, for only so shall we utilize to the full the correlation of our forces and make our council a progressive power for good. Diversity of opinion is the very salt of life, and we shall do well to encourage rather than deprecate its expression. " The task to which we must first devote all our ener- gies is the building up of Xational Councils of Nurses in every land. Let it be a labor of love. Ruskin says: ' It is useless to put your heads together if you can't put your hearts together. Shoulder to shoulder, right hand to right hand, among yourselves with no wrong hand to anybody else, and you'll win the world yet.' " Into these councils should be gathered, through vari- ous associations for mutual help and professional progress, every individual graduate nurse, and the chief work in Euro- pean countries for many years to come will be the educa- tion of these graduates in the immensity of human responsi- bility, which includes their duty towards their neighbor, other than their patient, and their duty to the Stated All worthy progress of women and their work must spring from this sense of corporate existence and reverence for political rights ; associations of women to be of any real value in the body politic must comprise mind as w-ell as matter. We have experience that associated masses of women devoid of the innate vigor of conscience fall an easy prey to the unscrupulous, and retard rather than promote the intellec- tual advancement of their sex. Realize then the patience, the singleness of purpose, and the fine courage required by those who would sow the seed of high endeavor in the fallow fields of the nursing world. Indeed, it is a stupendous project, and will need the aid of hope, faith, and charity un- bounded. " The inspiration is ours ; let the effort be forthcoming, and order must result. ' What the child admired, the youth endeavored and the man acquired.' Council Reports 383 " National Councils of sentient beings alone can form an International Council of any worth. Awaken and culti- vate the senses of each individual graduate nurse, and let the result be never so slow, it will be sure, a weighty Inter- national Council of Nurses must be. " 'Hope is of the valley; Effort stands Upon the mountain top, facing the sun; Hope dreams of dreams made true and great deeds done; Effort goes forth, with toiling feet and hands, To attain the far-off sky-touched table-lands Of great desire; and, till the end is won. Looks not belo\ii, where the long strife begun In pleasant fields, piet torrents, rocks and sands. Hope; but when Hope bids look within her glass, And shows the wondrous things which may befall. Wait not for destiny, wait not at all; This leads to failure's dark and dim morass; Sound thou to all thy powers a trumpet call. And, staff in hand, strive up the mountain pass.' " Nursing in Africa. MARGARET BREAY, Formerly Matron English Hospital. Zanzibar; Councillor International Council of Nurses. Africa is known as the *' Dark Continent," but dark- ness is giving- place to dawn, and dawn with tropical rapidity to broad daylight. A powerful factor in this development is the trained nurse, who, following the flag, has found her way to the heart of the Continent, until in Uganda, on the shores of the Victoria Nyanza, there is now a hospital hav- ing a three years' certificate nurse as a matron, and on the island of Likoma, on Lake Nyara. there is a well-appointed hospital nursed by certificated British nurses. The same may be said of Zomba, the headquarters of the British administration in British Central Africa. On the northern seaboard British nurses are doing excellent work in hospitals at Port Said, Alexandria, and Algiers, while further inland at Cairo there is a large hos- pital, the Kaiser-el-Aini, with an English matron and nurs- ing staff, in which native nurses are trained. On the west coast many lives have been saved by the good offices of members of our profession in the hospitals at Sierra Leone and Lagos, and trained nurses have also gone inland to nurse members of the West Frontier Force on expeditions into the interior. On the east coast there is at Mombasa a government hospital, founded originally by the Imperial British East African Company, which is nursed by religious sisters, at Tanga is another under the care of German dea- 384 Council Reports 385 conesses, while the island of Zanzibar, the metropolis of the east coast, has English, French and native hospitals. The former is interesting, inasmuch as in it some progress has been made in giving systematic instruction to native men and women in nursing. The hospital is maintained by the Universities' Mission to Central Africa, and has a nursing staflf of a matron and five or six British certificated nurses, who take considerable pains to train the natives who work under them. The value of this work is great, as the African thus receives instruction in habits of order, method, and discipline, and in an appreciation of the value of time, which are foreign to him naturally. So far the men have, on the whole, made better nurses than the women, partly because African women marry so early that few of them stay in the hospital long enough to pass through a full training, partly because in Zanzibar, as in other Oriental countries, the men are in advance of the women in educational development, partly again because the male wards are more used, and consequently afford a better training ground than the female ones, and it would outrage national feelings to place an unmarried woman in charge of male wards. Nevertheless some of the girls have proved themselves apt and trust- worthy pupils, and given equal advantages, would no doubt become as proficient as the men. Tliey have many of the characteristics essential in a good nurse, being gentle, kind, and sympathetic, dexterous with their hands and quiet in their movements. They are also as a rule devoted to chil- dren. On the other hand, they do not like performing those parts of their work which they consider menial, and they have not much sense of responsibility, neither have they much stamina. So far as practical work goes, both native men and women in Zanzibar have learnt enough to make them very useful. For instance, they can polish instruments and pre- pare for an operation in a way which would be creditable in an up-to-date London hospital. Their theoretical work has so far lagged behind the practical, and there are at pres- ent no nursing text-books in the Swahili language. 386 International Congress of Nurses The influence of the training given in this hospital is far reaching, because many of those who received it ulti- matelv return to their tribes up country^ and thus carry their nursing knowledge to villages where no European is stationed. Mention must also be made of a midwife who is at work in the town of Zanzibar, under the auspices of the Lady Dufferin fund. We must, however, turn to South Africa to find nursing organizations in an advanced condition. Nurses in South Africa are so far the only ones who have legal status and registration, a privilege granted to them largely by the efforts of Sister Henrietta of Kimberley. This registration is carried out by the Cape Medical Council. In 1891, when the new medical bill was brought before the Cape parliament, the trained nurses of the country almost unanimously — a little band of some 66 women then, now quite an army — petitioned for a place on the register and State control. With much care and forethought an admirable act was drawn up and passed, providing for the registration of foreign trained nurses, and the State exam- ination and then registration of the colonial trained. The bill was in two parts, the first referring to midwives, and the second to trained nurses. After ten years' trial, on the whole it has worked well. Nursing is a recognized profession, and trained nurses legally stand in the same position as doctors and lawyers, the certificate granted by the council being practically a license to practice. Miss M. H. Watkins, in her paper read in the Nursing Section at the International Congress of Women held in London, gave the following information as to the working of the act. " After the act was passed a year of grace was given, during which all nurses holding hospital certificates could register. When this year of grace was over, the medical council formed a syllabus of subjects in which nurses must be trained, which is much the same as in the best hospitals Council Reports 387 in Enj^lancl. They also suggested books to be studied by nurses. They have also appointed the following centers at which examinations shall be held: Cape Town, Kim- berley, Port Elizabeth, Grahamstown, and King William's Town. "The house surgeons generally, and in Kimberley some of the visiting surgeons, give courses of lectures on anti- septics, anatomy, physiology, etc. Examinations are held half-yearly, in June and December. Now the council will not examine any who have not had three years' hospital training in a hospital of not less than forty beds. "The written questions are uniform for each center, and are entrusted to two medical men, who sit as local commis- sioners during the time in which the answers are being written, and by whom they are returned to the medical council. These same two doctors conduct the viva-voce examination, which is generally held on the day following the written. The marks for the viva-voce are given by these doctors and reported to the medical council, who themselves examine the written papers, and in some two or three weeks' time send certificates to nurses who have passed their examinations successfully. The medical coun- cil publishes yearly a register of certificated nurses, which can be had for half a crown, "Hitherto registration has had a markedly tgood effect in the colony — 1st, by raising the standard of education for nurses : 2d, in raising the status of nurses ; 3d, in awak- ening ambition in nurses ; and 4th, in affording by their published register an opportunity to the public of know- ing that the nurse they engage is duly qualified, an oppor- tunity of which, I am glad to say, many avail themselves. "Of course, education and registration do not always ensure a nurse being an acceptable one. There are and always will be nurses and nurses, but I think registration has done as much as we might have expected in the time." A leading superintendent of nursing in South Africa writes in the Nursing Record : " The main advantage of 388 International Congress of Xnrses the register to nurses is that in any case of difficuhy they can appeal to the council, such as testimonials withheld, wrongful dismissal, or unjust accusation. The council goes thoroughly into the matter, and in the few cases which have been brought before it, it has shown itself much inclined to take the part of the nurse. Nurses can register as midwives do, either by producing approved certificates of some foreign country, and proof of three years' training and successful examinations, or, in the case of colonial nurses, proof of training and character, and passing of the council's examination for nurses. REPRESENTATION ON COUNCIL- But nurses have one great difficulty. There are on the council a representative dentist and chemist, elected by the dentists and chemists, and approved by the governor, to advise the council on subjects pertaining to dentistry and pharmacy respectively, and to lay before the council the claims of dentists and chemists. There should also be a representative nurse-midwife, who should be able, not to vote in the council, but to speak on midwifery and nursing questions. There have been various cases which show the need of this. A magistrate wrote to the council saying a case had come before him in which he could only commit the midwife for trial for manslaughter, but he believed there were extenuating circumstances into which, as a layman, he could not enter. He begged the council to appoint a commission of inquiry, and if the woman was acquitted on the graver charge to take such steps in dealing with her that another woman should not lose her life through her ignorance and carelessness. After a long time the council replied that as she was an amateur midwife, untrained and unregistered, they had no machinery in their hands to deal with her. Again, five licensed midwives in one town addressed the council about a quack (also licensed). They said it was a fact that in this place several women had died shortly after childbirth, that they had all been attended by this midwife, Council Reports 389 that various charges were being continually made against her competency and professional conduct. They urged the council for the sake of other midwives' professional status to grant an inquiry which would either clear the midwife in question or suspend her license for a period. After a fortnight the council answered by a facetious inquiry as to whether the midwives were prepared to write the death cer- tificates themselves for the women who they stated died shortly after childbirth ; and after a lapse of several weeks came another letter saying that the council could not listen to any request of the kind from midwives. Yet if a doctor reports a midwife to the council she is at once suspended without any inquiry for three, six, or nine months. What is wanted is representation on the council. Again, on nursing questions : A clause in the act provides that the council's certificate may be given to any foreign nurse who has been trained for three years by any training school which the council may consider competent to train, and who holds the certificate of that body. But this " competence " in the eyes of the council appears to me to be absolutely capri- cious. Now an Edinburgh Royal Infirmary nurse is refused her license and registration, now a Leicester nurse, a Bir- mingham General Hospital nurse, a Ryde Infirmary nurse, while again, nurses from obscure and petty training schools are passed. A nurse on the council could lay the different training in different schools before the council and advise them on the subject. Again, nurses have petitioned parliament, and written privately to the council, asking that three years' training may be the standard — even royalty has addressed the coun- cil on the subject on behalf of the South African nurses — but, for a year, one year's training was all they required; then for seven years, only two. The wishes oi nurses and matrons were wholly disregarded, but in 1899 a doctor in the council brought the subject forward. It was passed at once, approved by the governor, and forthwith became law. A representative nurse on the council could have done it from the first. No doubt the tendency of the council is 390 International Congress of Nurses to make all persons pass the Cape examinations, whatever their previous history has been ; as an M. A. of Oxford has to pass certain Cape examinations before he can enter the civil service, and it would cause less friction to say so fairly than to reject nurse after nurse, who have held ^ood posi- tions in England, on some trivial point or other. The great aim of nurses should be that no private nursing- institution should be allowed to send out an unreg- istered nurse, and no hospital receiving a government grant should be allowed to employ any woman as matron or sister who is unregistered. But this cannot be while registration is made so difficult and worrying to nurses, and until they are represented by a trained nurse holding a midwifery qual- ification on the council. The larger hospitals, such as the Kimberley Hospital, the Provincial Hospital, Buluwayo, Rhodesia, prepare pupils for the Cape government examination of nurses, for which those may enter who have received three years' training in the wards of the hospital. Certificates are no longer granted by individual schools, as the medical council has received the authority to issue certificates formerly permitted to hos- pital authorities. Some of the South African hospitals are fine buildings, such as the New Somerset Hospital, Cape Town, where there is a training school for nurses in charge of the All Saints Sisters, and the Johannesburg Hospital, which has 300 beds. The Memorial Hospital, Buluwayo, has, I am in- formed, an excellent up-to-date theatre, adjoining which are an anaesthetic room, and a small room in which a Rontgen ray apparatus is fitted. This has been much used recently, as many patients have been admitted with gun-shot wounds. As a rule the bulk of the cases are medical, including enteric, malaria, and hsemoglobinuria. Besides the hospitals which are able to give nurses a training which will qualify them for registration there are also smaller ones. The Chartered Company maintains sev- eral, one being at Gwels. The nurses are paid a good salary, and if they stay for three years they are entitled to six Council Reports 391 months' holiday, the company paying- all expenses of the passage home. In addition to the general hospitals there are various private nursing homes and institutions which send out pri- vate nurses in South Africa. I am informed on reliable authority that the work both in hospitals and in private homes is nmch harder than at home. The only service avail- able is that of native untrained servants, who usually pre- fer basking in the sun and living on a few herbs and mealies to working hard for the white people, who, after all. only feed them. It will be seen that while beyond Cape Colony little or no progress has been made in the organization of nurses, yet that north, south, east and west nurses are doing excel- lent work at isolated stations, and the development of the Continent during- the last quarter of a century has been so rapid that there is g-round for hoping that before the dawn of the next century National Councils of African Nurses may apply for membership of the International Council. Nursing in Australia. SARAH B. McGAHEY, Matron Prince Alfred Hospital, Sidney; Honorary Vice President International Council of Nurses. INSTRUCTION IN NURSING. 1. In all the principal hospitals systematic instruction is given to the members of the nursing staff in Elementary Nursing, Elementary Anatomy and Physiology, Hygiene, Medical and Surgical Nursing and Invalid Cookery. (a) Length of Course: Three years in almost every recognized training school. Prince Alfred Hospital and Sydney Hospital, Syd- ney, have a four (4) years' course. 2. Practical Work : Practical instruction is being given in the majority of training schools. (a) Organization of Nurses : The only organizations are the Australasian Trained Nurses' Associa- tion, and the Prince Alfred Hospital Trained Nurses' Reunion. 392 Nursing in Brazil. JAIfE A. JACKSON, Matron and Superintendent Strangers' Hospital, Brazil. There is no training school for nursing in the whole of Brazil, but every now and then there is a great talk about one, and then it dies out again. In the native hospi- tals here there are not any nurses at all, the work of the wards being undertaken by Sisters of Mercy and the Order of St. Vincent de Paul, and under them in the male wards they have men who wear a linen uniform, no collar or tie, slippers without socks, and smoke cigarettes. They call them "serventes." In the large hospital here, the Santa Casa da Miseri- cordia, which has two thousand beds, it is the same, the sisters getting up at midnight and 4 a. m. to give the medi- cines, and the ward is then left in charge of one of these men. It is a beautiful building, but the patients and bedding are filthy. In the Hospital for the Insane, which is just below us, the work is now, on the female side, under the care of Frenchwomen who have had some little training before coming out, but they are not certificated. That now being the hospital of the state, the sisters are not employed there. In the S. Sabastano Hospital for yellow fever they have boys who have been trained there under the superintendent, Dr. Seidel, and two years ago I had one from him, and he is still with me. He is very clean, but I had to teach him how to sponge patients, wash them, make beds, etc. Now he is most valuable, as he knows a great deal about yellow fever with all its sequelae, and I can leave him alone at night 393 394 International Con!j;rcss of Xurscs with patients. He can take temperature, pulse and respira- tion, and also, if the patient should have failure of the heart, which is a very common thing- in yellow fever, he knows just when to give caffeine, and I consider that a great deal in a Brazilian. Patients are never washed, or, I might say, very rarely, in the native hospitals, and very often fresh patients are put into the beds without change of bedding. In S. Paulo, at the Hospital Samaritano, they train pro- bationers, and I have written to the medical superintendent and asked him to kindly give me all the information he can. His reply I append here : " In reply to your letter of inquiry, I can only state that as far as S. Paula goes there is absolutely nothing done as to organization for training of nurses. In the Sama- ritano all our stafT nurses arc home-trained, and we have only two probationers' places. We require three years of service, including medical and surgical work. If they finish the term that is proof that their work has been satisfactory, and a certificate to that effect is given. In the national hospitals the trained nurse is an unknown quantity. Roman Catholic sisterhoods are nominally the source of supply of nurses, but what is done is done by uninstructed persons, male and female, who frequently have been patients them- selves, and, showing some interest in their fellow-patients, have been asked to remain as nurses ! " So far as I know Brazil and its hospitals, you may state that, with the exception of one or two hospitals, such as the Strangers' and the Samambano, which have English trained nurses, there is no such thing known in the native hospitals as the trained nurse in our acceptance of the term. They are in this respect at least one hundred years behind the times." Buenos Ayres is very much more progressive. The matron who was there for eleven years, Miss Eames, left last November, and is now in London. I think she was from St. Thomas' Hospital. Council Reports 395 The head nurses have mostly been trained at home^ and yet they have selected as matron one of their proba- tioners, with only the training possible there, which Miss Eames did not think quite sufficient. South America has still to be roused up, for it is twenty- five years behind every country. Every Brazilian doctor or visitor who comes up here exclaims at the cleanliness of the place and at ourselves in our white uniform, and one great compliment they pay us is that we are most punctual and better able to adapt ourselves to sick-nursing than the Brazilians. I am only sorry that I cannot give you a better account of the condition of things in hospital work in the capital of Brazil, and you will find my letter of very little use. I w^ish I could say that we are going with the times. All we can do is to try and keep up to the standard as far as we can that we were taught at home, and that is difficult in a country like this, where everything is lax. Nursing in Cuba. LUCY W. QUINTARD, Inspector of Hospitals, Department of Charities, Havana ; Councillor International Council of Nurses. One of the greatest problems presented to the govern- ment at the beginning- of the American occupation of the island of Cuba was how to deal with the appalling condition of her hospitals. A visit to some of these places would remind one of the Dark Ages. They were dens of immor- ality and uncleanness in every form. Their unsanitary condition was responsible for much of the sickness in the cities and surrounding country. No precautions were taken to prevent the spread of disease. In many instances where expensive apparatus had been pro- vided for the disinfection of clothes, it had never been used for this purpose. Dirty water from the baths and laundries was often disposed of by turning it into the streets. In some places clothes were washed in the rivers without a previous disin- fection, to breed disease wherever their waters were used. Those employed in the care of the sick were of the lowest type of humanity. The very name of "enfermero," or nurse, was a term of degradation. Recognizing the herculean task before them of cleaning up these hospitals, and realizing their helplessness to accom- plish it singlehanded, the men to whom this work was intrusted turned to the nursing profession for assistance, and they met with a hearty response. 396 Council Reports 397 Good women answered the call and went to work with a will, working^ early and late to cooperate with the heads of departments in every possible way. Preparations were made for establishing schools in the large hospitals for the education of Cuban girls in the prac- tical care of the sick. In August of 1899 the first school was opened in the Hospital Mercedes, Havana. The first class was composed of seven pupils. It was proposed at first to limit the course of instruc- tion to two years, but it was soon found impossible to bring these girls up to a proper standard in that time, and the course was extended to three years. In March of 1900 plans were formed for starting a school at Puerto Principi, in the center of the Island. This was to be a model hospital and school, and no expense was spared in renovating and furnishing the large Spanish military hospital, a building capable of accommo- dating from 250 to 300 patients, for this purpose. The work was however so delayed on the building that it was not ready for the reception of patients until the first week in November. This school was opened with twenty-five pupils,, which number has since been increased to thirty. In the summer of 1900 another school was opened in Hospital No. 1, in Havana, and one in the hospital in Cien- fuegos. In the autunm of the same year still another was started in connection with Hospital San Isabel, Matanzas. In January of 1901 plans were formulated for a school in connection with the Hospital Civil, Santiago de Cuba, but owing to delays in getting the estimates passed by the mil- itary governor this hospital was not opened until the begin- ning of April. This lattqr school has been one of the most difficult to establish, owing to the fact that the population of Santiago de Cuba is fully two-thirds negro. These six schools are all in a healthy flourishing con- dition. They have been established on a good firm founda- tion, and if the present status can be maintained, and good American graduates can be kept at the head of them until their own graduates have had sufficient experience after 398 International Congress uf Xurscs their training to occupy positions as superintendents and head nurses, there is no reason why Cuba should not in a few years be able to boast of a fine nursing service in her hospitals as well as a thoroughly trained corps of women to meet the demands of private individuals. These schools are organized as state institutions under the control of a central board which will govern them independently of the hospitals to which they are attached. The standard will thus be uniform. The course of training will be three years. The curriculum will cover much the same ground, simplified, as in our schools in the United States. The practical instruction will be given by American graduates, and will of course be adapted to the difference in climate and the nature of the diseases, many of which are much modified in Cuba. The examinations at the close of the first and second years will be held by the physicians of the hospital. The third year's examinations will be conducted before a board appointed from the School of Medicine and Pharmacy which will meet for this purpose in each of the cities where there is a school. The diplomas will be given by this board. This diploma will be recognized as giving the nurse a professional status, and without such diploma no person will be permitted to follow the practice of nursing. The director of the hos- pital will be the representative of the central board. The superintendent and her graduate assistants will receive their appointments from the board with the approval of the director. So far no schools have been organized in the small hospitals, as it has been impossible in so short a time to provide for all. It has been considered best to train the pupils in the larger hospitals where they could have the greater experience and send them for a few months in their third year to the smaller hospitals, thus giving them the benefit of skilled nursing. During the third year the pupils will also be sent to private cases for a period not exceeding three months. The Coiincil Reports 399 money received from this source is to be placed with the treasurer of the hospital and allowed to accumulate with the object of being used for the benefit of the nurses in some way not yet determined. This outside work may also be of some service to the pupil insomuch as it will try her in positions where she will be called upon for the first time in her life to act for herself, and yet where she will be in a certain measure under the supervision of her hospital. In organizing these schools much has had to be taken into account. The ill repute of the hospitals and their employees ; the habits and temperament of the people ; the rigid rules governing the lives of the women who have never known what freedom or independence meant; the strong prejudices against a woman occupying positions which would take her from the shelter of her own home, especially when it meant that she must live entirely away from her home for three years. This latter is not confined to Cuba. How many of us can remember the difficulties •experienced in the early history of our own schools on this line! In the eastern end of the Island, where nearly 80 per ■cent, of the population is negro, we are confronted with the race difficulty. It is almost impossible to draw the color line here where it can only be recognized by the educated €ye. Under such circumstances as these we have had to of¥er inducements to girls to enter, which, I am sorry to say, have taken the form of money compensation, and we are paying our pupils eight dollars a month for the first year, twelve dollars the second year, and twenty-five dollars the third year. Besides this an allowance of three dollars a month is made for uniforms during the first two years. This to me is the one weak point in organization, and yet I recognize the fact that it was necessary in order to get the better class of girls to enter our schools. This is contrary to conditions existing in the United States, but it can be explained and excused to a certain 400 International Congress of Xurscs extent by the fact that many of these girls have been obHged to contribute to the support of their famiHes by sewing, and cannot afford to devote three years to a work which will not enable them to continue this. Other conditions we have to contend with are a lack of education, stability, and truthfulness. The girls are intelligent, quick to pick up new ideas and adapt them, but they have no stability of character; one is never sure of them, and a Cuban girl thinks no more of telling a falsehood than the truth. This lack of truth- fulness arises no doubt from the conditions existing for so many years of intrigue and deception. In time of Spanish rule the Cubans never knew whether they were surrounded by friends or foes, even the members of their own house- holds might betray them. Time and training are the only remedies, and on these two factors we must depend for improvement. When one realizes the many perplexing problems to be solved in the training of these women is it any wonder that we feel the need of assistance from the graduates of our northern schools? Never could one undertake better missionary work than in devoting a couple of years to one of our Cuban schools. But we want women of strong char- acter, patient and painstaking, tactful and cheerful. These Cuban girls can be won by a smile and a kind word, but can never be driven. There is much that is lovely in their character ; there is also much to be eradicated. With all my disappointments and discouragements in regard to our work here, I still feel hopeful. My two years' work among this people has taught me that by educating these girls as nurses we are doing much to help the women of Cuba generally. There is a lack of nurses in Cuba, in fact there are none. When a mem_ber of the family is ill he or she is nursed by all the near relatives and many of the friends. It would be considered a want of feeling on the part of these if they did not attend in full force. These people are very helpless in time of sickness. Their sole idea of nurs- Council Reports 401 ingf is to g-ive all the medicine and food they can get the patient to swallow, to keep every door and window closed, and avoid all external use of water. There are many rocks ahead, one of the most danger- ous being the temptations which await our girls when they emerge from their school ready to take up their career in a world of which they have had so little knowledge. This is a matter which must be discussed, and some means must be provided for their protection as far as is possible. Our nursing organization in Cuba is still in its infancy, and while it appears a strong healthy infant, there remains the dang-er that all the changes which the new repubUc will bring may tend to crush out its young life, and our work of the past two years and a half will be destroyed. The next year will decide this question. This work has wrought such wonderful changes in our hospitals that the doctors of Cuba have learned the value of the service and will, I am sure, do all in their power to promote its interest. Nursing in Denmark. CHARLOTTE NORRIE, Secretary Danish Council of Women, Copenhagen; Councillor International Council of Nurses. fCommunehospital i Kobenhavn is our largest hos- pital. It contains more than 950 beds in six male and six female divisionts, viz: two surg-ical, two medical, one for nervous and mental patients (the latter are removed as soon as the diagnosis is certain), and one for diseases of the skin, etc. I have before me a printed communication from this hospital, signed July 30, 1898. Pupils desiring to enter the hospital career are received for a term of fifteen months, and they receive both practical and theoretical training; their work in the sick room is taken as equivalent for their training; they receive no sal- ary, but they have full board, lodging, uniform and laundry. The theoretical training, given by a house-surgeon, is suspended for the summer months. After this course of fifteen months, an examination takes place, and the successful candidates may be accepted as assistant nurses and receive the usual salary. Pupils who wisb to do private nursing, or to work in county hospitals, may take part in this training, but they receive neither lodging, dress nor laundry, and they have to pay thirty kroner (one krone is about Is. Id.) monthly for board. These extra pupils may, after having passed their examinations, continue their work at the hospital for six months without paying for their board, after which term they may have a certificate on leaving the hospital. 402 Council Reports 403 The age required for admission is generally between 22 and 30 years. Next to the Kommunehospital comes the Kongelige Frederiks Hospital. I have no information regarding the training of nurses at this hospital. Dronning Louises Bornehospital contains sixty to six- ty-five beds, surgical and medical cases, boys and girls, while they are small. The printed communication before me is dated January 1, 1900. Pupils are received for two years' practical and theo- retical training on the same terms as above. Besides the general training they will be taught to work at the theater and at out-patient department, to sterilize milk, etc. Theoretical training as above. During the second year thev may be looked upon as assistant nurses, if such a place is vacant ; they then receive the usual salary. Age of admission about 20 to 30 years. Day pupils are received for a term of three months ; they pay thirty kroner monthly for board. Froken Lovenhielm has given information to the effect that her nursing school is now a deaconesses' home, with a three years' training for deaconesses. Its name is now St. Lucas Stiftilse. Den Danske Diako7iissestiftilse has a hospital contain- ing about ninety beds for men and women, medical and surgical cases together. The lady superintendent writes me one week ago that the sisters going in for training at this institution will not all be sick-nurses. They always begin with thorough training in cleaning a house and keeping it so ; if possible, they also learn laundry work and house- keeping. Then they generally go to a home for incurables, and after this to the sick wards. Here they usually commence in the children's wards, and after a few months they go to the adult male and female wards. The pupil now works under the supervision of the elder sisters in the different wards for at least one year, if 404 International Congress of Xurses she is deemed fit for sick nursino: and is expected to work afterwards at county hospitals. The sisters who are to do district nursing are very often only eight months at the hospital, but generally they work for three months more at a maternity home. All the sisters, even if they enter for teaching or housekeeping, have at least six months' train- ing in the sick wards. Only those sisters who seem to be especially fit for it are admitted to do theater [operating room] work. The Qverloge (head physician) teaches pathology in one weekly lesson for nine months ; a sister gives one weekly hour instruction in anatomy, bandaging, etc. Such is the plan, which is not always strictly followed, as the individual necessities may require other measures, — but the tendency is towards prolongation. Kbbenhavns Garnisonssygelius is our metropolitan military hospital, and contains about 500 beds, medical and surgical cases together, in different divisions and clinics: three for medical and surgical cases, one for epidemic fevers, one for women and children [of the soldiers' families], for eyes, ears, etc. The nursing in this hospital is based on the same prin- ciples as in our best civil hospitals. I have my information partly from an article by the Danish surgeon-general, Dr. Hon. Johan Moller. in the April, 1898, number of a military medical quarterly paper, Melitorlogen, and partly from a written statement from one of the overplejersker (head nurses, superintendents of nurs- ing) received a week ago. Pupils are received for a term of six months, and are placed under the supervision of one of the elder nurses or assistant nurses for their practical training. During the three summer months one of the house surgeons lectures two hours weekly, teaching anatomy and military nursing. This training is finished by an examination, generally held before the stabsloge ag sygehuschef (medical superinten- dent). They receive no certificate. They have lodging, full board and laundry, and after Council Reports 405 two months of probation they receive a salary of 12 kroner monthly, and after the six months they may enter the hos- pital as assistant nurses. Besides the female nurses, each of whom has about ten patients, there are sygepassere (orderlies) taken amongst the best conscripts — we have compulsory conscription in Den- mark. Many of them have passed their final examinations at the university to become lawyers, ministers, etc., others are teachers, clerks, etc., besides a few artisans, as cabinet makers, saddlers, etc. They first go through a drill for two and one-half months, and then they go for six months to one of the military hospitals. During the first two and one-half months they are taught military deportment, dis- cipline, etc., besides elementary anatomy, physiology, and first aid to the injured. In the hospitals they take part in the nursing under the supervision of the nurses, from whom they take orders as far as nursing is concerned. The training at all our hospitals may be said to be based on the principle of training nurses for the use of the hospital. Outsiders may take part in this training, e. g., the Red Cross sisters are admitted on favorable terms to profit from this training. The Royal Lying-in Hospital liberally permits nurses, who have been trained elsewhere, to work there for about a month that they may learn to take care of women and children after confinement. As to the relatively excellent training of our midwives, I shall another day send you information. They pass an examination after training, and they are certificated and registered, and nobody else, save a medical man or woman, is permitted to assist at childbirth. The midwife very often leaves as soon as mother and baby are well at rest, and then the nurse takes her place. Danish nurses are associated in the Danish Council of Nurses, whose president is Mrs. Tschnerning, of the Kom- mune Hospital. ■^^\^ Nursing in Egypt. JANE G.WATKINS, Matron Government Hospital, Cairo. I. The only authorized training chool for nurses in Egypt is the government hospital, Kasr el Aini, Cairo. Here the patients, mostly Egyptians, are nursed by Egyptian nurses of their own sex, under the supervision of an English stafif consisting of a matron and seven sisters. The hospital, which contains 420 beds, is divided into two wings, one for male patients and the other for the hareem, or female patients. On the male side the nurses are men of the lower class, sufificiently educated to be able to read and write, who work- in the wards for a long or short period according to their capabilities. They receive no special training and, of course, no certificate. L" Ecole Medicate des Filles provides the nurses for the female patients. These pupils are under the superintendence of the matron of the hospital. They are chosen from the Sanich school, a government secular institution under the care of an English head mistress, and are obliged to bring with them a certificate of proficiency in reading and writing. The term of training is for three years. During the whole of this period the pupils work in the wards, medical, surgical, ophthalmic, midwifery, and gy-naecological, under 406 Council Reports 407 the supennsion of English sisters, who train them in prac- tical nursing. For theoretical work, during the first year, lectures are given by the physiologist (a native) of the med- ical school on elementary physiology and anatomy, and by the matron on nursing. At the end of this term an exam- ination is held on these subjects. During the second year the principal subjects taught are pharmacology by the professor of chemistry (a Ger- man), and theoretical nursing by the matron. The pupils are examined in these subjects at the end of twelve months. For the third year the lectures are on midwifery, nor- mal and abnormal labors, which are given by a native doctor, on anatomy of the pelvis and gynaecology by another native doctor, and on legal medicine by the director of the medical schools. The practical training in the wards in midwifery is given by the surgeons attending the cases. There is no English midwife in the hospital, and the pupils receive no special training in obstetrical nursing. The pupils have lessons in English and are instructed in physical exercises. At the end of her three years, if a pupil passes her final examination, and her conduct has been satisfactory, she receives a diploma from the sanitary department and is reg- istered by the state as a "hakeema." A "hakeema" has the following choice of work : She may practice as a midwife on her own account, or she may remain in the government employment in either of the following capacities : She may stay on in the hospital as a sort of staff nurse ; there are two of these posts at Kasr el Aini. She may be attached to one of the police divisions of Cairo or Alexandria, or she may go to a moodarieh (province), working with the doctor attached to the police station or province. Under these conditions a "hakeema" may legally certify cause of deaths write a simple prescription, attend cases of normal labor, treat gynaecological patients, and in case of an outbreak of an epidemic inspect females. A few Mohammedan families who object to a male doctor employ a certificated "hakeema" for sick female relatives. 408 International Congress of Nurses In addition to and quite distinct from the hakeemas are the "diahs." These are completely uneducated women, who receive theoretical instruction by a course of lectures on simple midwifery given by a doctor or midwife at Kasr el Aini or other government hospitals. The course of lectures usually occupies about fifteen days. At the end of this time they are examined by a doctor, and if passed by him are licensed by the state to attend cases of the simplest kind. The law is very strict with regard to the limitations of the " diah's " work. She may use no instrument of any kind, not even for rupturing the membranes. The cases of normal labor at Kasr el Aini Hospital are very few indeed, and are chiefly women undergoing a term of imprisonment at one of the state prisons. The abnormal cases are usually very difficult ones, as the patient has prob- ably been attended in her own home by a " diah," who has not recognized the difficulty of the case until the patient has been several days in labor and is in danger of death. There is very little demand for Egyptian women as nurses among Egyptians. The "hakeema" as a midwife has a recognized position, and so has the " diah." The great majority of women in Egypt are still veiled, and they have no authority in any household but their own. They are, therefore, simply use- less as nurses. The German hospitals, of which there are two in Egypt, one in Cairo, and one in Alexandria, are nursed by German deaconesses trained at Kaiserswerth. The French hospitals, three in number, one at Cairo, one at Suez, and one at Alexandria, are nursed by the sisters of St. Vin- cent de Paul. The British hospital at Port Said has an English super- intendent, who has four fully trained nurses under her, three for the hospital and one for private cases. They are all engaged from England for three years. The government hospital at Port Said is nursed by sis- ters of the Bon Pasteur order. The Greek hospital in Alexandria also employs English .sisters. Council Reports 409 II. ORGANIZATIONS OF CERTIFICATED NURSES. Of these there are three in Cairo : The English hospital and Victoria Nursing Home, the staff of which consists of a matron and seven nurses, all English. The- nurses are employed in the hospital and for outside work. The English Nursing Home, which has a superinten- dent and four nurses. The Marianne Hughes Nursing Fund, which employs two nurses. The nurses employed by it are engaged by the matron of Kasr el Aini Hospital and are under her super- vision. They nurse for any doctor in Cairo, and may be sent to other parts of Egypt by special permission from the committee of the fund. They are engaged for six to eighteen months, and when not nursing private patients they are employed in the government hospital. In Alexandria the Victoria Home, which is a home for governesses and a registry ol^ce for servants, keeps three nurses, whom it sends out to cases as they are required. Nursing in Fiji. MAY C. ANDERSON, Sister Superintendent. (Sent by courtesy of B. (Jlanville Corney, Chief Medical Officer, Fiji.) Away in the distant Pacific, far from the centers of civihzed hfe, one scarcely expects to meet with all the com- forts so easily obtainable in laro^e cities. Nevertheless, in one group of islands, one of the many in southern seas, we have our little hospital, which, thousfh not an imposing edifice of stone, tiles, etc.. still carries on its work from year to year, and achieves the primary end for which hospitals exist. Many things have a humble beginning, and this insti- tution is not an exception. The beginning was made in 1883, by erecting a few native houses of unsawn timber, reeds and thatch ; not aseptic, perhaps, many nurses may think, and quite correctly so, yet for a time they served their purpose in sheltering patients who came from neigh- boring or distant islands. Situated on rising ground, over- looking a beautiful harbor within coral reefs, and sur- rounded by tropical foliage, the spot was happily chosen for its future development. In course of time properly equipped wooden buildings superseded the primitive struc- tures of thatch, and accommodation was provided for a much greater number of patients. Until 1888 the hospital was in charge of a non-resident medical officer, and its domestic administration was presided 410 Council Reports 411 over by an untrained matron who was kind, indeed, to the patients, but lacked the knowledge so essential in nursing- the sick. The work of the wards was carried on by native and Melanesian laborers. The need for further improve- ment soon became very apparent, and the government decided to obtain the services of a trained nurse. Our pio- neer sister was a lady from St. Thomas' Hospital, London, who bravely set to work to surmount the difificulties inci- dental to life in a new country, previous lack of nursing organization, and an imfamiliar vernacular. During the early years Europeans rarely sought admission to the wards, for it was regarded as a native hospital only, and many necessary comforts were wanting. The sister soon found that it was impossible to work on alone, and accordingly made arrangements to train probationers, one of whom remained to complete her training (three years), and for some time worked under a sister who was trained in the London hospital and succeeded the one previously men- tioned. Subsequently the appointment became again vacant, and was next filled by an old-time probationer, who con- tinues in charge at the present time. From 1888 forwards, a resident medical superintendent has been installed. The wards are nine in number, detached, and contain in all 107 beds. The operating theater, dispensary, offtce. and eye room are included in the block which contains the European wards, but there are also two separate private wards for the latter class. Our patients include a very mixed variety, Europeans. Fijians, Indian coolies, repre- sentatives from almost every island in the South Pacific, and a few stray Japs and Chinese. Owing to the natural forma- tion of the land, it was impossible to build the wards in regular pavilions, and perhaps, in a climate like ours, this is no disadvantage, on account of race prejudices. In fair weather the walk from ward to ward is pleasant enough, and nurses and patients almost live in the open air ; but in the rainy season, which is a long one, the task is not quite so easy, for the distances to be traversed are too great to permit of covered ways. This, however, is a detail — the 412 International Congress of Nurses roughs of life are ever mixed with the smooth, and the pretty surroundings, in fine weather, compensate for the disagreeables of the heat and rain. The buildings are all timber, surrounded by spacious verandas, roofed with shin- gles; the floors stained and polished, and all kept spick and span. The Europeans' wards are fitted with all the ordinary ward furniture, and are very bright and cheerful. The native wards are not supplied with more than is really necessary, as native habits are usually somewhat grimy and disagreeable, and nurses must ever be on the alert to keep everything clean. Though the actual scrubbing, sweeping and polishing is done by native ward servants, they are so untrustworthy that an untiring supervision has to be main- tained over their work. Iron bedsteads are used through- out, and the Fijians use mats, blankets, and native pillows (a piece of wood or bamboo on two short legs, which sup- ports the nape of the neck), not our. idea of comfort, but suf- ficiently cherished by them. Very few indulge in the luxury of a soft pillow. Of course patients who are very ill are provided with all that is necessary, but unless there is any reason why a change should be made we allow them to fol- low their own customs in so far as is consistent with good sanitation and discipline. Attached to each ward is a lava- tory and shower bath with an abundance of excellent water ; for a daily bath is a necessity here, and often has to be insisted on. Not one of the least amusing of my duties is the early round and questionings to learn if each patient has had his " morning tub," and some of the evasive replies and frequently direct and unblushing falsehoods I meet with are very ingenious. The patient's delight is unbounded when he can show you some wet hair, and the laugh of sat- isfaction that passes around is infectious when a less fortu- nate perverter of the truth is promptly sent to have his bath. As with all uncultured people, the Fijians have curious ideas about soap and water, and when not under European supervision they allow their sick tO' lie for weeks and even months and never dream of washing or sponging them, or even combing their thick hair. Imagine our feelings when Council Reports 413 such cases arc brought to the hospital, — and those of the friends (who often stay a few hours), when they see the bath given. There is much, apart from actual nursing, that is interesting in the customs, ideas and languages of the people with whom we have to deal. Diets are sometimes a difficulty with native patients, and as we try to give to each according to their religious and caste prejudices, the diet list often presents a very com- plicated bill of fare. Rice enters largely into all their meals, with bread, yams, taro, breadfruit, tea,. all ordinary invalid delicacies, and some meat or fish. Smoking is habitual with all native races here, and is generally allowed outside or in the verandas, but patients sometimes steal a smoke in the wards, and pipe and tobacco are confiscated from a man who is not smart enough to hide them before a nurse appears. They love to secrete their little treasures under their mats, so, to keep the beds fresh, everything is sunned and aired each fine morning, and when the doctor comes round, the wards really look very quaint with the rows of beds, bright fringed mats, with brown, black and yellow patients. The nursing of some of our patients is often difficult, for they cannot understand our reasons for much that is done, but on the whole they are amenable and, if persuaded and firmly treated, are fairly submissive. Everj^ year adds some improvement to our wards or buildings, but, like Oliver Twist, we are always wanting more, though by patient wait- ing and steadfast adherence to purpose we usually get what we want in the end. Our admissions last year amounted to 1,472, but the number of out-patients treated is only about 550 annually. The diseases met with are, among others, dysentery, yaws, ankylostomiasis, tuberculosis, internal and external parasites of all sorts, and many others with which most nurses have to deal. Enteric fever is not prevalent in Fiji, but isolated cases sometimes occur and run a more or less irregular course. 414 International Congress of Xurses Your newly acquired territory- in Samoa, or, at any rate, the German portion of those islands, whose people we con- sider our neighbors, has, however, cjuite an evil reputation with regard to that disease, and almost all the worst cases of enteric fever we have nursed in our hospital have been brought to us from the warships on that station. Our operations are conducted on aseptic principles, and our death rate for all admissions only averaged 3.56 per cent, in the last five years. The European staff consists of a resident medical superintendent, visiting surgeons and phy- sicians, sister-in-charge, three nurses and a steward. The dispenser is a native Fijian, who is clever and competent. Native students are trained here and receive a three years' course of instruction in technical and practical work, after which, if successful in their examinations, they are sent out among the sick in the provinces. They sometimes work alone, but are for the most part under the supervision of a district medical officer. The cooks and other servants are Indian coolies. The training for the nurses extends over three years. Lectures are given by the medical staff, and they receive instruction in practical ward work and invalid cooking from the sister. A certificate is given if the examinations are passed creditably. As w^ell as our own work in connection with our wards, much is done to help the district medical officers and the native practitioners who requisition all their supplies from this, the parent hospital as it were. The Fijian group comprises over 200 islands, about 80 of which are inhabited, and some of these are very isolated. The total population is about 122,673. It is thus a difficult mat- ter to reach all the sick, but, during the last three years, provincial hospitals in charge of English medical men have been established and sanitary inspectors appointed to visit the more populated districts, so that, at the present time, the wants of the Fijian are being well cared for. In time we shall train more nurses, and some may like provincial work; just now the only trained nurses here are our own. Infant mortality in the villages is great. It is pitiful to see Council Reports 415 the condition of some babies broug^ht into hospital, and to note the apathetic, ignorant helplessness of the mothers. It is almost useless to try and teach the present generation of mothers very much. On one occasion, after talking to a number of women for some time, and demonstrating how children should be treated from birth onward, they listened most attentively, ag-reed ostensibly with all I said, and admired our methods ; but they finally remarked : " Yes, that is all very good and true for white people, but we are Fijians." As a rule they are pleased when anything is done for the children, and the mothers, who often come in with them, severely scold the little things if they cry or show any fear of us. In the native wards prayers are said every night and morning by one or another of the patients, who acts as a lay- reader; and a hymn is sung in which every one joins. Native games are played on the veranda, but nothing gives so much pleasure as a pack of cards for euchre, and the boys' delight is unlimited when presented with a few mar- bles. Story telling is a favorite pastime, and most natives are fluent speakers. One evening I listened to a man relat- ing the story of "Dick Whittington and his cat" to a most interested audience. So prolonged was the tale with addi- tions from his own inventive brain that irESS INSTITUTION AT ERSTA, Stockholm. (a) time of TRAINING FOR THE DEACONESSES. The deaconess is trained during twelve months at the hospital of the institution. The deaconess works eight months as probationer, four of which are spent in the vari- ous wards and three in the theater, the out-patient depart- ment and the dispensary, and one month on night duty. The last four months she returns to the wards as staflE nurse, and helps to train the new probationers. (b) subjects taught theoretically and practically. The chief part of the instruction is practical, and includes dispensing and the giving of anaesthetics. The medical man of the hospital of the institution on his daily rounds also points out to the deaconess all points worthy of notice, explains the different symptoms of disease and the reason why the nurse is expected to do a cenain thing to the patient. The theoretical instruction, properlv speaking, is given in regular courses of lectures during six months of the year by the medical man at the head of the hospital, who lec- tures an hour a week on medical and surgical nursing, and gives extra lectures as well on special subjects such as tubercular diseases, epidemics, etc.. or on any subject requested by the nurses themselves. The resident doctor also lectures an hour a week on anatomy and physiology-, and gives some notions of patholog>- as well. He also makes a post-mortem examination for the benefit of the 478 International Congress of Nurses deaconess probationers, and exhibits to them the principal organs of the body. The deaconess at the head of the hospital also lectures to the probationers on general nursing and other kindred subjects, and superintends the practice of bandaging. On entering the hospital for her year of training the deaconess has already learned housework, cooking, baking and sewing, so that she only needs to apply herself to nurs- ing, properly speaking. 11. (a) names and organizations of certificated nurses. (a) Though, properly speaking, not organizations of certified nurses, the above mentioned institutions — Sophia- hemmet, the Red Cross Society, Sabbatsberg and Ersta— act as such by providing nursing work, each for its own nurses, the Red Cross Society, in addition to this, when short of their own workers, giving cases to others as well, at the rate of a fee of one crown for each separate case. THE FREDRIKA BREMER SOCIETY, Drottninggatan 54, Stockholm. (b) the constitution and regulations of such societies. Every Swedish woman of unblameable conduct, and under the age of 42, who has made nursing her profession, and has had a course of theoretical and practical training at a hospital during a period of at least six months, and has done good duty as ward nurse in a general hospital as well during a period of at least six months, is entitled to be entered on the lists of the Fredrika Bremer Society. Council Reports 479 Upon special approval by the committee of the society in every special case such nurses as well may be entered, who have had no regular theoretical and practical training, but are able to prove by certificate from a medical man that they have served as ward nurses at a general hospital for the period of at least two years, as well as by such who can prove by certificate from a medical man that they have been engaged in private nursing to his satisfaction during a period of at least six months. Nurses pay a fee of one crown on being entered on the lists of the society. If permanent work is procured through the society the fee of one per cent, of the salary of the first year is paid. Nursing in Tasmania J. D. MILNE, Lady Superintendent General Hospital, Launceston. There are training schools in the general hospitals at Hobart and Launceston. The Hobart Hospital gives a three years' course with certificate of training in medical and surgical nursing. No test examinations are held. The Launceston Hospital gives a three years' course, with nursing of the insane, medical^ surgical, and infectious training. There are courses of lectures, twenty each year, given by physicians and by the matron, on the theory of the above subjects. There is no organization among nurses. We are pre- paring to form a branch of the Australasian Nurses' Asso- ciation. 480 Nursing in the United States. LAVmiA L. DOCK, Secretary Internationa,! Council of Nur.ses. The plan of nursing organization of the old world under which nurses may remain an integral part of their hospital schools, was not continued in the United States when the first training schools for nurses were founded at the Belle- vue, Massachusetts General, and New Haven hospitals, although the general plan of ward work and teaching fol- lowed the English plan to a certain extent, as the first super- intendent of the Bellevue school, who inaugurated the reforms there, was an English nurse. Sister Helen. The managers no doubt felt that this system, with its old age pensions and provisions for sickness, would not work well in a democracy, and it was not attempted, the only approach to it being the " school registry." This meant, sim- ply, that patients and doctors sent to the school to call for private duty nurses, and that the school sent such graduates as it could guarantee. In some schools this work was car- ried on solely as a service to the public, no charge being made to the patient or to the nurse for the accommoda- tion ; in other schools a yearly fee was paid by the nurse for the benefit to herself, and in such cases as the number of nurses increased the registry work became a definite business, with some profit accruing to the school which managed thus. As this financial profit may, in a large reg- istry, be considerable, it has proved that the " registry " 481 482 International Congress of Nurses question has become one of the troublesome ones in the progress of American nurses. Lay people of unfit quali- fications have attempted to make money in this way, and have often succeeded, owing to the professional pre-occu- pation of the nurse, and also to her indolence in dealinji with such affairs. It is still the case that in some places nurses pay not only a fee, but also a percentage of their earnings, to these registries, which are really only intelli- gence offices. Such conditions are obviously worse than the " Sisterhood " out of which the nurses developed, their redeeming feature being their transitoriness. Most firmly fixed of these commercially managed registries are certain ones controlled by the medical societies of the towns in which they belong; they are known to be very profitable, but no nurse has a voice, and all information is refused, even the addresses of nurses belonging to them being, in one well known instance, refused to any one for any purpose. The management is entirely that of a private monopoly, and intimidation is used in the control of the nurses, as they are told that if they register elsewhere the physicians will not employ them. Such registries are evidently a distinct draw- back to the social and civic development of the nurse, and are quite indefensible from the standpoint of medical pro- fessional ethics, being only explainable from the point of view of pure commercialism. Organization among nurses is definitely discouraged by the policy of such registries, as is shown by the actual facts, and on the other hand, the only attempts made at national pension funds, supported by charity, for nurses, are in places dominated by these med- ical registries. The most advanced and best organized nurses in the United States either belong to their school registries, or conduct their own, and the latter on the whole are the most numerous. The first registries attempted no further control of the nurse personally than to make a few rules as to her business obligations. They, however, fixed a price for her services, which should have been accepted as a minimum or average, Council Reports 483 leaving a fair amount of flexibility for the maximum, but which has instead unfortunately become established as a definite quantity, so that now, when from various causes there is a tendency to lower the rates of payment, the whole force of custom is against the nurse raising them under proper circumstances, as the doctors do. It will be seen that in their early history American nurses retained certain disadvantages from an old system, and lost its advantages. Their lives at this period were isolated, their modes of living dreary, and their outlook lim- ited. However, they were at least free to strike out for themselves, and the first associations were of graduates of one school banded together in " alumnae societies," Bellevue the first in 1889, and the Illinois Training School next in 1890. As a rule, in this stage, the graduates of one school only knew one another, and were not acquainted with those of other schools. In 1895 the first statistical report of such associations was made (Training School Alumnae Associations; paper read by Miss S. F. Palmer, before the American Society of Supermtendents of Training Schools for Nurses, 1895). Among 164 schools in the United States, thirty-one societies were reported, of which two were religious guilds, four were general clubs, admitting graduates from all good schools, and twenty-five were alumnae associations. These societies were quite small, not by any means including all the graduates who were eligible, the majority of whom seemed indifferent anc' preferred their isolation, so that the work of the comparatively few public spirited ones was most arduous and often discouraging. Objects were: the elevation of the profession (in a vague and general way), social meetings, and sick benefit funds, and the latter have been well managed and successful. In 1893 the Society of Superintendents of Training Schools for Nurses was formed at the World's Fair, a con- gress of nurses having been assembled at the suggestion of Mrs. Fenwick, the present head of our International Council. Mrs. Robb, then Miss Hampton, was chairman 484 International Congress of Nurses of the congress, and she, with other leading spirits of the nursing world, already had plans for a national association of graduate nurses, which was later organized under the name " Associated Alumna? of the United States and Can- ada." (Third Annual Report of the Society of Superintend- ents of Training Schools for Nurses. Annual Reports of the Nurses' Associated Alumnae.) With the necessity of incorporating this association, the name was altered later, leaving out Canada, and the Canadian nurses were asked to organize separately. The Canadian members remain in the superintendents' society, as this is not incorporated. Since then organization has taken on fresh energy, and has advanced rapidly, so that we may consider we are but just noting our earliest stages and are developing along the Hnes of a vast, comprehensive, and closely related yet individually free group of associations. State associations are now arising, New York, Vir- ginia, and Illinois having formed their outlines. Such soci- eties will necessarily be more liberal and inclusive in their membership qualifications than any we have yet had, and their peculiar work will be to influence the future status of nursing education by suitable legislation, restrictive on some lines and constructive on others.* In this task the magazine established in October, 1900, under the control of the National Alumnae is expected to prove a potent factor. The last step in organization was the affiliation of the National Alumnae and the society of superintendents under the name " American Federation of Nurses," in April, 1901. Under this form and title we have joined the National Council of Women, and this is the body which is ready to enter the International Council of Nurses. We have left this federation free to develop as the state societies come into membership with the national, or as other groups of nurses may desire to enter it. ♦This work is now definitely beginning in New York StatP where a registra tion bill is in preparation for the Legislature of 1902-3. Council Reports 485 NURSING EDUCATION IN THE UNITED STATES. Nursing education stands thus : — Preliminary require- ments : No fixed uniformity of preliminary examination or definite requirements has been reached, further than by gen- eral opinion. While a good common education is agreed upon, we have not put upon paper what this should be, exactly.* Refinement and accustomedness to nice ways of living are sought; ultimately, the personal character and capability of the pupil nurse are put ahead of technical attainments. PERIOD OF TRAINING. Two years was the almost universal course of our schools at first ; yet our school boards tacitly assumed that the training was finished in the first year, as in the second the pupils were made head nurses, and also sent out to pri- vate cases. As time went on the latter custom died away, so that two years' work in the hospital wards has been the rule throughout the country for the past ten years; since 1894 some seventy odd hospitals have adopted the three years' course ;f this will no doubt extend to all hospitals as the advantages are great. In the third year there is now a tendency to return to undergraduate private duty, which must be looked upon, on the whole, as an injurious ten- dency, which we must hope will prove temporary, as in the two years' course. COURSE OF THEORETICAL STUDY. The generally accepted course of study covers hygiene, anatomy, physiology, materia medica, principles of bacteri- ology, asepsis and antisepsis, and medical, surgical, gynaeco- logical and obstetrical nursing. Lectures on massage, spe- cialties (such as eye, ear, etc.) are included, and some *Some of our best schools require a High School education, but this is by no means universal. tSince the preparation of this article the number has risen to over a hundred 486 International Congress of Nurses attempt at teaching cooking for the sick is quite general, though not always as well worked out as might be. While lectures are universally of excellent quality, the criticism may be made that we have too many. From the practical standpoint this is the least useful form of study for the pupil. Teaching by demonstration, and the laboratory method, or having the pupil carefully watched in the performance of each duty, is less well developed, though this method is constantly extending. PRACTICAL WORK. Practical work follows the theoretical, as far as material allows. Besides the medical, surgical, gynaecological, and operation room ser^'ices, all schools of good grade provide obstetrical training for their pupils, either in their own wards or in some special hospital. Such training includes examination of patient, and delivery of uncomplicated cases, only in order that the nurse may be prepared to meet emer- gencies. The nurse never takes up midwifery work, and in private practice or district nursing goes only to obstetric cases where a doctor is in attendance. The midwife ques- tion, so distracting in other countries, does not exist here as a complication to nurses, and is consequently a question that we may leave to the medical profession to settle. Mid- wives are only in practice among the foreign population of our large cities, and the rising generation learns to call foi a doctor, either man or woman. The largest hospitals usually give their pupils training in contagious diseases, but the smaller ones seldom ; we mean scarlet fever, diphtheria, erysipelas, measles, etc. Typhoid fever is received in all general hospitals. Few hospitals give nervous or insane training. Com- paratively few yet give a really thorough-going practical training in cooking and housewifery, though almost all make some eflfort in this direction, and so far we have but one definite preliminary course, where a six months' train- ing is given in these two branches, and where the whole Council Reports 487 foundation of practical work is laid before the pupil is sent into the wards.* Examinations are held at the end of each year and are mostly written, conducted by the medical and surgical staflf. POST-GRADUATE WORK. There are several good post-graduate courses available in special hospitals, but no general hospital has yet planned out a systematic post-graduate course. STATE EXAMINATIONS AND REGISTRATION. As yet we have nothing of the kind ; but the state soci- eties will begin work in this direction within the next year or two. There are at present various quack schools in existence, which are managed by doctors, who, presumably, do not realize what they are doing; one is in Philadelphia, one in Chicago, the third and least pretentious in New York City. In the far West a number of imitators are arising. To attack these and bring about a complete general standard of training, by dint of urging co-operation instead of the extreme individualism now practiced by hospitals, will be the work of the future for our organizations, and will fully occupy their time for the rest of the twentieth century. ♦The Johns Hopkins Hospital. Since writing this article excellent prepara- tory courses on this plan have been established in the New York City and Metro- politan Hospitals, New York. End of Part II. APPENDIX Nursing in Norway. DR. L. GVAM. (Sent thruuKh courtesy uf Mi»i) (iina Krug.) Norwegian nurses are trained by different societies, as: The Deaconess organizations, The Norwegian Woman's Sanitary Society, The Society of the Red Cross, The Sister House of Bethania. While in training the nurses reside at the hospital home. They have courses in Anatomy and Physiology, with lectures by the physicians. Practical training is given in the wards of the different hospitals. Special training is given in Surgery and bandaging in private clinics ami classes. The time of training is never less than one year. The hours of duty are from 7 a. m. to 8 p. m., with ample time off for meals and rest. When a nurse is on night duty she has as a rule the next day to sleep. After being in the hospital for some time nurses are paid for their services. Upon graduation they usually receive their calls from the hospital, looking upon it as a home. As a rule they remain in the service of the hospital for at least five years. 488 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. Form L9-100in-9,'52(A3105)444 ^MB '^MiU/:_ OJIWDJO' 'fi:mV ^^AWMffna^' UC SOUTHERN REGIONAL LIBRARY FACILITY AA 000 617 536 8 ^6*AHVHHn-^^ ^tUNiVtRi)^ ^UiS-ANGEIij^ AIIFO% ^•UNIVERV^ ^lOSANGElfj^. iVHan-i^ ^i^ji30Nvsoi^ a '^^t'mhWM'^ .aNGEL£j> ^^t■[IBRARYa'^ ^lllBRARY^^ OFCAi{FO%^ ^0FCAIIF0%. wHan# ^^AHvaaiii^ i)^ ^33N^ s^lOSANGFIfj; /^ly mm