them. From this experience I became satisfied that the Scotch system can be introduced, under proper safeguards, in any Northern State, and would commend itself to the people as it long has in Scotland and Belgium, where they would never think of giving it up. Besides being an advantage to the patients, it saves the public the expense of building so many great asylums, and brings the knowledge of what insanity really is to many who would not otherwise understand it.

The fact that families can easily be found in the East and Middle West, at any rate, who are glad to add to their income by receiving children to board from the state, as in Massachusetts, or from private societies, as in Massachusetts, New York, Pennsylvania, and Illinois, shows that there is a population willing to take trouble and responsibility, in order to earn money within their own homes. There is no difference in the class of people boarding insane and children in Scotland. In fact, the same household cares for children and insane. Certainly, if one were to keep boarders, a dispassionate observation of those classed as sane and as insane gives the preference for amiability, contentment, and non-interference to the insane. Let me reiterate that the insane to be placed in families must be carefully chosen. There are many, and those, too, in many cases made most unhappy by the seclusion, who are never safe at large. There are others, no one knows how many, but Scotland and Belgium have shown it true as to one-fifth of the whole number, who can enjoy with great benefit to themselves, and with no harm to society, almost absolute freedom. The families must be carefully chosen, just as they are now chosen by public and private authority to board children. There still linger with us the traces of the old tradition that the insane are possessed of a devil, and it is this cruel delusion which bars our doors and even our sympathies against those sick with the baffling ailment we call insanity. If familiarity taught the peasants at Gheel not contempt, but fearless sympathy and skill a thousand years ago, why should we learn less readily now?

The question of relative cost of boarding-out and of institution care is of great practical importance. In the asylums of the Department of the Seine the daily per capita cost of care is 58 cents. At the colony of Dun the daily per capita is 28 cents. and at Lierneux the cost is about the same as at Dun.*

At Gheel

"En effet, le prix de pension d'un malade dans les Asiles de la Seine est de 2.90. A la colonie de Dun, il s'est abaissé à 1.40 (chiffre qui est le même qu'à Gheel et à Lierneux)."— L'Assistance Familiale urbaine pour les aliénés Inoffensifs. MM. A. Marie et Manheimer-Gommes. Published in L'Assistance Familiale, July 31, 1902.

In Scotland the current cost of boarding-out is about two-thirds that of hospital care. This statement disregards the item of the value of the hospital plant; i.e., the interest on the sum which is sunk in the building and improvements and repairs, and which can not be ignored in public financing any more than in private business operations.*

As has been said, the average cost of the bed must be added to current maintenance in order to arrive at actual cost. In American asylums this would certainly average not less than in Scotland, and many instances could be cited in which it would be far higher than the $45 which the bed is worth at the Inverness Asylum.

It will be noted that four distinct types have been mentioned: First. The Berlin system, in which an urban asylum boards out a fraction of its patients in close proximity,- as in the suburbs of Berlin, retaining them under the supervision of its physicians. This is valued not only for the lessening of cost and the relief to an overcrowded institution, but also because it affords an easy waystation for convalescents in the transition from the closed asylums back to the world. It is evident from the Mémoire of Dr. Marie that he hopes that some use of this method will be made by the hospitals of the Department of the Seine.

Second. The Belgian villages, which receive both acute and chronic cases, without previous commitment to an asylum, and at Gheel, at least, epileptics and imbeciles also, of both sexes and of varying ages. Both private patients and those dependent on the public are taken and accommodated according to former habit of life so far as possible.

Third. The French villages, Dun-sur-Auron, which receives only old women, and Ainay, its neighbor, which was opened in 1900 for Both men and women are those transferred from the closed asylums only.

men.

"Each of these patients is boarded for the modest sum of 5s. per week,- £13 per annum. Extras in the way of clothing, medical attendance, etc., may amount to £3 10s. per annum, certainly not more. The total cost is thus £16 10s. per annum. The net cost of maintenance in the Inverness District Asylum was last year £26 35. 5d. per head. The saving to the rate-payer by the boarding out system is thus £9 135. 5d. for each patient, or an aggregate saving in the one colony of £328 16s. 2d. per annum on maintenance alone. This takes no account of the value of the bed, which in the case of the Inverness Asylum costs the rate-payer at present more than £9 per patient yearly. The rate of board is a small one, but, boarded as they are with people who have most of the necessaries of life growing on their small holdings, it is, after all, not unremunerative. The money paid by the parochical authorities pays the rent of their holdings, and goes a long way in providing such things as tea, sugar, etc., for the household." Report by Dr. Charles MacPherson, Appendix C., Forty-third Report General Board of Commissioners in Lunacy for Scotland, p. 168.

Fourth. The Scotch plan, in which from the Lowlands to the Hebrides insane persons transferred from the closed asylums are boarded in villages, in scattered farm holdings, with crofters, etc. Both men and women are thus cared for. The patients' care is paid for by the parishes to which they belong; and they are under the immediate supervision of the parish authorities, above whom is the General Board of Lunacy Commissioners with a force of physicians as visiting deputies. No locality is allowed to become known distinctively, as one where insane patients are boarded.*

It is important to note that in the four instances referred to there is a well-organized system of public care and supervision, and that the officers intrusted with the management of the system are not political appointees in the unhappy sense, but are civil servants who have undertaken a dignified occupation with its own responsibilities and rewards, absolutely removed from the domain of politics. Such a system and such a personnel are essential to such an enlargement of method in the care of the insane as is meant by boarding-out.

In a photograph taken at Dun one sees a peaceful, bowery little garden with a woman sitting in the sunshine. Her face expresses that melancholy with which we are familiar in every asylum, but there is a placidity about her not so often seen behind locked doors. Is it fanciful to suggest that the open wicket which is shown leading out of the garden is a better guarantee of contentment than the jangling keys of the institution? We are well aware that long years of discussion will be needed before any plan of boarding-out can have general recognition in the United States; but is it not time to consider the subject?

For copies of forms used to record supervision of patients and visits, see Notes on Boarding Out in Scotland," Appendix to Illinois State Board of Charities Report, 1898.

VII.

Hospitals, Dispensaries, and Nursing.

THE WORK OF THE DISTRICT OR VISITING

NURSE.

BY MISS HARRIET FULMER,

SUPERINTENDENT OF NURSES, VISITING NURSE ASSOCIATION, CHICAGO.

The following is a short résumé of the system of the relief for the destitute sick in their own homes, carried on by the district or visiting nurse:

District or visiting nurse work covers that branch of nursing which cares for the sick poor in their own homes, when by reason of surrounding circumstances the patient may not be sent to the hospital. The work is likened to a large outdoor hospital, the various towns and localities being divided into wards or districts, the whole being responsible to the head or superintending nurse.

Philanthropic organizations providing skilled nursing care for the poor and the small wage-earners in their own homes have the advantage of having developed into such practical adjuncts to outdoor relief work among the poor that every small community is coming to look upon the organization of the visiting nurse system as a necessity. Its workings, if known and understood, must prove to the public its value in overcoming the great inadequacy of various sick relief agencies both of the county and city, caused often perhaps by lack of funds, many times unwisely and dishonestly spent. In its co-operation with kindred charities its workers are acknowledged and must be ever valuable agents in helping to place organized charity on the basis where modern effort would put it. The trained nurse as a visitor to the homes of the sick poor is unconsciously a living example of the well-worn Biblical saying, "I was

sick, and ye visited me." Her influence far outlives her actual presence, yet no class of charity workers see so quickly a response to their efforts as the visiting nurse. Daily instruction in habits of cleanliness and hygienic living to people in their own homes must some time bear fruit; and scarcely a week goes by that we do not hear from this and that quarter a story illustrating the effects of the personal contact of a woman skilled in this profession which belongs to her by reason of her birthright. Not long since one of these workers dropped in to pay a friendly visit to a family who not many months since had been patients. Here she found Tommy, a threeyear-old, yelling lustily because the little eight-year-old sister insisted upon giving him a bath, the child saying with an air of great responsibility that she had promised the visiting nurse to keep herself and her whole family clean, but Tommy always behaved so badly she was getting very tired. This same little one was herself clean and tidy; and her mother has told us since that she is constantly preaching cleanliness as a guard against illness, not only to her own family, but to the neighbors as well. She has been dubbed "the little health officer" in the locality.

The need of sick relief work is always apparent. It requires little red tape and not much investigation. If a person is suffering from bodily ills, he is immediately "a case," no matter what condition. brought the illness. Can there be any disputing the fact that the poor dying consumptive in his own cottage needs the visit of a nurse to give him clean linen and a bath, as no one other than skilled hands could do? or that the poor little child the county institution sends home because the case is " 'chronic," or the unfortunate woman with a malignant cancer, that no hospital will admit, need such care? If this system of relief work to the sick poor ministered only to those whom hospitals could not take, it would have even then more than ample excuse for existence; but, when we find avenues untold for just such service, it must be without question a benefaction to the poor.

The one established principle of the work is to teach and to preach cleanliness and right living in the homes and to help the people bear the burden of caring for their own sick rather than shifting the responsibility to an institution. Five per cent. of the cases in one society alone prove that having to care for a sick member of the family, with a nurse's advice and instruction, develops in the well members many a good quality, and places the responsibility of caring for their