NURSING-REFORM 
FOR THE INSANE. 
— BY— 
EDWARD COWLES, M. D., 
Superintendent of the McLean Asylum for the Insane, Somerville, Mass. 
[From the American Journal of Insanity, for October, 1887.] FIFTEEN NURSES. CLASS OF 1886. 
MCLEAN ASYLUM TRAINING-SCHOOL. 
COMPOSITE MADE BY NOTMAN. 
From THE CENTURY MAGAZINE for November, 1887. Nursing-Reform for the Insane.* 
IIY EDWARD COWLES, M. D., 
Superintendent of the McLean Asylum for the Insane, Somerville, Mass. 
It is a rare event when, in the cause of humanity, the gratitude 
of a great nation is earned as it was by Florence Nightingale in 
the noble reform which she began in 1854, in the Crimea; the 
whole world acknowledges its lasting debt to her. No greater 
work has ever been done for the amelioration of human suffering 
and the saving of human life than this, which has been accomplished 
in the brief time of one generation. The history of hospital 
reform, and of nursing reform in the general hospitals, is well 
known. But it seems not to be known so well that when Miss 
Nightingale went to Kaiserswerth in 1844, to be trained in the art of 
nursing the sick under the instruction of a Protestant Sisterhood, 
Parson Fliedner only represented there the humane spirit which 
had previously, in Germany, inspired also Dr. Jacobi in his wrork 
on “ Hospitals for the Insane.” The world know's what was done in 
France, years before that time, by Pinel. Dr. Jacobi despaired of 
his ideal in the attendance he desired for his patients; and since his 
book was republished in England in 1841, with Samuel Tuke’s 
introduction, nothing has been written which sets forth a clearer 
or more humane conception of the needs of the sick, and especially 
of the insane, in intelligent and sympathetic personal attention, 
than came then from those two men. The leadership in these 
ideas of reform then belonged to those wrho had the care of the 
insane; and those who have come after them in this work have 
constantly striven to put these ideas into effect. Dr. Browne, 
at the Crichton Institution, in 1854, the same year that Miss 
Nightingale was in the Crimea, had as high a purpose and as 
humane desires, in giving his thirty lectures to his officers and 
attendants, and striving to get for his insane patients what so 
many have longed for—the ideal nurse. But the crying need of 
this has come down to our own times, through a series of lamenta- 
tions that the boon could not be had, and of failures to gain it. 
In the meantime the way was opened for the general hospitals; 
the opportunity came, and with it the woman. She has created 
* Read before the Psychological Section of the International Medical 
Congress, Washington, D. C., September 8, 1887. 2 
an epoch for the hospitals, while the asylums were still groping to 
find the way in which they first felt the need of going. 
There were reasons for this failure of the asylums; and now 
that, under the stimulus and example of the work in the hospitals, 
the former have made a beginning in nursing reform for the insane, 
it will be profitable to study those reasons, and to get as clear a view 
as possible of the best way to carry on the reform. The move- 
ment has been begun in America with a scope of purpose and an 
effectiveness of early results that furnish something to study, for 
improvement or approval. At this stage of progress it is import- 
ant that good foundations shall be carefully laid, and that the 
contingencies which endanger the success of the movement shall 
be guarded against. “ Slow and sure” is a good motto in this, as- 
in many other things, because failure, or even qualified success, 
means at least the misfortune of delay in a great reform that is 
certain to prevail. 
While viewing the subject in its larger aspects, it is the present 
purpose to say something of the apparent difficulties in estab- 
lishing systematic methods of training nurses in our asylums,— 
difficulties that disappear if properly provided against; and 
especially to point out some of the real difficulties that will arise 
at the beginning and in the course of such a work, and threaten 
its failure. Something of warning and suggestion on my part 
may be justifiable, from its having happened to me, in the last 
fifteen years, to organize two training schools, one of them in a 
general hospital, and each requiring about five years for the prep- 
aration and establishment of the work. This must be the apology 
for assertions which it might require more extended discussion to 
sustain. Besides the difficulties that may be readily apprehended 
in making innovations in the usually well-ordered systems of 
asylum service, some other apparent ones, that seem to stand in 
the way of training nurses, may be mentioned as examples. It is 
thought by some that the educating and fitting of women, in the 
asylums, for general nursing will lead the nurses into this branch 
of the work for the public, and lose them to the asylums for whose 
benefit the labor of training is primarily undertaken; again, if to 
avoid this, they are trained simply for the especial nursing of the 
insane, they will find themselves without an occupation outside of 
the asylums, because there is so little done in the country in 
general in the private and home care of the insane. This at once 
shows that in addition to the interests of the [asylums and their 
inmates, there are, on the one hand, important^questions com cerning the interests of the public at large, and on the other, of 
the nurses themselves. 
To answer these questions and others let us take a large view of 
the subject, in order to include some of its less obvious bearings, 
and look first at the results of the reform in the general hospitals. 
Those in Boston furnish good examples of these results, both to 
the hospitals and to the public. Previous to 1873, the old order 
of things existed in all America. In that year in Boston, (and in 
the same year in New York and New Haven), there were imported 
the beginnings of that most beneficent 'work first organized in its 
secular and effective form, by Florence Nightingale, at the St. 
Thomas Hospital thirteen years before. At the Massachusetts 
General Hospital the work began in a few wards in 1873, and at 
the Boston City Hospital the formal organization of a school was 
complete in 1878 for the whole hospital. In 1873 the instructed 
nurse was an experiment, and a cause of apprehension. It was 
said she would know too much, or would think she need not obey 
the physician in all particulars; she would tamper with the 
treatment; she would want to be a doctor herself, etc. Now 
there are in this country, few general hospitals of importance, in 
which nurses are not carefully trained in their duties, according 
to well-established methods of instruction. 
In the short period of fourteen years, since the introduction of 
the reform in America, the following are some of the results of 
the work of the principal Boston schools—the Boston Training 
School at the Massachusetts General Hospital, and the Boston 
City Hospital Training School. The table shows the whole num- 
ber of graduates, the average number of graduates that remain 
in the service, and the average number of nurses, trained and 
untrained, on duty at all times: 
Whole No. of 
Average No. of 
Whole No. of 
Mass. Gen. Hospital, Graduates. 
Graduates Remaining. 
Nurses on Duty. 
in 14 Years, 159 
10 
60 
Boston City Hospital, 
in 9 Years, 141 
14 
70 
— 
— 
— 
Totals, 300 
24 
130 
Only so many graduates are retained each year as will fill the 
few vacancies that occur in the relatively permanent staff of head 
nurses, of whom there are only a little more than enough to furnish 
one for each ward, and to provide for some special service like 
night duty. At the Massachusetts General Hospital, the first 
class was graduated in 1875, of only three nurses; the second 4 
class numbered eleven; the third, five; the fourth, twenty; the 
fifth, six; and the numbers have since ranged from fourteen to 
twenty-one graduates annually. The Boston City Hospital School 
has a similar history, graduating its first class in 1880, and 
averaging eighteen graduates annually for the whole time. 
It is of interest here, to notice what has become of the three 
hundred graduates from these two schools. The figures are ap- 
proximately as follows: 
Kemaining in Parent Hospitals, as stated, 24 
In other institutions, 30 
In District Nursing 8 
Total in institution and public work, „ 62 
Engaged in private nursing, 170 
232 
Total continuing as nurses, 232 
Married, 37 
Died, 10 
Studied medicine 1 
Unknown as to abode and occupation 20 
68 
Total out of service, 68 
300 
Thus it appears that more than three-fourths are continuing the 
work of their new profession. It is significant that only one has 
stiidied medicine; Florence Nightingale said that woman was 
made to be a nurse and not a physician. The most of those in 
other institutions, and a number of the private nurses, are in 
other States. The City Hospital being the larger has done about 
one-half of this work in nine years, against the fourteen years of 
the Massachusetts General Hospital. 
The Registry for Nurses in Boston, has been in existence nine 
years; its work is represented in gross as follows: 
Number of male nurses registered, 84 
Non-graduate female nurses, 408 
Graduate female nurses, 245 
Total number registered, 737 
But in the year ending November, 1886, these two hundred 
and forty-five trained nurses were represented in the registry by 
only one hundred and sixteen of their number who remained con- 
nected with it; and the proportion of trained nurses to the untrained 5 
is increasing every year. In the training of nurses for more 
special work mention should be made of the New England 
Hospital for Women, and the Boston Lying-in Hospital. 
The showing here given, from only one centre of this nursing 
reform, indicates how ready and active is the growing demand for 
the services of this profession; how quickly the product of the 
schools is scattered; what an immense agency for good is being 
evolved by this movement; and what a small proportion of those 
graduated from the schools is found to be enough to be retained 
in the hospitals, in order to perpetuate the invaluable advantages 
of the new system. It is noteworthy, also, that so large a pro- 
portion as nearly one-fourth has so soon fallen out of the work. 
The annual product from the two hospitals, here specially 
mentioned, is about thirty-five graduates, and of these only about 
five to eight are retained, in both together, to fill vacancies made 
by retiring head nurses. It is remarkable that these results have 
come, in so short a time, from meagre beginnings; for several 
years it was difficult to find enough women to undertake the work, 
but now, in contrast, the number of applicants is far in excess of 
the requirements. All foreknown vacancies occurring from regular 
graduations, are filled a year in advance at the Massachusetts 
General Hospital, and it often happens, in both hospitals, that 
fifty applications are received in a single month. 
The Boston Registry frequently sends the city-trained nurses to 
places in all parts of New England; and applications are con- 
stantly being received, from all parts of the country, for nurses 
to go and settle in the cities where there is no supply. There are 
now in this country more than thirty such schools, and yet the 
supply of graduates from well-organized schools falls far short of 
the demand. At the last annual meeting of the Massachusetts 
Medical Society, a paper was read by Dr. Worcester, of Waltham, 
on “Training Nurses,” advocating the importance and feasibility 
of doing this for country practice. His arguments were drawn 
from practical experience in a small country hospital. It is the 
trained nurse that makes practicable the extension of the cottage 
hospital system, in which there is, happily, such a growing interest 
in America, and in which a good proportion of the graduates of 
the schools is already employed. The demand for this special 
work must increase, and it is probable that, in time, trained nurses 
will become as common as physicians, even in country towns; 
there is evidence now that the physicians of Massachusetts, for 
example, are generally ready to employ such nurses when they 
can get them. 6 
It is really no loss to the movement that so many of the nurses fall 
out into other ways of living; the more there are who marry, the 
more generally wdl be distributed, in domestic life, an understand- 
ing of the use and value of their training. It will take time, of 
course, to attain such general results as are here indicated, but it 
must be, always, a simple question of supply, demand, and 
diminishing cost to an acceptable aud equitable standard, just as 
it is for medical services. Any present evils, if such there be, of 
over-training or other errors of the system, are sure to be corrected 
in time, by the repressing influences that must always exist. 
Any one who has watched the progress of this reform, would 
undoubtedly say that from the beginning the demand for nurses 
has grown with the supply, and that it will be practically un- 
limited. In fact, in the country in general, it will be long before 
the present stage is passed, in which the supply must precede the 
demand, for the reason that the value and practicability of the 
common employment of such services can not become generally 
known except by the gradual diffusion of their actual use, which 
must come by the distribution of persons enough to render them 
available. The establishment of the Registry for Nurses in 
Boston, in 1879, has had a large and important influence in this 
matter, by regulating and facilitating the employment of these 
nurses, thus aiding greatly in introducing among the public a 
knowledge of their value, and making a market for the products 
of the schools. Were there no such market the manufactories, so 
to speak, would languish. 
These considerations lead to one of the points already- 
mentioned, which needs to be especially emphasized, and it is the 
main proposition of this paper. One of the most important 
requirements is, that there shall be an ample and continued 
demand, outside of the asylums, for the services of such a pro- 
fession, otherwise the new system would have failed long ago. 
In the old order of things, with only exceptions enough to prove 
the rule, the attendant has been a make-shift for the asylums; her 
asylum work is a make-shift for herself also, and will always be 
so until such work fits her for, and leads her to, a respectable and 
more remunerative, or otherwise desirable, life-supporting occupa- 
tion. When this is done, the benefit* of the asylums, as now of 
the hospitals, will lie in this very fact, and secondarily in the fact 
that not all graduate nurses will be so led away from institution 
work. Some will remain in it precisely as do medical men; 
indeed, with a difference only in the grade of the work, the ■analogy in this regard is very close between the professions of the 
physician and the nurse. 
There is a direct relation between our need of kind and 
intelligent nurses, and the necessity in their interest for fitting 
them to engage in a desirable occupation outside of the asylums, 
as an offset to the undesirable character of the service. Samuel 
Tuke, in 1841, describing the often repulsive and trying character 
of the work of caring for the insane, says “Can it be surprising 
then, if it be so difficult to meet with persons to fill properly the 
post of attendant on the insane; that instances of neglect or 
abuse so frequently occur ? ” lie quotes Dr. Jacobi as saying, 
“ I believe that this difficulty will never be surmounted till the 
spirit of the age becomes so far changed as to induce persons of 
cultivated minds and benevolent hearts to devote themselves to 
this employment from religious motives.” But Mr. Tuke’s com- 
ment on this is, that “such attendants would indeed be invaluable; 
experience however, in England as well as in Germany, does 
not lead us to expect a supply of this class.” And further, 
speaking of what we primarily want “ in those who have charge 
of the insane” as being “a sympathizing unselfish character con- 
nected with firmness and energy of mind,” he says “these traits 
are however, by no means commonly found in attendants.” In 
1876, Dr. Clouston still had to lament the unattainableness of the 
ideal asylum and attendants, which he feelingly and graphically 
describes; and in his paper before the British Medico-Psychological 
Society, he puts the practical sense of the situation into these 
words, “ I know of few members of this association who took to 
asylum life from ‘ higher motives’ alone, however much these 
motives may influence the way our work is done. We can not 
expect from others what did not influence ourselves.” In 1883, 
Dr. Clark advocated the education of attendants for a permanent 
occupation for the good of themselves as well as of the asylums. 
By this way, he said, we may advertise the asylums and attract to 
them the better raw material; by bringing more elevating 
influences to bear upon our attendants—in raising their social 
and industrial status, we shall raise them in the estimation of 
the public and themselves, and may reasonably expect a more 
marketable article by and by; their work will become a life-work 
worthy of the name. 
It is curious to notice how slowly these more practical views 
have been put into effect in the asylums,—even in this country 
where the most is being done. But these views were the main- 8 
springs of the principles that governed the work of the reform irr 
the general hospitals, from the beginning twenty-seven years ago, 
and made it successful. We can not go against nature; we must 
take healthy human nature as we find it and make use of the 
common principle of wholesome self-interest as an instrument for 
our purpose. With proper regard for this principle we may 
expect our subjects to be able to afford the philanthropy we seek 
in them. This is not a theoretical matter. The analysis just 
given of the work of the Boston Training Schools, and the influ- 
ence of the Registry for Nurses, proves every word here said, and 
that the application of these obvious business principles has 
already made the business success of this reform, as far as the 
general hospitals are concerned. 
Now the application of this to our immediate purpose teaches 
us not only what our first action should be in the premises, but 
also the reasons to which allusion has been made, for the many 
failures of the asylums in their gropings for this object in the last 
forty or fifty years. The asylums, all the time, began at the wrong 
end of the problem, ignoring too much the larger view. The 
limited object of the immediate interests of the service, and of 
the insane in the asylums, the ease of giving a few lectures which 
made a quick but deceptive show of “systematic training,” the 
lack of the sustaining moral and business force of the outside 
organizations by which the first training schools were established 
in the hospitals, have led to disappointment and failure. The 
warning is plain; the lesson is,—lay a good foundation for your 
work and build upon it safely and surely. In the general hospi- 
tals the order of importance is reversed,—lectures are regarded 
as of minor consequence, and true training as consisting of practical 
work in the wards and drill by teachers in class-room work in the 
text-books. Another of the prime causes of the failures was that 
no public demand had been created for asylum-trained nurses;— 
the superintendents could not,—and later did not when they 
could,—set before the prospective attendant anything beyond the 
moderately paid asylum work as an adequate object of a reason- 
able self-interest. The general hospital schools met a more obvi- 
ous want, thus having the advantage of the asylums; the hospitals 
have led the way; the asylums have only to recognize the funda- 
mental principles which sustain the former, and to follow their 
methods now well-established and approved by experience. There 
is no need of more “attempts” and “experiments.” 
Looking at this larger aspect of the movement, and on the basis 9 
of the proposition to which we now return, that it is essential to 
its success that there shall be a large and continued demand for 
the product of our schools, certain practical questions arise, and 
the answers to these furnish the solution of our problem. The 
truth of the foregoing proposition was made plain in the first six 
years of the reform in America; and when, in 1879, it was 
determined to carry it into the asylum at Somerville, we found 
ourselves confronted by the qtiestions just intimated. The use 
here of our experience may be pardoned, for the sake of clearer 
illustration; a few facts will be of more value than any theory. 
There was no uncertainty, with iis, in regard to what the school 
should be, as to its methods;—its needs, as to its organization and 
the provision of a suitable teaching staff, etc.; it was to be no 
“attempt;” all was clear enough on these points. But the first 
question was, “ How shall we make a nurse that will be useful to 
the public, and command its patronage; in other words, how shall 
we best subserve the grand purpose of all our work,—the public 
good, to which the personal interest of the nurse is incidental and 
complemental, and really a means to that greater good ? ” 
The specialist nurse, we knew, would be a failure; and upon 
the success of the individual nurse, in the public service, was 
believed to depend the ultimate success of asylum training. The 
precise question was, “ Can we teach the asylum attendant to be 
a good general nurse, with the limited amount of ‘ bodily’ nursing 
there is among the insane ? ” (With respect to this, by the way, 
the large asylums, with their “infirmary wards,” have an advant- 
age over so small a one as the McLean.) A collateral question 
was, “ If we put the work upon the basis of that of a general 
hospital,—adopt hospital methods,—hold the inmates in the atti- 
tude of being sick persons, and as ‘patients,’ will it be consistent 
with the best interests of the insane as to moral treatment,—pro- 
moting home-like conditions, etc.?” It was determined, however, 
at the outset, to call the patients “ patients,” as if to say, “ you 
are sick, and may get well;” to make the attendants “ nurses,” 
and the place a “ hospital.” All the details of bedside attendance 
upon the sick were amplified as much as possible,—the most was 
made of all opportunities. For example, nurses practiced in 
keeping a chart of the temperature, pulse, and respiration, and 
taking other notes, could thus learn to perform these quite me- 
chanical acts as understandingly as is necessary in any case. 
They would be relatively on a par with many medical graduates 
who see little of “cases,” till they come to treat them. 10 
The practical questions resolved themselves, therefore, into one 
of getting proper instructors and laying a foundation for thorough 
work in the training, so that when this formally began there would 
be no half-way efforts that would invite failure by their inefficiency. 
At first a number of trained nurses from the general hospitals 
were invited into the service. Indeed, one employed as early as 
1877, in a common ward for men, remained there five years, 
but with limited duty; still she and her successors,—the arrange- 
ment being extended to include other wards,—demonstrated the 
admissibility and the great advantages of the daily presence of 
unmarried nurses and ward-maids among male patients. From 
1880 to 1885, nine other such hospital nurses were employed in 
female wards, with a view to gaining their aid in the establish- 
ment of our school. With one exception the terms of service of 
these were only between one and six months; they would stay no 
longer. One other was appointed Superintendent of Curses, in 
1882, but withdrew after two years; and another, promoted to be 
supervisor, still remains after three years’ service, doing good 
work also as a teacher. From experience with these twelve 
nurses, there is ample warrant for saying that their general hospi- 
tal training had, in some respects, actually unfitted them for 
“ mental” nursing. They wanted to see some illness or injury, 
and to have something active to do; it was irksome to sit down 
and be companions to patients who did not do as they were told,—as 
the nurse had been led to expect among those having only 
“ bodily ” illnesses. Therefore these nurses were slow to acquire 
the true asylum spirit. The outcome of it was, that our female 
supervisor, who had been nearly twenty years in the asylum, was 
allowed by the authorities of the Boston City Hospital, to receive 
there a six months’ special and comprehensive course of training. 
She was instructed, not only in the points upon which her experi- 
ence was lacking, but she learned the technique of school methods. 
This done, (our whole service having been, by that time, brought 
up to doing the work in hospital ways, and to the expectation and 
desire for being trained), we were then, at once, able to have a 
school in full operation. The system of lectures,—the easiest part 
of it all to maintain,—was supplemental; this work, on the part 
of the medical staff, having been once prepared, there is after- 
wards comparatively little trouble in revising and repeating the 
lectures to successive classes. 
In my judgment the important thing is to make lai’ge account 
of the general nursing. In the two years of training, the eight 11 
months’ term of the first year are given almost wholly to this in 
about thirty recitations, one each week, in several text-books; and 
in thirty lectures. Very recently the superintendent of the school 
at the Massachusetts General Hospital said to me (of two of our 
graduates taking a supplementary course of a year for a second 
graduation there), “ they have been over this ground so thoroughly 
in their class-work and lectures with you, that they do not need 
that kind of instruction with us.” At the asylum, therefore, they 
are trained as “ bodily ” nurses the first year and acquire the pro- 
fessional spirit that animates good work in that field, besides 
gaining some satisfactory practical knowledge of this business. 
At the same time, they have been trained by practical example 
and exercise in “mental” nursing, which is farther developed in 
the school work of the second year, in another series of as many 
recitations and lectures as in the first year. 
The results now are that two classes, of sixteen and eight nurses 
respectively, have been graduated, and there is a senior class of 
fifteen pupils and a junior class of more than that number. Four 
only of the first class remain; two of these will probably enter 
the hospital, and after graduation there will come back to the 
asylum. Two, as has been said, are already finishing the extra 
year there. Ten have been engaged in private nursing with great 
success and are in active demand,—receiving fifteen dollars per 
week. None have been found wanting as “bodily” nurses, and 
some of the patients attended required a good knowledge of it. 
The second class of eight still remains with us. Ultimately we 
shall retain two or three of the first class, and so on of subsequent 
classes, and be entirely content to do only that.* 
On the basis of this experience, it seems proper even to urge 
the suggestions here made. The first thing is to make a good 
preparation; there can be no doubt as to results, with a right be- 
ginning. Do not try to begin with a simply hospital-trained 
woman in charge, if better can be done, but regard it as impera- 
tive that, whoever it is, she shall have some general hospital 
training. This will avert great trouble and loss of time. About 
the second or third year, it will be discovered that the wrork is 
growing harder,—that the zeal of all concerned is failing, and 
that petty difficulties arise which a woman experienced in a 
hospital school would get on with as a matter of course, without 
* A full account of the history of the school, with details of its organiza- 
tion, and courses of study, may be found in the Annual Reports of the 
McLean Asylum for the last six years,—particularly" in that for 1885. 12 
discouragement to the superintendent of the asylum. These 
drawbacks will be avoided, and the school will be self-perpetuating. 
In fact, the great point is, to keep clear in mind that the school 
system is anew and distinct department of asylum work;—provide 
it then with adequate and special officers, or specially train the 
existing ones, as teachers, and do not make its perpetuation depend- 
ent upon the continuous carrying on of its details and extra work 
by the medical staff, as a material addit ion to its duties. The best 
way is, to begin with the women alone, and get well organized on 
that basis; it is easier to get suitable assistance in teaching them. 
The men can be taken in afterwards with less risk and labor, when 
it is only necessary to extend an established system. As a head 
for the school, take some suitably woman already in the service, 
used to the ways of that particular asylum and its superintendent, 
and send her to some general hospital, to be fitted for the new 
work; a year’s training might be enough. The hospitals are 
likely to be willing to help in this way; such things were done for 
some of them in the beginning. Do this first, and time will be 
saved thereby in the long run. While she is away some minor 
details of the new system can be introduced. In default of having 
such a woman, get one if possible who has already had training in 
both a hospital and some other asylum. That such a preparation 
will lead to success has yet to be shown ; of course allowance must 
be made for the personal qualities which training can not change. 
Another way is possibly practicable. There must be some hospital- 
trained nurses who will enter upon asylum work with the right 
understanding and purpose when it comes to be known that there 
is in it an ample field for humane effort. Let such a woman be 
put into the wards, one after another, quietly keeping her own 
counsel, until she learns the peculiarities of the work, and gets the 
asylum idea and spirit if she can ; then promote her for the pur- 
pose in view. 
In regard to the training of men it is only to be said that we 
have been content to go slowly, and do one thing at a time. They 
do not lend themselves so pliably as women to the spirit of the 
work; the inducements can not as yet be made so strong for them. 
Last year we arrived at the point of beginning recitations and 
lectures, with the first class of fifteen men. All new comers now 
readily obligate themselves to take the full two years’ course. 
The second assistant physician mainly conducts this class. This 
year there will be two classes of men in operation, and the male 
supervisor is expected to become qualified to do a part of the 
class-room teaching, which eventually, with the assistance of some future graduate, he may almost wholly do, relieving the assistant 
physicians from this part of the work. This is another way of 
providing teachers,—made necessary because the general hospitals 
do not yet undertake the special training of men. The indications 
of substantial results are already good among the men. 
It has seemed to me to be fair, to hold out to young men and 
women, in our prospectuses and otherwise, the great advantages 
to be gained by them from this training, even if they have no 
idea of following the profession of nursing. The whole matter 
of instructing certain classes of people, as well as the public in 
general, by courses of what are called “emergency lectures” is 
becoming much in vogue and is precisely to the point in this regard. 
Young men and women, in an asylum training school, in addition 
to the regular compensation for service, would get this kind of 
valuable information, useful in any walk in life, and in a way to 
amount to something. Again, the primary education of those 
who can make great success in this calling is’defective in many 
cases, and can be improved in most by the educational means 
necessarily employed in such school exercises as have been 
described. The study of the ordinary school text-books on 
“Physiology and Hygiene,” and other methodical class work; 
the writing out of notes of lectures with the criticisms thereon— 
the mental discipline in general, from all such exercises, are of 
themselves educational in the best sense, in the fundamental 
requirements of the common schools. There is besides the moral 
education. One only knows the full force of this who has seen 
the transformation, under his own eyes, of a company of 
earnest excellent young women; there comes into their faces— 
one feels as if he had “ talked ” it into them—the sure and 
pleasing signs of mental growth, as from girls they come to be 
thoughtful women, in so short a time. Some proof of this is 
shown, better than in wTords, by a composite photograph of the 
nurses of our first class, a copy of which may be found in the 
Century Magazine for November, in a second article by Pro- 
fessor Stoddard, on Composite Photography. 
These considerations have impressed me with a more general 
one as to the interest and duty of the State in this matter. It is, 
to my mind, clearly within its interest to foster in the most 
efficient way, the progress of this reform; the diffusion of a 
practical knowledge of insanity, is, of itself, in the direction of 
prevention, and the wider the distribution of persons well- 
instructed even in elementary but practical knowledge of the 
subject, must be of great good. Why then should not asylum 14 
schools be regarded as a part of the public school system, and 
as entitled to the fostering care of the State on this ground? 
Among the ideas of the duty of the State now gaining recogni- 
tion in regard to industrial education, can not this work have its 
place, to a very direct end in the benefit of the State ? The last 
Massachusetts Legislature was asked to permit the annual use of 
a small part of the surplus of one of the State asylums for the 
foundation and support of a “Training School,” but for want of 
appreciation of the importance of the subject, it was lost in com- 
mittee. The “school” must come in the asylums, for the good is 
so great from the small outlay required. Two thousand to three 
thousand dollars should amply cover all additional cost, not only 
for increased salaries of the teachers, but to pay ten dollars per 
month extra, it necessary, to each of the ten or twelve graduates 
who will be induced to remain as head nurses. Not every ward 
will need a graduate head nurse; to put advanced pupils in 
charge of some of them will be an advantage. The head of the 
school and her assistants as supervisors for the day and night, (all 
as teachers), should have liberal compensation, for the work is of 
a higher order than it has been accounted, and the results are 
worth more than they will cost. The other expenses, besides 
these for services will be insignificant. 
The part of the asylums in the general movement begun by 
Florence Nightingale, may be made a large and proper one. The 
distribution of hospitals throughout the country is not general 
enough to do what the asylums can in this regard, these are so 
regularly situated as local centres. Thus each in its own locality 
may find sufficient demand for its products to stimulate their 
manufacture for the public service, and concurrently to supply its 
own wants. Every city of moderate size should have its registry 
for nurses, however humble it may begin ; it may finally serve 
the whole country of which it is the centre. In the preparatory 
years of the school at the McLean Asylum, fifty nurses were sent out 
to private cases, thirty-one women and nineteen men, many of them 
returning when the special service was ended ; the public was dili- 
gently led to[understand that nurses would be so supplied ; and for 
the sake of the ultimate greater good, the immediate convenience 
and economy of the asylum was often sacrificed by giving the best 
nurses the chances for the extra compensation. This was a strong 
stimulus for the school. In like manner, let the public expect to 
find general nurses by applying to all the asylums. Again, under 
a similar policy, any one of its departing graduate nurses is given employment, at the McLean Asylum, whenever she wishes to 
return, upon agreeing to stay at least three months. 
A word may be said in regard to the very large hospitals, with 
a corps of attendants that would be unwieldly in such school 
training. Classes of twelve pupils, each year, are quite large 
enough to be handled to the best advantage. It would seem that 
a working standard, suited to the circumstances, might be 
adopted, by which there could be two grades, one of attendants 
and one of nurses, selecting and promoting the most promising of 
the lower grade. Such a number of pupils would probably in 
time, supply the needs of any large asylum. 
Another question arises in regard to the promotion of the 
private care of the insane; there is much that may be said upon 
this subject. In this country it is probable that we are to repeat 
the history of British Lunacy in this respect. This is said with 
no disparagement to the honorable gentlemen doing legitimate 
work in the private establishments and in the home treatment of 
the insane. Of course such houses should be under governmental 
inspection and endorsement, even if for no higher purpose than 
the protection of their proprietors, while the “ home care ” of 
these unfortunates may be carried on in a particularly loose and 
irresponsible way in the present order of things. The deliberate 
sending out of trained asylum nurses is not to be considered as 
liable to foster any evil in this direction—that must be antagonized 
by the usual corrective effect of time and experience. Is not the 
truest corrective in this matter also, in the seeing to it that all who 
have to do with the insane shall receive from us all that is in our 
power to give of whatever is right, and true, and honest, in all that 
goes to promote the intelligent and humane care of these unhappy 
people? Our views in these matters will the sooner prevail, the 
more there are of the well-instructed missionaries that go out from us. 
Quite enough has probably been said, by way of warning, to 
redeem the promise in the beginning of this paper. Mention 
should be made, however, of a point of criticism of the new sys- 
tem, in New England, which may be instructive. There are 
conservative and intelligent physicians and surgeons who depre- 
cate what they regard as the injudicious ideas of certain promoters 
of these schools, which beget too much of the masquerading of 
“higher motives,” and the “woman’s mission.” It is not likely 
that this will amount to a serious evil;—in fact the tendency has 
been to resolve the sensational elements, at first not uncommon, 
into the plain common sense of simple good motives, and good 
conduct, and good work, in the seeking for an honest and respecta- 16 
ble livelihood. It was a timely caution, however, recently given 
by an eminent surgeon, against training the woman so that she 
becomes a sort of hybrid, which is neither nurse nor doctor. In 
the beginning of a school, a few nurses, who know how to do 
acceptable work, with no parade nor nonsense, will do more to 
help on the cause, outside and inside of the asylums, than anything 
else. Of our graduates, we should be able to feel content in 
saying, “By their works ye shall know them and us.” At the 
McLean Asylum the nurses are not taught to write theses and the 
like; they are quietly handed their diplomas when they are due, 
and there is rigid avoidance of promoting any other spirit than 
that of aiming at modest, quiet, unobtrusive devotion to honest 
work. In this we but imitate what is really the aim of the general 
hospital schools which have been established long enough to have 
settled down to the plain methods of solid business. 
The feeling is strong upon me that the importance of this 
nursing reform for the insane is not yet half realized. The keen 
psychological interest an intelligent nurse will take (when taught 
to do it), in the mental operations of an insane patient, is some- 
thing beyond even my very sanguine expectations. This puts a 
power into our hands for the moral treatment of our patients that 
opens wide possibilities in promoting their comfort and cure. One 
must believe this when he finds his nurses methodically and intel- 
ligently fitting their manner and speech to different patients, and 
with womanly gentleness, as well as with an effectiveness that 
comes from an almost unconscious knowledge (so to speak) of 
power to manage the varying mental states of the insane. The 
acute intuition of women, when trained to this work, becomes a 
most valuable instrument in our hands. 
It is not the least of the advantages of this system, that it 
develops the personal relation between officers and the nurses. 
One can not meet his people, even somewhat formally in the lec- 
ture-room, every week for a series of months, without being more 
keenly moved by a sympathetic interest in each of them,—in their 
troubles, their good efforts, and their attainments. They discover 
this feeling, of course, and there is soon a community of interest, 
a unity of purpose, and a mutual confidence that brings good to 
the common cause. Were no “graduates” to remain in the 
asylums, the value and comfort of this system would be so great, 
in the current benefit of carrying it on, that once appreciated, no 
asylum superintendent would be deprived of it. 
Finally: get ready before beginning; begin rightly; go slowly; 
do the work thoroughly; and there will surely be good results.