pital anywhere that is doing a legitimate, life-saving work, because it cannot, or does not, measure up to the plans that may fit the Johns Hopkins, the Mount Sinai, or the Royal Victoria.

I am fully convinced that we have been trying to advance too rapidly in these matters. Let us go a little more slowly and carefully in the pursuit of our ideals. Let our zeal for legislation and for educational ideals be based on a more thorough and sympathetic recognition of hospital needs and conditions as a whole; let it be seasoned with mercy, characterized by justice to all concerned, and balanced by patience and common sense. While admitting the justice of state recognition for our hospital graduates, I believe that in hospitals, as in individuals, real reform must come from within. In most genuine and wide-spread reforms it will be found that three forces have been at work-education, regeneration and legislation. In promoting rational education along primary and advanced lines, in patiently showing the way to better methods, and in the regeneration or quickening of the hospital conscience throughout these two countries, it is in the power of this association to do what can be accomplished through no other medium. I have no hesitation in stating my conviction that more real, genuine, practical improvement can be effected in our training schools, by the factors represented in this association working conscientiously, intelligently, concertedly and spontaneously toward that end, than by any amount of legislation. Before leaving this division of my subject I wish to submit one direct question. Should a hospital that is situated so as to give a general training in nursing, be denied recognition as a training school, because it gives less than three years' course?

Thus far I have spoken of the pupils, the subject matter, and of training school laws as they relate to hospital efficiency. I want now, as briefly as possible, to discuss present methods of training as they relate to the efficiency of the nurse superintendent of a hospital or training school. According to the United States Census report of 1904, out of the 1,484 hospitals listed, 1,147 reported 50 beds os less, occupied on January 1st of that year. These figures are given simply to show the overwhelming majority of small hospitals over large, that there are in the United States. (A considerable number of these hospitals have since added to

their bed capacity.) In the great majority of these small hospitals and in a great many medium-sized institutions, the superintendent is a nurse. In fact, I think from the figures given, and the general knowledge of conditions which I have obtained, I am perhaps justified in presuming that out of the 1,484 hospitals listed, the affairs of pretty close on to 1,000 of them are administered by nurses trained in our hospital schools. Besides these, there is the army of training school superintendents who are also nurses, and who have been, and are, destined to be a powerful factor in determining hospital efficiency. I believe I am also justified in presuming that the majority of these chief nurses and superintendents were trained in medium-sized or large hospitals. I do not mean to say that strong hospital women may not, and have not, come from the smaller hospitals, but we are accustomed to consider that fitting for private duty is the strong point of the smaller hospitals, and in fact a great many of such schools do not pretend to do more than that. It is customary, when a nurse superintendent is wanted, to write to some prominent well-known hospital for some one to fill the place. Those who are recommended for such positions are often recent graduates, or perhaps ward head nurses who have been good managers in their departments. Few of these have ever had charge of even a small household. While in the larger hospital, the responsibility for the purchase of supplies of all kinds, the engaging and supervision of the help, the management of the laundry or the kitchen, the keeping of books; in short, the responsibility for the general executive affairs is assumed by others. Neither as pupil nurses, nor as ward head nurses, do nurses have to even think about these problems. The boards of managers of many hospitals, especially the newer ones, have very little real knowledge of institutional work. There is, as a rule, never very much money in smaller hospitals to pay for experienced engineers, laundry workers, bookkeepers, or experienced expert workers of any kind. It will thus be readily seen that the responsibility for promoting hospital efficiency and economy in a vast number of hospitals, depends on this nurse superintendent, and her efficiency, at first, at least, must in large measure depend on the manner in which she was trained. In other words, the degree of efficiency attained in two-thirds of the hospitals of the Uni

ted States and Canada, is largely dependent on the way the other one-third train their nurses. I admit, of course, that personality, natural endowment, habits and womanly intuitions, will influence the situation, but training should count for as much in success in hospital management as in any other business. If, then, this is true, I wish to ask what training are the nurses getting in the average mediumsized or large hospital that will fit them for this many-sided administrative responsibility. Are our nurse graduates of to-day, as a whole, any better fitted to go out to manage hospitals or training schools than they were fifteen years ago. I seriously question it. Here and there is a school that has sandwiched in a few lectures on executive work, but in most cases the nurse superintendent takes up her task to learn by her blunders; to flounder around and evolve her own methods of hospital management; to depend on her own intuitions largely, as to how best to promote the economy and efficiency we are so anxious to see developed in the American hospital world. We have padded our curriculum here, puffed it there, and adorned it in the other place. We have brought in our twenty-four medical lecturers one by one, to discourse on embryology, chemistry and kindred subjects. We have led the nurses up hill and down dale according to our fancy, from class room to class room, into chemical laboratories, and bacteriological laboratories, making a careful study of germs, to pass away the time, but we have largely neglected this very important training that figures so mightily in the success and efficiency of our hospitals. Throughout the forty odd years of training school existence we have had our attention focused on fitting nurses for bedside work. I think the time has come when we should recognize that there is a region beyond this primary course, in our own legitimate field, which we should enter and work up if we would be true to our own highest interests. As I stated last year, I feel most strongly that this is a responsibility which devolves especially upon the larger hospitals; and that a general effort in this direction should be made by this association as soon as can be arranged for. It would be difficult to convince me that the Toronto General Hospital, the New York Big Four, or the Massachusetts General, or the Boston City hospitals, and the class of institutions they represent with their forces of trained workers, their superb

equipment and facilities and rich experience-it would be difficult to convince me that they have not a greater educational responsibility-a responsibility to provide a training beyond that which can be given in a small hospital where one lone woman must take the brunt of every difficulty that presents itself.

In considering the relation of the training school to the efficiency of the nurse superintendent, which would be best worth while a lesson on medical jurisprudence, or one on how to manage a hospital laundry; a lesson on the chemical composition of mineral waters, or one on how to purchase food supplies or surgical supplies, or keep a set of hospital books; a lesson on the foetal circulation or protoplasm, or one on how to make contracts with and manage servants, or on hospital office details? Suppose we skipped the lessons on embryology and started with the sick man as he is when he comes into the hospital. Suppose we just put him to bed, clean him up, study his symptoms, and take the best care of him that we can. Suppose we don't bother analyzing his teeth, and hair, and nails, and sweat ducts, and skin, and liver to learn the exact way in which each was developed.

Suppose we leave this kind of study for doctors, or people of leisure, or for nurses to study after graduation as soon as they feel the need of this kind of knowledge. Suppose we cut the 66 lectures on anatomy down to—would you be very much shocked if I said a dozen? Suppose we cut down the 24 exercises in the chemical and pathological laboratories to 3 or 4. Suppose we took a very short cut through the dissecting room. Suppose we reduced the 24 medical lectures to three or four, treated them in a practical business-like way, and paid them something for saving valuable time, and for keeping waste matter out of the course. Suppose we applied what I call my John Smith test to every lesson we propose to give. My John Smith test is simply this, and I am exceedingly anxious to popularize it. Will the nurse be any better fitted to take care of John Smith after she has had this lesson, than if she never had it? If not, then why do we give it? Suppose we devoted a great deal of time to instruction in correct methods of ward work and general bedside instruction, and some time to methods of teaching and general management. Don't you honestly believe, if we did this, it might tend to increase the ratio of

useful work for the energy expended? Has not the time arrived for a change of emphasis; for giving more attention to improving the methods of practical teaching in the wards; to training head nurses who will know how to use the opportunities for bedside teaching there are in every ward; to promoting thoroughness in all the details of hospital work? Perhaps this is a backward step, but even if we have to go backward in order to get on the right track, let us try to get there.

Between the extremes of training which I have mentioned, and the old-fashioned, haphazard methods of the past with which we are all familiar, there runs a line of cleavage called common sense. It seems to me it ought to be the duty of this association to investigate and find that line, and having found it, to stick to it as closely as possible, always keeping the main purpose, and the highest interests of the whole institution, in view.

And now my task is done. In closing, I wish to say that if my position regarding these questions is wrong; if I have not been fair and just in this discussion, then at least I am sincerely anxious to be set right; at least, I have tried to be impartial. I have no cast-iron theories or policies regarding these matters. My summing up of this paper is simply this. If we would achieve the highest possible ratio of useful work for the time and energy expended, let us discriminate, if possible, between essentials and non-essentials; let us define our responsibilities to our pupil nurses; let us study the things that make for practical efficiency in hospitals; let us seek justice for hospitals and for nurses; let us find our own field and stay in it, and study it, and by all means, in the primary training of nurses, let us stick to nursing.

SUGGESTIVE OUTLINE OF A SIX MONTH' NORMAL COURSE ON HOSPITAL METHODS AND MANAGEMENT.

4 lessons on duties and responsibilities of head nurses.

1 lesson on operating room management.

6 lessons on the principles and methods of teaching and class-room management.

2 lessons on institutional ethics.

8 lessons on how to teach practical methods by clinical demonstration.