HOME

NURSING

SKETCH

OF

THE HISTORY & PROGRESS
OF

DISTRICT NURSING
FROM

ITS COMMENCEMENT IN THE YEAR 1859
TO THE PRESENT DATE
INCLUDING THE

FOUNDATION BY T H E QUEEN OF T H E ' Q U E E N VICTORIA
JUBILEE I N S T I T U T E ' FOR NURSING T H E POORIN THEIR OWN HOMES

BY W I L L I A M

R A T H B O N E , M.P.

Dedicated by Permission to Her Majesty

London
M A C M I L L A N A N D CO.
AND NEW YORK

189O
All rights reserved

TO
Her Majesty the Queen

Who to the signal constitutional benefits conferred on her people,
during a long and glorious reign, has added the less conspicuous,
but not less important, claim on their gratitude, of encouraging by
example and sympathy the womanly virtues of faith, tenderness, and
compassion for the suffering, this account of the origin and progress
of one of woman's most characteristic and self-sacrificing works,
crowned by the Queen's large donation from the Women's Jubilee
Offering, is, by permission, dedicated by Her Majesty's humble servant,
W.

RATHBONE.

PREFATORY NOTE
THE work of nursing the sick poor in their
own homes by means of trained nurses,
working under an organised system, has
received

a

national sanction

from

the

decision of the Queen to devote to its
furtherance and improvement the bulk of
the sum presented to Her Majesty by the
women of England upon the occasion of
her Jubilee.

Now that this work has been

brought so prominently before the notice
of the public, interest may attach to the
following record of the origin of systematic
district nursing — a narrative which might

viii

truthfully
Successful

PREFATORY NOTE

be entitled
Experiment/

* The

Story

of a

A statement of

the results it has achieved, of the immense
benefits it has conferred, both directly and
indirectly, on the suffering poor of many of
our large towns, of defects which have been
discovered,

and improvements

been effected

that

in the organisation

have

of the

work, may be useful as well as interesting
to many at this time.

With these objects

in view, the present sketch has been compiled for me by two literary friends, one of
whom, Mr. Claude Barton, to our great loss
and regret, died immediately after its completion.
W. R.

INTRODUCTION
TO T H E

'HISTORY OF NURSING IN THE HOMES
OF THE POOR'
BY FLORENCE NIGHTINGALE
MORAL

TRAINING

' T h y kingdom come.'
T h e * kingdom of heaven' does not come
by departments, nor by institutions, though
these are necessary parts of our training and
education.
within.
The

The

' kingdom of heaven' is

But we must make it without also.

family

alone

is that which

us from the cradle to the grave.

follows
Let us

try to make each family the kingdom of
heaven.

x

INTRODUCTION

Now we may and do improve and train
inmates, patients, and nurses, sick and well,
in hospital institutions.
Numerous touching instances of the good,
religious and moral, so done, might be told,
showing that in deed and in truth to some
the ward was converted into the * kingdom
of heaven.'
In hospitals and infirmaries they may say,
'Where everything is provided, it is easy
to be clean and airy, orderly and godly, but
look at us in our one room — and a sick
person in it into the bargain—and with no
appliances/
Here the trained district nurse steps in.
Here, in the family, she meets them on their
own ground.

Besides nursing the patient,

she shows them in their own home how they
can help in this nursing, how they can be

INTRODUCTION

xi

clean and orderly, how they can call in official
sanitary help to make their poor one room
more healthy, how they can improvise appliances, how their home need not be broken
up.

She

cannot

make

blossom as the rose/
day of improved

i

the

wilderness

But now that the

dwellings for the

appears to be coming more largely,
district

nurse may be

poor
the

the forerunner in

teaching the disorderly how to use improved
dwellings — teaching

without

seeming

to

teach, which is the ideal of teaching.
Now to most people it will seem extravagant, perhaps ludicrous, to connect so small
a thing as district nursing, in their eyes
mere physical relief to some few sick poor,
with so large a subject as our struggle with
pauperised poverty.
T h e district nurse is indeed a very little

xii

INTRODUCTION

thing, ' only a cloud on the horizon;' but
the little cloud heralded rain on the thirsty
earth.

T h e district nurse is but ' a still

small voice/ but perhaps it shows us one
of the ways of Providence.

Perhaps it may

bear within it the germ of a new step in
the struggle, of a new departure, differing
alike

from

gigantic

subscriptions,

which

pauperise the place and raise the rates;
from co-operation, which fails to touch the
' black

sheep';

poverish

from

employers

strikes, which im-

and

employed;

and

from legislative panaceas — acting only as
it does by quiet personal influence, and
instructed, skilful, sympathetic aid upon ' t h e
poor, the sick, and the afflicted/
W e hear much of ' contagion
in disease.
health

andinfectiony

May we not also come to make

contagious

and

infectious ?

The

'

INTRODUCTION

xiii

germs of disease may be changed into the
germs of health.
W e see much of 'original

innate

sin'

May we not strive to bring forth original
virtue—innate morality ?
W e all know and see but too sadly how
the tendency in a bad neighbourhood is
downward to the lowest, both as to health
and morality.

But this is not a moral (or

immoral) law.

In the school, in the hospital

ward where a good tradition has been planted,
the ward, or the school, or the coffee-palace,
etc., humanises the inmates as they come
in.

T h e tendency becomes upward, under the

divine law of salvation as moral progress,
which is always restoring, if we will but use
the divine means, according to the original
type in the Creator's mind.

And how does

it do this, but by the living inflttence of indi-

xiv

INTRODUCTION

viduals acting in these outward means and
machineries and organisations, which do not
act of themselves without the influence, it
may be the silent influence, of the life ? Cannot we study this divine principle and its
working and push it farther ?
T h e vast poor law school does not depauperise the child which too often comes
back to the workhouse.

T h e little boarding-

out system under supervision does.
T h e old great parish infirmaries cured
neither body nor soul; the new ones under
the

influence

of

trained

educated

good

women tend to do both.
The

trained district

nurse

(under the

doctor) nurses the child or bread-winner
back to health

without

breaking up

the

home—the dread of honest workmen

and

careful mothers, who know the pauperising

INTRODUCTION

xv

influence of the workhouse even if only
temporary.

The

nurse also teaches the

family healthy and disease-preventing ways
by showing them her own in practice in
their homes.
T h e drinking father, the driven, dawdling, dirty mother
influence.

come also under

her

They are ashamed to let her see

themselves and their room again in such a
state (this is not a vision but a fact).
improvement

Their

becomes contagious to their

neighbours.
T h e sovereign, the mother of her people.
has laid her finger on this little germ; she
wishes

to

cherish

it,

to

extend

trained

district

nursing (which does not

include

alms-giving, though district nursing knows
the places and

institutions where to find

all sorts of help when necessary), to be
b

xvi

INTRODUCTION

her

representative

with

her

sick poor,

to be one valuable servant of her beloved
poor.
The spirit of a society, as has been most
truly said, depends on the spirit of the
individuals who compose it; this, which is
almost a truism, is hardly acknowledged yet
as a truth.
The good of an organisation depends
on every individual who is in it.

School,

hospital, coffee - rooms, institutions, district
nursing must depend on the living life and
love which are put into them.
Now let each district nurse ' in quietness
and in confidence,' directly serving

her

Queen, her country, and her God — always
striving forward

in humility to

efficiency, find her strength.

greater

It is said:

pioneers are always best until they become

INTRODUCTION

the fashion.

xvii

Then let each nurse be the

pioneer and no one of them the fashion.

If

no man can be great without humility, how
much less can any nurse be good without it.
In love too, 'the greatest thing in the world/
she must find her strength.

A wise man

has told us the ingredients of love or
charity — patience,
humility,

courtesy,

kindness,

generosity,

unselfishness,

good-

temper, guilelessness, sincerity.
And let her remember, this servant of
the poor, working for them, her Queen,
and her God, let her always bear in mind
training and efficiency—training, which must
continue all her life;

efficiency,

increasing

day,

with

every

always

or else

it

declines with every day; practical efficiency—moral efficiency too; these go hand
in hand.

INTRODUCTION

XV111

PHYSICAL TRAINING

The

tendency

is

now

to

make

a

formula of nursing; a sort of literary expression.
Now, no living thing can less lend itself
to a 'formula' than nursing.

Nursing has

to nurse living bodies and spirits.
not be formulated

like engineering.

cannot be

numbered

arithmetic

or

sympathetic.

It can-

or

population.

registered
It

must

It
like
be

It cannot be tested by public

examinations, though it may be tested by
current supervision.
T h e nurse's art cannot be made a formula any more than the painter's.
great painter

The

Fuseli was examined as to

how he mixed his colours.

' W i t h brains,

INTRODUCTION

sir/ was his answer.

xix

The good nurse can

often only answer, if examined how she
nurses, ' With brains and heart, sir, and with
training and practice/
A great physician was heard to say, when
asked how he treated pneumonia, ' I don't
treat pneumonia, I treat the person who has
pneumonia/

If this is true in medicine, in

which there is much that can be tested by
examinations, how much more true is it
of medicine's servant—nursing. Training,—
silent, thing - training, as well as wordtraining ; long years of training—moral and
sympathetic, as well as physical-training
in tact and sympathy,—conduct-training is
necessary.

And progress can never end but

with a nurse's life.
A good nurse must be a good woman,
with sympathetic insight.

She cannot be a

xx

INTRODUCTION

good nurse without

A good woman can-

not be gauged by words.

She must be

herself THE WORD—a name made divine to
us by our great Master, and which

He

expects each one of us women particularly,
to embody in her own duty, each in her own
tiny sphere.
One

word about

maternity

training,

which, though everybody must be born, is
at

its

very beginning.

We mean

by

maternity training, teaching the care of the
mother and infant after its birth, a most
important branch which seems to be yet
in its infancy, and a not very sanitary infancy it is.
Among the really initiated we hear the
complaint that from even so-called 'trained
midwives/ good maternity practice, especi-

INTRODUCTION

xxi

ally in sanitary things, and in feeding the
infant and teaching the mothers what to do,
cannot be expected at the lying-in woman's
own home.

This, then, is not district

nursing; and yet the midwife ought to be
essentially the teacher and the district nurse
of lyings-in at home.
It is added that there is difficulty in
making the midwives attend to these things
sufficiently, at lying-in

training hospitals,

even at the best.
This, then, is not district-midwife training.
Are there still but few who understand
these life and death minutiae in the ztncivilised
civilisation of the present day ?
Much more might be said, but had better
be lived.
And of one thing we may be sure, that if

xxii

INTRODUCTION

the poor receive good from the living, loving intercourse of the trained and educated
woman, she in her turn receives quite as
much good from theirs.

NURSING
IN THE

HOMES OF T H E POOR
IT has become almost unnecessary at the
present day, when dealing with the question
of nursing, to dwell upon the great importance of a thorough professional training for
nurses.

People are no longer ignorant of

the essential qualifications of nurses; they
need no longer to be assured that nursing
is a profession, and that as such it demands
a careful apprenticeship to ensure competency.

In fact, the vocation of a sick
B

2

NURSING

IN

THE

nurse has been rapidly raised from the inferior position in which it stood about thirty
years ago, to one of not merely respectability,
but of rare interest and attractiveness. There
is even danger, in consequence of the Royal
sanction and the attention lately drawn to
nursing, that many may be attracted to the
work who are neither strong enough for it,
nor have that real interest in it which is a
most necessary qualification.

Many of us

can remember a time when most of the
nurses in hospitals were mere drudges, and
too often of indifferent character; but at the
present day their places can only be filled
by women of irreproachable character, of
thorough training, and of considerable technical skill—and, as a fact, nursing has become
an employment that is freely sought after by
women of refinement and education—while

HOMES

OF THE

POOR

3

in times gone by, a woman who had been
engaged for a few weeks or months as an
attendant in the wards of a hospital, or even
without such training, was held to be amply
qualified for the duties of a sick nurse.

It is

a great cause for satisfaction that at the
present day the selection is much more carefully made, that the candidates for the
nursing profession are now tested by a high
standard, both as to moral character and
aptitude for their work, and that before they
are considered proficient for employment
they must undergo a lengthened and systematic course of practical training as probationer
nurses in the wards of a hospital, combined
with scientific instruction adapted to the
requirements of their calling.
Having said thus much, it may perhaps
seem to be beyond the scope of this history

4

NURSING

IN

THE

to dwell upon the means by which this
great revolution has been effected, but we
are so strongly impressed with the fact that
the success of every step which has been
taken in the development and extension of
the benefits of real nursing has depended, and
must in the future depend, upon a due acknowledgment being accorded to certain simple but
all-important principles of organisation in the
training and education of nurses, that we do
not hesitate to refer to them.
In the first place, it is clear that the
hospital must be made such a home as welleducated, refined, and virtuous young women
can live in and learn nursing in.

Of equal

importance, but not so fully recognised as
it should be, is the position of the matron.
The organisation which is essentia], not
only for the proper conduct of the nursing

HOMES

OF THE POOR

5

of every hospital, but also of every training school for nurses, must involve the
condition that the matron of the hospital
shall be the real head of the nursing stafi
and training school, fitted to be such by
personal character, education, and technical
acquirements, and by virtue of her office
holding such a position and endowed with
such authority as will enable her to be
responsible for the conduct and discipline
of the nurses, whether with regard to their
primary duty of carrying out the orders
given to them by the medical officers as to
the treatment of the patients, or with respect
to their general behaviour as members of
the hospital staff—in fact, their moral tone.
Such being, we believe, the public estimation of what a nurse ought nowadays to
be, of the kind of training she should pass

6

NURSING

IN

THE

through, and of the general organisation of
the nursing staff necessary to ensure its
successful working, it may be thought needless to dwell upon the immense benefits that
would be conferred upon the poor by providing trained nurses for their service in
their own homes.

We know how the poor

have long been able to enjoy (to say nothing
of hospitals) the great advantage of medical
attendance to a large extent free of cost, by
means of provident sick clubs and benefit
societies, or through the medium of the Poor
Law and free dispensaries.

But the further

charitable work of providing sick nurses for
them in their own homes is of comparatively
recent growth, and has hitherto been of local
application only.

Perhaps it is not a work,

the claims and usefulness of which are immediately understood, nor one which would

HOMES

OF THE

POOR

7

seem to promise great success in the experiment.

The public have been very naturally

impressed with the idea that for the sick
poor the hospitals and workhouse infirmaries
afford the proper and the only suitable means
of relief.

Moreover, it has appeared to them

self-evident that many a patient's chances of
recovery would be seriously diminished by
remaining in his own miserable and unwholesome dwelling instead of being moved into
more favourable surroundings.
We trust to satisfy those whose sympathy
we hope to enlist in the cause on this point,
viz. that a large number of the sick poor will
not be more suitably and adequately dealt with
in hospitals or infirmaries than in their own
homes.

And afterwards, in the story of the

first attempt at organising a system of district
nursing, it will be seen how various difficulties

8

NURSING

IN

THE

have been overcome, and what is that scheme
of organisation, for which experience enables
us to predict the most certain success.
People are apt to think that any attempt
to nurse the poor in their own homes is a
mistake, because it is an attempt to overcome
impossibilities.

The houses of the poor, it is

said, are too often such that in them invalids
cannot hope to be cured; their removal is the
first condition of doing any good.

All who

are smitten with disease should be transferred
to the proper hospitals and tended there.

To

attempt to cure them by any other means
must result in sheer waste of time, labour,
and money.
Everybody feels the weight of this objection.

It would seem that one of the first

requisites for recovery from an illness is a
suitable lodging, and that with the poor this

HOMES

OF THE

is frequently wanting.

POOR

9

In their narrow city

homes, ample space, quiet, fresh air and sunshine are almost impossible to procure.

The

sick lie mingled with those who are in health
disturbed by their coming and going, and by
the bustle of occupations which cannot be
suspended without taking away the means of
subsistence.

Nor can they depend upon the

regular performance of such offices as even
unskilled care can render.

The time and the

industry which are needed to keep a sickroom in the condition in which it should be,
are often more than can be obtained on behalf
of the poor invalid even from those whose
affection and zeal prompt them to do their
utmost.

Again, and this is a difficulty still

more serious, that elementary knowledge of
the laws of health, which is now pretty widely
diffused among people in easy circumstances,

io

NURSING

IN

THE

is rarely possessed by persons of the humbler
ranks.

Few working people realise the im-

mense importance in a sickroom of regular
but gentle ventilation; the necessity of removing every piece of furniture which takes
up unnecessary space, excludes light, or
collects dust; of constantly and thoroughly
cleansing every article which remains in the
room; and of strict attention to the cleanliness of the patient.

Their idea of comfort

is represented by a room overcrowded with
furniture; a room from which the outside air
is excluded is to them a safeguard against
illness; a room defective in point of cleanliness does not shock their senses, which have
been deadened by rude experience.

Add to

all these disadvantages the fact that the sickness of a bread-winner lessens, sometimes cuts
off altogether, an income which at its best can

HOMES

OF THE

POOR

n

purchase few of the comforts, still fewer of the
luxuries of life.

Not only the delicacies fit

for a sick person, but even necessaries may be
hard to procure for such an invalid.

Last of

all, in their lonely dwellings, the terrible uncertainty of the future too often presses with
fatal weight upon the spirits of the sick, and
anxiety, such as the strong could hardly bear,
comes to make exhaustion final.
Now, in answer to this very forcible argument, w;e have to urge four important considerations.
First, there frequently occur cases of
serious illness, which are either unsuited, or
are not admissible into general hospitals;
cases, for example, of chronic disease combined with extreme poverty.

Some of these

may be left to the workhouse infirmary, but
many others can, with the aid of private

12

NURSING

IN

THE

charity and good nursing, be properly and
more advantageously treated at home.

Such

are some classes of incurable diseases, as
cancer, consumption (in its later stages), and
paralysis, bronchitis, rheumatism, ulcers, etc.
etc., and many diseases connected with
confinements.
Secondly, the invalid often objects—or
his family object—to his removal from a place
which, however wretched, is still a home.
And the moral disadvantage of the removal
of a father or mother from their family is
serious.

It means, perhaps, nothing less

than the breaking up of the home, and,
where the outlook was already made gloomy
and foreboding by the arrival of sickness, it
is not surprising that hopeless disorder follows
upon the removal of the heads of the family,
who depend on them alone for guidance and

HOMES

support.

OF THE

POOR

13

Indeed, the value of district nursing

in cases such as these is incalculable.

The

comfort to the sick and to all the family which
the nurse is able to give, the relief of knowing
that the invalid need not be removed to the
hospital, the restoration of order, the awakening of new hopes and the introduction of a
more cheerful element—such are the happyresults of the nurse's work, which help to
abate the bitterness, the feeling of having
been abandoned by God and man, so deplorable and yet so natural in those who, often
without any fault of their own, find themselves plunged in inexpressible wretchedness.
Thirdly, there are not, and there never
can be, hospitals large enough and numerous
enough to take in all cases of grave illness
among the poor.

The hospitals now exist-

ing, which provide only for a small minority

14

NURSING

IN

THE

of such cases, are often in great straits for
the means to carry on their work.
Fourthly, the work done by district nursing is, in proportion to its results, far less
costly than that done by the hospitals.
We believe that these will be considered
sufficient reasons for inviting a further examination of the subject, and that it will be
easy to convince inquirers of the very great
advantages that have been, and may be
bestowed on the poor by this plan of nursing
them in their own homes.

And it is not an

untried scheme of doubtful utility, but one
which has already been eminently successful
in many places where the experiment has
been made.
Just thirty years ago (in 1859), the experience of sickness in a private family in Liverpool first suggested the establishment of

HOMES

OF THE

POOR

15

a system of district nursing for the poor.
The great comfort and advantage derived
from trained nursing, even in a home where
everything which unskilled affection could
suggest was provided, led to the conclusion
that among the less fortunate—the poor—
untold misery, lasting disability, and death
itself must ensue in cases where these comforts and appliances, as well as skilled nursing, are almost altogether wanting.

It was

resolved to try, even upon the smallest scale,
an experiment in reducing these evils.

The

nurse, who had given proof of her skill in
the case above referred to, was asked whether
she would undertake to nurse poor patients
in their own homes in a district of Liverpool.
She consented to do so, and was accordingly
supplied with the most necessary appliances,
whilst arrangements were made for providing

16

NURSING IN

THE

the nourishment and medical comforts likely
to be wanted.

She was to afford help both

by her own exertions and by teaching the
poor people a better way of tending their
sick.

As this was only an experiment, the

nurse was not engaged for more than three
months.

But when one month was passed,

she returned to her employer and entreated
to be released from the engagement. Accustomed though she was to many forms of
sickness and of death, she was not able to
endure the sight of the misery which she had
encountered among the poor.

But her em-

ployer persuaded her to persevere in her
work, and pointed out to her how much of
the evil which she had seen might be prevented, and that the satisfaction of abating
it would in time be sure to reconcile her to
the work.

Thus reasoned with, the nurse

HOMES

OF THE POOR

17

persevered, and at the end of three months
entirely corroborated the prediction.

She

found that she was able to do great and
certain good, and the satisfaction

of

her

achievements was so great that she begged
to be allowed to devote herself entirely to
nursing the poor, in the place of nursing in
wealthy families.
T h e effect, indeed, was far beyond anything

that

could

have

been

expected.

Patients who, in the special circumstances
of the case, had been given up as hopeless
by the doctors ; patients who, without the
assistance of skilled

nursing, would have

been hopeless even in well-provided homes,
were restored
afforded.

The

to health by the aid thus
good thus

accomplished

spread far beyond the person of the sufferer.
T h e nurse, in restoring to health the breadc

i8

NURSING IN

THE

winner or the mother, often restored to independence and to tolerable comfort the
whole family which had depended for food
or for care upon the sick person.

She

stopped the further spread of weakness and
disease.

More than this, she helped to pre-

vent the moral ruin, the recklessness, the
drunkenness and the crime which so often
follow upon hopeless misery.

Within the

space of a few months she had had two cases
in which the wife's sickness had thrown a
household into disorder, and the husband,
unable to face the wretchedness which he
knew not how to remedy, had taken to
drink.

The nurse showed what might be

done to restore order and to lessen suffering.
The husbands, who were well-meaning, industrious men, took heart again, left off
drinking, and were saved, together with their

HOMES

OF THE

POOR

19

families, from the state of utter wretchedness
and collapse towards which they were fast
drifting

when

the

nurse

came

to

their

rescue.
It became a duty to continue and extend
the work which had such a successful beginning.

There was, fortunately, no doubt that

the necessary funds would be forthcoming,
but there was another drawback of a serious
nature ; the skilled nurses—without whom
funds were useless—could nowhere be obtained.

Skilled nurses in those days were

scarce, and such as there were had full occupation.

Miss Nightingale, indeed, with the

aid of a fund placed at her disposal by the
public, had founded in i860 the ' Nightingale School' at St. Thomas's Hospital.

But

all the nurses trained in that school were
needed for the work of introducing a new

20

NURSING

IN

THE

system of nursing into hospitals, which was
the first step taken towards the general
improvement of the standard of nursing
throughout the kingdom.

Under the society

of St. John's House and Sisterhood, of which
Miss Mary Jones was the executive head,
an admirable training school had been established in King's College Hospital.

But

here again, every nurse sent out by the
school was employed either in the hospital
or in nursing private patients who could
afford to pay.

For it was by the income

thus derived that the school was partly maintained.

Thus, neither school could at that

time spare a single nurse to visit the poor in
their own homes.

In most of the other

London hospitals there were some very good
nurses, but the two already mentioned alone
possessed any organisation or school for

HOMES

training them.

OF THE

POOR

21

The only means, therefore,

of supplying the demand for trained nurses
was to form a school of nursing in Liverpool,
the course suggested and recommended by
Miss Nightingale,
It was not quite a new idea, for the
authorities of the Royal Infirmary in Liverpool had already realised the want of such a
school.

As a step towards the improvement

of the nursing standard, the matron of that
institution had been empowered to pay a
salary of ^"16 to any nurse who deserved it.
This salary was certainly not an exorbitant
one, and yet no more than four nurses could
be found worthy to receive it.

Any ordinary

nurse of that time, if paid more than the
usual salary of ,£10, would most probably
have incurred dismissal for drunkenness after
the first quarter-day.

A training school for

22

NURSING

IN

THE

nurses was therefore needed, not only for
district work, but quite as much for the
Infirmary and private nursing also.

The

Committee recognised this want, and Mr.
Gibbon, the chairman of the Infirmary, took
the preliminary step of making a personal
examination of the nursing organisation at
King's College and St. Thomas's Hospitals.
As the result of his investigation, he was led
to support an offer to erect a building to be
used as a training school in connection wTith
the Infirmary.

The proposal was accepted,

and in this way the Liverpool Training
School and Home for Nurses was established.
Its connection with the Infirmary was of
the closest nature.

The Home was built

on the ground of the Infirmary, and became its absolute property.

The Com-

HOMES

OF THE POOR

23

mittee of the School were selected from the
Infirmary

Committee, the chairman and

treasurer being ex-officio members.

This

subordination of the School to the Infirmary
was, under the particular circumstances, a
matter of necessity ; but it has been admitted
by a member of the Nurses' School Committee, well competent to judge, that, so far
from being a drawback, this was the most
desirable footing on which the School could
have been placed; and those who were
interested in procuring a supply of properly
qualified nurses felt that this result could only
be secured by identifying, as far as possible,
the Training School with the Hospital, but
only so far as the training and selection of
nurses is concerned.

It is essential that the

nurses to be employed in hospital, district,
and private nursing, should be kept distinct;

24

NURSING

IN

THE

and desirable that those engaged in nursing
the poor should live in a separate home or
homes.
The three main objects of the founders of
the Liverpool Training School and Home
for Nurses were set forth in the prospectus—
1. To provide thoroughly educated professional nurses for the Infirmary.
2. To provide district nurses for the
poor.
3. To provide sick nurses for private
families.
More interesting, and of greater importance for our present purpose, is a description of the organisation of district nursing
adopted in Liverpool.

This was in outline

as follows:—
The districts were made conterminous
with parishes, or with groups of parishes, so

HOMES

OF THE

POOR

25

as to facilitate the co-operation of the clergy
m the work of ministering to the sick, while
conducted on a purely

undenominational

basis so far as management was concerned.
In each district a lady, or a committee of
ladies, was provided to superintend the work,
but these ladies were not required to have
any professional knowledge of nursing. They
undertook to provide the medical comforts
required, to find lodgings for the nurse in a
good central situation, and—in beginning the
work in a new district—a meeting of the
clergy, of the ministers of the various religious bodies, and others living in the district,
was called in order to explain to them the
nature of the objects aimed at, and to request
that they would interest their friends and
parishioners in the work.
In each district the medical men, clergy-

26

NURSING

IN

THE

men and ministers of all denominations were
invited to recommend cases to the charity,
being at the same time requested to use this
power with the utmost discretion.

The Lady

Superintendent was herself provided with a
map of the district, a nurse's register book
and forms of recommendation and application.

She was to visit, either in person or

by deputy, all cases under treatment, so as
to obtain assurance that the nurse was working faithfully and well.

From time to time

she was to examine the nurse's register, to
consult with her on fresh cases, and to hear
her report on old ones.

It was her duty to

arrange for the supply, custody, and distribution of medical comforts and appliances, and
to keep memoranda of all expenses incurred,
and of articles lent.
The district nurse was expected to devote

HOMES

OF THE

POOR

27

at least five or six 1 hours a day to visiting
the sick.

She was to investigate as soon as

possible all cases recommended to her by the
proper persons and in proper form, to take
the recommendation to the Lady Superintendent to be filed by her, and then to report
upon the cases and take the Superintendent's
decision upon them at the earliest opportunity.

She was to report any cases in which

she judged that additional nourishment would
hasten the recovery of the patient; any cases
which could be better dealt with in a hospital
or a workhouse ; any case in which the neglect or disobedience of patients or their friends
made her efforts fruitless.

She was to render

all the assistance which the medical man
might require in any operation, and to do
1

Eight hours is considered the usual day's work in

the District Nurses' Homes.

28

NURSING

IN

THE

whatever was necessary for the patient and
but for her would be left undone.

In the

homes of the sick poor this includes, of
course, many things which are not generally
supposed to come under the title of nursing
at all, but which, in their case, are most
important accessories to i t ; such offices, for
example, as clearing the sickroom of lumber
and unnecessary furniture, sweeping floors
and lighting fires.

It was the nurse's duty,

moreover, to teach the patient and his family
the necessity of cleanliness, of ventilation, of
regularity in giving food and medicine, above
all of implicit obedience to the doctor's directions, and herself to set an example of that
neatness, order, sobriety, and obedience which
she was to impress upon others.

She was

exhorted to regard as sacred any knowledge
of family matters which might come to her

HOMES

OF THE

POOR

29

in the course of her duties, to avoid and discourage scandal, and especially to interfere
in no way with the patient's or other people's
religious opinions.

As a rule, the doctor and

the nurse could seldom visit the patient at
the same time unless by special arrangement, and to avoid the inconvenience resulting therefrom a slate and pencil were
hung up in the patient's room, on which the
doctor could write his instructions and make
an appointment with the nurse, and on which
she could enter any facts or ask any questions
which she might think necessary.
It was at first hoped that the pecuniary
profit derived from nursing patients who
could afford to pay would have gone far
towards maintaining the School and supplying nurses for the poor.

There was,

indeed, no lack of paying patients, but the

30

NURSING

IN

THE

work of supplying nurses for private cases
only ranked after both hospital work and
district work, and the demands made upon
the School by the Infirmary had increased so
rapidly and become so large, as the doctors
and

surgeons

came

to

understand

the

immense superiority of trained nurses, that
only a limited number could be supplied to
private families.
made

by the

T h e combined payments
Infirmary

and

by

private

patients were consequently not nearly enough
to defray the expenses of the School, so that
the wages of the district nurses and the cost
of supplying medical comforts and appliances
had to be defrayed by private subscription.
T h e burthen of providing the medical necessaries fell from the first upon the different
districts-—practically upon the Lady Superintendents and their friends and supporters, an

HOMES

OF THE

POOR

31

arrangement which might seem to demand
too large a contribution of their free services
from these generous and charitable voluntary
agents, but which was considered necessary
to secure careful administration.
Every system of district nursing runs a
risk of becoming merely a new system of
distributing relief among the poor.

It is far

easier, more agreeable, and more popular to
give relief than to nurse.

But the primary

object of the founders of the institution was
distinctly to provide nursing for the sick.
They specially wished to guard against the
possibility of a sort of competition arising
between the nurses and the relieving-officers
or the agents of charitable societies.

They

intended to supply medical comforts only in
so far as might be absolutely necessary to
make the labours of the district nurse effec-

32

tive.

NURSING

IN

THE

At first they did not succeed in alto-

gether maintaining the observance of this important principle. The outlay for nourishment
and stimulants rose rapidly in several districts.
It was more than questionable whether any
real and equivalent good was obtained by so
large an expenditure.

At least it was work

for relieving agencies and not for nurses
to undertake, and, whilst it seemed likely to
pauperise the patients, it certainly imposed
too heavy a tax upon the Lady Superintendent and her friends, out of whose pockets
the cost was being defrayed.

The best

check upon this waste was found to be a
spontaneous one, and resulted from

the

growing efficiency of the nurses themselves.
The more efficient each one of them became,
the more plentiful was the supply of cases
which really called for her professional help,

HOMES

OF THE

POOR

33

namely, for genuine nursing as distinct from
doling relief.

When a nurse gained a repu-

tation for her skill and devotion to her work,
the doctors found out her merits and sent
her to the most difficult cases, and as time
went on and people began to understand
better what were the functions of the district
nurse, the habit of recommending cases for
which nursing is less needed than ordinary
relief has steadily diminished, and the expenditure upon medical comforts and nourishment has been brought within reasonable
limits.
T h e Improvement of the quality of the district nursing in Liverpool has been due to
many causes, but especially to a reform introduced by Mr. Charles Langton, then honorary
secretary, and now chairman of the institution.

This reform

consisted
D

In

placing

34

NURSING

IN

THE

district nurses under skilled superintendence,
and giving them the advantages of a common
home and a common life, such as the probationers and nurses in the Infirmary already
enjoyed.

Instead of living alone in lodgings,

they were to live together in district homes
under the care of ladies who had received a
complete professional training.

Thus, as the

lady superintendents of the districts supervised and

controlled

the

non-professional

branches of the work, these matrons of the
district homes, on the other hand, became the
responsible and duly qualified managers of
the strictly professional part of the Nursing
School.

No sooner had this change been

made than it was found how much the nurses
living in a district home contributed to each
other's improvement, and how valuable was
the influence

exerted

over

them

by the

HOMES

matron.

OF THE

POOR

35

The common life promoted zeal

and esprit de corps. In their intercourse
with one another the nurses would eagerly
discuss points of interest in their work, and
dwell with satisfaction upon cases where they
had brought a patient safely through a serious
operation or through an illness regarded by
the doctors as almost hopeless.

From the

matron the nurses gained advice, encouragement, intelligent and sympathetic criticism.
She possessed a valuable power of control
over the selection of cases to be nursed, and
over the methods of nursing to be employed.
She kept the nurses to their appropriate
work, and checked any tendency which
might exist to allow relief-giving to take the
place of nursing.

So much had the matrons

of the district homes accomplished in this
respect that the expense of keeping up the

36

NURSING

IN

THE

home has been much more than balanced by
the economy in relief.
Such in outline is the Liverpool system
of district nursing.
was rapid.

Its early development

Within four years after the first

skilled nurse had been sent into the homes
of the poor, the whole of Liverpool.had been
divided into eighteen districts, and

every

district had been put under the charge of a
trained nurse, superintended by a lady or a
committee of ladies.

T h e value and success

of the system has been demonstrated by
thirty years of fruitful labour.

A great proof

of its usefulness lies in the fact that from the
time when it was first established until now
no single district of Liverpool has ever been
left without the services of a lady superintendent.

Individual ladies or committees of

ladies have always come forward to superin-

HOMES

OF THE POOR

37

tend the work and to defray the cost of
medical comforts and appliances for the sick
poor of their neighbourhood.

Never, it is

believed, did a lady withdraw from this work
when once she had

begun, unless under

the stress of new and imperative duties or of
growing infirmity.
We

have

dwelt

upon

the

immediate

results of the new organisation of district
nursing in Liverpool, but we should not do
justice to our subject if we neglected to
mention remoter results of a beneficial kind.
Perhaps no reform

initiated by the new

system was more beneficial than the reform
in the nursing of workhouse infirmaries.

In

London a reform in workhouse hospitals had
already been brought about by Act of Parliament, 1 but the introduction into parish hos1

Mr. Gathorne Hardy's Metropolitan Poor Act of 1867.

38

NURSING

IN

THE

pitals of trained nurses on the Nightingale
system grew directly out of the experience
and information gained in nursing the poor
in their own homes.
We may safely take, as an example of the
defective condition of workhouse infirmaries
at the time, the infirmary at Brownlow Hill
in Liverpool.

It contained twelve hundred

beds, which were occupied by persons in all
stages of every kind of disease.

Two female

officers superintended the nursing; these
received pay, but had not been trained as
nurses, and their only assistants were pauper
women who were as untrustworthy as they
were unskilful.

A slight acquaintance with

the system of hospital management and the
proper care of the sick is sufficient to make
it evident to everybody how thoroughly'
inadequate this arrangement was; and an

HOMES

OF THE

POOR

39

ordinary knowledge of human nature will
suggest ample reason for the intense suffering
and the failure to cure which existed then,
and was by better arrangement capable of
being greatly remedied.

But the Brownlow

Hill Infirmary was certainly no worse than
most other workhouse infirmaries throughout
the kingdom, for in none of them was a
single trained

nurse to be found.

The

Select Vestry of Liverpool, who were well
known for the efficiency of their management
and the purity of their administration, gladly
accepted an offer which afforded some hope
of amending the evils above described.

This

was an offer to defray the extra cost of trying
for three years in their hospital the employment of trained nurses under skilled superintendence.

It was made anonymously and

upon the understanding that nobody outside

40

NURSING

IN

THE

the vestry should have power to criticise or
interfere with the action of the parochial
authorities.

Upon the acceptance of the

offer, the vestry, with the assistance of Miss
Nightingale, secured as lady superintendent
Miss Agnes Jones, with a staff of nurses
trained in the

Nightingale School at St.

Thomas's Hospital, to undertake the charge
of the nursing.
At the time when this new regime began,
the workhouse was much overcrowded, and
the

discipline had become extremely lax.

T h e number of able-bodied men and women
in the body of the workhouse far exceeded
its powers of accommodation, and the infirmary

was so thronged that

sometimes

three or even four patients were put together
into a single bed. As a first step, Miss Jones
was very anxious to train some of the able-

HOMES

OF THE

POOR

41

bodied pauper women as nurses, who were
at once put on a more liberal diet, received
a small salary, and were promoted to the
rank of

'Assistant

Nurses.'

If anybody

could have succeeded with such an experiment, Miss Agnes Jones would have had
success.

But the event showed that she

entirely failed.

No less than fifty-six pauper

women were passed through the test, and
under it every one of them broke down.
T h e greater number used their first quarter's
salary, as soon as they could obtain leave to
go out of the workhouse, to get drunk.

The

painful fact was established that not a single
respectable and trustworthy person could be
found among the able-bodied women in the
house; the nursing was therefore

taken

entirely out of their hands.
T h e next step was to lighten the work by

42

NURSING

IN

THE

getting rid of a large number of patients
being treated in the infirmary who had no
claim to be there. Many of the male patients
with sore arms and legs were mere malingerers, who thought it more agreeable to hang
round the fire and be pampered with hospital
diet than to earn their own livelihood by
working outside.
At the suggestion of Miss Jones, the new
governor, who was an extremely able man,
instituted for these idle fellows a new system
of test labour and discipline, which induced
no less than two hundred of them to take
their discharge.

In such a manner the num-

ber of persons in the infirmary was brought
by degrees somewhat nearer to that which it
could properly accommodate, and the consequent improvement in the wholesomeness
and comfort of the place gave scope to the

HOMES

OF THE

POOR

43

skill of the nurses, whose labours began to
bear fruit beyond all expectation.

In less

than two years after the arrival of Miss Jones
and her staff, the Guardians announced their
intention of never reverting to the old system,
and of charging the rates with the expense
of the new one.
But a cloud appeared upon this bright
sky of satisfaction and success.

Unhappily

the strain of reforming a large, overcrowded,
and undisciplined hospital had proved too
much even for a constitution of wonderful
strength, and for a spirit as cheerful and courageous as it was enthusiastic and devoted.
Exhausted by her unremitting labours, Miss
Agnes Jones sank under a severe attack of
typhus fever.

In the church of the work-

house the beautiful 'Angel of the Resurrection,' by Tenerari, with inscriptions by

44

NURSING

IN

THE

Miss Nightingale and the Bishop of Derry,
preserves the memory of her life and death.
A still more beautiful and a more enduring
monument, however, remains in the transformation of the Liverpool parish hospital
from what we have described, into one of
the best-nursed hospitals and most useful
training schools in the kingdom.

T h e good

results of Miss Jones's work may, indeed, be
seen far beyond the bounds of Liverpool.
T h e system has spread over the country ;
many of the nurses trained in her school are
to be found in all parts of England, whilst
two of the largest workhouse hospitals—that
of Manchester with fifteen hundred, and that
of Birmingham with seventeen hundred beds
—are now under the charge of two of her
successors.
T h e success of the system of district nurs-

HOMES

OF THE

POOR

45

ing in Liverpool gave an impulse to this form
of charity in other places.

In several large

provincial towns nurses were sent to the
homes of the poor.
very successful.

The experiment proved

In the year 1868 the East

London Nursing Society was founded by the
joint efforts of the Hon. Mrs. Stuart Wortley,
Mr. Robert Wigram, and others.

It con-

formed in its main features to the Liverpool
methods, but it has not adopted the system of
district homes. The last report of the society
describes its 20th year as having been one of
progress and encouragement, and we believe
that its labours in the East of London have
been of great and ever-growing value.
In the year 1874 the nursing of the poor
received a new and most important impulse
from

the movement

which created

the

Metropolitan and National Nursing Associa-

46

NURSING

tion.

IN

THE

This movement was initiated by the

Council of the Order of St. John of Jerusalem,
and set on foot by Lady Strangford, Sir
Edmund Lechmere, and Mr. Wigram, together with other ladies and gentlemen whose
names appear in the list of the Council.1
The promoters of the Association invited
the support of the Duke of Westminster,
who joined them upon the understanding
that everything should be done upon a
well-considered plan, so as to build up an
institution
1

which might set the highest

Doctor (now Sir) H. W. Acland; Sir Rutherford

Alcock, K.C.B. ; Captain Blair; Mr. H. Bonham-Carter;
Mr. J. R. Hollond; Miss Florence Lees (now Mrs. Dacre
Craven) ; Lady Lechmere ; Mr. O'Malley ; Dr. Gibson ;
Dr. Sieveking $ The Hon. J. Stansfield, M.P. ; The Right
Hon. Viscountess Strangford; Mr. Nassau Senior; Mrs.
Nassau Senior; Mr. Robert Wigram ; and Mr. W. Rathbone, M.P.

HOMES

OF THE

POOR

standard of nursing for the sick poor.

47

The

National Association—such was its original
title—began by appointing a sub-committee
of reference and inquiry, which employed
more than nine months in collecting the
materials of a most elaborate and instructive
report.
Until this report had been drawn up,
it was impossible rightly to estimate the
condition of nursing in London at the time,
or to know how much remained to be done,
and what was the best way of doing it.

But

upon all these questions the report shed
much valuable light.

It showed that the

deficiencies of nursing in London—both as to
the number of nurses employed, and the
character of the nursing—were far greater
than had been imagined, that most of the
attempts to supply these deficiencies had

48

NURSING

IN

THE

been unconnected and unsystematic, and that
the number of really skilled nurses employed
was very small.

These are the important

facts demonstrated by the report, but it
contains so much useful information upon all
questions connected with nursing, that after
the lapse of fifteen years it may still be read
with advantage.
T h e objects of the Association, as stated
in its own publications, were as follows :-—
i. T o train and provide a body of skilled
nurses to nurse the sick poor in their own
homes.
2. T o establish in the Metropolis, and to
assist in establishing in the country, district
organisations for this purpose.
3. T o

establish a training

school

for

district nurses in connection with one of the
London hospitals.

HOMES

OF THE

POOR

49

4. T o raise, by all means in its power, the
standard of nursing and the social position of
nurses.
It will be seen from this statement that
the Association proposed to itself as its object
the furtherance of district nursing—of nursing
the poor in their own homes.
The Committee proposed

in the

first

instance to establish a central home and
training school for nurses in district wrork,
and afterwards to extend the work by planting other homes in suitable local centres.
Each home.was intended to lodge and board
about six nurses, placed under a trained
district superintendent.
A very important resolution was adopted
on the recommendation of Miss Florence
Lees, the first Superintendent of the Central
Home, namely, to recruit the nurses entirely
E

50

from

NURSING

the

class

IN

known

THE

as

gentlewomen.

There were several grounds for this decision ;
it was thought that in nursing the poor in
their own homes, nurses were placed

in

positions of greater responsibility in carrying
out the doctor's orders than in hospitals, that
women of education would be more capable of
exercising such responsibility, that the vocation would attract a large number of ladies
anxious for some independent employment,
and that a corps of nurses recruited altogether among ladies would have a greater
influence over

the patients, and by their

higher social position would tend to raise the
whole body of professional nurses in the
consideration of the public.
been fully justified

All this has

by experience.

Can-

didates for admission were, from the first,
numerous, and although a large proportion had

HOMES

OF THE

POOR

51

to be rejected as wanting in one or other of
the numerous qualifications necessary for the
nursing profession, a sufficient

number of

educated ladies, able and willing to become
district nurses, have presented themselves.
So far from any difficulty

at

present

existing from the backwardness of ladies in
coming forward as candidates, there is, on
the contrary, a danger to be apprehended
from the increasing popularity of the nursing vocation.
strongly

W e have elsewhere insisted

on the

paramount

necessity

of

engaging nobody for district or other nursing
who has not received a proper training, and
who is not, by nature and inclination, fitted
to undertake its duties and responsibilities.
The danger to be guarded against now is
the possibility of a number of ladies taking
up the work recklessly and without sincerity

52

NURSING

IN

THE

or forethought, to the detriment of that high
standard of nursing which has been reached
in recent years. There is even now a demand
for district nurses which it is unfortunately
found impossible to meet fully, because only
those who have been properly trained and
proved to be efficient are admitted to the
work.

But we must be grateful to those

in authority for consistently upholding this
condition, and thereby preventing a serious
demoralisation in the nursing standard.
It should be added in their praise, that
these lady-nurses have never shirked the
disagreeable offices which district nursing
incurs, but have been, on the contrary, even
more ready than women less delicately reared
to perform the most trying and repulsive
services to the sick.
One of the chief objects of the Metro-

HOMES OF THE POOR

53

politan and National Nursing Association
was to keep up a very high standard of nursing.

This standard was set by Miss Flor-

ence Lees at the Central Home, and by her
great practical skill and energy she succeeded
in attaining it.

The nurses were educated

on the following plan. In the first place> the
candidates were selected by the Superintendent-general.

They remained in the

Central Home for a month to learn the
general

nature of district nursing,

after

which they were placed in the hospital for a
year; upon the satisfactory completion of
the hospital course, the probationers returned
to the Central Home and combined further
training in district work with technical class
instruction for six months, at the end of
which time their training was usually considered complete.

54

NURSING

IN

THE

The plan of district work established by
Miss Lees is thus described in the Reports of
the Association—
'The Superintendent personally,or through
the Secretary, puts herself into communication with the Parish Doctors and other
Medical men practising among the poor and
residing within a reasonable distance, the
Poor Law Authorities, the Clergy, District
Visitors, Sisterhoods, Bible Readers and
Mission Women, as well as with the Charity
Organisation Society, the Society for the
Relief of Distress, and other persons or
Societies working amongst the poor. Applications for nursing service, when received
at the Home, are at once entered in the
Register, and in the first instance, if possible,
the case is visited by the Superintendent,
who, if it is, in her opinion, a proper nursing

HOMES

OF THE

POOR

55

case, assigns the patient to a nurse and gives
her directions. The Nurse continues to visit
daily, making her regular round of visits,
and keeping a record of each case for the
Superintendent.

When the case has been

sent by a medical man, his orders are at once
taken, and where not, the Nurse communicates with him at the first opportunity, or
when she cannot see him, obtains his instructions in writing.

The time the Nurse will

stay with, and the attention she will give to
the patient depend on the nature of the individual case.

In some instances the Nurse

may on her first visit have to place the room
in nursing order, and having taught the wife,
the mother, or the daughter of the patient
how the room can be arranged, and how the
ventilation can be best managed, she; will be
able to leave this part of her work to them,

56

NURSING

IN

THE

•and devote herself to the personal care of
her patient and to her strictly nursing duties.
In future visits she has then merely to see
that her instructions have been carried out.
In other cases no person may be at hand,
and she will in each visit have to do all the
work herself.'
What exactly is meant by putting the room
in nursing order will best appear from some
remarks by Miss Florence Lees herself—
' Upon entering a close, ill-ventilated room,
too often in an indescribable state of filth and
vermin, the nurse's first duty is to see that
the bed of the patient is so arranged as to
have the greatest amount of air, light, and
space possible, which, in most cases, necessitates a total rearrangement of the furniture
in the room.

That done, the nurse washes

and arranges the patient, makes the bed,

HOMES

OF THE

POOR

$7

applies any dressings required, then dusts
the room, ventilates it, empties and washes
all utensils, dirty

glasses, etc., and when

necessary* disinfects

utensils and

drains,

sweeps up the fireplace, fetches fresh water
and fills the kettle.
' W i t h helpless patients, she takes the
necessary precautions against the formation
of bed-sores; and in serious cases, or when
desired to do so by the doctor, takes a strict
note of those variations in the disease which
a nurse ought to know and observe.

In

fact, as far as possible, the patient's room is
made to resemble a small ward in a wellarranged hospital/
Putting the room in nursing order is,
indeed, an indispensable condition of nursing
with success.

But it at times involves hard

and unpleasant labour for the nurse.

58

NURSING

IN

THE

Great pains have been taken by the
Metropolitan and National Association to
prevent their nurses from becoming relieving
agents.

The Association supplies nothing

beyond the services of the nurse and the
strictly medical appliances for such purposes
as dressing sores or bandaging wounds.

It

obtains the supply of comforts and of nourishment from existing agencies, taking care that
the requirements of the patients are made
known to them.

Patients who, though poor,

are able to make some payment for the
services of the nurse, are invited to do so.
The Committee have always hoped for the
introduction of a system of subscription
among the poor themselves, which would
enable them to ensure the service of a nurse
in time of sickness, just as by means of thq
Provident Dispensary they now secure a

HOMES

OF THE

supply of medicine.

POOR

59

In some places the

Poor Law Guardians have granted an annual
subscription to the funds of the Association.
It will appear, even from this brief statement, that the London and Liverpool systems of district nursing, whilst on the whole
resembling each other, differ in some particulars of importance.

It is desirable to

bring into clear relief the respective advantages of the two systems.
in its own place.

Each is the best

Thus the London system,

in its total abstention from giving relief of
any kind, is justified by the circumstances of
London.

The extraordinary number and

variety of charities in the Metropolis, together with the parochial relief, have made
unnecessary in all but the poorest parts of
the town any organisation for supplying
nourishment and medical comforts, such as

60

NURSING

IN

THE

we have described in Liverpool.

By thus

entirely confining itself to the task of nursings and by taking its nurses solely from
the class of gentlewomen, the Metropolitan
and National Association does much to
ensure excellence and a high standard, and
appears therefore suitable to London, and
perhaps to other capital cities.
Moreover, as London is the principal
centre from which district nursing most
naturally spreads, the Association, by limiting
its training to women of education and refinement, supplies a better class of agents and
superintendents for the extension of district
nursing in the provinces.
On the other hand, the Liverpool system,
in its latest and best form, is believed by those
engaged in it to be suited to the wants of
most large provincial towns.

The District

HOMES

OF THE POOR

61

Home, with its six or eight nurses and
trained professional superintendent, ensures
the goodness of the nursing.

The assign-

ment to every nurse of a separate district, in
which she has the support of a lady superintendent or committee pledged to find the
necessary nourishment, comforts, and appliances for the sick, is an expedient which
awakens the interest and enlists the help of
the public.

In this way a fund is secured in

towns where charities are not very numerous,
and a friendly intercourse is encouraged
between the poor and those who wish to
benefit them at the very time when they
most urgently need advice and assistance.
The intensity of the suffering which the
nurses of the Metropolitan Association have
assuaged can be best conceived by reading
one or two of their reports of particular cases.

62

NURSING

IN

THE

T a k e such a case as the following, which is
but one of many :—
' In this instance we were called in by Dr.
W. to go to a case of typhoid.
ing of

nth

On the even-

September we first saw our

patient, an ill-nourished lad of sixteen, lying
on a bed hardly covered with various rags
and old garments, moaning in his delirium,
this being already the eighth day of the
fever.

It was a small back room, its narrow

window and fireplace both carefully closed
(happily one pane in the former being broken,
and only patched up ineffectually with paper,
some air did make its way in!) ; the dirty
floor, strewn with dirtier bits of oilcloth and
ragged carpet; the bed of iron, but broken
in the middle, was propped against the wall
in the corner and on a box ; the iron laths and
ropes gave way everywhere, and the boy

HOMES

OF THE

threatened to slip through.

POOR

63

T o open the

window at the top and have a small fire
lighted in the grate was the work of a few
minutes, and soon made a great change in
the close, damp atmosphere of the room, but
to get the floor cleared and washed with
carbolic, the bed moved out from the wall—
we found that it could stand, though in a
doubtful manner, with the assistance of the
box alone-—to remove from it every superfluous article of clothing, and replace these
by clean sheets and a warm rug, to fill a
large water pillow and get the patient on it ;
all this was not accomplished without some
difficulty, though it was done in the course
of two visits.

But it took many more to

alter in any considerable degree a condition
of things which was at first a great hindrance
to our nursing.

Our patient was

nearly

64

devoured

NURSING

IN

THE

by vermin, and

everything, in-

cluding his bed, full of them.

At first sight

it did seem almost in vain that the floor and
woodwork of the room were daily washed
with carbolic, the patient even sponged with
a weak solution of it, and everything on
it perpetually dusted with
Keating.

the

invaluable

But at last our perseverance has

been rewarded, and our patient has long lain
comfortably on his bed, and he tells his
mother she must never let Doll (his little
brother) sleep with him again, he finds the
present

arrangement so much

pleasanter.

H e was dirty enough when we first had him,
and cannot remember how we had to scrub
him to begin with, for he had gone to bed
with all the dirt of his occupation (he is a
plasterer's boy) upon him, and lain unwashed
till we came, his mother being " afraid to

HOMES

OF THE

touch him with water/'

POOR

65

But his returning

consciousness first showed itself by his inquiries when nurse was coming to wash him.
Hours before the time he would worry his
mother to have the fire ready, and the water
hot, etc., and when nurse did appear, one
thin arm was immediately stretched out from
beneath the bedclothes as though to intimate
that he was ready for the sponging he liked
so much.

H e has been very ill; at first the

head symptoms and the diarrhoea gave much
cause for anxiety, but he is now in a fair way
towards convalescence/
Or, take the following case, in some ways
more appalling than the last.

It was that of

a girl about sixteen years old who suffered
from curvature of the spine.

She was the

daughter of respectable people, and had been
an in-patient of St. Bartholomew's Hospital
F

66

NURSING

IN

THE

for some time, but was at length discharged
as incurable.
* Her friends, though most anxious to
nurse her, were ignorant how to change her
linen, or make her bed, without lifting her,
as the least movement caused her so much
pain.

In a very short time she contracted

frightful bed sores, and their difficulties were
then greatly increased, as the only way they
attempted to make her bed or change her
sheets was by lifting her from one bed to
another.

This caused her such intense

agony that it was only done very occasionally, and her father told us that although
he always carried her himself, as tenderly
and as gently as he could, he was so overcome by the shrieks of his daughter that on
more than one occasion he nearly fainted
when it was over!

They at last called in

HOMES

OF THE

POOR

67

the parish doctor, who wrote and begged us
to send a nurse at once.
'We found the patient in a small, dark
room, lying on a feather bed, soaked with
blood and the discharge from the wounds.
The room was their best parlour, covered
with carpeting, and crowded with furniture
and innumerable ornaments.

The windows

were tightly closed, and the air was hot, close,
and stifling, although no sun rays could ever
find their way into the room.
' We asked if they had no other room in
which the patient could get more sunlight
and air, and were told that if we could only
move her without hurting her she could have
the adjoining room, which had a southerly
aspect, and was much lighter and better
ventilated.
' We arranged the room and bed for her

68

NURSING

reception.

IN

THE

Whilst her new room was being

prepared the nurse removed her linen, and
carefully

washed

blankets.

her

all

over

between

It was the first time she had been

so thoroughly cleansed for nine months, and
she said, " Why, even in hospital they never
washed me like this ; it is beautiful! "
i

T h e old mother stood by, and as she saw

the soiled linen removed without giving pain,
and that her child could be washed all over,
without uncovering her at all, she uttered
various exclamations of wonder and delight,
continually ejaculating, "Sarah, my darling,
this is
s

Providence!',

T h e nurse carefully cleansed the wounds

and bed sores, from all of which proceeded
profuse discharge and hemorrhage, and applied the dressings ordered by the medical
man.

T h e wounds dressed, the nurse took

HOMES

OF THE

POOR

69

the usual precautions against the formation
of other bed sores, put on fresh linen, and
made the bed without removal of the patient.
She then combed and arranged her hair,
cleansed her teeth, etc.
' That afternoon the patient was removed
to the other room; the father was very
anxious to carry the sick child himself, as
he said he had always lifted her when
she

needed

it since she came

out of

hospital.
' We persuaded him, however, to allow us
to help him, and by passing a strong counterpane under the patient like a draw-sheet, she
could be carried to the bed in the other room
in a strictly recumbent position, without removing pillows or upper bed clothes, and
without

causing

her the slightest pain.

Indeed she said she rather liked it.

The

70

NURSING

IN

THE

counterpane was then withdrawn from under
her.
* From that day she has made steady but
real progress, although, of course, the affection of the spine can never be quite cured ;
several of the bed sores are healed, and the
patient is so much brighter and better in
herself that it is hard to realise that she can
be the same fretful, careworn girl that she
was when we first saw her.

The nurse visits

her daily, to wash her and make her bed,
etc. etc., as I have already described, and
twice daily to cleanse and dress her wounds.
The mother and sister of the patient carry
out so carefully all our directions with
regard to cleanliness, ventilation, etc., that
Mrs. Craven on visiting the case lately
said she could not find one of our rules
neglected.'

HOMES

OF THE

POOR

71

One more case, and we will not harrow
the reader's feelings further.
' Mrs. W., a poor woman suffering from
a very sad form of internal cancer, was
attended by nurses of the Association from
1st July to 24th September.

Hers was a

most distressing case, as, besides the cancer,
she had to undergo a very serious operation.
She lived in a small court off the Gray's Inn
Road.

Her husband, a carman, was out all

day, and the poor woman was waited upon
by her daughter, who did her utmost for her
mother, but there were many nursing services
required for the patient, which only a welltrained surgical nurse could do at all, and
which, therefore, the daughter had had to
leave undone.

At our first visit we found

the air of the room unbearable, partly from
the nature of the case, and neglect of all

72

NURSING

IN

THE

proper surgical dressings and appliances, and
partly from linen saturated with discharge
being under

the bed " until it could be

washed."
' T h e poor woman herself was so tender
and emaciated, and with the threatenings of
bed

sore, that

she could only bear the

gentlest handling, and was unwilling to be
touched or moved in any way.

She said,

" I won't have you to touch me, I tell you.
I do very well as I am, with my girl to attend
to me.

I won't let you come near me."

' W e had to tell her that she could tell the
doctor she did not want us again, but that
at this visit we must do as he had ordered,
which

we proceeded

to do.

After

the

doctor's orders had been carried out, and
she had been properly washed, and her bed
made without moving or hurting her, her

HOMES

OF THE

POOR

gratitude was very touching.

73

She caught

hold of the nurse's hand and kissed it, saying,
" Oh, nurse dear, I did not think it possible
for me ever to be made so comfortable again!
I can never thank you enough !"
1

We removed all the soiled linen from

under the bed, took off the bed hangings to
allow a free draught to pass under the bed,
and arranged for proper ventilation without
draught, had the soiled clothes removed to a
wash-house outside the house, and the floor
washed over with a solution of carbolic. The
effect was wonderful.

The air of the room

felt fresh and pleasant after our first visit, so
that no one could have guessed it was a
cancer case, or what it had been like before.
The nurse visited this case twice daily until
the poor woman died, eleven weeks after our
first visit.

Her face used to brighten up as

74

NURSING

IN

THE

the nurse entered; the nurse's visit was the
one bright spot and comfort in a most cheerless existence/
It would be needlessly painful to multiply
instances of this kind, nor would we have
given even these in detail, were they not
necessary to make real to those who enjoy
comfort and luxury the real needs of the sick
poor.
Well might Miss Nightingale write to the
Secretary of the Association : ' As to your
success.

What is not your success ? To

raise the homes of your patients so that they
never fall back again to dirt and disorder:
such is your nurses' influence.

To pull

through life and death cases—cases which
it would be an honour to pull through with
all the appurtenances of hospitals, or of the
richest in the land, and this without any

HOMES

OF THE

POOR

sickroom appurtenances at all.
whole families

75

To

keep

out of pauperism by pre-

venting the home from being broken up,
and nursing the bread-winner back to health.
T o drag the noble art of nursing out of the
sink of relief doles.

T o show rich and poor

what nursing is, and what it is not.

To

carry out practically the principles of preventing disease by stopping its causes and
the causes of infections which spread disease.
Last but not least, to show a common life
able to sustain the workers in this saving but
hardest work, under a working head, who will
personally keep the training and nursing at its
highest point.

Is not this a great success ?

' District nursing, so solitary, so without
the cheer and the stimulus of a big corps of
fellow-workers in the bustle of a public
hospital, but also without many of its cares

76

NURSING

IN

THE

and strains, requires what it has with you,
the constant supervision and inspiration of
a genius of nursing and a common home.
May it spread with such a standard over the
whole of London and the whole of the land.'
With H e r Majesty's help, sanction, and encouragement, this is what the Queen's Institute is intended to do.
Unhappily, although the Association has
maintained its standard of nursing, it has not
had the means to extend its work as much as
would be desirable.

That such a charity

should have been hampered by want of funds
is not creditable to the largest and richest
city in the world, which annually wastes
hundreds of thousands of pounds in slovenly
and therefore unprofitable almsgiving.

The

work done by the Association is necessarily
expensive, and although the donations made

HOMES

OF THE

POOR

77

at its first beginning were ample, the annual
subscriptions

have

usually been

scanty.

Accordingly, as the Association enlarged its
operations and established its branch homes
in different parts of London, it began to
incur a considerable debt.

It was found

advisable to reorganise the Association on
the principle of making the district homes
independent of the Central Home, and of
requiring them to find their own

means.

This reorganisation, in giving more freedom
and responsibility to the district homes, has
quickened local liberality, and very much
reduced the expenditure of the Central Home.
District homes have been established in nine
different parts of London. 1
1

North London (Holloway), Paddington, Marylebone,

Hampstead; South London (Battersea), Kensington, Walworth, Westminster, and Chelsea.

78 NURSING

IN THE HOMES

OF THE

POOR

Only when a new local centre is formed
does the Association provide it with funds,
and then only until the neighbourhood has
had the opportunity of appreciating its usefulness and of supporting it accordingly, as
they have almost always done in course of
time.

QUEEN VICTORIA'S INSTITUTE

THE present time is likely to prove an
important era in the history of the Association, and in the development of district
nursing.

The deep interest taken by the

Queen and the Royal family in the care of
the sick is well known, and the English
people will therefore not be surprised that
Her Majesty, moved by the great benefits
which her most suffering subjects

have

received from the care of trained nurses in
their own homes, has devoted the bulk of the
subscription raised by the women of England

80

NURSING

IN

THE

in honour of her jubilee to this great object,
and has thereby made this undertaking a
royal and a national one.
The Queen appointed the Duke of Westminster, Sir James Paget, and Sir Rutherford
Alcock to be trustees of the fund, and to
report to her upon the best way of applying
it for the benefit of the nurses and their
patients.

From information collected by the

Duke of Westminster for the trustees, it
appears that besides the work done in
London and Liverpool, there are district
nursing organisations

in

Derby,

Bristol,

Brighton, Manchester, Worcester,

Leeds,

Oxford, Newcastle, Maidstone, Edinburgh,
Glasgow, Belfast, Dublin, and many other
towns.

Several institutions for nursing the

rich send out some of their nurses to undertake poor cases gratuitously, and in many

HOMES

OF

THE

POOR

81

parishes and villages throughout the country
—in thirty or forty at least, perhaps in a
much larger

number—there

is a trained

nurse established to attend exclusively to
the sick poor of the locality.
In January 1888, Sir Rutherford Alcock
wrote to the Times, enclosing the Report of
the Committee.

They recommended that

the Jubilee Fund, which amounts to about
,£70,000, and may be expected to produce
an income of ^ 2 0 0 0

a year,

should

be

applied to found an institution for the education and maintenance of nurses for tending
the sick poor in their own homes.

The

formation of a Provisional Committee 1 was
1

The Provisional Committee consisted of the

three

trustees above named, the Countess of Rosebery,

Lord

Lyttelton (now Viscount Cobham), Mrs. Henry Grenfell,
Mrs. Dacre Craven, Mrs. Theodore Acland, Mr. H. BonG

82

NURSING

IN

THE

sanctioned by the Queen to consider and
settle the details of the projected charity.
They lost no time in entering upon their
duties.

T h e Jubilee Fund is a splendid

contribution to the work, but it is by no
means adequate by itself to the end contemplated ; for the scope of the new institution
embraces the whole of the United Kingdom.
But Her Majesty has approved a scheme
for employing the fund in connection with
the

ancient

Hospital.

charity

of

St.

Katharine's

This is an ecclesiastical corpora-

tion established formerly on the site of St.
Katharine's Wharf near

the Tower,

but

removed thence to the Regent's Park when
the dock was constructed. It was founded in
1148 by Queen Matilda, wife of Stephen,
ham-Carter, Mr. Caine, M.P., The Rev. Dacre Craven, and
Mr. Rathbone, M.P.

HOMES

OF THE

POOR

83

with the original intention of securing repose
for the souls of two of her children.

In 1273

it was chartered by Queen Eleanor, the
widow of King Henry III, and again in
1351 by Philippa, Queen of Edward III,
when the visitation of the sick and poor in
the neighbourhood of the hospital was expressly imposed as one of their duties upon
the members of the Corporation.1
The Queens of England have always
been the patrons of St. Katharine's Hospital,
which was handed down with all its estates
by Queen Philippa, ' Reginis Angliae nolio
succedentibus.'
In thus connecting the Queen's Jubilee
Institute with St. Katherine's Hospital, it is
1

The clause in the Charter is as follows :—c Item,

visitabunt debiles et infirmos ibidem regentes, tarn in divinis
officiis dicendis quam in aliis charitatis eis erogandis.'

84

NURSING

IN

THE

no doubt intended by Her Majesty that the
visitation of the sick should again become
one of the principal objects for which the
ancient corporation exists.

The

wasteful

system of the renewal of leases by fines,
which formerly existed in the institution,
has now been stopped, and it is hoped that
when the effect of that system upon its income has passed away, considerable funds
will be available for the Queen's Institute.
In the meantime the new charity must rely
upon the public for their liberal support, to
enable them to extend and
work.

improve

the

It is only the public who can make

the work a truly national o n e ; the Queen's
dedication of the Women's Jubilee Fund to
this object, combined with the support that
is expected after the lapse of some years to
come

from

the

surplus

revenues

of

St.

HOMES

OF THE

POOR

85

Katharine's Hospital, forms the nucleus of
a great national undertaking, which depends
largely, however, upon the generosity of the
people for its success.
In endeavouring to find the best employment for the fund entrusted to their care, the
Provisional Committee of the Queen's Jubilee
Institute have been guided chiefly by two
considerations.

In the first place, any in-

stitution bearing the Queen's name must be
placed on so sure a footing as to give an
example and set a standard for the whole
kingdom.

In the second place, it is necessary

so to organise the new institution as to enlist
in its behalf the local energy and interest of
the towns and places it is intended to assist.
T h e first duty of this Provisional Committee
was to establish or develop model training
schools for district nurses in London, Edin-

86

NURSING

IN

THE

burgh, Dublin, and elsewhere.

They there-

fore sought to discover or make in each
capital the nucleus of such a school.
London

For

the Committee have adopted

a nucleus the

Metropolitan and

Nursing Association, and

as

National

invited the co-

operation of the District Homes established
under its auspices.
T h e choice was determined by the fact
that this Association is acknowledged

by

the highest authorities to have been successful in bringing to the homes of the poor the
best nursing that has yet been attained;
and that the system of training
has

supplied

a

large

body

of

pursued
skilled

nurses to other institutions for nursing the
poor.
In Edinburgh, the energy of the president, Lady Rosebery, and of the honorary

HOMES

OF THE

POOR

S7

secretary, Miss Guthrie Wright, has laid
the foundations of a Scottish centre for the
training of nurses.

Glasgow, Aberdeen, and

other important places are represented on
the Edinburgh committee, which is already
in vigorous and judicious action.
In Dublin a commencement has

been

made, and negotiations have been entered
into with three nursing institutions, only one
of which was engaged in district nursing,
but no definite

settlement

has yet been

come to.
T h e Provisional Committee have further
arranged terms on which other provincial
institutions may be affiliated to the Queen's
Institute;

the

Liverpool Association

has

accepted these conditions of affiliation, and
many

other

example.

societies

are

following

its

S8

NURSING

IN

THE

Special arrangements have been made to
establish a nursing institution for Wales at
Cardiff.
T h e Provisional Committee have made a
good beginning, and have laid a firm foundation for future efforts.

Further details of

their transactions may be read in their Report, which is given in the Appendix to this
sketch.
Great patience and care are necessary in
starting a new work of this kind.

Many

rules have

many

to be

considered,

and

arrangements made, in order to adapt the
scheme to the varying wants and peculiarities of different places, without impairing its
unity or lessening its power for good.

The

response to the wishes expressed by H e r
Majesty has been cordial and satisfactory.
There is a bright prospect for the future

HOMES

OF THE

POOR

89

of the Queen Victoria Jubilee Institute for
Nurses.

T h e history of district nursing has

reached the commencement of a new chapter,
in which we believe the consolidation of local
efforts into one united royal and national
undertaking will mark a new epoch of its
success.

May

1890.—The above account brings

the history of district nursing and of Queen
Victoria's Institute up to last autumn.
On the 20th September a Royal Charter
was issued, giving the Institute a corporate
existence, and on the 10th February the
Council was appointed, consisting

of

the

Very Rev. the Master of St. Katharine's
Royal Hospital (Arthur L. B. Peile), President ; His Grace the Duke of Westminster,
K.G., Sir James Paget, Bart., Sir Ruther-

go

NURSING

ford

Alcock,

Theodore

IN

THE

K. C. B., Trustees;

Acland,

Mrs.

Mrs. Dacre Craven,

Mrs. Henry Grenfell, the Lady O'Hagan,
the Hon. Lady Ponsonby, the Countess
of Rosebery, Mr. Henry Bonham-Carter,
the

Rev. B. Darley, Sir

Dyce

Duck-

worth, M.D., Oliver Heywood, Esq., John
Jaffray, Esq.,

the Right Hon. the Earl

of Meath; Mr. W. Rathbone, M.P., VicePresident.
On the 25th March, the following were
appointed as the Scottish Council: The
Countess

of

Rosebery,

President;

the

Marchioness of Lothian, the Hon. Lady
Campbell, Mrs. William Ford, Mrs. Gairdner, Miss Lumsden (Hon. Supt.,

Royal

Infirmary, Aberdeen), Mrs. Trayner, Miss
Louisa Stevenson, Miss Guthrie Wright,
Sir Thomas Clark, Bart., Dr. Joseph Bell,

HOMES

Sir

Douglas

OF THE

POOR

91

Maclagan,

Dr.

Grainger

Stewart (President of College of Physicians),
Sheriff Crichton, the Right Hon. J. B.
Balfour; M.P., J. S. Pitman, W.S., H. A.
Hotson, Lord Hamilton of Dalzell, Rev. Dr.
Cameron Lees, Rev. Dr. Donald Macleod,
Rev. Dr. Wilson, Rev. Dr. Andrew Thomson, A. H. Moncur.
The Scottish Council have bought a
Central Home in Edinburgh, and are pushing forward their work with great energy
and success.
Two additional Branch Homes have been
established in London, and others are in
contemplation.

The

Cardiff

Branch is

commencing operations, and it is hoped that
the sphere of the Institute's influence will
gradually but steadily increase throughout
the country.

Its progress cannot, in the

92

NURSING

IN

THE

very nature of things, be very rapid.

In-

cluding her hospital coursej it takes a year
and a half to train a good district nurse,
or a year and nine months if she has also
instruction in midwifery : and all will admit
that anything done in the Queen's name
ought to be thorough and complete; and
unless it is so, no work is likely to be permanently useful.
T h e liberal gift of Mr. Tate will greatly
increase the power of expediting the work,
but it will be most undesirable to proceed
faster than really reliable and thoroughly
trained nurses can be sent out; and it must
be borne in mind that while the action of a
central body, who have limited funds, may
effectually stimulate and

promote

nursing

of a high standard, local institutions must
mainly depend, as the branches in London

HOMES

OF THE

POOR

93

have mainly depended, upon local effort and
contributions.
In the Appendix will be found—
(A) The Report to the Trustees from the
Provisional Committee of the Institute on
resigning their work.
(B) The First Annual Report of the Provisional Committee of the Scottish Branch.
(C) Conditions of Affiliation.
(D) Rules for the Training and Engagement of Nurses.
(E) Some papers contributed

by ex-

perienced nurses on points which did not
come within the scope of the Guide to District Nurses? written at the request of the
1

A Guide to District Nurses and Home Nursing.

By

Mrs. Dacre Craven (nee Florence Sarah Lees\ Inhaberin

94 NURSING

IN THE HOMES

OF THE POOR

Trustees of the Queen's Jubilee Fund byMrs. Dacre Craven.
des Verdienst Kreuzes fur Frauen und Jungfrauen, der
Kriegsdenkmiinze fiir 1870-71, and Honorary Associate of
the Order of St. John of Jerusalem in England.
and New York : Macmillan and Co.

London

APPENDICES
A
R E P O R T FROM THE PROVISIONAL COMMITTEE OF THE
Q U E E N VICTORIA JUBILEE INSTITUTE FOR NURSES,
LONDON, TO THE TRUSTEES.

W E have the honour to report to the Trustees of the
Queen Victoria Jubilee Institute for Nurses the steps
taken by us, as a Provisional Committee, to carry out
the wishes of the Queen, as conveyed to us by the
Trustees, and the results so far attained.
It is to be hoped and expected that the Queen's
desire to extend the benefits of skilled nursing to the
poor in their own homes throughout every town and
village of her dominions, and the example set by Her
Majesty in devoting the bulk of the sum raised by the
women of England to commemorate her jubilee to this

96

APPENDICES

object, will call forth large general and local efforts and
contributions.
For it is evident that the sum of ^ 2 0 4 9

a vear

? large

as it is as a royal contribution to that object, will go a
very small way towards accomplishing and

making

national so great and important an undertaking.

It

was obvious that the duty of the Trustees and Provisional
Committee, until in a position to ask for such general
and local support, must be confined to establishing, in a
few important centres, this branch of nursing on a
system which, in its organisation and high standard of
professional excellence, would form a model and encouragement for its subsequent extension.
The progress made in establishing an Institution
having its chief centre in London, and similar Central
Institutions in Edinburgh and Dublin, has been most
encouraging, and arrangements have been further made
for facilitating the affiliation of any institutions desiring
it, which are satisfactorily fulfilling, in any part of the
kingdom, the general purpose of the foundation.
The importance of initiating, as an example in a
National Institution bearing the Queen's name and sanction, the highest standard of training, character, and
education in the Queen's Nurses, has been

steadily

kept in view, and the arrangements made, and regula-

APPENDICES

97

tions laid down, will it is hoped be effectual in this
respect.
In London, as the principal centre, there already
existed, in the

Metropolitan

and National

Nursing

Association, a central school, established with the highest
standard of nursing, training only ladies, and with
branches, which originated from it, in different parts of
the Metropolis, all working on the same principles.

By

availing ourselves of its services to train nurses who
might introduce an equally good system elsewhere, we
not only availed ourselves of long and valuable experience and tried capacity, but avoided the expense of
establishing a new school, which would have absorbed
the greater part of the funds at our disposal.

We there-

fore made arrangements with the Metropolitan

and

National Nursing Association to act for the present as
the central school in London.
We further arranged for valuable courses of lectures,
by distinguished professors of medical science, bearing
specially on the duties and work of district nurses, and
which were open to nurses and probationers of the
Metropolitan and Branch Homes.
We further arranged terms of affiliation, in conformity
with the objects laid down, the acceptance of which was
under consideration and discussion with various Nursing
H

98

APPENDICES

Institutions, when the issue of the Charter brought the
duties of the Provisional Committee to an end.
Several societies have accepted in principle the conditions of affiliation, including that of Liverpool, where
district nursing first commenced thirty years ago, and
where for twenty-five years the system has been completely organised over the whole city.
In Edinburgh a most efficient Central Institution has
been formed, on the best principles and with the highest
standard of qualifications, and is in active operation,
and there can be little doubt that, worked with the
energy devoted to it, and the administrative talent for
which the Scotch are so remarkable, its influence and
example will extend over Scotland a most valuable and
complete system of nursing the poor in their own homes.
A Report of the Edinburgh Institution accompanies
that of the Provisional Committee.
In Dublin a Provisional Committee was formed, an
equal number of Roman Catholics and Protestants being
invited to allow their names to be submitted as members,
but, owing to the difficulties which religious and political
differences introduce into Irish affairs, it was found
impossible to carry out the system on the same lines as
in England and Scotland.
The Catholic authorities insisted upon separate homes

APPENDICES

99

and domestic supervision for Catholic and Protestant
nurses, and it was found necessary to concede this; but
other difficulties supervened, which led to the Dublin
Provisional Committee retiring from the work, stating
their unanimous opinion " that the work of Nursing the
poor of Dublin must be carried out by some of the
Institutions already existing in or near the city, and
that the establishment of any new Institution for the
purpose is not practicable."

They therefore recom-

mended that the Central ^Governing Body should communicate directly with the existing Institutions, with the
view of such affiliated Institutions working in direct
communication with the Central Governing Body.
It became necessary therefore to make a selection
between the Dublin Institutions, as the work would not
have sufficed to employ them all.
Three such Institutions therefore were selected: the
St. Patrick's Home, a Protestant Institution, nursing the
poor with trained lady nurses, and the only Institution
which has hitherto nursed the poor in their own homes
in Dublin; the Roman Catholic Usher's Quay Nursing
Institution, which has hitherto

only nursed

paying

patients; the City of Dublin Nursing Institution, which
is undenominational, but which hitherto has only nursed
paying patients.

IOO

APPENDICES

Each of these three Nursing Institutions has agreed
to employ and train a certain number of nurses to nurse
the poor in their own homes in Dublin, on the principles laid down by the Queen's Institute, and under
the superintendence of a highly qualified Lady Superintendent, who has already been appointed. An arrangement has been made to train a certain number of nurses
for Dublin, and it is hoped that the whole system will
be at work early next year.
Nevertheless, on some points, especially as to the
division of the Dublin work between the three Institutions, no definite settlement has yet been arrived at, and
until these points have been satisfactorily arranged the
organisation of the Dublin work cannot be considered
complete.
Though Wales was not mentioned in the original
letter, it requires special arrangement from the fact that
a considerable portion of the population of Wales do
not speak or understand English, and consequently it
will be desirable to have a certain number of Welshspeaking nurses trained for the Principality.
An opportunity arose at Cardiff for making arrangements which will ultimately enable this to be carried
out, by the offer from a gentleman to contribute ^ i o o
a year for three years, if the Cardiff people would find

APPENDICES

IOI

the necessary funds to carry out the system there.

The

Governing Body added the further offer to provide a
trained Lady Superintendent, whose salary they will pay
for two years.

A public meeting has been held at

Cardiff and a committee formed to establish a Nursing
Institution in that town, which, from its large population,
would constitute a good training centre for Wales.
From the above Report of the work done, it will be
evident that a broad foundation has been laid on sound
principles and good lines.
While the Governing Body was still provisional, the
work it could do, or could lead the public to undertake,
was confined within somewhat narrow limits, but the
response, on the part of those interested and occupied
in such subjects, to the Queen's initiative amply proves
that, when permanently established and more widely
known, the Queen's Institute, if built up on those lines,
and maintaining at the highest standard the work initiated, will carry out the Queen's benevolent intentions,
and will relieve suffering, and bring comfort and hope
into the most desolate and distressed homes of Her
Majesty's subjects throughout her dominions.
We cannot conclude our Report without stating that
as the work went on we became increasingly impressed
with its' importance and magnitude.

Such work cannot

102

APPENDICES

be carried out without great labour and very large funds,
much of which must be raised and spent by local effort
if the work is to succeed. We cannot, however, doubt
that if Her Majesty's subjects understand the importance
of the benefits conferred, and are satisfied that the work
will be thoroughly and well done, even the necessary
labour and those large resources will be freely forthcoming.
We hope soon to put in your hands a memorandum,
prepared and handed in to the Trustees for the information of our successors, containing a concise statement of
the different steps taken by the Provisional Committee,
of the considerations which guided them, of the regulations adopted, of the work which is being done by the
Metropolitan and National Association and existing
Institutions, and of the nurses actually trained and
under training during the past year.
The Provisional Committee cannot close their Report
without placing on record their sense of the valuable
services rendered by Mr. Rathbone, who undertook from
the commencement the onerous duties of Honorary
Secretary. The efficient manner in which the work
devolving upon him in that capacity has been carried
out for the benefit of the Institute and the promotion of
its objects, demanded unremitting attention on his part,

APPENDICES

and never failed.

103

Such labours in the initiatory stage

have been fully appreciated, and cannot be passed over
in silence by the Committee, which has so largely
profited by his assistance and wide experience in similar
work.
WESTMINSTER,
Chairman,
gth November 1889.

B
Q U E E N VICTORIA'S JUBILEE INSTITUTE FOR N U R S E S —
SCOTTISH BRANCH, EDINBURGH, F I R S T
REPORT,

ANNUAL

1889.

T H E Provisional Committee of the Scottish Branch of
Queen Victoria's Jubilee Institute for Nurses have the
pleasure of submitting their First Annual Report to the
Trustees and Subscribers.

The Queen was graciously

pleased to devote the surplus of the Women's Jubilee
Offering to found an Institute for promoting the training
and maintenance of nurses for the sick poor in their
own homes, the chief centre in London, but with similar
central institutions in Edinburgh and Dublin, to all of
which any institution satisfactorily fulfilling the purposes

APPENDICES

104

of the foundation might affiliate itself.
yielding an annual income of ^ 2 0 4 9 ,

was

This fund,
transferred

by the Queen to three Trustees—the Duke of Westminster, Sir James Paget, and Sir Rutherford Alcock.
Of this money ^ 3 0 0 a year has been allocated for the
District Training Home of the Scottish Branch, with an
additional ^ 1 0 0 to provide lectures and other special
instruction for the nurses.
A Provisional Governing Body, subsequently appointed by Her Majesty, drew up, with the Trustees,
certain fundamental conditions for the various branches
of the Institute; of these the chief were:

A uniform

standard for the qualification, training, and work of the
nurses; a requirement that, in large towns, the nurses
shall reside in homes under a qualified superintendent,
and nurse their patients, under the direction of medical
practitioners.

While not excluding cases of poor patients

able to make some contribution, the services of the
nurses must be strictly confined to the poor.
A Scottish Provisional Committee, under the presidency of the Countess of Rosebery, were next appointed.
One of their earliest acts was to summon a public
meeting in December 1888, in the Queen Street Hall,
under the presidency of the Lord Provost.

At this

meeting there was a large and influential attendance,

APPENDICES

105

and after a statement by Mr. J. B. Balfour on behalf
of the Provisional Committee, resolutions were passed
approving of the establishment of a Scottish Branch of
the Institute, and recommending it to the support of
the public.
The Committee, thus authorised, engaged the double
flat, 5 North Charlotte Street, as a temporary training
home, and, in December, engaged Miss Peter as superintendent. Miss Peter, who possessed special qualifications for the post of superintendent, was sent to
London to visit the various Nurses' Homes, and to
reside and work for a time at the Metropolitan District
Training Home, to acquaint herself fully with their
methods of district work. She began her work in
Edinburgh on the 1st April with three nurses, and five
others have been successively added.
In addition to their Hospital, Maternity, and District
Training, the nurses have attended a course of lectures
on Hygiene, with practical lessons, by Dr. Littlejohn,
assisted by Dr. Harvey Littlejohn, and lectures on'food
and practical cooking lessons. Arrangements are being
made for lectures on Gyncecology and on Physiology in
the course of the winter. It is required that the Queen
Victoria Nurses shall be highly trained and educated,
because, although they work under the direction of

io6

APPENDICES

medical men, these latter they rarely meet. They must,
therefore, be able to prepare notes on cases for the
doctor's visit, to extemporise hospital appliances, to act
in cases of emergency, and to do the work of sanitary
missionaries by promoting cleanliness, ventilation, and
other sanitary conditions.
One nurse has already been engaged by the Kilmarnock Nursing Association for the Sick Poor.
Another begins to work at Wemyss in November.
A third has been placed by arrangement with Miss
Cowan in Fountainbridge.
The medical officers of the Royal Dispensary, Richmond Street, have arranged for part services of a nurse.
Preliminary steps have been taken in Dundee towards
the foundation of a Nursing Association for the Sick Poor,
with a Nurses' Home in connection with the Institute.
The Committee have the pleasure of stating that the
work of the nurses has given much satisfaction to both
doctors and patients. The services of the nurses are
much appreciated, and sundry touching notes have
reached the Home, expressing gratitude for services
rendered. The nurses speak of the helpfulness and
goodness of the poor one to another, and of the ready
assistance they receive to keep up the high standard of
cleanliness which they require in the sickroom. Dis-

APPENDICES

107

trict work is supplementary to infirmary work, and many
cases are passed out from the infirmary when the district
nurse can be relied on to carry out the treatment prescribed. The nurses give one or more visits daily to
the patients, the length varying with the amount of
nursing required. Patients requiring continuous nursing are more suitable for the infirmary, but in cases of
emergency the superintendent has hitherto been able to
provide continuous or night nursing when required,
although the smallness of the staff renders this difficult.
The Institute is established with a view to aiding the
poor with the best nursing, and the wish of the Trustees
is that none of the money granted by them should be
spent on gifts of food, or clothing to patients. The
Committee have adopted this view in the management
of all the funds at their disposal. At the same time,
many cases of illness cannot be coped with satisfactorily
without warm clothing and food. To meet this difficulty
a Scottish Needlework Guild was formed by the Countess
of Rosebery to provide clothing and funds for food and
medical comforts. It has branches in sixteen Scottish
counties, and where branches of the Institute are formed,
the county subscriptions and garments from the Guild
will be given to these direct. The officials of the Guild
and of the Institute meet at the Home weekly to arrange

io8

APPENDICES

for grants of food and clothing. Nothing is given in
money; and the Committee acknowledge with gratitude
the valuable aid thus given to their work of nursing.
The Committee cannot close their report without a
special reference to the Queen's generous action in
regard to the Women's Jubilee Offering, an offering
made personally to herself. It is indeed a noble use to
which this money has been devoted, and one which,
expressive of Her Majesty's sympathy with the sick and
suffering poor, cannot fail to call out hearty co-operation
from the public, on whom it depends that the present
beginning shall serve as a nucleus for future development, and form the foundation of work on a larger
scale.
President—The Countess of ROSEBERY, Dalmeny Park.
^JOSEPH BELL, Esq., M.D., P.R.C.S.E., ExPresident of the College of Surgeons, W. S.,
2 Melville Crescent.
Vice-Presidents \
| Professor GAIRDNER, M.D., of the University of Glasgow.
COMMITTEE
The Marchioness of LOTHIAN, Mount Teviot, Jedburgh.
The Countess of ABERDEEN, Haddo House, Aberdeen.
The Hon. Lady CAMPBELL OF BLYTHSWOOD, Blythswood

House, Renfrew.
Lord HAMILTON OF DALZELL, Dalzell House, Motherwell.

APPENDICES

109

The Right Hon. J. B. BALFOUR, M.P., Q.C., 6 Rothesay
Terrace.
J. A. CRICHTON, Esq., Sheriff of the Lothians and Peeblesshire, 13 Nelson Street.
Mrs. FORD, 17 Grosvenor Crescent.
Mrs. HlGGINBOTHAM.

Miss LUMSDEN, Matron of the Aberdeen Royal Infirmary.
Mrs. TRAYNER, 27 Moray Place.
Miss LOUISA STEVENSON, Hon. Sec. of the Association for

the University Education of Women, etc., 13 Randolph
Crescent.
Sir THOMAS CLARK, Bart., D.L., F.R.S.E.,

Hon.

Hon.

Hon.

Treasurers*

Ex-Lord Provost, 11 Melville Crescent.
H. A. HOTSON, Esq., Manager of British
Linen Company Bank, 4 RothesayTerrace.

Financial Secretary—JOHN
Moray Place.

S. PITMAN, Esq., W.S., 36

Secretary — Miss G U T H R I E W R I G H T , Hon. Sec. of the

Edinburgh School of Domestic Economy, etc., 2 Landsdowne Crescent.

c
Q U E E N VICTORIA'S J U B I L E E
FOR
{Established

INSTITUTE

NURSES

under Royal

Charter)

THE Queen Victoria Jubilee Institute for Nurses owes
its foundation to the gracious gift by Her Majesty the

no

APPENDICES

Queen of the balance of the " Women's Jubilee Offering " (^72,538 :17 : 2—2 J per cent annuities) for the
purpose of providing improved means of nursing the
sick poor in their own homes throughout the United
Kingdom.
Her Majesty was pleased to appoint three Trustees
of the Fund, and a Provisional Committee, who should
act with them in organising a scheme for establishing a
system of nursing for the poor in connection with the
ancient Institution of St. Katharine's Royal Hospital in
the Regent's Park.
The general scheme, which the Provisional Committee have initiated, has had for its objects—
First The training of nurses in the special practice
of nursing the sick poor by visits at their own
homes (z.e. district nursing) in the three centres
—London, Edinburgh, and Dublin, by means,
as far as possible, of the Training Schools
already engaged in the work, and so maintaining
a continuous supply of qualified superintendents
and nurses to local associations already existing,
or to be formed for this special work throughout
the kingdom.
Secondly. As far as the income at their disposal

APPENDICES

in

would allow, to afford pecuniary aid towards
the first establishment of such local associations; and
Thirdly, By working in unison with affiliated local
associations to raise and maintain a high
standard of nursing for district nurses throughout the kingdom.
N.B.—These

objects have been carried out thus far by (i)

an agreement entered into with the Metropolitan and
National Nursing Association, Bloomsbury Square,
under which district nurses have been and are being
trained at the expense of " t h e Institute"; (2) the
formation of a Scottish Branch of the Institute, which
has established a District Nurses' Home and Training School in Edinburgh, and begun the supply of
nurses to other places in Scotland; (3) the employment and training of a certain number of nurses
in connection with certain Nursing Institutions in
Dublin, on the principles laid down by the Queen's
Institute; and (4) the appointment of Miss R. Paget,
a trained nurse, as General Inspector of Nursing.

By a Royal Charter, bearing date the 20th September 1889, Queen Victoria's Jubilee Institute for
Nurses was constituted a Body Corporate, under a
President and Council, to take charge of the annual
income of the fund and apply it for the purposes Her

APPENDICES

112

Majesty had designated—viz. " T h e training, support,
and maintenance of women to act as nurses for the
sick poor, and the establishment (if thought proper) of
a home or homes for such nurses, and generally the
promotion and provision of improved means for nursing
the sick poor."
The Queen, as Patron of St. Katharine's Royal
Hospital, has, by the Charter, appointed the Master
of St. Katharine's President of the Council, and has
nominated the Members of the Council and provided
for its location within the Hospital.
The Council are now prepared to carry out the work
which has been entrusted to them, by continuing and
extending what was initiated by the Provisional Committee.
They have accordingly prepared the following statement for the information of the public :—
The Council desire, in the first place, to point out
what in their judgment what will be the advantages of
affiliation to the Queen's Institute.
i.

It will place the affiliated associations in the

honourable position of being directly connected with
" T h e Institute" which bears the name and has been
established by the munificence of Her Majesty.
2. It will greatly assist in raising the standard of

APPENDICES

ii3

nursing for the poor, by securing that every Queen's
Nurse connected with the Institute shall be known to
be thoroughly trained and qualified for the work which
she is to undertake.
3. It will entitle the affiliated associations to be
supplied with superintendents and nurses when available, and to receive such pecuniary assistance as the
Council may consider right, and as they may be able
to meet from the funds at their disposal.
4. Nurses attached to Local Associations which have
become affiliated to the Institute will be eligible to rank
as Queen's Nurses, while nursing the poor in their
own homes, if they satisfactorily fulfil the Conditions of
Thorough Training, Efficient Work, and Unexceptionable Conduct.

CONDITIONS OF AFFILIATION

The following Conditions of Affiliation have been
approved by the Council:—
1. The standard of training and qualification of
nurses of any association to be affiliated

shall

be

practically the same as that adopted by the Council, in
accordance with the Regulations under which Queen's
Nurses are trained and enrolled.
I

APPENDICES

H4

2. In order that the same standard of efficiency may
be maintained, the Council reserve to themselves the
right of requiring reports from the affiliated associations
and of periodical inspection of the nurses' work.
3. The following qualifications shall be considered
requisite in order to entitle a nurse to be placed on the
roll of Queen's Nurses, namely—
(a) Training at some approved General Hospital or
Infirmary for not less than one year.
(b) Approved training in district nursing for not
less than six months, including the nursing
of mothers and their infants after childbirth.
(c) Nurses in country districts (in accordance with
paragraph 8 of these conditions), must have
at least three months' approved training in
midwifery.
N.B.—These

conditions are subject to modification by the

Council, to meet exceptional cases of those now engaged in district work who may afford satisfactory
evidence of competency.

4. In large towns the nurses shall reside in Homes,
and be under the charge of a trained Superintendent
approved by the Council

APPENDICES

115

5. The nursing of the patients shall be conducted
under the direction of the Medical Practitioners.
6. While not excluding cases of such patients as
are able to make some small contribution to the Local
Institution, the services of the nurses are to be strictly
confined to the poor.
7. In towns attendance as a midwife upon women
in childbed shall be excluded; but the nursing of
mothers and their infants after childbirth may be
undertaken when the Medical Attendant requires the
services of a skilled nurse, and on condition that
proper arrangements can be made for the nurse's other
cases.
8. In country districts the nursing of mothers and
their infants after childbirth may be undertaken whenever
required by the circumstances of the patients, but the
duties of a midwife, as distinguished from a nurse, are
not to be undertaken, except in cases of emergency, or
by the express permission of the Local Committee;
and with regard to such cases, on condition that proper
arrangements and precautions are taken with reference
to the nurse's other patients.
9. The nurses are strictly forbidden to interfere in
any way with the religious opinions of the patients or
the members of their families.

n6

APPENDICES

These conditions are subject to such modifications has further experience may from time to time
suggest.
With regard to the training of nurses in any School
for district nursing approved of by the Council,
they will make an annual grant to meet funds
locally provided for such purpose, and will continue
this aid for a specified term of years, so long as
the supervision and training are carried on to their
satisfaction.
In the case of Local Committees formed for the
purpose of introducing district nursing under the above
general conditions, the Council will be prepared, on
application, and so far as the demands upon them
can be met, to recommend a thoroughly trained and
experienced superintendent and one or more trained
nurses; and (so far as their funds will permit) to give
pecuniary aid towards the first establishment of such
District Homes, on receiving satisfactory assurance that
the necessary local aid will be obtained, from or by
the surrounding district, for their maintenance, subject to reports and inspection, as in the preceding
paragraph.
The Council hope that a general interest in this most
important matter will be awakened, and that they may

APPENDICES

117

be aided by the public in their efforts to make " The
Institute " worthy of the beneficent wishes and intentions
of Her Majesty.

A R T H U R

L

R

p£HJi

.

President of the Council,
ST. KATHARINE'S ROYAL HOSPITAL,
REGENT'S PARK, N.W.,
2$th March 1890.

D
MEMORANDUM ON THE TRAINING OF DISTRICT NURSES,
IN CONFORMITY WITH THE REQUIREMENTS OF THE
QUEEN'S

INSTITUTE. 1

Qualifications of Queen's Nurses—
(a) Training at some approved General Hospital or
Infirmary for not less than one year.
(b) Approved training in district nursing for not less
than six months, including the nursing of
mothers and their infants after childbirth.
(c) Nurses in country districts must have at least
three months' approved training in midwifery.
As the foregoing qualifications have been laid down
by the Council of the Queen's Institute as requisite to
1

It has been thought that the following details might be useful

to those hoping to start a district nurse or nurses.

n8

APPENDICES

enable a nurse to be placed on the roll, it may interest
the public to know in detail the reasons for such conditions, and the steps by which the required proficiency
can be attained, as the preparation for district nursing
differing in some ways from the preparation for private
nursing or Hospital appointments.
The primary object of the Queen's Institute is the
efficient nursing of the poor in their own homes. We
must, therefore, consider what is the training necessary
to fit nurses for these special duties.
In regard to the first condition (a) Training at some
approved General Hospital or Infirmary for not less than
one year, it would be desirable for all those intending
to become district nurses, and especially for those
intending to become district superintendents, to have
obtained a Hospital certificate. In many Hospitals
this means two or three years' service. In those cases
where the district nurse can only have one year's
Hospital training, this year should be spent as far as
possible with a view to what is specially necessary to
district work.
It would be advisable to divide the year somewhat
as follows:—
Three months in surgical and three months in medical
wards, evenly divided among men, women, and children;

APPENDICES

119

two in an obstetric ward, this special training being most
necessary for district nursing; and at least one month's
night duty in a medical ward. If during the remaining
three months the probationer could nurse some special
cases—typhoid, for instance, it would train her to
become skilled in note-taking, and to feel the responsibility involved in attending solely to one case. If to
this were added some experience in the surgery or outpatient department, including a little ophthalmic work,
a year could not be spent more profitably as a preparation for the object in view.
A variety of experience is of more importance to the
district nurse than the mastering of ward management
and detail. Of course, if the training is not confined to
one year, all these matters in turn receive due attention.
During this training the probationer would have the
opportunity of attending the excellent courses of lectures,
which in all large training schools are given during the
year by members of the medical staff. Of these she
should always take notes, and she should also enter her
cases with particulars about their symptoms and treatment in a pocket notebook.
In no training schools now do the nurses scrub floors
or clean grates, though complaints are often made by
probationers of the time taken up in doing " dirty work."

120

APPENDICES

This time should never be grudged by the intending
district nurse. She will find her district work made
much easier to her if she has been taught the best way
to perform what is a necessary part of her duties in the
homes of the poor.
Those who hope to become superintendents should
take every opportunity of perfecting themselves in all
matters connected with household management whether
of the ward or of the institution. Much larger experience and greater capacity are required to teach others
how to nurse than merely to do it oneself.
(b) Approved training in district nursing1 for not
less than six months.
During the district nursing training, special care should
be taken by the superintendent to supplement any deficiencies of their previous Hospital training. The probationers should attend courses of lectures and study
regularly under the superintendent's direction. At the
end of the term of training a report of their progress,
condensed from monthly records of their work, should
1

For many interesting particulars relative to the work of district
nursing, reference can be made to the Guide to District Nursing,
by Mrs. Dacre Craven (Macmillan and Co.) This lady speaks with
authority on the subject, as she was the first superintendent and
organiser of the Metropolitan and National District Nursing Association, since then so ably carried on by her successor, Miss Mansel.

APPENDICES

121

be supplied to the authorities by the district superintendent, who should note on her report the sort of district
work for which she considers the probationer most
adapted.
In some cases the district training might be extended
or curtailed, according to the capabilities of the probationer.
Technical Instruction.—During the six months' district
nursing training, regular courses of lectures should be
provided, bearing on the duties of district nursing, and
of a kind likely to be of practical use in future work.
Though fully-trained Hospital nurses will have received
instruction in elementary anatomy and physiology during
their Hospital training, it may be desirable that one
of the courses of lectures should be on this subject,
combined with medical and surgical nursing.
Other subjects specially necessary would be :—
A course of very practical hygiene^ including instruction in ventilation and other sanitary matters; on the
general principles of nutrition and diets for the sick and
healthy; and on dealing with nuisances, especially those
connected with the houses of the poor.
A course of instruction on fevers. Hospital nurses,
as a rule, have only experience in the nursing of typhoid
and perhaps diphtheria. Particular attention should,

APPENDICES

122

therefore, be paid to the diagnosis of infectious fevers
in early stages, the special dangers of infection in
each, and the means to be used for disinfection (see
Appendix).
A course of lectures on the diseases of women.

Dis-

trict nurses will find that a large proportion of the cases
they will meet with belong to this class.

Combined with

this course, some lectures on monthly nursing, including
the care of new-born infants, would be useful (this does
not mean lectures on midwifery).1
Before nurses leave the District Training School, the
superintendent should assure herself that they understand practical sick cookery, including the peptonising
of foods, and that they are good bandagers and understand the use of the various medical and surgical
appliances.

E
RESULTS OF AN EFFORT TO PREVENT THE SPREAD OF
INFECTIOUS DISEASE AND THE METHOD EMPLOYED.

A MEETING was held in November 1882, in the schoolroom of St. Mary's, Bryanston Square, to hear an address
1

We may here call attention to the fact that under the present
state of the law many women can and are practising and calling
themselves midwives who have no training whatever to qualify them
for doing so.

APPENDICES

123

by Mrs. Frances Johnstone, of St Leonards-on-the-Sea,
a lady who had long been impressed with the possibility
of effectually checking the spread of fever and other
infectious diseases. The subject excited considerable
interest, and the Hon. and Rev. Canon Fremantle, then
Rector of St. Mary's, having induced the Paddington and
Marylebone District Nursing Association to take the
matter up, it was decided to give Mrs. Johnstone's method
a trial in the crowded dwellings of the poor of the
district.
The necessary arrangements were left to Miss Persse,
the Lady Superintendent of the Association's Home, who
entered into the experiment with great interest and
enthusiasm. A special nurse was set apart to attend
infectious cases, and it is satisfactory to state that during
the four years this nurse has never caught infection, nor
has she conveyed it to the other nurses at the Home, or
to patients whom she may have attended elsewhere.
As regards the cases themselves, some of them of
severe character, it is believed that in no instance has
infection spread after the case has been taken up by the
nurse. The system was pursued with success even in
cases where the entire family occupied only one room.
In four instances, one child only (of several) had scarlet
fever, and being too unwell to be moved, was nursed

124

APPENDICES

through the illness to convalescence in the same apartment with the rest of the family.
The experience thus gained may be of service by
showing that the spread of infection is so entirely under
control. In emigrant ships, where cases of smallpox
and scarlet fever often appear, the authorities on board
may feel that, if proper precautions are taken at once, the
disease need not spread, and there need be no alarm or
panic on board, and no tedious quarantine at the end
of the voyage. It is hoped, too, when infectious disease
appears in a school or private family, that it need no
longer be allowed to run its course through the rest of
the household.
The following table gives the number of new infectious
cases attended by the nurse, to which is appended the
total number of all new cases nursed during each of the
last four years. Some of the infectious cases included
were sent to a hospital sooner or later after coming under
the care of the Association.

New Infectious Cases'!
attended in
J
Scarlet Fever .
Typhus „
.
Typhoid ,,
.
Smallpox
Chickenpox
Febricula
Measles .
German Measles
Diphtheria
Totals
Erysipelas
Ringworm
Scabies .
Mumps .
Total of all Infectious \
Cases .
.
.
J

1884

1885

1886

1887

1888

45
3
17
16

11

28

34

19

28
17

21

3i

22
1

24

25

4
35

8
36

16
25

19
39

7
2

5

15

"8

3

3
16
18
2
6

13

15

126
7
9
2

135
5
1
2

109
10

93
13

no
17

113
18

57
14
7

3

1

1

743
84
18
4
5
1 854

1883
73
2
16
2
3

1

1

1889

9 j

144

143

119

106

131

132

79

New Cases of all sorts ^
attended by the Associa- Jtion during each year
J 596

651

743

847

923

967

938

Total
219
5
159
36
7
70
180
2
65

j

1
to

APPENDICES

126

The nurse disinfects and ventilates the sickroom
directly she enters it.
It would be premature to conclude from the marked
diminution of new infectious cases treated from year to
year that the system adopted is diminishing infectious
disease generally in the district, but while such cases
have yearly diminished, both in number and severity, the
general cases attended have as steadily increased.

The

better the nurses are known the more their services are
in request, and the poor themselves have been so far
impressed with the value of disinfection that they now
frequently make personal application for the nurse to
visit them as soon as the symptoms of fever appear.
The increased number of cases of febricula treated by
the nurse point to this, and indicate that fevers at first
of doubtful character have been checked without further
development.
Whether or not any importance can be attached to
this view, there seems no doubt that the contact of the
nurses with the poorer classes, and entry into their
houses, have to some extent made them more careful
in sanitary matters and in general cleanliness.

More-

over, the opportunities afforded the nurses of speedily
drawing the attention of health officers to anything
irregular have been of use, so that their efficiency has

APPENDICES

127

been increased by the work of the Association, and
from, one cause or another the number of infectious
cases shows a marked diminution.
We are indebted to Miss Persse's reports for the
following details;—
The Paddington and Marylebone District Association began the nursing of infectious cases in February
1883, with the idea of preventing the spread of infection by strict attention to sanitary matters, cleanliness,
ventilation, and the timely use of disinfectants; by
inducing the removal of the patients to a hospital
where practicable; by isolating as far as possible those
suffering from the infectious complaint; by preventing
laundry and other work being taken into the house,
and by disinfecting if in the house; by preventing the
children of the family from going to school and those
in employment from entering the infected room or
approaching the patient, and by teaching the use of
disinfectants to members of the family.
The following articles will occasionally be wanted
by the nurse, but the quantities should be limited so
that every article may be disinfected and washed with
the least delay:—
India-rubber sheeting to prevent the bed being
stained.

128

APPENDICES

Clean cotton sheets and blankets.
Clean shirts, old and well worn are best.
Old linen rags, etc., to be disinfected and burnt
after use.
The disinfectants used have been—
Calvert's carbolic powder.
Do.
do.
acid liquid No. 5.
Do.
do.
soap.
Powdered sulphur and spirits of turpentine.
Permanganate of potash.
Chloride of lime.
The system pursued has been as follows :—
The carpets, curtains, valances, and all superfluous
furniture were removed and disinfected at once by
carbolic spray over them, — one part liquid carbolic
acid to ten or twenty parts hot water. When the
general fumigation took place after the patient's recovery the above articles were included in the treatment
(see below).
Dust and pails were cleared away at once, and, after
thorough cleansing, the latter disinfected by two
tablespoonfuls of carbolic powder.
All soiled linen was steeped in a carbolic solution of
one fluid ounce—say two tablespoonfuls—acid to six
quarts boiling water*

APPENDICES

129

Every portion of the floor was wiped over each
morning with a cloth well wrung out of a mixture of
chloride of lime, one small teacupful, say \
boiling water two quarts.

lb., and

This was continued daily

until the patient was free from all infection.
Carbolic spray (strength as above) was used in the
room twice daily.
In severe cases of all sorts disinfection with sulphur
and turpentine was sometimes used as in the case of
scarlet fever and diphtheria given below.
The patient was placed

daily

between

blankets

(warmed) and washed over with a piece of flannel
wrung out of a mixture of two tablespoonfuls (say
one ounce) vinegar to a small basin of hot water and
then rubbed dry with hot towels, carefully avoiding
chills.
In scarlet fever always, and sometimes in measles
and smallpox, Calvert's carbolic soap was used with the
vinegar and water.
A separate bed must of course be provided for the
patient, and

other

persons be prevented as far as

possible from entering the room or approaching the
patient.
The bed was made without the removal of the
patient.
K

130

APPENDICES

We would specially impress the importance of ventilation without draught in the room, and the avoidance
of chills.

The simplest and best means of ventilation

was obtained by leaving the top of the window a little
open, varying it according to circumstances, and keeping
a temperature of about 6o° F.
In scarlet fever, smallpox, diphtheria, and typhus,
a sheet saturated with carbolic solution, one ounce to
two quarts hot water was hung across the door.

The

sheet should be re-dipped or wetted often enough to
keep it constantly moist, say three times a day in ordinary weather.
In scarlet fever and diphtheria the room was disinfected twice daily,

morning and evening, with one

tablespoonful of powdered sulphur and one of spirits of
turpentine, burnt on a shovel moved about all over the
room.

This has been found preferable to carbolic acid.

In scarlet fever, diphtheria, and typhoid, the mouth
was cleansed three times daily with two or three crystals
permanganate of potash dissolved in a tumbler of water,
fresh each time.
In diphtheria carbolic spray of one in forty water was
used in the throat, and the moisture mopped out again
with a linen rag, which was at once burnt.
In

smallpox the pustules,

when

irritable,

were

APPENDICES

131

brushed over with camphorated oil, or, if very sensitive
with olive oil, on a earners' hair brush.
All food must be kept out of the infected room.
Direct definite permission was received from the doctor
before any baths were given to recovering patients.

For

bathing, an old hip bath or wash tub was provided, and
the patient well washed daily with carbolic soap, a piece
of flannel, and hot water.

Baths were given in all cases,

carefully avoiding chills.

It was found most convenient

to give the bath in the evening, so that the patient could
go from the bath straight into bed.

The bath was placed

close before the fire, and a towel horse or other screen
arranged to keep off any draught.
The patient was not allowed to go out of doors until
peeling was entirely over.
As soon as the doctor considered all infection over,
the clothes, bedding, and rooms were disinfected with
sulphur and turpentine—for a small room a quarter of a
pound of sulphur and half an ounce, or a tablespoonful,
of turpentine burnt on an iron pan, with the bedding,
clothes, etc. well exposed to the fumes for from four
to six hours.

The chimney should be closed and the

windows, doors, and other openings tightly closed by
pasting over with paper or otherwise.

In measles and

chickenpox this fumigation is scarcely necessary.

132

APPENDICES

Before leaving the patient's house, but not in the
patient's room, the nurse washed her hands with carbolic
soap, rinsed her mouth with fresh permanganate of
potash solution, removed her apron and sleeves before
associating with other persons, and was careful never to
take any overcloak into the infected apartment; she also
always wore a linen dress.
It is very necessary for the nurse herself to undertake
the actual disinfecting and arrangement of things to be
disinfected, as the people are slow to embrace the trifling
details that swell to grave results.
In order to be a real help to them, the nurse must
identify herself with the people in everything, their circumstances, capabilities, and hindrances, and instead of
ordering such and such a thing to be done, do it herself,
otherwise she can never depend on the success of her
work.
As all this work has been among the very poor, it has
been done in the simplest and least expensive manner.

THE END.

Printed by R. & R. CLARK, Edinburgh.