THE TRAINING SCHOOL IN THE INSANE HOSPITAL.'

BY EDWARD B. LANE, M. D.,

Late Medical Superintendent Boston Insane Hospital, Boston, Mass.

I assume no one will deny that an insane hospital is maintained primarily for the benefit of the public. Its first aim is to provide a safe place for those who would do harm if allowed their liberty and at the same time afford all remedial agents to restore every patient possible to the community. Our insane are peculiarly entitled to every consideration at the hands of the hospital authorities, the agents of that public who have taken great authority upon themselves in removing that patient from his home, usually against his will, and deprived him of his liberty by due process of law. The insane patient is confined not because he has wilfully violated the rights of society, but because as the result of disease, he has become unfit or unsafe to remain at large. It has always seemed to me that for this very reason our insane hospitals should be compelled to furnish the best of care, a skilled medical and nursing staff, abundant nourishing food, comfortable quarters and every remedial agent that is approved. Those who seek aid in general hospitals or almshouses do so voluntarily, because they believe they can be cared for better there than in their home surroundings. The public owes a peculiar debt to its insane wards which it may be said it cheerfully pays as a rule. The passing generation saw the care of the insane evolve from the jail and almshouse standards to the modern hospital, as we call it.

A number of philanthropic people, appalled at the prevalence of insanity in our midst, have earnestly advocated and attempted to put in practice the hospital method of caring for the insane. They urge upon us a rapid extension of the hospital methods and the adoption of the externals of the general hospital. With this reform our insane hospitals have adopted training schools for While a few insane hospitals have been born with train

nurses.

1Read at the sixty-second annual meeting of the American MedicoPsychological Association, Boston, Mass., June 12-15, 1906.

ing schools, more have achieved training schools, and many have had training schools thrust upon them. We now have "wards" for "halls," "nurses" instead of "attendants," "sleep charts" for night reports, etc. This movement is a good one, and I hope to see even further progress made in the same direction. The presence of the terrible scourge of insanity will always stimulate the community to use every device for its cure or prevention.

I wish to discuss with you to-day, not the question of the propriety of training our nurses-for I think that has already been answered in the affirmative-but the details of adaptation of the general hospital training school to the needs of the insane hospital. From what I said as to the duty of the insane hospital to the public, it follows that the training school should be for the benefit of the patients in the hospital, and we must not let the zeal of the reformer lead to the error of regarding the hospitals as maintained for the benefit of the training schools.

I was much interested in listening a few years ago to a very able plea made by Dr. James Russell, of Hamilton, Ont., for the asylum versus hospital. Many present to-day will remember the Doctor's caution lest we make too hasty an adoption of the hospital. Let me quote a few sentences from him: "If the torchlight of science has burned with greater brilliancy within the hospital than within the asylum, whose fault is it? Is it not a confession of weakness to commit an act of grand larceny by assuming a name we have not earned and thus take a short cut to popular favor!"

Again he says: "I propose now to show that the word hospital in its modern application is a misnomer when applied to an institution for the insane, and that the future evolution of the asylum must be on educational and industrial lines instead of hospital methods." He then points out that in his own hospital only 5 per cent require strictly hospital treatment, and 20 per cent, while physically healthy, are possibly curable, leaving 75 per cent as incurable, and later he says: "In all our large asylums there is a perfect Niagara of mental and physical force going to waste, and how to utilize this force from an economical and psychological standpoint is the great and burning question which confronts us to-day."

We must all agree that the strictly hospital work in our institutions is a small affair. It is important and often hitherto perforce slighted. Now the larger hospitals have well equipped infirmary wards, but practical difficulty in classifying our sick insane has hindered the development of a special hospital department. The American public is utilitarian, and is willing to spend money if that will cure the insane in our hospitals, but hesitate to provide so expensive quarters for those incurably ill. But we all know that curable or incurable the sick patient needs a great deal of attention and must have it. It is also true that many of the sickest curable cases, for a time, must be treated in the wards for extremely disturbed cases. Even could we diagnose the curable from the incurable on admission, what practical advantage would there be in maintaining duplicate wards for the two classes. I would have the infirmary in the insane hospital in charge of a nurse who had had experience in both an insane and a general hospital. This ward would attract pupil nurses who would learn there the essentials of sick nursing. And the nurse who acquits herself well in such a ward with its peculiarly difficult work has acquired a valuable experience. She will find herself equipped for a useful career in private practice in nursing medical cases. But with not over 10 per cent in our infirmaries, how are all our nurses going to get that experience? And this brings me to the first difficulty in the training school for insane hospitals. The inexperienced applicant is misled by the term hospital training school and is disappointed when she finds 90 per cent of her work in the school is with the physically well. This objection has long been met by an arrangement whereby those ambitious for a wider experience may enter a general hospital for a brief supplementary course. This is an excellent thing where it can be done. But even then what inducement is there for a bright young woman to take half her course in an insane hospital when the general hospital offers her the full course of more interesting work in its own wards? Many hospitals for the insane have been unable to promise such a postgraduate course for our training school pupils, and I have seen several after spending two years in an insane hospital begin at the bottom in a general hospital.

It would seem that we in the insane hospitals must demonstrate

by our good work that we can furnish the general hospitals with a superior class of applicants so that it will be for their advantage to take our graduates and allow them to enter at an advanced standing. The insane hospital has long been a training school for superintendents of the general hospitals. The insane hospitals are large and the organization is well perfected. Institution methods are as well, if not better, learned there than elsewhere. The pupil nurse has as good (I believe better) opportunities to acquire her preliminary studies of the training school in the insane hospital as in the general hospital. The experiment is now being made where institutions of learning shall provide a course of instruction to fit young women for nurses and relieve the hospital of the literary work of its school. That is well if it insures a definite standard of general education for probationers, but I believe such instruction given in the hospital alternating with hours of duty on the wards will prove more stimulating and valuable.

Among the advantages urged for a training school in our hospitals is that it will attract a superior grade of women. This is undoubtedly true if the school gets a reputation for good work. I believe such a reputation may be acquired even though our annual list showing the number of graduates who have married and their social status be not published. Still that may help.

To one who contemplates opening a training school in an insane hospital I would urge the importance of increasing the staff from 10 to 15 per cent. The school work demands about that proportion of the pupils' time, and if no allowance is made for that it simply means that the patients will get so much less care. Nor would I insist on every nurse being a member of the school, while such a state of affairs may be ideal it is not always practicable. I have found that such a rule leads to attracting an inferior grade of the attendant class who come for the smaller wages paid the training school members, and care nothing for the instruction given. There is a vast amount of necessary routine work that is done by the old-fashioned attendant more satisfactorily than by the young pupil nurse who is, in accordance with training school ideas, assigned in rapid rotation to various posts of duty. Here the general hospital methods, it seems to me, are unsuited to our needs. In the general hospital the average resi