The Evolution of the Trained Nurse

At the beginning of the Middle Ages sickness and suffering were in vogue, along with hair shirts, beds of broken stones, fasting, and flagellations, as among the recognized means of attaining eternal salvation. Visions of heaven kept the saints to their work till the right of sick people to be cared for was incidentally established. Such beautiful examples as St. Elizabeth of Hungary, unshrinking and tender, confirmed the value of holy deeds in place of holy meditations; then the crusades, filling Europe with poverty-stricken widows and orphans, gave rise to the Order of Beguines, lay sisters bound by no permanent vows, but simply pledged for the time being to serve the ailing and needy. This order was quickly rivaled by the semi-monastic Franciscans and Dominicans, till the rendering of bodily as well as spiritual aid had become an acknowledged function of the church, the gain to the nurse's soul being always coordinate with the amount of unpleasantness endured. Not satisfied with bathing his lepers, St. Francis sat with them at meat, eating out of their dishes; St. Hedwig washed the feet of those smitten with scurvy. Instinctively these great reformers felt the necessity of breaking down all reservations, all repulsions, in caring for anything so essentially odious as a diseased human body, and heaven as a perfectly sure reward would induce people to undergo the most indescribable disgusts. However different its expression, the wisdom of the world never materially changes, and our hospitals today feel compelled to put their pupils through a severe breaking in, to insure unquestioning acceptance of any horror with which the profession may legitimately confront them; but since nowadays it is not granted to every one to be happily certain of Paradise, some tangible earthly advantage may well be guaranteed the woman who undertakes a calling so taxing to mind and body.

In early times, English hospitals, like those of the Continent, were in the hands of religious orders, until the influence of the Reformation made them over to the mercies of convalescent patients or degraded nurses recruited from a class of women not good enough for ordinary domestic service. In 1546 St. Bartholomew's, previously a royal foundation, was given in charge by Henry VIII. to the Aldermen, Mayor, and Commonalty of the City of London, the new governing body binding themselves to establish upon the staff in three months "a matron and twelve women under her." From that time on, nursing in England was at a low ebb; arduous and ill paid, neither religious nor professional, it only attracted people who were quite unfit for any other occupation, often drunken and brutal, almost invariably inefficient. Particularly feeble paupers were considerately made night nurses, because the pittance so earned would enable them to buy better food than the ordinary workhouse fare.

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Hospitals of course were only used by the poorest people; for the ailing rich there was absolutely no provision, and illness of mind or body was attended by the most insufferable discomfort. In 1662 poor hysterical Mary Verney's doctor made the impressive diagnosis that "Zeletropia is gott into her perecranium," and she soon became a full-fledged maniac, under the ministrations of a devoted but highly incompetent husband doing a bewildered man's best, two "mayds" of more than doubtful humanity, and a family of relations-in-law naturally and heartily tired of having about the house an invalid whose "yumer" yielded neither to "Ephsome Waters," bleeding, nor vigorous remonstrance. With so low a standard of general comfort it was inevitable that the dregs of the community should have to put up with unendurable neglect and ill treatment.

In France, St. Vincent de Paul's hospital of St. Lazarre and the Hotel Dieu in Paris, both of which were still in the hands of the church, gave a more humane care to the sick than was to be found at the same time in England; but purely religious nursing which derived its impulse from a spiritual craving was peculiarly subject to limitations, and having reached a certain plane of excellence, showed a tendency to remain stationary, not however till the inherent claim of human suffering had been established for all time.

The forward movement was everywhere so gradual that in 1770, when John Howard began to investigate hospitals as an incidental feature of his work in prisons, he found almost no provision for sick criminals; where such existed it was frankly inadequate, as in the Castle at York, where one small room served as infirmary, so that "when persons of one sex happened to be in this, those of the other were excluded." On the Continent, except for characteristic cleanliness in Flanders, conditions showed little progress. Even in the famous hospice of St. Jean de Jerusalem at Malta, with its sumptuous table service of silver, Howard tells that patients were tended "by the most ragged, dirty, unfeeling, and inhuman wretches I ever saw. I once found nine or ten of them highly entertained by a delirious and dying person." These attendants were chosen from among debtors and criminals, and as there were only twenty-two of them for five hundred patients (against forty for twenty-six horses and twenty-six mules), they could hardly have been expected to take their employment very seriously.

The quickened sympathy of which the French Revolution was either the cause or the effect suggested still greater obligations to the miserable, while the Napoleonic Wars, filling the hospitals of Europe with ill cared for, mutilated young men, not despised paupers, but the flower of the community, effectively aroused the public conscience. Experiments were made in various directions. In 1819 the French Bureau of Administration conceived the happy idea of bringing up all soldiers' orphans to be nurses. The training was of the most rudimentary; and as wages, even so late as 1835, ranged from eight to twelve francs a month, it is not surprising this attempt was unsuccessful.

In 1825 organized training was discussed by a number of English publications (Blackwood's, the Quarterly, the London Medical Gazette, and Southey's Colloquies), and in 1829 Southey himself was interested in a plan "for educating a better class of persons as nurses for the poor. Mr. Hornby and Adam Hodgson of Liverpool hired a house, engaged a matron, received a number of inmates and sent out some few as nurses, but"—the paradoxical humor of this sounds like a bit of Mr. Bernard Shaw's delicious Socialism for Millionaires—these women "proved so valuable that the upper classes wanted to employ them as monthly nurses, an entire perversion of the whole scheme, which led to its speedy abandonment." Rather hard this on the unhappy rich, whose calamities at the hands of ignorant midwives differed in degree only, not in kind, from those of the poor in our city slums today. Little indeed could be hoped from nurses when so late as 1852 the professor of medicine in a leading American college wrote over his own name concerning the symptoms of puerperal fever: "I prefer attributing them to accident or Providence, of which I can form some conception, rather than to a contagion of which I cannot form any clear idea." This, of course, was not the prevailing idea, and Dr. Oliver Wendell Holmes's spirited crusade against dirty obstetrics only focused the observations of his predecessors.

The universal dissatisfaction of which Southey's attempt was an expression led in Germany to the foundation of Pastor Fliedner's far-reaching and admirable "Kaiserwerth System," roughly speaking, an order of nursing Protestant Deaconesses, which at once became the inspiration of many similar orders in England.

Then with the Crimean war came the crystallizing of a need and its remedy by Florence Nightingale's triumphant reform of field hospitals, which up to her time had improved but little since they were first established by Queen Isabella at the siege of Granada. Responding to the influence of one quiet Englishwoman, hospitals both civil and military became abodes of peace and comfort, where decency and humanity reigned in place of horror. Then by degrees the poor were seen to have advantages of which the rich would gladly avail themselves. Greatly doubting if a hireling's exact knowledge could ever be the equivalent of mother's love or filial devotion, private families tried the trained nurse, cautiously, apologetically then with enthusiasm as a relief from actual labor and unbearable responsibility, as a godsend at that trying moment when the doctor goes on to his next case, leaving hapless amateurs to meet emergencies unaided. Whatever variations in detail may have followed, whatever modifications have been introduced, the genius of Florence Nightingale, in 1853, said the last possible word on all essentials of nursing. Her inspired wisdom and untarnished nobility of purpose set forever the ideal standard both practical and ethical. Her opinion has been asked in organizing the most modern hospitals in America as well as in England; her Notes on Nursing still rank higher than the very newest nursing literature. Care of the sick at once became a profession for normally intelligent women with their livings to make, and soon the demand for such women at least equaled the supply. St. Elizabeth had become an article of commerce, a luxury the market afforded every able purse.

In the United States, prior to 1873, trained nurses had no existence. It is true that there are Revolutionary records of women in military hospitals; the Allison Papers give a list of nurses drawing pay, and one "Phillis Acheson, nurse," is mentioned among the wounded after a battle, probably Paoli, but these helpers were evidently of a low order, judging by their earnings. In the Journal of Congress for October 9, 1776, there is a resolution "that the wages of nurses be augmented to a dollar a week." On April 7, 1777, provision was made for a matron with nurses under her, one for every ten sick or wounded, at a remuneration of twenty-four ninetieths of a dollar and one ration daily, which was not pampering the nurse, as stablers received one dollar a day beside the ration.

During the civil war nursing was left to Sisters of Charity, convalescent patients, and untrained women, with a sprinkling of poets and philosophers; how little importance was attached to this branch of hospital service is shown by the scant allusions to it in official reports. The Surgical and Medical History of the War of the Rebellion states that "a good deal of trouble was sometimes experienced in getting satisfactory ward attendants. … Hired civilians were undesirable, as they often left at a moment's notice. ... Female nurses, often Sisters of Charity, sometimes volunteers, rendered their best service in connection with extra diets and the linen room and laundry." In many reports of the Sanitary Commission, absolutely no mention is made of nurses; one committee casually observes that they were "inexperienced," and speaks of "women and soldiers romping in a ward." Ten years later the Council of Geneva brought relief to soldiers in the field the world over by establishing the Red Cross Society. Trained nurses were for the first time officially engaged by the United States government during the Spanish war, and the steps since taken to put army nursing on a better footing will be invaluable in the future, but cannot be given space here.

Of course sick people were always tended after a fashion, but the real movement in this country began when the Bellevue Hospital opened a training school, in May, 1873. What such a hospital was then like may be judged by the fact that when a number of New York women met to see what could be done about the Bellevue, they were solemnly warned against engaging a high grade superintendent, because "a pauper hospital was no place for a refined, intelligent woman." Such a person, however, was found, the first of that series of admirable Englishwomen, under whose teachings American hospitals have been fitted to train head nurses of their own. In the autumn of 1873 the Massachusetts General Hospital organized a regular system of instruction, since when, throughout the country, schools have sprung up in connection with hospitals, turning out every year their quota of graduates, women whose preparation and subsequent conduct are of vital interest to society at large.

Although nursing is still the practice of many religious and semi-religious orders both Catholic and Protestant, this paper is concerned only with the attitude of the American nurse as a wage earner, and with the almost chaotic conditions at present governing her relation to the public. There is perhaps no class of people about whom so much nonsense is talked as nurses. They are either rapturously eulogized as noble women leading lives of complete self-sacrifice, or disliked as uppish minxes, giving more trouble in the house than they are worth to the patient. In spite of the objections urged against them, the demand for their services throughout the English-speaking world has induced young women, fit or unfit, to swarm into hospitals, to be equipped well or ill as the case may be. Meantime modern bacteriologists have revolutionized the care of contagious diseases, and aseptic surgery has introduced a nicety of treatment hitherto undreamt of; consequently the increased demand upon a nurse's actual deftness of hand and intelligent comprehension calls for a much higher and finer training than in the good old days of unclean surgery and unisolated infections. And yet, it is not infrequent to hear a wish for the old-fashioned upper servant who used to come in and help in time of illness. There lingers a feeling that a common school education with six months' or a year's practical training should be enough for any woman who has a real gift for such work. Even among the doctors themselves, many of whom have labored disinterestedly to improve the quality of nursing, men can still be found to oppose a wider theoretical instruction on the whimsical ground that it would inevitably make women prone to interfere with the treatment. It would be interesting to learn from what experience these gentlemen argue that a tendency to meddle is a product of true knowledge. Surely the old-fashioned nurse had views of her own, and by all accounts imposed them on her patients. In 1647, Sir Ralph Verney wrote to his wife, "Give the child noe Physic but such as the old women and midwives with the doctor's approbation doe prescribe, for assure yourself they by experience know better than any phisition how to treat such infants." Sairey Gamp was no slavish adherent to doctors' orders, and Sister Dora, who united partial instruction to much undisciplined ability and self-confidence, gives a spirited story of successfully combating a surgeon's wish to amputate a leg, the whole discussion taking place in the presence of the patient. If the nurses of today should even be taught to take a blood count they could hardly exceed that piece of insubordination.

Perhaps it is most essential of all, apart from mastering the handicraft of her profession and having an intelligent understanding of symptoms, that a nurse should know how to behave. In the wards she is subject to constant scrutiny, and if her conduct is not discreet there are plenty of people with will and authority to bring her to order; but in private houses we all know how much she is left to her own devices, and how infinite are her opportunities of annoyance. Pages might be filled with the enormities nurses have been known to commit, the property they have destroyed, and worst of all the servants they have caused to give notice, not to speak of family secrets divulged to the shocked but not always unreceptive ears of employers.

The significant fact about all this is that these faults, so apparent to the public, are thoroughly recognized by every good and able woman in the profession, each of whom is now working indefatigably to introduce such system and organization as will minimize the danger from nurses morally, mentally, or physically unfit to hold positions of responsibility.

Naturally there is no such thing as a school for saints; they are born, not made, and scarcely born often enough to justify reliance on a steady supply of them. No system of education will guarantee perfection, but a dull, inefficient, or unprincipled student is apt to show these defects in the course of three long and rigorous years, while excitement, ambition, and the spur of novelty will tide many a woman over a twelve-month or two rather creditably. Moreover, with her endless occupations, the head of a training school in a short time can hardly form a just opinion of a pupil's capacity; and, above all, the long training is of greatest value in the matter of drill. In a month or an hour a woman can be told how to be orderly, quick, and subordinate, but three years are none too long to acquire these qualities so that they become absolutely instinctive. Florence Nightingale significantly says that the only class of men endurable as nurses are soldiers and sailors. No one can imagine that nursing is a kind of secondary vocation with Jack and Tommy; this simply means that they are used to obey unquestioningly, broken in to control minds and bodies in a way born only of long-established routine.

The objection often made to a more elaborate and expensive training is that many patients cannot afford a highly finished nurse, although such a woman's services are not only a delightful luxury, but frequently may be a means of saving life. This objection is sound, and applies with equal force and logic to sweetbreads, champagne, Palm Beach, saddle horses, and sea voyages, all of which are permitted to exist, though undoubtedly beyond the reach of many invalids. While the owner of a palace hotel might feel prompted to offer its comforts to impecunious sufferers at the rate of cheap summer board, few people would consider the limitation of their own means (still less the slenderness of any one else's) as a reason for limiting the perfection of hotel appointments, or dream of claiming the use of them as a right; yet it is the commonest thing in the world for a nurse to be thought a heartless mercenary for making a higher charge than is convenient for a patient to pay. Here again the nurse suffers from her saintly ancestry; a beautiful halo, a ready-made nimbus of self-sacrifice is offered when she may be only a hard-working woman with family depending on her, and her own future to provide for.

Nurses' organizations, where they are at all known to the public, are looked on with disfavor as a particularly obnoxious kind of trade union, or a trust more intrinsically depraved than those which artificially raise the price of bread and meat; as a bold attempt to put an outrageous value upon all services rendered to the sick, whereas exactly the opposite is the case. The need for partly trained, inexpensive nurses cannot be more keenly felt by the public than it is within the profession, and no one can study the discussions of these organizations without realizing that they aim at the best interest of patients, no less than of nurses, who, at every turn, are held to the duty of looking after the poor and people with small means. Indeed, the enthusiasm with which women have gone into district nursing in Boston, Philadelphia, Chicago, Buffalo, Baltimore, and other cities, shows no tendency to disregard the claims of the needy, while the encouragement of a recognized class of "experienced," as distinguished from "trained," nurses is quite as much a part of the programme as the furtherance of their own interests. Fundamentally, the object of the leaders is that the whole relation of employer and employee should rest on a sounder basis, infinitely more satisfactory to both than the present loose, ill defined position, which permits many a woman unqualified by character or training to assume the full responsibilities and make the full charge of a reliable and well-equipped nurse. To this end two separate societies have been formed, the Associated Alumnae of Trained Nurses, having in 1901 a membership of four thousand, and the Society of Superintendents of Training Schools for Nurses in the United States and Canada, which has one hundred and twenty-four members.

At the conventions and annual meetings of these societies women come together from all parts of the country, telling of their experiments, bringing up new theories for criticism and suggestion, so that, profiting by the history of past mistakes or successes, they may strengthen and encourage one another to face the problems cropping up on every hand. What they have accomplished is significant enough. Many hospitals have already established a three years' course, which permits a longer probation, a shorter day's work, and a better mastery of the housekeeping as well as of the scientific branches of their work. The future platform was laid out in a resolution passed by the International Congress of Nurses at Buffalo in 1901: —

"Whereas, the nursing of the sick is a matter closely affecting all classes of the community in every land;

"Whereas, to be efficient workers Nurses should be carefully educated in the important duties which are now allotted to them;

"Whereas, at the present time there is no generally accepted term or standard of training, nor system, nor examination for nurses in any country;

"Whereas, there is no method—except in South Africa—of enabling the public to discriminate easily between Trained Nurses and any ignorant persons who assume that title;

"And Whereas, this is a fruitful source of injury to the sick and of discredit to the Nursing Profession;

"It is the opinion of the International Congress of Nurses, in General Meeting assembled, that —

"It is the duty of the Nursing Profession of every country to work for suitable legislative enactments regulating the education of Nurses, and protecting the interests of the public by securing the State Examinations and State Registration with the proper penalties for enforcing the same."

Now the need of a state examination for nurses is somewhat the same that has led to its adoption by physicians and chemists. At present every two-penny hospital is free to award presentable looking diplomas, and without a most unlikely amount of investigation employers have scant means of knowing how much or how little those diplomas are worth.

The writer examined one training school in which a sweet-mannered superintendent showed an operating room like a jewel box, a marvel of sparkling glass and nickel plate, a dispensary leaving nothing to criticise, a batch of immaculate pupil nurses, rows and rows of the neatest cots imaginable, — a little close for the regulation number of cubic feet of air or the use of a screen, which did not really signify since in the whole place the only thing they did not show was a patient. One there was, in solitary grandeur at the end of a lonely ward, but an inquisitive visitor was politely kept at a distance, nor was opportunity given to look at the charts hanging decoratively over the empty beds. To the eye, the diploma from this hospital is impressive enough, but it hardly guarantees a comprehensive training.

At another establishment (not a hospital), by a ten weeks' lecture course, with perhaps a few visits to poor patients in their homes, women are qualified to take any "ordinary case."

In answer to the question as to what might constitute "ordinary," was it typhoid? the superintendent answered, "Yes, light typhoid." The inquiry as to what would happen if the light typhoid were so inconsiderate as to move out of its class and grow serious caused a moment's hesitation, but she said, "Oh, I suppose our training would enable you to keep the case."

Another school gives an obstetric training only, not as supplementary to any other course, but as the sum total of a nurse's education. I have seen a woman from this place endeavor to manage a serious fracture, much to the patient's detriment.

A properly conducted state examination would at once create a line of demarcation between partly trained caretakers or attendants and nurses thoroughly equipped in every branch of their profession. As a preliminary to going up to this examination every nurse would have to show a diploma from a recognized school, and this diploma would be a personal as well as a professional guarantee. The vague term "trained nurse" would acquire an exact significance, and nurses partly trained would be conveniently differentiated. Fully to benefit by this, both doctors and public would have to use self-control in not employing nurses indiscriminately. To this end each city should encourage the forming of central registries or directories governed by the strictest rules and managed by the nurses themselves, so that there should be no division of responsibility in case of either success or failure. Although many excellent registries are now run by private committees, nurses' clubs, and hospitals, there is apt to be a lack of cooperation which permits of various abuses. Consequently some of the best nurses register nowhere, and can only be had by sending to their homes or boarding houses. The disadvantage of this is that a woman is not directly responsible to any outside authority, and no record is kept as to whether she continues to give satisfaction, while the public fall into a dangerous way of picking up a nurse anywhere, with less inquiry about her antecedents than is customary in engaging a laundress or a kitchen maid. How unsafe this is was tragically shown in a recent murder trial, in which more than one mysterious death was laid at the door of a very popular woman, who had however been expelled from a well-known training school within one month of graduation "for cause." She was plausible, and made herself acceptable to patients and physicians, who too readily believed her own account of her dismissal.

The point of a really complete directory would be that no nurse would venture to disregard it, under penalty of rating herself as second-class. Patients wanting high grade nurses would always know where to find them, and people not able to afford or disliking them would be rather better off than they are now. The fear of a rise in prices is not well grounded; with such an abounding commodity as young women, supply and demand may be trusted to regulate that issue automatically, and, all things considered, the present tariff is by no means exorbitant. Of course no graduate fresh from the wards should make a full charge, but in view of the length of an average day's work, twenty or twenty-five dollars a week is not high pay for a seasoned nurse, while a good dressmaker coming to the house and sewing, not strenuously for forty-eight hours a week often earns twelve and a half dollars, a private nurse rarely has less than a hundred and twelve hours' weekly duty, with such responsibility and strain that she can never hope to work for fifty-two consecutive weeks, and to avoid speedy breakdown must take frequent rests between cases.

As to the dread that hospitals aim at too fine a training, is there not something rather fantastic in the idea of discouraging a set of people who really wish to know their business better? Few of us would be in opposition if servants were of their own accord to suggest a regular standard of proficiency, manners, and ethics before our houses should be entrusted to their care; but—the saints again—for such a simple matter as the charge of a dangerously ill person vocation is expected to go a good half-way, with shorter apprenticeship than is required of plumbers or carpenters.

If it were possible to sift the complaints, the absolutely just ones, made by long suffering households of the "fine lady of a nurse who felt above her work, couldn't so much as lift her finger to wash a spoon," the chances are that she would prove to be the product of an inferior training, sprung from an inferior class, and looking to her work for social promotion. The exactions of such women are often incredible, intolerable to their employers, and damaging to the reputation of the entire profession. Not long since, a nurse on going to a place found to her great embarrassment a man servant stationed outside the bedroom door. It turned out that he was engaged for her special service, because a former nurse could not get along without a footman to wait on her. No business relation should be so absurdly lax. A nurse may shirk at all points, and impose on an innocent family as in this instance, while thoughtless or selfish people may overwork a plucky woman in ways unknown to any other profession.

Though a nurse's health is often her whole capital, till recently there has been a tacit feeling that she cannot do her duty without its being completely sacrificed. A decade ago it was said with resignation that a nurse's average working life was seven years; now it is being slowly recognized that she is entitled to the same consideration shop girls, typewriters, and day laborers. A few hospitals have now instituted an eight-hour day, which by the way means eight hours' hard physical work, all study lectures, and classes being additional. Twelve hours' actual duty is still the rule of many training schools, and even that is easier than the majority of private cases, especially as in a hospital when a nurse finally goes to her room she is free from responsibility or interruption.

In private cases there is absolutely no standard. A young nurse of my acquaintance was found early one morning unconscious on the entry floor; upon inquiry the doctor learned that from Monday morning till Thursday night she had been without sleep, or even enough time off to bathe and change her clothes. Of course she was extremely foolish to permit such a thing, on the patient's account as well as on her own, but it was her first private case, and feeling shy about obtruding personal wants in a time of general stress, she had relied on coffee and determination to pull her through. The stale joke, "Why! do you have to sleep? I thought you were trained!" unfortunately contains not a grain of exaggeration. I have gone to a house where after a day's nursing, and a night spent in sponging a typhoid patient, the nurse was still in charge at ten o'clock on the morning of the second day; no one had given her night lunch, breakfast, or even a cup of coffee. She had been on duty for twenty-six straight hours, working strenuously all the time; not a member of the household seemed equal to taking her place, or indeed dreamt of the necessity of doing so. Later it was rumored that this girl had become intemperate!

There are other complications even more in need of regulating, as when a young, attractive woman is purposely chosen to take care of a broken-down man, paying all the penalties of his pleasures. It is impossible to go into detail, but it is well known that patients of this kind are most objectionable even in private wards (curiously enough in general wards a uniform almost invariably commands respect), where the young nurses are under the powerful protection of the hospital. Except in desperate emergency, no amount of self-detachment can make it suitable for a girl to take these cases in private houses, yet they are often called upon to do so, merely because an older woman would naturally be less acceptable, and the young one, with her clientele to establish, seldom ventures to refuse or leave a patient.

No one is to blame for these conditions; they are the inevitable result of a complicated and unsettled trade relation, calling for wise, good-tempered adjustment, alike in the interest of employer and employee.

A nurse generally arrives in time of crisis, the patient is turned over to her, the family draw a long breath of comfort and relief, confide in her amazingly, question her about the doctor, the treatment, the patient's condition, her experience in similar cases, and unhesitatingly make her privy to their most personal affairs. Her spotless uniform and specialized ways present her as a being of a different race, free from all ordinary weaknesses of mind or body. This is very natural but demoralizing in the extreme, and a nurse needs a constitution of iron, along with the most exemplary discretion, not to become wrecked in health, and unduly inflated in her own esteem. Many a girl has lost equilibrium in a less perplexing household than that in which Sister Dora found herself obliged to steer a course between "the mad old lady who was fond of me, the relations who were jealous of me, and the footman who made love to me."

Beside possessing unblemished courage and professional skill, a nurse should be prepared to sweep, keep a room in order, arrange flowers, read aloud, write notes, and unobtrusively quiet such family jars as might affect her patient. She must understand what to do herself, what should be left to servants, remembering that this will vary in every household. She must be quick to see when her presence is necessary, and when she is in the way. She can allow herself no personal habits as to bed or board, no private existence or amusement, while at a case, and when the patient is safely through the exciting period of illness she has to settle down with good grace to the tedium of convalescence, never resenting the inevitable withdrawal of intimacy as the family resume a normal habit of life, and no longer make her the recipient of every thought and emotion.

The lack of any of these qualities will be bad for the patient, trying to the household. Considering the self-suppression such a life entails, the present rate of wages can hardly be regarded as too high. Nor do three years seem too long a preparation, particularly as during that time a girl has not only to learn her business, but to decide for which branch temperament and ability best fit her.

A perfectly conscientious woman of limited capacity may, without discredit, fail to comply with the rigorous conditions of the training school, in which case a good personal reference and the absence of a diploma at once relegate her to her proper place as a partly trained nurse entitled to lower remuneration, while many graduates will prove admirable at district work who lack adaptability for private nursing or executive power to cope with the many duties of a superintendent. Out of hundreds of graduates a small number only will be competent to direct a hospital and training school. Such places can only be filled by picked women, and few outsiders realize the moral, mental, and physical qualifications needed by a head nurse. She must see that her wards are spotless, that patients enjoy every possible care and indulgence, that her share of the elaborate machinery be administered with smoothness, generosity, and economy. In the intercourse between nurses and doctors she must be sufficiently woman of the world not to confuse unsuitable behavior with the natural familiarity of young people living at high pressure, more or less isolated from the outer world, and drawn to one another by a common occupation. Nurses' coquetting propensities are justly criticised. In this respect they are liable to be exactly as indiscreet as other girls, and because of the abundant temptation, the frequent meetings, the unchaperoned night watches, a young woman should be long enough in a hospital to lose her head a little and either find it, or prove permanently unworthy. "After all, why should not nurses marry doctors?" asked an exasperated head nurse. "I've no doubt they would infinitely prefer lawyers, but what other men do the poor things ever lay eyes on?" At bottom this attribute of celibacy is another saintly inheritance, and modern training is often held responsible for undue coquetry, in spite of the fact that history and literature are not without references to hooded nuns even having occasionally lapsed into distinctly human relations with patients. Jokes about the Beguines and wounded warriors are neither few nor far to seek; De Goncourt's spotless Soeur Philomele came perilously near a flirtation with the young surgeon in charge, and early in her career St. Theresa herself showed a suspiciously deep interest in the doings of a certain father confessor.

Besides keeping her pupils out of such mischief, a superintendent has also to protect them from their own recklessness in the matter of health; when she has done all this, incidentally showing proper attention to private patients and tiresome official visitors, she must find leisure and spirit for an infinite number of classes and lectures. In this she is mercifully helped by the many doctors who take time they can ill spare for gratuitous lecturing, but on the footing of regularly paid instruction such aid would be infinitely more valuable. It is unreasonable to expect a busy man to refuse an interesting and remunerative out of town consultation rather than put off an unimportant lecture, and while postponements play havoc with a closely scheduled course of study, a superintendent can hardly be so ungracious as to remonstrate. Recognizing the serious equipment needed for the heads of training schools, a leading university at the request of the Superintendents' Society has opened a course of Hospital Economics, available only for graduates of reliable schools, who have also served a term at private nursing. In this course, the cost of which is defrayed by the nurses themselves, the housekeeping side of the profession receives quite as much attention as anatomy, bacteriology, materia medica, and history; indeed, the pessimist who fears that colleges are educating women away from domesticity should take comfort in the effort of hospitals to create an intelligent and appreciative interest in household affairs.

If the task of a superintendent grows daily harder, much is being done to start probationers on a more rational basis than that of the old days when a girl who had lately turned faint at the mere sight of a ward would find herself called upon to administer medicines and use implements of whose very names and functions she had only the vaguest conception. Until very recently a wretched little probationer struggled on as best she could, confronting emergencies for which she knew herself unprepared, rightly frightened at every turn by her own ignorance. For example, a girl on night duty in a large ward had to meet unaided an outbreak of delirium tremens in a man fresh from a major operation. Too inexperienced to know whether the preceding symptoms were medical or surgical, she was caught unawares, and could only deal with the situation by the light of pluck and common sense, while a little more knowledge might have saved the patient from considerable danger and the ward from a most undesirable scare. Even now, in many hospitals, a nurse may have her whole experience in a medical ward with little or no instruction in that branch, all knowledge which would be of infinite use there coming just in time to confuse her mind as she goes on surgical duty; and this apparently stupid arrangement is often unavoidable where perfectly raw girls have so to be disposed in the wards as to give them their shifts of duty in proper sequence, without damage to the smoothness and efficiency of the whole machinery of the hospital. It is proposed to remedy this by giving all probationers six months' careful instruction, both practical and theoretical, before allowing them to enter the wards. The need for such preparatory instruction has been fully recognized, but it is still a moot point in the profession whether each hospital should provide a preliminary course for its own probationers under its own roof, or whether there should be special schools where the pupils of any hospital could have a thorough preparation for work in the wards. Such a school would have the undoubted economic advantage that one complete corps of teachers, one set of appliances, would suffice for the pupils of every hospital in a large city, and would also avoid the extra expense of their board and lodging during the first six months. On the other hand, a course in the hospital itself is enormously beneficial in familiarizing probationers with a strange new mode of life, in impressing each girl with the vital importance of her work, and at the same time affording the encouraging example of the absorption and trained cheerfulness of those already promoted to the wards. Thoroughly to imbue a neophyte with this atmosphere is well worth such additional outlay as has been freely made for clean sheets, proper diet, massage, aseptic surgery, isolation of infection, portable baths, orthopedic appliances, every improvement in fact which marks the difference between a hospital today and the Hotel Dieu of 1777, with its five or six patients to a bed, one basin to a ward, and a tallow factory on the ground floor, where holy candles were thriftily made from drippings of four thousand sheep annually eaten on the premises.

Not long since the writer visited such a school which has been established in the nurses' quarters of one of the most progressive hospitals in this country. The experiment is of too recent growth to speak positively of results, though every indication points to their being thoroughly satisfactory.

As I walked with the superintendent through the building, a pretty, gushing probationer rushed to my guide, pouring out a flood of personal information, beautifully unconscious that new recruits do not usually buttonhole the commander-in-chief for a few minutes' easy chat. "This is only her third day," said the superintendent in answer to my look of amusement; "she will soon know better without being told."

The morning of these pupils is divided between care of bedrooms (a hundred and fifty women sleep in the nurses' home), washing and putting breakfast things to rights, setting tables, preparing dinner, care of kitchen, pantry, cold storage and storeroom, and the study of special diet. After a midday dinner, household work stops, and the pupils attend classes and lectures, beside learning in the supply room to cut, wind, and sterilize every bandage, pad, and folder known to modern surgery. The standard of neatness is in itself an education to any one coming from an ordinary household. A nurse's belongings are open to inspection at any moment, and woe to the girl who has tucked something out of sight, or whose washstand presents an undue array of drugs or cosmetics. Beds must be made with mathematical accuracy, not once but many times, till muscles go through as few experimental movements as those of a sleeping-car porter. In the linen room the vast hospital wash has to be sorted and put away, and in doing this probationers learn something of the care and cost of napery.

No department is so striking as the kitchen with its modern labor-saving contrivances. Every cupboard and utensil shown like the deck of a man-of-war. I watched the preparation of dinner for a hundred and fifty people by a freshly arrived class under the graduate of a well-known cooking school.

It must be remembered that the object of this work is not to save money or service for the hospital, — the cost of instruction would more than pay experienced servants; indeed the pupils only cook one meal a day, just enough to learn the practical side of cookery, care of provisions, economical yet savory and nourishing catering. They study prices, marketing, food chemistry, the proper composition of meals, and the actual sleight of hand without which theoretical knowledge is only a snare. They also fit themselves to direct others by knowing the reasonable length of time needed for every kind of household work.

A bevy of girls were scouring sinks, watching soup caldrons, and preparing chickens from the bitter beginning. Among them stood a college graduate absorbedly peeling the first potato of a basketful. She seemed to be attacking it by differential calculus, by the light of higher criticism. An ordinary cook would have despised her awkwardness, but she was doing it with her ungrudging heart and soul.

Beyond, in the diet kitchen, they were making dishes for the private ward, real dainties warranted harmless, but most appetizingly unlike the white porridgy thing usually associated with a trained nurse's incursions into our kitchens. The walls were hung with bills of fare made out by the pupils, and with recipes giving exact calculation of cost and nourishing properties. The same order, the same cleanliness reigned throughout, and above all the same cheerful interest.

As we looked in again at the main kitchen the hands of the college graduate showed blisters, but her actions were perceptibly limberer, less like those of a man sewing, and she was making better time with the seventh potato.

"She'll do," murmured the superintendent with involuntary humor. "Slow as they are at first, in the end college-bred women are almost always satisfactory. You see, they have done one kind of work already, and the pain of effort doesn't surprise them. Then they generally come really wanting to learn, not because of an unlucky love affair, or nerves, or any of the thousand and one whims that send us girls with no true aptitude for the life. When all is said and done," she added, though thoughtfully, "for the care of sick people the best is none too good, and while it is perfectly right for women to go into nursing to make a living, there should be no place in our profession for any one who does not bring to it the highest principles and the warmest human sympathies."