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troublesome factors in the population. Perhaps more unintentional injustice has been done in the name of discipline, through the lack of proper understanding of these types, than from any other cause. The officer charged with the control of the group is likely to regard these manifestations of disorder as deliberate and wilful. He instinctively feels that his reputation as an officer and the authority vested in him are at once challenged by these attitudes, and that it is incumbent upon him to assert his authority against these individuals for the purpose of example, deterrence, and the maintenance of self-respect. Here we have a combination of factors which constitute a situation calling for the finest discrimination and very careful, mature judgment. The situation is made more acute by every display of authority and of force. Even well-adjusted individuals in the group instinctively feel, without being able to analyze or define their reasons, that an injustice is being done in the name of discipline and through the power of vested authority. I wish in some way, by processes of training or of reasoning, we could bring officials to realize that these outbursts of temper, stubbornness, and insolence are never to be regarded as insults, but rather as important symptoms of the disorders we are trying to correct in the individual. Rather than being reasons for severe resentment and punishment, they represent most urgent reasons for more and better psychiatric study and further reclassification.
I wish to repeat that discipline is the most technical and highly scientific aspect of institution management, and it is a pity that under our system this highly technical piece of administration is distributed throughout so large a number of people, the majority of whom are in no wise, either by training, temperament, or personality, fitted to exercise it.
But even when adjustments are well established we cannot drop the case; we must always have in mind from the beginning of classification that the ward must return to society. He shall not be released on the mere passage of time; that isn't fair to the individual or to society. The classification committee has given the ward a program to be worked out, and if, in working it out, he has succeeded in gaining control of himself—if he has succeeded in standardizing his conduct and has acquired habits of industry and good workmanship to a degree that will make him a successful member of his family and of his communityhe shall go home. Any other basis of release is faulty.
I realize that many of you may have many questions in mind. You are ready to ask how these plans apply to the wards with the gifted intelligence, and also to those with very dull minds? How can a low-grade moron standardize his conduct? How can a high-grade imbecile be taught satisfactory habits of industry? The answer is that every boy's program, if properly planned, has aimed at fitting the boy for some specific type of work for which he has, by nature or training, or both, an ability and an aptitude, a type of work fitted to his mentality and personality and that may be found and marketed by him in the kind of community he will naturally return to. If the boy cannot benefit by
any program of training to a degree to allow him to adjust socially and industrially he should not be released. In these cases the recommendation should be: "To a colony or institution for custodial care." Every activity of the institution can be made highly educational. The failure of institutions generally is that they have regarded the shop and farm work, and a small part of domestic work -the laundry, kitchen, bakery—as the only parts of the institution routine which offer vocational training. As a matter of fact, well directed, skilfully done janitor work is as high a type of vocational training for certain types of mind as is carpentry and machine work for other types. There is just as great a demand for good janitors as there is for good painters, and they are just as necessary to our comfort, and have just as important a place in our present scheme of living, as painters. But without job analyses and classification these homely tasks cannot be raised to the dignity of vocational training; they remain just the dirty punishment jobs of the general institutional upkeep.
Finally, the institution has a splendid opportunity to socialize this very antisocial group. It is as important to put experts on the program of recreation, entertainment, athletics, and general play as it is to have experts in the hospital and schoolroom. Club work of many varieties should be carried out. Home theatricals and dramatics, orchestras, glee clubs, debating clubs-the program should be rich in all these factors, thus training the wards how to use their spare time pleasantly. It were idle to give them extensive training in industry, with a view to helping them earn their living, and send them out paupers with reference to their idle hours. Sound character, a healthy outlook, and some religious convictions are not easily established through hard work and sharp discipline alone. Proper studies and skilful administration will allow the institution to help every adolescent to realize his fullest opportunity.
THE HOSPITAL AS A HEALTH CENTER
Charles P. Emerson, M.D., Indianapolis
The modern hospital is by no means the least interesting of the marvelous institutions of modern times. Originally merely a house of refuge for the destitute, and especially when sick, a hospital now not only offers to rich as well as to poor the best there is in medicine and surgery, but also serves as a great health center for the community at large. This is rather a surprise to the physicians of the past generation, but the modern hospital, like all other successful institutions, soon outgrew its original form and found itself confronted by unescapable and unexpected duties and responsibilities which might seem foreign to, or even irreconcilable with, the former idea of a hospital.
Not more than twenty-five years ago a hospital's doors stood open to anyone who needed medical care. The professional staffs considered themselves responsible for the patient only while he was their guest; whence he came and whither he went was, they felt, no concern of theirs. It was even their boast that patients returned for treatment for the same condition six, ten, and—as in the case of one poor woman with mitral stenosis-even twenty-six times. Then, in 1901, came the development of environmental medicine. That is, we began to teach the students to ascertain and evaluate as many as possible of the factors which aided in the production of each patient's condition, in order better to understand the problems which his case presented. Four years later came the splendid development of hospital social service, a movement which frankly recognized our responsibility that our professional service for the patient be not easily lost. After that hospital staffs ceased to boast that women with mitral stenosis returned even twenty-six times for treatment; they realized that such a record was in itself evidence of their failure to help that woman. Now, with the aid of a social service department, such cases probably would come to the ward but once or twice, since social workers would follow her to her home, would effect some reorganization of her life, would arrange treatment in an out-patient department, and, as a result, would aid her to live a much longer and more useful life. The man with aortic insufficiency is no longer forced by the circumstances of his life to return to the forge; and for the man with chronic lead poisoning now is found a less dangerous occupation. We remember so well that little foreign baby brought to the ward with gastro-intestinal troubles and sent home well; brought back again in a few weeks with the same trouble, and again relieved;
and brought back after a few weeks for the third time in a similar condition. It was then that the trustees of that hospital, business men and lawyers, none of them doctors, took a firm stand against such charity, stating that they did not feel morally justified in spending the trust funds under their care for expensive professional service which, even before it had been begun, we knew would quite certainly be wasted. If, said they, the food bought for the patients were wasted, if carelessness were proved in their salary roll, their critics would be unsparing. What, after all, was the essential difference between such waste and the waste of professional service? The result was that a nurse followed that baby to his home and taught the mother how to keep him well. Then it was that that hospital became a health center. The superintendent of a hospital for the insane in New York State found that his budget was too small with which to care for his ever increasing number of patients, and so, since he could not obtain a larger appropriation, he trained two nurses to follow to their homes the patients discharged well after an attack of manic depressive insanity in order to advise them, to organize their lives more carefully, and so to prevent a recurrence of their trouble. In this way, that is, by making that hospital a health center, he reduced the population of the hospital.
The next step in the evolution of the modern hospital is logically unescapable. That is, since a hospital thus well organized can serve the community as health center, since it is, in fact, the only institution which can serve the public helpfully in this capacity, then it is the hospital's duty to render this service whether its staff desires to or not. One of the first of these new activities was the examination of the other members of a patient's family in order to prevent the development of other similar cases. Another activity was the formation, in connection with the hospital, of classes of patients with very slight grades of one disease, as tuberculosis, "nervousness," etc., or with no definite troubles at all, in order that they might receive definite instruction in the methods of preventing a further development of their conditions and also of increasing the quality of their health in general. Then followed better out-patient departments, the organization of district nurses, of school nurses, dispensaries in community centers, campaigns of education, the development of summer camps, etc. Today the treatment of a patient in a hospital ward has far greater significance than the treatment of that patient, fine though that may be. In that ward the doctors, nurses, dietitians, and social workers of the future receive their training, and while the future career of each will be directed to the care of the sick, yet the greatest contribution of each will be the education of the community in matters of disease prevention and especially in methods of increasing physical efficiency; and all will be powerful forces in shaping public opinion in the interest of health. In short, the care of each patient is the least of the hospital's service, for treat one patient well, and you have treated one patient well, but show a doctor, a nurse, or a social worker how to treat that patient well, and you shall have helped all the future patients that student shall treat, and you shall have
strengthened his future influence in the cause of health in the community in which he later practices.
First, we feel that all nurses and medical social workers while engaged in any practical medical work should be more closely related to a responsible hospital staff organization. In reply to the question which doubtless now is on the lips of many: whether, granting such desired relationship is not possible, the nurse or social worker should stop her work, we would express the opinion that she should so proceed, but that the technical medical aspects of the work be greatly curtailed. There will be plenty of splendid social work to keep her more than busy. Unfortunately, one of the great temptations of each of us is to essay professional work a little beyond our depth. This is a dangerous sport. As we shall endeavor to show later, the great danger of American medicine today is the practical application of so much popular medicine by those who, whether doctors, nurses, or neither, are eager to do good, yet have not the training to attempt their problems without supervision.
Among the activities as health center which each modern hospital now accepts as unescapable moral obligations is the prenatal clinic, a most profitable health venture which prepares the mother to withstand her approaching ordeal with as much safety as possible, and gives the expected infant a better chance for a normal birth and for a healthy life; classes where mothers receive instruction and advice; child welfare clinics; classes for nervous patients, where the neurasthenic and psychasthenic may receive encouragement, and the incipient insane may be helped to recover without danger of commitment, etc. Thus it is that the modern hospital has indeed become a health center.
Thus far we all may agree. Concerning the details of the program we may not all agree. For illustration, we draw a sharp distinction between social workers assigned to medical cases, and medical social workers. The former group is composed of women more or less well trained in social work who are assigned duties in connection with medical cases, but who, in general, are more responsible to the head of the department of social service, and through her to the administration of the hospital, than to any physician. The medical social worker, on the other hand, is first of all well trained in social work, but one who belongs to a professional team and who is responsible to the professional head of the hospital staff. On this professional team she has her part to play just as have the bacteriologist, the Roentgenologist, the serologist, the physical therapist, and others. Like them, she has her professional rank and title. Her part in diagnosis and therapy is carefully mapped out for her, and her reports are not a unit, but a definite part of one case report. Such a medical social worker must, of course, depend on the department of social service for much of her assistance, but it is for her to dictate very definitely just what help she needs.
Second, we would urge that each patient, whatever his illness and whether real or incipient, should be actually registered in one of the major departments of a general hospital and, personally known, should be under the responsible