"Ward L is the ward devoted to the crippled. I found sixty men sitting there doing nothing, the very picture of desolation. There has come about, in process of time, what I call the transformation or the transfiguration of Ward L, and all this has taken place through the introduction of the work. The whole character of the ward was changed, a joke was in order, cheeriness and good-will were the rule. I call the ward now the hotel of busy bees."

The impression of the value of such employment that one of the inmates received, is shown by the following quotation from him:

"I came to Ward M in 1903, nearly helpless with locomotor ataxia, and almost beside myself with grief after many troubles. One day Miss Fowler was sent to persuade me to try my hand at basket-weaving, and after some urging I started a basket for her, just to please her, although I did not expect ever to finish it. As I worked with the rafia, and the basket grew, I became more interested, and my brain seemed clearer every night. My hands and arms trembled less and less as I used them and I can now control them so much that I can hone razors again. I used to be a barber.

In 1905 I was able to leave the Home on Blackwell's Island, and am now boarding in New York. I earn about $4.00 a month honing razors and making baskets, and my wife helps by her wages to pay my board. We hope some day to have our own home again."

Many examples might be given of the moral, as well as physical effects which this employment has on the workers, and of the spirit of sociability and comradeship which it engenders. Sometimes the proceeds of the sale of articles that they make are given to help a friend or relative in trouble. One man seeing that his neighbor had no article to send to an exhibit and sale which was to be held, gave him a basket that he himself had made.

The moral benefit of an employment is great, no matter how little the workers accomplish. The results are proof that light employment should be provided for every ward in which incurable men and women are cared for.

REASONS FOR SUCCESS OF COMMITTEE'S WORK.

There are several reasons for the success of the visiting committee in New York and these reasons apply where the same system is in force elsewhere:

First-The committee is independent. It is composed of public spirited citizens, voluntarily interesting themselves in the comfort and well-being of the sick and infirm in municipal institutions. It receives no support from public funds and, therefore, is peculiarly fitted to form an unbiased judgment of conditions and needs, and to add the weight of impartial judgment in support of requests for adequate appropriations for the public charities.

Second-Through its intimate knowledge of conditions and needs and its independence of public authority, it is able to create a public sentiment for adequate and humane care of the sick and infirm, which is of great aid in securing good administration and desirable improvements.

Third-It has the coöperation and good will of the officials in general and can obtain a coördination of opinions and suggestions to a degree that would not be possible for the same number of independent visitors.

Fourth-Its point of view is comprehensive. The New York City Visiting Committee visits all municipal, charitable institutions, and therefore is able to use the experience gained in connection with any one for the benefit of all. It is composed of citizens of all boroughs including expert advisers.

Fifth-Through the organization of its members and the systematizing of its work, it has the benefit of the records and experience of many years of intimate knowledge of the public charitable institutions. It is a continuing body, having now been in existence under authority of law for more than thirty-five years. While its members change, the organization goes on and the work of the individuals becomes incorporated in a continuing whole. Thus the best methods and traditions of administration are perpetuated, and a system created, under which it would be difficult for untrained or even vicious administrators to do great harm.

PROBLEMS IN THE MANAGEMENT OF SMALL HOSPITALS.

BY THEODORE MACCLURE, M.D.,

Surgeon and Superintendent of the Solvay General Hospital, Detroit, Michigan.

The problems of a small hospital do not differ from those of the large institution up to a certain point. There is the same worry over finance, servants and waste, the same professional jealousy and rivalry among physicians, the same difficulties regarding patients and their friends, and the same weaknesses of internes and nurses to deal with. Situations may differ but human nature does not change much. In the problems of hospitals great and small, the human equation figures largely. It is my belief that the duties in connection with the management of small hospitals are as great, in proportion to the corps of workers to deal with them, as those of the large hospital. Most large hospitals have at some time been small ones.

My experience with the management of a small hospital has been confined to one institution, and my relation has been somewhat different from that of the regular Superintendent, in that I have the combined duties of surgeon and superintendent.

The Solvay Hospital grew out of the needs of the Solvay Process Company, an industrial establishment manufacturing soda-ash and by-products and employing about fifteen hundred men. Because of its distance from the city hospitals the men frequently suffered for want of prompt and efficient aid in time of accident. It began with fifteen beds, and now can accommodate fifty patients. I have worked at its problems since before it was opened seven years ago, and believe I have suc

cessfully solved some of them. The hospital has since been incorporated as a general hospital admitting the employees of other manufacturing concerns and providing hospital facilities for the district in which it is located. Its affairs are controlled by a board of trustees, the Solvay Process Company donating the buildings and grounds and guaranteeing any deficiency that may occur.

SMALL HOSFITALS CAN BE FIRST CLASS.

One of the first problems that one will have in the management of small hospitals will be to make that institution first class. I believe it is possible to make a small hospital first class for cleanliness, for results in both surgical and medical cases, for the training of nurses, for the food and general care of patients and employee, and in practically every other respect. I believe that patients should be able to have as good service in a small as in a large hospital.

THE WASTEFUL USE OF HOSPITAL SUPPLIES.

I have no doubt but that the management of every hospital has to contend with a wasteful use of hospital supplies of every kind. It is certainly appalling and seems to occur in cycles. The greatest height of the diagrammatic curve representing this disregard of property, seems to be at a time furthest distant from the occasion of public criticism by the Superintendent, or the time that each nurse or employee is made to pay for thermometers, catheters, dishes, etc. I have found that talk had considerable weight, but that the payment for property wilfully, carelessly or unintentionally sacrificed by an employee, has much more weight and the good influence extends over a much longer period.

The systematic explanation of the proper use of various hospital supplies, and the cost of such is undoubtedly due each nurse or employee, for, in a great many instances, the extravagance is due to lack of knowledge and lack of judgment. Probably two or three lectures could well be interspersed during the

period of instruction each year. If we are to have special post-graduate courses for nurses wishing to do institutional work, and we certainly need them, the subject of hospital economics should occupy a prominent place in the curriculum.

THE BOARD OF TRUSTEES.

The members of the Board of Trustees should be selected because of their sympathy for hospital work and their standing in the community. The majority should be men of business prominence. The Board of a small hospital should not consist of less than six, and not more than ten, exclusive of the superintendent, who should be a member. At least one lady on this board is advisable; and one physician, who should be the chief of staff.

There has been considerable discussion pro and con whether or not a superintendent should be a member of the Board of Trustees. To my mind there is every reason why he should be, providing he is in the capacity outlined elsewhere in this paper. If he is a man of sound mind and a master of his position he will be able to suggest and advise the members of the board and assist them to a better performance of their duty. It cannot be expected that the members of the board will be in as close touch with the details as is the executive officer.

THE VISITING STAFF, AND VISITING PHYSICIANS AND

SURGEONS.

The members of the visiting staff should be elected by the Board of Trustees and their duties prescribed by a definite set of rules and regulations, which may be suggested by the staff, but should be approved by the Board of Trustees. The interpretation of these rules should be made by the superintendent working in conjunction with the chief of the staff. The deportment of other visiting physicians should be under the supervision and control of the superintendent. The assignment of staff cases should be by the superintendent. Whether or not such patient should receive free treat