ORGANIZATION OF NURSING if A LAB.SE TOWN SITE A a IIT'RODOCTIOU aed sates LEEDS UNIVERSITY LIBRARY Classmark: Colkc h'oA -fc . t Liverpool. Nurses Training Schqor & Home. ORGANIZATION OF NURSING AN ACCOUNT OF THE LIVERPOOL NURSES’ TRAINING SCHOOL, ITS FOUNDATION, PROGRESS, AND OPERATION IN HOSPITAL, DISTRICT, AND PRIVATE NURSING. BY A MEMBER OF THE COMMITTEE OF THE HOME & TRAINING SCHOOL. WITH AN INTRODUCTION, AND NOTES, BY FLORENCE NIGHTINGALE. LIVERPOOL : A. HOLDEN, 48, CHURCH STREET. LONDON : LONGMAN, GREEN, READER, AND DYER. 1865. Digitized by the Internet Archive in 2015 https://archive.org/details/b21512966 CONTENTS. View of the Building Plan of the Building Description of the Plan Page 5 Dedication to Miss Nightingale 7 Introduction by Miss Nightingale 9 Origin and Organization of Training School and Home for Nurses . . 17 Letter from Miss Nightingale on the Proposed Plan for the Employment of Women in Hospital, District, and Private Nursing .. 25 Prospectus 27 Explanations, Authorities, and Facts in relation to the foregoing Prospectus 33 Plan of Education for Nurses 50 List and Estimated Cost of Materials 52 Method of Working 55 Appendix : — A. Report of the Committee for 1864 67 B. Balance Sheets, and Items of Expenditure for 1863 and 1864 72 C. Tables of Work done in Districts, 1864 76 D. Arrangement with the Central Relief Society, and Forms of Recommendation 77 E. Rules and Forms of the Training School for District and Private Nursing . . 81 F. Memorandum submitted to Ladies when it is proposed that they should undertake a Nursing District .... 95 G. Ladies’ Superintendent Reports 95 II. Address to the Nurses on the New Year, 1864, by a Member of the Committee 101 It Map of Districts, as printed on the hack of recommendation 103 Liverpool Nurses Training- School Home . ground Plan. " * ... " * -* H p Horner a*c»> Livcrpool DESCRIPTION OF PLAN. The Liverpool Nurses’ Training School and Home forms a parallelo- gramic building, 85 feet b}- 46 feet externally. It consists of three storeys, each eleven feet high from floor to ceiling. The ground storey comprises an Entrance Hall, Parlour for the Lady Superin- tendent and for visitors, Nurses’ Dining Room, Kitchen, Pantries, Store Room (serving also as Housekeeper’s Sitting Room), and detached Dormitories for the use of the Night Nurses during their hours of rest in the day. The centre forms on this floor an open corridor 9 ft. 9 in. wide, with a stone stair leading to the gallery on the next floor, a distinct stair being included in the official part of the plan for the Superintendent. The first floor comprises a Day Room for the Nurses, Bed-rooms attached to the Superintendent’s dwelling, and single Dormitories for Nurses, as also Bath Room, Housemaids’ Closet, &c. The Dormitories are entered from a stone gallery formed over part of the ground floor rooms on the East side, and over the Night Nurses’ Dormitory passage on the West. The second floor is nearly similar in arrangement and disposal to the aforesaid ; but the large rooms on the South end of the building are appropriated for Sick Rooms, or Bedrooms for two or three Nurses in one room, and for the Servants of the Institution. The central space, by the added width of the galleries (of which that on the second floor is carried on iron brackets), becomes above the ground floor 9 ft. wide. Its height, from the ground floor to the ceiling above second floor, is 35 ft. 6 in., and to the top of skylight 41 ft. 9 in. The whole of the dormitories are ventilated into the DESCRIPTION OF BUILDING. central space of the building, by arched openings over the doors, filled in with perforated zinc, and fitted with hanging curtains. The central space itself has louvred ventilating openings at each end of the large skylight, occupying the middle part of its ceiling. The Superintendent’s part of the building can he shut off from the general body by locking the doors of communication at the ends of the galleries, while the interior can he inspected on each floor from the South end ; landings opening by fenced archways into the central space. The Scullery is projected into the Yard, which is in the greater part covered with glass, and with which are connected the Larder, with Cellar under it, back entrance, passage way to Royal Infirmary area, and receptacles for coal, coke, and ashes. The general warming is by ordinary open fires, and two of Nettleton’s (Chelsea) stoves are placed in the central space, and used singly or together in cold weather, having air channels opening beneath them from the outer walls, which admit cold air when the stoves are not lighted. The materials of the building are brick, with stone dressings exter- nally. The inside being plastered, and Keene’s cement used in the lower central corridor and other principal parts. The woodwork is for the most part varnished, and the entrance and lower central corridor are paved with Minton’s tiles, in plain coloured patterns. HENRY P. HORNER, Architect, No. 1, Derby Square, Liverpool. ®j)h jtitrpftf is respectfully btbrntfcb to FLORENCE NIGHTINGALE. In dedicating this short account of efforts made to improve the character of professional nursing and pro- vide for the better tendence of the sick to one to whom, as their beloved chief, all engaged in similar endeavours look for encouragement and guidance, the compiler had two objects in view. First, To call attention to the nature of the plans which, carried out under her direction and advice, have been attended with so much success in Liverpool, and to recommend others to adopt and improve upon them. Secondly, To express the warm gratitude which he feels, not only as an Englishman but as an inhabitant of Liverpool, for those especial benefits which his native town has derived from her aid and counsel, in addition to those which it shares with the country at large. INTRODUCTION BY FLORENCE NIGHTINGALE. I have read the following pages with much interest. I regret that we have been so busy, and my strength so over-tasked, that I have only now been able to do so ; hut, once taken up, I could not lay it down till I had read it through in two sittings, and then I read it through again. I have studied all the Rules and Forms with the greatest profit and interest to myself — as indicating a master hand in securing that unity yet independence of action, that personal responsibility and yet liberty, which are so vitally essential to the continuance and development of a great and wide charity like this. I am asked to write a few remarks by way of preface. I have some difficulty in doing this, because I am cited as authority for some part of the principles. A report on such a subject as the Training of Nurses, to supply “lack of service” towards the poor afflicted and dying, should of itself command attention, simply on its own merits. But, if any argument were required on its 10 INTRODUCTION behalf, in this practical age, the best argument is the success which has attended the efforts made in Liver- pool. These most satisfactory results, though not greater than you deserve, are greater than even the most sanguine hopes could have foreseen. Nowhere that I know of are the difficulties of organizing a system for nursing the sick in their own homes likely to be greater than have been there encountered, and so far overcome. There is a dense and rapidly increasing population, drawn from all quarters, most of them of that lower class which has to change its home in order to be able to live. There has been hitherto strong religious partizansliip, a very great amount of sickness (as is testified by the extent of local Medical Charities), a lamentably high death-rate, especially among chil- dren— always the readiest victims to want of good nursing in sickness — and, together with all this, much inevitable poverty, ignorance amongst the poor as to the proper management of their sick at home (this we find everywhere, but nowhere else, perhaps, so much) ; often want of ■ every appliance and nursing care which should surround the sick-bed, and great, though remediable, suffering as a consequence. It is the old story, often told ! but this book opens a new chapter of it. It gives us hope for a better state of things. An Institution for training Nurses in connection with the Infirmary has been built and organized. This is a matter of necessity, because all who wish to nurse efficiently must learn how to nurse in a Hospital. Nursing, especially that most important of all its branches — nursing of the sick BY FLORENCE NIGHTINGALE. 11 poor at home — is no amateur work. To do it as it ought to be done requires knowledge, practice, self-abnega- tion, and, as is so well said here, direct obedience to, and activity under, the highest of all Masters, and from the highest of all motives. It is an essential part of the daily service of the Christian Church. It has never been really otherwise. It has proved itself superior to all religious divisions, and is destined, by God’s blessing, to supply an agency, the great value of which, in our densely peopled towns, has been unaccountably overlooked until within these few years. Nothing, indeed, can afford a stronger argument for the local support of the Liverpool agency, than the simple fact of its past success ; while, at the same time, the example should be followed among other large populations, and will he. It is a comparatively indifferent matter under what organization a system of home-nursing of the poor is carried out. It may be done, and well done, by dis- tricts as in Liverpool, or by parishioners in parishes, or by members of Christian Churches. The great thing is, that it he done, and done well. And to those who want to know how such a work can be successfully carried out, in conformity with our English feeling for freedom of action, I would urgently recommend a careful study of this book. I need scarcely say, therefore, how earnestly I press for the publishing of this account of the work, as being a pioneer, rather than a model, for similar Institutions all over our country. The work in Liverpool requires greater extension, and more support, before all the fruits of it can ripen. 12 INTRODUCTION But, so far as it lias gone, it has proved its own future possibility by its past success, and promises to be one of the most important agencies for coping with human misery which the present day has put forth. Let us all wish it God speed. No words of mine are wanted to call attention to the subsidiary benefits to the poor involved in this great work. They are not new ; but they are not so widely put in practice in our country as they should he. For example : — “ They will, where it may be desirable to do so, send convalescent patients for recovery to the sea-side at Southport, where they will he sup- ported for three weeks’ residence. To obtain such aid the same course is necessary as stated above, with the addition that the certificate of the medical attendant must he obtained, prescribing sea-side residence or bathing for the patient.” — JR :rtr act of Letter to the Ladies Superintendent . — p. 78. The sending convalescent poor to the sea-side is a kind of relief of which it is impossible to calculate the benefit, any more than its results in diminishing pauperism. Every large town in the kingdom ought to have its Convalescent Institution for the poor by the sea- side, or in the country. For the rich the good of change of air, nay, even its necessity, is never doubted. It is ten times more necessary for the poor. Again — “ We may mention here that the owner of a house maybe compelled, by application to the Inspector of Nuisances, Cornwallis Street, to have it whitewashed when in an unwholesome state.” — Extract of Forms used in District Nurs'uuj. — p. 88. “ The Charity has also been of use in timely calling the attention of the Board of Health to fever cases, where whole families were infected, and the safety of the surrounding neighbourhood endangered.” — p. 97. BY FLORENCE NIGHTINGALE. 13 ‘ ‘ The Ladies Superintendent have in several instances called atten- tion to the state of the courts and houses where sickness has been prevalent, and their representations have always been well received ; where urgently required, the Ladies Superintendent have themselves provided the means for purifying and cleaning dwellings, bedding, &c. Two patients have been sent to Southport ; several have been provided with means to go to the country ; others have been supplied with clothing to fit them for respectable employment ; and the necessary expenses of getting children into the Blue Coat School have been defrayed. The Ladies Superintendent have found the Clergy, the Doctors, and the authorities of the Board of Health most willing to co-operate in the working of the charity.” — p. 99. These alone, if these were the only benefits, shew the wisdom and efficiency of incorporating in an organization the assistance of local authorities, and securing the willing co-operation of charitable volunteers. I do not mean to say these efforts are new and original ; but I mean that it is most satisfactory to find the Ladies Superintendent and Nurses exercising certain powers and influences in Sanitary matters, such as obtaining the cleansing and lime- wasliing of unhealthy houses and places. It is a wise addition to their duties. It improves the domestic habits of the poor. It protects their health. It pre- vents disease. Similar Sanitary duties should always be associated with Nursing. Yet, even now, though “Sanitary” has become almost a cant word, of which we are tired, few educated persons, even philanthropists, are practically acquainted with our Health Acts, so as to call in their help in time of need. Again— “I may just add, that it occurred to me a short time ago that 14 INTRODUCTION it would be a good plan to allow some of our poor patients dinners at the Workmen’s Dining Rooms for a little time after their return to their usual occupation. The Superintendents of the Dining Rooms are prepared to supply dinners on receiving a written request to that effect from the Lady Superintendent of a, district, and on the production by the applicant of a note in the same handwriting.” — Extract of Ladies' Superintendent Export. — p. 100. Wliat a merciful suggestion is that of supplying good food, properly cooked, from Workmen’s Dining Rooms, to poor patients recovering from sickness. It is a means only second to change of air, and to he employed after it in most cases. I have taken only a few instances out of the Appendix of collateral good arising from this work. — I cannot better end my preface than by quoting, from the “Address to the Nurses,” words which I would take to myself, and address to all engaged in this great work : — “ If you feel that you are members of a family, you will be ever desirous that the character of that family should be as high as possible, that it should be a credit to belong to it, that no act or word of yours should bring shame upon it, but on the contrary each of you will strive, by the gentleness, quietness, modesty, and truthfulness of your conduct, by constantly increasing proficiency in your profession, and by the thoroughness and conscientiousness of your work, continually to raise the character of the School, and of all belonging to it, higher and higher.” * * * “ There is no pride so mean, so contemptible, as that which makes a person above her work. There is nothing really mean, or degrading, or unclean, which BY FLORENCE NIGHTINGALE. 15 our duty calls us to do ; but if ever pride leads us to leave part of our duty or work undone, or ill-done, then indeed we are degraded.” * * * “ There is work, there will be times, for which all motives are too weak but one ; you can only do your work as it ought to be done, if you do it as servants, as brethren, of our Lord Jesus Christ.” “If you are merely hirelings, working for man’s wages or man’s praise, there will be much of your work that will be distasteful, wearisome, heartless ; if all your work is done as in His sight, and for His sake and God’s, ‘how different will all appear ?’ ” “ Your work lies, as much of His did, among the sick and suffering and dying; if you do it as feeling yourselves fell oav- workers with Him, it is impossible to say — you will never know, no one can ever know — how much good you may accomplish. Your patients may be irritable and ungrateful, but if they see that, patiently, and constantly, and where no master’s eye but God’s sees you, you go quietly on with your duty, neither discouraged nor weary in well doing, you may be sure you are sowing good seed which will not be lost, for Almighty power is working with you.” “Not only the life of your patients may depend on your faithfulness to duty, but by it you may also influence for good their virtue and happiness, here and hereafter. Remember, when wearied and perhaps discouraged by ingratitude, it is not alone the poor, wretched, irritable, and perhaps it may seem to you worthless, sufferer you are serving — ‘Inasmuch as ye did it unto the least of these, ye did it unto me ;’ — by his suffering, which you can alleviate, the object of 16 INTRODUCTION. your care becomes to you the representative of Him who died for you. Think of this, and your task will become a grateful one, your labour one of love.” — pp. 101, 102. I have read all this with the most intense interest, and can only hope that I too shall draw from it the profit which I ought — that I too shall read in it, and learn well, that lesson which I ought to learn anew every morning. God bless the work and the workers, is the earnest prayer of FLORENCE NIGHTINGALE. 1865. ORIGIN AND ORGANIZATION OF THE LIVERPOOL TRAINING SCHOOL AND HOME FOR NURSES. It is rather more than three years since the Prospectus of the Liverpool Training School and Home for Nurses was made public. The scheme therein sketched out received the cordial approbation of Liverpool men. A sum of T4,461 was raised by donations, and annual subscriptions were offered to the amount of <£988. Liverpool has been divided into eighteen districts, each to have a Nurse of its own ; and residents, — sometimes individual ladies, sometimes religious associations, sometimes the clergy and their wives, — have undertaken to provide the necessary medical stores, appliances, and comforts, and the superintendence required by the arrangements of the Society. Nurses have also been supplied to the Infirmary and to private families. Of course much has to be learnt and much to be done before our organization is brought to the highest degree of completeness and efficiency. Such a work is not perfected in three years. But even in its present imperfect condition it works well, and has fully realised the expectations with which it was set on foot. In regard to the operation of the Home and Training B 18 School itself, we have every reason to be thankful for the fulfilment of our hopes. It has greatly increased the supply of thoroughly educated professional Nurses for the Liverpool Infirmary — thus meeting a want of which the managers of most hospitals are painfully conscious ; and it has attracted to the work a very desirable class of women, superior in character and education to the generality of those who hitherto have entered on Nursing as a profession. The Nurses appreciate the cheerful home and companionship, and the motherly interest and influence, of the Lady Superintendent ; they take also, we believe, a whole- some pride in their school and their profession ; and these feelings render them so much attached to the Infirmary that they generally prefer the duties of the Hospital to either district or private nursing. Formerly, the feeling was very different, professional Nurses being wont to consider the position of a Hospital Nurse as anything but desirable. The Medical Board have expressed themselves in decided terms concerning the improvement which has been effected in the character and conduct of the Infirmary Nurses, and affirm that this improvement enables them to rely with much more confidence on the results of medical treatment, and to save many lives which, under less efficient nursing, must have been sacrificed. That this should be the case will not surprise any one who has read Miss Nightingale’s work, and observed the stress which a writer of such eminent experience and careful accuracy lays upon the impor- tance of good nursing, as often more vital even than medical treatment, and always indispensable to its full efficacy. 19 We are inclined to believe that the period of training- fixed by the Liverpool scheme (twelve months) repre- sents the time necessary fairly to qualify a woman of average intelligence and fitness. Two years training would produce still greater efficiency. Some women, gifted with unusual powers of observation, learn the art of Nursing very rapidly; but, even in these excep- tional cases, the experience acquired during a twelve- month’s probation is very valuable. After training the Nurses and supplying the Infir- mary, the next object has been to bring good nursing- home to the poor at their own doors, through an organized system of District Nursing. We believe that the results of this portion of the scheme have been especially beneficial. It has saved many lives, and alleviated much intense suffering. It has promoted cleanliness and knowledge of the laws of health ; and in its economical, beneficent, and religious results has realised the expectations set forth in the Prospectus. So far as mere economical considerations go, good nursing is so valuable in giving efficacy to medical care, and would go so far towards supplementing the effect of the drugs, food, and attendance which each parish is bound to provide for its poor, and making them more available for the relief of suffering and the cure of disease — it would do so much, moreover, to lessen that large amount of pauperism which is the con- sequence of sickness among the hard-working poor — that it would well repay the ratepayers were they to provide the wages and whole expenses of the District Nurse out of the rates. But, on other grounds, we do not desire to see this done. For under a system of parochial payment we should lose the best and most 20 useful accompaniment of private charity, the personal interest and superintendence of the givers. So long as the Nurse is supported by private benevolence, she and her patients enjoy the inestimable advantage of the control, advice, and aid of educated and refined women, who naturally undertake the supervision of a charity for which they provide the means, but who would neither be able nor willing to interfere, if the Nurse were a parish officer, and the nursing and food and medicine supplied from parochial funds. We regard this personal superintendence as an essential part of the plan of District Nursing, the absence of which would deprive it of half its value, and leave it open to errors and abuses which the support and direction of ladies effectually prevent ; and as beneficial hardly less to her who confers, than to those who receive the obligation. It is through the agency and under the superintendence of the rich and charitable — of the wives of landowners, of wealthy citizens, or even of religious societies — that we hope to see a system by which the sick poor may be cared for in their homes introduced into every ward and parish in England. To assist the poor, especially under misfortunes inflicted not by their own fault but by the visitation of God, is a duty imposed by religion on the Christian, and by humanity on every human being ; and whatever care and reserve may be necessary in ministering to the other wants of the poor, lest we aggravate the evils we would fain relieve, no one can fear to do harm by giving his aid to restore a poor man to health, or to lighten the misery of incurable disease. In this direction, at least, benevolence may work without fear 21 and without stint, unchecked by the warnings of science or the rebukes of a sterner morality. In providing Nurses for the sick in private families, we have been so far successful that such Nurses as we have been able to supply have been highly valued ; but we see little hope of being able to keep pace with the demand for such assistance. Experience of the value and vast superiority of educated and qualified Nurses will constantly increase the demand for their services. We can only hope that, as education spreads among the working and lower middle class, there will be found a greater number of women fit and available for the profession of Nursing ; and that, in other towns, schools for training them will be established in con- nection with the local hospitals. In the meantime we shall be grateful to any one who will recommend to us women qualified by nature and character for such a profession — women on whose truth, watchfulness, gentleness, firmness, and devotion to their duty full reliance can be placed. It may assist others who may contemplate a similar undertaking to know the nature of the plans which were adopted in Liverpool, and of the steps by which those plans were carried into execution. But it is probable that each place will present circumstances peculiar to itself, and that in each instance different conditions may require a different system and different rules. The School was the foundation of our enterprise ; and the School was of necessity dependent on the Infirmary. It was necessary, therefore, to obtain the 22 consent and assistance of the Committee by which that Institution is managed. This they were willing to afford ; but they were anxious before all things, and very properly anxious, that there should be no risk of collision or conflict arising from divided and clashing authorities. To meet this objection we placed ourselves unreservedly in their hands. The Home is built on the ground, and is the absolute property, of the Infirmary. The Committee of the School are selected from the Infirmary Committee, the Chairman and Treasurer being ex officio members. Though this subjection to the authorities of the Hospital was with us a matter of necessity, we should adopt it, had we the option, as a matter of wisdom. Where it can be done without unfairness to existing officers, it is desirable to carry the union still further. The Lady Superintendent of the School should also be the Matron of the Hospital, and the female officers of both should be entirely under her control. Our next step was to seek for a lady able and willing to undertake the office of Superintendent. This was no easy task. Our organization was on a large scale; and though some of its objects had elsewhere been carried out singly with success, their combination was a new feature in our enterprise. To take charge of such an Institution from its very commencement no ordinary qualities were required. A lady competent for such a post must be endowed with considerable energy and a hopeful spirit ; must have strong religious principles, yet be free from anything like sectarian prejudice and bigotry ; must possess a clear and sound judgment; must be devoted to her work, and have skill to select, and moral and mental power to control 23 and inspire, a number of young women brought together under circumstances affording them great opportunities of usefulness and self-improvement, but at the same time exposing them to considerable temptations. We were fortunate enough to find a lady who possessed the requisite qualifications, and to prevail on her to under- take the work. She went to the Nightingale School in connection with St. Thomas’s Hospital, and to King’s College Hospital, which is in charge of the Sisters of St, John’s House, to make herself acquainted with the system and organization of those two Nursing Schools, the method of study, and the surgical and medical training therein pursued. Matters had then reached the point at which we felt ourselves prepared to introduce our plans to the public. We called a public meeting, and invited and obtained donations and subscriptions. The following Prospectus fully explained our plans, and the course we intended to follow. Although out of date, it may be useful to reprint it, as matter of information. The Prospectus is followed by a statement of authorities and facts, and the plan of education we proposed to follow. The “ method of working” our scheme is next given. The details, forms, and other information are given in the Appendix. PROPOSED PLAN FOR THE TRAINING AND EMPLOYMENT OF WOMEN IN HOSPITAL. DISTRICT, AND PRIVATE NURSING, 1861. LETTER FROM MISS NIGHTINGALE To the Chairman of the Liverpool Training School for Nurses. London, November 80, 1861. Sir, In reply to your request for my opinion, I can only say that your plans for a School and Home for Nurses in Liverpool have deeply interested me from the very first : they appeared to me so well considered and laid out — they appeared to me so much needed, not only in Liverpool but in all the earth. Sickness is everywhere. Death is everywhere. But hardly anywhere is the training necessary to teach women to relieve sickness, to delay death. We consider a long education and discipline absolutely necessary to train our medical man ; we consider hardly any training at all necessary for our nurse ; although how often does not our medical man himself tell us, “ I can do nothing for you unless your nurse will carry out what I say.” I trust, then, that all, rich and poor, will at least study your Prospectus. All, rich and poor, have sick- ness among themselves at one time or another of their lives. It is singular that this necessity, which, perhaps, 26 no one son of Adam has ever escaped, for himself or his belongings, is the only one we never provide for. . Your plans are not only practicable, but promise extensive and invaluable good — good which will spread to every town and district in the kingdom, if wisely inaugurated in Liverpool. Your district nursing scheme especially deserves interest. I suppose every one will agree with me that every sick man (or woman) is better at home, if only he (or she) could have the same medical treatment and nursing there that he (or she) would have in hospital. But not having this, of how many a rich patient I have said, “ Would that I could send him (or her) into hospital.” Few know, except medical men in the largest prac- tice, how many rich lives, as well as poor ones, are lost for want of nursing, even among those who can com- mand every want under the sun that money can purchase. This want you propose to supply, by training nurses for all descriptions of people, as I understand. God bless you, and be with you in the effort, for it is one which meets one of our greatest national wants. Nearly every nation is before England in this, viz , in providing for nursing the sick at home. And one of the chief uses of a hospital (though almost entirely neglected up to the present time) is this : to train nurses for nursing the sick at home. I therefore most earnestly wish you success, and remain Yours, in good hope. FLORENCE N 1G H T1 N G AL E . PROSPECTUS. The Liverpool Training School and Home for Nurses is intended to supply a want universally felt by medical men, and now generally acknowledged by the public. The work which the new Institution is designed to effect divides itself into three heads, viz. : — 1. — To provide thoroughly educated Professional Nurses for ' the Infirmary. 2. — To provide District or Missionary Nurses for the poor. 3. — To provide Sick Nurses for private families. 1. — To provide thoroughly educated Professional Nurses for the Infirmary.* There are in the Infirmary Nurses of whose efficiency and kindness we cannot speak too highly, but the supply of good Hospital Nurses is quite inadequate to the requirements. And the misconduct of the unsuitable ones, who from necessity are employed, discredits a profession which is in its nature most honourable, and would otherwise attract many whose ability and character would peculiarly fit them for its duties. We refer to the testimony of the Medical Board on this point, and need hardly point out how much might be done by a complete system of nursing to save life and health, and to make the expenditure of an Hospital more effective, by giving increased power to the medical and other agencies, and by abridging the period requisite to effect a cure. 2. — To provide District or Missionary Nurses for the Poor. — * It has been ashed why our Hospital work is limited to the Infirmary. On consideration it will he evident that, if successful, the improvement will extend, hut that to attempt too much at once will ensure failure. The Infirmary is the principal and most comprehensive Hospital of Liverpool, and has, with a liberality unusual with Hospitals, consented to allow the introduction of the new system ; and it is, of course, entitled to its first advantage in the selection of Nurses. 28 In cases which are not suitable for and cannot be reached by Hospitals, to do in nursing what the Dispensaries do for them in medical aid. We propose to furnish Nurses to those districts which will, by means of local committees or individuals, find the necessary medical comforts and superintendence. The results of district nursing, though only tried on a small scale, and with an imperfect organization, have been invariably satisfactory. It relieves an amount of suffering most intense in its character, and capable of alleviation to a great extent, by a proportionately small expenditure. Ft does more than this ; it teaches the people to nurse their own sick, and, by introducing a knowledge of sanatory laws among the working classes, tends to prevent illness and strengthen health. In a merely economical poiut of view, by restoring parents to their work and place, it often prevents whole families from steadily sinking into hopeless poverty, misery, and vice, the consequences of which, in the end, take vengeance on society for its neglected duties In a moral and political point of view, aid thus given to the suffering poor does away with an irritation against God and man, the extent of which is not suspected by those who have not been in a position to see it. Such irritation is the frequent result of extreme suffering, when unmitigated by assistance from those who have the power to give it, leading men to brood bitterly over an inequality of conditions to which they are not reconciled by experiencing in their need the alleviation which wealth and knowledge could and should have provided. Assistance thus bestowed would open the hearts of the sufferers and of their families to all beuevoleut persons in their attempts to benefit the working classes, physically, morally, and religiously. For the explanation of this, and its confirmation by experience, we must refer to page 15, in the explanations, authorities, &c., which, if not annexed to this, may be had gratis, on application in writing to the Secretary of ' the Training School, Royal Infirmary, Liverpool ; or at the Publisher’s, Mr Holden, 48, Church Street, Liverpool, price Is. 3. — To ‘provide Sick Nurses for private families. It is a 29 fact well known by medical men, that far more patients die unnecessarily (or live with permanently impaired health) from defective nursing, in families who could and would gladly pay for efficient nursing if procurable, than even under the defective nursing which till lately was almost general in Hospitals. Most of the Hospital Nurses had at least some knowledge of what they were about. However devoted and watchful the relative or the private Nurse may he, while she is gaining her experience of what ought to bo done, the object of her care has often passed out of its reach, or her own health has given way, and death has thus multiplied its victims. If relieved by the aid of a trained Nurse, she might with an easy mind have left her charge and obtained the necessary rest. We refer to the explanations, page 25 of the fuller statement, for elucidation and confirmation of these views. “ Before proceeding further, we applied for opinions from competent judges; some of which we subjoin : Extracts from the Minutes of the Medical Board. “Liverpool Boyal Infirmary, April ti, 1801. “The opinion of the Medical Board of the Liverpool Royal Infirmary having been requested respecting a proposed scheme for the improvement of nursing, the following Resolution was agreed to; — “ ‘ The Medical Board of the Liverpool Royal Infirmary are of opinion that women trained' for hospital and district, as ■well as for private nursing, are very much required, and having read the scheme proposed to remedy this want, they consider it admirably adapted to meet the exigencies of the case.’ “ (Signed) James Vose, M. D. Henry Stubbs. James Turnbull, M. D. James Long, Thomas Inman, M. D. E. W. Bickerstetb.” Miss Nightingale says; — “ The public hitherto has had a very inadequate idea of what is meant by nursing the sick. There has been little demand for really good Nurses, and consequently very few such have been available. We know more clearly than heretofore that the care of the sick demands acquirements of a much higher order than the common Nurse can attain to. The Nurse’s work is in fact a very important part of medical practice, and for its due exercise requires a considerable amount of knowledge, both of the laws of health and of disease. At present a Nurse, however willing , has no oppor — 80 tunity of arriving at this knowledge. She has neither instruction nor training; and she comes to her duty with all her experience to learn, and nobody qualified to enlighten her. Everywhere this want is felt; and in a very short time it is to be hoped that every large town will make provision for training its Nurses, both for rich and poor, as well as for Hospital service.” Sir John McNeil) says: — “ The Physician relies mainly on his means of aiding the curative efforts which nature makes by the exercise of the vital powers, and every demand which is made upon those powers, to counteract irritating and depressing influences not necessarily consequent upon the disease from which the patient suffers, is so much subtracted from the forces on which the Physician must rely for effecting a cure. When the disease is formidable and the result of the struggle doubtful, the success or failure of the Phy- sician will in a great measure depend upon the skill and ability with which the Nurse economises and sustains the vital powers of the patient, whose recovery or death will depend quite as much on the qualifications of the Nurse as of the Physician. Indeed, in many cases, the Physician, who sees the patients only once or twice perhaps daily, must be guided in a great measure by the report of the Nurse, who is in constant attendance; and he cannot hope for success in his practice unless he can rely upon the fidelity and intelligence of the Nurse’s report. “ The aid of trained, intelligent, and trustworthy nurses is therefore iudispensable to the proper treatment of the sick ; but that aid cannot now be obtained, unless occasionally, and in a few cases.” Before deciding on the establishment or form of the Institution, we consulted the Medical and other authorities of the Liverpool Infirmary, and those elsewhere who are known to have success- fully devoted much time and thought to the subject of nursing. Miss Nightingale gave our plans the same consideration as if (to use her own words) she were going to be herself the matron. From the Lady Superintendent of the St. John's House Nursing Institution we received the most kind and valuable aid. Her experience in working successfully a Nursing Institution in intimate connection with a Hospital (as we proposed to do) made her advice peculiarly valuable. The Hon. Secretary of Devonshire Square Nursing Institution (the first establishment for training Nurses, founded by Mrs. Fry, and for more than twenty years in successful operation,) also aided us with advice and encouragement. We further had the valuable advice of 31 the Right Hon. Sir J. McNeiil, G. C.B., late Commissioner in the Crimea ; of General Sir Joshua Jebb, K.O.B., and Mr. Clough, Commissioners of the Nightingale fund; of Mrs. Wardroper, the Matron, and Mr. Whitfield, the resident Medical Officer, of St. Thomas’s Hospital, where the Nurses under the Nightingale fund are trained ; also of several of the ladies who have admirably managed a small Training Institute for private Nurses already existing in Liverpool.* We cannot speak too gratefully of the kindness and patience which we have experienced from these ladies and gentlemen. All are agreed on the necessity of Hospital train- ing for Nurses, and on the great advantages to be derived from the intimate connection which we propose between the Training School and the Hospital. We appeal, therefore, with confidence, to the benevolent feel- ings and enlightened judgments of the inhabitants of Liverpool to place us in the position to attain the manifold advantages which are open to the first who may introduce a thoroughly well- organised system of nursing in the North of England. The supply of persons suitable for the work is limited ; by being first in the field we may expect to obtain tbe best ; and the demand for their services, which will naturally arise as the move- ment spreads, will afford large opportunities to the persons trained in our Institution, which will continue to attract to it the most eligible of those who are willing to engage in nursing. Arrangements have been made for the erection, on the land belonging to the Infirmary, of a building capable of accommo- dating a staff of Nurses, with a superintendent, a deputy superin- tendent if required, and three servants. Funds have been pro- vided for its erection. The subsequent expenses it is impossible * We have been asked in what relation we shall stand to the Nurses’ Institute in Soho Street. The present plan embraces the Hospital and District Nursing, in addition to the private nursing of that valuable institution. The ladies connected with Soho Street have given us the kindest assistance and most valuable information in maturing our plans, and have shewn great interest in them. They are quite unable to supply the demand on them for Nurses, and that demand increases witli experience. Whether ultimately it may he wise to combine the two institutions or to let them work on side by side is a question which experience will probably decide. If it should be desirable to unite, benefits kindly conferred on the paid of the older institution and cordially felt and acknowledged on ours, will have prepared the way for it. 32 to estimate exactly at the outset of au entirely new undertaking. Money is required to furnish the building, to carry on the edu- cation and pay the wages of the Nurses employed, and to provide for casualties incident to the nature of the employment. To furnish the building entirely would cost about £ 1,000, but we shall probably not require to furnish the whole at first. The permanent annual in-door expenses will include the salaries and maintenance of the lady superintendent, three servants, aud about thirty-one nurses — the number likely to be under training and engaged in the Infirmary at one and the same time The sum required for such salaries and maintenance will probably exceed the sum received for nursing the Infirmary by £300. The expenses of lighting and warming the building, taxes, &c., are uncertain. Each district or missionary nurse will cost from £30 to £40, a year. At first the whole expenditure of the Institution, over and above the sum received from the Infirmary, must be met by donations and subscriptions. It is to be hoped that, in time, the sums received for private nursing, from those who can afford to pay, will cover a considerable part of the in-door expenses. Then the revenue derived from subscriptions would be devoted entirely to that part of the work which is in its essence charitable and gratuitous — the nursing of the poor, and of those who, though educated and belonging to the middle ranks, are yet too poor to provide efficient nurses for themselves From £800 to £l,000 a-year would probably be necessary, to supply such a staff of nurses for this department of our work as the town requires. To this amount the Institution must be per- manently dependent on charitable support. A large reserve ought to be accumulated during the early years of the Institution, ns later there will be expenses incident to the nature of the occupation. Though we have named the above amounts as requisite for the full development of our scheme, we shall do our best to make the sums entrusted to us, whether great or small, available to the utmost in the work for which they are given. EXPLANATIONS, AUTHORITIES, AND FACTS, IN RELATION TO THE FOREGOING PROSPECTUS, We now proceed to give in more detail, for the information of those who may have an interest in the subject, explanations of the proposals made in the preceding statement, as well as the authorities and facts on which we have relied. General and Introductory Remarks. What we propose is no untried scheme, but a safer and more humble task — that of availing ourselves of the experience of those who have been successful in similar undertakings, in order to discover and adopt the organization best suited to our local wants. As with many other enterprises of this generation, “ others have laboured, and we have entered into their labours.” The following statements consist in great part of information and suggestions extracted from the writings of those whose prac- tical experience supplies the reader with knowledge in place of conjecture. The want we seek to supply has long been felt in Liverpool. The subject has been repeatedly taken up by members of the Infirmary Committee, but accommodation being wanting, and the means of the Infirmary being absoihed in meeting evils arising out of the originally defective construction of the building, it was found impossible to do more than make careful selections from the Nurses who offered, and enforce discipline as strictly as could be done by a clever and efficient Matron. The following extract (taken from the Rev. Dr. Howson’s Paper on Nursing, read at the Social Science Meeting in 1858) c 34 must, from the names appended to it, have formed part of a Prospectus issued more than thirty years ago. It shows how early the want was felt, and the proper remedy seen. “ It has long been a subject of regret to those who are conversant with the details of sickness, that a most inadequate or unfit provision is made for the necessary attendance on the sufferer, the administration of remedies, and such alleviation of pain as may result from care and tenderness, directed by experienced skill. The poor are entirely without professed Nurses; even the rich are, in many instances, consigned to the negligence of an ignorant or unfeeling Nurse. The amount of misery which is thus occasioned is such as would astonish, if it were known. “That the misery is not irremediable, may be made evident; and, by those to whom it has been so evidenced, it is believed a practical remedy may be obtained : that remedy they are now seeking to find and apply. “ An Association is formed, whose object is to provide Nurses in every way qualified to minister to the comforts of the sick. These will be persons of religious principle and habits, carefully selected from Christians of all denominations holding the fundamentals of Christianity. They will be educated in the Hospitals; during the course of such education they will be resident in a house belonging to the Association, under the control of a Matron and a visiting Committee. They will carry out testimonials, renew- able by actual examinations from time to time; and their conduct in the various scenes of their future employment will be subject to the inspection or inquiry of the Committee who recommend them. “ The design of the Association is to extend itself, so that in time its objects may be obtained generally throughout the kingdom ; with which view, subscriptions will be sought generally from the first. Its actual operations will commence in Liverpool, under the auspices of the Public Infirmary (and other medical establishments) of that town. “The names of the gentlemen who have attended at meetings already held for the purpose of preliminary arrangements, are — Dr. Renwick, Dr. Briggs, Dr. Brandreth, Dr. Traill, Mr. Bickersteth, Mr. Batty, Rev. A. Campbell, Rev. R. P. Buddicom, Rev. W. Rawson, Rev. C. J. Swainson, Rev. -Josh J. Hornby, Chas. Lawrence, Esq., James Cropper, Esq., John Moss, Esq., Adam Hodgson, Esq., William Jones, Esq.” We have already mentioned the principal authorities on these 35 subjects, anti we give below" the titles of publications from which we .shall sometimes quote, and to which, when accessible in the original, we would strongly urge those interested in the subject to refer. Many of our quotations, however, are from the private letters and advice of Miss Nightingale and other authorities referred to. The following are our reasons for believing that the want we seek to supply is a real want, and that the organization we pro- pose is the one to supply it. In watching disease, both in private houses and in public hospitals, the thing which strikes the experienced observer most forcibly is this: that the symptoms or the sufferings generally considered to be inevitable and incident to the disease, are very often not symptoms of the disease at all, but of something quite different, — of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or of all of these, — and this quite as much in private as in hospital nursing.” At the census of 1851, 25,46G women were returned as Nurses by profession, exclusive of 39,139 Nurses in domestic service, and 2,822 Midwives. Yet, till recently, so little bad been done to fit this important class for duties on the fulfilment of which life or death may depend, that sobriety was comparatively a rare virtue in the Hospital or Sick Nurse, and consequently the inex- perienced and ignorant care of any honest women was preferred where attainable. In a celebrated hospital where the new system had been intro- duced, and where respectability was insisted on, all the Nurses, * Miss Nightingale’s Notes on Nnrsing. New edition, revised and enlarged. Harrison, Pall Mall. The Reports of the Institution for Nursing Sisters, Devonshire Square. H. Teape & Son, Tower Hill. The Reports of St. John’s House Training Institution for Nurses. Harrison & Sons, St. Martin’s Lane ; and of King’s College Hospital (nursed hy St. John’s House Institution). Richard Clay, Bread Street Hill. The Institution of Kaiserswerth on the Rhine. Hooliham & Sons, 15, Old Bond Street. On the employment of Trained Nurses among the Labouring Poor, considered chiefly in relation to Sanitary Reform and the Arts of Life. By a Physician. John Churchill, New Burlington Street. Quarterly Review, October, I860. 36 except four, forfeited their situations by repeated acts of drunken- ness during the first three months. On the other hand, the insufficient training and consequent inefficiency of the Nurses, who formed the majority of the above 25,466, are shown by the constant complaints of the medical men The fact that the Nurs- ing Institutions now existing are quite unable to supply applications for those willing to pay for the superior Nursing, shews that the public are becoming aware of its importance. One single Institution, in the space of six months, was compelled to reject fifty applications. People willingly bring Nurses from London Institutions to Liverpool, and from the Liverpool Institu- tion to London, at great additional expense, rather than, having once experienced the benefit of trained service, be obliged to fall back on the aid of the untaught. Miss Nightingale (“ Notes on Nursing,” p 219) says : — “As to nursing, I have had, during the last three years, several hun- dreds of applications to recommend qualified matrons or superintendents of institutions, qualified missionary or parish nurses, ( i . e. to nurse in a parish, with a salary derived not from boards of guardians, but from pro- prietors in the parish,) qualified sick nurses for private families, for hospi- tals, and workhouses. Now in all this the lack was of qualified nurses to fill the places, not of places for the nurses to fill ” Yet, while there are thus constant openiugs for properly qualified women, the evils arising from the want of sufficient employment for women are of frightful magnitude and intensity, and none can doubt the correctness of Miss Nightingale’s view, that “ It will be a great good if you can promote the honest employment of a number of poor women, in a way which shall protect, restrain, and elevate them. This I believe you will do effectually, if you can systematically train and improve the large class of women who wish to support themselves by nursing. You may hope in time to lead some to seek not mere mainte- nance in their work, but usefulness to man, and the service of God.” It is not unlikely, that when respectable accommodation and freedom from immoral companionship are provided, and the real usefulness of the work is better appreciated, many women, daugh- ters and widows of the middle classes, who would become valuable 37 assistants to the work, would find in it not only the maintenance which their circumstances require, but also a happy exercise for their faculties and affections. While, however, recommending this work as one which will find employment for many women from the different classes of society, we must caution those interested against the supposition that most women can easily become really good Nurses. This is far from the fact. To be a really efficient Nurse requires quietness, patience, watchfulness, method, accuracy of observation and report, gentleness, firmness, cheerfulness, devoted- ness, a sense of duty. Great care must therefore be exercised in recommending or selecting women for the work. See Notes on Nursing, new edition, “What is a Nurse?’' — pp 196 — 203. “ With regard to an oft-disputed question, whether it is desirable to train probationers entirely in a public hospital, 1 should say (without hesita- tion)' it is there only that they can be trained; and every "ell-judging superintendent will tell you that the students, governors, steward, &c., &c. (disagreeable as the collisions with them sometimes are) are the most valuable assistants in the training of her nurses. Whether in opposition or in kindness, she hears of all their short comings through the secular by standers, which she would hear of in no other way. I have rarely known a nurse worth the bread she ate, whether religious or secular, whether Roman Catholic Nun, Lutheran Deaconess, Anglican Sister, or paid Nurse, who had not been trained under a hospital discipline, consisting partly of the secular man authorities of the hospital, and partly of her own female superior. 1 don’t know which is the worst managed — the hospital which is entirely under the secular men heads, or the hospital which is entirelj under the superior of the nurses, whether religious or secular, whether male or female.’-— Miss Nightingale. Perhaps one of the most important results of the Hospital Training of Nurses will be the acquired habit of strict subordina- tion on the part of the Nurse to the medical authority. On the importance of a nursing institution being directly connected with a hospital, and nursing its patients when practicable, the Honorary Secretary of Devonshire Square, the Lady Superin- tendent of St. John’s House, and the Ladies of the Liverpool Nursing Institution express a decided opinion. To take our objects in detail;— 38 1. Hospital Nurses. The importance of our work for this object must be evident, from the above remarks. The unanimous authority of the Medical Board, and the fact that the Infirmary Committee have, after most careful enquiry and consideration, consented to our under- taking to nurse the Hospital, shew conclusively the opinion of those who, from their position and means of observation, are best able to form a sound judgment on the subject. In King’s College Hospital, London, the St. John’s House Training Institution for Nurses has for some years maintained a similar connection to that we now propose. The nursing there is, to use the expression we have heard from more than one high authority, nearer perfection than before was thought possible. Each report of the Council of the Hospital, since the connexion of the two institutions began, contains grateful acknowledgments of the resulting advantages. The following extract from the report of King’s College Hospital, issued in 1859, will be suffi- cient, as proving their sense of those advantages by the practical test of willingness to pay for them. “ The committee, fully alive to the numerous and important advantages which the hospital has derived from its connection with St. John’s House, and feeling that they ought not to expect that that institution should continue the connection at a considerable pecuniary loss, readily consented to reconsider the terms of arrangement. A meeting accordingly took place between a deputation of the committee and the council of St. John’s House, at which the terms of agreement were re-adjusted — the committee undertaking to pay HI,] 00 per annum, instead of 11800, as formerly. The committee consider this arrangement a just and equitable one; and they feel assured that the governors will unite with them in congratulating the hospital upon having secured a continuance of the services of a staff of ladies and nurses, of whose exertions it is impossible to speak too highly, and whose earnest zeal and self denying devotion have earned the gratitude of the patients and the committee, and contributed in no small degree to the high reputation which the hospital so deservedly enjoys.” 2. District or Missionary Nurses. If there has been so much neglect in the application of available means for the recovery of health and for the alleviation of suffering 39 among the educated and rich, how fearful is, and must he, the unavoidable waste of human life and health, how incalculable the unnecessary misery among the uneducated and poor. It is not surprising, then, that as soon as attention was directed to the importance of nursing, the idea occurred to many that some effort should be made to mitigate this evil ; and experiments have been tried in many quarters, in ignorance of such attempts elsewhere. “No expense is spared in providing drugs and medical attendance for the working classes. Indeed, the expenditure is out of all proportion to the amount of good done; and it is difficult to form any conception of the amount of talent, tune and labour that is absolutely wasted, from the want of an organized and efficient system of nursing. The hasty visit of the doctor will be of little avail if the diet and regimen are not attended to ; if there is no one present who can form an intelligent comprehension of medical directions; if the unfortunate patient is breathing a poisonous atmosphere, in a close, un ventilated dwelling, amidst dirt, confusion, and disorder ; if there is no one present who possesses any knowledge at all of the first principles of sanatory science, or the laws of our common nature. “ The poor do not know how to prepare the simple food which may be ordered in a palatable form ; they do not know how to prepare or use the applications which may be prescribed, such as the preparation and adminis- tration of injections, the application of leeches, rollers, blisters, poultices, fomentations, the management of bed sores, and many other requirements I need not allude to at present. “Under these circumstances, with so many opposing forces to counteract the benefits which medicine might confer, the most skilful physician will be utterly baffled. He therefore becomes careless or indifferent about the result of his treatment, or he retires in despair from such a hopeless war- fare."— Trained Nurses among the Labouring Poor. By a Physician. John Churchill. London : 1860. The admirable pamphlet from which the above extract was taken enters more into explanations and details than we can venture upon here. Any one not already convinced of the fearful extent and remediable nature of the evils we propose to deal with will find in it irresistible reasoning on both points. We believe we are correct in stating that the result of these independent experiments invariably shews not only that the relief given, in proportion to the expense, &c., has surprised all those engaged in the work, but that the unexpected and incidental 40 advantages arising from it are greater than its more immediate and evident effects. This will, perhaps, be most easily made clear by an example. In Liverpool, experience of sickness led to this desire to lessen, in some measure, the avoidable disease, pain and death, in the homes of the poor ; an experienced Nurse was furnished with a few cushions, blankets, an iron bedstead, bed rest, &c., and sent to visit sick cases pointed out to her, within certain districts, by parties whose judgment could be relied upon ; she was to show the people how to manage their sick better, and help them to do so. The wife of one of the Scripture Headers kindly undertook the preparation and issue of sago and other medical comforts to those so visited. The success attained has been far beyond the most sanguine hopes which any of those who made the attempt ventured to form. Though at first the attention of the Nurse was mainly given to consumptive cases, (as those which cannot well he pro- vided for by any of our Liverpool Hospitals,) with the idea of mitigating the extreme misery often attending the last stages of that fearful complaint, yet the number of cases in which apparently hopeless disease was arrested, and heads of families were enabled to return to their work, would, in an economical point of view alone, have repaid a far larger expenditure than was incurred. Of course, in dealing with consumption, the cases were still more numerous where great suffering and often consequent bitterness and hardened discontent were changed into comparative ease, peace, and thankfulness. There is surely something horrible even to human feelings in the idea that a fellow-creature’s last hours should be passed i;j suffering, enmity, and bitterness, which our care might have pre- vented. The Nurse, — who, after the first week’s visiting, came back crying, saying that she could not bear the scenes she had to witness,— soon found that the good she could do was so clear and satisfactory that she is happy and contented, and has quite given up her wish to return to her former work of nursing the rich. But in addition to alleviating pain and restoring health, the plan was found the most natural and efficient means of conveying to the poor increased sanatory knowledge, improved habits of cleanliness, 41 and neatness in their houses. Instruction, coming as a natural and necessary part of the Nurse’s duty to the sick, is felt as no interference, raises no opposition, and its authority is enforced by the visible and immediate improvement effected by the Nurse in the health or comfort of the patient. Nor is the evil stayed and the good done merely sanatory. The effect of hopeless misery is often to produce recklessness and crime in those in contact with it. The Nurse had two cases in six months, where, the wife’s sick- ness having thrown the household into disorder, the husband, unable to witness misery which he did not know how to alleviate, or to bear the utter wretchedness of his home, had taken to drinking. The nurse shewed what might be done to alleviate suffering and restore order ; the husbands, who -were kind, industrious men. became sober again, and they and their families were saved. In another case the Nurse washed and reduced to order the child of a sick mother, and got it sent to school, &c., &c. The attention of the Nurse was naturally most frequently directed to the cases requiring her care by the various ministers of religion ; and the feeling that Christian sympathy and kindness have sought out and alleviated the physical diseases of the poor proves a most efficient preparation for the more important work of religion. From the way, moreover, in which cases are brought under the notice of the Nurse, (being sought out, not having sought relief,) or from its being less easy to deceive the doctor than it often is the charitable reliever of destitution, the work has, so far, seemed remarkably free from imposition, or discontent; the visits of the Nurse, and the material aid given, though often very small in quantity, have been received with gratitude, and without the usual grumbling as to their insufficiency. Little extras or luxuries ( for so they appear to the poor ) have seemed natural expressions of goodwill, and are not calculated to wound those feelings of self-respect and independence which are more important than health itself. As few families are without sickness at one time or other, it is difficult to over-estimate the amount of good, physical and moral, which might be done in this manner. 42 Gradually, as this became more apparent, it was sought to extend the experiment. On enquiry, with a view to see how the work might be ex- tended, it was found that similar experiments had been equally successful and satisfactory elsewhere, and all agreed as to their importance. The report, in 1859, of the Devonshire Square Nursing Sisters (Mrs. Fry’s) says : — “ The services of several Sisters are also now granted by the Committee, to devote the whole of their time to visiting the sick poor, under the direction of the clergy of the parish to which they are appointed. “ This branch of their labours is found to be of peculiar importance." The Lady Superintendent of St. John’s House Institution, speaking of Missionary Nurses, says : — If a better system can be established in the dwellings of the poor; if light, ventilation, and cleanliness can, by Christian sympathy, kindness, and sound teaching, be better understood ; much will be gained in the war with epidemics at least, to say nothing of increased comfort and self-respect among the poorer labouring classes.” King's College Hospital has a large number of out-patients, and encouraged by the success of the missionary nursing, where tried by St. John’s House Nurses, the Lady Superintendent has established a system of out-nursing for the out-patients reported as requiring it by the medical men. In an account of the institution of Kaiserswerth on the Rhine, where the works we propose have been admirably carried out, we find the following statement; — “ Parish Deaconesses. “ One of the Kaiserswerth Sisters is Deaconess of the parish of Kaisers- werth ; and many have been sent out as such to distant parishes, at the request of pastors or of visiting societies. “ We know how much the want of capacity to visit well depresses and discourages our best-meant efforts. We say to ourselves, ‘But what good do 1 do? I ask the mother how many children go to school; perhaps 1 preach a little; I give a little broth and a blanket; I read a chapter out of the Bible, which they don’t understand; if somebody is ill, I send the doctor, who opens the ulcer too soon, that he may not have the trouble of coming again. How deplorable this sort of intercourse is. I see disorder, dirt, unthrift, want of management, but 1 don’t know how to help it. What 43 right have I to find fault with them? and I am too ignorant myself to show them how to do better. I see illness, but I don’t know how to manage it. And yet that would be the very thing I should like to do, through the body to find the way to the heart of the patient. What I want is something to do in the cottage; to sit on a chair, and ask questions, is not the way to have real intercourse from heart to heart with the poor, or with anybody. But if I knew how to nurse them, opportunities for doing more would arise of themselves, and I should have some definite errand to take mein. What is said with intention rarely does good; it is only what says itself, in the natural every-day intercourse, which strikes and bears fruit. Everybody knows this from their own experience of what has most influenced them- selves in life.’ “The question is now, how to educate ourselves so as to supply this our deficiency. Such an education the Kaiserswerth parish deaconesses receive. In the hospital, the school, the asylum, the household, they learn the wants of the poor, the wants in themselves, and how to treat them. It is beautiful to see the accomplished parish deaconess visiting : she makes her rounds in the morning; she performs little offices for the sick, which do not require a nurse living in the house, but which the relations cannot do well ; she teaches the children little trades — knitting, making list shoes, &c.; — and all this with a cordiality and charm of manner which wins sufficient con- fidence from the parents to induce them to ask to be taught to sweep, and cook, and put their house in order. The parish deaconess at Kaiserswerth is continually receiving curious little notes, written to ask her advice upon such-and-such household matters; and, wherever she goes, the cottage gradually puts on a tidy appearance. “ How often a parish clergyman sighs for such an assistant! - how often lady visitors sigh to be able to render such assistance ! “It may be a question whether it would not be better for each parish to send one of its own inhabitants to such an institution as Kaiserswerth to learn, than for a stranger to be sent out from thence. She would probably be more at home among the people ; but this is a matter of opinion. The fact remains that we must learn to visit, that we must be qualified to teach. “ It has sometimes been said that Protestants can never be found to expose themselves to death in the way in which Roman Catholics will do, because the former do not believe that they shall win Heaven by such martyrdom. This has been proved to be false by the undaunted heroines who have gone out from Kaiserswerth, wherever cholera, typhus fever, or other infectious diseases have raged; and, after saving many hundreds of lives, have died at their nost. Last year, twenty-one Sisters were engaged in nursing in towns wasted by the cholera. Most of them caught the infection; two, having ‘fought the good fight and finished their course, went to their eternal home.” 44 Besides Kaiserswerth, the success of which has been remarkable, we are informed by the Rev. Dr. Howson, that, since 1835, twenty independent Protestant Deaconess Institutions have come into operation on the Continent : they have spread from Germany into France, Switzerland, Sweden and Holland. Those belonging to Kaiserswerth alone have 303* women (ladies and others) employed. The growth has been steady, having increased 35 in 1859. In Strashurg, they began in 1843 with 3 women, and have now over 80. St. Loup began with 4, has now 35, exclusive of proba- tioners, &c., &c. Kaiserswerth alone has 7 6 j stations — mostly in Germany; but its Nurses are working far and wide t — -5, at Alex- andria, 5 at Jerusalem, 8 at Smyrna, 5 at Bucharest; while in the Protestant Hospital at Genoa English sailors have experienced the care of the well-trained Swiss Nurses of St. Loup. Any opinion of Miss Nightingale’s upon nursing carries weight with Englishmen; but when she places Missionary Nursing in importance above those branches of nursing in which her life has been spent and her health sacrificed, the most sceptical would allow that the authority for such superior importance is unim- peachable. She says : — “ I quite agree with you that missionary nurses are the end and aim of all our work; hospitals are, after all, but an intermediate stage of civiliza- tion. While devoting my life to hospital work, to this conclusion I have always come, viz., that hospitals were not the best place for the sick poor, except for severe surgical cases.” Having shewn the existence of the want, we will now explain the organization by which we propose to supply it; why we propose only to train and supply the Nurses ; and why we propose to leave to local efforts the supply of the necessary medical comforts and the local superintendence of their work. From these general remarks it will be understood that Nurses can be best trained in a hospital. From the combinations of the different plans and consequent concentration of Nurses, it will be more easy to apportion to each Nurse her most suitable work. Belonging all to one body, there will he more esprit de corps * 431 in 18fi4. — Florence Nightingale. + 105 in 1864. — Florence Nightingale. J From North America to Italy and Constantinople. — Florence Nightingale. 45 among them, and the general experience will become available for the use of each, so that improvement and education need not entirely cease after the Nurses’ first training. It is hoped that, through the connection of the District Nurse with the parent insti- tution, and her attachment to it, it will he possible to keep up a higher standard of character, and encourage more active efforts. But in the supply of medical comforts, and the superintendence of their distribution, the advantages are all in favour of local and individual, as compared with central, effort. A central association would not have the local knowledge necessary for such work ; it requires the utmost caution and economy to prevent a waste, which would (as too many other intended charities do) effect a moral evil, and fail even in the material good sought. If the labouring classes could only feel the importance of providing for sickness by self-supporting Provident Dispensaries, with Nurses attached, this arrangement would be the best in every way ; till this can be done, the more individual the work the better the effect, morally and materially. Those it is sought to benefit will be less inclined or able to impose on individuals than on a large public society ; there will be a keener sense of personal kindness, more willingness to follow instruction, less injury to self-respect from receipt of individual benefits than of public charity. Besides, this is a new work, in which much is yet to be learned ; and if, as we propose, a local committee or individual is left to work the district undertaken in their or his own way, it will be found, when they bring that local individual experience into a common stock, that much has been gained for the common object. The good does not end here, nor is it by any means confined to the poor. Much has been said and written of the duty and importance of more sympathy and intercourse between rich and poor, of the dangerous tendency of civilisation, and its sub- division of labour in widening the separation between them ; hut to do any good, such connection and intercourse must be natural and enforced. Now, in sickness and death, rich and poor are on common ground. In this work the sympathy between them is so natural, the results are so apparent, so immediate and satisfactory, that, if the proper Nurses could be furnished, we believe there would be comparatively little difficulty in interesting kindly disposed 46 persons connected with the different districts of Liverpool in the work of superintending and furnishing (or collecting) for their own district the necessary appliances and comforts. If once the feelings are interested, the power of and desire for usefulness rapidly increase ; instances of modest, uncomplaining striving are brought naturally under notice — cases which can be helped, and which it is a pleasure to help, with advice or temporary assistance — and in this quiet, unknown work, unsatisfied or bereaved affection, or minds sick with the failure of more am- bitious, and perhaps less unselfish, plans of usefulness would often find a peace and happiness at least as great as that they bestowed. For these reasons we propose to furnish and pay the wages of Nurses for the different districts of Liverpool as soon as we can supply suitable trained Nurses, and so far as our means will admit ; but we shall only do so where individuals or district committees satisfy us that they are prepared to find a suitable lodging for the Nurse, if required, and to supply medical comforts and superintend their distribution. We shall further leave the mode of working each district entirely to the individual or local committee under whose orders the Nurse is to act. If we consider a district is so badly worked as to waste the Nurse’s services, we shall reserve to ourselves the right of recall. In the districts worked hitherto the Clergy, Scripture Readers, or other Ministers of religion, have reported the cases to the Nurse or superintending lady, and the Nurse has then visited and aided them. The following are Reports of the Nursing : — District No. I. — Report of the Superintendent. “ The following examples will serve to show the nature of the object we have had in hand for some time past, viz., the mitigation of such unnecessary suffering, arising from want of attention, ignorance of proper remedies, want of cleanliness, &c., as prevails to such an extent among the sick poor. Example No. I. — “Afflicted with asthma, and other diseases. Found lj ing on the floor, covered with bed sores, and so thin that she had to be lifted on a sheet ; her husband is a porter, wdth two children, unable to pay for nursing; she vas attended by the Dispensary Doctor, but in other respects was left to the mercy of the world in a low neighbourhood, in dirt and bad air, wretched in body and mind, causing her husband to feel wretched also on coming home and finding his house in such a condition ; 47 to use the man’s own expression, he thought he was forsaken both by God and man. Our Nurse comes in, washes her, and lends bedstead and bedding, and shews how to use an air-cushion, changes her linen, &c., cleans the house, persuades the husband to whitewash the apartments ; suitable nourishment is sent, and she and the household are now in com- parative comfort; she is able to get up. The man is now helpful and hope- ful, and has added by his own exertions and savings to the comfort of his home.” “ Example No. 2. — -Afflicted with cancer internally. What was wanted here in this case was a nurse, to attend the surgical operation which took place, and carry out the remedies towards recovery, which she did. The woman is now able to resume her work.” “ Example No. 3. — Paralysis. The nurse attended, gave suitable instructions, and taught them how to apply them, and by sending nourish- ment he is apparently entirely recovered, and now follows his work.” District No. II. — Report of the Nurse. “Since I first undertook my duties as Nurse, in November, 1859, I have had cases of consumption, dropsy, &c., under my care. The people whom 1 have had to do with are most of them so ignorant that they do not know how to take care of themselves, or even prepare the common necessaries of life. I find by suitable advice that there is very great improvement in many houses as to cleanliness, particularly in their bedding, and more air, and in cooking in a common way. I give you below a few of the cases which I have had to contend with. “ Example No. 1.— Man with wife and six children. Symptoms of consumption; was too weak to work ; and the whole family really were starving. I lent them a few shillings (since repaid), procured the woman a little needlework, supplied warm clothing, flannels, and nourishment. The man is now apparently quite well, and gone to his work. “Example No. 2. — Consumption: This girl was under two medical men, who said it was a decided case of consumption. (Father paralytic, mother keeps a mangle.) She was so weak she had to be carried, and was refused admittance into hospital as too far gone. I supplied her with beef tea, wine, sago, and cod liver oil, and in the course of one month the girl was able to come to my house, and is now quite recovered. Example No. 3. — A boy with abscesses, and one of them over the heart, for which the medical man ordered nourishment. I supplied him with beef tea, sago, &c. The boy is now quite recovered and healthy, and able to resume his work. He earns six shillings per week, and came expressly (with his mother) to return thanks for the benefit he had received. His sister was also ill with typhus; was supplied like her brother, and recovered.” 48 III. — Sick Nurses for Private Families. It is almost unnecessary to add anything under this head. The following remarks, extracted from Miss Nightingale’s “Notes on Nursing,” would be amply confirmed by any physician in large practice among the rich. “ I am bound to say that 1 ihink more patients are lost by want of care and ingenuity in these momentous minutiae (attention 10 diet), in private nursing than in public hospitals; and I think there is more of the entente cordiale to assist one another's hands, between the doctor and his head nurse in the latter institutions, than between the doctor and the patient’s friends in the private house.” (See page 91.) Again, speaking of the management of the sick room, and injury to the patient from the ignorance or during the temporary absence of the friend or Nurse, and her neglect to leave proper directions, she says — “All the results of good nursing, as detailed in these notes, may be spoiled or utterly negatived by one defect, viz., in petty management, or, in other words, by not knowing how to manage that what you do when you are there shall be done when you are not there. The most devoted friend or nurse cannot be always there, nor is it desirable she should ; and she may give up her health, all her other duties — and yet, for want of a little management, be not half so efficient as another who is not half so devoted, but who has the art of multiplying herself ; that is to say, the patient of the first be not really so well cared for as the patient of the second.” (See page 49.) “ In institutions where many lives would be lost, and the effects of such want of management would be terrible and patent, there is less of it than in the. private house.” (See page 55.) It is because in hospitals the effect of such neglect would be so patent and terrible, and it is therefore guarded against, that they are the best training schools for Nursing. The steady increase in the receipts of the various Nursing Institutions from private Nursing is the best proof of the spread of sound opinion on this point. In St. John’s House the receipts from, and numbers employed in, private Nursing, have been as follows, in the years ending 31st March. 1855... ... £500 1858.. ...22 Nurses... ...£754 1856... ...26 ... 717 1859... ...23 ,. ... ... 971 1857... ...19 ... 735 1860... ...23 „ ... ... 1102 49 In the Liverpool Institution the progress has been : — 1856 10 Nurses £275 I 1858 16 Nurses £578 1857 18 488 I 1859 20 „ 764 We trust we have shown the importance and practicability of the work we propose to ourselves ; but in asking assistance for it, we must guard against the disappointment which, without faith and patience on the part of those who wish to aid in it, must in- evitably be felt. Any work, to be thorough, good, and permanent, must grow, and, for the most part, grow slowly. We have to begin from the beginning ; and though, to prevent waste, it is well to lay down a complete scheme and work up to it, each part will have to be worked out separately and slowly, bit by bit. Miss Nightingale’s advice to us is — “ Do nothing rashly ; do not fetter yourselves with many rules at first. Wait to see how things work, ancl what is found to answer best. Be pre- pared for all soils of disappointments. Do your duty, and trust the event to God. ‘In quietness and confidence shall be your strength. This is essentially a quiet, unostentatious work. We wish to appeal only to love of God and man, and faith in what woman can accomplish when influenced by a right spirit and doing her natural work. Where women have families, there is their proper field, and we seek no help at the cost of neglected duties. We claim no preference for this work, as nobler or greater. All we say is that for those who, possessing the natural abilities and affections for this work, have not such family cares, or whose families no longer fully occupy such talents, here is their natural work — a work in which, as in families, woman’s self-sacrificing, trustful love and care, can change pain and irritation and unrest into ease, peace, gratitude, faith, and hope ; where, long suffering and kind, seeking not her own, not easily provoked, bearing all things, believing all things, hoping all things, her work however humble, amid duties however apparently small, will endure. The cup of cold water given, or caused to be given, in this spirit to the object of her care, may, with God’s blessing, awaken feelings whose effect in ever-widening circles of blessing here, or whose eternal fruit in heaven, she cannot know, till she hears the voice say, “Come, ye blessed of my Father; inasmuch as ye did it to one of the least of these, ye did it unto me.” D 50 FLAN OF EDUCATION PROPOSED FOR NURSES. This must at first necessarily be imperfect, and only sugges- tive, to be worked out and modified by the Committee and Super- intendent, as the work goes on and experience increases. We propose to have five or six bead or training Nurses, say one to about every forty patients. This Nurse to have charge of the whole nursing of the hospital flat, and to be herself Nurse of the central or most important ward ; and to have charge of, and be responsible for, the administration of the medicines and stimu- lants on the flat. In her own ward, we propose that she should have a probationer or assistant Nurse. We propose that, having first ascertained, as far as we can, that the person seeking to be a Nurse is suitable in character and ability, she should become probationer, first for two months in a surgical ward, then for two months in a medical ward ; then, if sufficiently trained, that, under the superintendence of the head Nurse, she should serve four months as Nurse of a surgical, and four months as Nurse of a medical ward — in all twelve months’ training. All this, however, must be subject to modification by the superintendent. We propose to have no night Nurses, but that each should take her share of night duty when sufficiently trained to be trusted with it, which we hope will he after the first four months. We propose to engage the Nurses (subject to good behaviour and competency) for three years, including the year in the hos- pital, and to employ them in hospital, district, or private nursing, as their talents or the want of their services may require. They will, however, be told off for the separate works into dis- tinct bodies, and after they leave the hospital, to engage in district or private nursing, all connection with the hospital will cease, and they will not be allowed to enter it. The District 51 Nurses will reside in their district, and the private Nurses, when not engaged, will reside in the home. With from two to three months in a hospital, those nursing- institutes not immediately connected with hospitals have managed to give an amount of training which has been very useful. But, in the first place, the amount of personal attention required from the benevolent ladies who have managed them has been very great ; and in laying down a plan, with a view to its working well in permanence, and under various circumstances, it is not well to make it more than necessarily dependent on a continuance of such gratuitous and efficient services. And, in the second place, all the professional authorities agree that, with the majority of women, two or three months is not a sufficient time to enable them to acquire those habits of watchful, intelligent, and minute attention to the directions of the physician which is necessary ; while the amount of experience which can be gained in so short a time must be very limited. We believe, however, that after twelve months’ training, under the medical officers of the hospital and an able superintendent (the key-stone of the whole work), we shall be able to supply Nurses who will command confidence.* * On the above topics the lady superintendent of St. John’s House writes, “ I have been much interested in your account of the missionary nursing already done in Liverpool, and am very glad that you have been able to collect so much evidence of the good already done, and of the necessity and importance of an extension of such work. I do not think it is possible to over-estimate its impor- tance, in any considerations for the well-being of the sick poor specially, and of society generally. If well organized and well conducted, such work must be the groundwork of improvements in very many respects among our poorer neighbours which, without the aid of such kindly ministrations, it would be next to impos- sible to effect. I would like to see a branch working well under the care and conduct of every clergyman of a parish or district throughout our land. The nursing in private families of the higher classes is the most unsatisfactory of the three objects you have in view. Here there are more hindrances in the way of continued steady improvement, hut even here we must not he hopeless. “ Miss Nightingale’s hook has done very much, in shewing what nursing ought to be. I trust by and by we shall see its fruit in an improved state of things, to the great advantage of the Nurses so employed, and the greater benefit and comfort of the sick and suffering whom they are called to attend. “ I need scarcely say that the hospital itself is the only field for training Nurses, whether for rich or poor, whether to be employed in hospitals or infir- maries, in the houses of the rich or the dwellings of the poor ; and I confess to so deep an anxiety on this subject, that it is great joy to me to hear of any fresh effort to make hospitals more what they ought to he.” 52 After the expiration of the first three years, it will be open to the Institution and to the Nurses to re-engage for the same period. LIST AND ESTIMATED COST OF MATERIALS. To be provided by a Local Committee or Individual for a District Nurse, sup- posing an average of Twelve Cases on hand at a time, unable to pay for medical comforts. Items op Lending Stock Required in Commencing. 1 Iron Bedstead and Mattress . £1 0 0 6 Pairs of Sheets .... 1 4 0 6 Blankets ..... 1 10 0 2 Air Cushions ..... 0 8 0 1 Bed Rest ..... 0 15 0 6 Bed Gowns ..... 0 4 6 12 Chemises 0 12 0 Flannel — 2 Singlets each for 4 cases 1 5 0 £6 18 6 We have been recommended to add the following : — An India Rubber Lavement Apparatus. A common Respirator. A Hot-water Bottle for the Feet. A Water Pad for the Abdomen. The bed gowns, chemises, and flannel are things that will require renewing occasionally. Weekly Expenses. 1 Bottle of Wine at 2s. . . . .£020 Beef for tea, 6 lbs. at 5d. . . . . 0 2 6 Sugar, 3 lbs. at 5d. 0 13 Milk, 6 quarts at 3d. 0 16 Sago, 6 lbs. at 2|d. 0 13 Bread, say 48 cobs, at Jd. each . . . 0 2 0 Coals, Nutmegs, &c. . . . . . 0 16 £0 12 0 per week, Or £31 4 0 per aun. 53 In addition, there will be required for the year — Preserves, average 1 jar per week, at lid. .£276 Raspberry Vinegar, 1 bottle ,, at Is. . 2 12 0 Cod Liver Oil, 1 bottle ,, . . . 2 0 0 2 tins Arrowroot, weighing 28 lbs., at 9d. . 110 Stone Jars for boiling Sago, &c. . . . 0 4 0 £39 8 6 It need hardly be mentioned that a greater amount of nourish- ment, &c., would often be advantageous where means will allow it. Many may be willing to send preserves, bits of meat, vege- tables, &c., instead of money. The dispensaries supply cod liver oil to those who cannot afford to buy it, on payment of one penny per bottle. LETTER FROM CLERICAL SUPERINTENDENT OF THE CHURCH OF ENGLAND SCRIPTURE READERS SOCIETY, 67, BEDFORD STREET, SOUTH. 11, Peel Terrace, Falkner Square, Liverpool, November 20, 1860. My Dear Sir, I cheerfully testify to the value of the efforts to provide competent Nurses for the sick among our poorer classes at their own homes. Viewing the matter in its religious bearing, it is scarcely possible to exaggerate its importance, for the consolations of our holy faith are then most readily received, when the sufferer feels that his bodily infirmities are the objects of thoughtful and tender care. I enclose, with very sincere pleasure, the statements of those Scripture Readers in whose districts the agency is already in operation. Faithfully yours, ARTHUR GORE, Clerical Superintendent Scripture Readers Society. 55 METHOD OF WOBKING. After the Lady Superintendent had, as above stated, passed some time at King’s College and St. Thomas’s Hospitals, and was ready to undertake her duties, we obtained the assistance, as Training Nurses, of several of those educated in the School in connection with the latter Institution, established by the trustees of the Nightingale Fund. Of the system under which these Nurses had been educated, whether as regards disci- pline or medical instruction, we cannot speak too highly ; nor can we too gratefully acknowledge the benefits we, through their assistance, derived from it. Under these Training Nurses were placed the young women selected for education in the School, applicants of from twenty-five to thirty-five being preferred. These probationers received, while under training, fourteen guineas a-year, and afterwards were employed in the Infirmary, in District Nursing or private families, at a rate of wages varying with efficiency and length of service. The Hospital and Private Nursing is entirely under the direction of the Lady Superintendent, by whom it is managed in conformity with the rules laid down by the Infirmary and School Committees.* With a view to the organization of the District Nursing, the town was divided into sixteen (now increased to eighteen) districts, each containing two or more ecclesiastical districts. We adhered, as far as possible, to ecclesiastical boundaries, because, while * For particulars of Rules and Forms in use, refer to Appendix, E, p. 81. 56 tlie limitation of the district was a matter of indifference to the Dissenters, the coincidence of its limits with those of their cures much facilitated the co-operation in our work of the clergy of the Established Church. Each Nursing District contains from 11,500 to 41,347 inhabitants, the average being 24,929. The number of cases under a Nurse’s care at one time varies very much, being greater in winter than in summer ; some, it must be observed, require only occasional visits. Particulars of the work done in 1863-4 will be found in the Appendix, pp. 76, 77. The Central Society only undertakes to pay the wages of the District Nurse. It was necessary, there- fore, to find in each District ladies able and willing not only to superintend her work, but to provide or raise the funds required to pay for the Nurse’s lodging, for medicine, food, and comforts for her patients, and so forth. In 1864 the expenditure under these heads averaged T80 a district, particulars of which will be found in the Appendix.* Elsewhere f I have given a Memorandum which in several cases was laid before ladies when proposing to them to undertake this onerous charge. This district expenditure is met as follows : — In three districts the funds are provided by members of the religious congregation to which the local Lady Super- intendent belongs. In one, the wife of a clergyman, whose cure is included within the district, is Lady Superintendent, and raises the funds by subscription. In one, the clergyman, aided by three non-resident subscribers of T10 each, has become responsible for the funds, and a lady parishioner for the superintendence. In one, the wife of the minister of a large dissenting * Report of 186-1, p. 70. + Appendix, p. 95. 57 congregation has undertaken the Superintendent’s duty, and her husband has engaged to raise one-half the cost by subscriptions from his congregation, the other half being provided by employers of labour within the district, and other men of property. In one, subscrip- tions of from £2 to £10 from employers of labour within the district, and men of fortune unconnected with it, provide the requisite funds. In one, a gentleman who has ceased to reside in Liverpool furnishes ,£40 a-year, the Lady Superintendent finding the rest. In one, a mercantile firm pays the cost. In seven, the Lady Superintendent or her family pay the whole or the principal part. In December, 1864, the Liverpool Central Relief Society agreed in certain cases to give meat to patients under the charge of the District Nurses, to send con- valescents to the sea-side when desirable, and to relieve the families of patients, if found deserving.* The Lady Superintendent for each district being- found, funds provided, and a Trained Nurse established there, it only remains for the Central Society to ascer- tain, by periodical inspection, the efficiency of the Nurses, and the due execution of the intentions of its subscribers.! In other respects, all duties of manage- ment and direction in District Nursing devolve upon the Local Superintendents, each lady being supreme in her own district, and solely responsible for its manage- * Particulars of this arrangement, and the form of recommendation required under it, are given in the Appendix, p. 77. + This is done very effectively by the Assistant- Secretary and Out-door Inspector of Nurses — a Lady whose duty is solely to inspect the Nurses, and in no way to criticise the management of the district ; or, unless requested by the Local Superin- tendent, to take any part in its arrangements. She is, however, often of great use in making arrangements or inquiries at the parish offices and other institutions ; or, in the absence and at the request of the Lady Superintendent, taking the charge of the district. 58 ment. The first point is to find a lodging for the Nurse ; the next, to find some one to take charge of the stores, and to cook the sago, rice, beef tea, and so forth, for the patients. It is desirable that both the place for cooking and the Nurse’s lodging should be in a central position ; and this is especially important in regard to the cooking, as, though some member of the sufferer’s family, or a friendly neighbour, can generally bring the food from a short distance, they often cannot go far for it. If a respectable tradesman’s wife, or some other resident in the district, can be found to undertake the cooking from a wish to take a share in the good work, nothing better can he desired ; but it is rarely that the same person has both the will and the means to undertake such an office. In many cases the Nurse does the cooking. But this is not desirable where it can be avoided, as it takes up time which she can employ to better purpose. Moreover, where the same person makes the requisitions and supplies them, there is neither check nor voucher ; and thus the Nurse is exposed on the one hand to temptation, and on the other to suspicions which, however groundless, she has no means of refuting. When the Nurse and cooking-place are established, it is time to make the operation of the system generally understood. Either a meeting is called, to which the ministers of religion, medical officers of the district, and others likely to be interested in the cause are invited, and explanations upon the object and mode of working are publicly given ; or such explanations are made privately, by visits or by letter. The forms given in the Appendix * will explain the working of the district system in detail. Every quarter the Ladies Superintendent of districts * Appendix, pp. 87 — 94. 59 draw up a report of tlieir operations for the information of the Committee and of each other, and meet to discuss the wants or difficulties which may have arisen. Specimens of these reports, and extracts, noticahle for the suggestions they contain, are given in the Appendix.* At their annual meeting in 1863 they reported as follows : — “ The Ladies Superintendent wish to report that the objects of the District Nursing have been much more satisfactorily attained during the past year than in 1862. There has been more of actual nursing, and less of mere relief. They believe that its usefulness will be still further increased as more complete co-operation is established with the medical authorities and ministers of religion, and as the plan is better understood. “ They wish, however, to call attention to the fact, that in most of the districts there have been no contributions towards the medical comforts received through the ministers of religion of the district, though they understood the districts were as much as possible so arranged that they might include congregations capable of aiding.” In 1864 : — “ The Ladies Superintendent wish to report that the usefulness of the District Nursing has been much increased, and in most of the districts they have received the most kind and efficient co-operation from the medical men. The Ladies Superintendent earnestly invite contributions to the district funds, either in money, clothing, flannel, old or new blankets, old linen, wine, fruit, or delicacies suitable for the sick. It is requested that money may be sent to the Lady Superintendent of each district direct : other things can be sent to the Nurse ; but it is requested, and particularly in the case of wine, that a list of the articles should be sent to the Lady Superintendent.” In consequence of the suggestion above cited, the Chairman and Secretary of the Central Society invited the medical men in charge of the dispensaries and parochial districts to meet the Ladies Superintendent. * Appendix, pp. 95 — 100. 60 A discussion took place and explanations were given which have led in most districts to cordial and very beneficial co-operation. In a recent letter Miss Nightingale asks, “Will not the extension of Parish Nursing very soon make neces- sary some careful consideration of the subject of finance ? Every parish .or district should, as a rule, pay for its own Nurses. But this must vary in different places. Is it not required that some consistent prin- ciple should be established, either by church collection, donation, or otherwise ? ” This is a most important but most difficult question. There are two dangers to he studiously avoided. On the one hand half the virtue of the system is lost if the personal character of the work is impaired — if anything should be allowed to lessen the directness of the relation between the giver and the receiver. Much of the value of the District Nursing depends on the personal intercourse between the educated, refined and virtuous woman who gives of her abundance of means, mind, and heart, and the poor, ignorant, and often erring whom her bounty relieves and her sympathy soothes : while she receives, in return, that peace and enlargement of soul which I believe the rich can hardly obtain, save by taking personal interest in and care of their poorer neighbours. Every observant student of human nature must be struck with the amount of mischief caused to both rich and poor by the marked separation between their lives and interests — a separa- tion which the organization of civilized society ever tends to widen more and more. The poor are pauperised and degraded when they receive from the mechanical operation of organized societies that dole into which no feeling of true charity, of Christian brotherhood and 61 personal kindness, enters, to soften the sting of dependence and create a sense of personal affection ; or receive that dole almost as they receive the parish allowance, with as little thankfulness, and as little sense of the duty of enabling themselves speedily to do without it. The rich, on the other hand, who deal with the poor only through such societies, find no relief in this kind of mechanical charity from the narrowness, timidity, and unrest which riches so often create, and which are the natural fruits of hearts and intellects starved and stunted for want of that nourishment and exercise, in personal well-doing and in kind offices to living individuals, not to a class in the abstract, which God intended to correct the benumbing influences of wealth. It would therefore he very lamentable if the personal tie between the Lady Superintendent and her district should be weakened or superseded by a mechanical organization. On the other hand, the amount of money required to meet the expenses of a district is such that, if it is to be provided by the Lady Superin- tendent alone, the choice is too narrowly limited by the small number of those who can and will afford such an outlay. And if, by the death or removal of one Super- intendent, the district organization is for a moment interrupted, its permanence may be endangered by the difficulty of finding a successor with suitable qualifica- tions, leisure, and fortune. Perhaps the best way of meeting this difficulty would be by combining personal responsibility with social organization, an individual undertaking the duties of superintendence and pro- viding a certain proportion of the funds, and an organization, charitable or religious, the rest. Liverpool had several unconnected societies for alms- giving, whose separate operation led to great abuses. 62 These have been latterly combined into the Central Relief Society. Of the objects of that Society, the relief of the sick poor, now undertaken by the system of District Nursing, was one. A more intimate con- nection between the Societies would probably be desirable. The experience of the agents of the Central Relief Society would render material assistance in detecting imposture ; while the aid of the district organization would probably enable that Society to use its funds to still greater advantage. If it were arranged that the Central Relief Society should pay one-half the expense of a district, while the Lady Superintendent, representing either a family or a congregation, should pay the remainder, this might probably be found a good method of combining personal care and interest, economy and efficiency, with the adequacy of means and perma- nence which characterise the working of an organized charity. In other cases church collections might come to the aid of private benevolence, and bear a similar proportion of the cost ; or the expense might be defrayed by a large employer of labour, a landowner, or a subscription. Where no such arrangement could be effected, although the loss of the personal superinten- dence of an educated and independent woman would be a great drawback, it would still be good economy for the parish to retain the services of a trained District Nurse as one of its regular staff. One point has occasionally been raised to which it may be well to advert. Some have objected to allow the ladies of their family to take part in the work for fear of infection. With very slight precautions, this risk is much less than that incurred by calling in a doctor. The Nurse can always tell the Lady Superin- tendent where she may safely go, and can avoid visiting 63 her on days when, or in clothes in which, she has attended infectious cases ; whereas the doctor must go from patient to patient without any such precautions. But if the risk were greater than it is, we should have no right to flinch from it. Life was given not to be hoarded, but to be carefully and wisely spent. The rich and their children enjoy all the benefits of knowledge and of wealth ; among others, all the appliances that knowledge can devise and wealth can purchase to avert or to cure disease. Incumbent on the possession of wealth and knowledge is the duty of ministering to those who have them not, and the risks incident to that duty we are not at liberty to shun.* “A religious organization,” it has been suggested, “is necessary to the perfect success of your undertaking.” A religious organization, in the best sense of the phrase, I trust that we possess ; but what is too often meant by the words is a dogmatic or sectarian bond. This I believe to he neither necessary nor desirable. The Lady Superintendent of the Home and Training School has always endeavoured to instil religious motives and a religious sense of professional duty into the minds of her pupils ; and though among these are members of many different sects, we are never troubled with religious discord. Good work, faithfully performed, has a tendency to enlarge the mind of a Christian, and purify his spirit from sectarian bigotry ; to bring into strong relief those principles of faith and practice, which, as the Great Judge has assured us, will guide His judgment; and to indispose the labourers to “judge ” one another. * “ True nursing knows nothing of infection, except to prevent it. Clean- liness, fresh ah- from open windows, with unremitting attention to the patient are the only defence a true nurse either asks or needs. Wise and humane management of the patient is the hest safeguard against infection.” — Miss Nightingale's Notes on Nursing. No doubt religious sisterhoods have an advantage in this kind of work, tending, as they do, to merge all personal action and avoid anything like individual prominence. But such sisterhoods are regarded with deep and unreasoning mistrust by the great majority of Protestant Englishmen, and will probably remain subject to such mistrust until some one as perfectly free from sectarian bias or religious extravagance — as able, energetic, and discreet as Pastor Fliedner, and as remarkable for that tact in which some of the promoters of English sisterhoods have been so unhappily deficient, shall undertake their organization. It is most desirable that in an office like that of nursing, where a sense of duty, not a hope of praise, must be the moving principle ; where, “ in quietness and in confidence must be the strength ” of the labourer, everything that tends to give prominence to the individuality of those who undertake work should be studiously avoided. It will be observed that in the reports, in all accounts of individual cases, and in everything except the mere statistics of districts, we have never mentioned the names either of the writers or the subjects of the examples we have cited. The Society is obliged to publish the names of the Committee, and of the Ladies Superintendent of districts, together with details of the work done, in order to keep up the public interest and the confidence of subscribers. But I believe that most of those engaged in the work would be glad if such parade could be avoided, and if it could be carried on in silence and unnoticed ; would wish it to be impersonal as regards the public, and personal only in the relations between those who confer and those who receive its benefits. The profusion of flattery which attends the philanthropic efforts of the present day demoralises all whom it does not disgust, 65 and often ends by exercising a pernicious effect even on those who, conscious how far they fall short of their own aspirations and sense of duty, are at first repelled by it. In the Appendix * will be found an address delivered to the Nurses by one of the Committee on the first New Year’s entertainment in the Home. In its sentiments I believe that “ all who profess and call themselves Christians” could cordially unite. In working among the poor, we cannot be too careful to avoid the suspicion of any latent or subsequent purpose — any object other than that openly professed, which, in the present case, is that of curing their sick, alleviating their sufferings, and teaching them the rules of health. In this, as in most things, “ singleness of eye” is necessary to success. If the poor suspect that a benefactor seeks to gain them over to any sect, or induce them to attend any particular Church, they at once set down his kindness to selfish and insidious motives, and are neither grateful nor edified. Of course this feeling on their part is exagge- rated and unreasonable ; for even their conversion is desired as tending to their own happiness. But such is their feeling ; and since it is so, we cannot too carefully avoid any indication of sectarianism or proselytism. Of course, in proportion as this and our other duties are well performed, will be the influence of our example, and the disposition of the poor among whom we work to respect and adhere to the faith that bears such fruits; but to desire or seek for any more direct results of this kind in the work of healing or relieving the sick is to insure disappointment, and is certainly to depart widely from the practice of our Master. Prefixed to this sketch will be found a plan and descrip- tion of the Home. It was cheap, and has been found to * Appendix, H. p. 101. E 66 answer very well, being airy, light, and cheerful. To visitors I may as well say that the decoration and orna- ments, which might seem unnecessary, have not been executed or furnished at the expense of the Institution, but have been given by its friends, or those of the Lady Superintendent. I think, moreover, that such ornaments have been by no means useless, in attracting the Nurses and attaching them to their home. Ugly and ungraceful habitations are hardly economical, where it is desired to inspire a feeling of pride and affection in those who are to live and be educated there. In addition to the papers above mentioned, there will be found in the Appendix the balance-sheets and parti- culars of expenditure for 1863 and 1864,* and the Report of the Committee for the latter year.f That Committee consists not of benevolent enthusiasts or philanthropists by profession, but of practical men of business, who have abundant work and large experience in commerce, in politics, and in life, who know the value of time and money, and would not bestow either on an enterprise in which they did not find the results proportionate to the expenditure. All who value their own health and that of their families ; all who care for the limitation of pauperism and its attendant evils; all who feel a sense of duty towards or interest in their poorer neighbours ; will find themselves amply repaid for the time, trouble, and money it may cost them to introduce a similar organiza- tion into their own town or neighbourhood. * Appendix, B. pp. 72 — 75. + Appendix, A. p. 07. APPENDIX A. REPORT OF THE COMMITTEE FOR 1864. This is the first year in which we can be said to have been at full work in the Hospital, and in the greater part of the Town. Our Staff of Nurses is still insufficient to meet even the present demands upon us, while experience of the value of the services of trained Nurses seems to increase the demand far more rapidly than we can hope to find and train women suitable for the work. Success in the past year gives us confidence that every year will increase the efficiency and usefulness of each brauch of our undertaking. The Lady Superintendent’s care of the young women under her charge gains their respect and affection, and retains most entirely the confidence of the Committee and Medical authorities. The Report of the Lady Superintendent is as follows : — “ Gentlemen, “ Since the beginning of 1864, 33 young women have been admitted as Probationers ; five of these have left, being unsuitable for the occupation. Besides these, several older women have been engaged as Assistant Nurses, or with a hope that they would prove useful as District Nurses, but the need of earlier training has, in almost every case, become a barrier to their continuing in the service. “ The most effectual help has been given us in finding suitable candidates, by Ladies and Gentlemen in various parts of the country, who have communicated with the Superintendent ; and latterly, when vacancies have occurred, we have had no difficulty, by this means, in procuring those who could fill them. Many have been introduced through the Nurses and Probationers already here. At present we have no vacancy in the House, and there are several applicants on the list, for whom we have no room. Our staff of Nurses, exclusive of the 28 Probationers, consists of 14 in the Infirmary, 10 sent out to nurse in private houses, and 14 placed in the various Districts of Liverpool to nurse the poor. “ No considerable additions have been made to the Library, the books of which have been pretty generally read, and more would be acceptable. “Evening Classes have been held twice a week in the House for Probationers. “Amongst so large a number of young persons, it is unlikely that all would prove equally good and useful; but I have pleasure in assuring you that on the whole I have reason to consider the conduct and efficiency of our women satisfactory. There has been a great deal of quiet and steady self-sacrifice in 68 tlieir work, as well as hearty obedience to those they serve. I hope and believe that almost without exception they become attached to their employment, and to their Home; and that the foundation is thus laid for the permanent welfare of the Institution. “I am, Gentlemen, “ Yours faithfully, (Signed) “ M. MERRYWEATHER, “ Lady Superintendent." ROYAL INFIRMARY. We have to record our sincere thanks to the Members of the Medical Board, and to the House Surgeon, for the confidence and assistance the Lady Superintendent and Nurses have received from them. They have often spoken with approval of the conduct and efficiency of the Nurses; qualities in which we hope each year will show further progress. Miss E. Merryweather has again most kindly spent nearly the whole of the year in helping her sister, and her experience and knowledge of nursing, and unwearied gentleness and kindness, have been most useful, and deserve the gratitude of this Society. DISTRICT NURSING. Some alterations have been made in t.he boundaries of some of the districts, to meet alterations in the Ecclesiastical boundaries, as we are most anxious to facilitate the co-operation of the Clergy of the Church of England, as well as of all other denominations of Christians. The Map of Districts will be found at the end of this Report. Only 14 of the 17 districts have been at work in 1864, but No. 12 is now undertaken by a Lady, aided by the Churches in it; and No. 11 by members of an influential Congregation, assisted by the employers of labour in that district. Pecuniary aid has also been promised for the remaining district, No. 17, so that before the expiration of two months we hope the whole (own will have the benefit of an organized system of district nursing. We have again to report a decided improvement in both the quantity and the quality of the work done; and our opinion is confirmed, that with increased experience, and as we find and thoroughly train entirely suitable women, the extent and usefulness of our work will increase year by year. The number of patients who attended has been 2,358, being an increase of 582 over 1863. In addition to the sums expended by this Society in wages of District Nurses, the Ladies Superintendent of districts have expended in 1864 about £ 1,100 in the medical comforts, food, wine, &c , necessary for the sick, and in lodgings for the Nurses. This large sum, averaging over ,£81 per dis- trict, has to be provided out of her own means, or raised by the Lady Super- 69 intendent of each district. It will be evident that nothing but experience of the great value of the work done would induce the Ladies to meet, as they have done cheerfully, such a large and increasing tax on their time and means. We are happy to say that there have been, in two instances, Church collections made in aid of the funds of districts ; and in 1865 two districts will be added to those in which members of a comparatively wealthy congregation combine to supply funds for a district; but too many are left to depend entirely on the contribution of the Lady Superintendent of the district and her family and friends, without that aid which such a work may rightly claim from those who have means, and either worship or carry on business in the districts. The following communication was agreed upon by the Ladies Superin- endent of Districts at their Annual Meeting: — “The Ladies Superintendent wish to report that the usefulness of the district nursing has been much increased, and in most of the districts they have received the most kind and efficient co-operation from the medical men. The Ladies Superintendent earnestly invite contributions to the district funds, either in money, clothing, flannel, old or new blankets, old linen, wine, fruit, or delicacies, suitable for the sick. It is requested that money may he sent to the Lady Superintendent of each district direct : other things can be sent to the Nurse; but it is requested, and particularly in the case of wine, that a list of the articles should be sent to the Lady Superin- tendent.” It may interest some of those disposed to send assistance to the Ladies Superintendent of districts, as well as those contemplating similar work elsewhere, to know in what the expenditure of the districts consists. The expenditure is the same in kind as that required in hospitals, except that whereas the latter supply all the nourishment and medicines, the Lady Superintendent of a district only supplements in food the resources of the patients, and that only when necessary, while medicines are generally supplied by the parish or dispensaries. The expenditure varies in different districts from .£30 to £160, and the difference arises not only from the number of sick, hut also from the number of other agencies at work in the district, and the degree in which the work is limited to strict nursing. Thus two districts,' both similar in poverty, both efficiently worked and carefully looked after, have furnished about the same number of cases in 1864 ; in one under .£60 and in the other over £160 has been expended, and yet there has been care to do as much good as possible in the one, and to avoid waste in the other. In the apparently cheaper district the cases have been treated as they would have been in an hospital, that is, referred to other agencies where hopeless of cure, and needing rather the kind aid of charity than the tending of the Nurse; those other agencies were at hand, provided for the most part out of the same purses, and superintended to a great extent by the same Ladies, to do what was needed. In the other district. 70 and in many of the districts, if clothes were wanted to prevent the children of consumptive parents from being added to the list of sick, or to send con valescents to their work, or if cases of chronic sickness, such as furnish the inmates of the infirm wards oi workhouses, were to be made less wretched, the expense was provided out of the same fund as the nursing. Between the districts in question it is more a matter of account-keeping than actual difference, but, as sucb, very interesting, showing how much good may be done even with moderate means, if strictly limited to the most important part of nursing; and, on the other hand, how much more good may advantageously be done, and bow much money well spent, (as we are assured it is,) under the guidance of the information which the district work furnishes to those engaged in it. AVERAGE EXPENDITURE PER CASE, AND PER DISTRICT, OF TWO HUNDRED CASES, UNDER SUNDRY HEADS, IN 1864, FROM THE RETURNS OF NINE DISTRICTS. Average Expense per Case. Average Expense per Annum per District. s. d. 2 8.437 0 9.385 0 10765 0 7.926 0 11.476 0 3 305 0 3.709 1 3 250 1 5.350 £ s. d. 27 0 7 7 16 5 8 19 5 6 12 1 9 11 3 2 15 1 3 19 12 14 2 14 9 2 Milk Tota1 9 3.603 92 19 11 We give, in a tabular form, the result of the district nursing in 1864, and we also print some extracts from the valuable Reports of the Ladies, pp. 95 — 100. We have also to report the appointment of Miss Hunt as Assistant Secretary, and Out-door Inspector of Nurses. This appointment has already produced decided improvement in the efficiency of the District Nurses, whom she has counselled and encouraged ; and some of the Ladies Superintendent have, where it has been requested, found her aid most valuable. We have further the pleasure to report that our operations have been, to a certain extent, combined with those of the Central Relief Society, the Committee of which have found our agency useful in dealing with the objects of their bounty, and have kindly enabled our District Nurses to make additions to the benefits which their attendance confers upon the sick poor placed under their care. 71 PRIVATE NURSING. The amount we have been able to do in this branch of our work has increased ; but, we must repeat, it is only slowly that we can find and train a staff of suitable Nurses. At the date of last report we had only four Nurses engaged in Private Nursing; now we have ten, and at the end of 1865 we hope to have at least a similar increase to our staff. The services of the Nurses are highly appreciated and anxiously sought for We ask the aid of our friends in finding women suitable for Nurses. We repeat our belief that, when developed, this branch of the School will amply repay the subscribers or their families, by life and suffering saved, for their share in establishing the School FINANCES AND SUPERANNUATION FUND. The accounts of the past year show an increase in the deficiency from ,£346 Is. lOd. to £'469 17s. ^d., and we earnestly hope that the liberality of the public will enable us to extinguish the debt during the year. With regard to the future, besides the causes of decay which affect every Subscription List, and necessitate constant accessions to maintain its amount, we have a further reason for anxiety. The experience we have acquired makes it evident that, in order to carry out fully the new system, the chief feature of which is the enrolment of a higher class of women for the work of nursing, we must offer inducements which will cause it to be regarded as a permanent, not a temporary service ; the main requisite for this purpose is the establishment of Superannuation allowances for disabled Nurses, to which thoughtful women may look forward. Such a fund exists, and is regarded as essential, in similar London establishments, where it is reported to be attended with the best results. We are so impressed with the necessity of this measure, that we have determined to open a Superannuation Fund, (without as yet fixing its exact regulation,) and to appropriate thereto a sum of £100 out of the income of the present year. We have therefore earnestly to appeal to the public for more extended support, both to enable us to keep up the expenditure required for the general purposes of the Society, and also for the special object of the Superannuation Fund. THE BALANCE SHEETS AND ITEMS' OF EXPENDITURE FOR 1863 AND 1864. The Liverpool Training School and Home for Nurses in account with Thomas Dyson Hornby, Treasurer 72 O © O co O t-H t-H W ^ O H 04 O C CO 05 CO T-l C- CO o 50 CO O © CO CO CO Ol t- 05 05 t— CO 04 T— 1 04 05 t-H 10. b» CO 05 T}H o 10> iH t— 04 CO co co CO co 3 9 c-l co CO CO GO 00 bD ■< pq Ph O .5 H ^2 C3 O -3 ffl O tc - M ” 53 O ^3 32 cc O rj 03 c3 m m o o • 05 HO . CO CO rH t- CO t- © © *> 05 © © 05 O TH 1C H O 04 O s I PH o» O . § W a H '-3 *H Hf Pd p CO CO ^ CO pH CO a> <5 o I 2 dj (O OJ M H m p, •C : a Ph « .s 2 co o ^ P o P © o ■ PQ CO o 05 t> Tt( I> CO o» oi .2 Ti rd p PQ '• HOBNBY, Treasurer. 75 EXPENSES OF THE SCHOOL AND HOME, 1864. Butchers’ Meat, Poultry, Eggs, and Fish £309 9 10 Bread and Flour 99 8 8 Milk and Butter 123 3 11 Cheese and Bacon 55 14 0 Vegetables and Fruit 47 11 2 Groceries, Soap, and Candles 147 6 8 Ale, Beer, and Porter. 142 16 6 Wine and Spirits .... Coals and Coke 15 10 0 Gas 20 9 3 Furniture and Linen 55 14 0 Earthenware and Glass 3 0 3 Ironmongery, &c 10 18 6 Joiners’ Work 3 9 0 Plumbing, Painting, &c 7 9 9 Whitewashing 21 8 7 Stationery, Printing, and Advertising 44 19 0 Insurance against Fire 7 12 6 Water Bent 5 5 0 Incidental Expenses 19 5 4 Salaries and Wages 74 3 10 Travelling Expenses of Nurses 443 2 Washing 165 13 3 Books 4 13 0 £1,389 15 2 76 C. TABLES OF WORK DONE IN DISTRICTS, 1864. THE FOLLOWING IS THE ABSTRACT OF SICK CASES VISITED DURING 1864, IN THE THIRTEEN DISTRICTS WHICH HAVE COMMENCED WORKING SOME OF THEM HAVE NOT BEEN AT WORK THE WHOLE YEAR — No. 1 District. Abscess. ccidents and Wounds. Asthma. Bronchitis. Cancer. ases of Child Birth. onsmnption. tendency to onsumption. isease of the Heart. Dropsy. Erysipelas. Fever. >> B & ft e3 c o a a B Paralysis. heumatism. Sundries. Total. <1 o o ft S t-t ft Apparently cured Partially cured, suffi- i i 4 20 3 2 1 4 45 7 1 3 9 102 ciently to resume 1 1 3 i 6 8 8 3 0 9 42 Cases of alleviation of 1 suffering— since dead Under treatment, with i i i i 15 2 1 5 1 1 30 hope of complete or partial cure i 2 5 1 3 4 6 3 2 27 Probably hopeless as to cure, but under treat- ment for alleviation i 3 1 3 Dismissed for inatten- tion to advice of the Nurse, or as unsuit- able cases, or removed out of the district or to Hospital 4 1 2 3 1 3 8 2 1 8 33 8 4 I 6 8 31 24 9 8 3 8 62 34 7 9 26 242 i SIMILAR TABLES ARE PRINTED OF EACH DISTRICT, AND SUMMED UP AS FOLLOWS SUMMARY OF THE TABLES, 1864. Abscess. Accidents and Wounds. Asthma. Bronchitis. Cancer. Cases of Child Birth. Consumption. Tendency to Consumption. Disease of the 1 Heart. P. o ft Erysipelas. Fever. j General Debility. 1 Inflammation. Paralysis. Rheumatism. Sundries. ! Total. Apparently cured Partially cured, suffi- 39 17 10 32 141 12 186 7 13 27 336 103 18 3 26 136 936 ciently to resume their duties 17 1 32 12 12 15 43 55 11 18 14 35 52 14 38 87 456 Cases of alleviation of 403 suffering — since dead 12 2 14 14 9 7 152 6 23 25 1 59 23 1 9 3 43 Under treatment, with 1 hope of complete or partial cure 12 4 8 6 4 10 6 8 1 2 10 43 15 2 7 41 180 Probably hopeless as to cure, but under treat- ment for alleviation of misery 7 1 8 6 1 25 3 4 6 7 4 5 17 9 Dismissed for inatten- tion to advice of the Nurse, or as unsuit- able cases, or removed out of district or to Hospital 18 5 8 8 7 8 54 11 8 7 1 24 6 1 7 21 65 289 Total 105 30 80 72 3 182 292 96 53 69 53 503^ 236 22I 38 IO0I389S2358 77 SUMMARY OF THE TABLES, 1863. Abscess. Accidents and Wounds. Asthma. Bronchitis. Cancer. Cases of Child Birth. Consumption. Tendency to Consumption. Disease of the < Heart. ft •<-* ft Erysipelas Fever. 1 General Debility. | 1 Inflammation. 1 Paralysis. Rheumatism. j Sundries. aS O H Anparentlv cured 19 4 i 30 30 19 i 10 17 105 78 174 152 1 ^ CO Partially cured, sulfi- ciently to resume their duties 20 22 31 12 14 20 9 4 20 2 5 56 11 78 325 Cases of alleviation of suffering— since dead 155 2 20 20 10 4 5 13 3 3 4 19 26 46 337 Under treatment, with hope of complete or partial cure - • 14 10 12 3 3 10 3 1 6 2 6 25 10 23 139 Probably hopeless as to cure, but under treat- ment for alleviation of misery 41 2 3 7 6 3 5 2 7 9 2 18 19 124 Dismissed for matten- tion to advice of the Nurse, or as unsuit- able cases, or removed out of district or to Hospital 92 4 4 5 6 6 9 8 2 11 8 18 30 39|179 Total 271 59 1 99 1 1 (47 1 40 | 72 78 1 ; 46 26 | 1 1 59 28 128 214 251 358 177 D. ARRANGEMENT WITH THE CENTRAL RELIEF SOCIETY. AND FORMS OF RECOMMENDATION. LETTER TO THE LADIES SUPERINTENDENT, FROM THE SECRETARY OF THE NURSES TRAINING SCHOOL. Nurses Training School and Home, 8 th December , 1804. Dear Madam, — The Central Relief Committee, finding that the work performed by the District Nurses, and relief afforded through them to the sick, is an important branch of relief of the deserving poor, have decided to try whether a more united action of their Society with that of the District Nurses may not be beneficial, and they have therefore resolved to extend to the sick under the care of the Nurses, and to their families, aid in three wavs; subject however to a fundamental rule of the Central Relief Society, that such aid must be given only after visitation by their own officers. 1. They will relieve for a period not exceeding four weeks, to such extent as in each case may seem to them to be desirable, the families of those who are sick, and under the care of the District Nurse. To obtain such aid, an ordinary form of recommendation signed by the Lady Superintendent, or her representative, will be attended to by the visitor of the special cases of the Central Relief Society, on whose report they will act. Cases so relieved are subject to a weekly visitation, but a fresh recommendation is not required weekly. 78 2. They will, where it may be desirable to do so, send convalescent patients for recovery to the sea-side at Southport, where they will be supported for three weeks’ residence.* To obtain such aid the same course is necessary as stated above, with the addition that the certificate of the medical atten- dant must be obtained, prescribing sea-side residence or bathing for the patient. 3. They will where, in addition to the ordinary articles of nourishment given in a prepared or cooked state, extra nourishment in the form of butchers meat may be desirable, give it as soon as they can satisfy them- selves from the report of their own officer, that the cases are deserving of such aid. The Committee, however, consider that great care will be neces- sary to prevent imposition on the Lady Superintendent, and on themselves. They will therefore require, 1st, that the recommendation of the Lady Super- intendent or Nurse should be accompanied by a certificate from the Doctor, that meat is ordered by him for the patient; and, to save trouble in this respect, printed forms will be furnished by the Secretary of the Central Relief Committee if desired. Moreover, as considerable additional work will by this arrangement be thrown upon the Special Visitor, it will be ne- cessary for the Lady Superintendent, in cases requiring immediate relief iu the form of meat, still to give it herself, until the Special Visitor has had time to investigate the case, while in that part of the town on his other duties; this delay however will not exceed a week, and will be made as short as possible. It may happen that the Lady Superintendent or Nurse may differ from the Officer of the Central Relief Committee as to particular cases being desirable ones for this relief, and while the Committee must act on their own judgment, it is of course still open to the Lady Superintendent to give meat herself, as she would have done before this arrangement. Any Lady Superintendent wishing to avail herself of the aid of the Central Relief Committee, as stated above, will no doubt communicate with Mr. Heath, the Secretary, 7, Dale Street, that he may make the necessary arrangements for the supply of meat. It will probably be desirable that the orders for meat for each district should be sent from the Central Relief Society to the Nurse, and not to the patient direct, that she may secure, as much as possible, that it is given in the quantities and at the times directed, and that it really reaches the patient. It will be a great aid to our work, that a very expensive and important part of it should be undertaken by a powerful Central Society, whose per- manence will I trust make our existence less liable to be affected by individual deaths or removals; and I have assured the Committee that they will find the Ladies Superintendent most anxious to make their assistance produce as much good as possible, and to guard it from extravagance and abuse. I dare say it will seem occasionally as if the Committee might * “A kind of relief of which it is impossible to calculate the benefit to the sick poor, or the result in diminishing pauperism.” — Florence Nightingale. 79 trust to our knowledge and judgment of cases which we were visiting con- stantly, instead of acting on the report of their own Visitor ; but on the other hand I feel sure that, upon the whole, we shall derive great benefit from such visits, for I have found in the district which I visit, and with cases the Nurse thought she knew thoroughly, and where I had repeatedly visited myself, that the information apd experience of which the Relief Committee are the centre were of essential assistance to me. The Central Relief Committee only consented to undertake the supply of meat as an experiment, of the advisability of which they were not assured; and they did so with the understanding that if they did not think it successful they might discontinue it, without giving reasons for their decision. I have been requested to mention that the Central Relief Society do not as a rule profess to deal with chronic cases of distress, suitable for Parish relief, and although in cases of sickness they are willing in some instances to give aid in addition to the Parish allowance, they require that the latter be first applied for in such cases. If any difficulties should arise in working with the Central Relief Society, I shall be much obliged if the Ladies Superintendent, instead of writing direct to the Secretary or Committee, would write to Miss Hunt or to me, and leave us to arrange them. As the same difficulties are likely to arise in different districts, they can be arranged through our Central organization with the least possible trouble to all concerned, and the least risk to the successful and harmonious working of the arrangement. Your faithful Servant. SOUTHPORT HOSPITAL FORMS. Ladies and Gentlemen recommending Patients are requested carefully to peruse the Form, below, to ivhich they are about to append their names, before they sign it. MEDICAL CERTIFICATE. I have examined of whom I find afflicted with and I believe likely to be benefited by sea air and bathing. Age? How long ill? Physician or Surgeon. TO THE COMMITTEE OF THE SOUTHPORT CONVALESCENT HOSPITAL AND SEA-BATHING INFIRMARY. I beg leave to recommend of to be admitted into your institution. I have inquired into cii-cumstances, and I believe to be a proper object for the benefit of the charity. The patient has not furnished any part of the cost of the recommendation. Dated day of 186 . Recommender’s Name, Postal Address. 80 N. B. — The above Recommendation will be forfeited should it appear that it has been used to assist begging applications of any kind. Patients are desired to Take Notice that the Days of Admission are Thursdays only, at two o’clock p in. EXTRACTS FROM THE LAWS. GOVERNORS. Law 4. Every benefactor who may hereafter give twenty guineas or upwards at one time, and also any clergyman or minister who shall collect from his congregat'on at one time for this charity twenty guineas or up- wards, shall be a Governor during life ; and every subscriber of one guinea annually shall be a Governor during payment of such subscription. The Medical Officers of the Institution shall be Honorary Governors while they remain in office. Law 22. All recommendations shall be issued at the rate of thirty shillings for each recommendation, excepting that every Life Governor who has at one time given to the charity twenty guineas, in conformity with rule 4, shall be entitled to recommend one patient each year without charge. PATIENTS. Law 23. Each patient, in addition to the recommendation, shall bring a certificate from a Medical Practitioner, stating the complaint of the patient, and that such patient is likely to be benefited by sea-bathing or by temporary residence at the sea-side. Law 24. Each patient approved by the Committee shall be entitled to board, lodging, baths, and medicine for three weeks ; and each patient not residing in the house shall be entitled to receive eight shillings per week, instead of board and lodgings, for the same period. Law 25. No person suffering from the last stage of consumption, or from any infectious or objectionable disease, or incapable of attending to himself, shall be admitted as a patient of this charity; and in case any person recommended be deemed on any of these accounts an improper case for admission, a letter signed by the Chairman or one of the Honorary Secre- taries shall be sent to the subscriber recommending such patient, stating the reason for non-admission. EXTRACTS FROM THE BYE-LAWS. Every patient will be required to bring a proper change of clean linen, and to come provided with money for travelling expenses to and from the charity. Every patient is expected to render occasional assistance in the establish- ment when required, unless specially exempted by one of the Medical Officers of the institution. N. B. — It may be desirable to draw the attention of the public to the fact that the winter climate of Southport is peculiarly suited to all those classes of complaints in which a mild climate would be beneficial. 81 CENTRAL RELIEF SOCIETY’S FORMS. TO THE LIVERPOOL CENTRAL RELIEF SOCIETY. I recommend that residing at be allowed butcher’s meat, as follows, viz : — to be given a week for a period of Surgeon, &c. Date, 186 I believe the above case to be a deserving one, and that, to the best of my knowledge, the meat prescribed is not supplied or ordered for the patient by the parish authorities. Date, 186 Lady Superintendent of District No. Applications for relief are not permitted to be made at the Society's Office. LIVERPOOL CENTRAL RELIEF SOCIETY. Established for Visiting and Believing Deserving Persons in Temporary Distress. I recommend residing at to be visited, and relieved if found a deserving object of this charity. Signature and Address, &c., of party recommending. Date lab N.B. — Be careful to insert the correct address of the applicant, and the name of the head of the family. Instructions. — To insure being visited the same day, this note should be taken before eleven o’clock in the forenoon, and deposited in the receiving box for the district in which the applicant resides. The shops appointed for each district are as follows, viz. — First District — Messrs. Pegram & Co., 35, Currie Street, near Scotland Road Market. Second District — Mr. John Innes, 181, Richmond Row, end of Soho Street. Third District — Mr. Wm. Davis, 78, Whitechapel, and Mr. Thomas Frith, 71, Paddington. Fourth District — Mrs. Mary Rowland, 30, Northumberland Street. E. RULES AND FORMS OF THE TRAINING SCHOOL FOR DISTRICT AND PRIVATE NURSING. RULES OF THE LIVERPOOL NURSES TRAINING SCHOOL, DOVER STREET, LIVERPOOL, The Rules of the Society are — Rule I. That the Nurses are to attend the sick, both rich and poor, at F 82 hospitals or private houses, as the Committee or Lady Superintendent may appoint. Rule 2. That when sent from the Home to attend a patient, they receive their instructions from the Lady Superintendent, and do not leave the case without communicating with her; this they can do by letter at any time. Rule 3. That no present or gratuity of any kind be accepted by a Nurse beyond some very trifling remembrance from or of the patient. Rule 4. That nothing belonging to a deceased patient is to be accepted by the Nurse. Rule 5. That while on duty in the Home, at the Infirmary, or in private houses, the regulations of the establishment with regard to dress are to be observed by the Nurse. Rule 6. That no male visitors to the Nurses be admitted at the Home without special permission from the I.ady Superintendent. Rule 7. That the Nurses shall not take more than pints each of table beer in the twenty-four hours, and no wine or spirits, without a medical order; and that they shall carefully avoid adding unnecessarily to the expenses of a household, either in board or washing. Rule 8. That a Nurse is always to bring back with her a certificate of conduct and efficiency from the family of her patient, or from the Medical Attendant. It is expected that the Nurses will bear in mind the importance of the situation they have undertaken, and will evince, at all times, the self-denial, forbearance, gentleness, and good temper, so essential in their attendance on the sick, and also to their character as Christian Nurses. They are to take the whole charge of the sick room, doing everything that is requisite in it, when called upon to do so. When nursing in families where there are no servants, if their attention be not of necessity wholly devoted to then- patient, they are expected to make themselves generally useful. They are also most earnestly chai'ged to hold sacred the knowledge which, to a certain extent, they must obtain of the private affairs of such households or individuals as they may attend. Communxations from or on the subject of Nurses may be made per- sonally, or by letter, to the Lady Superintendent, Nurses’ Home, Dover Street, Liverpool. RULES AND FORMS FOR ADMISSION AND TRAINING OF PROBATIONER NURSES. Regulations us to Training i robationer Nurses, at the Liverpool Training School and Home for Nurses. 1. The Committee of the Liverpool Nurses’ Training School have made arrangements with the authorities of the Royal Infirmary for training women desirous of working as Hospital, District, or Private Sick Nurses. 83 2. Women desirous of receiving this training should apply to Miss Merryweather, the Lady Superintendent of the Training School, and if they are suitable, and there are vacancies, they will be received into the Home and School as Probationers. The age considered desirable for Probationers is from 25 to 85. A certificate of age and health, and testimonials of character, according to the forms supplied by the Lady Superintendent will be required. 3. — The Probationers will be under the authority of the Lady Superin- tendent, and they will be subject to the rules of the Royal Infirmary and the Training School for Nurses. 4. — They will be supplied with board (including tea and sugar), lodging and washing. 5. — If retained, the wages of a Probationer during her year of probation wdl be £14 4s., paid thus — 412 at the end of the first quarter, .£3 10s. at the end of the second quarter, £4 at the end of the third quarter, and £4 14s. at the end of the fourth quarter. The Probationers will be required to con- form to any regulations in regard to uniformity of outer clothing, and if supplied with materials for the same by the Institution, the cost (to an extent not exceeding £4 4s.) is to be retained from their wages. 6. — It is expected that at the end of a year they will be fitted for Nurses, and their engagement will require them to serve two years more in Hospital, District, or private nursing. 7. — At the expiration of three months from the date of entry, every Pro- bationer will be required to write a letter to the following effect : — To the Chairman of the Committee of the Liverpool Nurses’ Training School. Sir, Having now become practically acquainted with the duties required of a Nurse, 1 am satisfied that I shall be able and willing, on the completion of my year's training, to enter into service as a Nurse in a Hospital, District, or in private houses, and I promise to continue in such service for the space of at least two years, in whatever situations the Committee shall think suitable for my abilities, it being my intention from henceforth to devote myself to nursing the sick. I am, Sir, fyc., fc., Sfc. 8. — The names of the Probationers will be entered on a Register, in which a record will be kept of their conduct and qualifications. At the end of every month this record will be submitted to the Committee of the Institution. 9. — The Probationers will be subject to be discharged at any time by the Lady Superintendent in case of misconduct, or should she consider them inefficient or negligent in their duties. 10. — The Nurse or Probationer must be able to read written instructions and to write. 84 11. — The Nurse or Probationer is to keep the apartment allotted to her use neat, clean, and in proper order, and at all times to sweep, dust, and do all that is necessary in the Home, as well as to assist in the needlework there. 12. — The duties of the Nurses will be to attend the sick, both rich and poor, at Hospitals or private houses, as the Committee or Superintendent may appoint. 13. — All money received for the services of Nurses will belong to the Fund of the Training School. No Nurse will be permitted to receive any private remuneration in money or clothing. This would defeat the object of the Institution, which is to encourage unselfish and disinterested exertion on the part of the Nurse. 14. — The Nurses and Probationers will be required to attend public worship when at the Home. 15. — All Nurses and Probationers will be provided with a sufficient allowance of beer or porter to take at meal times; but they will not be allowed to procure or ask for wine or spirits without the express recommen- dation of a medical man, either at the Home, the Infirmary, or in private houses where they may be nursing, and any infraction of this rule will subject them to dismissal. Applications should he made to the Lady Superintendent, Training School and Home for Nurses, Royal Infirmary, Liverpool. LIVERPOOL TRAINING SCHOOL AND HOME FOR NURSES. Form lo befitted up by Persons applying jor Admission as Probationers. Name. Age. Place of Birth. Where Educated. Previous Occunation. Whether Single or Married, or Widow.* If Mamed,' or a Widow, whether with Children, and if so, with how many. References. * The Marriage Certificate will be required. / declare the above statements to be correct , Signature. 85 DUTIES OF PROBATIONER IN THE LIVERPOOL TRAINING SCHOOL AND HOME FOR NURSES. You are expected to be sober, honest, truthful, trustworthy, punctual, quiet and orderly, cleanly and neat. You are expected to undertake night duty when required, and to become skilful — 1. In the dressing of blisters, burns, sores, wounds, and in applying fomentations, poultices, and minor dressings. 2. In the application of leeches, externally and internally. 3. In the administration of enemas for men and women. 4. In the management of trusses, and appliances in uterine complaints. 5. In the best method of friction to the body and extremities. 6. In the management of helpless Patients, i. e., moving, changing, personal cleanliness of, feeding, keeping warm (or cool), preventing and dressing bed sores, managing position of. 7. In bandaging, making bandages and rollers, lining of splints, &c. 8. In making the beds of the patients, and removal of sheets while the patient is in bed. You are required. — 9. To attend at operations. 10. To be competent to cook gruel, arrowroot, egg flip, puddings, and drinks for the sick. 11. To understand ventilation, or keeping the ward fresh, by night as well as by day. 12. To be careful that great cleanliness is observed in all the utensils; those used for the secretions as well as those required for cooking. 13. To make strict observation of the sick in the following particulars:- — The state of secretions, expectoration, pulse, skin, appetite, intelligence, as delirium or stupor ; breathing, sleep, state of wounds, eruptions, formation of matter, effect of diet, or of stimulauts, and of medicines. 14. To learn the management of convalescents. Liverpool Royal Infirmary. 186 Sir, — Having been referred by the Lady Superintendent of the Liverpool Training School and Home for Nurses to you as the Medical attendant of and family, will you kindly reply to the questions required by the Council from each Candidate, before she can be appointed n Probationer. As you will readily understand bow indispensable it is, for the successful training of young women, that they should be not only morally, but physically and mentally, competent to undertake the duties of Hospital 86 Nursing, I will not apologise for giving you the trouble to fill up and return the Medical Certificate to me (by post) at your earliest convenience. I have the honor to be, Your obedient Servant, House Surgeon. MEDICAL CERTIFICATE. 1. How long have you been acquainted with 2. Is she intelligent and of active habits? o. What is her general appearance, configuration, height, weight? 4. General health ? 5. Any illness of importance ? When ? What? 6. If fulness of habit, or subject to head affections ? 7. Any tendency to pulmonary or scrofulous disease? Cough or shortness of breath ? 8. If any time spitting of blood? 9. If any heart disease ? 10. If vaccinated ? 11. Are her parents living? 12. Has there been any insanity in her family? I have thig day of 186 examined and hereby certify that she is apparently in good health, that she is not labouring under any deformity, and is, in my opinion, both physically and mentally com- petent to undertake the duties of Nurse in a general Hospital. (Signed) Bate Address LIVERPOOL NURSES’ TRAINING SCHOOL, DOVER STREET, LIVERPOOL. 1. JDate 2. Name 3. Have you read the Rules? 4. Are you willing to attend on the poor as well as on the rich ? 5. Do you understand clearly that you are not to accept any present from patients, or their friends, without the conseut of the Committee, except it be some article of small value (such as a book) as a remem- brance of a patient? 6. Do you understand also that, in case of the death of a patient, you are strictly forbidden to accept of anything belonging to the deceased? 7. Will you, both when in the Home and on duty, always wear the dress prescribed by the Committee? 87 8. Are you quite willing to conform strictly to every Rule of the Training School ? !). Are you aware that any transgression of the Rules of this Establish- ment will subject a Nurse to instant dismissal? FORMS AND RULES USED IN DISTRICT NURSING. TO LADIES SUPERINTENDENT. The following suggestions for organising a District are necessarily very incom- plete ; it is to the Ladies Superintendent we must look to tvork out a more complete system of operations. When a lady becomes the Superintendent of a district, a trained Nurse will be provided, receiving a salary from the Institution. The Lady Super- intendent undertakes to find the medical comforts, and also to provide the Nurse with lodgings in a good central situation. I. — When commencing a district, it may be desirable to call a Meeting of the various Ministers of religion in the district, to explain to them the objects proposed, give to them the power of recommending cases, requiring, at the same time, that the greatest care should be taken to recommend suitable cases only, excluding such as would be better dealt with in hospitals or the workhouse, or where the parties are able to help themselves. Want of care in this respect would necessitate the withdrawal of the power of recommendation, as it would involve the waste of means and time. Their kindly aid should be asked in interesting their parishioners and friends in the work, and in bespeaking personal assistance, contributions to the funds of the Institution, or gifts of food, wine, clothes, old linen, &c. The Lady Superintendent will also have to arrange for the custody and preparation of medical comforts. This may be done in various ways — 1st. By the Nurse herself merely consulting with the Superintendent ; this is not the best way, for obvious reasons. 2nd. It has been done by paying a weekly sum for local superintendence and cooking, with the expense of firing, and the extra help necessary to the person who undertakes these duties. A better plan, if possible, is to find in the neighbourhood the kind intelligent wife of a clerk or shop-keeper, who, for love of the work, would undertake this department of local superintendence. 11 — The Lady Superintendent should either visit herself, or depute some one to visit for her, so as to enable her to satisfy herself that the Nurse is working faithfully and sufficiently. III.— At fixed times, at least once a monlh, she should examine the Nurse’s Register, consult with her on fresh cases, and hear the report of former ones. She would find it desirable to keep memoranda of expenditm-e, and of the articles lent, and to see that they were all marked indelibly “lent 88 not to be pawned.” The accounts should be kept in her name; and it has been found best to pay all bills monthly. In any case of difficulty or importance it might be desirable to consult with the person who recom- mended the case. IV. — The Lady Superintendent will be provided with — 1. A Nurse’s Register Book. 2. A Map of the district. 8. Forms of Recommendation to be given to those authorised to recommend. 4. Form of Application for power to recommend, which must be signed by a Minister of Religion, Medical man, or other party authorised by the Lady Superintendent to recommend. 5. Forms for advising the party signing the recommendation, that the case is found unsuitable ; the Lady Superintendent will probably find it desirable to fill up this Form, and return it in all such cases. 6. Rules for District Nurses. 7. Rules for Patients and their friends. 8. Slates and Pencils for Nurses. V. — At certain periods there may be extra pressure on the Nurse, and watchfulness must be exercised that her strength is not over-taxed. Additional assistance can generally be found in some woman competent to act under the Nurse. This must be done by the district itself, as the Society has not at present extra Nurses. It may also be occasionally desirable to employ some strong person to cleanout a dwelling. We may mention here that the owner of a house may be compelled, by application to the Inspector of Nuisances, Cornwallis Street, to have it whitewashed when in an unwholesome state.* VI. — The Weekly Register Book of the Nurse is required to be taken to the Central Office, once a month, and given up to the Society at the end of the year. VII. — It is impossible here to enter into details; but, perhaps, even from this sketch, it may be gathered that the work is peculiarly susceptible of co-operation — one in which several friends may .join, and prevent the burden falling too heavily on any, and all find their own vocation, from the wealthy merchant, to the widow with her mite ; from the child who gives its untasted orange or its broken toy, to the experienced mother, who with her kindly preseuce brings more substantial aid to the sick little one. Those, too, on whom God has laid His hand, and withdrawn from active life, may have their vocation here. Many are the comforts devised and sent to poorer brethren from the thoughtful bed of sickness, with alleviations and pleasant books to beguile the weary hours of suffering. RULES FOR DISTRICT NURSES. 1. It is expected that each Nurse shall devote at least five to six hours a day to visiting the sick poor. ■ “A very important point for other places. It is very important to direct the attention of ladies (i. e. educated women) in all places to this, viz : To ascertain what power of this kind is given by local acts. They are lamentably ignorant on this point. So indeed are the ministers of religion." — Fi.ouence Nightingale. 89 2. Some cases require to be seen daily, but most not so frequently. 3. A Weekly Register is to be kept by the Nurse, in which each case is to be entered, and the Register taken to the Superintendent of the district at the times fixed by her, and when required submitted to the Central Society. 4. All recommendations of cases to be made by the Ministers of Religion, or by a Medical Man, or other authorised persons of the district, on a printed form, furnished by the Society for that purpose. This recommenda- tion to be taken to the Superintendent on the first opportunity, and to be kept and filed by her. 5. The Nurse to visit all cases so recommended as soon as possible, and report them to and consult the Superintendent upon them, at the earliest opportunity. Any difficult point that may arise to be of course submitted to the Superintendent.* 6. The Nurse is to report immediately to the Superintendent any case in which she judges that meat or other extra nourishment would restore heads of families more quickly to their work ; or which she thinks could be better or more suitably dealt with in an Hospital or Workhouse ; or where the family visited are able to obtain otherwise for themselves the relief required ; or where the neglect or disobedience of the Patients or their friends render her visits useless. No case duly recommended is to be left unattended to, without the knowledge and direct sanction of the Superin- tendent. 7. The Nurse to be ready and willing to render every assistance in any operation which the Surgeon may require. 8. The Nurse to render to the patients under her care such aid and instruction as may be necessary, and to urge upon them the great importance of cleanliness in person and dwelling, of the immediate removal of all things offensive both from the bed and room, and of care to keep the sick room clean and fresh at all times; of ventilation (fresh air), of giving nourish- ment and medicine at the right time, as directed, and of strict obedience to the orders of the medical attendant. She will often have to do what is necessary for the patient herself, and in most cases to instruct and enforce her instructions on the relations or attendants. She will tell them when and where to send for nourishment or comforts which are to be supplied to them. 9. No blankets, sheets, cushions, or other like articles, to be lent until fully marked. The articles lent are to be entered by the Nurse, with the date of the loan, and a corresponding list given to the responsible person receiving them, requiring that such articles be returned clean and in good order, at such times as the Nurse or Superintendent may appoint. * “I entirely appreciate the manner in which the permanence of this great charity is provided for, by rendering responsibility as far as possible local, instead of keeping it in the hands of the original founder or founders : also by interesting in it as many persons as possible, and securing to them so much independence of action, while keeping up so much necessary (and no unnecessary) uniformity.” — Florence Nightingale. 90 10. A slate and pencil to be hung up in the patient’s room, on which the doctor can write his instructions, and can, if he wishes, make an appoint- ment with the Nurse, and on which she can enter any facts or ask any questions she may think desirable. 11. The Nurse herself to be an example of neatness, order, cleanliness, and sobriety. She must be most careful to avoid and to discourage any tale-bearing, scandal, or other unprofitable conversation. She must not interfere with anyone's religious opinions. Strict obedience on the part of the Nurse to the directions of the medical man is indispensable. FORM OF APPLICATION FOR FORMS OF RECOMMENDATION OF PATIENTS TO DISTRICT NURSES. To Mrs. Lady Superintendent of District No. Madam, — I shall be obliged if you will furnish me with Forms of Recom- mendation for Patients to the Nurse of your district. 1 have read, and assent to, the stipulations at the foot of this letter, which shall be carefully attended to by me. 1 am, Madam, Your obedient Servant, Careful enquiry to be made previous to Recommendation, to ascertain — 1. That the Patient cannot otherwise obtain the relief required. 2. That the case is one inadmissible, or undesirable to send into an Hospital or Workhouse. If the Nurse should discover that there has been a mistake or. either of the above points, or that neglect, or disobedience, on the part of the Patients or their friends render her visits useless, she will report it to the Superintendent, who will direct her to discontinue her visits. The Lady Superintendent, being alone responsible, is not to be called upon for reasons in such cases. FORM OF RECOMMENDATION.^ To Nurse of District No. Address Name of Patient Address of do. Disease Circumstances Enquired into and Recommended by Signature Profession Address Date This recommendation is only in force for one month; if the Nurse's * Oil tlic back of this recommendation is printed a plan of tlic Town, and the Nursing Districts into which it is divided. 91 attendance is required beyond that time, a fresh recommendation should be obtained. FORM USED WHEN IT IS DESIRABLE TO INFORM THE SIGNER OF A RECOMMENDATION WHY THE PATIENT CANNOT BE TAKEN ON. Sir, The Case of Name Address has been visited, but does not appear to be a case for the Nurse’s visits. 1 am, your obedient Servant, Lady Superintendent. reason. Able to obtain otherwise the necessary relief. More suitable for Hospital or Workhouse. Patient or friends careless or disobedient. The Lady Superintendent to draw her pen through all the reasons but the one she has to give, or through all if she wishes to give no reason. FORM PRINTED ON A CARD, AND HUNG IN PATIENTS’ ROOM To Patients and their Friends. Ventilation, or the due admission of fresh air to the sick-room ; punctu- ality in giving medicine or food ; and perfect cleanliness of the room, bed, and person, being so absolutely necessary to the well-being and recovery of sick persons, you are expected to aid the efforts of your Medical man and the district Nurse by strict attention to the following points : — 1st. Strict attention to the directions of your Medical man as to the time and manner of giving medicines, &c.,* and other particulars relating to the sick room. 2nd. Particular care as to the cleanliness of the sick, both in person f and clothing. 3rd. The immediate removal of all things offensive, both from the bed and room ; and care to keep the sick room quite clean and fresh at all times.j * “ Food and drink.” — Florence Nightingale. + “ Bed linen ” — Florence Nightingale. 1 4tli. “Preserving quietness in the sick room, and avoiding everything likely to excite or exhaust the patient. Take care that, as far as practicable, nothing in the way of food, drink, or medicine is given to the patient except under the direction of the Doctor or Nurse.” — Florence Nightingale. 92 It is a part of the Nurse’s duty, in her visits, to see that these necessary things are properly carried out; and she will give you suitable advice and directions in these and all other particulars concerning the proper care of the sick person. Neglect of these instructions will make the Nurse’s visits useless, and she is directed in such case to discontinue them. FORM OF RECORD KEPT BY INSPECTOR OF NURSES, OF NURSE’S CONDUCT AND EFFICIENCY. No. of District , 22. Name of Nurse, Mrs. Days when visited. June 1. June 23. July 6. July 30. Regularity. G. M. IMP. V. G. Reliability Y. G. V. G. V. G. V. G. Method in Work IND. IMP. — G. General Ability and Insight G. G. G. G. Personal Neatness and Cleanliness M. M. IMP. G. Tenderness towards Patient B M. — IMP. G Management of Patient and Family. . . . Ventilation and Cleanliness in Sick V. G. IND. G. M. G. — M. IMP. G. Ameliorating Appliances G. Working well with Medical Men V. G. V. G. V G. V. G. Dressings and other Appliances under Medical direction V. G. V. G. V. G. V. G. Management of Convalescents M. — IMP. — Observations on the Sick G. G. G. G. V. G. Very Good. G. Good. M. Middling. IMP. Improved. IND. Indifferent. B. Bad. No opportunity of judging on that visit. GENERAL REMARKS. JUNE. There have been 35 Patients on the Book for 22 District this month, 19 Medical and 16 Surgical cases. The Nurse being a good Surgical Nurse, her cases in this line are increasing. Her District lies in a low dirty part of the town, so that she has more difficulty in keeping her clothes, &c., clean than some of the others. July. 93 Date when taken on. Date. Name. Residence. Abscess. Asthma. Bronchitis Cancer. Child Birth. Consumption, and tendency to Consumption. Disease of the Heart. Dropsy. Erysipelas. General Debility. Inflammation. Paralysis. Recovery from Fever. Rheumatism and Burns. Ulcers and Wounds. Sundries. No. of Family. Parish Reliefc or how Supported. Times Visited. Relief Granted in Kind and Quantity. Remark . FORM OF REGISTER KEPT IN FOOLSCAP SIZE, BY EACH NURSE, OF THE CASES OF SICKNESS UNDER HER CARE. 94 F0R.M SENT WITH NURSE, WHEN GOING TO NURSE PRIVATE PATIENTS. Liverpool Training School and Home for Nurses , Dover Street. Date, 186 This day the Nurse has been sent on the recommendation of to nurse in the case of Signed, Lady Superintendent. The rate of remuneration for attendance of the Nurses is fixed at Jl Is. per week ; travelling expenses and washing to be paid by the family em- ploying the Nurse. In infectious cases 15/. to be paid, to provide temporary Lodgings for the Nurse, as she cannot be allowed to return to the Home immediately. After four weeks, if it be wished to retain the Nurse longer, a communi- cation to be made, either by letter or personally, to the Lady Superintendent. It is particularly requested, — 1 . That the Nurse should in no case be informed of the sum paid to the Institution for her services. 2. That no gratuity be offered to the Nurse, the receipt of such payments being strictly forbidden by the rules, as they have always been found to be most prejudicial to the discipline and good conduct of Nurses. Abookorother article of small value, as a token of remembrance of a patient, may, however, be accepted by a Nurse without infringing this rule. Patients, or their friends, who wish to express gratitude for benefits received, can do so most effectually by donations towards a fund for the reward of good service amongst the Nurses, and for their support in sickness and old age. It is also hoped that by contributions to the general funds of the charity they will assist in enabling it to afford the advantage of gratuitous nursing to the poor, which is one of the objects for which it was established. 3. That no wine or spirits be given to the Nurse, unless at the request of the Medical Attendant. 4. That the Nurse be allowed to rest every third night, if possible, especially in a long illness ; and that when her services are needed for several consecutive nights, she be allowed at least six hours rest in the day out of the sick-room. 5. That when the Nurse’s services are no longer required, this sheet of paper may be returned, sealed up, with a candid statement, on the fly-leaf, of her conduct and efficiency, either from one of the family or the Medical Attendant; together with information of the amount intended to be paid, and whether it is enclosed, or will be paid at the Institution. Date, 186 The services of the Nurse being no longer required, she is this day set at liberty to return home, and the sum of £ being the remuneration for her attendance, is enclosed. CONDUCT AND EFFICIENCY, OR OTHER REMARKS. 95 F. MEMORANDUM WHICH IN SEVERAL CASES WAS SUBMITTED TO LADIES WHEN IT WAS PROPOSED THAT THEY SHOULD UNDERTAKE A NURSING DISTRICT. NURSING. The introduction of trained Nurses into the houses of the sick poor is calculated not only to heal the sick and prevent a great deal of needless misery, but also to promote cleanliness and ventilation in their dwellings, and to prevent as well as cure. Most people have doubtless experienced, in their efforts to make the poor sharers in their prosperity, how difficult it is to avoid doing harm, and in this respect this work will be fouud peculiarly satisfactory: the objects of the nurses’ care come generally recommended, either by visitors from whom they expect no physical relief (Clergymen, Scripture Readers, Town Missionaries,) or by the Parish and Dispensary Doctors, whom they cannot deceive; the call for relief (sickness) is one ascertainable, and in most cases not permanent; help in such cases is not felt a degradation or humiliation, any more than a present of grapes in sick- ness, from an equal who might happen to have them when we had not, would be an offence; sickness seems, to both giver and receiver, a reminder of their common humanity, and to give a right to mutual help. When the sickness and call for help ceases, so naturally does the help. There is not the otherwise frequent difficulty of knowing when to stop, and fear of making people careless and dependent. The work has also the advantage of bringing naturally, and without forcing, rich and poor into a communi- cation beneficial to both, where civilisation, by subdivision of duties aud labours, has destroyed the connection which formerly existed. If each prosperous family, in a large town, who may be fortunate enough to have some efficient ladies among their treasures, would undertake the super- intendence and supply of medical comforts in a district, the good that might be done is incalculable. I am convinced that after trial they would admit that no expenditure of time or money gave them more satisfaction ; they would get the same sort of interest in their district that a benevolent landlord has in the poor on his estate. It is difficult to limit the extent of influence for good which women of refinement and kindliness diffuse in such a position of Motherhood. If these remarks savour of enthusiasm, it is not the enthusiasm of imagination, but of experience of a work, the scope of which was unsuspected when it was begun. G-. LADIES’ SUPERINTENDENT REPORTS. Every quarter the Ladies Superintendent of Districts draw up Reports of 96 the working of their districts, for the information of the Committee, and for mutual information, and meet to discuss the wants or difficulties which may have arisen. The following extracts are selected as either explanatory of the work, or suggestive of improvements. The suggestions thus conveyed have already proved very useful. September, 1862. It is always desirable that men who have families should get to work as soon as possible. To such, when recommended by the Medical man, or seen to be desirable by the Nurse or visiting Superintendent, more strengthening food has been given in mutton chops and porter, and the Nurse has received instructions, where necessary, to cook the chops herself, and satisfy herself that the patient has the benefit of them. This treat- ment has proved successful in several cases which otherwise might have lingered a long time. December, 1862. Since the beginning of the quarter we have adopted the plan of limiting the time for which a patient can be recommended to one month. We find that we have had to make a large number of renewals, but think, never- theless, that the time is sufficiently long, as in many instances it is rather a good thing than not that a gentle reminder should be given, by the renewal, that the assistance is not to be indefinitely claimed as a right. December, 1862. The Nurse has given great satisfaction to her patients, and also to the ladies; she has frequently been complimented on the change she has effected in the cleanliness of the sick room, one gentleman remarking “ that she had accomplished more in one week than he had been able to do in three years;” she has a quiet firmness which gains its ends. December, 1862. Those in my district are often very destitute, and all the bad cases 1 relieve every day; but I have never given any wine; I have found an ample supply of milk has done quite well in most cases. Of those we have lost, ten were quite hopeless when they were found. September, 1862. There is sometimes a difficulty in taking the names off the nurse’s book in cases of general debility, recovery from fever, &c. Might it not be a good plan to put the names on for a certain time, and then renew the term of relief? One good effected by the Nurses is the rousing of the sick poor to active means for their recovery. They often sink * into a * “ Most true. Disease among the poor is generally the last stage of the process. It is the point at which the patient’s friends begin to interfere, the patient having long ceased to think for liimself. It is therefore the more necessary for the Nurse to rouse him (the patient) to active means for liis recovery." — Florence Nightingale. 97 helpless, despondent state, partly from a sense of inability to get the necessary food or pay the doctor, and go on for months, not even using the means they have, or making any exertion, when a few weeks of more active measures would effectually set them up, and enable them to go to work again. Many cases linger through long months if no friendly visitor like the Nurse goes to give them heart and help. Several cases of this description have occurred in this district. 1863. Much advantage has been found from lending sheets, blankets, and linen to the patients, which are changed twice or thrice a week, as the case may require. A lady has kindly undertaken to defray the expense of supplying and washing those articles. The lending of pillows and spitting-cups has also been found beneficial ; and in cases of recovery from fever, where white-washing was required, we have sometimes lent brushes and supplied lime. The water-beds have been of great service in many cases of severe rheumatism and consumption. The Charity has also been of use in timely calling the attention of the Board of Health to fever cases, where whole families were infected, and the safety of the surrounding neighbourhood endangered.* The following reports were received in two different years from the same lady ; and afford an example of the difference in the results obtained and reports sent in, according to the efficiency or inefficiency of the Nurse. Wherever it is found that there is an absence or great scarcity of surgical cases, or those requiring actual nursing rather than relief, on the list, this fact alone should almost suffice to cause the dismissal of the Nurse. If her heart is in her work, she will find no lack of such cases. The para- graphs in italics contain the remarks of the Secretary: — December, 1863. I have but few remarks to make respecting this district, indeed I wish 1 had more to say, for I fear we are getting into a routine which results mainly in dispensing chops, beef-tea, sago, rice, tea, and sugar. Almost all our patients come to us either in the last stages of consumption or age; of the latter, many are no doubt more suitable for the workhouse, and would be better off there if they could be persuaded to leave their miserable dwellings. We have scarcely any cases which promise even partial cure, though some few of our patients may rally sufficiently to be put off our books for a time, when warm weather comes. There is the satisfaction of feeling that we no doubt alleviate a considerable amount of misery ; but I think it right to state distinctly, that in this district I do not believe the * “ The attention of Ladies Superintendents of districts, and of the friends of the cause elsewhere, should he called to this.”- — Florence Nightingale. Or 98 right class of cases come into our hands. I am completely at a loss to account for this. The Secretary would remark on this report, that the complaint made is one the cause of which is generally removed as the nature of the work becomes known. In the district in question it has continued longer than usual, because the heart of the Nurse is not in her work, and unless a decided change takes place in this respect, she ivill be dismissed as soon as a more efficient one can be supplied. 1864. The following report is most satisfactory, as coming from a Lady Superin- tendent who, when she first began with a kind and good but not thoroughly trained Nurse, reported in the plainest terms that she was doing more the work of a charitable Society than that of Nursing, at an expense dispropor- tioned to results. Now, with a trained and efficient Nurse , she is meeting a greatly increased expenditure, with satisfaction to herself and great benefit to her District, and reports : — 31st December, 1864. Some of the most satisfactory cases have been those recovering from fever, the nourishment and comforts supplied having effected a good many real cures; one or two cases of alleviation have been very encouraging. One woman, who is dying of cancer, has expressed much gratitude for the relief that has been given her; another, who is suffering from iuternal illness, has been enabled to sit up for the first time for two years, in consequence of having been provided with an air-cushion ; others have obtained much benefit from supplies of flannel; and many have derived great comfort from the Nurse’s assistance, who, wherever it has been necessary, has applied poultices, bandages, &e., washed the patients, made their beds, &c. Many of those, under the head of partially cured, will probably be on again before long, and continue on and off most of the winter. The latter part of this year has been very satisfactory. There have been more cases of real nursing, not simply relieving, than we have ever yet had, which is prin- cipally, I think, to be attributed to the efficiency and earnestness of the Nurse, who seems most anxious to give every assistance in her power to those who require nursing ; she is in all respects very satisfactory. February, 1865. The working of this district has on the whole been very satisfactory. As the objects of the Institution become better understood, a larger proportion of suitable cases is received — by suitable cases meaning such as require the personal services of the Nurse. The difficulty of dealing with the other class of chronic and hopeless cases, and of pre- venting our Charity being made merely a supplement to the workhouse, still, however, exists. It becomes daily more evident how much the services of the Nurse are appreciated by the poor; she is constantly 99 sought for in cases of sudden need; her advice and instructions are readily followed, and she is everywhere cordially received. To her Ladies Superintendent the Nurse has given great satisfaction; she has been unwearied in her exertions, never grudging time nor trouble on behalf of her patients, and in every way she has been ready to assist the suffering and distressed with whom she has been brought into contact. The poor know so little how help is to be obtained in time of need, that merely as a medium of communication with the medical men and the Parish Authorities, the Nurse’s services are very valuable. The Ladies Superintendent have in several instances called attention to the state of courts and houses where sickness has been prevalent, and their representa- tions have always been well received; where urgently required, the Ladies Superintendent have themselves provided the means for purifying and cleaning dwellings, bedding, &c. Two patients have been sent to Southport; several have been provided with means to go to the country; others have been supplied with clothing to fit them for respectable employment ; and the necessary expenses of getting children into the Blue Coat School have been defrayed * The Ladies Superintendent have found the Clergy, the Doctors, and the Authorities of the Board of Health most willing to co-operate in the working of the Charity. 31st December, 1864. The majority of the cases we have treated arise from consumption and general debility; of tbe former two-thirds die, and of the latter three-fourths recover. In the former, the patients persevere in their daily labour until strength fails, and then, after a few weeks, they die; the utmost we can do is to contribute some addition to their diet and clothing in the way of physical comfort; but the Ladies of this district believe that the numerous expressions of the grateful sense of sympathy are heartfelt by the dying patients, and the visits of the Nurse diffuse a sense of moral comfort in homes otherwise cheerless, which fully repays the cost of their district. The cases of debility arise from insufficient food and neglect; these are soon restored to a state of comparative health by a little nourishment. February, 1865. There has been a great improvement in this district this year, and in the Nurse, owing I believe to regular visiting by a relative, and also to Miss Hunt’s visits. The Nurse, who always understood the professional part of her work, but took little interest in it, has become much more interested in her patients, and more suggestive. She has sent children that were run- ning to waste in the streets to school; she has found out and suggested cases * “ This alone, if this were the only benefit, shows the wisdom and efficiency of the organization by which the assistance of local authorities and charitable volunteers is incorpoi’ated in the system of the charity, and their willing co-operation^ secured.” -Florence Nightingale. 100 where the provision of flannel or other necessaries to children of sick parents checked incipient disease, and in one case she has at least given us some hope of saving a whole family from worse than death. A woman with three children, was deserted by her husband, and had fallen into the most wretched poverty, and, we fear, vice. She was ill ; one child was sinking into a decline, but now is wonderfully better, and another, running about the streets, is at school; the woman has been removed from a house in which the Visitors and Nurse one day found all the other inmates, including apparently even the children, riotously drunk; being provided with decent clothes, the woman is able to seek work, and, being a good workwoman, at least the chance is given her of profiting by her past misery and retrieving herself. I may just add, that it occurred to me a short time ago that it would be a good plan to allow some of our poor patients dinners at the Workmen’s Dining Rooms for a little time after their return to the usual occupation. The Superintendents of the Dining Rooms are prepared to supply dinners, on receiving a written request to that effect from the Lady Superintendent of a district, and on the produc- tion by the applicant of a note in the same handwriting. * * “ It is needless for me to testify wliat incalculable good is effected by this in pre- venting relapses, too often incurred by returning too soon to indispensable work.” — Flobence Nightingale. 101 H. ADDRESS TO THE NURSES ON THE NEW YEAR, 1864, BY A MEMBER OF THE COMMITTEE. For the first time the New Year finds our family gathered together in a Home of our own, under the kind and motherly care of its valued head. We hope that you have found your Home cheerful, comfortable, and convenient. We have spared no trouble to make it so, for we have felt that your work, if thoroughly and heartily done, must often be anxious and trying, and we are desirous that when it is over, you should return to a cheerful, comfortable Home. Moreover, we require from you, that whether you work in the Hospital, in private families, or among the poor, you should be models of cleanliness and neatness; that when you go into the houses of the poor to nurse them — and all of you are bound to go there if sent, and I trust will ever consider it the noblest and best part of your work — when you go there, we hope that you will enforce cleanliness, ven- tilation, and all those rules of health the observance of which might make their homes so different from what they are ; might not only materially promote health, but often prevent the poor man from being driven to the public-house, as a refuge from a place more fitted for a pigstye than a human dwelling. By giving you every facility for order and cleanliness here, we trust to strengthen your love for them. In the Lady Superintendent you have one in whom you will ever find a most kind guardian and friend, if you seek to do your duty. She left a position in which she had the promise of all which would seem most likely to gratify her tastes and feelings, and friends who were most anxious to keep her ; she left it and them because she felt that here she was likely to be even more useful, and that therefore here her Lord and Master willed that she should be. If you feel, as she is most anxious you should, that you are members of a family, you will be ever desirous that the character of that family should be as high as possible, that it should be a credit to belong to it, that no act or word of yours should bring shame upon it, but on the contrary each of you will strive, by the gentleness, quietness, modesty, and truthfulness of your conduct, by constantly increasing proficiency in your profession, and by the thoroughness and conscientiousness of your work, continually to raise the character of the School, and of all belonging to it, higher and higher. The character and position of Sick Nurses has not been always what it should be, or might be, because neither the Nurses themselves nor others considered how much depended on, how much might be done by, the Nurse. Miss Nightingale has shown the world its error, it remains with the Nurses themselves to do the rest. I hope we shall all work he tily to do 102 our part. But here I must give you one caution — we must beware lest a proper respect for our profession should degenerate into a cloak for a wretched pride. There is no pride so mean, so contemptible, as that which makes a person above her work. There is nothing really mean, or degrad- ing, or unclean, which our duty calls us to do ; but if ever pride leads us to leave part of our duty or work undone, or ill done, then indeed we are degraded. But, after all, gratitude for what has been done, or the care and affection of your Lady Superintendent, or pride in and fondness for your profession and your work, may help you to do well, but they are motives which, unaided, cannot make you what you ought to be as Nurses — cannot make your work all it ought to be. There is work, there will be times, for which all motives are too weak but one ; you can only do your work as it ought to be done, if you do it as servants, as brethren of our Lord Jesus Christ. His eye will be ever upon you, His hand ever near you ; His example should be ever before you. If you are merely hirelings, working for man’s wages or man’s praise, there will be much of your work that will be distasteful, wearisome, heartless; if all your work is done as in His sight, and for His sake and God’s, how different will all appear! Your work lies, as much of His did, among the sick, and suffering, and dying ; if you do it as feeling yourselves fellow workers with Him, it is impossible to say — you will never know, no one can ever know — how much good you may accomplish. Your patients may be irritable and ungrateful, but if they see that, patiently, and constantly, and when no master’s eye but God’s sees you, you go quietly on with your duty, neither discouraged nor weary in well doing, you may be sure you are sowing good seed, which will not be lost, for Almighty power is working with you. The long hours of sickness, the pain and the danger, often cause things to be remembered and thought of, which in the hurry of life and health would be forgotten. Not only the life of your patients may depend on your faithfulness to duty, but by it you may also influence for good their virtue and happiness, here and hereafter. Remember, when wearied and perhaps discouraged by ingratitude, it is not alone the poor, wretched, irritable, and perhaps it may seem to you worthless, sufferer you are serving — “ Inasmuch as ye did it unto the least of these, ye did it unto Me” — by his suffering which you can alleviate, the object of your care becomes to you the representative of Him who died for you. Think of this, and yo r task will become a grateful one, your labour one of love. The choice is before you. Will you be mere hirelings, or will you be respected members of a happy family on earth, and a still happier family hereafter? 103 MAP OF DISTRICTS, AS PRINTED ON THE BACK OF FORM OF RECOMMENDATION. (]0