Rural Hygiene

by Florence Nightingale

 

HEALTH TEACHING IN TOWNS AND VILLAGES

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RURAL HYGIENE

BY

FLORENCE NIGHTINGALE

LONDON

SPOTTISWOODE & CO., NEW-STREET SQUARE

1894

Price (illegible text)

 

 

Reprinted from a Paper read at the
Conference of Women Workers held at Leeds,
November 7th to 10th, 1893.

 

[Advertisements]

Health Missioners for Rural Districts.

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In the Spring of last year (1892) the North Bucks Technical Education Committee of the County Council employed Dr. De'Ath, of Buckingham, to give a course of instruction, including fourteen lectures, to ladies residing in the neighbourhood, on "Health at Home" in Country Villages. Of those who attended the whole course, six ladies passed satisfactorily an examination conducted by Dr. Wilson, Medical Officer of Health for Warwick, and, after a period of probation in practical work, were granted certificates as "Health Missioners," and four of them have since been engaged by the North Bucks Technical Education Committee to visit and lecture in the country villages of North Bucks, their salary being fixed at the rate of seven shillings per day for five days in the week, travelling expenses from one village to another being also allowed.

It is now under consideration that Dr. De'Ath should be asked to deliver a further course of lectures at Bletchley, which may be attended not only by ladies who are resident in Bucks, but also by those who are not, and who may find employment as "Health Missioners" in other counties.

It is proposed that non-residents who attend the course of lectures should contribute a fee of three guineas towards expenses.

Applications to attend the course should be addressed to Mr. H. M. Williams, Secretary of the North Bucks Technical Education Committee, Wolverton, who will give any further information required.

January, 1893.

 

HEALTH TEACHING IN TOWNS AND VILLAGES.

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RURAL HYGIENE.

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BY FLORENCE NIGHTINGALE.

I have been pressed to write a paper, for the Leeds Conference of Women Workers, on Rural Health and Rural Health Missioners; and, though sorely entangled by pressing matters, I am the more anxious to do so because of the great attention which many ladies seem to be giving to the subject, and which appears to be spreading not only West but East. In two of the provinces of wide India it has been asked whether something could not be done there by instructed native Lecturers, who were also to go round the village showing the people on the spot where to put their refuse, how to keep their water-supply pure, &c., &c. And in one of these provinces the Lecturers were to be seconded by instructed native women visiting and teaching health habits to the village poor native women in their own homes. And the true word has been spoken: What can be done for the health of the home without the woman of the home?

Let not England lag behind—especially not in the conviction that nothing can be done without personal friendship with the women to be taught. It is a truism to say that the women who teach in India must know the languages, the religions, superstitions, and customs of the women to be taught in India. It ought to be a truism to say the very same for England. We must not talk to them, or at them, but with them.

A great man who has just passed away from us used to advise his young men, when they entered life, to make personal acquaintance with the poor, whether they took or not to "works of philanthropy." He did not believe in any "philanthropy" which was not in fact what the word means—the love of men. But the knowledge of a man must go before the love for him—acquaintance, friendship, love can only come in this order; and the love that springs from the sympathy of a close and accurate knowledge of the ways, the habits, the lives of the poor is not a mere sentiment, but an active and a fruitful enthusiasm.

This is eminently the case with cottage mothers, in the matter of Rural Hygiene. You must know them, not as a class, but each one by herself, in order to do her service in this all-important matter.

And now I propose with your leave to touch upon—

1. The present machinery of Rural Public Health.

2. The present state of Rural Hygiene.

3. What the women have to do with it.

4. (In answer to many questions asked.) Some sketch of the scheme of Health-at-Home training and work.

5. What we mean by personal acquaintance and friendship between the women instructors and women to be instructed, always bearing in mind that the latter differ as widely from each other in character as they do in the circumstances of their lives

And to begin with:

1. What is the Existing Machinery of Public Health in what are called—with a grim sarcasm—our Rural Sanitary Districts? Is health or sickness, life or death, the greatest miracle in the present condition of things? To some of us the greatest miracle, repeated every day, is that we can live at all in the surroundings which our ignorance and neglect create.

There is the

Board of Guardians^[1]: "Sanitary Authority," who give the tag-end of their time to a subject which might monopolise the whole of it, and yet not be exhausted.

Medical Officer of Health: generally a busy man with a private practice covering a very large area, who earns a pittance for doing a most important public duty; a man appointed to his office and maintained in it by those whom he ought to criticise fearlessly and openly, when they are careless about the health of those dependent on them. His salary, which ought to be proportionate to his capital of knowledge ever accumulating, and his income of experience rolling up as years go on, which should give him an opportunity for sufficient leisure to work at public health as a scientific study, apart from his medical practice—his salary, which should be enough for this, is often hardly sufficient for his necessary travelling expenses as a public official—sometimes only a few pounds per annum.

Sanitary Inspector: an official appointed by the Guardians^[2], who are at liberty to select anyone they like, without any guarantee whatever that he has either the knowledge or the will to do his work, but upon the efficient performance of which may depend the health and even the lives of many hundred families in the district he inspects. He may be—sometimes has been—an unsuccessful farmer or tradesman, and he may be entirely independent of the control of the Medical Officer, who generally has had nothing whatever to do with his appointment, and is powerless to dismiss him.

We all know that in 1890 an Act was passed—there are more than 100 sections in it—for the Housing of the Working Classes. It is an Act which consolidates the wisdom and experience of experts, and was backed by the authority of the most influential men in the country. On paper there could hardly be a more perfect Health Directory for making our "Sanitary" Authorities and our "Sanitary" Districts worthy of the title they bear. We have everything defined for us that can require a definition. We have "powers" given to everyone who can possibly wish to have them. We have duties imposed upon our officials in language that is as clear and precise as the best draftsmen in England could make it. We have awful threats launched against any and every dwelling-house which appears to a Medical Officer of Health "to be in a state

so dangerous or injurious to health as to be unfit for human habitation." In fact, everything is provided for, except the two things more necessary than all the rest, namely, the money to pay for and the will to carry out the reforms. And it is perfectly well known that, if this law were enforced immediately and completely, say, three-fourths of the rural districts in England would be depopulated, and we should have hundreds of thousands of houseless poor upon our hands, for such, at least, is the proportion of houses unfit for habitation in our rural districts.

We all know that, even where the law can and ought to be enforced, it is daily and persistently evaded to the great danger of public health—e.g. where Dairies, Cow-sheds, and Milk-shops Regulations are supposed to be in force, and where there is practically no registration; and no inspection exists that is worthy of the name.

These are the facts as they are.

Now let us consider what they ought to be.

We want independent Medical Officers of Health—appointed by the County Council, and removable only by them—men trained up for this as a profession; we want Sanitary Inspectors, with a proper qualification, appointed with the Medical Officer's approval; we want that each Medical Officer should be informed as to all approaches of dangerous disease, and bound in his turn to supply the information for other neighbouring districts; we want Sanitary Inspectors who are duly qualified by examination, acting under the directions of the Medical Officers, in order that they may feel themselves responsible for their appointment and co-operators in their work; Sanitary Inspectors who are not removable unless for neglect of duty, and certain to be removed if they do persistently neglect it.

We want a fully trained Nurse^[3] for every district, and a Health Missioner. We want a Water-supply^[4] to each village, pure and plentiful; Rain-water properly stored; Earth closets—Scavenging^[4]: as necessary a public duty as paving and lighting; Gardens^[4] near houses, and allotments where refuse and privy contents are used for manure^[5]; Cottage-owners made amenable to sanitary laws, compelling the landlord to give his cottages the essentials for health as far as construction is concerned; School teaching of health rules, made interesting and clear by diagrams showing dangers of foul drains and so forth. [But we must not expect too much practical result from this. It has failed, except as a book or lesson, where it has been tried in India. The school-master himself should be a health apostle.] When our water is poisoned, we want to know it; then we shall avoid it. But it is far more difficult to get people to avoid poisoned air, for they drink it in by the gallon all night in their bedrooms, and too often in the day.

We will now deal with the

2. Present State of Rural Hygiene, which is indeed a pitiful and disgusting story, dreadful to tell.

For the sake of giving actual facts,—it is no use lecturing upon drainage, water-supply, wells, pig-sties, storage of excrement, storage of refuse, &c., &c., in general; they are dreadfully concrete,—I take leave to give the facts of one rural district, consisting of villages and one small market town, as described by a Local Government Board official this year; and I will ask the ladies here present whether they could not match these facts in every county in the kingdom. Perhaps, too, the lady lecturers on Rural Hygiene will favour us with some of their experiences.

A large number of the poor-cottages have been recently condemned as "unfit for human habitation," but though "unfit" many are still "inhabited," from lack of other accommodation.

Provision for conveying away surface and slop water is conspicuous either by its absence or defect. The slop-water stagnates and sinks into the soil all round the dwellings, aided by the droppings from the thatch. [It has been known that the bedroom slops are sometimes emptied out of window.] There are inside sinks, but the waste-pipe is often either untrapped or not disconnected.

It is a Government Official who says all this.

Water-supply almost entirely from shallow wells, often uncovered, mostly in the cottage garden, not far from a pervious privy pit, a pig-sty, or a huge collection of house refuse, polluted by the foulness soaking into it. The liquid manure from the pig-sty trickles through the ground into the well. Often after heavy rain the cottagers complain that their well-water becomes thick.

The water in many shallow wells has been analysed. And some have been closed; others cleaned out. But when no particular impurity is detected, no care has been taken to stop the too threatening pollution, or to prohibit the supply. In one village which had a pump, it was so far from one end that a pond in an adjoining field was used for their supply.

It may be said that, up to the present time, practically nothing has been done by the Sanitary Authorities to effect the removal of house refuse, &c.

In these days of investigation and statistics, where results are described with microscopic exactness and tabulated with mathematical accuracy, we seem to think figures will do instead of facts, and calculation instead of action. We remember the policeman who watched his burglar enter the house, and waited to make quite sure whether he was going to commit robbery with violence or without, before interfering with his operations. So as we read such an account as this we seem to be watching, not robbery, but murder going on, and to be waiting for the rates of mortality to go up before we interfere; we wait to see how many of the children playing round the houses shall be stricken down. We wait to see whether the filth will really trickle into the well, and whether the foul water really will poison the family, and how many will die of it. And then, when enough have died, we think it time to spend some money and some trouble to stop the murders going further, and we enter the results of our "masterly inactivity" neatly in tables; but we do not analyse and tabulate the saddened lives of those who remain, and the desolate homes in our "sanitary" "districts."

Storage of Excrement in these Villages.—This comes next. And it is so disgustingly inefficient that I write it on a separate sheet, to be omitted if desired. But we must remember that if we cannot bear with it, the national health has to bear with it, and especially the children's health. And I add, as a fact in another Rural District to the one quoted above, that, in rainy weather, the little children may play in the privy or in the so-called "barn" or small outhouse, where may be several privies, several pigs, and untold heaps of filth. And as the little faces are very near the ground, children's diarrhœa and diseases have been traced to this miasma.

Cess-pit privies.—The cess-pits are excavations in the ground; often left unlined. Sometimes the privy is a wooden sentry-box, placed so that the fœcal matter falls directly into a ditch. Cess-pits often very imperfectly or not at all covered. Some privies with a cubic capacity of 18 or 20 feet are emptied from once to thrice yearly. But we are often told that all the contents "ran away," and that therefore emptying was not required!

These privies are often close to the well—one within a yard of the cottagers' pump.

Earth closets are the exception, cess-pit privies the rule. [In another place 109 cess-pit privies were counted to 120 cottages. And, as might be expected, there was hardly a pure well in the place.]

In one, a market town, there are water-closets, so called from being without water.

Storage of Refuse and Ashes.—Ashpits are conspicuous by their absence. Huge heaps of accumulated refuse are found piled up near the house, sometimes under the windows, or near the well, into which these refuse heaps soak. Where there are ashpits, they are piled up and overflowing. Privy contents are often mixed up with the refuse or buried in a hole in the refuse-heap.

As to the final disposal, in most cases the cottagers have allotments, but differing in distance from but a few yards to as much as two miles from their homes. Their privy contents and ash refuse are therefore valuable as manure, and they would "strongly resent" any appropriation of it by the Sanitary Authority.

And we might take this into account by passing a bye-law to the effect that house refuse must be removed at least once a quarter, and that if the occupier neglected to do this, the Sanitary Authority would do it, and would appropriate it. This amount of pressure is thoroughly legitimate to protect the lives of the children.

Health Missioners might teach the value of co-operation in sanitary matters. For instance, suppose the hire of a sewage-cart is 1s. the first day, and sixpence every other day. If six houses, adjacent to each other, subscribed for the use of the sewage-cart, they would each get it far cheaper than by single orders.

The usual practice is to wait until there is a sufficient accumulation to make worth while the hiring of a cart. The ashes, and often the privy contents too, are then taken away to the allotments. A statement that removal takes place as much as two or three times a year is often too obviously untrue.

But, as a rule, the occupiers have sufficient garden space, i.e. curtilage, for the proper utilisation of their privy contents. [I would urge the reading of Dr. Poore's "Rural Hygiene" on this particular point.]

Often the garden is large enough for the utilisation of ashes and house refuse too. But occupiers almost always take both privy and ashpit contents to their allotments. Thus hoarding-up of refuse matters occurs. In some cases the cost of hiring horse and cart—the amount depending on the distance of the allotment from the dwelling—is so serious a consideration that if bye-laws compelled the occupiers to remove their refuse to their allotments, say every month, either the value of the manure would be nothing, or the scavenging must be done at the expense of the Sanitary Authority. From the public health point of view, the Sanitary Authority should of course do the scavenging in all the villages.

The health Economy of the Community demands the most profitable use of manure for the land. Now the most profitable use is that which permits of least waste, and if we could only regard economy in this matter in its true and broad sense, we should acknowledge that the Community is advantaged by the frequent removal of sewage refuse from the houses, where it is dangerous, to the land, where it is an essential. And if the Community is advantaged, the Community should pay for that advantage. The gain is a double one—safety in the matter of health—increase in the matter of food, besides the untold gain, moral as well as material, which results from the successful cultivation of land.

There are some villages without any gardens—barely room for a privy and ashpit. But even in these cases the occupiers generally have allotments.

Plenty of bye-laws may be imposed, but bye-laws are not in themselves active agents. And in many, perhaps in most, cases they are impossible of execution, and remain a dead letter.

Now let us come to

3. What the Women have to do with it—i.e. how much the cottage mothers, if instructed by instructed women, can remedy or prevent of these and other frightful evils.

And first

(1) Our Homes.—The Cottage Homes of England being, after all, the most important of the homes of any class, should be pure in every sense. Boys and girls must grow up healthy, with clean minds, and clean bodies, and clean skins. And the first teachings and impressions they have at home must all be pure, and gentle, and firm.

It is home that teaches the child after all, more than any other schooling. A child learns before it is three whether it shall obey its mother or not. And before it is seven its character is a good way to being formed.

When a child has lost its health, how often the mother says: "O, if I had only known, but there was no one to tell me!"

God did not intend all mothers to be accompanied by doctors, but He meant all children to be cared for by mothers.

(a) Back Yard and Garden.—Where and how are slops emptied? The following are some of the essential requisites: slops to be poured slowly down a drain, not hastily thrown down to make a pool round the drain; gratings of drain to be kept clean and passage free; soil round the house kept pure, that pure air may come in at the window; bedroom slops not to be thrown out of window; no puddles to be allowed to stand round walls; privy contents to be got into the soil as soon as possible—most valuable for your garden; cesspools not to be allowed to filter into your shallow wells; pump-water wells must be taken care of, they are upright drains, so soil round them should be pure. Bad smells are danger-signals. Pig-sties—Moss litter to absorb liquid manure, cheap and profitable; danger from pools of liquid manure making the whole soil foul.

Now, what have we to teach practically about the

(1b) Bedroom?—Is not what we want to get into a bedroom, fresh air, the most important thing of all, and sunshine, not merely light, but sunlight? What we want to get out of a bedroom, foul air? An unaired bedroom is a box of foul air. Opening of windows: but windows differ so much in their construction one from the other, that no general rule can be laid down, except that in all cases there must be ventilation near the ceiling; and the Health Missioner must see the kind of window and how it opens, in order to show the best way of airing the room. If, happily, there is a fireplace, no board or sack must fill up the chimney.

Furniture of Bedroom—Bed and Bedding.—No feather or flock bed to be allowed with unwashed tick, or which has not been pulled to pieces for years to be cleaned. Cleansing of chamber utensils—danger of unemptied slops—how to get rid of dust, and not merely to let it fly into the air and settle again. How to get rid of vermin. Lumber—not to turn the space under the bed into a lumber closet with rags and refuse, worn-out clothes and boots, coals and potatoes. Nothing to be kept under the bed but the chamber utensil with a lid. No vallance, only a frill. No carpet in the bedroom. Fresh air and sunshine in the bedroom by day promote sleep by night.

(1c) Kitchen.—Danger from refuse of food, grease in all the rough parts of kitchen table and chopping blocks, crumbs and scraps in chinks of ill-laid floor. Even typhoid has been known to result from this in barrack-rooms. How to fill up these chinks. Danger of remains of sour milk in jugs and saucepans. All refuse poisons the air, spoils fresh food, attracts vermin, rats, beetles, &c. Brick floor too porous, dangerous to sluice with too much water. Where do you get your water for cooking? Is it water plus sewage? Where do you get your milk? Is it milk plus water plus sewage? Where do you keep it? How to keep milk cool; how to clean kitchen table, crockery, pots and pans. Danger of dirty sink.

Parlour.—Danger of uninhabited rooms without sunlight and fresh air, and with blinds pulled down—genteel parlour chilling to the bone. Clean papers not to be put over dirty ones. Tea-leaves for sweeping carpets; but better to have no carpets nailed down.

(2a) Ourselves.—The Skin and How to Keep the Body Clean.—Simple account of functions of skin. Beauty dependent on healthy state of skin, not on a fine hat. Use of the skin as throwing out waste matter. Compare the village child with a beautiful clean skin—such a child as any mother would long to kiss—with the leper of the Scriptures, a loathsome object, the skin all sores, so repulsive to others, so painful to himself, that, as a miracle, he asks to be made "clean," and the gracious answer comes: "I will: be thou clean."

Then show that the difference between the child and the leper is just the difference between a healthy and unhealthy skin. The difference between a clean skin and a dirty skin is the difference between health and sickness.

Enter fully but not learnedly into the work of the pores. Dangers of a choked skin. The body choked and poisoned by its own waste substances might be compared to a house whence nothing was thrown away—the scullery choked with old fat, potato peelings, &c., the drain from the sink stopped up, the grate full of cinders, the floor of dust, the table of grease and crumbs. None of these things were dirty at first: it is the keeping them that makes the house uninhabitable.

Then speak very plainly of the offensive condition of an unwashed body, the smell of the feet, the horrible state of the hair, the decay and pain in the teeth, &c.; the consequent poisoning of the air of the room, &c. It is the human body that pollutes the air.

Then, how and when the body can best be washed; large vessels and much water not indispensable for daily cleansing. But there are great advantages in the Saturday's tub and plenty of soaping, and in friction of the skin. Not babies only, but men and women require daily washing. The body the source of defilement of the air.

The entire want of privacy in the bedrooms, the constant drive of the mother's occupations, make it a matter of difficulty when she can wash herself. [As a matter of fact, most women do not wash at all.] The Missioners should show the utmost sympathy—should, without giving offence, draw her out by careful questions, asking what plan the women would recommend rather than what they do.

Then comes the question of towels.

Then comes the question of hair and hair-brushes. Mothers should encourage their girls' natural wish to look nice, make them proud of beautifully brushed and well-plaited hair, rather than of the smart hat above it.

Then comes the question of tooth-brushes. [How often does it happen that the lady's own underservants come to her service without a tooth-brush?]

The Missioner should be able to give the price of each article she recommends—towels, hair-brushes, tooth-brushes, &c.

(2b) Clothes.—The Circulation, and How to Keep the Body Warm.—Simple account of how the heart and lungs act. Clothes to be warm and loose—no pressure. Test for tight lacing: if measurement round the waist is more with the clothes off than when stays are worn. Danger of dirty clothes next the skin—re-absorption of poison; danger of wearing the same underclothing day and night; best materials for clothing—why flannel is so valuable; danger of sitting in wet clothes and boots—too little air causes more chills than too much; the body not easily chilled when warm and well clothed.

(2c) Food.—The Digestion, and How to Nourish the Body.—Simple account of how food is digested and turned into blood. Worse food (well cooked) and fresh air better than best food (ill cooked) without fresh air. Diet, not medicine, ensures health. Uses of animal and of vegetable food. Danger of all ill-cooked and half-cooked food. Nourishing value of vegetables and whole-meal bread. Danger of too little food and too much at the wrong times. Dangers of uncooked meat, specially pork, diseased meat, decaying fish, unripe and over-ripe fruit, and stewed tea.^[6] Vital importance of cooked fruit for children, stewed apples and pears, damsons, blackberries. Value of milk as food. [Don't sell all your milk.] Influence of diet upon constipation, diarrhœa, indigestion, convulsions in children; small changes of diet promote appetite and health.

(3a) Extra Subjects.—Home Treatment.—What to do till the Doctor comes and after the Doctor has left.—Grave danger of being one's own doctor, of taking quack medicines, or a medicine which has cured someone else in quite a different case.

A cottage mother, not so very poor, fell into the fire in a fit while she was preparing breakfast, and was badly burnt. We sent for the nearest doctor, who came at once, bringing his medicaments, in his gig. The husband ran for the horse-doctor, who did not come, but sent an ointment for a horse. The wise woman of the village came of her own accord, and gave another ointment.

"Well, Mrs. Y.," said the lady who sent for the doctor, "and what did you do?"

"Well, you know, Miss, I studied a bit, and then I mixed all three together, because then, you know, I was sure I got the right one."

The consequences to the poor woman may be imagined.

Another poor woman, in a different county, took something which had been sent to her husband for a bad leg, believing herself to have fever. "Well, Miss, it did he a sight of good, and look at me, ban't I quite peart?" The "peartness" ended in fever.

Liquid food only to be given till the doctor comes. Danger-signals of illness, and how to recognise them. Hourly dangers from ruptures if not completely supported by trusses. What to do if clothes catch fire—and for burns, scalds, bites, cuts, stings, injuries to the head and to the eye, swallowing fruit-stones, pins, &c. Simple rules to avoid infection. After the doctor has left—how to take care of convalescents; how to feed. It is not uncommon to give such things as onion broth or solid food to people and children recovering from typhoid (enteric fever), which generally produces a relapse, sometimes fatal. In convalescent homes for children the urchins have refused their bread and milk and asked for pickles (which seem now to have taken the place of sweets), and when they have found that only bread and milk was to be had for breakfast, these urchins have gone out and succeeded in getting pickles, and even kippered fish, and the like, after breakfast. When to keep rooms dark, and when to admit plenty of light. Danger of chills.

(3b) Management of Infants and Children.—How to feed, clothe, and wash. Nursing, weaning, hand-feeding; regular intervals between feeding; flatulence, thrush, convulsions, bronchitis, croup. Simple hints to mothers about healthy conditions for children. Baths. Diet—how to prevent constipation and diarrhœa. What to do in sudden attacks of convulsions and croup. Deadly danger of giving "soothing syrups" or alcohol. Made foods not wholesome. Head-ache often caused by bad eyesight. Symptoms of overwork at school—head-ache, worry, talking in the sleep. Danger to babies and little children of any violence, jerks and sudden movements, loud voices, slaps, box on the ear. Good effects upon the health of gentleness, firmness, and cheerfulness. No child can be well who is not bright and merry, and brought up in fresh air and sunshine, and surrounded by love—the sunshine of the soul.

4. (In answer to many questions asked.) Some Sketch of the Scheme of Health-at-Home Training and Work.—The questions asked have been mainly: How to begin? What is your plan for Health-at-Home instruction and training the Health Missioners to train the cottage mothers in their homes: it is altogether different from nursing disease: it is preventing disease. The answer must needs be somewhat dry:

(1) First and foremost the pivot must be: a rural Medical Officer of Health chosen for fitness and experience by the proper local authority.

(2) The keys to the whole situation are the educated women desirous of becoming Health Missioners, to whom lectures, training in the village itself, are given by the earnest Medical Officer of Health.

(2a) The lectures by the Medical Officer to include elementary physiology: i.e. a simple explanation of the organs of the body—how each affects the health of the body, and how each can be kept in order. This constitutes the science of Hygiene, framed so as to give the practical scientific basis on which popular familiar teaching to village mothers and girls can be given. Other ladies may be admitted to this course of not less than fifteen lectures.

(2b) The Medical Officer of Health gives further instruction in classes to those who wish to qualify as Health Missioners, both by oral instruction and papers.

(2c) The Medical Officer now takes those who have attended the classes into the villages to visit the cottages, and shows them what to observe and how to visit.

If the Medical Officer is himself in touch with the village mothers, not only will he not give offence, but these visits will be welcomed.

(2d) The Medical Officer chooses the candidates he deems qualified to be examined for Health Missioners. These qualifications must be—good character, good health, personal fitness for teaching, tact and power, so as to be "in touch" and in love with the village mothers—to be acceptable to them—growing in sympathy for them, to be their personal friend, and to make them her personal friends—not "prying about," as the village mothers might say. Not Bacteriology, but looking into the drains, is the thing needed. Even Medical Students do not learn much from lectures, unless with the objects before them. [N.B. Both Medical Officer and Missioners must be enthusiasts in the work, must believe in Hygiene and Sanitation, believe in them as a life-and-death matter.]

(3) The candidates are now examined by an independent Examiner appointed by the local authority—one who is familiar with the conditions of rural and village life, so unlike town life—who then, in conjunction with the Medical Officer, recommends the candidates who have satisfied them both to the local authority, and the latter appoints as many as are required.

(4) The Health Missioners are appointed to districts, consisting each of a number of small villages grouped with a larger one, or the market town. Over these there is a District Committee which is represented on the local authority. Each village has a local committee, represented on the District Committee. The local committee makes arrangements for the lectures by the Health Missioner and for receiving her.

(5) The Health Missioner works under the supervision of the Medical Officer of Health, who as often as possible introduces her to the village in the first instance; and he makes it his business to inquire into the practical results of her work.

(6) The lectures to the cottage mothers are delivered in simple, homely language.

But (7) the lecture is only the beginning of the work, the prelude to it. The real work is when, having made friends with the cottage mothers, and being invited by them to their own homes, every one of whom and every one of which differs from every other, the Health Missioner practically shows the cottage mother there, in the bedroom, in the kitchen and parlour, in the backyard and garden, in washing everybody's skin clean, in clothing and food—aided by the cottage mothers, who alone can tell her how to make what she has taught practicable. They teach her as much as she teaches them. The mothers should help her by asking questions and by relating their own experiences. And, in a lecture, the Missioner should welcome such questions, even if asked rudely. If she snubs them, it is all over with her usefulness.

The eye and hand must be trained to see and deal with dangers to health. "No practical knowledge is possible on any subject without the meeting of the senses with the material."

(8) After a Health Missioner has become settled in a district, she will then be able to receive a Probationer, who, while attending the Medical Officer's lectures and classes, will find time to accompany the Health Missioner in her round of visiting. [It will depend on the tact of the two ladies if this is acceptable or not to the cottage mother; if unacceptable, it must, of course, cease.] The Lecturing Missioner must be well acquainted with the busy life of cottage mothers. The contrast is indeed strange between the poor woman who said (she was every day thirteen to fifteen hours on her feet), "O that I could sit down one hour a day, with nothing to do!" and the young lady who has her arms and legs pulled about by "Kinesipathy," or some such conundrum, to supply the want of exercise.

(9) You will doubtless ask: How shall we get the results of the Health Missioner's work fairly and completely tested? A question not at all easy to answer, because, in the first place, there can be no speedy results, the process is necessarily very slow; and because, in the second place, the results are often not on the surface, but in the intimate and private habits of life which a stranger who comes on a tour of inspection can hardly inquire about without giving offence. There are, however, two kinds of tests. The one is that which a carefully prepared system of written returns will give, showing attendance at village lectures, and the number of cottage visits paid by invitation, and other figures and facts that are capable of tabulation. The other test is that which can be obtained from a tactful Lady Visitor, who may go round either with (if she be a stranger to the people) or on the track of the Health Missioner, gathering as she goes, by the talk of those whom she visits and the condition of their cottages, what the influence of the Health Missioner has been, and how she has bettered the facts and conditions of the lives of the people.

5. What we Mean by Personal Acquaintance and Friendship between the Lady Lecturers and Cottage Mothers.—This is not to be made by lecturing upon bedrooms, sculleries, sties, and wells in general; but by actual examination of the particular bedroom, scullery, sty, and well, which differ as much in different cottages as the characters of the inmates. A lecturer is a prescribing person. But what would you say of a prescribing doctor who only saw his or her patient on the benches of a room, who never examined into the case of each individual, never visited his patients, or came into touch with any of them? This is the lecturer. He or she is not even a tutor who sees pupils separately. He or she never comes into contact with them. To the lectured mother it is like going to the play. The cottage mother is, as a rule, both civil and timid. But how often one has heard her say: "I be sure it's very kind of the ladies to come and lecture to we, or try to amuse we. But that's not what we want. They don't know what us wants." Sympathy with, interest in the poor so as to help them, can only be got by long and close intercourse with each in her own house—not patronising—not "talking down" to them—not "prying about;" sympathy which will grow in insight and love with every visit; which will enable you to show the cottage mother on the spot how to give air to the bedroom, &c. You could not get through the daily work of the cottage mother—the washing, cooking, cleaning, mending, making. So ask what plan she would recommend to carry out your suggestions rather than what she does. The old cottage mother has no idea of responsibility for the health of her family. It is all the "will of God." But the young mother, who has had some education, is anxious to be taught. A very pregnant remark was made: "How superior the animal mother is to the human mother in intelligent care of her offspring; the cow never tries to teach her calf to eat grass, and the cat licks her kitten all over before it is half-an-hour old." As has been said of other people, may yet more truly be said of cottage mothers. You cannot know them by just seeing them in class. You certainly cannot know their homes, their circumstances, their daily work so excessive, their troubles so bravely borne, their gossip—often their only recreation. You cannot know the points through which they can be influenced and influence others. They certainly cannot be managed or influenced in a lump—rather less than anybody else. You must know each and her individuality, separately at home, if you are to do any good. And you must be welcome to them. You must "mother" the cottage mothers, and the girls. And don't think that the gain is all on their side. How much we learn from the poor—how much from our patients in hospital—when heart meets heart. It is a rule among the best District Nurse Societies not to give alms (money).This also should be a rule of the Health Missioners. But without knowing the wants, the difficulties, temptations, fatigues, of their daily lives—without a serious study of their world—we cannot help them. Much fatigue is occasioned by their want of method. Their deplorable manners to their children have been noticed. "I'll bray your brains out if you don't do it voluntally"—this was an affectionate mother, about going to school. But then, the heroism of the poor! The lecture is only a foothold for knowing the cottage mothers. And let us remember the town can no more instruct the country than the country the town. The success of this or any work cannot be tested by the number of lectures delivered, or even by the attendance at the lectures, but only by the practical results that have actually appeared from the teaching applied in personal visits. Such results must of course be slow; but slow and sure wins the race. The test of success is the gaining the confidence of the village mothers, and being invited to help them in their own homes. They must feel that the Health Missioner comes not to find fault, but to find friends. And the lectures will indeed be a dismal failure unless the cottage women support the Missioners. "It seems to be of no use talking," said a great Sanitary Commissioner. And it is perfectly vain to try to convert the villagers without themselves. Results shown are the only test.

Conclusion.

The criticism on all this will be: "What an enormous time it will take! You are describing a process that will not take weeks, but months and years. Life is not long enough for this."

Our reply is that, for centuries there have been superstitions, for centuries the habits of dirt and neglect have been steadily and perseveringly learnt, and that, if we can transform by a few years' quiet persistent work the habits of centuries, the process will not have been slow, but amazingly rapid. What is "slow" in more senses than one is the eternal lecturing that is vox et præterea nihil—words that go in at one ear and out at the other. The only word that sticks is the word that follows work. The work that "pays" is the work of the skilful hand, directed by the cool head, and inspired by the loving heart. Join heart with heart and hand in hand, and pray for the perfect gift of love to be the spirit and the life of all your work.

Can there be any higher work than this? Can any woman wish for a more womanly work? Can any man think it unworthy of the best of women?

When the greatest men of science devote a large part of their lives to bring in simple language within the reach of all the results of their deepest study, the women of the highest cultivation and of the deepest sympathy may well take up such work as we have attempted here to sketch out.

But they must "stoop to conquer." Or rather, they must not think it "stooping," but following the Divine in their hearts, to be "at home" in the cottage mothers' homes.

 

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Spottiswoode & Co. Printers, New-street Square, London.

1. By the Local Government Act, 1894, all the powers and duties of the Board of Guardians, as Sanitary Authority, are transferred to the newly-constituted District Council of the Rural District, which takes the place of the Rural Sanitary District.
2. By the Local Government Act, 1894, all the powers and duties of the Board of Guardians, as Sanitary Authority, are transferred to the newly-constituted District Council of the Rural District, which takes the place of the Rural Sanitary District.
3. This Nurse must have supervision, even if only periodical, from a trained Superintendent Nurse. If she is a Queen’s Jubilee Nurse, this is provided for. But the question of her assistant requires the most careful management. An untrained assistant, who afterwards may say she has been trained, is disastrous, and justly prohibited by some associations.
4. By the Local Government Act, 1894, certain powers are conferred on the Parish Councils, thereby constituted, with regard to water-supply, sewers, and hiring of allotments.
5. For uses of earth, see Dr. Poore’s "Rural Hygiene."
6. In one county it is a common habit to add a spoonful of tea every day to the teapot, and empty it out only, say, once a month, stewing the tea all the while.