Buffalo Township (part 1 of 6)

Contents

Address of the President - Miss Isabel Mclsaac, Superintendent of Nursing, Illinois Training School, Chicago; Member American Society Superintendents of Training Schools; Honorary Member Matrons' Council, etc 22

1. (a) Hospital Administration in Great Britain - Miss Isla Stewart, Superintendent of Nursing, St. Bartholomew's Hospital, London, England; President of Matrons' Council 27

(b) Hospital Administration in Great Britain - Miss Mollett, Superintendent of Nursing, Royal South Hants and Southampton Hospital; Member of and Delegate from the Matrons' Council 38

2. Hospital Administration in America - Miss Maud Banfield, Superintendent of the Polyclinic Hospital, Philadelphia; Member of Hospital Superintendents' Association, American Society Superintendents of Training Schools, Matrons' Council; Lecturer in Hospital Economics, Teachers' College, etc 43

4. Women on Hospital Boards - Mrs. Robb, Late Superintendent of Nursing, Johns Hopkins and Illinois Training Schools; Member Board of Women Managers, Lakeside Hospital, Cleveland; Member of American Society Superintendents of Training Schools; Lecturer in Hospital Economics, Teachers' College, etc 80

Wednesday, 2 To 3 130 P. M.

3. Nurses' Federation of Australia - Miss S. B. McGahey, Superintendent of Nursing, Prince Alfred's Hospital, Sydney; Member Matrons' Council; Delegate from Federation Ill

2. What are we Doing with the Three Years' Course? - Miss L. L. Dock, Secretary of the American Society Superintendents of Training Schools, and International Council

3. Post-Graduate Work in Hospitals - Miss McMillan, Superintendent of Nursing, Lakeside Hospital, Cleveland; Member American Society Superintendents of Training Schools 156

1. Symposium of 15-minute papers on Opportunities and Responsibilities of the Graduate Nurse of Today - 1. Miss K. De Witt, Chicago, 111.; 2. Miss Richards, Taunton, Mass.; 3. Miss Patton, San Francisco, Cal 188-200

District Nursing

1. Historical Outline of Origin and Growth and Present Status of District Nursing in England - Miss Amy Hughes, Late Superintendent of Nurses' Co-operative Society ; Delegate -17

Army Nursing Organization

Great Britain and the Colonies, Mrs. Bedford Fenwick, London. B. In the United States, Miss Sylveen Nye, President of New York State Organization. C. In Canada, Miss Snively, Superintendent of Nursing Toronto General Hospital, Member American Society Superintendents of Training Schools, etc 335-351

Saturday Program At The Temple Of Music

2. A Retrospect and a Forecast - Miss C. J. Wood - Managing Director of Nurses' Hostel; late Superintendent of Nursing, Great Ormond Street Hospital, etc.; Delegate... 370

Part

Meetings held in the hall of the Women's Union building, Niagara square, Delaware avenue, in the Cit}' of Buffalo, Xew York, United States of America, on the 18th. 19th and 20th days of September, 1901.

The meeting was called to order at 10 o'clock in the forenoon for the first session, by the president, Miss Mclsaac, superintendent of the Illinois Training School for Nurses, Chicago, who spoke as follows :

We meet today in the shadow of a great national sorrow ; a calamity that has shaken the foundations of our government : it would seem fitting and proper that this Congress should express its sympathy %\"ith Mrs. McKinley, and I will therefore ask the secretary to read a resolution to that effect.

Resoh«ed : That the International Congress of Nurses now assembled in Buffalo expresses its deepest sympathy with Mrs. McKinley, and heartfelt sorrow at the loss which the American Nation has sustained in the untoward death of its President.

Miss Drown : I wish to express for the members of the Congress our approval of this resolution presented by the secretary, and also to move that it be sent in the form of a telegram to Mrs. McKinley and that it be recorded in the

The President : I now take pleasure in introducing to you Mr. Constantine, who has very kindly offered to substitute for Mr. Diehl, the Mayor of Buffalo, during the absence of the latter in consequence of the death of the President.

"It gives me great pleasure to welcome the Nurses Congress to Buffalo, but I regret that His Honor, Mayor Diehl, is not present to tender you the freedom of the city. A sad duty has called him elsewhere. He would have been pleased to meet and greet you, and talk with you about the noble work in which you are engaged. It would have given him great satisfaction to recount some of the many examples of your devotion and self-sacrifice which have come under his observation in nearly forty years of practice.

"To me is left the privilege and honor of saying a few simply homely words of welcome and to bid you God-speed in your work. We were gratified and highly honored when you selected Buffalo for your meeting place, and your local committee had made plans to make the occasion a festive one. But you have come to a city saddened by a terrible calamity and decked with the emblems of mourning. If your welcome is not joyous, it is none the less sincere and generous. We hope you will see much of our beautiful city and the Pan-American Exposition while here. You will find much to interest you - much to help you in your work. If you make the most of your opportunities I believe in after years you will look back upon your visit to Buffalo as one of the pleasantest and most profitable events in your life."

The President : I have the further pleasure of introducing Mrs. Townsend, who is the president of the Women's Educational and Industrial Union of Buffalo, an association which is identified with all of the most advanced movements in woman's work of all kinds.

"We meet under the shadow of a nation's grief, but there is a sad comfort in the thought that all good work must go on. I am reminded of the beautiful and significant epitaph to the great Wesley brothers in Westminister Abbey: *God takes away the workers, but carries on the work.'

"Organization and co-operation are watchwords for the new century. The first time I heard our world-famous Frances Willard speak she was giving her word of greeting from the Christian Temperance Union to the National Council of Women, convened at Washington, in her own marvelous way, and she spoke with a charm and a power seldom possessed by woman. She told a simple story of two children climbing a steep hill. After struggling alone for a distance the younger child reached up her hand to the elder and said : 'Let us take hold of hands, it is easier so.' The lesson and its application were pertinent. I have never forgotten them. You are here, several branches of the same organization, to help one another. In the path of your service rise hills that must be surmounted as you press on to the realization of your best ideals. Here you will take hold of hands and help each other to climb.

"It is my happy privilege, in behalf of our Union, to extend to you most cordial greeting. We hope that while here you will have time to make yourselves somewhat acquainted with the underlying principles of the Women's Educational and Industrial Union. Its purpose is to increase fellowship among women in order to promote the best practical methods for securing their educational, industrial and social advancement. In some lines our work is similar with yours - we minister to the sick and suffering; perhaps we may seek to relieve the trouble of the heart and soul more than those of the body, but the ministry of the skilled and faithful nurse is not only to the material. She cheers the sad heart, she strengthens the weak soul as she cares for the diseased body. Yours is a beautiful mission. In all your deliberations here, and wherever duty may call you, to each and every one, I bid earnest God-speed. May you feel at home in this building, consecrated to humanitarian work.

"It is with extreme pleasure and appreciation I respond in behalf of the Congress to the cordial welcome of Buffalo through Mrs. Townsend and Mr. Constantine, who have honored us not only by the warmth of their reception, but by their recognition of our profession. I have additional pleasure in extending the welcome of American nurses to the foreign delegates and representatives whose presence and participation in this Congress will contribute in so marked a degree to its interest and success.

"In approaching the discharge of my duties as presiding officer of this third International Congress of Nurses, I beg to express my appreciation of the generosity by which I have been called to such an honor.

"This appreciation becomes all the more pronounced when I reflect upon the conspicuous achievements of my predecessors and colleagues in all lands, who have labored zealously and with beneficent results, not alone in nursing fields, but in behalf of organization, to guard which must be one object of our labors upon this occasion.

"It requires a pen and tongue far more eloquent than mine to do justice to the feelings which arise when we consider the significance of this gathering. Every meeting of this kind is a record of our progress, and by each one we may determine how far forward we have gone. When we look back upon all the great movements of the world we should never lose sight of the great truth, that a cause which is righteous is never wholly lost. It may be obscured and

"If the phenomenal growth of nursing is any indication of its righteousness, then who can doubt our future? Small wonder that our pioneers, some of whom are still with us, express themselves as sometimes awed by the mighty impetus of the ball they started rolling scarcely more than a generation ago. The story of our beginning is so near to us that it is too well known to need repetition - our history so short that it is soon told.

"To our English colleagues we of the United States owe more than we can repay, and if in our swift American fashion we have broken from their leading-strings and made paths for ourselves, we none the less acknowledge our indebtedness with gratitude, and display our accomplishments with the same pride, mingled with a little doubt, with which sons and daughters display theirs to the friends at home. The tie of common speech and common interests is a strong one, even in the every-day work of commerce, but when the mutual interests concern life and death, the tie grows in strength and engenders a peculiar feeling of sympathy and kinship.

"Our first International gathering in Chicago in 1893 was marked very distinctly by the making of acquaintance, which sounds rather insignificant, but on second thought assumes its proper place, and we realize that it signified a tremendous force in nursing affairs. The exchange of experiences suddenly roused many women to the fact that the deficiencies and difficulties of their work were peculiar to the whole nursing profession, and not to one school or hospital. To that meeting we owe the greater part of the progress which has been made since then, in America. The second Congress, in London, gave some of our members an opportunity of studying nursing affairs abroad, and was the starting point of definite international relations between nurses ; and we will devoutly hope that from this Congress may come as much that is good and stimulating.

occasions still confront us in both continents, - the uniform requirements for admission to our schools, the uniform curriculum, what shall constitute a trained nurse. State registration, local and national organization, a code of ethics, and many minor questions.

"In America the extension of the training course from two to three years is nearer an accomplished fact than any other question, and while the curriculum is far nearer uniformity than it was eight years ago, there is still much to be desired.

"The question as to what constitutes a trained nurse seems farther from settlement in this country than at any time before. We Americans have strongly what the French call ' the faults of our qualities.' In our nervous energy and haste to embrace all things new and to get to the end by a short cut we often sacrifice quality and thoroughness to speed, and in no other work is this more glaring than in the enormous increase of so-called training-schools which have neither educational nor moral right to exist. We will listen with much interest and eagerness to our foreign delegates upon this subject, for it is one of extreme gravity to our profession. The establishment of a chair of Hospital Economics in Columbia University has been one of our most important undertakings, originating with the nurse who has done more for educational standards in our profession in America than any other one woman ; Isabel Hampton Robb, whose work is so well known to all of us. The Columbia course will undoubtedly be a most valuable leaven for the whole lump, and I may say, with no fear of giving offense, that the superintendents themselves know better than any one else the great need of better teachers of nursing. We cannot hope for improvement in pupils without a greater improvement in the heads of our schools. The organizations for nurses all over the world have developed wonderfully, and while we occasionally hear expressions of discouragement, we should not forget that we have learned much by contact, and should see our deficiencies now far more clearly than formerly, and if we continue to struggle

"A topic new to the nurses of the United States sinceour first meeting, although an old one in England, is army nursing - a huge problem undertaken here in an emergency, and one in which we sadly acknowledge we have not always done ourselves credit, nor, perhaps, always given credit where it may have been due. In this, alas, our friends across the sea share with us some of the same humiliation; but if all experience is good for us, then we should listen with open hearts and minds to those who can point out a better way for our future guidance, and take the criticism we deserve with the right spirit. For, after all is said and done, the roots of our shortcomings existed before the Spanish- American or South-African Wars.

"An undertaking of which we are justly proud is The American Journal of Nursing. To paraphrase our great Lincoln, ' a journal of nursing, for nurses and by nurses,' the work of which has been entirely done, until within a few weeks, by nurses hard worked in other lines; a monument to the courage and devotion of American nurses, we recognize it as a tremendous factor for good ; and feel that, whatever its standards and influence, it is and will be what nurses make it.

" Again I beg to express our thanks to our cordial hosts of Buffalo, and to extend the hand of fellowship to the distinguished guests within our gates who share with us this undertaking, and felicitate them upon their achievements in our profession."

The President : We would announce that the meeting on Thursday afternoon will convene at half past one and close at three o'clock. The day is to be a day of mourning and everything will be closed after that time on Thursday afternoon.

Unhappily one of the foreign delegates, Mrs. Strong, who came to this country to attend the Congress, has been delaved and I would ask the secretarv to read her letter.

Mrs. Robb : I take pleasure in moving that in response to Airs. Strong's letter a telegram be sent to her expressing the sense of regret of the Congress for her absence through illness. Carried.

The President : We have this morning three papers on Hospital Administration in Great Britain and America. It has been decided that all three papers will be read before we have any discussion. I have pleasure in presenting Aliss Isla Stewart to the Congress.

Isla Stewart

The broad lines of administration are much the same in a large majority of the hospitals of Great Britain and Ireland, which are either endowed, or partially or wholly supported by voluntary contribution. Many hospitals have as their highest representative, or figure head, a Patron or President, who in quite a large number of cases is a Royal personage, and they are by no means merely ornamental, as their patronage implies not only a personal contribution to the funds, but very material assistance in attracting the gifts of the public, who feel a certain guarantee of efficiency and probity is given by the use of the name being allowed. Nor is this a misplaced belief, as every care is taken in the way of enquiries and inspection, to prevent the name of any of the immediate Royal family being used in connection with any institution the general management of which is open to question. The subscribers elect the Governors from among themselves. These form a court which meets annually, half yearly or quarterly. They appoint a sub-committee, frequently known as the House Committee, which meets monthly or fortnightly, and in nearly all the large hospitals there is also a weekly board, empowered to deal with any minor matters that may arise. The ex-ofificio chairman of every board and committee is the treasurer, elected by the governors, in some hospitals for life and in others annually. There are also three or more trustees who are members ex-officio of the committees. In a few hospitals there are women on the governing board, but this is still rare, though not so much so as it was a few years ago. I may instance the Royal Infirmary in Edinburgh as the most important hospital where this is the case ; at this institution two women have been elected to serve on the committees. The Royal Infirmary in Glasgow has followed its example, but they have not only placed two women on their conmiittee, but also two working men. In many cases, indeed in almost all provincial hospitals and in Scotland and Ireland, the medical staff are represented on the board by two or more members. When this is not the case the medical staff form themselves into an advisory committee of their whole number, and are consulted by the lay governing body on all matters which affect their interest, or the well being of the patients.

These are the unpaid administrators, in whose hands rests the enormous responsibility of obtaining money for the institution, nursing its resources, and assuring themselves that the funds are carefully, wisely and honestly spent, and that the paid officials are capable, efficient, and upright.

In many of the London, Edinburgh and large provincial hospitals, the chief resident authority is a superintendent who may belong to the medical or legal professions or may be an army man or civilian of tried business capacity. He may be styled the Clerk, House Governor, or Superintendent. His duties are numberless, and comprise the decision of questions chiefly administrative which may involve considerable interest, or be very unimportant. He prepares the business for the different committees and reports to them the various matters which arise between the meetings of the board. The power and responsibility of this official are very great, and are but rarely abused. Under him are the heads of the various departments: the matron, head of the nurses and domestic department; the steward, head of the department which includes payment of wages, bills, catering, recording the admission and discharge of patients, and the control of the male attendants and porters ; the clerk of the works, wb.o has charge of the actual structure of the building and who has under him the carpenters and plumbers. In g-eneral each official reports personally, in writing, to the weekly and fortnightly board, but this is not always the case, and in so important a hospital as the Western Infirmary in Glasgow, where there are 420 beds, the matron is responsible only to the superintendent, and never sees the committee. This, of course, diminishes her authority and prestige considerably. So large a number of officers is only required in the great hospitals. With a decrease in the size of the institution, the number of these officials tends to diminish ; the clerk to the board (usually non-resident), and the matron dividing the work of the steward and clerk of the works, and in a large number of the smaller London and provincial hospitals the matron is the only permanent resident authority ; though she is frequently, even in her own immediate department, under the control of the medical resident.

There is a very large number of important Infirmaries originally under the Poor Law Board, the powers of which were transferred to the Local Government Board by Act of Parliament in 1871. These are entirely supported by rates. Each parish when populous, or group of parishes, when they are smaller or more scantily populated, supports its own institution which in the latter case is known as a Union Infirmary. In England and Ireland, Guardians, and in Scotland, County Councillors, who may be either men or women, are elected by the rate-payers, and hold office for three years. They deal with a great many matters affecting the well being of the parish, and amongst them govern the workhouse and hospital. They attend a fortnightly board which deals with all the matters which would be brought before the governors of the voluntary hospitals. Tliey have not, however, the supreme authority; that is vested in the Local Government Board. All matters of any importance, such as the appointment of officials, must be ratified by it, and it may or may not assent. To illustrate the extent of the authority held by the Local Government Board, I may mention that neither the guardians nor the Metropolitan Asylums Board (which governs the hospitals for infectious diseases) can expend £100 without its consent; and no structural alteration can be made costing- £5 or upwards without referring the matter to it.

The medical superintendent is in all cases the highest resident authority, and is directly responsible to the Local Government Board as well as to his board of guardians. The matron and steward act under his authority, and although he may allow them a fairly free hand he can call them to account when he considers it necessary. The matron and steward report personally to the board, but their written report frequently goes through the medical superintendent, who in some institutions is present when it is read, and when they see the committee. The matron is nominally the head of the nurses' staflf, but as each nurse can appeal, on any matter, to the medical superintendent her authority depends largely on him. These hospitals are periodically inspected by inspectors employed by the Local Government Board and who report direct to that board.

The hospitals for infectious diseases are also under the Poor Law, and are supported by the rates. In London they are directly governed by the Metropolitan Asylums Board, which is composed of representatives from the various boards of guardians, but one third of the whole number of members are nominated by the Local Government Board. The growth of the work of the Asylums Board and the increase in the number of their institutions have, during the last two years, led to a modification of administration whereby three central committees, viz : one for the fever hospitals, one for the asylums, and one for the children's homes have been appointed, with power to appoint sub-committees to visit the several institutions. This has brought about greater uniformity in details of management, but the powers of the sub-committees have been greatly modified, as they are unable to make regulations upon any matters which may be regarded as common to several institutions. Each hospital has a sub-committee appointed to it which meets at the hospital fortnightly and reports to a central committee, which in turn reports to the general board, but as in the case of the guardians, all important matters such as those relating- to finance, the purchase of land for building purposes and the appointment of the superior officers must be ratified by the Local Government Board who may prescribe regulations for the government of their institutions. These are also inspected by Local Government Board officials. In the Asylums Board hospitals also, the medical superintendent is the supreme resident authority. The matron and steward being subject to his control, he can curtail* their authority and regulate the internal administration of the hospital so far as it is compatible with the carrying out of the board rules. They report to the sub-committee on certain matters connected with their departments but in many cases the medical superintendent sees their report and is always present when they interview the sub-committee in order that his advice may be obtained upon any question that may arise.

This condition of afifairs is inevitable under the Local Government Board, who hold one officer legally responsible for the good management of the whole institution. A wise autocracy may constitute the best form of institutional government, and as in the case of the medical superintendents under the Asylums Board a large majority are wisely chosen after much experience as assistant medical officers. The system works well and with marvellously little friction. The chief fault lies in a certain lack of minute discipline, which is not so apparent now as it was in the past, and which may have been largely due to the fact that the matrons were untrained or partially trained women, often with little or no education, and who were given only partial control over the nursing staff, viz., when they are off duty. Now that both the guardians and the Metropolitan Asylums Board are appointing women of education, who are all fully trained nurses, the friction between the medical superintendent and the matron is disappearing, which condition results in much more efficient management and better discipline, though even now the discipline is not quite so perfect or strict as in the general hospitals. The control over the nurse is nothing like so absolute. She signs no contract on entering, and has no training certificate to look forward to. The administration of hospitals and infirmaries supported out of the rates must always be much more difBcult than that of the voluntary hospitals. They are not charitable institutions, and the inmates feel strongly their right to be there, and never for a moment forget that they have that right. In the infirmaries, the infirm patients are resident for a very long time ; months indeed may lengthen into years, and they know exactly how far they may go with impunity. In the past there is no doubt they had reason to complain, but this raises a class of difficulties, unknown in general hospitals. The object in the fever hospitals is to make residence therein as attractive as possible to the inmates with the view to encouraging the efficient working of the Public Health Act. The hospitals for infectious diseases have their own class of difficulties to deal with, arising sometimes from the fact that patients who have had a slight illness must remain until all fear of infection has gone, which is often long after they are to all appearance quite well. With children this is of little consequence and women bear the constrained residence fairly well, but with men it often gives rise to a certain amount of discontent. These little troubles, trivial it may be individually, make it necessary that they should be dealt with by some one who has an adequate authority, and who knows that if strained it will go beyond the weekly board.

The medical stafif in the large hospitals in London, Edinburgh, Dublin and in the important provincial towns consists of a consulting, a visiting, and a resident stafif. The consulting physicians and surgeons are mainly those who, having reached a prescribed limit of age, have retired from the visiting stafif, their duties being merely nominal. The senior visiting stafif are the physicians and surgeons who pay periodical visits to the hospitals and have a certain number of beds allotted to their care. They visit on certain days at regular hours in London, usually three or four days a week at 1 :30 o'clock. In some of the provincial hospitals they make their visits in the morning; they are liable to be sent for at any hour during the night or day, should a case be admitted or any emergency arise too critical for the resident staff to deal with. The junior visiting stafT see the out-patients and have one or two days a week allotted to each of them. There is a still younger junior staff who see the casualties every morning, and there are the heads of the various departments, gynecological, ophthalmic, aural, throat, dental, orthopedic and electric. There are two or more registrars, who superintend the recording of cases by the students, and a senior and junior anesthetist. The resident medical stafif consists of a house physician and surgeon to each of the visiting staff and to the heads of the gynecological and ophthalmic departments. The junior visiting stafif and the heads of the other departments have also understudies, but they are usually non-resident. All these medical and surgical officers in the large hospitals deal exclusively with matters affecting their patients' health. In some hospitals, notably St. Thomas', there is a principal medical and a principal surgical officer, who hold their appointments for three years, and who have authority over the more junior medical stafif. In others, as in Guy's hospital, the medical superintendent is the responsible officer during the absence of the visiting staff, and the house staff is under his control, but in the majority of hospitals the house staff is responsible for the patients during the absence of the visiting staff. In the smaller provincial hospitals the responsibility of the management of the institution is often given to the senior resident medical officer, who is usually quite a young man holding office for two or three years or even less. In the infirmaries and hospitals under the Poor Law there is no visiting staff attached, but the medical superintendent has under him resident assistant medical officers according to the number of beds. In the infirmaries this is smaller than in the hospitals for infectious diseases, as the cases are much less acute. In Lambeth Infirmary with 622 beds there are three assistant medical officers. In Birming- ham Poor Law Infirmary with 1540 beds there are four. In the South Western Fever Hospital with 360 beds there are three. This condition of things works very well in the large hospitals, where each official has work and responsibilities enough in his or her own department to fully occupy mind and time. But the relations are strained in the smaller hospitals where there is not so much to do, and where the authority is frequently placed in the hands of the senior medical resident physician, who is usually a young man holding and magnifying his first authority.

Perhaps the most remarkable change in the administration of hospitals of late years has been the enormous increase in the number of nurses and in the expense of the nursing department, which in some hospitals seems to have reached an excessive degree and points to the necessity for some competent authority to define the requirements of hospitals in this matter, having regard to the size of the institution and the chronic or acute nature of the cases received. The staffs of the various large hospitals vary in proportion to their patients to an almost incredible degree. In the London Hospital where there are 776 beds with an average of 659 patients the whole nursing staff, including the matron and her assistants, is 313 ; or one nurse to about 2Vz patients on the whole number of beds, and just over one nurse to two patients on the number of beds occupied. In King's College Hospital where there are 221 beds and an average of 168 patients there is a nursing staff of 69 which brings the proportion of nurses to patients to very much the same as the London Hospital. In St. Thomas' Hospital the beds number 570; the inclusive staff 161, which makes the proportion quite one to 3^ patients. In the Edinburgh Infirmary where there are 780 beds with an average of 711 patients, the nursing staff is 195, making an average of one nurse to four beds and rather less per patient. The Royal Infirmary, Glasgow, gives almost the same proportion with 582 beds, an average of 555 patients and a nursing staff of 142. The Western Infirmary, Glasgow, with 420 beds and a nursing staff of 128 gives a little better proportion. The

Mater Misericordia Hospital, Dublin, with 338 beds and a nursing staff of 152 gives a proportion of one nurse to 2^ patients. The General Hospital, Birmingham, with 346 beds and an average of 269 occupied has a nursing staff of 102 nurses, giving an average of one to just over 3 beds and one to 2j patients. Leeds General Infirmary with 402 beds has a staff of 83 nurses, giving an average of one nurse to four patients. The smaller county hospitals whose beds are undef 150 seem all to range about in a proportion of one nurse to four patients.

In the infirmaries and hospitals under the Poor Law the proportion of numbers is curiously different. In Bethnal Green Infirmary the number of beds being 669 with an average of 520 occupied, the number of the nursing staff is 80, giving a proportion of one nurse to about 6:^ patients. In the Lewisham Infirmary the number of beds being 400, with an average of 250 occupied, the average is one nurse to almost 7 patients. Both these infirmaries are in the London district. In the Poor Law Infirmary, Birmingham, with 1540 beds and an average of 1131 occupied, the nurses' staff gives an average of one nurse to ten patients. At Salford, near Manchester, the Poor Law Infirmary has 800 beds and has also an average of one nurse to ten patients. In the hospitals under the Metropolitan Asylum's Board the proportion is better, being about one nurse to three or in some four patients. The difference in proportion of patients and nurses in hospital and Poor Law infirmaries does not imply a corresponding lack of efficiency. Hospitals and infirmaries supported by voluntary contributions are increasing. Occupied by patients suffering from acute disease, their aim is to treat as large a number of patients as possible in as short a space of time as they can, compatible with efficiency, while the Poor Law infirmaries have a large number of chronic and infirm cases whose condition does not call for such constant attention on the part of the nurse. I mean that a larger proportion of patients per nurse may be efficiently attended to in a Poor Law infirmary than in a hospital in consequence of the chronic character of many of the patients in the former.

It seems to me that the maximum number of nurses necessary for ef^ciency must be reached or overstepped when the proportion of nurses is one to two patients or just under.

This large number of nurses connotes a proportionate number of wardmaids, servants and cleaners, and brings the whole female staff to a proportion of one to 1^ and If patients and makes the cost of the nurses and domestic department enormous. In the large hospitals the average cost of the nurses ranges from £40 to £63 per annum ; in the smaller general and special hospitals it ranges from £33 to £58. I can only find one Scottish hospital quoted, and that is the Dumfries Infirmary, which has an average of 46 beds occupied, a nursing staff of 15, costing £42 per nurse per annum. In the Belfast Royal Victoria Hospital with 189 beds and a nursing staff of 55 the average cost is £32 for each nurse. This is exclusive of service, which I cannot find estimated anywhere, but on a rough estimate made by myself I think that if we included service it would bring the average cost per nurse somewhere between £63 and £67 per annum. This amount either if paid out of the rates or met by voluntary subscription should not, I think, be exceeded.

The average cost per day per patient is almost as varied as the cost and number of nurses. The London Hospital costs 5s. 2d., Middlesex 5s. O^d., while St. Thomas' costs 6s. O^d. Leeds General Infirmary costs 3s. Ifd., and the Royal Infirmary, Bristol, 2s. lOd. In the Metropolitan Asylum Board Hospitals the cost per patient per day is about 4s. lOd. or 5s. This calculation includes not only the actual maintenance of the patients, but salaries and maintenance of officials, furniture, earthenware, stationery, insurance and the upkeep of the institution. It must be borne in mind that that is per patient, not per bed; and that the average stay in hospitals of the patients varies considerably, the greater number of patients, the less will be the average cost of each. As for instance, the average of the London is 3 weeks stay, the average of St. Bartholomew's Hospital is 4 weeks.

Of London hospitals, the majority have an annual expenditure of over £10 a bed. The Scottish hospitals spend about £50 a bed, the Irish £40, and the Provincial about £50.

The administration of the funds of the large hospitals is becoming more and more difificult as the expenses of each department increase, owing to the much greater regard being paid to the individual needs of the patients and their more scientific treatment. There must be some limit to the money obtainable for charity, and there should be some limit, more stringent and effective, to those who seek for free medical aid. There have sprung up in late years admirable societies for collecting and distributing money for the use of hospitals. We have the Sunday Fund, the Saturday Fund, and now the Prince of Wales' Fund. As these societies are in the hands of business men, they ha\f no doubt by careful selection and inspection done much to bring the hospitals into line and to increase their elBciency. The governing boards of hospitals are now largely composed of business men who have experience in the handling of great sums of money, and who give their time most ungrudgingly to the service of the hospitals.

Wilhelmina J. Mollett

Ladies, I rise with some diffidence to speak after Miss Stewarts able paper, dealing as it does with all the chief points of interest in hospital administration, - and my only excuse is, that I speak as Matron of a very different - though very important class of hospital - that is to say large County Hospitals unconnected with medical schools.

It will not perhaps be out of place if I commence with a few remarks regarding their importance from a statistical point of view in England, - I am excluding the hospitals of Scotland, Ireland and Wales, and all special hospitals.

London contains twelve general hospitals with medical schools attached - containing an aggregate of 4,674 beds. The Provinces (or counties) have tv/elve medical schools with an aggregate of 3,075 beds. Thus the total number of beds in general hospitals in England where regular clinical instruction is given to male students is 7,749. But there is further a very large number of general hospitals varying much in size, which have no medical schools attached to them, whose total number of beds, 14,974, is nearly double the amount of those devoted to clinical instruction.

Fifty of these contain 100 beds and over, and have a total of 7,526 beds, or nearly as many as the London and Provincial Medical schools combined.

All the above are Voluntary Hospitals - supported by subscriptions or endowments. None of them are aided by the Government or are rate supported. A very few receive a small proportion of paying patients, in fact they practically do not receive them. Except in certain primary matters it is not possible, in my opinion, to compare the management of a County Hospital in detail with that of a hospital having a medical school attached. The essential virtues of order, discipline, obedience and the subordination of the female stafif in disciplinary matters to the female head, are the same in both, but in detail they differ.

The highest authority in a County Hospital supported by voluntary contributions is always the Governors - the donors or subscribers in council assembled. The amount given or subscribed to become a Governor varies, but the outcome is the same, the formation of a large body with voting powers - meeting about one or twice a year to appoint committees and vote extraordinary sums or changes in the By-Laws of the Institution. They elect the management, financial and executive committees for the year, the president, the chairman, and so forth, - and these practically carry on the business of the hospital, appointing the executive officers, and being generally responsible to the Governors for the efficiency and economy of the place. It is here that both the strength and weakness of hospital government lies, - whilst on the one hand the management of the hospital is kept in touch with public opinion, on the other hand the proper government of the hospital is apt to be disturbed by well-meaning gentlemen who have no knowledge of the real needs and requirements of hospital wards, whilst it also lays them open to the influence of popular or strong executive officers. The honorary medical staff have representatives on the various committees, the manner of their representation varying slightly in different hospitals.

The executive administration in my hospital containing 130 beds, which I am following in this sketch, falls into three departments and I hold that it is in the proper balance of power between these three departments, the proper apportioning- of their various responsibilities, that the efficiency and good order of the hospital largely depends. They are the secretarial, the medical, and the nursing and domestic.

The secretary has charge, under the Finance Committee, of the financial afifairs of the hospital, the collecting of subscriptions, the hospital banking business, the balance sheets, and so forth. He attends to all correspondence that is not directly concerned with medical, nursing or domestic matters and, in my case, overlooks the engineer and the engine and the general repairs of the building-, etc. He acts in emergencies for the committee in their absence. He is a non-resident officer and, when a suitable man, a very valuable aid and counsellor. I am, personally, very fortunate in my secretary.

The principal resident medical officer is the senior house surgeon who, working under the honorary medical staff, acts for them in their absence and is in medical and surgical charge of the patients. But as he is, beside, the resident medical officer for the committee, he holds, and rightly, a very important post with regard to the patients. He is, generally speaking, responsible for the admission and discharge of the patients and for their treatment in the absence of the honorary stafif, but he is not an administrative officer as regards the nursing and domestic staff. They do not fall under his jurisdiction except in so far as he gives his orders for the patients to the sisters in charge of the various wards.

One of the greatest difficulties in a County Hospital is in securing a suitable man for the post of house surgeon. It is essential that they should be thoroughly good professional men and men of common sense, who work their way into their post without offending against all its conservative instincts. For they come, of course, from various medical schools ; each with its own fads - the Guy's man, the Bart's man, the London and the King's - all think their own school perfection and are often a trifle scornful of their predecessor's methods. But the main point is that they should not be slack but keen men for their work and, perhaps, from a matron's point of view, that they should not be too susceptible to the charms of attractive sisters and probationers.

The matron's department includes the nursing and domestic staff, the food, the laundry and the general management. She either selects the various sisters, or recommends candidates to the board, engages probationers and servants, and superintends their work, for which she is responsible.

She gives the orders to the assistant matron and to the cook and supervises more or less the food supplied to the patients. She stations the sisters and probationers in their wards, arranges the work, the holidays, and so forth. But it really is not necessary to enter to the present company into the details of her work, except to emphasize the fact that it is a combination of superintendent of nursing with that of matron. I will, however, add that it is essential, if she is to carry it out efificiently, that she should herself, as in my case, be directly responsible for it to the committee and not to any other official. Perhaps there is one other point I should mention as being of importance and that is that the nursing and domestic head should be the same. Good nursing depends so much on good domestic management and is so intimately connected with it, that the two should certainly be under the same control.

The nursing staff is divided into sisters at the head of the wards, a night superintendent, and probationers who train for three years, and are stationed on night or day duty. Their average daily time on duty, when meal times and off duty time is deducted, is a little more tkan ten hours. I see no reason, in a County Hospital, why that time should be lessened.

Ward maids are attached to the wards to do the roughest of the work, but there still remains a fair but not undue amount of ward cleaning to be done by the probationers. Ward orderlies are unknown in English civil hospitals ; all the nursing of the male patients is done by the sisters and nurses.

The whole scheme of hospital organization for County Hospitals resolves itself into a body of subscribers appointing committees for a given period, who in their turn control and regulate the hospital in accordance with certain rules and by-laws, and the fixed rule of most of these hospitals is that they are intended only for " fit objects of charity." This rule is carefully guarded by the medical profession, amongst whom the very idea of pay wards attached to a general hospital, which seems so usual here, is very generally regarded with great suspicion and disfavor. It must, however, be owned that they would solve a most serious difficulty with regard to the poorer middle classes, who are of all people the worst off in England in illness.

In some towns, especially large manufacturing towns, the work people contribute largely to the support of the hospital, and have their own representatives on the committees. This is the case, however, in only a few hospitals. It is not so in mine.

Further it is necessary to remember that these hospitals which are solely intended for the relief of the sick poor and working classes, and do not even contribute clinical instruction for students, are built and maintained entirely by the voluntary subscriptions of the more well-to-do classes and that they are beyond and outside the rate-supported institutions such as Workhouse Infirmaries and Asylums for the Insane. Above everything else, therefore, these hospitals are pre-eminently intended for the sick poor ; for their comfort, their convenience, their medical and surgical treatment ; and the first and finest lesson they have to teach to the nurses trained in their walls is that nothing, not the nurses' instruction, or convenience or comfort, is so important as the welfare of the patients confided to their care.

Maud Banfield

Superinteudent of the Polyclinic Hospital, Member of Hospital Superintendents" Association. American Society Superintendents of Training Schools, Matron's Council, Lecturer on Hospital Economics, Teachers' College,

In considering the administration of hospitals in this country we are confronted by the initial difficulty that, although an enormous amount of money is invested in these institutions, there is no uniform, or even customary, system of administration or accounting. The State institutions are, as a matter of course, dominated by politics ; and into this matter we will not enter, for the reason that most of our time would be taken up in describing political rather than hospital organization. The city hospitals, the funds for the support of which are secured by an appropriation of councils, are in some instances free from jx)litics and administered satisfactorily, notably in Boston and Cincinnati. But these institutions are also in a class by themselves. The average citizen is more concerned with the hospital which he helps to support by voluntary contributions and which, without State aid, he would be called upon to support more directly than he does at present, and it is of these I shall speak more particularly.

The business of running a hospital is like any other business, inasmuch as it needs to be learned. No one would take a man, whatever his personal attainments in his own special line, and set him down at the head of a bank, a store, a ship, or an army corps, and expect him at once to give a competent and valuable opinion on the various interests involved. Like anyone else he would just have to sit down and learn. He would leave himself entirely in the hands of the officers administerino^ that business, and unless he had confidence in them, would be rash to lend even the support of his name. If he interfered in the detail working without knowing anything^ about ft, he would be still more rash. Yet in a hospital, in which the issues of life and death daily concern many people, such hesitation is remarkably rare. The youngest physician or the most recent trustee thinks there must be something wrong if he does not immediately understand all about it, and is surprised at the strength and diversity of interests he finds tugging different ways. But, as a matter of fact, a hospital is no less full of the interests of life and progress because it also holds the sick and the dying', who are unwillingly loosening their grasjj of these same interests, to join those who sleep soundly in spite of it all.

Since I have told you that I cannot describe any general method of administration, where every institution is a law unto itself; that I can give you no trustworthy figures of cost per capita or other details which have proven so interesting in the able papers preceding mine, you may wonder what I have to say, and why I do not take the organization of one or two hospitals personally known to me and merely say, "and the others are rather like these." I do not do this because in the first place there is much of interest to be learned regarding the internal working of hospitals, and since we say in the announcement of our Teachers College Course in Hospital Economics, at Columbia University, that we " hope to teach our students the duties of a superintendent of a hospital," it may be well that they should hear a little of these matters. I think you will all admit that it is positively remarkable how a nurse will go through her three or more years in a hospital, and yet know absolutely nothing of its administration as a whole. She knows whether she gets her time ofi duty, a certain number of lectures, good food, and certain requirements for her patients ; but the machinery which provides her with all these things, she has no idea of . I think, however, that although these matters have perhaps little to do with nursing

Another reason why I have consented to speak on this subject, and the reason for my doing so with absolute candor, is that not only is much money admittedly wasted in the duplication of charities and the lax methods of administration, but the first to suffer from the maladministration of a hospital are undoubtedly the patients. This sounds to us like a truism, but the public does not yet appear to realize this elementary fact, nor that it alone has power to mend matters by the intangible but very real weight of public opinion and by ascertaining which are the right sort of charities, rightly and reasonably governed, before giving its money to them. Any person of average intelligence can do this, if he is willing to spend a little time about it and take a considerable amount of trouble.

It seems obvious that if too much is left to inexperienced men, if the food is badly served, if the patients are subject to undue interruptions, if a mean and petty spirit pervades the institution, instead of one of cheerfulness and peace, if the visiting staff do not visit, if through interest, jealously, or for all too common reasons, incompetent men are appointed on the staff, it is clearly the patient who suffers primarily. But no business is conducted with so little real inspection ; no doll's repair shop is provided with so little skilled labor in regard to administrative matters, or even when supplied with skilled labor has so many adverse conditions to struggle against as the average hospital in the large cities of America. As for the balance sheets and reports, we know that the statistics quoted therein are often not worth the paper they are printed on, are apparently more often meant to mislead than to inform, and in any other business would land those responsible therefor in the bankruptcy courts if not in the penitentiary. This is, of course, the result of corporate carelessnes rather than personal dishonesty. But it is wonderful how general it is, especially when it is remembered that hospital funds are, or should be, practically trust funds, and liable to a public accounting.

The public who have contributed this money in one form or another have at least a right to a plain and accurate statement, if one is issued at all.

I fear that a simple-minded inquirer who thinks that in order to ascertain the facts in regrard to any institution in which he is interested, he needs only to send for the last annual report, will find that his task is by no means so easy as it looks, either in regard to statements of receipts and expenditures, or the number of patients treated. He will find that frequently no attempt is made to separate income from principal ; that it is impossible to ascertain the amount of money really expended for maintenance or permanent improvements ; that often the vaguest ideas prevail even as to the total expenditures for the year, and the net profit or loss. He will find that in the detailed account for maintenance the milk and the coal, for instance, are, for some inscrutable reason, occasionally lumped together. I call to mind one item entered thus : " Received for board of soldiers, rebate on coal, etc." In such cases it is of course impossible to ascertain either the amount of money received from board of patients, or the actual cost of the lighting and heating. Nor is it possible to ascertain what or how much " etcetera " includes. In some cases interest on mortgages, water rent, insurance and other fixed charges, sometimes even lighting, heating and salaries are not included in the estimate of expenses per capita. This of course makes the expenditure of some hospitals appear excessive, whilst others appear abnormally low. In other reports the accounts of the treasurer and the superintendent have been known to dififer by as much as $3000, and the superintendent's fiscal year may begin at one time, and the treasurer's at another, whilst convalescent homes and other branches of the same institution may arrange for yet a third.* Where trustees or managers are so indififerent in regard to money matters, it is hardly to be wondered at that

*See editorial in Philadelphia Medical Journal for June 18. 1898. This hospital I note has since had the financial statement issued in its annual report revised by an expert accountant. It is encouraging that drawing attention to these matters makes for better and more careful work.

It is true that those institutions which receive State aid are required by the State to return an itemized account of their cash payments, divided as the State directs. In Pennsylvania, however, the State will only accept a statement of bills actually paid, and not those incurred. This statement obviously does not represent the expenditures of those institutions which habitually run on a deficit, and most of them do. The State Auditor told me this was done because it was found that hospital authorities sometimes made their deficit appear larger, and the consequent necessity for State aid, therefore, greater than it actually was, by running up large bills for maintenance, when these should rather be charged up to permanent improvements. For when the State makes a grant for building it requires that the sum allowed should be employed for building ; and if for maintenance that it should not be used for other purposes. This of course is quite proper.

But the method pursued to secure this end is both inadequate and misleading. The economy effected by the simple method of not paying your bills is more apparent than real.

An article on hospital finance as shown in printed reports, published as an editorial in the Philadelphia Medical Journal of June 18, 1898, written by an expert accountant who has gone into these things very thoroughly, would repay perusal by any one interested in these matters. I was somewhat surprised to find when this article came out, stating substantially what I have said above, but giving exact references, that it did not, so far as I am aware, arouse any comment whatever. A little book entitled Municipal Government, by Bird S. Coler, ex-comptroller of New York, is also most interesting, as showing that this kind of thing is not confined to Pennsylvania. He commences one of his chapters by saying " The subsidy system probably finds its greatest abuse in medical charities," and I consider his statements throughout exceedingly conservative.

One of the reasons (other than carelessness) for rendering inaccurate accounts of the number of patients treated, is that the claims put forth by the various hospitals for State aid are ostensibly based on the amount of work done, viz : the amount of free treatment given ward or dispensary patients, " the sick poor," It would seem hardly worth while, however, to do this, for, as a matter of fact, the hospital which has the most political pull usually gets the largest grant', and the quality and quantity of work done has little to do with it. This is an accepted and recognized fact, and has to be reckoned with as adding to the difficulty of honest administration of hospitals in this country. It has to be allowed for in institutions dependent in any way upon State aid, and is a handicap which often crops out at unexpected moments.

One hospital, in order to add to the ostensible number of cases treated, follows a simple expedient in counting the new patients, first as one visit ; then counting the total number of visits, including the first visit ; and adding the total number of new cases again to the total : thus, if there were three hundred new cases and a total number of nine hundred visits, it would be carried out as a " grand " total of twelve hundred. These simple little methods are by no means carefully hidden. Again, when a visit of a legislative committee is to occur, whose prerogative it is to inspect all hospitals applying through the State Board of Charities for State aid,, every possible dispensary service, surgical operation, or ward class, is quite easily arranged to fall in at that hour. Certain hospitals always know the exact hour at which tO' expect such visitors ; others do not. However, this makesno difference in the amount of money actually obtained, such matters being settled out of court, as it were ; and perhaps may be considered merely as a delicate attention to the visitors, serving to make their stay interesting.

Even a superficial examination of the minimum length of time and services rendered constituting a bed-day is also full of surprises and pitfalls for the unwary. Some hospitals regularly " admit " any dispensary patient who needs per- haps a slight operation and a " whiff of ether," and remains three or four hours to recover from the effects. Others consider that if a patient occupies a bed during the whole of a night, and possibly takes not only a " whiff of ether," but a good breakfast next morning, it makes one day, reckoning as some hotels do. Others again do not count as house cases any but those who are transferred to the in-patient wards, the unit being twenty-four hours. This last was the method agreed upon by the hospital authorities in Philadelphia when rendering their accounts to the United States Government for the board of soldiers cared for during or after the Spanish-American War, and if State aid were abolished this standard would probably be generally accepted. The twenty-four hour day is also used in Great Britain, and I think you will find has been so reckoned by Miss Stewart and Miss Mollett. It takes a little imagination to consider the two, three or four hours stay necessitated by the removal of a finger joint or the opening of a felon a "day," although possibly the time does seem to the patient to go slowly !

In Philadelphia the supply of beds is in excess of the demand. This probably is also true of other cities. Nevertheless new hospitals are constantly arising, irrespective of the need for them, and are given not only State charters, but State money. State aid is also given to private hospitals, which are used for special classes of cases already amply provided for, such as gynecological cases, and which do practically no dispensary or teaching work. They are often closed during the summer months while the physicians connected with them take their summer holidays. The reasons for the opening of these hospitals are too evident to need explanation, even to the casual observer. These hospitals " nurse " their patients cheaply by establishing " training schools." They issue " diplomas," and it is often not until the unfortunate pupil nurses have completed two years service that they find that in order to secure any standing in their profession, they have to begin all over again ; and that even when they are willing to do this, regular hospitals are

On the other hand, State aid is refused or very much cut down to hospitals in poor sections of the city which treat large numbers of out-patients and which have existed for several years. I once asked a member of the State Board of Charities why this was done, and the answer was a somewhat sweeping, " We do not approve of dispensaries." Considering the miscellaneous assortment of things the board did apparently approve, I thought this was sufficiently interesting to ask " Why do you not approve?" and the answer was, "Because the doctors do not approve." "Nor the druggists," murmured another member, " don't forget the druggists." I was not aware that the medical profession or the drug trade were " infant industries " to stand in need of a protective tariff, as it were, or that hospitals were established solely for their benefit. Moreover, these statements seemed to me to be hardly warranted by the facts.

It is my belief that the greater number of physicians get too much out of their dispensary practice to disapprove of It, and that they themselves would readily admit this. From the professional point of view numbers of medical men, both young and old, add much yearly to their medical lore by the study of dispensary patients. No one who has not had to buy them knows the number of new drugs used experimentally; if apparently successful, to be then used on in-patients under closer observation ; if still yielding satisfactory results, then in private practice. There are also many classes of cases, such as broken arms or skin diseases, nasal deformities, chronic but slight orthopedic deformities, slight organic heart diseases, which it is cruel and unnecessary to force into the hospital as in-patients. To oblige this class of patients to stop work entirely and break up their homes for an affection requiring frequent, although slight attention, is forcing pauperism upon them. To say that this class of patients can afford to go to a doctor's office is not the case. The physician who has a fairly good practice and an average experience, cannot afford to treat them. The young man who is only busy waitino^ for patients to drop in, has not only a very limited experience, but also possesses none of the material resources of a hospital. He cannot afford to give the patient lint, bandages, splints, ointments, or medicines, and the patient cannot afiford to buy them at retail druggist prices and pay the doctor even a small fee. But most of all, the patient whose health is his only capital, as well as his income, cannot afford the loss of time which inexpert treatment entails. The unnecessary loss of skilled artisan labor is also a loss to the community which may be reckoned in dollars and cents. Moreover, anyone who knows anything of hospital work, knows of many instances where patients have drifted into the dispensaries with ununited fractures, simple skin diseases which have lasted for years, and what not, saying they have spent all their money on doctors, and now haven't a cent left. Any case which the physician feels is imposing on his tinte and on the hospital supplies, he can easily question at the time he is taking the patient's history. By the manner of the replies as well as the matter, aided by his knowledge of human nature, he can frequently tell what sort of case it is. If a border line case, as it were, the patient can with perfect propriety be made to take his turn with his undoubtedly poorer neighbors, can be lectured on, or used for demonstration to students. This weeds out many. Or the physician can say simply that he does not consider him or her a proper case for hospital treatment. Such cases can be reported at the hospital ofifice, and investigated either by the Charity Organization Society, which will look into and promptly report upon such cases, or by the hospital inquirer who is deputed for this duty. It is also to be noted that physicians themselves not infrequently encourage the attendance of " interesting cases " quite irrespective of their social status. As I have lived most of my hospital life in teaching institutions of one sort or another, I must confess to a certain amount of sympathy from this standpoint.

dispensary abuse must necessaril}^ originate with the physician, and be carried out with his co-operation. It cannot be done without it. And from the patient's point of view I must again repeat that to force many patients to become hospital in-patients, is to force pauperism upon them. Few have any reserve fund, and coming into a hospital, especially for a semi-chronic condition, means breaking up their homes, selling their bits of furniture, and boarding the children out. I have not heard this point stated, but I know it to be a fact. The deserving poor are not always those who have not a cent in the world, nor are those the poorest. It is undoubted that there are just as many abuses from the medical side as there are from that of the patients, only the patients have no one to write their briefs for them.

Another point in dispensary service which I mention merely to show the many aspects which this question assumes, and the many interests involved, is brought up in an article by a physician recently published in a well known medical journal,* contrasting unfavorably the treatment accorded by hospital superintendents to physicians working in dispensary services, compared to that accorded physicians of equal standing in the wards of a hospital ; this more particularly in neglecting to furnish instruments for their use, and the unreasonable number of patients they are expected to treat in a given time; and recommending personal supervision by the superintendent as a remedy. So far as I have been able to observe, these statements are quite true of all large city hospitals from which I have been able to obtain data. But neither the reason or the remedy would appear to be well taken. The hospital superintendent does not, for instance, wilfully assign an undue number of patients to a certain physician, seeking to overwork or incommode him. The superintendent indeed generally has nothing whatever to do with the assignment of patients, each hospital having its own rules or customs in regard to this. When one remembers the " feelings " which are aroused by the sometimes accidental transference of patients from one service. to another, one wonders at this particular complaint being- brought ! In any case, the remedy would seem to lie with the physician himself, rather than with the superintendent of the hospital. The patients whom he finds himself unable to treat might be referred to another service, or even another hospital which is not so crowded. In the present overstocked condition of the medical profession, where the supply is greater than the demand, he might secure additional assistants, who, if they do not already know, might soon learn to carry out routine treatment, referring all doubtful cases to the " chief of clinic " or head physician for supervision and direction. Given sufficient space and light, this difficulty seems capable of solution in more ways than one.

In regard to the supply of instruments, it is only too well and widely known that hospital superintendents are not able to keep dispensary services supplied with instruments, because they so speedily disappear. I think it is seldom wilful neglect on the superintendent's part. It is merely that it is useless to supply them. In the recent report of the Bellevue Medical Board in connection with the reorganization of that institution, the recommendation was made that an officer be appointed whose duty it would be to see that hospital instruments and supplies were not removed. Judging from one's own experience, however, it would take manv duplicates of Sherlock Holmes to accomplish the desired result. For the foregoing reasons, the immediate supervision of dispensary services either by the hospital superintendent with his many other duties, or by an officer appointed for that sole purpose, is, I fear, impracticable. In this department the physician himself is quite properly supreme, and upon him alone falls the responsibility for right treatment of patients, or in the last resort upon the appointing power which places him there.

L.A.Y Vs. Medical Control

Governments, like lesser folks, are judged by results. Whether the government be called a limited monarchy, an autocracy, or a republic, is of less importance than that it should be efficient, and secure to the people their just rights and privileges. Lyman Abbott, in his Rights of Man, says of Government " Its function is the protection of the inherent indefeasible rights of person, property, reputation, family and liberty. It has other and secondary functions, but if a government fulfills this one function of protection justly and adequately, it is a good government whatever its form ; and whatever its form, it is a bad government if it fails to perform this function justly and adequately ; it is pre-eminently a bad government if, instead of protecting rights, it violates them." These words apply to the administration of hospitals, as well as of cities or countries. The rules, customs and government of a hospital often intimately concern the happiness, rights and persons of from two to eight hundred or more people, sick and well. And from whatever ranks the governors are drawn, lay, medical, or both, the government is practically an autocracy, from the decision of which there is no appeal. Therefore it behooves us, whenever we have the power of choice, to choose our autocrats wisely. To maintain a just and fair equilibrium between science, philanthropy, and an annual deficit is often the far from enviable lot of the board of trustees. Indeed finance is often the most urgent of the three, for the butcher and drug dealer are by no means as patient in the settlement of their account as is science ! Running a large business on a deficit needs very consistent and very thorough attention from some one if the doors are to be kept open, patients fed and even small salaries paid regularly to the necessary employes; and this quite without consideration for the supply of the newest scientific apparatus, the very latest discovery in drugs, and the repair of large and much used buildings. Whether medical men are generally constituted to fulfill the requirements of all good governments and also those of finance, I will leave you to consider. Your consideration will no doubt be aided by the somewhat acrimonious discussions on this subject which are frequently to be found in both the medical and lay press - particularly the former. The medical administration of the enormous City Hospital in Vienna is not to be entirely ignored. The conduct of nurses' registries and societies by medical men, where they have control, will doubtless be of use to you. There is also a very excellent chapter on this subject in Sir Henry Burdett's Hospitals and Charities for 1901, page 69.

The Hospital Superintendent

I have touched upon a few of the varied interests which are to be found in every large city hospital, and, as you know, there are very many more which I have not mentioned. Now to reconcile these diverse elements it would seem almost necessary to choose a man or woman of skilled knowledge, with marked executive ability, with ceaseless energy, a warm heart, a wide knowledge of human nature, and good health. Now what really happens? As Lord Alelbourne said of the Order of the Garter, "There is no damned merit about it."

Amongst the hospital superintendents I know of, there are, besides a very few physicians, an ex-newspaper reporter, a ward boss, a china factory hand, various clerks, and a still more varied assortment of clergymen. The clerks. who have possibly before occupied the position of hospital bookkeeper, are the only ones who can be said to have had any previous knowledge of the office or business routine of a hospital, and this after all is a point which is more easily acquired than any. A good superintendent is, of course, sometimes evolved, but it is at the expense of the institution as well as of the individual. Some, taught in the dear school of experience, undoubtedly become first rate hospital superintendents ; - I suppose on the principle that it is not advantages that make great men or women, but disadvantages ; - and many certainly work hard and unselfishly. But surely if there was ever a calling which needed preliminary training and skilled administration, it is that of hospital superintendent.

Teachers are taught to teach, engineers are taught engineering, bridge builders to build bridges, preachers to preach, doctors to doctor, but to reconcile the innumerable and various elements in a large and busy hospital no previous knowledge seems to be thought necessary ! Indeed, if a man has failed in other walks of life, or if a clergyman has neither the mental nor physical calibre to command success, he seems by some curious process of reasoning to be considered peculiarly fitted for such a position. In no business that I ever heard of in which the same amount of money is invested, is there so little skilled labor employed as in hospital administration. This acts and reacts in many ways, and renders institutional life in this country subject to many sudden upheavals and much friction. The patients complain, the physicians complain, the employes complain, in fact everybody complains, and the Board puts on a worried air - as well it might - for there seems to be a certain amount of justice in all the complaints, and whilst nobody appears to be as much in the wrong as asserted by the opposite party, still there is enough to perplex it very thoroughly. The superintendent either fails to control these matters at all, or else adds to the difificult3^ Then, in order that the domestic complaints may be removed, a committee of ladies is sometimes appointed ; they are not experts, often far from it, their only claim to knowledge being that of the " born housekeeper " which is sometimes supposed (erroneously, I think) to be inherent in every woman. The organization and management of institution households, however, having little in common with that of a few maids and no sick people, the management of details by Visiting Committees is often proved to be but an added discomfort.

Having trusted one superintendent and found him or her wanting, the Board of Management is naturally chary of trusting his or her successor. In the first place they don't as a rule know where to look for a successor. Hospital superintendents are usually just men who happen along. It is not so much a distinct calling at present as a tentative , occupation, usually applied for by a man who is " out of a job." If a large hospital with plenty of funds can aft'ord to pay a good salary to a medical man who has talent for detail, and prefers administrative work to the more active practice of his profession, it seems to be the best solution. He has a fixed salary and usually does no outside practice, and thus the difficulties in the way of his independence, which might apply to the outside practitioner, have not to be reckoned with. But he also has to learn how to take care of buildings, how to purchase supplies, obtain estimates, and keep the whole intricate machine in good running order ; and this costs the hospital money, for all large department stores will tell you that a good buyer is far more valuable than a good seller, and hospital buying is a fine art. He usually has a good steward whom, with the housekeeper, he trusts to purchase the household supplies. He often has a practical builder to attend to repairs, and a good office force. The details of the various departments, and the knowledge which the superintendent has of them of course depends upon the individual.

As a rule, if he shows himself faithful and just, no important steps are taken without his advice. He is held responsible for everything in regard to the administration of the institution, and for the employment of proper persons to carry on the work of the various departments. This is as it should be. Unfortunately, hospitals so administered can be counted almost on the fingers of one hand.* In one large hospital, the Johns Hopkins, according to the by-laws, the superintendent is a member of the executive board, but I do not think this is general.

Now the point which will be of special interest to you is, can a woman who is a trained nurse do this work? There is no reason why she should not. The reasons for and against lie within herself. In spite of the immense strides which women have made of late years in regard to public work, it is even yet, and even in this country, which Max O'Rell justly calls a paradise for women, undoubtedly more dilficult for a woman to carry out executive work concerning large numbers of people than it is for a man, and perhaps it always will be ; but to say that it is more difficult is not by any means to say that it is impossible. As there are com- paratively few medical men who desire such positions, or if they do desire them, possess the necessary quaUfications, and as the newspaper reporter, the clergyman, or the factory hand possess no knowledge at all of hospital work or requirements, it would seem that a woman who had worked in the wards of a hospital, who had lived there day in and day out for at least six or more years, should certainly be of more use than these, and have less of the technical part to learn. Florence Nightingale says that " in all departments of life there is no apprenticeship except in the workshop " and it is certainly the most thorough and the best, and worth whole books of theory. It seems to me that if women were more willing to take up this work, many of the difficulties, and much of the friction of hospital life might be avoided. If the visiting staff see that the superintendent is not only willing but anxious that they should have not only the necessaries, but all the luxuries or additions which make their work easier that the hospital can possibly afford, and knows exactly what these requirements are, they feel naturally far more friendly toward the administration as a whole. In many ways hospital keeping is but housekeeping on a larger scale.

It does not follow, however, that because a woman is a good nurse, or even a good superintendent of nurses, she is a good hospital superintendent. The work is very different. The hospital superintendent represents the hospital, not only to the patients and their friends, but to the tradespeople, building contractors, the city government in the matter of Boards of Health, and coroners' offices, and, in short, in all the varying phases in which this varied business touches the public weal. Decisions affecting varied interests and large numbers of people must often be made quickly. If it can be shown that a decision is narrowminded, petty, or errs in any particular, because unsuitable or too severe, the superintendent's judgment will naturally not be relied on in future. It is absolutely necessary that, humanly speaking, no mistakes should be made. More specially does this apply if the superintendent be a woman, because as there are fewer women superintendents of busy hospitals, any errors are more closely watched for, any failure is a double failure. If the same mistake were made by a man, the public or the individual concerned would merely say " they have made a mistake in selecting their superintendent," but if a woman, not only the individual, but her sex is at fault.

There is one point especially where there is room for the right use of woman's influence in hospital work and that is the influence of women for purity. Unfortunately, I know of more than one hospital, indeed, more than two or three, where this is still needed. It is an unfortunate fact that men in teaching institutions, holding the rank of professors, wall relate stories or indulge in coarse remarks, or even so clothe their instruction to undergraduate students, that their words necessarily make a modest or clean-minded woman exceedingly uncomfortable. It is also a fact that this is by no means accidental ; it is often quite obviously done for the purpose of making the nurses appear confused, or raising a laugh among the students. It is no part of a nurse's duty to put up with these things ; there is no reason why nurses should not be as modest and delicately minded as any other women, and as far as my own experience goes, I have found them so. But it is not fair to send a young girl to a clinic, to require her as a matter of obedience to be present whilst the professor makes unseemly jokes, or lectures on a case in an unnecessary way. But whilst I feel sorry for the nurse, I regret it even more for the sake of the students. Thev hear the professor, sometimes a man of almost worldwide renown, relating these stories and making these unseemly jests. They think it is a manly and professional thing to do. Where teachers offend in this wav, it is obvious that assistants will often follow suit. But even for the sake of holding the student's attention at lecture, is this a right thing to do? All young men have not good home influence to help them combat the effect of this loose way of talking and thinking. Many of them are drafted straight from college to positions as resident physicians in hospitals, where they make many mistakes as a result of this sort of teaching. That some " come out right in the end " is no argument in favor of it. Some do not. Surely the attitude of a teacher of such a profession - which should always be in fact the " noble profession " of medicine - should be somewhat different. It is not a pleasant task, but it is the manifest duty of every superintendent of a hospital, or superintendent of a training school, to see that the nurses at least are not subjected to this sort of thing. And the young men will also benefit, and some day, even though that day may be far ofif, they will thank you. Those of us who bear the burden of responsible positions have to face many unpleasant duties, but we have got to remember that, as President Roosevelt says, " Whoever possesses power, is by the mere possession of that power made responsible for its right employment."

As a matter of fact in a properly administered hospital, medical schools are a protection to the patient rather than otherwise, for it usually means that the hospital is a very live one, and thoroughly up with the times. The patient is safe-guarded by public sentiment which in this country is against overmuch experimentation. But this, as I have said, provided the hospital is carefully administered. That is to say, that although students are taught to work in the wards, proper consideration is had for the patients. I have found that patients, even pay patients in the wards, do not resent the doctor's describing their case as an interesting one ; they are quite willing as a general rule to be lectured upon before a class of students, and allow students to examine chest or heart and so on, in moderation. If you have a capable head nurse in the ward, she will keep her eye on any case which may be in process of examination by the students ; and a kindly word, saying that she is afraid the patient is tired now, and had better rest, I have never found resented.

students are assig-ned to certain beds, and the patient is not examined by forty or fifty young men one after another, as seems to be the popular conception. If the patients are women, a nurse is, of course, always at the bedside of the patient whilst the students are there. In teaching hospitals, whether under-graduate or post-graduate, the supplies are much more liberal than in non-teaching institutions, and I think that on the whole the patients are generally better nursed, for every one is kept up to the mark, including the professors. If the patients object to examination, I have always found that the students are perfectly willing to consider their feelings.

Inspection Of And Public Interest In Hospitals

It would be a distinct advantage if frequent official inspection of all charities receiving subscriptions from the public were ordered by the State or municipal government. Whilst it is true that a hospital must possess a charter of incorporation in order to hold property as a body, this does not prevent all sorts of abuse. Every institution whether it be a hospital, or any other charity, to which the general public is invited to subscribe, should be subject to this inspection at least once in three months, and if the inspectors are not satisfied with its condition, at least once every month. Institutions supported by the public are owned by the public, if the people would only realize it, and it is their duty as well as their privilege at least to see that these institutions do not become hot-beds of disease. Of course when the millenium comes no man or woman will ever engage in an undertaking for others without really trusteeing it. But as matters are at present, some sort of supervision is certainly necessary. To prove my contention, if it needs proof, I would again refer to the comments of the ex-comptroller of New York in the book which I have already quoted. In my opinion it would be for the greater good of the greater number, if an act of total prohibition, or at least high license, was passed, regarding so-called private hospitals. By this is meant a house rented by a physician as a personal venture, to which he sends his own patients. As a prominent physician said to me the other day, " the private hospital is a star chamber ; no one knows what goes on there and there is no way of finding- out." You will say at once that " the reputation of the man who owns it is sufficient," but as a matter of fact, this is not so. In the first place he cannot prevent another man with a lesser reputation, or a shady one, from doing exactly the same thing. As a rule the patients in private hospitals are not by any means so well nursed nor so well fed, as in the private rooms of a general hospital. The rates are often very high, and the friends of the patient often make every effort and stint themselves for years in order that the patient may receive treatment in the private hospital of some physician or surgeon, thinking, no doubt, that the article for which they pay so highly must be better in quality. It is true that there is greater privacy, but it must be remembered that it is not only in Trusts that publicity is protection. It is often protection for the patient as well. It seems also rather infra-dig. for physicians who have already made big names for themselves, to run this sort of a boarding house for gain. They may say that they can obtain better what they need in their own houses ; but anyone who knows the running of a well-equipped hospital, the attention given and the supplies furnished members of the staff, will hardly consider this a valid reason. The only cases to which exception might be made are nervous or mental cases which sometimes require to be isolated from their friends, and kept exceedingly quiet for weeks at a time. More particularly should the practitioner who is not connected with any hospital, who has certain classes of practice, such as gynecological or obstetrical, Ije required to show very good reasons to the city authorities before starting a " private hospital," or taking patients into his own house. And this for his own sake as well as theirs. In any case, the licensing of such houses, and an arrangement by which, although having the use of the house as required, the physician would have no direct monetary interest except in the

In conclusion, before any more definite information can be g^iven concerning the detailed arrang^ement and expense of hospitals in this country, it is necessary that a uniform system of accounts be established which shall be regularly audited by a certified accountant, and that a certain definite amount of information derived from figures resting on a definite basis be forthcoming from all institutions soliciting money from the public and not only those receiving State aid. As I have pointed out, a bed-day which varies in length from four hours to twenty-four, is of no use. It is indeed so misleading as to lead to a rcductio ad ahsiirdnm in some cases.

It seems as if there should be some check on the unnecessary multiplication of charities. Perhaps some of you may have heard or known of the time when the supply of orphans in New York gave out, to the dismay of those who were engaged in founding new asylums and liked to see their names on the front pages of reports? Hospitals in these big cities are nearly, if not quite, in the same case. Some day an organization of these charities will surely be required. For instance, it hardly seems necessary, where all hospitals admit their patients without distinction of color or creed, and allow the pastors of the various denominations to visit their sick without let or hindrance, that each separate denomination should multiply machinery and salaries, simply for the sake of calling a hospital by a denominational name. These hospitals are sometimes well supported by the rich members of the congregation, but they often suffer from many of the worst features I have described, and others which I have not. It is diflftcult to advise the total abolition of State aid for charities, even semi-private ones. The public, particularly the working element which mainly depends upon these institutions for help in time of sickness, has not learnt to support them ; and many of these institutions do a very useful work. The knowledge that they receive any aid from the State, however, takes away from the general masses of the people the feeling of responsibility for their support. And perhaps this may be the reason that neither the working man or the large employer of labor in mills, factories, etc., supports hospitals to the same extent as obtains in Great Britain, where the hospital system is purely voluntary (excepting, of course, poor-law infirmaries). The subscriptions received at street corners and in public buildings, on Hospital Saturday and Sunday alone, amounted in 1898 at Wolverhampton, a comparatively small manufacturing town in England, to £36.28 per 1000 of the population and in Liverpool to £23.16.* Contributions from work people are often entered separately, and in the Bristol General Hospital where this is the custom, amounted to £1,727 for the year above mentioned. The economy of organization is shown by the Organized Hebrew Charities of Philadelphia, which in its first year not only showed all its charities in a flourishing condition (many of which had previously languished) but a gain of over $26,000 in subscriptions.

Let me say, finally, that the foregoing facts and suggested remedies (where it has been possible to suggest any) do not apply to country hospitals, nor country districts, nor country physicians. These no doubt have their own trials, but they are not those of the great cities. And for this they may be duly thankful !

The President : I would like to call upon Miss Palmer,, the editor of the American Journal of Nursing, to open this discussion. She has been prominent in training school work and hospital work.

Miss Palmer : I feel somewhat embarrassed to be called upon to speak extemporaneously upon this subject of hospital administration after listening to the three papers so ably prepared. I am going to ask the privilege of speaking only from my own personal experience in the administration of