ment, or just how much he should pay for medical or surgical care should be at the discretion of the superintendent, and the amount paid in each case should be a matter of hospital record. In this way the abuse of free attention so often met with in hospital work, or the overcharging by members of the staff, could be controlled. Ward patients who can pay for medical or surgical attention should do so according to their means, the amount to be paid into the office and then turned over to the member of the staff to whose care the case has been assigned. It frequently occurs that there is a wasteful use of supplies, or an exorbitant demand for extra care for patients by the attending physician, but, this should always be by special permission of the superintendent, who can decide whether or not the patient should be made to pay for such extras. This abuse is especially met with in the prescribing of medicines. It seems to make no difference how large a stock of drugs the hospital may have, it will not be able to comply with the fancies of some attending physicians. This difficulty has been overcome by the hospital having a definite list of drugs, which it will supply without extra cost to the patient. The moving of a patient from one part of the hospital to another should be only by the permission of the superintendent.

EXTERNES AND INTERNES.

One problem in the management of small hospitals is the control of the internes. In some ways this is greater than in larger institutions because the members of the hospital family are in closer relation. The difficulty of keeping the nurses away from the internes I believe is even greater than keeping the internes away from the nurses. The strictest rules will not always be sufficient to accomplish this. There should be no familiarity between the internes and the nursing department, including the chief nurse, who often seems to think she has unlimited privileges not only with the internes, but with the visiting staff. Infringement of the rules on the part of the chief nurse in this respect is a common occurrence and leads to general laxity in the school. One great difficulty met with is the self-importance

and overconfidence of the recent graduate who serves as interne. He aptly illustrates the words of Oliver Goldsmith: "For e'en though vanquished he could argue still: While words of learned length and thundering sound amazed the gazing rustics ranged around -and still they gazed: and still the wonder grew: That one small head could carry all he knew."

Newly graduated physicians are apt to feel that there is little left for them to learn after having received their sheepskin the night before amidst the glare of many lights, the refrains of beautiful music and the singing of their praises for the great work just completed. Some never recover from this dream of ideality, but it is gratifying to state that sooner or later most do recover from this delusion; however it may not be until after they leave the hospital. In most cases it soon disappears when the young doctor comes in contact with the real practice of medicine.

Great care should be taken in the selection of internes; and for the first few months they should be told plainly by the chief of staff, or by the superintendent, exactly what he should expect and exactly what is expected from him. If he be of the right metal he will come to see the great importance of hospital practice where he has slight responsibility and need do no more than follow out the dictates of his superiors. In after life he will come to understand that one year in the hospital is equivalent to fully ten years of general practice.

THE SUPERINTENDENT.

Whether or not the superintendent is a medical man, he should be the executive representative of the board, and have absolute control of the management of the hospital in accordance with the directions of the board. If he be a physician he should in no way interfere with the visiting physician unless it be for the protection of the hospital. He should be free to employ or dismiss his assistants as occasion demands. Until he has been proved guilty of mismanagement, he should be upheld by the Board of Trustees. It sometimes occurs that disgruntled employees think they may secure redress

by direct appeal to the Board of Trustees; but, if this method be not recognized and such disgruntled employee, or ex-employee, be made to understand that his actions are entirely out of place, it will be much better for the future discipline of the institution, and the work of the executive officer will be much facilitated. Of course, if such disaffected employee goes to a member of the Board of Trustees with some tangible accusation of mismanagement, and has reduced the same to writing, such complaint should go before the board to be considered by the board as a whole, at a time when the executive officer will have opportunity to make explanation. But this courting of promiscous petty. complaints should be abhored and discountenanced, as in ninety-nine cases out of a hundred such criticisms. are unwarranted.

THE CHIEF NURSE.

Primary in importance in the management of small hospitals is the chief nurse I know of no other individual, of no department, or of no division of the work of the hospital that influences the success, or that hinders the tranquility of an institution, so much as does this potentate. For good or bad her influences are widespread in their effects. She may be serving as a chief nurse alone, or she may be filling the dual position of chief nurse and matron. It makes no difference what her duties are she is an important factor. I believe that the training school and its principal are the sources of most of the difficulty in the small hospital. A qualification of prime importance in this individual is that of honesty; loyalty to the institution by whom she is paid; and fairness to all with whom she, of necessity, must deal. In the words of Elbert Hubbard, if she works for an institution that pays her wages that supplies her bread and butter she should work for that institution, speak well of it, think well of it and stand by it. "If you must villify, condemn and eternally disparage, why, resign your position, and when you are outside, damn to your heart's content. But I pray you, so long as you are a part of an institution, do not condemn it. Not that you will injure the institution-not that but when

you disparage the concern of which you are a part, you disparage yourself."

She should make her actions conform with every rule and regulation, in order that those under her may have a good example to follow; because whatever she does she may expect her subordinates to do. It seems that many chief nurses and head nurses labor under a delusion; they think that rules and regulations do not apply to them.

She should see that the rules of the hospital are complied with and should deal promptly, fairly and without prejudice with every infraction that comes to her notice. It is within her power to create within those around her a respect for the institution, its rules and its management; or she may create disrespect, and lead her subordinates to violations of rules and to dissatisfaction, and even to dismissal; and while doing this she may think that her nefarious methods will be overlooked. I say nefarious because I believe that such actions coming from one who is usually intelligent and able to judge between right and wrong are wicked; that such actions which tear down something that has been built up by hard efforts, are premeditated and with malice aforethought. With some chief nurses it has been a case of rule or ruin. Usually such influences have weight only with the less developed and weakerminded pupils, and are soon counteracted by one having the welfare of the institution at heart.

A chief nurse is usually a fairly well paid employee, at least, she should be. If she is tactful she can greatly aid the management and especially the superintendent. She should listen to the complaints of the patients and endeavor to correct tactfully any wrongdoing and any misunderstanding that such patients may have. She should endeavor to carry out the wishes of the visiting physicians. She should never publicly criticise or permit others to criticise their actions or methods. She should carefully guard against the wasteful use of hospital supplies. She should consult freely with the superintendent and at all times endeavor to direct her efforts in the interest of the institution by which she is employed.

MATRON.

Much that has been said relative to the chief nurse applies to the position of matron; but from personal experience I have but little complaint to make about this incumbent.

One great difficulty has been the friction between the domestic and nursing departments. This strife may be laid at the door of either; but in my hospital experience it usually has been the nursing department at fault. I cannot see why there should be any strife between these two departments, as the duties of each incumbent are so widely different, but there is.

The matron should be one of more than ordinary intelligence, sound judgment, quiet demeanor and tactfulness in leadership. She should deal with her subordinates in a kindly but impressive manner, endeavoring at all times to impress upon her assistants the importance of their special duties. The higher the standard of intelligence that each domestic possess, the greater can be the appeal for their co-operation. There is I have found a natural fear or antipathy against hospital work, that demands a slightly higher wage than is commanded by other domestics. I believe the difficulties of this department are increased in proportion to the decrease of the standard of intelligence. Whenever possible the duties of the chief nurse and matron of the small hospital should be combined. One woman executive is sufficient to handle both departments if the right one can be found. This woman should be assistant superintendent and should be invested with sufficient authority to relieve the superintendent of many trifling and annoying details, the superintendent reserving the right for final action on the more important matters. Such an assistant should be a graduate nurse having age, experience, and tenacity of purpose. It is very difficult to secure such a person. Most new graduates lack poise and judgment, are too unsettled in their minds, and too fanciful in their views; middle-aged graduates of some experience do not care for institutional work; and the older graduates are either looking for a sinecure or are not physically able.