THE TRAINING SCHOOLS OF THE 
 FUTURE. 
 
 BY EDWARD COWLES, M.D., 
 
 SUPERINTENDENT OF THE MCLEAN ASYLUM FOR THE INSANE, SOMERVILLE, MASS. 
 
 It is one of the marvels and blessings in the progress of the pres- 
 ent age that in the time of one generation so great and universal a 
 reform has been brought about as that in the nursing of the sick. It 
 is marvellous also that so good a thing, and one so eagerly accepted, 
 should have waited so long for Florence Nightingale to show the 
 world its need. 
 
 The history of all this has become household words ; and the pur- 
 pose of this paper will be, not so much to dwell upon what nursing- 
 reform has already so nobly achieved, but to present the proposition 
 that we are as yet but at the beginning of the grand results of 
 which we may be living witnesses if we will only put our hands to 
 the work in the right way. 
 
 There is no longer need of presenting evidence and arguments to 
 show that the trained nurse is essential to a successful hospital, 
 her value to both patient and physician, and the nobility and at- 
 tractiveness of her calling as a profession for women. It is only 
 seventeen years since general hospital training schools were intro- 
 duced into this country, almost simultaneously at the Bellevue Hos- 
 pital, Massachusetts General Hospital, and the New Haven Hospital, 
 following the plan of Miss Nightingale’s St. Thomas Hospital School. 
 This should not detract, however, from the great credit due to the 
 New England Hospital for Women : at its foundation in 1863, one of 
 its three chief objects was declared in the by-laws to be “ to train 
 nurses for the care of the sick.” This hospital actually graduated 
 the first “ trained nurses ” educated in America. Now there is prob- 
 ably no one of our hospitals of any importance that does not have 
 its training school or is not moved by the question of adopting the 
 
2 
 
 
 school system. It is only within two or three years, however, that 
 this could be said of a few of the hospitals for the insane ; for it is 
 in these hospitals that even now there is but the beginning of as 
 great a reform as has been accomplished in the general hospitals. 
 The claim of the insane is of the strongest kind for the blessing of 
 the intelligent nursing that it is perfectly practicable for them to 
 have. It is the purpose of this paper to emphasize this, and to urge 
 the importance and practicability of training nurses in the hospitals 
 for them, not only for their immediate benefit, but for that of the 
 country at large. 
 
 The adoption of the training-school system in the general hospitals 
 of many cities throughout the country has been mentioned. But 
 though the system has been successfully and very usefully extended 
 to the smaller hospitals, now becoming so common in the larger 
 towns, there is still a tendency to think that to the larger hospitals of 
 the great cities belongs the real work of training nurses, while the 
 smaller ones — the town and cottage hospitals — should not aspire 
 to the pretension of having training schools. Here also is a point 
 for the enlightenment of even the professional mind of the country. 
 
 It is even sometimes said of the schools already successfully estabj 
 lished that their work will soon be overdone and the market over l 
 stocked with their graduates. The time has passed for pessimistii 
 obstructionists to say, “ You cannot find women enough who want to 
 be nurses,” — “They will not find employment when they are 
 trained,” — or, worst saying of all, “ They will leave your hospitals 
 and asylums as soon as they are trained, and you will get no good 
 from your labor with them.” 
 
 All such conceptions, that limit the active promotion of this great 
 reform, arise from too narrow a view of its importance and its scope. 
 The simple truth is that, aside from their service in the hospitals, 
 trained nurses are yet so few in number that they are practically 
 luxuries for the well-to-do, in private life. It is a matter of supply 
 and demand. The supply must first create the demand, and, the value 
 of such nurses being made known, then the demand will call forth 
 the adequate supply for the larger needs of the country in general. 
 These reactions of a gradually increasing demand and supply will be, 
 accompanied, in due time, by a reduction in the cost of the service of 
 such nurses. This is an important factor in the extension of their ^ 
 usefulness. They ought not only to be as common in every country 
 town and village as physicians are, but there should be many more 
 
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 of them. This is the ideal condition to which we should aim ; and 
 every hospital in the land, whether large or small, general or special, 
 as for the care of the insane, may educate nurses for its own pur- 
 poses, and at the same time find its own advantage in supplying the 
 public need of its own vicinity. All the graduates that all can pro- 
 duce may be sent out without overrunning the field for their employ- 
 ment, and the schools in the great hospitals may become largely the 
 normal or higher schools of nursing. 
 
 These may seem to be visionary statements: their truth can be 
 shown by a consideration of some of the elements of this great 
 reform now but fairly begun. The movement is still at the stage in 
 which the supply is creating the demand. Comparatively few people 
 in the great population of this country yet have any adequate knowl- 
 edge of the value of skilled nursing, and the large majority have not 
 the means of obtaining that boon of which they ought to have the 
 benefits. The work of the Boston Directory for Nurses, which is a 
 central point in this regard for all of New England, goes to prove 
 the truth of these statements ; and it is of great interest as exemplify- 
 ing the process of evolution of this beneficent reform. In its exist- 
 ence of eleven years, to September, 1889, the results accomplished 
 by the directory may be represented in gross as follows : * — 
 
 Total number of nurses registered in eleven years, 969 
 
 Total nominally available, September, 1889: — 
 
 Male nurses, 84 
 
 Non-graduate female nurses, 426 
 
 Graduate female nurses, 315 
 
 Masseuses, 14 839 
 
 
 v 
 
 The average registration is about 100 per year. The “casualties ” 
 of the last of the period of eleven years were 29. The average net 
 increase for several years has been about 50 per year, and the propor- 
 tional number of trained nurses registered has increased relatively 
 to the untrained. The “casualties,” however, for the last year 
 included only two deaths. Other nurses married or left the profes- 
 sion temporarily or permanently for various reasons ; but they were 
 not lost to the cause, as they carried their valuable knowledge and 
 experience into domestic and other relations, where they are calcu- 
 lated to be always useful. The annual increment of fifty nurses per 
 year in the directory comes chiefly, of course, from the larger hos- 
 
 * Compare article “Nursing Reform for the Insane,” A merican Journal of Insanity, October, 
 1887, by the writer of this paper. 
 
4 
 
 pitals of the vicinity, — the New England Hospital for Women, Mas- 
 sachusetts General Hospital, Boston City Hospital and Lying-in 
 Hospital, and McLean Asylum. The product of all these is about 
 eighty nurses per year. There are also among those registered in 
 the Directory representatives of the general hospitals at Portland, 
 Lowell, Lawrence, Providence, New Bedford, and New Haven, and 
 a few from outside of New England. All of these hospitals, of 
 course, chiefly furnish nurses for their own immediate vicinities. 
 Some of the other new hospitals recently established, or now under 
 construction or projected, in Eastern New England are at Hanover, 
 Concord, Manchester, Portsmouth, Lawrence, Malden, Lynn, Cam- 
 bridge, Newton, Waltham, Framingham, Worcester, Quincy, Taunton, 
 Woonsocket, and Newport. There are doubtless others, for this list 
 is not pretended to be complete. 
 
 The Boston Directory (notwithstanding its increase of business) 
 finds therefore a cessation of calls from all such new centres of self- 
 supply as they become established. Its work of the last year shows 
 the growing preference for trained nurses, of whom 271 were given 
 employment, while only 170 non-graduates were accepted by appli- 
 cants for nurses. Only five men were found employment during the 
 year. Some further indications are most significant. The rate paid 
 to trained female nurses was in the first years quite uniformly $15 
 per week, with somewhat more for nursing male patients. Three 
 years ago it was thought that the increasing supply would soon lower 
 the rates ; but, on the contrary, a common charge is now $21 and $25 
 per week by experienced nurses, and the former rate is largely limited 
 to recent graduates or the untrained. Male nurses commonly receive 
 $4 and $5 per day. These figures sustain the statement that in New 
 England the demand is increasing faster than the supply, and the 
 hospital trained nurse is still a luxury really beyond the means of 
 the great masses of people. There ought to be more nurses, and 
 good ones should be had at much less cost. It is estimated that in 
 Great Britain there are fifteen thousand to twenty thousand trained 
 nurses in the profession, and it is no bar to their continued produc- 
 tion by the hospitals. When will America be supplied in like pro- 
 portion ? 
 
 Let us now consider the future of the profession of nursing. Its 
 usefulness, as already demonstrated, indicates what it may be when 
 there is a general diffusion of its services throughout the country. 
 Let it be supposed that the ideal conditions to which we should aim 
 
5 
 
 have been attained, — it may be more than one generation hereafter, 
 — and that intelligent and skilled nursing is available for all the sick. 
 We may consider first what will be the nature of its benefits, and 
 next how they are to be attained. 
 
 The value of an intelligent, instructed nurse is now too obvious to 
 need statement here. Every physician who knows about it would be 
 glad to have such nursing for every one of his patients, poor as well 
 as rich. Should such a condition of things ever come about, it would 
 mean that commonly throughout the country there will be nurses 
 practising their profession as such, there will be married women who 
 have had special training as nurses, there will be single women whose 
 home duties have called them away from the active practice in the 
 larger towns of the profession in which they are skilled, and they 
 will be the neighborhood nurses. It goes without saying that the 
 cause of preventive medicine will thus be advanced most effectively 
 beyond anything we can now conceive, not only in general hygiene, 
 but in all that pertains to the early recognition of disease in general 
 medicine, and as well of the requirements in mental hygiene and the 
 protection, care, and treatment of the insane. Does this picture of 
 a future Utopia appear more impossible of realization than it would 
 have seemed for our fathers, in the first half of the present century, 
 to have been told of what Florence Nightingale’s reform has already 
 done for us? Certainly, these considerations show that there will be 
 ample room for a general diffusion of all knowledge that training in 
 nursing implies. This is the very reason for being of the Emergency 
 and Hygiene Associations, that are so zealously beginning their 
 work in the instruction of the general public. All these efforts are 
 calculated to do great good, and should be fostered in every way. 
 They reach, along their own peculiar lines, results that cannot other- 
 wise be attained. They educate the people to see the need of educa- 
 tion in such matters. Every such movement will find its true prov- 
 ince in the later adjustments that must come of the relations of all 
 the newly organized forces that are working for the general good. 
 
 Having set forth the possible benefits that may be hoped for, it 
 must now be shown how they are likely to be attained. The ele- 
 ments of the problem must first be considered. Of course the 
 methods of procedure, in the future progress of the reform, must 
 be an evolution from and an improvement upon what has already 
 been done. A study of these results and the processes by which they 
 have been gained reveals two fundamental principles essential to 
 
6 
 
 practical success. It is rather that these principles have had room 
 to work freely than that they have been fully recognized. They 
 are : (i) The giving to the nurse sufficient knowledge of disease to 
 teach her what to do, and thereby arousing the professional spirit 
 and giving intelligent play to the sympathetic feelings of the woman. 
 (2) The stimulation of a wholesome self-interest, by showing that in 
 a respectable and philanthropic calling she may honorably support 
 herself and get means to help those dear to her, as is her duty. The 
 progress of the reform, in a material degree, has been dependent 
 upon this natural element of self-help in human nature and our social 
 conditions. 
 
 Now, any hope that we may have of furthering this reform and en- 
 larging its scope must depend upon our recognition and careful 
 observance of these two principles. We may make use of them 
 to attain philanthropic ends. We may accept self-sacrifice in a good 
 cause and the exercise of the missionary spirit, when they come to 
 our aid; and we do find both of these wonderfully developed, in- 
 cidentally to the business of nursing the sick and the insane. We 
 may stimulate and exalt to a great degree in some persons the altru- 
 istic element in this professional service, but this philanthropy must 
 J^e worked by human instruments that must live. From the foregoing 
 considerations it follows therefore that, if we would have intelligent 
 and proper service for the sick in any hospital or anywhere, it must 
 be by instructing intelligence in the special work. Almost everybody 
 knows this well enough now. But, moreover, we must see to it that 
 to every individual so employed there must be held up the possibility 
 of gaining something desirable beyond the doing of the service we 
 ask : there must be a forecast of a profitable or satisfactory self-sup- 
 porting occupation. This is the principle that is not yet sufficiently 
 recognized. So far in the history of nursing-reform the two prin- 
 ciples stated have really had free play and effect, — admitting, of 
 course, the pure philanthropy of those who have had to inaugurate 
 and conduct the organizations through which alone systematic instruc- 
 tion can be given to those who are to render the personal services 
 required by this profession. The facts of the inducements of lucrative 
 work and personal credit have been the potent forces that have given 
 the reform its vitality and its momentum. Philanthropy is best gain- 
 ing its ends by making use of these inducements. It is entirely right 
 that these motive influences should continue to operate, and that the 
 highly trained nurses of the great hospitals should mainly serve the 
 
7 
 
 wealthier classes and be well paid for such service, or become 
 teachers of others and be well rewarded for their especially skilled 
 labors. The missionary spirit abounds among them in a due degree 
 it is true, and finds its fields in continued hospital service, in district- 
 nursing, and the like ; but there is no law nor sentiment by which 
 skilled nurses may be required to abate anything of their wage-earn- 
 ing power in performing poorly rewarded labor, from a professional 
 point of view. We may ask them to give as we give. For sweet 
 charity’s sake they do much : let no one say anything in qualification 
 of this. But, as a practical business matter, we must provide otherwise 
 for that greater part of the world’s nursing which can only be had 
 when afforded at a moderate cost to those who receive the service, 
 and by those who give it. There is no derogation, in these state- 
 ments, of the nobility of the profession of nursing. Let us claim for 
 it the same kind of nobility that is accorded to the medical profession. 
 Let both professions make their own living. Those who^are engaged 
 in promoting charitable works will greatly magnify the results they 
 gain, by as much as they contrive to make those results incidental to 
 the labors of a self-supporting calling. The physician finds his school 
 in the hospital and the dispensary district, and gives nobly of his 
 services to the poor. May not the nurse so combine her schooling 
 and charity-giving? 
 
 A broad estimate might be made, by way of illustration, of the pro- 
 portional relations between the different kinds of nursing service 
 which are required in the broad field that waits for it, based upon the 
 differences of training, of compensation, and of ability of people to 
 pay. It might be said that one-tenth of all the future nursing will be 
 done for the wealthy classes by nurses trained in the great hospitals; 
 two-tenths will be done for the poor within the hospitals ; and two- 
 tenths will be done for the poor in dispensary and district work. The 
 remaining five-tenths will have to be done at moderate rates, and 
 chiefly by nurses trained in the small hospitals, or otherwise. This 
 training must be done largely in the country towns, in the presence 
 of, and in exact adaptation to, the work and the conditions under 
 which it is to be done. The first three-tenths, including the well- 
 to-do and the poor in hospitals, according to this enumeration, will 
 be sufficiently well provided for by the present established systems 
 in the great hospitals. The district charity or dispensary service 
 must have greatly enlarged and more effective methods to accomplish 
 the work that lies before it. In fact, this work has only yet been 
 
tentatively attempted. There remains the large field of city nursing 
 at moderate cost, and that in the country districts, for which there 
 will be necessary larger sources of supply. There must be a special 
 evolution of methods, of which there has not been until recently any 
 adequate conception. 
 
 It has been set forth as one of the main propositions of this pres- 
 ent writing that by far the larger part of the field to be covered 
 by this eminently philanthropic, life-saving, disease-preventing reform 
 has as yet received no proper recognition, the importance of which it 
 is desired here to emphasize. Now, this discussion comes to the 
 chief point of our inquiry, as to how we may conceive it possible to 
 accomplish practically, without too great labor and cost, the raising 
 up of a self-supporting nursing force for the general service of the 
 country at large. There have now been established in America, with 
 the proof of demonstration, the beginnings of two movements des- 
 tined to have a large influence in working out the extensive results 
 here pictured as so desirable. These two methods are shown to be 
 ready at our hands for the practical carrying on of this great pur- 
 pose, on a larger and more effective scale than ever before, with the 
 incidental accomplishment of the strictly charitable work of nursing 
 the poor that it is found so difficult to establish. These two methods 
 are : — 
 
 1. A distinctly new system of training in general nursing. 
 
 2. The great work of training nurses of which the hospitals for the 
 insane are easily capable. 
 
 i. The new system of training nurses may now be considered. 
 The general extension of the present school system, even as it is put 
 in practice in New England with all its hospitals, as has been de- 
 scribed, cannot supply the great field of common nursing, so to 
 speak, that has its strongest claims upon the general physicians, who 
 practise among the poor or those of moderate means, either in town 
 or country. To discover a system of training nurses for this service 
 that will even only largely aid in accomplishing the important results 
 so much to be desired is to make an epoch in the evolution of 
 modern progress. It is inspiring to recognize the fact that such a 
 discovery has been made and its value demonstrated within the last 
 five years. It has been admirably described as “A New Way of 
 Training Nurses” in a little book bearing that title,* by Alfred 
 
 Published in Boston. Cupples & Hurd. 1888. 
 
9 
 
 Worcester, M.D., to whom the credit is due of devising, and inaugu- 
 rating the system in the Waltham Training School for Nurses, at 
 Waltham, Mass. The great merits of the system are its simplicity, 
 ease of organization, elasticity of adaptation to large or small require- 
 ments, effectiveness, and the fact that it can be put into operation 
 in anv large or small city or town of a few thousand inhabitants, 
 where a few physicians will co-operate in giving the required lectures. 
 Above all, it is unique in that it needs no hospital as a foundation , while 
 yet it may be an adjunct and an aid to the support of one ; and in 
 that it is self-supporting, or even more than that, under favorable cir- 
 cumstances. The poor of the community are nursed without charge 
 or at very low rates ; the well-to-do have nursing as good as any ; 
 night watchers and day nurses, by the hour, day, or week, can be 
 furnished on call for all the country round. If any one be sceptical 
 as to any part of this, let him read the book and visit Waltham, — it 
 is the only place in the world where such a thing can be seen, — and 
 the truth of all that is here said of it will be accepted. 
 
 The history of this School is most interesting and instructive. 
 Every one interested in these matters should read Dr. Worcester’s 
 entertaining book, noting that the most telling results have come to 
 pass in the two years since it was published. He had been familiar 
 with good nursing, and knew by experience how to teach ordinary 
 young women to be excellent lying-in nurses.* This caused an inten- 
 sification of some trying experiences with the old-style nuVse. He 
 conceived it to be the “physician’s duty not only to give proper direc- 
 tions for the management of every patient under his charge, but also 
 to see that his orders are intelligently obeyed.” “ There is no ex- 
 cuse,” he says, “ in the fact that trusty agents are not at his hand, for 
 it is his business to provide them ; and, until he can be sure of intelli- 
 gent, faithful nursing service, he must not undertake the management 
 of more cases of sickness than he can in person superintend.” This 
 is a high conception of a physician’s responsibility, but it determined 
 the effort to have instructed nurses in all cases. But only the rich 
 could afford the city-trained nurse, and Dr. Worcester’s problem was 
 “ to demonstrate the way in which the supply of trained nurses can 
 be so increased that their services may be had in every village of the 
 land.” His conclusion was that, “in the smaller towns and villages, 
 the physicians, if they desire the great advantages of this new dispen- 
 
 * “ Monthly Nursing.” Lectures given to nurses at the Boston Lying-in Hospital. By A. 
 Worcester, M.D. Boston, 1886. 
 
IO 
 
 sation, must train their own nurses .” He believed that “ there would 
 be no trouble in finding young and strong women well fitted and eager 
 for such training.” There was no hospital in Waltham ; but interest 
 was aroused, a plan adopted, and a school organized with seven pupils 
 in 1885, the method being “based upon the facts, first, that nurses 
 can be well trained in private practice outside of hospital walls ; and, 
 second, that excellent service is given by the student-nurses during 
 their course of training.” It was a recourse to the old way of train- 
 ing physicians by accompanying their preceptors in their general 
 practice, except that by this method the nurses can be trained in all 
 they need to know. 
 
 The responsibility of the School was assumed by the lady man- 
 agers. Some money was raised by donations for the first expenses. 
 Rooms were obtained for a headquarters, where the nurses could 
 board when not on duty, and go to receive their daily instruction at 
 the regular afternoon lesson hour. A trained nurse was employed to 
 be superintendent, to manage the School, conduct class exercises, 
 and visit particular cases, when need be, where the student-nurses 
 were employed. A two years’ course of instruction was prescribed. 
 Brief courses of lectures were given by a few physicians. The stu- 
 dent-nurses of the first year did service gratuitously or for small 
 compensation for the patients of these physicians. The second year 
 students were sent out upon the call of any physician, as in some of 
 the general hospitals. And the School prospered, — unlike many 
 other reforms, paying its own way. 
 
 The charge for student nurses of the first year is $1.25 per day, or 
 $7 per week, and board; of the second year, $1.50 per day, or $10 
 per week. When it is not convenient for the family to furnish board, 
 it is provided at the School at an additional charge of fifty cents per 
 day. The School pays the pupils $9 and $12 per month for the first 
 and second years respectively, and is supported by the income, with 
 a balance of profit. The donations for the first year amounted to 
 $2 33 ; for the last of the five years, $55. The expenses of the first 
 year were $1,051; for the last year, $4,952. The earnings for the 
 first year were $888 ; for the last year, $5,748. There is now a bal- 
 ance in the treasury of over $1,000. The School occupies a dormi- 
 tory building, with class-room, and pays an annual rental ; but the 
 building has been completely furnished by the School, at an expense 
 exceeding the entire amount of the donations. Dr. Worcester writes: 
 “ The total of donations is less than the outlay in permanent fittings ; 
 
and, after the end of the second year, the yearly donations amounted 
 to less than the balance carried forward to the School’s credit. 
 Indeed, after the second year, they came, in spite of our protest that 
 we needed nothing ; but the donors insisted on continuing the charity 
 we originally asked for. Instead of asking for money outright, we 
 asked for money for charity nursing ; that is, we asked Mrs. S. to 
 give to the nursing of Mrs. B., and so on. Now we can do all of the 
 charity nursing without extra help, our earnings being so largely in 
 excess of our expenses.” From this it appears possible to establish 
 such a school by making an investment in the plant, and having it 
 repaid in a few years ; but of course it is best to organize in a small 
 way upon donations, and incur no debts. 
 
 The School has graduated three classes of nurses, — a total of 
 twenty-five ; and there are as many more now engaged in the work as 
 pupils. Some of these graduates have continued in its service for 
 a time, and, with the student-nurses, have done a large amount of 
 work in all the country round, at the rates before stated, together 
 with a great deal of charity work, whenever or wherever it was 
 needed, on the call of any one of the physicians of the School. 
 Their especial training in home-nursing makes these nurses especially 
 acceptable to families and physicians. They say, “Better nurses 
 cannot be found.” It is an inspiration to witness their love of work 
 among the poor. The amount of the service the School has rendered 
 is indicated by the record of the employment of the nurses. In the 
 first year, it was 1,027 days 5 ' m th e ^ ast the five years, 5,378 days, 
 or 78 per cent, of all the days for which there were nurses ready for 
 service. The demand for these nurses is rapidly increasing in the 
 towns about Waltham. At the Boston Directory is noted an absence 
 of calls from this section. The class of the coming year is to be 
 of twenty pupils, — nearly double the number of any previous year. 
 A very significant circumstance is the fact that a number of the grad- 
 uate nurses have been most acceptably employed in some of the 
 small hospitals of this section of the State as being well-qualified 
 nurses. Another significant fact is in proof of the statements here 
 made as to the demand for such nurses. The earlier graduates of 
 this School now command the higher compensation equal to that re- 
 ceived by the city-trained nurses. This is good. It stimulates the 
 progress of the cause. 
 
 A small hospital is an outgrowth of these conditions ; but it is an 
 independent establishment, and pays the School for the service of 
 
12 
 
 those nurses it employs at cost, and at the same time it furnishes 
 a valuable adjunct to the means of training. But the success of the 
 School was established without the hospital. 
 
 While this system includes the method of outside pay service 
 adopted by some of the general hospitals in the second of their school 
 years, and while it is practised to some extent by the “ Deaconess 
 Houses,” or orders of nursing sisterhoods, where there are lim- 
 itations to expansion, it is obvious that an underlying principle 
 has here an original and unique application. It is the principle of 
 the conservation of values : the knowledge of the physician has a 
 value ; this is multiplied by imparting it to a class of nurses ; they 
 turn it into money in a ready market plus a large amount of 
 gratuitous nursing service enjoyed not only by those unable to pay 
 for it, but also by the physicians and their families ; the money 
 earned pays the expenses of the establishment. Putting together the 
 first and last terms in this sequence of elements of the system, the 
 lady managers, giving freely of their time and effort, get their rich 
 return in the large amount of charity nursing accomplished ; ttie 
 physicians for a little time and effort are repaid many times over by 
 the better nursing of their patients ; the nurses pay for their education 
 by giving their time and service, and, when all is done, they have a 
 self-supporting profession ; the public has brought within its reach 
 and means good nursing, for which it is glad to pay. 
 
 It is easy to see how a small hospital can make profit to itself and 
 fulfil a plain duty to its surrounding community by adapting this plan 
 to its own needs. But, if a school is to be attempted in such a hos- 
 pital, it should have a competent and well-paid head, who is capable 
 of overcoming the narrow limitations of the field of instruction. 
 By using the Waltham plan there will be a greater variety of prac- 
 tical work, and the teaching may be so developed as to turn out 
 really educated nurses. Then more women will be trained, more 
 nursing will be done for the public that supports the hospital, and 
 more interest will be taken in it because of the greater good received 
 from it. In a section of a large city, such a school for “teaching 
 nurses in private practice,” or “ home-nursing,” may be established. 
 A prime point is not to proclaim its object as charity nursing, — 
 that would repel the people who like to pay and from whom the 
 school must get its support : the charity work will be ^ done inci- 
 dentally , — it will actually be wanted as largely the T>asis of \he 
 teaching. The organizations for “District Nursing” may find their 
 
3 
 
 field and their usefulness enlarged by turning their attention directly 
 to the training of nurses by means of their charity work. The Visit- 
 ing Nurse Society of Philadelphia is making an interesting adaptation 
 of this system. 
 
 The population of Waltham was, in 1888, about 16,000. It is evi- 
 dent that in a smaller town this training-school system would work 
 successfully on a smaller scale. There is enough in the experience 
 of the Waltham School to show that there would be a ready absorp- 
 tion of a large amount of nursing work under similar conditions. 
 Even there, five years ago, there was at first little faith, other than 
 Dr. Worcester’s, that there was any place for such work there. The 
 Waltham system has demonstrated itself as an admirable and effi- 
 cient contribution to the urgent needs of the time. 
 
 Large credit and gratitude are due, and will in time be abundantly 
 given, to Dr. Worcester for his happy inspiration, to the lady man- 
 agers who have done so much to aid in working out the plan of the 
 School so that others have only to follow their leading, and to Miss 
 Hackett, its superintendent, who has largely shared in making it suc- 
 cessful. 
 
 2. It remains to speak briefly of the claim of the public, in the 
 country at large, upon the hospitals for the insane for the great work 
 of which they are capable. The general adoption of the Waltham 
 system, for training in “ Home ” and “ Visiting Nursing,” easy as it 
 is to organize, now that the way is shown, depends still upon the 
 voluntary efforts of wide-awake people in all the eligible localities 
 throughout the whole land. It would be long waiting in some parts 
 of our great country for this New England notion to become per- 
 vasive. But the hospitals for the insane are well-organized establish- 
 ments, and well distributed among the population of the various 
 States. There is no one thing that could now be done in regard to 
 them that will yield so much direct benefit to the patients, profit 
 to the hospitals in furthering their prime purpose of curing the sick, 
 and benefit to the State in promoting the welfare of its citizens by 
 the diffusion among them of this education, as the establishment of 
 such schools in all such hospitals. They would be educational, in 
 the strictest sense of the word. As a means of mental training of 
 the young men and women in regular class recitations, in the taking 
 down and writing out of notes of lectures and of original reports of 
 cases, and in the acquirement of useful knowledge, such schools are 
 like high schools. They have the claim of industrial schools : they 
 
would give special training, not only in a useful business, but one 
 that has a special economic value to the State in the prevention of 
 disease, besides the amelioration and abbreviation of disease. They 
 have also the claim of normal schools : they would produce the 
 teachers for smaller local schools, besides diffusing instruction upon 
 the most vital matters. They are entitled to the fostering care and 
 support of the State. But this need not be directly claimed : the 
 insane in the hospitals are entitled to the benefits that modern 
 enlightenment in these matters brings. The State has a right to 
 such returns for money spent upon its hospitals ; but let it be liberal 
 to the nursing service. The added expense of schools in such hospi- 
 tals is relatively very small : it would be money well spent if the 
 expense were much greater than it need be to introduce and carry on 
 this reform. It makes a true hospital of every asylum in which such 
 training of nurses is done. The medical staff that joins in the teach- 
 ing is directly benefited and made more efficient by such a duty. 
 He who teaches learns. 
 
 General nursing can be well taught in hospitals for the insane : 
 that is proved by the last eight years’ work of the McLean Asylum 
 'Training School for Nurses, with its 92 graduates, including 20 men, 
 representing some of the earliest work in the training of male nurses. 
 The annual product will hereafter be 20 to 30 nurses; ten or twelve 
 of these each year will be men. The graduates of the McLean 
 Asylum School have acquitted themselves well in general nursing in 
 private families, in competition with the highly trained nurses of the 
 city schools. 
 
 In the establishment of Asylum Schools, the two fundamental 
 principles should never be forgotten : — 
 
 1. The nurses should be given a full course of didactic instruction 
 in general nursing, and as much as possible of practical work. It is 
 remarkable how effective a use can be made of the conditions of an 
 asylum truly hospitalized. The truth is that a large, well-organized 
 asylum has some positive advantages in this regard over the small 
 general hospital. 
 
 2. The plan of training should include the intention of making the 
 pupils successful in private nursing among the people from whom 
 they come. Even in a population with limited means, the people will 
 attach a special value to the service of the instructed nurse ; and her 
 knowledge will thereby increase her power of self-support relatively 
 to that of other members of the community in which she lives. 
 
i5 
 
 The question of thoroughness of training is a most important one. 
 
 No disregard of that should be implied by this advocating of such 
 variations in the plans of conducting schools. The Waltham method 
 is good because its work is so thorough and earnest that it is a model 
 for its purpose. Every large asylum for the insane, with its consider- 
 able population long resident, has its hospital cases. With a proper 
 organization of a school and the development of the “hospital idea,” 
 the charge that the training in it is “one-sided” cannot be sustained. 
 There is bodily nursing enough to instruct the nurses well in its tech- 
 nique. But, above all things, let nothing be called a “ school ” unless 
 it is thoroughly organized and gives a full course, amplifying the 
 didactic, if there is any lack of practical instruction. There is one 
 other point that demands broad-minded consideration. In standing 
 up for the “ profession ” of nursing, it should be remembered that its 
 work cannot be limited to “ professionals,” as should be the practice 
 of medicine : it is more of an art and less of a science. Let all j | 
 
 teachers master its scientific side, if desirable ; but the art of nursing I \ > 
 
 consists largely of what every mother of a family, every woman^xTl \ 
 should know. The great schools will claim no monopoly of this + A \ 
 
 knowledge : it must be brought down to the people for whom its * 
 
 attainment is most difficult, whose need must longest wait. There is 
 an element of common education in it, and there should be “ common 
 schools ” in nursing as well as “ academies ” \ and there is the high- 
 est need of the “university” training of their teachers. It should 
 be remembered also that there is such a thing as overtraining women 
 for the common nursing, — this-will never be done by the relatively 
 few that can be highly trained. The more the people are trained 
 to know of these things, the more will they appreciate and exalt in 
 their esteem the skilled professional rturse. Any question of the 
 granting of diplomas can be settled as we go along. The schools 
 we must have. 
 
 The coming of this new dispensation imposes higher .obligations 
 upon the medical profession everywhere. Now that there is shown to 
 be a way to provide “ trusty agents,” the physician’s duty is plainly 
 greater “ to see that his orders are intelligently obeyed,” as Dr. 
 Worcester declares. It is plain, too, that physicians, in the greater 
 part, must “ train their own nurses ” ; and it is shown that they can 
 do it. The country will absorb all such knowledge that can be given, 
 and all the trained service that can be produced by the two new 
 methods here advocated. The conditions to be met may be illus- 
 
6 
 
 trated by a circumstance that has recently come to the writer’s 
 knowledge. In the western part of a large Southern State on the 
 Atlantic coast there is a considerable section of the country in which 
 the only woman who is regarded and valued as having any qualifica- 
 tion as a nurse is one who was for a time an attendant in the State 
 Hospital for the Insane. It is obvious, in regard to her, that good 
 training, such as is to be given under the new dispensation now be- 
 ginning, would have greatly enlarged the usefulness and accepta- 
 bility of this nurse. A like neighboring section of the same country 
 has furnished a pupil of the best capacity to a Northern Asylum 
 School for Nurses, from which she may return to be a great bless- 
 ing to her native State if the opportunity is but given her, — per- 
 haps in a hospital school. Such wide fields lie open and waiting 
 in every State, where there may be an uplifting of the cause of hu- 
 manity, and of the scientific treatment of the sick and the insane, 
 through the inspiration that will surely flow from the influence of 
 this great reform. It is a reform not limited in its deepening and 
 broadening influence to the service of nursing the sick, noble as 
 that may be : it puts into the hands of physicians a new order of 
 instruments, — intelligent and thinking, — that teach their users. The 
 spirit of humanity to man has been given a new embodiment.