per cent. of such in their clientele. College and Carlton Street doctors give from 30 to 50 per cent. as about the proportion; while doctors practicing south of this line state that from 80 per cent. to 90 per cent. of their families are unable to afford a graduate nurse. Remember that the question excludes all purely charitable cases, and refers to those who constitute the main body of our citizens. In the light of such figures the answer to my first question is very apparent.

Question No. 2 was: To what extent is the need of such a class of people supplied by district or other nurses, and at about what expense? The replies indicate that the need is supplied to a certain extent by, first, the district nurses and Victorian Order, at prices commensurate with the purse of the families visited; second, by the working nurse, who is also called the untrained nurse and sometimes the "experienced" nurse, and who charges from $7.00 to $10.00; occasionally as high as $14.00 per week.

These, they say, are usually women of middle life, of more or less ability, who often do exceedingly good work, who also are willing to help in the house. According to the replies received, these are viewed in some instances by the doctors as "doing as good work as a hospital nurse "; in others, as "a menace and a nuisance." But most physicians agree that in no instance are they to be compared in value to a trained nurse; yet they are largely in demand, because their charge is within the reach of the average Toronto income.

Medical men all testify to the value of the services rendered by the district and Victorian Order nurses; but their time is necessarily limited; they can make only brief daily visits, and while this is well in midwifery and certain other cases, it is not sufficient or satisfactory where the diseases are of a serious medical or surgical nature.

But the main objection to the service of the latter is that our average citizen feels that these are charitable organizations, and he has an instinctive pride that prefers not to make claim upon them.

A general practitioner on Bloor Street says that one of the registries will provide trained nurses who will attend midwifery cases, charging an initial fee of from three to five dollars, and subsequent visits at fifty cents each. It is not guaranteed, however, that the same nurse will follow the case through; she merely makes these occasional visits while she is waiting to be called to a case which will pay the regular rates.

The consensus of our replies to question No. 2 gives us to know that the majority of our citizens are compelled by reason of cost to make use of the services of the untrained nurse.

The last question was: Does any plan suggest itself to you as to what may be done to lessen any hardship this class of people may have in respect to nursing, (a) by hospitals or training schools, (b) by graduate nurses, (c) by visiting nursing organizations, or (d) by any other means you may think of.

A suggestion made by several of the correspondents is that there might be an arrangement by which nurses in training should be sent out into the homes, the people being asked to pay a specified fee for services; this, it is held, would give the nurse a wider experience, and teach them to adapt themselves to family environment; the change of work would stimulate interest in the regular hospital work; this visiting work to be under the supervision of graduate nurses. Another says, if a number of graduates were available as nurses in these homes for a short period after graduation, the results would be very beneficial to the people, to the hospital and to the nurses themselves.

One doctor says with an amusing combination of metaphors that the situation might be improved by constantly keeping before the minds of the undergraduates that they are entering a profession and not a trade; that, like medical practitioners, they should temper the wind to the shorn lamb and not exact the pound of flesh from all alike, meaning thereby that they should grade their charges to suit family needs. Of course, says another, it is a hardship to ask a nurse to take a case, devoting all her time at small fees, but this might be obviated by an endowment scheme to supplement the fees, and when nurses are off duty in the various homes visiting rates or at reduced fees, otherwise financial considerations will tend to make the ordinary experienced nurse the doctors' main assistant in all except wealthy patients' homes.

Another doctor says that the city might have a fund from which to pay the attending nurse, or some philanthropically inclined individual might provide a fund like the Straus' milk fund in New York City, from which nurses might be paid. Another doctor says that "an appeal might be made to the public for help. for such a fund. A registry supported in some such way might be able to provide nurses at prices within reach of the great middle class. This would be a great boon. Some plan, however, would have to be devised which would guard against imposition and fraud, and which would make people in some way prove they were unable to pay the regular trained nurses' fees."

"It seems to me," another writes, "that properly trained nurses should be available at the rate of $10 a week. There is no degree of seniority after graduation is once attained-one nurse is supposed to be as good as another. Let there be a classifying of graduates according to their standing in years or by competitive examination. The junior graduates, or those who

stood lowest, could secure steady work among the middle classes at a lower rate than that now charged by graduates. It would be better for them to have steady work at a lower rate than fitful engagements at a higher rate." This writer maintains that when hospital training is over the great art of dealing with human nature is only just beginning. In his experience, the older nurse has a value far above the recent graduate, which to be appreciated does not need the prolonged observation, subtle as this difference is when attempting to describe it.

A Bloor Street physician writes:

"In the old days, before graduate nurses existed to any extent in most families, there were women, either maiden ladies or widows, who were tacitly admitted to be the ones to be sent for when anyone in the family circle took ill. These women never had any hospital training, but had a natural turn for nursing and were invaluable. Nowadays they seem to have passed out of existence. He thinks that if in any way such nursing could be again encouraged it would be a great blessing to the community. One way to do this would be by having classes like the St. John's ambulance classes of some years ago, in which women who had an inclination toward nursing could be taught some of the most essential things that they should know; making the beds properly, arranging the patient's toilet, preparing the food, taking the temperature, making poultices, etc. These women would in no way interfere with the practice of the graduate nurse, who will always be invaluable in all cases of severe illness, but they would often be of immense value to their friends and relations. This writer thinks that in addition to the doctors giving lectures many graduate nurses would be willing to deliver addresses to classes of these women and thus help greatly toward the lessening of human suffering."

"If the general public felt," says another, "that they could call a professional nurse who would give a portion of her time. to the case requiring it, and would only charge for the time so occupied, I think possibly they might avail themselves of the services of such nurses to a greater degree. I do not think the people of Toronto recognize the value of trained nurses to as great an extent as do the people in American cities. The great bulk of those of moderate means, only in cases of great gravity, feel willing to pay the present rate asked by professional nurses fully trained.

"As a general practitioner who uses hospitals as little as possible, I am finding the best help by the teaching of cooking and dietetics to the young women of these families. When the rising generation of women are well trained in invalid cooking we

will be able to handle any case with a visit from a nurse for an hour a day."

So, we see, to sum up the opinion of the profession:

That the people of moderate means in the city are not well provided with trained nurses.

That it is desirable that they should be so provided.

That the work is in part done by nurses belonging to the Victorian Order, district nurses, "experienced " nurses, so-called, and by occasional graduate nurses.

That training schools might send out nurses to these families; this to constitute a part of their training, a fee being charged commensurate with the work done.

That the work might be done by graduate nurses, a fund being provided by some one to supplement the fees they would receive from the patients.

That we might resort to the resuscitation of the old type of family relative nurses, who would receive gratuitous instruction from medical men and graduate nurses.

That there is here a large field for nurses who are not as fully and as widely trained as the graduates of training schools with a three year course.

And further, that the work is one which is appealing more and more to graduate trained nurses who are not kept employed in the wealthier homes.

I have to-day learned from a nurse of another means apparently unknown to the doctors who replied to my queries, by which this want is commencing to be supplied, by an institution at which are registered the so-called "experienced" nurses and mothers' help, graduates from the smaller Canadian and American training schools, and of undergraduates, who, for good reason were not able to finish the regular course of training. The number of nurses on this list is thirty-five, and the work that they do is mostly among people of the middle class, who are able to pay less than the amount asked by graduate nurses.

Another fact my medical correspondents did not seem aware of has also been communicated to me that in one of the larger registries in which some 250 trained nurses are registered, those lowest on the list, when not busy, will respond to calls from middle-class and poor families at reduced rates.

We may conclude, then, that the need of trained nursing in the homes of people in moderate circumstances is being felt by both the medical and nursing profession, and that an effort is now being put forth to supply it which should receive the greatest possible encouragement. From the National Hospital Record.

NOTES ON NEURASTHENIA.

BY FREDK. J. HICKS, M.A., M.B. Oxon., etc.

In the everyday practice of the gynecologist there is frequently met with a class of cases which, for want of a better name, may be designated as those of atony in regard to marital obligations in the female sex.

Nor

In the above designation dyspareunia is not included. This belongs to quite a different category, and its causes are generally local and easily ascertained, and accordingly removable. has it anything to do with the question of sterility. In one patient I had to attend, coitus was followed by profound nervous shock and intense pain in the region of the ovaries, which necessitated morphia injections, but this patient was the mother of two children, and in both cases the pregnancies and parturitions were natural.

The condition referred to may also have many local causes, but when these have been removed by treatment suitable to each individual case, and this is so important a matter that no specific treatment can be effectually tried until it has been done, the apathy remains which, while it may not have anything to do with sterility, yet is a powerful factor against domestic happiness, as is much too insufficiently recognized, and is also an almost certain precursor of those very same ailments which originally brought the patient to her medical adviser.

The causes of such a condition are often obscure and difficult to investigate, the more so as the mere questioning may lead to the suspicion of pruriency, and reticence on the part of the patient is the natural outcome of the mode of education, wrongly based on one of the early chapters of Genesis, that the conditions of sex are to be regarded as something to be ashamed of.

But while the causes may be purely neurotic, psychic, or emotional, or inherited, they are generally to be looked for in the direction of, or perhaps it should be said estimated by, the intensity of the special senses, and more particularly in that of touch, which varies in individuals much in the same way as are the known variations in the power of seeing colors and detecting odors, to mention the two most frequently noticed aberrations from the normal.

This being the case it is evident the treatment has to be something other than local.

Of aphrodisiacs there are plenty so-called, all more or less useless, even in the male, for whom they are always in the main designed, and if generally useless here, they are more so for the purpose above mentioned. In speaking of the latest of these