women visitors. It has an amphitheater for clinical instruction, and its buildings are large and convenient.

All these hospitals maintain the principle that those who are treated in them should pay for the care they receive according to their ability. The price of board and treatment varies from five to forty dollars per week, according to the service required and other circumstances; but in all the institutions are free beds, endowed or supported by charity.

Out of this hospital work has grown another very important branch of service in the training schools for nurses. While estimating this new departure at its full value, I wish to pause a moment to pay a deserved tribute to the "old-fashioned nurse.' In New England, especially in our country towns, and I presume no less in other parts of the country, the nurse was an important and honored member of society. Although not regularly trained according to the modern demands, she was generally a woman deeply read in the great school of life; often a widowed mother, who earned her bread by giving to others the fruits of her own blighted family life; sometimes a maiden, who, losing the hope of a home of her own, found a wide and useful sphere for her energies and affections in care of the sick; sometimes the girl who had wrecked her life by youthful indiscretion (like Mrs. Gaskell's "Ruth "), in the ministry of help to others found a life which soothed her own sorrows and restored her to the respect of society. The nurse then gathered her knowledge as she could, watching through long winter nights with sick friends, and visiting among the poor when disease came upon them. Dickens has drawn cruel portraits of the nurse of olden time, true, perhaps, to flagrant instances, but forming a pitiful caricature of the whole class. The old nurse was more often the true friend of the family, summoned in every time of trouble, and loving the children whose birth she had watched, almost as if they were her own.

But with the advance of scientific medical practice it became necessary that the physician should have an assistant fitted to carry out his views skillfully as well as faithfully; and the trained nurse was called into being. She, as well as the physician, must have clinical education. How strongly this need was felt is shown by the almost simultaneous establishment of training schools in various countries. To Miss Nightingale is due the impulse which started the general movement.

The New England Hospital claims priority in this country, in announcing the training of nurses as an important part of its work in 1863; but its school was not fully established until the

return of Dr. Dimock from Europe in 1869, who placed it on its present foundation. The methods pursued in the various training schools now in operation are very similar, showing that the work has been carefully considered and is being satisfactorily done. Similar difficulties presented themselves to those found in all industrial education, of which one of the greatest was the impossibility of finding teachers trained for the work. Such women as I have described might be very valuable nurses, but they had not acquired their knowledge systematically, and were not skilled in the art of teaching. The doctor knows what qualities are wanted in a nurse, but cannot always give the instruction and discipline which will secure their development. The women physicians had some advantage in this respect. The very general employment of women as teachers has helped to supply this need. A young woman who had a natural aptitude for nursing, and the high moral qualities necessary for a superintendent of nurses, and who also had the experience of a few years of teaching, became well adapted to the new profession, and after a few years the training schools began to furnish graduates who could carry on the work as teachers.

Another difficulty was in the amount of time required for thorough training. The pupils seldom had resources to support them during one or two years of training. It is quite necessary, therefore, to pay the pupils a small salary, after their first month of probation, in addition to their board and lodging. This is sufficient to provide for their inexpensive clothing and all other necessary expenses, so that the graduate leaves the school without arrears of debt and able to look cheerfully forward to the exercise of her profession. A great step has been gained for women in thus raising this humble labor to the dignity of a profession. The woman who has given one or two years to preparation for her life-work, looks upon it very differently from one who has taken it up only on the pressure of necessity and has to learn her business in the doing of it. She feels a conscious strength in her position, which ought to stimulate her intellectual powers and elevate her moral character. It is true that the school gives her only the preparation for her work, and she must get the best part of her education from life, but she goes to her task with tools well sharpened for use, and a trained power of observation which should make every experience doubly valuable. Let her not lose in the pride of her acquisition the lovelier spirit and conscientious fidelity which made the old nurse the useful and trusted friend of the family.

The well-trained nurse is like another eye and hand to the

physician. She notes with reliable accuracy the changes of pulse and temperature, keeps the record of nourishment and sleep, watches every vital function with a practiced eye, and thus can give to the medical attendant a photographic picture of all that has occurred since his last visit. She carries out his directions intelligently, and thus enables him to calculate on strict application of the means he wishes to use.

In 1886, by the report of the Bureau of Education, there were 29 training schools for nurses, 139 instructors, 837 pupils, 349 graduates, in twelve different States and the District of Columbia. Some of these schools are connected with public hospitals, others with private charities. In a few cases the schools are independent of any institution, but the pupils are employed both in hospitals and private families.

The rules of admission are very similar in all schools. The minimum age ranges from twenty to twenty-five, the maximum from thirty-five to forty. As a general rule, twenty-five is a good age at which to enter a training school; the constitution should be well established, the character formed, and some experience of life gained before entering upon this difficult work. Good education and character are required, and in most cases certificates of good health and ability for the work.

The wages paid to pupils vary from seven dollars per month the first year, and twelve dollars the second year, to sixteen dollars per month for the highest grade of nurse, in a New York hospital. The time required for study ranges from one to two years, the last being the rule in a majority of cases. The Philadelphia school, which demands only one year, has an additional course of one year to train superintendents.

The expense of supplying the nursing of the hospital by a training school, in the only case known to me, is found to be about the same as by the old method of hired nurses. Trained nurses receive good pay in comparison with that of the ordinary employments of women, ranging from ten dollars per week upward to twenty, thirty, or even forty dollars, according to the difficulty of the case. While these prices are by no means higher than should reward a nurse who has given years to preparation for her profession and who works faithfully in it, they are yet burdensome to many families. A surgeon will sometimes refuse to take a case unless he can have the skilled nursing that he believes essential to success, and yet the pay of the nurse will take all the earnings of the father, on which the family rely for support.

But, on the other hand, the saving of expense in the number

of physician's visits is to be considered, since he can trust the report of the nurse, and so the patient is better cared for, without additional expense. During the last months of study, the nurse's work is among the poor, under the direction of the dispensary physicians. Not only are the patients much helped by this arrangement, but the experience is of great value to the nurses, as they see a greater variety of work than they can in a hospital and under differing conditions of life, and are thus fitted to meet what comes to them in their future practice. Societies are also formed by women for supplying nurses to the sick poor. Such associations employ a number of trained nurses in attendance on patients who are unable to pay full price. They work both in connection with dispensaries and independently of them. Usually a nurse makes two visits a day to her patient, doing for her whatever members of the household cannot do, but she is always required to instruct some of the family, if possible, in the simple methods of care of the sick. She also uses her opportunity to enforce common rules of hygiene and sanitary care on all the household. In this way it is hoped that much may be done for the prevention of disease as well at its cure.

66

The Visiting Nurse Society, of Philadelphia," may serve for a good model of such associations.*

While it has been impossible in limited space to do full justice to all the good work now doing in the training of nurses, there are yet two directions, of which I wish to speak, in which

* In New York city the Woman's Branch of the New York City Mission sends out five nurses among the poor. These nurses have all had a full course of training at some hospital. This mission claims to be the first society in America to have introduced trained nurses in its work.

The Department of United Relief Works of the Society of Ethical Culture, organized in 1879, furnishes nurses to Demilt and New York Dispensaries. During the year 1888-1889 these nurses paid on an average 2800 visits to about 700 patients, including all diseases, even of the most infectious nature, and quite irrespective of creed and nationality.

The Mt. Sinai Training School supplies, at its own expense (being at present a separate organization from the hospital) from among its nurses not yet graduated, but experienced in hospital training, a nurse who administers to the sick irrespective of creed, nationality, or disease, under the direction of physicians attached to what is called District Poor Service" of Mt. Sinai Hospital. Among the corps of physicians, all of whom give their services free, is one woman, Dr. Josephine Walter, who devotes on an average four mornings a week to this work in some of the poorest and most miserable districts of the city.

The order of Deaconesses, referred to in the chapter on Woman in Ministry, also act in the capacity of nurse. Among them are many regularly trained nurses who serve in the hospitals closely connected with the church.-ÉD. note.

it should be extended. It is desirable that women should be especially trained for the care of insane patients, who need peculiar care both in institutions and in private life. The extreme watchfulness and the power of control required for this service seem to demand a special training, which would be unnecessary or even prejudicial in ordinary nursing. This subject is already engaging the attention of those having the care of the insane, and I doubt not they will find means to carry out their ideas.

Again, I believe that nursing would afford a wide field of usefulness for the colored women of our Southern States. Their qualities of patience, sweetness, and affection are well adapted to this profession, and when to these is added the intellectual education which is now within the reach of many of them, there is no reason why, with good training, they should not do excellent service. Many of the best nurses in our Southern cities are of this class. The University of Atlanta, Ga., has made some attempt to introduce nursing into its practical education, and I hope other experiments will soon be made. So far as I know the New England Hospital is the only one that admits colored pupils to its training school. Here this measure has been entirely successful, and no disagreeable feeling has arisen on the part of patients or any one else. The colored students have maintained a fair average in their standing, and some have been superior. A good education is the most important prerequisite to the entrance of colored women into this field.

While my fruitful theme is by no means exhausted, I wish in conclusion to add one thought, viz., that however decidedly these hospitals of which I have spoken owe their existence to women, either as originating or endowing them, in every case within my knowledge there is a union of both sexes in the management of the institution. The arrangements are very various; in some cases the managers are all women and the physicians are men ; in others all the physicians but the consulting staff are women, while the board of management is divided between the sexes; in others we find the women have full charge, with an advisory board of men. This proves that women have been more anxious to secure good management than to establish their own claims. It is an earnest of future improvement when both sexes shall work together in all departments of life, each bringing her or his peculiar talents to the work, either as individuals or as representing a part of the community.